Efficacy and safety of NABOTA in post-stroke upper limb spasticity: a phase 3 multicenter, double-blinded, randomized controlled trial

A Randomized, Double-Blind, Active Control, Multicenter, Phase 3 Study to Evaluate the Efficacy and Safety of Liztox® versus Botox® in Post-Stroke Upper Limb Spasticity

Botulinum toxin type A (BTX-A) injection is a commonly used therapeutic intervention for upper limb spasticity in stroke patients. This study was designed as a randomized, active-drug-controlled, double-blind, multicenter, phase 3 clinical trial to evaluate the safety and efficacy of Liztox® in comparison to onabotulinum toxin A (Botox®) for individuals with post-stroke upper limb spasticity. The primary outcome was the alteration in wrist flexor muscle tone from the initial assessment to the fourth week, evaluated using the modified Ashworth scale (MAS). Secondary outcomes included MAS score changes for the wrist at weeks 8 and 12 from baseline; MAS score changes for finger and elbow flexors; and changes in the Disability Assessment Scale (DAS), Subject's Global Assessment (SGA), the Investigator's Global Assessment (IGA), and Caregiver Burden Scale (CBS) at weeks 4, 8, and 12 from baseline. The MAS score for wrist flexor spasticity decreased by -1.14 ± 0.59 in the Liztox® group and -1.22 ± 0.59 in the Botox® group from baseline to week 4. The difference [97.5% confidence interval (CI)] between the test and control groups was 0.08 [-∞, 0.26], confirming the non-inferiority of the test group compared to the control group. Furthermore, there were consistent improvements in the IGA, SGA, and CBS scores across all assessment intervals, with no statistically significant variances detected between the two groups. No safety-related concerns were reported during the study. In conclusion, Liztox® injection proved to be a secure and efficacious intervention for managing upper extremity spasticity in post-stroke patients.

Clinical investigation of botulinum toxin (prabotulinumtoxin A) for bruxism related to masseter muscle hypertrophy: A prospective study

This study aims to confirm the effectiveness and safety of a prabotulinumtoxin type A (praBTX-A) injection in patients with bruxism and masseter hypertrophy. The study included patients who ground or clenched their teeth while sleeping and had computed tomography (CT) scans that showed a maximum thickness of the masseter muscle of 15 mm or more. The praBTX-A was administered bilaterally into the masseter muscles; 15 U/side for group 1, 25 U/side for group 2, and 35 U/side for group 3. CT scans and bruxism questionnaires were conducted before and eight weeks after the injection. Thirty-seven patients were enrolled, but three dropped out due to loss of follow-up. After injection, masseter thickness decreased to 15.1 ± 2.0 mm for group 1, 14.3 ± 2.9 mm for group 2, and 13.4 ± 1.8 mm for group 3 (p = 0.043). Group 3 showed a statistically significant lower masseter thickness compared to group 1 (p = 0.039). Both subjective and objective frequencies of bruxism decreased for all groups, but there were no significant differences in either subjective (p = 0.396) or objective frequencies (p = 0.87) between the groups after the injection. The results of this study suggest that praBTX-A injection is a safe and effective treatment for bruxism and masseter hypertrophy. A dosage of 35 IU/side can effectively decrease masseter thickness and relieve bruxism symptoms. Even the minimum dosage of 15 IU/side can contribute to improvements in bruxism symptoms. This investigation provides valuable information for managing bruxism that is associated with hypertrophic masseter muscles.

Safety and efficacy of MT10107 in post-stroke upper limb spasticity treatment: A phase I randomized controlled trial

BACKGROUND

Botulinum toxin type A injection is widely used treatment option for the treatment of upper limb spasticity in stroke patients. The purpose of this study was to explore the safety and efficacy of MT10107, a new botulinum toxin type A, in patients with post-stroke upper limb spasticity.

METHODS

A prospective, randomized, double-blind, active drug-controlled, multi-center, phase I clinical trial. Thirty patients with post-stroke upper limb spasticity were received either MT10107 or onabotulinumtoxinA. Primary endpoint was change of modified Ashworth scale (MAS) score for wrist flexor from baseline to week 4. The secondary endpoints were changes of MAS scores for elbow and finger flexors, response rate, Disability Assessment Scale (DAS), and global assessment of treatment. The safety endpoints such as adverse events, vital signs, physical examination, and laboratory test were evaluated. The outcome measures were evaluated from baseline to week 4.

RESULTS

The primary endpoints were -1.07 ± 0.70 and -1.23 ± 0.56 for the MT10107 and onabotulinumtoxinA groups, respectively. The intergroup difference of change between the 2 groups was 0.17 (95% confidence interval -0.31 to 0.64, P = .5769). In secondary endpoints, both groups showed a significant improvement in both MAS and DAS. There was no significant between-group difference in all secondary endpoints and safety measures.

CONCLUSION

The safety and efficacy of MT10107 showed no significant difference compared to onabotulinumtoxinA in post-stroke upper limb spasticity treatment.

Safety and Efficacy of HU-014 in the Treatment of Post-Stroke Upper Limb Spasticity: A Phase I Pilot Study

Botulinum toxin type A (BTX-A) is widely used for treating post-stroke upper limb spasticity. We evaluated the safety and efficacy of HU-014 in treating post-stroke upper limb spasticity. Thirteen patients were administered with HU-014. The primary outcome was safety, including adverse events, vital signs, physical examination, laboratory tests, and antibody formation test. The secondary outcomes were changes in the Modified Ashworth Scale (MAS) score for wrist, elbow, and finger flexor; Disability Assessment Scale (DAS); Investigator's Global Assessment (IGA) and Subject's Global Assessment (SGA); Caregiver Burden Scale (CBS); and Columbia Suicide Severity Rating Scale (C-SSRS) at weeks 4, 8, and 12 from baseline. No notable safety-related issues were reported. MAS and DAS scores were significantly decreased from those at baseline at 4, 8, and 12 weeks (p < 0.05). At weeks 4, 8, and 12, the IGA and SGA scores were 5.85 ± 0.55, 5.69 ± 0.48, and 5.62 ± 0.65 and 5.46 ± 1.20, 5.85 ± 0.38, and 5.77 ± 0.73, respectively. CBS scores decreased at all timepoints and those for cutting fingernails significantly decreased at 8 and 12 weeks compared with baseline (p < 0.05). C-SSRS scores showed that suicidal ideation in all patients was "low" at all timepoints. HU-014 is a safe treatment that can improve post-stroke upper limb spasticity.

Efficacy and Safety of Botulinum Toxin Type A (NABOTA) for Post-stroke Upper Extremity Spasticity: A Multicenter Phase IV Trial

Objective

To evaluate the efficacy and safety of Daewoong botulinum toxin type A (NABOTA) after its launch in South Korea.

Methods

This prospective, multicenter, open-label phase IV clinical trial included 222 patients with stroke. All patients visited the clinic at baseline and at weeks 4, 8, and 12 after injection of upto 360 units of NABOTA into the wrist, elbow, and finger flexor muscles at the first visit. The primary outcome was the change in Modified Ashworth Scale (MAS) score for the wrist flexor muscles between baseline and week 4. The secondary outcomes were the changes in MAS, Disability Assessment Scale (DAS), and Caregiver Burden Scale (CBS) scores between baseline and each visit, and the Global Assessment Scale (GAS) score at week 12.

Results

There was a statistically significant decrease in the MAS score for the wrist flexors between baseline and week 4 (−0.97±0.66, p<0.001). Compared with baseline, the MAS, DAS and CBS scores improved significantly during the study period. The GAS was rated as very good or good by 86.8% of physicians and by 60.0% of patients (or caregivers). The incidence of adverse events was 14.4%, which is smaller than that in a previous trial.

Conclusion

NABOTA showed considerable efficacy and safety in the management of upper limb spasticity in stroke patients.

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.

Therapeutic efficacy of new botulinum toxin identified in CCUG 7968 strain

Botulinum neurotoxin type A (BoNT/A) induces muscle atrophy by cleaving synaptosomal-associated protein 25. Thus, BoNT/A has been actively utilized for the treatment of masseter and gastrocnemius hypertrophy. In this study, INI101 toxin was newly identified from the CCUG 7968 strain, and its therapeutic efficacy was evaluated both in vitro and in vivo. The INI101 toxin showed identical genetic sequence, amino acid sequence, and protein subunit composition to BoNT/A produced from strain Hall A. Electromyography (EMG), and immunofluorescence staining demonstrated that INI101 (at 2 ~ 8 U/rat) effectively blocked the neuromuscular junction with no toxicity in a rat model. The EMG results showed INI101 toxin-induced weight loss and volume reduction of the gastrocnemius, similar to the effects of Botox® (BTX). Histological and immunofluorescence staining was consistent with this EMG result, showing that INI101 toxin caused muscle fiber reduction in the gastrocnemius. Notably, INI101 toxin diffused less into adjacent muscle tissue than BTX, indicating that INI101 toxin may reduce potential side effects due to diffusion into normal tissues. INI101 toxin isolated from the novel strain CCUG 7968 is a newly identified meaningful biopharmaceutical comparable to the conventional BoNT/A in the medical field. KEY POINTS: • Botulinum neurotoxin type A (BoNT/A, INI101) was identified from the CCUG 7968 strain. • INI101 toxin showed similar safety and therapeutic efficacy comparable to conventional BoNT/A both in vitro and in vivo. • INI101 toxin is a meaningful biopharmaceutical comparable to the conventional BoNT/A in the medical field.

The Effect of Botulinum Toxin Injection into the Common Extensor Tendon in Patients with Chronic Lateral Epicondylitis: A Randomized Trial

BACKGROUND

Botulinum toxin (BTX) is widely used for pain control in various musculoskeletal disorders.

OBJECTIVES

We evaluated the analgesic effect of botulinum toxin type A (BTX-A) in chronic lateral epicondylitis and compared the effect between 10 and 50 IU of BTX-A.

METHODS

Sixty subjects with chronic lateral epicondylitis were included and underwent a BTX-A injection in the common extensor tendon. The subjects were randomly allocated into two groups: the small-dose group (SD group; 30 subjects, 10 IU) and large-dose group (LD group; 30 subjects, 50 IU). Treatment outcomes were evaluated by measuring the pain level using the numeric rating scale (NRS) and measuring grip strength before and one, two, three, four, five, and six months after treatment.

RESULTS

Subjects in both groups showed a significant decrease in NRS scores at all evaluation time points after treatment. The reduction in NRS scores was significantly greater in the LD group at one, two, three, and four months after treatment. Six months after treatment, 19 subjects (63.3%) in the SD group and 21 (70%) in the LD group reported successful pain relief (pain relief ≥50%). The rate of successful pain relief was not significantly different between the two groups. Grip strength was more increased in the LD group at one, two, three, four, and six months after treatment.

CONCLUSIONS

BTX-A injection into the common extensor tendon can be a good treatment option for chronic lateral epicondylitis. The 50-IU BTX-A injection achieved a better outcome than the 10-IU injection.

Efficacy and Safety of MT10107 (Coretox) in Poststroke Upper Limb Spasticity Treatment: A Randomized, Double-Blind, Active Drug-Controlled, Multicenter, Phase III Clinical Trial

OBJECTIVE

To compare the efficacy and safety of MT10107 (Coretox) with those of onabotulinum toxin A (Botox) in patients with poststroke upper limb spasticity DESIGN: Prospective, randomized, double-blind, active drug-controlled, multicenter, phase III clinical trial.

SETTING

Seven university hospitals in the Republic of Korea.

PARTICIPANTS

Patients (N=220) with poststroke upper limb spasticity.

INTERVENTIONS

All participants received a single injection of either MT10107 (Coretox group) or onabotulinum toxin A (Botox group).

MAIN OUTCOME MEASURES

The primary outcome was change in wrist flexor spasticity from baseline to week 4, which was assessed using the modified Ashworth scale (MAS). The secondary outcomes were MAS scores for wrist, elbow, and finger flexors; percentage of treatment responders (response rate); Disability Assessment Scale (DAS) score, and global assessment of treatment. Safety was evaluated based on adverse events, vital signs, physical examination findings, and laboratory test results. The efficacy and safety were evaluated at 4, 8, and 12 weeks postintervention.

RESULTS

The primary outcome was found to be -1.32±0.69 and -1.40±0.69 for the Coretox and Botox groups, respectively. MT10107 showed a non-inferior efficacy compared with onabotulinum toxin A, as the 95% confidence interval for between-group differences was -0.10 to 0.27 and the upper limit was less than the non-inferiority margin of 0.45. Regarding the secondary outcomes, MAS scores for all muscles and DAS scores showed a significant improvement at all time points in both groups, with no significant between-group difference. No significant between-group differences were observed regarding response rate, global assessment of treatment, and safety measures.

CONCLUSIONS

MT10107 showed no significant difference in efficacy and safety compared with onabotulinum toxin A in poststroke upper limb spasticity treatment.

Effect of Botulinum Toxin A on Scar Healing after Thyroidectomy: A Prospective Double-blind Randomized Controlled Trial

The persistence of neck scarring is a common concern among patients undergoing thyroidectomy. Botulinum toxin A (BTA (Botox)) has been shown to suppress scar enlargement at the incision site. The objective of this study was to evaluate the effect of intraoperative Botox administration on neck scarring after thyroidectomy. A prospective double-blind randomized clinical trial was performed in patients undergoing conventional thyroidectomy. Forty patients were randomly allocated to a Botox or a control group (both, n = 20). The wound was closed after injection into the platysma muscle of 50 U of Botox diluted in 1 mL of normal saline or 1 mL of saline alone. Skin scars were assessed using the modified Stony Brook Scar Evaluation Scale (SBSES) and Manchester Scar Scale (MSS) at 1, 12, and 24 weeks postoperatively. The SBSES and MSS scores of the Botox group were significantly better than those of the control group (p = 0.034 and p = 0.039). At 24 weeks postoperatively, the SBSES and MSS scores were significantly better in the Botox group (p = 0.006 and p = 0.030). BTA injected into the incision site can suppress postoperative scar formation and thereby improve the cosmetic outcome.

Efficacy and Safety of Prabotulinumtoxin A and Onabotulinumtoxin A for Crow's Feet: A Phase 3, Multicenter, Randomized, Double-Blind, Split-Face Study

BACKGROUND

Prabotulinumtoxin A has been shown to have efficacy for the treatment of upper-limb spasticity and improvement of moderate to severe glabellar lines. However, the efficacy and safety of prabotulinumtoxin A for crow's feet have not been evaluated.

OBJECTIVE

This study compared the efficacy and safety of prabotulinumtoxin A and onabotulinumtoxin A in the treatment of crow's feet.

PATIENTS AND METHODS

A multicenter, randomized, double-blind, active-controlled, split-face study was conducted in subjects with bilateral symmetric, moderate to severe crow's feet at maximum smile. The investigators assessed the severity of crow's feet by using the facial wrinkle scale, and the subjects reported the improvement in severity, their subjective satisfaction, and perceived age. The primary efficacy outcome was the proportion of subjects with Grade 0 or 1 severity of crow's feet at maximum smile at Week 4 as assessed by the investigators.

RESULTS

In the primary efficacy outcome assessment, there was no significant difference between the 2 groups (prabotulinumtoxin A, 65.02%; onabotulinumtoxin A, 62.56%; p = .0956). All secondary efficacy outcomes were also achieved. Adverse events related to injection were mild and recovered spontaneously.

CONCLUSION

Prabotulinumtoxin A and onabotulinumtoxin A have comparable efficacy and safety in the treatment of crow's feet.

External Robotic Arm vs. Upper Limb Exoskeleton: What Do Potential Users Need?

Robotic devices that practically assist activities of daily living (ADL) are scarce. The aim of this study was to investigate practical demands of potential users of external robotic arms and upper limb exoskeletons for assistance in ADL. A survey was performed in rehabilitation clinics in individuals with functional impairments in the upper extremity, divided into unilateral (UIG, n = 24) and bilateral impairment groups (BIG, n = 24). Descriptive analyses were performed for current dependency, objective importance, and subjective necessity of the 18 ADLs by using a 5-point Likert scale. Overall, handling foods, dressing, and moving close items were highly necessary functions for both robot types. The UIG demonstrated a high demand for self-exercise using exoskeletons, whereas one-hand ADLs showed low necessity. In the UIG, the exoskeleton had significantly higher demands than the external robotic arm in washing face (p = 0.005) and brushing teeth (p = 0.007). The subjects in the BIG replied that cleaning desks and eating are highly necessary abilities for the external robotic arm; and transfer and wheelchair control, for exoskeletons. In the BIG, the exoskeleton showed significantly higher necessity than the external robotic arms in dressing (p = 0.010), making phone calls (p = 0.026), using a smartphone (p = 0.011), and writing (p = 0.005). The practical demands of potential users were affected by laterality and robot type. Further robot developments should involve essential functions based on the survey results to meet end-user needs.

A comparison study of prabotulinumtoxinA vs onabotulinumtoxinA in myostatin-deficient mice with muscle hypertrophy

Botulinum toxin A (BoNT-A) is used clinically for various muscle disorders and acts by preventing the release of the neurotransmitter acetylcholine into the synapse space. Here, we compared the efficacy of prabotulinumtoxinA (PRA) and onabotulinumtoxinA (ONA) for the reduction in hypertrophy in myostatin-deficient (Mstn^-/- ) mice. Two different BoNT-A products (2.5, 10 and 25 U/kg) were injected to paralyse the hindlimb for 2 months, after which sciatic nerve conduction study, 3D micro-CT, haematoxylin and eosin (H&E) and dystrophin staining were conducted. Administration of BoNT-A products induced denervation-mediated atrophy and alleviated muscle hypertrophy generated in Mstn^-/- mice. The present study revealed that each BoNT-A regulates skeletal muscle size, myofibre number and myofibre diameter in Mstn^-/- mice. The potential applicability of BoNT-A for the treatment of rare muscle hypertrophic diseases was demonstrated. Compared with ONA, PRA had a comparable ability to act in the local area.

Safety and Efficacy of PrabotulinumtoxinA (Nabota®) Injection for Cervical and Shoulder Girdle Myofascial Pain Syndrome: A Pilot Study

Myofascial pain syndrome is a common painful condition encountered in the general population. Previous studies evaluating the efficacy of botulinum toxin for the treatment of myofascial pain syndrome are limited, with variable results. This prospective study investigated the efficacy and safety of direct injection of Prabotulinumtoxin A (Nabota^®) into painful muscle groups for cervical and shoulder girdle myofascial pain. Twelve patients with chronic myofascial pain syndrome of the neck and shoulder underwent an injection of Prabotulinumtoxin A. Painful muscles containing trigger points were injected in the mid-belly. Pain scores and quality of life measurements were assessed at baseline, as well as 6 weeks and 12 weeks post-injection. Safety and tolerability were also assessed. This trial is registered under clinical research information service (CRIS) number KCT0001634. Patients injected with Prabotulinumtoxin A showed a significant improvement in pain at 12 weeks (p < 0.001). At 6 weeks, the pain had not significantly improved compared with baseline (p = 0.063). However, at that time, 41.7% of patients were characterized as Prabotulinumtoxin A responders, with a 30% reduction in pain rating score compared to baseline. In the Neck Disability Index scores, the patients demonstrated significant improvement at both 6 weeks and 12 weeks. No serious adverse effects occurred during the study. Prabotulinumtoxin A injection into chronically painful muscles associated with cervical and shoulder girdle myofascial pain syndrome resulted in an improvement in pain scores and quality of life lasting at least 12 weeks. Additionally, the injections were well tolerated. As these are preliminary findings in a pilot study, future studies should carefully consider using randomized, controlled, prospective trials.

Extracorporeal Shock Waves Versus Botulinum Toxin Type A in the Treatment of Poststroke Upper Limb Spasticity: A Randomized Noninferiority Trial

OBJECTIVE

To investigate whether extracorporeal shock wave therapy (ESWT) is noninferior to botulinum toxin type A (BoNT-A) for the treatment of poststroke upper limb spasticity.

DESIGN

Randomized noninferiority trial.

SETTING

Referral medical center.

PARTICIPANTS

Patients (N=42) with chronic stroke (28 men; mean age, 61.0±10.6y).

INTERVENTIONS

Patients received either ESWT or BoNT-A. During the study period, all patients continued their regular rehabilitation.

MAIN OUTCOME MEASURES

Assessments were performed at baseline and at 1, 4, and 8 weeks after the intervention. The primary outcome was the change from baseline of the modified Ashworth scale (MAS) score of the wrist flexors at week 4. Secondary outcomes included the change of the MAS scores, Tardieu angles of the wrist and elbow flexors, wrist and elbow passive range of motion (PROM), and upper extremity Fugl-Meyer Assessment (UE-FMA) score during the study period, as well as the treatment response rate.

RESULTS

The primary outcome result in the ESWT group (-0.80±0.41) was similar to that in the BoNT-A group (-0.90±0.44), with a higher confidence limit (0.4) for the difference between groups within the prespecified margin of 0.5, indicating the noninferiority of ESWT to BoNT-A. The response rate was not significantly different between the 2 groups. Both groups showed significant improvement in secondary outcomes relative to baseline; however, the ESWT group yielded greater improvement in wrist and elbow PROM and UE-FMA score.

CONCLUSION

Our results suggest that ESWT is a noninferior treatment alternative to BoNT-A for poststroke upper limb spasticity. ESWT and BoNT-A caused similar reduction in spasticity of the wrist and elbow flexors; however, ESWT yielded greater improvement in wrist and elbow PROM and UE-FMA score.

The Effect of Intragastric Administration of Botulinum Toxin Type A on Reducing Adiposity in a Rat Model of Obesity Using Micro-CT and Histological Examinations

Background/Aims

Botulinum toxin type A (BTX), a long-acting inhibitor of muscular contraction in both striated and smooth muscles, is responsible for gastric motility. The aim of this study was to investigate the effects of an endoscopic intragastric BTX injection on weight loss, body fat accumulation, and gastric emptying time.

Methods

The BTX group consisted of 15 obese rats in which 20 U of BTX were injected into the gastric antrum. The saline group consisted of 15 obese rats injected with 20 U of saline, and the control group included 10 obese rats that did not receive a surgical intervention. The gastric emptying time, biochemical parameters, and body fat volume were evaluated using micro-computed tomography (micro-CT) and histologic evaluations.

Results

The postoperative body weight of the BTX group was significantly lower than those of the other groups (p<0.001) at 6 weeks after the operation. The gastric emptying time (156±54 minutes) was significantly delayed in the BTX group. The BTX group showed significantly lower lipid levels than the other groups. A reduction in body fat volume was observed in the BTX group using micro-CT and histological evaluations.

Conclusions

BTX application to the gastric antrum represents a potentially effective treatment for obesity and may help improve the lipid profile by increasing the gastric emptying time.

Biomechanical Reactions of Exoskeleton Neurorehabilitation Robots in Spastic Elbows and Wrists

Spasticity is an important factor in designing wearable and lightweight exoskeleton neurorehabilitation robots. The proposed study evaluates biomechanical reactions of an exoskeleton robot to spasticity and establishes relevant guidelines for robot design. A two-axis exoskeleton robot is used to evaluate a group of 20 patients post-stroke with spastic elbow and/or wrist joints. All subjects are given isokinetic movements at various angular velocities within the capable range of motion for both joints. The resistance torque and corresponding angular position at each joint are recorded continuously. Maximal resistance torques caused by low (modified Ashworth scale (MAS) 0, 1), intermediate (MAS 1+), and high (MAS 2 and 3) grade spasticity were 3.68 ± 2.42, 5.94 ± 2.55, and 8.25 ± 3.35 Nm for the elbow flexor ( , between each grades) and 4.23 ± 1.75, 5.68 ± 1.96, and 5.44 ± 2.02 Nm for the wrist flexor ( , for low versus intermediate, low versus high grade spasticity). The angular velocity did not significantly influence maximal resistance torque in either joint. The catch occurred more quickly at higher velocities for low and intermediate elbow flexor spasticity ( ). Spasticity caused considerable resistance to the robots during mechanically actuated movements. The resistance range according to the degree of spasticity should be considered when designing practical neurorehabilitation robots.

Botulinum Toxin Injection-Site Selection for a Smooth Shoulder Line: An Anatomical Study

Introduction. This study aimed to improve the accuracy of manual needle placement into the trapezius (TM) for smooth shoulder line. Methods. For macroscopic study 12 TMs and for microscopic study 4 cadavers were detached and then sampled, 1⁎1 cm at the four points from the origin to insertion site (0% at the most lateral point of external occipital protuberance and 100% at the most lateral point of acromion). Results. Most of the nerve endings observed during macroscopic investigations were concentrated in the 60–80% region, and the second most distributed region was the 40–60% region. The microscopic results revealed that the 60–80% region on the reference line had the most dense neuromuscular junction area, while the 40–60% and 80–100% areas were similar in their neuromuscular junction densities. Discussion. These anatomical results will be useful in clinical settings especially for cosmetic surgeons.

Improvement of upper trunk posture during walking in hemiplegic patients after injections of botulinum toxin into the arm

BACKGROUND

It has been hypothesized that altered trunk movements during gait in post-stroke patients or children with cerebral palsy are compensatory to lower limb impairment. Improvement of trunk movements and posture after injections of botulinum toxin into the affected arm would be at variance with this hypothesis and hint towards a multifactorial trunk control deficit.

PATIENTS AND METHODS

Clinical gait analysis was performed in 11 consecutively recruited hemiplegic patients immediately before and 4weeks after a botulinum toxin type A-injection into the affected arm. Kinematic data were collected using an 8 camera optical motion-capturing system and reflective skin-markers were attached according to a standard plug-in-gait model. Deviation of the trunk in lateral and forward direction and the trajectory of the C7-marker in a sacrum-fixed horizontal plane were analyzed in addition to classical gait parameters. The Wilson-signed-rank test was used for pre/post-botulinum toxin comparisons.

FINDINGS

After botulinum toxin injections a significant improvement of forearm flexion scores from 2.57 to 2.0 (p<0.014), and a reduced lateral deviation of the upper trunk from 3.5degrees to 2.5degrees (p<0.014) were observed. Free-walkers tended to walk faster (p<0.046, 1-sided), with reduced pre-swing duration of both legs and an increased step length of the non-affected leg. The C7-marker trajectory was shifted towards the midline.

INTERPRETATION

Injections of botulinum toxin into the affected arm of hemiplegic patients improve abnormal trunk lateral flexion. This shift of the center of mass of the upper body towards the midline improves various gait parameters including gait speed.

Impact of Neu-botulinumtoxinA on the Severity and Quality of Life of Cervical Dystonia Patients

Background

Cervical dystonia (CD) is a debilitating neurological disorder that may gravely affect a patient’s quality of life (QoL). Botulinum toxin treatment has been approved as a first-line treatment for this condition. This study aims to look at the efficacy and impact on the QoL of neu-botulinumtoxinA, a newer and cheaper botulinum toxin type A, in patients with CD.

Methods

This is a prospective, open-label, single-arm study. CD patients were recruited and evaluated for severity of CD using the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS), and for QoL using the Craniocervical Dystonia Questionnaire (CDQ-24), and the 36-item Short Form Health Survey questionnaire (SF-36) at baseline and 6 weeks after injection.

Results

Twenty patients were recruited. Significant improvement was shown in part 1 and total TWSTRS score and total CDQ-24 scores. Analysis of individual items of the TWSTRS scale showed significant improvement in rotation, duration of CD, and work ability. Significant improvements in the QoL were also seen in some items of the stigma, emotional wellbeing, and energy/fatigue domains of the CDQ-24 and SF-36 questionnaires.

Discussion

Neu-botulinumtoxinA is efficacious in treating CD symptoms and improving QoL of patients with CD. A larger, double-blinded study is needed to study the extent of improvements.