THE EFFECTS OF BOTOX® (BOTULINUM TOXIN) INJECTION AND PHYSICAL THERAPY ON AN INDIVIDUAL WITH ANKLE PLANTAR FLEXOR HYPERTONICITY SECONDARY TO HEMICORD INJURY. Evan Cohen* Physical Therapy, Touro College, New York, NY UNIQUE: This case study considered the use of Botox® botulinum toxin (BTX) injection in conjunction with Physical Therapy (PT) to manage the ankle plantar flexor (PF) hypertonia of an individual with a cervical hemicord injury. This case study is unique as there is little published data on the result of BTX use for people with this pathology. Much data exists for the use of BTX in managing hypertonia in other pathologies, such as children with cerebral palsy and adults with hemiplegia due to cerebrovascular accident. Even in the more widely examined population groups, results have conflicted. PURPOSE: There is a gap in the knowledge regarding the use of BTX as an adjunct to PT in the management of individuals with hemicord injury. The subject considered in this case study had been participating in an ongoing PT program that consisted of a weekly one-hour visit combined with a home program. The impairments of right (R) ankle PF hypertonia and limited ankle dorsiflexion (DF) range of motion (ROM) restricted the progress of the individual’s performance of many functional tasks. Due to these impairments, the individual relied on a cumbersome molded plastic ankle foot orthosis (AFO) with a metal hinge joint, resulting in significant deviations to his gait. Traditional stretching and joint mobilization failed to gain additional ROM. A static ankle DF stretching device was then utilized with little success. Having exhausted more conservative options, arrangements were made for BTX injections into the hypertonic R gastrocnemius in an effort to regain ROM, improve performance of functional activities, and to progress to a less restrictive brace while maintaining or improving his gait. FOUNDATION: BTX has been widely used in rehabilitation in the management of hypertonia. BTX is a neuroparalytic agent that acts at the neuromuscular junction. Although the connections affected by the drug are permanently lost, collateral sprouting from nearby neurons create new synapses between motor nerve and muscle. The administration of BTX into skeletal muscle results in local paralysis that lasts approximately 2 to 4 months. Studies have shown varied results regarding the benefits of BTX combined with PT interventions. It was believed that the administration of BTX into the hypertonic gastrocnemius muscle of this individual with hemicord injury, combined with a program of PT, would result in notable improvements in outcome measures. DESCRIPTION: Pre-testing was performed one week prior to injection of BTX. Ankle ROM measures were taken using established goniometry techniques. Functional tests of balance and mobility included the Timed-Up and Go Test (TUG), the Berg Balance Test (BBT), the Four-Square Step Test, and Forward and Backward Functional Reach Tests. Temporospatial gait parameters were recorded with the GAITRite Portable Walkway System® under four different conditions: 1. with AFO and a single-point cane (SPC); 2. With the AFO alone; 3. With the SPC alone; and 4. Without assistive devices. The rehabilitation program remained essentially unchanged from the pre-injection protocol, with the exception of more frequent PT visits immediately after the procedure (5 sessions in the first 9 days) to monitor the individual’s reaction to the injection and to provide early aggressive mobilization. Once it was deemed that no negative side effects occurred, the PT program returned to the prior schedule of a weekly 1-hour session for the next 14 weeks. PT sessions included a variety of interventions that addressed impairments and functional limitations. The treatment progression was based on published algorithms of care for individuals with neuromuscular system disorders. The program focused on regaining ankle DF ROM and strength, and on maximizing standing balance and functional mobility. The subject performed a home program on non-therapy days. Post-testing was performed 4 months after the injection date to allow the direct effects of the medication to wear off. By waiting this duration, comparison could be made between testing prior to and after the drug administration while eliminating a medication effect during measurement. OBSERVATIONS: An initial finding was this subject’s ability to function with a less cumbersome ankle brace. The individual progressed from using a custom molded articulated AFO to functioning well with a prefabricated plastic posterior leaf spring (PLS). Ankle DF ROM improved by 18 degrees. Preliminary review of the temporospatial parameters of gait show post-intervention improvements in velocity, cadence, base of support, and Functional Ambulation Profile scores across testing conditions. Also noted were small changes in some functional performance measures including the BBT and the TUG. CONCLUSIONS: In this case study, the use of BTX in conjunction with an existing PT program resulted in several functional improvements for this adult with a hemicord injury. BTX may be considered as an adjunct to a case-specific PT program for individuals with similar impairments. Additional research needs to be performed before this information can be generalized to the population as a whole. A case series, followed by a randomized, controlled clinical trial should be undertaken to further analyze outcomes, as well as the appropriate dosing of pharmacologic and rehabilitation oriented interventions. FUNDING SOURCE: None. KEYWORDS: Botulinum toxin, Hemicord injury, Plantarflexion contracture, Hypertonia Copyright 2010 by the American Physical Therapy Association. Requests for reprints should be directed to the corresponding author of the article. Educators, students, and other academic customers may receive permission to reprint copyrighted material from Physical Therapy (ISSN 1538-6724) by contacting the Copyright Clearance Center Inc, 222 Rosewood Dr, Danvers, MA 01923. Other types of customers who want permission to reprint should contact the APTA Editorial Office, Attn: Physical Therapy.