Elsevier

Pediatric Neurology

Volume 36, Issue 1, January 2007, Pages 30-39
Pediatric Neurology

Original article
Effect of Multilevel Botulinum Toxin A and Comprehensive Rehabilitation on Gait in Cerebral Palsy

https://doi.org/10.1016/j.pediatrneurol.2006.09.010Get rights and content

To evaluate the effect of multilevel botulinum toxin A and comprehensive rehabilitation on gait pattern, muscle length, and spasticity, a multicenter randomized trial was performed in 46 children with spastic cerebral palsy who walk with flexed knees. Their mean age was 8.0 years (range 4 to 11 years). They were randomly allocated to the intervention group (multilevel botulinum toxin A and comprehensive rehabilitation) or the control group (usual care). After 6 weeks, a significant treatment effect in the intervention group was observed on: improved knee extension during midstance and terminal swing (7° and 5°, P < 0.01, respectively); hip rotation during terminal swing (4°, P = 0.02); gait score (1.7, P < 0.01); decreased spasticity in hamstrings (11°, P < 0.01), gastrocnemius (6°, P = 0.01), and soleus (5°, P = 0.02); and increased muscle length in hamstrings (9°, P < 0.01) and gastrocnemius (5°, P < 0.01). The improved muscle length was maintained up to 24 weeks. This study demonstrated that multilevel botulinum toxin A and comprehensive rehabilitation improves knee extension during gait, increases muscle length, and decreases spasticity in injected muscles after 6 weeks in children who walk with flexed knees. Although the effect on muscle length was maintained after 24 weeks, the effect on gait and spasticity had disappeared.

Introduction

Many children with cerebral palsy have a deviating gait pattern. One of the typical patterns that is often observed in cerebral palsy is characterized by flexion of the knee during midstance [1]. It has been demonstrated that the natural course of development in these children leads to a further deterioration in this flexion pattern [2]. Because this is generally accompanied by a deterioration in mobility [3], treatment is indicated for these children at an early age.

Although the exact cause of the flexion pattern is not known, it is acknowledged that it is attributable to imbalance of the flexor and extensor muscles. It is postulated that this muscle imbalance results from an underlying combination of decreased length of the flexor muscles, decreased strength of the extensor muscles, and abnormal involuntary increased activity of the flexor muscles during gait, such as spasticity [4]. Therefore, in order to improve or prevent further deterioration in the flexion pattern, treatment should focus on restoring these underlying deficits; this requires a comprehensive treatment approach, which should begin with physiotherapy, orthoses, and serial casting. If there is an insufficient response to improve the gait pattern, injection with botulinum toxin A is indicated.

Botulinum toxin A decreases spasticity in the injected muscle and reduces the muscle tone for approximately 8 to 12 weeks [5]. When botulinum toxin A is indicated to improve the gait pattern in children who walk with a flexion pattern, multiple muscle groups should be treated in one session. This method is referred to as multilevel botulinum toxin A treatment. It is generally thought that the reduction in tone in the flexor muscles after multilevel botulinum toxin A injections creates basic conditions that are essential for the further improvement of muscle length and muscle strength in these children. Therefore, to optimize the success of multilevel botulinum toxin A injections, a comprehensive rehabilitation program seems to be crucial. Physiotherapy should be intensified during the pharmacologic period of botulinum toxin A [6] and aim, in particular, at stretching the flexor muscles, strengthening the extensor muscles, and exercises to improve gait pattern. Serial castings [7] should be applied to stretch shortened muscles and thus increase muscle length, and new orthoses should be prescribed to prevent a relapse of muscle shortening and to improve knee extension during stance. Multilevel botulinum toxin A injections followed by such comprehensive rehabilitation may result in an improvement of the gait pattern of these children.

This total treatment package has been standard clinical practice in recent years. A few randomized [8], [9], [10] and nonrandomized studies [7], [11] have evaluated the effect of multilevel botulinum toxin A injections in children with cerebral palsy characterized by various gait patterns. However, little information is available about the effect of multilevel botulinum toxin A on the gait pattern of children who walk with flexed knees. These studies also failed to include a control group receiving usual care. It is important to determine the overall effectiveness of the best clinical practice in these children (multilevel botulinum toxin A plus physiotherapy, orthotics, and, if necessary, serial casting), as opposed to usual care.

The aim of the present study was to measure the effect of lower extremity multilevel botulinum toxin A injections and comprehensive rehabilitation, compared with usual care in ambulatory children with cerebral palsy who walk with flexed knees during midstance. We hypothesized that multilevel botulinum toxin A injections plus comprehensive rehabilitation would decrease knee flexion during gait, decrease spasticity, and improve muscle length.

Section snippets

Study Patients

From October 2001, children were screened for this multicenter trial in four Dutch departments of rehabilitation medicine. The screening included standardized medical history taking and a clinical examination, and frontal and sagittal gait video-recordings with surface electromyography [12]. Inclusion was based on consensus between all four participating pediatric physiatrists, reached during a teleconsultation session in which the data collected during screening were discussed via a

Results

During an intake period of 19 months, 58 children were screened and 47 were included in the study. The selection and randomization procedures are presented as a graph in Figure 1. In the control group, one child dropped out after the first baseline assessment at the request of the parents. This child was excluded from all analyses. The groups did not differ with regard to the personal characteristics summarized in Table 3. In the intervention group, 42 limbs were treated with botulinum toxin A.

Discussion

This randomized clinical trial evaluated the effect of treatment with multilevel botulinum toxin A and comprehensive rehabilitation on gait pattern, muscle length, and spasticity in children with cerebral palsy who walked with flexion of the knee in midstance. The study demonstrated that multilevel botulinum toxin A injections in the hamstring muscle, in some combination with the psoas and gastrocnemius muscle, followed by intensive rehabilitation, significantly improved the knee extension

Conclusion

In this multicenter randomized clinical trial, multilevel botulinum toxin A injections and comprehensive rehabilitation (as opposed to usual care) resulted in a significant improvement in knee extension during gait, muscle length, and spasticity in the injected muscles of children with cerebral palsy whose gait is characterized by a flexed knee pattern. Muscle shortening should not be a contraindication, because the treatment was specifically effective in achieving a significant improvement in

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