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      The Effect of Repeated Botulinum Toxin A Therapy Combined with Intensive Rehabilitation on Lower Limb Spasticity in Post-Stroke Patients

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          Abstract

          Objectives: This study is a retrospective investigation of the effects of repetitive botulinum toxin A therapy (BoNT-A) and intensive rehabilitation (IR) on lower limb spasticity in post-stroke patients. Methods: Thirty-five post-stroke patients was included in this study and received BoNT-A for the first time. A 12-day inpatient protocol was with 4 cycles of the treatment protocol. The severity of spasticity, motor function and brace status were evaluated. Results: The modified Ashworth Scale (MAS) score of ankle dorsiflexors, range of motion, walking speed and balancing ability were significantly improved after cycle 1. The improvement of spasticity and motor function was persistent through cycles 2–4. One-third of brace users were able to discontinue the use of a brace. All of these brace users showed a forward gait pattern prior to therapy. Conclusions: Repeated BoNT-A combined with IR improved lower limb spasticity in post-stroke patients. Our results suggest that patients who show the forward gait pattern prior to therapy may be able to discontinue the use of their brace after therapy.

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          The Fugl-Meyer Assessment of Motor Recovery after Stroke: A Critical Review of Its Measurement Properties

          Cynthia J. Danells, Sandra Black, David J Gladstone (2016)
          Measurement of recovery after stroke is becoming increasingly important with the advent of new treatment options under investigation in stroke rehabilitation research. The Fugl-Meyer scale was developed as the first quantitative evaluative instrument for measuring sensorimotor stroke recovery, based on Twitchell and Brunnstrom's concept of sequential stages of motor return in the hemiplegic stroke patient. The Fugl-Meyer is a well-designed, feasible and efficient clinical examination method that has been tested widely in the stroke population. Its primary value is the 100-point motor domain, which has received the most extensive evaluation. Excellent interrater and intrarater reliability and construct validity have been demonstrated, and preliminary evidence suggests that the Fugl-Meyer assessment is responsive to change. Limitations of the motor domain include a ceiling effect, omission of some potentially relevant items, and weighting of the arm more than the leg. Further study should test performance of this scale in specific subgroups of stroke patients and better define its criterion validity, sensitivity to change, and minimal clinically important difference. Based on the available evidence, the Fugl-Meyer motor scale is recommended highly as a clinical and research tool for evaluating changes in motor impairment following stroke.
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            Spasticity after stroke: its occurrence and association with motor impairments and activity limitations.

            Disa K Sommerfeld, Elsy Eek, Anna-Karin Svensson … (2004)
            There is no consensus concerning the number of patients developing spasticity or the relationship between spasticity and disabilities after acute stroke. The aim of the present study was to describe the extent to which spasticity occurs and is associated with disabilities (motor impairments and activity limitations). Ninety-five patients with first-ever stroke were examined initially (mean, 5.4 days) and 3 months after stroke with the Modified Ashworth Scale for spasticity; self-reported muscle stiffness; tendon reflexes; Birgitta Lindmark motor performance; Nine Hole Peg Test for manual dexterity; Rivermead Mobility Index; Get-Up and Go test; and Barthel Index. Of the 95 patients studied, 64 were hemiparetic, 18 were spastic, 6 reported muscle stiffness, and 18 had increased tendon reflexes 3 months after stroke. Patients who were nonspastic (n=77) had statistically significantly better motor and activity scores than spastic patients (n=18). However, the correlations between muscle tone and disability scores were low, and severe disabilities were seen in almost the same number of nonspastic as spastic patients. Although spasticity seems to contribute to disabilities after stroke, spasticity was present in only 19% of the patients investigated 3 months after stroke. Severe disabilities were seen in almost the same number of nonspastic as spastic patients. These findings indicate that the focus on spasticity in stroke rehabilitation is out of step with its clinical importance. Careful and continual evaluation to establish the cause of the patient's disabilities is essential before a decision is made on the most proper rehabilitation approach.
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              Prevalence of spasticity post stroke.

              C Watkins, M Leathley, J M Gregson … (2002)
              To establish the prevalence of spasticity 12 months after stroke and examine its relationship with functional ability. A cohort study of prevalence of spasticity at 12 months post stroke. Initially hospitalized but subsequently community-dwelling stroke survivors in Liverpool, UK. One hundred and six consecutively presenting stroke patients surviving to 12 months. Muscle tone measured at the elbow using the Modified Ashworth Scale and at several joints, in the arms and legs, using the Tone Assessment Scale; functional ability using the modified Barthel Index. Increased muscle tone (spasticity) was present in 29 (27%) and 38 (36%) of the 106 patients when measured using the Modified Ashworth Scale and Tone Assessment Scale respectively. Combining the results from both scales produced a prevalence of 40 (38%). Those with spasticity had significantly lower Barthel scores at 12 months (p < 0.0001). When estimating the prevalence of spasticity it is essential to assess both arms and legs, using both scales. Despite measuring tone at several joints, spasticity was demonstrated in only 40 (38%) patients, lower than previous estimates.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Toxins (Basel)
                Journal ID (iso-abbrev): Toxins (Basel)
                Journal ID (publisher-id): toxins
                Title: Toxins
                Publisher: MDPI
                ISSN (Electronic): 2072-6651
                Publication date (Electronic): 31 August 2018
                Publication date Collection: September 2018
                Volume: 10
                Issue: 9
                Electronic Location Identifier: 349
                Affiliations
                [1 ]Department of Rehabilitaion Medicine, The Jikei University School of Medicine, 1058461 Tokyo, Japan; abo@ 123456jikei.ac.jp (M.A.); nobsasa1005@ 123456gmail.com (N.S.); mela012921@ 123456yahoo.co.jp (N.Y.); pomardon2010@ 123456gmail.com (M.N.)
                [2 ]Department of Rehabilitaion Medicine, Kikyogahara Hospital 1295, 3996461 Nagano, Japan; hhara448@ 123456orange.plala.or.jp (H.H.); shimamoto@ 123456keijin-kai.jp (Y.S.)
                Author notes
                Article
                Publisher ID: toxins-10-00349
                DOI: 10.3390/toxins10090349
                PMC ID: 6162421
                PubMed ID: 30200281
                SO-VID: b1df7727-dd69-4add-a62f-cd1a26f9c0d9
                Copyright © © 2018 by the authors.
                License:

                Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license ( http://creativecommons.org/licenses/by/4.0/).

                History
                Date received : 15 August 2018
                Date accepted : 30 August 2018
                Categories
                Subject: Article

                ScienceOpen disciplines: Molecular medicine
                Keywords: botulinum toxin a therapy,stroke,rehabilitation
                Data availability:
                ScienceOpen disciplines: Molecular medicine
                Keywords: botulinum toxin a therapy, stroke, rehabilitation

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