The strain used is Clostridium botulinum type A. It works by blocking acetylcholine release at neuromuscular junctions. The injection starts to work after a few days with the maximum effect at about 2 weeks. However the treatment will only last for 3-4 months. After this the effects wear off and the patient is reassessed before being re injected again if required. There are three products licensed in UK – Botox, Dysport and Xeomin.
Using ultrasound to guide injections
It can be difficult to place the dose of toxin in to the muscle in the most effective position. Ultrasound is one way to guide to the area of muscle for treatment. Electrical stimulation and EMG are also common modes of injection guidance.
Site of injections
Flexors of the thumb injection sites to prevent thumb in palm
Ideal site of Botulinum Toxin injection is at the neuromuscular junction or motor end plate. This gives maximal paralysing effect.
Almost all muscles of the legs and arms have a single innervation band, situated in the middle of the muscle. Rarely innervation bands are scattered along the entire length of the muscle. The effect progressively diminishes as the distance between the injection site and the end plate increases.
Botulinum toxin A (BT) inhibits the release of acetylcholine at the neuromuscular injection thus producing temporary weakness and relaxation of the targeted muscles, allowing them to be stretched more easily, provided the muscle is not contracted
Two key prerequisites for the successful use of BT in management of spasticity:
There must be a significant component of muscle over activity
Injection must be followed by an appropriate programme of stretching and/or splinting to maximise the effects of muscle relaxation
Patients must be followed up as this treatment has a temporary effect and each patient responds differently to their initial dose. Outcomes should be based on measurable changes where possible and by benefits to functional tasks as reported by the patient.
Introduction to blood pressure lowering medication
Medication to lower blood pressure should be considered for secondary prevention after either ischaemic or haemorrhagic stroke
The best time to start blood pressure lowering therapy depends on several factors, including the type of stroke (ischaemic or haemorrhagic), and what co-morbidities the patient may have.
Ongoing research aims to establish whether blood pressure lowering should be started immediately after stroke onset.
For patients presenting within 6 hours of stroke onset due to intracerebral haemorrhage, acute blood pressure reduction to <140mmHg systolic for the first 7 days is often attempted if BP is >150mmHg systolic.
Blood pressure is sometimes lowered acutely to facilitate thrombolysis e.g if >180/110mmHg.
Typically thiazides, e.g. Bendroflumethiazide and/or ACE inhibitors e.g. Lisinopril, are used after stroke, although other classes of blood pressure lowering agents are often used. It is common to need several different drugs to achieve a target blood pressure.
It is useful to have a working knowledge of their common adverse effects so that if these arise they can be attributed to the correct drug
A target systolic blood pressure of less than 130mmHg is appropriate for most patients, although there are specific exceptions including severe extracranial vascular disease, or frailty.
Lifestyle factors, such as reducing salt intake, weight loss, and avoiding excess alcohol also contributes to BP reduction
Think about impacts of spasticity for each individual and their specific goals for management
Inform patient of what a specialist service might be able to offer in terms of assessment, treatment and discuss their expectations and goals for treatment
Ensure the patient agrees to the referral being made
Members of the team cooperate on the patient’s management which is tailored to the individual. The team may include medical staff, nurses, physiotherapists, occupational therapists and orthotists.
Management of tone can include:
Education around management of trigger factors to promote self management
Referral for upper/lower limb splints
Referral for therapy intervention
Management with oral anti-spasticity medications
Targeted treatment with Botulinum Toxin to specific muscles
Less common are referrals for surgical options or nerve block injections
Advice for difficult to treat or complex spasticity issues but who still have treatment options
A specialist spasticity service is a multidisciplinary team providing comprehensive assessment and management for people with complex spasticity due to neurological disorders including stroke.
What should a specialist service offer?
A comprehensive assessment of spasticity by the multidisciplinary team
Identify impacts of spasticity for the person
Identify and manage trigger factors
Deliver focused treatment
Assist patient in setting realistic treatment goals
Formulate a treatment plan to manage spasticity and prevent long-term problems where possible
The strain used is Clostridium botulinum type A. It works by blocking acetylcholine release at neuromuscular junctions. The injection starts to work after a few days with the maximum effect at about 2 weeks. However the treatment will only last for 3-4 months. After this the effects wear off and the patient is reassessed before being re injected again if required. There are three products licensed in UK – Botox, Dysport and Xeomin.
Use an aphasia friendly/vertical pain assessment tool
