Transcript Botulinum Toxin Therapy for the Upper Limb

Botulinum Toxin Therapy for the
Upper Limb
CP Network
May 2013
Susan Horsburgh
Outline of Session
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How BTX-A works
Evidence to support use
History of Service
Case Studies
How BTX-A Works
• BTX-A blocks the release of acetylcholine at
the neuromuscular junction
• Produces a short-term, and reversible,
paralysis of the treated muscle
• Effects are at their maximum after 10 to 12
days
• Best evidence supports therapy after injection
to maximise outcomes
BTX-A Therapy
• BTX-A is protein produced by the bacterium
Clostridium Botulinum
– Botox® Allergan
– Dysport
• Given by intramuscular injection as near to
the motor end plate as possible
• Protein is reconstituted in 0.9% saline solution
Best Practice
• Good pre- and post-treatment assessment with
appropriate outcome measures linked to the ICF
and child’s GMFCS level
• Identification of the muscle using
– EMG stimulation
– US guidance
• Number of Units
– 4-6 units/kg body wt. within a range 1-20U/kg
– Maximum 100U for large muscles, 50U for small
• Volume of Dilution
– 100U per 1-2ml solution
Factors Influencing
Treatment
• Site of Injection
– Muscles of children with cerebral palsy are not
where expect to be
– Need to use US to detect upper limb muscles
– Slows process increasing stress
• Dilution
– Too much solution can spread too far, takes longer
to inject
– Too little and effect is inadequate
Factors Influencing
Treatment
• Clinic Process
– Younger children have oral sedation prior to
injection
• Midazolam
– Older children can use Entonox
– Local anaesthesia
• Ethyl Chloride spray
• LMX/Emla cream - lidocaine
Question
• Does botulinum toxin improve hand function
in children with cerebral palsy and upper limb
spasticity?
Evidence
Pubmed
• Search Terms – botulinum toxin; cerebral palsy; upper
limb spasticity
• 41 articles – 18 reviews
• 5 relevant, peer reviewed, English Language, several
authors
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Reeuwijk et al (2006) Clinical Rehab
Boyd et al (2001) European Journal of Neurology
Hoare et al (2010) Cochrane Database
Lukban et al (2009) Journal of Neural Transmission
Delgado et al (2010) American Academy of Neurology
Evidence
• Younger children respond better
• First treatment produces the largest response
• BTX-A should be combined with OT input for
maximum benefit
• Careful selection of muscles required
Muscle Selection
• 6 articles
– Search Terms: Upper limb spasticity; muscle selection;
botulinum toxin; cerebral palsy
– 4 – 1 case report, 2 clinical reviews, 1 RCT (effect on nerve
endings)
– Children can have unusual muscle action therefore muscle
palpation is very inaccurate
– Pronator teres may be first muscle to contribute to ↓ ROM
– Small doses, serial treatment, and multi-level for function
– large dose, multi-level for cosmetic/ease of handling
– Thumb significant in grasp – muscle selection unclear
Lanarkshire/Yorkhill
Service
• Pre- and post-treatment assessment takes
place in Lanarkshire
• Children are seen in Yorkhill Hospital with
Consultant Neurologist and Community
Consultant Paediatrician
• Treatment of upper limb since April 2012
• Recently purchased US machine
• Supply of low dose vials
Aims of Treatment
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Cosmetic
Ease of handling
Reduce pain
Maintain/Improve range of movement
– Splinting
• Improve function
Personal Experiences of
Treatment for Upper Limb
• Cosmetic
– Teenager with hemiplegia
• Ease of handling
– GMFCS level 5 dressing upper garments
• Improve tolerance of splint
• Function
Cosmetic
15 year old boy with hemiplegia GMFCS level 1; teased at
school because of associated reactions causing arm to flex
on effort
• Pre-Assessment
– None
• Treatment
– 50U each to brachialis and brachioradialis
• Post-Assessment
– Subjectively ROM increased but forearm very pronated; less
marked associated reactions on walking
– Teenager happy with outcome
• Future
– Visual analogue scale
– ROM
Ease of Handling
7 year old boy with dystonic athetosis GMFCS level
5; post hip surgery with gross asymmetry
• Pre-Assessment
– CPUP for lower limbs
– Subjective upper limbs
• Treatment
– 50U bilateral pectorals
• Post-Assessment
– Ease of all areas of ADL
– Improved alignment
• Now use Care and Comfort Questionnaire
Maintain Range of
Movement
14 year old boy with spastic quadriplegia GMFCS 5;
wants to maintain range of movement at his
wrists for accessing computer and wheelchair
• Pre-Assessment
– Comprehensive ROM upper limb
• Treatment
– 25U very specific treatment using US guidance
• Post-Assessment
– All joints improved ROM
– Improved access to playstation
Improve Function
12 year old girl with athetoid hemiplegia dystonia
GMFCS level 1; had treatment with no
assessment with excellent outcomes
• Pre-Assessment
– Comprehensive ROM
• Treatment
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Brachialis due to -4° elbow extension 25U
Pronator Teres due to ¾ range 25U
FDP 2 sites due to flexion fingers 30U
FDS 2 sites 30U
Thenar eminence due to thumb adduction 10U
BUT
• Post-Assessment
– Full ROM all joints
– Unable to use hand functionally
• Fixing hair
• Closing car door
– Lost natural swing of arm for walking and running
Summary
• BTX-A is a useful adjunct to therapy
– Can ease management for families of more
severely impaired children
– Can reduce pain (calf muscles, back, splints)
– Can improve function
BUT
• Needs to be linked to OT assessment and
treatment