Abstract
BackgroundThis study reports on the effects of botulinum toxin A (BoNT-A) injections in the upper extremity (UE) in children with unilateral Cerebral Palsy (uCP) combined with bimanual task-oriented therapy (BITT) or either treatment modality performed separately. Bimanual activities were measured with the Assisting Hand Assessment (AHA), the ABILHand-Kids questionnaire (AK), the Observational Skills Assessment Score (OSAS). Goal achievement was measured with Goal Attainment Scaling (GAS), using blind video assessment, and the Canadian Occupational Performance Measure (COPM).MethodsThirty-five children, mean age 7.14 years (SD 2.63), 11 Manual Ability Classification Score (MACS) I, 15 MACS II and 9 MACS III, participated. The trial started with four study groups: BoNT-A-only (n = 5), BITT-only (n = 11), BoNT-A + BITT (n = 13), and control (n = 6). Twenty-two children were randomised, 13 children received their parents’ preferred treatment: BoNT-A + BITT or BITT-only. Three comparisons were analysed: BITT (BoNT-A + BITT and BITT-only; n = 24) versus no BITT (BoNT-A-only and control; n = 11), BoNT-A (BoNT-A-only and BoNT-A + BITT; n = 18) versus no BoNT-A (BITT-only and control; n = 17), and the additional effect of BoNT-A (BoNT-A + BITT versus BITT-only). Follow-up time: 24 weeks.ResultsNo significant differences between the groups were found on the AHA. The amount of use of both hands on the OSAS was significantly better in the BoNT-A group in the beading and sandwich-making task. The BoNT-A group also showed significant improvement in the quality scores of the OSAS: the wrist position during grasping and holding, especially in the younger children. The BITT group improved significantly on the AK and significantly more on the performance and satisfaction scores of the COPM at 12 and 24 weeks regarding several goals. BoNT-A showed a significant negative effect at 12 and 24 weeks in the most important goal. BITT, more than BoNT-A + BITT, showed positive effects on the GAS score at 12 (significant), 18 and 24 weeks.ConclusionsBoNT-A has a positive effect on quality of movement and amount of use of the affected UE during the 3 months’ working time. BoNT-A has no additional effect on bimanual performance and goal achievement. BITT has a positive effect on goal achievement and bimanual performance, even up to 6 weeks after therapy had stopped.Trial registration: Current Controlled Trials ISRCTN69541857.Electronic supplementary materialThe online version of this article (doi:10.1186/s12883-015-0404-3) contains supplementary material, which is available to authorized users.
Highlights
This study reports on the effects of botulinum toxin A (BoNT-A) injections in the upper extremity (UE) in children with unilateral Cerebral Palsy combined with bimanual task-oriented therapy (BITT) or either treatment modality performed separately
The studies themselves reported no significant differences on the Melbourne Assessment of Unilateral Upper Limb Function (MUUL) and limited effects on the Quality of Upper Extremities Skills Test (QUEST), a meta analysis of the pooled data in this review [1] showed slight positive effects on both tests 3 months after injection of BoNT-A, which had disappeared at 6 months
In the present study, we investigated the effects of BoNT-A injections in the UE combined with bimanual task-oriented therapy (BITT) or either treatment modality performed separately on the ICF activity level, on bimanual performance, measured with the Assisting Hand Assessment (AHA) and the ABILHAND-Kids questionnaire (AK) [19], on the amount of use and capacity of the assisting hand with the Observational Skills Assessment Score (OSAS), and on goal achieving, measured with Goal Attainment Scaling (GAS) and the Canadian Occupational Performance Measure (COPM)
Summary
This study reports on the effects of botulinum toxin A (BoNT-A) injections in the upper extremity (UE) in children with unilateral Cerebral Palsy (uCP) combined with bimanual task-oriented therapy (BITT) or either treatment modality performed separately. According to the Cochrane review [1], the combination of botulinum toxin A (BoNT-A) in the upper extremity (UE) and intensive physiotherapy(PT)/occupational therapy(OT) is more effective than intensive therapy alone in improving the activity level of the International Classification of Functioning (ICF, www.who.int/entity/classifications/icf/en/) and in goal achievement in children with unilateral spastic Cerebral Palsy (uCP). Assessments used to measure effects at the activity level in the studies in this review are the Melbourne Assessment of Unilateral Upper Limb Function (MUUL) [2], the Quality of Upper Extremities Skills Test (QUEST) [3] and the Pediatric Disability Inventory (PEDI) [4]. Olesch et al studied young children (mean age 3 years 8 months) with uCP and found no significant differences on the QUEST between repeated BoNT-A + OT and OT alone They did find positive effects on GAS of BoNT-A + OT [7]. This should be taken into account, while interpreting these results
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