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Effectiveness of Botulinum Toxin Treatment for Upper Limb Spasticity Poststroke Over Different ICF Domains: A Systematic Review and Meta-Analysis

  • Aukje Andringa
    Affiliations
    Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Department of Rehabilitation Medicine, Amsterdam Movement Sciences, Amsterdam Neuroscience, Amsterdam, the Netherlands
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  • Ingrid van de Port
    Affiliations
    Revant Rehabilitation Centre Breda, Breda, the Netherlands
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  • Erwin van Wegen
    Affiliations
    Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Department of Rehabilitation Medicine, Amsterdam Movement Sciences, Amsterdam Neuroscience, Amsterdam, the Netherlands
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  • Johannes Ket
    Affiliations
    Medical Library, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
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  • Carel Meskers
    Correspondence
    Corresponding author Carel Meskers, MD, PhD, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Department of Rehabilitation Medicine, PO Box 7057, 1007 MB Amsterdam, the Netherlands.
    Affiliations
    Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Department of Rehabilitation Medicine, Amsterdam Movement Sciences, Amsterdam Neuroscience, Amsterdam, the Netherlands

    Department of Physical Therapy and Human Movement Sciences, Northwestern University, Chicago, Illinois, the United States
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  • Gert Kwakkel
    Affiliations
    Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Department of Rehabilitation Medicine, Amsterdam Movement Sciences, Amsterdam Neuroscience, Amsterdam, the Netherlands

    Department of Physical Therapy and Human Movement Sciences, Northwestern University, Chicago, Illinois, the United States

    Department of Neurorehabilitation, Amsterdam Rehabilitation Research Centre, Reade, Amsterdam, the Netherlands
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Published:February 20, 2019DOI:https://doi.org/10.1016/j.apmr.2019.01.016

      Abstract

      Objective

      To provide a comprehensive overview of reported effects and scientific robustness of botulinum toxin (BoNT) treatment regarding the main clinical goals related to poststroke upper limb spasticity, using the International Classification of Functioning, Disability and Health.

      Data Sources

      Embase, PubMed, Wiley/Cochrane Library, and Ebsco/CINAHL were searched from inception up to May 16, 2018.

      Study Selection

      We included randomized controlled trials comparing upper limb BoNT injections with a control intervention in patients with a history of stroke. A total of 1212 unique records were screened by 2 independent reviewers. Forty trials were identified, including 2718 patients with history of stroke.

      Data Extraction

      Outcome data were pooled according to assessment timing (ie, 4-8wk and 12wk after injection), and categorized into 6 main clinical goals (ie, spasticity-related pain, involuntary movements, passive joint motion, care ability, arm and hand use, and standing and walking performance). Sensitivity analyses were performed for the influence of study and intervention characteristics, involvement of pharmaceutical industry, and publication bias.

      Data Synthesis

      Robust evidence is shown for the effectiveness of BoNT in reducing resistance to passive movement, as measured with the (Modified) Ashworth Score, and improving self-care ability for the affected hand and arm after intervention (P<.005) and at follow-up (P<.005). In addition, robust evidence is shown for the absence of effect on arm-hand capacity at follow-up. BoNT was found to significantly reduce involuntary movements, spasticity-related pain, and caregiver burden, and improve passive range of motion, while no evidence was found for arm and hand use after intervention.

      Conclusions

      In view of the robustness of current evidence, no further trials are needed to investigate BoNT for its favorable effects on resistance to passive movement of the spastic wrist and fingers, and on self-care. No trials are needed to further confirm the lack of effects of BoNT on arm-hand capacity, whereas additional trials are needed to establish the suggested favorable effects of BoNT on other body functions, which may result in clinically meaningful outcomes at activity and participation levels.

      Keywords

      List of abbreviations:

      ARAT (Action Research Arm Test), AS (Ashworth Scale), BoNT (botulinum toxin), CI (confidence interval), ICF (International Classification of Functioning, Disability and Health), MAS (Modified Ashworth Scale), MD (mean difference), PEDro (Physiotherapy Evidence Database), pROM (passive range of motion), RCT (randomized controlled trial), SES (summary effect size), SMD (standardized mean difference)
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