Kay Robert M, Rethlefsen Susan A, Fern-Buneo Anna, Wren Tishya A L, Skaggs David L
Childrens Orthopaedic Center, MS #69 Children's Hospital Los Angeles, 4650 Sunset Boulevard, Los Angeles, CA 90027, USA.
J Bone Joint Surg Am. 2004 Nov;86(11):2377-84. doi: 10.2106/00004623-200411000-00003.
Although botulinum toxin A is frequently used to augment serial casting in the treatment of soft-tissue contractures in children with cerebral palsy, its effectiveness for this purpose has not been evaluated. The purpose of the present study was to determine whether botulinum toxin A injection increases the efficacy of serial casting.
A prospective, randomized trial was undertaken to compare serial casting only with serial casting combined with botulinum toxin A (Botox) injection for the treatment of ankle equinus contractures in twenty-three children with cerebral palsy. Range-of-motion testing, spasticity assessment, and computerized gait analysis were performed as long as twelve months after treatment.
There was no difference between the groups with regard to the duration of casting required to correct the equinus contracture. Both groups maintained a significant improvement in passive ankle dorsiflexion throughout the follow-up period, although the group managed with casting and Botox had a significant loss of dorsiflexion when the values at six, nine, and twelve months were compared with the value at three months. Peak dorsiflexion during the stance and swing phases was significantly improved in both groups at three months but only in the group managed with casting alone at twelve months. Plantar flexor spasticity was significantly decreased at three months in both groups, but it was significantly decreased at six, nine, and twelve months only in the group managed with casting alone. Spasticity was significantly greater in the group managed with casting and Botox than it was in the group managed with casting only at six, nine, and twelve months.
The present study demonstrates the efficacy of serial casting in the treatment of equinus contractures in children with cerebral palsy who are able to walk. Contrary to our hypothesis, the addition of botulinum toxin A to a serial casting regimen led to earlier recurrence of spasticity, contracture, and equinus during gait. The results of the present study suggest that botulinum toxin combined with serial casting for the treatment of fixed contractures will lead to a recurrence of plantar flexor spasticity and equinus contracture by six months in this patient population. While previous research has indicated that the injection of botulinum toxin A is superior to casting for the treatment of dynamic equinus, the present study suggests that serial casting alone is preferable for the treatment of fixed equinus contractures in children with cerebral palsy.
尽管A型肉毒毒素常用于辅助小儿脑性瘫痪患者软组织挛缩的系列石膏固定治疗，但尚未对其在此类治疗中的有效性进行评估。本研究的目的是确定A型肉毒毒素注射是否能提高系列石膏固定的疗效。
进行了一项前瞻性随机试验，比较仅采用系列石膏固定与系列石膏固定联合A型肉毒毒素（保妥适）注射治疗23例小儿脑性瘫痪马蹄足挛缩的效果。在治疗后长达12个月的时间内进行活动范围测试、痉挛评估和计算机化步态分析。
在矫正马蹄足挛缩所需的石膏固定持续时间方面，两组之间没有差异。在整个随访期间，两组的被动踝关节背屈均有显著改善，尽管与3个月时的值相比，采用石膏固定加保妥适治疗的组在6个月、9个月和12个月时背屈明显丧失。在3个月时，两组在站立期和摆动期的最大背屈均有显著改善，但在12个月时仅采用石膏固定治疗的组有改善。两组在3个月时跖屈肌痉挛均显著降低，但仅在采用石膏固定治疗的组在6个月、9个月和12个月时显著降低。在6个月、9个月和12个月时，采用石膏固定加保妥适治疗的组痉挛明显高于仅采用石膏固定治疗的组。
本研究证明了系列石膏固定在治疗能够行走的小儿脑性瘫痪马蹄足挛缩中的疗效。与我们的假设相反，在系列石膏固定方案中添加A型肉毒毒素导致在步态期间痉挛、挛缩和马蹄足更早复发。本研究结果表明，在此类患者中，肉毒毒素联合系列石膏固定治疗固定性挛缩将导致6个月时跖屈肌痉挛和马蹄足挛缩复发。虽然先前的研究表明注射A型肉毒毒素在治疗动力性马蹄足方面优于石膏固定，但本研究表明，对于小儿脑性瘫痪固定性马蹄足挛缩，仅采用系列石膏固定治疗更佳。
