Long-term repeated botulinum toxin a treatment over 12 years gradually changes gait characteristics: single-case study

Hiroki Tanikawa; Hitoshi Kagaya; Shota Itoh; Kento Katagiri; Hikaru Kondoh; Kenta Fujimura; Satoshi Hirano; Toshio Teranishi

doi:10.2340/jrm-cc.v7.40827

Authors

Hiroki Tanikawa Faculty of Rehabilitation, School of Health Sciences, Fujita Health University, Toyoake, Aichi, Japan
Hitoshi Kagaya Department of Rehabilitation Medicine, National Center for Geriatrics and Gerontology, Obu, Aichi, Japan; Department of Rehabilitation Medicine, School of Medicine, Fujita Health University, Toyoake, Aichi, Japan
Shota Itoh Department of Rehabilitation, Fujita Health University Hospital, Toyoake, Aichi, Japan
Kento Katagiri Department of Rehabilitation, Fujita Health University Hospital, Toyoake, Aichi, Japan
Hikaru Kondoh Department of Rehabilitation, Fujita Health University Hospital, Toyoake, Aichi, Japan
Kenta Fujimura Faculty of Rehabilitation, School of Health Sciences, Fujita Health University, Toyoake, Aichi, Japan
Satoshi Hirano Department of Rehabilitation Medicine, School of Medicine, Fujita Health University, Toyoake, Aichi, Japan
Toshio Teranishi Faculty of Rehabilitation, School of Health Sciences, Fujita Health University, Toyoake, Aichi, Japan

DOI:

https://doi.org/10.2340/jrm-cc.v7.40827

Keywords:

Muscle Spasticity, Gait Analysis, Gait Disorders, Stroke, Botulinum Toxins

Abstract

Objective: To demonstrate the long-term efficacy of repeated botulinum toxin A injections into the same muscles for ameliorating lower limb spasticity and gait function.

Design: Single-case study

Patient: A 36-year-old woman with right cerebral haemorrhage received her first botulinum toxin A injection 1,296 days after onset. The patient underwent 30 treatments over 12 years after the first injection to improve upper and lower limb spasticity and abnormal gait patterns. The mean duration between injections was 147 days.

Methods: The Modified Ashworth Scale, passive range of motion, gait velocity, and degree of abnormal gait patterns during treadmill gait were evaluated pre-injection and at 2, 6, and 12 weeks after every injection.

Results: The follow-up period showed no injection-related adverse events. Comfortable overground gait velocity gradually improved over 30 injections. The Modified Ashworth Scale and passive range of motion improved after each injection. Pre-injection values of the degree of pes varus, circumduction, hip hiking, and knee extensor thrust improved gradually. However, the degree of contralateral vaulting, excessive lateral shift of the trunk, and insufficient knee flexion did not improve after 30 injections.

Conclusion: Repeated botulinum toxin A injections effectively improve abnormal gait patterns, even when a single injection cannot change these values.

Downloads

Download data is not yet available.

References

Rosales RL, Chua-Yap AS. Evidence-based systematic review on the efficacy and safety of botulinum toxin-A therapy in post-stroke spasticity. J Neural Transm (Vienna) 2008; 115: 617–623.

https://doi.org/10.1007/s00702-007-0869-3

Tanikawa H, Kagaya H, Saitoh E, Ozaki K, Hirano S, Itoh N, et al. Efficacy of botulinum toxin A treatment for pes varus during gait. J Stroke Cerebrovasc Dis 2015; 24: 2416–2422.

https://doi.org/10.1016/j.jstrokecerebrovasdis.2015.06.035

Tanikawa H, Kagaya H, Inagaki K, Kotsuji Y, Suzuki K, Fujimura K, et al. Quantitative as-sessment for flexed-elbow deformity during gait following botulinum toxin A treatment. Gait Posture 2018; 62: 409–414.

https://doi.org/10.1016/j.gaitpost.2018.04.006

Bakheit AM, Fedorova NV, Skoromets AA, Timerbaeva SL, Bhakta BB, Coxon L. The benefi-cial antispasticity effect of botulinum toxin type A is maintained after repeated treatment cycles. J Neurol Neurosurg Psychiatry 2004; 75: 1558–1561.

https://doi.org/10.1136/jnnp.2003.035139

Elovic EP, Brashear A, Kaelin D, Liu J, Millis SR, Barron R, et al. Repeated treatments with botulinum toxin type A produce sustained decreases in the limitations associated with focal upper-limb poststroke spasticity for caregivers and patients. Arch Phys Med Rehabil 2008; 89: 799–806.

https://doi.org/10.1016/j.apmr.2008.01.007

Santamato A, Panza F, Intiso D, Baricich A, Picelli A, Smania N, et al. Long-term safety of repeated high doses of incobotulinumtoxinA injections for the treatment of upper and lower limb spasticity after stroke. J Neurol Sci 2017; 378: 182–186.

https://doi.org/10.1016/j.jns.2017.04.052

Ro T, Ota T, Saito T, Oikawa O. Spasticity and range of motion over time in stroke patients who received multiple-dose botulinum toxin therapy. J Stroke Cerebrovasc Dis 2020; 29: 104481.

https://doi.org/10.1016/j.jstrokecerebrovasdis.2019.104481

Itoh N, Kagaya H, Saitoh E, Ohtsuka K, Yamada J, Tanikawa H, et al. Quantitative assess-ment of circumduction, hip hiking, and forefoot contact gait using Lissajous figures. Jpn J Compr Rehabil Sci 2012; 3: 78–84.

https://doi.org/10.11336/jjcrs.3.78

Tanikawa H, Ohtsuka K, Mukaino M, Inagaki K, Matsuda F, Teranishi T, et al. Quantitative assessment of retropulsion of the hip, excessive hip external rotation, and excessive late-ral shift of the trunk over the unaffected side in hemiplegia using three-dimensional tre-admill gait analysis. Top Stroke Rehabil 2016; 23: 311–317.

https://doi.org/10.1080/10749357.2016.1156361

Hishikawa N, Tanikawa H, Ohtsuka K, Mukaino M, Inagaki K, Matsuda F, et al. Quantitative assessment of knee extensor thrust, flexed-knee gait, insufficient knee flexion during the swing phase, and medial whip in hemiplegia using three-dimensional treadmill gait ana-lysis. Top Stroke Rehabil 2018; 25: 548–553.

https://doi.org/10.1080/10749357.2018.1497272

Tanikawa H, Inagaki K, Ohtsuka K, Matsuda F, Mukaino M, Yamada J, et al. Validity of quantitative assessment of posterior pelvic tilt and contralateral vaulting in hemiplegia using 3D treadmill gait analysis. Top Stroke Rehabil 2021; 28: 96–103.

https://doi.org/10.1080/10749357.2020.1783919

Matsuda F, Mukaino M, Ohtsuka K, Tanikawa H, Tsuchiyama K, Teranishi T, et al. Bio-mechanical factors behind toe clearance during the swing phase in hemiparetic patients. Top Stroke Rehabil 2017; 24: 177–182.

https://doi.org/10.1080/10749357.2016.1234192

Esquenazi A. Botulinum toxin in the treatment of lower limb spasticity. In: Brashear A, Elovic E, editors. Spasticity: diagnosis and management. New York: Demos Medical Publishing; 2010, p. 119–129.

Aymard C, Giboin LS, Lackmy-Vallee A, Marchand-Pauvert V. Spinal plasticity in stroke after botulinum neurotoxin A injection in ankle plantar flexors. Physiol Rep 2013; 1: e00173.

https://doi.org/10.1002/phy2.173

Francis HP, Wade DT, Turner-Stokes L, Kingswell RS, Dott CS, Coxon EA. Does reducing spasticity translate into functional benefit? An exploratory meta-analysis. J Neurol Neu-rosurg Psychiatry 2004; 75: 1547–1551.

https://doi.org/10.1136/jnnp.2003.025551

Hara T, Momosaki R, Niimi M, Yamada N, Hara H, Abo M. Botulinum toxin therapy com-bined with rehabilitation for stroke: a systematic review of effect on motor function. Tox-ins 2019; 11: 707.

https://doi.org/10.3390/toxins11120707

Lee J, Park JE, Kang BH, Yang SN. Efficiency of botulinum toxin injection into the arm on postural balance and gait after stroke. Sci Rep 2023; 13: 8426.

https://doi.org/10.1038/s41598-023-35562-1

Esquenazi A, Mayer N, Garreta R. Influence of botulinum toxin type A treatment of elbow flexor spasticity on hemiparetic gait. Am J Phys Med Rehabil 2008; 87: 305–310; quiz 311, 329.

https://doi.org/10.1097/PHM.0b013e318168d36c