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Botulinum toxin A combined with casting does not improve idiopathic toe walking
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Researchers found no differences between casting-only and casting with botulinum toxin A injections when treating children with idiopathic toe-walking.
“Whether the effect of botulinum toxin-A treatment for idiopathic toe-walking can be improved with repeated injections, addition of bracing or more vigorous physiotherapy programs is unknown and should thus be studied in future randomized controlled trials,” Pähr Engström, MD, and colleagues wrote in their study.
The investigators conducted a randomized controlled trial of children with idiopathic toe-walking between 2005 and 2010. Patients were divided into a group that either received below-the-knee casts for 4 weeks (26 patients) or underwent calf injections with 12 units/kg body weight injections of botulinum toxin A (Botox, Allergan; Irvine, Calif.), followed by below-the knee casts 1 to 2 weeks after injection (21 patients).
The patients underwent 3-D gait analysis at baseline and at 3 months and 12 months after cast removal. Investigators measured each patient’s passive hip, knee and ankle motion and ankle dorsiflexor strength. Each child underwent a screening with a neuropsychiatric questionnaire.
The investigators found no differences in outcomes and improvement in three of the parameters in both groups. During gait analysis, investigators found maximum ankle dorsiflexion in stance changed at mean 9° from a plantar flexed position to dorsiflexion and patients showed better maximal dorsiflexion during swing phase from plantar flexed to neutral position. Ankle dorsal extensor strength increased in the casting group at 12 months and in the casting and botulinum toxin A group at 3 months and 12 months. Flexed and extended ankle dorsiflexion strength improved at both 3 month and 12 months in each group. Coexisting neuropsychiatric problems did not correlate with treatment outcomes in either group.
Disclosure: This study was funded by grants from the Centre of Competence, Blekinge County Council, Promobilia Foundation and the Samariten Foundation.
Perspective
Back to TopCylie Williams, PhD
This comparative case control study between the use of botulinum toxin A and serial casting has provided new insight into nonsurgical treatment of equinus, but the publication has a number of design concerns. These limitations were acknowledged: the small numbers of participants and limited follow-up together with the absence of a control group.
In light of these limitations, it is my opinion that botulinum toxin A should not be entirely discounted in this population. While comparative trials play an important role to better understand the impact of treatment options, these limitations challenge the strength of the results reported within this study. This is especially pertinent when there is a natural progression of gait normalization, as is often the case with long-term idiopathic toe-walking. What this study has provided is valuable information about equinus and muscle imbalances that clinicians often observe with idiopathic toe walking. It is unknown if the positive changes in muscle length and balance were due to the exercises, stretches or casting, but this small and valuable outcome should guide future research. These changes in length and strength may be instrumental in long-term gait change.
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