Suggestions in India (Rajasthan) for specialist using Botox for spasticity

[physiobob]

Dear members,

Right now I am in Udaipur in India working on elements of our site and enjoying the friendly hospitality of the Udaipur people.

Importantly I have been visiting with my main coders and a lovely family who have two sons (both over 30 yrs of age) with some degree of learning disability. The family had let me know before coming that one of them was born with a club foot. So yesterday I decided to go take a look.

What it looks like to me is an overactive stretch reflex (or an un-modulated one) to his achilles (bilaterally). The end result has been that he walks on the demi-pointe like a dancer or a woman in high heels only without the shoes!

In looking at a possible treatment approach we do need to consider his ability to be compliant with the treatment. His fluctuating emotions would make an orthopaedic (surgical) approach inappropriate however I thought perhaps a combination of the right supportive footware (a large pair of platforms that gradually reduce in heel height over time) with some measured botox for anti spasticity might be worth a go.

I look to the India and foreign physiotherapists in India who might know of someone using this approach for head injured patients as we have been using this for a long time in the UK and Australia.

I would also welcome any comment from anyone who has used this approach as a treatment option and would appreciate any insites into the pros, cons and difficulties in trying this.

Many thanks to all

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[gcoe]

Hi Physiobob

Botox is definitely something to consider but there are a few things to think through before referring on. I take it you are finding velocity dependent resistance to passive dorsiflexion. (ie spasiticity). I presume he also has some contracture - almost bound to be. the botox will only work when the spasticity is really a very marked component in contracture. Just be aware that resistance through range is often mistaken for spasticity when it is in fact due to structural shortening of the musculotendinous unit. Contracture has been found to be the big factor in most cases of spasticity. When you do the quick PROM test if the catch and/or resistance comes on early in the range and when you repeat the movement slowly you don't elicit the response that may indicate a big spastic component.

If spasticity is a key feature then yes Botox may help but one should also think that the botox is a supplement to the physio to letngthen the MT unit and establish heel-toe walking. If serial casting is out of the question AFOs that can be adjusted during the day and resting splints at night that aim to maintain the increased extensibility during the night may help but it should also include physio aimed at avoiding the toe walking. resting splints and night can often be well tolerated as if they are well fitted they can be quite comfortable and light. Botox will only temporarily reduce spasticity (1-3 months max) and will not deal with the contracture problem or the motor control issue. I think you would need to do something more than just lowering the heel over time. What are resources like for orthotics etc? Often such treatment is quite fiddly and adjustments need to be made. And what about the skill of the Specialist? Botox injections are very much an "art" and badly delivered injections can not only be useless but can do harm. the injection should be with a needle wired to an FES unit to stimulate the muscle and guide the needle to the maximum number of neuromuscular junctions that can be knocked out.

Of course "toe walking" can also have nothing to do with spasticity. As I am not a paediatric physio I may be speaking a bit out of turn here - but children with "low tone" may result to over activating their plantar flexors to improve their power in walking - (apologies to the paediatric physios if that is a really bad description). In which case such treatment is completely misguided.

Hope that is of help - I am more an adult neuro physio so paediatric physios feel free to correct or add to what I have said.

[physiobob]

Thanks for that and all your points are valid. Splinting and regular physio are not an option due to location, cost and his intellectual limitations. Unfortunately serial casting won't currently be tolerated due to his irritable/aggitated daily moods swings (not violent just he preseverates on things which winds him up and results in high blood pressure). Orthotics are indeed a possibility and we are looking into finding the right person locally to assist with that. He has one pair of boots that have been made by a local cobbler which he does tolerate when it is cool. Right now it is in the high 30's and it's winter! so you get my drift. Thanks for the points again on spasticity as I did test PROM in a few positions and there is obviously muscle shortening involved. The degree of what is what is a little difficult as he was born like this bilaterally. It's does not look like a typical talipes presentation due to womb position as really he is simple walking on his toes. The rest of him seems rather normal in function although I did not get into looking at his hip region. That said this type of walking would only make things worse if that were the issue.

I have mentioned to the family that I am not sure how long botox would last but maybe as little as 6 weeks. I also don't know if you can partially 'relax' the muscle using it rather than fully inhibiting it? It's been a while since I worked in that area. Hence anyone who has input on that would be great. I'll try to get a photo that I can add to this posting tomorrow. Maybe even try a video on my digital camera.

[abishek.pt]

how long the effect of botox stays...?