The Use of Botulinum Toxin in the Management of Cerebral Palsy in Pediatric Patients

  • L. Andrew Koman
  • James F. MooneyIII
  • Beth P. Smith


The intramuscular use of botulinum toxin (Botox) for the purpose of neuromuscular blockade is accepted therapy for certain ocular and facial muscular imbalances, and its mechanism of action has been well described.1–15 The therapeutic use of Botox in larger skeletal muscle groups is not as well established. Direct intramuscular injections of Botox into the stemocleidomastoid, trapezius, and splenii muscles have resulted in clinical improvement in spasmodic torticollis;16,17 preliminary studies using Botox to treat focal foot and hand dystonias, upper limb spasticity in stroke patients, and spastic adductor muscles in patients with multiple sclerosis have been reported.4,5,18 Until recently, however, there have been no reports of Botox being used to manage the spasticity of cerebral palsy. Before discussing the use of Botox in this population, it is important to present a general overview of the pathophysiology of cerebral palsy and to point out the large number of patients with this disorder.


Cerebral Palsy Botulinum Toxin Botulinum Toxin Injection Hemifacial Spasm Focal Dystonia 
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  1. 1.
    Alpar AJ. Botulinum toxin and its uses in the treatment of ocular disorders. Am J Optom Physiol Optics 1987; 64: 79.CrossRefGoogle Scholar
  2. 2.
    Arthurs B, Flanders M, Codere F, Gauthier S, Dresner S, Stone L. Treatment of blepharospasm with medication, surgery and Type A botulinum toxin. Can J Ophthalmol 1987; 22: 24.PubMedGoogle Scholar
  3. 3.
    Carruthers J, Stubbs HA. Botulinum toxin for benign essential blepharospasm, hemifacial spasm and age-related lower eyelid entropion. Can J Neurol Sci 1987; 14: 42.PubMedGoogle Scholar
  4. 4.
    Cohen LG, Hallett M, Geller BD, Hochberg F. Treatment of focal dystonias of the hand with botulinum toxin injections. J Neurol Neurosurg Psychiatry 1989; 52: 355.PubMedCrossRefGoogle Scholar
  5. 5.
    Das TK, Park DM. Botulinum toxin in treating spasticity. Br J Clin Pract 1989; 43: 401.PubMedGoogle Scholar
  6. 6.
    Dutton JJ, Buckley EG. Botulinum toxin in the management of blepharospasm. Arch Neurol 1986; 43: 380.PubMedCrossRefGoogle Scholar
  7. 7.
    Elston JS. Botulinum toxin therapy for involuntary facial movement. Eye 1988; 2: 12.PubMedCrossRefGoogle Scholar
  8. 8.
    Kraft SP, Lang AE. Cranial dystonia, blepharospasm and hemifacial spasm: Clinical features and treatment, including the use of botulinum toxin. Can Med Assoc J 1988; 139: 837.Google Scholar
  9. 9.
    Ludlow CL, Naunton RF, Sedory SE, Schulz GM, Hallett M. Effects of botulinum toxin injections on speech in adductor spasmodic dysphonia. Neurology 1988; 38: 1220.PubMedCrossRefGoogle Scholar
  10. 10.
    Miller RH, Woodson GE, Jankovic J. Botulinum toxin injection of the vocal fold for spasmodic dysphonia. A preliminary report. Arch Otolaryngol Head Neck Surg 1987; 113: 603.PubMedCrossRefGoogle Scholar
  11. 11.
    Tsui JKC, Eisen A, Caine DB. Botulinum toxin in spasmodic torticollis. Adv Neurol 1988; 50: 593.PubMedGoogle Scholar
  12. 12.
    Tsui JK, Eisen A, Mak E, Carruthers J, Scott A, Caine DB. A pilot study on the use of botulinum toxin in spasmodic torticollis. Can J Neurol Sci 1985; 12: 314.PubMedGoogle Scholar
  13. 13.
    Tsui JKC, Fross RD, Caine S, Caine DB. Local treatment of spasmodic torticollis with botulinum toxin. Can J Neurol Sci 1987; 14: 533.PubMedGoogle Scholar
  14. 14.
    Tsui JKC, Eisen A, Stoessl AJ, Caine S, Caine DB. Double-blind study of botulinum toxin in spasmodic torticollis. Lancet 1986; 2: 245.PubMedCrossRefGoogle Scholar
  15. 15.
    Brin MF, Fahn S, Moskowitz C, Friedman A, Shale HM, Greene PE, Blitzer A, List T, Lange D, Lovelace, RE, McMahon D. Localized injections of botulinum toxin for the treatment of focal dystonia and hemifacial spasm. Mov Disord 1987; 2: 237.PubMedCrossRefGoogle Scholar
  16. 16.
    Gelb DJ, Lowenstein DH, Aminoff MJ. Controlled trial of botulinum toxin injections in the treatment of spasmodic torticollis. Neurology 1989; 39: 80.PubMedCrossRefGoogle Scholar
  17. 17.
    Stell R, Thompson PD, Marsden DC. Botulinum toxin in spasmodic torticollis. J Neurol Neurosurg Psychiatry 1988; 51: 920.PubMedCrossRefGoogle Scholar
  18. 18.
    Tsui JKC, Snow B, Bhatt M, Varelas M, Hashimoto S, Caine DB. New applications of botulinum toxin in the lower limbs (Abstract). Neurology 1990; 40 (Suppl 1): 382.Google Scholar
  19. 19.
    Bleck EE. Orthopaedic Management in Cerebral Palsy. Philadelphia: J.B. Lippincott (1987).Google Scholar
  20. 20.
    Cerebral Palsy—Facts and Figures (Fact Sheet). United Cerebral Palsy Association, Inc., New York, August 9 (1986).Google Scholar
  21. 21.
    Barabas G, Taft LT. The early signs and differential diagnosis of cerebral palsy. Pediatr Ann 1986; 15: 203.PubMedGoogle Scholar
  22. 22.
    Albright AL, Cervi A, Singletary J. Intrathecal baclofen for spasticity in cerebral palsy, JAMA 1991; 265: 1418.PubMedCrossRefGoogle Scholar
  23. 23.
    Diamond M. Rehabilitation strategies for the child with cerebral palsy. Pediatr Ann 1986; 15: 230.PubMedGoogle Scholar
  24. 24.
    Peacock WJ, Arens LJ, Berman B. Cerebral palsy spasticity. Selective posterior rhizotomy. Pediatr Neurosci 1987; 13: 61.PubMedCrossRefGoogle Scholar
  25. 25.
    Silver RL, de la Garza J, Rang M. The myth of muscle balance: A study of relative strengths and excursions of normal muscles about the foot and ankle. J Bone Joint Surg 1985; 67-B:432.Google Scholar
  26. 26.
    Piper MC, Kunos VI, Willis DM, Mazer BL, Ramsay M, Silver KM. Early physical therapy effects on the high-risk infant: A randomized controlled trial. Pediatrics 1986; 78: 216.PubMedGoogle Scholar
  27. 27.
    Wright T, Nicholson J. Physiotherapy for the spastic child: An evaluation. Dev Med Child Neurol 1973; 15: 146.CrossRefGoogle Scholar
  28. 28.
    Carpenter EB. Role of nerve blocks in the foot and ankle in cerebral palsy: Therapeutic and diagnostic. Foot Ankle 1983; 4: 164.CrossRefGoogle Scholar
  29. 29.
    Carpenter EB, Seitz DG. Intramuscular alcohol as an aid in management of spastic cerebral palsy. Dev Med Child Neurol 1980; 22: 497.PubMedCrossRefGoogle Scholar
  30. 30.
    Tardieu G, Tardieu C, Hariga J, Gagnard L. Treatment of spasticity by injection of dilute alcohol at the motor point or by epidural route. Clinical extension of an experiment on the decerebrate cat. Dev Med Child Neurol 1968; 10: 555.PubMedCrossRefGoogle Scholar
  31. 31.
    Silver RL, Rang M, Chan J, de la Garza J. Adductor release of nonambulant children with cerebral palsy. J Pediatr Orthop 1985; 5: 672.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 1993

Authors and Affiliations

  • L. Andrew Koman
    • 1
  • James F. MooneyIII
  • Beth P. Smith
    • 1
  1. 1.Department of Orthopaedic Surgery, The Bowman Gray School of MedicineWake Forest UniversityWinston-SalemUSA

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