Does Botulinum Toxin A Make Walking Easier in Children With Cerebral Palsy? (WE)

In Norway, about 60% of all children with cerebral palsy (CP) are being treated with botulinum toxin A (BoNT-A) at 6 years of age, mainly in the legs. Despite this widespread use of the drug, the evidence for a positive effect on walking is insufficient. Moreover, large variation in effect is seen by clinicians. The main objective of the present study is to investigate whether injections with BoNT-A in the calf muscles make walking easier in children with spastic CP within 6 months, reflected by reduced energy cost during walking.

Study Overview

• Status: Completed
• Conditions: Cerebral Palsy; Muscle Spasticity
• Intervention / Treatment: Drug: botox; Drug: placebo

Detailed Description

This is an industry independent multicentre clinical trial. The randomization will be done by a computer number random generator and will be carried out and held by the unit of Applied Clinical Research at NTNU. Two strata: age and center.

The study will be conducted according to Consort guidelines and guidelines for Good Clinical Practice. It is approved by the local Ethical committee (REK Nord) and the Norwegian Drug Agency.

Primary research question is: Do BoNT-A injections in the calf muscles make walking easier in children with CP? Secondary research questions: 1) Do BoNT-A injections in the calf muscles increase activity? 2) Do BoNT-A injections in the calf muscles improve walking capacity 3) Do BoNT-A injections in the calf muscles improve perceived performance and satisfaction related to mobility tasks and 4) Do BoNT-A injections in the calf muscles reduce recurrent musculoskeletal pain? The participants will receive the treatment with both local anaesthesia and conscious sedation with oral or nasal benzodiazepines.Outcome measures are made at baseline and 4, 12 and 24 weeks after treatment, with primary endpoint at 12 weeks.

Data will be analyzed using a linear mixed model (LMM). The difference in change in the primary outcome measure (energy cost during walking) between the treated and placebo groups will be done using a post hoc test following the LMM. Secondary, the same model will be used to test for an effect also at 4 and 24 weeks post injection. Age, GMFCS Level, number of prior BoNT-A treatments and study center will be considered as potential covariates.

A substudy will be conducted within the frames of this RCT, aiming to identify characteristics of those who respond to the treatment compared to those who do not respond (outcome measures 6, 7,8 and 9).

• Study Type: Interventional
• Enrollment (Actual): 61
• Phase: Phase 4

Contacts and Locations

Study Locations

• France
  • Nice, France
    • Lenval Foundation Children's Hospital
• Norway
  • Bergen, Norway, 5000
    • Haukeland University Hospital
  • Oslo, Norway
    • Oslo University Hospital
  • Tromsø, Norway
    • University Hospital of North-Norway
  • Trondheim, Norway
    • Department of Orthopaedic Surgery, St. Olavs University Hospital
  • Tønsberg, Norway
    • Vestfold Hospital trust
• Poland
  • Warsaw, Poland
    • Mazowieckie Centrum Neuropsychiatrii, Zagorze

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 2 years to 15 years (Child)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion criteria:

• Diagnosed with unilateral or bilateral CP
• GMFCS level I and II
• Signed informed consent
• expected cooperation of the patients for the treatment and follow up.

Exclusion Criteria:

• BoNT-A injections in the lower legs in the last 6 months before intervention
• history of adverse reactions to BoNT-A
• Known hypersensitivity to BoNT-A or to any of the excipients
• Orthopedic surgery in the legs in the last 2 years
• Major cognitive impairments (must be able to take verbal instructions and conduct the test procedure)
• infection at the proposed injection site(s)
• Subclinical or clinical evidence of defective neuromuscular transmission e.g. myasthenia gravis or Lambert-Eaton Syndrome in patients with peripheral motor neuropathic diseases (e.g. amyotrophic lateral sclerosis or motor neuropathy)
• other underlying neurological disorders that may be affected by BoNT-A injections
• Use of aminoglycoside antibiotics or spectinomycin, or other medicinal products that interfere with neuromuscular transmission (e.g. neuromuscular blocking agents)
• Pregnant or breast-feeding
• Childbearing potential not using contraception
• any reason why, in the opinion of the investigator, the patient should not participate
• Children needing deep sedation under treatment

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Quadruple

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: botox; Botox® (onabotulinumtoxin A),injections in the calf muscles. The total maximum body dose of Botox® in this study will be 420 Units. Maximum dose per injection site will be 50 Units. The gastrocnemius muscle will receive 5-6 Units Botox® per kg, but maximum 180 Units in each leg. The soleus muscle will receive 2 Units Botox® per kg with maximum dose 60 Units in each leg. Dilution: 100 Units Botox® in 1 ml 0.9% sodium chloride, and the maximum volume per injection site will be 0,5 ml in both study groups. The route of administration is intramuscular injection.	Drug: botox; The agent will be given only once at point zero in the time scheme for the project.; Other Names: botulinum toxin A
Placebo Comparator: placebo; Sterile 0,9% Sodium Chloride injection The placebo dose will be the same dose in ml as the reconstituted Botox	Drug: placebo; The agent will be given only once at point zero in the time scheme for the project.; Other Names: sodium chloride

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Energy cost during walking	Will be measured by a 5 minutes walk test (overground walking at comfortable speed) with simultaneous gas exchange.	6 months

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Activity	Daily activity, measured by a body worn accelerometer over 4 periods of 7 consecutive days.	6 months
Perceived improved performance and satisfaction	Assessed by The Canadian Occupational Performance Measure	6 months
Recurrent musculoskeletal pain	Assessed by the Child Health Questionnaire (Norwegian version), and elements from the Brief Pain Inventory (Norwegian version)	6 months
Walking capacity	Assessed with OMNI-RPE (OMNI Rating of Perceived Exertion) and a 1 Minute walk test at maximal gait speed	6 months

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Gait pattern	3D gait analysis will be carried out on a subset of participants.	6 months
Ankle strength	Isometric strength of ankle plantar- and dorsiflexors, will be made on a subset of the participants.	6 months
Spasticity	Will be assessed by the use of Tardieu scale. On a subset of participants, concurrent velocity, position and muscle activation will be measured.	6 months
Self-perceived effect on walking	A qualitative interview will be conducted on a subset of the participants at baseline and post 1 (4 weeks post injection)	4 weeks

Collaborators and Investigators

• Sponsor: St. Olavs Hospital
• Collaborators: Oslo University Hospital; Fondation Lenval; University Hospital of North Norway; Norwegian University of Science and Technology; Haukeland University Hospital; The Hospital of Vestfold; Mazowieckie Centrum Neuropsychiatrii, Warszawa
• Investigators: Study Director: Petter Aadahl, md prof, St. Olavs Hospital

Publications and helpful links

General Publications

• Braendvik SM, Roeleveld K, Andersen GL, Raftemo AE, Ramstad K, Majkic-Tajsic J, Lamvik T, Lund B, Follestad T, Vik T. The WE-Study: does botulinum toxin A make walking easier in children with cerebral palsy?: Study protocol for a randomized controlled trial. Trials. 2017 Feb 6;18(1):58. doi: 10.1186/s13063-016-1772-8.

Study record dates

Study Major Dates

• Study Start: September 1, 2015
• Primary Completion (Actual): October 15, 2021
• Study Completion (Actual): October 15, 2021

Study Registration Dates

• First Submitted: September 9, 2015
• First Submitted That Met QC Criteria: September 9, 2015
• First Posted (Estimate): September 11, 2015

Study Record Updates

• Last Update Posted (Actual): January 11, 2022
• Last Update Submitted That Met QC Criteria: January 10, 2022
• Last Verified: January 1, 2022

More Information

Terms related to this study

• Keywords: Walking; Botulinum Toxins, Type A
• Additional Relevant MeSH Terms: Brain Diseases; Central Nervous System Diseases; Nervous System Diseases; Neurologic Manifestations; Brain Damage, Chronic; Musculoskeletal Diseases; Muscular Diseases; Neuromuscular Manifestations; Muscle Hypertonia; Cerebral Palsy; Muscle Spasticity; Physiological Effects of Drugs; Neurotransmitter Agents; Molecular Mechanisms of Pharmacological Action; Peripheral Nervous System Agents; Cholinergic Agents; Membrane Transport Modulators; Acetylcholine Release Inhibitors; Neuromuscular Agents; Botulinum Toxins; Botulinum Toxins, Type A
• Other Study ID Numbers: 2013/1195; 2014-002539-32 (EudraCT Number)

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No