Changes in movement characteristics of the spastic upper extremity after botulinum toxin injection.

OBJECTIVE To examine the longitudinal effects of botulinum toxin injection on movement characteristics of the spastic upper extremity in children by using motor control testing (MCT) techniques and standard clinical measures. DESIGN Open-label clinical trial. SETTING Motor control laboratory at an academic medical center. PARTICIPANTS A convenience sample of 9 subjects (5 boys, 4 girls; age range, 7-16 y) with cerebral injury (stroke or cerebral palsy) and asymmetric upper-extremity function because of spasticity. Eight subjects had right-sided involvement. INTERVENTIONS Botulinum toxin injection to the involved upper extremity, involving elbow, wrist, and finger flexors, depending on clinical presentation. MAIN OUTCOME MEASURES Clinical measures included range of motion (ROM), the Ashworth Scale, FIM trade mark instrument, Pediatric Evaluation of Disability Inventory, portions of the Bruininks-Oseretsky Test of Motor Proficiency, and the Purdue pegboard. MCT consisted of visually guided reaching, bilateral finger-to-nose movements, hand tapping, and isometric pinch force tasks. Kinematic assessments were made before and at 2, 4, 6, 12, 18, and 24 weeks after botulinum toxin injection. RESULTS All subjects had increased ROM and decreased Ashworth values throughout the testing period. In motor control tasks, improvement typically occurred earlier in the least complex movements, such as hand tapping, with 6 of 9 subjects showing a maximum, although transient, unilateral tapping speed by 6 weeks. A similar time course was observed for pinch force tasks. Improvement in more complex, forward-reaching tasks occurred much later (week 12 or later) or did not occur at all. As with the hand tasks, improved reach performance declined toward the end of the testing period. All subject showed minimal or no improvement in bilateral finger-to-nose movements. Neither maximum changes in ROM or Ashworth values correlated with improvements in functional elbow extension during sit and reach tasks, with 3 subjects with normal active ROM showing late onset or no change in reach. CONCLUSIONS Although botulinum toxin reduced tone and increased ROM of the spastic upper extremity, the time course and degree of motor improvement appears to depend on the complexity of the task. Future research should focus on the value of adjunct therapy, such as task-specific training, in addition to botulinum toxin treatments to facilitate functional improvement of the spastic upper extremity.

[1]  Andrea Utley BA Pgce,et al.  Interlimb coupling in children with hemiplegic cerebral palsy during reaching and grasping at speed , 1998 .

[2]  V. Wong,et al.  Use of botulinum toxin injection in 17 children with spastic cerebral palsy. , 1998, Pediatric neurology.

[3]  D. Sutherland,et al.  Injection of botulinum A toxin into the gastrocnemius muscle of patients with cerebral palsy: a 3-dimensional motion analysis study , 1996 .

[4]  A P Cosgrove,et al.  BOTULINUM TOXIN IN THE MANAGEMENT OF THE LOWER LIMB IN CEREBRAL PALSY , 1994, Developmental medicine and child neurology.

[5]  Botulinum toxin in upper limb spasticity: study of reciprocal inhibition between forearm muscles , 1997, Neuroreport.

[6]  G. Peterson,et al.  Dose‐response curve of human extensor digitorum brevis muscle function to intramuscularly injected botulinum toxin type A , 1996, Neurology.

[7]  T K Das,et al.  Effect of treatment with botulinum toxin on spasticity. , 1989, Postgraduate medical journal.

[8]  S. Azen,et al.  Reliability of goniometric measurements. , 1978, Physical therapy.

[9]  N. Hogan An organizing principle for a class of voluntary movements , 1984, The Journal of neuroscience : the official journal of the Society for Neuroscience.

[10]  J. Cooke,et al.  Influence of joint interactional effects on the coordination of planar two-joint arm movements , 2004, Experimental Brain Research.

[11]  M. Merzenich,et al.  Functional reorganization of primary somatosensory cortex in adult owl monkeys after behaviorally controlled tactile stimulation. , 1990, Journal of neurophysiology.

[12]  B. Bhakta,et al.  Use of botulinum toxin in stroke patients with severe upper limb spasticity. , 1996, Journal of neurology, neurosurgery, and psychiatry.

[13]  V. Mathiowetz,et al.  Grip and pinch strength: norms for 6- to 19-year-olds. , 1986, The American journal of occupational therapy : official publication of the American Occupational Therapy Association.

[14]  S. Brown,et al.  Motor control testing of upper limb function after botulinum toxin injection: a case study. , 2000, Archives of physical medicine and rehabilitation.

[15]  A Münchau,et al.  Generalised muscular weakness after botulinum toxin injections for dystonia: a report of three cases , 1999, Journal of neurology, neurosurgery, and psychiatry.

[16]  F. Walker,et al.  Serial neurophysiological studies of intramuscular botulinum‐A toxin in humans , 1994, Muscle & nerve.

[17]  S. Wall,et al.  Botulinum A chemodenervation: a new modality in cerebral palsied hands. , 1993, British journal of plastic surgery.

[18]  J. Liepert,et al.  Changes of cortical motor area size during immobilization. , 1995, Electroencephalography and clinical neurophysiology.

[19]  G. Molenaers,et al.  Recommendations for the use of botulinum toxin type A in the management of cerebral palsy. , 2000, Gait & posture.

[20]  M. Hallett,et al.  Single-joint rapid arm movements in normal subjects and in patients with motor disorders. , 1996, Brain : a journal of neurology.

[21]  H. Polatajko,et al.  Use of the Bruininks-Oseretsky test of motor proficiency in occupational therapy. , 1995, The American journal of occupational therapy : official publication of the American Occupational Therapy Association.

[22]  L. Fetters,et al.  Quantification of control: a preliminary study of effects of neurodevelopmental treatment on reaching in children with spastic cerebral palsy. , 1990, Physical therapy.

[23]  J. Ferro,et al.  Botulinum toxin type A for the treatment of arm and hand spasticity in stroke patients , 1997, Clinical rehabilitation.

[24]  D Fehlings,et al.  An evaluation of botulinum-A toxin injections to improve upper extremity function in children with hemiplegic cerebral palsy. , 2000, The Journal of pediatrics.

[25]  M M Horger,et al.  The reliability of goniometric measurements of active and passive wrist motions. , 1990, The American journal of occupational therapy : official publication of the American Occupational Therapy Association.

[26]  Roslyn N. Boyd,et al.  Objective measurement of clinical findings in the use of botulinum toxin type A for the management of children with cerebral palsy , 1999 .

[27]  S. Smith,et al.  A double-blind placebo-controlled study of botulinum toxin in upper limb spasticity after stroke or head injury , 2000, Clinical rehabilitation.

[28]  Richard W. Bohannon,et al.  Interrater reliability of a modified Ashworth scale of muscle spasticity. , 1987, Physical therapy.

[29]  A P Cosgrove,et al.  Botulinum toxin A in hamstring spasticity. , 1999, Gait & posture.

[30]  M. Johnston,et al.  Effects of botulinum toxin A on upper limb spasticity in children with cerebral palsy. , 2000, American journal of physical medicine & rehabilitation.

[31]  F. A. Hellebrandt,et al.  The Measurement of Joint Motion: Part III—Reliability of Goniometry , 1949 .

[32]  B. Steenbergen,et al.  Bimanual movement coordination in spastic hemiparesis , 1996, Experimental Brain Research.

[33]  R Ivry,et al.  Timing and motor control in clumsy children. , 1992, Journal of motor behavior.

[34]  R. Nudo,et al.  Neural Substrates for the Effects of Rehabilitative Training on Motor Recovery After Ischemic Infarct , 1996, Science.

[35]  D. Sugden,et al.  INTERLIMB COUPLING IN CHILDREN WITH HEMIPLEGIC CEREBRAL PALSY , 1995, Developmental medicine and child neurology.

[36]  W M Jenkins,et al.  A primate model for studying focal dystonia and repetitive strain injury: effects on the primary somatosensory cortex. , 1997, Physical therapy.

[37]  J. Fagard,et al.  Bimanual stereotypes: bimanual coordination in children as a function of movements and relative velocity. , 1987, Journal of motor behavior.

[38]  A. Rodriquez,et al.  Botulinum toxin injection of spastic finger flexors in hemiplegic patients. , 2000, American journal of physical medicine & rehabilitation.

[39]  R. Price,et al.  Selective dorsal rhizotomy: efficacy and safety in an investigator‐masked randomized clinical trial , 1998, Developmental medicine and child neurology.

[40]  A. Gentile,et al.  A kinematic comparison of single and multijoint pointing movements , 2004, Experimental Brain Research.

[41]  Larry H. Ludlow,et al.  Pediatric Evaluation of Disability Inventory , 1994 .

[42]  T. Flash,et al.  The control of hand equilibrium trajectories in multi-joint arm movements , 1987, Biological Cybernetics.

[43]  D. M. Simpson,et al.  Botulinum toxin type A in the treatment of upper extremity spasticity , 1996, Neurology.

[44]  M. Barnes,et al.  Botulinum toxin and spasticity , 2000, Journal of neurology, neurosurgery, and psychiatry.

[45]  L. A. Koman,et al.  Botulinum Toxin Type A Neuromuscular Blockade in the Treatment of Lower Extremity Spasticity in Cerebral Palsy: A Randomized, Double-blind, Placebo-controlled Trial , 2000 .