Successful treatment of long-term, poststroke, upper-limb spasticity with onabotulinumtoxinA

High clinician- and patient-reported satisfaction with individualized onabotulinumtoxinA treatment for spasticity across several etiologies from the ASPIRE study

Etiology-specific onabotulinumtoxinA utilization to manage spasticity is largely unknown. In this 1-year interim analysis, we evaluated real-world onabotulinumtoxinA utilization and effectiveness across several etiologies from the Adult Spasticity International Registry (ASPIRE) study. ASPIRE is a multicenter, prospective, observational registry (NCT01930786) examining stroke, multiple sclerosis [MS], cerebral palsy [CP], traumatic brain injury [TBI], and spinal cord injury [SCI] patients with spasticity treated with onabotulinumtoxinA at the clinician's discretion. Assessments included onabotulinumtoxinA utilization (each session), clinician (subsequent session)/patient (5±1 weeks post-treatment) satisfaction, and the Disability Assessment Scale (DAS; subsequent session). 730 patients received ≥1 onabotulinumtoxinA treatment, with 37% naïve to botulinum toxin(s) for spasticity. The most common etiology was stroke (n=411, 56%), followed by MS (N=119, 16%), CP (N=77, 11%), TBI (N=45, 6%), and SCI (N=42, 6%). The total body mean cumulative dose (±SD) of onabotulinumtoxinA per session ranged from 296 U (±145) in CP to 406 U (±152) in TBI. The most commonly treated upper limb presentations were clenched fist (stroke, MS, and SCI), flexed wrist (CP), and flexed elbow (TBI). Equinovarus foot was the most commonly treated lower limb presentation in all etiologies. Stroke patients showed improved DAS scores for nearly all subscales in both limbs, indicative of improved global function. All etiologies showed improved lower limb mobility DAS scores. Across all sessions, clinicians (range: 87.4% [SCI]-94.2% [CP]) and patients (range: 67.6% [TBI]-89.7% [SCI]) reported extreme satisfaction/satisfaction that onabotulinumtoxinA helped manage spasticity, and clinicians (range: 94.6% [TBI]-98.8% [CP]) and patients (range: 88.4% [stroke]-91.2% [TBI]) would definitely/probably continue treatment. Treatment-related adverse events (TRAEs) and treatment-related serious adverse events (TRSAEs) were reported as follows: stroke: 10 TRAEs (2.2% patients), 3 TRSAEs (0.5%); MS: 5 TRAEs (4.2%), 0 TRSAEs; CP: 0 TRAEs, 0 TRSAEs; TBI: 1 TRAEs (2.2%), 0 TRSAEs; SCI: 0 TRAEs, 0 TRSAEs. No new safety signals were identified. High clinician- and patient-reported satisfaction were observed following individualized onabotulinumtoxinA treatment, as well as improved global function. Interim results from ASPIRE demonstrate etiology-specific similarities and differences in clinical approaches to manage spasticity.

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ASPIRE found etiology-specific similarities and differences in real-world onabotulinumtoxinA utilization for spasticity.

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Across all etiologies, there was high clinician- and patient-reported satisfaction with onabotulinumtoxinA treatment.

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In DAS, all etiologies showed improved global function in lower limb mobility following onabotulinumtoxinA treatment.

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Adverse event data varied by etiology of spasticity; however, no new safety signals were identified.

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ASPIRE data may guide clinical strategies and educational programs to improve onabotulinumtoxinA spasticity management.

A Novel Quantitative Spasticity Evaluation Method Based on Surface Electromyogram Signals and Adaptive Neuro Fuzzy Inference System

Stroke patients often suffer from spasticity. Before treatment of spasticity, there are often practical demands for objective and quantitative assessment of muscle spasticity. However, the common quantitative spasticity assessment method, the tonic stretch reflex threshold (TSRT), is time-consuming and complicated to implement due to the requirement of multiple passive stretches. To evaluate spasticity conveniently, a novel spasticity evaluation method based on surface electromyogram (sEMG) signals and adaptive neuro fuzzy inference system (i.e., the sEMG-ANFIS method) was presented in this paper. Eleven stroke patients with spasticity and four healthy subjects were recruited to participate in the experiment. During the experiment, the Modified Ashworth scale (MAS) scores of each subject was obtained and sEMG signals from four elbow flexors or extensors were collected from several times (4–5) repetitions of passive stretching. Four time-domain features (root mean square, the zero-cross rate, the wavelength and a 4th-order autoregressive model coefficient) and one frequency-domain feature (the mean power frequency) were extracted from the collected sEMG signals to reflect the spasticity information. Using the ANFIS classifier, excellent regression performance was achieved [mean accuracy = 0.96, mean root-mean-square error (RMSE) = 0.13], outperforming the classical TSRT method (accuracy = 0.88, RMSE = 0.28). The results showed that the sEMG-ANFIS method not only has higher accuracy but also is convenient to implement by requiring fewer repetitions (4–5) of passive stretches. The sEMG-ANFIS method can help stroke patients develop proper rehabilitation training programs and can potentially be used to provide therapeutic feedback for some new spasticity interventions, such as shockwave therapy and repetitive transcranial magnetic stimulation.

Individualized OnabotulinumtoxinA Treatment for Upper Limb Spasticity Resulted in High Clinician- and Patient-Reported Satisfaction: Long-Term Observational Results from the ASPIRE Study

Introduction

OnabotulinumtoxinA treatment for spasticity is dependent on numerous factors and varies according to selected treatment goals.

Objective

To examine real‐world onabotulinumtoxinA treatment utilization and effectiveness in patients with upper limb spasticity over 2 years from the Adult Spasticity International Registry (ASPIRE) study.

Design

Multicenter, prospective, observational registry (NCT01930786).

Setting

Fifty‐four international clinical sites in North America, Europe, and Asia.

Patients

Adults (naïve or non‐naïve to botulinum toxins for spasticity) with upper limb focal spasticity related to upper motor neuron syndrome across multiple etiologies.

Interventions

OnabotulinumtoxinA administered at clinician's discretion.

Main Outcome Measures

OnabotulinumtoxinA utilization, clinician and patient satisfaction.

Results

Four hundred eighty‐four patients received ≥1 treatment of onabotulinumtoxinA for upper limb spasticity. Patients were on average 55.1 years old, 50.8% male, predominantly Caucasian (72.3%), and 38.6% were naïve to botulinum toxins. Stroke was the most frequently reported underlying etiology (74.0%). Most patients (81.2%) had moderate to severe spasticity at baseline. The most commonly treated upper limb clinical presentation was clenched fist (79.1% of patients). Across all presentations, onabotulinumtoxinA doses ranged between 5‐600U. Electromyography (EMG) was most often utilized to localize muscles (≥57.0% of treatment sessions). Clinicians (92.9% of treatment sessions) and patients (85.7%) reported being extremely satisfied/satisfied that treatment helped manage spasticity, and clinicians (98.6%) and patients (92.2%) would definitely/probably continue onabotulinumtoxinA treatment. One hundred seventy‐nine patients (37.0%) reported 563 adverse events (AEs); 15 AEs in 14 patients (2.9%) were considered treatment related. Sixty‐nine patients (14.3%) reported 137 serious AEs; 3 serious AEs in 2 patients (0.4%) were considered treatment related. No new safety signals were identified.

Conclusions

ASPIRE captured the real‐world individualized nature of onabotulinumtoxinA utilization for upper limb spasticity over 2 years, with consistently high clinician‐ and patient‐reported satisfaction. Data in this primary analysis will guide clinical use of onabotulinumtoxinA, as well as provide insights to improve educational programs on spasticity management.

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.

Botulinum toxin A injection in the management of shoulder muscle overactivity: A scoping review

The majority of studies examining botulinum toxin A (BTX-A) in the management of upper limb muscle overactivity and pain focus on the distal arm and hand. Research has begun to look at BTX-A efficacy in more proximal upper limb muscles, with literature showing equivocal findings. This scoping review identified 15 studies meeting inclusion criteria whose data were examined against three outcome variables: muscle overactivity, range of movement and pain. Overall, while the majority of injected participants improved on these variables, between-study methodological variability such as research design potentially underpowered studies and arbitrary decision making gave a high likelihood of influencing the interpretation of their results. Future research is warranted, with a robust focus on functional anatomy, a critical appraisal of how BTX-A may help the individual being studied and utilising individualised rather than protocol-driven research paradigms.

Ultrasound Elastography to Assess Botulinum Toxin A Treatment for Post-stroke Spasticity: A Feasibility Study

The aim of the study was to evaluate the feasibility of using ultrasound elastography to assess the effect of botulinum toxin A (BoNT-A) treatment on post-stroke spasticity of the upper limb. In this prospective study, we performed ultrasound elastography (strain imaging and acoustic radiation force impulse-based shear wave elastography) of the spastic biceps brachii muscle in seven patients (five men and two women, mean age: 45y) who underwent BoNT-A injection treatment for post-stroke spasticity of the upper limb. We measured ultrasound elasticity parameters including axial strain ratio (SR) (SR = muscle strain/reference strain), longitudinal SR and shear wave velocity of the biceps muscle immediately before and 17-30 d (mean: 22 d) after BoNT-A injection. Statistical analyses included a two-tailed paired t-test to examine the difference in ultrasound elasticity parameters of bilateral biceps muscles before and after BoNT-A treatment and a Spearman rank correlation coefficient (r_s) to analyze the correlation of ultrasound elasticity parameters to clinical assessment with the Modified Ashworth Scale (MAS) and Tardieu Scale (TS). The difference in ultrasound elasticity parameters before and after BoNT-A treatment was significant (p < 0.05) in the treated spastic muscle. The correlation of ultrasound elasticity parameters with MAS and the angle of catch and range of motion in TS were also significant (r_s = 0.55-0.95, p < 0.05). Our results suggest that ultrasound elastography is feasible in assessment of the effectiveness of BoNT-A treatment for post-stroke spasticity of the upper limb.

Side effects and potential risk factors of botulinum toxin type A intramuscular injections in knee flexion contractures of hemophiliacs

INTRODUCTION

Knee flexion contracture (KFC) is a common complication of recurrent hemarthrosis in children and young adults with hemophilia. If the KFC is not prevented (by means of primary prophylaxis) and treated properly and early (be means of physical medicine and rehabilitation), it will become fixed. Areas covered: The aim of this article is to review the potential role of botulinum toxin type A (BTX-A) intramuscular injections for the treatment of KFC in people with hemophilia (PWH). Expert commentary: Although two recent reports have mentioned the benefits of intramuscular injections of BTX-A in PWH with KFC, the data are still scant and too preliminary. The use of intramuscular injections of BTX-A in PWH today should not be recommended until more case studies/small series (ideally well-designed clinical trials) fully demonstrate that this is safe and effective. The risks of intramuscular injections to a hemophilia patient cannot be underestimated (iatrogenic muscle hematomas and pseudotumors). This paper calls the attention of hemophilia treaters on the potential risks of this apparently interesting technique. The current use of BTX-A intramuscular injections in KFC of PWH could make no sense. Raising false expectations in these patients should be avoided.

Upper limb spasticity management for patients who have received Botulinum Toxin A injection: Australian therapy practice

BACKGROUND/AIM

To describe Australian physiotherapy and occupational therapy practice for patients who receive upper-limb Botulinum Toxin-A (BoNT-A).

METHOD

Anonymous online survey asking about practice experience. Convenience sample of 128 BoNT-A experienced occupational therapists and physiotherapists.

RESULTS

The primary work setting was multidisciplinary inpatient or outpatient rehabilitation services where therapists had automatic referral to BoNT-A patients. Patients expected BoNT-A to improve functional movement, reduce hypertonicity, increase passive range, reduce pain, improve appearance and hand hygiene. Most patients were injected in multidisciplinary public hospital clinics and had median 2 pre-injection (range 0-30) and 8 post-injection (range 0-50) therapy sessions. Biceps, flexor digitorum profundus/superficialis and brachoradialis were most frequently injected. Injectors used therapist assessment information to select sites 68% of the time; only 44% of services had assessment protocols. Standardised therapy assessments examined motor performance, pain and function in that order of frequency. The greater the awareness and perceived relevance of an assessment the more often therapists used it. All therapists set goals, most collaboratively, and these mirrored patient expectations. The most common treatments were stretch, task-specific functional training, strength training and home programmes.

CONCLUSION

While trends in Australian assessment, goals and treatment practice were observed, greater consistency could be achieved if therapy practice guidelines existed. The gap is exacerbated by the absence of Australian BoNT-A organisation and process of care spasticity management guidelines. This creates an environment where practice variability is inevitable. Recommendations to improve local service quality are made.

Use of injectable spasticity management agents in a cancer center

PURPOSE

This study aims to analyze the utilization and effectiveness of injectable spasticity medications by the physiatry team at a referral-based tertiary cancer center.

METHODS

A retrospective review and analysis of patient and injection characteristics were obtained from patients who had received onabotulinum toxin or phenol nerve block injections from December 1, 2007 through January 31, 2012. Out of 3,724 physiatry consultations during this period, 20 (less than 1 %) different cancer patients received a total of 54 total procedures.

RESULTS

The majority of patients (17/20, 85 %) had a positive response to the injection. A positive response to the injection was defined by: (1) if the patient qualified to receive and was given another injection or (2) if there is a record of improvement if they did not receive another injection. A total of ten of 20 (50 %) patients received only one injection. Of these, seven of ten (70 %) reported a positive response to the injected agent. Those with only one injection tended to live farther away and die sooner. Four of 54 (7 %) injection procedures resulted in undesirable reported side effects (two for phenol, two for botulinum toxin). Nine of 54 (17 %) procedures occurred while the patients were on a chemotherapy protocol. All patients were injected at least 1 year out from initial diagnosis.