Computerized gait analysis of botulinum toxin treatment in children with cerebral palsy

Purpose. Intramuscular botulinum toxin A (BTA) injection is a local reversible treatment with a wide range of therapeutic applications, including temporary reduction of spasticity. The aim of this work was a quantitative, computerized objective evaluation of BTA-induced improvement of the walking functional ability in a group of children with cerebral palsy (CP).

Methods. Fifteen children with CP and 20 healthy children were evaluated. All patients were equinus walkers without fixed contractures of triceps surae muscles and they were evaluated before and after about 1.5 months from BTA injections into the calf muscles. The effectiveness of treatment was evaluated by 3D computerized gait analysis.

Results. Data analysis revealed a significant improvement of equinus foot and ankle range of motion during gait after BTA injection. Positive effects were evident also at the knee joint as documented by the improvement of kinetics characteristics (moment and power).

Conclusions. Computerized gait analysis is a valid method for quantification of BTA effect on walking in children with CP, allowing a detailed evaluation of improvement at each joint and a quantitative evaluation of treatment outcome.     

Use of botulinum toxin A in management of children with cerebral palsy

QUESTION: What is the role of intramuscular botulinum toxin injections in the management of spasticity and related morbidity in children with cerebral palsy? ANSWER: When botulinum toxin A is injected into the limbs of children with spastic paresis, it induces temporary reduction in muscle tone. It also promotes better motor function when used in combination with conservative treatments such as physiotherapy. Although there is a growing body of evidence for its effective and safe treatment, there is still a lack of consensus on dose, treatment regimens, and the best integration with other clinical modalities.     

Hip migration percentage in children with cerebral palsy treated with botulinum toxin type A

OBJECTIVE: To determine hip radiographic findings in children with cerebral palsy (CP) treated with botulinum toxin type A (BTX-A). DESIGN: Retrospective chart review with correlation to radiographic findings. SETTING: Academic center. PARTICIPANTS: Sixteen subjects with CP. INTERVENTION: BTX-A treatment to adductor muscles. MAIN OUTCOME MEASURE: The Reimers hip migration percentage before and after BTX-A. RESULTS: Thirty-two hips in 16 children with CP were treated. We examined the effect of initial migration percentage and initial migration percentage age on the change in migration percentage after BTX-A injection. A significant effect for initial migration percentage (<30% or >/=30%; F=19.05, P <.001) and a significant interaction between initial migration percentage and initial migration percentage age (F=7.5, P <.01) was noted. Initial migration percentage age (24 mo) was not significant (F=.95, P =.34). Patients who had an initial migration percentage of 30% or more and were less than 24 months old were more likely to have a decrease in migration percentage after BTX-A injection compared with patients who were older than 24 months and who had an initial migration percentage of 30% or more. CONCLUSIONS: Improvement in hip migration percentage after BTX-A injection is a function of age and the initial migration percentage. BTX-A injections to adductor muscles may be beneficial for some children with CP.     

肉毒毒素A在治疗脑性瘫痪儿童痉挛中的应用

肉毒毒素A由于能产生可逆的化学性去神经作用而被应用于治疗脑性瘫痪(脑瘫)儿童痉挛。评定肉毒毒素A疗效的常用指标,包括GMFM,Ashworth量表、关节活动度等。在综述了证明肉毒毒素A治疗脑瘫儿童上肢或下肢痉挛的有效性和安全性的文献(含非对照性研究和对照性研究)后,得出了肉毒毒素A用于治疗脑瘫儿童痉挛是安全、有效的和可以很好的被耐受的结论,还需更多的研究去论证结合多种途径(传统的物理治疗、作业治疗、石膏、支具、矫形手术)治疗的有效性。     

A型肉毒毒素治疗对痉挛型脑瘫患儿足底压力改变的影响

目的:探讨A型肉毒毒素(BTX-A)对痉挛型脑瘫患儿足底压力改变的影响。方法:213例痉挛型脑瘫患儿随机分为BTX-A组108例(BTX-A注射结合物理治疗)和对照组105例(单纯物理治疗)。2组患儿在医院接受2周康复治疗,之后在家接受10周家庭康复治疗。在治疗前、治疗后2周和12周,对2组患儿进行以下评定:足底压力测试仪测试足底各区压力占全足的百分比,粗大运动功能测试量表中的站立与步行功能项评定粗大运动功能,改良Ashworth量表评定痉挛程度,医师等级评价量表评定步态。结果:BTX-A组的足底各区压力分布、站立和步行功能、痉挛程度和步态,在治疗后2周、12周与治疗前比较,均有明显改善(P<0.05);对照组各项评分在治疗12周后才有明显改善(P<0.05);治疗后12周,2组间的足底各区压力分布、站立和步行功能、痉挛程度和步态进行比较,BTX-A组均明显优于对照组(P<0.05)。结论:BTX-A注射结合物理治疗更利于改善痉挛型脑瘫患儿的足底压力分布、缓解其肌肉痉挛、提高其步行能力、改善其步态。     

Effects of botulinum toxin A therapy with electrical stimulation on spastic calf muscles in children with cerebral palsy

OBJECTIVE: To assess the additive effect of adjuvant electrical stimulation on botulinum toxin A injection in children with spastic diplegic cerebral palsy. DESIGN: Eighteen children with dynamic foot equinus deformity were treated with botulinum toxin A injection into the calf muscles. Seven children were assigned to a treatment group who received botulinum toxin A and adjuvant electrical stimulation, and 11 children were assigned to a control group with botulinum toxin injection only. Before botulinum injection, and at 2 wks and 3 mos after injection, the Physician Rating Scale, passive ranges of ankle and knee motion, and the modified Ashworth scale were measured. RESULTS: A significant increase in passive range of ankle motion was observed at 2 wks after injection in the treatment group and at 3 mos after injection in both groups. Both groups showed significant improvements by the modified Ashworth scale at 2 wks after injection. Subscales of the Physician Rating Scale (equinus foot, crouched gait) and total Physician Rating Scale scores were significantly improved in the treatment group at 3 mos after injection, but this was not observed in the control group. CONCLUSIONS: Adjuvant electrical stimulation for a short period after botulinum toxin A injection was found to benefit early improvement of range of motion and maintenance of gait improvement in children with spastic diplegia cerebral palsy showing dynamic equinus.     

酚阻滞术治疗痉挛型脑瘫的长期疗效分析

目的 探讨酚阻滞术缓解脑瘫患儿痉挛的长期疗效。方法 42例年龄为2一17岁的痉挛型脑瘫患儿应用5％的酚溶液进行74次阻滞，酚用量0.5-4.6ml/次，平均2.2ml。采用修改的Ashworth评分法评定疗效。结果 66次酚阻滞术取得成功，患儿肌张力有所下降，运动功能有所提高，有效率为89.2%，显效率为59.5%，且副作用少。结论 酚阻滞术有缓解痉挛见效快，选择性强、操作简单、安全、费用低廉等优点。     

Effect of botulinum toxin type A on cerebral palsy with upper limb spasticity

OBJECTIVE: The objective of this study was to investigate the effects of botulinum toxin type A injections in reducing upper limb muscular spasticity and in improving motor function in children with cerebral palsy. DESIGN: Fifteen children with spastic cerebral palsy who were undergoing regular physical and occupational therapy were enrolled. Botulinum toxin type A injections in clinically indicated target muscle groups were administered after the children had received 3 mo of therapy. A follow-up study was carried out at 6 wk and 12 wk, respectively, after the botulinum toxin type A injections. The main outcome measurements included the Modified Ashworth Scale, the upper limb Physician's Rating Scale, the Bruininks-Oseretsky Test of Motor Proficiency, and the self-care domain of the Pediatric Evaluation of Disability Inventory. RESULTS: The reduction of spasticity in the treated muscle groups differed significantly between the control period and both study periods. Improvements on the Physician's Rating Scale score during the study period also differed significantly as compared with improvements during the control period. There was a significant difference in the improvement of fine motor skills, as measured with Bruininks-Oseretsky Test of Motor Proficiency, between the control period and both study periods. Improvements in self-care capability differed significantly between the control period and 12 wk after botulinum toxin type A treatment, but not between the control period and at 6 wk after treatment. Muscle strength of grasp and pinch did not differ significantly between the control and the study period. Distribution of body parts involvement, disease severity, and function in daily living activities had no significant correlation with functional improvement after the treatment. CONCLUSIONS: Our findings support the premise that botulinum toxin type A injections are effective in reducing upper limb spasticity and in improving movement pattern and fine motor function of patients with spastic cerebral palsy. A reduction in caregivers' burden and improved quality of life were demonstrated through the study period.     

Intraparotid injection of botulinum toxin A as a treatment to control sialorrhea in children with cerebral palsy

OBJECTIVE: To determine the efficacy of botulinum toxin A in the management of drooling (sialorrhea) in children and young adults with cerebral palsy. DESIGN: Twenty-one children were enrolled in an open-label, nonblinded prospective study. Subjective and objective measures were used to determine the effect of botulinum toxin A on drooling and saliva production. Subjective measures included visual scales to document the child's severity and frequency of drooling. Objective measures included the number of bibs used per day and salivary secretion. At the initial visit, subjective and objective measures established the child's baseline drooling and saliva production. Fifteen units of botulinum toxin A was injected into each parotid glans. At each fellow-up visit of telephone survey, subjective and objective measures were recorded to monitor the child's drooling and saliva production. A postinjection questionnaire evaluated overall effect and caregiver satisfaction. RESULTS: The visual analog scales and number of bibs used per day demonstrated statistically significant reduction in severity and frequency of drooling at 2 wks, 1 mo and 2 mos. Salivary production was significantly reduced at 1-mo fellow-up. Eighty-nine percent of the caregivers reported and improvement of their child's drooling after botulinum toxin A injection. Severity-nine percent of caregivers were satisfied with the treatment and would perform the treatment again. CONCLUSION: Intraparotid injections of botulinum toxin A are efficacious in decreasing severity and frequency of drooling, the number of bibs used per day, and the production of saliva in children with cerebral palsy. The injections are relatively safe and adverse effects were observed in this study.     

A型肉毒毒素用于治疗痉挛型脑性瘫痪的临床研究

目的:探讨A型肉毒毒素注射治疗痉挛型脑性瘫痪儿童肌肉痉挛的疗效。方法:选择痉挛型脑性瘫痪儿童200例,A型肉毒毒素注射组(注射组)和单纯康复治疗组(对照组)各100例。其中注射组将A型肉毒毒素准确注射到患儿痉挛肌群,注射后次日开始进行康复训练(共12周)。所有病例在治疗前及治疗后1周、2周、4周、8周、12周分别采用改良Ashworth量表、粗大运动功能量表及医师等级评价量表进行相关评价。结果:注射组在注射后各观察时点肌肉痉挛改善程度和运动功能评分均优于注射前(P<0.05),注射组治疗效果明显优于对照组。结论:A型肉毒毒素注射治疗可以快速、有效地缓解痉挛;注射治疗结合康复训练相较于单纯康复训练,更有助于提高运动功能、缩短治疗时间。     

肉毒毒素注射结合功能训练对痉挛型脑瘫患儿站立与步行功能的影响

目的：观察A型肉毒毒素（BTX-A）注射结合功能训练对痉挛型脑瘫患儿站立与步行功能的影响。方法：100例痉挛型脑瘫患儿随机分为BTX-A组50例和对照组50例。BTX-A组采用BTX-A注射下肢痉挛肌群结合功能训练,对照组仅采用单纯的功能训练。患儿在治疗前和治疗后2周、3个月、6个月进行综合痉挛量表（CSS）评分及粗大运动功能量表（GMFM）中的D和E两项评分。结果：治疗后2周、3及6个月时,2组患儿CSS评分均较治疗前呈逐渐下降趋势（P〈0.05）,且在治疗后3及6个月时BTX-A组CSS评分更低于对照组（P〈0.05）;2组患儿GMFM（DE区）评分均较治疗前呈逐渐上升趋势（P〈0.05）,且在治疗后3及6个月时BTX-A组GMFM（DE区）评分更高于对照组（P〈0.05）。结论：肉毒毒素注射和单纯的功能训练均能缓解脑瘫患儿肢体痉挛,改善运动功能,但BTX-A注射结合功能训练能更有效缓解脑瘫患儿的肢体痉挛,提高其运动能力,能明显缩短治疗时间,改善患儿的步态,提高其站立与步行功能。     

Effects of botulinum toxin type A on upper limb function in children with cerebral palsy: a systematic review

OBJECTIVE: To evaluate whether botulinum toxin type A injections improve upper limb function in children with cerebral palsy. METHODS: An extensive search was carried out in PUBMED, CINAHL, PICARTA, EMBASE, PEDRO and the Cochrane Controlled Trials Register. Controlled and uncontrolled studies were included and evaluated on the basis of a best evidence synthesis. RESULTS: Twelve out of 645 identified studies were included: three randomized controlled trials (RCTs) (N=64) of high methodological quality, and nine uncontrolled studies (N=107) of sufficient methodological quality. In one of the three RCTs a short-term, significant decrease of spasticity was found in favour of the botulinum toxin type A group, which was supported by five of the seven uncontrolled studies that also measured spasticity. In one RCT significant changes in range of motion were reported for wrist and thumb extension. This finding was supported by two out of seven uncontrolled studies. One RCT reported a significant improvement in activities after one month, according to the Quality of Upper Extremity Skills Test and the Pediatric Evaluation Disability Inventory, whereas five out of the nine uncontrolled studies reported an improvement in functional activities. CONCLUSION: Insufficient evidence is found for the effects of botulinum toxin type A injections to reduce spasticity or to increase range of motion and upper limb function in children with cerebral palsy. Besides differences in treatment goals, the lack of evidence is mainly due to the use of invalid assessment instruments and insufficient statistical power to demonstrate treatment effects.     

Comparison of botulinum toxin type A injection and soft-tissue surgery to treat hip subluxation in children with cerebral palsy

Yang EJ, Rha D-W, Kim HW, Park ES. Comparison of botulinum toxin type A injection and soft-tissue surgery to treat hip subluxation in children with cerebral palsy.

Objective

To compare the effects of botulinum toxin type A (BTX-A) injection into the hip adductor muscles on hip displacement with soft-tissue surgery and assess the factors related to a favorable outcome after intervention in children with bilateral spastic cerebral palsy (CP).

Design

Retrospective chart review with regard to radiographic findings.

Setting

University hospital.

Participants

Children with CP (N=194).

Interventions

BTX-A injection and soft-tissue surgery into the hip adductor muscles.

Main Outcome Measure

The Reimers hip migration percentage (MP).

Results

Sixty-nine children did not receive any therapeutic intervention for hip displacement, whereas 60 children underwent soft-tissue surgery and 65 children took BTX-A injection for the spasticity of their hip muscles. MP was measured on each radiograph of the pelvis. The annual change of MP was improved in both the soft-tissue surgery and BTX-A groups, whereas it worsened in the nonintervention group. The annual improvement of MP in the BTX-A group did not differ significantly from that of the soft-tissue surgery group. The improvement in hip displacement after therapeutic intervention was greater in young children and high-functioning groups compared with older children and low-functioning groups. Hip displacement was progressive in the severely hip subluxated group despite therapeutic intervention.

Conclusions

Comparable effects of BTX-A injection to soft-tissue surgery in our study suggest that BTX-A injection, if timely reinjected, may replace soft-tissue surgery as a prophylactic procedure against progressive hip subluxation or dislocation in children. Age at intervention, functional level, and initial MP before therapeutic intervention were the factors affecting the outcomes.     

肉毒毒素A治疗痉挛型脑瘫探讨

目的 探讨肉毒毒素A(botulinum toxin A,BTX-A)在脑瘫康复治疗中的应用价值。方法 将47例痉挛型脑瘫儿童随机分为治疗组(32例)和对照组(15例)，两组均接受正规康复训练，治疗组辅以痉挛肌注射BTX-A，观察商组患儿的内收肌角与回常生活活动能力(activities of daily living,ADL)变化。结果 治疗3个月和6个月后，治疗组患儿的内收肌角、ADL改善精况明显优于对照组(P＜0．01)。结论 康复训练仍是有效的脑瘫治疗手段，BTX-A局部注射作为一种重要的输助方法，可为康复训练提供良好时机，两者结合可明显缩短疗程、提高疗效，在脑瘫康复治疗中具有应用价值。     

Effects of biofeedback treatment on gait in children with cerebral palsy

PURPOSE: We evaluated the effectiveness of biofeedback treatment on gait function in children with cerebral palsy. METHOD: Thirty-six children with spastic cerebral palsy and dynamic equinus deformity were included in the study. The biofeedback group consisted of 21 children who each received EMG biofeedback training plus conventional exercise programme. The control group consisted of 15 children who each received conventional exercise programme only. Active range of motion of the ankle joints, muscle tone of plantar flexors, and gait function of the children were evaluated and compared. RESULTS: The biofeedback group displayed statistically significant improvements regarding tonus of plantar flexor muscles and active ROM of ankle joints (p < 0.000 for all parameters). Gait function showed statistically significant progress in both of the groups, but the biofeedback group was superior to controls. CONCLUSIONS: Children with cerebral palsy and dynamic equinus deformities may benefit from biofeedback treatment for ambulation.     

Effects of biofeedback treatment on gait in children with cerebral palsy

Purpose:?We evaluated the effectiveness of biofeedback treatment on gait function in children with cerebral palsy.

Method:?Thirty-six children with spastic cerebral palsy and dynamic equinus deformity were included in the study. The biofeedback group consisted of 21 children who each received EMG biofeedback training plus conventional exercise programme. The control group consisted of 15 children who each received conventional exercise programme only. Active range of motion of the ankle joints, muscle tone of plantar flexors, and gait function of the children were evaluated and compared.

Results:?The biofeedback group displayed statistically significant improvements regarding tonus of plantar flexor muscles and active ROM of ankle joints (p?<?0.000 for all parameters). Gait function showed statistically significant progress in both of the groups, but the biofeedback group was superior to controls.

Conclusions:?Children with cerebral palsy and dynamic equinus deformities may benefit from biofeedback treatment for ambulation.     

Combining botulinum toxin and phenol to manage spasticity in children

OBJECTIVE: To describe the specific techniques and adverse reactions of using concurrent, multiple injections of both botulinum toxin and phenol to manage spasticity in children with cerebral palsy (CP) and other neurologic conditions. DESIGN: A retrospective case series. SETTING: A tertiary care children's hospital. PARTICIPANTS: Consecutive patients (N=68) with spasticity related to CP or other neurologic conditions. INTERVENTION: Ninety injection sessions combining botulinum toxin and phenol to manage spasticity. MAIN OUTCOME MEASURE: Documentation of adverse reactions. RESULTS: The mean phenol dosage was 9.5mL at a mean of 0.6mL/kg per injection dose. The mean botulinum toxin type A (Botox) dose injected was 193U (12U/kg), and the mean of botulinum toxin type B (Myobloc) dose injected was 7750U (530U/kg). The mean number of muscles injected was 14. Adverse reactions are described but were infrequent. Dysesthetic hand pain occurred in 2 patients. One patient developed a systemic reaction to Myobloc. CONCLUSIONS: Using botulinum toxin and phenol injections allowed many muscles to be injected to manage spasticity in children with CP and other neurologic conditions. Using this combination allowed an increased number of injections at the maximal recommended dose.