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)To read this article in full you will need to make a payment
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Article Info
Publication History
Published online: February 20, 2019
Footnotes
Supported by the European Research Council (grant no. 291339 , 4D-EEG project) and the Netherlands Organisation for Health Research and Development (ZonMw grant no. 104003008 , PROFITS program). The funders had no role in study design, data collection, data analysis, data interpretation, or the writing of the report. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication.
Disclosures: none.
Identification
Copyright
© 2019 by the American Congress of Rehabilitation Medicine
