Botulinum neurotoxin versus tizanidine in upper limb spasticity: a placebo-controlled study

Treatment of adult spasticity with Botox (onabotulinumtoxinA): Development, insights, and impact

Upper and lower limb spasticity (ULS, LLS) often occur following a stroke or in patients with other neurological disorders, leading to difficulties in mobility and daily living and decreased quality of life. Prior to the use of onabotulinumtoxinA, antispastic medications had limited efficacy and often caused sedation. Phenol injections were difficult for physicians to perform, painful, and led to tissue destruction. The success of onabotulinumtoxinA in treating cervical dystonia led to its use in spasticity. However, many challenges characterized the development of onabotulinumtoxinA for adult spasticity. The wide variability in the presentation of spasticity among patients rendered it difficult to determine which muscles to inject and how to measure improvement. Another challenge was the initial refusal of the Food and Drug Administration to accept the Ashworth Scale as a primary endpoint. Additional scales were designed to incorporate a goal-oriented, patient-centered approach that also accounted for the variability of spasticity presentations. Several randomized, double-blind, placebo-controlled trials of post-stroke spasticity of the elbow, wrist, and/or fingers showed significantly greater improvements in the modified Ashworth Scale and patient treatment goals and led to the approval of onabotulinumtoxinA for the treatment of ULS in adult patients. Lessons learned from the successful ULS trials were applied to design an LLS trial that led to approval for the latter indication. Additional observational trials mimicking real-world treatment have shown continued effectiveness and patient satisfaction. The use of onabotulinumtoxinA for spasticity has ushered in a more patient-centered treatment approach that has vastly improved patients' quality of life.

Safety and efficacy of MT10107 in post-stroke upper limb spasticity treatment: A phase I randomized controlled trial

BACKGROUND

Botulinum toxin type A injection is widely used treatment option for the treatment of upper limb spasticity in stroke patients. The purpose of this study was to explore the safety and efficacy of MT10107, a new botulinum toxin type A, in patients with post-stroke upper limb spasticity.

METHODS

A prospective, randomized, double-blind, active drug-controlled, multi-center, phase I clinical trial. Thirty patients with post-stroke upper limb spasticity were received either MT10107 or onabotulinumtoxinA. Primary endpoint was change of modified Ashworth scale (MAS) score for wrist flexor from baseline to week 4. The secondary endpoints were changes of MAS scores for elbow and finger flexors, response rate, Disability Assessment Scale (DAS), and global assessment of treatment. The safety endpoints such as adverse events, vital signs, physical examination, and laboratory test were evaluated. The outcome measures were evaluated from baseline to week 4.

RESULTS

The primary endpoints were -1.07 ± 0.70 and -1.23 ± 0.56 for the MT10107 and onabotulinumtoxinA groups, respectively. The intergroup difference of change between the 2 groups was 0.17 (95% confidence interval -0.31 to 0.64, P = .5769). In secondary endpoints, both groups showed a significant improvement in both MAS and DAS. There was no significant between-group difference in all secondary endpoints and safety measures.

CONCLUSION

The safety and efficacy of MT10107 showed no significant difference compared to onabotulinumtoxinA in post-stroke upper limb spasticity treatment.

Safety and Efficacy of HU-014 in the Treatment of Post-Stroke Upper Limb Spasticity: A Phase I Pilot Study

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.

Quantitative measurement of resistance force and subsequent attenuation during passive isokinetic extension of the wrist in patients with mild to moderate spasticity after stroke

Background

Spasticity is evaluated by measuring the increased resistance to passive movement, primarily by manual methods. Few options are available to measure spasticity in the wrist more objectively. Furthermore, no studies have investigated the force attenuation following increased resistance. The aim of this study was to conduct a safe quantitative evaluation of wrist passive extension stiffness in stroke survivors with mild to moderate spastic paresis using a custom motor-controlled device. Furthermore, we wanted to clarify whether the changes in the measured values could quantitatively reflect the spastic state of the flexor muscles involved in the wrist stiffness of the patients.

Materials and methods

Resistance forces were measured in 17 patients during repetitive passive extension of the wrist at velocities of 30, 60, and 90 deg/s. The Modified Ashworth Scale (MAS) in the wrist and finger flexors was also assessed by two skilled therapists and their scores were averaged (i.e., average MAS) for analysis. Of the fluctuation of resistance, we focused on the damping just after the peak forces and used these for our analysis. A repeated measures analysis of variance was conducted to assess velocity-dependence. Correlations between MAS and damping parameters were analyzed using Spearman’s rank correlation.

Results

The damping force and normalized value calculated from damping part showed significant velocity-dependent increases.

There were significant correlations (ρ = 0.53–0.56) between average MAS for wrist and the normalized value of the damping part at 90 deg/s. The correlations became stronger at 60 deg/s and 90 deg/s when the MAS for finger flexors was added to that for wrist flexors (ρ = 0.65–0.68).

Conclusions

This custom-made isokinetic device could quantitatively evaluate spastic changes in the wrist and finger flexors simultaneously by focusing on the damping part, which may reflect the decrease in resistance we perceive when manually assessing wrist spasticity using MAS.

Trial registration UMIN Clinical Trial Registry, as UMIN000030672, on July 4, 2018

Assessment, goal setting, and botulinum neurotoxin a therapy in the management of post-stroke spastic movement disorder: updated perspectives on best practice

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.

Time course response after single injection of botulinum toxin to treat spasticity after stroke: Systematic review with pharmacodynamic model-based meta-analysis

BACKGROUND

The time-course response after a single injection of botulinum toxin (BoNT) for post-stroke spasticity is debated. We addressed this issue by conducting a systematic review and a pharmacodynamic model-based meta-analysis.

METHODS

We searched Medline, PeDro and Google Scholar databases up to March 2020, selecting randomized controlled trials of post-stroke and traumatic brain injury patients with arm or leg muscle hypertonia, comparing BoNT to placebo, or different BoNT preparations. The main outcome was change in Modified Ashworth Scale (MAS) score. A non-linear mixed effect model was used to estimate maximal toxin and placebo effects (Emax and EPlacebo), the effect disappearance half-life (T1/2off) of BoNT and the doses achieving 50 and 80% of Emax (D50 and D80). The equivalence ratios between different BoNT preparations were calculated from D50 values. Adverse events were recorded.

RESULTS

Altogether, 2,236 unique records were screened by 2 independent reviewers: 35 eligible trials including 3011 patients (95% post-stroke) were identified. For all BoNT preparations, the BoNT Emax of -1.11 (95% credible interval -1.31; -0.29) was reached at 5 weeks; the maximal placebo effect was -0.30 (-0.37; -0.22). Both D50 and D80 differed significantly by muscle volume. At D50, the equivalence ratio was significantly higher for abobotulinumtoxinA (3.35) than onabotulinumtoxinA and lower for letibotulinumtoxinA (0.41). T1/2off was longer for abobotulinumtoxinA than for onabotulinumtoxinA and the other preparations (13.1 weeks [95% credible interval 7.7; 19.3] vs 8.6 weeks [7.1; 10.1]). Adverse events were minor, with a weak, but significant, dose-response relation for muscle weakness.

CONCLUSIONS

This first pharmacodynamic model-based meta-analysis of individuals with stroke revealed that for all BoNT-A preparations, BoNT-A injections to treat spasticity have maximal effect at 5 weeks. The T1/2off was longer for abobotulinumtoxinA than other preparations. Differences between certain BoNT unit scales were also confirmed.

AbobotulinumtoxinA Versus OnabotulinumtoxinA in Adults with Upper Limb Spasticity: A Randomized, Double-Blind, Crossover Study Protocol

INTRODUCTION

The safety and efficacy of both abobotulinumtoxinA and onabotulinumtoxinA for upper limb spasticity are well established, but head-to-head comparisons are lacking.

METHODS

DIRECTION is an international, randomized, double-blind, crossover study comparing the safety and efficacy of abobotulinumtoxinA with onabotulinumtoxinA in the management of upper limb spasticity at doses at or near maximum recommended in product labelling. Participants (18-75 years) will be randomized (1:1) to either one cycle of abobotulinumtoxinA (900U) followed by onabotulinumtoxinA (360U) or vice versa. To maintain blinding, a fixed volume (3.6 ml) will be injected into the target upper limb muscles (four wrist and finger flexors and biceps brachii). The second treatment cycle will begin at Week 12 if retreatment criteria are fulfilled, and if not, they will be reassessed every 4 weeks until they meet retreatment parameters.

PLANNED OUTCOMES

The primary hypothesis is that there is comparable safety between products; non-inferiority will be tested based on treatment-emergent adverse event (TEAE) rates from injection to Week 12. A secondary hypothesis is that abobotulinumtoxinA has longer duration of effect than onabotulinumtoxinA. This hypothesis will be tested with secondary efficacy endpoints, including injection cycle duration, Modified Ashworth Scale, Disability Assessment Scale and Physician Global Assessment.

TRIAL REGISTRATION

EudraCT ( http://eudract.ema.europa.eu ): 2021-000161-32 and Clinicaltrials.gov ( http://clinicaltrials.gov ): NCT04936542. Overview of the study protocol by the principal investigator (MP4 185265 KB).

Objective assessment of spasticity by pendulum test: a systematic review on methods of implementation and outcome measures

Background

Instrumented pendulum test is an objective and repeatable biomechanical method of assessment for spasticity. However, multitude of sensor technologies and plenty of suggested outcome measures, confuse those interested in implementing this method in practice. Lack of a standard agreement on the definition of experimental setup and outcome measures adds to this ambiguity and causes the results of one study not to be directly attainable by a group that uses a different setup. In this systematic review of studies, we aim to reduce the confusion by providing pros and cons of the available choices, and also by standardizing the definitions.

Methods

A literature search was conducted for the period of 1950 to the end of 2019 on PubMed, Science Direct, Google Scholar and IEEE explore; with keywords of “pendulum test” and “Spasticity”.

Results

Twenty-eight studies with instrumented pendulum test for assessment of spasticity met the inclusion criteria. All the suggested methods of implementation were compared and advantages and disadvantages were provided for each sensor technology. An exhaustive list categorized outcome measures in three groups of angle-based, angular velocity-based, and angular acceleration-based measures with all different names and definitions.

Conclusions

With the aim of providing standardized methodology with replicable and comparable results, sources of dissimilarity and ambiguity among research strategies were found and explained with the help of graphical representation of pendulum movement stages and corresponding parameters on the angular waveforms. We hope using the provided tables simplify the choices when implementing pendulum test for spasticity evaluation, improve the consistency when reporting the results, and disambiguate inconsistency in the literature.

Can the early use of botulinum toxin in post stroke spasticity reduce contracture development? A randomised controlled trial

Objective:

Does early treatment of spasticity with botulinum-toxin (BoNTA), in (hyper)acute stroke patients without arm-function, reduce contractures and improve function.

Design:

Randomised placebo-controlled-trial

Setting:

Specialised stroke-unit.

Participants & Intervention:

Patients with an Action Research Arm Test (ARAT) grasp-score⩽2 who developed spasticity within six-weeks of a first stroke were randomised to receive injections of: 0.9%sodium-chloride solution (placebo) or onabotulinumtoxin-A (treatment).

Outcome-Measures:

Spasticity, contractures, splint use and arm function (ARAT) were taken at baseline, 12-weeks post-injection and six-months after stroke. Additionally, spasticity and contractures were measured at weeks-two, four and six post-injection.

Results:

Ninety three patients were randomised. Mean time to intervention was 18-days (standard deviation = 9.3). Spasticity was lower in the treatment group with difference being significant between week-2 to 12 (elbow) and week-2 to 6 (wrist). Mean-difference (MD) varied between –8.5(95% CI –17 to 0) to –9.4(95% CI –14 to –5) µV.

Contracture formation was slower in the treatment group. Passive range of motion was higher in the treatment group and was significant at week-12 (elbow MD6.6 (95% CI –0.7 to –12.6)) and week-6 (wrist MD11.8 (95% CI 3.8 to 19.8)). The use of splints was lower in the treatment group odds ratio was 7.2 (95% CI 1.5 to 34.1) and 4.2 (95% CI 1.3 to 14.0) at week-12 and month-6 respectively.

Arm-function was not significantly different between the groups MD2.4 (95% CI –5.3 to 10.1) and 2.9 (95% CI –5.8 to 11.6) at week-12 and month-6 respectively.

Conclusion:

BoNTA reduced spasticity and contractures after stroke and effects lasted for approximately 12-weeks. BoNTA reduced the need for concomitant contracture treatment and did not interfere with recovery of arm function.

Trial Registration:

EudraCT (2010-021257-39) and ClinicalTrials.gov-Identifier: NCT01882556.

Efficacy and Safety of MT10107 (Coretox) in Poststroke Upper Limb Spasticity Treatment: A Randomized, Double-Blind, Active Drug-Controlled, Multicenter, Phase III Clinical Trial

OBJECTIVE

To compare the efficacy and safety of MT10107 (Coretox) with those of onabotulinum toxin A (Botox) in patients with poststroke upper limb spasticity DESIGN: Prospective, randomized, double-blind, active drug-controlled, multicenter, phase III clinical trial.

SETTING

Seven university hospitals in the Republic of Korea.

PARTICIPANTS

Patients (N=220) with poststroke upper limb spasticity.

INTERVENTIONS

All participants received a single injection of either MT10107 (Coretox group) or onabotulinum toxin A (Botox group).

MAIN OUTCOME MEASURES

The primary outcome was change in wrist flexor spasticity from baseline to week 4, which was assessed using the modified Ashworth scale (MAS). The secondary outcomes were MAS scores for wrist, elbow, and finger flexors; percentage of treatment responders (response rate); Disability Assessment Scale (DAS) score, and global assessment of treatment. Safety was evaluated based on adverse events, vital signs, physical examination findings, and laboratory test results. The efficacy and safety were evaluated at 4, 8, and 12 weeks postintervention.

RESULTS

The primary outcome was found to be -1.32±0.69 and -1.40±0.69 for the Coretox and Botox groups, respectively. MT10107 showed a non-inferior efficacy compared with onabotulinum toxin A, as the 95% confidence interval for between-group differences was -0.10 to 0.27 and the upper limit was less than the non-inferiority margin of 0.45. Regarding the secondary outcomes, MAS scores for all muscles and DAS scores showed a significant improvement at all time points in both groups, with no significant between-group difference. No significant between-group differences were observed regarding response rate, global assessment of treatment, and safety measures.

CONCLUSIONS

MT10107 showed no significant difference in efficacy and safety compared with onabotulinum toxin A in poststroke upper limb spasticity treatment.

Individualized OnabotulinumtoxinA Treatment for Upper Limb Spasticity Resulted in High Clinician- and Patient-Reported Satisfaction: Long-Term Observational Results from the ASPIRE Study

Introduction

OnabotulinumtoxinA treatment for spasticity is dependent on numerous factors and varies according to selected treatment goals.

Objective

To examine real‐world onabotulinumtoxinA treatment utilization and effectiveness in patients with upper limb spasticity over 2 years from the Adult Spasticity International Registry (ASPIRE) study.

Design

Multicenter, prospective, observational registry (NCT01930786).

Setting

Fifty‐four international clinical sites in North America, Europe, and Asia.

Patients

Adults (naïve or non‐naïve to botulinum toxins for spasticity) with upper limb focal spasticity related to upper motor neuron syndrome across multiple etiologies.

Interventions

OnabotulinumtoxinA administered at clinician's discretion.

Main Outcome Measures

OnabotulinumtoxinA utilization, clinician and patient satisfaction.

Results

Four hundred eighty‐four patients received ≥1 treatment of onabotulinumtoxinA for upper limb spasticity. Patients were on average 55.1 years old, 50.8% male, predominantly Caucasian (72.3%), and 38.6% were naïve to botulinum toxins. Stroke was the most frequently reported underlying etiology (74.0%). Most patients (81.2%) had moderate to severe spasticity at baseline. The most commonly treated upper limb clinical presentation was clenched fist (79.1% of patients). Across all presentations, onabotulinumtoxinA doses ranged between 5‐600U. Electromyography (EMG) was most often utilized to localize muscles (≥57.0% of treatment sessions). Clinicians (92.9% of treatment sessions) and patients (85.7%) reported being extremely satisfied/satisfied that treatment helped manage spasticity, and clinicians (98.6%) and patients (92.2%) would definitely/probably continue onabotulinumtoxinA treatment. One hundred seventy‐nine patients (37.0%) reported 563 adverse events (AEs); 15 AEs in 14 patients (2.9%) were considered treatment related. Sixty‐nine patients (14.3%) reported 137 serious AEs; 3 serious AEs in 2 patients (0.4%) were considered treatment related. No new safety signals were identified.

Conclusions

ASPIRE captured the real‐world individualized nature of onabotulinumtoxinA utilization for upper limb spasticity over 2 years, with consistently high clinician‐ and patient‐reported satisfaction. Data in this primary analysis will guide clinical use of onabotulinumtoxinA, as well as provide insights to improve educational programs on spasticity management.

IncobotulinumtoxinA Treatment in Upper-Limb Poststroke Spasticity in the Open-Label Extension Period of PURE: Efficacy in Passive Function, Caregiver Burden, and Quality of Life

BACKGROUND

Poststroke spasticity affects motor function and the ability to perform activities of daily living, with the potential to affect quality of life (QoL) and increase caregiver burden.

OBJECTIVE

To investigate the effect of repeated incobotulinumtoxinA treatment on spasticity-associated functional disability, caregiver burden, and QoL in the 36-week open-label extension of the phase 3 PURE study (NCT01392300).

DESIGN

Open-label extension period of a prospective, double-blind, placebo-controlled, randomized, multicenter study.

SETTING

Forty-six investigation sites in seven countries (Czech Republic, Germany, Hungary, India, Poland, Russia, United States).

PARTICIPANTS

Adults, aged 18-80 years, ≥12 months since last botulinum neurotoxin injection or entirely toxin naïve, with median poststroke upper-limb spasticity of >2 years' duration.

METHODS

Participants who completed the 12-week, double-blind main period could enter the open-label extension and receive up to three additional incobotulinumtoxinA treatments (fixed total dose 400 U at 12-week intervals) into the affected muscles of one upper limb.

MAIN OUTCOME MEASURES

Functional disability (Disability Assessment Scale; DAS), caregiver burden (Carer Burden Scale), and quality of life (QoL; EuroQol [EQ] 5-dimensions three-level [EQ-5D-3L]).

RESULTS

The open-label extension included 296 treated patients. Mean DAS score for the principal target domain improved significantly from the main period baseline to the end-of-study visit (P < .0001). Carer Burden Scale scores also significantly improved from the main period baseline to the end-of-study visit (P < .05 for all caregiving activities except "applying a splint"). At the end-of-study visit, versus the main period baseline, 19.7%-33.3% of patients experienced improvements for each parameter on the EQ-5D-3L, except "mobility," with significant improvement in EQ-5D visual analog scale scores (P < .001).

CONCLUSIONS

Repeated incobotulinumtoxinA treatments at 12-week intervals in participants with chronic poststroke upper-limb spasticity resulted in significant improvements in QoL, as well as significant reductions in upper-limb functional disability and caregiver burden.

Cost-Utility Analysis of Incobotulinumtoxin-A Compared With Conventional Therapy in the Management of Post-Stroke Spasticity in Romania

Objectives: In Romania, the strokes' incidence is of 61,500 per year and improving upper limb function is the essence in rehabilitation after a stroke to maximize the patient quality of life and reduce disability. In this study, it is compared the cost-effectiveness of the treatment of post-stroke upper limb spasticity with incobotulinumtoxin-A (INCO), with or without electromyographic control, against the conventional therapy programme alone (CON). Methods: A Markov state transition model was developed to effectuate a cost-utility analysis (CUA). Measurements of health-related quality of life were derived from relevant clinical trials. Utility values for quality of life by response status were derived from the Short-Form-12 (SF-12) Health Survey data from a published study. The incremental cost-effectiveness ratio (ICER) of INCO (fixed, every 12 weeks) against CON was calculated in Ron per quality-adjusted life-year (QALY) gained for both therapies. Costs and outcomes were discounted using different scenarios at 3% and 5% per year with a time horizon of 3 and 5 years because Romanian legislative norms don't specify the discount rates and time horizon for pharmacoeconomic analysis. Probabilistic sensitivity analyses (PSA) were managed on the base case with distributions attributed to the frequency of repeat dosing and utility valuation of the responder and the non-responder for health utilities derived from both mental and physical health state. Results: Compared with CON, in all 4 scenarios, therapy with INCO had an incremental cost-effectiveness ratio (ICER) of less than 950 Euro per QALY gained (1 Euro = 4.7 Ron). INCO proved to be more favorable treatment option than CON in the treatment of upper limb spasticity in Romania. Despite costs being higher for patients treated with INCO, this treatment has more advantageous Incremental Cost-Effectiveness Ratio. Conclusions: This therapy should be taken into account when considering rehabilitation options because it is highly cost-effective at < EURO 1,000/QALY gained, a very low WTP (Willingness To Pay) threshold. INCO proved to be a disruptive innovation because it is a new and more effective treatment, and, in the end, much higher in quality of life for patients with post-stroke upper limb spasticity.

Efficacy and Safety of Botulinum Toxin Type A for Limb Spasticity after Stroke: A Meta-Analysis of Randomized Controlled Trials

Background

Inconsistent data have been reported for the effectiveness of intramuscular botulinum toxin type A (BTXA) in patients with limb spasticity after stroke. This meta-analysis of available randomized controlled trials (RCTs) aimed to determine the efficacy and safety of BTXA in adult patients with upper and lower limb spasticity after stroke.

Methods

An electronic search was performed to select eligible RCTs in PubMed, Embase, and the Cochrane library through December 2018. Summary standard mean differences (SMDs) and relative risk (RR) values with corresponding 95% confidence intervals (CIs) were employed to assess effectiveness and safety outcomes, respectively.

Results

Twenty-seven RCTs involving a total of 2,793 patients met the inclusion criteria, including 16 and 9 trials assessing upper and lower limb spasticity cases, respectively. For upper limb spasticity, BTXA therapy significantly improved the levels of muscle tone (SMD=-0.76; 95% CI -0.97 to -0.55; P<0.001), physician global assessment (SMD=0.51; 95% CI 0.35-0.67; P<0.001), and disability assessment scale (SMD=-0.30; 95% CI -0.40 to -0.20; P<0.001), with no significant effects on active upper limb function (SMD=0.49; 95% CI -0.08 to 1.07; P=0.093) and adverse events (RR=1.18; 95% CI 0.72-1.93; P=0.509). For lower limb spasticity, BTXA therapy was associated with higher Fugl-Meyer score (SMD=5.09; 95%CI 2.16-8.01; P=0.001), but had no significant effects on muscle tone (SMD=-0.12; 95% CI -0.83 to 0.59; P=0.736), gait speed (SMD=0.06; 95% CI -0.02 to 0.15; P=0.116), and adverse events (RR=1.01; 95% CI 0.71-1.45; P=0.949).

Conclusions

BTXA improves muscle tone, physician global assessment, and disability assessment scale in upper limb spasticity and increases the Fugl-Meyer score in lower limb spasticity.

IncobotulinumtoxinA Efficacy and Safety in Adults with Upper-Limb Spasticity Following Stroke: Results from the Open-Label Extension Period of a Phase 3 Study

Introduction

The objective of the study was to investigate the efficacy and safety of repeated incobotulinumtoxinA injections for the treatment of upper-limb post-stroke spasticity in adults.

Methods

Adults 18–80 years of age with post-stroke upper-limb spasticity who completed the 12-week randomized, double-blind, placebo-controlled main period (MP) of a phase 3 trial (NCT01392300) were eligible to enrol in the 36-week open-label extension period (OLEX). The OLEX included three treatment cycles at fixed 12-week injection intervals; subjects were injected with 400 U incobotulinumtoxinA into the affected upper limb. Efficacy assessments included evaluation of muscle tone using the Ashworth Scale (AS) and the Global Impression of Change Scale (GICS) assessed by the investigator, subject, and caregiver. The incidence of adverse events (AEs) was monitored throughout the OLEX.

Results

A total of 296 of 299 subjects (99.0%) who completed the MP received incobotulinumtoxinA in the OLEX, and 248 subjects completed the 36-week OLEX. The proportion of subjects with at least a 1-point improvement in AS score from each incobotulinumtoxinA treatment to the respective 4-week post-injection visit ranged by cycle from 52.3% to 59.2% for wrist flexors, 49.1% to 52.3% for elbow flexors, 59.8% to 64.5% for finger flexors, 35.5% to 41.2% for thumb flexors, and 37.4% to 39.9% for forearm pronators (P < 0.0001 for all). Over 90% of subjects were assessed by the investigator to be at least minimally improved (4 weeks post-injection) on the GICS during each injection cycle; 61.0% in the 1st cycle, 58.2% in the 2nd cycle, and 57.4% in the 3rd cycle were considered much improved or very much improved on the GICS. Three percent of subjects (9/296) reported treatment-related AEs; the most frequently reported were pain in the extremity (n = 2, 0.7%) and constipation (n = 2, 0.7%). Serious AEs were reported by 22 subjects (7.4%); however, none were considered treatment-related.

Conclusions

Repeated injections of incobotulinumtoxinA for the treatment of post-stroke upper-limb spasticity led to significant improvements in muscle tone and investigator’s global impression of change. Treatment was well tolerated, with no serious treatment-related AEs.

Funding

Merz Pharmaceuticals GmbH.

[Medical care of patients with spasticity following stroke : Evaluation of the treatment situation in Germany with focus on the use of botulinum toxin]

BACKGROUND

Upper limb spasticity is a common complication following stroke. Cohort studies found 19% of post-stroke patients had upper limb spasticity at 3 months and 38% of patients at 12 months. For focal spasticity, intramuscular injections of botulinum toxin are indicated. In Germany, it is assumed that patients with the described indication are undersupplied with botulinum toxin.

OBJECTIVE

The aim of the present study is to evaluate the medical care of patients with upper limb spasticity post-stroke with the focus on the use of botulinum toxin as one treatment option.

METHODS

A standardized questionnaire was developed and a postal survey of a representative national random sample of 800 neurologists to capture the actual medical care situation.

RESULTS

The response rate amounted to 37% (n = 292). 59% of the neurologists surveyed had never used botulinum toxin. In total, 87% of neurologists noticed barriers regarding the use of botulinum toxin, where the amount of the doctor's remuneration in 40% and the lack of reimbursement of costs in off-label use in 60% were the most commonly used answers. The achievement of an advanced training in using botulinum toxin was also stated as a general obstacle for resident neurologists.

DISCUSSION

Due to a response rate of 37% for the postal survey a selection bias cannot be excluded. Although botulinum toxin is recommended in the national treatment guidelines, many neurologists do not use botulinum toxin. The reasons can be seen from the barriers described.

[Treatment of spasticity after traumatic brain injury in children: the role of botulinum toxin therapy]

Traumatic brain injury (TBI) is one of the main reasons of death and disability in children and adolescents in Russia and abroad. Spasticity is a frequent outcome of the TBI that influences on the rehabilitation prognosis, degree of movement disorders and quality of life after trauma. Early spasticity correction and complex rehabilitation lead to the optimal recovery and prevent secondary complications. This review presents the current data about the prognostic role of the spasticity in children after TBI, methods of its correction and their scientific evidence. Limitations and challenges of per-oral antispastic agents are described especially for the patients with local spasticity. Attention is focused on the methods of treatment of local hypertonus, in particular botulinum toxin A (BTA) injections proved to be effective in adults with acquired brain injury. The article summarizes the results of international investigations, systematic reviews and consensus statements about the efficacy and safety of botulinum toxin treatment in children after the TBI. The authors describe an algorithm of the optimal patient selection and goal setting for BTA injections in children with acquired brain injury.

Interventions for managing skeletal muscle spasticity following traumatic brain injury

BACKGROUND

Skeletal muscle spasticity is a major physical complication resulting from traumatic brain injury (TBI), which can lead to muscle contracture, joint stiffness, reduced range of movement, broken skin and pain. Treatments for spasticity include a range of pharmacological and non-pharmacological interventions, often used in combination. Management of spasticity following TBI varies from other clinical populations because of the added complexity of behavioural and cognitive issues associated with TBI.

OBJECTIVES

To assess the effects of interventions for managing skeletal muscle spasticity in people with TBI.

SEARCH METHODS

In June 2017, we searched key databases including the Cochrane Injuries Group Specialised Register, CENTRAL, MEDLINE (Ovid), Embase (Ovid) and others, in addition to clinical trials registries and the reference lists of included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and cross-over RCTs evaluating any intervention for the management of spasticity in TBI. Only studies where at least 50% of participants had a TBI (or for whom separate data for participants with TBI were available) were included. The primary outcomes were spasticity and adverse effects. Secondary outcome measures were classified according to the World Health Organization International Classification of Functioning, Disability and Health including body functions (sensory, pain, neuromusculoskeletal and movement-related functions) and activities and participation (general tasks and demands; mobility; self-care; domestic life; major life areas; community, social and civic life).

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Data were synthesised narratively; meta-analysis was precluded due to the paucity and heterogeneity of data.

MAIN RESULTS

We included nine studies in this review which involved 134 participants with TBI. Only five studies reported between-group differences, yielding outcome data for 105 participants with TBI. These five studies assessed the effects of a range of pharmacological (baclofen, botulinum toxin A) and non-pharmacological (casting, physiotherapy, splints, tilt table standing and electrical stimulation) interventions, often in combination. The studies which tested the effect of baclofen and tizanidine did not report their results adequately. Where outcome data were available, spasticity and adverse events were reported, in addition to some secondary outcome measures.Of the five studies with results, three were funded by governments, charities or health services and two were funded by a pharmaceutical or medical technology company. The four studies without useable results were funded by pharmaceutical or medical technology companies.It was difficult to draw conclusions about the effectiveness of these interventions due to poor reporting, small study size and the fact that participants with TBI were usually only a proportion of the overall total. Meta-analysis was not feasible due to the paucity of data and heterogeneity of interventions and comparator groups. Some studies concluded that the intervention they tested had beneficial effects on spasticity, and others found no difference between certain treatments. The most common adverse event was minor skin damage in people who received casting. We believe it would be misleading to provide any further description of study results given the quality of the evidence was very low for all outcomes.

AUTHORS' CONCLUSIONS

The very low quality and limited amount of evidence about the management of spasticity in people with TBI means that we are uncertain about the effectiveness or harms of these interventions. Well-designed and adequately powered studies using functional outcome measures to test the interventions used in clinical practice are needed.

Imaging three-dimensional innervation zone distribution in muscles from M-wave recordings

OBJECTIVE

To localize neuromuscular junctions in skeletal muscles in vivo which is of great importance in understanding, diagnosing and managing of neuromuscular disorders.

APPROACH

A three-dimensional global innervation zone imaging technique was developed to characterize the global distribution of innervation zones, as an indication of the location and features of neuromuscular junctions, using electrically evoked high-density surface electromyogram recordings.

MAIN RESULTS

The performance of the technique was evaluated in the biceps brachii of six intact human subjects. The geometric centers of the distributions of the reconstructed innervation zones were determined with a mean distance of 9.4  ±  1.4 cm from the reference plane, situated at the medial epicondyle of the humerus. A mean depth was calculated as 1.5  ±  0.3 cm from the geometric centers to the closed points over the skin. The results are consistent with those reported in previous histology studies. It was also found that the volumes and distributions of the reconstructed innervation zones changed as the stimulation intensities increased until the supramaximal muscle response was achieved.

SIGNIFICANCE

Results have demonstrated the high performance of the proposed imaging technique in noninvasively imaging global distributions of the innervation zones in the three-dimensional muscle space in vivo, and the feasibility of its clinical applications, such as guiding botulinum toxin injections in spasticity management, or in early diagnosis of neurodegenerative progression of amyotrophic lateral sclerosis.

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

Objective:

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®).

Design:

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

Setting:

Six university hospitals in Korea.

Subjects:

A total of 187 stroke participants with upper limb spasticity.

Interventions:

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).

Main measures:

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.

Results:

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).

Conclusions:

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

Pharmacological interventions other than botulinum toxin for spasticity after stroke

BACKGROUND

The long-term risk of stroke increases with age, and stroke is a common cause of disability in the community. Spasticity is considered a significantly disabling impairment that develops in people who have had a stroke. The burden of care is higher in stroke survivors who have spasticity when compared with stroke survivors without spasticity with regard to treatment costs, quality of life, and caregiver burden.

OBJECTIVES

To assess if pharmacological interventions for spasticity are more effective than no intervention, normal practice, or control at improving function following stroke.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (May 2016), the Cochrane Central Register of Controlled Trials (CENTRAL, 2016, Issue 5), MEDLINE (1946 to May 2016), Embase (2008 to May 2016), CINAHL (1982 to May 2016), AMED (1985 to May 2016), and eight further databases and trial registers. In an effort to identify further studies, we undertook handsearches of reference lists and contacted study authors and commercial companies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared any systemically acting or locally acting drug versus placebo, control, or comparative drug with the aim of treating spasticity.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the studies for inclusion and extracted the data. We assessed the included studies for both quality and risk of bias. We contacted study authors to request further information when necessary.

MAIN RESULTS

We included seven RCTs with a total 403 participants. We found a high risk of bias in all but one RCT. Two of the seven RCTs assessed a systemic drug versus placebo. We pooled data on an indirect measure of spasticity (160 participants) from these two studies but found no significant effect (odds ratio (OR) 1.66, 95% confidence interval (CI) 0.21 to 13.07; I² = 85%). We identified a significant risk of adverse events per participant occurring in the treatment group versus placebo group (risk ratio (RR) 1.65, 95% CI 1.12 to 2.42; 160 participants; I² = 0%). Only one of these studies used a functional outcome measure, and we found no significant difference between groups.Of the other five studies, two assessed a systemic drug versus another systemic drug, one assessed a systemic drug versus local drug, and the final two assessed a local drug versus another local drug.

AUTHORS' CONCLUSIONS

The lack of high-quality RCTs limited our ability to make specific conclusions. Evidence is insufficient to determine if systemic antispasmodics are effective at improving function following stroke.

[The efficacy of botulinum toxin therapy in patients with upper limb spasticity due to traumatic brain injury]

Spasticity is a type of muscle hyperactivity that occurs in patients after focal lesions of the Central nervous system due to various diseases: stroke, traumatic brain injury or spinal cord injury, neurosurgical intervention, as well as multiple sclerosis and other diseases of the Central nervous system and is the most disability manifestation of the syndrome of upper motor neuron (UMNS). Focal spasticity of the upper limb requires a complex treatment. Botulinum toxin therapy is an effective treatment for focal/multifocal spasticity in reducing muscle tone and improving function with the highest level of evidence according to the latest American and European guidelines for treatment of spasticity. There are many publications devoted to BTA use in post-stroke patients. This article provides a review of the BTA use in patients with the upper limb spasticity due to severe traumatic brain injury. Some local data on the BTA efficacy in the cohort of patients with traumatic brain injury are also presented.

Ankle Intrinsic Stiffness in Subcortical Poststroke Subjects

The authors' purpose was to evaluate bilateral ankle intrinsic stiffness in subcortical poststroke subjects. Ten subcortical poststroke subjects and 10 healthy controls participated in this study. The ankle passive stiffness at 3 different speeds and the electromyographic activity of the soleus, the gastrocnemius, and the tibialis anterior muscles of poststroke contralesional (CONTRA) and ipsilesional (IPSI) limbs and of one limb of healthy subjects were assessed. Ankle electromyographic activity was collected to ensure that reflexive or voluntary muscle activity was not being elicited during the passive movements. A significant interaction was observed between the effects of the limb (IPSI vs. CONTRA vs. control) and ankle position, F(4, 28) = 3.285, p = .025, and between the effects of the limb and the velocity of stretch, F(2, 14) = 4.209, p = .037. While increased intrinsic stiffness was observed in the CONTRA limb of poststroke subjects at ankle neutral position when the passive stretch was applied with a velocity of 1°/s (p = .021), the IPSI limb of poststroke subjects presented increased stiffness at 20º of plantar flexion when the stretch was applied with a velocity of 5°/s (p = .009) when compared to healthy group. Subcortical poststroke subjects present increased intrinsic stiffness in both the CONTRA and IPSI limbs in specific ankle amplitudes.

[Efficacy of early neurological and neurosurgical rehabilitation : Evidence-based treatment, outcome and prognostic factors]

BACKGROUND

Early neurological and neurosurgical rehabilitation (ENNR) as a complex post-acute form of treatment for patients with severe neurological diseases and continued need for intensive care is well established in Germany.

OBJECTIVE

To assess the efficacy of ENNR from the perspective of evidence-based medicine as well as to present data on the outcome of ENNR patients including the analysis of prognostic factors.

MATERIAL AND METHODS

A search was carried out in PubMed databases to identify early rehabilitation treatment forms evaluated by randomized controlled trials and with respect to large multicenter surveys of outcome and prognostic factors.

RESULTS

For ENNR as a complex treatment concept, effectiveness not has been shown with regard to evidence-based medicine but it includes individually effective treatment forms. In two large multicenter evaluations the average duration of treatment was between 51 and 57 days and mortality was between 6 % and 10 %, increasing with the proportion of mechanically ventilated patients. Lower need for nursing support on admission indicated better outcome, whereas mechanical ventilation was more likely to be associated with poor outcome. Long-term outcome was negatively influenced by mechanical ventilation as well as severe neurogenic dysphagia with and without the need for a tracheal cannula and/or percutaneous endoscopic gastrostomy (PEG) and also by severely impaired communication at the end of ENNR.

DISCUSSION

These prognostic factors indicate the primary aims of ENNR, which are to reduce the need for nursing support and to establish the capability for rehabilitation. If these aims are achieved, favorable functional and long-term outcome can be expected for ENNR patients. The presented studies verify the sustained efficacy of ENNR as an essential part of the overall treatment concept for severely neurologically impaired patients.

Practice guideline update summary: Botulinum neurotoxin for the treatment of blepharospasm, cervical dystonia, adult spasticity, and headache: Report of the Guideline Development Subcommittee of the American Academy of Neurology

OBJECTIVE

To update the 2008 American Academy of Neurology (AAN) guidelines regarding botulinum neurotoxin for blepharospasm, cervical dystonia (CD), headache, and adult spasticity.

METHODS

We searched the literature for relevant articles and classified them using 2004 AAN criteria.

RESULTS AND RECOMMENDATIONS

Blepharospasm: OnabotulinumtoxinA (onaBoNT-A) and incobotulinumtoxinA (incoBoNT-A) are probably effective and should be considered (Level B). AbobotulinumtoxinA (aboBoNT-A) is possibly effective and may be considered (Level C). CD: AboBoNT-A and rimabotulinumtoxinB (rimaBoNT-B) are established as effective and should be offered (Level A), and onaBoNT-A and incoBoNT-A are probably effective and should be considered (Level B). Adult spasticity: AboBoNT-A, incoBoNT-A, and onaBoNT-A are established as effective and should be offered (Level A), and rimaBoNT-B is probably effective and should be considered (Level B), for upper limb spasticity. AboBoNT-A and onaBoNT-A are established as effective and should be offered (Level A) for lower-limb spasticity. Headache: OnaBoNT-A is established as effective and should be offered to increase headache-free days (Level A) and is probably effective and should be considered to improve health-related quality of life (Level B) in chronic migraine. OnaBoNT-A is established as ineffective and should not be offered for episodic migraine (Level A) and is probably ineffective for chronic tension-type headaches (Level B).

Botulinum neurotoxin for the treatment of blepharospasm, cervical dystonia, adult spasticity, and headache: Payment policy perspectives

This article is presented as a companion to the American Academy of Neurology guideline update on the use of botulinum neurotoxin (BoNT) for the treatment of blepharospasm, cervical dystonia, adult spasticity, and headache. Whereas the guideline update provides clarity on the efficacy of different BoNT-branded preparations for the 4 listed indications, this companion piece identifies ambiguities in the evidence for efficacy among various brand names for a given clinical indication, their dosing equivalencies, as well as different clinical indications. This article provides guidance and background information to reduce obstacles for third party payment, especially when uncertainties exist and levels of evidence are lower.

Spotlight on botulinum toxin and its potential in the treatment of stroke-related spasticity

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.

Comparison of Effects of Botulinum Toxin Injection Between Subacute and Chronic Stroke Patients: A Pilot Study

The aim of this study was to compare the effects of botulinum toxin injection between subacute and chronic stroke patients. Eighteen stroke patients (9 subacute and 9 chronic) with spasticity of 1+ or higher in the hemiplegic elbow or wrist joint, based on the modified Ashworth scale were recruited. Modified Ashworth scale, modified Tardieu scale, manual muscle testing, passive range of motion, Brunnstrom stage, modified Barthel index, and Fugl-Meyer scale evaluations of the hemiplegic upper extremity were performed just before the injection and 4 weeks later. A total dose of 200 U of botulinum toxin type A was injected into each patient. One or more of the elbow flexor muscles and one or more of the wrist flexor or finger flexor muscles were included. Modified Ashworth scale, manual muscle testing, passive range of motion, and modified Barthel index results were improved in subacute patients only. However, modified Tardieu scale for the elbow and Fugl-Meyer scale results were improved in both groups, and the improvement was comparable. In conclusion, botulinum toxin injection in subacute patients was more helpful for spasticity, contracture, and function than in chronic patients. However, beneficial effects of botulinum toxin injection on spasticity and function in chronic patients were found in the assessments of the modified Tardieu scale and Fugl-Meyer scale.

Randomized, placebo-controlled trial of incobotulinumtoxina for upper-limb post-stroke spasticity

INTRODUCTION

Efficacy and safety of incobotulinumtoxinA in post-stroke upper-limb spasticity were studied.

METHODS

Subjects randomized 2:1 to incobotulinumtoxinA (fixed dose 400 U) or placebo, with fixed doses for the primary target clinical pattern (PTCP; flexed elbow, 200 U; flexed wrist, 150 U; clenched fist, 100 U). Doses for non-primary patterns were flexible within predefined ranges.

RESULTS

At week 4, incobotulinumtoxinA led to larger improvements in PTCP Ashworth scale (AS) scores than placebo [least-squares mean change ± standard error: -0.9 ± 0.06 (n = 171) vs. -0.5 ± 0.08 (n = 88); P < 0.001], and more subjects were PTCP AS responders (≥1-point improvement) with incobotulinumtoxinA (69.6%) than with placebo (37.5%; P < 0.001). Investigator's Global Impression of Change confirmed superiority of incobotulinumtoxinA vs. placebo (P = 0.003). IncobotulinumtoxinA was associated with functional improvements, as demonstrated in responder rates for Disability Assessment Scale principal target at week 4 (P = 0.007). Adverse events were mainly mild/moderate, and were reported by 22.4% (incobotulinumtoxinA) and 16.8% (placebo) of subjects.

CONCLUSIONS

IncobotulinumtoxinA significantly improved upper-limb spasticity and associated disability, and was well-tolerated.

Adverse Clinical Effects of Botulinum Toxin Intramuscular Injections for Spasticity

OBJECTIVE

The adverse events (AEs) with botulinum toxin type-A (BoNTA), used for indications other than spasticity, are widely reported in the literature. However, the site, dose, and frequency of injections are different for spasticity when compared to the treatment for other conditions and hence the AEs may be different as well. The objective of this study was to summarize the AEs reported in Canada and systematically review the AEs with intramuscular botulinum toxin injections to treat focal spasticity.

METHODS

Data were gathered from Health Canada (2009-2013) and major electronic databases.

RESULTS

In a 4 year period, 285 AEs were reported. OnabotulinumtoxinA (n=272 events): 68% females, 53% serious, 18% hospitalization, and 8% fatalities. The type of AEs reported were - muscle weakness (19%), oropharyngeal (14%), respiratory (14%), eye related (8%), bowel/bladder related (8%), and infection (5%). IncobotulinumtoxinA (n=13): 38% females, 62% serious, and 54% hospitalization. The type of AEs reported were - muscle weakness (15%), oropharyngeal (15%), respiratory (38%), eye related (23%), bowel/bladder related (15%), and infection (15%). Commonly reported AEs in the literature were muscle weakness, pain, oropharyngeal, bowel/bladder, blood circulation, neurological, gait, and respiratory problems.

CONCLUSION

While BoNTA is useful in managing spasticity, future studies need to investigate the factors that can minimize AEs. A better understanding of the underlying mechanisms of the AEs can also improve guidelines for BoNTA administration and enhance outcomes.

Safety and efficacy of abobotulinumtoxinA for hemiparesis in adults with upper limb spasticity after stroke or traumatic brain injury: a double-blind randomised controlled trial

BACKGROUND

Resistance from antagonistic muscle groups might be a crucial factor reducing function in chronic hemiparesis. The resistance due to spastic co-contraction might be reduced by botulinum toxin injections. We assessed the effects of abobotulinumtoxinA injection in the upper limb muscles on muscle tone, spasticity, active movement, and function.

METHODS

In this randomised, placebo-controlled, double-blind study, we enrolled adults (aged 18-80 years) at least 6 months after stroke or brain trauma from 34 neurology or rehabilitation clinics in Europe and the USA. Eligible participants were randomly allocated in a 1:1:1 ratio with a computer-generated list to receive a single injection session of abobotulinumtoxinA 500 U or 1000 U or placebo into the most hypertonic muscle group among the elbow, wrist, or finger flexors (primary target muscle group [PTMG]), and into at least two additional muscle groups from the elbow, wrist, or finger flexors or shoulder extensors. Patients and investigators were masked to treatment allocation. The primary endpoint was the change in muscle tone (Modified Ashworth Scale [MAS]) in the PTMG from baseline to 4 weeks. Secondary endpoints were Physician Global Assessment (PGA) at week 4 and change from baseline to 4 weeks in the perceived function (Disability Assessment Scale [DAS]) in the principal target of treatment, selected by the patient together with physician from four functional domains (dressing, hygiene, limb position, and pain). Analysis was by intention to treat. This study is registered with ClinicalTrials.gov, number NCT01313299.

FINDINGS

243 patients were randomly allocated to placebo (n=81), abobotulinumtoxinA 500 U (n=81), or abobotulinumtoxinA 1000 U (n=81). Mean change in MAS score from baseline at week 4 in the PTMG was -0·3 (SD 0·6) in the placebo group (n=79), -1·2 (1·0) in the abobotulinumtoxinA 500 U group (n=80; difference -0·9, 95% CI -1·2 to -0·6; p<0·0001 vs placebo), and -1·4 (1·1) in the abobotulinumtoxinA 1000 U group (n=79; -1·1, -1·4 to -0·8; p<0·0001 vs placebo). Mean PGA score at week 4 was 0·6 (SD 1·0) in the placebo group (n=78), 1·4 (1·1) in the abobotulinumtoxinA 500 U group (n=80; p=0·0003 vs placebo), and 1·8 (1·1) in the abobotulinumtoxinA 1000 U group (n=78; p<0·0001 vs placebo). Mean change from baseline at week 4 in DAS score for the principal target of treatment was -0·5 (0·7) in the placebo group (n=79), -0·7 (0·8) in the abobotulinumtoxinA 500 U group (n=80; p=0·2560 vs placebo), and -0·7 (0·7) in the abobotulinumtoxinA 1000 U group (n=78; p=0·0772 vs placebo). Three serious adverse events occurred in each group and none were treatment related; two resulted in death (from pulmonary oedema in the placebo group and a pre-existing unspecified cardiovascular disorder in the abobotulinumtoxinA 500 U group). Adverse events that were thought to be treatment related occurred in two (2%), six (7%), and seven (9%) patients in the placebo, abobotulinumtoxinA 500 U, and abobotulinumtoxinA 1000 U groups, respectively. The most common treatment-related adverse event was mild muscle weakness. All adverse events were mild or moderate.

INTERPRETATION

AbobotulinumtoxinA at doses of 500 U or 1000 U injected into upper limb muscles provided tone reduction and clinical benefit in hemiparesis. Future research into the treatment of spastic paresis with botulinum toxin should use active movement and function as primary outcome measures.

FUNDING

Ipsen.

Efficacy and safety of NABOTA in post-stroke upper limb spasticity: a phase 3 multicenter, double-blinded, randomized controlled trial

Botulinum toxin A is widely used in the clinics to reduce spasticity and improve upper limb function for post-stroke patients. Efficacy and safety of a new botulinum toxin type A, NABOTA (DWP450) in post-stroke upper limb spasticity was evaluated in comparison with Botox (onabotulinum toxin A). A total of 197 patients with post-stroke upper limb spasticity were included in this study and randomly assigned to NABOTA group (n=99) or Botox group (n=98). Wrist flexors with modified Ashworth Scale (MAS) grade 2 or greater, and elbow flexors, thumb flexors and finger flexors with MAS 1 or greater were injected with either drug. The primary outcome was the change of wrist flexor MAS between baseline and 4weeks post-injection. MAS of each injected muscle, Disability Assessment Scale (DAS), and Caregiver Burden Scale were also assessed at baseline and 4, 8, and 12weeks after the injection. Global Assessment Scale (GAS) was evaluated on the last visit at 12weeks. The change of MAS for wrist flexor between baseline and 4weeks post-injection was -1.44±0.72 in the NABOTA group and -1.46±0.77 in the Botox group. The difference of change between both groups was 0.0129 (95% confidence interval -0.2062-0.2319), within the non-inferiority margin of 0.45. Both groups showed significant improvements regarding MAS of all injected muscles, DAS, and Caregiver Burden Scale at all follow-up periods. There were no significant differences in all secondary outcome measures between the two groups. NABOTA demonstrated non-inferior efficacy and safety for improving upper limb spasticity in stroke patients compared to Botox.

The efficacy of Botulinum Toxin A for limb spasticity on improving activity restriction and quality of life: a systematic review and meta-analysis using the GRADE approach

Objectives:

A systematic review and meta analysis using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach. The aim was to evaluate the efficacy of Botulinum Toxin type A for limb spasticity on improving activity restriction and quality of life outcomes.

Data sources:

Pubmed, Cinahl, Amed, Embase and Cochrane databases. English Language. Search to January 2015.

Review methods:

All randomized, placebo controlled trials on adults with active function or quality of life measures for the arm and leg relating to spasticity of any origin and treated with a single dose of Botulinum Toxin A. Evidence quality was assessed by GRADE.

Results:

Twenty-five studies were reviewed. Meta analysis was carried out on six upper limb and six lower limb studies. Evidence quality for the upper limb was low/very low. A significant result for Botulinum Toxin A was found at four to twelve weeks for the upper limb for active function (SMD 0.32 CI 0.01, 0.62, P=0.04) These effects were maintained for up to six months for Active Research Arm Test (ARAT) only (MD 1.87 CI 0.53, 3.21, P=0.006). Evidence quality was very low for the lower limb. No significant effect was found. Meta analysis was not possible for quality of life measures.

Conclusion:

Botulinum Toxin A may improve active outcomes in the upper limb but further evidence is needed. No conclusion can be drawn about the effect on active outcomes for the lower limb or for quality of life measures in either limb.

Neuronox versus BOTOX in the Treatment of Post-Stroke Upper Limb Spasticity: A Multicenter Randomized Controlled Trial

BACKGROUND

Botulinum toxin type A is widely used for treating spasticity. Neuronox (Neu-BoNT/A), a newly manufactured botulinum toxin a, has not yet been investigated for its efficacy and safety in the treatment of post-stroke upper limb spasticity.

OBJECTIVE

We evaluated the efficacy and safety of Neuronox (Neu-BoNT/A) compared with BOTOX (onabotulinum toxin A) for treating post-stroke upper limb spasticity.

METHODS

In total, 196 stroke patients with moderate to severe upper limb spasticity were randomly assigned to either Neuronox or BOTOX intervention. The wrist flexors were mandatory and elbow, finger, and thumb flexors were optional muscles to be injected. Assessments were performed at baseline and 4, 8, and 12 weeks after the intervention. The primary outcome measure was the change from baseline of the Modified Ashworth Scale (MAS) at the wrist flexors at week 4. Secondary outcome measures included the change of MAS at each visit, response rate, Disability Assessment Scale (DAS), Carer Burden Scale, and Global Assessment of treatment benefit.

RESULTS

Primary outcome measures were -1.39±0.79 and -1.56±0.81 in the Neuronox and BOTOX groups, respectively. The difference was within the noninferiority margin of 0.45 (95% upper limit=0.40). There were no significant differences between the groups in the secondary outcome and safety measures, except the change of the MAS at the elbow flexors at week 12 (-0.88±0.75 in the Neuronox group, -0.65±0.74 in the BOTOX group; P=0.0429). Both groups showed significant improvements in the MAS, DAS, and Carer Burden Scale at weeks 4, 8, and 12.

CONCLUSION

Neuronox showed equivalent efficacy and safety compared with BOTOX for treating post-stroke upper limb spasticity.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01313767.

Cortical activation changes and improved motor function in stroke patients after focal spasticity therapy--an interventional study applying repeated fMRI

BACKGROUND

Impaired dominant hand function in stroke patients is a common clinical problem. Functional improvement after focal spasticity therapy is well documented but knowledge about central correlates is sparse. Brain activity was therefore followed during therapy with repeated functional magnetic resonance imaging (fMRI). The purpose was to analyse motor function and central nervous system (CNS) correlates in response to a standardized motor task in stroke patients after a comprehensive focal spasticity therapy.

METHODS

Six consecutive first-time chronic stroke patients [4 women; mean age (SD) 66 (10) years] with right-sided hand paresis and spasticity were studied. Peripheral effects after focal spasticity management including intramuscular botulinum toxin type A (BoNT-A) injections were assessed on 3 occasions (baseline, 6 and 12 weeks) with functional tests. Brain effects were assessed on the same occasions by fMRI blood oxygen level dependent (BOLD) technique during a standardized motor task focusing on the motor and pre-motor cortex (Brodmann areas, BA4a, BA4p & BA6). For reference 10 healthy individuals [5 women; mean age (SD) of 51(8) years], were studied twice with ≥ 6 weeks interval.

RESULTS

After therapy there was a significant reduction in spasticity and functional improvement in 5 of 6 patients. In response to the motor task there was a ~1.5 - 3% increase in brain activity in the motor and pre-motor cortex. At baseline, this increase was larger in the non-injured (ipsilateral) than in the contralateral hemisphere. Compared with healthy subjects the patients showed a significantly (2-4.5 times) higher brain activity, especially on the ipsilateral side. After therapy, there was a larger decrease in the ipsilateral and a minor decrease in the contralateral response, i.e. a clear lateralization of left-to-right in a normalizing direction in all areas.

CONCLUSIONS

Comprehensive focal spasticity management was also in this study associated with brain reorganization in a "normalizing" left/right lateralization direction in addition to improved motor function. Furthermore, quantification of BOLD intensity in specified BAs showed reduced neuronal "over-activity" in the injured brain after therapy.

A randomized, placebo controlled pilot trial of botulinum toxin for paratonic rigidity in people with advanced cognitive impairment

OBJECTIVE

Evaluate safety and efficacy of Incobotulinumtoxin A in elderly patients with dementia and paratonia.

SETTING

University-affiliated hospital, spasticity management Clinic.

PARTICIPANTS

Ten subjects were enrolled.

INCLUSION CRITERIA

1) severe cognitive impairment 2) diagnosis of Alzheimer's disease, vascular dementia, or frontotemporal dementia, and 3) score >3 on the paratonic assessment instrument, with posture in an arm(s) interfering with provision of care.

EXCLUSION CRITERIA

1) alternate etiologies for increased tone and 2) injection with botulinum toxin within the 6 months preceding the study.

DESIGN

Single center, randomized, double blind, placebo-controlled, crossover trial with two treatment cycles of 16 weeks. Assessments occurred at 2, 6, 12 and16 weeks following injections. Subjects received up to 300 U of Incobotulinumtoxin A in arm(s).

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome measure was the modified caregiver burden scale (mCBS); exploratory secondary outcome measures were also performed. Analysis of variance and mixed modeling techniques were used to evaluate treatment effects.

RESULTS

Incobotulinumtoxin A treatment produced significant improvement in mCBS total score -1.11 (-2.04 to -0.18) (Treatment effect and 95% CI), dressing sub-score -0.36 (-0.59 to 0.12), and cleaning under the left and right armpits sub-score -0.5 (-0.96 to -0.04), -0.41 (-0.79 to -0.04) respectively. PROM in the left and right elbow increased by 27.67 degrees (13.32-42.02) and 22.07 degrees (9.76-34.39) respectively. PROM in the left and right shoulder increased by 11.92 degrees (5.46-18.38) and 8.58 degrees (3.73-13.43) respectively. No significant treatment effect was found for GAS, VAS and PAINAD scales or change in time to perform care. No adverse drug reactions occurred.

CONCLUSIONS

Administration of Incobotulinumtoxin A in elderly people with advanced dementia and paratonia may be an efficacious and safe treatment to increase range of motion and reduce functional burden. Further studies are needed to confirm results.

TRIAL REGISTRATION

ClinicalTrials.Gov NCT02212119.

Current uses of botulinum toxin A as an adjunct to hand therapy interventions of hand conditions

STUDY DESIGN

Literature review.

DISCUSSION

Botulinum toxin A, a neurotoxin causing temporary muscle paralysis at the neuromuscular junction, has been used to treat multiple acquired conditions of the hand and upper extremity. Initially approved for use in treating blepharospasm and strabismus in the 1980s, indications have expanded to include spasticity associated with cerebrovascular accidents, vasospastic disorders, focal dystonias, and pain conditions. This article reviews the current literature discussing the efficacy of botulinum toxin A in management of disorders of the hand and upper extremity relevant to hand therapists.

LEVEL OF EVIDENCE

NA.

Botulinum toxin for neuropathic pain and spasticity: an overview

In recent years, a large body of data has surfaced reporting the therapeutic benefit of botulinum toxin injection in multiple conditions. The aim of this review is: to summarize the highest quality literature pertaining to clinical application of botulinum toxin in neuropathic pain conditions including postherpetic neuralgia, trigeminal neuralgia, diabetic polyneuropathy, post-traumatic neuralgia, carpal tunnel syndrome, complex regional pain syndrome, phantom limb and stump pain, and occipital neuralgia; to provide an overview of the clinical trials using botulinum toxin in adult spasticity; and to assign levels of evidence according to the American Academy of Neurology guidelines. In summary, there is level A evidence for established efficacy in postherpetic neuralgia and adult spasticity; level B evidence for probable efficacy in trigeminal neuralgia and post-traumatic neuralgia; level B evidence for probable lack of efficacy in carpal tunnel syndrome; level C evidence for possible efficacy in diabetic polyneuropathy; and level U (insufficient) evidence in complex regional pain syndrome, phantom limb and stump pain, and occipital neuralgia.

The efficacy of Botulinum Toxin A on improving ease of care in the upper and lower limbs: a systematic review and meta-analysis using the Grades of Recommendation, Assessment, Development and Evaluation approach

OBJECTIVES

A systematic review and meta-analysis using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach; evaluating Botulinum Toxin type A efficacy on improving ease of care in the upper/lower limb.

DATA SOURCES

Pubmed, Cinahl, Amed, Embase and Cochrane databases. English Language. Search to July 2014.

REVIEW METHODS

All randomized, placebo controlled trials on adults with difficulty in caring for the upper/lower limb resulting from spasticity of any origin and treated with a single dose of Botulinum Toxin A. Evidence quality was assessed by GRADE.

RESULTS

A total of 32 studies were reviewed. Meta-analysis was carried out on 11 upper limb and three lower limb studies. Evidence quality for the upper limb was moderate. A significant result for Botulinum Toxin A was found at four to 12 weeks for the upper limb (SMD 0.80, CI 0.55, 1.06, p < 0.0001). The effects were maintained for up to six months (SMD 0.48, CI 0.34, 0.62, p < 0.0001). Evidence quality was very low for the lower limb. Meta-analysis was only possible for global assessment of benefit. No significant effect was found. (

PATIENT

RR 1.37 CI (0.94, 2.00) p = 0.11; clinician: RR 1.06 (0.84, 1.34) p = 0.60.)

CONCLUSION

Botulinum Toxin A improves ease of care in the upper limb for up to six months. No conclusion can be drawn for the lower limb.