Effect of Botulinum Toxin on Equinus Foot Deformity in Cerebral Palsy Patients: A Systematic Review and Network Meta-analysis

Abstract

Background: Cerebral palsy (CP) is a brain disorder that affects the development of movement and posture leading to limitation of Range of Movement (ROM) in the growing children. CP leads to deformities as equinus foot deformity. We aim to investigate the efficacy of different botulinum toxin (BTX) products with or without serial casting in reducing the muscle spasticity in equinus foot deformity in patients with CP. Methods: A systematic review of the literature was performed via searching of the different electronic databases. The following databases were used PubMed, Scopus, Web of Science (WOS), and GHL. We analyzed the extracted data by network meta-analysis method using R software package (version 3.5.0). Results: Regarding Modified Ashworth score (MAS), BTX-A was superior compared to placebo and BTX-A plus immediate casting (MD = −0.39, 95% CI [−0.60; −0.18]) and (MD = −0.50, 95% CI [−0.98; −0.02]) respectively. Concerning growth motor function movement Classification System (GMFM), Neuronox ranked above at 3 months (MD = −1.60, 95% CI [−2.87; −0.33]) and at six months (MD = −1.90, 95% CI [−3.48; −0.32]) compared to BTX-A. Regarding the Modified Tardieu scale (MTS) with knee flexion, BTX-A was superior to BTX-A plus immediate casting (MD = 8.60, 95% CI [1.76; 15.44]). Concerning passive range of movement (PROM) with Knee flexion or extension at 3 months, BTX-A showed a significant improvement compared to BTX-A plus immediate casting. Conclusion: BTX-A ranked best on physician rating scale (PRS), MAS, MTS with knee flexion and PROM (Knee flexion and extension) compared to Neuronox and Botulax. BTX-A alone was also better than BTX-A plus immediate casting.

Efficacy of conservative treatment for spastic cerebral palsy children with equinus gait: a systematic review and meta-analysis

“…The possible explanation may be from heterogeneity caused by gait assessment scales, small number of studies, and baseline passive ankle dorsiflexion. On the contrary, the network meta-analysis found that BoNT-A significantly improved passive ankle dorsiflexion with knee extension at 3 months compared to BoNT-A plus casting [18]. These inconsistent results may be due to The AFO was known to enhance ankle dorsiflexion during walking.…”

“…BoNT-A can improve gait pattern measured by PRS and VGA with minor side effects when compared to placebo [17]. BoNT-A plus delayed casting might be the best treatment to improve ankle dorsiflexion at stance, while BoNT-A alone was at the highest rank for passive ankle motion at knee extension, followed by immediate casting, BoNT-A plus delayed casting, and BoNT-A with immediate casting [18]. However, none of them showed significantly a different peak dorsiflexion at stance and passive ankle motion [18].…”

“…BoNT-A plus delayed casting might be the best treatment to improve ankle dorsiflexion at stance, while BoNT-A alone was at the highest rank for passive ankle motion at knee extension, followed by immediate casting, BoNT-A plus delayed casting, and BoNT-A with immediate casting [18]. However, none of them showed significantly a different peak dorsiflexion at stance and passive ankle motion [18]. The posterior ankle-foot orthosis (AFO) significantly increased ankle dorsiflexion at initial contact in children with equinus gait when compared to bare foot [19].…”

“…With regard to BoNT-A, casting, AFO, and physiotherapy for equinus treatment, the previous systematic reviews and meta-analysis were limited due to various casting protocols [18], improper effect size estimation [17], no risk-of-bias assessment [17,19], and no comparisons among these conservative treatments. Therefore, we aimed to conduct a systematic review and meta-analysis comparing usual care/placebo/control, BoNT-A, casting, physiotherapy, and orthosis in terms of the changes in gait and ankle movement in spastic cerebral palsy children presenting with equinus foot.…”

Outcome Using Either Intradermal Botox Injection or Endoscopic Thoracic Sympathectomy for Patients with Primary Palmar Hyperhidrosis: A Comparative Study

“…Botulinum neurotoxin (BoNT), produced by Clostridium botulinum, is the most potent toxin; [5] it is a zinc protease that acts through the cleavage of neuronal vesicle-associated proteins responsible for the release of acetylcholine into the neuromuscular junction [6]. While there are seven biological serotypes of BoNT, only two are used in clinical practice [7]: BoNT serotypes A and B are used for a variety of medical indications, including facial wrinkles, dystonia, spasticity, migraines, multiple sclerosis, post-stroke gait disorders, and cerebral palsy deformities [8][9][10][11].…”