Spastic Equinus Gait Research Articles

Over 25 Years of Pediatric Botulinum Toxin Treatments: What Have We Learned from Injection Techniques, Doses, Dilutions, and Recovery of Repeated Injections?

Botulinum toxin type A (BTXA) has been used for over 25 years in the management of pediatric lower and upper limb hypertonia, with the first reports in 1993. The most common indication is the injection of the triceps surae muscle for the correction of spastic equinus gait in children with cerebral palsy. The upper limb injection goals include improvements in function, better positioning of the arm, and facilitating the ease of care. Neurotoxin type A is the most widely used serotype in the pediatric population. After being injected into muscle, the release of acetylcholine at cholinergic nerve endings is blocked, and a temporary denervation and atrophy ensues. Targeting the correct muscle close to the neuromuscular junctions is considered essential and localization techniques have developed over time. However, each technique has its own limitations. The role of BTXA is flexible, but limited by the temporary mode of action as a focal spasticity treatment and the restrictions on the total dose deliverable per visit. As a mode of treatment, repeated BTXA injections are needed. This literature reviewed BTXA injection techniques, doses and dilutions, the recovery of muscles and the impact of repeated injections, with a focus on the pediatric population. Suggestions for future studies are also discussed.

Positive effects of backward downhill treadmill training on spastic equinus gait

Positive effects of backward downhill treadmill training on spastic equinus gait

Clinical outcome with Botulinum toxin-A in spastic cerebral palsy children with equinus gait

Objective: Analysis of spastic equinus gait, ankle movements, and spasticity change in Indian cerebral palsy (CP) children. Design: Prospective study with follow up at 2 weeks and 2 months after injection. Setting: Department of Physical Medicine and Rehabilitation, AIIMS, New Delhi between 2009 and 2011. Participants: 22 Spastic CP children (12 diplegic and 10 hemiplegic), 14 males and 8 females aged 2-8 years (mean 4.44 years) having gastrocnemius spasticity with equinus gait. Intervention: Botulinum Toxin-A marketed as Botox® (Allergan, Inc.) was administered in both the medial and lateral heads of gastrocnemius. Dosage: 4 Unit/kg/muscle, maximum of 50 U per injection site, 50 U/ml with 0.9% normal saline dilution. After injection, the children continued participating in routine rehab exercise therapy and provided ankle foot orthosis. Main Outcome Measure(s): Temporospatial parameter of gait (stride, step length, cadence, velocity, percentage contact of foot with ground), Spasticity as per modified Ashworth Scale, active and passive range of motion at ankle. Results: Significant improvement (n = 34, P 90% of children in terms of comfort, ease of care, and walking. The improvement lasted for 2 months. Conclusions: Botulinum Toxin-A injection is effective in treatment of equinus gait with easy OPD procedure and minimal side effects which are very tolerable.

Neuronox versus BOTOX for spastic equinus gait in children with cerebral palsy: a randomized, double-blinded, controlled multicentre clinical trial

The aim of this study was to evaluate the efficacy and safety of a newly manufactured botulinum toxin, Neuronox, compared with BOTOX for the treatment of the spastic equinus gait in children with cerebral palsy. A total of 127 children with cerebral palsy, aged 2 to 10 years, who presented at three university hospitals with spastic equinus gait were assessed for eligibility to participate in this double-blinded, randomized, controlled trial. Of the 119 eligible participants (mean age 4.33 y; SD 2.07; 76 males and 43 females; 79 with diplegia and 40 with hemiplegia), 57 were classified as Gross Motor Function Classification System level I, 29 as level II, and 33 as level III. Participants were randomly assigned to receive an injection of Neuronox (n=60) or BOTOX (n=59) to the calf muscles at a dose of 4U/kg for those with hemiplegia and 6U/kg for those with diplegia. Assessments were performed at baseline (V1) and at 4 (V2), 12 (V3), and 24 (V4) weeks after the intervention. The primary outcome measure was response rate at V3, with a positive response being defined as at least a 2-point increase in the Physicians' Rating Scale (PRS) score. The non-inferiority margin was set as -20% for the difference in the response rate. The secondary outcome measures included PRS score, passive range of motion (PROM) of the ankle and knee, and Gross Motor Function Measure 88 (GMFM-88). Any adverse events were investigated for safety implications. The response rate of the Neuronox group at V3 was not inferior to that of the BOTOX group (90% lower limit=-11.58%). There were significant improvements in PRS, PROM of ankle dorsiflexion, and GMFM scores at V2, V3, and V4 in both groups. The changes in PRS score were not statistically different between the two groups in serial evaluation (p=0.96). PROM of the ankle dorsiflexion increased without any significant difference between the two groups, either overall (p=0.56) or at each visit (V2, p=0.32; V3, p=0.66; V4, p=0.90). The increase in GMFM score in serial measurements were not significantly different between the two groups (p=0.16), whereas it was larger in the BOTOX group than in the Neuronox group at V2 and V4 (p=0.03 and 0.05 respectively). The frequency of adverse events was not significantly different between the two groups (p=0.97), and drug-related complications of Neuronox treatment were not addressed. The outcomes of Neuronox, based on PRS, proved to be as effective and safe as those of BOTOX for the treatment of spasticity in individuals with cerebral palsy.

Botulinum Toxin Type A Injections for Treatment of Spastic Equinus in Cerebral Palsy

To investigate markers predicting favorable botulinum toxin injection outcomes in treating spastic equinus gait in children with cerebral palsy. Thirty-six children (21 boys and 15 girls, aged 1.5-9.6 yrs; 20 with unilateral and 16 with bilateral cerebral palsy levels I to IV with the Gross Motor Function Classification System) with 49 treated lower limbs were included. Passive range of movement, selective dorsiflexion, dynamic muscle length (modified Tardieu Scale), calf tone (modified Ashworth Scale), attainment of anticipated gait pattern (Goal Attainment Scale), and video gait analysis (Observational Gait Scale) were assessed before and 1, 2, and 4 mos after intervention. Participants were classified as poor or good responders, according to the Goal Attainment Scale response at 2 mos. Good response was noted in 23 (64%) children and 29 (59%) legs, whereas 13 (36%) children and 20 (41%) legs were defined as poor responders. In a multivariate regression analysis, the best predictors of good response per child were higher initial Observational Gait Scale total scores, one-level treatment, and normal cognition; and the best predictors per leg were good initial selective motor control in the ankle and capability of occasional flatfoot contact at pretreatment. These results suggest that children with less severe functional deficit, fair to good selective motor control in the ankle, and mild equinus gait respond best to focal botulinum toxin type A treatment, with an eye to flatfoot or heel strike contact. Likewise, children with higher cognitive level seem to derive functional benefit from the treatment.

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.

Treatment of Spastic Equinus Gait with Botulinum Toxin A: Does Dose Matter? Analysis of a Clinical Cohort

This study reports the effects of various doses of BTX-A when treating equinus gait in cerebral palsy in a clinical setting at a tertiary hospital. Twenty-nine children with CP (age 1.5-9.6 yrs, GMFCS I-IV) met the preset inclusion criteria. The treatment episodes per child ranged from 1 to 5 and the effects on a total of 80 legs in 55 treatment sessions were evaluated. BTX-A doses injected into the gastroc-soleus muscle were divided into low- (<or= 6 units/kg bw) and high- (> 6 units/kg bw) dose groups. The outcome measurements included active and passive ankle range of movement, Modified Ashworth Scale, dynamic muscle length, Selective Motor Control score, Observational Gait Scale score, and Goal Attainment Scale score at pre-treatment and 1, 2, and 4 months post-treatment. The only differences between the treatment groups were observed at 2 and 4 months in terms of change in passive ankle ROM and at 4 months in change in selective dorsiflexion, favouring the low-dose group. The incidence and severity of side-effects did not differ between the groups. Doses over 6 units/kg bw injected into the gastroc-soleus muscle do not necessarily yield superior results compared with lower doses.

Improvement of spastic equinus gait in CP: a protocol for integrated orthotic and orthopaedic treatment

The aim of the present study was to assess the effect of postural insoles on gait performance in children with Cerebral Palsy (CP). Twenty four children between four and 12 years of age were randomly allocated either the control group (n = 12) or experimental group (n = 12). The control group used placebo insoles and the experimental group used postural insoles. Three-dimensional gait analysis was performed under three conditions: barefoot, in shoes and in shoes with insoles. Three evaluations were carried out: 1)immediately following placement of the insoles; 2)after three months of insole use; and 3)one month after suspending insole use. Regarding the immediate effects and after three months use of insole, significant improvements in gait velocity and cadence were found in the experimental group, along with an increase in foot dorsiflexion, a reduction in knee flexion and a reduction in internal rotation. Conversely, these changes were not maintained in the third assessment, one month after withdrawal of the insoles. The use of postural insoles led to improvements in gait performance in children with CP.