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CURRENT CONCEPT REVIEW
The use of botulinum toxin A in children with cerebral palsy,
with a focus on the lower limb
Guy Molenaers •Anja Van Campenhout •
Katrien Fagard •Jos De Cat •Kaat Desloovere
Received: 14 July 2009 / Accepted: 12 February 2010 / Published online: 18 March 2010
EPOS 2010
Abstract
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 selec-
tion, defining appropriate individual goals, timing, dosing
and dilution, accuracy of injection technique and how to
measure outcomes will be questioned. Therefore, ‘‘reflec-
tion is more important than injection’’ remains an actual
statement.
Keywords Cerebral palsy Botulinum toxin A
Multi-level treatment Lower limb
Introduction
Cerebral palsy (CP) has been described by Mercer Rang as
‘‘an insult of the developing brain that produces a disorder
of movement and posture that is permanent but not
unchanging’’ [1]. It is the most frequent cause of motor
disability amongst children in Europe [2]. The prevalence
in Europe has been rather stable over the last 30 years and
ranges between 1.5 and 3.0 per 1,000 live births [3].
Children with CP may present with a variety of motor
problems, changing with growth and development. Primary
problems are directly related to the lesion in the central
nervous system, influencing muscle tone, balance, strength
and selectivity, whereas static muscle contractures and bony
deformities (secondary problems) develop slowly over time
in response to the primary problems. Furthermore, the child
often develops adaptive mechanisms or ‘coping responses’
in gait to overcome the primary and secondary problems.
G. Molenaers (&)A. Van Campenhout
Department of Paediatric Orthopaedics, University Hospital
Pellenberg, Weligerveld 1, 3212 Pellenberg, Belgium
e-mail: guy.molenaers@uz.kuleuven.ac.be
G. Molenaers A. Van Campenhout
Musculoskeletal Sciences, Katholieke Universiteit Leuven,
Leuven, Belgium
K. Fagard J. De Cat K. Desloovere
Clinical Motion Analysis Laboratory, University Hospital
Pellenberg, Pellenberg, Belgium
K. Desloovere
Department of Rehabilitation Sciences,
Katholieke Universiteit Leuven, Leuven, Belgium
123
J Child Orthop (2010) 4:183–195
DOI 10.1007/s11832-010-0246-x
Of all primary problems, spasticity is the main cause of
the development of secondary problems. A treatment pro-
gramme should, therefore, be focused on the reduction or
normalisation of tone to prevent the development of sec-
ondary problems and delaying or obviating the need for
surgical intervention.
Spasticity can be addressed with oral medication, phe-
nol, selective dorsal rhizotomy and intrathecal baclofen. In
the past two decades, botulinum toxin serotype A (BTX-A)
has been introduced as a selective treatment option for
spasticity in children with CP. BTX-A, when injected into
the muscles, will reduce muscle tone. It became clear that
the use of BTX-A was a major advance in the treatment of
CP and it is now widely accepted in the management of
paediatric posture and movement disorders.
Figure 1gives an overview of the different motor
problems in children with CP and the action location of
BTX-A.
BTX-A is one of the seven different serotypes of botu-
linum toxin (A–G) produced by the anaerobic bacterium
Clostridium botulinum [4]. The serotypes differ in neuro-
toxin complex size, activation level, intracellular site of
action, acceptor/receptor sites, muscle-weakening efficacy,
duration of action and target affinity [5]. BTX-A has been
commercially available for clinical use for the longest time.
There are currently four commercially available prepara-
tions of BTX-A: Botox
(Allergan), Dysport
(Ipsen),
Xeomin
(Merz Pharmaceuticals GmbH; only available in
Germany) and Hengli, a Chinese form [6,7]. The only
approved botulinum toxin type B (BTX-B) formulation is
known as Myobloc
in the United States and as Neurob-
loc
outside of the United States. The clinical trials with
BTX-B for CP are limited, mostly open-label pilot studies,
and include patients who were secondary non-responders to
BTX-A therapy. The regional and systemic anticholinergic
adverse side effects of BTX-B limit its clinical use [8].
After BTX-A has been injected directly into the muscle,
it is selectively taken up by endocytosis at the cholinergic
nerve terminal, where it blocks the release of acetylcholine.
This chemical denervation causes a temporary reduced
muscular activity in the injected muscles. The process is
reversible. Recovery occurs by terminal sprouting and
definitive repair is established by the return of vesicle
turnover to the original terminals. The return of synaptic
function to the original neuromuscular junction associated
with elimination of the sprouts requires approximately
91 days. The period of clinically useful relaxation is usu-
ally 12–16 weeks [7,9,10].
Although BTX-A has a high potential therapeutic value
as a tone reducer, it should be noted that it also has to be
considered as one of the strongest poisons of the world and
is potentially lethal if not used in a safe way. Because the
different commercial preparations have different formula-
tions, molecular structures and purification methods, they
are unlikely to be clinically equivalent. Individual dosages
should be calculated independently for the preparations,
guided by the dosing instructions specific to each product
and based on previous response and clinical experience.
Fixed dose-conversion factors are not applicable in the
treatment of spasticity in children with CP [11]. While
BTX-A produces a dose-dependent chemical denervation,
systematic side effects or untoward responses occur as the
total dose of BTX-A increases. Because several muscles
are often injected simultaneously within one treatment
session, multi-level treatments may involve a higher total
dosage when compared to single-level treatments [12,13].
Each dose should be expressed in units/kg/muscle. The
total dose also has to be expressed in units/kg/body weight
(U/kg/bw).
There has been enormous progress in the treatment of
gait problems in children with CP. In the last 20 years,
orthopaedic surgery in CP has evolved from staged surgery
performed on an annual basis, where each deformity was
corrected individually, to the current practice of a single-
event multi-level procedure [1,14,15]. The previously
used routine led to the so-called ‘birthday syndrome,’
where the child with CP spent a large part of his youth
hospitalised or in intensive rehabilitation after surgery,
instead of playing around with other children.
For purely orthopaedic interventions, Wenger and Rang
[16] and Gage [14] convinced us that the overall result is
better if all major muscles involved are lengthened and/or
transferred, and bony deformities are corrected during the
course of a single surgical procedure, so that all lower
extremity joints are balanced simultaneously.
Three-dimensional gait analysis was crucial in proving
that a better functional outcome was achieved with the
Selectivity
Strength Mal-alignments
Balance
Fixed contractures
Primary problems Secundary problemsTertiary problems
Tone
Growth
Maturity
Coping
Lever-arm dysfunction
BTX-A
Fig. 1 Motor problems experienced by children with cerebral palsy
(CP) and the action location of botulinum toxin serotype A (BTX-A)
184 J Child Orthop (2010) 4:183–195
123
single-event multi-level procedure [17–19]. The ability to
objectively document kinematics, kinetics and electromy-
ography (EMG) of the lower extremities, pelvis and trunk
has resulted in a better understanding of the pathome-
chanics of gait and treatment outcomes [18].
A good understanding of the maturity of gait for normal
children and for each individual child with CP is crucial in
planning the treatment.
From the scientific literature, it can be concluded that
many research groups are convinced that mature gait
is achieved after the age of 6 years in normal children
[20,21]. Children with CP develop mature gait and/or
other motor capacities at a more advanced age.
There is general agreement that surgical intervention to
improve gait should be avoided until gait has matured,
usually between the ages of 8 and 10 years. Before the age
of 8 years, the gait of children with CP is often charac-
terised by inconsistency, which complicates a clear rec-
ognition of all major problems in gait and motor function
[14].
Moreover, delaying surgery is important because the
results of early surgery are less predictable and have a
higher risk of failure and relapse. Before the age of 8 years,
the recurrence rate or need for a secondary procedure for
equinus gait increases in children who have undergone heel
cord procedures [14,15,22,23].
Furthermore, it is also well described that the surgical
manipulation of soft tissues affect the moment-generating
capacity, indicating that repeated muscle and, certainly,
tendon lengthening should be avoided to prevent weakness
[24].
A delay of orthopaedic surgery should be complemented
by a conservative treatment regimen that improves, if
possible, the overall condition of the child and optimises
motor function, thereby, reducing the development of
secondary problems and the need for complex surgery.
When this conservative therapy only includes physio-
therapy and the use of orthoses, the dynamic contractures
often progress to fixed contractures and even skeletal
deformations, causing severe biomechanical lever-arm
dysfunction. However, when these therapies are comple-
mented by a selective treatment for the spasticity, such as
BTX-A injections, it is hoped that the consequences of the
persistent muscle tone can be limited. The reduction in
muscle tone allows a combined treatment and is intended to
provide an opportunity to optimise the effects of casting
and orthotic management, which enhance both motor
ability and functional skills and potentially delay the need
for surgery [19,25].
Studies suggest that BTX-A treatment approach may
lessen the complexity of future surgery and may help to
delay surgery until the optimal timing is achieved, because
repeated BTX-A injections can help to prevent the
development of muscle contractures and bony deformities
if started at an early age [11,15,19,22,26,27].
BTX-A injections were first given therapeutically for
strabismus in the early 1980s by Allan Scott in the USA
[28]. In the following years, the therapeutic spectrum of
BTX-A has been successively expanding. The treatment
was adopted for other neurologic conditions, such as
blepharospasm, cervical dystonia and hemifascial spasm.
The use of BTX-A in spasticity was first tried in multiple
sclerosis in 1990 [29]. In 1988, the first clinical trials using
BTX-A for spasticity in patients with CP were started by
Andrew Koman and co-workers. The preliminary results
were reported in Koman et al. [30].
The original application of BTX-A in CP was limited to
the treatment at one level (mainly to treat an equinus
problem). However, a child with CP rarely presents with an
isolated problem at one level. Based on the results of gait
analysis and clinical examination, the necessity for multi-
level treatment with BTX-A became apparent. Many of the
common gait patterns in CP can only be adequately treated
if several muscles are addressed simultaneously in one
treatment session. This is why multi-level treatments with
BTX-A are more appropriate.
A multitude of BTX-A studies has been published in the
last decade. Most of them, however, focus on single, one-
level BTX-A treatment in CP [30–35]. A few studies,
though, highlight the need and overall better response of
multi-level injections [12,36–39]. Bakheit et al. [36]
concluded, from a study of 1,594 treatments in children
with muscle spasticity, that multi-level treatments with
BTX-A resulted in a better overall response than single-
level treatments. Galli et al. [37] and Mall et al. [38] also
emphasised the need for multi-level treatment.
In summary, BTX-A can be seen as a valuable treatment
option within the variety of tone reduction treatments,
because it:
– can reduce muscle tone
– is safe at a young age
– is reversible
– is selective
– allows combined treatment
– is dose-dependent
Application of BTX-A injections: an integrated
multi-level treatment
In order to influence all aspects of the child with CP, an
ultimate treatment strategy (Fig. 2) has been set up, in
which BTX-A is optimally combined with the common
conservative treatment options (physiotherapy, orthotic
management, casting and even oral medication). The aim
J Child Orthop (2010) 4:183–195 185
123
of the combined treatment is to change and to improve the
motor pattern of children with CP. This innovative
approach has been used at the Pellenberg University
Hospital since 1996.
The fundamentals of this integrated approach are proper
muscle selection,anappropriate dosage of BTX-A, and
an accurate injection technique. These three aspects are
absolute prerequisites to assure a good outcome.
Once these fundamentals have been established, it is
clear that other factors are crucial to the optimum ‘long-
term’ outcome, namely, pre- and post-injection care,
patient selection, timing, appropriate goal settings and an
extended evaluation of the outcome. Only when all of these
aspects are properly addressed is the success of BTX-A
treatment guaranteed.
Within the integrated approach, the interdisciplinary
team is of major importance. Because of the complexity of
the motor disorder in children with CP and a variety of
neurological deficits compounded by the effect of growth
on the pathological process, the treatment of a child with
CP should utilise a team approach with a variety of medical
professionals.
Muscle selection
BTX-A injections should be fine-tuned for each patient
individually following an extended standardised clinical
examination and an evaluation of posture, gait and/or other
motions.
The clinical examination focuses on spasticity, range of
motion, strength and selective muscle control. However,
even a well standardised physical examination cannot
provide a complete description of the complex pathology
of CP. Due to the dynamic nature of spastic CP, an accurate
assessment of the child should include motion (spasticity is
velocity-dependent). Desloovere et al. [40] studied the
correlation between gait analysis data and clinical mea-
surements, and evaluated the combined predictive value of
static and dynamic clinical measurements on the gait data
of children with CP. They found that gait analysis data
cannot be sufficiently predicted by a combination of clin-
ical measurements and concluded that both clinical
examination and gait analysis data provide important
information for delineating the problems of children with
CP.
The observation of movement is thought to be a decisive
factor in the ‘fine-tuning’ of BTX-A treatment, and, hence,
gait analysis plays a crucial role in the identification of
target muscles [41]. Objective gait/motion analysis allows
the specific description of the pattern of motion at each
joint and the identification of the muscles that cause the
pathological pattern, according to which the treatment can
be modified [14].
It should be noted that the motion analysis is limited to a
standardised video recording (walking, crawling, sitting,
rolling) in the different anatomical planes for children who
are too young to maintain concentration or with limited
anatomical height and for more involved children (Gross
Motor Function Classification System [GMFCS] IV and
V). It is known that children with GMFCS IV and V are
more vulnerable to develop hip dysplasia and scoliosis/
kyphosis, so X-rays are mandatory in their regular follow-
up. Conclusions from these objective evaluations, related
to individually defined goal settings, will be crucial for the
final selection of the muscles that should be injected. A
supplementary clinical evaluation under anaesthesia can
provide additional information.
Appropriate dosage
As confidence with BTX-A has grown over the years,
increasingly higher doses have been used. These dose
increases have involved not only more units of BTX-A per
injected muscle, but also the injection of multiple muscle
groups in one session. As verified by the objective evalu-
ations, many of the common pathological patterns in CP
can only be adequately treated if several muscles are
addressed simultaneously in one treatment session.
The optimal dosage per muscle depends on the muscle
volume, the amount of spasticity and the degree of the
muscle’s involvement in the pathological pattern. Less
involved muscles need a lower dosage [12] compared with
severely involved muscles, which dictate the pathological
pattern of posture, gait or movement.
Using the multi-level approach to administer BTX-A, it
was necessary to increase the total dosage. In the literature,
total dosages ranging from 2 to 29 U/kg/bw can be found.
Because most early studies included only equinus treat-
ment, the most frequently referred dose range referred to
Selectivity
Strength Mal-alignments
Balance
Fixed contractures
Primary problems Secundary problemsTertiary problems
Tone
Growth
Maturity
Coping
Lever-arm dysfunction
BTX-A
Integrated treatment!!!
Fig. 2 Integrated treatment in children with CP
186 J Child Orthop (2010) 4:183–195
123
was 4–8 U/kg/bw. When a multi-level treatment was used,
the maximal doses in the literature ranged from 10 to 29 U/
kg/bw. In one study [42,43], a dose of up to 40 U/kg/bw
was used within multi-level treatment. These authors
concluded that BTX-A (Botox
) treatment at the higher
dose is safe. In an overview of the studies that were per-
formed, with the multi-level/multi-site technique, on
monkeys, Aoki et al. [44] stated that there were no
observable systematic effects at doses below 33 U/kg/bw.
However, there was toxicity progressing to death at doses
of 38–42 U/kg/bw.
Safe recommended total dosages recently reported in the
literature for children with CP are [11]:
Botox
Dysport
Neuroblock
/
Myoblock
Range (U/kg bw) 1–20 (25) 1–20 (25) Not established
Maximum total
dose (U)
400 (-600) 500–1,000 Not established
Range maximum
dose/site (U)
10–50 50–250 Not established
Increasing the dose of BTX-A brings an increased
potential for adverse side effects. However, widespread use
support the safety of high-dosage BTX-A treatments in
children with CP, as the total dose is distributed over multiple
muscles and over multiple injection sites per muscle [11,12,
41,45]. Significant unwanted adverse effects are rare [11,36,
46,47]. Described adverse events tend to be expected con-
sequences of muscle relaxation, such as weakness or initial
loss of function, which can occur as patients learn to readjust
their postural control in response to altered muscle tone [45,
48]. Recovery and strengthening exercises and orthotics
should control these problems. Temporary incontinence has
been reported occasionally.
Willis et al. [49] suggest that doses of BTX-A between
15 and 25 U/kg can be administered to the lower limbs of
children with CP regardless of aetiology, clinical pheno-
type, severity, functional ability or medication use, with
an adverse event rate that is comparable with lower doses.
However, caution has been expressed regarding children
with severe spastic quadriplegia who have dysphagia, for
whom the total dosage should be limited (\18 U/kg/bw).
Adair and Graham [50] found that the incidence of
adverse events increased sequentially from GMFCS I to
GMFCS V.
In children who are overweight, we advise to adjust their
total body weight to the reference of their typical pairs’
height/weight ratio.
The multi-sites theory (with a safe distance between
injection sites) is of major importance. This theory is based
on the principle that a muscle is like a sponge, which can
absorb a certain amount of fluid. If we exceed that volume,
the muscle will leak and the toxin will enter the general
blood circulation, provoking adverse side effects. There-
fore, the total dose per muscle always has to be divided
between more sites, with an absolute maximum of 25–
50 U/site, and, due to different dilutions, to an absolute
maximum of 1 ml/site (in our hands, never more than
25 U/site and/or 1 syringe of 1 ml/site) and an inter-site
distance of a minimum of 4–5 cm [51,52].
Appropriate ranges for Botox
per muscle group of the
lower limbs are indicated Table 1.
Each 100-U vial of Botox
is usually reconstituted with
1–2 ml of saline. Two controlled studies found no differ-
ences in therapeutic effect between high- and low-volume
preparations [53,54]. However, recently study results,
suggest an improved effect for higher dilutions. A possible
explanation for the increased effects of higher dilution
compared to lower dilution could be that a larger volume/
dilution enables a greater spread of the toxin to neuro-
muscular junctions and, therefore, improved paralysis and
reduction in muscle tone [55,56]. Gracies et al. [56] also
showed the superior efficacy of BTX-A in a spastic muscle
when injected using an end plate targeting technique.
Guidelines indicate that the frequency of injecting
should not be more than one session of injections every
three months. By applying the integrated approach in
which BTX-A injections are combined with casting,
orthotic management and intensive physical therapy, the
duration of the BTX-A effect is increased. The averaged
duration of effect according to this approach was found to
be more than one year [57]. This is an important finding
Table 1 Indications for appropriate ranges for Botox
per muscle
group of the lower limbs
Muscle group Dosage
(units/kg/body
weight)
Gastrocnemius 3–6
Soleus 1–3
Tibialis posterior 1–2
Medial hamstrings (semitendinosus,
semimembranosus, gracilis)
3–5
Lateral hamstrings 1–2
Hip adductors 1–3
Rectus femoris 1–2
Iliopsoas 1–4
Dosage per injection site Max of 50 units
Botox
/site
J Child Orthop (2010) 4:183–195 187
123
because the higher the frequency of treatments, the higher
the risk of antibody formation [58]. Brashear et al. [59]
investigated the long-term dose consistency of BTX-A and
the intervals between treatments over a period of two years
in cervical dystonia patients. Their outcomes indicated that
doses and intervals between BTX-A treatments were con-
sistent throughout two years of observation, thereby, indi-
rectly indicating the non-development of antibody
formation. Recent data confirm these findings in children
with CP and found that total dosages and treatment intervals
remained stable within subsequent BTX-A treatments [57].
More research is needed to expand the results of this study.
Accurate injection technique
BTX-A injections can be administered under local anaes-
thesia, conscious sedation or general anaesthesia [27]. If
multiple levels are involved, it is recommended to
administer BTX-A under general anaesthesia. This also
permits an additional clinical evaluation while the patient
is under anaesthesia.
Correct needle placement (usually 26 gauge 923 mm
and 22 gauge 930 mm) for the different selected muscle
groups is defined by using palpation with the muscle under
stretching and by manual testing. By applying a passive
motion to the joint, the needle will be moving with the
muscle and the correct needle placement can be confirmed.
This is particularly interesting for separating bi- and mono-
articular muscle groups.
However we are convinced that ultrasonography with or
without EMG guidance or electrical stimulation is the most
appropriate technique to localise and identify the muscles to
be injected, especially for the smaller muscle groups [11].
Once the fundamentals of the multi-level BTX-A
treatment are properly addressed, several other crucial
factors are important in achieving successful outcomes.
The first factor is the optimum pre- and post-injection care
(which is a combination of casting, physical therapy and
orthotic management). To set up a long-term treatment
plan, appropriate patient selection with ideal timing and
individually defined goal-settings is crucial to obtain suc-
cessful results of BTX-A treatment. Finally, including
perfectly timed BTX-A treatments, detailed measurement
of the outcome is also crucial.
Aftercare
Alhusaini et al. [60] found no changes in the passive tissue
characteristic of the calf muscles following BTX-A, despite
a reduction in spasticity. They concluded that additional
treatment approaches are required to supplement the effects
of BTX-A injections when managing children with calf
muscle spasticity in CP. Desloovere [61] confirmed that
aftercare issues, such as casting, orthotic management and
physical therapy, significantly influenced a successful
outcome after BTX-A injection in children with CP.
Casting and day and night orthoses are used in con-
junction with physical therapy to prolong improved muscle
length and facilitate the carry-over of improved motor
control following BTX-A injections. The combination of
these different conservative treatments is crucial within the
integrated approach and should be seen as a continuum in
which the treatments are strongly linked to each other,
mainly by the use of physical therapy.
Casting
For some time, the general indication for toxin injection
was ‘‘the presence of a dynamic contracture, interfering
with function, in the absence of a fixed myostatic con-
tracture’’ [62]. However, in many cases, there are compo-
nents of both dynamic muscle shortening and early
contractures. Various combinations of injections with
periods of casting may then be appropriate, and may extend
the window of a strict BTX-A treatment. There is evidence
that BTX-A alone is as effective as casting alone in the
management of dynamic equinus, having a similar mag-
nitude of response but a longer duration [27,63,64]. From
the work of Molenaers et al. [65] and Desloovere et al.
[66], the additional benefits of the combined treatment
have become clear. Children that were treated with BTX-A
injections combined with casting showed an improved
second-ankle rocker and longer-lasting effects as compared
to children that were treated without casting. From a pro-
spective study, Desloovere et al. [41] concluded that more
benefits, mainly in the proximal joints, were seen for the
children who were casted after injections as compared to
the children who were casted before injections.
Most of the studies have examined the effects of casting
on spastic equinus. However, casting can also be applied
for other muscles at other levels. Because of the inconve-
nience of casting proximal muscles and proximal joints,
these casts should be removable and be worn for only a part
of the day. It should be noted that, although several studies
and long-term clinical practice indicated the advantages of
combining BTX-A injections with casting, Blackmore
et al. [67] concluded in their review that there is still no
strong and consistent evidence that combining casting and
BTX-A is superior to using either intervention alone, or
that either casting or BTX-A is superior to the other
immediately after treatment.
Nevertheless, our own data, objective and even
dynamic, prove, on several different occasions, that com-
bining BTX-A with casting is far more effective in short-
and long-term outcomes than casting or BTX-A as a
standalone procedure. But we have to admit that we always
188 J Child Orthop (2010) 4:183–195
123
combine casting and BTX-A with the use of orthoses as
part of the aftercare and treatment protocol (which is what
we strongly recommend).
Physical therapy
As previously mentioned, the overall aim is to make
functional progress or at least to preserve a status quo in the
medium- to long-term. In physical therapy treatment of
children with CP, varying approaches and techniques are
used, ranging from very conservative and conventional
techniques like tonification, manual stretching, massage
etc., to more complex motor learning-based theories like
neurodevelopmental treatment, Vojta, Peto
¨and several
others.
A number of studies emphasise the importance of
physical therapy combined with BTX-A treatment [39,68–
75]. Because of the shortage of knowledge on therapy
contents and the different outcome measures used in these
studies, no consensus can be reached concerning the con-
tent of the physiotherapy programme after treatment with
BTX-A. Desloovere et al. [26] showed that an individually
defined specific physical therapy programme after BTX-A
results in an improved effect of the combined treatment
(physical therapy and BTX-A) as compared to traditional
therapy post-BTX-A.
At the University Hospital of Pellenberg, Belgium,
special treatment plans have been developed for children
that were planned for BTX-A treatment, based on general
principles in motor training.
First, the physical therapist should ensure the child’s
optimum preparation before the BTX-A treatment,
including the definition of goal-setting, starting new spe-
cific motor training (training new postures and specific
movements), warning the child of a possible initial loss of
functionality shortly after the injections and, as a conse-
quence, the need to start a more intensive physical therapy
programme.
Post-BTX-A injection physical therapy starts at the time
of the casting period and should focus on: (1) analytical
therapy by electrostimulation and/or proprioceptive train-
ing of, for instance, the tibialis anterior and gluteus maxi-
mus muscles, specific muscle training in open and closed
loops, fast motion exercises and the training of specific
muscle activities in parts of the active range of motion,
such as full hip and knee extension, that are unknown and
not used by the child and (2) functional therapy by active
gait rehabilitation and the use of newly recovered muscle
activity in daily life. The long-term physical therapy should
then focus on preserving gained muscle length by stretch-
ing and the use of orthoses, casts and positioning, contin-
uing strengthening and proprioceptive training of the
antagonists and/or agonists and (3) automation of new
motor development (Lokomat, treadmill). Treadmill
walking provides increased opportunity to repetitively train
the whole gait cycle and facilitate an improved gait pattern
[76].
For the functional children, training the sense of new
movements and the full joint amplitude during active
motion is especially important. An analytical approach
may be used to assist in establishing the balance between
agonists, antagonists and synergistic muscles [77]. Con-
verting muscle function into functional activities is also
important because it allows more automatic performance of
new motions (for instance, by treadmill training), ensuring
the carry-over effect. Employing a dynamic approach and
building variability into the functional activities will make
the learning process more interesting for the child, provide
more functional possibilities and help to prevent the child
from relapsing to the same posture and movement as
before.
In the more involved child, postural problems caused by
muscle contractions and skeletal/joint deformations are of
major concern. Through the use of tone-controlling injec-
tions and rehabilitation, physical therapy stimulates a more
symmetrical active posture, with major focus on active
trunk control. In addition, these children are stimulated by
sitting, standing and other modalities of treatment, such as
a walking belt (robotic training), standing table, sitting aid,
pressure splint and/or body jacket. This will enable them to
be more active and gain better motor control, which will
improve muscle length and stiffness.
Orthotic management
After BTX-A injections, the use of night splinting and
day orthoses appears to be a critical factor in influencing
the long-term effects of BTX-A treatment (the effects on
both preserving muscle length and providing stability to
distal joints are thought to be important). This allows
selective training of more proximal muscle groups (‘tar-
get training’). For some children, day splinting contrib-
utes to proprioceptive training, and for children who lack
selective control of certain muscle groups, the day splints
are crucial for normalising gait (for instance, for cor-
recting a drop foot) [12]. Orthoses supply the appropriate
biomechanical alignment to allow practice and ensure
functional carry-over outside periods of targeted motor
training conducted by the physical therapist. Bilateral leaf
springs are common post-injection day orthoses. For
spastic adductors (with hips at risk), the combination of
BTX-A and the use of variable hip abduction orthoses
may be indicated [27,78]. At night (or in the evening),
fixed ankle–foot orthoses (AFOs) with knee extension
braces and an abduction–external rotation rod are often
applied [79].
J Child Orthop (2010) 4:183–195 189
123
Patient selection, timing and goal settings
BTX-A treatments in children with CP are usually referred
when there is a lack in motor control progress, develop-
ment of muscle contractures, intolerance of day and night
splinting, and/or decrease in functionality. Treatments are
appropriate for a variety of diagnoses (predominantly
spastic type of hemiplegia, diplegia, triplegia and quadri-
plegia) and GMFCS functional levels I–V. Treatment goals
for BTX-A have been expanded in recent times. Because
treatment indications have been extended and because
children with CP reflect a very heterogeneous group with
regard to motor impairment and ability, treatment goals
need to be well defined and tailored to the individual needs
of the patient. More involved children, as well as more
functional children, can benefit from BTX-A treatment, as
long as the goal settings are adapted to the specific prob-
lems. The study of Fagard et al. [80] showed that BTX-A
treatment was successful in more functional as well as in
less functional children with CP. They also found differ-
ences in goal setting and the success rate of these goals
between both groups. Goals around the hip were more
frequent in less functional children, but the success rate
was higher in the more functional children. The second-
ankle rocker also showed a higher success rate in the
functional group. Further research is needed to evaluate if
specific physiotherapy exercises with special attention to
these goals lead to a higher success rate in less functional
children.
It should be noted that BTX-A is not only used to treat
spasticity in children with CP, but it is also an effective
therapy in children and adolescents with an acquired brain
injury to improve leg and arm function, comfort and well-
being [81].
Treatment goals for different indications may be focused
on improving function (gait) and, thereby, influencing the
pathological process for the functional child (GMFCS level
I–III) and improving balance, control of sitting, positioning
and facilitating hygienic care and bracing for non-ambu-
latory patients (GMFCS level IV–V). More specific goals
are listed below [27,46,68,82–84]:
– Facilitation of orthotic management
– Continuation of conservative management until matu-
rity of gait is achieved
– Evaluation of short-term functional gain, providing
crucial information for the future treatment plan
– Simulation of orthopaedic or neurosurgery facilitating
training in order to achieve a better condition before
going into surgery
– Assisting in the prevention of hip subluxation by
controlling spasticity in hip adductors and flexors, with
a hip abduction brace
– Decreasing spasms for patients with highly fluctuating
tone in the upper and lower limbs
– Allowing improved positioning and control of posture
– Treatment of pain caused by spasms (spastic-athetoid)
– Treatment of back pain due to hyperlordosis, where
tone reduction of the psoas muscle can help
– Relief of pain post-operatively
– Use of BTX-A as an adjunctive treatment for regional
or generalised spasticity
Our data revealed some differences in treatment with
BTX-A between children with hemiplegia and children
with diplegia:
– Children with hemiplegia mostly have spasticity in the
soleus muscle. Therefore, the soleus is often injected
with BTX-A in these children. In children with
diplegia, however, the soleus muscle is usually rather
weak and not very spastic. So, treatment of the soleus is
not indicated in patients with diplegia
– The adductor muscles are more often treated in children
with hemiplegia and quadriplegia
– Children with diplegia receive more repeated BTX-A
injections compared to children with hemiplegia
Between 1996 and 2006, 906 children were treated with
BTX-A in the University Hospital of Pellenberg. More than
half of them were classified as diplegic CP (Fig. 3). When
we evaluated 116 children who received at least two
repeated injections, most of them (79%; 92/116) were
children with diplegia (Fig. 4).
Spasticity will usually develop quickly within the first
years of age. From the onset of spasticity, the motor
development will be influenced and the contractures will
start to develop.
Ideally, therefore, BTX-A treatment should start at a
young age when gait patterns and motor function are still
flexible, allowing gross motor function learning during the
time window of tone reduction. The optimal timing is often
reported to be between 2 and 6 years of age [27,62,85].
Older children usually benefit from a more targeted treat-
ment approach.
BTX-A is contraindicated in the presence of infection at
the proposed injection site(s), individuals with known
hypersensitivity to any botulinum toxin preparation or to
any of the components in the formulation, and in patients
with myasthenia gravis, Eaton–Lambert syndrome, amyo-
trophic lateral sclerosis or other significant diseases that
might interfere with neuromuscular function.
In 2008, a multi-centre study (UZ Pellenberg, UZ Gent,
UZ Antwerp, UCL Brussels and ULB-VUB Brussels) for
the Belgium government was set up to evaluate the effect
of integrated multi-level BTX-A treatment both in young
and older children with CP (287 children). Therefore, the
190 J Child Orthop (2010) 4:183–195
123
study group was divided into two age groups (\9 years and
C9 years). Although the mean GAS scores slightly
decreased with increasing age, they remained above the
expected outcome of 50 in both age groups and the dif-
ference in mean GAS scores between the two age groups
was not significant. This implicates that BTX-A is effective
in younger as well as in older children.
Desloovere [61] delineated crucial factors within the
BTX-A treatment strategy which may predict a positive
outcome. The results indicated that age, diagnosis, muscle
selection, and frequency of physical therapy and orthotic
management after injection can be considered as crucial
factors influencing the effect of BTX-A.
Evaluation of outcome
In the post-BTX-A treatment evaluation, we are interested
in the individual’s treatment result and in evaluating the
treatment hypothesis. In addition, also the correlation
between outcome results and the subjective experience of
the patient is important.
The individual’s treatment result provides new and
interesting information that may be important in the fur-
ther development or fine-tuning of that child’s overall
treatment strategy. By carefully evaluating the treatment
outcome, we learn how the child develops new motor
abilities in therapy, gait or movements, and normal daily
life. In particular, the functional use of the antagonist and
restoration of the agonist/antagonist balance is important
in this respect. An objective evaluation after BTX-A
injections can also help to highlight other problems,
especially the contributions of weakness, poor balance
and inadequate trunk stability. Moreover, post-injection
gait analysis data are useful to distinguish between pri-
mary gait deviations and coping mechanisms. Differences
between the two can be quite subtle; however, by defi-
nition, coping mechanisms will disappear spontaneously
once the primary gait problems are resolved [14]. Finally,
BTX-A treatment has a role as a pre-surgical evaluation
method for children in whom the benefits of surgery
(orthopaedic or neurosurgery) are difficult to predict, or
for whom the fine-tuning of the operation requires more
fundamental information about underlying motor prob-
lems [84,86].
The post-BTX-A treatment evaluation can also be used
to evaluate the present treatment hypothesis. BTX-A has a
variety of short-term successful outcome parameters, such
as a reduction of muscle tone [63,85], an increased range
of joint motion [32,63,85,87], an improved gait pattern
[32,87], an increased muscle length [88] and improved
function through the Gross Motor Function Measure [39].
Different types of assessment tools were used in the per-
formed studies until now, which may explain the variety of
treatment outcome parameters. Variability in outcome may
also be related to crucial factors like dose, antibody for-
mation, aftercare and age [45,85].
There are only a limited number of studies on the long-
term outcome. Desloovere et al. [25] demonstrated that
BTX-A treatment, in combination with common conser-
vative treatment options, delays and reduces the fre-
quency of surgical procedures and result in a gait pattern
that is less defined by secondary problems (e.g. bony
deformities) at 5–10 years of age, minimising the need for
complex surgery at a later age and enhancing quality of
life. This is in agreement with the results of Molenaers
et al. [19], which showed that botulinum toxin type A
treatment can delay and reduce the need for surgery in the
follow-up of children with cerebral palsy, provided that
the treatment is started while gait patterns are still
flexible.
Our patients’ subjective experience shows an overall
satisfaction rate of 69.2%. Approximately 60% believe that
the effect of treatment lasts for 6–12 months and 36% are
convinced that the effect lasts for longer than 1 year.
Total of received BTX-A treatments
n=906
8%
15%
22%
55%
Diplegia
Hemiplegia
Quadriplegia
Other diseases
Fig. 3 Number of BTX-A treatments between 1996 and 2006 at
University Hospital of Pellenberg
Repeated treatments
n=116
13%
8%
79%
Diplegia
Hemiplegia
Quadriplegia
Fig. 4 Repeated treatments in function of diagnosis
J Child Orthop (2010) 4:183–195 191
123
Long-term use of BTX-A
Because of the temporary effect of BTX-A, for the
majority of the patients repeated injections are needed. As
mentioned before, dosages and treatment intervals of
approximately one year remain stable within subsequent
BTX-A treatments [57]. By evaluating the effect of two to
four repeated BTX-A treatments in children with CP using
the Goal Attainment Scale (GAS), we found that the GAS
score decreased between the first and last BTX-A session,
however the overall mean GAS T-score remained signifi-
cantly higher than the expected mean of 50, indicating a
successful outcome [89]. Further research is needed to
expand these findings.
We also evaluated the ongoing treatment after four and
five BTX-A treatments in 106 children with CP [57]. Fifty
percent of the patients in the study group continued with
BTX-A treatments after the four investigated BTX-A
treatments. Another 19.8% of the patients received their
last treatment one year or less before the end of data col-
lection (and may or may not continue BTX-A treatment).
Follow-up data after five treatment sessions disclosed
39.6% of patients who continued treatment and 22.6% who
received their last injection of BTX-A 1 year or less before
the end of data collection (and may or may not continue
BTX-A treatment).
Financial cost
A discussion of the financial cost of BTX-A is complex,
because the costs of one BTX-A vial varies between
countries. However, a financial cost comparison between
BTX-A injections and soft tissue surgery (lengthening of
muscles) was made for children with diplegia (in both
treatment of psoas, hamstrings and gastrocnemius bilat-
eral), treated at the University Hospital of Pellenberg
(Table 2). The total cost takes into account the cost for
the technical act (operation), anaesthesia, the cost of the
BTX-A product and hospital stay. On average, the cost of
the BTX-A product is 770 Euros for a patient with diplegia
between four and six years of age. Hospital stay was
the primary cost driver for the BTX-A treatment sessions,
as well as for soft tissue surgery. The hospital stay of
4–7 days after soft tissue surgery is much longer than the
1-day hospital stay (1-day clinic) after BTX-A treatment.
Moreover for soft tissue surgery, there is still the cost for
the rehabilitation period of about 4–6 weeks in rehabilita-
tion hospital (where they can attend school), which was not
included in the total cost.
Conclusion
From different studies and two decades of clinical experi-
ence it can be concluded that BTX-A treatment, applied
according to an integrated approach and started at a young
age, will improve the overall condition of children with CP.
Children who received BTX-A demonstrate several
advantages such as less loss of muscle strength, less
financial costs, better objective gait data and less absences
in school, compared to patients who already underwent a
surgical intervention at a young age. Moreover, soft tissue
surgery also has a high recurrence rate and a higher risk of
lengthening muscles or tendons which were in fact
dynamically not too short at all (objective gait data).
BTX-A treatment and surgical intervention can be
viewed as complementary rather than mutually exclusive,
and may be used concurrently or sequentially to increase
the benefit, for instance, lever-arm deformities can be
corrected simultaneous with BTX-A treatment for spas-
ticity, and BTX-A treatment can be used as an outcome
predictor for surgical interventions, such as in selective
dorsal rhizotomy or intrathecal baclofen treatment.
BTX-A can also be used at an older age to control
spasticity during the pubertal growth spurt, even
when children already previously underwent a surgical
intervention.
It should be noted that applying the BTX-A treatment in
a careless manner, we may spoil the chances of maximal
improvement of the child, and repeated injections may then
be less effective, even without having antibody formation.
Long-term repeated treatments are assured to be successful
only if all conditions are fulfilled (integrated approach,
multi-level multi-site injections when needed, appropriate
muscle selection, secure injection technique). However,
long-term BTX-A treatment cannot always prevent the
development of secondary deformities such as lever-arm
dysfunctions (due to underlying weakness, lack of good
selective motor control etc.). These secondary problems
can then be successfully addressed by orthopaedic surgical
corrections with good long-standing outcomes.
Table 2 Financial cost comparison between BTX-A treatment and
soft tissue surgery in children with diplegia (in both treatment of
psoas, hamstrings and gastrocnemius bilateral), treated at the Uni-
versity Hospital of Pellenberg, Belgium
BTX-A treatment
(Euros)
Soft tissue
surgery (Euros)
Operation 60 750
Anaesthesia 50 300
Hospital stay 166.11 (1 day) 2,500–3,500 (4–7 days)
BTX-A product 770 –
Total cost 1,046.11 [3,550–4,550
192 J Child Orthop (2010) 4:183–195
123
We should be aware that BTX-A is still the most potent
poison available, potentially lethal, and, therefore, the
application rules should be followed strictly. In this
respect, for a quadriplegic patient (GMFCS IV–V) with
swallowing or respiration problems, the total doasage
should never exceed 16–18U/kg/BW.
If a multi-level high-dose treatment is applied, the dose
should always be divided over several sites per muscle with
special attention to the inter-site distance (5 cm) and with
the maximum dose per site (25 U and, if diluted by more
than 4–5 ml, maximum 1 syringe/site).
Following the above precautions, adverse effects will be
very rare or even absent.
Further instructions can be found in the consensus paper
by Heinen et al. [11].
However, not all of our questions are yet solved. Dif-
ferent challenges in the future still require new studies such
as:
– How to organise the optimum treatment plan in one
patient with CP for the different BTX-A treatment
indications (such as hyperhidrosis, hyperactive bladder,
migraine, drooling, spasticity, postoperative pain)?
– What is the most appropriate dilution (1, 2, 3, 4…
ml/vial)?
– How to decrease the dosage by injecting at the motor
end plate, while assuring a good efficacy? Will we be
able to identify the motor end plates in a clinical
setting?
Conflict of interest statement For some of the referred studies, the
authors received an unrestricted educational grant from Allergan
N.V., Belgium.
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