Case report
Botulinum toxin type A combined with cervical spine manual therapy for masseteric hypertrophy in a patient with Alzheimer-type dementia: a case report

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Abstract

Objective

The purpose of this case study is to present the findings of combining botulinum toxin type A (BoNT-A) and cervical spine manual therapy to address masseter muscle spasticity in a patient with Alzheimer-type dementia.

Case Report

A 78-year-old woman with bilateral spasticity of the masseteric regions for 2 years was referred for physiotherapy. She had trismus and bruxism, and could neither close nor open her mouth normally; thus, she was unable to be fed orally in a normal manner.

Intervention and Outcome

The patient underwent combined treatment with BoNT-A and cervical spine manual therapy. A medical physician (neurologist) performed the BoNT-A injections into 2 points at the center of the lower third of the masseter muscle. A physical therapist performed manual therapy interventions targeted at the cervical spine. Manual therapy started the day after the BoNT-A injection and continued for 5 sessions per week for a total period of 2 weeks. Clinical outcomes were measured including spasticity (Modified Ashworth Scale), functionality (Barthel Index), and jaw opening. Outcomes were conducted at baseline, 2 weeks after treatment, and at 2-month follow-up session after finishing the treatment. The patient improved in all of the outcomes at the end of treatment, and these results were maintained during the follow-up. After treatment, the patient was able to feed with minimal caregiver dependency because oral feeding was possible.

Conclusion

The patient in this study responded positively to a combination of BoNT-A and manual therapy, resulting in decreased masseter muscles spasticity and improved trismus and bruxism.

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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