Evaluation of independent versus integrated effects of reciprocal electrical stimulation and botulinum toxin-A on dynamic limits of postural stability and ankle kinematics in spastic diplegia: a single-blinded randomized trial.

BACKGROUND: Combination of medical and physical therapy protocols are increasingly recommended for cerebral palsied children. However, the clinicians frequently choose between independent or integrated treatment delivery based on little empirical evidence. AIM: The aim of this study was to analyze the independent versus the integrated effects of reciprocal electrical stimulation (RES) and botulinum toxin-A (BoNT-A) in terms of dynamic limits of postural stability and ankle kinematics in spastic diplegia. DESIGN: A single-blinded randomized trial. SETTING: Physical therapy laboratories and out-patient clinic and a tertiary local hospital. POPULATION: Sixty children with spastic diplegia were allocated to RES, BoNT, or Integrated RES and BoNT interventions (20 children for each group). METHODS: All children participated in a 60-minutes exercise program, three times/week for 12 successive weeks. Additionally, The RES group received reciprocal electrical stimulation of ankle dorsi and plantar flexors for 30 minutes before each exercise session, the BoNT group were injected by botulinum toxin-A to calf muscles one-week prior to commencing the exercise program, and the Integrated RES and BoNT group received both interventions. Ankle joint kinematics (displacement angle at initial contact, maximum dorsiflexion-stance, and peak dorsiflexion-swing) and dynamic limits of postural stability (anterior/posterior [AP-LOS], medial/lateral [ML-LOS], and overall [O-LOS]) were assessed at entry and after intervention. RESULTS : Study groups were comparable with respect to all outcome measures at entry (P>0.05). Compared to the independent effect of either RES or BoNT-A, the integrated RES and BoNT-A produced a preferable improvement of O-LOS, maximum dorsiflexion-stance, and peak dorsiflexion-swing subsequently after intervention (P<0.05). Further, significant differences between BoNT-A and RES regarding the AP-LOS and ML-LOS were observed in favor of BoNT-A (P<0.05). CONCLUSIONS: Integration of RES and BoNT-A has the capability to restore postural stability and ankle kinematics in diplegic children. CLINICAL REHABILITATION IMPACT : Integration of RES and BoNT-A has a considerable effect on some of the essential elements that contribute toward the improvement of ankle biomechanics and postural stability. The demonstrated effect provides the basis for its application in the treatment of spastic diplegia.