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Chris Kirtley
04-23-1996, 11:32 AM
The replies to my Botox query have flooded in, so I'm posting this early
summary now. If I get any more I'll post them in a sequel. Thanks to all
the prompt responders - it really is a tribute to the efficiency of this
list (even outside of orthoodox biomechanics!).

>> I am not using Bot Tox but I know that there is alot of work
>> being done at the National Hospitals for Neurology and Neurosurgery,
>> Queen Square, London.
>> The physiotherapist that has lots of practical experience, and
>> I think has been involved with methods of evaluation of Bot Tox so far
>> as I know is Sue Edwards but she doesn't have email. However Jane
>> Nicklin (PT in the same department) does have email ...
>> jnickli@ion.bpmf.ac.uk and I'm sure she would pass on info.

Gill Baer
Lecturer in Physiotherapy
Queen Margaret College, Edinburgh EH6 8HF
email phbaer@links.qmced.ac.uk

Dear Sir,
You should get in touch with Ms Roslyn Boyd, she has at least 5 years of
expertise in the assessment of CP having received BOTOX. She was in London
bur by now she must be back in Australia:
Roslyn BOYD
Research Assistant Hugh WilliamsonGait Laboratory
Royal Children's Hospital
Flemington Road
Parkville,3052 Melbourne Victoria
Phone 03 9345 5450
=46ax 03 9345 6668
She is working with an Irish ortopaedic surgeon very familiar with Botox
injection.
Sincerely,
yves
Yves BLANC
Laboratoire de Cin=E9siologie
Hopital cantonal Universitaire
1211 GENEVE 14 suisse
=46ax xx 41 22 / 37 27 799
Phone xx 41 22 / 37 27 827


I am working with a physiatrist here at the Mayo Clinic in the movement
disorders lab who is doing exactly what you are interested in. His name
is Dr. Jeffrey Strommen and his experience is quite extensive. He can be
reached by:

strommen.jeffrey@mayo.edu

best wishes,

d.g.

David A. Gabriel, Ph.D.
Department of Orthopedics
Biomechanical Research
Mayo Clinic/Mayo Foundation
200 First Street Southwest
Rochester, Minnesota 55905

Phone: 507-284-2262
Fax: 507-284-5392

I have read your question on the BOTOX. I am working in Leuven (Belgium), an=
d
recently we started using BOTOX in CP children.
In this we have been concentrating mainly on young hemiplegic children with
dynamic
contractures esp. the gastrocnemius has been injected so far. Only two child=
ren
received multiple injections (gastroc-hamstrings).
As we only recently started, we can only say all of the children
injected so far (ie 3) all showed an increased ROM after injection
during bench testing. a positive effect on gait was demonstrated
after three weeks, however its extent was limited comparing to the
analytical gain. THerefore, we would like to follow these children to
see whether this effect is changed when the child gets more used to
the new situation.

The dosage we are using is about 7 units / BW (It is however the
orthopaedic surgeon
who is in charge of this so you should contact him in this respect (++ 32
16 338800:
Dr. Molenaers)). Injection site is controlled by visual observation of the
needle motion
when manipulating the neighbouring joints. The injection is done using gener=
al
anaesthetics.

=46or your information I attached a short description of the study protocol=
we are
designing to follow up the effect.

=46or training purposes, we went to see Dr. Cosgrove (Musgrave Park Hospital=
,
Belfast,
Ireland) who has an extensive experience in using the injections in CP
children.

I would be happy to continue this discussion in case you think it could be
useful.

I would like to ask you explicitly not to include the study protocol in the =
comp
ilation of
the answers you will send to the list, since I do not have permission of
Allergan to
release it.

Kind Regards,


Ilse Jonkers


Use of Botulinum-A Toxin in the treatment of CP-children:
Biomechanical evaluation of Botulin-A Toxin injected in the M.
gastrocnemius on gait
characteristics of hemiplegic CP children

Jonkers I (*), Molenaers G( ), Spaepen A(*), Fabry G( ).
(*) Ergonomics Laboratory, Faculty of physical education and physiotherapy,
Catholic University Leuven.
( ) Orthopaedic Department, UZ- Pellenberg.

The effect of intramuscular injection of Botulinum-A toxin at the motor
end-plate of the
M. gastrocnemius on gait characteristics of hemiplegic CP children, showing =
a
dynamic equinus (Type 1-2 as defined by Gage, 1991) will be studied by means=
of
repeated gait analysis.

In literature, studies reported a positive effect of BAT-A on muscle
hypertonia and, in
consequence, on range of motion and gait pattern of cerebral palsy children =
with
dynamic contractures. The conclusion that these functional gains persisted
even after
the tone reducing effect of the toxin had worn off, requires further
investigation
(Cosgrove et al, 1994). For the use of BAT-A in the treatment of a dynamic
equinus
of the foot, the hypothesis was proposed that by removing the dynamic
contracture of
the M. gastrocnemius, functional improvement of the M. tibialis anterior is
promoted.
The positive effect on the gait pattern continues even after the M.
gastrocnemius
paralysis ceases (Cosgrove et al, 1994, Walton of Detchant, 1993). This
hypothesis,
however, has not been subjected to further testing.

Surface electromyography (EMG) showing the timing and level of muscular
activation,
will be used to evaluate the effect of BAT-A on the M. Gastrocnemius.
Additionally,
the function of M. tibialis anterior will be monitored after the injection
of BAT-A.

Apart from these local effects, the influence of changes in muscle balance
around the
ankle joint on the mechanical characteristics of the gait pattern will be
evaluated. In
order to evaluate this, the combined use of three dimensional movement analy=
sis,
force platform and surface EMG is required. In this way the causal relation
between
changes in activation balance and timing of the M. gastrocnemius and M. tibi=
alis
anterior and the changes in gait pattern expressed in kinetic and kinematic
entities ,
can be established.

STUDY OBJECTIVES:

The major contribution of the present study could be summarised as:

- Improvement of the indication for use of Botox injections in children
with hemiplegia
showing a dynamic equinus, based on a quantitative evaluation of the gait
pattern.

- Objectivation of the impact of the Botox injection on the ROM of the
ankle joint,
measured both in clinical testing and during gait.

- Objectivation of the impact of Botox injection of the M. gastrocnemius on
the overall
gait pattern.

- Derivation of parameters from the quantitative gait analysis that can be
used in the
follow up of treatment and indicating the need for re-injection of the muscl=
e.


METHODOLOGY:

Prior to inclusion to the study population informed consent of the parents
is needed.

All children are evaluated prior to injection. Re-evaluation is done after
three weeks.
=46urther evaluations are done within a two or three month interval (to be
decided).

After injections all children continue with physical therapy treatment.

A complete test consists of the following measurements:

Clinical examination:

A standardised clinical examination will be performed by a physical therapis=
t,
evaluating apart from muscle tone and strength, ROM and selectivity of movem=
ent.
(See appended evaluation form)

Video Registration;

A video registration is made of the child walking free, in both sagittal
and frontal plane.
This registration is used for documentation of the child's gait pattern and
guides
towards further problem detection in the quantitative gait analysis.

Surface-EMG:

Small Beckmann electrodes are used to follow the timing of the muscle
groups that
are most likely to disturb the gait pattern: M. tibialis anterior, M.
gastrocnemius, M.
soleus, Medial and lateral hamstrings, M. rectus femoris and M. vastus
lateralis.
Timing of the muscle is related to the different phases of gait.

Three-dimensional Movement analysis:

Bilateral lower limb motion is registered by means of an infra-red movement
analysis
system. Therefore, retroflective markers are attached to defined anatomical
sites of
the lower limb.
A biomechanical model allows the calculation of three dimensional joint moti=
on
(flexion/extension- Abduction/adduction- Internal and external rotation).
A force plate is mounted in the walkway. In case a clear foots strike
occurs, the
loading of the limb is registered. A biomechanical model can then be used
to combine
force plate data with the movement analysis data, in order to calculate
joint torque and
power. These parameters allow the interpretation of the registered muscular
activation
patterns.

PRESENT SITUATION AND MAJOR PROBLEMS ENCOUNTERED SO FAR:

At present two children have been injected. So far, only one of them was
seen for
post-injection gait analysis. In addition, 6 children underwent a gait
analysis prior to
injection.

View the relative young age of the children, problems arise in the three
dimensional
movement analysis due to the limited inter-marker distance and consequent
overlap
of markers. However, careful study of camera positioning improved the
measurements
considerably.

In addition, it is difficult to get a clear force plate strike when the
child is walking free.
Therefore, most children (with age below 6-7 year) walk holding the hand of
one of the
parents.

The standardised gait analysis and clinical examination often reveals other
factors
contributing to the pathological gait pattern (eg. spastic medial
hamstrings or co-
spasticity of soleus). This often leads to the decision to inject several
muscle groups
at once.

Initially a monthly follow up was proposed in order to follow closely the
modifications
in the gait pattern. View the load this is imposing on the families, a new
evaluation
scheme needs to be discussed.

I got your mailing regarding BoTox via NeuroMus. I am not now using BoTox,
and I
am not a clinician, so I guess I am not exactly the type of person that you =
had
in mind when you sent the mailing. However, I am interested in the effects o=
f
BoTox on muscle fibers and motoneurons. I am a basic scientist, and I have a=
n
interest in how motoneurons respond to clinically applied BoTox in lab anima=
ls.
I don't believe that the effects of the toxin on motoneuron properties,
afferent
feedback onto motoneurons, or how paralysis of one muscle or group influence=
s
the properties of other muscles and their motoneurons have been widely
investigated. I would like to do some simple experiments to look at these
issues. The information that you turn up from your query would be very
interesting to me. I wonder if you would mind sharing what you find out?
Thank a
lot in advance.
Arthur W. English, Ph.D.
art@anatomy.emory.edu

Department of Anatomy & Cell Biology
Emory University School of Medicine
1648 Pierce Drive
Atlanta, GA 30322

(404) 727-6250 Voice (404) 727-3677 Fax

=46rom: SMZOLLO@aol.com
Date: Tue, 23 Apr 1996 11:33:30 -0400
To: ikirtley@info.curtin.edu.au
Subject: Re: Botox

Debra Wilson, OT, of Long Beach Memorial Medical Center, Long Beach,
California, (who is working on a spacticity book for me) knows of two doctor=
s
who use Botox and are considered experts in its use. Her phone number is
310-933-2000. Mention my name, Steve Zollo at Aspen Publishers.

you may wish to contact the Gait Lab at Children's Hospital San Diego (USA).
They have recently conducted a double blind, placebo controlled study of
gait in CP children. Published under the name of David H. Sutherland in Gait
and Posture.

There were apparently also several papers given at the AACPDM meeting
(Academy of Child ___ and Developmental Medicine.) if one could find the
proceedings.

I do not have an e-mail contact for this group, although the major
players are David Sutherland, MD , Director; Kent Kaufman, Ph.D., engineer;
Marilynn Wyatt, MA, PT, Research PT. Phone contact is 619/576-5807.


At the Braintree Rehabilitation Hospital (located outside of Boston) they
are using BOTOX in adult populations. I don't have names of contacts for
you, although you could call the hospital and ask for the spasticity or
BOTOX clinic. It has been recently established (on the order of ~ the
last 1-2 years).


It seems you are interested in gait. I do have some other contacts of
people who are using BOTOX for other applications: spasmodic torticollis,
laryngeal dystonia, etc. Feel free to contact me back if you wish to know
about this.

All the best.

Carolynn Patten, MS, PT
Motor Control Laboratory
Department of Exercise Science
University of Massachusetts - Amherst

Date: Tue, 23 Apr 1996 13:24:49 -0700
Mime-Version: 1.0
To: Chris Kirtley
=46rom: burgar@roses.stanford.edu (Chuck Burgar)
Subject: Botox

Your inquiry regarding clinical use of Botulinum toxin was forwarded to me.

I am a physiatrist at the Palo Alto VA and Stanford University hospitals.
Most of my time is spent in rehabilitation research, however.

I currently use Botox in selected patients with hypertonia following
strokes, head injuries and spinal cord injuries. I also use it in patients
with dystonias, such as torticollis. About 1/3 of my injections are Botox,
the rest of the time I use phenol or alcohol blocks.

Dosage ranges from 10 units in hand muscles to 200 or more units in large
muscles, such as gastrocnemius or adductor magnus. I limit the total dose
to 300 units/treatment in keeping with the manufacturer's recommendations.
I do not repeat the injections within 3 months, even if suboptimal results
are obtained, to avoid development of toxin resistance. The doses above
are for the Allergan (USA) product and differ significantly from those
using the system for measuring potency in Europe.

The results have been generally good to excellent, depending on treatment
goals and patient expectations. When in doubt about the potential for
achieving a desired result, I first do a motor point block with
bupivacaine. I perform all Botox injections using needle EMG guidance and
occasionally use EMG to help evaluate the results.

I use the modified Ashworth scale to document changes in tone and the
=46ugl-Meyer for following functional capabilities. We just completed
development of a robotic upper limb manipulator incorporating force
transducers to quantify internal and external forces during arm motion. I
plan to use this to assess changes in tone and function resulting from
future clinical interventions. For objective lower limb assessment, we
have an ergometer instrumented with pedal force transducers. We are still
in the process of gathering normative data for both systems.

I hope this information is useful. Since I am not on the NEUROMUS list,
I'd appeciate a copy of the responses to your inquiry.

-Chuck

=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3 D=3D=3D=3D=3D=3D=3D=3D=3D=
=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3 D=3D=3D=3D=3D=3D=3D=3D=3D=
=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3 D

Charles G. Burgar, MD
Medical Director, Rehab Research and Development Center
Palo Alto VA Health Care System
3801 Miranda Ave. (153)
Palo Alto, CA 94304

=46rom: mara@gait52.mgh.harvard.edu
To: c.kirtley@info.curtin.edu.au
Cc: mara@gait52.mgh.harvard.edu
Subject: botox request
Date: Tue, 23 Apr 96 17:46:08 -0400
X-Mts: smtp

Dr. Kirtley
As a PT, I have recommended botox for patients with spasticity secondary to
traumatic head injury, stroke, and CP. Results have shown mild reduction in
spasticity in the former two cases, which is primarily measured by increased
range of motion in open and closed chain (i.e. gait) positions. As a gait
analysis consultant for children with CP, I often recommend botox to decreas=
e
spasticity as a more conservative approach before (instead of) surgery.
Unfortunately, I usually don't see the results of these kids since insuranc=
e
often does not allow for follow up gait analysis...
I do not know doses of injection off hand.

Two articles that I have in my files

Snow BJ, Tsui JK, Bhatt MH et al. Treatment of Spasticity with Botulin=
Toxin: A
double blind study. Annals of Neurology Vol 28 NO 4, October 1990 512-515

Borg Stein J, Stein J. Pharmacology of botulinum toxin and implications for =
use
in disorders of muscle tone. Journal of Head Trauma Rehabiliation 1993;
8(3):103-106

Please let me know if you would like me to fax these articles to you.

Also, I was at Curtin University in August '92 as a PT - please say hello t=
o
Chris Pickart for me. I loved Perth, and the friendly staff at Curtin
university and in the rehab hospital. ( I worked in outpatient neuro)


Most sincerely
Mara Wernick MS, PT
mara@gait52.mgh.harvard.edu

Date: Wed, 24 Apr 1996 09:00:16 +1000
X-Sender: s8100008@pop3.unsw.edu.au
Mime-Version: 1.0
To: Chris Kirtley
=46rom: Simon Gandevia
Subject: Re: Botox

Yes Burke/Dunne/Gandevia and others are involved in a multicentred trial of
the effects botox in adults post-stroke with spasticity. It is aimed at the
lower limb. I would be happy to discuss further.
02 382 2677

__________________________________________________ __________________
Dr. Chris Kirtley MB ChB, PhD c.kirtley@info.curtin.edu.au
^
Lecturer, Bio-engineering --_ / \
/ \
School of Physiotherapy, Perth #_.---._/
Curtin University of Technology, V
GPO Box U1987,
Perth 6001, Tel +61 9 351 3649
Western Australia. Fax +61 9 351 3636

WWW: http://www.curtin.edu.au/curtin/dept/physio/pt/staff/kirtley/
Internet Relay Chat: irc.curtin.edu.au (port 6667) "bio-engineering"
NetPhone: IP address 34311.180.105
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