Limited evidence of botox superiority in alleviating muscle tightness in children with CP

A review found limited evidence that botox outperforms other forms of treatment in improving walking, joint motion, or muscle spasticity in children with cerebral palsy (CP). The study was published in the Cochrane Database of Systematic Reviews.

Six months ago, 13-year-old Georges Vermast rode her bike for the first time in her life – from her home in the coastal city of Oostduinkerke straight to the beach. Even though she wasn’t riding a real bike but a tricycle, it was a remarkable achievement and a demonstration of how endurance and devotion can eventually pay off. A year before, Georges had been bound to her wheelchair, believing she would never be able to ride a bike or even walk independently. Dieter Telemans photo, Children’s Rehabilitation Department of UZ Leuven Pellenberg

by Joana Carvalho MSc, Cerebral Palsy News Today October 16, 2019

CP comprises a group of disorders that affect posture and restrict movement, and is caused by brain lesions that occur during pregnancy or infancy. Spastic cerebral palsy, the most common form of the disease, is characterized by joint stiffness, spasms, and muscle stiffness (spasticity) that restricts movement and affects posture and gait.

When a child has isolated spasticity, a condition in which only a specific group of muscles is continuously contracted, local botox injections may be recommended as a first-line treatment.

Botox (botulinum neurotoxin type A, or BoNT-A) is a toxin produced by the bacteria Clostridium botulinum which blocks the communication between nerves and muscles, resulting in short-term muscle relaxation. For this reason, botox is sometimes used as a form of treatment for disorders with associated muscle spasms and excessive muscle contraction.

The systematic review summarized the main findings of studies that evaluated the safety and effectiveness of botox in alleviating leg spasticity in children with CP compared with a placebo or other treatments currently available.

A literature search in online databases — CENTRAL, Pubmed, and four others — and two trial registers, followed by a thorough screening, yielded a total of 31 clinical trials involving 1,508 children with CP who were selected to be included in the systematic review.

Most studies focused on children from 3 to 7 years old, who were still able to walk without assistance and had been diagnosed with more than one type of motor CP.

Nearly half (14) of the studies included in the review compared the safety and effectiveness of botox to standard physiotherapy. The remaining studies compared the safety and effectiveness of botox to a placebo or sham treatment (12 studies), leg plaster casts (four), or orthoses (one).

Botox was associated with improvements in gait (walking pattern), joint range of motion, treatment satisfaction, and muscle spasms, compared to standard care physiotherapy or placebo treatment. However, in some measures of motor function, the benefits of botox over physiotherapy or a placebo were mild.

The frequency of treatment side effects was similar in children receiving botox or a placebo.

Compared with plaster casts that were placed below the knee, botox led to similar improvements in gait, joint range of motion, and muscle spasms. One of the studies reported that botox was more effective than orthoses at improving joint range of motion.

However, in most studies, the quality of the evidence provided was considered to be low or very low by both review authors who analyzed the data, limiting their ability to draw conclusions as to whether botox is superior to other forms of treatment.

“There is limited evidence that, compared to placebo or regular care, BoNT‐A improves walking, joint motion, satisfaction with the outcome of treatment, and muscle spasticity in children with CP,” the authors said. “BoNT‐A was no better than plaster casts in any of our analyses, but was better than splints at improving range of motion and spasticity.”

Source Cerebral Palsy News Today

Joana Carvalho MSc
Joana is currently completing her PhD in Biomedicine and Clinical Research at Universidade de Lisboa. She also holds a BSc in Biology and an MSc in Evolutionary and Developmental Biology from Universidade de Lisboa. Her work has been focused on the impact of non-canonical Wnt signaling in the collective behavior of endothelial cells — cells that make up the lining of blood vessels — found in the umbilical cord of newborns.
Fact checked by Ana de Barros PhD
Ana holds a PhD in Immunology from the University of Lisbon and worked as a postdoctoral researcher at Instituto de Medicina Molecular (iMM) in Lisbon, Portugal. She graduated with a BSc in Genetics from the University of Newcastle and received a Masters in Biomolecular Archaeology from the University of Manchester, England. After leaving the lab to pursue a career in Science Communication, she served as the Director of Science Communication at iMM.
  Reference
Botulinum toxin type A in the treatment of lower limb spasticity in children with cerebral palsy, João Carlos Belloti, Marcel JS Tamaoki, José A Pinto. Cochrane Database of Syst Rev. 08 October 2019. doi: 10.1002/14651858.CD001408.pub2 Full text
  Further reading
Botulinum Toxin in the Management of Children with Cerebral Palsy, Multani I, Manji J, Hastings-Ison T, Khot A, Graham K. Paediatr Drugs. 2019 Aug;21(4):261-281. doi: 10.1007/s40272-019-00344-8. Full text

Efficacy and Safety of Letibotulinum Toxin A for the Treatment of Dynamic Equinus Foot Deformity in Children with Cerebral Palsy: A Randomized Controlled Trial, Chang HJ, Hong BY, Lee SJ, Lee S, Park JH, Kwon JY. Toxins (Basel). 2017 Aug 18;9(8). pii: E252. doi: 10.3390/toxins9080252. Full text

Longitudinal assessment of gait quality in children with bilateral cerebral palsy following repeated lower limb intramuscular Botulinum toxin-A injections, Read FA, Boyd RN, Barber LA. Res Dev Disabil. 2017 Sep;68:35-41. doi: 10.1016/j.ridd.2017.07.002. Epub 2017 Jul 20.

Quantitative evaluation for spasticity of calf muscle after botulinum toxin injection in patients with cerebral palsy: a pilot study, Lin YC, Lin IL, Chou TF, Lee HM. J Neuroeng Rehabil. 2016 Mar 12;13:25. doi: 10.1186/s12984-016-0135-8. Full text

Combining strength training and botulinum neurotoxin intervention in children with cerebral palsy: the impact on muscle morphology and strength, Williams SA, Elliott C, Valentine J, Gubbay A, Shipman P, Reid S. Disabil Rehabil. 2013 Apr;35(7):596-605. doi: 10.3109/09638288.2012.711898. Epub 2012 Aug 28.

Effectiveness of botulinum toxin A for upper and lower limb spasticity in children with cerebral palsy: a summary of evidence, Lukban MB, Rosales RL, Dressler D. J Neural Transm (Vienna). 2009 Mar;116(3):319-31. doi: 10.1007/s00702-008-0175-8. Epub 2009 Jan 14. Review.

Botulinum toxin type A in the treatment of lower limb spasticity in cerebral palsy, Ade-Hall RA, Moore AP. Cochrane Database Syst Rev. 2000;(2):CD001408. Review.

Also see
Scientists Find the Cause and a Novel Treatment for Muscle Contractures in Childhood Paralysis in Cincinnati Children’s Hospital Medical Center

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