Étude comparative de l’effet de l’abobotulinumtoxin A et de la rééducation dans le traitement du pied équin spastique de l’enfant paralysé cérébral marchant Comparative study of the effect of abobotulinumtoxin A and rehabilitation in the treatment of spastic equine foot of the cerebral palsy child walking

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Abstract

Introduction - La forme spastique de la paralysie cérébrale (PC) est très fréquente,représentant plus de 80% des cas de PC. La spasticité entraîne des contracturesmusculaires et des déformations osseuses responsables de limitations d’activité etde restriction de participation chez des enfants en pleine croissance. L’atteinte dupied et de la cheville est fréquente chez les patients atteints d’une PC, les musclesle plus souvent trop actifs étant les gastrocnémiens et le soléus, le tibial postérieuret le tibial antérieur. Le traitement de la spasticité des membres inférieurs, lorsqu’elleest gênante, repose essentiellement sur les injections intramusculaires dela toxine botulique A et la rééducation.Les objectifs de notre étude étaient de comparer l’évolution thérapeutique de laspasticité du pied équin chez les enfants PC marchants au cours des contrôles (àun mois, à trois mois et à six mois) par rapport à l’évaluation initiale faite avant letraitement, dans les groupes traités respectivement, par la toxine botulique A, larééducation et l’association de ces deux thérapeutiques et de comparer les résultatsde l’évolution thérapeutique dans les trois groupes sur la marche.Patients et méthodes - Il s’agit d’une étude descriptive randomisée comparativedans trois groupes thérapeutiques, groupe randomisé pour des injections de toxinebotulique «A» associée à la rééducation (G1), groupe de toxine botulique «A» (TBA)seule (G2), groupe de rééducation seule (G3). Cette étude a concerné 122 membresinférieurs de 72 enfants atteints d’une PC spastique (24 enfants par groupe), classésselon le système de classification de la fonction motrice globale GMFCS (I à III)et âgés de 2 à 16 ans. L’évaluation était faite avant le traitement et au cours descontrôles (à un, trois et six mois), par l’échelle de Tardieu modifiée (MTS) pour les

Abstract

Ankle spasticity in the cerebral palsy walking child: comparative study botulinum toxin A versus rehabilitation. The spastic form of cerebral palsy (PC) is very common, accounting for more than 80% of PC cases. Spasticity leads to muscle contractures and bone deformities accountable for activity and participation limitations in growing children. The treatment of ankle spasticity relies mainly on intramuscular injections of botulinum toxin A and rehabilitation. Aim - The purpose of this paper was to access the efficacy and the limits of bot toxinA in comparing the therapeutic evolution of the ankle spasticity during three controls (at one month, three months and six months) in the groups treated respectively by botulinum toxin A alone, rehabilitation alone and the combination of these two the-rapies, and to compare the outcomes of therapeutic evolution in the three groups on gait. Patients and methods - A comparative randomized descriptive study in three the-rapeutic groups (botulinum toxin group «A» associated with rehabilitation (G1), bo-tulinum toxin group «A» (TBA) alone (G2), rehabilitation group alone (G3) during the controls and involving 122 lower limbs of 72 children (24 children per group) with spastic CP, classified GMFCS (I to III) and aged from 2 to 16 years. The clinical evaluation was done by the Modified Tardieu scale (MTS) for passive amplitudes and spasticity, PRS (Physicians Rating Scale) for walking. This study was carried out in the physical and rehabilitation medicine PRM department of Oran’s hospital and univer-sity center during the period of January 2016 to June 2017. The Tardieu Scale mea-sures spasticity using 2 parameters: the spasticity angle X is the difference between the angles of arrest at slow speed and of catch-and-release or clonus at fast speed, whereas the spasticity grade Y is an ordinal variable that grades the intensity and thus measures the gain of the muscle reaction to fast stretch.Results - In the intervention groups, the combination of TBA and rehabilitation gave a statistically significant improvement in the ankle of the mean angle of passive dor-siflexion of the flexed knee ankle (p = 0.04) and tense knee (p = 0.003) in the first month. This improvement continues in the third and sixth months. The decrease in the mean angle of onset of flexed knee and tense knee spasticity was statistically significant in the first month (p = 0.03, p≤10-3) and in the third month. Mean soleus and gastrocnemius tone decreased statistically significantly in all three controls. In G2, the improvement of the average angle of the dorsal flexion, flexed knee and stretched knee, occurs in the third month (p = 0.05, p = 0.003). The improvement in the average angle of onset of spasticity and tone was statistically significant in the first and third months. In the G3 improvement of the mean of all these parameters was statistically insignificant. Conclusion - Rehabilitation associated with abobotulinumtoxin «A» injections gives better results on joint amplitudes, muscle tone and walking quality in children walk-ing spastic CP. These results are maintained until the sixth month.