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Chapter 20 - Treatment of Stiff-Person Syndrome with Botulinum Toxin
- Edited by Daniel Truong, University of California, Riverside, Dirk Dressler, Hannover Medical School, Mark Hallett, National Institutes of Health (NIH), Christopher Zachary, University of California, Irvine, Mayank Pathak, Truong Neuroscience Institute
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- Book:
- Manual of Botulinum Toxin Therapy
- Published online:
- 02 November 2023
- Print publication:
- 23 November 2023, pp 174-179
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Summary
Stiff-person syndrome (SPS), formerly termed stiff-man syndrome, is characterized by muscular rigidity and episodic spasms mainly involving the trunk and lower limbs. The typical form is an autoimmune disease characterized by progressive axial rigidity, predominantly involving the paraspinal and abdominal muscles, along with hyperlordosis of the lumbar spine, spontaneous or stimulus sensitive disabling muscle spasms of the abdominal wall, lower extremities and other proximal muscles. Ninety-five percent of patients had GAD-65 and 89% had islet cell antibodies (ICA). A sizeable number of patients also have other antibodies such as those against glycine receptor and glycine transporter 2. SPS associated with neoplasms tends to involve the upper limbs and neck and cranial nerves. Patients with carcinoma of the breast or lung (oat cell carcinoma) may develop SLS with high titers of anti-amphiphysin antibodies. This chapter illustrates the use of botulinum toxin (BoNT) in the treatment of SPS, along with anatomical illustrations demonstrating the typical involved musculature, and approach to injection with botulinum neurotoxin, with tabulated dosing recommendations for the various BoNT formulations.
Chapter 33 - Treatment of Plantar Fasciitis/Plantar Fasciopathy with Botulinum Neurotoxins
- Edited by Daniel Truong, University of California, Riverside, Dirk Dressler, Hannover Medical School, Mark Hallett, National Institutes of Health (NIH), Christopher Zachary, University of California, Irvine, Mayank Pathak, Truong Neuroscience Institute
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- Book:
- Manual of Botulinum Toxin Therapy
- Published online:
- 02 November 2023
- Print publication:
- 23 November 2023, pp 269-274
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Summary
Plantar fasciitis (PF) is the most common cause of chronic heel pain, predominantly impacting those who perform heavy footwork, are avid runners or lare ong-distance walkers. Overuse injury leads to repetitive microtears of the plantar fascia near the calcaneus, irritating pain fibers and producing secondary inflammation. Patients typically have intense heel pain, described as aching, jabbing or burning. Pain usually starts with the first few steps in the morning and is reproduced by palpation of the median tubercle of the calcaneum and with dorsiflexion of the toes.
Conventional treatments such as ice, heel cup orthoses, deep-tissue massage and night splints, periods of immobilization and stretching/strengthening exercise programs can reduce pain satisfactorily. Persistent discomfort may respond to treatments such as ultrasound, iontophoresis and phonophoresis. More severe and recalcitrant cases require extracorporeal shock wave therapy (ECSWT) or local corticosteroid injections. When medical approaches fail, surgery is advocated but can only offer modest results.
This chapter reviews pertinent studies to date on the application of botulinum neurotoxin to plantar fasciitis, and discusses injection technique and dosing, including the WRAMC–Yale technique for injecting the soleus muscle, along with the plantar fascia. Clear anatomical illustrations are provided.
Chapter 19 - Treatment of stiff-person syndrome with botulinum neurotoxin
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- By Diana Richardson, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA, Bahman Jabbari, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
- Edited by Daniel Truong, Dirk Dressler, Mark Hallett, Christopher Zachary
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- Book:
- Manual of Botulinum Toxin Therapy
- Published online:
- 05 February 2014
- Print publication:
- 23 January 2014, pp 168-173
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Summary
Introduction
Stiff-person syndrome (SPS) is characterized by muscular rigidity and episodic spasms that principally involve the trunk and lower limbs. The muscle spasms are typically symmetric, more proximal in distribution and associated with an increased sensitivity to external stimuli.
The syndrome was first described by Frederick Moersch and Henry Woltman in the Proceedings of the Staff Meeting of the Mayo Clinic in 1956 (Moersch and Woltman, 1956). These astute clinicians eventually described a total of 14 afflicted patients who were observed over a 32-year period. Because of the magnitude of this finding and such meticulous records, the condition was also coined Moersch–Woltman syndrome, but this term is not used any more.
In the 1980s, increased levels of antibodies against glutamic acid decarboxylase (GAD; catalyzing production of gamma-aminobutyric acid from glutamic acid in the central nervous system) were isolated in patients with SPS. Since then, an association with other autoimmune diseases such as type 2 diabetes mellitus, pernicious anemia and thyroiditis has been well established. Symptoms usually begin during adult life and affect both sexes, with a slight preference towards women. Stiff person syndrome can easily be misdiagnosed, especially in the early stages. If untreated, the symptoms can become disabling (Dalakas et al., 2000). Electromyography demonstrates continuous and spontaneous firing of motor units in the rigid muscles.
Chapter 28 - Treatment of plantar fasciitis with botulinum neurotoxins
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- By Bahman Jabbari, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA, Shivam Om Mittal, Department of Neurology, Case Western Reserve University, Cleveland, OH, USA
- Edited by Daniel Truong, Dirk Dressler, Mark Hallett, Christopher Zachary
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- Book:
- Manual of Botulinum Toxin Therapy
- Published online:
- 05 February 2014
- Print publication:
- 23 January 2014, pp 243-246
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Summary
Introduction
Plantar fasciitis (PF) is the most common cause of chronic heel pain and is a major health issue in runners and long-distance walkers. It affects 2 million people in the USA and results in approximately 1 million visits to the physician office, 62% of which are to primary care physicians. The annual cost of treatments is estimated to be between $192 and $376 million (Tu and Bytomski, 2011). Overuse injury may lead to repetitive microtears of the plantar fascia near the calcaneus, irritating pain fibers and producing secondary inflammation. Other risk factors include obesity, flat or overarched feet and improper shoes. The pain usually involves the inferior and medial aspect of the heel (calcaneus), at the medial aspect of the calcaneal tubercle. However, the entire course of the plantar fascia may be involved. Patients typically have intense heel pain, described as aching, jabbing or burning pain, with the first couple of steps in the morning. Pain is reproduced by palpation of the median tubercle of the calcaneum and with dorsiflexion of the toes (Windlass test) (Young, 2012). In many patients, the application of ice and/or the use of heel cup orthosis activity modification and a stretching/strengthening exercise program reduce the pain satisfactorily. Further measures include deep-tissue massage therapy, night splints and periods of immobilization. Persistent problems may respond to treatment with posterior night splints, ultrasound, iontophoresis, phonophoresis, extracorporal shock wave therapy or even local corticosteroid injections (Goff and Crawford, 2011). Where medical approaches fail, surgery is advocated but has modest results. Approximately 10–12% of patients fail to achieve pain relief from medical and/or surgical treatment.
22 - Treatment of stiff-person syndrome with botulinum toxin
- Edited by Daniel Truong, Dirk Dressler, Mark Hallett
-
- Book:
- Manual of Botulinum Toxin Therapy
- Published online:
- 28 July 2009
- Print publication:
- 12 February 2009, pp 189-194
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Summary
Introduction
Stiff-person syndrome (SPS), formerly termed stiff-man syndrome and Moersch–Woltmann syndrome, was first described in 1956 as a condition of muscular rigidity and episodic spasms that principally involved the trunk and lower limbs (Moersch & Woltman, 1956). The idiopathic (typical) form of SPS is now considered an autoimmune disorder, often associated with type I diabetes and increased levels of antibodies against glutamic acid decarboxylase (GAD), the enzyme that catalyzes gamma-amino butyric acid from glutamic acid. Symptoms usually begin during adult life and affect both sexes. Early in the disease course symptoms can be confused with orthopedic conditions, but as the disease progresses, a clear distinction can be made. Increasing symptoms of axial and limb rigidity and painful muscle spasms eventually lead to disability. Electromyography demonstrates continuous and spontaneous firing of motor units in the rigid muscles.
Clinical features
Brown and Marsden (1999) describe a typical form (classic) and several atypical forms (i.e., plus variants) of SPS. The typical form of SPS is characterized by progressive axial rigidity predominantly involving the paraspinal and abdominal muscles along with hyperlordosis of the lumbar spine, and spontaneous or stimulus sensitive disabling muscle spasms of the abdominal wall, lower extremities, and other proximal muscles. Muscle rigidity in typical SPS is attributed to dysfunction of the inhibitory interneurons of the spinal cord. These patients have high incidence of anti-GAD and islet cell antibodies (ICA) (96% GAD-65 antibodies and 89% ICA in Mayo clinic series) (Walikonis & Lennon, 1998).
21 - Treatment of plantar fasciitis with botulinum toxin
- Edited by Daniel Truong, Dirk Dressler, Mark Hallett
-
- Book:
- Manual of Botulinum Toxin Therapy
- Published online:
- 28 July 2009
- Print publication:
- 12 February 2009, pp 185-188
-
- Chapter
- Export citation
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Summary
Introduction
Plantar fasciitis (PF) is the most common cause of chronic heel pain and is a major health issue in runners and long-distance walkers. Overuse injury may lead to repetitive micro-tears of the plantar fascia near the calcaneus, irritating pain fibers and producing secondary inflammation. Other risk factors include obesity, flat or over arched feet, and improper shoes. The pain usually involves the inferior and medial aspect of the heel (calcaneus), at the medial aspect of the calcaneal tubercle. However, the entire course of the plantar fascia may be involved (Barrett & O'Malley, 1999). Patients describe pain variably as aching, jabbing or burning. In many patients, the application of ice and/or use of heel cup orthosis activity modification and a stretching/strengthening exercise program reduces the pain satisfactorily. Further measures include deep-tissue massage therapy, night splints, and periods of immobilization. Persistent cases may respond to treatment with posterior night splints, ultrasound, iontophoresis, phonophoresis, extracorporeal shock wave therapy (ECSWT), or even local corticosteroid injections (DeMaio et al., 1993). In cases of medical failures, surgery is advocated, with modest results. Approximately 10–12% of the patients fail to achieve pain relief from medical and/or surgical treatment.
Anatomy of the plantar fascia
The plantar fascia is composed of dense collagen fibers that extend longitudinally from the calcaneus to the base of each proximal phalanx (Figure 21.1a). The fascia has medial, central, and lateral parts, underneath which the flexor digitorum brevis (FDB) and the abductor hallucis (AH) muscles reside (Figure 21.1b).