Does intramuscular botulinum toxin A injection improve upper-limb function in children with hemiplegic cerebral palsy?

Clinical question " Does intramuscular botulinum toxin A injection improve upper-limb function in children with hemiplegic cerebral palsy? " An occupational therapist requested information about the efficacy of botulinum toxin A injection in the upper limb in the light of its success in reducing spasticity and improving gait and range of movement in the lower limb. Search question The patients relevant to this search were children under 18 years of age with hemiplegic cerebral palsy. The intervention was the use of intramuscular botulinum toxin A and the outcome was improved motor function in the upper limb. The ideal study design to answer this clinical question would be a randomised-controlled trial comparing the effect of intramuscular botulinum toxin A with a control treatment or placebo. Search The search terms " cerebral palsy " , " muscle spasticity " , " botulinum toxin " , " Botox " and " Dysport " were combined to identify all relevant English language articles published between 1966 and June 2001. Databases searched included the Cochrane Library, Best Evidence, MEDLINE and CINAHL (Cumulative Index to Nursing and Allied Health Literature). The search identified two randomised-controlled trials. Non-randomised studies were excluded. Summary of findings Corry et al 1 compared the effects of intramuscular botuli-num toxin A (either Botox [Allergan] 90–250 U at 4–7 U/kg or Dysport [Ipsen] 160–400 U at 8–9 U/kg) with normal saline on the hemiplegic upper limb in 14 patients with cerebral palsy (mean age, 9 years). Outcome assessments were performed at baseline, two weeks and 12 weeks. At the two-week assessment, the group receiving intra-muscular botulinum toxin A had increased maximum active elbow (P = 0.026) and thumb (P = 0.036) extension and reduced tone at the wrist (P = 0.003) and elbow (P = 0.01) than those in the placebo group. There was no significant change at either 2 or 12 weeks in wrist and meta-carpophalangeal extension. In a single-blind study, Fehlings et al 2 compared the use of intramuscular botulinum toxin A (Botox 2–6 U/kg) with occupational therapy (treatment group) or occupational therapy alone (control group) in 29 children aged 2.5–10 years. Primary outcome measures at baseline, 1, 3, and 6 months included the Quality of Upper Extremity Skills Test (QUEST) and a caregiver-completed Pediatric Evaluation Disability Inventory (PEDI). At the four-week assessment, the treatment group scored significantly better on QUEST than the control group on a two-way analysis of variance …