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Battaglia M, Borg MB, Loro A, Cosenza L, Scotti L, Picelli A, Filippetti M, Bertoni M, Spina S, Santamato A, Carda S, Baricich A. Post-stroke spasticity: follow-up and functional implications of chronic long-term treatment with botulinum toxin. Eur J Phys Rehabil Med 2024; 60:581-590. [PMID: 38888735 PMCID: PMC11391392 DOI: 10.23736/s1973-9087.24.08429-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2024]
Abstract
BACKGROUND Around 40% of stroke survivor develop spasticity. Plantar flexors (PF) muscles are often affected, with severe functional impairment. The treatment of choice is botulinum toxin type A (BoNT-A) combined with adjuvant treatments. The temporary pharmacological effect implies periodic reassessment and reinjection. These long-term chronic programs require monitoring the functional impact of each cycle and the clinical evolution in relation to aging and repeated interventions. AIM Evaluating changes of functional level in patients with post-stroke spasticity treated with BoNT-A by assessing the long-term maintenance of the therapeutic efficacy. DESIGN Retrospective longitudinal observational study. SETTING Outpatients. POPULATION Chronic stroke survivors undergoing BoNT-A treatment and subsequent intensive rehabilitation (10 sessions in a day-hospital regime). METHODS Medical records of the enrolled patients were consulted. The primary endpoint was the change in PF spasticity by at least 1 point on the Modified Ashworth Scale (MAS) at each cycle. Secondary endpoints were the assessment of possible trends in gait parameters (Six Minute Walking Test [6MWT]; Timed Up and Go [TUG], and 10 Meters Walking Test [10mWT]) pre- and post-injection and at each cycle. RESULTS Thirty-six patients were enrolled. A reduction of at least one MAS point for PF was recorded after each cycle in all subjects. A time-dependent reduction in the proportion of patients reporting an improvement higher than the minimal clinically important difference (MCID) in 6MWT and 10mWT was observed. In the case of TUG, this data kept stable at all cycles. A one-point increase in the basal functional ambulation classification (FAC) score resulted in a reduction in the probability of having a TUG improvement greater than the MCID. The opposite correlation was found for 6MWT and 10mWT. CONCLUSIONS With the proposed treatment, the clinical significance TUG improvement remains constant throughout repeated cycles and the proportion of patients with improvement in 6MWT and 10mWT tends to decline over time. The predictive value of basal FAC on the functional variables expected improvement may provide a potential treatment targeting tool. CLINICAL REHABILITATION IMPACT These results may deliver prognostic indication allowing an optimized integration of different post-BoNT-A rehabilitation approaches, agreeing with current evidence. Adequate monitoring and treatment protocols are crucial for the stability of functional level and may prevent excessive fluctuations.
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Affiliation(s)
- Marco Battaglia
- Physical and Rehabilitation Medicine, Department of Health Sciences, "Università del Piemonte Orientale", Novara, Italy -
- Physical and Rehabilitation Medicine Unit, Maggiore della Carità University Hospital, Novara, Italy -
| | - Margherita B Borg
- Physical and Rehabilitation Medicine, Department of Health Sciences, "Università del Piemonte Orientale", Novara, Italy
- Physical and Rehabilitation Medicine Unit, Maggiore della Carità University Hospital, Novara, Italy
| | - Alberto Loro
- Physical and Rehabilitation Medicine, Department of Health Sciences, "Università del Piemonte Orientale", Novara, Italy
- Physical and Rehabilitation Medicine Unit, Maggiore della Carità University Hospital, Novara, Italy
| | - Lucia Cosenza
- Physical and Rehabilitation Medicine Unit, Maggiore della Carità University Hospital, Novara, Italy
| | - Lorenza Scotti
- Department of Translational Medicine, "Università del Piemonte Orientale", Novara, Italy
| | - Alessandro Picelli
- Neuromotor and Cognitive Rehabilitation Research Center, Department of Neurosciences, Biomedicine and Movement Sciences University, Verona, Italy
| | - Mirko Filippetti
- Neuromotor and Cognitive Rehabilitation Research Center, Department of Neurosciences, Biomedicine and Movement Sciences University, Verona, Italy
| | - Michele Bertoni
- Department of Physical Medicine and Rehabilitation, ASST Settelaghi, Varese, Italy
| | - Stefania Spina
- Spasticity and Movement Disorders "ReSTaRt" Unit, Physical Medicine and Rehabilitation Section, Policlinico Riuniti Hospital, University of Foggia, Foggia, Italy
| | - Andrea Santamato
- Spasticity and Movement Disorders "ReSTaRt" Unit, Physical Medicine and Rehabilitation Section, Policlinico Riuniti Hospital, University of Foggia, Foggia, Italy
| | - Stefano Carda
- Department of Clinical Neurosciences, Service of Neuropsychology and Neurorehabilitation, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Alessio Baricich
- Physical and Rehabilitation Medicine, Department of Health Sciences, "Università del Piemonte Orientale", Novara, Italy
- Physical and Rehabilitation Medicine Unit, Maggiore della Carità University Hospital, Novara, Italy
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Facciorusso S, Spina S, Picelli A, Baricich A, Francisco GE, Molteni F, Wissel J, Santamato A. The Role of Botulinum Toxin Type-A in Spasticity: Research Trends from a Bibliometric Analysis. Toxins (Basel) 2024; 16:184. [PMID: 38668609 PMCID: PMC11053519 DOI: 10.3390/toxins16040184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 04/01/2024] [Accepted: 04/08/2024] [Indexed: 04/29/2024] Open
Abstract
Botulinum toxin type-A (BoNT-A) has emerged as a key therapeutic agent for the management of spasticity. This paper presents a comprehensive bibliometric and visual analysis of research concerning BoNT-A treatment of spasticity to elucidate current trends and future directions in this research area. A search was conducted in the Web of Science database for articles focused on the use of BoNT-A in spasticity published between 2000 and 2022. We extracted various metrics, including counts of publications and contributions from different countries, institutions, authors, and journals. Analytical methods in CiteSpace were employed for the examination of co-citations, collaborations, and the co-occurrence of keywords. Our search yielded 1489 publications. Analysis revealed a consistent annual increase in research output. The United States, United Kingdom, and Italy were the leading contributors. The top institution in this research was Assistance Publique Hopitaux, Paris. The journal containing the highest number of relevant publications was Toxins. Key frequently occurring keywords were 'stroke', 'cerebral palsy', 'adult spasticity', and 'upper extremity'. This study identified 12 clusters of keywords and 15 clusters of co-cited references, indicating the main focus areas and emerging themes in this field. This study comprehensively analyzed and summarized trends in BoNT-A research in the field of spasticity over the past 22 years.
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Affiliation(s)
- Salvatore Facciorusso
- Spasticity and Movement Disorders “ReSTaRt”, Unit Physical Medicine and Rehabilitation Section, Department of Medical and Surgical Sciences, University of Foggia, 71122 Foggia, Italy; (S.F.); (A.S.)
- Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy
| | - Stefania Spina
- Spasticity and Movement Disorders “ReSTaRt”, Unit Physical Medicine and Rehabilitation Section, Department of Medical and Surgical Sciences, University of Foggia, 71122 Foggia, Italy; (S.F.); (A.S.)
| | - Alessandro Picelli
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37100 Verona, Italy;
| | - Alessio Baricich
- Physical Medicine and Rehabilitation, Department of Health Sciences, Università del Piemonte Orientale, 28100 Novara, Italy;
| | - Gerard E. Francisco
- Department of Physical Medicine & Rehabilitation, University of Texas Health McGovern Medical School, Houston, TX 77030, USA;
| | - Franco Molteni
- Villa Beretta Rehabilitation Center, Valduce Hospital Como, 23845 Costa Masnaga, Italy;
| | - Jörg Wissel
- Department of Neurorehabilitation and Physical Therapy, Vivantes Hospital Spandau, 13585 Berlin, Germany;
| | - Andrea Santamato
- Spasticity and Movement Disorders “ReSTaRt”, Unit Physical Medicine and Rehabilitation Section, Department of Medical and Surgical Sciences, University of Foggia, 71122 Foggia, Italy; (S.F.); (A.S.)
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Intiso D, Centra AM, Gravina M, Chiaramonte A, Bartolo M, Di Rienzo F. Botulinum Toxin-A High-Dosage Effect on Functional Outcome and Spasticity-Related Pain in Subjects with Stroke. Toxins (Basel) 2023; 15:509. [PMID: 37624266 PMCID: PMC10467116 DOI: 10.3390/toxins15080509] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 08/08/2023] [Accepted: 08/14/2023] [Indexed: 08/26/2023] Open
Abstract
Stroke patients can develop spasticity and spasticity-related pain (SRP). These disorders are frequent and can contribute to functional limitations and disabling conditions. Many reports have suggested that higher doses than initially recommended of BTX-A can be used effectively and safely, especially in the case of severe spasticity; however, whether the treatment produces any benefit on the functional outcome and SRP is unclear. Studies published between January 1989 and December 2022 were retrieved from MEDLINE/PubMed, Embase, and Cochrane Central Register. Only obabotulinumtoxinA (obaBTX-A), onabotulinumtoxinA, (onaBTX-A), and incobotulinumtoxinA (incoBTX-A) were considered. The term "high dosage" indicates ≥600 U. Nine studies met the inclusion criteria. Globally, 460 subjects were treated with BTX-A high dose, and 301 suffered from stroke. Studies had variable method designs, sample sizes, and aims. Only five (55.5%) reported data about the functional outcome after BTX-A injection. Functional measures were also variable, and the improvement was observed predominantly in the disability assessment scale (DAS). SRP pain was quantified by visual analog scale (VAS) and only three studies reported the BTX-A effect. There is no scientific evidence that this therapeutic strategy unequivocally improves the functionality of the limbs. Although no clear-cut evidence emerges, certain patients with spasticity might obtain goal-oriented improvement from high-dose BTX-A. Likewise, data are insufficient to recommend high BTX dosage in SRP.
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Affiliation(s)
- Domenico Intiso
- Unit of Neuro-Rehabilitation Unit and Rehabilitation Medicine, IRCCS ‘Casa Sollievo della Sofferenza’, Viale dei Cappuccini 1, San Giovanni Rotondo, 71013 Foggia, Italy; (A.M.C.); (M.G.); (A.C.); (F.D.R.)
| | - Antonello Marco Centra
- Unit of Neuro-Rehabilitation Unit and Rehabilitation Medicine, IRCCS ‘Casa Sollievo della Sofferenza’, Viale dei Cappuccini 1, San Giovanni Rotondo, 71013 Foggia, Italy; (A.M.C.); (M.G.); (A.C.); (F.D.R.)
| | - Michele Gravina
- Unit of Neuro-Rehabilitation Unit and Rehabilitation Medicine, IRCCS ‘Casa Sollievo della Sofferenza’, Viale dei Cappuccini 1, San Giovanni Rotondo, 71013 Foggia, Italy; (A.M.C.); (M.G.); (A.C.); (F.D.R.)
| | - Angelo Chiaramonte
- Unit of Neuro-Rehabilitation Unit and Rehabilitation Medicine, IRCCS ‘Casa Sollievo della Sofferenza’, Viale dei Cappuccini 1, San Giovanni Rotondo, 71013 Foggia, Italy; (A.M.C.); (M.G.); (A.C.); (F.D.R.)
| | - Michelangelo Bartolo
- Department of Rehabilitation, Neurorehabilitation Unit, HABILITA Zingonia, Ciserano, 24040 Bergamo, Italy;
| | - Filomena Di Rienzo
- Unit of Neuro-Rehabilitation Unit and Rehabilitation Medicine, IRCCS ‘Casa Sollievo della Sofferenza’, Viale dei Cappuccini 1, San Giovanni Rotondo, 71013 Foggia, Italy; (A.M.C.); (M.G.); (A.C.); (F.D.R.)
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Vova JA, Green MM, Brandenburg JE, Davidson L, Paulson A, Deshpande S, Oleszek JL, Inanoglu D, McLaughlin MJ. A consensus statement on the use of botulinum toxin in pediatric patients. PM R 2021; 14:1116-1142. [PMID: 34558213 DOI: 10.1002/pmrj.12713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 08/12/2021] [Accepted: 09/10/2021] [Indexed: 11/10/2022]
Abstract
Botulinum toxin has been used in medicine for the past 30 years. However, there continues to be controversy about the appropriate uses and dosing, especially in the pediatric population. A panel of nine pediatric physiatrists from different regions and previous training programs in the United States were nominated based on institutional reputation and botulinum toxin (BoNT) experience. Based on a review of the current literature, the goal was to provide the rationale for recommendations on the administration of BoNT in the pediatric population. The goal was not only to review safety, dosing, and injection techniques but also to develop a consensus on the appropriate uses in the pediatric population. In addition to upper and lower limb spasticity, the consensus also provides recommendations for congenital muscular torticollis, cervical dystonia, sialorrhea, and brachial plexus palsies.
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Affiliation(s)
- Joshua A Vova
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Michael M Green
- University of Utah/Primary Children's Hospital, Salt Lake City, Utah, USA
| | | | - Loren Davidson
- University of California Davis, Sacramento, California, USA
| | - Andrea Paulson
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Gillette Children's Specialty Healthcare, Minneapolis, Minnesota, USA
| | - Supreet Deshpande
- Gillette Children's Specialty Healthcare, Minneapolis, Minnesota, USA
| | | | - Didem Inanoglu
- Children's Health Specialty Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Botulinum Toxin Services for Neurorehabiliation: Recommendations for Challenges and Opportunities during the COVID-19 Pandemic. Toxins (Basel) 2021; 13:toxins13080584. [PMID: 34437456 PMCID: PMC8402461 DOI: 10.3390/toxins13080584] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 08/11/2021] [Accepted: 08/18/2021] [Indexed: 11/17/2022] Open
Abstract
The COVID-19 pandemic severely impacted the function of medical facilities and rehabilitation services worldwide, including toxin services delivering Botulinum toxin treatments for neuromuscular conditions such as spasticity, dystonia, and sialorrhea. The aim of this paper is to understand how toxin services have dealt with the situation and what strategies have been adopted to continue services. The recommendations are based on a virtual round table held with toxin services experts from different European countries who shared their experiences and discussed the best practices. The challenges for toxin services were reviewed based on the experts' experiences and on relevant literature from 2020 and 2021. A set of recommendations and best practices were compiled, focusing firstly on guidance for clinical practice, including assessing patients' health and risk status and the urgency of their treatment. Secondly, it was discussed how patients on botulinum toxin therapy can be cared for and supported during the pandemic, and how modern technology and tele-medicine platforms can be generally used to optimize effectiveness and safety of toxin treatments. The technological advances prompted by the COVID-19 crisis can result in better and more modern patient care in the future.
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Picelli A, Filippetti M, Sandrini G, Tassorelli C, De Icco R, Smania N, Tamburin S. Electrical Stimulation of Injected Muscles to Boost Botulinum Toxin Effect on Spasticity: Rationale, Systematic Review and State of the Art. Toxins (Basel) 2021; 13:toxins13050303. [PMID: 33922855 PMCID: PMC8146442 DOI: 10.3390/toxins13050303] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 04/08/2021] [Accepted: 04/22/2021] [Indexed: 01/11/2023] Open
Abstract
Botulinum toxin type A (BoNT-A) represents a first-line treatment for spasticity, a common disabling consequence of many neurological diseases. Electrical stimulation of motor nerve endings has been reported to boost the effect of BoNT-A. To date, a wide range of stimulation protocols has been proposed in the literature. We conducted a systematic review of current literature on the protocols of electrical stimulation to boost the effect of BoNT-A injection in patients with spasticity. A systematic search using the MeSH terms “electric stimulation”, “muscle spasticity” and “botulinum toxins” and strings “electric stimulation [mh] OR electrical stimulation AND muscle spasticity [mh] OR spasticity AND botulinum toxins [mh] OR botulinum toxin type A” was conducted on PubMed, Scopus, PEDro and Cochrane library electronic databases. Full-text articles written in English and published from database inception to March 2021 were included. Data on patient characteristics, electrical stimulation protocols and outcome measures were collected. This systematic review provides a complete overview of current literature on the role of electrical stimulation to boost the effect of BoNT-A injection for spasticity, together with a critical discussion on its rationale based on the neurobiology of BoNT-A uptake.
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Affiliation(s)
- Alessandro Picelli
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37100 Verona, Italy; (A.P.); (M.F.); (N.S.)
| | - Mirko Filippetti
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37100 Verona, Italy; (A.P.); (M.F.); (N.S.)
| | - Giorgio Sandrini
- Department of Brain and Behavioral Sciences, University of Pavia, 27100 Pavia, Italy; (G.S.); (C.T.); (R.D.I.)
- Headache Science & Neurorehabilitation Center, IRCCS Mondino Foundation, 27100 Pavia, Italy
| | - Cristina Tassorelli
- Department of Brain and Behavioral Sciences, University of Pavia, 27100 Pavia, Italy; (G.S.); (C.T.); (R.D.I.)
- Headache Science & Neurorehabilitation Center, IRCCS Mondino Foundation, 27100 Pavia, Italy
| | - Roberto De Icco
- Department of Brain and Behavioral Sciences, University of Pavia, 27100 Pavia, Italy; (G.S.); (C.T.); (R.D.I.)
- Headache Science & Neurorehabilitation Center, IRCCS Mondino Foundation, 27100 Pavia, Italy
| | - Nicola Smania
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37100 Verona, Italy; (A.P.); (M.F.); (N.S.)
| | - Stefano Tamburin
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37100 Verona, Italy; (A.P.); (M.F.); (N.S.)
- Correspondence:
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Abstract
Spasticity is one component of the upper motor neuron (UMN) syndrome resulting from a multitude of neurologic conditions, such as stroke, brain injury, spinal cord injury, multiple sclerosis, and cerebral palsy. It is clinically recognized as a phenomenon of velocity-dependent increase in resistance, i.e., hypertonia. Recent advances in the pathophysiology of spasticity improve our understanding of mechanisms underlying this complex phenomenon and its relations to other components of UMN syndrome (weakness and disordered motor control), as well as the resultant clinical problems. This theoretical framework provides a foundation to set up treatment goals and to guide goal-oriented clinical assessment and treatment. Among a spectrum of treatment options, botulinum toxin (BoNT) therapy is the preferred treatment for focal spasticity. The evidence is very robust that BoNT therapy effectively reduces spasticity; however, it does not improve voluntary movement. In this chapter, we highlight a few issues on how to achieve the best clinical outcomes of BoNT therapy, such as dosing, dilution, guidance techniques, adjunctive therapies, early treatment, repeated injections, and central effects, as well as the ways to improve motor function in selected subgroups of patients with spasticity. We also discuss the reasons of poor responses to BoNT therapy and when not to use BoNT therapy.
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Affiliation(s)
- Sheng Li
- Department of Physical Medicine and Rehabilitation, McGovern Medical School, University of Texas Health Science Center Houston (UTHealth), Houston, TX, USA.
- TIRR Memorial Hermann Hospital, Houston, TX, USA.
| | - Gerard E Francisco
- Department of Physical Medicine and Rehabilitation, McGovern Medical School, University of Texas Health Science Center Houston (UTHealth), Houston, TX, USA
- TIRR Memorial Hermann Hospital, Houston, TX, USA
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Fairmont I, Winkler A. Novel Cosmetic Uses of Botulinum Toxin in the Head and Neck. CURRENT OTORHINOLARYNGOLOGY REPORTS 2020. [DOI: 10.1007/s40136-020-00309-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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High Dosage of Botulinum Toxin Type A in Adult Subjects with Spasticity Following Acquired Central Nervous System Damage: Where Are We at? Toxins (Basel) 2020; 12:toxins12050315. [PMID: 32397674 PMCID: PMC7291232 DOI: 10.3390/toxins12050315] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 04/28/2020] [Accepted: 05/07/2020] [Indexed: 11/16/2022] Open
Abstract
Spasticity is a common disabling disorder in adult subjects suffering from stroke, brain injury, multiple sclerosis (MS) and spinal cord injury (SCI). Spasticity may be a disabling symptom in people during rehabilitation and botulinum toxin type A (BTX-A) has become the first-line therapy for the local form. High BTX-A doses are often used in clinical practice. Advantages and limitations are debated and the evidence is unclear. Therefore, we analysed the efficacy, safety and evidence for BTX-A high doses. Studies published from January 1989 to February 2020 were retrieved from MEDLINE/PubMed, Embase, Cochrane Central Register. Only obabotulinumtoxinA (obaBTX-A), onabotulinumtoxinA (onaBTX-A), and incobotulinumtoxinA (incoBTX-A) were considered. The term “high dosage” indicated ≥ 600 U. Thirteen studies met the inclusion criteria. Studies had variable method designs, sample sizes and aims, with only two randomised controlled trials. IncoBTX-A and onaBTX-A were injected in three and eight studies, respectively. BTX-A high doses were used predominantly in treating post-stroke spasticity. No studies were retrieved regarding treating spasticity in MS and SCI. Dosage of BTX-A up to 840 U resulted efficacious and safety without no serious adverse events (AEs). Evidence is insufficient to recommend high BTX-A use in clinical practice, but in selected patients, the benefits of high dose BTX-A may be clinically acceptable.
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Kirshblum S, Solinsky R, Jasey N, Hampton S, Didesch M, Seidel B, Botticello A. Adverse Event Profiles of High Dose Botulinum Toxin Injections for Spasticity. PM R 2020; 12:349-355. [PMID: 31408270 DOI: 10.1002/pmrj.12240] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 08/06/2019] [Indexed: 11/10/2022]
Affiliation(s)
- Steven Kirshblum
- Kessler Institution for Rehabilitation West Orange NJ
- Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School Newark NJ
- Kessler Foundation East Hanover NJ
| | - Ryan Solinsky
- Spaulding Rehabilitation Hospital Boston MA
- Department of Physical Medicine and RehabilitationHarvard Medical School Boston MA
| | - Neil Jasey
- Kessler Institution for Rehabilitation West Orange NJ
- Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School Newark NJ
| | - Stephen Hampton
- Department of Physical Medicine & RehabilitationUniversity of Pennsylvania Perelman School of Medicine Philadelphia PA
| | - Michelle Didesch
- Physical Medicine and Rehabilitation, Confluence Health Wenatchee WA
| | - Benjamin Seidel
- Physical Medicine and Rehabilitation, Burke Rehabilitation Hospital White Plains NY
| | - Amanda Botticello
- Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School Newark NJ
- Kessler Foundation East Hanover NJ
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Santamato A, Cinone N, Panza F, Letizia S, Santoro L, Lozupone M, Daniele A, Picelli A, Baricich A, Intiso D, Ranieri M. Botulinum Toxin Type A for the Treatment of Lower Limb Spasticity after Stroke. Drugs 2019; 79:143-160. [PMID: 30623347 DOI: 10.1007/s40265-018-1042-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
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.
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Affiliation(s)
- Andrea Santamato
- Physical Medicine and Rehabilitation Section, "OORR Hospital", University of Foggia, Viale Pinto, 71100, Foggia, Italy.
- "Fondazione Turati" Rehabilitation Centre, Vieste, Foggia, Italy.
| | - Nicoletta Cinone
- Physical Medicine and Rehabilitation Section, "OORR Hospital", University of Foggia, Viale Pinto, 71100, Foggia, Italy
| | - Francesco Panza
- Neurodegenerative Disease Unit, Department of Basic Medical Sciences, Neuroscience and Sense Organs, University of Bari "Aldo Moro", Bari, Italy
- Department of Clinical Research in Neurology, Center for Neurodegenerative Diseases and the Aging Brain, University of Bari "Aldo Moro", "Pia Fondazione Cardinale G. Panico", Tricase, Lecce, Italy
- Geriatric Unit, Fondazione IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo, Foggia, Italy
| | - Sara Letizia
- Physical Medicine and Rehabilitation Section, "OORR Hospital", University of Foggia, Viale Pinto, 71100, Foggia, Italy
| | - Luigi Santoro
- Physical Medicine and Rehabilitation Section, "OORR Hospital", University of Foggia, Viale Pinto, 71100, Foggia, Italy
| | - Madia Lozupone
- Neurodegenerative Disease Unit, Department of Basic Medical Sciences, Neuroscience and Sense Organs, University of Bari "Aldo Moro", Bari, Italy
| | - Antonio Daniele
- Institute of Neurology, Catholic University of Sacred Heart, Rome, Italy
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Alessandro Picelli
- Department of Neurosciences, Biomedicine and Movement Sciences, Neuromotor and Cognitive Rehabilitation Research Center, University of Verona, Verona, Italy
- Neurorehabilitation Unit, Department of Neurosciences, Hospital Trust of Verona, Verona, Italy
| | - Alessio Baricich
- Health Sciences Department, Università del Piemonte Orientale, Novara, Italy
| | - Domenico Intiso
- Department of Neuro-Rehabilitation IRCCS, Casa Sollievo della Sofferenza, San Giovanni Rotondo, Foggia, Italy
| | - Maurizio Ranieri
- Physical Medicine and Rehabilitation Section, "OORR Hospital", University of Foggia, Viale Pinto, 71100, Foggia, Italy
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Ahn C, Kang S, Sa HS. Repeated injections of botulinum toxin-A for epiphora in lacrimal drainage disorders: qualitative and quantitative assessment. Eye (Lond) 2019; 33:995-999. [PMID: 30765885 DOI: 10.1038/s41433-019-0362-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 11/29/2018] [Accepted: 12/30/2018] [Indexed: 11/09/2022] Open
Abstract
PURPOSE To report the outcome of repeated botulinum toxin-A (BTA) injections in the lacrimal glands in patients with epiphora. METHODS We performed retrospective chart review of patients who were injected with 2.5 units of BTA in the lacrimal gland. Epiphora and tear production were assessed by the Munk score and Schirmer-1 test, respectively, pre-injection and at 1 and 3 months post injection. Regarding repeated injections, the effects of the first were compared to those of the second and third injections. RESULTS Forty-six eyes of 35 patients had an average of 2.3 injections per eye (range, 1-6). The mean Munk score significantly decreased from 3.72 to 1.87 at 1 month (p < 0.001) and 2.21 at 3 months (p < 0.001) after injection. The mean Schirmer-1 score also significantly decreased from 15.35 mm to 10.52 mm at 1 month (p < 0.001) and 12.48 mm at 3 months (p < 0.001) after injection. The mean reduction rates of Munk and Schirmer-1 scores after the second (66.1% and 29.8%, respectively) and the third injections (56.1% and 23.3%, respectively) were not significantly different from those after the first injection (63.3% and 26.1%, respectively) (p > 0.05 for each comparison). There was a significant correlation between the difficulty in exposing the lacrimal gland for injection and the risk of complication (p = 0.017). CONCLUSION BTA injection in the lacrimal gland showed favourable outcomes; repeated injections did not compromise efficacy. BTA injection can be safely repeated for epiphora, especially in patients whose lacrimal gland can be easily exposed.
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Affiliation(s)
- Chanjoo Ahn
- Department of Ophthalmology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Sunah Kang
- Department of Ophthalmology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Ho-Seok Sa
- Department of Ophthalmology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea.
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Marciniak C, Munin MC, Brashear A, Rubin BS, Patel AT, Slawek J, Hanschmann A, Hiersemenzel R, Elovic EP. IncobotulinumtoxinA Efficacy and Safety in Adults with Upper-Limb Spasticity Following Stroke: Results from the Open-Label Extension Period of a Phase 3 Study. Adv Ther 2019; 36:187-199. [PMID: 30484117 PMCID: PMC6318229 DOI: 10.1007/s12325-018-0833-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Indexed: 01/12/2023]
Abstract
Introduction The objective of the study was to investigate the efficacy and safety of repeated incobotulinumtoxinA injections for the treatment of upper-limb post-stroke spasticity in adults. Methods Adults 18–80 years of age with post-stroke upper-limb spasticity who completed the 12-week randomized, double-blind, placebo-controlled main period (MP) of a phase 3 trial (NCT01392300) were eligible to enrol in the 36-week open-label extension period (OLEX). The OLEX included three treatment cycles at fixed 12-week injection intervals; subjects were injected with 400 U incobotulinumtoxinA into the affected upper limb. Efficacy assessments included evaluation of muscle tone using the Ashworth Scale (AS) and the Global Impression of Change Scale (GICS) assessed by the investigator, subject, and caregiver. The incidence of adverse events (AEs) was monitored throughout the OLEX. Results A total of 296 of 299 subjects (99.0%) who completed the MP received incobotulinumtoxinA in the OLEX, and 248 subjects completed the 36-week OLEX. The proportion of subjects with at least a 1-point improvement in AS score from each incobotulinumtoxinA treatment to the respective 4-week post-injection visit ranged by cycle from 52.3% to 59.2% for wrist flexors, 49.1% to 52.3% for elbow flexors, 59.8% to 64.5% for finger flexors, 35.5% to 41.2% for thumb flexors, and 37.4% to 39.9% for forearm pronators (P < 0.0001 for all). Over 90% of subjects were assessed by the investigator to be at least minimally improved (4 weeks post-injection) on the GICS during each injection cycle; 61.0% in the 1st cycle, 58.2% in the 2nd cycle, and 57.4% in the 3rd cycle were considered much improved or very much improved on the GICS. Three percent of subjects (9/296) reported treatment-related AEs; the most frequently reported were pain in the extremity (n = 2, 0.7%) and constipation (n = 2, 0.7%). Serious AEs were reported by 22 subjects (7.4%); however, none were considered treatment-related. Conclusions Repeated injections of incobotulinumtoxinA for the treatment of post-stroke upper-limb spasticity led to significant improvements in muscle tone and investigator’s global impression of change. Treatment was well tolerated, with no serious treatment-related AEs. Funding Merz Pharmaceuticals GmbH.
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Affiliation(s)
- Christina Marciniak
- Department of Physical Medicine and Rehabilitation and Department of Neurology, Northwestern University Feinberg School of Medicine, Shirley Ryan AbilityLab, Chicago, IL, USA.
| | - Michael C Munin
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Allison Brashear
- Department of Neurology, Wake Forest School of Medicine, Wake Forest Baptist Medical Center, Winston Salem, NC, USA
| | | | - Atul T Patel
- Kansas City Bone & Joint Clinic, Overland Park, KS, USA
| | - Jaroslaw Slawek
- Department of Neurological-Psychiatric Nursing, Medical University of Gdansk, Gdansk, Poland
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Safety Profile of High-Dose Botulinum Toxin Type A in Post-Stroke Spasticity Treatment. Clin Drug Investig 2018; 38:991-1000. [DOI: 10.1007/s40261-018-0701-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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15
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Santamato A, Panza F. Benefits and Risks of Non-Approved Injection Regimens for Botulinum Toxins in Spasticity. Drugs 2018; 77:1413-1422. [PMID: 28726023 DOI: 10.1007/s40265-017-0786-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Spasticity with muscle paresis and loss of dexterity is a common feature of upper motor neuron syndrome due to injuries or the pyramidal tract in several neurological conditions. Botulinum toxin type A has been considered the gold standard treatment for spasticity and movement disorders, with efficacy, reversibility, and low prevalence of complications. During the last 30 years, thousands of studies of its use have been performed, but few guidelines are available. Therefore, there is great variability in both the doses and intervals of administration and the approaches taken by clinicians with considerable experience in spasticity and movement disorder treatment. In the present review article, we provide a short overview of the benefits and risks of non-approved injection regimens and doses for botulinum toxins, focusing on the treatment of post-stroke spasticity, where there is great interest in the potential for increasing the number of treatment/years and the dose of botulinum toxin treatment for subjects with upper and lower limb spasticity. However, many doubts exist regarding antibody development and possible adverse effects.
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Affiliation(s)
- Andrea Santamato
- Physical Medicine and Rehabilitation Section, "OORR Hospital", University of Foggia, Viale Pinto, 71100, Foggia, Italy.
- "Fondazione Turati" Rehabilitation Centre, Vieste, Foggia, Italy.
| | - Francesco Panza
- Complex Structure of Geriatrics, Department of Medical Sciences, IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo, Foggia, Italy
- Unit of Neurodegenerative Disease, Department of Basic Medicine Sciences, Neuroscience, and Sense Organs, University of Bari "Aldo Moro", Bari, Italy
- Unit of Neurodegenerative Disease, Department of Clinical Research in Neurology, University of Bari "Aldo Moro" at "Pia Fondazione Card. G. Panico", Tricase, Lecce, Italy
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Wein T, Esquenazi A, Jost WH, Ward AB, Pan G, Dimitrova R. OnabotulinumtoxinA for the Treatment of Poststroke Distal Lower Limb Spasticity: A Randomized Trial. PM R 2018; 10:693-703. [DOI: 10.1016/j.pmrj.2017.12.006] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Revised: 09/29/2017] [Accepted: 12/11/2017] [Indexed: 01/03/2023]
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17
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Li J, Zhang R, Cui BL, Zhang YX, Bai GT, Gao SS, Li WJ. Therapeutic efficacy and safety of various botulinum toxin A doses and concentrations in spastic foot after stroke: a randomized controlled trial. Neural Regen Res 2017; 12:1451-1457. [PMID: 29089990 PMCID: PMC5649465 DOI: 10.4103/1673-5374.215257] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
No recommended guidelines currently exist for the therapeutic concentration or dose of botulinum toxin type A (BTXA) injected into the muscle to treat limb spasticity. Therefore, in this randomized controlled trial, we explored the safety and efficacy of two concentrations and two doses of BTXA in the treatment of spastic foot after stroke to optimize this treatment in these patients. Eligible patients (n = 104) were randomized into four groups. The triceps surae and tibialis posterior on the affected side were injected with BTXA at one of two doses (200 U or 400 U) and two concentrations (50 U/mL or 100 U/mL). The following assessments were conducted before as well as 4 days and 1, 2, 4, and 12 weeks after treatment: spasticity, assessed using the modified Ashworth scale; basic functional mobility, assessed using a timed up and go test; pace, assessed using a 10-meter timed walking test; and the ability to walk, assessed using Holden's graded scale and a visual analog scale. The reported results are based on the 89 patients that completed the study. We found significant differences for the two doses and concentrations of BTXA to improve the ability of patients to walk independently, with the high-dose/low-concentration combination providing the best effect. Onset and duration of the ameliorating effects of BTXA were 4–7 days and 12 weeks, respectively. Thus, BTXA effectively treated foot spasms after stroke at an optimal dose of 400 U and concentration of 50 U/mL.
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Affiliation(s)
- Jiang Li
- Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Ru Zhang
- Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Bo-Li Cui
- Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Yong-Xiang Zhang
- Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Guang-Tao Bai
- Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Si-Shan Gao
- Department of Neurology, Traditional Medicine Hospital of Huangdao District, Qingdao, Shandong Province, China
| | - Wen-Jian Li
- Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
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