Ilse Jonkers

Botulinum toxin type A treatment of cerebral palsy: an integrated approach

We have applied a multilevel approach to the management of spasticity associated with cerebral palsy (CP). All of the following factors are important in forming an integrated strategy for botulinum toxin type A (BTX‐A) therapy: the timing of injections, patient selection, multilevel BTX‐A treatment, optimal dosage and injection technique, follow‐up treatment and objective measurements of functional outcome. Data on all these factors are presented here. CP patients had a mean age of 6.5 years (n = 315), and the dose of BTX‐A (BOTOX®) ranged from 2 to 29 U/kg body weight (n= 156). The combination of muscles injected in our multilevel approach differed for patients with diplegia, hemiplegia and quadriplegia: patients with hemiplegia received injections in the gastrocnemius and medial hamstrings; this combination was extended to the adductors for patients with diplegia and quadriplegia (n= 156). For patients with quadriplegia, muscles in a three‐level (gastrocnemius, medial hamstrings, adductors and iliopsoas) or two‐level (excluding the gastrocnemius) combination were also frequently injected. The duration of effect of BTX‐A treatment was mainly determined by follow‐up treatment consisting of: serial casting, day and night orthoses and physiotherapy. No major side effects of BTX‐A were reported. This integrated approach appears to prolong the duration of BTX‐A treatment, resulting in a duration of about 1 year between injections.

A multilevel approach to botulinum toxin type A treatment of the (ilio)psoas in spasticity in cerebral palsy

In spasticity, flexion deformity of the hip is frequently associated with contracture or hyper‐reflexia of the psoas muscle. Botulinum toxin type A (BTX‐A) has been used for some considerable time in the management of paediatric gait disorders. We have been using a multilevel approach to manage spasticity in cerebral palsy for several years, the combination of gait analysis and clinical evaluation being important for the selection of target muscles for BTX‐A injections. Twenty cerebral palsy children (12 female) with spasticity were treated with BTX‐A injections (BOTOX® mean dose, 2 U/kg body weight) into the psoas muscle. Patients were monitored using range of motion measurements of maximal hip extension, clinical estimates of hypertonia in the hip flexors, gait analysis (three‐dimensional kinematics and kinetics) and surface electromyography of major lower limb muscles. Full gait analysis was carried out on 12 of the patients. Significant clinical improvements were observed following 15 of the 21 psoas treatments. Furthermore, the kinematics results of gait analysis showed improvement in one or more parameters in nine of the 12 patients. In conclusion, we have demonstrated the value of a multilevel approach to BTX‐A treatment in the management of spasticity in children with cerebral palsy.