Spasticity associated with cerebral palsy in children: guidelines for the use of botulinum A toxin

Successful Treatment of Schwartz-Jampel Syndrome with Botulinum Toxin Type A

Schwartz-Jampel syndrome (SJS) is a rare autosomal recessive disorder characterized by typical facial dysmorphism, generalized muscle stiffness, joint contracture, and skeletal abnormalities. This condition is caused by mutations in the heparan sulfate proteoglycan 2 (HSPG2) gene, which encodes perlecan, a component of the basement membrane. The management of patients with SJS primarily aims to alleviate symptoms related to muscle stiffness. In this report, we describe a male patient with SJS type 1A. Trio whole-exome sequencing identified a pathogenic mutation (NM_001291860.1: c.10897C>T; p.Arg3633Ter) and variants of unknown significance (NM_001291860.2: c.413+10G>T). The patient experienced difficulty in opening his eyes and mouth, which significantly limited his daily activities. Botulinum toxin A injection was administered and demonstrated significant clinical improvement after the treatment.

Utilization of shear wave elastography to quantify and predict response to upper extremity botulinum toxin injections in patients with cerebral palsy: A pilot study

OBJECTIVE

Shear wave elastography (SWE) was used to quantify change in upper extremity muscle stiffness in patients with unilateral spastic cerebral palsy (USCP) following botulinum toxin A (BTX-A) therapy. We hypothesized that SWE measures would decrease following ultrasound-guided BTX-A injection, and correlate with functional improvement.

METHODS

SWE measures of BTX-A treated muscles were recorded immediately pre-injection, and at 1-, 3- and 6-months post-injection. At the same timepoints, functional assessment was performed using the Modified Ashworth Scale (MAS), and passive and active range of motion (PROM and AROM) measures. Correlation of SWE with MAS, PROM and AROM, as well as the relationship between change in SWE and change in MAS, PROM and AROM was determined using Spearman's rank correlation coefficient and generalized estimating equation modeling.

RESULTS

16 muscles were injected and longitudinally assessed. SWE and MAS scores decreased following BTX-A injection (p = 0.030 and 0.004, respectively), reflecting decreased quantitative and qualitative muscle stiffness. Decreased SWE reached statistical significance at 1- and 3-months, and 1-, 3- and 6-months for MAS. When comparing relative change in SWE to relative change in AROM, larger change in SWE strongly correlated with positive change in AROM (p-value range:<0.001-0.057). BTX-A responders also demonstrated lower baseline SWE (1.4 m/s) vs. non-responders (1.9 m/s), p = 0.035.

CONCLUSION

Ultrasound-guided BTX-A injections in patients with USCP resulted in decreased quantitative and qualitative muscle stiffness. Strong correlation between change in SWE and AROM, as well as the significant difference in baseline SWE for BTX-A responders and non-responders, suggests SWE may provide a useful tool to predict and monitor BTX-A response.

Machine learning approach to gait deviation prediction based on isokinetic data acquired from biometric sensors

BACKGROUND

Analyzing gait deviation is one of the crucial factors during the diagnosis and treatment of children with Cerebral Palsy (CP). The typical diagnostic procedure requires an expensive and complicated three-dimensional gait analysis system based on visual sensors. In this work, we focus on predicting well-known gait pathology scores using only information collected from the BS4P, the affordable isokinetic dynamometer. Using such equipment, it is possible to determine gait pathological indices such as the gait deviation index (GDI) or the Gillette gait index (GGI).

RESEARCH QUESTION

Are there correlations between the results of examining patients with CP on the Biodex Pro 4 device and the gait quality metrics (GDI and GGI)?

METHODS

The isokinetic data acquired from biometric sensors (74 records) were analyzed using big data methods. We used several Machine Learning methods to find the correlation between gait deviation and isokinetic data: Adaptive Boosting Regression, K-nearest Neighbor, Decision Tree Regression, Random Forest Regression, and Gradient Boost Regression.

RESULTS

In this paper, we provided a detailed comparison of different machine learning regression models in predicting gait quality in patients with CP based only on the data gathered from affordable Biodex 4 Pro device. The best result was obtained using the gradient boosting regression model with Mean Absolute Percentage Error of 6%. However, it was not possible to precisely predict the GGI index using this method.

SIGNIFICANCE

The results obtained showed promising results in the evaluation of gait index scores, which gives the possibility of diagnosing patients with CP without the use of expensive optometric systems. Evaluating gait metrics using the approach proposed in this paper could be very helpful for both physicians and physiotherapists in assessing the condition of patients with CP, as well as other diseases related to gait problems.

Prevalence of knee contractures is high in children with cerebral palsy in Denmark

INTRODUCTION

Cerebral palsy (CP) is a neurological disease occurring in children at early gestation, often resulting in pronounced functional limitations. A Swedish cross-sectional study (Cloodt, et al., 2018) discovered that 22% of children with CP had a knee contracture, which was associated with higher levels of Gross Motor Function Classification System (GMFCS), higher age, and higher levels of spasticity measured by the Modified Ashworth Scale (MAS). The current study investigated these associations in a Danish population.

METHODS

This is a cross-sectional study including 1,163 children with CP aged 0-15 years, registered in the Danish National Cerebral Palsy Registry between 2017 and 2019. Prevalence of knee contracture was estimated, and logistic regression analysis was applied with results presented as odds ratio (OR) with 95% confidence intervals (CI).

RESULTS

A total of 511 children with CP had knee contracture resulting in a prevalence of 44%. Age groups 4-6 years (OR: 1.73, CI: 1.19; 2.52), 7-9 years (OR: 1.85, CI: 1.29; 2.66) and 10-12 years (OR: 2.12, CI: 1.39; 3.24) were significantly associated with a higher prevalence of knee contractures compared to age group 0-3 years. Knee contractures were significantly more frequent at GMFCS levels IV (OR: 1.9, CI: 1.21; 2.97) and V (OR: 3.62, CI: 2.36; 5.55) compared to level I. Knee contractures were not associated with higher levels of MAS.

CONCLUSIONS

Knee contractures are highly prevalent and significantly associated with high levels of GMFCS and increased age until 12 years, but not with high levels of spasticity in children with CP in Denmark.

Botulinum toxin type A for spasticity in cerebral palsy patients: Which impact on popliteal angle to hamstring length? A proof-of-concept study

BACKGROUND

Cerebral palsy (CP) is the most common physical disability in childhood. It is a heterogeneous condition in terms of etiology, motor type and severity of impairments. Clinical impairments, such as increased muscle tone (spasticity), muscle weakness and joint stiffness contribute to the abnormal development of functional activities, including gait.

OBJECTIVE

The objective of this study was to investigate the popliteal angle to hamstring length after ultrasound guided Incobotulinum toxin A injections for spasticity in CP patients.

METHODS

In this proof-of-concept study, we included outpatients with CP and crouch gait correlated to hamstrings spasticity referred to the Pediatric Rehabilitation outpatient clinic of Umberto I University Hospital, Sapienza University of Rome, in the period between February and October 2018.

METHODS

Modified Ashworth Scale (MAS) of hamstring muscles, Popliteal Angle and Modified Popliteal Angle, Passive Knee Extension and 10 Meter Walk Test (10MWT) were assessed at baseline (T0) and three weeks after ultrasound guided injection (T1) of Incobotulinum Toxin A (dose weight and site dependent).

RESULTS

Thirteen patients (5 male and 8 female), mean aged 9.91 ± 3.59, were included. The clinical evaluation at T0 showed hamstring muscles spasticity, with MAS of 2.4 ± 0.6, popliteal angle -51.7∘± 11.0∘, modified popliteal angle of -39.5∘± 11.0∘, passive knee extension of -14.0∘± 8.7∘ and 10MWT of 14.3 ± 4.6 seconds. At T1, hamstring muscles MAS mean value was 1.7 ± 0.6 (p< 0.01), popliteal angle 41.3∘± 7.0∘ (p< 0.001), modified popliteal angle -32.9∘± 10.4∘ (p< 0.001), passive knee extension -4.0∘± 4.2∘ (p< 0.05) and 10MWT 12.6 ± 4.8 seconds (p< 0.05). None of the treated patients reported any adverse event related to Incobotulinum Toxin A injection.

CONCLUSION

Incobotulinum toxin A treatment has been proven to be safe and effective for hamstring muscles spasticity management in CP patients. Further studies with larger samples and longer follow-up are warranted to assess the efficacy of this treatment on the popliteal angle.

Management of arthrofibrosis in neuromuscular disorders: a review

Arthrofibrosis, or rigid contracture of major articular joints, is a significant morbidity of many neurodegenerative disorders. The pathogenesis depends on the mechanism and severity of the precipitating neuromuscular disorder. Most neuromuscular disorders, whether spastic or hypotonic, culminate in decreased joint range of motion. Limited range of motion precipitates a cascade of pathophysiological changes in the muscle-tendon unit, the joint capsule, and the articular cartilage. Resulting joint contractures limit functional mobility, posing both physical and psychosocial burdens to patients, economic burdens on the healthcare system, and lost productivity to society. This article reviews the pathophysiology of arthrofibrosis in the setting of neuromuscular disorders. We describe current non-surgical and surgical interventions for treating arthrofibrosis of commonly affected joints. In addition, we preview several promising modalities under development to ameliorate arthrofibrosis non-surgically and discuss limitations in the field of arthrofibrosis secondary to neuromuscular disorders.

Relationship between clinical outcome measurements and muscle thickness in cerebral palsy

BACKGROUND: The World Health Organization (WHO) uses the International Classification of Functioning, Disability, and Health (ICF) model to provide physical therapy diagnoses and interventions. However, the relationship between clinical assessment and imaging remains unclear. OBJECTIVE: This study aimed to determine the relationships between body function/structure, activity, and participation outcomes following neurorehabilitation in children with cerebral palsy (CP). METHODS: Nineteen children (9 girls mean age 8.8 ± 1.8 years) with CP participated in this study. Clinical motor function tests included the quality of upper extremity skills test (QUEST), Wolf motor function test (WMFT), Functional Independence Measure for Children (WeeFIM), and the Jebsen-Taylor Hand Function Test (JTHFT). Ultrasound imaging was used to measure muscle thickness, which characterizes the body structure, and activity domain variables. RESULTS: The correlations between body structure domain (muscle thickness), activity domain (QUEST, WMFT, WeeFIM) and participants variable (JTHFT) were significant, ranging from r=-0.484 to 0.893, P< 0.05. CONCLUSIONS: These novel findings suggest that muscle thickness ultrasound imaging is closely associated with WMFT, WeeFIM, and QUEST variables. This finding provides important clinical insights when using broad clinical assessment and imaging in children with CP.

An overview of the effects of whole-body vibration on individuals with cerebral palsy

The purpose of this review is to examine how whole-body vibration can be used as a tool in therapy to help improve common physical weaknesses in balance, bone density, gait, spasticity, and strength experienced by individuals with cerebral palsy. Cerebral palsy is the most common movement disorder in children, and whole-body vibration is quickly becoming a potential therapeutic tool with some advantages compared to traditional therapies for individuals with movement disorders. The advantages of whole-body vibration include less strain and risk of injury, more passive training activity, and reduced time to complete an effective therapeutic session, all of which are appealing for populations with physiological impairments that cause physical weakness, including individuals with cerebral palsy. This review involves a brief overview of cerebral palsy, whole-body vibration's influence on physical performance measures, its influence on physical performance in individuals with cerebral palsy, and then discusses the future directions of whole-body vibration therapy in the cerebral palsy population.

Protocol for The Toxin Study: Understanding clinical and patient reported response of children and young people with cerebral palsy to intramuscular lower limb Botulinum neurotoxin-A injections, exploring all domains of the ICF. A pragmatic longitudinal observational study using a prospective one-group repeated measures design

INTRODUCTION

Botulinum neurotoxin-A (BoNT-A) is an accepted treatment modality for the management of hypertonia in children and young people with cerebral palsy (CYPwCP). Nevertheless, there are concerns about the long-term effects of BoNT-A, with a lack of consensus regarding the most meaningful outcome measures to guide its use. Most evidence to date is based on short-term outcomes, related to changes at impairment level (restrictions of body functions and structures), rather than changes in adaptive skills (enabling both activity and participation). The proposed study aims to evaluate clinical and patient reported outcomes in ambulant CYPwCP receiving lower limb BoNT-A injections over a 12-month period within all domains of the WHO's International Classification of Functioning, Disability and Health and health-related quality of life (HRQoL).

METHODS AND ANALYSIS

This pragmatic prospective longitudinal observational study will use a one-group repeated measures design. Sixty CYPwCP, classified as Gross Motor Function Classification System (GMFCS) levels I-III, aged between 4 and 18 years, will be recruited from an established movement disorder service in London, UK. Standardised clinical and patient reported outcome measures within all ICF domains; body structures and function, activity (including quality of movement), goal attainment, participation and HRQoL, will be collected preinjection and at 6 weeks, 6 months and up to 12 months postinjection. A representative subgroup of children and carers will participate in a qualitative component of the study, exploring how their experience of BoNT-A treatment relates to clinical outcome measures.

ETHICS AND DISSEMINATION

Central London Research Ethics Committee has granted ethics approval (#IRAS 211617 #REC 17/LO/0579). Findings will be disseminated in peer-reviewed publications, conferences and via networks to participants and relevant stakeholders using a variety of accessible formats including social media.

IncobotulinumtoxinA for the treatment of lower-limb spasticity in children and adolescents with cerebral palsy: A phase 3 study

PURPOSE

Investigate the efficacy and safety of multipattern incobotulinumtoxinA injections in children/adolescents with lower-limb cerebral palsy (CP)-related spasticity.

METHODS

Phase 3 double-blind study in children/adolescents (Gross Motor Function Classification System - Expanded and Revised I-V) with unilateral or bilateral spastic CP and Ashworth Scale (AS) plantar flexor (PF) scores ⩾ 2 randomized (1:1:2) to incobotulinumtoxinA (4, 12, 16 U/kg, maximum 100, 300, 400 U, respectively) for two 12- to 36-week injection cycles. Two clinical patterns were treated. Pes equinus (bilateral or unilateral) was mandatory; if unilateral, treatment included flexed knee or adducted thigh.

ENDPOINTS

Primary: AS-PF change from baseline to 4 weeks; Coprimary: investigator-rated Global Impression of Change Scale (GICS)-PF at 4 weeks; Secondary: investigator's, patient's, and parent's/caregiver's GICS, Gross Motor Function Measure-66 (GMFM-66).

RESULTS

Among 311 patients, AS-PF and AS scores in all treated clinical patterns improved from baseline to 4-weeks post-injection and cumulatively across injection cycles. GICS-PF and GICS scores confirmed global spasticity improvements. GMFM-66 scores indicated better motor function. No significant differences between doses were evident. Treatment was well-tolerated, with no unexpected treatment-related adverse events or neutralising antibody development.

CONCLUSION

Children/adolescents with lower-limb spasticity experienced multipattern benefits from incobotulinumtoxinA, which was safe and well-tolerated in doses up to 16 U/kg, maximum 400 U.

Clinical Relevance of State-of-the-Art Analysis of Surface Electromyography in Cerebral Palsy

Surface electromyography (sEMG) can be used to assess the integrity of the neuromuscular system and its impairment in neurological disorders. Here we will consider several issues related to the current clinical applications, difficulties and limited usage of sEMG for the assessment and rehabilitation of children with cerebral palsy. The uniqueness of this methodology is that it can determine hyperactivity or inactivity of selected muscles, which cannot be assessed by other methods. In addition, it can assist for intervention or muscle/tendon surgery acts, and it can evaluate integrated functioning of the nervous system based on multi-muscle sEMG recordings and assess motor pool activation. The latter aspect is especially important for understanding impairments of the mechanisms of neural controllers rather than malfunction of individual muscles. Although sEMG study is an important tool in both clinical research and neurorehabilitation, the results of a survey on the clinical relevance of sEMG in a typical department of pediatric rehabilitation highlighted its limited clinical usage. We believe that this is due to limited knowledge of the sEMG and its neuromuscular underpinnings by many physiotherapists, as a result of lack of emphasis on this important methodology in the courses taught in physical therapy schools. The lack of reference databases or benchmarking software for sEMG analysis may also contribute to the limited clinical usage. Despite the existence of educational and technical barriers to a widespread use of, sEMG does provide important tools for planning and assessment of rehabilitation treatments for children with cerebral palsy.

Perspective of an International Online Patient and Caregiver Community on the Burden of Spasticity and Impact of Botulinum Neurotoxin Therapy: Survey Study

Background

Patient- and caregiver-reported data are lacking on the burden of spasticity, and the impact of botulinum neurotoxin type A (BoNT-A) treatment for this condition, on patients' daily lives. As recommended in recent guidance from the US Food and Drug Administration, online patient communities can represent a platform from which to gather specific information outside of a clinical trial setting on the burden of conditions experienced by patients and caregivers and their views on treatment options in order to inform evidence-based medicine and drug development.

Objective

The objective of our study is to characterize spasticity symptoms and their associated burdens on Western European and US patients and caregivers in the realms of work, daily activities, quality of life (QoL), as well as the positive and negative impacts of treatment with BoNT-A (cost, time, QoL) using Carenity, an international online community for people with chronic health conditions.

Methods

We performed a noninterventional, multinational survey. Eligible participants were 18 years old or older and had, or had cared for, someone with spasticity who had been treated with BoNT-A for at least 1 year. Patients and caregivers were asked to complete an internet-based survey via Carenity; caregivers reported their own answers and answered on behalf of their patients. Questions included the burden of spasticity on the ability to work, functioning, daily-living activities, and QoL, the impact of BoNT A therapy on patients' lives, and the potential benefits of fewer injections.

Results

There were 615 respondents (427 patients and 188 caregivers). The mean age of patients and caregivers was 41.7 years and 38.6 years, respectively, and the most commonly reported cause of spasticity was multiple sclerosis. Caregivers were most often the parents (76/188, 40%) or another family member (51/188, 27%) of their patients. Spasticity had a clear impact on patients' and caregivers' lives, including the ability to work and injection costs. For patients, spasticity caused difficulties with activities of daily living and reduced QoL indices. The median number of BoNT-A injections was 4 times per year, and 92% (393/427) of patients reported that treatment improved their overall satisfaction with life. Regarding the BoNT-A injection burden, the greatest patient-reported challenges were the cost and availability of timely appointments. Overall, 86% (368/427) of patients believed that a reduced injection frequency would be beneficial. Caregivers answering for their patients gave largely similar responses to those reported by patients.

Conclusions

Spasticity has a negative impact on both patients' and caregivers' lives. All respondents reported that BoNT A treatment improved their lives, despite the associated challenges. Patients believed that reducing the frequency of BoNT-A injections could alleviate practical issues associated with treatment, implying that a longer-acting BoNT-A injection would be well received.

Maturation of the Locomotor Circuitry in Children With Cerebral Palsy

The first years of life represent an important phase of maturation of the central nervous system, processing of sensory information, posture control and acquisition of the locomotor function. Cerebral palsy (CP) is the most common group of motor disorders in childhood attributed to disturbances in the fetal or infant brain, frequently resulting in impaired gait. Here we will consider various findings about functional maturation of the locomotor output in early infancy, and how much the dysfunction of gait in children with CP can be related to spinal neuronal networks vs. supraspinal dysfunction. A better knowledge about pattern generation circuitries in infancy may improve our understanding of developmental motor disorders, highlighting the necessity for regulating the functional properties of abnormally developed neuronal locomotor networks as a target for early sensorimotor rehabilitation. Various clinical approaches and advances in biotechnology are also considered that might promote acquisition of the locomotor function in infants at risk for locomotor delays.

[Botulinum toxin type A (Incobotulinum toxin A) in spastic forms of cerebral palsy: a retrospective analysis of clinical experience]

OBJECTIVE

A retrospective analysis of the experience of using Incobotulinum toxin A injections for the treatment of spasticity in children with cerebral palsy (CP).

MATERIAL AND METHODS

One hundred and eighty-five children with spastic forms of CP, including 114 boys (61,6%), were studied. The average age of the patients was 3,8±2,5 years; the average weight was 14,2±6,9. The patients received injections of Incobotulinum toxin A according to registered indications or recommendations of a consultation of specialists and voluntary informed consent of the patient's representative. At least 1 point decrease of muscle tone according to the modified Ashworth scale was used as a criterion of the antispastic effect of Incobotulinum toxin A.

RESULTS

The total dose of Incobotulinum toxin A for the whole group of patients with CP was 154,5±67,7 U and 11,6±4,7 U per kg/body weight. The gracilis muscle (65,4% of cases, 95%CI 58,1-72,2) and the gastrocnemius muscle (49,4% of cases, 95%CI 41,8-56,6) were the most frequently injected targets in the lower extremities, and the pronator teres muscle (58,9% of cases, 95%CI 51,5-66,1) - in the upper extremities. Adverse events were observed in 13 patients (7,0%). They were mild in 9 patients and moderate in 4 patients.

CONCLUSION

Our data confirmed the effectiveness and safety of Incobotulinum toxin A injections in spastic CP. The calculated average doses of Incobotulinum toxin A for target muscles and the frequency of different spasticity patterns could serve as a reference for the botulinum therapy planning.

Over 25 Years of Pediatric Botulinum Toxin Treatments: What Have We Learned from Injection Techniques, Doses, Dilutions, and Recovery of Repeated Injections?

Botulinum toxin type A (BTXA) has been used for over 25 years in the management of pediatric lower and upper limb hypertonia, with the first reports in 1993. The most common indication is the injection of the triceps surae muscle for the correction of spastic equinus gait in children with cerebral palsy. The upper limb injection goals include improvements in function, better positioning of the arm, and facilitating the ease of care. Neurotoxin type A is the most widely used serotype in the pediatric population. After being injected into muscle, the release of acetylcholine at cholinergic nerve endings is blocked, and a temporary denervation and atrophy ensues. Targeting the correct muscle close to the neuromuscular junctions is considered essential and localization techniques have developed over time. However, each technique has its own limitations. The role of BTXA is flexible, but limited by the temporary mode of action as a focal spasticity treatment and the restrictions on the total dose deliverable per visit. As a mode of treatment, repeated BTXA injections are needed. This literature reviewed BTXA injection techniques, doses and dilutions, the recovery of muscles and the impact of repeated injections, with a focus on the pediatric population. Suggestions for future studies are also discussed.

Botulinum toxin injection, dilution confusion: The impact of toxin diffusion on clinical practice

Botulinum toxins (BoNT) are a standard of care for spasticity management of children with a variety of neuromuscular (NM) conditions. BoNT relaxes skeletal muscles by inhibiting the release of acetylcholine from the neuromuscular junction (NMJ). As part of their training physiatrist become proficient in the targeted injections of BoNT into affected skeletal musculature. While the pharmacology and pharmacokinetics of BoNT are well characterized, there is limited literature on the clinical impact that varying the volume of diluent that a toxin is reconstituted within. In theory, injection of a larger volume of dilute BoNT would allow for a larger spread affect reaching more distant NMJs; the reverse is also be true. Dilution volume of BoNT injections in children produces some unique situations due to their low weight, smaller muscle bulk, an increased relative risk of spread to surrounding structures, and novel differences in concentration of NMJ in immature muscle. Some of these factors may act as guiding principles that providers can use when adjusting from their standard BoNT dilutional practices. Although, there are recommended dosing strategies available each child's spasticity pattern represents a unique situation and providers must be allowed flexibility to think creatively about dilution strategies for BoNT injections.

Safety and Efficacy of a Propofol and Ketamine Based Procedural Sedation Protocol in Children with Cerebral Palsy Undergoing Botulinum Toxin A Injections

BACKGROUND

Pediatric patients with cerebral palsy often undergo intramuscular botulinum toxin (BoNT-A) injections. These injections can be painful and may require procedural sedation. An ideal sedation protocol has yet to be elucidated.

OBJECTIVE

To investigate the safety and efficacy of a propofol and ketamine based sedation protocol in pediatric patients with cerebral palsy requiring BoNT-A injections.

DESIGN

Retrospective chart review.

SETTING

The sedations took place in a procedural sedation suite at a tertiary children's hospital from February 2013 through September 2017.

PATIENTS

164 patients with diagnoses of cerebral palsy undergoing propofol and ketamine based sedation for injections with botulinum toxin A.

METHODS

An initial bolus of 0.5 mg/kg ketamine followed by a 2 mg/kg bolus of propofol was administered with supplemental boluses of propofol as needed to achieve deep sedation during the intramuscular BoNT-A injections.

MAIN OUTCOME MEASUREMENTS

Propofol dosages, adverse events, serious adverse events, and sedation time parameters were reviewed.

RESULTS

345 sedations were successfully performed on 164 patients. The median total dose of propofol was 4.7 mg/kg (interquartile range [IQR]: 3.5, 6.3). Adverse events were encountered in 10.1% of procedures including hypoxemia responsive to supplemental oxygen (9.6%) and transient apnea (1.4%). The mean procedure time, recovery time, and total sedation time were 10, 11 and 33 minutes, respectively. With regard to patient variables, including age, weight, dose of propofol, sedation time, and Gross Motor Function Classification System classification, there was no association with increased incidence of adverse events.

CONCLUSION

Our sedation protocol of propofol and ketamine is safe and effective in children with cerebral palsy undergoing procedural sedation for intramuscular injections with BoNT-A. The adverse events encountered appeared to be related to airway and respiratory complications secondary to musculoskeletal deformities, emphasizing the importance of airway monitoring and management in these patients.

LEVEL

IV.

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.

Botulinum toxin A-induced muscle paralysis stimulates Hdac4 and differential miRNA expression

At sufficient dose, intramuscular injection of Botulinum toxin A causes muscle wasting that is physiologically consistent with surgical denervation and other types of neuromuscular dysfunction. The aim of this study was to clarify early molecular and micro-RNA alterations in skeletal muscle following Botulinum toxin A-induced muscle paralysis. Quadriceps were analyzed for changes in expression of micro- and messenger RNA and protein levels after a single injection of 0.4, 2 or 4U Botulinum toxin A (/100g body weight). After injection with 2.0U Botulinum toxin A, quadriceps exhibited significant reduction in muscle weight and increased levels of ubiquitin ligase proteins at 7, 14 and 28 days. Muscle miR-1 and miR-133a/b levels were decreased at these time points, whereas a dose-responsive increase in miR-206 expression at day 14 was observed. Expression of the miR-133a/b target genes RhoA, Tgfb1 and Ctfg, and the miR-1/206 target genes Igf-1 and Hdac4, were upregulated at 28 days after Botulinum toxin A injection. Increased levels of Hdac4 protein were observed after injection, consistent with anticipated expression changes in direct and indirect Hdac4 target genes, such as Myog. Our results suggest Botulinum toxin A-induced denervation of muscle shares molecular characteristics with surgical denervation and other types of neuromuscular dysfunction, and implicates miR-133/Tgf-β1/Ctfg and miR-1/Hdac4/Myog signaling during the resultant muscle atrophy.

Management of Joint Contractures in the Spastic Upper Extremity

Upper extremity contractures in the spastic patient may result from muscle spasticity, secondary muscle contracture, or joint contracture. Knowledge of the underlying cause is critical in planning successful treatment. Initial management consists of physical therapy and splinting. Botulinum toxin can be helpful, as a therapeutic treatment in relieving spasticity and as a diagnostic tool in determining the underlying cause of the contracture. Surgical management options include release or lengthening of the causative muscle/tendon unit and joint capsular release, as required. Postoperative splinting is important to maintain the improved range of motion and protect any associated tendon lengthening or transfer.

Effects of Botulinum Toxin Treatment in Nonambulatory Children and Adolescents With Cerebral Palsy: Understanding Parents' Perspectives

Children and adolescents with cerebral palsy often receive botulinum toxin A (BoNT-A) to manage hypertonia. This qualitative study aimed to describe and categorize BoNT-A effects that parents observed using the WHO's International Classification of Functioning, Disability and Health (ICF) framework. An interpretive description methodology was used; semi-structured interviews were conducted with 15 parents of nonambulatory young people with cerebral palsy (mean age 10.2 years, SD 3.9, 7 males) who received BoNT-A. Parents reported BoNT-A effects on each ICF category. Through interpretive description, an overall theme emerged: "finding the right path to do what is best." Five subthemes included (1) Parents' hopes, (2) Parents' goals for their child, (3) Parents' learning what works, (4) Parents' reflections, and (5) Parents' destination. This study provides insights into parents' journeys of how they learned about BoNT-A effects in their child, which helped them to identify goals for future treatment.

Pathophysiology of chronic pain in cerebral palsy: implications for pharmacological treatment and research

The high prevalence of chronic pain in individuals with cerebral palsy (CP) across the lifespan has been well documented, as has its negative impact on quality of life. However, without an understanding of the underlying (possibly unique) pathophysiology of pain in CP, identification of more effective management options, such as innovative and individualized pharmacological approaches to non-opioid pain treatment, will be significantly hindered. We review, briefly, what is known about chronic pain in CP and present what we need to know with respect to the neurobiology of pain and new developments in pain treatment research that might be applied to CP.

WHAT THIS PAPER ADDS

Pain conditions in cerebral palsy have differing mechanisms and will not respond to the same treatments. Novel analgesics under development include inhibitors of ion channels, nerve growth factor, and calcitonin gene-related peptide.

Management of Pediatric Movement Disorders: Present and Future

Management of movement disorders in children is an evolving field. This article outlines the major categories of treatment options for pediatric movement disorders and general guidelines for their use. We review the evidence for existing therapies, which continue to lack large-scale controlled trials to guide treatment decisions. The field continues to rely on extrapolations from adult studies and lower quality evidence such as case reports and case series to guide treatment guidelines and consensus statements. Developments in new pharmaceuticals for rare diseases have begun to provide hope for those cases in which a genetic diagnosis can be made. Advances in surgical therapies such as deep brain stimulation as well as new modes of treatment such as gene therapy, epigenetic modulation, and stem cell therapy hold promise for improving outcomes in both primary and secondary causes of movement disorders. There is a critical need for larger, multicenter, controlled clinical trials to fully evaluate treatments for pediatric movement disorders.

Effectiveness of Botulinum Toxin A for Persistent Upper Limb Pain After Breast Cancer Treatment: A Double-Blinded Randomized Controlled Trial

OBJECTIVE

To investigate the effect of a single botulinum toxin A (BTX-A) infiltration in the pectoralis major muscle in addition to a standard physical therapy program for treatment of persistent upper limb pain in breast cancer survivors.

DESIGN

Double-blinded (patient and assessor) randomized controlled trial.

SETTING

A university hospital.

PARTICIPANTS

Breast cancer patients (N=50) with pain.

INTERVENTION

The intervention group received a single BTX-A infiltration. The control group received a placebo (saline) infiltration. Within 1 week after the infiltration, all patients attended an individual physical therapy program (12 sessions) during the first 3 months and a home exercise program up to 6 months after infiltration.

MAIN OUTCOME MEASURES

The primary outcome was change in pain intensity at the upper limb (visual analog scale, 0-100) after 3 months. Secondary outcomes were prevalence rate of pain, pressure hypersensitivity, pain quality, shoulder function, and quality of life. Measures were taken before the intervention and at 1, 3, and 6 months' follow-up.

RESULTS

No significant difference in change in pain intensity after 3 months was found (mean difference in change, 3/100; 95% confidence interval [CI], -13 to 19). From baseline up to 6 months, a significantly different change in upper limb pain intensity was found between groups in favor of the intervention group (mean difference in change, 16/100; 95% CI, 1-31).

CONCLUSIONS

A single BTX-A infiltration in combination with an individual physical therapy program significantly decreased pain intensity at the upper limb in breast cancer survivors up to 6 months. However, the effect size was not clinically relevant, and no other beneficial effects were found.

Factors affecting procedural pain in children during and immediately after intramuscular botulinum toxin injections for spasticity

PURPOSE

To evaluate variables that modulate pain during intramuscular botulinum toxin A injections in children.

METHODS

As part of a Quality Improvement project, this retrospective analysis compared reported pain during and five minutes post injections with patient and procedural variables using subgroup and regression analyses (N= 593 procedures with 249 unique patients).

RESULTS

Mean procedural pain for all procedures (n= 563) was 3.8 ± 3.0. Most children reported no pain (83.8%) or mild pain (12.1%) five minutes after the procedure. Provider, previous patient experience, and dose did not significantly impact pain. Linear regression analysis (R=2 0.64) demonstrated that younger age (p< 0.05), use of vapo-coolant spray or topical anesthetic (p< 0.01), and body region injected (p< 0.01) were significantly associated with increased procedural pain. Logistic regression (R=2 0.14) demonstrated that pain during the procedure (p< 0.001) and older age (p< 0.01) increased the likelihood of pain post-procedure. Utilization of personnel for distraction did not significantly predict pain ratings at either time point.

CONCLUSION

Age, topical anesthesia, and injected region impact procedural pain and in nearly 96% of cases, patients report mild or no pain within five minutes. Additional research into these predictors is necessary, but short-lived procedural pain may suggest that frequent use of sedation/anesthesia is unnecessary.

The extent of intrauterine growth restriction determines the severity of cerebral injury and neurobehavioural deficits in rodents

Background

Cerebral Palsy (CP) is the most common physical pediatric neurodevelopmental disorder and spastic diplegic injury is its most frequent subtype. CP results in substantial neuromotor and cognitive impairments that have significant socioeconomic impact. Despite this, its underlying pathophysiological mechanisms and etiology remain incompletely understood. Furthermore, there is a need for clinically relevant injury models, which a) reflect the heterogeneity of the condition and b) can be used to evaluate new translational therapies. To address these key knowledge gaps, we characterized a chronic placental insufficiency (PI) model, using bilateral uterine artery ligation (BUAL) of dams. This injury model results in intrauterine growth restriction (IUGR) in pups, and animals recapitulate the human phenotype both in terms of neurobehavioural and anatomical deficits.

Methods

Effects of BUAL were studied using luxol fast blue (LFB)/hematoxylin & eosin (H&E) staining, immunohistochemistry, quantitative Magnetic Resonance Imaging (MRI), and Catwalk neurobehavioural tests.

Results

Neuroanatomical analysis revealed regional ventricular enlargement and corpus callosum thinning in IUGR animals, which was correlated with the extent of growth restriction. Olig2 staining revealed reductions in oligodendrocyte density in white and grey matter structures, including the corpus callosum, optic chiasm, and nucleus accumbens. The caudate nucleus, along with other brain structures such as the optic chiasm, internal capsule, septofimbrial and lateral septal nuclei, exhibited reduced size in animals with IUGR. The size of the pretectal nucleus was reduced only in moderately injured animals. MAG/NF200 staining demonstrated reduced myelination and axonal counts in the corpus callosum of IUGR animals. NeuN staining revealed changes in neuronal density in the hippocampus and in the thickness of hippocampal CA2 and CA3 regions. Diffusion weighted imaging (DWI) revealed regional white and grey matter changes at 3 weeks of age. Furthermore, neurobehavioural testing demonstrated neuromotor impairments in animals with IUGR in paw intensities, swing speed, relative print positions, and phase dispersions.

Conclusions

We have characterized a rodent model of IUGR and have demonstrated that the neuroanatomical and neurobehavioural deficits mirror the severity of the IUGR injury. This model has the potential to be applied to examine the pathobiology of and potential therapeutic strategies for IUGR-related brain injury. Thus, this work has potential translational relevance for the study of CP.

AbobotulinumtoxinA: A Review in Pediatric Lower Limb Spasticity

AbobotulinumtoxinA (Dysport^®) is currently the only botulinum toxin A formulation approved by the US FDA for the treatment of lower limb spasticity in pediatric patients aged ≥2 years. Intramuscular abobotulinumtoxinA was approved based on the results of a pivotal phase 3 trial in children with lower limb spasticity due to cerebral palsy. In this trial, a single treatment cycle with abobotulinumtoxinA 10-15 U/kg/leg injected into the gastrocnemius and soleus muscles significantly improved ankle plantar flexor muscle tone (primary endpoint), with abobotulinumtoxinA recipients showing a significant response to treatment relative to placebo. AbobotulinumtoxinA treatment also improved spasticity grade. The improvements in muscle tone and spasticity were associated with an improved ability to attain functional goals. Clinical benefits of abobotulinumtoxinA treatment lasted for 16-22 weeks in most patients, and were maintained with multiple treatment cycles during 1 year in an open-label extension study. AbobotulinumtoxinA was generally well tolerated, with a relatively low incidence of treatment-related adverse events. In summary, abobotulinumtoxinA is an effective and generally well tolerated treatment option for children with lower limb spasticity.

Early Intensive Leg Training to Enhance Walking in Children With Perinatal Stroke: Protocol for a Randomized Controlled Trial

BACKGROUND

Development of motor pathways is modulated by activity in these pathways, when they are maturing (ie, critical period). Perinatal stroke injures motor pathways, including the corticospinal tracts, reducing their activity and impairing motor function. Current intervention for the lower limb emphasizes passive approaches (stretching, braces, botulinum toxin injections). The study hypothesis was that intensive, early, child-initiated activity during the critical period will enhance connectivity of motor pathways to the legs and improve motor function.

OBJECTIVE

The study objective was to determine whether early intervention with intensive activity is better than standard care, intervention delivered during the proposed critical period is better than after, and the outcomes are different when the intervention is delivered by a physical therapist in an institution vs. a parent at home.

DESIGN

A prospective, delay-group, single-blind, randomized controlled trial (RCT) and a parallel, cohort study of children living beyond commuting distance and receiving an intervention delivered by their parent.

SETTING

The RCT intervention was provided in university laboratories, and parent training was provided in the childs home.

PARTICIPANTS

Children 8 months to 3 years old with MRI-confirmed perinatal ischemic stroke and early signs of hemiparesis.

INTERVENTION

Intensive, play-based leg activity with weights for the affected leg and foot, 1 hour/day, 4 days/week for 12 weeks.

MEASUREMENTS

The primary outcome was the Gross Motor Function Measure-66 score. Secondary outcomes were motion analysis of walking, full-day step counts, motor evoked potentials from transcranial magnetic stimulation, and patellar tendon reflexes.

LIMITATIONS

Inter-individual heterogeneity in the severity of the stroke and behavioral differences are substantial but measurable. Differences in intervention delivery and assessment scoring are minimized by standardization and training.

CONCLUSIONS

The intervention, contrary to current practice, could change physical therapy interventions for children with perinatal stroke.

Outcomes of Botulinum Toxin Type A for equinovarus deformity in patients with CVA: A case series

BACKGROUND

There is evidence that Botulinum Toxin-A (BTX-A) reduces focal spasticity associated with equinovarus to improve gait in patients poststroke. However, there is little research examining whether gait improvements are maintained after the effectiveness period of BTX-A injections. The purpose of this observational study was to determine whether there was a difference in gait parameters in three patients before BTX-A injection versus four and ten weeks after.

CASE SERIES

Three women, ages 63, 60, and 42 postischemic stroke with hemiparesis and equinovarus underwent measurements for: plantar flexor spasticity, ankle dorsiflexion ROM, temporal-spatial gait parameters, and gait endurance. All participants improved in ankle ROM. At week 10, spasticity had returned to initial measurement levels in participants A and C. Base of support and step length symmetry ratios did not improve following injections. Participants A and B, who received physical therapy during the study, showed modest gains in gait endurance and velocity.

CONCLUSION

Although BTX-A injections improved spasticity, this improvement did not translate to gait outcomes. Addition of physical therapy interventions appeared to improve gait outcomes in this case series. We suggest future randomized control studies to compare effects of physical therapy alone to BTX-A combined with physical therapy on gait outcomes.

Botulinum Toxin Treatment for Limb Spasticity in Childhood Cerebral Palsy

CP is the most common cause of chronic disability in childhood occurring in 2–2.5/1000 births. It is a severe disorder and a significant number of patients present cognitive delay and difficulty in walking. The use of botulinum toxin (BTX) has become a popular treatment for CP especially for spastic and dystonic muscles while avoiding deformity and pain. Moreover, the combination of physiotherapy, casting, orthotics and injection of BTX may delay or decrease the need for surgical intervention while reserving single-event, multi-level surgery for fixed musculotendinous contractures and bony deformities in older children. This report highlights the utility of BTX in the treatment of cerebral palsy in children. We include techniques for administration, side effects, and possible resistance as well as specific use in the upper and lower limbs muscles.

Botulinum Toxin in the Treatment of Pediatric Upper Limb Spasticity

Botulinum neurotoxin (BoNT) is one of the mainstays in the treatment of pediatric spasticity and dystonia. When considering initiation of BoNT treatment for spasticity, treatment goals and responses to prior conservative measures such as passive range of motion exercises, splinting, and other medication trials should be reviewed. As a general rule, children should be engaged in therapy services around the time of the injections and have a robust home program in place. When managing spasticity in children with BoNT injections, the practitioner should be well versed in functional anatomy with specialized training in injection techniques. Localization techniques in addition to anatomical landmarks are recommended for improved efficacy and include limited electromyography, electrical stimulation, and/or ultrasound guidance. A follow-up visit for the purpose of reassessment during the peak effect of the drug is advised. It is known that BoNT is effective at reducing spasticity and improving range of motion, but it remains to be determined to what degree this translates into improved function, activity, and participation.

Upper extremity spasticity in children with cerebral palsy: a randomized, double-blind, placebo-controlled study of the short-term outcomes of treatment with botulinum A toxin

PURPOSE

Botulinum A toxin (BoNT-A) injections are used widely to manage lower extremity spasticity in children with cerebral palsy. However, their use in the upper extremity is less well defined. This randomized, double-blind, placebo-controlled clinical trial evaluated the safety and efficacy of upper extremity intramuscular injections of BoNT-A in a cross-section of children with varying levels of function.

METHODS

Upper extremity function of study participants (N = 73; M:F = 47:26; age range, 3-18 y) was evaluated using the House Classification system (scores, 0-8, where a higher score indicates higher functional ability). Three groups of children were identified based on their House scores: 0-2 (n = 10), 3-5 (n = 54), and 6-8 (n = 9). Following randomization, children received a BoNT-A or placebo injection at baseline. Injections were administered at 8 and 20 weeks if clinically indicated. Occupational therapists evaluated study participants at screening, at baseline, and at 4, 8, 14, 20, and 26 weeks. Physician evaluations occurred at baseline and at 8, 20, and 26 weeks. The Melbourne Assessment of Unilateral Upper Limb Function evaluated the quality of upper extremity function before and after injections and served as the primary outcome variable.

RESULTS

The majority of study participants underwent 3 injection sessions. Muscles injected were individualized based on each child's particular spasticity pattern. A statistically higher percentage of children receiving BoNT-A injections showed an improvement in the Melbourne assessment at 26 weeks compared with the children receiving placebo. The range, frequency, and severity of postinjection adverse events were similar in both groups.

CONCLUSIONS

Children receiving BoNT-A injections demonstrated clinically meaningful short-term improvements in upper extremity function. Injections were well tolerated and safe. In contrast to other studies, study participants underwent multiple injection sessions based on their individual spasticity patterns.

Botulinum toxin type A treatment in children with cerebral palsy: evaluation of treatment success or failure by means of goal attainment scaling

BACKGROUND

There is considerable variability in the amount of response to BTX-A treatment between and within patients with cerebral palsy (CP).

AIMS

The purpose of this retrospective cohort study was to evaluate the clinical responsiveness of Botulinum toxin type A (BTX-A) treatment in children with CP and specifically delineate features of treatment success and failure.

METHODS

Four hundred and thirty-eight children (251 boys, 187 girls; mean age 8 years 2 months, SD 4 years) were included into the study. Goal Attainment Scaling (GAS) was used to classify and evaluate treatment efficacy. Two study groups were defined: one group with an excellent response (GAS≥60.0) and one group with a lack of response (GAS≤40.0) to BTX-A.

RESULTS

Seventy-five patients (17.1%) had an excellent response and treatment was found to be unsuccessful for 31 patients (7.1%). Children with a lack of response to BTX-A were significantly older compared to children with a high responsiveness (p=0.0013). In the latter group, more children received multi-level injections and fewer children had injections in proximal parts of the lower limb compared to the low responsiveness group (p=0.0024). Moreover, there was a significant difference in the use of different types of casts between both study groups (p=0.0263).

CONCLUSION

Age, level of treatment and casting seem to be crucial features of BTX-A treatment success or failure in children with CP.

Long-lasting paracrine effects of human cord blood cells on damaged neocortex in an animal model of cerebral palsy

Neonatal asphyxia is an important contributor to cerebral palsy (CP), for which there is no effective treatment to date. The administration of human cord blood cells (hUCBCs) is emerging as a therapeutic strategy for the treatment of neurological disorders. However, there are few studies on the application of hUCBCs to the treatment of neonatal ischemia as a model of CP. Experiments and behavioral tests (mainly motor tests) performed on neonatal hypoxia/ischemia have been limited to short-term effects of hUCBCs, but mechanisms of action have not been investigated. We performed a study on the use of hUCBCs in a rat model of neonatal hypoxia/ischemia and investigated the underlying mechanism for therapeutic benefits of hUCBC treatment. hUCBCs were intravenously transplanted into a rat model of neonatal hypoxia ischemia. hUCBCs increased microglia temporarily in the periventricular striatum in the early phase of disease, protected mature neurons in the neocortex from injury, paved the way for the near-normalization of brain damage in the subventricular zone (SVZ), and, in consequence, significantly improved performance in a battery of behavioral tests compared to the vehicle-treated group. Although the transplanted cells were rarely observed in the brain 3 weeks after transplantation, the effects of the improved behavioral functions persisted. Our preclinical findings suggest that the long-lasting positive influence of hUCBCs is derived from paracrine effects of hUCBCs that stimulate recovery in the injured brain and protect against further brain damage.

Effectiveness and safety of botulinum toxin type a in children with musculoskeletal conditions: what is the current state of evidence?

Children with musculoskeletal conditions experience muscle weakness, difficulty walking and limitations in physical activities. Standard treatment includes physiotherapy, casting, and surgery. The use of botulinum toxins appears as a promising treatment on its own, but usually as an adjunct to other treatment modalities and as an alternative to surgery. The objectives were to establish the evidence on the effectiveness, safety and functional outcome of BTX-A in children with musculoskeletal conditions. A literature search using five electronic databases identified 24 studies that met our inclusion criteria. Two randomized clinical trials were included; most studies were case studies with small sample sizes and no control group. Improvements in gait pattern, function, range of motion, reduction of co-contractions, and avoidance of surgical procedures were found following BTX-A injections. Adverse events were not reported in 10 studies, minor adverse events were reported in 13 children and there were no severe adverse events. Additional doses appear safe. BTX-A is a promising treatment adjunct in improving functional outcomes in children with musculoskeletal conditions. Future studies including larger samples, longer follow-up periods and a comparison group are required to provide evidence on the effectiveness and safety of this drug in children with musculoskeletal conditions.

Botulinum toxin A (Dysport®): in dystonias and focal spasticity

Dysport®, a formulation of botulinum toxin A, blocks acetylcholine release at neuromuscular junctions causing denervation and temporary muscle paralysis. It is used to treat several medical conditions, including dystonias and focal spasticity. Subcutaneous Dysport® was effective in improving functional disability in adults with blepharospasm in a placebo-controlled trial with 16 weeks' follow-up, and in adults with hemifacial spasm in case series. Similarly, intramuscular Dysport® was effective in improving symptoms of cervical dystonia in adults, focal spasticity in adults with post-stroke upper limb spasticity and dynamic equinus spasticity in paediatric patients with cerebral palsy in placebo-controlled trials with up to 20 weeks' follow-up. However, in two 12-week, placebo-controlled trials in adults with focal lower limb spasticity (spastic equinovarus deformity after stroke and hip adductor spasticity associated with multiple sclerosis) intramuscular Dysport® had limited efficacy. Available longer-term data indicated that Dysport® treatment was effective over several treatment cycles in patients with cervical dystonia or upper limb spasticity. Dysport® was generally well tolerated in patients with dystonias or focal spasticity. Most adverse events were mild to moderate and transient.

Dose- and volume dependent-response to intramuscular injection of botulinum neurotoxin-A optimizes muscle force decrement in mice

Botulinum neurotoxin-A (BoNTA) is a potent neurotoxin used to alter muscle tone to manage spasticity and to provide tendon bioprotection; however, the appropriate dose and injection volume to administer is not defined. Male mice (n = 120) received BoNTA injections into one gastrocnemius with either a constant volume (10 µl) with a variable dose (1, 3, 6 U/kg) or a constant dose (3 U/kg) in a variable volume (2.5, 5, 10, 20, 30 µl). Electromyographic (EMG) examination, muscle force generation (MFG), and wet muscle mass were measured in the ipsilateral and contralateral limbs at 1, 2, 4, or 12 weeks post-injection. MFG and EMG responses decreased to approximately 40% of contralateral after a 1 U/kg injection and 0% of contralateral by 3 and 6 U/kg injection at 1 week after injection. Neuromuscular blockade was greatest with a 10 µl injection volume. MFG, EMG examination, and wet muscle mass reached contralateral values 12 weeks after injection for all injection doses and volumes tested. Effective injection doses and volumes were identified for producing full and partial neuromuscular blockade in the mouse gastrocnemius. These findings have important clinical implications in the intramuscular administration of BoNTA to manage muscle tone.

Botulinum toxin assessment, intervention and follow-up for paediatric upper limb hypertonicity: international consensus statement

The primary objective of this paper was to evaluate the published evidence of efficacy and safety of botulinum neurotoxin (BoNT) injections in paediatric upper limb hypertonia (PULH). Secondary objectives included the provision of clinical context, based on evidence and expert opinion, in the areas of assessment, child and muscle selection, dosing, and adjunctive treatment. A multidisciplinary panel of authors systematically reviewed, abstracted, and classified relevant literature. Recommendations were based on the American Academy of Neurology (AAN) evidence classification. Following a literature search, 186 potential articles were screened for inclusion, and 15 of these met the criteria and were reviewed. Grade A evidence was found to support the use of BoNT to reach individualized therapeutic goals for PULH. There is grade B evidence (probably effective) for tone reduction following BoNT injections and grade U evidence (inconclusive) for improvement in upper limb (UL) activity and function. BoNT injections were generally found to be safe and well tolerated with the most common side effect identified as a transient decrease in grip strength.

Children with cerebral palsy: a systematic review and meta-analysis on gait and electrical stimulation

Objective: To conduct a systematic review and meta-analysis using the International Classification of Functioning to determine the summary effect of electrical stimulation on impairment and activity limitations relevant to gait problems of children with cerebral palsy.

Methods: We identified 40 cerebral palsy and electrical stimulation studies, and 17 gait studies qualified for inclusion. Applying enablement classification methods to walking abnormalities created two subgroups: impairment (N = 14) and activity limitations (N = 15). Overall, 238 participants experienced electrical stimulation treatments and 224 served as a no stimulation control group. Calculations followed conventional data extraction and meta-analysis techniques: (a) individual standardized mean differences, (b) summary effect size, (c) I 2heterogeneity test, (d) fail-safe N analysis and (e) moderator variable analyses.

Results: Common outcome measures associated with impairment (n = 3) and activity limitations (n = 6) were submitted to separate random effects models meta-analyses, and revealed significant cumulative effect sizes: (a) impairment = 0.616 (SE = 0.10) and (b) activity limitations = 0.635 (SE = 0.14). I 2indicated low and medium amounts of dispersion, whereas fail-safe analyses revealed high N-values for both disablement categories. Moderator variable analyses further confirmed the positive treatment effects from both functional and neuromuscular stimulation.

Conclusions: The present systematic review and meta-analyses determined medium effect sizes for electrical stimulation on walking impairment and activity limitations of children with cerebral palsy.

Long-term use of botulinum toxin type A in children with cerebral palsy: treatment consistency

At the University Hospital of Pellenberg (Belgium), more than 1000 patients have been treated with Botulinum toxin type A (BTX-A) over the last decade. Ten percent of these patients (n=106) received multiple (at least four times), multi-level, high-dosage treatments. The aim of this study was to evaluate the stability of dosage and treatment intervals in long-term, multi-level, high-dosage treated children with cerebral palsy and to evaluate the evidence for a safe and stable response to this treatment. Data on disease, age, dosage and target muscles were extracted for each treatment session of 106 patients who received multiple BTX-A treatment sessions. Patients had a follow-up of 4y 6mo (range 1y 8mo-8y 9mo) on average and received 4 to 12 BTX-A treatments within the period of January 1996 and December 2005. Patients received a mean dosage of 23.5+/-5.2U/kgbw at first treatment with stable subsequent values. Mean dosages for children with diplegia, hemiplegia and quadriplegia were 24.5+/-4.7U/kgbw, 15.9+/-3.7U/kgbw and 22.0+/-4.8U/kgbw, respectively. Mean age at first treatment was 4y 6mo (range 1y 11mo-18y 10mo) with a majority of patients (76.4%) first treated within 2 and 4y of age. Treatment intervals of approximately 1y remained stable within four, five and six subsequent treatments. Long-term, high-dosage, multi-level BTX-A applications can be considered as a safe and stable treatment option for children with cerebral palsy and the formation of antibodies, responsible for secondary non-response, can be indirectly precluded.

New clinical and research trends in lower extremity management for ambulatory children with cerebral palsy

Cerebral palsy (CP) is the most prevalent physical disability in childhood and includes a group of disorders with varying manifestations. This article focuses on current and future intervention strategies for improving mobility and participation during the lifespan for ambulatory children with CP. The provision and integration of physical therapy and medical and orthopedic surgery management focused primarily on the lower extremities are discussed here. Some of the newer trends are more intense and task-related exercise strategies, greater precision in tone identification and management, and a shift towards musculoskeletal surgery that focuses more on promoting dynamic bony alignment and less on releasing or lengthening tendons. Advances in basic and clinical science and technology development are changing existing paradigms and offering renewed hope for improved functioning for children with CP who face a lifelong disability with unique challenges at each stage in life.

Increasing physical function through physiatric intervention for children with paediatric neurotransmitter disorders

Most children with paediatric neurotransmitter diseases have global functional deficits secondary to central nervous system damage. Paediatric physiatrists, working in conjunction with a multi-disciplinary team, help to improve physical function by normalizing muscle tone and improving body position. Components of spasticity, rigidity, and dystonia may all need to be considered in a comprehensive treatment programme. Complications of disordered tone include skin breakdown, pain, sleep disturbance, and dysphagia. With an integrated approach to use of medications and equipment as well as implementation of therapy and therapeutic exercise, physiatrists can help maximize functional independence for children with this group of disorders. Pharmacological treatment includes GABA-agonists including baclofen and benzodiazepines, alpha-2 adrenergic agonists, L: -dopa and dopaminergic agents, and dantrolene. Intrathecal baclofen may be used in patients refractory to these medications. In addition, physicians may utilize botulinum toxin, phenol, or surgical interventions such as selective dorsal rhizotomy or tendon lengthening. Pharmacological treatment must be used in conjunction with appropriate adaptive equipment in order to maximize therapeutic benefit. Focus on function in an attempt to increase independence is targeted to improve the child's quality of life. We present a framework and rationale to the management of the functional consequences of the paediatric neurotransmitter diseases.

A randomized controlled trial to compare two botulinum toxin injection techniques on the functional improvement of the leg of children with cerebral palsy

OBJECTIVE

To compare the efficacy of botulinum toxin type A injection guided by different localizing techniques, electrical stimulation and palpation, to treat spasticity of the ankle plantar flexors.

DESIGN

Randomized controlled trial.

SETTING

Hospital neurology and rehabilitation department.

PARTICIPANTS

Sixty-five children with spastic hemiplegic or diplegic cerebral palsy.

INTERVENTIONS

Botulinum toxin injection guided by electrical stimulation or palpation, and two weeks of physiotherapy.

MAIN OUTCOME MEASURES

Passive range of movement (ROM), modified Ashworth Scale, Composite Spasticity Scale, D and E dimensions of the Gross Motor Function Measure, walking velocity.

RESULTS

Three groups improved significantly (P<50.05). The mean improvements between baseline and the end of follow-up were respectively 20, 16.2 and 11.9 degrees for passive ROM, -1.9, -1.4 and -0.7 for modified Ashworth Scale scores, -5.8, -4.2 and -2.3 for Composite Spasticity Scale scores, 18.6, 11.3 and 6.9 for Gross Motor Function Measure scores, and 0.2, 0.1 and 0.1 m/s for walking velocity in the botulinum toxin group guided by electrical stimulation injection plus physiotherapy, the botulinum toxin group guided by palpation injection plus physiotherapy, and the physiotherapy only group. The botulinum toxin injection guided by electrical stimulation group showed greater improvement in passive ROM (P<50.05), modified Ashworth Scale scores (P<50.05), Composite Spasticity Scale scores (P<50.05), and Gross Motor Function Measure scores (P<50.05) than the other two groups after treatment for three months.

CONCLUSIONS

Botulinum toxin injection guided by electrical stimulation plus physiotherapy is likely to be best in improving spasticity and functional performance in children with cerebral palsy.

Effectiveness of sedation using nitrous oxide compared with enteral midazolam for botulinum toxin A injections in children

This randomized, double-blind, placebo-controlled study compared the efficacy of inhaled nitrous oxide (N(2)O) with enteral midazolam for sedation of children with cerebral palsy (CP) undergoing botulinum toxin A (BoNT-A) injections. Fifty children (29 males, 21 females; mean age 8y 2mo [SD 4y 5mo]; range 1-16y) were randomized to sedation with N(2)O (n=25) or midazolam (n=25). Groups were similar in type of CP (diplegia, 11; triplegia, three; quadriplegia, 16; hemiplegia, 16; other, three) and Gross Motor Function Classification System level (Level I, 4; II, 24; III, 4; IV, 13; V, 5). Both groups were equally sedated at time of injection (p=0.661), but those in the midazolam group were more sedated at time of discharge (p<0.001). N(2)O was more effective in reducing pain compared with midazolam as measured using the Face, Legs, Activity, Cry, Consolability (FLACC) scale (p=0.010), parental estimate of pain (p=0.009), and nursing estimate of pain (p=0.007). Parents in the N(2)O group rated it better than prior sedation with midazolam for BoNT-A injections (p=0.031). Physicians and nurses reported no difference in ease of procedure between the groups. One child in the midazolam group and eight in the N(2)O group had adverse effects, all of which resolved promptly. N(2)O appears to be an effective means of sedation for children undergoing outpatient BoNT-A injections.

Botulinum toxin use as an adjunctive modality in a patient with multiple flexor tendon ruptures

Botulinum toxin A has been described in treatment protocols for several disease processes, from primary axillary hyperhydorosis to esophageal dysfunction. It is best known for its use in plastic and dermatological practices. Botulinum toxin has a straightforward mechanism of action. The toxin inhibits acetylcholine release at the neuromuscular junction causing a chemical denervation, which ceases contractions of the muscle. With its minimal side effect profile, botulinum toxin should be considered when muscle spasm is a detriment. This case involves an injury to the hand of a patient with a history of intermittent diffuse muscle spasms. Subsequently, due to the patient's previous upper extremity muscle spasms, repeated flexor tendon repair ruptures of the index finger occurred until botulinum toxin was administered to the offending muscle. The patient has not required any additional surgical interventions for the repaired tendon and is now actively flexing all digits. This case report demonstrates how botulinum toxin can be used in a clinical scenario when decreased muscle activity is desired to promote tendon healing.