Advertisement

Poststroke Postural Sway Improved by Botulinum Toxin: A Multicenter Randomized Double-blind Controlled Trial

Published:August 27, 2019DOI:https://doi.org/10.1016/j.apmr.2019.04.024

      Abstract

      Objective

      To assess the effects of injecting botulinum toxin into the lower limb muscles of people with hemiparesis post stroke in terms of their sway areas.

      Design

      A multicenter randomized double-blind trial on the effects of active botulinum toxin treatment vs placebo.

      Setting

      Clinical examinations and postural sway assessments were performed before botulinum toxin injection and again 4-6 weeks after the injection.

      Participants

      People with hemiparesis with chronic post stroke lower limb spasticity (N=40).

      Interventions

      Intramuscular injection of a placebo (physiological serum) was performed on the control group, and botulinum toxin injections were performed on the treatment group. Participants and physical and rehabilitation medicine specialists were given no information as to which of the 2 treatments was applied.

      Main Outcome Measures

      The sway area of the center of pressure was recorded for 30 seconds in 3 conditions: eyes open, eyes open in a dual task (a postural control task combined with an arithmetic task), and eyes closed. Spasticity was measured using the Modified Ashworth Scale.

      Results

      Forty people post stroke were enrolled and randomized into 2 groups, one of which was treated with botulinum toxin (n=19) and the other with placebo (n=21). Spasticity decreased significantly in the treatment group (−0.7, P=.049 in the soleus muscles; −0.8, P=.035 in the gastrocnemii muscles). The sway area did not differ significantly between the 2 groups before treatment. The most conspicuous effect was observed in the case of the dual task, where a significant decrease (P=.005) in the sway area occurred in the treatment group (−3.11±6.92) in comparison with the placebo group (+0.27±3.57).

      Conclusion

      Treating spasticity by injecting botulinum toxin into people’s lower limb muscles post stroke seems to improve their postural sway. The dual task used here to assess sway seems to be a useful, sensitive test for this purpose.

      Keywords

      List of abbreviations:

      BTX-A (botulinum toxin type A), FAC (Functional Ambulation Classification), MAS (Modified Ashworth Scale), PRM (physical and rehabilitation medicine)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Feigin V.L.
        • Forouzanfar M.H.
        • Krishnamurthi R.
        • et al.
        Global and regional burden of stroke during 1990-2010: findings from the Global Burden of Disease Study 2010.
        Lancet. 2014; 383: 245-255
        • Paul S.L.
        • Srikanth V.K.
        • Thrift A.G.
        The large and growing burden of stroke.
        Curr Drug Targets. 2007; 8: 786-793
        • Wissel J.
        • Ward A.B.
        • Erztgaard P.
        • et al.
        European consensus table on the use of botulinum toxin type A in adult spasticity.
        J Rehabil Med. 2009; 41: 13-25
        • Ward A.B.
        • Aguilar M.
        • Beyl Z.D.
        • et al.
        Use of botulinum toxin type A in management of adult spasticity-a European consensus statement.
        J Rehabil Med. 2003; 35: 98-99
        • Maeda N.
        • Kato J.
        • Shimada T.
        Predicting the probability for fall incidence in stroke patients using the Berg Balance Scale.
        J Int Med Res. 2009; 37: 697-704
        • de Haart M.
        • Geurts A.C.
        • Huidekoper S.C.
        • Fasotti L.
        • van Limbeek J.
        Recovery of standing balance in postacute stroke patients: a rehabilitation cohort study.
        Arch Phys Med Rehabil. 2004; 85: 886-895
        • Geurts A.C.
        • de Haart M.
        • van Nes I.J.
        • Duysens J.
        A review of standing balance recovery from stroke.
        Gait Posture. 2005; 22: 267-281
        • Phadke C.P.
        • Ismail F.
        • Boulias C.
        • Gage W.
        • Mochizuki G.
        The impact of post-stroke spasticity and botulinum toxin on standing balance: a systematic review.
        Expert Rev Neurother. 2014; 14: 319-327
        • Rahimzadeh Khiabani R.
        • Mochizuki G.
        • Ismail F.
        • Boulias C.
        • Phadke C.P.
        • Gage W.H.
        Impact of spasticity on balance control during quiet standing in persons after stroke.
        Stroke Res Treat. 2017; 2017: 6153714
        • Burbaud P.
        • Wiart L.
        • Dubos J.
        • et al.
        A randomised, double blind, placebo controlled trial of botulinum toxin in the treatment of spastic foot in hemiparetic patients.
        J Neurol Neurosurg Psychiatry. 1996; 61: 265-269
        • Pittock S.J.
        • Moore A.
        • Hardiman O.
        • et al.
        A double-blind randomised placebo-controlled evaluation of three doses of botulinum toxin type A (Dysport®) in the treatment of spastic equinovarus deformity after stroke.
        Cerebrovasc Dis. 2003; 15: 289-300
        • Kaji R.
        • Osako Y.
        • Suyama K.
        • Maeda T.
        • Uechi Y.
        • Iwasaki M.
        Botulinum toxin type A in post-stroke lower limb spasticity: a multicenter, double-blind, placebo-controlled trial.
        J Neurol. 2010; 257: 1330-1337
        • Foley N.
        • Murie-Fernandez M.
        • Speechley M.
        • Salter K.
        • Sequeira K.
        • Teasell R.
        Does the treatment of spastic equinovarus deformity following stroke with botulinum toxin increase gait velocity? A systematic review and meta-analysis.
        Eur J Neurol. 2010; 17: 1419-1427
        • Cioni M.
        • Esquenazi A.
        • Hirai B.
        Effects of botulinum toxin-A on gait velocity, step length, and base of support of patients with dynamic equinovarus foot.
        Am J Phys Med Rehabil. 2006; 85: 600-606
        • Hesse S.
        • Jahnke M.
        • Luecke D.
        • Mauritz K.
        Short-term electrical stimulation enhances the effectiveness of botulinum toxin in the treatment of lower limb spasticity in hemiparetic patients.
        Neurosci Lett. 1995; 201: 37-40
        • Nardone A.
        • Galante M.
        • Lucas B.
        • Schieppati M.
        Stance control is not affected by paresis and reflex hyperexcitability: the case of spastic patients.
        J Neurol Neurosurg Psychiatry. 2001; 70: 635-643
        • Rousseaux M.
        • Compère S.
        • Launay M.J.
        • Kozlowski O.
        Variability and predictability of functional efficacy of botulinum toxin injection in leg spastic muscles.
        J Neurol Sci. 2005; 232: 51-57
        • Rousseaux M.
        • Buisset N.
        • Daveluy W.
        • Kozlowski O.
        • Blond S.
        Comparison of botulinum toxin injection and neurotomy in patients with distal lower limb spasticity.
        Eur J Neurol. 2008; 15: 506-511
        • Bhakta B.
        • Cozens J.
        • Bamford J.
        • Chamberlain M.
        Use of botulinum toxin in stroke patients with severe upper limb spasticity.
        J Neurol Neurosurg Psychiatry. 1996; 61: 30-35
        • Viriyavejakul A.
        • Vachalathiti R.
        • Poungvarin N.
        Botulinum treatment for post-stroke spasticity: low dose regime.
        J Med Assoc Thail Chotmaihet Thangphaet. 1998; 81: 413-422
        • Jiang L.
        • Wei X.
        • Dou Z.
        • et al.
        Clinical effect of ultrasound combined with anatomy-measure guidance botulinum toxin type A injection in poststroke patients with spasticity.
        Zhonghua Yi Xue Za Zhi. 2012; 92: 1045-1048
        • Trappier T.
        • Bensoussan L.
        • Milhe V.
        • Viton J.
        • Delarque A.
        [Influence of treatment with botulinum toxine after stroke to control posture] [French].
        Ann Readapt Med Phys. 2006; 49: 155-165
        • Bensoussan L.
        • Viton J.M.
        • Schieppati M.
        • et al.
        Changes in postural control in hemiplegic patients after stroke performing a dual task.
        Arch Phys Med Rehabil. 2007; 88: 1009-1015
        • Yelnik A.P.
        • Simon O.
        • Parratte B.
        • Gracies J.M.
        How to clinically assess and treat muscle overactivity in spastic paresis.
        J Rehabil Med. 2010; 42: 801-807
        • Pang M.Y.
        • Eng J.J.
        Fall-related self-efficacy, not balance and mobility performance, is related to accidental falls in chronic stroke survivors with low bone mineral density.
        Osteoporos Int. 2008; 19: 919-927
        • Cakar E.
        • Durmus O.
        • Tekin L.
        • Dincer U.
        • Kiralp M.
        The ankle-foot orthosis improves balance and reduces fall risk of chronic spastic hemiparetic patients.
        Eur J Phys Rehabil Med. 2010; 46: 363-368
        • Mori T.
        • Takeuchi N.
        • Izumi S.I.
        Prefrontal cortex activation during a dual task in patients with stroke.
        Gait Posture. 2018; 59: 193-198
        • Yang L.
        • Lam F.
        • Huang M.
        • He C.
        • Pang M.
        Dual-task mobility among individuals with chronic stroke: changes in cognitive-motor interference patterns and relationship to difficulty level of mobility and cognitive tasks.
        Eur J Phys Rehabil Med. 2018; 54: 526-535
        • Al-Yahya E.
        • Johansen-Berg H.
        • Kischka U.
        • Zarei M.
        • Cockburn J.
        • Dawes H.
        Prefrontal cortex activation while walking under dual-task conditions in stroke: a multimodal imaging study.
        Neurorehabil Neural Repair. 2016; 30: 591-599
        • Collette F.
        • Olivier L.
        • Van der Linden M.
        • et al.
        Involvement of both prefrontal and inferior parietal cortex in dual-task performance.
        Cogn Brain Res. 2005; 24: 237-251