Pharmacologic Management of Spasticity in Adults With Brain Injury

[Treatment of spasticity after traumatic brain injury in children: the role of botulinum toxin therapy]

Traumatic brain injury (TBI) is one of the main reasons of death and disability in children and adolescents in Russia and abroad. Spasticity is a frequent outcome of the TBI that influences on the rehabilitation prognosis, degree of movement disorders and quality of life after trauma. Early spasticity correction and complex rehabilitation lead to the optimal recovery and prevent secondary complications. This review presents the current data about the prognostic role of the spasticity in children after TBI, methods of its correction and their scientific evidence. Limitations and challenges of per-oral antispastic agents are described especially for the patients with local spasticity. Attention is focused on the methods of treatment of local hypertonus, in particular botulinum toxin A (BTA) injections proved to be effective in adults with acquired brain injury. The article summarizes the results of international investigations, systematic reviews and consensus statements about the efficacy and safety of botulinum toxin treatment in children after the TBI. The authors describe an algorithm of the optimal patient selection and goal setting for BTA injections in children with acquired brain injury.

An unusual case of Dantrolene sodium-induced urinary retention in post-traumatic minimally responsive state

INTRODUCTION

An unusual case of urinary retention is reported occurring during the inpatient rehabilitation of minimally responsive state (MRS) following severe traumatic brain injury (TBI).

CLINICAL PICTURE

Urodynamic evaluation showed detrusor acontractility and subsequent management involved intermittent bladder catheterization and treatment of a single urinary tract infection.

TREATMENT

Factors contributing to her bladder paralysis included severe immobility, tetraplegia and treatment of diffuse spasticity with oral Dantrolene sodium 250 mg per day. Constipation, diabetes and spinal cord injury were absent. In addition, she received unilateral partial sciatic neurolysis with 50% alcohol for severe knee flexor spasticity and intra-muscular Botulinum toxin A to both spastic upper limbs.

OUTCOME

Bladder acontractility resolved completely when Dantrolene was reduced with subsequent achievement of a catheter-free status and small post-void residual volumes. Repeat urodynamics showed spontaneous detrusor contractions.

CONCLUSION

A discussion of possible aetiologic factors for detrusor acontracility following TBI is presented including a brief review of the literature.

Role of botulinum toxin in hand and upper limb disorders relevant to hand therapy

Introduction

This article reviews the mechanism of action of botulinum toxin and provides an overview of its use in hand disorders relevant to hand therapy such as hyperhidrosis, spasticity, dystonia, tremor, Parkinson's, obstetrical brachial plexus palsy, flexor tendon rehabilitation, lateral epicondylitis, Raynaud's and carpal tunnel syndrome.

Methods

A narrative review of the literature retrieved through electronic databases using keywords botulinum toxin, hand, therapy, and reviewing the bibliographic references cited.

Results

Sixty-five original articles and meta-analyses were reviewed. The number and quality of the published reports for each disorder are very variable but generally botulinum toxin is reported to be an effective adjunct to therapy in the treatment of a wide variety of hand and upper limb pathologies.

Discussion

A surprising number of hand and upper limb conditions have been successively treated with botulinum toxin, but most require botulinum toxin to be used in conjunction with hand therapy to achieve more effective outcomes for longer duration. Neuromuscular disorders seem to be most responsive to botulinum toxin treatment. Therapists should be aware of the potential benefits of botulinum toxin injections for a wide range of hand disorders and when appropriate discuss these with patients and other health professionals.

Conclusion

Botulinum toxin has an effective and growing role in hand therapy.

Botulinum toxin in upper limb spasticity after acquired brain injury: a randomized trial comparing dilution techniques

OBJECTIVE

To compare the efficacy of two different volume preparations of the same dose of botulinum toxin-A in relieving spasticity in wrist and finger flexors secondary to acquired brain injury.

DESIGN

Thirteen adult patients who had modified Ashworth scale scores of 3 for both wrist and finger flexors were included in this randomized, controlled trial. Wrist and finger flexors were each injected. Blinded modified Ashworth scale ratings of wrist and finger flexor spasticity were measured.

RESULTS

Spasticity in both muscles decreased significantly in both treatment groups. However, the high-volume and low-volume groups did not differ significantly in spasticity reduction.

CONCLUSIONS

Because this preliminary study found no difference in spasticity reduction between high- and low-volume preparations of a 60-unit dose of botulinum toxin-A, a larger-sample study seems warranted to compare the efficacy of high-volume and low-volume preparations.