Reproducibility of an instrumented measure for passive ankle dorsiflexion in conscious and anaesthetized children with cerebral palsy

Hastings-Ison, Tandy; Blackburn, Christine; Opie, Nicholas L.; Graham, H Kerr; Rawicki, Barry; Wolfe, Rory; Simpson, Pamela; Baker, Richard

doi:10.1111/dmcn.12276

Cited by 9 publications

(12 citation statements)

References 28 publications

(56 reference statements)

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“…As with many other trials, surrogate measures were required, with an instrumented measure of passive ankle dorsiflexion used. 9 , 18 , 24 The trial found no significant difference between 12-monthly and four-monthly injection regimens on passive ankle dorsiflexion or secondary functional outcome measures. 18 At the time of study exit, the mean age of children was five years seven months and most were familiar with clinical assessment and able to cooperate with IGA; 3D kinematics were therefore captured one month before and one month after the final injection of BoNT-A and the purpose of this study was to report changes in gait kinematics irrespective of prior injection frequency.…”

Section: Discussionmentioning

confidence: 90%

“… Ankle Plantarflexor-Knee Extension couple index. 24 Sagittal gait pattern areas are represented by labelled boxes. Note that whilst all groups improve in ankle dorsiflexion post-injection, this is accompanied by greater knee flexion in midstance (AE, apparent equinus; WNL, within normal limits; Hemi, hemiplegia/unilateral involvement; Di, diplegia/bilateral involvement).…”

Section: Resultsmentioning

confidence: 99%

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

Hastings-Ison

Sangeux

Thomason

et al. 2018

Journal of Children's Orthopaedics

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PurposeBotulinum toxin-A (or Botox) is widely used for the management of equinus gait in children with cerebral palsy but few recent studies have included instrumented gait analysis.MethodsThis was a prospective cohort study. Gait analysis was performed four weeks before and four weeks after Botulinum toxin-A injection for spastic equinus to detect the maximum effects on gait kinematics. Outcome measures included the Gait Profile Score (GPS), the Gait Variable Score (GVS) for the ankle, maximal ankle dorsiflexion and maximal knee extension at midstance.ResultsIn all, 37 children participated (20 boys); mean age five years seven months (4 years 1 month to 8 years 2 months); 19 with unilateral and 18 bilateral involvement. At a mean four weeks post-injection, the GPS and ankle GVS were unchanged. However maximum ankle dorsiflexion increased for the whole group; median 7.7° (confidence interval (CI) 4° to 10.6°) to 11.5° (CI 7.7° to 12.9°), p = 0.02. Maximum midstance knee extension was unchanged for the whole group, but median knee flexion increased in children with bilateral involvement; 10.9° (CI 7.4° to 20.8°) to 16.5° (CI 8.4° to 19.7°), p = 0.58.ConclusionInjections of the gastrocsoleus for spastic equinus did not result in objective improvements in overall gait. Improvements in ankle dorsiflexion for children with bilateral involvement may be offset by deterioration at the knee.Level of EvidenceII - prospective cohort study, before and after intervention

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Section: Discussionmentioning

confidence: 90%

Section: Resultsmentioning

confidence: 99%

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

Hastings-Ison

Sangeux

Thomason

et al. 2018

Journal of Children's Orthopaedics

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“…Accuracy and reliability are improved by training and by two clinicians working together, one to stabilise the joint and the second to apply the goniometer to recognised anatomical landmarks and read the appropriate angle. Reliability of goniometric measurements can be improved by standardising the applied force and by using digital photography of anatomic landmarks as described by Hastings-Ison et al [43].…”

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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“…Passive ankle dorsiflexion at baseline and 26 months was performed under mask anaesthesia by an assessor blinded to group allocation. Measurement was performed immediately before injection, using a precise and reliable method with standard error of measurement 3.9 degrees (SD 2.0, 95% confidence interval (CI) 3.3–4.0) which has been fully described previously . The applied torque was standardized to 50% body weight, with a digital photograph taken and software used to measure passive dorsiflexion …”

Section: Methodsmentioning

confidence: 99%

“…20 The applied torque was standardized to 50% body weight, with a digital photograph taken and software used to measure passive dorsiflexion. 20…”

Section: Primary Outcome Measurementioning

confidence: 99%

Injection frequency of botulinum toxin A for spastic equinus: a randomized clinical trial

Hastings-Ison

Blackburn

Rawicki

et al. 2015

Develop Med Child Neuro

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FAQRESULTS Forty-two children entered the trial with 21 participants randomized to each group.There were three withdrawals and two children received serial casting midway through the trial. There was no significant difference in passive dorsiflexion between 12-monthly and 4-monthly regimens (p=0.41). There were also no significant between group differences on secondary outcome measures. There were no serious adverse events -the rate was 1.2 adverse events per child per year in the 12-monthly group and 2.2 adverse events per child per year in the 4-monthly group. Subgroup analysis revealed a significant difference in passive dorsiflexion between children with hemiplegia and diplegia (p=0.01).

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Reproducibility of an instrumented measure for passive ankle dorsiflexion in conscious and anaesthetized children with cerebral palsy

Cited by 9 publications

References 28 publications

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

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

Botulinum Toxin in the Management of Children with Cerebral Palsy

Injection frequency of botulinum toxin A for spastic equinus: a randomized clinical trial

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