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Legg-Calve-Perthes Disease
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Legg-Calve-Perthes Disease - August 24, 2001 1:53:00 AM
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Hirsch
Posts: 43
Joined: October 16, 2000
From: Germany
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Has anyone had any experience with Perthes children after the hip adductors have been injected with botulinum toxin? We are looking into the effect botulinum injection combined with PT compared to no botulinum toxin injection with PT has on hip ROM and gait in these children using 3-D video gait analysis. Just wondering if any of you had experience with Perthes or BT. Thanks.
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Re: Legg-Calve-Perthes Disease - August 24, 2001 5:58:00 AM
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Andrew M. Ball, MS, PT
Posts: 500
Joined: October 8, 1999
From: Chapel Hill, NC, USA
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Hirsch,
LCP disease is a disorder of avascular necrosis (caused by disruption femoral artery blood supply) to the femoral head usually affecting adolescent males. Although the largely invalid flexion-adduction test (the loss of flexion-adduction is often the first affected range of movement), it must be understood that (even if valid) this is an orthopedic, not neurologic sign (Woods and MacNicol, 2001 - examinied validity of this clinical test).
Botox, on the other hand, is used in cases of hypertonia to block transmission acetylcholine at the neuromuscular junction. The functional effect is that it temporarily (usually for about 3 months) paralizes the muscular bundle/muscle.
There is no information in the MEDLINE database examining the effects of Botox upon LCP disease. I'd suppose that there isn't likely to be any research in this area anytime soon either because treating LCP with Botox doesn't make a whole lot of sense in terms of theory (e.g. Treatment approches designed to adress neurologic tone don't typically have an effect upon problems of orthopedic origin.
Hope that helps. Anyone else have a thought?
Drew
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Andrew M. Ball, MS, PT, MBA
PhD Candidate
[This message has been edited by Andrew M. Ball, MS, PT (edited August 24, 2001).]
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Re: Legg-Calve-Perthes Disease - August 27, 2001 3:36:00 AM
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Hirsch
Posts: 43
Joined: October 16, 2000
From: Germany
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Hi Andrew,
Thanks for your reply regarding BT for LCPD. I understand your reply. Actually, there is a small pilot study that was done in Germany but it is not indexed in Medline and I was wondering if there are any innovative studies in the USA that are using BT in LCPD that you may have heard of. I guess the answer is "No". The logic is as follows: These children often have high adductor tone which makes PT difficult and paninful and our hypothesis is that BT injection into, say, the adductor magnus will reduce tone to that muscle and increase ROM, making these children more manageable in PT, and this will have a positive effect on kinetic and kinematic gait parameters, containment etc. Does this clear it up for you, a bit? Mark Hirsch
[QUOTE]Originally posted by Andrew M. Ball, MS, PT:
Hirsch,
LCP disease is a disorder of avascular necrosis (caused by disruption femoral artery blood supply) to the femoral head usually affecting adolescent males. Although the largely invalid flexion-adduction test (the loss of flexion-adduction is often the first affected range of movement), it must be understood that (even if valid) this is an orthopedic, not neurologic sign (Woods and MacNicol, 2001 - examinied validity of this clinical test).
Botox, on the other hand, is used in cases of hypertonia to block transmission acetylcholine at the neuromuscular junction. The functional effect is that it temporarily (usually for about 3 months) paralizes the muscular bundle/muscle.
There is no information in the MEDLINE database examining the effects of Botox upon LCP disease. I'd suppose that there isn't likely to be any research in this area anytime soon either because treating LCP with Botox doesn't make a whole lot of sense in terms of theory (e.g. Treatment approches designed to adress neurologic tone don't typically have an effect upon problems of orthopedic origin.
Hope that helps. Anyone else have a thought?
Drew
[/QUOTE]
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Re: Legg-Calve-Perthes Disease - August 27, 2001 4:31:00 AM
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Andrew M. Ball, MS, PT
Posts: 500
Joined: October 8, 1999
From: Chapel Hill, NC, USA
Status: offline
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I've heard this, but I'm still skeptical about its utility for two reasons:
First, because it's not written up anywhere and it seems that some MD's are trying this approach "willy-nilly").
Second, I'm not sure that I agree with the use of BoTox to address this kind of "tone". Usually, it's more of a guarding paratonia than true tone. Kids with LCP are guarded for a reason, and most kids self-resolve (albeit a long process) without medical intervention. I'm not sure that all of the surgeries and injections can be truly justified.
Drew
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Re: Legg-Calve-Perthes Disease - September 3, 2001 2:25:00 AM
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Hirsch
Posts: 43
Joined: October 16, 2000
From: Germany
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Hi again Andrew,
so you have heard of it being used, which was my original question. Can you recall where you heard of this procedure and perhaps refer me to this persons eamil or address so I can talk to them about it?
We're not doing anything willy-nilly here, I can assure you of that. We are doing research on the interaction of PT and BT and then we'll write up our results and then you and the rest of the scientific community can still decide if its useful or not.
Mark Hirsch
[QUOTE]Originally posted by Andrew M. Ball, MS, PT:
I've heard this, but I'm still skeptical about its utility for two reasons:
First, because it's not written up anywhere and it seems that some MD's are trying this approach "willy-nilly").
Second, I'm not sure that I agree with the use of BoTox to address this kind of "tone". Usually, it's more of a guarding paratonia than true tone. Kids with LCP are guarded for a reason, and most kids self-resolve (albeit a long process) without medical intervention. I'm not sure that all of the surgeries and injections can be truly justified.
Drew[/QUOTE]
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Re: Legg-Calve-Perthes Disease - September 3, 2001 2:31:00 AM
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Hirsch
Posts: 43
Joined: October 16, 2000
From: Germany
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I read in the literature that most (i.e., less than 50%) do not resolve spontaneously. By the way, do you know of any clinical trials on the efficacy of PT in LCPD? There is nothing I could find on medline. I agree with your statements regarding justification of surgery. They are not ALL justified, but there is literature on long-term follow up without treatment and it doesn't look good foraround 40% of LCPD patients. So if surgery is of questionable benefit and there is no "serious" evidence that PT works fort these patients, we should be doing research looking into what does, don't you agree? Mark
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Re: Legg-Calve-Perthes Disease - September 4, 2001 8:47:00 AM
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gerry
Posts: 238
Joined: July 6, 1999
From: Montgomery, AL, USA
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Mark,
I'll be interested in what you guys find out. I haven't heard of this being done, personally, so can't help you there. What adductor muscles are you guys targeting with the Botox? I have not really thought of these kids having increased tone. Do y'all use bracing in conjunction with the Botox and PT?
I wonder how the temporary loss of some of the adductor muscle pull will affect the reshaping of the head of the femur as it revascularizes. Hopefully it will be beneficial. Let us know what your results are!
gerry
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Re: Legg-Calve-Perthes Disease - September 5, 2001 12:40:00 AM
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Hirsch
Posts: 43
Joined: October 16, 2000
From: Germany
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Hi Gerry,
we are targeting the adductor magnus with the toxin. We will also be looking at how this perhaps affects postural control, especially use of hip versus ankle strategies during balance. I have a hunch that BT injection will improve range of motion at the hip and, radiographically, I'll put my money on better containment after BT. As far as balance goes...we have a dynamic platform posturography here (EquiTest), which I've used previously with Stroke and Parkinson's patients and now we will look at postural control in LCPD patients...it'll be interesting to see if their balance (hip control) changes after BT injection. Perhaps BT helps them to walk more "functionally", improves containment, but has a dysfunctional effect on pßostural control mechanisms. We'll see. Mark
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