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Vázquez Doce A, De León García FJ, Mena A, Ortiz-Fernández L, Spottorno MP, Medina F, Maisonobe P, Herrera A, García I, Juan-García FJ. Assessment of pain relief after four botulinum toxin A injection cycles in patients with post-stroke lower limb spasticity: A prospective, observational study. Rehabilitacion (Madr) 2024; 58:100856. [PMID: 38795502 DOI: 10.1016/j.rh.2024.100856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 02/06/2024] [Accepted: 04/27/2024] [Indexed: 05/28/2024]
Abstract
INTRODUCTION Spasticity is common after a stroke and is an independent risk factor for developing pain. BotulinumtoxinA injection is the treatment of choice for focal spasticity. We examined the effect of intramuscular botulinumtoxinA on pain relief in patients in routine clinical practice who were experiencing pain as a primary complaint associated with post-stroke lower limb spasticity. METHODS Prospective, multicentre, post-marketing observational study. The study period was 16 months. The primary effectiveness variable was the mean change from baseline on the pain 0-10 Numerical Rating Scale after four botulinumtoxinA injection cycles. Secondary endpoints included changes from baseline on the pain 0-100 Visual Analogue Scale, Goal Attainment Scale, modified Ashworth Scale, 10-Meter Walk Test, Penn Spasm Frequency Scale, and 36-item Short-Form Health Survey. RESULTS Of 186 enrolled patients, 180 (96.8%) received botulinumtoxinA at least once. The mean (standard deviation) pain 0-10 Numerical Rating Scale score decreased significantly (p<0.0001) from 4.9 (2.2) at baseline to 2.5 (2.1) at study end, representing a 50% decrease in pain severity. Relief of pain due to spasticity was supported by improvement from baseline in all secondary variables except the 10-Meter Walk Test. Two adverse events (erysipelas and phlebitis) in one patient were considered likely to be related to botulinumtoxinA injection. CONCLUSION BotulinumtoxinA appears to provide pain relief as an additional benefit of local treatment in patients with post-stroke lower limb spasticity for whom pain relief is a primary therapeutic goal (a Lay Abstract has been provided as Appendix A).
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Affiliation(s)
- A Vázquez Doce
- Physical Medicine and Rehabilitation Department, Hospital Universitario de La Princesa, Madrid, Spain
| | - F J De León García
- Physical Medicine and Rehabilitation Department, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | - A Mena
- Physical Medicine and Rehabilitation Department, Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas de Gran Canaria, Las Palmas, Spain
| | - L Ortiz-Fernández
- Physical Medicine and Rehabilitation Department, Cruces University Hospital - Osakidetza-Basque Health Service, Barakaldo, Spain
| | - M P Spottorno
- Physical Medicine and Rehabilitation Department, Hospital Universitario de La Princesa, Madrid, Spain
| | - F Medina
- Physical Medicine and Rehabilitation Department, Complejo Hospitalario, Universitario Materno Infantil Gran Canaria, Las Palmas de Gran Canaria, Las Palmas, Spain
| | - P Maisonobe
- Biometry, Ipsen, Boulogne-Billancourt, France
| | - A Herrera
- Medical Affairs, Ipsen, Torre Realia BCN, L'Hospitalet de Llobregat, Barcelona, Spain
| | - I García
- Medical Affairs, Ipsen, Torre Realia BCN, L'Hospitalet de Llobregat, Barcelona, Spain
| | - F J Juan-García
- Physical Medicine and Rehabilitation Department, Área Sanitaria de Vigo, Hospital Meixoeiro, Vigo, Pontevedra, Spain.
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Suputtitada A, Chatromyen S, Chen CPC, Simpson DM. Best Practice Guidelines for the Management of Patients with Post-Stroke Spasticity: A Modified Scoping Review. Toxins (Basel) 2024; 16:98. [PMID: 38393176 PMCID: PMC10892074 DOI: 10.3390/toxins16020098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Revised: 01/19/2024] [Accepted: 02/07/2024] [Indexed: 02/25/2024] Open
Abstract
This article aims to provide a concise overview of the best available evidence for managing post-stroke spasticity. A modified scoping review, conducted following the PRISMA guidelines and the PRISMA Extension for Scoping Reviews (PRISMA-ScR), involved an intensive search on Medline and PubMed from 1 January 2000 to 31 August 2023. The focus was placed on high-quality (GRADE A) medical, rehabilitation, and surgical interventions. In total, 32 treatments for post-stroke spasticity were identified. Two independent reviewers rigorously assessed studies, extracting data, and evaluating bias using GRADE criteria. Only interventions with GRADE A evidence were considered. The data included the study type, number of trials, participant characteristics, interventions, parameters, controls, outcomes, and limitations. The results revealed eleven treatments supported by GRADE A evidence, comprising 14 studies. Thirteen were systematic reviews and meta-analyses, and one was randomized control trial. The GRADE A treatments included stretching exercises, static stretching with positional orthosis, transcutaneous electrical nerve stimulation, extracorporeal shock wave therapy, peripheral magnetic stimulation, non-invasive brain stimulation, botulinum toxin A injection, dry needling, intrathecal baclofen, whole body vibration, and localized muscle vibration. In conclusion, this modified scoping review highlights the multimodal treatments supported by GRADE A evidence as being effective for improving functional recovery and quality of life in post-stroke spasticity. Further research and exploration of new therapeutic options are encouraged.
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Affiliation(s)
- Areerat Suputtitada
- Department of Rehabilitation Medicine, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Rama 4 Road, Patumwan, Bangkok 10330, Thailand
- Principles and Practice of Clinical Research (PPCR) Program, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
| | - Supattana Chatromyen
- Neurological Institute of Thailand, Department of Medical Services, Ministry of Public Health, Bangkok 10400, Thailand;
| | - Carl P. C. Chen
- Department of Physical Medicine & Rehabilitation, Chang Gung Memorial Hospital at Linkou, College of Medicine, Chang Gung University, Guishan District, Taoyuan City 33343, Taiwan;
| | - David M. Simpson
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York City, NY 10029, USA;
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Ni P, Xu YY, Wang LN, Cao JQ, Luo WF, Zhang QL, Li X, Zhou XP, Liu J. Evaluation of therapeutic benefits of botulinum toxin for foot dystonia associated with Parkinson's disease. Toxicon 2024; 238:107587. [PMID: 38142904 DOI: 10.1016/j.toxicon.2023.107587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 12/20/2023] [Accepted: 12/21/2023] [Indexed: 12/26/2023]
Abstract
BACKGROUND Foot dystonia occurs in patients with Parkinson's disease (PD) and leads to pain, malformation, and difficulty with walking. Botulinum toxin injections may be effective for foot dystonia, but the extent of improvement and effects on motor function are unclear. METHODS In this study, we performed botulinum toxin injections for foot dystonia in 25 patients with PD. At 3 weeks and 3 months post-infection, we assessed changes in plantar pressure distribution utilizing the Pressure Plate system; dystonia using the Modified Ashworth Spasm score; pain using the visual analog scale (VAS) score; and lower extremity function using the Calf-raise Senior (CRS) test, Timed Up and Go (TUG) test, and gait parameters (eg, stride length, step length). RESULTS We found improved Modified Ashworth Spasm score (p < 0.01) and VAS score (p < 0.01) post-injection. CRS test score (3 weeks, p = 0.006; 3 months, p = 0.068), stride length (3 weeks, p = 0.012; 3 months, p = 0.715), and step length (3 weeks, p = 0.011; 3 months, p = 0.803) also improved. Plantar pressure distribution improved after botulinum toxin injection (metatarsal 1, 3 weeks, p = 0.031; 3 months, p = 0.144; metatarsal 2, 3 weeks, p = 0.049; 3 months, p = 0.065; metatarsal 3, 3 weeks, p = 0.002; 3 months, p = 0.017; metatarsal 4, 3 weeks, p = 0.017; 3 months, p = 0.144; medial heel, 3 weeks, p = 0.01; 3 months, p = 0.395; lateral heel, 3 weeks, p = 0.035; 3 months, p = 0.109). CONCLUSION Botulinum toxin injection for foot dystonia in patients with PD can reduce spasms and pain and normalize plantar pressure distribution, which improves balance and lower extremity function.
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Affiliation(s)
- Ping Ni
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Ying-Ying Xu
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Lin-Na Wang
- Lanzhou Biotechnique Development Co., LTD, China
| | - Jia-Qian Cao
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Wei-Feng Luo
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China; Jiangsu Key Laboratory of Translational Research and Therapy for Neuro-Psychiatric-Diseases, Soochow University, Suzhou, China
| | - Qi-Lin Zhang
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Xiang Li
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Xu-Ping Zhou
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China.
| | - Jing Liu
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China; Jiangsu Key Laboratory of Neuropsychiatric Diseases and Institute of Neuroscience, Soochow University, Suzhou, Jiangsu, 215123, China.
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Bumbea AM, Rogoveanu OC, Turcu-Stiolica A, Pirici I, Cioroianu G, Stanca DI, Criciotoiu O, Biciusca V, Traistaru RM, Caimac DV. Management of Upper-Limb Spasticity Using Modern Rehabilitation Techniques versus Botulinum Toxin Injections Following Stroke. Life (Basel) 2023; 13:2218. [PMID: 38004358 PMCID: PMC10672122 DOI: 10.3390/life13112218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 11/04/2023] [Accepted: 11/08/2023] [Indexed: 11/26/2023] Open
Abstract
Our purpose is to emphasize the role of botulinum toxin in spasticity therapy and functional recovery in patients following strokes. Our retrospective study compared two groups, namely ischemic and hemorrhagic stroke patients. The study group (BT group) comprised 80 patients who received focal botulinum toxin as therapy for an upper limb with spastic muscle three times every three months. The control group (ES group) comprised 80 patients who received only medical rehabilitation consisting of electrostimulation and radial shockwave therapy for the upper limb, which was applied three times every three months. Both groups received the same stretching program for spastic muscles as a home training program. We evaluated the evolution of the patients using muscle strength, Ashworth, Tardieu, Frenchay, and Barthel scales. The analysis indicated a statistically significant difference between the two groups for all scales, with better results for the BT group (p < 0.0001 for all scales). In our study, the age at disease onset was an important prediction factor for better recovery in both groups but not in all scales. Better recovery was obtained for younger patients (in the BT group, MRC scale: rho = -0.609, p-value < 0.0001; Tardieu scale: rho = -0.365, p-value = 0.001; in the ES group, MRC scale: rho = -0.445, p-value < 0.0001; Barthel scale: rho = -0.239, p-value = 0.033). Our results demonstrated the effectiveness of botulinum toxin therapy compared with the rehabilitation method, showing a reduction of the recovery time of the upper limb, as well as an improvement of functionality and a reduction of disability. Although all patients followed a specific kinetic program, important improvements were evident in the botulinum toxin group.
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Affiliation(s)
- Ana Maria Bumbea
- Department of Physical Medicine and Rehabilitation, University of Medicine and Pharmacy of Craiova, Petru Rares 2, 200349 Craiova, Romania; (A.M.B.); (O.C.R.)
| | - Otilia Constantina Rogoveanu
- Department of Physical Medicine and Rehabilitation, University of Medicine and Pharmacy of Craiova, Petru Rares 2, 200349 Craiova, Romania; (A.M.B.); (O.C.R.)
| | - Adina Turcu-Stiolica
- Department of Pharmacoeconomics, University of Medicine and Pharmacy of Craiova, Petru Rares 2, 200349 Craiova, Romania;
| | - Ionica Pirici
- Department of Anatomy, University of Medicine and Pharmacy of Craiova, Petru Rares 2, 200349 Craiova, Romania
| | - George Cioroianu
- Doctoral School, University of Medicine and Pharmacy of Craiova, Petru Rares 2, 200349 Craiova, Romania;
| | - Diana Iulia Stanca
- Department of Neurology, University of Medicine and Pharmacy of Craiova, Petru Rares 2, 200349 Craiova, Romania;
| | - Oana Criciotoiu
- Department of Neurology, University of Medicine and Pharmacy of Craiova, Petru Rares 2, 200349 Craiova, Romania;
| | - Viorel Biciusca
- Department of Internal Medicine, University of Medicine and Pharmacy of Craiova, Petru Rares 2, 200349 Craiova, Romania;
| | - Rodica Magdalena Traistaru
- Medical Rehabilitation Department, Nursing Faculty, University of Medicine and Pharmacy, Petru Rares 2, 200349 Craiova, Romania; (R.M.T.); (D.V.C.)
| | - Danut Visarion Caimac
- Medical Rehabilitation Department, Nursing Faculty, University of Medicine and Pharmacy, Petru Rares 2, 200349 Craiova, Romania; (R.M.T.); (D.V.C.)
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Dorner MB, Wilking H, Skiba M, Wilk L, Steinberg M, Worbs S, Çeken S, Kaygusuz S, Simon S, Becher F, Mikolajewska A, Kornschober C, Bütler T, Jourdan-Da-Silva N, An der Heiden M, Schaade L, Stark K, Dorner BG, Frank C. A large travel-associated outbreak of iatrogenic botulism in four European countries following intragastric botulinum neurotoxin injections for weight reduction, Türkiye, February to March 2023. Euro Surveill 2023; 28:2300203. [PMID: 37289431 PMCID: PMC10318948 DOI: 10.2807/1560-7917.es.2023.28.23.2300203] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 05/14/2023] [Indexed: 06/09/2023] Open
Abstract
In March 2023, 34 associated cases of iatrogenic botulism were detected in Germany (30 cases), Switzerland (two cases), Austria (one case), and France (one case). An alert was rapidly disseminated via European Union networks and communication platforms (Food- and Waterborne Diseases and Zoonoses Network, EpiPulse, Early Warning and Response System) and the International Health Regulation mechanism; the outbreak was investigated in a European collaboration. We traced sources of the botulism outbreak to treatment of weight loss in Türkiye, involving intragastric injections of botulinum neurotoxin. Cases were traced using a list of patients who had received this treatment. Laboratory investigations of the first 12 German cases confirmed nine cases. The application of innovative and highly sensitive endopeptidase assays was necessary to detect minute traces of botulinum neurotoxin in patient sera. The botulism notification requirement for physicians was essential to detect this outbreak in Germany. The surveillance case definition of botulism should be revisited and inclusion of cases of iatrogenic botulism should be considered as these cases might lack standard laboratory confirmation yet warrant public health action. Any potential risks associated with the use of botulinum neurotoxins in medical procedures need to be carefully balanced with the expected benefits of the procedure.
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Affiliation(s)
- Martin Bernhard Dorner
- Biological Toxins (ZBS3), Centre for Biological Threats and Special Pathogens, Robert Koch Institute, Berlin, Germany
| | - Hendrik Wilking
- Department for Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany
| | - Martin Skiba
- Biological Toxins (ZBS3), Centre for Biological Threats and Special Pathogens, Robert Koch Institute, Berlin, Germany
| | - Laura Wilk
- Biological Toxins (ZBS3), Centre for Biological Threats and Special Pathogens, Robert Koch Institute, Berlin, Germany
| | - Maximilian Steinberg
- Biological Toxins (ZBS3), Centre for Biological Threats and Special Pathogens, Robert Koch Institute, Berlin, Germany
| | - Sylvia Worbs
- Biological Toxins (ZBS3), Centre for Biological Threats and Special Pathogens, Robert Koch Institute, Berlin, Germany
| | - Sabahat Çeken
- General Directorate of Public Health, Ministry of Health, Ankara, Türkiye
| | - Sedat Kaygusuz
- General Directorate of Public Health, Ministry of Health, Ankara, Türkiye
| | - Stéphanie Simon
- Université Paris Saclay, Commissariat à l'énergie atomique et aux énergies alternatives (CEA), Institut national de recherche pour l'agriculture, l'alimentation et l'environnement (INRAE), Département Médicaments et Technologies pour la Santé (DMTS), SPI, Gif-sur-Yvette, France
| | - François Becher
- Université Paris Saclay, Commissariat à l'énergie atomique et aux énergies alternatives (CEA), Institut national de recherche pour l'agriculture, l'alimentation et l'environnement (INRAE), Département Médicaments et Technologies pour la Santé (DMTS), SPI, Gif-sur-Yvette, France
| | - Agata Mikolajewska
- Strategy and Incident Response (ZBS7), Centre for Biological Threats and Special Pathogens, Robert Koch Institute, Berlin, Germany
| | | | - Timo Bütler
- National International Health Regulation (IHR) Focal Point for Switzerland, Swiss Federal Office of Public Health, Division of Communicable Diseases, Bern, Switzerland
| | | | - Maria An der Heiden
- Department for Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany
| | - Lars Schaade
- Centre for Biological Threats and Special Pathogens, Robert Koch Institute, Berlin, Germany
| | - Klaus Stark
- Department for Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany
| | - Brigitte Gertrud Dorner
- Biological Toxins (ZBS3), Centre for Biological Threats and Special Pathogens, Robert Koch Institute, Berlin, Germany
- These authors contributed equally to the work and share the last authorship
| | - Christina Frank
- These authors contributed equally to the work and share the last authorship
- Department for Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany
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The Efficacy of Transvaginal Ultrasound-Guided BoNT-A External Sphincter Injection in Female Patients with Underactive Bladder. Toxins (Basel) 2023; 15:toxins15030199. [PMID: 36977090 PMCID: PMC10057054 DOI: 10.3390/toxins15030199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 02/25/2023] [Accepted: 02/27/2023] [Indexed: 03/08/2023] Open
Abstract
Owing to the diverse treatment outcomes after a botulinum toxin A (BoNT-A) injection to the external sphincter, this study aimed to develop a new technique: an ultrasound-guided BoNT-A external sphincter injection. This single-center prospective cohort study was conducted at a tertiary medical center in Taichung, Taiwan. From December 2020 to September 2022, 12 women were enrolled. The patients were evaluated for lower urinary tract syndrome using patient perception of bladder condition (PPBC), international prostate symptom score (IPSS), uroflowmetry, post-void residual volume (PVR), cystometry, and external sphincter electromyography. We evaluated the patients the day before surgery and 1 week after the BoNT-A injection. For the patients requiring self-catheterization, we recorded the number of times they required clean intermittent catheterization (CIC) per day before the procedure and 1 month after the procedure. The IPSS, PPBC, and PVR were significantly better after the transvaginal ultrasound-guided BoNT-A external sphincter injection. The number of times the patients required daily CIC was also reduced after the injection. Only one patient developed de novo urge urinary incontinence. Our results demonstrated that a transvaginal ultrasound-guided BoNT-A injection was efficacious and safe in the treatment of underactive bladder.
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Takekawa T, Hara T, Yamada N, Sato T, Hasegawa Y, Takagi S, Kobayashi K, Kitajima T, Abo M. Treatment outcome of local injection of botulinum toxin for claw toe: Differences between cerebral hemorrhage and infarction. Clin Neurol Neurosurg 2023; 226:107620. [PMID: 36805253 DOI: 10.1016/j.clineuro.2023.107620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 01/20/2023] [Accepted: 02/06/2023] [Indexed: 02/11/2023]
Abstract
BACKGROUND Some patients with post-stroke claw toe respond well to botulinum toxin (BoNT) treatment while others do not. This study was designed to assess the impact of stroke type (cerebral hemorrhage and cerebral infarction) on the outcome of BoNT treatment for claw toe. METHODS We retrospectively examined the medical records of patients who received local BoNT (onabotulinumtoxin A) injections into the flexor hallucis longus (FHL) and flexor digitorum longus (FDL) muscles. All patients suffered stroke-related leg paralysis and spasticity. RESULTS The study participants were 58 patients (mean age, 61.4 ± 10.3 years, ± SD) with time since stroke of 6.7 ± 4.4 years. The stroke type was cerebral hemorrhage (n = 38) and cerebral infarction (n = 20). After a total of 124 BoNT administrations with medical records entries on the subjective symptoms, the odds for symptomatic improvement was approximately 5.8 times higher in patients of the infarction group compared with the hemorrhage group (OR = 5.787, 95% CI = 2.369-14.134, p = 0. 000). Fifty-one patients (32 with cerebral hemorrhage, 19 with cerebral infarction) received the first local BoNT injection and had available medical records, analysis of which showed a significantly higher rate of symptomatic improvement in patients of the infarction group than those of the hemorrhage group (p = 0.006). After adjustment by factors known to influence treatment outcome (degree of spasticity and paralysis, BoNT dosage, and extent of FDL muscle control of toe movements), the treatment effect was predominantly higher in patients with cerebral infarction. CONCLUSION The BoNT treatment response was better for claw toes in cerebral infarction patients than in hemorrhage patients, possibly suggesting that claw toe is associated with more severe spasticity in this group of patients.
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Affiliation(s)
- Toru Takekawa
- Department of Rehabilitation Medicine, The Jikei University School of Medicine, Tokyo 105-8461, Japan.
| | - Takatoshi Hara
- Department of Rehabilitation Medicine, The Jikei University School of Medicine, Tokyo 105-8461, Japan; Department of Rehabilitation Medicine, National Center of Neurology and Psychiatry, Kodaira, Tokyo 187-8551, Japan.
| | - Naoki Yamada
- Department of Rehabilitation Medicine, The Jikei University School of Medicine, Tokyo 105-8461, Japan.
| | - Tomoharu Sato
- Motoyama Rehabilitation Hospital, Kobe, Hyogo 658-0015, Japan.
| | - Yuki Hasegawa
- Department of Rehabilitation Medicine, The Jikei University School of Medicine, Tokyo 105-8461, Japan; Department of Rehabilitation Medicine, Tokyo General Hospital, Tokyo 165-0022, Japan.
| | - Satoshi Takagi
- Department of Rehabilitation Medicine, The Jikei University School of Medicine, Tokyo 105-8461, Japan; Shinagawa Rehabilitation Hospital, Tokyo 141-0001, Japan.
| | - Kazushige Kobayashi
- Department of Rehabilitation Medicine, The Jikei University School of Medicine, Tokyo 105-8461, Japan.
| | - Tomohide Kitajima
- Department of Cerebrospinal Surgery, Narita Hospital, Narita, Chiba 286-0845, Japan.
| | - Masahiro Abo
- Department of Rehabilitation Medicine, The Jikei University School of Medicine, Tokyo 105-8461, Japan.
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Wong C. The Relationship between Pain and Spasticity and Tell-Tale Signs of Pain in Children with Cerebral Palsy. Toxins (Basel) 2023; 15:152. [PMID: 36828465 PMCID: PMC9967793 DOI: 10.3390/toxins15020152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 02/06/2023] [Accepted: 02/10/2023] [Indexed: 02/15/2023] Open
Abstract
Pain and quality of life are closely interrelated in children with cerebral palsy (CCP). Even though 67% of CCP experience pain, it is overlooked and untreated. In this study, our purpose was two-fold: first, to examine the relationship between pain and spasticity by evaluating the effects of AbobotulinumtoxinA/Dysport (BoNT), and second, to describe the symptoms and location of pain in CCP. The subjects were 22 CCP in at least moderate pain. They were evaluated for spasticity by the modified Ashworth and Tardieu scale and for pain by the r-FLACC and the pediatric pain profile. After one injection of BoNT, the subjects were re-evaluated. We found a significant reduction in pain, but no significant relationship between the reduction of pain and spasticity. We found no association between the dose of BoNT and pain or spasticity. Pain in the lower extremity was located primarily in the hip region. The effect of ultrasound-guided intermuscular injections of BoNT suggests that pain in CCP has an extra-articular component. We found that pain in CCP manifests as specific tell-tale signs and problems in daily living. In conclusion, we found no relationship between pain and spasticity. Signs and manifestations of pain are described in detail. Lower extremity (hip) pain seems to have a soft tissue/extra-articular component.
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Affiliation(s)
- Christian Wong
- Department of Orthopedic Surgery, University Hospital of Copenhagen, 2650 Hvidovre, Denmark; ; Tel.: +45-35459411
- Department of Orthopedic Surgery, University Hospital of Copenhagen, Rigshospitalet, 2100 Copenhagen, Denmark
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Tamburin S, Filippetti M, Mantovani E, Smania N, Picelli A. Spasticity following brain and spinal cord injury: assessment and treatment. Curr Opin Neurol 2022; 35:728-740. [PMID: 36226708 DOI: 10.1097/wco.0000000000001114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
PURPOSE OF REVIEW Spasticity is a common sequela of brain and spinal cord injury and contributes to disability, reduces quality of life, and increases economic burden. Spasticity is still incompletely recognized and undertreated. We will provide an overview of recent published data on the definition, assessment, and prediction, therapeutic advances, with a focus on promising new approaches, and telemedicine applications for spasticity. RECENT FINDINGS Two new definitions of spasticity have been recently proposed, but operational criteria should be developed, and test-retest and inter-rater reliability should be explored. Cannabinoids proved to be effective in spasticity in multiple sclerosis, but evidence in other types of spasticity is lacking. Botulinum neurotoxin injection is the first-line therapy for focal spasticity, and recent literature focused on optimizing its efficacy. Several pharmacological, interventional, and nonpharmacological therapeutic approaches for spasticity have been explored but low-quality evidence impedes solid conclusions on their efficacy. The recent COVID-19 pandemic yielded guidelines/recommendations for the use of telemedicine in spasticity. SUMMARY Despite the frequency of spasticity, robust diagnostic criteria and reliable assessment scales are required. High-quality studies are needed to support the efficacy of current treatments for spasticity. Future studies should explore telemedicine tools for spasticity assessment and treatment.
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Affiliation(s)
- Stefano Tamburin
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Italy
| | - Mirko Filippetti
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Italy
| | - Elisa Mantovani
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Italy
| | - Nicola Smania
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Italy
| | - Alessandro Picelli
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Italy
- Canadian Advances in Neuro-Orthopaedics for Spasticity Congress (CANOSC), Kingston, Ontario, Canada
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Lee J, Chun MH. Safety and Efficacy of HU-014 in the Treatment of Post-Stroke Upper Limb Spasticity: A Phase I Pilot Study. Toxins (Basel) 2022; 14:toxins14110730. [PMID: 36355980 PMCID: PMC9693132 DOI: 10.3390/toxins14110730] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 10/19/2022] [Accepted: 10/22/2022] [Indexed: 01/26/2023] Open
Abstract
Botulinum toxin type A (BTX-A) is widely used for treating post-stroke upper limb spasticity. We evaluated the safety and efficacy of HU-014 in treating post-stroke upper limb spasticity. Thirteen patients were administered with HU-014. The primary outcome was safety, including adverse events, vital signs, physical examination, laboratory tests, and antibody formation test. The secondary outcomes were changes in the Modified Ashworth Scale (MAS) score for wrist, elbow, and finger flexor; Disability Assessment Scale (DAS); Investigator's Global Assessment (IGA) and Subject's Global Assessment (SGA); Caregiver Burden Scale (CBS); and Columbia Suicide Severity Rating Scale (C-SSRS) at weeks 4, 8, and 12 from baseline. No notable safety-related issues were reported. MAS and DAS scores were significantly decreased from those at baseline at 4, 8, and 12 weeks (p < 0.05). At weeks 4, 8, and 12, the IGA and SGA scores were 5.85 ± 0.55, 5.69 ± 0.48, and 5.62 ± 0.65 and 5.46 ± 1.20, 5.85 ± 0.38, and 5.77 ± 0.73, respectively. CBS scores decreased at all timepoints and those for cutting fingernails significantly decreased at 8 and 12 weeks compared with baseline (p < 0.05). C-SSRS scores showed that suicidal ideation in all patients was "low" at all timepoints. HU-014 is a safe treatment that can improve post-stroke upper limb spasticity.
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Wissel J, Ri S. Assessment, goal setting, and botulinum neurotoxin a therapy in the management of post-stroke spastic movement disorder: updated perspectives on best practice. Expert Rev Neurother 2021; 22:27-42. [PMID: 34933648 DOI: 10.1080/14737175.2021.2021072] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
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.
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Affiliation(s)
- Jörg Wissel
- Department of Neurorehabilitation and Physical Therapy, Vivantes Klinikum Spandau, Neue Bergstrasse 6, 13585 Berlin, Germany.,Neurology and Psychosomatics at Wittenbergplatz, Out-Patient-Clinic, Ansbacher straße 17-19, 10787 Berlin, Germany
| | - Songjin Ri
- Neurology and Psychosomatics at Wittenbergplatz, Out-Patient-Clinic, Ansbacher straße 17-19, 10787 Berlin, Germany.,Department of Neurology, Charité University Hospital (CBS), Hindenburgdamm 30, Berlin 12203, Germany
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Ultrasonographic Evaluation of Three Approaches for Botulinum Toxin Injection into Tibialis Posterior Muscle in Chronic Stroke Patients with Equinovarus Foot: An Observational Study. Toxins (Basel) 2021; 13:toxins13110829. [PMID: 34822612 PMCID: PMC8622442 DOI: 10.3390/toxins13110829] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 11/11/2021] [Accepted: 11/19/2021] [Indexed: 02/04/2023] Open
Abstract
Spastic equinovarus (SEV) foot deformity is commonly observed in patients with post-stroke spasticity. Tibialis posterior (TP) is a common target for botulinum toxin type-A (BoNT-A) injection, as a first-line treatment in non-fixed SEV deformity. For this deep muscle, ultrasonographic guidance is crucial to achieving maximum accuracy for the BoNT-A injection. In current clinical practice, there are three approaches to target the TP: an anterior, a posteromedial, and a posterior. To date, previous studies have failed to identify the best approach for needle insertion into TP. To explore the ultrasonographic characteristics of these approaches, we investigated affected and unaffected legs of 25 stroke patients with SEV treated with BoNT-A. We evaluated the qualitative (echo intensity) and quantitative (muscle depth, muscle thickness, overlying muscle, subcutaneous tissue, cross-sectional area) ultrasound characteristics of the three approaches for TP injection. In our sample, we observed significant differences among almost all the parameters of the three approaches, except for the safety window. Moreover, our analysis showed significant differences in cross-sectional area between treated and untreated. Advantages and disadvantages of each approach were investigated. Our findings can thus provide a suitable reference for clinical settings, especially for novice operators.
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