The updated European Consensus 2009 on the use of Botulinum toxin for children with cerebral palsy

doi:10.1016/j.ejpn.2009.09.005

European Journal of Paediatric Neurology

Volume 14, Issue 1, January 2010, Pages 45-66

https://doi.org/10.1016/j.ejpn.2009.09.005 Get rights and content

Abstract

An interdisciplinary European group of clinical experts in the field of movement disorders and experienced Botulinum toxin users has updated the consensus for the use of Botulinum toxin in the treatment of children with cerebral palsy (CP). A problem-orientated approach was used focussing on both published and practice-based evidence. In part I of the consensus the authors have tabulated the supporting evidence to produce a concise but comprehensive information base, pooling data and experience from 36 institutions in 9 European countries which involves more than 10,000 patients and over 45,000 treatment sessions during a period of more than 280 treatment years. In part II of the consensus the Gross Motor Function Measure (GMFM) and Gross Motor Function Classification System (GMFCS) based Motor Development Curves have been expanded to provide a graphical framework on how to treat the motor disorders in children with CP. This graph is named “CP^Graph Treatment Modalities – Gross Motor Function” and is intended to facilitate communication between parents, therapists and medical doctors concerning (1) achievable motor function, (2) realistic goal-setting and (3) treatment perspectives for children with CP. The updated European consensus 2009 summarises the current understanding regarding an integrated, multidisciplinary treatment approach using Botulinum toxin for the treatment of children with CP.

Section snippets

Legend to the consensus table

The Consensus update 2009 presents a conceptual framework for best practice in the use of Botulinum toxin (BoNT) in children with cerebral palsy (CP). Since the first European consensus table on Botulinum toxin for children with CP in 2006¹ basic research, clinical trials, new treatment strategies and safety regards have evolved in the expanding field of CP management. The aim of this updated, annotated, and tabulated evidence report (Table 1) is to incorporate the recent advances in knowledge

Cerebral palsy (section 1)

CP is the most common cause of spastic movement disorders in children.4, 5 Epidemiologic data has shown that with the advanced care in neonatal medicine the incidence and severity of CP in premature children of very low birth weight in Europe⁶ and northern America⁷ is decreasing. Our understanding of the etiology, or at least the pathogenesis, of the disease has been greatly advanced by the development of Magnetic Resonance Imaging techniques, which allow the identification of the underlying

The need and chance for visualisation

A further development of this updated consensus table is the introduction of an integrative treatment graph for children with bilateral spastic cerebral palsy (CP^Graph Treatment Modalities – Gross Motor Function (Fig. 1)).

This graph was presented as a draft and discussed at the consensus meeting and has been adapted on the basis of vivid discussions. It represents the likely path of motor development in a group of children with bilateral spastic CP based on the GMFM/GMFCS-based Motor

Conflicts of interest

Dr. Heinen and Dr. Berweck have received speaker's honoraria, research support and travel grants from manufacturers of the different BoNT preparations available (Allergan, Germany, IPSEN, Germany, Merz Pharmaceuticals, Germany). Dr. Schroeder reports having received lecture fees and travel grants from Allergan, Germany.

Dr. Molenaers and Mrs. Desloovere have received unrestricted educational grants, research support, speaker's honoraria and travel grants from Allergan. Dr Hustedt and

Acknowledgements

Florian Heinen, University of Munich, Ingeborg Krägeloh-Mann, University of Tuebingen, and Guy Molenaers, University of Leuven initiated the meeting that was held at and with the support of the University of Munich, Germany. The realisation of the meeting and the consensus table was made possible by an educational grant from Allergan. We thank Ashley Communications for the professional help in organisational aspects of the meeting and in organisational support for preparing this manuscript.

The

References (238)

F. Heinen et al.
European consensus table 2006 on Botulinum toxin for children with cerebral palsy
Eur J Paediatr Neurol
(2006)
M.J. Platt et al.
Trends in cerebral palsy among infants of very low birthweight (<1500 g) or born prematurely (<32 weeks) in 16 European centres: a database study
Lancet
(2007)
K.R. Aoki
A comparison of the safety margins of botulinum neurotoxin serotypes A, B, and F in mice
Toxicon
(2001)
B.E. Crowner et al.
Prospective study examining remote effects of Botulinum toxin a in children with cerebral palsy
Pediatr Neurol
(2008)
E.J. Yang et al.
Accuracy of manual needle placement for gastrocnemius muscle in children with cerebral palsy checked against ultrasonography
Arch Phys Med Rehabil
(2009)
A.G. Py et al.
Evaluation of the effectiveness of Botulinum toxin injections in the lower limb muscles of children with cerebral palsy. Preliminary prospective study of the advantages of ultrasound guidance
Ann Phys Rehabil Med
(2009)
P. Rosenbaum et al.
The World Health Organization International Classification of Functioning, Disability, and Health: a model to guide clinical thinking, practice and research in the field of cerebral palsy
Semin Pediatr Neurol
(2004)
G.L. Andersen et al.
Cerebral palsy in Norway: prevalence, subtypes and severity
Eur J Paediatr Neurol
(2008)
K. Himmelmann et al.
Bilateral spastic cerebral palsy–prevalence through four decades, motor function and growth
Eur J Paediatr Neurol
(2007)
S. Jarvis et al.
Cerebral palsy and intrauterine growth in single births: European collaborative study
Lancet
(2003)

L.A. Koman et al.

Cerebral palsy

Lancet

(2004)

H.K. Graham et al.

Recommendations for the use of Botulinum toxin type A in the management of cerebral palsy

Gait Posture

(2000)

R. Balkrishnan et al.

Parent caregiver-related predictors of health care service utilization by children with cerebral palsy enrolled in Medicaid

J Pediatr Health Care

(2002)

Botulinumtoxin: Unerwünschte Wirkungen

(2008)

Follow-up to the February 8, 2008

Early communication about an ongoing safety review of Botox and Botox cosmetic (Botulinum toxin type A) and myobloc (Botulinum toxin type B)

(2008)

K. Himmelmann et al.

The changing panorama of cerebral palsy in Sweden. IX. Prevalence and origin in the birth-year period 1995–1998

Acta Paediatr

(2005)

A. Hoon et al.

Cerebral palsy

C.M. Robertson et al.

Changes in the prevalence of cerebral palsy for children born very prematurely within a population-based program over 30 years

JAMA

(2007)

S. Ashwal et al.

Practice parameter: diagnostic assessment of the child with cerebral palsy: report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society

Neurology

(2004)

A.R. Hart et al.

Magnetic resonance imaging and developmental outcome following preterm birth: review of current evidence

Dev Med Child Neurol

(2008)

M.N. Robinson et al.

Magnetic resonance imaging findings in a population-based cohort of children with cerebral palsy

Dev Med Child Neurol

(2009)

I. Krageloh-Mann

Imaging of early brain injury and cortical plasticity

Exp Neurol

(2004)

SCPE

Surveillance of cerebral palsy in Europe: a collaboration of cerebral palsy surveys and registers. Surveillance of Cerebral Palsy in Europe (SCPE)

Dev Med Child Neurol

(2000)

U. Petruch et al.

The reference and trainigs manual of the SCPM (Surveillance of Cerebral Palsy in Europe)

Neuropediatrics

(2004)

R. Palisano et al.

Development and reliability of a system to classify gross motor function in children with cerebral palsy

Dev Med Child Neurol

(1997)

E. Wood et al.

The gross motor function classification system for cerebral palsy: a study of reliability and stability over time

Dev Med Child Neurol

(2000)

G. Hagglund et al.

Characteristics of children with hip displacement in cerebral palsy

BMC Musculoskelet Disord

(2007)

J.W. Gorter et al.

Limb distribution, motor impairment, and functional classification of cerebral palsy

Dev Med Child Neurol

(2004)

K. Himmelmann et al.

Gross and fine motor function and accompanying impairments in cerebral palsy

Dev Med Child Neurol

(2006)

P. Rosenbaum et al.

A report: the definition and classification of cerebral palsy April 2006

Dev Med Child Neurol Suppl

(2007)

D. Kinnett

Botulinum toxin A injections in children: technique and dosing issues

Am J Phys Med Rehabil

(2004)

K. Lowe et al.

Low-dose/high-concentration localized Botulinum toxin A improves upper limb movement and function in children with hemiplegic cerebral palsy

Dev Med Child Neurol

(2006)

G. Hagglund et al.

Prevention of severe contractures might replace multilevel surgery in cerebral palsy: results of a population-based health care programme and new techniques to reduce spasticity

J Pediatr Orthop B

(2005)

G. Molenaers et al.

The effects of quantitative gait assessment and Botulinum toxin a on musculoskeletal surgery in children with cerebral palsy

J Bone Joint Surg Am

(2006)

N. Lannin et al.

AACPDM systematic review of the effectiveness of therapy for children with cerebral palsy after Botulinum toxin A injections

Dev Med Child Neurol

(2006)

A. Meyer-Heim et al.

Improvement of walking abilities after robotic-assisted locomotion training in children with cerebral palsy

Arch Dis Child

(2009)

I. Borggraefe et al.

Improved gait parameters after robotic-assisted locomotor treadmill therapy in a 6-year-old child with cerebral palsy

Mov Disord

(2008)

S.E. Fasoli et al.

Upper limb robotic therapy for children with hemiplegia

Am J Phys Med Rehabil

(2008)

A. Meyer-Heim et al.

Feasibility of robotic-assisted locomotor training in children with central gait impairment

Dev Med Child Neurol

(2007)

J.P. Phillips et al.

Ankle dorsiflexion fMRI in children with cerebral palsy undergoing intensive body-weight-supported treadmill training: a pilot study

Dev Med Child Neurol

(2007)

K.J. Dodd et al.

Partial body-weight-supported treadmill training can improve walking in children with cerebral palsy: a clinical controlled trial

Dev Med Child Neurol

(2007)

J. Rodda et al.

Classification of gait patterns in spastic hemiplegia and spastic diplegia: a basis for a management algorithm

Eur J Neurol

(2001)

D. Wenger et al.

The art and practice of children's orthopedics

(1993)

F. Heinen et al.

When it comes to Botulinum toxin, children and adults are not the same: multimuscle option for children with cerebral palsy

Mov Disord

(2006)

G. Molenaers et al.

A multilevel approach to Botulinum toxin type A treatment of the (ilio)psoas in spasticity in cerebral palsy

Eur J Neurol

(1999)

Huss K, Berweck S, Schroeder AS, Mall V, Borggaefe I, and Heinen F. Interventional-neuropaediatric spectrum of...

R.L. Rosales et al.

Extrafusal and intrafusal muscle effects in experimental Botulinum toxin-A injection

Muscle Nerve

(1996)

W.H. Jost et al.

Efficacy and tolerability of a Botulinum toxin type A free of complexing proteins (NT 201) compared with commercially available Botulinum toxin type A (BOTOX) in healthy volunteers

J Neural Transm

(2005)

WeMove, Management of Spasticity with Botulinum Toxin Type A (Botox®) – suggested pediatric Botox® dosing;...

C.M. Shaari et al.

Quantifying how location and dose of Botulinum toxin injections affect muscle paralysis

Muscle Nerve

(1993)

Cited by (242)

Botulinum neurotoxin type A responders among children with spastic cerebral palsy: Pattern-specific effects
2024, European Journal of Paediatric Neurology
To identify short-term effects of botulinum neurotoxin type A (BoNT) injections on gait and clinical impairments, in children with spastic cerebral palsy (CP), based on baseline gait pattern-specific subgroups.
Short-term effects of BoNT injections in the medial hamstrings and gastrocnemius were defined in a retrospective convenience sample of 117 children with CP (median age: 6 years 4 months; GMFCS I/II/III: 70/31/16; unilateral/bilateral: 56/61) who had received gait analyses before and 2 months post-BoNT. First, baseline gait patterns were classified. Statistical and meaningful changes were calculated between pre- and post-BoNT lower limb sagittal plane kinematic waveforms, the gait profile score, and non-dimensional spatiotemporal parameters for the entire sample and for pattern-specific subgroups. These gait waveforms per CP subgroup at pre- and post-BoNT were also compared to typically developing gait and composite scores for spasticity, weakness, and selectivity were compared between the two conditions.
Kinematic improvements post-BoNT were identified at the ankle and knee for the entire sample, and for subgroups with apparent equinus and jump gait. Limbs with baseline patterns of dropfoot and to a lesser extent true equinus showed clear improvements only at the ankle. In apparent equinus, jump gait, and dropfoot, spasticity improved post-BoNT, without leading to increased weakness or diminished selectivity. Compared to typical gait, knee and hip motion improved in the crouch gait subgroup post-BoNT.
This comprehensive analysis highlighted the importance of investigating BoNT effects on gait and clinical impairments according to baseline gait patterns. These findings may help identify good treatment responders.
Incontinence training in children with cerebral palsy: A prospective controlled trial
2022, Journal of Pediatric Urology
Urinary incontinence is the most frequently observed lower urinary tract symptom in children with cerebral palsy (CP). Being continent can positively influence quality of life of the child and the social environment.
To investigate the effectiveness of incontinence training with urotherapy in children with CP.
A population-based case-control study was conducted including 21 children with CP and 24 typically developing children between 5 and 12 years old, both with daytime incontinence or combined daytime incontinence and enuresis.
Children received treatment for one year with three-monthly examination by means of uroflowmetry, a structured questionnaire and bladder diaries. Children started with three months of standard urotherapy. After three, six and nine months of training, specific urotherapy interventions (pelvic floor muscle training with biofeedback, alarm treatment or neuromodulation) and/or pharmacotherapy could be added to the initial treatment. Therapy was individualized to probable underlying conditions.
Effectiveness was controlled for spontaneous improvement due to maturation and analysed by means of longitudinal linear models, generalized estimating equations and multilevel cumulative odds models. Comparison with typically developing children was assessed by means of Kaplan–Meier survival analysis.
Results suggest effectivity rate of incontinence training is lower and changes occur more slowly in time in children with CP compared to typically developing children (Figure).
Within the group of children with CP, significant changes during one year of training were found for daytime incontinence (p < 0.001), frequency of daytime incontinence (p = 0.002), frequency of enuresis (p = 0.048), storage symptoms (p = 0.011), correct toilet posture (p = 0.034) and fecal incontinence (p = 0.026).
Maximum voided volume and fluid intake at the start of training were significantly lower in children with CP and could explain a delayed effectiveness of urotherapy. Treatment of constipation demonstrated a positive effect on maximum voided volume and should be initiated together with standard urotherapy when constipation is still present after implementation of a correct fluid intake schedule. Future research with a larger sample size is recommended.
Incontinence training with urotherapy can be an effective treatment for urinary incontinence in children with cerebral palsy. In the current cohort, effectivity rate of incontinence training was lower and changes occurred more slowly in children with cerebral palsy compared to typically developing children.
Long-term efficacy and safety of repeated botulinum toxin a applications based on function and anesthesia type in children with cerebral palsy
2022, Journal of Orthopaedics
This study evaluates the motor development of patients undergoing three or more repeated Botulinum toxin A (BoNT-A) applications in a tertiary pediatric hospital as well as the safety of three different types of anesthesia.
Seventy-five children who underwent BoNT-A applications at least three consecutive times at six-month intervals and a total of 320 procedures were examined. Gross Motor Function Classification System (GMFCS) was employed in motor development evaluation. The three anesthesia methods (sedation analgesia, anesthesia with larengeal mask [LMA] and inhalation mask) were compared in terms of sedation, procedure, recovery, and total operation room time.
Following the procedures, significant motor development was observed in 60 (80%) patients. In sedation analgesia group during the first three procedures, the recovery time was seen to be significantly shorter, while there was no difference between the anesthesia methods of any procedures following the fourth. Regardless of the type of anesthesia, the recovery times of those having undergone six or more procedures were longer than those with less than six procedures.
As repeated BoNT-A application provides motor step progress, it can be applied safely and effectively under anesthesia. Sedation analgesia provides an easier recovery compared to LMA and mask only within the first three applications. However, recovery time increases with four or more repeated applications, specifically increasing as the number of applications increases.
III.
Beyond pediatrics: noninvasive spinal neuromodulation improves motor function in an adult with cerebral palsy
2024, Bioelectronic Medicine
Reliability and validity of the Japanese version of the Visual Function Classification System for children with cerebral palsy
2024, Child: Care, Health and Development
Safety and Feasibility of Functional Repetitive Neuromuscular Magnetic Stimulation of the Gluteal Muscles in Children and Adolescents with Bilateral Spastic Cerebral Palsy
2023, Children

View all citing articles on Scopus

View full text

Review articleThe updated European Consensus 2009 on the use of Botulinum toxin for children with cerebral palsy

Abstract

Section snippets

Legend to the consensus table

Cerebral palsy (section 1)

The need and chance for visualisation

Conflicts of interest

Acknowledgements

Eur J Paediatr Neurol

Lancet

Toxicon

Pediatr Neurol

Arch Phys Med Rehabil

Ann Phys Rehabil Med

Semin Pediatr Neurol

Eur J Paediatr Neurol

Eur J Paediatr Neurol

Lancet

Lancet

Gait Posture

J Pediatr Health Care

Botulinumtoxin: Unerwünschte Wirkungen

Follow-up to the February 8, 2008

Early communication about an ongoing safety review of Botox and Botox cosmetic (Botulinum toxin type A) and myobloc (Botulinum toxin type B)

The changing panorama of cerebral palsy in Sweden. IX. Prevalence and origin in the birth-year period 1995–1998

Acta Paediatr

Cerebral palsy

Changes in the prevalence of cerebral palsy for children born very prematurely within a population-based program over 30 years

JAMA

Practice parameter: diagnostic assessment of the child with cerebral palsy: report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society

Neurology

Magnetic resonance imaging and developmental outcome following preterm birth: review of current evidence

Dev Med Child Neurol

Magnetic resonance imaging findings in a population-based cohort of children with cerebral palsy

Dev Med Child Neurol

Imaging of early brain injury and cortical plasticity

Exp Neurol

Surveillance of cerebral palsy in Europe: a collaboration of cerebral palsy surveys and registers. Surveillance of Cerebral Palsy in Europe (SCPE)

Dev Med Child Neurol

The reference and trainigs manual of the SCPM (Surveillance of Cerebral Palsy in Europe)

Neuropediatrics

Development and reliability of a system to classify gross motor function in children with cerebral palsy

Dev Med Child Neurol

The gross motor function classification system for cerebral palsy: a study of reliability and stability over time

Dev Med Child Neurol

Characteristics of children with hip displacement in cerebral palsy

BMC Musculoskelet Disord

Limb distribution, motor impairment, and functional classification of cerebral palsy

Dev Med Child Neurol

Gross and fine motor function and accompanying impairments in cerebral palsy

Dev Med Child Neurol

A report: the definition and classification of cerebral palsy April 2006

Dev Med Child Neurol Suppl

Botulinum toxin A injections in children: technique and dosing issues

Am J Phys Med Rehabil

Low-dose/high-concentration localized Botulinum toxin A improves upper limb movement and function in children with hemiplegic cerebral palsy

Dev Med Child Neurol

Prevention of severe contractures might replace multilevel surgery in cerebral palsy: results of a population-based health care programme and new techniques to reduce spasticity

J Pediatr Orthop B

The effects of quantitative gait assessment and Botulinum toxin a on musculoskeletal surgery in children with cerebral palsy

J Bone Joint Surg Am

AACPDM systematic review of the effectiveness of therapy for children with cerebral palsy after Botulinum toxin A injections

Dev Med Child Neurol

Improvement of walking abilities after robotic-assisted locomotion training in children with cerebral palsy

Arch Dis Child

Improved gait parameters after robotic-assisted locomotor treadmill therapy in a 6-year-old child with cerebral palsy

Mov Disord

Upper limb robotic therapy for children with hemiplegia

Am J Phys Med Rehabil

Feasibility of robotic-assisted locomotor training in children with central gait impairment

Dev Med Child Neurol

Ankle dorsiflexion fMRI in children with cerebral palsy undergoing intensive body-weight-supported treadmill training: a pilot study

Dev Med Child Neurol

Partial body-weight-supported treadmill training can improve walking in children with cerebral palsy: a clinical controlled trial

Dev Med Child Neurol

Classification of gait patterns in spastic hemiplegia and spastic diplegia: a basis for a management algorithm

Eur J Neurol

The art and practice of children's orthopedics

When it comes to Botulinum toxin, children and adults are not the same: multimuscle option for children with cerebral palsy

Mov Disord

Review article
The updated European Consensus 2009 on the use of Botulinum toxin for children with cerebral palsy