Effect of repetitive arm cycling following botulinum toxin injection for poststroke spasticity: evidence from FMRI

Intramuscular Neural Distribution of the Gluteus Maximus Muscle: Diagnostic Electromyography and Injective Treatments

INTRODUCTION

The purpose of this study was to investigate neural patterns within the gluteus maximus (Gmax) muscle to identify optimal EMG placement and injection sites for botulinum toxin and other injectable agents.

METHODS

This study used 10 fixed and 1 non-fixed adult Korean cadavers. Intramuscular arborization patterns were confirmed in the cranial, middle, and caudal segments of 20 Gmax muscles using Sihler staining. Ultrasound images were obtained from one cadaver, and blue dye was injected using ultrasound guidance to confirm the results.

RESULTS

The intramuscular innervation pattern of the Gmax was mostly in the middle part of this muscle. The nerve endings of the Gmax are mainly located in the 40-70% range in the cranial segment, the 30-60% range in the middle segment, and the 40-70% range in the caudal segment.

DISCUSSION

Addressing the spasticity of the gluteus maximus requires precise, site-specific botulinum toxin injections. The use of EMG and other injection therapies should be guided by the findings of this study. We propose that these specific sites, which correspond to areas with the densest nerve branches, are the safest and most efficient locations for both botulinum toxin injections and EMG procedures.

Distribution of the intramuscular innervation of the triceps brachii: Clinical importance in the treatment of spasticity with botulinum neurotoxin

This study aimed to identify ideal sites for botulinum toxin injection by analyzing the intramuscular nerve patterns of the triceps brachii muscles. A modified Sihler's method was applied to the triceps brachii muscle (15 specimens), with long, medial, and lateral heads. The intramuscular arborization areas of the long, medial, and lateral heads of the triceps brachii muscle were measured as a percentage of the total distance from the midpoint of the olecranon (0%) to the anteroinferior point of the acromion (100%), by dividing the medial and lateral parts based on the line connecting the midpoint of the olecranon and the anteroinferior point of the acromion. Intramuscular arborization patterns were observed at the long head at two medial regions, proximally 30%-50% and distally 60%-70%; medial head of 30%-40%; and lateral head of 30%-60%. These results suggest that the treatment of spasticity of the triceps brachii muscles involves botulinum toxin injections in specific areas. The areas corresponding to the areas of maximum arborization are recommended as the most effective and safe points for botulinum toxin injection.

Changes in Cortical Activity in Stroke Survivors Undergoing Botulinum Neurotoxin Therapy for Treatment of Focal Spasticity

Background: Botulinum NeuroToxin-A (BoNT-A) relieves muscle spasticity and increases range of motion necessary for stroke rehabilitation. Determining the effects of BoNT-A therapy on brain neuroplasticity could help physicians customize its use and predict its outcome.

Objective: The purpose of this study was to investigate the effects of Botulinum Toxin-A therapy for treatment of focal spasticity on brain activation and functional connectivity.

Design: We used functional Magnetic Resonance Imaging (fMRI) to track changes in blood oxygen-level dependent (BOLD) activation and functional connectivity associated with BoNT-A therapy in nine chronic stroke participants, and eight age-matched controls. Scans were acquired before BoNT-A injections (W0) and 6 weeks after the injections (W6). The task fMRI scan consisted of a block design of alternating mass finger flexion and extension. The voxel-level changes in BOLD activation, and pairwise changes in functional connectivity were analyzed for BoNT-A treatment (stroke W0 vs. W6).

Results: BoNT-A injection therapy resulted in significant increases in brain activation in the contralesional premotor cortex, cingulate gyrus, thalamus, superior cerebellum, and in the ipsilesional sensory integration area. Lastly, cerebellar connectivity correlated with the Fugl-Meyer assessment of motor impairment before injection, while premotor connectivity correlated with the Fugl-Meyer score after injection.

Conclusion: BoNT-A therapy for treatment of focal spasticity resulted in increased brain activation in areas associated with motor control, and cerebellar connectivity correlated with motor impairment before injection. These results suggest that neuroplastic effects might take place in response to improvements in focal spasticity.

Botulinum Neurotoxins in Central Nervous System: An Overview from Animal Models to Human Therapy

Botulinum neurotoxins (BoNTs) are potent inhibitors of synaptic vesicle fusion and transmitter release. The natural target of BoNTs is the peripheral neuromuscular junction (NMJ) where, by blocking the release of acetylcholine (ACh), they functionally denervate muscles and alter muscle tone. This leads them to be an excellent drug for the therapy of muscle hyperactivity disorders, such as dystonia, spasticity, and many other movement disorders. BoNTs are also effective in inhibiting both the release of ACh at sites other than NMJ and the release of neurotransmitters other than ACh. Furthermore, much evidence shows that BoNTs can act not only on the peripheral nervous system (PNS), but also on the central nervous system (CNS). Under this view, central changes may result either from sensory input from the PNS, from retrograde transport of BoNTs, or from direct injection of BoNTs into the CNS. The aim of this review is to give an update on available data, both from animal models or human studies, which suggest or confirm central alterations induced by peripheral or central BoNTs treatment. The data will be discussed with particular attention to the possible therapeutic applications to pathological conditions and degenerative diseases of the CNS.

Anatomical locations of the motor endplates of sartorius muscle for botulinum toxin injections in treatment of muscle spasticity

PURPOSE

This study aimed to detect the idyllic locations for botulinum neurotoxin injection by analyzing the intramuscular neural distributions of the sartorius muscles.

METHODS

An altered Sihler's staining was conducted on sartorius muscles (15 specimens). The nerve entry points and intramuscular arborization areas were measured as a percentage of the total distance from the most prominent point of the anterior superior iliac spine (0%) to the medial femoral epicondyle (100%).

RESULTS

Intramuscular neural distribution were densely detected at 20-40% and 60-80% for the sartorius muscles. The result suggests that the treatment of sartorius muscle spasticity requires botulinum neurotoxin injections in particular locations.

CONCLUSIONS

These locations, corresponding to the locations of maximum arborization, are suggested as the most suggestive points for botulinum neurotoxin injection.

Adjunct therapies after botulinum toxin injections in spastic adults: systematic review and SOFMER recommendations

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).

The Central Effects of Botulinum Toxin in Dystonia and Spasticity

In dystonic and spastic movement disorders, however different in their pathophysiological mechanisms, a similar impairment of sensorimotor control with special emphasis on afferentation is assumed. Peripheral intervention on afferent inputs evokes plastic changes within the central sensorimotor system. Intramuscular application of botulinum toxin type A (BoNT-A) is a standard evidence-based treatment for both conditions. Apart from its peripheral action on muscle spindles, a growing body of evidence suggests that BoNT-A effects could also be mediated by changes at the central level including cerebral cortex. We review recent studies employing electrophysiology and neuroimaging to investigate how intramuscular application of BoNT-A influences cortical reorganization. Based on such data, BoNT-A becomes gradually accepted as a promising tool to correct the maladaptive plastic changes within the sensorimotor cortex. In summary, electrophysiology and especially neuroimaging studies with BoNT-A further our understanding of pathophysiology underlying dystonic and spastic movement disorders and may consequently help develop novel treatment strategies based on neural plasticity.

Botulinum Toxin Modulates Posterior Parietal Cortex Activation in Post-stroke Spasticity of the Upper Limb

Post-stroke spasticity (PSS) is effectively treated with intramuscular botulinum toxin type A (BoNT-A), although the clinical improvement is likely mediated by changes at the central nervous system level. Using functional magnetic resonance imaging (fMRI) of the brain, this study aims to confirm and locate BoNT-A-related changes during motor imagery with the impaired hand in severe PSS. Temporary alterations in primary and secondary sensorimotor representation of the impaired upper limb were expected. Thirty chronic stroke patients with upper limb PSS undergoing comprehensive treatment including physiotherapy and indicated for BoNT treatment were investigated. A change in PSS of the upper limb was assessed with the modified Ashworth scale (MAS). fMRI and clinical assessments were performed before (W0) and 4 weeks (W4) and 11 weeks (W11) after BoNT-A application. fMRI data were acquired using 1.5-Tesla scanners during imagery of finger-thumb opposition sequences with the impaired hand. At the group level, we separately modeled (1) average activation at each time point with the MAS score and age at W0 as covariates; and (2) within-subject effect of BoNT-A and the effect of time since W0 as independent variables. Comprehensive treatment of PSS with BoNT-A significantly decreased PSS of the upper limb with a maximal effect at W4. Task-related fMRI prior to treatment (W0) showed extensive activation of bilateral frontoparietal sensorimotor cortical areas, bilateral cerebellum, and contralesional basal ganglia and thalamus. After BoNT-A application (W4), the activation extent decreased globally, mostly in the bilateral parietal cortices and cerebellum, but returned close to baseline at W11. The intra-subject contrast revealed a significant BoNT-A effect, manifesting as a transient decrease in the activation of the ipsilesional intraparietal sulcus and superior parietal lobule. We demonstrate that BoNT-A treatment of PSS of the upper limb is associated with transient changes in the ipsilesional posterior parietal cortex, possibly resulting from temporarily altered sensorimotor upper limb representations.

Effect of electrical stimulation as an adjunct to botulinum toxin type A in the treatment of adult spasticity: a systematic review

OBJECTIVE

To investigate whether electrical stimulation (ES) as an adjunct to BTX-A boosts botulinum activity and whether the combined therapeutic procedure is more effective than BTX-A alone in reducing spasticity in adult subjects.

DATA SOURCES

A search was conducted in PubMed, EMBASE, Cochrane Central Register, and CINAHL from January 1966 to January 2016.

STUDY SELECTION

Only randomized controlled studies (RCT) involving the combination of BTX-A and ES were considered. RCTs were excluded if BTX plus ES was investigated in animals or healthy subjects; certain techniques were used as an adjunct to BTX-A, but ES was not used; BTX-A or ES were compared but were not used in combination. ES was divided into neuromuscular stimulation (NMS), functional electrical stimulation (FES), and transcutaneous electrical nerve stimulation (TENS). Two authors independently screened all search results and reviewed study characteristics using the Physiotherapy Evidence Database (PEDro) scale.

RESULTS

Fifteen RCTs were pinpointed and nine studies were included. Trials varied in methodological quality, size, and outcome measures used. ES was used in the form of NMS and FES in seven and two studies, respectively. No study investigating BTX-A plus TENS was found. BTX-A plus ES produced significant reduction in spasticity on the Ashworth Scale (AS) and on the modified AS in seven studies, but only four showed high quality on the PEDro scale. Significant reduction in compound muscular action potential (CMAP) amplitude was detected after BTX-A plus ES in two studies.

CONCLUSIONS

ES as an adjunctive therapy to BTX-A may boost BTX-A action in reducing adult spasticity, but ES variability makes it difficult to recommend the combined therapy in clinical practice. Implications for rehabilitation Electrical stimulation (ES) as adjunct to botulinum toxin type A (BTX-A) injections may boost neurotoxin action in treating adult spasticity. Given the variability of ES characteristics and the paucity of high-quality trials, it is difficult to support definitively the use of BTX-A plus ES to potentiate BTX-A effect in clinical practice. A vast array of rehabilitation interventions combined with BTX-A have been provided in reducing spasticity, but the present evidence is not sufficient to recommend any combined therapeutic strategy.

Technology-assisted stroke rehabilitation in Mexico: a pilot randomized trial comparing traditional therapy to circuit training in a Robot/technology-assisted therapy gym

Background

Stroke rehabilitation in low- and middle-income countries, such as Mexico, is often hampered by lack of clinical resources and funding. To provide a cost-effective solution for comprehensive post-stroke rehabilitation that can alleviate the need for one-on-one physical or occupational therapy, in lower and upper extremities, we proposed and implemented a technology-assisted rehabilitation gymnasium in Chihuahua, Mexico. The Gymnasium for Robotic Rehabilitation (Robot Gym) consisted of low- and high-tech systems for upper and lower limb rehabilitation. Our hypothesis is that the Robot Gym can provide a cost- and labor-efficient alternative for post-stroke rehabilitation, while being more or as effective as traditional physical and occupational therapy approaches.

Methods

A typical group of stroke patients was randomly allocated to an intervention (n = 10) or a control group (n = 10). The intervention group received rehabilitation using the devices in the Robot Gym, whereas the control group (n = 10) received time-matched standard care. All of the study subjects were subjected to 24 two-hour therapy sessions over a period of 6 to 8 weeks. Several clinical assessments tests for upper and lower extremities were used to evaluate motor function pre- and post-intervention. A cost analysis was done to compare the cost effectiveness for both therapies.

Results

No significant differences were observed when comparing the results of the pre-intervention Mini-mental, Brunnstrom Test, and Geriatric Depression Scale Test, showing that both groups were functionally similar prior to the intervention. Although, both training groups were functionally equivalent, they had a significant age difference. The results of all of the upper extremity tests showed an improvement in function in both groups with no statistically significant differences between the groups. The Fugl-Meyer and the 10 Meters Walk lower extremity tests showed greater improvement in the intervention group compared to the control group. On the Time Up and Go Test, no statistically significant differences were observed pre- and post-intervention when comparing the control and the intervention groups. For the 6 Minute Walk Test, both groups presented a statistically significant difference pre- and post-intervention, showing progress in their performance. The robot gym therapy was more cost-effective than the traditional one-to-one therapy used during this study in that it enabled therapist to train up to 1.5 to 6 times more patients for the approximately same cost in the long term.

Conclusions

The results of this study showed that the patients that received therapy using the Robot Gym had enhanced functionality in the upper extremity tests similar to patients in the control group. In the lower extremity tests, the intervention patients showed more improvement than those subjected to traditional therapy. These results support that the Robot Gym can be as effective as traditional therapy for stroke patients, presenting a more cost- and labor-efficient option for countries with scarce clinical resources and funding.

Trial registration

ISRCTN98578807.

Intramuscular nerve distribution pattern of ankle invertor muscles in human cadaver using sihler stain

INTRODUCTION

We sought to the ideal sites for botulinum toxin injection by examining the intramuscular nerve patterns of the ankle invertors.

METHODS

A modified Sihler method was performed on the flexor hallucis longus, tibialis posterior, and flexor digitorum longus muscles (10 specimens each). The muscle origins, nerve entry points, and intramuscular arborization areas were measured as a percentage of the total distance from the most prominent point of the lateral malleolus (0%) to the fibular head (100%).

RESULTS

Intramuscular arborization patterns were observed at 20-50% for the flexor hallucis longus, 70-80% for the tibialis posterior, and 30-40% for the flexor digitorum longus.

CONCLUSIONS

These findings suggest that treatment of muscle spasticity of the ankle invertors involves botulinum toxin injections in specific areas. These areas, corresponding to the areas of maximum arborization, are recommended as the most effective and safest points for injection.

Sensorimotor modulation by botulinum toxin A in post-stroke arm spasticity: Passive hand movement

INTRODUCTION

In post-stroke spasticity, functional imaging may uncover modulation in the central sensorimotor networks associated with botulinum toxin type A (BoNT) therapy. Investigations were performed to localize brain activation changes in stroke patients treated with BoNT for upper limb spasticity using functional magnetic resonance imaging (fMRI).

METHODS

Seven ischemic stroke patients (4 females; mean age 58.86) with severe hand paralysis and notable spasticity were studied. Spasticity was scored according to the modified Ashworth scale (MAS). fMRI examination was performed 3 times: before (W0) and 4 (W4) and 11weeks (W11) after BoNT. The whole-brain fMRI data were acquired during paced repetitive passive movements of the plegic hand (flexion/extension at the wrist) alternating with rest. Voxel-by-voxel statistical analysis using the General Linear Model (GLM) implemented in FSL (v6.00)/FEAT yielded group session-wise statistical maps and paired between-session contrasts, thresholded at the corrected cluster-wise significance level of p<0.05.

RESULTS

As expected, BoNT transiently lowered MAS scores at W4. Across all the sessions, fMRI activation of the ipsilesional sensorimotor cortex (M1, S1, and SMA) dominated. At W4, additional clusters transiently emerged bilaterally in the cerebellum, in the contralesional sensorimotor cortex, and in the contralesional occipital cortex. Paired contrasts demonstrated significant differences W4>W0 (bilateral cerebellum and contralesional occipital cortex) and W4>W11 (ipsilesional cerebellum and SMA). The remaining paired contrast (W0>W11) showed activation decreases mainly in the ipsilesional sensorimotor cortex (M1, S1, and SMA).

CONCLUSIONS

The present study confirms the feasibility of using passive hand movements to map the cerebral sensorimotor networks in patients with post-stroke arm spasticity and demonstrates that BoNT-induced spasticity relief is associated with changes in task-induced central sensorimotor activation, likely mediated by an altered afferent drive from the spasticity-affected muscles.

Changes in Cerebellar Activation After Onabotulinumtoxin A Injections for Spasticity After Chronic Stroke: A Pilot Functional Magnetic Resonance Imaging Study

OBJECTIVE

To investigate the effect of reducing spasticity via onabotulinumtoxin A (Obtx-A) injection on cerebellar activation after chronic stroke during unilateral gripping.

DESIGN

Pre-post, case series.

SETTING

Outpatient spasticity clinic.

PARTICIPANTS

Individuals with chronic spasticity (N=4).

INTERVENTIONS

Upper-limb Obtx-A injection.

MAIN OUTCOME MEASURES

Functional magnetic resonance imaging (fMRI) was used to measure changes in cerebellar activation before and after upper-limb Obtx-A injection. During fMRI testing, participants performed the same motor task before and after injection, which was 15% and 30% of maximum voluntary isometric gripping measured before Obtx-A injection.

RESULTS

After Obtx-A injection, cerebellar activation increased bilaterally during gripping with the paretic hand and during rest. During both pre- and postinjection scans, the paretic hand showed larger cerebellar activation during gripping compared with the nonparetic hand. Cerebellar activation during gripping with the nonparetic hand did not change significantly after Obtx-A injection.

CONCLUSIONS

Reducing spasticity via Obtx-A injection may increase cerebellar activation both during gripping tasks with the paretic hand and during rest. To our knowledge, this is the first study that examines changes in cerebellar activation after spasticity treatment with Obtx-A.

Systematic review of adjunct therapies to improve outcomes following botulinum toxin injection for treatment of limb spasticity

OBJECTIVE

To determine the quality of evidence from randomized controlled trials on the efficacy of adjunct therapies following botulinum toxin injections for limb spasticity.

DATA SOURCES

MEDLINE, EMBASE, CINAHL, and Cochrane Central Register of Controlled Trials electronic databases were searched for English language human studies from 1980 to 21 May 2015.

STUDY SELECTION

Randomized controlled trials assessing adjunct therapies postbotulinum toxin injection for treatment of spasticity were included. Of the 268 studies screened, 17 met selection criteria.

DATA EXTRACTION

Two reviewers independently assessed risk of bias using the Physiotherapy Evidence Database (PEDro) scale and graded according to Sackett's levels of evidence.

DATA SYNTHESIS

Ten adjunct therapies were identified. Evidence suggests that adjunct use of electrical stimulation, modified constraint-induced movement therapy, physiotherapy (all Level 1), casting and dynamic splinting (both Level 2) result in improved Modified Ashworth Scale scores by at least 1 grade. There is Level 1 and 2 evidence that adjunct taping, segmental muscle vibration, cyclic functional electrical stimulation, and motorized arm ergometer may not improve outcomes compared with botulinum toxin injections alone. There is Level 1 evidence that casting is better than taping, taping is better than electrical stimulation and stretching, and extracorporeal shock wave therapy is better than electrical stimulation for outcomes including the Modified Ashworth Scale, range of motion and gait. All results are based on single studies.

CONCLUSION

There is high level evidence to suggest that adjunct therapies may improve outcomes following botulinum toxin injection. No results have been confirmed by independent replication. All interventions would benefit from further study.

Cortical activation changes and improved motor function in stroke patients after focal spasticity therapy--an interventional study applying repeated fMRI

BACKGROUND

Impaired dominant hand function in stroke patients is a common clinical problem. Functional improvement after focal spasticity therapy is well documented but knowledge about central correlates is sparse. Brain activity was therefore followed during therapy with repeated functional magnetic resonance imaging (fMRI). The purpose was to analyse motor function and central nervous system (CNS) correlates in response to a standardized motor task in stroke patients after a comprehensive focal spasticity therapy.

METHODS

Six consecutive first-time chronic stroke patients [4 women; mean age (SD) 66 (10) years] with right-sided hand paresis and spasticity were studied. Peripheral effects after focal spasticity management including intramuscular botulinum toxin type A (BoNT-A) injections were assessed on 3 occasions (baseline, 6 and 12 weeks) with functional tests. Brain effects were assessed on the same occasions by fMRI blood oxygen level dependent (BOLD) technique during a standardized motor task focusing on the motor and pre-motor cortex (Brodmann areas, BA4a, BA4p & BA6). For reference 10 healthy individuals [5 women; mean age (SD) of 51(8) years], were studied twice with ≥ 6 weeks interval.

RESULTS

After therapy there was a significant reduction in spasticity and functional improvement in 5 of 6 patients. In response to the motor task there was a ~1.5 - 3% increase in brain activity in the motor and pre-motor cortex. At baseline, this increase was larger in the non-injured (ipsilateral) than in the contralateral hemisphere. Compared with healthy subjects the patients showed a significantly (2-4.5 times) higher brain activity, especially on the ipsilateral side. After therapy, there was a larger decrease in the ipsilateral and a minor decrease in the contralateral response, i.e. a clear lateralization of left-to-right in a normalizing direction in all areas.

CONCLUSIONS

Comprehensive focal spasticity management was also in this study associated with brain reorganization in a "normalizing" left/right lateralization direction in addition to improved motor function. Furthermore, quantification of BOLD intensity in specified BAs showed reduced neuronal "over-activity" in the injured brain after therapy.

Current uses of botulinum toxin A as an adjunct to hand therapy interventions of hand conditions

STUDY DESIGN

Literature review.

DISCUSSION

Botulinum toxin A, a neurotoxin causing temporary muscle paralysis at the neuromuscular junction, has been used to treat multiple acquired conditions of the hand and upper extremity. Initially approved for use in treating blepharospasm and strabismus in the 1980s, indications have expanded to include spasticity associated with cerebrovascular accidents, vasospastic disorders, focal dystonias, and pain conditions. This article reviews the current literature discussing the efficacy of botulinum toxin A in management of disorders of the hand and upper extremity relevant to hand therapists.

LEVEL OF EVIDENCE

NA.

Rehabilitation therapies after botulinum toxin-A injection to manage limb spasticity: a systematic review

BACKGROUND

Botulinum toxin A (BoNT-A) injections are increasingly used to treat muscle spasticity and are often complemented by adjunctive rehabilitation therapies; however, little is known about the effect of therapy after injection.

PURPOSE

The aim of this study was to identify and summarize evidence on rehabilitation therapies used after BoNT-A injections to improve motor function in adults with neurological impairments.

DATA SOURCES

Searches were conducted in PubMed, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL, National Research Register, metaRegistry of Controlled Trials, PEDro, and OTseeker.

STUDY SELECTION

Randomized and quasi-randomized controlled trials were considered for inclusion. Participants with neurological impairments received BoNT-A to treat focal spasticity in limbs, with rehabilitation interventions provided to experimental groups only. Primary outcome measures were joint mobility, function of the affected limb, and spasticity. Eleven studies with 234 participants, most of whom had stroke, were included in the review.

DATA EXTRACTION

Two reviewers extracted study details and data.

DATA SYNTHESIS

Methodological quality was rated using the PEDro scale. Both fixed-effects and random-effects models were used to calculate effect size.

RESULTS

Studies were of variable quality: 3 were poor (PEDro score 1 to 4), and 8 were moderate (PEDro score 6 to 7). No study investigated effects for longer than 24 weeks (6 months). Included trials presented 9 therapy types, including ergometer cycling, electrical stimulation, stretch (casting, splinting, taping, or manual or exercise-induced stretch), constraint-induced movement therapy, task-specific motor training, and exercise programs. Statistical findings suggest that combined therapy and BoNT-A is slightly more effective than BoNT-A alone.

CONCLUSION

Evidence relating to impact of adjunct therapy is available, but the heterogeneity of studies limits the opportunity to demonstrate overall impact. Researchers need to consider the benefits of greater consistency in study approaches and measures so that meaningful evaluations of overall adjunct therapy effects can be made.

Development of an Apparatus for Bilateral Rhythmical Training of Arm Movement Via Linear and Elliptical Trajectories of Various Directions

Clinical rehabilitation of individuals with various neurological disorders requires a significant number of movement repetitions in order to improve coordination and restoration of appropriate muscle activation patterns. Arm reaching movement is frequently practiced via motorized arm cycling ergometers where the trajectory of movement is circular thus providing means for practicing a single and rather nonfunctional set of muscle activation patterns, which is a significant limitation. We have developed a novel mechanism that in the combination with an existing arm ergometer device enables nine different movement modalities/trajectories ranging from purely circular trajectory to four elliptical and four linear trajectories where the direction of movement may be varied. The main objective of this study was to test a hypothesis stating that different movement modalities facilitate differences in muscle activation patterns as a result of varying shape and direction of movement. Muscle activation patterns in all movement modalities were assessed in a group of neurologically intact individuals in the form of recording the electromyographic (EMG) activity of four selected muscle groups of the shoulder and the elbow. Statistical analysis of the root mean square (RMS) values of resulting EMG signals have shown that muscle activation patterns corresponding to each of the nine movement modalities significantly differ in order to accommodate to variation of the trajectories shape and direction. Further, we assessed muscle activation patterns following the same protocol in a selected clinical case of hemiparesis. These results have shown the ability of the selected case subject to produce different muscle activation patterns as a response to different movement modalities which show some resemblance to those assessed in the group of neurologically intact individuals. The results of the study indicate that the developed device may significantly extend the scope of strength and coordination training in stroke rehabilitation which is in current clinical rehabilitation practice done through arm cycling.

Functional Brain Correlates of Upper Limb Spasticity and Its Mitigation following Rehabilitation in Chronic Stroke Survivors

Background. Arm spasticity is a challenge in the care of chronic stroke survivors with motor deficits. In order to advance spasticity treatments, a better understanding of the mechanism of spasticity-related neuroplasticity is needed. Objective. To investigate brain function correlates of spasticity in chronic stroke and to identify specific regional functional brain changes related to rehabilitation-induced mitigation of spasticity. Methods. 23 stroke survivors (>6 months) were treated with an arm motor learning and spasticity therapy (5 d/wk for 12 weeks). Outcome measures included Modified Ashworth scale, sensory tests, and functional magnetic resonance imaging (fMRI) for wrist and hand movement. Results. First, at baseline, greater spasticity correlated with poorer motor function (P = 0.001) and greater sensory deficits (P = 0.003). Second, rehabilitation produced improvement in upper limb spasticity and motor function (P < 0.0001). Third, at baseline, greater spasticity correlated with higher fMRI activation in the ipsilesional thalamus (rho = 0.49, P = 0.03). Fourth, following rehabilitation, greater mitigation of spasticity correlated with enhanced fMRI activation in the contralesional primary motor (r = -0.755, P = 0.003), premotor (r = -0.565, P = 0.04), primary sensory (r = -0.614, P = 0.03), and associative sensory (r = -0.597, P = 0.03) regions while controlling for changes in motor function. Conclusions. Contralesional motor regions may contribute to restoring control of muscle tone in chronic stroke.

BoNT-A related changes of cortical activity in patients suffering from severe hand paralysis with arm spasticity following ischemic stroke

BACKGROUND

Investigations were performed to localize and analyze the botulinum toxin (BoNT-A) related changes of cerebral cortex activation in chronic stroke patients suffering from severe hand paralysis with arm spasticity. Effects on task- related cerebral activation were evaluated by functional magnetic resonance imaging (fMRI).

METHODS

14 patients (5 males, 9 females, mean age 55.3 years) suffering from upper limb post-stroke spasticity were investigated. The change of arm spasticity was assessed by using the modified Ashworth scale (MAS). FMRI sessions were performed before (W0), four weeks (W4) and 11 weeks (W11) after BoNT-A application. Patients were scanned while performing imaginary movement with the impaired hand. Group fMRI analysis included patient age as a covariate.

RESULTS

BoNT-A treatment was effective in alleviation of arm spasticity. Mean MAS was at Week 0: 2.5 (SD 0.53), at Week 4: 1.45 (SD 0.38), at Week 11: 2.32 (SD 0.44). Task-related fMRI prior to the treatment showed extensive activation of bilateral frontoparietal sensorimotor cortical areas, anterior cingulate gyrus, pallidum, thalamus and cerebellum. Effective BoNT-A treatment (W4) resulted in partial reduction of active network volume in most of the observed areas, whereas BoNT-free data (W11) revealed further volume reduction in the sensorimotor network. On direct comparison, significant activation decreases associated with BoNT-A treatment were located in areas outside the classical sensorimotor system, namely, ipsilesional lateral occipital cortex, supramarginal gyrus and precuneus cortex. On comparison of W4 and W11, no activation increases were found, instead, activation further decreased in ipsilesional insular cortex, contralesional superior frontal gyrus and bilateral frontal pole.

CONCLUSIONS

Whole brain activation patterns during BoNT-A treatment of post-stroke arm spasticity and further follow up document predominantly gradual changes both within and outside the classical sensorimotor system.

Cortical activation changes in patients suffering from post-stroke arm spasticity and treated with botulinum toxin a

BACKGROUND AND PURPOSE

Botulinum toxin (BoNT) treatment relieves focal arm spasticity after stroke, likely acting at several hierarchical levels of the motor system. The central correlate of BoNT-induced spasticity relief may be detected using repeated functional MRI (fMRI) during motor task.

METHODS

Five patients (4 males, 1 female, mean age 67 years) with hemiparesis and distal arm spasticity after chronic ischemic stroke were studied. FMRI was performed while moving the paretic hand in three sessions: before and 4 and 11 weeks after BoNT treatment.

RESULTS

Arm spasticity significantly decreased following BoNT treatment across the group (mean modified Ashworth scale change .6). FMRI prior to BoNT treatment showed extensive bilateral active networks, whereas post-BoNT activation was limited to midline and contralateral sensorimotor cortices, and the third examination, when the toxin effect has worn off, again showed extensive activation similar to pre-BoNT examination. Post-BoNT session 2 compared to sessions 1 and 3 demonstrated a significantly less activation in contralateral frontoparietal areas including inferior frontal, postcentral, and middle frontal gyri as well as transient crossed cerebellar activation.

CONCLUSION

Relief of post-stroke arm spasticity may be associated with changes at several hierarchical levels of the cortical sensorimotor system, including the prefrontal cortex.

Botulinum Toxin Effect on Voluntary and Stretch Reflex–Related Torque Produced by the Quadriceps

Background. An understanding of the mechanical effects of botulinum toxin type A (BoNT A) on spastic and voluntary muscle contraction may help predict functional responders. Objective. To compare the effect of BoNT A on the voluntary and stretch reflex–related torques produced by activation of the rectus femoris (RF). Methods. This was a prospective open study where 15 incomplete spinal cord injury patients, impaired by a stiff-knee gait, with RF hyperactivity in mid-swing quantified by formal gait analysis (GA), were assessed before and after RF BoNT A injection (Botox, 200 UI). Main outcome measures included isokinetic peak torque (and angle at peak torque) at 0° (supine) and 90° (seated) during passive stretch (10 deg/s, 90 deg/s, and 150 deg/s), and voluntary contraction (60 deg/s) of the quadriceps. Secondary measures included impairment by Modified Tardieu Scale (MTS), peak knee flexion and spatial-temporal data by GA, activity (6-minute walking test, timed stair climbing), and discomfort (Verbal Rating Scale). Results. Voluntary torque decreased (−16%; P = .0004) but with only a trend toward a decrease in stretch reflex–related torque. The angle at spastic torque increased at 90 deg/s (+5°; P = .03), whereas MTS, peak knee flexion (+4°; P = .01), spatial-temporal data, timed stair climbing test (25%; P = .02), and discomfort were significantly improved. Conclusion. BoNT A appeared to delay the stretch-reflex angle at peak torque, whereas the voluntary torque decreased. After strict patient selection, BoNT A injection into the RF muscle led to improvements in impairment, activity, and discomfort.