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Bagues A, Hu J, Alshanqiti I, Chung MK. Neurobiological mechanisms of botulinum neurotoxin-induced analgesia for neuropathic pain. Pharmacol Ther 2024; 259:108668. [PMID: 38782121 PMCID: PMC11182613 DOI: 10.1016/j.pharmthera.2024.108668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 05/15/2024] [Accepted: 05/20/2024] [Indexed: 05/25/2024]
Abstract
Botulinum neurotoxins (BoNTs) are a family of neurotoxins produced by Clostridia and other bacteria that induce botulism. BoNTs are internalized into nerve terminals at the site of injection and cleave soluble N-ethylmaleimide-sensitive factor attachment protein receptor (SNARE) proteins to inhibit the vesicular release of neurotransmitters. BoNTs have been approved for multiple therapeutic applications, including the treatment of migraines. They have also shown efficacies for treating neuropathic pain, such as diabetic neuropathy, and postherpetic and trigeminal neuralgia. However, the mechanisms underlying BoNT-induced analgesia are not well understood. Peripherally administered BoNT is taken up by the nerve terminals and reduces the release of glutamate, calcitonin gene-related peptide, and substance P, which decreases neurogenic inflammation in the periphery. BoNT is retrogradely transported to sensory ganglia and central terminals in a microtubule-dependent manner. BoNTs decrease the expression of pronociceptive genes (ion channels or cytokines) from sensory ganglia and the release of neurotransmitters and neuropeptides from primary afferent central terminals, which likely leads to decreased central sensitization in the dorsal horn of the spinal cord or trigeminal nucleus. BoNT-induced analgesia is abolished after capsaicin-induced denervation of transient receptor potential vanilloid 1 (TRPV1)-expressing afferents or the knockout of substance P or the neurokinin-1 receptor. Although peripheral administration of BoNT leads to changes in the central nervous system (e.g., decreased phosphorylation of glutamate receptors in second-order neurons, reduced activation of microglia, contralateral localization, and cortical reorganization), whether such changes are secondary to changes in primary afferents or directly mediated by trans-synaptic, transcytotic, or the hematogenous transport of BoNT is controversial. To enhance their therapeutic potential, BoNTs engineered for specific targeting of nociceptive pathways have been developed to treat chronic pain. Further mechanistic studies on BoNT-induced analgesia can enhance the application of native or engineered BoNTs for neuropathic pain treatment with improved safety and efficacy.
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Affiliation(s)
- Ana Bagues
- Área de Farmacología, Nutrición y Bromatología, Dpto. C.C. Básicas de la Salud, Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos, Unidad Asociada I+D+i al Instituto de Química Médica (CSIC), Alcorcón, Spain; High Performance Research Group in Experimental Pharmacology (PHARMAKOM), Spain
| | - Jiaxin Hu
- Department of Neural and Pain Sciences, School of Dentistry, University of Maryland Baltimore, Baltimore, MD 21201, USA
| | - Ishraq Alshanqiti
- Department of Neural and Pain Sciences, School of Dentistry, University of Maryland Baltimore, Baltimore, MD 21201, USA; Program in Dental Biomedical Sciences, University of Maryland Baltimore, School of Dentistry, Baltimore, MD 21201, USA; Department of Basic and Clinical Sciences, School of Dentistry, Umm Al-Qura University, Makkah 24382, Kingdom of Saudi Arabia
| | - Man-Kyo Chung
- Department of Neural and Pain Sciences, School of Dentistry, University of Maryland Baltimore, Baltimore, MD 21201, USA; Program in Dental Biomedical Sciences, University of Maryland Baltimore, School of Dentistry, Baltimore, MD 21201, USA; Center to Advance Chronic Pain Research, University of Maryland Baltimore, Baltimore, MD 21201, USA.
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LaMarca AL, Krenn MJ, Kelso-Trass MA, MacDonald KC, Demeo CC, Bazarek SF, Brown JM. Selective Tibial Neurotomy Outcomes for Spastic Equinovarus Foot: Patient Expectations and Functional Assessment. Neurosurgery 2023; 93:1026-1035. [PMID: 37199494 DOI: 10.1227/neu.0000000000002530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 03/27/2023] [Indexed: 05/19/2023] Open
Abstract
BACKGROUND Spastic equinovarus foot (SEF) is a common dysfunctional foot posture after stroke that impairs balance and mobility. Selective tibial neurotomy (STN) is a simple but underutilized surgical option that can effectively address critical aspects of SEF and thereby provide enduring quality of life gains. There are few studies that examine both functional outcomes and patient satisfaction with this treatment option. OBJECTIVE To elucidate the patient goals that motivated their decision to undergo the procedure and compare subjective and objective changes in balance and functional mobility as a consequence of surgery. METHODS Thirteen patients with problematic SEF who had previously failed conservative measures were treated with STN. Preoperative and postoperative (on average 6 months) assessments evaluated gait quality and functional mobility. In addition, a custom survey was conducted to investigate patient perspectives on STN intervention. RESULTS The survey showed that participants who opted for STN were dissatisfied with their previous spasticity management. The most common preoperative expectation for STN treatment was to improve walking, followed by improving balance, brace comfort, pain, and tone. Postoperatively, participants rated the improvement in their expectations and were, on average, 71 on a 100-point scale, indicating high satisfaction. The gait quality, assessed with the Gait Intervention and Assessment Tool, improved significantly between preoperative and postoperative assessment (M = -4.1, P = .01) with a higher average difference in stance of -3.3 than in swing -0.5. Improvement in both gait endurance (M = 36 m, P = .01) and self-selected gait speed (M = .12 m/s, P = .03) was statistically significant. Finally, static balance (M = 5.0, P = .03) and dynamic balance (M = 3.5, P = .02) were also significantly improved. CONCLUSION STN improved gait quality and functional mobility and was associated with high satisfaction in patients with SEF.
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Affiliation(s)
- Amber L LaMarca
- Department of Neurosurgery, The Paralysis Center, Massachusetts General Hospital, Boston , Massachusetts , USA
- Rehabilitation Sciences, MGH Institute of Health Professions, Boston , Massachusetts , USA
- Physical Therapy Department, Spaulding Rehabilitation Hospital, Boston , Massachusetts , USA
| | - Matthias J Krenn
- Department of Neurosurgery, The Paralysis Center, Massachusetts General Hospital, Boston , Massachusetts , USA
- Department of Neurosurgery, University of Mississippi Medical Center, Jackson , Mississippi , USA
- Center for Neuroscience and Neurological Recovery, Methodist Rehabilitation Center, Jackson , Mississippi , USA
| | - Molly A Kelso-Trass
- Physical Therapy Department, Wentworth-Douglass Hospital, Dover , New Hampshire , USA
| | - Kathryn C MacDonald
- Rehabilitation Sciences, MGH Institute of Health Professions, Boston , Massachusetts , USA
- Physical Therapy Department, Spaulding Rehabilitation Hospital, Boston , Massachusetts , USA
- Physical Therapy Department, Wentworth-Douglass Hospital, Dover , New Hampshire , USA
| | - Cristina C Demeo
- Department of Neurosurgery, The Paralysis Center, Massachusetts General Hospital, Boston , Massachusetts , USA
| | - Stanley F Bazarek
- Department of Neurosurgery, The Paralysis Center, Massachusetts General Hospital, Boston , Massachusetts , USA
- Harvard Medical School, Cambridge , Massachusetts , USA
- Brigham and Women's Hospital, Boston , Massachusetts , USA
| | - Justin M Brown
- Department of Neurosurgery, The Paralysis Center, Massachusetts General Hospital, Boston , Massachusetts , USA
- Rehabilitation Sciences, MGH Institute of Health Professions, Boston , Massachusetts , USA
- Harvard Medical School, Cambridge , Massachusetts , USA
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Cotinat M, Bensoussan L, Kerzoncuf M, Lotito G, Milhe de Bovis V, Pellas F, Calmels P, Delarque A, Viton JM. Treating post-stroke plantar flexor spasticity does not improve spatiotemporal gait parameters: Why another negative RCT? Ann Phys Rehabil Med 2023; 66:101748. [PMID: 37271021 DOI: 10.1016/j.rehab.2023.101748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 02/27/2023] [Accepted: 03/03/2023] [Indexed: 06/06/2023]
Affiliation(s)
- Maeva Cotinat
- Department of Physical and Rehabilitation Medicine, University Hospital of Marseille, France; Aix Marseille Université, CNRS, INT UMR 7289, Marseille, France.
| | - Laurent Bensoussan
- Department of Physical and Rehabilitation Medicine, University Hospital of Marseille, France; Aix Marseille Université, CNRS, INT UMR 7289, Marseille, France; UGECAM Institut Universitaire de Réadaptation de Valmante Sud
| | | | - Guillaume Lotito
- Department of Physical and Rehabilitation Medicine, University Hospital of Marseille, France
| | - Virgine Milhe de Bovis
- Department of Physical and Rehabilitation Medicine, University Hospital of Marseille, France
| | - Frédéric Pellas
- Department of Physical and Rehabilitation Medicine, University Hospital of Nîmes, France
| | - Paul Calmels
- Department of Physical and Rehabilitation Medicine, University Hospital of Saint Etienne, France
| | - Alain Delarque
- Department of Physical and Rehabilitation Medicine, University Hospital of Marseille, France; Aix Marseille Université, CNRS, INT UMR 7289, Marseille, France
| | - Jean-Michel Viton
- Department of Physical and Rehabilitation Medicine, University Hospital of Marseille, France; Aix Marseille Université, CNRS, INT UMR 7289, Marseille, France
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Tenniglo MJB, Nene AV, Rietman JS, Buurke JH, Prinsen EC. The Effect of Botulinum Toxin Type A Injection in the Rectus Femoris in Stroke Patients Walking With a Stiff Knee Gait: A Randomized Controlled Trial. Neurorehabil Neural Repair 2023; 37:640-651. [PMID: 37644725 DOI: 10.1177/15459683231189712] [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] [Indexed: 08/31/2023]
Abstract
BACKGROUND Over activity of the rectus femoris is often cited as a main cause for stiff knee gait (SKG). Botulinum toxin (BoNT) can be used to reduce this over activity. Inconsistent results for the effect of BoNT injections were found in literature which can possibly be explained by the study design as these were uncontrolled or non-randomized studies. OBJECTIVE To conduct a randomized controlled trial (RCT) to investigate the effect of botulinum toxin type A (BoNT-A) injections in the rectus femoris on gait kinematics and functional outcome in adult stroke patients. METHODS Twenty-six participants were included in this triple-blind cross-over RCT. The intervention consisted of an injection with BoNT-A. Placebo is an injection with saline. Besides knee and hip kinematics, functional outcomes were measured. RESULTS Comparison of the effect of BoNT-A injection to placebo injection showed a significant increase in peak knee flexion and knee range of motion of 6.7° and 4.8° respectively. There was no difference in hip kinematics. In functional outcomes, only the 6 Minute Walking Test showed a significant increase of 18.3 m. CONCLUSIONS BoNT-A injections in the rectus femoris is a valuable treatment option for stroke patients walking with a SKG to improve knee kinematics. To study the effect on functional outcome more research is necessary with different functional outcome measures that can capture the effect in kinematics. It is important to use kinematic measurements to demonstrate effects in quality of movement that are not captured by commonly used functional outcome measurements post stroke.Clinical Trial Registration: https://trialsearch.who.int/Trial2.aspx?TrialID=NTR2169.
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Affiliation(s)
- Martin J B Tenniglo
- Roessingh Research and Development, Enschede, The Netherlands
- Roessingh Centre for Rehabilitation, Enschede, The Netherlands
- Faculty of Electrical Engineering, Mathematics and Computer Science, Department of Biomedical Signals and Systems, Technical Medical Centre, University of Twente, Enschede, The Netherlands
| | - Anand V Nene
- Roessingh Centre for Rehabilitation, Enschede, The Netherlands
| | - Johan S Rietman
- Roessingh Research and Development, Enschede, The Netherlands
- Roessingh Centre for Rehabilitation, Enschede, The Netherlands
- Faculty of Engineering Technology, Department of Biomechanical Engineering, Technical Medical Centre, University of Twente, Enschede, The Netherlands
| | - Jaap H Buurke
- Roessingh Research and Development, Enschede, The Netherlands
- Faculty of Electrical Engineering, Mathematics and Computer Science, Department of Biomedical Signals and Systems, Technical Medical Centre, University of Twente, Enschede, The Netherlands
| | - Erik C Prinsen
- Roessingh Research and Development, Enschede, The Netherlands
- Faculty of Engineering Technology, Department of Biomechanical Engineering, Technical Medical Centre, University of Twente, Enschede, The Netherlands
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Freire B, Bochehin do Valle M, Lanferdini FJ, Foschi CVS, Abou L, Pietta-Dias C. Cut-off score of the modified Ashworth scale corresponding to walking ability and functional mobility in individuals with chronic stroke. Disabil Rehabil 2023; 45:866-870. [PMID: 35171052 DOI: 10.1080/09638288.2022.2037753] [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] [Indexed: 11/03/2022]
Abstract
PURPOSE To determine the optimal cut-off score for the Modified Ashworth Scale (MAS) corresponding to unfavorable outcomes for mobility and walking ability. METHODS The level of plantar flexor muscle spasticity and the 10-meter walking test (10mWT), timed up and go (TUG), and five time sit-to-stand (FTSTS) outcomes were evaluated in individuals after stroke. The correlation between MAS and the tests was investigated, and the optimal cut-off score, sensitivity, and specificity were evaluated through receiver operating characteristic (ROC) curve. RESULTS Twenty-one participants with chronic stroke and plantar flexors spasticity (11 men; 10 women; mean age = 57.6 ± 12.5 years) participated in the study. Significant correlations between MAS and 10mWT (r= -0.45; p < 0.05), MAS and TUG (r = 0.48; p < 0.05) were found. The optimal cut-off scores were MAS > 2 for unfavorable 10mWT (sensitivity = 100%; specificity = 54.5%; ROC = 0.782) and MAS ≤ 2 for favorable TUG outcomes (sensitivity = 55.5%; specificity = 91.6%; ROC = 0.782). CONCLUSIONS This study revealed that moderate level of plantar flexors spasticity results in the highest sensitivity to predict poor gait speed performance and the highest specificity to predict good mobility performance in individuals after stroke. These findings will help clinicians in their evidence-based decision making on the role of spasticity for mobility and walking ability.Implications for rehabilitationModerate level of spasticity (MAS <2) is the optimal cut-off score for 10mWT and TUG tests.Reducing the level of spasticity of plantar flexors below this cut-off point might be associated with an increased walking speed in this population.MAS <2 might not limit walking and mobility in individuals after stroke.Calf muscles spasticity might not compromise five time sit-to-stand (FTSTS) performances and might be related to a smaller influence on the sit to stand task.
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Affiliation(s)
- Bruno Freire
- Health and Sports Sciences Center, Santa Catarina State University, Florianópolis, Brazil
| | | | - Fabio Juner Lanferdini
- Exercise Research Laboratory, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | | | - Libak Abou
- Department of Kinesiology and Community Health, College of Applied Health Sciences, University of Illinois at Urbana-Champaign, Urbana, IL, USA
| | - Caroline Pietta-Dias
- Exercise Research Laboratory, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
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Yu HX, Liu SH, Wang ZX, Liu CB, Dai P, Zang DW. Efficacy on gait and posture control after botulinum toxin A injection for lower-limb spasticity treatment after stroke: A randomized controlled trial. Front Neurosci 2023; 16:1107688. [PMID: 36726851 PMCID: PMC9884969 DOI: 10.3389/fnins.2022.1107688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 12/28/2022] [Indexed: 01/18/2023] Open
Abstract
Objectives To observe the efficacy of botulinum toxin type A (BoNT-A) for the spasticity of the lower-limb post-stroke on gait and posture control. Methods A total of 46 patients with hemiplegia gait were randomly divided into the experimental group (23 patients) and the control group (23 patients). In patients in the experimental group received injections of BoNT-A by electrical stimulation-guided. At the same time, patients of the two groups received routine physical therapy. Gait analysis, plantar pressure analysis, lower-limb Fugl-Meyer assessment (L-FMA), 10 meter walking test (10MWT), timed "Up and Go" test (TUGT), and modified Ashworth Scale assess (MAS) of the lower limbs were performed at 0, 1, 4, and 12 weeks after treatment. Results At 1, 4, and 12 weeks after treatment, the L-FMA, stride length, speed, and TUGT significantly improved than 0 week in both groups. The L-FMA and peak of forefoot pressure, and MAS results in the experimental group were better than those in the control group at 4 and 12 weeks. The TUGT, speed, and stride length in experimental group was significantly shortened than that in control group at 1, 4, and 12 weeks. Conclusion Botulinum toxin type A injection can improve motor functions of the lower limb, gait, spasticity, forefoot pressure, and posture control of patients after stroke.
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Novarella F, Carotenuto A, Cipullo P, Iodice R, Cassano E, Spiezia AL, Capasso N, Petracca M, Falco F, Iacovazzo C, Servillo G, Lanzillo R, Brescia Morra V, Moccia M. Persistence with Botulinum Toxin Treatment for Spasticity Symptoms in Multiple Sclerosis. Toxins (Basel) 2022; 14:toxins14110774. [PMID: 36356024 PMCID: PMC9693315 DOI: 10.3390/toxins14110774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 11/05/2022] [Accepted: 11/08/2022] [Indexed: 11/11/2022] Open
Abstract
Botulinum toxin (BT) is an effective treatment for spasticity symptoms in multiple sclerosis (MS). Despite its wide use in clinical practices, only few studies have explored long-term persistence. We aim to evaluate the rate of discontinuation of BT treatment and the correlation with MS, spasticity, and injection variables. This retrospective study on 3-year prospectively collected data included 122 MS patients receiving BT injections for spasticity. We collected MS clinical variables (disease durations, Expanded Disability Status Scales [EDSSs], disease-modifying treatments [DMT], and Symbol Digit Modalities Tests [SDMTs]), modified Ashworth scales [MASs], concomitant treatments, and injection variables (formulation, dose, number of injections, and intervals between injections). A total of 14 out of the 122 patients discontinued BT after a mean time of 3.0 ± 1.5 years. In the Cox regression model including the MS clinical variables, the probability of BT discontinuations increased in patients with DMT changes during follow-ups (HR = 6.34; 95%Cl = 2.47, 18.08; p < 0.01) and with impaired SDMTs (HR = 1.20; 95%Cl = 1.04, 1.96; p < 0.01). In the model including the spasticity variables, there were no associations between BT discontinuation and MAS or other spasticity treatments. In the model including the injection variables, the probability of discontinuation decreased by 80% for each cumulative injection (HR = 0.16; 95%Cl = 0.05, 0.45; p < 0.01), but increased by 1% for each additional day over the 3-month interval between injections (HR = 1.27; 95%Cl = 1.07, 1.83; p < 0.01). BT discontinuation was associated with concomitant MS-related issues (e.g., treatment failure and DMT change) and the presence of cognitive impairment, which should be accounted for when planning injections. The interval between injections should be kept as short as possible from regulatory and clinical perspectives to maximize the response across all of the spasticity symptoms and to reduce discontinuation in the long term.
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Affiliation(s)
- Federica Novarella
- Multiple Sclerosis Clinical Care Unit, Federico II University Hospital, 80131 Naples, Italy
- Department of Neurosciences, Federico II University of Naples, 80131 Naples, Italy
| | - Antonio Carotenuto
- Multiple Sclerosis Clinical Care Unit, Federico II University Hospital, 80131 Naples, Italy
- Department of Neurosciences, Federico II University of Naples, 80131 Naples, Italy
| | - Paolo Cipullo
- Department of Neurosciences, Federico II University of Naples, 80131 Naples, Italy
| | - Rosa Iodice
- Multiple Sclerosis Clinical Care Unit, Federico II University Hospital, 80131 Naples, Italy
- Department of Neurosciences, Federico II University of Naples, 80131 Naples, Italy
| | - Emanuele Cassano
- Multiple Sclerosis Clinical Care Unit, Federico II University Hospital, 80131 Naples, Italy
- Department of Neurosciences, Federico II University of Naples, 80131 Naples, Italy
| | - Antonio Luca Spiezia
- Multiple Sclerosis Clinical Care Unit, Federico II University Hospital, 80131 Naples, Italy
- Department of Neurosciences, Federico II University of Naples, 80131 Naples, Italy
| | - Nicola Capasso
- Multiple Sclerosis Clinical Care Unit, Federico II University Hospital, 80131 Naples, Italy
- Department of Neurosciences, Federico II University of Naples, 80131 Naples, Italy
| | - Maria Petracca
- Multiple Sclerosis Clinical Care Unit, Federico II University Hospital, 80131 Naples, Italy
- Department of Neurosciences, Federico II University of Naples, 80131 Naples, Italy
- Department of Human Neurosciences, Sapienza University of Rome, 00185 Rome, Italy
| | - Fabrizia Falco
- Department of Neurosciences, Federico II University of Naples, 80131 Naples, Italy
| | - Carmine Iacovazzo
- Department of Neurosciences, Federico II University of Naples, 80131 Naples, Italy
| | - Giuseppe Servillo
- Department of Neurosciences, Federico II University of Naples, 80131 Naples, Italy
| | - Roberta Lanzillo
- Multiple Sclerosis Clinical Care Unit, Federico II University Hospital, 80131 Naples, Italy
- Department of Neurosciences, Federico II University of Naples, 80131 Naples, Italy
| | - Vincenzo Brescia Morra
- Multiple Sclerosis Clinical Care Unit, Federico II University Hospital, 80131 Naples, Italy
- Department of Neurosciences, Federico II University of Naples, 80131 Naples, Italy
| | - Marcello Moccia
- Multiple Sclerosis Clinical Care Unit, Federico II University Hospital, 80131 Naples, Italy
- Department of Molecular Medicine and Medical Biotechnology, Federico II University of Naples, 80131 Naples, Italy
- Correspondence:
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An Observational Cross-Sectional Study of Gender and Disability as Determinants of Person-Centered Medicine in Botulinum Neurotoxin Treatment of Upper Motoneuron Syndrome. Toxins (Basel) 2022; 14:toxins14040246. [PMID: 35448855 PMCID: PMC9024520 DOI: 10.3390/toxins14040246] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 03/27/2022] [Accepted: 03/28/2022] [Indexed: 02/04/2023] Open
Abstract
The motor behaviour of patients with Upper Motor Neuron Syndrome (UMNS) is characterised by spasticity. The first-line treatment for this clinical condition is Botulinum neurotoxin A (BoNTA), but the number and key locations of muscles which need to be treated is not much discussed in the literature. Cross-sectional analysis of outpatient cohort with UMNS spasticity, who were potential candidates for BoNTA treatment, was performed. Between November 2020 and November 2021, all consecutive adult patients eligible for BoNTA treatment were enrolled. The inclusion criteria encompass UMNS spasticity (onset being ≥6 months), with disabling muscles hypertonia. Patients underwent a clinical evaluation, a comprehensive assessment with the Modified Ashworth Scale, with the Modified Rankin Scale, and a patients’ perception-centred questionnaire. In total, 68 participants were enrolled in the study, among them 40 (58.8%) were male; mean age 57.9 ± 15.1. In women, BoNTA was more frequently required for adductor group muscles, independently from potential confounders (OR = 7.03, 95%CI: 1.90–25.97). According to the pattern of disability, patients with hemiparesis more frequently need to be treated in the upper limb, whereas the diplegia/double-hemiparesis group needed to be treated more frequently at the adductor and crux muscles compared to their counterparts. UMNS spasticity in women could require more attention to be paid to the treatment of adductor muscle spasticity, potentially because the dysfunction of those muscles could influence sphincteric management, required for perineal hygiene and/or sexual life.
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Varvarousis DN, Martzivanou C, Dimopoulos D, Dimakopoulos G, Vasileiadis GI, Ploumis A. The effectiveness of botulinum toxin on spasticity and gait of hemiplegic patients after stroke: A systematic review and meta-analysis. Toxicon 2021; 203:74-84. [PMID: 34626599 DOI: 10.1016/j.toxicon.2021.09.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 09/19/2021] [Accepted: 09/21/2021] [Indexed: 10/20/2022]
Abstract
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.
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Affiliation(s)
- Dimitrios N Varvarousis
- Division of Physical Medicine and Rehabilitation, Deparment of Surgery, University of Ioannina Medical School, 45110, Ioannina, Greece.
| | - Christina Martzivanou
- Division of Physical Medicine and Rehabilitation, Deparment of Surgery, University of Ioannina Medical School, 45110, Ioannina, Greece.
| | - Dimitris Dimopoulos
- Division of Physical Medicine and Rehabilitation, Deparment of Surgery, University of Ioannina Medical School, 45110, Ioannina, Greece.
| | - Georgios Dimakopoulos
- Medical Statistics, Epirus Science and Technology Park Campus of the University of Ioannina, Ioannina, 45110, Greece.
| | - George I Vasileiadis
- Division of Physical Medicine and Rehabilitation, Deparment of Surgery, University of Ioannina Medical School, 45110, Ioannina, Greece.
| | - Avraam Ploumis
- Division of Physical Medicine and Rehabilitation, Deparment of Surgery, University of Ioannina Medical School, 45110, Ioannina, Greece.
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Do gait parameters improve after botulinum toxin injections in post stroke patients? A prospective study. Toxicon 2021; 200:189-197. [PMID: 34384786 DOI: 10.1016/j.toxicon.2021.08.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 07/16/2021] [Accepted: 08/04/2021] [Indexed: 11/23/2022]
Abstract
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.
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Allart E, Mazevet D, Idée S, Constant Boyer F, Bonan I. Adjunct therapies after botulinum toxin injections in spastic adults: systematic review and SOFMER recommendations. Ann Phys Rehabil Med 2021; 65:101544. [PMID: 34091058 DOI: 10.1016/j.rehab.2021.101544] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 03/19/2021] [Accepted: 04/05/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Adjunct therapies (ATs) may further improve outcomes after botulinum toxin injections in spastic patients, but evidence was unclear in previous systematic reviews. OBJECTIVE To assess the efficacy of non-pharmacological ATs in spastic adults according to the International Classification of Functioning, Disability and Health and build an expert consensus based on a Delphi process. METHODS Four electronic databases were searched up to May 2020 for reports of comparative trials of non-pharmacologic ATs after botulinum toxin injections in spastic adults. Then 25 French experts participated in a two-round Delphi process to build recommendations on the use of ATs. RESULTS We included 32 studies (1202 participants, median 32/study) evaluating the effects of physical agents (n=9), joint posture procedures (JPPs, n=11), and active ATs (n=14), mainly after stroke. The average quality of articles was good for randomised controlled trials (median [interquartile range] PEDro score = 7 [6-8]) but moderate (n=2) or poor (n=2) for non-randomised controlled trials (Downs & Black checklist). Meta-analysis was precluded owing to the heterogeneity of ATs, control groups and outcome measures. There is evidence for the use of JPPs except low-dose manual stretching and soft posture techniques. Continuous postures (by taping or casting) are recommended; discontinuous postures (by orthosis) may be preferred in patients with active function. Device-free or device-assisted active ATs may be beneficial in the mid-term (> 3 months after botulinum toxin injections), particularly when performed at a high intensity (>3 hr/week) as in constraint-induced movement therapy. Self-rehabilitation remains understudied after a focal treatment, but its interest is highlighted by the experts. The use of physical agents is not recommended. CONCLUSIONS JPPs and active ATs (device-assisted or device-free) may further improve impairments and activities after botulinum toxin injections. Further studies are needed to better define the best strategies for ATs as a function of the individual treatment goals, participation and quality of life. Review Registration. PROSPERO (CRD42018105856).
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Affiliation(s)
- Etienne Allart
- CHU Lille, Neurorehabilitation Unit, 59000 Lille, France; Université Lille, INSERM UMR-S-1172, Lille Neuroscience and Cognition, 59000 Lille, France.
| | | | - Stéphane Idée
- CHU Strasbourg, PRM Department, 67000 Strasbourg, France
| | | | - Isabelle Bonan
- CHU Rennes, PRM Department, University of Rennes 1 & 2, 35000 Rennes, France; Unité Empenn (ex-Visages) U1228 INSERM-INRIA, IRISA UMR CNRS 6074, Campus de Beaulieu, 35042 Rennes cedex, France
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Choudhry S, Patritti BL, Woodman R, Hakendorf P, Huang L. Goal Attainment: A Clinically Meaningful Measure of Success of Botulinum Toxin-A Treatment for Lower Limb Spasticity in Ambulatory Patients. Arch Rehabil Res Clin Transl 2021; 3:100129. [PMID: 34124643 PMCID: PMC8175278 DOI: 10.1016/j.arrct.2021.100129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
- Subbuh Choudhry
- Division of Rehabilitation, Aged and Palliative Care, Flinders Medical Centre, Adelaide
| | - Benjamin L Patritti
- Division of Rehabilitation, Aged and Palliative Care, Flinders Medical Centre, Adelaide.,College of Medicine and Public Health, Flinders University, Adelaide
| | - Richard Woodman
- Flinders Health and Medical Research Institute, Health Data Sciences, College of Medicine and Public Health, Flinders University, Adelaide
| | - Paul Hakendorf
- Flinders Health and Medical Research Institute, Health Data Sciences, College of Medicine and Public Health, Flinders University, Adelaide.,Clinical Epidemiology Unit, Flinders Medical Centre, Adelaide, Australia
| | - Lydia Huang
- Division of Rehabilitation, Aged and Palliative Care, Flinders Medical Centre, Adelaide.,College of Medicine and Public Health, Flinders University, Adelaide
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Deveci H. Evaluation of the Effectiveness of Treatment with Botulinum Toxin on Sleep Quality in Stroke-Related Spasticity. J Stroke Cerebrovasc Dis 2020; 29:105160. [PMID: 32912522 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 06/26/2020] [Accepted: 07/11/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND AND PURPOSE Botulinum toxin (BoNT) is a commonly used agent in the treatment of stroke-related spasticity. Sleep disorders can often be seen as a comorbidity or complication in stroke patients. Based on the data that spasticity is associated with sleep disorders, in this study, we aimed to evaluate whether sleep quality has changed in patients with stroke treated with BoNT. METHODS Thirty five (17 female / 18 male) stroke patients with gastrocnemius and / or soleus spasticity were included in this observational cross-sectional study. In clinical evaluation before and three months after BoNT injection; for spasticity evaluation modified Ashworth scale (MAS), pain assessment visual analog scale (VAS), functional evaluation; passive joint range of motion (ROM) measurement, functional independence measurement (FIM), lower limb Brunstrom staging, life quality assessment short form-36 (SF-36) quality of life scale, and sleep quality assessment Pittsburgh sleep quality index (PSQI) scales were used. RESULTS After the BoNT injection, there was a statistically significant decrease in MAS and VAS scores, a significant increase in passive ROM measurements, FIM, lower limb Brunstrom staging, and SF-36 physical function sub parameter. There was also a significant decrease in PSQI scores. Before and after treatment, there was no correlation found between PSQI values with pain and spasticity. However, there was a weak negative correlation between post-treatment PSQI values, passive ROM, SF-36 physical function and SF-36 physical role sub parameters (respectively: r: -0.335 p: 0.049, r: -0.364, 0.032, r: -0.404, p: 0.016). Conlusion: The results of our study suggest that BoNT, which is frequently used in the treatment of spasticity in stroke patients, has positive effects on sleep quality.
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Affiliation(s)
- Hulya Deveci
- Department of Physical Medicine and Rehabilitation, Tokat Gaziosmanpasa University Medical Faculty, 60100 Tokat, Turkey.
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14
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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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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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Beyond speed: Gait changes after botulinum toxin injections in chronic stroke survivors (a systematic review). Gait Posture 2019; 70:389-396. [PMID: 30974394 DOI: 10.1016/j.gaitpost.2019.03.035] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 03/03/2019] [Accepted: 03/31/2019] [Indexed: 02/02/2023]
Abstract
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.
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Alcantara CC, Blanco J, De Oliveira LM, Ribeiro PFS, Herrera E, Nakagawa TH, Reisman DS, Michaelsen SM, Garcia LC, Russo TL. Cryotherapy reduces muscle hypertonia, but does not affect lower limb strength or gait kinematics post-stroke: a randomized controlled crossover study. Top Stroke Rehabil 2019; 26:267-280. [PMID: 31012824 DOI: 10.1080/10749357.2019.1593613] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Based on the premise that spasticity might affect gait post-stroke, cryotherapy is among the techniques used to temporarily reduce spasticity in neurological patients. This effective technique would enhance muscle performance, and ultimately, functional training, such as walking. However, understanding whether a decrease in spasticity level, if any, would lead to improving muscle performance and gait parameters is not based on evidence and needs to be clarified. OBJECTIVES to investigate the immediate effects of cryotherapy, applied to spastic plantarflexor muscles of subjects post-stroke, on tonus level, torque generation capacity of plantarflexors and dorsiflexors, and angular/spatiotemporal gait parameters. METHODS Sixteen chronic hemiparetic subjects participated in this randomized controlled crossover study. Cryotherapy (ice pack) or Control (room temperature sand pack) were applied to the calf muscles of the paretic limb. The measurements taken (before and immediately after intervention) were: 1) Tonus according to the Modified Ashworth Scale; 2) Torque assessments were performed using an isokinetic dynamometer; and 3) Spatiotemporal and angular kinematics of the hip, knee, and ankle (flexion/extension), obtained using a tridimensional movement analysis system (Qualisys). RESULTS Cryotherapy decreased plantarflexor tonus but did not change muscle torque generation capacity and did not affect spatiotemporal or angular parameters during gait compared to control application. These findings contribute to the evidence-based approach to clinical rehabilitation post-stroke. CONCLUSIONS The findings of this study suggest that cryotherapy applied to the calf muscles of subjects with chronic hemiparesis reduces muscle hypertonia but does not improve dorsiflexors and plantarflexors performance and gait parameters.
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Affiliation(s)
- Carolina Carmona Alcantara
- a Laboratory of Neurological Physiotherapy Research, Department of Physical Therapy , Federal University of São Carlos (UFSCar) , São Carlos , Brazil
| | - Julia Blanco
- a Laboratory of Neurological Physiotherapy Research, Department of Physical Therapy , Federal University of São Carlos (UFSCar) , São Carlos , Brazil
| | - Lucilene Maria De Oliveira
- a Laboratory of Neurological Physiotherapy Research, Department of Physical Therapy , Federal University of São Carlos (UFSCar) , São Carlos , Brazil
| | - Paula Fernanda Sávio Ribeiro
- a Laboratory of Neurological Physiotherapy Research, Department of Physical Therapy , Federal University of São Carlos (UFSCar) , São Carlos , Brazil
| | - Esperanza Herrera
- b Physical Therapy School , Universidad Industrial de Santander (UIS) , Bucaramanga , Colombia
| | - Theresa Helissa Nakagawa
- a Laboratory of Neurological Physiotherapy Research, Department of Physical Therapy , Federal University of São Carlos (UFSCar) , São Carlos , Brazil
| | - Darcy S Reisman
- c Department of Physical Therapy , University of Delaware , Newark , DE , USA
| | - Stella Maris Michaelsen
- d Department of Physical Therapy , Universidade do Estado de Santa Catarina , Florianópolis, SC , Brazil
| | - Luccas Cavalcanti Garcia
- a Laboratory of Neurological Physiotherapy Research, Department of Physical Therapy , Federal University of São Carlos (UFSCar) , São Carlos , Brazil
| | - Thiago Luiz Russo
- a Laboratory of Neurological Physiotherapy Research, Department of Physical Therapy , Federal University of São Carlos (UFSCar) , São Carlos , Brazil
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Efficacy and Safety of Botulinum Toxin Type A for Limb Spasticity after Stroke: A Meta-Analysis of Randomized Controlled Trials. BIOMED RESEARCH INTERNATIONAL 2019; 2019:8329306. [PMID: 31080830 PMCID: PMC6475544 DOI: 10.1155/2019/8329306] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 01/22/2019] [Accepted: 03/13/2019] [Indexed: 01/10/2023]
Abstract
Background Inconsistent data have been reported for the effectiveness of intramuscular botulinum toxin type A (BTXA) in patients with limb spasticity after stroke. This meta-analysis of available randomized controlled trials (RCTs) aimed to determine the efficacy and safety of BTXA in adult patients with upper and lower limb spasticity after stroke. Methods An electronic search was performed to select eligible RCTs in PubMed, Embase, and the Cochrane library through December 2018. Summary standard mean differences (SMDs) and relative risk (RR) values with corresponding 95% confidence intervals (CIs) were employed to assess effectiveness and safety outcomes, respectively. Results Twenty-seven RCTs involving a total of 2,793 patients met the inclusion criteria, including 16 and 9 trials assessing upper and lower limb spasticity cases, respectively. For upper limb spasticity, BTXA therapy significantly improved the levels of muscle tone (SMD=-0.76; 95% CI -0.97 to -0.55; P<0.001), physician global assessment (SMD=0.51; 95% CI 0.35-0.67; P<0.001), and disability assessment scale (SMD=-0.30; 95% CI -0.40 to -0.20; P<0.001), with no significant effects on active upper limb function (SMD=0.49; 95% CI -0.08 to 1.07; P=0.093) and adverse events (RR=1.18; 95% CI 0.72-1.93; P=0.509). For lower limb spasticity, BTXA therapy was associated with higher Fugl-Meyer score (SMD=5.09; 95%CI 2.16-8.01; P=0.001), but had no significant effects on muscle tone (SMD=-0.12; 95% CI -0.83 to 0.59; P=0.736), gait speed (SMD=0.06; 95% CI -0.02 to 0.15; P=0.116), and adverse events (RR=1.01; 95% CI 0.71-1.45; P=0.949). Conclusions BTXA improves muscle tone, physician global assessment, and disability assessment scale in upper limb spasticity and increases the Fugl-Meyer score in lower limb spasticity.
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Leung J, King C, Fereday S. Effectiveness of a programme comprising serial casting, botulinum toxin, splinting and motor training for contracture management: a randomized controlled trial. Clin Rehabil 2019; 33:1035-1044. [PMID: 30813776 DOI: 10.1177/0269215519831337] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To determine the effectiveness of a programme comprising serial casting, botulinum toxin, splinting and motor training in contracture management. DESIGN A randomized trial with concealed allocation and assessor blinding, a deferred treatment cross-over design within the control group, was conducted. SETTING Inpatient Brain Injury Unit of a rehabilitation centre. SUBJECTS A total of 10 patients with severe acquired brain injury (13 ankles). INTERVENTIONS The intervention group received botulinum toxin and then serial casting. The control group was placed on a wait list for six weeks (control phase) and then received the same interventions as the intervention group (intervention phase). Both groups received splinting and motor training following serial casting. MAIN MEASURES The primary outcome was passive ankle dorsiflexion range. Secondary outcomes included spasticity, ankle dorsiflexor strength, Functional Independence Measure score for the walking item and walking speed. RESULTS The mean between-group difference for passive ankle dorsiflexion range at completion of casting was 26° (95% confidence interval (CI): 17-35); at Week 2, after casting was 24° (95% CI: 14-33). The mean within-group differences for passive ankle dorsiflexion at completion of casting, Week 2 after casting and Week 8 after casting were 26° (95% CI: 20-31), 26° (95% CI: 18-33) and 24° (95% CI: 19-30), respectively. These improvements were sustained at Week 2 and Week 8 after casting. CONCLUSIONS A programme for contracture management comprising serial casting, botulinum toxin, motor training and splinting can be useful in improving joint range.
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Affiliation(s)
- Joan Leung
- Brain Injury Unit, Royal Rehab, Sydney, NSW, Australia
| | - Clayton King
- Brain Injury Unit, Royal Rehab, Sydney, NSW, Australia
| | - Sarah Fereday
- Brain Injury Unit, Royal Rehab, Sydney, NSW, Australia
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Küçükdeveci AA, Stibrant Sunnerhagen K, Golyk V, Delarque A, Ivanova G, Zampolini M, Kiekens C, Varela Donoso E, Christodoulou N. Evidence-based position paper on Physical and Rehabilitation Medicine professional practice for persons with stroke. The European PRM position (UEMS PRM Section). Eur J Phys Rehabil Med 2019; 54:957-970. [DOI: 10.23736/s1973-9087.18.05501-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Sánchez-Mila Z, Salom-Moreno J, Fernández-de-Las-Peñas C. Effects of dry needling on post-stroke spasticity, motor function and stability limits: a randomised clinical trial. Acupunct Med 2018; 36:358-366. [PMID: 29986902 DOI: 10.1136/acupmed-2017-011568] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2018] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To determine the effects of inclusion of deep dry needling into a treatment session following the Bobath concept on spasticity, motor function and postural control after a stroke. METHODS 26 patients who had suffered a stroke were randomly assigned to one of two treatment groups: Bobath only, or Bobath plus dry needling. Both groups received a session including strengthening, stretching and reconditioning exercises following the principles of the Bobath concept. Patients in the Bobath plus dry needling group also received a single session of ultrasound-guided dry needling of the tibialis posterior. Spasticity (Modified Modified Ashworth Scale), function (Fugl-Meyer Scale) and stability limits (computerised dynamic posturography using the SMART EquiTest System) were collected before and 10 min after treatment by a blinded assessor. The parameters of the stability limits included movement velocity (MVL), maximum excursion (MXE), end-point excursion (EPE) and directional control (DCL). RESULTS A greater number of individuals receiving Bobath plus dry needling exhibited a decrease in spasticity after treatment (P<0.001). Analysis of covariance (ANCOVA) showed that patients receiving Bobath plus dry needling exhibited greater improvements in the balance (0.8, 95% CI 0.2 to 1.4), sensory (1.7, 95% CI 0.7 to 2.7) and range of motion (3.2, 95% CI 2.0 to 4.4) domains of the Fugl-Meyer Scale than those receiving Bobath only. ANCOVA also found that subjects receiving dry needling showed a greater increase in MVL non-affected forward direction, EPE non-affected direction, MXE backward and MXE affected/non-affected, DCL backward and DCL affected backward direction, than those who did not receive it. CONCLUSIONS The inclusion of deep dry needling into a treatment session following the Bobath concept was effective at decreasing spasticity and improving balance, range of motion and the accuracy of maintaining stability in patients who had experienced a stroke. TRIAL REGISTRATION NUMBER NCT02579291.
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Affiliation(s)
- Zacarías Sánchez-Mila
- Alumno de Doctorado, Escuela Internacional de Doctorado, Universidad Rey Juan Carlos, Alcorcon, Spain
| | - Jaime Salom-Moreno
- Department of Physical Therapy, Occupational Therapy, Physical Medicine and Rehabilitation, Universidad Rey Juan Carlos, Alcorcon, Spain.,Cátedra de Investigación y Docencia en Fisioterapia: Terapia Manual y Punción Seca, Universidad Rey Juan Carlos, Alcorcón, Spain
| | - César Fernández-de-Las-Peñas
- Department of Physical Therapy, Occupational Therapy, Physical Medicine and Rehabilitation, Universidad Rey Juan Carlos, Alcorcon, Spain.,Cátedra de Investigación y Docencia en Fisioterapia: Terapia Manual y Punción Seca, Universidad Rey Juan Carlos, Alcorcón, Spain
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The Effects of Botulinum Toxin Injections on Plantar Flexor Spasticity in Different Phases After Stroke: A Secondary Analysis From a Double-Blind, Randomized Trial. PM R 2018; 10:789-797. [DOI: 10.1016/j.pmrj.2018.02.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 02/13/2018] [Accepted: 02/17/2018] [Indexed: 11/18/2022]
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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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Gupta AD, Chu WH, Howell S, Chakraborty S, Koblar S, Visvanathan R, Cameron I, Wilson D. A systematic review: efficacy of botulinum toxin in walking and quality of life in post-stroke lower limb spasticity. Syst Rev 2018; 7:1. [PMID: 29304876 PMCID: PMC5755326 DOI: 10.1186/s13643-017-0670-9] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 12/20/2017] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Improved walking is one of the highest priorities in people living with stroke. Post-stroke lower limb spasticity (PSLLS) impedes walking and quality of life (QOL). The understanding of the evidence of improved walking and QOL following botulinum toxin (BoNTA) injection is not clear. We performed a systematic review of the randomized control trials (RCT) to evaluate the effectiveness of BoNTA injection on walking and QOL in PSLLS. METHODS We searched PubMed, Web of Science, Embase, CINAHL, ProQuest Thesis and Dissertation checks, Google Scholar, WHO International Clinical Trial Registry Platform, ClinicalTrials.gov , Cochrane, and ANZ and EU Clinical Trials Register for RCTs looking at improvement in walking and QOL following injection of BoNTA in PSLLS. The original search was carried out prior to 16 September 2015. We conducted an additional verifying search on CINHAL, EMBASE, and MEDLINE (via PubMed) from 16 September 2015 to 6 June 2017 using the same clauses as the previous search. Methodological quality of the individual studies was critically appraised using Joanna Briggs Institute's instrument. Only placebo-controlled RCTs looking at improvement in walking and QOL were included in the review. RESULTS Of 2026 records, we found 107 full-text records. Amongst them, we found five RCTs qualifying our criteria. No new trials were found from the verifying search. Two independent reviewers assessed methodological validity prior to inclusion in the review using Joanna Briggs Institute's appraisal instrument. Two studies reported significant improvement in gait velocity (p = 0.020) and < 0.05, respectively. One study showed significant improvement in 2-min-walking distance (p < 0.05). QOL was recorded in one study without any significant improvement. Meta-analysis of reviewed studies could not be performed because of different methods of assessing walking ability, small sample size with large confidence interval and issues such as lack of power calculations in some studies. Findings from our systematic and detailed study identify the need for a well-designed RCT to adequately investigate the issues highlighted. CONCLUSIONS This review could not conclude there was sufficient evidence to support or refute improvement on walking or QOL following BoNTA injection. Reasons for this are discussed, and methods for future RCTs are developed.
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Affiliation(s)
- Anupam Datta Gupta
- Department of Rehabilitation Medicine, The Queen Elizabeth Hospital, 28 Woodville Road, Adelaide, South Australia, 5011, Australia.
| | - Wing Hong Chu
- School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - Stuart Howell
- Data, Design and Statistics Service, University of Adelaide, Adelaide, South Australia, 5005, Australia
| | | | - Simon Koblar
- South Australian Health and Medical Research Institute (SAHMRI), GPO Box 11060, Adelaide, South Australia, 5001, Australia
| | - Renuka Visvanathan
- The Queen Elizabeth Hospital, 28 Woodville Road, Adelaide, South Australia, 5011, Australia
| | - Ian Cameron
- Head John Walsh Centre for Rehabilitation Research, Sydney Medical School, University of Sydney, Sydney, NSW, 2006, Australia
| | - David Wilson
- Department of Medicine, University of Adelaide, Adelaide, South Australia, 5011, Australia
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Abstract
Stroke, or cerebrovascular accident, involves injury to the central nervous system as a result of a vascular cause, and is a leading cause of disability worldwide. People with stroke often experience sensory, cognitive, and motor sequelae that can lead to difficulty walking, controlling balance in standing and voluntary tasks, and reacting to prevent a fall following an unexpected postural perturbation. This chapter discusses the interrelationships between stroke-related impairments, problems with control of balance and gait, fall risk, fear of falling, and participation in daily physical activity. Rehabilitation can improve balance and walking function, and consequently independence and quality of life, for those with stroke. This chapter also describes effective interventions for improving balance and walking function poststroke, and identifies some areas for further research in poststroke rehabilitation.
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Affiliation(s)
- Avril Mansfield
- Toronto Rehabilitation Institute, University Health Network and Department of Physical Therapy, University of Toronto, Toronto, ON, Canada.
| | - Elizabeth L Inness
- Toronto Rehabilitation Institute, University Health Network and Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
| | - William E Mcilroy
- Department of Kinesiology, University of Waterloo and Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Waterloo, ON, Canada
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Pohl M, Bertram M. [Efficacy of early neurological and neurosurgical rehabilitation : Evidence-based treatment, outcome and prognostic factors]. DER NERVENARZT 2016; 87:1043-1050. [PMID: 27531205 DOI: 10.1007/s00115-016-0183-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Early neurological and neurosurgical rehabilitation (ENNR) as a complex post-acute form of treatment for patients with severe neurological diseases and continued need for intensive care is well established in Germany. OBJECTIVE To assess the efficacy of ENNR from the perspective of evidence-based medicine as well as to present data on the outcome of ENNR patients including the analysis of prognostic factors. MATERIAL AND METHODS A search was carried out in PubMed databases to identify early rehabilitation treatment forms evaluated by randomized controlled trials and with respect to large multicenter surveys of outcome and prognostic factors. RESULTS For ENNR as a complex treatment concept, effectiveness not has been shown with regard to evidence-based medicine but it includes individually effective treatment forms. In two large multicenter evaluations the average duration of treatment was between 51 and 57 days and mortality was between 6 % and 10 %, increasing with the proportion of mechanically ventilated patients. Lower need for nursing support on admission indicated better outcome, whereas mechanical ventilation was more likely to be associated with poor outcome. Long-term outcome was negatively influenced by mechanical ventilation as well as severe neurogenic dysphagia with and without the need for a tracheal cannula and/or percutaneous endoscopic gastrostomy (PEG) and also by severely impaired communication at the end of ENNR. DISCUSSION These prognostic factors indicate the primary aims of ENNR, which are to reduce the need for nursing support and to establish the capability for rehabilitation. If these aims are achieved, favorable functional and long-term outcome can be expected for ENNR patients. The presented studies verify the sustained efficacy of ENNR as an essential part of the overall treatment concept for severely neurologically impaired patients.
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Affiliation(s)
- M Pohl
- Helios Klinik Schloss Pulsnitz, Wittgensteiner Strasse 1, 01896, Pulsnitz, Deutschland.
| | - M Bertram
- Kliniken Schmieder, Heidelberg, Deutschland
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