EUR J PHYS REHABIL MED 2009;45:501-6

Long lasting benefits following the combination

of static night upper extremity splinting
A
with botulinum toxin A injections in cerebral palsy children
C
DI A. D. KANELLOPOULOS 1, A. F. MAVROGENIS 1, E. A. MITSIOKAPA 2, D. PANAGOPOULOS 1,
H. SKOUTELI 3, S. G. VRETTOS 4, G. TZANOS 2, P. J. PAPAGELOPOULOS 1

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Aim. Botulinum toxin A injections and orthotics have 1First Department of Orthopedics
been used to manage upper extremity spasticity in hemi- Athens University Medical School, Athens, Greece
plegic children. The authors performed a study to eval- 2Department of Physical Medicine and Rehabilitation
uate the necessity and effectiveness of a static night

A
Thriasio Hospital, Elefsis, Greece

T
splint following outpatient botulinum toxin A treatment 3Consultant Pediatric Neurologist, Athens, Greece
in children with upper limb spastic cerebral palsy. 4Pediatric Physical Therapist, Athens, Greece

RV
Methods. Twenty children with upper limb spastic cere-

H
bral palsy were treated with botulinum toxin A injections.
A static night splint was applied in half of them. Objective
assessment of upper limb function was performed at base-

CG
line, at 2 and 6 months after botulinum toxin A injection

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using the Quality of Upper Extremity Skills Test. erebral palsy is a disorder of movement and pos-
Results. After botulinum toxin A treatment, both groups ture resulting from a non-progressive injury to
showed an improvement on their previous functional the immature brain.1 The most common movement

IN YR
level of the injected upper extremity. At 2 months, chil- disorder in cerebral palsy is spastic. Spasticity and
dren in group A showed a 15.4% improvement, where- contractures in the upper limbs translate to function-
as children in group B improved by 12.2% from baseline;
these were not statistically significant (P=0.326). At 6
al difficulties of reaching, grasping, releasing and
manipulation, dressing and axillary hygiene, sublux-

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months, group A still maintained a 15.9% improvement
in function compared to group B which differed only by ations and dislocations, and poor cosmesis.2-4
4.2% from prebotulinum toxin A baseline; these differ- The most common upper limb deformities caused

O
ences were statistically significant (P=0.000). Complica- by spasticity in cerebral palsy include wrist and elbow
tions related to the botulinum toxin A injection were flexion contractures, thumb adduction contracture,
not observed. The static night upper extremity splints and “swan-neck” deformities of the fingers. Flexion

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have been well tolerated by the hemiplegic children.
Conclusion. Static night splinting following botulinum
toxin A injections has shown a definite treatment effect
in reducing spasticity and improving function in chil-
dren with upper limb spastic cerebral palsy.
KEY WORDS: Cerebral palsy - Upper extremity - Botulinum
toxins.
Received on November 19, 2007.
Accepted for publication on December 2, 2008.
Epun ahead of print on January 21, 2009.
Corresponding author: A. F. Mavrogenis, MD, First Department of
Orthopedics, Athens University Medical School, Athens, Greece.
E-mail: andreasfmavrogenis@yahoo.gr
deformities of the elbow are caused by spastic biceps,
brachialis anterior and brachioradialis muscles. The
forearm is almost always held in pronation by spas-
tic pronator teres, pronator quadratus, and flexor carpi
ulnaris muscles. Wrist flexion is often accompanied by
ulnar deviation because of the spastic ulnar devia-
tors. The common “thumb-in-palm” deformity is due
to spastic adductor pollicis longus or flexor pollicis bre-
vis muscles.2-6
Botulinum toxin A injections can be used as adjunct
management of the spastic muscles.3, 7-12 Botulinum
toxin A has been shown effective in improving the
range of motion and reducing tone, and also poten-

Vol. 45 - No. 4 EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE 501

KANELLOPOULOS UPPER EXTREMITY SPLINTING WITH BTX A IN CEREBRAL PALSY

tially effective in improving motor control in children
with hypertonia, both spasticity and dystonia.7, 12-15
However, despite intensive postinjection occupational
therapy these beneficial effects are relatively short
lived.2-4, 8, 9
The use of casting with and without botulinum tox-
in A has also been studied for children with a dynam-
muscles selected, the size of each muscle, the degree
of hypertonia and the desired effect. Botulinum tox-
in A was injected into the vicinity of the neuromuscular
junction of clinically indicated target muscle groups by
anatomic knowledge and palpation. Injection was
done into at least 2 muscles of the upper extremity
including a forearm muscle (pronator teres, brachio-

CA
ic contracture.16-20 Splints and serial casting may be
used to passively stretch contracted agonist muscles
or in dynamic functional situations. At present, the
radialis, or adductor pollicis longus muscles).
Following botulinum toxin A injection, the chil-
dren were randomly allocated into 2 groups: group

DI
best results appear to be with those that combine
casting with botulinum toxin A for dynamic contrac-
tures.13, 20 However, there is considerable uncertainty
and variation associated with the clinical use of bot-
A consisted of 10 children in which a thermoplastic
static night splint was applied for 6 months (Table
I); group B consisted of 10 children in which a night
splint was not applied (Table II). The splint was

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ulinum toxin A injection for the management of upper lightweight, durable and easy to modify; it covered
limb spasticity in children with cerebral palsy. In addi- two thirds of the forearm and it was stabilized with
tion, there is insufficient evidence to either support or velcros. The wrist was positioned in neutral, the

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refute the use of adjunct therapy interventions after
botulinum toxin A injections in these children. The
rationale of the present study was to evaluate the
thumb in abduction, and the fingers slightly extend-
ed (Figure 1).
The children were discharged from hospital the

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necessity and effectiveness of a static night splint fol- same day. The families received instructions for the

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lowing outpatient botulinum toxin A treatment in chil-
dren with upper limb spastic cerebral palsy.

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importance of upper extremity function in all types of
motion according to the functional level of each child.
Additionally, instructions were given for at least 3 ses-

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sions of occupational therapy per week, and partici-

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Materials and methods pation of the family in the mobility program of their

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children in the post botulinum toxin A injection peri-
The authors prospectively treated 20 spastic cere- od.
bral palsy hemiplegic children with upper extremity Objective assessment of upper limb function was

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involvement with selective botulinum toxin A injec-
tions (Botox®, Allergan, Irvine, CA, USA) at the
Department of Pediatric Orthopedics of Athens
University School of Medicine. There were 13 boys
performed at baseline, and at 2 and 6 months after bot-
ulinum toxin A injection using the Quality of Upper
Extremity Skills Test (QUEST).21, 22 The QUEST is used
for children with upper extremity spasticity; it is a

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and 7 girls, aged 2.5 to 12 years (mean, 7 years). None
of the children had mental retardation. All the children
standardized, validated and reliable instrument that
documents baseline upper extremity function in four

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were under the care of the senior authors; their par- domains including dissociated movement, grasp, pro-
ents gave written informed consent to be included in tective extension and weight bearing. Also, it may
this study. assess changes following treatment.21

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The indications for the procedure were a primary
contracture in the upper limb that interfered with the
patients’ dexterity of reaching, grasping, releasing and
manipulation, and the appearance of the involved
limb. Children with neuromotor disorders such as
Statistical analysis
Statistical analysis was done using the one-way
ANOVA test (SPSS-13 statistical software).
spina bifida, neuromuscular or musculoskeletal dis-
eases, or previous neurosurgical procedures such as
selective dorsal rhizotomy or intrathecal baclofen Results
were excluded.
The required dose of botulinum toxin A was cal- Both groups showed an improvement on their pre-
culated on a unit per muscle per kilogram body weight vious functional level of the injected upper extremi-
basis and determined also on the number of target ty after botulinum toxin A treatment as measured by

502 EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE December 2009

UPPER EXTREMITY SPLINTING WITH BTX A IN CEREBRAL PALSY KANELLOPOULOS

TABLE I.—Diagnosis, age, and functional outcome of the hemiplegic upper extremity of the 10 children treated with botulinum toxin
A (btA) injections followed by a static night splint for 6 months (group A).
QUEST Improvement (%)
Age
Pts Diagnosis Splint
(years) 2 mos 6 mos 2 mos 6 mos
Pre-btA post-btA post-btA post-btA post-btA

1 Hemiplegics 9 Static night 56 73 73 30.4 30.4

A
2 5 thermoplastic 87 94 94 8.0 8.0
3 2.5 splint 39 47 45 20.5 15.4
4 8 74 79 79 6.8 6.8

C
5 11 71 88 88 23.9 23.9

I
6 5 73 87 87 19.2 19.2
7 5 58 71 73 22.4 25.9
8 9 66 69 71 4.5 7.6

D
9 2.5 82 88 91 7.3 11.0
10 12 84 93 93 10.7 10.7

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Average improvement = 15.4 15.9

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TABLE II.—Diagnosis, age, and functional outcome of the hemiplegic upper extremity of the 10 children treated with botulinum
toxin A (btA) injections without a static night splint (group B).
QUEST Improvement (%)

A T
Age
Pts Diagnosis Splint
(years) 2 mos 6 mos 2 mos 6 mos
Pre-btA post-btA post-btA post-btA post-btA

1
2
3

RV H
Hemiplegics 5
7
7
None 55
60
85
62
70
86
57
65
85
12.7
16.7
1.2
3.6
8.3
0.0

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4 8 60 72 66 20.0 10.0

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5 5 74 79 76 6.8 2.7
6 11 71 80 75 12.7 5.6
7 4 85 90 86 5.9 1.2

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8 8 63 68 64 7.9 1.6
9 5 57 73 59 28.1 3.5
10 9 78 86 82 10.3 5.1

Average improvement = 2.2 4.2

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Figure 1.—The thermoplastic static night splint is lightweight, durable and easy to modify; it covers two thirds of the forearm and it is sta-
bilized with velcros. The wrist was positioned in neutral, the thumb in abduction, and the fingers slightly extended.

Vol. 45 - No. 4 EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE 503

KANELLOPOULOS
the QUEST. At 2 months, children in group A showed
a 15.4% improvement from baseline (Table I), where-
as children in group B had an average 12.2% improve-
ment (Table II). At 6 months, children in group A still
maintained a 15.9% improvement in function com-
pared to group B which differed only by 4.2% from pre
botulinum toxin A baseline. For the two month peri-
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od, the F ratio (the ration of between group mean
square with the within group mean square) is 1.022,
and its significance is 0.326 (P=0.326) that is not sta-
DI
tistically significant. For the six month period, the F
ratio is 21 473, and its significance is 0.000 (P=0.000)
that is statistically significant 100%.
Complications related to botulinum toxin A injection
E
and/or to the night splint were not observed. The sta-
tic night splint has been well-tolerated by the chil-
dren.
M ® Discussion
A
T
The principles of treatment of the upper limb in
V
cerebral palsy are to improve upper extremity active
H
function, ease care, dressing and hygiene, improve
R
cosmesis and appearance of the involved limb, and
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reduce the risk of developing fixed contractures, or
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delay the onset of contractures to a time closer to
skeletal maturity.2, 23 For the hands, current interven-
tions aim at one or more of three functions; grasp
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that is closing and holding onto an object, release
that is letting go the object, and delivery that is getting
the hand to and oriented for grasp and release.2, 24-26
Functional gains following treatment are limited if the
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child has severe sensory or motor deficits and severe
cognitive impairment.3, 4, 27
O
Oral antispasticity agents, chemodenervation, neu-
rosurgical interventions, orthopedic surgery, occupa-
tional and physical therapy, and orthotics may all play
C
a role in the properly selected child.23, 28, 29 When
deformities are dynamic, they can be managed with
non-surgical interventions to reduce spasticity. When
fixed contractures develop, muscle-tendon surgery 2,
3, 6, 24 or serial casting 13, 19 is usually required.
Neurodevelopmental therapy,30 cognitive or learning
approaches,31 and constraint induced movement ther-
apy 32, 33 have also been suggested for the treatment
of children with upper limb spasticity.13
Upper limb injections of botulinum toxin A have
been reported to improve function and ease pain.3, 8-
11, 15 Compared with placebo, intramuscular injections
504 EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE
UPPER EXTREMITY SPLINTING WITH BTX A IN CEREBRAL PALSY
of botulinum toxin A resulted in consistent reduction
in spasticity and muscle stiffness in injected upper
limb muscles.8 In selected cases, botulinum toxin A
injections into long finger flexors with mild to mod-
erate contractures can lead to lengthening of the mus-
cle tendons units if an aggressive program of serial
casting is carried out. Patients who do not respond
usually have well-established fixed contractures or
significant sensory deficits or impairments of motor
control.3 Results of the present series are consistent
with the literature. All patients of both groups showed
improvement after botulinum toxin A injection in the
spastic upper extremity.
Physical and occupational therapy, home stretching
exercises and orthotics are essential for the neuro-
physiological and musculoskeletal management of
upper limb spasticity in cerebral palsy, and are often
incorporated within other intervention strategies such
as post-surgical, or after botulinum toxin injection.6, 16,
28, 29, 34, 35 However, in a literature search, Lannin et al.14
reported that there is insufficient evidence to either
support or refute the use of therapy interventions
after botulinum toxin A injections in cerebral palsy
children. In addition, Wasiak et al.12 have not found
sufficient evidence to support or refute the use of
intramuscular injections of botulinum toxin A as an
adjunct to managing the upper limb in children with
spastic cerebral palsy.
Orthotics, thermoplastic splints, soft or semidy-
namic splints, and casting are regularly used for the
appropriate alignment of bone and adjustment of the
range of motion at joints, to lengthen and to keep
tight muscles stretched, to provide biomechanical
support, joint stability and function in practice.2, 16-18,
36-38
The use of serial casting has been studied in patients
with upper motor neuron paralysis or brain impair-
ment.39-44 Results of these studies have shown that an
overnight splint-wearing regimen with the affected
hand in the functional position does not reduce wrist
contractures or extensibility of long flexor muscles, nor
it produces clinically beneficial effects in adults with
acquired brain impairment.
Previous studies in spastic cerebral palsy children
with lower extremity involvement have shown that
although botulinum toxin A reduces spasticity and
improves functional performance in standing and
walking, association with casting provides more
marked and enduring results.20 In addition, although
botulinum toxin A is superior to casting for the treat-
December 2009
UPPER EXTREMITY SPLINTING WITH BTX A IN CEREBRAL PALSY
ment of dynamic foot deformities, serial casting alone
is preferable for the treatment of fixed equinus con-
tractures in children with spastic cerebral palsy.19
In the present series, the use of a thermoplastic
static night splint has been evaluated following bot-
ulinum toxin A treatment in spastic cerebral palsy
children with upper extremity involvement. Post bot-
A
ulinum toxin A injection, muscle tone, range of motion
and motor function as measured by the QUEST, and
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cosmetic appearance improved in all children of both
DI
groups. However, in the group of children in which
a static night splint has been used, improvement was
superior at 2 months and statistically superior at 6
months, compared to the group of children in which
E
a night splint has not been used.
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Conclusions
The presented herein study has shown a definite
A T
treatment effect of botulinum toxin A combined to
static night splinting in reducing spasticity and improv-
V
ing function in children with upper limb spastic cere-
H
bral palsy. Static night upper extremity splints are
R
well tolerated by hemiplegic children following bot-
G
ulinum toxin A treatment for upper extremity spas-
E I
ticity. Night splints, together with appropriate occu-
pational therapy may help to initially enhance and
then maintain functional gains from botulinum toxin
IN YR
A treatment of the hemiplegic upper extremity for at
least 6 months thereafter.
M P
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506 EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE December 2009