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Therapeutic Modalities

         1. Muscle Afferent Block (MAB)

Muscle Afferent Block or MAB is a peripheral mode of managing muscle spasticity or focal involuntary movements like dystonia (characterized by sustained or persistent vigorous often painful muscular contractions). Conditions for which MAB is utilized include cervical dystonia, writer's cramp, limb spasticity. MAB regimen consists of 95-99% ethanol and 0.5% lidocaine.

Problematic (persistently and forcefully contracting) muscles are injected at the muscle belly with the MAB regimen. EMG guidance may be used when necessary.

Effect last from 30 minutes to a week. Repeatetd injections weekly may increase duration of effect (several weeks to few months). Reported side effects are transient pain and bleeding on injected site, mild local inflammation and dizziness.

Reference: Kaji R, Kohara N et al, Muscle Nerve, Feb 1995

         2. Botulinum Neurotoxin A (BoNT A) injections

Like MAB, Botulinum Neurotoxin is also utilized to treat muscle spasticity and involuntary movements. The neurotoxin is injected intramuscularly or subcutaneously. EMG-guidance may likewise be provided.

Locally, BoNT A is marketed as Dysport by Ipsen and Botox by Allergan.

WARNING: BoNT A dosing per unit are not interchangeable between these two brands. Please refer to their respective prescribing information.

Presently, Bureau of Food and Drugs (BFAD) has approved Botulinum Neurotoxin A (BoNT A) for the following indications:

  • Adult Arm Spasticity*

  • Axillary Hyperhidrosis

  • Blepharospasm

  • Dynamic Equinus Foot Deformity in Children with Cerebral Palsy

  • Glabellar Lines

  • Hemifacial Spasm

  • Spasmodic Torticollis (Cervical Dystonia)

  • Strabismus**

                                              *Dysport only
                                              **Botox only

                                              (MIMS 107th edition, 2006)

Clinical improvement of spasticity occurs within 2 weeks after the injection. Spasticity-associated pain is usually the first symptoms that is rapidly relieved (1-2 days). Each treatment can be repeated, depending on the response which is expected to last approximately 16 weeks.

Under no circumstances should the injections be repeated after less than two months (interval of 3 months is preferred). Giving booster doses more frequently exposes the patient to the risk of developing tolerance to the treatment due to antibody formation.

Reported adverse reactions were paralysis of nearby muscle and muscle groups, allergic reactions (skin rashes, influenza-like symptoms) and painful or burning sensation due to injection. Other rare side effects observed among some treated pediatric patients with cerebral palsy were urinary incontinence, somnolence,asthenia and fatigue.

           

REQUIREMENTS

  1. Referrals are required from primary physicians or other specialty services. When necessary, clearances for procedures are obtained from primary or referring physicians.

  2. Procedures are done by appointment.

  3. Patients must be able to cooperate and follow directions during MAB and BoNT A injections. Inability to do so may interfere with conduct of the procedure.


PREPARATION

  1. Electroencephalography (EEG)

  • Clean scalp with thorough hair wash.

  • No gel, lotions or oils applied to hair and scalp.

  • Sleep deprivation (optional)

  • No fasting required before the test.

  1. Clinical Electromyography (NSS / EMG)

                     1. Nerve Conduction Studies (NSS)

                           1. Motor or Sensory Nerve Conduction Study (NSS) / Late Responses (F wave, H reflex, Blink reflex)

  • Full bath or adequate cleansing of area

  • No skin application of oils or lotions

  • Loose-fitting clothing allowing access to muscles and nerves to be tested. Hospital gowns are provided.

  • No need to fast before the test

                           2. Repetitive Nerve Stimulation (RNS)

  • Full bath or adequate cleansing of area

  • No skin application of oils or lotions

  • Loose-fitting clothing allowing access to muscles and nerves to be tested. Hospital gowns are provided.

  • No need to fast before the test

  • Temporary withholding of anticholinesterase medications prior procedure (preferable but requires clearance Mild sedation for pediatric patients (optional and requires clearance/endorsement from referring doctor)

                        CONTRAINDICATIONS FOR NSS

  • Patients with pacemaker, Swan-Ganz catheter

  • Wounds or infection at site to be tested

  • AV fistula at site to be tested


2. Monopolar Needle Electromyography

  • Full bath or adequate cleansing of area

  • No skin application of oils or lotions

  • Loose-fitting clothing allowing access to muscles

  • No need to fast before the test

  • Requires withholding of anti-coagulant medications at least 7 days prior procedure (requires clearance from referring doctor)

                            CONTRAINDICATIONS FOR NEEDLE EMG

    • Ongoing anticoagulant theraphy (e.g. aspirin, warfarin/coumadin, heparin, etc.)

    • Active bleeding and bleeding disorders (e.g. thrombocytopenia, hemophilia, etc.)

    • Wounds or infection at site(s) to be tested

    • Patients who are susceptible to developing infections (e.g. valvular heart disease, prosthetic valves, endocarditis)

    • Patients with pacemaker, Swan-Ganz catheter


    RELEASE OF RESULTS

    Official results are available within 24 hours.