Children with Spastic Cerebral Palsy Might Not Actually Benefit from Botox Injections Prior to Physiotherapy

Doctors often prescribe botulinum toxin A (botox) injections to patients with cerebral palsy who are ambulatory (able to walk), in order to reduce spasticity. Generally, botox injections are given as part of a combined treatment plan also involving other interventions. However, studies on whether botox injections improve outcomes for children undergoing comprehensive rehabilitation programs have shown mixed results. Children with spastic cerebral palsy who were given botox combined with non-pharmacological interventions have shown improvement; however, some studies have failed to use adequate controls. For example, to look at the impacts of botox – or indeed, of any drug – it is essential to ensure that the experimental and control groups have similar rehabilitation regimes.

New study on effectiveness of botox injections for children with spastic CP

Fabienne Schasfoort and colleagues from the Netherlands recently published a study comparing the effectiveness of comprehensive non-pharmacological rehabilitation (physiotherapy, casting, and orthotic devices) with and without the use of botox. Their subjects were 64 children aged 4-12; all had spastic cerebral palsy, and they were equally distributed among GMFCS levels. 41 children were in the experimental group (they received botox) while 24 children were in the control group (no botox). The authors compared their improvement at baseline, after 12 weeks of intervention, and at a 24-week follow-up. They considered functional leg muscle strength, cerebral palsy-related pain, walking speed, and several other variables.

Results: Botox appears not to increase the effectiveness of comprehensive rehabilitation

Schasfoort et al. found no statistically significant differences between the two groups, with exception of one variable (angle-of-catch of the rectus femoris), which actually improved more in the group without botox. The authors note that, “These results may appear to contradict previous findings, but this is not the case. When the literature is critically appraised, there are some indications that the relative contribution of factors other than BoNT-A [botox] to overall effectiveness of combined treatment packages may have been underestimated.” Moreover, there are disadvantages to botox treatment, including that it is a toxin, involves the use of anesthesia, requires repeated doses, and can be expensive. Therefore, the authors emphasize that it is necessary to “critically reconsider” the widespread use of botox in treating children with spastic CP.


Schasfoort, F., Pangalila, R., Sneekes, E., Catsman, C., Becher, J., Horemans, H., … & Bussmann, H. (2018). Intramuscular botulinum toxin prior to comprehensive rehabilitation has no added value for improving motor impairments, gait kinematics and goal attainment in walking children with spastic cerebral palsy. Journal of rehabilitation medicine, 50(8), 732-742.

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