Botulinum Toxin Injections For Spasticity Research Articles

Cutaneous Allergic Reaction to Intramuscular Botulinum Toxin Injection for Spasticity – A Case Report

Cutaneous Allergic Reaction to Intramuscular Botulinum Toxin Injection for Spasticity – A Case Report

Use of immersive virtual reality for stress reduction during botulinum toxin injection for spasticity (RVTOX): a study protocol of a randomised control trial

IntroductionBotulinum toxin injection is a common way to help reduce spasticity in the body caused by central neurological damage such as cerebral stroke, multiple sclerosis or traumatic brain injury. The...

Worldwide Survey of Clinician Practice on use of Adjunctive Therapies Following Botulinum Toxin Injection for Spasticity.

ObjectiveNon-pharmacological adjunctive therapies can be used alongside botulinum toxin injection to enhance its efficacy. The objective of this global study was to determine the current practice and perception among clinicians of the use of adjunctive therapies after botulinum toxin injections for the treatment of limb spasticity.MethodsA questionnaire with 22 questions on clinical practice demographics, self-reported use and clinician opinion on barriers to the use of complementary therapies, and priorities for future research was translated into 7 languages and distributed worldwide through national and international professional associations concerning (neuro)rehabilitation.ResultsA total of 527 clinicians from 52 countries responded to the survey. Most commonly used physical interventions were: active exercise programmes at home (81%), stretching programmes at home (81%), and splinting (70%), followed by active movement exercises (65%) and within 30 min of botulinum toxin injection and constraint induced movement therapy (63%). The main barriers reported by clinicians to provision of these interventions were clinicians’ lack of time, limited financial resources, and lack of evidence. Future research should focus primarily on immediate active movement exercises and passive stretching.ConclusionWorldwide, clinicians often recommend adjunctive therapies after a botulinum toxin injection to reduce spasticity. The most commonly used physical interventions among clinicians were active exercises at home, stretching at home, and splinting. Lack of evidence, time and financial constraints were identified as barriers to providing these interventions.LAY ABSTRACTA neurological injury, such as a stroke, traumatic brain injury or spinal cord injury, may cause muscle stiffness, a condition known as spasticity. Among available treatments for spasticity, botulinum toxin, a neurotoxin injected into the muscle, is used in cases of focal spasticity. Adjunctive therapies are therapies other than drugs that are used to enhance the efficacy of a treatment, such as botulinum toxin. The aim of this worldwide survey of clinicians was to determine the current clinical practice and perception of the use of adjunctive therapies following botulinum toxin injections. The results showed that the most frequently prescribed adjunctive therapies were active exercises at home, stretching at home, and splinting. The main barriers reported by clinicians to provision of these interventions were clinicians’ lack of time, limited financial resources, and lack of evidence.

Practice Patterns of Physicians Using Adjunct Therapies with Botulinum Toxin Injection for Spasticity: A Canadian Multicenter Cross-Sectional Survey.

Adjunct therapies are nonpharmacological treatments used with botulinum toxin (BoNT) injection that may improve spasticity outcomes. It has been suggested that physicians consider adjunct therapies as a part of comprehensive spasticity management. It is unclear which adjunct therapies are used by physicians in clinical practice. To determine physician practice patterns and perceptions of use of adjunct therapies following BoNT injection for limb spasticity. Cross-sectional national survey of current clinical practice using a 22-item questionnaire developed by the authors. Not applicable. Survey respondents were physicians actively administering BoNT injections for limb spasticity management across Canada (N = 48). Not applicable. Types of adjunct therapies used by physicians; physician opinions on barriers to adjunct therapy use, patient preferences, and future research priorities. Most physicians prescribe home stretching programs, home active exercise programs, and splinting; however, many physicians perceive that these same adjunct therapies are unwanted by patients. A minority of physicians prescribe electrical stimulation (ES), transcutaneous electrical nerve stimulation (TENS), casting, and extracorporeal shockwave therapy; financial limitations and perceived lack of evidence were identified as barriers to their use. Significantly more physicians practicing in academic settings compared with nonacademic, community, and private practice settings used functional ES (59% vs 11%) and TENS (41% vs 0%) as adjunct therapies (P < .05). Research priorities included determining the effectiveness of immediate postinjection application of adjunct therapies (eg, injected muscle activation with ES or stretching) and nutraceuticals. Canadian physicians frequently use adjunct therapies in combination with BoNT injection to treat spasticity. Financial and time constraints are identified as barriers to implementation of adjunct therapies that are currently supported by research, and patient preferences may also affect compliance. Future research should focus on adjunct therapies that overcome these barriers.

Factors Influencing Gait Velocity Improvement Following Botulinum Toxin Injection for Spasticity of the Plantar Flexors in Patients with Stroke.

ABSTRACTObjective:In patients with hemiplegia, botulinum toxin type A injection for ankle spasticity of the plantar flexors reportedly improves walking speed. This improvement may be affected by background factors and patient baseline physical performance. This study aimed to clarify the factors affecting gait velocity improvement after botulinum toxin type A injection.Methods:Background and evaluation data were collected for 60 patients with stroke who received botulinum toxin type A injection for spasticity of the plantar flexors. The patients were divided into improvement (n=27) and non-improvement (n=33) groups based on the gait velocity change from before injection to 2 weeks after injection. Logistic regression analysis was performed with the improvement and non-improvement groups as response variables and background data and evaluation data at baseline as explanatory variables.Results:The presence or absence of physical therapy following botulinum toxin type A injection (odds ratio: 7.82) was the only significant explanatory variable for gait velocity change.Conclusion:Background factors and physical performance at baseline did not affect gait velocity improvement after botulinum toxin type A injection. If botulinum treatment of the ankle plantar flexors in patients with stroke is targeted at walking performance improvement, then physical therapy following botulinum toxin type A injection should be an essential part of the treatment strategy.

Adverse Event Profiles of High Dose Botulinum Toxin Injections for Spasticity.

Botulinum toxin injections are effective in relieving focal spasticity resulting from upper motor neuron injuries. Doses approved in the United States for onabotulinumtoxinA and incobotulinumtoxinA are up to 400 units, yet higher doses are often used. To determine differences in risk of adverse events when using higher (>600 units) as compared to lower doses within clinically applicable categories; the difference in adverse events between types of botulinum toxin-A, and any association of the injection of cervical muscles with increased risk for adverse events. Retrospective analysis of injections performed over a 3-year period at a freestanding rehabilitation hospital network. Persons with spasticity or dystonia undergoing ona- and/or incobotulinumtoxinA injections. Not applicable. Adverse events for injections were divided into the three dose ranges (≤400 units, 401-600 units, or > 600 units). 889 injections in 342 patients met inclusion criteria with 65% ≤400 units, 21% 401-600 units, and 14% >600 units. Adverse events were not significantly increased in doses of 401-600 units relative to ≤400 units (OR 0.97, 95% CI 0.31, 2.98). Doses of toxin over 600 units were associated with significantly increased relative risk of adverse events (OR 2.98, 95% CI 1.12, 8.13). There were no significant differences between adverse event rates for onabotulinumtoxinA or incobotulinumtoxinA (P >.99). Inclusion of cervical muscles in isolation did significantly increase the risk of adverse events (OR 4.21, 95% CI 1.15, 15.46). Risk for adverse events were not significantly increased in doses of ona- and/or incobotulinumtoxinA up to 600 units, suggesting that the current 400 units upper bound of approved dose may need to be reexamined. Doses above 600 units were found to increase the rate of adverse effects and clinical benefit versus risk should be taken into account. III.

A 10-year retrospective review of lower limb botulinum toxin injection for spasticity

A 10-year retrospective review of lower limb botulinum toxin injection for spasticity

Decreasing pediatric pain and agitation during botulinum toxin injections for spasticity with virtual reality: Lessons learned from clinical use.

Recurrent botulinum toxin (BoNT) injections are used in the pediatric population for management of spasticity, but the procedure is often associated with significant pain and anxiety for patients. Non-pharmacologic treatment alternatives for procedural discomfort are limited. Immersive virtual reality (VR) has shown efficacy in treatment of procedural discomfort in pediatric patients. A retrospective chart review was performed to assess feasibility and use of treating BoNT procedure-related discomfort in pediatric patients with VR. Fourteen patients undergoing elective BoNT injections viewed VR videos using a mobile VR headset during the procedure. Face, Legs, Activity, Cry, Consolability scale (FLACC) scores were obtained and feedback was elicited following injections. The VR intervention was well tolerated, and patients' guardians requested that it be used again in 9/14 cases. The remainder either had high FLACC scores despite VR and neutral or negative guardian impressions of intervention, or were unable to utilize the device. VR was helpful in reducing BoNT procedure-related discomfort in a majority of patients. Challenges with VR setup, patient tolerance, and selecting viewing experiences were identified to guide further research and use of VR in a clinical environment.

Factors affecting procedural pain in children during and immediately after intramuscular botulinum toxin injections for spasticity.

To evaluate variables that modulate pain during intramuscular botulinum toxin A injections in children. As part of a Quality Improvement project, this retrospective analysis compared reported pain during and five minutes post injections with patient and procedural variables using subgroup and regression analyses (N= 593 procedures with 249 unique patients). Mean procedural pain for all procedures (n= 563) was 3.8 ± 3.0. Most children reported no pain (83.8%) or mild pain (12.1%) five minutes after the procedure. Provider, previous patient experience, and dose did not significantly impact pain. Linear regression analysis (R=2 0.64) demonstrated that younger age (p< 0.05), use of vapo-coolant spray or topical anesthetic (p< 0.01), and body region injected (p< 0.01) were significantly associated with increased procedural pain. Logistic regression (R=2 0.14) demonstrated that pain during the procedure (p< 0.001) and older age (p< 0.01) increased the likelihood of pain post-procedure. Utilization of personnel for distraction did not significantly predict pain ratings at either time point. Age, topical anesthesia, and injected region impact procedural pain and in nearly 96% of cases, patients report mild or no pain within five minutes. Additional research into these predictors is necessary, but short-lived procedural pain may suggest that frequent use of sedation/anesthesia is unnecessary.

Poster 127: Factors Affecting Procedural Pain in Children During and Immediately After Intramuscular Botulinum Toxin Injections for Spasticity

Poster 127: Factors Affecting Procedural Pain in Children During and Immediately After Intramuscular Botulinum Toxin Injections for Spasticity

Intramuscular nerve distribution of the hamstring muscles: Application to treating spasticity.

The aim of this article is to elucidate the ideal sites for botulinum toxin injection by examining the intramuscular nerve distributions in the hamstring muscles. The hamstring muscles, biceps femoris, semitendinosus, and semimembranosus (10 specimens each) were stained by the modified Sihler method. The locations of the muscle origins, nerve entry points, and intramuscular arborized areas were recorded as percentages of the total distance from the line crossing the medial and lateral tibial condyles (0%) to the ischial tuberosity (100%). Intramuscular arborization patterns were observed at 15-30% and 50-60% for the biceps femoris, 25-40% and 60-80% for the semitendinosus, and 20-40% for the semimembranosus. This study suggests that botulinum toxin injection for spasticity of the hamstring muscles should be targeted to specific areas. These areas, where the arborization of intramuscular nerve branches is maximal, are recommended as the most effective and safest points for injection. Clin. Anat. 29:746-751, 2016. © 2016 Wiley Periodicals, Inc.

More than a black box of rehabilitation: Characterizing therapy programmes following botulinum toxin injections for spasticity in adults with stroke.

To describe ambulatory rehabilitation programmes (physical and occupational therapy activities and interventions) following botulinum toxin injections for post-stroke spasticity using a stroke rehabilitation taxonomy. To explore the relationship between therapy provided and injected limb/s and treatment goals. Prospective, observational cohort study. Stroke survivors (n = 47) participating in ambulatory rehabilitation programmes following botulinum toxin injections for upper limb, lower limb or upper and lower limb spasticity. Standardized therapy documentation forms were completed prospectively for each occupational and physical therapy session. Main outcomes were the proportion of total therapy time spent in various therapeutic activities; total sessions during which each intervention was used to facilitate the activities most time was spent in; and goals related to each activity category. Sub-analysis was carried out for participants, based on limb/s injected. Most time was spent in "upper extremity control" activities as the upper limb was more often injected. A large proportion of therapy time was spent in activities remediating "performance skills or body structure and function impairments". In the upper and lower limb, and upper limb groups 38.7% and 46.2% of goals, respectively, related to this activity category, but less than 10% in the lower limb group. Little time was spent in community participation and leisure activities, whilst over one-third of lower limb group goals related to this category. Ambulatory rehabilitation programmes following botulinum toxin injections for post-stroke spasticity varied depending on limb/s injected and reflected treatment goals to some extent.

Physical therapy for an adult with chronic stroke after botulinum toxin injection for spasticity: a case report.

In this case report, we describe the type and duration of a physical therapy and botulinum toxin type A (BoNTA) intervention directed at lower limb spasticity and the gait and balance improvement in a patient post-stroke. Treatment of focal spasticity with BoNTA intramuscular injections combined with physical therapy is recommended by rehabilitation experts. However, the optimal type and duration of physical therapy intervention to optimize any functional gains that follow chemodenervation induced by BoNTA has not been established. One individual with chronic stroke who received BoNTA injections for upper and lower extremity spasticity was included. Physical therapy intervention consisted of 45- to 60-min sessions twice weekly for 12 weeks, based on the Bobath-neurodevelopmental therapy approach, and an activity-based home program. After BoNTA injections and physical therapy, the patient made clinically significant improvements in balance and gait speed and became more independent with his ambulation. This case report demonstrates that physical therapy after BoNTA injections can result in significant functional improvements for individuals with spasticity after chronic stroke that may not be possible with BoNTA injections alone.

Neurodegeneration With Brain Iron Accumulation Disorder Mimics Autism

This 15-year-old Thai girl who was diagnosed with autism by a child psychiatrist at 3 years of age. She was born to healthy, nonconsanguineous parents. Pregnancy, labor, and delivery were normal, and her neonatal period was uneventful. The patient had normal development until 3 months of age and had a global delay of 12 months compared with normal milestones. When she was one year old, she began to crawl. Her parents noticed her walking on the tips of her toes with ataxia and frequent falls. At 18 months, she spoke only a few words. When she entered the prekindergarten level, her teacher reported that she had a poor attention span, remarking that she could finish her work quickly but that the work was filled with mistakes. The child often played by herself and demonstrated repetitive and stereotypic behavior without imaginative play. Her speech development was slow. She began talking in broken sentences with poor pronunciation and comprehension. At age 3 years, a child psychiatrist diagnosed autism. Six months later, a pediatric neurologist diagnosed autism with spastic diplegia as spasticity increased in her lower extremities. Normal investigations included electroencephalography, auditory brainstem responses, and thyroid function tests. She received physical, occupational, and speech therapy and along with botulinum toxin injections for spasticity. Her first in a series of magnetic resonance imaging (MRI) examinations was performed 18 months after her presentation; it demonstrated abnormally low signal intensity in the globus pallidus, posterior limb of the internal capsule, substantia nigra, and pontine corticospinal tract (Fig 1). The findings were consistent with iron deposition in the brain. The diagnosis of neurodegeneration with brain iron accumulation (NBIA) was made in spite of a lack of the “eye-of-the-tiger” sign. At 5 years 10 months, her spasticity increased, and she lost her ability to walk. Two years later, she lost her sitting balance and developed dysphonia and dysphagia. At 10 years of age, she developed dystonic movements and tonic seizures. At 14 years, her condition FIGURE 1. The initial T2 brain magnetic resonance imaging demonstrated abnormal low signal intensity in globus pallidus and posterior limb of internal capsule.

Intrafusal effects of botulinum toxin injections for spasticity: Revisiting a previous paper

Botulinum toxin, frequently used to manage focal limb spasticity, has been reported to affect both extrafusal and intrafusal fibers of the injected muscle. Since most studies have used spinal reflexes, it is difficult to isolate the intrafusal effects from extrafusal and central effects. In a paper by On et al. [7], both stretch and H-reflexes were used to examine the intrafusal effects of botulinum toxin injections. Revisiting the data from On et al. [7] presented a unique opportunity to describe a novel method of measuring the effect of botulinum toxin-A on muscle spindle activity in patients with spasticity. H-reflex, maximum M-wave, and Achilles tendon reflex were serially assessed in ten patients with stroke pre-, 2, 4, and 12 weeks post-botulinum. In order to assess the intrafusal effects, we subtracted the %change in H-reflex amplitude from baseline (representing extrafusal and central effects) from the %change in Achilles tendon reflex amplitude from baseline (representing intrafusal, extrafusal and central effects). Using this formula, our results suggest that botulinum induces significant chemodenervation of the intrafusal muscle fibers (33% decreases). Intrafusal effects were greatest at 2 weeks, but tapered off by 12 weeks post-botulinum (p<0.017). We found a significant positive correlation between the intrafusal effects of botulinum toxin and changes in modified Ashworth scale. Our method of assessing the effects of botulinum toxin shows significant effect on intrafusal fibers, which correlates with clinical manifestation of spasticity. Future studies need to investigate ways to maximize intrafusal effects and minimize extrafusal effects of botulinum therapy.

Physical and occupational therapy considerations in adult patients receiving botulinum toxin injections for spasticity

Physical and occupational therapists play important roles in the evaluation and management of patients receiving botulinum toxin injections for spasticity. Baseline evaluation includes areas beyond the muscles being injected, since local spasticity reduction may lead to more widespread functional changes. Because the evaluation itself influences tone, a consistent order of muscle evaluation is recommended. The range of preinjection assessments includes evaluation of tone, mobility, strength, balance, endurance, assistive devices, and others. After injection, therapeutic interventions have multiple aims, including strengthening and facilitation, increasing range of motion, retraining of ambulation and gait, improving the fit and tolerance of orthoses, and improved functioning in ADLs.

Physical and occupational therapy considerations in adult patients receiving botulinum toxin injections for spasticity

Physical and occupational therapy considerations in adult patients receiving botulinum toxin injections for spasticity

Poster 152 Safety of ‘high dose’ botulinum toxin injection for spasticity in adults: Donna J. Roggenbuck, MD (Baylor College of Medicine, Houston, TX); Stuart A. Yablon, MD.

Poster 152 Safety of ‘high dose’ botulinum toxin injection for spasticity in adults: Donna J. Roggenbuck, MD (Baylor College of Medicine, Houston, TX); Stuart A. Yablon, MD.