Botulinum Toxin in Poststroke Spasticity

Abstract

Poststroke hemiparesis, together with abnormal muscle tone, is a major cause of morbidity and disability. Although most hemiparetic patients are able to reach different ambulatory levels with rehabilitation efforts, upper and lower limb spasticity can impede activities of daily living, personal hygiene, ambulation and, in some cases, functional improvement.The goals of spasticity management include increasing mobility and range of motion, attaining better hygiene, improving splint wear and other functional activities. Conservative measures, such as positioning, stretching and exercise are essential in spasticity management, but alone often are inadequate to effectively control it. Oral antispastic medications often provide limited effects with short duration and frequent unwanted systemic side effects, such as weakness, sedation and dry mouth.Therefore, neuromuscular blockade by local injections have become the first choice for the treatment of focal spasticity, particularly in stroke patients. Botulinum toxin (BTX), being one of the most potent biological toxins, acts by blocking neuromuscular transmission via inhibiting acetylcholine release. Currently, focal spasticity is being treated successfully with BTX via injecting in the spastic muscles.Two antigenically distinct serotypes of BTX are available on the market as type A and B. Clinical studies of BTX used for spastic hemiplegic patients are reviewed in this article in two major categories, upper and lower limb applications. This review addresses efficacy in terms of outcome measures, such as muscle tone reduction and functional outcome, as well as safety issues. Application modifications of dose, dilutions, site of injections and combination therapies with BTX injections are also discussed.

The Evaluation of Botulinum Toxin Injection Effect for Poststroke Spasticity Treatment

“…Bhakta et al (32) showed that the effects of BTX-A were sustained 11 months later in patients who were also involved in a regular rehabilitation program. Findings reported in some studies including a decrease in effectiveness at 12 months and differences in functional status may be caused by insufficient dose, patient selection, existence of contractures, and lack of effective and sufficient rehabilitation program (3,7,10). …”

“…A maximum 100 points can be achieved. Patients with 0-20 points are considered as fully dependent, 21-61 points as highly dependent, 62-90 points moderately dependent, 91-99 points as mildly dependent, and 100 points as fully independent (10).…”

Spastic Paresis and Rehabilitation – The Patient Journey

“…14 The introduction of BoNT-A has had a significant impact on the treatment of focal spasticity in the upper limbs, and it is widely viewed as a welltolerated and efficacious treatment option (when used appropriately, based on the relevant country-specific guidance and applicable summary of product characteristics) in conjunction with physical therapy programmes. 25,[34][35][36][37][38] Preliminary studies suggest that it is best delivered early, when spastic paresis first sets in, in order to minimise the development of secondary complications, such as contractures. 39 It is important to note that patients must also exercise and receive physical and occupational therapy, as long-term disuse can induce muscle atrophy.…”

A single group, pretest-posttest clinical trial for the effects of botulinum toxin injection using dual guidance into the upper extremity muscles for the treatment of focal spasticity in patients with chronic stroke

“…Spasticity can negatively affect daily activities and a patient's physical appearance, balance, and gait pattern (2). Botulinum toxin (BTX) injection is a safe, effective, and commonly used method for the treatment of focal and multifocal spasticity.…”