Botulinum toxin (e.g. Botox ©, Dysport ©) has been used to help manage spasticity for a number of years. Patient function can significantly improve when focal spasticity is managed, and botulinum toxin is an effective treatment of focal spasticity that does not involve the systemic side effects produced by oral anti-spasticity agents.
The MBS and PBS recently reviewed the subsidised indications of botulinum toxin in spasticity to improve patient access to this excellent treatment. There have been a number of restrictions lifted and the following are now eligible for subsidised botulinum toxin treatment:
- Patients with cerebral palsy can now be treated with botulinum toxin even if the first treatment did not start under the age of 18.
- Patients with spasticity related to any acute neurological event (and not just stroke).
- Lower limb spasticity caused by stroke or another neurological event
Below are the current subsidised indications for the use of botulinum toxin in spasticity (bold are new items):
| REGION | INDICATION |
| Lower limb | Spasticity of the lower limb following an acute event |
| Lower limb | Spasticity of the lower limb following an acute event and who have previously received non-PBS subsidised treatment |
| Dynamic equinovarus foot deformity | Treatment of dynamic foot deformity due to spasticity in an ambulant cerebral palsy patient > 18 years of age |
| Upper limb | Moderate to severe upper limb spastcity due to cerebral palsy in a patient over 18 years of age |
| Upper limb | Treatment of moderate to severe spasticity of the upper limb following a stroke |
| Lower limb | Treatment of dynamic equinovarus deformity in a patient with cerebral palsy at least 2 years of age |
| Upper limb | Treatment of moderate to severe upper limb spasticity due to cerebral palsy in a patient at least 2 years of age |
Presently the restriction on the number of treatments for post-stroke upper limb spasticity remains but it is likely that this restriction will be lifted at the end of 2019 or very early 2020.
As a practical guide we suggest the following clinical scenarios where treatment with botulinum toxin may help your patients with spasticity. Please speak with one of our neurologists if you would like to discuss any specific case and whether there would be a role for botulinum toxin treatment.
Upper limb without residual function
1) To prevent contractures thereby
reducing pain and increasing limb mobility (such as treatment of biceps spasticity).
2) To improve patient care for
example treating pectoral spasticity to facilitate dressing.
3) To improve hand hygiene. For
example patients with severe finger flexion spasticity causing a permanent fist
often experience damp and macerated skin on the palm which is very difficult to
clean. This can be improved or resolved with botulinum toxin to finger flexor
muscles.
Upper limb with residual function
1) To modify the balance of muscle
activity/overactivty thereby to improve functional movements. An example is
a patient who needs to wear gloves for work. Treatment of finger flexion
spasticity can improve a patient’s ability to put the gloves on.
2) To prevent contractures as above.
Lower limb
1) To prevent contractures as above. For example to prevent Achilles’ tendon of hamstring shortening which will adversely impact on mobility.
2) To reduce falls caused by foot scuffing in patients with spastic equinovarus deformity.
3) To reduce pain from muscle overactivity such as a striatal toe.
4) To improve gait dynamics, for
example treatment of adductor spasticity causing scissoring gait.
The neurologists at Northern Beaches Neurology use combinations of EMG, ultrasound and needle stimulation to guide accurate botulinum toxin injections.
Please contact us on 9982 2270 to discuss your patient’s needs with one of our neurologists.
