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The dosage of botulinum toxin type A (Botox, onabotulinumtoxinA) injection in each muscle for each child.
Source publication
Objective
To assess the effectiveness of combining botulinum toxin type A (BoNT-A) with functional occupational therapy (OT) at 9-month follow-up in children with cerebral palsy (CP) with bilateral upper limb impairments from the perspectives of both child and caregiver.
Methods
Twelve children with CP and their caregivers were assessed across 5 t...
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Citations
... Children with CP commonly experience cognitive deficits, hearing and vision impairments, communication difficulties, and seizures [13,14]. These challenges, together with mental health issues, limit their ability to participate in physical and skill-based activities typically performed outdoors, leading to a negative impact on their daily routines, quality of life, occupational performance, and social functioning [15][16][17]. Since 1862, significant scientific and medical advancements have been made in the prevention and management of CP. ...
Cerebral palsy (CP) is a condition resulting from injury to the developing brain. Treatment modalities vary based on symptomatology and may range from physiotherapy to pharmacologic intervention and surgical intervention. Despite the current therapeutic strategies, outcomes remain suboptimal. In light of limited data regarding the therapeutic effects of oil-based massages on neonates with CP, this study aimed to investigate the potential neurological benefits of incorporating herbal oils into massage treatments for these infants. In this investigation, we conducted a thorough exploration of the medicinal herbs described in the paralysis section of medical and pharmaceutical sources in Persian medicine. Subsequently, we conducted an extensive literature review on the neurological effects of oils or essential oils derived from these herbs. Our search was conducted up to 2023 using pertinent keywords such as Pimpinella anisum L., anise, aniseed, Foeniculum vulgare Miller, fennel, Carum carvi L., caraway, Piper nigrum L., pepper, Cinnamomum zeylanicum, cinnamon, Nigella sativa L., black seed, Vitis vinifera L., grape seed, Olea europaea L., olive, Rosa x damascena Herrm., and rose flower. We specifically focused on studies related to neuroprotection, neurology, massage, and cerebral palsy, and obtained relevant information from data sources such as PubMed, Scopus, and Google Scholar. Our investigation revealed that massage therapy has an impact on CP and that herbal oils possess neurological properties, such as anticonvulsant and neuroprotective effects, as well as enhancements in behavior, memory, learning, and cerebral function. Based on the advantageous mechanisms of action of herbal oils, we postulate that massage therapy utilizing herbal oils may offer a promising complementary approach in the management of newborns with CP. We recommend further experimental and clinical studies to establish their effectiveness.
... Such a positive relationship of the psychological QOL domain, particularly in caregivers' "positive feelings", along with improvement in their children's gait functions after hippotherapy was demonstrated in a previous study via the WHOQOL-BREF questionnaire [14]. In contrast, several reports revealed that caregivers' healthrelated QOL was not necessarily related to their children's motor function levels [24] or improvements in their level of performance [15]. Although the sample size of this study was small, which may have restricted the interpretation of the data, it was conceivable that hippotherapy had the potential to improve health-related QOL in the family caregivers of children with CP, as they recognized improvements in their children's gait function through successful hippotherapy sessions. ...
Background: Despite accumulating data regarding the beneficial effects of hippotherapy on gait and balance skills in children with cerebral palsy (CP), its effects on caregivers’ quality of life (QOL) are limited, presumably due to a lack of reliable and valid measurement tools. This study aims to evaluate the impact of hippotherapy on the health-related QOL of primary caregivers using the Japanese version of the Cerebral Palsy Quality of Life for Children (CP QOL) questionnaire. Methods: A quasi-experimental design embedded within our existing cohort was utilized. A total of 29 children with CP (range 4–12 years) and their caregivers participated in either a weekly hippotherapy or recreation (usual care) program for 1 year. In addition to gait-related measurements (Gross Motor Function Measure [GMFM]-E) of children, CP QOL-evidenced determinants of the caregivers’ health-related QOL and well-being were compared before and after the intervention. Results: In addition to improvements in children’s GMFM-E scores, hippotherapy improved CP QOL domains related to participation and physical health, children’s emotional well-being, and parents’ overall health (p < 0.05). Linear regression analysis showed a positive relationship between the children’s GMFM-E scores and their caregivers’ health domains in participants who received hippotherapy (r2 = 0.404; p = 0.011). Conclusions: Hippotherapy has a beneficial effect on the physical and mental well-being and satisfaction of Japanese parents caring for children with CP.
... Para mejorar las funciones de las EESS en PC se utilizan fármacos, fisioterapia, terapias neurodesarrollantes, terapia ocupacional (TO), órtesis, cirugías, entre otras 10 , siendo la intervención farmacológica con toxina botulínica tipo A (TBA) efectiva en el manejo de la espasticidad local 10-12 y en la mejora de funcionalidad de EESS al combinarse con TO o terapia robótica Armeo spring (AS) 10,13 . ...
... La terapia AS utiliza un exoesqueleto que combina asistencia robótica con realidad virtual en un espacio de trabajo 3D 10,14 . Se utiliza en usuarios con afecciones neurológicas que requieren de rehabilitación en EESS 14 y funciona con un soporte gravitacional del segmento que magnifica cualquier movimiento activo residual del brazo, informando así sobre parámetros de resistencia, fuerza, rango de movimiento y coordinación 6,14 . ...
... Se utiliza en usuarios con afecciones neurológicas que requieren de rehabilitación en EESS 14 y funciona con un soporte gravitacional del segmento que magnifica cualquier movimiento activo residual del brazo, informando así sobre parámetros de resistencia, fuerza, rango de movimiento y coordinación 6,14 . Evidencia disponible describe efectos positivos de AS en términos de fluidez y coordinación del movimiento 15 , funcionalidad y motivación 16 , además de considerarse seguro para el paciente 6,10 . ...
Objetivo: Comparar la efectividad de la terapia robótica Armeo spring (AS) con la Terapia Ocupacional (TO) para mejorar la funcionalidad de extremidad superior de niños/as entre 4-10 años con Parálisis cerebral (PC) unilateral e inyectados intramuscularmente con toxina botulínica tipo A en Instituto Teletón Concepción-Chile. Pacientes y métodos: Ensayo clínico controlado aleatorio de grupos paralelos AS y TO con una muestra de veinte niños clasificados con MACS I, II, III (10 paciente por grupo). Se realizaron 15 sesiones de tratamiento, 3 veces/semana. Se aplicó escala QUEST y ABILHAND-kids, en tiempos basal, post intervención y seguimiento a 6 meses por Terapeuta Ocupacional que desconocía la asignación de los grupos. Resultados: No hay diferencias significativas en subdimensiones y puntaje total QUEST en ambos grupos. En grupo TO se observan diferencias entre los tiempos T1 y T3 en las subdimensiones movimiento disociado, agarre, carga de peso y puntaje total QUEST; y entre los tiempos T2 y T3 para movimiento disociado, carga de peso y puntaje total QUEST. En el grupo AS hubo diferencias entre T1 y T2 en movimiento disociado y puntaje total QUEST, y entre el T1 y T3 en puntaje disociado. En ABILHAND-kids no hay diferencias significativas entre ambos grupos y sólo en el grupo AS hay diferencias significativas entre los tiempos T1-T3 y T2-T3. Discusión: La terapia robótica AS y la TO logran mejorar la funcionalidad de extremidad superior en niños con PC unilateral, no encontrándose diferencias entre ambos grupos.
... Eight studies included both unilateral and bilateral CP (Akbari et al., 2009;Ketelaar et al., 2001;Lowing et al., 2009;Peungsuwan et al., 2017;Scholtes et al., 2010;Storvold & Jahnsen, 2010;van Vulpen et al., 2017). Five studies included children with bilateral CP (Ahl et al., 2005;Blundell et al., 2003;Kusumoto et al., 2016;Liao et al., 2007;Lin et al., 2015). Three studies did not specify the subtype of CP (Gorter et al., 2009;Lammi & Law, 2003;Lee et al., 2015). ...
Aim: To review definitions and elements of interventions in studies, which used the word “functional” to describe their intervention for children with cerebral palsy (CP), and to determine whether definitions and elements are similar to criteria of functional therapy described in the Dutch Guidelines.
Methods: Systematic review of intervention studies, which used the word “functional” to describe interventions for children with CP. We described criteria of functional therapy that were used to describe the intervention, and whether criteria were described similarly to the descriptions used in the Dutch Guidelines.
Results: Of the 27 included studies, criteria “based on the activities/participation level of the ICF-CY”, “goal-directed” and “context-specific” were referred to the most (40–59.3%). Descriptions of these criteria were less comparable to the suggested definition (43.8–69.2%). The remaining three criteria (“active involvement”, “task-specific”, and “focused on functionality instead of normality”) were referred to less frequently (18.5–33.3%). The descriptions reported for these criteria were, however, the most comparable with the suggested definitions (80–100%).
Conclusions: The included studies, in general have not used criteria of functional therapy. Future studies have to describe the elements of interventions in detail. Moreover, it is important to reach consensus on the definition and elements of functional therapy.
... Interestingly, this result validated the suspicion of a positive relationship between the changes in the psychological QOL, particularly in the "positive feeling, " of caregivers and improvement in the children's gait functions after hippotherapy. Conversely, several reports have shown that the health-related QOL of caregivers is not necessarily associated with their children's level of functioning (35) or with improvements in their level of performance (23). Although the sample size in our study was small, which may have restricted the interpretation of our results, it is conceivable that hippotherapy may provide better psychological QOL within the family caregivers of children with CP by recognizing impact of a hippotherapy program on the psychological outcomes of caregivers in more detailed, as measured by factors such as caregiver burden; QOL; anxiety; depression; perceived control; stress mastery; and caregiver confidence, preparedness, and mastery. ...
Background: Cerebral palsy (CP) is a permanent motor disorder that occurs at birth or during early infancy. Despite advances in fetal and maternal medicine, the incidence of CP remains high. Hippotherapy has gradually been recognized as an excellent rehabilitation tool for children with CP. However, a scientific basis for how it achieves long-term functional improvements or provides additional benefits to patients' caregivers remains unknown.
Objectives: We performed a prospective trial to determine how hippotherapy affects the gross motor and gait functions in children with CP and how it may also impact the quality of life (QOL) of patients' caregivers.
Methods: In total, 24 children with CP (11 boys, 13 girls; age: 4–14 years; Gross Motor Function Classification System [GMFCS] II-III) underwent a program (30 min/day, once a week) of hippotherapy or day-care recreation (control) over a 1-year intervention and a 3-month follow-up period. Assessment measures used for the children were gait parameters for a 5-m walk test, Gross Motor Function Measure (GMFM)-66, and GMFM dimension-E (GMFM-E). The QOL of the caregivers was estimated using a brief version of the World Health Organization Quality Of Life (WHOQOL-BREF) self-assessment questionnaire.
Results: In addition to better GMFM-66 and GMFM-E scores, hippotherapy was associated with increased cadence, step length, and mean acceleration; stabilized horizontal/vertical displacement of patients; and better relationship between the psychological status and QOL of the caregivers than those seen in the control group (p < 0.05). Additionally, the initially improved children's step length and their caregivers' psychological QOL domain (particularly in the “positive feeling” facet) tended to be preserved up to the 3-month follow-up.
Conclusion: These data suggest that compared with common day-care recreational activities, a 1-year program of once-weekly hippotherapy can improve not only the walking ability of children with CP but also the psychological health and QOL of their caregivers.
Clinical Trial Registration:: www.umin.ac.jp/ctr/, identifier: UMIN000022986
... Because these data could not be retrieved, the two studies 64,65 were excluded. Therefore, this review included 15 studies [66][67][68][69][70][71][72][73][74][75][76][77][78][79][80] investigating the efficacy of interventions on upper limb function in children with bilateral CP. ...
... In three studies the setting was not documented. In 10 studies exclusion criteria were reported, 66,67,72,[74][75][76][77][78][79][80] including different types of comorbidity: severe hearing loss, visual impairment, epilepsy, autism, history of BoNT-A or phenol injections, neurosurgery, or ophthalmic surgery. ...
... Contextual factors were reported by three studies, including subjective parent reported symptoms, 80 a caregivers report on achieved goals, 70 and caregiver's health-related quality of life. 74 However, measures of these studies were minimally related to upper limb function and therefore are not presented. ...
Aim
To systematically review the efficacy of interventions on upper limb function in children 0 to 19 years of age with bilateral cerebral palsy on the basis of outcome measures of upper limb function and measures of activities and/or participation according to the International Classification of Functioning, Disability and Health.
Method
Cochrane, PubMed, Embase, CINAHL, and Web of Science were searched from inception to September 2017. Methodological quality and strength of evidence were analysed by two independent raters using Sackett's level of evidence and the American Academy for Cerebral Palsy and Developmental Medicine (AACPDM) guidelines.
Results
Fifteen studies with a large variety of interventions and heterogeneity in outcome measures met the inclusion criteria. Twelve studies provided level IV evidence according to AACPDM guidelines. For three small randomized controlled trials the level of evidence was II. Only one of these trials showed strong methodological quality: a study on hand–arm bimanual intensive therapy including lower extremities.
Interpretation
We identified a large variety of interventions, heterogeneity in outcome measures, and generally weak to moderate methodological quality for most studies. We recommend further research specifically aimed at bimanual‐intensive, goal‐directed, and task‐specific training programmes for the upper limb in children with bilateral cerebral palsy, using either high‐quality (multicentre) trials or well‐designed single‐case trials.
What this paper adds
There is a large variety of interventions on upper limb function in children with bilateral cerebral palsy.
Heterogeneity of outcome measures and interventions impeded firm conclusions about intervention efficacy.
Most studies had low‐level evidence and weak to moderate methodological quality.
The strongest evidence from a small randomized controlled trial was for hand–arm bimanual intensive therapy including lower extremities.
... BoNT-A has been used to reduce spasticity in children with CP for more than two decades (82,108,109,111,112). BoNT-A is injected in the muscle, often under general anaesthesia, nitrous oxide sedation or other sedation, and analgesia (113,114). ...
https://gupea.ub.gu.se/handle/2077/56354
Background: For children with unilateral spastic cerebral palsy (USCP), activities in daily life pose a challenge due to reduced function in one hand. Aim: To study the development of hand function and occupational performance in children with USCP after intervention with occupational therapy (OT) combined with botulinum neurotoxin A (BoNT-A), and describe learning of bimanual activities in everyday life from a parental perspective and from self-perceived experiences of children and adolescents with USCP. Methods: Twenty children with USCP (inclusion median age 3y and 1 mo) participated in a randomized controlled trial to evaluate the effects of repeated BoNTA+OT compared to OT alone over a course of one year. Annual assessments were performed the following three years. Comparisons between the two study groups, and a reference group from a national quality register were made. To capture experiences of learning of bimanual activities in daily living, focus group discussions according to Krueger were conducted with parents of children with USCP, and interviews were conducted with young people with USCP, analysed according to Grounded Theory. Results: BoNT-A+OT appeared superior to OT alone for bimanual performance (p<0.03). Active supination and goal achievement improved in both groups. At final follow-up, the improved bimanual performance in the BoNT-A+OT group was maintained. The OT group increased the bimanual performance during follow-up to the same level as the BoNT-A+OT group. Active supination increased in the total group compared with the reference group (p<0.001). The parents described that learning took place in activities that could wake the children´s inner drive, and that children developed their own way to perform an activity, sometimes with support. Other activities were not possible to learn. An overall theme emerged: 'Finding harmony between pleasure and effort is the key to learning'. In the individual interviews, the learning of bimanual activities was described as a process taking place in interaction with the dynamics of everyday situations, summarized as: ‘Managing to learn bimanual activities as life unfolds’. Conclusion: Learning of bimanual activities should be viewed from multiple perspectives. The impact of development with age, timing of the right interventions, evaluated in long term, and experiences from parents and people with USCP themselves, need to be considered.
... It has been estimated that between 50% and 70% of children with CP will have upper limb spasticity, with higher prevalence rates in children with hemiparesis (Colver, Fairhurst, & Pharoah, 2014;Santos et al., 2015). Botulinum toxin type-A (BoNT-A) is a commonly used pharmacologic option to reduce upper limb spasticity (Hoare, 2014;Strobl et al., 2015), and accumulating evidence now suggests that longterm BoNT-A treatment is more effective when combined with a physical/occupational therapy intervention, compared to BoNT-A therapy alone (Ferrari et al., 2014;Hoare et al., 2010;Karaca, Unlu, Kose, Gonen, & Cakci, 2016;Lin et al., 2015;Wallen, O'Flaherty, & Waugh, 2007). Based on data from 10 randomized controlled trials, the most recent Cochrane review concluded that "BoNT-A should not be used in isolation but should be accompanied by planned occupational therapy (Hoare et al., 2010)." ...
Aims:
To create a standardized home exercise therapy program that could be implemented by international sites to provide a consistent level of therapeutic intervention for pediatric patients participating in an ongoing Phase-III, randomized, controlled trial of repeat abobotulinumtoxinA injections for pediatric upper limb spasticity (NCT02106351).
Methods:
Physical therapists, occupational therapists, and medical doctors worked collaboratively to design an exercise therapy program to be implemented in the home setting. In this article, we describe the development process and the finalized program that is currently being used in the Phase-III trial.
Results:
The final program is presented as a "toolbox" for therapists, and includes a standardized step-wise process for choosing the most appropriate exercises and functional activities to achieve the agreed treatment goals of each abobotulinumtoxinA injection. The core toolbox includes: a clear protocol for clinicians, information sheets, signature of commitment forms, exercise score charts, and the library of exercises and functional activities that therapists choose from to aid the patient in achieving their treatment goals.
Conclusions:
Implementation of this home therapy program provides a standardized background of good practice against which to test the efficacy of abobotulinumtoxinA. Preliminary data show that the program is readily accepted by patients and their families.
... BoNT-A decreases spasticity at the level of body structure and function. It may lead to improved execution of walking activity and participation in daily life as demonstrated in improved levels of activity and participation based on the World Health Organization (WHO)'s international Classification of Functioning, Disability, and Health (ICF) [9,10]. To comprehensively understand the effects of BoNT, from body function to activity and participation, further studies are required. ...
Cerebral palsy (CP) is the most common pediatric disease to cause motor disability. Two common symptoms in CP are spasticity and contracture. If this occurred in the ankle plantar flexors of children with CP, it will impair their gait and active daily living profoundly. Most children with CP receive botulinum toxin type A (BoNT-A) injection to reduce muscle tone, but a knowledge gap exists in the understanding of changes of neural and non-neural components of spasticity after injection. The purpose of this study was to determine if our device for quantitative modified Tardieu approach (QMTA) is a valid method to assess spasticity of calf muscles after botulinum toxin injection.
In this study, we intended to develop a device for quantitative measurement of spasticity in calf muscles based on the modified Tardieu scale (MTS) and techniques of biomedical engineering. Our QMTA measures the angular displacement and resistance of stretched joint with a device that is light, portable and can be operated similar to conventional approaches for MTS. The static (R2), dynamic (R1) and R2-R1 angles derived from the reactive signals collected by the miniature sensors are used to represent the non-neural and neural components of stretched spastic muscles. Four children with CP were recruited to assess the change in spasticity in their gastrocnemius muscles before and 4 weeks after BoNT-A injection.
A simulated ankle model validated the performance of our device in measuring joint displacement and estimating the angle of catch. Data from our participants with CP showed that R2 and R2-R1 improved significantly after BoNT-A administration. It indicates both neural and non-neural components of the spastic gastrocnemius muscles improved at four weeks after BoNT-A injection in children with CP.
Our device for QMTA can objectively measure the changes in spasticity of the gastrocnemius muscle in children with cerebral palsy after BoNT-A injection.
Objective
To describe the current state of the art in the therapeutic administration of botulinum toxin with indications, efficacy, and safety profile for children and adolescents with cerebral palsy.
Data source
An integrative review was conducted. The MEDLINE/PubMed database was searched twice within the last decade using distinct terms, and only studies written in the English language were included. The study population was limited to those aged 0–18 years. Articles that were duplicates or lacked sufficient methodology information were excluded.
Data synthesis
We found 256 articles, of which 105 were included. Among the included studies, most were conducted in developed countries. Botulinum toxin demonstrated good safety and efficacy in reducing spasticity, particularly when administered by a multidisciplinary rehabilitation team. It is primarily utilized to improve gait and upper limb function, facilitate hygiene care, reduce pain, prevent musculoskeletal deformities, and even decrease sialorrhea in patients without a functional prognosis for walking.
Conclusions
The administration of botulinum toxin is safe and efficacious, especially when combined with a multi-professional rehabilitation team approach, which increases the probability of functional improvement. It can also be beneficial for patients with significant functional impairments to help with daily care tasks, such as hygiene, dressing, and reducing sialorrhea. Pediatricians must be familiar with this treatment and its indications to attend to and refer patients promptly when necessary, and to exploit their neuroplasticity. Further research on this topic is required in developing countries.
Keywords:
Botulinum toxin; Cerebral palsy; Spasticity; Rehabilitation
