Constraint-Induced Movement Therapy Combined With Botulinum Toxin for Post-stroke Spasticity: A Systematic Review and Meta-Analysis

Abstract

Stroke is considered one of the main causes of adult disability and the second most serious cause of death worldwide. The combination of botulinum toxin type A (BTX) with rehabilitation techniques such as modified constraint-induced movement therapy (mCIMT) has emerged as a highly efficient intervention for stroke patients to start synchronized motor function along with spasticity reduction. The current systematic review and meta-analysis were conducted in order to evaluate the available literature about the safety and efficacy of constraint-induced movement therapy (CIMT) combined with BTX in stroke patients with upper limb spasticity.Searches were conducted on WoS (Web of Science), Ovid, EBSCO-ASC&BSC, and PubMed for identifying relevant literature published from 2000-2020. Randomized Controlled Trials (RCTs) and Quasi-experimental studies were considered for inclusion. Rayyan (systematic review tool) QCRI (Qatar Computing Research Institute) was used for independent screening of the studies by two reviewers. For risk of bias and study quality assessment, Cochrane risk of bias tool (RoB 2) and Physiotherapy Evidence Database (PEDro) scales were used. Cochrane review manager was used to carry out the meta-analyses of the included studies.The search resulted in a total of 13065 references, of which 4967 were duplicates. After the title, abstract and full-text screening, two RCTs were deemed eligible for inclusion. Both the RCTs scored 8 on PEDro and were level evidence. The studies were heterogeneous. The findings of this meta-analysis in all the three joints post-stroke spasticity assessed on modified Ashworth scale (MAS) at four weeks post-injection aren't statistically significant (elbow P-value 0.74, wrist P-value 0.57, fingers P-value 0.42), however, according to one of the included studies the therapeutic efficacy of the combination of BTX-mCIMT injection assessed at four weeks post-injection in wrist and finger flexors was promising.The effectiveness of BTX-CIMT combination over conventional therapy (CT) for improving post-stroke spasticity still needs to be explored with long-term, multicenter rigorously designed RCTs having a good sample size. However, the BTX-CIMT combination is promising for enhancing motor function recovery and improving activities of daily living (ADLs).

A practical guide to botulinum neurotoxin treatment of shoulder spasticity 2: Injection techniques, outcome measurement scales, and case studies

“…There are currently no published papers on such treatments in patients with shoulder muscle spasticity, and some treatments, such as taping and casting, are not feasible in this anatomical region. The only treatments that have been described (in publications) after BoNT-A injection in shoulder muscles are transcutaneous electrical nerve stimulation ( 41 ) and constraint-induced movement therapy ( 42 ). However, the addition of passive mobilization, shoulder posturing, and, when possible, task-oriented active physiotherapy and occupational therapy were recommended by the expert team.…”

The Effectiveness of Botulinum Toxin Injections to Treat Post-Stroke Arm Dysfunction

“…Of the six RCTs that evaluated motor function, 23,[25][26][27][28][29] one found a significant improvement in motor function in the BoNT group before and after injection, 26 and two found between-group differences favoring BoNT groups. 25,27 Similarly, most reviews concluded that the effect of BoNT on motor function is unclear, 16,18 with one review reporting significant improvement 30 and another finding no significant difference between BoNT and controls. 20 The mixed results indicate that more research is necessary to draw conclusions on the effectiveness of BoNT on motor function.…”

Comprehensive rehabilitation of patients with post-stroke upper limb dysfunction: a randomized controlled trial

“…Однако до настоящего времени продолжают обсуждаться оптимальные реабилитационные стратегии, и ряд исследований показывают эффективность и безопасность применения БТ комбинированной с роботизированными технологиями [42], двигательной терапией, вызванной ограничением движения (CIMT) [43], позиционированием, пассивным и активным растяжением спастических мышц [2], функциональной электростимуляцией [44][45][46], ортезированием [47]. Но, по данным шотландских исследователей, использование ортезов для запястья и паль-цев кисти в течение 4 нед.…”

“…MEDITSINSKIY SOVET 2022;16 (21): [36][37][38][39][40][41][42][43][44][45] Cerebrovascular diseases ВВЕДЕНИЕ Церебральный инсульт (ЦИ) является третьей по значимости причиной инвалидности во всем мире [1,2]. Среди факторов, ограничиваю щих повседневное функционирование людей после инсульта, ведущее место занимают двигательные нарушения (статолокомоторные, дисфункция верхней конечности), которые включают спастичность, слабость (спастический парез) и контрактуры, а также когнитивные и эмоциональные расстройства [3][4][5][6][7].…”