Botulinum Toxin a Injection Combined with Radial Extracorporeal Shock Wave Therapy in Children with Spastic Cerebral Palsy: Shear Wave Sonoelastographic Findings in the Medial Gastrocnemius Muscle, Preliminary Study

Dong Rak Kwon, Dae Gil Kwon, Dong Rak Kwon, Dae Gil Kwon

Abstract

Therapeutic strategies to boost the effect of botulinum toxin may lead to some advantages, such as long lasting effects, the injection of lower botulinum toxin dosages, fewer side effects, and lower costs. The aim of this study is to investigate the combined effect of botulinum toxin A (BTA) injection and extracorporeal shock wave therapy (ESWT) for the treatment of spasticity in children with spastic cerebral palsy (CP). Fifteen patients with spastic CP were recruited through a retrospective chart review to clarify what treatment they received. All patients received a BTA injection on gastrocnemius muscle (GCM), and patients in group 1 underwent one ESWT session for the GCM immediately after BTA injection and two consecutive ESWT sessions at weekly intervals. Ankle plantar flexor and the passive range of motion (PROM) of ankle dorsiflexion were measured by a modified Ashworth scale (MAS) before treatment and at 1 and 3 month(s) post-treatment. In group 1, the shear wave velocity (SWV) of GCM was measured. The PROM and MAS in group 1 and 2 before treatment significantly improved at 1 and 3 month(s) after treatment. The change in PROM was significantly different between the two groups at 1 and 3 month(s) after treatment. The SWV before treatment significantly decreased at 1 month and 3 months after treatment in group 1. Our study has shown that the combination of BTA injection and ESWT would be effective at controlling spasticity in children with spastic CP, with sustained improvement at 3 months after treatment.

Keywords: botulinum toxin; cerebral palsy; extracorporeal shock wave; shear wave ultrasound; spasticity.

Conflict of interest statement

The authors declare no conflict of interest.

Figures

Figure 1
Figure 1
(A) Botulinum toxin A injection at the gastrocnemius (GCM) muscle under sonographic guidance (white arrow: needle). (B) Application of radial extracorporeal shock wave therapy (ESWT) on the GCM of an 87-month-old child with spastic cerebral palsy.
Figure 2
Figure 2
Representative longitudinal acoustic radiation force impulse (ARFI) image of the medial gastrocnemius muscle. (A) B-mode ultrasonography. (B) “Quality map” indicates the quality and reliability of the shear wave measurements. These correspond to the areas where the shear waves with sufficient quality for quantification are shown in green. (C) The shear-wave velocity (2.84 m/s) was measured in the region of interest of the medial gastrocnemius muscle using ARFI imaging.
Figure 3
Figure 3
The flowchart of the study.

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