We read with great interest the recently published article in your distinguished journal by Alvarez et al.1 The authors performed a retrospective review of cases of painful legs and moving toes (PLMT) or painful limbs moving extremities (PLME) and among others reported that GABAergic agents seem most effective. The authors discuss the limited degree of efficacy with other treatment approaches, including local anesthetic nerve blocks and injections of botulinum toxin type A. Their electrophysiological testing showed involvement of dystonic mechanisms in the pathogenesis of PLMT.

Relating to the effective treatment options for PLME, there is substantial data in favor of the use of botulinum toxin type A injections. In the retrospective review chart of Alvarez et al.,1 GABAergic agents were administered in the majority of cases, whereas none of the patients was treated with botulinum toxin injections. We therefore suggest that this might be the reason for why authors are conclusive and supportive to the use of GABAergic agents over botulinum toxin injections. On the contrary, our experience2, 3 bolsters the argument that botulinum toxin injections should be considered in the treatment of PLMT. This treatment strategy seems to provide both significant pain relief and improvement of involuntary movements because of reduction of muscle spindle discharge and subsequent decreased activity of gamma loop and central sensitization.4 Botulinum toxin injections also exert antisympathetic, antiglutamergic, and anti-inflammatory effects and inhibition of local pain neurotransmitters.5, 6

In summary, we suggest that the use of botulinum toxin injections in the treatment of PLME should be considered based on the available clinical data. Our view is supported by the significant contributing role dystonic mechanisms seem to play in the pathogenesis of the PMLE.


Dr. Papapetropoulos is currently employed in Biogen Idec.


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Andreas A. Argyriou MD, PhD*, Spyridon Papapetropoulos MD, PhD†, * Department of Neurology, “Saint Andrew's” General Hospital of Patras, Patras, Greece, † Department of Neurology, University of Miami, Miller School of Miami, Florida, USA.