Effectiveness of resistance training in combination with botulinum toxin-A on hand and arm use in children with cerebral palsy: a pre-post intervention study

Abstract

BackgroundThe aim of this pilot study was to examine the effects of additional resistance training after use of Botulinum Toxin-A (BoNT-A) on the upper limbs in children with cerebral palsy (CP).MethodsTen children with CP (9–17 years) with unilaterally affected upper limbs according to Manual Ability Classification System II were assigned to two intervention groups. One group received BoNT-A treatment (group B), the other BoNT-A plus eight weeks resistance training (group BT). Hand and arm use were evaluated by means of the Melbourne assessment of unilateral upper limb function (Melbourne) and Assisting Hand Assessment (AHA). Measures of muscle strength, muscle tone, and active range of motion were used to assess neuromuscular body function. Measurements were performed before and two and five months after intervention start. Change scores and differences between the groups in such scores were subjected to Mann–Whitney U and Wilcoxon Signed Rank tests, respectively.ResultsBoth groups had very small improvements in AHA and Melbourne two months after BoNT-A injections, without differences between groups. There were significant, or close to significant, short-term treatment effects in favour of group BT for muscle strength in injected muscles (elbow flexion strength, p = .08) and non-injected muscles (elbow extension and supination strength, both p = .05), without concomitant increases in muscle tone. Active supination range improved in both groups, but more so in group BT (p = .09). There were no differences between the groups five months after intervention start.ConclusionsResistance training strengthens non-injected muscles temporarily and may reduce short-term strength loss that results from BoNT-A injections without increasing muscle tone. Moreover, additional resistance training may increase active range of motion to a greater extent than BoNT-A alone. None of the improvements in neuromuscular impairments further augmented use of the hand and arm. Larger clinical trials are needed to establish whether resistance training can counteract strength loss caused by BoNT-A, whether the combination of BoNT-A and resistance training is superior to BoNT-A or resistance training alone in improving active range of motion, and whether increased task-related training is a more effective approach to improve hand and arm use in children with CP.

Do we really know what they were testing? Incomplete reporting of interventions in randomised trials of upper limb therapies in unilateral cerebral palsy

“…However, decision points or guidelines for progression or adaptation of the intervention based on individual participants' response to therapy were described by a few studies (Charles, Wolf, Schneider, & Gordon, 2006;Elvrum, Braendvik, Saether, Lamvik, Vereijken, & Roeleveld, 2012;Gordon, Schneider, Chinnan, & Charles, 2007;Gordon, Hung, Brandao, Ferre, Kuo, Friel et al, 2011). One study of resistance training and Botulinum Toxin injections described the grading of the program: "Once the participants were able to perform three sets of ten repetitions in an exercise, intensity was build up progressively on an individualized basis by increasing the weights by 0.25 -0.5kg."…”

“…One study of resistance training and Botulinum Toxin injections described the grading of the program: "Once the participants were able to perform three sets of ten repetitions in an exercise, intensity was build up progressively on an individualized basis by increasing the weights by 0.25 -0.5kg." (Elvrum et al, 2012). Thirty-nine (65%) of studies adequately reported the procedure (Item 4) for the research intervention, detailing the activities and/or processes used.…”

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

“…Twelve studies were of very high methodologic quality, scoring $8 on the PEDro scale. 10 Fourteen studies were of poor methodologic quality, scoring ,6 on the PEDro scale (BoNT-A, [21][22][23] cCIMT, 6,25,26 mCIMT, 7,29,30,38,44 forced-use therapy, 48 and other UL interventions 50,54,56 ). Twenty-six studies (57%) did not report concealed allocation.…”

“…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), …”

Upper-Limb Therapy in Children Following Injection of Botulinum Neurotoxin A

“…Children with cerebral palsy are weak (Mockford and Caulton 2010). Considering the denervation effect of BoNT-A, structured upper-limb resistance training following BoNT-A should be considered (Elvrum et al 2012). It is important to recognize that in children muscle strength can occur in the absence of muscle hypertrophy following resistance training programs (Stackhouse et al 2005).…”