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Annals of Indian Academy of Neurology
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Table of Contents
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


Department of Neurosurgery, Teikyo University Mizonokuchi Hospital, Takatsu-ku, Kawasaki, Department of Neurosurgery, Saitama Neurosurgical Institute, Konosu, Saitama, Japan

Date of Submission16-Aug-2018
Date of Acceptance17-Oct-2018
Date of Web Publication10-Jun-2020

Correspondence Address:
Prof. Shoko Merrit Yamada
Department of Neurosurgery, Teikyo University Mizonokuchi Hospital, 5-1-1 Futago, Takatsu-ku, Kawasaki, Kanagawa 213-8507
Japan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aian.AIAN_360_18

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   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.


Keywords: Botox, flexed fingers, injection, onabotulinum toxin A


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;23:344-7

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 Oct 31];23:344-7. Available from: https://www.annalsofian.org/text.asp?2020/23/3/344/257022





   Introduction Top


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 Top


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: (A)-(a) Standard injection points for finger spasticity injection into flexor pollicis longus (a), flexor digitorum superficialis (b), and flexor digitorum profundus (c) muscles are a general way for finger spasticity treatment. (B) New injection points for finger spasticity Botox injection into the palmer side of the proximal and middle phalanx of each finger (flexor carpi radialis and flexor carpi ulnaris muscles) are the new points. For injection into thenar muscles, two-point injection is recommended to acquire better effect. Each point needs 10 units of Botox

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   Results Top


Epidemiology [Table 1]
Table 1: Data of patients

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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: (A) Botulinum A toxin injection targeting the intrinsic muscles of the hand. (a) Before injection: It is difficult to extend the fingers passively in the patients with spastic flexed fingers due to the rigidity of fingers (Modified Modified Ashworth Scale Grade 4), and for injection, each finger should be forcedly extended. (b) One month after injection: Although there is mild contracture in proximal and distal interphalangeal joints, all fingers are easily extended passively with minimal resistance (Modified Modified Ashworth Scale Grade 1) and the photo shows that the patient is easily extending his thumb with unaffected hand. (B) Botulinum A toxin injection into the intrinsic muscles of the hand. (a) Before injection: The wrist and fingers of the patient were flexed, and it was difficult for her to extend wrist and fingers by herself because of strong rigidity (Modified Modified Ashworth Scale Grade 4). (b) One month after injection: There is no increase in muscle tone in wrist and fingers after the treatment (Modified Modified Ashworth Scale Grade 0). The patient can move her wrist naturally and extend her affected fingers by putting her unaffected hand gently on the affected fingers

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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 Top


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 Top


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.



 
   References Top

1.
Jankovic J, Brin MF. Therapeutic uses of botulinum toxin. N Engl J Med 1991;324:1186-94.  Back to cited text no. 1
    
2.
Montecucco C, Molgó J. Botulinal neurotoxins: Revival of an old killer. Curr Opin Pharmacol 2005;5:274-9.  Back to cited text no. 2
    
3.
Brashear A, Gordon MF, Elovic E, Kassicieh VD, Marciniak C, Do M, et al. Intramuscular injection of botulinum toxin for the treatment of wrist and finger spasticity after a stroke. N Engl J Med 2002;347:395-400.  Back to cited text no. 3
    
4.
Vinti M, Costantino F, Bayle N, Simpson DM, Weisz DJ, Gracies JM, et al. Spastic cocontraction in hemiparesis: Effects of botulinum toxin. Muscle Nerve 2012;46:926-31.  Back to cited text no. 4
    
5.
Nalysnyk L, Papapetropoulos S, Rotella P, Simeone JC, Alter KE, Esquenazi A, et al. OnabotulinumtoxinA muscle injection patterns in adult spasticity: A systematic literature review. BMC Neurol 2013;13:118.  Back to cited text no. 5
    
6.
Molteni E, Rigoldi C, Morante M, Rozbaczylo C, Haro M, Albertini G, et al. Quantification of long-term effects of botulinum injection in a case of cerebral palsy affecting the upper limb movement. Dev Neurorehabil 2015;18:145-8.  Back to cited text no. 6
    
7.
Kalliainen LK, O'Brien VH. Current uses of botulinum toxin A as an adjunct to hand therapy interventions of hand conditions. J Hand Ther 2014;27:85-94.  Back to cited text no. 7
    
8.
Ghotbi N, Nakhostin Ansari N, Naghdi S, Hasson S. Measurement of lower-limb muscle spasticity: Intrarater reliability of modified modified ashworth scale. J Rehabil Res Dev 2011;48:83-8.  Back to cited text no. 8
    
9.
Kaji R, Osako Y, Suyama K, Maeda T, Uechi Y, Iwasaki M, et al. Botulinum toxin type A in post-stroke lower limb spasticity: A multicenter, double-blind, placebo-controlled trial. J Neurol 2010;257:1330-7.  Back to cited text no. 9
    


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