What are The Botulinum Toxin in Cerebral Palsy

Clinical use of botulinum was recognized by Bergen et al. in 1949 by identifying the effect of botulinum toxin on neuromuscular transmission. Once it was thought to be potent biological toxin to human body, now its potential is being utilized as therapeutic agent for different clinical problems specially spasticity & cosmetic purpose. In all variety of botulinum toxin, type A is used for the clinical application. This is being utilized in Mx of cerebral palsy since 20 years.

This toxin is used as intramuscular injection at most condensed site of neuromuscular junction of affected muscle. This toxin block acetylcholine release from neuromuscular junction & causes local temporary chemo-denervation and effect last for 4-6 month. Even after disappearance of drugs, some modulation of nerve transmission has been seen, so effect persist beyond the time limit and dystonic posture also get corrected due to slight diffusion of drugs in systemic manner.  It is being commonly used for spastic & dystonic cerebral palsy Treatment.

Cerebral Palsy Treatment

Dose & safety margin depends upon brand of botulinum toxin, number of muscle and wt of child. Total maximum dose is about 10-12 unit per Kg of body Wt. it is being used in all affected spastic muscles and usually at multiple site (3-4 in each muscle). 

Effect of botulinum toxin can be prolonged with post injection plaster, proper patient & muscle selection, injection under anesthesia and post injection braces and good therapeutic protocol. Plaster is given for only 7-10 days then patient is advised braces and therapy.

It is very effective when child have dynamic spasticity between the age group of 2-5 years and not so useful when child develop contracture and deformity. Botox injection is advisable when Spasticity is interfering in therapy programme and muscle excursion become too less.

Usually botulinum toxin injection are used in all affected muscle in a single setting and it is better to give it under anesthesia, because it require multiple injection puncture and is painful and it also save the toxin from wastage. Most commonly botulinum toxin is used in Gastrocnemius, Hamstring, Rectus Femoris, Adductor, Pronator Teres, and Flexor Digitorum.

Injection can be repeated every three monthly but if proper postoperative therapeutic protocol has been taken into consideration it may not be so frequent. At Samvedna, we rarely require repetition of toxin due to good therapeutic protocol and use of braces. It reduces pain, facilitate therapy, better cooperation of child, better functional and motor gain.

By the use of toxin, OSSCS Surgery also can be delayed till the maturity of gait. Antibodies to toxin have been one of the possible problems with repeated injection that can interfere in next injection of toxin.  Otherwise it is well tolerated. Side effects are very -2 rare.

Cerebral Palsy : More About Cerebral Palsy Children

Physical disability exists in the society in its worst form even after success of polio eradication programme. Main reason for this is damage to some part of the brain during or just after birth resulting in cerebral palsy. We cannot eradicate this disease but at least we can certainly reduce its effects by new techniques of treatment.

Cerebral palsy is a word taken from Latin which means damaged brain. Cerebral palsy Symptoms means some disorder related to damaged brain which occurs within two years of the birth of the child. At present it is the main cause of physical disability in childhood. In India approximately 40 lacks children are suffering from Cerebral Palsy in India. This occurs due to damage to brain during or after pregnancy.

Cerebral palsy can occur due to infection during pregnancy, low birth weight, oxygen deficiency in new born, septicemia, sever jaundice, head injury, brain fever etc. The parents used to wander from pillar to post because of lack of effective treatment till recently. They used all the traditional methods like jadu tona, jhhad phunk, and then after tiring from all these use to sit idle accepting the situation as a result the child used to remain disabled for whole life. Now new advancement and availability of new techniques have brought new hopes that these techniques may give them too a better and more fulfilling life.

But to achieve this aim, it is very important that these children should be diagnosed and treated as early as possible because at an early age deformities have not yet fully developed and there are more chances that the brain can be trained more successfully with the aid of latest advancement in the therapeutic modalities like NDT and SI along with light weight braces

Exercise done wrongly can even be harmful by which a walking child can become disable. In early phase of advancing age & increasing weight, deformities did not fixed & child stops improving in spite of continuous therapy or even may deteriorate. At this stage some time we need botulinum toxin.  Botulinum toxin is used for children with spastic cerebral palsy. This is needed only in severally spastic children and who don’t cooperate in therapy because of tightness. This is used for releasing the tightness of muscles.

It is used mainly in affected muscles in Cerebral Palsy Children between the age of 2 to 5 years. Its effect remains there for 4-6 months. There is hardly any need of repeating the injection if we continue doing good exercise after this. Some time these children also require light weight polypropylene braces along with walking aid.

With advancement of age, tightness get increase so much that improvement with therapy gets stopped and even deterioration start at a faster speed, then child requires surgical intervention. But traditional methods of surgery did not have definite outcome. Sometimes those even harmed the child. Recently, OSSCS surgical technique has come as boon for these children. This surgical concept is based on Spasticity of muscles crossing two or more joints. In this concept all the affected long muscles of body are balanced during one single event surgery (SEMLS) and small muscles making the balance of the body are not touched.
After surgery tone in body becomes more balanced and within few months of specialized therapy programme, child starts showing good response in terms of physical improvement.

There is marked increase in movements of the child and also child gets rid of the pain of repeated surgeries. This technique can be applied in children of more than 6 years age and even much elder age group. Child who has good neck holding & spinal balance and is able to stand with any support can have excellent results after surgery.

With the timely use of correct combination of all latest modality of treatment & concept of early intervention more than 80% children can be given good quality of life. Till now Samvedna has got excellent outcome in more than 1000 children by this integrated approach management.