Botulinum toxin type A treatment of cerebral palsy: an integrated approach

We have applied a multilevel approach to the management of spasticity associated with cerebral palsy (CP). All of the following factors are important in forming an integrated strategy for botulinum toxin type A (BTX‐A) therapy: the timing of injections, patient selection, multilevel BTX‐A treatment, optimal dosage and injection technique, follow‐up treatment and objective measurements of functional outcome. Data on all these factors are presented here. CP patients had a mean age of 6.5 years (n = 315), and the dose of BTX‐A (BOTOX®) ranged from 2 to 29 U/kg body weight ( n = 156). The combination of muscles injected in our multilevel approach differed for patients with diplegia, hemiplegia and quadriplegia: patients with hemiplegia received injections in the gastrocnemius and medial hamstrings; this combination was extended to the adductors for patients with diplegia and quadriplegia ( n = 156). For patients with quadriplegia, muscles in a three‐level (gastrocnemius, medial hamstrings, adductors and iliopsoas) or two‐level (excluding the gastrocnemius) combination were also frequently injected. The duration of effect of BTX‐A treatment was mainly determined by follow‐up treatment consisting of: serial casting, day and night orthoses and physiotherapy. No major side effects of BTX‐A were reported. This integrated approach appears to prolong the duration of BTX‐A treatment, resulting in a duration of about 1 year between injections.