Effect Of Botulinum Toxin Injection Research Articles

Comparison of botulinum toxin and propranolol for essential and dystonic vocal tremors

OBJECTIVES:Vocal tremors, which cause social difficulties for patients, may be classified as resting or action tremors. Of the vocal action tremors, essential and dystonic tremors are the most common. Botulinum toxin and oral medications have been used to treat vocal tremors, but no comparative clinical trials have been performed. The aim of this study was to compare the effects of botulinum toxin injection and the oral administration of propranolol in the treatment of essential and dystonic vocal tremors.METHODS:This clinical trial recruited 15 patients, divided into essential and dystonic vocal tremor groups. Patients in both groups received successive treatment with botulinum toxin and propranolol. The treatments were administered at different times; the order of treatment was randomly selected. Patients were assessed with flexible nasofibrolaryngoscopy and with perceptual and acoustic voice evaluations. A statistical significance level of 0.05 (5%) was used.RESULTS:Botulinum toxin produced statistically significant improvements in perceptual measures of vocal instability in patients with dystonic vocal tremors compared with baseline values and treatment with propranolol. The acoustic measure of variability in the fundamental frequency was significantly lower in patients with dystonic vocal tremors after treatment with botulinum toxin.CONCLUSION:Essential and dystonic vocal tremors responded differently to treatment. Dystonic vocal tremors responded significantly to treatment with botulinum toxin but not oral propranolol. Essential vocal tremors did not respond significantly to either treatment, perhaps due to the small number of patients, which is a limitation of this research.

P.356 - Effects of botulinum toxin injections in the cricopharyngeal muscle of OPMD and IBM myopathies with dysphagia

Certain myopathies have dysphagia as a pronounced and very troublesome symptom, but no established treatment exists. Botulinum toxin injection in the cricopharyngeal muscle has at case level been reported to be effective. To systematically evaluate the safety and efficacy of injections of botulinum toxin in the cricopharyngeal muscle in patients with dysphagia due to inclusion body myositis (IBM) or oculopharyngeal muscular dystrophy (OPMD). Patients with confirmed diagnoses of IBM or OPMD and dysphagia were included if no other cause for dysphagia was present, and if dysphagia, assessed by a timed water swallow test, a dysphagia questionnaire and by meal registration, was pronounced. Additional baseline registration included body weight, number of pneumonia episodes, muscle strength and enzyme measurements. Initially, laryngoscopia was performed followed by needle electromyography to confirm activity in the cricopharyngeal muscle and to establish needle placement. Botulinum toxin was then injected through the hollow EMG needle. An individualized dose of 5–10 units was applied bilaterally the first time and the dose was then titrated up with at least 12 weeks' intervals. Suspected side effects were noted at each visit. Outcome measures were change in timed water swallowing test, dysphagia questionnaire and meal registration. 12 subjects were included, 3 with OPMD. Preliminary results from 6 subjects show that 4 felt a clear improvement, whereas 2 were excluded due to that a worsening was suspected based on subjective observations and worsening in the meal registration assessment. In the dysphagia questionnaire, however, every single subject improved (p < 0.001). No overall change was seen in the meal registration assessment and the timed water swallow test. Preliminary results suggest a positive effect on dysphagia of cricopharyngeal botulinum toxin in patients with OPMD and IBM.

Safety and effectiveness of botulinum toxin injection in children younger than 2 years old: A systematic review

Botulinum toxin injection is increasingly used in children with musculoskeletal disorders. The literature supports the hypothesis that the earlier the injection is carried out the better the efficiency is. The aim of this study was to systematically review the literature reporting on the safety and effectiveness of botulinum toxin injection in infants (younger than 2 years old). From 947 articles extracted from 5 database, seventeen articles including data available for children younger than 2 years was included in the systematic review (11 articles included specifically children younger than 2 years). Data from 482 infants with cerebral palsy ( n = 64), brachial plexus palsy ( n = 112), clubfoot ( n = 257), congenital torticollis ( n = 44) were analyzed. Adverse effects did not appear to be more severe or more frequent than in older children. The risks were not related to the age but more to the severity of the disability and associated impairments. The first studies exhibiting an effectiveness of the botulinum toxin injections were of low grade of evidence (2 RCTs). There were scarce descriptions of the injection protocol. Recommendations based on the lowest age and highest doses reported are made according to the different pathologies for clinical practice. In 482 infants with various musculoskeletal disorders, botulinum injection toxin injection does not present specificities in term of safety compared to older children. More randomized control trials are needed to assess the efficacy of early botulinum injection in infants with musculoskeletal disorders.

Effectiveness of botulinum toxin injection on upper-limb motor function of children with OBPP

Obstetrical brachial plexus palsy (OBPP) is often complicated by contractures of shoulder internal rotators and/or co-contractions of the biceps/triceps brachii muscles. They are responsible of early limitations of the upper limb movements and thus limit children at the activity and participation level. The aim of this study was to evaluate the effect of botulinum toxin injections (BTI) on the active movements of the upper limb. Eighty-three children with C5-C7 injury received BTI with an average age of 4.2 years (ET: 55 months): 39 children in the intern rotators (IR), 44 in the triceps brachii (TB). The primary outcome measure was the Mallet scale at baseline, 3 months followed by a measure at 6 months of ITB. Comparisons using paired t -test were used to assess the statistical significance of the between-group differences. Sub-group analysis on different variables were carried out (age, gender, Mallet sub-score…). For the RI group, the total Mallet score increased significantly at 3 months (+4.3 on average out of a maximum score of 25) and remained significantly greater at 6 months (+2.6) compared to baseline with a greater improvement on the abduction task. For the TB group, the total Mallet score increased significantly at 3 months (+3.8) and remained significantly greater at 6 months (+2.6) compared to baseline with a greater improvement during the hand to mouth task. This study suggests that ITB is likely to improve the motor function of the upper limb of children with OBPP as it has been previously suggested in studies involving smaller groups. It also suggests a specific functional effect depending on the site of the injections and a prolonged effect until 6 months. Randomized controlled trials are needed to definitely confirm these preliminary results.

The effects of Botulinum Toxin injection in an elite sportsman with Functional Popliteal Artery Entrapment Syndrome: A case report

BackgroundBotulinum Toxin-A (BoNT-A) is an effective intervention for Functional Popliteal Artery Entrapment Syndrome (FPAES) however, concerns with this intervention include reductions in strength and performance. Case reportThis case presents an elite male athlete with FPAES who underwent BoNT-A injection and the results of testing before and after injection. The athlete experienced a decrease in strength and performance at one week post-injection however, he returned to baseline levels within four weeks. When comparing sprint distance during games, before and after injection, the athlete had an increase in his sprint distance per game post-injection. Finally on ultrasound he had visible medial gastrocnemius denervation atrophy with a decrease in arterial flow velocity at four weeks post-injection. ConclusionBoNT-A may be an effective minimally invasive treatment option for FPAES however, athletes may experience a transient decrease in function following BoNT-A injection and consequently caution must be taken with regard to treatment timing.

Combined Effect Of Botulinum Toxin And Splinting On Motor Components And Function Of People With Stroke

Background and objective: Spasticity is one of the problems following stroke. Due to this increase in muscle tone, patients are confronted to problems in motor control and difficulties in activities of daily living and complications such as shortness and contracture. The aim of this study was to examine the effects of Simultaneous use of both splint and botulinum toxin-A (BTX-A) injection on spasticity, range of motion and upper extremity function in a 3-month period.Methods: The design of this study was a comparison between 3 groups of interventions, conducted in rehabilitation clinics in Tehran. Sixty people with chronic stroke were recruited. Based on the inclusion criteria, a total of 39 stroke patients after completing the consent forms were entered to intervention groups; splint or botulinum toxin injection or combined splint/botulinum toxin injection. They were followed up about 3 months and the evaluations were done monthly. Goniometry was the method to measure range of motion, and Modified Ashworth scale was used to examine the spasticity and the upper extremity function was scored based on Fugl-Meyer assessment. Statistical analysis was done using SPSS 17. And ANOVAs was used for comparison between groups and times. Significance was set at 0.05.Results: All outcome measures improved within each group but the differences between splint group and BTX-A group and the BTX-A-splint group was not significant in most outcomes during 3 periods (first evaluation until end of the first month, the end of first month until the end of second month, the end of second month until the end of the third month) (p&gt; 0 / 05). The results also showed that the changes in elbow`s spasticity {p= 0.05} and wrist`s spasticity {p= 0.007} and upper extremity function { p = 0.04} were obvious between the three groups over the 3-months and the difference in the group of combined use of botulinum toxin and splint was more than other groups.Conclusion: In this study, the effects of botulinum toxin injection and Volar-Dorsal Wrist/Hand Immobilization splint and the combined use of botulinum injection and splint were obvious in all groups but was not significantly different between the interventions in a 3-month follow-up.

PP135 Stakeholder Involvement In A Health Technology Assessment Of Hyperhidrosis

INTRODUCTION:Hyperhidrosis is characterized by uncontrollable excessive sweating, which occurs at rest, regardless of temperature. Symptoms can significantly affect quality of life. There is substantial variation in the secondary care treatment of hyperhidrosis and uncertainty regarding optimal patient management. The objective of the Health Technology Assessment (HTA) was to review the evidence and establish the expected value of undertaking additional research into effective interventions for the management of primary hyperhidrosis in secondary care. Capturing the perspectives of patients and clinicians treating hyperhidrosis was an important part of the research.METHODS:The assessment included a systematic review and economic model, including value of information analysis. Patients, dermatologists, a vascular surgeon and a specialist nurse (who set up the UK Hyperhidrosis Support Group) provided advice at various stages, including at an end-of-project workshop, to help interpret results and prioritize research recommendations.RESULTS:Patient and clinician advisors were unsurprised by the finding that there is evidence of a large effect of botulinum toxin injections on axillary hyperhidrosis symptoms in the short to medium term; there was consensus amongst patients and clinicians that botulinum toxin injections were very effective. The advisors agreed that a trial of botulinum toxin injections (plus anesthetic) versus iontophoresis for palmar hyperhidrosis would be useful. Patients and clinicians were happy with the sequence of treatments identified as being cost effective for axillary hyperhidrosis: iontophoresis, botulinum toxin injections, anticholinergic medication, curettage, endoscopic thoracic sympathectomy. All patients agreed that the Hyperhidrosis Quality of Life index (HidroQoL©) tool was superior to other commonly used tools for assessing quality of life in hyperhidrosis.CONCLUSIONS:Patients and clinicians considered the key findings of the systematic review and economic analyses to be appropriate. Advisors advocated a trial of botulinum toxin injections (plus anaesthetic) versus iontophoresis for palmar hyperhidrosis. Patients preferred the HydroQoL® tool over other commonly used quality of life tools in hyperhidrosis research.

VP16 Interventional Management Of Hyperhidrosis: A Systematic Review

INTRODUCTION:Hyperhidrosis is characterized by uncontrollable excessive sweating, which occurs at rest, regardless of temperature, and can significantly affect quality of life. There is substantial variation in the availability of treatments in secondary care and uncertainty regarding optimal patient management. A systematic review was undertaken to assess the clinical effectiveness of treatments prescribed by dermatologists (iontophoresis, anticholinergic medications, botulinum toxin injections) and minor surgical treatments (curettage and newer energy based technologies) for primary hyperhidrosis and identify areas for further research.METHODS:Fifteen databases and trial registers were searched to July 2016. Pairwise meta-analyses were conducted for comparisons between botulinum toxin injections and placebo for axillary hyperhidrosis. For other treatments data were synthesised narratively due to limited and heterogeneous data.RESULTS:Fifty studies were included in the review; thirty-two randomized controlled trials (RCTs), seventeen non-RCTs and one case series. There was substantial variation between the studies in terms of country of origin (indicating climate and population differences), interventions and methods of outcome assessment. Most studies were small, at high risk of bias and poorly reported. There was moderate quality evidence of a large statistically significant effect of botulinum toxin injections on axillary hyperhidrosis symptoms in the short to medium term (up to 16 weeks), compared with placebo. There was weak but consistent evidence for iontophoresis for palmar hyperhidrosis. Evidence for other interventions was low or very low quality. Combining the evidence and patient advisor input, we established that further research on the clinical and cost-effectiveness of botulinum toxin injections (with anesthesia) versus iontophoresis for palmar hyperhidrosis would be useful.CONCLUSIONS:The evidence for the effectiveness and safety of treatments for primary hyperhidrosis is limited overall and few firm conclusions can be drawn. However, there is moderate quality evidence to support the use of botulinum toxin injections for axillary hyperhidrosis. A trial comparing botulinum toxin injections with iontophoresis for palmar hyperhidrosis is warranted.

Effect of botulinum toxin injections on gait of children with hereditary spastic paraplegia

Effect of botulinum toxin injections on gait of children with hereditary spastic paraplegia

Successive motor nerve blocks to identify the muscles causing a spasticity pattern: example of the arm flexion pattern.

Botulinum Toxin A has been the main treatment for spasticity since the beginning of the 1990s. Surprisingly, there is still no consensus regarding injection parameters or, importantly, how to determine which muscles to target to improve specific functions. The aim of this study was to develop a systematic approach to determine this, using the example of the arm flexion pattern. We first determined anatomical landmarks for selective motor block of the brachialis nerve, using 20 forearms from 10 fresh cadavers in Ecole Européenne de Chirurgie and a university-based dissection centre, Paris, France. We then carried out selective blocks of the motor nerves to the brachialis, brachioradialis and biceps brachii in patients with stroke with an arm flexion pattern, in a University Rehabilitation Hospital, Garches, France. We measured: the resting angle of the elbow angle in standing (manual goniometer), active and passive range of extension, and spasticity using the Held and Tardieu and the Modified Ashworth scales. Range of passive elbow extension was also measured with the shoulder in 90° of flexion. The resting angle of the elbow in standing decreased by 35.0° (from 87.6±23.7 to 52.6±24.2°) with inhibition of brachialis, by a further 3.9° (from 52.6±24.2 to 48.7±23.7°) with inhibition of brachioradialis and a further 14.5° (from 48.7±23.7to 34.2±20.7°) with inhibition of biceps brachii. These results were consistent with the clinical evaluation of passive elbow range of motion with the shoulder at 90°. Sequential blocking of the nerves to the three main elbow flexors revealed that the muscle that limited elbow extension the most, was brachialis. This muscle should be the main target to improve the arm flexion pattern. These results show that it is important not simply to inject the most superficial or powerful muscles to treat a spastic deformity. A comprehensive assessment is required. The strategy proposed in this paper should increase the effectiveness of botulinum toxin injections by ensuring that the relevant muscles are targeted.

Internal obturator muscle: Proposition of a transforaminal way under ultrasound guidance for botulinum toxin injections

Among pelvitrochanteric muscles, the internal obturator muscle is implicated in some pain projected at the buttock or perineum. Even though the pathophysiology is not completely understood, its responsibility is often held in clinical practice and in the literature due to effectiveness of botulinum toxin injections, constituting a therapeutic test. The objective is to enhance the couple ultrasound/EMG in difficult injections. Eighteen patients were treated in the physical medicine department (Besançon) from September 2015 to February 2016 for gluteal or perineal pain suspected to be related to abnormal spasm of the internal obturator muscle. All patients had a normal MRI of the pelvis. They received an injection of botulinum toxin associated with an anesthetic in the internal obturator muscle under ultrasound and electromyographic guidance. There were 11 women and 7 men (mean age 57 years). The effectiveness of botulinum toxin injections cannot be evaluated because some of the patients were included as part of a national study (PHRC) whose results are not yet known. Regarding the gesture as such, the tolerance is good with, visual analog scale (VAS) is given to 3.1 [1.5–7] in the immediate aftermath of the injection, and 2.8 [1–6.5] to the memory of the injection gesture during a new evaluation 6 to 8 weeks later. It has not been described complication (no hematoma, any orthopedic, visceral or neurological disorders have been reported). Botulinum toxin injections into the internal obturator muscle can be performed under CT control, the patient is placed in the prone position. The aim is to achieve the muscular endopelvic part. This position does not allow under ultrasound guidance to follow the end of the needle, which is why we developed the transforaminal approach of injection in gynecological position. The clinical tolerance of this gesture is good and the images are of very good quality to optimize and secure this type of injection. The couple ultrasound/EMG is available to the clinician and should be enhanced to guide some injections especially for deep sites.

The effect of botulinum toxin injection to the external urethral sphincter on detrusor wall thickness in patients with detrusor-sphincter dyssynergia

Objective To evaluate the effect of injecting botulinum toxin A (BTX-A) to the external urethral sphincter on detrusor wall thickness (DWT) and the bladder function of spinal cord injury patients with detrusor-sphincter dyssynergia (DSD). Methods Twenty-one adult patients with DSD due to spinal cord injury were recruited. A single 100 IU dose of botulinum toxin A was injected into their external urethral sphincters via an ultrasound-guided transperineal route. DWT, detrusor leak-point pressure (DLPP), post-void residual volume (PRV) and maximum bladder capacity(MBC) were assessed by urodynamic examination and ultrasound evaluation before and 4 and 8 weeks after the injection. Results Four weeks later a significant decrease in PRV was observed, but no significant difference in DWT, DLPP or MBC. After eight weeks the mean DWT value had decreased by 17%, a significant reduction. There were also significant improvements in DLPP, PRV and MBC at eight weeks compared with the of baseline values. Conclusions BTX-A injection to the external urethral sphincter can reduce DWT and improve bladder function in spinal cord injury patients with DSD. Key words: Botulinum toxin A; Detrusor wall thickness; Spinal cord injury; Detrusor-sphincter dyssynergia

Revisión sistemática de la eficacia del tratamiento combinado de fisioterapia junto con toxina botulínica tipo A en la espasticidad de miembros inferiores en niños con parálisis cerebral

IntroductionCerebral palsy is the result of non-progressive damage to the central nervous system and causes, among other possible symptoms, pathological muscle tone. Spasticity is very common and leads to limitations in activities of daily living. There are many physical and drug therapies for this altered muscle tone but their effectiveness is widely debated because the results are very different from one individual to another. ObjectiveThe objective of this study was to conduct a systematic review of the effectiveness of treatment of lower limb spasticity in any type of cerebral palsy, using physiotherapeutic and drug treatment with type A botulinum toxin. This effectiveness refers to the achievement of an increase in joint range, a decrease in muscle tone or an improvement in gait that will be reflected in specific rating scales and assessment of scales of activities of daily living. Secondary objectives were to determine the adverse effects of botulinum toxin injection and variability in the duration of its effects. Material and methodA literature search was conducted of studies published from January 2006 to January 2013, inclusive, in the following databases: Cochrane Library, Medline, CINAHL, ISI Web of Knowledge and PEDro. The quality of the clinical trials as well as those of the prospective and retrospective studies was evaluated by the Jadad Scale (also known as the Oxford Quality Scale) and by the Assessment of Multiple Systematic Reviews measurement tool. ResultsFourteen articles met the inclusion criteria. Nine of these studies observed a decrease in muscle tone, an increase in joint range and an improvement in gross motor function. These results varied from one patient to another due to age (better results in patients younger than 6 years old), injected muscles (better results in the sural triceps), use of ultrasound-guided injection for greater injection accuracy, and the patient's cognitive status. DiscussionStatistically significant results were found in the short-term decrease of spasticity in 12 studies, the best moment being detected approximately between the 4th and 5th week after the injection. However, only one study reported that this decrease in muscle tone was maintained in the long term (one year). The use of a large number of different scales hampered comparison of the results of muscle tone measurement or gross motor function assessment in distinct studies. Some articles did not describe the frequency and effects of the implemented rehabilitation programme and therefore it was difficult to determine the extent of the influence of these factors on the effectiveness of botulinum toxin. Orthopaedic treatment was included in 8 studies, obtaining better results in ankle dorsiflexion and in gross motor function. There is wide debate on when botulinum toxin injections should be started to achieve maximal effectiveness; 5 studies claim better results in decreased muscle tone in children younger than 6 years, whereas another study asserts that age is not a conclusive factor. Future studies should incorporate the use of ultrasound during injection, explain the rehabilitation techniques applied and their frequency, include larger and more homogeneous samples to improve quality, and use the most updated and widely accepted scales. ConclusionsCombined treatment with physiotherapy and type A botulinum toxin reduces muscle tone, increases joint range of motion and improves gross motor function, which includes enhanced transfers and gait, especially if orthopaedic treatment is added. Patients showed a peak improvement in muscle tone at approximately one month after the injection. However, this improvement was not maintained in the long term, with pathological muscle tone developing once again.

Effects of botulinum toxin injections on function and quality of life in children with cerebral palsy

Our objective was to show the effects of botulinum toxin injections (BT) on function and quality of life in children with cerebral palsy (CP). A prospective study including 60 children, aged from 2 to 18 years old, who received repeated injections of BT was conducted. Evaluations were done before and after injections including spasticity using the modified Ashworth scale (MAS), functional evaluation using the Gross Motor Function Classification System (GMFCS) and the Manual Ability Classification System (MACS), a videographic record, an evaluation of satisfaction (Visual Analogical Scale) and an evaluation of the quality of life using the Child Health Questionnaire Parent form 50 Questionnaire (CHQ-PF50). The average of the MAS was 2.5 for all injected muscles. Sixty-five percent of children were classed level I, II or III of MACS. All our patients had BT injections. The sural triceps was the most injected muscle. The improvement of spasticity after BT injections in the lower limb was more important for 6-year-old children (improvement of 46%, P < 0.001). We noted a significant increase of the number of walking patients ( P < 0.001) and a beneficial effect on the pattern gait especially for children level III of GMFCS. The percentage of children improved (in GMFCS and MACS) and the average of visual analogical satisfaction scale as well, increased from one injection to another reaching a constant level in the last 2 injections ( P <0.001). We have noted an improvement in the score of CHQ-PF50 (physical and psychosocial score), which was correlated with the functional improvement. Our study shows how BT injections can induce a functional gain in children with CP. An improvement of upper extremity's function, gait pattern and the quality of life upturn were plainly noticed after these injections. Similar benefits of BT [1] , [2] were mentioned in literature.

Safety and efficacy of botulinum toxin injection therapy for esophageal achalasia in Japan.

Botulinum toxin injection is an accepted treatment modality for esophageal achalasia in western countries. This pilot study aimed to clarify the effectiveness of botulinum toxin injection for esophageal achalasia in Japanese patients. We enrolled 10 patients diagnosed with esophageal achalasia between 2008 and 2014. A total of 100 U botulinum toxin A was divided into eight aliquots and injected around the esophagogastric junction. We compared the lower esophageal sphincter pressure before and 1 week after treatment. Scores of subjective symptoms for esophageal achalasia were assessed using a visual analog scale (VAS) before and after 1 week of follow-up of treatment. Barium passage was improved in barium esophagography and passage of contrast agent was also improved. Mean Eckardt score was reduced from 5.5 to 1.6 after treatment (p<0.001). By esophageal manometric study, mean lower esophageal sphincter pressure was reduced from 46.9 to 29.1 mmHg after treatment (p = 0.002). One week after treatment, mean VAS score was reduced from 10 to 3.9 (p<0.001). There were no side effects in any cases. Botulinum toxin injection for esophageal achalasia was safe and effective with few complications. Therefore, botulinum toxin could be used as minimally invasive therapy for esophageal achalasia in Japan.

Antispastic therapy with botulinum toxin type A in patients with traumatic spinal cord lesion.

Objectives: The purpose of this study was to determine the effect of botulinum toxin injections for the treatment of spasticity after traumatic spinal cord injury. Methods: 9 patients were included in this prospective designed study, with a follow-up of at least 2 years. All patients suffered from a massive spasticity after traumatic spinal cord lesion. Conservative treatment options did not show satisfying results. All patients were injected a maximal dose of 2,000 units of botulinum toxin A in no more than 6 skeletal muscle groups. Clinical control examinations were performed after 2 weeks and after at least 2 years. Results: 6 patients reported a good or very good result. One patient offered increasing difficulty in walking for a short time after injection. 2 patients showed no beneficial effects. One patient experienced a modest temporary general weakness for 3 days. After 2 years, 3 patients showed improved function with persistent reduction of spasticity. In the other cases, the beneficial effect lasted for an average of 9 months. Conclusion: Botulinum toxin A injection seems to be an effective complementary therapy option in the treatment of spasticity of paraplegic patients with complete deficit of their motor function (ASIA A and B) and a spastic distribution pattern, effecting only a limited number of muscle groups. Caution has to be recommended for incomplete paretic patients, who are able to walk.

The use of botulinum toxin injections to manage drooling in amyotrophic lateral sclerosis/motor neurone disease: a systematic review.

Difficulty in managing oral secretions is commonly experienced by patients with amyotrophic lateral sclerosis (ALS)/motor neurone disease (MND) and associated bulbar weakness including dysphagia. There are no definitive evidence-based treatment guidelines to manage the distressing symptom of drooling. We reviewed the evidence for the effectiveness of botulinum toxin injections to reduce saliva in ALS/MND. The search strategy was conducted in four stages: (1) electronic search of relevant databases, (2) hand searches of all international ALS/MND symposium journals, (3) email request to MND care centres in the UK and Ireland, and (4) hand searching of reference lists. All studies were critically appraised and relevant data extracted. Botulinum toxin type A and type B were analysed separately. Due to heterogeneity, it was not possible to calculate a pooled estimate of effect. Twelve studies met the inclusion criteria (9 for type A and 3 for type B). Only two randomised controlled trials were identified. Study sample sizes were small with a mean of 12.5 subjects. The most frequently reported outcomes were weight of cotton rolls and number of tissues used. All studies claimed the intervention tested was effective, but only seven studies (4 for type A and 3 for type B) reported statistically significant differences. Although there is evidence to suggest that botulinum toxin B can reduce drooling, the evidence base is limited by a lack of randomized controlled trials. Evidence to support the use of botulinum toxin A is weaker. Larger trials will help remove the uncertainty practitioners face in treating this disabling symptom.

Effect of multisite botulinum toxin injections on gait quality in adults with cerebral palsy

Purpose: In the management of adults with cerebral palsy (CP), one of the goals is to monitor and prevent spasticity-related deteriorations in gait. Botulinum Toxin Injections (BTI) are commonly used to treat this spasticity in these patients. The purpose of this study was to evaluate (i) the effect of multi-site BTI on gait patterns in adults with CP and (ii) to determine if these modifications could be detected by the Gait Deviation Index (GDI). Method: Spontaneous-velocity gait was recorded using 3D gait analysis before and 1 month after multi-site BTI in lower limb muscles. Spatiotemporal parameters (STP), kinematic parameters (KP) and the GDI were computed. Results: Post BTI, stride length, peak hip flexion and peak knee flexion during Swing Phase (SW) were significantly increased while the GDI was not significantly modified. Conclusion: A single multi-site BTI improved STP and KP of adults with CP but the GDI was not sensitive enough to detect these changes.Implications for RehabilitationOnly few study on adults with cerebral palsy BTI approach on the gait patterns are largely unknown.BTI session induced only some smaller improvement of KP and STP.This improvement did not modify the GDI.We cannot determine if GDI is a relevant tool to evaluate changes following BTI or other types of treatment.

Combined Effects of Botulinum Toxin Injection and Hind Limb Unloading on Bone and Muscle

Bone receives mechanical stimulation from two primary sources, muscle contractions and external gravitational loading; but the relative contribution of each source to skeletal health is not fully understood. Understanding the most effective loading for maintaining bone health has important clinical implications for prescribing physical activity for the treatment or prevention of osteoporosis. Therefore, we investigated the relative effects of muscle paralysis and reduced gravitational loading on changes in muscle mass, bone mineral density, and microarchitecture. Adult female C57Bl/6J mice (n = 10/group) underwent one of the following: unilateral botulinum toxin (BTX) injection of the hind limb, hind limb unloading (HLU), both unilateral BTX injection and HLU, or no intervention. BTX and HLU each led to significant muscle and bone loss. The effect of BTX was diminished when combined with HLU, though generally the leg that received the combined intervention (HLU+BTX) had the most detrimental changes in bone and muscle. We found an indirect effect of BTX affecting the uninjected (contralateral) leg that led to significant decreases in bone mineral density and deficits in muscle mass and bone architecture relative to the untreated controls; the magnitude of this indirect BTX effect was comparable to the direct effect of BTX treatment and HLU. Thus, while it was difficult to definitively conclude whether muscle force or external gravitational loading contributes more to bone maintenance, it appears that BTX-induced muscle paralysis is more detrimental to muscle and bone than HLU.

Effectiveness of botulinum toxin injection with and without needle electromyographic guidance for the treatment of spasticity in hemiplegic patients: a randomized controlled trial

Purpose: To compare the effects of botulinum toxin injection with and without needle electromyographic guidance for the treatment of spasticity. Method: A randomized controlled study was conducted in a tertiary university hospital. Twenty-seven adult hemiplegic patients with spasticity due to brain or spinal cord damage were included. Spastic muscles were injected with botulinum toxin with or without EMG guidance. The modified Ashworth scale and modified Barthel index in each patient pre- and post-injection were documented. Results: In group A, which consisted of 15 patients (55.55%), the injection was administered with needle electromyographic guidance, while in 12 patients (44.44%) of group B without electromyographic guidance with the use of anatomic landmarks only. The follow-up period was 3 months. At 3 weeks post-injection, spasticity was decreased (p < 0.05) in all patients and the mean (SD) reduction of spasticity was higher (p < 0.05) in group A (1.67 (0.5)) than group B (1.25 (0.46)). Similarly, the mean (SD) functional modified Barthel index improved statistically significantly (p < 0.001) post-injection (45.37 (8.43)) than pre-injection (54.07 (9.610), especially in group A (p < 0.05). Conclusion: The effectiveness of intramuscular botulinum toxin injection for the treatment of spasticity in hemiplegic patients is superior when performed with needle electromyographic guidance than without electromyography.Implications for RehabilitationIt is recommended that botulinum toxin muscle injections of hemiplegic limbs be performed with EMG guidanceMore spasticity reduction and functional improvement at 3 months post-injection was observed in patients injected with botulinum toxin by the use of combined EMG guidance and anatomic landmarksEMG guidance might also save amount of botulinum toxin due to less spasticity observed during injection than when injection is performed with anatomic landmarks only