Effect of a rigid ankle-foot orthosis on hamstring length in children with hemiplegia

Eighteen children with hemiplegia, mean age 8 years 5 months, underwent gait analysis and musculoskeletal modelling using specially designed software. The maximum lengths of the hamstrings were determined for each child walking in and out of an ankle-foot orthosis (AFO). The muscles were deemed to be short if shorter than the normal average -1SD. In bare feet 8 participants had short medial hamstrings with a higher proportion of these in the less involved individuals. All participants showed an increase in maximum hamstring length when wearing an AFO. In all but one child this was sufficient to restore hamstring length to within normal limits. These finding suggest that hamstring pathology in hemiplegic gait is usually secondary to more distal lower limb pathology.     

The epidemiology and clinical manifestations of hamstring muscle and plantar foot flexor shortening

A population of 920 healthy children was studied with the aim of assessing the incidence of hamstring muscle and plantar foot flexor tightness, and to correlate such symptoms with gait, posture, and low back discomfort or pain. Special attention was paid to the popliteal angle and dorsal foot flexion. The borderline values for the popliteal angle in the following age groups were, boys: 3 to 5 years, 40^o; 6 to 15 years, 50^o; and 16 to 19 years, 40^o; girls: 3 to 5 years, 30^o; 6 to 14 years, 45^o; 15 to 19 years, 30^oo. The borderline values for dorsal foot flexion in the following age groups were 3 to 4 years, 7^o; 5 to 13 years, 10^o; and 14 to 19 years, 5^o. The results obtained indicate a natural increase in hamstring tightness, particularly shortly before the pubertal growth spurt. This seems to be linked with the natural evolution of lumbar lordosis and pelvic tilt. When hamstring tightness surpassed borderline values, dorsiflexion and lumbar lordosis decreased leading to postural deformities, bending-forward deficit, discomfort when sitting, and a shambling gait.     

Relation between walking speed and muscle strength is affected by somatosensory loss in multiple sclerosis

OBJECTIVE: To evaluate the correlation between gait speed and strength in multiple sclerosis (MS) with particular regard to patients presenting with proprioceptive loss. METHODS: Gait evaluation and isokinetic testing of muscular function were performed in 20 patients with unaided gait (expanded disability status scale < 6). Patients were separated into two groups in relation to the occurrence of somatosensory involvement: pyramidal group (8 patients) and sensory-pyramidal group (12 patients). Ten healthy subjects of similar age, sex, and height constituted a control group to evaluate gait parameters. RESULTS: In the whole patient group, gait speed was reduced and strongly related to hamstring peak torque but not with quadriceps peak torque. The gait speed and peak torques of quadriceps and hamstrings were similar in both groups of patients. However, in the patients with proprioceptive loss there was both a strong correlation between gait speed and hamstring torque and a significant correlation with quadriceps torque. In the pyramidal group there was poor or no correlation. CONCLUSION: In patients with undifferentiated MS there is some correlation between gait speed and muscle strength. In the case of sensory loss, a higher contribution of both flexor and extensors of the lower limbs was observed, suggesting that muscular compensation occurred in this situation to maintain gait speed. These results are relevant to assess rehabilitation modalities in MS.     

Lower limb muscle activity in ambulatory children with cerebral palsy before and after the treatment with Botulinum toxin A

Purpose: The study investigated the effect of Botulinum toxin A on the gait and lower limb muscle activity of ambulatory CP children. Methods: 19 spastic diplegic and 4 left hemiparetic CP children were injected with a mean dose of 23.5 units of Botulinum toxin A/kg body weight into the gastrocnemius and hamstring muscles. Muscle tone and gait analysis including the kinesiological electromyogram of the shank and thigh muscles were assessed before and four weeks after injection and compared with the help of a multivariate analysis (p < 0.05). Results: Botulinum toxin A caused a definite reduction of plantarflexor, knee and hip hypertonia in 21 children, resulting in a more plantar grade and erect gait in 17 children four weeks after injection. Gait analysis showed a statistically significant improvement in peak ankle dorsi-flexion and knee extension during stance, and the length of the force point of action under both feet increased. Electromyography revealed sig-nificantly less co-contraction of the lower leg muscles, due to a more phasic instead of a tonic activity of the tibialis anterior muscle, and an improved activation pattern of the left rectus and biceps femoris muscles. Conclusions: The present study demonstrated that the injection of Botulinum toxin A resulted in a more mature muscle activation pattern of CP children. Most of the children walked more plantigrade and erect, the functional gait parameters, however, did not change.     

Electromyographic evaluation of the sound and involved side during gait of spastic hemiplegic children with cerebral palsy

The purpose of this study was to investigate the surface electromyogram (EMG) of the lower limbs of hemiplegic children with spastic cerebral palsy during gait. The EMG of seven muscles was analyzed for 17 children (5-12 years old). The EMG of the involved side was decreased for the examined shank muscles and increased for the hamstrings, during certain phases of the gait cycle, compared with the sound side. The rectus femoris of the involved side showed prolonged activation during the swing phase. The enhanced activation of the hamstrings may be beneficial/compensatory, preventing knee hyperextension. The presence of equinus foot obstructs the foot clearance and hence the prolonged rectus femoris EMG activity during the swing phase may contribute to shorten the lower limb by flexing the hip. Possible compensatory mechanisms of the proximal muscles of the involved lower limb that can be measured with instrumented gait analysis should be taken into account before the decision for a specific treatment.     

Gait Electromyography in Normal and Spastic Children, with Special Reference to Quadriceps Femoris and Hamstring Muscles

Telemetered gait electromyography was used to investigate gait patterns and the phasic behavior of the quadriceps femoris and medial hamstring muscles in 26 normal children and 32 children with spastic cerebral palsy. The average child with spastic cerebral palsy was found to have a shorter stance phase than the normal, but the cadence, while more variable, was nearly the same as normal. The spastic muscles typically exhibited prolonged phasic activity or a dysphasic pattern. Most of the patients with spastic hamstrings also had spastic quadriceps, suggesting that over-weakening the hamstrings may produce an unwanted genu recurvatum or hyperextended knee gait. Care must be taken to balance hamstring spasticity with quadriceps spasticity. A final result with slight knee flexion is preferable to hyperextension.     

Continuous, bilateral Achilles’ tendon vibration is not detrimental to human walk

Sensory feedback from the moving limbs contributes to the regulation of animal and human locomotion. However, the question of the specific role of the various modalities is still open. Further, functional loss of leg afferent fibres due to peripheral neuropathy does not always lead to major alteration in the gait pattern. In order to gain further insight on proprioceptive control of human gait, we applied vibratory tendon stimulation, known to recruit spindle primary afferent fibres, to both triceps surae muscles during normal floor walk. This procedure would disturb organisation and execution of walking, especially if spindles fire continuously and subjects are blindfolded. Vibration induced significant, though minor, changes in duration and length of stance and swing phase, and on speed of walking and kinematics of lower limb segments. No effect was induced on angular displacement of the ankle joint or trunk and head kinematics. This paucity of effects was at variance with the perception of the subjects, who reported illusion of leg stiffness and gait imbalance. These findings would speak for a selective gating of Ia input during locomotion and emphasise the notion that the central nervous system can cope with an unusual continuous input along the Ia fibres from a key muscle like the soleus.     

Continuous, bilateral Achilles' tendon vibration is not detrimental to human walk.

Sensory feedback from the moving limbs contributes to the regulation of animal and human locomotion. However, the question of the specific role of the various modalities is still open. Further, functional loss of leg afferent fibres due to peripheral neuropathy does not always lead to major alteration in the gait pattern. In order to gain further insight on proprioceptive control of human gait, we applied vibratory tendon stimulation, known to recruit spindle primary afferent fibres, to both triceps surae muscles during normal floor walk. This procedure would disturb organisation and execution of walking, especially if spindles fire continuously and subjects are blindfolded. Vibration induced significant, though minor, changes in duration and length of stance and swing phase, and on speed of walking and kinematics of lower limb segments. No effect was induced on angular displacement of the ankle joint or trunk and head kinematics. This paucity of effects was at variance with the perception of the subjects, who reported illusion of leg stiffness and gait imbalance. These findings would speak for a selective gating of Ia input during locomotion and emphasise the notion that the central nervous system can cope with an unusual continuous input along the Ia fibres from a key muscle like the soleus.     

Exoskeleton-assisted gait in chronic stroke: An EMG and functional near-infrared spectroscopy study of muscle activation patterns and prefrontal cortex activity

ObjectivesGait impairment dramatically affects stroke patients’ functional independence. The Ekso™ is a wearable powered exoskeleton able to improve over-ground gait abilities, but the relationship between the cortical gait control mechanisms and lower limbs kinematics is still unclear. Our aims are: to assess whether the Ekso™ induces an attention-demanding process with prefrontal cortex activation during a gait task; to describe the relationship between the gait-induced muscle activation pattern and the prefrontal cortex activity.MethodsWe enrolled 22 chronic stroke patients and 15 matched controls. We registered prefrontal cortex (PFC) activity with functional Near-Infrared Spectroscopy (fNIRS) and muscle activation with surface-electromyography (sEMG) during an over-ground gait task, performed with and without the Ekso™.ResultsWe observed prefrontal cortex activation during normal gait and a higher activation during Ekso-assisted walking among stroke patients. Furthermore, we found that muscle hypo-activation and co-activation of non-paretic limb are associated to a high prefrontal metabolism.ConclusionsAmong stroke patients, over-ground gait is an attention-demanding task. Prefrontal activity is modulated both by Ekso-assisted tasks and muscle activation patterns of non-paretic lower limb. Further studies are needed to elucidate if other Ekso™ settings induce different cortical and peripheral effects.SignificanceThis is the first study exploring the relationship between central and peripheral mechanisms during an Ekso-assisted gait task.     

Soleus muscle length, stretch reflex excitability, and the contractile properties of muscle in children and adults: a study of the functional joint angle

The influence of the joint angle on stretch reflex excitability of the soleus muscle at the ankle has been studied in 22 children aged 3.9 to 13.6 years and 9 adults aged 19 to 70 years. For all subjects, reflex EMG and mechanical twitch torque gain were trivial at resting plantar flexion. The reflex EMG gain reached a maximum between-15^o and-10^o of plantar flexion beyond the neutral angle, 0^o, denned as the foot at right angle to the tibia, diminishing steeply with further dorsiflexion. The reflex mechanical gain rose to a peak between 0^o and +10^o of dorsiflexion beyond neutral, declining steeply thereafter. By contrast, axonally stimulated muscle twitch torque increased serially up to +30^o dorsiflexion beyond neutral. For the soleus muscle, the optimal reflex neuromechanical angle lies approximately midway between the angle for optimal reflex EMG gain (in mild plantar flexion, at which the largest and strongest motor units can be activated) and the optimal muscle mechanical angle (at the extreme of soleus muscle dorsiflexion). These studies confirm that the excitability of the spinal alpha motor neuron pool in vivo is strongly influenced by muscle length and explain the variability in reflex excitability within and between subjects, if the joint angle is not controlled. They also indicate how posture influences movement, agreeing with the known function of the soleus muscle in the stance phase of gait and the modulation of motor unit recruitment during voluntary alternating movements at the ankle. Soleus muscle twitch characteristics show a fivefold to eightfold increase in peak force associated with a tenfold reduction in compliance in the first two decades of life and an apparent speeding up of twitch time in the first decade.     

Effect of multilevel botulinum toxin a and comprehensive rehabilitation on gait in cerebral palsy

To evaluate the effect of multilevel botulinum toxin A and comprehensive rehabilitation on gait pattern, muscle length, and spasticity, a multicenter randomized trial was performed in 46 children with spastic cerebral palsy who walk with flexed knees. Their mean age was 8.0 years (range 4 to 11 years). They were randomly allocated to the intervention group (multilevel botulinum toxin A and comprehensive rehabilitation) or the control group (usual care). After 6 weeks, a significant treatment effect in the intervention group was observed on: improved knee extension during midstance and terminal swing (7 degrees and 5 degrees , P < 0.01, respectively); hip rotation during terminal swing (4 degrees , P = 0.02); gait score (1.7, P < 0.01); decreased spasticity in hamstrings (11 degrees , P < 0.01), gastrocnemius (6 degrees , P = 0.01), and soleus (5 degrees , P = 0.02); and increased muscle length in hamstrings (9 degrees , P < 0.01) and gastrocnemius (5 degrees , P < 0.01). The improved muscle length was maintained up to 24 weeks. This study demonstrated that multilevel botulinum toxin A and comprehensive rehabilitation improves knee extension during gait, increases muscle length, and decreases spasticity in injected muscles after 6 weeks in children who walk with flexed knees. Although the effect on muscle length was maintained after 24 weeks, the effect on gait and spasticity had disappeared.     

Botulinum toxin injection in patients with hereditary spastic paraparesis

In an open label study, we analyzed the efficacy of botulinum toxin injection at the lower limbs of patients with hereditary spastic paraparesis (HSP). Fifteen patients who showed disabling spasticity with no or poor effect of oral treatment were recruited consecutively. Botulinum toxin was injected (400 U; Botox^®) into the spastic muscles identified by clinical examination (equinus, varus, and pathological hip adduction). Patients were regularly assessed from the first day to the fifth month: spasticity (Ashworth), motor strength, range of movements, Functional Ambulation Categories (FAC), gait parameter, Rivermead Motor Assessment, self-analysis of benefit and satisfaction. We observed a moderate and significant ( P  < 0.05) reduction of ankle plantar flexor and hip adductor spasticity, with a partial increase in the range of the active and passive motion at the ankle and in gait velocity. At an individual level, six of 15 patients showed an increase in gait velocity. The FAC and RMA did not change. Patients often reported partial improvement in foot position and lower limb propulsion, and fair satisfaction. In conclusion, botulinum toxin injection can be effective in HSP patients with relatively ancient spasticity. This technique can be introduced into the therapeutic panel, which also includes physiotherapy, oral treatment and baclofen pump.     

"Task-oriented" exercise improves hamstring strength and spastic reflexes in chronic stroke patients.

BACKGROUND AND PURPOSE: Despite the belief that after cerebral infarction only limited functional gains are possible beyond the subacute period, we tested the hypothesis that a 12-week program of "task-oriented" treadmill exercise would increase muscle strength and decrease spastic reflexes in chronic hemiparetic patients. METHODS: Fourteen subjects, aged 66+/-3 (mean+/-SEM) years, with residual gait deviations due to remote stroke (>6 months), underwent repeated measures of reflexive and volitional (concentric and eccentric) torque with use of isokinetic dynamometry on the hamstring musculature bilaterally. Torque output was measured at 4 angular velocities (30(o), 60(o), 90(o), and 120(o)/s). RESULTS: After 3 months of 3 times/wk low-intensity aerobic exercise, there were significant main effects (2 legs [P<0.01]x2 times [P<0. 01]x4 angular velocities [P<0.05]) for concentric torque production. Torque/time production in the concentric mode also improved significantly in the paretic (50%, P<0.01) and nonparetic hamstrings (31%, P<0.01). Eccentric torque/time production increased by 21% (P<0.01) and 22% (P<0.01) in the paretic and nonparetic hamstrings, respectively. Passive (reflexive) torque/time generation in the paretic hamstrings decreased by 11% (P<0.027). Reflexive torque/time was unchanged in the nonparetic hamstrings (P=0.45). CONCLUSIONS: These findings provide evidence that progressive treadmill aerobic exercise training improves volitional torque and torque/time generation and reduces reflexive torque/time production in the hemiparetic limb. Strength changes associated with improved functional mobility in chronic hemiparetic stroke survivors after treadmill training will be reported in future articles.     

Effects of augmented proprioceptive cues on the parameters of gait of individuals with Parkinson's disease

Context:

Impairment of initiating sequential movements and processing of proprioception contribute to characteristic Parkinson''s disease (PD) gait abnormalities. Many studies have used a single external cue or 2 different cues to correct PD gait.

Aim:

An aim of this study was to determine the influence of paired proprioceptive cues on gait parameters of individuals with PD.

Setting and Design:

Double-blind randomized controlled trial.

Materials and Methods:

Subjects were 30 PD patients who had mild to moderate impairment according to the United Parkinson''s Disease Rating Scale (UPDRS). They were randomly assigned to either a routine physiotherapy program or treadmill training with vibratory stimuli applied to the feet plantar surfaces and proprioceptive neuromuscular facilitation (PNF) as well as the same physiotherapy program. All Participants received a 45-minutes session of low intensity physiotherapy program, 3 times a week, for 8 weeks. The duration of treadmill training was 5 minutes at baseline and 25 minutes at the end of treatment. Walking speed and distance were recorded from the treadmill control panel for both groups before and immediately after the end of treatment. The Qualysis ProReflex motion analysis system was used to measure cadence, stride length, hip, knee, and ankle joints’ angular excursion.

Results:

The cadence, stride length, and lower limb joints’ angular excursion showed a significant improvement in both groups (P ≤ 0.05). These improvements in spatio-temporal parameters and angular excursion were higher in the study group than in the control group (P ≤ 0.05).

Conclusion:

Potentiated proprioceptive feedback improves parkinsonian gait kinematics, the hip, knee, and ankle joints’ angular excursion.     

Effectiveness of botulinum toxin A for upper and lower limb spasticity in children with cerebral palsy: a summary of evidence

Botulinum toxin type A (BoNT-A) therapy has gained wide acceptance in the management of spasticity in cerebral palsy (CP). Clinical experience from numerous case reports and series, retrospective and prospective open label cohort studies, and randomized controlled trials (RCT) has grown over the past 10 years. Several independent systematic reviews on the role of BoNT-A for upper and lower limb spasticity have been written by various authors. The objective of this paper is to summarize past systematic reviews and recent RCT not yet included in the systematic reviews that assess the effectiveness of BoNT-A in upper and lower limb spasticity in children with CP. We reviewed four Class II RCT discussed in five independent systematic reviews and two new Class II trials on the use of BoNT-A alone or with occupational therapy compared to placebo or occupational therapy alone in children with upper limb spasticity. There were 229 children recruited in these six trials and of those, 115 children received BoNT-A in the upper limbs. Five of six RCT showed a time limited decrease in muscle tone most especially at the wrist. Four of six trials showed improvement of hand function on a few specific functional tests. Four systematic reviews concluded that there is insufficient and inconsistent evidence to support or refute the effectiveness of BoNT-A in upper limb spasticity but one recent review recommended that BoNT-A should be considered as a treatment option in upper limb spasticity. For lower limb spasticity, we reviewed 13 RCT discussed in six systematic reviews and two new trials comparing BoNT-A with placebo or other rehabilitation modalities such as physiotherapy, occupational therapy, casting or electrical stimulation. In these studies, 617 children were recruited and of those, 360 children received BoNT-A in the lower limbs. There were six Class I and nine Class II trials. Three Class I trials documented significant improvement in gait pattern in children with gastrocnemius spasticity and one Class I study showed significant reduction in tone in the hip adductors. The most recent review establishes BoNT-A as an effective treatment for equinovarus deformity. Adverse events in these trials were mild and self-limited. The most common complaints were pain in the injection sites and transient weakness. BoNT-A is considered safe for use in children. In conclusion, there is now growing convincing evidence for the time limited beneficial effect of BoNT-A in decreasing muscle tone in children with upper and lower limbs spasticity associated with CP. Decrease muscle tone in the lower limbs translates to improved gait in CP children with spastic equinovarus however more systematic studies are necessary to show sufficient evidence for improved hand function from BoNT-A injection in the upper limbs.     

Gait pattern in myotonic dystrophy (Steinert disease): a kinematic, kinetic and EMG evaluation using 3D gait analysis

We investigated the gait pattern of 10 patients with myotonic dystrophy (Steinert disease; 4 females, 6 males; age: 41.5+7.6 years), compared to 20 healthy controls, through manual muscle test and gait analysis, in terms of kinematic, kinetic and EMG data. In most of patients (80%) distal muscle groups were weaker than proximal ones. Weakness at lower limbs was in general moderate to severe and MRC values evidenced a significant correlation between tibialis anterior and gastrocnemius medialis (R=0.91). An overall observation of gait pattern in patients when compared to controls showed that most spatio-temporal parameters (velocity, step length and cadence) were significantly different. As concerns kinematics, patients' pelvic tilt was globally in a higher position than control group, with reduced hip extension ability in stance phase and limited range of motion; 60% of the limbs revealed knee hyperextension during midstance and ankle joints showed a quite physiological position at initial contact and higher dorsiflexion during stance phase if compared to healthy individuals. Kinetic plots evidenced higher hip power during loading response and lower ankle power generation in terminal stance. The main EMG abnormalities were seen in tibialis anterior and gastrocnemius medialis muscles. In this study gait analysis gives objective and quantitative information about the gait pattern and the deviations due to the muscular situation of these patients; these results are important from a clinical point of view and suggest that rehabilitation programs for them should take these findings into account.     

Effect of Electrical Stimulation of Hamstrings and L3/4 Dermatome on Gait in Spinal Cord Injury

Objective. To determine the effect of electrical stimulation of hamstrings and L3/4 dermatome on the swing phase of gait. Materials and Methods. Five subjects with incomplete spinal cord injury (SCI) with spasticity were included. Two electrical stimulation methods were investigated, i.e., hamstrings and L3/4 dermatome stimulation. Both interventions were applied during the swing phase of gait. The main outcome measures were step length, maximum hip, and knee flexion during the swing phase of gait. In three subjects changes of spinal inhibition during gait were evaluated using the Hoffman reflex/m (motor)–wave (H/M) ratio at mid swing. Results. The hip flexion decreased 4.6° (p < 0.05) when the hamstrings were stimulated during the swing phase, whereas the knee flexion was not changed. The step length did not change significantly. One subject showed a decrease of the H/M ratio to a nonpathologic level during hamstrings stimulation. Conclusion. It was concluded that hamstrings stimulation during the swing phase results in a reduction of the hip flexion in all five SCI subjects. The H/M ratio of the vastus lateralis was normalized using hamstrings stimulation in one of three subjects. Stimulation of the L3/4 dermatome provides no significant changes in gait performance, but in one subject the H/M ratio increased.     

A multilevel approach to botulinum toxin type A treatment of the (ilio)psoas in spasticity in cerebral palsy

In spasticity, flexion deformity of the hip is frequently associated with contracture or hyper-reflexia of the psoas muscle. Botulinum toxin type A (BTX-A) has been used for some considerable time in the management of paediatric gait disorders. We have been using a multilevel approach to manage spasticity in cerebral palsy for several years, the combination of gait analysis and clinical evaluation being important for the selection of target muscles for BTX-A injections. Twenty cerebral palsy children (12 female) with spasticity were treated with BTX-A injections (BOTOX® mean dose, 2 U/kg body weight) into the psoas muscle. Patients were monitored using range of motion measurements of maximal hip extension, clinical estimates of hypertonia in the hip flexors, gait analysis (three-dimensional kinematics and kinetics) and surface electromyography of major lower limb muscles. Full gait analysis was carried out on 12 of the patients. Significant clinical improvements were observed following 15 of the 21 psoas treatments. Furthermore, the kinematics results of gait analysis showed improvement in one or more parameters in nine of the 12 patients. In conclusion, we have demonstrated the value of a multilevel approach to BTX-A treatment in the management of spasticity in children with cerebral palsy.     

Dysferlinopathy (LGMD2B): a 23-year follow-up study of 10 patients homozygous for the same frameshifting dysferlin mutations

The limb-girdle muscular dystrophies are a group of inherited neuromuscular disorders which are clinically and genetically heterogeneous. We have been able to carry out a follow-up study on 10 patients from a large Palestinian family with a confirmed mutation in the dysferlin gene. These patients have been followed for more than 23 years since the onset of the disease. They all had normal developmental milestones. The onset of the disease was usually in the second decade, more rarely in the third and fourth decades. The first symptoms were difficulty with running and climbing stairs. Patients showed a distinct type of gait due to the unique pattern of muscle involvement which was characterised by early involvement of the posterior muscle compartment of the thighs and legs (hamstrings, adductors, gastrocnemius and soleus). The shoulder and upper limb musculature became involved later, especially supra and infraspinatus and biceps. In the early stages of disease these patients may clinically show only proximal lower limb-girdle muscle weakness; however, the use of muscle imaging techniques were very important, always detecting in these patients also distal lower limb muscle involvement, so that the pattern of muscle involvement found in dysferlin deficiency may not strictly conform to the definition of limb-girdle muscular dystrophy. The pattern of muscular dystrophy is essentially uniform and has clearly distinct features (involving mainly the initial pattern of muscle involvement and the mode of gait) which differ significantly from the well reported clinical features associated with sarcoglycanopathy, calpainopathy and Miyoshi myopathy.     

Botulinum toxin-A therapy for palmar and plantar hyperhidrosis

In an open study regarding focal hyperhidrosis, we injected 45-65 mouse units of botulinum toxin A (Btx-A) per palm and 100 per sole intracutaneously to 28 hands and 6 feet. We observed patients for up to 10 months to evaluate the efficacy and tolerability of Btx-A for palmar and plantar hyperhidrosis. The mean sweat production significantly declined for both palmar and plantar hyperhidrosis quantitatively on the first month of therapy (P < 0.01). One patient had transient muscle weakness and mild thenar atrophy interfering with her daily activities for 10 days. Injections were otherwise tolerated well by the patients. In this trial Btx-A injection is found to be an effective and safe method of treatment for palmar and plantar hyperhidrosis.