Why should non-ambulatory children get botox for cerebral palsy? It improves care.

I have performed botox injections as a rehabilitation technique since 2000. As the only neurologist in Houston who is a member of the AACPDM, I am often asked why I offer this procedure?

In non-ambulant children it makes a significant difference in quality of life.  

I lament the fear-mongering about adverse effects. While these events can happen, they are very rare. Almost all families return for repeat procedures. I see families who drive from Louisiana, Dallas and San Antonio who come every 3-4 months. 

Here is another article demonstrating efficacy without major adverse effects!

Dr. R

J Pediatr. 2014 Mar 12. pii: S0022-3476(14)00078-X. doi: 10.1016/j.jpeds.2014.01.050. [Epub ahead of print]

Botulinum Toxin A for Nonambulatory Children with Cerebral Palsy: 

A Double Blind Randomized Controlled Trial.

Copeland L1, Edwards P2, Thorley M2, Donaghey S2, Gascoigne-Pees L2, Kentish M2, Cert G2, Lindsley J2, McLennan K2, Sakzewski L3, Boyd RN3.

Author information

Abstract

OBJECTIVES:

To examine the efficacy and safety of intramuscular botulinum toxin A (BoNT-A) to reduce spasticity and improve comfort and ease of care in nonambulant children with cerebral palsy (CP).

STUDY DESIGN:

Nonambulant children with CP (n = 41; Gross Motor Function Classification System level IV = 3, level V = 38; mean age 7.1 years, range 2.3-16 years, 66% male) were randomly allocated to receive either intramuscular BoNT-A injections (n = 23) or sham procedure (n = 18) combined with therapy. The analysis used generalized estimating equations with primary outcome the Canadian Occupational Performance Measure (COPM) at 4 weeks postintervention and retention of effects at 16 weeks. Adverse events (AE) were collected at 2, 4, and 16 weeks by a physician masked to group allocation.

RESULTS:

There were significant between group differences favoring the BoNT-A-treated group on COPM performance at 4 weeks (estimated mean difference 2.2, 95% CI 0.8, 3.5; P = .002) and for COPM satisfaction (estimated mean difference 2.2, 95% CI 0.5, 3.9; P = .01). These effects were retained at 16 weeks for COPM satisfaction (estimated mean difference 1.8, 95% CI 0.1, 3.5; P = .04). There were more mild AE at 4 weeks for the BoNT-A group (P = .002), however, there were no significant between-group differences in the reporting of moderate and serious AE.

CONCLUSIONS:

In a double-blind randomized sham-controlled trial, intramuscular BoNT-A and therapy were effective for improving ease of care and comfort for nonambulant children with CP. There was no increase in moderate and severe AE in the children who had BoNT-A injections compared with the sham group.

Crown Copyright © 2014. Published by Mosby, Inc. All rights reserved.

The effects (or non-effects) of botulinum toxin injection frequency on calf muscle growth

Chemodenervation is a standard of care for treating spasticity in children.

There is a question of whether repeat injections can cause muscle atrophy, because atrophy has been noted in rabbits who get repeat injections of botox. This phenomenon has not been observed in children.  

Weakness is increasingly noted in CP now that we can better control spasticity.

Let me just quote the summary of this article:

"It is currently recommended that spasticity should be treated before children with spastic CP reach the age of 5 or 6 years, so that muscle spasticity and the progression of muscle contracture is reduced [52].

 The standard of care for spasticity management involves a combination of modalities, including physiotherapy, orthotics, oral pharmacological agents and neuromuscular blocking agents such as BoNT-A"

The effects of botulinum toxin injection frequency on calf muscle growth in young children with spastic cerebral palsy: a 12-month prospective studyJournal of Children's Orthopaedics

• Lee Barber, Tandy Hastings-Ison, Richard Baker, H. Kerr Graham, Rod Barrett, Glen Lichtwark

This study was a 12-month prospective investigation of changes in the medial gastrocnemius (MG) muscle morphology in children aged 2–5 years with spastic cerebral palsy (CP) who had received no previous intramuscular injections of botulinum neurotoxin type-A (BoNT-A) and were randomised to receive either single or multiple (three) BoNT-A injections to the gastrocsoleus. MG morphological changes were compared to age-matched typically developing (TD) peers.

Methods

Thirteen children with spastic CP with a mean age of 45 (15) months and 18 TD children with a mean age of 48 (14) months participated in the study. The principal outcome measures were MG muscle volume, fascicle length, pennation angle and physiological cross-sectional area (PCSA), which were obtained using 2D and 3D ultrasound.

Results

The single and multiple injection frequency groups significantly increased MG muscle volume at 12 months relative to the baseline by 13 and 15 %, respectively. There were no significant differences in the MG muscle volume 28.5 (12.3) versus 30.3 (3.8) ml, fascicle length 48.0 (10.4) versus 44.8 (1.2) mm or PCSA 7.0 (1.2) versus 6.6 (1.7) cm2 between the single and multiple injection groups, respectively, at 12 months follow-up. The change in MG muscle volume in the single and multiple injection groups was significantly lower than the TD peers by 66 and 60 %, respectively.

Interpretation

In young children with spastic CP, naive to BoNT-A treatment, MG muscle growth over 12 months does not appear to be influenced by intramuscular BoNT-A injection frequency. However, MG muscle growth in the spastic CP groups was significantly lower than the age-matched TD peers.

pediatric rehabilitation houston, botox for children

ESSENTIAL article for anyone with Cerebral Palsy - A Systematic Review of Treatments

 As a longtime member American Academy of Cerebral Palsy and  Developmental  Medicine with 13 years devoted to functional treatment of children and adults with CP,  I am very excited to see this systematic review of cerebral palsy treatments.   Of the recorded treatments, only 16% met the criteria  for the green light recommendations.  Only 24% of the listed interventions are proven to be effective.   - JR


A systematic review of interventions 

for children with cerebral palsy - 

state of the evidence.

Green Light - GO-  interventions for Cerebral Palsy

In the papers retrieved, the following CP interventions were shown to be effective: 

(1) botulinum toxin (BoNT), diazepam, and selective dorsal rhizotomy for reducing muscle spasticity; 

(2) casting for improving and maintaining ankle range of motion; 

(3) hip surveillance for maintaining hip joint integrity; 

(4) constraint-induced movement therapy, bimanual training, context-focused therapy, goal-directed/functional training, occupational therapy following BoNT, and home programmes for improving motor activity performance and/or self-care; 

(5) fitness training for improving fitness; 

(6) bisphosphonates for improving bone density; 

(7) pressure care for reducing the risk of pressure ulcers; and 

(8) anticonvulsants for managing seizures (despite no CP-specific anticonvulsant evidence existing, the panel rated the strength of the recommendation as strong plus (do it) because good-quality evidence supports anticonvulsants in non-CP populations,and serious harm, even death, can arise from no treatment).

FULL article here