Background: Spasticity and loss of function in an affected arm are common after stroke. Although botulinum toxin is used to reduce spasticity, its functional benefits are less easily demonstrated. This paper reports an exploratory meta-analysis to investigate the relationship between reduced arm spasticity and improved arm function. Method: Individual data from stroke patients in two randomised controlled trials of intra-muscular botulinum toxin were pooled. The Modified Ashworth Scale (elbow, wrist, fingers) was used to calculate a ''Composite Spasticity Index''. Data from the arm section of the Barthel Activities of Daily Living Index (dressing, grooming, and feeding) and three subjective measures (putting arm through sleeve, cleaning palm, cutting fingernails) were summed to give a ''Composite Functional Index''. Change scores and the time of maximum change were also calculated. Results: Maximum changes in both composite measures occurred concurrently in 47 patients. In 26 patients the improvement in spasticity preceded the improvement in function with 18 showing the reverse. There was a definite relationship between the maximum change in spasticity and the maximum change in arm function, independent of treatment (r = 20.2822, p = 0.0008, n = 137). There was a clear relationship between the changes in spasticity and in arm function in patients treated with botulinum toxin (Dysport) at 500 or 1000 units (r = 20.5679, p = 0.0090, n = 22; r = 20.4430, p = 0.0018, n = 47), but not in those treated with placebo or 1500 units. Conclusions: Using a targeted meta-analytic approach, it is possible to demonstrate that reducing spasticity in the arm is associated with a significant improvement in arm function.

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The Syme amputation is an old operation that has been used during this century primarily as a means of treating traumatic injuries to the forefoot in military patients. In 1984 we made a deliberate attempt to perform the operation in a highly selective group of dysvascular patients with forefoot necrosis who happened to have a palpable posterior tibial pulse. We reviewed the charts of 26 patients who underwent a one-stage (3 patients) or two-stage (23 patients) Syme amputation. The mean age was 60 years, (range 32 to 74 years). There were 17 insulin-dependent diabetic patients, and 3 diet-controlled diabetic patients. Twenty-two patients (85%) had a palpable posterior tibial pulse before surgery. Fourteen patients (54%) underwent a preliminary Ray (4) or transmetatarsal (10) amputation to rid the forefoot of an active infection. Overall, 20 patients (77%) had successful Syme amputations. Nineteen of 22 patients (85%) with a palpable posterior tibial pulse had a successful amputation in contrast to one out of four patients (25%) who did not have a palpable pulse before surgery (p = 0.04). The mean follow-up of all patients was 23 months. The durability of the operation was demonstrated in finding that only one patient in 20 initially successful Syme amputations required revision to the below-knee level. The two-stage Syme amputation can be a very gratifying operation with success rates approaching 85%, even if offered to elderly diabetic patients. The single most important feature for success is to limit the operation to those patients with a palpable posterior tibial pulse before operation.