Spasticity treatment with botulinum toxins

Spasticity is a physiological consequence of an insult to the brain or spinal cord, which can lead to life-threatening, disabling and costly consequences. This typically occurs following stroke, brain injury, spinal cord injury, multiple sclerosis and other disabling neurological diseases and cerebral palsy. It is but one feature of the upper motor neurone syndrome and there have been considerable developments in its management through new drugs and technology. The sole indication for treating spasticity is when it is causing harm and interferes with active or passive functioning. Successful treatment strategies have now been developed and there is good evidence of treatment effectiveness. Treatment is essentially aimed at reducing abnormal sensory inputs, which have an impact on excessive and uncontrolled alpha-motor neuron activity. Attending to the physical characteristics of muscle shortening is the basis of spasticity management. All pharmacological interventions are adjunctive to a programme of physical intervention and there is a good evidence base for this in relation to botulinum toxin treatment. Management therefore centres around the development of a formal treatment plan is important to document the intended outcomes, which should be written and agreed upon with the patient. Anti-spastic drugs treat spasticity. They do not treat contractures and they will not make hemiplegic limbs function, unless the patient's function is impeded by the spasticity. The management of spasticity is physical and all pharmacological interventions are adjunctive to that. This article therefore deals with the principles of management of spasticity and treatment with botulinum toxin. It covers treatment planning, patient assessment, goal setting and covers the range of available treatments. It also describes how botulinum toxin works, the evidence for its use in spasticity management and practical aspects of treatment, such as muscle location, the injection procedure and post-injection care. Finally, there is a word on the organisation of services. The contribution of botulinum toxin to spasticity management is now well recognised. The trick in clinical management is to use it intelligently and to know when and when not to use it. It is a useful short-term means of improving patients' function and the distressing features of spasticity following an insult to the central nervous system. This is usually against the background of a long-term condition, for which a long-term management strategy is required. Botulinum toxin provides a window of opportunity to improve the outcomes from physical management of the focal and multi-focal problems of spasticity.