Post Botox Guidelines

Whilst on rural prac, I spent most of time working in paediatric community physiotherapy. One of the most common conditions I was working with was Cerebral Palsy (CP): spastic diplegic/quadriplegic of varying severity. We had several children referred from PMH post botox treatment (each had injections into either gastroc or hamstrings). They were referred with an attaching form asking for “intensive physiotherapy”.

However on further investigation, no one seemed to know what the best practice/guidelines for physiotherapy treatment was post botox. I spoke to PMH, TCCP and various other experienced paediatric physiotherapists. Each had their own idea of treatments (techniques, frequency, duration of therapy) but with no consensus.

I then proceeded to do a literature review to investigate the recent research into this area. Although there is a lot of literature about the benefits and best practice for botox injections there is very little information about physiotherapy input. Almost every article recognised the importance of physiotherapy and other allied health input, stressing that botox should only be used as an adjunct to physiotherapy, however as to what type of physiotherapy is best is not clear.

Obviously, maintaining muscle length, muscle strength and gait re-education are all important, but how do you justify to a government agency that a child needs 3 x week input of 45-60 mins of therapy for 6 weeks to maintain and improve the gains from botox injections. How do we treat according to evidence based practice when there is none. There is a variety of ideas about physiotherapy post botox, inlcuding:

Duration: between 4 weeks of “intensive” or “comprehensive” intervention up to 8 months.
Frequency: 1 x week up to 7 x week
Types of intervention (not specific): strength, balance, stretching, gait reeducation, functional training (no indications of strength reps or sets or even which muscle group – often suggested you need to strengthen the botoxed muscle as much as its antagonist)

Therefore, we saw our clients 1 x week for 60mins to monitor gait, ROM, muscle length, and took them through strengthening exercises (concentric and eccentric) and provided a home exercise program. The plan is to provide treatment over a six week block. At that point in time, there were not the resources to be able to provide further therapy. My supervisor plans to conduct her own informal research and see what improvements she gains/maintains by conducting relatively similar treatment protocols (type, frequency, duration).

Whilst very few conclusions can be drawn from the lit review about best practice post botox, it does indicate an area that is lacking…maybe a good research project for the future…..?