BoNT-A Injection Research Articles

Adverse events after chemodenervation with onabotulinum neurotoxin A in children with hypertonia and sialorrhea.

To identify the incidence and type of adverse events reported after chemodenervation with onabotulinum neurotoxin A (BoNT-A) in children with hypertonia and sialorrhea and compare adverse events in the on-label or off-label use of BoNT-A with regard to dose, patient's age, and location of the injection. Using a retrospective chart review, we studied BoNT-A injections occurring from January 2017 to December 2020 in patients at a pediatric hospital. The electronic health record was examined to identify adverse events reported within 2 months of the injection. Data included the patient's age, sex, race, and ethnicity, as well as the type of toxin injected, the dose, the location of injection, and the patient's weight. We analyzed 1733 procedures. Adverse events were infrequent (2.5%) and not serious, most commonly reported as pain or discomfort. All adverse events were temporary and there were no deaths. We did not observe a meaningful difference in the frequency of adverse events for injections that exceeded the 2022 US Food and Drug Administration (FDA)-approved maximum dose compared to injections that were within the FDA-approved dose range. The likelihood of adverse events did not increase with higher doses of BoNT-A. More adverse events were reported for injection into the salivary glands (4.37%) than into the extremities (2.26%). Higher doses of injected BoNT-A in a pediatric population may be safe. Further work is needed to investigate the relationship between dose and efficacy.

Review of simultaneous treatment with intradetrusor onabotulinumtoxinA injections during transurethral prostate surgery for men with bladder outlet obstruction and overactive bladder

ABSTRACT Bladder outlet obstruction (BOO) is common in males with benign prostate enlargement (BPE) and often presents with different lower urinary tract symptoms. Overactive bladder (OAB) has been reported to be related to BOO, although it can also be idiopathic. The storage symptoms of BOO are often similar to those of OAB. The etiology and pathophysiology of both BPE and OAB are multifactorial with metabolic syndrome known as one of the factors. As of today, transurethral prostate surgery remains the gold standard for treating BOO associated with BPE. Intradetrusor onabotulinumtoxinA (BoNT-A) injections have been shown to be effective in treating OAB. However, they are usually administered after transurethral prostate surgery. In view of the strong therapeutic effects of both surgery and injections, the feasibility of combining them in one setting to increase patient comfort, convenience, and possibly results while decreasing costs is appealing to physicians. However, patient safety and possible complications have to be considered. In this article, we review available studies of concurrent intradetrusor BoNT-A injections during transurethral prostate surgery. Although there is no definitive evidence supporting the concurrent use of intradetrusor BoNT-A during transurethral prostate surgery, there are no reports of increased complications too. Further large-scale randomized controlled trials would be necessary to validate the feasibility of combining the treatments in one setting and observe for possible complications.

Ultrasonographic assessment of the lateral pterygoid muscle for BoNT-A injection.

The upper head of the lateral pterygoid muscle (LPM) is known to insert into the capsule of the temporomandibular joint and articular disc, and therefore its relationship with temporomandibular disorders (TMD) has been consistently suggested. The aim of the study was to determine the anatomical features of the LPM using ultrasonographic (US) imaging. Around 120 hemifaces from 60 healthy Korean volunteers were included in this study. US images were taken with the subject's mouth 2 cm open. The transducer was placed at a position where the infratemporal fossa could be observed through the mandibular notch, and its position was recorded. The locations of the coronoid process (CorP), lateral margin of the condylar process (ConP), and midpoint of CorP and ConP (MP) were measured with reference to the ala-tragus line. The thicknesses of the skin and subcutaneous tissue, the masseter muscle, the temporalis muscle, and the depth of the LPM were measured at the MP. The masseter muscle, temporalis muscle, and LPM were observed in all cases and located in order from superficial to deep. The MP was located 39.6 ± 3.3 mm anterior and 7.8 ± 1.6 mm inferior to the tragus. The thicknesses of the skin and subcutaneous tissue, the masseter muscle, the temporalis muscle, and the depth of the LPM at the MP were 9.7 ± 1.0, 10.3 ± 1.3, 10.9 ± 1.6, and 30.9 ± 1.9 mm, respectively. The information reported in this study may be useful for determining the location of the LPM and adjacent anatomical structures in TMD patients and provide accurate and safe injection guidelines.

Long-Term Management of Post-Stroke Spasticity with Botulinum Toxin: A Retrospective Study.

Stroke-induced spasticity is a prevalent condition affecting stroke survivors, significantly impacting their quality of life. Botulinum Toxin A injections are widely used for its management, yet the long-term effects and optimal management strategies remain uncertain. This retrospective study analyzed medical records of 95 chronic stroke patients undergoing long-term BoNT-A treatment for spasticity. Demographic data, treatment duration, dosage variability, and dropout rates were assessed over a period ranging from 2 to 14 years. The study revealed a notable extension of the interval between BoNT-A injections throughout the treatment duration. Dropout rates peaked during the initial 5 years of treatment, perhaps due to perceived treatment ineffectiveness. Additionally, a trend of escalating dosage was observed across all groups, indicating a potential rise in the severity of spasticity or changes in treatment response over time. BoNT-A injections emerged as the predominant treatment choice for managing post-stroke spasticity. The delayed initiation of BoNT-A treatment underscores the need for heightened awareness among healthcare providers to recognize and manage spasticity promptly post-stroke. Patients' expectations and treatment goals should be clearly defined to optimize treatment adherence, while the observed escalation in dosage and treatment intervals emphasizes the dynamic nature of spasticity and underscores the importance of monitoring long-term treatment outcomes.

Comparison between botulinum toxin type A injection on masseter muscle only and additional injection on anterior belly of digastric muscle in sleep bruxism patients: A clinical trial.

This study aims to evaluate the effects on bite force and muscle thickness of the botulinum toxin (BoNT) injection for patients with sleep bruxism (SB) by comparing injections into the masseter muscle only and both the masseter and the anterior belly of the digastric muscle (ABDM) in a clinical trial. Twelve SB patients received BoNT-A injections using US-guided techniques into the masseter muscle only (Group A), while the remaining 12 SB patients received injections into both the masseter and ABDM (Group B). Bite force and muscle thickness were measured before injection, as well as 1 and 2 months after injection. The bite force and masseter muscle thickness decreased in both Group A and Group B before injection, and at 1 and 2 months after injection. However, there was no significant difference (p > .05, repeated measures analysis of variance) between the two groups, and there was also no significant difference in ABDM thickness (p > .05, repeated measures analysis of variance). This study is the first to assess the short-term effects of BoNT injected into ABDM for SB control. Results show no influence on SB reduction, suggesting the need for further research on BoNT's effectiveness in controlling intense ABDM contractions during sleep and assessing suprahyoid muscle potential impact on rhythmic masticatory muscle activity occurrence.

Anatomical considerations of medial eye wrinkles: Guidelines for botulinum neurotoxin injections.

Crow's feet lines in the lateral canthal region are a common concern among aging patients, initially appearing as dynamic wrinkles during facial expressions and becoming more pronounced with age. Botulinum neurotoxin temporarily paralyzes muscles by inhibiting acetylcholine release, smoothing wrinkles and enhancing skin's youthful appearance. Effective treatment requires tailored approaches considering individual anatomy and muscle activity. Recent cadaveric studies identified the tear trough muscle, emphasizing its role in infraorbital support and aging. Clinically, patients often present medial eye wrinkles after BoNT treatment for crow's feet, prompting exploration of underlying mechanisms and management strategies. Three cases demonstrated that medial BoNT injections in the orbicularis oculi muscle significantly improve medial eye wrinkles and tear trough appearance. The study underscores the importance of understanding muscle hyperactivity and anatomical variations for precise treatment. Enhanced injection techniques targeting specific areas can achieve better outcomes and minimize complications, particularly in culturally sensitive regions where facial expressions are valued. This research highlights the necessity for comprehensive anatomical knowledge and patient-specific treatment strategies to address medial eye wrinkles effectively.

The Complex Role of Botulinum Toxin in Enhancing Goal Achievement for Post-Stroke Patients.

The rehabilitation medical team is responsible for the therapeutic management of post-stroke patients and, therefore, for the complex therapeutic approach of spasticity. Considering the generous arsenal at our disposal in terms of both pharmacological treatment, through the possibility of administering botulinum toxin to combat spasticity, and in terms of accurate assessment through developed functional scales such as the GAS (Goal Attainment Scale), one of our purposes is to monitor the parameters that influence the achievement of functional goals set by patients together with the medical team in order to render the patients as close as possible to achieving their proposed functional goals, thus enhancing their quality of life. By assessing and establishing statistical and clinical correlations between the GAS and quantifiable parameters related to the affected post-stroke upper limb, namely degree of spasticity, motor control, pain level and evolution of pain under treatment with BoNT-A (abobotulinum toxin A), and patients' overall response to BoNT-A treatment, we aim to quantify the improvement of the therapeutic management of post-stroke patients with spasticity and develop a more personalized and effective approach to their disability and impairment. The analysis concluded that there were two independent predictors of the Achieved GAS-T score (the study's endpoint parameter) motor control at any level of the upper limb and number of prior BoNT-A injections. The number of prior BoNT-A injections was an independent predictor of Achieved GAS-T score improvement but had no significant influence over Baseline GAS-T score. Enhancement in proximal and intermediate motor control showed a GAS score improvement of 3.3 points and a 0.93-point GAS score improvement for wrist motor control progress. From a separate viewpoint, patients with motor deficit on the left side have shown significantly greater improvement in Changed GAS-T scores by 2.5 points compared to patients with deficits on the right side; however, we note as a study limitation the fact that there was no statistical analysis over the dominant cerebral hemisphere of each patient. Improvement in the Achieved GAS-T score means better achievement of patients' goals. Thus, after the BoNT- A intervention, at follow-up evaluation, GAS was found to be directly correlated with improvement in motor control of the affected upper limb. Mobility of the corresponding limb was enhanced by pain decrease during p-ROM (passive range of motion) and by amelioration of spasticity. We conducted an observational, non-randomized clinical study on 52 stroke patients, a representative sample of patients with post-stroke spasticity and disability from our neurological rehabilitation clinic, who have been treated and undergone a specific rehabilitation program in our tertiary diagnostic and treatment medical center, including BoNT-A focal treatment for spasticity in the affected upper limb. The primary objective of the study was to assess the influence of abobotulinum toxin A treatment on the Goal Attainment Scale. Secondary objectives of the study included the assessment of BoNT-A treatment efficacy on spasticity with the MAS (Modified Ashworth Scale), pain with the NRS (Numerical Rating Scale), and joint passive range of motion (p-ROM), identifying demographic, clinical, and pharmacological factors that influence the response to BoNT-A treatment, as well as to conduct a descriptive and exploratory analysis of the studied variables.

OnabotulinumtoxinA as a promising treatment for primary trochlear headache: A retrospective case series.

To report the efficacy of onabotulinumtoxinA (BoNTA) injections in relieving pain in patients with primary trochlear headache (PRTH). Examination of medical records for patients diagnosed with PRTH according to the International Classification of Headache Disorders, 3rd edition criteria and treated with BoNTA. Data were collected for variables related to pain relief, duration of effectiveness, and adverse effects. Six patients were included in the study. All had previously undergone standard care interventions, including infiltrations or oral treatments, yet experienced treatment failure or symptom recurrence. All patients received 20 units of BoNTA, administered in the corrugator and procerus muscles. Subsequent to the BoNTA injections, all six patients reported substantial pain relief, with five achieving complete remission of symptoms. The analgesic effect persisted for a duration of 3 months. No adverse events were reported in any of the cases. Our case series presents the first evidence of the potential of BoNTA as a safe and effective treatment option for PRTH. From a clinical standpoint, having a safer alternative is of paramount significance for patients with limited treatment options, such as those with PRTH. Further research is warranted to validate these findings and explore the long-term efficacy of BoNTA in PRTH management.

(029) Safety and Efficacy of Botulinum Neurotoxin in the Treatment of Erectile Dysfunction Refractory to Phosphodiesterase Inhibitors: Results of a Randomized Controlled Trial

Abstract Introduction There has been recent interest in the use of botulinum neurotoxin (BoNT) in the field of Andrology, whereby it has been investigated in the treatment of penile retraction and premature ejaculation. Objective To evaluate the safety and efficacy of intracavernosal BoNT-A injection in the treatment of patients with erectile dysfunction (ED) refractory to oral phosphodiesterase inhibitors (PDE5Is). Methods A double-blind randomized placebo-controlled prospective comparative study conducted at one center and involved 70 patients with ED refractory to PDE5Is. At baseline, the following data were collected: erection hardness score (EHS), peak systolic velocity (PSV), end diastolic velocity (EDV), sexual health inventory for men (SHIM), and the sexual encounter profile 2&3 (SEP-2&3) questionnaires. Treatment group (n = 35) received a single ICI of 100 units of BoNT-A in 2 ml of saline and control group (n = 35) received a single ICI of 2 ml of saline. EHS, PSV, and EDV were assessed at 2 weeks post treatment. SHIM, SEP-2, SEP-3, and global assessment questionnaire (GAQ-Q1&Q2) were completed at 2-, 6-, and 12-weeks post treatment. Results Two weeks post treatment, the treatment group showed a statistically significant improvement in the mean EHS, PSV, EDV, and GAQ-Q1 positive responders (p < 0.001) compared to the control group. At 6- and 12-weeks post treatment, the treatment group showed a statistically significant improvement in the SHIM scores, SEP-2, and GAQ-Q1&Q2 positive responders compared to the control group. At 6 weeks, where there was a 5-point improvement in the mean SHIM score of the treatment group (10±5.9 from 5.4±1.7 at baseline) versus no improvement in the placebo group, 18 patients in the treatment group (53%) were able to have an erection hard enough for vaginal penetration versus only one patient in the control group. Conclusions BoNT-A is safe and effective as a potential treatment for ED refractory to PDE5I therapy. Disclosure No.

Effects of onabotulinum toxin-A injection on sexual function in women with refractory interstitial cystitis/bladder pain syndrome: A prospective study.

To determine the effect of intravesical onabotulinum toxin-A (BoNT-A) treatment on sexual functions in female patients with refractory interstitial cystitis/bladder pain syndrome (IC/BPS). Female patients with IC/BPS refractory to previous treatments were included in the study between January 2020 and April 2022. Patients were treated with the trigone-sparing injection (Group 1) or trigone-included injection (Group 2) techniques. 100 Units of BoNT-A was applied submucosally on 20 different points. The patients were evaluated with visual analog scale (VAS), O'Leary-Sant Interstitial Cystitis Symptom Index (ICSI), Interstitial Cystitis Problem Index (ICPI), Female Sexual Function Index (FSFI) questionnaires, 3-day voiding diary, uroflowmetry, and post-voiding residual volume analysis in the preoperative period, as well as on the 30th and 90th days postoperatively. For the repeated measurements, analysis of variance was used to assess the time-dependent variation across groups. The baseline FSFI score of the patients was 15.96 ± 3.82. Following the treatment, the FSFI scores were 22.43 ± 4.93 and 24.41 ± 5.94 on the 30th and 90th days, respectively (p < .001). We observed statistically significant improvement in all FSFI subdomains (p < .05). Statistically significant improvements with treatment on ICSI, ICPI, and VAS scores were achieved (p < .05). Preoperative FSFI scores were similar in Group 1 and Group 2 (p = .147). While the preoperative FSFI scores were 17.00 ± 3.73 and 14.84 ± 3.72 for Group 1 and Group 2, respectively, the scores after the treatment were 22.85 ± 5.01 and 21.98 ± 5.01 on the 30th day, and 24.62 ± 6.06 and 24.19 ± 6.05 on the 90th day postoperatively. Significant improvement was observed in FSFI scores with treatment, and no difference was observed between the two groups in terms of treatment response (p = .706). Intravesical BoNT-A injection in the treatment of women with refractory IC/BPS improves sexual functions. It also significantly improves pain and symptom scores. Both trigone-sparing and trigone-including injections are similarly safe and effective.

Botulinum neurotoxin type A responders among children with spastic cerebral palsy: Pattern-specific effects

AimTo identify short-term effects of botulinum neurotoxin type A (BoNT) injections on gait and clinical impairments, in children with spastic cerebral palsy (CP), based on baseline gait pattern-specific subgroups. MethodShort-term effects of BoNT injections in the medial hamstrings and gastrocnemius were defined in a retrospective convenience sample of 117 children with CP (median age: 6 years 4 months; GMFCS I/II/III: 70/31/16; unilateral/bilateral: 56/61) who had received gait analyses before and 2 months post-BoNT. First, baseline gait patterns were classified. Statistical and meaningful changes were calculated between pre- and post-BoNT lower limb sagittal plane kinematic waveforms, the gait profile score, and non-dimensional spatiotemporal parameters for the entire sample and for pattern-specific subgroups. These gait waveforms per CP subgroup at pre- and post-BoNT were also compared to typically developing gait and composite scores for spasticity, weakness, and selectivity were compared between the two conditions. ResultsKinematic improvements post-BoNT were identified at the ankle and knee for the entire sample, and for subgroups with apparent equinus and jump gait. Limbs with baseline patterns of dropfoot and to a lesser extent true equinus showed clear improvements only at the ankle. In apparent equinus, jump gait, and dropfoot, spasticity improved post-BoNT, without leading to increased weakness or diminished selectivity. Compared to typical gait, knee and hip motion improved in the crouch gait subgroup post-BoNT. ConclusionThis comprehensive analysis highlighted the importance of investigating BoNT effects on gait and clinical impairments according to baseline gait patterns. These findings may help identify good treatment responders.

(272) Botulinum Toxin Injection in Vulva and Vagina: Evidence from a Literature Systematic Review

Abstract Introduction Vaginismus, vulvodynia and chronic pelvic pain are a group of pain syndromes that may have, in addition to pain, other types of symptoms. Often no specific etiology can be identified, and the choice of treatment is complicated. Although several treatment methods have been proposed, evidence-based therapies are limited. Therapies can be classified in medical, surgical and interventional treatment. Interventional therapy contemplates injection therapy with botulinum toxin, proposed in 1997 Objective To evaluate the BoNT injection in the comprehensive care of vaginismus, vulvodynia and chronic pelvic pain and to enhance the impact on the sexual arousal. Methods 1108 patients, Randomized Controlled Trials (RCT) were 7. The Retrospective Studies Without a control group were 4, With a control group: 1. Besides, the Prospective Studies Without a control group were, . 2 patients were With a control group. The BoNT Dosage Range was: Minimum: 12 UI Maximum: 500 UI Types of BoNT Products: Botox® (onabotulinumtoxinA): 14 Xeomin® (incobotulinumtoxinA): 3 Dysport® (abobotulinumtoxinA): 3 Unspecified BoNT Product: 1 EMG-Guided Injection: 5 I used as BoNT Administration Techniques, the Digital Palpation: 12, the unspecified Injection Procedure: 4. My methods were 17 patients in Intramuscular Injection, 3 patients with Vaginal Submucosal Plane, and one patient with Subcutaneous Injection. Results For Vaginismus, Significant improvement in sexual and orgasmic dysfunction Successful intercourse Reduction of vaginal muscle resistance Improved sexual function (evaluated by Female Sexual Function Index) Pain reduction and improved quality of life (Short-Form Health Survey) BoNT reduced muscular hyperactivity. Both BoNT and placebo improved sexual pain, function, and distress for patients with vulvodynia, Significant improvement in pain 4, improved quality of life 2 and increase of sexual activity due to the reduced pelvic hypertonicity. Other Study Results: Significant improvement in pelvic pain [22, 23, 31, 32] Reduction of vaginal pressure [32] Improvement in quality of life, sexual activity, and reduced pelvic floor muscles myoelectrical activity [31] Conclusions Different endpoints and different methods of analysis. Different types of participants. Various techniques and timing. Adverse events. For this reason, even though BoNT seems a promising treatment, a clear standardization in clinical guidelines is still lacking. A clear standardization is needed for practical guidelines. Future perspectives should address reproducible protocols for BoNT administration. Disclosure No.

Botulinum Toxin for the Management of Parkinson's Disease: A Systematic Review.

Parkinson's disease (PD) is a terminal, debilitating neurodegenerative disorder typically affecting individuals over 60. It is associated with various conditions that drastically affect the patient's quality of life (QoL). Although there is no cure for PD, its symptoms can be significantly improved and even resolved through different treatments. Mainstay treatments for PD include levodopa combined with carbidopa, dopamine agonists, and even deep brain stimulation (DBS) of the subthalamic nucleus. New treatment methods have emerged, such as botulinum toxin (BoNT), which further improve symptoms and, thus, the QoL of patients with PD. Botulinum toxin is a potent neurotoxin produced byClostridium botulinumthat typically causes descending paralysis by suppressing acetylcholine secretion. Serotypes used to treat various disorders include serotype A (BoNT-A) and serotype B (BoNT-B). This paper aims to evaluate the outcomes of BoNT injection on different symptoms associated with PD. An extensive review using PubMed, ScienceDirect, and ProQuest articles concerning 'botulinum toxin and Parkinson's disease' was done per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, resulting in 23,803 articles. After applying strict inclusion and exclusion criteria, the total number of articles was finally 41. The results showed that movement disorders were a common occurrence in PD, consisting of tremors, dystonia, and freezing of gait (FOG), with tremors being the most common symptom. Tremors and dystonia were significantly improved following BoNT-A, correlating with significant improvements in various scales subjectively and objectively evaluating the symptoms and QoL. In contrast, FOG was not significantly improved by either BoNT-A or BoNT-B. Pain is associated with movement disorders such as PD and was the primary indication for the administration of BoNT; studies found pain and QoL were significantly improved following BoNT injection. Quality of life can also be affected by sialorrhea and overactive bladder, which often occur as the disease progresses. Injections of BoNT-A and BoNT-B were shown to significantly improve saliva production, flow rate, drooling frequency, voiding frequency, and urinary urge incontinence. Across all studies analyzed, it is evident that BoNT may have a significant effect on improving the QoL of patients suffering from PD. While research continues to find a cure or stop the progression of PD, it remains critical to continue focusing on improving patients' QoL. Future research should evaluate whether BoNT can be used to successfully treat other symptoms of PD, such as epiphora or constipation.

What is 'botox', what are fillers, and how safe are these cosmetic injectables?

Botulinum neurotoxin type A (BoNT-A, popularly referred to as 'botox') is a muscle-relaxant that is injected into the mimic facial muscles to soften wrinkles in more than two percent of Dutch women annually. A similar number of women undergo filler injections with hyaluronic acid hydrogels, used to counteract the aging appearance of the skin, or to create desired facial contours. Complications are generally mild in nature and rare (certainly compared to surgical complication rates) and include nodules, bumps and a temporary heavy feeling of the eyebrows. Vascular complications related to filler injections (1:7000) can potentially lead to unilateral blindness or skin necrosis. In the Netherlands, the risk of blindness over the past six years is estimated to be 1 in every 1.4 million filler injections. Permanent skin damage due to gangrene has never been reported in the Netherlands. In conclusion, BoNT-A and hyaluronic acid filler injections are safe procedures in the hands of appropriately trained healthcare professionals.

An analysis of the efficacy of botulinum neurotoxin type a in treating cervical dystonia.

The first-line treatment for cervical dystonia (CD) consists of repeated intramuscular injections of botulinum toxin (BoNT). However, the efficacy in some patients may be unsatisfactory and they may discontinue treatment. To examine the factors associated with the maximum rate of remission in patients with CD after initial botulinum neurotoxin type A (or botulinum toxin type A abbreviated as BTX-A or BoNT-A) treatment. Patients with CD who received BoNT-A injections were evaluated using the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) and the Tsui scale, with follow-up endpoints lasting until the start of the second injection. Patients who did not receive a second injection of BoNT-A were followed up for at least 5 months. The maximum remission rates were determined using the lowest Tsui and TWSTRS total scores during the follow-up period. We obtained basic information about these patients such as age, gender, duration of disease, presence of additional disease, types of torticollis, presence of anxiety, depression, tremors, single-photon emission computed tomography (SPECT) findings, injected dose, and so on from their medical records. A total of 70 patients with CD participated in this study, with males comprising 35.7% (25 individuals) with an average age of 45 ± 14 years old. The duration of disease was an independent risk factor for determining whether a complete remission has been attained using the Tsui scale (odds ratio [OR] = 0.978, 95% confidence interval [CI]: 0.959-0.997, P= 0.026). The optimal cut-off point for predicting patients who were unable to achieve complete remission based on duration of disease was 7.5 months (AUG = 0.711). Patients with CD with additional disease had greater difficulty achieving complete remission than those with CD alone based on TWSTRS assessments (P= 0.049). During the study, approximately 17% of all participants reported experiencing adverse reactions that lasted between 1 to 3 weeks before disappearing. BoNT is an effective and safe method for treating CD. The maximum remission rates of patients after their first injections are influenced by the duration of their disease. Thus, treatment using BoNT injections must be administered as soon as possible.

Certified Child Life Specialist role in implementation of individualized coping plans for children receiving botulinum toxin injections.

The purpose of this paper is to describe the implementation of evidence-based, individualized coping plans and to compare the rates of child anxiety, child cooperation, and parent anxiety before and after implementation of these coping plans for children receiving recurring BoNT-A injections emphasizing the role of Certified Child Life Specialists (CCLSs) within the interdisciplinary team approach. A retrospective chart review was conducted for children receiving BoNT-A injections at a Physical Medicine clinic pre- and post-implementation of the coping plan. Descriptive statistics were used to evaluate care plan implementation, child cooperation, child anxiety, and parent anxiety. Post-implementation of coping care plans, children experienced improved cooperation during BoNT-A injections. Parental anxiety decreased once coping plans were implemented. Documentation improved after the implementation of coping plans specific to areas involving cooperation, child's anxiety and distress, and parental anxiety and distress. It was also noted that there was an increase in child anxiety assessments within documentation. CCLS were able to utilize their expertise to collaboratively create individualized coping care plans to increase child's cooperation and decrease parental anxiety during BoNT-A injections.

Functional improvement of young children with cerebral palsy treated with integrated/intensive rehabilitation and botulinum toxin injections.

Patients with cerebral palsy (CP) present mobility limitations altering their activity and participation in social life. The aim of this study was to assess changes in Gross Motor Function Classification System (GMFCS) and Functional Mobility Scale (FMS) in children with CP who received repeated BoNT-A injections within a rehabilitation treatment over a five-year follow-up period. This retrospective, observational study included 200 consecutive children with bilateral CP (GMFCS I-IV). Annual assessments of the five-year follow-up period were analysed. The mean age of the patients at the beginning was 32.23 months (± 6.96). The GMFCS level improved in 67 (33.5%) (p < 0.001) and worsened in four (2%) children. In children with GMFCS III and IV levels, improvement was observed in 50% and 40%, respectively. FMS 5 and 50 metres improved in 54% and 52.5% of children respectively. Our study showed a significant, positive effect of integrated treatment on functional mobility in patients with CP.

Effects of Intradermal Botulinum Toxin Injections on Herpes Zoster Related Neuralgia.

Postherpetic neuralgia (PHN), which represents the most common chronic complication of herpes zoster, is characterized by intense pain and is difficult to treat. In fact, no treatments are currently available that can effectively reduce the pain associated with PHN. Recent evidence has been presented indicating that Botulinum toxin (BoNT-A) can serve as an effective and safe treatment for peripheral neuropathic pain. The effects of intradermal BoNT-A injections on herpes zoster related neuralgia were investigated in this study. Patients diagnosed with herpes zoster related acute neuralgia (N=13 - acute group) and those diagnosed with postherpetic neuralgia (N=17 - PHN group) were enrolled in this study. The two groups were treated with intradermal injections of BoNT-A at the site of their affected pain areas and were then assessed at 1 day, 1 week, 2 weeks, 1 month, 2 months and 3 months after their BoNT-A treatments. When compared with pre-treatment values, Visual Analogue Scores (VAS) in all patients were all significantly decreased at all times tested following BoNT-A injection. Before treatment, PHN patients had significantly higher VAS than those in the acute group. However, after 1 day of treatment, there was no difference in VAS between the two groups. None of the patients in the acute phase treated with BoNT-A developed PHN. BoNT-A injections significantly reduced herpetic-related pain and proved to be a more effective treatment for the PHN versus acute pain group. Moreover, an early application of BoNT-A can alleviate the probability of developing PHN.

Effectiveness of Adjunctive Therapies Following Botulinum Toxin Type A Injections in Children with Cerebral Palsy

Objectives: To investigate the effectiveness of intermittent vs. continuous adjunctive therapies following BoNT-A injections for children with cerebral palsy (CP).Methods: A quasi-experimental study was conducted with 80 participants with CP who received adjunctive therapies including physiotherapy and functional electrical stimulation after BoNT-A injections. The participants were randomly divided into two groups. In group A, half of the participants received intermittently adjunctive therapies. In group B, adjunctive therapies were organized continuously for another half. We measured changes in spasticity and dynamic spasticity used by the Modified Ashworth Scale and the Modified Tardieu Scale, and gross motor function used the Gross Motor Function Measure-88. Measurement of spasticity was carried out pre-injections and then 1- and 3-months post-injections. Measurement of gross motor function was organized pre- and post-injections.Results: The effectiveness of BoNT-A injections presented significant improvement in spasticity and gross motor function when it was combined with adjunctive therapies. The continuous adjunctive therapies had a greater reduction of spasticity. Both intermittent and continuous adjunctive therapies had a significant improvement in gross motor function.Conclusions: Our findings add to the evidence of the effectiveness of using different intervals of short-term adjunctive therapies for children with CP after BoNT-A injections.

Management of Severe Botulinum-Induced Eyelid Ptosis With Pre-tarsal Botulinum Toxin and Oxymetazoline Hydrochloride 0.1.

Eyelid ptosis following periocular onabotulinumtoxinA (BoNT-A) treatment is a known complication which can be frustrating for both patients and practitioners. Iatrogenic blepharoptosis occurs due to local spread of the BoNT-A from the periocular region into the levator palpebrae superioris muscle; while injectors should have a thorough understanding of the relevant anatomy in order to prevent it, BoNT-A induced ptosis can occur even in the most experienced hands. To describe a case series of patients effectively treated with Oxymetazoline HCl 0.1% and pre-tarsal BoNT-A injections in the setting of botox-induced ptosis. Eight patients were included who underwent recent cosmetic BoNT-A treatment preceding the sudden onset of unilateral upper eyelid ptosis. A diagnosis of severe ptosis (>3 mm) was made in all the cases in this series. Pre-tarsal BoNT-A injections alone or in association with topical administration of Upneeq eyedrops (Upneeq, Osmotica Pharmaceuticals, Marietta, GA) significantly reversed the ptosis in all treated cases. This is the first documented case series of patients effectively treated with Oxymetazoline HCl 0.1% and pre-tarsal BoNT-A injections in the setting of botox-induced ptosis. This treatment combination is a safe and effective option in these cases.