Treatment Of Spasticity In Children Research Articles

Selective Dorsal Rhizotomy for Spastic Cerebral Palsy: Report of 18 Cases Performed in the North of Vietnam

The purpose of this report is to describe a case series of children undergoing selective dorsal rhizotomy (SDR) for the treatment of spastic cerebral palsy in Vietnam. Also described is an international cooperation model to facilitate the development of a new, multidisciplinary team for the evaluation and treatment of these children. Details of international collaboration are described, including in-person travel and virtual interactions. All cases of children younger than 18 years undergoing SDR for treatment of spastic cerebral palsy at a single center in Hanoi, Vietnam are described, including preoperative evaluation of spasticity and gait as well as results at 6 and 12 months. Results are summarized using descriptive statistics. Since the beginning of cooperation in training and transferring SDR techniques by experts from the United States, in the period from June 2016 to December 2022, 18 SDR surgeries were performed in Hanoi. Patients' ages ranged from 2 to 14 years; 13 were male and 5 were female. Overall, approximately 60% of nerve rootlets were cut. Modified Ashworth Scale scores at 6 and 12 months after surgery in the hip, knee, and ankle joints showed improvement from preoperative values. There were 2 recorded complications: intracranial hypotension causing subdural hemorrhage and a case of skin infection at the incision site. The ongoing international cooperation between Vietnamese and American physicians has helped improve the surgical treatment of spasticity in children with cerebral palsy in Hanoi, providing children with a surgical treatment option with successful outcomes.

Pain Management Strategies for Botulinum Toxin Type A Injections in Children: A Comprehensive National Survey and Procedural Protocol.

Botulinum toxin type Ainjections are a first-line treatment forspasticity in children. Our purpose is to delineate the national landscape concerning pain management for botulinum toxin type A injections in pediatric patients and to formulate a protocol grounded in current scientific evidence. We conducted a nationwide survey targeting physical medicine and rehabilitation specialists performing botulinum toxin type A injections for focal spasticity in children in Portugal. We conducted a literature review to compare the survey results with clinical guidelines, good practice manuals, and protocols published in the literature. Finally, we developed a procedural protocol for pain management in botulinum toxin procedures. The survey was completed by 17 out of 18 identified specialists. All but one use some form of periprocedural analgesia. Five do not use any type of sedation. The majority do not assess pain during the procedures. From the reviewed articles, we obtained 23 articles, 19 of which provided data for detailed analysis. A prevailing concern centers around pain management during botulinum toxin procedures in children. Nevertheless, a distinct absence of uniformity persists in appraising and managing procedure-related pain. This notion is further underscored by the marked heterogeneity and paucity of published literature within this realm. The systematic implementation of a procedural protocol thus becomes highly crucial.

Safety and effectiveness of ethanol neurolysis with and without onabotulinumtoxinA in children with cerebral palsy.

OnabotulinumtoxinA is commonly used to relieve spasticity in children with neurologic disorders. Ethanol neurolysis may be used to target more muscles but is less well studied, especially in pediatrics. To determine the safety and effectiveness of ethanol neurolysis with onabotulinumtoxinA injections compared to only onabotulinumtoxinA injections for the treatment of spasticity in children with cerebral palsy. Prospective cohort study including patients with cerebral palsy receiving onabotulinumtoxinA and/or ethanol neurolysis from June 2020 to June 2021. Outpatient physiatry clinic. A total of 167 children with cerebral palsy not undergoing other treatments during injection period. Injection with either onabotulinumtoxinA only (112 children) or a combination of ethanol and onabotulinumtoxinA injections (55 children) using both ultrasound guidance and electrical stimulation. A post-procedure evaluation at 2 weeks after injection documented any adverse effects experienced by the child and perceived magnitude of improvement using an ordinal scale from 1 to 5. Multiple linear regression was used to identify and control for covariates including Gross Motor Function Classification System, gender, age, weight, ethnicity, race, and dosage. Only weight was identified as a confounding factor. When controlled for weight, combined onabotulinumtoxinA and ethanol injections had a greater magnitude of improvement (3.78/5) compared with onabotulinumtoxinA injections alone (3.44/5), a difference of 0.34 points on the rating scale (95% confidence interval: 0.01-0.69; p = .045). However, the difference was not clinically significant. One patient in the onabotulinumtoxinA-only group and two patients in the combined onabotulinumtoxinA and ethanol group reported mild, self-limiting adverse effects. Ethanol neurolysis under ultrasound and electrical stimulation guidance may be a safe and effective treatment for children with cerebral palsy that allows more spastic muscles to be treated than onabotulinumtoxinA alone.

Effect of session frequency of radial extracorporeal shockwave therapy on gastrocnemius muscle spasticity in children with spastic cerebral palsy: a double-blinded, randomised clinical trial

Background/aims Extracorporeal shockwave therapy has been effective in reducing spasticity in patients with spastic cerebral palsy, but there has yet to be a recommended guideline for the treatment of spasticity in children using extracorporeal shockwave therapy. The aim of this study was to evaluate the effect of session frequency of radial extracorporeal shockwave therapy on gastrocnemius muscle spasticity in children with spastic cerebral palsy. Methods This was a double-blinded, randomised controlled trial consisting of 14 patients with spastic cerebral palsy (8 boys and 6 girls), aged 5 to 12 years, who were divided into two groups. Group 1 received five true radial extracorporeal shockwave therapy sessions. Group 2 received three true radial extracorporeal shockwave therapy sessions and two sham extracorporeal shockwave therapy sessions. The Australian Spasticity Assessment Scale was measured at nine time points: 1) pre-extracorporeal shockwave therapy, 2–6) immediately after each radial extracorporeal shockwave therapy session, 7) 4 weeks after the fifth radial extracorporeal shockwave therapy session, 8) 8 weeks after the fifth radial extracorporeal shockwave therapy session, and 9) 12 weeks after the fifth radial extracorporeal shockwave therapy session. Results Both groups had a significant reduction in degree of resistance to passive movements of ankle plantar-flexor muscles measured using the Australian Spasticity Assessment Scale at all time points, relative to baseline. The mean ankle Australian Spasticity Assessment Scale in the two groups were not significantly different after the fifth extracorporeal shockwave therapy treatment (group 1: 1.13 ± 0.62; group 2: 1.50 ± 0.90, P=0.28), 4 weeks after the fifth radial extracorporeal shockwave therapy treatment (group 1: 1.12 ± 0.66; Group 2: 1.50 ± 0.90, P=0.40), 8 weeks after the fifth radial extracorporeal shockwave therapy treatment (group 1: 1.25 ± 0.68; group 2: 1.50 ± 0.90, P=0.54) and 12 weeks after the fifth radial extracorporeal shockwave therapy treatment (group 1: 1.19 ± 0.75; Group 2: 1.58 ± 0.90, P=0.28). Conclusions: The effect of radial extracorporeal shockwave therapy on spastic gastrocnemius in children with spastic cerebral palsy is not dependent on session frequency. There has yet to be a recommended guideline and research showing the factors that affect the efficacy of radial extracorporeal shockwave therapy on spastic gastrocnemius muscles in children with spastic cerebral palsy.

Botulinum Toxin a Injection Combined with Radial Extracorporeal Shock Wave Therapy in Children with Spastic Cerebral Palsy: Shear Wave Sonoelastographic Findings in the Medial Gastrocnemius Muscle, Preliminary Study.

Therapeutic strategies to boost the effect of botulinum toxin may lead to some advantages, such as long lasting effects, the injection of lower botulinum toxin dosages, fewer side effects, and lower costs. The aim of this study is to investigate the combined effect of botulinum toxin A (BTA) injection and extracorporeal shock wave therapy (ESWT) for the treatment of spasticity in children with spastic cerebral palsy (CP). Fifteen patients with spastic CP were recruited through a retrospective chart review to clarify what treatment they received. All patients received a BTA injection on gastrocnemius muscle (GCM), and patients in group 1 underwent one ESWT session for the GCM immediately after BTA injection and two consecutive ESWT sessions at weekly intervals. Ankle plantar flexor and the passive range of motion (PROM) of ankle dorsiflexion were measured by a modified Ashworth scale (MAS) before treatment and at 1 and 3 month(s) post-treatment. In group 1, the shear wave velocity (SWV) of GCM was measured. The PROM and MAS in group 1 and 2 before treatment significantly improved at 1 and 3 month(s) after treatment. The change in PROM was significantly different between the two groups at 1 and 3 month(s) after treatment. The SWV before treatment significantly decreased at 1 month and 3 months after treatment in group 1. Our study has shown that the combination of BTA injection and ESWT would be effective at controlling spasticity in children with spastic CP, with sustained improvement at 3 months after treatment.

Treatment of spasticity in children and adolescents with cerebral palsy in Northern Europe: a CP-North registry study

BackgroundSpasticity is present in more than 80% of the population with cerebral palsy (CP). The aim of this study was to describe and compare the use of three spasticity reducing methods; Botulinum toxin-A therapy (BTX-A), Selective dorsal rhizotomy (SDR) and Intrathecal baclofen therapy (ITB) among children and adolescents with CP in six northern European countries.MethodsThis registry-based study included population-based data in children and adolescents with CP born 2002 to 2017 and recorded in the follow-up programs for CP in Sweden, Norway, Denmark, Iceland and Scotland, and a defined cohort in Finland.ResultsA total of 8,817 individuals were included. The proportion of individuals treated with SDR and ITB was significantly different between the countries. SDR treatment ranged from 0% ( Finland and Iceland) to 3.4% (Scotland) and ITB treatment from 2.2% (Sweden) to 3.7% (Denmark and Scotland). BTX-A treatment in the lower extremities reported 2017–2018 ranged from 8.6% in Denmark to 20% in Norway (p < 0.01). Mean age for undergoing SDR ranged from 4.5 years in Norway to 7.3 years in Denmark (p < 0.01). Mean age at ITB surgery ranged from 6.3 years in Norway to 10.1 years in Finland (p < 0.01). Mean age for BTX-A treatment ranged from 7.1 years in Denmark to 10.3 years in Iceland (p < 0.01). Treatment with SDR was most common in Gross Motor Function Classification System (GMFCS) level III, ITB in level V, and BTX-A in level I. The most common muscle treated with BTX-A was the calf muscle, with the highest proportion in GMFCS level I. BTX-A treatment of hamstring and hip muscles was most common in GMFCS levels IV-V in all countries.ConclusionThere were statistically significant differences between countries regarding the proportion of children and adolescents with CP treated with the three spasticity reducing methods, mean age for treatment and treatment related to GMFCS level. This is likely due to differences in the availability of these treatment methods and/or differences in preferences of treatment methods among professionals and possibly patients across countries.

PND37 Cost-Effectiveness of BoNT-A Products for Treatment of Pediatric Spasticity in the United Kingdom

For children with impaired motor function, pain, or other functional difficulties attributable to focal spasticity, the UK National Institute for Health and Clinical Excellence guidelines recommend treatment with botulinum neurotoxin type A (BoNT-A). Two BoNT-A products are licensed for pediatric use in the United Kingdom: abobotulinumtoxinA (aboBoNT-A) and onabotulinumtoxinA (onaBoNT-A), but these treatments differ in terms of doses, costs, and injection frequencies. The objective of this analysis was to evaluate the average expenditure per response obtained with aboBoNT-A or onaBoNT-A for managing pediatric spasticity of the upper (ULS) and lower (LLS) limbs. Cost-effectiveness analyses were conducted for BoNT-A treatment of ULS and LLS in the UK. Effectiveness was defined as response to therapy and was based on data from systematic literature reviews and meta-analyses of randomized controlled trials. BoNT-A dose was based on product label and the average weight of a pediatric (6-year-old) patient in the UK. Injection interval was based on clinical trial data, adjusted to consider differences in use observed in real-world studies of BoNT-A use in adult spasticity. Resource use for responders and non-responders was based on a survey of UK physicians treating pediatric LLS. Unit costs were informed by UK fee schedules. AboBoNT-A resulted in lower annual costs compared with onaBoNT-A for the management of ULS (£487 saved) and LLS (£429 saved). Results were driven by differences in injection intervals and a higher treatment response rate for people receiving aboBoNT-A compared with onaBoNT-A. Total cost per responder was lower for people receiving aboBoNT-A compared with onaBoNT-A (ULS: £37,880 vs. £50,100; LLS: £46,459 vs. £66,037). Results were robust to sensitivity analyses. AboBoNT-A may be a cost-effective choice for treatment of spasticity in children. These findings could help deliver more effective and efficient healthcare in the UK.

Sustained efficacy of incobotulinumtoxinA over 6 injection cycles for the treatment of lower-limb spasticity in children and adolescents with cerebral palsy

Sustained efficacy of incobotulinumtoxinA over 6 injection cycles for the treatment of lower-limb spasticity in children and adolescents with cerebral palsy

IncobotulinumtoxinA for the treatment of spasticity in children with cerebral palsy \u2013 a retrospective case series focusing on dosing and tolerability

BackgroundIncobotulinumtoxinA (Xeomin®) is a botulinum neurotoxin type A with established efficacy in the treatment of upper-limb spasticity in adults. This retrospective case series in a university hospital setting aimed to elucidate the safety and tolerability of incobotulinumtoxinA for treatment of spasticity in children with cerebral palsy.MethodsParticipants received incobotulinumtoxinA injections up to a maximum total dose of 600 U, 24 U/kg body weight. Medical records were reviewed for key demographic information, incobotulinumtoxinA exposure, and adverse effects (AEs).ResultsSixty-nine children were included (mean age [SD], 8.3 [3.9] years; 44/69 [63.8%] male). One-hundred-and-ninety-one injections were administered, with mean (SD) of 2.8 (1.5) treatment cycles/participant and dosing interval of 6.0 (1.7) months. The number of muscles injected increased from 2.4 (1.2) at cycle 1 to 4.2 (1.9) at cycle 6. The mean (SD) total incobotulinumtoxinA dose increased from 191.7 (126.2) U, (8.5 [5.4] U/kg body weight) at cycle 1 to 368.0 (170.1) U, (9.9 [5.5] U/kg body weight) at cycle 6. Seventy four adverse effects (37.5% of injections) were reported, the most frequent was injection pain (93.2% of AEs). Only three AEs were considered directly treatment-related by injectors: muscle weakness, generalized weakness, and fever.ConclusionsOur clinical experience indicates that incobotulinumtoxinA is a well-tolerated treatment option for focal spasticity in children with cerebral palsy.Trial registrationAs the study was observational and retrospective, no EudraCT registration number was requested. The internal code assigned to the study in the administrative resolution was: 1143-N-15.

Botulinum toxin type A (Incobotulinum toxin A) in spastic forms of cerebral palsy: a retrospective analysis of clinical experience

A retrospective analysis of the experience of using Incobotulinum toxin A injections for the treatment of spasticity in children with cerebral palsy (CP). One hundred and eighty-five children with spastic forms of CP, including 114 boys (61,6%), were studied. The average age of the patients was 3,8±2,5 years; the average weight was 14,2±6,9. The patients received injections of Incobotulinum toxin A according to registered indications or recommendations of a consultation of specialists and voluntary informed consent of the patient's representative. At least 1 point decrease of muscle tone according to the modified Ashworth scale was used as a criterion of the antispastic effect of Incobotulinum toxin A. The total dose of Incobotulinum toxin A for the whole group of patients with CP was 154,5±67,7 U and 11,6±4,7 U per kg/body weight. The gracilis muscle (65,4% of cases, 95%CI 58,1-72,2) and the gastrocnemius muscle (49,4% of cases, 95%CI 41,8-56,6) were the most frequently injected targets in the lower extremities, and the pronator teres muscle (58,9% of cases, 95%CI 51,5-66,1) - in the upper extremities. Adverse events were observed in 13 patients (7,0%). They were mild in 9 patients and moderate in 4 patients. Our data confirmed the effectiveness and safety of Incobotulinum toxin A injections in spastic CP. The calculated average doses of Incobotulinum toxin A for target muscles and the frequency of different spasticity patterns could serve as a reference for the botulinum therapy planning.

Do clowns attenuate pain and anxiety undergoing botulinum toxin injections in children?

Botulinum toxin injection (BTI) is the primary treatment for spasticity in children. Anxiety and pain are important concerns to address to attenuate the discomfort of BTI. The aim of this study was to compare the effectiveness of medical clowns and usual distractions, both added to nitrous oxide (N2O) and analgesic cream, on pain and anxiety during BTI sessions in children. The primary outcome was pain evaluated by the Face, Legs, Activity, Cry, Consolability (FLACC) scale. Secondary criteria were pain rated on a Visual Analog Scale (VAS) by the child and parent, anxiety rated on a VAS before and during BTIs by the child and parent(s), rating of the success of the sessions on a 4-point Likert scale by the physician and parent(s), and rating of the benefits of the distraction by the parent(s). Non-parametric tests were used for between-group comparisons. Baseline group characteristics of the clown and control groups did not differ. During 88 BTI sessions (40 with clown distraction and 48 with control distraction) in 59 children (35 boys; 52 with cerebral palsy, 12 with moderate to severe cognitive disorders), median maximal FLACC score was 2.5 (interquartile range [IQR]: 1-4) in the clown group and 3 (IQR: 1-4.3) in the control group. VAS self-reported pain score was 2.5 (IQR: 0-5) and 3 (IQR: 1-6.3) in the clown and control groups (P=0.56), and VAS proxy-reported pain score was 2.5 (IQR: 0.3-3.4) and 3 (IQR: 1-4.5) (P=0.25). After BTI sessions, the 2 groups did not differ in VAS self- and proxy-reported anxiety (P=0.83 and P=0.81). Physician and parent ratings of the success of sessions were similar between the groups (P=0.89 and P=0.11). Parent ratings of the perceived benefits of distraction were higher in the clown than control group (P=0.004). Although clown distraction was particularly appreciated by parents, it did not significantly reduce pain or anxiety in children as compared with usual distraction. ClinicalTrials.gov ID: NCT03149263.

Use of botulinum toxin A in children with cerebral palsy.

For more than 20 years, intramuscular injections of botulinum toxin A have been an established treatment for spasticity in children with cerebral palsy. We investigated the proportion of children with cerebral palsy who receive such treatment in Norway and the guidelines that apply to the treatment. Data from the five-year registration in the Cerebral Palsy Registry of Norway were used to investigate the proportion of children with cerebral palsy born in the period 1999-2010 treated with botulinum toxin A, and whether there were any variations in the proportion of children treated between the habilitation centres. We conducted an online survey to identify the treatment guidelines that were applied in all of the 21 habilitation centres. A total of 1 414 children (average age 6.3 years) were included, of whom 775 (55%) had been treated with botulinum toxin A. The proportion of children who received treatment varied considerably between the habilitation centres (38-80%; p < 0.001). The maximum dose of botulinum toxin A per treatment per patient was 200-600 units of Botox. Five centres reported to have written guidelines for the treatment indication. The proportion of children with cerebral palsy who are treated with botulinum toxin A varies considerably between Norwegian habilitation centres.

Uso prático da AbobotulinumtoxinA no tratamento de espasticidade em crianças com paralisia cerebral

AbobotulinumtoxinA (ABO) tem sido utilizada para o tratamento da espasticidade em criancas com paralisia cerebral (PC). Seu uso requer uma administracao cuidadosa, quanto a dosagem, selecao de locais de aplicacao, intervalo entre aplicacoes, eficacia e seguranca. Este foi o primeiro painel de especialistas no tratamento da espasticidade que desenvolveu um guia sobre questoes gerais relacionadas a terapeutica de medicos que utilizam ABO, incluindo a indicacao da dosagem a ser aplicada por musculo. O tratamento deve ser iniciado o mais rapido, idealmente entre dois e seis anos de idade. Uma avaliacao clinica deve identificar os musculos espasticos e determinar o objetivo: melhora funcional, analgesia, facilidade de cuidados e posicionamento, prevencao da luxacao dos quadris, melhora da marcha e postura, facilitacao do processo de educacao, maior participacao social e/ou melhora estetica. Os pre-requisitos para alcancar bons resultados sao a selecao muscular adequada, a dosagem de ABO e a tecnica de injecao. Muitos padroes patologicos comuns podem ser tratados se varios musculos forem simultaneamente injetados em uma unica sessao de tratamento; O planejamento da dose de ABO por musculo deve levar em consideracao a dosagem maxima em unidades por musculo e a dose de ABO maxima total por sessao (30 U / kg de peso corporal do paciente, nao superior a 1000 U). Apos a aplicacao, as criancas devem ser submetidas a programas de fisioterapia e terapia ocupacional, focadas em orientacoes domiciliares e em orientacoes para a familia, aumentando as chances de ganho terapeutico. O tratamento com ABO e multidisciplinar e requer abordagens integradas.

Long-term impact of childhood selective dorsal rhizotomy on pain, fatigue, and function: a case-control study.

Selective dorsal rhizotomy (SDR) is a surgical treatment for spasticity in children with cerebral palsy (CP). Studies suggest long-lasting effects of SDR on spasticity; long-term effects on symptoms and function are not clear. This study tested whether adults with CP (average 22y after SDR) report less pain, fatigue, and functional decline than a retrospectively assessed non-surgical comparison group. This was a case-control study. Eighty-eight adults with CP (mean age 27y; SDR=38 male/female/missing=20/16/2; non-surgical [comparison]=50, male/female=19/31) recruited from a tertiary care center and the community completed a battery of self-reported outcome measures. Regression models were used to test whether SDR status predicted pain, fatigue, functional change, and hours of assistance (controlling for Gross Motor Function Classification System level). SDR status did not significantly predict pain interference (p=0.965), pain intensity (p=0.512), or fatigue (p=0.404). SDR related to lower decline in gross motor functioning (p=0.010) and approximately 6 fewer hours of daily assistance than for those in the comparison group (p=0.001). Adults with CP who had SDR in childhood reported less gross motor decline and fewer daily assistance needs than non-surgically treated peers, suggesting the functional impact of SDR persists long after surgery.

Effect of multilevel lower-limb botulinum injections & intensive physical therapy on children with cerebral palsy.

Background & objectives:Botulinum toxin is considered as an effective treatment for spasticity in children with cerebral palsy (CP). However, there are only a few long-term studies, and the effects on motor function have been inconclusive. Moreover, due to its high cost and need for intensive post-injection therapy, utility in context of developing nations has not been established. This retrospective study was undertaken to assess the long term effects of botulinum toxin-A with physical therapy in children with CP.Methods:This retrospective study was conducted at a tertiary care centre in India, where a limited supply of botulinum toxin was introduced in the year 2009. It was used in a selective group of patients with CP along with intensive physical therapies. All children who received lower-limb botulinum injections over a 42-month period were analyzed. For evaluation of treatment effect, the measurement at 1st pre-injection assessment and the last measurements, i.e. 12 wk after last injection received by that child were compared.Results:Twenty nine patients (20 males, median age 51 months) received 69 sessions of botulinum toxin injections in the lower limbs over a 42-month period. Thirteen patients were diplegic, 10 were quadriplegic, five were triplegic and one was hemiplegic. There was a significant improvement in pre- and post-injection scores on Observational Gait Scale (right side 7.1±3.6 to 10.7±3.7, left side 6.7±3.5 to 9.9±3.4), Gross Motor Function Measure Scale (47.9±17.7 to 67.6±17.2), Modified Ashworth Scale, passive range of motion and Gross Motor Function Classification System. Most of the patients showed gain in motor milestones as well.Interpretation & conclusions:Our results showed that judicious use of botulinum injections along with intensive physio/occupational therapies could yield good results in children with CP.

Clinical practice with incobotulinumtoxina (Xeomin) in the treatment of spasticity in children with cerebral palsy

Clinical practice with incobotulinumtoxina (Xeomin) in the treatment of spasticity in children with cerebral palsy

Cost-minimization analysis in the treatment of spasticity in children with cerebral palsy with botulinum toxin type A: an observational, longitudinal, retrospective study

ObjectiveCost-minimization analysis of onabotulinumtoxinA and abobotulinumtoxinA, taking into account the real dose administered to children with spasticity associated with dynamic equinus foot deformity due to cerebral palsy. MethodA single centre, observational, longitudinal, and retrospective study which included spastic paediatric patients aged 2-to-18-years and treated with onabotulinumtoxinA or abobotulinumtoxinA from December 1995 to October 2012, in the Paediatric Neurology Unit of a first-level Spanish hospital. A longitudinal analysis of spasticity severity was made to confirm the similar effectiveness of both treatments. Cost minimization was analyzed using the dose administered and the direct costs (pharmacological and medical visits costs) from the perspective of the National Health System (in 2016 euros). ResultsWe analyzed 895 patients with paediatric spasticity: 543 were treated only with onabotulinumtoxinA, 292 only with abobotulinumtoxinA, and 60 with both treatments. The mean doses administered were 5.44 U/kg (SD = 2.17) for onabotulinumtoxinA, and 14.73 U/kg (5.26) for abobotulinumto xinA. The total annual direct cost (pharmacological and medical visits) was € 839.56 for onabotulinumtoxinA and € 631.23 for abobotulinumtoxinA, which represents a difference of € 208.34 per year in favour of treatment with abobotulinumtoxinA. ConclusionsIt has been shown that in real clinical practice, the cost per patient and year for treatment of paediatric spasticity was lower when abobotulinumtoxinA was used.

Intrathecal baclofen for treating spasticity in children with cerebral palsy.

Cerebral palsy is a disorder of movement and posture arising from a non-progressive lesion in the developing brain. Spasticity, a disorder of increased muscle tone, is the most common motor difficulty and is associated with activity limitation to varying degrees in mobility and self care.Oral baclofen, a gamma-aminobutyric acid (GABA) agonist, has been used in oral form to treat spasticity for some time, but it has a variable effect on spasticity and the dose is limited by the unwanted effect of excessive sedation. Intrathecal baclofen produces higher local concentrations in cerebrospinal fluid at a fraction of the equivalent oral dose and avoids this excessive sedation. To determine whether intrathecal baclofen is an effective treatment for spasticity in children with cerebral palsy. We searched the CENTRAL, MEDLINE, EMBASE and CINAHL databases, handsearched recent conference proceedings, and communicated with researchers in the field and pharmaceutical and drug delivery system companies. We included studies which compared the effect of intrathecal baclofen treatment on spasticity, gross motor function or other areas of function with controls. Two authors selected studies, two authors extracted data and two authors assessed the methodological quality of included studies. Six studies met the inclusion criteria. The data obtained were unsuitable for the conduct of a meta-analysis; we have completed a qualitative summary.All studies were found to have high or unclear risk of bias in some aspects of their methodology.Five of the six studies reported data collected in the randomised controlled phase of the study. A sixth study did not report sufficient results to determine the effect of intrathecal baclofen versus placebo. Of these five studies, four were conducted using lumbar puncture or other short-term means of delivering intrathecal baclofen. One study assessed the effectiveness of implantable intrathecal baclofen pumps over six months.The four short-term studies demonstrated that intrathecal baclofen therapy reduces spasticity in children with cerebral palsy. However, two of these studies utilised inappropriate techniques for statistical analysis of results. The single longer-term study demonstrated minimal reduction in spasticity with the use of intrathecal baclofen therapy.One of the short-term studies and the longer term study showed improvement in comfort and ease of care. The longer term study found a small improvement in gross motor function and also in some domains of health-related quality of life.Some caution is required in interpreting the findings of the all the studies in the review due to methodological issues. In particular, there was a high risk of bias in the methodology of the longer term study due to the lack of placebo use in the control group and the absence of blinding to the intervention after randomisation for both participants and investigators. There is some limited short-term evidence that intrathecal baclofen is an effective therapy for reducing spasticity in children with cerebral palsy. The effect of intrathecal baclofen on long-term spasticity outcomes is less certain.The validity of the evidence for the effectiveness of intrathecal baclofen in treating spasticity in children with cerebral palsy from the studies in the review is constrained by the small sample sizes of the studies and methodological issues in some studies.Spasticity is a impairment in the domain of body structure and function. Consideration must also be given to the broader context in determining whether intrathecal baclofen therapy is effective. The aim of therapy may be, for example, to improve gross motor function, to increase participation at a social role level, to improve comfort, to improve the ease of care by others or to improve the overall quality of life of the individual. Intrathecal baclofen may improve gross motor function in children with cerebral palsy, but more reliable evidence is needed to determine this.There is some evidence that intrathecal baclofen improves ease of care and the comfort and quality of life of the individuals receiving it, but again small sample sizes and methodological issues in the studies mean that these results should be interpreted with caution.Further evidence of the effectiveness of intrathecal baclofen for treating spasticity, increasing gross motor function and improving comfort, ease of care and quality of life is needed from other investigators in order to validate these results.The short duration of the controlled studies included in this review did not allow for the exploration of questions regarding whether the subsequent need for orthopaedic surgery in children receiving intrathecal baclofen therapy is altered, or the safety and the economic implications of intrathecal baclofen treatment when long-term therapy is administered via an implanted device. Controlled studies are not the most appropriate study design to address these questions, cohort studies may be more appropriate.

P185. From contracture to functional movement – Minimally invasive neuro-orthopedic surgery is a feasible tool for the treatment of severe spasticity in young adults in early neurological rehabilitation

Using photography and video we report on 3 young adults treated in our center for early neurological rehabilitation between 2011 and 2014 after acute brain injury (blood loss, anoxia, tentorial herniation). All of them developed severe painful contractures early on, were bedridden and incapable of functional movements. Systemic anti-spastic therapy and daily physiotherapy were not able to modify the degree of spasticity in a substantial manner. We applied minimally invasive tendon lengthening – i.e. myotenofasciotomy as developed by Ulzibat and colleagues for the treatment of spasticity in children – along with classical tendon lengthening techniques and extensive physiotherapy in the weeks following the procedures. In all patients we achieved normalization of leg axis, sustained verticalization including 1 patient who became able to walk again for short distances, and restoration of hand movements for assisted oral food intake. We conclude that minimally invasive tendon lengthening is a safe, effective and beneficial procedure for young adults in the setting of neurologic early rehabilitation.

Use of botulinum toxin in the treatment of ankle plantar flexor spasticity in children with cerebral palsy.

The aim of this study was to assess the effects of botulinum on spasticity of gastrocnemius and soleus muscles. Forty-one children with spastic cerebral palsy were assessed (muscle tone, range of motion of ankle joint extension with straightened and bent knee, and gait pattern using the Physician Rating Scale) before administration and 2, 6, and 13 weeks after. Changes on Physician Rating Scale and dorsiflexion with extended knee were significant after 2, 6, and 13 weeks. Differences in the remaining parameters were significant after the first two check-ups. Over 90% of the changes were positive. This research confirms the effectiveness of botulinum in reducing spasticity, increasing the range of motion, and improving the gait pattern.