BOTULINUM TOXIN TYPE-A FOR THE MANAGEMENT OF THE UPPER
LIMB SPASTICITY IN STROKE PATIENTS.
Tasiopoulos N, Zikopoulos K, Sivetidou S.
“ANAPLASI” REHABILITATION CENTER, ATHENS, GREECE.
INTRODUCTION
Spasticity is a very common problem met during the process of a therapeutic rehabilitation
program for stroke patients. When localized in lower limbs, spasticity interferes with gait,
ambulation, transfers, hygiene, urination and defecation and leads to adoption of bad body
postures. When affecting upper limbs it may result in hand deformities, in poor motor
improvement, in a decrease of the normal range of motion of the ipsilateral shoulder.
Furthermore, spasticity interferes with the therapeutic interventions of the physical and
occupational therapists and results in a decreased ability to perform activities of daily living,
especially hygiene and dressing.
AIM
To evaluate the therapeutic effect of botulinum toxin type-A (Dysport) on the spasticity of the
upper limb of hemiplegic patients, following a rehabilitation program, on an outpatient basis.
MATERIAL AND METHOD
Twenty patients suffering from CVA and severe hypertonia of upper limb, were included in
the study (12 with Left hemiplegia and 8 with Right) ( MAS score  2). Average age was
63,4. All participants had poor voluntary control and spastic flexion deformity of elbow, wrist
and fingers. All patients were following a rehabilitation program, on an outpatient basis,
usually on alternate days.
Different types of therapy were included, like neuropsychological therapy, speech therapy,
physical therapy, occupational therapy, biofeedback, recreational therapy (e.g. basketball
inside the therapeutic pool etc). Furthermore, home modifications and adaptations in
conjuction with assistive devices were used to enhance function and independence.
The assessment of the effectiveness of the treatment was performed by the rehabilitation team
members, at regular intervals, therefore establishing coordination of care within the team. All
patients were evaluated prior to receiving botulinum toxin and 1 week, 1 month and 3 months
after, with:
1. Modified Ashworth Scale (ΜΑS), for the assessment of spasticity
2. Motricity Index, for the assessment of motor deficits
3. Barthel Index (BI), for the assessment of functional abilities
4. Wrist Goniometry, for the measurement of wrist joint range of movement
Botulinum toxin was injected under EMG guidance. Total toxin dose was 1500 IU per patient.
Toxin in each vial was diluted with 2 ml of injectable solution NaCl (0.9%) and 0.25 ml (60
IU) were administered per site, in 2-3 injection sites per muscle. Muscles injected were
pectoralis major, biceps brachii, brachioradialis, flexor carpi ulnaris and radialis, flexor
digitorum superficialis and profundus.
RESULTS
A significant reduction in spasticity and in MAS score (at least one grade in all patients) was
found, resulting in functional benefits (mainly in hygiene and dressing) and a reduction in
discomfort and pain. The need for administration of antispasticity medication was reduced.
Patients were more actively involved in their rehabilitation program. No side effects were
observed.
1. Measurements (mean) in Modified Ashworth Scale
BEFORE INJECTION
Modified Ashworth Scale
(mean)
2,45
1 WEEK AFTER
2,00
1 MONTH AFTER
1,85
3 MONTHS AFTER
1,90
2. Measurements (mean) in Barthel Index
Barthel Index (mean)
BEFORE INJECTION
73
1 WEEK AFTER
79
1 MONTH AFTER
84
3 MONTHS AFTER
89
3. Measurements (mean) in Motricity Index
Upper limb
Motricity Index
40
BEFORE INJECTION
Lower limb
Motricity Index
34
1 WEEK AFTER
48
34
1 MONTH AFTER
55
54
3 MONTHS AFTER
60
54
4. Measurements (mean) of active and passive range of movement
BEFORE INJECTION
Dorsal wrist ROM (mean)
ACTIVE 0º
Palmar wrist ROM (mean)
ACTIVE 10º
1 WEEK AFTER
PASSIVE 25º
ACTIVE 15º
PASSIVE 65º
ACTIVE 20º
1 MONTH AFTER
PASSIVE 25º
ACTIVE 15º
PASSIVE 65º
ACTIVE 55º
3 MONTHS AFTER
PASSIVE 45º
ACTIVE 25º
PASSIVE 80º
ACTIVE 65º
PASSIVE 65º
PASSIVE 80º
DISCUSSION
No satisfactory treatment for neurological impairments appearing after a vascular cerebral
injury, has been found so far. Therefore, the only remaining choice, is to try to reduce
disability by improving patient’s physical abilities, with the help of a well planned
rehabilitation program, enriched with a symptomatic pharmaceutical treatment.
Spasticity is one of the symptoms of the upper motor neuron syndrome. Potentially, it may
become a deteriorating factor for the hemiplegic patient mobility and his functional ability.
When localised in lower limbs concomitantly with muscle weakness, spasticity may result in
poor ambulation and movement. When localised in upper limbs, spasticity restricts joint
mobility and may result in hand deformities, in poor motor improvement, in a decrease of the
normal range of motion of the ipsilateral shoulder. Furthermore, spasticity interferes with the
therapeutic interventions of the physical and occupational therapists and results in a decreased
ability to perform self care activities, especially hygiene and dressing.
Spasticity treatment is necessary when a patient feels pain, has a significant impairment of
mobility and develops hand deformities and a bad posture. Also, when the activities of self
care are poorly performed and when therapeutic interventions of the therapists are difficult to
implement.
Pharmacological management has not been satisfactory. Anti-spasticity medication
(baclofen, dantrolene, diazepam, tizanidine) can be occasionally effective. However, these
agents have systemic side effects, including level of consciousness impairment. Selective
spasticity treatment would be the ideal approach, to induce patient mobility and functional
ability.
Botulinum toxin is a neurotoxin produced by the anaerobic bacterium causing botulism. It
inhibits acetylcholine release in neuromuscular junction. The therapeutic administration of
botulinum toxin, acts selectively in the specific muscles that cause inability to the patient and
achieves selective suppression of spasticity. It is a useful symptomatic treatment. However, it
creates a brief temporary time window of reduced spasticity, facilitating therefore the work
and increasing the efficacy of interventions of the therapists.
Thus, botulinum toxin treatment should be part of a comprehensive rehabilitation program
and should be administered only when the patient is following a rehabilitation program, that
continues after the botulinum toxin administration. In such a rehabilitation program, a daily
routine of prolonged muscle stretching, strengthening exercises, coordination exercises,
occupational therapy, biofeeback, splint application etc. may be included.
Our patients followed such a rehabilitation program. They presented a significant impairment
in mobility and performance of daily activities, due to severe upper limb spasticity, and all of
them have been following a rehabilitation program, that was continued after the botulinum
toxin treatment.
Already from the first week after toxin treatment, an apparent reduction of spasticity and an
improvement of self care ability were noticed. Furthermore, we noticed a reduction of MAS
index score, an increase of patients’ ability to perform self care activities (hygiene and lower
limb dressing), an increase of BI score and a decrease in the need for anti-spasticity
medication. All patients showed a more active participation in their rehabilitation program.
This improvement lasted for three months. After this period, spasticity started to worsen, but
the functional abilities of the patients had already improved significantly.
CONCLUSION
Local injections of botulinum toxin type-A can provide a significant relief of the upper limb
spasticity in stroke patients, enhancing their functional abilities to perform self care activities
and facilitating their rehabilitation program.