Objective: Objective: We present a rare case and literature review of Painless Hand with Moving Fingers (PHMF) that adequately responded to Onabotulinum toxin A (Botox) injections with long lasting relief of abnormal movements and improvement in fine motor control.

Background: Background:  PHMF is believed to be a variant of Painful Limbs with Moving Extremities. To date, the etiology of the syndrome remains unclear and very few cases have been reported. Proposed associated pathological conditions include: peripheral neuropathy, spinal cord and cauda equina injury, radiculopathy, peripheral nerve trauma, herpes zoster and chemotherapy. A literature review found several case reports detailing successful treatment with clonazepam or gabapentin and a single report of treatment with Botox.

Method: Methods: A thorough literature review was conducted via PubMed using the terms “painless”, “arm”, “limb”, “moving”, “fingers”, “toes”, and “extremities”.

Results: Results:We report a 60 y/o man presenting with a 7-year history of continuous, writhing, involuntary movements of the left hand.  Movements were temporarily improved with holding objects. There was no report of trauma, symptoms of radiculopathy, peripheral neuropathy or pain. Left hemifacial spasm was observed during physical exam. MRI of the brain and c-spine were unremarkable, as was serum metabolic and autoimmune-paraneoplastic work up. EMG/NCV revealed involuntary motor unit recruitment of normal units in multiple muscles of the left arm and hand. Botox injections using EMG guidance were administered into the muscles most affected by involuntary movements. One-week post injection, the patient reported adequate reduction of involuntary movements allowing for fine motor tasking without significant degradation in dexterity.

Conclusion: Conclusions: Botox is an effective and well-established therapeutic option for treatment of muscle spasticity and dystonia. This agent bestowed our patient with a satisfactory level of relief from involuntary movements and appears to be an effective therapy for this condition. The involuntary nature, response to Botox injection and sensory trick (holding object in affected hand) imply a potential dystonic mechanism.However, the fundamental etiology of this rare syndrome remains unknown and will require further research to identify the most effective method for identification and treatment.

References: [1] Singer C. Papapetropoulos S. A case of painless arms/moving fingers responsive to botulinum toxin injections. Parkinsonism and Rel Disord 13 (2007) 55-56. [2] Supiot F, Gazagnes MD, Blecic SA, Zegers de Be3yl D. Painful arm and moving fingers: clinical features of four new cases. Mov Disord 2002:17(3):616-8. [3] Jabbari B, molloy FM, Erikson M, Floeter MK. Bilateral painful hand-moving fingers: electrophysiological assessment of the central nervous system oscillatory. Mov Disord 2000;15(6):1259-63. [4] Funakawa I, Mano Y, Takayangi T. Painful hand and moving fingers. A case report. J Neurol 1987;234(5):342-3. [5] Dash S. Painless Limbs and Moving Extremities Syndrome: A Variant of Painful Moving Limbs and Extremities. J Med & Med Research 15(1):1-4, 2016. [6] Kwon S, Kim J, Jeon B. A case report of Painless Moving Toes Syndrome. J Clin Neurol 4(1):33-35, 2008 [7] Miyakawa T, Yoshimoto M, Takebayashi T, Yamashita T. Painful Limbs/Moving Extremities. Clin Orthop Relat Res (2010) 468:3419-3425.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/positive-response-to-botulinum-toxin-injections-in-a-patient-with-painless-hand-with-moving-fingers-a-case-report-and-literature-review/