A randomized study of combined botulinum toxin type A and casting in the ambulant child with cerebral palsy using objective outcome measures

Desloovere, Kaat; Molenaers, Guy; Jonkers, Ilse; Cat, Josse De; Borre, L De; Nijs, J; Eyssen, M; Pauwels, Paul; Cock, Paul De

doi:10.1046/j.1468-1331.2001.00040.x

Cited by 124 publications

(117 citation statements)

References 23 publications

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“…We believe that the prolonged positive effect of BoNT/A -until the end of the study in some cases -is also related to the results of physiotherapy 11,17 . Thus, BoNT/A should not be considered a substitute for physiotherapy or orthoses, but rather an additional therapeutic strategy 10,18 . Better biomechanical alignment through muscular relaxation, such as improved range of motion of the ankle, allows the patient to adapt better to orthoses 10,11 .…”

Section: Discussionmentioning

confidence: 99%

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

Camargo

Teive

Zonta

et al. 2009

Arq. Neuro-Psiquiatr.

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-We evaluated the safety and effectiveness of botulinum toxin A (BoNT/A) in the treatment of spasticity in 20 children with spastic diplegic cerebral palsy (CP). All the patients received injections in the gastrocnemius and soleus, and 15 received injections in the adductors. The total dose varied from 70 to 140 U (99.75±16.26 U), or 7.45±2.06 U/kg per patient. The treatment improved the patients' walking and gait pattern significantly. There was also a significant alteration in the heel-ground distance and increased motion of the ankle joint. These structural changes in the feet were sustained until the end of the follow-up, although the same was not observed for the functional parameters. Three patients complained of weakness in the lower limbs. In conclusion, BoNT/A is safe and effective when used in a single session of injections and produces a sustained structural modification of the lower limbs. However, functional changes are temporary and are only observed during the peak effect of the drug.Key Words: cerebral palsy, botulinum toxin, spasticity. Toxina botulínica tipo A como tratamento para espasticidade de membros inferiores em crianças com paralisia cerebralResumo -Para avaliação da segurança e eficácia do tratamento com toxina botulínica A (TB-A) na espasticidade na paralisia cerebral (PC), foram selecionadas 20 crianças com a forma diplegia espástica. Todos os pacientes receberam injeções nos gastrocnêmios e sóleos, 15 receberam doses nos adutores da coxa. A dose total variou de 70 a 140 Us (99,75±16,26 U), 7,45±2,06 U/Kg por paciente. o tratamento com a TB-A melhorou significativamente a deambulação e o padrão de marcha. Houve também significativa alteração da distância tornozelo-solo e aumento da amplitude de movimento da articulação do tornozelo. essas mudanças estruturais dos pés se mantiveram até o final do acompanhamento. o mesmo não foi observado com parâmetros funcionais. Três pacientes apresentaram fraqueza em membros inferiores. Conclui-se que a TB-A, em uma única aplicação, é segura e eficaz. Há modificação sustentada da estrutura motora dos membros inferiores, porém mudanças funcionais são temporárias, durante o pico de ação do medicamento.PAlAvrAs-CHAve: paralisia cerebral, espasticidade, toxina botulínica.

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Section: Discussionmentioning

confidence: 99%

“…It has been stressed recently that assessment of functional improvement is more important than assessment of the reduction in muscle tonus or the increase in the range of motion of the joint 10,18 . The physiological and mechanical effects of BoNT/A treatment are genuine and measurable in patients with spastic diplegia.…”

Section: Discussionmentioning

confidence: 99%

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

Camargo

Teive

Zonta

et al. 2009

Arq. Neuro-Psiquiatr.

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“…However, widespread use support the safety of high-dosage BTX-A treatments in children with CP, as the total dose is distributed over multiple muscles and over multiple injection sites per muscle [11,12,41,45]. Significant unwanted adverse effects are rare [11,36,46,47].…”

Section: Appropriate Dosagementioning

confidence: 99%

“…Children that were treated with BTX-A injections combined with casting showed an improved second-ankle rocker and longer-lasting effects as compared to children that were treated without casting. From a prospective study, Desloovere et al [41] concluded that more benefits, mainly in the proximal joints, were seen for the children who were casted after injections as compared to the children who were casted before injections.…”

Section: Castingmentioning

confidence: 99%

The use of botulinum toxin A in children with cerebral palsy, with a focus on the lower limb

Molenaers

Campenhout

Fagard³

et al. 2010

Journal of Children's Orthopaedics

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Purpose The purpose of this review is to clarify the role of botulinum toxin serotype A (BTX-A) in the treatment of children with cerebral palsy (CP), with a special focus on the lower limb. Background The treatment of spasticity is central in the clinical management of children with CP. BTX-A blocks the release of acetylcholine at the motor end plate, causing a temporary muscular denervation and, in an indirect way, a reduced spasticity. Children with increased tone develop secondary problems over time, such as muscle contractures and bony deformities, which impair their function and which need orthopaedic surgery. However in these younger children, delaying surgery is crucial because the results of early surgical interventions are less predictable and have a higher risk of failure and relapse. As BTX-A treatment reduces tone in a selective way, it allows a better motor control and muscle balance across joints, resulting in an improved range of motion and potential to strengthen antagonist muscles, when started at a young age. The effects are even more obvious when the correct BTX-A application is combined with other conservative therapies, such as physiotherapy, orthotic management and casts. There is now clear evidence that the consequences of persistent increased muscle tone can be limited by applying an integrated multi-level BTX-A treatment approach. Nevertheless, important challenges such as patient selection, defining appropriate individual goals, timing, dosing and dilution, accuracy of injection technique and how to measure outcomes will be questioned. Therefore, ''reflection is more important than injection'' remains an actual statement.

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“…4,7,9,11,14 In most studies, injections were given in the ankle flexors (gastrocnemius and soleus muscles), although authors of one study investigated the effect of BTA injections in multiple sites. 9 In two studies, outcomes were compared for placement of serial casts and BTA injections as separate treatments.…”

Section: Serial Casts and Btamentioning

confidence: 99%

The use of botulinum toxin therapy for lower-extremity spasticity in children with cerebral palsy

Criswell¹,

Crowner²,

Racette³

2006

Neurosurgical Focus

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✓ Hypertonicity is a leading cause of disability for children with cerebral palsy (CP). Botulinum toxin A (BTA) chemically denervates muscle tissue and is commonly used in the management of lower-extremity hypertonicity in children with CP because of its focal effects and wide safety margin. Randomized controlled trials have demonstrated that BTA injections in the ankle flexors, hamstrings, and adductors reduce spasticity and result in improved passive and active range of motion. In other studies, improvements in gait and measurements of functional outcome were found in appropriately selected children who had been injected with BTA. A multidisciplinary treatment approach that includes physical therapists, occupational therapists, orthotists, neurologists, physicians with expertise in performing botulinum toxin injections, orthopedic surgeons, and neurosurgeons is critical to optimize care in children with lower-extremity tone due to CP. In this paper, the authors propose treatment algorithms based on clinical presentation, detailed dosing, and technical information to optimize the treatment of these children. With a multidisciplinary approach, children with lower-extremity hypertonicity due to CP can experience improvements in muscle tone and function.

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A randomized study of combined botulinum toxin type A and casting in the ambulant child with cerebral palsy using objective outcome measures

Cited by 124 publications

References 23 publications

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

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

The use of botulinum toxin A in children with cerebral palsy, with a focus on the lower limb

The use of botulinum toxin therapy for lower-extremity spasticity in children with cerebral palsy

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