What's the "catch" in upper-limb post-stroke spasticity: expanding the role of botulinum toxin applications.
ABSTRACT More than a third of stroke patients will develop post-stroke spasticity, especially involving the paretic upper limbs. Despite established, intensive rehabilitation programmes in place, spasticity may still affect a post-stroke patient's quality of life and create economic and caregiver burdens. Hence, there is a need to explore how botulinum toxin (BTX) therapy may further improve patient outcomes. Consensus guidelines on the clinical use of BTX for established and symptomatic upper-limb spasticity are now available. While BTX therapy has been universally shown to reduce muscle tone in spasticity, its corresponding improvement in functional-outcome measures are far from consistent. This review article attempts to analyse the reasons for the inconsistency and makes the case that improved and reliable functional outcomes after BTX therapy may be achieved when: patient-specific goals that incorporate realistic expectations (such as improving passive as well as active functions and reducing pain) are used as functional-outcome measures; patients are followed up over a reasonable amount of time so as to optimise learning, rehabilitation and possibly even allow plasticity to occur; and, correct and thoughtful muscle targeting that considers various factors, such as spread, technique and avoidance of compensatory muscles, is employed. This article also summarises the characteristics of post-stroke patients who are at greatest risk for developing spasticity and those who are most likely to become the "best responders;" and, it attempts to outline the potential advantages of early BTX therapy in the acute to sub-acute post-stroke period, while spasticity is still evolving.
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ABSTRACT: Botulinum neurotoxin type A (BoNT-A) reduces upper-extremity poststroke spasticity when given 6 or more months after stroke. Effects on functional use of the arm and hand are less apparent. To determine the effect and safety of very early use of BoNT-A for patients with upper-limb spasticity. The Asia Botulinum Toxin-A Clinical Trial ed for Early Post-stroke Spasticity (ABCDE-S; NCT00234546) was a multicenter, randomized, placebo-controlled trial conducted in patients recruited within 2 -12 weeks of first-ever stroke. Participants with a Modified Ashworth Scale (MAS) score of 1+ or above received BoNT-A (Dysport) 500 U or placebo to one or more wrist and elbow mover muscles, plus unstructured rehabilitation. The primary outcome was the MAS score in the most affected joint 4 weeks after first injection. Follow-up was 24 weeks. A total of 163 patients were enrolled and assigned to placebo (n = 83) or BoNT-A (n = 80). Mean time since stroke was about 7 weeks. At 4 weeks postinjection, BoNT-A significantly improved MAS scores. Treatment effect-size estimates increased with higher baseline MAS scores from 0.45 (Q1) to 0.70 (Q3). MAS scores for all secondary end points improved with BoNT-A versus placebo at all time points (P < .0001, all visits). The Functional Motor Assessment Scale did not reveal clinically significant differences. No group differences in adverse events were found. Interpretation. BoNT-A 500 U can provide a sustained reduction in poststroke upper-limb spasticity when combined with rehabilitation in Asian patients who have mild-to-moderate hypertonicity and voluntary movement, within 2 -12 weeks of stroke. Functional use of the arm and hand was not affected.Neurorehabilitation and neural repair 02/2012; 26(7):812-21. DOI:10.1177/1545968311430824 · 4.62 Impact Factor
- Dystonia - The Many Facets, 03/2012; , ISBN: 978-953-51-0329-5
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ABSTRACT: To evaluate whether botulinum toxin can decrease the burden for caregivers of long term care patients with severe upper limb spasticity. This was a double-blind placebo-controlled trial with a 24-week follow-up period. A 250-bed long term care hospital, the infirmary units of 3 regional hospitals, and 5 care and attention homes. Participants included 55 long term care patients with significant upper limb spasticity and difficulty in basic upper limb care. Patients were randomized into 2 groups that received either intramuscular botulinum toxin A or saline. The primary outcome measure was provided by the carer burden scale. Secondary outcomes included goal attainment scale, measure of spasticity by modified Ashworth score, passive range of movement for shoulder abduction, and elbow extension and finger extension. Pain was assessed using the Pain Assessment in Advanced Dementia Scale. A total of 55 patients (21 men; mean age = 69, SD =18) were recruited. At week 6 post-injection, 18 (60%) of 30 patients in the treatment group versus 2 (8%) of 25 patients in the control group had a significant 4-point reduction of carer burden scale (P < .001). There was also significant improvement in the goal attainment scale, as well as the modified Ashworth score, resting angle, and passive range of movement of the 3 regions (shoulder, elbow, and fingers) in the treatment group which persisted until week 24. There were also fewer spontaneous bone fractures after botulinum toxin injection, although this did not reach statistical significance. No significant difference in Pain Assessment in Advanced Dementia scale was found between the 2 groups. No serious botulinum toxin type A-related adverse effects were reported. Long term care patients who were treated for upper limb spasticity with intramuscular injections of botulinum toxin A had a significant decrease in the caregiver burden. The treatment was also associated with improved scores on patient-centered outcome measures.Journal of the American Medical Directors Association 04/2012; 13(5):477-84. DOI:10.1016/j.jamda.2012.03.005 · 4.78 Impact Factor