Posts Tagged botulinum toxin

[Abstract] Botulinum Toxin Injection Techniques for the Management of Adult Spasticity

Abstract

Spasticity is often experienced by individuals with injury or illness of the central nervous system from etiologies such as stroke, spinal cord injury, brain injury, multiple sclerosis, or other neurologic conditions. Although spasticity may provide benefits in some patients, it more often leads to complications negatively impacting the patient. Nonpharmacologic treatment options often do not provide long-term reduction of spasticity, and systemic interventions, such as oral medications, can have intolerable side effects. The use of botulinum neurotoxin injections is one option for management of focal spasticity. Several localization techniques are available to physicians that allow for identification of the selected target muscles. These methods include anatomic localization in isolation or in conjunction with electromyography guidance, electrical stimulation guidance, or ultrasound guidance. This article will focus on further description of each of these techniques in relation to the treatment of adult spasticity and will discuss the advantages and disadvantages of each technique, as well as review the literature comparing the techniques.

 

via Botulinum Toxin Injection Techniques for the Management of Adult Spasticity – ScienceDirect

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[ARTICLE] Botulinum toxin type A in post-stroke lower limb spasticity: a multicenter, double-blind, placebo-controlled trial – Full Text

Abstract

Lower limb spasticity in post-stroke patients can impair ambulation and reduces activities of daily living (ADL) performance of patients. Botulinum toxin type A (BoNTA) has been shown effective for upper limb spasticity. This study assesses the treatment of lower limb spasticity in a large placebo-controlled clinical trial. In this multicenter, randomized, double-blind, parallel-group, placebo-controlled study, we evaluate the efficacy and safety of one-time injections of botulinum toxin type A (BoNTA) in Japanese patients with post-stroke lower limb spasticity. One hundred twenty patients with lower limb spasticity were randomized to a single treatment with BoNTA 300 U or placebo. The tone of the ankle flexor was assessed at baseline and through 12 weeks using the Modified Ashworth Scale (MAS). Gait pattern and speed of gait were also assessed. The primary endpoint was area under the curve (AUC) of the change from baseline in the MAS ankle score. Significant improvement in spasticity with BoNTA 300 U was demonstrated by a mean difference in the AUC of the change from baseline in the MAS ankle score between the BoNTA and placebo groups (−3.428; 95% CIs, −5.841 to −1.016; p = 0.006; t test). A significantly greater decrease from baseline in the MAS ankle score was noted at weeks 4, 6 and 8 in the BoNTA group compared to the placebo group (p < 0.001). Significant improvement in the Clinicians Global Impression was noted by the investigator at weeks 4, 6 and 8 (p = 0.016–0.048, Wilcoxon test), but not by the patient or physical/occupational therapist. Assessments of gait pattern using the Physician’s Rating Scale and speed of gait revealed no significant treatment differences but showed a tendency towards improvement with BoNTA. No marked difference was noted in the frequency of treatment-related adverse events between BoNTA and placebo groups. This was the first large-scale trial to indicate that BoNTA significantly reduced spasticity in lower limb muscles.

Introduction

Spasticity is defined by Lance as a motor disorder characterized by a velocity-dependent increase in tonic stretch reflexes (muscle tone) with exaggerated tendon jerks, resulting from hyperexcitability of the stretch reflex, as one of the components of upper motor neuron syndrome [1].

BoNTA (botulinum toxin type A, onabotulinumtoxinA1) is a specific formulation of a locally injected muscle relaxant whose active ingredient is botulinum toxin type A produced by Clostridium botulinum. Botulinum toxin type A binds to the receptors in the presynaptic, cholinergic motor nerve terminal and is taken up by the nerve cells where the light chain of toxin cleaves a synaptosome-associated protein (SNAP-25) to inhibit acetylcholine release from the nerve terminal. As its muscle relaxant effect is exerted in the hypertonic muscle, BoNTA offers an alternative treatment for spastic patients who have difficulty with oral muscle relaxants that can produce generalized weakness and drowsiness, cognitive impairment, and/or a reduced level of arousal. Locally injected BoNTA is expected to improve limb position and functional ability, and reduce pain in patients with spasticity. Moreover, BoNTA has no sedative action, unlike existing oral antispastic treatments, and therefore can be used in patients with cognitive impairment or a reduced level of arousal. Based on these considerations, BoNTA is a first-line treatment choice if the upper and lower limb spasticity is focal and reversible without contracture [2].

The efficacy and safety of BoNTA in patients with post-stroke lower limb spasticity have been suggested by randomized-controlled trials of limited scale [345678] and meta-analysis [9]. The efficacy of BoNTA in patients with severe brain injury has also been demonstrated in a randomized-control trial [10]. Approved treatments of spasticity in Japan include peripheral and central muscle relaxants, alcohol, phenol block, and intrathecal baclofen (only in cases of severe spastic paralysis). We conducted a clinical study to evaluate the efficacy and safety of BoNTA in Japanese patients with post-stroke lower limb spasticity who received a single placebo-controlled injection of BoNTA followed by open-label repeated treatment of up to three sessions. This article reports the efficacy and safety results of the double-blind phase. […]

 

Continue —->  Botulinum toxin type A in post-stroke lower limb spasticity: a multicenter, double-blind, placebo-controlled trial | SpringerLink

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[ARTICLE] A systematic review: efficacy of botulinum toxin in walking and quality of life in post-stroke lower limb spasticity – Full Text

Abstract

Background

Improved walking is one of the highest priorities in people living with stroke. Post-stroke lower limb spasticity (PSLLS) impedes walking and quality of life (QOL). The understanding of the evidence of improved walking and QOL following botulinum toxin (BoNTA) injection is not clear. We performed a systematic review of the randomized control trials (RCT) to evaluate the effectiveness of BoNTA injection on walking and QOL in PSLLS.

Methods

We searched PubMed, Web of Science, Embase, CINAHL, ProQuest Thesis and Dissertation checks, Google Scholar, WHO International Clinical Trial Registry Platform, ClinicalTrials.gov, Cochrane, and ANZ and EU Clinical Trials Register for RCTs looking at improvement in walking and QOL following injection of BoNTA in PSLLS. The original search was carried out prior to 16 September 2015. We conducted an additional verifying search on CINHAL, EMBASE, and MEDLINE (via PubMed) from 16 September 2015 to 6 June 2017 using the same clauses as the previous search. Methodological quality of the individual studies was critically appraised using Joanna Briggs Institute’s instrument. Only placebo-controlled RCTs looking at improvement in walking and QOL were included in the review.

Results

Of 2026 records, we found 107 full-text records. Amongst them, we found five RCTs qualifying our criteria. No new trials were found from the verifying search. Two independent reviewers assessed methodological validity prior to inclusion in the review using Joanna Briggs Institute’s appraisal instrument. Two studies reported significant improvement in gait velocity (p = 0.020) and < 0.05, respectively. One study showed significant improvement in 2-min-walking distance (p < 0.05). QOL was recorded in one study without any significant improvement. Meta-analysis of reviewed studies could not be performed because of different methods of assessing walking ability, small sample size with large confidence interval and issues such as lack of power calculations in some studies. Findings from our systematic and detailed study identify the need for a well-designed RCT to adequately investigate the issues highlighted.

Conclusions

This review could not conclude there was sufficient evidence to support or refute improvement on walking or QOL following BoNTA injection. Reasons for this are discussed, and methods for future RCTs are developed.

Background

Stroke is a common cause of adult disability worldwide [1]. More than two thirds of the stroke survivors develop post-stroke sequelae including impaired motor functions and spasticity [2]. The prevalence of post-stroke spasticity ranges from 19.0 to 42.6% [3]. There have been many recent developments in diagnosis, management, and prevention of stroke, while advances in rehabilitation have been modest [4]. There has, however, been progress with the use of botulinum toxin (BoNTA) as a treatment to improve spasticity in the upper limb [567]. Three systematic reviews [8910] have addressed research progress on both the upper and lower limbs, with the conclusion from two of these that the effect on the upper and lower limbs spasticity favored BoNTA [89]; however, these reviews did not fulfill the criteria for inclusion in this study.

As far as the lower limb is concerned, improvement in spasticity while important is only a first stage in post-stroke improvement, and the aim of RCTs should be to address the more important questions of functional activity including walking. How well this outcome has been addressed is the aim of this study. This is also an important question for many countries to resolve, because to date, botulinum toxin A is not approved for use in the post-stroke lower limb spasticity (PSLLS) by the pharmaceutical authorities except in the USA [11].

Lower limb spasticity most commonly involves the foot and the ankle leading to equinovarus (plantarflexion and inversion) deformity. Post-stroke patients with equinovarus deformity fail to achieve optimal contact with the ground leading to a poor stance, loss of heel to toe rhythm while walking and post-stroke patients walk predominantly with plantarflexion/inversion of the foot. Transfers and walking are essentially bipedal activity involving phases like balancing on one leg and swinging the other leg forward. The awkward position of the foot in addition to spasticity impairs balance, transfer, stride, gait, and mobility, besides causing spasm and pain. In many cases, complications like falls, fractures, deep vein thrombosis, and pressure ulcers may also result [12]. Inability to walk is associated with loss of independence and premature residential aged care placement [1314] and in the older population contributes substantially to adverse health outcomes including activities of daily living and mortality [15]. Improving and maintaining walking ability and activities of daily living are therefore vital for post-stroke survivors [16] and a major contributor to functional improvements. The overall human and economic cost of spasticity is, therefore, considerable, and interventions potentially can deliver significant benefits [17].

Given the evidence for efficacy of BoNTA in reducing spasticity, the objective of this review was to assess the available evidence of BoNTA injection: (1) to improve mobility (using gait velocity and walking distance as measuring parameters) and quality of life (QOL) and (2) to make appropriate recommendations for further research regarding these questions. […]

 

Continue —> A systematic review: efficacy of botulinum toxin in walking and quality of life in post-stroke lower limb spasticity | Systematic Reviews | Full Text

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[ARTICLE] Patient Registry of Spasticity Care World: Data Analysis Based on Physician Experience – Full Text

Objective The aim of the study was to report physician experience–based “real-world” treatment patterns with botulinum toxin type A in patients with stroke and traumatic brain injury.

Design A prospective, multicenter, international observational registry design was used.

Results Six hundred twenty-seven participants with stroke and 132 participants with traumatic brain injury were assessed and treated by 17 more experienced physicians and 12 less experienced physicians. Due to the limited usage of abobotulinumtoxinA Dysport and incobotulinumtoxinA Xeomin, data were reported on onabotulinumtoxinA BOTOX only. Based on physician experience, onabotulinumtoxinA doses were statistically different with larger mean doses injected by more experienced physicians in the upper limb (59.9 [39.0], P = 0.001) and in the lower limb (101.8 [69.2], P < 0.001). Treated deformities significantly differed for both upper limb and lower limb (P < 0.001). More experienced physicians showed a larger mean change in Ashworth Scale scores from baseline for the equinovarus/equinus foot and stiff knee (P = 0.001 and 0.03). Less experienced physicians showed a larger mean change in Ashworth Scale scores from baseline for the adducted thigh (P = 0.05). Less experienced physicians had statistically significant larger change in hand pain scores for clenched fist deformity treatment at follow-up compared with more experienced physicians (P = 0.01). Physician experience demonstrated a significant difference on patients reported satisfaction toward their secondary goal with higher scores for more experienced physician (P = 0.04).

Conclusions This international registry provides clinical nuances of treatment based on physician clinical experience in a robust sample size.

 

Every year, 15 million people worldwide are adversely affected by a stroke, and according to the World Health Organization, traumatic brain injury (TBI) will surpass by 2020 many other diseases as the major cause of death and disability.1 Functional problems caused by stroke or a TBI may include paralysis, cognitive and speech changes, and impaired motor control and dexterity as well as abnormal muscle activity that include spasticity, clonus, dystonia, co-contraction, associated reactions, and flexor and extensor spasms as seen in the upper motor neuron syndrome.2Spasticity as a motor behavior is a specific physiologic sign that has classically been described by Lance et al.3 as one component of the upper motor neuron syndrome, distinguishable from other positive features of muscle overactivity (e.g., dystonia, co-contraction). For simplification, all of these abnormal muscle activation patterns are frequently referred to as “spasticity.”4 We have elected the term spastic muscle overactivity as a more encompassing and better suited term.5–7Muscle overactivity can result in multiple patterns of clinical motor dysfunction affecting the lower (e.g., equinovarus, stiff knee, striatal toe, adducted thighs, flexed hip) and/or upper limbs (flexed elbow, internally rotated shoulder, flexed wrist, clenched fist, thumb-in-palm, intrinsics).4

Botulinum toxin has become a widely used biological toxin for a growing number of clinical applications. Clinical trials provide evidence that botulinum toxin can improve symptoms of muscle overactivity when appropriate muscles, doses, and the number of injection sites are selected.4,7 The proper use of these treatments in a “real-world” setting is not restricted to a regimented dosing structure provided by a clinical trial requires appropriate training and education. As in other areas of medicine, physician experience may play a role in care delivery. Physician level of experience may serve as a surrogate in understanding physician practice patterns variation that can inform healthcare services use8 and reduce physician care variations.9 Given these information void, we proposed and conducted a global, multicenter, observational study of participants treated with botulinum toxins in patients with stroke- or TBI-related spastic muscle overactivity to generate real-world data. The use of botulinum toxin A varies internationally; onabotulinumtoxinA (onaBoNTA) BOTOX has been approved for use in the United States for many years, whereas abobotulinumtoxinA (aboBoNTA) Dysport and incobotulinumtoxinA (incoBoNTA) Xeomin were only recently approved (2016). The onaBoNTA and aboBoNTA have been in use in Europe for more than 20 yrs, and incoBoNTA was approved only 10 yrs ago. Published registries have presented real-life data on the treatment of spasticity with onaBonTA10–12; however, to our knowledge, this is the first international registry that includes real-world longitudinal data that include baseline, injection, and outcomes when using the various botulinum toxins available while considering physician experience for its stratification and analysis. Despite the available evidence of botulinum toxin use, it is unclear whether physician level of experience may play a role in the appropriate delivery of toxin-related care. We hypothesized that the physician experience level may impart differences in care patterns in the use of botulinum toxin for spasticity management. Specifically, we focus on analyses based on the physician experience related to the identification of the problem presentation, muscle selection for treatment, formulation selected, dosing, injection technique, dilution, and number of injection sites. We also recorded the primary and secondary goals for treatment as selected by the patient and agreed upon by the treating physician. The primary purpose for this registry was to describe treatment patterns and clinical presentation used in these populations from a global perspective on the basis of clinical experience. Ashworth Scale (AS), presence of pain, and patient-reported satisfaction after treatment were stratified on the basis of reported physicians’ clinical experiences to determine treatment effect.[…]

Continue —> Patient Registry of Spasticity Care World: Data Analysis Bas… : American Journal of Physical Medicine & Rehabilitation

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[ARTICLE] Objective assessment of cortical activity changes in stroke patients before and after hand rehabilitation with and without botulinum toxin injection – Full Text

Abstract

Background Upper limb spasticity is a disabling condition and may result in severe functional limitation. The peripheral action of botulinum toxin (BTX) injection on spasticity is well known, but there are debates around its possible central action.
Aim The aim of this study was to assess the clinical, functional, and cortical activation outcome of two antispastic treatments for stroke of the hand and wrist. Thirty patients with upper limb poststroke spasticity were recruited in this study.
Patients and methods They were randomly allocated to two groups: group A and group B. Both groups received rehabilitation program, whereas group B received additional BTX injection. All patients were assessed at baseline and 8 weeks after treatment using the Modified Ashworth Scale, the Action Research Arm Test and Nine-Hole Peg Test, and somatosensory-evoked potential study of the median nerve.
Results Group B showed a higher percentage of change in Modified Ashworth Scale of the wrist flexors and long flexors of fingers and in Action Research Arm Test compared with group A.
Conclusion BTX injection in spastic muscles of the wrist and hand, followed by a rehabilitation program led to greater clinical and functional improvement compared with implementing the rehabilitation program alone.

Introduction

Upper limb spasticity can be disabling and can result in several functional limitations. Although some neural plasticity following stroke contributes to motor recovery, maladaptive plasticity can weaken motor function and limits the recovery. Spasticity represents an example of maladaptive plasticity [1].

Local injection of botulinum toxin-A (BTX) is the standard treatment for spasticity, particularly in poststroke patients. In addition to its peripheral action, evidence of its possible effects on central nervous systems has emerged [1].

Somatosensory-evoked potential (SEP) studies in patients with spasticity showed improvement in SEP following BTX injection, which may support the possible central action of BTX in the cerebral cortex [2],[3].[…]

Continue —> Objective assessment of cortical activity changes in stroke patients before and after hand rehabilitation with and without botulinum toxin injection Abu-Bakr OA, Nassar NM, Al-Ganzoury AM, Ahmed KA, Tawfik EA – Egypt Rheumatol Rehabil

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[ARTICLE] ADULT SPASTICITY INTERNATIONAL REGISTRY STUDY: METHODOLOGY AND BASELINE PATIENT, HEALTHCARE PROVIDER, AND CAREGIVER CHARACTERISTICS – Full Text PDF

Objective: The main aim of this study was to determine
the utilization patterns and effectiveness of onabotulinumtoxinA (Botox®) for treatment of spasticity in clinical practice.

Design: An international, multicentre, prospective, observational study at selected sites in North America, Europe, and Asia.

Patients: Adult patients with newly diagnosed or established focal spasticity, including those who had previously received treatment with onabotulinumtoxinA.

Methods: Patients were treated with onabotulinumtoxinA, approximately every 12 weeks, according to their physician’s usual clinical practice over a period of up to 96 weeks, with a final follow-up interview at 108 weeks. Patient, physician and caregiver data were collected.

Results: Baseline characteristics are reported. Of the 745 patients enrolled by 75 healthcare providers from 54 sites, 474 patients had previously received onabotulinumtoxinA treatment for spasticity. Lower limb spasticity was more common than upper limb spasticity, with stroke the most common underlying aetiology. The Short-Form 12 (SF-12) health survey scores showed that patients’ spasticity had a greater perceived impact on physical rather than mental aspects.

Conclusion: The data collected in this study will guide the development of administration strategies to optimize the effectiveness of onabotulinumtoxinA in the management of spasticity of various underlying
aetiologies.

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[Abstract] Combined Effect Of Botulinum Toxin And Splinting On Motor Components And Function Of People With Stroke  

Abstract

Background and objective: Spasticity is one of the problems following stroke. Due to this increase in muscle tone, patients are confronted to problems in motor control and difficulties in activities of daily living and complications such as shortness and contracture. The aim of this study was to examine the effects of Simultaneous use of both splint and botulinum toxin-A (BTX-A) injection on spasticity, range of motion and upper extremity function in a 3-month period.

Methods: The design of this study was a comparison between 3 groups of interventions, conducted in rehabilitation clinics in Tehran. Sixty people with chronic stroke were recruited. Based on the inclusion criteria, a total of 39 stroke patients after completing the consent forms were entered to intervention groups; splint or botulinum toxin injection or combined splint/botulinum toxin injection. They were followed up about 3 months and the evaluations were done monthly. Goniometry was the method to measure range of motion, and Modified Ashworth scale was used to examine the spasticity and the upper extremity function was scored based on Fugl-Meyer assessment.   Statistical analysis was done using SPSS 17. And ANOVAs was used for comparison between groups and times.  Significance was set at 0.05.

Results: All outcome measures improved within each group but the differences between splint group and BTX-A group and the BTX-A-splint group was not significant in most outcomes during 3 periods (first evaluation until end of the first month, the end of first month until the end of second month, the end of second month until the end of the third month) (p> 0 / 05). The results also showed that the changes in elbow`s spasticity {p= 0.05} and wrist`s spasticity {p= 0.007} and upper extremity function { p = 0.04} were obvious between the three groups over the 3-months and the difference in the group of combined use of botulinum toxin and splint was more than other groups.

Conclusion: In this study, the effects of botulinum toxin injection and Volar-Dorsal Wrist/Hand Immobilization splint and the combined use of botulinum injection and splint were obvious in all groups but was not significantly different between the interventions in a 3-month follow-up.

Source: Combined Effect Of Botulinum Toxin And Splinting On Motor Components And Function Of People With Stroke | Shamili | Advances in Bioscience and Clinical Medicine

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[ARTICLE] How Can We Improve Current Practice in Spastic Paresis? – Full Text

Abstract:

Spastic paresis can arise from a variety of conditions, including stroke, spinal cord injury, multiple sclerosis, cerebral palsy, traumatic brain injury and hereditary spastic paraplegia. It is associated with muscle contracture, stiffness and pain, and can lead to segmental deformity. The positive, negative and biomechanical symptoms associated with spastic paresis can significantly affect patients’ quality of life, by affecting their ability to perform normal activities. This paper – based on the content of a global spasticity interdisciplinary masterclass presented by the authors for healthcare practitioners working in the field of spastic paresis – proposes a multidisciplinary approach to care involving not only healthcare practitioners, but also the patient and their family members/carers, and improvement of the transition between specialist care and community services. The suggested treatment pathway comprises assessment of the severity of spastic paresis, early access to neurorehabilitation and physiotherapy and treatment with botulinum toxin and new technologies, where appropriate. To address the challenge of maintaining patients’ motivation over the long term, tailored guided self-rehabilitation contracts can be used to set and monitor therapeutic goals. Current global consensus guidelines may have to be updated, to include a clinical care pathway related to the encompassing management of spastic paresis.

Spastic paresis may be caused by a variety of conditions, including stroke, spinal cord injury, multiple sclerosis, retroviral and other infectious spinal cord disorders, cerebral palsy, traumatic brain injury and hereditary spastic paraplegia.1 The exact prevalence of spastic paresis (in which spasticity is the most commonly recognised manifestation) is not known. However, it is estimated that around 30% of stroke survivors are affected by significant spasticity2 and 50% who present to hospital with stroke develop at least one severe contracture.3

Spastic paresis is a complex condition that may be associated with soft tissue contracture, pain and limitations of day-to-day activities, which have a substantial impact on patients’ and caregivers’ quality of life.4 Although treatment guidelines have been developed for (focal) spasticity,5 there remains a lack of consensus on key aspects of diagnosis, approaches to care and the care pathway that would help healthcare practitioners to more fully understand and manage this condition.

To address some of these limitations, a group of physicians and a physiotherapist with expertise in the management of spastic paresis developed a global spasticity masterclass for healthcare practitioners working in this field in order to share best practices and to discuss issues and current trends in the management of patients with spasticity. The outputs of this masterclass are presented here.

Continue —> How Can We Improve Current Practice in Spastic Paresis? | Touch Neurology | Independent Insight for Medical Specialists

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[ARTICLE] How Can We Improve Current Practice in Spastic Paresis? – Full Text HTML

Abstract:

Spastic paresis can arise from a variety of conditions, including stroke, spinal cord injury, multiple sclerosis, cerebral palsy, traumatic brain injury and hereditary spastic paraplegia. It is associated with muscle contracture, stiffness and pain, and can lead to segmental deformity. The positive, negative and biomechanical symptoms associated with spastic paresis can significantly affect patients’ quality of life, by affecting their ability to perform normal activities. This paper – based on the content of a global spasticity interdisciplinary masterclass presented by the authors for healthcare practitioners working in the field of spastic paresis – proposes a multidisciplinary approach to care involving not only healthcare practitioners, but also the patient and their family members/carers, and improvement of the transition between specialist care and community services. The suggested treatment pathway comprises assessment of the severity of spastic paresis, early access to neurorehabilitation and physiotherapy and treatment with botulinum toxin and new technologies, where appropriate. To address the challenge of maintaining patients’ motivation over the long term, tailored guided self-rehabilitation contracts can be used to set and monitor therapeutic goals. Current global consensus guidelines may have to be updated, to include a clinical care pathway related to the encompassing management of spastic paresis.

Spastic paresis may be caused by a variety of conditions, including stroke, spinal cord injury, multiple sclerosis, retroviral and other infectious spinal cord disorders, cerebral palsy, traumatic brain injury and hereditary spastic paraplegia.1 The exact prevalence of spastic paresis (in which spasticity is the most commonly recognised manifestation) is not known. However, it is estimated that around 30% of stroke survivors are affected by significant spasticity2 and 50% who present to hospital with stroke develop at least one severe contracture.3

Spastic paresis is a complex condition that may be associated with soft tissue contracture, pain and limitations of day-to-day activities, which have a substantial impact on patients’ and caregivers’ quality of life.4 Although treatment guidelines have been developed for (focal) spasticity,5 there remains a lack of consensus on key aspects of diagnosis, approaches to care and the care pathway that would help healthcare practitioners to more fully understand and manage this condition.

To address some of these limitations, a group of physicians and a physiotherapist with expertise in the management of spastic paresis developed a global spasticity masterclass for healthcare practitioners working in this field in order to share best practices and to discuss issues and current trends in the management of patients with spasticity. The outputs of this masterclass are presented here.

Pathophysiology and definitions
Spastic paresis
Spasticity is one of several components of spastic paresis, also known as the upper motor neuron (UMN) syndrome. Spastic paresis is primarily characterised by a quantitative lack of command directed to agonist muscles involved in performing movements.1,6,7 In addition, hyperactive spinal reflexes mediate some of the positive phenomena seen in spastic paresis, while other positive symptoms are related to disordered control of voluntary movement in terms of an abnormal efferent drive or are caused

Continue —> How Can We Improve Current Practice in Spastic Paresis? | Touch Neurology | Independent Insight for Medical Specialists

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[Abstract] 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.

Source: Effect of electrical stimulation as an adjunct to botulinum toxin type A in the treatment of adult spasticity: a systematic review: Disability and Rehabilitation: Vol 0, No 0

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