title: Botulinum toxin type A combined with cervical spine manual therapy for masseteric hypertrophy in a patient with Alzheimer-type dementia: a case report.
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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Physical Therapist, Department of Physical Therapy, Residenza Sanitaria Assistenziale "A. Maritano," Sangano, Italy ; Physical Therapist, Private Practitioner, Torino, Italy.
authors.forename: Jorge H
authors.initials: JH
authors.lastname: Villafañe
authors.forename: Cesar
authors.initials: C
authors.lastname: Fernandez-de-Las-Peñas
authors.forename: Paolo
authors.initials: P
authors.lastname: Pillastrini
keywords: Alzheimer disease; Botulinum toxin type A; Masseter muscle, cervical spine; Muscle spasticity; Physiotherapy; Stroke