Botox is most commonly known for its use in the cosmetics industry but it's also used with people who have experienced a neurological injury affecting muscle tone such as cerebral palsy and dystonia. Botox is also used to treat spasticity where people have very tight muscles or in cases of fluctuating muscle tone. It's also used to help with urinary difficulties or drooling.

What is BTA?

Botulinum Toxin A (BTA) is a muscle relaxant derived from the bacterium Clostridium Botulinum. Although this bacteria can be poisonous, when used in small, controlled doses, it can provide safe, effective relief from a number of conditions. BTA has been successfully used to treat muscular conditions in children and adults for over 20 years. Clinical studies and trials have indicated positive and helpful results.

BTA is effective on muscle tone in various parts of the body such as the arms and hands if grip is an issue or around the orbital (eye) area for dystonia affecting eye movement. However, it's primarily used on the lower limbs to aid standing and walking. 

Many children who have difficulty with movement due to tight muscle tone will walk on the balls of their feet with the heel off the ground. The feet may also turn inwards. This makes it difficult, or impossible, to place the foot flat on the floor.

When injected into the calf or lower leg muscles, BTA can relax these muscles. This makes walking easier and more comfortable, as well as improving balance and reducing falls.

Tightness in the hamstring muscles at the back of the thigh makes it difficult to straighten legs, resulting in a crouch or squat gait. Injection with BTA can help straighten the legs, resulting in improvements in walking, sitting and transferring. BTA also works well on the adductor muscles in the hip and groin area, a common problem area for children with spastic cerebral palsy.

High muscle tone

High muscle tone in the hip and groin makes it difficult to keep the legs apart. This is called scissoring. For those with upper limb spasticity, BTA can reduce muscle tone around the elbow, wrist and thumb areas, enabling straightening of the arm. This can help with personal care and hygiene or improve pinching, grasping and releasing movements.

BTA can also reduce the development of secondary problems. Spasticity can create an imbalance in muscle tone across a joint that not only interferes with movement but can also lead to fixed contractures - permanent shortening of the muscle and tendon, bony abnormalities and joint instability such as hip dislocation.

Surgery

If surgery occurs too early, the child may need to have repeat or other surgery as they grow and mature. Lowering the tone of the more active muscles by using BTA can restore balance across the joint, increase the stretch of the muscle and promote growth. This can avoid or minimise potential damage to that joint and the need for surgery. At present, it's rare to have orthopaedic surgery without trying Botox first.

As BTA has become more widespread, it's been used for:

  • pain relief
  • improved positioning
  • tremor and spasm control
  • drooling management
  • facilitation of personal care

Treatment may delay or reduce the need for orthopaedic surgery. If used before adductor release surgery, it can significantly reduce post-operative pain and the length of stay in hospital. Many surgeons use BTA during operations to reduce painful post-operative spasms and to protect soft tissue from involuntary movement until the healing process is complete.

Many teenagers and adults with cerebral palsy report a high level of satisfaction with the cosmetic improvement that BTA can bring to their appearance as well as the comfort from reduction of tone and spasm, even where there has been no significant change in function or movement.

Tiredness can often be a problem for disabled people due to the increased effort required in moving around. As movement becomes more fluid following BTA treatment, there is often a reduction in energy consumption.

How does BTA work?

Your muscles contract and relax as a result of chemical messages from the brain. Problems can occur when the chemical messengers are blocked or do not connect properly with specific muscles. This chemical is called acetylcholine.

When BTA is injected into the muscle, the release of acetylcholine is blocked, resulting in a relaxation of overactive muscles. The injections generally take effect within a few days and last for several months.

However, physiotherapy is also be required as part of the treatment and to aid effectiveness of the injection.

Who decides who is suitable for Botox?

Usually the medical team may include a consultant, paediatrician, paediatric neurologist, or orthopaedic surgeon and a physiotherapist. An orthotist or occupational therapist may also be present.

If your walking is affected, such as walking on tip toe or turning your feet inward, the assessment will probably involve a detailed movement study (gait analysis), which is often videoed.

After a full examination, the team will decide whether the treatment is appropriate for you or your child and which muscle or range of muscles will be injected. You should get a clear indication what outcomes are expected.

Access to BTA treatment

Although BTA is now becoming more common, not all NHS Trusts will fund it. As with all medical treatments, you should ask your GP or consultant to refer you. An anaesthetic cream may reduce any discomfort from the injection. Oral sedation is frequently used, or sometimes a local or general anaesthetic, especially if the individual is very young and/or anxious, or where the area to be injected is difficult to access.

The muscles to be injected are identified by manual palpation, ultrasound, electromyography (EMG) or stimulation of the nerve.

The amount of BTA used is determined by the size and number of muscles to be treated, the degree of tightness in the muscle and the weight of the patient, up to a maximum recommended dose. Multi-level injections, where a number of sites are injected during the one treatment, are common.

What happens after BTA?

Following the injection, there are various ways to maximise the effects of BTA. These include more intensive physiotherapy, increased use of walking aids or splinting or some specific changes to the daily routine to incorporate greater use of the treated muscles. Sometimes BTA may be used with casting to maximise muscle stretch.

There will be a follow-up appointment to assess how successful the injections have been. On average the interval between injections varies from between 6 to 9 months. Re-injection will usually be recommended when muscle tone begins to interfere with function rather than when it returns to pre-injection levels. There is no limit to the number of re-injections. 

Possible side-effects of BTA

In the main, reported side-effects of Botulinum Toxin A (BTA) are mild and short-lived. They include: 

  • Post-injection pain requiring simple pain relief
  • Increased frequency of falls within first 2 weeks of injection
  • Mild cold or flu-like symptoms
  • Temporary incontinence
  • Positive effect on constipation
  • Difficulty with swallowing, especially where upper limb or neck injected
  • Mood swings and irritability
  • Fatigue
  • Anaphylaxis (severe allergic reaction) but this is rare

In the UK, The Medicines and Healthcare Products Regulatory Industry advises you to be alert to reactions from the spread of the toxin.

These include:

  • dysphagia (swallowing difficulty)
  • dysphonia (disorder of the voice)
  • weakness, difficult or painful breathing or respiratory distress

Seek immediate medical attention if any of these problems develop, from soon after treatment to several weeks afterwards.

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