Upper limb therapy following botulinum toxin-a in young children with hemiplegic cerebral palsy

Abstract: This research program aimed to evaluate the effectiveness of intervention following upper limb injection of Botulinum toxin-A (BoNT-A) in children with hemiplegic cerebral palsy. The program of research included two Cochrane systematic reviews that synthesised current research evidence in support of a) upper limb injection of BoNT-A and b) constraint-induced movement therapy (CIMT). These demonstrated that BoNT-A and occupational therapy (OT) was more effective than OT alone and; modified CIMT (mCIMT) program was more effective than customary care. A single blinded, randomized controlled trial evaluated the effectiveness of mCIMT in comparison to bimanual occupational therapy (BOT) following BoNT-A. Outcomes were assessed at baseline, 1, 3 and 6 months. The primary outcome was the Assisting Hand Assessment (AHA). Secondary outcomes included the Quality of Upper Extremity Skills Test, Pediatric Evaluation of Disability Inventory, Canadian Occupational Performance Measure and Goal Attainment Scaling. The modified Ashworth scale and modified Tardieu scale monitored the effect of BoNT-A. Thirty-four children (20 males, 14 females; 18 months to 6 years, mean 3 years ± 1 year 4 months) with hemiplegic cerebral palsy completed the trial. There was no evidence of a difference between groups following treatment on the AHA. The mean effect of mCIMT (n=17) was 0.62 logits less than BOT (n=17) on AHA scores (95% CI -1.46 to 0.22, p=0.14). At 6-months the mean effect of mCIMT was 0.58 logits less than BOT (95% CI -1.43 to 0.28, p=0.19). Children receiving either mCIMT (p=0.01) or BOT (p=<0.001) had improved bimanual performance immediately following intervention. For secondary outcomes, there was evidence that children in both groups improved on all measures except quality of movement. Following injection of BoNT-A, children with hemiplegic cerebral palsy who received twice-weekly mCIMT or BOT for 8 weeks, achieved important improvements in bimanual performance. These gains were maintained at 6 months.

Submission note: A thesis submitted in total fulfilment for the requirements for the degree of Doctor of Philosophy [to the School of Occupational Therapy], Faculty of Health Sciences, La Trobe University, Bundoora.