Effect of Botulinum Toxin on Equinus Foot Deformity in Cerebral Palsy Patients: A Systematic Review and Network Meta-analysis

Background: Cerebral palsy (CP) is a brain disorder that affects the development, movement and posture leading to limitation of Range of Movement (ROM) in the growing children. CP leads to deformities such as equinus foot deformity. We aim to investigate the efficacy of different botulinum toxin (BTX) products with or without serial casting in reducing the muscle spasticity in equinus foot deformity in patients with CP. Methods: A systematic review of the literature was performed by searching different electronic databases. Pub- Med, Scopus, Web of Science (WOS), and GHL databases were used. We analyzed the extracted data by network meta-analysis method using the R software package (version 3.5.0). Results: Regarding Modified Ashworth score (MAS), BTX-A was superior compared to placebo and BTX-A plus immediate casting (MD = −0.39, 95% CI [−0.60; −0.18]) and (MD = −0.50, 95% CI [−0.98; −0.02]), respectively. Concerning growth motor function movement Classification System (GMFM), Neuronox ranked above at 3 months (MD = −1.60, 95% CI [−2.87; −0.33]) and at six months (MD = −1.90, 95% CI [−3.48; −0.32]) compared to BTX-A. Regarding the Modified Tardieu scale (MTS) with knee flexion, BTX-A was superior to BTX-A plus immediate casting (MD = 8.60, 95% CI [1.76; 15.44]). Concerning passive range of movement (PROM) with Knee flexion or extension at 3 months, BTX-A showed a significant improvement compared to BTX-A plus immediate casting. Conclusion: BTX-A ranked best on a physician rating scale (PRS), MAS, MTS with knee flexion and PROM (Knee flexion and extension) compared to Neuronox and Botulax. BTX-A alone was also better than BTX-A plus immediate casting.