Effects of early spasticity treatment on children with hemiplegic cerebral palsy: a preliminary study

Zonta, Marise Bueno; Bruck, Isac; Puppi, Marilene; Muzzolon, Sandra; Neto, Arnolfo de Carvalho; Santos, Lúcia Helena Coutinho dos

doi:10.1590/0004-282X20130061

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Articles • Arq. Neuro-Psiquiatr. 71 (7) • July 2013 • https://doi.org/10.1590/0004-282X20130061 copy

Effects of early spasticity treatment on children with hemiplegic cerebral palsy: a preliminary study

Efeitos do tratamento precoce da espasticidade em crianças com paralisia cerebral hemiplégica: um estudo preliminar

Authorship SCIMAGO INSTITUTIONS RANKINGS

Objective

To compare motor and functional performance of two groups of children with hemiplegic cerebral palsy (HCP). Only the study group (SG) received early treatment of spasticity with botulinum neurotoxin type A (BXT-A).

Methods

Gross Motor Function Measure (GMFM), functional performance (Pediatric Evaluation of Disability Inventory - PEDI), range of movement, gait pattern (Physician Rating Scale - PRS) and the speed of hand movements were considered.

Results

The SG, composed of 11 HCP (45.64±6.3 months), was assessed in relation to the comparison group, composed of 13 HCP (45.92±6.4 months). SG showed higher scores in four of the five GMFM dimensions, which included scores that were statistically significant for dimension B, and higher scores in five of the six areas evaluated in the PEDI. Active wrist extension, the speed of hand movements and PRS score were higher in the SG.

Conclusion

Children who received early BXT-A treatment for spasticity showed higher scores in motor and functional performance.

child; botulinum toxins; type A; cerebral palsy; hemiplegia

	P	G	Age	Invol Side	Advers events	Epilepsia	Age walking	Wrist extention	Hemineglect	GMFCS	GMFM	Motor curve	Self-care	Mobility	Neuroimage
Study group	1	M	41	L	No	Yes	24	30	No	I	81%	5%↓Med	23%↓	16%↓	1
	2	M	41	L	Yes	Yes	24	20	No	I	94.1%	Med	5% ↓	15%↓	1
	3	M	41	R	Yes	No	32	-30	Yes	II	58.5%	10%↓-	16%↓	9%↓	4
	4	M	55	R	Yes	No	23	0	No	I	98.3%	2%↑+2 SD	6%↓	7%↓	2
	5	F	48	R	Yes	No	13	30	Yes	I	93.8%	Med	11%↓	7%↓	2
	6	M	53	L	Yes	No	18	10	Yes	I	97%	1%↑+2 SD	17%↓	5%↓	3
	7	M	45	L	Yes	No	19	45	No	I	94.7%	5%↑Med	1%↑	5%↓	2
	8	M	55	L	No	No	17	90	No	I	93.2%	5%↑Med	6%↓	13%↓	5
	9	M	46	L	Yes	No	18	90	No	I	95%	2%↑+2 SD	3 %↑	5%↓	3
	10	F	38	L	Yes	No	18	30	Yes	I	92%	5%↑Med	9%↓	3%↓	2
	11	F	39	L	Yes	Yes	20	60	No	I	93%	5%↑Med	23%↓	6%↓	1
Comparison group	1	M	40	L	Yes	No	20	10	No	I	92.5%	5%↑Med	11%↓	1%↑	3
	2	M	39	L	No	No	15	10	No	II	92%	1%↑+2 SD	13%↓	1%↓	2
	3	M	51	L	No	No	48	10	#	I	53%	17%↓-2 SD	13%↓	37%↓	4
	4	M	41	R	No	No	24	10	No	I	90.3%	1%↑Med	36%↓	23%↓	2
	5	F	39	R	No	No	20	45	No	I	93%	5%↑Med	26%↓	11%↓	1
	6	M	45	R	Yes	No	12	-30	Yes	I	86%	Med	12%↓	10%↓	2
	7	M	53	R	Yes	No	30	90	No	I	96%	1%↑Med	10%↓	14%↓	2
	8	M	46	R	Yes	No	30	-60	Yes	I	72%	8%↓-2 SD	18%↓	2%↓	3
	9	M	41	R	Yes	No	16	20	No	I	85.6%	3%↓Med	10%↓	8%↓	1
	10	M	58	R	No	No	14	70	Yes	I	95.6%	Med	10%↓	6%↓	1
	11	F	50	L	Yes	No	36	10	#	I	80.2%	1%↓-2 SD	5%↓	20%↓	4
	12	M	41	R	No	No	12	30	Yes	I	95%	7%↑Med	33%↓	12%↓	1
	13	M	53	L	Yes	No	13	0	No	I	96%	Med	3%↓	9%↓	2

Age (n=11)	BXT-A dose and distribution
Age (n=11)	Dose per kg	Number of sessions (n=41)
Up to 12 months	10.98	12
Between 13 and 24 months	11.89	16
Between 25 and 36 months	14.07	8
Between 37 and 48 months	11.81	4
Above 49 months	15.2	1

Frequency of muscles injections/session	Muscles injected	Percentage
Upper limb	PM	84%
	BR	87%
	PT	87%
	FDS	84%
	FPB	76%
	AP	76%
Lower limb	GA	97%
	Soleus	82%
	Adductors	29%
	Medial HA	24%

Initial and final muscle tonus evaluation (Aswhorth scale)
Patient	1		2		3		4		5		6		7		8		9		10		11
Muscle	I	F	I	F	I	F	I	F	I	F	I	F	I	F	I	F	I	F	I	F	I	F
PM	2	2	2	1	1	3	2	1	2	2	3	2	2	1	2	1	2	2	2	2	1	1
BR	2	2	2	1	2	1	2	1	2	2	3	3	2	2	2	1	2	2	2	2	1	1
PT	2	2	2	1	1	2	2	3	1	1	2	1	3	2	2	1	2	2	2	2	2	1
FCR	1	1	1	1	2	3	2	3	2	2	3	2	2	2	1	1	2	1	1	2	1	1
FCU	1	1	1	1	2	3	2	3	2	2	2	2	2	2	1	1	2	1	1	2	1	1
FDS	2	2	2	1	3	3	2	3	2	2	2	2	2	2	2	1	2	1	2	2	2	1
FPB	2	1	2	1	1	1	2	3	1	2	2	1	2	2	2	1	2	1	2	1	2	1
AP	2	1	1	1	1	3	2	2	1	2	1	1	2	1	1	1	1	1	2	2	2	1
GA	2	1	2	1	2	2	2	2	3	2	3	4	2	4	1	1	2	2	2	2	1	2
AD	1	1	1	1	2	1	1	1	2	1	3	1	1	1	1	1	1	1	1	1	1	1
HA	1	1	1	1	3	1	2	2	3	1	3	1	1	1	1	1	1	1	1	1	1	1

Patient	Passive extension of the wrist		Active extension of the wrist
Patient	Initial	Final	Initial	Final
1	90	90	10	30
2	90	90	30	20
3	90	90	^* SD: standard deviation; GMFM: Gross Motor Function Measure; PEDI: Pediatric Evaluation Disability Inventory; FS: functional skills; CA: caregiver assistance; MDC: Motor Development Curve; PPFRC: Pediatric Physical Functioning Reference Curves.	-30
4	70	75	0	0
5	90	90	^* SD: standard deviation; GMFM: Gross Motor Function Measure; PEDI: Pediatric Evaluation Disability Inventory; FS: functional skills; CA: caregiver assistance; MDC: Motor Development Curve; PPFRC: Pediatric Physical Functioning Reference Curves.	30
6	90	90	^* SD: standard deviation; GMFM: Gross Motor Function Measure; PEDI: Pediatric Evaluation Disability Inventory; FS: functional skills; CA: caregiver assistance; MDC: Motor Development Curve; PPFRC: Pediatric Physical Functioning Reference Curves.	10
7	60	90	20	45
8	90	90	20	90
9	90	90	30	90
10	60	90	10	30
11	90	90	10	60

Patient	GMFCS	GMFM 1	GMFM 2	GMFM 3	GMFM 4	GMFM 5	GMFM 6
1	I		17%↓-2 SD	8%↓ MED	20%↓-2 SD	20%↓ MED	5%↓MED
2	I			8%↓ MED	2%↓-2 SD	1%↓ MED	MED
3	II	2%↓-2 SD	2%↓ MED	3%↓-2 SD	5%↓-2 SD	20%↓ MED	10%↓-2 SD
4	I		2%↑ MED	2%↑ MED	2%↑MED	2%↑+2 SD	2%↑+2 SD
5	I		8%↓ MED	3%↑ MED	MED	MED	MED
6	I	5%↑+2 SD	5%↑+2 SD	2%↑+2 SD	5%↑ MED	5%↑ MED	1%↑+2 SD
7	I		12%↓-2 SD	6%↓ MED	6%↓ MED	MED	5%↑ MED
8	I			8%↑ MED	2%↑ MED	1%↑ MED	5%↑ MED
9	I		20%↑+2 SD	8%↑+2 SD	8%↑ MED	2%↑+2 SD	2%↑+2 SD
10	I			1%↓ MED	5%↑ MED	MED	5%↑ MED
11	I		2%↓-2 SD	2%↑+2 SD	1%↑+2 SD	4%↑ MED	5%↑ MED

Variables	Study group			Comparison group			p-value
Variables	Mean	SD	Range	Mean	SD	Range	p-value
Age (months)
At evaluation	45.64	6.3	38-55	45.92	6.4	39-58	0.914
Signs of hemiplegia	4.36	1.43	2-6	6.5	4.8	1-16	0.566
Head control	5.36	1.86	3-9	5.5	3.23	3-12	0.566
Sitting control	9.18	2.4	6-12	10.36	5.32	6-24	0.949
Independent walking	20.55	5.03	13-32	22.31	10.96	12-48	0.820
Cognitive function
Performance	71.09	19.10	47-106	77	26.29	47-126	0.833
Verbal	82.55	15.80	52-105	88.92	30.16	48-152	0.740
Total	74.55	18.27	45-101	81.83	30.94	43-141	0.833
GMFM (%)
Dimension A	96	10	68.6-100	98	3	90-100	0.820
Dimension B	97	7	76.6-100	94	6	83.3-100	0.035
Dimension C	89	26	14.2-100	83	28	16.6-100	0.361
Dimension D	89	5	82-97.4	84	16	33.3-100	0.459
Dimension E	82	13	49-94	74	15	36.1-90.2	0.134
Total score	91	12	58.5-98.3	87	12	53-96	0.119
PEDI
FS normative score
Self-care	35.04	9,07	18-50	23.71	20,3	-10-41.4	0.277
Mobility	27.40	7.95	12.2-35.9	22.02	25,12	-10-56	0.608
Social function	27.13	15.88	-10-46.8	32.64	12.23	13.7-52	0.424
CA normative score
Self-care	43.92	14.24	23.3-68.6	31.25	21.32	-10-52	0,424
Mobility	39,95	13.70	12.7-58.8	33.28	19.17	-10-58.3	0,494
Social function	52.47	13.62	27.5-68.7	49.70	12.31	24-68.9	0,569
Distance MDC (cm)	0.64	6.31	-16-5	-2.15	8.91	-20-7	0.531
Distance in PPFRC
Self-care	9.09	7.71	-3-23	14.85	10.61	3-36	0.252
Mobility	8.27	4.43	3-36	11.69	10.28	-1-37	0.459
Range of moviment
Active wrist extension	34,09	36.25	-30-90	16,54	38.48	-60-90	0.228
Hand moviment velocity
Transfer of the ball (%)	49.53	23.14	22-100	43.20	23.49	10-95	0.566
Transfer of the rings (%)	50.49	24.16	22-100	50.04	12.45	35-77	0.740
Physician's Rating Scale	13	2	10-14	11.61	2.4	7-14	0.424

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[1] Correspondence: Marise Bueno Zonta; Rua Floriano Essenfelder 81; 80060-270 Curitiba PR - Brasil; E-mail: marisebzonta@gmail.com