Barry Rawicki

Botulinum toxin assessment, intervention and after-care for upper limb hypertonicity in adults: international consensus statement

Upper limb spasticity affecting elbow, wrist, and finger flexors can be safely and effectively reduced with injections of botulinum toxin type‐A (BoNT‐A). It has been best studied in adults in the context of post‐stroke spasticity. The clinical benefits include reduction in pain and deformity, improvement in washing and dressing the upper limb, and a reduction in caregiver burden (Class I evidence, recommendation level A). Some patients show improvement in function performed by active movement of the affected upper limb (Class III evidence, recommendation C), but predicting and measuring this is difficult, and further research is needed. An individually based approach to treatment and outcome measurement is preferred (Class IV, recommendation U). More research is needed to resolve many unknown issues of assessment and treatment, using research methods appropriate to the question.

Functional outcome following Botulinum toxin A injection to reduce spastic equinus in adults with traumatic brain injury

Primary objective: The aim of this study was to assess the effect of Botulinum toxin A in the management of spastic equinus resulting from traumatic brain injury. Research design: A before–after intervention design was used without controls. Methods and procedures: Subjects were seven patients suffering from traumatic brain injury of average duration 14 (4–38) months as a result of motor vehicle trauma, who had spastic equinus interfering with gait. Experimental intervention: The patients were treated with injections of Botulinum toxin A into the spastic calf muscles: gastrocnemius, soleus and tibialis posterior. Assessments were made pre-injection and at 2 weeks and 3 months post-injection. Main outcome and results: At the end of the 3-month period, all patients showed a significant improvement in gait velocity, cadence and stride length. Conclusions: The findings suggest that Botulinum toxin A may be useful in the management of spastic equinus following traumatic brain injury.

Australian Cerebral Palsy Child Study Protocol of a prospective population based study of motor and brain development of preschool aged children with cerebral palsy

BackgroundCerebral palsy (CP) results from a static brain lesion during pregnancy or early life and remains the most common cause of physical disability in children (1 in 500). While the brain lesion is static, the physical manifestations and medical issues may progress resulting in altered motor patterns. To date, there are no prospective longitudinal studies of CP that follow a birth cohort to track early gross and fine motor development and use Magnetic Resonance Imaging (MRI) to determine the anatomical pattern and likely timing of the brain lesion. Existing studies do not consider treatment costs and outcomes. This study aims to determine the pathway(s) to motor outcome from diagnosis at 18 months corrected age (c.a.) to outcome at 5 years in relation to the nature of the brain lesion (using structural MRI).MethodsThis prospective cohort study aims to recruit a total of 240 children diagnosed with CP born in Victoria (birth years 2004 and 2005) and Queensland (birth years 2006–2009). Children can enter the study at any time between 18 months to 5 years of age and will be assessed at 18, 24, 30, 36, 48 and 60 months c.a. Outcomes include gross motor function (GMFM-66 & GMFM-88), Gross Motor Function Classification System (GMFCS); musculoskeletal development (hip displacement, spasticity, muscle contracture), upper limb function (Manual Ability Classification System), communication difficulties using Communication and Symbolic Behaviour Scales-Developmental Profile (CSBS-DP), participation using the Paediatric Evaluation of Disability Inventory (PEDI), parent reported quality of life and classification of medical and allied health resource use and determination of the aetiology of CP using clinical evaluation combined with MRI. The relationship between the pathways to motor outcome and the nature of the brain lesion will be analysed using multiple methods including non-linear modelling, multilevel mixed-effects models and generalised estimating equations.DiscussionThis protocol describes a large population-based study of early motor development and brain structure in a representative sample of preschool aged children with CP, using direct clinical assessment. The results of this study will be published in peer reviewed journals and presented at relevant international conferences.Trial registrationAustralia and New Zealand Clinical Trials Register (ACTRN1261200169820)

The Relationship between Motor Abilities and Early Social Development in a Preschool Cohort of Children with Cerebral Palsy.

AIM To investigate the relationship between motor ability and early social development in a cohort of preschool children with cerebral palsy (CP). DESIGN Population-based cohort study. METHODS Participants were 122 children with CP assessed at 18, 24 and 30 months, corrected age (ca). Motor ability was measured by the Gross Motor Function Classification System (GMFCS) with classification assigned by physiotherapists. The sample was representative of a population-based cohort (I=48, 38.4%, II=19, 15.2%, III=17, 13.6%, IV=22, 17.6% and V=19, 15.2%). Social development was measured by the Paediatric Evaluation of Disability Inventory (PEDI) and included capabilities in social interaction, social communication, interactive play and household/community tasks. RESULTS Cross-sectional analyses indicated a significant relationship between motor ability and social development at 18 months, F(4, 56)=11.44, p<.0001, η(2)=.45, at 24 months, F(4, 79)=15.66, p<.0001, η(2)=.44 and at 30 months, F(4, 76)=16.06, p<.0001, η(2)=.49. A longitudinal analysis with a subset of children (N=24) indicated a significant interaction between age at assessment and GMFCS, F(2, 21)=7.02, p=.005, η(2)=.40. Comparison with community norms indicated that at 18 months corrected age, 44.3% of the cohort was greater than two standard deviations below the mean (>2SD) for social development and a further 27.9% of the cohort was greater than one standard deviation below the mean (>1SD). INTERPRETATION There is a relationship between motor ability and social development in preschool children with CP. Children with CP may require support for social development in additional to physical interventions, from as early as 18 months.

Rehabilitation Therapies After Botulinum Toxin-A Injection to Manage Limb Spasticity: A Systematic Review

Background Botulinum toxin A (BoNT-A) injections are increasingly used to treat muscle spasticity and are often complemented by adjunctive rehabilitation therapies; however, little is known about the effect of therapy after injection. Purpose The aim of this study was to identify and summarize evidence on rehabilitation therapies used after BoNT-A injections to improve motor function in adults with neurological impairments. Data Sources Searches were conducted in PubMed, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL, National Research Register, metaRegistry of Controlled Trials, PEDro, and OTseeker. Study Selection Randomized and quasi-randomized controlled trials were considered for inclusion. Participants with neurological impairments received BoNT-A to treat focal spasticity in limbs, with rehabilitation interventions provided to experimental groups only. Primary outcome measures were joint mobility, function of the affected limb, and spasticity. Eleven studies with 234 participants, most of whom had stroke, were included in the review. Data Extraction Two reviewers extracted study details and data. Data Synthesis Methodological quality was rated using the PEDro scale. Both fixed-effects and random-effects models were used to calculate effect size. Results Studies were of variable quality: 3 were poor (PEDro score 1 to 4), and 8 were moderate (PEDro score 6 to 7). No study investigated effects for longer than 24 weeks (6 months). Included trials presented 9 therapy types, including ergometer cycling, electrical stimulation, stretch (casting, splinting, taping, or manual or exercise-induced stretch), constraint-induced movement therapy, task-specific motor training, and exercise programs. Statistical findings suggest that combined therapy and BoNT-A is slightly more effective than BoNT-A alone. Conclusion Evidence relating to impact of adjunct therapy is available, but the heterogeneity of studies limits the opportunity to demonstrate overall impact. Researchers need to consider the benefits of greater consistency in study approaches and measures so that meaningful evaluations of overall adjunct therapy effects can be made.

Injection frequency of botulinum toxin A for spastic equinus: a randomized clinical trial.

We compared two botulinum toxin A (BoNT‐A) injection frequency regimens, 12‐monthly versus 4‐monthly, for spastic equinus in a randomized clinical trial. The primary outcome measure was passive ankle dorsiflexion.

Do external stimuli impact the gait of children with idiopathic toe walking? A study protocol for a within-subject randomised control trial

Introduction Frequently, toe walking gait is the result of disease processes, trauma or neurogenic influences. Idiopathic toe walking (ITW) is, by definition, the diagnosis of a toe walking gait adopted in the absence of one of these medical conditions. Long-term ITW has been associated with reduced ankle range of motion. Reported treatments have included serial casting, Botulinum toxin type A or surgery to improve the ankle range of motion. Investigating the impact of simple and non-invasive treatment options for ITW is important for future research and clinical outcomes. This study investigates the immediate impact of footwear, footwear with orthotics and whole body vibration on ITW to determine if any one intervention improves heel contact and spatial-temporal gait measures. This determination is important for future clinical trials into treatment effectiveness. Methods and analysis Design: this protocol describes a within-subject randomised controlled trial that measures changes in gait following changes in external stimuli. Participants: 15 children diagnosed with an ITW gait will be recruited from the Victorian Paediatric Rehabilitation Service at Monash Childrens Hospital Toe Walking Clinic provided they have ITW and meet the inclusion criteria. Procedure: participants will have their gait recorded walking barefoot, in usual footwear, a custom-made, full-length carbon fibre orthotic in usual footwear and following whole body vibration. Outcome measures will include the presence of bilateral heel contact preintervention and postintervention, stride length (cm), stride width (cm), left and right stride time (s), left and right stance and swing percentage of the gait cycle, gait velocity (m/s), left and right foot toe in/toe out angle (°) and weight-bearing lunge pre and post each condition. Ethics and dissemination The results of this study will be published at the conclusion and have been approved by Southern Health HREC:12102B. Clinical trial registry number ACTRN12612000975897.

Tertiary paediatric hospital admissions in children and young people with cerebral palsy

BACKGROUND Many previous studies that have investigated hospital admissions in children and young people with cerebral palsy lack information on cerebral palsy severity and complexity. Consequently, little is known about factors associated with the frequency and type of hospital admissions in this population. This study used hospital admission data available for all children and young people known to a population-based cerebral palsy register to describe the patterns of use of tertiary paediatric hospital services over a 5-year period. METHODS This was a retrospective cohort analysis of routinely collected admission data from the two tertiary paediatric hospitals in the Australian state of Victoria. Data on admissions of individuals born between 1993 and 2008 registered on the Victorian Cerebral Palsy Register were analysed (n = 2183). RESULTS Between 2008 and 2012, 53% of the cohort (n = 1160) had at least one same-day admission, and 46% (n = 996) had one or more multi-day admissions. Those with a moderate to severe motor impairment and those with a co-diagnosis of epilepsy had more admissions, and for multi-day admissions, longer lengths of stay, P < 0.05. Across all severity levels, respiratory and musculoskeletal diseases were the most frequently reported reasons for medical and surgical admissions, respectively. All-cause readmission rates for urgent multi-day stays within 7, 30 and 365 days of an index admission were 10%, 23% and 63%, respectively. CONCLUSIONS The reasons for hospital admissions reported here reflect the range of comorbidities experienced by children and young people with cerebral palsy. This study highlights priority areas for prevention, early diagnosis and medical management in this group. Improved primary and secondary prevention measures may decrease non-elective hospital admissions and readmissions in this group and reduce paediatric inpatient resource use and healthcare expenditure attributable to cerebral palsy.

Does early communication mediate the relationship between motor ability and social function in children with cerebral palsy

BACKGROUND Children diagnosed with neurodevelopmental conditions such as cerebral palsy (CP) are at risk of experiencing restrictions in social activities negatively impacting their subsequent social functioning. Research has identified motor and communication ability as being unique determinants of social function capabilities in children with CP, to date, no research has investigated whether communication is a mediator of the relationship between motor ability and social functioning. AIMS To investigate whether early communication ability at 24 months corrected age (ca.) mediates the relationship between early motor ability at 24 months ca. and later social development at 60 months ca. in a cohort of children diagnosed with cerebral palsy (CP). METHOD A cohort of 71 children (43 male) diagnosed with CP (GMFCS I=24, 33.8%, II=9, 12.7%, III=12, 16.9%, IV=10, 14.1%, V=16, 22.5%) were assessed at 24 and 60 months ca. Assessments included the Gross Motor Function Measure (GMFM), the Communication and Symbolic Behaviour Scales-Developmental Profile (CSBS-DP) Infant-Toddler Checklist and the Paediatric Evaluation of Disability Inventory (PEDI). A mediation model was examined using bootstrapping. RESULTS Early communication skills mediated the relationship between early motor abilities and later social functioning, b=0.24 (95% CI=0.08-0.43 and the mediation model was significant, F (2, 68)=32.77, p<0.001, R(2)=0.49. CONCLUSIONS AND IMPLICATION Early communication ability partially mediates the relationship between early motor ability and later social function in children with CP. This demonstrates the important role of early communication in ongoing social development. Early identification of communication delay and enriched language exposure is crucial in this population.

Tertiary paediatric emergency department use in children and young people with cerebral palsy

The aim of this study was to describe the pattern of tertiary paediatric emergency department (ED) use in children and young people with cerebral palsy (CP).