Parent evaluation of spasticity treatment in cerebral palsy using botulinum toxin type A

OBJECTIVE: To assess parent ratings of treatment acceptability associated with botulinum toxin type A (BTX-A) injection for spasticity in children with cerebral palsy (CP). DESIGN: A single-point survey design across a sequentially recruited cohort, using a standardized evaluation measure. SETTING: Regional specialty health care center medical clinic and pain research program. PARTICIPANTS: Fifty-nine parents of children with CP receiving BTX-A injection for spasticity. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: The Treatment Evaluation Inventory. RESULTS: Overall, parent ratings of treatment acceptability ranged from moderate to high. There were no significant differences for caregiver ratings in relation to characteristics of the raters (age, sex, marital status) or of the children (age, sex, mental retardation, severity of disability) characteristics. CONCLUSIONS: These findings indicate that on average, parents of children with CP consider BTX-A treatment for the management of spasticity to be an acceptable form of treatment.     

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.     

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。     

Robotic therapy and botulinum toxin type A: a novel intervention approach for cerebral palsy

The combined effects of robotic therapy and botulinum toxin type A (BTX-A) on upper-limb movement and function were studied in an 8(1/2)-yr-old child with hemiplegic cerebral palsy. Robotic therapy comprising repetitive, goal-directed reaching tasks was administered two times per week for 8 wks. Clinical measures included the Modified Ashworth Scale, the Quality of Upper Extremity Skills Test, and the Fugl-Meyer Assessment (upper-limb section). Improvements in upper-limb coordination and quality of motor performance were apparent throughout the robotic therapy trial. The observed gains are comparable with those attained from conventional occupational therapy combined with BTX-A. A parent questionnaire indicated that the amount of paretic arm use also improved during daily activities at home. This preliminary study indicates that robotic therapy may be a useful clinical tool when combined with BTX-A injections for improving upper-limb coordination and quality of motor performance in children with cerebral palsy.     

A型肉毒毒素改善脑性瘫痪儿童下肢痉挛状态的效果评价

目的评估A型肉毒毒素(botulinumtoxinA,BTX-A)在下肢痉挛性脑性瘫痪(CP)患儿的治疗作用。方法11例痉挛性CP患儿,采用BTX-A3～6IU/kg注射下肢痉挛肌肉,依照马氏等制定的疗效与评估标准和修订的Ashworth量表评估注射前与注射后72h、1、2、4、8周不同时期的运动功能、痉挛状态及肌张力的变化。结果运动功能恢复和肌肉痉挛状态改善,注射后较注射前比较差异有显著或非常显著性意义(P<0.05,P<0.01).结论BTX-A注射疗法有较好的改善运动功能和降低下肢肌肉痉挛状态。     

The role of botulinum toxin a in the management of lower limb spasticity in patients with cerebral palsy

This study aimed to determine the effects of botulinum toxin-A (btA) on spasticity in children with cerebral palsy (CP). Thirty-five children with spastic CP were evaluated. The injection group consisted of 25 patients who were injected with btA and received conventional physical therapy. The control group consisted of 10 patients who were treated with conventional physical therapy only. In the injection group, btA was applied to the lower extremity spastic muscles at a total dose of 8-10 lU/kg. Spasticity was measured by the Ashworth scale. Gait function was evaluated by clinical gait assessment in all patients and temporal distance factors in 16 patients. All the parameters were recorded before treatment, after three days and after one month of therapy. Following injection of btA, significant improvement in all parameters was observed. No statistically significant progression was noted in the control group except clinical gait analysis scores. Comparing the three-day and one-month measurements of spasticity of the two groups, statistically significant results were obtained in favour of the injection group in all parameters except for clinical gait analysis scores. The findings of this study showed btA injection to be an effective treatment for reducing spasticity and improving gait function in patients with spastic CP     

肉毒毒素A对肌肉痉挛患者功能康复的作用

目的：探讨A型肉毒毒素（botulinum toxin type A，BTX—A）对上运动神经元损伤后肢体肌肉痉挛的治疗价值及其剂量影响。方法：选择48例上运动神经元损伤患者采用肉毒毒素A电刺激引导下局部肌肉注射治疗肌痉挛，其中把小腿三头肌、肱二头肌、屈指肌随机分成高低两个剂量组，观察剂量不同对疗效的影响，同时对所有患者制订注射后的目标，观察其达标情况。结果：肉毒毒素A注射后肌肉张力明显降低（P〈0．05），但在小腿三头肌、肱二头肌及屈指肌群中均未发现明显的量效关系，各配对大小剂量组肌张力评分差异无显著性意义（P〉0．05）；患者功能显著改善，康复目标总达标率为70．4％，肉毒毒素对上肢的粗大运动及下肢的步行功能的改善效果明显，而对手的精细活动功能的恢复效果欠佳。结论：肉毒毒素A对缓解上运动神经元损伤后的肢体肌肉痉挛，提高其生活自理能力及运动功能疗效显著，肉毒毒素作用的量效关系尚有待确认.     

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.     

Gait training using a hybrid assistive limb after botulinum toxin treatment for cerebral palsy: a case report

[Purpose] Hybrid Assistive Limb^® (HAL; Cyberdyne, Tsukuba, Japan) is a wearable robot that assists patients based on their voluntary movements. We report gait training with HAL after botulinum toxin treatment for spasticity of the lower limb in cerebral palsy (CP). [Participant and Methods] The participant was a 36 year-old male with spastic diplegia due to periventricular leukomalacia, with Gross Motor Function Classification System (GMFCS) level II. HAL training was performed in 20-minute sessions (3 sessions/week for 4 weeks). The outcome measures were range of motion, spasticity, walking ability, muscle strength, gross motor function measure (GMFM), Canadian Occupational Performance Measure (COPM), and Pediatric Evaluation of Disability Inventory measured before, immediately after, and one, two, and three months after HAL training. [Results] No adverse events were observed during training. After the HAL intervention, gait speed, step length, cadence, 6-min walking distance (6MD), knee extension strength, GMFM, and COPM increased, and Physiological Cost Index declined. Three months post-intervention, gait speed, step length, cadence, 6MD, and GMFM remained higher than those observed within the first two months. [Conclusion] Gait training with HAL can be a safe and feasible method for patients with CP who undergo botulinum toxin treatment to improve walking ability and motor function.     

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.     

A型肉毒毒素治疗儿童痉挛型脑瘫疗效的Meta分析

目的：系统评价A型肉毒毒素（BTX-A）治疗儿童痉挛型脑瘫的临床疗效及安全性。方法：计算机检索PubMed、EMbase、Cochrane Library、中国生物医学文献数据库(CMB)、中国知网（CNKI）和万方数据库（WanFang Data）。搜集关于BTX A治疗儿童痉挛型脑瘫患者的随机对照试验（RCT）,检索时限均为从建库至2018年11月1日。由至少2位评价员按纳入与排除标准进行文献筛查、资料提取和质量评价。利用Review Manager 5.3及State 12软件进行Meta分析。结果：共有22篇研究符合纳入标准,共1218例患者,肉毒素治疗组620例,对照组598例。Meta 分析结果显示:肉毒素治疗组在MAS评分［MD =-0.82,95%CI(-0.86,-0.79),Z=50.34,P＜0.05］,GMFM评分［MD =9.22,95%CI(7.80,10.65),Z=12.70,P＜0.05］,ADL评分［MD =11.38,95%CI(7.51,15.24),Z=5.77,P＜0.05］,CSS评分［MD =-1.9,95%CI(-3.45,-0.35),Z=2.4,P＜0.05］,关节屈曲度［MD =0.7,95%CI(0.39,1.02),Z=4.4,P＜0.05］及有效率［RR =1.3,95%CI(1.13,1.5),Z=3.63,P＜0.05］方面优于对照组,差异有统计学意义(P＜0.05)。结论：BTX A结合康复训练能够明显改善痉挛型脑瘫患儿的肢体运动功能、肌肉紧张状态及生活质量,是一种有效的治疗儿童痉挛型脑瘫的方法;但在临床应用过程中应严格把握治疗剂量,根据患儿病情综合考虑。     

不同定位技术引导肉毒毒素治疗脑瘫患儿踝跖屈肌群痉挛的对照研究

目的 比较电刺激定位技术与经验定位引导肉毒毒素A（BTX-A）注射治疗脑瘫患儿踝跖屈肌群痉挛的临床疗效。方法 45例脑瘫患儿随机分为电刺激定位组23例，经验定位组22例。2组接受BTX-A注射后3d，开始进行10d物理治疗，之后改由家长在家治疗。患儿在治疗前和治疗后3d、2周、1个月、2个月、3个月进行以下评定：①踝关节被动活动范围（PROM）；②改良Ashworth量表（MAS）评分；③综合痉挛量表（CSS）评分；④粗大运动功能量表（GMFM）D、E项评分；⑤步行速度。结果 2组患儿的PROM、MAS评分、CSS评分、GMFM评分和步行速度，在治疗后2周、1个月、2个月、3个月分别与治疗前比较，差异均有统计学意义（P〈0．001）。PROM、CSS评分在治疗后3d、2周、1个月、2个月、3个月组间差异有统计学意义（P〈0．05）。MAS评分在治疗后3d、2个月、3个月时组间差异有统计学意义（P〈0．05）。GMFM评分在治疗后2个月、3个月组间差异有统计学意义（P〈0．05）。步行速度差值在治疗后2个月、3个月时组间差异有统计学意义（P〈0．05）。结论 电刺激定位技术较经验定位引导BTX-A注射结合物理治疗能更好地缓解脑瘫患儿踝跖屈肌群痉挛，提高患儿运动能力。     

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。