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Botulinum Toxin Therapy for the Upper Limb CP Network May 2013 Susan Horsburgh Outline of Session • • • • How BTX-A works Evidence to support use History of Service Case Studies How BTX-A Works • BTX-A blocks the release of acetylcholine at the neuromuscular junction • Produces a short-term, and reversible, paralysis of the treated muscle • Effects are at their maximum after 10 to 12 days • Best evidence supports therapy after injection to maximise outcomes BTX-A Therapy • BTX-A is protein produced by the bacterium Clostridium Botulinum – Botox® Allergan – Dysport • Given by intramuscular injection as near to the motor end plate as possible • Protein is reconstituted in 0.9% saline solution Best Practice • Good pre- and post-treatment assessment with appropriate outcome measures linked to the ICF and child’s GMFCS level • Identification of the muscle using – EMG stimulation – US guidance • Number of Units – 4-6 units/kg body wt. within a range 1-20U/kg – Maximum 100U for large muscles, 50U for small • Volume of Dilution – 100U per 1-2ml solution Factors Influencing Treatment • Site of Injection – Muscles of children with cerebral palsy are not where expect to be – Need to use US to detect upper limb muscles – Slows process increasing stress • Dilution – Too much solution can spread too far, takes longer to inject – Too little and effect is inadequate Factors Influencing Treatment • Clinic Process – Younger children have oral sedation prior to injection • Midazolam – Older children can use Entonox – Local anaesthesia • Ethyl Chloride spray • LMX/Emla cream - lidocaine Question • Does botulinum toxin improve hand function in children with cerebral palsy and upper limb spasticity? Evidence Pubmed • Search Terms – botulinum toxin; cerebral palsy; upper limb spasticity • 41 articles – 18 reviews • 5 relevant, peer reviewed, English Language, several authors – – – – – Reeuwijk et al (2006) Clinical Rehab Boyd et al (2001) European Journal of Neurology Hoare et al (2010) Cochrane Database Lukban et al (2009) Journal of Neural Transmission Delgado et al (2010) American Academy of Neurology Evidence • Younger children respond better • First treatment produces the largest response • BTX-A should be combined with OT input for maximum benefit • Careful selection of muscles required Muscle Selection • 6 articles – Search Terms: Upper limb spasticity; muscle selection; botulinum toxin; cerebral palsy – 4 – 1 case report, 2 clinical reviews, 1 RCT (effect on nerve endings) – Children can have unusual muscle action therefore muscle palpation is very inaccurate – Pronator teres may be first muscle to contribute to ↓ ROM – Small doses, serial treatment, and multi-level for function – large dose, multi-level for cosmetic/ease of handling – Thumb significant in grasp – muscle selection unclear Lanarkshire/Yorkhill Service • Pre- and post-treatment assessment takes place in Lanarkshire • Children are seen in Yorkhill Hospital with Consultant Neurologist and Community Consultant Paediatrician • Treatment of upper limb since April 2012 • Recently purchased US machine • Supply of low dose vials Aims of Treatment • • • • Cosmetic Ease of handling Reduce pain Maintain/Improve range of movement – Splinting • Improve function Personal Experiences of Treatment for Upper Limb • Cosmetic – Teenager with hemiplegia • Ease of handling – GMFCS level 5 dressing upper garments • Improve tolerance of splint • Function Cosmetic 15 year old boy with hemiplegia GMFCS level 1; teased at school because of associated reactions causing arm to flex on effort • Pre-Assessment – None • Treatment – 50U each to brachialis and brachioradialis • Post-Assessment – Subjectively ROM increased but forearm very pronated; less marked associated reactions on walking – Teenager happy with outcome • Future – Visual analogue scale – ROM Ease of Handling 7 year old boy with dystonic athetosis GMFCS level 5; post hip surgery with gross asymmetry • Pre-Assessment – CPUP for lower limbs – Subjective upper limbs • Treatment – 50U bilateral pectorals • Post-Assessment – Ease of all areas of ADL – Improved alignment • Now use Care and Comfort Questionnaire Maintain Range of Movement 14 year old boy with spastic quadriplegia GMFCS 5; wants to maintain range of movement at his wrists for accessing computer and wheelchair • Pre-Assessment – Comprehensive ROM upper limb • Treatment – 25U very specific treatment using US guidance • Post-Assessment – All joints improved ROM – Improved access to playstation Improve Function 12 year old girl with athetoid hemiplegia dystonia GMFCS level 1; had treatment with no assessment with excellent outcomes • Pre-Assessment – Comprehensive ROM • Treatment – – – – – Brachialis due to -4° elbow extension 25U Pronator Teres due to ¾ range 25U FDP 2 sites due to flexion fingers 30U FDS 2 sites 30U Thenar eminence due to thumb adduction 10U BUT • Post-Assessment – Full ROM all joints – Unable to use hand functionally • Fixing hair • Closing car door – Lost natural swing of arm for walking and running Summary • BTX-A is a useful adjunct to therapy – Can ease management for families of more severely impaired children – Can reduce pain (calf muscles, back, splints) – Can improve function BUT • Needs to be linked to OT assessment and treatment