The Effectiveness of Combining Botulinum Toxin Type A and Therapeutic Exercise in Treating Spasticity in a Patient with Complicated Stiff-Person Syndrome: A Case Report.

Stiff-person syndrome is rare and disabling autoimmune condition that most frequently affects women, with no real predisposition by race. Diagnosis is often arduous, which is why patients concomitantly suffer from anxiety and depression. To date, drug therapy is based on the use of benzodiazepines, barbiturates, and baclofen. Refractory cases are treated with intravenous immunoglobulin, plasmapheresis, B lymphocyte depletion with rituximab, and even the implantation of intrathecal baclofen devices. Botulinum toxin injection is frequently used, even if it still has an unclear role in the literature. Our case report aims to demonstrate the efficacy of a combined treatment of botulinum toxin and therapeutic exercise in a 65-year-old patient with biceps brachii muscle hypertonia and diffuse spasms of the axial musculature, using rating scales such as the Numeric Rating Scale (NRS) and Modified Ashworth Scale (MAS), joint range of motion (ROM) measurement, and muscle dynamic stiffness mensuration, which is performed by using the MyotonPro®. All the assessments were conducted at the first evaluation (T0), soon after the combined treatment with botulin toxin and therapeutic exercise (T1), three months (T2), six months (T3), and eight months after the botulinum toxin injection (T4). The patient demonstrated benefits for more than 6 months with no side effects. The combined therapy of botulinum toxin and therapeutic exercise had an excellent result in our patient.

Intrathecal Baclofen Infusion-Botulinum Toxin Combined Treatment Efficacy in the Management of Spasticity due to Cerebral Palsy.

BACKGROUND: Cerebral Palsy (CP) is a group of permanent, but not unchanging, disorders of movement and/or posture and motor function, which are due to a non-progressive interference, lesion, or abnormality of the developing/immature brain. One clinical presentation is muscle spasticity, which leads to a significant impact on the individual's functionality and quality of life. Spasticity treatment is multidisciplinary and includes pharmacological and physical intervention; intrathecal baclofen shows a positive effect in severe spasticity and suboptimal response to oral drugs, while local injection of Botulinum toxin type A (BTXA) improves muscle tone, motion and pain. OBJECTIVE: The aim of this study was to evaluate the efficacy of the combined intrathecal baclofen infusion (ITB) - botulinum toxin treatment in the management of spasticity in CP. METHODS: 8 patients with spastic tetraparesis were enrolled. All patients were treated with intrathecal Baclofen; in lower limbs, no spastic symptoms appeared, while marked spasticity was noted in upper limbs. We injected the right and left Biceps Brachial (BB) and Flexor Digitorum Superficialis (FDS) muscles with botulinum toxin type A. All patients underwent Myometric measurement, Ashworth Scale, Numerical Rating Scale, and Visual Analogic Scale evaluation before infiltration (T0), 30 days after injection (T1), 60 days after injection (T2), and 90 days after treatment (T3). RESULTS: All data demonstrated an improvement in spasticity, pain, quality of life, and self-care during the study, with p < 0.05. No side effects appeared. CONCLUSION: This study demonstrated the efficacy and safety of intrathecal baclofen infusion and botulinum toxin combined treatment in the management of spasticity, pain, quality of life, and selfcare in CP patients.

Effects of Intradermal Therapy (Mesotherapy) on Bilateral Cervicobrachial Pain.

BACKGROUND: Mesotherapy is a procedure or a process of injecting drugs into the skin. This technique can help decrease the total drug dose due to its drug-sparing effect on the systemic route and can be utilized to treat nonspecific neck pain that occurs in the lateral and posterior neck. METHODS: Ten patients with bilateral cervicobrachial pain were recruited and evaluated at T0 before treatments, T1 at the end of the treatment (42 days after T0), and T2 (72 days after T0). Assessments consisted of performing the Visual Analogue Scale (VAS) to evaluate pain evolution; a range of movement (ROM) and Bilateral trapezius' tone, elasticity, and dynamic stiffness mensuration were performed using MyotonPro®. All patients underwent mesotherapy treatment in the trapezius muscles with 1 cc of Diclofenac Sodium and 1 cc of lidocaine diluted in 3 cc of saline for a total of 6 weeks. RESULTS: VAS value statistically decreased at T1 and T2; ROM of neck flexion statistically increased at T1 and T2, and miometric tone and stiffness value statistically improved at T1 and T2. CONCLUSION: mesotherapy with Diclofenac Sodium reduced pain intensity and improved functional outcomes, with no significant adverse effects in patients with myofascial pain syndrome of cervicobrachial localization.

Is There a New Road to Spinal Cord Injury Rehabilitation? A Case Report about the Effects of Driving a Go-Kart on Muscle Spasticity.

BACKGROUND: Traumatic spinal cord injury (SCI) is a neurological disorder that causes a traumatic anatomical discontinuity of the spinal cord. SCI can lead to paraplegia, spastic, or motor impairments. Go-karting for people with SCI is an adapted sport that is becoming increasingly popular. The purpose of this case report is to shed light on the effects of driving a go-kart on a patient with SCI-related spasticity and to deepen understanding of the possible related role of whole-body vibration (WBV) and neuroendocrine reaction. METHODS: The patient was a 50-year-old male with a spastic paraplegia due to traumatic SCI. He regularly practiced go-kart racing, reporting a transient reduction in spasticity. He was evaluated before (T0), immediately after (T1), 2 weeks after (T2), and 4 weeks after (T3) a go-kart driving session. On both sides, long adductor, femoral bicep, and medial and lateral gastrocnemius spasticity was assessed using the Modified Ashworth Scale (MAS), and tone and stiffness were assessed using MyotonPro. RESULTS: It was observed that a go-kart driving session could reduce muscle spasticity, tone, and stiffness. CONCLUSIONS: Go-kart driving can be a valid tool to obtain results similar to those of WBV and hormone production in the reduction of spasticity.

Clinical Onset of Action of Incobotulinum Toxin A Preparation.

BACKGROUND: Many studies in vitro compared the onset of action, maximum efficacy, and duration of botulinum toxin type A (BoNT/A) preparations. OBJECTIVE: In this study, we analyzed the onset of action of BoNT/A preparation free of complexing proteins in patients with upper limb spasticity post stroke up to 30 days after treatment. METHODS: 75 patients affected by Biceps Brachii spasticity were enrolled. Outcome measures were instrumental muscle tone modification (myometric measurement), improvement of Modified Ashworth Scale (MAS), improvement of elbow's passive extension, and improvement of compound muscle action potential (cMAP) evaluated by electroneurography. We analyzed data at t0 (pre-injection), t1 (1 day after), t2 (7 days after), t3 (14 days after), and t4 (30 days after). RESULTS: All measurements decreased at t2, t3, and t4 with initial improvement at t2 and maximum improvement at t4; no statistical difference at t1 was found. CONCLUSION: This study demonstrated the onset of Incobotulinumtoxin A efficacy started after 7 days; this rapid action and efficacy of BoNT/A preparation could improve an intensive rehabilitation program after some days post-injection. Early clinical onset of action could be by the absence of complexing proteins in the preparation.

Real-Time Muscle Activity and Joint Range of Motion Monitor to Improve Shoulder Pain Rehabilitation in Wheelchair Basketball Players: A Non-Randomized Clinical Study.

Wheelchair basketball (WB) involves sports gestures that expose the shoulder to high biomechanical stress and frequently lead to shoulder pain (SP). Due to their physical peculiarities and sporting performance, these athletes require specific rehabilitation programs that are as fast, personalized and effective as possible. However, there are few studies specifically dedicated to these purposes. Surface electromyography (sEMG) seems a promising tool for better customization and achieving more targeted rehabilitation results. The aim of this study was to evaluate the usefulness of sEMG to monitor SP rehabilitation outcomes in WB players. Thirty-three athletes were enrolled in this non-randomized clinical study and divided into two groups. Both groups underwent a shoulder rehabilitation protocol, but only the experimental group was monitored in real time with sEMG on the shoulders. At enrollment (T0), at the end of 4 weeks of the rehabilitation program (T1), and 8 weeks after T1 (T2), the following outcome measures were collected: Wheelchair User's Shoulder Pain Index (WUSPI), 20 m straight line test, shoulder abduction range of motion (ROM). There was a statistically significant difference for WUSPI and ROM scores in the comparison between groups (p < 0.001), and for all outcomes in the comparison between times and in the interaction between time and group (p < 0.001). Therefore, the experimental group showed a better improvement at all detection times compared to the control group. sEMG seems a useful tool for improving the monitoring of SP rehabilitation outcomes in WB players. This monitoring speeds up and improves the rehabilitative results, limiting the risk of sport abandonment and increasing the possibility for people with disabilities to quickly return to practice physical activity.

Effects of 5-Week of FIFA 11+ Warm-Up Program on Explosive Strength, Speed, and Perception of Physical Exertion in Elite Female Futsal Athletes.

Futsal is a sport that originates from soccer and is increasingly practiced all over the world. Since training and warm-up protocols should be sport-specific in order to reduce injuries and maximize performance, this study aimed to evaluate the effects of 5 weeks of the FIFA 11+ warm-up program on explosive strength, speed, and perception of physical exertion in elite female futsal athletes. Twenty-nine elite female futsal athletes participating in the Italian national championships were divided into two groups: the experimental group (EG) underwent 5 weeks of the FIFA 11+ warm-up program, and the control group (CG) underwent 5 weeks of a dynamic warm-up. We evaluated any effect on explosive strength (by Squat Jump test), speed (by Agility T-test), and perception of physical exertion (by Borg CR-10 scale). All measurements were carried out by a technician of the Italian Football Federation before (T0), at the middle (T1), and at the end (T2) of the protocol. The EG showed significant improvements on performances between T0 vs. T1 and T0 vs. T2 both in the Squat Jump test (p = 0.0057 and p = 0.0030, respectively) and in the Agility T-test (p = 0.0075 and p = 0.0122). No significant differences were found in the Squat Jump test performances in the CG, while significant improvements were detected in the Agility T-test performances (p = 0.0004 and p = 0.0053, T0 vs. T1 and T0 vs. T2, respectively). As for the Borg CR-10 scale, we found a significant difference between T0 and T2 in the EG (p = 0.017) and no differences in the CG. This study showed that 5 weeks of the FIFA 11+ warm-up program improves the jumping performance of female futsal athletes without adversely affecting speed. These findings can be useful for coaches and athletic trainers in order to consider FIFA 11+ warm-up program also in female futsal athletes.

Electronic Method (Pro-Kin) for Improving And Speeding up The Recovery after Ankle Sprain.

BACKGROUND AND OBJECTIVE: Ankle sprains, very common injuries occurred especially during sports activities, are mainly caused by indirect trauma, which influences exaggerated stress exceeding the strength of stabilization mechanisms. Up to 85% of such injuries result from a sudden flexion and inversion of the foot. In this study, we analyzed the effectiveness of the platform Pro-kin, an innovative system that has given us the possibility to combine the functionality of the older proprioceptive boards with very accurate software in order to improve and accelerate the recovery after ankle injuries. METHODS: 30 patients with moderate ankle sprain outcomes in two groups (A and B) were included in this study. Group A was only treated with proprioceptive exercises for 3 weeks, while the group B was trained with the innovative Pro-kin. In both groups, we evaluated VAS scale, the ratio between the number of circumductions performed by the injured foot and the time spent on doing them and the percentage of load among the injured and the healthy foot in statics and dynamics with electronic baropodometry. Our data has been collected at t0 (beginning of study), t1(one week later), t2 (two weeks later), t3 (one month later), t4 (two months later), and then analyzed by the two-way analysis of variance (2-way ANOVA) test. RESULTS: At t0 no statistical differences of pain in the 2 groups (3.3 and 3.4); the values were similar, as well as at time t1, t2, t3 and t4. Therefore we deduce that Pro-kin treatment is not painful. The number of circumductions performed was definitely better in B group since the first week; for the A group the values considerably increased only at t3 (one month later). Comparing the load percentages on two feet detected by the electronic baropodometer in statics and in dynamics, we deduced that the patients of A group tend to lean mostly on the healthy foot than B group. CONCLUSIONS: This study demonstrates that new technological resources (such as Pro-kin) may be helpful to improve and speed up the recovery of ankle sprain in athletes.

Electrophysiological and Clinical Improvement in Non-Invasive Treatment of Carpal Tunnel Syndrome.

BACKGROUND AND OBJECTIVE: Carpal tunnel syndrome (CTS) is the most common form of nerve entrapment. Clinically, various signs and symptoms compare due to overexposure to mechanical vibrations transmitted to the wrist bones and cartilage, resulting in compression of the sensory and motor nerve fibers of the median nerve. Early symptoms include nocturnal paresthesia and electromyography reveals reduced sensory nerve conduction velocity. Aim of this study was to evaluate the efficacy of a dietary integrator composed of acetyl-L-carnitine, α-lipoic acid, quercetin, bromelain, pantothenic acid, C and B1 and B2 and B6 and B12 vitamins in patients with early (minimal) carpal tunnel syndrome. METHODS: 36 patients (28 female and 8 male) with early CTS characterized by sensory nerve demyelination and inflammation of the transverse carpal ligament. Patients were divided into two groups, group A (18 patients received physical therapy) and group B (18 patients received physical therapy and an oral integrator). Clinical (sleep quality questionnaire to measure severity of paresthesia) and neurophysiological assessment (Sensory Nerve Conduction Velocity) performed at baseline, and then at 30 and 60 days after treatment. RESULTS: Sleep quality and Sensory Nerve Conduction Velocity data analysis show improvement in both groups at 30 and 60 days, with statistical difference between them in both time of analysis. CONCLUSION: In the early CTS, with sensory fibers damage, use of dietary integrator, such as Micronil Dol®, composed of acetyl-L-carnitine, α-lipoic acid, quercetin, bromelain, pantothenic acid, C and B1 and B2 and B6 and B12 vitamins can be effective in quick recovery of median nerve sensory.

Botulinum Toxin Type A and Physiotherapy in Spasticity of the Lower Limbs Due to Amyotrophic Lateral Sclerosis.

Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disease (unknown pathogenesis) of the central nervous system that causes death within 1-5 years. Clinically, flabby paralysis, areflexia, muscular atrophy, and muscle fasciculations, signs of II motor neuron damage, appear. Sometimes, clinical manifestations of damage of the I motor neuron come out in lower limbs; spastic paralysis, iperflexia, and clonus emerge, and they impair deambulation and management of activities of daily living, such as personal hygiene or dressing. Thus, the first therapeutic approach in these patients involves antispasmodic drugs orally followed by botulinum toxin type A injection (BTX-A). In this study, we study the efficacy of BTX-A and physiotherapy in lower limb spasticity due to ALS and no response to treatment with oral antispastic drugs. We evaluated 15 patients (10 male and five female), with a mean age of 48.06 ± 5.2 with spasticity of adductor magnus (AM), at baseline (T0, before BTX-A treatment) and in the following three follow-up visits (T1 30 days, T2 60 days, and T3 90 days after infiltration). We evaluated myometric measure of muscle tone, the Modified Ashworth Scale of AM, Barthel Index, Adductor Tone Rating Scale, and Hygiene Score. The study was conducted between November 2018 and April 2019. We treated AM with incobotulinum toxin type A (Xeomin®, Merz). Spasticity (myometric measurement, Adductor Tone Rating Scale, and Modified Ashworth Scale) and clinical (Barthel Index and Hygiene Score) improvements were obtained for 90 days after injection (p < 0.05). Our study shows the possibility of using BTX-A in the treatment of spasticity in patients with ALS and no response to oral antispastic drugs, with no side effects. The limitation of the study is the small number of patients and the limited time of observation; therefore, it is important to increase both the number of patients and the observation time in future studies.

Pain and Muscles Properties Modifications After Botulinum Toxin Type A (BTX-A) and Radial Extracorporeal Shock Wave (rESWT) Combined Treatment.

BACKGROUND AND OBJECTIVE: Spasticity (most common disability in upper motor neuron syndrome or UMNS) caused an inability of patients' to perform daily activities and a decrease inquality of life. One of the promising methods nowadays, but still not widely used in everyday practice, for spasticity reduction is extracorporeal shock wave. The aim of this study was to evaluate the objective clinical effects of combined treatment botulinum toxin type A and radial Extracorporeal Shock Wave Therapy in spasticity post stroke. METHODS: We considered 30 subjects (14 female and 16 male) with post stroke spasticity of Biceps Brachii, Superficial Flexor Digitorum, Gastrocnemius Medialis and Lateralis and we divided patients into two groups (group A received botulinum toxin injection and physiotherapy while group B received botulinum toxin injection, rESWT and physiotherapy). Assessments were performed before treatment (t0), after 1 (t1), 2 (t2) e 3 (t3) months using Modified Ahworth Scale, Visual Analogical Scale for pain and MyotonPro® device (to assessed myometric evaluation of muscles tone and stiffness). RESULTS: Visual Analogical Scale, Modified Ahworth Scale, muscles tone and stiffness statistically decreased until t3 in the group A and in the group B, but the differences between the two groups were significant at the t1 only. CONCLUSION: Radial Extracorporeal Shock Wave Therapy could be an effective physical treatment aimed at the reduction of upper and lower limbs spasticity and could lead to the improvement of trophic conditions of the spastic muscles in post-stroke.

Efficacy and Non Invasive Treatment of Sialorrhea in the Goldenhar Syndrome.

BACKGROUND AND OBJECTIVE: Goldenhar syndrome (ocular-auricular-vertebral syndrome), a rare congenital condition arising from defects in the first and second brachial arches, consists in clinical variety of features ranging from facial abnormalities, ear-eye abnormalities, vertebral defects and congenital heart problems and severe obstructive sleep apnea. Due to craniofacial abnormalities, patients presents mechanical obstructive phenomena and sialorrhea that cause prone position, language's fastening, use of nasopharyngeal cannulas and tracheal intubation. METHODS: In this article, we report a case of a 16 years old child affected by Goldenhar syndrome and sialorrhea to demonstrate improvement of the daily patient management, through inoculations of botulinum toxin type A. Due to severe sialorrhea which caused tracheobronchial daily aspirations, the caregivers used an external aspirators. RESULTS: In the first infiltration (August 2016) the parotid and submandibular glands bilaterally were inoculated with incobotulinum toxin type A (Xeomin®, Merz Pharma) with dosages of 5 UI for each of them, for a total of 20 UI without clinical efficacy (no quantitative and qualitative saliva reducing during 3 months). In the second (November 2016) and third (February 2017) infiltrations each parotid and each submandibular glands were injected with a (dosage of 7 UI and 5 UI respectively (total of 24 UI of incobotulinumtoxin A) with important clinical results (saliva production and tracheo-bronchial aspirations reduced). CONCLUSION: Therefore, botulinum toxin type A could be a good and non invasive treatment of sialorrhea in Goldenhar syndrome to improve oral hygiene and daily patient management.

"Appropriate Treatment" and Therapeutic Window in Spasticity Treatment with IncobotulinumtoxinA: From 100 to 1000 Units.

Many neurological diseases (ischemic and hemorrhagic stroke, multiple sclerosis, infant cerebral palsy, spinal cord injuries, traumatic brain injury, and other cerebrovascular disorders) may cause muscle spasticity. Different therapeutic strategies have been proposed for the treatment of spasticity. One of the major treatments for tone modulation is botulinum toxin type A (BTX-A), performed in addition to other rehabilitation strategies based on individualized multidisciplinary programs aimed at achieving certain goals for each patient. Therapeutic plans must be precisely defined as they must balance the reduction of spastic hypertonia and retention of residual motor function. To perform and optimize the treatment, an accurate clinical and instrumental evaluation of spasticity is needed to determine how this symptom is invalidating and to choose the best doses, muscles and times of injection in each patient. We introduce an “appropriate treatment” and no “standard or high dosage treatment” concept based on our retrospective observational study on 120 patients lasting two years, according to the larger Therapeutic Index and Therapeutic Window of Incobotulinumtoxin A doses from 100 to 1000 units. We studied the efficiency and safety of this drug considering the clinical spasticity significance for specialist physicians and patients.

Helping people in a minimally conscious state develop responding and stimulation control through a microswitch-aided program.

BACKGROUND: Postcoma persons in a minimally conscious state (MCS) and with extensive motor impairment cannot independently access and control environmental stimulation. AIM: Assessing the effects of a microswitch-aided program aimed at helping MCS persons develop responding and stimulation control and conducting a social validation/evaluation of the program. DESIGN: A single-subject ABAB design was used for each participant to determine the impact of the program on his or her responding. Staff interviews were used for the social validation/evaluation of the program. SETTING: Rehabilitation and care facilities that the participants attended. POPULATION: Eleven MCS persons with extensive motor impairment and lack of speech or any other functional communication. METHODS: For each participant, baseline (A) phases were alternated with intervention (B) phases during which the program was used. The program relied on microswitches to monitor participants' specific responses (e.g., prolonged eyelid closures) and on a computer system to enable those responses to control stimulation. In practice, the participants could use a simple response such as prolonged eyelid closure to generate a new stimulation input. Sixty-six staff people took part in the social validation of the program. They were to compare the program to basic and elaborate forms of externally controlled stimulation, scoring each of them on a six-item questionnaire. RESULTS: All participants showed increased response frequencies (and thus higher levels of independent stimulation input/control) during the B phases of the study. Their frequencies for each intervention phase more than doubled their frequencies for the preceding baseline phase with the difference between the two being clearly significant (P<0.01). Staff involved in the social validation procedure provided significantly higher scoring (P<0.01) for the program on five of the six questionnaire items. CONCLUSIONS: A microswitch-aided program can be an effective and socially acceptable tool in the work with MCS persons. CLINICAL REHABILITATION IMPACT: The participants and staff's data can be taken as an encouragement for the use of a microswitch-aided program within care and rehabilitation settings for MCS persons.

Use Of External Intrathecal Infusion Pumps In The Management Of Septic Complications: A Case Report.

Spasticity is a motor disorder with an increased muscle tone, typically associated with spasms, weakness and lack of coordination. It is an invalidating and debilitating pathology, characterized by pain, limited autonomy in activities of daily living, development of severe lesions. Spasticity can be adequately treated with physiotherapy, muscle relaxants drugs or topical treatment with botulinic toxin type A. Intrathecal baclofen therapy is very effective in the treatment of severe and generalized spasticity. Sometimes, soft tissues adjacent to the implant intrathecal infusion become infected; removing intrathecal infusion and systemic antibiotic therapy are best solution for clinical cure. However, removing intrathecal baclofen therapy could increase muscle spasticity with enhancement of pain and clonus that can worsen quality of life. In this study, we evaluated clinical improvement after complete healing of the septic focus and implantation of a new infuser.

Objective Assessment of the Rheological Muscle Property in the Treatment of Fibromyalgia.

Fibromyalgia (FM), clinical condition characterized by several signs and symptoms such as widespread pain, trigger point, morning stiffness and extreme tiredness for scarce hours of sleep, is linked to several changes in several brain neurotransmitters, particularly serotonin and norepinephrine. Consequently, the Neural Vegetative System works more and so it generates an exaggerated muscular contraction, sweating and constriction of blood vessels. The aim of our study was to treat a selected group of female patients suffering from FM with duloxetine with physiotherapy. We used two clinical scales (VAS and FIQ) and an objective evaluation such as myometric. The analysis of the data Myoton used during any inspection showed a statistically significant reduction in the values of muscle tone in each district analyzed. This finding was also confirmed by the patients themselves who have experienced a significant welfare and less muscle tension in different locations, as evidenced by data obtained from the clinical scales used by us. In addition, our patients were thought to be satisfied with the improvements not only subjective, but also with the objective witnessed myometry, making them a share of the study and feeling constantly monitored for treatment aimed at a real reduction in muscle stiffness. In conclusion, our study demonstrates combined treatment duloxetine- physiotherapy effectively reduces a symptom often disabling and particularly troublesome in patients with FM as the exaggerated muscle contraction.