Botulinum toxin in the management of spasticity in adults

Botulinum Toxin: From Poison to Possible Treatment for Spasticity in Spinal Cord Injury

Botulism has been known for about three centuries, and since its discovery, botulinum toxin has been considered one of the most powerful toxins. However, throughout the 20th century, several medical applications have been discovered, among which the treatment of spasticity stands out. Botulinum toxin is the only pharmacological treatment recommended for spasticity of strokes and cerebral palsy. Although its use as an adjuvant treatment against spasticity in spinal cord injuries is not even approved, botulinum toxin is being used against such injuries. This article describes the advances that have been made throughout history leading to the therapeutic use of botulinum toxin and, in particular, its application to the treatment of spasticity in spinal cord injury.

Functional outcomes of spasticity-reducing surgery and rehabilitation at 1-year follow-up in 30 patients

The effects of spasticity-reducing surgery in the upper extremity were assessed in a prospective observational study of 30 consecutive patients with stroke (n = 13), incomplete spinal cord injury (n = 9), traumatic brain injury (n = 5), cerebral palsy (n = 2), and degenerative central nervous system disease (n = 1). Surgery, which included lengthening of tendons and release of muscles, was followed by early rehabilitation at three intensity levels depending on the patients' specific needs and conditions. At 12 months follow-up there were significant improvements in all outcome measures with the following mean values: spasticity decreased by 1.4 points (Modified Ashworth Scale, 0-5), visual analogue pain score by 1.3 points, and both Canadian Occupational Performance Measures increased (performance by 3.4 and satisfaction by 3.6), and most measures of joint position or mobility improved. Hand surgery combined with early and comprehensive rehabilitation improves function, activity and patients' satisfaction in patients with disabling spasticity with improvement lasting for at least 1 year.Level of evidence: II.

Treatment of spasticity in spinal cord injury with botulinum toxin

CONTEXT

Spasticity is one of the most frequent complications in spinal cord injury (SCI), and is routinely managed with oral pharmacologic therapy. Botulinum toxin (BT) is not accepted as a treatment for spasticity in SCI in Spain but may be used in certain cases of focal distribution.

OBJECTIVE

To report the results with BT for treatment of spasticity in SCI.

DESIGN AND SETTING

Descriptive retrospective study conducted at a specialist SCI rehabilitation center in Spain, covering patients first treated from 2012 through 2014, and successfully followed up for a minimum of 1 year. Data were collected on the following variables: demographic and SCI characteristics (level and grade); nature of spasticity, e.g. tone, distribution, spasms, articular involvement and pain; function; application of BT; tolerance and adverse reactions.

RESULTS

The study covered 90 patients, predominantly male with incomplete injuries. Improvement in tone as measured by the modified Ashworth scale was a mean of 1.17 points. Goniometric improvement was achieved in 65.6% and improvement in pain in 38.9% of cases. There were no adverse side-effects. Patients with focal spasticity showed a significantly greater improvement in tone (P < 0.0001). The earlier the BT injection, the greater the improvement in goniometric performance (P < 0.006) and pain (P < 0.033), with the best results being obtained within the first 6 months of clinical course. ASIA D injuries showed a greater improvement in tone (P < 0.0001).

CONCLUSIONS

BT can be both an effective treatment for focal spasticity in SCI and a good coadjuvant for oral treatments in generalized spasticity.

OnabotulinumtoxinA Injection for Poststroke Upper-Limb Spasticity: Guidance for Early Injectors From a Delphi Panel Process

BACKGROUND

OnabotulinumtoxinA reduces muscle hypertonia associated with poststroke spasticity (PSS). PSS manifests as several common postures.

OBJECTIVE

To define treatment paradigms for PSS upper-limb common postures.

DESIGN

Modified Delphi method.

SETTING

Expert panel.

PARTICIPANTS

Ten injectors experienced in the treatment and clinical research of PSS (physiatrists and neurologists) were invited to participate in the Delphi panel.

METHODS

The Delphi panel reviewed an electronic worksheet with PSS upper-limb postures to define onabotulinumtoxinA treatment paradigms (Round 1). During Round 2, panel members discussed in person Round 1 results and voted until consensus (≥66% agreement). Recommendations were geared toward those with new or early injection experience.

MAIN OUTCOME MEASUREMENTS

Expert consensus on onabotulinumtoxinA treatment parameters for PSS including muscles to inject, dose per muscle and posture, and treatment adjustments for suboptimal response.

RESULTS

For each posture, consensus was reached on targeted subsets of muscles. Doses ranged for individual muscles (10-100 U) and total doses per posture (50-200 U). An onabotulinumtoxinA dilution 50 U/mL (2:1 dilution ratio) was considered most appropriate; dilution ratios of 1:1 to 4:1 may be appropriate in some circumstances. The majority (89%) of panel members would increase the dose and/or the number of muscles treated for a suboptimal response to onabotulinumtoxinA. The panel identified 3 common aggregate upper-limb postures: (1) adducted shoulder + flexed elbow + pronated forearm + flexed wrist + clenched fist; (2) flexed elbow + pronated forearm + flexed wrist + clenched fist; and (3) flexed wrist + clenched fist. The recommended starting dose per aggregate was 300 U, 300 U, and 200 U, with a total maximum dose of 400 U, 400 U, and 300 U, respectively. Localization guidance techniques were considered essential for all postures.

CONCLUSIONS

Consensus on common muscles and onabotulinumtoxinA treatment paradigms for postures associated with upper-limb PSS was achieved via a modified Delphi method. The purpose of this analysis is to educate early onabotulinumtoxinA injectors rather than provide an evidence-based review.

LEVEL OF EVIDENCE

V.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Symptomatic treatment and management of multiple sclerosis

The range of symptoms which occur in multiple sclerosis (MS) can have disabling functional consequences for patients and lead to significant reductions in their quality of life. MS symptoms can also interact with each other, making their management challenging. Clinical trials aimed at identifying symptomatic therapies have generally been poorly designed and have tended to be underpowered. Therefore, the evidence base for the management of MS symptoms with pharmacologic therapies is not strong and tends to rely upon open-label studies, case reports, and clinical trials with small numbers of patients and poorly validated clinical outcome measures. Recently, there has been a growing interest in the management of MS symptoms with pharmacologic treatments, and better-designed, randomized, double-blind, controlled trials have been reported. This chapter will describe the evidence base predominantly behind the various pharmacologic approaches to the management of MS symptoms, which in most, if not all, cases, requires multidisciplinary input. Drugs routinely recommended for individual symptoms and new therapies, which are currently in the development pipeline, will be reviewed. More interventional therapies related to symptoms that are refractory to pharmacotherapy will also be discussed, where relevant.

The process of developing a non-medical (advanced allied health) botulinum toxin A prescribing and injecting model of care in a public rehabilitation setting

Objective The aim of this paper was to describe the process undertaken to develop a non-medical (advanced allied health extended role) botulinum toxin A prescription and injection project for adults with upper and lower limb spasticity secondary to an acquired brain injury. The hypertonicity clinic in the present study was located in a metropolitan public hospital in Queensland where multidisciplinary services are provided by a rehabilitation specialist and an advanced occupational therapist and physiotherapist. Methods The process of developing the model included establishing potential benefits for the role extension project and documentation of a project plan. Results Project outcomes included the development of a relevant governance structure, a research evidence-based project evaluation framework, a draft research ethics application, delineation of the key eligibility criteria and competencies required for physiotherapist and occupational therapist prescribers, and a final project report. Conclusion Non-medical prescribing has the potential to increase patient access to botulinum toxin A injection for the management of focal spasticity. A process that supports early patient engagement, extensive consultation with relevant stakeholders, a strong governance structure, a high-quality research project and a long lead time may maximise the potential for successful completion of advanced allied health role extension projects, including prescription and injection of botulinum toxin A. What is known about the topic? Non-medical prescribing has been recommended as a strategy for facilitating responsive health care and addressing health workforce shortages in Australia and overseas. What does this paper add? A detailed description of the process used to develop a non-medical prescribing and injecting project within a public hospital rehabilitation unit, as well as an analysis of the facilitators and barriers to progression. What are the implications for practitioners? A process that supports early patient engagement, extensive consultation with relevant stakeholders, a strong governance structure, a high-quality research project and a long lead time may maximise the potential for successful completion of advanced allied health role extension projects, including prescription and injection of botulinum toxin A.

[Botulinum toxin in the treatment of adult spasticity. An interdisciplinary German 10-point consensus 2010]

Spasticity is one of the major causes of functional impairment in adults with lesions of the central nervous system. For instance, approximately 30% of post-stroke patients suffer from different degrees of spasticity with possible consecutive impairments. Numerous studies or meta-analyses showed that local injections of botulinum toxin in spastic muscles lead to dose-dependent reduction in muscle tone and improvement of passive movements (e. g. facilitated care), especially following repeated injections.However, country-specific regulations and patient-remote administration in German health care often do not allow adequate provision of this therapy. Thus, the present consensus statement based on the EBM analyses of the published international literature tries to highlight recent advances and the standard in the field of local spasticity treatment, aiming to facilitate communication between the decision makers and German reimbursement institutions in health care. Prior to initiation of BoNT-A injections, patient-oriented goals should be identified in a multiprofessional context to assure realistic goals for this specific treatment and patient expectations. In Germany for the treatment of focal spasticity following stroke three products have been approved: Botox® (Pharm Allergan, Ettlingen), Dysport® (Ipsen Pharma, Ettlingen) and Xeomin® (Merz Pharma, Frankfurt/Main). For all preparations safety has been repeatedly shown. Functional improvements have also been illustrated for selected patients concerning hand/arm function and gait. The dose per muscle and the selection of muscles to be injected have to be individualized according to the patient's symptoms and should be accompanied by modern neurorehabilitative therapies such as redression or repetitive activation of the injected and antagonistic muscles.

Pooled analysis of the safety of botulinum toxin type A in the treatment of poststroke spasticity

OBJECTIVE

To examine the safety of botulinum toxin type A (BTX-A).

DESIGN

Analysis of pooled data of 9 double-blind, placebo-controlled studies of patients with spasticity after stroke.

SETTING

University hospitals and specialty rehabilitation centers in the United States.

PARTICIPANTS

A total of 482 patients with upper-limb spasticity and 310 with lower-limb spasticity (overall mean age, 58y; 60% men).

INTERVENTION

Treatment with BTX-A (n=534; 1-3 treatments; mean dose, 231U) or placebo (n=258).

MAIN OUTCOME MEASURE

Adverse events.

RESULTS

Most patients (69%) received only 1 treatment with BTX-A. Patients were followed for a mean of 17.8 weeks (range, 0.1-44.7wk) after each treatment. A total of 352 (65.9%) patients in the BTX-A group and 163 (63.2%) in the placebo group reported at least 1 adverse event (P=.475). The most frequent adverse events reported by patients (>5% but <10% in either group) were respiratory infection, seizures, incoordination, and injection site pain, none of which occurred at a significantly higher rate in the BTX-A group (all P>.05). The majority of adverse events were rated as mild or moderate in severity. Only nausea was reported at a significantly higher rate in the BTX-A group (12/534 [2.2%]) than the placebo group (0/258) (P=.011); in contrast, injection site pain, chest pain, and allergic reaction were reported significantly more frequently in the placebo group.

CONCLUSIONS

BTX-A has an acceptable safety profile for treatment of patients with focal spasticity following stroke, a population in which adverse events and comorbidities are common.

FOCAL SPASTICITY THERAPY WITH BOTULINUM TOXIN: EFFECTS ON FUNCTION, ACTIVITIES OF DAILY LIVING AND PAIN IN 100 ADULT PATIENTS

OBJECTIVE

Analysis of the effects of a comprehensive focal spasticity program in adult patients.

DESIGN

Retrospective study of an out-patient cohort.

PATIENTS

One hundred patients were enrolled in the study (54 men and 46 women, mean age 41 years (SD 14). Cerebral palsy and stroke were equally common (80% in total). The remaining patients had miscellaneous diagnoses, including traumatic brain injury.

METHODS

On average 230 units (SD 101) of botulinum toxin A Botox was given for 227 principal therapy targets chosen by the patient or the caregiver. One patient could have several targets for therapy. Administration of botulinum toxin was combined with 260 additional therapeutic interventions, most of which were forms of physical therapy. The effects were assessed after 6 weeks and compared with baseline functional abilities 1-2 weeks prior to therapy.

RESULTS

Improvement was observed for 211 (93%) therapy targets, no change in 15 (7%), and impairment in 1, corresponding to an overall improvement in 90 patients (90%), 9 unchanged (9%) and worsening in 1. Spasticity assessment (Ashworth scale 0-4; 30 patients) showed a statistically significant improvement (median at baseline was 3 vs 2 after therapy, mean difference 1.2, p<0.001).

CONCLUSION

Improvement was observed in >or=90% of patients and in their principal therapeutic targets in a cohort receiving their first focal spasticity treatment with botulinum toxin A and additional therapy. A strict strategy for patient selection and comprehensive management was followed.

Goal attainment for spasticity management using botulinum toxin

BACKGROUND AND PURPOSE

To determine whether goal attainment scaling (GAS) can demonstrate functional gains following injection of botulinum toxin (BTX) for spasticity in severely disabled patients.

METHOD

Subjects were categorized as 'responder' (positive clinical outcome) and 'non-responder' (non-significant clinical outcome) on the basis of their overall clinical response. GAS scores for functional goals were calculated retrospectively and compared with standard outcome assessments undertaken at the time of intervention. Integrated care pathway (ICP) proformas were interrogated for 18 patients with acquired brain injuries. Mean age was 44.4 (SD 13.4) years.

RESULTS

Baseline GAS and Barthel scores were similar for the responder and non-responder groups. The outcome GAS score was significantly greater in the responder than in the non-responder group (Mann-Whitney U = 11.0; p = 0.011) as was the change in GAS score (Mann-Whitney U = 8.0; p = 0.004). GAS scores reflected change recorded in focal outcome measures. However, the Barthel Index measured change in only one case.

CONCLUSIONS

This exploratory retrospective study provides preliminary support for the hypothesis that GAS provides a useful measure of functional gains in response to treatment with BTX, and is more sensitive than global measures such as the Barthel Index.

Cost-effectiveness of botulinum toxin type a in the treatment of post-stroke spasticity

OBJECTIVE

Treatment strategies for post-stroke spasticity include oral anti-spastic drugs, surgery, physiotherapy and botulinum toxin type A injection. The objective of this study was to compare the cost-effectiveness and outcomes of oral therapy vs. botulinum toxin type A treatment strategies in patients with flexed wrist/clenched fist spasticity.

METHODS

Treatment outcome and resource use data were collected from an expert panel experienced in the treatment of post-stroke spasticity. A decision tree model was developed to analyse the data.

RESULTS

Thirty-five percent of patients receiving oral therapy showed an improvement in pre-treatment functional targets which would warrant continuation of therapy, compared with 73% and 68% of patients treated with botulinum toxin type A first- and second-line therapy, respectively. Botulinum toxin type A treatment was also more cost-effective than oral therapy with the "cost-per-successfully-treated month" being 942 pounds, 1387 pounds and 1697 pounds for botulinum toxin type A first-line, botulinum toxin type A second-line and oral therapy, respectively.

CONCLUSION

In conclusion, botulinum toxin type A is a cost-effective treatment for post-stroke spasticity.

Botulinum toxin: dosing and dilution

In the United States, the popularity of botulinum toxins as agents to treat muscle hypertonia has grown significantly over the last decade, despite lack of approval from the Food and Drug Administration for the indication of spasticity. Botox (botulinum toxin type A) and Myobloc (botulinum toxin type B) are Food and Drug Administration-approved for other indications, such as cervical dystonia. Another commercial preparation of type A, Dysport, has yet to reach the United States market as of this writing. Although botulinum toxin's efficacy in influencing spastic hypertonia is well accepted, the impact of certain clinical issues, such as dosing and dilution, on treatment outcome is not well established by published studies. This article will review important articles and selected abstracts on the use of botulinum toxin, specifically for spastic hypertonia in adults, with emphasis on current clinical practices as they relate to dosing and dilution.

Physical therapy in spasticity

Physiotherapists are part of the rehabilitation team involved in the management of adult spasticity. Physical therapy is one part of the armoury in the fight against this disabling symptom of the upper motor neurone syndrome. Identifying the physiological changes brought about by physical therapy or physiotherapy, is difficult. As with many interventions in rehabilitation, this area is poorly studied and, until recently, there was little or no evidence for its effectiveness. The aim of this presentation is to identify key components of a physiotherapy approach and outline specific techniques. The key components considered are: education of the patient and their carers; the 'intervention cycle' - involving accurate assessment, careful measurement, intervention and evaluation; accurate goal setting and a staged stepwise approach over prolonged periods. The specific techniques used include treatments targeted at: muscle length changes, muscle strengthening and functional performance. Broadly these techniques can be divided into biomechanical, cognitive and neurophysiological, each being interdependent on the others. Physiotherapy combined with the other available treatments should meet the challenge arising from adult spasticity.