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Botulinum Toxin and Spasticity

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danielle jackson

on 11 October 2013

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Transcript of Botulinum Toxin and Spasticity

Botulinum Toxin and Spasticity

What is Botulinum Toxin?
What is Spasticity?
Botulinum Toxin: Mechanism of Action at NMJ
Clinical Use of Botulinum Toxin
Role of PT/OT
Botulinum Toxin
Neurotoxin produced by the bacteria
Clostridium botulinum

Clinical use: A* and B only

Trade Names: Botox®, Dysport®

Used to treat: spasticity*, migraines, depression, ocular dysfunctions, cosmesis
Clinical Use of Botulinum Toxin

Decreased discomfort related to spasticity
Increase in function to allow other interventions/ therapy
Chance to see effects of decreased spasticity
Danielle Jackson, Sandra Ibrahim, Morgan Hall, Blaire MacMillan & Lindsay Olberg
Spasticity results from a lesion in the upper motor neuron (CNS) in one or more areas along the descending motor pathway.
What is spasticity?
“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.”
(Lance, 1980)
Neurophysiology of Spasticity
Decrease in excitatation of the neurons (UMN) that send inhibitory signals
Causes increased excitatory impulses to lower motor neurons - resulting in a spastic muscle

Botulinum toxin should not be used in patients with the following:
Known NMJ disease
Prescription for antibiotics
Motor-neuron disease
Prescription for aminoglycosides

Spasticity occurs as a result of a lesion to one or a combination of 3 sites:
brain stem
cerebral cortex
spinal cord

Neurophysiology of Spasticity
Botulinum Toxin
at the Neuromuscular Junction
Rehabilitation Goals
These lesions may be found in the following populations:
Spinal Cord Injury
Multiple Sclerosis
Traumatic Brain Injury
Cerebral Palsy
Strengthening exercises

Possible side-effects
Temporary Results (3-4 Months)
Hyperexcitability of muscle stretch reflex
Focal spasticity
When systemic medication or treatment is not appropriate
In combination with other therapies (OT/ PT), orthoses, and often oral medication (Davis & Barnes, 2000)
Role of OT/PT
(Allergan, Inc. 2010)

Allergan, Inc. (2010). Botox, Mechanism of Action. Retrieved from http://www.allergan.com/products/neurosciences/index.htm

Barnes, M. & Johnson, G. Upper motor neuron syndrome and spasticity: Clinical management and neurophysiology. 2nd Edition ed. United Kingdom: Cambridge University Press; 2008.

Blumenfeld, H. (2010). Neuroanatomy through Clinical Cases, Second Edition. Sinauer Associates, Inc. Sunderland, MA. Print.

Brashear, A., & Elovic, E. (2011). Spasticity diagnosis and management. New York : Demos Medical Pub

Burridge, J. (2009). Principles of motor learning in rehabilitation. Proceedings of the International Neurorehabilitation Symposium, University of Zurich, Switzerland. Retrieved from http://www.inrs2009.com/fileadmin/user/PDF/INRS/Burridge_MotorLearning_INRS2009.pdf

Criswell, S.R. Crowner, B.E. & Racette, B.A. (2006). The use of Botulinum toxin therapy for lower-extremity spasticity in children with cerebral palsy. Neurosurgical Focus, 21(2):1.

Davis, E.C., & Barnes, M.P. (2000). Botulinum toxin and spasticity. Journal of Neurology, Neurosurgery, and Psychiatry, 69: 143-9.

Denham, S.P. (2008). Augmenting occupational therapy treatment of upper-extremity spasticity with Botulinum toxin A: A case report of progress at discharge and 2 years later. The American Journal of Occupational Therapy, 62(4), 473-479.

Giovannelli, M., Borriello, G., Castri, P. Prosperini, L. & Pozzilli, C. (2007). Early physiotherapy after injection of botulinum toxin increases the beneficial effects on spasticity in patients with multiple sclerosis. Clinical Rehabilitation, 21, 331-337. doi: 10.1177/0269215507072772

Lance, J. (1980). Spasticity: disorders motor control. In: Thibaut, A., Chatelle, C., Ziegler, E. Bruno, M.A., Laureys, S. & Gosseries, O. (2013). Spasticity after stroke: Physiology, assessment and treatment. Brain Injury, 27(10): 1093-1105

Mergel, M. (2010). Botulinum toxin. Toxipedia: Connecting Science and People. Retrieved October 6, 2011 from http://toxipedia.org/display/toxipedia/Botulinum+Toxin

Nigam, P.K. & Nigam, A. (2010). Botulinum toxin. Indian Journal of Dermatology, 55(1), 8-14. doi: 10.4103/0019-5154.60343

Royal College of Physicians (2009). National Guidelines. Spasticity in adults: management using botulinum toxin. Retrieved from: http://www.rcplondon.ac.uk/sites/default/files/documents/spasticity-in-adults-management-botulinum-toxin.pdf

Purves, D., Augustine, G. J., Fitzpatrick, D., Hall, W. C., LaMantia, A., McNamara, J. O. & White, L. E. (2008). Neuroscience, Fourth Edition. Sinauer Associates, Inc. Sunderland, MA. Print.

Simpson, D. M., Gracies, J. M., Graham, H. K., Miyasaki, J. M., Naumann, M., Russman, B., ... & So, Y. (2008). Assessment: Botulinum neurotoxin for the treatment of spasticity (an evidence-based review) Report of the Therapeutics and Technology Assessment Subcommittee of the
American Academy of Neurology. Neurology, 70(19), 1691-1698.

Thibaut, A., Chatelle, C., Ziegler, E. Bruno, M.A., Laureys, S. & Gosseries, O. (2013). Spasticity after stroke: Physiology, assessment and treatment. Brain Injury, 27(10): 1093-1105

Turner-Stokes, L., & Ashford, S. (2007). Serial injection of botulinum toxin for muscle imbalance due to regional spasticity in the upper limb. Disability & Rehabilitation, 29(23), 1806-1812.

Weiss, E., & Lin, D. (2007). Spasticity. In G. Cooper (Ed.), Therapeutic uses of Botulinum toxin, 7-18. New Jersey: Humana Press Inc.

Williams, G., Olver, J., de Graaff, S. & Singer, B.J. (2012). The use of Botulinum toxin type A in the management of adult onset focal spasticity: A survey of Australian allied health professionals. Australian Occupational Therapy Journal, 59, 257-264. doi: 10.1111/j.1440-1630.2012.01027.x
Rehabilitation can also help increase the opportunity for areas of the the brain to adapt, a concept known as neuroplasticity
(Purves, et al., 2008)
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