Pediatric Hypertonia: Whats New OACRS 2005

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Pediatric Hypertonia Whats New?OACRS 2005

• Darcy Lynn Fehlings, MD, MSc, FRCP(C)
• Irene Koo, BSc, PT

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Objectives

• Clinical Pathways for Decision Making with
  Botulinum Toxin
• To highlight new clinical developments in
• 1) Botulinum Toxin (BTA) hip
  subluxation, upper extremity dosing
• 2) Treatment of Dystonia
• 3) Prevention of Contractures

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Hypertonia Management Use of Clinical Pathways
for Decision Making

• Irene Koo, BSc, PT
• OACRS October 4, 2005

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Objectives

• Review use of GMFCS levels in Botox Clinic
• Review use of Outcome Measures
• Review Clinical Pathways in Botox Clinic

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Indicators for Botox

• Change in function
• Growth
• Pain
• Hip migration
• Hip subluxation
• Caregiving issues
• Contracture (?)

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GMFCS levels

• Gross Motor Function Classification System for
  Cerebral Palsy
• for details, download GMFCS levels from CanChild
  website
• www. fhs.mcmaster.ca/canchild
• Palisano et. al. (1997)

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Spastic Equinus
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Gait Deviations
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Functional Changes
 
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Anatomical Changes
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Hips at Risk
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Outcomes Used

• Tardieu and Modified Ashworth Scale
• Selective Motor Control Scale
• Physician Rated Observational Gait Scale
• GMFM
• Goal Attainment Scaling

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Clinic Ax Tardieu Scale
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Clinic Ax Modified Ashworth Scale

• MAS of 0 or 1 children have no or very minimal
  tone and generally would not benefit from Botox
• MAS of 4 children have fixed contracture
  deformity, Botox generally not indicated
• MAS 1, 2 or 3 more likely to become Botox
  candidates

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Clinical Pathways from Botox Clinic to P.T.
treatment
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Randomized Trial of BTA combined with hip
bracingBoyd et al. DMCN 2004, 46 9

• Randomized trial of 90 children with spastic CP
  to Tx of BTA q 6 monthly into adductors and
  hamstrings and SWASH brace 8 hours per day or
  control group (monitoring) over 3 year period
• Control Group progressed faster to hip surgery
  (X-ray MP gt 40 or AIgt 27 lead to surgical
  referral)

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Prevention of Hip Disolocation with BTAMarek et
al.. DMCN 2005 47, 12

• RCT of 67 children with spastic CP to Tx group of
  BTA q3 monthly to iliopsoas, adductors,
  hamstrings or control group (observation)
• Results Mean Progression of MP was
• 1 0 in tx group and 3 in control group
  (plt0.00001)

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A Randomized Controlled Trial Comparing Low Dose
and High Dose BTA in the Upper Extremity of
Children with Hypertonia

• A. Kawamura, MD, FRCP(C)
• K. Campbell, PhD
• D. Fehlings, MD, MSc, FRCP(C)

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Conclusions

• Low dose as effective as a high dose in improving
  hand function
• Hypothesis that lower dose would be more
  effective was not proven
• No differences in grip strength or side effect
  profile

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Dosing Guideline Recommendations

• Biceps 1U/kg
• Brachioradialis 0.75U/kg
• Finger/Wrist Flexors 1.5U/kg
• Pronator teres 0.75U/kg
• Thumb adductor 0.3U/kg (max 10U)
• Thumb opponens 0.3U/kg (max 10U)

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Oral PharmacotherapyTrihexyphenidyl (Artane)

• Can be useful in children with dystonia
• Suppresses an overactivity of central cholinergic
  effects in dystonia
• Dosage start at a low dosage and work up every
  two weeks (0.5 mg bid - work up to tid and
  increase until effect noted) - can get up to
  doses of 40 mg
• Side Effects constipation, urinary retention

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Chocolate Trial(Childhood Hypertonia of central
origin an open-label trial of anticholinergic
treatment effects)Sanger et al.. DMCN 200547, 17

• Primary Objective to see if Artane improved UE
  function
• 23 children with dystonia in dominant UE, GMFCS
  II-IV
• Small improvements measured on the Melbourne at
  14 weeks, no impact on QL,
• Hyperkinetic Group deteriorated
• Adverse effects chorea, hyperactivity

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Prevention of Severe Contractures might replace
multi-level surgery in CP.Hagglund et al..
JofPedOrtho 2005, 14 269-273

• In 1994 in Sweden a CP register and health care
  program to prevent hip dislocation and
  contractures was initiated
• Health Care Program standardized follow-up 2x
  per year (CP sub-type, GMFCS, PROM, GM function,
  X-ray of hips)
• In 1992 ITB, in 1993 SDR, 1998 BTA
• Also serial casting, orthoses, and PT
• Children analyzed at 8 years of age

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Results

• 209 children in the study
• Tables demonstrate good PROM at many levels (eg
  in GMFCS I-III 153 of 157 children could
  dorsiflex to neutral)
• Decrease in Orthopedic Surgery and procedures
  became single-level

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Conclusion

• With new techniques to reduce spasticity paired
  with a population-based screening program it
  seems possible to prevent the development of
  severe contractures in children with CP, reducing
  the need for multi-level orthopedic procedures.

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References

• Bottos, M et. al. (2003). Botulinum toxin with
  and without casting in ambulant children with
  spastic diplegia a clinical and functional
  assessment. Dev Med Child Neurol. 45 758-762.
• Boyd, R.N., et. al. (2001). The effect of
  botulinum toxin type A and variable hip abduction
  orthosis on gross motor function a randomized
  control trial. European Journal of Neurology.
  8(Suppl.5) 109-119.
• Kay, R.M., et. al. (2004). Botulinum toxin as an
  adjunct to serial casting treatment in children
  with cerebral palsy. J. Bone and Joint Surgery.
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• Koman, L.A., et. al. (2000). Botulinum toxin
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  lower extremity spasticity in cerebral palsy a
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• Palisano, R. et. al. (1997). Gross motor
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• Pidcock, F.S. et. al. (2005). Hip migration
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• Plazek, R. et. al. (2004). Treatment of
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