Scolaris Content Display Scolaris Content Display

Botulinum toxin A as an adjunct to treatment in the management of the upper limb in children with spastic cerebral palsy

This is not the most recent version

Abstract

Background

Cerebral palsy (CP) is a central nervous system deficit resulting from a non‐progressive lesion in the developing brain. Although the brain lesions are static, the movement disorders that arise are not unchanging and are characterised by atypical muscle tone, posture and movement (Rang 1990). The spastic motor type is the most common form of CP and its conventional therapeutic management may include splinting/casting, passive stretching, facilitation of posture and movement, spasticity‐reducing medication and surgery. More recently, health care professionals have begun to use botulinum toxin A (BtA) as an adjunct to interventions in an attempt to reduce muscle tone and spasticity to improve function

Objectives

To assess the effectiveness of intramuscular BtA injections as an adjunct to managing the upper limb in children with spastic CP.

Search methods

We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 4, 2003), MEDLINE (1966 to March Week 3 2004), EMBASE (1980 to 2003 Week 16) and CINAHL (1982 to Week 3 March 2004).

Selection criteria

All randomised controlled trials (RCTs) comparing intramuscular BtA injections into any muscle group of the upper limb with placebo, no treatment or other interventions.

Data collection and analysis

Two authors using standardised forms extracted the data independently. Each trial was assessed for internal validity with differences resolved by discussion. Data was extracted and entered into RevMan 4.2.3.

Main results

Two trials met the inclusion criteria, each having short‐term follow up, a small number of subjects and using a single set of injections.

The study by Corry 1997 compared BtA with an injection of normal saline and found promising results in elbow extension, elbow and wrist muscle tone. At three months, encouraging results for wrist muscle tone and grasp and release were noted. The trial reported median change, range of changes and the difference in these measures between groups.

The study by Fehlings 2000 compared BtA with no intervention. When data were analysed no treatment effect was found for quality of upper limb function, passive range of motion, muscle tone, grip strength or self‐care ability.

Authors' conclusions

This systematic review has not found sufficient evidence to support or refute the use of intramuscular injections of BtA as an adjunct to managing the upper limb in children with spastic cerebral palsy. Only one of the two identified RCTs reported some promising results in support of reduced muscle tone following BtA injections. Further research incorporating larger sample sizes, rigorous methodology, measurement of upper limb function and functional outcomes is essential.

PICOs

Population
Intervention
Comparison
Outcome

The PICO model is widely used and taught in evidence-based health care as a strategy for formulating questions and search strategies and for characterizing clinical studies or meta-analyses. PICO stands for four different potential components of a clinical question: Patient, Population or Problem; Intervention; Comparison; Outcome.

See more on using PICO in the Cochrane Handbook.

Plain language summary

There is insufficient evidence to support or refute the effectiveness of botulinum toxin (BtA) as an adjunct to managing the upper limb in children with spastic cerebral palsy.

BtA causes weakness when injected into muscles to increase movement and function in treated limbs. In the absence of significant side effects and with only some supporting evidence, there is a need for further research to explore its use as an adjunct to standard therapy in the upper limb of children with spastic cerebral palsy.