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Efficacy of Botulinum Toxin A in Children With Cerebral Palsy in Gross Motor
Efficacy of Botulinum Toxin A in Children With Cerebral Palsy in Gross Motor
Efficacy of Botulinum Toxin A in Children With Cerebral Palsy in Gross Motor
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DEVELOPMENTAL MEDICINE & CHILD NEUROLOGY REVIEW
1 Kids Rehab Department, The Children's Hospital at Westmead, Westmead, NSW; 2 School of Science and Health, The University of Western Sydney, Penrith, NSW;.
3 Faculty of Medicine, University of New South Wales, NSW, Australia.
Correspondence to Dr Tamis Pin, School of Science and Health, The University of Western Sydney, Locked Bag 1797, Penrith, NSW 2751, Australia. E-mail: tamispin@hotmail.com
PUBLICATION DATA AIM Previous studies have shown the efficacy of botulinum toxin type A (BoNT-A) in the manage-
Accepted for publication 12th July 2012. ment of ambulant individuals with cerebral palsy (CP). There is little evidence on its use in non-
Published online 24th October 2012. ambulant children with CP. This review aimed to investigate indications and efficacy for BoNT-A
use in managing pain, care, and comfort, and improving function in children with CP in Gross
Motor Function Classification System (GMFCS) levels IV and V.
METHOD Electronic databases were searched from the earliest available date to June 2012 using a
combination of subject headings and free text. Inclusion criteria consisted of studies with (1) par-
ticipants aged 18 or under, (2) participants with CP in GMFCS levels IV and V, (3) participants
receiving BoNT-A treatment, and (4) studies published in English-language peer-reviewed jour-
nals.
RESULTS The search resulted in a total of 814 studies, of which 19 met the inclusion criteria.
Eighteen studies provided level IV or V evidence and one level I evidence according to the Ameri-
can Academy for Cerebral Palsy and Developmental Medicine guidelines for the development of
systematic reviews. Most of the studies were of weak to moderate methodological quality.
INTERPRETATION The evidence that BoNT-A is effective in reducing postoperative pain in children
with CP in GMCFS levels IV and V is limited, with only one level I study identified. Remaining indi-
cations were general pain reduction, maintaining hip integrity, achieving functional changes, and
goal attainment. A high percentage of participants in the studies showed positive changes in these
areas. With the poor level of evidence of the included studies, no definite conclusion could be
drawn on the indications for BoNT-A use in children with CP in GMCFS levels IV and V. Further
investigation by rigorous studies is required.
Cerebral palsy (CP) refers to a group of non-progressive The Gross Motor Function Classification System
movement and posture disorders resulting from injuries to the (GMFCS) has been shown to be a reliable method of classify-
developing fetal or infant brain.1 Owing to a diverse and multi- ing children with CP according to age-specific gross motor
factorial aetiology, CP is often accompanied by epilepsy, sec- function.7,8 It is an ordinal grading system of five levels (I–V),
ondary musculoskeletal abnormalities, and deficits in in which self-initiated movements, such as sitting, standing, or
sensation, cognition, behaviour, and communication.1 The walking, are described in relation to different age groups. Dis-
worldwide incidence of CP is 2 to 3 per 1000 live births, mak- tinctions between levels I to V are based on assessment of
ing it the most common cause of physical disability in child- functional abilities or limitations and reliance on assistive tech-
hood.2,3 Classifications of CP are usually based on nology (walking aids or wheeled mobility). Children of levels I
topographical distribution, functional motor abilities, and and II can generally walk without aids while children of level
types of muscle tone.4 III can walk with aids for short distances but usually choose
Topographical classification describes the distribution of wheeled mobility in community settings. Children at level IV
affected body parts. These include hemiplegia (unilateral dis- have limited motor ability in assisted standing, stepping, and
tribution), diplegia (bilateral involvement, usually the lower transfers. Children classified as level V are completely depen-
limbs more affected than the upper limbs), and quadriplegia dent on others for transportation in a wheelchair and lack
(involvement of all four limbs, the head and trunk).5 This clas- antigravity postural control.7,8
sification is commonly employed despite being of questionable Types of muscle tone are generally classified as spastic,
reliability and validity.1,6 dystonic ⁄ dyskinetic, ataxic, or mixed.2 Spasticity is a
304 DOI: 10.1111/j.1469-8749.2012.04438.x ª The Authors. Developmental Medicine & Child Neurology ª 2012 Mac Keith Press
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velocity-dependent increase in resistance of a muscle when the What this paper adds
muscle is moved passively or stretched.9 It is the most common • The majority of studies on the use BoNT-A for children with severe CP in
motor type, accounting for 70% to 80% of individuals with GMFCS levels IV and V were of poor methodological quality.
CP.10 Individuals with spastic CP experience stiffness in • Moderate evidence was shown to support the use of BoNT-A in reducing pain
affected limbs due to focal muscular hyperactivity, resulting in after hip adductor release surgery with one level I RCT.
• Clinical application of the evidence of benefits of BoNT-A is limited by the low
limited or awkward movements. Dystonia ⁄ dyskinesia, affecting quality of the studies.
10% to 20% of individuals with CP,10 is characterized by fluc-
tuating muscle tone, causing slow writhing and twisting move- of this review with information provided in the studies. Rele-
ments, repetitive movement, and ⁄ or abnormal postures.9 Ataxic vant data from studies with participants of mixed GMFCS lev-
CP is the least common form of CP, in which individuals have els would be included in this review if the results for
poor coordination and balance due to low muscle tone.2 participants in GMCFS levels IV and V could be separated.
Management of spasticity in CP involves multidisciplinary The same principle was applied to studies containing a mixed
intervention intended to increase functionality, sustain health, group of participants with a diagnosis of CP and other neuro-
and improve quality of life for individuals and their carers.11 logical disorders. All studies involving the use of BoNT-A to
This may include physiotherapy, occupational therapy, ortho- treat drooling were excluded, as the main focus of this review
ses, surgical interventions, and pharmacological agents such as was on the impact of BoNT-A on reducing pain, improving
botulinum toxins.12 Botulinum toxin type A (BoNT-A) is a ease of care and positioning, and improving the motor
serotype of botulinum toxin, produced by the Gram-positive function of the individuals.
bacterium Clostridium botulinum.13 This potent neurotoxin
selectively inhibits the release of acetylcholine from peripheral Search strategy
nerve terminals by binding to synaptic vesicles.12 Interruption The literature search was begun from the earliest date avail-
of neuromuscular conduction by BoNT-A induces a tempo- able in each database to June 2012 across the following data-
rary weakness, which reduces focal spasticity. The effects of bases: MEDLINE, EMBASE, CINAHL, and PsycINFO.
BoNT-A last for approximately 3 months as the muscle will The terms ‘cerebral palsy’, ‘spasticity’, ‘dystonia’, ‘Botulinum
recover via proximal axonal sprouting, the formation of new toxin A’, ‘Botox’, ‘BTX’, ‘BTA’, ‘BoNT’, ‘Dysport’, and
neuromuscular junctions, and the regeneration of the original ‘Myobloc’ were searched as subject headings and free text if
neuromuscular junctions.14,15 supported by the databases. Results were limited to studies
The efficacy of BoNT-A in the management of individuals involving humans aged 18 years or less and published in the
with CP has been widely reported in the literature. Several English language. The reference lists of relevant studies and
studies have proven its effectiveness in the treatment of spastic reviews were also searched for citation tracking and by hand.
equinus in ambulant children with CP (i.e. GMFCS levels The titles and abstracts of articles identified in the initial
I–III) with the aim of improving gait pattern.16,17 Use of search were screened against inclusion and exclusion criteria
BoNT-A to improve hand function has also been shown in separately by the first two authors (TP and JE). When in
children with less impairment.18,19 On the other hand, doubt, the full text of an article was read to determine its suit-
BoNT-A has been used in children with severe functional lim- ability. Any disagreement between the two authors was
itations (i.e. GMFCS levels IV and V), aimed at reducing pain resolved by consensus. No authors of excluded studies were
and improving ease in care and positioning.20,21 In our clinical approached to investigate if relevant data could be extracted.
experience, these are the main goals for the use of BoNT-A in
these more involved children. Nevertheless, the effectiveness Levels of evidence and quality assessment
of BoNT-A intervention in this group of children has not The level of evidence of each included study was graded
been thoroughly examined. The aim of this review was to according to the American Academy for Cerebral Palsy and
investigate whether BoNT-A has been used to treat children Developmental Medicine Treatment Outcome Committee
with CP in GMCFS levels IV and V for pain, care and com- (AACPDM TOC) guidelines for the development of system-
fort, and motor function, and, if so, to report its efficacy. atic reviews.22 In general, the higher the level of the study, the
more likely the intervention of interest was responsible for the
METHOD outcomes.
Inclusion and exclusion criteria Studies were also given a quality assessment score based on
Studies were included in this review if they met the following the scoring system of the AACPDM TOC guidelines.22 These
criteria: (1) participants were aged 18 years of age or less, (2) scores were used to grade each study as ‘strong’, ‘moderate’,
participants were diagnosed with CP equivalent to GMFCS or ‘weak’ according to the methodological rigour of the study.
levels of IV or V, (3) participants were receiving BoNT-A The AACPDM TOC does not recommend the use of this
treatment, (4) the research design was anything other than a quality assessment system for levels IV and V studies.22 How-
review or expert opinion that did not provide data for analysis, ever, preliminary screening of this review showed that the
and (5) studies were published in English-language peer- majority of studies conducted under the topic of interest had
reviewed journals. Studies were excluded if participants were less rigorous research designs and hence, it was decided that
not classified according to their GMFCS level and if it was not included studies were critically reviewed and scored as a means
possible to classify the participants accurately by the authors of informing future studies.
Review 305
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RESULTS two case studies,28,33 and one single-subject design study.27
Of the 814 studies identified in our electronic database Only one study, a double-blinded randomized controlled trial
search, 68 met the inclusion criteria (Fig. 1). Full-text analysis (RCT), provided level I evidence.24 Quality assessment of the
of these 68 articles led to the exclusion of a further 49 articles level IV and V studies of showed weak to moderate methodo-
for the following reasons: (1) study population was non-CP logical rigour, whereas the level I RCT was a rigorous study
or mixed (CP and non-CP) and data for participants with CP (see Tables SII–SIV, online supporting information).
could not be separated; (2) results for participants in GMCFS Table I summarizes the purpose, study design, and demo-
levels IV and V could not be isolated from a group analysis; graphics of the 19 included studies. Study purposes were var-
or (3) participants were not classified according to GMFCS ied, and included investigating the effects of BoNT-A on pain
but according to topographical classification and there was reduction, maintaining hip integrity, functional changes to
inadequate information for the authors to reclassify the par- attainment of preset goals. Two32,34 of the 19 studies recruited
ticipants (Table SI, online supporting information). Hence, participants over 18 years and their data were excluded in the
19 studies investigating the use of BoNT-A in children with statistical analysis carried out for this review. Only two stud-
CP in GMCFS levels IV and V were included in this ies24,31 investigated the use of BoNT-A solely in children clas-
review.20,21,23–39 sified as GMFCS levels IV and V. Nine studies25,27,29,30,32,35–38
Of the 19 studies, 18 were classified as providing level IV or V consisted of participants with mixed GMFCS levels and
evidence: 15 non-controlled cohort studies,20,21,23,25,26,29–32,34–39 the data for participants in levels IV and V were separated for
Figure 1: Inclusion and exclusion of studies found in literature searches. GMFCS, Gross Motor Function Classification System.
Total
Level of evidence ⁄ n⁄ Age range
Study Aim research designa Population CP type drop-outs Mean (SD) ⁄ sex
Arens Effect of BoNT-A on dynamic IV ⁄ non-controlled cohort Group 1, spastic (n=5); group 2, Hemiplegia (n=5), diplegia (n=5), 15 ⁄ 0 Range 5–17y; mean 10y
et al.23 spasticity and dystonic study, before and after design dystonic (n=5), group 3, mixed quadriplegia (n=5) 10mo
posturing spastic and dystonic (n=5)
Barwood Effect of BoNT-A on post I ⁄ double-blinded RCT Severe spastic CP with ‘hips at Diplegia (n=3), quadriplegia 17 ⁄ 1b Range 2–10y; mean
et al.24 operative pain risk’; GMFCS IV (n=4) or V (n=12) (n=13) 4y 3mo (1y 3mo) ⁄ 6M, 10F
Cosgrove Indications, safety procedures, IV ⁄ non-controlled cohort study, Community ambulators (n=7), Hemiplegia (n=8), diplegia 26 ⁄ 0 Range 2–17y; mean
et al.20 and effects of BoNT-A before and after design i.e. GMFCS I ⁄ II;c functional (n=7), quadriplegia (n=11) 6y ⁄ 19M, 7F
ambulators (n=8), i.e. GMFCS
II ⁄ III;c non-functional ambulators
(n=8), i.e. GMFCS III or IV;c
non-ambulators (n=3), i.e.
GMFCS IV or Vc
Coutinho Effect of BoNT-A on quality of life IV ⁄ cross-sectional study, GMFCS I (n=7), II (n=18), III Spastic hemiplegia (n=21), 57 ⁄ 0 Mean 6y (2y 4mo) ⁄ 34M, 23F
dos before and after design (n=6), IV (n=13), V (n=13) spastic diplegia (n=14), spastic
Santos quadriplegia (n=10),
et al.25 others (n=12)
Fattal- Markers for a favourable IV ⁄ non-controlled cohort Independent walkers (n=12), i.e. Hemiplegia (n=7), spastic 26 ⁄ 0 Range 2–5y; mean 3y 7mo
Valeviski outcome with BoNT-A study, before and after design GMFCS I or II;c walkers with diplegia (n=19) (1y 2mo) ⁄ 16M, 10F
et al.26 aids (n= 9), i.e. GMFCS III;c
non-walkers (n=5),
i.e. GMFCS IV or Vc
Fragala Effect of BoNT-A on impairment, V ⁄ multiple single-participant AB CP with lower extremity Hemiplegia (n=3), 7⁄0 Range 3–11y ⁄ 6M, 1F
et al.27 disability, and parent design spasticity, GMFCS I (n=3), II diplegia (n=4)
satisfaction (n=2), III (n=1), IV (n=1)
Gooch and Effect of BoNT-A on spasticity V ⁄ case study, before and Severe athetoid, dependent in Quadriplegia (n=1), hemiplegia 3⁄0 Ages 17y, 11y, 3y ⁄ 2M, 1F
Sandell28 and athetosis after design all cares (n=1), i.e. GMFCS IV (n=1), athetosis (n=1)
or V;c spastic quadriplegia in
wheelchair (n=1), i.e. GMFCS IV
or V;c spastic hemiplegia
ambulant (n=1), i.e. GMFCS I–IIIc
Jung et al.29 Effect of BoNT-A on hip IV ⁄ non-controlled cohort study, Bilateral spastic CP with bilateral Bilateral spastic (n=26), 27 ⁄ 0 Range 2–10y; mean 5y 2mo
lateralization before and after design adductor spasticity, GMFCS I dyskinetic (n=1) (1y 11mo) ⁄ 18M, 9F
(n=1), II (n=3), III (n=3), IV
(n=12), V (n=8)
Koman Efficacy of BoNT-A on the IV ⁄ non-controlled cohort study, Group 1, non-ambulatory severe Hemiplegia (n=8), diplegia 27 ⁄ 0 Range 3–16y;
et al.21 management of muscle before and after design spastic and mixed quadriparesis (n=9), quadriplegia (n=8), mean 7y ⁄ 14M, 13F
imbalance in paediatric CP (n=3), i.e. GMFCS IV or V;c quadriplegia with
group 2, severe spasticity in athetosis (n=2)
lower limbs affecting
positioning and hygiene
(n=8), i.e. GMFCS IV or V;c
group 3, ambulatory (n=16),
i.e. GMFCS I–IIIc
Linder Medium-term (1y) efficacy of IV ⁄ non-controlled cohort study, Spastic CP, GMFCS I (n=5), Hemiplegia (n=4), diplegia 25 ⁄ 0 Range 1y 6m–15y 6m;
et al.30 BoNT-A on gross motor before and after design II (n=5), III (n=4), IV (n=7), V (n=12), quadriplegia (n=9) mean 6y 2mo; 15M, 10F
function (n=4)
Review
307
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Table I: Continued.
Total
Level of evidence ⁄ n⁄ Age range
Study Aim research designa Population CP type drop-outs Mean (SD) ⁄ sex
Lundy Effect of BoNT-A on pain IV ⁄ non-controlled cohort study, CP with spasticity and pain at hip Quadriplegia (n=26) 26 ⁄ 0 Range 2–19y; mean 11y 6mo
et al.31 due to hip spasms before and after design level; GMFCS V (n=26) (4y 9mo); 12M, 14F
Mall Effect of BoNT-A on disability V ⁄ case study, before and Participant 1 – severe spastic Diplegia (n=1), tetraparesis 3⁄0 Participant 1 M, 13y; participant
et al.33 and QOL after design tetraparesis i.e. GMFCS IV or V;c (n=2) 2 F, 16y; participant 3 M, 15y
participant 2 – spastic tetraparesis
with hand contracture, unknown
GMFCS;d participant
3 – ambulant spastic diplegia i.e.
GMFCS II–IIIc
a
Grading of evidence according to levels of evidence proposed by the American Academy for Cerebral Palsy and Developmental Medicine methodology for developing systematic reviews of
treatment interventions (Revision 1.2), 2008.22 bEight participants in each intervention and control group. cGross Motor Function Classification System (GMFCS) level classified by the authors
according to the information provided in the paper. dInadequate information provided in the paper to allow classification according to GMFCS. eParticipants over 18 years of age were excluded from
analysis in this review. CP, cerebral palsy; BoNT, botulinum toxin; RCT, randomized controlled trial; M, male; F, female; y, years; mo, months.
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analysis in this review. In the remaining eight
participants who had a positive result as the nominator and total number of participants in that study as the denominator; SS, statistically significant difference; IV-M, level IV evidence with moderate
Fattal-Valevski et al.26
In this study, improvement in Visual Analogue Scale standing score for nine participants and in Visual Analogue Scale walking score for five participants. GMFM, Gross Motor Function Measure;
(IV-M) (n=5): NA
research rigor; NS, no statistically significant difference; V-M, level V evidence with moderate research rigor; NA, not statistically analysed; IV-W, level IV evidence with weak research rigor; V-W,
Goal attainment
according to the GMFCS using the information provided in
the papers.
(n=26): NA
(n=13): NS
(n=1): NA
GMFCS, Gross Motor Function Classification System; I-S, level I evidence with strong research rigor; n, the number of participants with a positive result. In case of a fraction, n, number of
Table SII shows the outcome measures and results of the
included studies. In five studies with participants of mixed
GMFCS levels,29,30,32,34,37 separate statistical analyses were
performed in this review for participants with levels IV and V
Wong39 (IV-M)
studies, descriptive outcome measures were used and no statis-
(n=3 ⁄ 6): NA
(n=14):a SS
(n=1): NA
(n=3): NA
(n=1): NA
(n=1): NA
tical analysis was applied (Table SII). The main outcomes of
interest in these 19 studies could be grouped under pain
reduction, hip integrity, functional changes, and goal attain-
ment. Table II regroups, under these four main outcomes of
Table II: Summary of 19 included studies showing positive results under the four main outcomes of interest for participants with GMFCS levels IV and V only
(IV-W) (n=5): SS
(V-W) (n=2): NA
(V-W) (n=1): NA
(V-M) (n=1): NA
Manzano et al.34
Fragala et al.27
from the intervention. Reduction in muscle tone and improve-
Ease of care
Mall et al.33
(n=13):SS
ments in ranges of motion were also shown in several studies
(Table SII).20,25–28,30,32–34,36,39
Functional changes
Pain reduction
Of the six studies21,28,33,37 investigating the effects of BoNT-A
(n=12 ⁄ 13): NA
(n=5 ⁄ 15): NA
Maintaining hip integrity
Only one study29 investigated the effect of BoNT-A on hip
integrity (Tables II and SII). The results showed a non-signifi-
cant difference in hip migration percentage over a 2-year per-
iod (n=27).
Koman et al.21 (IV-M)
Gooch and Sandell28
Fragala et al.27 (V-M)
Ease of positioning
(V-W) (n=1): NA
Functional changes
Ease of positioning and care, improvements in the GMFCS
(n=1): NA
(n=8): NA
Jung et al.29
Review 309
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improvements, including transfers and ambulation, without and V, but the clinical application of this evidence may be
conducting statistical analyses on the data20,23,27,33,39 (n=9 in limited by the lack of further high-quality RCTs to support
total; Tables II and SII). this outcome. In the study by Vles et al.,37 pain, as assessed by
Visual Analogue Scale scores, was reduced non-significantly
Goal attainment after the BoNT-A injections (Tables II and SII). This result
Four studies26,27,31,38 investigated the efficacy of BoNT-A on may have been insignificant because of the very small number
the attainment of preset goals by the participants and ⁄ or their of participants who were assessed (2 ⁄ 55 participants in the
carers (Tables II and SII). Three studies26,27,31 noted positive study). This review has found moderate evidence to support
results using descriptive measures (n=32 in total) and one the use of BoNT-A for pain reduction in children undergoing
study38 showed non-statistically significant changes using a hip adductor release surgery and weak to moderate evidence
modified goal attainment scale (n=13). for its use in the reduction of spasticity-related pain.
Among children with severe CP, spastic hip disease is a com-
DISCUSSION mon problem, putting their hips at ‘high risk’ of disloca-
BoNT-A has been closely scrutinized for its effectiveness in tion.41,42 It has also been shown that hip lateralization occurs
treating ambulant children with CP (i.e. GMFCS levels I–III) in as many as 90% of children in GMFCS level V.43 Only one
with the aim of improving their gait pattern.16,17 Clinically, study29 we found investigated the effects of BoNT-A on main-
this intervention has also been used for pain reduction and tenance of hip integrity, using the migration percentage as an
improvement in positioning or ease of hygiene40 in non- outcome measure (Tables II and SII). The authors of this study
ambulant children with CP (i.e. GMFCS levels IV and V); found that the mean changes in the migration percentage were
however, its effectiveness has not been thoroughly reviewed. of no clinical significance (<10%) over a 2-y period, indicating
This review was carried out attempting to fill in the gap in that the BoNT-A assisted in maintaining hip stability. Owing
existing knowledge. We found 19 studies that examined the to the low level of evidence, moderate methodological rigour,
use of BoNT-A in children with CP in GMFCS levels IV and and lack of a control group in this study (Table SII), it is not
V for pain reduction, better positioning, ease of hygiene, and possible to conclude that BoNT-A had real impact on hip
better motor function. As almost all of these studies had low integrity for these participants. Indeed, another RCT with a
levels of evidence and low to moderate methodological qual- high level of evidence has shown that children with hip adduc-
ity, except the RCT by Barwood et al.,24 caution is advised tor spasticity would require surgery for hip integrity in the
when interpreting the results of this review. Over two-thirds long term.44 While it appears that hip integrity may be a possi-
of the included studies demonstrated that the use of BoNT-A ble indication for the use of BoNT-A in children in GMCFS
reduced spasticity and increased range of movements in the levels IV and V, existing evidence in this area is weak. Studies
related joints at the impairment level with or without statistical with rigorous study designs are needed to verify this possible
analyses (Table SII). These are believed to be known out- indication for the use of BoNT-A in maintaining hip status for
comes based on the mechanism of BoNT-A at neuromuscular children in GMCFS levels IV and V.
junctions.12,14,15 Pain reduction and maintaining hip integrity Fourteen studies found positive results of BoNT-A treat-
are less frequently reported outcomes at this level. At the level ment on ease of positioning and care, improvements in
of function and activity, it appears that after the BoNT-A GMFM scores or GMFCS levels, and motor function, such as
injections positive results were demonstrated in terms of transfer and assisted ambulation (Tables II and SII). In all
achieving functional changes and attaining goals. These out- studies in which statistical analyses were performed, statistical
comes (i.e. pain reduction, maintaining hip integrity, achieving significance was achieved,25,30,32,34,37 whereas those studies
functional changes, and attaining preset goals) are the main using descriptive measures reported marked improvement in
focus of this review. gross motor function, standing, walking, ambulatory status,
Several studies were found to investigate if BoNT-A was transfer, positioning, and ease of care20,21,23,27,28,33,35,36,39
effective in reducing general pain as well as specific post- (Table SII). Three studies25,35,36 used the GMFCS level to
orthopaedic surgery pain in children classified as GMFCS document changes in the gross motor function of the partici-
levels IV and V. Outcome measures used to assess pain varied pants. Over half of the participants in these studies showed
among the studies. Descriptive measures were used in three improvement in the GMFCS level post BoNT-A injections
studies,21,28,33 while Lundy et al.31 used both objective ques- (Tables II and SII). GMFCS levels have been shown to be sta-
tionnaires and subjective parent description to assess the pain ble with time in older children and adolescents with CP, but
reduction post intervention. In these studies, the majority of not in children under 6 years of age.45,46 The study partici-
participants demonstrated positive changes (Tables II and pants in these three studies25,35,36 were relatively young (mean
SII). In their RCT, Barwood et al.24 used three outcome mea- age 6, 5.7, and 4.4y, respectively) (Table I), which might
sures – amount of analgesia required, pain score, and hospital explain the large improvement in their gross motor function
admission time – and found a statistically significant reduction after BoNT-A intervention. In fact, the GMFCS is a classifica-
in all these outcome measures in the treatment group tion of motor abilities of individuals with CP, not a functional
(Table SII). With its strong methodological quality, this study assessment, and hence more robust outcome measures, such as
provided good evidence to show that BoNT-A is effective in the GMFM or the Pediatric Evaluative of Disability Inven-
reducing post-operative pain in children in GMCFS levels IV tory,47 should be used to document changes in motor function
Review 311
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in GMCFS levels IV and V. Maintaining blinding in the causal inferences from the study results. Positive changes fol-
intervention group is not possible as changes in spasticity are lowing BoNT-A intervention were demonstrated in the
often conspicuous. Nowadays, use of BoNT-A is almost part majority of participants in terms of pain reduction, maintain-
of standardized intervention regime for children with ing hip integrity, achieving functional changes, and attaining
CP.8,19,50 It appears to be unethical to have a control group preset goals. Only one level I RCT showed statistically signifi-
without intervention because of the known benefits of BoNT- cant reduction in the postoperative pain for children who had
A in treating muscle spasticity. It is also difficult to justify hav- received BoNT-A injections, which provided moderate evi-
ing to subject children in the control group to an injection dence for this intervention in reducing pain after orthopaedic
procedure for a sham placebo. Moreover, finding a suitable surgery. For the remaining outcomes of interest, the efficacy
control group that is comparable in terms of co-interventions of BoNT-A was inconclusive. Future studies of rigorous
and comorbidities is a challenge in a disorder as varied as CP, methodological quality are required to investigate the indica-
especially in a population of children in GMCFS levels IV and tions for the use of BoNT-A in children in GMFCS levels IV
V who usually have complex medical needs. Hence, large and and V.
expensive RCTs may not be appropriate when investigating
the indications for the use of BoNT-A in this population SUPPORTING INFORMATION
group. Alternative research designs such as high-quality longi- The following additional material may be found online.
tudinal population-based studies or multiple single-participant Table SI: Excluded studies and reasons for exclusion.
study designs with sensitive outcome measures may be more Table SII: Summary of study methods, outcome measure,s and results of
viable options for future research studies in this area. 19 included studies.
Table SIII: Quality conduct of the 18 group studies
CONCLUSION Table SIV: Quality conduct of the single-participant design study.
Nineteen studies were included in this review examining the Please note: This journal provides supporting online information sup-
efficacy of BoNT-A in terms of ease of pain, care and comfort, plied by the authors. Such materials are peer reviewed and may be re-orga-
and improvement in motor abilities in children with CP in nized for online delivery, but may not be copy-edited or typeset.
GMFCS levels IV and V. Almost all of the included studies Technical support issues or other queries (other than missing files) should
provided level IV or V evidence and were of poor to moderate be addressed to the authors.
methodological rigour. Caution is required when drawing
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