No abstract

SUMMARY The role of intramuscular botulinum toxin A in the treatment of 26 children with cerebral palsy was evaluated. The indication for injection was the presence of a dynamic contracture of lower‐limb muscles interfering with positioning or walking. Spastic target muscles were identified by clinical examination and, in ambulant children, by gait analysis. Between 50 and 320 units of botulinum toxin were injected into each muscle group to a total dose of 100 to 400 units per child. The effects of injection were monitored by repeated clinical examination and gait analysis. There were no clinically detectable systemic side‐effects, and all but one patient had a reduction in tone, which occurred within three days and persisted for two to four months. There were significant improvements in ambulatory status and in sagittal‐plane kinematics. In some cases these gains persisted after the tone‐reducing effects of the toxin had worn off. RÉSUMÉ La toxine boiulinique dans le iraiiemenl de ľIMC au niveau des membres inférieurs Ľaction dc la toxine botulinique A en intramusculaire a étéévaluée chez 26 enfants IMC. Ľindication de ľinjection était la presence de contractions dynamiques des muscles du membre inférieur perturbant la station‐locomotion. Les cibles musculaires spastiques furent identifiées par ľexamen clinique et par ľanalyse de la démarche chez les enfants marchant. Entre 50 et 320 unités de toxine botulinique ont été injectées dans chaque groupe musculaire avec une dose totale de 100 a 400 unités par enfant. Les effets de ľinjection ont été contrôlés par des examens cliniques répétés et une analyse de la demarche. II n'a été découvert cliniquement aucun effet secondaire, et chez tous les patients sauf un, il a été observe une diminution du tonus, survenant au bout de trois jours et durant de deux à quatre mois. II fut noté des améliorations significatives dans ľallure de la démarche et dans la cinematique du plan sagittal. Dans quelques cas, les améliorations ont persiste alors même que les effets de réduction de tonus de la toxine avaient disparu. ZUSAMMENFASSUNG Botulinum Toxin zur Behandlung der unteren Extremitát bei Cerebralparese Bei 26 Kindern mit Cerebralparese wurde die Wirkung von intramuskulär injiziertem Botulinum Toxin A untersucht. Die Indikation fúr die Injektion war eine dynamische Kontraktur der Beinmuskeln, wodurch Lagerung oder Laufen beeinträchtigt waren. Die spastischen Zielmuskeln wurden durch klinische Untersuchungen und bei gehfähigen Patienten durch Ganganalysen identifiziert. In jede Muskelgruppe wurden 50 bis 320 E Botulinum Toxin injiziert, bis zu einer Gesamtdosis von 100 bis 400 E pro Kind. Die Wirkung der Injektionen wurde durch wiederholte klinische Untersuchungen und Ganganalysen überwacht. Es fanden sich keine klinisch manifesten Nebenwirkungen und bei alien Patienten, außer einem, konnte eine Tonusverminderung festgestellt werden, die innerhalß von drei Tagen auftrat und zwei bis vier Monate anhielt. Es fanden sich signifikante Besserungen der Gehfähigkeit und der sagittale...

This study evaluated the efficacy and safety of three doses of botulinum toxin A (BTX-A; Dysport) in 125 patients (mean age 5.2 years, SD 2; 54% male)with dynamic equinus spasticity during walking. Participants were randomized to receive Dysport (10, 20, or 30 units/kg) or placebo to the gastrocnemius muscle of both legs. Muscle length was calculated from electrogoniometric measurements and the change in the dynamic component of gastrocnemius shortening at four weeks was prospectively identified as the primary outcome measure. All treatment groups showed statistically significant decreases in dynamic component compared with placebo at 4 weeks. Mean improvement in dynamic component was most pronounced in the 20 units/kg group, being equivalent to an increase in dorsiflexion with the knee extended at 19 degrees, and was still present at 16 weeks. The safety profile of the toxin appears satisfactory.

Thirty-nine ambulant children (22 with hemiplegia, 17 with diplegia) with spastic cerebral palsy receiving isolated gastrocnemius muscle injection with botulinum toxin A were studied prospectively. The children had a mean age of 6 years (range 3 to 13 years). Measurement of gastrocnemius muscle length was used to estimate the dynamic component of each child's spasticity and to quantify the response. There was a strong correlation between the dynamic component of spasticity before injection and the corresponding magnitude of the response after injection. Children undergoing repeated injections showed similar correlations. A strong correlation was found between the duration of response and the dynamic component. Children with hemiplegia showed twice the duration for a given dynamic component compared with those with diplegia when injected with the same total dose per unit body weight. Long-term lengthening did not occur for the cohort, although some patients showed a response at a 12-month follow-up. By delaying shortening, the injections may have a role in delaying the need for surgery. Injections were well tolerated with few side effects.

Botulinum toxin A (BTX-A) is widely used in the management of muscle spasticity in children. However, at present the dose of BTX-A for a given patient is selected empirically. The aim of this study is to provide dosage guidelines that are based on risk/benefit assessment. This was a multicentre retrospective study of the safety profile and efficacy of BTX-A in children with chronic muscle spasticity. Data in 758 patients who received a total of 1594 treatments were analysed (mean age 7.2 years; 429 males, 329 females). Spastic cerebral palsy (CP) was the most common diagnosis (94% of the study sample). Of all treatments 7% resulted in adverse events; incidence was related to the total dose rather than the dose calculated on the basis of body weight. The highest incidence of adverse events was observed in patients who received >1000 IU of BTX-A per treatment session. The odds of an adverse event was 5.1 times greater for this group of patients than for those who had 250 IU or less (p<0.001). A good overall response to treatment was reported in 82% and treatment goals were fully or partially achieved in 3% and 94% of participants respectively. More patients in the highest dose group reported functional deterioration. Interestingly, multilevel treatments resulted in a better response than single-level treatments (odds ratio 1.7, 95% CI 1.3 to 2.2,p=0.001).