Management of Spasticity with

Botulinum Toxin Type A (botox ) ®

EDITION 3.0
suggested adult botox dosing ®

Avg. Starting BOTOX Dose

®
Number of
Clinical Pattern Potential Muscles Involved Dose/Units Units/Visit Injection Sites

UPPER LIMBS
Adducted/Internally pectoralis complex 100 50 – 200 2–4
Rotated Shoulder latissimus dorsi 100 50 – 200 2–4
teres major 50 25 – 100 1–2
subscapularis 75 50 – 100 1–2
Flexed Elbow brachioradialis 60 25 – 100 1–3
biceps 80 75 – 200 2–4
brachialis 50 40 – 150 1–2
Pronated Forearm pronator quadratus 25 10 – 50 1
pronator teres 40 – 50 25 – 75 1–2
Flexed Wrist flexor carpi radialis 50 25 – 100 1–2
flexor carpi ulnaris 40 20 – 100 1–2
Thumb-in-Palm flexor pollicis longus 20 10 – 50 1
adductor pollicis 10 5 – 30 1
flexor pollicis brevis/opponens 10 5 – 30 1
Clenched Fist flexor digitorum superficialis (per fascicle) 20 20 – 50 1
flexor digitorum profundus (per fascicle) 20 20 – 50 1
Intrinsic Plus Hand lumbricales/interossei (per lumbrical) 10 5 – 15 1

LOWER LIMBS
Flexed Hip iliopsoas † 100 50 – 200 2
† For localization of psoas, fluoroscopy/
psoas 100 50 – 200 2
ultrasound is recommended rectus femoris 100 75 – 200 2–4
Flexed Knee medial hamstrings 100 50 – 200 2–3
gastrocnemius (as knee flexor) 125 50 – 150 2–4
lateral hamstrings 100 75 – 200 2–3
Adducted Thighs adductor longus/brevis/magnus 200/leg 75 – 300 6/leg
Stiff (Extended) Knee quadriceps mechanism 100 50 – 300 6
Equinovarus Foot gastrocnemius medial/lateral 100 50 – 250 2–4
soleus 100 50 – 200 2–4
tibialis posterior 75 50 – 150 1–3
tibialis anterior 50 50 – 150 1–3
flexor digitorum longus 75 50 – 100 1–3
flexor digitorum brevis 25 20 – 40 1
flexor hallucis longus 50 25 – 75 1–2
Striatal Toe extensor hallucis longus 50 20 – 100 1–2

SUGGESTED ADULT BOTOX DOSING CONTINUED ON REVERSE SIDE

© WE MOVE™| REVISED AUGUST 2005 | EDITION 3.0

 suggested adult botox dosing (continued) ®

Avg. Starting BOTOX Dose ®

Number of
Potential Muscles Involved Dose/Units Units/Visit Injection Sites

HEAD AND NECK

sternocleidomastoid (scm)† † 40 25 – 75** 1–3
scalenus complex 30 15 – 50 1–3
splenius capitis 50 30 – 150 1–3
†† The dose should be reduced by 50% if both semispinalis capitis 60 50 – 150 1–3
scm muscles are injected. longissimus capitis 60 50 – 150 1–3
**Neck weakness may be a risk from injection of trapezius 50 50 – 150 1–3
neck extensors at the upper end of the dose range levator scapulae 60 25 – 100 1–3
masseter 40/side 20 – 60/side 2/side

temporalis 20/side 20 – 40/side 1 – 2/side

dosing guidelines for adults

Total maximum body dose per visit = Maximum volume per site = 0.5 – 1.0 Reinjection v 3 months, except in
400–600 Units, except in select situations mL, except in select situations select situations
The suggested doses in this table represent updates to the original dosing recommendations. These were 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, 2002

dose modifiers
CLINICAL SITUATION DOSE PER MUSCLE
A Decrease in Dose An Increase in Dose
May be Indicated if: 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
Underlying voluntary control Good Poor
Concern that treatment may result in excess weakness High Low
Results of previous therapy Too much weakness Inadequate response
Before prescribing any pharmacologic agent, review the complete prescribing information, including indications, contraindications, warnings, precautions, and adverse events.

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
Reassessment at 3 – 6 weeks is recommended to evaluate patient response
The decision to re-treat is not a forgone conclusion and should be revisited after each Dosing tables are web viewable
therapy session and downloadable at
www.mdvu.org
© WE MOVE™| REVISED AUGUST 2005 | EDITION 3.0