Low-dose/high-concentration localized botulinum toxin A improves upper limb movement and function in children with...

Area of Science:

• Neurology
• Pediatrics
• Rehabilitation Medicine

Background:

• Hemiplegic cerebral palsy (CP) significantly impacts upper limb function in children.
• Occupational therapy is a cornerstone in managing CP, but enhancing its effectiveness remains a focus.
• Botulinum toxin A (BTX-A) injections are used to manage spasticity, but their role in improving overall function and movement quality in conjunction with therapy requires further investigation.

Purpose of the Study:

• To evaluate the efficacy of low-dose, high-concentration, dual localized botulinum toxin A (BTX-A) injections combined with occupational therapy for improving upper limb movement quality and function in children with hemiplegic cerebral palsy.
• To assess the impact of BTX-A on various functional and quality of movement metrics over a 6-month period.
• To determine if BTX-A enhances occupational therapy outcomes beyond its direct pharmacological effects.

Main Methods:

• Evaluator-blinded, randomized, controlled trial involving 42 children (2-8 years) with Gross Motor Function Classification System level I hemiplegic cerebral palsy.
• Participants received occupational therapy; the treatment group (n=21) additionally received one series of BTX-A injections (mean 6 muscles, mean dose 139 units).
• Outcomes measured included the Quality of Upper Extremity Skills Test (QUEST), Canadian Occupational Performance Measure (COPM), Goal Attainment Scaling (GAS), Pediatric Evaluation of Disability Inventory (PEDI), and Ashworth scale at 1, 3, and 6 months.

Main Results:

• The primary outcome, QUEST at 6 months, was not statistically significant (p=0.318).
• However, secondary outcomes significantly favored the BTX-A treatment group at various time points: QUEST (p<0.001), COPM performance (p=0.002) and satisfaction (p=0.007), parent and therapist GAS (p=0.001, p<0.001), PEDI functional skills (p=0.030), and Ashworth scale (p<0.001).
• Improvements in movement quality were noted at 1 and 3 months, and functional improvements were sustained up to 6 months, suggesting BTX-A amplifies therapy benefits.

Conclusions:

• While occupational therapy alone is effective for hemiplegic cerebral palsy, combining it with low-dose, high-concentration BTX-A injections enhances upper limb function and movement quality.
• BTX-A appears to augment the outcomes of occupational therapy beyond its direct muscle-relaxing effects, offering sustained functional benefits.
• The study suggests that precise needle placement in BTX-A injections may contribute to improved outcomes, as indicated by early Ashworth and QUEST scores.