Botulinum toxin injections for the treatment of neurogenic thoracic outlet syndrome: A systematic review

Botulinum toxin (BTX) injections into the musculature surrounding the brachial plexus have been examined as a potential treatment for neurogenic thoracic outlet syndrome (nTOS). This systematic review identified 15 publications, of which one was a randomized controlled trial. BTX injections performed with ultrasound or electromyographic guidance, and with the inclusion of the pectoralis minor muscle, in addition to the anterior and/or middle scalenes, tended to provide greater symptom improvement and may predict response to first rib resection. Importantly, most studies were of low quality; thus, the results should be interpreted with caution. Further high-quality studies are needed to confirm these findings.

Spasticity evaluation and management tools

Spasticity is a complex and often disabling symptom for patients with upper motor neuron syndromes. Although spasticity arises from neurological disease, it often cascades into muscle and soft tissue changes, which may exacerbate symptoms and further hamper function. Effective management therefore hinges on early recognition and treatment. To this end, the definition of spasticity has expanded over time to more accurately reflect the spectrum of symptoms experienced by persons with this disorder. Once identified, clinical and research quantitative assessments of spasticity are hindered by the uniqueness of presentations both for individuals and for specific neurological diagnoses. Objective measures in isolation often fail to reflect the complex functional impact of spasticity. Multiple tools exist to quantitatively or qualitatively assess the severity of spasticity, including clinician and patient-reported measures as well as electrodiagnostic, mechanical, and ultrasound measures. A combination of objective and patient-reported outcomes is likely required to better reflect the burden of spasticity symptoms in an individual. Therapeutic options exist for the treatment of spasticity along a broad spectrum from nonpharmacologic to interventional procedures. Treatment strategies may include exercise, physical agent modalities, oral medications, injections, pumps, and surgery. Optimal spasticity management most often requires a multimodal approach, combining pharmacological management with interventions that match the functional needs, goals, and preferences of the patient. Physicians and other healthcare providers who manage spasticity must be familiarized with the full array of spasticity interventions and must frequently reassess results of treatment to ensure the patient's goals of treatment are met.

Limb myorhythmia treated with chemodenervation: a case report

We describe a case of limb myorhythmia successfully palliated with botulinum toxin injections. The patient is a 30-year-old male evaluated for abnormal movements of the left lower foot that began after an ankle injury for which the patient underwent Achilles tendon scar tissue debridement without improvement. On examination, he had near-constant involuntary, slow, rhythmic flexion/extension tremor of toes 2-4 that was diminished during active movement. Needle electromyography (EMG) revealed a rhythmic, 2-3 Hz tremor isolated to the flexor digitorum brevis. After failure of medical management with muscle relaxants, gabapentin, and levodopa trials, the patient underwent two EMG-guided chemodenervation procedures with incobotulinum toxin A injections of the left flexor digitorum brevis. At 3-month follow-up, he had achieved a sustained 50% reduction in the intensity of the movements and improved quality of life. Myorhythmia is a rare condition characterized by a repetitive, rhythmic, slow frequency (1-4 Hz) movement affecting the cranial and limb muscles. The most common causes include stroke, demyelinating disorders, drug or toxin intake, trauma, and infections. The management of this condition is very limited with pharmacologic agents such as anticholinergics, antispasmodics, anticonvulsants, or dopaminergic agents showing limited efficacy. The use of botulinum toxin chemodenervation aided by EMG muscle targeting can be a useful therapeutic intervention in cases of medication-refractory regionally distributed myorhythmia involving accessible muscles.

Use of Botulinum Toxin in Spasmodic Dysphonia: A Review of Recent Studies

Spasmodic dysphonia (SD), also known as laryngeal dystonia, is a neurological voice disorder that causes involuntary spasms of the vocal cord muscles. This impacts speech to varying degrees and results in strained and strangled voice quality, as in adductor spasmodic dysphonia, or weak, quiet, and breathy, as in abductor spasmodic dysphonia. While there is currently no cure for SD, voice therapy and chemodenervation with botulinum toxin (btx) injections remain the mainstay of management. Surgery may be performed in some cases; however, btx injections are widely used to treat both adductor and abductor forms of SD. While btx injections may show vocal improvement in both types of SD, results can depend on several factors such as the general health of the patient, onset and severity of the condition, dosage, interval between injections, and expertise of the practitioner. While many studies have documented the efficacy of btx for improving vocal symptoms in individuals with SD, this review aims to discuss some of those studies from the last 10 years.

[Botulinum therapy for acute esotropia]

PURPOSE

To determine the effectiveness of the use of botulinum toxin type A in the treatment of acute esotropia in children.

MATERIAL AND METHODS

A retrospective analysis of the results of using botulinum toxin type A in the treatment of acute convergent strabismus in 16 children was performed. Children's ages ranged from 3 to 15 years. Botulinum toxin was injected into the medial rectus muscles. In 6 patients with acute esotropia, botulinum toxin was injected into the internal rectus muscle of both eyes, in the rest of patients the toxin was injected into one eye. Two patients underwent chemodenervation of extraocular muscles twice. The injected dose of botulinum toxin (from 1 to 5 U) was chosen depending on the strabismus angle, the patient's age, and the duration of the disease. In order to form binocular vision, all patients underwent orthopto-diploptic treatment. The observation period lasted 12 to 18 months.

RESULTS

One month after chemodenervation, the orthoposition of the eyes was persistently restored in 7 children (43.75%). Esodeviation angle decreased steadily to 2 degrees in 4 patients (25%). A second injection of botulinum toxin was required to achieve orthotropy in 2 patients (12.5%) 4-6 months after chemodenervation. An increase of esodeviation angle was recorded in 3 patients (18.75%), which required classical surgical treatment of strabismus. One month after the injection, unstable binocular vision developed in 11 children (68.75%). After 1 year, binocular vision was successfully formed 13 patients (81.25%).

CONCLUSION

Chemodenervation in the majority of children with acute esotropia led to persistent orthoposition of the eyes. This created favorable conditions for the restoration of binocular vision during subsequent orthopto-diploptic treatment.

Comparative Effectiveness of Botulinum Toxin Injections and Extracorporeal Shockwave Therapy for Post-Stroke Spasticity: A Systematic Review and Network Meta-Analysis

BACKGROUND

The anti-spasticity efficacy of botulinum toxin (BoNT) injection has been well established for patients with chronic stroke; however, extracorporeal shock wave therapy (ESWT), i.e. focused shockwave (FSW) and radial shockwave (RSW), has recently been applied. We aimed to investigate the comparative effectiveness of BoNT vs. ESWT in the reduction of spasticity among stroke survivors.

METHODS

PubMed, EMBASE, MEDLINE and Cochrane CENTRAL were searched from the earliest record to September 2021 for randomized controlled trials. Weighted mean differences (WMDs) on the reduction of the Modified Ashworth Scale before or at the 6th post-treatment week (short-term) and between the 7th and 12th weeks (mid-term) after the intervention were calculated. Ranking probabilities of the WMD were simulated to determine which treatment had the potential to possess the best effectiveness. inplasy.com registration: INPLASY202170018.

FINDINGS

A total of 33 studies comprising 1,930 patients were enrolled. The network meta-analysis revealed that BoNT injections, FSW and RSW were better in spasticity reduction than the control treatment(s) at the short term, with WMDs of -0.69 (95% CI, -0.87 to -0.50), -0.36 (95% CI, -0.69 to -0.03) and -0.62 (95% CI, -0.84 to -0.40), respectively. Likewise, mid-term effects of BoNT injections, FSW and RSW also revealed superiority, with WMDs of -0.44 (95% CI, -0.62 to -0.26), -0.74 (95% CI, -1.26 to -0.23) and -0.79 (95% CI, -1.07 to -0.51), respectively. Ranking probability analysis revealed that RSW had the highest probability of being the best treatment for spasticity reduction at the short-term (62.2%) and mid-term (72.3%) periods during the follow up.

INTERPRETATION

BoNT injections and ESWT are effective in alleviating post-stroke spasticity at the mid-term. The effectiveness of ESWT was comparable to BoNT injections, and RSW had the potential to be the best treatment for spasticity reduction among the three treatment options. More prospective trials incorporating head-to-head comparisons of BoNT injections vs. ESWT are needed to validate the role of ESWT in reducing post-stroke spasticity.

FUNDING

The current research project was supported by (1) National Taiwan University Hospital, Bei-Hu Branch; (2) Ministry of Science and Technology (MOST 106-2314-B-002-180-MY3 and 109-2314-B-002-114-MY3); 3) Taiwan Society of Ultrasound in Medicine.

Ergonomic Recommendations in Ultrasound-Guided Botulinum Neurotoxin Chemodenervation for Spasticity: An International Expert Group Opinion

Ultrasound (US)-guided botulinum neurotoxin (BoNT) injections are becoming a mainstay in the treatment of muscle spasticity in upper motor neuron syndromes. As a result, there has been a commensurate increase in US-guided BoNT injection for spasticity training courses. However, many of these courses do not emphasize the importance of ergonomics. This paper aims to highlight the importance of ultrasound ergonomics and presents ergonomic recommendations to optimize US-guided BoNT injection techniques in spasticity management. Expert consensus opinion of 11 physicians (4 different continents; representing 8 countries, with an average of 12.6 years of practice using US guidance for BoNT chemodenervation (range 3 to 22 years)). A search using PubMed, College of Physicians and Surgeons of British Columbia database, EMbase was conducted and found no publications relating the importance of ergonomics in US-guided chemodenervation. Therefore, recommendations and consensus discussions were generated from the distribution of a 20-question survey to a panel of 11 ultrasound experts. All 11 surveyed physicians considered ergonomics to be important in reducing physician injury. There was complete agreement that physician positioning was important; 91% agreement that patient positioning was important; and 82% that ultrasound machine positioning was important. Factors that did not reach our 80% threshold for consensus were further discussed. Four categories were identified as being important when implementing ultrasound ergonomics for BoNT chemodenervation for spasticity; workstation, physician, patient and visual ergonomics. Optimizing ergonomics is paramount when performing US-guided BoNT chemodenervation for spasticity management. This includes proper preparation of the workspace and allowing for sufficient pre-injection time to optimally position both the patient and the physician. Lack of awareness of ergonomics for US-guided BoNT chemodenervation for spasticity may lead to suboptimal patient outcomes, increase work-related injuries, and patient discomfort. We propose key elements for optimal positioning of physicians and patients, as well as the optimal setup of the workspace and provide clinical pearls in visual identification of spastic muscles for chemodenervation.

Management of Anterocapitis and Anterocollis: A Novel Ultrasound Guided Approach Combined with Electromyography for Botulinum Toxin Injection of Longus Colli and Longus Capitis

Chemodenervation of cervical musculature using botulinum neurotoxin (BoNT) is established as the gold standard or treatment of choice for management of Cervical Dystonia (CD). The success of BoNT procedures is measured by improved symptomology while minimizing side effects and is dependent upon many factors including: clinical pattern recognition, identifying contributory muscles, BoNT dosage, and locating and safely injecting target muscles. In patients with CD, treatment of anterocollis (forward flexion of the neck) and anterocaput (anterocapitis) (forward flexion of the head) are inarguably challenging. The longus Colli (LoCol) and longus capitis (LoCap) muscles, two deep cervical spine and head flexor muscles, frequently contribute to these patterns. Localizing and safely injecting these muscles is particularly challenging owing to their deep location and the complex regional anatomy which includes critical neurovascular and other structures. Ultrasound (US) guidance provides direct visualization of the LoCol, LoCap, other cervical muscles and adjacent structures reducing the risks and side effects while improving the clinical outcome of BoNT for these conditions. The addition of electromyography (EMG) provides confirmation of muscle activity within the target muscle. Within this manuscript, we present a technical description of a novel US guided approach (combined with EMG) for BoNT injection into the LoCol and LoCap muscles for the management of anterocollis and anterocaput in patients with CD.

[Ophthalmic manifestations of facial nerve palsy]

Facial nerve palsy is a common pathology that develops due to various diseases, traumas and medical interventions. The most common peripheral type of facial paralysis leads to acute unilateral involvement of facial muscles along with the development of paralytic lagophthalmos. The absence of adequate and timely medical treatment in patients with paralytic lagophthalmos can lead to severe corneal complications such as cornea perforation causing loss of eye and consequently restricted professional ability, work capacity and significant decrease of patient's life quality. Patients with paralytic lagophthalmos require timely, complex, planned treatment involving various correction methods aimed at protection of the cornea, as well as anatomical and functional recovery of the eyelids. Chemodenervation of the upper eyelid muscles is a pathogenetically substantiated method that can help restore the protective function of the upper eyelid and prevent corneal complications; it can be recommended for early stages of the disease.

Muscle Selection for Focal Limb Dystonia

Selection of muscles for botulinum toxin injection for limb dystonia is particularly challenging. Limb dystonias vary more widely in the pattern of dystonic movement and involved muscles than cervical dystonia or blepharospasm. The large variation in how healthy individuals perform skilled hand movements, the large number of muscles in the hand and forearm, and the presence of compensatory actions in patients with dystonia add to the complexity of choosing muscles for injection. In this article, we discuss approaches to selecting upper and lower extremity muscles for chemodenervation treatment of limb dystonia.

Ultrasound Guidance for Botulinum Neurotoxin Chemodenervation Procedures

Injections of botulinum neurotoxins (BoNTs) are prescribed by clinicians for a variety of disorders that cause over-activity of muscles; glands; pain and other structures. Accurately targeting the structure for injection is one of the principle goals when performing BoNTs procedures. Traditionally; injections have been guided by anatomic landmarks; palpation; range of motion; electromyography or electrical stimulation. Ultrasound (US) based imaging based guidance overcomes some of the limitations of traditional techniques. US and/or US combined with traditional guidance techniques is utilized and or recommended by many expert clinicians; authors and in practice guidelines by professional academies. This article reviews the advantages and disadvantages of available guidance techniques including US as well as technical aspects of US guidance and a focused literature review related to US guidance for chemodenervation procedures including BoNTs injection.

Chemodenervation of the Larynx

Botulinum neurotoxin (BoNT) has existed for thousands of years; however, it was not medically utilized until investigations into its therapeutic use began in sincerity during the late 1970s and 1980s. This, coupled with the reclassification of spasmodic dysphonia as a focal dystonia, led to the use of chemodenervation for this disorder, which has since become a refined technique. Indeed, due to its safety and efficacy, BoNT has been investigated in multiple neurolaryngology disorders, including spasmodic dysphonia, vocal tremor, and muscle tension dysphonia. BoNT has been shown to be a useful and safe adjunct in the treatment for these disorders and may reduce or eliminate oral pharmacotherapy and/or prevent the need for a surgical intervention. We present the historical background, development, proposed mechanisms of action, uses, and techniques for administering BoNT for laryngeal disorders, with a particular focus on spasmodic dysphonia.

[Peripheral nerves alcoholization in the spasticity managament]

INTRODUCTION

Spasticity is velocity dependent increased resistance to passive lengthening of the muscle. Mild spasticity doesn't require treatment, but severe impede with hygiene, constrict range of motion and mobility, interfere with gait pattern and can be the cause of pain and discomfort. Proper spasticity management is crucial for correct rehabilitation.

THE AIM OF THE STUDY

The assesment of chemodenervation with ethyl alcohol in spasticity treatment.

MATERIAL AND METHODS

13 patients (5 female, 8 male) age 18-68 yrs (mean 46,8±13,3). Qualification to the procedure requiered high level of spasticity (mean 3,4 ± 0,5 in Ashworth scale), no response for pharmacological treatment, low level in Bartel scale. Patients were evaluated with VAS pain scale, EQ-5D before, day after and 6 weeks after procedure.

RESULTS

Ashworth scale before procedure: 3-4 (mean 3.44±0.52), after procedure: 0-3 (mean 2.0±1.26), 6 weeks after procedure: 1-3 (mean 2.0±1.0). VAS before procedure: 0-4 (mean 1.49±1.9), after procedure: 0-2 (mean 1.33±1.0), 6 weeks after procedure (mean 1.0±1.0). Bartel scale before procedure: 0-16 (mean 9.25±6.7), after procedure: 0-16 (mean 6.0±8.71), 6 weeks after procedure: 0-16 (mean 9.25±6.7). EQ-5D results showed on Fig 5-19.

CONCLUSION

Results shows improvement in every examinated aspect (decrease in spasticity level, decrease in pain, increase in quality of life and disability scale).

Botulinum toxin in the management of blepharospasm: current evidence and recent developments

Blepharospasm is a focal (although usually bilateral) dystonia of the orbicularis oculi muscles, producing excessive eye closure. This produces significant disability through functional blindness. Botulinum neurotoxins (BoNT) have become the treatment of choice for blepharospasm; the impressive response rate and the tolerable safety profile have been proven through multiple clinical studies. There are currently four BoNT approved in the United States for different indications - we review the data on blepharospasm for each of these drugs. Currently, incobotulinumtoxinA and onabotulinumtoxinA have the most evidence of benefit for patients with blepharospasm. Current evidence, recent development and future directions are discussed.

Botox Therapy in Dentistry: A Review

There are many medical and dental conditions which do not have complete treatment modalities in conventional ways. The botulinum toxin can be used as an alternative treatment modality working through chemo denervation method in many medical and dental conditions. An internet research was done for botulinum toxin used in dentistry and all articles and studies were selected, articles related to dentistry were extracted and summarized. This article explains the basic of botulinum toxin and some of its uses in dentistry. In next parts, the extensive details of its use in dentistry will be dealt with.

Dual treatment of hemichorea-hemiballismus syndrome with tetrabenazine and chemodenervation

BACKGROUND

Hemichorea-hemiballismus involves unilateral involuntary flailing movements and random jerking movements involving proximal or distal muscles. We describe a case of hemichorea-hemiballismus with dystonia after stroke. Treatment with tetrabenazine and chemodenervation produced beneficial responses. Effective treatment of both hemichorea-hemiballismus and dystonia due to stroke has not been reported.

CASE REPORT

A 65-year-old male developed left hemichorea-hemiballismus and dystonia after a right hemisphere stroke. He underwent initial treatment with neuroleptics and anticonvulsants without improvement. Subsequent treatment with tetrabenazine improved the hemichorea-hemiballismus and chemodenervation reduced the dystonia.

DISCUSSION

Hemichorea-hemiballismus associated with dystonia can be improved with both tetrabenazine and chemodenervation.

Balanced botox chemodenervation of the upper face: symmetry in motion

Cosmetic botulinum toxin type A (Botox, Allergan, Inc., Irvine, CA) has revolutionized minimally invasive treatment of the upper face. Increasingly sophisticated outcomes result in facial symmetry in motion. The face is a three-dimensional moving unit, not an isolated photograph. This is why the advanced injector must hone an astute ability to observe casual microexpressions. Consideration is then given to the patient's age, facial anatomy, facial asymmetry, and dynamic rhytids. The ratio of dosing to agonist and antagonist muscles that allows unopposed action is determined. Nuance in placement and dose combined with adjunct therapy results in natural and appropriate facial emotion and avoids unnatural or bizarre patterns of movement. Asymmetrical scenarios are presented to exemplify this process of analysis and treatment. Many authors have detailed the mechanism of action, history of Botox development, and specific muscle group treatment in the periorbital region. In this discussion, I leave behind rigorous academic analysis and wish to offer my approach, which has evolved through 15 years experience treating the aesthetic patient with Botox. The clinician can read about recommended patterns of injection, and the procedure is quite simple. It is only through skilled observation and understanding of expressive nuance and anatomy that the advanced injector will meet the goal of a natural communicative result with chemodenervation. Experience is accumulated through critical analysis of patient results over time. This discussion first directs attention to why it is important to learn how to look at the face in motion as well as at facial rhytids. A plan is developed for treatment including drug preparation, dosing decisions, precise three-dimensional delivery, and adjunct therapy. Perils may generally be avoided by choosing appropriate dosing and placement. The asymmetrical patient scenario is used to demonstrate nuance in evaluation and treatment.

Neurologic uses of botulinum neurotoxin type A

This article reviews the current and most neurologic uses of botulinum neurotoxin type A (BoNT-A), beginning with relevant historical data, neurochemical mechanism at the neuromuscular junction. Current commercial preparations of BoNT-A are reviewed, as are immunologic issues relating to secondary failure of BoNT-A therapy. Clinical uses are summarized with an emphasis on controlled clinical trials (as appropriate), including facial movement disorders, focal neck and limb dystonias, spasticity, hypersecretory syndromes, and pain.