A randomized controlled trial to compare two botulinum toxin injection techniques on the functional improvement of the leg of children with cerebral palsy

Objective: To compare the efficacy of botulinum toxin type A injection guided by different localizing techniques, electrical stimulation and palpation, to treat spasticity of the ankle plantar flexors. Design: Randomized controlled trial. Setting: Hospital neurology and rehabilitation department. Participants: Sixty-five children with spastic hemiplegic or diplegic cerebral palsy. Interventions: Botulinum toxin injection guided by electrical stimulation or palpation, and two weeks of physiotherapy. Main outcome measures: Passive range of movement (ROM), modified Ashworth Scale, Composite Spasticity Scale, D and E dimensions of the Gross Motor Function Measure, walking velocity. Results: Three groups improved significantly (P<0.05). The mean improvements between baseline and the end of follow-up were respectively 20, 16.2 and 11.9 degrees for passive ROM, -1.9, -1.4 and -0.7 for modified Ashworth Scale scores, -5.8, -4.2 and -2.3 for Composite Spasticity Scale scores, 18.6, 11.3 and 6.9 for Gross Motor Function Measure scores, and 0.2, 0.1 and 0.1 m/s for walking velocity in the botulinum toxin group guided by electrical stimulation injection plus physiotherapy, the botulinum toxin group guided by palpation injection plus physiotherapy, and the physiotherapy only group. The botulinum toxin injection guided by electrical stimulation group showed greater improvement in passive ROM (P<0.05), modified Ashworth Scale scores (P<0.05), Composite Spasticity Scale scores (P<0.05), and Gross Motor Function Measure scores (P<0.05) than the other two groups after treatment for three months. Conclusions: Botulinum toxin injection guided by electrical stimulation plus physiotherapy is likely to be best in improving spasticity and functional performance in children with cerebral palsy.