Wednesday, March 17, 2010

Botox for Upper Extremity Spasticity

Until recently, the therapeutic use of non-cosmetic BOTOX (onabotulinumtoxinA) for adult upper extremity spasticity was considered off-label use. Last week, the U.S. Food and Drug Administration (FDA) approved Botox to treat spasticity in the upper extremity flexor muscles in adults.

Spasticity is common after stroke, traumatic brain injury, or the progression of multiple sclerosis. Spasticity is defined as

“a motor disorder characterized by a velocity-dependent increase in tonic stretch reflexes (muscle tone) with exaggerated tendon jerks, resulting from hyper-excitability of the stretch reflex as one component of the upper motor neuron syndrome.”

Spasticity often creates problems with mobility, self-care, and function. The spastic muscles can become stiff. Associated joints can be affected by lack decreased range-of-motion with contractures forming.

Botox works by temporarily blocking the connections between nerves and muscles, resulting in a temporary paralysis of the spastic muscle. Advantages of using Botox to treat muscle spasm include the ability to target specific muscles which when successful allows reduction of other systemic medications (ie Zanaflex, Baclofen, Dantrium).

Botox does not take the place of conservative measures, such as positioning, stretching and exercise in spasticity management. These measures remain essential.

Botox can decrease the dosage or use of oral antispastic medications which often provide only limited effects with short duration and frequent unwanted systemic side effects, such as weakness, sedation and dry mouth.

Botox has a Black Box Warning that states the effects of the botulinum toxin may spread from the area of injection to other areas of the body, causing symptoms similar to those of botulism. Those symptoms include swallowing and breathing difficulties that can be life-threatening.

The most common adverse reactions to Botox reported by patients with upper limb spasticity were nausea, fatigue, bronchitis, muscle weakness, and pain in the arms.

Botox has not been shown to be safe and effective treatment for other upper limb muscles, spasticity in the legs, or for treatment of fixed contracture – a condition that affects range of motion. Treatment with Botox is not intended to substitute for physical therapy or other rehabilitative care.

REFERENCES

FDA News Release

Botulinum toxin type A in the treatment of upper extremity spasticity: A randomized, double-blind, placebo-controlled trial; NEUROLOGY 1996;46:1306; D. M. Simpson, MD, D. N. Alexander, MD, C. F. O'Brien, MD, M. Tagliati, MD, A. S. Aswad, MS, J. M. Leon, PhD, J. Gibson, MD, J. M. Mordaunt, MS and E. P. Monaghan, PhD

Botulinum Toxin in Poststroke Spasticity; Clin Med Res. 2007 June; 5(2): 132–138; Suheda Ozcakir, MD and Koncuy Sivrioglu, MD

2 comments:

StorytellERdoc said...

Excellent post. What a great treatment for these patients who suffer from this. I had an essential tremor briefly in my career, and I can't even imagine those with such extreme symptoms from this illness.

MediTouch said...

A good analogy for increase in muscle tone due to spasticity is when the central traffic control computer of a big city malfunctions and all the local traffic lights and drivers do their best on a local level to allow the continuation of traffic flow.

In the above analogy the traffic control centre is the motor cortex of the brain that controls deep tendon reflex. An increase in deep tendon reflex will increase muscle tone and spasticity and a decrease will lead to flacidity. The local action of the drivers and local control of the traffic lights is peripheral control of deep tendon reflexes.

An experienced physical/ occupational therapist will be able to reduce their patients' spasticiy for the short term without botox by means of techniques such as manipulation, stretching and positioning of the patient and limb. This will allow the patient to work on intensive task and isolated exercise based tasks. While the spasticity is reduced the patient will begin to improve their movement or motor sensory ability. This improved motor/ sensory ability may well then allow the patient to do active daily living tasks that they were not able to do before the treatment sessions despite an increased spasticity.

Traditional Occupational and Physical therapy provides the patient task orientated training (TOT). TOT is intensive repetition of everyday functional tasks or Active daily living tasks. The MediTouch HandTutor is a rehabilitation glove and software which offers impairment oriented training (IOT) and augmented feedback. The HandTutor provides repetitive customized isolated or inter joint co-ordinated finger and wrist hand exercises and rehabilitates fine movements of the hand and wrist. At the same time the dedicated rehabilitation software motivates the patient to continue intensive repetitive exercises by providing challenging games that have been designed around both neurological and Orthopedic conditions.

Research with the HandTutor confirms that task oriented training should be combined with Impairment oriented (IOT) training to achieve enhanced functional recovery. The HandTutor is used in hospitals and community hand therapy clinics and home care to give an intensive active isolated exercise program.

Examples of patients that are treated include Stroke, TBI, spinal cord injury CP, Orthopedic hand and arm surgery, development co-ordination disorders in children etc.