Canadian Physicians' Use of Perioperative Botulinum Toxin Injections to Spastic Limbs: A Cross-sectional National Survey

Objective

To investigate the practice patterns of Canadian physicians who use perioperative botulinum toxin (BoNT) injections to improve surgical outcomes on spastic limbs.

Design

A cross-sectional national survey composed of an invitation email and an 18-item questionnaire was disseminated by a national physical medicine and rehabilitation (PMR) society to 138 physician members involved in spasticity management.

Setting

Not applicable.

Participants

Twenty-five percent of the participants (N=34) fully completed the survey.

Interventions

Not applicable.

Main Outcome Measures

Participants completed an online questionnaire that examined the practice patterns and surgical outcomes associated with perioperative BoNT injections.

Results

The majority (n=21; 84%) of Canadian physicians who inject BoNT perioperatively to improve outcomes of surgeries performed on spastic limbs are specialists in PMR practicing in academic settings. Most respondents (74%) used BoNT injections for perioperative treatment for patients with limb spasticity undergoing surgery. Of those surveyed, 65% of physicians used BoNT preoperatively, 21% used BoNT intraoperatively, and 24% used BoNT postoperatively.Of the physicians who performed BoNT injections preoperatively, 6% performed BoNT injections 7 to 12 weeks preoperatively, 32% performed BoNT injections 4 to 6 weeks preoperatively, 47% performed BoNT injections 2 to 3 weeks preoperatively, and 15% performed BoNT injections 0 to 1 week preoperatively. The majority of physicians (85%) responded that injecting BoNT perioperatively may improve a patient's surgical outcome and all of the participants (100%) stated that BoNT did not contribute to any perioperative complications or adverse effects. Qualitative responses emphasized that successful outcomes from the perioperative BoNT were linked to enhanced collaboration with surgeons and that more research is needed to determine the optimal timing of perioperative BoNT.

Conclusion

Canadian physicians, mostly PMR specialists, administer perioperative BoNT to improve outcomes of surgeries performed on spastic limbs. The optimal timing for perioperative BoNT was suggested to be 2 to 3 weeks before the surgery by 47% of survey respondents. All participating physicians responded that perioperative BoNT did not contribute to any known perioperative complications or adverse events. This study highlights the importance of conducting more robust research to better understand optimal timing for perioperative BoNT injection, enhancing collaboration between physicians and surgeons, and increasing awareness of perioperative BoNT when planning for surgeries on spastic limbs.

Comparative Effectiveness of Botulinum Toxin Injections and Extracorporeal Shockwave Therapy for Post-Stroke Spasticity: A Systematic Review and Network Meta-Analysis

BACKGROUND

The anti-spasticity efficacy of botulinum toxin (BoNT) injection has been well established for patients with chronic stroke; however, extracorporeal shock wave therapy (ESWT), i.e. focused shockwave (FSW) and radial shockwave (RSW), has recently been applied. We aimed to investigate the comparative effectiveness of BoNT vs. ESWT in the reduction of spasticity among stroke survivors.

METHODS

PubMed, EMBASE, MEDLINE and Cochrane CENTRAL were searched from the earliest record to September 2021 for randomized controlled trials. Weighted mean differences (WMDs) on the reduction of the Modified Ashworth Scale before or at the 6th post-treatment week (short-term) and between the 7th and 12th weeks (mid-term) after the intervention were calculated. Ranking probabilities of the WMD were simulated to determine which treatment had the potential to possess the best effectiveness. inplasy.com registration: INPLASY202170018.

FINDINGS

A total of 33 studies comprising 1,930 patients were enrolled. The network meta-analysis revealed that BoNT injections, FSW and RSW were better in spasticity reduction than the control treatment(s) at the short term, with WMDs of -0.69 (95% CI, -0.87 to -0.50), -0.36 (95% CI, -0.69 to -0.03) and -0.62 (95% CI, -0.84 to -0.40), respectively. Likewise, mid-term effects of BoNT injections, FSW and RSW also revealed superiority, with WMDs of -0.44 (95% CI, -0.62 to -0.26), -0.74 (95% CI, -1.26 to -0.23) and -0.79 (95% CI, -1.07 to -0.51), respectively. Ranking probability analysis revealed that RSW had the highest probability of being the best treatment for spasticity reduction at the short-term (62.2%) and mid-term (72.3%) periods during the follow up.

INTERPRETATION

BoNT injections and ESWT are effective in alleviating post-stroke spasticity at the mid-term. The effectiveness of ESWT was comparable to BoNT injections, and RSW had the potential to be the best treatment for spasticity reduction among the three treatment options. More prospective trials incorporating head-to-head comparisons of BoNT injections vs. ESWT are needed to validate the role of ESWT in reducing post-stroke spasticity.

FUNDING

The current research project was supported by (1) National Taiwan University Hospital, Bei-Hu Branch; (2) Ministry of Science and Technology (MOST 106-2314-B-002-180-MY3 and 109-2314-B-002-114-MY3); 3) Taiwan Society of Ultrasound in Medicine.

Perioperative Botulinum Toxin Injections to Enhance Surgical Outcomes in Patients With Spasticity: Preoperative, Intraoperative, and Postoperative Case Reports

Spasticity causes an array of disabilities, which in turn may lead to the need for surgical intervention. Spasticity itself may also negatively affect surgical outcomes. This report reviews the potential benefit of perioperative (before, during, or after surgery) botulinum toxin (BoNT) injections for 3 patients with spasticity due to spinal cord injury, stroke, or multiple sclerosis. We discuss perioperative BoNT in 3 time periods: preoperatively, intraoperatively, and postoperatively. The cases demonstrate the use of perioperative BoNT in decreasing pain, improving wound healing, and improving surgical outcomes. We conclude by discussing the potential use of perioperative BoNT for surgical interventions in patients with spasticity and the need for further high-quality research in this field.

Reliability and Validity of the Modified Heckmatt Scale in Evaluating Muscle Changes With Ultrasound in Spasticity

Objectives

To determine the reliability and validity of the Modified Heckmatt scale in assessing muscle echotexture in spasticity.

Design

Prospective, observational, 2-center study. Two residents and 2 ultrasound experienced staff physicians each rated 100 ultrasound images that were also analyzed using quantitative gray-scale.

Setting

Academic ambulatory spasticity clinic.

Participants

Participants (N=50) included 45 patients with upper or lower extremity spasticity and 5 healthy references.

Interventions

Not applicable.

Main Outcome Measures

Modified Heckmatt scale ratings and quantitative gray-scale scores

Results

Inter- and intra-rater intraclass correlation coefficients were 0.76 and 0.81, respectively (P<.001), indicating good to excellent reliability. A significant relationship was found between Modified Heckmatt scores and quantitative gray-scale scores (r=0.829; P<.001).

Conclusions

The Modified Heckmatt scale demonstrated good reliability and validity to assess the pathologic muscle changes that occur in patients with spasticity.

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Spasticity can alter muscle architecture as viewed with ultrasound.

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Spastic muscles can show increased echointensity (EI).

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Spastic muscles with increased EI may respond less favorably to botulinum toxin.

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Muscle EI can be quantified using the Modified Heckmatt scale.

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The Modified Heckmatt scale demonstrated good reliability and validity.

Cryoneurotomy as a Percutaneous Mini-invasive Therapy for the Treatment of the Spastic Limb: Case Presentation, Review of the Literature, and Proposed Approach for Use

Objective

To provide a proof-of-concept study demonstrating that the decades old procedure of cryoneurotomy, used traditionally for analgesia, is a safe adjunctive and effective treatment for limb spasticity.

Design

Case series.

Setting

Publicly funded outpatient hospital spasticity clinic and community interventional anesthesia clinic.

Participants

Patients (N=3) who had plateaued with standard of care spasticity treatments including botulinum toxin. Two hemiplegic stroke patients with elbow spasticity and 1 pregnant patient with multiple sclerosis and a spastic equinovarus foot for whom botulinum toxin was now contraindicated.

Interventions

Selective anesthetic diagnostic motor nerve blocks with ultrasound and e-stimulation with 1cc of 1% lidocaine to the motor nerve to the targeted spastic muscle were performed to either the musculocutaneous nerve to brachialis, radial nerve to the brachioradialis or the tibial nerve. If the benefits included improved active and passive range motion and or decreased clonus, a percutaneous cryoneurotomy was performed.

Main Outcome Measures

Active and passive range of motion were measured using the Modified Tardieu Scale. The change in resistance to passive stretch was measured using the Modified Ashworth Scale (MAS). Videos of the before and after treatment were collected.

Results

Both elbows’ treatments resulted in MAS improving from a 3 to a 1+. Greatly improved active range of motion was noted at 94 and 64 degrees, respectively, as well as improvements in passive range on the Modified Tardieu Scale. The tibial nerve cryoneurotomy resulted in improvements in all parameters with a much improved gait. Results were maintained up to 17 months of follow-up.

Conclusion

Cryoneurotomy as a treatment for spasticity is a novel safe adjuvant treatment. Our initial results suggest patients can achieve significantly increased active and passive range of motion in the upper extremity and decreased clonus, and improved gait after tibial nerve cryoneurotomy.