title: Botulinum toxin type A injections into the calf muscles for treatment of spastic equinus in cerebral palsy: a randomized trial comparing single and multiple injection sites.
abstract: OBJECTIVE
  To investigate the hypothesis that the multiple-site injection technique is associated with better outcomes than the single-point injection method in children with cerebral palsy and spastic equinus gait.
  
  
  METHODS
  A total of 17 children (nine boys, eight girls ages 1.8-9.4 yrs; eight hemiplegics, eight diplegics, one quadriplegic; levels I-IV with the Gross Motor Function Classification System) with 25 treated lower limbs were randomized into two groups: a single-point group receiving a standard dose of botulinum toxin A injection into one site and a multiple-points group into two sites on both heads of the gastrocnemius. Active and passive range of movement, selective dorsiflexion, dynamic muscle length (modified Tardieu scale), calf tone (modified Ashworth scale), attainment of anticipated gait pattern (Goal Attainment Scale), and video gait analysis (Observational Gait Scale [OGS]) were assessed before and 1, 2, and 4 mos after intervention.
  
  
  RESULTS
  Both groups improved in dynamic muscle length, muscle tone, OGS-total scores and initial foot contact scores and a similar number of children attained their goals on the Goal Attainment Scale. The only significant difference between the groups was observed at 2 mos in passive dorsiflexion with the knee flexed, favoring the single-point group. Though not significantly, the incidence of adverse effects was higher in the multiple-points group.
  
  
  CONCLUSIONS
  Using the methods described, no major changes in main outcome measures were associated with the number of injection sites. Issues other than efficacy guide the decision on whether to inject in single or multiple sites when treating spastic equinus with botulinum toxin.
authors.affiliation: Department of Paediatric Neurology, Tampere University Hospital, Tampere, Finland.
authors.forename: Heli
authors.initials: H
authors.lastname: Sätilä
authors.forename: Tarja
authors.initials: T
authors.lastname: Pietikäinen
authors.forename: Terhi
authors.initials: T
authors.lastname: Iisalo
authors.forename: Pirjo
authors.initials: P
authors.lastname: Lehtonen-Räty
authors.forename: Marja
authors.initials: M
authors.lastname: Salo
authors.forename: Riina
authors.initials: R
authors.lastname: Haataja
authors.forename: Matti
authors.initials: M
authors.lastname: Koivikko
authors.forename: Ilona
authors.initials: I
authors.lastname: Autti-Rämö
mesh_terms: D019274:Botulinum Toxins, Type A / Q000008:administration & dosage*; D002547:Cerebral Palsy / Q000150:complications* / Q000534:rehabilitation; D002648:Child; D002675:Child, Preschool; D004305:Dose-Response Relationship, Drug; D004863:Equinus Deformity / Q000188:drug therapy* / Q000534:rehabilitation; D005260:Female; D006801:Humans; D007223:Infant; D007273:Injections, Intramuscular / Q000379:methods; D008297:Male; D018482:Muscle, Skeletal / Q000187:drug effects*; D009465:Neuromuscular Agents / Q000008:administration & dosage*; D016059:Range of Motion, Articular; D020127:Recovery of Function
chemical_list: D009465:Neuromuscular Agents; D019274:Botulinum Toxins, Type A