Single event multilevel botulinum toxin type A treatment and surgery: similarities and differences

Abstract

The present study attempts to provide objective evidence of two treatment options for children with cerebral palsy (CP): multilevel botulinum toxin type A (BTX-A) injections and multilevel surgery. The purpose of the study was to clarify the differences and the similarities, and common treatment principles of both treatment strategies. Objective three dimensional gait analysis data were studied retrospectively in two patient groups pre- and post-treatment (randomly selected from a group of children that were treated between 1998 and 1999). In the first group, 29 children with CP were managed with BTX-A injections according to an integrated multilevel approach (Molenaers et al., 1999a). A second group of 23 children with CP were managed by a more traditional single event multilevel surgery, also according to an integrated approach. Our aim was to evaluate the differences as well as the similarities between both patient groups, using a set of 56 parameters selected from three-dimensional gait analysis. The unifying concept between management with BTX-A injections and orthopaedic surgery was the adoption of a multilevel approach at one session. The groups demonstrated considerable differences with respect to age, pretreatment condition and amount and level of improvement after treatment. The children who received BTX-A were typically younger, and showed primary gait problems in the distal joints, whereas the children who underwent surgery demonstrated a higher frequency of gait deviations in the transverse plane and had more complications. Although the benefit of both treatments was confirmed by the present study, a difference in the amount and level of improvement was also demonstrated. In conclusion, these treatment modalities should be regarded as complementary rather than mutually exclusive treatments, with both calling for an integrated approach.

Botulinum A toxin for treatment of lower limb spasticity in cerebral palsyGait analysis in 49 patients

“…We found an improvement in 3 gait variables after multilevel injections. This accords with the findings of Molenaers et al (2001), who proposed multilevel injections only in young patients, to avoid the development of fixed contractures and bony deformities. Moreover, we believe that if all patients were evaluated during a period of 3-6 months, which is the duration of the chemodenervation effect of BTX-A, the improvement in gait patterns might have been slightly better.…”

Motor function following multilevel botulinum toxin type A treatment in children with cerebral palsy

“…The two groups showed similar distributions of known factors that could influence motor development, except in the use of day orthoses, which were used more intensively in the BTX-A group. 9,13,23 The groups in this study were treated identically, with the exception of BTX-A, and in accordance with the same strategies, implying that all children received appropriate individualized sessions of physiotherapy, occupational therapy, and orthotic management. The pathological pattern at the level of the pelvis and hip in the sagittal plane was significantly less pronounced for the BTX-A group than for the control group.…”

Musculoskeletal Aspects of Cerebral Palsy

“…Some groups, however, have developed an integrated multilevel approach, which in clinical effect is equivalent to a medical rhizotomy. 30 The benefits of the drug Baclofen are limited by sideeffects when administered orally. The poor lipid solubility means that the drug reaches the target tissue in very low concentrations.…”