Posts Tagged onabotulinumtoxinA

[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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[ARTICLE] Rehabilitation plus OnabotulinumtoxinA Improves Motor Function over OnabotulinumtoxinA Alone in Post-Stroke Upper Limb Spasticity: A Single-Blind, Randomized Trial – Full Text HTML

Abstract

Background: OnabotulinumtoxinA (BoNT-A) can temporarily decrease spasticity following stroke, but whether there is an associated improvement in upper limb function is less clear. This study measured the benefit of adding weekly rehabilitation to a background of BoNT-A treatments for chronic upper limb spasticity following stroke. Methods: This was a multi-center clinical trial. Thirty-one patients with post-stroke upper limb spasticity were treated with BoNT-A. They were then randomly assigned to 24 weeks of weekly upper limb rehabilitation or no rehabilitation. They were injected up to two times, and followed for 24 weeks. The primary outcome was change in the Fugl–Meyer upper extremity score, which measures motor function, sensation, range of motion, coordination, and speed. Results: The ‘rehab’ group significantly improved on the Fugl–Meyer upper extremity score (Visit 1 = 60, Visit 5 = 67) while the ‘no rehab’ group did not improve (Visit 1 = 59, Visit 5 = 59; p = 0.006). This improvement was largely driven by the upper extremity “movement” subscale, which showed that the ‘rehab’ group was improving (Visit 1 = 33, Visit 5 = 37) while the ‘no rehab’ group remained virtually unchanged (Visit 1 = 34, Visit 5 = 33; p = 0.034). Conclusions: Following injection of BoNT-A, adding a program of rehabilitation improved motor recovery compared to an injected group with no rehabilitation.

1. Introduction

While several blinded and open-label studies have demonstrated the ability of botulinum toxin to temporarily decrease spasticity following stroke, as measured by standard assessments such as the Modified Ashworth Scale [1,2,3,4,5,6,7,8], the ability of botulinum toxin to improve upper limb function following stroke is less clear, with some studies [1,3,4,5,6,7,8], though not all [2,7], reporting functional improvement. Two recent meta-analyses of randomized controlled trials demonstrated that botulinum toxin treatment resulted in a moderate improvement in upper limb function [9,10]. Despite large clinical trials [2,3,11] and FDA approval, the exact timing, use of adjunct rehabilitation, and continuation of lifelong botulinum toxin treatment remains unclear [12,13].
A recent Cochrane Review included three randomized clinical trials for post-stroke spasticity involving 91 participants [14]. It aimed to determine the efficacy of multidisciplinary rehabilitation programs following treatment with botulinum toxin, and found some evidence supporting modified constraint-induced movement therapy and dynamic elbow splinting. There have been varied study designs exploring rehabilitation in persons after the injection of botulinum toxin or a placebo [13,15], rehabilitation in persons after the injection of botulinum toxin or no injection [16], or rehabilitation after the injection of botulinum toxin with no control condition [17]. As the use of botulinum toxin expands and is beneficial in reducing spasticity and costs [18], the benefit of adding upper limb rehabilitation continues to be questioned. We designed this multi-center, randomized, single-blind clinical trial to assess improvement in patient sensory and motor outcome following the injection of onabotulinumtoxinA (BoNT-A), comparing the effects of rehabilitation versus no rehabilitation, using the upper extremity portion of the Fugl–Meyer Assessment of Sensorimotor Recovery After Stroke [19] as the primary outcome measure. While patients could not be blinded to their randomization to receive additional rehabilitation versus no rehabilitation, the assessments of all of the outcome measures were performed by evaluators blinded to rehabilitation assignment in this single-blind design.

2. Results

Thirty-one patients with post-stroke upper limb spasticity were enrolled, with 29 completing the study (Figure 1). The strokes occurred an average of 6 years prior to study entry, with a range of 6 months to 16½ years. The upper extremity postures treated included flexed elbow, pronated forearm, flexed wrist, flexed fingers, and clenched fist, and were evenly distributed between the treatment groups (the initial dose of BoNT-A administered was left up to the clinician’s judgment based on the amount of spasticity present, and did not differ between groups). One participant (‘no rehab’, injected at Visits 1 and 3A) left the study after Visit 3A due to a deterioration in general health and an inability to travel to study visits. A second participant (‘no rehab’, injected at Visits 1 and 3A) left the study after Visit 4 due to a fall with a broken affected wrist. All of the participants were injected at Visit 1, 19 were injected at Visit 3 (8 ‘rehab’; 11 ‘no rehab’), and 7 were injected at Visit 3A (3 ‘rehab’; 4 ‘no rehab’). Those participants who did not receive injections at Visits 3 or 3A had a level of spasticity that either did not meet the injection criteria due to an Ashworth score of <2 in the wrist (and/or fingers) or one that was felt to be too low to warrant injection. Table 1 provides a description of each group with regard to age, sex, race, whether the stroke occurred in the dominant hemisphere, and clinical measures. At baseline, the treatment groups did not differ on any demographic or clinical variables. […]

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[Abstract+References] Safety and efficacy of letibotulinumtoxinA(BOTULAX®) in treatment of post stroke upper limb spasticity: a randomized, double blind, multi-center, phase III clinical trial

To investigate a new botulinum neurotoxin type A, termed letibotulinumtoxinA(Botulax®) and compare its efficacy and safety for post-stroke upper limb spasticity with that of onabotulinumtoxinA(Botox®).

A prospective, double-blinded, multicenter, randomized controlled clinical study.

Six university hospitals in Korea.

A total of 187 stroke participants with upper limb spasticity.

Two kinds of botulinum neurotoxin type A were used. One set of injection was performed and total injected doses were 309.21±62.48U(Botulax) and 312.64±49.99U(Botox)(P>0.05).

Primary outcome was measured using the modified Ashworth scale for wrist flexors at week 4 and secondary outcome was measured using modified Ashworth scale for wrist flexors, elbow flexors, finger flexors, and thumb flexors as well as Global Assessment in spasticity, Disability Assessment Scale, and Caregiver Burden Scale. Safety measures including adverse events, vital signs and physical examination, and laboratory tests were also monitored.

The mean ages for the Botulax group were 56.81±9.49 and which for the Botox group were 56.93±11.93(P>0.05). In primary outcome, the change in modified Ashworth scale for wrist flexors was -1.45±0.61 in the Botulax group and -1.40±0.57 in the Botox group, and the difference between the two groups was -0.06(95% CI:-0.23–0.12,P>0.05). In secondary outcome, both groups demonstrated significant improvements with respect to modified Ashworth scale, Global Assessment in spasticity, Disability Assessment Scale, and Caregiver Burden Scale (P<0.05), and no significant difference was observed between the two groups (P>0.05). In addition, safety measures showed no significant differences between the two groups (P>0.05).

The efficacy and safety of Botulax were comparable with those of Botox in treatment of post-stoke upper limb spasticity.

 

1. Kanovsky P, Slawek J, Denes Z, . Efficacy and safety of botulinum neurotoxin NT 201 in poststroke upper limb spasticity. Clin Neuropharmacol 2009; 32: 259265. Google Scholar CrossRef, Medline
2. Slawek J, Bogucki A, Reclawowicz D. Botulinum toxin type A for upper limb spasticity following stroke: an open-label study with individualised, flexible injection regimens. Neurol Sci 2005; 26: 3239. Google Scholar CrossRef, Medline
3. Jost WH, Hefter H, Reissig A, . Efficacy and safety of botulinum toxin type A (Dysport) for the treatment of post-stroke arm spasticity: results of the German-Austrian open-label post-marketing surveillance prospective study. J Neurol Sci 2014; 337: 8690. Google Scholar CrossRef, Medline
4. Simpson DM, Alexander DN, O’Brien CF, . Botulinum toxin type A in the treatment of upper extremity spasticity: a randomized, double-blind, placebo-controlled trial. Neurology 1996; 46: 13061310. Google Scholar CrossRef, Medline
5. Brashear A, Gordon MF, Elovic E, . Intramuscular injection of botulinum toxin for the treatment of wrist and finger spasticity after a stroke. N Engl J Med 2002; 347: 395400. Google Scholar CrossRef, Medline
6. Shaw LC, Price CI, van Wijck FM, . Botulinum toxin for the upper limb after stroke (BoTULS) trial: effect on impairment, activity limitation, and pain. Stroke 2011; 42: 13711379. Google Scholar CrossRef, Medline
7. Childers MK, Brashear A, Jozefczyk P, . Dose-dependent response to intramuscular botulinum toxin type A for upper-limb spasticity in patients after a stroke. Arch Phys Med Rehabil 2004; 85: 10631069. Google Scholar CrossRef, Medline
8. Simpson DM, Gracies JM, Yablon SA, . Botulinum neurotoxin versus tizanidine in upper limb spasticity: a placebo-controlled study. J Neurol Neurosurg Psychiatry 2009; 80: 380385. Google Scholar CrossRef, Medline
9. Seo HG, Paik NJ, Lee SU, . Neuronox versus BOTOX in the Treatment of Post-Stroke Upper Limb Spasticity: A Multicenter Randomized Controlled Trial. PLoS One 2015; 10: e0128633. Google Scholar CrossRef
10. Bohannon RW, Smith MB. Interrater reliability of a modified Ashworth scale of muscle spasticity. Phys Ther 1987; 67: 206207. Google Scholar Medline
11. Brashear A, Zafonte R, Corcoran M, . Inter- and intrarater reliability of the Ashworth Scale and the Disability Assessment Scale in patients with upper-limb poststroke spasticity. Arch Phys Med Rehabil 2002; 83: 13491354. Google Scholar CrossRef, Medline
12. Wang HC, Hsieh LF, Chi WC, . Effect of intramuscular botulinum toxin injection on upper limb spasticity in stroke patients. Am J Phys Med Rehabil 2002; 81: 272278. Google Scholar CrossRef, Medline
13. Bhakta BB, Cozens JA, Chamberlain MA, . Impact of botulinum toxin type A on disability and carer burden due to arm spasticity after stroke: a randomised double blind placebo controlled trial. J Neurol Neurosurg Psychiatry 2000; 69: 217221. Google Scholar CrossRef, Medline

Source: Safety and efficacy of letibotulinumtoxinA(BOTULAX®) in treatment of post stroke upper limb spasticity: a randomized, double blind, multi-center, phase III clinical trial – Jan 25, 2017

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[ARTICLE] OnabotulinumtoxinA Improves Pain in Patients with Post-Stroke Spasticity: Findings from a Randomized, Double-Blind, Placebo-Controlled Trial – Full Text HTML/PDF

Abstract

Context

Patients with post-stroke spasticity (PSS) commonly experience pain in affected limbs, which may impact quality of life.

Objectives

To assess onabotulinumtoxinA for pain in patients with PSS from the BOTOX® Economic Spasticity Trial, a multicenter, randomized, double-blind, placebo-controlled trial.

Methods

Patients with PSS (N=273) were randomized to 22- to 34-weeks double-blind treatment with onabotulinumtoxinA + standard care (SC) or placebo injection + SC and were eligible to receive open-label onabotulinumtoxinA up to 52 weeks. Assessments included change from baseline on the 11-point pain numeric rating scale, proportion of patients with baseline pain ≥4 achieving ≥30% and ≥50% improvement in pain, and pain interference with work at week 12, end of double-blind treatment, and week 52.

Results

At baseline, most patients (74.3%) experienced pain and 47.4% had pain ≥4 (pain subgroup). Mean pain reduction from baseline at week 12 was significantly greater with onabotulinumtoxinA + SC (–0.77, 95% CI –1.14 to –0.40) than placebo + SC (–0.13, 95% CI –0.51 to 0.24; P < 0.05). Higher proportions of patients in the pain subgroup achieved ≥30% and ≥50% reductions in pain at week 12 with onabotulinumtoxinA + SC (53.7% and 37.0%, respectively) compared with placebo (28.8% and 18.6%, respectively;P<0.05). Reductions in pain were sustained through week 52. Compared with placebo + SC, onabotulinumtoxinA consistently reduced pain interference with work.

Conclusion

This is the first randomized, placebo-controlled trial demonstrating statistically significant and clinically meaningful reductions in pain and pain interference with work with onabotulinumtoxinA in patients with PSS.


Introduction

Pain prevalence varies widely (10–70%) among post-stroke patients 1, 2, 3 and 4. Several mechanisms may contribute to this range (e.g., peripheral nerve damage, soft tissue trauma, central post-stroke pain, complex regional pain syndrome 5, 6, 7 and 8). Spasticity and pain are factors contributing to “learned non-use” of the affected limb and are often disabling, interfering with daily activities, sleep, walking, physiotherapy, leisure activities, and ultimately affecting patients’ quality of life 9, 10 and 11.

In randomized, double-blind, placebo-controlled trials, onabotulinumtoxinA has been shown to significantly reduce excess muscle tone and decrease disability among patients with upper-limb spasticity 12 and 13, and to further reduce spasms and improve gait in patients with lower-limb spasticity 14 and 15. OnabotulinumtoxinA is effective at reducing pain in patients with cervical dystonia and chronic migraine 16. Prospective open-label studies have shown that onabotulinumtoxinA can reduce pain in patients with post-stroke spasticity (PSS) 8, 17 and 18. However, the efficacy of onabotulinumtoxinA in reducing pain in patients with PSS has not been demonstrated in a large, randomized, placebo-controlled study.

The BOTOX® Economic Spasticity Trial (BEST) was a prospective clinical trial designed to compare the efficacy of onabotulinumtoxinA or placebo (in addition to standard care [SC]) in helping patients with PSS achieve their personal functional goals 19. Here we present results from BEST comparing the effectiveness of onabotulinumtoxinA + SC versus placebo + SC on pain.

Continue —> OnabotulinumtoxinA Improves Pain in Patients with Post-Stroke Spasticity: Findings from a Randomized, Double-Blind, Placebo-Controlled Trial

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[ARTICLE] Spotlight on botulinum toxin and its potential in the treatment of stroke-related spasticity – Full Text HTML/PDF

Abstract: Poststroke spasticity affects up to one-half of stroke patients and has debilitating effects, contributing to diminished activities of daily living, quality of life, pain, and functional impairments. Botulinum toxin (BoNT) is proven to be safe and effective in the treatment of focal poststroke spasticity. The aim of this review is to highlight BoNT and its potential in the treatment of upper and lower limb poststroke spasticity. We review evidence for the efficacy of BoNT type A and B formulations and address considerations of optimal injection technique, patient and caregiver satisfaction, and potential adverse effects of BoNT.

Introduction

Spasticity is a velocity-dependent increase in muscle tone as a part of the upper motor neuron syndrome and is seen in a wide variety of neurologic diseases including stroke.1 Poststroke spasticity can develop as early as 1 week after stroke,2 and it is estimated to occur in up to one-half of stroke survivors.3 The most frequent predictors of spasticity include weakness and reduced motor control.2 Long-term spasticity may lead to tendon contractures and limb deformities that can cause significant pain and functional impairment. Depending on the location of the spasticity, this can impact mobility, activities of daily living such as toileting, dressing, and transferring, and quality of life (QoL) and increase the dependence on caregivers.4

The aim of the treatment in poststroke spasticity is focused on muscle limb overactivity reduction. Treatment modalities are used to alleviate spasticity including physical therapy, systemic and intrathecal medications, and surgery. Systemic medications can be helpful if spasticity is generalized. Agents such as baclofen (gamma-aminobutyric acid [GABA]-B receptor agonist) diazepam (GABA-A receptor agonist), dantrolene (decreases calcium release from skeletal muscle sarcoplasmic reticulum), or tizanidine (TZD; alpha-2 adrenergic receptor agonist) often have systemic side effects such as dry mouth, dizziness, sedation, or generalized weakness.5 After several months of treatment, tolerance may develop to systemic medications.

Chemodenervation and neurolytic procedures with alcohol or phenol may be utilized as second-line management. These techniques are more localized and are injected perineurally to destroy the nerve causing spasticity. The effect may be limited by partial nerve regeneration and adverse effects such as bladder, bowel, and sexual dysfunction.6 Intrathecal baclofen acts on GABA receptors in the lumbar spinal cord and may improve walking speed and functional mobility in poststroke spasticity. However, this therapy is invasive and limited by side effects including nausea, vomiting, and urinary retention. Overdosing may lead to death.7,8

The aim of this review is to highlight botulinum toxin (BoNT) and its potential in the treatment of upper and lower limb poststroke spasticity. Optimal treatment may include BoNT injections into focal muscles in conjunction with an integrated multidisciplinary team approach and intensive rehabilitation programs or to help utilize affected muscles.9 Higher-intensity rehabilitation programs (≥3 1-hour weekly session for ~10 weeks) may help patients achieve more upper limb goals following BoNT injections for spasticity when compared with usual care programs (≤2 1-hour weekly sessions).10 A recent consensus panel of 44 neurologists and physiatrists with experience in BoNT therapy recommended starting a rehabilitation program during the first week after BoNT injection therapy.11

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[Abstract] Botulinum Toxin Injection and Rehabilitation for Neurosurgical Patients with Spasticity.

Abstract

Objectives

Spasticity gives rise to impairment in motor functions and activities of daily living. Botulinum toxin (BTX) can be injected to temporarily paralyze the affected muscles, which provides a window of opportunity for rehabilitation. We present our 2.5-year experience with BTX injection and a patient-specific rehabilitation program provided by a multidisciplinary team, which consists of neurosurgeons, nurses, physiotherapists, occupational therapists and prosthetic orthotists.

Methodology

It is a retrospective study of prospectively collected data in a local hospital including twenty-two patients suffering from spasticity. Outcome measures include goal attainment, caregiver burden and biomechanical assessment by Modified Ashworth Scale and Modified Tardieu Scale (MTS).

Results

OnabotulinumtoxinA injection together with rehabilitation facilitates the attainment of patient-centred physical goals in daily activities. It reduces caregiver burden. Spasticity is reduced particularly for finger and wrist flexors as well as hip adductors. Responses of ankle plantarflexors are less satisfactory which may be due to inadequate dosages. Initial improvement in the R2 component of the MTS for ankle plantarflexors and hip adductors may be attributable to the application of ankle-foot orthosis and abduction pillow.

Conclusions

Multidisciplinary management for spasticity is feasible within our healthcare setting and our promising findings indicate its wider adoption in this locality.

Source: Botulinum Toxin Injection and Rehabilitation for Neurosurgical Patients with Spasticity – See – Surgical Practice – Wiley Online Library

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[ARTICLE] Safety and efficacy of incobotulinumtoxinA as a potential treatment for poststroke spasticity – Full Text HTML/PDF

Abstract: Spasticity is a common disabling symptom for several neurological conditions. Botulinum toxin type A injection represents the gold standard treatment for focal spasticity after stroke showing efficacy, reversibility, and low prevalence of complications. In recent years, incobotulinumtoxinA, a new Botulinum toxin type A free of complexing proteins, has been used for treating several movement disorders with safety and efficacy. IncobotulinumtoxinA is currently approved for treating spasticity of the upper limb in stroke survivors, even if several studies described the use also in lower limb muscles. In the present review article, we examine the safety and effectiveness of incobotulinumtoxinA for the treatment of spasticity after stroke.

Introduction

Spasticity with muscle paresis and loss of dexterity represents one of the most common and discomforting complications affecting stroke survivors. It can have a disabling effect on stroke patients through pain and reduced mobility, affecting quality of life, and can be highly detrimental to daily functioning. Previous studies, based on the estimates of health care professionals, suggested that the prevalence of poststroke spasticity was ~60%, even if this value can be lower than the real value considering the difficulties in measuring spasticity routinely in rehabilitative settings.1

In a recent study, conducted in a clinical setting, 39% of patients with first-ever stroke were spastic after 12 months.2 Lundström et al reported that an estimated prevalence of spasticity 1 year after the first-ever stroke was 17% and that it was more prevalent in the upper limb than in the lower limb.3

In another study, spasticity was present in only 19% of the 95 subjects investigated 3 months after stroke.4 The same group of authors reported that 13 subjects out of 63 displayed spasticity after 18 months of stroke.5

There is no consensus concerning the number of patients developing spasticity. The discrepancies about the prevalence of spasticity onset after stroke might be related to various study settings and samples as well as the difficulty to measure and to identify its early development, discriminating between spastic-dystonia, muscle contracture, increase of stiffness, and other biomechanical factors. It is known that spastic hypertone can be responsible for motor impairments and activity limitations as well as for forced limb posture and pain at rest and during passive movements. The degree of spasticity may change according to the position of the patients, the task being performed, and the presence of aggravating factors such as pressure ulcers, skin infections, or urinary tract infections. Therefore, considering the variability of clinical features of stroke survivors, the assessment of spasticity is difficult as well as the need for treatment. In fact, for example, it has also been suggested that for stroke patients, the overactivity of leg extensor muscles enables them to support their body, standing position, and stance phase of gait cycle but interferes with knee flexion during the swing phase, so in this case, a botulinum toxin (BoNT) injection into rectus femoris or vastus intermedius muscles can be useful to reduce this impairment.6

Spasticity is also divided into generalized and focal when few muscles are involved. This type of classification can influence the choice of treatment considering not only the therapy but also the aim to improve limb posture and body image, to apply splinting, to consent hygiene, to increase passive articular range of motion, to walk and stand, to decrease pain and discomfort, to reduce the burden of care, or to prevent contracture. The purpose of this review article is to evaluate the effectiveness of the employment of incobotulinumtoxinA, a recent marked formulation of botulinum toxin type A (BoNT-A), to reduce spasticity in stroke survivors through an analysis of published clinical studies.

Continue (HTML) —-> Source: Safety and efficacy of incobotulinumtoxinA as a potential treatment fo | NDT

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[ARTICLE] Hemiparetic gait and changes in functional performance due to OnabotulinumtoxinA injection to lower limb muscles

Highlights

  • Measurement of temporal spatial gait parameters helps assess function in hemiparetic patients.
  • Dynamic EMG is valuable in the selection of muscles in hemiparetic gait.
  • Gait parameters showed significant increase in walking velocity and cadence after OnabotA injection to ankle muscles.
  • Average of 320 (± 107) units of OnabotA injection to selected ankle muscles enhances functional ambulation in hemiparetic gait.

Abstract

Objective: To review gait alterations and evaluate the effects of OnabotulinumtoxinA on spatiotemporal walking parameters of patients with hemiparetic gait.

Design: Retrospective pre- and post-intervention analysis.

Setting: Gait analysis laboratory in a tertiary level rehabilitation hospital.

Participants: 42 patients with hemiparesis. 19 males and 23 females, age 18-78 years were included.

Intervention: Spatiotemporal parameters collected before and within 4 to 10 weeks after OnabotA injection to the ankle muscles. Data was recorded at self-selected velocity on a 12 meter instrumented walkway. The most common muscles injected were medial and lateral gastrocnemius, soleus and tibialis posterior. Average total OnabotulinumtoxinA dose was 320±107 units.

Main Outcome: Spatiotemporal parameters of walking assessed before (T0) and within 4 to 10 weeks post injection (T1). Paired t-test was used to compare pre- and post-intervention data. A sequential Holm-Bonferroni procedure was used to adjust for multiple comparisons and minimize the risk of type I error. Statistical significance was set at p<0.05.

Results: Statistically significant increases were seen for walking velocity (20%) (T0=0.40±0.26 m/s and T1=0.48±0.29 m/s; p=0.006), and increased cadence (T0=63.48±23.93 steps/min, and T1=70.88±23.65 steps/min; p=0.006) following OnabotulinumtoxinA injections.

Conclusion: This study demonstrates that injection of OnabotulinumtoxinA 320 units to ankle muscles selected with the aid of dynamic electromyography can significantly increase gait velocity and enhance functional ambulation in adults with hemiparesis due to upper motor neuron syndrome.

μέσω Hemiparetic gait and changes in functional performance due to OnabotulinumtoxinA injection to lower limb muscles.

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