The efficacy of botulinum toxin A lower limb injections in addition to physiotherapy approaches in children with cerebral palsy: A systematic review

Abstract

BACKGROUND: To assess treatment effect of lower limb botulinum toxin type A (BTX-A) in combination with physiotherapy approaches on gross motor functions in children with cerebral palsy compared with only physiotherapy treatment. OBJECTIVE: The purpose of this review was to analyze the efficacy botulinum toxin a lower limb injections in addition to physiotherapy approaches in children with cerebral palsy. METHODS: A literature search was conducted in the following databases: Cochrane, PEDro, PubMed, MEDLINE, AMED and EMBASE. The searches were limited to the period from July 2009 to July 2015. The intervention had to contain BTX-A into the lower limb plus physiotherapy approaches and be compared with only physiotherapy. The methodological quality and clinical relevance were independently assessed by the authors. RESULTS:The database search resulted in a total of 1521 studies, of which 4 (Level II of evidence) trials were included in this review. The population represented by were age between from 11 month to 15 years. Overall there were 153 children all diagnosed with CP (87 Male, 66 Female). CONCLUSIONS: The use of BTX-A injections in addition to physiotherapy approaches seems to have positive effect on spasticity and ROM. However, the question of whether the treatment of BTX-A plus physiotherapy has a greater improvement on functional capacity, such as gross motor function or gait parameter than only physiotherapy treatments, was inconclusive. Further investigation by rigorous studies is required.

The Effect of Botulinum Toxin Injections on Gross Motor Function for Lower Limb Spasticity in Children with Cerebral Palsy

“…In previous studies, BoNT-A injections, or combined therapy with BoNT-A and physiotherapy, led to greater improvements on the GMFM-88 in children with CP than physiotherapy [8,16,17,18,19], although one report found conflicting evidence [20]. In addition, injection technique [21], gross motor function, and age [4,22] were suggested as factors associated with changes on the GMFM-88 [23].…”

“…There are some positive reports showing gains on the GMFM-88 after administering injections to children with CP [8,9,22,24]. However, the question of whether BoNT-A injections in combination with physical therapy facilitates greater improvements in gross motor function is inconclusive because of the poor level of existing evidence, according to systematic reviews [23,32].…”

Tratamiento con toxina botulínica en niños con parálisis cerebral espástica.

“…En este sentido, el abordaje más efectivo es indicar TB mientras el músculo se encuentre en la fase dinámica, previo al desarrollo de las contracturas musculares (18) , y el equino dinámico, causado por espasticidad del tríceps sural, es frecuentemente la primera indicación de tratamiento con TB en niños con PC a partir de los 2 años (24) . Múltiples estudios han demostrado los efectos del tratamiento con TB en términos de reducción de la espasticidad, mejoría del rango de movimiento y en medidas de evaluación funcional (20,(24)(25)(26) . En la mayoría de las revisiones sistemáticas se plantea que el tratamiento con TB debe recomendarse fuertemente (3,(17)(18)(19) .…”

“…En los estudios que incluyen medidas de evaluación funcional, la mayoría utilizan la Gross Motor Function Measure (GMFM) y los parámetros de la marcha (20,24) . Si bien el uso de TB asociado a la fisioterapia produce un cambio positivo en la espasticidad y en la función de la marcha, y la asociación de las dos terapias parece tener un mayor efecto positivo en la espasticidad y en el rango del movimiento articular que la fisioterapia aislada, no está totalmente definido si esta mejoría adicional de la terapia combinada se traslada a la capacidad funcional, evaluada a través de escalas como el GMFCS o de parámetros de la marcha (26) .…”

Functional assessment of stretch hyperreflexia in children with cerebral palsy using treadmill perturbations

“…The effect of other treatments, such as botulinum toxin injections, considered to affect spasticity, can also be studied using treadmill perturbations. This will add to the current clinical decision making and treatment evaluation, which mostly has to rely on less specific ordinal measures such as the Modified Ashworth Scale, and indirect functional measures such as passive ankle range of motion, walking speed, or—in more exceptional rehabilitation centers—the total muscle activity patterns during normal walking [ 67 – 69 ]. Larger sample sizes with more homogenous groups (e.g., only toe- or crouch walking) are needed to perform a generalizability study [ 70 ] to assess the smallest detectable differences of stretch hyperreflexia within and between patients.…”