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Does botulinum toxin treatment improve upper limb active function? - 14/07/19

Doi : 10.1016/j.rehab.2018.05.1320 
Jonathan Levy a, b, c, , Franco Molteni d , Giovanni Cannaviello d , Thibaud Lansaman a , Nicolas Roche a, b, c , Djamel Bensmail a, b, c
a Department of Physical and Rehabilitation Medicine, Raymond Poincaré Teaching Hospital, AP–HP, 104, boulevard Raymond-Poincaré, 92380 Garches, France 
b UMR1179, Neuromuscular handicap, Inserm-University of Versailles–St-Quentin-en-Yvelines, 78180 Montigny-le-Bretonneux, France 
c Fondation Garches, Raymond-Poincaré Hospital, 92380 Garches, France 
d Villa Beretta Rehabilitation Center, Valduce Hospital, 23845 Costa Masnaga, Lecco, Italy 

Corresponding author. UFR des sciences de la santé Simone-Veil, UMR1179, équipe 2, 104, boulevard Raymond-Poincaré, 92380 Garches, France.UFR des sciences de la santé Simone-Veil, UMR1179, équipe 2104, boulevard Raymond-PoincaréGarches92380France

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Highlights

There is no evidence of grasp activity improvement resulting from reducing upper-limb spasticity with botulinum toxin injection.
When goals are correctly set, they are achieved in most cases.
Goals related to passive function or impairment are more frequently achieved.
The better the underlying motor control, the higher the functional expectations.
The selection of less disabled patients, repeated injections, extended assessment time and combined therapies may help demonstrate the functional effects of botulinum toxin injections on upper-limb spasticity.

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Abstract

Background

Spasticity following lesions of the central nervous system such as stroke is a major cause of impairment and disability, especially when it affects the upper limb, and can be focally relieved by intramuscular injections of botulinum toxin (BT). Functional improvements of the affected upper limb after a BT focal treatment remain controversial.

Objective

We aimed to assess the functional effects of BT treatment on upper-limb spasticity in the literature, identify flaws and deficiencies in proving these effects and propose leads for future trials.

Methods

We searched the MEDLINE and Cochrane databases for trials, reviews and meta-analyses assessing the effect of BT injection in upper-limb spasticity. This was a non-systematic narrative review, and the selection of articles was based on the authors’ expertise. The review focused on stroke-related spasticity and disability.

Results

Patients’ therapeutic targets involved use of the disability assessment scale (DAS) or goal attainment scale (GAS). Impairments and passive function goals prevailed for active function and participation and were more frequently achieved for the former than the latter. Meta-analyses showed no to mild effect sizes for improvement in upper-limb function but failed to show higher and/or better use of the paretic upper limb in activities of daily living after BT injection.

Conclusion

BT injections for impairment and passive function are related to improved kinematic parameters; however, the relation between relief of spasticity and improved upper-limb activity has not been established. Possible explanations for the lack of functional effect in studies are first, disability is mainly due to muscle weakness rather than spasticity, so patients with the best underlying motricity may benefit the most from BT injections; second, assessment methods may not be adapted to screen eligible patients; third, most studies’ endpoints were at 4 to 12 weeks after a single injection, but repeated treatment sessions might be needed to observe functional outcome on the upper limbs; and finally, the association of rehabilitation programs or non-pharmacological treatments may enhance the functional effects of BT injections.

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Keywords : Spasticity, Botulinum toxin, Rehabilitation, Outcome, Upper limb, Stroke


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Vol 62 - N° 4

P. 234-240 - juillet 2019 Retour au numéro
Article précédent Article précédent
  • Orthopaedic surgery for patients with central nervous system lesions: Concepts and techniques
  • F. Genêt, P. Denormandie, M.A. Keenan
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  • Immunogenicity induced by botulinum toxin injections for limb spasticity: A systematic review
  • Laure Mathevon, Arnaud Declemy, Isabelle Laffont, Dominic Perennou

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