Local botulinum toxin type A injections in the treatment of spastic toes

OBJECTIVE: To investigate the efficacy and safety of botulinum toxin type A treatment of spastic toes using varying doses based on the degree of spasticity (Modified Ashworth Scale). DESIGN: Single-center, open-label, prospective study. Hemiplegic patients with either hitchhiker's great toes (persistent extension of the great toes) or toe flexor spasms with pain during walking were treated with local intramuscular injections of botulinum toxin type A. Initial botulinum toxin type A dose per muscle was 25 units for patients with a baseline Ashworth score of 2, 50 units for a score of 3, and 75 units for a score of 4. Additional botulinum toxin type A injections were allowed if there was an insufficient clinical response to initial treatment. The muscles injected included flexor digitorum, extensor hallucis longus, and/or flexor hallucis longus. All injections were made using electromyographic guidance. Outcome measures were the Modified Ashworth Scale, a visual pain scale, a visual percentage of function scale, and adverse effects. RESULTS: Twenty patients were enrolled. The dose of botulinum toxin type A used ranged from 25 to 35 units per muscle for an Ashworth score of 2, from 50 to 70 units per muscle for a score of 3, and from 75 to 95 units per muscle for a score of 4. There were improvements in all outcome measures. In most patients, the benefits lasted 5-6 mo, with a few patients exhibiting benefits for > or =2 yr. There were no adverse effects. CONCLUSIONS: Botulinum toxin type A treatment using doses based on spasticity severity seems to be safe and effective in the treatment of spastic toes, and further study is warranted.