1. Benefits of Botox
for Cerebral Palsy
Patients
Focus on Children with Cerebral Palsy
Erin Sullivan
4-11-2016

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Patient Demographics
A Caucasian 3 year old male who, at birth, was diagnosed with Cerebral Palsy (CP), Spastic Diplegia, and
Developmental Delay. He currently attends preschool 2 days a week.
Patient’s Medical History and Medical Care
At birth, his mother had placenta abruptio (when the placenta detaches from the womb before
delivery). His history includes the following surgeries: Laser retinopathy, bilateral inguinal hernias, and
removal of his tonsils and adenoids. His mother looked into him having a rhizotomy (a surgical
procedure to sever nerve roots in the spinal cord), but was found too immature to have the procedure
performed as of yet. He has a history of seizures and mild-to-moderate behavioral problems.
Upon his initial evaluation on 7/8/2015, our patient walked with a reverse walker, wore bilateral braces
for his feet (AFO’s), and had eye glasses. He attended First Steps for Physical Therapy (PT)/Occupational
Therapy (OT)/Speech Therapy (ST)/Developmental Therapy. His medicines included/include: Albuterol
(to help prevent bronchospasm), Qvar (for asthma), and a seizure medication not related to our
department’s staff.
As of his re-evaluation on 2/2/2016, our patient has new AFO’s, uses forearm crutches to walk, is on the
same lung medications, and has a new seizure medication.
As of 3/3/2016, our patient began to ambulate independently on forearm crutches.
As of 3/8/2016, our patient was given Botox injections into both his lower extremities, based off of
information given by his mother to the patient’s acting Physical Therapist (PT).
Our Patient’s Prior Level of Function (PLOF)
Information taken from his initial evaluation by the patient’s acting PT on 7/8/2015:
Patient able to ambulate with reverse walker. Patient had “old” AFO’s. Patient did not want his Range of
Motion (ROM) taken, so Goniometric Measurements of bilateral lower extremities were approximated:
Hamstring Flexion (HS) Dorsiflexion (DF) Hip Abductors (ABD)
Right: -40˚ Right: 10˚ Right: 18˚

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Left: -38˚ Left: 5˚ Left: 25˚
Bilateral Hip and Knee Flexion: Within Normal Limits (WNL)
Manual Muscle Test (MMT): Overall score was 4+/5.
Gait/Posture/Mobility: Patient crawls independently. He can climb over things. He’ll ask for help if he
gets stuck. He needs an assist to stand up. Patient presents with a tip-toe stance. He ambulates
without a heel strike. He presents with a scissors gait (internal rotation (IR)/knees flexed). He can
ambulate with a hand hold assist (HHA) and/or a walker. Patient can walk at home with a reverse
walker that he pulls behind him. Patient is impulsive, curious, and energetic.
What is CP, etc.?
According to www.cerebralpalsy.org1
, CP is considered first a neurological disease that has secondary
orthopedic complications. CP is not contagious, non-communicable, non-progressive, permanent, and
chronic. It is based off of a one-time brain trauma/injury/malformation “that occurs while the child’s
brain is under development…. [It] will not produce further degeneration of the brain.”1
The orthopedic complications show in general body movement, including reflexes, posture, balance, and
muscle tone/coordination/control. Though CP continues to remain throughout a child’s life, that child
should be able to live well into adult-hood, especially if they have early treatments such as surgeries,
Botox injections and other treatments of the like, medication, and allied health therapies to name a
few.1
Standard of Care1
/Goals1
Emphasis on individual goal setting/treatment.
Optimize mobility and ability to communicate – Directly related to PT.
Maximize independence.
Enhance social and peer interactions.
Manage primary conditions.

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Foster self-care.
Control pain.
Maximize learning potential – Related to PT by developing new ways for child to learn how to move.
Provide quality of life – A general goal of PT.
Prevent/manage complications, associative conditions, and co-mitigating factors – Directly related to PT.
PT Plan of Care (POC) – Goals as of 2/2/2016 Re-Evaluation
Short Term Goals (STG):
Patient will be able to stand independently for 10 seconds.
Patient will ambulate 100 feet independently with forearm crutches.
Long Term Goals (LTG):
Patient will be able to stand independently for 30-45 seconds.
Patient will ambulate 200 feet or farther with crutches independently and safely.
Patient will be able to squat down to pick up a toy and stand back up.
Activities of POC:
Ambulation with 1 Assist, bilateral forearm crutches, or pushing a cart.
Stand at a table with or without standing on a Bozu Ball or foam; Stand and reach; Pull to stand.
Kneel on foam, in tall kneel, or in half kneel.
PROM for bilateral hip flexors and HS’s.
Other activities include: Pedaling a Big Wheels bike, lying prone, straddling over a bolster (to decrease
high hip adduction (ADD) tone), and squatting down (say to pick up a toy) to standing back up.
Article 1:
The Use of Botulinum Toxin A in Children with Cerebral Palsy, with a Focus on the Lower Limb2
P: Children with CP
I: Botox Injections
C: Diplegic v. Hemiplegic, Normal Children v. Children with CP
O: Benefits of Botox injections for children with CP

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STG: What are the immediate effects of Botox injections for children with CP?
LTG: What are the lasting effects of Botox injections for children with CP?
Description
This article looked at several case studies over twenty years to review the benefits of Botox A injections
in the lower extremities of children who are diagnosed with CP.2
The studies varied in test measures,
etc., yet the outcomes were fairly similar upon their review. The ultimate goal of this article was “to
clarify the role”2
of Botox treatments, specifically of the lower extremities, in children with CP.2
Internal and External Validity came from comparing all studies to each other and seeing where similar
data fit in and did not fit with each study’s outcomes. Confounding Variabilities came from the fact that
several studies were reviewed together, which spanned over two decades with various test measures,
etc., and which can potentially lead to huge variability. Another confounding variability is that there was
a conflict of interest listed at the end of the article: “For some of the referred studies, the authors
received an unrestricted educational grant from Allergan N.V., Belgium.”2
Outcomes
Because Botox blocks a certain neurotransmitter (acetylcholine, a chemical that helps activate muscles),
it gives temporary “denervation,” or lack of muscle activation, to a muscle. This can indirectly reduce a
muscle spasm.2
Because Botox is such a potent chemical, the phrase “reflection is more important that
injection” is apparently often used for such treatments, especially in children.2
This means that such
measures, like having a neurologist, an orthopedist, or a PT observe an individual child’s gait analyses
and clinical exams are essential to a beneficial Botox treatment before the treatment occurs.
Specific Items of Interest/Outcomes of Studies
The period of most benefit from Botox injections is 12-16 weeks post injection. This means that co-
treatments and therapies are most useful to gain/develop as many new skills as possible while in this
time period. It was suggested that during PT for functional children, training new movements and

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utilizing the full available ROM in a joint, in particular in a fun/interesting way for the child, was
especially important.2
Individual children’s age, goals, and physical limitations need to be taken into account through clinical
exams and gait analyses before any injection is made. Most normal children develop a mature gait
around age 6. Children with CP tend to develop their mature gait later, around ages 8-10.2
Bone
growths and other complications tend to develop up till this point, too, according to many of the
studies.2
By taking these items into account before an injection happens helps to reduce dangers, such
as over-dosage, misplaced injection sites, and give the best timing for injections as possible.
As to Botox injection timing, it was reviewed in the studies that Botox treatments were more effective
starting at an early age (between ages 2-6 oftentimes). The studies also showed that orthopedic
surgeries were not as effective or had higher recurrence rates due to development of bony growths, etc.
when performed at an early age.2
Tendon/muscle lengthening surgeries specifically were seen an non-
beneficial at an early age because [the tendons or muscles] “were in fact dynamically not too short at
all” to begin with.2
In fact, Botox treatments performed at an early age were thought to help reduce the
need for surgeries and help prevent bony formations/contractures from forming.2
It also stated that
injections should happen no sooner than 3 months after the previous injection.
Tests/Measures
The most notable measure and outcomes used were based off of the Gross Motor Function Measure
(GMFM). The take-home outcomes were as follows:
STG: Botox was shown to “reduce muscle tone, increase ROM of joint motion, improve gait patterns,
increase muscle length, and improve function,”2
according to GMFM results.
LTG: Only limited numbers of the studies have looked into the lasting effects of Botox injections.2
However, one study (Desloovere et al.) revealed that combining Botox and conservative treatments (like

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casting and PT) delay and reduce the frequency of surgical procedures resulting from secondary
problems (like bony deformities) and enhance general quality of life.
Article 2:
Long-Term Effect of Repeated Injections of Botulinum Toxin in Children with Cerebral Palsy: A
Prospective Study3
P: Children with CP
I: Botox injections, repeated Botox injections
C: Single v. repeated Botox injections in children with CP
O: Long-term effects for repeated injections of Botox in children with CP
Article Description
The goal of this article was to evaluate the future outcomes/long-term effects of repeated Botox A (BTX-
A) injections in children with CP.3
26 children between the ages of 2-6 years old, with diplegic or hemiplegic CP, were given a maximum of
4 BTX-A injections over a 2 year period. These injections were administered into the children’s lower
extremities, specifically the calf (gastrocnemius soleus), hamstrings, or both. BTX-A dosages did not
exceed 12U/kg. Participants were required to have good forced PROM and good muscle strength of
affected limb/s (4-5/5 MMT). Individual functional levels were assessed before and after each injection
by utilizing the Growth Motor Function Classification (GMFC).3
5 children got 1 injection. 12 children got 2 injections. 6 children got 3 injections. 3 children got 4
injections. The most common reason for discontinuing the study (which were 17 participants) was the
need for orthopedic surgery.3
Internal Validity took into account age, dosage amount, and functional level (which was normal to mildly
declined cognition), participants had no previous contractures or surgeries, and had familial
inclusion/participation.3
External Validity came from the study being approved by the Tel Aviv Sourasky

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Medical Center’s ethics committee. The main Confounding Variable is that most participants came
directly from the same CP clinic in Tel Aviv.3
Tests/Measures
Outcomes were based off of the GMFC, GMFM, and Ashworth scales for functionality and ROM.3
Outcomes
No difference was found between the groups of participants based on classifications of diplegic v.
hemiplegic CP, developmental differences, age, number of injections, nor the number of injections to
GMFC levels.3
GMFM scores prior to and one-month post each injection for each child showed a
“significant increase after the first and second injections, but not following the third.”3
In conclusion, Botox injections have a short-term effect on muscle tone for children with CP, the “long-
term effect [is] on gross motor function in children with CP. The effect apparently declines with
repeated injections, with most children benefitting from 2-3 injections”3
total.
Our Patient Re-Visited
The SPTA who worked with this particular patient had a co-therapist interaction for the child’s
intervention (such as holding the child while PT threw a ball at him or held his gait belt while PT had him
stand on a Bozu Ball while the patient took turns playing a game on a table, etc.).
The last time working with him, however, the patient had a Botox treatment 3 weeks prior. The SPTA
and her CI, the acting PT in with this patient, discussed ways that the SPTA could lead the session. Based
off working alongside the patient and his PT previously, the SPTA knew the child liked “things that go,”
such as monster trucks, cars, and bikes.
Thinking about the articles and the child’s interest, the SPTA thought it may be fun for our patient to
pedal on a Big Wheel because it’s a “thing that goes” and he could utilize his full available ROM during
the activity. It was also within that 12-16 weeks post injection timeframe, which is optimal for co-
treatments. This idea was approved by the PT (who assisted with this session).

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However, as the therapists ended up discussing post treatment, our patient was just a little too short to
get the full effect of the Big Wheel. They padded the seat to have him sit closer to the fixed pedals, but
ultimately the SPTA gave tactile cueing throughout this particular intervention as the patient kept yelling
that he “couldn’t make [the bike] go!” without her help. The PT wondered with the SPTA if the patient
also just didn’t know/understand how to ride a bike or how a bike works.
Mitigating factors were as follows:
Our patient had a Botox treatment, on 3/8/2016, prior to this session. After his injections, he got a head
cold which postponed a treatment session (on 3/17/2016) between the time of injection and the above
mentioned session. After that, he was on antibiotics for the cold, and finished them according to his
mother, by 3/24/2016. After that time, however, he seemed his normal energetic self. His mother
informed us that he would be having another Botox treatment in June, 2016.
His goniometric measurements were taken in approximation due to patient tolerance, as follows:
Initial Evaluation, 7/8/2015
HS: Right: -40˚
Left: -38˚
DF: Right: 10˚
Left: 5˚
2/4/2016 Session
HS: Right: -41˚
Left: -38˚
No DF taken this date
3/3/2016 Session (Date patient showed independent ambulation with bilateral forearm crutches)
HS: Right: -25˚
Left: -35˚
DF: Right: 15˚
Left: 10˚
3/8/2016, First Botox injection
3/10/2016 Session
HS: Right: -15˚
Left: -20˚
DF: Right: 15˚
Left: 17˚

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References
1. http://www.cerebralpalsy.org/ . Copyright 2016 Stern Law. PLLC. Reviewed 4/10.2016
2. Molenaers, Guy. The Use of Bolulinum Toxin A in Children with Cerebral Palsy, with a Focus on
the Lower Limb. Journal of Children’s Orthopaedics. 2010; 4 (3): 183-195.
3. Fattal-Valevski, Aviva. Long-term Effect of Repeated Injections of Botulinum Toxin in Children
with Cerebral Palsy: A Prospective Study. Journal of Children’s Orthopaedics. 2008; 2 (1): 29-35.