Case reportBotulinum toxin type A combined with cervical spine manual therapy for masseteric hypertrophy in a patient with Alzheimer-type dementia: a case report
Introduction
Bruxism is often noted in patients with altered states of consciousness, but its occurrence after brain injury is unknown.1 Resolution of bruxism may be associated with improvement in the level of consciousness.2 It seems that there is an intimate functional relationship between the temporomandibular joint and the cervical spine, as suggested by their anatomical and biomechanical interrelationships, although current evidence is conflicting.3 Eriksson et al4 reported that mouth opening is accompanied by head-neck extension and mouth closing is accompanied by head-neck flexion, with a precise coordination between jaw-neck movements dependent on the speed of the movement.5
Botulinum toxin type A (BoNT-A) is widely used for treating spasticity and other forms of muscle overactivity.6 Botulinum toxin type A is derived from Clostridium botulinum; and when injected into a spastic muscle, it inhibits acetylcholine release, causing a blockade of the neuromuscular patches without affecting the antagonist muscles.7 Botulinum toxin type A has been used in the past with mild improvements in conjunction with physiotherapeutic approaches.8, 9 However, to our knowledge, publication of this combination with manual therapy has not been reported. There are only a few randomized controlled studies and some systematic reviews10, 11 reporting a favorable effect of BoNT-A on craniofacial and neck pain as well as bruxism. Nevertheless, previously published studies have not investigated the effect of BoNT-A on neck pain caused by bruxism because they only assessed jaw pain due to bruxism or neck pain due to cervical dystonia.12
The purpose of this case study is to present the findings from combining BoNT-A and cervical spine manual therapy for a patient with masseter muscle spasticity and Alzheimer dementia disorder.
Section snippets
Case report
A 78-year-old woman (weight, 52 kg; height, 154 cm) with Alzheimer-type dementia since the age of 65 years and a bilateral spasticity of the masseteric regions that persisted for 2 years presented for care. The patient was referred to the Department of Physical Therapy, Residenza Sanitaria Assistenziale “A. Maritano,” Sangano, Italy, for trismus and bruxism. She could neither close nor open her mouth normally. Clinical examination revealed a mouth opening of 0 mm. The patient received oral tube
Discussion
This case report showed that the combination of BoNT-A injection and manual therapy was able to improve severe masseteric hypertrophy in a patient with dementia. The subject had experienced her symptoms for 2 years before beginning the treatment. Before treatment, her spasticity and mouth opening had failed to respond to various medical therapies and dental procedures, providing further evidence of the severity of her condition. In the current study, 2 weeks after the application of BoNT-A in
Limitations
The current case report demonstrates only a single case; and, therefore, the management protocol cannot be generalized to all cases of severe bruxism. A cause-and-effect relationship cannot be inferred through one case report. Because of this and also the lack of a placebo intervention, further studies are necessary to establish whether this patient would have improved without treatment; however, this is unlikely because of the severity and the duration of her symptoms.
Perhaps the biggest
Conclusion
The current case report showed that combined manual therapy and BoNT-A injection decreased masseter muscles spasticity and improved trismus and bruxism in a patient with Alzheimer dementia, enabling her to be fed normally.
Funding sources and potential conflicts of interest
No funding sources or conflicts of interest were reported for this study.
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2013, Journal of Chiropractic MedicineCitation Excerpt :The sacral pressure sore has been improved after spasticity reduction and better positioning, and it healed completely a few months later. Various treatment modalities have been reported to be useful for severe spasticity and related disorders, but there is no consensus on the best therapeutic option.29,30 Ryuji Kaji et al8 found that BoNT-A significantly reduced spasticity in the lower limb muscles in a study in which 120 patients with lower limb spasticity were randomized to a single treatment with 300 U BoNT-A or placebo.