Neuromuscular Conditions Research Articles

Decoding of facial strains via conformable piezoelectric interfaces.

Devices that facilitate nonverbal communication typically require high computational loads or have rigid and bulky form factors that are unsuitable for use on the face or on other curvilinear body surfaces. Here, we report the design and pilot testing of an integrated system for decoding facial strains and for predicting facial kinematics. The system consists of mass-manufacturable, conformable piezoelectric thin films for strain mapping; multiphysics modelling for analysing the nonlinear mechanical interactions between the conformable device and the epidermis; and three-dimensional digital image correlation for reconstructing soft-tissue surfaces under dynamic deformations as well as for informing device design and placement. In healthy individuals and in patients with amyotrophic lateral sclerosis, we show that the piezoelectric thin films, coupled with algorithms for the real-time detection and classification of distinct skin-deformation signatures, enable the reliable decoding of facial movements. The integrated system could be adapted for use in clinical settings as a nonverbal communication technology or for use in the monitoring of neuromuscular conditions.

Which types of conditions should be included in reproductive genetic carrier screening? Views of parents of children with a genetic condition

Reproductive genetic carrier screening identifies couples with an increased chance of having children with autosomal and X-linked recessive conditions. Initially only offered for single conditions to people with a high priori risk, carrier screening is becoming increasingly offered to individuals/couples in the general population for a wider range of genetic conditions. Despite advances in genomic testing technology and greater availability of carrier screening panels, there is no consensus around which types of conditions to include in carrier screening panels. This study sought to identify which types of conditions parents of children with a genetic condition believe should be included in carrier screening. Participants (n = 150) were recruited through Royal Children's Hospital (RCH) Melbourne outpatient clinics, the Genetic Support Network of Victoria (GSNV) and a databank of children with hearing loss (VicCHILD). This study found that the majority of participants support offering carrier screening for: neuromuscular conditions (n = 128/134, 95.5%), early fatal neurodegenerative conditions (n = 130/141, 92.2%), chronic multi-system disorders (n = 124/135, 91.9%), conditions which cause intellectual disability (n = 128/139, 92.1%) and treatable metabolic conditions (n = 120/138, 87.0%). Views towards the inclusion of non-syndromic hearing loss (n = 88/135, 65.2%) and preventable adult-onset conditions (n = 75/135, 55.6%) were more mixed. Most participants indicated that they would use reproductive options to avoid having a child with the more clinically severe conditions, but most would not do so for clinically milder conditions. A recurring association was observed between participants’ views towards carrier screening and their lived experience of having a child with a genetic condition.

CONGENITAL MYOPATHIES 2: P.93 Novel TTN variants identified by whole exome sequencing in patients with prenatal onset titinopathy

The TTN gene encodes the largest human protein, titin, which is of functional and structural importance at the sarcomere. Pathogenic variants in TTN have been reported for a variety of skeletal muscle disorders and cardiomyopathies and exhibit both autosomal dominant and recessive inheritance. Next generation sequencing (NGS) and whole exome sequencing (WES) have allowed for routine sequencing of a large number of genes, including the full TTN gene. These advancements have helped to delineate the phenotypic spectrum in patients with mutations in several neuromuscular genes, including TTN. In 2014, the first patient with arthrogryposis multiplex congenita (AMC) and pathogenic variants in TTN was reported, but additional published cases are limited. Utilizing WES, we have identified four unrelated cases in which the proband presented prenatally or neonatally with features suggestive of a severe neuromuscular condition such as polyhydramnios, hydrops fetalis, talipes equinovarus, arthrogryposis, hypotonia, and/or respiratory insufficiency. In one of these cases, the maternal family history was also suggestive for dilated cardiomyopathy in two siblings. Case one - homozygous c.25063+1G>A (I-band). Case two - c.100296dup (p.Glu33433*, M-band) and c.36402del (p.Val12135Cysfs*23, I-band). Case three - c.38442dupA (p.Pro12815Thrfs*37, I-band) and c.88594+1G>T (A-band). Case four has a maternally inherited c.61921C>T (p.Arg20641*, A-band); however, a second paternal variant was not identified. Although truncating variants in the Z-disc, I-band and M-band in TTN may not confer cardiomyopathy risk, some of these variants may be pathogenic for severe, recessive neuromuscular conditions. TTN variants, in particular protein truncating variants, should be considered in cases of lethal congenital contracture syndrome, AMC, congenital myopathies, and hydrops fetalis. These cases expand our knowledge and understanding of the more severe phenotypic spectrum for titinopathies.

SMA - CLINICAL: P.89 Scoliosis in Spinal muscular atrophy type I in the nusinersen era

Spinal muscular atrophy (SMA) (5q) is an autosomal recessive neurodegenerative neuromuscular condition. SMA is associated with a high rate of mortalities and morbidities. Scoliosis is one of the common morbidities associated with this condition. Nusinersen is a relatively new treatment for SMA patients. A lot is unknown about the long-term effect of nusinersen. To document the development and progression of scoliosis in SMA-type I treated with nusinersen. In this retrospective study, patients with SMA-type I, treated with nusinersen were enrolled.

Prevalence of TMD in patients visiting private dental institution - A retrospective study

Temporomandibular disorder is a collective term for a group of musculoskeletal and neuromuscular conditions. Patients will complain of pain in the TMJ region and the fatigue of the Cranio cervico facial muscles. The aim of the study was to assess the prevalence of TMD in patients visiting a private dental college. This was a retrospective study. Samples were collected from June 2019 to March 2020. The sample size was 55 patients. Data of Temporomandibular disorders were collected. Excel tabulation was done. Chi-Square test was performed and results were obtained using SPSS software. Out of 55 patients, the prevalence of group I of RDC criteria was 34.5%, prevalence of group II of RDC criteria was 62% and the prevalence of group III of RDC criteria was 3.5%. From the present study, it can be concluded that the prevalence of TMD in patients visiting a private dental College was very less. Group II of our RDC criteria was found to be high, with a percentage of 62%.

Structural and Biochemical Characterization of Botulinum Neurotoxin Subtype B2 Binding to Its Receptors.

Botulinum neurotoxins (BoNTs) can be used therapeutically to treat a wide range of neuromuscular and neurological conditions. A collection of natural BoNT variants exists which can be classified into serologically distinct serotypes (BoNT/B), and further divided into subtypes (BoNT/B1, B2, …). BoNT subtypes share a high degree of sequence identity within the same serotype yet can display large variation in toxicity. One such example is BoNT/B2, which was isolated from Clostridium botulinum strain 111 in a clinical case of botulism, and presents a 10-fold lower toxicity than BoNT/B1. In an effort to understand the molecular mechanisms behind this difference in potency, we here present the crystal structures of BoNT/B2 in complex with the ganglioside receptor GD1a, and with the human synaptotagmin I protein receptor. We show, using receptor-binding assays, that BoNT/B2 has a slightly higher affinity for GD1a than BoNT/B1, and confirm its considerably weaker affinity for its protein receptors. Although the overall receptor-binding mechanism is conserved for both receptors, structural analysis suggests the lower affinity of BoNT/B2 is the result of key substitutions, where hydrophobic interactions important for synaptotagmin-binding are replaced by polar residues. This study provides a template to drive the development of future BoNT therapeutic molecules centered on assessing the natural subtype variations in receptor-binding that appears to be one of the principal stages driving toxicity.

Botulinum Toxin Injection in Facial Paralysis and Other Neuromuscular Conditions

Botulinum toxin A (BTX-A) has long been used for the management of the sequelae of facial paralysis and other neuromuscular conditions. Evidence is limited in its efficacy and outcomes, and there is a lack of standardisation in its use. Both objective and subjective outcomes in BTX-A injections for facial paralysis are favourable. Differences are seen depending on type of botulinum toxin used, but most studies recommend OnabotulinumtoxinA. BTX-A injection is an effective method in the treatment of these disorders, improving patient outcomes through a minimally invasive approach. There is however a paucity of randomised control trials and standardisation of protocols of its use.

P98. Radiographic sagittal alignment in the asymptomatic elderly: what is normal for age?

BACKGROUND CONTEXT Over the past several years, there has been an increasing awareness of the impact of positive sagittal alignment in the overall health related quality of life (HRQOL). However, attempts to restore normal spino-pelvic parameters in the elderly population can introduce challenges with risk factors inherent in this age group, and complications such as proximal junctional failure are high. PURPOSE The purpose of this study was to help define ‘normal for age’ sagittal vertical axis (SVA) in asymptomatic individuals ranging 60 to 80 years in order to facilitate most appropriate care. STUDY DESIGN/SETTING This is a prospective cohort study. PATIENT SAMPLE One hundred and fifty-one volunteers were recruited and divided into age groups of 60, 65, 70, 75 and 80 years with equal numbers of men and women. Exclusion criteria included any history of back pain requiring medical attention within previous year, prior spinal surgery, neuromuscular condition, or compression fracture. OUTCOME MEASURES The primary outcome measure was the SVA and secondary measurements included thoracic kyphosis (T4-T12), total lumbar lordosis (L1-S1), lumbar lordosis (L4-S1), pelvic tilt (PT), pelvic incidence (PI), pelvic incidence lumbar lordosis mismatch (PI-LL), sacral slope (SS), and T1 spino-pelvic inclination (T1SPi) were made using Surgimap software. Oswestry Disability Index (ODI);Veterans Rand 12 (VR-12) HRQOL measures were completed. METHODS After informed consent, subjects completed PROMs and full-standing lateral radiographs were obtained. All statistical analysis was conducted with SAS/STAT version 9.4 (Carey, NC). Normality testing was performed and all radiographic measurements were normally distributed and the ODI and VR12 scores were not normally distributed. Measures of central tendency and variance were calculated. Kruskal Wallis tests were used to determine differences across age groups in the ODI and VR12 scores. An analysis of variance with a least square (LS) means test and a Tukey-Kramer adjustment was used to compare, unadjusted and adjusted by gender, differences in all radiographic measurements across age groups. RESULTS There was no significant (p=.07) difference in the gender adjusted LS mean SVA (mm) across age-groups. For the 60, 65, 70, 75 and 80-year old age groups were (20.2, 19.7, 27.7, 37.3, 37.9), respectively which are were in the normal range of CONCLUSIONS Elderly patients with ASD undergoing corrective surgery are vulnerable to increased complications which can negatively affect HRQL outcomes. Our study showed that asymptomatic elderly individuals maintain a normal sagittal profile with an average SVA FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Obstructive Sleep Apnea.

Obstructive sleep apnea (OSA) is often overlooked by clinicians; however, undiagnosed OSA can lead to negative outcomes for patients, including patients with underlying neurologic conditions. Clinicians should be aware of what questions to ask, what diagnostic tests to use, and what treatments to consider in patients with OSA. OSA influences many neurologic conditions, including stroke, epilepsy, headache, and neuromuscular conditions. Treatment of OSA is effective, especially with patient-tailored options, the correct education, and support. OSA is a serious medical condition with impacts on patients' health, safety, and quality of life. Clinicians should identify patients at high risk for OSA and arrange for appropriate diagnosis and treatment, which, in turn, may lead to the improvement of or reduction in risk for neurologic and other health conditions.

Genome-wide detection of tandem DNA repeats that are expanded in autism.

Tandem DNA repeats vary in the size and sequence of each unit (motif). When expanded, these tandem DNA repeats have been associated with more than 40 monogenic disorders1. Their involvement in disorders with complex genetics is largely unknown, as is the extent of their heterogeneity. Here we investigated the genome-wide characteristics of tandem repeats that had motifs with a length of 2-20 base pairs in 17,231 genomes of families containing individuals with autism spectrum disorder (ASD)2,3 and population control individuals4. We found extensive polymorphism in the size and sequence of motifs. Many of the tandem repeat loci that we detected correlated with cytogenetic fragile sites. At 2,588 loci, gene-associated expansions of tandem repeats that were rare among population control individuals were significantly more prevalent among individuals with ASD than their siblings without ASD, particularly in exons and near splice junctions, and in genes related to the development of the nervous system and cardiovascular system or muscle. Rare tandem repeat expansions had a prevalence of 23.3% in children with ASD compared with 20.7% in children without ASD, which suggests that tandem repeat expansions make a collective contribution to the risk of ASD of 2.6%. These rare tandem repeat expansions included previously undescribed ASD-linked expansions in DMPK and FXN, which are associated with neuromuscular conditions, and in previously unknown loci such as FGF14 and CACNB1. Rare tandem repeat expansions were associated with lower IQ and adaptive ability. Our results show that tandem DNA repeat expansions contribute strongly to the genetic aetiology and phenotypic complexity of ASD.

The Ponseti method of treatment for neuromuscular and syndromic (non-idiopathic) clubfeet: evaluation of a programme-based approach at a mean follow-up of 5.8years.

To analyse the results of the Ponseti method in the treatment of non-idiopathic clubfeet and compare them with idiopathic clubfeet in a programme-based setting using a standardized protocol METHODS: We reviewed two groups of 782 children treated prospectively in our programme-based Clubfoot Clinic: group I comprised of 89 patients (146 feet) with non-idiopathic clubfoot and group II comprised of 693 patients (1032 feet) with idiopathic clubfoot. Both groups were compared on the basis of patient demographics, number of casts, tenotomy rate, success rate, rate of recurrences, and the need for additional secondary procedures. Non-idiopathic clubfeet had a higher incidence of bilateral involvement (p = 0.0093) and affected both males and females equally (p = 0.002) as compared with idiopathic clubfeet. Non-idiopathic clubfeet (group I) required significantly more casts (6.75 ± 4.2) compared with idiopathic clubfeet (4.23 ± 4.14), had a higher rate of Achilles tenotomy (90.4% vs 75%, p < 0.0001), and had a lower initial correction rate compared with idiopathic clubfeet (92.5% vs 100%, p < 0.0001). There was a significant difference in the recurrence rates between the two groups, as 42.5% of non-idiopathic feet (38 patients) relapsed compared with 10.2% (71 patients) in the idiopathic group (p < 0.0001). Most recurrences in group I were amenable to re-casting, with only nine patients (14 non-idiopathic clubfeet) requiring extensive soft tissue releases. The final success rate in the non-idiopathic group at a mean follow-up of 5.8years (2-8years) was 87.7%. We recommend the use of the Ponseti method as an effective treatment for non-idiopathic clubfeet associated with neuromuscular and syndromic conditions.

A systematic review of adults` sitting balance assessments in neurological and neuromuscular condition.

Objectives:To find out new assessment tools for sitting, in patients with neurological and neuromuscular conditions, to be recommended for rehabilitation practice locally in Saudi Arabia and internationally.Methods:Four databases were used: PubMed, Web of Science, Ovid Medline, and Cochrane. Inclusion criteria were articles published between the years 2009–2019; sitting, not standing or walking; assessment not intervention; published in English and studies on adults only. Exclusion criteria were any assessment that measures the standing/walking ability or has items for that, and studies that include pediatric or adolescent or both.Results:Ten articles met our criteria including 464 patients and divided into 3 main neurological conditions (stroke, SCI, and MS). One assessment (Function in Sitting Test) showed promising potential being implemented with both stroke and multiple sclerosis, Cronbach’s alpha, α were 0.91 and 0.98 indicating high internal consistency. It was used with SCI patients, however, no access was available to include this study in this review.Conclusion:This review indicates an extension of what was carried out by previous systematic reviews with neurological conditions. It seems that Function in Sitting Test is the most frequent assessment in this review with multiple neurological conditions (stroke, MS and SCI) with high internal consistency and high quality studies according to available data. However, this review showed that there is an absence of evidence for individuals with brain injury. Further work needs to be carried out to address such groups of patients to extend the choices that clinicians can use in rehabilitation sittings.

Infants without apparent risk factors with aspiration as a cause of respiratory symptoms - a retrospective study.

Dysphagia is common in children born prematurely or those with neuromuscular conditions or airway malformations. Few studies have reported on children with isolated dysphagia and there is significant variation in the literature regarding clinical outcomes. The aim of this study was to characterise the clinical presentation of children with isolated dysphagia as well as the diagnostic evaluation, treatment strategies and clinical outcomes. A retrospective chart review was conducted of children with isolated dysphagia presenting to a tertiary paediatric centre over a 10-year period. We describe these patients' presentation, clinical feeding assessment findings, radiological findings, treatment strategies and outcomes. Seventeen children were identified. Recurrent respiratory tract infections were the most common presentation (82%). Oral feeds were continued in 9 (53%) with the remaining being NG fed. Gastrostomy tubes were required for long-term nutrition in 6/8 (75%) of these cases. At follow-up, 11/17 (65%) had resolution of symptoms and are on full oral feeds. The mean age at resolution is 3.45years. Of those who required gastrostomy 50% have had them removed. Isolated dysphagia should be considered in children presenting with recurrent, otherwise unexplained respiratory symptoms. Resolution can take a number of years.

Femoral anteversion: significance and measurement.

Femoral neck anteversion (FNA) is the angle between the femoral neck and femoral shaft, indicating the degree of torsion of the femur. Differences in FNA affect the biomechanics of the hip, through alterations in factors such as moment arm lengths and joint loading. Altered gait associated with differences in FNA may also contribute to the development of a wide range of skeletal disorders including osteoarthritis. FNA varies by up to 30° within apparently healthy adults. FNA increases substantially during gestation and thereafter decreases steadily until maturity. There is some evidence of a further decrease at a much lower rate during adulthood into old age, but the mechanisms behind it have never been studied. Development of FNA appears to be strongly influenced by mechanical forces experienced during everyday movements. This is evidenced by large differences in FNA in groups where movement is impaired, such as children born breech or individuals with neuromuscular conditions such as cerebral palsy. Several methods can be used to assess FNA, which may yield different values by up to 20° in the same participant. While MRI and CT are used clinically, limitations such as their cost, scanning time and exposure to ionising radiation limit their applicability in longitudinal and population studies, particularly in children. More broadly, applicable measures such as ultrasound and functional tests exist, but they are limited by poor reliability and validity. These issues highlight the need for a valid and reliable universally accepted method. Treatment for clinically problematic FNA is usually de‐rotational osteotomy; passive, non‐operative methods do not have any effect. Despite observational evidence for the effects of physical activity on FNA development, the efficacy of targeted physical activity remains unexplored. The aim of this review is to describe the biomechanical and clinical consequences of FNA, factors influencing FNA and the strengths and weaknesses of different methods used to assess FNA.

Botulinum toxin injection, dilution confusion: The impact of toxin diffusion on clinical practice.

Botulinum toxins (BoNT) are a standard of care for spasticity management of children with a variety of neuromuscular (NM) conditions. BoNT relaxes skeletal muscles by inhibiting the release of acetylcholine from the neuromuscular junction (NMJ). As part of their training physiatrist become proficient in the targeted injections of BoNT into affected skeletal musculature. While the pharmacology and pharmacokinetics of BoNT are well characterized, there is limited literature on the clinical impact that varying the volume of diluent that a toxin is reconstituted within. In theory, injection of a larger volume of dilute BoNT would allow for a larger spread affect reaching more distant NMJs; the reverse is also be true. Dilution volume of BoNT injections in children produces some unique situations due to their low weight, smaller muscle bulk, an increased relative risk of spread to surrounding structures, and novel differences in concentration of NMJ in immature muscle. Some of these factors may act as guiding principles that providers can use when adjusting from their standard BoNT dilutional practices. Although, there are recommended dosing strategies available each child's spasticity pattern represents a unique situation and providers must be allowed flexibility to think creatively about dilution strategies for BoNT injections.

Palliative care for young adults with life-limiting conditions: public health recommendations

ObjectiveTo engage young adults (18–35 years of age) with life-limiting neuromuscular conditions, their parents, and health and community providers in the development of a public health approach to palliative care....

Immediate Effects of Bilateral Neuromuscular Taping on Upper Trapezius Muscle in Patients with Chronic Mechanical Neck Pain: A Randomized Clinical Trial

Abstract Background Researchers investigated the effects of neuromuscular taping on different musculoskeletal conditions. Considering the demonstrated short-term effectiveness of neuromuscular taping for the management of shoulder pain, kinesiotaping may also be beneficial in reducing pain in patients with chronic mechanical neck pain. Objective To determine the immediate effects of neuromuscular taping on head position, neck pain and cervical range of motion in individuals with neck pain. Methods Sixty subjects with chronic neck pain were randomly assigned to 1 of 2 groups: the experimental group received neuromuscular taping on upper trapezius bilaterally (with tension) and the placebo group received a sham neuromuscular taping application (without tension). Visual analogue scale (VAS), craniocervical angle and cervical range of motion data were collected at baseline and immediately after the neuromuscular taping application. Results The group-by-time interaction for t-test was statistically significant for pain recorded by visual analogue scale (p&lt; 0.001). Patients in the experimental group obtained a similar improvement in pain to those in the control group (p&lt; 0.001). Conclusions Patients with mechanical neck pain who received and application of neuromuscular taping with proper tension or sham neuromuscular taping exhibited similar reductions in neck pain intensity, but not in cervical range of motion.

Illness Perceptions in Pediatric Spinal Muscular Atrophy: Agreement between Children and their Parents, and its Association with Quality of Life

In adults with neuromuscular conditions illness perceptions show a strong relation with QoL. For young patients, illness perceptions are shaped through interaction with their parents. A shared perception between child and parent may benefit the child’s QoL. This study investigated agreement in illness perceptions of children with Spinal Muscular Atrophy (SMA) and their parents, the association between the child’s illness perceptions and QoL, and the relation between child-parent agreement in illness perceptions and the child’s QoL. Twenty-six children and their parents completed the Brief Illness Perception Questionnaire (BIPQ) and the Kidscreen-52 QoL questionnaire (children only). Correspondence between children’s and parents’ illness perceptions was low. Generally, parents held more negative illness perceptions about SMA. Whereas children’s illness perceptions were related to QoL, no clear association was found between agreement in illness perceptions and children’s QoL. Therefore, to understand and improve QoL, healthcare professionals should discuss children’s own illness perceptions during consultations.

Temporomandibular disorders: Guidelines and Self-Care for Patients During COVID-19 Pandemic

Background: Temporomandibular disorder (TMD) belongs to a heterogeneous group of musculoskeletal and neuromuscular conditions involving the temporomandibular joint complex, musculature and adjacent components. These conditions can generate signs and symptoms and be influenced by an altered biopsychosocial condition. Objective: This study aims to seek information to assist the patient in the presence of TMD signs and symptoms and Orofacial Pain, associated with the period of social isolation during the COVID-19 pandemic. Material and methods: For the preparation of this manual, a bibliographic search was performed in the databases PubMed, Latin American and Caribbean Health Sciences Literature (LILACS), BBO (BVS), Scopus, Web of Science and The Cochrane Library, using the keywords: orofacial pain, temporomandibular disorders, bruxism, stress, anxiety, biopsychosocial, diagnosis, self-care with important information on how to reduce and control the signs and symptoms of TMD and Orofacial Pain in this moment of pandemic that we are experiencing a social detachment. Results: The results show that the pandemic of COVID-19 and the need for social isolation, generates psychological impact that raises the pattern of anxiety and can directly affect patients with bruxism and TMD. Conclusion: Psychological factors associated with the pandemic can lead to an increased risk of developing, worsening and perpetuating bruxism, especially waking bruxism and TMD, so dentists should be aware of the occurrence of signs and symptoms to manage the multifactorial aspects of this condition. At that time, individual self-management strategies are advised for the patient, which consist of self-massage techniques, body education, exercise practices, sleep hygiene, meditation and making available the use of tools and online devices that facilitate this activity.KeywordsOrofacial pain; Temporomandibular disorders; Bruxism; Stress; Anxiety; Biopsychosocial; Diagnosis; Self-care; COVID-19.

Efficacy of Botulinum Toxin for Treating Sialorrhea in Neuromuscular Conditions.

Background: Drooling related to bulbar weakness and dysfunction is a common concern in patients with neuromuscular disease. While there are numerous medications to manage sialorrhea, they are often limited by side effects and lack of efficacy. Botulinum toxin has shown to benefit ALS patients in a few studies, but there is scant data on the benefit in other neuromuscular conditions.Objective: To assess the effectiveness of Botulinum toxin in reducing sialorrhea in patients with various neuromuscular disease.Design/Methods: 25 patients (19M, 6F; 54.36 ± 17.09 yr) with documented neuromuscular illness and concern for drooling was followed for 6 weeks after Botulinum toxin injection. These patients had one of the following diagnoses: Duchenne muscular dystrophy (3), myotonic dystrophy (3), oculopharyngeal muscular dystrophy (1), inclusion body myositis (2), primary lateral sclerosis (1), amyotrophic lateral sclerosis (9), spinal muscular atrophy type 2 and 3 (2), spinal-bulbar muscular atrophy (2), and Becker's muscular dystrophy (2). A subjective drooling scale (1: markedly worse, 5: markedly better) and drooling thickness score (0=normal, 100=thick) was calculated on these patients prior to the injection and 4 and 6 weeks after the injection. Botulinum toxin 20–30 units were injected into bilateral parotid gland (70% of the dose) and submandibular gland (30% of the dose).Results: The drooling thickness score at before the injection was 75.2 ± 10.46. At 4 and 6 weeks, average scores reduced to 47.2 ± 6.14 and 18.8 ± 5.26, respectively (p < 0.05). The average pre injection perception about drooling was 3.0 (p < 0.05). The average change in perception was +0.84 and +1.28 at 4 and 6 weeks, respectively, (p < 0.05) implying significant improvement. There were no reported adverse effects.Conclusion: This study provides preliminary evidence for the use of botulinum toxin for refractory sialorrhea for a variety of neuromuscular conditions.