Use of Botulinum Toxin Type A in the Management of Neonatal Brachial Plexus Palsy

• Published in: PM & R 2014-12, Vol.6 (12), p.1107-1119
• Main Authors: Michaud, Linda J., MD, PT, Louden, Emily J., MPH, Lippert, William C., MPH, Allgier, Allison J., OTR/L, Foad, Susan L., MPH, Mehlman, Charles T., DO, MPH
• Format: Article
• Language: English
• Subjects: Botulinum Toxins, Type A - therapeutic use; Brachial Plexus Neuropathies - drug therapy; Brachial Plexus Neuropathies - physiopathology; Child, Preschool; Female; Humans; Infant; Infant, Newborn; Male; Neuromuscular Agents - therapeutic use; Physical Medicine and Rehabilitation; Range of Motion, Articular - physiology; Retrospective Studies; Treatment Outcome; Upper Extremity - physiopathology
• ISSN: 1934-1482; 1934-1563
• DOI: 10.1016/j.pmrj.2014.05.002

Objective To evaluate functional outcomes and the impact on surgical interventions after the use of botulinum neurotoxin type A (BoNT-A) for muscle imbalance, cocontractions, or contractures with neonatal brachial plexus palsy. Design A retrospective cohort study. Setting A brachial plexus center in a tertiary children's hospital. Participants Fifty-nine patients with neonatal brachial plexus palsy (75 injection procedures, 91 muscles and/or muscle groups) received BoNT-A injections (mean age at injection, 36.2 months; range, 6-123 months; 31 boys; 30 right-sided injuries, 28 left-sided injuries, 1 bilateral injury). Methods Data collected retrospectively from medical records, from procedure notes and clinic visits before BoNT-A use, at ≤6 months follow-up (BoNT-A active [BA]) and at ≥7 months follow-up (BoNT-A not active [BNA]) included demographics, injection indication, side, and site(s), previous surgical history, occupational therapy and/or physical therapy plan, and outcome measurements. Main Outcome Measurements Outcomes assessed before and after injections included active and passive range of motion, Mallet and Toronto scores, parent comments about arm function, preinjection surgical considerations, and postinjection surgical history. Results Injection procedures included 51 to shoulder internal rotators, 15 triceps, 15 pronator teres, 9 biceps, and 1 flexor carpi ulnaris. Active and passive shoulder external rotation (SER) range of motion improved after shoulder internal rotator injections ( P  = .0003 and P  = .002, respectively), as did Mallet scores with BA; the latter were sustained with BNA. Surgical intervention was averted, modified, or deferred after BoNT-A in 45% (n = 20) under surgical consideration before BoNT-A. Active elbow flexion improved in 67% ( P  = .005), sustained BNA ( P  = .004) after triceps injections; 2 of 7 patients averted surgery. Active supination improved with BA ( P  = .002), with gains sustained BNA ( P  = .016). Passive elbow extension improved after biceps injections by an average 17° ( P  = .004) BA, although not sustained BNA. Conclusions BoNT-A is an effective adjunct to therapy and surgery in managing muscle imbalance, cocontractions, and contractures in neonatal brachial plexus palsy. Use of BoNT-A can result in averting, modifying, or deferring surgical interventions in a number of affected children.