Monday, July 22nd, 2013
Muscle spasticity is a negative symptom which can occur following a central nervous system disorder (Kinnear, 2012). The use of Botulinum Toxin Type A (BTX-A), commonly referred to as Botox, is used extensively in the treatment of muscle spasticity following stroke and other neurological conditions. Following BTX-A injections, physical and occupational therapy are typically provided and include stretching, casting, splinting, strengthening, and functional movement retraining (Kinnear, 2012).
Having provided the above types of occupational therapy interventions with numerous individuals who have received Botox injections to the UE, I have formulated my own opinions as to the functional benefits of Botox injections in the UE. I recently did a literature review to find out what the research reports.
Van Kuijk, Geurts, Bevaart, and van Limbeek (2002) completed a systematic review of studies published from January 1996 through to October 2000. The results of the review support the efficacy of BTX-A on tone reduction and on improving passive range of motion which results in improved positioning and care of the involved UE. One study indicated that clients reported that their arm was more relaxed with ambulation after receiving BTX-A injections to the elbow flexors, however, there was no clear effectiveness as to the impact on improved functional hand use with BTX-A.
The results of the above systematic review support my own observations. With therapy following BTX-A injections, increased passive range of motion, improved positioning, decreased pain, and improved ability to care for the UE were achieved, but I did not see specific improved hand function with BTX-A injections to the extrinsic or intrinsic hand muscles.
The above systematic review indicated that one study found superior outcomes utilizing BTX-A in combination with electrical stimulation and the authors recommended that larger controlled studies to compare the effectiveness of different and/or combined treatment interventions for spasticity was warranted.
Two studies were found that assessed the effectiveness of BTX-A in the elbow, wrist, and hand in combination with modified constraint induced movement therapy (mCIMT). All participants were required to meet the minimum wrist and finger active extension requirements before participating in the study. Sun, Hsu, Sun, Hwang, Yang, and Wang (2010) compared the effectiveness of BTX-A with mCIMT versus BTX-A with NDT. Wolf, Milton, Reiss, Easley, Shenvi, and Clark (2012) compared the effectiveness of mCIMT with and without BTX-A. Results of both studies indicated that all those who received the BTX-A had less spasticity. Wolf, Milton, Reiss et al. (2012) concluded that BTX-A results in decreased tone, pain, and improved positioning but a combination of BTX-A with mCIMT versus mCIMT alone does not contribute to increased UE function in chronic stroke survivors. Sun, Hsu, Sun et al. (2010) reported no differences in spasticity between the two groups at one and 3 months, but the experimental group, who received BTX-A and mCIMT, continued to have decreased tone in the elbow, wrist, and hand as well as increased scores on the Action Research Arm Test (ARAT) and Motor Activity Log (MAL) and increased use of the UE at a 6 month follow compared to the group that received BTX-A and NDT. Sun, Hsu, Sun, et al. (2010) also identified the need to assess other potential treatment combinations.
One study has been found that compares the effectiveness of the combined use of BTX-A and manual therapy both with and without the adjunctive use of dynamic splinting on the elbow (Lai, Francisco, & Willis, 2009). Active elbow range of motion and tone, as measured by the Modified Ashworth Score, were measured. The results indicated that the experimental group with the combined the use of adjunctive dynamic splinting, demonstrated a mean 33.5% improvement in AROM and a mean 9.3% improvement on the MAS scores as compared to 18.7% and 8.6% respectively in the control group who did not utilize adjunctive dynamic splinting.
All studies have indicated that BTX-A is effective in managing tone and improving range of motion, however, adjunctive treatments are also necessary to optimize functional improvements with electrical stimulation, dynamic splinting, and repetitive, functional retraining (mCIMT) showing more promising results. All studies recommended categorizing participants based on impairment severity level in order to assess the ability to predict who would benefit most from what type of interventions.
Though no formal study has been completed to date on the use of BTX-A in combination with dynamic hand splinting, you can view a single session video of an individual incorporating the use of the SaeboFlex dynamic hand orthoses after having received BTX-A in the extrinsic finger flexors 7-10 days prior by clicking the following link:
Shannon Scott, OTR/L, is the Clinical Assistant Professor at Stony Brook University Southampton. She is a graduate of the University of British Columbia in Vancouver, Canada and is currently pursuing her doctorate in OT through Quinnipiac University. She has over 23 years of clinical experience, specializing in Neurorehabilitation. She is Level One Brain Injury Certified and is NDT trained. Shannon was one of the first 10 therapists trained in the use of Saebo. Prior to teaching at Stony Brook, Shannon was the Director of Clinical Services at Saebo.
Kinnear, B. Z. (2012). Physical therapies as an adjunct to Botulinum toxin-A injection of the upper and lower limb in adults following neurological impairment. Systematic Reviews, 1:29.
Lai, J.M., Francisco, G. E., & Willis, F. B. (2009). Dynamic splinting after treatment with botulinum toxin type A: a randomized controlled pilot study. Adv Ther 26(2), 241-248.
Sun, S., Hsu, C., Sun, H., Hwang, C., Yang, C., & Wang, J. (2010). Combined botulinum toxin type A with modified constraint-induced movement therapy for chronic stroke patients with upper extremity spasticity: A randomized controlled study. Neurorehabil Neural Repair, 24 (1), 34-41.
Van Kuijk, A.A., Geurts, A.C., Bevaart, B.J., & van Limbeek, J. (2002). Treatment of upper extremity spasticity in stroke patients by focal neuronal or neuromuscular blockade: a systematic review of the literature. J Rehabil Med 34, 51-61.
Wolf, S. L, Milton, B., Reiss, A., Easley, K. A., Shenvi, N. V., & Clark, P. C. (2012). Further assessment to determine the additive effect of botulinum toxin type A on an upper extremity exercise to enhance function among individuals with chronic stroke but extensor capability. Arch Phys Med Rehabil, 93, 578-587.
Whether you are a caregiver, occupational therapist or even a stroke survivor yourself, Saebo provides stroke survivors young or old access to transformative and life changing products. We pride ourselves on providing affordable, easily accessible, and cutting-edge solutions to people suffering from impaired mobility and function. We have several products to help with the stroke recovery and rehabilitation process. From the SaeboFlex, which allows clients to incorporate their hand functionally in therapy or at home, to the SaeboMAS, an unweighting device used to assist the arm during daily living tasks and exercise training, we are commitment to helping create innovative products for stroke recovery. Check out all of our product offerings or let us help you find which product is right for you.