Comparison of Tendon Transfer, Botox Injections and Ongoing Treatment in Hemiplegic Cerebral Palsy

The specific aims of this study and the methodology for achieving them are:

1. To determine if tendon surgery for the forearm, wrist and thumb deformities of UECP is
more effective than Botulinum toxin injections or regular ongoing treatment at
improving function and quality of life for children with UECP. Children who are
candidates for tendon surgery will be prospectively randomized to one of three
treatment groups: standard tendon surgery, a series of three Botulinum toxin injections
over a period of 12 months, and regular ongoing treatment. Validated tests of
cognition, function and quality of life with tests of stereognosis and range of motion
will be administered before, during and after treatment in order to compare outcomes of
the three treatment groups.

2. To determine if serial Botulinum toxin injections have long-term beneficial effects on
upper extremity function which outlast their paralytic effects.

Botulinum toxin has been shown to have beneficial effects on UE function while the muscles
injected remain weakened by the toxin. Clinicians have theorized that improvements in UE
function are maintained after the toxin wears off, but this has not been proven. Children
randomized to the Botulinum toxin injection group will receive 3 injections. Their function
will be tested before the first injection, while the paralytic results of the second
injection are still in effect, and after the paralytic effects of the third injection have
worn off, and the results compared in order to determine if functional improvements outlast
the medicinal effects.

Inclusion Criteria:

- diagnosis of UECP

- aged four to 17 years

- candidate for standard surgical management (tendon transfer)

Exclusion Criteria:

- subject could benefit from procedures in addition to standard surgical
management and releases, and these procedures could be performed at the same
anesthetic (for example, elbow flexor release)

- previous Botulinum toxin injection session in the affected UE in < 1 year

- previous ipsilateral UE surgery

- primary language other than English or Spanish

- subject and/or parent unwilling to attend eight therapy sessions and perform home
exercise protocol