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Botulinum Toxin Type A Injections into the Calf Muscles for Treatment of Spastic Equinus in Cerebral Palsy: A Randomized Trial Comparing Single and Multiple Injection Sites

Sätilä H, Pietikäinen T, Iisalo T, Lehtonen-Räty P, Salo M, Haataja R, Koivikko M, Autti-Rämö I: Botulinum toxin type a injections into the calf muscles for treatment of spastic equinus in cerebral palsy: a randomized trial comparing single and multiple injection sites. Am J Phys Med Rehabil 2008;87:386–394. Objective:To investigate the hypothesis that the multiple-site injection technique is associated with better outcomes than the single-point injection method in children with cerebral palsy and spastic equinus gait. Design:A total of 17 children (nine boys, eight girls ages 1.8–9.4 yrs; eight hemiplegics, eight diplegics, one quadriplegic; levels I–IV with the Gross Motor Function Classification System) with 25 treated lower limbs were randomized into two groups: a single-point group receiving a standard dose of botulinum toxin A injection into one site and a multiple-points group into two sites on both heads of the gastrocnemius. Active and passive range of movement, selective dorsiflexion, dynamic muscle length (modified Tardieu scale), calf tone (modified Ashworth scale), attainment of anticipated gait pattern (Goal Attainment Scale), and video gait analysis (Observational Gait Scale [OGS]) were assessed before and 1, 2, and 4 mos after intervention. Results:Both groups improved in dynamic muscle length, muscle tone, OGS–total scores and initial foot contact scores and a similar number of children attained their goals on the Goal Attainment Scale. The only significant difference between the groups was observed at 2 mos in passive dorsiflexion with the knee flexed, favoring the single-point group. Though not significantly, the incidence of adverse effects was higher in the multiple-points group. Conclusions:Using the methods described, no major changes in main outcome measures were associated with the number of injection sites. Issues other than efficacy guide the decision on whether to inject in single or multiple sites when treating spastic equinus with botulinum toxin.