Which treatment is most effective in decreasing spasticity and/or contracture and increasing ROM in the lower extremity for children diagnosed with spastic cerebral palsy: Botulinum toxin A, casting, or a combination of both?

Clinical Bottom Line: Due to the paucity of research, use of unreliable and invalid outcome measures, and the conflicting results reported we were unable to determine which treatment was more effective in decreasing spasticity and/or contracture and increasing ROM in children diagnosed with spastic cerebral palsy. The treatments compared were Botulinum toxin A (BTX-A), serial casting, or a combination of both. Although the combination treatment appears to be slightly more effective than using each treatment by itself, studies have not definitely shown that using the combination treatment is better than using either of these treatments by themselves. Clinical scenario: In an outpatient pediatric facility, a child with spastic CP wants to be able to walk with a more normal gait pattern. Through clinical gait analysis and passive range of motion, you find that your patient has dynamic calf tightness and consider the current treatment options of BTX-A injection, fixed serial casting, or both to decrease spasticity in the calf muscles and increase ROM, to improve your patient’s gait. Clinically answerable question and PICO: Which treatment is most effective in decreasing spasticity and/or contracture and increasing ROM in the lower extremity for children diagnosed with spastic cerebral palsy: Botulinum toxin A, casting, or a combination of both? P: Children diagnosed with CP with lower extremity spasticity and/or equinus I: Botulinum toxin A/Casting alone or combination of both C: Botulinum toxin A/Casting alone or placebo O: Decrease in spasticity, measured with surface EMG testing, and increase in ROM in the lower extremit