Cerebral Palsy, Muscle Spasticity
Conditions
Keywords
Botulinum Toxins, Type A, Walking
Brief summary
In Norway, about 60% of all children with cerebral palsy (CP) are being treated with botulinum toxin A (BoNT-A) at 6 years of age, mainly in the legs. Despite this widespread use of the drug, the evidence for a positive effect on walking is insufficient. Moreover, large variation in effect is seen by clinicians. The main objective of the present study is to investigate whether injections with BoNT-A in the calf muscles make walking easier in children with spastic CP within 6 months, reflected by reduced energy cost during walking.
Detailed description
This is an industry independent multicentre clinical trial. The randomization will be done by a computer number random generator and will be carried out and held by the unit of Applied Clinical Research at NTNU. Two strata: age and center. The study will be conducted according to Consort guidelines and guidelines for Good Clinical Practice. It is approved by the local Ethical committee (REK Nord) and the Norwegian Drug Agency. Primary research question is: Do BoNT-A injections in the calf muscles make walking easier in children with CP? Secondary research questions: 1) Do BoNT-A injections in the calf muscles increase activity? 2) Do BoNT-A injections in the calf muscles improve walking capacity 3) Do BoNT-A injections in the calf muscles improve perceived performance and satisfaction related to mobility tasks and 4) Do BoNT-A injections in the calf muscles reduce recurrent musculoskeletal pain? The participants will receive the treatment with both local anaesthesia and conscious sedation with oral or nasal benzodiazepines.Outcome measures are made at baseline and 4, 12 and 24 weeks after treatment, with primary endpoint at 12 weeks. Data will be analyzed using a linear mixed model (LMM). The difference in change in the primary outcome measure (energy cost during walking) between the treated and placebo groups will be done using a post hoc test following the LMM. Secondary, the same model will be used to test for an effect also at 4 and 24 weeks post injection. Age, GMFCS Level, number of prior BoNT-A treatments and study center will be considered as potential covariates. A substudy will be conducted within the frames of this RCT, aiming to identify characteristics of those who respond to the treatment compared to those who do not respond (outcome measures 6, 7,8 and 9).
Interventions
DRUGbotox
The agent will be given only once at point zero in the time scheme for the project.
DRUGplacebo
The agent will be given only once at point zero in the time scheme for the project.
Sponsors
Norwegian University of Science and Technology
The Hospital of Vestfold
University Hospital of North Norway
Oslo University Hospital
Haukeland University Hospital
Fondation Lenval
Mazowieckie Centrum Neuropsychiatrii, Warszawa
St. Olavs Hospital
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
QUADRUPLE (Subject, Caregiver, Investigator, Outcomes Assessor)
Eligibility
Sex/Gender
ALL
Age
4 Years to 17 Years
Healthy volunteers
No
Inclusion criteria
* Diagnosed with unilateral or bilateral CP * GMFCS level I and II * Signed informed consent * expected cooperation of the patients for the treatment and follow up.
Exclusion criteria
* BoNT-A injections in the lower legs in the last 6 months before intervention * history of adverse reactions to BoNT-A * Known hypersensitivity to BoNT-A or to any of the excipients * Orthopedic surgery in the legs in the last 2 years * Major cognitive impairments (must be able to take verbal instructions and conduct the test procedure) * infection at the proposed injection site(s) * Subclinical or clinical evidence of defective neuromuscular transmission e.g. myasthenia gravis or Lambert-Eaton Syndrome in patients with peripheral motor neuropathic diseases (e.g. amyotrophic lateral sclerosis or motor neuropathy) * other underlying neurological disorders that may be affected by BoNT-A injections * Use of aminoglycoside antibiotics or spectinomycin, or other medicinal products that interfere with neuromuscular transmission (e.g. neuromuscular blocking agents) * Pregnant or breast-feeding * Childbearing potential not using contraception * any reason why, in the opinion of the investigator, the patient should not participate * Children needing deep sedation under treatment
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Energy cost during walking | 6 months | Will be measured by a 5 minutes walk test (overground walking at comfortable speed) with simultaneous gas exchange. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Activity | 6 months | Daily activity, measured by a body worn accelerometer over 4 periods of 7 consecutive days. |
| Perceived improved performance and satisfaction | 6 months | Assessed by The Canadian Occupational Performance Measure |
| Recurrent musculoskeletal pain | 6 months | Assessed by the Child Health Questionnaire (Norwegian version), and elements from the Brief Pain Inventory (Norwegian version) |
| Walking capacity | 6 months | Assessed with OMNI-RPE (OMNI Rating of Perceived Exertion) and a 1 Minute walk test at maximal gait speed |
Other
| Measure | Time frame | Description |
|---|---|---|
| Ankle strength | 6 months | Isometric strength of ankle plantar- and dorsiflexors, will be made on a subset of the participants. |
| Spasticity | 6 months | Will be assessed by the use of Tardieu scale. On a subset of participants, concurrent velocity, position and muscle activation will be measured. |
| Self-perceived effect on walking | 4 weeks | A qualitative interview will be conducted on a subset of the participants at baseline and post 1 (4 weeks post injection) |
| Gait pattern | 6 months | 3D gait analysis will be carried out on a subset of participants. |
Countries
France, Norway, Poland
Outcome results
None listed