Abstract
Aims: Does the addition of botulinum toxin type A increase the effect of casting for improving wrist extension after stroke in people with upper limb spasticity? Methods: Randomized trial with concealed allocation, assessor blinding and intention-to-treat analysis which was part of a larger trial included 18 adults with upper limb spasticity two years after stroke (89%) or stroke-like conditions (11%). The experimental group (n=7) received botulinum toxin type A injections to upper limb muscles for spasticity management followed by two weeks of wrist casting into maximum extension. The control group (n=11) received two weeks of casting only. Range of motion (goniometry) measured at baseline and after two weeks of casting. Results: Passive wrist extension for the experimental group improved over two weeks from 22 degrees (SD 16) to 54 degrees (SD 16), while the control group improved from 21 degrees (SD 29) to 43 degrees (SD 26). The experimental group increased passive wrist extension 13 degrees (95% CI 4 to 31) more than the control group which was not statistically significant. Conclusion: Joint range of motion improved over a two-week period for both groups. Botulinum toxin type A injection followed-by casting produced a mean, clinically greater range of motion than casting alone, therefore, a fully-powered trial is warranted.
Highlights
Botulinum toxin type A has been shown to reduce spasticity after stroke [1, 2]
There was a larger effect (MD 15 degrees, 95% CI 4 to 26) of long-term stretch in the lower limb after traumatic brain injury if it was applied continuously via casting in one randomized trial [4], with another randomized trial of casting after traumatic brain injury showing similar results in the upper limb (MD 22 degrees, 95% CI 13 to 31) [5]
After two weeks of casting, passive wrist extension improved in both groups
Summary
Botulinum toxin type A has been shown to reduce spasticity after stroke [1, 2] It is often the decrease in joint range of motion which limits the ability to use the limb, rather than the presence of spasticity itself [3]. In the presence of spasticity, it is assumed that using botulinum toxin type A plus casting will increase range of motion more than casting used in isolation. Randomized trials showed no effect of adding botulinum toxin type A to casting after traumatic brain injury [6] (MD 2 degrees, 95% CI 9 to 13) or in children with cerebral palsy [7] (MD 5 degrees, 95% CI 4 to 13). Adding botulinum toxin type A to casting to reduce contracture has not been examined in a randomized trial after stroke. A single-group study [8] of botulinum toxin type A followed by three weeks of casting resulted in reduction in contracture of 7 degrees (95% CI 5 to 9) in people with chronic stroke and moderate to severe spasticity (Grade 3–4 on the modified Ashworth scale)
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