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Crisafulli S, Ciccimarra F, Khan Z, Maccarrone F, Trifirò G. Understanding Clinical Effectiveness and Safety Implications of Botulinum Toxin in Children: A Narrative Review of the Literature. Toxins (Basel) 2024; 16:306. [PMID: 39057946 PMCID: PMC11281390 DOI: 10.3390/toxins16070306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Revised: 06/20/2024] [Accepted: 07/01/2024] [Indexed: 07/28/2024] Open
Abstract
Since its first approval by the Food and Drug Administration in 1989 for strabismus, botulinum toxin indications of use have been widely expanded. Due to its anticholinergic properties, this toxin is currently approved in adult patients for the treatment of a wide range of neuromuscular, otolaryngologic, orthopedic, gastrointestinal, and urologic disorders. Approved pediatric indications of use include the treatment of blepharospasm associated with dystonia, strabismus, lower-limb spasticity, focal spasticity in patients with cerebral palsy, and neurogenic detrusor overactivity. Alongside these approved indications, botulinum toxin is extensively used off-label. Although several clinical studies have shown that botulinum toxin is effective and well-tolerated in children, uncertainties persist regarding its long-term effects on growth and appropriate dosing in this population. As such, further research is needed to better define the botulinum toxin risk-benefit profile and expand approved uses in pediatrics. This narrative review aimed to provide a broad overview of the evidence concerning the clinical effectiveness and safety of BoNT with respect to its principal authorized and non-authorized pediatric therapeutic indications, as well as to describe perspectives on its future use in children.
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Affiliation(s)
| | - Francesco Ciccimarra
- Department of Diagnostics and Public Health, University of Verona, 37124 Verona, Italy; (F.C.); (F.M.)
| | - Zakir Khan
- Department of Pharmacy Practice, Riphah Institute of Pharmaceutical Sciences, Riphah International University, Gulberg Green Campus, Islamabad 44000, Pakistan;
| | - Francesco Maccarrone
- Department of Diagnostics and Public Health, University of Verona, 37124 Verona, Italy; (F.C.); (F.M.)
| | - Gianluca Trifirò
- Department of Diagnostics and Public Health, University of Verona, 37124 Verona, Italy; (F.C.); (F.M.)
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Facciorusso S, Spina S, Picelli A, Baricich A, Francisco GE, Molteni F, Wissel J, Santamato A. The Role of Botulinum Toxin Type-A in Spasticity: Research Trends from a Bibliometric Analysis. Toxins (Basel) 2024; 16:184. [PMID: 38668609 PMCID: PMC11053519 DOI: 10.3390/toxins16040184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 04/01/2024] [Accepted: 04/08/2024] [Indexed: 04/29/2024] Open
Abstract
Botulinum toxin type-A (BoNT-A) has emerged as a key therapeutic agent for the management of spasticity. This paper presents a comprehensive bibliometric and visual analysis of research concerning BoNT-A treatment of spasticity to elucidate current trends and future directions in this research area. A search was conducted in the Web of Science database for articles focused on the use of BoNT-A in spasticity published between 2000 and 2022. We extracted various metrics, including counts of publications and contributions from different countries, institutions, authors, and journals. Analytical methods in CiteSpace were employed for the examination of co-citations, collaborations, and the co-occurrence of keywords. Our search yielded 1489 publications. Analysis revealed a consistent annual increase in research output. The United States, United Kingdom, and Italy were the leading contributors. The top institution in this research was Assistance Publique Hopitaux, Paris. The journal containing the highest number of relevant publications was Toxins. Key frequently occurring keywords were 'stroke', 'cerebral palsy', 'adult spasticity', and 'upper extremity'. This study identified 12 clusters of keywords and 15 clusters of co-cited references, indicating the main focus areas and emerging themes in this field. This study comprehensively analyzed and summarized trends in BoNT-A research in the field of spasticity over the past 22 years.
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Affiliation(s)
- Salvatore Facciorusso
- Spasticity and Movement Disorders “ReSTaRt”, Unit Physical Medicine and Rehabilitation Section, Department of Medical and Surgical Sciences, University of Foggia, 71122 Foggia, Italy; (S.F.); (A.S.)
- Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy
| | - Stefania Spina
- Spasticity and Movement Disorders “ReSTaRt”, Unit Physical Medicine and Rehabilitation Section, Department of Medical and Surgical Sciences, University of Foggia, 71122 Foggia, Italy; (S.F.); (A.S.)
| | - Alessandro Picelli
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37100 Verona, Italy;
| | - Alessio Baricich
- Physical Medicine and Rehabilitation, Department of Health Sciences, Università del Piemonte Orientale, 28100 Novara, Italy;
| | - Gerard E. Francisco
- Department of Physical Medicine & Rehabilitation, University of Texas Health McGovern Medical School, Houston, TX 77030, USA;
| | - Franco Molteni
- Villa Beretta Rehabilitation Center, Valduce Hospital Como, 23845 Costa Masnaga, Italy;
| | - Jörg Wissel
- Department of Neurorehabilitation and Physical Therapy, Vivantes Hospital Spandau, 13585 Berlin, Germany;
| | - Andrea Santamato
- Spasticity and Movement Disorders “ReSTaRt”, Unit Physical Medicine and Rehabilitation Section, Department of Medical and Surgical Sciences, University of Foggia, 71122 Foggia, Italy; (S.F.); (A.S.)
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Almutairi AB, Alrashdi NZ, Vogtle L, Alotaibi MM. Effect of psychostimulant medications on physical function in children with cerebral palsy: scoping review. Pediatr Res 2024; 95:1217-1223. [PMID: 38071277 DOI: 10.1038/s41390-023-02933-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 10/18/2023] [Accepted: 11/14/2023] [Indexed: 04/24/2024]
Abstract
The aim of this scoping review is to examine the extent and depth of the literature on effects of central nervous system (CNS) stimulant medications on physical function in children with cerebral palsy (CP). A systematic search for relevant peer-reviewed studies was conducted of PubMed, CINAHL, Cochrane, SPORTDiscus, Embase, & Scopus (January 2002 & August 2022). We included studies that examined the effects of CNS stimulants on physical function in children with CP. Four studies met our selection criteria. All studies explored the effect of Modafinil on physical function outcomes. Three studies of the four included studies reported positive effects of Modafinil on spasticity, motor performance, and gait, whereas one study reported no significant effects of Modafinil. Our findings suggest that there is very low-quality evidence that suggests that Modafinil may enhance physical improvements in body structure and function, including reduction in spasticity and improvements in gait parameters. IMPACT: Central nervous system stimulants were examined for efficacy on physical function and spasticity in children with cerebral palsy. The evidence on the effects of central nervous system stimulants on physical function in children with CP is limited and inconsistent.
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Affiliation(s)
- Anwar B Almutairi
- Department of Physical Therapy, Faculty of Allied Health, Kuwait University, Jabriya, Kuwait.
| | - Naif Z Alrashdi
- Department of Physical Therapy and Health Rehabilitation, College of Applied Medical Sciences, Majmaah University, Al-Majmaah, Saudi Arabia
| | - Laura Vogtle
- Department of Occupational Therapy, School of Health Professions, Birmingham, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Mansour M Alotaibi
- Department of Rehabilitation, Faculty of Applied Medical Sciences, Northern Border University, Arar, Saudi Arabia
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Alotaibi M, Almutairi AB, Alhirsan S, Alkazemi A, Alharbi M, Alrashdi N, Taqi A, Alamiri B, Vogtle L, Alqahtani MM. Psychostimulant Medications for Physical Function and Spasticity in Children With Cerebral Palsy: Protocol for a Randomized Controlled Trial. JMIR Res Protoc 2024; 13:e53728. [PMID: 38441919 PMCID: PMC10951828 DOI: 10.2196/53728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 02/06/2024] [Accepted: 02/09/2024] [Indexed: 03/07/2024] Open
Abstract
BACKGROUND Cerebral palsy (CP) is a prevalent nonprogressive disorder that leads to impaired movement (ie, spasticity), posture, and balance, which affects functions such as walking and upper extremity tasks. Current medical treatments show efficacy in improving motor performance but have considerable side effects. Emerging off-label use of central nervous system (CNS) medications for improving motor performance has shown promising results in children with CP and other populations. OBJECTIVE The aim of this study is to describe a protocol for a pilot randomized controlled trial (RCT) to examine the safety, tolerability, and efficacy of methylphenidate (MPH) and modafinil on spasticity and motor performance in children with CP. METHODS This will be a protocol study for a pilot, triple-masked, placebo-controlled RCT (a class I trial following the American Academy of Neurology criteria) with blinded patients, outcome assessors, and intervention delivery team. Eligible children should be diagnosed with CP levels I or II based on the Gross Motor Function Classification System and be aged between 7 and 12 years. Thirty-six children with CP will be randomized into 3 groups to receive (1) MPH (2.5 mg of MPH + 100 mg placebo), (2) modafinil (100 mg modafinil + 2.5 mg placebo), or (3) a placebo (2.5 mg placebo + 100 mg placebo), in addition to physical therapy for 12 weeks. Primary outcomes include the Gross Motor Function Measure-66 and the Modified Ashworth Scale. Secondary outcomes include the Timed Up and Go test, 5 Time Sit to Stand test, Modified Clinical Test for Sensory Interaction of Balance, and 10-Meter Walk Test. RESULTS The protocol has been accepted by Kuwait University (VDR/EC-225) and the Ministry of Health of Kuwait (2022/2157). The inclusion of participants will start in June 2024. CONCLUSIONS The combination of CNS stimulant medications and controlling for rehabilitation has not been studied yet. The findings of this study may determine if using CNS stimulant medications is beneficial for the reduction of spasticity and improvement of physical function in children with spastic CP. TRIAL REGISTRATION ClinicalTrials.gov NCT05675098; https://clinicaltrials.gov/study/NCT05675098. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) PRR1-10.2196/53728.
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Affiliation(s)
- Mansour Alotaibi
- Department of Rehabilitation, Faculty of Applied Medical Sciences, Northern Border University, Arar, Saudi Arabia
- Center for Health Research, Northern Border University, Arar, Saudi Arabia
| | - Anwar B Almutairi
- Department of Physical Therapy, Faculty of Allied Health, Kuwait University, Kuwait City, Kuwait
| | - Saleh Alhirsan
- Department of Physical Therapy, College of Applied Medical Sciences, Jouf University, Aljouf, Saudi Arabia
| | - Afrah Alkazemi
- Department of Pharmacy Practice, College of Pharmacy, Kuwait University, Kuwait City, Kuwait
| | - Maha Alharbi
- Department of Pharmacy Practice, College of Pharmacy, Kuwait University, Kuwait City, Kuwait
| | - Naif Alrashdi
- Department of Physical Therapy and Health Rehabilitation, College of Applied Medical Sciences, Majmaah University, Al-Majmaah, Saudi Arabia
- The Health and Scientific Research Center, Majmaah University, Majmaah, Saudi Arabia
| | - Ahmad Taqi
- Department of Pharmacy Practice, College of Pharmacy, Kuwait University, Kuwait City, Kuwait
| | - Bibi Alamiri
- Kuwait Center for Mental Health, Public Authority for Disability Affairs, Almanara, Kuwait
| | - Laura Vogtle
- Department of Occupational Therapy, School of Health Professions, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Mohammed M Alqahtani
- Department of Respiratory Therapy, College of Applied Medical Sciences, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
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Papageorgiou E, Peeters N, Staut L, Molenaers G, Ortibus E, Van Campenhout A, Desloovere K. Botulinum neurotoxin type A responders among children with spastic cerebral palsy: Pattern-specific effects. Eur J Paediatr Neurol 2024; 49:131-140. [PMID: 38518417 DOI: 10.1016/j.ejpn.2024.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 10/31/2023] [Accepted: 02/29/2024] [Indexed: 03/24/2024]
Abstract
AIM To identify short-term effects of botulinum neurotoxin type A (BoNT) injections on gait and clinical impairments, in children with spastic cerebral palsy (CP), based on baseline gait pattern-specific subgroups. METHOD Short-term effects of BoNT injections in the medial hamstrings and gastrocnemius were defined in a retrospective convenience sample of 117 children with CP (median age: 6 years 4 months; GMFCS I/II/III: 70/31/16; unilateral/bilateral: 56/61) who had received gait analyses before and 2 months post-BoNT. First, baseline gait patterns were classified. Statistical and meaningful changes were calculated between pre- and post-BoNT lower limb sagittal plane kinematic waveforms, the gait profile score, and non-dimensional spatiotemporal parameters for the entire sample and for pattern-specific subgroups. These gait waveforms per CP subgroup at pre- and post-BoNT were also compared to typically developing gait and composite scores for spasticity, weakness, and selectivity were compared between the two conditions. RESULTS Kinematic improvements post-BoNT were identified at the ankle and knee for the entire sample, and for subgroups with apparent equinus and jump gait. Limbs with baseline patterns of dropfoot and to a lesser extent true equinus showed clear improvements only at the ankle. In apparent equinus, jump gait, and dropfoot, spasticity improved post-BoNT, without leading to increased weakness or diminished selectivity. Compared to typical gait, knee and hip motion improved in the crouch gait subgroup post-BoNT. CONCLUSION This comprehensive analysis highlighted the importance of investigating BoNT effects on gait and clinical impairments according to baseline gait patterns. These findings may help identify good treatment responders.
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Affiliation(s)
- E Papageorgiou
- KU Leuven Department of Rehabilitation Sciences, Leuven, Belgium; Clinical Motion Analysis Laboratory, University Hospitals Leuven, Leuven, Belgium.
| | - N Peeters
- KU Leuven Department of Rehabilitation Sciences, Leuven, Belgium; Clinical Motion Analysis Laboratory, University Hospitals Leuven, Leuven, Belgium
| | - L Staut
- KU Leuven Department of Rehabilitation Sciences, Leuven, Belgium; Clinical Motion Analysis Laboratory, University Hospitals Leuven, Leuven, Belgium
| | - G Molenaers
- KU Leuven, Locomotor and Neurological Disorders, Department of Development and Regeneration, Leuven, Belgium; Department of Orthopedics, University Hospitals Leuven, Leuven, Belgium
| | - E Ortibus
- KU Leuven, Locomotor and Neurological Disorders, Department of Development and Regeneration, Leuven, Belgium; Center for Developmental Disabilities, Leuven, Belgium
| | - A Van Campenhout
- KU Leuven, Locomotor and Neurological Disorders, Department of Development and Regeneration, Leuven, Belgium; Department of Orthopedics, University Hospitals Leuven, Leuven, Belgium
| | - K Desloovere
- KU Leuven Department of Rehabilitation Sciences, Leuven, Belgium; Clinical Motion Analysis Laboratory, University Hospitals Leuven, Leuven, Belgium
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Moreira E, Rodrigues M, Beça G. Pain Management Strategies for Botulinum Toxin Type A Injections in Children: A Comprehensive National Survey and Procedural Protocol. Cureus 2023; 15:e48311. [PMID: 38058339 PMCID: PMC10697500 DOI: 10.7759/cureus.48311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/05/2023] [Indexed: 12/08/2023] Open
Abstract
INTRODUCTION Botulinum toxin type A injections are a first-line treatment for spasticity in children. Our purpose is to delineate the national landscape concerning pain management for botulinum toxin type A injections in pediatric patients and to formulate a protocol grounded in current scientific evidence. METHODS We conducted a nationwide survey targeting physical medicine and rehabilitation specialists performing botulinum toxin type A injections for focal spasticity in children in Portugal. We conducted a literature review to compare the survey results with clinical guidelines, good practice manuals, and protocols published in the literature. Finally, we developed a procedural protocol for pain management in botulinum toxin procedures. RESULTS The survey was completed by 17 out of 18 identified specialists. All but one use some form of periprocedural analgesia. Five do not use any type of sedation. The majority do not assess pain during the procedures. From the reviewed articles, we obtained 23 articles, 19 of which provided data for detailed analysis. CONCLUSIONS A prevailing concern centers around pain management during botulinum toxin procedures in children. Nevertheless, a distinct absence of uniformity persists in appraising and managing procedure-related pain. This notion is further underscored by the marked heterogeneity and paucity of published literature within this realm. The systematic implementation of a procedural protocol thus becomes highly crucial.
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Affiliation(s)
- Elisa Moreira
- Physical and Rehabilitation Medicine, Centro Hospitalar Tondela Viseu, Viseu, PRT
| | - Margarida Rodrigues
- Spinal Cord Injuries Department, Centro de Reabilitação do Norte - Centro Hospitalar de Vila Nova de Gaia Espinho, Porto, PRT
| | - Gustavo Beça
- Physical Medicine and Rehabilitation, Centro de Reabilitação do Norte - Centro Hospitalar de Vila Nova de Gaia Espinho, Porto, PRT
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Gormley M, Chambers HG, Kim H, Leon J, Dimitrova R, Brin MF. Treatment of pediatric spasticity, including children with cerebral palsy, with Botox (onabotulinumtoxinA): Development, insights, and impact. Medicine (Baltimore) 2023; 102:e32363. [PMID: 37499087 PMCID: PMC10374189 DOI: 10.1097/md.0000000000032363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/29/2023] Open
Abstract
Spasticity is a velocity-dependent increase in muscle tone that has a negative effect on quality of life and hinders the ability of others to provide care. In children, most cases are caused by cerebral palsy. Traditionally, many children are treated with surgery, sometimes performed before their limbs had grown sufficiently to permit long-term success. Nonsurgical treatment comprises oral pharmacological options, but their efficacy is limited and side effects such as drowsiness and decreased short-term memory are common; nerve block procedures can cause painful dysesthesias and muscle scarring. OnabotulinumtoxinA was first approved for the treatment of pediatric lower limb spasticity in Europe in the 1990s and is now licensed for use in pediatric patients in over 80 countries worldwide, based on a large body of clinical evidence demonstrating its efficacy and safety. In 2019 the U.S. Food and Drug Administration approved onabotulinumtoxinA for the treatment of pediatric patients with upper or lower limb spasticity. This approval represents 3 decades of work to refine the dose, measurements, patient selection, and muscle selection. The availability of onabotulinumtoxinA as a treatment for pediatric spasticity can have a substantial impact on a patient's quality of life. The use of onabotulinumtoxinA in combination with orthoses and occupational/physical therapy can postpone corrective surgery until growth is nearly complete and minimize the number of corrective surgeries.
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Affiliation(s)
- Mark Gormley
- Gillette Children's Specialty Healthcare, St Paul, MN, USA
| | - Henry G Chambers
- University of California and Rady Children's Hospital San Diego, San Diego, CA, USA
| | - Heakyung Kim
- Columbia University Irving Medical Center and New York Presbyterian Hospital, New York, NY, USA
| | - Judith Leon
- Allergan, an AbbVie company, Irvine, CA, USA
| | | | - Mitchell F Brin
- Allergan/AbbVie, Irvine, CA, USA
- University of California, Irvine, CA, USA
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Yang H, Chen S, Shen J, Chen Y, Lai M, Chen L, Fang S. Safety and Efficacy of Botulinum Toxin Type A in Children With Spastic Cerebral Palsy Aged <2 Years: A Systematic Review. J Child Neurol 2023; 38:454-465. [PMID: 37431191 DOI: 10.1177/08830738231183484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/12/2023]
Abstract
In this study, we reviewed the safety and efficacy of botulinum toxin type A (BoNT-A) injection with respect to motor development in children with spastic cerebral palsy aged <2 years. Randomized controlled trials of BoNT-A published between July 1993 and May 2021 were searched in PubMed, WANFANG, CNKI (Chinese National Knowledge Infrastructure), and Cochrane Library Central Register of Controlled Trials using keywords "Botulinum Toxin," "cerebral palsy," "nao xing tan huan," "nao tan," and "rou du du su." The 11-item PEDro Scale was used to rate the quality of all the identified studies. Twelve studies, involving 656 subjects, met the inclusion criteria, and of these, 2 involved patients aged <2 years. Treatment safety was assessed based on adverse event (AE) number and frequency, and efficacy was assessed based on spasticity, range of movement, and motor development. We observed that 3 self-limiting adverse events that were frequently reported included weakness, dysesthesia of the skin, and pain at the injection site. Moreover, there was a significant decrease in the incidence of spasticity and a notable improvement in the range of movement of BoNT-A-treated patients. Therefore, BoNT-A injection shows great safety and efficacy in the treatment of children with cerebral palsy aged <2 years.
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Affiliation(s)
- Hongyi Yang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Shiwei Chen
- Second Clinical Medical College, Southern Medical University, Guangzhou, China
| | - Jiaqi Shen
- Second Clinical Medical College, Southern Medical University, Guangzhou, China
| | - Yijing Chen
- Department of Pediatrics, Zhujiang Hospital, Southern Medical University, Guangzhou, China
- Dianliang Tongnian Pediatric Clinic, Guangzhou, China
| | - Minlin Lai
- Second Clinical Medical College, Southern Medical University, Guangzhou, China
| | - Linfei Chen
- Second Clinical Medical College, Southern Medical University, Guangzhou, China
| | - Suzhen Fang
- Department of Pediatrics, Zhujiang Hospital, Southern Medical University, Guangzhou, China
- Dianliang Tongnian Pediatric Clinic, Guangzhou, China
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Hedberg-Graff J, Granström F, Krumlinde-Sundholm L. Physical characteristics and upper-limb treatment with botulinum neurotoxin A in children with cerebral palsy: A population-based study. Dev Med Child Neurol 2023; 65:571-579. [PMID: 36177964 DOI: 10.1111/dmcn.15426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/28/2022] [Indexed: 11/03/2022]
Abstract
AIM To describe the use of upper-limb botulinum neurotoxin A (BoNT-A) treatment in a population-based sample of children with cerebral palsy (CP), by investigating whether factors may be related to a first upper-limb BoNT-A treatment and whether passive range of motion (ROM) is related to a first BoNT-A treatment after adjustment for confounders. METHOD Data from five regions in Sweden, in the national registry and follow-up programme for CP (CPUP), were collected for children with spastic or dyskinetic CP assessed between 2000 and 2017. CP subtypes, functional classification levels, and traffic-light-based passive ROM categories were investigated. Data were analysed with logistic regression (odds ratios). RESULTS Of a total of 496 children (317 males, 179 females; median 2 years, interquartile range 1-5 years, range 1-15 years at first measurement occasion), 22% (n = 108) had received upper-limb BoNT-A treatment, 45% of whom by 1 to 3 years of age. Those classified in Manual Ability Classification System levels IV and V showed the highest crude odds ratio for a first upper-limb BoNT-A treatment. Children with full passive ROM with tightness at the end of the movement range were most likely to receive an upper-limb BoNT-A treatment, also after adjustment for confounders. Thumb and forearm muscles were the most targeted at the first upper-limb BoNT-A treatment. INTERPRETATION Full passive ROM with tightness at the end of the movement range increases the likelihood of a first upper-limb BoNT-A treatment. This new traffic-light category is an aspect to consider in the dialogue about upper-limb BoNT-A. WHAT THIS PAPER ADDS Among children receiving upper-limb botulinum neurotoxin A (BoNT-A), 45% had their first treatment before the age of 4 years. Thumb and forearm muscles were the most treated with BoNT-A, finger flexor muscles the least. Full passive range of motion with tightness was related to first upper-limb BoNT-A treatment.
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Affiliation(s)
- Jenny Hedberg-Graff
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Fredrik Granström
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
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How does treadmill training contribute to botulinum toxin application plus routine physical therapy in ambulatory children with spastic bilateral cerebral palsy? A randomized controlled trial. Ir J Med Sci 2023; 192:209-217. [PMID: 35224682 DOI: 10.1007/s11845-022-02960-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 02/15/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND In spite of treadmill training and multilevel botulinum toxin (BoNT-A) injection being the two most commonly used treatment methods in pediatric rehabilitation management, there was no study investigating the effect of treadmill training after BoNT-A injection in children with cerebral palsy (CP). AIM The aim of this study was to investigate the effect of treadmill training in addition to routine physical therapy after BoNT-A injection in ambulatory children with spastic bilateral CP on lower extremity muscle strength, selective motor control, and mobility. METHODS A total of 30 spastic bilateral children with CP classified level II-III by the Gross Motor Function Classification System were randomly assigned the study and control groups. Both groups continued routine physical therapy treatments after multilevel BoNT-A injection into lower extremities, while the study group additionally underwent 8 weeks of treadmill training (20 min, two sessions per week). Handheld dynamometer, selective control assessment of lower extremity, temporospatial evaluation of gait, and Pediatric Evaluation of Disability Inventory were assessed before and after 8 weeks. RESULTS In both groups, hip, knee, and ankle muscle strength increased at the end of 8 weeks (p < 0.05); however, in the study group, hip flexor/extensor muscle strength (p < 0.05, ES ≥ 0.50), selective motor control of ankle (p < 0.01, ES = 1.17), walking speed (p < 0.01, ES = 2.60), step lengths (p < 0.01, ES = 1.32), and mobility (p < 0.01, ES = 1.37) increased significantly compared to those of the control group. CONCLUSIONS Treadmill training in addition to routine physical therapy after BoNT-A injection is beneficial for hip muscle strength, ankle selective motor control, walking quality, and functional mobility in the short term. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT03580174.
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Murgia M, de Sire A, Ruiu P, Agostini F, Bai AV, Pintabona G, Paolucci T, Bemporad J, Paoloni M, Bernetti A. Botulinum toxin type A for spasticity in cerebral palsy patients: Which impact on popliteal angle to hamstring length? A proof-of-concept study. J Back Musculoskelet Rehabil 2023; 36:1193-1201. [PMID: 37458025 DOI: 10.3233/bmr-220381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
BACKGROUND Cerebral palsy (CP) is the most common physical disability in childhood. It is a heterogeneous condition in terms of etiology, motor type and severity of impairments. Clinical impairments, such as increased muscle tone (spasticity), muscle weakness and joint stiffness contribute to the abnormal development of functional activities, including gait. OBJECTIVE The objective of this study was to investigate the popliteal angle to hamstring length after ultrasound guided Incobotulinum toxin A injections for spasticity in CP patients. METHODS In this proof-of-concept study, we included outpatients with CP and crouch gait correlated to hamstrings spasticity referred to the Pediatric Rehabilitation outpatient clinic of Umberto I University Hospital, Sapienza University of Rome, in the period between February and October 2018. METHODS Modified Ashworth Scale (MAS) of hamstring muscles, Popliteal Angle and Modified Popliteal Angle, Passive Knee Extension and 10 Meter Walk Test (10MWT) were assessed at baseline (T0) and three weeks after ultrasound guided injection (T1) of Incobotulinum Toxin A (dose weight and site dependent). RESULTS Thirteen patients (5 male and 8 female), mean aged 9.91 ± 3.59, were included. The clinical evaluation at T0 showed hamstring muscles spasticity, with MAS of 2.4 ± 0.6, popliteal angle -51.7∘± 11.0∘, modified popliteal angle of -39.5∘± 11.0∘, passive knee extension of -14.0∘± 8.7∘ and 10MWT of 14.3 ± 4.6 seconds. At T1, hamstring muscles MAS mean value was 1.7 ± 0.6 (p< 0.01), popliteal angle 41.3∘± 7.0∘ (p< 0.001), modified popliteal angle -32.9∘± 10.4∘ (p< 0.001), passive knee extension -4.0∘± 4.2∘ (p< 0.05) and 10MWT 12.6 ± 4.8 seconds (p< 0.05). None of the treated patients reported any adverse event related to Incobotulinum Toxin A injection. CONCLUSION Incobotulinum toxin A treatment has been proven to be safe and effective for hamstring muscles spasticity management in CP patients. Further studies with larger samples and longer follow-up are warranted to assess the efficacy of this treatment on the popliteal angle.
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Affiliation(s)
- Massimiliano Murgia
- Department of Anatomy, Histology, Forensic Medicine and Orthopedics, Sapienza University, Rome, Italy
| | - Alessandro de Sire
- Department of Medical and Surgical Sciences, University of Catanzaro "Magna Graecia", Catanzaro, Italy
| | - Pierangela Ruiu
- Department of Anatomy, Histology, Forensic Medicine and Orthopedics, Sapienza University, Rome, Italy
| | - Francesco Agostini
- Department of Anatomy, Histology, Forensic Medicine and Orthopedics, Sapienza University, Rome, Italy
| | | | - Giovanni Pintabona
- Specialist Functional Rehabilitation Unit, Scientific Institute, IRCCS E. Medea, Bosisio Parini, Italy
| | - Teresa Paolucci
- Department of Oral Medical Science and Biotechnology, G. D'Annunzio University of Chieti-Pescara, Chieti, Italy
| | | | - Marco Paoloni
- Department of Anatomy, Histology, Forensic Medicine and Orthopedics, Sapienza University, Rome, Italy
| | - Andrea Bernetti
- Department of Anatomy, Histology, Forensic Medicine and Orthopedics, Sapienza University, Rome, Italy
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12
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CARRANZA-DEL RÍO J, DURSUN N, CEKMECE C, BONIKOWSKI M, PYRZANOWSKA W, DABROWSKI E, TILTON A, OLESZEK J, VOLTEAU M, PAGE S, SHIERK A, DELGADO MR. Goal Attainment after Treatment with Abobotulinumtoxina and a Tailored Home Therapy Programme in Children with Upper Limb Spasticity: Descriptive, Exploratory Analysis of a Large Randomized, Controlled Study. J Rehabil Med 2022; 54:jrm00349. [PMID: 36306168 PMCID: PMC9762673 DOI: 10.2340/jrm.v54.2540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE This exploratory analysis of a large, randomized, double-blind study (NCT02106351) describes the effect of treatment with abobotulinumtoxinA followed by a tailored home exercises therapy programme in enabling children with upper limb spasticity due to cerebral palsy to achieve their functional goals using goal attainment scaling (GAS). METHODS Children with cerebral palsy and spasticity in ≥ 1 upper limb received up to 4 injection cycles of abobotulinumtoxinA (2 U/kg (cycle 1 only), 8U/kg and 16U/kg) into the elbow and wrist flexors and other upper limb muscles selected to support individual treatment goals. Children followed a home exercises therapy programme, which included stretches and exercises specifically chosen to facilitate goal achievement and engagement in activities. RESULTS For cycle 1, most children had active function goals set as their primary goal (69.7% vs 19.2% passive function goals). GAS T- scores and goal responder rates at week 16 indicated that most types of primary goal were achieved at least as expected during cycle 1 (all groups). Primary goal GAS T-scores were generally maintained for the first 3 abobotulinumtoxinA treatment cycles. CONCLUSION Most children with upper limb spasticity treated with repeat cycles of abobotulinumtoxinA supported by an individualized home exercises therapy programme achieved their functional goals.
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Affiliation(s)
| | - Nigar DURSUN
- Kocaeli University Faculty of Medicine Department of Physical Medicine and Rehabilitation, Turkey
| | - Cigdem CEKMECE
- Kocaeli University Faculty of Medicine Department of Physical Medicine and Rehabilitation, Turkey
| | | | | | - Edward DABROWSKI
- Beaumont Health, Oakland University School of Medicine, Grosse Pointe, MI
| | - Ann TILTON
- LSU Health Sciences Center and Children’s Hospital New Orleans, New Orleans, LA
| | | | | | | | - Angela SHIERK
- University of Texas Southwestern Medical Center and Scottish Rite Hospital for Children, Dallas, TX, USA
| | - Mauricio R. DELGADO
- University of Texas Southwestern Medical Center and Scottish Rite Hospital for Children, Dallas, TX, USA
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13
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Botulinum Toxin Intervention in Cerebral Palsy-Induced Spasticity Management: Projected and Contradictory Effects on Skeletal Muscles. Toxins (Basel) 2022; 14:toxins14110772. [PMID: 36356022 PMCID: PMC9692445 DOI: 10.3390/toxins14110772] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 10/22/2022] [Accepted: 11/04/2022] [Indexed: 11/09/2022] Open
Abstract
Spasticity, following the neurological disorder of cerebral palsy (CP), describes a pathological condition, the central feature of which is involuntary and prolonged muscle contraction. The persistent resistance of spastic muscles to stretching is often followed by structural and mechanical changes in musculature. This leads to functional limitations at the respective joint. Focal injection of botulinum toxin type-A (BTX-A) is effectively used to manage spasticity and improve the quality of life of the patients. By blocking acetylcholine release at the neuromuscular junction and causing temporary muscle paralysis, BTX-A aims to reduce spasticity and hereby improve joint function. However, recent studies have indicated some contradictory effects such as increased muscle stiffness or a narrower range of active force production. The potential of these toxin- and atrophy-related alterations in worsening the condition of spastic muscles that are already subjected to changes should be further investigated and quantified. By focusing on the effects of BTX-A on muscle biomechanics and overall function in children with CP, this review deals with which of these goals have been achieved and to what extent, and what can await us in the future.
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14
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De Pieri E, Romkes J, Wyss C, Brunner R, Viehweger E. Altered Muscle Contributions are Required to Support the Stance Limb During Voluntary Toe-Walking. Front Bioeng Biotechnol 2022; 10:810560. [PMID: 35480978 PMCID: PMC9036482 DOI: 10.3389/fbioe.2022.810560] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Accepted: 03/02/2022] [Indexed: 01/02/2023] Open
Abstract
Toe-walking characterizes several neuromuscular conditions and is associated with a reduction in gait stability and efficiency, as well as in life quality. The optimal choice of treatment depends on a correct understanding of the underlying pathology and on the individual biomechanics of walking. The objective of this study was to describe gait deviations occurring in a cohort of healthy adult subjects when mimicking a unilateral toe-walking pattern compared to their normal heel-to-toe gait pattern. The focus was to characterize the functional adaptations of the major lower-limb muscles which are required in order to toe walk. Musculoskeletal modeling was used to estimate the required muscle contributions to the joint sagittal moments. The support moment, defined as the sum of the sagittal extensive moments at the ankle, knee, and hip joints, was used to evaluate the overall muscular effort necessary to maintain stance limb stability and prevent the collapse of the knee. Compared to a normal heel-to-toe gait pattern, toe-walking was characterized by significantly different lower-limb kinematics and kinetics. The altered kinetic demands at each joint translated into different necessary moment contributions from most muscles. In particular, an earlier and prolonged ankle plantarflexion contribution was required from the soleus and gastrocnemius during most of the stance phase. The hip extensors had to provide a higher extensive moment during loading response, while a significantly higher knee extension contribution from the vasti was necessary during mid-stance. Compensatory muscular activations are therefore functionally required at every joint level in order to toe walk. A higher support moment during toe-walking indicates an overall higher muscular effort necessary to maintain stance limb stability and prevent the collapse of the knee. Higher muscular demands during gait may lead to fatigue, pain, and reduced quality of life. Toe-walking is indeed associated with significantly larger muscle forces exerted by the quadriceps to the patella and prolonged force transmission through the Achilles tendon during stance phase. Optimal treatment options should therefore account for muscular demands and potential overloads associated with specific compensatory mechanisms.
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Affiliation(s)
- Enrico De Pieri
- Laboratory for Movement Analysis, University of Basel Children’s Hospital, Basel, Switzerland
- Department of Biomedical Engineering, University of Basel, Basel, Switzerland
- *Correspondence: Enrico De Pieri,
| | - Jacqueline Romkes
- Laboratory for Movement Analysis, University of Basel Children’s Hospital, Basel, Switzerland
- Department of Biomedical Engineering, University of Basel, Basel, Switzerland
| | - Christian Wyss
- Laboratory for Movement Analysis, University of Basel Children’s Hospital, Basel, Switzerland
- Department of Biomedical Engineering, University of Basel, Basel, Switzerland
| | - Reinald Brunner
- Laboratory for Movement Analysis, University of Basel Children’s Hospital, Basel, Switzerland
- Department of Biomedical Engineering, University of Basel, Basel, Switzerland
- Department of Paediatric Orthopaedics, University of Basel Children’s Hospital, Basel, Switzerland
| | - Elke Viehweger
- Laboratory for Movement Analysis, University of Basel Children’s Hospital, Basel, Switzerland
- Department of Biomedical Engineering, University of Basel, Basel, Switzerland
- Department of Paediatric Orthopaedics, University of Basel Children’s Hospital, Basel, Switzerland
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15
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Armani-Franceschi G, Luz C, Lucena PH, d'Afonseca D, Sales H, Carvalho AL, Siqueira IC, Silva K, Portuense S, Monteiro L, Bandeira ID, Melo A, Lucena R. Botulinum Toxin Type A in the Spasticity of Cerebral Palsy Related to Congenital Zika Syndrome: An Observational Study. Dev Neurorehabil 2022; 25:162-169. [PMID: 34387523 DOI: 10.1080/17518423.2021.1960917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE Investigate the effect of botulinum toxin type-A (BoNT-A) on spasticity and motor performance in children with Cerebral Palsy (CP) related to Congenital Zika Syndrome (CZS). METHODS Prospective longitudinal observational study of 34 children with CP referred for BoNT-A treatment. Outcomes were evaluated with a muscle tone assessment scale (Modified Ashworth Scale - MAS) and the Patients' Global Impression of Improvement (PGI-I) scale. RESULTS Mean age was 32.06 ± 3.07 months and 85% were classified as Gross Motor Function Classification System (GMFCS) V. Primitive reflexes were present in 56% of the sample. The majority of the parents (97.9%) reported improvement in range of motion or reduction in spasticity after treatment with botulinum toxin. No side effects were recorded. When compared to the baseline, median reduction in the MAS was 0.5 (IQR = 0). CONCLUSIONS The findings of this study suggest that BoNT-A may effectively promote functional improvements and reduce muscle tone, improving the child's and family's quality of life.
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Affiliation(s)
| | - Cleber Luz
- Universidade Federal da Bahia, Salvador, Brazil
| | - Pedro H Lucena
- Escola Bahiana de Medicina e Saúde Pública, Salvador, Brazil
| | | | | | | | | | | | | | | | | | - Ailton Melo
- Universidade Federal da Bahia, Salvador, Brazil
| | - Rita Lucena
- Universidade Federal da Bahia, Salvador, Brazil
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16
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Dursun N, Akyuz M, Gokbel T, Akarsu M, Yilmaz E, Karacan C, Dursun E. GMFCS level improvement in children with cerebral palsy treated with repeat botulinum toxin injections and intensive rehabilitation: A retrospective study. J Pediatr Rehabil Med 2022; 15:107-112. [PMID: 35275571 DOI: 10.3233/prm-210013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE The Gross Motor Functional Classification System (GMFCS) provides a standardized classification of motor disability in children with cerebral palsy (CP) that is typically considered longitudinally stable. Here, changes in GMFCS levels of children with CP who received repeated botulinum toxin A (BoNT-A) injections within an intensive rehabilitation approach were evaluated. METHODS This retrospective, observational study included 503 children with CP (GMFCS I-V) treated in a single university rehabilitation clinic. Individualized treatment plans and a variety of rehabilitation techniques were incorporated within an integrated model of care. Each child received≥2 repeated BoNT-A injections as well as an intensive rehabilitation program. RESULTS GMFCS level following repeat treatment improved in 42.1% of the patients and worsened in 3 patients; 14.9% of children showed improvement after 1 treatment cycle, 12.3% after 2 cycles, 7.6% after 3 cycles, 3.6% after 4 cycles, and 3.8% after≥5 cycles. Type of involvement (p < 0.001), baseline GMFCS (p = 0.001), number of treatment cycles (p < 0.001) and presence of severe dystonia (p = 0.032) were significant predictors of GMFCS improvement, but age and gender were not. CONCLUSION Children with CP may change GMFCS level when intensive rehabilitation programs are combined with repeated BoNT-A injections.
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Affiliation(s)
- Nigar Dursun
- Kocaeli University Medical Faculty Department of Physical Medicine and Rehabilitation, Kocaeli, Turkey
| | - Merve Akyuz
- Bursa State Hospital Department of Physical Medicine and Rehabilitation, Bursa, Turkey
| | - Tugba Gokbel
- Kocaeli University Medical Faculty Department of Physical Medicine and Rehabilitation, Kocaeli, Turkey
| | - Melike Akarsu
- Kocaeli University Medical Faculty Department of Physical Medicine and Rehabilitation, Kocaeli, Turkey
| | - Esin Yilmaz
- Kocaeli University Medical Faculty Department of Physical Medicine and Rehabilitation, Kocaeli, Turkey
| | - Cagla Karacan
- Gedik University Faculty of Sports Sciences, Istanbul, Turkey
| | - Erbil Dursun
- Kocaeli University Medical Faculty Department of Physical Medicine and Rehabilitation, Kocaeli, Turkey
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17
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Sozbilen MC, Evren Sahin K. Long-term efficacy and safety of repeated botulinum toxin a applications based on function and anesthesia type in children with cerebral palsy. J Orthop 2021; 29:22-27. [PMID: 35027815 PMCID: PMC8731691 DOI: 10.1016/j.jor.2021.12.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 12/27/2021] [Accepted: 12/28/2021] [Indexed: 01/03/2023] Open
Abstract
PURPOSE This study evaluates the motor development of patients undergoing three or more repeated Botulinum toxin A (BoNT-A) applications in a tertiary pediatric hospital as well as the safety of three different types of anesthesia. METHODS Seventy-five children who underwent BoNT-A applications at least three consecutive times at six-month intervals and a total of 320 procedures were examined. Gross Motor Function Classification System (GMFCS) was employed in motor development evaluation. The three anesthesia methods (sedation analgesia, anesthesia with larengeal mask [LMA] and inhalation mask) were compared in terms of sedation, procedure, recovery, and total operation room time. RESULTS Following the procedures, significant motor development was observed in 60 (80%) patients. In sedation analgesia group during the first three procedures, the recovery time was seen to be significantly shorter, while there was no difference between the anesthesia methods of any procedures following the fourth. Regardless of the type of anesthesia, the recovery times of those having undergone six or more procedures were longer than those with less than six procedures. CONCLUSIONS As repeated BoNT-A application provides motor step progress, it can be applied safely and effectively under anesthesia. Sedation analgesia provides an easier recovery compared to LMA and mask only within the first three applications. However, recovery time increases with four or more repeated applications, specifically increasing as the number of applications increases. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Murat Celal Sozbilen
- Department of Orthopaedic Surgery, School of Medicine Hospital, Ege University, Bornova, Izmir, Turkey,Corresponding author.
| | - Kubra Evren Sahin
- Department of Anesthesiology and Reanimation, Dr Behcet Uz Child Diseases and Surgery Research and Training Hospital, Konak, Izmir, Turkey
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18
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Dimitrova R, Kim H, Meilahn J, Chambers HG, Racette BA, Bonikowski M, Park ES, McCusker E, Liu C, Brin MF. Efficacy and safety of onabotulinumtoxinA with standardized physiotherapy for the treatment of pediatric lower limb spasticity: A randomized, placebo-controlled, phase III clinical trial. NeuroRehabilitation 2021; 50:33-46. [PMID: 34957954 PMCID: PMC8925123 DOI: 10.3233/nre-210070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND: Spasticity is common in cerebral palsy and can result in pain and diminished health-related quality of life. OBJECTIVE: To evaluate the safety and efficacy of onabotulinumtoxinA for lower limb spasticity treatment in children with cerebral palsy. METHODS: In this registrational phase 3, multinational, randomized, double-blind, placebo-controlled trial (NCT01603628), children (2–< 17 years) with cerebral palsy and ankle spasticity (Modified Ashworth Scale-Bohannon [MAS] score≥2) were randomized 1 : 1 : 1 to standardized physical therapy and onabotulinumtoxinA (4 or 8 U/kg), or placebo. Primary endpoint was average change from baseline at weeks 4 and 6 in MAS ankle score. Secondary endpoints included the Modified Tardieu Scale (MTS) and Global Attainment Scale (GAS). RESULTS: 381 participants were randomized. MAS scores averaged at weeks 4 and 6 were significantly reduced with both onabotulinumtoxinA doses (8 U/kg: –1.06, p = 0.010; 4 U/kg: –1.01, p = 0.033) versus placebo (–0.8). Significant improvements in average dynamic component of spasticity, measured by MTS, and in function, measured by GAS, were observed at several time points with both onabotulinumtoxinA doses versus placebo. Most adverse events were mild or moderate. CONCLUSIONS: OnabotulinumtoxinA was well tolerated and effective in reducing lower limb spasticity and improving functional outcomes versus placebo in children.
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Affiliation(s)
| | - Heakyung Kim
- Columbia University Medical Center, New York, NY, USA
| | - Jill Meilahn
- Marshfield Clinic Health System, Marshfield, WI, USA
| | | | - Brad A Racette
- Washington University School of Medicine, St. Louis, MO, USA.,School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Parktown, SouthAfrica
| | | | | | | | | | - Mitchell F Brin
- Allergan, an AbbVie company, Irvine, CA, USA.,University of California, Irvine, CA, USA
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19
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Effect of Botulinum Toxin Injection on the Progression of Hip Dislocation in Patients with Spastic Cerebral Palsy: A Pilot Study. Toxins (Basel) 2021; 13:toxins13120872. [PMID: 34941710 PMCID: PMC8707328 DOI: 10.3390/toxins13120872] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 12/02/2021] [Accepted: 12/05/2021] [Indexed: 11/25/2022] Open
Abstract
Hip adductor spasticity is a contributing factor to hip dislocation in patients with cerebral palsy (CP). We hypothesized that botulinum toxin injected into the hip adductor muscles would reduce spasticity and help prevent hip dislocation. Twenty patients with bilateral spastic CP aged 2 to 10 years with gross motor function classification system level IV or V were included. Botulinum toxin was injected into the hip adductor muscles at baseline and at 6-month follow-up. Muscle tone was measured with an eight-channel surface electromyography (EMG) recorder. A hip X-ray was performed, and Reimer’s hip migration index (MI) was measured. The Wilcoxon signed-rank test was used to compare the surface EMG values of the hip muscles at baseline and follow-up. The mean root mean square surface EMG value of the hip adductor muscles was significantly reduced at 1, 2, 3, and 7 months after the first injection, up to approximately 53% of the baseline. The 1-year progression of the hip MI was −0.04%. Repeated sessions of botulinum toxin injections at the hip adductor muscles significantly reduced muscle tone and hip displacement. A botulinum toxin injection may be used as an adjunctive treatment in the prevention of hip dislocation.
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20
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Dabrowski E, Chambers HG, Gaebler-Spira D, Banach M, Kaňovský P, Dersch H, Althaus M, Geister TL, Heinen F. IncobotulinumtoxinA Efficacy/Safety in Upper-Limb Spasticity in Pediatric Cerebral Palsy: Randomized Controlled Trial. Pediatr Neurol 2021; 123:10-20. [PMID: 34339951 DOI: 10.1016/j.pediatrneurol.2021.05.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 05/07/2021] [Accepted: 05/15/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND This randomized phase 3 study with double-blind main period (MP) and open-label extension (OLEX; NCT02002884) assessed incobotulinumtoxinA safety and efficacy for pediatric upper-limb spasticity treatment in ambulant/nonambulant (Gross Motor Function Classification System [GMFCS] I-V) patients, with the option of combined upper- and lower-limb treatment. METHODS Patients were aged two to 17 years with unilateral or bilateral spastic cerebral palsy (CP) and Ashworth Scale (AS) score ≥2 in treatment-selected clinical patterns. In the MP, patients were randomized (2:1:1) to incobotulinumtoxinA 8, 6, or 2 U/kg body weight (maximum 200, 150, 50 U/upper limb), with optional lower-limb injections in one of five topographical distributions (total body dose ≤16 to 20 U/kg, maximum 400 to 500 U, depending on body weight and GMFCS level). In the OLEX, patients received three further treatment cycles, at the highest MP doses (8 U/kg/upper limb group). Outcomes included AS, Global Impression of Change Scale (GICS), and adverse events (AEs). RESULTS AS scores improved from baseline to week 4 in all MP dose groups (n = 350); patients in the incobotulinumtoxinA 8 U/kg group had significantly greater spasticity improvements versus the 2 U/kg group (least-squares mean [standard error] for upper-limb main clinical target pattern -1.15 [0.06] versus -0.93 [0.08]; P = 0.017). Investigator's, child/adolescent's, and parent/caregiver's GICS scores showed improvements in all groups. Treatment benefits were sustained over further treatment cycles. AE incidence did not increase with dose or repeated treatment across GMFCS levels. CONCLUSIONS Data provide evidence for sustained efficacy and safety of multipattern incobotulinumtoxinA treatment in children and adolescents with upper-limb spasticity.
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Affiliation(s)
- Edward Dabrowski
- Beaumont Pediatric Physical Medicine & Rehabilitation - Royal Oak, Royal Oak, Michigan.
| | | | | | - Marta Banach
- Department of Neurology, Collegium Medicum, Jagiellonian University, Krakow, Poland
| | - Petr Kaňovský
- Faculty of Medicine and Dentistry and University Hospital, Palacký University Olomouc, Olomouc, Czech Republic
| | - Hanna Dersch
- Merz Pharmaceuticals GmbH, Frankfurt am Main, Germany
| | | | | | - Florian Heinen
- LMU Klinikum Munich, Division of Pediatric Neurology & LMU Center for Children with Medical Complexity, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University, Munich, Germany
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21
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Vova JA, Green MM, Brandenburg JE, Davidson L, Paulson A, Deshpande S, Oleszek JL, Inanoglu D, McLaughlin MJ. A consensus statement on the use of botulinum toxin in pediatric patients. PM R 2021; 14:1116-1142. [PMID: 34558213 DOI: 10.1002/pmrj.12713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 08/12/2021] [Accepted: 09/10/2021] [Indexed: 11/10/2022]
Abstract
Botulinum toxin has been used in medicine for the past 30 years. However, there continues to be controversy about the appropriate uses and dosing, especially in the pediatric population. A panel of nine pediatric physiatrists from different regions and previous training programs in the United States were nominated based on institutional reputation and botulinum toxin (BoNT) experience. Based on a review of the current literature, the goal was to provide the rationale for recommendations on the administration of BoNT in the pediatric population. The goal was not only to review safety, dosing, and injection techniques but also to develop a consensus on the appropriate uses in the pediatric population. In addition to upper and lower limb spasticity, the consensus also provides recommendations for congenital muscular torticollis, cervical dystonia, sialorrhea, and brachial plexus palsies.
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Affiliation(s)
- Joshua A Vova
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Michael M Green
- University of Utah/Primary Children's Hospital, Salt Lake City, Utah, USA
| | | | - Loren Davidson
- University of California Davis, Sacramento, California, USA
| | - Andrea Paulson
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Gillette Children's Specialty Healthcare, Minneapolis, Minnesota, USA
| | - Supreet Deshpande
- Gillette Children's Specialty Healthcare, Minneapolis, Minnesota, USA
| | | | - Didem Inanoglu
- Children's Health Specialty Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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22
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Akkol EK, Karatoprak GŞ, Carpar E, Hussain Y, Khan H, Aschner M. Effects of Natural Products on Neuromuscular Junction. Curr Neuropharmacol 2021; 20:594-610. [PMID: 34561984 DOI: 10.2174/1570159x19666210924092627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 05/05/2021] [Accepted: 06/01/2021] [Indexed: 11/22/2022] Open
Abstract
Neuromuscular junction (NMJ) disorders result from damage, malfunction or absence of one or more key proteins involved in neuromuscular transmission, comprising a wide range of disorders. The most common pathology is antibody-mediated or downregulation of ion channels or receptors, resulting in Lambert-Eaton myasthenic syndrome, myasthenia gravis, and acquired neuromyotonia (Isaac's syndrome), and rarely congenital myasthenic syndromes caused by mutations in NMJ proteins. A wide range of symptomatic treatments, immunomodulating therapies, or immunosuppressive drugs have been used to treat NMJ diseases. Future research must be directed at better understanding of the pathogenesis of these diseases, and developing novel disease-specific treatments. Numerous secondary metabolites, especially alkaloids isolated from plants have been used to treat NMJ diseases in traditional and clinical practices. An ethnopharmacological approach has provided leads for identifying new treatment for NMJ diseases. In this review, we performed a literature survey in Pubmed, Science Direct, and Google Scholar to gather information on drug discovery from plant sources for NMJ disease treatments. To date, most research has focused on the effect of herbal remedies on cholinesterase inhibitory and antioxidant activities. This review provides leads for identifying potential new drugs from plant sources for the treatment of NMJ diseases.
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Affiliation(s)
- Esra Küpeli Akkol
- Department of Pharmacognosy, Faculty of Pharmacy, Gazi University, 06330, Ankara. Turkey
| | - Gökçe Şeker Karatoprak
- Department of Pharmacognosy, Faculty of Pharmacy, Erciyes University, 38039, Kayseri. Turkey
| | - Elif Carpar
- Department of Psychiatry, Private French La Paix Hospital, 34360, Istanbul. Turkey
| | - Yaseen Hussain
- College of Pharmaceutical Sciences, Soochow University, Suzhou, Jiangsu, China
| | - Haroon Khan
- Department of Pharmacy, Abdul Wali Khan University Mardan, 23200, Mardan. Pakistan
| | - Michael Aschner
- Department of Molecular Pharmacology, Albert Einstein College of Medicine Forchheimer 209 1300 Morris Park Avenue, Bronx, NY 10461, United States
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Delgado MR, Tilton A, Carranza‐Del Río J, Dursun N, Bonikowski M, Aydin R, Maciag‐Tymecka I, Oleszek J, Dabrowski E, Grandoulier A, Picaut P. Efficacy and safety of abobotulinumtoxinA for upper limb spasticity in children with cerebral palsy: a randomized repeat-treatment study. Dev Med Child Neurol 2021; 63:592-600. [PMID: 33206382 PMCID: PMC8048784 DOI: 10.1111/dmcn.14733] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/12/2020] [Indexed: 12/12/2022]
Abstract
AIM To assess the efficacy and safety of repeat abobotulinumtoxinA injections in reducing upper limb spasticity in children with cerebral palsy (CP). METHOD This was a double-blind, repeat-cycle study (NCT02106351) in children with CP (2-17y). Children were randomized to receive 2U/kg (control), 8U/kg, or 16U/kg abobotulinumtoxinA injections into the target muscle group (wrist or elbow flexors) and additional muscles alongside occupational therapy via a home-exercise therapy program (HETP; minimum five 15min sessions/wk). Children received 8U/kg or 16U/kg plus HETP in cycles 2 to 4. RESULTS During cycle 1, 210 children (126 males, 84 females; mean age [SD] 9y [4y 5mo], range 2-17y; n=70/group) had at least one upper limb abobotulinumtoxinA injection and 209 complied with the HETP. At week 6 of cycle 1, children in the 8U/kg or 16U/kg groups had significantly lower Modified Ashworth scale scores versus the 2U/kg group (primary outcome: treatment differences of -0.4 [p=0.012] and -0.7 [p<0.001] respectively). All groups improved on Physician Global Assessment and children in all groups achieved their treatment goals at least as expected. Therapeutic benefits were sustained during cycles 2 to 4; muscular weakness was the only treatment-related adverse event reported in at least one child/group (4.3% and 5.7% vs 1.4% respectively). INTERPRETATION Treatment with 8U/kg or 16U/kg abobotulinumtoxinA significantly reduced upper limb spasticity versus the 2U/kg control dose. Therapeutic benefits of abobotulinumtoxinA plus HETP were sustained with repeat treatment cycles. WHAT THIS PAPER ADDS AbobotulinumtoxinA injections significantly reduced upper limb spasticity in children with cerebral palsy. Children treated with abobotulinumtoxinA and targeted home exercises showed global improvement and goal attainment. Benefits were sustained over 1 year with repeat cycles of abobotulinumtoxinA and home exercises. AbobotulinumtoxinA injections into the upper limb were well tolerated over 1 year.
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Affiliation(s)
- Mauricio R Delgado
- Department of NeurologyUniversity of Texas Southwestern Medical CenterScottish Rite Hospital for ChildrenDallasTXUSA
| | - Ann Tilton
- Department of NeurologyLSUHSC and Children's Hospital New OrleansNew OrleansLAUSA
| | | | - Nigar Dursun
- Department of Physical Medicine and RehabilitationFaculty of MedicineKocaeli UniversityKocaeliTurkey
| | | | - Resa Aydin
- Department of Physical Medicine and RehabilitationIstanbul Faculty of MedicineIstanbul UniversityIstanbulTurkey
| | | | - Joyce Oleszek
- Department of Physical Medicine and RehabilitationUniversity of Colorado and Children's Hospital ColoradoAuroraCOUSA
| | - Edward Dabrowski
- Department of Pediatric Physical Medicine and RehabilitationBeaumont HealthOakland University School of MedicineGrosse PointeMIUSA
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Katchburian LR, Oulton K, Main E, Morris C, Carr LJ. Protocol for The Toxin Study: Understanding clinical and patient reported response of children and young people with cerebral palsy to intramuscular lower limb Botulinum neurotoxin-A injections, exploring all domains of the ICF. A pragmatic longitudinal observational study using a prospective one-group repeated measures design. BMJ Open 2021; 11:e049542. [PMID: 33883158 PMCID: PMC8061828 DOI: 10.1136/bmjopen-2021-049542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Botulinum neurotoxin-A (BoNT-A) is an accepted treatment modality for the management of hypertonia in children and young people with cerebral palsy (CYPwCP). Nevertheless, there are concerns about the long-term effects of BoNT-A, with a lack of consensus regarding the most meaningful outcome measures to guide its use. Most evidence to date is based on short-term outcomes, related to changes at impairment level (restrictions of body functions and structures), rather than changes in adaptive skills (enabling both activity and participation). The proposed study aims to evaluate clinical and patient reported outcomes in ambulant CYPwCP receiving lower limb BoNT-A injections over a 12-month period within all domains of the WHO's International Classification of Functioning, Disability and Health and health-related quality of life (HRQoL). METHODS AND ANALYSIS This pragmatic prospective longitudinal observational study will use a one-group repeated measures design. Sixty CYPwCP, classified as Gross Motor Function Classification System (GMFCS) levels I-III, aged between 4 and 18 years, will be recruited from an established movement disorder service in London, UK. Standardised clinical and patient reported outcome measures within all ICF domains; body structures and function, activity (including quality of movement), goal attainment, participation and HRQoL, will be collected preinjection and at 6 weeks, 6 months and up to 12 months postinjection. A representative subgroup of children and carers will participate in a qualitative component of the study, exploring how their experience of BoNT-A treatment relates to clinical outcome measures. ETHICS AND DISSEMINATION Central London Research Ethics Committee has granted ethics approval (#IRAS 211617 #REC 17/LO/0579). Findings will be disseminated in peer-reviewed publications, conferences and via networks to participants and relevant stakeholders using a variety of accessible formats including social media.
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Affiliation(s)
- Lesley R Katchburian
- Neuroscience Unit,The Wolfson Neurodisability Movement Disorder Service, Great Ormond Street Hospital For Children, London, UK
- Physiotherapy, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Kate Oulton
- Centre for Outcomes and Experience Research in Children's Health, Illness and Disability (ORCHID), Great Ormond Street Hospital for Children, London, UK
| | - Eleanor Main
- Physiotherapy, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Christopher Morris
- Peninsula Childhood Disability Research Unit (PenCRU), University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Lucinda J Carr
- Neuroscience Unit,The Wolfson Neurodisability Movement Disorder Service, Great Ormond Street Hospital For Children, London, UK
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Weidensteiner C, Madoerin P, Deligianni X, Haas T, Bieri O, Akinci D'Antonoli T, Bracht-Schweizer K, Romkes J, De Pieri E, Santini F, Rutz E, Brunner R, Garcia M. Quantification and Monitoring of the Effect of Botulinum Toxin A on Paretic Calf Muscles of Children With Cerebral Palsy With MRI: A Preliminary Study. Front Neurol 2021; 12:630435. [PMID: 33935939 PMCID: PMC8085320 DOI: 10.3389/fneur.2021.630435] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 03/01/2021] [Indexed: 11/23/2022] Open
Abstract
Background: Muscles from patients with cerebral palsy (CP) are often spastic and form contractures that limit the range of motion. Injections of botulinum toxin A (BTX) into the calf muscles are an important treatment for functional equinus; however, improvement in gait function is not always achieved. BTX is also used to test muscle weakening for risk evaluation of muscle lengthening surgery. Our aim was to assess the effect of BTX over time on calf muscle properties in pediatric CP patients with MRI. Material and Methods: Six toe-walking CP patients (mean age 11.6 years) with indication for lengthening surgery were prospectively enrolled and received BTX injections into the gastrocnemius and soleus muscles. MRI scans at 3T of the lower legs and clinical examinations were performed pre-BTX, 6 weeks (6w), and 12 weeks (12w) post-BTX. A fat-suppressed 2D multi-spin-echo sequence was used to acquire T2 maps and for segmentation. Fat fraction maps were calculated from 3D multi-echo Dixon images. Diffusion tensor imaging (DTI) with a 2D echo-planar imaging (EPI) sequence yielded maps of the mean apparent diffusion coefficient (ADC) and of the fractional anisotropy (FA). Hyperintense regions of interest (ROIs) on the T2-weighted (T2w) images at 6w were segmented in treated muscles. Mean values of T2, fat fraction, ADC, and FA were calculated in hyperintense ROIs and in reference ROIs in non-treated muscles. Results: Hyperintensity on T2w scans and increased T2 (group mean ± standard deviation: 35 ± 1 ms pre-BTX, 45 ± 2 ms at 6w, and 44 ± 2 ms at 12w) were observed in all patients at the injection sites. The T2 increase was spatially limited to parts of the injected muscles. FA increased (0.30 ± 0.03 pre-BTX, 0.34 ± 0.02 at 6w, and 0.36 ± 0.03 at 12w) while ADC did not change in hyperintense ROIs, indicating a BTX-induced increase in extracellular space and a simultaneous decrease of muscle fiber diameter. Fat fraction showed a trend for increase at 12w. Mean values in reference ROIs remained unchanged. Conclusion: MRI showed limited spatial distribution of the BTX-induced effects in pediatric CP patients. It could be a promising non-invasive tool for future studies to test BTX treatment protocols.
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Affiliation(s)
- Claudia Weidensteiner
- Division of Radiological Physics, Department of Radiology, University Hospital of Basel, Basel, Switzerland.,Department of Biomedical Engineering, University of Basel, Allschwil, Switzerland
| | - Philipp Madoerin
- Division of Radiological Physics, Department of Radiology, University Hospital of Basel, Basel, Switzerland
| | - Xeni Deligianni
- Division of Radiological Physics, Department of Radiology, University Hospital of Basel, Basel, Switzerland.,Department of Biomedical Engineering, University of Basel, Allschwil, Switzerland
| | - Tanja Haas
- Division of Radiological Physics, Department of Radiology, University Hospital of Basel, Basel, Switzerland
| | - Oliver Bieri
- Division of Radiological Physics, Department of Radiology, University Hospital of Basel, Basel, Switzerland.,Department of Biomedical Engineering, University of Basel, Allschwil, Switzerland
| | - Tugba Akinci D'Antonoli
- Department of Radiology, University Hospital of Basel, Basel, Switzerland.,Department of Radiology, University Children's Hospital Basel, Basel, Switzerland
| | | | - Jacqueline Romkes
- Laboratory for Movement Analysis, University Children's Hospital Basel, Basel, Switzerland
| | - Enrico De Pieri
- Department of Biomedical Engineering, University of Basel, Allschwil, Switzerland.,Laboratory for Movement Analysis, University Children's Hospital Basel, Basel, Switzerland
| | - Francesco Santini
- Division of Radiological Physics, Department of Radiology, University Hospital of Basel, Basel, Switzerland.,Department of Biomedical Engineering, University of Basel, Allschwil, Switzerland
| | - Erich Rutz
- Murdoch Children's Research Insitute, The University of Melbourne, Pediatric Orthopedic Department, The Royal Children's Hospital, Parkville, VIC, Australia.,Faculty of Medicine, The University of Basel, Basel, Switzerland
| | - Reinald Brunner
- Laboratory for Movement Analysis, University Children's Hospital Basel, Basel, Switzerland.,Department of Orthopedic Surgery, University Children's Hospital Basel, Basel, Switzerland
| | - Meritxell Garcia
- Department of Radiology, Division of Neuroradiology, University Hospital of Basel, Basel, Switzerland
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Farag SM, Mohammed MO, El-Sobky TA, ElKadery NA, ElZohiery AK. Botulinum Toxin A Injection in Treatment of Upper Limb Spasticity in Children with Cerebral Palsy: A Systematic Review of Randomized Controlled Trials. JBJS Rev 2021; 8:e0119. [PMID: 32224633 PMCID: PMC7161716 DOI: 10.2106/jbjs.rvw.19.00119] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Cerebral palsy (CP) is the most common cause of childhood disability globally. Botulinum toxin A injections are widely used to manage limb spasticity in children with CP. Intramuscular botulinum toxin A has been used in the upper limbs of children with CP to manage preoperative and postoperative pain, facilitate nursing, and achieve functional and/or cosmetic improvement of hand position. These goals are achieved primarily through reduction of spasticity. The aim of this review was to assess the evidence for the effect of botulinum toxin A injections used to manage upper limb spasticity in children with spastic CP. Specifically, we examined the role of botulinum toxin A as an adjunctive treatment to other physical therapy modalities. Additionally, we analyzed the associated complications. METHODS The literature extraction process involved 4 phases: identification, screening, eligibility, and inclusion. We used a combination of Google Scholar, PubMed, and ScienceDirect. The choice of the search terms was based on the Medical Subject Headings. We extracted the relevant studies using a combination of words or terms related to (1) patient population, (2) pathology, (3) clinical intervention, and (4) anatomical distribution of pathology. Studies were included if they were randomized controlled trials conducted on children and/or adolescents with CP targeting the upper extremities in which botulinum toxin A was used as an adjunctive treatment to a primary intervention. RESULTS The literature extraction process yielded 15 randomized controlled trials for inclusion in this review. The total number of participants enrolled in the included studies was 499, with 255 in the intervention group (51%) and 244 controls (49%). All participants in the eligible studies had unilateral spastic CP except for those in 4 studies (27%) with 198 participants (40%) that included a heterogeneous sample of unilateral and bilateral spastic CP. The mean age of participants in the intervention group ranged from 2.6 to 10.7 years among the individual studies. The mean age of participants in the control group ranged from 3.1 to 10.55 years among the individual studies. This review indicated that botulinum toxin A had a positive effect on the degree of spasticity and cosmetic appearance of the injected upper limb. The results with respect to functional gains and quality of life were either conflicting or not significant. CONCLUSIONS Randomized controlled trials of botulinum toxin A injection in the treatment of upper limb spasticity in children with CP used variable outcome measures and yielded mixed results. Overall, there is some evidence to support the use of botulinum toxin A as an adjuvant treatment to other physical therapy regimens or placebo to reduce spasticity in the short term. There is insufficient evidence to support its use as an adjunctive treatment to improve upper limb function or quality of life. The complications were acceptable and did not outweigh the clinical gains incurred. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Sara M Farag
- Department of Physical Medicine and Rehabilitation, National Institute of Neuromuscular Disorders, Cairo, Egypt
| | - Manal O Mohammed
- Department of Physical Medicine and Rehabilitation (M.O.M., N.A.E., and A.K.E.) and Division of Pediatric Orthopedics, Department of Orthopedic Surgery (T.A.E.), Ain-Shams University, Cairo, Egypt
| | - Tamer A El-Sobky
- Department of Physical Medicine and Rehabilitation (M.O.M., N.A.E., and A.K.E.) and Division of Pediatric Orthopedics, Department of Orthopedic Surgery (T.A.E.), Ain-Shams University, Cairo, Egypt.,Department of Pediatric Orthopedics, Sultan Bin Abdulaziz Humanitarian City, Riyadh, Saudi Arabia
| | - Nadia A ElKadery
- Department of Physical Medicine and Rehabilitation (M.O.M., N.A.E., and A.K.E.) and Division of Pediatric Orthopedics, Department of Orthopedic Surgery (T.A.E.), Ain-Shams University, Cairo, Egypt
| | - Abeer K ElZohiery
- Department of Physical Medicine and Rehabilitation (M.O.M., N.A.E., and A.K.E.) and Division of Pediatric Orthopedics, Department of Orthopedic Surgery (T.A.E.), Ain-Shams University, Cairo, Egypt
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Kurenkov AL, Klochkova OA, Kuzenkova LM, Bursagova BI, Karimova KM. [Multilevel botulinum toxin treatment in severe spastic forms of cerebral palsy (GMFCS IV-V)]. Zh Nevrol Psikhiatr Im S S Korsakova 2021; 120:57-66. [PMID: 33459542 DOI: 10.17116/jnevro202012012157] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To evaluate the most typical target muscles and dosages for the first and repeated botulinum toxin A (BTA) injections in cerebral palsy (CP) patients with severe motor deficit - GMFCS IV-V. MATERIAL AND METHODS A retrospective analysis of 677 protocols of the first and repeated Abobotulinumtoxin A (AboA) injections in 333 patients with CP GMFCS IV and V, aged 1 to 18 years, was carried out. RESULTS Ninety-seven percent of patients received multilevel injections. In the lower extremities the most typical target muscles were: m.gracilis - 221 (66.4%) patients, hip adductors - 164 (49.2%), medial hamstring - 144 (43.2%). In the upper extremities the most typical muscles were: m.pronator teres - 237 (71.2%) patients, m.biceps brachii+m.brachialis - 197 (59.2%). The total dosages of AboA and dosages for every target muscle were calculated. Several patients required high dosages (more than 30 U/kg of AboA). Higher dosages per kg were used in younger children and for repeated injections. The age-related evolution of spastic patterns was described. Adverse events were observed in 36 cases (5.3% of all injections). CONCLUSION The majority of patients with GMFCS IV-V required multilevel BTA injections in high dosages, especially in young age. Described selection of target muscles and dosages of AboA could be taken into account as a practical experience and reference for the BTA therapy in GMFCS IV-V patients.
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Affiliation(s)
- A L Kurenkov
- National Medical Research Center for Children's Health, Moscow, Russia
| | - O A Klochkova
- National Medical Research Center for Children's Health, Moscow, Russia
| | - L M Kuzenkova
- National Medical Research Center for Children's Health, Moscow, Russia
| | - B I Bursagova
- National Medical Research Center for Children's Health, Moscow, Russia
| | - Kh M Karimova
- National Medical Research Center for Children's Health, Moscow, Russia
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Chirurgische Therapieoptionen bei spastischen Bewegungsstörungen der Extremitäten. Monatsschr Kinderheilkd 2020. [DOI: 10.1007/s00112-020-01033-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Zusammenfassung
Hintergrund
Schäden des 1. Motoneurons führen zu spastischen Lähmungen an den Extremitäten, die bei Kindern und Erwachsenen einschneidende Veränderungen der Bewegungsfähigkeit zur Folge haben und Lebensqualität sowie -teilhabe durch Funktionsverlust und Schmerzen einschränken.
Methode
Auf Grundlage eigener Behandlungserfahrungen in Verbindung mit einer PubMed-Literaturrecherche werden aktuelle Diagnose- und Behandlungsverfahren sowie deren Kombinationen vorgestellt.
Ergebnisse
Prinzipiell stehen Physio- und Ergotherapie mit vereinbarten alltagsrelevanten Therapiezielen, Medikamente (Botulinumtoxin und Baclofen) und Orthetik im Vordergrund. Chirurgische Maßnahmen an Muskeln, Sehnen, Gelenken und Knochen können dem betroffenen Patienten zu verbesserter Beweglichkeit, Wachstumskorrektur und vereinfachter Alltagsbewältigung verhelfen. Die selektive Neurektomie bei fokaler Spastik erlebt derzeit eine Renaissance. Die intrathekale Baclofentherapie kann bei entsprechend hoher Katheterlage auch eine Tonusreduktion an der oberen Extremität erreichen.
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Chung TM, Jacinto LJ, Colosimo C, Bhatia KP, Tiley J, Bhidayasiri R. Botulinum Neurotoxin-A Injection in Adult Cervical Dystonia and Spastic Paresis: Results From the INPUT (INjection Practice, Usage and Training) Survey. Front Neurol 2020; 11:570671. [PMID: 33041997 PMCID: PMC7525121 DOI: 10.3389/fneur.2020.570671] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 08/13/2020] [Indexed: 01/13/2023] Open
Abstract
Botulinum toxin-A (BoNT-A) is an effective treatment for cervical dystonia (CD) and spastic paresis (SP), but it requires in-depth knowledge of anatomy and injection techniques. The Ixcellence Network® is an educational programme to provide neurology, neuropaediatrics, and physical medicine and rehabilitation (PMR) specialists with access to best clinical practices and innovations regarding SP and CD management with BoNT-A. To assess the benefits of such educational programmes and identify unmet needs, a multidisciplinary scientific committee designed INPUT (INjection Practice, Usage & Training), an international multicentric survey describing training and practices among this trained and experienced population. A self-completed questionnaire was sent online to 553 trainees and 14 trainers from the Ixcellence Network®. Among the 131 respondents, 92% specialized in PMR (48%) or neurology (44%), with a mean experience of 15.5 years in their clinical fields and 10.9 years of BoNT-A injection. Most of them (98%) reported having received training before performing their first BoNT-A injection and attending specific courses on how to perform it without any instrumental guidance (76%), and with ultrasound (73%), electrical stimulation (44%) or electromyography (41%). In terms of practices, 92% of respondents reported using at least one guidance technique while injecting, with ultrasound being the most used technique (48%). Attending specific courses was significantly associated with greater self-confidence and use, e.g. for injection with ultrasound, mean self-confidence, on a scale from 1 (not confident) to 10 (fully confident), was 7.9 for trained respondents (vs 4.0 for untrained respondents, p < 0.001) of whom 70% stated that they used this technique regularly or systematically (vs. 11% of untrained healthcare professionals (HCPs), p < 0.0001). Moreover, 84% of respondents reported having trained colleagues, residents or fellows through theoretical (70%) or practical teaching in individuals (80%) or in small groups (65%). Overall, 86% of respondents reported a notable increase over the past 5 years of the number of patients treated with BoNT-A. INPUT is the first international survey describing training and practices in SP and CD management of physicians who attended a dedicated educational programme. The results highlighted the importance of training for self-confidence, and the use of specific techniques and new approaches.
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Affiliation(s)
- Tae Mo Chung
- Faculty of Medicine, Institute of Physical Medicine and Rehabilitation, University of São Paulo, São Paulo, Brazil
| | - Luis Jorge Jacinto
- Serviço de Reabilitação de adultos, Centro de Medicina de Reabilitacao do Alcoitão, Alcabideche, Portugal
| | - Carlo Colosimo
- Department of Neurology, Azienda Ospedaliera S.Maria, Terni, Italy
| | - Kailash P Bhatia
- Institute of Neurology, University College London, London, United Kingdom
| | - Julie Tiley
- Global Medical Affairs, Ipsen, Boulogne Billancourt, France
| | - Roongroj Bhidayasiri
- Chulalongkorn Centre of Excellence for Parkinson's Disease & Related Disorders, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
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Kurenkov AL, Kuzenkova LM, Bursagova BI, Klochkova OA, Chernikov VV, Kuznetsova MA, Ashrafova US, Kuprianova OS. [Botulinum toxin type A (Incobotulinum toxin A) in spastic forms of cerebral palsy: a retrospective analysis of clinical experience]. Zh Nevrol Psikhiatr Im S S Korsakova 2020; 120:68-77. [PMID: 32790979 DOI: 10.17116/jnevro202012007168] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE A retrospective analysis of the experience of using Incobotulinum toxin A injections for the treatment of spasticity in children with cerebral palsy (CP). MATERIAL AND METHODS One hundred and eighty-five children with spastic forms of CP, including 114 boys (61,6%), were studied. The average age of the patients was 3,8±2,5 years; the average weight was 14,2±6,9. The patients received injections of Incobotulinum toxin A according to registered indications or recommendations of a consultation of specialists and voluntary informed consent of the patient's representative. At least 1 point decrease of muscle tone according to the modified Ashworth scale was used as a criterion of the antispastic effect of Incobotulinum toxin A. RESULTS The total dose of Incobotulinum toxin A for the whole group of patients with CP was 154,5±67,7 U and 11,6±4,7 U per kg/body weight. The gracilis muscle (65,4% of cases, 95%CI 58,1-72,2) and the gastrocnemius muscle (49,4% of cases, 95%CI 41,8-56,6) were the most frequently injected targets in the lower extremities, and the pronator teres muscle (58,9% of cases, 95%CI 51,5-66,1) - in the upper extremities. Adverse events were observed in 13 patients (7,0%). They were mild in 9 patients and moderate in 4 patients. CONCLUSION Our data confirmed the effectiveness and safety of Incobotulinum toxin A injections in spastic CP. The calculated average doses of Incobotulinum toxin A for target muscles and the frequency of different spasticity patterns could serve as a reference for the botulinum therapy planning.
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Affiliation(s)
- A L Kurenkov
- National Medical Research Center for Children's Health, Moscow, Russia
| | - L M Kuzenkova
- National Medical Research Center for Children's Health, Moscow, Russia
| | - B I Bursagova
- National Medical Research Center for Children's Health, Moscow, Russia
| | - O A Klochkova
- National Medical Research Center for Children's Health, Moscow, Russia
| | - V V Chernikov
- National Medical Research Center for Children's Health, Moscow, Russia
| | - M A Kuznetsova
- National Medical Research Center for Children's Health, Moscow, Russia
| | - U S Ashrafova
- National Medical Research Center for Children's Health, Moscow, Russia
| | - O S Kuprianova
- National Medical Research Center for Children's Health, Moscow, Russia
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Dursun N, Bonikowski M, Dabrowski E, Matthews D, Gormley M, Tilton A, Carranza J, Grandoulier AS, Picaut P, Delgado MR. Efficacy of Repeat AbobotulinumtoxinA (Dysport®) Injections in Improving Gait in Children with Spastic Cerebral Palsy. Dev Neurorehabil 2020; 23:368-374. [PMID: 31691605 DOI: 10.1080/17518423.2019.1687602] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Purpose: This secondary analysis of a randomized, double-blind study plus open-label extension (NCT01249417/NCT01251380) evaluated the efficacy of abobotulinumtoxinA versus placebo in improving gait pattern in children with dynamic equinus due to cerebral palsy (CP) as assessed by the observational gait scale (OGS). Methods: Ambulatory children with CP (N = 241, aged 2-17) and dynamic equinus were randomized to treatment with abobotulinumtoxinA (10 or 15U/kg/leg) or placebo injected into the gastrocsoleus. All children received abobotulinumtoxinA in the open-label phase. Results: In the double-blind phase, abobotulinumtoxinA significantly improved OGS total scores versus placebo at Week 4 (treatment effect vs. placebo: 10U/kg/leg: 1.5 [0.7, 2.3], p = .0003; 15U/kg/leg: 1.1 [0.3, 1.9], p = .01). In the open-label phase, treatment with abobotulinumtoxinA continued to improve the OGS score at the same magnitude as seen in the double-blind study. Conclusion: Repeat treatment with abobotulinumtoxinA improved gait in children with dynamic equinus.
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Affiliation(s)
| | | | | | | | - Mark Gormley
- Gillette Children's Speciality Healthcare , St Paul, MN, USA
| | - Ann Tilton
- LSUHSC and Children's Hospital New Orleans , New Orleans, LA, USA
| | | | | | | | - Mauricio R Delgado
- University of Texas Southwestern Medical Center and Texas Scottish Rite Hospital for Children , Dallas, TX, USA
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Sätilä H. Over 25 Years of Pediatric Botulinum Toxin Treatments: What Have We Learned from Injection Techniques, Doses, Dilutions, and Recovery of Repeated Injections? Toxins (Basel) 2020; 12:toxins12070440. [PMID: 32640636 PMCID: PMC7404978 DOI: 10.3390/toxins12070440] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 07/02/2020] [Accepted: 07/03/2020] [Indexed: 12/20/2022] Open
Abstract
Botulinum toxin type A (BTXA) has been used for over 25 years in the management of pediatric lower and upper limb hypertonia, with the first reports in 1993. The most common indication is the injection of the triceps surae muscle for the correction of spastic equinus gait in children with cerebral palsy. The upper limb injection goals include improvements in function, better positioning of the arm, and facilitating the ease of care. Neurotoxin type A is the most widely used serotype in the pediatric population. After being injected into muscle, the release of acetylcholine at cholinergic nerve endings is blocked, and a temporary denervation and atrophy ensues. Targeting the correct muscle close to the neuromuscular junctions is considered essential and localization techniques have developed over time. However, each technique has its own limitations. The role of BTXA is flexible, but limited by the temporary mode of action as a focal spasticity treatment and the restrictions on the total dose deliverable per visit. As a mode of treatment, repeated BTXA injections are needed. This literature reviewed BTXA injection techniques, doses and dilutions, the recovery of muscles and the impact of repeated injections, with a focus on the pediatric population. Suggestions for future studies are also discussed.
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Affiliation(s)
- Heli Sätilä
- Department of Neuropediatrics, Päijät-Häme Central Hospital, Lahti, Finland, Keskussairaalankatu 7, 15850 Lahti, Finland
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Abstract
Identifying the subtypes of hypertonia is becoming increasingly important. Treatment strategies, including tone-modulating surgical interventions, medication type and dosing, and chemodenervation, may differ depending on the type of hypertonia present. It is important to delineate how hypertonia interferes with function and quality of life so that the appropriate intervention can be selected at the right time. Outcomes of treatment depend heavily on clear communication of goals. Botulinum toxin should not be used in isolation but as an adjunct to rehabilitation modalities.
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Affiliation(s)
- Rochelle Dy
- PM&R, Texas Children's Hospital, 6701 Fannin Street, Suite D1280, Houston, TX 77030, USA.
| | - Desiree Roge
- Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA 98105, USA
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Williams G, Singer BJ, Ashford S, Brian H, Hastings-Ison T, Fheodoroff K, Berwick S, Sutherland E, Hill B. A synthesis and appraisal of clinical practice guidelines, consensus statements and Cochrane systematic reviews for the management of focal spasticity in adults and children. Disabil Rehabil 2020; 44:509-519. [PMID: 32503375 DOI: 10.1080/09638288.2020.1769207] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Objective: To identify and appraise the existing clinical practice guidelines, consensus statements and Cochrane systematic reviews for the management of adult and paediatric focal spasticity to generate a single synthesized guideline.Methods: Systematic review of 12 electronic databases. Clinical practice guidelines, consensus statements and Cochrane systematic reviews for focal spasticity in adults and children. Included studies were appraised according to the AGREE II criteria.Results: A total of 25 papers were included in this review, comprising 12 clinical practice guidelines, nine consensus statements and four Cochrane systematic reviews. The areas most strongly endorsed were: (1) management to be provided by a multi-disciplinary team, (2) therapy should be goal-directed, (3) goals to be developed in conjunction with the patient and family, and (4) importance of follow-up evaluations. There was a greater focus on activity outcomes and classification in the paediatric papers. The guidelines varied considerably in their quality, with AGREE II scores ranging from 52.8 to 97.1%.Conclusions: This systematic review has synthesized the key elements regarding principles of focal spasticity management, outcome measures, physical interventions and educational recommendations into a single, readily applied guideline available for clinical use. Despite considerable variability in the quality of the guidelines, several strong themes emerged.Implications for rehabilitationFocal spasticity management should be multi-disciplinary, patient-centred and goal-directed.Routine measurement of impairment and activity are strongly endorsed.Botulinum toxin A injection should only be provided as part of an integrated approach to focal spasticity management.
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Affiliation(s)
- Gavin Williams
- Physiotherapy Department, Epworth Healthcare, Melbourne, Australia.,School of Physiotherapy, Faulty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia
| | - Barby J Singer
- Centre for Training in Subacute Care, WA Health, Fremantle Hospital, Fremantle, WA, USA.,School of Medical and Health Science, Edith Cowan University, Joondalup, WA, USA
| | - Stephen Ashford
- Regional Hyper-acute Rehabilitation Unit, Northwick Park Hospital, London North West Healthcare NHS Trust, London, UK.,Centre for Nurse, Midwife and Allied health led Research, University College London Hospitals, London, UK.,Department of Palliative Care, Policy and Rehabilitation, Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| | - Hoare Brian
- School of Occupational Therapy, La Trobe University, Bundoora, Australia.,Department of Paediatrics, Monash University, Clayton, Australia
| | - Tandy Hastings-Ison
- Hugh Williamson Gait Analysis Laboratory, Royal Children's Hospital, Parkville, Australia
| | | | - Steffen Berwick
- Speciality Clinic for Pediatric Neurology, Neurorehabilitation and Epilepsy, Schön Clinic Vogtareuth, Vogtareuth, Germany.,von Hauners' Childrens Hospital, Munich University, Munich, Germany
| | | | - Bridget Hill
- Physiotherapy Department, Epworth Healthcare, Melbourne, Australia.,School of Physiotherapy, Faulty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia
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Johnston K, Danchenko N, Hansen R, Dinet J, Liovas A, Armstrong A, Bains S, Sullivan SD. Cost effectiveness and impact on quality of life of abobotulinumtoxinA and onabotulinumtoxinA in the treatment of children with lower limb spasticity in Canada. J Med Econ 2020; 23:631-640. [PMID: 31985313 DOI: 10.1080/13696998.2020.1722138] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Background: Injectable botulinum neurotoxins are a mainstay of treatment for pediatric spasticity. AbobotulinumtoxinA and onabotulinumtoxinA are both injectable toxin therapies used to treat pediatric lower limb (PLL) spasticity in Canada. The objective of this study was to assess the cost-effectiveness of abobotulinumtoxinA vs. onabotulinumtoxinA in the treatment of PLL spasticity in Canada.Methods: A probabilistic Markov cohort model with a 2-year time horizon was developed, with health states defined by response to therapy, as characterized by the goal attainment scale (GAS). Based on randomized controlled trial evidence, response to therapy was similar or higher for abobotulinumtoxinA relative to onabotulinumtoxinA; uncertainty was incorporated into model parameters, however, as the two therapies have not been compared head-to-head. Canadian resource use and cost data were incorporated.Results: In the base case, abobotulinumtoxinA generated 1.48 quality-adjusted life years over the model time horizon, compared to 1.47 for onabotulinumtoxinA. AbobotulinumtoxinA was associated with cost savings of $123 CAD, reflecting lower costs in both medication acquisition and health services. The estimated improvement to quality of life and reduced costs result in an estimate of economic dominance for abobotulinumtoxinA over onabotulinumtoxinA. This dominant result persisted across probabilistic and scenario analyses.Key points for decision makersBased on a review of available clinical evidence, abobotulinumtoxinA was found to have significant and/or numerical efficacy benefits to onabotulinumtoxinA on functional outcomes (Goal Attainment Scale) and tone (Modified Ashworth Scale) and in the treatment of pediatric lower limb spasticityIn this cost-effectiveness analysis, abobotulinumtoxinA was found to be associated with greater quality-adjusted life years and lower costs than onabotulinumtoxinA (economically dominant)A limitation of this analysis was the uncertainty around key parameters. Specifically, the lack of head-to-head comparison data for the two therapies, and variable data regarding likely onabotulinumtoxinA dosing in PLL in clinical practice. However, across a range of plausible scenarios, the economic dominant result remained.
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Affiliation(s)
- Karissa Johnston
- Broadstreet Health Economics and Outcomes Research, Vancouver, Canada
| | | | - Ryan Hansen
- Choice Institute, University of Washington, Seattle, WA, USA
| | - Jerome Dinet
- Ipsen Biopharmaceuticals Canada, Mississauga, Canada
| | - Anna Liovas
- Ipsen Biopharmaceuticals Canada, Mississauga, Canada
| | - Ava Armstrong
- Ipsen Biopharmaceuticals Canada, Mississauga, Canada
| | | | - Sean D Sullivan
- Choice Institute, University of Washington, Seattle, WA, USA
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León-Valenzuela A, Palacios JS, Del Pino Algarrada R. IncobotulinumtoxinA for the treatment of spasticity in children with cerebral palsy - a retrospective case series focusing on dosing and tolerability. BMC Neurol 2020; 20:126. [PMID: 32268880 PMCID: PMC7140581 DOI: 10.1186/s12883-020-01702-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 03/26/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND IncobotulinumtoxinA (Xeomin®) is a botulinum neurotoxin type A with established efficacy in the treatment of upper-limb spasticity in adults. This retrospective case series in a university hospital setting aimed to elucidate the safety and tolerability of incobotulinumtoxinA for treatment of spasticity in children with cerebral palsy. METHODS Participants received incobotulinumtoxinA injections up to a maximum total dose of 600 U, 24 U/kg body weight. Medical records were reviewed for key demographic information, incobotulinumtoxinA exposure, and adverse effects (AEs). RESULTS Sixty-nine children were included (mean age [SD], 8.3 [3.9] years; 44/69 [63.8%] male). One-hundred-and-ninety-one injections were administered, with mean (SD) of 2.8 (1.5) treatment cycles/participant and dosing interval of 6.0 (1.7) months. The number of muscles injected increased from 2.4 (1.2) at cycle 1 to 4.2 (1.9) at cycle 6. The mean (SD) total incobotulinumtoxinA dose increased from 191.7 (126.2) U, (8.5 [5.4] U/kg body weight) at cycle 1 to 368.0 (170.1) U, (9.9 [5.5] U/kg body weight) at cycle 6. Seventy four adverse effects (37.5% of injections) were reported, the most frequent was injection pain (93.2% of AEs). Only three AEs were considered directly treatment-related by injectors: muscle weakness, generalized weakness, and fever. CONCLUSIONS Our clinical experience indicates that incobotulinumtoxinA is a well-tolerated treatment option for focal spasticity in children with cerebral palsy. TRIAL REGISTRATION As the study was observational and retrospective, no EudraCT registration number was requested. The internal code assigned to the study in the administrative resolution was: 1143-N-15.
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Affiliation(s)
- Angel León-Valenzuela
- Unidad de Gestión Clínica de Rehabilitación, Hospital Puerto Real, Puerto Real, Cádiz, Spain. .,Grupo iRehab, Instituto de Investigación e Innovación Biomédica de Cádiz, Cádiz, Spain. .,Departamento Materno-Infantil, Facultad de Medicina, Universidad de Cádiz, Cádiz, Spain.
| | | | - Rogelio Del Pino Algarrada
- Unidad de Gestión Clínica de Rehabilitación, Hospital Puerto Real, Puerto Real, Cádiz, Spain.,Grupo iRehab, Instituto de Investigación e Innovación Biomédica de Cádiz, Cádiz, Spain
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Kitai Y, Hirai S, Okuyama N, Hirotsune M, Nishimoto S, Mizutani S, Okumura A, Kumada S, Arai H. A questionnaire survey on the efficacy of various treatments for dyskinetic cerebral palsy due to preterm bilirubin encephalopathy. Brain Dev 2020; 42:322-328. [PMID: 32063420 DOI: 10.1016/j.braindev.2020.01.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 01/06/2020] [Accepted: 01/21/2020] [Indexed: 12/29/2022]
Abstract
OBJECTIVES Preterm children with severe dyskinetic cerebral palsy due to bilirubin encephalopathy often suffer from marked generalised hypertonus as they age. We performed a questionnaire survey to investigate patient-reported outcomes of treatments for improving their activities of daily life. METHODS A mail questionnaire was administered to the caregivers of 67 children with preterm bilirubin encephalopathy aged >4 years. We asked about the type of treatments they received and their efficacy using a five-point subjective scale for the following five domains: motor function, postural stability, sleep, pain, and care burden. The names of oral drugs and their efficacies were also explored. RESULTS The response rate of the questionnaires was 62.7% (42/67), and we analysed the results from 41 validated cases. All children underwent rehabilitation. A total of 30 children received oral drugs, 22 botulinum toxin, 12 orthopaedic surgery, and 3 intrathecal baclofen. Each of these treatments was subjectively reported to be effective in more than half of the recipients for each of the five domains, whereas 23 (56%) required more than two types of treatments other than rehabilitation. Chlordiazepoxide was the most commonly used oral drug, by 28 children (68%), and was discontinued in 7 patients (25%) only. In the sleep domain, the rate of a positive effect was significantly higher for oral drugs (92.7%) than the other treatments (p < 0.01). CONCLUSION All treatments were partially effective, but their appropriate combination based on a multidisciplinary approach is essential for muscle tone management in children with preterm bilirubin encephalopathy.
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Affiliation(s)
- Yukihiro Kitai
- Department of Pediatric Neurology, Bobath Memorial Hospital, Osaka, Japan.
| | - Satori Hirai
- Department of Pediatric Neurology, Bobath Memorial Hospital, Osaka, Japan
| | - Naomi Okuyama
- Department of Pediatric Neurology, Bobath Memorial Hospital, Osaka, Japan
| | - Mika Hirotsune
- Department of Pediatric Neurology, Bobath Memorial Hospital, Osaka, Japan
| | - Shizuka Nishimoto
- Department of Pediatric Neurology, Bobath Memorial Hospital, Osaka, Japan
| | - Satoshi Mizutani
- Department of Pediatric Neurology, Osaka Women's and Children's Hospital, Izumi, Japan
| | - Akihisa Okumura
- Department of Pediatrics, Aichi Medical University, Nagakute, Japan
| | - Satoko Kumada
- Department of Neuropediatrics, Tokyo Metropolitan Neurological Hospital, Tokyo, Japan
| | - Hiroshi Arai
- Department of Pediatric Neurology, Bobath Memorial Hospital, Osaka, Japan
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Kim SK, Rha DW, Park ES. Botulinum Toxin Type A Injections Impact Hamstring Muscles and Gait Parameters in Children with Flexed Knee Gait. Toxins (Basel) 2020; 12:toxins12030145. [PMID: 32120947 PMCID: PMC7150820 DOI: 10.3390/toxins12030145] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 02/22/2020] [Accepted: 02/25/2020] [Indexed: 12/02/2022] Open
Abstract
The aim of this study was to determine if botulinum toxin type A (BoNT-A) injection into the medial hamstring can improve gait kinematics and muscle-tendon length in spastic cerebral palsy (CP) with a flexed knee gait (FKG). Twenty-nine children with spastic CP (Gross Motor Function Classification System I–III) with FKG were recruited for this prospective study. BoNT-A was injected into the semitendinosus and semimembranosus (SM) muscles under ultrasonography guidance. Assessments included Gross Motor Function Measure (GMFM), Modified Ashworth Scale (MAS), Modified Tardieu Scale (MTS), 3-dimensional computerized gait analysis, calculated SM muscle-tendon length and lengthening velocity during gait using musculoskeletal modeling at baseline, 4 and 16 weeks after the injection. Compared to baseline data, significant improvements in GMFM, MAS, and MTS were demonstrated at weeks 4 and 16, and also a significant increase in maximum knee extension during the stance phase was observed at week 4. In addition, the mean lengthening velocity during the swing phase was increased at week 16 without a change in the SM muscle length. Furthermore, there was a significant increase in anterior pelvic tilt at week 4, compared to baseline data. The significant decrease in hip internal rotation after injection was observed only in children with excessive hip internal rotation at initial contact before injection. BoNT-A injection into hamstrings leads to a significant increase in knee extension and anterior pelvic tilt with an increase in lengthening velocity of SM in spastic CP with FKG.
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40
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Lidman GRM, Nachemson AK, Peny-Dahlstrand MB, Himmelmann KME. Long-term effects of repeated botulinum neurotoxin A, bimanual training, and splinting in young children with cerebral palsy. Dev Med Child Neurol 2020; 62:252-258. [PMID: 31225647 DOI: 10.1111/dmcn.14298] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/08/2019] [Indexed: 11/28/2022]
Abstract
AIM To investigate long-term development of hand function after repeated botulinum neurotoxin A (BoNT-A) and occupational therapy at a young age. METHOD Twenty children with unilateral spastic cerebral palsy (CP) (14 males, six females; median inclusion age 3y 1mo, range 1y 11mo-4y 3mo) participated in this longitudinal study. Ten children received occupational therapy after a randomized controlled trial and 10 repeated BoNT-A plus occupational therapy during 1-year. The Assisting Hand Assessment (AHA) and active supination, assessed the following 3 years. The assessments were compared with data from a reference group to investigate development over time. RESULTS The improvement in AHA (7.5 AHA units) after BoNT-A plus occupational therapy was maintained at final follow-up. The occupational therapy group, unchanged after 1-year, improved by 5 AHA units (96% confidence interval [CI] 2-10), thus there was no difference between the groups. Median active supination increased in comparison with the reference group. In the BoNT-A/occupational therapy group, 9 out of 10 (97.85% CI 45 115) children improved in active supination. In the occupational therapy group, 7 out of 10 (97.85% CI -2 to 68) children improved in active supination. No correlation between active supination and AHA was found. INTERPRETATION Bimanual performance achieved after BoNT-A plus occupational therapy was maintained, while it increased by follow-up in the occupational therapy group, suggesting that combined intervention gave earlier access to bimanual skills. Active supination was unrelated to AHA. WHAT THIS PAPER ADDS Children whose bimanual performance improved after botulinum neurotoxin A and/or occupational therapy, maintained skills or progressed during follow-up. Bimanual performance increased with age, similar to a quality-register reference group. Increased active supination after intervention improved at follow-up but was not related to bimanual performance.
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Affiliation(s)
- Git R M Lidman
- Institute of Neuroscience and Physiology at the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Regional Rehabilitation Centre for Children and Adolescents, Queen Silvia's Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Ann K Nachemson
- Department of Hand Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Marie B Peny-Dahlstrand
- Institute of Neuroscience and Physiology at the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Regional Rehabilitation Centre for Children and Adolescents, Queen Silvia's Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Kate M E Himmelmann
- Regional Rehabilitation Centre for Children and Adolescents, Queen Silvia's Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Paediatrics, Institute of Clinical Sciences at the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Kurenkov A, Kuzenkova L, Fisenko D, Klochkova O, Bursagova B, Chernikov V. Changes of the spasticity patterns in children with cerebral palsy GMFCS III at the age of 2 to 12 years. Zh Nevrol Psikhiatr Im S S Korsakova 2020; 120:36-44. [DOI: 10.17116/jnevro202012006136] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Vova JA, Leung E. A pragmatic approach to Botulinum Toxin safety. J Pediatr Rehabil Med 2020; 13:195-199. [PMID: 32568125 DOI: 10.3233/prm-200716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Botulinum Toxin (BoNT) is widely used to treat hypertonia in pediatric patients. Although serious adverse events (AEs) occur infrequently, they can lead to significant patient morbidity and mortality. This paper will discuss potential safety risks that may affect outcomes, medical comorbidities, medication dosing, targeting techniques, and muscle morphology. It is the responsibility of the physician to discuss risks and benefits regarding the use of BoNT and mitigate risks of AEs while maximizing the effectiveness of the medication.
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Rombaldi MC, Neto WFS, Holanda FC, Cavazzola LT, Fraga JC. Ventral hernia secondary to giant omphalocele in a child: combined approach of botulinum toxin and preoperative progressive pneumoperitoneum. Hernia 2019; 24:1397-1400. [PMID: 31858310 DOI: 10.1007/s10029-019-02084-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Accepted: 11/03/2019] [Indexed: 10/25/2022]
Abstract
Omphalocele is a congenital abdominal wall defect that occurs approximately 1 in 4000-6000 live births. The abdominal-visceral disproportion, large diameter of the defect, volume of liver in the sac along with high incidence of associated anomalies make the surgical management a real challenge. Currently, there are two strategies for managing giant omphaloceles, staged surgical closure and nonoperative delayed closure. The combined treatment with PPP and BoNT/A injection has recently been described in adults. There is strong evidence on safety and efficacy of the use of BoNT/As in other areas of pediatrics and no recent reports of PPP use in children. Also, there are no data available about the combination of both techniques in pediatric population. The purpose of this manuscript is to report a case of a 7-year-old female child that was referred to our institution with a large ventral hernia secondary to omphalocele. We opted for a combined approach with BoNT/A injection and PPP before the definitive surgery. The surgical result was great with midline closure with no tension and no need for prosthetic substitution or component separation needed. To our knowledge, this is the first case report of BoNT/A injection and PPP for large ventral hernias in children. BoNT/A application was safe and the PPP technique was also proved to be applicable on children. We believe that the combination of BoNT/A and PPP presented to be a safe approach with an excellent result, particularly for not needing abdominal wall prosthetic substitution.
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Affiliation(s)
- M C Rombaldi
- Department of Pediatric Surgery, Hospital de Clínicas, Porto Alegre, Brazil.
| | - W F S Neto
- Department of Pediatric Surgery, Hospital de Clínicas, Porto Alegre, Brazil
| | - F C Holanda
- Department of Pediatric Surgery, Hospital de Clínicas, Porto Alegre, Brazil
| | - L T Cavazzola
- Department of General Surgery, Hospital de Clínicas, Porto Alegre, Brazil
- Universidade Federal Do Rio Grande Do Sul, Porto Alegre, Brazil
| | - J C Fraga
- Department of Pediatric Surgery, Hospital de Clínicas, Porto Alegre, Brazil
- Universidade Federal Do Rio Grande Do Sul, Porto Alegre, Brazil
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Sedation-analgesia protocol for the injection of botulinum toxin A in cerebral palsy. An Pediatr (Barc) 2019. [DOI: 10.1016/j.anpede.2019.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Management of Spastic Paresis and Cervical Dystonia: Access to Therapeutic Innovations Through an International Program of Practical Courses. Clin Ther 2019; 41:2321-2330.e4. [PMID: 31607560 DOI: 10.1016/j.clinthera.2019.09.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 08/20/2019] [Accepted: 09/16/2019] [Indexed: 11/21/2022]
Abstract
PURPOSE Our purpose was to determine satisfaction and confidence of the Ixcellence Network training program on health care practitioners using botulinum toxin A (BoNT-A) for neurologic disorders, including spastic paresis and cervical dystonia. METHODS The Ixcellence Network training program was designed by a scientific committee of 6 experts and then tested at centers in Europe, and Latin America. The training, provided by 16 experienced neurologists and rehabilitation specialists, consisted of theoretic and practical sessions that covered the different stages of the patient's journey from diagnosis to tailored treatment and rehabilitation. Trainees' feedback and the impact on participants' practice were evaluated by 2 individual questionnaires, at the end of the session (T0) and at 6 months (T6). Trainers' feedback was also collected through an individual questionnaire. FINDINGS Between September 2012 and December 2017, 728 trained physicians participated in training programs with 48%, 23%, and 29% of attendees participating in training sessions dedicated to adult spastic paresis, child spastic paresis, and cervical dystonia, respectively. At T0, 93% of attendees thought that they had been given new information and 90% thought that the training would change their daily practice. This was confirmed at T6 by 93% of respondents. Trainees were highly satisfied with the program, in particular with the practical sessions. Trainers expectations were met for attendees' level of expertise, motivation, language, and participation. IMPLICATIONS In this descriptive study, we show that the Ixcellence Network program represents a new educational approach to promote consistency in care practices and dissemination of expertise on the use of BoNT-A for neurologic disorders.
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Valentine J, Davidson SA, Bear N, Blair E, Ward R, Thornton A, Stannage K, Watson L, Forbes D, Elliott C. Botulinum toxin and surgical intervention in children and adolescents with cerebral palsy: who, when and why do we treat? Disabil Rehabil 2019; 43:936-943. [PMID: 31415723 DOI: 10.1080/09638288.2019.1644381] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
INTRODUCTION This audit aimed to increase understanding of the long-term outcomes of evidence-based medical and surgical interventions to improve gross motor function in children and adolescents with Cerebral Palsy. METHODS Retrospective audit of a birth cohort (2000-2009) attending a tertiary service in Western Australia. RESULTS The cohort comprises 771 patients aged 8 to 17 years. Percentage of children receiving no Botulinum Toxin treatments in each Gross Motor Functional Classification System level was: I: 40%, II: 26%, III: 33%, IV: 28% and V: 46%. Of the total cohort, 53% of children received 4 or less Botulinum Toxin treatments and 3.7% received more than 20 treatments. Statistically significant difference in the rate of use of Botulinum Toxin pre and post-surgery (p < 0.001) was documented. Children levels IV and V had 5 times the odds of surgery compared to children levels I-III (Odds Ratio 5.2, 95% Confidence Interval 3.5 to 7.8, p < 0.001). For 578 (75%) of participants the last recorded level was the same as the first. CONCLUSION This audit documents medical intervention by age and Gross Motor Functional Classification System level in a large cohort of children with cerebral palsy over time and confirms stability of the level in the majority.IMPLICATIONS FOR REHABILITATIONThe information from this audit may be of use in discussions with families regarding the timing and use of Botulinum toxin and surgical intervention for motor function in children and adolescents with Cerebral Palsy.Long term use of Botulinum Toxin within an integrated evidence-based clinical program is not associated with loss of gross motor function in the long term as evidenced by the maintenance of Gross Motor Functional Classification System stability.
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Affiliation(s)
- Jane Valentine
- School of Medicine University of Western Australia, Perth, Australia
| | - Sue-Anne Davidson
- Department of Paediatric Rehabilitation, Perth Children's Hospital, Perth, Australia
| | - Natasha Bear
- Department of Child Research, Child Adolescent Health Service, Perth, Australia
| | - Eve Blair
- Telethon Kids Institute, Perth, Australia
| | - Roslyn Ward
- School of Occupational Therapy, Social Work and Speech Pathology, Curtin University, Perth, Australia
| | - Ashleigh Thornton
- School of Medicine University of Western Australia, Perth, Australia
| | - Katherine Stannage
- Department of Orthopaedic Surgery, Perth Children's Hospital, Perth, Australia
| | - Linda Watson
- WA Register of Developmental Anomalies, King Edward Memorial Hospital, Subiaco, Australia
| | | | - Catherine Elliott
- School of Occupational Therapy, Social Work and Speech Pathology, Curtin University, Perth, Australia
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Pitto L, Kainz H, Falisse A, Wesseling M, Van Rossom S, Hoang H, Papageorgiou E, Hallemans A, Desloovere K, Molenaers G, Van Campenhout A, De Groote F, Jonkers I. SimCP: A Simulation Platform to Predict Gait Performance Following Orthopedic Intervention in Children With Cerebral Palsy. Front Neurorobot 2019; 13:54. [PMID: 31379550 PMCID: PMC6650580 DOI: 10.3389/fnbot.2019.00054] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Accepted: 07/03/2019] [Indexed: 12/19/2022] Open
Abstract
Gait deficits in cerebral palsy (CP) are often treated with a single-event multi-level surgery (SEMLS). Selecting the treatment options (combination of bony and soft tissue corrections) for a specific patient is a complex endeavor and very often treatment outcome is not satisfying. A deterioration in 22.8% of the parameters describing gait performance has been reported and there is need for additional surgery in 11% of the patients. Computational simulations based on musculoskeletal models that allow clinicians to test the effects of different treatment options before surgery have the potential to drastically improve treatment outcome. However, to date, no such simulation and modeling method is available. Two important challenges are the development of methods to include patient-specific neuromechanical impairments into the models and to simulate the effect of different surgical procedures on post-operative gait performance. Therefore, we developed the SimCP framework that allows the evaluation of the effect of different simulated surgeries on gait performance of a specific patient and includes a graphical user interface (GUI) that enables performing virtual surgery on the models. We demonstrated the potential of our framework for two case studies. Models reflecting the patient-specific musculoskeletal geometry and muscle properties are generated based solely on data collected before the treatment. The patient's motor control is described based on muscle synergies derived from pre-operative EMG. The GUI is then used to modify the musculoskeletal properties according to the surgical plan. Since SEMLS does not affect motor control, the same motor control model is used to define gait performance pre- and post-operative. We use the capability gap (CG), i.e., the difference between the joint moments needed to perform healthy walking and the joint moments the personalized model can generate, to quantify gait performance. In both cases, the CG was smaller post- then pre-operative and this was in accordance with the measured change in gait kinematics after treatment.
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Affiliation(s)
- Lorenzo Pitto
- Department of Movement Sciences, KU Leuven, Leuven, Belgium
| | - Hans Kainz
- Department of Movement Sciences, KU Leuven, Leuven, Belgium
| | | | | | - Sam Van Rossom
- Department of Movement Sciences, KU Leuven, Leuven, Belgium
| | - Hoa Hoang
- Department of Movement Sciences, KU Leuven, Leuven, Belgium
| | - Eirini Papageorgiou
- Department of Rehabilitation Sciences, Doctoral School of Biomedical Sciences, KU Leuven, Leuven, Belgium.,Clinical Motion Analysis Laboratory, University Hospitals Leuven, Leuven, Belgium
| | - Ann Hallemans
- Department of Rehabilitation Sciences and Physiotherapy, University of Antwerp, Antwerp, Belgium
| | - Kaat Desloovere
- Department of Rehabilitation Sciences, Doctoral School of Biomedical Sciences, KU Leuven, Leuven, Belgium.,Clinical Motion Analysis Laboratory, University Hospitals Leuven, Leuven, Belgium
| | - Guy Molenaers
- Department of Orthopedics, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Anja Van Campenhout
- Department of Orthopedics, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | | | - Ilse Jonkers
- Department of Movement Sciences, KU Leuven, Leuven, Belgium
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Adjunct therapies to improve outcomes after botulinum toxin injection in children: A systematic review. Ann Phys Rehabil Med 2019; 62:283-290. [DOI: 10.1016/j.rehab.2018.06.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 05/28/2018] [Accepted: 06/30/2018] [Indexed: 11/17/2022]
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Pulgar S, Bains S, Gooch J, Chambers H, Noritz GH, Wright E, Sawhney TG, Pyenson B, Ferro C. Prevalence, Patterns, and Cost of Care for Children with Cerebral Palsy Enrolled in Medicaid Managed Care. J Manag Care Spec Pharm 2019; 25:817-822. [PMID: 31232210 PMCID: PMC10398069 DOI: 10.18553/jmcp.2019.25.7.817] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND In the United States, many children with cerebral palsy (CP) obtain health care coverage through managed Medicaid, but little is known about the current demographics or management of this high-need, complex population. OBJECTIVE To develop U.S. population-level information about the prevalence of CP, management patterns, and costs. METHODS Data (2013-2015) were analyzed from a managed Medicaid database with coverage of children and adolescents in 15 states. Analyses included demographic information and use of 10 prespecified CP management options often used to manage spasticity. Code-based algorithms were applied to indicate presence of spasticity and determine the likely ambulatory status. RESULTS In this claims analysis, the prevalence estimate of CP was 1.78 per 1,000 patients. Most (69.8%) children with CP had spasticity, of which 20.8% had hemiplegia, 15.6% diplegia, 32.9% quadriplegia, and 30.5% CP unspecified. Overall, 42.4% of children with CP were not treated with any of the 10 CP management options via Medicaid. Among treated children, the most common management options were physical therapy (37.1%), orthotics (29.9%), oral baclofen (13.5%) and botulinum toxins (9.4%). Overall annualized Medicaid costs were higher for children with CP versus children in the overall database population ($22,383 vs. $1,358). Within the CP population, costs were higher for those children who were likely nonambulatory than for those who were likely ambulatory ($43,687 vs. $10,368, respectively). CONCLUSIONS Most children with CP have spasticity, and the costs of care are high. This study highlights wide variation in the way CP is managed, with many young patients not receiving CP management options via Medicaid. DISCLOSURES This analysis was funded by Ipsen Biopharmaceuticals and conducted by Milliman. Pulgar and Bains were employees of Ipsen Biopharmaceuticals during the conduct of this study. Chambers is a consultant for OrthoPediatrics and an employee of the University of California. Pyenson and Ferro are employees of Milliman, as was Sawhney during the analysis. Gooch, Noritz, and Wright report no conflicts of interest. Part of this work was presented as a poster at TOXINS 2017: Basic Science and Clinical Aspects of Botulinum and Other Neurotoxins, held January 18-21, 2017, in Madrid, Spain.
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Affiliation(s)
- Sonia Pulgar
- Ipsen Biopharmaceuticals, Basking Ridge, New Jersey
| | | | | | - Henry Chambers
- Rady Children’s Hospital-San Diego, San Diego, California
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Botulinum toxin A injection in the management of shoulder muscle overactivity: A scoping review. BRAIN IMPAIR 2019. [DOI: 10.1017/brimp.2019.14] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractThe majority of studies examining botulinum toxin A (BTX-A) in the management of upper limb muscle overactivity and pain focus on the distal arm and hand. Research has begun to look at BTX-A efficacy in more proximal upper limb muscles, with literature showing equivocal findings. This scoping review identified 15 studies meeting inclusion criteria whose data were examined against three outcome variables: muscle overactivity, range of movement and pain. Overall, while the majority of injected participants improved on these variables, between-study methodological variability such as research design potentially underpowered studies and arbitrary decision making gave a high likelihood of influencing the interpretation of their results. Future research is warranted, with a robust focus on functional anatomy, a critical appraisal of how BTX-A may help the individual being studied and utilising individualised rather than protocol-driven research paradigms.
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