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Adult BTX-A Therapy
Management of Spasticity with Botulinum Toxin Type A
05 November 2004
| SUGGESTED ADULT BOTOX® DOSING |
| Clinical Pattern |
Potential Muscles Involved |
Avg. Starting
Dose/Units |
Botox® Dose
Units/Visit |
Number of
Injection Sites |
| Upper Limbs |
| Adducted/Internally Rotated
Shoulder |
pectoralis complex |
100 |
75-150 |
2-4 |
| latissimus dorsi |
100 |
50-150 |
3-4 |
| teres major |
50 |
25-100 |
1-2 |
| subscapularis |
75 |
50-100 |
1-2 |
| Flexed Elbow |
brachioradialis |
60 |
25-100 |
1-3 |
| biceps |
100 |
75-200 |
2-4 |
| brachialis |
60 |
40-100 |
2 |
| Pronated Forearm |
pronator quadratus |
25 |
10-50 |
1 |
| pronator teres |
40 |
25-75 |
1-2 |
| Flexed Wrist |
flexor carpi radialis |
50 |
25-100 |
2 |
| flexor carpi ulnaris |
40 |
20-70 |
2 |
| Thumbs-in-Palm |
flexor pollicis longus |
20 |
10-30 |
1 |
| adductor pollicis |
10 |
5-25 |
1 |
| flexor pollicis brevis/opponens |
10 |
5-25 |
1 |
| Clenched Fist |
flexor digitorum superficialis (per fascicle) |
20 |
20-40 |
1 |
| flexor digitorum profundus (per fascicle) |
20 |
20-40 |
1 |
| Intrinsic Plus Hand |
lumbricales/interossei (per lumbrical) |
10 |
5-10 |
1 |
| Lower Limbs |
| Flexed Hip
†For localization of psoas, fluoroscopy/ultrasound is recommended
|
iliopsoas† |
150 |
50-200 |
2 |
| psoas |
100 |
50-200 |
2 |
| rectus femoris |
100 |
75-200 |
3 |
| Flexed Knee |
medial hamstrings |
100 |
50-200 |
3 |
gastrocnemius
(as knee flexor) |
150 |
50-150 |
4 |
| lateral hamstrings |
100 |
100-200 |
3 |
| Adducted Thighs |
adductor longus/brevis/magnus |
200/leg |
75-300 |
6/leg |
| Stiff (Extended) Knee |
quadriceps mechanism |
100 |
50-200 |
6 |
| Equinovarus Foot |
gastrocnemius medial/lateral |
100 |
50-250 |
4 |
| soleus |
100 |
50-200 |
2 |
| tibialis posterior |
75 |
50-150 |
2 |
| tibialis anterior |
75 |
50-150 |
2-3 |
| flexor digitorum longus |
75 |
50-100 |
3 |
| flexor digitorum brevis |
25 |
20-40 |
1 |
| flexor hallucis longus |
50 |
25-75 |
2 |
| Striatal Toe |
extensor hallucis longus |
50 |
20-100 |
2 |
| Head and Neck |
| ††The dose should be
reduced by 50% if both SCM muscles are injected. |
strenocleidomastoid (SCM)†† |
40 |
25-100 |
3 |
| scalenus complex |
30 |
15-50 |
3 |
| splenius capitis |
60 |
50-150 |
3 |
| semispinalis capitis |
60 |
50-150 |
3 |
| longissimus capitis |
60 |
50-150 |
3 |
| trapezius |
60 |
50-150 |
3 |
| levator scapulae |
80 |
25-100 |
3 |
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masseter |
40/side |
20-60/side |
2/side |
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temporalis |
20/side |
20-40/side |
1-2/side |
| DOSING GUIDELINES FOR ADULTS |
| Total maximum body dose per visit=400-600 Units,
except in select situations |
Maximum volume per site=0.5-1.0mL, except in select
situations |
Reinjection >3 months, except in select
situations |
Dosing recommendations are based on the consensus opinion of the
Spasticity Study Group. For further discussion, see Mayer NH, Simpson DM,
editors. Spasticity, Etiology, Evaluation, Management, and the Role of
Botulinum Toxin Type A. New York: WE MOVE 2001
| DOSE MODIFIERS |
| CLINICAL SITUATION |
DOSE PER MUSCLE |
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A Decrease in Dose May Be
Indicated if: |
An Increase in Dose May Be
Indicated if: |
| Patient weight |
Low |
High |
| Likely duration of therapy |
Chronic |
Acute |
| Muscle bulk |
Very small |
Very large |
| Number of muscles being injected
simultaneously |
Many |
Few |
| Ashworth score |
Low |
Very High |
| Concern that treatment may result in
excess weakness |
High |
Low |
| Results of previous therapy |
Too much weakness |
Inadequate response |
| KEY POINTS |
| Meaningful assessment of treatment outcome
depends on careful definition of objectives beforehand |
| Patients may benefit from anxiolytics and/or
topical anesthetics before injection |
| Most patients begin to feel a therapeutic
effect within 24-72 hours after injection, with the peak effect
occurring at approximately 1-4 weeks |
| Concurrent therapies may improve likelihood
of reaching treatment objectives |
| Every patient will develop a portfolio of
response to BTX-A therapy, which is used to guide future treatment |
| The decision to re-treat is not a foregone
conclusion and should be revisited after each therapy session |
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