Botulinum toxin-A injections for the arm and hand combined with occupational therapy

Last update: 2 Nov 2016

Botulinum toxin-A is an anti-spasticity medication that is injected into muscles to temporarily reduce muscle tightness
Receiving occupational therapy after the injections can further improve a person’s movement
Botulinum toxin-A can also be called by its trade names including BOTOX® and Dysport®.

Who are these for?

Botulinum toxin-A injections in the arm and hand, combined with occupational therapy, may be suitable for children and adults with cerebral palsy who have the following characteristics:
Type of cerebral palsy : Bilateral cerebral palsy, Hemiplegia, Quadriplegia, Triplegia, Unilateral cerebral palsy

More information about cerebral palsy is contained in the What is CP? section.


Gross Motor Function Classification System (GMFCS) – classifies severity of mobility difficulties of children and adolescents with CP.

Walks without limitations in the home and community, climbs stairs and can run and jump, difficulties with speed and coordination.

Walks with limitations, difficulties with long distances and uneven surfaces, uses a railing for climbing stairs, limited running and jumping.

Walks using a hand-held mobility device such as crutches or walking frame, may use wheeled mobility for long distances.

Usually relies on wheeled mobility with assistance, may use powered mobility, usually needs special seating and assistance with transfers.

Usually transported in a manual wheelchair, requires specialised seating and full assistance for transfers.


Manual Ability Classification System (MACS) – classifies severity of upper limb impairment: how children with cerebral palsy use their hands to handle objects in daily activities in the home, school, and community settings.

MACS Level I
Handles objects easily and successfully.

Handles most objects but with somewhat reduced quality and/or speed of achievement.

Handles objects with difficulty; needs help to prepare and/or modify activities.

Handles a limited selection of easily managed objects in adapted situations.

MACS Level V
Does not handle objects and has severely limited ability to perform even simple actions.

Communication ability : CFCS I, CFCS II, CFCS III, CFCS IV, CFCS V

Communication Function Classification System (CFCS) – classifies severity of everyday communication of people with cerebral palsy.

CFCS Level I
Effective Sender and Receiver with unfamiliar and familiar partners.

Effective but slower paced Sender and/or Receiver with unfamiliar and/or familiar partners.

Effective Sender and Receiver with familiar partners.

Inconsistent Sender and/or Receiver with familiar partners.

CFCS Level V
Seldom effective Sender and Receiver even with familiar partners.

Movement disorder : Dystonia, Spasticity

More information about movement disorders can be found on our websites.

Intellectual ability : No intellectual disability, Mild intellectual disability, Moderate intellectual disability, Severe intellectual disability

A person’s thinking skills – ability to understand ideas, learn and solve problems. People with intellectual disability have difficulty with intellectual functioning which may influence learning, communication, social and daily living skills. Intellectual disability may be mild to very severe.

Botulinum toxin-A injections are provided by doctors and rehabilitation teams, mainly through the public hospital system.

Specialist occupational therapists at Cerebral Palsy Alliance can help you decide whether this is a good choice for you and your child and are skilled at providing therapy after the injections.

Find a Cerebral Palsy Alliance service

Fees will apply for occupational therapy assessment and intervention and will depend on the provider and the number of sessions needed. Check with the provider whether fees will also apply for development of a home program, report writing or therapist travel.

Ask the occupational therapist if you are eligible for funding to assist with fees. People with a disability living in Australia may be eligible for a health care rebate through Medicare or funding from the National Disability Insurance Scheme.

The Pharmaceutical Benefits Scheme will fund the full cost of the Botulinum toxin-A injections for eligible people. Speak with the doctor providing injections or visit the Pharmaceutical Benefits Scheme website for more information.

  • An appointment for the Botulinum toxin-A injections usually takes at least three hours, and often requires fasting beforehand.
  • Research suggests that 8 to 12 weeks of occupational therapy, in combination with a home program is completed after the injections

More about botulinum toxin-A injections

Over 85 per cent of people with cerebral palsy experience some spasticity, causing muscle overactivity and tightness. This affects their movement and can cause pain and deformity. Botulinum toxin-A injections are a relatively safe and effective treatment for arm spasticity1 for children, particularly when combined with occupational therapy.

Botulinum toxin-A is injected into the muscles by a doctor in a hospital or clinic, usually with local anaesthetic, sedation or general anaesthetic. The treatment temporarily reduces unwanted overactivity in the muscle, which lessens the muscle’s tightness and resistance to movement. In three to six months, muscle tightness can return, and re-injection may be suggested2.

Occupational therapists often take advantage of the window of opportunity of reduced muscle tightness after the injections to further improve movement. They will provide therapy sessions, along with activities to practice at home.

The main aims of botulinum toxin-A combined with occupational therapy depend on the needs and goals of individual children and the severity of their impairments3.
Goals for these children could include improving arm movement, function and the ability to complete everyday activities. Occupational therapy may involve: motor training, environmental modification, splinting, casting, practice of specific goal activities4, modified constraint-induced movement therapy5 and bimanual upper limb therapy5.
Goals for children with significant physical disability might include improving ease of care (such as making it easier to dress and to wash hands) and helping to prevent secondary physical symptoms such as pain, bony deformity, skin breakdown and hygiene issues1,6. Occupational therapy could include stretching of muscles using casting and/or splinting1.


Some temporary side effects have been reported after botulinum toxin-A injections, including vomiting or nausea from the sedation, pain, bruising and weakness of muscles around the injection site, and flu-like symptoms1,7.


More serious effects, such as generalised weakness, worsening dysphagia (difficulty swallowing), upper and lower respiratory tract infection and seizures have been occasionally reported7. These side effects are more often found in children with severe motor impairment or those receiving higher doses of botulinum toxin-A1. Before injections, children and families are informed about the potential risks, so that they can provide informed consent.


There are two types of assessments required when undertaking botulinum toxin-A injections combined with occupational therapy.

An occupational therapy assessment is necessary before botulinum toxin-A injections, to help set goals and plan the therapy.

The second type of assessment is to measure the outcome of intervention, to ensure it has met the person’s needs and goals. The occupational therapist, together with the child and family will decide on the most suitable measure. These outcome measures are commonly used:

Best available research evidence

We searched the medical and allied health literature to find research evaluating the outcomes of occupational therapy after botulinum toxin-A injections in the arms of children with spastic cerebral palsy.

The search aimed to find the best available evidence as to i) whether occupational therapy improves the effects of botulinum toxin-A injections on a child’s goal achievement, arm function, arm quality of movement, and self-care and ii) what type of occupational therapy achieves the best outcomes.

Systematic reviews and randomised controlled trials (RCTs), the highest levels of evidence, were included if they were published in English and evaluated interventions defined as occupational therapy.

i) Does occupational therapy enhance the effects of botulinum toxin-A injections on a child’s goal achievement, arm function, arm quality of movement and self-care?

The best available evidence was one high quality RCT4, also included in a high quality Cochrane systematic review8. In the RCT 40 children with spastic cerebral palsy, aged two years old to 14 years old received either botulinum toxin-A injections to their arm followed by occupational therapy or botulinum toxin-A injections alone. The occupational therapy consisted of one hour for 12 weeks at a children’s hospital and included a range of therapy interventions such as stretching, casting, splinting, motor training, environmental modification and practice of specific goal activities.

Overall, moderate quality evidence supports the effectiveness of occupational therapy following botulinum toxin-A injections to the arms of children with spastic cerebral palsy, so that functional goals are reached earlier.

ii) What is the best type of occupational therapy to have after botulinum toxin-A injections?

The best available evidence was one high quality RCT comparing modified constraint-induced therapy and bimanual upper limb therapy following botulinum toxin-A injections for children with hemiplegic cerebral palsy5. This study of 34 children aged 18 months old to six years old reported similar improvements in arm function, self-care and goal attainment in both groups.

Overall, moderate quality evidence concludes that bimanual upper limb therapy and modified constraint-induced movement therapy following botulinum toxin-A injections are similarly effective for children with hemiplegic cerebral palsy. This suggests that these intensive evidence-based interventions are effective for children with hemiplegia. There was no research to inform us which interventions are effective for children with other forms of cerebral palsy who have botulinum toxin-A injections.

Children receiving injections plus occupational therapy achieved their functional goals more quickly

One study compared the outcomes of children receiving botulinum toxin-A injections plus occupational therapy with those who had injections alone4. At the end of 12 weeks, the botulinum toxin-A plus occupational therapy group achieved significantly more of their functional goals (55%) than the botulinum toxin-A group (32%). By six months, goal attainment was similar between the groups (botulinum toxin-A plus occupational therapy group 60% compared with botulinum toxin-A alone 53%).

Children receiving injections plus occupational therapy improved their ability to complete important every day activities

The same study found that the botulinum toxin-A plus occupational therapy group achieved clinically significant change in their ability to do everyday actions that were important to them (for example, dressing, eating and leisure activities). Family satisfaction with a child’s abilities in these areas also increased. Although the botulinum toxin-A group did not achieve a clinically significant change in goal achievement, there was no statistically significant difference between the two groups.

No improvement to quality of movement and self-care after six months

Improvement in quality of movement and self-care were not observed in either group six months after the treatment.

Date of literature searches: July 2016

  1. Hoare, B. (2014). Rationale for using botulinum toxin A as an adjunct to upper limb rehabilitation in children with cerebral palsy. Journal of Child Neurology, 29(8), 1066-76. See abstract
  2. Managing Spasticity in Children with Botulinum Toxin Injections. Retrieved August 19, 2014, from
  3. Fehlings, D., Novak, I., Berweck, S., Hoare, B., Stott, N.S., Russo, R.N. (2010). Botulinum toxin assessment, intervention and follow-up for paediatric upper limb hypertonicity: international consensus statement. European Journal of Neurology, 17(Suppl 2), 38-56. doi: doi: 10.1111/j.1468-1331.2010.03127.x. See abstract
  4. Wallen, M., O’Flaherty, S.J., Waugh, M.C. (2007). Functional outcomes of intramuscular botulinum toxin type A and occupational therapy in the upper limbs of children with cerebral palsy: a randomized controlled trial. Archives of Physical Medicine and Rehabilitation, 88(1), 1-10. doi:
  5. Hoare, B., Imms, C., Villaneuva, E., Rawicki, H.B., Matyas, T., Carey, L. (2013). Intensive therapy following upper limb botulinum toxin A injection in young children with unilateral cerebral palsy: a randomized trial. Developmental Medicine and Child Neurology, 55, 238-247. doi: 10.1111/dmcn.12054.
  6. Copeland, L., Edwards, P., Thorley, M., Donaghey, S., Gascoigne-Pees, L., Kentish, M., Lindsley, J., McLennan, K., Sakzewski, L., Boyd, R.N. (2014). Botulinum toxin A for nonambulatory children with cerebral palsy: A double blind randomized controlled trial. The Journal of Pediatrics, 165, 140-6. See abstract
  7. O’Flaherty, S.J., Janakan, V., Morrow, A.M., Scheinberg, A.M., Waugh, M-C.A. (2011). Adverse events and health status following botulinum toxin type A injections in children with cerebral palsy. Developmental Medicine and Child Neurology, 53, 125-30.
  8. Hoare, B.J., Wallen, M.A., Imms, C., Villaneuva, E., Rawicki H.B., Carey, L. (2010). Botulinum toxin A as an adjunct to treatment in the management of the upper limb in children with spastic cerebral palsy (UPDATE). Cochrane Database of Systematic Reviews 2010, Issue 1. Art. No.: CD003469. doi:10.1002/14651858.CD003469.pub4.