title: Botulinum toxin A does not improve the results of cast treatment for idiopathic toe-walking: a randomized controlled trial.
abstract: BACKGROUND
  There are many treatments for idiopathic toe-walking, including casts with or without injection of botulinum toxin A. Combined treatment with casts and botulinum toxin A has become more common even though there have been few studies of its efficacy and safety problems. Our aims were to conduct a randomized controlled trial to test the hypotheses that combined treatment with casts and botulinum toxin A is more effective than casts alone in reducing toe-walking by patients five to fifteen years of age, and that the treatment effect correlates with the extent of coexisting neuropsychiatric problems.
  
  
  METHODS
  All patients who had been consecutively admitted to the pediatric orthopaedics department of our institution because of idiopathic toe-walking between November 2005 and April 2010 were considered for inclusion in the study. Forty-seven children constituted the study population. The children were randomized to undergo four weeks of treatment with below-the-knee casts either as the sole intervention or to undergo the cast treatment one to two weeks after receiving injections of botulinum toxin A into the calves. Before treatment and three and twelve months after cast removal, all children underwent three-dimensional (3-D) gait analysis. The severity of the idiopathic toe-walking was classified on the basis of the gait analysis, and the parents rated the time that their child spent on his/her toes during barefoot walking. Passive hip, knee, and ankle motion as well as ankle dorsiflexor strength were measured. Before treatment, all children were evaluated with a screening questionnaire for neuropsychiatric problems.
  
  
  RESULTS
  No differences were found in any outcome parameter between the groups before treatment or at three or twelve months after cast removal. Several gait-analysis parameters, passive ankle motion, and ankle dorsiflexor strength were improved at both three and twelve months in both groups, even though many children still demonstrated some degree of toe-walking. The treatment outcomes were not correlated with coexisting neuropsychiatric problems.
  
  
  CONCLUSIONS
  Adding botulinum toxin-A injections prior to cast treatment for idiopathic toe-walking does not improve the outcome of cast-only treatment.
authors: Department of Women's and Children's Health. Karolinska University Hospital, 171 76 Stockholm, Sweden. pahr.engstrom@ki.se
authors: Pähr
authors: P
authors: Engström
authors: Åsa
authors: Å
authors: Bartonek
authors: Kristina
authors: K
authors: Tedroff
authors: Christina
authors: C
authors: Orefelt
authors: Yvonne
authors: Y
authors: Haglund-Åkerlind
authors: Elena M
authors: EM
authors: Gutierrez-Farewik
mesh_terms: D000293:Adolescent; D000843:Ankle Joint / Q000502:physiology; D019274:Botulinum Toxins, Type A / Q000008:administration & dosage / Q000494:pharmacology*; D002370:Casts, Surgical; D002648:Child; D002675:Child, Preschool; D004334:Drug Administration Schedule; D005260:Female; D005500:Follow-Up Studies; D005684:Gait / Q000187:drug effects* / Q000502:physiology; D006801:Humans; D007273:Injections, Intramuscular; D057194:Intention to Treat Analysis; D008297:Male; D009465:Neuromuscular Agents / Q000008:administration & dosage / Q000494:pharmacology*; D009483:Neuropsychological Tests; D017063:Outcome Assessment, Health Care; D016059:Range of Motion, Articular / Q000187:drug effects; D011795:Surveys and Questionnaires; D014034:Toes
chemical_list: D009465:Neuromuscular Agents; D019274:Botulinum Toxins, Type A