The Use of Botulinum Toxin Therapy For Lower-Extremity Spasticity in Children With Cerebral Palsy

Susan R. Criswell, M.D.; Beth E. Crowner, P.T.; M.S., Brad A. Racette, M.D.


Neurosurg Focus. 2006;21(2):1 

In This Article

Abstract and Introduction


Hypertonicity is a leading cause of disability for children with cerebral palsy (CP). Botulinum toxin A (BTA) chemically denervates muscle tissue and is commonly used in the management of lower-extremity hypertonicity in children with CP because of its focal effects and wide safety margin. Randomized controlled trials have demonstrated that BTA injections in the ankle flexors, hamstrings, and adductors reduce spasticity and result in improved passive and active range of motion. In other studies, improvements in gait and measurements of functional outcome were found in appropriately selected children who had been injected with BTA. A multidisciplinary treatment approach that includes physical therapists, occupational therapists, orthotists, neurologists, physicians with expertise in performing botulinum toxin injections, orthopedic surgeons, and neurosurgeons is critical to optimize care in children with lower-extremity tone due to CP. In this paper, the authors propose treatment algorithms based on clinical presentation, detailed dosing, and technical information to optimize the treatment of these children. With a multidisciplinary approach, children with lower- extremity hypertonicity due to CP can experience improvements in muscle tone and function.


Cerebral palsy is the most common motor disorder in children, occurring in 2 to 2.5 per 1000 live births. It is the result of abnormal development of or injury to both gray and white matter within the central nervous system.[33] Most children with CP experience hypertonia with components of spasticity and dystonia.[31] This mixed hypertonicity limits muscle movement around a joint, interferes with voluntary motor movement, and decreases longitudinal muscle growth.[16] As a result, CP commonly interferes with functional mobility, positioning, and self-care.

There are numerous treatment options for the hypertonicity that is characteristic of CP, including physical and occupational therapy,[37] orthoses,[6] oral medications,[39] baclofen pumps,[1] chemodenervation,[17] tendon lengthening,[41] and dorsal rhizotomy.[35] Chemodenervation is most commonly performed using BTA and has the potential advantages of a relatively focal effect and wide safety margin. Numerous researchers have assessed the safety and efficacy of this intervention by using a wide variety of delivery techniques and outcome assessment scales.[11,16,27,30,32,38]

Despite the large body of promising evidence and more than 10 years of use in clinical practice, there are few treatment guidelines for the use of BTA in children. In this article, we will review the evidence for the use of BTA and outline proposed algorithms for management of hypertonicity in children with CP.


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