Open-label study of botulinum toxin for upper limb spasticity in cerebral palsy

The Impact of Umbilical Cord Mesenchymal Stem Cells on Motor Function in Children with Cerebral Palsy: Results of a Real-world, Compassionate use Study

The aim of this study was to analyze the impact of human umbilical cord-derived MSCs (hUC-MSCs) on motor function in children with cerebral palsy (CP). The study enrolled 152 children with CP who received up to two courses of five hUC-MSCs injections. Children's motor functions were assessed with the Gross Motor Function Measure (GMFM), 6-Minute Walk Test (6-MWT), Timed Up and Go test (Up&Go test), and Lovett's test, and mental abilities were assessed with the Clinical Global Impression (CGI) scale. Data collected at visit 1 (baseline) and visit 5 (after four injections) were analyzed retrospectively. After four hUC-MSCs administrations, all evaluated parameters improved. The change in GMFM score, by a median of 1.9 points (IQR: 0.0-8.0), correlated with age. This change was observed in all GFMCS groups and was noticed in all assessed GMFM areas. A median increase of 75 m (IQR: 20.0-115.0) was noted on the 6-MWT, and this correlated with GMFM score change. Time on the Up&Go test was reduced by a median of 2 s (IQR: -3 to - 1) and the change correlated with age, GMFM score at baseline, and the difference observed on the 6-MWT. Results of Lovett's test indicated slight changes in muscle strength. According to the CGI, 75.5% (96/151) of children were seriously (level VI) or significantly ill (level V) at the 1st visit, with any improvement observed in 63.6% (96/151) of patients at the 5th visit, 23.8% (36/151) with improvement (level II) or great improvement (level I). In conclusion, the application of hUC-MSCs generally enhanced functional performance, but individual responses varied. The therapy also benefited children with high level of disability but not to the same extent as the initially less disabled children. Although younger patients responded better to the treatment, older children can also benefit. Trial Registration 152/2018/KB/VII and 119/2021/KB/VIII. Retrospective registration in ClinicalTrials: ongoing.

Effects of botulinum toxin type A on upper limb function in children with cerebral palsy: a systematic review

Objective: To evaluate whether botulinum toxin type A injections improve upper limb function in children with cerebral palsy.

Methods: An extensive search was carried out in PUBMED, CINAHL, PICARTA, EMBASE, PEDRO and the Cochrane Controlled Trials Register. Controlled and uncontrolled studies were included and evaluated on the basis of a best evidence synthesis.

Results: Twelve out of 645 identified studies were included: three randomized controlled trials (RCTs) ( n = 64) of high methodological quality, and nine uncontrolled studies ( n = 107) of sufficient methodological quality. In one of the three RCTs a short-term, significant decrease of spasticity was found in favour of the botulinum toxin type A group, which was supported by five of the seven uncontrolled studies that also measured spasticity. In one RCT significant changes in range of motion were reported for wrist and thumb extension. This finding was supported by two out of seven uncontrolled studies. One RCT reported a significant improvement in activities after one month, according to the Quality of Upper Extremity Skills Test and the Pediatric Evaluation Disability Inventory, whereas five out of the nine uncontrolled studies reported an improvement in functional activities.

Conclusion: Insufficient evidence is found for the effects of botulinum toxin type A injections to reduce spasticity or to increase range of motion and upper limb function in children with cerebral palsy. Besides differences in treatment goals, the lack of evidence is mainly due to the use of invalid assessment instruments and insufficient statistical power to demonstrate treatment effects.

Outcomes of Botulinum Toxin Type A Injection Followed by Rehabilitation in Cases of Cerebral Palsy With Upper Extremity Involvement

We evaluated the efficiency of botulinum toxin type A injection followed by a rehabilitation program including individual therapy, group therapy, and occupational therapy in cases of cerebral palsy with upper extremity involvement. A total of 29 injections were performed on 25 patients, and the patients were placed on rehabilitation program. At 3-month and 6-month assessments, there was a significant improvement in lateral grip strength, 9 Hole Peg test, Upper Limb Physician's Rating Scale and pediatric functional independence measure total scores. There were significant decreases in active range of motion in elbow extension, supination, and wrist extension, and Modified Ashworth Scale in elbow flexion, elbow pronation, and wrist flexion at 6-week, 3-month, and 6-month assessments. Combination of group therapy with traditional therapy methods after injection is effective in cases of cerebral palsy with upper extremity involvement.

The developing shoulder has a limited capacity to recover after a short duration of neonatal paralysis

Mechanical stimuli are required for the proper development of the musculoskeletal system. Removal of muscle forces during fetal or early post-natal timepoints impairs the formation of bone, tendon, and their attachment (the enthesis). The goal of the current study was to examine the capacity of the shoulder to recover after a short duration of neonatal rotator cuff paralysis, a condition mimicking the clinical condition neonatal brachial plexus palsy. We asked if reapplication of muscle load to a transiently paralyzed muscle would allow for full recovery of tissue properties. CD-1 mice were injected with botulinum toxin A to paralyze the supraspinatus muscle from birth through 2 weeks and subsequently allowed to recover. The biomechanics of the enthesis was determined using tensile testing and the morphology of the shoulder joint was determined using microcomputed tomography and histology. A recovery period of at least 10 weeks was required to achieve control properties, demonstrating a limited capacity of the shoulder to recover after only two weeks of muscle paralysis. Although care must be taken when extrapolating results from an animal model to the human condition, the results of the current study imply that treatment of neonatal brachial plexus palsy should be aggressive, as even short periods of paralysis could lead to long-term deficiencies in enthesis biomechanics and shoulder morphology.

Hand function in the play behavior of children with cerebral palsy

OBJECTIVE

The aim of this study was to evaluate the influence of hand function on the occupational performance of playing for children with cerebral palsy.

METHODS

Twenty children with cerebral palsy took part in the study, of both genders, aged 3-10 years, with motor abilities ranging from I to V and manual abilities from II to IV. Data were collected using the Assessment of Ludic Behaviour before and after botulinum toxin was applied in the upper limbs to reduce spasticity.

RESULTS

Significant differences were found between the scores before and after the application of botulinum toxin in relation to the total Assessment of Ludic Behaviour score (p < 0.001), as well as in basic ludic interest (p = 0.003), basic ludic ability (p < 0.001), ludic attitude (p = 0.008), and communication of needs and feelings (p = 0.025), except for general level of interest (p = 0.957).

CONCLUSIONS

The reduction of spasticity permits better handling of the play materials, which promotes the children's involvement in play situations.

Botulinum toxin treatment in upper limb spasticity: treatment consistency

This study assessed treatment consistency of botulinum toxin administration in spastic upper limbs under pragmatic conditions, as derived through stability of dosages and between injections intervals. Over a period of 8 years, 153 children (81 with bilateral spastic cerebral palsy, 72 with unilateral) were treated according to accepted, experience-based guidelines with Botox and Dysport. Treatment response was based on assessment of spasticity and attainment of pre-determined goals at 3, 6 and 12 months post each treatment. Mean age at treatment onset was 6y 4mo (SD: 4y 10mo), median F/U, 2.5 years (4 months-6 8/12 years). Number of injection sessions was 1-10; few had more than 6 sessions. In 106 (69.28%) children, more than one anatomic regions of the limb were injected. Most (56.2%), had at least two injection sessions; median time interval between the sessions was 9 months (IQR: 4-35 months, similar for unilateral and bilateral cerebral palsy, p = 0.874). Children >4 years old at the first treatment had longer intervals between sessions (25.8%) compared to younger ones (p = 0.010). The mixed effects models demonstrated that botulinum toxin dosage was stable over subsequent visits (p = 0.144) and that intermediate intervals for subsequent visits were similar to the first one (p = 0.279).

Botulinum toxin assessment, intervention and follow-up for paediatric upper limb hypertonicity: international consensus statement

The primary objective of this paper was to evaluate the published evidence of efficacy and safety of botulinum neurotoxin (BoNT) injections in paediatric upper limb hypertonia (PULH). Secondary objectives included the provision of clinical context, based on evidence and expert opinion, in the areas of assessment, child and muscle selection, dosing, and adjunctive treatment. A multidisciplinary panel of authors systematically reviewed, abstracted, and classified relevant literature. Recommendations were based on the American Academy of Neurology (AAN) evidence classification. Following a literature search, 186 potential articles were screened for inclusion, and 15 of these met the criteria and were reviewed. Grade A evidence was found to support the use of BoNT to reach individualized therapeutic goals for PULH. There is grade B evidence (probably effective) for tone reduction following BoNT injections and grade U evidence (inconclusive) for improvement in upper limb (UL) activity and function. BoNT injections were generally found to be safe and well tolerated with the most common side effect identified as a transient decrease in grip strength.

Botulinum toxin, physical and occupational therapy, and neuromuscular electrical stimulation to treat spastic upper limb of children with cerebral palsy: a pilot study

Spasticity has been successfully managed with different treatment modalities or combinations. No information is available on the effectiveness or individual contribution of botulinum toxin type A (BTA) combined with physical and occupational therapy and neuromuscular electrical stimulation to treat spastic upper limb. The purpose of this study was to assess the effects of such treatment and to inform sample-size calculations for a randomized controlled trial. BTA was injected into spastic upper limb muscles of 10 children. They received 10 sessions of physical and occupational therapy followed by 10 sessions of neuromuscular electrical stimulation on the wrist extensors (antagonist muscles). Degree of spasticity using the Modified Ashworth scale, active range of motion, and manual function with the Jebsen hand test, were assessed. Meaningful improvement was observed in hand function posttreatment (P = 0.03). Median spasticity showed a reduction trend and median amplitude of wrist range of motion registered an increase; however, neither of these were significant (P > 0.05). There is evidence of a beneficial effect of the combined treatment. Adequate information has been obtained on main outcome-measurement variability for calculating sample size for a subsequent study to quantify the treatment effect precisely.

Botulinum toxin A as an adjunct to treatment in the management of the upper limb in children with spastic cerebral palsy (UPDATE)

BACKGROUND

Cerebral palsy (CP) is "a group of permanent disorders of the development of movement and posture causing activity limitation(s) that are attributed to non-progressive disturbance that occurred in the developing fetal or infant brain" (Rosenbaum 2007, p.9). The spastic motor type is the most common form of CP. Therapeutic management may include splinting/casting, passive stretching, facilitation of posture/movement, spasticity-reducing medication and surgery. Botulinum toxin-A (BoNT-A) is now used as an adjunct to these techniques in an attempt to reduce spasticity, improve range of movement and function.

OBJECTIVES

To assess the effectiveness of injections of BoNT-A or BoNT-A and occupational therapy in the treatment of the upper limb in children with CP.

SEARCH STRATEGY

We searched the Cochrane Controlled Trials Register/CENTRAL (The Cochrane Library, Issue 3, 2008), MEDLINE (1966 to August Week 1 2008), EMBASE (1980 to 2008 Week 28) and CINAHL (1982 to August Week 1 2008).

SELECTION CRITERIA

All randomised controlled trials (RCTs) comparing BoNT-A injection or BoNT-A injection and occupational therapy in the upper limb(s) with other types of treatment (including no treatment or placebo) in children with CP.

DATA COLLECTION AND ANALYSIS

Two authors using standardised forms extracted the data independently. Each trial was assessed for internal validity and rated for quality using the PEDro scale. Data were extracted and entered into RevMan 5.0.15.

MAIN RESULTS

Ten trials met the inclusion criteria. PEDro quality ratings ranged from 6/10 to 10/10. Concentration of BoNT-A ranged from 50U/1.0ml to 200U/1.0ml saline with doses of 0.5U to 16U/kg body weight and total doses of 220 to 410 Units (Botox(R)).A combination of BoNT-A and occupational therapy is more effective than occupational therapy alone in reducing impairment, improving activity level outcomes and goal achievement, but not for improving quality of life or perceived self-competence. When compared with placebo or no treatment, there is moderate evidence that BoNT-A alone is not effective.

AUTHORS' CONCLUSIONS

This systematic review found high level evidence supporting the use of BoNT-A as an adjunct to managing the upper limb in children with spastic CP. BoNT-A should not be used in isolation but should be accompanied by planned occupational therapy.Further research is essential to identify children most likely to respond to BoNT-A injections, monitor longitudinal outcomes, determine timing and effect of repeated injections and the most effective dosage, dilution and volume schedules. The most effective adjunct therapies including frequency and intensity of delivery also requires investigation.

Effects of botulinum toxin type A and a programme of functional activity to improve manual ability in children and adolescents with cerebral palsy

We aimed to evaluate the effectiveness of a clinical programme that combined botulinum toxin injections with a functional activity programme to improve manual ability in children and adolescents with cerebral palsy. A total of 25 young people age range 2 to 19 years participated. They were given injections of botulinum toxin type A into spastic muscles in the upper extremities and participated in a functional activity training programme. Standardised clinical assessments were made before injections, one to two months after, and six months after, the final injections. To assess if the treatment had changed their ability to use the treated hand in activities of everyday life a questionnaire was given to the parents. The families thought that the ability had improved, and that the improvements took place both during the first three months after treatment and after more than six months after the final injections. The ability to extend wrist and fingers actively and the position of the thumb had improved significantly both in the short and long- term. This study supports the assumption that a programme combining botulinum toxin A injections with training in functional activity improves manual ability in young people with cerebral palsy.

Recovery potential after postnatal shoulder paralysis. An animal model of neonatal brachial plexus palsy

BACKGROUND

Injury to the brachial plexus during birth results in paralysis of the upper extremity in as many as one in 250 births and can lead to substantial functional deficits in the shoulder. The goal of this study was to characterize the development of bone and joint deformities in paralyzed neonatal shoulders and to assess the improvement of these deformities after muscle function recovery with use of an animal model.

METHODS

Intramuscular injections of botulinum toxin were used to paralyze the supraspinatus, infraspinatus, and posterior deltoid of the left shoulders of mice at birth. Seventy mice were divided into three groups: Botox, recovery, and normal. The twenty-five mice in the Botox group received botulinum toxin injections until they were killed. The twenty mice in the recovery group received botulinum toxin injections for different durations and then were allowed injection-free recovery periods until they were killed. The twenty-five mice in the normal group received saline solution injections until they were killed. Radiographs were used to measure shoulder and elbow contractures. Microcomputed tomography was used to examine anatomical parameters of the supraspinatus muscle, humerus, and scapula.

RESULTS

The Botox group showed bone and joint deformities including delayed mineralization and flattening of the humeral head, hypoplasia, and introversion (i.e., anteversion) of the humerus, contractures of the shoulder and elbow, hypoplasia of shoulder muscles, hypoplasia of the scapula, and hypoplasia and retroversion of the glenoid. In the recovery group, a significant trend toward normal properties was observed with longer recovery periods (p<0.05). However, only soft-tissue contractures of the shoulder and elbow were resolved completely with the longest recovery period.

CONCLUSIONS

This mouse model successfully simulates human neonatal brachial plexus palsy, reproducing most of the bone and joint deformities found in the human condition. The deformities started to develop early in the postnatal period in the paralyzed shoulders and progressed with longer durations of paralysis. Early restoration of muscle function completely resolved the soft-tissue contractures of the shoulder and elbow. However, osseous deformities of the humerus and scapula were never resolved completely. These findings demonstrate the time-dependence of reversibility of musculoskeletal deformities in developing shoulders with neurological deficits.

Upper-limb botulinum toxin A injection and occupational therapy in children with hemiplegic cerebral palsy identified from a population register: a single-blind, randomized, controlled trial

OBJECTIVES

The purpose of this work was to assess the effect of botulinum toxin A and occupational therapy compared with occupational therapy alone on body structure, activities participation, and self-perception in a sample of children (aged 3-16 years) with hemiplegic cerebral palsy recruited from a statewide register.

PATIENTS AND METHODS

Participants of this single-blind, randomized, controlled trial identified from a population-based cerebral palsy register received either an individually prescribed and localized injection of botulinum toxin A with 4 sessions of occupational therapy over 4 weeks (intervention) or occupational therapy alone (control). Outcomes were assessed from 2 domains of the World Health Organization International Classification of Functioning, Disability, and Health: body structure (Modified Ashworth Scale and Tardieu Scale) and activities participation (Assessment of Motor and Process Skills, Goal Attainment Scale, Pediatric Evaluation of Disability Inventory, and Pediatric Quality of Life Inventory). Self-perception was also measured.

RESULTS

All of the participants (intervention: n = 21; control: n = 22) provided data at baseline and 3 and 6 months. Mean age was 8.6 years; 23 were boys and 20 were girls. At 3 months, children allocated to receive the intervention performed significantly better in terms of body structure and activities participation. They reported improvements in self-perception for the global self-worth domain. At 6 months, the differences between the intervention and control groups persisted for the measures of body structure but not for activities participation or self-perception.

CONCLUSION

Botulinum toxin A injection combined with a low-intensity occupational therapy program achieves significant improvements in body structure, activity participation, and self-perception.

Functional outcomes of intramuscular botulinum toxin type a and occupational therapy in the upper limbs of children with cerebral palsy: a randomized controlled trial

OBJECTIVE

To investigate the functional outcomes of botulinum toxin type A (BTX-A) injections to the upper limb in combination with occupational therapy (OT) in children with cerebral palsy (CP).

DESIGN

Randomized controlled trial with follow-up at 2 weeks, 3 months, and 6 months.

SETTING

Specialist outpatient physical disabilities clinic within a public pediatric teaching hospital.

PARTICIPANTS

Eighty children with spastic quadriplegic, triplegic, or hemiplegic CP from these clinics were randomly assigned to BTX-A plus OT, BTX-A alone, OT alone, or a no-treatment control group.

INTERVENTIONS

Single set of BTX-A (Botox) injections and 12 weeks of OT.

MAIN OUTCOME MEASURES

Canadian Occupational Performance Measure (COPM) and Goal Attainment Scale (GAS).

RESULTS

The combination of BTX-A and OT resulted in accelerated attainment of functional goals measured by the COPM and GAS. There were no differences between groups on the Melbourne Assessment of Unilateral Upper Limb Function, Quality of Upper Extremity Skills Test, Pediatric Evaluation of Disability Inventory, Child Health Questionnaire, or active and passive range of motion. As expected, there was a significant reduction in muscle tone at follow-up 2 weeks after injection, which returned to baseline level by 6 months.

CONCLUSIONS

OT enhanced individualized functional outcomes following BTX-A injections in the upper limbs of children with CP.

Botulinum toxin type A injection for management of upper limb spasticity in children with cerebral palsy: a literature review

The aim of this article was to present a review of the research literature on the outcome of botulinum toxin type A (BTX-A) injection for management of upper limb spasticity in children with cerebral palsy (CP). We searched the electronic databases of MEDLINE, CINAHL and PUBMED for all published studies with full-length English text available. For each study, the quality of the methods and the strength of evidence were assessed by 2 independent reviewers based on the American Academy for Cerebral Palsy and Developmental Medicine (AACPDM) guidelines. Four studies of level I, 8 studies of level IV and 4 studies of level V were identified. Due to the limited number of studies with high quality evidence and inconsistent results among studies, we were unable to support or refute the usefulness of BTX-A injection for management of upper limb spasticity in children with CP. Moreover, we identified several variables that may affect the outcome of injection, such as timing of age, dosage, dilution volumes, localization techniques of target muscles and participant characteristics. In summary, we have presented a review the literature and a discussion of the considerable uncertainty and variation associated with the clinical use of BTX-A injection for management of upper limb spasticity in children with CP.

Clinical assessment of spasticity in children with cerebral palsy: a critical review of available instruments

This study reviews the instruments used for the clinical assessment of spasticity in children with cerebral palsy, and evaluates their compliance with the concept of spasticity, defined as a velocity-dependent increase in muscle tone to passive stretch. Searches were performed in Medline, Embase, and Cinahl, including the keywords 'spasticity', 'child', and 'cerebral palsy', to identify articles in which a clinical method to measure spasticity was reported. Thirteen clinical spasticity assessment instruments were identified and evaluated using predetermined criteria. This review consists of reports on the standardization applied for assessment at different velocities, testing posture, and quantification of spasticity. Results show that most instruments do not comply with the concept of spasticity; standardization of assessment method is often lacking, and scoring systems of most instruments are ambiguous. Only the Tardieu Scale complies with the concept of spasticity, but this instrument has a comprehensive and time-consuming clinical scoring system.

Botulinum neurotoxin type A causes shifts in myosin heavy chain composition in muscle

Botulinum neurotoxin type A has gained widespread use for treatment of a host of neuromuscular conditions. However, the potential effect of this toxin has on the histological and biochemical properties of skeletal muscle remains largely unexplored. The purpose of this study was to characterize the myosin heavy chain (MHC) distribution of adult rat skeletal muscle treated with botulinum neurotoxin type. Varying doses of the toxin were injected into the triceps surae muscle group of one hind limb. Force production was assessed periodically to access the functional deficit incurred. After 10 weeks, animals were sacrificed, muscles removed, and MHC composition determined. Body weight, muscle weight and force of the injected leg were significantly reduced in all groups, while loss of muscle weight and force in the contralateral leg was variable. In the injected plantaris and gastrocnemius muscles, type I MHC increased approximately 100%, while type IIa/x decreased approximately 50%. In the contralateral gastrocnemius, types I and IIa/x MHC increased approximately 100%, while type IIb decreased approximately 45%. These data suggest that botulinum neurotoxin causes shifts in MHC composition in injected and contralateral muscles that are contrary to those seen with denervation and similar to those seen with aging.

Cadaveric Study of Methods for Subscapularis Muscle Needle Insertion

OBJECTIVE

To evaluate the accuracy for three methods for needle insertion into the subscapularis muscle for electromyography, botulinum toxin injection, and phenol nerve block.

DESIGN

Three needle insertion methods were evaluated by cadaver injection by an American Board of Electrodiagnostic Medicine certified physician. An anatomist, blinded to the method used, served as the dissector to evaluate the effectiveness of the methods tested.

RESULTS

A posterior axillary approach was most effective for needle insertion into the subscapular muscle compared with a medial scapular or a superior scapular approach. No approach was ideal for subscapular nerve injection.

CONCLUSIONS

A posterior axillary approach is best for needle insertion of the subscapularis muscle for electromyography or botulinum toxin injection. Subscapular nerve injection is difficult from all of the three approaches tested.

Noncosmetic uses of botulinum toxin

In conclusion, botulinum toxin usage over the past 2 to 3 decades has expanded exponentially. Almost every discipline in medicine has found some therapeutic use for this toxin. Botulinum toxin has been shown to be safe, effective, and relatively easy to administer with proper training.

Noncosmetic uses of botulinum toxin

Since the introduction of botulinum toxin (BTX) as a therapeutic tool in the 1970s, the number of uses for this substance has increased exponentially. BTX's mechanism of action involves degrading the SNARE proteins blockading the release of acetylcholine into the neuromuscular junction. In many body systems, decrease of contractility, strength, and tension of certain muscle groups result in improved clinical outcomes. Applications now include cosmetic, gastroenterologic, otolaryngologic, genitourinary, neurologic, and dermatologic uses. In fact, BTX can be considered as a potential treatment in any situation involving inappropriate or exaggerated muscle contraction. Currently, the FDA has approved BTX-A (Botox) for treating glabellar lines, blepharospasm, strabismus, hemifacial spasm, cervical dystonia, and spasticity. With the addition of cosmetic applications to the FDA's approval list, the use of BTX has increased dramatically.

[Botulinum toxin type A in children: evaluation of indications with a review of the literature]

INTRODUCTION

The aim of this study is to review the literature to indications of botulinum toxin type A in children.

METHOD

We review the international literature from 1990 to 2002 by querying the Pubmed database with the keywords "children" and "botulinum toxin".

RESULTS

Two hundred and forty-eight articles are retrieved. We selected the most relevant 64 articles among them. Several questions remain pending: which optimal dose, which periodicity for injections, which optimal age to prolong efficiency? The main criteria to estimate efficiency is functional ability improvement. No significant side effects are noted. The main use of botulinum toxin is the management of the spastic lower limb in cerebral palsy.

DISCUSSION

This review of the literature makes it possible to specify the interests and the operational limits of botulinum toxin in the child. Its effectiveness with the upper limb is not proven. The other indications remain to be studied in a more precise way.

CONCLUSION

This review shows many studies give the indications of botulinum toxin in children. The main indication is the lower limb spaticity in cerebral palsy. New prospective and double-blind studies should be performed with larger samples.

Treatment of spasticity with botulinum toxin

Spasticity is an abnormal increase in muscle contraction often caused by damage to central motor pathways that control voluntary movement. During clinical examination, spasticity manifests as an increase in stretch reflexes, producing tendon jerks and resistance appearing as muscle tone. There are many causes of spasticity, including demyelination from multiple sclerosis, congenital damage from diseases such as cerebral palsy, trauma to the brain or spinal cord, hemorrhage or infarction, and other pathologic conditions that interrupt neural pathways. Effects of spasticity range from mild muscle stiffness to severe, painful muscle contractures and repetitive spasms that reduce mobility and substantially impede normal activities of daily living. Botulinum toxin therapy reduces spasticity and pain associated with several disorders. Local treatment with botulinum toxins can be used as adjunctive therapy, along with oral antispasticity medications, or alone to provide localized decrease in symptoms of spasticity and pain. Botulinum toxin therapy may be particularly useful for patients with spasticity due to stroke, whose treatment can be tailored based on recovery of function over time. In addition, botulinum toxin therapy is safe for pediatric patients, including children with cerebral palsy, who may not be able to tolerate the cognitive side effects of oral medications. Results of studies evaluating botulinum toxin for the treatment of spasticity due to various causes are presented here.