Botulinum toxin type A in post-stroke lower limb spasticity: a multicenter, double-blind, placebo-controlled trial. J Neurol. 2010;257:1330-1337. [PMID: 20358216 PMCID: PMC2910313 DOI: 10.1007/s00415-010-5526-3]

Task-Oriented Training by a Personalized Electromyography-Driven Soft Robotic Hand in Chronic Stroke: A Randomized Controlled Trial

BACKGROUND

Intensive task-oriented training has shown promise in enhancing distal motor function among patients with chronic stroke. A personalized electromyography (EMG)-driven soft robotic hand was developed to assist task-oriented object-manipulation training effectively. Objective. To compare the effectiveness of task-oriented training using the EMG-driven soft robotic hand.

METHODS

A single-blinded, randomized controlled trial was conducted with 34 chronic stroke survivors. The subjects were randomly assigned to the Hand Task (HT) group (n = 17) or the control (CON) group (n = 17). The HT group received 45 minutes of task-oriented training by manipulating small objects with the robotic hand for 20 sessions, while the CON group received 45 minutes of hand-functional exercises without objects using the same robot. Fugl-Meyer assessment (FMA-UE), Action Research Arm Test (ARAT), Modified Ashworth Score (MAS), Box and Block test (BBT), Maximum Grip Strength, and active range of motion (AROM) of fingers were assessed at baseline, after intervention, and 3 months follow-up. The muscle co-contraction index (CI) was analyzed to evaluate the session-by-session variation of upper limb EMG patterns.

RESULTS

The HT group showed more significant improvement in FMA-UE (wrist/hand, shoulder/elbow) compared to the CON group (P < .05). At 3-month follow-up, the HT group demonstrated significant improvements in FMA-UE, ARAT, BBT, MAS (finger), and AROMs (P < .05). The HT group exhibited a more significant decrease in muscle co-contractions compared to the CON group (P < .05).

CONCLUSIONS

EMG-driven task-oriented training with the personalized soft robotic hand was a practical approach to improving motor function and muscle coordination.

CLINICAL TRIAL REGISTRY NAME

Soft Robotic Hand System for Stroke Rehabilitation.

CLINICAL TRIAL REGISTRATION-URL

https://clinicaltrials.gov/.

UNIQUE IDENTIFIER

NCT03286309.

Clinical neurophysiology in the treatment of movement disorders: IFCN handbook chapter

In this review, different aspects of the use of clinical neurophysiology techniques for the treatment of movement disorders are addressed. First of all, these techniques can be used to guide neuromodulation techniques or to perform therapeutic neuromodulation as such. Neuromodulation includes invasive techniques based on the surgical implantation of electrodes and a pulse generator, such as deep brain stimulation (DBS) or spinal cord stimulation (SCS) on the one hand, and non-invasive techniques aimed at modulating or even lesioning neural structures by transcranial application. Movement disorders are one of the main areas of indication for the various neuromodulation techniques. This review focuses on the following techniques: DBS, repetitive transcranial magnetic stimulation (rTMS), low-intensity transcranial electrical stimulation, including transcranial direct current stimulation (tDCS) and transcranial alternating current stimulation (tACS), and focused ultrasound (FUS), including high-intensity magnetic resonance-guided FUS (MRgFUS), and pulsed mode low-intensity transcranial FUS stimulation (TUS). The main clinical conditions in which neuromodulation has proven its efficacy are Parkinson's disease, dystonia, and essential tremor, mainly using DBS or MRgFUS. There is also some evidence for Tourette syndrome (DBS), Huntington's disease (DBS), cerebellar ataxia (tDCS), and axial signs (SCS) and depression (rTMS) in PD. The development of non-invasive transcranial neuromodulation techniques is limited by the short-term clinical impact of these techniques, especially rTMS, in the context of very chronic diseases. However, at-home use (tDCS) or current advances in the design of closed-loop stimulation (tACS) may open new perspectives for the application of these techniques in patients, favored by their easier use and lower rate of adverse effects compared to invasive or lesioning methods. Finally, this review summarizes the evidence for keeping the use of electromyography to optimize the identification of muscles to be treated with botulinum toxin injection, which is indicated and widely performed for the treatment of various movement disorders.

Assessment of pain relief after four botulinum toxin A injection cycles in patients with post-stroke lower limb spasticity: A prospective, observational study

INTRODUCTION

Spasticity is common after a stroke and is an independent risk factor for developing pain. BotulinumtoxinA injection is the treatment of choice for focal spasticity. We examined the effect of intramuscular botulinumtoxinA on pain relief in patients in routine clinical practice who were experiencing pain as a primary complaint associated with post-stroke lower limb spasticity.

METHODS

Prospective, multicentre, post-marketing observational study. The study period was 16 months. The primary effectiveness variable was the mean change from baseline on the pain 0-10 Numerical Rating Scale after four botulinumtoxinA injection cycles. Secondary endpoints included changes from baseline on the pain 0-100 Visual Analogue Scale, Goal Attainment Scale, modified Ashworth Scale, 10-Meter Walk Test, Penn Spasm Frequency Scale, and 36-item Short-Form Health Survey.

RESULTS

Of 186 enrolled patients, 180 (96.8%) received botulinumtoxinA at least once. The mean (standard deviation) pain 0-10 Numerical Rating Scale score decreased significantly (p<0.0001) from 4.9 (2.2) at baseline to 2.5 (2.1) at study end, representing a 50% decrease in pain severity. Relief of pain due to spasticity was supported by improvement from baseline in all secondary variables except the 10-Meter Walk Test. Two adverse events (erysipelas and phlebitis) in one patient were considered likely to be related to botulinumtoxinA injection.

CONCLUSION

BotulinumtoxinA appears to provide pain relief as an additional benefit of local treatment in patients with post-stroke lower limb spasticity for whom pain relief is a primary therapeutic goal (a Lay Abstract has been provided as Appendix A).

Pain, disability, and quality of life in participants after concurrent onabotulinumtoxinA treatment of upper and lower limb spasticity: Observational results from the ASPIRE study

INTRODUCTION

Upper and lower limb spasticity is commonly associated with central nervous system disorders including stroke, traumatic brain injury, multiple sclerosis, cerebral palsy, and spinal cord injury, but little is known about the concurrent treatment of upper and lower limb spasticity with botulinum toxins.

OBJECTIVE

To evaluate onabotulinumtoxinA (onabotA) utilization and to determine if concurrent onabotA treatment of the upper and lower limbs has supported improvements in participants with spasticity.

DESIGN

Sub-analysis of a 2-year, international, prospective, observational registry (ASPIRE, NCT01930786).

SETTING

International clinic sites (54).

PARTICIPANTS

Adult spasticity participants across etiologies, who received ≥1 concurrent onabotA treatment of the upper and lower limbs during the study.

INTERVENTION

Participants were treated with onabotA at the clinician's discretion.

OUTCOMES

Baseline characteristics and outcomes of disability (Disability Assessment Scale [DAS]), pain (Numeric Pain Rating Scale [NPRS]), participant satisfaction, physician satisfaction, and quality of life (QoL; Spasticity Impact Assessment [SIA]) were evaluated. Adverse events were monitored throughout the study.

RESULTS

Of 744 participants enrolled, 730 received ≥1 dose of onabotA; 275 participants received treatment with onabotA in both upper and lower limbs during ≥1 session; 39.3% of participants were naïve to onabotA for spasticity. The mean (SD) total dose per treatment session ranged from 421.2 (195.3) to 499.6 (188.6) U. The most common baseline upper limb presentation was clenched fist (n = 194, 70.5%); lower limb was equinovarus foot (n = 219, 66.9%). High physician and participant satisfaction and improvements in pain, disability and QoL were reported after most treatments. Nine participants (3.3%) reported nine treatment-related adverse events; two participants (0.7%) reported three serious treatment-related severe adverse events. No new safety signals were identified.

CONCLUSION

More than a third of enrolled participants received at least one concurrent onabotA treatment of the upper and lower limbs, with reduced pain, disability, and improved QoL after treatment, consistent with the established safety profile of onabotA for the treatment of spasticity.

Robotic gait training and botulinum toxin injection improve gait in the chronic post-stroke phase: A randomized controlled trial

BACKGROUND

Improving walking ability is one of the main goals of rehabilitation after stroke. When lower limb spasticity increases walking difficulty, botulinum toxin type A (BTx-A) injections can be combined with non-pharmacologic interventions such as intensive rehabilitation using a robotic approach. To the best of our knowledge, no comparisons have been made between the efficacy of robotic gait training and conventional physical therapy in combination with BTx-A injections.

OBJECTIVE

To conduct a randomized controlled trial to compare the efficacy on gait of robotic gait training versus conventional physiotherapy after BTx-A injection into the spastic triceps surae in people after stroke.

METHOD

Thirty-three participants in the chronic stroke phase with triceps surae spasticity inducing gait impairment were included. After BTx-A injection, participants were randomized into 2 groups. Group A underwent robotic gait training (Lokomat®) for 2 weeks, followed by conventional physiotherapy for 2 weeks (n = 15) and Group B underwent the same treatment in reverse order (n = 18). The efficacy of these methods was tested using the 6-minute walk test (6MWT), comparing post-test 1 and post-test 2 with the pre-test.

RESULTS

After the first period, the 6MWT increased significantly more in Group A than in Group B: the mean difference between the interventions was 33 m (95%CI 9; 58 p = 0.007; g = 0.95), in favor of Group A; after the second period, the 6MWT increased in both groups, but the 30 m difference between the groups still remained (95%CI 5; 55 p = 0.019; g = 0.73).

CONCLUSION

Two weeks of robotic gait training performed 2 weeks after BTx-A injections improved walking performance more than conventional physiotherapy. Large-scale studies are now required on the timing of robotic rehabilitation after BTx-A injection.

Myoelectric interface for neurorehabilitation conditioning to reduce abnormal leg co-activation after stroke: a pilot study

BACKGROUND

The ability to walk is an important factor in quality of life after stroke. Co-activation of hip adductors and knee extensors has been shown to correlate with gait impairment. We have shown previously that training with a myoelectric interface for neurorehabilitation (MINT) can reduce abnormal muscle co-activation in the arms of stroke survivors.

METHODS

Here, we extend MINT conditioning to stroke survivors with leg impairment. The aim of this pilot study was to assess the safety and feasibility of using MINT to reduce abnormal co-activation between hip adductors and knee extensors and assess any effects on gait. Nine stroke survivors with moderate to severe gait impairment received 6 h of MINT conditioning over six sessions, either in the laboratory or at home.

RESULTS

MINT participants completed a mean of 159 repetitions per session without any adverse events. Further, participants learned to isolate their muscles effectively, resulting in a mean reduction of co-activation of 70% compared to baseline. Moreover, gait speed increased by a mean of 0.15 m/s, more than the minimum clinically important difference. Knee flexion angle increased substantially, and hip circumduction decreased.

CONCLUSION

MINT conditioning is safe, feasible at home, and enables reduction of co-activation in the leg. Further investigation of MINT's potential to improve leg movement and function after stroke is warranted. Abnormal co-activation of hip adductors and knee extensors may contribute to impaired gait after stroke. Trial registration This study was registered at ClinicalTrials.gov (NCT03401762, Registered 15 January 2018, https://clinicaltrials.gov/study/NCT03401762?tab=history&a=4 ).

Statement of the Rehabilitation Medicine Society of Australia and New Zealand for the therapeutic use of botulinum toxin A in spasticity management

The Rehabilitation Medicine Society of Australia and New Zealand advocates the safe, effective and evidence-based use of botulinum toxin type A for spasticity management. The process requires appropriate training, alongside considerable knowledge and skills, to maximise efficacy. The processes before and after injection contribute to effectiveness. The gold standard of managing spasticity is for assessment by a multidisciplinary specialist team, deriving patient-centric goals, and designing an injection protocol to match these goals. The patient and/or carers are considered part of the decision-making team. Postinjection therapy and measurement of goal achievement are highly recommended as part of the wider holistic approach to management. The Society believes treatment failures can be minimised by following clear clinical guidelines.

Myoelectric interface for neurorehabilitation conditioning to reduce abnormal leg co-activation after stroke: a pilot study

Background

The ability to walk is an important factor in quality of life after stroke. Co-activation of hip adductors and knee extensors has been shown to correlate with gait impairment. We have shown previously that training with a myoelectric interface for neurorehabilitation (MINT) can reduce abnormal muscle co-activation in the arms of stroke survivors.

Methods

Here, we extend MINT conditioning to stroke survivors with leg impairment. The aim of this pilot study was to assess the safety and feasibility of using MINT to reduce abnormal co-activation between hip adductors and knee extensors and assess any effects on gait. Nine stroke survivors with moderate to severe gait impairment received six hours of MINT conditioning over six sessions, either in the laboratory or at home.

Results

MINT participants completed a mean of 159 repetitions per session without any adverse events. Further, participants learned to isolate their muscles effectively, resulting in a mean reduction of co-activation of 70% compared to baseline. Moreover, gait speed increased by a mean of 0.15 m/s, more than the minimum clinically important difference. Knee flexion angle increased substantially, and hip circumduction decreased.

Conclusion

MINT conditioning is safe, feasible at home, and enables reduction of co-activation in the leg. Further investigation of MINT's potential to improve leg movement and function after stroke is warranted. Abnormal co-activation of hip adductors and knee extensors may contribute to impaired gait after stroke.

Trial registration

This study was registered at ClinicalTrials.gov (NCT03401762, Registered 15 January 2018, https://clinicaltrials.gov/study/NCT03401762?tab=history&a=4).

Treatment of adult spasticity with Botox (onabotulinumtoxinA): Development, insights, and impact

Upper and lower limb spasticity (ULS, LLS) often occur following a stroke or in patients with other neurological disorders, leading to difficulties in mobility and daily living and decreased quality of life. Prior to the use of onabotulinumtoxinA, antispastic medications had limited efficacy and often caused sedation. Phenol injections were difficult for physicians to perform, painful, and led to tissue destruction. The success of onabotulinumtoxinA in treating cervical dystonia led to its use in spasticity. However, many challenges characterized the development of onabotulinumtoxinA for adult spasticity. The wide variability in the presentation of spasticity among patients rendered it difficult to determine which muscles to inject and how to measure improvement. Another challenge was the initial refusal of the Food and Drug Administration to accept the Ashworth Scale as a primary endpoint. Additional scales were designed to incorporate a goal-oriented, patient-centered approach that also accounted for the variability of spasticity presentations. Several randomized, double-blind, placebo-controlled trials of post-stroke spasticity of the elbow, wrist, and/or fingers showed significantly greater improvements in the modified Ashworth Scale and patient treatment goals and led to the approval of onabotulinumtoxinA for the treatment of ULS in adult patients. Lessons learned from the successful ULS trials were applied to design an LLS trial that led to approval for the latter indication. Additional observational trials mimicking real-world treatment have shown continued effectiveness and patient satisfaction. The use of onabotulinumtoxinA for spasticity has ushered in a more patient-centered treatment approach that has vastly improved patients' quality of life.

Botulinum toxin for motor disorders

Botulinum neurotoxins are a group of biological toxins produced by the gram-negative bacteria Clostridium botulinum. After intramuscular injection, they produce dose-related muscle relaxation, which has proven useful in the treatment of a large number of motor and movement disorders. In this chapter, we discuss the utility of botulinum toxin treatment in three major and common medical conditions related to the dysfunction of the motor system, namely dystonia, tremor, and spasticity. A summary of the existing literature is provided along with different techniques of injection including those recommended by the authors.

The effect of oral baclofen and botulinum toxin treatments in hemiplegic spasticity on the nociceptive flexor reflex: A randomized clinical trial

Objectives

This study aimed to analyze the effect of oral baclofen treatment and botulinum toxin type A (BT-A) injection treatment in hemiplegic patients with spasticity on the electromyographic nociceptive flexor reflex (NFR) threshold.

Patients and methods

A total of 29 spastic hemiplegic patients (20 males, 9 females; mean age: 52.9±10.1; range, 27 to 64) with Modified Ashworth Scale (MAS) grades 2-4 were included in the prospective, randomized study between May 2018 and March 2019. The patients were divided into two groups: the BT-A group consisted of 15 patients that underwent a BT-A injection and the baclofen group consisted of 14 patients treated with baclofen. Modified Ashworth Scale, Visual Analog Scale (VAS), Barthel daily life activity index, and NFR threshold values were used in the evaluation of the patients before and after the treatment at the sixth week. The motor evaluation of the patients was performed using Brunnstrom motor staging.

Results

In both groups, MAS and VAS values decreased significantly compared to pretreatment (p<0.05). There was a significant decrease in ankle MAS score (p<0.001) and a significant increase in Brunnstrom hand recovery stages in the BT-A group compared to pretreatment (p=0.020). While the NFR threshold statistically significantly increased in the baclofen group compared to pretreatment (p=0.007), there was no significant change in the BT-A group (p=0.669).

Conclusion

These results suggest that BT-A injections do not cause a significant change in the NFR threshold in the treatment of spasticity.

A Pilot Study of A2NTX, a Novel Low-Molecular-Weight Neurotoxin Derived from Subtype A2 for Post-Stroke Lower Limb Spasticity: Comparison with OnabotulinumtoxinA

All the currently used type A botulinum neurotoxins for clinical uses are of subtype A1. We compared the efficacy and safety for the first time head-to-head between a novel botulinum toxin A2NTX prepared from subtype A2 and onabotulinumtoxinA (BOTOX) derived from A1 for post-stroke spasticity. We assessed the modified Ashworth scale (MAS) of the ankle joint, the mobility scores of Functional Independence Measure (FIM), and the grip power of the unaffected hand before and after injecting 300 units of BOTOX or A2NTX into calf muscles. The procedure was done in a blinded manner for the patient, the injecting physician, and the examiner. Stroke patients with chronic spastic hemiparesis (15 for A2NTX and 16 for BOTOX) were enrolled, and 11 for A2NTX and 13 for BOTOX (MAS of ankle; > or = 2) were entered for the MAS study. Area-under-curves of changes in MAS (primary outcome) were greater for A2NTX by day 30 (p = 0.044), and were similar by day 60. FIM was significantly improved in the A2NTX group (p = 0.005), but not in the BOTOX group by day 60. The hand grip of the unaffected limb was significantly decreased in the BOTOX-injected group (p = 0.002), but was unaffected in the A2NTX-injected group by day 60, suggesting there was less spread of A2NTX to the upper limb than there was with BOTOX. Being a small-sized pilot investigation with an imbalance in the gender of the subjects, the present study suggested superior efficacy and safety of A2NTX, and warrants a larger scale clinical trial of A2NTX to confirm these preliminary results.

Validation of a semiological maneuver for the evaluation of spastic dynamic clubfoot: an approach based on the judgment of experts in physical medicine and rehabilitation

BACKGROUND

The evaluation of spasticity of the plantar flexors in dynamic clubfoot is difficult due to the almost invariable concomitance of Achilles clonus, which is a semiological artifact. No description was found in the literature of a technique for inhibiting or reducing the discharge generated by Achilles clonus to allow a correct assessment of spasticity in this segment.

AIM

Validation of a semiological maneuver that reduces or eliminates Achilles clonus for the adequate evaluation of spastic dynamic clubfoot.

DESIGN

Multicenter cross-sectional study.

SETTING

The study was conducted by 12 experts in physical medicine and rehabilitation from various clinics and hospitals in Colombia.

POPULATION

Thirty-five adults with dynamic spastic clubfoot and Achilles clonus secondary to upper motor neuron syndrome who attended outpatient consultation at physical medicine and rehabilitation services in eight cities Colombia from August 2020 to February 2021.

METHODS

The usual method for examining spastic plantar flexors was compared to the proposed semiological maneuver to evaluate the proposed maneuver contributed to the reduction or elimination of Achilles clonus to allow a more accurate measure of spasticity in this segment. Four dimensions were evaluated by the experts: time required for application, simplicity, effectiveness and clinical utility. A cutoff point was established to identify whether the maneuver was unacceptable, acceptable or excellent.

RESULTS

The application of the maneuver was able to reduce or eliminate Achilles clonus as a masking sign of spasticity in the plantar flexors in 100% of the patients and was considered excellent in 77.1% of the cases for the four dimensions evaluated. A decrease in the degree of spasticity of the plantar flexors was observed when the maneuver was applied.

CONCLUSIONS

The proposed maneuver reduces or eliminates Achilles clonus, which could allow a more precise evaluation of spasticity in this segment. All of the experts recommended including the maneuver in routine examinations of this population.

CLINICAL REHABILITATION IMPACT

Applying the proposed maneuver could improve the selection of patients with spastic dynamic clubfoot who require specific treatment.

Association of Lower Limb Focal Spasticity With Kinematic Variables During Walking in Traumatic Brain Injury

BACKGROUND AND PURPOSE

Focal muscle spasticity is defined as spasticity that affects a localized group of muscles. It is prevalent in many adult-onset neurological conditions, yet the relationship of focal muscle spasticity with walking remains unclear. Therefore, the aim of this study was to determine the relationship of focal muscle spasticity with the kinematics of walking in traumatic brain injury (TBI).

METHODS

Ninety-one participants with TBI underwent clinical gait analysis and assessment of focal lower limb muscle spasticity in a prospective cross-sectional study. A matched group of 25 healthy controls (HCs) were recruited to establish a reference dataset. Kinematic data for each person with and without focal muscle spasticity following TBI were compared with the HC cohort at a matched walking speed.

RESULTS

The TBI and HC cohorts were well matched. Only those with focal hamstring muscle spasticity walked significantly different to those without. They had significantly greater knee flexion (23.4° compared with 10.5°, P < 0.01) at initial contact. There were no other significant differences in kinematic variables between those with and without focal muscle spasticity. There was no significant association between focal muscle spasticity and walking speed.

DISCUSSION AND CONCLUSIONS

Focal muscle spasticity and abnormal kinematics whilst walking were common in this cohort of people with TBI. However, focal muscle spasticity had little relationship with kinematic variables, and no significant relationship with walking speed. This finding has implications for the treatment of focal muscle spasticity to improve walking following TBI. Focal muscle spasticity had little relationship with kinematic variables and walking speed in this cohort of people with TBI who could walk without assistance.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A381).

Efficacy and Safety of IncobotulinumtoxinA in the Treatment of Lower Limb Spasticity in Japanese Subjects

Objective

To confirm the efficacy and safety of incobotulinumtoxinA (Xeomin®, Merz Pharmaceuticals GmbH; total dose 400 U) in Japanese subjects with lower limb (LL) poststroke spasticity using the Modified Ashworth Scale spasticity score for the plantar flexors (MAS-PF).

Methods

This phase III study (Japic clinical study database No. CTI-153030, 7 October 2015) included a double-blind, 12-week main period (MP) in which 208 subjects were randomized to receive one injection cycle of incobotulinumtoxinA 400 U (n = 104) or placebo (n = 104) in the pes equinus muscles, and an open-label extension (OLEX) that enrolled 202 subjects who received three injection cycles, 10–14 weeks in duration (the last cycle was fixed at 12 weeks). Changes in MAS-PF for incobotulinumtoxinA vs. placebo from baseline to Week 4 of the MP and to the end-of-cycle visits in the OLEX were evaluated.

Results

The area under the curve for the change in MAS-PF was statistically significantly greater with incobotulinumtoxinA vs. placebo in the MP (mean: −7.74 vs. −4.76; least squares mean: −8.40 vs. −5.81 [p = 0.0041]). In the OLEX, mean changes in MAS-PF from baseline to end-of-study showed continued improvement with repeated injections. No new safety concerns were observed with the incobotulinumtoxinA treatment. Its efficacy and safety were consistent regardless of the length of the injection cycle interval in the OLEX.

Conclusion

This study demonstrated that incobotulinumtoxinA (total dose 400 U) is an effective and a well-tolerated treatment for LL spasticity in Japanese subjects using flexible injection intervals of 10–14 weeks.

Comparative Effectiveness of Botulinum Toxin Injections and Extracorporeal Shockwave Therapy for Post-Stroke Spasticity: A Systematic Review and Network Meta-Analysis

BACKGROUND

The anti-spasticity efficacy of botulinum toxin (BoNT) injection has been well established for patients with chronic stroke; however, extracorporeal shock wave therapy (ESWT), i.e. focused shockwave (FSW) and radial shockwave (RSW), has recently been applied. We aimed to investigate the comparative effectiveness of BoNT vs. ESWT in the reduction of spasticity among stroke survivors.

METHODS

PubMed, EMBASE, MEDLINE and Cochrane CENTRAL were searched from the earliest record to September 2021 for randomized controlled trials. Weighted mean differences (WMDs) on the reduction of the Modified Ashworth Scale before or at the 6th post-treatment week (short-term) and between the 7th and 12th weeks (mid-term) after the intervention were calculated. Ranking probabilities of the WMD were simulated to determine which treatment had the potential to possess the best effectiveness. inplasy.com registration: INPLASY202170018.

FINDINGS

A total of 33 studies comprising 1,930 patients were enrolled. The network meta-analysis revealed that BoNT injections, FSW and RSW were better in spasticity reduction than the control treatment(s) at the short term, with WMDs of -0.69 (95% CI, -0.87 to -0.50), -0.36 (95% CI, -0.69 to -0.03) and -0.62 (95% CI, -0.84 to -0.40), respectively. Likewise, mid-term effects of BoNT injections, FSW and RSW also revealed superiority, with WMDs of -0.44 (95% CI, -0.62 to -0.26), -0.74 (95% CI, -1.26 to -0.23) and -0.79 (95% CI, -1.07 to -0.51), respectively. Ranking probability analysis revealed that RSW had the highest probability of being the best treatment for spasticity reduction at the short-term (62.2%) and mid-term (72.3%) periods during the follow up.

INTERPRETATION

BoNT injections and ESWT are effective in alleviating post-stroke spasticity at the mid-term. The effectiveness of ESWT was comparable to BoNT injections, and RSW had the potential to be the best treatment for spasticity reduction among the three treatment options. More prospective trials incorporating head-to-head comparisons of BoNT injections vs. ESWT are needed to validate the role of ESWT in reducing post-stroke spasticity.

FUNDING

The current research project was supported by (1) National Taiwan University Hospital, Bei-Hu Branch; (2) Ministry of Science and Technology (MOST 106-2314-B-002-180-MY3 and 109-2314-B-002-114-MY3); 3) Taiwan Society of Ultrasound in Medicine.

Assessment, goal setting, and botulinum neurotoxin a therapy in the management of post-stroke spastic movement disorder: updated perspectives on best practice

INTRODUCTION

Post-stroke spastic movement disorder (PS-SMD) appears up to 20% in the first week following stroke and 40% in the chronic phase. It may create major hurdles to overcome in early stroke rehabilitation and as one relevant factor that reduces quality of life to a major degree in the chronic phase.

AREAS COVERED

In this review, we discuss predictors,early identification, clinical assessments, goal setting, and management in multiprofessional team, including Botulinum neurotoxin A (BoNT-A) injection for early and chronic management of PS-SMD.

EXPERT OPINION

The earlier PS-SMD is recognized and managed, the better the outcome will be. The comprehensive management in the subacute or chronic phase of PS-SMD with BoNT-A injections requires detailed assessment, patient-centered goal setting, technical-guided injection, effective dosing of BoNT-A per site, muscle, and session and timed adjunctive treatment, delivered in a multi-professional team approach in conjunction with physical treatment. Evidence-based data showed BoNT-A injections are safe and effective in managing focal, multifocal, segmental PS-SMD and its complications. If indicated, BoNT-A therapy should be accompanied with adjunctive treatment in adequate time slots. BoNT-A could be added to oral, intrathecal, and surgical treatment in severe multisegmental or generalized PS-SMD to reach patient/caregiver's goals, especially in chronic PS-SMD.

Efficacy and safety of onabotulinumtoxinA with standardized physiotherapy for the treatment of pediatric lower limb spasticity: A randomized, placebo-controlled, phase III clinical trial

BACKGROUND:

Spasticity is common in cerebral palsy and can result in pain and diminished health-related quality of life.

OBJECTIVE:

To evaluate the safety and efficacy of onabotulinumtoxinA for lower limb spasticity treatment in children with cerebral palsy.

METHODS:

In this registrational phase 3, multinational, randomized, double-blind, placebo-controlled trial (NCT01603628), children (2–< 17 years) with cerebral palsy and ankle spasticity (Modified Ashworth Scale-Bohannon [MAS] score≥2) were randomized 1 : 1 : 1 to standardized physical therapy and onabotulinumtoxinA (4 or 8 U/kg), or placebo. Primary endpoint was average change from baseline at weeks 4 and 6 in MAS ankle score. Secondary endpoints included the Modified Tardieu Scale (MTS) and Global Attainment Scale (GAS).

RESULTS:

381 participants were randomized. MAS scores averaged at weeks 4 and 6 were significantly reduced with both onabotulinumtoxinA doses (8 U/kg: –1.06, p = 0.010; 4 U/kg: –1.01, p = 0.033) versus placebo (–0.8). Significant improvements in average dynamic component of spasticity, measured by MTS, and in function, measured by GAS, were observed at several time points with both onabotulinumtoxinA doses versus placebo. Most adverse events were mild or moderate.

CONCLUSIONS:

OnabotulinumtoxinA was well tolerated and effective in reducing lower limb spasticity and improving functional outcomes versus placebo in children.

Evaluating the Effects of Botulinum Toxin Injection and Physiotherapy on Post-Stroke Patients During One Year Observation - a Pilot Study

Introduction: Stroke is a serious health problem in the modern population. Spasticity is one of the consequences of stroke and affects about 30% of people. Increased muscle tone affects postural control disorders. Due to the specificity of spasticity, therapy in post-stroke patients is a challenge for neurological physiotherapy. Therefore, it requires the development of appropriate management standards . Study aim: The aim of the study was to evaluate the effectiveness of 3 combination therapy cycles based on botulinum toxin injection and physiotherapy for muscle tone, muscle strength and postural stability in post-stroke patients qualified for the spasticity treatment programme of the lower and upper limbs. Material and methods: The pilot study involved 12 patients (6 from the lower limb and 6 from the upper limb programme). The 1-year combination therapy programmes included 3 botulinum toxin injections and 3 weeks of physiotherapy after each injection. Clinical evaluation was conducted before and after the 1-year observation cycle. The results were evaluated using: MAS (Modified Ashworth Scale), MRC (Medical Research Council Scale) and posture stability test on a balance platform (BiodexSD). Results: A decrease was observed in muscle tone of the lower and upper limbs, as well as an increase in muscular strength of the upper limb. However, there were no noted statistical significance of the studied parameters. Conclusions: Physiotherapy in combination with the botulinum toxin is an important element of improvement in post-stroke patients. However, further research is needed to explicitly confirm its effectiveness.

Time course response after single injection of botulinum toxin to treat spasticity after stroke: Systematic review with pharmacodynamic model-based meta-analysis

BACKGROUND

The time-course response after a single injection of botulinum toxin (BoNT) for post-stroke spasticity is debated. We addressed this issue by conducting a systematic review and a pharmacodynamic model-based meta-analysis.

METHODS

We searched Medline, PeDro and Google Scholar databases up to March 2020, selecting randomized controlled trials of post-stroke and traumatic brain injury patients with arm or leg muscle hypertonia, comparing BoNT to placebo, or different BoNT preparations. The main outcome was change in Modified Ashworth Scale (MAS) score. A non-linear mixed effect model was used to estimate maximal toxin and placebo effects (Emax and EPlacebo), the effect disappearance half-life (T1/2off) of BoNT and the doses achieving 50 and 80% of Emax (D50 and D80). The equivalence ratios between different BoNT preparations were calculated from D50 values. Adverse events were recorded.

RESULTS

Altogether, 2,236 unique records were screened by 2 independent reviewers: 35 eligible trials including 3011 patients (95% post-stroke) were identified. For all BoNT preparations, the BoNT Emax of -1.11 (95% credible interval -1.31; -0.29) was reached at 5 weeks; the maximal placebo effect was -0.30 (-0.37; -0.22). Both D50 and D80 differed significantly by muscle volume. At D50, the equivalence ratio was significantly higher for abobotulinumtoxinA (3.35) than onabotulinumtoxinA and lower for letibotulinumtoxinA (0.41). T1/2off was longer for abobotulinumtoxinA than for onabotulinumtoxinA and the other preparations (13.1 weeks [95% credible interval 7.7; 19.3] vs 8.6 weeks [7.1; 10.1]). Adverse events were minor, with a weak, but significant, dose-response relation for muscle weakness.

CONCLUSIONS

This first pharmacodynamic model-based meta-analysis of individuals with stroke revealed that for all BoNT-A preparations, BoNT-A injections to treat spasticity have maximal effect at 5 weeks. The T1/2off was longer for abobotulinumtoxinA than other preparations. Differences between certain BoNT unit scales were also confirmed.

Functional mobility in walking adult population with ataxia of Charlevoix-Saguenay

BACKGROUND

This study aimed to describe lower limbs impairments, balance and activity limitations related to indoor mobility in adult walkers with autosomal recessive spastic ataxia of Charlevoix-Saguenay (ARSACS).

RESULTS

Twenty-five participants were recruited with a mean age of 32.2 (± 10.4) years with 45.7% using a walking aid. There is a significant difference between participants with and without a walking aid in terms of lower limbs coordination, balance and mobility. Although participants who walk without a walking aid perform better than the others and they are below predictive or reference values. Despite significant mobility limitations, only mild spasticity and passive range of motion limitations were observed. However, there is a significant difference between unaffected individuals and participants with ARSACS for lower limb muscle cocontraction.

CONCLUSIONS

Results show a high level of lower limb impairments, balance and mobility limitation in adults' participants with ARSACS that are still walking, including people not using a walking aid. One of the most original finding is the presence of excessive cocontraction and a relatively mild level of spasticity in the lower limbs muscles. Results of this study better circumscribes the impairments and activities that should be the focus of intervention including rehabilitation in ARSACS.

The effectiveness of botulinum toxin on spasticity and gait of hemiplegic patients after stroke: A systematic review and meta-analysis

The aim of the study is to evaluate the evidence supporting the efficacy of botulinum toxin type A (BTA) injections in lower limb of hemiplegic patients, after stroke or cerebrovascular accident, and their gait analysis. This study included: randomized controlled trials (RCTs), non-randomized or controlled clinical trials (CCTs) or cluster trials, clinical trials of various phases (I-III), interrupted time series (ITS) studies with at least three data points before and after the intervention, controlled before and after (CBA) studies, prospective and retrospective comparative cohort studies, case-control and multicentred studies. The patients included in these studies had similar characteristics: age over 18 years, history of stroke and following hemiplegia, minimum modified Ashworth scale (MAS) score of 2 and duration since stroke over 6 months. The number of studies included in this review was 21. A meta-analysis was performed on a fraction of them depending on the reported index and the methodology as reported in detail in the results section. MAS score, following BTA injections, was significantly improved (Hedges' g: -1.17; 95% CI: -1.66, 0.67; p < 0.001). The same applied for the 10 Meter Walk Test (MWT) (-0.35; 95% CI: -0.68, -0.02; p = 0.016). The gait velocity showed improvement, yet without statistical significance (0.27; 95% CI: -0.09, 0.63; p = 0.285). We concluded that botulinum toxin injections showed effectiveness on lower limb hypertonia reduction of hemiplegic patients after stroke. Apart from significantly reducing the MAS scores, 10 MWT was also improved. However, more research is required in order to determine the advancement in specific gait and posture parameters.

A severe case of non-infective myositis six weeks post intramuscular injections of Onabotulinum toxin A (Botox) in a young man with tetraplegia: case report

INTRODUCTION

Myositis of unknown aetiology might be a very rare complication of intramuscular injections of onabotulinum toxin A (Botox) for spasticity treatment.

CASE PRESENTATION

We describe a case of significant myositis of unknown aetiology in a 17-year-old man, who was admitted for rehabilitation 4 months after his initial spinal cord injury (SCI) as a result of a mountain bike accident. He has an incomplete tetraplegia, C4 AIS B international Standards for Neurological Classification for Spinal Cord Injury (ISNCSCI) [1] due to C5 vertebra 3 column fracture [2]. He had severe spasticity of his lower limb muscles treated with Botox, following which, he required two acute hospital transfers for diagnosis and management of myositis.

DISCUSSION

This is a severe unusual presentation of myositis caused by intramuscular botulinum toxin for treatment of spasticity, in the frequent setting of spasticity where intramuscular botulinum toxin injections are routinely used.

Do gait parameters improve after botulinum toxin injections in post stroke patients? A prospective study

The intramuscular injection of botulinum toxin is one of the most efficient ways to treat localized spasticity in patients suffering from Central Nervous System lesions like stroke, cerebral palsy and multiple sclerosis. The gait analysis based on kinetics and kinematics is a recognized way of measurement of the effect of intramuscular injection of botulinum toxin in spastic patients suffering from chronic stroke. The aim of this study is to provide evidence of the beneficial effect of botulinum toxin on characteristics of gait pattern on patients suffering from chronic stroke. So, thirteen patients with spasticity due to chronic stroke were included in the protocol and were treated by botulinum toxin injections in the lower extremity. All patients were evaluated before the injection as well as one month after the botulinum injection on a foot pressure sensitive walkway with a power plate and by the readings of seven inertial measurements units which recorded spatio-temporal specific parameters during walking, and the spasticity was measured according to modified Ashworth Scale. While all spatio-temporal parameters of motion analysis and balance improved for most of the patients after botulinum toxin injection, only one parameter, the normal to hemiplegic step length, reached statistical significant improvement (p < 0.03). Moreover the modified Ashworth score was statistically improved post injection (p < 0.001). In conclusion the use of botulinum toxin injections is beneficial in post stroke patients as this is depicted in gait parameters improvement which accompanies the spasticity reduction.

Quantified clinical measures linked to ambulation speed in hemiparesis

Background: In spastic paresis, the respective contributions to active function of antagonist hypoextensibility, spasticity, and impaired descending command remain unknown. Objectives: We explored correlations between ambulation speed and coefficients of shortening, spasticity and, weakness for three lower limb extensors.Methods: This retrospective study identified 140 subjects with chronic hemiparesis (>6 months since injury) assessed during a single visit with barefoot 10-meter ambulation at comfortable and fast speed, and measurements of passive range of motion (X_V1), angle of catch at fast stretch (X_V3) and active range of motion (X_A) against the resistance of gastrocnemius, rectus femoris, and gluteus maximus. Coefficients of shortening (C_SH=[X_N-X_V1]/X_N; X_N, normal expected amplitude based on anatomical values), spasticity (C_SP=[X_V1-X_V3]/X_V1), and weakness (C_WK=[X_V1-X_A]/X_V1) were derived. For each muscle, multivariable analysis explored C_SH, C_SP, and C_WK as potential predictors of ambulation speed.Results: Ambulation speed was 0.62±0.28m/s (mean±SD, comfortable) and 0.84±0.38m/s (fast) and was correlated with C_SH and C_WK against gastrocnemius (C_SH, comfortable, ns; fast, β=-0.20, p=.03; C_WK, comfortable, β=-0.21, p=.010; fast, β=-0.21, p =.012), rectus femoris (C_SH, comfortable, β=-0.41, p=6E^-7; fast, β=-0.43, p=5E^-7; C_WK, comfortable, β=-0.36, p=5E^-5; fast, β=-0.33, p=.0003) and gluteus maximus (C_SH, comfortable, β=-0.19, p=.02; fast, β=-0.26, p=.002; C_WK, comfortable, β=-0.26, p=.002; fast, β=-0.22, p=.010). Ambulation speed was not correlated with C_SP.Conclusions: In chronic hemiparesis, ambulation speed correlates with coefficients of shortening and of weakness in lower limb extensors, but not with their spasticity level. This may encourage therapists to focus treatment primarily on muscle shortening by stretching programs and on impaired descending command by active training.

Continuous Increase of Efficacy under Repetitive Injections of Botulinum Toxin Type/A beyond the First Treatment for Adult Spastic Foot Drop

The objective of this study was to quantify the increase in efficacy during the first four cycles of treatment with botulinum toxin type/A (BoNT/A) in 24 free-walking BoNT/A naïve adult patients with post-stroke hemispasticity and spastic foot drop. Patients were followed over 390 days and received five injections of 800 U aboBoNT/A every three months. Patients assessed the treatment effect at eight visits using a global assessment scale, physicians scored the muscle tone at the ankle joint, measured active and passive ranges of motion (aRoMs, pRoMs) at the knee and ankle joint and determined the distance patients succeeded to walk during a minute. Patients' assessments significantly (p < 0.006) increased with time and significantly correlated with all parameters measured. The best correlation (r = 0.927; p < 0.0001) was found with the sum of the aRoMs of knee and ankle joint. After one year of treatment outcome measures were better than and significantly correlated with the peak effect of the first injection. This correlation was higher for pRoMs (r = 0.855; p < 0.00001) compared to aRoMs (r = 0.567; p < 0.009). When BoNT/A treatment of the spastic foot in chronic hemispasticity is performed regularly every three months for at least one year, patients will experience a significant increase of benefit beyond the first treatment, but have to learn how to adapt to and use the new degree of freedom induced by the injections.

Efficacy and Optimal Dose of Botulinum Toxin A in Post-Stroke Lower Extremity Spasticity: A Systematic Review and Meta-Analysis

Post-stroke spasticity impedes patients’ rehabilitation progress. Contradictory evidence has been reported in using Botulinum Neurotoxin type A (BoNT-A) to manage post-stroke lower extremity spasticity (PLES); furthermore, an optimum dose of BoNT-A for PLES has not yet been established. Therefore, we conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to identify the efficacy and optimal dose of BoNT-A on PLES. "Meta" and "Metafor" packages in R were used to analyze the data. Hedges’ g statistic and random effect model were used to calculate and pool effect sizes. Twelve RCTs met the eligibility criteria. Muscle tone significantly improved in week four, week eight, and maintained to week twelve after BoNT-A injection. Improvements in functional outcomes were found, some inconsistencies among included studies were noticed. Dosage analysis from eight studies using Botox® and three studies using Dysport® indicated that the optimum dose for the commonest pattern of PLES (spastic plantar flexors) is medium-dose (approximately 300U Botox® or 1000 U Dysport®). BoNT-A should be regarded as part of a rehabilitation program for PLES. Furthermore, an optimal rehabilitation program combined with BoNT-A management needs to be established. Further studies should also focus on functional improvement by BoNT-A management in the early stage of stroke.

Goal Attainment: A Clinically Meaningful Measure of Success of Botulinum Toxin-A Treatment for Lower Limb Spasticity in Ambulatory Patients

Objectives

The objectives of this study were to evaluate whether botulinum toxin type A (BoNT-A) treatment for lower limb spasticity leads to patient goal attainment and identify factors associated with positive goal attainment and to assess the effect of BoNT-A treatment on patients’ gait.

Design

Retrospective cohort study between June 2014 and February 2019.

Setting

Public outpatient spasticity clinic in a tertiary hospital.

Participants

Thirty patients (N=30; 50% female; average age, 50.5y) with lower limb spasticity of heterogenous etiologies (96.7% cerebral±spinal origin and 3.3% isolated spinal origin); 73.3% (N=22) of patients had previously received BoNT-A treatment.

Interventions

BoNT-A injection to lower limb muscles.

Main Outcome Measures

The primary outcome measure was goal attainment measured using Goal Attainment Scaling. The Modified Ashworth Scale (MAS) was used to assess spasticity. Gait was characterized by spatiotemporal parameters.

Results

Fifty-six treatment episodes were analyzed and showed that BoNT-A treatment resulted in a significant reduction in spasticity (pretreatment MAS=3.18±0.73; posttreatment MAS=2.27±0.89; P<.001) with no associated change in gait parameters. Logistic regression revealed that most patients (74.1%) achieved all of their goals, with younger patients having a high likelihood of goal attainment regardless of their gait profile identified by latent profile analysis of the gait parameters. Patients considered to have a low functioning gait profile demonstrated a significantly greater likelihood of goal attainment than patients with the other gait profiles combined (odds ratio, 45.6; 95% confidence interval, 1.3-1602.1; P=.036). Chronic spasticity and pretreatment severity of spasticity (MAS) and its reduction were not associated with likelihood of goal attainment.

Conclusions

The success and efficacy of BoNT-A treatment in improving patient perceived gait quality and reducing the negative symptoms of spasticity were best measured using Goal Attainment Scaling. The study emphasizes the importance of measuring patient goals as a clinical outcome. Gait parameters were most informative when used collectively to classify patients based on their overall gait profile, which assisted in identifying differences between patients’ likelihood of goal attainment after treatment.

Claw Toe: Anatomic Guide for Injection of Botulinum Toxin into Foot Muscles

BACKGROUND

Poor response to injection of botulinum toxin (BoNT) into the flexor digitorum longus (FDL) muscle has been reported especially in patients with claw foot deformity. We previously advocated BoNT injection into the flexor hallucis longus (FHL) muscle in such patients. Here, we determined the functional and anatomical relationships between FHL and FDL.

METHODS

Toe flexion pattern was observed during electrical stimulation of FHL and FDL muscles in 31 post-stroke patients with claw-foot deformity treated with BoNT. The FHL and FDL tendon arrangement was also studied in five limbs of three cadavers.

RESULTS

Electrical stimulation of the FHL muscle elicited big toe flexion in all 28 cases examined and second toe in 25, but the response was limited to the big toe in 3. FDL muscle stimulation in 29 patients elicited weak big toe flexion in 1 and flexion of four toes (2nd to 5th) in 16 patients. Cadaver studies showed division of the FHL tendon with branches fusing with the FDL tendon in all five limbs examined; none of the tendons was inserted only in the first toe. No branches of the FDL tendon merged with the FHL tendon.

CONCLUSION

Our results showed coupling of FHL and FDL tendons in most subjects. Movements of the second and third toes are controlled by both the FDL and FHL muscles. The findings highlight the need for BoNT injection in both the FDL and FHL muscles for the treatment of claw-toe deformity.

Improving gait adaptability in patients with hereditary spastic paraplegia (Move-HSP): study protocol for a randomized controlled trial

Background

People with hereditary spastic paraplegia (HSP) experience difficulties adapting their gait to meet environmental demands, a skill required for safe and independent ambulation. Gait adaptability training is possible on the C-Mill, a treadmill equipped with augmented reality, enabling visual projections to serve as stepping targets or obstacles. It is unknown whether gait adaptability can be trained in people with HSP.

Aim

The aim of Move-HSP is to study the effects of ten 1-h sessions of C-Mill training, compared with usual care, on gait adaptability in people with pure HSP. In addition, this study aims to identify key determinants of C-Mill training efficacy in people with pure HSP.

Method

Move-HSP is a 5-week, two-armed, open-label randomized controlled trial with a cross-over design for the control group. Thirty-six participants with pure HSP will be included. After signing informed consent, participants are randomized (1:1) to intervention or control group. All participants register (near) falls for 15 weeks, followed by the first assessment (week 16), and, thereafter, wear an Activ8 activity monitor for 7 days (week 16). The intervention group receives 10 sessions of C-Mill training (twice per week, 1-h sessions; weeks 17–21), whereas control group continues with usual care (weeks 17–21). Afterwards, both groups are re-assessed (week 22). Subsequently, the intervention group enter follow-up, whereas control group receives 10 sessions of C-Mill training (weeks 23–27), is re-assessed (week 28), and enters follow-up. During follow-up, both groups wear Activ8 activity monitors for 7 days (intervention group: week 23, control group: week 29) and register (near) falls for 15 weeks (intervention group: weeks 23–37, control group: weeks 29–43), before the final assessment (intervention group: week 38, control group: week 44). The primary outcome is the obstacle subtask of the Emory Functional Ambulation Profile. Secondary outcomes consist of clinical tests assessing balance and walking capacity, physical activity, and fall monitoring.

Discussion

Move-HSP will be the first RCT to assess the effects of C-Mill gait adaptability training in people with pure HSP. It will provide proof of concept for the efficacy of gait adaptability training in people with pure HSP.

Trial registration

Clinicaltrials.gov NCT04180098. Registered on November 27, 2019.

Supplementary information

Supplementary information accompanies this paper at 10.1186/s13063-020-04932-9.

Does anodal trans-cranial direct current stimulation of the damaged primary motor cortex affects wrist flexor muscle spasticity and also activity of the wrist flexor and extensor muscles in patients with stroke?: a Randomized Clinical Trial

Spasticity is a common symptom in stroke survivors. This study is double-blinded, sham-controlled randomized, clinical trial with three parallel arms. The aim of the study was to investigate the effects of anodal trans-cranial direct current stimulation (a-tDCS) over the damaged primary motor cortex (M1) on spasticity of the wrist flexor and also the activity of wrist flexor and extensor muscles in sub-acute stroke patients. This study was performed on 32 stroke patients. The patients are assigned to three groups (intervention, sham, and control). All participants in the first two groups received 20-min concurrent M1 a-tDCS or sham tDCS and functional electrical stimulation (FES) for 10 sessions (5 sessions per week), while participants in control group were given only 20-min FES for 10 sessions. Modified Ashworth scale of wrist flexors and also electromyography (EMG) activity of flexor carpi radialis (FCR) and extensor carpi radialis (ECR) were recorded before, immediately, and 1 month after the interventions. A significant reduction was shown in the MAS and EMG activity of FCR muscle at passive rest position of the wrist, immediately and 1 month after the intervention in M1 a-tDCS compared to sham and control groups (p < 0.001). Also, the EMG activity of FCR and ECR muscles during active wrist flexion and extension increased immediately and 1 month after intervention in M1 a-tDCS compared to the other groups, respectively (p < 0.001). M1 a-tDCS can significantly decrease the spasticity of wrist flexor muscle and also increase the wrist flexor and extensor muscles activity in stroke patients during active flexion and extension.

Long-Term Observational Results from the ASPIRE Study: OnabotulinumtoxinA Treatment for Adult Lower Limb Spasticity

INTRODUCTION

OnabotulinumtoxinA treatment for spasticity varies according to numerous factors and is individualized to meet treatment goals.

OBJECTIVE

To explore real-world onabotulinumtoxinA utilization and effectiveness in patients with lower limb spasticity from the Adult Spasticity International Registry (ASPIRE) study.

DESIGN

Two-year, multicenter, prospective, observational registry (NCT01930786).

SETTING

Fifty-four international clinical sites.

PATIENTS

Adults (naïve or non-naïve to botulinum toxin[s] treatment for spasticity, across multiple etiologies) with lower limb spasticity related to upper motor neuron syndrome.

INTERVENTIONS

OnabotulinumtoxinA administered at the clinician's discretion.

MAIN OUTCOME MEASURES

OnabotulinumtoxinA treatment utilization, clinician- and patient-reported satisfaction.

RESULTS

In ASPIRE, 530 patients received ≥1 onabotulinumtoxinA treatment for lower limb spasticity (mean age, 52 years; stroke, 49.4%; multiple sclerosis, 20.4%). Equinovarus foot was treated most often (80.9% of patients), followed by flexed knee (26.0%), stiff extended knee (22.5%), and flexed toes (22.3%). OnabotulinumtoxinA doses ranged between 10 and 1100 U across all presentations. Electromyography (EMG) was most commonly used for injection localization (≥41.1% of treatment sessions). Despite low patient response on the satisfaction questionnaire, clinicians (94.6% of treatment sessions) and patients (84.5%) reported satisfaction/extreme satisfaction that treatment helped manage spasticity, and clinicians (98.3%) and patients (91.6%) would probably/definitely continue onabotulinumtoxinA treatment. These data should be interpreted with care. Twenty-one adverse events (AEs) in 18 patients (3.4%) were considered treatment-related. Sixty-seven patients (12.6%) reported 138 serious AEs; 3 serious AEs in two patients (0.4%) were considered treatment-related. No new safety signals were identified.

CONCLUSIONS

ASPIRE provides long-term observational data on the treatment of lower limb spasticity with onabotulinumtoxinA. Real-world data from this primary analysis can help to guide the clinical use of onabotulinumtoxinA to improve spasticity management.

Impact of early intervention with onabotulinumtoxinA treatment in adult patients with post-stroke lower limb spasticity: results from the double-blind, placebo-controlled, phase 3 REFLEX study

The aim of this study in patients with post-stroke lower limb spasticity (PSLLS) was to evaluate the relationship between time of onabotulinumtoxinA treatment relative to stroke and efficacy outcomes. This was a phase 3, international, multicenter, randomized, 12-week, double-blind study, followed by a repeated treatment, open-label extension. Patients were aged 18–85 years with PSLLS (Modified Ashworth Scale [MAS] ≥ 3) of the ankle with the most recent stroke occurring ≥ 3 months before screening. Patients (double-blind phase) were randomized (n = 468) to onabotulinumtoxinA 300–400 U (300 U, mandatory ankle muscles (gastrocnemius, soleus, tibialis posterior); and ≤ 100 U, optional lower limb muscles (flexor digitorum longus, flexor hallucis longus, flexor digitorum brevis, extensor hallucis, and rectus femoris]) or placebo. Primary endpoint: MAS change from baseline (average score of weeks 4 and 6). Secondary endpoints: physician-assessed Clinical Global Impression of Change (CGI) average score of weeks 4 and 6 and physician-assessed Goal Attainment Scale (GAS; active and passive, weeks 8 and 12). When stratified by time since stroke (≤ 24 months, n = 153; > 24 months, n = 315, post hoc), patients treated ≤ 24 months post-stroke experienced greater improvements from baseline versus placebo in MAS (− 0.31 vs − 0.17), CGI (0.49 vs 0.12), and passive GAS scores (week 12, 0.37 vs 0.26). A ≥  − 1-point improvement in active (week 12; p = 0.04) and passive (week 8; p = 0.02) GAS scores versus placebo was achieved by more patients treated ≤ 24 months post-stroke; in patients treated > 24 months post-stroke, improvements were only observed in active scores (week 8; p = 0.04). OnabotulinumtoxinA 300–400 U was well tolerated, with no new safety findings.

Factors Influencing Gait Velocity Improvement Following Botulinum Toxin Injection for Spasticity of the Plantar Flexors in Patients with Stroke

Objective:

In patients with hemiplegia, botulinum toxin type A injection for ankle spasticity of the plantar flexors reportedly improves walking speed. This improvement may be affected by background factors and patient baseline physical performance. This study aimed to clarify the factors affecting gait velocity improvement after botulinum toxin type A injection.

Methods:

Background and evaluation data were collected for 60 patients with stroke who received botulinum toxin type A injection for spasticity of the plantar flexors. The patients were divided into improvement (n=27) and non-improvement (n=33) groups based on the gait velocity change from before injection to 2 weeks after injection. Logistic regression analysis was performed with the improvement and non-improvement groups as response variables and background data and evaluation data at baseline as explanatory variables.

Results:

The presence or absence of physical therapy following botulinum toxin type A injection (odds ratio: 7.82) was the only significant explanatory variable for gait velocity change.

Conclusion:

Background factors and physical performance at baseline did not affect gait velocity improvement after botulinum toxin type A injection. If botulinum treatment of the ankle plantar flexors in patients with stroke is targeted at walking performance improvement, then physical therapy following botulinum toxin type A injection should be an essential part of the treatment strategy.

High clinician- and patient-reported satisfaction with individualized onabotulinumtoxinA treatment for spasticity across several etiologies from the ASPIRE study

Etiology-specific onabotulinumtoxinA utilization to manage spasticity is largely unknown. In this 1-year interim analysis, we evaluated real-world onabotulinumtoxinA utilization and effectiveness across several etiologies from the Adult Spasticity International Registry (ASPIRE) study. ASPIRE is a multicenter, prospective, observational registry (NCT01930786) examining stroke, multiple sclerosis [MS], cerebral palsy [CP], traumatic brain injury [TBI], and spinal cord injury [SCI] patients with spasticity treated with onabotulinumtoxinA at the clinician's discretion. Assessments included onabotulinumtoxinA utilization (each session), clinician (subsequent session)/patient (5±1 weeks post-treatment) satisfaction, and the Disability Assessment Scale (DAS; subsequent session). 730 patients received ≥1 onabotulinumtoxinA treatment, with 37% naïve to botulinum toxin(s) for spasticity. The most common etiology was stroke (n=411, 56%), followed by MS (N=119, 16%), CP (N=77, 11%), TBI (N=45, 6%), and SCI (N=42, 6%). The total body mean cumulative dose (±SD) of onabotulinumtoxinA per session ranged from 296 U (±145) in CP to 406 U (±152) in TBI. The most commonly treated upper limb presentations were clenched fist (stroke, MS, and SCI), flexed wrist (CP), and flexed elbow (TBI). Equinovarus foot was the most commonly treated lower limb presentation in all etiologies. Stroke patients showed improved DAS scores for nearly all subscales in both limbs, indicative of improved global function. All etiologies showed improved lower limb mobility DAS scores. Across all sessions, clinicians (range: 87.4% [SCI]-94.2% [CP]) and patients (range: 67.6% [TBI]-89.7% [SCI]) reported extreme satisfaction/satisfaction that onabotulinumtoxinA helped manage spasticity, and clinicians (range: 94.6% [TBI]-98.8% [CP]) and patients (range: 88.4% [stroke]-91.2% [TBI]) would definitely/probably continue treatment. Treatment-related adverse events (TRAEs) and treatment-related serious adverse events (TRSAEs) were reported as follows: stroke: 10 TRAEs (2.2% patients), 3 TRSAEs (0.5%); MS: 5 TRAEs (4.2%), 0 TRSAEs; CP: 0 TRAEs, 0 TRSAEs; TBI: 1 TRAEs (2.2%), 0 TRSAEs; SCI: 0 TRAEs, 0 TRSAEs. No new safety signals were identified. High clinician- and patient-reported satisfaction were observed following individualized onabotulinumtoxinA treatment, as well as improved global function. Interim results from ASPIRE demonstrate etiology-specific similarities and differences in clinical approaches to manage spasticity.

•

ASPIRE found etiology-specific similarities and differences in real-world onabotulinumtoxinA utilization for spasticity.

•

Across all etiologies, there was high clinician- and patient-reported satisfaction with onabotulinumtoxinA treatment.

•

In DAS, all etiologies showed improved global function in lower limb mobility following onabotulinumtoxinA treatment.

•

Adverse event data varied by etiology of spasticity; however, no new safety signals were identified.

•

ASPIRE data may guide clinical strategies and educational programs to improve onabotulinumtoxinA spasticity management.

The Interdisciplinary Management of Foot Drop

BACKGROUND

Foot drop can be caused by a variety of diseases and injuries. Although it is a common condition, its overall incidence has not been reported to date. Foot drop markedly restricts the everyday activities of persons suffering from it. There is, therefore, a need for an optimized strategy for its diagnosis and treatment that would be standardized across the medical specialties encountering patients with this problem.

METHODS

This article consists of a review on the basis of pertinent publications re- trieved by a search in the Pubmed/MEDLINE and Cochrane databases, as well as a description of the authors' proposed strategy for the diagnosis and treatment of foot drop.

RESULTS

Foot drop can be due to a disturbance at any central or peripheral location along the motor neural pathway that terminates in the dorsiflexor muscles of the foot, or at multiple locations in series. Optimal localization of the lesion(s) is a pre- requisite for appropriate treatment and a successful outcome. The most common causes are L5 radiculopathy and peroneal nerve injury. An operation by a neuro- surgeon or spinal surgeon is a reasonable option whenever there is a realistic chance that the nerve will recover. In our opinion, any patient with a subjectively disturbing foot drop and a clinically suspected compressive neuropathy of the peroneal nerve should be informed about the option of surgical decompression of the nerve at the fibular head, which can be performed with little risk. In case of a permanent foot drop, some patients can benefit from muscle-transfer surgery. For spastic foot drop, the option of botulinum toxin injections should be evaluated.

CONCLUSION

The care of patients with foot drop could be optimized by interdisciplin- ary foot-drop clinics involving all of the relevant specialists. The goals of treatment should always be improved mobility in everyday life and the prevention of falls, pain, and abnormal postures.

IncobotulinumtoxinA for upper- and lower-limb spasticity in Japanese patients

Introduction: The safety and tolerability of incobotulinumtoxinA 400 U for upper- and lower-limb post-stroke spasticity was assessed in a small cohort of Japanese patients during the open-label lead-in tolerability periods (LITP) of two phase 3 studies (CTI-153029 and CTI-153030; Japan Pharmaceutical Information Centre).Methods: Adult patients received a single incobotulinumtoxinA injection session (total dose of 400 U) in the upper (J-PURE) or lower limb (J-PLUS). Adverse events (AEs) were assessed at 1, 4, 8 and 12 weeks post-injection during the 12 week follow-up.Results: The LITP of J-PURE and J-PLUS included 11 patients each. Mild/moderate AEs were reported by 5/11 (45.5%) and 8/11 (72.7%) patients in J-PURE and J-PLUS, respectively. No serious AEs were reported. Non-serious, transient AEs of special interest reported by two patients in J-PURE comprised muscular weakness and eyelid ptosis. No patient discontinued due to AEs.Conclusion: Preliminary results in this small population suggest that incobotulinumtoxinA 400 U is well tolerated for treating upper- or lower-limb post-stroke spasticity in Japanese patients.

Efficacy of incobotulinumtoxinA for the treatment of adult lower-limb post-stroke spasticity, including pes equinovarus

BACKGROUND

Lower-limb spasticity can impair ambulation and gait, impacting quality of life.

OBJECTIVES

This ancillary analysis of the TOWER study (NCT01603459) assessed the efficacy of incobotulinumtoxinA for lower-limb post-stroke spasticity including pes equinovarus.

METHODS

Participants received escalating incobotulinumtoxinA doses (400-800U) across 3 injection cycles. Changes were compared for those treated in the lower limb (with/without upper-limb treatment) or the upper limb only or for participants treated or untreated for pes equinovarus. Outcome measures were those used in the seminal study: resistance to passive movement scale (REPAS), Ashworth Scale (AS), functional ambulation and lower-limb goal attainment.

RESULTS

Among 132/155 (85%) participants with post-stroke spasticity, in cycles 1, 2 and 3, 99, 119 and 121 participants received lower-limb treatment with mean (SD) total limb incobotulinumtoxinA doses of 189.2 (99.2), 257.1 (115.0) and 321.3 (129.2) U, respectively. Of these, 80, 105 and 107, respectively, were treated for pes equinovarus. The mean (SD) improvement in REPAS lower-limb score was greater with treatment in the lower limb versus the upper limb only: -1.6 (2.1) versus-0.4 (1.4); -1.9 (1.9) versus -0.6 (1.6); -2.2 (2.2) versus -1.0 (0.0) (P=0.0005, P=0.0133 and P=0.3581; analysis of covariance [ANCOVA], between-group differences) in cycles 1, 2 and 3, respectively. For all cycles, the mean improvement in ankle joint AS score from injection to 4 weeks post-treatment was greater for participants treated versus not treated for pes equinovarus, with a significant between-group difference in cycle 1 (P=0.0099; ANCOVA). At the end of cycle 3, 42% of participants walked independently and 63% achieved 2 of 2 lower-limb treatment goals (baseline 23% and 34%, respectively).

CONCLUSIONS

This study supports the efficacy of incobotulinumtoxinA for treatment of pes equinovarus and other patterns of lower-limb post-stroke spasticity.

Botulinum Toxin Therapy Combined with Rehabilitation for Stroke: A Systematic Review of Effect on Motor Function

Aim: The purpose of this study was to examine the effectiveness of botulinum toxin A (BoNT-A) therapy combined with rehabilitation on motor function in post-stroke patients. Methods: The following sources up to December 31, 2018, were searched from inception for articles in English: Pubmed, Scopus, CINAHL, Embase, PsycINFO, and CENTRAL. Trials using injections of BoNT-A for upper and lower limb rehabilitation were examined. We excluded studies that were not performed for rehabilitation or were not evaluated for motor function. Results: Twenty-six studies were included. In addition to rehabilitation, nine studies used adjuvant treatment to improve spasticity or improve motor function. In the upper limbs, two of 14 articles indicated that significant improvement in upper limb motor function was observed compared to the control group. In the lower limbs, seven of 14 articles indicated that significant improvement in lower limb motor function was observed compared to the control group. Conclusions: The effect of combined with rehabilitation is limited after stroke, and there is not sufficient evidence, but results suggest that BoNT-A may help to improve motor function. In future studies, the establishment of optimal rehabilitation and evaluation times of BoNT-A treatment will be necessary for improving motor function and spasticity.

Spasticity and Range of Motion Over Time in Stroke Patients Who Received Multiple-Dose Botulinum Toxin Therapy

OBJECTIVE

This study examined how the effects of botulinum toxin therapy changed over time by sequential evaluation of clinical improvements in spasticity and contracture in 24 chronic-stage stroke patients on repeated botulinum toxin therapy who were receiving fewer rehabilitation interventions.

METHODS

Botulinum toxin injection was administered into the spastic muscle of the paralyzed upper or lower limb 5 times with at least 3-month intervals. Modified Ashworth Scale and range of motion were measured before and 2 weeks after each dose in the extremities to compare the first measurement value with subsequent values. Each predose value was also compared with the first predose value.

RESULTS

Compared with predose scores, Modified Ashworth Scale significantly improved in all flexors after 2 weeks from the first to fifth doses. Range of motion significantly improved in wrist dorsiflexion and ankle dorsiflexion. Comparison of values before each dose versus the first predose value showed significant improvement both in the Modified Ashworth Scale score of wrist flexors, finger flexors, and ankle planter flexors, and the range of motion of elbow extension, wrist dorsiflexion, and ankle dorsiflexion.

CONCLUSION

The comparison of predose values versus 2-week postdose values indicated that the effect of botulinum toxin formulation would not lessen after repeated injections with continuous improvements of Modified Ashworth Scale and range of motion. The comparison of predose values versus the first predose value also suggested that multiple injections of botulinum toxin formulation could be more effective in reducing spasticity and increasing the range of motion than a single injection.

Poststroke Postural Sway Improved by Botulinum Toxin: A Multicenter Randomized Double-blind Controlled Trial

OBJECTIVE

To assess the effects of injecting botulinum toxin into the lower limb muscles of people with hemiparesis post stroke in terms of their sway areas.

DESIGN

A multicenter randomized double-blind trial on the effects of active botulinum toxin treatment vs placebo.

SETTING

Clinical examinations and postural sway assessments were performed before botulinum toxin injection and again 4-6 weeks after the injection.

PARTICIPANTS

People with hemiparesis with chronic post stroke lower limb spasticity (N=40).

INTERVENTIONS

Intramuscular injection of a placebo (physiological serum) was performed on the control group, and botulinum toxin injections were performed on the treatment group. Participants and physical and rehabilitation medicine specialists were given no information as to which of the 2 treatments was applied.

MAIN OUTCOME MEASURES

The sway area of the center of pressure was recorded for 30 seconds in 3 conditions: eyes open, eyes open in a dual task (a postural control task combined with an arithmetic task), and eyes closed. Spasticity was measured using the Modified Ashworth Scale.

RESULTS

Forty people post stroke were enrolled and randomized into 2 groups, one of which was treated with botulinum toxin (n=19) and the other with placebo (n=21). Spasticity decreased significantly in the treatment group (-0.7, P=.049 in the soleus muscles; -0.8, P=.035 in the gastrocnemii muscles). The sway area did not differ significantly between the 2 groups before treatment. The most conspicuous effect was observed in the case of the dual task, where a significant decrease (P=.005) in the sway area occurred in the treatment group (-3.11±6.92) in comparison with the placebo group (+0.27±3.57).

CONCLUSION

Treating spasticity by injecting botulinum toxin into people's lower limb muscles post stroke seems to improve their postural sway. The dual task used here to assess sway seems to be a useful, sensitive test for this purpose.

Repetitive Peripheral Magnetic Nerve Stimulation (rPMS) as Adjuvant Therapy Reduces Skeletal Muscle Reflex Activity

Background: The reduction of muscle hypertonia and spasticity, as well as an increase in mobility, is an essential prerequisite for the amelioration of physiotherapeutical treatments. Repetitive peripheral magnetic nerve stimulation (rPMS) is a putative adjuvant therapy that improves the mobility of patients, but the underlying mechanism is not entirely clear.

Methods: Thirty-eight participants underwent either an rPMS treatment (N = 19) with a 5 Hz stimulation protocol in the posterior tibial nerve or sham stimulation (N = 19). The stimulation took place over 5 min. The study was conducted in a pre-test post-test design with matched groups. Outcome measures were taken at the baseline and after following intervention.

Results: The primary outcome was a significant reduction of the reflex activity of the soleus muscle, triggered by a computer-aided tendon-reflex impact. The pre-post differences of the tendon reflex response activity were −23.7% (P < 0.001) for the treatment group. No significant effects showed in the sham stimulation group.

Conclusion: Low-frequency magnetic stimulation (5 Hz rPMS) shows a substantial reduction of the tendon reflex amplitude. It seems to be an effective procedure to reduce muscular stiffness, increase mobility, and thus, makes the therapeutic effect of neuro-rehabilitation more effective. For this reason, the 5 Hz rPMS treatment might have the potential to be used as an adjuvant therapy in the rehabilitation of gait and posture control in patients suffering from limited mobility due to spasticity. The effect observed in this study should be investigated conjoined with the presented method in patients with impaired mobility due to spasticity.

Botulinum Toxin Type A for the Treatment of Lower Limb Spasticity after Stroke

Post-stroke lower limb spasticity impairs balance and gait leading to reduced walking speed, often increasing wheelchair use and caregiver burden. Several studies have shown that appropriate treatments for lower limb spasticity after stroke include injections of botulinum toxin type A (BoNT-A), phenol or alcohol, surgical correction and a rehabilitation program. In the present article, we review the safety and effectiveness of BoNT-A for the treatment of lower limb spasticity after stroke, with a focus on higher doses of BoNT-A. The cumulative body of evidence coming from the randomized clinical trials and open-label studies selected in the article suggest BoNT-A to be safe and efficacious in reducing lower limb spasticity after stroke. Studies of high doses of BoNT-A also showed a greater reduction of severe post-stroke spasticity. In stroke survivors with spasticity of the ankle plantar-flexor muscles, a combined approach between surgery and BoNT-A can be indicated. However, controversy remains about improvement in motor function relative to post-stroke spasticity reduction after BoNT-A treatment.

Use of botulinum toxin for movement disorders

The term movement disorders encompasses all disorders hypokinetic and hyperkinetic, which were previously known as extrapyramidal syndromes. With the definition of movement disorders and their diagnostic criteria and classifications, new studies for therapeutics could be performed. New drugs were launched, functional neurosurgery was developed, and the introduction of botulinum toxin (BoNT) for hyperkinesias was introduced. BoNT is an important therapy for dystonia, tics, myoclonus, and tremors. The aim of this review is to present the new and well-established uses of BoNT for movement disorders.

Efficacy of botulinum toxin in modifying spasticity to improve walking and quality of life in post-stroke lower limb spasticity - a randomized double-blind placebo controlled study

Background

Post-stroke lower limb spasticity (PSLLS) has a prevalence of 28–37%. PSLLS can cause difficulty in walking and reduce quality of life (QOL). Post stroke spasticity impairs the ability to intervene to improve walking ability. Botulinum Toxin A (BT) is an effective intervention for focal spasticity, but its use is currently restricted in many countries by their reimbursement system stating that the evidence for improvement in walking and quality of life (QOL) is not robust for treatment in the lower limb. This randomized control trial (RCT) will investigate the effectiveness of BT in modifying spasticity, and improving functioning (mobility, walking, activities of daily living (ADL’s) and QOL.

Methods/design

A double-blind placebo-controlled trial injection will assess the effect of BT compared with a placebo (normal saline) in a sample of n = 94 patients. Following treatment of spasticity measured by Modified Ashworth Scale (MAS), the primary outcome of gait velocity will be measured by i) Gait Rite (Electronic Walkway); ii) walking by 2 Min Walk Test; iii) balance by Berg Balance Scale; mobility by iv) Timed Up and Go (TUG); v) lower limb function by ABILICO; vi) patient related goal by Goal Attainment Scale (GAS); vii) QOL by SF 12 (Rand version); viii) activities of daily living by the Functional Autonomy Measurement System (SMAF). There will be an associated health economic analysis.

Discussion

The study methodology is based on our systematic review 2026 studies, which concluded the evidence for improving mobility following use of BT to reduce spasticity was not robust. The results of this study could establish the use of BT in improving gait and lower limb function in PSLLS. This study could provide the evidence needed for reimbursement schemes to consider and changes to its funding policy for BT in PSLLS.

Trial registration

The trial is registered with the Australia New Zealand Clinical Trails Registry (ANZCTR)-ANZCTRN12617001603303. Registered 07/12/2017.

Beyond speed: Gait changes after botulinum toxin injections in chronic stroke survivors (a systematic review)

BACKGROUND

The mechanisms by which spasticity reductions after botulinum toxin A (BoNT) affect gait in stroke are not well understood. We systematically reviewed the effects of BoNT on spatiotemporal, kinematic, kinetic and electromyographic (EMG) measures during gait.

QUESTION

What are the effects of botulinum toxin on gait mechanics in stroke patients?

METHODS

Systematic search using PubMed and Web of Science. We considered all studies that reported laboratory-based and instrumented gait measures as primary or secondary outcomes to determine the effects of BoNT on walking performance in stroke populations only. Selected studies were classified and analysed based on the injection sites.

RESULTS

A total of 240 articles were identified of which 22 were selected for analysis. Overall, 91% of the studies reported spatiotemporal, 64% kinematics, 23% kinetics, 32% EMG and 23% other gait measures. All but one study found significant effects of BoNT on gait measures using instrumented assessments even when clinical measures (i.e. speed) did not significantly improve. However, the majority of the studies had a high risk of bias. Overall, BoNT improved: a) dorsiflexion during stance, propulsive forces and timing and activity of more proximal musculature with injections in the plantarflexors; b) hip, knee and ankle angles and velocities, coordination and energetic cost with injections in the rectus femoris; c) segmental coordination and energetic cost when several lower limb muscles were injected; and, d) elbow and trunk angles when upper limb muscles were injected.

CONCLUSION

Instrumented and laboratory measures of gait improve after BoNT injections in different muscle groups even in the absence of clinical changes.