Treatment of spasticity with botulinum toxin

Innovations in Stroke Recovery and Rehabilitation: Poststroke Pain

Pain can be a significant barrier to a stroke survivors' functional recovery and can also lead to a decreased quality of life. Common pain conditions after stroke include headache, musculoskeletal pain, spasticity-related pain, complex regional pain syndrome, and central poststroke pain. This review investigates the evidence of diagnostic and management guidelines for various pain syndromes after stroke and identifies opportunities for future research to advance the field of poststroke pain.

The 3D muscle morphology and intramuscular innervation of the digital bellies of flexor digitorum profundus: Clinical implications for botulinum toxin injection sites

Spasticity of flexor digitorum profundus is frequently managed with botulinum toxin injections. Knowledge of the 3D morphology and intramuscular innervation of the digital bellies of flexor digitorum profundus is necessary to optimize the injections. The purpose of this study was to digitize and model in 3D the contractile and connective tissue elements of flexor digitorum profundus to determine muscle morphology, model and map the intramuscular innervation and propose sites for botulinum toxin injection. Fiber bundles (FBs)/aponeuroses and intramuscular nerve branches were dissected and digitized in 12 formalin embalmed cadaveric specimens. Cartesian coordinate data were reconstructed into 3D models as in situ to visualize and compare the muscle morphology and intramuscular innervation patterns of the bellies of flexor digitorum profundus. The 3rd, 4th and 5th digital bellies were superficial to the 2nd digital belly and located adjacent to each other in all specimens. Each digital belly had distinct intramuscular innervation patterns. The 2nd digital belly received intramuscular branches from the anterior interosseus nerve (AIN). The superior half of the 3rd digital belly was innervated intramuscularly by the ulnar nerve (n = 4) or by both the anterior interosseus and ulnar nerves (n = 1). The inferior half of the belly received dual innervation from the anterior interosseus and ulnar nerves in 2 specimens, or exclusively from the AIN (n = 2) or the ulnar nerve (n = 1). The 4th digital belly was innervated by intramuscular branches of the ulnar nerve. One main branch, after coursing through the 4th digital belly, entered the lateral aspect of the 5th digital belly and arborized intramuscularly. The morphology of the FBs, aponeuroses and intramuscular innervation of the digital bellies of FDP were mapped and modelled volumetrically in 3D as in situ. Previous studies were not volumetric nor identified the course of the intramuscular nerve branches within each digital belly. Based on the intramuscular innervation of each of the digital bellies, one possible optimized botulinum toxin injection location was proposed. This injection location, at the junction of the superior and middle thirds of the forearm, would be located in dense nerve terminal zones of the anterior interosseus and ulnar nerves. Future anatomical and clinical investigations are necessary to evaluate the efficacy of these anatomical findings in the management of spasticity.

The Isolated Mouse Jejunal Afferent Nerve Assay as a Tool to Assess the Effect of Botulinum Neurotoxins in Visceral Nociception

For the past two decades, botulinum neurotoxin A (BoNT/A) has been described as a strong candidate in the treatment of pain. With the production of modified toxins and the potential new applications at the visceral level, there is a real need for tools allowing the assessment of these compounds. In this study, we evaluated the jejunal mesenteric afferent nerve assay to investigate BoNT/A effects on visceral nociception. This ex vivo model allowed the continuous recording of neuronal activity in response to various stimuli. BoNT/A was applied intraluminally during three successive distensions, and the jejunum was distended every 15 min for 3 h. Finally, samples were exposed to external capsaicin. BoNT/A intoxication was validated at the molecular level with the presence of cleaved synaptosomal-associated protein of 25 (SNAP25) in nerve terminals in the mucosa and musculosa layers 3 h after treatment. BoNT/A had a progressive inhibitory effect on multiunit discharge frequency induced by jejunal distension, with a significant decrease from 1 h after application without change in jejunal compliance. The capsaicin-induced discharge was also affected by the toxin. This assay allowed the description of an inhibitory effect of BoNT/A on afferent nerve activity in response to distension and capsaicin, suggesting BoNT/A could alleviate visceral nociception.

Review of Tone Management for the Primary Care Provider

Movement disorders in a pediatric population represent a spectrum of secondary functional deficits affecting ease of care, ambulation, and activities of daily living. Cerebral palsy represents the most common form of movement disorder seen in the pediatric population. Several medical and surgical options exist in the treatment of pediatric spasticity and dystonia, which can have profound effects on the functionality of these patients. Given the complex medical and surgical problems in these patients, children are well served by a multidisciplinary team of practitioners, including physical therapists, physical medicine and rehabilitation physicians, and surgeons.

Effectiveness of Treatment in Children With Cerebral Palsy

OBJECTIVE

 The objective of this study was to assess the effectiveness of conservative and surgical treatment in cerebral palsy children by evaluating the Medical Research Council (MRC) grading system, modified Ashworth scale, and Barthel Activities of Daily Life (ADL) scale.

METHOD

This prospective case series was performed using a non-probability consecutive sampling technique at the Department of Orthopedic Surgery and Traumatology, King Edward Medical University/Mayo Hospital, Lahore from October 2011 to November 2013. Two hundred children of all ages, having cerebral palsy diagnosed on history and clinical examination were enrolled in the study. Children were treated with conservative and surgical treatment. Pre- and post-treatment, all children were classified based on movement disorder (spastic, athetoid, ataxic, and mixed), parts of the body involved (paraplegic, tetraplegic, diplegic, hemiplegic, monoplegic, double hemiplegic, and triplegic), and gross motor function (GMFCS level I-IV). Their muscle power and tone were assessed using the MRC grading system and modified Ashworth scale, respectively. Assessment of disability and daily function was done by ranking disability grading and Barthel ADL, respectively. The range of motion (ROM) of each joint was assessed clinically. Children were divided based on the treatment method as non-surgical versus surgical treatment.

RESULTS

Out of a total of 200 children, the mean age of the children was 7.86±4.17year. There were 134 (67.0%) males and 66 (33.0%) female children. Classification on basis of movement disorder, body part involved, and gross motor function at three-month intervals till twelve months was performed. From the first presentation of children till the last follow-up time period, i.e., 12th month there was no change in the movement disorder (a type of CP, body parts involved, and GMFCS). The final rating of overall treatment results shows that there were 84 (42%) patients who had a poor outcome, and only 35 (17.50%) patients had a fair treatment outcome and 81 (40.50%) patients had good treatment outcomes.  Conclusion: The conservative and surgical management showed no effect on movement disorder of the child although, on the final rating scale fair to good treatment outcome was observed in all children. There was an improvement in muscle power grading on the ADL, but no significant improvement was seen on the improvement of type, parts of the body involved, gross motor function classification, modified Ashworth, and ranking disability grading of the children.

Early clinical predictors of post stroke spasticity

Background and Purpose: Up to 40% of stroke patients with paresis develop post-stroke spasticity (PSS), which induces difficult complications including pain, contracture, posture disorder. The most important factor for PSS management is its early initiation, so that early recognition of PSS is required in clinical practice.Methods: This prospective observational cohort study was conducted with a high standard of PSS assessment and a comprehensive protocol investigating possible predictive factors to identify early predictors of PSS already in the acute phase following stroke (<7 days). PSS was assessed with the Resistance to Passive movement Scale (REPAS) for major joint movements in upper- and lower limbs, based on Ashworth scale, within 7 days following stroke and after 3 months. Binary logistic regression analysis with significant clinical parameters was applied with 95% of confidence intervals (CI) to find predictors of PSS.Results: Of 145 consecutive first-ever stroke patients, 34 patients (23.4%) exhibited PSS. The Modified Rankin Scale (MRS), National Institutes of Health Stroke Scale (NIHSS), and Mini-Mental State Examination (MMSE) were revealed as strong clinical predictors of PSS. The combination of an MRS >2 (Odds Ratio (OR): 56.538, 95% CI: 17.150-186.394), NIHSS >2 (OR: 57.137, 95% CI:15.685-208.142) and MMSE <27 (OR: 6.133, 95% CI:2.653-14.178) showed positive predictive (95.2%) value for prediction of PSS (sensitivity 94.4%, specificity 93.3%).Conclusions: Besides evaluating PSS itself with a reliable and valid rating scale the common clinical scales in stroke units practice (NIHSS, MRS, MMSE) allow early identification of patients at high risk for PSS.

Impact of early intervention with onabotulinumtoxinA treatment in adult patients with post-stroke lower limb spasticity: results from the double-blind, placebo-controlled, phase 3 REFLEX study

The aim of this study in patients with post-stroke lower limb spasticity (PSLLS) was to evaluate the relationship between time of onabotulinumtoxinA treatment relative to stroke and efficacy outcomes. This was a phase 3, international, multicenter, randomized, 12-week, double-blind study, followed by a repeated treatment, open-label extension. Patients were aged 18–85 years with PSLLS (Modified Ashworth Scale [MAS] ≥ 3) of the ankle with the most recent stroke occurring ≥ 3 months before screening. Patients (double-blind phase) were randomized (n = 468) to onabotulinumtoxinA 300–400 U (300 U, mandatory ankle muscles (gastrocnemius, soleus, tibialis posterior); and ≤ 100 U, optional lower limb muscles (flexor digitorum longus, flexor hallucis longus, flexor digitorum brevis, extensor hallucis, and rectus femoris]) or placebo. Primary endpoint: MAS change from baseline (average score of weeks 4 and 6). Secondary endpoints: physician-assessed Clinical Global Impression of Change (CGI) average score of weeks 4 and 6 and physician-assessed Goal Attainment Scale (GAS; active and passive, weeks 8 and 12). When stratified by time since stroke (≤ 24 months, n = 153; > 24 months, n = 315, post hoc), patients treated ≤ 24 months post-stroke experienced greater improvements from baseline versus placebo in MAS (− 0.31 vs − 0.17), CGI (0.49 vs 0.12), and passive GAS scores (week 12, 0.37 vs 0.26). A ≥  − 1-point improvement in active (week 12; p = 0.04) and passive (week 8; p = 0.02) GAS scores versus placebo was achieved by more patients treated ≤ 24 months post-stroke; in patients treated > 24 months post-stroke, improvements were only observed in active scores (week 8; p = 0.04). OnabotulinumtoxinA 300–400 U was well tolerated, with no new safety findings.

Determinants of botulinum toxin discontinuation in multiple sclerosis: a retrospective study

The purpose of the present study was to investigate the long-term persistence to treatment with botulinum toxin type A (BoNT-A) for multiple sclerosis (MS)-related spasticity and the determinants of BoNT-A discontinuation in daily clinical setting. We retrospectively collected data of patients who started BoNT-A injections and underwent regular follow-up visits. Determinants of BoNT-A discontinuation were explored in a time-to-event Cox regression analysis which included as independent variables a large set of demographic and clinical characteristics. A total of 185 patients started BoNT-A injections from 2002 to 2014 and were followed up to September 2016. Of them, data on 121 were considered in our analysis. At follow-up, 53 (44%) patients were still on treatment and 68 (56%) patients discontinued BoNT-A after a median time of 1.2 years [interval 6 months to 7.4 years]. The reasons for discontinuation were loss of efficacy (n = 45), logistic problems or barriers to reach the structure (n = 16), and adverse events (n = 7). The absence of caregiver (hazard ratio = 1.69, p = 0.03) and lack of regular rehabilitation (hazard ratio = 1.78, p = 0.02) were two independent predictors for BoNT-A discontinuation. Our study confirms the beneficial effect of combining BoNT-A injections with rehabilitation and highlights the crucial role of caregivers for achieving better long-term outcomes in people with MS suffering from spasticity.

Botulinum toxin therapy for treatment of spasticity in multiple sclerosis: review and recommendations of the IAB-Interdisciplinary Working Group for Movement Disorders task force

Botulinum toxin (BT) therapy is an established treatment of spasticity due to stroke. For multiple sclerosis (MS) spasticity this is not the case. IAB-Interdisciplinary Working Group for Movement Disorders formed a task force to explore the use of BT therapy for treatment of MS spasticity. A formalised PubMed literature search produced 55 publications (3 randomised controlled trials, 3 interventional studies, 11 observational studies, 2 case studies, 35 reviews, 1 guideline) all unanimously favouring the use of BT therapy for MS spasticity. There is no reason to believe that BT should be less effective and safe in MS spasticity than it is in stroke spasticity. Recommendations include an update of the current prevalence of MS spasticity and its clinical features according to classifications used in movement disorders. Immunological data on MS patients already treated should be analysed with respect to frequencies of MS relapses and BT antibody formation. Registration authorities should expand registration of BT therapy for spasticity regardless of its aetiology. MS specialists should consider BT therapy for symptomatic treatment of spasticity.

Botulinum Toxin type A injections for patients with painful hallux valgus: a double-blind, randomized controlled study

Hallux valgus (HV) related pain and disability remains a medical challenge to date. We have evaluated the therapeutic effect of intramuscular Botulinum Toxin type A (BTX-A) injection on painful HV in a double-blind randomized controlled trial. Sixteen patients having painful HV in at least one foot from the Department of Physical Medicine and Rehabilitation at a medical center in northern Taiwan have participated. Patients were randomized into two groups to receive intramuscular injections of either BTX-A or normal saline (NS) to the oblique and transverse heads of the adductor hallucis, flexor hallucis brevis and extensor hallucis longus muscles. Primary outcome measurements were selected from the Taiwan Chinese version of the Foot Function Index subscales on pain (questions 1-6, 9) and disability (question 10-18). The secondary outcome measurement was the HV angle. Patients were assessed at baseline and at 1, 2, 3, and 6 months after treatment. The demographic data and measurements were comparable between the two groups at baseline (p>0.05). BTX-A and NS reduced pain and disability one month after injection. Pain reduction induced by BTX-A injection lasted for at least 6 months while that induced by NS lasted for only 1 month. In addition, patients in the BTX-A group showed greater improvement in pain score (p<0.001), disability score (p<0.05), and HV angle (p<0.05) than patients in the NS group. The results reflected that HV-related muscle injection of BTX-A resulted in a marked reduction in pain for up to 6 months.

Controlled nerve ablation with direct current: parameters and mechanisms

Spastic hypertonus (muscle over-activity) often develops after spinal cord injury or stroke. Chemodenervating agents such as Botulinum toxin A (BtA) and phenol are often used to treat this condition. We have previously shown that the use of direct current (DC) to create controlled lesions of peripheral nerves may provide a means of reducing spastic hypertonus. Here, we explored a range of stimulation parameters that could be used clinically. Nerves were lesioned with DC in chronically implanted animals and the outcome was tracked over many months. In addition, we used DC to ablate nerves in animals with decerebrate rigidity (an animal model of spastic hypertonus) and we explored the possible mechanisms of DC nerve ablation. We found that nerve ablation with DC was effective in reducing hypertonus. Some stimulation paradigms were more likely to be clinically acceptable than others. Furthermore we showed that nerve regeneration occurs in the months following DC nerve ablation and we demonstrated that the ablation procedure is repeatable, much like BtA treatment. Regarding mechanism, our results did not support the hypothesis that DC caused nerve damage by overactivating sodium channels. Rather, the mechanism of damage seems to be related to changes in pH.

Systematic test of neurotoxin dose and volume on muscle function in a rat model

INTRODUCTION

Onabotulinum toxin serotype A (BT-A) is used for a variety of motor and sensory disorders related to abnormal muscle activity.

METHODS

We developed a high-resolution rodent model to allow precise determination of the effect of BT-A dose (measured in units) and injectate volume (measured in μl) on the efficacy of the injection and systemic side effects. Dorsiflexion is the best indicator of injected and contralateral muscle function.

RESULTS

One month after injection, dorsiflexion torque of BT-A-injected limbs was decreased significantly in all experimental groups compared with saline controls (P < 0.05). Torque was also compared among the BT-A groups, which demonstrated a significant effect of dose (P < 0.001), but no effect of volume (P > 0.2) and no dose × volume interaction (P > 0.3). Similar results were observed for other parameters measured.

CONCLUSIONS

These data demonstrate that injection dose and not volume or concentration is the primary determinant of neurotoxin efficacy in a rodent model.

Epidemiological, humanistic, and economic burden of illness of lower limb spasticity in adults: a systematic review

BACKGROUND

The purpose of this study was to investigate the epidemiological, humanistic, and economic burden of illness associated with adult lower limb spasticity (LLS) and its complications.

METHODS

A systematic search of MEDLINE and EMBASE identified 23 studies published between January 2002 and October 2012 that assessed the epidemiology, impact, and resource use associated with LLS. A hand-search of four neurology conferences identified abstracts published between 2010 and 2012.

RESULTS

LLS was found to occur in one third of adults after stroke, half to two thirds with multiple sclerosis, and three quarters with cerebral palsy. LLS limits mobility and reduces quality of life. No clear association was found between LLS and occurrence of pain, development of contractures, or risk of falls.

CONCLUSION

The evidence on the burden of LLS and its complications is surprisingly limited given the condition's high prevalence among adults with common disorders, such as stroke. Further research is needed to clarify the impact of LLS, including the likelihood of thrombosis in spastic lower limbs. The dearth of high-quality evidence for LLS suggests a lack of awareness of, and interest in, the problem, and therefore, the unmet need among patients and their carers.

Botulinum toxin as a postoperative diplopia test - it can also reduce the angle of deviation prior to surgery

PURPOSE

To investigate how frequently botulinum toxin, when used as a postoperative diplopia test, reduces the angle of deviation prior to subsequent strabismus surgery.

METHODS

A retrospective study of 39 adult patients with constant concomitant horizontal strabismus who had undergone botulinum toxin injections to assess the risk of postoperative diplopia and then subsequently underwent strabismus surgery.

RESULTS

Fourteen out of 39 patients (36%) sustained a reduction of 15 prism diopters or more for near and/or distance when comparing the pre-injection angle of deviation with the preoperative angle of deviation.

CONCLUSION

Approximately one-third of patients receiving botulinum toxin as a postoperative diplopia test maintained a significant reduction in the angle of their deviation prior to undergoing surgery.

OnabotulinumtoxinA muscle injection patterns in adult spasticity: a systematic literature review

Background

OnabotulinumtoxinA has demonstrated significant benefit in adult focal spasticity. This study reviews the injection patterns (i.e., muscle distribution, dosing) of onabotulinumtoxinA for treatment of adult spasticity, as reported in published studies.

Methods

A systematic review of clinical trials and observational studies published between 1990 and 2011 reporting data on muscles injected with onabotulinumtoxinA in adult patients treated for any cause of spasticity.

Results

28 randomized, 5 nonrandomized, and 37 single-arm studies evaluating 2,163 adult patients were included. The most frequently injected upper-limb muscles were flexor carpi radialis (64.0% of patients), flexor carpi ulnaris (59.1%), flexor digitorum superficialis (57.2%), flexor digitorum profundus (52.5%), and biceps brachii (38.8%). The most frequently injected lower-limb muscles were the gastrocnemius (66.1% of patients), soleus (54.7%), and tibialis posterior (50.5%). The overall dose range reported was 5–200 U for upper-limb muscles and 10–400 U for lower-limb muscles.

Conclusions

The reviewed evidence indicates that the muscles most frequently injected with onabotulinumtoxinA in adults with spasticity were the wrist, elbow, and finger flexors and the ankle plantar flexors. OnabotulinumtoxinA was injected over a broad range of doses per muscle among the studies included in this review, but individual practitioners should be mindful of local regulatory approvals and regulations.

Long-term follow-up after botulinum toxin A (BTX-A) injection into the detrusor for treatment of neurogenic detrusor hyperactivity in children

Purpose

To prove the long-term efficacy of BTX-A injection in the management of children with neurogenic detrusor hyperactivity.

Materials and methods

28 out of 145 children with neurogenic bladder (15 male and 13 female, mean age 10.7 years) who were treated between 2002 and 2010 and became non-responders to conservative treatment were included into the retrospective study.

We injected 10-12 U/kg of BTX-A (Botox^®) into the detrusor at 20-30 sites, sparing the trigone. The mean follow-up was 48 months (range 6-84 months).

Results

Group 1. 14 patients had a single injection of BTX-A. Five of them were successful.

Mean bladder reflex volume increased (from 62.9 to 117.5 ml), maximum detrusor pressure decreased (from 59 to 37.5 cm H₂O), detrusor compliance increased (from 4.8 to 9.5 ml/cm H₂O), and leak-point-pressure decreased (from 46.5 to 24.2 cm H₂O). Four patients did not respond and were treated by ileocystoplasty. Another five were lost to follow-up. Group 2. 14 patients had repeated (mean 2.5) injections of BTX-A with a mean interval of 13.7 months. In thirteen patients, urodynamic parameters of the first and last injection were similar to those obtained in Group 1, showing a good response. One patient received an ileocystoplasty.

Conclusion

BTX-A is a safe alternative in the treatment of detrusor hyperactivity in children with myelomeningocele (MMC). The efficacy lasted a mean of 12 months and urodynamic response was unchanged even after several injections. In our series, 21.7% of children with severe low-compliance bladders were non-responders.

Successful treatment of long-term, poststroke, upper-limb spasticity with onabotulinumtoxinA

BACKGROUND AND PURPOSE

Poststroke spasticity often negatively affects functional activities and daily living and frequently is accompanied by pain, abnormal limb postures, and contractures. The purpose of this case report is to describe the long-term benefit of botulinum toxin A in a patient with poststroke spasticity.

CASE DESCRIPTION

A 35-year-old woman with poststroke upper-limb spasticity who had lost function in her left hand was treated with onabotulinumtoxinA and physical therapy. Over 25 months, the patient received a physical therapy and occupational therapy program and received onabotulinumtoxinA injections into muscles of the left hand and arm, significantly reducing tone and facilitating recovery of function. Practical assessments, the Ashworth Scale, and electrophysiology were used to measure changes over time. No functional scales or dexterity scales were used to measure changes.

OUTCOMES

OnabotulinumtoxinA injections were discontinued when treatment goals were attained, and no further improvements were achieved. After more than 2½ years without further onabotulinumtoxinA treatments, the patient maintained range of motion and some functional use and dexterity in her left hand.

DISCUSSION

This case report illustrates the efficacy and long-term benefit of onabotulinumtoxinA, combined with physical therapy and occupational therapy, in the successful treatment of poststroke spasticity.

Obturator nerve block with botulinum toxin type B for patient with adductor thigh muscle spasm -a case report-

Obturator nerve block has been commonly used for pain management to prevent involuntary reflex of the adductor thigh muscles. One of several options for this block is chemical neurolysis. Neurolysis is done with chemical agents. Chemical agents used in the neurolysis of the obturator nerve have been alcohol, phenol, and botulinum toxin. In the current case, a patient with spasticity of the adductor thigh muscle due to cervical cord injury had obturator nerve neurolysis done with botulinum toxin type B (BoNT-B). Most of the previous studies have used BoNT-A with only a few reports that have used BoNT-B. BoNT-B has several advantages and disadvantages over BoNT-A. Thus, we report herein a patient who successfully received obturator nerve neurolysis using BoNT-B to treat adductor thigh muscle spasm.

Botulinum toxin decreases hyperalgesia and inhibits P2X3 receptor over-expression in sensory neurons induced by ventral root transection in rats

OBJECTIVES

We aim to determine the effects of Botulinum toxin type A (BTX-A) on neuropathic pain behavior and the expression of P2X(3) receptor in dorsal root ganglion (DRG) in rats with neuropathic pain induced by L5 ventral root transection (L5 VRT).

METHODS

Neuropathic pain was induced by L5 VRT in male Sprague-Dawley rats. Either saline or BTX-A was administered to the plantar surface. Behavioral tests were conducted preoperatively and at predefined postoperative days. The expression of P2X(3) receptors in DRG neurons was detected by immunoreactivity at postoperative days 3, 7, 14, and 21.

RESULTS

The number of positive P2X(3) neurons in the ipsilateral L5 DRG increased significantly after L5 VRT (P<0.001). This increase persisted for at least 3 weeks after the operation. No significant changes in P2X(3) expression were detected in the contralateral L5, or in the L4 DRGs bilaterally. Subcutaneous administration of BTX-A, performed on the left hindpaw at days 4, 8, or 16 post VRT surgery, significantly reduced mechanical allodynia bilaterally and inhibited P2X(3) over-expression induced by L5 VRT.

CONCLUSIONS

L5 VRT led to over-expression of P2X(3) receptors in the L5 DRG and bilateral mechanical allodynia in rats. Subcutaneous injection of BTX-A significantly reversed the neuropathic pain behavior and the over-expression of P2X(3) receptor in nociceptive neurons. These data not only show over-expression of purinergic receptors in the VRT model of neuropathic pain but also reveal a novel mechanism of botulinum toxin action on nociceptive neurons.

Subcutaneous injection of botulinum toxin a is beneficial in postherpetic neuralgia

OBJECTIVE

To assess the benefits of subcutaneous injection of botulinum toxin A (BTX-A) for the treatment of postherpetic neuralgia (PHN).

DESIGN

We investigated the therapeutic benefits of BTX-A in subjects with PHN in a randomized, double-blind, placebo-controlled study. Sixty subjects with PHN were randomly and evenly distributed into BTX-A, lidocaine, and placebo groups.

MEASURES

After randomization, one of the following solutions was injected subcutaneously in the affected dermatome: 5u/mL BTX-A, 0.5% lidocaine, or 0.9% saline (placebo). Visual analog scale (VAS) pain and sleeping time (hours) were evaluated at the time of pretreatment, day 1, day 7, and 3 months posttreatment. Opioid usage was calculated at day 7 and 3 months posttreatment.

RESULTS

  Compared with pretreatment, VAS pain scores decreased at day 7 and 3 months posttreatment in all three groups (P<0.01). However, the VAS pain scores of the BTX-A group decreased more significantly compared with lidocaine and placebo groups at day 7 and 3 months posttreatment (P<0.01). Sleep time (hours) had improved at day 7 and at 3 months compared with pretreatment in all three groups, but the BTX-A group improved more significantly compared with lidocaine and placebo groups (P<0.01). The percent of subjects using opioids posttreatment in the BTX-A group was the lowest (21.1%) compared with the lidocaine (52.6%) and placebo (66.7%) groups (P<0.01).

CONCLUSIONS

Subcutaneous administration of BTX-A significantly decreased pain in PHN and reduced opioid use compared with lidocaine and placebo at day 7 and 3 months post-treatment. It also increased subjects' sleep times.

Nerve lesioning with direct current

Spastic hypertonus (muscle over-activity due to exaggerated stretch reflexes) often develops in people with stroke, cerebral palsy, multiple sclerosis and spinal cord injury. Lesioning of nerves, e.g. with phenol or botulinum toxin is widely performed to reduce spastic hypertonus. We have explored the use of direct electrical current (DC) to lesion peripheral nerves. In a series of animal experiments, DC reduced muscle force by controlled amounts and the reduction could last several months. We conclude that in some cases controlled DC lesioning may provide an effective alternative to the less controllable molecular treatments available today.

Nerve lesioning with direct current

Spastic hypertonus (muscle over-activity due to exaggerated stretch reflexes) often develops in stroke and spinal cord injury (SCI) survivors and individuals who suffer from multiple sclerosis. In previous published experiments we have shown that Direct Current (DC), when used to lesion nerves, can attenuate muscle force in a gradual manner, and this attenuation can last for several months. In this paper we present initial experimental results that profile the current required to cause controlled nerve ablation.

The use of botulinum toxin A in children with cerebral palsy, with a focus on the lower limb

PURPOSE

The purpose of this review is to clarify the role of botulinum toxin serotype A (BTX-A) in the treatment of children with cerebral palsy (CP), with a special focus on the lower limb.

BACKGROUND

The treatment of spasticity is central in the clinical management of children with CP. BTX-A blocks the release of acetylcholine at the motor end plate, causing a temporary muscular denervation and, in an indirect way, a reduced spasticity. Children with increased tone develop secondary problems over time, such as muscle contractures and bony deformities, which impair their function and which need orthopaedic surgery. However in these younger children, delaying surgery is crucial because the results of early surgical interventions are less predictable and have a higher risk of failure and relapse. As BTX-A treatment reduces tone in a selective way, it allows a better motor control and muscle balance across joints, resulting in an improved range of motion and potential to strengthen antagonist muscles, when started at a young age. The effects are even more obvious when the correct BTX-A application is combined with other conservative therapies, such as physiotherapy, orthotic management and casts. There is now clear evidence that the consequences of persistent increased muscle tone can be limited by applying an integrated multi-level BTX-A treatment approach. Nevertheless, important challenges such as patient selection, defining appropriate individual goals, timing, dosing and dilution, accuracy of injection technique and how to measure outcomes will be questioned. Therefore, "reflection is more important than injection" remains an actual statement.

Parent-proxy ratings of pain before and after botulinum toxin type A treatment for children with spasticity and cerebral palsy

OBJECTIVE

To test the hypothesis that pain would be reduced after botulinum toxin type A (Btx/A) treatment for children with cerebral palsy (CP).

METHOD

Thirty-four pediatric patients with CP (mean age 9 y; 56% male) and their parents were recruited through a regional specialty healthcare center medical clinic and pain research program. A 1-group pretest, posttest treatment design was used on the basis of a standardized parent-proxy report of their child's pain.

RESULTS

Overall parent ratings of their child's pain were significantly reduced after Btx/A injection with 62% of parents reporting the absence of pain 1 month after injection (proportion=0.38; 95% confidence interval=0.23-0.55). There were no significant differences for males or females.

CONCLUSIONS

Although there is considerable evidence that Btx/A is efficacious for the treatment of spasticity associated with CP, there is little direct evidence specific to associated analgesic effects after Btx/A treatment. These preliminary findings indicate that Btx/A treatment for spasticity resulted in significant pain reduction for this patient sample. This was the first study to directly ask parents about their child's pain pre-Btx/A and post-Btx/A treatment. These findings have implications for the management of pain associated with spasticity and CP and suggest further research is warranted.

Primary care of the child with cerebral palsy: a review of systems (part II)

Cerebral palsy (CP) is a disorder of movement and posture with additional potential to affect cognitive status. Thus, the goals for management of the child with CP include the following: to promote optimal function; to maintain general health; to foster acquisition of new skills; to assist and educate parents and caregivers; and to anticipate, prevent, and treat the complications of this disorder. Pediatric management of the child with CP should begin at the time of diagnosis. This article is the second of two articles on CP. The first article focused on the diagnosis of CP, and this article will focus on a review of systems approach for management as well as resources for the family and the nurse practitioner.

Botulinum toxin in poststroke spasticity

Poststroke hemiparesis, together with abnormal muscle tone, is a major cause of morbidity and disability. Although most hemiparetic patients are able to reach different ambulatory levels with rehabilitation efforts, upper and lower limb spasticity can impede activities of daily living, personal hygiene, ambulation and, in some cases, functional improvement. The goals of spasticity management include increasing mobility and range of motion, attaining better hygiene, improving splint wear and other functional activities. Conservative measures, such as positioning, stretching and exercise are essential in spasticity management, but alone often are inadequate to effectively control it. Oral antispastic medications often provide limited effects with short duration and frequent unwanted systemic side effects, such as weakness, sedation and dry mouth. Therefore, neuromuscular blockade by local injections have become the first choice for the treatment of focal spasticity, particularly in stroke patients. Botulinum toxin (BTX), being one of the most potent biological toxins, acts by blocking neuromuscular transmission via inhibiting acetylcholine release. Currently, focal spasticity is being treated successfully with BTX via injecting in the spastic muscles. Two antigenically distinct serotypes of BTX are available on the market as type A and B. Clinical studies of BTX used for spastic hemiplegic patients are reviewed in this article in two major categories, upper and lower limb applications. This review addresses efficacy in terms of outcome measures, such as muscle tone reduction and functional outcome, as well as safety issues. Application modifications of dose, dilutions, site of injections and combination therapies with BTX injections are also discussed.

Botulinum Toxin in Closed Treatment of Mandibular Condylar Fracture

BACKGROUND

The topic of condylar injury in adults has generated more discussion and controversy than any other in the field of maxillofacial trauma. The treatment of condylar fractures in adults is still a highly debated theme.

METHODS

Patients with unilateral subcondylar or condylar neck fractures of the mandibula without any significant angulation of the condylar head were managed with closed-treatment protocol. Closed treatment was applied through the injection of 100 units of botulinum toxin A, diluted to a concentration of 20 IU/mL, into the muscles of mastication of the fractured side. Masseter and anterior fibers of temporalis muscles were reached through percutaneous extraoral route and 30 IU of the toxin was injected to each muscle. Additional 40 IU of the toxin was injected around the fractured bone fragments through transmucosal intraoral route to paralyze medial and lateral pterygoid muscles as much as possible. An asymmetric occlusal splint was applied for maxillomandibular fixation to restore the vertical height for 10 days. Functional therapy with intermaxillary guiding elastics was advocated for 2 months.

RESULTS

There were no complications related to either toxin injections or splint application procedures. The toxin was effective on all occasions. Fractured condylar process and ramus of the mandibula were in good approximation and remained in reduced positions. None of the patients had any occlusal disturbance, mandibular asymmetry, or joint dysfunction in the follow-up period.

CONCLUSIONS

We believe that modification of treatment options concerning the clinical situation of the patients is the best method for condylar injury. The purpose of this study is to present and discuss the results achieved in closed treatment of a selected group of patients with mandibular condylar fractures to whom botulinum toxin A was injected to relieve the spasm of muscles of mastication, along with special splint application.

Multiple Sclerosis as A Painful Disease

Pain is a common problem of patients with multiple sclerosis (MS) and may be due to central/neuropathic or peripheral/somatic pathology. Rarely MS may present with pain, or pain may herald an MS exacerbation, such as in painful tonic spasms or Lhermitte's sign. In other patients, pain may become chronic as a long-term sequela of damage to nerve root entry zones (trigeminal neuralgia) or structures in central sensory pathways. Migraine headache may develop as a consequence of MS, and headache can also be a side effect of interferon treatment. The pathophysiology of pain in MS may be linked to certain plaque locations which disrupt the spinothalamic and quintothalamic pathways, abnormal impulses through motor axons, development of an acquired channelopathy in affected nerves, or involve glial cell inflammatory immune mechanisms. At this time, the treatment of pain in MS employs the use of antiepileptic drugs, muscle relaxers/antispasmodic agents, anti-inflammatory drugs, and nonpharmacological measures. Research concerning cannabis-based treatments shows promising results, and substances which block microglial or astrocytic involvement in pain processing are also under investigation.

Results of Botilinum Toxin

Schwartz-Jampel syndrome (SJS) is a rare congenital disorder of continuous myotonia, causing visual and eyelid problems such as blepharospasm, acquired ptosis, and blepharophimosis. We report the management of blepharospasm in two sisters with Schwartz-Jampel syndrome with application of botulinum toxin type A (BTX-A), as an alternative to the surgical treatments, such as orbicularis oculi myectomy, levator aponeurosis resection, and lateral canthopexy as described in the literature. Three consequent doses of commercially available BTX-A (Botox-Allergan, Inc. 100 u/via) were injected to orbicularis oculi muscle in two sisters with Schwartz-Jampel syndrome. At the least, the authors waited for a six-month interval to prevent development of sensitivity to BTX-A in patients. No significant improvement was observed after the injection of first dose of BTX-A, with the total dose of 25 units of BTX-A to each orbicularis oculi muscle of the eyes. The muscle tone weakened after the second dose, which was the twice as such of the first applied total dose (50 units of BTX-A to each orbicularis oculi muscle of the eyes) and significant functional and cosmetic improvements were achieved after injection of the third dose, in which the total applied dose was the same as the one applied in second dose. The blepharospasm and eyelid alterations caused by Schwartz-Jampel syndrome should be treated to provide functional and cosmetic improvements. Application of BTX-A to orbicularis oculi muscle for the treatment of blepharospasm could be considered as an alternative to levator resection, and lateral canthopexy in Schwartz-Jampel syndrome.

Botulinum toxin in multiple sclerosis

Local administration of botulinum toxin (BoTx) inhibits presynaptic acetylcholine release. All cholinergically innervated muscles and glands can be paralyzed accordingly. Studies on the application of BoTx in multiple sclerosis have shown good results for focal spasticity, in particular, of the extremities. The first promising data were published on bladder disorders, especially with regard to detrusor sphincter dyssynergia and detrusor hyperreflexia. Hyperhidrosis, hypersalivation and proctologic symptoms might be other areas of application. Approval, however, has been greatly restricted which limits the therapeutic range of use.

Pharmacotherapy of spasticity in children with cerebral palsy

Spasticity is one of the most common symptoms presented by neurologic patients. Apart from surgical management, drug therapy is an important treatment of children suffering from spasticity. In this review, recent advances in the pharmacologic armamentarium are reported in detail. In particular, there are oral medications (benzodiazepines, baclofen, dantrolene sodium, alpha 2 adrenergic agonists) and parenteral medications (botulinum toxin type A and B, alcohol). Moreover, there is also baclofen that can be administered intrathecally. There are some reports supporting the use of intramuscular alcohol (45% and/or 5-7% phenol) to reduce spasticity without the loss of voluntary movement or loss of sensation. Among these drugs, intrathecal baclofen is one of the most effective substances that can reduce spasticity significantly in the upper and lower extremities. Finally, the effectiveness of therapy with botulinum toxin type A in the management of spasticity is analyzed. Botulinum toxin type A reduces hypertonia in the injected muscles for a period of 2 to 4 months without important side effects. The purpose of this article is to provide an overview of available oral and parenteral drugs for treatment of spasticity in cerebral palsy and to outline indications and contraindications.

Botulinum toxin-A injections for spastic toe clawing

Spastic toe clawing describes extension at the metatarsophalangeal joints of the feet, flexion at the proximal interphalangeal joints and flexion at the distal interphalangeal joints that results from upper motor neuron lesions, such as stroke, intracranial hemorrhage, cervical myelopathy and brain tumors. Even though toe clawing is often asymptomatic, it can be painful. Previous studies have described the efficacy of injections of botulinum toxin type-A (BTX-A) to the long flexors of the toes, but this is often unsatisfactory as high dosages (up to 175 units) have been required, and patients often report significant residual toe clawing. We performed an open label, prospective study to assess the efficacy of BTX-A injections, targeting the long and short flexors of the toes, performed with electrical (motor point) stimulation under electromyographic guidance. Outcome measures, which included timed walking over 20m, objective assessment of toe clawing (modified Ashworth scale and a visual analog scale rating) and patient assessment of functional disability, were assessed before injections and at six-weeks' follow-up. Seven patients (five male and two female) of mean age 51 (range 38-70) were recruited. Four had spasticity from underlying intracranial hemorrhage, the remaining three from cerebral infarct, astrocytoma and post-traumatic cervical myelopathy. The total dose of BTX-A injected for toe clawing ranged from 40 to 90 units. Improvements were observed in all outcome measures except timed walking. Injecting BTX-A to the long and short flexors of the toes, with electrical stimulation under electromyographic guidance, is well tolerated and efficacious in the treatment of toe clawing from spasticity, allowing for lower dosages to be used.

Botulinum toxin type A injections: Adverse events reported to the US Food and Drug Administration in therapeutic and cosmetic cases

BACKGROUND

Botulinum toxin type A (BTA) (Botox) received Food and Drug Administration (FDA) approval for therapeutic treatment of strabismus and blepharospasm in 1989, cervical dystonia in 2000, and cosmetic treatment of glabellar wrinkles (Botox Cosmetic) in 2002. In 2002 alone there were approximately 1.1 to 1.6 million patients using cosmetic BTA. Our objective was to review adverse event (AE) reporting to the FDA after BTA administration.

METHODS

We reviewed all (therapeutic and cosmetic use) serious (per FDA regulations) AEs reported to the FDA for the 13.5 years since licensure of the product (December 1989-May 2003) and nonserious AEs reported from December 2001 to November 2002. AEs are reported to the FDA through the MedWatch system.

RESULTS

We reviewed 1437 AE reports; 406 followed therapeutic use of BTA (217 serious and 189 nonserious) and 1031 followed cosmetic use (36 serious and 995 nonserious). Reported AEs occurred predominantly in female patients, with a median age of 50 years. In the year December 2001 to November 2002, when both serious and nonserious reports were evaluated, the proportion of reports classified as serious was 33-fold higher for therapeutic than for cosmetic cases. The 217 serious AEs reported in therapeutic cases involved a wide spectrum of events and included all 28 reported deaths. Among cosmetic users, no deaths were reported and, of the 36 serious AEs, 30 were included as possible complications in the FDA-approved label. The remaining 6 serious AEs did not display a pattern suggesting a common causal relationship to BTA. Among the 995 cosmetic cases reported to have nonserious AEs, most commonly noted were lack of effect (623, 63%), injection site reaction (190, 19%), and ptosis (111, 11%).

CONCLUSIONS

Serious AEs were more likely to be reported for therapeutic than for cosmetic use, which may be related to higher doses, complicated underlying diseases, or both. Among cosmetic cases, few serious AEs were reported, and these were predominantly events that were previously recognized in clinical trials of BTA for the labeled use. This study is limited primarily by the incomplete nature of AE reporting by clinicians. Numerous departures from FDA-approved recommendations for drug dose, dilution, handling, site of injection, and storage were noted in these AE reports.

Efficacy of botulinum-A toxin in the treatment of detrusor overactivity incontinence: a prospective nonrandomized study

OBJECTIVE

This study was undertaken to investigate the efficacy and safety of botulinum-A toxin (BTX-A) treatment for non-neurogenic detrusor overactivity incontinence.

STUDY DESIGN

This prospective nonrandomized ongoing study was performed in a tertiary referral urogynecology department. In 26 women with urge incontinence and urodynamically demonstrated detrusor overactivity incontinence resistant to conventional treatment 100 units of BTX-A were injected into the detrusor muscle at 30 sites. Clinical and urodynamic evaluations and a quality of life assessment were performed at baseline and 4, 12, and 36 weeks after BTX-A treatment.

RESULTS

Of 26 women, 14 were dry after 4 weeks, 13 of 20 women after 12 weeks, and 3 of 5 women after 36 weeks. Two women failed to respond. Two women were on self-catheterization temporarily. There were no other complications besides 9 urinary tract infections within the 51 follow-up visits.

CONCLUSION

BTX-A treatment seems to be a safe and efficacious new treatment option for patients with detrusor overactivity incontinence.

Conformational sampling of the botulinum neurotoxin serotype a light chain: implications for inhibitor binding

Botulinum neurotoxins (BoNTs) are the most potent of the known biological toxins, and consequently are listed as category A biowarfare agents. Currently, the only treatments against BoNTs include preventative antitoxins and long-term supportive care. Consequently, there is an urgent need for therapeutics to counter these enzymes--post exposure. In a previous study, we identified a number of small, nonpeptidic lead inhibitors of BoNT serotype A light chain (BoNT/A LC) metalloprotease activity, and we identified a common pharmacophore for these molecules. In this study, we have focused on how the dynamic movement of amino acid residues in and surrounding the substrate binding cleft of the BoNT/A LC might affect inhibitor binding modes. The X-ray crystal structures of two BoNT/A LCs (PDB refcodes=3BTA and 1E1H) were examined. Results from these analyses indicate that the core structural features of the examined BoNT/A LCs, including alpha-helices and beta-sheets, remained relatively unchanged during 1 ns dynamics trajectories. However, conformational flexibility was observed in surface loops bordering the substrate binding clefts in both examined structures. Our analyses indicate that these loops may possess the ability to decrease the solvent accessibility of the substrate binding cleft, while at the same time creating new residue contacts for the inhibitors. Loop movements and conformational/positional analyses of residues within the substrate binding cleft are discussed with respect to BoNT/A LC inhibitor binding and our common pharmacophore for inhibition. The results from these studies may aid in the future identification/development of more potent small molecule inhibitors that take advantage of new binding contacts in the BoNT/A LC.

Botulinum toxin in children with cerebral palsy

Botulinum toxin is a neurotoxin that blocks the synaptic release of acetylcholine from cholinergic nerve terminals mainly at the neuromuscular junction, resulting in irreversible loss of motor end plates. It is being widely tried as a targeted antispasticity treatment in children with cerebral palsy. A number of studies have shown that it reduces spasticity and increases the range of motion and is particularly useful in cases with dynamic contractures. However improvement in function has not been convincingly demonstrated. It is an expensive mode of therapy and the injections need to be repeated after 3-6 months. Whereas Botulinum toxin can be a valuable adjunct in select cases, it should not be projected as a panacea for children with spastic cerebral palsy.

Cerebral palsy

Cerebral palsy, a range of non-progressive syndromes of posture and motor impairment, is a common cause of disability in childhood. The disorder results from various insults to different areas within the developing nervous system, which partly explains the variability of clinical findings. Management options include physiotherapy, occupational and speech therapy, orthotics, device-assisted modalities, pharmacological intervention, and orthopaedic and neurosurgical procedures. Since 1980, modification of spasticity by means of orally administered drugs, intramuscular chemodenervation agents (alcohol, phenol, botulinum toxin A), intrathecally administered drugs (baclofen), and surgery (neurectomy, rhizotomy) has become more frequent. Family-directed use of holistic approaches for their children with cerebral palsy includes the widespread adoption of complementary and alternative therapies; however, the prevalence of their use and the cost of these options are unknown. Traditional medical techniques (physiotherapy, bracing, and orthopaedic musculoskeletal surgery) remain the mainstay of treatment strategies at this time. This seminar addresses only the musculoskeletal issues associated with cerebral palsy and only indirectly discusses the cognitive, medical, and social issues associated with this diagnosis.

[Botulism toxin in practice]

Botulinum toxins (A and B) are neurotoxins derived from Clostridium botulinum. Clostridium are anaerobic bacteria. C. botulinum produces exotoxins (A to G) with distinct antigenicities. The neurotoxins inhibit the release of the neurotransmitter acetylcholine from the axon terminals of motor neurons. Botulinum toxin is officially used in clinic for the treatment of muscular hyperactivity (strabismus, blepharospam, cervical dystonia). Botulinum toxins are also used in non recognized clinical applications: neurogenic incontinence, palmar and axillary hyperhidrosis, chronic anal fissure. The respective formulations of Botox, Dysport and Neurobloc are described. Special considerations for administration are introduced.

Prevention and management of shoulder pain in the hemiplegic patient

OBJECTIVE

The objective of this review was to summarise the best available research related to the prevention and management of shoulder pain in the hemiplegic patient.

INCLUSION CRITERIA

This review considered all studies that included hemiplegic patients post-cerebral vascular accident (CVA). Interventions of interest were any treatments or programs used to manage or prevent shoulder pain secondary to hemiplegia. The primary outcomes of interest were those related to pain. This review considered any randomised controlled trials (RCT) that evaluated the effectiveness of interventions that addressed shoulder pain in hemiplegic patients. In the absence of RCT, other research designs such as non-randomised controlled trials, time series and case series were also considered for inclusion in a narrative summary.

SEARCH STRATEGY

The search sought to find both published and unpublished studies. Databases were searched up to February 2002 and included Medline, CINAHL, Current Contents, Cochrane Library, Expanded Academic Index, Electronic Collections Online, Turning Research Into Practice (TRIP), Dissertation Abstracts and Proceedings First. The reference lists of all studies identified were searched for additional studies.

ASSESSMENT OF METHODOLOGICAL QUALITY

All studies were checked for methodological quality by two reviewers and data was extracted using a data extraction tool.

RESULTS

Current research evaluating the effectiveness of treatment interventions on hemiplegic shoulder pain is very limited. The studies were very diverse in their nature of research. There has been no replication of studies, with the studies found using different populations, interventions or outcome measures. Not one study could be compared with another. Meta-analysis was unable to be performed not only because of inadequate reporting of results, but more often due to differences between the studies' participants and the range of interventions used. The diversity in interval post-CVA also makes it difficult to make any comparisons between studies. For this reason the review is in narrative form.

CONCLUSIONS

With this limited evidence, no single intervention has been identified that offers a dramatic effect in terms of treating pain in the hemiplegic shoulder. There is potential for some benefits for the patient's functional and comfort status, thereby improving their quality of life and maximising their social participation.Preventive interventions demonstrated that a shoulder positioning policy had no statistically significant effect on pain. Strapping within 48 h significantly delayed the onset of pain and current research evaluating exercise is not limited to just one area of exercise, but a diverse range, making it difficult to make any comparisons. Some studies did suggest evidence of improvement, albeit limited. However, some of the exercise techniques aggravated shoulder pain. Treatment interventions demonstrated that electromyogram biofeedback cannot be evaluated as a stand-alone therapy as it is used in conjunction with relaxation therapy. Intra-articular Triamcinolone Acetonide injections in a small RCT have not been proven to be beneficial, and are associated with a high incidence of side-effects. Different exercise techniques may aggravate shoulder pain more than others (e.g. Bobath technique compared to cryotherapy). The systematic review on the effectiveness of functional electrical stimulation was used for prevention and treatment and concluded that there is currently no evidence for effect.