Botulinum toxin assessment, intervention and follow‐up for paediatric upper limb hypertonicity: international consensus statement

Abstract

The primary objective of this paper was to evaluate the published evidence of efficacy and safety of botulinum neurotoxin (BoNT) injections in paediatric upper limb hypertonia (PULH). Secondary objectives included the provision of clinical context, based on evidence and expert opinion, in the areas of assessment, child and muscle selection, dosing, and adjunctive treatment. A multidisciplinary panel of authors systematically reviewed, abstracted, and classified relevant literature. Recommendations were based on the American Academy of Neurology (AAN) evidence classification. Following a literature search, 186 potential articles were screened for inclusion, and 15 of these met the criteria and were reviewed. Grade A evidence was found to support the use of BoNT to reach individualized therapeutic goals for PULH. There is grade B evidence (probably effective) for tone reduction following BoNT injections and grade U evidence (inconclusive) for improvement in upper limb (UL) activity and function. BoNT injections were generally found to be safe and well tolerated with the most common side effect identified as a transient decrease in grip strength.

Selection of a dose of the botulinum toxin A in spastic forms of cerebral palsy

“…Ботулинотерапия -часть восстановительного лечения ребенка с ДЦП, что неоднократно подчер-кивалось в консенсусах по лечению таких больных [3,10,11], а также в нескольких обзорах и метаана-лизах [2,12]. Этот метод входит в число основных лечебных подходов (наряду с функциональными методами терапии и консервативным ортопедиче-ским лечением), которые применяются у большин-ства пациентов со спастическими формами ДЦП [3].…”

“…В международном консенсусе, касающемся вве-дения БТА в мышцы верхних конечностей у детей со спастичностью [10], были рекомендованы высокие дозы диспорта (суммарная доза до 30 Ед/кг), при том что для отдельной мышцы рекомендованные дозы составляли 5 Ед/кг для мелких мышц предпле-чья и кисти, 5-10 Ед/кг -для мышц плеча и пред-плечья и даже 10-15 Ед/кг -для трехглавой мыш-цы плеча. Учитывая, что большинству детей с ДЦП необходимо введение препаратов БТА в мышцы нижних конечностей, использование простого сум-мирования всех доз для отдельных мышц ног и рук может привести к опасному завышению суммарной дозы.…”

Surgical Management of the Wrist in Children with Cerebral Palsy and Traumatic Brain Injury

“…These modalities (e.g., botulinum toxins) can delay excessive musculotendinous shortening of the wrist and finger motors, delay or prevent intrinsic joint contracture, and minimize adaptive osseous deformity [13][14][15][16][17]. However, none of these modalities provide optimal results in isolation, and only 50 % of patients respond sufficiently to botulinum toxin injections to objectively justify continual treatment.…”

“…Injections can also enhance function and delay the need for surgery [17]. In addition, botulinum toxin injections can be used to predict and/or plan hand surgery [15,31]. Preoperative injections of botulinum A toxin combined with upper extremity functional assessments can be used to identify children with spastic hemiplegia who would not benefit from surgery [31].…”

“…Botulinum toxins produce selective and partial flaccid muscle paralysis and balance muscle forces across the wrist [13][14][15][16][17]30]. In many patients, 100-200 units of botulinum A toxin diluted in 4-6 cm 3 can be intramuscularly injected into hypertonic flexor muscles to improve active and passive motion.…”