Botulinum Toxin A in the Management of Spastic Gait Disorders in Children and Young Adults with Cerebral Palsy: A Randomized, Double-Blind Study of "High-Dose" versus "Low-Dose" Treatment*

Wissel, J.; Heinen, Florian; Schenkel, A.; Doll, B.; Ebersbach, Georg; Müller, Jörg; Poewe, Werner

doi:10.1055/s-2007-973475

Cited by 114 publications

(65 citation statements)

References 1 publication

(1 reference statement)

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“…The optimal timing is often reported to be between 2 and 6 years of age [27,62,85]. Older children usually benefit from a more targeted treatment approach.…”

Section: Orthotic Managementmentioning

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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“…The optimal timing is often reported to be between 2 and 6 years of age [27,62,85]. Older children usually benefit from a more targeted treatment approach.…”

Section: Orthotic Managementmentioning

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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“…4,19,38 There have been no randomized controlled trials in which the effects of BTA were evaluated after isolated hamstring injections. However, Wissel and colleagues 40 found a significant mean increase in knee ROM (passive 15˚, active 20˚) after BTA injections in multiple muscle groups, including the hamstrings, hip adductors, and ankle flexors. Mall, et al, 23 performed a double-blind randomized controlled trial of combined BTA injections in the hamstrings and hip adductors of 61 children with CP (39 with leg-dominant tetraparesis and 22 with tetraparesis).…”

Section: Range Of Motionmentioning

confidence: 98%

“…2,32,40 Baker and colleagues 2 injected BTA into the ankle flexors of 125 children with dynamic equinus spasticity. They found a statistically significant increase in active ROM in all treatment groups (10, 20, or 30 U/kg Dysport) when compared with placebo groups.…”

Section: Range Of Motionmentioning

confidence: 99%

“…Multiple randomized controlled trials have demonstrated reduced modified Ashworth Scale scores after injection of BTA in ankle flexors, hamstrings, and hip adductors. 3,11,29,32,40 Typically, modified Ashworth Scale scores were reduced by 1 to 2 points from baseline following injection. In most studies the modified Ashworth Scale scores remained below baseline for up to 3 to 4 months after injection, but in one study the scores remained lower for up to 6 months following injection.…”

Section: Effect Of Bta On Spasticitymentioning

confidence: 99%

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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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“…More recently Bakheit and coworkers (2001) suggested that doses of up to 1000 units/kg do not increase susceptibility to adverse events but were not able to make any definitive conclusions about efficacy. Only one published study (Wissel et al 1999) has investigated the effects of different doses of BTX-A, but this study was not placebo controlled.…”

mentioning

confidence: 99%

Botulinum toxin treatment of spasticity in diplegic cerebral palsy: a randomized, double‐blind, placebo‐controlled, dose‐ranging study

Baker

Jasiński

Maciąg-Tymecka³

et al. 2002

Develop Med Child Neuro

121

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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 1920, and was still present at 16 weeks. The safety profile of the toxin appears satisfactory.

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Botulinum Toxin A in the Management of Spastic Gait Disorders in Children and Young Adults with Cerebral Palsy: A Randomized, Double-Blind Study of "High-Dose" versus "Low-Dose" Treatment*

Cited by 114 publications

References 1 publication

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

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

Botulinum toxin treatment of spasticity in diplegic cerebral palsy: a randomized, double‐blind, placebo‐controlled, dose‐ranging study

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