Management of stroke patients submitted to botulinum toxin type A therapy: a Delphi survey of an Italian expert panel of specialist injectors

BACKGROUND

Spasticity is a common disabling symptom of several neurological conditions including stroke. Botulinum toxin type A (BTX-A) injection represents the gold standard therapy for focal spasticity. Post-stroke management of patients receiving BTX-A therapy has been variously investigated, but general agreement on how and when to implement rehabilitation is lacking.

AIM

To perform a national survey of experts on the most appropriate rehabilitation procedures after BTX-A therapy for the focal treatment of spasticity.

DESIGN

The study employed the Delphi technique through the COSMO project (Consensus on Post-Injection Management in Post-stroke Spasticity).

METHODS

Italian neurologists and physiatrists with experience in BTX-A therapy were selected to participate in the survey. Their anonymous opinions on key issues in treatment strategies in post-stroke spasticity were collected in three sequential rounds facilitated by a web platform. Consensus on a given issue was defined as agreed opinion by at least 66% of the survey participants.

RESULTS

In all, 44 Italian experts were involved. Positive consensus was reached on the need to start rehabilitation during the first week after BTX-A injection therapy, with a rehabilitation program comprising both stretching combined with electrical stimulation and exercise therapy. Functional surgery may be considered only after 12-24 months in cases of BTX-A therapy failure. The use of commercial or custom-made orthoses in selected cases was recommended. The appropriate time interval between two BTX-A injections is 3-6 months, and clinical assessment should be performed 1 month after injection.

CONCLUSION

The results of this national survey confirm that clinical experts on the use of BTX-A therapy for spasticity after stroke agree on the need to initiate rehabilitation treatment immediately after BTX-A injection: muscle stretching exercises, eventually combined with neuromuscular electrical stimulation, may enhance the effect of BTX-A therapy. Outcome after BTX-A therapy should be assessed at repeated follow-up visits.

CLINICAL REHABILITATION IMPACT

This expert panel survey can provide guidance for clinicians in the assessment of patients treated with BTX-A therapy.

Effects of a Weight-Bearing Exercise Training on Bone Mineral Density and Neuromuscular Function of Osteopenic Women

This study was designed to evaluate whether a weight-bearing exercise training played 3 times a week can have benefits on bone mineral density and neuromuscular function in women with a diagnosis of osteopenia. The study enrolled 22 women aged between 45 and 65, with densitometric diagnosis of osteopenia. The participants were randomly assigned to a group of exercise (n=11) and a control group (n=11). The exercise program lasted for 45 min and consisted of a combination of strength exercises that seek to cause a mechanical osteoblastic stimulus by use of gravity, body weight, fall with antigravity reaction, in combination with exercises for the improvement of balance and coordination. The outcome measures used to assess the result on bone mass are the bone Mineralometric DEXA method for femoral head-neck region and lumbar spine and biochemical markers of bone turnover (resorption and neoformation) and for the evaluation of neuromuscular function was chosen to use surface electromyography (sEMG) as an indicator of overall activity and speed activation of lumbar paravertebral muscles and of the lower limbs antigravity muscles, stabilometric analysis and 6' Walk Test. In addition each person enrolled was given EuroQol and ICF core set of osteoporosis, respectively, to assess the quality of life, as well as activity limitations and participation restrictions associated. In the exercise group, mean values and changes in average rates for the balance, muscle strength, walking ability and quality of life, mean bone mineral content and bone turnover markers, corresponding to the assessments made at 0 (before rehabilitation intervention) and Time 1 (program ended), showed a statistically significant improvement. The results of this study demonstrate that a group rehabilitation program of exercises based on gravitational load, aimed to improve muscle strength and trophism, coordination and balance, can provide advantages of unquestionable importance, not only on the slope of increase bone mass of neuromuscular function and reducing risk of falling, but on health in general.

A quantitative approach in the treatment of hemiplegic patients using an electropneumatic platform

Exercise is the central feature in the rehabilitative treatment of hemiplegic patients. In cognitive rehabilitation, great importance is attributed to the recovery of a sufficient number of proprioceptive channels before expecting the patient to regain voluntary control. The PERM [Piattaforma (Platform), Elettropneumatica (Electropneumatic) per (for) Riabilitazione (Rehabilitation) Motoria (Motor)] is a new device that can be used in the treatment of the lower limbs to provide the patient with controlled and quantifiable mechanical stimuli, thus enabling the therapist to adopt a more rigorous approach to treatment even in the very early stages of rehabilitation. Alternatively, the system can be used in a different operating mode as a normal biofeedback system capable of displaying on-screen the extent to which voluntary load has been transferred to the lower limb.