1. Botulinum Toxin Injections for Spasticity Management
Jenny Wilson, MD
Amanda Stoltz, PT, DPT
Nov 11, 2016

2. Disclosures
Jenny Wilson is involved in a research study sponsored by Ipsen

3. Cerebral Palsy
Cerebral palsy (CP) describes a group of permanent disorders of the development of movement and posture, causing activity limitation, that are attributed to nonprogressive disturbances that occurred in the developing fetal or infant brain.
Cerebral Palsy - Definition

4. Classification of Cerebral Palsy
Spastic
Extrapyramidal
Choreoathetoid
Dystonic
(Dyskinetic)
Ataxic
Hypotonic
C. Mixed

5. Muscle tone Too low—hypotonia Too high—hypertonia Normal
= the resting tension in the muscle
= resistance to passive stretch
Too low—hypotonia
Too high—hypertonia
Normal

6. Increased muscle categorized as:
Spasticity
Velocity-dependent (“catch”) increase in tone
Exaggerated deep tendon reflexes
Agonist-antagonist muscle imbalance
Contractures
Dystonia
Involuntary sustained or intermittent muscle contractions causing twisting and repetitive movements, abnormal postures, or both.
Voluntary movement overflow
Tone often normal at rest; abnormal postures triggered by movement
Rigidity
Increased tone, not rate dependent, co-contraction of agonist/antagonist

7. Tone Management Approach
(Spasticity, dystonia)

8. What is botulinum toxin
Neurotoxin produced by the bacterium Clostridium botulinum
One of the most poisonous toxins
Causes botulism:
Food born
Wound botulism
Infant botulism
BoNT-A and BoNT-E cleave synaptosome-associated protein (SNAP-25), a presynaptic membrane protein required for fusion of neurotransmitter-containing vesicles. [4]
BoNT-B, BoNT-D, and BoNT-F cleave a vesicle-associated membrane protein (VAMP), also known as synaptobrevin.
BoNT-C acts by cleaving syntaxin, a target membrane protein

9. History
Dr. Herman Sommer first isolated in purified form botulinum toxin type A (BoNT- A)
Dr. Alan B. Scott used botulinum toxin to treat strabismus
1989 – Botox approved for treatment of strabismus, blepharospasm, and hemifacial spasm in patients aged younger than 12 years.
2016 – Dysport approved for lower extremity spasticity in children over 2 years

10. Mechanism 7 types of toxins Intramuscular injection
Acts at neuromuscular junction
Irreversible blockage of acetylcholine release
Onset of action: days, peak effect: weeks
Function can be recovered by the sprouting of nerve terminals. This usually takes months.

11. Types, indications *Dosing not equivalent between formulations
lower extremity spasticity in children
*Dosing not equivalent between formulations

12. Botulinum toxin: procedure
Anxiolysis – versed for most, topical (LMX), general anesthesia for some
Decide muscle targets, establish tone problem (distinguish from contracture), goals
Determine dose (Botox: max dose 18 units per kg; smaller muscles 1-2 units/kg, larger muscles 3-6 units per kg)
Localization – EMG, nerve stimulator, ultrasound
6 week follow-up after first injection
Repeat injections every 3-6 months, if effective

14. Adverse effects Soreness at site of injection
Excessive weakness in injected muscle
Generalized weakness
Dysphagia (particularly neck injections)
Rare incontinence
Hypersensitivity reactions
Respiratory infections
Neutralizing antibodies
Patients with neuromuscular disorders at higher risk
Deaths have been reported in children with baseline impaired respiratory status and dysphagia

15. Botox Clinic at SHC Multi-disciplinary team approach Neurologist PT OT
Nursing
Care Manager
Child Life

16. Botox evaluation

17. Using the ICF model for goal setting
Health Condition
Activity
Motor skills
Mobility
Functional tasks
Walking ability
Participation
Involvement in daily activities at home, school, and community with family or peers
Body Structure & Function
Tone / Spasticity
ROM
Strength
Selective control
Balance
Environmental Factors
Accessibility at home, school, community
Family / friend support
Personal Factors
Motivation
Development / age
Priorities and goals

18. Botox Evaluation What are the goals? Functional
Improve gait (foot flat, scissoring, crouch), decrease tripping/falling, improve balance or endurance
Tolerate AFOs or hand splints
Ease caregiver diapering/dressing/hygiene needs
Improve UE reach/hand function
Maintain skin integrity
Improve sitting posture or tolerance in wc
Improve weight bearing for assisted standing transfer
Improve tolerance to standing in stander, stretching program
Pain management
Long term-prolong/prevent/lessen need for orthopedic surgery

19. Botox Evaluation Spasticity ROM MAS Tardieu (slow vs quick stretch)
The larger the Tardieu, the more likely botulinum toxin injections will be effective
Interfering with function?
Isolated muscle groups?
ROM
Contracture?
Serial casting or splinting necessary?

20. Botox Evaluation Gait analysis (if ambulatory) Other factors?
Pre/post video
Other factors?
What has already been tried?
previous botulinum toxin injections, casting, bracing
Current AFOs/splints
Outpatient PT/OT services
optimize muscle strengthening, gait, stretching, functional skills (fine motor, gross motor)
Equipment (stander, wheelchair)
Child’s age… surgery more appropriate?

21. Serial Casting
Used in conjunction with botox injected into gastrocnemius muscle to prolong effect of botulinum toxin injections
Below-knee
Fiberglass
Walking casts
If the child has acceptable dorsiflexion motion
1 cast for 2-3 weeks
Start casting day of botulinum inject or wait 1- 2 weeks
If the child has equinus contracture
4-6 weeks casting
Cast change every 7-14 days
Post the heel if needed
Coordinate new AFO delivery with cast removal

22. Post-Botox Evaluation
Review outcome and goals with child/parent
Re-check range of motion, spasticity, gait pattern
post-botox gait video
Consider adding or changing muscle group(s) based on outcome
Review pre/post videos with multidisciplinary team and make further recommendations

23. Cases

24. Case 1 4 year old girl with right hemiplegic CP and toe walking
Significant spasticity and contracture of the right ankle

25. Pre Injection video

26. Case 1 Botox to the right gastrocnemius and posterior tibialis
Serial casting for the contracture

27. Post Injection video

28. Case 2 9 year old boy with spastic diplegia CP
Spasticity in his bilateral adductors contributing to difficulty ambulating in his walker, and difficulty with toileting, dressing and bathing

29. Pre Injection Video

30. Intervention
Botox to bilateral adductors to decrease scissoring and improve hygiene/dressing needs

31. Post Injection Video

32. Summary
Botulinum toxin is a reversible treatment for focal spasticity or dystonia
Setting goals is essential for determining effectiveness of botulinum toxin injections
PT and OT should be considered in conjunction with botulinum toxin injections to optimize results
Multi-disciplinary team approach is important in providing patient-centered care and setting functional goals

33. Thank you!