A practical guide to optimizing the benefits of post-stroke spasticity interventions with botulinum toxin A: An international group consensus

Abstract

A group of doctors from around the world, who are experts in treating muscle stiffness and spasm (also called spasticity), reviewed the current scientific evidence supporting the effectiveness of using botulinum toxin injections in treatment of spasticity that results from a stroke. When evidence is not available, they discussed and agreed on the best way to treat spasticity using botulinum toxin. The recommendations made by these expert doctors can be used by less-experienced doctors as a guide to how best to use botulinum toxin injection in treating spasticity after a stroke. This consensus paper is derived from a meeting of an international group of 19 neurological rehabil itation specialists with a combined experience of more than 250 years (range 4-25 years; mean 14.1 years) in treating poststroke spasticity with bot ulinum toxin A. The group undertook critical assess ments of some recurring practical challenges, not yet addressed in guidelines, through an exten sive literature search. They then discussed the results in the light of their individual clinical experience and developed consensus statements to present to the wider community who treat such patients. The analy sis provides a comprehensive overview of treatment with botulinum toxin A, including the use of adjunctive therapies, within a multidisciplinary con text, and is aimed at practicing clinicians who treat patients with poststroke spasticity and require further practical guidance on the use of botulinum toxin A. This paper does not replicate information published elsewhere, but instead aims to provide practical advice to help optimize the use of botulinum toxin A and maximize clinical outcomes. The recom mendations for each topic are summarized in a se ries of statements. Where published highquality evidence exists, the recommendations reflect this. However, where evidence is not yet conclusive, the group members issued statements and, in some cas es, made recommendations based on their clinical experience.

Botulinum Toxin Services for Neurorehabiliation: Recommendations for Challenges and Opportunities during the COVID-19 Pandemic

“…With a collective experience of more than 250 years (range 4–25 years; average 14 years), the group is dedicated to advancing the science of BoNT treatment in movement disorders. Some of ToxNet’s published works to date include a consensus on optimization of post-stroke spasticity interventions with BoNT, an evaluation of spasticity patients using telemedicine, and an opinion paper on the role of physical and rehabilitation medicine in the COVID-19 pandemic [ 5 , 36 , 44 ].…”

“…We agree with other experts that this is not the case. If BoNT is administered correctly and under instrumental guidance as recommended [ 5 , 34 , 35 ], the risk of muscle weakness events is very low, even in areas near the respiratory muscles. The possibility of spasticity/dystonia symptoms or sialorrhea worsening to unacceptable levels presents a much higher risk to patients’ health status.…”

“…The ongoing COVID-19 pandemic severely impacted the routine function of medical facilities and rehabilitation services worldwide [ 1 , 2 , 3 ], including toxin services delivering Botulinum toxin (BoNT) treatments for neuromuscular conditions. BoNT injections are the standard of care for focal spasticity [ 4 , 5 ] and dystonia [ 6 , 7 ]. They are also recommended for the treatment of sialorrhea (drooling), a common issue in various neurological conditions, including cerebral palsy, Parkinson’s disease, and stroke [ 8 , 9 ].…”

“…We would like to share the clinical experience and perspective of leading experts from Europe in the area of neurorehabilitation. The authors are part of the ToxNet group (www.toxnet.net, accessed on 21 August 2021), a worldwide network of physicians with long-standing experience delivering toxin services to patients with spasticity, dystonia, or sialorrhea, aiming to establish solutions and best practices [5]. In the following, we detail our recommendations for continuous patient care and follow-up, and we give recommendations for optimizing the benefits of BoNT treatment.…”

Electrical Stimulation of Injected Muscles to Boost Botulinum Toxin Effect on Spasticity: Rationale, Systematic Review and State of the Art

“…To date, several rehabilitation procedures have been proposed as adjuvant treatments associated with BoNT-A injection for the management of spasticity, including muscle stretching; taping; casting; splinting; orthoses; and physical modalities such as extracorporeal shock wave therapy, therapeutic ultrasound, vibration therapy, electrical stimulation, and transcutaneous electrical nerve stimulation [ 23 , 24 ].…”