Effect of intramuscular botulinum toxin injection on upper limb spasticity in stroke patients

Botulinum toxin treatment for difficult-to-treat finger pressure ulcers caused by severe hand flexion: case report

We report the successful treatment of two cases of difficult-to-treat pressure ulcers with botulinum toxin type A (BoNT-A). A 71-year-old male patient with Parkinson's disease presented with severe hand grip deformities of the fingers and a pressure ulcer (PU) on the right hand. He received 240U of BoNT-A into the upper limb muscles, which improved finger mobility during passive extension and resulted in resolution of the palm PU. No recurrence was noted. A 69-year-old female patient with Lewy body dementia presented with a PU on the palm side of the middle finger apex of the right hand, with exposure of the phalanx bone and dark red oedematous granulation of the tip of the finger. Severe muscle tone was noted. She received 240U of BoNT-A injected into the muscles of the upper extremities. This resulted in the disappearance of the contracture between the middle finger cusp and palm, and prompt healing of the PU. A protective finger orthosis was also used to improve hand finger grip and prevent further PUs. Although BoNT-A injection resulted in only slight improvement in the range of motion, it produced relief of pressure with consequent healing of the PU. Injection of BoNT-A into the affected muscles of the patients in this case report was effective in reducing flexor muscle tone, relief of pressure on the palm skin and healing of hand PUs.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Evaluating the functional outcomes of ultrasound-guided botulinum toxin type A injections using the Euro-musculus approach for upper limb spasticity treatment in post-stroke patients: an observational study

BACKGROUND

Ultrasound-guided botulinum toxin type A injection is an effective treatment for spasticity. Euro-musculus spasticity approach is a new method for administering injections to the correct point of the correct muscle. The clinical outcomes of this practical approach are not yet available in the literature.

AIM

The purpose of this study was to evaluate the effects on spasticity and the functional outcomes of ultrasound guided botulinum toxin type A injections via the Euro-musculus spasticity approach to treat upper limb spasticity in post-stroke patients.

DESIGN

Observational study.

SETTING

Inpatient post-stroke patients.

POPULATION

Twenty-five post-stroke patients with post-stroke upper limb spasticity were recruited.

METHODS

The ultrasound-guided botulinum toxin type A injections were administered into the spastic target muscles using the Euro-musculus spasticity approach, and all of the patients were enrolled in rehabilitation programs after the injections. This research included the innervation zone and injection site figures and ultrasound images of each muscle in the upper limb. The degree of spasticity was assessed via the Modified Ashworth Scale and the upper limb motor function via the Fugl Meyer Upper Extremity Scale at the baseline and 4 and 12 weeks after the botulinum toxin type A injection.

RESULTS

Significant decreases in the Modified Ashworth Scale scores of the upper limb flexor muscle tone measured 4 and 12 weeks after the botulinum toxin type A injection were found when compared to the baseline scores (P<0.025). When compared with the baseline Fugl Meyer Upper Extremity subgroup scores, the sitting position, wrist and total scores at 4 and 12 weeks were significantly improved (P<0.025). However, only the Fugl Meyer Upper Extremity hand scores were significantly improved 12 weeks after the injection (P<0.025).

CONCLUSIONS

Ultrasound-guided botulinum toxin type A injection via the Euro-musculus spasticity approach is a practical and effective method for administering injections to the correct point of the correct muscle. Ultrasound-guided botulinum toxin type A injections combined with rehabilitation programs decrease spasticity and improve the upper extremity motor functions in stroke patients.

CLINICAL REHABILITATION IMPACT

This new approach for ultrasound-guided botulinum toxin type A injection is very practical and effective method for upper extremity spasticity.

Safety and efficacy of letibotulinumtoxinA(BOTULAX®) in treatment of post stroke upper limb spasticity: a randomized, double blind, multi-center, phase III clinical trial

Objective:

To investigate a new botulinum neurotoxin type A, termed letibotulinumtoxinA(Botulax®) and compare its efficacy and safety for post-stroke upper limb spasticity with that of onabotulinumtoxinA(Botox®).

Design:

A prospective, double-blinded, multicenter, randomized controlled clinical study.

Setting:

Six university hospitals in Korea.

Subjects:

A total of 187 stroke participants with upper limb spasticity.

Interventions:

Two kinds of botulinum neurotoxin type A were used. One set of injection was performed and total injected doses were 309.21±62.48U(Botulax) and 312.64±49.99U(Botox)( P>0.05).

Main measures:

Primary outcome was measured using the modified Ashworth scale for wrist flexors at week 4 and secondary outcome was measured using modified Ashworth scale for wrist flexors, elbow flexors, finger flexors, and thumb flexors as well as Global Assessment in spasticity, Disability Assessment Scale, and Caregiver Burden Scale. Safety measures including adverse events, vital signs and physical examination, and laboratory tests were also monitored.

Results:

The mean ages for the Botulax group were 56.81±9.49 and which for the Botox group were 56.93±11.93( P>0.05). In primary outcome, the change in modified Ashworth scale for wrist flexors was -1.45±0.61 in the Botulax group and -1.40±0.57 in the Botox group, and the difference between the two groups was -0.06(95% CI:-0.23–0.12, P>0.05). In secondary outcome, both groups demonstrated significant improvements with respect to modified Ashworth scale, Global Assessment in spasticity, Disability Assessment Scale, and Caregiver Burden Scale ( P<0.05), and no significant difference was observed between the two groups ( P>0.05). In addition, safety measures showed no significant differences between the two groups ( P>0.05).

Conclusions:

The efficacy and safety of Botulax were comparable with those of Botox in treatment of post-stoke upper limb spasticity.

Successive motor nerve blocks to identify the muscles causing a spasticity pattern: example of the arm flexion pattern

Botulinum Toxin A has been the main treatment for spasticity since the beginning of the 1990s. Surprisingly, there is still no consensus regarding injection parameters or, importantly, how to determine which muscles to target to improve specific functions. The aim of this study was to develop a systematic approach to determine this, using the example of the arm flexion pattern. We first determined anatomical landmarks for selective motor block of the brachialis nerve, using 20 forearms from 10 fresh cadavers in Ecole Européenne de Chirurgie and a university-based dissection centre, Paris, France. We then carried out selective blocks of the motor nerves to the brachialis, brachioradialis and biceps brachii in patients with stroke with an arm flexion pattern, in a University Rehabilitation Hospital, Garches, France. We measured: the resting angle of the elbow angle in standing (manual goniometer), active and passive range of extension, and spasticity using the Held and Tardieu and the Modified Ashworth scales. Range of passive elbow extension was also measured with the shoulder in 90° of flexion. The resting angle of the elbow in standing decreased by 35.0° (from 87.6 ± 23.7 to 52.6 ± 24.2°) with inhibition of brachialis, by a further 3.9° (from 52.6 ± 24.2 to 48.7 ± 23.7°) with inhibition of brachioradialis and a further 14.5° (from 48.7 ± 23.7to 34.2 ± 20.7°) with inhibition of biceps brachii. These results were consistent with the clinical evaluation of passive elbow range of motion with the shoulder at 90°. Sequential blocking of the nerves to the three main elbow flexors revealed that the muscle that limited elbow extension the most, was brachialis. This muscle should be the main target to improve the arm flexion pattern. These results show that it is important not simply to inject the most superficial or powerful muscles to treat a spastic deformity. A comprehensive assessment is required. The strategy proposed in this paper should increase the effectiveness of botulinum toxin injections by ensuring that the relevant muscles are targeted.

Comparison of Effects of Botulinum Toxin Injection Between Subacute and Chronic Stroke Patients: A Pilot Study

The aim of this study was to compare the effects of botulinum toxin injection between subacute and chronic stroke patients. Eighteen stroke patients (9 subacute and 9 chronic) with spasticity of 1+ or higher in the hemiplegic elbow or wrist joint, based on the modified Ashworth scale were recruited. Modified Ashworth scale, modified Tardieu scale, manual muscle testing, passive range of motion, Brunnstrom stage, modified Barthel index, and Fugl-Meyer scale evaluations of the hemiplegic upper extremity were performed just before the injection and 4 weeks later. A total dose of 200 U of botulinum toxin type A was injected into each patient. One or more of the elbow flexor muscles and one or more of the wrist flexor or finger flexor muscles were included. Modified Ashworth scale, manual muscle testing, passive range of motion, and modified Barthel index results were improved in subacute patients only. However, modified Tardieu scale for the elbow and Fugl-Meyer scale results were improved in both groups, and the improvement was comparable. In conclusion, botulinum toxin injection in subacute patients was more helpful for spasticity, contracture, and function than in chronic patients. However, beneficial effects of botulinum toxin injection on spasticity and function in chronic patients were found in the assessments of the modified Tardieu scale and Fugl-Meyer scale.

Long-term effects of injection of botulinum toxin type A combined with home-based functional training for post-stroke patients with spastic upper limb hemiparesis

The aim of this study was to assess the effects of botulinum toxin type A (BoNT-A) injection with home-based functional training for passive and active motor function, over a 6-month period in post-stroke patients with upper limb spasticity. We studied 190 patients with at least 6-month history of stroke. They received injections of BoNT-A in upper limb muscles and detailed one-to-one instructions for home-based functional training. At baseline (before therapy), and at 1-, 3- and 6-month follow-up, Fugl-Meyer assessment (FMA) and Wolf motor function test (WMFT) were used to assess active motor function, the modified Ashworth scale (MAS) for assessment of spasticity, and the range of motion (ROM) for passive motor function. The total score for upper limb and scores of categories A and B of the FMA increased significantly at 1, 3 and 6 months, while the FMA score for category D increased significantly at 3 and 6 months, but not at 1 month. Significant decreases in the MAS scores were noted in all muscles examined at 1, 3 and 6 months, compared with baseline. The ROM for elbow joint extension significantly improved at 1, 3, and 6 months, while that for wrist joint extension increased significantly at 1 month, but not 3 or 6 months, compared with baseline. The results suggest that comprehensive improvement of motor function requires improvement of motor function in the proximal part of the upper limb and that BoNT-A followed by rehabilitation reduces spasticity and improves motor function of fingers.

OnabotulinumtoxinA muscle injection patterns in adult spasticity: a systematic literature review

Background

OnabotulinumtoxinA has demonstrated significant benefit in adult focal spasticity. This study reviews the injection patterns (i.e., muscle distribution, dosing) of onabotulinumtoxinA for treatment of adult spasticity, as reported in published studies.

Methods

A systematic review of clinical trials and observational studies published between 1990 and 2011 reporting data on muscles injected with onabotulinumtoxinA in adult patients treated for any cause of spasticity.

Results

28 randomized, 5 nonrandomized, and 37 single-arm studies evaluating 2,163 adult patients were included. The most frequently injected upper-limb muscles were flexor carpi radialis (64.0% of patients), flexor carpi ulnaris (59.1%), flexor digitorum superficialis (57.2%), flexor digitorum profundus (52.5%), and biceps brachii (38.8%). The most frequently injected lower-limb muscles were the gastrocnemius (66.1% of patients), soleus (54.7%), and tibialis posterior (50.5%). The overall dose range reported was 5–200 U for upper-limb muscles and 10–400 U for lower-limb muscles.

Conclusions

The reviewed evidence indicates that the muscles most frequently injected with onabotulinumtoxinA in adults with spasticity were the wrist, elbow, and finger flexors and the ankle plantar flexors. OnabotulinumtoxinA was injected over a broad range of doses per muscle among the studies included in this review, but individual practitioners should be mindful of local regulatory approvals and regulations.

Impairment and function: the difficulty with definition and measurement of outcome in clinical practice

Background:

The term function is used in rehabilitation both as an expression of patient status (e.g. low functional capacity) and also as a term to capture the extent of change following rehabilitation interventions (e.g. improved walking efficiency); however there is a lack of consensus as to the possible terms used to encompass the term function. There is uncertainty about the primary focus of interventions within rehabilitation in the sense that some clinicians work on reducing impairment whereas others believe they are working at a functional level. This suggests that the terms are used interchangeably in clinical practice and that an assumed link exists between altering the impairment and improving function.

Aim:

This analysis paper investigates the distinctiveness and commonality between function and impairment in rehabilitation within a conceptual framework and encourages clinicians to discuss and debate the potential for a universally recognised definition of function.

Conclusion:

Function and impairment are not always considered as being distinct, resulting in attributing observed changes in impairment to a change in functional status without the evidence to support the process.

Therapeutic effects of intra-articular botulinum neurotoxin in advanced knee osteoarthritis

BACKGROUND

Osteoarthritis (OA) is a major cause of musculoskeletal pain that causes morbidity, physical limitation, and poor quality of life. The purpose of this study was to evaluate the therapeutic effects of intra-articular (IA) injection of botulinum neurotoxin A (BoNT/A) for advanced knee OA.

METHODS

Twenty-four patients (38 knees) were enrolled, and the subjects were radiographically verified as having stage III or IV OA according to the Kellgren-Lawrence classification. We used the Western Ontario and McMaster Universities Osteoarthritis Index to evaluate the therapeutic effects monthly for 6 months. BoNT/A (100 U) was reconstituted with 4.0 mL saline and was injected into the symptomatic knee joints after baseline evaluation and 3 months later.

RESULTS

The therapeutic effects of BoNT/A were clinically significant at 1 month after the first injection, but statistical significance was not noted until 3 months after the first IA injection. Pain and stiffness improved clinically; however, the effect of BoNT/A achieved statistical significance only for the pain subscale in stage III OA. There was no significant difference between the stage III and IV groups. There was no significant muscle atrophy or serious adverse effect in any group after treatment.

CONCLUSION

IA BoNT/A provides a new therapeutic option for refractory pain in patients with advanced knee OA. Although IA BoNT/A appears to be effective and safe for the management of advanced knee OA, these results cannot be generalized to patients with mild knee joint pain or nonspecific soft tissue pain in the knee joint region.

A preliminary assessment of the benefits of the addition of botulinum toxin a to a conventional therapy program on the function of people with longstanding stroke

OBJECTIVE

To determine if botulinum toxin type A (BTX-A) combined with therapy can facilitate improved upper-extremity (UE) functional status versus therapy alone.

DESIGN

Double-blind randomized crossover trial.

SETTING

Tertiary care outpatient rehabilitation center.

PARTICIPANTS

Convenience sample of 21 men and women (ages 19-80 y) with stroke more than 6 months after insult who had tone greater than 3 on the Ashworth Scale for 2 joints in the involved UE.

INTERVENTION

Subjects were consecutively recruited and randomized to a double-blind crossover trial. Subjects received either BTX-A combined with a defined therapy program or placebo injection combined with a therapy program in two 12-week sessions.

MAIN OUTCOME MEASURES

The primary functional outcome measure was the Motor Activity Log (MAL). Subjects were also assessed on physiologic measures including tone (Ashworth Scale), range of motion, and motor strength.

RESULTS

Improvements were noted in the functional status of the subjects in both arms of the study as measured by the MAL. All subjects had a significant change in functional status on MAL with therapy (P<.05). The use of BTX-A combined with therapy as compared with therapy only improved the functional status of the subjects on the MAL Quality of Movement subscale (P=.0180, t test) and showed a trend toward significance in the Amount of Use subscale (P=.0605, analysis of variance). Six weeks after treatment, the BTX-A combined with therapy decreased the Ashworth score statistically (P=.0271), but the therapy alone group decreased a similar amount at 6 weeks (P=.0117), indicating that most of the physiologic tone change could be attributed to therapy. After each 12-week period, tone had largely returned to baseline (P>.05).

CONCLUSION

A focused therapy program showed the most improvement in function in this defined stroke population. BTX-A combined with a focused traditional therapy program slightly enhanced the functional status of stroke subjects beyond that obtained with therapy alone 12 weeks after injection.

Effect of baseline spastic hemiparesis on recovery of upper-limb function following botulinum toxin type A injections and postinjection therapy

OBJECTIVE

To determine whether baseline hand spastic hemiparesis assessed by the Chedoke-McMaster Assessment influences functional improvement after botulinum toxin type A (BTX-A) injections and postinjection therapy.

DESIGN

Prospective cohort study.

SETTING

Outpatient spasticity clinic.

PARTICIPANTS

Participants (N=14) with spastic hemiparesis divided into 2 groups: Chedoke-McMaster Assessment Hand-Higher Function (stage> or =4, n=5) and Chedoke-McMaster Assessment Hand-Lower Function (stage=2 or 3, n=9).

INTERVENTIONS

Upper-limb BTX-A injections followed by 6 weeks of postinjection therapy.

MAIN OUTCOME MEASURES

Primary outcomes were Motor Activity Log-28 and Motor Activity Log items. Secondary outcomes were Action Research Arm Test (ARAT), Motor Activity Log-Self-Report, and Modified Ashworth Scale (MAS). Measures were assessed at baseline (preinjection), 6 weeks, 9 weeks, and 12 weeks postinjection.

RESULTS

Primary and secondary outcomes improved significantly over time in both groups. Although no significant differences in ARAT or MAS change scores were noted between groups, Chedoke-McMaster Assessment Hand-Higher Function group demonstrated greater change on Motor Activity Log-28 (P=.013) from baseline to 6 weeks and Motor Activity Log items (P=.006) from baseline to 12 weeks compared to Chedoke-McMaster Assessment Hand-Lower Function group.

CONCLUSIONS

BTX-A injections and postinjection therapy improved hand function and reduced spasticity for both Chedoke-McMaster Assessment Hand-Higher Function and Chedoke-McMaster Assessment Hand-Lower Function groups. Clinicians should expect to see larger gains for persons with less baseline impairment.

Intramuscular botulinum toxin-A reduces hemiplegic shoulder pain: a randomized, double-blind, comparative study versus intraarticular triamcinolone acetonide

BACKGROUND AND PURPOSE

Shoulder pain is frequent after stroke and interferes with the rehabilitative process and outcome. However, treatments used for hemiplegic shoulder pain are limited and largely ineffective. This prospective, randomized, double-blind controlled study was conducted to compare the efficacies of botulinum toxin type A (BoNT-A) and triamcinolone acetonide (TA) on hemiplegic shoulder pain and their effects on arm function in patients with stroke.

METHODS

Twenty-nine hemiplegic stroke patients with shoulder pain (duration <or=24 months, pain on numeric rating scale >or=6/10) were randomized into 2 groups. One group received intramuscular injections of BoNT-A (BOTOX 100 U total) during one session to the infraspinatus, pectoralis and subscapularis muscles in conjunction with an intraarticular injection of normal saline to painful shoulder joint, whereas the other group received an intraarticular injection of TA (40 mg) and an intramuscular injection of normal saline to the same muscles. Outcome measures were pain (measured using a numeric rating scale), physician's global rating scale, shoulder range of motion (ROM) in 4 directions, arm function measured using Fugl-Meyer score, and spasticity measured using the modified Ashworth scale. Measurements were made at baseline and 2, 6, and 12 weeks after injection.

RESULTS

At 12 weeks after treatment mean decrease in pain was 4.2 in the BoNT-A-treated group versus 2.5 in the TA-treated group (P=0.051), and improvements in overall ROM were 82.9 degrees versus 51.8 degrees in these groups (P=0.059), showing a strong trend toward there being less pain and better ROM among those treated with BoNT-A than with TA. However, no significant differences were observed between the 2 groups in terms of improvement in physician global rating, Fugl-Meyer score or modified Ashworth scales. No adverse effect was observed in either group.

CONCLUSIONS

Results from this study suggest that injection of BoNT-A into selected muscles of the shoulder girdle might provide more pain relief and ROM improvement than intraarticular steroid in patients with hemiplegic shoulder pain. A larger clinical trial needs to be undertaken to confirm the benefits of this approach.

Botulinum toxin a, evidence-based exercise therapy, and constraint-induced movement therapy for upper-limb hemiparesis attributable to stroke: a preliminary study

OBJECTIVE

To determine whether the combination of botulinum toxin A (BTX-A) treatment for the upper limb and a 4-wk course of exercise therapy could improve motor function sufficiently to allow those with poststroke hemiparesis and spasticity to achieve the minimal motor criteria (MMC) to be enrolled in constraint-induced movement therapy (CIMT), and to determine the feasibility of enrolling participants into CIMT if they meet MMC after treatment with a combination of BTX-A plus exercise therapy.

DESIGN

Twelve individuals received BTX-A and exercise therapy for 1 hr/day, three times per week, for 4 wks. Those who met MMC were enrolled in 2 wks of CIMT, and the rest received a home exercise program. Outcome measures included the Ashworth Scale, Wolf Motor Function Test (WMFT), the Motor Activity Log (MAL), the Box and Blocks Test (BBT), and the upper-extremity subtest of the Fugl-Meyer Assessment of Motor Function (FM-UE).

RESULTS

Ashworth Scale scores declined from a mean score of 2.0-1.2 (P = 0.01). Four of 12 subjects were able to achieve MMC (P = 0.026). CIMT participants improved in the BBT, the MAL, and the WMFT compared with their own baseline. Gains achieved during CIMT receded by week 24 as spasticity returned.

CONCLUSION

BTX-A plus exercise therapy shows potential to improve function for those with severe hand paresis and spasticity after stroke. Those who meet MMC may initially realize further modest gains through CIMT. However, gains are likely to recede as spasticity returns. Adding medications or modifying the therapy protocol to include activities such as functional neuromuscular stimulation or robotic training may yield a more potent effect.

Treatment of shoulder pain in spastic hemiplegia by reducing spasticity of the subscapular muscle: a randomised, double blind, placebo controlled study of botulinum toxin A

OBJECTIVE

This randomised, double blind, placebo controlled, two parallel group study was conducted to assess the beneficial effect of injection of botulinum toxin A (Dysport) into the subscapularis muscle on shoulder pain in stroke patients with spastic hemiplegia.

METHODS

A single dose of botulinum toxin A (500 Speywood units) or placebo was injected into the subcapularis muscle. Pain was assessed using a 10 point verbal scale. Subscapularis spasticity was assessed by the change in passive shoulder lateral rotation and abduction. Upper limb spasticity was assessed using the Modified Ashworth Scale for shoulder medial rotators, and elbow, wrist and finger flexors. Assessments were carried out at baseline and at weeks 1, 2 and 4.

RESULTS

Twenty patients (10 patients per group), 11 with ischaemic stroke and 9 with haemorrhagic stroke, completed the study. Pain improvement with botulinum toxin A was observed from week 1; score difference from baseline at week 4 was 4 points versus 1 point with placebo (p = 0.025). Lateral rotation was also improved, with a statistically significant difference compared with placebo at week 2 (p = 0.05) and week 4 (p = 0.018). A general improvement in upper limb spasticity was observed; it was significant for finger flexors at week 4 (p = 0.025).

CONCLUSIONS

Subscapularis injection of botulinum toxin A appears to be of value in the management of shoulder pain in spastic hemiplegic patients. The results confirm the role of spasticity in post-stroke shoulder pain.

Botulinum toxin in poststroke spasticity

Poststroke hemiparesis, together with abnormal muscle tone, is a major cause of morbidity and disability. Although most hemiparetic patients are able to reach different ambulatory levels with rehabilitation efforts, upper and lower limb spasticity can impede activities of daily living, personal hygiene, ambulation and, in some cases, functional improvement. The goals of spasticity management include increasing mobility and range of motion, attaining better hygiene, improving splint wear and other functional activities. Conservative measures, such as positioning, stretching and exercise are essential in spasticity management, but alone often are inadequate to effectively control it. Oral antispastic medications often provide limited effects with short duration and frequent unwanted systemic side effects, such as weakness, sedation and dry mouth. Therefore, neuromuscular blockade by local injections have become the first choice for the treatment of focal spasticity, particularly in stroke patients. Botulinum toxin (BTX), being one of the most potent biological toxins, acts by blocking neuromuscular transmission via inhibiting acetylcholine release. Currently, focal spasticity is being treated successfully with BTX via injecting in the spastic muscles. Two antigenically distinct serotypes of BTX are available on the market as type A and B. Clinical studies of BTX used for spastic hemiplegic patients are reviewed in this article in two major categories, upper and lower limb applications. This review addresses efficacy in terms of outcome measures, such as muscle tone reduction and functional outcome, as well as safety issues. Application modifications of dose, dilutions, site of injections and combination therapies with BTX injections are also discussed.

Botulinum Toxin for Post-stroke Spastic Hypertonia: A Review of its Efficacy and Application in Clinical Practice

Botulinum toxins (BTX) have revolutionised the management of focal post-stroke spastic hypertonia. Published literature has supported the efficacy and safety of BTX in reducing spastic hypertonia but has not convincingly demonstrated the ability to enhance function. While clinicians and stroke survivors have reported impressive clinical outcomes, randomised, con-trolled trials (RCTs), have demonstrated only significant improvement in muscle tone but not functional changes. This paper will review the evidence supporting the efficacy of BTX for spastic hypertonia and discuss current clinical practice. Key words: Botulinum toxins, Cerebrovascular accident, Spasticity, Stroke

Taping versus electrical stimulation after botulinum toxin type A injection for wrist and finger spasticity. A case-control study

OBJECTIVE

To compare results from two approaches used in conjunction with botulinum toxin type A administration in rehabilitation: the application of a taping system and the electrical stimulation of the injected muscles and splinting.

DESIGN

Case-control study.

SETTING

Two tertiary care rehabilitation hospitals in Italy.

SUBJECTS

Sixty-five adult subjects affected by spasticity of the wrist and finger flexors.

INTERVENTIONS

After injection with botulinum toxin type A, the group at hospital A (n=33) was treated with adhesive taping for six days and those at hospital B (n=32) with electrical stimulation and splinting for six days. Spastic hypertonia at the injected muscles was assessed before treatment, one week and one month post injection.

MAIN MEASURES

Modified Ashworth Scale.

RESULTS

In group A, the mean Modified Ashworth Scale reduction was 2.76 +/- 0.94 for wrist flexors and 2.45 +/- 0.92 for finger flexors; in group B the mean Modified Ashworth Scale reduction was 2.18 +/- 1.11 for wrist flexors and 2.1 +/- 0.98 for finger flexors. The observed difference between the two groups was statistically relevant (p < 0.05).

CONCLUSIONS

Patients treated with adhesive taping and botulinum toxin type A achieved a greater reduction in spastic hypertonia as measured with Modified Ashworth Scale, with less time dedicated for the treatment.

Cadaveric Study of Methods for Subscapularis Muscle Needle Insertion

OBJECTIVE

To evaluate the accuracy for three methods for needle insertion into the subscapularis muscle for electromyography, botulinum toxin injection, and phenol nerve block.

DESIGN

Three needle insertion methods were evaluated by cadaver injection by an American Board of Electrodiagnostic Medicine certified physician. An anatomist, blinded to the method used, served as the dissector to evaluate the effectiveness of the methods tested.

RESULTS

A posterior axillary approach was most effective for needle insertion into the subscapular muscle compared with a medial scapular or a superior scapular approach. No approach was ideal for subscapular nerve injection.

CONCLUSIONS

A posterior axillary approach is best for needle insertion of the subscapularis muscle for electromyography or botulinum toxin injection. Subscapular nerve injection is difficult from all of the three approaches tested.

The lowest effective dose of botulinum A toxin in adult patients with upper limb spasticity

OBJECTIVE

To define the lowest effective dose of botulinum toxin type A (Dysport) and safety in the treatment of adult patients with upper limb spasticity.

DESIGN

This was a prospective, randomized, double-blind, dose-ranging study. Patients received either a placebo or one of three does of Dysport (350, 500 100) U) into five muscles of affected arm by anatomical and electromyography guidance. Efficacy was assessed periodically throughout the 6-month study period by the Modified Ashworth Scale (MAS), the Action Research Arm Test (ARA), the Barthel Index (BI) and the Visual Analogue Pain Scale (VAS).

RESULTS

fifty patients were recruited. The four study groups were comparable at baseline with respect to their demographical characteristics and severity of spasticity. All doses of Dysport studied showed a significant reduction from baseline of muscle tone and pain compared to placebo. However, the effect of functional disability was best at a dose of 500 U and the peak improvement was at week 8 after injection. A dose of 1000 U Dysport produced such an excess degree of muscle weakening that the number of randomized patients was reduced to five. BI and ARA of all patients were decrease after injection. No other adverse event was considered related to the study medication.

CONCLUSION

This study suggest that treatment with Dysport reduces muscle tone in adult patients with upper limb spasticity. The optimal dose for treatment of patients with residual voluntary movement in the upper limb appears to be 500 U.

Botulinum toxin: dosing and dilution

In the United States, the popularity of botulinum toxins as agents to treat muscle hypertonia has grown significantly over the last decade, despite lack of approval from the Food and Drug Administration for the indication of spasticity. Botox (botulinum toxin type A) and Myobloc (botulinum toxin type B) are Food and Drug Administration-approved for other indications, such as cervical dystonia. Another commercial preparation of type A, Dysport, has yet to reach the United States market as of this writing. Although botulinum toxin's efficacy in influencing spastic hypertonia is well accepted, the impact of certain clinical issues, such as dosing and dilution, on treatment outcome is not well established by published studies. This article will review important articles and selected abstracts on the use of botulinum toxin, specifically for spastic hypertonia in adults, with emphasis on current clinical practices as they relate to dosing and dilution.

Is the reduction of spasticity by botulinum toxin a beneficial for the recovery of motor function of arm and hand in stroke patients?

To determine the functional benefit of botulinum toxin A (BtxA) in spasticity of arm flexors, we conducted an open-label study with 10 stroke patients. 480 mouse units BtxA (Dysport((R))) were injected into flexor muscles. Outcome measures were done by the Modified Ashworth Scale, Rivermead Motor Assessment (arm section), active and passive ranges of motion (ROM), grip strength and a 3-dimensional motion analysis. The functional capacity of the entire arm, even of the shoulder, and the ROM of fingers and wrist increased. Despite a diminution of muscle tone, grip strength remained unchanged or increased. An improvement of forearm extension was only observed in cases of preserved voluntary extensor motricity. Injection of BtxA into spastic distal flexor muscles may lead to a functional improvement of the entire arm. Grip strength is not necessarily reduced.

[Post stroke hemiplegia: interest of botulinum toxin injection at the upper limb]

OBJECTIVES

To present data about the effect of botulinum toxin injection on the upper limb of stroke patients.

METHODS

We used the Medline data bank. Analysis took into account the international classification of functioning and disability. Important technical or pragmatic points were analysed separately.

RESULTS

Botulinum toxin reduces spasticity of the injected muscles, with a mean gain of about 1 point on the Ashworth scale in the 4 to 6 weeks post injection, but with a large variability. This is associated to an increase in the passive range of motion, especially at wrist, and at times to a facilitation of active movements, when they are still possible. Improvement in functional tests is observed when fair proximal and distal motricity persists. Reduction in the dependence in daily living activities has not been shown by group studies. Several patients have an improvement in using the hand for blocking and transporting objects, mainly in a facilitating position (pronation, partial wrist flexion). Comfort of patients and caregivers is more regularly improved. Results are partially predictable; improvement in function is observed in patients with fair distal motricity (extension) and low spasticity, and improvement in comfort in those with severe spasticity and low motricity.

CONCLUSION

Further studies are required, on one hand for better assessment of distal functional improvement, on the other hand at earlier phases of the disease.

Treatment of spasticity with botulinum toxin

Spasticity is an abnormal increase in muscle contraction often caused by damage to central motor pathways that control voluntary movement. During clinical examination, spasticity manifests as an increase in stretch reflexes, producing tendon jerks and resistance appearing as muscle tone. There are many causes of spasticity, including demyelination from multiple sclerosis, congenital damage from diseases such as cerebral palsy, trauma to the brain or spinal cord, hemorrhage or infarction, and other pathologic conditions that interrupt neural pathways. Effects of spasticity range from mild muscle stiffness to severe, painful muscle contractures and repetitive spasms that reduce mobility and substantially impede normal activities of daily living. Botulinum toxin therapy reduces spasticity and pain associated with several disorders. Local treatment with botulinum toxins can be used as adjunctive therapy, along with oral antispasticity medications, or alone to provide localized decrease in symptoms of spasticity and pain. Botulinum toxin therapy may be particularly useful for patients with spasticity due to stroke, whose treatment can be tailored based on recovery of function over time. In addition, botulinum toxin therapy is safe for pediatric patients, including children with cerebral palsy, who may not be able to tolerate the cognitive side effects of oral medications. Results of studies evaluating botulinum toxin for the treatment of spasticity due to various causes are presented here.