Upper limb function after botulinum toxin A treatment in cerebral palsy: Two years follow-up of six cases

Abstract

The objective of this study was to investigate the effects of botulinum toxin A (BTXA) treatment on impairment and function of the upper limb during a 2-year follow-up period. A prospective longitudinal study design with assessments before and after intervention was utilized, involving six patients with cerebral palsy (three boys and three girls) aged 3 years 4 months to 11 years 11 months at commencement of study. The outcome measures were spasticity (modified Ashworth, MAS), active and passive range of movement (ROM), grips (pinch, key grip, 3-finger grip, narrow cylinder grip, wide cylinder grip, pen grip and diagonal grip; grasping, releasing; pronation-supination), bimanual functions, fine motor functions (Melbourne Assessment of Unilateral Upper Limb Function), movement pattern (Upper Limb Physician's Rating Scale, ULPRS), functional skills and self-care capability (Paediatric Evaluation of Disability Inventory, PEDI), upper extremity use (House Classification) and cosmetic appearance. The assessments were repeated by the same examiners at baseline and at 1, 3 and 6 months after each BTXA treatment and then every 6 months until 24 months. One subject received a total of four injections (at 0, 6, 12 and 18 months), one two injections (at 0 and 12 months) and four one injection at the beginning of the study period. Upper extremity surgery was performed on two subjects during the study and one was operated on 2 months after completion of the study. All children benefited from the BTXA treatment in terms of reduction in muscle tone and increase in active and passive ROM. By 6 months, spasticity returned, but in four children passive and especially active ROM remained better than at baseline. No significant changes in grips, bimanual tasks or Melbourne Assessment scores were detected. The change in movement pattern (ULPRS) was maintained for 3 months in two children and beyond this in four, thus extending beyond the pharmacologic effects of botulinum toxin A. All but one child showed improvement in PEDI functional skill and caregiver assistance scale scores during the 2-year period. The House classification showed a one-grade improvement in one child at 1 month and in one child at 3 months and a three-grade improvement in one child at 3 months after BTXA treatment. After each treatment, the parents reported at least a one-grade improvement in cosmetic appearance in all children at 1 month and in four children maintained at least until 6 months. In two subjects operated during the study period, a distinct improvement in active and passive ROM and a two-grade improvement in the House classification were observed after the operation. In this limited series, the reduction in muscle tone after BTXA treatment did not translate into better gripping or quality of fine motor functions (Melbourne Assessment) of the affected hand, but seemed to have a positive effect on upper limb movement pattern (ULPRS), upper extremity use (House Classification) and cosmetic appearance. Assessment of upper limb function in a child with ...

Review of quantitative measurements of upper limb movements in hemiplegic cerebral palsy

“…Moreover, some of these outcome assessments have been criticised for not being sensitive enough to detect clinically meaningful change in upper limb function after intervention [8].…”

Hemiplegic cerebral palsy: role of repeat botulinum toxin A injections as an adjunct to occupational therapy

“…1,3,5 In a 2-year longitudinal case series of children with various CP subtypes, repeat BTX-A injections were well tolerated, had a positive effect on upper-limb movement patterns, and improved upper-limb tone, passive range of motion and cosmesis, but not function. 2 In their current longitudinal study, Lowe et al extended their previous trial 4 for an additional 2 years, but made a marked change in their treatment paradigm by giving both groups BTX-A injections at 6 and 18 months. The findings of this study are compelling and show that repeated BTX-A injections, combined with ongoing occupational therapy, are well tolerated and produce sustained, long-lasting improvements in upperextremity movement and function.…”

“…1,2 BTX-A has gained popularity among clinicians as a useful tool for reducing spasticity and improving upper-limb range of motion and function in patients with CP, despite a lack of well controlled trials to establish its efficacy. [1][2][3] In a previous evaluator-blinded, randomized controlled trial, Lowe and colleagues 4 evaluated the effectiveness of BTX-A as an adjunct to occupational therapy, compared with occupational therapy alone, in children with hemiplegic CP. BTX-A produced greater functional gains than did occupational therapy alone at 1 and 3 months but not at 6 months.…”

Preliminary reliability and validity of a battery for assessing functional skills in children with Sturge-Weber syndrome

“…The MHC was described to have good construct validity with the Manual Ability Classification Scale and ABILHAND-Kids [10]. A high level of intra-rater (0.96) and inter-rater reliability (ICC=0.92) have been shown [20], and the MHC has been used as an outcome measure of treatment to improve upper limb function [29,28]. There is a high ceiling for test items, and the assessment is sensitive to typical hemiplegic compensatory movement patterns and limitations.…”