Written by Emily Hayles – Physiotherapist and Owner, and author of ‘Braver than you think: How to help your child with a disability live their best life’

With one of our biannual Paediatric Rehab outreach clinics coming up just next week, we thought it would be timely to share some information about the ins and outs of Botox, so that you can understand more about this intervention and whether it will be suitable for your child.

What is Botox?

Botox is a highly purified version of the Botulinum toxin Type A, a chemical toxin produced by the bacteria that causes Botulism.  Botulinum toxin Type A can be injected into muscles to cause muscle weakness.

Specifically speaking, ‘Botox’ is actually the name of the most common brand of Botulinum toxin, although there are other brands used in Australia such as Dysport.  For the purposes of this article (and to save us from confusing everyone!), we will just use the word Botox to mean any of these different versions.

What is Botox used for?

In the general media, Botox is most commonly known for its cosmetic use for treating wrinkles. However, Botox is also commonly used to help manage muscle spasticity in adults and children with neurological conditions.  For the children we work with at Move and Play, Botox is sometimes used to improve or manage spasticity for children with cerebral palsy, acquired brain injury or other neurological conditions.

Muscle spasticity can cause overactive and tight muscles, which can cause children to have difficulties with their ability to move well, do the things they need or want to do in life, and also sometimes with their care and comfort.  Common difficulties or situations in which Botox might be recommended for a child include:

  • Difficulties with movements. This will include gross movements such as crawling, standing, or walking, and fine or hand movements such as using our hands to play, point, dress or write with a pencil.  These difficulties occur as a result of the spasticity interfering with their muscle coordination and control.
  • Abnormalities in joints or posture. This might include abnormalities in your child’s overall body posture, or abnormalities in a specific body part such as a wrist or ankle.  These abnormalities of posture occur as a result of the spasticity pulling a body part into an unusual position.
  • Difficulties with tolerating braces or orthotics, such as AFO’s, due to pain or rubbing. This occurs as a result of the muscle spasticity pulling the body part within the brace, causing it not to fit well or pressure marks.
  • Difficulties with hygiene. This might include being able to open your child’s legs for nappy changes, or if your child’s hand and fist is tightly closed making it difficult to clean their hand and fingers.
  • Difficulties with pain and comfort levels. Sometimes the muscle spasticity causes really tight muscles and that strongly pull on the tendons and joints, which can cause pain or discomfort.

How does Botox work?

Botox injections work by stopping the communication between the nerves and the muscles. When Botox is injected into the muscle, it blocks off the channels between the nerves and the muscles so that messages from the nerve have more difficulty getting through to the muscle. The effect is that the muscle cannot activate as well and therefore becomes weaker.

However, Botox injections do not last forever.  Over a period of approximately 3 months following the Botox injections, the nerve and muscle form new connections, which eventually restore the ability for the muscle to activate, and the muscle can become strong and overactive again.

As a result, the purpose of the Botox injection is to give your child a ‘window of opportunity’ – an approximately 3 month window when your child can stretch their tight muscles, gain movement in their previously tight muscles, and learn to move in a different way that the previously were unable to as a result of their spastic muscles.  It is these gains in range of movement, muscle length, muscle strength and movement control that provide ongoing effects after the Botox has worn off.

Which children will benefit from Botox?

Botox might be useful for your child if they meet the following criteria:

  • Over 2 years of age: Botox is only approved to be used in children who are at least 2 years old.
  • Your child has spasticity or overactivity of some muscles: The spasticity present in your child’s muscles can be assessed by their treating doctor or therapist, but functionally can look like muscles that are stiff or tight, and are impacting on their ability to do things.
  • Your child’s muscle spasticity is impacting on their ability to do things in their life: Botox will only be used if there is a functional purpose, or it will give a specific gain such as improved movement abilities, improved self-care, or improved posture (as described above)
  • The spasticity is only causing difficulties in a few muscles: For example, your child’s hamstrings and calves might be causing them some difficulties with walking, or their wrist and thumb muscles might be impacting on their ability to open their hand up to hold things. Botox can only be injected in small doses, so if your child has spasticity affecting numerous body parts, Botox may not be appropriate for them (instead your rehab paediatrician might recommend a medicine to help decrease your child’s tone throughout their body).
  • Have not had Botox in the previous 4 months.

There can also be other precautions to receiving Botox, which your child’s rehab paediatrician will screen for before considering Botox to ensure it is appropriate and safe for your child.

When might Botox not be suitable for my child?

  • Your child does not have spasticity or muscle overactivity: Botox is designed to work on muscles that are too active.  If your child’s muscles are floppy, underactive, or weak, then Botox is not likely to be suitable for your child.
  • Your child uses their spasticity to help them to do things in their daily life: The most common example of this is when children use the spasticity in their legs to stand to transfer.  If we take that spasticity away, then your child might lose the ability to stand up to transfer.  In this instance, Botox might not be beneficial for your child.
  • When spasticity is NOT the biggest contributor to your child’s movement difficulties: Many things can contribute to your child’s movement difficulties, and in a number of cases your child’s muscle weakness and lack of motor control are impacting on your child’s functional progress, rather spasticity.
  • When the weakness caused by the Botox will NEGATIVELY impact on your child’s functional abilities: Your child might want to learn to do things like jump, run, and hop.  All of these tasks require your child to be strong and powerful – however, Botox will weaken their muscles, so may not be suitable for your child.

Final, but most important point…

Making sure your child does the required follow-up therapy or treatments can have a significant impact on the success of your child’s Botox injections

Botox injections are not designed to be used on their own – they should always be combined with some sort of follow-up therapy, or serial casting, or stretching, or activity program.  As mentioned above, Botox simply provides a ‘window of opportunity’ and the Botox wears off after 3 months.  It is the rest of the therapy your child does while the Botox is working that creates lasting change.  So please always make sure you do your best to ensure your child attends the therapy or casting appointments following their Botox injections.

Feeling fully informed about whether Botox could be beneficial for your child will help you to feel confident in deciding whether you would like to go ahead with the injections or not.

If you have any questions about Botox and whether it will be beneficial for your child, our therapists would be happy to answer any questions we can.  Alternatively, you can discuss your questions with the rehab paediatrician and team during your child’s Botox assessment.