Departments: Letters to the Editor
To the Editor:
In their article “Physiotherapy Assessment and Treatment for an Ambulant Child With Cerebral Palsy After Botox A to the Lower Limbs,” Mulligan et al1 conclude that increased level of physiotherapy can contribute to the successful outcomes after botulinum toxin A (BTX-A) injections to hamstring and gastrocnemius muscles in a 3.5-year-old child with spastic diplegia.
We agree with the authors that effective and easily implemented increased levels of physiotherapy may contribute to increased ability in function in a child with cerebral palsy. There is a general agreement that physical therapy is necessary to rehabilitate patients with focal spasticity. However, formal evidence is still lacking to establish the real benefit of physical and occupational therapy in the rehabilitation of equinus foot patients, particularly in the pediatric literature.
Relaxation of spastic muscles, such as tibialis posterior, gastrocnemius, and soleus, improves gait and posture and can be established by using several methods described in the article. It is also important to stress that BTX-A injections can be part of a program that aims at reducing disability and promoting social rehabilitation. However, no information was given about exact dose of BTX-A in this case report. Although there are no standard guidelines on doses in children with spastic eqinuis foot, doses of 2 to 6 U/kg with a maximum total dose of 29 U/kg have been reported in the literature.2 In this article, the dose of BTX-A per kilogram is missing and needs to be clarified.
In addition to various examination tools, we have found that the Tardieu Scale can quantify spasticity and is more reliable than the modified Ashworth Scale as a bedside tool for assessing spasticity in pediatric patients.3
Alper I. Dai, MD
Department of Pediatrics, Division of Pediatric Neurology, School of Medicine, Gaziantep University, Turkey
1. Mulligan H, Wilmshurst E. Physiotherapy assessment and treatment for an ambulant child with cerebral palsy after botox a to the lower limbs: a case report. Pediatr Phys Ther.
2. Koman LA, Smith BP, Shilt JS. Cerebral palsy [review]. Lancet.
3. Flett PJ. Rehabilitation of spasticity and related problems in childhood cerebral palsy [review]. J Paediatr Child Health.