Effectiveness Of Onabotulinumtoxina On Reduction Of Rest Tremor In Parkinsons Disease: A Pilot Study
D. Roque, D. Drazheva, N. Browner, M. Sklerov, M. Collins
Objective: To determine the feasibility of a prospective study design aimed specifically at comparing the effect of onabotulinumtoxinA to placebo injections on persons with Parkinsons suffering from medically-refractory rest tremor.
Background: Rest tremor remains one of the most disabling and medically-refractory symptoms of Parkinsons disease. Prior publications have injected botulinum toxins into limbs affected by rest tremor, largely concluding that they can suppress tremor amplitude through multiple injection techniques. However, changes in limb function after injections have been harder to establish. Furthermore, results can be affected by weakness caused by the injections, especially when using higher doses traditionally reserved for dystonia. If we are to ever interpret future study results favorably for botulinum toxin use in PwPs, accounting for such confounders through thoughtful study design is necessary.
Results: A total of 16 subjects completed all study visits, and the study is closed to proceed with data analysis.
To cite this abstract in AMA style:
Effective Care And Advancing Research
Parkinsons disease is a progressive, degenerative disorder of the nervous system that causes people to gradually lose control over movement and other functions. The cause of PD is unknown, and currently there is no cure.
The physicians in UT Southwesterns Movement Disorders Clinic have advanced training and significant experience in managing PD. Our team collaborates with specialists across the medical center to help patients continue living their fullest possible lives, through a combination of treatment and rehabilitation.
UT Southwestern offers coordinated care for patients with Parkinsons, providing the full range of services and support needed to diagnose this illness and manage its symptoms and complications.
Excessive Sweating And Body Odor
For those who sweat too much or who have trouble reducing their body odor with the use of traditional deodorants, Botox injections may be helpful, research has shown. Normally, sweat is produced when the small muscles around sweat glands squeeze the liquid out, Maman said.And if you can paralyze those small muscles, then the sweat glands are no longer functioning like they normally would, he said.
In a 2007 study published in the journal Dermatologic Surgery, researchers injected Botox into the armpits of 51 people. Both the participants and the independent raters of smell samples from the peoples armpits said the peoples underarm odor was less unpleasant after they received the injections. Botox was approved by the FDA to treat excessive sweating in 2004.
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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.
Efficacy Of Botulinum Toxin For Treating Sialorrhea In Neuromuscular Conditions
- 1Department of Neurology, University of Missouri, Columbia, MO, United States
- 2Assistant Professor of Neurology, Department of Neurology, University of Missouri, Columbia, MO, United States
Background: Drooling related to bulbar weakness and dysfunction is a common concern in patients with neuromuscular disease. While there are numerous medications to manage sialorrhea, they are often limited by side effects and lack of efficacy. Botulinum toxin has shown to benefit ALS patients in a few studies, but there is scant data on the benefit in other neuromuscular conditions.
Objective: To assess the effectiveness of Botulinum toxin in reducing sialorrhea in patients with various neuromuscular disease.
Design/Methods: 25 patients with documented neuromuscular illness and concern for drooling was followed for 6 weeks after Botulinum toxin injection. These patients had one of the following diagnoses: Duchenne muscular dystrophy , myotonic dystrophy , oculopharyngeal muscular dystrophy , inclusion body myositis , primary lateral sclerosis , amyotrophic lateral sclerosis , spinal muscular atrophy type 2 and 3 , spinal-bulbar muscular atrophy , and Beckers muscular dystrophy . A subjective drooling scale and drooling thickness score was calculated on these patients prior to the injection and 4 and 6 weeks after the injection. Botulinum toxin 2030 units were injected into bilateral parotid gland and submandibular gland .
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Types Of Movement Disorders That May Be Helped By Botox
In addition to Parkinsons disease, cerebral palsy, and MS, Botox may help people with spinal cord injury, restless legs syndrome, and writers cramp. These conditions and others cause different types of movement disorders that may benefit from chemical denervation with , including:
- Dystonia: Involuntary muscle contractions that cause repetitive movements or abnormal postures that may be painful. Dystonia may affect one muscle or many muscles. There are various types of , including blepharospasm , cervical dystonia , and dystonia of the foot or leg.
- Myoclonus: Muscle jerks or that most often affect the neck, torso, arms or hands. About half of people with myoclonus also develop dystonia.
- Spasticity: Abnormally tight muscles due to muscle contraction. Spasticity is often associated with brain, spinal cord or motor nerve damage due to cerebral palsy, spinal cord injury, multiple sclerosis, and .
- Tremor: Rhythmic shaking of a body part due to muscle contractions. It may be intermittent or continuous. Tremors are often seen in people with Parkinsons disease.
- Motor and complex tics: Sporadic appearance of brief, sudden, exaggerated movements.
Drooling In Parkinson’s Disease
People with Parkinson’s disease, who have problems with their muscle function and may swallow less frequently than normal, sometimes develop excessive drooling. But Botox may help to treat this symptom. In a study published in 2006 in the journal Movement Disorders, researchers administered Botox to the salivary glands of 32 people with Parkinson’s disease who had been experiencing excessive drooling. The researchers found that after the treatment, the people drooled less and produced less saliva. The people did not experience any side effects from the Botox, according to the study.
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Dropped Head Syndrome And Camptocormia
Approximately 5-10% of people with PD have a more pronounced problem with their posture. One potential difficulty is a pronounced forward flexion of their head, called dropped head syndrome . Another, is a pronounced flexion of their entire trunk, called camptocormia or bent spine syndrome . These two conditions have many causes besides PD including other neurodegenerative diseases such as the Parkinson plus syndrome, multiple system atrophy , amyotrophic lateral sclerosis , and muscle or nerve diseases such as chronic inflammatory demyelinating polyneuropathy .
Typically, in dropped head syndrome and camptocormia, the forward flexion is present with sitting and increases with walking. When lying down on the back however, the neck and trunk can mostly or completely straighten out. This distinguishes it from a fixed posture of the neck or back called kyphosis or kyphoscoliosis, which does not straighten out when lying on the back. Kyphosis is common as people age and is not related to PD. It can be caused by osteoporosis, leading to compression fractures of the spine, arthritic changes in the spine, and degenerative disc disease. Both kyphosis and camptocormia can co-exist in one person, which complicates the diagnosis. Both are also more common in women than men.
Am I A Good Candidate For Botulinum Toxin For Movement Disorders
You may be a good candidate for botulinum toxin injections if you are at least 18 years old and have been diagnosed with one of the conditions above.
Although this drug is technically a toxin, it is generally safe and effective when used in correct dosages by trained providers. The most common side effect is temporary muscle weakness near injection sites. You may also experience pain, bruising, or bleeding at the injection sites. Rarely, it can cause generalized weakness or flu-like symptoms.
You should not take botulinum toxin if you:
- Are allergic to any of its ingredients or have had an allergic reaction to another botulinum toxin 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.
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More Than A Cosmetic Solution
Botulinum toxin injections may be familiar for cosmetic use getting rid of wrinkles but they have been used primarily to help patients with dystonia and spasticity, in which there are involuntary muscle movements because of damage to the portion of the brain or spinal cord that controls voluntary movement. Spasticity can occur in a person who has had a stroke, multiple sclerosis, traumatic brain injury or cerebral palsy.
The injections have also been successful for patients who attend the weekly Spasticity Clinic at Cedars-Sinai. The clinic which takes place every Friday from 8 a.m. to noon provides relief to patients who need assistance with tightened muscles. The botulinum toxin injections help patients improve their ability to move, and combined with physical and occupational therapy enable them to increase their flexibility as they move their arms and legs and stretch their bodies.
“We have patients who, obviously after a devastating stroke or traumatic brain injury, are unable to walk, move or feed themselves,” said Echo E. Tan, MD, a neurologist at Cedars-Sinai. The injections can allow a patient to open their fist so their palms can be cleaned, which can prevent skin erosion, and their nails can be clipped to prevent them from cutting into their palms.
Patient Specific Treatment Plans
Treatment with botulinum toxin injections should be administered by a trained physician however collaboration from various specialties is very helpful for developing a comprehensive treatment plan. Your doctor may refer you to other specialties that work closely together including physical and occupational therapy, psychology, psychiatry and social work.
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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.
Treatments For Parkinson’s Disease
Although PD has no cure, the symptoms of the disease are treatable.
Because each patient experiences symptoms differently, physicians base each patients treatments on his or her specific symptoms. The Movement Disorders team works closely with other UT Southwestern specialists such as those in psychiatry and speech, physical, and occupational therapy to provide patients with individualized care to manage symptoms and maximize mobility, balance, and coordination.
Treatments for Parkinsons disease include:
- Medication: Many experts now believe that medication should be initiated immediately after diagnosis. Medication can help manage problems with walking, movement, and tremor by correcting or compensating for dopamine deficiency in the brain.
- Botulinum toxin injection: UT Southwestern specializes in the use of botulinum toxin injections for a variety of conditions that result in involuntary muscle contractions. Botulinum toxin weakens the muscle that it is injected into, thus promoting relaxation of muscle spasm. These injections can be a particularly effective treatment for PD patients with dystonia , eye twitching, and drooling. Patients who might benefit from botulinum toxin are examined to determine which muscles are overactive. The botulinum toxin is injected into only those muscles. Benefits gradually develop over seven to 10 days. The treatment is usually effective for three months, so injections are repeated several times a year to maintain ongoing benefits.
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A Exercises To Improve Swallowing Difficulty :
A speech-swallow therapist evaluates how your muscles move while swallowing. They can teach you important exercises to improve swallowing difficulty and prevent Aspiration.
Speech therapists specially trained in Parkinsons can teach you exercises such as Expiratory Muscle Strength Training or Lee Silverman Speech Therapy or LOUD therapy.
These specialized training sessions are tremendously helpful in improving voice. But these exercises also make swallowing easier.
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Support For People With Parkinson’s Disease
If a patient wishes, the Movement Disorders team maintains an ongoing relationship that includes follow-up appointments with physicians and advanced practice providers to monitor the condition as it progresses. Family members are included in discussions about the goals of a patients treatment and rehabilitation program. Caregivers have access to services such as psychological counseling, support groups, and educational programs.
UT Southwestern also hosts an annual Parkinsons Disease Patient and Caregiver Symposium for patients, their families, their caregivers, and anyone interested in learning more about the disease. The symposium reviews the latest clinical treatments, ongoing research projects, new drugs, and leading-edge developments that are on the horizon.
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Different Types Of Botulinum Toxin
There are eight different botulinum toxin species that occur in nature. There are only two however, that are produced commercially Botulinum toxin A and B.
The commercially available products are:
Each of the above agents are FDA approved for a slightly different list of clinical indications.
Are There Potential Side Effects
Side effects from botulinum toxin injections are infrequent and transient. For blepharospasm patients, mild side effects may include drooping of the eyelid, blurred vision, facial asymmetry and double vision. Tearing may occur.
General side effets of botulinum toxin injections may include pain, tenderness and/or bruising at the injection site, difficulty swallowing, upper respiratory infection, neck pain and headache. Most side effects recover spontaneously.
Rare but serious side effects include severe problems swallowing, serious heart problems and severe allergic reactions. If you are experiencing a severe side effect, contact emergency services immediately.
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S Of The Body Affected By Dystonia
- Arms, hands, legs and feet: Involuntary movements, spasms or twisting and curling
- Neck: May twist uncomfortably, causing the head to be pulled down or to the side. This is called cervical dystonia or spasmodic torticollis
- Muscles around the eyes: May squeeze involuntarily, leading to a person to blink too much or to have difficulty opening the eyes. This is also called blepharospasm
- Vocal chords and swallowing muscles: May cause a persons voice to sound softened, hoarse or breathy
- Jaw: May open or close forcefully or there may be grimacing of the face
- Abdominal wall: May cause sustained contractions and involuntary, writhing movements of the abdominal wall
What Does Botulinum Toxin Treatment For Parkinsons Look Like
The effects of Botulinum toxin take hold about 3-10 days after the injections and last approximately three to four months, so the treatments typically need to be repeated on a regular basis. Although this means routine injections, it also means that Botulinum toxin injections do not have any permanent side effects. Some side effects may still occur with Botulinum toxin injections and the doctor who performs the procedure will review these with you. An advantage of using Botulinum toxin for the treatment of the conditions noted above, is that the toxin typically only impacts the areas into which it is injected, as opposed to oral medications which have a more widespread effect, and therefore more potential for side effects.
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What Is Botulinum Toxin
Botulinum toxin is a substance produced by the bacteria Clostridium botulinum. Botulism is caused by the harmful effects of this toxin. If the toxin enters the bloodstream, it can spread throughout the body, causing widespread muscle weakness. In its full-blown form, botulism can cause difficulty with swallowing and breathing by causing weakness of the muscles that control these functions.
The good news is that decades ago, scientists learned how to isolate the toxin and harness its power for medical use, and it can be safely injected into particular muscles in order to decrease unwanted movements of those muscles.
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.
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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 Parkinsons 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 Parkinsons disease having deep brain stimulation experiencing disabling foot dystonia.
METHODS:Dystonic foot and ankle muscles were identified and injected with 250400 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 Parkinsons 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 Parkinsons disease deep brain stimulation.
J Rehabil Med 2016 48: 0000