Benign masseter hypertrophy causes swelling at the angulus mandibulae and may be associated with masticatory myofascial pain due to hyperfunction from bruxism. The aim of this research was to use the systematic review process to investigate the true or reliable scientific evidence contained in four major databases pertaining to the efficacy and safety of intra-muscular injections of botulinum toxin A (BTX-A) for the treatment of masticatory myofascial pain and benign masseter hypertrophy associated with bruxism, compared with placebo or other traditional treatments prescribed for bruxism such as occlusal splints, pharmacotherapy, or lifestyle modification. Using the PICO format, a research question was formulated, MeSH terms were derived, and an electronic literature search was conducted in PubMed, Embase, Web of Science, and Cochrane. This sequence was followed by a screening and selection of articles by two independent reviewers according to defined inclusion and exclusion criteria. The selected studies were then evaluated and assessed based on study quality and identification of biases, and the results were summarized and reported. This review highlighted the lack of well-designed, randomized controlled trials to evaluate the efficacy and safety of botulinum toxin A for reducing the size/volume of the masseter muscles and for improving masticatory myofascial pain in patients who present with bruxism. Thus, the results were inconclusive.

Thesis (MScPhysio (Physiotherapy))--Stellenbosch University, 2008. / Cerebral palsy (CP) is a common neurological condition seen in children which results in childhood disability. Damage to the developing brain results in abnormal muscle tone and decreased force generation, which leads to loss of independent function. Previous studies investigating interventions targeting the typical equinus gait pattern seen in spastic CP have reported inconclusive and widespread outcomes. Objectives The objectives of the study were to determine (1) the effect of functional electrical stimulation (FES) after a single botulinum toxin injection into the triceps surae muscle as a functional orthosis on various gait parameters and economy of movement; (2) caregivers’ perceptions of the impact of the intervention on their child’s function and participation, and (3) optimal timing intervals for introducing FES after a botulinum toxin injection. Method Single-subject research with a multiple baseline approach was conducted on five ambulant subjects (average age 5.1 years, SD=1.4) in the Cape Metropole with a dynamic equinus gait due to hemiplegic CP. Two-dimensional gait analysis, isometric dynamometry, Energy Expenditure Index (EEI), and a caregiver questionnaire were used to gather data on walking speed, ankle angles at initial contact of gait, isometric plantarand dorsiflexior muscle strength, energy expenditure during gait, as well as caregiver perception on participation changes. Statistical analysis was conducted by means of ANOVA tests and graphic data illustrations. Results A statistically significant pre- to post intervention (FES after botulinum toxin) change was found for plantarflexor muscle strength. This effect was partially maintained over the withdrawal phase. Caregivers felt the intervention to have a positive influence on their children’s walking speeds, as well as on age-appropriate function and participation. Selfselected walking speed, dorsiflexor muscle strength, and ankle angles at initial contact did not change significantly. A 32-day interval between between botulinum toxin and the FES programme resulted in the most pronounced improvements in terms of walking speed, EEI scores, and plantarflexor muscle strength. Conclusion FES to the lower limb, 32 days after botulinum toxin into the triceps surae, applied for 30 minutes per day, five times a week over a total of four weeks, seemed to improve selected gait parameters as well as caregiver perception of impact on function and activities of daily living. However, further research is needed.

Objetivo:Investigar "in vivo" la supervivencia de las motoneuronas del núcleo del VI par craneal tras la inyección intramuscular de toxina botulínica tipo A (TxBA) y doxorrubicina (DXR). Método: En el músculo recto lateral de las ratas se inyectó fluorogold(FG) y se determinó el número de motoneuronas del núcleo del VI par craneal. Tras el marcaje con FG de dichas motoneuronas se realizó la inyección intramuscular de diferentes dosis de TxBA y de DXR. Resultados: El número de motoneuronas marcadas con FG en los animales que fueron inyectados con TxBA fue similar al encontrado en los animales control. Sin embargo, era menor el número de motoneuronas marcadas en los animales inyectados con DXR. Conclusiones: La inyección intramuscular de TxBA no induce muerte de motoneuronas. La inyección intramuscular de DXR induce una muerte neuronal dosis dependiente en las motoneuronas del núcleo del VI par craneal. / Purpose: To investigate "in vivo" the survival of abducens motoneurons (AMNs) after a single intramuscular injection of the botulinum toxin A (BTxA) or doxorubicin (DXR). Methods: In rats, the AMNs were labeled with fluorogold (FG), which was applied intramuscularly in the lateral rectus muscle. The number of labeled neurons were determined in control animals; in animals that had received intramuscular injections of BTxA; and in rats that had received DXR. Result: The numbers of FG-labeled neurons in the animals that had been injected with BTxA were similar to those found in control animals. However, there were fewer FG-labeled neurons in the animals injected with DXR. Conclusion: The intramuscular injection of BTxA does not induce significant motoneuron death. Doxorubicin injected intramuscularly causes variable amounts of motoneuron death that is related to the amount of DXR injected.

This thesis provides a capabilities-based approach to assessing the bioterrorism threat from non-state actors. Through comparative case study, prior bioterrorism attacks are analyzed to assess capability in the three areas necessary to complete a biological weapons attack: obtaining or isolating a pathogen, weaponizing the agent, and employing or disseminating the weapon. The three cases are the Rajneeshee cult in 1984, the Aum Shinrikyo cult in the early 1990's, and the United States Postal System anthrax attacks of 2001. In contrast to current wisdom that employing biological weapons is too difficult for non-state actors, this thesis reveals a broad spectrum of capability in all studies in the areas necessary to culminate an attack. Applications of these findings must be used to assess risk generally rather than against specific groups because capability is deemed to be exptremely difficult to track. The these finds that a significant threat exists but not large enough to be over-hyped above other national security concerns. In light of this, recommendations are provided for U.S. biodefense policy emphasis in the areas of the nonproliferation regime, attribution capabilities, and defending against the changing nature of future attacks with a particular emphasis on the public health system.

Introdução: A Distonia Cervical (DC) é o tipo mais comum de distonia focal primária e atualmente o tratamento padrão ouro consiste na aplicação periódica de toxina botulínica nos músculos afetados. Considerando que cada formulação de toxina botulínica é farmacologicamente distinta, nesta pesquisa foi realizada a comparação de dois tipos de toxina botulínica tipo A (TBA) disponíveis no Brasil: Dysport® (Abobotulinumtoxin A) e Prosigne® (Lanzhou botulinum toxin type A). Metodologia: Foi conduzido um estudo prospectivo, randomizado e duplo cego com dois braços em uso de substância ativa, Dysport® e Prosigne®. Foram recrutados 34 pacientes do ambulatório de toxina botulínica (ATXB) do Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (HCFMRP) de maio de 2010 a junho de 2011, foram incluídos apenas pacientes com diagnóstico de distonia cervical idiopática. Cada indivíduo foi acompanhado por um período de 13 meses, sendo que nesse período foram submetidos a 5 aplicações de TBA com intervalo de 3 meses entre cada procedimento. Como instrumento para aferir a melhora dos movimentos involuntários, aplicamos a Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS), escala completa com subescalas de gravidade, incapacidade e dor, antes da primeira aplicação e um mês após, e antes da última aplicação e um mês após. Após cada aplicação os pacientes foram submetidos à entrevista estruturada para aplicação da escala de melhora global Clinician Interview-Based Impression of Change (CIBIC) e colher dados sobre tempo de duração do efeito benéfico da toxina e efeitos colaterais apresentados. Para análise estatística foram utilizados o teste t para amostras pareadas, o teste não-paramétrico de Mann-Whitnney, o teste não paramétrico de Friedman e o teste do qui quadrado. Resultados: Foram recrutados 14 indivíduos para o grupo Dysport® e 20 indivíduos para o grupo Prosigne®, a média de idade foi de 57,21 anos no primeiro grupo e 51,95 no segundo (p = 0,239). Após a primeira aplicação houve uma redução média nos valores da TWSTRS de 12,78 pontos no grupo sendo tratado com Dysport® e 9,98 pontos no grupo sendo tratado com Prosigne® (p = 0,38). Após a última aplicação a redução desses valores foi de 11,87 pontos no primeiro grupo e 11,35 no segundo (p = 0,86). Em relação à escala CIBIC a grande maioria dos pacientes referiu algum grau de melhora após as aplicações, sem diferença estatística entre os dois braços do estudo. Também não houve diferença estatística entre os grupos em relação ao tempo de duração da melhora após aplicações. Disfagia foi o efeito colateral mais comum, ocorrendo em 27,27 % das aplicações, seguido por dor local e fraqueza muscular. Não houve diferença significativa entre os grupos em relação à incidência de efeitos colaterais. Conclusão: Nossos dados mostram que as toxinas botulínicas Dysport® e Prosigne® tem perfil de eficácia similar para o tratamento da distonia cervical idiopática. Além disso, ambas as toxinas são equivalentes em relação à segurança e tolerabilidade. / Introduction: Cervical dystonia (CD) is the most frequent type of primary focal dystonia and treatment with botulinum toxin is currently the gold standard. Considering that each botulinum toxin brand is pharmacologically distinct, in this paper we compared two botulinum toxins available in Brazil: Abobotulinumtoxin A (Dysport®) and Lanzhou botulinum toxin type A (Prosigne®). Methodology: We conducted a prospective, randomized, double blind trial with one group being treated with Dysport® and the other Prosigne®. We recruited 34 patientes from Ribeirao Preto Medical Schools (HCFMRP) botulinum toxin clinic (ATXB) from may 2010 to june 2011, only patients with idiopathic CD were included in the trial. Each individual was followed during a 13 month period, during which 5 TBA injection sessions were conducted with 3 month intervals between them. To assess objective improvement we used the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS), full scale and severity, disability and pain subscales, before and after the first and fifth treatment sessions. After each treatment session we assessed improvement with the Clinician Interview Based Impression of Change (CIBIC) scale and asked about side effects and duration of improvement. For statistical analysis we used the following tests: t test for paired samples, Mann-Whitneys non parametrical test, Friedmans non parametrical test and qui square test. Results: Fourteen patients were randomized to receive Dysport® and twenty to receive Prosigne®. Mean age in Dysport® group was 57.21 years and in Prosigne® group was 51.95 (p = 0.23). After first injection, mean TWSTRS values reduced 12.78 points in Dysport® group and 9.98 in Prosigne® group (p = 0.38). After last injection the reduction in TWSTRS values was 11.87 points for Dysport® and 11.35 points for Prosigne® (p = 0.86). CIBIC scores showed that the majority of patients reported some level of improvement after injections without statistical differences between groups. Dysphagia was the commonest adverse effect, occurring after 27.27 % of all injections, followed by local pain and muscle weakness. Once again there were no statistical difference between groups regarding adverse effects. Conclusion: Our data showed similar efficacy and safety profiles when comparing both toxins, Dysport® and Prosigne®.

INTRODUÇÃO: A presença de rugas na face devido à hipercinese muscular é comum nas regiões frontal, glabelar e peri-orbitárias. São descritos diversos métodos para o tratamento das rugas de expressão, como a dermoabrasão, a ablação a laser, o laser não ablativo, preenchimentos, cirurgia e aplicações de toxina botulínica. O tratamento das rugas da face com toxina botulínica tipo A é método consagrado, porém são pouco definidos os efeitos a longo prazo. Este estudo retrospectivo teve como objetivo avaliar as rugas das regiões frontal e glabelar da face em pacientes submetidas a aplicações seriadas da toxina botulínica tipo A com finalidade estética, analisando os intervalos entre as aplicações e as doses utilizadas. MÉTODOS: Foram analisadas 24 pacientes do sexo feminino, submetidas entre 5 a 7 aplicações da toxina botulínica tipo A, no período de julho de 1997 a junho de 2006. O tempo médio de acompanhamento foi de 42,2 (± 4,0) meses e o intervalo médio entre as aplicações de 8 (± 0,51) meses. A idade média observada de início da aplicação foi de 48,0 (± 3,0) anos, e da última aplicação foi de 51,6 (± 3,0) anos. Foram métodos de avaliação a análise da documentação fotográfica de antes da primeira e antes da última aplicação, sendo as rugas frontais e glabelares avaliadas segundo escala padronizada, e dados colhidos dos prontuários. RESULTADOS: A longo prazo, verificou-se: 1) amenização das rugas estáticas da região frontal em 62,5% das pacientes e em 37,5% tais rugas se mantiveram inalteradas; 2) amenização das rugas estáticas da região glabelar em 47,2% das pacientes, em 50% tais rugas se mantiveram inalteradas e em 2,8% verificou-se pouca acentuação; 3) amenização das rugas dinâmicas da região frontal em 84,7% das pacientes e em 15,3% tais rugas se mantiveram inalteradas; 4) amenização das rugas dinâmicas da região glabelar (corrugadores) em 63,9% das pacientes, em 26,4% tais rugas se mantiveram inalteradas e em 9,7% verificou-se pouca acentuação. 5) amenização das rugas dinâmicas da região glabelar (prócero) em 57% das pacientes, em 32% tais rugas se mantiveram inalteradas e em 11% verificou-se pouca acentuação. A média da dose total de toxina botulínica utilizada por sessão no presente estudo foi de 43,83 ± 1,25 U, e a dose total cumulativa foi de 272,08 ± 20,42 U. CONCLUSÕES: No longo prazo, existe maior porcentagem de pacientes com amenização ou aspecto inalterado das rugas estáticas e dinâmicas das regiões frontal e glabelar da face em relação a pacientes com acentuação das mesmas. Não houve variação estatisticamente significativa das médias dos intervalos entre as aplicações. A dose total de toxina botulínica aumentou de forma estatisticamente significativa até a terceira aplicação, mantendo-se sem variação significativa a partir de então. / INTRODUCTION: The presence of wrinkles on the face due to the over activity of muscles is rather common on the frontal, glabellar, and periocular regions. A number of methods for the treatment of face lines, such as skin abrasion, laser resurfacing, fillers, surgery and botulinum toxin A have been described. The treatment of facial rhytids with botulinum toxin A is widely used. However, its long term effects are not well defined. This retrospective study assesses the rhytids of both the frontal and glabellar regions of the face on patients submitted to multiple botulinum toxin A applications for aesthetic use, analyzing intervals between applications and dosages. METHODS: 24 female patients who had undergone 5 to 7 botulinum toxin A applications from July, 1997 to June, 2006 were studied. The mean time of follow up was 42.2 (± 4.0) months and the mean interval between applications was 8 (± 0.51) months. The mean age of the patients at the beginning of application was 48.0 (± 3.0) years old, and 51.6 (± 3.0) years old at the last application. The evaluation was carried through the analysis of photographic documentation from before the first and last applications, and both frontal and glabellar rhytids were evaluated according to standardized scale, as well as data collected from patients charts. RESULTS: the long term analysis demonstrated that: 1) improvement of the static rhytids of the frontal region in 62,5% of patients and such rhytids remained unaltered in 37.5% of the patients; 2) improvement of the static rhytids of the glabellar region in 47.2% of the patients, they remained unaltered in 50% of the patients and there was a slight worsening in 2.8% of the patients; 3) improvement of the dynamic rhytids of the frontal region in 84.7% of patients, and they remained unaltered in 15.3% of the patients; 4) improvement of the dynamic rhytids of the glabellar region (corrugator) in 63.9% of the patients, they remained unaltered in 26.4% of the patients and there was a slight worsening in 9.7% of the patients; 5) improvement of the dynamic rhytids of the glabellar region (procerus) in 57% of the patients, they remained unaltered in 32% and there was a slight worsening in 11% of the patients. The mean total dosage of botulinum toxin A used per session in this study was 43.83 ± 1.25 U, and the total cumulative dosage was 272.08 ± 20.42 U. CONCLUSIONS: In the long run, a higher percentage of patients showed improvement or unaltered aspect of their static and dynamic rhytids of the frontal and glabellar regions of the face, when compared to the patients that showed worsening. There was no variation of the mean intervals between the applications. The total dosage of botulinum toxin was significantly increased up to the third application, and kept stable in the following sessions.

Os objetivos deste estudo foram: caracterizar, comparar e correlacionar, em indivíduos com distonia laríngea, antes e após 30 e 120 dias da aplicação da toxina botulínica tipo A no músculo tireoaritenoideo unilateralmente, os parâmetros vocais perceptivo-auditivos e visuais e o impacto vocal na qualidade de vida. Participaram do estudo 16 indivíduos com diagnóstico de distonia laríngea, sendo 11 de gênero feminino e cinco de gênero masculino, com idade média de 57 anos e dois meses, sendo que 68,75% deles apresentaram tremor vocal associado. Todos foram submetidos à aplicação da toxina botulínica tipo A (Dysport®), no músculo tireoaritenoideo unilateralmente, guiado por eletromiografia, gravação do sinal vocal e preenchimento do protocolo de qualidade de vida, Índice de Desvantagem Vocal, antes da injeção da toxina botulínica, no primeiro retorno de seguimento, em média, após 36 dias, e no segundo retorno, coincidente com o dia da nova aplicação de toxina botulínica, que foi em média, 137 dias. Os resultados para análise perceptivo-auditiva e visual de sinais e sintomas vocais, realizada por dois juízes especialistas em voz, revelou, na comparação entre a pré-aplicação e o primeiro retorno, diminuição da severidade da oscilação de intensidade, quebras de voz (sonoridade) e tremor vocal (p=0,002), portanto sem alterações no segundo retorno. No grau de severidade da qualidade da voz, voz tensa-estrangulada, rugosidade, soprosidade e astenia não foram observadas alterações nos três tempos. Para esta análise, notou-se concordância excelente e muito boa (0,71 a 0,99) intrajuízes. Na comparação entre a pré-aplicação e o primeiro retorno, para o Índice de desvantagem vocal, verificou-se diminuição dos valores para o escore total (p=0,039) e para o domínio emocional (p=0,035). Quanto à comparação entre a pré-aplicação e segundo o retorno, houve redução significativa para o domínio funcional (p=0,03) unicamente. De modo que, entre a análise perceptivo-auditiva e visual, do grau de severidade da qualidade vocal e o escore total do índice de desvantagem vocal, evidenciou-se correlação moderada na pré-aplicação e segundo retorno e fraca no primeiro retorno. Portanto, concluiu-se que o tratamento com toxina botulínica para os indivíduos com distonia laríngea mostrou-se eficiente na diminuição de sinais e sintomas vocais, bem como no impacto vocal na qualidade de vida, gerando mudanças na função fonatória e facilitando a comunicação após 30 dias da aplicação, com retorno dos sintomas vocais para a maioria dos indivíduos após 120 dias. / The purpose of this study was to characterize, compare, and correlate the laryngeal dystonia in individuals before, after 30, and 120 days after the application of botulinum toxin type A in the unilateral thyroarytenoid muscle the perceptual vocal and visual parameters and the vocal impact in quality of life. 16 individuals with diagnosed laryngeal dystonia participated in the study, 11 being of the female gender and five of the male gender, with an average age of 57 years and two months, being that 68.75% of individuals having presented associated vocal tremor. All individuals were subjected to: the application of botulinum toxin type A (Dysport®) via electromyography in the unilateral thyroarytenoid muscle, a recording of the vocal sound waves, filling out a survey about his/her quality of life and an Voice Handicap Index (VHI) before the botulinum toxin injection, in the first follow-up on average 36 days after, and in the second follow-up concurrent with the new botulinum toxin application visit, which was on average after 137 days. The results for the perceptual auditory and visual analysis of vocal sound waves and symptoms, conducted by two adjudicating voice specialists, revealed in the comparison between the pre-application and the first follow-up a decrease in the severity of the oscillation intensity, voice breaks (sonority), and vocal tremor (p=0.002), however, revealed no changes in the second follow-up. During the three visits, no changes were observed in grading the severity of voice quality in tense-strangled voice, roughness, breathiness and asthenia. For this analysis, a very good and excellent agreement between the adjudicators was noted (0.71 to 0.99). Comparing the pre-application and the first follow-up, for the index of vocal disability, a decrease in the values of total score (p=0.039) and of emotional mastery (p=0.035) was observed, whereas comparing the pre-application and the second follow-up, there was a significant decrease only for functional mastery (p=0.03). In this way, between perceptual auditory and visual analysis, grading the severity of vocal quality and the total score of the Voice Handicap Index, a moderate correlation was evident in the pre-application and second follow-up and a faint correlation was evident in the first follow-up. Therefore, it can be concluded that the treatment with botulinum toxin for individuals with laryngeal distonia who participated in this study proved effective in the decrease of symptoms, as well as in a vocal impact of quality of life which created changes in the phonatory function and facilitated communication after 30 days of the application, with a return of vocal symptoms for the majority of individuals after 120 days.

INTRODUÇÃO: O blefaroespasmo essencial é uma distonia focal caracterizada por contrações involuntárias, espasmódicas e bilaterais dos músculos protratores das pálpebras. O glaucoma é a principal causa de cegueira irreversível em adultos de países desenvolvidos e a elevação da pressão intra-ocular é o maior fator de risco para o desenvolvimento da doença. A contração voluntária forçada das pálpebras pode causar aumentos da pressão intra-ocular de até 90 mmHg. Uma vez que pacientes com blefaroespasmo essencial apresentam contrações palpebrais freqüentes e de forte intensidade, eles poderiam compor um grupo de risco para o desenvolvimento do glaucoma. MÉTODOS: Vinte e oito pacientes com blefaroespasmo essencial e 28 pacientes de grupo controle, formado por indivíduos com doenças palpebrais ou no seu pós-operatório, foram submetidos a um exame oftalmológico completo. No grupo de pacientes com blefaroespasmo, a avaliação foi realizada em 8 a 11 dias após o tratamento com toxina botulínica. Efetuou-se exame de refração e medida de melhor acuidade visual corrigida com tabela de Snellen, biomicroscopia em lâmpada de fenda, tonometria de aplanação, campo visual computadorizado, teste de sobrecarga hídrica e biomicroscopia de fundo para avaliação da papila óptica. RESULTADOS: 1) A prevalência de glaucoma nos pacientes com blefaroespasmo foi significativamente maior do que nos indivíduos do grupo controle, sendo diagnosticada em 14,3% e 3,6% dos casos, respectivamente (p=0,008). 2) A pressão intra-ocular foi significativamente maior nos pacientes com blefaroespasmo (15,80 ± 3,80 mmHg) do que nos indivíduos do grupo controle (13,90 ± 2,75 mmHg) (p= 0,004). 3) O pico da pressão intra-ocular na prova de sobrecarga hídrica foi significativamente maior nos pacientes com blefaroespasmo essencial (18,82 ± 4,47 mmHg) do que nos indivíduos do grupo controle (16,27 ± 2,69 mmHg) (p=0,0421). DISCUSSÃO: Diversos estudos descreveram a influência da compressão palpebral sobre a pressão intra-ocular. A prova de sobrecarga hídrica tem sido considerada uma ferramenta indireta para se avaliar a capacidade do fluxo de drenagem do trabeculado, além de exibir correlação com os picos de pressão intra-ocular que muitas vezes não são detectados em exames de rotina. Os pacientes com blefaroespasmo essencial apresentaram pressões intra -oculares e picos de pressão intra-ocular na prova de sobrecarga hídrica mais elevados do que os pacientes do grupo controle, o que poderia indicar um baixo fluxo de drenagem. Estas altíssimas variações de pressão intra -ocular a que estes indivíduos são submetidos constantemente, em pacientes com menor fluxo de drenagem poderiam causar um aumento crônico da pressão intra -ocular e o desenvolvimento do glaucoma. CONCLUSÕES: Os resultados observados sugerem que estes pacientes compõem um grupo de risco para o desenvolvimento de glaucoma e esta doença deve ser pesquisada de maneira sistemática na avaliação inicial e durante o seguimento desses casos / INTRODUCTION: Essential blepharospasm is a focal distonia characterised by involuntary, spasmodic, bilateral contractions of eyelid protractors. Glaucoma is the most important cause of irreversible blindness in adults in developed countries and high intraocular pressure is the major risk factor for development of the disease. Voluntary forced eyelid closure can produce an intraocular pressure increase of 90 mmHg. As patients with essential blepharospasm present frequent and strong eyelid contractions, they could be at risk for glaucoma development. METHODS: Twenty eight patients with essential blepharospasm and 28 patients of a control group, with eyelid diseases or in the post-operative period, were submitted to a complete ophthalmic examination. In the group of patiens with blepharospasm, the evaluation was done between 8 to 11 days after botulinum toxin treatment. We performed refractometry and best corrected visual acuity with Snellen chart, slitlamp biomicroscopy, applanation tonometry, automated perimetry, water drinking test and dilated funduscopy to evaluate optic discs. RESULTS: 1) Prevalence of glaucoma in patients with blepharospasm (14,3%) was higher than in the individuals from control group (3,6%) (p=0,008). 2) Intraocular pressure was higher in patients with blepharospasm (15,80 ± 3,80 mmHg) than in the individuals from control group (13,90 ± 2,75 mmHg) (p=0,004). 3) Intraocular pressure peaks in the water drinking test were higher in patients with essential blepharospasm (18,82 ± 4,47 mmHg) than in the individuals from control group (16,27 ± 2,69 mmHg) (p=0,0421). DISCUSSION: Several studies reported the influence of eyelid compression over intraocular pressure. The water drinking test has been considered as an indirect tool to measure outflow facility and it has good correlation with intraocular pressure peaks which are frequently missed in routine examinations. Patients with essential blepharospasm had higher mean intraocular pressures and intraocular pressure peaks in the water drinking test than patients from control group, which could indicate low outflow facility. These high intraocular pressure variations in patients with low outflow facility could increase the intraocular pressure chronically and lead to development of glaucoma. CONCLUSION: Our results suggest that patients with essential blepharospasm be at higher risks for development of glaucoma and this disease should be always investigated at presentation and during follow-up of these cases

A distonia é uma síndrome que consiste de contrações musculares involuntárias que resultam em movimentos distorcidos e repetitivos e/ou posturas anormais. O tratamento pode ser por farmacoterapia, com drogas anticolinérgicas ou com a injeção de toxina botulínica no grupo de músculos afetados. O objetivo do trabalho foi avaliar a deglutição nos pacientes com distonia laríngea, antes e após o tratamento com a toxina botulínica. Nossa hipótese foi que a toxina botulínica modificaria a deglutição dos pacientes com distonia laríngea. Foram avaliados 17 indivíduos adultos, acima de 18 anos de idade, com diagnóstico clínico de distonia laríngea antes e após o tratamento com o uso de toxina botulínica do tipo A, e 20 indivíduos adultos saudáveis como controles. Os participantes foram submetidos à anamnese fonoaudiológica e avaliação videofluoroscópica da deglutição. Os pacientes com distonia foram avaliados antes e 30 dias após a injeção de toxina botulínica, guiada por eletromiografia. Na videofluoroscopia foram avaliadas 6 deglutições de 5mL, sendo 3 na consistência líquida (sulfato de bário 100%, e 3 na consistência pastosa (3g do espessante alimentar ThickenUp Clear, em 50 mL de sulfato de bário (100%) oferecidas em uma colher. A ordem das deglutições foi aleatória. Foram estudadas as fases oral e faríngea da deglutição, com registro de 30 quadros por segundo. Os pacientes com distonia laríngea apresentaram aumento de resíduos na região oral e em valécula e maior número de deglutições. Os pacientes apresentaram tempo de trânsito faríngeo (TTF) menor do que os controles (p<0,01), para os bolos nas consistências líquida e pastosa. O TTF foi menor após aplicação do que antes da aplicação da toxina botulínica, quando da deglutição do bolo pastoso. Portanto, concluiu-se que os pacientes com distonia laríngea, comparado a controles, têm trânsito mais rápido pela faringe, aumento de resíduos na região oral e em valécula e maior número de deglutições para o mesmo volume.Trinta dias após a aplicação da toxina botulínica foi observado diminuição da duração do trânsito pela faringe, com o bolo pastoso, e resposta tardia do movimento do osso hióide em relação à chegada do bolo na faringe. / Dystonia is a syndrome consisting of involuntary muscle contractions that result in distorted and repetitive movements and/or abnormal postures. Treatment may be by pharmacotherapy with anticholinergic drugs or with the injection of botulinum toxin in the affected muscle group. The aim of this study was to evaluate swallowing in patients with dystonia before and after treatment with botulinum toxin. Our hypothesis was that botulinum toxin modify the swallowing of patients with spastic dystonia. Seventeen adult subjects over the age of 18 years with clinically diagnosed dystonia were evaluated before and after treatment with botulinum toxin type A and compared to 20 healthy adults as controls. Participants underwent phonologic anamnesis and videofluoroscopy assessment of swallowing. Patients with dystonia were assessed before and 30 days after injection of botulinum toxin, guided by electromyography. In fluoroscopy, 6 swallows were evaluated of 5ml: 3 in a liquid consistency (100% barium sulfate) and 3 in a pasty consistency (3g of food thickener, ThickenUp Clear) in 50 mL of 100% barium sulfate, offered on a spoon. The oral and pharyngeal phases of swallowing were studied from swallows of random order, with registration of 30 frames per second. Patients with dystonia showed an increase of residue in the oral region and vallecula and greater number of multiple swallows. Patients had less pharyngeal transit time (PTT) than controls (p<0.01) for boluses of liquid and pasty consistencies. PTT was lower after the application of botulinum toxin than before with the swallowing of a pasty bolus. It was concluded that patients with dystonia, compared to controls, have more rapid transit through the pharynx, increased residues in the oral region and vallecula and a greater number of swallows for the same volume. Thirty days after the botulinum toxin, it was observed a shorter pharyngeal transit time with paste bolus, and delayed hyoid movement response to bolus presence in pharynx.

[Truncared abstract] Introduction: The assessment of any therapy requires not only an understanding of how that therapy works but also how it affects health related quality of life (HRQOL). Botulinum Toxin A(BoNT-A) therapy for upper limb spasticity management in children with hemiplegic cerebral palsy(CP) is currently under trial. Despite its use for over a decade for lower limb spasticity, little is known about the mechanisms involved in improving motor function and the effect on the child and their familys HRQOL. Both central and peripheral mechanisms are hypothesised[1]. Whilst evidence of improved quality of movement and ability to perform tasks is emerging[2-4], this cannot be directly correlated with an improvement in HRQOL. In addition, the traditional method of assessing child HRQOL by parent proxy reports has come under question[5, 6]. The World Health Organisation now recommends the collection of both parent proxy and child self-reports[7]. Aims: 1. Investigate the corticomotor projections to the upper limb in school aged children with hemiplegic CP and the changes that occur with BoNT-A therapy by transcranial magnetic stimulation (TMS). 2. Investigate the effect of upper limb BoNT-A therapy on HRQOL of school aged children with hemiplegic CP by completion of the PedsQL 4.0 Generic Core Scales and 3.0 CP Module. 3. Determine the concordance between Child Self-Report and Parent Proxy Report scores for the PedsQL 4.0 Generic Core Scales and 3.0 CP Module. 4. Determine the concordance between PedsQL scores and function as assessed by the Melbourne Assessment of Unilateral Upper Limb Function (MUUL). Methods: Design: Prospective randomised pilot study. Setting: Department of Paediatric Rehabilitation, Princess Margaret Hospital, and Centre for Neurological and Neuromuscular Disorders, Perth. Participants: 22 school aged children with hemiplegic CP aged 7yr 0mth-13yr 11mth (12 treatment, 10 control). 3 Treatment: One episode BoNT-A injections (dose 1-2U/kg/muscle) into the upper limb for treatment group. The control group received usual care. ... Conclusion: This pilot study provides preliminary evidence of the effects of upper limb BoNT-A therapy at both a central physiological and a broader quality of life level in school aged children with hemiplegic CP. At a central level, corticomotor pathway reorganisation occurs in the setting of BoNT-A. However the reorganisation is not limited to the affected side pathways suggesting a systemic BoNT-A effect or developmental changes. Similarly, in this pilot study, there was no statistically significant effect of upper limb BoNT-A on the childs HRQOL as assessed by the PedsQL although positive trends were observed 4 for a number of physical and psychosocial domains. The collection of both child self-report and parent proxy reports when assessing HRQOL is recommended, and function needs to be assessed independently. Larger studies across the broader CP population, the design of CP specific HRQOL tools appropriate for use in the higher functioning CP cohort, and alternative better tolerated methods of investigating the motor system in children with movement disorders are recommended.