BOTOX® - Clinical Use

Patient Selection

Clinical Scenario	Picture
This patient with head injury demonstrates an adducted/internally rotated shoulder, flexed elbow, pronated forearm, bent wrist, and clenched fist. The patient also has a thumb-in-palm deformity.
Severe spastic wrist flexion
Equinovarus foot
Striatal toe (hitchhiker's great toe) caused by an overactive extensor hallucis longus.
Persistent knee extension of the "stiff knee," shown here with marked equinus

• muscles that often contribute to spastic adduction/internal rotatation dysfunction of the shoulder include latissmus dorsi, teres major, the clavicular and sternal heads of pectoralis major, and subscapularis.
• in the flexed elbow, brachioradialis is spastic more often than biceps and brachialis.
• in the flexed wrist, carpal tunnel symptoms may occur secondary to compression of the median nerve.
• flexion with radial deviation implicates flexor carpi radialis.

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• Botulinum Toxin has been used in clinical trials for spasticity from multiple sclerosis, cerebral palsy, traumatic brain injury, spinal cord injury and stroke
• Multiple Sclerosis: injection of 400u of BTX into the thigh adductors resulted in significant improvement in spasticity and hygiene vs placebo
• Spinal cord injury: injection of 20-80u into the rhabdospincter resulted in decreased urethral ressure and post-void residual
• Cerebral Palsy: injection of 1.0u/kg of BTX into the medial and lateral gastrocnemius of each leg resulted in an improvement in gait pattern vs placebo
• Stroke: injection of 75-300u of BTX into the elbow and wrist flexors resulted in significant improvement in the Ashworth scale vs placebo

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