Botulinum toxin
Botulinum toxin injections are given into muscles that are spastic or sometimes dystonic, the aim being to reduce the muscle hypertonus that can be painful. A reduction in muscle tone can also facilitate bracing and the use of orthotics. Both lower extremity and upper extremity muscles are injected. Botulinum toxin is focal treatment, meaning that a limited number of muscles can be injected at the same time. The effect of the toxin is reversible and a reinjection may be needed every 4–6 months. In children it decreases spasticity and improve range of motion and thus has become commonly used. Botulin toxin has been used in CP treatment for around two decades and can be recommended for children above the age of two. Two systematic reviews published in 2010 and 2020 found that there is high level evidence in the use of botulinum toxin as an add on therapy to occupational therapy among other physical therapies modalities in order to manage spasticity in the arms of children with cerebral palsy. However, there is no strong research associated with the use of botulinum toxin in the management of spasticity in the legs or improving gait compared to casting. More evidence related to the frequency and dosage of injections as it relates to long-term outcomes is needed in order to support or refute the use of botulinum toxin in the management of lower limb spasticity in children with cerebral palsy.