Botox use in young adult with 4 x CVA

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HI all,
I have a male patient in his 30's who suffered 4 CVAs in 2 days. Subsequently he walks on the lateral aspect of his right foot (fully inverted, main weight bearing site on the lateral aspect of the 5th metatarsal). Can anyone tell me where in Melbourne (or Gippsland or LaTrobe) i could refer him for botox injections in his foot invertors. The physio and I are working hard with massage, stretches and an ASO but after several years of leaving this condition without treatment he will need botox to get him in a rigid AFO.
I think a neurologist is the right person? Can anyone recommend one who works in the public health service?
Cheers all,
Beck R

 

Beck,

The Angliss hospital in Ferntree Gully runs a "Rehabilitation Medicine Clinic and Spasticity Clinic " within the Community Rehabilitation Program that includes a BoTox clinic run by a Rehab physician.
contact details are here

there are PBS restrictions on the eligibility for publicly funded BoTox, and very limited availability for patients in public hospitals who fall outside these criteria, which I think your patient will, but worth a call to Eastern Health access unit.

 

Hi Beck
Dr Kate Kotschet (Neurologist) & Janine Simondson (Senior Neurophysiotherapist) at St.Vincent's Hospital Melbourne also provide an excellent service for CVA clients who require botox. Locally, Dr Prasannan (Rehabilitation Consultant) at Latrobe Regional Hospital may also be able to assist your client.

As per Stephen's post, if your client is unable to access botox under the pbs, I feel that it would be appropriate for an orthotist to consult with the client and your team. Locally, mBrace Orthotics in Traralgon are very experienced in complex neurology and will be able to provide a comprehensive orthotic assessment.

In our practice, we manage many CVA clients with severe equinovarus. If clients cannot access botox, we still try to correct the foot/ankle complex to its best possible position with an orthosis and attempt to walking fluency and improve weight bearing through the affected leg. Depending on the client's presentation, that might mean for example that initially our orthosis is fixed in 20 degrees of plantarflexion but we may have been able to abduct the client's forefoot to a more neutral position in the orthosis.

In this instance, the orthotic prescription must also incorporate a heel raise on the affected side, lateral heel and sole flare on the affected side and if the affected leg has no pre-existing leg length discrepancy, a heel and sole raise on the sound side must also be added. If the foot/ankle alignment improves, it is not uncommon for multiple changes of orthosis and footwear modifications to occur over a period of years until optimal position for walking and function is achieved.

Another thing you may want to consider. It sounds like your client is a public client and cannot fund services privately. If your client needs an AFO or equivalent, an orthotist may have to support a funding application to the Statewide Equipment Program (SWEP) and SWEP funding can take up to 12 months to be approved. Linking in with an orthotist now may improve timely service provision, especially if he can access botox under the pbs.

I hope this helps.
Thanks Darren

 

Darren / Beck,
Kate does a session a week with us on Monday's, so I'll ask what she thinks.