Can the early use of botulinum toxin in post stroke spasticity reduce contracture development? A randomised controlled trial

Risk factors for post-stroke spasticity: a retrospective study

Background

Post-stroke spasticity (PSS) is a common complication after stroke and is an important cause of high rates of disability after stroke. At present, modern medicine has made great progress in the treatment of PSS, 'early detection, early treatment' has become a general consensus for the treatment of PSS in the clinic. Clarifying the risk factors of PSS can help to detect and treat the functional disorders caused by PSS at an earlier stage.

Methods

This is a retrospective study. 436 stroke patients who visited the Neurology Department of the Third Affiliated Clinical Hospital of Changchun University of Chinese Medicine from June 2020 to November 2020 were selected as study subjects, and finally 257 patients were included in the final analysis, and divided into 101 cases with spasticity and 156 cases without spasticity, depending on whether or not the stroke victim had a spasm at the time of admission.

Results

The multivariate regression analysis showed that basal ganglia as the cerebral hemorrhage or infarction site (OR = 4.930, 95%CI = 2.743-8.86, p = 0.000), cerebral hemorrhage or infarction volume (OR = 1.087, 95%CI = 1.016-1.164, p = 0.016) and NIHSS scores (OR = 1.232, 95%CI = 1.089-1.393, p = 0.001) are independent influencing factors and independent risk factors for spasticity (p < 0.05). A risk prediction model for spasticity in stroke patients is derived with the multivariate logistic regression analysis Logit (P) = 1.595 * Basal ganglia +0.084 * infarct volume + 0.208 * NIHSS scores - 2.092. An evaluation of the goodness of fit using the ROC curve showed AUC (95% CI) = 0.786 (0.730-0.843), an indication of a high degree of model fit.

Conclusion

Independent risk factors for Post-stroke spasticity include basal ganglia as the cerebral hemorrhage or infarction site, cerebral hemorrhage or infarction volume and NIHSS scores.

Long-Term Management of Post-Stroke Spasticity with Botulinum Toxin: A Retrospective Study

Stroke-induced spasticity is a prevalent condition affecting stroke survivors, significantly impacting their quality of life. Botulinum Toxin A injections are widely used for its management, yet the long-term effects and optimal management strategies remain uncertain. This retrospective study analyzed medical records of 95 chronic stroke patients undergoing long-term BoNT-A treatment for spasticity. Demographic data, treatment duration, dosage variability, and dropout rates were assessed over a period ranging from 2 to 14 years. The study revealed a notable extension of the interval between BoNT-A injections throughout the treatment duration. Dropout rates peaked during the initial 5 years of treatment, perhaps due to perceived treatment ineffectiveness. Additionally, a trend of escalating dosage was observed across all groups, indicating a potential rise in the severity of spasticity or changes in treatment response over time. BoNT-A injections emerged as the predominant treatment choice for managing post-stroke spasticity. The delayed initiation of BoNT-A treatment underscores the need for heightened awareness among healthcare providers to recognize and manage spasticity promptly post-stroke. Patients' expectations and treatment goals should be clearly defined to optimize treatment adherence, while the observed escalation in dosage and treatment intervals emphasizes the dynamic nature of spasticity and underscores the importance of monitoring long-term treatment outcomes.

Surgical reconstruction for spasticity and contracture: An underutilised rehabilitative strategy of adult stroke

Post-stroke spasticity and contracture remain prevalent and pose significant challenges in stroke rehabilitation. While non-surgical management is the mainstay, surgical reconstruction offers a valuable adjunct when conservative measures are exhausted. This clinical review article provides an overview of surgical reconstruction for limb spasticity and contracture following adult stroke, encompassing the rationale and specifics of these interventions. It highlights the underutilization of surgical reconstruction in rehabilitation of adult stroke patients with spasticity and contracture, and the importance of multidisciplinary collaboration including surgeons in stroke rehabilitation to optimize functional outcomes.

Botulinum neurotoxin as early treatment in acute-onset lesional hemiballism

BACKGROUND

Hemiballism (HB) and hemichorea (HC) are the most frequent secondary movement disorders, usually caused by cerebrovascular diseases. In only a minority of cases, these involuntary movements are not self-limited, and they may severely compromise patients' quality of life, so that symptomatic treatments are required. Typical and atypical neuroleptics as well as tetrabenazine are considered therapies of choice. However, anecdotal reports of antiseizures medications and botulinum neurotoxin injection effectiveness have been described.

METHODS

We described a case of severely disabling acute-onset lesional HB/HC, where high dosage of first- and second-line therapies was contraindicated due to patient's comorbidities.

RESULTS

After botulin neurotoxin (BoNT) injections in his left upper limb muscles (biceps brachii, triceps brachii, teres major, and deltoid), the patient experienced gradual reduction of hyperkinetic movements. The gradual discontinuation of topiramate (TPM) did not worsen the clinical picture.

DISCUSSION

The reduction of hyperkinetic movements led to rhabdomyolysis resolution as well as cutaneous injuries healing with renal function improvement, so that the patient was able to be eligible for rehabilitation, which was prevented by HB/HC itself. The clinical improvement was consistent with BoNT pharmacokinetic. The administration of BoNT early after the onset of lesional HB/HC remarkably modified the clinical management and drove toward comorbidities resolution and rehabilitation.

CONCLUSION

The present case highlights the effectiveness of unconventional therapeutic options in disabling acute onset lesional HB/HC when first-line therapies are contraindicated. Particularly, this report may encourage BoNT application in the early stage of movement disorder emergencies.

Comprehensive Observational and Longitudinal study on the Outbreak of Stroke-related Spasticity focusing on the Early Onset management with Botulinum NeuroToxin (COLOSSEO-BoNT): protocol for a real-world prospective observational study on upper limb spasticity

INTRODUCTION

Poststroke spasticity (PSS) affects up to 40% of patients who had a stroke. Botulinum neurotoxin type A (BoNT-A) has been shown to improve spasticity, but the optimal timing of its application remains unclear. While several predictors of upper limb PSS are known, their utility in clinical practice in relation to BoNT-A treatment has yet to be fully elucidated. The COLOSSEO-BoNT study aims to investigate predictors of PSS and the effects of BoNT-A timing on spasticity-related metrics in a real-world setting.

METHODS AND ANALYSIS

The recruitment will involve approximately 960 patients who have recently experienced an ischaemic stroke (within 10 days, V0) and will follow them up for 24 months. Parameters will be gathered at specific intervals: (V1) 4, (V2) 8, (V3) 12, (V4) 18 months and (V5) 24 months following enrolment. Patients will be monitored throughout their rehabilitation and outpatient clinic journeys and will be compared based on their BoNT-A treatment status-distinguishing between patients receiving treatment at different timings and those who undergo rehabilitation without treatment. Potential predictors will encompass the Fugl-Meyer assessment, the National Institute of Health Stroke Scale (NIHSS), stroke radiological characteristics, performance status, therapies and access to patient care pathways. Outcomes will evaluate muscle stiffness using the modified Ashworth scale and passive range of motion, along with measures of quality of life, pain, and functionality.

ETHICS AND DISSEMINATION

This study underwent review and approval by the Ethics Committee of the Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy. Regardless of the outcome, the findings will be disseminated through publication in peer-reviewed journals and presentations at national and international conferences.

TRIAL REGISTRATION NUMBER

NCT05379413.

The effectiveness of early interventions for post-stroke spasticity: a systematic review

PURPOSE

To synthesize evidence on the effect of early post-stroke spasticity interventions.

METHODS

Systematic literature search (PubMed, Embase, and Web of Science) encompassing studies on spasticity reducing interventions within 3 months post stroke on outcome defined within the International Classification of Functioning (ICF).

RESULTS

In total, 27 studies were identified with n = 1.658 cases. Botulinum toxin (2-12 weeks; 10 studies, n = 794) showed consistent and significant reduced spasticity by Modified Ashworth Scale (MAS) or electromyography (EMG). Electrical muscle stimulation (1-8 weeks; 6 studies, n = 335) showed lower MAS/Composite Spasticity Scale scores in 4 studies. Transcranial stimulation (3 studies; n = 131), oral spasmolytics (1 study; n = 38), shockwave (1 study; n = 40), orthotics (3 studies; n = 197 and robot-assisted therapy (3 studies; n = 123) showed inconclusive results. Effects on ICF activity domain could not be established due to limited data and large outcome measures heterogeneity. One out of two studies showed significant benefit for early compared to late BoNT intervention (< 90 vs> 90 days).

CONCLUSION

This study provides evidence for early applied (<3 months) BoNT to effectively reduce spasticity and probable effectiveness of electrical stimulation. Establishing effects of interventions in the acute/hospitalization phase (<7 days) needs further work, specifically on the ICF activity domain. Standardization of outcome measures is required.

The Role of Botulinum Toxin Type-A in Spasticity: Research Trends from a Bibliometric Analysis

Botulinum toxin type-A (BoNT-A) has emerged as a key therapeutic agent for the management of spasticity. This paper presents a comprehensive bibliometric and visual analysis of research concerning BoNT-A treatment of spasticity to elucidate current trends and future directions in this research area. A search was conducted in the Web of Science database for articles focused on the use of BoNT-A in spasticity published between 2000 and 2022. We extracted various metrics, including counts of publications and contributions from different countries, institutions, authors, and journals. Analytical methods in CiteSpace were employed for the examination of co-citations, collaborations, and the co-occurrence of keywords. Our search yielded 1489 publications. Analysis revealed a consistent annual increase in research output. The United States, United Kingdom, and Italy were the leading contributors. The top institution in this research was Assistance Publique Hopitaux, Paris. The journal containing the highest number of relevant publications was Toxins. Key frequently occurring keywords were 'stroke', 'cerebral palsy', 'adult spasticity', and 'upper extremity'. This study identified 12 clusters of keywords and 15 clusters of co-cited references, indicating the main focus areas and emerging themes in this field. This study comprehensively analyzed and summarized trends in BoNT-A research in the field of spasticity over the past 22 years.

Stroke Recovery Is a Journey: Prediction and Potentials of Motor Recovery after a Stroke from a Practical Perspective

Stroke recovery is a journey. Stroke survivors can face many consequences that may last the rest of their lives. Assessment of initial impairments allows reasonable prediction of biological spontaneous recovery at 3 to 6 months for a majority of survivors. In real-world clinical practice, stroke survivors continue to improve their motor function beyond the spontaneous recovery period, but management plans for maximal recovery are not well understood. A model within the international classification of functioning (ICF) theoretical framework is proposed to systematically identify opportunities and potential barriers to maximize and realize the potentials of functional recovery from the acute to chronic stages and to maintain their function in the chronic stages. Health conditions of individuals, medical and neurological complications can be optimized under the care of specialized physicians. This permits stroke survivors to participate in various therapeutic interventions. Sufficient doses of appropriate interventions at the right time is critical for stroke motor rehabilitation. It is important to highlight that combining interventions is likely to yield better clinical outcomes. Caregivers, including family members, can assist and facilitate targeted therapeutic exercises for these individuals and can help stroke survivors comply with medical plans (medications, visits), and provide emotional support. With health optimization, comprehensive rehabilitation, support from family and caregivers and a commitment to a healthy lifestyle, many stroke survivors can overcome barriers and achieve potentials of maximum recovery and maintain their motor function in chronic stages. This ICF recovery model is likely to provide a guidance through the journey to best achieve stroke recovery potentials.

Post-Stroke Spastic Movement Disorder and Botulinum Toxin A Therapy: Early Detection And Early Injection

Post-stroke spastic movement disorder (PS-SMD) develops in up to 40% of stroke survivors after a first ever stroke within the first year. Chronic PS-SMD is often associated with severe disabilities and complications, emphasizing the importance of its early recognition and early adequate management. Extensive research has aimed to accurately predict and sensitively detect a PS-SMD. Symptomatic therapies include conventional rehabilitation and local intramuscular injections of botulinum toxin A (BoNT-A). The latter is widely used, but primarily in the chronic phase of stroke. However, recent studies have shown the safety and efficacy of BoNT-A therapy even in the acute phase and early sub-acute phase after stroke, i.e., within three months post-stroke, leading to an improved long-term outcome in stroke rehabilitation. Local BoNT-A injections evolve as the primary approach in focal, multifocal, and segmental chronic or acute/subacute PS-SMD. Patients at high risk for or manifest PS-SMD should be identified by an early spasticity risk assessment. By doing so, PS-SMD can be integral part of the patient-centered goal-setting process of a multiprofessional spasticity-experienced team. The benefit of an early PS-SMD treatment by BoNT-A should predominate putative degenerative muscle changes due to long-term BoNT-A therapy by far. This, as early treatment effectively avoids complications typically associated with a PS-SMD, i.e., contractures, pain, skin lesions. The management of PS-SMD requires a comprehensive and multidisciplinary approach. Early assessment, patient-centered goal setting, early intervention, and early use of BoNT-A therapy prevents from PS-SMD complications and may improve rehabilitation outcome after stroke.

Early versus late injections of Botulinumtoxin type A in post-stroke spastic movement disorder: A literature review

Post-stroke spastic movement disorder (PS-SMD) is one of the main causes of severe disability in the chronic phase after stroke. The prevalence of SMD rises up with time after stroke to more than 28% in the chronic phase, and its secondary complications such as contracture, abnormal postures and/or movement patterns, spasticity-associated pain, also increases with time after stroke when physical and medical management of PS-SMD had been delayed in the early stroke phase. It has been published by several controlled studies that the earlier physical and medical measures, such as botulinum toxin type A (BoNT-A) therapy are included in rehabilitative strategies for the SMD, the lesser secondary complications, especially soft tissue contractures and pain occurred. Several studies showed that goal-orientated management of PS-SMD including BoNT-A therapy, applied within a few weeks and 3 months - in the early subacute phase after stroke onset - prevented or reduced the development of severe or disabling SMD and its secondary complications, more effective than late application of BoNT-A therapy - in the chronic phase after stroke. In multiple prospective cohort studies, various predictors and predictive approaches for detection of patients on risk to development PS-SMD were found. Based on that information and the controlled studies that showed reduction in PS-SMD complications following early treatment with BoNT-A nowadays, early treatment of PS-SMD in the early subacute phase following stroke is recommended to avoid or reduce the development of post-stroke disability and to improve the outcome of rehabilitation. In this review, we discuss on the optimal timing to apply BoNT-A therapy in patients with already present as well as in high risk of severe PS-SMD.

Estimating the cost consequence of the early use of botulinum toxin in post-stroke spasticity: Secondary analysis of a randomised controlled trial

OBJECTIVE

To estimate the cost-consequence of treating spasticity early with botulinum toxin in the acute stroke unit.

DESIGN

Secondary cost-consequence analysis, using data from a double-blind randomised-controlled trial.

SETTING

Single-centre specialised stroke unit.

SUBJECTS AND INTERVENTIONS

Patients with Action Research Arm Test grasp-score of <2 and who developed spasticity within six weeks of a first stroke were randomised to receive injections of: 0.9% sodium-chloride solution (placebo) or onabotulinumtoxin-A (treatment).

MAIN MEASURES

Resource use costs were calculated for the study. Mean contracture costs for each group were calculated. The Barthel Index and Action Research Arm Test were used to generate a cost per unit of improvement.

RESULTS

There were no significant differences associated with early treatment use. The mean contracture cost for the treatment group was £817 and for the control group was £2298 (mean difference = -£1481.1(95% CI -£2893.5, -£68.7) (p = 0.04). The cost per unit of improvement for the Barthel Index was -£1240 indicating that the intervention costs less and is more effective. The cost per unit of improvement for the Action Research Arm Test was -£450 indicating that the intervention costs less and is more effective.

CONCLUSIONS

Treating spasticity early in stroke patients at risk of contractures with botulinum toxin leads to a significant reduction in contracture costs. The cost per improvement of Barthel and Action Research Arm Test indicates that the intervention costs less and is more effective.

TRIAL REGISTRATION DATA

EudraCT(2010-021257-39) and ClinicalTrials.gov-Identifier:NCT01882556.

Research progress in extracorporeal shock wave therapy for upper limb spasticity after stroke

Spasticity is one of the most common complications after stroke. With the gradual intensification of spasticity, stroke patients will have a series of problems such as joint ankylosis and movement restriction, which affect the daily activities and increase the burden on patients' families, medical staff and society. There are many ways to treat post-stroke spasticity before, including physical therapy and exercise therapy, drug therapy, surgery and so on, but not satisfied because of a few shortcomings. In recent years, many researchers have applied extracorporeal shock wave therapy (ESWT) for the treatment of post-stroke spasm and achieved good clinical effect, because it is non-invasive, safe, easy to operate, low cost and other advantages compared with other treatment methods. This article reviews the research progress and existing problems of ESWT in the treatment of post-stroke spasticity.

The Place of Botulinum Toxin in Spastic Hemiplegic Shoulder Pain after Stroke: A Scoping Review

Stroke is a common pathology worldwide, with an age-standardized global rate of new strokes of 150.5 per 100,000 population in 2017. Stroke causes upper motor neuron impairment leading to a spectrum of muscle weakness around the shoulder joint, changes in muscle tone, and subsequent soft tissue changes. Hemiplegic shoulder pain (HSP) is the most common pain condition in stroke patients and one of the four most common medical complications after stroke. The importance of the appropriate positioning and handling of the hemiplegic shoulder for prevention of HSP is therefore of high clinical relevance. Nevertheless, HSP remains a frequent and disabling problem after stroke, with a 1-year prevalence rate up to 39%. Furthermore, the severity of the motor impairment is one of the most important identified risk factors for HSP in literature. Spasticity is one of these motor impairments that is likely to be modifiable. After ruling out or treating other shoulder pathologies, spasticity must be assessed and treated because it could lead to a cascade of unwanted complications, including spastic HSP. In clinical practice, Botulinum toxin A (BTA) is regarded as the first-choice treatment of focal spasticity in the upper limb, as it gives the opportunity to target specifically selected muscles. It thereby provides the possibility of a unique patient tailored focal and reversible treatment for post stroke spasticity. This scoping review aims to summarize the current evidence of BTA treatment for spastic HSP. First, the clinical manifestation and outcome measures of spastic HSP will be addressed, and second the current evidence of BTA treatment of spastic HSP will be reviewed. We also go in-depth into the elements of BTA application that may optimize the therapeutic effect of BTA. Finally, future considerations for the use of BTA for spastic HSP in clinical practice and research settings will be discussed.

Aging after stroke: how to define post-stroke sarcopenia and what are its risk factors?

BACKGROUND

Sarcopenia, generally described as "aging-related loss of skeletal muscle mass and function", can occur secondary to a systemic disease.

AIM

This project aimed to study the prevalence of sarcopenia in chronic ambulatory stroke survivors and its associated risk factors using the two most recent diagnostic criteria.

DESIGN

A cross-sectional observational study.

SETTING

A scientific laboratory.

POPULATION

Chronic stroke.

METHODS

Twenty-eight ambulatory chronic stroke survivors (12 females; mean age=57.8±11.8 years; time after stroke=76±45 months), hand-grip strength, gait speed, and appendicular skeletal muscle mass (ASM) were measured to define sarcopenia. Risk factors, including motor impairment and spasticity, were identified using regression analysis.

RESULTS

The prevalence of sarcopenia varied between 18% and 25% depending on the diagnostic criteria used. A significant difference was seen in the prevalence of low hand grip strength on the affected side (96%) when compared to the contralateral side (25%). The prevalence of slow gait speed was 86% while low ASM was present in 89% of the subjects. Low ASM was marginally negatively correlated with time since stroke and gait speed, but no correlation was observed with age, motor impairment, or spasticity. ASM loss, bone loss and fat deposition were significantly greater in the affected upper limb than in the affected lower limb. Regression analyses showed that time since stroke was a factor associated with bone and muscle loss in the affected upper limb, spasticity had a protective role for muscle loss in the affected lower limb, and walking had a protective role for bone loss in the lower limb.

CONCLUSIONS

The prevalence of sarcopenia in stroke survivors is high and is a multifactorial process that is not age-related. Different risk factors contribute to muscle loss in the upper and lower limbs after stroke.

CLINICAL REHABILITATION IMPACT

Clinicians need to be aware of high prevalence of sarcopenia in chronic stroke survivors. Sarcopenia is more evident in the upper than lower limbs. Clinicians also need to understand potential protective roles of some factors, such as spasticity and walking for the muscles in the lower limb.

[Clinical practice guideline for the treatment of spasticity: Consensus and algorithms]

Spasticity is a complex phenomenon of extremely variable clinical expression, a dynamic and evolutionary process that can condition the activity and treatment of the patient. The current recommendation for early treatment aims to avoid progression and complications, and involves an individualized approach based on a wide range of pharmacological and non-pharmacological measures. This guide results from a forum of expert specialists who faced some frequent uncertainties in the assessment process and therapeutic approach of the spastic patient such as the suitability of initiating treatment, considerations for initiating, continuing and ceasing treatment with botulinum toxin, adjuvant treatments, pain or follow-up. The result is one algorithm of decision for the therapeutic approach of spasticity. Both scientific progress and the exchange of clinical experience on which this guide is based, can support decision-making on some areas of gloom that we find in daily practice.

Evidence of treating spasticity before it develops: a systematic review of spasticity outcomes in acute spinal cord injury interventional trials

Introduction: Spasticity is a common consequence of spinal cord injury (SCI), estimated to affect up to 93% of people living with SCI in the community. Problematic spasticity affects around 35% people with SCI spasticity. The early period after injury is believed to be the most opportune time for neural plasticity after SCI. We hypothesize that clinical interventions in the early period could reduce the incidence of spasticity. To address this, we evaluated the spasticity outcomes of clinical trials with interventions early after SCI.Methods: We performed a systematic review of the literature between January 2000 and May 2021 to identify control trials, in humans and animals, that were performed early after SCI that included measures of spasticity in accordance with PRISMA guidelines.Results: Our search yielded 1,463 records of which we reviewed 852 abstracts and included 8 human trial peer-reviewed publications and 9 animal studies. The 9 animal trials largely supported the hypothesis that early intervention can reduce spasticity, including evidence from electrophysiological, behavioral, and histologic measures. Of the 8 human trials, only one study measured spasticity as a primary outcome with a sample size sufficient to test the hypothesis. In this study, neuromodulation of the spinal cord using electric stimulation of the common peroneal nerve reduced spasticity in the lower extremities compared to controls.Conclusion: Given the prevalence of problematic spasticity, there is surprisingly little research being performed in the early period of SCI that includes spasticity measures, and even fewer studies that directly address spasticity. More research on the potential for early interventions to mitigate spasticity is needed.

Comprehensive Assessment of the Time Course of Biomechanical, Electrophysiological and Neuro-Motor Effects after Botulinum Toxin Injections in Elbow Flexors of Chronic Stroke Survivors with Spastic Hemiplegia: A Cross Sectional Observation Study

Botulinum neurotoxin (BoNT) is commonly used to manage focal spasticity in stroke survivors. This study aimed to a perform comprehensive assessment of the effects of BoNT injection. Twelve stroke subjects with spastic hemiplegia (age: 52.0 ± 10.1 year; 5 females) received 100 units of BoNT to the spastic biceps brachii muscles. Clinical, biomechanical, electrophysiological, and neuro-motor assessments were performed one week (wk) before (pre-injection), 3 weeks (wks) after, and 3 months (mons) after BoNT injection. BoNT injection significantly reduced spasticity, muscle strength, reflex torque, and compound muscle action potential (CMAP) amplitude of spastic elbow flexors (all p < 0.05) during the 3-wks visit, and these values return to the pre-injection level during the 3-mons visit. Furthermore, the degree of reflex torque change was negatively correlated to the amount of non-reflex component of elbow flexor resistance torque. However, voluntary force control and non-reflex resistance torque remained unchanged throughout. Our results revealed parallel changes in clinical, neurophysiological and biomechanical assessment after BoNT injection; BoNT injection would be more effective if hypertonia was mainly mediated by underlying neural mechanisms. BoNT did not affect voluntary force control of spastic muscles.

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

INTRODUCTION

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

AREAS COVERED

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

EXPERT OPINION

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

Early Use of Phenol Neurolysis Likely Reduces the Total Amount of Botulinum Toxin in Management of Post-Stroke Spasticity

The main objective was to examine practice patterns of phenol neurolysis for post-stroke spasticity management in the early stage. We performed a chart review of patients who were admitted for inpatient rehabilitation within 6 months after first-ever stroke and received phenol neurolysis within 15 months post-stroke. Out of 2,367 stroke admissions from January 2014 and December 2018, 68 patients met the criteria. 52.9% of these patients received phenol neurolysis within 12 weeks, i.e., early stage. The earliest phenol neurolysis procedure was at 19 days after stroke. On average, patients received first phenol injections at 16.3 weeks after stroke with an average dose of 7.3 ml. Most commonly injected nerves were tibial nerve motor branches (41/68), sciatic nerve motor branches (37/68), lateral pectoral nerve (16/68), medial pectoral nerve (15/68), obturator nerve (15/68) and musculocutaneous nerve (15/68). Among 68 patients, 24 received phenol only; 17 received phenol neurolysis first followed by botulinum toxin (BoNT) injections; 19 received BoNT injections first followed by phenol neurolysis; 8 received both phenol and BoNT injections at the same time. The interval from stroke to first procedure was similar between the Phenol-First group (13.3 weeks) and the BoNT-First group (12.6 weeks). The total amount of BoNT was significantly lower in the Phenol-First group (361.3 units) than in the BoNT-First group (515.8 units) (p = 0.005). The total amount of phenol was not statistically different between the Phenol-First group (5.9 ml) and the BoNT-First group (8.3 ml). The interval between the first procedure and its subsequent procedure was not statistically different between the Phenol-First group (18.3 weeks) and the BoNT-First group (10.7 weeks). These long intervals suggest that the subsequent injection (type and dose) was not planned during the first procedure. The general patterns of target areas were similar between BoNT injections and phenol neurolysis, except that phenol neurolysis rarely targeted the upper extremity distal muscles. No side effects after phenol or BoNT injections in the early stage after stroke were observed in the chart review. In summary, phenol neurolysis was started as early as 19 days after stroke. On average, patients received first phenol about 4 months after stroke with an average of 7.3 ml of phenol. Early use of phenol neurolysis likely decreases the total amount of BoNT for management of post-stroke spasticity without increased side effects.

Early Botulinum Toxin Type A Injection for Post-Stroke Spasticity: A Longitudinal Cohort Study

Early management of spasticity may improve stroke outcome. Botulinum toxin type A (BoNT-A) is recommended treatment for post-stroke spasticity (PSS). However, it is usually administered in the chronic phase of stroke. Our aim was to determine whether the length of time between stroke onset and initial BoNT-A injection has an effect on outcomes after PSS treatment. This multicenter, longitudinal, cohort study included stroke patients (time since onset <12 months) with PSS who received BoNT-A for the first time according to routine practice. The main outcome was the modified Ashworth scale (MAS). Patients were evaluated before BoNT-A injection and then at 4, 12, and 24 weeks of follow-up. Eighty-three patients with PSS were enrolled. MAS showed a significant decrease in PSS at 4 and 12 weeks but not at 24 weeks after treatment. Among the patients with a time between stroke onset and BoNT-A injection >90 days, the MAS were higher at 4 and 12 weeks than at 24 weeks compared to those injected ≤90 days since stroke. Our findings suggest that BoNT-A treatment for PSS should be initiated within 3 months after stroke onset in order to obtain a greater reduction in muscle tone at 1 and 3 months afterwards.

A New Definition of Poststroke Spasticity and the Interference of Spasticity With Motor Recovery From Acute to Chronic Stages

The relationship of poststroke spasticity and motor recovery can be confusing. "True" motor recovery refers to return of motor behaviors to prestroke state with the same end-effectors and temporo-spatial pattern. This requires neural recovery and repair, and presumably occurs mainly in the acute and subacute stages. However, according to the International Classification of Functioning, Disability and Health, motor recovery after stroke is also defined as "improvement in performance of functional tasks," i.e., functional recovery, which is mainly mediated by compensatory mechanisms. Therefore, stroke survivors can execute motor tasks in spite of disordered motor control and the presence of spasticity. Spasticity interferes with execution of normal motor behaviors ("true" motor recovery), throughout the evolution of stroke from acute to chronic stages. Spasticity reduction does not affect functional recovery in the acute and subacute stages; however, appropriate management of spasticity could lead to improvement of motor function, that is, functional recovery, during the chronic stage of stroke. We assert that spasticity results from upregulation of medial cortico-reticulo-spinal pathways that are disinhibited due to damage of the motor cortex or corticobulbar pathways. Spasticity emerges as a manifestation of maladaptive plasticity in the early stages of recovery and can persist into the chronic stage. It coexists and shares similar pathophysiological processes with related motor impairments, such as abnormal force control, muscle coactivation and motor synergies, and diffuse interlimb muscle activation. Accordingly, we propose a new definition of spasticity to better account for its pathophysiology and the complex nuances of different definitions of motor recovery.