Botulinum Toxin Type A (BTX-A)

GOAL SETTING

Treatment Decision-Making

The upper motor neuron (UMN) syndrome often leads to neurological deficits affecting patient function. Upon confirmation of UMN syndrome and resulting muscle overactivity, the treatment team should determine if a controlled reduction in muscle tone is appropriate, taking into consideration the following factors:

Chronicity
Treatment goals and choices are influenced by the duration of spasticity. The development of spasticity depends on the locus and severity of injury, which is neither universal nor necessarily immediate. Spasticity management may be short term, long term, or unnecessary. Chemodenervation may play an important role in both short and long term management of spasticity based on the goals and objectives of the patient, caregivers and the treatment team. Early use of BTX-A injections in combination with aggressive physical and occupational therapy may be a highly practical approach for the treatment of spasticity while it is still evolving. When severe spasticity is chronic in nature, chemodenervation may be used as transitional or adjunctive therapy to a permanent procedure.

Distribution
The distribution of spasticity is vital to determining whether to use focal or global treatment, and to deciding which measures should be used. Patients with focal spasms are candidates for focal treatment with BTX-A. Patients with segmental or non-generalized spasticity may be candidates for systemic or ITB treatment, with BTX-A added for focal symptom relief.

Severity
Mild spasticity may respond to more conservative treatment, whereas severe spasticity often requires more aggressive treatments or combination therapies.

Locus of injury
A patient with spasticity resulting from an injury to any area of the body can be considered as a possible candidate for BTX-A treatment since it is a local therapy.

Co-morbidities
Generally, there is an inverse relationship between spasticity and voluntary motor control. Severely spastic patients often have less voluntary movement than mildly spastic patients. Underlying motor control, strength, and coordination should be assessed to project the functional results of reducing spasticity. Since spasticity reduction in patients with poor selective motor control may not provide mobility, treatment goals of improving positioning, care giving or comfort may be more appropriate. Patients with cognitive deficits may not be able to take full advantage of their spasticity reduction; treatment aimed at easing their care or pain may be more beneficial. Patients with painful spasms or contracture often experience significant pain relief after treatment with BTX-A.

Availability of care and support
Many patients require ongoing care and support to fully benefit from their spasticity management plan. Treatment with BTX-A is temporary; patients usually require reinjection every 3 to 4 months to maintain therapeutic benefit. When patients do not have the support necessary for ongoing therapy, proper management is highly limited.

Goals of treatment
The delineation of specific technical and functional goals are essential prerequisites to patient selection and treatment with BTX-A . Common functional goals include improving gait, hygiene, and activities of daily living, easing pain and care, and decreasing spasm frequency. Technical objectives are to promote denervation, tone reduction, improved range of motion, and joint position.

Once begun, treatment with BTX-A is constantly evaluated; follow-up is crucial to gauge the response to BTX-A therapy and to fine tune muscle selection and dose as necessary. In addition, when used in spasticity management, treatment with BTX-A is almost never used as monotherapy. Complementary therapies, such as physical and occupational therapy, are frequently utilized to maximize anticipated outcomes. These therapies are usually instituted or modified after injection.

No appropriate treatment decisions can be made without considering the goals of the therapy

Botulinum Toxin Type A (BTX-A) Algorithm for Spasticity Management Patient presents with spasticity as a result of SCI, TBI, CP, CVA, MS, or neurodegeneration Patient and Caregiver Objectives To identify patient and caregiver goals Functional Objectives To improve gait, hygiene, ADLs, pain relief, ease of care, and to decrease spasm frequency and pain Technical Objectives To promote denervation, tone reduction, improved range of motion, and joint position Initiate comprehensive spasticity management program to include some or all of the following: Elimination of noxious stimuli Physical occupational therapies Oral medications Injections of botulinum toxin Intrathecal baclofen Phenol injections Surgery Others

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