Best clinical practice in botulinum toxin treatment for children with cerebral palsy

Abstract

Botulinum toxin A (BoNT-A) is considered a safe and effective therapy for children with cerebral palsy (CP), especially in the hands of experienced injectors and for the majority of children. Recently, some risks have been noted for children with Gross Motor Classification Scale (GMFCS) of IV and the risks are substantial for level V. Recommendations for treatment with BoNT-A have been published since 1993, with continuous optimisation and development of new treatment concepts. This leads to modifications in the clinical decision making process, indications, injection techniques, assessments, and evaluations. This article summarises the state of the art of BoNT-A treatment in children with CP, based mainly on the literature and expert opinions by an international paediatric orthopaedic user group. BoNT-A is an important part of multimodal management, to support motor development and improve function when the targeted management of spasticity in specific muscle groups is clinically indicated. Individualised assessment and treatment are essential, and should be part of an integrated approach chosen to support the achievement of motor milestones. To this end, goals should be set for both the long term and for each injection cycle. The correct choice of target muscles is also important; not all spastic muscles need to be injected. A more focused approach needs to be established to improve function and motor development, and to prevent adverse compensations and contractures. Furthermore, the timeline of BoNT-A treatment extends from infancy to adulthood, and treatment should take into account the change in indications with age.

Keywords: BoNT-A; Cerebral palsy; botulinum toxin; child development; spasticity; treatment recommendation.

Figure 1

Reported/recommended total dose of botulinum toxin A (onabotulinumtoxinA) for the treatment of infantile cerebral palsy [4,5,7,8,9,10].GMFCS, Gross Motor Function Classification System. 1. 2–4 units [7]; 2. 5–10 units [8]; 3. 12 units [9]; 4. 25 units [10]; 5. 20 units [4]; 6. 12–16 units [5] for GMFCS V; 16–20 units* for GMFCS I–IV; unitsonabotulinumtoxinA/kg body weight.

Figure 2

Physiological development/motor milestones with available therapy options listed in the left box. To every milestone, the affected muscles (key muscles for Botulinum toxin injection) are displayed. In case of stagnation (dashed arrows), secondary alterations and deformities are shown in the right box. GMFCS level descriptors can be viewed separately as supplementary material.