Botulinum toxin treatment of pes cavovarus in a child suffering from autosomal recessive axonal Charcot-Marie-Tooth neuropathy (AR-CMT2).

In a 12-year old girl suffering from autosomal recessive axonal Charcot-Marie-Tooth (CMT) neuropathy, pes cavovarus was treated with botulinum toxin injection in the tibialis posterior. The patient underwent a clinical evaluation, video analysis of spatiotemporal gait parameters and dynamic foot plantar pressure assessment before treatment and then two weeks, three months and six months thereafter. The video gait analysis revealed a decrease in varus during the swing phase of gait. The dynamic foot plantar pressure decreased by 50% in the excessive pressure at the side of the foot six months after the injection (maximal pressure=42.6N/cm2 before treatment and 18.9 N/cm2 after 6 month). Botulinum toxin injection appears to be an efficacious means of correcting pes cavovarus in CMT disease. A larger-scale clinical trial is now required to evaluate the putative longer-term preventive effect of this treatment on the pes cavus deformity.

Botulinum Toxin in the management of hitchhiker's toe.

INTRODUCTION: Hyperextension of the extensor hallucis longus (EHL) muscle is a well recognised disabling sequel of either pyramidal or extrapyramidal lesions causing what is known as striated or hitchhiker's toe. Surgery was the only effective strategy to manage EHL hyperextension before botulinum toxin's use to manage muscular dystonia and spasticity became widely popular. METHODS: A multicentre retrospective study. A standard proforma was sent to specialists in neurological rehabilitation dealing routinely with this problem. The data was analysed using descriptive statistics. RESULTS: Four consultants and two trainees representing five separate neurological rehabilitation services agreed to participate in the study. Full data was available from the 29 proformas completed. The subjects were 15 females with an age range between 20 and 78 years (mean 58.7). Stroke was the primary diagnosis in 18 subjects. Four subjects had bilateral involvement. 16 subjects had either an associated foot drop or equino varus deformity. Dysport® was used in 15 subjects with an average dose of 170 units per injection and Botox® in the other 14 with an average dose of 65 units. The treatment was effective in 24 subjects (83%). All patients receiving Dysport® responded to the treatment. Whilst 5 Botox® treated patients failed to respond to it (35% failure rate). Most of the non respondents seemed to receive insufficient doses of Botox® (below 60 units). Surgical management was successful in 3 out of the 5 non respondent cases. CONCLUSION: Botilinum Toxin is an effective and safe method to manage hitchhicker's toe. In our study the conversion ratio between Dysport® and Botox® was 2.5:1. Third of the patients receiving Botox® failed to respond to the treatment most probably due to insufficient doses used.

Differential effect of spironolactone in chronic constriction injury and vincristine-induced neuropathic pain in rats.

The present study was designed to investigate the ameliorative potential of spironolactone in chronic constriction injury and vincristine-induced neuropathic pain in rats. The chronic constriction injury was induced by placing four loose ligatures around the sciatic nerve, while vincristine (50 µg/kg) was administered for 10 days to induce chemotherapy-induced neuropathic pain. Acetone drop, pin-prick, hot plate and paint brush tests were performed to assess cold allodynia; mechanical and heat hyperalgesia; dynamic mechanical allodynia, respectively. The spontaneous pain and postural index in terms of foot deformity was also assessed. The levels of TNF-α were measured in the sciatic nerve as an index of inflammation. Chronic constriction injury led to significant development of cold allodynia; mechanical and heat hyperalgesia; dynamic mechanical allodynia; spontaneous pain and foot deformity along with rise in the levels of TNF-α. Administration of vincristine was associated with the development of allodynia and hyperalgesia without spontaneous pain, foot deformity and elevation in the levels of TNF-α. Administration of spironolactone (10 and 20 mg/kg) significantly attenuated chronic constriction injury-induced pain related behaviour and foot deformity along with attenuation of TNF-α levels, without modulating vincristine-induced neuropathic pain. The attenuating effect of spironolactone in chronic constriction injury may be due to its anti-inflammatory properties and ability to decrease pro-inflammatory cytokines, while involvement of non-inflammatory mechanisms in the pathogenesis of vincristine-induced pain may probably explain its lack of beneficial effect in chemotherapy associated pain.

Randomized trial of botulinum toxin to prevent pes cavus progression in pediatric Charcot-Marie-Tooth disease type 1A.

Pes cavus in Charcot-Marie-Tooth disease type 1A (CMT1A) is thought to be due to muscle imbalance of the lower leg. Botulinum toxin type A (BoNT-A) can modify foot deformity in other conditions of muscle imbalance. We tested the safety and effectiveness of BoNT-A on pes cavus progression in pediatric CMT1A. A 24-month, randomized, single-blind trial of BoNT-A was undertaken in 10 affected children (20 legs), aged 3-14 years. The treated leg received intramuscular BoNT-A injections at 6-month intervals in the tibialis posterior and peroneus longus. The control leg received no injections. Primary outcome was radiographic alignment at 24 months. Secondary outcomes were foot posture, ankle flexibility, and strength, assessed every 6 months. Radiographically, BoNT-A produced a small non-significant reduction in cavus progression. There was no effect of BoNT-A on secondary outcomes. There were no serious adverse events. At 24 months, the intramuscular BoNT-A injections proved safe and well-tolerated but did not affect the progression of pes cavus in CMT1A.

Propofol withdrawal seizures (or not).

Propofol is associated with abnormal motor events resembling seizures, the exact nature of these events remains to be elucidated. We describe here a case of seizure-like activity after propofol-induced conscious sedation accompanied by a prolactin rise, together suggesting that the event was ictal.

Clinical usefulness of botulinum toxin in the lower extremity.

As the literature that pertains to botulinum toxin expands, the scope of treatment options broadens. Although initial uses of botulinum toxin focused around the head and neck, there are many uses for the toxin in the area of the foot and ankle; more possibilities are under investigation every day. We review the uses and techniques for botulinum toxin in the foot and ankle and present results of botulinum toxin treatment in 10 idiopathic toe walkers.

Fascite plantar: estudo comparativo / Plantar fasciitis: a comparative study

A fascite plantar constitui causa freqüente de talalgia, principalmente em indivíduos que apresentam distúrbio postural dos pés e que passam a praticar atividade por tempo prolongado. Vários procedimentos sao descritos para o tratamento da fascite plantar. O objetivo deste trabalho é de avaliar a incidência da síndrome dolorosa miofascial em pacientes portadores de fascite plantar e comparar os resultados terapêuticos obtidos através do agulhamento e da infiltraçao de anestésicos locais, com os do uso de agentes físicos e cinesioterápicos. Sao avaliados 29 pacientes (26 femininos e três masculinos) com idades entre 30 e 70 anos (média:49 anos) portadores de fascite plantar. Os resultados sao avaliados mediante escala visual analógica. Todos apresentam síndrome dolorosa miofascial associada à fascite plantar. A reduçao, estatisticamente significante, da intensidade da dor é observada em ambos os grupos. A inativaçao dos "pontos-gatilho" miofasciais permite o alívio sintomático da dor e a recuperaçao funcional em menor tempo quando comparada ao uso de agentes físicos e cinesioterápicos isoladamente.