Critically Appraised Topic
The patient who has led me to pursue this question is a 5 year-old girl, with a diagnosis of spastic diplegic cerebral palsy. She is ambulatory with a reverse walker. She has undergone botulinum toxin A treatments in the past and has shown some improvements, but continues to exhibit equinus gait, with limited ankle dorsiflexion range of motion, both active and passive, and bilateral lower extremity spasticity.
Is serial casting an effective treatment for equinus gait in children with cerebral palsy and does the addition of botulinum toxin A augment this intervention?
Clinical Bottom Line
Based on the results of the outcomes from Flett et al. and Hayek et al. both serial casting and botulinum toxin A plus casting significantly improve equinus gait in children with spastic cerebral palsy. Flett et al. found a significant increase in dorsiflexion range of motion, of 8.87 degrees and a significant decrease in spasticity of 0.66 on the modified Ashworth scale using serial casting over a 6-month period. There is some uncertainty to the significance of Gross Motor Function Measure (GMFM) improvements, although there was a mean GMFM change of 7.47. With botulinum toxin A alone, there was only a significant improvement in dorsiflexion, by 6.15 degrees. The two groups were not significantly different in any outcome measure. This study had good internal and external validity, with the exception of a small sample size, which slightly compromises the ability to generalize results.
Hayek et al. found that the addition of serial casting to botulinum toxin A injections significantly improves active dorsiflexion and GMFM scores. Botulinum toxin A alone resulted in a significant increase in active dorsiflexion range of motion of 5.1 degrees and in GMFM scores, of 7.7. Botulinum toxin A with casting resulted in a significant increase in active and passive dorsiflexion, of 12.4 and 6.4 degrees respectively, along with GMFM scores, of 9.7. Authors reported both groups experienced a significant decrease in spasticity using the modified Tardieu scale, but not the modified Ashworth scale, however no raw data was provided for this outcome measure. This study did have some threats to internal and external validity, including a lack of randomization, blinding, intention-to-treat analysis and a small sample size, which limits the ability to generalize the results to a larger population. Additional research using larger sample sizes with randomization and blinding is needed to help fully answer my clinical question.
Smith, Amy, "The Effectiveness of Casting and Botulinum Toxin A for Treating Equinus Gait in Children with Cerebral Palsy" (2011). PT Critically Appraised Topics. Paper 6.