Management of spasticity with onabotulinumtoxinA: practical guidance based on the italian real-life post-stroke spasticity survey

Abstract

SummaryThe present paper provides practical guidance on the management of adult spasticity with OnabotulinumtoxinA. Advisory Board members reviewed the available evidence and discussed their personal experiences in order to address the unmet needs in the management of spasticity with botulinum toxin type A identified by the recent Italian Real-Life PostStroke Spasticity Survey. Stroke patients should be referred to spasticity services that have adequate facilities and multidisciplinary teams with the necessary training, competence and expertise. The current literature shows a strong correlation between the development of post-stroke spasticity and the degree of central sensorimotor system destruction/disorganization. Use of tools such as the Poststroke Checklist may help clinicians in the long-term follow-up of stroke patients. The maximum dose of onabotulinumtoxinA -according to the current literature this ranges from 300U to 400U for upper limb and from 500U to 600U for lower limb aggregate postures -should be re-considered. In addition, there is a need for future consensus (also based on pharmacoeconomic considerations) on consistent clinical care models for the management of patients with post-stroke spasticity.

BoNT-A for Post-Stroke Spasticity: Guidance on Unmet Clinical Needs from a Delphi Panel Approach

“…To the best of our knowledge, there are no Delphi-based studies providing insight into expert opinion on these issues. The previous surveys published in 2017 [ 22 ] and 2018 [ 24 ] provided a foundation to this further analysis, which is very specific and concerns well-defined topics: Initiation and follow-up, dosages, and treatment objectives. Although there is high-level evidence supporting the safety and effectiveness of BoNT-A in post-stroke spasticity (Grade A), there is little clinical trial-based evidence on how to manage, monitor, reassess, change goals when using BoNT-A for the management of post-stroke spasticity [ 25 ].…”

“…Based on these findings the expert panel also confirmed that monitoring patients, especially in the first year after stroke, is mandatory. Sandrini et al, in a study published in 2018, support that a post-stroke checklist may allow early detection of post-stroke spasticity, assist in the early management of disability and in rehabilitation planning [ 24 ]. Several predictors of early post-stroke spasticity have been proposed, including increased muscle tone, greater severity of paresis, hypoesthesia, and low Barthel Index score [ 3 ].…”

“…To address these issues, a post-stroke checklist designed to identify treatable post-stroke problems, facilitate referral for treatment, and improve the standard of long-term management of stroke survivors was previously created [ 23 ]. A further Italian survey published in 2018 about the overall management of post-stroke spasticity with OnabotulinumtoxinA, also stressed the need for a major consensus on consistent clinical care models for the management of patients with post-stroke spasticity [ 24 ].…”

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

“…In real-world practice, to achieve appropriate clinical and neurorehabilitative goals, the treatment of multifocal spasticity may require doses of BoNT-A that are higher than the recommended regimen [ 12 ]. Thus, depending on the clinical presentation of spasticity in some patients, the cumulative and/or per muscle dose of BoNT-A may be higher than that recommended by the product label [ 13 , 14 ]. Adverse events and antibody development must be considered as potential risks of high-dose BoNT-A therapy [ 12 ].…”

Effects of Radial Extracorporeal Shock Wave Therapy on Flexor Spasticity of the Upper Limb in Post-stroke Patients: Study Protocol for A Randomized Controlled Trial

“…Aggressive and appropriate spasticity management contributes to motor re-learning and function recovery during chronic stages [2,6]. Currently, mainstream interventions for upper limb hypertonicity, include stretching, oral antispasticity medications, focal botulinum toxin (BTX) injections and surgical treatment [6][7][8][9]. However, the above treatment methods have drawbacks or are controversial, in terms of their effectiveness and safety [7,[10][11][12].…”