Clinimetric Properties of the Motor Activity Log for the Assessment of Arm Use in Hemiparetic Patients Botulinum Toxin for the Upper Limb After Stroke (BoTULS) Trial: Effect on Impairment, Activity Limitation, and Pain Effect of constraint-induced movement therapy on upper extremity function 3 to 9 months after stroke: the EXCITE randomized clinical trial. Low-dose botulinum toxin with ankle taping for the treatment of spastic equinovarus foot after stroke. Reliability of the Modified Tardieu Scale and the Modified Ashworth Scale in adult patients with severe brain injury: a comparison study A single-blinded, randomized pilot study of botulinum toxin type A combined with non-pharmacological treatment for spastic foot. Botulinum toxin type A for upper limb spasticity following stroke: an open-label study with individualised, flexible injection regimens Rationale and design of a multicentre, double-blind, prospective, randomized, European and Canadian study: evaluating patient outcomes and costs of managing adults with post-stroke focal spasticity. Dose-dependent response to intramuscular botulinum toxin type A for upper-limb spasticity in patients after a stroke. Combined effects of botulinum toxin and casting treatments on lower limb spasticity after stroke. Casting, taping or stretching after botulinum toxin type A for spastic equinus foot: a single-blind randomized trial on adult stroke patients Short-term electrical stimulation enhances the effectiveness of Botulinum toxin in the treatment of lower limb spasticity in hemiparetic patients Efficacy of botulinum toxin A in upper limb function of hemiplegic patients Botulinum toxin type A and short-term electrical stimulation in the treatment of upper limb flexor spasticity after stroke: a randomized, double-blind, placebo-controlled trial Botulinum Toxin A, Evidence-Based Exercise Therapy, and Constraint-Induced Movement Therapy for Upper-Limb Hemiparesis Attributable to Stroke: A Preliminary Study Impact of botulinum toxin type A on disability and carer burden due to arm spasticity after stroke: a randomised double blind placebo controlled trial Low-Dose Botulinum Toxin with Short-Term Electrical Stimulation in Poststroke Spastic Drop Foot: A Preliminary Study A randomized controlled trial of botulinum toxin on lower limb spasticity following acute acquired severe brain injury Goal attainment scaling: A general method for evaluating comprehensive community mental health programs The effect of combined use of botulinum toxin type A and functional electric stimulation in the treatment of spastic drop foot after stroke: a preliminary investigation. Functional electrical stimulation combined with botulinum toxin type A to improve hand function in children with spastic hemiparesis – a pilot study Is botulinum toxin type A effective in the treatment of spastic shoulder pain in patients after stroke? A double-blind randomized clinical trial. Goal attainment scaling in the evaluation of treatment of upper limb spasticity with botulinum toxin: a secondary analysis from a double-blind placebo-controlled randomized clinical trial. A preliminary assessment of the benefits of the addition of botulinum toxin a to a conventional therapy program on the function of people with longstanding stroke. Applying the clinical practice improvement approach to stroke rehabilitation: methods used and baseline results. Combined Botulinum Toxin Type A With Modified Constraint-Induced Movement Therapy for Chronic Stroke Patients With Upper Extremity Spasticity: A Randomized Controlled Study Intramuscular injection of botulinum toxin for the treatment of wrist and finger spasticity after a stroke. Dynamic splinting after treatment with botulinum toxin type-A: A randomized controlled pilot study Cyclic functional electrical stimulation does not enhance gains in hand grasp function when used as an adjunct to onabotulinumtoxinA and task practice therapy: a single-blind, randomized controlled pilot study. The Role of Kinesiotaping Combined With Botulinum Toxin to Reduce Plantar Flexors Spasticity After Stroke Botulinum toxin A for treatment of upper limb spasticity following stroke: a multi-centre randomized placebo-controlled study of the effects on quality of life and other person-centred outcomes.
Background and Purpose — The Motor Activity Log ( MAL ) is a semistructured interview for hemiparetic stroke patients to assess the use of their paretic arm and h and ( amount of use [ AOU ] ) and quality of movement [ QOM ] ) during activities of daily living . Scores range from 0 to 5 . The following clinimetric properties of the MAL were quantified : internal consistency ( Cronbach α ) , test – retest agreement ( Bl and and Altman method ) , cross-sectional construct validity ( correlation between AOU and QOM and with the Action Research Arm [ ARA ] test ) , longitudinal construct validity ( correlation of change on the MAL during the intervention with a global change rating [ GCR ] and with change on the ARA ) , and responsiveness ( effect size ) . Methods — Two baseline measurements 2 weeks apart and 1 follow-up measurement immediately after 2 weeks of intensive exercise therapy either with or without immobilization of the unimpaired arm ( forced use ) were performed in 56 chronic stroke patients . Results — Internal consistency was high ( AOU : α=0.88 ; QOM : α=0.91 ) . The limits of agreement were −0.70 to 0.85 and −0.61 to 0.71 for AOU and QOM , respectively . The correlation with the ARA score ( Spearman ρ ) was 0.63 ( AOU and QOM ) . However , the improvement on the MAL during the intervention was only weakly related to the GCR and to the improvement on the ARA , Spearman ρ was between 0.16 and 0.22 . The responsiveness ratio was 1.9 ( AOU ) and 2.0 ( QOM ) . Conclusion — The MAL is internally consistent and relatively stable in chronic stroke patients not undergoing an intervention . The cross-sectional construct validity of the MAL is reasonable , but the results raise doubt about its longitudinal construct validity Background and Purpose — Botulinum toxin is increasingly used to treat upper limb spasticity due to stroke , but its impact on arm function is unclear . We evaluated botulinum toxin for upper limb spasticity and function poststroke . Methods — Three hundred thirty-three patients with stroke with upper limb spasticity and reduced arm function participated in a multicenter r and omized controlled trial . The intervention group received botulinum toxin type A injection(s ) plus a 4-week therapy program . The control group received the therapy program alone . Repeat injection(s ) and therapy were available at 3 , 6 , and 9 months . The primary outcome was upper limb function at 1 month ( Action Research Arm Test ) . Secondary outcomes included measures of impairment , activity limitation , and pain at 1 , 3 , and 12 months . Outcome assessment s were blinded and analysis was by intention to treat . Results — There was no significant difference in achievement of improved arm function ( Action Research Arm Test ) at 1 month ( intervention group : 42 of 167 [ 25.1 % ] , control group 30 of 154 [ 19.5 % ] ; P=0.232 ) . Significant differences in favor of the intervention group were seen in muscle tone at 1 month ; upper limb strength at 3 months ; basic arm functional tasks ( h and hygiene , facilitation of dressing ) at 1 , 3 , and 12 months ; and pain at 12 months . Conclusions — Botulinum toxin type A is unlikely to be useful for improving active upper limb function ( eg , reaching and grasping ) in the majority of patients with spasticity after stroke , but it may improve basic upper limb tasks ( h and hygiene , facilitation of dressing ) and pain CONTEXT Single-site studies suggest that a 2-week program of constraint-induced movement therapy ( CIMT ) for patients more than 1 year after stroke who maintain some h and and wrist movement can improve upper extremity function that persists for at least 1 year . OBJECTIVE To compare the effects of a 2-week multisite program of CIMT vs usual and customary care on improvement in upper extremity function among patients who had a first stroke within the previous 3 to 9 months . DESIGN AND SETTING The Extremity Constraint Induced Therapy Evaluation ( EXCITE ) trial , a prospect i ve , single-blind , r and omized , multisite clinical trial conducted at 7 US academic institutions between January 2001 and January 2003 . PARTICIPANTS Two hundred twenty-two individuals with predominantly ischemic stroke . INTERVENTIONS Participants were assigned to receive either CIMT ( n = 106 ; wearing a restraining mitt on the less-affected h and while engaging in repetitive task practice and behavioral shaping with the hemiplegic h and ) or usual and customary care ( n = 116 ; ranging from no treatment after concluding formal rehabilitation to pharmacologic or physiotherapeutic interventions ) ; patients were stratified by sex , prestroke dominant side , side of stroke , and level of paretic arm function . MAIN OUTCOME MEASURES The Wolf Motor Function Test ( WMFT ) , a measure of laboratory time and strength-based ability and quality of movement ( functional ability ) , and the Motor Activity Log ( MAL ) , a measure of how well and how often 30 common daily activities are performed . RESULTS From baseline to 12 months , the CIMT group showed greater improvements than the control group in both the WMFT Performance Time ( decrease in mean time from 19.3 seconds to 9.3 seconds [ 52 % reduction ] vs from 24.0 seconds to 17.7 seconds [ 26 % reduction ] ; between-group difference , 34 % [ 95 % confidence interval { CI } , 12%-51 % ] ; P<.001 ) and in the MAL Amount of Use ( on a 0 - 5 scale , increase from 1.21 to 2.13 vs from 1.15 to 1.65 ; between-group difference , 0.43 [ 95 % CI , 0.05 - 0.80 ] ; P<.001 ) and MAL Quality of Movement ( on a 0 - 5 scale , increase from 1.26 to 2.23 vs 1.18 to 1.66 ; between-group difference , 0.48 [ 95 % CI , 0.13 - 0.84 ] ; P<.001 ) . The CIMT group achieved a decrease of 19.5 in self-perceived h and function difficulty ( Stroke Impact Scale h and domain ) vs a decrease of 10.1 for the control group ( between-group difference , 9.42 [ 95 % CI , 0.27 - 18.57 ] ; P=.05 ) . CONCLUSION Among patients who had a stroke within the previous 3 to 9 months , CIMT produced statistically significant and clinical ly relevant improvements in arm motor function that persisted for at least 1 year . Trial Registration clinical trials.gov Identifier : NCT00057018 OBJECTIVE To evaluate the efficacy of a combined treatment for spastic foot using selective injections of botulinum toxin ( BTA ) into the tibialis posterior muscle followed by ankle taping , and to compare it with current BTA treatment procedure . DESIGN Single-blind r and omized control trial . Three-month follow-up after treatment . SETTING Neurorehabilitation clinic . SUBJECTS Eighteen out patients with equinovarus foot due to severe spasticity after stroke . INTERVENTIONS ( 1 ) Injection of 190 to 320 BTA U into several calf muscles ( group A ) ; ( 2 ) injection of 100 BTA U into the tibialis posterior muscle , followed by ankle-foot taping ( group B ) . MAIN OUTCOME MEASURES Ankle range of motion ( ROM ) , Ashworth scale , gait velocity , and step length . RESULTS Average Ashworth scores decreased 1 point in both groups , but the benefit appeared of shorter duration in group B. Changes in both foot position at rest and passive ankle ROM were observed in all patients , without treatment-related differences , except for gain in passive dorsiflexion that appeared higher in group A. Gait velocity and step length showed similar increases in both groups . CONCLUSION The combination of selective injections of low BTA doses with ankle-foot taping is as effective as the injection of the current doses for the reduction of foot inversion with positive effects on gait parameters Objective : To assess and to compare the reliability of the Modified Tardieu Scale with the Modified Ashworth Scale in patients with severe brain injury and impaired consciousness . Design : Cross-sectional observational comparison study . Setting : An early rehabilitation centre for adults with neurological disorders . Subjects : Thirty patients with impaired consciousness due to severe cerebral damage of various aetiologies . Measurement protocol : Four experienced physical therapists rated each patient in a r and omized order once daily for two consecutive days . Shoulder , elbow , wrist , hip , knee and ankle spasticity were assessed by the use of Modified Tardieu Scale and Modified Ashworth Scale data collection procedures . Main outcome measures : Test - retest and inter-rater reliability ( k = kappa value ) of the Modified Tardieu Scale and the Modified Ashworth Scale .  Results : The test-retest reliability of the Modified Ashworth Scale was moderate to good ( k = 0.47 - 0.62 ) and of the Modified Tardieu Scale moderate to very good ( k = 0.52 - 0.87 ) . Test - retest reliability was significantly higher within the Modified Tardieu Scale in comparison with the Modified Ashworth Scale ( Z<1.96 ; p<0.05 ) except for shoulder extensor and internal rotator muscles ( Z<1.96 ; p<0.05 ) . Although inter-rater reliability of both scales was poor to moderate ( Modified Ashworth Scale : k = 0.16 - 0.42 ; Modified Tardieu Scale : k = 0.29 - 0.53 ) , significantly higher k-values were revealed with the Modified Tardieu Scale for all tested muscle groups ( Z<1.96 ; p<0.05 ) except for wrist extensors ( Z<1.96 ; p<0.05 ) . Conclusion : In patients with severe brain injury and impaired consciousness the Modified Tardieu Scale provides higher test-retest and inter-rater reliability compared with the Modified Ashworth  Scale and may therefore be a more valid spasticity scale in adults OBJECTIVE To explore the effect of treatment after botulinum toxin type A combined with treatments for the spastic foot . DESIGN Single-blind , r and omized trial , with 3-month follow-up . SUBJECTS Twenty-three chronic hemiplegic adult patients with spastic equinus foot . METHODS Following botulinum toxin type A injection at the medial and lateral gastrocnemius , patients were assigned r and omly to 3 groups , and treated with taping , electrical stimulation or stretching . They were evaluated before treatment ( t0 ) , and at 10 ( t1 ) , 20 ( t2 ) and 90 ( t3 ) days after treatment . Outcome measures were : Modified Ashworth Scale ; passive range of motion at the ankle ; measurement of muscle action potential at the gastrocnemius medialis ; and measurement of maximum ankle dorsiflexion angle in stance using gait analysis . RESULTS The group treated with electrical stimulation performed better at t1 on the Modified Ashworth Scale . The taping and electrical stimulation groups performed better in all outcome measures at t3 . The taping group performed better mainly for maximum ankle dorsiflexion angle in stance . The stretching group showed a less durable result , with some worsening at the t3 evaluation compared with the assessment performed before treatment . CONCLUSIONS This pilot study indicates that combining botulinum toxin type A administration for the ankle plantar flexors with taping and electrical stimulation might be beneficial Current antispastic medications are unsatisfactory for spasticity treatment , but botulinum toxin type A ( BTX-A ) shows promise as a new therapeutic option . This open-label , prospect i ve study aim ed to assess the effectiveness of BTX-A in improving functional mobility in the early post-stroke population using an individualised , flexible range of doses and targeted muscle groups . Twenty-one stroke patients ( 13 male , 8 female ) were enrolled and injected with BTX-A ( Botox , Allergan , mean dose : 255 U ; range : 185–300 ) according to individual spasticity patterns . Assessment s were made at baseline and weeks 2 , 4 , 6 , 10 and 16 post-treatment . Outcome measures comprised : Modified Ashworth Scale ( MAS ) , finger flexion scale ( Bhakta ) , MRC scale , Physician ’s Rating Scale ( PRS ) , Nine Hole Peg Test ( 9HPT ) , Motor Assessment Scale , Clinical Global Impression ( CGI ) , Global Assessment of Spasticity ( GASS ) and Visual Analogue Scale ( VAS ) for pain assessment . Statistically significant improvements in muscle tone as determined by the MAS were found in all areas ( except arm ) till week 16 ( p<0.05 ) . Finger positioning improved for the study duration , whilst muscle power increased only slightly in specific muscles . PRS revealed significant improvements to week 10 and slight improvement in 9HPT performance in selected patients was observed . Motor Assessment Scale results were statistically significant for arm , h and and advanced h and functions , although the overall functional benefit was mild . GASS and CGI results also showed improvement . Pain was present only in 11 patients and did not significantly improve following treatment . Individualised BTX-A injection regimens may be an effective , reversible and safe new treatment option for patients with spasticity . Nevertheless , functional improvement may be reached only in selected patients OBJECTIVE This report describes the design of a study aim ing to provide evidence for the extended use of botulinum toxin A in focal post-stroke upper and lower limb spasticity and to evaluate the impact of incorporating botulinum toxin treatment into the rehabilitation of patients with spasticity . DESIGN International , prospect i ve , r and omized , double-blind , placebo-controlled study with an open-label extension . METHODS Approximately 300 adults with a stroke occurring ≥ 3 months before screening , presenting with symptoms and signs of an upper motor neuron syndrome and focal spasticity-related functional impairment , were r and omized to botulinum toxin ( BOTOX ® , Allergan Inc. ) + st and ard care or placebo + st and ard care . Study medication was administered at baseline and again at Week 12 if required , with follow-up to 52 weeks . The primary endpoint was the number of patients who achieved their investigator-rated principal active functional goal ( as measured by Goal Attainment Scaling ) , at 10 weeks after the second injection ( Weeks 22 - 34 ) or at the 24-week visit if no second injection was administered . Secondary endpoints included changes from baseline in level of goal achievement , health-related quality of life and re source utilization . CONCLUSION Botulinum toxin A Economic Spasticity Trial ( BEST ) will provide information regarding clinical and cost-effectiveness of botulinum toxin + st and ard care vs st and ard care alone in patients with upper and /or lower limb post-stroke spasticity typically seen in clinical practice . TRIAL REGISTRATION Clinical Trials.gov number NCT-00549783 OBJECTIVE To test the hypothesis that intramuscular ( IM ) botulinum toxin type A ( BTX ) reduces excessive muscle tone in a dose-dependent manner in the elbow , wrist , and fingers of patients who experience spasticity after a stroke . DESIGN R and omized , double-blind , placebo-controlled , multicenter , 24-week trial . SETTING Six academic and 13 private US outpatient medical centers . PARTICIPANTS Ninety-one patients with a mean age of 60 years ( range , 30 - 79 y ) . Mean time elapsed from ischemic or hemorrhagic stroke to study enrollment was 25.8 months ( range , 0.9 - 226.9 mo ) . INTERVENTIONS Up to 2 treatments of placebo , or 90 , 180 , or 360U of BTX . Concurrent splinting and physical therapy protocol s were permitted , but no changes were allowed during the study . MAIN OUTCOME MEASURES Wrist , elbow , and finger flexor tone assessed by the Modified Ashworth Scale , physician and patient global assessment s , pain , FIM instrument , and Medical Outcomes Study 36-Item Short-Form Health Survey ( SF-36 ) . RESULTS Muscle tone decreased more with injections of BTX than with placebo in the wrist flexors at weeks 1 , 2 , 3 , 6 , and 9 ( P < or = .026 ) ; in the elbow flexors at weeks 1 , 2 , 3 , 4 , 5 , and 9 ( P < or = .033 ) ; and in the finger flexors at weeks 1 and 3 ( P < or = .031 ) . A dose-dependent response was generally observed in tone reduction but not in pain , FIM , or SF-36 measures . CONCLUSIONS IM BTX reduced muscle tone in a dose-dependent manner in the elbow , wrist , and fingers of patients who experience spasticity after a stroke but did not appear to affect global quality of life or disability Optimal treatment of spasticity requires a combination of pharmacotherapy and muscle lengthening . We evaluated 13 stroke patients with equinovarus foot r and omized to treatment with either botulinum toxin A ( BTA ) injection plus ankle-foot casting ( n=6 ) or BTA alone ( n=7 ) . The tibialis posterior and calf muscles ( range of BTA injection : 190 to 320 U ) were treated in each patient . Castings were worn at night for four months . Each patient was examined before , and at two and four months after BTA injection using the static and dynamic baropodometric tests , the Modified Ashworth Scale and the 10-meter walking test . At two months , therapeutic effects were observed in both groups . At four months , the study group showed further clinical improvement , while the control group returned to baseline performance . Thus , prolonged stretching of spastic muscles after BTA injection affords long-lasting therapeutic benefit , enhancing the effects of the toxin alone Objective : To investigate the effect of different adjunctive treatments after botulinum toxin type A. Design : Single-blind , r and omized trial , with three-month follow-up . Setting : Secondary rehabilitative care . Subjects : Convenience sample of 69 chronic hemiplegic adult patients with spastic equinus foot . Interventions : Following botulinum toxin type A injection at the plantar flexors , patients were r and omly assigned to three groups and treated with either taping , casting or stretching for one week , and with stretching and gait training for the next week . Outcome measures : Modified Ashworth Scale at plantar flexors , passive range of motion at the ankle , six-minute walking test , 10-metre walking test , Functional Ambulation Categories , ankle dorsiflexor strength were evaluated before treatment ( t0 ) at 20 days ( t1 ) and 90 days ( t2 ) after treatment . Results : At t1 only the taping and casting groups showed significant improvements in Modified Ashworth Scale , six-minute walking test , 10-metre walking test and passive range of motion ( P < 0.02 ) . At t2 , while the results were maintained in the casting group , only six-minute walking test and Modified Ashworth Scale were still significantly improved in the taping group . Ankle dorsiflexor strength and Functional Ambulation Categories did not change in any of the groups at any time . At t2 the casting group performed better than the taping and stretching groups at Modified Ashworth Scale and passive range of motion , and better than the stretching group at six-minute walking test ( P < 0.02 ) . Conclusions : Combining botulinum toxin type A to the ankle plantar flexors with casting or taping gives better and longer lasting results than with stretching alone The study tested the spasmolytic effect of Botulinum toxin A in two groups of hemiparetic patients with lower limb spasticity : in the first group ( n = 5 ) 2000 U Dysport  were injected into the soleus , tibialis posterior and both heads of gastrocnemius muscles alone ; the second ( n = 5 ) received additional repetitive alternating electrical stimulation of M. tibialis anterior and plantar flexors for 30 min six times per day during the 3 days following the injection . Muscle tone , rated by the Ashworth spasticity score , and gait analysis including recording of vertical ground reaction forces , were assessed before and 4 weeks after injection . The combined treatment proved to be more effective with respect to the clinical ly assessed reduction of muscle tone , gait velocity , stride length , stance- and swing-symmetry ( P < 0.05 ) . The result is discussed with reference to animal experiments demonstrating enhanced toxin uptake and accelerated onset of its paralytic effect by electrical stimulation Abstract Botulinum toxin A has been reported to reduce spasticity and increase the comfort of  hemiplegic patients . The aim of this study was to assess the efficacy of the treatment on disability , especially in manual activities , and to attempt to identify predictive factors of improvement . Twenty patients ( mean age : 54.4 years ; M : 14 ; right hemiplegia : 12 ) were included , with a delay of at least three months after unilateral hemispheric stroke .  Botulinum toxin A ( BOTOX ® ) was injected into the arm adductors ( 8 cases ) , forearm flexors ( 17 cases ) , pronators , wrist and finger flexors ( 20 cases ) , with a total dose of 200 to 300 U. Examination ( day 1 and 15 , month 2 and 5 ) consisted of spasticity assessment ( modified Ashworth scale ) , muscle strength , passive range of motion ( goniometry ) , and pain , followed by functional tests , especially the Rivermead Motor Assessment ( RMA ) and Nine-hole Peg Test ( NHPT ) . Performance in daily living was assessed with the Functional Independence Measure ( FIM ) , and an original analysis of h and grasp , grip and pinches used in domestic activities ( 9 items ) , and of comfort of patients and caregivers . Significant reduction in spasticity was observed on the elbow flexors , pronators , wrist and fingers flexors , especially at day 15 ( mean 0.90 to 1 point ) , with wide variations in effect . Muscle strength was increased in wrist and fingers extensors , with concomitant increase in the opening of the thumb to index finger space . There was no effect on the NHPT requiring distal manipulation , but the RMA , which especially concerned picking up and releasing a tennis ball , showed significant improvement . Furthermore , use of the upper limb in daily living increased , particularly for internal grasping of objects , and for grasping by the top , transporting and releasing of objects . Patients and caregivers reported facilitation in dressing , and in proximal and distal care of the upper limb . The global flexor position of the limb improved . Adverse reactions were rare and mostly consisted of transitory pain during injection . The improvement in the RMA was better explained by the quality of the initial motor comm and on distal prehension ( positive correlation with motor strength ) , and that in h and using in domestic activities by a lower level of spasticity on pronators and wrist flexors ( negative correlations with spasticity ) . Conversely , the severity of the motor deficit ( negative correlations with motor strength ) and a high level of spasticity before injection ( positive correlations with spasticity ) mostly explained the improvement in comfort . In conclusion , botulinum toxin A is efficient in improving h and use in patients with relatively preserved distal motricity , and in increasing comfort in patients with severe global disorders Objective : To investigate whether the combined approach of botulinum toxin type A ( BtxA ) and electrical stimulation was more effective than the toxin alone in the treatment of chronic upper limb spasticity after stroke . Design : R and omized , placebo-controlled study with four treatment groups : 1000 units BtxA ( Dysport ® ) + electrical stimulation ( A ) , 1000 units BtxA ( B ) , placebo + electrical stimulation ( C ) and placebo ( D ) . Setting : A neurological rehabilitation clinic . Subjects : Twenty-four stroke patients with chronic upper limb spasticity after stroke , six patients in each treatment group . Interventions : Intramuscular injection of either toxin or placebo into six upper limb flexor muscles . In group A and C additional electrical stimulation of the injected muscles with surface electrodes , three times half an hour each day for three days . Main outcome measures : Muscle tone rated with the modified Ashworth score , limb position at rest and difficulties encountered during three upper limb motor tasks assessed before and 2 , 6 and 12 weeks after injection . Results : Most improvements were observed in patients of group A. Cleaning the palm ( p = 0.004 ) differed across groups . Pairwise comparison for this target variable showed that group A differed from group B and D ( p < 0.01 ) , but not from C. Indicative across-group differences were obtained for elbow spasticity reduction ( p = 0.011 ) , and improvement of putting the arm through a sleeve ( p = 0.020 ) . Conclusions : The placebo-controlled trial favours the conceptthat electrical stimulation enhances the effectiveness of BtxA in the treatment of chronic upper limb flexor spasticity after stroke Levy CE , Giuffrida C , Richards L , Wu S , Davis S , Nadeau SE : Botulinum toxin A , evidence -based exercise therapy , and constraint-induced movement therapy for upper-limb hemiparesis attributable to stroke : a preliminary study . Am J Phys Med Rehabil 2007;86:696–706 Objective : To determine whether the combination of botulinum toxin A ( BTX-A ) treatment for the upper limb and a 4-wk course of exercise therapy could improve motor function sufficiently to allow those with poststroke hemiparesis and spasticity to achieve the minimal motor criteria ( MMC ) to be enrolled in constraint-induced movement therapy ( CIMT ) , and to determine the feasibility of enrolling participants into CIMT if they meet MMC after treatment with a combination of BTX-A plus exercise therapy . Design : Twelve individuals received BTX-A and exercise therapy for 1 hr/day , three times per week , for 4 wks . Those who met MMC were enrolled in 2 wks of CIMT , and the rest received a home exercise program . Outcome measures included the Ashworth Scale , Wolf Motor Function Test ( WMFT ) , the Motor Activity Log ( MAL ) , the Box and Blocks Test ( BBT ) , and the upper-extremity subtest of the Fugl – Meyer Assessment of Motor Function ( FM-UE ) . Results : Ashworth Scale scores declined from a mean score of 2.0–1.2 ( P = 0.01 ) . Four of 12 subjects were able to achieve MMC ( P = 0.026 ) . CIMT participants improved in the BBT , the MAL , and the WMFT compared with their own baseline . Gains achieved during CIMT receded by week 24 as spasticity returned . Conclusion : BTX-A plus exercise therapy shows potential to improve function for those with severe h and paresis and spasticity after stroke . Those who meet MMC may initially realize further modest gains through CIMT . However , gains are likely to recede as spasticity returns . Adding medications or modifying the therapy protocol to include activities such as functional neuromuscular stimulation or robotic training may yield a more potent effect OBJECTIVES After stroke , abnormal arm posture due to spasticity in a functionally useless arm may interfere with self care tasks . In these patients botulinum toxin treatment presents an opportunity to reduce disability . The purpose was to investigate whether reduction in spasticity after botulinum toxin treatment translates into reduction in disability and carer burden . METHODS Forty patients with stroke with spasticity in a functionally useless arm ( median duration 3.1 years ) were r and omised to receive  intramuscular botulinum toxin type A ( BT-A ; Dysport ) ( n=20 ) or placebo ( n=20 ) in a total dose of 1000 MU divided between elbow , wrist , and finger flexors . Spasticity ( using the modified Ashworth scale ) , muscle power , joint movement , and pain were assessed . Disability and carer burden were measured using an eight item and a four item scale respectively . Two baseline and three post-treatment assessment s ( weeks 2 , 6 , and 12 ) were made . Concurrent treatments as far as possible remained unchanged and not optimised . RESULTS Disability improved at week 6 with BT-A compared with placebo . This effect , present at week 2 , wore off by week 12 . Reduction in carer burden was seen at week 6 with BT-A and continued for at least 12 weeks . Forearm flexor spasticity was reduced with BT-A up to 12 weeks after treatment . Although significant improvement in elbow flexor spasticity was seen at week 2 with BT-A compared with placebo , this effect was not evident at weeks 6 and 12 . Arm pain was not improved after BT-A. Grip strength was reduced with BT-A. No serious BT-A related adverse effects were reported . CONCLUSION BT-A is useful for treating patients with stroke who have self care difficulties due to arm spasticity . The decision to treat should also include relief of carer burden . As muscle weakness may occur , its potential impact on functional activities must be assessed before intervention Bayram S , Sivrioglu K , Karli N , Ozcan O : Low-dose botulinum toxin with short-term electrical stimulation in poststroke spastic drop foot : A preliminary study . Am J Phys Med Rehabil 2006;85:75–81 . Objective : To compare low-dose botulinum toxin injections followed by short-term electrical stimulation with high-dose botulinum toxin for poststroke spastic drop foot . Design : Twelve patients with spastic drop foot were r and omly assigned to two treatment groups . The first group ( n = 6 ) received low-dose ( 100 units ) botulinum toxin injection to the posterior tibial muscle in combination with short-term electrical stimulation , and the second group ( n = 6 ) received a total of 400 units of botulinum toxin injections in equal doses to the posterior tibial , soleus , medial , and lateral gastrocnemius muscles . The patients were evaluated before and 2 , 4 , 8 , and 12 wks after the treatment by the following variables : resting position angle , active and passive ankle range of motion , Modified Ashworth Scale , time walking 10 m , clonus score , Brace Wear Scale , and Global Assessment of Spasticity Scale . Results : Improvement was recorded in both groups for all variables except brace wear . No significant difference was found between the study groups after treatment . The effects lasted shorter in the first group , whereas more side effects were seen in the second group . Conclusions : Our preliminary single-blind study was unable to find a difference in terms of effectiveness between low-dose ( 100 units ) botulinum toxin combined with short-term electrical stimulation and high-dose ( 400 units ) application in spastic drop foot Objective : To determine whether serial casting combined with botulinum toxin reduces the development of calf contracture after severe head injury . Design : A double-blind placebo-controlled trial of three parallel treatments for lower limb spasticity . Setting : Acute general hospital in the UK . Subjects : Adults aged 17–70 years admitted to hospital following a severe brain injury . Interventions : Current physical treatment ( group I ) , lower leg casting plus injections with either saline ( group II ) , or with botulinum toxin ( group III ) into gastrocnemius and soleus muscles . Measures : Limit of ankle dorsiflexion at entry and exit after up to 12 weeks , the Glasgow Outcome Scale ( GOS ) and Modified Ashworth Scale ( MAS ) . Results : Two hundred and fifty-three patients were screened and 35 were entered into the trial . Three patients died and four failed to complete the trial . Eighty-eight per cent of those entering the r and omized part of the study developed spasticity within 14 days of their injury and the mean range of improvement in the angle of passive ankle dorsiflexion was 4.598 in controls , 11.698 in cast and saline and 13.598 in cast and botulinum toxin . There were significant improvements in the MAS scores in actively treated groups , but not in controls . Cast and botulinum toxin patients also demonstrated a significant improvement in the GOS . Conclusions : Active intervention with casting prevents talipes equinovarus deformities in patients losing ankle movement following severe brain injury . Casting alone in these patients is sufficient ; the role of additional botulinum toxin needs further investigation , but is safe in these patients A mental health enterprise may be described by either ( a ) rather general philosophical total mental health goals , or ( b ) highly diverse and individualized patient-therapist goals . Goals a. have not provided a workable framework for program evaluation . This paper proposes that evaluation be done in the framework of goals b. by setting up , before treatment , a measurable scale for each patient-therapist goal , and specifying , for each patient , a transformation of his overall goal attainment into a st and ardized T-score . This method , together with r and om assignment of patients to treatment modes , was devised to permit comparison of treatment modes within a program , but it also provides a good basis for a judgmental evaluation of the total program OBJECTIVE To investigate the effect of combined botulinum toxin type A ( BTX ) and functional electric stimulation ( FES ) treatment on spastic drop foot in stroke . DESIGN Nonblinded r and omized controlled trial . SETTING Hospitals . PARTICIPANTS Consecutive sample of 21 ambulant adults within 1 year after stroke with a spastic drop foot , of whom 18 completed the study . INTERVENTIONS The treatment group received BTX injections ( Dysport ) on 1 occasion into the medial and lateral heads of the gastrocnemius ( 200U each ) and tibialis posterior ( 400U each ) muscles and FES , used on a daily basis for 16 weeks to assist walking . Both groups continued with physiotherapy at the same rate . MAIN OUTCOME MEASURES Walking speed , Physiological Cost Index , Modified Ashworth Scale , Rivermead Motor Assessment , and Medical Outcomes Study 36-Item Short-Form Health Survey . RESULTS Walking speed increased over 12 weeks in both control ( P=.020 ) and treatment groups ( nonstimulated , P=.004 ; stimulated , P=.042 ) . The baseline corrected ( analysis of covariance ) increase in mean walking speed at 12 weeks , relative to controls , was.04 m/s ( 95 % confidence interval [CI],.003-.090 ) without stimulation , and .09 m/s ( 95 % CI,.031-.150 ) with stimulation . CONCLUSIONS Combined treatment effectively improved walking and function . A larger study is needed to quantify the treatment effect and to investigate its impact on quality of life ZusammenfassungHINTERGRUND : Kinder mit spastischer Hemiparese leiden häufig unter einer eingeschränkten H and funktion . Gründe dafür sind Paresen , Spastizität sowie eine gestörte motorische Kontrolle . Ziel dieser Studie war die Effektivität der kombinierten Anwendung von funktioneller Elektrostimulation mit Botulinum Toxin A bei diesen Kindern zu untersuchen . DESIGN : R and omisiert , kontrolliert , Beobachter-geblindet , Pilotstudie . PATIENTEN : Kinder mit eingeschränkter H and funktion aufgrund einer spastischen Hemiparese . INTERVENTIONEN : Die Einteilung erfolgte in zwei Gruppen : Die erste Gruppe erhielt eine kombinierte Beh and lung von funktioneller Elektrostimulation mit Botulinum Toxin A , die zweite Gruppe wurde nur mit Botulinum Toxin A beh and elt . Das Toxin wurde entsprechend der Klinik in die Armmuskulatur injiziert . Nach fünf bis sechs Tagen wurde mit der funktionellen Elektrostimulation der H and - und Fingerextensoren begonnen . Die Beh and lung erfolgte mittels Heimgerät zuhause und wurde zweimal täglich für 15 Minuten , über insgesamt drei Monate , appliziert . UNTERSUCHUNGSPARAMETER : Aktiver und passiver Bewegungsumfang , Muskeltonus , Muskelkraft und Funktionstests für Kinder . ERGEBNISSE : Sechs Kinder i m Alter zwischen 7 und 17 Jahren mit spastischer Hemiparese wurden in die Studie eingeschlossen . In beiden Gruppen verbesserten sich der aktive und passive Bewegungsumfang , der Muskeltonus und die Muskelkraft nach 3 und 6 Monaten i m Vergleich zur Ausgangsuntersuchung . Eine Verbesserung bei den Funktionstests zeigte sich nur in der Gruppe mit der kombinierten Beh and lung . DISKUSSION : Die Kombination von funktioneller Elektrostimulation mit Botulinum Toxin A ist eine vielversprechende Therapieoption zur Verbesserung der H and funktion bei Kindern mit spastischer Hemiparese . Summary BACKGROUND : Children with spastic hemiparesis frequently present with impaired h and function due to paresis , spasticity , and disturbed motor control . The aim of this study was to examine the effectiveness of functional electrical stimulation in combination with botulinum toxin type A in these children . DESIGN : R and omized , controlled , observer-blinded pilot study . SUBJECTS : Children with impaired h and function . INTERVENTIONS : Either a combined treatment group ( functional electrical stimulation and botulinum toxin type A ) or a botulinum toxin type A group alone . Botulinum toxin type A was injected into arm muscles according to the patient 's clinical requirements . Functional electrical stimulation of the wrist and finger extensor muscles was started after five to six days . Patients were given a stimulation device and asked to use it at home twice daily for 15 min , for a total period of three months . MAIN MEASURES : Active and passive range of motion , muscle tone , muscle strength , and functional tests for children . RESULTS : Six children aged between 7 and 17 years with spastic hemiparesis were enrolled . In both groups , active and passive range of motion , muscle tone , and muscle strength improved after three and six months compared to baseline data . The functional score was improved only in the group that received combined treatment . CONCLUSIONS : Combined treatment with functional electrical stimulation and botulinum toxin type A is a promising treatment option to improve upper limb function in children with spastic hemiparesis OBJECTIVE To determine the efficacy of botulinum toxin type A for the treatment of spastic shoulder pain in patients after stroke . DESIGN Double-blind r and omized clinical trial . PATIENTS Of 31 patients enrolled from an acute-care hospital in Spain , 2 cases dropped out ( drop-out rate 6.5 % ) . Fourteen subjects were treated with infiltration of 500 units of botulinum toxin type A in the pectoralis major muscle of the paretic side , and 15 with a placebo . METHODS After infiltration , both groups received transcutaneous electrical nerve stimulation for 6 weeks . Patients were assessed by the use of the Visual Analogue Scale for pain . A good result concerning pain was considered when the Visual Analogue Scale score was below 33.3 mm or less than half the initial score . The patients were followed-up for 6 months . RESULTS The patients treated with botulinum toxin type A showed a significantly greater pain improvement from the first week post-infiltration . Persistent shoulder pain was observed more frequently in the placebo group , with relative risks in the range 0.32 - 0.41 during the follow-up period . CONCLUSION Patients with spastic shoulder pain treated with a botulinum toxin type A infiltration in the pectoralis major muscle of the paretic side have a higher likelihood of pain relief ( between 2.43- and 3.11-fold ) OBJECTIVE To examine goal attainment scaling for evaluation of treatment for upper limb post-stroke spasticity with  botulinum toxin-A. DESIGN Secondary analysis of a multi-centre double-blind , placebo-controlled r and omized clinical trial . SETTING Six outpatient clinics in Australia . PARTICIPANTS Patients ( n=90 ) completing per protocol 2 cycles of treatment/placebo . Mean age 54.5 ( st and ard deviation 13.2 ) years . Mean time since stroke 5.9 ( st and ard deviation 10.5 ) years . INTERVENTIONS Intramuscular botulinum toxin-A ( Dysport 500 - 1000U ) or placebo given at 0 and 12 weeks . Measurement points were baseline , 8 and 20 weeks . MAIN OUTCOME MEASURES Individualized goal attainment and its relationship with spasticity and other person-centred measures - pain , mood , quality of life and global benefit . RESULTS A significant treatment effect was observed with respect to goal attainment ( Mann-Whitney z=-2.33 , p < or = 0.02 ) . Goal -attainment scaling outcome T-scores were highly correlated with reduction in spasticity ( rho=0.36 , p=0.001 ) and global benefit ( rho=0.45 , p<0.001 ) , but not with other outcome measures . Goal -attainment scaling T-scores were lower than expected ( median 32.4 , interquartile range 29.6 - 40.6 ) . Goals related to passive tasks were more often achieved than those reflecting active function . Qualitative analysis of goals nevertheless demonstrated change over a wide area of patient experience . CONCLUSION Goal -attainment scaling provided a responsive measure for evaluating focal intervention for upper limb spasticity , identifying outcomes of importance to the individual/carers , not otherwise identifiable using st and ardized measures OBJECTIVE To determine if botulinum toxin type A ( BTX-A ) combined with therapy can facilitate improved upper-extremity ( UE ) functional status versus therapy alone . DESIGN Double-blind r and omized crossover trial . SETTING Tertiary care outpatient rehabilitation center . PARTICIPANTS Convenience sample of 21 men and women ( ages 19 - 80 y ) with stroke more than 6 months after insult who had tone greater than 3 on the Ashworth Scale for 2 joints in the involved UE . INTERVENTION Subjects were consecutively recruited and r and omized to a double-blind crossover trial . Subjects received either BTX-A combined with a defined therapy program or placebo injection combined with a therapy program in two 12-week sessions . MAIN OUTCOME MEASURES The primary functional outcome measure was the Motor Activity Log ( MAL ) . Subjects were also assessed on physiologic measures including tone ( Ashworth Scale ) , range of motion , and motor strength . RESULTS Improvements were noted in the functional status of the subjects in both arms of the study as measured by the MAL . All subjects had a significant change in functional status on MAL with therapy ( P<.05 ) . The use of BTX-A combined with therapy as compared with therapy only improved the functional status of the subjects on the MAL Quality of Movement subscale ( P=.0180 , t test ) and showed a trend toward significance in the Amount of Use subscale ( P=.0605 , analysis of variance ) . Six weeks after treatment , the BTX-A combined with therapy decreased the Ashworth score statistically ( P=.0271 ) , but the therapy alone group decreased a similar amount at 6 weeks ( P=.0117 ) , indicating that most of the physiologic tone change could be attributed to therapy . After each 12-week period , tone had largely returned to baseline ( P>.05 ) . CONCLUSION A focused therapy program showed the most improvement in function in this defined stroke population . BTX-A combined with a focused traditional therapy program slightly enhanced the functional status of stroke subjects beyond that obtained with therapy alone 12 weeks after injection UNLABELLED Gassaway J , Horn SD , DeJong G , Smout RJ , Clark C , James R. Applying the clinical practice improvement approach to stroke rehabilitation :  methods used and baseline results . OBJECTIVES To describe the methods used and baseline data for the Post-Stroke Rehabilitation Outcomes Project ( PSROP ) . DESIGN Prospect i ve observational cohort study . SETTING Seven inpatient rehabilitation facilities ( IRFs ) in the United States and New Zeal and . PARTICIPANTS Consecutive convenience sample of 1291 poststroke rehabilitation patients , age older than 18 , who were treated between 2001 and 2003 in 7 IRFs ( 1161 patients in 6 U.S. IRFs ) . INTERVENTIONS Not applicable . MAIN OUTCOME MEASURES Change in FIM score , change in severity of illness , and discharge destination . RESULTS For the U.S. sample , the average age was 66 years , 52 % were men , 60 % were white , and 23 % were black . Medicare was the most frequent payer . Seventy-seven percent of strokes were ischemic , with 43 % in the left brain , 44 % in the right brain , and 11 % bilateral . Mean admission total FIM score was 61 , with a mean motor FIM score of 40 and mean cognitive FIM score of 21 . Lower FIM scores are associated with higher severity-of-illness scores . Mean rehabilitation length of stay was 18.6 days ; 78 % of patients were discharged home . At discharge , the average increase in total FIM score was 26 , in motor FIM score was 22 , and in cognitive FIM score was 4 . CONCLUSIONS This article outlines methods used in the PSROP , provides an overview of participating IRFs , describes the data base , and summarizes key characteristics to enable readers of subsequent articles to better interpret study findings and determine generalizability Background and objective . Botulinum toxin type A ( BtxA ) injection and modified constraint-induced movement therapy ( mCIMT ) are both promising approaches to enhance recovery after stroke . The combined application of these 2 promising modalities has rarely been studied . The aim was to investigate whether combined BtxA and mCIMT would improve spasticity and upper extremity motor function more than BtxA plus conventional rehabilitation in chronic stroke patients with upper extremity spasticity . Methods . In a prospect i ve , r and omized controlled , observer-blinded trial with 6-month follow-up , 32 patients ( ≥1 year after stroke ) with ability to actively extend > 10 ° at metacarpophalangeal and interphalangeal joints and 20 ° at wrist of the affected upper limb were r and omized to receive BtxA + mCIMT ( combination group ) or BtxA + conventional rehabilitation ( control group ) for 2 hours/day , 3 days/week for 3 months . The primary outcome assessed spasticity on the Modified Ashworth Scale . Secondary outcomes assessed real-world arm function ( Motor Activity Log ) , laboratory motor activity ( Action Research Arm Test ) , and patients ’ global satisfaction . Results . A total of 32 stroke patients were recruited , and 29 completed the study . Spasticity significantly improved in all subjects at 4 weeks and 3 months postinjection without between-group differences . The combination group showed significantly greater improvements in elbow , wrist , and finger spasticity ( P = .019 , P = .019 , and P < .001 , respectively ) , affected upper extremity real-world arm function ( P < .001 ) and laboratory motor activity ( P < .001 ) than the control group at 6-month postinjection . Patients reported considerable satisfaction and no serious adverse events occurred . Conclusions . Combining BtxA and mCIMT is an effective and safe intervention for improving spasticity and motor function in chronic stroke patients . The results are promising enough to justify further studies . We recommend future research to address the likely need for including rehabilitation with BtxA to improve function in patients with poststroke spasticity BACKGROUND Spasticity is a disabling complication of stroke , and it is uncertain whether intramuscular injections of botulinum toxin type A reduce disability in persons with spasticity of the wrist and fingers after a stroke . METHODS We performed a r and omized , double-blind , placebo-controlled , multicenter trial to assess the efficacy and safety of one-time injections of botulinum toxin A ( 200 to 240 units ) in 126 subjects with increased flexor tone in the wrist and fingers after a stroke . The primary outcome measure was self-reported disability in four areas : personal hygiene , dressing , pain , and limb position ( on a four-point scale ranging from no disability to severe disability ) at six weeks ; at base line , each subject selected one of these areas in which there was moderate-to-severe disability as the principal target of treatment . RESULTS Subjects who received botulinum toxin A had greater improvement in flexor tone in the wrist and fingers at all follow-up visits through 12 weeks than did subjects who received placebo ( P<0.001 for all comparisons ) . Subjects treated with botulinum toxin A had greater improvement in the principal target of treatment at weeks 4 , 6 , 8 , and 12 ( P<0.001 , P<0.001 , P=0.03 , and P=0.02 , respectively ) ; at week 6 , 40 of the 64 subjects in the botulinum-toxin group ( 62 percent ) , as compared with 17 of the 62 in the placebo group ( 27 percent ) , reported improvement of at least one point on the Disability Assessment Scale in the principal target of treatment ( P<0.001 ) . There were no major adverse events associated with injection of botulinum toxin A. CONCLUSIONS Intramuscular injections of botulinum toxin A reduce spasticity of the wrist and finger muscles and associated disability in patients who have had a stroke Introduction Over 1.5 million Americans are diagnosed with a stroke each year , and excessive flexion or extension ( hypertonia ) of upper extremity joints are common secondary conditions . The purpose of this study was to compare the efficacy of botulinum toxin type-A and manual therapy , with the adjunct treatment of dynamic splinting on range of motion , spasticity , and elbow flexor hypertonia , in a r and omized trial . Methods Thirty-six subjects were recruited for this pilot study and all exhibited hypertonia in elbow flexion . Six patients were excluded due to noncompliance . Testing was done with pre/post active range of motion in elbow extension , and the Modified Ashworth Scale ( extension ) for spasticity . All patients received the current st and ard of care : botulinum toxin type-A injections and manual therapy . Experimental patients were r and omly assigned adjunct treatment with Elbow Extension Dynasplint ® . Results Thirty patients completed the study ( mean age [ SD ] 52±17 years ) . The percentage of change in active range of motion in elbow extension was greater for the experimental than for control subjects ( 33.5 % vs. 18.7 % ) . The Modified Ashworth Scale ( extension ) scores showed comparable changes of a mean 9.3 % improvement for experimental versus 8.6 % for the control subjects . Conclusion This study confirmed the efficacy of botulinum toxin type-A in tone management and occupational therapy in contracture reduction . It also showed the value of dynamic splinting in maintaining gains in range of motion OBJECTIVE To determine whether onabotulinumtoxinA injections and task practice training with or without functional electrical stimulation ( FES ) improve upper limb motor function in chronic spastic hemiparesis . DESIGN R and omized controlled trial . SETTING Outpatient spasticity clinic . PARTICIPANTS Participants ( N=23 ) had chronic spastic hemiparesis with moderate-severe h and impairment based on Chedoke-McMaster Assessment greater than or equal to 2 . INTERVENTIONS OnabotulinumtoxinA injections followed by 12 weeks of postinjection task practice . Participants r and omly assigned to FES group were also fitted with an orthosis that provided FES . MAIN OUTCOME MEASURES Motor Activity Log (MAL)-Observation was the primary outcome . Secondary outcomes were Action Research Arm Test ( ARAT ) and MAL-Self-Report . RESULTS For the entire cohort , MAL-Observation mean item scores improved significantly from baseline to week 6 ( P=.005 ) but did not remain significant at week 12 . MAL-Self-Report mean item scores improved significantly ( P=.009 ) from baseline to week 6 and remained significantly higher ( P=.014 ) at week 12 . ARAT total scores also improved significantly from baseline to week 6 ( P=.018 ) and were sustained at week 12 ( P=.032 ) . However , there were no significant differences between the FES and no-FES groups for any outcome variable over time . CONCLUSIONS Rehabilitation strategies that combine onabotulinumtoxinA injections and task practice therapy are feasible and effective in improving upper-limb motor function and reducing spasticity in patients with chronic spastic hemiparesis . However , the cyclic FES protocol used in this study did not increase gains achieved with the combination of onabotulinumtoxinA and task practice alone Abstract Purpose : To evaluate the effect of kinesiotaping as an adjuvant therapy to botulinum toxin A ( BTX-A ) injection in lower extremity spasticity . Methods : This is a single-center , r and omized , and double-blind study . Twenty hemiplegic patients with spastic equinus foot were enrolled into the study and r and omized into 2 groups . The first group ( n=10 ) received BTX-A injection and kinesiotaping , and the second group ( n=10 ) received BTX-A injection and sham-taping . Clinical assessment was done before injection and at 2 weeks and 1 , 3 , and 6 months . Outcome measures were modified Ashworth scale ( MAS ) , passive ankle dorsiflexion , gait velocity , and step length . Results : Improvement was recorded in both kinesiotaping and sham groups for all outcome variables . No significant difference was found between groups other than passive range of motion ( ROM ) , which was found to have increased more in the kinesiotaping group at 2 weeks . Conclusion : There is no clear benefit in adjuvant kinesiotaping application with botulinum toxin for correction of spastic equinus in stroke OBJECTIVE Botulinum toxin is known to relieve upper limb spasticity , which is a disabling complication of stroke . We examined its effect on quality of life and other person-centred perspectives . DESIGN A multi-centre , r and omized , double-blind , placebo-controlled study . PATIENTS Ninety-six patients were r and omized ( mean age 59.5 years ) at least 6 months post-stroke . Mean time since stroke was 5.9 years . METHODS Patients received either botulinum toxin type A or placebo into the affected distal upper limb muscles on 2 occasions , 12 weeks apart . Assessment was undertaken at baseline , 8 , 12 , 20 and 24 weeks . The primary outcome measure was the Assessment of Quality of Life scale ( AQoL ) . Secondary outcome assessment s included Goal Attainment Scaling ( GAS ) , pain , mood , global benefit , Modified Ashworth Scale ( MAS ) , disability and carer burden . RESULTS The groups did not differ significantly with respect to quality of life , pain , mood , disability or carer burden . However , patients treated with botulinum toxin type A had significantly greater reduction in spasticity ( MAS ) ( p < 0.001 ) , which translated into higher GAS scores ( p < 0.01 ) and greater global benefit ( p < 0.01 ) . CONCLUSION Although no change in quality of life was demonstrated using the AQoL , botulinum toxin type A was found to be safe and efficacious in reducing upper limb spasticity and improving the ability to achieve personal goals
BACKGROUND Spasticity may affect stroke survivors by contributing to activity limitations , caregiver burden , pain and reduced quality of life ( QoL ) .
Spasticity management guidelines recommend multidisciplinary ( MD ) rehabilitation programmes following botulinum toxin ( BoNT ) treatment for post-stroke spasticity .
However , the evidence base for the effectiveness of MD rehabilitation is unclear .
OBJECTIVES To assess the effectiveness of MD rehabilitation , following BoNT and other focal intramuscular treatments such as phenol , in improving activity limitations and other outcomes in adults and children with post-stroke spasticity .
To explore what setting s , types and intensities of rehabilitation programmes are effective .