Prof. Anisuddin Bhatti describes spasticity management in Cerebral Palsy patients. Botulinum Toxin (BOTOX) therapy and its application techniques live demonstration given. lectured delivered on zoom.us on 13th September 2020 for Trainees & trainers at Pakistan. Acknowledged for few text material & pictures taken from google.com and E Blecks book on Cerebral Palsy.

1. Management of spasticty
in Cerebral Palsy
Botox Therapy
With Live Demonstration
Prof. Anisuddin Bhatti
Paediatric Orthopaedic Surgeon
Dr. Ziauddin University Hospital
Clifton, Karachi
13th September, 2020
@Zoom.us

2. Spasticity: Rx
Priority Setting to improve:
• Speech
• Hearing
• Vision
• Intellect
• Movement Disorder
Orthopedic surgeons,
Expertise in performing Botulinum
toxin injections,
• A multidisciplinary treatment approach.
• Critical to optimize care in children with
lower-extremity tone.

3. Multidisciplinary Approach
Schematic diagram showing the components of a multidisciplinary
approach to care. PT/OT = physical therapy/occupational therapy

4. DIAGNOSTIC MATRIX

5. Objectives of
ClinicalAssessment
1. Identify the problem
2. Clinical analysis
3. Plan effective management
 Medical
 Surgical
 Rehabilitation
 Orthosis

6. Detailed Evaluation
• Gait & Posture
• Spasticity &
Contractures
• Clinical Tests
• GMFS
• Gait Analysis

8. Spasticity Rx Options
To control of Hypertonicity /
Spasticity
To improve function
• Physical Therapy
• Occupational therapy,
• Orthosis,
• Oral medications,
• Baclofen pumps,
• Chemo-Denervation,
• Tendon lengthening / Transfer,
• Selective Dorsal rhizotomy

9. Spasticity Control.Medical Rx
Baclofen
FDA Approved, age >12 Y
Dantrolne

10. Spasticity Contol: Surgical RX
Osteotomies Fusions
Dorsal
Rhizotomy
Muscle
Fractional
Lengthening
Tendon
Lengthening /
transfer
Arthroplasty

11. Selective Dorsal Rhizotomy: SDR
Goals:
• To reduces spasticity, tonicity & pain [lower limb]
• To prevent hip dislocations & manage perineal
Hygiene.
• To improve the long-term quality of life &
posture
Technique
• Dorsal spinal cord is exposed.
• Sensory nerve rootlets are separated from
motor rootlets.
• Each rootlet is electrically stimulated and the
response is monitored.
• The rootlets producing the most abnormal
muscle contractions are cut.

12. Chemo-Denervation
Botulinum Toxin A
• Seven types of BT: A-G.
• BTA - is used for Chemo-denervatin
• Chemically denervates the muscle.
• Most performed Procedure
• Reduce Spasticity / Dynamic Spasticity
Advantages:
oRelatively focal effect.
oImprove passive and active range of
motion.
oImprove Gait & Function.
oWide safety margin.

13. Dynamic
spasticity
• Patients are spring
loaded
• Releasing / relaxing one
spring tightens another

14. Hamstring tightness. I

15. Hamstring tightness . II

16. Chemo – Denervation: Botox
• Help to relax overactive muscles for a
short period of time.
• During this period a targeted therapy
programme is implemented to stretch
shortened muscles, stiff joints & improve
weak muscles power.
• That further help to improve function e.g.
walking or grip or self care to manage
personal hygiene.

17. Botox: Indications
• Effective treatment for numerous movement
disorders associated with increased muscle tone
or muscle over activity: Spasticity, Dystonia etc.
• Used by Beauticians to Physicians & Surgeons.
• Used an alternative treatment for TEV deformity
and obviate the need for surgery prior to gait
maturity.
• Autonomic disorders
• etc

18. • Provides a
pharmacological
neuromuscular
blockade that results in
temporary muscle
paralysis.
• Also a valuable agent to
treat autonomic
disorders associated
with localized
cholinergic over activity.
Botox: Mechanism of Action
• Provide an indirect
effects on the spinal
cord and brain that
result from changes in
the normal balance of
efferent and afferent
signals.

19. Botox: Action Reversal
• The very long duration of effect of Botox results
in the formation of temporary sprouts that
substitute for the paralyzed nerve terminal.
•
• Sprout formation appears to correlate with the
wearing off, of clinical effect.
• A longer-term re-innervation of the parent
terminal occurs, eventually as the sprouts die
back.

20. Botox: Contra indications
• Hypersensitivity to ingredients (albumin),
• Neuromuscular disease,
• Pregnancy and lactation,
• Anticoagulation therapy,
• Phobia of injection,
• Poor psychological adjustment, and
• Reactions to certain medications
(aminoglycosides, Penicillamine, Quinine, and
Calcium channel blockers).

21. Botox: Contra indications
• Fixed contracture & Structural joint deformities.
• Having recently received Btx injections, a
relative contraindication
• Too early reinjection increases the risk of
developing neutralizing antibodies that render
further Btx treatment ineffective.
• Minimum recommended intervening period = 3
months

22. Botox: Complications
Local complications:
• Pain,
• Edema,
• Erythema,
• Ecchymosis, and
• Short-term
hyperesthesia.
Systemic reactions:
• Nausea, fatigue,
malaise,
• Flulike symptoms
• Distant rashes.
Excessive weakness..
Common as result of
”unmasking” of
weakness following
chemo-denervation.
Prevention: adequate
compensatory muscle
strength before Botox &
post inj. Rehabilitation.
Systemic weakness…
rare…. over dosage

26. BTx. Injection Sites

28. BTx Dosage Toxicity
• Although no randomized controlled trials have
used this dose for children with CP, literature
show patients who received injections at this
dosage more than 250 times and have seen no
evidence of systemic toxicity.
• Patients are injected with a maximum of 50 U
per site and must wait a minimum of 3 months
between BTx treatments.

29. Dosage Preparation
Calculated as per Weight / size of muscle.
• BTx is diluted in 2 ml preservative- free
normal saline for greater spread in the
injected muscle.
• The starting dose is Botox at 5 to 10 U/kg
of body weight for each Muscle, with a
maximum total dose of 20 U/kg.
• No more than 50 U is injected at each site.
• The total dose administered per treatment
session should not exceed 6 Units/kg or
200 Units in a 3 months interval.

30. Toe Walkers … sites
Gastrocnemius - 4 locations:
• Proximal and distal injection in both
the medial and lateral heads of the
gastrocnemius muscle.
Soleus - 2 locations:
• First site just distal to the belly of the
medial gastrocnemius
• Second site 1 to 2 cm distal along the
length of the muscle.

31. Toe Walkers….. Dosage
• Typically start with Botox at 5 U/kg of body
weight for each heel cord.
• If the response is inadequate as
determined by a failure to achieve
predefined treatment goals, increase the
dose to 10U/kg for each heel cord with a
maximum total body dose of 20 U/kg.

32. Crouched Gait: Botox
• Patients who present with dynamic knee
contracture usually have a crouched gait,
although not all such children are
ambulatory.
• Like children who exhibit toe walking,
children who have hypertonicity primarily
caused by dystonia are also treated with
BTx and physical therapy.

33. Crouched Gait: MTS Criteria i
• Modified Tardieu Scale criteria: Majority
having hypertonicity is secondary to spasticity
is classified into mild, moderate, or severe
categories.
• Modified Tardieu Scale measurements are
obtained with a handheld goniometer while
the child lies supine with the hip flexed at 90°
(90/90 position), and then the leg is fully
extended (terminal knee extension).
• In the 90/90 position, the knee is
• extended to R1 (first catch) and R2 (end
range).
R2 -70

34. Crouched Gait: MTS Criteria ii
Modified Tardieu Scale criteria:
• Patients who have mildly increased tone (modified Tardieu
Scale R2 . -25) are treated with physical therapy and knee
immobilizers.
• Patients who have moderately increased tone (modified
Tardieu Scale R2 -25 to -40) are considered candidates for
BTx injections, knee immobilizers, and physical therapy.
• Patients who have severely increased tone (modified Tardieu
Scale R2 , -40) who are unable to reach a neutral position (R2 ,
0) in terminal knee extension are referred for Ultraflex splints
in addition to BTx and physical therapy.

35. Crouched gait: sites & dose i
Begin treatment with injections in the
HAMSTRING.
• Injections are distributed every 1 to 2 cm
along the length of the medial hamstring,
with up to 50 U injected.
• Patients who respond well to BTx are
generally re-injected every 3 to 6 months.
• Patients who have no response are
considered candidates for surgical release.

36. Crouched gait: Scissoring i
Excessive adductor & Gracilis tone.
Hypertonicity categories:
• Patients who have prominent dystonia (nearly
normal ROM on the modified Tardieu Scale) are
treated with BTx and physical therapy
• Patients primarily demonstrating spasticity
(reduced ROM as shown by modified Tardieu
Scale) are divided into categories of mild,
moderate, or severe on the basis of modified
Tardieu Scale criteria.

37. Crouched gait: Scissoring ii
• Patients suffering from moderate or severe
spasticity are considered candidates for
adductor & Gracils BTx injection and physical
therapy in addition to orthotic interventions.
• Patients experiencing moderately increased tone
and hip dislocation and all patients who have
severely increased tone receive Ultraflex splints,
physical therapy, and BTx and / or Surgery
Each child's adductor ROM is
measured while the patient lies supine
with the knee flexed and then
extended Phelp’s Test.

38. Crouched Gait: Scissoring iii
• Adductor muscles are injected starting
approximately 1 to 2 cm below the pubis
symphysis and extending about two thirds of
the distance along a line drawn to the medial
epicondyle.
• Just as with those who have crouched gait,
children with a good response receive injections
every 3 to 6 months.
• Patients who fail to respond are referred for
possible surgical intervention.

39. Evaluation of Response
• Schedule for a 1-month follow-up visit.
• At this visit, physical therapists use repeated modified
Tardieu Scale measurements, a modified Ashworth Scale,
and the Gross Motor Function Measure to assess the
effects of BTx at the time of peak benefit.
• Clinical goals are reviewed and updated with the
parents. Patients who have a good response to BTx
continue therapy with repeated injections on a 3- to 6-
month injection schedule.
• Patients who do not respond may be considered for
surgical intervention.

40. LiteratureReview
Effects of Dose and Dilution.
• Koman, et al. Improvement was noted in those who received
Botox at a dose of 1 to 2 U/kg of body weight for each of the
targeted muscles, Amulticenter, open-label clinical trial, they
demonstrated benefit without adverse reactions by using a
higher dose of Botox (4 U/kg of body weight).
• Baker and colleagues studied the safety and efficacy of three
doses (10, 20, and 30 U/kg of body weight) on the dynamic
component of gastrocnemius length during gait.
• They found that all doses resulted in improvement compared
with a placebo, with the group that received the 20 U/kg
dose demonstrating the greatest effect relative to groups
receiving other doses.
• The beneficial effects were still present at a follow up at 4
months.

41. Literature Review
Serial Casting & Combination
• BTA appears equally as effective as the
placement of serial casts for treatment of
dynamic contractures, and the combination may
be beneficial for a subset of patients.

42. LiteratureReview
Clinical Benefits
• Considering progress and understanding of clinical benefits for
BTA in children with CP, many unknown variables needs
consideration.
• Variable includes:
1) selection of patients most likely to benefit from therapy.
2) Effect of larger doses of toxin on clinical outcomes
3) long-term efficacy of botulinum toxin therapy
4) long-term benefits of botulinum toxin therapy
5) relative advantages or disadvantages of therapy with BTx
compared with surgical therapies;
6) appropriate duration of therapy
7) effect of early therapy on degenerative changes in soft
tissues and joints in adult patients who have CP.

43. Key Points: Botox Therapy
Rarely cause complications or significant
adverse effect in Paediatrics.
Pre-Inection Anxiolytics &/or
Topical anaesthtics helps
significantly
General anaesthesia for irritable
child is better option
Meaningful assesment of
treatment outcome depends on a
careful objectives.
BTx effects are seen within several days
and lasts for 3-4 months, and thereafter
weans off
Post injection Plaster cast help
for a week or helps to gain good
results +/-

44. Botox therapy Technique
Case 1
• 3 years old female CP
child
• Right upper and lower
limb Stiffness
• Toe walking for last
12 months
Birth history:
• Born full term svd
• h/o Birth Aphaxia
• Kept in incubator for
24 hours
• Delayed milestone
Right hemiplegic CP
With significant
spasticity and Dynamic
contracture
Pronation + mild Elbow
flexion
Toe walking
Pop angle normal
Right foot equinus
Silfverskiold test +ve

45. • Case 1 3+ years
• Right hemiplegic
CP
• Significant
spasticity and
Dynamic Equine
contracture
• Pronation + mild
Elbow flexion D.
Contractures
• Progressively
increasing Toe
walking
Botox therapy
Technique:GastroSoleus
& Pronator Teres
Follow Video Demonstration on
<youtube.com/user/1orthojpmc>

46. Case2.
6 years old
• Spastic Diplegia
• Jump Gait with mild
Scissor
• GMFS II
• Silverskiold +ve
• PoP angle 700
• Combined Adduction
60
• Phelp +ve
• Aly Duncan -ve
• Intelectual good
Follow Video Demonstration on
<youtube.com/user/1orthojpmc>

47. Case 2: Botox TherapyTechnique:
Hamstrings
Follow Video Demonstration on
<youtube.com/user/1orthojpmc>

48. Case 2: Botox Therapy Technique:
GastroSolius
Follow Video Demonstration on
<youtube.com/user/1orthojpmc>

49. Case2: Botox Therapy Technique:
Adductors
Follow Video Demonstration on
<youtube.com/user/1orthojpmc>

50. Case III
• 6 years old CP male
• H/O Birth asphyxia
• Right Equinus Gait, mild
upper limb spasticity
• observed by parents at the age of
16 months
• VAOGA: True Equinus
• Had Botox Therapy effective for
two therapies
• Recently developed Progressive
RECURVATUM Knee deformity
• What to do: open to discuss

51. youtube.com/user/1orthojpmc
Anisuddin Bhatti