Use of Botulinum Neurotoxin in Parkinson's Disease: A Critical Appraisal

Abstract

For well over 30 years, the botulinum neurotoxin (BoNT) has been used for a large number of indications, some of which however have not been licensed. Admittedly, approval varies in many countries and this permits a large spectrum for evaluation. Thus, BoNT is used for patients with Parkinson's disease (PD) and other Parkinson's syndromes (PS) in varying degrees of frequency. We have to distinguish between (1) indications that are either approved or (2) those not approved, (3) indications that might be a result of PS and (4) finally those which appear independent of PS. The most important indication for BoNT in PS patients is probably sialorrhea, for which approval has been granted in the majority of countries. Cervical dystonia is a frequent symptom in PS, with anterocollis as a specific entity. A further indication is blepharospasm in the different forms, especially the inhibition of eyelid opening in atypical PS. The use of BoNT in cases of camptocormia, the Pisa syndrome and neck rigidity is still a matter of debate. In dystonia of the extremities BoNT can be recommended, especially in dystonia of the feet. One well-known indication, for which however sufficient data are still lacking, involves treating tremor with BoNT. As to autonomic symptoms: Focal hyperhidrosis and detrusor hyperactivity can be mentioned, in this last case BoNT has already been approved. A number of further but rare indications such as freezing-of-gait, dyskinesia, and dysphagia will be discussed and evaluated.

Keywords: Parkinson’s disease; Pisa syndrome; blepharospasm; botulinum neurotoxin; camptocormia; dyskinesia; focal dystonia; non-motor symptoms; sialorrhea; torticollis; tremor.

Figure 1

Tarsal injection of the orbicularis oculi muscle [14].

Figure 2

Ultrasound image of the levator scapulae muscle. Clearly visible are the four parts of the muscle and the change in morphology compared to the norm (notably rounded).

Figure 3

(a) Injection into the parotid gland; (b) sonography of submandibular gland.

Figure 4

Sonography of the calf with the long toe flexor (M. flexor digitorum longus).