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- Engström, Pähr, et al.
(författare)
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Botulinum toxin A does not improve cast treatment for idiopathic toe-walking - a randomized controlled trial
- 2013
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Ingår i: Journal of Bone and Joint Surgery. American volume. - 0021-9355 .- 1535-1386. ; 95:5, s. 400-407
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Tidskriftsartikel (refereegranskat)abstract
- Background: There are many treatments for idiopathic toe-walking, including casts with or without injection of botulinum toxin A. Combined treatment with casts and botulinum toxin A has become more common even though there have been few studies of its efficacy and safety problems. Our aims were to conduct a randomized controlled trial to test the hypotheses that combined treatment with casts and botulinum toxin A is more effective than casts alone in reducing toewalking by patients five to fifteen years of age, and that the treatment effect correlates with the extent of coexisting neuropsychiatric problems. Methods: All patients who had been consecutively admitted to the pediatric orthopaedics department of our institution because of idiopathic toe-walking between November 2005 and April 2010 were considered for inclusion in the study. Forty-seven children constituted the study population. The children were randomized to undergo four weeks of treatment with below-the-knee casts either as the sole intervention or to undergo the cast treatment one to two weeks after receiving injections of botulinum toxin A into the calves. Before treatment and three and twelve months after cast removal, all children underwent three-dimensional (3-D) gait analysis. The severity of the idiopathic toe-walking was classified on the basis of the gait analysis, and the parents rated the time that their child spent on his/her toes during barefoot walking. Passive hip, knee, and ankle motion as well as ankle dorsiflexor strength were measured. Before treatment, all children were evaluated with a screening questionnaire for neuropsychiatric problems. Results: No differences were found in any outcome parameter between the groups before treatment or at three or twelve months after cast removal. Several gait-analysis parameters, passive ankle motion, and ankle dorsiflexor strength were improved at both three and twelve months in both groups, even though many children still demonstrated some degree of toe-walking. The treatment outcomes were not correlated with coexisting neuropsychiatric problems. Conclusion: Adding botulinum toxin-A injections prior to cast treatment for idiopathic toe-walking does not improve the outcome of cast-only treatment. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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| 2. |
- Engström, Pähr, et al.
(författare)
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Does Botulinum toxin A improve the walking pattern in children with idiopathic toe-walking?
- 2010
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Ingår i: Journal of Children's Orthopaedics. - : SAGE Publications. - 1863-2521 .- 1863-2548. ; 4:4, s. 301-308
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Tidskriftsartikel (refereegranskat)abstract
- Background: Numerous recommendations have been made for treating idiopathic toe-walking (ITW), but the treatment results have been questioned. The purpose of this study was to investigate whether botulinum toxin A (BTX) improves the walking pattern in ITW as examined with 3-D gait analysis. Participants and methods: A consecutive series of 15 children (aged 5-13 years) were enrolled in the study. The children underwent a 3-D gait analysis prior to treatment with a total of 6 units/kg bodyweight Botox® in the calf muscles and an exercise program. The gait analysis was repeated 3 weeks and 3, 6, and 12 months after treatment. A classification of toe-walking severity was made before treatment and after 12 months. The parents rated the perceived amount of toe-walking prior to treatment and 6 and 12 months after treatment. Results: Eleven children completed the 12-month follow-up. The gait analysis results displayed a significant improvement, indicating decreased plantarflexion angle at initial contact and during swing phase and increased dorsiflexion angle during midstance at all post-treatment testing instances. According to the parents' perception of toe-walking, 3/11 children followed for 12 months had ceased toe-walking completely, 4/11 decreased toe-walking, and 4/11 continued toe-walking. After 6-12 months, the toe-walking severity classification improved in 9 of the 14 children for whom data could be assessed. Conclusions: A single injection of BTX in combination with an exercise program can improve the walking pattern in children with ITW seen at gait analysis, but the obvious goal of ceasing toe-walking is only occasionally reached.
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| 3. |
- Engström, Pähr
(författare)
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Idiopathic toe-walking in children : prevalence, neuropsychiatric symptoms and the effect of botulinum toxin A treatment
- 2012
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Idiopathic toe-walking (ITW) is a term used to describe a state in which a child, in the absence of a known cause, walks on his or her toes, as compared to the normal heel-toe gait. The diagnosis is thus used when other defined causes are excluded. Problems that may develop with untreated ITW are shortened calf muscles with limited mobility in the ankle, pain, balance and foot problems. It has been shown that impaired ankle mobility is common in patients seeking orthopaedic help for foot problems. It is not uncommon for children with ITW to have problems playing sports or to be bullied. It has thus far been unknown how common it is for children to walk on toes. The first study in this thesis evaluates the prevalence of ITW in children evaluated at their final check-up (aged 5.5 years) at their local Child Welfare Centre (CWC). The result shows that out of 1,436 examined children, 2.09% were still toe-walking and 2.79% had been toe-walking but stopped prior to the final check-up. Neuropsychiatric conditions include among others ADHD, tics and autism. It is known that toe-walking is a common phenomenon in children with autism. The general impression among clinicians working with children and young people with other neuropsychiatric conditions is that toe-walking is more common also among these children. This potential comorbidity had not previously been investigated. The second study in this thesis shows that out of 51 children referred to Astrid Lindgren Children’s Hospital for ITW and evaluated for neuropsychiatric symptoms with a validated screening tool, about 25% are likely to have some sort of neuropsychiatric problem. There are many treatment options for ITW ranging from observation and stretch exercises to cast treatment and surgical procedures. Treatment of ITW with botulinum toxin A (BTX) is increasingly being used in clinical practice despite little scientific evidence as to its effectiveness in children with ITW. Studies 3 & 4 examine whether BTX treatment can improve the walking pattern in children with ITW, wherein Study 3 cautiously suggests that it can. Study 4 is a randomised controlled study that compares two groups of children with one group being treated with casts for 4 weeks and the second group receiving the same type of cast treatment in addition to treatment with BTX injections in the calf muscles. However, the results show that BTX does not improve the treatment outcome compared to cast treatment only. Clinical implications: The prevalence and early spontaneous course of ITW in children aged 5.5 years has been established and will affect the accuracy of the information we can give parents and influence the choice of treatment strategy for these children. We have become aware that children with ITW can have a variety of neuropsychiatric problems and that ITW should not always be seen as an isolated phenomenon. It is furthermore advisable to stop BTX treatment for ITW, thus preventing children from being exposed to ineffective treatment.
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