BoTULS: a multicentre randomised controlled trial to evaluate the clinical effectiveness and cost-effectiveness of treating upper limb spasticity due to stroke with botulinum toxin type A

Conceptualisation and development of the arm activity measure (ArmA) for assessment of activity in the hemiparetic arm

PURPOSE

To develop a patient reported outcome measure of active and passive function in the hemiparetic upper limb.

METHODS

Potential items for inclusion were identified through (a) systematic review and analysis of existing measures and (b) analysis of the primary goals for treatment in a spasticity service. Item reduction was achieved through consultation with a small, purposively selected multi-disciplinary group of experienced rehabilitation professionals (n = 10) in a three-round Delphi process. This was followed by a confirmatory survey with a larger group of clinicians (n = 36) and patients and carers (n = 13 pairs).

RESULTS

From an initial shortlist of 75 items, 23 items were initially identified for inclusion in the arm activity measure (ArmA), and subsequently refined to a 20-item instrument comprising 7 passive and 13 active function. In common with the six measures identified in the systematic review, a five-point ordinal scaling structure was chosen, with ratings based on activity over the preceding 7 days.

CONCLUSIONS

The ArmA is designed to measure passive and active function following focal interventions for the hemiparetic upper limb. Content and face validity have initially been addressed within the development process. The next phase of development has involved formal evaluation of psychometric properties.

IMPLICATIONS FOR REHABILITATION

In clinical practice or research, outcome measures in rehabilitation need to have face and content validity. Following stroke or brain injury, goals for rehabilitation of the hemiparetic upper limb may be: to restore active function, if there is return of motor control or to improve passive function making it easier to care for the limb (e.g. maintain hygiene) if no motor return is possible, measurement of both constructs should be considered. This study describes the systematic development of the ArmA, a measure of active and passive function in the hemiparetic upper limb.

Treatment with botulinum toxin improves upper-extremity function post stroke: a systematic review and meta-analysis

OBJECTIVE

To examine whether treatment with botulinum toxin type A (BTX-A) is associated with improvements in activity capacity or performance associated with poststroke spasticity in the upper extremity.

DATA SOURCES

MEDLINE, EMBASE, Scopus, and ISI Web of Science databases were searched from 1985 to November 2011.

DATA SELECTION

Studies were included if (1) the study design was a randomized controlled trial comparing injection of BTX-A with placebo or a nonpharmacologic treatment condition; (2) at least 60% of the sample was composed of adult subjects recovering from either first or subsequent stroke; (3) subjects presented with moderate to severe upper-extremity spasticity of the wrist, finger, or shoulder; and (4) activity was assessed as an outcome. Studies were limited to those published in the English language.

DATA EXTRACTION

Data pertaining to participant characteristics, treatment contrasts, and outcomes assessing activity limitations were extracted from each trial. The World Health Organization's International Classification of Functioning, Disability and Health was used to identify outcomes that captured the domain of activity used within each of the included studies. Where possible, a treatment effect size was calculated for each study using the standardized mean difference ± standard error (95% confidence interval) and the results pooled.

DATA SYNTHESIS

Sixteen randomized controlled trials were identified, 10 of which reported sufficient data for inclusion in the pooled analysis (n=1000). Six different outcomes that assessed activity limitations had been used, including the Disability Assessment Scale, the Action Research Arm Test, and the Barthel Index. Overall, BTX-A was associated with a moderate treatment effect (standardized mean difference=.536±.094, 95% confidence interval=.352-.721, P<.0001).

CONCLUSIONS

The use of BTX-A was associated with moderate improvement in upper-extremity activity capacity or performance after stroke.

Manual needle placement: accuracy of botulinum toxin A injections

INTRODUCTION

Electrophysiological or ultrasound guidance can facilitate botulinum toxin A (BoNt-A) injection accuracy, but clinical landmarks and palpation are often used for superficial muscles. We evaluated the accuracy of manual needle placement in the gastrocnemius muscles (GC) guided only by anatomical landmarks and palpation.

METHODS

Bilateral limbs from 30 cadavers were used to evaluate ink injection into the GC. One anatomist and one orthopedic surgeon verified the accuracy of manual needle placement postinjection by calf muscle dissection. Injection was considered a failure if the ink was not located in the head of the target GC.

RESULTS

One hundred twenty-one practitioners were evaluated. Fifty-two injections were successful (43%), and 69 failed (57%). This result was unrelated to injector experience (P = 0.097).

CONCLUSIONS

Our findings show a poor success rate, regardless of injector experience. Therefore, muscle palpation and anatomical landmarks are insufficient to ensure the accuracy of BoNt-A injections, even for large, superficial muscles.

Evaluation of the cost per patient per injection of botulinum toxin A in upper limb spasticity: comparison of two preparations in 19 countries

Background

Botulinum toxin A injections are indicated for the management of movement disorders, including upper limb spasticity. The aim of this study was to compare the cost per patient per injection for two botulinum toxin A preparations in 19 countries.

Methods

Doses of botulinum toxin A are expressed in noninterchangeable units (U), ie, Botox^® in 100 Allergan units (100 U) and Dysport^® in 500 Speywood units (500 U). Recommended dosages were derived from country-specific summaries of product characteristics or prescribing information. Cost analysis was based on official list prices and expressed in 2011 Euros. The cost per patient per injection was calculated using the recommended dosage in upper limb spasticity combined with price per vial in each country.

Results

For upper limb spasticity, the recommended dosage for Dysport in the summary of product characteristics is 1000 U per patient, whereas for Botox the recommended dosage when recommendations were made is 300 U. Allowing for different prices per vial in each country, the cost per patient per injection for upper limb spasticity was less for Dysport than for Botox in 18 (95%) of the 19 countries (mean 17% less across countries). The difference was 20% or higher in nearly half (47%) of the countries. Sensitivity analyses considering available “real-world” dosing showed consistent results, with Dysport being less costly than Botox in all 19 countries.

Conclusion

Considering costs per patient per injection based on analysis of recommended dosages in the summary of product characteristics, Dysport remains cheaper than Botox in most countries. Thus, when extrapolated to a national level, substantial savings could be realized by using Dysport in the treatment of upper limb spasticity.

Measuring participation after stroke: a review of frequently used tools

OBJECTIVE

To identify and critique the measures currently used to assess participation in clinical stroke studies.

DATA SOURCES

Relevant articles published between January 2001 and April 2012 identified through Medline, CINAHL, and ProQuest Central databases.

STUDY SELECTION

Published articles involving poststroke assessment of participation. Case studies, cohort studies, and randomized controlled trials were included.

DATA EXTRACTION

The most frequently used measures were identified and the psychometric properties evaluated. Three raters independently evaluated each measure relative to the first and second coding levels of the International Classification of Functioning, Disability and Health (ICF) Activities and Participation domain categories.

DATA SYNTHESIS

Thirty-six measures were identified. The Stroke Impact Scale (SIS), London Handicap Scale, Assessment of Life Habits (LIFE-H), Frenchay Activities Index, and Activity Card Sort (ACS) were used most frequently. No single measure met criteria across all psychometric indices, and not one covered all 9 of the ICF Activities and Participation domains. The SIS, LIFE-H, and ACS covered the widest range. The domains covered most frequently were Community, Social and Civic Life, Domestic Life, and Mobility. Learning and Applying Knowledge, General Tasks and Demands, and Communication were the domains less frequently covered.

CONCLUSIONS

This review identified and evaluated the most frequently used participation measures in clinical stroke studies. The SIS, LIFE-H, and ACS covered the ICF Activities and Participation domain categories most comprehensively. However, none of the measures covered all the ICF Activities and Participation domain categories. The information provided in this systematic review can be used to guide the selection of participation measures to meet specific clinical and research purposes.

Botulinum toxin type A combined with neurodynamic mobilization for upper limb spasticity after stroke: a case report

OBJECTIVE

The purpose of this study is to report a case in which combinatory therapy of botulinum toxin type A (BoNT-A) and neurodynamic mobilization (NM) was used as treatment for a patient with severe upper limb spasticity and pain after stroke.

CLINICAL FEATURES

A 76-year-old male patient had spastic muscles in the upper limb 10 months after an ischemic stroke.

INTERVENTION AND OUTCOME

The patient underwent combined treatment with BoNT-A and NM of the upper limb in 6 monthly applications. Evaluation was performed pretreatment, 3 months after the first injection, 3 months after the second injection, and at a follow-up session 9 months after starting the treatment. The following outcomes were measured: pain by using a numeric rating scale, spasticity by the Modified Ashworth Scale for Grading Spasticity, acceptance and emotional reaction to the treatment by the Hospital Anxiety and Depression Scale, and functionality by ranges of motion. The patient improved in all outcomes after treatment, and results were maintained during the follow-up sessions.

CONCLUSION

The combined NM and BoNT-A treatment appeared to decrease pain and improve joint ranges of motion during treatment for this patient. The patient showed decreased anxiety and depression during and after the treatment.

Care management of spasticity with botulinum toxin-A in patients with severe acquired brain injury: a 1-year follow-up prospective study

OBJECTIVE

To evaluate the efficacy and the safety of repeated botulinum toxin type A (BT-A) injections in patients with severe acquired brain injury (ABI) and to gain a better knowledge of possible clinical or demographic characteristics associated with a better rehabilitation outcome.

DESIGN

Prospective study with a 1-year follow-up period.

SUBJECTS

Twenty-one patients with spasticity due to severe ABI and no further improving with rehabilitation treatment and oral anti-spastic drugs.

INTERVENTION

Repeated BT-A injections associated to a rehabilitation programme.

MAIN MEASURES

Barthel Index (BI), Modified Ashworth Score (MAS) and VAS score for pain subjective perception were recorded.

RESULTS

At the end of the follow-up study, MAS, BI and VAS significantly improved. Despite the number of BT-A injections, a shorter interval between severe ABI onset and first BT-A treatment correlated to a better BI improvement. None of the patients experienced adverse events attributable to BT-A.

CONCLUSION

BT-A was effective and safe in the treatment of spasticity in severe ABI patients, with a better functional outcome in those subjects treated earlier after spasticity onset. The lack of correlation between clinical outcome and number of injections suggests, in addition to a direct inhibition at the neuromuscular junction, a more distant BT-A long-term effect.

Outcomes of tendon fractional lengthenings to improve shoulder function in patients with spastic hemiparesis

BACKGROUND

Patients with spastic hemiparesis after upper motor neuron (UMN) injury often exhibit limited shoulder movement. We evaluated the outcomes of shoulder tendon fractional lengthenings in patients with spasticity and preserved volitional control.

METHODS

A consecutive series of 34 adults with spastic hemiparesis from UMN injury (23 post-stroke, 11 post-traumatic brain injury) and limited shoulder movement with preserved volitional motor control who underwent shoulder tendon fractional lengthenings (pectoralis major, latissimus dorsi, teres major) were evaluated. Active and passive shoulder motion, spasticity, pain, and satisfaction were considered pre- and postoperatively.

RESULTS

There were 15 males and 19 females with a mean age of 44.1 years. Mean follow-up was 12.2 months. Mean Modified Ashworth spasticity score was 2.4 preoperatively compared to 1.9 postoperatively (P = .001). Active flexion, abduction, and external rotation improved compared to the normal contralateral side (P < .001) with most dramatic gains in external rotation. Similarly, passive extension, flexion, abduction, and external rotation improved compared to the normal contralateral side (P < .01). Ninety-four percent (15/16) with preoperative pain had improved pain relief postoperatively with 14 (88%) being pain-free. Thirty-one (92%) were satisfied with the outcome.

CONCLUSION

Shoulder tendon lengthenings can be an effective means of pain-relief, improved motion, enhanced active motor function, and decreased spasticity in patients with spastic hemiparesis from UMN injury.

Valid and reliable instruments for arm-hand assessment at ICF activity level in persons with hemiplegia: a systematic review

BACKGROUND

Loss of arm-hand performance due to a hemiparesis as a result of stroke or cerebral palsy (CP), leads to large problems in daily life of these patients. Assessment of arm-hand performance is important in both clinical practice and research. To gain more insight in e.g. effectiveness of common therapies for different patient populations with similar clinical characteristics, consensus regarding the choice and use of outcome measures is paramount. To guide this choice, an overview of available instruments is necessary. The aim of this systematic review is to identify, evaluate and categorize instruments, reported to be valid and reliable, assessing arm-hand performance at the ICF activity level in patients with stroke or cerebral palsy.

METHODS

A systematic literature search was performed to identify articles containing instruments assessing arm-hand skilled performance in patients with stroke or cerebral palsy. Instruments were identified and divided into the categories capacity, perceived performance and actual performance. A second search was performed to obtain information on their content and psychometrics.

RESULTS

Regarding capacity, perceived performance and actual performance, 18, 9 and 3 instruments were included respectively. Only 3 of all included instruments were used and tested in both patient populations. The content of the instruments differed widely regarding the ICF levels measured, assessment of the amount of use versus the quality of use, the inclusion of unimanual and/or bimanual tasks and the inclusion of basic and/or extended tasks.

CONCLUSIONS

Although many instruments assess capacity and perceived performance, a dearth exists of instruments assessing actual performance. In addition, instruments appropriate for more than one patient population are sparse. For actual performance, new instruments have to be developed, with specific focus on the usability in different patient populations and the assessment of quality of use as well as amount of use. Also, consensus about the choice and use of instruments within and across populations is needed.

Botulinum toxin injection for hypertonicity of the upper extremity within 12 weeks after stroke: a randomized controlled trial

BACKGROUND

Botulinum neurotoxin type A (BoNT-A) reduces upper-extremity poststroke spasticity when given 6 or more months after stroke. Effects on functional use of the arm and hand are less apparent.

OBJECTIVE

To determine the effect and safety of very early use of BoNT-A for patients with upper-limb spasticity.

METHODS

The Asia Botulinum Toxin-A Clinical Trial

DESIGN

ed for Early Post-stroke Spasticity (ABCDE-S; NCT00234546) was a multicenter, randomized, placebo-controlled trial conducted in patients recruited within 2 -12 weeks of first-ever stroke. Participants with a Modified Ashworth Scale (MAS) score of 1+ or above received BoNT-A (Dysport) 500 U or placebo to one or more wrist and elbow mover muscles, plus unstructured rehabilitation. The primary outcome was the MAS score in the most affected joint 4 weeks after first injection. Follow-up was 24 weeks.

RESULTS

A total of 163 patients were enrolled and assigned to placebo (n = 83) or BoNT-A (n = 80). Mean time since stroke was about 7 weeks. At 4 weeks postinjection, BoNT-A significantly improved MAS scores. Treatment effect-size estimates increased with higher baseline MAS scores from 0.45 (Q1) to 0.70 (Q3). MAS scores for all secondary end points improved with BoNT-A versus placebo at all time points (P < .0001, all visits). The Functional Motor Assessment Scale did not reveal clinically significant differences. No group differences in adverse events were found. Interpretation. BoNT-A 500 U can provide a sustained reduction in poststroke upper-limb spasticity when combined with rehabilitation in Asian patients who have mild-to-moderate hypertonicity and voluntary movement, within 2 -12 weeks of stroke. Functional use of the arm and hand was not affected.

Assessing the neurophysiological effects of botulinum toxin treatment for adults with focal limb spasticity: a systematic review

To examine effectiveness of botulinum toxin therapy (BoNT), accurate quantification of the neurological component of underlying spasticity is needed.

PURPOSE

Systematically identify and summarize literature on neurophysiological methods to test the effectiveness of BoNT, discuss methodological aspects, and recommend best techniques for clinical and research settings.

METHODS

Electronic databases were searched using specific keywords. Reviews and reference lists were hand-checked to find relevant studies. Studies in adults with focal limb spasticity were included.

RESULTS

Over 300 articles were scanned for relevance, and a list of 90 relevant articles was made. After excluding reviews and studies in healthy controls or non-spasticity related BoNT, 22 articles were reviewed. Neurophysiological techniques included electromyography (EMG; n = 11), electrical nerve stimulation (n = 13), transcranial magnetic stimulation (TMS; n = 1), functional magnetic resonance imaging (fMRI; n = 1), reflex threshold (n = 4), Achilles tendon reflex (n = 1), reflex latency (n = 1).

DISCUSSION

Maximum M-wave amplitude (M-max) and stretch reflex threshold techniques were successfully used to measure the neurophysiological effects of BoNT and have high test-retest reliability. EMG techniques require effective magnitude normalization techniques and establishing test-retest reliability.

CONCLUSION

Serial electrical nerve stimulation can be incorporated into clinical practice to assist in follow-up. We recommend using M-max and stretch reflex threshold techniques to assess the neurophysiological effects.

Therapeutic use of botulinum toxin in neurorehabilitation

The botulinum toxins (BTX), type A and type B by blocking vesicle acetylcholine release at neuro-muscular and neuro-secretory junctions can result efficacious therapeutic agents for the treatment of numerous disorders in patients requiring neuro-rehabilitative intervention. Its use for the reduction of focal spasticity following stroke, brain injury, and cerebral palsy is provided. Although the reduction of spasticity is widely demonstrated with BTX type A injection, its impact on the improvement of dexterity and functional outcome remains controversial. The use of BTX for the rehabilitation of children with obstetrical brachial plexus palsy and in treating sialorrhea which can complicate the course of some severe neurological diseases such as amyotrophic lateral sclerosis and Parkinson's disease is also addressed. Adverse events and neutralizing antibodies formation after repeated BTX injections can occur. Since impaired neurological persons can have complex disabling feature, BTX treatment should be viewed as adjunct measure to other rehabilitative strategies that are based on the individual's residual ability and competence and targeted to achieve the best functional recovery. BTX therapy has high cost and transient effect, but its benefits outweigh these disadvantages. Future studies must clarify if this agent alone or adjunctive to other rehabilitative procedures works best on functional outcome.

Shoulder tenotomies to improve passive motion and relieve pain in patients with spastic hemiplegia after upper motor neuron injury

HYPOTHESIS

Shoulder adduction and internal rotation contractures commonly develop in patients with spastic hemiplegia after upper motor neuron (UMN) injury. Contractures are often painful, macerate skin, and impair axillary hygiene. We hypothesize that shoulder tenotomies are an effective means of pain relief and passive motion restoration in patients without active upper extremity motor function.

MATERIALS AND METHODS

A consecutive series of 36 adults (10 men, 26 women) with spastic hemiplegia from UMN injury, shoulder adduction, and internal rotation contractures, and no active movement, who underwent shoulder tenotomies of the pectoralis major, latissimus dorsi, teres major, and subscapularis were evaluated. Patients were an average age of 52.2 years. Pain, passive motion, and satisfaction were considered preoperatively and postoperatively.

RESULTS

Average follow-up was 14.3 months. Preoperatively, all patients had limited passive motion that interfered with passive functions. Nineteen patients had pain. After surgery, passive extension, flexion, abduction, and external rotation improved from 50%, 27%, 27%, and 1% to 85%, 70%, 66%, and 56%, respectively, compared with the normal contralateral side (P < .001). All patients with preoperative pain had improved pain relief at follow-up, with 18 (95%) being pain-free. Thirty-five (97%) were satisfied with the outcome of surgery, and all patients reported improved axillary hygiene and skin care. Age, gender, etiology, and chronicity of UMN injury were not associated with improvement in motion.

DISCUSSION

We observed improvements in passive ROM and high patient satisfaction with surgery at early follow-up. Patients who had pain with passive motion preoperatively had significant improvements in pain after shoulder tenotomy.

CONCLUSION

Shoulder tenotomy to relieve spastic contractures resulting from UMN injury can be an effective means of pain relief and improved passive range of motion in patients without active motor function.

Poststroke Chronic Disease Management: Towards Improved Identification and Interventions for Poststroke Spasticity-Related Complications

This paper represents the opinion of a group of researchers and clinicians with an established interest in poststroke care and is based on the recognised need for long-term care following stroke, especially in view of the global increase of disability due to stroke. Among the more frequent long-term complications following stroke are spasticity-related disabilities. Although spasticity alone occurs in up to 60% of stroke survivors, disabling spasticity affects only 4–10%. Spasticity further interferes with important functions of daily life when it occurs in association with pain, motor impairment, and overall declines of cognitive and neurological function. It is proposed that the aftermath of stroke be considered a chronic disease requiring a multifactorial and multilevel approach. There are, however, knowledge gaps related to the prediction and recognition of poststroke disability. Interventions to prevent or minimise such disabilities require further development and evaluation. Poststroke spasticity research should focus on reducing disability and be considered as part of a continuum of chronic care requirements and should be recognised as a part of a comprehensive poststroke disease management programme.