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Botulinum toxin is particularly useful when specific overactive muscles cause pain, restrict movement, interfere with walking or use of the arm, complicate hygiene or caregiving, or maintain an abnormal limb posture. The goal is not simply to reduce muscle tone, but to address a meaningful functional problem for the individual patient.
Spasticity develops after injury to the central nervous system and is associated with abnormal muscle activation, increased resistance to movement and characteristic abnormal movement patterns.
It may appear as a flexed arm, clenched fist, internally rotated shoulder, abnormal foot posture, difficulty extending the knee or other persistent positions of an affected limb.
Increased muscle tone alone is not automatically an indication for botulinum toxin injections.
Treatment is considered when particular muscles interfere with movement, cause pain or spasms, create an unwanted limb posture, make hygiene or caregiving difficult, or limit rehabilitation.
Before treatment, it is important to define what should become easier after reducing abnormal activity in the selected muscles.
A common cause of adult spasticity, affecting the arm, leg or both limbs on one side.
Spasticity may particularly affect the legs, walking, balance, pain and everyday activity.
Brain injury can produce complex patterns of increased muscle activity in both upper and lower limbs.
Spasticity may be widespread, while local botulinum toxin treatment can still be useful when specific muscles create a defined problem.
Botulinum toxin is most suitable for focal or multifocal spasticity, when specific muscles responsible for a clinically important problem can be identified.
In severe generalized spasticity, the problem may involve too many muscle groups to be managed by local injections alone. Botulinum toxin may then be one component of a broader treatment plan that can include systemic medication, rehabilitation, orthoses and other approaches.
One or more meaningful goals should ideally be defined before injections.
Reduce resistance from overactive muscles that directly interfere with useful movement.
Decrease painful spasms and discomfort related to abnormal muscle activity.
Make hand hygiene, dressing, positioning or caregiving easier.
Create better conditions for movement training, stretching, orthotic management and functional therapy.
Stroke, traumatic injury and other central nervous system disorders can produce different abnormal postures of the arm. Treatment planning requires identifying not only the visible posture but also the muscles actually responsible for it.
Botulinum toxin may be considered when a specific spastic pattern affects foot position, weight bearing, walking, positioning, caregiving or causes pain.
Limb posture does not always reveal which muscle is causing the problem. Some muscles may drive the abnormal pattern, while others may be compensating for weakness.
Weakening a compensatory muscle can fail to improve function and may sometimes make it worse.
The target muscle is the one whose abnormal activity actually prevents achievement of the selected clinical goal.
For some superficial muscles, clinical examination and anatomical landmarks may be sufficient. In other situations, more precise localisation is useful.
Ultrasound can visualise the target muscle, its depth and nearby anatomical structures.
EMG can help confirm activity in a particular muscle, particularly in more complex movement patterns.
These techniques can improve precision, but they do not replace clinical movement analysis and definition of a meaningful treatment goal.
The spastic pattern, muscle strength, range of motion and the patient's main problem are evaluated.
A specific clinical or functional goal is defined before treatment.
Target muscles are selected and the dose is distributed individually.
After reducing abnormal muscle activity, work on movement and function continues.
Botulinum toxin does not teach the limb a new movement. It reduces unwanted activity in selected muscles and creates a period in which it may be easier to work on a specific functional task.
Rehabilitation should relate directly to the goal for which the injections were performed. If the goal is better use of the arm, the treatment period should be used to train arm function.
If a joint can no longer be moved passively into the desired position, reducing muscle overactivity may not restore the lost range of motion.
When weakness rather than overactivity is the main functional problem, further muscle weakening may not provide the desired benefit.
When many muscle groups are affected, local injections alone may not adequately address the overall problem.
Without a specific treatment goal, it is difficult to select the right muscles and objectively judge the result.
Botulinum toxin treatment is generally well tolerated. Possible effects include local discomfort, a small bruise and temporary weakness in the treated area.
Unwanted weakness is particularly relevant in patients whose function is already limited by the underlying neurological condition.
Dr Lidiia Prakhova, MD, PhD, is a neurologist in Israel with experience in the treatment of spasticity and the use of botulinum toxin in neurological disorders.
Treatment planning considers not only increased muscle tone, but also its impact on movement, pain, limb position, caregiving and rehabilitation potential.
Target muscles and dose distribution are selected individually according to the spastic pattern and the treatment goal.
If botulinum toxin treatment has been performed previously, information about the product, doses, injected muscles, duration of benefit and adverse effects can be useful.
It is particularly useful for focal or multifocal spasticity when specific muscles interfere with function, cause pain, complicate care or create an unwanted limb posture.
No. Functional improvement depends on appropriate goal setting, preserved muscle strength, the absence of fixed contracture and suitable rehabilitation.
Yes. It is widely used for focal upper- and lower-limb spasticity after stroke when excessive activity of specific muscles causes a clinically important problem.
Yes. It may be useful for local spastic patterns, particularly when selected muscles interfere with walking, cause pain or limit function.
No. They can be particularly useful for deep muscles, complex patterns or when more precise localisation is needed.
The effect lasts for several months. The timing of the next cycle is individualized according to duration of benefit, recurrence of symptoms and the result of the previous treatment.
Its effect is limited when a fixed contracture is already present. Botulinum toxin reduces excessive muscle activity, but does not reverse an established mechanical restriction of the joint.
If spasticity after stroke, multiple sclerosis, traumatic brain injury or spinal cord injury causes pain, interferes with movement or walking, changes limb posture or complicates caregiving, consultation with Dr Lidiia Prakhova can help determine whether botulinum toxin treatment is appropriate and define realistic treatment goals.
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