Ann Rehabil Med.  2015 Feb;39(1):1-9. 10.5535/arm.2015.39.1.1.

Short-Term Effect of Botulinum Toxin A Injection on Spastic Equinovarus Foot in Cerebral Palsy Patients: A Study Using the Foot Pressure Measurement System

• Son SM
• Park IS
• Yoo JS

• KMID: 2273012
• DOI: http://doi.org/10.5535/arm.2015.39.1.1

Abstract

OBJECTIVE
To evaluate the therapeutic effect of botulinum toxin A (BTX-A) injection on spastic gastrocnemius (GCM) and tibialis posterior muscles (TPo) by using the foot pressure measurement system (FPMS).
METHODS
Eighteen ambulatory CP patients were recruited in this study. BTX-A was injected into the GCM at a dose of 6-12 units/kg and TPo at a dose of 4-9 units/kg according to the severity of equinus and varus deformity. Foot contact pattern, pressure time integral (PTI), coronal index using the FPMS and Modified Ashworth Scale (MAS), and visual inspection of gait pattern were used for evaluation of the therapeutic effect of BTX-A injection. Clinical and FPMS data were statistically analyzed according to the muscle group.
RESULTS
A significant decrease in the MAS score of the GCM and TPo was observed, and spastic equinovarus pattern during gait showed improvement after injection. The GCM+TPo injection group showed a significant decrease in forefoot, lateral forefoot pad, and lateral column PTI, and a significant increase in hindfoot PTI and coronal index. In the GCM only injection group, forefoot PTI and lateral column PTI were significantly decreased and hindfoot PTI was significantly increased. The TPo only injection group showed a significant decrease in lateral column PTI and a significant increase in the coronal index. Change in PTI in the hindfoot showed a significant correlation with the change in MAS score of the GCM. Change in PTI of the lateral column and coronal index showed a significant correlation with the change in MAS score of the TPo.
CONCLUSION
The FPMS demonstrated the quantitative therapeutic effect of BTX-A on abnormal pressure distribution in equinovarus foot in detail. The FPMS can be a useful additional tool for evaluation of the effect of BTX-A injection.

Keyword

Equinovarus foot; Type A botulinum toxins; Foot pressure; Foot scan; Cerebral palsy

MeSH Terms

Botulinum Toxins*
Cerebral Palsy*
Clubfoot*
Congenital Abnormalities
Foot*
Gait
Humans
Muscle Spasticity*
Muscles
Botulinum Toxins

Figure

• 

  Fig. 1 Foot pressure measurement image. The foot pressure image of a normal foot and the changed image of equinovarus foot pressure between pre-injection and post-injection in a single child (A, toe; B, hallux; C, lateral forefoot; D, medial forefoot; E, lateral midfoot; F, medial midfoot; G+H, hind foot; a, contact length; b, forefoot contact width; c, midfoot contact width; and d, hindfoot contact width).

Reference

1. Park ES, Kim HW, Park CI, Rha DW, Park CW. Dynamic foot pressure measurements for assessing foot deformity in persons with spastic cerebral palsy. Arch Phys Med Rehabil. 2006; 87:703–709. PMID: 16635634.

2. Chang CH, Miller F, Schuyler J. Dynamic pedobarograph in evaluation of varus and valgus foot deformities. J Pediatr Orthop. 2002; 22:813–818. PMID: 12409913.

3. Tylkowski CM, Horan M, Oeffinger DJ. Outcomes of gastrocnemius-soleus complex lengthening for isolated equinus contracture in children with cerebral palsy. J Pediatr Orthop. 2009; 29:771–778. PMID: 20104161.

4. Oddy MJ, Brown C, Mistry R, Eastwood DM. Botulinum toxin injection site localization for the tibialis posterior muscle. J Pediatr Orthop B. 2006; 15:414–417. PMID: 17001247.

5. Mayer NH, Esquenazi A, Childers MK. Common patterns of clinical motor dysfunction. Muscle Nerve Suppl. 1997; 6:S21–S35. PMID: 9826981.

6. Molteni F, Bertoni M, Caimmi M. Equinovarus foot in upper motor neuron syndrome. In : Esquenazi A, editor. Gait analysis. Philadelphia: Hanley & Belfus;2002. p. 263–286.

7. Bollens B, Gustin T, Stoquart G, Detrembleur C, Lejeune T, Deltombe T. A randomized controlled trial of selective neurotomy versus botulinum toxin for spastic equinovarus foot after stroke. Neurorehabil Neural Repair. 2013; 27:695–703. PMID: 23757297.

8. Park CI, Park ES, Shin JC, Kim SW, Kim DY, Ahn JG. Effects of botulinum toxin A therapy on gastrocnemius in spastic cerebral palsied children. J Korean Acad Rehabil Med. 1999; 23:504–515.

9. Koman LA, Mooney JF 3rd, Smith BP, Walker F, Leon JM. Botulinum toxin type A neuromuscular blockade in the treatment of lower extremity spasticity in cerebral palsy: a randomized, double-blind, placebo-controlled trial. BOTOX Study Group. J Pediatr Orthop. 2000; 20:108–115. PMID: 10641699.

10. Riad J, Coleman S, Henley J, Miller F. Reliability of pediobarographs for paediatric foot deformity. J Child Orthop. 2007; 1:307–312. PMID: 19308525.

11. Armstrong DG, Lavery LA. Plantar pressures are higher in diabetic patients following partial foot amputation. Ostomy Wound Manag. 1998; 44:30–32. 3436 passim

12. Armstrong DG, Peters EJ, Athanasiou KA, Lavery LA. Is there a critical level of plantar foot pressure to identify patients at risk for neuropathic foot ulceration? J Foot Ankle Surg. 1998; 37:303–307. PMID: 9710782.

13. Holmes GB Jr, Timmerman L. A quantitative assessment of the effect of metatarsal pads on plantar pressures. Foot Ankle. 1990; 11:141–145. PMID: 2074081.

14. Lavery LA, Armstrong DG, Wunderlich RP, Tredwell J, Boulton AJ. Predictive value of foot pressure assessment as part of a population-based diabetes disease management program. Diabetes Care. 2003; 26:1069–1073. PMID: 12663575.

15. Minns RJ, Craxford AD. Pressure under the forefoot in rheumatoid arthritis: a comparison of static and dynamic methods of assessment. Clin Orthop Relat Res. 1984; 187:235–242. PMID: 6744725.

16. Singh N, Armstrong DG, Lipsky BA. Preventing foot ulcers in patients with diabetes. JAMA. 2005; 293:217–228. PMID: 15644549.

17. Oeffinger DJ, Pectol RW Jr, Tylkowski CM. Foot pressure and radiographic outcome measures of lateral column lengthening for pes planovalgus deformity. Gait Posture. 2000; 12:189–195. PMID: 11154928.

18. Liggio FJ, Kruse R. Split tibialis posterior tendon transfer with concomitant distal tibial derotational osteotomy in children with cerebral palsy. J Pediatr Orthop. 2001; 21:95–101. PMID: 11176361.

19. Park ES, Rha DW, Choi JE, Park CW, Chung HI. The changes of foot pressure distribution in spastic cerebral palsy with equinus deformity following corrective surgery. J Korean Acad Rehabil Med. 2005; 29:507–512.

20. Park ES, Park CI, Kim JY, Park JW, Kim EJ. Foot pressure distribution and path of center of pressure (COP) of foot during ambulation in the children with spastic cerebral palsy. J Korean Acad Rehabil Med. 2002; 26:127–132.

21. Chang CH, Albarracin JP, Lipton GE, Miller F. Long-term follow-up of surgery for equinovarus foot deformity in children with cerebral palsy. J Pediatr Orthop. 2002; 22:792–799. PMID: 12409910.

22. Huber H, Dutoit M. Dynamic foot-pressure measurement in the assessment of operatively treated clubfeet. J Bone Joint Surg Am. 2004; 86A:1203–1210. PMID: 15173293.

23. Metaxiotis D, Accles W, Pappas A, Doederlein L. Dynamic pedobarography (DPB) in operative management of cavovarus foot deformity. Foot Ankle Int. 2000; 21:935–947. PMID: 11103766.

24. Boulay C, Jacquemier M, Pomero V, Castanier E, Authier G, Chabrol B, et al. Dynamic EMG of peroneus longus in hemiplegic children with equinovarus. Ann Phys Rehabil Med. 2014; 57:185–192. PMID: 24656606.

25. Ben-Shabat E, Palit M, Fini NA, Brooks CT, Winter A, Holland AE. Intra- and interrater reliability of the Modified Tardieu Scale for the assessment of lower limb spasticity in adults with neurologic injuries. Arch Phys Med Rehabil. 2013; 94:2494–2501. PMID: 23851419.

26. Papavasiliou AS, Nikaina I, Bouros P, Rizou I, Filiopoulos C. Botulinum toxin treatment in upper limb spasticity: treatment consistency. Eur J Paediatr Neurol. 2012; 16:237–242. PMID: 21862370.

27. Baker R, Jasinski M, Maciag-Tymecka I, Michalowska-Mrozek J, Bonikowski M, Carr L, et al. Botulinum toxin treatment of spasticity in diplegic cerebral palsy: a randomized, double-blind, placebo-controlled, dose-ranging study. Dev Med Child Neurol. 2002; 44:666–675. PMID: 12418791.

28. Colovic H, Dimitrijevic L, Stankovic I, Nikolic D, Radovic-Janosevic D. Estimation of botulinum toxin type A efficacy on spasticity and functional outcome in children with spastic cerebral palsy. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2012; 156:41–47. PMID: 22580859.

29. Degelaen M, de Borre L, Kerckhofs E, de Meirleir L, Buyl R, Cheron G, et al. Influence of botulinum toxin therapy on postural control and lower limb intersegmental coordination in children with spastic cerebral palsy. Toxins (Basel). 2013; 5:93–105. PMID: 23344454.

30. Bakheit AM, Severa S, Cosgrove A, Morton R, Roussounis SH, Doderlein L, et al. Safety profile and efficacy of botulinum toxin A (Dysport) in children with muscle spasticity. Dev Med Child Neurol. 2001; 43:234–238. PMID: 11305399.

31. Lee SJ, Sung IY, Jang DH, Yi JH, Lee JH, Ryu JS. The effect and complication of botulinum toxin type A injection with serial casting for the treatment of spastic equinus foot. Ann Rehabil Med. 2011; 35:344–353. PMID: 22506143.

32. Falso M, Fiaschi A, Manganotti P. Pedobarometric evaluation of equinus foot disorder after injection of botulinum toxin A in children with cerebral palsy: a pilot study. Dev Med Child Neurol. 2005; 47:396–402. PMID: 15934488.

33. Bowen TR, Miller F, Castagno P, Richards J, Lipton G. A method of dynamic foot-pressure measurement for the evaluation of pediatric orthopaedic foot deformities. J Pediatr Orthop. 1998; 18:789–793. PMID: 9821137.

34. Chang CH, Albarracin JP, Lipton GE, Miller F. Long-term follow-up of surgery for equinovarus foot deformity in children with cerebral palsy. J Pediatr Orthop. 2002; 22:792–799. PMID: 12409910.

35. Davitt JS, MacWilliams BA, Armstrong PF. Plantar pressure and radiographic changes after distal calcaneal lengthening in children and adolescents. J Pediatr Orthop. 2001; 21:70–75. PMID: 11176357.

36. Sutherland DH, Kaufman KR, Wyatt MP, Chambers HG, Mubarak SJ. Double-blind study of botulinum A toxin injections into the gastrocnemius muscle in patients with cerebral palsy. Gait Posture. 1999; 10:1–9. PMID: 10469936.

37. Koog YH, Min BI. Effects of botulinum toxin A on calf muscles in children with cerebral palsy: a systematic review. Clin Rehabil. 2010; 24:685–700. PMID: 20554641.

38. Bottos M, Benedetti MG, Salucci P, Gasparroni V, Giannini S. Botulinum toxin with and without casting in ambulant children with spastic diplegia: a clinical and functional assessment. Dev Med Child Neurol. 2003; 45:758–762. PMID: 14580131.