A French observational study of botulinum toxin use in the management of children with cerebral palsy: BOTULOSCOPE.

BACKGROUND: Dystonia and spasticity are common symptoms in children with Cerebral Palsy (CP), whose management is a challenge to overcome in order to enable the harmonized development of motor function during growth. AIM: To describe botulinum toxin A (BTX-A) use and efficacy as a treatment of focal spasticity in CP children in France. METHODS: This prospective observational study included 282 CP children mostly administered according to French standards with BTX-A in lower limbs. Realistic therapeutic objectives were set with parents and children together before treatment initiation and assessed using the Visual Analogue Scale (VAS). Child management was recorded and the efficacy of injections was assessed during a 12-month follow-up period by physicians (Modified Ashworth Scale, joint range of motion, Physician Rating Scale, Gillette Functional Assessment Questionnaire and Gross Motor Function Measure-66) and by patients/parents (Visual Analogue Scale). RESULTS: BTX-A treatment was administered in different muscle localizations at once and at doses higher than those recommended by the French Health Authorities. Children were treated in parallel by physiotherapy, casts and ortheses. Injections reduced spasticity and improved joint range of motion, gait pattern and movement capacity. Pain was reduced after injections. BTX-A administration was safe: no botulism-like case was reported. The log of injected children who were not included in the study suggested that a large population could benefit from BTX-A management. CONCLUSIONS: We showed here the major input of BTX-A injections in the management of spasticity in CP children. The results are in favor of the use of BTX-A as conservative safe and efficient treatment of spasticity in children, which enables functional improvement as well as pain relief.

[High doses of botulinum toxin type A in children: efficacy and safety in clinical practice]. / Utilisation de fortes doses de toxine botulique de type A chez l'enfant: intérêt et sécurité en pratique clinique.

The purpose of this article is to examine the current state of administering high doses botulinum toxin type A for the treatment of childhood spasticity, particularly Cerebral Palsy. The inter-relationship between the Cerebral Palsy neurological maturation and the early management is discussed, including identification of common gait patterns and the choice of target muscles for focal or multi focal spasticity management. High doses of botulinum toxin type A, when multilevel and integrated management approach is indicated, appear to be a safe, efficacious treatment for multi focal Cerebral Palsy spasticity. A review of literature guides the clinician about necessary adaptation of botulinum toxin doses and found no evidence that higher doses result in a increase of complications. Further studies would be interesting in order to evaluate long term safety and efficacy of this therapy in Cerebral Palsy.

Experience with external pump trial prior to implantation for intrathecal baclofen in ambulatory patients with spastic cerebral palsy.

OBJECTIVES: To evaluate effectiveness and safety of intrathecal baclofen administration (ITB) testing with continuous infusion via an external pump before the implantation of an internal one in ambulatory spastic patients with cerebral palsy (CP). PATIENTS AND METHODS: Seven CP patients (3 diplegic, 4 quadriplegic - 18.4+/-7.0 years) with a progressive decrease in walking ability were included. Assessments included: Ashworth's scale, Observational Gait Scale (OGS), and GMFM-66. RESULTS: During the ITB test (45-150 microg/24h), spasticity decreased by more than two points on Ashworth's scale (p<0.001) and walking ability improved (median OGS increased from 7 to 9, p

[Interest of anesthetic blocks for assessment of the spastic patient. A series of 815 motor blocks]. / L'apport des blocs anesthésiques dans l'évaluation du patient spastique. A propos d'une serie de 815 blocs moteurs.

BACKGROUND: The purpose of the study was to emphasize the value of anesthetic blocks in the approach to the spastic patient. The report relates our experience concerning 566 patients (ranging in age from 4 to 72 years, mean 48 years) tested by 815 motor blocks performed within a "spasticity and dystonia evaluation" unit. The spasticity was mainly due to stroke (56%), cerebral palsy (21%) and traumatic brain injury (14%). METHODS: Motor blocks were performed with standardized procedure (specific needle, neurostimulator, localization technique), analytic and functional assessment. RESULTS: The anesthetic was mostly 1% non-adrenalized etidocaine, chosen for its onset and duration of action. Re-injections were few and side effects exceptional. Quality and motor blocks results were technique-dependent and required patient cooperation. The spasticity disappeared in blocked muscles. Tardieu and Ashworth modified scale showed constantly decreased spasticity (2 to 3 points) with better sensitivity for the Tardieu modified score. Local anesthetic blocks determined the relative contributions of overactivity and of muscle shortening in the generation of the pathologic posture, the muscle or muscles responsible for the spastic pattern and the level of active performance of the antagonistic muscle. New stability was evaluated by functional assessment of gait posture and prehension. CONCLUSION: At the present time, anesthetic motor blocks represent a necessary and decisive stage procedure as regards spastic patient assessment. This method is particularly useful to anticipate a new functional balance and simulate treatment. Motor blocks provide acute knowledge of the pathological pattern and a better adjustment of therapeutic directions.

Effects of propofol on H-reflex in humans.

BACKGROUND: Depression of spinal cord motoneuron excitability has been proposed to contribute to surgical immobility. The H-reflex, which measures alpha-motoneuron excitability, is depressed by volatile anesthetics, whereas the action of propofol is unknown. The objective of this study was to determine the effects of propofol anesthesia on the H-reflex. METHODS: In 13 patients (group 1), H-reflex was measured before (T0), 3 min after (T1), and 10 min after (T2) a 2-mg/kg bolus dose of propofol, followed by an infusion of 10 mg x kg(-1) x h(-1). Ten patients (group 2) were studied when propofol was given via a programmable pump set to a propofol blood concentration of 6 microg/ml, and 10 patients (group 3) were studied with the pump set to 9 microg/ml. Latencies and amplitudes of H-reflexes (H0, H1, H2) and M-responses (M0, M1, M2) of the soleus muscle were recorded, and H/M ratios (H0/M0, H1/M1, H2/M2) were calculated. RESULTS: In group 1, H-reflex amplitudes and the H/M ratio were diminished after induction with propofol (H0 vs. H1, P = 0.033; H0/M0 vs. H1/M1, P = 0.042). After 10 min of propofol infusion, the H2/M2 ratio was still decreased versus H0/M0 (P = 0.031). In group 2, no difference was detected. In group 3, propofol depressed H-reflex amplitudes at T2 (H0 vs. H2, P < 0.01), and amplitudes were also lower at T2 than at T1 (H1 vs. H2, P < 0.01). In this group, the H/M ratio decreased from T0 to T2 (H0/M0 vs. H2/M2, P < 0.002). CONCLUSIONS: During steady state conditions using propofol as the sole agent, a depression of the H-reflex is observed only at a high blood concentration of 9 microg/ml. The authors suggest that immobility during propofol anesthesia is not caused by a depression of spinal motoneuron circuit excitability.

Soleus neurotomy for treatment of the spastic equinus foot. Groupe d'Evaluation et de Traitement de la Spasticité et de la Dystonie.

OBJECTIVE: This prospective, nonrandomized, noncontrolled study was performed to evaluate the results of a new type of neurotomy, namely the soleus neurotomy, for treatment of the spastic equinus foot. METHODS: Between May 1996 and March 1998, 46 patients were treated for a spastic equinus foot. Clinical status, spasticity (Ashworth Scale score), and kinematic parameters of the gait were determined before and after surgery. The neurotomy was performed on the upper nerve of the soleus in all cases and was associated with other neurotomies (lower nerve of the soleus, 21 patients; gastrocnemius, 9 patients, tibialis posterior, 18 patients; flexor hallucis longus, 16 patients; and flexor digitorum longus, 17 patients). RESULTS: The mean follow-up period was 15 months (range, 8-28 mo). The equinus deformity disappeared clinically in all patients. Before the operation, all patients had an Ashworth Scale score of 2, with an inexhaustible clonus present on knee extension and persisting with knee flexion (Tardieu Scale score, 4), which was abolished in 95% of the patients after surgery. Two patients still had some clonus on knee extension; this did not interfere with their clinical improvement. Knee recurvatum disappeared in eight patients. Analysis of kinematic parameters demonstrated a statistically significant increase in joint motion of the second rocker (P = 0.0026) of the ankle during stance. The duration of the stance or swing phase, length of the walking cycle, and velocity or rate of spontaneous walking were not significantly modified. CONCLUSION: The study demonstrated that soleus neurotomy is effective for the treatment of spastic equinus foot, leading to abolition of spasticity and improvement in the range of ankle motion during the stance phase of gait.

[Lower limb spasticity in adults. Clinical evaluation with motor block]. / La spasticité des membres inférieurs chez l'adulte. Evaluation clinique et blocs moteurs.

Clinical assessment of spastic lower limbs in adults requires identification of neurologic components (motor deficit, spasticity, co-contraction, sensory deficit) and non-neurological components (contracture) of the motor disorder and the intrinsic mechanism of the "spastic" gait. In order to determine the nature of a complex motor disorder, the clinical can call on different diagnostic tools such as motor blocks or gait analysis measuring time-distance parameters, kinematic, kinetics, gait dynamic electromyography and energy expenditure for gait performance. Clinical assessment is guided by the therapeutic goal (function, gait, mobility, pain relief, nursing), both to propose treatment and objectively monitor treatment results in terms of deficit (strength, flexibility, appropriate contraction, muscle activation) and handicap (gait, transfers, activities of daily living).

[Peripheral neurotomy in the treatment of spasticity. Indications, techniques and results in the lower limbs]. / Les neurotomies périphériques dans le traitement de la spasticité. Indications, technique et résultats aux membres inférieurs.

INTRODUCTION: The aim of this study was to review the principle of peripheral neurotomy for the treatment of lower limb spasticity. The importance of clinical assessment is stressed (with particular focus on motor block) for determining the best surgical indications. MATERIAL AND METHOD: Between 1989 and 1997, 392 neurotomies were performed in 277 patients in the neurosurgery department of the Henri Mondor Hospital, Créteil, France. Surgical technique consisted in partial and segmental resection, involving each motor collateral branch of muscles with excessive spasticity. For the lower limb, the most frequent neurotomy was performed on collateral branches of the posterior tibial nerve (66%) for the spastic foot. RESULTS: Preoperative motor block provided the advantage of "mimicking" the effect of the neurotomy and therefore gave the patients an idea of the expected result of surgery. For the spastic foot, posterior neurotomy led to the disappearance of ankle clonus in all patients. When antagonist muscles were present, splints were no longer needed after neurotomy. Cinematic analysis showed that tibial neurotomy improved angular variations of the second rocker of the ankle during stance. CONCLUSION: Peripheral neurotomies are simple and safe procedures for the treatment of lower limb spasticity and should be routinely used in general neurosurgery practice.

[Treatment of spasticity with injections of botulinum toxin. Review of the literature]. / Traitement de la spasticité par injections de toxine botulique. Revue de la littérature.

Botulinum toxin injections are a new treatment for limb spasticity. Intramuscular injections can be performed in spastic muscles; efficacy occurs one or two weeks later, with a mean duration of three months. Clinical action is related to chemical denervation of presynaptic motor end nerves by the botulinum toxin. Double blind studies versus placebo have demonstrated the improvement of limb spasticity after injections of botulinum toxin. Ashworth scales, articular angulations, pain and spasms improve both in upper and lower limb spasticity. Functional scores are not changed in the upper limb, but quality of life improves. Kinematic parameters of gait are improved in lower limb spasticity, especially in children with cerebral palsy disorders. There were no reports of serious side effects. Botulinum toxin is a safe and effective treatment of localized spasticity in adults and children.

Peripheral selective neurotomy of the brachial plexus collateral branches for treatment of the spastic shoulder: anatomical study and clinical results in five patients.

A new type of peripheral selective neurotomy involving the collateral branches of the brachial plexus has been perfected for treatment of the spastic shoulder. Anatomical study of six cadaveric shoulders led to the specification of a surgical approach to the pectoralis major and teres major nerves, which innervate the main muscles implicated in shoulder spasticity. Between August 1994 and September 1995, five patients (four men and one woman) underwent two to four associated neurotomies of the upper limb, which included neurotomies of the pectoralis major (all five patients) and the teres major (two patients). The average follow-up period was 11 months, during which there were no local or general complications. The spasticity of the treated muscles resolved in all five patients (Held score range 3-0). The neurotomies led to statistically significant average amplitude increases in shoulder mobility, especially in abduction (+30 degrees), antepulsion (+50 degrees), retropulsion (+20 degrees), and external rotation (+20 degrees). The functionally useful active amplitude scores increased from 2.66 to 5.16/6. This functional improvements mainly involved the standing position and walking stability, as well as improvement in the range of motion of the lower limb. These results encourage the increasing use of this new type of neurotomy in treatment of the spastic upper limb.

Physiological effects of selective tibial neurotomy on lower limb spasticity.

OBJECTIVES: To assess by electrophysiology the effect of tibial selective neurotomy on muscle imbalance of the spastic ankle. METHOD: The amplitudes of the H reflexes, M responses (muscle contractions recorded after stimulation of the tibial nerve), and Hmax:Mmax ratio were recorded in 12 patients with chronic lower limb spasticity, before and one month after tibial selective neurotomy. Recordings were done on medial and lateral gastrocnemius and soleus muscles. Clinical evaluation was done with both global (Held's score) and analytical tests (step measurements, gait velocity, and ankle angulation during active and passive movements). RESULTS: After neurotomy, gait improved in all patients. Held's score of spasticity was better in all patients. Active dorsiflexion of the ankle was unchanged in three patients, but the others improved by 5 degrees to 12 degrees. Hmax, Mmax, and Hmax:Mmax ratios were lower. The Hmax on the gastrocnemius muscle, clinical strength, Mmax of all the muscles, and Hmax:Mmax ratio for the soleus and lateral gastrocnemius muscle were significantly lower after surgery. CONCLUSION: There was an improvement of clinical and electrophysiological spastic indices after selective tibial neurotomy. Neurotomy acted not only on motor neurons by decreasing strength, but also the reflex enlargement by decreasing sensory afferents.

[Selective peripheral neurotomy of the hamstring branches of the sciatic nerve in the treatment of spastic flexion of the knee. Apropos of a series of 11 patients]. / Neurotomies périphériques sélectives des collatérales pour les muscles ischio-jambiers dans le traitement de la spasticité en flexion du genou. A propos d'une série de 11 patients.

BACKGROUND: A series of 11 patients (9 adults and 2 children) were operated on by selective peripheral neurotomy for spastic knee in flexion. The objective of surgery was to restore bipodal stance and therefore walking for the adult patients and to improve walking for the diplegic children. METHODS: Spasticity was secondary to stroke or cranial trauma for the adult patients. The two children presented with Little disease. The delay between onset and surgery was on the average of 2 years. All the patients had a passive flexum of the knee of 20 degrees, and an excessive spasticity of the hamstrings (average Held score of 4.55). Peripheral selective neurotomies consist of a partial section of the spastic muscle's motor fascicles. The partial section concerns the afferent fibers to the spinal cord whose interruption leads to the disappearance of spasticity. The section also involves the motoneurones' axons and thus leads to partial denervation. RESULTS: The spasticity of the treated muscles disappeared in the 11 patients. Average follow-up was 16 months. The neurotomies led to improvement of walking without splint for 3 walking patients, and restored walking with a splint for 5 patients. One patient failed to walk. The two children had a dramatic improvement of their walk. CONCLUSION: Our results incite us to increasingly indicate this type of neurotomy in the treatment of the spastic lower limb.

[Plea for interactive rehabilitation during coma]. / Plaidoyer pour une prise en charge interactive pendant le coma.

The question of head trauma reasons, and the shock of traditional family and therapeutic references, make the authors examine clinic coma evolution till awakening. From signs of libidinal values collected by care-team, another way during coma and till life recovery, is rebuilt.

[Abnormalities of the sensation of the need to urinate in multiple sclerosis. Clinical and urodynamic study. Apropos of 100 cases]. / Les anomalies de la sensation du besoin d'uriner au cours de la sclérose en plaques. Etude clinique et urodynamique. A propos de cent cas.

A hundred patients with multiple sclerosis and urinary disorders were examined clinically and by gas or water cystometry. Particular attention was paid to abnormalities in the voiding need sensation. These abnormalities can best be studied by cystometry combined with urethral striated sphincter electromyography. When the sequence of the three degrees of need (usual need, pressing need and urgent need) is respected, there is a good correlation between the progression of the voiding need during the filling phase of the cystometry and during the detrusor action. When there is interference with the sequence of these three degrees of the voiding need, especially the absence of the sensation normally contemporaneous with the detrusor action or immediately preceding it, there is exaggeration of either the hyperactivity or the hypoactivity of the bladder, and this aggravates vesical sensitivity: premature contraction of the detrusor muscle eliminates the first two degrees (usual need and pressing need), while progressive distension of the detrusor muscle eliminates all three stages. As the multiple sclerosis evolves a stage is reached at which there are functional mictional disorders exclusively connected with the interference with the degrees of voiding need pollakiuria and urgency.