Download botox for spasticity

BOTOX FOR SPASTICITY
HAMZA ALSAYOUF
NEUROLOGIST WITH SPECIAL QUALIFICATION IN CHILD NEUROLOGY
AMERICAN BOARD.
GOALS
• 1. Mechanism of action of Botox.
• 2. Therapeutic use of Botox.
• 3. Side Effects of botox.
WHAT IS SPASTICITY??
• “a motor disorder characterized by a velocity-dependent increase in tonic stretch reflexes (muscle tone)
with exaggerated tendon jerks, resulting from hyperexcitability of the stretch and loss of central
inhibition ”
Spasticity can be defined as increased
tightness in affected muscles
Increased tightness in muscles
•
Chest wall  Difficulty raising arm to the side, putting on clothing
•
Elbow flexors  Difficulty straightening arm to reach for items or dressing
•
Wrist flexors
•
Finger flexors  Difficulty opening hand voluntarily or passively (releasing items, hand hygiene)
•
Hamstrings  Difficulty straightening leg
•
Quadriceps  Stiff-knee gait
•
Calf muscles  Difficulty clearing toes when walking (tripping), foot turns in when walking
•
Inner thighs  Legs cross over each other when walking, difficulty pulling legs apart for hygiene
UPPER EXTREMITY SPASTICITY
LOWER EXTREMITY SPASTICITY
SPASTICITY COMPLICATIONS
• Positioning.
• Mobility.
• Hygiene.
• Sitting or Standing Balance.
• Contractures.
TREATMENT GOALS
• Improvements in position
• Mobility
• Pain
• Contracture prevention
• Ease of care if possible
SPASTICITY MANAGEMENT STEPS
Therapeutic modalities:
• Oral Medications
• Nerve blocks & Chemo-denervation (Botox
injections)
• Orthopedic procedures
• Intrathecal Medications
PRIOR TO INTERVENTION
• Assess baseline status Video if possible.
• Determine specific goals.
• Patient and family education
• PT and OT role after intervention
• Consider serial casting.
THERAPEUTIC EXERCISE
• Stretching and range of motion.
• Joint mobilization
• Active assistive, active and resistive exercise
• Endurance training
BOTULINUM TOXIN TYPE A (BOTOX®):
HISTORY OF DEVELOPMENT
FDA approval of
BOTOX®
Dr. Schantz
begins
investigation
C. botulinum
identified
1989
1978
1944
1920s
1895
Botulinum toxin
type A first
isolated
Dr. Scott initiates
first therapeutic
testing in humans
BOTOX® (BOTULINUM TOXIN TYPE A):
A FOCAL THERAPEUTIC
• Injected directly into overactive muscles.
• Reduces contractions.
• Relaxes muscle.
• Allow more normal growth of muscle.
• Allow better response to PT.
• More normal use of the affected muscles.
• Advantages of local injection
− Targeted to specific muscles that are causing the symptoms.
− When used at recommended doses, avoids systemic, overt distant clinical effects.
MECHANISM OF ACTION
• Botulinum toxin acts by binding presynaptically to high-affinity recognition sites
on the cholinergic nerve terminals and decreasing the release of acetylcholine,
causing a neuromuscular blocking effect.
• Recovery occurs through proximal axonal sprouting and muscle re-innervation
by formation of a new neuromuscular junction. eventually the original
neuromuscular junction regenerates
De Paiva A, Meunier FA, Molgo J, Aoki KR, Dolly JO. Functional repair of motor endplates after
botulinum neurotoxin type A poisoning: biphasic switch of synaptic activity between nerve sprouts
and their parent terminals. Proc Natl Acad Sci U S A. Mar 16 1999;96(6):3200-5
DOSING FOR LE SPASTICITY
Muscle
dosing
Number of sites
GASTRONEMIUS
100 (50-250)
2-4
SOLEUS
100
1-4
TIBIALIS POSTERIOR
75 ( 50-150)
1-3
MEDIAL HAMSTRINGS
100 (50-200)
2-4
LATERAL HAMSTRINGS
100(50-200)
2-4
ADDUCTOR
• LONGU/BREVIS/MAGNUS
Dilution : 1:4.
200 IU LEG (75-300)
2-6
• ILIOPSOAS
0.9 % NS
100 (50-200)
2-4
• IF PAINFUL YOU CAN USE LIDOCAINE INSTEAD OF NS.
SIDE EFFECTS
• Local weakness, created by diffusion of Botox and is site specific
• Pain.
• Distant spread and generalazied weakness is a possibility but extremely uncommon.
• Hematoma and bruising are seen regardless of the site injected
MUSCLE IDENTIFICATION
• Three main methods
• Exam and anatomic atlas
• EMG assistance and guidance
• Electronic stimulation
GENERAL RULES
1.Never inject more than every 3 months.
2.Never inject more than 50 IU in one site.
3.Dilute in up to 4 ml of NS.
4.Lidocaine can be used if injection is very painful for patients after injections.
5.To be safe in Kids don’t use more than 15 IU/KG one session.
BOOKS WE RECOMMEND AND USE.
REFERENCES:
• 1. Can Fam Physician. 2011 Sep; 57(9): 1006–1073. Use of botulinum toxin A in management of
children with cerebral palsy. Bat-Chen Friedman, MD and Ran D. Goldman, MD FRCPC.
• 2. Paediatr Child Health. 2005 Sep; 10(7): 379–381. The use of botulinum toxin in paediatric hypertonia
• Darcy Fehlings, MD MSc FRCPC.
• 3. Pediatrics. 2007 Jul;120(1):49-58.Botulinum toxin for spasticity in children with cerebral palsy: a
comprehensive evaluation. Bjornson K1, Hays R, Graubert C, Price R, Won F, McLaughlin JF, Cohen M.