Botulinum Toxin Treatment in the Healing of Pressure Ulcers Resulting from Spasticity in Multiple Sclerosis

Special Article – Spasticity Management and Rehabilitation

Phys Med Rehabil Int. 2017; 4(5): 1129

Botulinum Toxin Treatment in the Healing of Pressure Ulcers Resulting from Spasticity in Multiple Sclerosis

Buchanan K1,2*, Christofi G1,2, Farrell R1,2,3, Keenan E1,2 and Stevenson VL1,2,3

¹Department of Therapy and Rehabilitation, The National Hospital for Neurology and Neurosurgery, London, UK,

²UCLH NHS Foundation Trust, London, UK

³University College London, Institute of Neurology, London, UK

*Corresponding author: Buchanan K, Department of Therapy and Rehabilitation, The National Hospital for Neurology and Neurosurgery, PO Box 113, 2nd Floor, 8-11 Queen Square, London, WC1N 3BG, UK

Received: September 25, 2017; Accepted: October 17, 2017; Published: October 24, 2017


Treatment of spasticity in patients with multiple sclerosis (MS) can be complex and challenging. Oral treatments can be poorly tolerated and despite their use, secondary complications such as contracture(s), bony deformity and pressure ulcers can ensue. We report the use of botulinum toxin (BoNT) injections to facilitate healing of pressure ulcers resulting from spasticity and spasm, in a patient with secondary progressive MS. The results suggest that treatment with BoNT, as part of a multi-disciplinary approach, may play a role in facilitating healing by reducing spasticity, spasm and pain, altering resting alignment and promoting more effective pressure relief.

Keywords: Spasticity; Spasm; Botulinum toxin; Pressure ulcers; Healing; Multiple sclerosis


Botulinum toxin treatment offers a targeted approach to managing focal spasticity in a variety of neurological conditions [1,2,3]. In patients with lower limb spasticity, injection of BoNT has been shown to reduce hypertonia, increase passive range of motion, and reduce pain [4]. To date there are very few research studies evaluating the use of BoNT in the treatment of spasticity specifically in multiple sclerosis. Hyman et al [5] demonstrated a significant reduction in spasticity and increased ease of passive care when BoNT was administered to the hip adductors of patients with MS. The role of a combined approach of BoNT and physiotherapy in the treatment of MS related spasticity was evaluated by Giovanelli et al [6]. Results demonstrated a reduction in spasticity post BoNT and a suggestion that concomitant physiotherapy produces a better outcome.

A review of the literature supporting the use of BoNT as an adjunct to aid healing of pressure ulcers was undertaken. Two single case studies were identified [7,8] involving patients who had developed spasticity, spasms or dyskinesia after sustaining either brain or spinal cord injury. Both patients developed pressure ulcers resistant to standard topical treatments. Targeted treatment with BoNT was administered into the muscles in proximity to the pressure ulcers and successful healing was achieved. The authors concluded that BoNT may facilitate breaking the cycle of stimulation of spasm, pain, poor resting posture and lack of pressure relief and its impact on healing of the ulcers.

Case Presentation

We present the case of a 51-year-old woman with secondary progressive multiple sclerosis (SPMS), experiencing spasms pulling her feet into plantarflexion and inversion, a progressive loss of range of movement at the ankles resulting in an abnormal resting position (Figure 1) and difficulty sourcing and applying appropriate footwear. In addition, she had developed significant painful, infected pressure ulcers of both feet. Other than Nabiximols (THC: CBD oromucosal spray: delta-9-tetrahydrocannabinol: cannabidiol: Sativex®, GW Pharma Ltd, UK), which partially reduced her spasms, she was unable to tolerate oral antispasmodic medications due to side effects of sedation and weakness. Physical management strategies such as stretches and splinting had been trialled unsuccessfully due to the strength of the spasm and the poor skin quality. Intrathecal baclofen had been raised as a treatment option but the patient declined surgery. She had no other medical history; other medications included modafinil, calcium and vitamin D supplements.