BOTULİNUM TOKSİNİ ENJEKSİYONU UYGULANAN SEREBRAL PALSİLİ ÇOCUKLARDA GASTROKNEMİUS SPASTİSİTESİNİN SHEAR-WAVE ELASTOGRAFİ YÖNTEMİ İLE DEĞERLENDİRİLMESİ: ÖLÇÜM İÇİN UYGUN POZİSYONU BELİRLEME

Öz

Giriş: Serebral palsi (SP), çocukluk çağının en sık görülen nöromusküler bozukluğudur. Beyinde nonprogresif bir hasar sonucunda gelişen motor disfonksiyon ile karakterize bu hastalık klinikte çoğunlukla spastisite ile karşımıza çıkar. Spastisitenin azaltılması için botulinum toksini enjeksiyonu sıkça uygulanan bir yöntemdir. Ultrasonografi alanında yeni bir gelişme olan elastografi yöntemi ile adele sertliğinin belirlenebildiği saptanmıştır. Bu çalışmanın amacı SP hastalarındaki gastroknemius adele sertliğinin botulinum toksini enjeksiyonu öncesi ve sonrasında elastografi yöntemi ile değerlendirilmesi ve bir tedavi algoritması oluşturulmasına katkıda bulunmaktır. Gereç ve Yöntem: Hastanemiz ortopedi ve travmatoloji departmanına başvuran ve gastroknemius adelesine botulinum toksini enjeksiyonu planlanan SP hastalarından rastgele seçilen 30 hasta çalışmaya dahil edildi. Çalışmaya katılan hastalara enjeksiyon öncesi, sonrası 3. hafta ve 3. ayda her iki gastroknemius adelesine shear wave elastografi (SWE) çekildi. Hemiparezik hastalarda karşı bacak kontrol grubu olarak alındı. Klinik değerlendirme amaçlı hastaların Modifiye Ashworth Skala (MAS) değerleri kaydedildi. Bulgular: Dizin tam ekstansiyonda, ayak bileğinin pasif dorsifleksiyonda olduğu pozisyonda gastroknemius adelesi medial başının elastografik değerleri ile enjeksiyon öncesi ve sonrası 3. hafta ile 3. aydaki MAS değerleri arasında istatistiksel olarak anlamlı ilişki tespit edilmiştir (p<0.05). Sonuç: SP hastalarında gastroknemius adelesindeki spastisiteye bağlı kas sertliği elastografik ölçümlerle gösterilmiştir. Bu ölçümlerle klinik MAS değerleri arasında korelasyon tespit edilmiştir. Korelasyon için en uygun pozisyon dizin tam ekstansiyonda ayak bileğinin pasif dorsifleksiyonda olduğu pozisyondur. Elastografi yönteminin daha çok gelişmesi ile ileride nöromuskuler hastalıkların tanı ve tedavi takibinde daha sık kullanılmaya başlayacaktır.

Anahtar Kelimeler

• elastografi
• sonoelastografi
• serebral palsi

Evaluation of Gastrocnemius Spasticity With Shear-Wave Elastography in Children with Cerebral Palsy after Botulinum Toxin Injection: Defining A Proper Position for Measurement

Abstract

Aim: Cerebral Palsy (CP) is the most common neuromuscular disorder in children and it is characterized by a dysfunction in movement and posture. Botulinum toxin injection is a treatment method used for muscle spasticity in patients with CP. Elastography is a new method which is used for measuring muscle stiffness. This study aims to evaluate the gastrocnemius muscle stiffness in cerebral palsy patients before and after botulinum toxin injection by using the elastography method and contribute to the establishment of a treatment algorithm with a proper position for measurement.
Materials and Method: The participants of this study were chosen from the patients of our hospital’s orthopaedics and traumatology department. Among the patients on whom botulinum injection to gastrocnemius muscle was planned, 30 patients were randomly selected. Elastography of both gastrocnemius muscles were taken before the injection of botulinum toxin, in the third week and third month after the injection. Simultaneously with the elastography, Modified Ashworth Scale (MAS) values were noted. In hemiparetic patients, contralateral legs were taken as the control group.
Results: The elastographic values of the medial head of gastrocnemius when the knee is in extension and ankle in passive dorsiflexion, were found to be statistically significantly related (p<0.05) to the MAS values before botulinum toxin injection, third week and third month post-injection.
Conclusion: Stiffness due to spasticity in gastrocnemius muscle in CP patients was demonstrated through elastographic evaluation. A correlation was found between clinical MAS values. The most proper position was in which the knee is fully extended and the ankle is passively dorsiflexed. Elastographic measurements may be able to be used in these patients as a method of diagnosis in the future and it will help to assess the effectiveness of the treatment after the injection of botulinum toxin.

Keywords

• elastography
• sonoelastography
• cerebral palsy

References

1. 1. Bax M, Goldstein M, Rosenbaum P, et al. Proposed definition and classification of cerebral palsy. Dev Med Child Neurol. 2005;47:571–6.
2. 2. Cans C. Surveillance of Cerebral Palsy in Europe: a collaboration of cerebral palsy surveys and registers. Dev Med Child Neurol. 2000;42:816–24.
3. 3. Liu JM, Li S, Lin Q, Li Z. Prevalence of cerebral palsy in China. Int J Epidemiol. 1999;28:949-54.
4. 4. Haerer AF, Anderson DW, Schoenberg BS. Prevalence of cerebral palsy in the biracial population of Copiah County, Mississippi. Dev Med Child Neurol. 1984;26:195-9.
5. 5. Reddihough DS, Collins KJ. The epidemiology and causes of cerebral palsy. Aust J Physiother. 2003;49:7-12.
6. 6. Clopton N, Dutton J, Featherston T, et al. Interrater and intrarater reliability of the Modified Ashworth Scale in children with hypertonia. Pediatr Phys Ther. 2005;17:268-73.
7. 7. Brandenburg JE, Eby SF, Song P, et al. Ultrasound elastography: the new frontier in direct measurement of muscle stiffness. Arch Phys Med Rehabil. 2014;95:2207-19.
8. 8. Pedersen M, Fredberg U, Langberg H. Sonoelastography as a diagnostic tool in the assessment of musculoskeletal alterations: a systematic review. Ultraschall Med. 2012;33:441-6.

9. 9. Vasilescu D, Vasilescu D, Dudea S, et al. Sonoelastography contribution in cerebral palsy spasticity treatment assessment, preliminary report: a systematic review of the literature apropos of seven patients. Med Ultrason. 2010;12:306-10.
10. 10. Maisetti O, Hug F, Bouillard K, Nordez A. Characterization of passive elastic properties of the human medial gastrocnemius muscle belly using supersonic shear imaging. J Biomech. 2012;45:978-84.
11. 11. Kwon DR, Park GY, Lee SU, Chung I. Spastic cerebral palsy in children: dynamic sonoelastographic findings of medial gastrocnemius. Radiology. 2012;263:794-801.
12. 12. Koman LA, Mooney JF, Smith B, et al. Management of cerebral palsy with Botulinum-A toxin: preliminary investigation. J. Pediatr Orthop. 1993;13:489–95.
13. 13. Aoki KR. Pharmacology and immunology of botulinum toxin type A. Clin Dermatol. 2003;21:476–80.
14. 14. Kahraman A, Seyhan K, Deger U, et al. Should botulinum toxin A injections be repeated in children with cerebral palsy? A systematic review. Dev Med Child Neurol. 2016;58:910-7.
15. 15. Flett PJ. Rehabilitation of spasticity and related problems in childhood cerebral palsy. J Paediatr Child Health. 2003;39:6-14.
16. 16. Pavone V, Testa G, Restivo DA, et al. Botulinum toxin treatment for limb spasticity in childhood cerebral palsy. Front Pharmacol. 2016;7:29.
17. 17. Wu CH, Wang TG. Measurement of muscle stiffness in children with spastic cerebral palsy. Radiology. 2012;265:647; author reply 647-8.
18. 18. Chino K, Akagi R, Dohi M, et al. Reliability and validity of quantifying absolute muscle hardness using ultrasound elastography. PLoS One. 2012;7:e45764.
19. 19. Akagi R, Chino K, Dohi M, Takahashi H. Relationships between muscle size and hardness of the medial gastrocnemius at different ankle joint angles in young men. Acta Radiol. 2012;53:307-11.
20. 20. Park GY, Kwon DR. Sonoelastographic evaluation of medial gastrocnemius muscles intrinsic stiffness after rehabilitation therapy with botulinum toxin a injection in spastic cerebral palsy. Arch Phys Med Rehabil. 2012;93:2085-9.
21. 21. Arda K, Ciledag N, Aktas E, et al. Quantitative assessment of normal soft-tissue elasticity using shear-wave ultrasound elastography. AJR Am J Roentgenol. 2011;197:532-6.
22. 22. Chin TY, Nattrass GR, Selber P, Graham HK. Accuracy of intramuscular injection of botulinum toxin A in juvenile cerebral palsy; a comparison between manual needle placement and placement guided by electrical stimulation. J Pediatr Orthop. 2005;25:286–9.