Effects of early spasticity treatment on children with hemiplegic cerebral palsy: a preliminary study

Influence of adapted hip-hop dancing on quality of life and social participation among children/adolescents with cerebral palsy

OBJECTIVE

To describe the influence of adapted hip-hop dancing on the quality of life (QoL) and biopsychosocial profile of children/adolescents with cerebral palsy (CP).

METHODS

Pilot study including 18 children/adolescents with CP and Gross Motor Function Classification System levels I and II. Nine participants took part in an adapted hip-hop dance practice (study group; SG), and nine others served as the control group (CG). All participants were assessed with the Pediatric Outcomes Data Collection Instrument and the Child Behavior Checklist at baseline and after at least three months of dance practice and a public performance (SG) or a similar period without intervention (CG).

RESULTS

Improvement in QoL was observed in the SG in the domains of transfer and basic mobility (p = 0.00*), sporting and physical function (p = 0.04*), and global function and symptoms (p = 0.01*). In the SG, there was a reduction in emotional and behavioral problems and an increase in social competence in the biopsychosocial profile. Greater participation in adapted hip-hop dancing was associated with a greater gain in the transfer and basic mobility domains (p = 0.05*) of the Pediatric Outcomes Data Collection Instrument and in the activities (p = 0.05*) and social (p = 0.04*) scales of the Child Behavior Checklist.

CONCLUSIONS

Children/adolescents with CP participating in adapted hip-hop dance practice showed improvement in QoL and biopsychosocial profile scores.

Botulinum toxin type A in the treatment of lower limb spasticity in children with cerebral palsy

BACKGROUND

Cerebral palsy (CP) is the most common cause of physical disabilities in children in high-income countries. Spasticity is the most common motor disturbance in CP. Botulinum toxin type A (BoNT-A) is considered the first-line treatment for focal spasticity in people with CP.

OBJECTIVES

To evaluate the effectiveness and safety of BoNT-A compared to other treatments used in the management of lower limb spasticity in children with CP.

SEARCH METHODS

We searched CENTRAL, PubMed, four other databases, and two trial registers in October 2018. We also searched the reference lists of relevant studies and reviews and contacted experts in the field. We did not apply any date or language restrictions.

SELECTION CRITERIA

Randomised controlled trials of children with CP, aged between birth and 19 years, treated with BoNT-A injections in the lower limb muscles compared to other interventions. The primary outcomes were gait analysis and function. The secondary outcomes were joint range of motion, quality of life, satisfaction, spasticity, and adverse events.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, extracted data, assessed risk of bias, and rated the quality of the evidence using GRADE. A third review author arbitrated in case of disagreements. We conducted meta-analyses of available data whenever possible, analysing dichotomous data with risk ratios (RR), and continuous data with mean differences (MD) or standardised mean differences (SMD), with 95% confidence intervals (CI). We considered a 5% significance level for all analyses.Whenever possible, we analysed outcomes at the time points at which they were assessed: short term (2 to 8 weeks); medium term (12 to 16 weeks); and long term (> 24 weeks).

MAIN RESULTS

We included 31 randomised controlled trials assessing 1508 participants. Most studies included ambulatory patients with more than one motor type of CP, and with a mean age of between three and seven years. There was a slight predominance of males.Studies compared BoNT-A in the lower limb muscles to usual care or physiotherapy (14 studies), placebo or sham (12 studies), serial casting (4 studies), or orthoses (1 study).We rated studies as at high or unclear risk of bias mainly due to random sequence generation, allocation concealment, blinding of participants and personnel, and blinding of outcome assessment.BoNT-A versus usual care or physiotherapyBoNT-A might improve overall gait scores at medium-term follow-up (MD 2.80, 95% CI 1.55 to 4.05; 1 study, 40 children; very low-quality evidence) and is moderately effective at improving function at short-term (SMD 0.59, 95% CI 0.23 to 0.95; 2 studies, 123 children) and medium-term (SMD 1.04, 95% CI 0.16 to 1.91; 4 studies, 191 children) follow-up (all very low-quality evidence).BoNT-A improves ankle range of motion, satisfaction, and ankle plantarflexors spasticity at one or more time points (very low-quality evidence).The proportion of adverse events in the BoNT-A group was 0.37 (95% CI 0.08 to 0.66; I² = 95%; very low-quality evidence). No adverse events were reported in the control group.BoNT-A versus placebo or shamBoNT-A improves overall gait scores at short-term (RR 1.66, 95% CI 1.16 to 2.37, P = 0.006; 4 studies, 261 assessments) and medium-term (RR 1.90, 95% CI 1.32 to 2.74, P < 0.001; 3 studies, 248 assessments) follow-up, and may improve peak ankle dorsiflexion in stance (MD 15.90 degrees, 95% CI 4.87 to 26.93, P = 0.005; 1 study, 19 children) and in swing (MD 10.20 degrees, 95% CI 4.01 to 16.39, P = 0.001; 1 study, 19 children) at short-term follow-up (all moderate-quality evidence).BoNT-A is not more effective than placebo or sham at improving function at short-term (SMD 0.24, 95% CI -0.35 to 0.83, P = 0.42; 4 studies, 305 children) or long-term (SMD -0.07, 95% CI -0.48 to 0.35, P = 0.76; 2 studies, 91 children) follow-up, but has a small positive effect at medium-term follow-up (SMD 0.28, 95% CI 0.06 to 0.49, P = 0.01; 5 studies, 327 children) (all moderate-quality evidence).BoNT-A improves passive ankle range of motion, satisfaction, and ankle plantarflexors spasticity at one or more time points (moderate-quality evidence).There was no difference between groups in the rate of adverse events at short-term follow-up (RR 1.29, 95% CI 0.87 to 1.93, P = 0.21; 12 studies, 918 children; moderate-quality evidence).BoNT-A versus serial castingThere was no difference between groups for overall gait scores at short-term (MD 0.00, 95% CI -1.66 to 1.66); medium-term (MD 0.65, 95% CI -1.21 to 2.51); or long-term (MD 0.46, 95% CI -1.33 to 2.25) follow-up in one study with 18 children (moderate-quality evidence).BoNT-A improved instrumented gait analysis only in terms of ankle dorsiflexion at initial contact (MD 6.59 degrees, 95% CI 1.39 to 11.78, P = 0.01; 2 studies, 47 children). There was no difference between groups for peak ankle dorsiflexion in stance and swing, and gait speed at any time point (moderate- and low-quality evidence).BoNT-A is not more effective than serial casting at improving function, ankle range of motion, and spasticity at any time point (moderate- and low-quality evidence).BoNT-A is not associated with a higher risk of adverse events than serial casting (RR 0.59, 95% CI 0.03 to 11.03; 3 studies, 64 children; low-quality evidence).BoNT-A versus orthosesThere was no difference between groups for function at medium-term follow-up (MD 11.14, 95% CI -0.05 to 22.33; 1 study, 43 children), but BoNT-A is more effective than orthoses at improving hip range of motion and hip adductors spasticity (all very low-quality evidence).

AUTHORS' CONCLUSIONS

The quality of the evidence was low or very low for most of the outcomes analysed. We found limited evidence that BoNT-A is more effective than placebo or a non-placebo control at improving gait, joint range of motion, satisfaction, and lower limb spasticity in children with CP, whereas the results for function were contradictory. The rate of adverse events with BoNT-A is similar to placebo. BoNT-A is not more effective than ankle serial casting to treat ankle contractures for any of the assessed outcomes, but is more effective than orthotics at improving range of motion and spasticity.

The efficacy of botulinum toxin A lower limb injections in addition to physiotherapy approaches in children with cerebral palsy: A systematic review

BACKGROUND

To assess treatment effect of lower limb botulinum toxin type A (BTX-A) in combination with physiotherapy approaches on gross motor functions in children with cerebral palsy compared with only physiotherapy treatment.

OBJECTIVE

The purpose of this review was to analyze the efficacy botulinum toxin a lower limb injections in addition to physiotherapy approaches in children with cerebral palsy.

METHODS

A literature search was conducted in the following databases: Cochrane, PEDro, PubMed, MEDLINE, AMED and EMBASE. The searches were limited to the period from July 2009 to July 2015. The intervention had to contain BTX-A into the lower limb plus physiotherapy approaches and be compared with only physiotherapy. The methodological quality and clinical relevance were independently assessed by the authors.

RESULTS

The database search resulted in a total of 1521 studies, of which 4 (Level II of evidence) trials were included in this review. The population represented by were age between from 11 month to 15 years. Overall there were 153 children all diagnosed with CP (87 Male, 66 Female).

CONCLUSIONS

The use of BTX-A injections in addition to physiotherapy approaches seems to have positive effect on spasticity and ROM. However, the question of whether the treatment of BTX-A plus physiotherapy has a greater improvement on functional capacity, such as gross motor function or gait parameter than only physiotherapy treatments, was inconclusive. Further investigation by rigorous studies is required.

Effectiveness of multiple botulinum toxin sessions and the duration of effects in spasticity therapy in children with cerebral palsy

PURPOSE

The aim of this study was to assess the effectiveness of long-term therapy with multiply botulinum neurotoxin (BoNT) injections.

METHODS

In 2004-2010, 60 children with spastic cerebral palsy aged 2-16 were treated multiple botulinum toxin sessions (injections in gastrocnemius muscle and soleus muscles). In each patient, we rated muscle tone by Modified Ashworth Scale, passive range of motion in ankle joint with extended, and flexed knee joint and gait using the Physician Rating Scale. Assessment was done before and after injection, up to eight BoNT sessions.

RESULTS

The generalized additive models showed that a single treatment effect was visible for 3 months. The number of injections did not impact the effectiveness. Improvement in muscle tone was greater in children with hemiplegia than diplegia (β = - 0.294; p = 0.014). Improvement in range of motion with extended knee joint was greater in hemiplegic than diplegic types (β = 0.414; p =0.002), and improvement in range of motion with flexed knee was greater in children with more severe impairment (Gross Motor Function Classification System III vs. I, β = 0.0603, p = 0.025; V vs. I, β = 0.691, p = 0.023). The gait improvement rate decreased with patient age (p = 0.007).

CONCLUSIONS

BoNT therapy is effective regardless of the number of injection sessions and duration of treatment. However, it is affected by the patient's age, type of cerebral palsy, and degree of impairment.

Early Fesoterodine Fumarate Administration Prevents Neurogenic Detrusor Overactivity in a Spinal Cord Transected Rat Model

Background

In spinal cord injury, onset of detrusor overactivity (DO) is detrimental for quality of life (incontinence) and renal risk. Prevention has only been achieved with complex sophisticated electrical neuromodulation techniques.

Purpose

To assess the efficacy of early fesoterodine fumarate (FF) administration in preventing bladder overactivity in a spinal cord transected (SCT) rat model.

Methods

33 Sprague-Dawley rats were allocated to 6 groups–Group 1: 3 normal controls; Group 2: 6 SCT controls; Group 3: 6 SCT rats + FF 0.18 mg/kg/d; Group 4: 6 SCT rats + FF 0.12 mg/kg/d; Group 5: 6 SCT rats + FF 0.18 mg/kg/d + 72-h wash-out period; Group 6: 6 SCT rats + FF 0.12 mg/kg/d + 72-h wash-out period. SCT was performed at T10. FF was continuously administered. Cystometry was undertaken 6 weeks after SCT in awake rats recording intermicturition pressure (IMP), baseline pressure, threshold pressure (Pthres) and maximum pressure (Pmax). Normal controls and SCT controls were initially compared using the Mann-Whitney U tests in order to confirm the SCT effect on cystometric parameters. The comparisons in cystometric and metabolic cage parameters between SCT controls and treated rats were done using post-hoc Dunn’s tests for Kruskal-Wallis analysis. Statistical testing was conducted at the two-tailed α-level of 0.05.

Results

Pressure parameters were significantly higher in SCT control group compared to normal controls. Six weeks after SCT, IMP was significantly lower in low dose treated group than in SCT controls. Pmax was significantly lower in 3 treated groups compared to SCT controls. Pthres was significantly lower in full time treated groups than in SCT controls.

Conclusion

Early administration of FF modulates bladder overactivity in a SCT rat model. Whereas short-term prevention has been demonstrated, the long-term should be further analyzed. Clinical application of these results should confirm this finding through randomized research protocols.

Age specificity in general and rehabilitation medical services in children with cerebral palsy

Objective

To review the medical utilization in children with cerebral palsy according to age and discern particularities

Methods

From January 2007 to December 2007, 10,659 children and adolescents between 1 and 18 years of age who had filed national insurance claims for a diagnosis of cerebral palsy were selected. Age was chosen as an independent variable, and the population was categorized into specific age groups to verify any differences in medical service utilization. Admission duration to rehabilitation, number of visits to rehabilitation outpatient clinics, numbers of admission dates and outpatient clinic visits for general medical services, number of rehabilitation utilizations, and type of rehabilitations treatment were selected as dependent variables. One-way ANOVA was used for statistical evaluation, and analysis was done with SAS software.

Results

In general medical use, adolescences diagnosed with cerebral palsy had the highest mean admission duration (p<0.001). The mean visit day to outpatient clinics for general medical services was highest for infants (p<0.001). In rehabilitation treatment, infants diagnosed with cerebral palsy had the highest mean admission duration (p<0.001). The mean visit day to outpatient clinics for rehabilitation treatment was highest for infants (p<0.001).

Conclusion

Significant differences in use of general and rehabilitation medical services among pediatric age groups with cerebral palsy were evident. This implies that particular attention is necessary when setting up a national medical care policy for patient with cerebral palsy.