Repeated Multilevel Botulinum Toxin A Treatment Maintains Long-Term Walking Ability in Children with Cerebral Palsy

Aims: Botulinum toxin type A (BoNT-A) offers a targeted form of therapy to reduce spasticity and has become a standard form of treatment in children with cerebral palsy (CP). However, the effects of repeated BoNT-A treatment over a longer periods of time are not well known. We hypothesized that children treated with multi-level, high-dose, repeated BoNT-A applications would not deteriorate in their gait function over a minimum period of four years. Materials and methodology: Gait in 18 children with spastic diplegic CP, mean age 6 years 9 months, Gross Motor Function Classification System I-III, treated according to the concept of integrated BoNT-A application over a minimum of four years was evaluated using the kinematic and kinetic gait analysis. The main outcome measure was the Gait Deviation Index (GDI). Results: The mean follow-up time was 5 years and 9 months (SD 1 year 5 months). Each child received a mean of 1.02 (SD 0.37) applications of BoNT-A per year. The gait function assessed by GDI remained unchanged. However, gait kinematic and kinetic parameters revealed some intra-individual changes and documented an evolution of gait pattern. The majority of improvements occurred at the level of ankle, while hip function was deteriorating despite the therapy. Conclusions: The study demonstrated that integrated multilevel BoNT-A treatment can be effective in maintaining the same level of walking in children with spastic diplegic cerebral palsy over a period of more than five years. The described integrated approach has limitations in the management of hip flexor and hamstrings tightness.