Approach to the treatment of limb disorders with botulinum toxin A. Experience with 187 patients
S. L. Pullman, P. Greene, S. Fahn and S. F. Pedersen
Department of Neurology, College of Physicians and Surgeons, Columbia University, New York, USA.
OBJECTIVE: To determine the dosing, response expectation, efficacy, and
most rational strategy for using intramuscular injections of botulinum
toxin A (BTX) for limb disorders. DESIGN: Open-label prospective analysis
of outcome after BTX treatment in patients with limb disorders. PROCEDURE:
Botulinum toxin A prepared from lyophilized botulinum toxin was injected
into selected upper and lower limb muscles under electromyographic
guidance. Booster injections were given every 10 to 14 days during the
first month (if needed) until optimal effects were achieved. Clinical data
and muscle strength testing were obtained before the first injections and
repeated at each visit. Level of disability, global functional improvement,
and relief of pain were evaluated 6 to 8 weeks after the first set of
injections. Practical and meaningful BTX doses by muscle, limb, or
condition according to specified levels of efficacy were developed. MAIN
OUTCOME MEASURES: Botulinum toxin A efficacy was calculated as an
arithmetic combination of changes in the 3 clinical ratings before and
after administration of BTX. RESULTS: Botulinum toxin A injections were
given to 187 patients with limb disorders during an 8-year period (136 with
dystonia, 37 with parkinsonian, essential, and cerebellar tremors, and 14
with spasticity). Four overall outcomes from no effect to almost complete
improvement in the use of the limb or relief of pain were found, and
determined the strategy for follow-up injections. Average BTX efficacy for
all patients was 65% and ranged from 83.5% for focal hand dystonia to 35.7%
for parkinsonian tremor. Botulinum toxin A injections relieved pain,
independent of motor function, in 82.7% of patients with painful muscle
spasms. CONCLUSIONS: Botulinum toxin A was found to be a safe and useful
treatment of various limb conditions. Botulinum toxin A was significantly
more effective when only a few muscles needing low doses were injected, and
tended to be more useful in dystonia and spasticity than tremor. Candidates
for BTX injection could be categorized functionally into 3 groups
independent of the underlying disorders. The only significant adverse
effect of BTX injection in limbs was transient weakness in injected or
neighboring muscles.
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