The ever-expanding universe of botulinum neurotoxin in movement disorders

Botulinum neurotoxin (BoNT) has become a cornerstone in the management of movement disorders since its introduction into neurological practice. Initially established as a first-line therapy for focal dystonias and other hyperkinetic conditions, its efficacy is supported by robust clinical evidence and guideline recommendations. BoNT exerts its therapeutic effects through inhibition of acetylcholine release via cleavage of SNARE proteins, resulting in reversible chemodenervation, with additional evidence supporting modulation of sensory pathways and central motor circuits. This present review intends to summarize the clinical use of BoNT beyond established ones in dystonia and spasticity, as expanding applications accrue. The expanse includes treatment of Parkinson and Non-Parkinson-related movement disorders, hyperexcitability syndromes, autonomic blockade and pain reduction. Emerging utility of BoNT clinical use include the applications at Intensive Care Unit, the pre-emptive use of BoNT during surgeries and the device aided BoNT deliveries. These developments highlight its evolving role as a versatile therapy beyond purely motor control. Despite growing clinical experience, many emerging indications remain supported by limited or heterogeneous evidence. Further studies are needed to define optimal patient selection, dosing strategies, and long-term outcomes. As understanding of disease mechanisms continues to evolve, BoNT is poised to remain at the forefront of personalized and precision-based therapies in movement disorders.