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

Background

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

Methods

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

Results

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

Conclusions

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

WITHDRAWN: Orthotic devices after stroke and other non-progressive brain lesions

BACKGROUND

Post-stroke motor impairments cause difficulty controlling the joints of the affected limbs to produce useful movements. One way to manage this to use an orthosis to control the movement of the affected joints but evidence for their benefit is lacking.

OBJECTIVES

To determine the effectiveness of upper or lower limb orthoses on activity and impairment in people with stroke and other non-progressive brain lesions.

SEARCH STRATEGY

In February 2007 we searched the trials registers of the Cochrane Stroke, Movement Disorders and Injuries Groups, the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 1, 2007), MEDLINE (from 1966), EMBASE (from 1980), CINAHL (from 1983), AMED (from 1985), PsycINFO (from 1967) and RECAL (from 1990), and other databases and trials registers. We screened reference lists, contacted lead authors and other researchers in the field.

SELECTION CRITERIA

We included randomised controlled trials of orthoses applied to the upper or lower limb in people with stroke and other non-progressive brain lesions.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified trials, extracted data, and assessed trial quality. Results for continuous outcomes were combined and analysed using mean difference or standardised mean difference, both with 95% confidence intervals and fixed-effect model.

MAIN RESULTS

We analysed 14 trials with 429 participants. The overall effect of lower limb orthoses on walking disability (speed), walking impairment (step/stride length) and balance impairment (weight distribution in standing) was significant and beneficial. There was no significant effect on postural sway (balance impairment) or mobility disability but the numbers of studies and participants were low. However, these were all cross-over trials that looked at the immediate effect while wearing the orthosis; they did not assess the effects of wearing an orthosis over the long term. Upper limb orthoses showed no effect on upper limb function, range of movement at the wrist, fingers or thumb, nor pain. However, this was based on only three trials.

AUTHORS' CONCLUSIONS

A lower limb orthosis can improve walking and balance but the included studies have only examined the immediate effects while wearing the orthosis; the effects of long-term use have not been investigated. An upper limb orthosis does not effect on upper limb function, range of movement at the wrist, fingers or thumb, nor pain, but this conclusion is based on only three trials.

Orthotic devices after stroke and other non-progressive brain lesions

BACKGROUND

Post-stroke motor impairments cause difficulty controlling the joints of the affected limbs to produce useful movements. One way to manage this to use an orthosis to control the movement of the affected joints but evidence for their benefit is lacking.

OBJECTIVES

To determine the effectiveness of upper or lower limb orthoses on activity and impairment in people with stroke and other non-progressive brain lesions.

SEARCH STRATEGY

In February 2007 we searched the trials registers of the Cochrane Stroke, Movement Disorders and Injuries Groups, the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 1, 2007), MEDLINE (from 1966), EMBASE (from 1980), CINAHL (from 1983), AMED (from 1985), PsycINFO (from 1967) and RECAL (from 1990), and other databases and trials registers. We screened reference lists, contacted lead authors and other researchers in the field.

SELECTION CRITERIA

We included randomised controlled trials of orthoses applied to the upper or lower limb in people with stroke and other non-progressive brain lesions.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified trials, extracted data, and assessed trial quality. Results for continuous outcomes were combined and analysed using mean difference or standardised mean difference, both with 95% confidence intervals and fixed-effect model.

MAIN RESULTS

We analysed 14 trials with 429 participants. The overall effect of lower limb orthoses on walking disability (speed), walking impairment (step/stride length) and balance impairment (weight distribution in standing) was significant and beneficial. There was no significant effect on postural sway (balance impairment) or mobility disability but the numbers of studies and participants were low. However, these were all cross-over trials that looked at the immediate effect while wearing the orthosis; they did not assess the effects of wearing an orthosis over the long term. Upper limb orthoses showed no effect on upper limb function, range of movement at the wrist, fingers or thumb, nor pain. However, this was based on only three trials.

AUTHORS' CONCLUSIONS

A lower limb orthosis can improve walking and balance but the included studies have only examined the immediate effects while wearing the orthosis; the effects of long-term use have not been investigated. An upper limb orthosis does not effect on upper limb function, range of movement at the wrist, fingers or thumb, nor pain, but this conclusion is based on only three trials.

Motor control testing of upper limb function after botulinum toxin injection: a case study

OBJECTIVE

To evaluate changes in upper extremity function in a hemiparetic patient after treatment with botulinum toxin (BTX) using motor-control testing (MCT) techniques.

DESIGN

Interventional with longitudinal study, open label.

SETTING

A children's hospital and a motor-control laboratory at a major academic center.

PARTICIPANTS

A 16-year-old male with right hemiparetic cerebral palsy and a healthy 12-year-old control subject.

INTERVENTIONS

BTX injections to the elbow and wrist flexors.

MAIN OUTCOME MEASURES

MCT was used to examine 4 upper extremity movements: forward reach, bilateral rhythmic movements (both muscle homologous and direction homologous), isometric pinch, and hand tapping. The patient was tested before treatment and at 2, 4, 6, 12, 18, and 24 weeks after treatment. In addition, range of motion (ROM), the Ashworth scale of spasticity, Functional Independence Measure, and the mobility and activities of daily living (ADL) sections of the Pediatric Evaluation of the Disability Inventory were performed.

RESULTS

Forward reach demonstrated little change initially despite patient reports of "feeling looser." Improvement was noted after 18 weeks, but returned to baseline level at 24 weeks. Bilateral rhythmic movements also showed slight improvement at 18 weeks. Pinch force increased significantly after 2 weeks, but declined again at 6 weeks. Improvements occurred in ROM and the Ashworth rating of spasticity, but were not temporally associated with each other or with MCT results. Functional assessment data did not change during the study period.

CONCLUSIONS

Improvements in more complex motor tasks were noted after significant delay from the time of treatment, while simpler tasks demonstrated a more rapid improvement, followed by a rapid return to baseline levels. This case suggests that MCT techniques can provide quantitative and qualitative data, which can add new information about upper extremity motor disability and the outcome of treatment.

Botulinum toxin type A and short-term electrical stimulation in the treatment of upper limb flexor spasticity after stroke: a randomized, double-blind, placebo-controlled trial

OBJECTIVE

To investigate whether the combined approach of botulinum toxin type A (BtxA) and electrical stimulation was more effective than the toxin alone in the treatment of chronic upper limb spasticity after stroke.

DESIGN

Randomized, placebo-controlled study with four treatment groups: 1000 units BtxA (Dysport) + electrical stimulation (A), 1000 units BtxA (B), placebo + electrical stimulation (C) and placebo (D).

SETTING

A neurological rehabilitation clinic.

SUBJECTS

Twenty-four stroke patients with chronic upper limb spasticity after stroke, six patients in each treatment group.

INTERVENTIONS

Intramuscular injection of either toxin or placebo into six upper imb flexor muscles. In group A and C additional electrical stimulation of the injected muscles with surface electrodes, three times half an hour each day for three days.

MAIN OUTCOME MEASURES

Muscle tone rated with the modified Ashworth score, limb position at rest and difficulties encountered during three upper limb motor tasks assessed before and 2, 6 and 12 weeks after injection.

RESULTS

Most improvements were observed in patients of group A. Cleaning the palm (p = 0.004) differed across groups. Pairwise comparison for this target variable showed that group A differed from group B and D (p <0.01), but not from C. Indicative across-group differences were obtained for elbow spasticity reduction (p = 0.011), and improvement of putting the arm through a sleeve (p = 0.020).

CONCLUSIONS

The placebo-controlled trial favours the concept that electrical stimulation enhances the effectiveness of BtxA in the treatment of chronic upper limb flexor spasticity after stroke.

Low-dose botulinum toxin with ankle taping for the treatment of spastic equinovarus foot after stroke

OBJECTIVE

To evaluate the efficacy of a combined treatment for spastic foot using selective injections of botulinum toxin (BTA) into the tibialis posterior muscle followed by ankle taping, and to compare it with current BTA treatment procedure.

DESIGN

Single-blind randomized control trial. Three-month follow-up after treatment.

SETTING

Neurorehabilitation clinic.

SUBJECTS

Eighteen outpatients with equinovarus foot due to severe spasticity after stroke.

INTERVENTIONS

(1) Injection of 190 to 320 BTA U into several calf muscles (group A); (2) injection of 100 BTA U into the tibialis posterior muscle, followed by ankle-foot taping (group B).

MAIN OUTCOME MEASURES

Ankle range of motion (ROM), Ashworth scale, gait velocity, and step length.

RESULTS

Average Ashworth scores decreased 1 point in both groups, but the benefit appeared of shorter duration in group B. Changes in both foot position at rest and passive ankle ROM were observed in all patients, without treatment-related differences, except for gain in passive dorsiflexion that appeared higher in group A. Gait velocity and step length showed similar increases in both groups.

CONCLUSION

The combination of selective injections of low BTA doses with ankle-foot taping is as effective as the injection of the current doses for the reduction of foot inversion with positive effects on gait parameters.

A battery-powered constant current stimulator for motor end-point detection

The device described was developed as an external electrical stimulator to assist in the accurate location of motor end-points prior to the injection of nerve blocking agents in the treatment of spasticity. Monophasic pulses are produced with a duration of 10-100 microseconds and a current from 0 to 10 mA. The current is maintained over a wide range of electrode impedance and is independent of battery voltage.

Multiple sclerosis: symptomatic treatment

Reports of new therapeutic agents designed to suppress inflammatory processes in multiple sclerosis have excited much interest but, thus far, have had little influence on symptoms, disability and handicap in patients. The clinical application of recent advances in physical, pharmacological and surgical approaches to management will, at least in the medium-term future, therefore offer significantly greater opportunities for improving the quality of life of patients with multiple sclerosis. Here, symptomatic treatment of the whole range of difficulties encountered by patients with multiple sclerosis is reviewed in the context of the multidisciplinary strategy crucial to an optimal outcome.

Use of botulinum toxin in stroke patients with severe upper limb spasticity

OBJECTIVES

Spasticity can contribute to poor recovery of upper limb function after stroke. This is a preliminary evaluation of the impact of botulinum toxin treatment on disability caused by upper limb spasticity after stroke.

METHODS

Seventeen patients with severe spasticity and a non-functioning arm were treated with intramuscular botulinum A neurotoxin (median age at treatment 54.5 years; median time between onset of stroke and treatment 1.5 years). Baseline and assessments two weeks after treatment were compared to assess efficacy. The duration of improvement in disability was documented. Outcome measures used were; passive range of movement at the shoulder, elbow, wrist, and fingers; modified Ashworth scale to assess spasticity of biceps and forearm finger flexors; an eight point scale to assess the degree of difficulty experienced by the patient or carer for each functional problem defined before treatment; the presence of upper limb pain. The biceps, forearm finger flexors, and flexor carpiulnaris were treated with intramuscular botulinum toxin. Up to a total dose of 400-1000 mouse units (MU) of Dysport (Speywood) or 100-200 MU of BOTOX (Allergan) was used in each patient.

RESULTS

Functional problems reported by the patients before treatment were difficulty with cleaning the palm, cutting fingernails, putting the arm through a sleeve, standing and walking balance, putting on gloves, and rolling over in bed. Hand hygiene improved in 14 of 17 patients; difficulty with sleeves improved in four of 16; standing and walking balance improved in one of four; shoulder pain improved in six of nine; wrist pain improved in five of six. Passive range of movement at shoulder, elbow, and wrist improved after treatment. Benefit was noted within two weeks and lasted one to 11 months. No adverse effects occurred.

CONCLUSION

This preliminary study suggests that intramuscular botulinum toxin is a safe and effective treatment for reducing disability in patients with severe upper limb spasticity.

Rehabilitation medicine

The nature of rehabilitation medicine is outlined in terms of its objectives, its methods, the patient groups which it seeks to help and its relationships to other specialties. Some major advances of recent years are discussed, such as the development of the impairment/disability/handicap framework. With particular emphasis upon neurological rehabilitation, the breadth of the specialty is then illustrated with examples of current preoccupations. These include recovery patterns of the damaged nervous system, testing the efficacy of existing therapies, applying new treatment techniques and developing quantitative measures of disability and handicap. Looking to the future, some key areas are identified where further advances might be sought.