Use of Botulinum Toxin Type A in the Management of Neonatal Brachial Plexus Palsy. Issue 12 (2nd May 2014)

• Record Type: Journal Article
• Authors: Michaud, Linda J.; Louden, Emily J.; Lippert, William C.; Allgier, Allison J.; Foad, Susan L.; Mehlman, Charles T.
• Is Part Of: PM&R. Volume 6:Issue 12(2014)
• Page Start: 1107
• Page End: 1119
• Publication Date: 2014-05-02
• Subjects: Medical rehabilitation -- Periodicals; Physical therapy -- Periodicals; Physical Therapy Modalities -- Periodicals; 615.5
• DOI: 10.1016/j.pmrj.2014.05.002
• Languages: English
• ISSNs: 1934-1482

Abstract

Abstract : Objective: To evaluate functional outcomes and the impact on surgical interventions after the use of botulinum neurotoxin type A (BoNT‐A) for muscle imbalance, cocontractions, or contractures with neonatal brachial plexus palsy. Design: A retrospective cohort study. Setting: A brachial plexus center in a tertiary children's hospital. Participants: Fifty‐nine patients with neonatal brachial plexus palsy (75 injection procedures, 91 muscles and/or muscle groups) received BoNT‐A injections (mean age at injection, 36.2 months; range, 6‐123 months; 31 boys; 30 right‐sided injuries, 28 left‐sided injuries, 1 bilateral injury). Methods: Data collected retrospectively from medical records, from procedure notes and clinic visits before BoNT‐A use, at ≤6 months follow‐up (BoNT‐A active [BA]) and at ≥7 months follow‐up (BoNT‐A not active [BNA]) included demographics, injection indication, side, and site(s), previous surgical history, occupational therapy and/or physical therapy plan, and outcome measurements. Main Outcome Measurements: Outcomes assessed before and after injections included active and passive range of motion, Mallet and Toronto scores, parent comments about arm function, preinjection surgical considerations, and postinjection surgical history. Results: Injection procedures included 51 to shoulder internal rotators, 15 triceps, 15 pronator teres, 9 biceps, and 1 flexor carpi ulnaris. Active and passive shoulder external rotation (SER) range of motion improved after shoulder internal rotator injections ( P = .0003 and P = .002, respectively), as did Mallet scores with BA; the latter were sustained with BNA. Surgical intervention was averted, modified, or deferred after BoNT‐A in 45% (n = 20) under surgical consideration before BoNT‐A. Active elbow flexion improved in 67% ( P = .005), sustained BNA ( P = .004) after triceps injections; 2 of 7 patients averted surgery. Active supination improved with BA ( P = .002), with gains sustained BNA ( P = .016). Passive elbow extension improved after biceps injections by an average 17° ( P = .004) BA, although not sustained BNA. Conclusions: BoNT‐A is an effective adjunct to therapy and surgery in managing muscle imbalance, cocontractions, and contractures in neonatal brachial plexus palsy. Use of BoNT‐A can result in averting, modifying, or deferring surgical interventions in a number of affected children.