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.