Botulinum Toxin For Foot Dystonia In Patients With Parkinsons Disease Having Deep Brain Stimulation: A Case Series And A Pilot Study
Anupam Datta Gupta, MD, FAFRM1 and Renuka Visvanathan, FRACP, PhD2
From the 1Department of Rehabilitation Medicine and 2Aged and Extended Care Services, Queen Elizabeth Hospital, Woodville South, South Australia
BACKGROUND:Six patients with Parkinson’s disease with deep brain stimulation who were experiencing disabling foot dystonia were referred to the spasticity clinic for a trial of botulinum toxin. The foot and ankle muscles were injected with onabotulinum toxin to determine the effects on foot dystonia, pain and lower limb functional outcomes.
SUBJECTS/PATIENTS: Six patients with Parkinson’s disease having deep brain stimulation experiencing disabling foot dystonia.
METHODS:Dystonic foot and ankle muscles were identified and injected with 250–400 units botulinum toxin and re-coded pre- and 3 weeks post-injection with the Burke Fahn Marsden Dystonia score, visual analogue score of pain, Unified Parkinson’s Disease Rating Scale – lower limb score, Timed up and Go test , 6-Minute Walk Test , gait velocity, cadence in an instrumented walkway, and Goal Attainment Scale .
RESULTS:Three weeks after botulinum toxin injection, significant improvements were noted in dystonia, pain, UPDRS, 6MWT, gait velocity, and cadence. Five out of 6 patients improved on the TUG test. Patients also reported improvements in their GAS goals.
Key words: foot dystonia; Parkinson’s disease; deep brain stimulation.
J Rehabil Med 2016; 48: 00–00
Since Toxin Exposure Is A Possible Cause Of Parkinsons Does Using Botox Cosmetic Increase The Chances Of Developing Pd sara357
Parkinsons runs in my family, so I have a slightly increased chance of getting it. Credible medical sites suggest increased exposure to certain toxins may increase likelihood of getting PD, especially if you have a genetic predisposition. Botox Cosmetic is derived from a toxin, so I assume it somehow may increase my chances of developing PD. Since toxins may be a potential contributing factor to PD, could long term use of Botox Cosmetic potentially increase the likelihood of developing PD?
Second Opinion Leads To Dystonia Diagnosis Botox And A Road To Independence
Mar 16, 2017Cedars-Sinai Staff
Looking at Beth Oringher now, you would never suspect that, at one point, she couldn’t lift a spoon to put food into her mouth or confidently pour a glass of lemonade.
“I didn’t socialize, and I wouldn’t go out with anyone unless they were a really close friend. It was horrible. I hated it. I hated it. I hated it.”
Before botulinum toxin injections controlled the shaking in Oringher’s hands and head, she avoided public places at all cost. Her jerking motions were frustrating and embarrassing.
“I didn’t socialize, and I wouldn’t go out with anyone unless they were a really close friend,” the 67-year-old said. “It was horrible. I hated it. I hated it. I hated it.”
What Are The Possible Side Effects Of A Botulinum Toxin Injection
Botulinum toxin in the right hands in the commonly used doses is a relatively safe procedure and there are actually very few serious side-effects. The local side-effects of injection will be different depending on the area into which it is being injected. If injected to treat a spasming eyelid for example, some possible side-effects include drooping of the eyelid, blurred vision, and over production of tears and even some local bruising.Often after injection, there can be a little bit of excessive weakness in the muscles and if injected into an area like the neck can result in difficulties in swallowing, speaking and even cause noisy breathing. This is because the injection has found its way into some other areas which is sometimes difficult to avoid because of the anatomy.More general side-effects can include some pain around the site of injection, a rash, some itchiness, headache and tiredness. There may also occasionally may be flu-like symptoms which are usually short-lived.Aside from the above, there are some serious side effects of botulinum toxin injections but they are exceedingly rare.Botulinum toxin is generally avoided during pregnancy, as is breastfeeding in the days following an injection.
Conditions Treated Using Botulinum Toxin In Parkinsons Disease
Common Side Effects People Have Besides Parkinson’s Disease *:
Botulinum Toxin Calms Muscles Restoring Natural Body Position
The mainstay of treatment of dystonia is with injection of botulinum toxin, such as Botox or Xeomin.
Botulinum toxin injections work by causing a disruption between the nerve and the muscle, thereby weakening the muscle into which it is injected.
Conditions treated with botulinum toxin injection:
- Blepharospasm and hemifacial spasm: facial muscles are injected to reduce involuntary blinking or grimacing movements.
- Spasticity due to stroke or multiple sclerosis or other conditions: upper or lower limb muscles are injected to relax abnormal muscle posture and stiffness.
- Migraine: muscles of the face and neck are injected to reduce muscle tension that contributes to headache. There may also be a reduction in the release of substance P, which contributes to the pain pathway.
- Sialorrhea : salivary glands are injected to reduce release of saliva.
- Cervical dystonia: muscles that are pulling or twisting the neck to one side are overactive, Botox works to calm those specific muscles down and allows for a more natural and neutral head position.
Depending on the muscle injected, EMG guidance may be used during Botox injection to verify muscle activity and ensure the most active part of the muscle is being injected.
What Should I Do Now That I Have Been Diagnosed With Dystonia
Knowledge is your best tool. Work closely with your doctor to find a treatment plan that works for you. There are plenty of interventions that can be done to help alleviate symptoms. Be sure to alert your doctor if your treatment plan has undesirable side effects or if you have questions or concerns. Remember to persevere and keep a positive attitude.
Body Parts That Can Be Affected With Dystonia In Parkinsons
Repetitive and sustained eye closure is known as blepharospasm. To the observer, this looks like increased blinking, which may increase in certain situations such as in bright light. The frequent blinking/eye closures can interfere with activities such as reading or driving. This can be associated with PD, but may also accompany other forms of parkinsonism such as Progressive Supranuclear Palsy. The most common treatment for this disorder is Botulinum toxin injections.
In PD, the trunk can tilt to one side or flex forward. Forward flexion of the trunk is known as camptocormia. Similar to neck flexion, it is unclear whether the flexion is due to dystonia causing overactivity of muscles that pull the trunk down, or weakness of the muscles that keep the trunk upright. Typically, although the forward flexion may appear very profound when upright, the patient can lie flat in a bed or sometimes even straighten up against a wall, demonstrating that the flexion is not due to a permanent deformation. Treatment options are similar to those available for neck flexion. Spinal surgeries which attempt to straighten the torso have been reported in a handful of patients. Results were mixed including a very high rate of surgical complications. These surgeries are generally not performed.
Parkinson’s Disease Caused By Stroke: Vascular Parkinsonism
A stroke involving the substantia nigra or basal ganglia is called vascular Parkinsonism. Similar to other strokes, damage is caused primarily by a lack of blood supply to these regions of the brain. Generally, the strokes associated with Parkinsonism are termed small vessel strokes as they aren’t normally catastrophic. Diagnosis of small vessel strokes can be confirmed with diagnostic tests such as CT or MRI of the brain.
It typically takes several small strokes to produce the symptoms of vascular Parkinsonism. In some cases, small vessel strokes can also produce a type of dementia called vascular dementia. As such, it is not unusual for people who have vascular Parkinsonism to also have vascular dementia.
Am I A Good Candidate For Botox For Movement Disorders
You may be a good candidate for Botox injections if you are at least 18 years old and have been diagnosed with one of the conditions above.
You should not take Botox if you:
- Are allergic to any of its ingredients or have had an allergic reaction to another Botox product
- Are pregnant
- Have a neuromuscular condition or myasthenia gravis)
- Have Lambert-Eaton syndrome
Tell your doctor about all of your medical conditions and medications during your evaluation for Botox therapy.
What Is Involved In Having A Botulinum Toxin Injection
A botulinum toxin injection is usually a quick and relatively simple procedure that can be done in a doctor’s office. Firstly, the area for injection will be cleaned. There may be a little pain or pressure associated with the injection related to the needle and fluid itself, but a local anaesthetic agent is usually not required. The actual injection is just like having a vaccination shot, with a smaller amount of liquid being injected into the desired area.The effects can be variable but wear off in time and so the injection will probably have to be repeated then.No preparation is needed before you go to have an injection. If you are using a drug that thins the blood aside from aspirin, the clinician may wish to know.
Can I Continue Taking My Oral Medications For Dystonia
Botulinum toxin injections can be used in conjunction with oral medications as well as in place of oral medications. The response to drug therapies for dystonia can be inconsistent. No single drug works for every individual and several trials of medications may be necessary. Establishing a satisfactory treatment plan requires patience on the part of the patient and the neurologist.
Medications typically used to treat cervical dystonia include:
Atypical Parkinsonism Or ‘parkinson’s Plus Syndromes’
“Parkinson’s Plus Syndromes” are less common than Parkinson’s disease.
Some atypical parkinsonism syndromes include:
Multiple system atrophy This is a category of several disorders in which one or more body systems deteriorate.
Your doctor may classify you as having MSA-P, in which parkinsonian symptoms are dominant; or MSA-C, in which dysfunction of the cerebellum is dominant.
The names of some of these syndromes include olivopontocerebellar atrophy , Shy-Drager syndrome , and striatonigral degeneration .
Progressive supranuclear palsy Symptoms of this condition usually begin after age 50 and proceed more rapidly than Parkinson’s disease.
In people with PSP, problems with eye movement can lead to blurry vision. Falls tend to occur early in the course of the disease, and dementia may occur later in the disease.
Corticobasal degeneration This condition may cause jerking and loss of control in a limb, often without weakness in that limb.
If you have this disorder, you may be given Botox to help your limb relax.
In this condition, the same Lewy bodies occur in the brain as in Parkinson’s disease, but in multiple areas of the brain.
If you have LBD, you may experience speech problems, hallucinations, and gradual cognitive decline.
Things You Should Know About Botox For Tremor Control
How many of Hollywood’s male and female actors are driven by vanity and career opportunities to appear young by using Botox injections? Well, there’s no way to know – and anyway, what does it matter? But now let’s ask, how many people have Essential Tremor , the most common movement disorder? Estimates are as high as 10% of the U.S. population. While ET can begin at any age, it most commonly begins after age 40, and is most prevalent in older adults. For those who can’t live normally due to tremors, finding a solution matters greatly.
Healthfirst: Botox Treatment For Parkinsons Disease
A popular wrinkle treatment is bringing great relief to some people with Parkinson’s disease and other muscular disorders.
HealthFirst reporter Leslie Toldo explains why the magic of Botox® is much more than skin deep.
This is a non-surgical option that is sparing people some of the worst symptoms of diseases like Parkinson’s – tremors, pain and balance.
For five years, 61-year-old Doug Eshelman had to fight to stand, walk or even sit. He wasn’t in control, Parkinson’s was. “Well, I tripped a lot. Because I dragged my right leg, I just, subconsciously, you just don’t pick it up, so I dragged it. And I mean I could literally trip over a line on a basketball court.”
Help came from something he never expected. “Doctor said I want to try Botox® on you, and we laughed. We thought Botox® was basically a cosmetic drug.”
At the Muhammad Ali Parkinson’s Center, patients with Parkinson’s and other muscular disorders get multiple targeted injections of botulism toxin, guided by electromyography.
The neurotoxin in Botox® can release the grip of muscle spasms, tremors and pain.
“The Botox®, what it does is it goes into the nerve terminals and then makes those nerve terminals fire less. And by firing less, the muscles or the limbs return to their original or more normal position,” Dr. Guillermo Moguel-Cobos said.
Botox® is FDA-approved to treat Parkinson’s. It’s no cure, but by relieving the worst symptoms, the injections may spare some patients surgery.
For more information:
Side Effects Requiring Immediate Medical Attention
Along with its needed effects, onabotulinumtoxinA may cause some unwanted effects. Although not all of these side effects may occur, if they do occur they may need medical attention.
Check with your doctor or nurse immediately if any of the following side effects occur while taking onabotulinumtoxinA:
Applies to onabotulinumtoxinA: injectable powder for injection
Botox Injections A Mainstay Treatment Of Dystonia
Therapeutic botulinum toxin, commonly referred to as Botox therapy, has been used to treat disorders such as dystonia, spasticity and cerebral palsy for over 30 years. Botox® injections can be used effectively to relax excessive muscle contraction in individuals with movement disorders. While exceptionally toxic in large doses, when purified and used in controlled doses botulinum toxin calms muscles and helps reduce or halt muscle activity and control motor symptoms.
Botox Lawsuit Alleges Brain Damage From Treatment
- February 18, 2010
A Virginia woman has filed a Botox lawsuit against Allergan, Inc., claiming that injections meant to cure a head tremor caused her to suffer brain injuries, movement disorders and dementia.
The complaint was filed by Cynthia Vandenboom in Richmond City Court, alleging that Allergan failed to warn consumers that Botox side effects can cause serious autoimmune responses, brain injury and botulism. The lawsuit is the latest in a series of claims against Allergan over problems with Botox.
Vandenboom indicates that she was given Botox injections to treat a head tremor. As a side effect of Botox, Vandenboom alleges that she suffered a variety of serious and permanent injuries caused by the injections. She experienced rashes, fever, vomiting, severe pain and confusion shortly after being given the injections. Eventually, she developed autoimmune encephalitis movement disorder, lost some of her cognitive functions and now trouble walking. As a result of the Botox injury, the lawsuit claims that she requires care and help from others to conduct a number of daily activities.
Botox is approved for both cosmetic use to reduce the appearance of wrinkles in the skin and to treat medical conditions such as strabismus , hyperhidrosis , cervical dystonia and blepharospasms . However, it also commonly used off-label, such as for treatment of stiff and jerky movements associated with cerebral palsy in children.
Parkinsonism Due To Other Neurological Disorders
The following neurological disorders are known to cause parkinsonian symptoms:
Vascular parkinsonism Also known as arteriosclerotic parkinsonism, this condition is caused by multiple small strokes.
The onset of symptoms can be sudden or gradual, and often includes mobility problems in your legs. Symptoms may level off for a period of time.
Vascular parkinsonism has the slowest rate of progression of all atypical parkinsonisms. It doesn’t usually cause tremors, either.
Post-traumatic parkinsonism Also known as post-traumatic encephalopathy or “punch-drunk syndrome,” this condition may be caused by a severe head injury or by frequent head trauma, such as from boxing or football.
Post-traumatic parkinsonism can lead to a type of dementia called chronic traumatic encephalopathy . In March 2016, the National Football League admitted that there might be a link between CTE and head trauma.
Essential tremor This is a tremor that tends to run in families and become worse over time. It’s usually seen most severely in the hands, especially when the hands are moving.
Normal pressure hydrocephalus This condition is caused by an abnormal increase in fluid in the cavities of the brain.
NPH can sometimes be treated by draining the extra fluid into your abdomen using a shunt.
Environmentally Caused Parkinsonism
The following disorders are caused by outside factors like drugs and infection:
The following substances can cause drug-induced parkinsonism:
Tackling Neuropathy Fatigue And Gi Issues In Pd
While it’s known as a movement disorder, people who live with Parkinson’s disease experience many non-movement, or non-motor, symptoms too – though not all of them are related to the disease. Peripheral neuropathy, or nervous system damage, fatigue and GI issues are common PD challenges that can also stem from other causes. Working with your doctor to identify the source of your symptoms is key to effective treatment.
This article is based on the Parkinson’s Foundation Expert Briefing series; Symptom Management: Is it PD, Medication or Aging? Exploring Non-motor Symptoms: Neuropathy, Fatigue, GI Issues presented by Ellen Walter, Nurse Practitioner, Cleveland Clinic, and Steven Swank, Clinical Pharmacist, University of Kansas Medical Center. Both organizations are Parkinson’s Foundation Centers of Excellence.
Causes of neuropathy, fatigue and impaired gastrointestinal function during the course of PD can be wide-ranging – and include everything from normal aging to medication side effects.
With any health challenge, it’s recommended to log symptoms. This can help your doctor rule out potential causes. When did symptoms start? Are there any patterns?
What Else Can Be Done To Help With The Symptoms
Stress can worsen the symptoms of dystonia. Using stress management and relaxation techniques may be beneficial. Education is vital when dealing with a dystonia diagnosis and reassurance from family, friends and others is beneficial. Support groups can be beneficial by offering encouragement and camaraderie.
Experiencing Pain Or Symptoms That Concern You
While it is relatively uncommon, cervical dystonia is by no means rare. Exact prevalence rates are not available, but an estimated 60,000 – 160,000 Americans are living with cervical dystonia. In one study, only half of these patients reported being treated for their condition. Cervical dystonia often comes on in mid-life but can begin at any age, and typically affects women twice as frequently as men.
In addition to neck pain, many patients may manifest with a head tremor. Often patients assume that tremor is due to more common causes, such as Parkinson’s disease and essential tremor. However, isolated head tremor should be considered undiagnosed cervical dystonia until proven otherwise.
A tremor in cervical dystonia tends to be jerky and irregular and often is worse in the direction of the head away from the abnormal positioning. So, if cervical dystonia is causing a head turn to the right, tremor may be worst when the patient attempts to turn their head to the left.
Cervical dystonia is known by many names, and the terminology can get confusing at times. The most common alternate name is spasmodic torticollis, but torticollis may also refer to the specific position of head turning to left or right, whereas head tilt is known as laterocollis. When the neck is extended it is known as retrocollis, whereas neck flexion is known as anterocollis.
Uses Of Botulinum Toxin In Parkinsons Disease
You most likely know that Botulinum toxin is used for cosmetic purposes to decrease wrinkles. Prior to being used in this way, Botulinum toxin was used for medical purposes to control abnormal movements. In the right hands, it can be a very effective measure to control a variety of problems related to PD.
Potential Side Effects Of Botox Injections
Side effects of Botox injections for movement disorders are generally mild and wear off quickly. Patients should go home and rest immediately following the injection and refrain from strenuous activity for two to three days.
The most common side effects of Botulinum toxin are temporary general weakness, soreness at the injection site or affecting your whole body, and weakness in muscles that have been injected. Difficulty swallowing, upper respiratory infection, neck pain and headache may be signs of an allergic reaction or rare but serious side effects and should be brought to the attention of your doctor immediately.
According to the FDA warning on this class of drugs, the risk of symptoms is greatest in children with cerebral palsy treated for spasticity.
How Dystonia Is Caused In Parkinsons Cases
First and foremost, dystonia can be a symptom of Parkinson’s disease itself. Particularly in young onset PD, foot dystonia may appear as the first motor symptom that is experienced. If dystonia occurs in isolation, the diagnosis of PD may only become clear as other symptoms appear. If dystonia occurs as the predominant symptom of PD, the patient and his/her doctor must decide how to treat it – either by starting dopaminergic medications to see if this helps the dystonia or by targeting the dystonia itself, possibly with Botulinum toxin injections.
Once medications for PD have been started, dystonia may appear when there is a decrease in brain dopamine levels, which could occur first thing in the morning before taking medication or when a dose of medication is wearing off. If this is the pattern that is noted, there are various strategies that can be implemented to decrease OFF time. Depending on when the OFF time occurs, these approaches may include taking a long-acting Levodopa formulation before bed, increasing the number of doses per day or adding a medication to lengthen the amount of time that a dose works.
Controlling The Tremor Source Using Mrgfus
Sperling Neurosurgery Associates offers source control of tremor with a treatment called MRI-guided Focused Ultrasound . Increasingly recognized as a revolution in ET treatment, MRgFUS stops tremors by deadening the “relay station” in the part of the brain that forwards dysfunctional brain transmissions outward to the limbs and other areas. What makes it particularly special is that no incisions or holes drilled in the skull are needed during this outpatient treatment – AND results are immediate and durable!
For more information, contact Sperling Neurosurgery Associates.
1 Samotus O, Kumar N, Rizek P, Jog M. Botulinum Toxin Type A Injections as Monotherapy for Upper Limb Essential Tremor Using Kinematics. Can J Neurol Sci. 2017 Nov 21:1-12. doi: 10.1017/cjn.2017.260.2 Zakin E, Simpson D. Botulinum Toxin in Management of Limb Tremor. Toxins . 2017 Nov 10;9.3 Ibid.
How Much Does Botulinum Toxin Therapy Cost
In Australia, the Phamaceutical Benefits Scheme fully subsidises the cost of the toxin preparation for only the conditions blepharospasm, hemifacial spasm, torticollis and primary axillary hyperhidrosis . In addition, the doctor may levy a charge for the injection procedure itself, which may or may not be part or fully recompensable under the Medicare Benefit Schedule depending on the procedure.Article kindly reviewed by:Associate Professor Karl Ng MB BS FRCP FRACP PhD CCT Clinical Neurophysiology Consultant Neurologist –Sydney North Neurology and Neurophysiology ; Conjoint Associate Professor –Sydney Medical School, University of Sydney; and Editorial Advisory Board Member of the Virtual Neuro Centre.
|For more information on neurological disorders that affect movement, and their treatments, see Neurological Rehabilitation and Movement Disorders.|
Things To Know About Botulinum Injections
Most people know botulinum toxin by its trade name, Botox. This drug is a neurotoxin, meaning it has a toxic effect on muscles and nerves. When used properly, it is safe. And, when the tremors are controlled, BoNT is appealing because there are no systemic side effects as there are with oral medicines. Here are four important things to keep in mind about the use of BoNT for ET:
Botox Helps Relieve Parkinson’s Symptoms
“Well, I tripped a lot,” said Eshelman. “Because I dragged my right leg, I just subconsciously — you just don’t pick it up, so I dragged it, and I mean I could literally trip over a line on a basketball court.”
Help came from something he never expected.
“Doctor walks in the room, said, ‘I want to try Botox on you,’ and we laughed. We both thought Botox was basically a cosmetic drug,” said Eshelman.
At the /*Muhammad Ali Parkinson Center*/ in Phoenix, patients with Parkinson’s and other muscular disorders get multiple targeted injections of botulism toxin, guided by electromyography .
The neurotoxin in Botox can release the grip of muscle spasms, tremors and pain.
“The Botox, what it does is it goes into the nerve terminals and then makes those nerve terminals fire less, and by firing less the muscles or the limbs return to their original or more normal position,” said Dr. Guillermo Moguel-Cobos, a neurologist at the center.
“He gave me nine shots in my leg and within a week, that inside muscle relaxed and my foot went back into place and I walked fine,” said Eshelman. “Sometimes I cry when I think about it, like right now. My whole life is back.”
An active man taking control of his Parkinson’s disease one step at a time.
Botox is FDA-approved to treat Parkinson’s patients. Injections are administered about every 90 days. It’s not a cure, but doctors say by relieving some of the worst symptoms, Botox therapy can help patients avoid surgery.
BOTOX FOR PARKINSON’S
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How Do Botulinum Toxin Injections Work
Botulinum toxin injections work by blocking the signals that are sent from the nerve cells to the muscles. When these signals are blocked, the release of acetylcholine is prevented. Acetylcholine is neurotransmitter found in the body and when its release is blocked, the affected muscles are rendered unable to contract. Patients treated with botulinum toxin injections usually notice the effects 3 days to 2 weeks following treatments. After approximately 3 months, the effects of the botulinum toxin will diminish.
The success of a botulinum toxin injection depends on:
- the dose
- the injection site in the muscle
- experience of the physician administering the injection
- clear communication between the physician and patient regarding the symptoms being treated and the potential outcomes
It is important to remember that it may take more than one cycle of injections before the optimal benefit is achieved.