“Botox” injection: Information leaflet for patients, families and therapists - Infant to allow arm out

Botulinum toxin (also known as Botox) is a purified form of a toxin that affects the nerves (a neurotoxin). It works by blocking signals from the nerve to the muscle that has been injected. The nerve is then unable to tell the muscle to move.

Muscles usually work in pairs or groups where one switches on (prime mover) and the other (antagonist) switches off to allow movement around a joint. Nerve injuries can sometimes lead to problems with muscles and their ability to switch on and off. Sometimes both groups of muscles switch on at the same time (a bit like a tug-ofwar between the muscles). We call this co-contraction. If both sets of muscles are  co-contracting it can limit the amount of movement in a joint. Botox switches off the muscle which is overworking and allows the ‘prime mover’ to do its job.

It is also suggested that Botox may have an effect on the brain’s ability to talk to the muscles. It is thought that Botox is able to help with the mixed messages being sent and received by the brain (similar to turning a computer off in order to reset it).

The aim of Botox is to improve the every day use of the affected arm and to help prevent contractures, deformities and neglected use of the arm.

The injection may take 3 weeks to take full effect. The main thing patients often notice is that the arm feels freer. For example movements such as reaching and bringing the hand to mouth may become easier.

It is best to start the exercises that are outlined in this leaflet as soon as possible following the Botox injection. It is advised that formal physiotherapy starts from 3 weeks after the injection. This may be at the RNOH or at your local Physiotherapy department.

Your child’s pectoral, Latissimus Dorsi and/or subscapularis muscle(s) have been injected because they have been limited in the amount they can turn their arm out to the side to reach for objects.

It may take up to three weeks for Botox to take full effect and it is important that your child keeps using their arm as they normally would.

You will be given an appointment to see a physiotherapist approximately 3 weeks after the injection. This can either be at the RNOH or at a hospital which is more local to you if preferred (appointment to be arranged prior to receiving Botox injection).

The following exercises are recommended following the injection. These exercises should be completed with the child in lying. Ensure the shoulder/elbow/forearm is well positioned and supported.

The exercises should be done frequently (at least 5 times a day with approximately 20 repetitions) but stopped if your child starts to use compensatory movements (for example: bending/twisting their back or hitching their shoulder).

You should also continue with any exercises or stretches that you have previously been given by your therapist.

1. External Rotation in Neutral
   With one hand, support the front of the shoulder and keep the arm  by the side of the body.
   With your other hand hold and support around the wrist and roll the forearm outwards.
   Keep the elbow by their side.
    
2. External rotation in Abduction
   With one hand, stabilise the front of the shoulder and lift the arm up  and out to 90 degrees (a right angle) from the body.
   With the other hand, hold the wrist and rotate the forearm backwards towards the bed.
   

Play activities to help with reaching to the side:

• Holding, throwing and catching a large ball/ bean bags
• Holding onto a swing
• Skipping backwards with a rope
• Sweeping
• Pulling apart popper toys and stickle bricks
• Playing the cymbals – if you can stand the noise!
• Swinging a bat