Barbara J. Singer

A prospective, multicentre, randomized, double-blind, placebo-controlled trial of onabotulinumtoxinA to treat plantarflexor/invertor overactivity after stroke:

Objective: To examine the safety and efficacy of onabotulinumtoxinA (Botox) for plantarflexor overactivity following stroke. Design: Double-blind randomized controlled trial, open-label extension phase. Setting: Neurology rehabilitation facilities. Subjects: Eighty-five subjects with lower limb hypertonia received 200 U (n = 28) or 300 U (n = 28) of onabotulinumtoxinA or saline (n = 29) injection. Primary measures: Plantarflexor Ashworth scores at 12 weeks post injection and adverse events. Secondary measures: self-reported spasm frequency and pain, physician rating of hypertonia severity, gait quality and active dorsiflexion. Results: Differences were not seen between onabotulinumtoxinA groups; hence data were pooled. Incidence of adverse events was not different between groups (P = 0.61). Reduction in hypertonia was not different between groups at 12 weeks (P = 0.53); however for subjects with Ashworth scores of >3 at baseline, 14/31 in the onabotulinumtoxinA group demonstrated a reduction of >1 grade versus 1/17 receiving placebo injection (P = 0.01). Overall, onabotulinumtoxinA-injected subjects demonstrated significantly greater improvement in spasm frequency (22/54 versus 4/29, P = 0.01), pain reduction (8/54 versus 1/29, P = 0.02), active dorsiflexion (8/54 versus 1/29 P = 0.03) and gait quality (17/54 versus 6/29, P = 0.02) than controls. In the open-label phase, a second onabotulinumtoxinA injection was associated with greater hypertonia reduction (P = 0.005) and gait quality (P = 0.002) compared with single injection. Conclusions: OnabotulinumtoxinA injection for ankle flexor overactivity after stroke was safe and well tolerated but did not alter local spasticity at 12 weeks; it did reduce spasms and improve gait quality. There were no detectable differences between higher and lower doses. A second injection may be associated with greater change.

The role of botulinum toxin injections in the management of muscle overactivity of the lower limb

Muscle overactivity is common in patients with adult onset central nervous system damage. It can produce significant disablement in conjunction with other impairments such as adaptive soft tissue shortening and loss of muscle strength. Muscle overactivity is not evenly distributed throughout the body; across joints there is frequently imbalance between agonist and antagonist, producing abnormal joint postures and movement patterns. Due to the asymmetric nature of the abnormal activity across joints, in general we recommend local treatment targeting the more overactive of the two agonists, rather than systemic treatment. Considerable experience with the use of botulinum toxin, both serotypes A and B, in the treatment of muscle overactivity has been accumulated in the last two decades through pragmatic clinical practice and open label studies, supported by an increasing number of randomized controlled trials. In most cases, it is important to use botulinum toxin injection for treatment of muscle overactivity in the setting of wider rehabilitation goals and interventions. Focal and partial blocks with botulinum toxin should be used as a component of a general neurorehabilitation programme rather than as an alternative to other treatments. We review the evidence supporting the use of botulinum toxin to treat muscle overactivity in the lower limb, present practical guidelines on when and how to use botulinum toxin and provide direction for future research.

The effect of EMG triggered electrical stimulation plus task practice on arm function in chronic stroke patients with moderate-severe arm deficits

PURPOSE We examined the feasibility and outcome of electromyographically triggered electrical muscle stimulation (EMG-ES) plus unilateral or bilateral task specific practice on arm function in chronic stroke survivors with moderate-severe hemiplegia. Transcranial magnetic stimulation was used to examine inter-hemispheric inhibition (IHI) acting on the stroke-affected hemisphere in a subset of eight participants. METHODS Twenty-one stroke survivors (14 males; mean time post stroke 57.9 months) participated in this pilot investigation. Participants underwent a six-week program of daily EMG-ES training with random assignment to concurrent task practice using the stroke-affected hand only or both hands. The upper-extremity subscale of the Fugl-Meyer (FMUE) and the Arm Motor Ability Test (AMAT) were completed at baseline, 0-, 1-, and 3-months post-intervention. RESULTS Following the intervention, FMUE (F(3, 57) = 3.89, p = .01, ηp2 = .17) and AMAT (F(3, 57) = 12.6, p = .01, ηp2 = .39) scores improved, and remained better than baseline at three months re-assessment. The difference between groups was not significant. A non-significant decrease in IHI was observed post-intervention. CONCLUSIONS An intensive program of EMG-ES assisted functional training is feasible, well tolerated, and leads to improvements in moderate-severe deficits of arm function post stroke. Larger placebo controlled studies are needed to explore any advantage of bilateral over unilateral EMG-ES assisted training.

The use of botulinum toxin type A in the management of adult-onset focal spasticity: A survey of Australian allied health professionals

BACKGROUND Recently, the European Journal of Neurology published international consensus statements for the assessment, treatment and aftercare associated with the use of botulinum neurotoxin type A. This survey examined current allied health practice in relation to botulinum neurotoxin type A use in Australia in the light of these guidelines. METHODS An electronic questionnaire was distributed to members of neurology groups of the Australian Physiotherapy Association and Occupational Therapy Australia. The questionnaire explored assessment processes used, familiarity with pharmaceutical benefits scheme indications for botulinum neurotoxin type A use, goal setting and outcome measurement, follow-up therapy and access to spasticity management services. RESULTS The 123 survey respondents (81 from the Australian Physiotherapy Association - response rate 16.2%, 42 from Occupational Therapy Australia - response rate 6.4%) reported that focal spasticity was a major problem for which botulinum neurotoxin type A was a primary intervention. The Tardieu scale was more frequently used than the modified Ashworth scale (82% vs. 48%). Most therapists (76.3%) reported being confident diagnosing spasticity and its functional implications (84.2%), but fewer were confident discussing referral for botulinum neurotoxin type A with doctors (56.1%). Goals were set in conjunction with the client (93.6%). Barriers to injection and adjunctive therapy (motor training etc.) included waiting times for botulinum neurotoxin type A injection, access to specialist adjunctive therapists and referral for treatment. CONCLUSIONS Allied health practitioners in Australia report clinical practice to be closely aligned with international guidelines for the use of botulinum neurotoxin type A in adult spasticity. Therapist confidence in advocating for botulinum neurotoxin type A injection, consistent use of objective measures of spasticity and treatment outcomes and barriers to providing adjunctive therapy need to be addressed.

Clinical Evaluation of Hypertonia in the Triceps Surae Muscles

Abstract Hypertonia of the triceps surae muscles is a common consequence of acquired brain injury. The increased resistance to passive lengthening results from rheologic changes within the musculotendinous unit, in addition to altered descending facilitatory influences on the alpha motor-neurone pool. Hypertonia can contribute to abnormal ankle joint biomechanics during the performance of functional tasks. In order to achieve effective outcomes, therapeutic interventions need to be based on accurate measurement and analysis of the various components of hypertonia. Some options for the clinical evaluation of hypertonia at the ankle joint are discussed in this paper. Reflex hyper-excitability and rheologic changes within the musculotendinous unit are inextricably linked. Serial evaluation of passive range of motion and muscle stiffness in patients with hypertonia provides useful information for treatment planning. In addition to measurement of the available passive range of motion when maximal force is applied, there is a need to consider methods of monitoring changes in muscle stiffness following brain injury.

Prolonged vastus lateralis denervation after botulinum toxin type A injection.

Intramuscular injection of botulinum toxin (BoNT) produces reversible blockade of neuromuscular transmission. In animal experimental models, recovery begins within four weeks and is usually complete by twelve weeks. We present evidence of prolonged denervation following BoNT injection of the vastus lateralis (VL) muscle to correct quadriceps muscle imbalance in patients with chronic anterior knee pain. Needle electromyography data were obtained from 10 subjects who had received a single BoNT treatment 5 to 19 months earlier as part of a clinical trial. Insertional and spontaneous activity, recruitment, and motor unit action potentials were examined. Clear differences between the injected and non‐injected VL muscles, which correlated with the time since injection, were identified in all subjects. All 10 subjects studied with needle EMG showed evidence of persisting denervation in the BoNT‐A injected VL muscle beyond the period of neuromotor recovery expected from animal experimental studies.

Assessing student clinical learning experiences

This article describes the use of an activity worksheet and questionnaire to investigate the learning experience of students on clinical placement. The worksheet measures the amount of time students spend in different learning activities, and the questionnaire explores student satisfaction and preferred learning activities.

The Role of Botulinum Toxin Type A in the Clinical Management of Refractory Anterior Knee Pain

Anterior knee pain is a highly prevalent condition affecting largely young to middle aged adults. Symptoms can recur in more than two thirds of cases, often resulting in activity limitation and reduced participation in employment and recreational pursuits. Persistent anterior knee pain is difficult to treat and many individuals eventually consider a surgical intervention. Evidence for long term benefit of most conservative treatments or surgical approaches is currently lacking. Injection of Botulinum toxin type A to the distal region of vastus lateralis muscle causes a short term functional “denervation” which moderates the influence of vastus lateralis muscle on the knee extensor mechanism and increases the relative contribution of the vastus medialis muscle. Initial data suggest that, compared with other interventions for anterior knee pain, Botulinum toxin type A injection, in combination with an active exercise programme, can lead to sustained relief of symptoms, reduced health care utilisation and increased activity participation. The procedure is less invasive than surgical intervention, relatively easy to perform, and is time- and cost-effective. Further studies, including larger randomized placebo-controlled trials, are required to confirm the effectiveness of Botulinum toxin type A injection for anterior knee pain and to elaborate the possible mechanisms underpinning pain and symptom relief.

Enduring efficacy of Botulinum toxin type A injection for refractory anterior knee pain

Purpose: To examine long-term outcomes of Botulinum toxin type A (BoNT-A) injection to vastus lateralis (VL) for refractory anterior knee pain (AKP). Methods: Two cohorts (private clinic referrals and previous research participants) injected with BoNT-A for AKP by one neurologist were surveyed retrospectively. Primary outcomes were self-reported benefit, duration of symptom relief, and knee surgery post-injection. Secondary outcomes were changes in utilization of medication/physiotherapy treatment, AKP symptoms and activity limitation. Results: Overall, average symptom duration was 76 months (SD 98). Responses were available from 46 of 53 private patients. Thirty-eight reported benefit from injection, which was ongoing in 29. Average benefit was 25 months (SD 21). Nine individuals reported symptom recurrence after an average of 14 months (SD 21). Ten had knee surgery post-injection; six of whom had not benefitted from BoNT-A injection. Nineteen of 23 previous research participants were contactable. Initially, all responded favorably to injection. Symptomatic benefit, with an average duration of 44 months (SD 20), persisted in 15. Two subjects proceeded to surgical intervention. Conclusions: A single BoNT-A treatment to VL led initially to improved function and relief of knee-related symptoms in 57 of 65 individuals. Improvements were sustained at follow-up, with an average benefit of 34 months (SD 25) post-injection, in 44 of 57 cases. Implications for Rehabilitation Persistent anterior knee pain (AKP) can be difficult to treat and many individuals seek surgical intervention, often with variable results. Injection of Botulinum toxin type A (BoNT-A) to Vastus Lateralis muscle offers an effective alternative treatment for individuals with refractory AKP associated with patella mal-tracking related to quadriceps muscle imbalance. BoNT-A injection can provide sustained benefit, is less invasive than surgical intervention, is relatively easy to perform, and is very time- and cost-effective.

An exploration of factors influencing physical activity levels amongst a cohort of people living in the community after stroke in the south of England.

Abstract Purpose: To explore factors influencing physical activity (PA) reported by people living in rural/semi-rural communities in the south of England post-stroke, and to understand relationships between personal, interpersonal and environmental barriers and self-reported levels of PA. Method: A survey was mailed to patients of NHS Trusts who were identified as potential participants. Self-reported PA levels, type, and frequency of reported barriers were tabulated. Spearman’s rank correlation coefficient was used to explore associations between self-reported PA level and: age, gender, level of physical function, fear of falling, beliefs regarding PA, available supports, and socioeconomic status. Results: Seventy-six of 322 questionnaires distributed were returned (24%). Only 55.2% of respondents reported undertaking PA of sufficient intensity to meet current guidelines. Personal barriers included fear of falling, stroke-related disability, pain, and fatigue. Interpersonal and environmental barriers included lack of social support, transport, and inclement weather. Significant relationships existed between self-reported PA and fear of falling, functional mobility, and beliefs relating to PA. Conclusions: Almost half of the survey cohort reported PA levels insufficient to meet current guidelines. Similar to barriers reported in previous studies in USA and other parts of the UK, numerous interlinking and overlapping personal, interpersonal, and environmental barriers to undertaking PA were identified. Implications for Rehabilitation This study found that although more than 60% of the survey population were able to ambulate >200 m, only 55.2% reported undertaking sufficient PA to meet current guidelines, putting them at increased risk of further stroke and other co-morbidities. Participants reported a number of interlinking and overlapping personal, interpersonal, and environmental barriers to undertaking PA, which may explain this discrepancy between mobility status and self reported activity levels. Rehabilitation professionals and primary care providers are well positioned to address the barriers identified in this survey, such as providing interventions to reduce fear of falling, pain, and fatigue, providing support and education about safely increasing physical activity and addressing unhelpful beliefs about PA. Behaviour change strategies, such as increasing self-efficacy, and partnering with the person with stroke to problem solve strategies to address the barriers identified by this, and related research, are likely to be more successful in increasing PA than providing information alone.