botox-patientselection

Injection of Botulinum Toxin: Patient Selection

The most challenging aspect of BTX-A therapy is patient selection. Each patient's treatment must be individualized. Chronicity, severity, distribution, locus of injury, co-morbidities, availability of care, and treatment goals are important decision-making factors in managing spasticity. The use of BTX-A must be part of a comprehensive treatment plan. Increased range of motion, reduction in spasm frequency, or reduced pain are primary goals leading to what most patients desire, improved function. Treatment begins with mutually agreed upon goals and expectations, a treatment plan that addresses all the clinical issues, and a working partnership between patients and qualified professionals.

Successful treatment depends upon identification of the appropriate clinical situation for use, realistic goal setting is key.
Successful treatment of spasticity with botulinum toxin depends as much on careful patient selection as it does on proper drug administration.
Pre-injection muscle imbalance is present with identifiable and relatively stronger spastic agonist muscle(s).
Antagonist muscle(s) must be:
- sufficiently powerful for functional control if "agonists" are weakened, or...
- capable of hypertrophy and strengthening if allowed to perform through the appropriate range of motion, or..
- acceptable in flaccid state.

See ITB - Goal Setting
See BOTOXŽ - Treatment Decision Making

The residual function of the spastic limb and the condition of the adjacet agonist and the antagonist muscles must be carefully assessed to ensure the the induction of partial or of complete paralysis of one or more muscles will improve the overall condition of the patient.

Exclusion Criteria:

No fixed joint deformity present.
Weakening of the spastic limb will not further compromise the residual function - including the gait.

Spasticity may be beneficial in some patients, and should not automatically be treated before assessing this possibility.

Cautions:

During pregnancy and lactation (safety unkown)
In patients with pre-existing disorders of neuromuscular function: myasthenia gravis, Eaton-Lambert syndrome, or motor neuron disease
In patients taking aminoglycosides class of antibiotics (these drugs may enhance the effect of the toxin)

Guidelines for Therapy for Spasticity Treatment

Maximize current abilities prior to BTX injection or ITB therapy
Institute rehabilitation program prior to BTX injection or placement of pump
BTX or ITB therapy may result in sudden and dramatic change inclinical and functional status and body image
Re-evaluate patient as a "new" patient post injection or pump placement
- Immediate attention should be given to appropriateness of the existing assistive device, possible pressure and/or skin breakdown from splints/braces, and balance disturbance

Current Indications

In the USA, the FDA has approved BOTOXŽ "for treatment of strabismus and blepharospasm associated with dystonia, including benign essential blepharospasm of VII nerve disorders in patients 12 years of age and above"
Use in other conditions considered "extra-label use" if the indication is "accepted as safe and effective" e,g.: spasticity, cervical dystonia, spasmodic dysphonia, writer's cramp, tremor.

NIH Consensus Statement 1990

CLINICAL APPLICATIONS OF BOTULINUM TOXIN

FOCAL DYSTONIA
- Blepharospasm (lid "apraxia")
- Oromandiibular-facial-lingual dystonia
- Cervical dystonia (torticollis)
- Laryngeal dystonia (spasmodic dysphonia)
- Task-specific dystonia (occupational cramps)
- Other focal dystonia (idiopathic, secondary)
OTHER INVOLUNTARY MOVEMENTS
- Voice, head, and limb tremor
- Palatal myoclonus
- Hemifacial spasm
- Tics
OTHER APPLICATIONS
- Protective ptosis
- Essential hyperhidrosis
- Cosmetic (wrinkles, facial asymmetry)
- Debarking dogs
OTHER INAPPROPRIATE CONTRACTIONS
- Strabismus
- Nystagmus
- Myokymia
- Bruxism (TMJ)
- Stuttering
- Painful rigidity
- Muscle contraction headaches
- Lumbosacral strain and back spasm (myofascial)
- Radiculopathy with secondary muscle spasm
- Spasticity
- Spastic bladder
- Achalasia (esophageal)
- Pelvirectal spasms (anismus, vaginismus)
- Other spastic disorders
Proper choice of the dose and of the administration site are the most important determinants of a favorable response to BTX treatment
Clinical effects are typically seen within 1 week of injection
Benefits typically last between 3 - 6 months
The safety, effectiveness, specificity, and reversibility of BTX therapy make it an extremely useful therapy

Focal clinical patterns that may benefit from BTX-A treatment include:

Upper Limb
- Adducted/internally rotated shoulder
- Flexed elbow
- Pronated forearm
- Flexed wrist
- Thumb-in-palm
- Clenched fist
- Intrinsic plus hand
Lower Limb
- Flexed hip
- Flexed knee
- Adducted thighs
- Stiff (extended) knee
- Equinovarus foot
- Striatal toe (Hitchhiker's great toe)

Clinical Applications

Pictorial