Changes in spastic muscle stiffness after botulinum toxin A injections as part of rehabilitation therapy in patients with spastic cerebral palsy

Boyacı, Ahmet; Tutoğlu, Ahmet; Boyacı, Nurefşan; Koca, İrfan; Çalık, Mustafa; Şakalar, Ali; Kilicaslan, Nihat

doi:10.3233/nre-141107

Cited by 21 publications

(25 citation statements)

References 28 publications

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“…Nevertheless, it is assumed that when hyperactive stretch reflexes are reduced, the muscle will experience more of the tensile stimulus applied by an adjunctive stretching intervention. There is limited evidence that BoNT-A combined with rehabilitation is effective in altering muscle structure or preventing contracture (Boyaci et al, 2014), even though there are indications of short term improvement in joint ROM, gait and function, as measured by the goal attainment scale (Molenaers et al, 2013;Novak et al, 2013). Specifically, promising results have been observed in functional improvements, as measured by the Goal Attainment Scale, after combining BoNT-A with different kinds of stretching therapies (Molenaers et al, 2013).…”

Section: Botulinum Toxin-a and Stretchingmentioning

confidence: 99%

Stretching Interventions in Children With Cerebral Palsy: Why Are They Ineffective in Improving Muscle Function and How Can We Better Their Outcome?

et al. 2020

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Hyper-resistance at the joint is one of the most common symptoms in children with cerebral palsy (CP). Alterations to the structure and mechanical properties of the musculoskeletal system, such as a decreased muscle length and an increased joint stiffness are typically managed conservatively, by means of physiotherapy involving stretching exercises. However, the effectiveness of stretching-based interventions for improving function is poor. This may be due to the behavior of a spastic muscle during stretch, which is poorly understood. The main aim of this paper is to provide a mechanistic explanation as to why the effectiveness of stretching is limited in children with CP and consider clinically relevant means by which this shortcoming can be tackled. To do this, we review the current literature regarding muscle and tendon plasticity in response to stretching in children with CP. First, we discuss how muscle and tendon interact based on their morphology and mechanical properties to provide a certain range of motion at the joint. We then consider the effect of traditional stretching exercises on these muscle and tendon properties. Finally, we examine possible strategies to increase the effectiveness of stretching therapies and we highlight areas of further research that have the potential to improve the outcome of non-invasive interventions in children with cerebral palsy.

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Section: Botulinum Toxin-a and Stretchingmentioning

confidence: 99%

Stretching Interventions in Children With Cerebral Palsy: Why Are They Ineffective in Improving Muscle Function and How Can We Better Their Outcome?

et al. 2020

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“…The rational of this treatment combination is that paralysis, followed by passive immobilization in a neutral position, results in tissue elongation through physiological adaptation to prolonged stretch. However, few clinical studies reported the effects of BoNT-A treatment at the muscle level (10)(11)(12)(13)(14)(15)(16)(17)(18). Synthesis of existing clinical studies that include post-treatment assessment of muscle morphology is hindered by methodological differences between studies and lack of normalization to account for natural muscle growth.…”

Section: Introductionmentioning

confidence: 99%

Joint and Muscle Assessments of the Separate Effects of Botulinum NeuroToxin-A and Lower-Leg Casting in Children With Cerebral Palsy

et al. 2020

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Botulinum NeuroToxin-A (BoNT-A) injections to the medial gastrocnemius (MG) and lower-leg casts are commonly combined to treat ankle equinus in children with spastic cerebral palsy (CP). However, the decomposed treatment effects on muscle or tendon structure, stretch reflexes, and joint are unknown. In this study, BoNT-A injections to the MG and casting of the lower legs were applied separately to gain insight into the working mechanisms of the isolated treatments on joint, muscle, and tendon levels. Thirty-one children with spastic CP (GMFCS I-III, age 7.4 ± 2.6 years) received either two weeks of lower-leg casts or MG BoNT-A injections. During full range of motion slow and fast passive ankle rotations, joint resistance and MG stretch reflexes were measured. MG muscle and tendon lengths were assessed at resting and at maximum dorsiflexion ankle angles using 3D-freehand ultrasound. Treatment effects were compared using non-parametric statistics. Associations between the effects on joint and muscle or tendon levels were performed using Spearman correlation coefficients (p < 0.05). Increased joint resistance, measured during slow ankle rotations, was not significantly reduced after either treatment. Additional joint resistance assessed during fast rotations only reduced in the BoNT-A group (−37.6%, p = 0.013, effect size = 0.47), accompanied by a reduction in MG stretch reflexes (−70.7%, p = 0.003, effect size = 0.56). BoNT-A increased the muscle length measured at the resting ankle angle (6.9%, p = 0.013, effect size = 0.53). Joint angles shifted toward greater dorsiflexion after casting (32.4%, p = 0.004, effect size = 0.56), accompanied by increases in tendon length (5.7%, p = 0.039, effect size = 0.57; r = 0.40). No associations between the changes in muscle or tendon lengths and the changes in the stretch reflexes were found. We conclude that intramuscular BoNT-A injections reduced stretch reflexes in the MG Peeters et al. Separate Effects of BoNT-A and Castingaccompanied by an increase in resting muscle belly length, whereas casting resulted in increased dorsiflexion without any changes to the muscle length. This supports the need for further investigation on the effect of the combined treatments and the development of treatments that more effectively lengthen the muscle.

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“…Ultrasonography is an effective tool for evaluating fibrotic lesions within the SCM and for measuring muscle or mass thickness and is therefore widely used in musculoskeletal medicine [11,12]. Ultrasound elastography has been used as a noninvasive method for evaluating and detecting tumors in various tissues, including the liver, breast, kidney, thyroid, and spleen, and has also been developed to allow the objective assessment of muscle stiffness [13][14][15][16]. Acoustic radiation force impulse (ARFI) elastography is an ultrasound elastography technique in which stress or force is applied to deform the target tissue, and the tissue's mechanical properties are then evaluated by detecting this internal physiological motion.…”

Section: Introductionmentioning

confidence: 99%

Changes in Muscle Stiffness in Infants with Congenital Muscular Torticollis

et al. 2019

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Congenital muscular torticollis (CMT) results from unilateral shortening of the sternocleidomastoid (SCM) muscle, usually associated with a fibrotic mass. Although CMT may resolve with physical therapy, some cases persist, resulting in long-term musculoskeletal problems. It is therefore helpful to be able to monitor and predict the outcomes of physical therapy. Shear-wave velocity (SWV) determined by acoustic radiation force impulse (ARFI) elastography can provide a quantitative measure of muscle stiffness. We therefore measured SCM SWV in 22 infants with unilateral CMT before and after 3 months of physical therapy and evaluated the relationships between SWV and SCM thickness and various clinical features, including cervical range of motion (ROM). SWV was initially higher and the ROM was smaller in affected muscles before physical therapy. SWV decreased significantly (2.33 ± 0.47 to 1.56 ± 0.63 m/s, p < 0.001), indicating reduced stiffness, and muscle thickness also decreased after physical therapy (15.64 ± 5.24 to 11.36 ± 5.71 mm, p < 0.001), both in line with increased neck ROM of rotation (64.77 ± 18.87 to 87.27 ± 6.31 • , p < 0.001) and lateral flexion (37.50 ± 11.31 to 53.64 ± 9.41 • , p < 0.001). However, the improved ROM more closely reflected the changes in SWV than in muscle thickness. These results suggest that a change in SWV detected by ARFI elastography could help to predict improvements in clinical outcomes, such as stiffness-related loss of motion, in patients with CMT undergoing physical therapy.

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Changes in spastic muscle stiffness after botulinum toxin A injections as part of rehabilitation therapy in patients with spastic cerebral palsy

Cited by 21 publications

References 28 publications

Stretching Interventions in Children With Cerebral Palsy: Why Are They Ineffective in Improving Muscle Function and How Can We Better Their Outcome?

Stretching Interventions in Children With Cerebral Palsy: Why Are They Ineffective in Improving Muscle Function and How Can We Better Their Outcome?

Joint and Muscle Assessments of the Separate Effects of Botulinum NeuroToxin-A and Lower-Leg Casting in Children With Cerebral Palsy

Changes in Muscle Stiffness in Infants with Congenital Muscular Torticollis

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