Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada.
Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada.
Dev Med Child Neurol. 2021 Sep;63(9):1038-1050. doi: 10.1111/dmcn.14874. Epub 2021 Mar 27.
To update a systematic review of evidence published up to December 2015 for pharmacological/neurosurgical interventions among individuals with cerebral palsy (CP) and dystonia.
Searches were updated (January 2016 to May 2020) for oral baclofen, trihexyphenidyl, benzodiazepines, clonidine, gabapentin, levodopa, botulinum neurotoxin (BoNT), intrathecal baclofen (ITB), and deep brain stimulation (DBS), and from database inception for medical cannabis. Eligible studies included at least five individuals with CP and dystonia and reported on dystonia, goal achievement, motor function, pain/comfort, ease of caregiving, quality of life (QoL), or adverse events. Evidence certainty was evaluated using GRADE.
Nineteen new studies met inclusion criteria (two trihexyphenidyl, one clonidine, two BoNT, nine ITB, six DBS), giving a total of 46 studies (four randomized, 42 non-randomized) comprising 915 participants when combined with those from the original systematic review. Very low certainty evidence supported improved dystonia (clonidine, ITB, DBS) and goal achievement (clonidine, BoNT, ITB, DBS). Low to very low certainty evidence supported improved motor function (DBS), pain/comfort (clonidine, BoNT, ITB, DBS), ease of caregiving (clonidine, BoNT, ITB), and QoL (ITB, DBS). Trihexyphenidyl, clonidine, BoNT, ITB, and DBS may increase adverse events. No studies were identified for benzodiazepines, gabapentin, oral baclofen, and medical cannabis.
Evidence evaluating the use of pharmacological and neurosurgical management options for individuals with CP and dystonia is limited to between low and very low certainty. What this paper adds Meta-analysis suggests that intrathecal baclofen (ITB) and deep brain stimulation (DBS) may improve dystonia and pain. Meta-analysis suggests that DBS may improve motor function. Clonidine, botulinum neurotoxin, ITB, and DBS may improve achievement of individualized goals. ITB and DBS may improve quality of life. No direct evidence is available for oral baclofen, benzodiazepines, gabapentin, or medical cannabis.
更新截至 2015 年 12 月发表的关于脑瘫（CP）伴张力障碍者药物/神经外科干预的系统评价证据。
更新检索（2016 年 1 月至 2020 年 5 月），纳入对象为口服巴氯芬、苯海索、苯二氮䓬类、可乐定、加巴喷丁、左旋多巴、肉毒毒素（BoNT）、鞘内巴氯芬（ITB）和深部脑刺激（DBS），以及从数据库建立起纳入医用大麻。符合条件的研究至少纳入 5 例 CP 伴张力障碍者，并报告张力障碍、目标实现、运动功能、疼痛/舒适度、照护便利性、生活质量（QoL）或不良事件。使用 GRADE 评估证据确定性。
19 项新研究符合纳入标准（2 项苯海索、1 项可乐定、2 项 BoNT、9 项 ITB、6 项 DBS），与原始系统评价中的研究合并后，共有 46 项研究（4 项随机对照、42 项非随机对照），纳入 915 例参与者。低确定性证据支持氯硝西泮、ITB 和 DBS 改善张力障碍，可乐定、BoNT、ITB 和 DBS 改善目标实现。低到极低确定性证据支持 DBS 改善运动功能，氯硝西泮、BoNT、ITB 和 DBS 改善疼痛/舒适度，氯硝西泮、BoNT、ITB 和 DBS 改善照护便利性，ITB 和 DBS 改善 QoL。苯海索、可乐定、BoNT、ITB 和 DBS 可能增加不良事件。未发现苯二氮䓬类、加巴喷丁、口服巴氯芬和医用大麻的相关研究。
评估 CP 伴张力障碍者药物和神经外科治疗选择的证据仅限于低到极低确定性。本文新增内容荟萃分析提示，鞘内巴氯芬（ITB）和深部脑刺激（DBS）可能改善张力障碍和疼痛。荟萃分析提示 DBS 可能改善运动功能。可乐定、肉毒毒素、ITB 和 DBS 可能改善个体化目标的实现。ITB 和 DBS 可能改善生活质量。尚无口服巴氯芬、苯二氮䓬类、加巴喷丁或医用大麻的直接证据。
