July 2019

Botulinum Toxin Type A and Physiotherapy in Spasticity of the Lower Limbs Due to Amyotrophic Lateral Sclerosis

Authors: Riccardo Marvulli, Marisa Megna, Aurora Citraro, Ester Vacca, Marina Napolitano, Giulia Gallo, Pietro Fiore and Giancarlo Ianieri

Affiliations: Department of Basic Sciences, Neuroscience and Sense Organs, University of Bari “Aldo Moro”, Italy

Journal: Toxins - 2019, 11(7), 381 (DOI: 10.3390/toxins11070381)

Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disease (unknown pathogenesis) of the central nervous system that causes death within 1–5 years. Clinically, flabby paralysis, areflexia, muscular atrophy, and muscle fasciculations, signs of II motor neuron damage, appear. Sometimes, clinical manifestations of damage of the I motor neuron come out in lower limbs; spastic paralysis, iperflexia, and clonus emerge, and they impair deambulation and management of activities of daily living, such as personal hygiene or dressing. Thus, the first therapeutic approach in these patients involves antispasmodic drugs orally followed by botulinum toxin type A injection (BTX-A). In this study, we study the efficacy of BTX-A and physiotherapy in lower limb spasticity due to ALS and no response to treatment with oral antispastic drugs. We evaluated 15 patients (10 male and five female), with a mean age of 48.06 ± 5.2 with spasticity of adductor magnus (AM), at baseline (T0, before BTX-A treatment) and in the following three follow-up visits (T1 30 days, T2 60 days, and T3 90 days after infiltration). We evaluated myometric measure of muscle tone, the Modified Ashworth Scale of AM, Barthel Index, Adductor Tone Rating Scale, and Hygiene Score. The study was conducted between November 2018 and April 2019. We treated AM with incobotulinum toxin type A (Xeomin®, Merz). Spasticity (myometric measurement, Adductor Tone Rating Scale, and Modified Ashworth Scale) and clinical (Barthel Index and Hygiene Score) improvements were obtained for 90 days after injection (p < 0.05). Our study shows the possibility of using BTX-A in the treatment of spasticity in patients with ALS and no response to oral antispastic drugs, with no side effects. The limitation of the study is the small number of patients and the limited time of observation; therefore, it is important to increase both the number of patients and the observation time in future studies.

Keywords: amyotrophic lateral sclerosis; lower limb spasticity; botulinum toxin type A; activities of daily living; physiotherapy

Our study demonstrated the efficacy of incobotulinumtoxin A in the treatment of the bilateral adductor magnus spasticity in patients with ALS and no response to oral antispastic drugs. In the near future the clinical monitoring of patients is planned with myometric measurements (“MyotonPRO” device) after the subsequent infiltrations. We also plan to increase number of patients to obtain more information about the efficacy of BTX-A in the spasticity of these patients.