Annals of Indian Academy of Neurology
CASE REPORT
Year
: 2020  |  Volume : 23  |  Issue : 3  |  Page : 344--347

New injection points of onabotulinum toxin a for spastic paralysis of the fingers: Eight cases of report


Shoko Merrit Yamada, Shinnosuke Takashima, Yoshiro Takaoka, Hiroshi Matsuura 
 Department of Neurosurgery, Teikyo University Mizonokuchi Hospital, Takatsu-ku, Kawasaki, Department of Neurosurgery, Saitama Neurosurgical Institute, Konosu, Saitama, Japan

Correspondence Address:
Prof. Shoko Merrit Yamada
Department of Neurosurgery, Teikyo University Mizonokuchi Hospital, 5-1-1 Futago, Takatsu-ku, Kawasaki, Kanagawa 213-8507
Japan

Abstract

Objective: Onabotulinum toxin A (botulinum A toxin) is utilized to extend flexed extremities in spastic hemiparesis. Injection points are important to obtain a better effect. Injecting botulinum A toxin into the forearm muscles is a standard method for flexed wrist and fingers; however, we developed new injection points in the intrinsic muscles of the hand to acquire more reliable effect. Methods: The authors injected botulinum A toxin into the palmar side of the proximal and middle phalanx of each finger and thenar muscles. Eight patients with poststroke flexed wrist and fingers were treated by this method. Results: In all patients, the spasticity improved to 0 or 1 from 3 or 4 in Modified Modified Ashworth Scale 1 month after the treatment. They were satisfied with our treatment because they could keep their affected fingers hygienic by washing fingers cleanly after the treatment. Conclusions: Our botulinum A toxin injection points for finger spastic paralysis are accurate spots producing great effect to flexed fingers.



How to cite this article:
Yamada SM, Takashima S, Takaoka Y, Matsuura H. New injection points of onabotulinum toxin a for spastic paralysis of the fingers: Eight cases of report.Ann Indian Acad Neurol 2020;23:344-347


How to cite this URL:
Yamada SM, Takashima S, Takaoka Y, Matsuura H. New injection points of onabotulinum toxin a for spastic paralysis of the fingers: Eight cases of report. Ann Indian Acad Neurol [serial online] 2020 [cited 2020 Aug 8 ];23:344-347
Available from: http://www.annalsofian.org/text.asp?2020/23/3/344/257022


Full Text



 Introduction



Botulinum toxins are neurotoxic proteins produced by bacterium Clostridium botulinum and related species, and botulinum A toxin is one of the botulinum toxins arranged for medical use.[1],[2] This toxin can effectively weaken muscle tone and is utilized for treatment of spastic hemiparesis in the upper and lower extremities caused by central nervous system disorders.[3],[4],[5],[6] For finger spasticity and stiffness, botulinum A toxin is injected into the extrinsic muscles of the hand, including flexor carpi radialis, flexor carpi ulnaris, flexor digitorum profundus, flexor digitorum superficialis, and flexor hallucis longus muscles.[7] However, the treatment is not so effective as the patients expect.

 Methods



This study was performed from April 2017 to March 2018. Study details were explained to each patient and family, and informed consent was obtained in written form with a signature. This article includes no information to identify individuals. Eight patients, who were unable to extend fingers in the hemiparesis side, were selected. In all the patients, the finger spasticity demonstrated the score 3–4 in Modified Modified Ashworth Scale (MMAS).[8] Botulinum A toxin (Botox: GlaxoSmithKline Japan, Tokyo, Japan) of 200 units was dissolved in 2 ml saline (10 units/0.1 ml). Thirty units of botulinum A toxin (0.3 ml) was injected into flexor pollicis longus, flexor digitorum superficialis, and flexor digitorum profundus muscles, respectively [Figure 1]A. Ten units of botulinum A toxin (0.1 ml) was injected into the palmar side of the proximal and middle phalanx of each finger (10 units × 9 points), and 20 units was injected into thenar muscles [Figure 1]B. All the injection procedures of botulinum A toxin were performed by one doctor.{Figure 1}

 Results



Epidemiology [Table 1]{Table 1}

In the eight patients (four males and four females), two males and two females became spastic hemiparesis because of intracranial hemorrhage and the others because of cerebral infarctions. The average age of the eight patients was 64.6 ± 11.6 years (43–76 years). The average duration from the onset of the diseases to the first botulinum A toxin injection was 52.6 ± 26.7 months (17–101 months). Their flexed fingers were very rigid with MMAS-3 in two patients and MMAS-4 in six patients.

Effectiveness of onabotulinum toxin a injection

For botulinum A toxin injection in the palmar side of the proximal and middle phalanx, each finger should be forcedly extended against the hypertonicity in all patients [Figure 2]A-a. No patients complained of pain when botulinum A toxin injection was performed in the fingers. One month after the injection, all patients could easily extend their wrist and fingers using their unaffected hand [Figure 2]A and [Figure 2]B with MMAS-0 in four patients and MMAS-1 in four patients [Table 1].{Figure 2}

Satisfaction of the patients

The satisfaction of each patient to the treatment was evaluated by five grades: very satisfied, satisfied, neither, unsatisfied, and very unsatisfied. Six patients chose “very satisfied” and the rest of two “satisfied.” All the patients' families were also satisfied with our treatment because quantity of care decreased. The advantages after the treatment include the following: (1) the patients were able to wash the flexed fingers with soap and wipe up the water completely from the fingers with towel by themselves, (2) cut fingernails easily by themselves, and (3) they do not feel finger pain in hand rehabilitation. Some of them were pleased to have their meals putting a rice bowl or a saucer on the affected palm according to a Japanese custom. The botulinum A toxin treatment is performed every 4–6 months in all the cases.

 Discussion



Botulinum A toxin weakens muscle tones but does not improve hemiparesis itself.[1],[2],[3],[4],[5],[6] However, if their rigid flexed wrist and fingers due to muscle stiffness can be easily extended passively, the patients can live a better quality of life. The essential points in botulinum A toxin treatment are (1) excluding the patients who have contracture of joints in the wrist or fingers and (2) injecting sufficient amount of the drug into the accurate points. For finger spasticity and stiffness, injection of botulinum A toxin into flexor pollicis longus, flexor digitorum superficialis, and flexor digitorum profundus muscles is a standard way of the treatment.[6] However, through our experience of the treatment in several patients, the effect was not satisfactory for them. When we slightly bend only fingers separately, no movement of these muscles is recognized and only lumbrical and palmar interosseous muscles work. Furthermore, we can move proximal interphalangeal joints and distal interphalangeal joints without moving metacarpophalangeal joints. Based on the fact, the authors inject botulinum A toxin into the intrinsic muscles of the hand in addition to inject into forearm muscles for finger spasticity and stiffness [Figure 1]B. These intrinsic muscles arise from metacarpals and end at proximal phalanges. The injection into the palmar side of the proximal and middle phalanx of each finger and into thenar muscles was considered as new injection points, and the injection to the points did not cause pain to the patients. Our method provides an excellent effect of the extension of fingers unless the interphalangeal joints of the hand are not fixed as shown in [Figure 2]A-[Figure 2]b and [Figure 2]B-[Figure 2]b. After our treatment, not only the patients but also their family got convinced of the importance of the botulinum A toxin treatment to reduce the load of caregivers. All of them chose “very satisfied” in the five grades to the treatment.

Another important point of botulinum A toxin treatment for the finger spastic paralysis is to target only finger and wrist joints to inject higher dose. Kaji et al. reported that the higher dose of botulinum A toxin was clinically more effective for the wrist and fingers without causing doselimiting adverse events.[9] Most patients with spastic hemiparesis have stiffness in the shoulder, elbow, wrist, and fingers. Insurance company covers the fee of up to 240 units of botulinum A toxin for injection in the upper limb,[9] and the dosage is extremely low to deliver the maximum dose in all portions. The patients are satisfied with the botulinum A toxin treatment when they obtain maximum effect in a certain portion rather than when they acquire halfway effect in all portions. Therefore, for fixed wrist and fingers, the maximum dose should be injected into muscles which flex the wrist and fingers.

 Conclusion



Our botulinum A toxin injection points for finger spastic paralysis produce great effect to flexed fingers.

Acknowledgment

All authors express our gratitude to Edanz Group for editing of our manuscript.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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