Ivanhoe_Cardiology_book_temp 25/09/2009 10:40 Page 40
Brain Trauma Stroke
treatment causing reporting of mild to moderate side effects, if any at all. demonstrate greater clinical improvement, fewer BTX-A-related side
Treatment with BTX-A may also obviate the need for other spasticity effects due to injection of the adequate dose of BTX-A to the accurate site
management options described above that may be contraindicated or of hyperactive muscles, and greater clinical improvement due to
cause further problems in patients. confirmation of hyperactivity of muscles with the use of EMG-guided
injections.
20
Administration of BTX-A is often performed blindly and the
Discussion procedure is not always well described in studies. These differences and
There are numerous issues that make research for treatment of others contribute to accounts of outcomes. This is compounded by the
neurological rehabilitation patients difficult. Among them is the debate unresolved problem with measuring spasticity.
21
surrounding measurement tools. The AS and MAS remain the most
commonly used clinical scales in the measurement of spasticity.
9
There have been many advances over the years for the treatment of post-
Differences in training of examiners and the variability of spasticity with stroke spasticity. Of these, BTX-A is an accepted intervention. The
position, stress, temperature, illness, etc. make it very difficult to achieve improvement of measuring tools for spasticity, improved outcome
standardized measurements. The variability of QoL results of these measurement tools, and research regarding dosing and injection
reviewed studies and others like them continue to drive the debate. QoL techniques are still required. Ideally, these measurement tools could take
is a patient- and/or care-giver-specific issue. For example, patients have into account the goals of the patient or care-giver when evaluating
described perceived improvement in their physical appearance that may functional improvement. Once this is done, it is possible to quantify
correlate with improved quality of life; however, it is extremely difficult to improvements that have thus far been mostly qualitative in nature. n
measure such a subjective point. For this reason, QoL measures will likely
always be difficult to objectify. There exists great debate as to the actual
Cindy B Ivanhoe, MD, PA, is an Associate Professor of
functional improvements that can be achieved in patients with severe
Physical Medicine and Rehabilitation at Baylor College
spasticity and differing degrees of paresis after BTX-A injections. Research of Medicine and Medical Director of NeuroRehabilitation
has focused on using advanced techniques to improve injection accuracy
Specialists in Houston. She is also an Adjunct Associate
Professor of Physical Medicine and Rehabilitation at the
such as electromyographic guidance (EMG) and electrical stimulation (ES)
University of Texas, and an Attending Physician in the
in patients who are unresponsive or sedated.
17
Improvements seen in Brain Injury and Stroke Program and Medical Director at
function in the above studies cannot be generalized to all stroke patients.
Mentis NeuroRehabilitation in Houston.
More studies are needed with narrowly selected patient populations in
order to provide further guidelines for treatment in specific patient Natasha K Eaddy-Rose, MD, is a Physician at
populations. It should also be noted that upper-extremity function can be
NeuroRehabilitation Specialists in Houston. She is a fellow
trained in brain injury and stroke rehabilitation and also
more important than lower-limb function for independent living and self-
provides care in the acute inpatient rehabilitation setting
esteem.
18,19
Additionally, there is no established standard approach to the at The Institute for Rehabilitation and Research (TIRR) and
administration of BTX-A. The dosing regimen, targeted muscle groups,
in the residential brain injury rehab setting. Dr Eaddy
received her MD from the University of Michigan and
and practice of administration vary with the clinical presentation of
completed residency training at Baylor College of
patients, as do the approach of the individual injecting the drug and goals Medicine/University of Texas Health Science Center-
of injections. The extent of denervation is determined largely by the dose
Houston Physical Medicine and Rehabilitation Alliance.
and volume of the injection given.
11,16
Studies are available that
1. Trompetto C, Bove M, Avanzino L, et al., Intrafusal effects of strategies, Restor Neurol Neurosci, 2004;359–69. movement therapy for an individual with chronic
botulinum toxin in post-stroke upper limb spasticity. European 9. Pizzi A, Carlucci G, Falsini C, et al., Evaluation of upper-limb upper-extremity spasticity after stroke, Physical Ther,
journal of Neurology, J Eur Fed Neurol Soc, 2008;15:4: spasticity after stroke: A clinical and Neurophysiologic Study, 2006;86:1387–97.
367–70. Arch Physical Med Rehab, 2005;86:410–15. 16. Brin M, Botulinum toxin: Chemistry, Pharmacology, Toxicity, and
2. Cardoso E, Pedreira G, Prazeres A, et al., Does botulinum toxin 10. Turkel C, Bowen B, Liu J, Brin M, Pooled Analysis of the safety Immunology, Muscle Nerve,1997;(Suppl. 6):S146–68.
improve the function of the patient with spasticity after of botulinum toxin type A in the treatment of poststroke 17. O’Brien C, Injection Techniques for botulinum toxin using
stroke?, Arquivos de Neuropsiquiatria, 2007;65:3A:592–5. spasticity, Arch Phys Med Rehab, 2006;87:786–92. electromyography and electrical stimulation, Muscle Nerve,
3. Slawek J, Bogucki A, Reclawowicz D, Botulinum toxin type A 11. Childers M, Brashear A, Jozefczyk P, et al., Dose-dependent 1997:(Suppl. 6):S176–80.
for upper limb spasticity following stroke: an open-label study response to intramuscular botulinum toxin type A for 18. Granger C, Hamilton B, Gresham G, et al., The stroke
with individualised, flexible injection regimensm, Neurol Sci, upper-limb spasticity in patients after a stroke, Arch Phys Med rehabilitation outcome study: part II. Relative merits of the
2005;26:32–9. Rehab, 2004;85:1063–9. total Barthel Index score and a four item subscore in
4. Miscio G, Del Conte C, Pianca D, et al., Botulinum toxin in post- 12. Levy C, Giuffrida C, Richards L, et al., Botulinum Toxin A, predicting patient outcomes, Arch Phys Med Rehab, 1989;70:
stroke patients: stiffness modifications and clinical Evidence-Based Exercise Therapy, and Constraint-Induced 100–103.
implications, J Neurol, 2004;251;189–96. Movement Therapy for Upper-Limb Hemiparesis Attributable 19. Galliet R, Levy B, Blood K, Upper extremity sensory feedback
5. Bakheit O, Fedorova N, Skoromets A, et al., The beneficial to Stroke: A Preliminary Study, Arch Phys Med Rehab, 2007;86: therapy in chronic cerebrovascular accident patients with
antispasticity effect of botulinum toxin type A is maintained 696–706. impaired expressive aphasia and auditory comprehension,
after repeated treatment cycles, J Neurol, Neurosurg Psych, 13. Yelnik A, Colle F, Bonan I, Vicaut E, Treatment of shoulder pain Arch Phys Med Rehab, 1986;67:304–10.
2004;75:1558–61. in spastic hemiplegia by reducing spasticity of the subscapular 20. Lee LH, Chang WN, Chang CS, The finding and evaluation of
6. Cardoso E, Rodrigues B, Lucena R, et al., Botulinum toxin type muscle: a randomized, double blind, placebo controlled study EMG-guided BOTOX injection in cervical dystonia, Acta Neurol
A for the treatment of the upper limb spasticity after stroke, of botulinum toxin A, J Neurol, Neurosurg Psych, 2007;78;845–8. Taiwan, 2004;13:2;71–6.
Arquivos de Neuropsiquiatria, 2005;63:30–33. 14. Denham S, Augmenting occupational therapy treatment of 21. Clopton N, Dutton J, Featherston T, et al., Interrater and
7. Rosales R, Chua-Yap A, Evidence-based systematic review on upper-extremity spasticity with botulinum toxin A: A case intrarater reliability of the Modified Ashworth Scale in children
the efficacy and safety of botulinum toxin-A therapy in post- report of progress at discharge and 2 years later, Am J with hypertonia, Pediatric Physical Ther, 2005;17:4:
stroke spasticity, J Neural Trans, 2008;115:617–23. Occupational Ther, 2008;63:473–9. 268–74.
8. Hesse S, Recovery of gait and other motor functions after 15. Sun S, Hsu C, Hwang C, et al., Application of combined
stroke: Novel physical and pharmacological treatment botulinum toxin type A and modified constraint-induced
40 US NEUROLOGY
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