Indications: focal spasticity, including arm symptoms in conjunction with physiotherapy, dynamic equinus foot deformity caused by spasticity in ambulant paediatric cerebral palsy patients over 2 years, and hand and wrist disability associated with stroke; blepharospasm; hemifacial spasm; spasmodic torticollis; severe hyperhidrosis of axillae.

Cautions: history of dysphagia; pregnancy; breast- feeding; Special cautions for blepharospasm or hemifacial spasm.

Cautions: if risk of angle-closure glaucoma; reduced blinking can lead to corneal exposure, persistent epithelial defect and corneal ulceration (especially in those with VII nerve disorders) careful testing of corneal sensation in previously operated eyes, avoidance of injection in lower lid area to avoid ectropion, and vigorous treatment of epithelial defect needed.

Contra-indications: generalised disorders of muscle activity (e.g. myasthenia gravis)

Side Effects: increased electrophysiologic jitter in some distant muscles; misplaced injections may paralyse nearby muscle groups and excessive doses may paralyse distant muscles; influenza-like symptoms; rarely arrhythmias, myocardial infarction, seizures, hypersensitivity reactions including rash, pruritus and anaphylaxis, antibody formation (substantial deterioration in response), and injection-site reactions.

Specific side effects: for blepharospasm or hemifacial spasm: Ptosis; keratitis, lagophthalmos, dry eye, irritation, photophobia, lacrimation; facial oedema; less commonly facial weakness (including drooping), dizziness, tiredness, ectropion, entropion, diplopia, visual disturbances; rarely eyelid bruising and swelling (minimised by applying gentle pressure at injection site immediately after injection); very rarely angle-closure glaucoma, corneal ulceration.

Special side effects in paediatric cerebral palsy: Drowsiness, paraesthesia, urinary incontinence, myalgia Special side effects in torticollis: Dysphagia and pooling of saliva (occurs most frequently after injection into sternomastoid muscle), nausea, dry mouth, rhinitis, drowsiness, headache, dizziness, hypertonia, stiffness; less commonly dyspnea, voice alteration, diplopia, and ptosis; rarely respiratory difficulties (associated with high doses); CSM has warned of persistent dysphagia and sequelae (including death)—important.

Special side effects in axillary hyperhidrosis: Non- axillary sweating, hot flushes; less commonly myalgia and joint pain.

Specific side effects: in focal upper-limb spasticity associated with stroke Dysphagia; hypertonia; less commonly arthralgia and bursitis.

Dose: specific to each individual preparation