Effect Of Botulinum toxin-A Injection Research Articles

Effect of Botulinum Toxin- A injection for the Lower Limb in Children with Spastic Cerebral Palsy

Objectives: To investigate the effect of botulinum toxin-A (BoNT-A) on the age groups and gross motor function classification level in children with cerebral palsy (CP).Method: In this study, 116 children with spastic CP were investigated. BoNT-A was injected into the spastic muscles of the lower limbs of all participants. All participants received physiotherapy and functional electrical stimulation for 3 months after injection. We measured the change in spasticity using the Modified Ashworth Scale and gross motor function using the GMFM-88. Spasticity was measured before injection and at 1 and 3 months after injection. Measurement of gross motor function was performed before and after the injections. Results: The effect of BoNT-A injection in combination with physiotherapy and electrical stimulation significantly improved spasticity and gross motor function. After BoNT-A injection, younger children showed reduced spasticity and improved gross motor skills compared to older children. At the gross motor level, sitting, standing, and walking improved in children with gross motor function classification levels I-III, and posture and mobility improved in children with gross motor function classification levels IV-V.Conclusions: We conclude that BoNT-A injection is effective for improving gross motor function in patients younger than 72 months of age.

Adverse effect of botulinum toxin-A injections on mandibular bone: A systematic review and meta-analysis.

Botulinum toxin-A (BTX) is a potent neurotoxin that is emerging in the scope of dental practice for its ability to temporarily paralyse musculature and reduce hyperfunction. This may be desirable in diseases/disorders associated with hyperactive muscles such as the muscles of mastication, most implicated in painful temporomandibular disorders (TMDs). The use of BTX extends beyond its indications with off-label use in TMD's and other conditions, while potential adverse effects remain understudied. BTX is well-established hindlimb paralysis model in animals leading to significant bone loss with underlying mechanisms remaining unclear. The objective of this study is to systematically review the literature for articles investigating changes in mandibular bone following BTX injections and meta-analyse available data on reported bone outcomes. Comprehensive search of Medline, Embase and Web of Science retrieved 934 articles. Following the screening process, 36 articles in animals and humans were included for quantitative synthesis. Articles in human individuals (6) and three different animal species (14) presented mandibular bone outcomes that were included in the meta-analysis. The masseter and temporalis muscles were frequently injected across all species. In humans, we observe a decrease of about 6% in cortical thickness of mandibular regions following BTX injection with no evident changes in either volume or density of bone structures. In animals, bone loss in the condylar region is significantly high in both cortical and trabecular compartments. Our analysis supports the concept of BTX-induced bone-loss model in animal mandibles. Further, bone loss might be confined to the cortical compartments in humans. Most studies did not address the reality of repeated injections and excessive dosing, which occur due to the reversible action of BTX. More rigorous trials are needed to draw a full picture of potential long-term adverse effects on bone.

Effect of Botulinum Toxin Injection in Treatment of Upper Limb Spasticity in Childhood Cerebral Palsy: A Systematic Review

Abstract Cerebral palsy (CP) is the most common cause of childhood disability globally. It manifests in restricted functional mobility and impacts the quality of life negatively. Botulinum toxin injections are widely used to manage limb spasticity in children with cerebral palsy. In the upper limbs of CP children intramuscular botulinum toxin-A has been used to manage pre and post-operative pain, facilitate nursing and achieve functional and/or cosmetic improvement of hand position. These goals are achieved primarily through reduction of spasticity.. This review aims at providing the evidence for effect of botulinum toxin-A injections to manage upper limb spasticity in spastic cerebral palsy cases. The literature extraction process yielded 15 articles for inclusion in this review. After reviewing these articles we concluded that botulinum toxin-A had a positive effect on the degree of spasticity, motor functions and cosmetic appearance of the injected upper limb but its effect increased by addition of another regimen as O.T.,P.T, casting or splintage.

The effect of botulinum toxin-A injection into the masseter muscles on prevention of plate fracture and post-operative relapse in patients receiving orthognathic surgery

BackgroundBotulinum toxin-A (BTX-A) injection into muscle reduces muscular power and may prevent post-operative complication after orthognathic surgery. The purpose of this study was (1) to evaluate BTX-A injection into the masseter muscle on the prevention of plate fracture and (2) to compare post-operative relapse between the BTX-A injection group and the no injection group.MethodsSixteen patients were included in this study. Eight patients received BTX-A injection bilaterally, and eight patients served as control. All patients received bilateral sagittal split ramus osteotomy for the mandibular setback and additional surgery, such as LeFort I osteotomy or genioplasty. Post-operative plate fracture was recorded. SNB angle, mandibular plane angle, and gonial angle were used for post-operative relapse.ResultsTotal number of fractured plates in patients was 2 out of 16 plates in the BTX-A injection group and that was 8 out of 16 plates in the no treatment group (P = 0.031). However, there were no significant differences in post-operative changes in SNB angle, mandibular plane angle, and gonial angle between groups (P > 0.05).ConclusionsBTX-A injection into the masseter muscle could reduce the incidence of plate fracture.

O 019 - Do Botulinum Toxin-A and lower leg casting alter calf muscle and tendon lengths in children with spastic cerebral palsy?

IntroductionAnkle joint hyper-resistance in children with spastic cerebral palsy (SCP) is commonly treated with Botulinum Toxin-A (BoNT-A) injections in the medial gastrocnemius (MG) combined with lower-leg casting. The overall aim of this combined treatment is to reduce spasticity and increase range of motion (1). Since hyper-resistance assessment mainly focuses on the joint level, whereas the treatment is directed at the muscle, it is worthwhile investigating the individual effects of BoNT-A and casting on MG and tendon lengths, to provide insight into the working mechanisms and to help improving treatment efficacy. Research questionWhat are the effects of BoNT-A injections and lower-leg casting on the MG and tendon lengths, at resting position and maximum dorsiflexion, in children with SCP? MethodsChildren with SCP were assigned by minimization to receive either two weeks of lower-leg casts (n = 12, mean age 8.27 years; GMFCS-level I-III) or MG BoNT-A injections (n = 11, mean age: 6.75 years; GMFCS-level I-III). Data was acquired by 3D-freehand-ultrasound (2) at baseline and two weeks post-intervention with the knee in flexion (30.9° ± 3.7°) and the ankle in resting position and maximum dorsiflexion (maxDF). The same assessor extracted muscle and tendon lengths from the 3D reconstructions twice, and the standard error of measurement (SEM) was quantified. Muscle tendon unit (MTU) length was calculated as the summation of muscle (ML) and tendon length (TL). The change in ML and TL between rest and maxDF was used to calculate extensibility. Within-group treatment effect was evaluated with Wilcoxon signed rank tests and treatment differences, with Mann-Whitney U tests. Post-treatment changes were considered significant when >SEM and p < 0.05. ResultsAt baseline, groups did not differ for age, joint angles and lengths. Post-casting, resting angle, maxDF, MTU and TL at maxDF significantly increased. While two weeks post-BoNT-A-injection only MTU length and ML at rest significantly increased. There was no treatment effect on the extensibility. The change in maxDF, and ML at rest were significantly larger post-casting compared to post-BoNT-A. Similarly, the post-treatment change in MTU length at maxDF was significantly larger after casting compared to BoNT-A. DiscussionThe results suggest that two weeks casting resulted in increased maxDF and MTU-length by increased TL (or compliance). This confirms previous research on the effects of ankle foot orthoses on MG morphology (3). BoNT-A on the other hand, affected the muscle’s resting length, however without gain in extensibility or MTU-length. This emphasizes the requirement to combine both treatments, but also cautions the use of stretching casts for having adverse effects on the tendon. The treatment-effects on the MTU on the long-term and their carry over effect to gait is material for further investigation.

Effect of botulinum toxin-A injection in the rectus femoris on stiff-knee gait in patients after a stroke

There is scarce available information on the treatment or prophylaxis with anticoagulant drugs of outpatients with medical diseases and complex clinical conditions. There are no clinical practice guidelines and/or specific recommendations for this patient subgroup, which are frequently treated by internists. Complex clinical conditions are those in which, due to comorbidity, age, vital prognosis or multiple treatment with drugs, a clinical situation arises of disease-disease, disease-drug or drug-drug interactions that is not included within the scenarios that commonly generate the scientific evidence. The objective of this narrative review is collecting and adapting of the clinical guidelines recommendations and systematic reviews to complex clinical conditions, in which the direct application of recommendations based on studies that do not include patients with this complexity and comorbidity could be problematic.La información disponible sobre el tratamiento o profilaxis con fármacos anticoagulantes en pacientes ambulatorios con enfermedades médicas y situaciones clínicas complejas es escasa, y no existen guías de práctica clínica y/o recomendaciones específicas para este subgrupo de sujetos, quienes son frecuentemente atendidos por los internistas. Entendemos por situaciones clínicas complejas aquellas en que por la comorbilidad, edad, pronóstico vital o tratamiento múltiple con fármacos de los pacientes, se configura una situación clínica de interacciones enfermedad-enfermedad; enfermedad-fármaco o fármaco-fármaco que no se incluye dentro de los escenarios sobre los que habitualmente se generan las evidencias científicas. El objetivo de esta revisión narrativa es recopilar y adaptar las recomendaciones de guías clínicas y revisiones sistemáticas a situaciones clínicas complejas, donde puede ser conflictivo la aplicación directa de recomendaciones basadas en estudios que no incorporan a pacientes con dicha complejidad y comorbilidad.

The influence of physical therapy and anti-botulinum toxin antibody on the efficacy of botulinum toxin-A injections in children with spastic cerebral palsy

Objective: To identify factors associated with the efficacy of botulinum toxin-A (BoNT-A) injections. Methods: Thirty-eight children with spastic cerebral palsy (CP) received BoNT-A injections into the gastrocnemius. The baseline anti-botulinum antibodies were checked. The Static dorsiflexion range of motion (ROM), Modified Tardieu Scale (MTS) and Physician Rating Scale (PRS) were assessed at pre-injection as well as 4- and 12-week post-injection. Results: No samples contained anti-botulinum antibodies. Greater baseline MTS dynamic range was associated with greater changes in MTS dynamic ranges at 4-week post-injection. More frequent physical therapy was associated with greater changes in static dorsiflexion ROM at 4-week post-injection and greater changes in PRS at 4- and 12-week post-injection. Conclusion: The improvement in PRS at 12-week post-injection was associated with the frequency of physical therapy. Therefore, intensive physical therapy programs may be necessary to maintain the beneficial effects of BoNT-A injections in children with CP.

Can goal setting be isolated from activity‐focused intervention in cerebral palsy?

SIR–The systematic review by Carlberg and L€ owing was particularly thought-provoking and addressed a critical and contemporary issue in paediatric rehabilitation. We would like to offer some perspectives on this publication. The aim of the review was to identify if the process of goal setting could influence treatment outcome of activity-focused interventions measured by standardized assessment. The authors reported that ‘. . . none of the studies was designed specifically to determine the effect of goal setting per se,’ and it was ‘. . . difficult to separate the effect of the goal setting from the effect of intervention . . .’ as goal setting was integral to guiding the activity-focused interventions being examined. Intuitively, it is plausible that involving families in goal setting focuses attention on priority activities and may influence parents to engage with their child to focus on mastery of goals. Important and clinically useful information would result from understanding whether goal setting influences treatment outcome. As the authors didn’t find studies evaluating the effects of goal setting per se, they recommended that studies are needed which ‘. . . specifically assess the effect of goal setting on treatment outcome . . .’ Two options are possible when contemplating the highest level of evidence that would isolate goal setting as an intervention. In the first, participants would be randomized to a group participating in goal setting and no intervention, or a comparison group receiving no intervention. This option is unlikely to be palatable to participants, researchers, or ethics bodies. In the other option, participants could be randomized to goal setting and activityfocused intervention or activity-focused intervention alone to isolate goal setting as the independent variable. Activityfocused intervention, however, is reliant on goal setting to direct and focus the nature and course of intervention. Consequently, neither option is feasible, which illustrates why Carlberg and L€ owing did not locate studies evaluating goal setting per se. Another more feasible option exists, albeit providing lower level evidence. Randomized controlled trials (RCTs) with a non-treatment control group, where outcome measurement included goal attainment, would provide information of the effects of goal setting. Failure of such control groups to achieve a meaningful treatment effect in the presence of a significant between-group difference would provide evidence that goal setting alone may not influence outcomes. If, on the other hand, the control group achieved clinically meaningful outcomes, evidence may exist in support of goal setting alone influencing outcomes. Two RCTs illustrate this option, both of which were included in Carlberg and L€ owing’s review. Wallen et al.’s four-group RCT evaluated the effects of botulinum toxin-A injections, with and without occupational therapy, to the upper limbs of children with cerebral palsy. The no-treatment group failed to reach average goal achievement using Goal Attainment Scaling (GAS) at either 3or 6-month endpoints. The control group in Novak et al.’s study of home programme implementation failed to achieve any change on the GAS over the course of the study. Results from these studies suggest goal setting alone may not be sufficient to effect meaningful change. Carlberg and L€ owing concluded that their review did not ‘. . . provide support for a positive effect of goal setting . . .’ These words are reminiscent of Braithwaite’s six dangerous words in evidence-based medicine: ‘There is no evidence to suggest . . .’ The conclusion that the review failed to find support for a positive effect of goal setting could mean that the evidence reviewed was inconclusive or that the evidence suggested that goal setting did not affect outcome. The conclusion reported by Carlberg and L€ owing is not strictly incorrect but it is ambiguous and potentially, though unintentionally, misleading. Rather than failing to find support for goal setting, Carlberg and L€ owing didn’t actually find a study which addressed the review question. Alternatively, accurately reporting that they did not locate any studies which addressed the review question would have been precise, unambiguous, and clearly identified the status of available evidence. Such a conclusion provokes consideration of the intricacies of conducting research that would isolate goal setting as the independent variable in studies of activity-focused intervention. Goal setting is inherently intertwined with many current and evidence-based, activity-focused interventions for children with cerebral palsy.

Curative Effect of Botulinum Toxin-A Injection in Myopia Treatment: Two Case Reports

Purpose: To study the curative effect of botulinum toxin-A injection in myopia treatment and whether this method can promote the vision of the patients with myopia. Methods: The left visual acuity of a 37 years old woman was improved from 0.5 to 0.8 after cosmetic injection in July 2011. Another 9 years old girl with pseudomyopia was treated by bilateral ciliary injection in September 2012, and the doses were 2.5IU respectively. Results: The woman was true myopia, and her left visual acuity was lasting at 0.8 for 5 months. The left visual acuity of the girl was enhanced from 0.6 to 0.8, and the right was improved from 0.7 to 1.0. And the improvement is for more than 18 months. Conclusions: BTX-A injection can relax the ciliary muscle tension and promote the myopic vision, especially in pseudomyopia patients.

Objective quantification of the effect of botulinum toxin-A injections in the medial hamstrings in children with spastic cerebral palsy

[1] Boulay C, Pomero V, Viehweger E, et al. Dynamic equinus with hindfoot valgus in children with hemiplegia. Gait and Posture. Available online. 15.03.12. [2] Davids JR, Gibson TW, Pugh LI. Quantitative segmental analysis of weightbearing radiographsof the foot andankle for children:normal alignment. Journal of Pediatric Orthopaedics. 2005;25 November–December (6):769–76. [3] WestberryDE,Davids JR,RoushTF, PughLI.Qualitativeversusquantitative radiographic analysis of foot deformities in children with hemiplegic cerebral palsy. Journal of Pediatric Orthopaedics. 2008;28 April–May (3):359–65.

Feasibility of Video Clip Analysis on Effect of Botulinum Toxin-A Injection for Post-Stroke Upper Limb Spasticity

Existing functional evaluation tools do not accurately reveal the improved function following botulinum toxin A (BTX-A) injection for post-stroke upper limb spasticity. With the aim of developing an alternate method of measuring functional improvement following BTX-A injection, this study tested the feasibility, validity and reliability of video clip analysis performed by the clinicians. Seventy-nine patients administered BTX-A due to post-stroke upper limb spasticity, were retrospectively evaluated using video clip analysis. Pre- and post-injection video clips recorded at 1-month intervals were randomly allocated and sent to three blinded physician evaluators who were asked to choose the one that seemed more improved in terms of hand motion and associated upper limb reaction during gait. The three physicians chose the post-injection video clip as depicting improved hand motion (82.3%, 79.7%, and 72.2%) and associated upper limb reaction during gait (73.4%, 70.9%, and 70.9%). Kappa and intraclass correlation coefficient as a measure of interrater reliability among the three physicians was 0.86 and 0.79 for the hand, and 0.92 and 0.92 for associated upper limb reaction during gait, respectively. The percent overall agreement of the physicians was 78.1% and 71.7% for hand function and associated upper limb reaction, respectively. Retrospective pre- and post-BTX-A injection video clip analyses is a clinically feasible alternative method to evaluate the improvement following BTX-A injection for post-stroke upper limb spasticity, especially in busy clinical practice setting.