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Repeat botulinum toxin-A injections in the upper limb of children with hemiplegia: a randomized controlled trial
Christine A Olesch1, Susan Greaves, Christine Imms
1Developmental Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia.
Insights
Repeat botulinum toxin A (BoNT-A) injections combined with occupational therapy (OT) improved upper limb function and reduced spasticity in young children with hemiplegic cerebral palsy. This treatment approach enhanced parental perception of performance and movement quality.
Area of Science:
- Pediatric Neurology
- Rehabilitation Medicine
- Movement Disorders
Background:
- Cerebral palsy (CP) is a group of movement disorders due to early brain damage.
- Hemiplegic CP affects one side of the body, often impacting upper limb function.
- Botulinum toxin A (BoNT-A) injections are used to manage spasticity in CP.
Purpose of the Study:
- To evaluate the effectiveness of repeat BoNT-A injections combined with occupational therapy (OT) in children with hemiplegic cerebral palsy.
- To assess the impact on spasticity, upper extremity function, and parental-reported outcomes.
Main Methods:
- A randomized controlled trial involving 22 children with hemiplegic CP (aged 1-5 years).
- Intervention groups received either three cycles of BoNT-A injections plus OT, or OT alone.
- Outcomes measured included spasticity (Modified Tardieu Scale), upper extremity function (QUEST, PDMS-FM), and parental perception (COPM, GAS).
Main Results:
- The BoNT-A+OT group demonstrated progressively reduced spasticity compared to the OT-alone group.
- Significant improvements were noted in parental perception of performance (COPM) and goal attainment (GAS) in the BoNT-A+OT group.
- No significant differences were found in overall quality of movement (QUEST) or fine motor skills (PDMS-FM).
Conclusions:
- Repeat BoNT-A injections in the upper limb, when combined with OT, lead to sustained reductions in spasticity.
- This combined approach improves functional performance as perceived by parents.
- BoNT-A injections represent a valuable therapeutic option for managing spasticity in young children with hemiplegic cerebral palsy.
Aim:
To test the effectiveness of repeat botulinum toxin A (BoNT-A) injections in the affected arm of 22 children with hemiplegic cerebral palsy (19 males, three females), aged 1 year 10 months to 4 years 10 months (mean 3y 8mo, SD 9mo) in a randomized controlled trial.
Method:
Children received either three series of BoNT-A injections plus twice-weekly occupational therapy (OT) or OT alone in 16-week cycles. Muscles targeted at each injection cycle in the 11 children receiving BoNT-A+OT were the adductor pollicis (n=9), flexor pollicis longus (n=5), flexor digitorum superficialis (n=8), flexor digitorum profundus (n=8), flexor carpi radialis (n=2), flexor carpi ulnaris (n=6), pronator teres (n=10), and biceps brachii (n=11). Parental perception of treatment efficacy was assessed using the Canadian Occupational Performance Measure (COPM) and the Goal Attainment Scale (GAS), quality of movement using the Quality of Upper Extremity Skills Test (QUEST), fine motor skills using the Peabody Developmental Motor Scale - Fine Motor (PDMS-FM), and spasticity using the Modified Tardieu Scale (MTS). Between-group differences at 12 months were analysed using independent-sample t-tests.
Results:
All children were at Gross Motor Function Classification System levels I (BoNT-A+OT n=6; OT n=8) or II (n=5 and n=3 respectively) and were too young to be classified using the Manual Ability Classification System. The BoNT-A+OT group had higher COPM performance scores (mean difference -0.8, 95% confidence interval [CI] -1.5-0.0) and higher GAS T scores (mean difference -6.9, 95% CI -13.8 to -0.1]). No significant difference was found for the COPM satisfaction, PDMS-FM, or QUEST scores. The BoNT-A+OT group showed progressive reduction in spasticity compared with the OT group. At study completion MTS mean difference was 50.0 degrees (95% CI 22.4-77.6) for pronators and 20.9 degrees (95% CI 2.4-39.4) for wrist flexors.
Interpretation:
Repeat BoNT-A injections in the upper limb combined with OT resulted in progressively reduced spasticity and improved parental perception of performance.
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