Role for botulinum toxin in back pain treatment in adults with cerebral palsy: report of a case

OBJECTIVE: To report a case illustrating the usefulness of botulinum toxin A in the treatment of spinal dystonia responsible for low back pain and postural disorders. METHODS: Critical appraisal of a case report. CASE REPORT: A young woman with cerebral palsy had lumbar paraspinal muscle dystonia responsible for pain and hyperlordosis unresponsive to oral medications for muscle spasm. Botulinum toxin A (Botox(R), 200 U) was injected into the paraspinal muscles at six sites, to good effect. DISCUSSION: The few reported cases consistently show a favorable effect of local botulinum toxin A injections in patients with painful paraspinal muscle dystonia related to neurological disease or chronic low back pain. CONCLUSION: Botulinum toxin A may be a useful treatment for incapacitating painful dystonia of the paraspinal muscles. This treatment improves posture in the sitting position and facilitates the fitting of orthotic devices. Furthermore, botulinum toxin A treatment may help to determine whether an intrathecal baclofen test is in order.     

Comparison of Botulinum Toxins A and B in the Aesthetic Treatment of Facial Rhytides

Botulinum toxin injections have become a popular treatment for minimizing or eliminating facial wrinkles. After injection, the toxin acts to paralyze or weaken facial mimetic muscles. Two antigenically distinct serotypes, botulinum toxin type A (BTX-A) and botulinum toxin type B (BTX-B), are currently available. BTX-A is a lyophilized powder preparation requiring reconstitution; BTX-B is a ready-to-use liquid formulation. Both agents produce the same resultant clinical effect (i.e., muscle weakening). However, in addition to differences with respect to formulation, they are pharmacologically distinct in terms of molecular size, cellular mechanism of action, and species sensitivity. BTX-A has been used for aesthetic purposes for more than 10 years. Clinical studies and observations have shown that it is an effective agent for treating hyperkinetic facial lines. BTX-B was approved for use in cervical dystonia in 2000, but it has been used off-label to treat facial wrinkles as reported in several open-label studies. These preliminary dose-ranging studies have demonstrated that BTX-B is also effective. Both agents are extremely safe nonsurgical modalities for hyperkinetic facial lines. This article reviews the pharmacology and molecular features of BTX-A and BTX-B and highlights some of the key clinical studies that have been published to date with these two agents.     

Botulinum toxin in the management of dystonia

Dystonia is a neurologic disorder that can occur at any age and often results in significant disability. The therapeutic application of botulinum toxin has revolutionized the treatment of this disorder, particularly for the adult-onset focal forms such as cervical dystonia and blepharospasm. The two available commercial preparations, botulinum toxin types A and B, have been shown to be equally efficacious in cervical dystonia and are both reasonable first-line choices for treating other forms of focal dystonia. Preliminary studies have suggested that differences in tolerability and immunogenicity may exist between the two preparations, but this has not been adequately evaluated. Because of high cost, complicated administration, potentially serious side effects, and the risk of developing immunoresistance, this treatment should be administered only by a physician with sufficient background in the diagnosis and treatment of dystonia, to ensure optimal outcomes.     

Botulinumtoxin Typ A

Nowadays botulinum toxin type A is an important therapeutic option in routine oral and maxillofacial practice. Even if most of the forms of treatment with botulinum toxin take effect within the scope of aesthetic corrective measures, basic knowledge about the pharmacology and the therapeutic margin is essential in our field. Especially rare neurological diseases which need special knowledge about the complicated dysfunctional conditions in the jaw and facial area in the treatment with botulinum toxin should be integrated even more into the therapeutic spectrum.     

Cryoanalgesia With Dichlorotetrafluoroethane Lessens the Pain of Botulinum Toxin Injections for the Treatment of Palmar Hyperhidrosis

BACKGROUND: Hyperhidrosis is a troublesome problem that can be embarrassing in both social and professional situations. Botulinum toxin injections have proven efficacious in the treatment of hyperhidrosis. However, when treating palmar hyperhidrosis, pain at the injection site limits this therapy. We describe a method of cryoanalgesia using dichlorotetrafluoroethane to lessen the pain of botulinum toxin injections during the treatment of palmar hyperhidrosis. OBJECTIVE: To show the successful use of dichlorotetrafluoroethane or Frigiderm in the treatment of palmar hyperhidrosis. METHODS: This is a case report of a patient with a 20-year history of palmar hyperhidrosis who had previously tried several unsuccessful techniques to control pain during botulinum toxin injections to his palms. The left hand of the patient was pretreated with a spray of Frigiderm for 5 seconds before each of the botulinum injections. Two to 3 seconds of dichlorotetrafluoroethane at a distance of 2 to 4 inches were sprayed before each palmar injection. There was 1 to 2 seconds of frosting on the skin before the botulinum toxin was administered. After the botulinum toxin injection was administered, the patient was subjectively asked about pain during injection. RESULTS: The patient subjectively reported a 75% decrease in the intensity of pain with the Frigiderm application, which he said made the injections much more tolerable. No epidermal changes were noted at the time of treatment or at the telephone follow-up visit. The patient presented for follow-up 3 months later. He stated that the sweating had minimally returned but that he had not yet returned to baseline. CONCLUSION: The use of botulinum toxin for the treatment of palmar hyperhidrosis is often limited because of the pain of multiple injections. In this case report, we describe the successful use of cryoanalgesia with dichlorotetrafluoroethane or Frigiderm to lessen the pain of botulinum toxin injections during the treatment of palmar hyperhidrosis.     

Dystonia

Opinion statement Therapy for most people with dystonia is symptomatic, directed at lessening the intensity of the dystonic contractions. For a small minority of patients (eg, those with dopa-responsive dystonia [DRD], Wilson’s disease, or psychogenic dystonia), specific therapy directed at one of the many causes of dystonia is available. Before initiating treatment, clinicians need to decide if a patient has a form of dystonia amenable to such therapy. The most sensitive and least costly method to diagnose DRD is a therapeutic trial of levodopa. It is, therefore, recommended to treat all those with dystonia beginning in childhood or adolescence with low-dose levodopa. For patients with generalized or segmental signs who do not respond to levodopa, other oral medications, including anticholinergics, baclofen, and benzodiazepines, may provide mild to moderate relief; these medications are often given in combinations. For those with focal dystonia, most having adult-onset disease, botulinum toxin A injections often effectively control contractions. The injections produce transient weakness and need to be repeated, generally every 3 to 5 months. There is growing renewed interest in surgical treatment. Peripheral denervating procedures may be helpful for patients with torticollis who do not obtain adequate benefit with botulinum toxin A. The central procedures of pallidotomy and pallidal stimulation are under study; their place in the treatment of the many dystonia subtypes (eg, limb vs axial, generalized vs focal, primary vs secondary) still needs to be established. There are very few studies evaluating physical and psychological therapies or the impact of diet or lifestyle in dystonia. Most clinicians consider physical therapy, including massage, a potential adjunct to medical therapy, and psychological support and stress reduction may help individuals cope with this chronic and frequently disabling condition.     

New indications for botulinum toxin in rheumatology

Previously known only as a deadly bacterial poison responsible for severe paralysis, botulinum toxin is now a well-recognized therapeutic agent used to relieve involuntary movements, dystonia-related functional impairments, spasticity, and autonomic disorders such as hyperhidrosis. Musculoskeletal pain in patients with rheumatic disorders is among the emerging indications for botulinum toxin therapy. Preliminary data have been obtained in patients with cervical or thoracolumbar myofascial pain syndrome, chronic low back pain, piriformis muscle syndrome, tennis elbow, and stiff person syndrome. At present, the effects of botulinum toxin and its use for pain relief remain controversial. Carefully designed prospective trials are needed to investigate the efficacy and safety of botulinum toxin in pain disorders.     

Antibody-Induced Failure of Botulinum Toxin Type A Therapy in a Patient with Masseteric Hypertrophy

BACKGROUND With the expanding use of botulinum toxin, much concern about the antibody against botulinum toxin is arising. Unlike neurologic indications such as cervical dystonia, antibody-induced failure of botulinum toxin therapy has never been reported in the cosmetic field.
OBJECTIVE The objective was to describe a case of an antibody-induced failure of botulinum toxin type A (BTX-A) therapy (BOTOX, Allergan, Inc.) that occurred in a patient with masseteric hypertrophy.
METHODS AND MATERIALS We present a 20-year-old girl who developed antibody-induced therapy failure after the fourth injection series. Sixty units of toxin was injected at each series and the intertreatment interval was four to five months.
RESULTS Frontalis test revealed no paresis of muscle after a unilateral injection of BTX-A. Circulating antibodies against BTX-A were detected by indirect enzyme-linked immunosorbent assay and mouse protection assay.
CONCLUSION This case is unique in that, first, immunoresistance developed in a patient of cosmetic indication where only a small dose of BTX-A was administered and, second, antibodies developed on the so-called new formulation of BOTOX. Our case alerts cosmetic surgeons to the importance of antibody against the botulinum toxin.     

A prospective blinded evaluation of deep brain stimulation for the treatment of secondary dystonia and primary torticollis syndromes

OBJECT: The aim of this study was to provide an objective assessment of deep brain stimulation (DBS) for groups of patients with mixed secondary dystonia and primary torticollis syndromes by a blinded evaluation of 13 consecutive patients who underwent ineffective medical treatment and botulinum toxin injections. METHODS: Nine patients with secondary dystonia and 4 with cranial dystonia involving prominent spasmodic torticollis were selected for a DBS implant after they underwent unsuccessful medical treatment. Preoperative videos and neurological assessments were obtained and the DBS implant was inserted into the globus pallidus internus. Postoperatively, DBS parameters were adjusted to provide optimal benefit. Postoperative videotapes and quality of life scores were obtained. Blinded randomized evaluation of videotapes was performed by a neurologist specializing in movement disorders. Videos were scored using the Unified Dystonia Rating Scale, Toronto Western Spasmodic Torticollis Rating Scale, Burke-Fahn-Marsden Dystonia Rating Scale, or Abnormal Involuntary Movement Scale. Quality of life scoring was assessed using a standardized 7-point Global Rating Scale. RESULTS: All 13 patients completed preoperative videotaping, medical assessment, and surgery. Optimal DBS programming was completed in 6.5 visits over 5.9 months. Seven patients reported marked improvement, 3 reported moderate improvement, 2 reported slight improvement or no change, and 1 was lost to follow-up. Examiner scores on the Global Rating Scale reflected patient self-reported scores. CONCLUSIONS: Global subjective gains and notable objective improvement were observed in 11 of 13 patients. Although the benefits were variable and not fully predictable, they were of sufficient magnitude to justify offering the procedure when medications and botulinum toxin injections have failed.     

Effect of Botulinum Toxin Type A on Movement-Associated Rhytides Following CO2 Laser Resurfacing

BACKGROUND: Many patients who undergo CO2 laser resurfacing for correction of rhytides experience recurrence of movement-associated wrinkles within 6 to 12 months following the laser procedure. OBJECTIVE: The purpose of this study was to evaluate the effect of botulinum toxin type A (Botox) injections on movement-associated rhytides following cutaneous laser resurfacing. METHODS: Forty patients who had received full face CO2 laser resurfacing for the treatment of facial rhytides were randomized to receive Botox injections to the glabella, forehead or lateral canthal regions or to receive no additional treatment (control group). Clinical and photographic assessments were performed at baseline and at 3, 6 and 9 months. RESULTS: Enhanced and more prolonged correction of forehead, glabellar and/or lateral canthal rhytides was observed in patients treated with Botox injections postoperatively compared to non-Botox treated control patients. CONCLUSION: The use of botulinum toxin type A following cutaneous CO2 laser resurfacing results in prolonged correction of movement-associated rhytides. It is advised that patients receive information regarding the benefits of maintenance therapy with botulinum toxin as part of their routine preoperative education.     

Treatment of Focal Dystonia

OPINION STATEMENT: Dystonia is characterized by repetitive twisting movements or abnormal postures due to involuntary muscle activity. When limited to a single body region it is called focal dystonia. Examples of focal dystonia include cervical dystonia (neck), blepharospasm (eyes), oromandibular dystonia, focal limb dystonia, and spasmodic dysphonia, which are discussed here. Once the diagnosis is established, the therapeutic plan is discussed with the patients. They are informed that there is no cure for dystonia and treatment is symptomatic. The main therapeutic option for treating focal dystonias is botulinum toxin (BoNT). There have been several attempts to characterize the procedure, the type of toxin, dosage, techniques, and combination with physical measures in each of the focal dystonia forms. The general treatment principles are similar. The affected muscles are injected at muscle sites based on evidence and experience using standard dosages based on the type of toxin used. The injections are repeated after 3 to 6?months based on the individual response duration. In the uncommon event of nonresponse with BoNT, the dose and site are reassessed. Oral drug treatment could be considered as an additional option. Once the condition is thought to be medically refractory, the opinion from the deep brain stimulation (DBS) team for the suitability of the patient for DBS is taken. The successful use of DBS in cervical dystonia has led to increased acceptance for trial in other forms of focal dystonias. DBS surgery in focal dystonias other than cervical is, however, still experimental. The patients may be offered the surgery with adequate explanation of the risks and benefits. Patient education and directing the patients towards dystonia support groups and relevant websites that provide scientific information may be useful for long-term compliance and benefit.     

Botulinum toxin injection in the treatment of tennis elbow. A double-blind, randomized, controlled, pilot study

BACKGROUND: A recent report has suggested that local injection of botulinum toxin type A is an effective method of treatment for chronic tennis elbow. The toxin is thought to provide temporary paralysis of the painful common extensor origin, thereby allowing a healing response to occur. To test this theory, we performed a double-blind, randomized, controlled, pilot trial comparing injections of botulinum toxin type A with those of a placebo (normal saline solution) in the treatment of chronic tennis elbow. METHODS: Forty patients with a history of chronic tennis elbow for which all conservative treatment measures, including steroid injection, had failed were randomized into two groups. Half the patients received 50 units of botulinum toxin type A, and the remainder received normal saline solution. The intramuscular injections were performed 5 cm distal to the maximum point of tenderness at the lateral epicondyle, in line with the middle of the wrist. The two solutions used for the injections were identical in appearance and temperature. The results of a quality-of-life assessment with the Short Form-12 (SF-12), the pain score on a visual analogue scale, and the grip strength measured with a validated Jamar dynamometer were recorded before and three months after the injection. RESULTS: Three months following the injections, there was no significant difference between the two groups with regard to grip strength, pain, or quality of life. CONCLUSIONS: With the numbers studied, we failed to find a significant difference between the two groups; thus, we have no evidence of a benefit from botulinum toxin injection in the treatment of chronic tennis elbow.     

Selective peripheral denervation for the treatment of intractable spasmodic torticollis: experience with 168 patients at the Mayo Clinic

OBJECT: Selective peripheral denervation is currently the primary surgical treatment for intractable cervical dystonia. The authors assessed preoperative factors to determine which, if any, correlated with outcomes in patients with torticollis who had undergone this procedure. METHODS: The records of 168 consecutive patients who had undergone selective peripheral denervation for cervical dystonia between 1988 and 1996 at the Mayo Clinic were reviewed. There were 89 women (53%) and 79 men (47%) with a mean age of 53.4 years. Selection of muscles for denervation was based on the patient's clinical presentation and electromyography mapping results. The most common torticollis vectors were rotational in 141 patients (84%) and laterocollis in 59 (35%). Seventy patients (42%) presented with combined vectors. The technique used to remedy both conditions involved denervation of the ipsilateral posterior cervical paraspinal and splenius capitis muscles. Denervation of the sternocleidomastoid muscle was performed on the contralateral side for rotational torticollis and on the ipsilateral side for laterocollis. A rigorous physical therapy program followed surgery. At the 3-month postoperative evaluation, 125 patients (77%) of the 162 who were available for follow up had moderate to excellent improvement in their head position, and pain was moderately to markedly improved in 131 patients (81%). The long-term follow up lasted a mean of 3.4 years and was undertaken in 130 patients. The original level of moderate to excellent improvement in head position and pain was retained in at least 71 patients (70%). Outcome was not predicted by preoperative head position, severity of abnormal posture of head, symptom duration, presence of tremor or phasic dystonic movements, or failure to respond to botulinum toxin treatment. Five patients recovered from postoperative complications including one myocardial infarction, one pulmonary embolism, and three respiratory failures. Three patients suffered from persistent C-2 distribution dysesthesias and three from slight shoulder weakness; one had a wound infection, and one died of respiratory arrest. CONCLUSIONS: Selective peripheral denervation is an effective method of achieving lasting improvement of dystonia in most patients with intractable torticollis.     

Comparison of Botulinum Toxin Types A And B: A Bilateral and Double-Blind Randomized Evaluation in the Treatment of Canthal Rhytides

BACKGROUND: The obligate bacterium Clostridium botulinum produces exotoxins (A, B, C-1, C-2, D, E, F, G) that are serologically and antigenically distinct. All serotypes have similar neurotoxic properties resulting in flaccid muscle paralysis. Types A and B are commercially available and are used widely for the reduction of dynamic facial rhytides. Although extensive information is known about type A, type B has recently become available; however, there is a limited clinical familiarity. Some of the remaining unknown distinctions between the two subtypes are the extent of toxin diffusion from the site of injection, the onset of action, the dose equivalency, and the duration of effect. OBJECTIVE: The purpose of this preliminary double-blind study was to compare the duration of muscle paralysis and rhytid reduction of botulinum toxin types A and B. Additional relevant information was obtained, all of which can be useful in toxin selection. METHOD: Ten women, ages 28 through 60, voluntarily consented to undergo a double-blind trial and were randomly assigned to have botulinum toxin type A injected into one set of lateral canthal rhytides and toxin type B into the contralateral periocular region. Based on dose-ranging investigations performed in patients with cervical dystonia, participants received treatment at the lowest reported effective ratio of 1:50 (1 U of toxin type A to 50 U of toxin type B). Three injections of 5 U of type A (total 15 U) and three injections of 250 U of undiluted type B (total 750 U) were injected into the lateral fibers of the orbicularis oculi muscle. RESULTS: Patients were evaluated at 7, 30, 60, and 90 days. Findings were compared by the treating physician, patient self-assessment, and photographic images. CONCLUSION: All patients noted rapid and satisfactory reduction in the rhytides in both periocular areas. However, upon unblinding of the solutions at the same volumes with a 1:50 ratio, type B toxin was found to be associated with slightly more discomfort upon injection, quicker onset of action, a sensation of "tightness" of the treated area, and a briefer duration of muscle paralysis.     

Botulinum toxin type A in the healing of chronic lesion following bilateral spasticity of gluteus muscle

Use of botulinum toxin is expanding as the clinical studies demonstrate new potential therapeutic applications. In rehabilitation, botulinum toxin is above all used as adjunct therapy for the treatment of spasticity, but it may prove useful for other atypical clinical situations. A 17‐year‐old man had a sub‐arachnoid haemorrhage following the rupture of cerebral aneurism. The patient presented gluteus maximus and medius bilaterally spasticity that produced a chronic lesion in the intergluteal cleft, a flexed wrist and a flexed elbow. As treatment for this spasticity, a total of 100 U botulinum toxin type A were injected into the glutei muscles. This treatment allowed for application of topical medication and subsequently, chronic lesion healing. Botulinum toxin A may be an important therapeutic aid for clinicians faced with treating persistent pathological conditions caused by spasticity.     

Prospective, Double-Blind, Randomized, Parallel-Group, Dose-Ranging Study of Botulinum Toxin Type A in Men with Glabellar Rhytids

BACKGROUND: The effective dose for treating glabellar lines with botulinum toxin type A in men has not been studied adequately. OBJECTIVE: To compare the safety, efficacy, and duration of response of four doses of botulinum toxin type A on glabellar rhytids in men. METHODS: Eighty men were randomized to receive a total dose of either 20, 40, 60, or 80 U of botulinum toxin type A (BOTOX, BOTOX Cosmetic, or Vistabel, Allergan, Inc., Irvine, CA, USA) in the glabellar area. Glabellar lines were assessed at rest and maximum frown by a trained observer at baseline, 2 and 4 weeks, and monthly thereafter. Patients provided self-evaluations at the same visits. Adverse events were monitored throughout. RESULTS: The 40, 60, and 80 U doses of botulinum toxin type A were consistently more effective in reducing glabellar lines than the 20 U dose (duration, peak response rate, improvement from baseline). There was a dose-dependent increase in both the response rate at maximum frown and the duration of effect assessed by the trained observer. In addition, the participants reported a dose-dependent reduction in the ability to frown, improvement in their global assessment, and increased feelings of attractiveness, self-confidence, and satisfaction. The incidence of adverse events was not increased with higher doses. CONCLUSION: Male participants with glabellar rhytids benefit from starting doses of at least 40 U of botulinum toxin type A.     

Evidence against trigger point injection technique for the treatment of cervicothoracic myofascial pain with botulinum toxin type A

BACKGROUND: Traditional strategies for myofascial pain relief provide transient, incomplete, variable, or unpredictable outcomes. Botulinum toxin is itself an analgesic but can also cause sustained muscular relaxation, thereby possibly affording even greater relief than traditional therapies. METHODS: The study goal was to determine whether direct injection of botulinum toxin type A (BoNT-A) into trigger points was efficacious for cervicothoracic myofascial pain, and if so, to determine the presence or absence of a dose-response relation. One hundred thirty-two patients with cervical or shoulder myofascial pain or both and active trigger points were enrolled in a 12-week, randomized, double-blind, placebo-controlled trial. After a 2-week washout period for all medications, patients were injected with either saline or 10, 25, or 50 U BoNT-A into up to five active trigger points. The maximum doses in each experimental group were 0, 50, 125, and 250 U per patient, respectively. Patients subsequently received myofascial release physical therapy and amitriptyline, ibuprofen, and propoxyphene-acetaminophen napsylate. Follow-up visits occurred at 1, 2, 4, 6, 8, and 12 weeks. Outcome measures included visual analog pain scores, pain threshold as measured by pressure algometry, and rescue dose use of propoxyphene-acetaminophen napsylate. RESULTS: No significant differences occurred between placebo and BoNT-A groups with respect to visual analog pain scores, pressure algometry, and rescue medication. CONCLUSIONS: Injection of BoNT-A directly into trigger points did not improve cervicothoracic myofascial pain. The role of direct injection of trigger points with BoNT-A is discussed in comparison to other injection methodologies in the potential genesis of pain relief.     

Botulinum toxin-physiology and applications in head and neck disorders

This article is structured around a literature review that was carried out using Ovid and Medline with the key words "botulinum," "toxin," and "ENT." Botulinum toxin has been used safely in humans for more than 20 years. The effects are transient, such that treatments are required to be repeated at intervals. Its application to ENT provides a useful tool to treat dystonia, autonomic dysfunction, facial nerve paresis, and hyperfunctional lines. It may also be of benefit in laryngeal rebalancing and the treatment of headaches. Further research is being carried out and new indications for treatment with botulinum toxin may include sialorrhea and rhinorrhea.     

Evidence against Trigger Point Injection Technique for the Treatment of Cervicothoracic Myofascial Pain with Botulinum Toxin Type A

Background: Traditional strategies for myofascial pain relief provide transient, incomplete, variable, or unpredictable outcomes. Botulinum toxin is itself an analgesic but can also cause sustained muscular relaxation, thereby possibly affording even greater relief than traditional therapies.

Methods: The study goal was to determine whether direct injection of botulinum toxin type A (BoNT-A) into trigger points was efficacious for cervicothoracic myofascial pain, and if so, to determine the presence or absence of a dose-response relation. One hundred thirty-two patients with cervical or shoulder myofascial pain or both and active trigger points were enrolled in a 12-week, randomized, double-blind, placebo-controlled trial. After a 2-week washout period for all medications, patients were injected with either saline or 10, 25, or 50 U BoNT-A into up to five active trigger points. The maximum doses in each experimental group were 0, 50, 125, and 250 U per patient, respectively. Patients subsequently received myofascial release physical therapy and amitriptyline, ibuprofen, and propoxyphene-acetaminophen napsylate. Follow-up visits occurred at 1, 2, 4, 6, 8, and 12 weeks. Outcome measures included visual analog pain scores, pain threshold as measured by pressure algometry, and rescue dose use of propoxyphene-acetaminophen napsylate.

Results: No significant differences occurred between placebo and BoNT-A groups with respect to visual analog pain scores, pressure algometry, and rescue medication.