Management of Spasticity in Cerebral Palsy with Neuromuscular Blockade:

The Role of Botulinum Toxin

1. Introduction

1. Neuromuscular blockade is an important option in management of the effects of spasticity (Carpenter 1,2; Koman 1993, 2000; Corry 1994)

2. Spasticity

1. Definition

2. Typical patterns of extremity spasticity (Table I)

3. Agonist-antagonist balance

3. Principles of botulinum toxin as neuromuscular blockade

2. Historical Perspective

1. Neuromuscular blockade (chemodenervation)

2. Botulinum A toxin as a therapeutic agent

3. Botulinum A toxin in cerebral palsy

3. Anatomical and Physiologic Considerations

1. Localization of injection

1. Neuromuscular junctions

2. Muscles and groups

2. Pharmacology (Pharmacokinetics)

1. Traditional long-lasting neuromuscular blockade agents

2. Botulinum Toxin

1. General behavior

2. Botox® Type A Structure (Figure 1)

3. Botox® Type A Mode of Action (Figure 2)

4. External link: Allergan professional information on Botox^®

4. Natural History

1. Neuromuscular blockade agents

1. Timing of chemodenervation agents

2. Effective durations of agents (Table II)

2. Clinical experience with botulinum A toxin

   1. Trials

   2. Outcome

3. Specific evaluation of outcome in cerebral palsy

   1. Classification

   2. Severity

   3. Degree of spasticity

   4. Function

      1. Upper extremity

      2. Lower extremity

   5. Health-related quality of life

   6. Economic impact

5. Diagnosis and Recognition

1. Principle of management

2. Longitudinal assessment

3. Optimal evaluation

4. Evaluation technique

6. Treatment

   1. Clinical considerations

      1. Clinical indications

      2. Clinical contraindications

      1. Absolute

      2. Relative

      3. Advantages

      4. Disadvantages

   2. Preparation

      1. Drug preparation

      2. Volume

      3. Dosage

   3. Localization technique

   1. Palpation-under-stretch

   2. Ultrasound

   3. Electromyography

   1. Diagnostic

   2. Motor stimulation

   4. Specific muscles / groups

   1. Upper extremity

   2. Paraspinal / Neck

   3. Lower extremity

7. Summary