Efficacy of conservative treatment for spastic cerebral palsy children with equinus gait: a systematic review and meta-analysis

Abstract

Background: Comparisons between various conservative managements of spastic equinus deformity in cerebral palsy demonstrated limited evidences, to evaluate the efficacy of conservative treatment among cerebral palsy children with spastic equinus foot regarding gait and ankle motion.

Methods: Studies were identified from PubMed and Scopus up to February 2022. Inclusion criteria were randomized controlled trial (RCT), conducted in spastic cerebral palsy children with equinus deformity, aged less than 18 years, compared any conservative treatments (Botulinum toxin A; BoNT-A, casting, physical therapy, and orthosis), and evaluated gait improvement (Physician Rating Scale or Video Gait Analysis), Observational Gait Scale, Clinical Gait Assessment Score, ankle dorsiflexion (ankle dorsiflexion at initial contact, and passive ankle dorsiflexion), or Gross Motor Function Measure. Any study with the participants who recently underwent surgery or received BoNT-A or insufficient data was excluded. Two authors were independently selected and extracted data. Risk of bias was assessed using a revised Cochrane risk-of-bias tool for randomized trials. I² was performed to evaluate heterogeneity. Risk ratio (RR), the unstandardized mean difference (USMD), and the standardized mean difference were used to estimate treatment effects with 95% confidence interval (CI).

Results: From 20 included studies (716 children), 15 RCTs were eligible for meta-analysis (35% had low risk of bias). BoNT-A had higher number of gait improvements than placebo (RR 2.64, 95% CI 1.71, 4.07, I² = 0). Its combination with physical therapy yielded better passive ankle dorsiflexion at knee extension than physical therapy alone (USMD = 4.16 degrees; 95% CI 1.54, 6.78, I² = 36%). Casting with or without BoNT-A had no different gait improvement and ankle dorsiflexion at knee extension when compared to BoNT-A. Orthosis significantly increased ankle dorsiflexion at initial contact comparing to control (USMD 10.22 degrees, 95 CI% 5.13, 15.31, I² = 87%).

Conclusion: BoNT-A and casting contribute to gait improvement and ankle dorsiflexion at knee extension. BoNT-A specifically provided gait improvement over the placebo and additive effect to physical therapy for passive ankle dorsiflexion. Orthosis would be useful for ankle dorsiflexion at initial contact. Trial registration PROSPERO number CRD42019146373.

Keywords: Ankle; Cerebral palsy; Equinus; Gait; Management.

Fig. 1

PRISMA flow diagram of study selection process

Fig. 2

Forest plot showing meta-analysis of Botulinum toxin A (BoNT-A) versus placebo on number of gait improvement. Gait improvement was determined by at least 2 scores of Physician’s Rating Scale [7, 23] or at least of 1 point of Video Gait Analysis improvement [11, 12]

Fig. 3

A funnel plot of the comparison of botulinum toxin A (BoNT-A) versus placebo showed asymmetry of the plot. A contour-enhanced funnel plot demonstrated that missing studies were in the area of non-significance indicating a publication bias

Fig. 4

Forest plots showing meta-analysis for composite scores of A. botulinum toxin A (BoNT-A) versus casting evaluated by composite scores of Physician’s Rating Scale [9, 10], B. BoNT-A plus casting versus BoNT-A alone assessed by composite scores of Observational Gait Scale [31, 32], and C. BoNT-A plus physical therapy versus physical therapy indicated by composite scores of Clinical Gait Assessment Score [13, 20]

Fig. 5

Forest plot showed meta-analysis of the efficacy of the ankle–foot orthosis (AFO) versus control on ankle dorsiflexion at initial contact

Fig. 6

A funnel plot and a contour-enhanced funnel plot of the comparison between orthosis and control on ankle dorsiflexion showed asymmetry. Missing studies were broadly in the area of statistical significance (no shading) which indicated the influences from other factors rather than a publication bias

Fig. 7

Forest plot showing meta-analysis for passive ankle dorsiflexion with knee extension of A botulinum toxin A (BoNT-A) versus casting alone, B BoNT-A plus casting versus BoNT-A alone, and C BoNT-A plus physical therapy versus physical therapy alone