Riccardo Marvulli

New approach in the assessment of the tone, elasticity and the muscular resistance: nominal scales vs MYOTON.

Spasticity can be defined as a motor disorder to tonic stretching reflexes (muscle tone), and is symptomatic of damage to the first CNS motor neuron. It may be due to the CNS hyperexcitability a, hyperexcitability y. Spasticity especially affects the antigravity muscles, the upper limb flexors (pectoralis major, flexor forearm, hand and fingers, pronator teres) and the extensor of the lower limbs (the triceps surae, quadriceps, adductor magnus). These muscles develop strong resistance to passive stretch that increases proportionally to the speed and extent of the passive movement. This resistance has many causes, both the central (such as alteration of synaptic gain, modulation segmental injunction, synaptic inhibition) peripheral (such as changes in muscle strength, reduced muscle fibers, reduced blood flow). The histological, anatomical and physiological properties of muscle tissue are dependent on fluid-dynamics. In case of blood flow alteration clinically changes in tone can be seen, which can be increased (situation associated with muscle pain and loss of performance). The alterations of muscle tone are being studied in clinical practice to evaluate good drug treatment-rehabilitation of spastic hypertone. To analyze the degree of spastic hypertone, we used two general clinical scales: the Ashworth scale (AS) and the Modified Ashworth Scale (MAS) (1). Both of these assess the muscular resistance to passive movement, but these scales are depended on the judgement of the operators (2). The aim of our study is to assess the state of muscle contraction in patients with muscle spasticity in an objective way, using the myometric measurement and AS and MAS scales to quantify the muscle tone. MATERIALS AND METHODS

Botulinum toxin type A in cervical dystonia.

Cervical dystonia is a syndrome characterized by anomalous postures and unintentional repetitive movements of the head and the neck. Aim of this study is to show the effectiveness of the combined treatment botulinum toxin-FKT through the use of a recent methodic of investigation, myoton, and of the classical clinical evaluations, such as Tsui and VAS scales. 15 patients (9 females, 6 males) have been selected. During the initial visit and in the following controls, performed every month, patients have been submitted to physiatric examination, clinical evaluation of the dystonia through the Tsui scale, clinical evaluation of the pain through the VAS scale, myometric evaluation. We obtained statistically reduction of muscular tones value in passive elongation (t0=16,34±l,23) until 4 month (t4 =16,11±1,23), when we performed a second infiltration. After 4 months from the second infiltration (t8=15,99±1,11) value did not present more some statistical correlation and was necessary to perform a new infiltration. Values of elasticity, stiffness, Tsui and VAS scale followed the same course of the tone. Our study demonstrates that combined treatment botulinum toxin-FKT is effective. It emerges that if to the treatment with botulinum toxin follows a suitable FKT treatment, the effect of the drug lasts 4 months and not 3 months as described by the literature. Our study has underlined that using myometric measurement we can consider least changes in muscular tone, elasticity and stiffness; we have a broader view of the spastic muscle, and we can better plan appropriate rehabilitative care for each patient.

“Appropriate Treatment” and Therapeutic Window in Spasticity Treatment with IncobotulinumtoxinA: From 100 to 1000 Units

Many neurological diseases (ischemic and hemorrhagic stroke, multiple sclerosis, infant cerebral palsy, spinal cord injuries, traumatic brain injury, and other cerebrovascular disorders) may cause muscle spasticity. Different therapeutic strategies have been proposed for the treatment of spasticity. One of the major treatments for tone modulation is botulinum toxin type A (BTX-A), performed in addition to other rehabilitation strategies based on individualized multidisciplinary programs aimed at achieving certain goals for each patient. Therapeutic plans must be precisely defined as they must balance the reduction of spastic hypertonia and retention of residual motor function. To perform and optimize the treatment, an accurate clinical and instrumental evaluation of spasticity is needed to determine how this symptom is invalidating and to choose the best doses, muscles and times of injection in each patient. We introduce an “appropriate treatment” and no “standard or high dosage treatment” concept based on our retrospective observational study on 120 patients lasting two years, according to the larger Therapeutic Index and Therapeutic Window of Incobotulinumtoxin A doses from 100 to 1000 units. We studied the efficiency and safety of this drug considering the clinical spasticity significance for specialist physicians and patients.

Efficacy And Non Invasive Treatment Of Sialorrhea In The Goldenhar Syndrome

BACKGROUND AND OBJECTIVE Goldenhar syndrome (ocular-auricular-vertebral syndrome), a rare congenital condition arising from defects in the first and second brachial arches, consists in clinical variety of features ranging from facial abnormalities, ear-eye abnormalities, vertebral defects and congenital heart problems and severe obstructive sleep apnea. Due to craniofacial abnormalities, patients presents mechanical obstructive phenomena and sialorrhea that cause prone position, languages fastening, use of nasopharyngeal cannulas and tracheal intubation. METHODS In this article, we report a case of a 16 years old child affected by Goldenhar syndrome and sialorrhea to demonstrate improvement of the daily patient management, through inoculations of botulinum toxin type A. Due to severe sialorrhea which caused tracheobronchial daily aspirations, the caregivers used an external aspirators. RESULTS In the first infiltration (August 2016) the parotid and submandibular glands bilaterally were inoculated with incobotulinum toxin type A (Xeomin®, Merz Pharma) with dosages of 5 UI for each of them, for a total of 20 UI without clinical efficacy (no quantitative and qualitative saliva reducing during 3 months). In the second (November 2016) and third (February 2017) infiltrations each parotid and each submandibular glands were injected with a (dosage of 7 UI and 5 UI respectively (total of 24 UI of incobotulinumtoxin A) with important clinical results (saliva production and tracheo-bronchial aspirations reduced). CONCLUSION Therefore, botulinum toxin type A could be a good and non invasive treatment of sialorrhea in Goldenhar syndrome to improve oral hygiene and daily patient management.

Incobotulinumtoxina (Xeomin®) Versus Onabotulinumtoxina (Botox®): Evaluation of Clinical Onset of Action with Rating Scales and Electroneurography

Onset of action, duration and maximum efficacy of different botulinum toxin type A (BoNT/A) preparations have been compared mainly in in vitro studies. This single-center open study compared onset of action of the two BoNT/A preparations onabotulinumtoxinA (complex size 900 kDa) and incobotulinumtoxinA (free of complexing proteins, 150 kDa) in patients with spasticity after cerebral stroke over a 15-day treatment period. Outcome measures were changes in muscle tone, increase in passive extension of the elbow, changes in limb functionality, and variation of the amplitude of the compound muscle action potential (cMAP) determined by electroneurography. A total of 108 patients (mean age 64.8 ± 11.3 years) were included in the study, 54 in each treatment arm. Muscle tone, elbow motion range, and limb function significantly improved in both groups from baseline to day 15 after BoNT/A injection (p<0.0001). Improvements were significantly greater under incobotulinumtoxinA compared to onabotulinumtoxinA after 7 treatment days (p<0.0001) but were comparable after 15 days. Regarding cMAP amplitude, a faster reduction in the first 7 treatment days with no further significant reductions during the next week was observed for in cobotulinum toxinA patients, whereas on a botulinum toxinA patients showed a slower, progressive reduction in action potential resulting in comparable values between the two groups after 15 days. Overall, the efficacy of both BoNT/A preparations was comparable two weeks after injection.

Objective Assessment of the Rheological Muscle Property in the Treatment of Fibromyalgia

Fibromyalgia (FM), clinical condition characterized by several signs and symptoms such as widespread pain, trigger point, morning stiffness and extreme tiredness for scarce hours of sleep, is linked to several changes in several brain neurotransmitters, particularly serotonin and norepinephrine. Consequently, the Neural Vegetative System works more and so it generates an exaggerated muscular contraction, sweating and constriction of blood vessels. The aim of our study was to treat a selected group of female patients suffering from FM with duloxetine with physiotherapy. We used two clinical scales (VAS and FIQ) and an objective evaluation such as myometric. The analysis of the data Myoton used during any inspection showed a statistically significant reduction in the values of muscle tone in each district analyzed. This finding was also confirmed by the patients themselves who have experienced a significant welfare and less muscle tension in different locations, as evidenced by data obtained from the clinical scales used by us. In addition, our patients were thought to be satisfied with the improvements not only subjective, but also with the objective witnessed myometry, making them a share of the study and feeling constantly monitored for treatment aimed at a real reduction in muscle stiffness. In conclusion, our study demonstrates combined treatment duloxetine- physiotherapy effectively reduces a symptom often disabling and particularly troublesome in patients with FM as the exaggerated muscle contraction.