An evaluator-blinded randomized controlled trial evaluating therapy effects and prognostic factors for a general and an individually defined physical therapy program in ambulant children with bilateral spastic cerebral palsy.

BACKGROUND: Cerebral palsy (CP) is characterized by a heterogeneous nature with a variety of problems. Therefore, individualized physical therapy might be more appropriate to address the needs for these children. AIM: The first aim was to compare the effectiveness of an individually-defined therapy program (IT) and a general therapy program (GT) on gait and gross motor function in children with CP. The second aim was to evaluate interaction-effects, time-effects, treatment with botulinum toxin A, age, gross Motor Function Classification Scale (GMFCS), treatment frequency and quality as factors influencing outcome. DESIGN: An evaluator-blinded, randomized controlled trial. SETTING: Outpatient rehabilitation unit. POPULATION: Forty ambulant children with spastic bilateral CP (mean age 6 years 1 month). METHODS: All children were randomly assigned to receive either IT or GT over a 10 week period. Nineteen of these children were enrolled into a second and/or third program, resulting in 60 interventions. Primary outcome was assessed with the Goal Attainment Scale (GAS) for gross motor function goals and z-scores for goals based on specific 3D gait parameters. Secondary outcome included the Gross Motor Function Measure-88 (GMFM-88) scores, time and distance gait parameters, Gait Profile Score, Movement Analysis Profiles and time needed to complete Timed-Up-and-Go and Five-Times-Sit-To-Stand tests. RESULTS: There were higher, but non-significant GAS and z-score changes following the IT program compared to the GT program (GAS: 46.2 for the IT versus 42.2 for the GT group, P=0.332, ES 0.15; z-score: 0.135 for the IT compared to 0.072 for the GT group, P=0.669, ES 0.05). Significant time-effects could be found on the GAS (P<0.001) and the GMFM-88 total score (P<0.001). Age was identified as a predictor for GAS and GMFM-88 improvement (P=0.023 and P=0.044). CONCLUSION: No significant differences could be registered between the effects of the IT and the GT. The favorable outcome after the IT program was only a trend and needs to be confirmed on larger groups and with programs of longer duration. CLINICAL REHABILITATION IMPACT: Both programs had a positive impact on the children's motor functioning. It is useful to involve older children more actively in the process of goal setting.

The effect of different physiotherapy interventions in post-BTX-A treatment of children with cerebral palsy.

AIM: To distinguish the effects of different physiotherapeutic programs in a post BTX-A regime for children with Cerebral Palsy (CP). DESIGN: Retrospective, controlled intervention study. PARTICIPANTS AND INTERVENTIONS: A group of 38 children (X¯ = 7y7m, GMFCS I-III, 27 bilateral, 11 unilateral CP) receiving an individually defined Neurodevelopment Treatment (NDT) program, was matched and compared to a group of children with the same age, GMFCS and diagnosis, receiving more conventional physiotherapy treatment. All patients received selective tone-reduction by means of multilevel BTX-A injections and adequate follow-up treatment, including physiotherapy. OUTCOME MEASURES: Three-dimensional gait analyses and clinical examination was performed pre and two months post-injection. Treatment success was defined using the Goal Attainment Scale (GAS). RESULTS: Both groups' mean converted GAS scores were above 50. The average converted GAS score was higher in the group of children receiving NDT than in the group receiving conventional physiotherapy (p < 0.05). In the NDT group, overall treatment success was achieved in 76% of the goals, compared to 67% of the goals defined for the conventional physiotherapy group. Especially for the goals based on gait analyses (p < 0.05) and in the group of children with bilateral CP (p < 0.05), treatment success was higher in the NDT group. CONCLUSION: In a post-BTX-A regime, the short-term effects of an NDT approach are more pronouncedthan these from a conventional physiotherapy approach.

The effect of individually defined physiotherapy in children with cerebral palsy (CP).

AIM: This prospective double blind intervention study aims to evaluate the effectiveness of an individually defined physiotherapy program on the function and gait pattern of 16 children with diplegia (age 3-12 year, GMFCS I-II). METHOD: A 6 weeks general training program was followed by a specific training program based on individual goals determined by the results of 3D gait analyses, GMFM-88 and a clinical evaluation. Goal attainment scores were used for the evaluation of the achievement of individual goals. RESULTS: After the general training program, 6.7% of the children achieved the treatment goals, 33.3% stayed at the same level and 60% worsened and this in comparison to 40, 33.3 and 26.6% of the children respectively after the individually defined training program. The improvement for walking, running and jumping of the GMFM-88 was significantly more pronounced after the individually defined (p < 0.05), compared to the general training program. Whereas ankle dorsiflexion, spasticity of the hamstrings (p < 0.01), selectivity of hip abductors, knee extensors and ankle dorsiflexors significantly improved over the complete period of study (p < 0.01), hip extension, step length, stride length, ankle power generation and all hip parameters changed specifically after the individually defined training program (p < 0.01). CONCLUSION: A quantified effect is manifest with the application of an individually defined training program over a six weeks period.

[Botulinum toxin A in the treatment of infantile cerebral palsy. Taking into account multilevel, integrated treatment]. / Botulinum toxin A bei der Behandlung der infantilen Zerebralpalse. Under desonderer Berücksichtigung der Mehretagen- und Kombinationsbehandlung.

Botulinum toxin A represents a significant development in the management of children and adolescents with spastic cerebral palsy. Prerequisites for an adequate result are a correct indication, an exact injection technique and an intensive post-treatment programme. Spastic muscle overactivity and the constant tendency of the involved muscles to shorten with growth cannot be treated by only one method. Therefore a multilevel approach and an integrated treatment schedule including plaster of Paris, orthoses and physiotherapy are currently the best ways to modify the disease process. The inclusion of objective clinical documentation techniques combined with 3-D instrumented gait analysis allows the determination of the indications more exactly and for monitoring the post-treatment results. If started early and correctly, this integrated management approach has the potential to modify the natural history of the disorder, and to reduce the frequency of later surgery.

A randomized study of combined botulinum toxin type A and casting in the ambulant child with cerebral palsy using objective outcome measures.

It is recognized that objective gait analysis is of great value in planning a multilevel botulinum toxin type A (BTX-A) treatment. After BTX-A treatment, objective outcome measures can provide new and interesting information for each individual child with cerebral palsy (CP). Moreover, by studying group results, we may evaluate our treatment hypotheses. The present prospective study attempts to document the effect of integrated multilevel BTX-A treatment on objective gait parameters and to define the optimal strategy for the combined treatment of BTX-A with casting in children with cerebral palsy. Objective three-dimensional gait analysis (3DGA) data were collected pre- and 2 months post-treatment, in two randomized patient groups: a first group of 17 children treated with lower leg casting prior to BTX-A injections, and a second group of 17 patients who received casting immediately after injections. The present study demonstrates that improved gait can be achieved after a multilevel BTX-A treatment, combined with casting, using a set of 90 gait parameters. The most pronounced improvement was seen at the ankle joint. The results in the knee, hip and pelvis imply that multilevel treatment of the child with CP should start at an early age, in order to prevent development of muscle contractures. Slightly more pronounced benefits, mainly in the proximal joints, were seen for the children who were casted after injections as compared to the children who were casted before injections.

Single event multilevel botulinum toxin type A treatment and surgery: similarities and differences.

The present study attempts to provide objective evidence of two treatment options for children with cerebral palsy (CP): multilevel botulinum toxin type A (BTX-A) injections and multilevel surgery. The purpose of the study was to clarify the differences and the similarities, and common treatment principles of both treatment strategies. Objective three dimensional gait analysis data were studied retrospectively in two patient groups pre- and post-treatment (randomly selected from a group of children that were treated between 1998 and 1999). In the first group, 29 children with CP were managed with BTX-A injections according to an integrated multilevel approach (Molenaers et al., 1999a). A second group of 23 children with CP were managed by a more traditional single event multilevel surgery, also according to an integrated approach. Our aim was to evaluate the differences as well as the similarities between both patient groups, using a set of 56 parameters selected from three-dimensional gait analysis. The unifying concept between management with BTX-A injections and orthopaedic surgery was the adoption of a multilevel approach at one session. The groups demonstrated considerable differences with respect to age, pretreatment condition and amount and level of improvement after treatment. The children who received BTX-A were typically younger, and showed primary gait problems in the distal joints, whereas the children who underwent surgery demonstrated a higher frequency of gait deviations in the transverse plane and had more complications. Although the benefit of both treatments was confirmed by the present study, a difference in the amount and level of improvement was also demonstrated. In conclusion, these treatment modalities should be regarded as complementary rather than mutually exclusive treatments, with both calling for an integrated approach.