Botulinum toxin with and without casting in ambulant children with spastic diplegia: a clinical and functional assessment

This study compared clinical and functional outcomes after treatment with botulinum toxin A (BTX-A) and BTX-A with casting in children with dynamic equinus foot. Ten children (seven males, three females; mean age 6 years 4 months, SD 2 years 7 months; range 4 to 11 years) with mild spastic diplegia and independent walking were divided into two groups: group 1, BTX-A and group 2, BTX-A plus casting. BTX-A was injected in the triceps surae bilaterally at multiple sites while the children were sedated with mask anaesthesia. Dysport((R)) toxin was used, 15 to 20IU/kg in each muscle. Immediately after injection an ankle-foot orthosis was applied to children in group 1 and a cast to children in group 2. Clinical assessment using the Ashworth scale, Gross Motor Function Measure (GMFM), range of movement measurement, and gait analysis was performed before treatment and 1, 4, and 12 months after treatment. Spasticity decreased significantly at 1-month examination in both groups (p=0.002), at 4-month examinations (Wilcoxon test P=0.003), and 12 month (P=0.052) examinations in group 2. GMFM highlighted a significant improvement in group 2 at the 4-month examination (p=0.052 for standing, p=0.007 for walking). Gait analysis showed a significant increase in the walking speed in group 2 (p=0.04). No change was detected in ankle kinematics and kinetics or in muscular activity during the gait cycle. We confirmed that BTX-A reduces spasticity and improves functional performance in standing and walking; association with casting provides more marked and enduring results.