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

BC Children's Hospital, Department of Pediatrics, Vancouver, BC V6H 3V4, Canada.
Canadian family physician Medecin de famille canadien (Impact Factor: 1.34). 09/2011; 57(9):1006-73.
Source: PubMed


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.

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    • "No cure exists at this time for CP, but many treatments are used to improve gait and function. These include tendon lengthening [6], transfers, releases, selective dorsal rhizotomy [7], Botulinum toxin injections [8], Baclofen, stretching, casting, orthotics and robotic rehabilitation [9] [10] [11]. Recent results indicate that increases in ankle or knee strength after training can improve gait and function in children with CP [12] [13]. "
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    ABSTRACT: Objective: To investigate the feasibility of gamebased robotic training of the ankle in children with cerebral palsy (CP). Design: Case study, 12 weeks intervention, with no follow-up. Setting: University research laboratory. Participants: A referred sample of 3 children with cerebral palsy, age 7 to 12, all male, were enrolled. All completed the intervention. Interventions: Participants trained on the Rutgers Ankle CP system for 36 rehabilitation sessions (12 weeks, 3 times/week), playing two custom virtual reality games. The games were played while participants were seated, and trained one ankle at-a-time for strength, motor control, and coordination. Main Outcome Measures: The primary study outcome measures were for impairment (DF/PF torques, DF initial contact angle and gait speed), function (GMFM) and quality of life (Peds QL). Secondary outcome measures relate to game performance (game scores as reflective of ankle motor control and endurance). Results: Gait function improved substantially in ankle kinematics, speed and endurance. Overall function (GMFM) indicated improvements that were typical of other ankle strength training programs. Quality of life increased beyond what would be considered a minimal clinical important difference. Game performance improved in both games during the intervention. Conclusions: This feasibility study supports the assumption that game-based robotic training of the ankle benefits gait in children with CP. Game technology is appropriate for the age group and was well accepted by the participants. Additional studies are needed however, to quantify the level of benefit and compare the approach presented here to traditional methods of therapy.
    IEEE transactions on neural systems and rehabilitation engineering: a publication of the IEEE Engineering in Medicine and Biology Society 07/2012; 21(2). DOI:10.1109/TNSRE.2012.2206055 · 3.19 Impact Factor
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    ABSTRACT: Cerebral palsy is the most common cause of childhood physical disability in developed countries, affecting two children per 1000 live births. Hip displacement affects about one-third of children with cerebral palsy and may result in pain, deformity, and impaired function. The prevention of hip displacement has not been studied in a randomized trial as far as we know. A randomized, controlled trial was conducted to examine the effect of intramuscular injections of botulinum toxin A combined with use of a variable hip abduction brace on the progression of hip displacement in children with cerebral palsy. The patients in the treatment group received injections of botulinum toxin A to the adductor and hamstring muscles every six months for three years and were prescribed a hip abduction brace to be worn for six hours per day. In the control group, no hip bracing was used nor were injections performed. The primary outcome measure was hip displacement from the acetabulum as determined by serial measurements of the migration percentage. Ninety children with bilateral cerebral palsy and so-called hips at risk (a migration percentage of >10% but <40%) were entered into the study. Fifty-nine patients were boys, and the mean age was three years. Progressive hip displacement, as determined by serial measurements of the migration percentage, was found in both the treatment and control groups. The rate of hip displacement was reduced in the treatment group by 1.4% per year (95% confidence interval, -0.6% to 3.4%; p = 0.16) when weighted for the uncertainty in rates due to the differing numbers of migration percentage measurements per subject. There may be a small treatment benefit for the combined intervention of intramuscular injection of botulinum toxin A and abduction hip bracing in the management of spastic hip displacement in children with cerebral palsy. However, progressive hip displacement continued to occur in the treatment group, and our data do not support recommending this treatment.
    The Journal of Bone and Joint Surgery 01/2008; 90(1):23-33. DOI:10.2106/JBJS.F.01416 · 5.28 Impact Factor
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    ABSTRACT: Paralysis of the masticatory muscles using botulinum toxin (BTX) is a common treatment for cosmetic reduction of the masseters as well as for conditions involving muscle spasm and pain. The effects of this treatment on mastication have not been evaluated, and claims that the treatment unloads the jaw joint and mandible have not been validated. If BTX treatment does decrease mandibular loading, osteopenia might ensue as an adverse result. Rabbits received a single dose of BTX or saline into one randomly chosen masseter muscle and were followed for 4 or 12 weeks. Masticatory muscle activity was assessed weekly, and incisor bite force elicited by stimulation of each masseter was measured periodically. At the endpoint, strain gages were installed on the neck of the mandibular condyle and on the molar area of the mandible for in vivo bone strain recording during mastication and muscle stimulation. After termination, muscles were weighed and mandibular segments were scanned with micro CT. BTX paralysis of one masseter did not alter chewing side or rate, in part because of compensation by the medial pterygoid muscle. Masseter-induced bite force was dramatically decreased. Analysis of bone strain data suggested that at 4 weeks, the mandibular condyle of the BTX-injected side was underloaded, as were both sides of the molar area. Bone quantity and quality were severely decreased specifically at these underloaded locations, especially the injection-side condylar head. At 12 weeks, most functional parameters were near their pre-injection levels, but the injected masseter still exhibited atrophy and percent bone area was still low in the condylar head. In conclusion, although the performance of mastication was only minimally harmed by BTX paralysis of the masseter, the resulting underloading was sufficient to cause notable and persistent bone loss, particularly at the temporomandibular joint.
    Bone 12/2011; 50(3):651-62. DOI:10.1016/j.bone.2011.11.015 · 3.97 Impact Factor
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