肉毒桿菌素自費治療之新

趨勢
By 高醫大　施邦英副教授
PHS:0966200377
Tell: 6558 E:payish@kmu.edu.tw
Fax:(07)3134998 Jan.2008

醫師公會演講
曾文溪口
的肉毒桿菌故事

→
黑面琵 鷺 冬天 的故 鄉
美麗與 哀愁 ～黑 面琵鷺
哀愁 : 黑面琵鷺的悲歌
Also from dead fish
半侧 面神經抽痙
美麗是女人 ? 的第二生命

2004/04/01
2004/01/30
Synki ne sia pos t f aci al
pal sy 騎摩拖車不會再撞到前面的
人
TORTICOLIS 假動作太多的難怪
被診斷為 PSYC HO SI S

2003/09/03

2002/09/03

2003/10/28
To rtic olis re si dual
hand tremor: Hard for
feeding

2003/09/05

2004/01/09

2004/03/08
東山晴來西山雨 ?
EPS O F An te Co ll is
after Pro metin e
-
-------------
-
-
-
----------------------------------------
垂頭喪氣 又更憂鬱
St atus a fter Bo tox
treatme nts 千萬別去開刀喔 !!
財明兄怎麼了 ?? 因為 IPD 吃藥
後腹脹再去吃腸胃科解賬藥後
就 ----
他也是嗎 ? 才稍一陣子不見就
@#!!
Br usism 磨牙
EPS c ause d b y Ga st er
Ga ste r EPS t eeth
Post anoxic (Chocking w Cyanosis)
Symptomatic Dystonia
Grinding teeth

2003/02/04 2004/04/12
2months aft 250u Dysport
米高梅獅吼 Tardive OMD post
Haidol use
Botox 治療後 hypophonia
swallowing difficulty
Pre / Post Botox treatment
 1. pre / 2. during / 3. after botox

2003/01/06

2002/10/30

1 已痊癒
申請未過
2004/01/20
Writ er,s c ramp

老外寫毛筆
Hand write aids for grips
Writ er’s c ramp:
( Dy stonia)

Sensory trik

悲慘的阿伯

建保單開太多
Writ er’s c ramp:
( Dy stonia

舉重若輕 + over flow phenomenon

Wri ter’ s tremor :
( A for m of dystoni a) 壹個悲哀
的故事

誰是病人誰是醫生 ?
Pa in ful le g & Mo vin g
toe
A k in d of t remor
EMG guid e in je ctio n
Ex t. Hall ucis l ongus 1 5
U
Fle xor h all ucis lo ngus
25 U .
 Mechanism of Action: 1

Heavy chain of
BOTOX molecule
binds to
presynaptic
membrane of
nerve terminal

Neurotoxin Pharmacology
 Mechanism of Action: 2

BOTOX light
chain is
internalized via
endocytosis

Neurotoxin Pharmacology
Inhibition of Acetylcholine

Kathryn Turton, John A. Chaddock and K. Ravi Acharya

TRENDS in Biochemical Sciences Vol.27 No.11 November 2002: 552
 Mechanism of Action: 3

BOTOX light
chain (protease
component) Inner
cleaves SNAP-25 surface of
and interferes cellular
with the fusion membrane
process required
for vesicular
docking

Neurotoxin Pharmacology
 Pharmacology
1 2 3

4 5
 Hypothesis
• Botulinum Toxin/A subcutaneous or IM
inhibits peripheral sensitization of
nociceptive fibers and indirectly reduces
central sensitization
Inhibiting release of peripheral
peptides in epidermis
Glutamate

Neurokinin A

Substance P

Axon
Terminal
CGRP

CGRP
Postsynaptic
Receptor

Reproduced with permission from: Silberstein SD, et al. Headache in Clinical Practice.
Isis Medical Media; 1998:41-55.
 Inhibition of Neuropeptide Release:
In-Vitro and In-Vivo Support
In-vitro
1981-2000: ~30 Type Inhibition
pre-clinical study Rat trigeminal ganglion cGRP
models
Rat Synaptosomes [3H]NE, [3H]DA SP, Glu

In-vivo Rabbit ocular tissue ACh & SP

Type Findings Hippocampal /Aplysia Glu
Decrease in neurogenic
Rat carragenan Rat cerebellar cells Ala, Glu
inflammation
Rat formalin- Decrease in subjective response to
behavioral pain Rat cortical astrocytes Glu

Rat formalin Inhibition of phase II not phase I

Xenopus Insulin
Chung- Intrathecal PC12 cells SP & evoked NE
-inhibited allodynia & Phase I
administration
Mouse synaptosomes Des.-induced Glu
Hot plate Increased tolerance to painful stimuli
Rat eDRG SP, Glu
Guinea Pig
L-glu
Synaptosomes
Selective Pain Relief Reports For BOTOX®
• Cervical dystonia
– Tsui 1985, Brin 1986, Relja 2004
• Migraine prophylaxis
– Binder et al (2000)
– 2005 (Allergan Phase 2) abstracts and publications
• Spasticity
– CF O’Brien, Clin J Pain 18(6):S182, 2002
– Barwood et al, Dev Med Child Neurol 42(2):116, 2000
• Post herpetic neuralgia
– Case report (A. Kagen, AJPM 12(2), 2002)
– AGN DBPC trial (in progress)
• Myofascial Pain
– AM Lang. Am J Pain Manage 10(3):108, 2000
 What About Headache and Bladder?

Pain Fiber Involvement

Vatican Museum, 2003

 Hypothesis for Botulinum Toxin Type A
Antinociceptive Mechanism
• Local administration and local effect
– No central transport of active material
• Biochemical mechanism consistent
– Requires an exocytosis event
• Pain mechanism involves a local release
of neurotransmitter
• BoNT/A inhibits release of local pain
transmitter
 Reduction of Neuromuscular
Neurotransmission and
Neck Pain in Cervical Dystonia
Biochemical Neurotransmitter Inhibited Clinical Benefit

ACh in Muscle
motor nerves Relaxation
Cleavage of
SNAP25

Neuropeptides
(SP, CGRP, etc)
Reduction
in Nociceptive nerves of Neck Pain
 Reduction of Neurotransmission
and Pain Perception

Biochemical Neurotransmitter Inhibited Clinical Benefit

ACh in Muscle
motor nerves Relaxation

Cleavage of
SNAP25

Neuropeptides
(SP, CGRP, etc)
Reduction
in Nociceptive nerves of Pain
Peripheral
 Pain Pathway

http://www.sfn.org/content/Publications/BrainBriefings/pain.html
 Nociceptive (Pain) Fiber Types
Acute Pain
• A fiber
– “First Pain” / cutaneous pricking
pain
– Relatively rapid conduction
• 6 - 30 m/sec
• Myelinated
– High spatial resolution
– Mechanical & heat nociceptors
– Easily tolerated, associated with http://www.library.ucla.edu/libraries/bi
omed/his/painexhibit/boyfire.htm
reflex withdrawal
– Generally contains excitatory amino
acids or ATP neurotransmitters
 Nociceptive (Pain) Fiber Types
Burning Pain
• C fiber
– “Second Pain” / burning pain
– Slow conduction
• 1 – 2.5 m/sec
• Unmyelinated
– Significant delay (~ 1s) http://www.library.ucla.edu/lib
raries/biomed/his/painexhibit/
boyfire.htm
– Polymodal
– Poor localization
– Poor tolerance
– Generally contains
neuropeptides
BoNT/A Targets: Sensory (Pain)

Fundamental Neuroscience 2nd ed

 Peripheral Sensitization Leads to
Central Sensitization

Peripheral Release of Glutamate

Stimulation and Peptides in CNS

CNS
Antidromic Activation

Release of Glutamate and Peptides Additional Activation

Central
Peripheral Sensitization Sensitization
TRPV1 expression
Increased afferent signals
 Botulinum Toxin Prevents Peripheral
Sensitization (direct) and Central
Sensitization (indirect)
Peripheral Release of Glutamate
Stimulation and Peptides in TNC

Botulinum
toxin/A
CNS

Antidromic Activation

Prevents:
• Release of Glutamate,
CGRP, SP
• Peripheral Sensitization
• Formalin P-II pain
• (TRPV1 expression)
X
Indirectly Prevents:
• Central Sensitization
Additional Activation • Inhibits c-Fos
• Receptor field expansion
• Allodynia

Clinical relevance of these preclinical results remain to be established

 Botulinum Toxin Pain Model Summary *
• Subcutaneous pretreatment
• Acute (nociceptive) pain – No efficacy
– Heat
– Phase I formalin
• Chronic pain – efficacy is model dependent
– Formalin – phase 2 pain relieved, fos expression at
dorsal horn prevented
– Capsaicin induced thermal hyperalgesia, tactile
allodynia, receptor field expansion prevented
– Nerve ligation (Chung) – no effect
– Diabetic rat – reversal of established tactile allodynia

* Studies conducted at Allergan Inc. with BOTOX®

Assessing Botulinum Mechanism of Action
• Behavioral testing in the rat models of pain and
motor function
– Inflammatory pain (formalin)
– Neuropathic pain (Chung)
– Thermal escape
– Motor function (Rotarod)
• Formalin pain model
– assessment of pain in phase I and phase II
– capsaicin-induced thermal hyperalgesia
– peripheral glutamate release
– firing of WDRs
– c-fos expression in dorsal horn
 BoNT/A Pain Relief Summary
• Not a local anesthetic
– Acute pain (heat, mechanical, chemical) is NOT
blocked
• Chronic pain relief
– Peripheral nociceptive nerve sensitization (via local
neuropeptide release inhibition) based pain
– Central sensitization (indirect) reduced over time
• Migraine prophylaxis hypothesis
– Reduce peripheral sensitization in subpopulation
– MOA in progress
 Trigeminal Neuralgia
(Silberstein et al. 2005, Neurology)

• 13 patiens
• Injection sites: patients’ descriptions
and anatomically outlined pain sites
• Subdermal injection
• Injection dose: 3.22 units/cm2
– V1: 3.31 units/cm2
– V2: 3.17 units/cm2
– V3: 3.19 units/cm2
 Trigeminal Neuralgia
(Silberstein et al. 2005, Neurology)

• Improvement: Within 10 Days

• Duration: At least lasting for 60 days
• Preventive medications: reduced by
more than 50% (Some completely
stopped, or some taking multiple
medication converted to monotherapy
• No adverse interactions
Burning Pain of Spinal Cord Origin
(Jabbari et al., 2002)

• Case reports: 2 patients

• Spinal cord injury
• Developed hyperesthesia, allodynia and
spontaneous burning pain in a segmental
distribution
• Multiple subcutaneous injections (16-20 sites)
of 5U (total dose, approximately 100U)
• Pain relief at Botox injection site, repeat
injection every 2-3 month up to 3 years
 Post-herpetic Neuralgia
(Freund & Schwartz, 2001)
• 7 patients, trigeminal, thoracic and
lumbar presentations of neuralgia
• Subcutaneous injection
• 5U per 0.1 ml of normal saline for every
9 cm2 of painful skin
• Total dose: not exceeded 200U
• Evaluation: VAS, algometric test
• Patients with trigeminal PHN had a
better outcome
Intradermal BOTOX treats Neuropathic Pain
(John Claude Krusz, 2005)

• 16 patients (CRPS pain, diabetic neuropathy,

carpal tunnel pain, trigeminal neuralgia, TMJ
pain, scar pain)
• Intradermal injection
• Dose: 20U – 100U
• Evaluation: VAS or NRS, monthly follow-up
• 14/16 Pain reduction, 78% pain reduction by
MRS, Mean duration: 15.4 weeks
 Emerging evidence for
BOTOX: an alternative to
oral prophylactic
headache medications
Injection Sites/Dose for Migraine

Preparation of 2.5 cc per 100 U vials yields 4.0 U per 0.1 cc

Fixed-site approach for migraine:
initial dosing
• 2 units x 2-4 sites: each frontalis
• 2-4 units: each corrugator
• 4 units: procerus
• 4-8 units x 2-4 sites: each temporalis
• 4 units: each occipitalis
• Total: 30 - 100 units

Preparation of 2.5 cc per 100 U vials yields 4.0 U per 0.1 cc

 Bilateral Injection Sites:
Glabellar and Frontal Regions
Frontalis
muscle

X X X Bilateral
Procerus
muscle
Injections
X X

V1 distribution
Corrugator
muscle

Adapted with permission from: Netter FH. Atlas of Human Anatomy. Icon Learning Systems; Teterboro, NJ. 1997
 Injection Site: Temporalis Muscle
Temporalis

X
X X
X

Adapted with permission from: Netter FH. Atlas of Human Anatomy. Icon Learning Systems; Teterboro, NJ. 1997
 Injection Site: Occipitalis Muscle

C2
Distribution
X X

Adapted with permission from: Netter FH. Atlas of Human Anatomy. Icon Learning Systems; Teterboro, NJ. 1997.
Muscles of the jaw and face
BOTOX doses for OMD (A Blitzer, USA)
dose (Units) range(U)

• masseter 24.5 +/- 17.7 2-100

• temporalis 18.5 +/- 11.9 2-75
• int. pterygoid 16.3 +/- 8.1 5-40
• ext. pterygoid 15.9 +/- 8.7 2.5-60
• ant. digastric 9.8 +/- 4.4 3.75- 30
 Follow-the-pain approach for
Tension Headache
• Variable sites and doses depend on
history and examination
• Doses per muscle are much less than
in standard cervical dystonia
• Muscles injected include: Trapezius,
Splenius Capitus, Semispinalis capitus,
Occipitalis, Temporalis, and Frontalis
• Variable dose dependent on number of
muscles
 Injection Site: Suboccipital Region

Trapezius
muscle Splenius capitis
X muscle
X

Adapted with permission from: Netter FH. Atlas of Human Anatomy. Icon Learning Systems; Teterboro, NJ. 199
 Potential Follow the Pain sites

Splenius capitis, 10 units

Sternocleidomastoid, 10 units

Splenius cervicis, 10 units

Levator scapulae, 10 units

Trapezius, 10- 20 units
Typical appearance
of
patients with daily
headache:
forward shift

Is this dystonia,
“poor posture” or a
contributing factor
in creating the
“pain” perceived by
these patients ???
Travell and Simons, 1999
Co mmon perso n sta rt
li ke t his
No rmal lo rdotic
curva ture
Loss o f curva ture,
in itia l change
Ideal plumb line passes through:
Tragus of ear
Upper medial trapezius
Lumbar vertebral bodies
Slightly posterior to center of hip
joint
Slightly anterior to axis of knee joint
Through calcaneocuboid joint
 Potential role of BOTOX in
chronic headache patient
• Treat those with migraine using the standard
injections in V1 and C2 dermatomal regions
• Reduce pain in the areas of muscle
tenderness in the head, neck and shoulder
with injections into these sites
• Help facilitate correction of abnormal posture
by relaxing specific muscles presumed to be
causative and then enabling patients to
undergo appropriate strengthening/stretching
exercises to restore normal posture and
mechanical load
 Cervical Dystonia
Involuntary contraction of neck and shoulder
muscles cause abnormal posture of head
and/or shoulder; cause abnormal “dexterity”
of head movements; cause limitation in range
of motion
 Cervical Dystonia

Ipsilateral
splenius
capitis

Contralateral
sternocleidomastoid
 Laterocollis

Longissimus (mid &

deep layer ventral
to splenius
capitis)

Sternocleidomastoid Splenius
capitis
Ipsilateral
scalene
complex
 Antecollis

Scalene

Sternocleidomastoid
 Retrocollis

Splenius
capitis
Semispinalis
Longissimus
capitis
BOTOX® Dosing for Cervical Dystonia

Splenius capitis, 50-100 U

Sternocleidomastoid, 15-30 U
Levator scapulae, 15- 30 U

Scalene complex, 10-25 U

Trapezius, 25-50 U

Range of doses
indicative of individual
patient characteristics:
severity, number of other
muscles injected, risk for
side effects
 SUMMARY: Clinical uses for
Botulinum in Headache
• Refractory headache – failed multiple
prophylactic treatments
• Poorly compliant or inability to use
oral prophylactic treatment
• Tender spastic cervical muscles
contributing to headaches
• Detoxification from medication
overuse headache
Use of Botulinum for muscular
pain
 Botulinum Toxin Type A for Myofascial Pain
Study
Summary
Wheeler, 1998
33 pts; 75% of patients improved after 2nd
injection

Lang, 2000 OL retrospective; 72 pts; 74/95 CT and 20/95 LS

60% good to excellent on 8 week evaluation

Foster, 2001 DBPC for LBP; 200U in L1 to S2; VAS improved > 50%
in 60% vs 13% pts; Oswestry 67% vs 19% at 8 weeks
Freund, 2000 DBPC for whiplash cervical pain; improved VAS, ROM

Porta, 2000 DBPC for comparison with methylprednisolone; VAS

improved when BOTOX combined with physiotherapy

Wissel, 2000 OL prospective; 60 pts with spasticity; 41/60 spasms;

90% pain relief while only 30% functional gain
 Porta, 2000
Study Design

• 23 piriformis pain patients

enrolled:
– BOTOX 100 U/2 mL + 2 mL
0.5% bupivacaine (13)
– Methylprednisolone 80 mg +

2 mL 0.5% bupivacaine (10)

 Porta, 2000
Study Design

• 7 iliopsoas pain patients

enrolled:
– BOTOX 150 U/3 mL + 2 mL
0.5% bupivacaine (3)
– Methylprednisolone 80 mg +
3 mL 0.5% bupivacaine (4)
姿勢的重要 These bo th are
IP D pati ents 一個左傾一個右
斜

2003/08/14
2005/0 7/2 8
2005/0 9/2 6
2005/1 2/0 9
2007/0 8/1 7 痛到不行終於要
打
2007/0 8/3 0 2 we eks
after botulin um to xin
in jection
2004/10/14 蘋果日報
 Porta, 2000
Study Design
• 10 scalenus anterior
pain patients enrolled:
– BOTOX 80 U/2 mL + 2 mL
0.5% bupivacaine (4)
– Methylprednisolone 80 mg
+ 2 mL 0.5% bupivacaine
(6)
 Myofascial Pain and Trigger Points

• Trigger points are the hallmark for diagnosis

• Localized, nodular masses in taut muscular bands
• Twitch response on mechanical stimulation
• Referred pain pattern on mechanical stimulation
• There is muscle weakness without atrophy
• Restricted range of motion
• Pathophysiology is still unknown
What are the Commonly Injected Muscles ?

• Anterior scalene
• Pectoralis major
• Supra and infraspinatus
• Trapezius
• Semispinalis
• Splenius capitis and splenius cervicis
• Rhomboid
• Levator scapulae
• Paravertebrals in thoracic and lumbar spine
• Piriformis
 Botulinum Toxin A Treatment
• Technique: not a trigger point injection
– Must identify all muscles responsible for pain symptoms, altered posture,
and altered bio-mechanical forces (loading) at joints
– Determine number of injections per muscle
– Determine dilution/ diluent of Botulinum toxin
– Follow-up injection at least 12-16 weeks not 1-2-3 weeks

• Dose: Not everyone gets the same

– Severity of symptoms
– Muscle(s) responsible for condition: size, relative importance
– Overall number of muscles to be injected (limit of total dose per patient)
– Response to prior treatment, if previously treated

• Response: different from trigger point injection

– Assess for clinical effects at 4-8 weeks not 1-3 days
 Measuring Treatment Results/ Benefit

• Reduced pain and improved quality of life

• Decreased functional disability
• Reduction in medication use
• Reduction or elimination of oral medication-
induced side effects (lethargy, memory loss,
weight gain, depression, constipation, dry mouth)
• Reduction in demand for medical services
(physician visits, procedures such as frequent
trigger point injections, physiotherapy sessions)
A c ase o f h eadache
wit h blephalo sp asm
total 30 U.
7 unit

3
2

4 3

8 unit
No rmal lo rdotic
curva ture
Loss o f curva ture,
in itia l change
IPD with extreme stooping
Unable to walk at all !!
Kyphosi s with 5 on 6
spondyl ol ithesi s Grade 1
顏回曲肱為枕 ?!
He is a s uccessf ul
pedi atri ci an
over hundre ds o f
pati ents , he had IPD

Poor guy, you don’ t

have to make so much
money!!
Abnormality of Posture
Assess patient from lateral view for forward shift

Target muscles:
Medial scalene
Pectoralis minor
0
.5 1 1.5
Ideal plumb line passes through:
Tragus of ear
Upper medial trapezius ------
Lumbar vertebral bodies
Slightly posterior to center of hip
joint
Slightly anterior to axis of knee
joint
Through calcaneocuboid joint

Even she is not perfectly aligned !

Cervi cal Myof asci al Pain and
Headache Joanne Bor g-Stei n
MD
Cur rent Pa in an d H ea dac he Rep or ts 200 2, 6: 32 4-3 30
 Botulinum toxin type A appears to be emerging
as a promising but expensive new agent used
to treat chronic myofascial pain syndromes. In
two recent studies of myofascial pain ,
botulinum toxin injections provided greater
relief of pain symptoms compared with
placebo. In another study, Wheeler et al. was
unable to demonstrate a statistically significant
difference compared with placebo. There may
be a peripheral and central mechanism that
explains the apparent efficacy of botulinum
toxin in the treatment of chronic
myofascial pain .
Bot ulinum Toxi n A Improved Bur ni ng P ain a nd
Allodynia in T wo P atient s With Spi nal Cord
Pat ho lo gy I .
Pain Medicine Volume 4 Iss ue 2  Pag e 206   - J une

2003 doi:10.1046/ j.1526-4637.2003.03013.x

 We administered a total of 80 units (100

units/ mL) of botulinum toxin A
subcutaneously at 16 sites, eight in the
right lower neck and eight in the right
shoulder region. Ten days later, she
reported significant reductions in skin
sensitivity and spontaneous burning pain.
The effect lasted for approximately 3
months.
Pain and Allo dynia in s pin al cord
le sion II

 In conclusion, we have shown satisfactory

analgesic effects in two patients with central
pain following subcutaneous administration of
botulinum toxin A. This observation warrants
conducting a controlled study with this agent
for central pain. If effective, this approach has
significant advantages over the majority of
current treatment strategies in that it renders
no systemic side effects (at current doses) or
addictive potential and is minimally invasive.
Botul in um Toxi n A reduces
neurogeni c f lare but has al most
no ef fe ct on pai n and
hyperal gesia in human ski n .
 However, hyperalgesia to pin-prick and
allodynia after electrical stimulation were
unchanged.In conclusion our results indicate
that peripheral neuropeptide release is
attenuated by BoNT/A. In contrast, the
analgesic effect of BoNT/A was very limited.
Therefore we assume that other than
neuropeptide mechanisms must be important
for BoNT/A induced pain relief in clinical pain
syndromes.
Bot ul inum neurotoxi n f or the t reatm ent of
mi grai ne and other pri mar y headache
di sor ders: f rom bench to bedsi de.

 Recent clinical findings suggest that botulinum

toxin type A may inhibit pain associated with
migraine and other types of headache.
However, the mechanism by which this toxin
inhibits pain is not fully understood and is
under investigation. Research findings suggest
that botulinum toxin type A inhibits the release
of neurotransmitters from nociceptive nerve
terminals and, in this way, may possess an
analgesic effect. Headache. 2003 Jul-Aug;43 Suppl 1:S25-33
Botuli num To xin Types A and B
Effe ctive F or C ert ain Ty pes o f
He adache
Botuli num To xin A Eff ectiv e In Op en-
Label Stu dy
 Of the 334 patients who received one to eight
treatments, the mean improvement in score was 3.6
points. Mean score improvements were similar for each
headache type (chronic daily headache, 3.5; migraine,
3.8; episodic tension-type headache, 3.5). Patients
who received two treatments improved more than
those administered one (n=278; P <0.05), and those
who received three improved more than those who
received two (n=164; P <0.05). Overall, 91% of
patients had some improvement. Adverse events were
limited to minor, transient injection-site pain
Botuli num To xin Type A Not
Effe ctive F or C hro nic T ensio n-Ty pe
He adache

 "We could not prove botulinum toxin to

be more effective than placebo in
patients with chronic tension-type
headache," Dr. de Bruijn commented.
"These results do not favor the
hypothesis that muscle contraction plays
a key role in chronic tension-type
headache. Further studies are needed."
Pro misin g R esults Wit h Bo tu lin um
Toxin Type B

 "This study shows that Myobloc is effective for

the treatment of chronic daily headaches, and
patients can expect six to eight weeks of
improvement," Dr. Gwynn concluded. He
added that while the number of patients
evaluated thus far is small and not sufficient to
demonstrate a significant difference between
placebo and botulinum toxin, a much greater
percentage of patients were responders in the
botulinum toxin treatment group than in the
placebo group.
Headache: The Journal of
Head and Face Pain

 Volume 44 Issue 1 Page 35 - January 2004

doi:10.1111/j.1526-
4610.2004.04007.x Research Submissions
Regulation of Calcitonin Gene-Related
Peptide Secretion From Trigeminal Nerve
Cells by Botulinum Toxin Type A:
Implications for Migraine TherapyPaul L.
Durham, PhD; Ryan Cady; Roger Cady, MD
Where to be in je cted ?
In Sp ast icity
What to b e t re ated ?
Treatment of Spast ici ty
aft er Repeated st roke
(17Yrs. )
想像香港腳的味道 !!
9 Da ys a ft. Dysp ort
9 Da ys o nly !! Sk in
st art healin g ! !
Po st St roke At hetosis

2003/07/03
2004/02/20
3 we eks aft er i nje ctio n
最大問題在沒力走路

2004/03/11
Ro le o f st reach refle x
Re curr ent st roke wit h
right h emip aresis
Procedure Evaluati on and
Desi gn and Inj ect ion
extended knee & gras ping
foot
Re su lt : Rt . Should er
Pa in su bsid ed
Rt hemi faci al s psm+
Stri atal toe+ spasm odi c
dysphoni a post Stroke

2004/01/09 2004/03/26 three wks after injection

治療失敗時
During World War II Rapid Progress
Dyst onic sp asm
No n-dysto nic musc le
contr actio n
 還在吃！！
Not a good candidate
朱蔡寶貝 basal ganglia (parasellar
tumor with extension)/Tardive
dyskinesia
朱蔡寶貝
After Pk-Mertz & Keppra
Drugs induce TD
-----------------------------------------------------------------------------------------------
中藥也有問題 ?

保肝丸？

我家的狗不會咬人！
咦？今日那ㄝ安ㄋㄟ？
泰國五塔散
 與醫生互動之重要 , “History” 要嚴刑逼供


血壓：太 低？　　　 　　　　　 保肝丸，保腎 丸，紅軍 固氣丸

便秘：安 腦丸，五塔 散 沒力嗎 ？請吃 大補丸
 頻尿：攝 護腺
 食慾不佳 ： Primperan, Prometin.

失眠：頭 暈目眩

幻覺：安 神藥

噁心，嘔 吐 : Primperan. Dogmatyl
 心律不整 : Cordaron
 高血壓 : Capoten

胃潰瘍 : Cimetidine

肺結核 : INAH

頭暈，偏 頭痛，中風 後 : Sibelium
 憂鬱 : SSRI ，ＳＮＲ Ｉ
南部某市某安診所的停經藥聽說
是校友 ?
000000000000
 His Wif e !!

2006/01/19 2006/02/20
朱 OO 貝 basal ganglia (parasellar
tumor with extension)/Tardive
dyskinesia
朱 OO 貝
 No botulinum toxin, No operation
Not all medical therapy are futile !
Conservative treatment should tried
first
不適用之 contracture
R1=R2
Pontine myelinosis
Re peated-St roke:
Clo nus, Ma ss re fl ex, Pr olo nged
vegeta tive
Contracture: not fit for botolinum
toxin
Hyperhydo sis o r 狐臭 Stop
apocri ne or sw eati ng
secreti on throu gh Ach
nerve endi ng
---------------------------------------------------
-
-
-
多汗症
Sia lo rrh ea a case of
IPD

2004/02/05 2004/04/08
 si alorh ea

2004/02/05 一大包衛生紙 2004/04/08 一小包就夠

 Tardive Myoclonus ? (of hand)
Dystonia (Retrocollis) Oculogyric
crisis

Oculogyric appearance withswallowing improvement by L-dopa

When hostility aggravated.
Oculogyric subside,hand wait to be
resolved

2005/08/30
Tardive belching/ resperatory
F3-C3

T3-O1

50 µV
*P3-T5 1 sec

*Fp1-C3

F4-C3

T5-C3

*P4-T6

*Fp2-C3
 F3-C3
10uV/mm
T3-O1

100uV/mm *P3-T5

*Fp1-C3

F4-C3
Maseter
T5-C3
S_C_M

*P4-T6
PectoralisMajor

*Fp2-C3
Rectus Abdominal
MRI
F 3 - F 4

T 3 - F 4

T 4 - P 4

P 3 - P 4

P z - C 3

C 4 - C 3

O 1 - O z

O 2 - O z
1 week latter after 100u Botox
Thank y ou, for y our
attent ion !
 Thank for your attention