Wang Ying-Hong, Department of Pediatrics, The First Affiliated Hospital of Henan College of Traditional Chinese Medicine, Zhengzhou City, Henan Province 450003, China
Abstract
Objective: To observe the therapeutic effect of botulinum toxin type A (BTXA) injection guided by electrical stimulation localization combined with rehabilitation therapy on spastic cerebral palsy. METHODS: Twenty-seven children with spastic cerebral palsy underwent electrical stimulation localization-guided botulinum toxin type A injection and rehabilitation therapy after 3 d. The changes in muscle tone, passive joint range of motion, motor function, posture and gait of the lower limb muscle groups of the children before, two weeks and seven months after BTXA injection were evaluated. RESULTS: Two weeks and 7 months after BTXA injection, the muscle tone of the lower limbs of the children was significantly lower than before the injection, and there was a significant difference (P < 0.01); joint mobility was significantly greater two weeks and seven months after BTXA injection than before the injection, and there was a significant difference (P < 0.01) between before and after the injection; motor function, posture and gait were significantly better than before the BTXA injection. Conclusion: BTXA injection and subsequent rehabilitation therapy significantly reduced lower limb muscle tone, increased lower limb joint mobility, significantly improved motor function, and improved posture and gait in children with spastic cerebral palsy. Wang Yinghong, Department of Pediatrics, The First Affiliated Hospital of Henan College of Traditional Chinese Medicine
Keywords: botulinum toxin type A; electrical stimulation; rehabilitation therapy; cerebral palsy
Effects of botulinum toxin A injection guided by electric stimulation combined with rehabilitation therapy for treatment of spastic cerebral palsy
Ying-Hong Wang Department of Pediatrics, the First Affiliated Hospital, Henan College of Traditional Chinese Medical, Zhengzhou 450003, China
Abstract
AIM: To observe the combined effect of botulinum toxin A (BTXA) injection and rehabilitation therapy on spastic cerebral palsy.
METHODS: A total number of 27 cases of spastic cerebral palsy received combination treatment of BTXA injection and rehabilitation therapy at 3 days after The clinical evaluation which included the range of passive movement and the muscle tone of the lower limbs, the motor function, the sitting, The clinical evaluation which included the range of passive movement and the muscle tone of the lower limbs, the motor function, the sitting, kneeling, standing and walking posture was done before injection and 2 weeks as well as 7 months after the combination treatment.
RESULTS: All the children showed a decrease of the muscle tone in the lower limbs and the improvement of passive movement after the combination treatment of BTXA injection and rehabilitation therapy. All the children showed a decrease of the muscle tone in the lower limbs and the improvement of passive movement after the combination treatment of BTXA injection and rehabilitation therapy at 2 weeks and 7 months than that of before combination treatment (P2cm.
Rehabilitation therapy: The children were hospitalized in our hospital before BTXA injection and treated by a full-time rehabilitation therapist for 2 weeks, and then evaluated to decide to proceed with Botox injection according to the response to treatment, and continued rehabilitation therapy on the third day after injection without abnormal reaction. The rehabilitation treatment emphasizes the combination of Chinese and Western medicine, with Chinese massage, herbal fumigation or fumigation combined with functional training. Rehabilitation engineering: The patient will be evaluated again 1-2 weeks after the injection to decide whether orthotic devices are needed.
Fourth, the efficacy assessment method: We performed muscle tone, passive joint mobility, motor function and clinical gait analysis on the children before, two weeks after and 7 months after the application of BTXA to understand the changes. Assessment of changes in muscle tone: The modified Ashworth scale [2 ] was used to determine the changes in muscle tone of spastic muscles. Measurement of joint mobility: The angles of passive joint movement, including the hip adductor angle, N-fossa angle, and foot dorsiflexion angle, were measured with a joint goniometer. Observation of motor function and clinical gait analysis: visual observation of sitting, kneeling, crawling, standing (independent, single or/and two-handed support), walking status, thigh inversion; hip flexion and knee flexion; knee hyperextension; horseshoe foot and pointed foot gait, etc.
V. Statistical treatment: Data were expressed as X±S, and SPSS11.0 statistical software was applied to process the data, and LSD-t test was used. Differences were considered significant at P < 0.05.
Results
I. Efficacy The effect of BTXA started 2-3 days after injection, and the effect reached its peak in 2 weeks. No significant side effects occurred in the children, and only 6 children had mild pain at the injection site. Only 6 children had mild pain at the injection site. 26 cases had complete rehabilitation and follow-up data, and the shortest follow-up time was 6 months and the longest was 12 months, and no re-elevation of muscle tone occurred.
The changes in muscle tone of the internal femoral retractor, N cord and gastrocnemius muscles after BTXA injection are shown in Table 1.
Table 1 Changes on muscle tone before and after application of BTXA and after rehabilitation training (n=26) (X±S)
Muscle tone (level)
LSD
Before medication After medication (2 weeks) After rehabilitation (7 months)
Before and after medication Before medication and after rehabilitation After medication and after rehabilitation
Intrafemoral adductor muscle
N cord muscle
Gastrocnemius muscle
2.9±0.4 1.4±0.3 1.3±0.2
3.1±0.2 1.6±0.2 1.5±0.1
3.0±0.3 1.5±0.2 1.4±0.2
1.493 1.643 0.17*
1.500 1.540 0.40
1.505 1.625 0.120
P
＜0.01 ＜0.01
*P＜0.05
III. Changes in passive joint mobility See Table 2.
Table 2 Changes in joint mobility before and after application of BTXA and after rehabilitation training (n=26) (X±S)
Passive joint mobility (degree)
LSD
Before medication After medication (2 weeks) After rehabilitation (7 months)
Before and after medication Before medication and after rehabilitation After medication and after rehabilitation
Adductor angle
N-fossa angle
Dorsiflexion angle of foot
54.9±9.2 101.0±8.3 107.8±8.1
96.1±5.8 135.4±7.4 139.3±5.6
100.0±6.7 74.6±4.1 71.2±3.3
-46.10 -52.95 -6.85＊
-39.35 -43.25 -3.9
25.45 28.80 3.35*
P ＜0.01 ＜0.01
* P < 0.05
IV. Changes in posture and gait
Fourteen of the 27 cases had obvious flexion of both knees in sitting position before BTXA injection, forward tilt of trunk, arching back in long sitting, and easy to fall backwards. all of them improved significantly after BTXA injection, and the sitting posture improved further after rehabilitation training. one case of spastic quadriplegia recovered slightly, but it was easy to care for. Eight cases could not crawl before BTXA injection or had joint hip movement and uncoordinated posture when crawling. 6 cases could crawl after BTXA injection, and all 8 cases could crawl after rehabilitation training, and their posture was more coordinated than before. Before BTXA injection, 8 cases could not kneel straight, but after injection and rehabilitation training, 6 cases could kneel straight, and 3 cases had reduced posterior pelvic tilt when kneeling straight. Before the injection of BTXA, 10 cases were unable to stand with pointed feet, crossed feet, hip retrusion and knee retroflexion, but after the injection and rehabilitation training, 3 cases could stand alone, 5 cases could stand with one hand and 2 cases could stand with both hands. Before BTXA injection, 8 cases could not walk, and after injection and rehabilitation training, 6 cases could walk with support. 9 cases could walk independently before BTXA injection, but had abnormal postures such as heel off the ground and toe inversion and internal rotation, and after injection and rehabilitation training, 8 cases walked with a wider stride than before surgery, with heel on the ground and no cross-step, and abnormal postures such as toe inversion and internal rotation during walking were significantly improved.
Discussion
BTXA is used in children and adults with localized spasticity and tone abnormalities to reduce muscle tone and improve function, but the effects of BTXA in children are different from those in adults. Children undergo two stages of growth and development unique to children based on hypertonia. The effect of spasticity on growth is to cause disproportionate muscle and long bone growth, with rapid bone growth and slow muscle growth, and shortened muscles affecting joint mobility and soft tissue contracture deformities. bTXA injection therapy reduces muscle spasticity so that the shortening and deformities it causes are reduced, synchronizing muscle and bone growth rates. in addition to the effect of BTXA on growth, it alters selective motor control after it has affected motor skill acquisition (e.g., walking) also has a significant impact. Although BTXA addresses high muscle tone first, changes in tone can affect a child’s balance, strength, and motor control, as can poor alignment, fixation contractures, and functional impairment. If the gastrocnemius disorder is hypertonic, it can prevent the contraction of its antagonist tibialis anterior muscle and its development in normal gait. A gait analysis study found that gastrocnemius injection of BTXA resulted in activation of tibialis anterior muscle action, improved standing position of the foot, preparatory posture of the foot and toe-off function, and better motor control was achieved. Meanwhile, because children with spastic cerebral palsy often use spasticity to move, have joint reactions, no or little movement in the affected area, small movement amplitude and repetitive movement in spastic patterns, this aggravates spasticity on the one hand and makes children with cerebral palsy move under a fixed pattern and lack the experience of normal movement patterns on the other. By BTXA injection, the children get a new motor experience without the influence of hypertonia, and the new motor experience modifies the motor output and prospective system and promotes the children to establish normal motor patterns.
In this group, there were different degrees of reduction in muscle tone after BTXA injection, but not to normal, mainly because the amount of BTXA injection is decided according to the size of the target muscle volume and the degree of spasticity, plus the effect of the drug has some individual differences, so it is difficult to decide the exact dose for each muscle group in clinical practice. In our group, after BTXA injection, the spasticity of the children was significantly reduced, muscle tone was significantly lower than before, abnormal posture was significantly corrected, and their active motor ability was improved.
The effect of BTXA usually appears a few days after injection and can be maintained for 3-6 months. At this time, individualized comprehensive treatment, such as functional muscle training, soft tissue pulling, wearing a brace, etc., should be carried out in time to make full use of the rehabilitation opportunities brought by the reduction of muscle tone. The spasticity will rise again 4-6 months after injection, but neither the degree of spasticity nor the motor ability will return to the pre-injection level, and can be reinjected if necessary [2,3 ]. We observed that the effect of BTXA was generally evident 3 days after injection and reached its peak at 2 weeks, and we intentionally chose to follow up at 7 months after BTXA injection when the effect of BTXA might be lost. There was no re-increase in spasticity and no re-decrease in motor ability at 9 and 12 months follow-up, which is consistent with the above report. Our good results are related to our focus on rehabilitation training after BTXA injection. Based on the fact that motor training is highly specific and functional reorganization of the brain is dependent on the repetition of specific practical skills, functional training should be performed in the form of specific movements in life, e.g., sitting to standing is a closed-chain movement of the lower limb, and treatment should be directed to this skill or other forms of movement with the same mechanical characteristics [4,5], and 6 treatment should be standardized and specialized, otherwise there is a risk of reinforcing or exacerbating the abnormal pattern [ 6]. We are a professional rehabilitation therapist who conducts comprehensive rehabilitation treatment after the patient is evaluated by a treatment team including rehabilitation physicians and orthopedists. In the rehabilitation treatment, we use a combination of Chinese and Western medicine, emphasizing the importance of Chinese medicine treatment, such as Tui-Na massage, following the meridians and pushing and pressing to unblock the meridians, run the qi and blood, balance the yin and yang, and point rubbing, which can loosen the contracted muscles and muscle health, improve tissue blood circulation, increase local blood flow, promote blood circulation, reduce muscle tension and improve muscle strength; combined with Chinese medicine fumigation or fumigation, the external use of Chinese medicine to activate blood circulation and fumigation of In addition, we will combine Chinese herbal medicine fumigation or fumigation to reduce muscle tension and reduce contracture with functional training, and emphasize the importance of active movement in functional training. In the absence of active movement, passive movement training can be used, requiring passive movement of both lower limbs from three days after BTXA injection, encouraging active muscle movement and joint activity, giving full play to the subjective initiative of the child and parents, while neuromuscular electrical stimulation and various easy-to-use techniques to induce active movement, once active movement appears, active movement training should be the main focus. And pay attention to repeated reinforcement training. The brain plasticity study proved that the functional reorganization of the brain depends on the repeated reinforcement of task-oriented training [7,8,9 ]. The muscle tone adjustment is accompanied by attention to the necessary muscle strength training and physical training [ 10]. Since not only abnormal muscle tone but also decreased muscle strength can occur after CNS injury, we especially strengthen the muscle strength training of weight-bearing muscles and spastic muscle antagonists, mainly gluteus maximus, quadriceps and triceps.
The current treatment of cerebral palsy emphasizes multi-system analysis and problem solving. Starting from a multisystemic approach, various influencing factors are corrected in a targeted manner to bring movements to or near normal mechanical alignment, because movements with correct biomechanical alignment are efficient and low energy consuming [ 10 ].The application of orthoses and auxiliary supports after BTXA injection helps children to have better biomechanical alignment, which enables more effective muscle activation, increases the range of motion available, and promotes normal movement, and we We give various suitable orthoses to children within 1 week to 2 weeks after BTXA injection according to their condition to further assist in controlling muscle spasm and deformities that are not fully relieved after BTXA injection, limiting abnormal joint movements, improving stability, maintaining muscle length, and assisting in improving motor function. For example, BTXA injections for children with triceps spasticity are equipped with hinged ankle-foot orthoses to activate the anterior tibial muscles and give the child a normal walking experience, and fixed ankle-foot orthoses for arch and ankle deformities, thus assisting in improving treatment outcomes.
The key to the success of BTXA treatment lies on the one hand in the selection of the child and the determination of the treatment goals [ 3 ]. The importance of early treatment is emphasized by the fact that older children respond less well to BTXA than younger children and have a shorter duration of efficacy [11]. We have achieved good results in the selection of children, who are generally between 1 and 5 years old and respond well to BTXA. On the other hand, we performed BTXA injection under the guidance of EMG, which can accurately inject BTXA into the motor point, i.e., the neuromuscular junction, so that the spasm relieving effect of BTXA can be well utilized. This can improve the efficacy while reducing the incidence of clinical side effects. This is consistent with the foreign literature report Chin et al [12] who concluded that electrical stimulation localization technique was effective after analyzing 266 cases of limb spasticity in children with cerebral palsy treated with BTXA injections.
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