Botox, Think Twice?
Dr. Reetu Patel-Tiwari DPT, PCS
What is Botox and How Does it Work?
Botulinum toxin (Botox) is made from a bacteria called Clostridium botulinum. This toxin blocks the electrical impulse that travels from the nerve to the muscle. It is typically recommended for people with spasticity (increased muscle tone) and is frequently done in the gastrocnemius, hamstrings, and adductor muscle groups in children with cerebral palsy.
What is the Physiological Cost?
While Botox decreases the stiffness in the muscle, thus temporarily improving the range of motion, it also causes paresis(weakness). Typically, the muscles must contract and relax to build strength. When administered, this toxin causes a decreased ability for muscle to contract, weakening it. Botox typically lasts approximately 2-4 months; thus, the tightness returns and leaves the muscle weaker than before. In the end, Botox may have added a few degrees of range of motion, but it will come at the cost of strength, muscle atrophy, and sometimes even function.
What does the Literature Suggest?
Across my search, the literature suggests we use it sparingly and that there is a greater need to develop guidelines for dosage, frequency, and time of recommendation. 1 It also suggests the effectiveness of serial casting with and without Botox is similar.2,3 Moreover, the short-term effectiveness of Botox on the range of motion and spasticity has been positive; there has been limited research suggesting the effect on functional parameters and long-term implications of Botox administration.1 Lastly, it is important to avoid repeated rounds of Botox to prevent repetitive muscle weakening, particularly when improvements are not being observed.1
Never say Never.
There are circumstances where Botox is necessary and optimal. Children with level IV and V CP sometimes benefit from Botox to manage adductor muscle spasticity and prevent hip dislocation. Botox has been effective in pain management. Certain upper extremity contractures have also been well managed with Botox. Thus, there is a time and place for them.
Our Take
We suggest weighing the pros and cons before choosing Botox for your child. Functional strengthening may be an excellent alternative and has shown amazing clinical results when paired with electrical stimulation. Make sure to clearly understand why your healthcare provider chose this option for your child and whether it aligns with your therapeutic, social, and functional goals.
References
- Multani I, Manji J, Hastings-Ison T, Khot A, Graham K. Botulinum Toxin in the Management of Children with Cerebral Palsy.Paediatr Drugs. 2019;21(4):261-281. doi:10.1007/s40272-019-00344-8
- Carey T, Leitch K, Scholtes C, Stephenson F. Effects of Serial Casting with and without Botulinum Toxin Injections as Interventions for Spastic Ankle Equinus. Orthop Procs. 2009;91-B(SUPP_II):235-235. doi:10.1302/0301-620X.91BSUPP_II.0910235a
- Glanzman AM, Kim H, Swaminathan K, Beck T. Efficacy of botulinum toxin A, serial casting, and combined treatment for spastic equinus: a retrospective analysis.Dev Med Child Neurol. 2004;46(12):807-811. doi:10.1017/s0012162204001410