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Facciorusso S, Spina S, Picelli A, Baricich A, Francisco GE, Molteni F, Wissel J, Santamato A. The Role of Botulinum Toxin Type-A in Spasticity: Research Trends from a Bibliometric Analysis. Toxins (Basel) 2024; 16:184. [PMID: 38668609 PMCID: PMC11053519 DOI: 10.3390/toxins16040184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 04/01/2024] [Accepted: 04/08/2024] [Indexed: 04/29/2024] Open
Abstract
Botulinum toxin type-A (BoNT-A) has emerged as a key therapeutic agent for the management of spasticity. This paper presents a comprehensive bibliometric and visual analysis of research concerning BoNT-A treatment of spasticity to elucidate current trends and future directions in this research area. A search was conducted in the Web of Science database for articles focused on the use of BoNT-A in spasticity published between 2000 and 2022. We extracted various metrics, including counts of publications and contributions from different countries, institutions, authors, and journals. Analytical methods in CiteSpace were employed for the examination of co-citations, collaborations, and the co-occurrence of keywords. Our search yielded 1489 publications. Analysis revealed a consistent annual increase in research output. The United States, United Kingdom, and Italy were the leading contributors. The top institution in this research was Assistance Publique Hopitaux, Paris. The journal containing the highest number of relevant publications was Toxins. Key frequently occurring keywords were 'stroke', 'cerebral palsy', 'adult spasticity', and 'upper extremity'. This study identified 12 clusters of keywords and 15 clusters of co-cited references, indicating the main focus areas and emerging themes in this field. This study comprehensively analyzed and summarized trends in BoNT-A research in the field of spasticity over the past 22 years.
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Affiliation(s)
- Salvatore Facciorusso
- Spasticity and Movement Disorders “ReSTaRt”, Unit Physical Medicine and Rehabilitation Section, Department of Medical and Surgical Sciences, University of Foggia, 71122 Foggia, Italy; (S.F.); (A.S.)
- Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy
| | - Stefania Spina
- Spasticity and Movement Disorders “ReSTaRt”, Unit Physical Medicine and Rehabilitation Section, Department of Medical and Surgical Sciences, University of Foggia, 71122 Foggia, Italy; (S.F.); (A.S.)
| | - Alessandro Picelli
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37100 Verona, Italy;
| | - Alessio Baricich
- Physical Medicine and Rehabilitation, Department of Health Sciences, Università del Piemonte Orientale, 28100 Novara, Italy;
| | - Gerard E. Francisco
- Department of Physical Medicine & Rehabilitation, University of Texas Health McGovern Medical School, Houston, TX 77030, USA;
| | - Franco Molteni
- Villa Beretta Rehabilitation Center, Valduce Hospital Como, 23845 Costa Masnaga, Italy;
| | - Jörg Wissel
- Department of Neurorehabilitation and Physical Therapy, Vivantes Hospital Spandau, 13585 Berlin, Germany;
| | - Andrea Santamato
- Spasticity and Movement Disorders “ReSTaRt”, Unit Physical Medicine and Rehabilitation Section, Department of Medical and Surgical Sciences, University of Foggia, 71122 Foggia, Italy; (S.F.); (A.S.)
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Campisi ES, Khan O, Agur AMR, Reebye R. An Anatomical Perspective to Botulinum Toxin Injection of Flexor Digitorum Profundus. Can J Neurol Sci 2024:1-2. [PMID: 38465370 DOI: 10.1017/cjn.2024.34] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Affiliation(s)
- Emma Stefanie Campisi
- Division of Anatomy, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Omar Khan
- Hotel Dieu Shaver Health and Rehabilitation Centre, St. Catharines, ON, Canada
- Canadian Advances in Neuro-Orthopedics for Spasticity Consortium (CANOSC), Kingston, ON, Canada
| | - Anne Marie Reet Agur
- Division of Anatomy, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Rajiv Reebye
- Canadian Advances in Neuro-Orthopedics for Spasticity Consortium (CANOSC), Kingston, ON, Canada
- Division of Physical Medicine & Rehabilitation, University of British Columbia, Vancouver, BC, Canada
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Asimakidou E, Sidiropoulos C. A Bayesian Network Meta-Analysis and Systematic Review of Guidance Techniques in Botulinum Toxin Injections and Their Hierarchy in the Treatment of Limb Spasticity. Toxins (Basel) 2023; 15:toxins15040256. [PMID: 37104194 PMCID: PMC10145352 DOI: 10.3390/toxins15040256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 03/22/2023] [Accepted: 03/29/2023] [Indexed: 04/03/2023] Open
Abstract
Accurate targeting of overactive muscles is fundamental for successful botulinum neurotoxin (BoNT) injections in the treatment of spasticity. The necessity of instrumented guidance and the superiority of one or more guidance techniques are ambiguous. Here, we sought to investigate if guided BoNT injections lead to a better clinical outcome in adults with limb spasticity compared to non-guided injections. We also aimed to elucidate the hierarchy of common guidance techniques including electromyography, electrostimulation, manual needle placement and ultrasound. To this end, we conducted a Bayesian network meta-analysis and systematic review with 245 patients using the MetaInsight software, R and the Cochrane Review Manager. Our study provided, for the first time, quantitative evidence supporting the superiority of guided BoNT injections over the non-guided ones. The hierarchy comprised ultrasound on the first level, electrostimulation on the second, electromyography on the third and manual needle placement on the last level. The difference between ultrasound and electrostimulation was minor and, thus, appropriate contextualization is essential for decision making. Taken together, guided BoNT injections based on ultrasound and electrostimulation performed by experienced practitioners lead to a better clinical outcome within the first month post-injection in adults with limb spasticity. In the present study, ultrasound performed slightly better, but large-scale trials should shed more light on which modality is superior.
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Lungu C, Nmashie A, George MC, Karp BI, Alter K, Shin S, Tse W, Frucht SJ, Wu T, Koo V, Considine E, Norato G, Hallett M, Simpson DM. Comparison of Ultrasound and Electrical Stimulation Guidance for Onabotulinum Toxin-A Injections: A Randomized Crossover Study. Mov Disord Clin Pract 2022; 9:1055-1061. [PMID: 36523503 PMCID: PMC9631842 DOI: 10.1002/mdc3.13546] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Revised: 07/11/2022] [Accepted: 07/24/2022] [Indexed: 09/09/2023] Open
Abstract
Background Botulinum neurotoxin (BoNT) injection is an established therapy for limb spasticity and focal limb dystonia. Comparative benefits of injection guidance procedures have not been rigorously studied. Objectives We compared 2 targeting techniques for onabotulinumtoxin-A (onabotA) injection for the treatment of focal hand dystonia and upper limb spasticity: electrophysiologic guidance using electrical stimulation (E-stim) and ultrasound (US). Methods This was a 2-center, randomized, crossover, assessor-blinded trial. Participants with focal hand dystonia or upper limb spasticity, on stable onabotA therapy for at least 2 previous injection cycles, were randomly assigned to either E-stim or US with crossover at 3 months. The primary outcome was improvement in dystonia or spasticity severity on a visual analog scale (VAS; 0-100) measured 1 month after each injection. The secondary outcome was participant discomfort assessed on a VAS. Repeated-measures analysis of covariance was used with linear mixed-model covariate selection. Results A total of 19 participants (13 men) completed the study, 10 with upper limb spasticity and 9 with dystonia. Benefit was equivalent between the 2 techniques (VAS least-square mean [LSmean] 51.5 mm with US and 53.1 with E-stim). E-stim was perceived as more uncomfortable by participants (VAS LSmean 34.5 vs. 19.9 for E-stim and US, respectively). Procedure duration was similar with the 2 procedures. There were no serious adverse events related to either approach. Conclusions US and E-Stim localization guidance techniques provide equivalent efficacy in onabotA injections for spasticity and dystonia. US guidance injections are more comfortable for participants. Both techniques are effective guidance methods, with US potentially preferable based on participant comfort.
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Affiliation(s)
- Codrin Lungu
- Division of Clinical Research, National Institute of Neurological Disorders and StrokeNational Institutes of HealthBethesdaMarylandUSA
| | - Alexandra Nmashie
- Department of PediatricsNew York Medical College/NYCHealth Hospitals/MetropolitanNew YorkNew YorkUSA
| | | | - Barbara I. Karp
- Division of Clinical Research, National Institute of Neurological Disorders and StrokeNational Institutes of HealthBethesdaMarylandUSA
| | - Katharine Alter
- Department of Rehabilitation MedicineClinical Center, National Institutes of HealthBethesdaMarylandUSA
| | - Susan Shin
- Department of NeurologyIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Winona Tse
- Department of NeurologyIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Steven J. Frucht
- Department of NeurologyNew York University Grossman School of MedicineNew YorkNew YorkUSA
| | - Tianxia Wu
- Clinical Trials UnitNational Institute of Neurological Disorders and Stroke, National Institutes of HealthBethesdaMarylandUSA
| | - Vivian Koo
- Human Motor Control SectionNational Institute of Neurological Disorders and Stroke, National Institutes of HealthBethesdaMarylandUSA
| | - Elaine Considine
- Human Motor Control SectionNational Institute of Neurological Disorders and Stroke, National Institutes of HealthBethesdaMarylandUSA
| | - Gina Norato
- Clinical Trials UnitNational Institute of Neurological Disorders and Stroke, National Institutes of HealthBethesdaMarylandUSA
| | - Mark Hallett
- Human Motor Control SectionNational Institute of Neurological Disorders and Stroke, National Institutes of HealthBethesdaMarylandUSA
| | - David M. Simpson
- Department of NeurologyIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
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Schnitzler A, Dince C, Freitag A, Iheanacho I, Fahrbach K, Lavoie L, Loze JY, Forestier A, Gasq D. AbobotulinumtoxinA Doses in Upper and Lower Limb Spasticity: A Systematic Literature Review. Toxins (Basel) 2022; 14:toxins14110734. [PMID: 36355984 PMCID: PMC9698883 DOI: 10.3390/toxins14110734] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 10/12/2022] [Accepted: 10/20/2022] [Indexed: 01/26/2023] Open
Abstract
Disabling limb spasticity can result from stroke, traumatic brain injury or other disorders causing upper motor neuron lesions such as multiple sclerosis. Clinical studies have shown that abobotulinumtoxinA (AboBoNT-A) therapy reduces upper and lower limb spasticity in adults. However, physicians may administer potentially inadequate doses, given the lack of consensus on adjusting dose according to muscle volume, the wide dose ranges in the summary of product characteristics or cited in the published literature, and/or the high quantity of toxin available for injection. Against this background, a systematic literature review based on searches of MEDLINE and Embase (via Ovid SP) and three relevant conferences (2018 to 2020) was conducted in November 2020 to examine AboBoNT-A doses given to adults for upper or lower limb muscles affected by spasticity of any etiology in clinical and real-world evidence studies. From the 1781 unique records identified from the electronic databases and conference proceedings screened, 49 unique studies represented across 56 publications (53 full-text articles, 3 conference abstracts) were eligible for inclusion. Evidence from these studies suggested that AboBoNT-A dose given per muscle in clinical practice varies considerably, with only a slight trend toward a relationship between dose and muscle volume. Expert-based consensus is needed to inform recommendations for standardizing AboBoNT-A treatment initiation doses based on muscle volume.
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Affiliation(s)
- Alexis Schnitzler
- PRM Department, GH St Louis Lariboisière F. Widal, Paris University, 75010 Paris, France
| | - Clément Dince
- Ipsen, 92100 Boulogne-Billancourt, France
- Correspondence:
| | | | | | | | | | | | | | - David Gasq
- Department of Functional Physiological Explorations, University Hospital of Toulouse, 31400 Toulouse, France
- ToNIC, Toulouse NeuroImaging Center, Université de Toulouse, Inserm, UPS, 31300 Toulouse, France
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6
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Reebye R, Balbert A, Bensmail D, Walker H, Wissel J, Deltombe T, Francisco G. Module 2: Nonsurgical management of Spasticity. THE JOURNAL OF THE INTERNATIONAL SOCIETY OF PHYSICAL AND REHABILITATION MEDICINE 2022. [DOI: 10.4103/2349-7904.347808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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7
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Wissel J, Ri S. Assessment, goal setting, and botulinum neurotoxin a therapy in the management of post-stroke spastic movement disorder: updated perspectives on best practice. Expert Rev Neurother 2021; 22:27-42. [PMID: 34933648 DOI: 10.1080/14737175.2021.2021072] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
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.
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Affiliation(s)
- Jörg Wissel
- Department of Neurorehabilitation and Physical Therapy, Vivantes Klinikum Spandau, Neue Bergstrasse 6, 13585 Berlin, Germany.,Neurology and Psychosomatics at Wittenbergplatz, Out-Patient-Clinic, Ansbacher straße 17-19, 10787 Berlin, Germany
| | - Songjin Ri
- Neurology and Psychosomatics at Wittenbergplatz, Out-Patient-Clinic, Ansbacher straße 17-19, 10787 Berlin, Germany.,Department of Neurology, Charité University Hospital (CBS), Hindenburgdamm 30, Berlin 12203, Germany
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8
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Vova JA, Green MM, Brandenburg JE, Davidson L, Paulson A, Deshpande S, Oleszek JL, Inanoglu D, McLaughlin MJ. A consensus statement on the use of botulinum toxin in pediatric patients. PM R 2021; 14:1116-1142. [PMID: 34558213 DOI: 10.1002/pmrj.12713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 08/12/2021] [Accepted: 09/10/2021] [Indexed: 11/10/2022]
Abstract
Botulinum toxin has been used in medicine for the past 30 years. However, there continues to be controversy about the appropriate uses and dosing, especially in the pediatric population. A panel of nine pediatric physiatrists from different regions and previous training programs in the United States were nominated based on institutional reputation and botulinum toxin (BoNT) experience. Based on a review of the current literature, the goal was to provide the rationale for recommendations on the administration of BoNT in the pediatric population. The goal was not only to review safety, dosing, and injection techniques but also to develop a consensus on the appropriate uses in the pediatric population. In addition to upper and lower limb spasticity, the consensus also provides recommendations for congenital muscular torticollis, cervical dystonia, sialorrhea, and brachial plexus palsies.
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Affiliation(s)
- Joshua A Vova
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Michael M Green
- University of Utah/Primary Children's Hospital, Salt Lake City, Utah, USA
| | | | - Loren Davidson
- University of California Davis, Sacramento, California, USA
| | - Andrea Paulson
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Gillette Children's Specialty Healthcare, Minneapolis, Minnesota, USA
| | - Supreet Deshpande
- Gillette Children's Specialty Healthcare, Minneapolis, Minnesota, USA
| | | | - Didem Inanoglu
- Children's Health Specialty Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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9
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Abstract
Spasticity is one component of the upper motor neuron (UMN) syndrome resulting from a multitude of neurologic conditions, such as stroke, brain injury, spinal cord injury, multiple sclerosis, and cerebral palsy. It is clinically recognized as a phenomenon of velocity-dependent increase in resistance, i.e., hypertonia. Recent advances in the pathophysiology of spasticity improve our understanding of mechanisms underlying this complex phenomenon and its relations to other components of UMN syndrome (weakness and disordered motor control), as well as the resultant clinical problems. This theoretical framework provides a foundation to set up treatment goals and to guide goal-oriented clinical assessment and treatment. Among a spectrum of treatment options, botulinum toxin (BoNT) therapy is the preferred treatment for focal spasticity. The evidence is very robust that BoNT therapy effectively reduces spasticity; however, it does not improve voluntary movement. In this chapter, we highlight a few issues on how to achieve the best clinical outcomes of BoNT therapy, such as dosing, dilution, guidance techniques, adjunctive therapies, early treatment, repeated injections, and central effects, as well as the ways to improve motor function in selected subgroups of patients with spasticity. We also discuss the reasons of poor responses to BoNT therapy and when not to use BoNT therapy.
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Affiliation(s)
- Sheng Li
- Department of Physical Medicine and Rehabilitation, McGovern Medical School, University of Texas Health Science Center Houston (UTHealth), Houston, TX, USA.
- TIRR Memorial Hermann Hospital, Houston, TX, USA.
| | - Gerard E Francisco
- Department of Physical Medicine and Rehabilitation, McGovern Medical School, University of Texas Health Science Center Houston (UTHealth), Houston, TX, USA
- TIRR Memorial Hermann Hospital, Houston, TX, USA
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Chung TM, Jacinto LJ, Colosimo C, Bhatia KP, Tiley J, Bhidayasiri R. Botulinum Neurotoxin-A Injection in Adult Cervical Dystonia and Spastic Paresis: Results From the INPUT (INjection Practice, Usage and Training) Survey. Front Neurol 2020; 11:570671. [PMID: 33041997 PMCID: PMC7525121 DOI: 10.3389/fneur.2020.570671] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 08/13/2020] [Indexed: 01/13/2023] Open
Abstract
Botulinum toxin-A (BoNT-A) is an effective treatment for cervical dystonia (CD) and spastic paresis (SP), but it requires in-depth knowledge of anatomy and injection techniques. The Ixcellence Network® is an educational programme to provide neurology, neuropaediatrics, and physical medicine and rehabilitation (PMR) specialists with access to best clinical practices and innovations regarding SP and CD management with BoNT-A. To assess the benefits of such educational programmes and identify unmet needs, a multidisciplinary scientific committee designed INPUT (INjection Practice, Usage & Training), an international multicentric survey describing training and practices among this trained and experienced population. A self-completed questionnaire was sent online to 553 trainees and 14 trainers from the Ixcellence Network®. Among the 131 respondents, 92% specialized in PMR (48%) or neurology (44%), with a mean experience of 15.5 years in their clinical fields and 10.9 years of BoNT-A injection. Most of them (98%) reported having received training before performing their first BoNT-A injection and attending specific courses on how to perform it without any instrumental guidance (76%), and with ultrasound (73%), electrical stimulation (44%) or electromyography (41%). In terms of practices, 92% of respondents reported using at least one guidance technique while injecting, with ultrasound being the most used technique (48%). Attending specific courses was significantly associated with greater self-confidence and use, e.g. for injection with ultrasound, mean self-confidence, on a scale from 1 (not confident) to 10 (fully confident), was 7.9 for trained respondents (vs 4.0 for untrained respondents, p < 0.001) of whom 70% stated that they used this technique regularly or systematically (vs. 11% of untrained healthcare professionals (HCPs), p < 0.0001). Moreover, 84% of respondents reported having trained colleagues, residents or fellows through theoretical (70%) or practical teaching in individuals (80%) or in small groups (65%). Overall, 86% of respondents reported a notable increase over the past 5 years of the number of patients treated with BoNT-A. INPUT is the first international survey describing training and practices in SP and CD management of physicians who attended a dedicated educational programme. The results highlighted the importance of training for self-confidence, and the use of specific techniques and new approaches.
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Affiliation(s)
- Tae Mo Chung
- Faculty of Medicine, Institute of Physical Medicine and Rehabilitation, University of São Paulo, São Paulo, Brazil
| | - Luis Jorge Jacinto
- Serviço de Reabilitação de adultos, Centro de Medicina de Reabilitacao do Alcoitão, Alcabideche, Portugal
| | - Carlo Colosimo
- Department of Neurology, Azienda Ospedaliera S.Maria, Terni, Italy
| | - Kailash P Bhatia
- Institute of Neurology, University College London, London, United Kingdom
| | - Julie Tiley
- Global Medical Affairs, Ipsen, Boulogne Billancourt, France
| | - Roongroj Bhidayasiri
- Chulalongkorn Centre of Excellence for Parkinson's Disease & Related Disorders, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
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11
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Francisco GE, Bandari DS, Bavikatte G, Jost WH, McCusker E, Largent J, Zuzek A, Esquenazi A. High clinician- and patient-reported satisfaction with individualized onabotulinumtoxinA treatment for spasticity across several etiologies from the ASPIRE study. Toxicon X 2020; 7:100040. [PMID: 32875289 PMCID: PMC7452133 DOI: 10.1016/j.toxcx.2020.100040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Revised: 04/23/2020] [Accepted: 05/14/2020] [Indexed: 11/30/2022] Open
Abstract
Etiology-specific onabotulinumtoxinA utilization to manage spasticity is largely unknown. In this 1-year interim analysis, we evaluated real-world onabotulinumtoxinA utilization and effectiveness across several etiologies from the Adult Spasticity International Registry (ASPIRE) study. ASPIRE is a multicenter, prospective, observational registry (NCT01930786) examining stroke, multiple sclerosis [MS], cerebral palsy [CP], traumatic brain injury [TBI], and spinal cord injury [SCI] patients with spasticity treated with onabotulinumtoxinA at the clinician's discretion. Assessments included onabotulinumtoxinA utilization (each session), clinician (subsequent session)/patient (5±1 weeks post-treatment) satisfaction, and the Disability Assessment Scale (DAS; subsequent session). 730 patients received ≥1 onabotulinumtoxinA treatment, with 37% naïve to botulinum toxin(s) for spasticity. The most common etiology was stroke (n=411, 56%), followed by MS (N=119, 16%), CP (N=77, 11%), TBI (N=45, 6%), and SCI (N=42, 6%). The total body mean cumulative dose (±SD) of onabotulinumtoxinA per session ranged from 296 U (±145) in CP to 406 U (±152) in TBI. The most commonly treated upper limb presentations were clenched fist (stroke, MS, and SCI), flexed wrist (CP), and flexed elbow (TBI). Equinovarus foot was the most commonly treated lower limb presentation in all etiologies. Stroke patients showed improved DAS scores for nearly all subscales in both limbs, indicative of improved global function. All etiologies showed improved lower limb mobility DAS scores. Across all sessions, clinicians (range: 87.4% [SCI]-94.2% [CP]) and patients (range: 67.6% [TBI]-89.7% [SCI]) reported extreme satisfaction/satisfaction that onabotulinumtoxinA helped manage spasticity, and clinicians (range: 94.6% [TBI]-98.8% [CP]) and patients (range: 88.4% [stroke]-91.2% [TBI]) would definitely/probably continue treatment. Treatment-related adverse events (TRAEs) and treatment-related serious adverse events (TRSAEs) were reported as follows: stroke: 10 TRAEs (2.2% patients), 3 TRSAEs (0.5%); MS: 5 TRAEs (4.2%), 0 TRSAEs; CP: 0 TRAEs, 0 TRSAEs; TBI: 1 TRAEs (2.2%), 0 TRSAEs; SCI: 0 TRAEs, 0 TRSAEs. No new safety signals were identified. High clinician- and patient-reported satisfaction were observed following individualized onabotulinumtoxinA treatment, as well as improved global function. Interim results from ASPIRE demonstrate etiology-specific similarities and differences in clinical approaches to manage spasticity. ASPIRE found etiology-specific similarities and differences in real-world onabotulinumtoxinA utilization for spasticity. Across all etiologies, there was high clinician- and patient-reported satisfaction with onabotulinumtoxinA treatment. In DAS, all etiologies showed improved global function in lower limb mobility following onabotulinumtoxinA treatment. Adverse event data varied by etiology of spasticity; however, no new safety signals were identified. ASPIRE data may guide clinical strategies and educational programs to improve onabotulinumtoxinA spasticity management.
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Affiliation(s)
- Gerard E Francisco
- The University of Texas Health Science Center McGovern Medical School and TIRR Memorial Hermann, Houston, TX, USA
| | - Daniel S Bandari
- Multiple Sclerosis Center of California & Research Group, Newport Beach, CA, USA
| | | | - Wolfgang H Jost
- University of Freiburg, Department of Neurology, Freiburg im Breisgau, Germany.,Parkinson-Klinik Ortenau, Wolfach, Germany
| | | | - Joan Largent
- IQVIA Real-World Evidence Solutions, Cambridge, MA, USA
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12
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Rectus Femoris Characteristics in Post Stroke Spasticity: Clinical Implications from Ultrasonographic Evaluation. Toxins (Basel) 2020; 12:toxins12080490. [PMID: 32751934 PMCID: PMC7472004 DOI: 10.3390/toxins12080490] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 07/26/2020] [Accepted: 07/29/2020] [Indexed: 11/21/2022] Open
Abstract
In stroke survivors, rectus femoris (RF) spasticity is often implicated in gait pattern alterations such as stiff knee gait (SKG). Botulinum toxin type A (BoNT-A) is considered the gold standard for focal spasticity treatment. However—even if the accuracy of injection is crucial for BoNT-A efficacy—instrumented guidance for BoNT-A injection is not routinely applied in clinical settings. In order to investigate the possible implications of an inadequate BoNT-A injection on patients’ clinical outcome, we evaluated the ultrasound-derived RF characteristics (muscle depth, muscle thickness, cross-sectional area and mean echo intensity) in 47 stroke survivors. In our sample, we observed wide variability of RF depth in both hemiparetic and unaffected side of included patients (0.44 and 3.54 cm and between 0.25 and 3.16 cm, respectively). Moreover, our analysis did not show significant differences between treated and non-treated RF in stroke survivors. These results suggest that considering the inter-individual variability in RF muscle depth and thickness, injection guidance should be considered for BoNT-A treatment in order to optimize the clinical outcome of treated patients. In particular, ultrasound guidance may help the clinicians in the long-term follow-up of muscle quality.
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13
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Marciniak C, Munin MC, Brashear A, Rubin BS, Patel AT, Slawek J, Hanschmann A, Hiersemenzel R, Elovic EP. 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. PM R 2020; 12:491-499. [PMID: 31647185 DOI: 10.1002/pmrj.12265] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 10/04/2019] [Indexed: 11/10/2022]
Abstract
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.
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Affiliation(s)
- Christina Marciniak
- Department of Physical Medicine and Rehabilitation and Department of Neurology, Northwestern University Feinberg School of Medicine and Shirley Ryan Ability Lab, Chicago, IL
| | - Michael C Munin
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Allison Brashear
- Department of Neurology, Wake Forest School of Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC
| | | | - Atul T Patel
- Kansas City Bone & Joint Clinic, Overland Park, KS
| | - Jaroslaw Slawek
- Department of Neurological-Psychiatric Nursing, Medical University of Gdansk, Gdansk, Poland
| | | | | | - Elie P Elovic
- Department of Medicine, University of Nevada at Reno, Reno, NV
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14
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Ferrer Pastor M, Iñigo Huarte V, Juste Díaz J, Goiri Noguera D, Sogues Colom A, Cerezo Durá M. [Systematic review of the treatment of spasticity in acquired adult brain damage]. Rehabilitacion (Madr) 2020; 54:51-62. [PMID: 32007183 DOI: 10.1016/j.rh.2019.06.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Revised: 05/12/2019] [Accepted: 06/25/2019] [Indexed: 10/25/2022]
Abstract
Spasticity is a motor disorder characterised by an increase in muscle tone that appears as a consequence of a central nervous system disorder, leading to deficit and disability and impairing quality of life. In acquired adult brain damage, spasticity is a severe and frequent problem, appearing in 20-30% of patients with stroke and in 13-20% of patients with moderate-severe traumatic brain injury. The main objective of this study was to perform a systematic review of the treatments used in spasticity in adult patients with acquired brain damage secondary to stroke and head trauma. A systematic search of randomised controlled trials, published between January 1, 2013 and June 30, 2017 in English and Spanish, was carried out in the PubMed, Cochrane plus Library and Ovid databases. We finally selected 17 studies, with methodological quality that was at least acceptable according to the Jadad scale. The most frequently investigated treatments are botulinum toxin, especially serotype A, together with rehabilitative measures. Clinical scales are the most frequently used to assess spasticity.
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Affiliation(s)
- M Ferrer Pastor
- Servicio de Medicina Física y Rehabilitación, Consorcio Hospital General Universitario de Valencia, Valencia, España.
| | - V Iñigo Huarte
- Servicio de Medicina Física y Rehabilitación, Consorcio Hospital General Universitario de Valencia, Valencia, España
| | - J Juste Díaz
- Servicio de Medicina Física y Rehabilitación, Consorcio Hospital General Universitario de Valencia, Valencia, España
| | - D Goiri Noguera
- Servicio de Medicina Física y Rehabilitación, Consorcio Hospital General Universitario de Valencia, Valencia, España
| | - A Sogues Colom
- Servicio de Medicina Física y Rehabilitación, Consorcio Hospital General Universitario de Valencia, Valencia, España
| | - M Cerezo Durá
- Servicio de Medicina Física y Rehabilitación, Consorcio Hospital General Universitario de Valencia, Valencia, España
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15
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Hara T, Momosaki R, Niimi M, Yamada N, Hara H, Abo M. Botulinum Toxin Therapy Combined with Rehabilitation for Stroke: A Systematic Review of Effect on Motor Function. Toxins (Basel) 2019; 11:toxins11120707. [PMID: 31817426 PMCID: PMC6950173 DOI: 10.3390/toxins11120707] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 11/29/2019] [Accepted: 12/03/2019] [Indexed: 11/16/2022] Open
Abstract
Aim: The purpose of this study was to examine the effectiveness of botulinum toxin A (BoNT-A) therapy combined with rehabilitation on motor function in post-stroke patients. Methods: The following sources up to December 31, 2018, were searched from inception for articles in English: Pubmed, Scopus, CINAHL, Embase, PsycINFO, and CENTRAL. Trials using injections of BoNT-A for upper and lower limb rehabilitation were examined. We excluded studies that were not performed for rehabilitation or were not evaluated for motor function. Results: Twenty-six studies were included. In addition to rehabilitation, nine studies used adjuvant treatment to improve spasticity or improve motor function. In the upper limbs, two of 14 articles indicated that significant improvement in upper limb motor function was observed compared to the control group. In the lower limbs, seven of 14 articles indicated that significant improvement in lower limb motor function was observed compared to the control group. Conclusions: The effect of combined with rehabilitation is limited after stroke, and there is not sufficient evidence, but results suggest that BoNT-A may help to improve motor function. In future studies, the establishment of optimal rehabilitation and evaluation times of BoNT-A treatment will be necessary for improving motor function and spasticity.
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Affiliation(s)
- Takatoshi Hara
- Department of Rehabilitation Medicine The Jikei University School of Medicine 3-25-8, Nishi-Shinbashi, Minato-Ku, Tokyo 105-8461, Japan
- Correspondence: ; Tel.: +81-3-3433-1111; Fax: +81-3-3431-1206
| | - Ryo Momosaki
- Department of Rehabilitation Medicine, Teikyo University School of Medicine University Hospital, Mizonokuchi, Kanagawa 213-8507, Japan
| | - Masachika Niimi
- Department of Rehabilitation Medicine The Jikei University School of Medicine 3-25-8, Nishi-Shinbashi, Minato-Ku, Tokyo 105-8461, Japan
| | - Naoki Yamada
- Department of Rehabilitation Medicine The Jikei University School of Medicine 3-25-8, Nishi-Shinbashi, Minato-Ku, Tokyo 105-8461, Japan
| | - Hiroyoshi Hara
- Rehabilitation Center, Ainomiyako Neurosurgery Hospital, Osaka 538-0044, Japan
| | - Masahiro Abo
- Department of Rehabilitation Medicine The Jikei University School of Medicine 3-25-8, Nishi-Shinbashi, Minato-Ku, Tokyo 105-8461, Japan
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16
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Wallace AC, Talelli P, Crook L, Austin D, Farrell R, Hoad D, O'Keeffe AG, Marsden JF, Fitzpatrick R, Greenwood R, Rothwell JC, Werring DJ. Exploratory Randomized Double-Blind Placebo-Controlled Trial of Botulinum Therapy on Grasp Release After Stroke (PrOMBiS). Neurorehabil Neural Repair 2019; 34:51-60. [PMID: 31747825 DOI: 10.1177/1545968319887682] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background. OnabotulinumtoxinA injections improve upper-limb spasticity after stroke, but their effect on arm function remains uncertain. Objective. To determine whether a single treatment with onabotulinumtoxinA injections combined with upper-limb physiotherapy improves grasp release compared with physiotherapy alone after stroke. Methods. A total of 28 patients, at least 1 month poststroke, were randomized to receive either onabotulinumtoxinA or placebo injections to the affected upper limb followed by standardized upper-limb physiotherapy (10 sessions over 4 weeks). The primary outcome was time to release grasp during a functionally relevant standardized task. Secondary outcomes included measures of wrist and finger spasticity and strength using a customized servomotor, clinical assessments of stiffness (modified Ashworth Scale), arm function (Action Research Arm Test [ARAT], Nine Hole Peg Test), arm use (Arm Measure of Activity), Goal Attainment Scale, and quality of life (EQ5D). Results. There was no significant difference between treatment groups in grasp release time 5 weeks post injection (placebo median = 3.0 s, treatment median = 2.0 s; t(24) = 1.20; P = .24; treatment effect = -0.44, 95% CI = -1.19 to 0.31). None of the secondary measures passed significance after correcting for multiple comparisons. Both groups achieved their treatment goals (placebo = 65%; treatment = 71%), and made improvements on the ARAT (placebo +3, treatment +5) and in active wrist extension (placebo +9°, treatment +11°). Conclusions. In this group of stroke patients with mild to moderate spastic hemiparesis, a single treatment with onabotulinumtoxinA did not augment the improvements seen in grasp release time after a standardized upper-limb physiotherapy program.
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Affiliation(s)
| | | | - Lucinda Crook
- UCL Institute of Neurology, Queen Square, London, UK
| | - Duncan Austin
- UCL Institute of Neurology, Queen Square, London, UK
| | - Rachel Farrell
- UCL Institute of Neurology, Queen Square, London, UK.,National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | - Damon Hoad
- UCL Institute of Neurology, Queen Square, London, UK
| | | | | | | | - Richard Greenwood
- National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | | | - David J Werring
- UCL Institute of Neurology, Queen Square, London, UK.,National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
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17
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Kim Y, Bulea TC, Park HS. Transcutaneous high-frequency alternating current for rapid reversible muscle force reduction below pain threshold. J Neural Eng 2019; 16:066013. [PMID: 31344687 DOI: 10.1088/1741-2552/ab35ce] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE The development of non-invasive, quickly reversible techniques for controlling undesired muscle force production (e.g. spasticity) could expand rehabilitation approaches in those with pathology by increasing the type and intensity of exercises that can be performed. High-frequency alternating current (HFAC) has been previously established as a viable method for blocking neural conduction in peripheral nerves. However, clinical application of HFAC for nerve conduction block is limited due to the invasiveness of surgical procedures and the painful onset response. This study aimed to examine the use of transcutaneous HFAC (tHFAC) at various stimulation frequencies to address these shortfalls. APPROACH Ten individuals participated in the study. Surface electrodes were utilized to apply tHFAC (0.5-12 kHz) to the median and ulnar nerves. Individual pain threshold was determined by gradual increase of stimulation amplitude. Subjects then performed a force-matching task by producing grip forces up to the maximal voluntary contraction level with and without application of tHFAC below the pain threshold. MAIN RESULTS Pain threshold current amplitude increased linearly with stimulation frequency. Statistical analysis showed that both stimulation frequency and charge injected per phase had significant effects (p < 0.05) on grip force reduction. At the group level, application of tHFAC below pain threshold reduced grip force by a maximum of 40.7% ± 8.1%. Baseline grip force trials interspersed between tHFAC trials showed consistent grip force, indicating that fatigue was not a factor in force reduction. SIGNIFICANCE Our results demonstrate the effectiveness of tHFAC at reducing muscle force when applied below the pain threshold, suggesting its potential clinical viability. Future studies are necessary to further elucidate the mechanism of force reduction before clinical application.
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Affiliation(s)
- Yushin Kim
- Major of Sports Health Rehabilitation, Cheongju University, Cheongju, Republic of Korea
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18
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Paulson A, Zigler CK, Houtrow A, Pruitt D. Botulinum Toxin: Techniques Within Pediatric Physiatry. PM R 2019; 11:38-44. [DOI: 10.1016/j.pmrj.2018.06.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 06/15/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Andrea Paulson
- Department of Pediatrics; University of Cincinnati College of Medicine; Cincinnati OH 45267; Division of Pediatric Rehabilitation Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Christina K. Zigler
- Department of Physical Medicine and Rehabilitation; University of Pittsburgh; Pittsburgh PA
| | - Amy Houtrow
- Department of Physical Medicine and Rehabilitation; University of Pittsburgh; Pittsburgh PA
| | - David Pruitt
- Department of Pediatrics; University of Cincinnati College of Medicine; Cincinnati OH; Division of Pediatric Rehabilitation Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
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19
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Riedel P, Marino MH. Pharmacologic Treatment Tools: Systemic Medications and Toxins, Opportunities, and Pitfalls. Phys Med Rehabil Clin N Am 2019; 29:501-517. [PMID: 30626511 DOI: 10.1016/j.pmr.2018.04.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Treatment of pathologic muscle overactivity associated with upper motor neuron syndrome can be multifaceted. One of the initial decisions to be made when formulating an overarching treatment plan is selecting a combination of strategies that is most applicable. Strategies may include physical interventions, such as stretching or splinting modalities, or surgery, whereas pharmacotherapeutic strategies encompass oral/systemic medications as well as agents, such as toxins and alcohols, used for focal chemodenervation. This article reviews the oral/systemic therapies as well as toxins that are used focally. Although medication can also be administered via intrathecal pumps, this treatment approach is discussed elsewhere.
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Affiliation(s)
- Peter Riedel
- Physical Medicine and Rehabilitation, Moss Rehab, 60 Township Line Road, Elkins Park, PA 19027, USA
| | - Michael H Marino
- Physical Medicine and Rehabilitation, Moss Rehab, 60 Township Line Road, Elkins Park, PA 19027, USA; Physical Medicine and Rehabilitation, ReMed, 16 Industrial Boulevard, Paoli, PA 19301, USA.
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20
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Sandrini G, Baricich A, Cisari C, Paolucci S, Smania N, Picelli A. Management of spasticity with onabotulinumtoxinA: practical guidance based on the italian real-life post-stroke spasticity survey. FUNCTIONAL NEUROLOGY 2019; 33:37-43. [PMID: 29633695 DOI: 10.11138/fneur/2018.33.1.037] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The present paper provides practical guidance on the management of adult spasticity with OnabotulinumtoxinA. Advisory Board members reviewed the available evidence and discussed their personal experiences in order to address the unmet needs in the management of spasticity with botulinum toxin type A identified by the recent Italian Real-Life Post-Stroke Spasticity Survey. Stroke patients should be referred to spasticity services that have adequate facilities and multidisciplinary teams with the necessary training, competence and expertise. The current literature shows a strong correlation between the development of post-stroke spasticity and the degree of central sensorimotor system destruction/disorganization. Use of tools such as the Poststroke Checklist may help clinicians in the long-term follow-up of stroke patients. The maximum dose of onabotulinumtoxinA - according to the current literature this ranges from 300U to 400U for upper limb and from 500U to 600U for lower limb aggregate postures - should be re-considered. In addition, there is a need for future consensus (also based on pharmacoeconomic considerations) on consistent clinical care models for the management of patients with post-stroke spasticity.
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21
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Marciniak C, Munin MC, Brashear A, Rubin BS, Patel AT, Slawek J, Hanschmann A, Hiersemenzel R, Elovic EP. IncobotulinumtoxinA Efficacy and Safety in Adults with Upper-Limb Spasticity Following Stroke: Results from the Open-Label Extension Period of a Phase 3 Study. Adv Ther 2019; 36:187-199. [PMID: 30484117 PMCID: PMC6318229 DOI: 10.1007/s12325-018-0833-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Indexed: 01/12/2023]
Abstract
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.
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Affiliation(s)
- Christina Marciniak
- Department of Physical Medicine and Rehabilitation and Department of Neurology, Northwestern University Feinberg School of Medicine, Shirley Ryan AbilityLab, Chicago, IL, USA.
| | - Michael C Munin
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Allison Brashear
- Department of Neurology, Wake Forest School of Medicine, Wake Forest Baptist Medical Center, Winston Salem, NC, USA
| | | | - Atul T Patel
- Kansas City Bone & Joint Clinic, Overland Park, KS, USA
| | - Jaroslaw Slawek
- Department of Neurological-Psychiatric Nursing, Medical University of Gdansk, Gdansk, Poland
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22
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Botulinum Toxin Injections and Electrical Stimulation for Spastic Paresis Improve Active Hand Function Following Stroke. Toxins (Basel) 2018; 10:toxins10110426. [PMID: 30366407 PMCID: PMC6267216 DOI: 10.3390/toxins10110426] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Revised: 10/19/2018] [Accepted: 10/21/2018] [Indexed: 01/17/2023] Open
Abstract
Botulinum toxin type A (BTX-A) injections improve muscle tone and range of motion (ROM) among stroke patients with upper limb spasticity. However, the efficacy of BTX-A injections for improving active function is unclear. We aimed to determine whether BTX-A injections with electrical stimulation (ES) of hand muscles could improve active hand function (AHF) among chronic stroke patients. Our open-label, pilot study included 15 chronic stroke patients. Two weeks after BTX-A injections into the finger and/or wrist flexors, ES of finger extensors was performed while wearing a wrist brace for 4 weeks (5 days per week; 30-min sessions). Various outcomes were assessed at baseline, immediately before BTX-A injections, and 2 and 6 weeks after BTX-A injections. After the intervention, we noted significant improvements in Box and Block test results, Action Research Arm Test results, the number of repeated finger flexions/extensions, which reflect AHF, and flexor spasticity. Moreover, significant improvements in active ROM of wrist extension values were accompanied by marginally significant changes in Medical Research Council wrist extensor and active ROM of wrist flexion values. In conclusion, BTX-A injections into the finger and/or wrist flexors followed by ES of finger extensors improve AHF among chronic stroke patients.
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23
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Boulias C, Ismail F, Phadke CP, Bagg S, Bureau I, Charest S, Chen R, Cheng A, Ethans K, Fink M, Finlayson H, Gulasingam S, Guo M, Haziza M, Hosseini H, Khan O, Lang M, Lapp T, Leckey R, Li Pi Shan R, Liem N, Lo A, Mason M, McNeil S, McVeigh S, Miller T, Mills PB, Naud P, O'Connell C, Petitclerc M, Prevost J, Reebye R, Richardson D, Satkunam L, Sharma S, Short C, Sirois G, Unarket M, Wein T, Wilkins K, Winston P. A Delphi-Based Consensus Statement on the Management of Anticoagulated Patients With Botulinum Toxin for Limb Spasticity. Arch Phys Med Rehabil 2018; 99:2183-2189. [PMID: 29803825 DOI: 10.1016/j.apmr.2018.04.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 04/19/2018] [Accepted: 04/22/2018] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To create a consensus statement on the considerations for treatment of anticoagulated patients with botulinum toxin A (BoNTA) intramuscular injections for limb spasticity. DESIGN We used the Delphi method. SETTING A multiquestion electronic survey. PARTICIPANTS Canadian physicians (N=39) who use BoNTA injections for spasticity management in their practice. INTERVENTIONS After the survey was sent, there were e-mail discussions to facilitate an understanding of the issues underlying the responses. Consensus for each question was reached when agreement level was ≥75%. MAIN OUTCOME MEASURES Not applicable. RESULTS When injecting BoNTA in anticoagulated patients: (1) BoNTA injections should not be withheld regardless of muscles injected; (2) a 25G or smaller size needle should be used when injecting into the deep leg compartment muscles; (3) international normalized ratio (INR) level should be ≤3.5 when injecting the deep leg compartment muscles; (4) if there are clinical concerns such as history of a fluctuating INR, recent bleeding, excessive or new bruising, then an INR value on the day of injection with point-of-care testing or within the preceding 2-3 days should be taken into consideration when injecting deep compartment muscles; (5) the concern regarding bleeding when using direct oral anticoagulants (DOACs) should be the same as with warfarin (when INR is in the therapeutic range); (6) the dose and scheduling of DOACs should not be altered for the purpose of minimizing the risk of bleeding prior to BoNTA injections. CONCLUSIONS These consensus statements provide a framework for physicians to consider when injecting BoNTA for spasticity in anticoagulated patients. These consensus statements are not strict guidelines or decision-making steps, but rather an effort to generate common understanding in the absence of evidence in the literature.
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Affiliation(s)
- Chris Boulias
- West Park Healthcare Centre, Toronto, Ontario, Canada; Physical Medicine and Rehabilitation, University of Toronto, Toronto, Ontario, Canada.
| | - Farooq Ismail
- West Park Healthcare Centre, Toronto, Ontario, Canada; Physical Medicine and Rehabilitation, University of Toronto, Toronto, Ontario, Canada
| | - Chetan P Phadke
- West Park Healthcare Centre, Toronto, Ontario, Canada; Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada; Graduate Program in Kinesiology and Health Science, York University, Toronto, Ontario, Canada
| | - Stephen Bagg
- Providence Care Hospital and School of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Isabelle Bureau
- Centre for Integrated Health and Social Service (CISSS) for Chaudière-Appalaches Region, Hôtel-Dieu de Lévis, Lévis, Québec, Canada
| | - Stephane Charest
- Spasticity Clinic, H Mauricie Center of Quebec, Trois-Rivières, Québec, Canada
| | - Robert Chen
- University Health Network, Toronto, Ontario, Canada; Division of Neurology, University of Toronto, Toronto, Ontario, Canada
| | - Albert Cheng
- Physical Medicine and Rehabilitation, University of Toronto, Toronto, Ontario, Canada; University Health Network, Toronto, Ontario, Canada; Providence Healthcare, Toronto, Ontario, Canada
| | - Karen Ethans
- Winnipeg Health Sciences Centre and Physical Medicine and Rehabilitation, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Milo Fink
- Wascana Rehabilitation Centre and University of Saskatchewan, Regina, Saskatchewan, Canada
| | - Heather Finlayson
- GF Strong Rehabilitation Center and Division of Physical Medicine and Rehabilitation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sivakumar Gulasingam
- Physical Medicine and Rehabilitation, University of Toronto, Toronto, Ontario, Canada; University Health Network, Toronto, Ontario, Canada
| | - Meiqi Guo
- Physical Medicine and Rehabilitation, University of Toronto, Toronto, Ontario, Canada
| | - Muriel Haziza
- Physiatry Clinic, CDN Institute of Rehabilitation, Montreal, Québec, Canada
| | | | - Omar Khan
- Regional Rehabilitation Centre, Hamilton, Ontario, Canada; Hotel Dieu Shaver, St. Catharines, Ontario, Canada
| | | | - Timothy Lapp
- Muskoka Algonquin Health Care and Northern Ontario School of Medicine, Sudbury, Ontario, Canada
| | - Robert Leckey
- Stan Cassidy Centre, Fredericton, New Brunswick, Canada; Division of Physical Medicine and Rehabilitation, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Rodney Li Pi Shan
- Foothills Medical Centre, Calgary, Alberta, Canada; University of Calgary, Calgary, Alberta, Canada
| | - Nathania Liem
- Hôtel-Dieu Grace Healthcare, Windsor, Ontario, Canada
| | - Alexander Lo
- University Health Network, Toronto, Ontario, Canada
| | | | - Stephen McNeil
- Foothills Medical Centre, Calgary, Alberta, Canada; University of Calgary, Calgary, Alberta, Canada
| | - Sonja McVeigh
- Division of Physical Medicine and Rehabilitation, Dalhousie University, Halifax, Nova Scotia, Canada; Nova Scotia Rehabilitation Centre, Halifax, Nova Scotia, Canada
| | - Thomas Miller
- St. Joseph's Health Care London, Western University, London, Ontario, Canada
| | - Patricia B Mills
- GF Strong Rehabilitation Center and Division of Physical Medicine and Rehabilitation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Pierre Naud
- Capital Health Complex, Quebec City, Québec, Canada
| | - Colleen O'Connell
- Stan Cassidy Centre, Fredericton, New Brunswick, Canada; Division of Physical Medicine and Rehabilitation, Dalhousie University, Halifax, Nova Scotia, Canada
| | | | - Julie Prevost
- Saint-Jérôme Regional Hospital, Saint-Jérôme, Québec, Canada
| | - Rajiv Reebye
- GF Strong Rehabilitation Center and Division of Physical Medicine and Rehabilitation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Denyse Richardson
- Physical Medicine and Rehabilitation, University of Toronto, Toronto, Ontario, Canada; University Health Network, Toronto, Ontario, Canada
| | - Lalith Satkunam
- Glenrose Rehabilitation Hospital and Division of Physical Medicine & Rehabilitation, University of Alberta, Edmonton, Alberta, Canada
| | - Satyendra Sharma
- University Health Network, Toronto, Ontario, Canada; Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Christine Short
- Division of Physical Medicine and Rehabilitation, Dalhousie University, Halifax, Nova Scotia, Canada; Nova Scotia Rehabilitation Centre, Halifax, Nova Scotia, Canada
| | - Genevieve Sirois
- Quebec of Institute of Rehabilitation and Physical Impairment and Laval University, Québec City, Québec, Canada
| | - Milan Unarket
- Physical Medicine and Rehabilitation, University of Toronto, Toronto, Ontario, Canada; University Health Network, Toronto, Ontario, Canada
| | - Theodore Wein
- Montreal General Hospital and McGill University, Montreal, Québec, Canada
| | | | - Paul Winston
- CBI Health Centre, Victoria, British Columbia, Canada
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Buyukavci R, Akturk S, Ersoy Y. Evaluating the functional outcomes of ultrasound-guided botulinum toxin type A injections using the Euro-musculus approach for upper limb spasticity treatment in post-stroke patients: an observational study. Eur J Phys Rehabil Med 2018; 54:738-744. [PMID: 29422486 DOI: 10.23736/s1973-9087.18.05086-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Ultrasound-guided botulinum toxin type A injection is an effective treatment for spasticity. Euro-musculus spasticity approach is a new method for administering injections to the correct point of the correct muscle. The clinical outcomes of this practical approach are not yet available in the literature. AIM The purpose of this study was to evaluate the effects on spasticity and the functional outcomes of ultrasound guided botulinum toxin type A injections via the Euro-musculus spasticity approach to treat upper limb spasticity in post-stroke patients. DESIGN Observational study. SETTING Inpatient post-stroke patients. POPULATION Twenty-five post-stroke patients with post-stroke upper limb spasticity were recruited. METHODS The ultrasound-guided botulinum toxin type A injections were administered into the spastic target muscles using the Euro-musculus spasticity approach, and all of the patients were enrolled in rehabilitation programs after the injections. This research included the innervation zone and injection site figures and ultrasound images of each muscle in the upper limb. The degree of spasticity was assessed via the Modified Ashworth Scale and the upper limb motor function via the Fugl Meyer Upper Extremity Scale at the baseline and 4 and 12 weeks after the botulinum toxin type A injection. RESULTS Significant decreases in the Modified Ashworth Scale scores of the upper limb flexor muscle tone measured 4 and 12 weeks after the botulinum toxin type A injection were found when compared to the baseline scores (P<0.025). When compared with the baseline Fugl Meyer Upper Extremity subgroup scores, the sitting position, wrist and total scores at 4 and 12 weeks were significantly improved (P<0.025). However, only the Fugl Meyer Upper Extremity hand scores were significantly improved 12 weeks after the injection (P<0.025). CONCLUSIONS Ultrasound-guided botulinum toxin type A injection via the Euro-musculus spasticity approach is a practical and effective method for administering injections to the correct point of the correct muscle. Ultrasound-guided botulinum toxin type A injections combined with rehabilitation programs decrease spasticity and improve the upper extremity motor functions in stroke patients. CLINICAL REHABILITATION IMPACT This new approach for ultrasound-guided botulinum toxin type A injection is very practical and effective method for upper extremity spasticity.
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Affiliation(s)
- Raikan Buyukavci
- Department of Physical Medicine and Rehabilitation, Inonu University, Malatya, Turkey -
| | - Semra Akturk
- Department of Physical Medicine and Rehabilitation, Inonu University, Malatya, Turkey
| | - Yüksel Ersoy
- Department of Physical Medicine and Rehabilitation, Inonu University, Malatya, Turkey
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Wissel J. Towards flexible and tailored botulinum neurotoxin dosing regimens for focal dystonia and spasticity - Insights from recent studies. Toxicon 2018; 147:100-106. [PMID: 29407165 DOI: 10.1016/j.toxicon.2018.01.018] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 11/27/2017] [Accepted: 01/28/2018] [Indexed: 10/18/2022]
Abstract
Botulinum neurotoxin (BoNT) is an effective, well-tolerated, and well-established option for the treatment of dystonic and spastic movement disorders. However, a single approach does not suit all patients, even within one disease indication. The degree of flexibility in treatment protocols is determined by individual product licenses, which often lag behind real-world clinical experience. A number of patient/practitioner surveys conducted recently have highlighted a desire for greater flexibility than that currently approved, both in BoNT doses and in the intervals between consecutive doses. New evidence arising from research conducted during the last few years has opened new avenues for tailoring BoNT treatment to patients' needs. Data suggest that escalating incobotulinumtoxinA doses enables treatment of a greater number of spasticity patterns than current dose limitations allow, without compromising safety or tolerability. Similarly, in patients with cervical dystonia (CD), repeated injections of incobotulinumtoxinA at intervals as early as 6 weeks after a previous treatment, based on individual patient need, were effective and well tolerated. Here, the BoNT doses and dosing intervals currently indicated in the USA and European Union are reviewed, together with the use of BoNT for the treatment of spasticity, CD, and blepharospasm. Opportunities for tailored BoNT therapy are also discussed.
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Affiliation(s)
- Jörg Wissel
- Department of Neurorehabilitation and Physical Therapy, Department of Neurology, Vivantes Hospital Spandau, Neue Bergstraße, 13585 Berlin, Germany.
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Picelli A, Baricich A, Cisari C, Paolucci S, Smania N, Sandrini G. The Italian real-life post-stroke spasticity survey: unmet needs in the management of spasticity with botulinum toxin type A. FUNCTIONAL NEUROLOGY 2018; 32:89-96. [PMID: 28676142 DOI: 10.11138/fneur/2017.32.2.089] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
The present national survey seeking to identify unmet needs in the management of spasticity with botulinum toxin type A focused on the use of OnabotulinumoxinA, since this is the brand with the widest range of licensed indications in Italy. Physicians from twenty-four Italian neurorehabilitation units compiled a questionnaire about "real-life" post-stroke spasticity management. OnabotulinumtoxinA was reported to be used in the following average doses: upper limb 316.7 ± 79.1 units; lower limb 327.8 ± 152.3; upper and lower limb 543.7 ± 123.7 units. Of the physicians surveyed, 37.5% felt that increasing the frequency of OnabotulinumtoxinA injection would improve its efficacy; 70.8% use electrical stimulation/electromyography guidance (one fourth of injections with no instrumental guidance). Instrumental evaluation was used by 41.7% of the physicians. The participants expressed the view that early identification of post-stroke spasticity would be facilitated by the availability of a post-stroke checklist, and that this should be used by physiotherapists (91.7%), physiatrists (58.3%), family doctors (50%), stroke unit physicians (25%), patients and caregivers (79.2%). According to our findings, the management of poststroke spasticity has several unmet needs that, were they addressed, might improve these patients' clinical outcomes and quality of life. These needs concern patient follow-up, where a clearly defined pathway is lacking; furthermore, there is a need to use maximum doses per treatment and to ensure early intervention on post-stroke spasticity.
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Alter KE, Karp BI. Ultrasound Guidance for Botulinum Neurotoxin Chemodenervation Procedures. Toxins (Basel) 2017; 10:toxins10010018. [PMID: 29283397 PMCID: PMC5793105 DOI: 10.3390/toxins10010018] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 12/12/2017] [Accepted: 12/21/2017] [Indexed: 12/28/2022] Open
Abstract
Injections of botulinum neurotoxins (BoNTs) are prescribed by clinicians for a variety of disorders that cause over-activity of muscles; glands; pain and other structures. Accurately targeting the structure for injection is one of the principle goals when performing BoNTs procedures. Traditionally; injections have been guided by anatomic landmarks; palpation; range of motion; electromyography or electrical stimulation. Ultrasound (US) based imaging based guidance overcomes some of the limitations of traditional techniques. US and/or US combined with traditional guidance techniques is utilized and or recommended by many expert clinicians; authors and in practice guidelines by professional academies. This article reviews the advantages and disadvantages of available guidance techniques including US as well as technical aspects of US guidance and a focused literature review related to US guidance for chemodenervation procedures including BoNTs injection.
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Affiliation(s)
- Katharine E Alter
- Functional and Applied Biomechanics Section, Rehabilitation Medicine, Clinical Center, National Institutes of Health, Bethesda, MD 20892-1604, USA.
| | - Barbara I Karp
- Combined Neurosciences IRB, National Institutes of Health, Bethesda, MD 20892-1604, USA.
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Hara T, Abo M, Hara H, Kobayashi K, Shimamoto Y, Shibata Y, Sasaki N, Yamada N, Niimi M. Effects of botulinum toxin A therapy and multidisciplinary rehabilitation on lower limb spasticity classified by spastic muscle echo intensity in post-stroke patients. Int J Neurosci 2017; 128:412-420. [PMID: 28985683 DOI: 10.1080/00207454.2017.1389927] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES The purpose of the present study was to investigate retrospectively the relationship between botulinum toxin type A plus multidisciplinary rehabilitation and muscle echo intensity in post-stroke patients with spasticity. The primary aim was to investigate whether the effects of the intervention on the improvement of spasticity depend on muscle echo intensity, and the secondary aim was to investigate whether the motor function of the lower limbs depends on muscle echo intensity. METHODS A 12-day inpatient protocol was designed for 102 post-stroke patients with spasticity due to lower limb paralysis. Muscle echo intensity of the triceps surae muscle was measured by ultrasonography, and the patients were categorized into four groups based on Heckmatt scale grades (Grades I-IV). RESULTS All four groups classified by the Heckmatt scale showed significant pre-to-post-intervention differences in the knee and ankle modified Ashworth scale scores (p < 0.05). Grades I-III patient groups showed a significant improvement in lower limb motor function following intervention. Grade IV patients did not show a significant improvement in lower limb motor function. CONCLUSIONS We observed significant improvements in the modified Ashworth scale scores after botulinum toxin type A and multidisciplinary rehabilitation therapy on post-stroke patients with spasticity. Although patients with lower muscle echo intensity demonstrated improvements in motor function, the improvement was poor in those with higher muscle echo intensity.
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Affiliation(s)
- Takatoshi Hara
- a Department of Rehabilitaion Medicine , The Jikei University School of Medicine , Tokyo , Japan.,b Department of Rehabilitaion Medicine , Kikyougahara Hospital , Nagano , Japan
| | - Masahiro Abo
- a Department of Rehabilitaion Medicine , The Jikei University School of Medicine , Tokyo , Japan
| | - Hiroyoshi Hara
- b Department of Rehabilitaion Medicine , Kikyougahara Hospital , Nagano , Japan
| | - Kazushige Kobayashi
- a Department of Rehabilitaion Medicine , The Jikei University School of Medicine , Tokyo , Japan
| | - Yusuke Shimamoto
- b Department of Rehabilitaion Medicine , Kikyougahara Hospital , Nagano , Japan
| | - Yamato Shibata
- b Department of Rehabilitaion Medicine , Kikyougahara Hospital , Nagano , Japan
| | - Nobuyuki Sasaki
- a Department of Rehabilitaion Medicine , The Jikei University School of Medicine , Tokyo , Japan
| | - Naoki Yamada
- a Department of Rehabilitaion Medicine , The Jikei University School of Medicine , Tokyo , Japan
| | - Masachika Niimi
- a Department of Rehabilitaion Medicine , The Jikei University School of Medicine , Tokyo , Japan
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Botulinum toxin use in rehabilitation clinics: a survey to highlight differences and similarities. Int J Rehabil Res 2017; 40:370-373. [PMID: 28806237 DOI: 10.1097/mrr.0000000000000247] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Spasticity is a complex condition and its management is multifaceted, involving physical therapies as well as interventions with botulinum toxin. There is currently no standard for best practice and also wide variation in spasticity service set-ups and the background of clinicians involved in treatment. This could potentially cause large differences in practice. The aim of this survey was to attempt to identify some of the common elements of service delivery as well as highlight any significant variations in service models. It was hoped that the results would assist healthcare professionals working with toxins to gauge or improve their own service provision in the light of any findings. A survey of 48 botulinum toxin experts was conducted at a national conference in the UK. Questions included (i) numbers of patients referred and diagnostic groups, (ii) staff composition of each clinic, (iii) methods of spasticity assessment, (iv) outcome measures and treatment goals commonly used and (v) follow-up arrangements. There were broad areas of agreement between experts such as methods of assessment of spasticity, treatment, injection guidance and follow-up arrangements. However, there were differences in diagnostic groups seen, staff composition and in outcome measurement across a wide range of clinic settings. There are considerable variations in practice between toxin experts. This survey may help practitioners identify areas of improvement in their services or explore alternative service arrangements.
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Gracies JM, O'Dell M, Vecchio M, Hedera P, Kocer S, Rudzinska-Bar M, Rubin B, Timerbaeva SL, Lusakowska A, Boyer FC, Grandoulier AS, Vilain C, Picaut P. Effects of repeated abobotulinumtoxinA injections in upper limb spasticity. Muscle Nerve 2017; 57:245-254. [PMID: 28590525 PMCID: PMC5811783 DOI: 10.1002/mus.25721] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Revised: 05/31/2017] [Accepted: 06/02/2017] [Indexed: 01/24/2023]
Abstract
Introduction: The efficacy of single injections of abobotulinumtoxinA (Dysport) is established in adults with upper limb spasticity. In this study we assessed the effects of repeated injections of abobotulinumtoxinA over 1 year. Methods: Patients (n = 258, safety population) received 500 U, 1,000 U, or 1,500 U (1,500‐U dose included 500‐U shoulder injections) for up to 4 or 5 treatment cycles. Assessments included treatment‐emergent adverse events (TEAEs), muscle tone, passive and active range of motion (XV1, XA), angle of catch (XV3), Disability Assessment Scale (DAS) score, Modified Frenchay Scale (MFS) score, and Physician Global Assessment (PGA) score. Results: The incidence of TEAEs decreased across cycles. Muscle tone reduction and XV1 remained stable across cycles, whereas XV3 and XA continued to improve at the finger, wrist, and elbow flexors. DAS and PGA improved across cycles. MFS improved best with 1,500 U. Discussion: A favorable safety profile and continuous improvements in active movements and perceived and active function were associated with repeated abobotulinumtoxinA injections in upper limb muscles. Muscle Nerve57: 245–254, 2018
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Affiliation(s)
- Jean-Michel Gracies
- EA 7377 BIOTN, Université Paris-Est Créteil, Service de Rééducation Neurolocomotrice, Hôpitaux Universitaires Henri Mondor, 51, avenue du Maréchal De Lattre De Tassigny, 94010, Créteil, France
| | - Michael O'Dell
- Department of Rehabilitation Medicine, Weill Cornell Medicine, Baker Pavilion, New York, New York, USA
| | - Michele Vecchio
- Department of U.O. Physical Medicine and Rehabilitation, Policlinico Vittorio Emanuele University Hospital, Catania, Italy
| | - Peter Hedera
- Department of Neurology, Division of Movement Disorders, Vanderbilt University, Nashville, Tennessee, USA
| | - Serdar Kocer
- Centre de Rééducation Hôpital du Jura, Porrentruy, Switzerland
| | - Monika Rudzinska-Bar
- Department of Neurology, Faculty of Medicine, Medical University of Silesia, Katowice, Poland
| | - Bruce Rubin
- Design Neuroscience Center, Doral, Florida, USA
| | | | - Anna Lusakowska
- Department of Neurology, Medical University of Warsaw, Poland
| | - François Constant Boyer
- EA 3797, Unités de Médecine Physique et de Réadaptation, Hôpital Universitaire Sébastopol, Champagne Ardenne, France
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Picelli A, Vallies G, Chemello E, Castellazzi P, Brugnera A, Gandolfi M, Baricich A, Cisari C, Santamato A, Saltuari L, Waldner A, Smania N. Is spasticity always the same? An observational study comparing the features of spastic equinus foot in patients with chronic stroke and multiple sclerosis. J Neurol Sci 2017; 380:132-136. [PMID: 28870553 DOI: 10.1016/j.jns.2017.07.026] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Revised: 07/17/2017] [Accepted: 07/18/2017] [Indexed: 12/20/2022]
Abstract
Spasticity is common in stroke and multiple sclerosis. To treat spasticity we have a wide range of interventions, whose application may depend not only on the severity of spasticity but also on its etiology. Consequently, a better understanding of muscle spasticity in different neurological diseases may inform clinicians as to the more appropriate therapeutic approach. Our aim was to compare the clinical and ultrasonographic features of spastic equinus in patients with chronic stroke and multiple sclerosis. Thirty-eight patients with secondary progressive multiple sclerosis and 38 chronic stroke patients with spastic equinus were evaluated at the affected ankle according to the following outcomes: modified Ashworth scale, Tardieu scale, passive range of motion, spastic gastrocnemius muscle echo intensity and thickness. Affected calf muscles tone was significantly greater in patients with chronic stroke (modified Ashworth scale P=0.008; Tardieu scale angle P=0.004) as well as spastic gastrocnemius muscle echo intensity (P<0.001). Affected ankle range of motion was significantly greater in patients with multiple sclerosis (P<0.001) as well as spastic gastrocnemius muscle thickness (medialis: P=0.003; lateralis: P=0.004). Our findings evidenced that the same pattern of spasticity (equinus foot) has some different features according to its etiology. This may help the management of spasticity.
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Affiliation(s)
- Alessandro Picelli
- Neuromotor and Cognitive Rehabilitation Research Center, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy.
| | - Gabriella Vallies
- Neuromotor and Cognitive Rehabilitation Research Center, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Elena Chemello
- Neuromotor and Cognitive Rehabilitation Research Center, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Paola Castellazzi
- Neuromotor and Cognitive Rehabilitation Research Center, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Annalisa Brugnera
- Neuromotor and Cognitive Rehabilitation Research Center, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Marialuisa Gandolfi
- Neuromotor and Cognitive Rehabilitation Research Center, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy; Neurorehabilitation Unit, Department of Neurosciences, Hospital Trust of Verona, Verona, Italy
| | - Alessio Baricich
- Health Sciences Department, Università del Piemonte Orientale, Novara, Italy
| | - Carlo Cisari
- Health Sciences Department, Università del Piemonte Orientale, Novara, Italy
| | - Andrea Santamato
- Physical Medicine & Rehabilitation Section, 'OORR' Hospital, University of Foggia, Foggia, Italy
| | - Leopold Saltuari
- Department of Neurology, Hochzirl Hospital, Zirl, Austria; Research Unit of Neurorehabilitation, South Tyrol, Bolzano, Italy
| | - Andreas Waldner
- Research Unit of Neurorehabilitation, South Tyrol, Bolzano, Italy; "Villa Melitta" Rehabilitation Clinic, Bolzano, Italy
| | - Nicola Smania
- Neuromotor and Cognitive Rehabilitation Research Center, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy; Neurorehabilitation Unit, Department of Neurosciences, Hospital Trust of Verona, Verona, Italy
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Marciniak C, McAllister P, Walker H, Brashear A, Edgley S, Deltombe T, Khatkova S, Banach M, Gul F, Vilain C, Picaut P, Grandoulier AS, Gracies JM. Efficacy and Safety of AbobotulinumtoxinA (Dysport) for the Treatment of Hemiparesis in Adults With Upper Limb Spasticity Previously Treated With Botulinum Toxin: Subanalysis From a Phase 3 Randomized Controlled Trial. PM R 2017. [DOI: 10.1016/j.pmrj.2017.06.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Chan AK, Finlayson H, Mills PB. Does the method of botulinum neurotoxin injection for limb spasticity affect outcomes? A systematic review. Clin Rehabil 2017; 31:713-721. [PMID: 27370102 DOI: 10.1177/0269215516655589] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Abstract
OBJECTIVE To systematically review randomized controlled trials of botulinum neurotoxin for limb spasticity to determine whether different injection techniques affect spasticity outcomes. METHODS MEDLINE, EMBASE, CINAHL, and Cochrane Central Register of Controlled Trials electronic databases were searched for English language human randomized controlled trials from 1990 to 13 May 2016. Studies were assessed in duplicate for data extraction and risk of bias using the Physiotherapy Evidence Database scale and graded according to Sackett's levels of evidence. RESULTS Nine of 347 studies screened met selection criteria. Four categories of botulinum neurotoxin injection techniques were identified: (1) injection localization technique; (2) injection site selection; (3) injectate volume; (4) injection volume and site selection. There is level 1 evidence that: ultrasound, electromyography, and electrostimulation are superior to manual needle placement; endplate injections improve outcomes vs. multisite quadrant injections; motor point injections are equivalent to multisite injections; high volume injections are similar to low volume injections; and high volume injections distant from the endplate are more efficacious than low volumes closer to the endplate. CONCLUSION Level 1 evidence exists for differences in treatment outcomes using specific botulinum neurotoxin injection techniques. Findings are based on single studies that require independent replication and further study.
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Affiliation(s)
- Aaron K Chan
- 1 Department of Medicine, Division of Physical Medicine and Rehabilitation, University of British Columbia, Vancouver, Canada
- 2 G.F. Strong Rehabilitation Centre, Vancouver, Canada
| | - Heather Finlayson
- 1 Department of Medicine, Division of Physical Medicine and Rehabilitation, University of British Columbia, Vancouver, Canada
- 2 G.F. Strong Rehabilitation Centre, Vancouver, Canada
- 3 Rehabilitation Research Program, Vancouver Coastal Health Research Institute, Vancouver, Canada
| | - Patricia B Mills
- 1 Department of Medicine, Division of Physical Medicine and Rehabilitation, University of British Columbia, Vancouver, Canada
- 2 G.F. Strong Rehabilitation Centre, Vancouver, Canada
- 3 Rehabilitation Research Program, Vancouver Coastal Health Research Institute, Vancouver, Canada
- 4 ICORD (International Collaboration on Repair Discoveries), Vancouver, Canada
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Picelli A, La Marchina E, Gajofatto F, Pontillo A, Vangelista A, Filippini R, Baricich A, Cisari C, Smania N. Sonographic and clinical effects of botulinum toxin Type A combined with extracorporeal shock wave therapy on spastic muscles of children with cerebral palsy. Dev Neurorehabil 2017; 20:160-164. [PMID: 26890193 DOI: 10.3109/17518423.2015.1105320] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The aim of this study was to compare the combined sonographic and clinical effects of botulinum toxin type A (BoNT-A) and extracorporeal shock wave therapy (ESWT) versus BoNT-A alone in children with cerebral palsy. METHODS Ten children with spastic cerebral palsy were randomly assigned to one of two groups. Group 1 received BoNT-A injection into the spastic muscles of the affected limbs plus three ESWT sessions. Group 2 received BoNT-A alone. Assessment was performed before and 1 month after injection. Sonographic outcomes were injected muscles echo intensity and their hardness percentage, and clinical outcomes the modified Ashworth scale and the Tardieu scale. RESULTS At 1-month evaluation, significant differences in the injected muscles percentage of hardness (P = 0.021) and the modified Ashworth scale (P = 0.001) were found between groups. CONCLUSIONS Our results support the hypothesis that the combined effects of BoNT-A and ESWT derive from their respective action on neurological and non-neural rheological components in spastic muscles.
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Affiliation(s)
- Alessandro Picelli
- a Neuromotor and Cognitive Rehabilitation Research Centre, Department of Neurological , Biomedical and Movement Sciences, University of Verona , Verona , Italy
| | - Elisabetta La Marchina
- a Neuromotor and Cognitive Rehabilitation Research Centre, Department of Neurological , Biomedical and Movement Sciences, University of Verona , Verona , Italy
| | | | - Angelo Pontillo
- a Neuromotor and Cognitive Rehabilitation Research Centre, Department of Neurological , Biomedical and Movement Sciences, University of Verona , Verona , Italy
| | | | | | - Alessio Baricich
- c Physical and Rehabilitative Medicine , University Hospital "Maggiore della Carità" , Novara , Italy.,d Department of Health Sciences , Piemonte Orientale University , Novara , Italy
| | - Carlo Cisari
- c Physical and Rehabilitative Medicine , University Hospital "Maggiore della Carità" , Novara , Italy.,d Department of Health Sciences , Piemonte Orientale University , Novara , Italy
| | - Nicola Smania
- a Neuromotor and Cognitive Rehabilitation Research Centre, Department of Neurological , Biomedical and Movement Sciences, University of Verona , Verona , Italy.,e Neurorehabilitation Unit , Hospital Trust of Verona , Verona , Italy
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Zeuner KE, Knutzen A, Kühl C, Möller B, Hellriegel H, Margraf NG, Deuschl G, Stolze H. Functional impact of different muscle localization techniques for Botulinum neurotoxin A injections in clinical routine management of post-stroke spasticity. Brain Inj 2016; 31:75-82. [DOI: 10.1080/02699052.2016.1218545] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
| | - Arne Knutzen
- Department of Neurology, Kiel University, Germany
| | - Carina Kühl
- Department of Neurology, Kiel University, Germany
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Morel C, Hauret I, Andant N, Bonnin A, Pereira B, Coudeyre E. Efficacy of two injection-site localisation techniques for botulinum toxin injections: a single-blind, crossover, randomised trial protocol among adults with hemiplegia due to stroke. BMJ Open 2016; 6:e011751. [PMID: 27852706 PMCID: PMC5129049 DOI: 10.1136/bmjopen-2016-011751] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Botulinum toxin injections are an effective treatment for limb spasticity following stroke. Different tracking techniques are used for this purpose: palpation, electrostimulation, electromyography and ultrasound. Yet very few studies have compared these different techniques, and none has successfully proved the superior efficacy of ultrasound-guided injections compared to another tracking method. The primary objective of our study was therefore to compare the efficacy of botulinum toxin injections depending on the tracking technique used: ultrasound versus electrostimulation. METHODS AND ANALYSIS This is a clinical, single-centre, prospective, interventional, single-blind, crossover, randomised trial. In total, 30 patients aged between 18 and 80 years presenting with triceps surae spasticity (evaluated >1 on the modified Ashworth scale) associated with hemiplegia sequelae due to stroke will be included. The patients will be selected among those who attend for consultation the Physical Medicine and Rehabilitation Department of the Clermont-Ferrand University Hospital. One group will receive the abobotulinumtoxinA (BoNT-A) injection guided by electrostimulation then ultrasound, and the second group's botulinum toxin injections will be guided by ultrasound then electrostimulation. For each patient, the duration of study participation is 5 months. The primary end point is variation in passive ankle dorsiflexion range of motion at slow and high speeds (Tardieu scale) with the knee straight. ETHICS AND DISSEMINATION This study received ethics approval form the CPP of Rhônes-Alpes region. Results will be published in a peer-reviewed journal. TRIAL REGISTRATION NUMBER NCT01935544; pre-results.
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Affiliation(s)
- Claire Morel
- Service de Médecine Physique et de Réadaptation; CHU Clermont-Ferrand, Clermont-Ferrand, France
- Université Clermont Auvergne, Clermont-Ferrand, France
| | - Isabelle Hauret
- Service de Médecine Physique et de Réadaptation; CHU Clermont-Ferrand, Clermont-Ferrand, France
- Centre médical Etienne Clémentel, Enval, France
| | - Nicolas Andant
- Biostatistics Unit, Délégation Recherche Clinique & Innovation (DRCI), CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Armand Bonnin
- Service de Médecine Physique et de Réadaptation; CHU Clermont-Ferrand, Clermont-Ferrand, France
- Université Clermont Auvergne, Clermont-Ferrand, France
| | - Bruno Pereira
- Biostatistics Unit, Délégation Recherche Clinique & Innovation (DRCI), CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Emmanuel Coudeyre
- Service de Médecine Physique et de Réadaptation; CHU Clermont-Ferrand, Clermont-Ferrand, France
- Université Clermont Auvergne, Clermont-Ferrand, France
- INRA, Unité de Nutrition Humaine (UNH, UMR 1019), Clermont-Ferrand, France
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Aquatic Therapy Improves Outcomes for Subacute Stroke Patients by Enhancing Muscular Strength of Paretic Lower Limbs Without Increasing Spasticity. Am J Phys Med Rehabil 2016; 95:840-849. [DOI: 10.1097/phm.0000000000000512] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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McGuire J, Heath K, O'Dell MW. Should Ultrasound Be Used Routinely to Guide Botulinum Toxin Injections for Spasticity? PM R 2016; 8:1004-1010. [PMID: 27769363 DOI: 10.1016/j.pmrj.2016.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Accepted: 09/15/2016] [Indexed: 11/19/2022]
Affiliation(s)
- John McGuire
- Associate Professor PM&R, Medical Director of Comprehensive Spasticity Management, Medical Director for Stroke Rehabilitation, Medical College of Wisconsin, Froedtert Memorial Lutheran Hospital, Milwaukee, WI
| | - Kelly Heath
- Assistant Professor, Neurorehabilitation, Department of Physical Medicine & Rehabilitation, Hospital of the University of Pennsylvania, Philadelphia, PA; Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
| | - Michael W O'Dell
- Division of Rehabilitation Medicine, Weill Cornell Medicine, 525 E. 68th Street, 16th FL, New York, NY 10065
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Govindarajan R, Shepard KM, Moschonas C, Chen JJ. Botulinum neurotoxin for the treatment of blepharospasm, cervical dystonia, adult spasticity, and headache: Payment policy perspectives. Neurol Clin Pract 2016; 6:281-286. [PMID: 29443136 DOI: 10.1212/cpj.0000000000000243] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
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.
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Affiliation(s)
- Raghav Govindarajan
- University of Missouri (RG), Columbia, MO; American Academy of Neurology (KMS), Minneapolis, MN; Four Peaks Neurology (CM), Scottsdale, AZ; and Marshall B. Ketchum University (JJC), Fullerton, CA
| | - Katie M Shepard
- University of Missouri (RG), Columbia, MO; American Academy of Neurology (KMS), Minneapolis, MN; Four Peaks Neurology (CM), Scottsdale, AZ; and Marshall B. Ketchum University (JJC), Fullerton, CA
| | - Constantine Moschonas
- University of Missouri (RG), Columbia, MO; American Academy of Neurology (KMS), Minneapolis, MN; Four Peaks Neurology (CM), Scottsdale, AZ; and Marshall B. Ketchum University (JJC), Fullerton, CA
| | - Jack J Chen
- University of Missouri (RG), Columbia, MO; American Academy of Neurology (KMS), Minneapolis, MN; Four Peaks Neurology (CM), Scottsdale, AZ; and Marshall B. Ketchum University (JJC), Fullerton, CA
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Kaku M, Simpson DM. Spotlight on botulinum toxin and its potential in the treatment of stroke-related spasticity. DRUG DESIGN DEVELOPMENT AND THERAPY 2016; 10:1085-99. [PMID: 27022247 PMCID: PMC4789850 DOI: 10.2147/dddt.s80804] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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.
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Affiliation(s)
- Michelle Kaku
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - David M Simpson
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Zeuner KE, Deuschl G. Pharmacokinetics and pharmacodynamics of incobotulinumtoxinA influencing the clinical efficacy in post-stroke spasticity. Expert Opin Drug Metab Toxicol 2016; 12:457-66. [DOI: 10.1517/17425255.2016.1152262] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Schramm A, Bäumer T, Fietzek U, Heitmann S, Walter U, Jost WH. Relevance of sonography for botulinum toxin treatment of cervical dystonia: an expert statement. J Neural Transm (Vienna) 2015; 122:1457-63. [PMID: 25547861 PMCID: PMC4591194 DOI: 10.1007/s00702-014-1356-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2014] [Accepted: 12/20/2014] [Indexed: 11/26/2022]
Abstract
Botulinum neurotoxin A (BoNT A) is the first-line treatment for cervical dystonia. However, although BoNT A has a favorable safety profile and is effective in the majority of patients, in some cases the treatment outcome is disappointing or side effects occur when higher doses are used. It is likely that in such cases either the target muscles were not injected accurately or unintended weakness of non-target muscles occurred. It has been demonstrated in clinical trials for spastic movement disorders that sonography-guided BoNT A injections could improve treatment outcome. As the published evidence for a benefit of sonography-guided BoNT injection in patients with cervical dystonia is scarce, it is the aim of this review to discuss the relevance of sonography in this indication and provide a statement from clinical experts for its use. The clear advantage of sonography-guided injections is non-invasive, real-time visualization of the targeted muscle, thus improving the precision of injections and potentially the treatment outcomes as well as avoiding adverse effects. Other imaging techniques are of limited value due to high costs, radiation exposure or non-availability in clinical routine. In the hands of a trained injector, sonography is a quick and non-invasive imaging technique. Novel treatment concepts of cervical dystonia considering the differential contributions of distinct cranial and cervical muscles can reliably be implemented only by use of imaging-guided injection protocols.
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Affiliation(s)
- Axel Schramm
- Department of Neurology, University of Erlangen, Erlangen, Germany
| | - Tobias Bäumer
- Department of Movement Disorders and Neuropsychiatry, University of Lübeck, Lübeck, Germany
| | - Urban Fietzek
- Department of Neurology and Clinical Neurophysiology, Schön Klinik München Schwabing, Munich, Germany
| | - Susanne Heitmann
- Department of Neurology, Deutsche Klinik für Diagnostik, Wiesbaden, Germany
| | - Uwe Walter
- Department of Neurology, University of Rostock, Rostock, Germany
| | - Wolfgang H Jost
- Department of Neurology, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany.
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Jiang L, Dou ZL, Wang Q, Wang QY, Dai M, Wang Z, Wei XM, Chen YB. Evaluation of clinical outcomes of patients with post-stroke wrist and finger spasticity after ultrasonography-guided BTX-A injection and rehabilitation training. Front Hum Neurosci 2015; 9:485. [PMID: 26388761 PMCID: PMC4557080 DOI: 10.3389/fnhum.2015.00485] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Accepted: 08/21/2015] [Indexed: 11/20/2022] Open
Abstract
Objective: Using ultrasonography (US) to guide botulinum toxin type A (BTX-A) injection in patients with post-stroke wrist and finger flexor muscle spasticity and assessing clinical outcomes after the injection and rehabilitation intervention. Methods: Twenty-three patients with wrist and finger spasticity after stroke were recruited in this study from May 2012 to May 2013. Under US guidance, the proper dose (250 U) of BTX-A was injected into each spastic muscle at two injection sites. Then, conventional rehabilitation training started next day after BTX-A injection. The degree of spasticity was assessed by modified Ashworth scale (MAS) and wrist and finger motor function by active rang of movement (AROM), and Fugl-Meyer assessment (FMA) at the baseline, 1, 2, 4 and 12 weeks after BTX-A injection. Results: Significant decreases (p < 0.02) in the MAS scores of both the finger flexor muscle tone and wrist flexor muscle tone measured at 1, 2, 4, and 12 weeks after the BTX-A injection were found in comparison with the baseline scores. Compared with the baseline, the AROM values of the wrist and finger extensions and the FMA scores of the wrist and hand significantly increased (p < 0.02) at 2, 4 and 12 weeks after the BTX-A injection. Conclusions: US-guided BTX-A injection combined with rehabilitation exercise decrease spasticity of the wrist and finger flexor muscles and improve their motor function in stroke patients up to 12 weeks following BTX-A injection.
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Affiliation(s)
- Li Jiang
- Department of Rehabilitation Medicine, The Third Affiliated Hospital, Sun Yat-sen University Guangzhou, China
| | - Zu-Lin Dou
- Department of Rehabilitation Medicine, The Third Affiliated Hospital, Sun Yat-sen University Guangzhou, China
| | - Qing Wang
- Institute of Medical Information, School of Biomedical Engineering, Southern Medical University Guangzhou, China
| | - Qiao-Yuan Wang
- Department of Ultrasound Medicine, The Third Affiliated Hospital, Sun Yat-sen University Guangzhou, China
| | - Meng Dai
- Department of Rehabilitation Medicine, The Third Affiliated Hospital, Sun Yat-sen University Guangzhou, China
| | - Zhen Wang
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic Rochester, MN, USA ; Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic Rochester, MN, USA
| | - Xiao-Mei Wei
- Department of Rehabilitation Medicine, The Third Affiliated Hospital, Sun Yat-sen University Guangzhou, China
| | - Ying-Bei Chen
- Department of Rehabilitation Medicine, The Third Affiliated Hospital, Sun Yat-sen University Guangzhou, China
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Gracies JM, Brashear A, Jech R, McAllister P, Banach M, Valkovic P, Walker H, Marciniak C, Deltombe T, Skoromets A, Khatkova S, Edgley S, Gul F, Catus F, De Fer BB, Vilain C, Picaut P. 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. Lancet Neurol 2015; 14:992-1001. [PMID: 26318836 DOI: 10.1016/s1474-4422(15)00216-1] [Citation(s) in RCA: 124] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Revised: 07/15/2015] [Accepted: 08/03/2015] [Indexed: 12/16/2022]
Abstract
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.
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Affiliation(s)
- Jean-Michel Gracies
- EA 7377 BIOTN, Université Paris-Est, Hospital Albert Chenevier-Henri Mondor, Service de Rééducation Neurolocomotrice, Créteil, France.
| | - Allison Brashear
- Wake Forest University School of Medicine, Department of Neurology, Winston-Salem, NC, USA
| | - Robert Jech
- Department of Neurology, First Faculty of Medicine, Charles University and General Faculty Hospital, Prague, Czech Republic
| | - Peter McAllister
- New England Institute for Neurology and Headache, Stamford, CT, USA
| | - Marta Banach
- Department of Neurology, Jagiellonian University Medical College, Krakow, Poland
| | - Peter Valkovic
- Second Department of Neurology, Comenius University and University Hospital, Bratislava, Slovakia
| | | | - Christina Marciniak
- Northwestern University and Rehabilitation Institute of Chicago, Chicago, IL, USA
| | - Thierry Deltombe
- Service de Médecine Physique et de Réadaptation, Centre Hospitalier Universitaire Dinant Godinne/Université catholique de Louvain Namur, Yvoir, Belgium
| | - Alexander Skoromets
- State Budgetary Educational Institution of Higher Professional Education, St Petersburg State Medical University I P Pavlov, St Petersburg, Russia
| | - Svetlana Khatkova
- Neurology Department, Federal State Hospital Treatments and Rehabilitation Center of Ministry of Health and Social Development of Russian Federation, Moscow, Russia
| | - Steven Edgley
- University of Utah School of Medicine, Division of Physical Medicine and Rehabilitation, Salt Lake City, UT, USA
| | - Fatma Gul
- University of Texas Southwestern Medical Center, Dallas, TX, USA
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Grigoriu AI, Dinomais M, Rémy-Néris O, Brochard S. Impact of Injection-Guiding Techniques on the Effectiveness of Botulinum Toxin for the Treatment of Focal Spasticity and Dystonia: A Systematic Review. Arch Phys Med Rehabil 2015; 96:2067-78.e1. [PMID: 25982240 DOI: 10.1016/j.apmr.2015.05.002] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Revised: 04/16/2015] [Accepted: 05/04/2015] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To conduct a systematic review of the impact of different injection-guiding techniques on the effectiveness of botulinum toxin type A (BoNT-A) for the treatment of focal spasticity and dystonia. DATA SOURCES MEDLINE via PubMed, Academic Search Premier, PASCAL, The Cochrane Library, Scopus, SpringerLink, Web of Science, EM Premium, and PsycINFO. STUDY SELECTION Two reviewers independently selected studies based on predetermined inclusion criteria. DATA EXTRACTION Data relating to the aim were extracted. Methodological quality was graded independently by 2 reviewers using the Physiotherapy Evidence Database assessment scale for randomized controlled trials (RCTs) and the Downs and Black evaluation tool for non-RCTs. Level of evidence was determined using the modified Sackett scale. DATA SYNTHESIS Ten studies were included. Seven were randomized. There was strong evidence (level 1) that instrumented guiding (ultrasonography [US], electrical stimulation [ES], electromyogram [EMG]) was more effective than manual needle placement for the treatment of spasmodic torticollis, upper limb spasticity, and spastic equinus in patients with stroke, and spastic equinus in children with cerebral palsy. Three studies provided strong evidence (level 1) of similar effectiveness of US and ES for upper and lower limb spasticity in patients with stroke, and spastic equinus in children with cerebral palsy, but there was poor evidence or no available evidence for EMG or other instrumented techniques. CONCLUSIONS These results strongly recommend instrumented guidance of BoNT-A injection for the treatment of spasticity in adults and children (ES or US), and of focal dystonia such as spasmodic torticollis (EMG). No specific recommendations can be made regarding the choice of instrumented guiding technique, except that US appears to be more effective than ES for spastic equinus in adults with stroke.
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Affiliation(s)
| | - Mickael Dinomais
- LUNAM, University of Angers, University Hospital of Angers, Rehabilitation Department, Angers, France; LUNAM, University of Angers, Angers Laboratory for Research in Engineering Systems (LARIS)-UPRES EA, Angers, France
| | - Olivier Rémy-Néris
- University Hospital of Brest, Rehabilitation Department, Brest, France; Western Brittany University, Brest, France; National Institute of Health and Medical Research (INSERM) UMR 1101, Medical Data Treatment (LaTIM), Brest, France
| | - Sylvain Brochard
- University Hospital of Brest, Rehabilitation Department, Brest, France; Western Brittany University, Brest, France; National Institute of Health and Medical Research (INSERM) UMR 1101, Medical Data Treatment (LaTIM), Brest, France
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Baricich A, Grana E, Carda S, Santamato A, Cisari C, Invernizzi M. High doses of onabotulinumtoxinA in post-stroke spasticity: a retrospective analysis. J Neural Transm (Vienna) 2015; 122:1283-7. [PMID: 25724294 DOI: 10.1007/s00702-015-1384-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Accepted: 02/19/2015] [Indexed: 11/27/2022]
Abstract
We retrospectively evaluated the efficacy and safety of high doses of onabotulinumtoxinA (from 600 to 800 units) in 26 patients affected by upper and/or lower limb post-stroke spasticity. They were assessed before, 30 and 90 days after treatment. We observed a significant muscle tone reduction and a significant functional improvement (assessed with the Disability Assessment Scale). No adverse events were reported. In our retrospective analysis the treatment with high doses of onabotulinumtoxinA showed to be effective and safe.
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Affiliation(s)
- Alessio Baricich
- Physical and Rehabilitative Medicine - University Hospital "Maggiore della Carità", Novara, Italy,
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Cameron MH, Bethoux F, Davis N, Frederick M. Botulinum toxin for symptomatic therapy in multiple sclerosis. Curr Neurol Neurosci Rep 2015; 14:463. [PMID: 24952479 DOI: 10.1007/s11910-014-0463-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Botulinum toxin (BT) is a neurotoxin that paralyzes muscles by inhibiting release of acetylcholine from presynaptic vesicles at the neuromuscular junction. In people with multiple sclerosis (MS), clinical experience and research studies show that local injection of minute quantities of BT can temporarily control skeletal muscle spasticity, bladder detrusor hyperreflexia, and tremor. Specifically, BT injections have been shown to reduce muscle tone and improve passive function, and possibly improve active function, in patients with spasticity. Injection of BT into the bladder wall is a uniquely effective, safe, and durable treatment in patients with neurogenic detrusor hyperreflexia due to MS who have insufficient response or who do not tolerate oral antimuscarinic medications. This procedure has markedly reduced the need for indwelling catheters and bladder surgery. In addition, a recent study suggests BT may be effective for select patients with MS-associated upper extremity tremor. Appropriate use of BT can improve quality of life for many patients with MS.
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Affiliation(s)
- Michelle H Cameron
- Neurology Department, Oregon Health & Science University and Portland VA Medical Center, 3181 SW Sam Jackson Park Rd, L226, Portland, OR, USA,
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Santamato A, Micello MF, Ranieri M, Valeno G, Albano A, Baricich A, Cisari C, Intiso D, Pilotto A, Logroscino G, Panza F. Employment of higher doses of botulinum toxin type A to reduce spasticity after stroke. J Neurol Sci 2015; 350:1-6. [PMID: 25684341 DOI: 10.1016/j.jns.2015.01.033] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Revised: 01/07/2015] [Accepted: 01/30/2015] [Indexed: 11/30/2022]
Abstract
Spasticity is a common disabling symptom for several neurological conditions. Botulinum toxin type A injection represents the gold standard treatment for focal spasticity with efficacy, reversibility, and low prevalence of complications. Current guidelines suggest a dose up to 600 units (U) of onabotulinumtoxinA/incobotulinumtoxinA or up to 1,500 U of abobotulinumtoxinA to treat post-stroke spasticity to avoid important adverse effects. However, recently, higher doses of botulinum toxin type A were employed, especially in case of upper and lower limb severe spasticity. With searches of US National Library of Medicine databases, we identified all studies published from December 1989 to July 2014 concerning the use of higher doses of this neurotoxin for spasticity treatment with at least a dose of 600 U of onabotulinumtoxinA and incobotulinumtoxinA or 1,800 U of abobotulinumtoxinA. The cumulative body of evidence coming from the eight studies selected suggested that higher doses of botulinum toxin type A appeared to be efficacious in reducing spasticity of the upper and lower limbs after stroke, with adverse effects generally mild. However, further investigations are needed to determine the safety and reproducibility in larger case series or randomized clinical trials of higher doses of botulinum toxin type A also after repeated injections.
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Affiliation(s)
- Andrea Santamato
- Physical Medicine and Rehabilitation Section-"OORR Hospital", University of Foggia, Foggia, Italy.
| | - Maria Francesca Micello
- Physical Medicine and Rehabilitation Section-"OORR Hospital", University of Foggia, Foggia, Italy
| | - Maurizio Ranieri
- Physical Medicine and Rehabilitation Section-"OORR Hospital", University of Foggia, Foggia, Italy
| | - Giovanni Valeno
- Physical Medicine and Rehabilitation Section-"OORR Hospital", University of Foggia, Foggia, Italy
| | - Antonio Albano
- Physical Medicine and Rehabilitation Section-"OORR Hospital", University of Foggia, Foggia, Italy
| | - Alessio Baricich
- Physical Medicine and Rehabilitation, Department of Health Sciences, University of Eastern Piedmont, Novara, Italy
| | - Carlo Cisari
- Physical Medicine and Rehabilitation, Department of Health Sciences, University of Eastern Piedmont, Novara, Italy
| | - Domenico Intiso
- Department of Neuro-Rehabilitation IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo, Foggia, Italy
| | - Alberto Pilotto
- Gerontology-Geriatrics Research Laboratory, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Foggia, Italy; Geriatric Unit, Azienda ULSS 16 Padova, S. Antonio Hospital, Padova, Italy
| | - Giancarlo Logroscino
- Neurodegenerative Disease Unit, Department of Basic Medicine, Neuroscience, and Sense Organs, University of Bari Aldo Moro, Bari, Italy; Department of Clinical Research in Neurology, University of Bari Aldo Moro, "Pia Fondazione Cardinale G. Panico", Tricase, Lecce, Italy
| | - Francesco Panza
- Gerontology-Geriatrics Research Laboratory, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Foggia, Italy; Neurodegenerative Disease Unit, Department of Basic Medicine, Neuroscience, and Sense Organs, University of Bari Aldo Moro, Bari, Italy; Department of Clinical Research in Neurology, University of Bari Aldo Moro, "Pia Fondazione Cardinale G. Panico", Tricase, Lecce, Italy.
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Santamato A, Micello MF, Panza F, Fortunato F, Baricich A, Cisari C, Pilotto A, Logroscino G, Fiore P, Ranieri M. Can botulinum toxin type A injection technique influence the clinical outcome of patients with post-stroke upper limb spasticity? A randomized controlled trial comparing manual needle placement and ultrasound-guided injection techniques. J Neurol Sci 2014; 347:39-43. [PMID: 25263601 DOI: 10.1016/j.jns.2014.09.016] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Revised: 08/25/2014] [Accepted: 09/12/2014] [Indexed: 10/24/2022]
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50
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Walker HW, Lee MY, Bahroo LB, Hedera P, Charles D. Botulinum Toxin Injection Techniques for the Management of Adult Spasticity. PM R 2014; 7:417-27. [DOI: 10.1016/j.pmrj.2014.09.021] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Revised: 09/26/2014] [Accepted: 09/28/2014] [Indexed: 12/31/2022]
Affiliation(s)
- Heather W. Walker
- Department of Physical Medicine and Rehabilitation, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, NC
| | - Michael Y. Lee
- Department of Physical Medicine and Rehabilitation, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, NC
| | | | - Peter Hedera
- Department of Neurology, Vanderbilt University, Nashville, TN
| | - David Charles
- Department of Neurology, Vanderbilt University, Nashville, TN
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