Journal of Children's Orthopaedics vol:4 issue:3 pages:183-195
Purpose The purpose of this review is to clarify the role
of botulinum toxin serotype A (BTX-A) in the treatment of
children with cerebral palsy (CP), with a special focus on
the lower limb.
Background The treatment of spasticity is central in the
clinical management of children with CP. BTX-A blocks
the release of acetylcholine at the motor end plate, causing
a temporary muscular denervation and, in an indirect way,
a reduced spasticity. Children with increased tone develop
secondary problems over time, such as muscle contractures
and bony deformities, which impair their function and
which need orthopaedic surgery. However in these younger
children, delaying surgery is crucial because the results of
early surgical interventions are less predictable and have a
higher risk of failure and relapse. As BTX-A treatment
reduces tone in a selective way, it allows a better motor
control and muscle balance across joints, resulting in an
improved range of motion and potential to strengthen
antagonist muscles, when started at a young age. The
effects are even more obvious when the correct BTX-A
application is combined with other conservative therapies,
such as physiotherapy, orthotic management and casts.
There is now clear evidence that the consequences of
persistent increased muscle tone can be limited by applying
an integrated multi-level BTX-A treatment approach.
Nevertheless, important challenges such as patient selection, defining appropriate individual goals, timing, dosing and dilution, accuracy of injection technique and how to measure outcomes will be questioned. Therefore, ‘‘reflection is more important than injection’’ remains an actual statement.