Adjunct therapies after botulinum toxin injections in spastic adults: systematic review and SOFMER recommendations - 03/06/21

Doi : 10.1016/j.rehab.2021.101544

Etienne Allart, MD PhD ^1,^2,⁎ , Dominique Mazevet, MD PhD ³, Stéphane Idée, MD ⁴, François Constant Boyer, MD PhD ⁵, Isabelle Bonan, MD PhD ^6,⁷
¹ CHU Lille, Neurorehabilitation Unit, F-59000 Lille, France
² Univ. Lille, INSERM UMR-S-1172 – Lille Neuroscience and Cognition, F-59000 Lille, France
³ AP-HP, Hôpital Pitié Salpêtrière, F-75013 Paris, France
⁴ CHU Strasbourg, PRM Department, F-67000 Strasbourg, France
⁵ CHU Reims Champagne-Ardenne, PRM Department, Sébastopol Hospital, F-51092 Reims, France
⁶ CHU Rennes, PRM Department, University of Rennes 1 & 2, F-35000 Rennes, France
⁷ Unité Empenn (ex-Visages) U1228 INSERM-INRIA, IRISA UMR CNRS 6074, Campus de Beaulieu, F-35042 Rennes Cedex, France

^⁎Corresponding author: Service de Rééducation Neurologique Cérébrolésion / Neurorehabilitation Unit Hôpital Swynghedauw, CHRU de Lille, Rue André Verhaeghe, F-59037 Lille cedex, FranceService de Rééducation Neurologique Cérébrolésion / Neurorehabilitation Unit Hôpital Swynghedauw, CHRU de LilleRue André VerhaegheLille cedexF-59037France

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Abstract

Background. Adjunct therapies (ATs) may further improve outcomes after botulinum toxin injections in spastic patients, but evidence was unclear in previous systematic reviews.

Objective. To assess the efficacy of non-pharmacological ATs in spastic adults according to the International Classification of Functioning, Disability and Health and build an expert consensus based on a Delphi process.

Methods. Four electronic databases were searched up to May 2020 for reports of comparative trials of non-pharmacologic ATs after botulinum toxin injections in spastic adults. Then 25 French experts participated in a two-round Delphi process to build recommendations on the use of ATs.

Results. We included 32 studies (1202 participants, median 32/study) evaluating the effects of physical agents (n=9), joint posture procedures (JPPs, n=11), and active ATs (n=14), mainly after stroke. The average quality of articles was good for randomised controlled trials (median [interquartile range] PEDro score = 7 [6–8]) but moderate (n=2) or poor (n=2) for non-randomised controlled trials (Downs & Black checklist). Meta-analysis was precluded owing to the heterogeneity of ATs, control groups and outcome measures. There is evidence for the use of JPPs except low-dose manual stretching and soft posture techniques. Continuous postures (by taping or casting) are recommended; discontinuous postures (by orthosis) may be preferred in patients with active function. Device-free or device-assisted active ATs may be beneficial in the mid-term (> 3 months after botulinum toxin injections), particularly when performed at a high intensity (>3 hr/week) as in constraint-induced movement therapy. Self-rehabilitation remains understudied after a focal treatment, but its interest is highlighted by the experts. The use of physical agents is not recommended.

Conclusions. JPPs and active ATs (device-assisted or device-free) may further improve impairments and activities after botulinum toxin injections. Further studies are needed to better define the best strategies for ATs as a function of the individual treatment goals, participation and quality of life.

Review Registration. PROSPERO (CRD42018105856)

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Key words : Muscle spasticity, botulinum toxin, adjunct therapy, stroke, systematic review, delphi