Search

Anecdotal clinical experience shows that patients often indicate that their spasticity improves on the day of treatment with intramuscular botulinum injection. Previous research shows that compound motor action potentials (CMAPs) decrease 48 h post-injection. However, no studies to date have assessed the neurophysiological changes less than 48 h post-injection.Fifteen healthy control subjects (10 F; mean age 41 ± 11 years) participated in this randomized double-blind study. We injected 10 units of either onabotulinumtoxinA or incobotulinumtoxinA in the extensor digitorum brevis (EDB) muscle, one in each foot. We performed serial CMAP assessments using nerve conduction study of the peroneal nerve at following time intervals after botulinum injection - 2, 4, 6, 24, 26, 28, 30, 48, 72 h and 6 days post-injection. We used an ANOVA with repeated measures separately for each type of toxin.Post-hoc tests using the Bonferroni correction revealed that there was a statistically significant decrease in the mean EDB CMAP amplitude from baseline starting at 24 h post-injection in the incobotulinumtoxinA group (p 0.05) and 4 h post-injection in the onabotulinumtoxinA group (p 0.05).We conclude that both toxin formulations tested in this study exert a significant decrease in EDB CMAP amplitude in the period of48 h post-injection.

Introduction In patients taking warfarin, the level of anticoagulation status using the International Normalized Ratio (INR) is one consideration before botulinum toxin type-A (BoNTA) injections; however, there is wide diversity in physician approaches and preferences in using INR status and the INR cut-off values to determine suitability of anticoagulated patients for BoNTA injections. There is no standard approach for treating spasticity with BoNTA injections in patients who are on warfarin or direct anticoagulants (DOACs). Objective: Our objective was to review the challenges in the use of BoNTA in patients who are receiving anticoagulants and to present highlights of the Canadian Delphi Study on the management of anticoagulated patients with limb spasticity. Methods We present a hypothetical case of a patient with focal spasticity who is also receiving anticoagulants. Results The results when injecting BoNTA in anticoagulated patients were as follows: 1) BoNTA injections should not be withheld purely because a patient is anticoagulated and other factors need to be considered. 2) A 25G (or higher) needle should be used when injecting into the deepleg compartment muscles. 3) The INR level ≤3.5 should be used when injecting the deep posterior leg compartment muscles. 4) The concern regarding bleeding when using DOACs remain the same as with warfarin when INR is in the therapeutic range. 6) The dose and scheduling of DOACs need not be altered prior to BoNTA injections. Conclusions The Canadian consensus statements assist clinicians by providing a framework for consideration to navigate the challenges when injecting BoNTA in anticoagulated patients with spasticity.

The purpose of this study was to assess the prevalence of compartment syndrome or major bleeding episodes and compare compartment syndrome, patient and intervention characteristics in 110 patients with stroke (treated with Warfarin, new oral anticoagulants, antiplatelet, or no anticoagulants) treated for spasticity in deep leg compartment muscles with botulinum toxin injections [onabotulinumtoxinA (n = 77); incobotulinumtoxinA (n = 33)]. We reviewed 674 injection cycles (range 1–25 cycles per patient) and found no cases of compartment syndrome in any patient groups.