Botox injections to treat children with cerebral palsy

Botox injections are best known for reducing wrinkles on the face. However, experts at Loyola University Health System are finding new ways to use the injections in children with cerebral palsy, with most benefit in patients who are younger than 5 years old.

“Children with cerebral palsy have very tight muscles, which get even tighter as the child grows,” said Dr. Deirdre Ryan, a pediatric orthopaedic surgeon at Loyola who has been using Botox injections in these patients for several years. Ryan also specializes in treating infant hip disorders, spina bifida, pediatric trauma and clubfeet, deformities of the ankles or the feet that are usually present at birth.

Traditionally, physical therapy is used to help relax the muscles of these patients. However, most of these children need multiple surgeries to lengthen their muscles. “Botox can help us avoid surgery or decrease the number of surgeries needed in some cases,” Ryan noted. “Botox also has helped some of these patients walk and care for themselves,” said Ryan.

Congenital cerebral palsy is a group of motor problems and physical disorders that result from brain injury or abnormal brain development that may occur during fetal growth or at the time of birth. An estimated 6,000 new cases of cerebral palsy occur in the United States every year. The condition leads to spasticity or tightness of the muscles and can be diagnosed as early as 15 months of age. The brain injury does not change but the tightness of the muscles gets worse over time, thereby interfering with day-to-day activities like walking, sitting and even the child’s hygiene.

Recent national figures indicate that the costs to maintaining the quality of life in these patients can be as high as $20 billion annually.

Botulinum toxin A (Botox) is the toxin responsible for a form of food poisoning called botulism. Paralysis is the most serious complication of botulism. However, the doses used to treat muscle tightness are very low with few side effects. Side effects may include weakness in the muscles at the site of injection. The weakness generally lasts for a period of three to six months. Local pain, redness or irritation occasionally occurs in the first few days following Botox injection. In addition, some children may experience a mild flu-like syndrome and fever after the injection.

Botox works by blocking the release of a substance the nerve uses to signal the muscle to contract. The injection treatments have proven useful in patients with muscle tightness because it temporarily relaxes the muscles. According to Ryan, the injections have been used for at least a decade to treat spasticity in patients with cerebral palsy and other neuromuscular conditions. Approval for this use is still being reviewed by the U.S. Food and Drug Administration.

The injection treatment is frequently used in combination with a cast, a technique that is used to improve the position of the extremities. If performed, casting usually begins one or two weeks after the Botox injection. Botox also is used in combination with ongoing physical therapy.

The treatment is injected into the affected muscles during a simple clinic procedure. Approximately one half hour before the injection, a numbing medicine is placed on the child’s skin at the injection site. A small needle is used for the Botox injection itself, which usually causes minimal discomfort. For very young children, anesthesia may be used. Almost any muscle can be injected. “However, since there is a total maximum dose than can be given to any child, based on that child’s weight, usually no more than two or three muscles can be injected at any one time,” said Ryan. “What’s best, the child’s activity does not need to be restricted after the Botox injection.”

The initial effects of the treatment are typically seen as early as three to five days after injection, with more visible effects seen by the first or second week. The effects generally last between three and six months. At that time, the nerve makes new fibers and resumes sending signals to the muscle to contract.