Botulinum toxin A and upper limb functional skills in hemiparetic cerebral palsy: a randomized trial in children receiving intensive therapy

Abstract

The objective of this study was to determine whether the use of intramuscular botulinum toxin A (BTX‐A) increases upper limb function and skills in the context of a specific therapy programme in children with hemiparetic cerebral palsy. Twenty children (nine females, 11 males) aged 4 to 16 years who were thought likely to benefit from BTX‐A treatment were included. After matched pairs were made, on the basis of Zancolli grade and age, randomization took place. All patients were given structured rehabilitation (physiotherapy and occupational therapy three times a week for 6 months), and half of the patients received intramuscular BTX‐A. No placebo injections were given in the control group. Participants were assessed at baseline, at 2 and 6 weeks, and at 3, 6, and 9 months after injection. The Ash worth scale, active range of motion of arm joints, the Melbourne assessment of upper limb function, the Pediatric Evaluation of Disability Inventory, and the nine‐hole peg test were used for outcome measurement. Observers were blinded for treatment allocation only for scoring the Melbourne test. The children in the treatment group showed a clinically relevant increase in active dorsal flexion, and tone reduction of the wrist. For the functional outcome measures, no statistically significant differences between the groups could be demonstrated. Intramuscular BTX‐A added to an intensive therapy programme reduces impairment for at least 9 months; the effect on activity level is still uncertain.

Efficacy of Upper Limb Therapies for Unilateral Cerebral Palsy: A Meta-analysis

“…[14][15][16][17][18][19][20]24 This finding reinforces that activity-based therapy focusing on goals identified as important by children and their caregivers is an integral aspect of UL intervention.…”

“…16,17,20,22 Total doses of therapy ranged from 4 to 78 hours. 15,19,24 Higher intensities and dosage of intervention were reported in studies of cCIMT, mCIMT, HABIT, and hybrid therapy. Short-duration, highintensity programs ranged from 2 to 3 weeks' duration providing 6 hours of daily therapy, with totals of 60 to 126 hours.…”

“…Data from 6 studies (9 publications) were not included in meta-analyses. One study reported median scores, 15 6 did not present summary statistics of central tendency and variability, 21,22,25,28,38,56 and 2 reported change scores with or without SDs. 41,55 For quantitative comparison of outcomes, data were available to pool across trials and 2 main comparisons were performed: (1) BoNT-A and OT versus OTalone and (2) cCIMT or mCIMT versus (a) a control group or therapy group receiving a lesser dosage of therapy or (b) a comparison group receiving an equivalent dosage of an alternative intervention.…”

“…OT after UL injections of BoNT-A ranged from 1 session per fortnight 14 to 3 times per week 15,24 for a minimum of 4 weeks 19 to a maximum of 6 months. 15,24 Home programs were provided in 4 studies, with minimal detail. 16,17,20,22 Total doses of therapy ranged from 4 to 78 hours.…”

“…Thirteen types of UL interventions and numbers of participants were identified: NDT (2 studies; n = 122), 12,13 intramuscular injections of BoNT-A and OT (11 studies; n = 322), [14][15][16][17][18][19][20][21][22][23][24] cCIMT (3 studies; n = 56), 6,[25][26][27][28] mCIMT (15 studies; n = 578), 7,[29][30][31][32][33][34][35][36][37][38][39][40][41][42][43][44][45][46][47] hybrid model (mCIMT and bimanual training; 2 studies; n = 68), 8,9 forced-use therapy (2 studies; n = 54), 48,49 HABIT (1 study; n = 20), 50 OT home programs (1 study; n = 35), 51 UL lycra splints (1 study; n = 16), 52 contextfocused therapy (1 study; n = 128), 53 mirror box therapy (1 study; n = 10), 54 acupuncture combined with OT (1 study; n = 75), …”