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Apraxia of Eyelid Opening
Apraxia of eyelid opening sometimes is associated with Parkinson’s disease and parkinsonian disorders such as progressive supranuclear palsy. Patients with this condition may be unable to open their eyes without contracting the frontalis muscle. The literature contains no randomized controlled trials of botulinum toxin for this indication, but open-label studies, such as one from Inoue and Rogers, suggest a benefit. Reports indicate that the pretarsal is the most appropriate injection target. An initial dose of 10–20 units of onabotulinum or incobotulinum toxin can be administered to the orbicularis oculi.
Sialorrhea
Sialorrhea is common among patients with Parkinson’s disease and may result from impaired swallowing or autonomic dysregulation. Anticholinergic drugs such as glycopyrrolate often have limited efficacy for sialorrhea and may cause side effects. Several randomized controlled trials have examined botulinum toxin as a potential treatment. A review by Seppi et al concluded that botulinum toxin types A and B are efficacious for this indication, although it is an off-label use.
Two injection sites have been considered for this treatment: the submandibular gland, which is responsible for continuous saliva secretion, and the parotid gland, which is responsible for stimulated secretion. Most studies have used the parotid gland or the parotid and submandibular glands as targets. One small study directly compared the two injection sites and found a trend toward a greater benefit from injection into the submandibular gland. “One approach could be to inject the parotid gland, and if it is still not effective, you can inject the submandibular gland,” said Dr. Chen. The dose for the parotid gland ranges between 5 and 50 units of onabotulinum or incobotulinum toxin, and a dose of 5 units generally is used for the submandibular gland.
The injection site may be localized using ultrasound or anatomical landmarks. A study in which the target was the parotid gland found slightly better results with ultrasound guidance, but ultrasound may be more necessary for injections into the submandibular gland, said Dr. Chen. Whether ultrasound guidance improves outcomes of botulinum toxin for sialorrhea thus has not been established, he added.
Jaw Tremor and Upper-Limb Tremor
Levodopa is the first-line treatment for tremor in Parkinson’s disease, but some patients do not respond well to this therapy. Schneider and colleagues studied abobotulinum toxin for jaw tremor in Parkinson’s disease. They administered the treatment to three people through bilateral masseter injection. Patients had an excellent response without side effects. Another protocol is an injection of 40 units of onabotulinum or incobotulinum toxin into the masseter and 10 units into the temporalis, said Dr. Chen.
No randomized controlled trials of botulinum toxin for arm tremor related to Parkinson’s disease have been published, but Rahimi et al published two case series. In one series published in 2015, the investigators administered injections to 28 patients at baseline, 16 weeks, and 32 weeks. The study was open-label, and muscles were selected using kinematic analysis. They found reduced tremor with treatment, and patients had mild muscle weakness.
Dystonia
Patients with Parkinson’s disease or multiple system atrophy may develop cervical dystonia that manifests as anterocollis. Patients with progressive supranuclear palsy may develop retrocollis. Although botulinum toxin is not indicated for it, case reports suggest that the treatment may be effective for cervical dystonia. The sternomastoid, scalene, and the longus colli are appropriate injection targets. Neurologists may need imaging guidance to inject botulinum toxin into the longus colli. For one patient with cervical dystonia secondary to corticobasal syndrome, Dr. Chen administered 30 units (onabotulinum or incobotulinum toxin) to the right trapezius, 60 units to the levator scapulae, and 20 units to the sternomastoid.
Dystonic clenched fists also may occur in Parkinson’s disease and Parkinson-plus syndromes. In 2001, Cordivari et al studied botulinum toxin as a treatment for dystonic clenched fists in seven patients with Parkinson’s disease and seven patients with other disorders. The researchers used electromyography to distinguish between muscle contraction and contracture. The injection sites were the flexor digitorum superficialis, flexor digitorum profundus, flexor pollicis longus, and lumbricals. The treatment reduced pain, relaxed muscles, and helped to resolve palmar infections.
Leg dystonia can be a presenting symptom in young-onset Parkinson’s disease and sometimes is observed in peak-dose dyskinesia. However, the typical presentation is off-period foot inversion and toe flexion. The big toe may be flexed or extended. The largest study of botulinum toxin for leg dystonia included 30 patients with Parkinson’s disease and painful off dystonia and was published in 1995. Open-label treatment improved pain and spasm for all patients, and seven patients with on dystonia had improved posture on walking. In 2016, Gupta et al administered 250–400 units of onabotulinum toxin to six patients with Parkinson’s disease and leg dystonia treated with deep brain stimulation. The treatment improved dystonia, pain, walking, gait velocity, and cadence.
Pain
Neurologists also have used botulinum toxin to treat pain in Parkinson’s disease. Bruno and colleagues performed a retrospective chart review of patients with Parkinson’s disease who received botulinum toxin for various indications over a 20-year period. The main indication for treatment was pain, and 81% of patients who received botulinum toxin for pain reported benefit after the first injection. The benefit was sustained with further injections.
Overactive Bladder
Overactive bladder affects between 38% and 71% of people with Parkinson’s disease. Symptoms include urinary urgency, urinary frequency, nocturia, and incontinence. Behavioral modification is the first-line treatment, and antimuscarinic agents may provide benefit. Overactive bladder is an approved indication for onabotulinum toxin. The usual dose is 200 units, but it can range between 100 and 300 units. Treatment is injected into the detrusor muscles, and the benefit lasts for six months to nine months. Urine retention is a potential side effect of this treatment.
—Erik Greb
Suggested Reading
Bruno VA, Fox SH, Mancini D, Miyasaki JM. Botulinum toxin use in refractory pain and other symptoms in parkinsonism. Can J Neurol Sci. 2016;43(5):697-702.
Cordivari C, Misra VP, Catania S, Lees AJ. Treatment of dystonic clenched fist with botulinum toxin. Mov Disord. 2001;16(5):907-913.
Giannantoni A, Conte A, Proietti S, et al. Botulinum toxin type A in patients with Parkinson’s disease and refractory overactive bladder. J Urol. 2011;186(3):960-964.
Glass GA, Ku S, Ostrem JL, et al. Fluoroscopic, EMG-guided injection of botulinum toxin into the longus colli for the treatment of anterocollis. Parkinsonism Relat Disord. 2009;15(8):610-613.
Gupta AD, Visvanathan R. Botulinum toxin for foot dystonia in patients with Parkinson’s disease having deep brain stimulation: A case series and a pilot study. J Rehabil Med. 2016;48(6):559-562.
Inoue K, Rogers JD. Botulinum toxin injection into Riolan’s muscle: somatosensory ‘trick’. Eur Neurol. 2007;58(3):138-141.
Pacchetti C, Albani G, Martignoni E, et al. “Off” painful dystonia in Parkinson’s disease treated with botulinum toxin. Mov Disord. 1995;10(3):333-336.
Rahimi F, Samotus O, Lee J, Jog M. Effective management of upper limb parkinsonian tremor by incobotulinumtoxinA injections using sensor-based biomechanical patterns. Tremor Other Hyperkinet Mov (NY). 2015;5:348.
Schneider SA, Edwards MJ, Cordivari C, et al. Botulinum toxin A may be efficacious as treatment for jaw tremor in Parkinson’s disease. Mov Disord. 2006;21(10):1722-1724.
Seppi K, Weintraub D, Coelho M, et al. The Movement Disorder Society evidence-based medicine review update: treatments for the non-motor symptoms of Parkinson’s disease. Mov Disord. 2011;26 Suppl 3:S42-S80.
Apraxia of Eyelid Opening
Apraxia of eyelid opening sometimes is associated with Parkinson’s disease and parkinsonian disorders such as progressive supranuclear palsy. Patients with this condition may be unable to open their eyes without contracting the frontalis muscle. The literature contains no randomized controlled trials of botulinum toxin for this indication, but open-label studies, such as one from Inoue and Rogers, suggest a benefit. Reports indicate that the pretarsal is the most appropriate injection target. An initial dose of 10–20 units of onabotulinum or incobotulinum toxin can be administered to the orbicularis oculi.
Sialorrhea
Sialorrhea is common among patients with Parkinson’s disease and may result from impaired swallowing or autonomic dysregulation. Anticholinergic drugs such as glycopyrrolate often have limited efficacy for sialorrhea and may cause side effects. Several randomized controlled trials have examined botulinum toxin as a potential treatment. A review by Seppi et al concluded that botulinum toxin types A and B are efficacious for this indication, although it is an off-label use.
Two injection sites have been considered for this treatment: the submandibular gland, which is responsible for continuous saliva secretion, and the parotid gland, which is responsible for stimulated secretion. Most studies have used the parotid gland or the parotid and submandibular glands as targets. One small study directly compared the two injection sites and found a trend toward a greater benefit from injection into the submandibular gland. “One approach could be to inject the parotid gland, and if it is still not effective, you can inject the submandibular gland,” said Dr. Chen. The dose for the parotid gland ranges between 5 and 50 units of onabotulinum or incobotulinum toxin, and a dose of 5 units generally is used for the submandibular gland.
The injection site may be localized using ultrasound or anatomical landmarks. A study in which the target was the parotid gland found slightly better results with ultrasound guidance, but ultrasound may be more necessary for injections into the submandibular gland, said Dr. Chen. Whether ultrasound guidance improves outcomes of botulinum toxin for sialorrhea thus has not been established, he added.
Jaw Tremor and Upper-Limb Tremor
Levodopa is the first-line treatment for tremor in Parkinson’s disease, but some patients do not respond well to this therapy. Schneider and colleagues studied abobotulinum toxin for jaw tremor in Parkinson’s disease. They administered the treatment to three people through bilateral masseter injection. Patients had an excellent response without side effects. Another protocol is an injection of 40 units of onabotulinum or incobotulinum toxin into the masseter and 10 units into the temporalis, said Dr. Chen.
No randomized controlled trials of botulinum toxin for arm tremor related to Parkinson’s disease have been published, but Rahimi et al published two case series. In one series published in 2015, the investigators administered injections to 28 patients at baseline, 16 weeks, and 32 weeks. The study was open-label, and muscles were selected using kinematic analysis. They found reduced tremor with treatment, and patients had mild muscle weakness.
Dystonia
Patients with Parkinson’s disease or multiple system atrophy may develop cervical dystonia that manifests as anterocollis. Patients with progressive supranuclear palsy may develop retrocollis. Although botulinum toxin is not indicated for it, case reports suggest that the treatment may be effective for cervical dystonia. The sternomastoid, scalene, and the longus colli are appropriate injection targets. Neurologists may need imaging guidance to inject botulinum toxin into the longus colli. For one patient with cervical dystonia secondary to corticobasal syndrome, Dr. Chen administered 30 units (onabotulinum or incobotulinum toxin) to the right trapezius, 60 units to the levator scapulae, and 20 units to the sternomastoid.
Dystonic clenched fists also may occur in Parkinson’s disease and Parkinson-plus syndromes. In 2001, Cordivari et al studied botulinum toxin as a treatment for dystonic clenched fists in seven patients with Parkinson’s disease and seven patients with other disorders. The researchers used electromyography to distinguish between muscle contraction and contracture. The injection sites were the flexor digitorum superficialis, flexor digitorum profundus, flexor pollicis longus, and lumbricals. The treatment reduced pain, relaxed muscles, and helped to resolve palmar infections.
Leg dystonia can be a presenting symptom in young-onset Parkinson’s disease and sometimes is observed in peak-dose dyskinesia. However, the typical presentation is off-period foot inversion and toe flexion. The big toe may be flexed or extended. The largest study of botulinum toxin for leg dystonia included 30 patients with Parkinson’s disease and painful off dystonia and was published in 1995. Open-label treatment improved pain and spasm for all patients, and seven patients with on dystonia had improved posture on walking. In 2016, Gupta et al administered 250–400 units of onabotulinum toxin to six patients with Parkinson’s disease and leg dystonia treated with deep brain stimulation. The treatment improved dystonia, pain, walking, gait velocity, and cadence.
Pain
Neurologists also have used botulinum toxin to treat pain in Parkinson’s disease. Bruno and colleagues performed a retrospective chart review of patients with Parkinson’s disease who received botulinum toxin for various indications over a 20-year period. The main indication for treatment was pain, and 81% of patients who received botulinum toxin for pain reported benefit after the first injection. The benefit was sustained with further injections.
Overactive Bladder
Overactive bladder affects between 38% and 71% of people with Parkinson’s disease. Symptoms include urinary urgency, urinary frequency, nocturia, and incontinence. Behavioral modification is the first-line treatment, and antimuscarinic agents may provide benefit. Overactive bladder is an approved indication for onabotulinum toxin. The usual dose is 200 units, but it can range between 100 and 300 units. Treatment is injected into the detrusor muscles, and the benefit lasts for six months to nine months. Urine retention is a potential side effect of this treatment.
—Erik Greb
Suggested Reading
Bruno VA, Fox SH, Mancini D, Miyasaki JM. Botulinum toxin use in refractory pain and other symptoms in parkinsonism. Can J Neurol Sci. 2016;43(5):697-702.
Cordivari C, Misra VP, Catania S, Lees AJ. Treatment of dystonic clenched fist with botulinum toxin. Mov Disord. 2001;16(5):907-913.
Giannantoni A, Conte A, Proietti S, et al. Botulinum toxin type A in patients with Parkinson’s disease and refractory overactive bladder. J Urol. 2011;186(3):960-964.
Glass GA, Ku S, Ostrem JL, et al. Fluoroscopic, EMG-guided injection of botulinum toxin into the longus colli for the treatment of anterocollis. Parkinsonism Relat Disord. 2009;15(8):610-613.
Gupta AD, Visvanathan R. Botulinum toxin for foot dystonia in patients with Parkinson’s disease having deep brain stimulation: A case series and a pilot study. J Rehabil Med. 2016;48(6):559-562.
Inoue K, Rogers JD. Botulinum toxin injection into Riolan’s muscle: somatosensory ‘trick’. Eur Neurol. 2007;58(3):138-141.
Pacchetti C, Albani G, Martignoni E, et al. “Off” painful dystonia in Parkinson’s disease treated with botulinum toxin. Mov Disord. 1995;10(3):333-336.
Rahimi F, Samotus O, Lee J, Jog M. Effective management of upper limb parkinsonian tremor by incobotulinumtoxinA injections using sensor-based biomechanical patterns. Tremor Other Hyperkinet Mov (NY). 2015;5:348.
Schneider SA, Edwards MJ, Cordivari C, et al. Botulinum toxin A may be efficacious as treatment for jaw tremor in Parkinson’s disease. Mov Disord. 2006;21(10):1722-1724.
Seppi K, Weintraub D, Coelho M, et al. The Movement Disorder Society evidence-based medicine review update: treatments for the non-motor symptoms of Parkinson’s disease. Mov Disord. 2011;26 Suppl 3:S42-S80.
Apraxia of Eyelid Opening
Apraxia of eyelid opening sometimes is associated with Parkinson’s disease and parkinsonian disorders such as progressive supranuclear palsy. Patients with this condition may be unable to open their eyes without contracting the frontalis muscle. The literature contains no randomized controlled trials of botulinum toxin for this indication, but open-label studies, such as one from Inoue and Rogers, suggest a benefit. Reports indicate that the pretarsal is the most appropriate injection target. An initial dose of 10–20 units of onabotulinum or incobotulinum toxin can be administered to the orbicularis oculi.
Sialorrhea
Sialorrhea is common among patients with Parkinson’s disease and may result from impaired swallowing or autonomic dysregulation. Anticholinergic drugs such as glycopyrrolate often have limited efficacy for sialorrhea and may cause side effects. Several randomized controlled trials have examined botulinum toxin as a potential treatment. A review by Seppi et al concluded that botulinum toxin types A and B are efficacious for this indication, although it is an off-label use.
Two injection sites have been considered for this treatment: the submandibular gland, which is responsible for continuous saliva secretion, and the parotid gland, which is responsible for stimulated secretion. Most studies have used the parotid gland or the parotid and submandibular glands as targets. One small study directly compared the two injection sites and found a trend toward a greater benefit from injection into the submandibular gland. “One approach could be to inject the parotid gland, and if it is still not effective, you can inject the submandibular gland,” said Dr. Chen. The dose for the parotid gland ranges between 5 and 50 units of onabotulinum or incobotulinum toxin, and a dose of 5 units generally is used for the submandibular gland.
The injection site may be localized using ultrasound or anatomical landmarks. A study in which the target was the parotid gland found slightly better results with ultrasound guidance, but ultrasound may be more necessary for injections into the submandibular gland, said Dr. Chen. Whether ultrasound guidance improves outcomes of botulinum toxin for sialorrhea thus has not been established, he added.
Jaw Tremor and Upper-Limb Tremor
Levodopa is the first-line treatment for tremor in Parkinson’s disease, but some patients do not respond well to this therapy. Schneider and colleagues studied abobotulinum toxin for jaw tremor in Parkinson’s disease. They administered the treatment to three people through bilateral masseter injection. Patients had an excellent response without side effects. Another protocol is an injection of 40 units of onabotulinum or incobotulinum toxin into the masseter and 10 units into the temporalis, said Dr. Chen.
No randomized controlled trials of botulinum toxin for arm tremor related to Parkinson’s disease have been published, but Rahimi et al published two case series. In one series published in 2015, the investigators administered injections to 28 patients at baseline, 16 weeks, and 32 weeks. The study was open-label, and muscles were selected using kinematic analysis. They found reduced tremor with treatment, and patients had mild muscle weakness.
Dystonia
Patients with Parkinson’s disease or multiple system atrophy may develop cervical dystonia that manifests as anterocollis. Patients with progressive supranuclear palsy may develop retrocollis. Although botulinum toxin is not indicated for it, case reports suggest that the treatment may be effective for cervical dystonia. The sternomastoid, scalene, and the longus colli are appropriate injection targets. Neurologists may need imaging guidance to inject botulinum toxin into the longus colli. For one patient with cervical dystonia secondary to corticobasal syndrome, Dr. Chen administered 30 units (onabotulinum or incobotulinum toxin) to the right trapezius, 60 units to the levator scapulae, and 20 units to the sternomastoid.
Dystonic clenched fists also may occur in Parkinson’s disease and Parkinson-plus syndromes. In 2001, Cordivari et al studied botulinum toxin as a treatment for dystonic clenched fists in seven patients with Parkinson’s disease and seven patients with other disorders. The researchers used electromyography to distinguish between muscle contraction and contracture. The injection sites were the flexor digitorum superficialis, flexor digitorum profundus, flexor pollicis longus, and lumbricals. The treatment reduced pain, relaxed muscles, and helped to resolve palmar infections.
Leg dystonia can be a presenting symptom in young-onset Parkinson’s disease and sometimes is observed in peak-dose dyskinesia. However, the typical presentation is off-period foot inversion and toe flexion. The big toe may be flexed or extended. The largest study of botulinum toxin for leg dystonia included 30 patients with Parkinson’s disease and painful off dystonia and was published in 1995. Open-label treatment improved pain and spasm for all patients, and seven patients with on dystonia had improved posture on walking. In 2016, Gupta et al administered 250–400 units of onabotulinum toxin to six patients with Parkinson’s disease and leg dystonia treated with deep brain stimulation. The treatment improved dystonia, pain, walking, gait velocity, and cadence.
Pain
Neurologists also have used botulinum toxin to treat pain in Parkinson’s disease. Bruno and colleagues performed a retrospective chart review of patients with Parkinson’s disease who received botulinum toxin for various indications over a 20-year period. The main indication for treatment was pain, and 81% of patients who received botulinum toxin for pain reported benefit after the first injection. The benefit was sustained with further injections.
Overactive Bladder
Overactive bladder affects between 38% and 71% of people with Parkinson’s disease. Symptoms include urinary urgency, urinary frequency, nocturia, and incontinence. Behavioral modification is the first-line treatment, and antimuscarinic agents may provide benefit. Overactive bladder is an approved indication for onabotulinum toxin. The usual dose is 200 units, but it can range between 100 and 300 units. Treatment is injected into the detrusor muscles, and the benefit lasts for six months to nine months. Urine retention is a potential side effect of this treatment.
—Erik Greb
Suggested Reading
Bruno VA, Fox SH, Mancini D, Miyasaki JM. Botulinum toxin use in refractory pain and other symptoms in parkinsonism. Can J Neurol Sci. 2016;43(5):697-702.
Cordivari C, Misra VP, Catania S, Lees AJ. Treatment of dystonic clenched fist with botulinum toxin. Mov Disord. 2001;16(5):907-913.
Giannantoni A, Conte A, Proietti S, et al. Botulinum toxin type A in patients with Parkinson’s disease and refractory overactive bladder. J Urol. 2011;186(3):960-964.
Glass GA, Ku S, Ostrem JL, et al. Fluoroscopic, EMG-guided injection of botulinum toxin into the longus colli for the treatment of anterocollis. Parkinsonism Relat Disord. 2009;15(8):610-613.
Gupta AD, Visvanathan R. Botulinum toxin for foot dystonia in patients with Parkinson’s disease having deep brain stimulation: A case series and a pilot study. J Rehabil Med. 2016;48(6):559-562.
Inoue K, Rogers JD. Botulinum toxin injection into Riolan’s muscle: somatosensory ‘trick’. Eur Neurol. 2007;58(3):138-141.
Pacchetti C, Albani G, Martignoni E, et al. “Off” painful dystonia in Parkinson’s disease treated with botulinum toxin. Mov Disord. 1995;10(3):333-336.
Rahimi F, Samotus O, Lee J, Jog M. Effective management of upper limb parkinsonian tremor by incobotulinumtoxinA injections using sensor-based biomechanical patterns. Tremor Other Hyperkinet Mov (NY). 2015;5:348.
Schneider SA, Edwards MJ, Cordivari C, et al. Botulinum toxin A may be efficacious as treatment for jaw tremor in Parkinson’s disease. Mov Disord. 2006;21(10):1722-1724.
Seppi K, Weintraub D, Coelho M, et al. The Movement Disorder Society evidence-based medicine review update: treatments for the non-motor symptoms of Parkinson’s disease. Mov Disord. 2011;26 Suppl 3:S42-S80.