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Spasticity management with Botulinum Toxin type A in cerebral palsy patients.

Cerebral palsy is the most common cause of physical disability in children. Spasticity is a disabling clinical symptom that is prevalent in those patients and it’s responsible for several clinical outcomes. It causes severe motor dysfunctions like loss of balance, strength and selective motor control of the muscles, as well as increased muscle tone that leads to secondary problems such as fixed contractures and bone deformities.

Generally, therapy for spasticity is symptomatic with the aim of increasing functional capacity and relieving discomfort. The approach to treatment should be multidisciplinary, including a rehabilitation program with physical therapy, occupational therapy and hydrotherapy, surgeries, prescription of orthoses and medication. A variety of oral medications are used to diminish spasticity with modest benefits.

Treatment with botulinum toxin type A (BTX-A) is a well-established option in the management of spasticity, providing focal reductions in muscle tone in Cerebral Palsy patients. Many medical studies have demonstrated the effectiveness of BTX-A injections in reducing muscle tone, increasing the range of motion, and improving posture and gait in Cerebral Palsy patients.

 Defining the goals of Cerebral Palsy treatment with BTX-A injection is very important. The goals like reduction of muscle tone, increase in range of motion of the joints, functional improvement of upper and lower extremities, delay a surgery, and prediction of surgical results should be individualized for each patient. BTX-A injections should always be considered as an adjunctive treatment to traditional therapies, including physiotherapy, orthoses, occupational therapy, and serial casting.

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The injections are administered in a multilevel approach at a single injection session. The dosage for Botox (Allergan, GR) range from 15–20 U/kg, and that for Dysport (Ipsen, GR) was 30 U/kg. The total maximum doses for Botox and Dysport are 300 U and 500 U. The injections are administered under electromyography (EMG) or electrical stimulation guidance for the exact identification of target muscles and motor points. Special monopolar needle electrodes are used for the injections.

The patients follow an intensive physiotherapy program that starts 2-3 days after the multilevel BTX-A injections. The physiotherapy sessions consist of active and passive stretching of flexor muscles, strengthening of extensor muscles, and balance and gait training (Bobath method).

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Many times, orthoses are used to support the result after the BTX-A injections.

The patients must be assessed at baseline and every three months post-injection for six months.

In conclusion, we believe that optimally timed, multilevel BTX-A injections is effective in reducing spasticity and maintaining functional gains six months after the injection. The importance of rehabilitation programs and appropriate orthoses should always be mentioned to improve the efficacy of the toxin in maintaining improvement in strength, selective motor control, balance and gait.

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