Equinus In Children Research Articles

Single procedure tibialis anterior tendon shortening in combination with Achilles tendon lengthening in unilateral cerebral palsy improves swing phase dorsiflexion in gait.

Tibialis anterior tendon shortening combined with tendon Achilles lengthening showed satisfactory short- and long-term outcomes for pes equinus treatment. This retrospective study aimed to evaluate the effectiveness of a single tibialis anterior tendon shortening-tendon Achilles lengthening procedure for treating pes equinus, in a homogeneous unilateral cerebral palsy patient group. Gait analysis was conducted on 22 unilateral cerebral palsy patients (mean age at surgery = 13.3 years, standard deviation = 3 years) before and within 2.5 years (standard deviation = 0.61 years) after the tibialis anterior tendon shortening-tendon Achilles lengthening procedure. Primary outcome measures included foot drop occurrence in swing, foot dorsiflexion and the first ankle rocker presence compared to healthy reference data. Movement analysis profile and gait profile score were also calculated for the entire gait cycle. The clinical exam and the A2 peak ankle power were analyzed. Statistical analysis used the paired Wilcoxon's sign rank test (p < 0.05). Post-operatively, significant improvements were observed in ankle dorsiflexion during swing (p = 0.0006) and reduced foot drop in swing (p = 0.0107). The occurrence of a first ankle rocker did not significantly change (p = 0.1489). Significant improvements in gait profile score and movement analysis profile for all joints and planes indicate overall gait quality improvement. The foot progression changed significantly (p = 0.0285), with a greater external orientation. Nineteen out of 22 patients were able to quit wearing their ankle foot orthoses. Tibialis anterior tendon shortening and tendon Achilles lengthening combination yielded positive outcomes, showing increased foot dorsiflexion, first ankle rocker presence, and overall improved gait quality. These findings support the effectiveness of this surgical approach for treating pes equinus in children with unilateral spastic cerebral palsy.

Anterior Hemi-epiphysiodesis of the Distal Tibia for Residual Equinus Deformity in Children with Clubfeet

Background: Residual equinus deformity in toddlers with a history of clubfoot can be managed with soft tissue release, provided there is no articular incongruity. Distal tibia osteotomy is a reasonable choice in mature patients with a flattened talus provided the growth plate is closed. Anterior distal tibia hemi-epiphysiodesis is an option for children with articular incongruity who have substantial growth remaining. The aim of this study is to evaluate radiographic and clinical outcomes of this method. Methods: Fourteen clubfoot patients (20 ankles) with residual equinus deformity were treated between 2010-2015 with anterior distal tibial hemi-epiphysiodesis utilizing size appropriate modular plate and screw constructs. Patients were evaluated clinically and radiographically. Oxford Ankle Foot Questionnaire for Children (and caregivers) with supplemental questions were requested at most recent follow-up. Results: There were 12 males and 2 females, mean age 10 years at surgery (50-152 months), with the minimum 18 months of radiographic follow-up (Mean 34 months). Pre-surgical mean radiographic anterior distal tibial angle (ADTA) was 87.8 degrees (79-100) and mean maximum dorsiflexion was -5.7 degrees (-40-7). At follow-up, mean improvement of radiologic ADTA was 18 degrees and mean clinical dorsiflexion improvement was 8.4 degrees. On the Oxford Ankle Foot Questionnaire, children reported a mean functional score of 47% in the “Physical” domain, 71% in “School and Play”, 70% in “Emotional”, and 38% in footwear. Parents reported mean scores of 45% in Physical, 69% in School and Play, 56% in Emotional, and 28% in footwear. Sixty percent of parents reported increased foot flexibility, 80% noted improvement in their child’s walking, and 100% would choose this surgery again. Conclusions: Anterior distal tibial hemi-epiphysiodesis is a viable option for treatment of residual equinus in children with a clubfoot history and open growth plates. Radiographic improvement was at least 2x greater than the clinically measured improvements of dorsiflexion; yet each family would undergo the surgery again as they perceived an improvement in function.

Joint and Muscle Assessments of the Separate Effects of Botulinum NeuroToxin-A and Lower-Leg Casting in Children With Cerebral Palsy.

Botulinum NeuroToxin-A (BoNT-A) injections to the medial gastrocnemius (MG) and lower-leg casts are commonly combined to treat ankle equinus in children with spastic cerebral palsy (CP). However, the decomposed treatment effects on muscle or tendon structure, stretch reflexes, and joint are unknown. In this study, BoNT-A injections to the MG and casting of the lower legs were applied separately to gain insight into the working mechanisms of the isolated treatments on joint, muscle, and tendon levels. Thirty-one children with spastic CP (GMFCS I-III, age 7.4 ± 2.6 years) received either two weeks of lower-leg casts or MG BoNT-A injections. During full range of motion slow and fast passive ankle rotations, joint resistance and MG stretch reflexes were measured. MG muscle and tendon lengths were assessed at resting and at maximum dorsiflexion ankle angles using 3D-freehand ultrasound. Treatment effects were compared using non-parametric statistics. Associations between the effects on joint and muscle or tendon levels were performed using Spearman correlation coefficients (p < 0.05). Increased joint resistance, measured during slow ankle rotations, was not significantly reduced after either treatment. Additional joint resistance assessed during fast rotations only reduced in the BoNT-A group (−37.6%, p = 0.013, effect size = 0.47), accompanied by a reduction in MG stretch reflexes (−70.7%, p = 0.003, effect size = 0.56). BoNT-A increased the muscle length measured at the resting ankle angle (6.9%, p = 0.013, effect size = 0.53). Joint angles shifted toward greater dorsiflexion after casting (32.4%, p = 0.004, effect size = 0.56), accompanied by increases in tendon length (5.7%, p = 0.039, effect size = 0.57; r = 0.40). No associations between the changes in muscle or tendon lengths and the changes in the stretch reflexes were found. We conclude that intramuscular BoNT-A injections reduced stretch reflexes in the MG accompanied by an increase in resting muscle belly length, whereas casting resulted in increased dorsiflexion without any changes to the muscle length. This supports the need for further investigation on the effect of the combined treatments and the development of treatments that more effectively lengthen the muscle.

Current practice and preferences to management of equinus in children with ambulatory cerebral palsy: A survey of orthopedic surgeons.

Introduction: The consensus among orthopedic surgeons on the management of equinus deformity in cerebral palsy (CP) children has not been reported previously despite being a prevalent deformity. The goals of this study were to examine the orthopedic surgeons’ current practice regarding the management of equinus deformity in children with ambulatory CP, and analyze variations in current practice between general orthopedic and pediatric orthopedic surgeons.Methods: We implemented a brief cross-sectional self-reported questionnaire that addressed the areas of clinical examination and decision-making skills of management of equinus deformity in CP children. We targeted a convenience sample of 400 participants. Surgeons that provided complete responses to the questionnaire were 223 with a response rate of 56%, of which 123 (55%) were general orthopedic surgeons, whereas 100 (45%) were pediatric orthopedic surgeons. The target population consisted of orthopedic surgeons who were further sub-classified in accordance with practice age, general versus pediatric, and exposure to children’s orthopedics during the last three years of their practice. For analytical statistics, the Chi-Square test and Fisher’s exact test were used to examine the relationship between two qualitative variables.Results: The overall clinical practice preferences of all survey participants were unimpressive with discordant survey responses. Pediatric orthopedic surgeons generally demonstrated a statistically significant difference regarding clinical assessment skill items of the survey, in contrast to general orthopedic surgeons. However, we found no differences between pediatric orthopedic and general orthopedic surgeons regarding most of the decision-making/knowledge items.Discussion: Generally, there are insufficient clinical practice trends of both general and pediatric orthopedic surgeons regarding equinus treatment in CP children. This may indicate a knowledge–practice gap with potential risks to CP children undergoing surgery for equinus. There is a need for a more competent exposure to CP in orthopedic surgeons’ educational curricula and an updated health referral system.

Evidence-based Recommendations for Pediatric Orthopaedic Practice.

The evidence-based approach to guide clinical practice has gained great importance in the medical field. High-quality evidence is of paramount importance to inform clinical decision-making and optimize patient outcomes. The generation of high-quality evidence relies on sound methodology and study design to facilitate appropriate interpretation and subsequent application of the clinical findings. The purpose of this review is to objectively critique the methodological design and clinical findings of 2 pediatric orthopaedic studies on children with cerebral palsy (CP) to assess their potential to impact clinical practice. This is the second in a series of evidence-based reviews in pediatric orthopaedics. The pediatric orthopaedic literature was reviewed for randomized controlled trials (RCTs) published in 2015 and 2016. One RCT was selected from the journal Pediatrics, and one RCT was selected from the journal Developmental Medicine and Child Neurology, both investigating the use of botulinum toxin for the treatment of spastic equinus in children with CP. These RCTs were subjected to in-depth methodological review by orthopaedic surgeons with advanced research degrees and a PhD researcher. Two clinical experts then reviewed the articles to rate the clinical impact or value of each study. Methodological and clinical reviews were compiled, and a final recommendation on impact to change clinical practice was made based on both review components at the consensus of the panel. The first study reviewed investigated the single-dose efficacy and safety of botulinum neurotoxin type-A (1BoNT-A) in children with CP-associated spasticity and equinus foot deformity. The reviewers deemed the placebo-controlled study to be of sound design, and conclusions appropriate for the methodology used and clinical findings. Although findings suggest 1BoNT-A may provide benefit in treating equinus foot deformity, the optimal dose for achieving maximal impact on functional improvement remains undetermined. The second study reviewed investigated the impact of multiple dosing schedules on spastic equinus in CP. Although of relatively sound design, this study was limited by a small sample size and lack of justification for the chosen effect size. Without further study, no recommendation to change clinical practice could be made. Both RCTs reviewed were superiority studies, the first demonstrating efficacy of botulinum toxin over placebo, the second showing no significant difference in 4- and 12-monthly botulinum toxin injections. Despite a positive result demonstrating an effect of botulinum toxin treatment on spastic equinus in CP, the long-term functional impact and optimal dose remains to be determined. In addition, the negative result in the second study demonstrates the need for a noninferiority trial design to appropriately demonstrate no difference between 2 treatment options.

Long-term follow-up after tibialis anterior tendon shortening in combination with Achilles tendon lengthening in spastic equinus in cerebral palsy

Using Tibialis Anterior Shortening (TATS) in combination with Achilles Tendon Lengthening (TAL) to treat spastic equinus in children with cerebral palsy (CP) was described in 2011. Short-term results have indicated a good outcome, especially an improvement of the drop foot in swing phase and the correction of equinus in stance phase. The aim of this study was to analyse the results of the long-term follow-up and to determine the relapse rate of TATS and TAL.The kinematics of the sagittal, frontal and transversal planes were measured by using instrumented 3D gait analysis at three defined time points and then described using the Gait Profile Score (GPS) and Movement Analysis Profile (MAP). The data was exported into Gaitabase and then the preoperative (T0), short- term (T1) and long-term (T2) follow-up data was statistically compared.23 patients (mean age at index-surgery=14.9years) were included, there was a mean follow-up time of 5.8 years. 3 children (13%) have shown a relapse. The data of 12 children with spastic hemiplegia (12 legs), as well as 8 children with spastic diplegia (10 legs) has been analysed. There has been a significant (p<0.05) improvement in GPS and MAP for ankle dorsiflexion (describes equinus and drop foot) of the operated legs versus not operated legs.TATS in combination with TAL shows a satisfactory long-term result after 5.8 years in the correction of fixed equinus and drop foot in children with CP. Postoperatively all subjects were able to walk without an AFO.

The influence of timing of knee recurvatum on surgical outcome in cerebral palsy

Recent reports have shown that timing of genu recurvatum (GR) might be caused by different underlying factors and that equinus leads to GR especially during early stance. The purpose of this study was to investigate the reduction of GR after surgical correction of equinus in children with bilateral spastic cerebral palsy and whether the children with early and late type GR show differences in reduction of knee hyperextension after a surgery. In 24 limbs (mean age 10.3 years, GMFCS I-III) showing equinus and GR the kinematics of the knee and ankle as well as the kinetics of the knee were evaluated before and one year (mean follow up period: 12.8 months) after surgical correction of equinus. The study was approved by the local ethical committee. Limbs with early type GR showed a reduction by 11.1° (p<0.001) and those with late type GR by 6.0° (p<0.049) in GR after surgery. Before surgery limbs with early type GR showed increased external extending moments, which decreased significantly after surgery. In contrast limbs with late GR did not show a significant reduction of those moments. The findings of this study underline the influence of equinus on early GR as an underlying factor. As equinus is attributed to early knee hyperextension and proximal factors are more important as underlying factors in late type GR, a classification into early and late onset GR is useful to identify underlying factors and to choose adequate treatment.

A Critical Evaluation of the Updated Evidence for Casting for Equinus Deformity in Children with Cerebral Palsy.

Equinus deformity is common in ambulant children with cerebral palsy (CP). Although lower leg casting is frequently used, the physiological basis for casting and effects beyond range of motion (ROM) gains are unclear. This review critically evaluates the updated evidence for casting in the management of ankle equinus in children with CP. Comprehensive searches were conducted using electronic databases AMED, MEDLINE, CINAHL, Scopus, PEDro and the Cochrane Database of Systematic Reviews, publication years 2005-2014, in order to identify literature published since an earlier comprehensive systematic review. Only studies evaluating lower leg casting for conservative management of equinus deformity in children with CP were considered. Two independent raters critically appraised studies against the hierarchy of levels of evidence and rigour of study conduct questions proposed by the American Academy of Cerebral Palsy and Developmental Medicine's methodology for systematic review. Four relevant systematic reviews were identified, although these largely concerned earlier literature. Five original studies were included, all demonstrating improvement in dorsiflexion ROM. Combined treatment with botulinum toxin and casting offered greater and/or more sustained ROM gains than botulinum toxin alone in three studies. Effects on gait parameters and motor function were inconsistent. Participation outcomes were not evaluated. Methodological limitations make firm conclusions difficult. Recent years have offered little progress in the state of evidence for casting in the management of equinus deformity. Casting appears to offer at least short-term improvement in ankle dorsiflexion, although the proposition that this improves function or avoids surgery is not well substantiated. Future research needs to ensure more robust study design and broader evaluation across domains of the International Classification of Functioning, Disability and Health to determine the functional and long-term effect of casting for equinus deformity. Greater knowledge is required of the effect of casting on muscle structure and function in spastic CP. Copyright © 2015 John Wiley & Sons, Ltd.

Impact of injection-guiding techniques on the effectiveness of botulinum toxin for the treatment of focal spasticity and dystonia: A systematic review

To conduct a systematic review of the impact of different injection-guiding techniques on the effectiveness of BoNT-A for the treatment of focal spasticity and dystonia. Articles were identified through a comprehensive search of the following computerized databases: MEDLINE via Pubmed, Academic Search Premier, Pascal, the Cochrane Library, Scopus, SpringerLink, Web of Science, EM Premium and PsychINFO. Two reviewers (AG and MD) independently selected potential studies based on pre-determined inclusion criteria. The main data were extracted. Methodological quality was graded independently by 2 reviewers using the Physiotherapy Evidence Database (PEDro) assessment scale for randomized controlled trials (RCTs) and the Downs and Black (D&B) evaluation tool for non-RCTs. Level of evidence was determined using the modified Sackett scale. Ten studies were included. Seven were randomized. There was strong evidence (Level 1) that instrumented guiding (Ultrasound [US], Electrical-stimulation [ES], Electromyography [EMG]) was more effective than manual needle placement for the treatment of spasmodic torticollis, upper limb spasticity and spastic equinus in patients with stroke and spastic equinus in children with cerebral palsy. A few studies provided strong evidence (Level 1) of similar effectiveness of US and ES for upper and lower limb spasticity in patients with stroke and spastic equinus in children with cerebral palsy, but there was poor evidence or no evidence available for EMG or other instrumented techniques. These results strongly recommend the use of instrumented guiding techniques for BoNT-A injection for the treatment of spasticity in adults and children (ES or US) and of focal dystonia such as spasmodic torticollis (EMG). No specific recommendations can be made regarding the choice of instrumented guiding techniques.

A randomized controlled trial studying efficacy and tolerance of a knee-ankle-foot orthosis used to prevent equinus in children with spastic cerebral palsy

Objective: To examine whether using a knee-ankle-foot orthosis helps maintain ankle-foot dorsiflexion range of motion over time. Design: A multicentre randomized controlled trial. Setting: Two hospitals and one rehabilitation centre in the Netherlands and the USA. Subjects: Children (4-16 years old) with spastic cerebral palsy who were able to walk. Intervention: Use of a knee-ankle-foot orthosis, equipped with an Ultraflex® ankle power unit, for at least 6 hours every other night for one year. Main measures: Primary outcome measure: ankle-foot dorsiflexion range of motion. Secondary outcome measures: ankle-foot and knee angle in gait and gross motor function. Wearing time was also measured. Measurements were taken at baseline and at 3, 6, 9 and 12 months. Results: 28 children (experimental group: n=15, control group: n=13) participated in the study. 11 participants (experimental: n=4, control: n=7) did not complete all five measurements, as they needed additional treatment. No significant difference was found in the decrease of ankle-foot dorsiflexion range of motion between the experimental and control groups (difference: −1.05°, 95% confidence interval: −4.71° – 2.61°). In addition, secondary outcome measures did not show differences between groups. Despite good motivation, knee-ankle-foot orthosis wearing time was limited to a mean±SD of 3.2±1.9 hours per prescribed night due to discomfort. Conclusions: Knee-ankle-foot orthosis with dynamic ankle and fixed knee are poorly tolerated and are not beneficial in preventing a reduction in ankle-foot dorsiflexion range of motion in children with spastic cerebral palsy, at least with limited use.

Combining serial casting with botulinum toxin A in the treatment of spastic equinus in children with cerebral palsy

Objective To compare the effect of injection with botulinum toxin type A (BTX-A) before serial casting with BTX-A injection alone for the treatment of spastic equinus in children with cerebral palsy (CP).Methods Sixty patients were divided into an experimental group and a control group with 30 patients in each.Those io the experimental group received a BTX-A injection followed by serial casting,while the controls received BTX-A only.Before treatment and 1 month,3 months and 6 months after treatment,the dorsiflexion range of motion (ROM)of the ankle recorded while the knee in flexion and extension were measured,and gait was evaluated with an observational gait scale.Results Before treatment there was no significant inter-group difference in any of the 3 outcome measures.At 1 montb,3 months and 6 months after treatment,there were significant inter-group differences in all 3 measures,and also significant differences compared with before treatment in both groups.Conclusion Lower muscle tone,greater ankle mobility and better gait patterns can be promoted in CP children with spastic equinus using serial casting combined with BTX-A injection.The improvements may last longer than those after BTX-A injection alone. Key words: Serial casting; Botulinum toxin type A; Cerebral palsy; Equinus

Splint: the efficacy of orthotic management in rest to prevent equinus in children with cerebral palsy, a randomised controlled trial.

BackgroundRange of motion deficits of the lower extremity occur in about the half of the children with spastic cerebral palsy (CP). Over time, these impairments can cause joint deformities and deviations in the children's gait pattern, leading to limitations in moblity. Preventing a loss of range of motion is important in order to reduce secondary activity limitations and joint deformities. Sustained muscle stretch, imposed by orthotic management in rest, might be an effective method of preventing a decrease in range of motion. However, no controlled study has been performed.MethodsA single blind randomised controlled trial will be performed in 66 children with spastic CP, divided over three groups with each 22 participants. Two groups will be treated for 1 year with orthoses to prevent a decrease in range of motion in the ankle (either with static or dynamic knee-ankle-foot-orthoses) and a third group will be included as a control group and will receive usual care (physical therapy, manual stretching). Measurements will be performed at baseline and at 3, 6, 9 and 12 months after treatment allocation. The primary outcome measure will be ankle dorsiflexion at full knee extension, measured with a custom designed hand held dynamometer. Secondary outcome measures will be i) ankle and knee flexion during gait and ii) gross motor function. Furthermore, to gain more insight in the working mechanism of the orthotic management in rest, morphological parameters like achilles tendon length, muscle belly length, muscle fascicle length, muscle physiological cross sectional area length and fascicle pennation angle will be measured in a subgroup of 18 participants using a 3D imaging technique.DiscussionThis randomised controlled trial will provide more insight into the efficacy of orthotic management in rest and the working mechanisms behind this treatment. The results of this study could lead to improved treatments.Trial Registration NumberNederlands Trial Register NTR2091

Botulinum Toxin A Injection into Calf Muscles for Treatment of Spastic Equinus in Cerebral Palsy

To compare the clinical outcomes of two different injection techniques, one guided by electric stimulation and the other by sonography, for botulinum toxin A injection into calf muscles for the treatment of spastic equinus in children with cerebral palsy. Thirty-two children with cerebral palsy with spastic equinus gait were enrolled in separate categories according to their level under the Gross Motor Function Classification System and divided into two groups with alternate allocation: sonography-guided group and electric stimulation-guided group. Equal amounts of botulinum toxin A were injected into the gastrocnemius at four to six points in 30 children with cerebral palsy. The injection was guided by electric stimulation in 14 and by ultrasonography in 16 children. Modified Ashworth Scale, Modified Tardieu Scale, Selective Motor Control, and Physician's Rating Scale were measured at baseline, 1 mo, and 3 mos posttreatment. Subscales of the Physician's Rating Scale (gait pattern and hindfoot position-maximum foot/floor contact during stance) significantly improved in the sonography-guided group. No statistical differences were noted in Modified Ashworth Scale, Modified Tardieu Scale, and Selective Motor Control. Visual feedback by ultrasonography could improve the accuracy of selective neuromuscular blocking of the gastrocnemius.

Determinants of responsiveness to botulinum toxin, casting, and bracing in the treatment of spastic equinus in children with cerebral palsy

The objective was to determine whether specific intrinsic (age, pattern of cerebral palsy [CP], child's motivation) and extrinsic (number of treatments, parenting stress) characteristics were associated with responsiveness to botulinum toxin A (BoNT-A) injections in children with CP 3 months after injection into the gastrocnemius muscle. Children with hemiplegia or diplegia recruited from a BoNT-A programme were evaluated before and 3 months following injection of BoNT-A into the gastrocnemius. Outcome measures included muscle tone, range of motion, gait pattern, level of ambulation, gross motor function, and functional independence. Determinants of responsiveness to BoNT-A considered were age, number of treatments, distribution of CP, parenting stress, and motivation. Thirty-one children were recruited (17 males, 14 females)--22 with hemiplegia and nine with diplegia. Twenty-eight were classified at Gross Motor Function Classification System (GMFCS) level I and three at level III. The mean age was 6 years 4 months (SD 2y 11mo). Younger age (p=0.015) and fewer number (p=0.024) of BoNT-A treatments were associated with greater change in gross motor function. Child's motivation and parenting stress were significantly associated with improvements in muscle tone (p=0.006-0.017), passive range of motion (p=0.008-0.033), gait pattern (p=0.005-0.042), level of ambulation (p=0.001-0.043), and functional independence (p=0.004-0.027). The results indicate that child, family, and treatment characteristics influence the degree of responsiveness to BoNT-A treatment. The contribution of contextual factors (personal and environmental) on responsiveness may be underappreciated in children with CP.

A systematic review of the effects of casting on equinus in children with cerebral palsy: an evidence report of the AACPDM

This systematic review examines the effects of casting, either alone or in combination with botulinum toxin type A (BTX-A), on equinus in children with cerebral palsy (CP). Comparisons are made between casting alone and no treatment, between casting alone and BTX-A alone, between combined casting and BTX-A and each treatment by itself, and between casting followed by BTX-A and BTX-A followed by casting. A search of PUBMED, CINAHL, Proquest Health and Medical Complete, Cochrane Database of Systematic reviews, Physiotherapy Evidence Database (PEDro), OTseeker, Database of Reviews of Effectiveness (DARE), and Infotrieve yielded 184 citations. Articles were included in the review if they reported the effects of an intervention using casting for equinus in particpants with CP aged 20 or less, if they appeared in a peer-reviewed scholarly journal in 1970 or later, with no language restriction, and if casting was not used in conjunction with surgery. Twenty-two articles were selected, including seven randomized controlled trials (RCTs). There is little evidence that casting is superior to no casting, but the protocols of casting in current use have not been compared with no treatment in any RCT. There is no strong and consistent evidence that combining casting and BTX-A is superior to using either intervention alone, or that either casting or BTX-A is superior to the other immediately after treatment. Finally, there is no evidence that order of treatment (casting before BTX-A versus BTX-A before casting) affects outcome. Much of the evidence both for and against differences is weak, and results may be explained by methodological limitations. Future research needs to use adequate sample sizes, long-term follow-ups, and broader and more global measures.

Comparing botulinum toxin A with casting for treatment of dynamic equinus in children with cerebral palsy

The purpose of this study was to compare the cumulative efficacy (three treatment sessions) of botulinum toxin A (BTX‐A) alone, casting alone, and the combination of BTX‐A and casting in the management of dynamic equinus in ambulatory children with spastic cerebral palsy (CP). Thirty‐nine children with spastic CP (mean age 5y 10mo, range 3 to 9y) were enrolled in the study. A multicenter, randomized, double blind, placebo‐controlled prospective study was used. Children were randomly assigned to one of three treatment groups: BTX‐A only (B), placebo injection plus casting (C), or BTX‐A plus casting (B+C). The dosage for the BTX‐A injections was 4U/kg per extremity. Assessments were performed at baseline, 3,6,7.5, and 12 months with a total of three treatments administered after the evaluations at baseline, 3, and 6 months. Primary outcome measures were ankle kinematics, velocity, and stride length. Secondary outcome measures were ankle spasticity, strength, range of motion, and ankle kinetics. Group B made no significant change in any variable at any time. Groups C and B+C demonstrated significant improvements in ankle kinematics, spasticity, passive range of motion, and dorsiflexor strength. Results of this 1‐year study indicate that BTX‐A alone provided no improvement in the parameters measured in this study, while casting and BTX‐A/casting were effective in the short‐ and long‐term management of dynamic equinus in children with spastic CP.

Comparing botulinum toxin A with casting for treatment of dynamic equinus in children with cerebral palsy

The purpose of this study was to compare the cumulative efficacy (three treatment sessions) of botulinum toxin A (BTX-A) alone, casting alone, and the combination of BTX-A and casting in the management of dynamic equinus in ambulatory children with spastic cerebral palsy (CP). Thirty-nine children with spastic CP (mean age 5y 10mo, range 3 to 9y) were enrolled in the study. A multicenter, randomized, double blind, placebo-controlled prospective study was used. Children were randomly assigned to one of three treatment groups: BTX-A only (B), placebo injection plus casting (C), or BTX-A plus casting (B+C). The dosage for the BTX-A injections was 4U/kg per extremity. Assessments were performed at baseline, 3, 6, 7.5, and 12 months with a total of three treatments administered after the evaluations at baseline, 3, and 6 months. Primary outcome measures were ankle kinematics, velocity, and stride length. Secondary outcome measures were ankle spasticity, strength, range of motion, and ankle kinetics. Group B made no significant change in any variable at any time. Groups C and B+C demonstrated significant improvements in ankle kinematics, spasticity, passive range of motion, and dorsiflexor strength. Results of this 1-year study indicate that BTX-A alone provided no improvement in the parameters measured in this study, while casting and BTX-A/casting were effective in the short- and long-term management of dynamic equinus in children with spastic CP.

Serial Casting vs Combined Intervention with Botulinum Toxin A and Serial Casting in the Treatment of Spastic Equinus in Children

Serial casting has been an effective tool used by physical therapists to increase ankle dorsiflexion range of motion and improve functional gait. The purpose of this retrospective study was to determine whether injection with botulinum toxin type A (BtA) before serial casting vs serial casting alone was associated with any changes in (1) the number of weeks necessary to reach the desired dorsiflexion range of motion and (2) the number of degrees of dorsiflexion range of motion gained per week of casting. Data were obtained through review of records maintained on patients undergoing serial casting. Thirty subjects comprised the two groups of 15 patients each. One group had received BtA before serial casting while the other group had received no BtA before serial casting. Data were analyzed using two t tests to determine whether there were significant differences, and the appropriate statistical adjustment (Bonferroni) was applied. Fewer weeks were required to reach the goal of 15 to 20 degrees of ankle dorsiflexion (or plateau) for the group receiving BtA than for the group that did not receive BtA. Results also indicated that the group receiving BtA had a significantly greater increase in range of motion per week than the group that received no BtA. Using serial casting in conjunction with BtA may achieve range of motion goals in less time than serial casting alone.

Botulinum toxin type A in the management of equinus in children with cerebral palsy: an evidence-based economic evaluation.

The aim of this study was to compare two methods of conservative management of calf spasticity and equinus gait--intramuscular injection of botulinum toxin type A (BTX-A) and serial casting. An economic evaluation framework was adopted to assess whether BTX-A offers value for money in the management of equinus gait due to calf spasticity in children with cerebral palsy. Short- to medium-term health care costs and outcomes were estimated for the comparison. This study was embarked upon to provide clinical and economic data as part of an application to the Pharmaceutical Benefits Advisory Committee (PBAC) for the reimbursement of BOTOX by the Australian Commonwealth Government. This is the primary mechanism for reimbursement of pharmaceuticals in Australia, as they are not routinely reimbursed through health insurance companies. The perspective of the analysis was that of the Australian health system. Randomized controlled trials (RCTs) exist comparing one treatment cycle of BTX-A with serial casting (Corry et al., 1998; Flett et al., 1999). A long-term prospective study provided data on multiple cycles of BTX-A treatment in a more naturalistic setting (Boyd et al., 1999). A simple economic modelling approach was used to establish resource utilization by treatment arm. Only direct medical costs were considered (BTX-A, medical personnel time and medical consumables). Clinical efficacy was obtained from the randomized controlled trials (Corry et al., 1998; Flett et al., 1999). Patient/parent preference was obtained from long-term follow-up (Corry et al., 1998) and a preference questionnaire (Flett et al., 1999). Australian treatment patterns and patient demographics were obtained from the naturalistic study (Boyd et al., 1999). The RCTs demonstrated equivalent efficacy of BTX-A and serial casting; however, with BTX-A the effect lasted longer and was clearly the preferred treatment. For patients with hemiplegia the costs of an episode of treatment with BTX-A or serial casting are ($AUD) $595 and $435, respectively, and thus the additional costs associated with BTX-A are $160. The corresponding costs for patients with diplegia are $1045 for BTX-A treatment and $870 for serial casting and thus the additional cost associated with BTX-A is $175. With an overall treatment duration of 3.7 years and an average treatment interval of 10 months, patients would receive an average of 5.4 treatments. Thus, for patients with hemiplegia the total additional cost, discounted at 5% annually, for BTX-A is $793. For patients with diplegia the total additional cost for BTX-A is $867. CONCLUSIONS AND CLINICAL INTERPRETATIONS: BTX-A is an effective, safe and acceptable treatment modality and is associated with only a modest increase in direct medical costs per child per year. BTX-A can be considered a valuable and cost-effective treatment in the conservative management of equinus due to calf spasticity in children with cerebral palsy. This conclusion is supported by the acceptance of the Pharmaceutical Benefits Advisory Committee (PBAC) recommendation that BOTOX should attract a full Government subsidy in Australia.

MANAGING EQUINUS IN CHILDREN WITH CEREBRAL PALSY: ELECTRICAL STIMULATION TO STRENGTHEN THE TRICEPS SURAE MUSCLE

A new therapeutic proposal for the management of equinus in children with cerebral palsy is to strengthen the calf muscles instead of weakening them surgically. Prior research indicates that in children with cerebral palsy the triceps surae muscle is weak and needs strengthening. Neuromuscular electrical stimulation (NMES) was used as an adjunct to physical therapy. A portable NMES unit with a hand-held remote switch stimulated an active muscle gait cycle. Results are discussed for four children, who showed improved gait, balance, posture, active and passive ankle range of motion, and foot alignment. The toe walkers became plantigrade and the equinovalgus posture of the foot decreased. Spasticity did not increase.