Comparison of Tendon Transfer, Botox Injections and Ongoing Treatment in Hemiplegic Cerebral Palsy - Full Text View

Purpose

Doctors use different treatments for people with Cerebral Palsy. Surgery is one option. Botulinum toxin injections are another option; these are given directly into spastic muscles to weaken them temporarily. Regular ongoing treatment (splinting, stretching and exercises) is another option. The investigators want to find out if surgery works better than Botulinum Toxin (Botox) injections or regular ongoing treatment (therapy), and if the effects of Botulinum Toxin injections last for longer than six months.

Condition	Intervention
Cerebral Palsy	Procedure: Upper Extremity Tendon transfer Procedure: Botulinum Toxin injections in Upper Extremity Procedure: Regularly ongoing therapy

Study Type:	Interventional
Study Design:	Allocation: Randomized Endpoint Classification: Efficacy Study Intervention Model: Parallel Assignment Masking: Open Label
Official Title:	Multi Center Project: Comparison of Functional Outcomes of Tendon Transfer Surgery, Botulinum Toxin Injections and Regular Ongoing Treatment in Hemiplegic Upper Extremity Cerebral Palsy

Resource links provided by NLM:

MedlinePlus related topics: Botox Cerebral Palsy Paralysis

Drug Information available for: OnabotulinumtoxinA

U.S. FDA Resources

Further study details as provided by Shriners Hospitals for Children:

Primary Outcome Measures:

Scores on functional assessments at initial, 6 month and 1 year post intervention. [ Time Frame: 1 year ] [ Designated as safety issue: No ]

Secondary Outcome Measures:

Scores on questionnaires that assess participation and patient satisfaction at initial, 6 month and 1 year post intervention. [ Time Frame: 1 Year ] [ Designated as safety issue: No ]

Enrollment:	38
Study Start Date:	February 2005
Estimated Study Completion Date:	December 2012
Estimated Primary Completion Date:	December 2012 (Final data collection date for primary outcome measure)

Arms	Assigned Interventions
Active Comparator: Therapy Group Therapy only	Procedure: Regularly ongoing therapy
Active Comparator: Surgery Group surgical intervention	Procedure: Upper Extremity Tendon transfer
Active Comparator: Botox Injections botulinum toxin	Procedure: Botulinum Toxin injections in Upper Extremity

Detailed Description:

The specific aims of this study and the methodology for achieving them are:

To determine if tendon surgery for the forearm, wrist and thumb deformities of UECP is more effective than Botulinum toxin injections or regular ongoing treatment at improving function and quality of life for children with UECP. Children who are candidates for tendon surgery will be prospectively randomized to one of three treatment groups: standard tendon surgery, a series of three Botulinum toxin injections over a period of 12 months, and regular ongoing treatment. Validated tests of cognition, function and quality of life with tests of stereognosis and range of motion will be administered before, during and after treatment in order to compare outcomes of the three treatment groups.
To determine if serial Botulinum toxin injections have long-term beneficial effects on upper extremity function which outlast their paralytic effects.

Botulinum toxin has been shown to have beneficial effects on UE function while the muscles injected remain weakened by the toxin. Clinicians have theorized that improvements in UE function are maintained after the toxin wears off, but this has not been proven. Children randomized to the Botulinum toxin injection group will receive 3 injections. Their function will be tested before the first injection, while the paralytic results of the second injection are still in effect, and after the paralytic effects of the third injection have worn off, and the results compared in order to determine if functional improvements outlast the medicinal effects.

Eligibility

Ages Eligible for Study:	4 Years to 17 Years
Genders Eligible for Study:	Both
Accepts Healthy Volunteers:	No

Criteria

Inclusion Criteria:

diagnosis of UECP
aged four to 17 years
candidate for standard surgical management (tendon transfer)

Exclusion Criteria:

subject could benefit from procedures in addition to standard surgical management and releases, and these procedures could be performed at the same anesthetic (for example, elbow flexor release)
previous Botulinum toxin injection session in the affected UE in < 1 year
previous ipsilateral UE surgery
primary language other than English or Spanish
subject and/or parent unwilling to attend eight therapy sessions and perform home exercise protocol

Contacts and Locations

Please refer to this study by its ClinicalTrials.gov identifier: NCT00250081

Locations

United States, California
Shriners Hospitals for Children Northern California
Sacramento, California, United States, 95817
United States, Delaware
Alfred I duPont Childrens Hospital
Wilmington, Delaware, United States, 19803
United States, District of Columbia
Children's National Medical Center
Washington, District of Columbia, United States, 20010-2970
United States, Florida
Shriners Hosptials for Children
Tampa, Florida, United States, 33612
United States, Illinois
Shriners Hospitals for Children Chicago
Chicago, Illinois, United States, 60707
United States, Louisiana
Shriners Hospitals for Children
Shreveport, Louisiana, United States, 71103
United States, Minnesota
Shriners Hospitals for Children, Twin Cities
Minneapolis, Minnesota, United States, 55414
United States, Missouri
Children's Mercy Hospital
Kansas City, Missouri, United States, 64108
United States, South Carolina
Shriners Hospitals for Children
Greenville, South Carolina, United States, 29605
United States, Utah
Shriners Hosptials for Children, Intermountain
Salt Lake City, Utah, United States, 84103

Sponsors and Collaborators

Shriners Hospitals for Children

Investigators

Principal Investigator:	Michelle James, MD	Shriners Hospitals for Children, Northern Calfiornia
Principal Investigator:	Ann Van Heest, MD	Shriners Hospitals for Children, Twin Cities
Principal Investigator:	Anita Bagley, PhD	Shriners Hospitals for Children, Northern California

More Information

Additional Information:

Official website for Shriners Hospitals for Children, a network of 22 hospitals that provide expert, no-cost orthopaedic and burn care to children under 18 This link exits the ClinicalTrials.gov site

This link exits the ClinicalTrials.gov site

Publications:

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Autti-Ramo I, Larsen A, Peltonen J, Taimo A, von Wendt L. Botulinum toxin injection as an adjunct when planning hand surgery in children with spastic hemiplegia. Neuropediatrics. 2000 Feb;31(1):4-8.

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Wallen MA, O'flaherty SJ, Waugh MC. Functional outcomes of intramuscular botulinum toxin type A in the upper limbs of children with cerebral palsy: a phase II trial. Arch Phys Med Rehabil. 2004 Feb;85(2):192-200. Erratum in: Arch Phys Med Rehabil. 2994 May;85(5):862.

Fehlings D, Rang M, Glazier J, Steele C. An evaluation of botulinum-A toxin injections to improve upper extremity function in children with hemiplegic cerebral palsy. J Pediatr. 2000 Sep;137(3):331-7.

El-Said NS. Selective release of the flexor origin with transfer of flexor carpi ulnaris in cerebral palsy. J Bone Joint Surg Br. 2001 Mar;83(2):259-62.

Hoffer MM, Lehman M, Mitani M. Long-term follow-up on tendon transfers to the extensors of the wrist and fingers in patients with cerebral palsy. J Hand Surg [Am]. 1986 Nov;11(6):836-40.

Thometz JG, Tachdjian M. Long-term follow-up of the flexor carpi ulnaris transfer in spastic hemiplegic children. J Pediatr Orthop. 1988 Jul-Aug;8(4):407-12.

Tonkin M, Gschwind C. Surgery for cerebral palsy: Part 2. Flexion deformity of the wrist and fingers. J Hand Surg [Br]. 1992 Aug;17(4):396-400.

Wenner SM, Johnson KA. Transfer of the flexor carpi ulnaris to the radial wrist extensors in cerebral palsy. J Hand Surg [Am]. 1988 Mar;13(2):231-3.

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Manske PR. Redirection of extensor pollicis longus in the treatment of spastic thumb-in-palm deformity. J Hand Surg [Am]. 1985 Jul;10(4):553-60.

Hoffer MM, Perry J, Melkonian G. Postoperative electromyographic function of tendon transfers in patients with cerebral palsy. Dev Med Child Neurol. 1990 Sep;32(9):789-91.

Perry J, Hoffer MM. Preoperative and postoperative dynamic electromyography as an aid in planning tendon transfers in children with cerebral palsy. J Bone Joint Surg Am. 1977 Jun;59(4):531-7.

Hoffer MM. The use of the pathokinesiology laboratory to select muscles for tendon transfers in the cerebral palsy hand. Clin Orthop Relat Res. 1993 Mar;(288):135-8.

Kozin SH, Keenan MA. Using dynamic electromyography to guide surgical treatment of the spastic upper extremity in the brain-injured patient. Clin Orthop Relat Res. 1993 Mar;(288):109-17.

Mowery CA, Gelberman RH, Rhoades CE. Upper extremity tendon transfers in cerebral palsy: electromyographic and functional analysis. J Pediatr Orthop. 1985 Jan-Feb;5(1):69-72.

Johanson ME, James MA, Skinner SR. Forearm muscle activation during power grip and release. J Hand Surg [Am]. 1998 Sep;23(5):938-44.

Johanson ME, Skinner SR, Lamoreux LW. Phasic relationships of the intrinsic and extrinsic thumb musculature. Clin Orthop Relat Res. 1996 Jan;(322):120-30.

Johanson ME, Skinner SR, Lamoreux LW, St Helen R, Moran SA, Ashley RK. Phasic relationships of the extrinsic muscles of the normal hand. J Hand Surg [Am]. 1990 Jul;15(4):587-94.

Palmieri TL, Petuskey K, Bagley A, Takashiba S, Greenhalgh DG, Rab GT. Alterations in functional movement after axillary burn scar contracture: a motion analysis study. J Burn Care Rehabil. 2003 Mar-Apr;24(2):104-8.

Rab G, Petuskey K, Bagley A. A method for determination of upper extremity kinematics. Gait Posture. 2002 Apr;15(2):113-9.

Mosqueda T, James MA, Petuskey K, Bagley A, Abdala E, Rab G. Kinematic assessment of the upper extremity in brachial plexus birth palsy. J Pediatr Orthop. 2004 Nov-Dec;24(6):695-9.

Albright AL, Barry MJ, Painter MJ, Shultz B. Infusion of intrathecal baclofen for generalized dystonia in cerebral palsy. J Neurosurg. 1998 Jan;88(1):73-6.

Fedrizzi E, Pagliano E, Andreucci E, Oleari G. Hand function in children with hemiplegic cerebral palsy: prospective follow-up and functional outcome in adolescence. Dev Med Child Neurol. 2003 Feb;45(2):85-91. Erratum in: Dev Med Child Neurol. 2003 Mar;45(3):206.

Law M, King G. Parent compliance with therapeutic interventions for children with cerebral palsy. Dev Med Child Neurol. 1993 Nov;35(11):983-90.

Manske PR, Langewisch KR, Strecker WB, Albrecht MM. Anterior elbow release of spastic elbow flexion deformity in children with cerebral palsy. J Pediatr Orthop. 2001 Nov-Dec;21(6):772-7.

Rodriquez AA, McGinn M, Chappell R. Botulinum toxin injection of spastic finger flexors in hemiplegic patients. Am J Phys Med Rehabil. 2000 Jan-Feb;79(1):44-7.

Tonkin MA, Hatrick NC, Eckersley JR, Couzens G. Surgery for cerebral palsy part 3: classification and operative procedures for thumb deformity. J Hand Surg [Br]. 2001 Oct;26(5):465-70.

Van Heest AE, House JH, Cariello C. Upper extremity surgical treatment of cerebral palsy. J Hand Surg [Am]. 1999 Mar;24(2):323-30.

Bourke-Taylor H. Melbourne Assessment of Unilateral Upper Limb Function: construct validity and correlation with the Pediatric Evaluation of Disability Inventory. Dev Med Child Neurol. 2003 Feb;45(2):92-6.

Responsible Party:	Michelle James, Chief of Orthopaedics, Shriners Hospitals for Children
ClinicalTrials.gov Identifier:	NCT00250081 History of Changes
Other Study ID Numbers:	83004-278826
Study First Received:	November 3, 2005
Last Updated:	December 11, 2012
Health Authority:	United States: Institutional Review Board

Keywords provided by Shriners Hospitals for Children:

Cerebral Palsy
Tendon Transfer
Botulinum Toxin Type A
Occupational Therapy
Child

Additional relevant MeSH terms:

Cerebral Palsy
Paralysis
Brain Damage, Chronic
Brain Diseases
Central Nervous System Diseases
Nervous System Diseases
Neurologic Manifestations

Signs and Symptoms
Botulinum Toxins
Anti-Dyskinesia Agents
Central Nervous System Agents
Therapeutic Uses
Pharmacologic Actions

ClinicalTrials.gov processed this record on May 22, 2013

Comparison of Tendon Transfer, Botox Injections and Ongoing Treatment in Hemiplegic Cerebral Palsy (UECP)