Use of botulinum toxin a to manage upper limb spasticity in children with cerebral palsy

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Objective: To investigate the impact on of conventional therapy and resistance therapy augmented with botulinum toxin A (BoNTA) in children with hemiplegic cerebral palsy (CP) on upper limb (UL) function and quality of movement. Assessment of movement quality was considered important, because early brain injuries are more susceptible to 'maladaptative' plasticity, which might result in abnormal movement behaviours. Study Design: Single blind, randomised control trial (RCT) using matched pairs. Methods: A control group continued with their usual community based ‘conventional’ therapy. The treatment group received either 1. BoNTA injections to the upper limb with conventional therapy or; 2. BoNTA injections to the upper limb with conventional therapy plus upper limb resistance training at the peak effect of the BoNTA. Twenty-five participants aged between 8 and 16 years were enrolled. Assessments for this group included the Melbourne Assessment of Unilateral Upper Limb Function (MUUL); goal attainment using goal attainment scales (GAS) and kinematic analysis of reaching with the quantification of normalised jerk (NJ) reflecting movement fluency, and directness index (DI) reflecting movement efficiency. CNS changes were measured using Transcranial Magnetic Stimulation to map corticospinal pathways. Results: GAS improved significantly in recipients who received resistance training augmented with BoNTA relative to controls at 1, 3 and 6 months (mean 58.1, SD 11.1, p<0.05). Therapy augmented with BoNTA resulted in improvements in movement fluency and efficiency and neuroplastic changes in some, but not all the children studied. The children who had preserved contralateral corticospinal pathways displayed less maladaptive movement behaviour with lower variability of NJ and DI, and higher MUUL score. Conclusion: Augmenting physical therapies with BoNTA improves function, movement fluency and induces CNS changes in children with hemiplegic spastic CP. More significant gains in UL function were achieved in a shorter time when muscle resistance training was combined with BoNTA and maintained after the effect of the BoNTA had worn off.

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