Onabotulinum toxin-A (Botox) for spastic equinus in cerebral palsy: A prospective kinematic study

Hastings-Ison, Tandy; Sangeux, Morgan; Thomason, Pam; Rawicki, Barry; Fahey, Michael; Graham, H. Kerr

doi:10.1302/1863-2548.12.180044

Cited by 21 publications

(35 citation statements)

References 31 publications

(86 reference statements)

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“…Earlier studies utilised isolated kinematic measures at the ankle and knee and were able to detect improvements following injection of BoNT-A [54]. More recently, dynamic electromyography, kinetics and summary statistics of gait such as the Gait Profile Score (GPS) have also been reported [55, 56]. A combination of kinematic parameters and a summary statistic of overall gait pattern (GPS) are recommended as the highest level for objective documentation of changes in gait in children with CP [55, 56].…”

Section: Measurement Scales and Outcome Measuresmentioning

confidence: 99%

Botulinum Toxin in the Management of Children with Cerebral Palsy

et al. 2019

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During the past 25 years, botulinum toxin type A (BoNT-A) has become the most widely used medical intervention in children with cerebral palsy. In this review we consider the gaps in our knowledge in the use of BoNT-A and reasons why muscle morphology and function in children with cerebral palsy are impaired. We review limitations in our knowledge regarding the mechanisms underlying the development of contractures and the difficulty in preventing them. It is clear from this review that injection of BoNT-A in the large muscles of both the upper and lower limbs of children with cerebral palsy will result in a predictable decrease in muscle activity, which is usually reported as a reduction in spasticity, for between 3 and 6 months. These changes are noted by the use of clinical tools such as the Modified Ashworth Scale and the Modified Tardieu Scale. Decreased muscle over-activity usually results in improved range of motion in distal joints. Injection of the gastrocnemius muscle for toe-walking in a child with hemiplegia or diplegia usually has the effect of increasing the passive range of dorsiflexion at the ankle. In our review, we found that this may result in a measurable improvement in gait by the use of observational gait scales or gait analysis, in some children. However, improvements in gait function are not always achieved and are small in magnitude and short lived. We found that some of the differences in outcomes in clinical trials may relate to the use of adjunctive interventions such as serial casting, orthoses, night splints and intensive therapy. We note that the majority of clinical trials of the use of BoNT-A in children with cerebral palsy have focussed on a single injection cycle and this is insufficient to understand the balance between benefit and harm. Most outcomes were reported in terms of changes in muscle tone and there were fewer studies with robust methodology that reported improvements in function. Changes in the domains of activities and participation have rarely been reported in studies to date. There were no clinical reviews to date that consider the findings of studies in human volunteers and in experimental animals and their relevance to clinical protocols. In this review we found that studies in human volunteers and in experimental animals show muscle atrophy after an injection of BoNT-A for at least 12 months. Muscle atrophy was accompanied by loss of contractile elements in muscle and replacement with fat and connective tissue. It is not currently known if these changes, mediated at a molecular level, are reversible. We conclude that there is a need to revise clinical protocols by using BoNT-A more thoughtfully, less frequently and with greatly enhanced monitoring of the effects on injected muscle for both short-term and long-term benefits and harms.

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Section: Measurement Scales and Outcome Measuresmentioning

confidence: 99%

Botulinum Toxin in the Management of Children with Cerebral Palsy

et al. 2019

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“…gait via increased ankle DF) in children with CP and suggest that the effects on ankle DF PROM may be slightly stronger when coupled with BTX-A. These findings however, need to be balanced against recent research which showed that small improvements in ankle DF achieved from BTX-A injections to the gastrocnemius (without the addition of serial casting) were offset by potentially harmful effects of deteriorating knee kinematics, moving children with spastic diplegia CP towards crouch gait patterns [34]. Clinicians may use the information gained from the present systematic review when developing individualized treatment plans for children who have CP during shared decision-making consultations clients and their families.…”

Section: Discussionmentioning

confidence: 91%

“…This uncertainty is attributed to a wide range of study designs, casting protocols, and combinations of additional therapies documented in the current literature, making it difficult to isolate and determine the efficacy of serial casting as an intervention [17,25] independent of pharmacological therapies. Considering recent contributions to the empirical literature regarding the potentially damaging effects of BTX-A to gait in children with CP [34], the findings from this systematic review are warranted to assist clinicians, parents and clients in shared decision-making processes. As such, the purpose of this systematic review was to critically appraise and synthesize the empirical literature regarding the effects of serial casting, compared to serial casting with pharmacological intervention, on the different variables influencing function of the lower limbs, in children with CP.…”

Section: Introductionmentioning

confidence: 99%

The effects of serial casting on lower limb function for children with Cerebral Palsy: a systematic review with meta-analysis

2020

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Background: Lower limb serial casting is commonly used therapeutically in paediatric clinical practice with some evidence to support its efficacy. This systematic review aimed to determine the effects of serial casting in isolation or combination with other therapies for the management of lower limb dysfunction in children with Cerebral Palsy (CP). Methods: A systematic literature search was conducted in February 2019 across eight databases (PUBMED, EMBASE, CINAHL, PEDro, OTSeeker, Cochrane, Scopus and Proquest) using key terms 'Cerebral Palsy' and 'serial casting' and associated synonyms. A meta-synthesis and meta-analysis were undertaken when sufficient results were available showing the effect of serial casting on functional outcomes including: Ankle range of motion; neurological measures of hypertonicity and spasticity, functional gait measures and; gross motor function. Results: Twenty-five articles from 3219 possible citations were included. Serial casting was found to be effective for: Improving ankle dorsiflexion (DF) passive range of motion (PROM) in the immediate to short-term, decreasing hypertonicity measured by Modified Ashworth Scale (MAS) in the short-term and, enhancing functional gait outcomes in the mid-term. Serial casting with or without botulinum toxin type-A (BTX-A) did not significantly affect gross motor capacity measured by Gross Motor Function Measure (GMFM). Serial casting with pharmacological intervention achieved significantly more DF PROM than serial casting alone (MD − 3.19 degrees; 95% CI − 5.76 to − 0.62; P = 0.01; I 2 = 0%), however the clinical importance of improving ankle DF PROM by an additional three degrees remains unclear. Conclusions: Lower limb serial casting, improves several outcomes relevant to lower limb function supporting its clinical use for improving DF PROM, reducing hypertonicity and improving gait in children with CP. Further research using stronger methodological study designs, is indicated to explore long-term effects of serial casting on functional lower limb outcomes such as gross motor function in children with CP. Clinicians can use this information when developing individualised treatment plans for children who have CP during shared decisionmaking consultations.

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“…Since its introduction in 2009, the Gait Profile Score has been used in clinical practice world-wide, particularly in children with cerebral palsy to improve understanding of their complex gait patterns [19], evaluate the use of Botulinum toxin [20] and evaluate surgical outcomes [21]. In addition to cerebral palsy, there is published research using GPS in other populations such as Charcot-Marie Tooth [22], Hereditary Spastic Paraplegia [23], Multiple Sclerosis [24], Parkinson's Disease [25] , and amputees [26].…”

Section: Concurrent Validitymentioning

confidence: 99%

Validation of the foot profile score

et al. 2019

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BACKGROUND There are numerous static measures of foot posture but there is no published score of dynamic foot motion. Three-dimensional gait analysis can include a multi-segment foot model like the Oxford Foot Model (OFM) to comprehensively quantify foot kinematic deviations across the gait cycle but it lacks an overall score, like the Gait Profile score (GPS), used to summarize the quality of lower extremity motion. RESEARCH QUESTION This paper introduces the Foot Profile Score (FPS), a single number, analogous to the GPS but based on kinematic data of the OFM. The aim of this study is to validate the FPS by studying its properties and design, and analyse it against a clinical assessment of foot deformity. METHODS Concurrent validity was established for the FPS analysing the relationship with Clinical Foot Deformity Score (CFDS) in 60 subjects with a condition affecting the lower limbs globally Content validity was established for the six Foot Variable Scores (FVS) that make up the FPS using a multiple regression of the CFDS on the 6 FVS in the 60 subjects. Predictive validity was established analysing the relationship of the FPS and GPS comparing 60 global involvement subjects with 60 subjects with isolated foot deformity. RESULTS Pearson correlation between the FPS and CFDS was significant at 0.62 (p<0.001). Each element of FVS contributes positively to predicting the CFDS with R2 = 0.456 (p<0.001). FPS contributed independently to the prediction of CFDS (t=3.9, p<0.001). The correlation between the GPS and FPS in the global involvement group was significant at r = 0.64 (p<0.001), while there was no correlation found with r = 0.08 (p=0.54) in the foot deformity group. SIGNIFICANCE The FPS is the first validated score of dynamic foot motion.

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Onabotulinum toxin-A (Botox) for spastic equinus in cerebral palsy: A prospective kinematic study

Cited by 21 publications

References 31 publications

Botulinum Toxin in the Management of Children with Cerebral Palsy

Botulinum Toxin in the Management of Children with Cerebral Palsy

The effects of serial casting on lower limb function for children with Cerebral Palsy: a systematic review with meta-analysis

Validation of the foot profile score

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