Dear Suzanne & others, re Botox, Just some anecdotal comments .....
I've seen it used with MS, CVA and head injury and in all cases the
following principles seem to hold true:
1. Once injected, the limb need to be held in a lengthened position; whether
by custom made cast/ splint, off the shelf variable splint e.g. ratchet
hinged knee/elbow splint for hamstrings/biceps or judicious use of seating
e.g. pommel following adductor injection, depends on exactly which muscle
you are targeting.
2. Specific soft tissue mobilisation, along the lines of Glen Hunter's
work,but try and get ritation in, seems to help keep/gain length, - be sure
to reeducate the kinetic control of the muscle though i.e. the patient has
to use the increased length functionally within that session if possible ,
to maintain the increased length.I believe theoretically, Botox only affects
hypertonia and not contracture, but the subsequent physio CAN have an effect
on contracture, if you really get stuck in and find the "knotty " bits in
the muscle to work on.
3. None of this will be any good if the underlying poor postural control is
not addressed ( in my experience for every 'up' i.e. area of 'spasticity',
there is always an equal and opposite 'down' i.e. area of poor postural
control - forgive me for scrambling Newton's 2nd?law ). So for instance in
the case of the ankle, I would check for weakness around hip/ pelvis/ trunk
in the first instance.
As an example: a lady with M.S., longstanding spasticity lower limbs &
trunk. Tends to sit in wheelchair with moulded seat (to allow for hip
retraction plus windsweeping to right with knock on effect on spine ), but
no footrests. Presented with severe knee flexion contractures leading to
popliteal pressure sore on right, and unable to sit, even when supported, as
legs spasming off surface & having to hang on with hands.
Rx: Botox both hamstrings, then SSTM to hamstrings, hip flexors, gastroc/
soleus, trunk etc. etc. - sounds simple, but took 2 - 3 pairs of hands and a
lot of strength! Advised to spend time lying on left or back instead of just
right.Underneath it all some selective activity in legs but not enough to
use functionally, BUT a very wobbly trunk dependent on arms to stabilise. So
work to gain increased trunk control with decreased dependence on arms and
less retraction of left hip.
NOW: Pressure sore healed, able to sit in ordinary wheelchair with feet ON
footplates ( rather than above and behind them ), and arms relaxed on lap.
N.B. used positioning rather than splinting to maintain increased length in
this case.
Overall result; one more comfortable & relaxed patient at less risk of
developing a further pressure sore for a while at least & one exhausted
physio!
Hope that's of some help
Debbie, U.K. physio.
> From: Suzanne Solomons Resnick <[log in to unmask]>
> Reply-To: [log in to unmask]
> Date: Sun, 28 May 2000 03:42:42 +0200
> To: [log in to unmask]
> Subject: Re: Botox request.
>
> I have a 50 year old man s/p bilat CVA with hihg tonus in the gastrocs and
> severe achilles contractures, ankles are in 30degrees pf who just underwent
> Botox injections to both sides -gastrosoleus. I would appreciate any rehab
> ideas other than standing with heklp of standing board. Manual stretching is
> pretty useless
> at the moment but may become easier after the injections. Casting , some
> months ago was also pretty futile. What to expect?
> I also wanted to know if anyone had heard of Botox in the treatment of
> excessive drooling in children with CP
> Thanks
> Suzanne Solomons PT
> Garry T Allison wrote:
>
>> DJ Simpson BSc(Hons) Pod SRCh MChS RN wrote:
>>> is anyone aware of Botox injections? and their outcomes in the
>>> rehabilitation of adults with chronic TEV & spasticity following head
>>> injuries??
>>
>> I am currently supervising a research project through The Centre for
>> Musculoskeletal Studies & Royal Perth Hospital (Physiotherapy Department)
>> in Perth Western Australia with one arm of the intervention using Botox
>> injections.
>>
>> There is a lot of information as to the specific adaptations to muscles
>> following Botox - how this translates to measureable changes in the
>> outcomes of certain groups of individuals is of interest.
>> We are interested in the changes which occur at the ankle in individuals
>> with traumatic head injuries.
>>
>> We should have some data for publication in the next few months -
>>
>> Defining assessing - spasticity, stiffness, range of motion, noticable
>> tension, .... is of great 'interest' to us.
>>
>> If anyone has any new ideas / suggestions in regard to assessing the ankle
>> in this population - I would be most interested (Not so much dystonis more
>> ROM and velocity dependent factors of resistance to movement and muscle
>> activation). Clinicians comments more than welcomed - this project is
>> driven by clinicians.
>> I'll make a summary if mailed personally.
>>
>> cheers
>> Garry.
>>
>> ________________________________________________
>> Garry T Allison (A/Professor of Physiotherapy)
>> The Centre for Musculoskeletal Studies http://www.cms.uwa.edu.au/
>> Department of Surgery, The University of Western Australia.
>> Level 2 Medical Research Foundation Building
>> Rear 50 Murray Street
>> Perth Western Australia 6000.
>> email <[log in to unmask]>
>> ph: (618) 9224 0219
>> Fax (618) 9224 0204
>
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