COMPARISON OF PHENOL BLOCK AND BOTULINUM TOXIN TYPE A IN THE TREATMENT OF SPASTIC FOOT AFTER STROKE: A RANDOMIZED, DOUBLE-BLIND TRIAL
Y.Kirazli, A.On, B.Kismali, R.Aksit, Ege University, Izmir, Turkey
Plantar flexor spasticity is the most commonly seen manifestation of central nervous system involvement with spasticity. This randomized, double-blind study is the first trial that was designed to find out whether Botulinum toxin A (BTX-A) and phenol relieves the signs of ankle plantar flexor and foot invertor spasticity after stroke and if any of them offer advantages and disadvantages over each other. Twenty patients who were included in this study were randomly assigned to receive a single treatment of 400M.U of BTX-A into the calf muscles or tibial nerve blockade with 3 cc of 5% phenol. A combination of subjective and objective measures were used to assess functional change at baseline, at week 2, 4, 8 and 12. The change in the Aschworth score at week 2 and 4 were significantly better in the BTX-A group but there was not a significant difference between two groups at week 8 and 12. The decrease in clonus duration which was detected by EMG was significant at all visits for both groups but the decrease in the BTX-A group was significantly better at weeks 2 and 4. The ambulation score, global assessment, brace tolerance score, active and passive range of motion became better with treatment in both groups. No significant adverse effects were observed in the BTX-A group whereas 50% of the patients in the phenol group observed painful dysesthesia in the phenol group. It is concluded that both BTX injections and phenol blockade are effective in plantar flexor spasticity after stroke.
PHENOL OR BOTULINUM TOXIN? HIGH TONE MANAGEMENT IN THE HEAD INJURY PATIENT
Dr Scott A R Hannan, Dr Gregory T Bowring (St George Hospital, Sydney, Australia)
Botulinum Toxin has severe limitations in its usage in paralysing large or multiple muscle groups in the head injured patient. High tone can severely interfere with independence training. Our aim was to improve independence by the selective motor point blocking of a spastic right hemiplegic patient.
The patient was a 37 year old male with a fight spastic hemiplegia 11 months after a severe closed head injury. His length of post traumatic amnesia was over 8 weeks. His Functional Independence Measure (FIM) score had plateaued at 88-90 (between weeks 30 - 44 weeks post injury) despite continuing physiotherapy. Both Phenol and Botox were used to achieve reduced tone. Phenol motor point blocks and Botox blocks were performed to his right arm and leg.
With the intervention of selective Phenol motor point blocks to his fight leg and arm his FIM score rose immediately to 100 (week 46) without any other intervention, and six weeks later his FIM score was 119 with conventional physiotherapy. Two years post injury the patient remains fully independent with a FIM score of 121 without the need for any further intervention.
Phenol remains a very useful tool in the management of high tone. Phenol was successful in causing a permanent reduction in tone where Botox was not, in this patient. This differential response poses significant questions as to the choice of blocking medium in specific clinical situations.