Upper-Limb Therapy in Children Following Injection of Botulinum Neurotoxin A

Abstract

Botulinum neurotoxin A (BoNT-A) is a useful medication for the reduction of muscle overactivity in the upper limb(s) of children with cerebral palsy. The method for BoNT-A delivery, dose, and muscle localization criteria are established. Children who are being treated require appropriate assessment at the impairment and activity levels of functioning. Once injected, children require specific therapy delivered by an occupational therapist according to the specified goals that are set out prior to injection, by the child, family, and health-care workers. BoNT-A injection offers the child with cerebral palsy a period of reduced muscle overactivity and is a useful adjunct to evidence-based upper-limb therapy.

After injection and intensive therapy, the client was really happy to be able to catch and throw a ball with his school friends.

Appendices

The Case Study of Anna: Activity-based Therapy Following Upper-Limb Injections of Botulinum Neurotoxin A

Keywords

Botulinum neurotoxin A, cerebral palsy, upper-limb rehabilitation

Introduction

The theme of this case study is to improve the functional use of the more affected upper limb in a young child with unilateral cerebral palsy.

The student’s tasks include:

• Understanding the etiology, definition, types, and symptoms of cerebral palsy (Bax et al. 2005)

• Reasons for using botulinum neurotoxin A in the upper limb in children with cerebral palsy (Hoare et al. 2010; Hoare et al. 2013)

• Understanding the types and evidence for upper-limb occupational therapy intervention in children with cerebral palsy (Valvano 2004; Novak et al. 2013; Eliasson et al 2013)

• Synthesizing the information into a report

As a starting point, students should use the following references to gather background information.

Important references include:

Bax M, Goldstein M, Rosenbaum P, Leviton A, Paneth N, Dan B et al (2005) Proposed definition and classification of cerebral palsy, April 2005. Dev Med Child Neurol 47(8):571–576

Eliasson A-C, Krumlinde-Sundholm L, Gordon A, Feys H, Klingels K, Aarts P, Rameckers E, Autti-Rämö I, Hoare B (2013) Guidelines for future research in Constraint-induced movement therapy for children with unilateral cerebral palsy: An expert consensus. Dev Med Child Neurol (in Press)

Hoare BJ, Wallen MA, Imms C, Villanueva E, Rawicki HB, Carey L (2010) Botulinum toxin A as an adjunct to treatment in the management of the upper limb in children with spastic cerebral palsy (UPDATE). Cochrane Database Sys Rev (Online)(1) CD003469

Hoare B, Imms C, Villanueva E, Rawicki HB, Matyas T, Carey L (2013) Intensive therapy following upper limb botulinum toxin A injection in young children with unilateral cerebral palsy: a randomized trial. Dev Med Child Neurol 55(3):238–247

Novak I, McIntyre S, Morgan C, Campbell L, Dark L, Morton N, Stumbles E, Wilson SA, Goldsmith S (2013) A systematic review of interventions for children with cerebral palsy: state of the evidence. Dev Med Child Neurol 55(10):885–910

Valvano J (2004) Activity-focused motor interventions for children with neurological conditions. Phys Occup Ther Pediatr 24(1–2):79–107

Overview of the Content

Major Goals of the Actual Intervention

The major goal for injection of botulinum neurotoxin A is to reduce muscle overactivity thereby reducing the risk for development of increased muscle stiffness and permanent muscle shortening. As an adjunct to upper-limb activity-based intervention, injection of BoNT-A also offers a window of reduced muscle overactivity and improved posture to maximize the effect of activity-based therapy that aims to improve upper-limb function and occupational performance.

Learning Objectives

By the end of studying this chapter, the learner will:

• Be able to use a literature review to solve the case based on the CM

• Be able to apply the CM in clinical reasoning to the specific case study and similar clinical situations.

• Understand the justification and ethical considerations related to using botulinum neurotoxin A in children with cerebral palsy.

• Write a scientific report on using botulinum neurotoxin A as an adjunct to upper-limb therapy in children with cerebral palsy.

The background history of the clinical case study:

Personal Information

Anna is an 18-month-old girl who lives with her parents, James and Kate. James works full time and Kate works 3 days a week. While her parents are working, Anna attends child-care for 2 days a week and is cared for by her maternal grandparents on the other day.

Medical Information Including Prognoses

Anna was born at term via an uncomplicated pregnancy. At 4 months of age, Kate noticed that Anna’s right hand was fisted with her thumb tucked into the palm. Anna also had a strong left-hand preference during play and avoided use of her right hand. At 7 months of age, Anna was assessed by a pediatric neurologist who suspected a diagnosis of right unilateral cerebral palsy . This was confirmed by an MRI at 8 months of age. Anna now sits independently and uses a commando crawl to move around on the floor. She does not crawl. She has recently started to pull to stand and is able to take steps while holding onto furniture. She has started to use single words and responds well to verbal cues.

Occupational Therapy Interventions

Following her diagnosis, Anna was referred to the physical rehabilitation clinic at a local hospital. She was assessed by the multidisciplinary team and goals discussed with her parents. James and Kate were very concerned about Anna’s lack of spontaneous use of her right upper limb and their primary goal was for Anna to play with toys using two hands. As a result, Anna received an 8-week block of modified constraint-induced movement therapy (mCIMT) with her occupational therapist. She was also provided with a static overnight stretching splint with a supination strap. Anna made significant improvements following mCIMT. She now spontaneously initiates the use of her right hand to touch and hold objects. She is able to grasp, hold, transport, and release smaller objects but has difficulty with larger objects. She also has difficulty stabilizing objects on the table and pulling objects apart. Anna has full passive range of motion in all joints and no catch is present on high-velocity passive stretch. During her post-intervention assessment, Anna’s occupational therapist was concerned with increasing abnormal posture in her right shoulder, forearm, and thumb. During active use of the right upper limb, Anna’s shoulder appeared to internally rotate, the forearm hyper-pronated, and thumb adducted across her palm. This made the effective grasp of objects difficult. The occupational therapist felt an injection of botulinum neurotoxin A would assist in improving posture during active use of the limb and an appointment was made for consultation with the rehabilitation specialist at the physical rehabilitation clinic.

The Student’s Report

The following guiding questions have been identified in developing possible solutions for Anna. These questions were generated from the references found in the literature search:

• What are the major definitions and concepts used in this case?

• What is the aim of the static night splint with supination strap?

• Is Anna an appropriate candidate for upper-limb botulinum neurotoxin A? What valid and reliable assessments could be used to help determine the need of an upper-limb injection?

• What muscles would be considered for injection of botulinum neurotoxin A?

• What type of activity level intervention would be appropriate for Anna following injection of BoNT-A? What intensity and how long should this intervention be provided for? What is the evidence for this intervention?

• What are some examples of age-appropriate and challenging activities to use in therapy sessions?

• What are some considerations for the treatment environment to ensure Anna achieves the level of practice required to improve her hand skills?

• What are some of the personal and environmental barriers to implementing a home program for Anna?