A型肉毒毒素治疗痉挛型脑性瘫痪

脑性瘫痪中,痉挛型所占比例最大,造成患儿肌肉痉挛、关节及骨骼畸形学,严重影响患儿的运动功能及社会能力。相对于其他类型,痉挛型脑性瘫痪是治疗效果相对较好的一型。在其治疗中曾探索应用中神经阻滞剂、脊神经后根切断术等治疗方法,疗效均不满意。近年来,A型肉毒毒素局部肌肉注射因为其具有可以选择性地使肌肉痉挛程度降低以及相对较小的毒副作用,引起了医疗界的广泛关注,开辟了脑性瘫痪治疗的新领域。现结合文献,就该型脑性瘫痪的A型肉毒毒素治疗作一综述。     

A型肉毒毒素在治疗脑性瘫痪中的应用

脑性瘫痪 (cerebralpalsy ,CP)是由于围生期脑损伤所致的中枢性运动障碍和姿势异常 ,其发病率在发达国家不低于0 .2 %。由于低出生体重婴儿成活率的增加 ,世界范围内CP发病率明显增高。CP是造成儿童肢体残疾的主要疾病 ,由于始终没有满意的治疗方法而成为世界性难题。CP有很多分型 ,其中 2 / 3是痉挛型。因此 ,降低肌张力、减轻肌痉挛成为治疗中的重要环节。以往常用口服药物或手术矫形等方法。目前对痉挛型CP新疗法 ,除选择性脊神经后根切断术、鞘内巴氯芬注射疗法外[1] ,还有肉毒杆菌毒素A(botulinumtoxinA ,BTXA)肌肉注射。BTXA…     

肉毒毒素A注射治疗痉挛性脑性瘫痪的研究进展

肉毒毒素A作为小儿脑性瘫痪的一种新型辅助治疗药物,已越来越多的受到临床医师的关注。结合近几年来对该药不断深入的认识以及临床经验的总结,采用文献回顾的方法对该药的生物学特性、作用机制、临床应用等方面进行综述,以期为该药的合理应用提供帮助。     

A型肉毒毒素治疗脑性瘫痪的剂量-反应关系的研究

目的 观察不同剂量A型肉毒毒素(BTX-A)治疗痉挛型脑性瘫痪(CP)的剂量-反应关系。方法用BTX-A对58例下肢痉挛型CP患儿局部肌肉注射,高剂量组32例,低剂量组26例。以MAS改良肌张力量表评定肌张力。分析治疗前后肌张力改善状况及副作用,进行统计学x2检验。结果 高剂量组中,肌张力改变显著、有效、无效病例分别为20、7、5例;低剂量组分别为7、13、6例。两组治疗前后肌张力改善情况,有显著性差异P<0.05。两组均副作用少、轻微,呈暂时性,无全身性副作用发生,两组比较无显著性差异P>0.05。结论 不同剂量BTX-A治疗CP的效果不同,一定范围内,高剂量组较低剂量组更有效。     

A型肉毒毒素治疗痉挛型脑性瘫痪

脑性瘫痪中,痉挛型所占比例最大,造成患儿肌肉痉挛、关节及骨骼畸形等,严重影响患儿的运动功能及社交能力。相对于其他类型,痉挛型脑性瘫痪是治疗效果相对较好的一型。在其治疗中曾探索应用了神经阻滞剂、脊神经后根切断术等治疗方法,疗效均不满意。近年来,Ａ型肉毒毒素局部肌肉注射因为其具有可以选择性地使肌肉痉挛程度降低以及相对较小的毒副作用,引起了医疗界的广泛关注,开辟了脑性瘫痪治疗的新领域。现结合文献,就该型脑性瘫痪的Ａ型肉毒毒素治疗作一综述。     

重复注射A型肉毒毒素治疗痉挛型脑性瘫痪

目的观察重复肌肉注射A型肉毒毒素(BTX-A)治疗痉挛型脑性瘫痪的疗效。方法用BTX-A对30例重度痉挛型脑性瘫痪患儿进行2次局部肌肉注射,2次注射间隔为3个月,注射剂量4 U/(kg.次)。以改良阿氏量表(MAS)评定肌张力,以运动评价量表(PRS)评定运动功能。分析注射前、2次重复注射后3个月的肌张力、PRS分数变化。应用配对t检验进行统计分析。结果BTX-A第2次治疗前后肌张力、PRS分值均具有显著性差异(P均<0.001)。结论局部重复肌肉注射BTX-A能有效治疗重度痉挛型脑性瘫痪,提高运动功能。     

A型肉毒毒素辅助综合康复训练治疗痉挛型脑性瘫痪

目的研究A型肉毒毒素辅助综合康复训练对痉挛型脑性瘫痪的治疗效果。方法选择43例痉挛型脑性瘫痪患儿用国产BTX-A进行下肢痉挛肌肉局部注射辅助综合康复训练，应用改良Ashworth痉挛等级量表（MAS）、医师等级评价量表（PRS）方法进行治疗前后的疗效评价。结果BTX-A注射后不同时间与注射前比较肌张力降低及异常姿势改善有统计学差异。结论BTX-A注射辅助综合康复训练治疗痉挛型脑瘫较好地改善了肌肉痉挛状态及异常姿势，提高了康复疗效。     

超声定位A型肉毒毒素肌肉注射治疗痉挛型脑性瘫痪30例疗效观察

目的探讨不同定位术A型肉毒毒素肌肉注射治疗痉挛型脑性瘫痪患儿的临床疗效。方法选取痉挛型脑瘫患儿,按就诊次序编号,单号编入意愿分为超声定位A型肉毒毒素痉挛肌靶点注射术组(观察组),双号编入神经电生理刺激仪定位神经肌肉接头处阻滞术组(对照组),两组各30例患儿。两组患儿均给予一般康复训练和治疗,如针灸、推拿、功能训练,疗程3个月。治疗前后进行GMFM量表评分、关节活动度比较;操作时程比较;好转率比较。结果两组患儿经不同探测定位方式注射A型肉毒毒素后疗效比较,观察组好转率明显高于对照组,差异有统计学意义(P<0.05);在GMFM评分比较中,注射后3个月时两组对比结果:观察组评分明显提高,与对照组比较差异有统计学意义(P<0.05);两组操作时程在45min以内结果比较差异有统计学意义(P<0.05)。结论超声定位A型肉毒毒素肌肉注射治疗方法优于神经电生理刺激仪定位神经肌肉接头处阻滞术。     

Ａ型肉毒毒素治疗痉挛型脑性瘫痪下肢肌群的剂量-反应关系研究

近年来,应用A型肉毒毒素（BTX-A）局部肌肉注射治疗痉挛性脑性瘫痪已被广泛接受,并取得了较好疗效,但目前尚无儿童最佳治疗剂量。本文通过前瞻性随机对照方法对此进行研究,报道如下。     

超声定位A型肉毒毒素治疗脑性瘫痪患儿下肢肌肉痉挛的疗效

目的 观察超声定位A型肉毒毒素(BTX-A)注射治疗脑性瘫痪患儿下肢肌肉痉挛的疗效.方法 选择下肢肌肉痉挛的脑性瘫痪患儿75例,分为超声定位BTX-A注射治疗组37例(注射组)和单纯康复治疗组38例(对照组).其中注射组在超声定位后予BTX-A注射患儿下肢痉挛肌群,注射后次日开始进行康复训练.所有患儿在治疗前及治疗2周、1个月、3个月、6个月分别采用改良Ashworth量表(MAS)和粗大运动功能量表(GMFM)行相关评价.结果 注射组在注射2周、1个月、3个月、6个月肌肉痉挛的改善及GMFM评分均优于注射前(P均＜0.01),且痉挛程度在注射2周、1个月改善最明显.注射组治疗效果明显优于对照组(P＜0.05).注射组3个月和6个月MAS评分差异无统计学意义,BTX-A注射有时效性,6个月后可重复注射.结论 采用超声定位BTX-A注射治疗脑性瘫痪患儿下肢肌肉痉挛,定位准确、安全,患儿依从性好,疗效优于单纯康复治疗.     

European consensus table 2006 on botulinum toxin for children with cerebral palsy

An interdisciplinary group of experienced botulinum toxin users and experts in the field of movement disorders was assembled, to develop a consensus on best practice for the treatment of cerebral palsy using a problem-orientated approach to integrate theories and methods. The authors tabulated the supporting evidence to produce a condensed but comprehensive information base, pooling data and experience from nine European countries, 13 institutions and more than 5500 patients. The consensus table summarises the current understanding regarding botulinum toxin treatment options in children with CP.     

A型肉毒毒素注射治疗9~36月龄脑瘫患儿腓肠肌痉挛的前瞻性研究

目的探讨A型肉毒毒素(BTX-A)注射对9~36月龄脑瘫患儿下肢腓肠肌痉挛的长期临床疗效及不良反应。方法选择9~36月龄腓肠肌痉挛脑瘫患儿80例,随机分为BTX-A注射组和常规治疗组,每组40例。BTX-A注射组在彩色多普勒超声仪引导下行BTX-A注射,注射后给予4疗程常规康复训练;常规治疗组仅给予4疗程相同常规康复训练。治疗前及治疗后1、2、3、6个月采用改良Tardieu量表(MTS)评定腓肠肌痉挛程度,采用表面肌电图(s EMG)被动状态数值评估肌张力,采用粗大运动功能测试(GMFM)评价粗大运动功能。结果在降低MTS评分和s EMG被动状态数值方面,BTX-A注射组优于常规治疗组(P0.05);在增大MTS踝关节角度R1、R2和提高大运动GMFM评分方面,BTX-A注射组优于常规治疗组(P0.05)。未见严重的BTX-A注射相关不良反应。结论 BTX-A注射治疗9~36月龄脑瘫患儿腓肠肌痉挛是有效和安全的。     

Botulinum toxin in children with cerebral palsy

Botulinum toxin is a neurotoxin that blocks the synaptic release of acetylcholine from cholinergic nerve terminals mainly at the neuromuscular junction, resulting in irreversible loss of motor end plates. It is being widely tried as a targeted antispasticity treatment in children with cerebral palsy. A number of studies have shown that it reduces spasticity and increases the range of motion and is particularly useful in cases with dynamic contractures. However improvement in function has not been convincingly demonstrated. It is an expensive mode of therapy and the injections need to be repeated after 3–6 months. Whereas Botulinum toxin can be a valuable adjunct in select cases, it should not be projected as a panacea for children with spastic cerebral palsy.     

Long-term use of botulinum toxin type A in children with cerebral palsy: Treatment consistency

At the University Hospital of Pellenberg (Belgium), more than 1000 patients have been treated with Botulinum toxin type A (BTX-A) over the last decade. Ten percent of these patients (n = 106) received multiple (at least four times), multi-level, high-dosage treatments. The aim of this study was to evaluate the stability of dosage and treatment intervals in long-term, multi-level, high-dosage treated children with cerebral palsy and to evaluate the evidence for a safe and stable response to this treatment. Data on disease, age, dosage and target muscles were extracted for each treatment session of 106 patients who received multiple BTX-A treatment sessions. Patients had a follow-up of 4 y 6 mo (range 1 y 8 mo–8 y 9 mo) on average and received 4 to 12 BTX-A treatments within the period of January 1996 and December 2005. Patients received a mean dosage of 23.5 ± 5.2 U/kg bw at first treatment with stable subsequent values. Mean dosages for children with diplegia, hemiplegia and quadriplegia were 24.5 ± 4.7 U/kg bw, 15.9 ± 3.7 U/kg bw and 22.0 ± 4.8 U/kg bw, respectively. Mean age at first treatment was 4 y 6 mo (range 1 y 11 mo–18 y 10 mo) with a majority of patients (76.4%) first treated within 2 and 4 y of age. Treatment intervals of approximately 1 y remained stable within four, five and six subsequent treatments. Long-term, high-dosage, multi-level BTX-A applications can be considered as a safe and stable treatment option for children with cerebral palsy and the formation of antibodies, responsible for secondary non-response, can be indirectly precluded.     

A型肉毒毒素治疗儿童痉挛型脑性瘫痪的临床研究

目的　观察局部肌肉注射A型肉毒毒素 (BTX A)治疗痉挛型脑性瘫痪的疗效。方法　于 2 0 0 1年 5月至 2 0 0 3年 9月 ,用BTX A对 73例痉挛型脑性瘫痪的患儿进行局部肌肉注射 ,其中男性 5 2例 ,女性 2 1例。年龄1 6～ 15 (10 4± 2 5 )岁。以改良阿氏量表 (MAS)评定肌张力 ,以运动评价量表 (PRS)评定运动功能。分析治疗前、治疗后 4周及治疗后 3个月的肌张力、PRS评分改变情况 ,并随访治疗后BTX A产生疗效时间及副反应。结果　BTX A治疗前、治疗后 4周及治疗后 3个月肌张力、PRS评分有明显改善。治疗后 4周 ,PRS各项评分均有明显改善 (P <0 0 5 ) ,其中步态、关节弯曲度改善最明显 (P <0 0 0 1)。 4 8例 (6 6 % )患儿在治疗 2～ 3d出现疗效。副反应短暂、轻微 ,无全身副反应。结论　局部肌肉注射BTX A能够安全地治疗痉挛型脑性瘫痪 ,有效改善步态、提高行走能力     

电刺激定位引导肉毒毒素治疗脑性瘫痪患儿踝蹠屈肌群痉挛的对照研究

目的比较电刺激定位引导肉毒毒素A(BTX-A)注射结合物理治疗与单纯物理治疗对脑性瘫痪(脑瘫)患儿踝蹠屈肌群痉挛的临床疗效。方法43例脑瘫患儿,年龄35~82个月(52·4±13·2个月),随机分为2组:①电刺激定位引导BTX-A注射结合物理治疗组(BTX-A组,23例);②单纯物理治疗组(20例)。患儿入选后分别在治疗前,治疗后的2周、1、2、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),③综合痉挛量表(CSS),④粗大运动功能量表(GMFM)中的D和E两项,⑤步行速度。BTX-A组在注射后72h、单纯物理治疗组入组后开始为期10d的物理治疗并配戴踝足矫形器,所有患儿10d后改由家长在家进行治疗。结果两组患儿踝PROM、MAS、CSS、GMFM评分及步行速度治疗前差异无统计学意义(P>0·05),治疗后2周、1、2、3个月组内差异均有统计学意义(P均<0·001)。PROM、MAS、CSS评分治疗后2周、1、2、3个月组间差异均有统计学意义(治疗后3个月:t值分别为6·48、9·74、9·59,P均<0·05)。GMFM评分治疗后1、2、3个月组间差异均有统计学意义(t值分别为2·20、3·26、4·13,P均<0·05)。步行速度治疗后2、3个月组间差异均有统计学意义(t值分别为2·12、2·57,P均<0·05)。结论电刺激定位引导BTX-A注射结合物理治疗较单纯物理治疗能更好地缓解脑瘫患儿踝蹠屈肌群痉挛,提高患儿的运动能力。     

A French observational study of botulinum toxin use in the management of children with cerebral palsy: BOTULOSCOPE

Background

Dystonia and spasticity are common symptoms in children with Cerebral Palsy (CP), whose management is a challenge to overcome in order to enable the harmonized development of motor function during growth.

Aim

To describe botulinum toxin A (BTX-A) use and efficacy as a treatment of focal spasticity in CP children in France.

Methods

This prospective observational study included 282 CP children mostly administered according to French standards with BTX-A in lower limbs. Realistic therapeutic objectives were set with parents and children together before treatment initiation and assessed using the Visual Analogue Scale (VAS). Child management was recorded and the efficacy of injections was assessed during a 12-month follow-up period by physicians (Modified Ashworth Scale, joint range of motion, Physician Rating Scale, Gillette Functional Assessment Questionnaire and Gross Motor Function Measure-66) and by patients/parents (Visual Analogue Scale).

Results

BTX-A treatment was administered in different muscle localizations at once and at doses higher than those recommended by the French Health Authorities. Children were treated in parallel by physiotherapy, casts and ortheses. Injections reduced spasticity and improved joint range of motion, gait pattern and movement capacity. Pain was reduced after injections. BTX-A administration was safe: no botulism-like case was reported. The log of injected children who were not included in the study suggested that a large population could benefit from BTX-A management.

Conclusions

We showed here the major input of BTX-A injections in the management of spasticity in CP children. The results are in favor of the use of BTX-A as conservative safe and efficient treatment of spasticity in children, which enables functional improvement as well as pain relief.     

Botulinumtoxin A treatment in toddlers with cerebral palsy

Aims: In this study the aim was to evaluate the effect of botulinum toxin A (BoNT‐A) treatment on muscle tone, contracture development and gait pattern in young children with cerebral palsy (CP). Method: Fifteen children with spastic CP (mean age = 16 months) were included in a randomized control study. All received a daily stretching programme and children in the BoNT‐A group additionally received two injections, 6 months apart in the gastrocnemius muscle. Outcomes were assessed at baseline, and after 1 and 3.5 years. A 3D gait‐analysis was performed at 5 years of age. Results: Plantarflexor muscle tone in the BoNT‐A group was significantly reduced after 3.5 years, while the muscle tone at the ankle and knee in the control group remained unchanged. The change‐score in knee‐flexion muscle tone between the groups was significantly different after 3.5 years. The knee joint ROM was significantly increased at 1 year in the BoNT‐A group but reduced at the knee and ankle joints in the control group after 3.5 years. No group differences were found for gait analysis, GMFM‐66 or PEDI. Conclusion: Early treatment of BoNT‐A in children with spastic CP may decrease muscle tone and decelerate contracture development after 3.5 years. The effect on gait development remains inconclusive.