Use Of Botulinum Toxin Injections Research Articles

BoNT clinical trial update: Sialorrhea.

Sialorrhea is the excessive accumulation of saliva, a prevalent symptom among a number of neurologic conditions in both pediatric and adult patients. Over the years, the management of sialorrhea has evolved and included a variety of interventions, ranging from nonpharmacologic, pharmacologic, and surgical treatment options. The most common option for treatment has been the use of botulinum toxin injections in the management of sialorrhea. While there have been several clinical trials to assess the efficacy of botulinum toxin in the treatment of sialorrhea, the largest randomized control trials to date have been with incobotulinumtoxin (2019) and rimabotulinumtoxin (2020) which show consistent reduction in salivary flow rate and improvement in clinical outcomes with comparable duration of treatment effectiveness. In this update, we review the evolution of treatment and injection methods for sialorrhea among many neurologic diseases. We discuss the challenges in evaluating and measuring efficacy in clinical trials for sialorrhea and compare the contemporary botulinum toxin clinical trials in the treatment of sialorrhea.

Quality of life and its predicting factors for Tunisian children with cerebral palsy.

Cerebral palsy (CP) can cause motor, sensory, perceptual, cognitive, communication and behavioural disorders. The complexity of this condition justifies measuring the quality of life (QOL) of children with CP. This measurement depends on personal and socio-economic factors, hence the relevance of performing it in our cultural context of Tunisia. The objectives of this study were to assess the QOL of Tunisian children with CP and to identify predictive factors for QOL. A cross-sectional study using a self-administered questionnaire (the CP QOL-Child) was employed. It included 68 children with CP and their parents who consulted the outpatient clinics of Physical Medicine and Rehabilitation of the University Hospital of Sahloul Sousse. The QOL of children with CP was altered, and the mean total score for the CP QOL-Child was 59.3 (± 14). All domains were affected by this alteration. Six predictive factors for lowered QOL in children with CP were identified, namely age older than 6 years, swallowing disorders, more intense chronic pain, greater level of motor impairment, the use of botulinum toxin injection and the absence of verbal communication. Intervention with children with CP must be mindful of their altered QOL. Five out of the six predictive factors of QOL are modifiable through a multidisciplinary approach within the framework of the International Classification of Functioning, Disability and Health (ICF). The multiplicity of the factors associated with QOL revealed by this study incites clinicians to adopt the ICF approach by displaying its practical implications on the efficiency of the medical intervention.

The utilization of botulinum toxin for Hirschsprung disease

Patients with Hirschsprung disease (HD) can struggle with persistent obstructive symptoms even after a successful pull-through. These symptoms lead to stasis of stool and can result in Hirschsprung associated enterocolitis (HAEC). Recurrent episodes of HAEC warrant further workup; if there are no signs of mechanical obstruction or an aganglionic pull-through, the use of botulinum toxin injections to the internal anal sphincter has been utilized to relieve these symptoms.In this review, we describe the variations in botulinum toxin injection use and describe ongoing studies to prevent obstructive symptoms and Hirschsprung-associated enterocolitis (HAEC). Botulinum toxin injection utilization has been described for obstructive symptoms after HD pull-through, in the setting of active HAEC, and has been proposed to be part of the treatment algorithm for prevention of HAEC after pull-through. Dosing utilized for the injections, along with the complications, are also described.Prospective, multi-institutional trials are needed to identify the effectiveness of botulinum toxin injections in the outpatient/prophylactic setting as current data suggest some benefits in preventing future obstructive symptoms; however, other studies have conflicting results.

Trigger point injections for myofascial pelvic pain

The objectives of this video are to define myofascial pelvic pain syndrome, illustrate relevant pelvic floor anatomy and exam techniques for the assessment of pelvic floor myofascial pain, and demonstrate trigger point injections to the pelvic floor muscles in a cadaver model. Myofascial pelvic pain syndrome is characterized by contracted bands of skeletal muscles that contain discrete, painful nodules known as trigger points. Trigger points may develop as the primary source of pain or may develop as a downstream effect from other disorders within the pelvis. Myofascial pelvic pain tends to co-exist with other visceral pelvic diseases such as endometriosis or bladder pain syndrome. There is good evidence to support the use of trigger point injections for myofascial pelvic pain. Injections may consist of local anesthetics with or without a steroid. Studies have also evaluated the use of botulinum toxin injections to the pelvic floor muscles for treatment of refractory pelvic floor myofascial pain. This video demonstrates a pelvic floor muscle examination using a cadaver model in addition to performing trigger point injections to the pelvic floor muscles. In conclusion, myofascial pelvic pain syndrome is an important contributor to chronic pelvic pain; a thorough pelvic floor muscle assessment will allow identification of potential trigger points, and trigger point injections may be performed for both diagnostic and therapeutic benefit.

Botulinum Toxin for Treating Temporomandibular Disorders: What is the Evidence?

To systematically review the scientific literature for evidence concerning the clinical use of botulinum toxin (BTX) for the management of various temporomandibular disorders (TMDs). A comprehensive literature search was conducted in the Medline, Web of Science, and Cochrane Library databases to find randomized clinical trials (RCT) published between 2000 and the end of April 2021 investigating the use of BTX to treat TMDs. The selected articles were reviewed and tabulated according to the PICO (patients/problem/population, intervention, comparison, outcome) format. A total of 24 RCTs were selected. Nine articles used BTX injections to treat myofascial pain, 4 to treat temporomandibular joint (TMJ) articular TMDs, 8 for the management of bruxism, and 3 to treat masseter hypertrophy. A total of 411 patients were treated by injection of BTX. Wide variability was found in the methods of injection and in the doses injected. Many trials concluded superiority of BTX injections over placebo for reducing TMD pain levels and improving maximum mouth opening; however, this was not universal. There is good scientific evidence to support the use of BTX injections for treatment of masseter hypertrophy and equivocal evidence for myogenous TMDs, but very little for TMJ articular disorders. Studies with improved methodologic design are needed to gain better insight into the utility and effectiveness of BTX injections for treating both myogenous and TMJ articular TMDs and to establish suitable protocols for treating different TMDs.

Long-term Effects of Repeated Botulinum Toxin Injection in Cosmetic Therapeutics.

Botulinum toxin (BT), a potent neurotoxin, has been used in clinical medicine since the 1970s for cosmetic and therapeutic purposes. Studies have consistently shown positive outcomes with a very limited adverse effect profile and a conventional understanding that results dissipate after 3 to 5 months. However, more recent evidence suggests that changes in muscle composition, function, and appearance persist for much longer, even years. To examine the potential implications of these findings on cosmetic use of BT injections in reduction of skin lines and wrinkles, we first needed to further our understanding of the current literature on long-term outcomes after repeated BT injections. A comprehensive review of the literature on long-term outcomes after repeated BT injections for cosmetic indications was performed. We evaluated the study designs, and results were compared. A total of 22 publications met our inclusion criteria, of which 14 were clinical trials. Few studies extended outcome measurement past 6 months postinjection, and many were funded or supported by industry. However, the studies that extended follow-up saw persistent changes after BT injection, in some cases as far as 4 years postinjection. The current body of knowledge on the long-term results after repeated cosmetic BT injections is very limited, and the available literature provides insufficient evidence on how prolonged effects could alter clinical use of BT. Further clinical studies with extended follow-up periods with inclusion of both subjective and objective measured outcomes of appearance and muscle function are required to better understand the long-term impacts of repeated BT injections.

Dextrose prolotherapy versus BOTOX injection for the management of TMJ disc displacement with reduction

Background: Temporomandibular disc displacement is a widely faced clinical condition and the management options are vast with varying difficulty and success rates. This study aims to evaluate the use of Botulinum Toxin injection and dextrose prolotherapy for such cases. Methods: 20 joints were included in this study divided into 2 groups; Group 1 receiving 25% 3mL Dextrose injection (with local anesthetic and saline solution) into the retrodiscal region while group 2 received 35 U Botulinum Toxin – Type A injection in the lateral pterygoid muscle. Pain (according to the visual analogue scale), clicking and maximal interincisal opening were assessed preoperatively and at 4 months followup. Results: The results showed no statistically significant differences between the 2 groups. The click disappeared in 7/10 joints in group 1 and 9/10 in group 2. The maximal interincisal opening was regained and slightly increased in all participants of the study. All patients reported better pain scores at the end of the followup period. Conclusions: Within the limitations of this study, we conclude that both treatment options tested are considered acceptable in the management of TMJ anterior disc displacement with reduction. Moreover, the results do not allow recommending one over the other as no statistically significant differences were found.

Do gait parameters improve after botulinum toxin injections in post stroke patients? A prospective study

The intramuscular injection of botulinum toxin is one of the most efficient ways to treat localized spasticity in patients suffering from Central Nervous System lesions like stroke, cerebral palsy and multiple sclerosis. The gait analysis based on kinetics and kinematics is a recognized way of measurement of the effect of intramuscular injection of botulinum toxin in spastic patients suffering from chronic stroke. The aim of this study is to provide evidence of the beneficial effect of botulinum toxin on characteristics of gait pattern on patients suffering from chronic stroke. So, thirteen patients with spasticity due to chronic stroke were included in the protocol and were treated by botulinum toxin injections in the lower extremity. All patients were evaluated before the injection as well as one month after the botulinum injection on a foot pressure sensitive walkway with a power plate and by the readings of seven inertial measurements units which recorded spatio-temporal specific parameters during walking, and the spasticity was measured according to modified Ashworth Scale. While all spatio-temporal parameters of motion analysis and balance improved for most of the patients after botulinum toxin injection, only one parameter, the normal to hemiplegic step length, reached statistical significant improvement (p < 0.03). Moreover the modified Ashworth score was statistically improved post injection (p < 0.001). In conclusion the use of botulinum toxin injections is beneficial in post stroke patients as this is depicted in gait parameters improvement which accompanies the spasticity reduction.

P-MD014. Long term repeated use of botulinum toxin injection for hemifacial spasms in sri lanka

Introduction. Hemifacial spasm is a common indication for botulinum toxin use. Aim of this study was to find out the efficacy and safety of long-term use of botulinum toxin for hemifacial spasms in Sri Lanka. Methods. A group of 28 patients with hemifacial spasms who had been given botulinum toxin for more than 7 years were included in the study. Botulinum toxin was given at multiple sites including over the eyelid, at the ipsilateral orbicularis oculi, nasalis, orbicularis oris, mentalis and contralateral orbicularis oris sites on a dilution of 2 ml/100 units. Patients were then followed up every 3 months. Degree of improvement, side effects if any, the total number of units used and the information regarding the last injection used were collected. Results. There were 24 females with a female preponderance of 86%. Mean age (SD) at first injection of the patients was 58.7 (9.1) years. Mean (SD) duration of the repeated use was 10.5 (2.2) years. Range of the duration of treatment was from 7 to 15 years. During this duration, mean (SD) number of injections given was 25.2 (8). Average number of units given for each patient during these multiple injections was 20.3 (2.6). Improvement was seen in 96.5% of the times and side effects were seen only in 2.7% of the time and included heaviness of the eye, mild lower facial weakness and pain at the site of injection which did not last long. Patient compliance was good even after repeated long term use. There were no systemic side effects and drug resistance to botulinum toxin was not seen in these patients. Conclusion. These findings show that the long-term use of botulinum toxin for more than 10 years seems to be safe and efficacious for hemifacial spasm.

The use of botulinum toxin injection into the mentalis muscle in aesthetic medicine procedures

Botulinum toxin, produced by the bacteria Clostridium botulinum, paralyzes muscle contraction by inhibiting the conduction of nerve impulses. Injections of the preparation are widely used as a non-surgical method of improving the face appearance. The mentalis muscles and the surrounding soft tissue are considered key structures in lower facial rejuvenation treatments.The ability to precisely locate the muscle is a challenge for every doctor who performs treatments with the use of neurotoxin and determines therapeutic success. The muscle extends 5–10 mm from the midline and 20–30 mm from the horizontal line joining the mouth, and is present at a depth of 6.7–10.7 mm under the skin. Typically, a single midline injection of 4 to 10 units of onobotulin, incobotulin, parabotulin or 12–30 U of abobotulin is sufficient. Two injections laterally from the center of the chin are allowed, using 4–5 units of the toxin (12–15 U for abobotulin). The aim of the article is to review the use of neurotoxin injection into the mental muscle in aesthetic medicine procedures.

Use of Botulinum Toxin Injections for the Treatment of Chronic Anal Fissure: Results From an American Society of Colon and Rectal Surgeons Survey.

Chronic anal fissure (CAF) is commonly treated by colorectal surgeons. Pharmacological treatment is considered first-line therapy. An alternative treatment modality is chemical sphincterotomy with injection of botulinum toxin (BT). However, there is a lack of a consensus on the BT administration procedure among colorectal surgeons. A national survey approved by the American Society of Colon and Rectal Surgeons (ASCRS) Executive Council was sent to all members. An eight-question survey was sent via ASCRS email correspondence between December 2019 and February 2020. Questions were derived from available meta-analyses and expert opinions on BT use in CAF patients and included topics such as BT dose, injection technique, and concomitant therapies. The survey was voluntary and anonymous, and all ASCRS members were eligible to complete it. Responses were recorded and analyzed via an online survey platform. 216 ASCRS members responded to the survey and 90% inject 50-100U of BT. Most procedures are performed under MAC anesthesia (56%). A majority of respondents (64%) inject into the internal sphincter and a majority (53%) inject into 4 quadrants in the anal canal circumference. Some respondents perform concomitant manual dilatation (34%) or fissurectomy (38%). Concomitant topical muscle relaxing agents are not used uniformly among respondents. Injection of BT for CAF is used commonly by colorectal surgeons. There is consensus on BT dosage, administration site, technique, and the use of monitored anesthesia care.

Functional Dystonia: Differentiation From Primary Dystonia and Multidisciplinary Treatments.

Dystonia is a common movement disorder, involving sustained muscle contractions, often resulting in twisting and repetitive movements and abnormal postures. Dystonia may be primary, as the sole feature (isolated) or in combination with other movement disorders (combined dystonia), or as one feature of another neurological process (secondary dystonia). The current hypothesis is that dystonia is a disorder of distributed brain networks, including the basal ganglia, cerebellum, thalamus and the cortex resulting in abnormal neural motor programs. In comparison, functional dystonia (FD) may resemble other forms of dystonia (OD) but has a different pathophysiology, as a subtype of functional movement disorders (FMD). FD is the second most common FMD and amongst the most diagnostically challenging FMD subtypes. Therefore, distinguishing between FD and OD is important, as the management of these disorders is distinct. There are also different pathophysiological underpinnings in FD, with for example evidence of involvement of the right temporoparietal junction in functional movement disorders that is believed to serve as a general comparator of internal predictions/motor intentions with actual motor events resulting in disturbances in self-agency. In this article, we present a comprehensive review across the spectrum of FD, including oromandibular and vocal forms and discuss the history, clinical clues, evidence for adjunctive “laboratory-based” testing, pathophysiological research and prognosis data. We also provide the approach used at the Massachusetts General Hospital Dystonia Center toward the diagnosis, management and treatment of FD. A multidisciplinary approach, including neurology, psychiatry, physical, occupational therapy and speech therapy, and cognitive behavioral psychotherapy approaches are frequently required; pharmacological approaches, including possible targeted use of botulinum toxin injections and inpatient programs are considerations in some patients. Early diagnosis and treatment may help prevent unnecessary investigations and procedures, while facilitating the appropriate management of these highly complex patients, which may help to mitigate frequently poor clinical outcomes.

Synergic use of botulinum toxin injection and radial extracorporeal shockwave therapy in Multiple Sclerosis spasticity.

Background and aim:In Multiple Sclerosis (MS) spasticity worsens the patient’s quality of life. Botulinum NeuroToxin TypeA (BoNT-A) is extensively used in focal spasticity, frequently combined with physical therapies. Radial extracorporeal shock waves (rESW) were already used in association with BoNT-A. Considering that loss of efficacy and adverse events are determinants of BoNT-A treatment interruption, this study aimed to evaluate the possibility to prolong BoNT-A’s effect by using rESW in MS focal spasticity.Methods:Sixteen MS patients with spasticity of triceps surae muscles were first subjected to BoNT-A therapy and, four months later, to 4 sections of rESWT. Patients were evaluated before, 30, 90 days after the end of the treatments, by using Modified Ashworth Scale (MAS), Modified Tardieu Scale (MTS), and kinematic analysis of passive and active ankle ROM.Results:BoNT-A determined a significant reduction of spasticity evaluated by MAS with a reduction of positive effects after 4months (p<0.05); MTS highlighted the efficacy only 90 days after injection (p<0.05). rESWT decreased MAS values at the end and 30 days later the treatment (p<0.01); MTS values showed instead a prolonged effect (p<0.01). BoNT-A determined a gain of passive and active ankle ROM, persisting along with treatment and peaking the maximum value after rESWT (p<0.05).Conclusions:rESWT can prolong BoNT-A effect inducing a significant reduction of spasticity and improvement in passive and active ankle ROM in MS patients. The use of rESWT following BoNT-A injection is useful to avoid some limitations and to prolong the therapeutic effects of BoNT-A therapy. (www.actabiomedica.it)

Non-surgical techniques for facial rejuvenation

Introduction: Non-surgical techniques to correct aesthetic facial changes associated with the ageing process are a huge part of the ever expanding cosmetic industry due to a lack of regulation and because practitioners do not need to trained doctors or cosmetic surgeons. Commonly used techniques are the use of Botulinum toxin injections, injectable fillers and thread lift procedures.

The Therapeutic Use of Botulinum Toxin Injections for Conditions Affecting the Head and Neck

Botulinum toxin has been used for the past few decades to treat conditions in the head and neck. In recent years, its use is expanding. This article presents a summary of the wide range of uses in the laryngeal, pharyngeal, cervical, oromandibular and facial muscles. As well as the uses discussed in this article, botulinum toxin has also been used more recently for a newly recognized condition: retrograde cricopharyngeus dysfunction. The condition and its treatment are discussed. Botulinum toxin is a safe and generally successful treatment for spasmodic dysphonia, Meige syndrome and oromandibular and cervical dystonia; neurological conditions, such as multiple system atrophy and migraine; and finally the oropharynx, post-laryngectomy, cricopharyngeal dysphagia, Zenker’s diverticulum and retrograde cricopharyngeal dysfunction disorder.

Botulinum Toxin Injections as a Treatment of Postoperative Chronic Neck Pain Secondary to Cervical Spine Surgery

AbstractPostoperative neck pain is a relatively common consequence of cervical spine surgeries such as anterior cervical discectomy with fusion and laminoplasty. Botulinum toxin injections are a relatively new treatment option to target muscle spasms, a possible cause of postoperative neck pain. This systematic review aims to evaluate the current literature highlighting the utilization of botulinum toxin for treating postoperative neck pain. The literature search resulted in one preliminary case–control trial, one case series and one case report. The use of Botox in these studies had promising benefits on postoperative neck pain, by reducing visual analog scores and improving objective measures of muscle tone such as cervical lordosis angle. While not seen in these studies, the use of botulinum toxin injections into the muscles of the region of the head, neck, and shoulder is not without risks such as focal muscle loss, joint instability, and respiratory and swallowing difficulty. With this in mind, while botulinum toxin may be a promising treatment for these patients, further well-designed studies are needed to further assess the treatments efficacy and safety in this patient population.

Endoscopic management of gastrointestinal motility disorders – part 1: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

ESGE recommends the use of a graded pneumatic dilation protocol in achalasia, starting with a 30-mm dilation and followed by a 35-mm dilation at a planned interval of 2 - 4 weeks, with a subsequent 40-mm dilation when there is insufficient relief, over both a single balloon dilation procedure or the use of a larger balloon from the outset.Strong recommendation, high quality of evidence, level of agreement 100 %.ESGE recommends being cautious in treating spastic motility disorders other than achalasia with peroral endoscopic myotomy (POEM).Strong recommendation, very low quality of evidence, level of agreement 87.5 %.ESGE recommends against the routine use of botulinum toxin injections to treat patients with non-achalasia hypercontractile esophageal motility disorders (Jackhammer esophagus, distal esophageal spasm). However, if, in individual patients, endoscopic injection of botulinum toxin is chosen, ESGE recommends performing injections into four quadrants of the lower esophageal sphincter and in the lower third of the esophagus.Strong recommendation, low quality of evidence, level of agreement 78.6 %.ESGE recommends that endoscopic pylorus-directed therapy should be considered only in patients with symptoms suggestive of gastroparesis in combination with objective proof of delayed gastric emptying using a validated test, and only when medical therapy has failed.Strong recommendation, very low quality of evidence, level of agreement 100 %.ESGE recommends against the use of botulinum toxin injection in the treatment of unselected patients with gastroparesis. Strong recommendation, high quality of evidence, level of agreement 92.9 %.ESGE recommends consideration of gastric peroral endoscopic myotomy (G-POEM) in carefully selected patients only, because it is an emerging procedure with limited data on effectiveness, safety, and durability. G-POEM should be performed in expert centers only, preferably in the context of a clinical trial.Strong recommendation, low quality of evidence, level of agreement 100 %.

Botulinum Toxin Injections for Masseter Reduction in East Asians.

Cultural ideals for a slimmer face have led to an upsurge in interest in facial contouring among East Asians. Although surgical resection has traditionally been the main treatment option, botulinum toxin injection is becoming a popular, noninvasive alternative. To describe the use of botulinum toxin injection for masseter reduction in East Asians. An electronic search of the PubMed database was performed for studies published from 2000 to 2017 that meet the word combination of botulinum toxin, masseter, hypertrophy, and/or lower face contouring. Only the studies conducted in East Asian countries were analyzed in this review, exception of one study from Thailand. A total of 12 publications were identified. Each study was reviewed to extract relevant information on patient selection, injection techniques, efficacy, dosage, frequency, and main side effects of treating masseters with botulinum toxin. Botulinum toxin injection for masseter reduction in East Asians is efficacious and generally considered safe with no significant side effects. Future areas for investigation include defining the criteria for benign masseteric hypertrophy, minimum effective dosage of botulinum toxin, and the potential long-term effects of the injection.

Management of hyperhidrosis in secondary care

Hyperhidrosis is uncontrollable excessive sweating, which occurs at rest, regardless of temperature. It can have a major impact on people's quality of life. Primary hyperhidrosis is thought to affect at least 1% of the UK population. There is considerable variation in the availability of treatments in specialist care. This systematic review from the UK assessed the effectiveness of treatments used in specialist care for patients with hyperhidrosis. A comprehensive search was undertaken to find relevant studies of hyperhidrosis treatments. The quality of the studies was assessed. Patient advisors contributed to the interpretation of the results. Fifty studies were included in the review, most were small and of poor quality. The treatments assessed were iontophoresis, botulinum toxin injections, anticholinergic medications, curettage and other technologies that damage the sweat gland. Some studies assessing botulinum toxin injections for hyperhidrosis of the armpit were pooled together to estimate average effects. Our review found that there was moderate quality evidence that botulinum toxin injections reduce symptoms of armpit hyperhidrosis in the short and medium term (up to 16 weeks), compared with placebo (no treatment). There was weak but consistent evidence of some benefit from using iontophoresis for hyperhidrosis of the hands. Evidence for other interventions was of low or very low quality. Overall, the evidence for the effectiveness of treatments for primary hyperhidrosis is limited and few firm conclusions can be drawn. However, there is moderate quality evidence to support the use of botulinum toxin injections in clinical practice. A well conducted, adequately powered, randomised controlled trial of botulinum toxin injections compared with iontophoresis (which is the current standard treatment in many dermatology units for palmar hyperhidrosis, which affects the palms of the hands) for palmar hyperhidrosis may be warranted.

The Use of Botulinum Toxin Injection for Brachial Plexus Birth Injuries: A Systematic Review of the Literature.

Most brachial plexus birth injuries (BPBIs) are caused by traction on the brachial plexus during a difficult delivery. Fortunately, the possibility of complete recovery from such an incident is relatively high, with only 10% to 30% of patients having prolonged and persistent disability. These patients have muscle imbalances and co-contractions typically localized around the shoulder and elbow. These imbalances and co-contractures cause abnormal motor performances and bone/joint deformities. Typically, physical/occupational therapies are the conventional therapeutic modalities but are often times inadequate. Botulinum toxin A (BTX-A) injections into targeted muscles have been used to combat the muscular imbalances and co-contractions. With compliance to PRISMA guidelines, a systematic review was performed to identify studies published between 2000 and 2017 that used BTX-A to treat neonatal brachial plexus palsies. Ten studies were included, involving 325 patients. Three groups of indications for the use of BTX-A were identified: (1) internal rotation/adduction contracture of the shoulder; (2) elbow flexion lag/elbow extension lag; and (3) forearm pronation contracture. The included studies show an overall beneficial effect of BTX-A in treating co-contractures seen in patients with BPBI. Specifically, BTX-A is shown to reduce internal rotation/adduction contractures of the shoulder, elbow flexion/extension contractures, and forearm pronation contractures. These beneficial effects are blunted when used in older patients. Nevertheless, BTX-A is a useful treatment for BPBIs with a relatively low-risk profile.