(Kiosk 1) Diabetic Deconditioning: An Uncommon GI Use of Botulinum Toxin to Promote Improved Function and Quality of Life

Case Diagnosis: Diabetic mixed axonal-demyelinating polyneuropathy, diabetic amyotrophy, and gastroparesis.

Case Description or Program Description: A 25-year-old female with poorly controlled type 1 diabetes, gut-wrenching gastroparesis refractory to symptomatic management, and multiple hospitalizations for diabetic ketoacidosis transferred to inpatient rehabilitation following prolonged deconditioning. During her previous hospitalization, her severe gastroparesis, intractable nausea and vomiting, and abdominal pain inhibited her from adequate oral and nasogastric intake, causing her failure to thrive. She denied constipation with loose bowel movements. CT abdomen showed pyloric narrowing. Her weakness and gastrointestinal symptoms precluded her from making significant therapeutic progress so GI was consulted. They recommended an off-labeled botulinum injection at the pylorus with EGD, to which the patient consented. Afterward, the patient experienced improved nausea, reduced abdominal pain, formed stool, and PO tolerance; she began participating in therapies and was transferred to inpatient rehabilitation.

Setting: Inpatient rehabilitation.

Assessment/Results: Improved diabetic gastroparesis and rehabilitation participation post-pyloric botulinum injection
.

Discussion (relevance): The use of botulinum toxin is not novel in PM&R, with common applications for spasticity, dystonia, and headache management. The use of botulinum to treat gastroparesis is gaining traction, having burgeoned within the last decade. Thus, uncommon botulinum toxin use in PM&R warrants a conversation of other indications to promote rehabilitation outcomes for patients.

Botulinum toxin acts by blocking acetylcholine exocytosis in cholinergic nerve endings, promoting muscle relaxation. This mechanism of action is particularly useful in focal dystonias (e.g. blepharospasm, torticollis, dysphonia), involuntary muscle contraction (e.g. synkinesis, myoclonus, bruxism), conjugate eye movement disorders (i.e. strabismus, nystagmus, oscillopsia), pain (e.g. headaches, osteoarthritis, neuropathic pain), cosmetics, and muscle spasms (e.g. sphincters, skeletal muscles). Per GI, botulinum was a last resort recommendation because of multiple failed treatments, and recent studies have shown significant improvements post-botulinum (not FDA approved). For our patient, botulinum allowed active participation in rehabilitation goals.

Conclusions: Botulinum toxins have the potential for gastric dysmotility management in rehabilitation.