Botulinum toxin as treatment of cerebral palsy

Objective. To review the results and adverse effects to botulinum toxin type A (BTA), Botox, in cerebral palsy (CP) spastic and/or dystonic in an open prospective study. Material and methods. The first 39 cases treated were analyzed. They received 1-2 doses and were followed up to 12 months. BTA indications were wide: to improve limb function, to avoid surgical orthopedics or improve hygienics or dressing. O'Brien Global Assessment Scale (scored separately by neurologist, physiotherapist or-parents), Ashworth spasticity scale, functional scale for dystonic upper limb (Sindou-Millet) and exam of position of foot, knee and hip, were used. Results. Total doses/session was 1-10 U/kg. We observed adverse effects in 6 cases (15.4%), always mild and lasting only few days (general weakness, tiredness, instability). Positive effects lasted 4 months in upper limbs and 4.5 months in lower limbs. In upper limbs (9 cases injected) it was observed a global positive result of mild grade in 11-40%, moderate without functional improvement in 11-22%, and moderate-important with functional improvement in 40-78% of patients, being parent's evaluation the best and physiotherapist's one the worst. Spasticity improved 2 or more grades in Ashworth scale in 7/9 cases. Dystonia improved in proportion to dose. In lower limbs gastrocnemius muscles were injected in 29 cases (55 sessions), adductors in 14 cases (33 sessions), ischiotibialis in 8 cases (27 sessions), posterior tibialis in 8 cases (12 sessions). It was observed a global improvement null or mild in 20% moderate without functional change in 35-44%, and moderate or important with functional improvement in 35-44% with significative correlation between parent's, physiotherapist and neurologist's scores. Spasticity was also significatively reduced after treatment. It went down 2 or more grades in Ashworth scale in 40% of ischiotibialis, 60% of adductors and 65% of gastrocnemius, in general with a doses-effect association. Foot position in walking improved from moderate to important grade in 2/3 of cases, as improved foot position while standing. Knee flexion and hip hyperadduction and reduced moderate-importantly in 60% and 40% of cases respectively Conclusion. BTA is highly effective in the treatment of CP, and if associate with physiotherapy long and even permanent effect can be achieved [REV NEUROL 1997; 25: 1369-75].