Background: Due to the Coronavirus disease 2019 (COVID-19) pandemic, non-emergency services like botulinum toxin A (BoNT) injections were temporarily discontinued. Objective: We aimed to create standard practices that optimize the management of patients needing BoNT injections while ensuring both patients' and healthcare professionals' safety. Methods: We evaluated published guidelines and best practices to determine their applicability for BoNT injection during this pandemic. We then devised a decision tree algorithm for use in our hospital. Results: A decision tree algorithm has been formulated based on patient evaluation and risk stratification, triaging, the urgency of the procedure, and proper precautions on personal protective wear as appropriate for the procedure’s risk stratification. Conclusion The algorithm is in place to ensure the safety of both the patient and healthcare professional. It can be adopted and revised by other centers to suit their clinic needs.
Movement Disorders ; COVID-19 ; Botulinum Toxins ; Therapeutics ; Pandemics

Targeted for relief of spasms, posturing, pain, impaired function and disfigurement, botulinum toxin type-A (BoNT-A) was injected in dystonias of X-linked dystonia-parkinsonism (XDP). From 1992-2012, focal/ multifocal dystonia combinations were injected in XDP at the following regions: Peri-ocular (21 cases), oromandibular (50 cases), ligual (35 cases), laryngeal (5 cases), cervical (56 cases), truncalaxil (24 cases) upper limbs (13 cases) and lower limbs (18 cases). Pain was frequently reported in 40/50 cases with oromandibular dystonia, 28/56 cases with cervical dystonia, 18/24 cases with truncal-axil dystonia and 16/31 cases with limb dystonia. Outcomes were assessment through the global dystonia rating scale (DRS) at week 4, VAS pain reduction at week 4, duration of BoNT-A effects and safety. Cranial, laryngeal and cervical dystonia showed substantial improvement (DRS median score of 3-4), whereas truncal-axil and limb dystonias showed moderate improvement (DRS median score of 2), following BoNT-A. Pain reduction ranged from 30-100% (VAS), for those dystonias that reported co-morbid pain. BoNT-A effects had a duration ranging from 8-20 weeks. Procedures were generally well tolerated, and the adverse events were most significant in laryngeal injections (voice breathiness, but was eventually followed by a strong voice). The other events were mouth dryness, dysphagia and weekness in oromandibular, cervical and limb dystonias, respectively. Therefore, BoNT-A is a safe and valuable therapeutic option for the dystonias of XDP, especially the disabling and painful dystonias. BoNT-A injection working protocols could be adopted in dystonia that adheres to cost minimization (e.g. lower dose end per selected muscles), yet achieving a substantial benefit, and a reduced adverse event profile. Futhermore, this present study allowed us to recommend a "high potency, low dillution" of BoNT-A in oromandibular, linual, laryngeal, cervical and distal limb dystonias. In dystonias of the abdominal, paraspinal and proximal limb muscles, the "low potency, high dilution" BoNT-A injection protocol could be adopted.

Human ; Botulinum Toxins, Type A ; Deglutition Disorders ; Dystonic Disorders ; Genetic Diseases, X-linked ; Lower Extremity ; Pain ; Spasm ; Torticollis ; Xerostomia

Amongst stroke patients, more than a third will develop spasticity, especially those that involve the paretic upper limbs. Despite establish intensive rehabilitaion programs in place, spasticity still affect a post-stroke patient's quality of life and create significant economic and caregiver burdens. The rationale for botulinum toxin type A (BoNT-A) use in spasticity is hinged on the toxin's ability to reduce muscle overactivity via a dual cholinergic blockede of extrafusal and intrafusal muscle. Efficacy and safety of BoNT-A in established post-stroke spasticity have been widely published, effectively establishing robustness of data and first line recommendation. Consensus guidelines and algorithms on the clinical use of BoNT-A for symptomatic upper limb spasticity are now also available. While BoNT-A has been universally shown to reduce muscle tone in spasticity, optimizing therapy requires judicious use of the toxin, while raising one's consciousness of adverse event, including muscle weakness, unwanted or desired in therapy. BoNT-A should not be administered alone in post-stroke spasticity, and its effects are best optimized in concert with a comprehensive neurorehabilitation program.

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INTRODUCTION: We present a case of Polyarteritis Nodosa along the neurocutaneous distribution of the peroneal nerve with characteristic clinical, electrophysiological and histopathological features. Prevalence was estimated to be in the range of 2.0-9.0/ million in the United States. In the Philippines, no reliable data on prevalence is available.

CLINICAL PRESENTATION: We report a case of a 34-year old male, seafarer, working aboard a bulk carrier ship, who presented right lower extremity pain associated with ascending numbness and erythematous patches on the affected area. Review of the family history of similar condition or detectable neuropathies were not found.

DIAGNOSTIC WORK-UP: Initial laboratory tests showed elevated ESR, a non-reactive Hepatitis Profile and negative LE panel. EMG was done and revealed mononeuritis involving the motor and sensory components of the right peroneal nerve. A right peroneal nerve and skin biopsy were done and histopathology showed panmural necrotizing vasculitis along documented blood vessels.

TREATMENT AND FOLLOW-UP: Treatment with corticosteroids was started. Over the months of treatment, patient was noted to have episodes of increased blood pressure. Anti-hypertensive medication was started with Nifedipine 30mg/tab once a day. Renal studies done were normal. Patient's condition improved with resolution of erythematous patches over the affected area, but symptoms of mononeuropathies persisted to some degree.

Arteritis ; Arteritis Nodosa ; Peroneal Nerve ; Vascular Diseases ; Vasculitis

This is a rare case of a Filipina with "Bellydancer's Dystonia". She presented with persistent involuntary, writing contractions of the abdominal wall, absent during sleep. Patient had a history of a fall two years prior to consult. MRI or the whole spine showed a T6 and T8 compression fracture. The potential role of trauma in dystonia was thus, enunciated. Patient was then treated with Botulinum toxin A into the hyperactive muscles of the abdominal wall. A month after the intervention there was a significant decrease in the abdominal contractions.

Human ; Botulinum Toxins, Type A ; Abdominal Wall ; Dystonia