Injection Workbook for Focal Spasticity Identifying Patients, Advanced Anatomy, and the BOTOX® Treatment Framework Indications Spasticity: Upper Limb Spasticity BOTOX® for injection is indicated for the treatment of upper limb spasticity in adult patients to decrease the severity of increased muscle tone in elbow, wrist, finger, and thumb flexors (biceps, flexor carpi radialis, flexor carpi ulnaris, flexor digitorum profundus, flexor digitorum sublimis, adductor pollicis, and flexor pollicis longus). Lower Limb Spasticity BOTOX® is indicated for the treatment of lower limb spasticity in adult patients to decrease the severity of increased muscle tone in ankle and toe flexors (gastrocnemius, soleus, tibialis posterior, flexor hallucis longus, and flexor digitorum longus). Important Limitations Safety and effectiveness of BOTOX® have not been established for the treatment of other upper or lower limb muscle groups or for the treatment of spasticity in pediatric patients under age 18 years. BOTOX® has not been shown to improve upper extremity functional abilities, or range of motion at a joint affected by a fixed contracture. Treatment with BOTOX® is not intended to substitute for usual standard of care rehabilitation regimens. IMPORTANT SAFETY INFORMATION, INCLUDING BOXED WARNING WARNING: DISTANT SPREAD OF TOXIN EFFECT Postmarketing reports indicate that the effects of BOTOX® and all botulinum toxin products may spread from the area of injection to produce symptoms consistent with botulinum toxin effects. These may include asthenia, generalized muscle weakness, diplopia, ptosis, dysphagia, dysphonia, dysarthria, urinary incontinence, and breathing difficulties. These symptoms have been reported hours to weeks after injection. Swallowing and breathing difficulties can be life threatening, and there have been reports of death. The risk of symptoms is probably greatest in children treated for spasticity, but symptoms can also occur in adults treated for spasticity and other conditions, particularly in those patients who have an underlying condition that would predispose them to these symptoms. In unapproved uses, including spasticity in children, and in approved indications, cases of spread of effect have been reported at doses comparable to those used to treat cervical dystonia and spasticity and at lower doses. Please see additional Important Safety Information about BOTOX® inside. Introduction This course is designed to help hone your skills in identifying Focal Spasticity patients who may be BOTOX® candidates and implementing the BOTOX® Treatment Framework. We’ll also discuss the resources and services offered by Allergan as part of our commitment to support your practice. Table of contents Identifying BOTOX® candidates Advanced diagnosis .........................................................4 Patient assessment ..........................................................8 Injecting BOTOX® patients The BOTOX® Treatment Framework ................................ 10 The right goals ................................................................ 12 The right muscles/dose ................................................... 14 The right plan .................................................................44 Sample BOTOX® Treatment Framework documentation ...46 Dilution, reconstitution, and injection ...............................52 Preparing your practice Allergan resources and support ......................................56 IMPORTANT SAFETY INFORMATION (continued) CONTRAINDICATIONS BOTOX® is contraindicated in the presence of infection at the proposed injection site(s) and in individuals with known hypersensitivity to any botulinum toxin preparation or to any of the components in the formulation. Please see additional Important Safety Information about BOTOX® on following pages. 3 Advanced diagnosis Prevalence of common spasticity causes1 Patient considerations Presentation is similar across conditions, but it’s important to consider additional factors Traumatic events like a stroke can cause muscle stiffness/ Stroke2 ✓ tightness, which can interfere with treatment goals2 58% (N = 504) ✓ Conditions like adult cerebral palsy can result in balance difficulties7 Advanced diagnosis Adult Multiple Behavioral/cognitive issues can stem from traumatic 3 Cerebral Palsy6 Sclerosis ✓ brain injuries8 73% 5 84% (N = 23,795) (N = 20,969) Spasticity can present intermittently in chronic Most Common ✓ conditions, such as multiple sclerosis9 Causes of Spasticity Spinal Traumatic Cord Injury5 Brain Injury4 65% 23% (N = 354) (N = 338) IMPORTANT SAFETY INFORMATION (continued) WARNINGS AND PRECAUTIONS Lack of Interchangeability Between Botulinum Toxin Products The potency Units of BOTOX® are specific to the preparation and assay method utilized. They are not interchangeable with other preparations of botulinum toxin products and, therefore, units of biological activity of BOTOX® cannot be compared to nor converted into units of any other botulinum toxin products assessed with any other specific assay method. 4 Please see additional Important Safety Information about BOTOX® on following pages. 5 Advanced diagnosis Spasticity can worsen over time Focal symptoms can manifest in generalized 12 In separate studies of post-stroke patients… and regional spasticity Types of spasticity of post-stroke patients There are 3 types of spasticity, based on % have signs of spasticity how much of the body is affected 27 within 6 weeks (N = 86)10 Generalized Increased muscle tightness/tonality that affects widespread portions of the body Regional Affects motor skills over a large region of the Advanced diagnosis body, such as the torso or entire left side STROKE MONTH MONTH MONTH MONTH MONTH MONTH 1 2 3 4 5 6 Focal Muscle tightness/tonality that affects 1 or more body parts in an isolated area, which can adversely affect the patient of post-stroke patients % present with contracture within 6 months in at 52 11 least 1 joint (N = 165) Notes STROKE MONTH MONTH MONTH MONTH MONTH MONTH 1 2 3 4 5 6 BOTOX® has not been shown to improve upper extremity functional abilities, range of motion at a joint affected by a fixed contracture, or prevent disease progression. IMPORTANT SAFETY INFORMATION (continued) WARNINGS AND PRECAUTIONS (continued) Spread of Toxin Effect See Boxed Warning. 6 Please see additional Important Safety Information about BOTOX® on following pages. 7 Patient assessment Multiple approaches may be useful when It may be time to revisit these patients’ assessing Focal Spasticity treatment plans Consider using “mild/moderate/severe” framework when Do you have Focal Spasticity patients in your practice who... capturing observations Lower limb spasticity Ambulatory Patients Nonambulatory Patients* • Evaluate all affected joints of ankle and toe • Look for potential skin breakdown in all positions: supine, seated, standing, caused by spasticity and moving • Compare positioning when sitting • Observe and evaluate patient’s gait, vs lying down including gait cycle, as part of • Determine if patient’s leg position Patient assessment determining severity Are on muscle Are meeting Do not follow their impedes transfers relaxants and only treatment goals treatment regimen? • Measure the time it takes for patient to call in for refills? on current therapy? walk a set distance or get up from seated position and walk to a set point *Nonambulatory patients were excluded from the BOTOX® lower limb spasticity clinical trial. Upper limb spasticity PT/OT Diagnosis Technique Observations Ask the patient what has impacted “Muscle tightness” and “stiffness” are usually Have finished PT/OT sessions, Are contraindicated post-stroke treatment goals mentioned the most but want to continue to certain treatment working on symptoms? options? Ask the patient if they have ever taken muscle May indicate if another physician had noticed relaxants the spasticity Have the patient stand up Helps determine the effect of symptoms on balance and exposes the patient’s limbs IMPORTANT SAFETY INFORMATION (continued) Shake the patient’s hand Patient must extend 1 arm, allowing you to WARNINGS AND PRECAUTIONS (continued) check for signs and symptoms in both limbs Serious Adverse Reactions With Unapproved Use Serious adverse reactions, including excessive weakness, dysphagia, and aspiration pneumonia, with some adverse Have patient raise their arms above their head Allows you to quickly look for effects of reactions associated with fatal outcomes, have been reported in patients who received BOTOX® injections for and/or straight out spasticity on elbow, wrist, and fingers unapproved uses. In these cases, the adverse reactions were not necessarily related to distant spread of toxin, but may have resulted from the administration of BOTOX® to the site of injection and/or adjacent structures. In several of the cases, patients had pre-existing dysphagia or other significant disabilities. There is insufficient information to identify factors associated with an increased risk for adverse reactions associated with the unapproved uses of BOTOX®. The safety and effectiveness of BOTOX® for unapproved uses have not been established. 8 Please see additional Important Safety Information about BOTOX® on following pages. 9 BOTOX® Treatment Framework For each Focal Spasticity patient, establish… BOTOX® Treatment Framework Overview Establish specific and realistic goals to help guide the course of care • Determine how BOTOX® fits into the overall treatment plan to help achieve these goals • When using BOTOX®, it’s