Revisión sistemática de la eficacia del tratamiento combinado de fisioterapia junto con toxina botulínica tipo A en la espasticidad de miembros inferiores en niños con parálisis cerebral

Abstract

IntroductionCerebral palsy is the result of non-progressive damage to the central nervous system and causes, among other possible symptoms, pathological muscle tone. Spasticity is very common and leads to limitations in activities of daily living. There are many physical and drug therapies for this altered muscle tone but their effectiveness is widely debated because the results are very different from one individual to another. ObjectiveThe objective of this study was to conduct a systematic review of the effectiveness of treatment of lower limb spasticity in any type of cerebral palsy, using physiotherapeutic and drug treatment with type A botulinum toxin. This effectiveness refers to the achievement of an increase in joint range, a decrease in muscle tone or an improvement in gait that will be reflected in specific rating scales and assessment of scales of activities of daily living. Secondary objectives were to determine the adverse effects of botulinum toxin injection and variability in the duration of its effects. Material and methodA literature search was conducted of studies published from January 2006 to January 2013, inclusive, in the following databases: Cochrane Library, Medline, CINAHL, ISI Web of Knowledge and PEDro. The quality of the clinical trials as well as those of the prospective and retrospective studies was evaluated by the Jadad Scale (also known as the Oxford Quality Scale) and by the Assessment of Multiple Systematic Reviews measurement tool. ResultsFourteen articles met the inclusion criteria. Nine of these studies observed a decrease in muscle tone, an increase in joint range and an improvement in gross motor function. These results varied from one patient to another due to age (better results in patients younger than 6 years old), injected muscles (better results in the sural triceps), use of ultrasound-guided injection for greater injection accuracy, and the patient's cognitive status. DiscussionStatistically significant results were found in the short-term decrease of spasticity in 12 studies, the best moment being detected approximately between the 4th and 5th week after the injection. However, only one study reported that this decrease in muscle tone was maintained in the long term (one year). The use of a large number of different scales hampered comparison of the results of muscle tone measurement or gross motor function assessment in distinct studies. Some articles did not describe the frequency and effects of the implemented rehabilitation programme and therefore it was difficult to determine the extent of the influence of these factors on the effectiveness of botulinum toxin. Orthopaedic treatment was included in 8 studies, obtaining better results in ankle dorsiflexion and in gross motor function. There is wide debate on when botulinum toxin injections should be started to achieve maximal effectiveness; 5 studies claim better results in decreased muscle tone in children younger than 6 years, whereas another study asserts that age is not a conclusive factor. Future studies should incorporate the use of ultrasound during injection, explain the rehabilitation techniques applied and their frequency, include larger and more homogeneous samples to improve quality, and use the most updated and widely accepted scales. ConclusionsCombined treatment with physiotherapy and type A botulinum toxin reduces muscle tone, increases joint range of motion and improves gross motor function, which includes enhanced transfers and gait, especially if orthopaedic treatment is added. Patients showed a peak improvement in muscle tone at approximately one month after the injection. However, this improvement was not maintained in the long term, with pathological muscle tone developing once again.