botulinum toxin assessment, intervention and after-care for lower limb spasticity in children with...

Botulinum toxin assessment, intervention and after-care for upperlimb hypertonicity in adults: international consensus statement

G. Sheeana, N. A. Lanninb, L. Turner-Stokesc, B. Rawickid and B. J. Snowe

aNeurosciences, University of California, San Diego, CA, USA; bRehabilitation Studies Unit, Sydney Medical School, The University of

Sydney, Ryde, NSW, Australia; cKing�s College London School of Medicine, Harrow, Middlesex, UK; dVictorian Paediatric Rehabilitation

Service, Monash Medical Centre, Clayton, Vic., Australia; and eDepartment of Neurology, Auckland City Hospital, Auckland, New Zealand

Keywords:

brain injury, consensus

statement, spasticity,

stroke, systematic review,

upper extremity

Received 9 July 2009

Accepted 14 May 2010

Upper limb spasticity affecting elbow, wrist, and finger flexors can be safely and

effectively reduced with injections of botulinum toxin type-A (BoNT-A). It has been

best studied in adults in the context of post-stroke spasticity. The clinical benefits

include reduction in pain and deformity, improvement in washing and dressing the

upper limb, and a reduction in caregiver burden (Class I evidence, recommendation

level A). Some patients show improvement in function performed by active movement

of the affected upper limb (Class III evidence, recommendation C), but predicting and

measuring this is difficult, and further research is needed. An individually based ap-

proach to treatment and outcome measurement is preferred (Class IV, recommen-

dation U). More research is needed to resolve many unknown issues of assessment and

treatment, using research methods appropriate to the question.

Introduction

As with other body areas, spasticity in the upper limb

(UL) can produce pain and deformity, and can interfere

with function. The relatively small size of the UL

muscles makes them attractive targets for botulinum

toxin type-A (BoNT-A) injection. The general

approach to management is similar to other body areas

in terms of assessment, goal setting, and outcome

measurement. The authors therefore have attempted to

limit overlap, only repeating that which is valuable in

the context of UL spasticity and that which will allow

this consensus to serve as a stand-alone document.

Objective

The purposes of this international consensus statement

are to provide guidance about �best practice� to clini-

cians in the assessment and treatment of upper limb

hypertonicity in adults and to identify areas for future

research based on gaps in the literature. Literature was

searched and appraised using a conventional evidence

hierarchy. The highest levels of evidence available were

used to develop recommendations, with randomized

controlled trials (RCTs) and systematic reviews

preferentially sought. Only when RCT or systematic

review evidence was not available, was lower level

evidence and practice-based evidence included to

answer clinical questions raised at the International

BoNT Consensus Workshop. Expert opinion where

included have been clearly labelled and should be

interpreted with judicious caution. Recommendations

for research were made based on the gaps indentified in

the literature. All recommendations were graded based

on the American Academy of Neurology evidence

classification [1]. The authors were both researchers and

clinicians with experience in BoNT and were a multi-

disciplinary team including rehabilitation physicians, an

occupational therapist, and neurologists.

Which patients should be treated?

The mainstay of treatment for spasticity is the preven-

tion and relief of provocative factors (infection, noci-

ceptive stimuli, tight clothing, etc.) and a regimen of

care that includes positioning, stretching and (where

relevant) the facilitation of active movement to main-

tain muscle length and prevent soft tissue contracture.

BoNT-A treatment should be viewed as an adjunct to a

neurorehabilitation programme rather than the other

way around. An algorithm for treatment with BoNT-A

is presented in Fig. 1.

Decisions about whether and how a patient�s UL

spasticity should be treated are individually determined.

These decisions may be influenced by the chronicity,

Correspondence: Dr G. Sheean, Clinical Professor of Neurosciences,

UCSD, Director of Neuromuscular Division, 402 Dickinson St, Suite

190, San Diego, CA 92103-8465, USA (tel.: +1 619 543 5300;

fax: +1 619 543 5793; e-mail: [email protected]).

74� 2010 The Author(s)

Journal compilation � 2010 EFNS

European Journal of Neurology 2010, 17 (Suppl. 2): 74–93 doi:10.1111/j.1468-1331.2010.03129.x

severity, and distribution of the spasticity as well as

weakness, the presence and severity of co-morbidities,

the availability of support and the goals of treatment.

Spasticity is not always harmful, but it can be painful

and distressing. Unlike the lower limb, spasticity in the

UL is rarely functionally useful.

The effects of spasticity are most commonly

described at the level of impairment [2] (hypertonicity,

associated reactions, limb deformity, etc.). However, it

is also important to consider the impact on function.

Functional activities may be divided into the following

two categories:

• Active function, where a functional task is performed

byactivemovement of the individual�s affected limb, or

• Passive function, where a task is carried out on the

affected limb by the individual using the unaffected

limb, or by a carer [3,4].

Evidence for effectiveness

Botulinum toxin has been clearly shown to reduce

clinical indicators of UL spasticity (Class I evidence);

however, functional improvement, and not just reduc-

tion in spasticity itself should be the goal of therapy

(Class IV). Following treatment, there can be improve-

ments in symptoms (pain), and �passive function� (carer

management of dressing the UL, hygiene of the hand,

elbow and axilla) and cosmetic limb position (Class I)

[5]. Individually tailored BoNT-A treatment has also

been shown to improve caregiver burden for tasks such

as hygiene, cutting fingernails and dressing (Class I) [6].

Given the two studies with consistent results, we

recommend BoNT-A treatment for the reduction in

pain and improvement in passive function in patients

with UL spasticity, using individualized injection pat-

terns and treatment goals established for each patient

(Level A rating) [5,6]. There are three studies specifically

addressing shoulder pain associated with post-stroke

spasticity that included injection into the subscapularis

muscle. Two studies showed clear reduction in pain

(Yelnik et al., Lim et al.: Class 1) [7,8], whilst the third

study did not (de Boer) [9]. Given this contradiction and

methodological variations, we recommend considering

injections into shoulder girdle muscles to reduce

shoulder pain (Level U).

No randomized controlled study has shown clear

benefit in active function of the spastic UL [4,10].

Inconsistency of improvements in active function has,

however, been noted in open-label studies, with some

studies reporting benefit [11–14] whilst others have not

[15–17]. Paediatric studies in which participants

received BoNT-A injections and occupational therapy

Patient presents with problem

due to focal spastic motor overactivity

Patient* satisfaction achieved?

Cost-effective? Decide parameters for re-injection

If quantitative difference, review treatment plan

If qualitative difference, re-evaluate role ofBoNT in treatment

Review patient’s expectations*

Disability goals achieved?

Search for confounding factors and treat accordingly

Still a problem?No further Rx

Continue therapy

Consider alternativetreatments

Consider alternativetreatments

Yes

Yes

Yes

Yes

Yes

Yes

No

Still a problem?

Consider BoNT and discuss costs,

risks, benefits

NoYes

Technical goals achieved (impairments)?

Review• Treatment plan• Confounding variables

* and caregiver

Review

Inject and continue with adjunctive Rx

Perform baseline evaluation

Acceptable?

Formulate management plan

1. Define clinical problem – impairment, disability, handicap2. Choose outcome measures and timing of review3. Treatment plan a. Injection plan b. Adjunctive treatment

No

No

No

Re-evaluate causal relationship between

impairments and disability

No

No

Physical therapy:OT, PT

Hyperkinetic (involuntary movements)

Spasms (flexor, extensor, adductor)

Associated reactions

Mass movements

Action-induced spastic dystonia†Evaluated by tone and active or passive range of movement. The hyperkinetic spastic

forms occur when the spastic muscle contractions produce involuntary movements while

in the hypokinetic forms the muscle contractions impair movement, active or passive.

2. Define disability in terms of

a. Function

i. Active

ii. Passive

b. Symptoms

i. Pain

ii. Cosmetic

iii. Unwanted involuntary movements

3. Confounding variables

a. Musculoskeletal

i. Soft tissue stiffness

ii. Joint calcification

b. Aggravating factors

i. Noxious stimulation

ii. Medications

Notes:

1. Technical goal is to reduce impairments = spastic motor over activity, which is of 2 types:

Hypokinetic (impairment of movement)†

Spasticity

Static spastic dystonia

Spastic co-contraction

Figure 1 Algorithm: managing spasticity.

BoNT-A consensus statement: AUL 75

� 2010 The Author(s)Journal compilation � 2010 EFNS European Journal of Neurology 17 (Suppl. 2), 74–93

demonstrated greater improvements in self-care and

upper-extremity movement function than those chil-

dren who received BoNT-A or occupational therapy

only [18,19]. Although not demonstrated in adults,

these paediatric findings suggest that, when combined

with functional, activity-based interventions, BoNT-A

may provide an opportunity to improve the functional

use of a spastic UL. However, there is often a time lag

between maximum reduction in spasticity and func-

tional gain [20], possibly reflecting time taken to learn

how to use the new reduction in hypertonicity. We

therefore conclude that improvement in active function

of the UL may occur in some patients (recommendation

C, Class III) but not necessarily simultaneously with

reduction in spasticity.

Evidence for the use of BoNT-A in the UL for adults

is summarized in Table 1. Papers were included if they

were Class I (AAN), that is, double-blinded random-

ized, controlled trials with adequate methods, with an

additional requirement of adequate statistical power.

Recommendation 1

In summary, the following is recommended:*

• The effects of spasticity should be described at the level of both

impairment and impact on function (active; passive)

• Treatment decisions should be based on individual evaluation,

including chronicity, severity, and distribution of the spasticity and

weakness; the presence and severity of co-morbidities, such as

contracture; the availability of support; and the goals of treatment

• BoNT-A treatment is appropriate for the reduction in pain and

improvement in passive function in patients with UL spasticity,

using individualized injection patterns and treatment goals estab-

lished for each patient

*Expert opinion

What is the best way to assess?

Treatment should be individually tailored to the spastic

muscles that are judged to be causing the disability.

Patients who are most likely to benefit from treatment

with BoNT-A are those in whom focal or multi-focal

UL spasticity is making a substantial contribution to a

clinical problem. Patients in whom the dominant

problem is fixed contracture or those with generalized

spasticity are unlikely to benefit from management with

BoNT-A.

Assessment must therefore measure the clinical phe-

nomena (including muscle contracture, pain and joint

range of movement) as well as the passive and active

functional impairments experienced by the patient.

The key steps in patient assessment are as follows:

(i) To confirm the patient meets patient selection cri-

teria (outlined in Table 2).

(ii) To identify and agree on the goals of treatment by:

s Identifying functional impairments (both pas-

sive and active) and differential contributions

of components the UL deformity, and

s Understanding the extent to which spasticity

and muscle overactivity, weakness and con-

tracture contribute to the UL functional

impairments.

(iii) To determine the current levels of therapy received

and potential arrangements for follow-up therapy.

(iv) To define and agree on how overall outcome will be

determined.

Goals for intervention

Goals for treatment typically include managing symp-

toms, preventing or slowing down the progression of

impairments, and improving passive or active function.

Occasionally, goals relate to process, for example to

optimize the effects of other interventions such as

therapy or systemic medication. Common treatment

goals are outlined in Table 3.

Having identified the main goal areas, clearly defined

treatment goals should be collaboratively determined

with the patient and their carers. Agreed goals should

be SMART (i.e. specific, measurable, achievable, real-

istic and timed). The expected outcome, thus carefully

defined, should be agreed by all parties to be worth-

while, and the time-point for evaluation should be set in

advance [33].

Baseline assessment

Baseline assessment should include evaluation of the

spasticity itself. The Ashworth (or Modified Ashworth)

and Tardieu scales provide a clinical indicator of

spasticity, assessing resistance to passive movement.

• The Ashworth scale provides a baseline indicator of

severity and may indicate clinically important chan-

ges, though validity, reliability and sensitivity have

limitations [34].

• The Tardieu scale, which has a velocity component to

its measurement of tone, has demonstrated higher

validity, reliability and clinical utility for the clinical

measurement of spasticity [34].

It is important to distinguish hypertonia by spasticity

from that due to soft tissue changes because of the

additional treatment options available for spasticity.

So, despite potentially taking longer, use of the Tardieu

scale is recommended over the Ashworth wherever

possible, as research findings suggest that the Tardieu

Scale is able to differentiate spasticity from soft tissue

hypertonia, whereas the Ashworth Scale cannot [35]. It

76 G. Sheean et al.


Table

1Evidence

fortheuse

ofBoNT-A

inupper

limbhypertonicityin

adults

Citation

Design

Participants

Intervention

Outcomes

Adverse

events

Level

ofevidence

(per

AAN)

Sim

psonDM

etal.Neurology,

1996

PEDro

8[21]

Randomized,double-

blinded,placebo-

controlled,

multicenterclinical

trial

N=

39chronic

UL

spasticityafter

stroke

ULIM

injectionsofatotal

dose

ofeither

75,150,or

300U

ofBoNT-A

or

placebo(biceps,flexorcarpi

radialis,

andflexorcarpi

ulnarismuscles)

•300U

BoNT-A

resulted

insigmean

decrease

inwrist

flexortoneof1.2

(P=

0.028),1.1

(P=

0.044),and

1.2

(P=

0.026)points

andelbow

flexortoneof1.2

(P=

0.024),1.2

(P=

0.028),and1.1

(P=

0.199)

atwks2,4,and6post-injection.

•In

theplacebogp,tonereductionat

thewristwas0.3,0.2,and0.0

andat

theelbow

was0.3,0.3,and0.6

at

wks2,4,and6post-injection.

•BoNT-A

gpsreported

sig

improvem

entonthephysicianand

patientGlobalAssessm

entof

Response

totx

atwks4and6post-

injection

Nostatisticallysigdif.No

seriousAEs

Class

I

BakheitAM

etal.

Stroke;

2000[22]

PEDro

8

Prospective,

randomized,double-

blinded,placebo-

controlled,dose-

rangingstudy

N=

83ULspasticity

after

stroke

BoNT-A

/Dysport

�500,1000,

1500U

•AlldosesofBoNT-A

showed

sig

reductionfrom

baselineofmuscle

tonecomparedwithplacebo.

•Effectonfunctionaldisabilitywas

notstatisticallysigandwasbestat

dose

1000U.

•Txwaseffectiveatdosesof500,

1000,and1500U.

•Optimaldose

fortx

ofpts

with

residualvoluntary

movem

ents

in

theULappears

tobe1000U

Nostatisticallysigdif

Class

I

Bhakta

BBet

al.J

Neurol

Neurosurg

Psychiatry;2000

[6]

Randomized,double-

blinded,single-

centretrial

N=

40

•1000MU

ofBoNT-A

(Dysport

�)vsplacebo

dilutedin

10ml0.9%

saline.

•Flexibilitywasallowed

betweenpts

inthedose

of

trialdruggiven

to

individualmuscles.

•Dose

selectionfor

individualmusclesbasedon

clinicaljudgem

entbyone

investigator

•Betweengpdifsnotreported.

•Statisticallysignificantlygreater

improvem

ents

reported

inBoNT-A

gpvsplacebofor:

•disabilityatwk6(w

orn

off

by

wk12)

•carerburden

atwk6(continued

atwk12)

•forearm

flexorspasticityatwks

6(continued

atwk12)

•elbow

flexorspasticityatwk2

only

•Noim

provem

ents

inarm

pain,and

gripstrength

wasreducedwith

BoNT-A

•BoNT-A

gp:2pts

developed

self-lim

itingarm

pain

within

1wkof

injectionand1ptreported

worseningofmuscle

spasm

•NoseriousBoNT-A

-related

AEsreported.

•In

theplacebogp,1pt

reported

herpes

labialis

7dayspost-injection,1pt

reported

2transient

ischaem

icattacks12days

post-injection,and1pthad

exacerbationofcardiac

failure

4wksafter

tx

Class

II



Table

1(C

ontinued).

Citation

Design

Participants

Intervention

Outcomes

Adverse

events

Level

ofevidence

(per

AAN)

SmithSJet

al.

ClinRehabil;

2000[23]

PEDro

7

Double-blinded

placebo-controlled

randomized

dose-

rangingstudy

21(19post-stroke,

twopost-head

injury)

Pts

randomized:0(sterile

saline),500,1000or

1500MU

ofIM

BoNT-A

(Dysport

�).

Rangeofmusclesinjected

andthusdose

depended

on

distributionofspasticity

•Combiningdata

from

all

dosesofBoNT

therewasa

sigreductionin

spasticityat

thewrist

andfingers

associatedwithagreater

rangeofpassivemovem

ent

atthewrist

andless

finger

curlatrest

•Nochangein

ULdisability

•Sig

increase

inpts

�global

assessm

entofbenefit

•BoNT-A

generally

welltolerated

•Noincreased

weakness

•1ptdeveloped

hip

pain

(feltunrelated

toinjection)

•1pthad

�flu-like

symptoms�for

2dayspost-

injection

•1ptcomplained

ofa

tendency

for

affectedlimbwith

sensory

neglect

to

occasionallyget

caughtin

thespokes

ofthewheelchair

after

the1000Mu

dose

Class

I

BakheitAM

etal.

EurJNeurol;

2001[24]

PEDro

8

Double-blinded,

multicentreRCT

N=

59

OnecycleofDysport

�

(1000U)injected

into

five

musclesin

thearm

and

forearm

(fixed

regim

en)vs

placebo

•Sig

improvem

ents

in

spasticity,rangeof

movem

entandglobal

benefitatendofstudy

Nosigdifin

pain,Barthel

index

ornumber

ofgoals

attained

20pts

inplacebogp

and16in

BoNT

gp

reported

AEs

Nonemajorand

most

notrelatedto

thestudy

Nosigdifin

AE

reportingbetween

gps

Class

I

BrashearA

etal.

NEnglJMed;

2002[5]

PEDro

7

Double-blinded,

multicentreRCT

126pts

withpost-

strokespasticity

OnecycleBoNT-A

(BOTOX

�)into

wrist

and

fingersvsplacebo.

Primary

outcome:

self-

report

ofdisabilityat6wks

•62%

BOTOX

�vs17%

placeboim

proved

byat

least

onepointonthe

disabilityscale

(P<

0.001).BoNT-A

reducedspasticityin

the

wrist

andfingers,andits

associateddisability

•Note

thatbetween-gps

comparisonsoncontinuous

outcomes

notreported

Nostatisticallysigdif

betweengps

Class

II

78 G. Sheean et al.


Table

1(C

ontinued).

Citation

Design

Participants

Intervention

Outcomes

Adverse

events

Level

ofevidence

(per

AAN)

FranciscoGE

etal.Am

JPhys

Med

Rehabil;

2002[25]

PEDro

7

Single-blinded

RCT

13adultswithstoke

ortraumaticbrain

injury

Comparisonofhighandlow

volumes

of(50U/m

land

100U/m

l)injected

into

wrist

andforearm

flexors

Both

gpsshowed

sigreductionin

spasticity(M

AS),butnogp

interaction

Noadverse

incidents

werereported

byany

ofthepts

Class

IV

BrashearA

etal.

2004[26]

PEDro

7

Double-blinded

RCT

15strokepts

BoNT-B

elbow,wrist,fingers

andthumb

•Short

term

(<4/52)changein

Ashworthin

wrist

andelbow

Improvem

ents

no

sustained

Class

II

ChildersMK

etal.ArchPhys

Med

Rehabil.;

2004[27]

PEDro

7

RCT

N=

91

BoNT90,180or360into

UL

vsplacebo

•Im

proved

tone

•Noim

provem

entin

QOL

2pts

pain

and

haem

atoma

Class

I

Suputtitadaet

al.

DisabilRehabil;

2005[28]

RCT

50pts,post-stroke.

EMG

guidance

Dysport

�350,500or1000U

vsplacebo

•MAS,ActionResearchArm

Test

(ARA),Barthel,VAS

•Alldosesproduced

decreasedtone.

500U

gavebest

functionalchange,

1000tooweak

Class

I

Bhakta

BBet

al.J

RehabilMed;

2008[29]

Randomized

placebo-

controlled

trial

N=

40Pareticarm

spasticity

BoNT-A

(Dysport

�;flexors);

1000MU

divided

between

elbow,wrist

andfinger

•Peakassociatedreactionsforcewas

reducedatwk6withBoNT-A

comparedwithplacebo(m

eangp

dif19.0

N;95%

confidence

interval:

7.2,30.9;P

<0.01)andwk2

(P=

0.005),withtheeffect

wearingoffbywk12(P

=0.09)

•10of12pts

receivingBoNT-A

and

2of12receivingplaceboreported

reductionin

associatedreactions

interferingwithdailyactivities

(P=

0.02)(these24previouslysaid

thesemovem

ents

interfered

with

dailyactivities)

Notstated

Class

I



Table

1(C

ontinued).

Citation

Design

Participants

Intervention

Outcomes

Adverse

events

Level

ofevidence

(per

AAN)

Mayer

NH

etal.

ArchPhysMed

Rahabil;2008

[30]

Parallel-gp,RCT

with

blinded

outcome

assessm

ent.

(injectiontechnique

randomized)

N=

31adults

acquired

brain

injury

(21traumatic

brain

injury,8

stroke,

and2

hypoxic

encephalopathy)

Motorpointinjections

occurred

atonesite

inthe

biceps(60U,2.4

ml)and1

site

inthebrachioradialis

(30U,1.2

ml).

Distributedinjectionsat

foursitesin

thebicepsand

twositesin

the

brachioradialis(15U,

0.6

mlper

site).Totaldose

(90U)andvol(3.6

ml)were

constantforboth

gps;only

injectionsitesand

localizationtechniques

varied

betweengps

•Post-interventiontestingat3wks:

nosigdifsbetweengps(P

range,

0.31–0.82across

3outcome

measures)

•Within

each

gp,sigtx

effectswere

observed

onalloutcomemeasures

(allP<

0.01)

•Fortheuninjected

brachialis

muscle,electromyographic

reductionwasgreaterforthe

distributedgp

NoseriousAEs

Class

III

McC

rory

P,et

al.

JRehabilMed;

2009[31a]

Multicentre,

randomized,double-

blinded,placebo-

controlled

study

N=

96meanage

59.5

years)

‡6monthspost-

stroke(m

ean

5.9

years)

hem

iplegic

stroke

andsevere/moderate

spasticityfollowing

stroke

BoNT-A

injection(D

ysport

�)

orplacebo.(range750–

1000U)into

principal

spastic

musclesofdistalUL

atwk0;re-txatwk12

Sig

reduction(M

ASmeasure)in

muscle

spasticityforBoNT-A

-vs

placebo,atalltime-points.

Significantlygreaterattainmentof

person-centred

goals.Nosigdifin

QOL

BoNT-A

:67%

AEs(5.5%

tx

related)

Placebo:62%

AEs(9.5%

tx

related)

TheseAEs

generallymild.

Nodeaths;no

hospitalizations

fortx-related

events.

Noinstances

respiratory

failure

or

swallowing

problemsto

suggestdistance

muscular

weakness

Class

I

BoNT-A

,Botulinum

toxin

type-A;AE,adverse

events;RCT,randomized

controlled

trial;pts,patients;tx,treatm

ent;yr,year;U,units;IM

,intramuscular;sig,significant;dif,difference;gp/s,group/s;

wk/s,week/s;mnth/s,month/s;UL,upper

limb;MAS,Modified

Ashworthscale;QOL,quality

oflife;MU:Mouse

Units.

80 G. Sheean et al.


should be acknowledged, however, that research to date

has primarily been undertaken in larger muscle groups

such as the elbow flexors and that there is limited

research investigating the validity or reliability of either

measure in the smaller muscle groups that are com-

monly injected. Surface or needle electromyography can

also help to show whether active muscle contraction is

contributing to hypertonia.

Once the specific goals for treatment have been iden-

tified, the outcomemeasures that will be used to evaluate

the effects of intervention are chosen and recorded at

baseline. An outcome measure should be clearly defined,

easily measured, and ideally can be objectively or inde-

pendently confirmed. Thesemay be either a standardized

measure or, more commonly in clinical practice, an

individualized measure. For example, one of the most

sensitive individualized methods for evaluating outcome

Table 2 Preliminary checklist for patient selection [32]

• Problem attributed to focal or multi-focal UL spasticity, rather

than fixed contracture

• Provocative factors for spasticity have been excluded or treated

• Condition likely to respond to BoNT-A injection

• No contraindications to BoNT-A injection

• Goals of treatment have been determined, with patient input

• Arrangements in place for implementation of appropriate physical

treatment strategies and monitoring

• Appropriate outcome measures identified

• Informed consent for treatment from patient, or family assents on

their behalf

Adapted from: Royal College of Physicians, British Society of

Rehabilitation Medicine, Chartered Society of Physiotherapy, Asso-

ciation of Chartered Physiotherapists Interested in Neurology. Spas-

ticity in adults: management using botulinum toxin. National

guidelines. London: RCP, 2009.

Copyright � 2009 Royal College of Physicians. Adapted by permission.

Table 3 Common treatment goals and some objective measurements that may be used to record them

ICF level Goal area

Some examples of goals for

treatment

Measurements to record goal

achievement

Impairment

symptom

management

Relief of symptoms • Pain relief

• Muscle spasm frequency

• Involuntary movements e.g.

associated reactions

• Numerical or Visual analogue pain scores

• Spasm frequency counts

• The Associated Reaction Rating Scale [38]

Avoiding progression of

impairment

• Prevention of contractures and

deformity – ease of splint

application and prolonged use

• Optimizing posture and seating to

improve tissue viability

• Torque-controlled Goniometry [39]

• Goniometry (without controlling torque

forces)

• Anatomical distances (e.g. finger-palm

distance)

• Digital photos of position

Activity Passive function

Decrease carer burden

• Ease of moving, handling and

positioning

• Routine day-to-day care (e.g.

axillary hygiene, dressing)

Individual measures

• Carer ratings of ease of care (e.g. score out

of 10)

Standardized measures

• The Leeds Adult Spasticity Impact scale

(LASIS)

• The Arm Activity Scale (ArMa) (Passive

subscale)

Active function Improved ability in the following

tasks:

• Dexterity and reaching

• Self-care e.g. washing, dressing

• Eating/drinking

• Sexual activity

• Mobility e.g. balance, quality or

gait pattern or endurance of

wheelchair propulsion

Individual measures

• Self-rated ease of accomplishing activity

Video recordings

Standardized measures

• Motor function scales, e.g. The Action

Research Arm Test (ARAT), UL Motor

Assessment Scale (UL-MAS);

• Self-report UL use scales e.g. Motor

Activity Log (MAL) or Arm Activity Scale

(ArMa) (Activity subscale)

Participation Aesthetic and postural

appearance

Improve body image

Improve fit of clothes

• Self-rated body image

• Digital photos

Process goals

Enhance impact of

conventional

rehabilitation

intervention

Optimize effectiveness of

therapies

Reduce use of systemic

medication to treat

spasticity

Inform potential surgical

treatment



is that of Goal Attainment Scaling (GAS) [36]. GAS has

been used to demonstrate clinically important changes in

the context of UL spasticity management [31b,37]. GAS

will be discussed again in the section on evaluation of

treatment outcomes.

Some assessments that may be used to define goals, as

well as baseline performance levels are shown in Table 3.

Recommendation 2


• Goals for treatment typically include managing symptoms,

preventing or slowing down the progression of impairments, and

improving passive or active function

• Treatment goals should be collaboratively determined with the

patient and their carers

• Establish baseline spasticity using reliable and valid scale

• Distinguish hypertonia caused by spasticity from that because of

soft tissue changes

• Outcome measures should be chosen and recorded at baseline

*Expert opinion

What is the optimal botulinum toxinintervention regimen?

There is no clear evidence from the literature to guide

optimal timing of interventions (e.g. early versus late),

frequency of interventions, dilutions, injection sites, or

doses. Accurate localization of injected muscles is likely

to result in improved benefit and requires a good

knowledge of surface anatomy. Muscle localization can

also be confirmed using such technology as neuromus-

cular electrical stimulation, ultrasound, or EMG. EMG

is useful to confirm the presence of muscle overactivity

and that the injection needle is within muscle tissue.

However, accurate identification of a specific muscle is

difficult with EMG because of the patient�s loss of

selective activation of individual muscles and because

many other muscles in the same compartment may be

overactive. Electrical stimulation is more accurate for

localization, particularly of small muscles controlling

the fingers and thumb, and for difficult to reach mus-

cles, such as subscapularis, pronator quadratus, and

individual finger flexor fascicles.

Table 4 summarizes suggestions for dosing in differ-

ent muscles based on recommendations of experienced

injectors derived from the UK guidelines. In general,

total dosing per session in the UL would not usually

exceed 400 units of BOTOX� (Allergan, Irvine, CA,

USA) or 750 units of Dysport� (Ipsen, Paris, France).

Some injectors prefer to use multiple injection tech-

niques and lower concentrations (more dilute) for larger

muscles. High-volume injections or end-plate targeting

produce better results in the biceps brachii [40], and

although intuitively sensible for other muscles, this is at

present a matter for clinical judgement.

Initiating regimen

Botulinum toxin type-A should be consideredwhen there

is an absence of absolute contraindications, and after

relative contraindications have been weighed carefully.

There is no arbitrary minimum duration of symp-

toms before treatment should be initiated, although it is

appropriate to commence when the spasticity is a sig-

nificant impediment to beginning occupational therapy

or physiotherapy, or when the problem has reached a

plateau or is worsening despite such therapies. A trial of

oral antispasticity agents is unnecessary for focal UL

spasticity [41].

The therapy or neurorehabilitation programme

should be continued following the injection. This may

require the addition of techniques that were not possi-

ble prior to BoNT-A injection, such as stretching or

fitting orthotics to improve passive function, or motor

training for active functional goals (see later).

Reinjection

Reinjection of the originally injected muscles may be

performed, after a minimum of 3 months, if it is clear

that the spastic motor overactivity being treated is

returning, despite continuing therapy, guided by the

baseline and outcome measures already identified.

Recommendation 3


• Patients most likely to benefit from BoNT-A have focal or multi-

focal UL spasticity

• BoNT-A treatment should:

s be viewed as adjunct to a neurorehabilitation programme;

programme should be continued after injection

s only be considered in the absence of absolute contraindications

s commence when the spasticity is a significant impediment to

therapy or when problem is worsening or plateaus.

• Muscle localization may be based on surface anatomy, EMG

neuromuscular electrical stimulation, ultrasound or other appro-

priate imaging (e.g. CT)

*Expert opinion

What are the optimal adjunctiveinterventions?

Therapeutic intervention and BoNT-A

Spasticity management involves a multi-disciplinary

approach that includes:

82 G. Sheean et al.


Table

4Injectionsite,dose

andinjectionprocedures[32,42]

Muscle

Action

Dose

(U)

Injectionpoint

BOTOX

�Dysport

�

Shoulder

girdle

Trapezius

Scapularelevationandrotation

50–75

150–250

Largemuscle

betweenneckandshoulder

Rhomboid

Extensionofscapulae

50–60

150

Superficial,betweenscapula

andspine

Supraspinatus

Abductionofarm

from

0–15

�above

90

�40

100–150

Supraspinousfossaonscapula

Infraspinatus

Externalrotationofarm

50

100–150

Infraspinoussurface

ofscapula

(Caution:playsan

importantrole

inglenohumeralstability)

Subscapularis

Internalrotationofarm

50

100–150

Inject

under

lateralborder

ofscapula

(usuallyrequires

imagingforaccurate

placement)

Deltoid

Arm

adduct

from

15–90

�50–75

100–200

Inject

anterior,middle

andposteriorfibres

Teres

major

Adducts,mediallyrotatesand

extendsarm

30

100

Lateralaspectlower

scapula

(accurate

injectionvery

important–iftoofarcranio-laterally,mayinject

Teres

Minor(externalrotator)

Teres

minor

Adductsandlaterallyrotates

30

100

Lateralaspectscapula

above

Latissim

usdorsi

Adducts,retractsandmedially

rotatesUL

80

150–300

Findin

posteriorfold

ofaxilla

whilst

askingpatientto

pulldownelevatedarm

(Caution:Only

inject

inthe

presence

ofsufficienttrunkstability)

Serratusanterior

ProtractsUL

60–70

150–300

Lateralaspectofupper

eightribs

Pectoralismajor

Adductsandmediallyrotates

75

200–300

Anterioraxillary

fold

Pectoralisminor

Draw

scapula

downandforw

ards,

depresses

shoulder

40

150

Deepto

upper

part

ofpectoralismajor

Arm

Bicepsbrachii

Supinationandelbow

flexion

75–100

200–300

Anterioraspectofupper

arm

.Inject

both

heads

Tricepsbrachii

Elbow

extension

75–100

200–300

Threeheadsonpost-aspectofarm

Coracobrachialis

Flexes

andadductsupper

arm

40

120

Medialto

upper

humerusbetweenitandneurovascular

bundle

Brachialis

Flexes

elbow

50

150–200

Lower

anteriorhumerusmedialandlateralofbiceps

tendon

Forearm

–extensoraspect

Brachioradialis

Elbow

flexion

50

150–200

Radialsideupper

forearm

Supinator

Supinatesforearm

30–40

100–200

Extensoraspectofarm

below

radialneck–deep

Extensorcarpiradialislongus

Extendsandadductshandatwrist

30–40

100–200

Posteriorto

brachioradialisonback

offorearm

Extensorcarpiradialisbrevis

Extendsandadductshandatwrist

20–30

60–100

Posteriorandmedialto

ECR

longus

Extensorcarpiulnaris

Extendswrist

andelbow

andadducts

hand

30–40

100–150

Most

mediallyplacedextensormuscle.Halfwaydown

ulnashaft

Extensordigitorum

communis

Extendswrist

andfingers

30–40

100–150

Middle

ofback

offorearm

distalto

radialtuberosity



Table

4(C

ontinued).

Muscle

Action

Dose

(U)

Injectionpoint

BOTOX

�Dysport

�

Extensordigitiminim

iExtends5th

finger

30–40

50–100

Medialto

extdigitorum

Extensorpollicislongus

Extendsalljoints

ofthumb

20–30

50–100

Midwaydownback

offorearm

Extensorpollicisbrevis

ExtendsCMC

andMCPjoints

of

thumb

20–25

50–75

Distalthirdofforearm

.Palpate

bymovingCMC

and

MCPjoints

Adductorpollicis

longus

Adductsthumbandhand

20–40

50–100

Proxim

alto

extpollicisbrevisonback

offorearm

.

Palpate

action

Extensorindicis

Extendsforefinger

20–30

50–100

Foundmedialofmost

lateraltendonofExtdigit

communis

Forearm

–Flexoraspect

SuperficialflexormusclesPronatorteres

Pronatesforearm

andflexes

elbow

30–40

100–200

Medialborder

ofanteriorcubitalfossa–medialto

brachialartery

Flexorcarpiradialis

Flexes

wrist

andelbow

30–40

100–200

Upper

forearm

just

below

bicipitalaponeurosisand

medialto

pronatorteres

Flexorcarpiulnaris

Flexes

andadductshandatwrist

30–40

100–150

Upper

forearm

medialaspectofflexorsurface

below

bicipitalaponeurosis.Medialto

FCR.Observeaction

ofwrist

flexion.

Flexordigitorum

superficialis

PIP

jointflexorandMCPjointflexor

25–30

100–200

Middle

offorearm

halfwaydownto

either

sideof

palm

aristendon

Flexordigitorum

profundus

Flexes

allfinger

joints

30–40

100–200

Upper

thirdofforearm

.Deepmuscle

abovelateral

border

ofulna

Flexorpollicislongus

Flexes

alljoints

ofthumb

20–30

100–150

Mid

forearm

over

anterioraspectofradius

Flexorpollicisbrevis

Pronatorquadratus

Pronatesforearm

20–30

100–150

Approach

muscle

from

extensoraspectofforearm

just

proxim

alto

wrist

andadvance

throughinterosseous

mem

brane

Lumbricals

10

Adaptedfrom:RoyalCollegeofPhysicians,British

SocietyofRehabilitationMedicine,

Chartered

SocietyofPhysiotherapy,AssociationofChartered

Physiotherapists

Interested

inNeurology.

Spasticityin

adults:managem

entusingbotulinum

toxin.Nationalguidelines.London:RCP,2009.Copyright

�2009RoyalCollegeofPhysicians.Adaptedbypermission.Adaptedfrom

BrinMuscle

andNerve.

1997;6:S208–S220.ReproducedwithpermissionofJohnWiley

&Sons,Inc.

84 G. Sheean et al.


• Proactive identification and relief of provocative

factors

• Positioning and handling in a range of positions to

vary the stretch on different muscles and body parts

throughout the 24-h day

• An active programme of occupational therapy or

physiotherapy with the following aims

s Maintaining muscle and soft tissue length across

joints

s Facilitating care giving (improvements in passive

function)

s Motor training to increase active participation in

tasks (improvements in active function)

Botulinum toxin type-A can make an important con-

tribution to a comprehensive rehabilitation programme

by decreasing spasticity making it easier to stretch and

maintain the length of soft tissues.

Evidence for effectiveness of adjunctive interventions

The evidence for effectiveness of �adjunctive therapeu-

tic intervention� is hard to extract from the literature

for a number of reasons. Therapy intervention con-

stitutes �normal treatment� for spasticity, and so is of-

ten coupled with BoNT-A both in trials and in clinical

practice. However, the interventions are rarely de-

scribed in detail, rather referred to simply as �treatment

in line with routine practice�. They are so well accepted

that to deprive the patient of this routine treatment has

ethical implications. As yet there are only two ran-

domized trials published in adult populations in which

the effect of adjunctive therapy plus BoNT-A injec-

tions into UL musculature has been compared to

BoNT-A injections alone [43,44]. Therefore, the inde-

pendent effects of BoNT-A treatment alone versus

those of therapy alone versus those generated by the

combination of the two are largely unknown [45]. In

any event, this discussion misses the point that in

clinical practice the BoNT-A injection is really the

adjunctive treatment.

Table 5 lists the adjunctive UL therapies that have

been used in the published literature to date, with evi-

dence of effectiveness of the therapies included.

Frequency and duration of adjunctive therapy

There is no standard regimen of adjunctive therapy that

is widely applied after BoNT-A injection into the UL

[44] and this is not surprising given the diversity of

presentation of clinical problems. At the current time,

therapists must rely on professional judgment to

determine potential changes and areas of improvement

in spasticity patients following BoNT-A injections.

In the absence of formal research evidence, other

guidelines [32] recommend a therapy review to assess

and plan adjunctive therapy at approximately 7–

14 days after injection when the clinical effect of spas-

ticity reduction is evident.

In studies that have provided UL therapies in con-

junction with BoNT-A injections into the UL of adults

with neurological conditions, the frequencies of therapy

provided post-injection are listed in Table 6.

Recommendation 4


• Mainstay of spasticity management is a multi-disciplinary approach

• BoNT-A can make an important contribution to a comprehensive

rehabilitation programme

*Expert opinion

Management algorithm

The algorithm (Figure 1) introduces a new classification

of the positive phenomena of the upper motor neurone

(UMN) syndrome, borrowing from movement disor-

ders by dividing them into hyperkinetic (producing

unwanted involuntary movement) and hypokinetic

(restricting active and passive movement). Whilst this

classification has no technical implications (dosing,

sites, dilution, etc.) it does emphasize that the UMN

syndrome is essentially a movement disorder, that there

are many more types of spastic motor overactivity than

basic spasticity, and helps provide a visualizable foun-

dation for the phenomena.

Evaluation of treatment outcomes

The evaluation of treatment outcomes should involve

goal attainment, measures of symptoms or impairments,

and measures of active/passive function depending on

the goals for treatment. It may also be appropriate to

assess whether there has been an improvement at the

level of participation, including well-being or quality of

life, and to consider cost-effectiveness.

No single outcome measure will wholly evaluate

treatment benefits as individual goals differ.

Have the treatment goals been achieved?

One of the simplest and most sensitive methods for

evaluating outcome from treatment is to record the

achievement of the specific goals using GAS as

described by Kiresuk and Sherman 1968 [36].

Achievement of individual goals is recorded on a

5-point scale from )2 to +2 (see Fig. 2 for decision



Table 5 Augmentative upper limb therapies

Augmentative upper limb

therapies

Evidence of effectiveness from

�BoNT-A + Therapy� vs �BoNT-

A�-alone trials within an adult

neurological population


non-BoNT-A trials (adult population)

Electrical Stimulation to elicit

functional movement of

muscles

Electrical stimulation plus BoNT-A

is more effective than BoNT-A

alone in reducing the carer burden

for cleaning the palm of the affected

hand (Level II) [44]. Stimulation

protocol used: an alternating

electrical stimulation of both the

arm (biceps and triceps) and

forearm (wrist and finger flexors

and extensors) muscles for ½ hour

3· per day during the three days

following the injection

Electrical stimulation of the forearm muscles

increases range of motion at the wrist: study results

suggest, however, that effects are only short term –

i.e. benefits occurred whilst treatment was applied

but quickly reduced when treatment ceased (Level

III) [46]

UL positioning programmes No published trials • Prolonged positioning of the shoulder in

maximum comfortable external rotation

maintained range of motion of this muscle group

in one trial (i.e., prevented contracture); however,

no difference was noted for other shoulder

muscles (Level II) [47]. No difference was found

for any other muscle groups in separate trials

(Levels I/II) [48–52]

• One systematic review found there is insufficient

evidence to draw conclusions on the effect of

supportive devices such as slings, wheelchair

attachments in preventing subluxation or UL pain

[53]

UL mobilization programme Lack of published trials to date • Use of overhead pulleys to maintain range of

motion increased shoulder pain [54]

• Insufficient evidence to determine efficacy of UL

self-ranging or UL range of movement exercise

programs

Self-exercise/home

programmes

Lack of published trials to date Video self-modelling (i.e., exercise performance

videoed with subsequent feedback from a therapist

using the video footage) is an effective and efficient

way of increasing the amount of practice [55]

UL strength training Lack of published trials to date • Weakness is one of the major impairments in the

UL after stroke, irrespective of spasticity

• Spasticity does not increase as a result of

increasing strength [56–58]

• A number of studies have found positive effects of

increasing strength. These include:

s Progressive resistance exercises (Level II) [59]

s Electromyographic (EMG) biofeedbackwhen

applied in conjunction with conventional

therapy (Level II) [55,60]

s Electrical stimulation (Level I) [61]

Task-specific training (Level II) [62,63]

Wrist and hand splinting Lack of published trials to date • Use of nightly hand splinting had no effect on

range of motion of the wrist either alone (REF) or

when applied in addition to prolonged UL

positioning [64]

• One systematic review [64] reported there is only

low-quality evidence in support of the use of

dynamic splints (Level III) [65] of Lycra splints

(Level IV) [63,66] and of cone positioning splints

(Level IV) [67,68]

Elbow splinting Lack of published trials to date Lack of published trials to date

86 G. Sheean et al.


tree) and composite T scores are derived for the chosen

goal set using the standard formula [31b, 37].

Has intervention improved impairment?

Use of the Tardieu and Ashworth scales to evaluate

hypertonicity has already been discussed. Documenta-

tion of improvement in range of movement may be

recorded through goniometry or anatomical distances

(e.g. fingers to palm), although these are prone to

observer error. In practice, the achievement of impair-

ment-related goals, such as ability to apply a splint or

orthosis, may be more relevant.

In the context of research, standardized torque forces

should ideally be used when documenting change in

passive range [88], but it is accepted that this may not be

practical in the clinical situation.

Has intervention improved symptoms?

Visual analogue scales and verbal rating scales can be

used to record symptoms such as pain or perceived

muscle stiffness before and after treatment. The pa-

tient is typically asked to classify the severity of their

target symptom with a numerical score out of 10,

or on a verbal scale e.g. �none – mild – moderate –

severe�.Some patients with cognitive or communication dif-

ficulties may have difficulty in responding to a standard

verbal or visual analogue scale. Pictorial graphic rating

Table 5 (Continued).

Augmentative upper limb

therapies


�BoNT-A + Therapy� vs �BoNT-

A�-alone trials within an adult

neurological population


non-BoNT-A trials (adult population)

Casting for contracture

management

Lack of published trials to date • A systematic review of casting (i.e., casting at the

wrist or elbow which may have been one cast or a

series of casts) in people with traumatic brain

injury or stroke found casting improves range of

motion immediately following cast removal [69]

• An RCT of elbow casting found a mean

improvement in muscle extensibility of 11� (95%

confidence interval )21� to 0�) favouring the cast

group one day after removal, but that any effect

from cast-wear had almost completely

disappeared by the follow-up 4 weeks after (mean

difference 2�, 95% CI )13� to 17�). UL function

results showed no between-group differences [70]

Surgical release of elbow

flexor tendons

Lack of published trials to date Lack of published trials to date

Facilitation training for arm

extension and reach and

grasp

Lack of published trials to date Studies on UL activity have found the following:

• Task-specific training in conjunction with strength

training was superior to neuro-developmental

therapy [63]. Task-specific training was also

superior to repetition alone in improving UL

activity [71]

• Repetitive protraction of the arm was superior to

placebo in the severely disabled [72]. There is

conflicting evidence for bilateral retraining [73–

76]. No improvement in activity has been reported

by higher level trials [73–76].

• Neither NDT [77] nor sensorimotor integration

[78] was more effective than the orthopaedic

approach in improving UL activity

• Joint position feedback in conjunction with

conventional therapy improved the quality of

reaching [79]

• Robot-assisted shoulder–elbow movement

improved reaching [80–82]

• Constraint-induced movement therapy improved

UL activity [83]

Training of carer in moving

and handling of limb

Lack of published trials to date Lack of published trials to date



scales, e.g. the Scale of Pain Intensity (SPIN) [89] may

be used to assist self-report in this context.

Has intervention improved function?

A number of standardized scales can be used to

compare outcomes between individuals and groups.

The goals for treatment will determine the appropriate

scale.

Passive function

Options for assessment of �passive function� include

verbal or visual analogue ratings of ease of care, timed

care tasks e.g. time taken for dressing, and formal scales

that measure dependency or carer burden. Digital

photography before and after treatment can provide a

useful record of skin maceration.

Standardized scales developed for outcome assess-

ment in spasticity management include the Leeds

Adult Spasticity Impact Scale (LASIS) [6] and the

Arm Activity Scale (ArMA), a passive function sub-

scale [90].

Active function

It becomes more difficult to attribute outcomes to any

one particular rehabilitation intervention as one moves

away from body function towards participation, as

many variables other than the interventions might

account for changes observed. Global scales of inde-

pendence in activities of daily living are rarely sensitive

to focal interventions for UL spasticity, as most scales

do not measure which UL performs the task but mea-

sure only performance of the task.

Tests of upper-extremity motor function used to

assess change in active function in people who have

received BoNT-A include those used in the clinical

population and which have not been developed specif-

ically for people with spasticity. Common scales include

the Action Research Arm Test [91,92] and the Motor

Assessment Scale [93,94].

Other focal UL assessments that have been used in

this context include the Motor Activity Log and the

ABILHAND, both of which capture self-reported

rather than therapist-observed behaviours. However,

many of the activities incorporated in these tools are set

at a higher functional level than can be achieved by

most patients with significant spasticity [95]. The

recently described ArMA includes an active function

subscale and was specifically developed as a self-report

tool for use in UL spasticity [96]: This promising scale

deserves further study.

Has intervention influenced patient experience?

Global assessments of well-being or quality of life tend

to be poor indicators of the success of treatment. Verbal

or visual analogue rating scales, patient and carer sat-

isfaction questionnaires, and goal attainment rating can

be used to determine global assessment of patient

experience.

How should patients be monitored?

Botulinum toxin is usually well tolerated by patients;

however, side effects and adverse events can occur.

Injectors should be mindful of the possibility of diffu-

sion of the toxin locally and systemically and the risks

of needle injury to other structures, such as nerves and

blood vessels.

The major adverse effects relate to unwanted

muscle weakness, and other systemic effects such as

dysphagia. Care should be taken when injecting the

proximal UL in patients who already have compro-

mised swallowing, as these larger muscles often

need larger doses with consequential potential for

systemic spread. For a full list of contraindications

and special warnings and precautions for the use of

BoNT-A, clinicians should refer to the prescribing

information. In the controlled trials referred to in this

guide, adverse events have not been significantly dif-

ferent between the treatment groups and the control

groups.

Recommendation 5


• Evaluation of treatment outcomes should involve goal attainment,

measures of impairment, symptoms and function

• Consider possibility of diffusion locally and systemically and the

risks of needle injury to other structures

• Care should be taken when injecting the proximal UL in patients

with compromised swallowing

*Expert opinion

Yes

No

Over-achieved

Achieved

Is the goal achieved?

A lot

A little

+2

+1

0

Partially achieved

Not at all (or worse)

–1

–2

GoalratingGoal

Figure 2 Rating goal attainment using the five-point scale.

88 G. Sheean et al.


Future directions

At present, there are deficiencies in knowledge at all

levels of management of adult UL spasticity with

BoNT-A, except the very few associated with Class I

evidence already described, and also regarding the

safety of the drug.

The knowledge gaps require that most of the paper

is based on low levels of evidence, chiefly expert

opinion.

Future goals for research and clinical practice may

include:

• Study techniques to accentuate the paralytic effect of

the toxin.

s Study injection technique – dilution, injection site,

localization method.

s Develop electrical stimulation post-injection.

• Studies to predict improvement in active move-

ment, designed from a perspective that BoNT-A is

used as an adjunct to standard, ideally proven,

therapies.

• Develop and study measures of active upper limb

function sensitive to reduction in spasticity – includ-

ing further evaluation of the ArMa.

• Study the role of early injection BoNT-A as pre-

ventive for development of contracture or unmasking

potential for active movement.

• Develop internationally agreed datasets to facilitate

large prospective cohort studies conducted in the

context of real-life clinical practice to identify which

patients respond best to which approaches.

Acknowledgements

The Cerebral Palsy Institute sincerely thank the Prin-

cipal Authors involved in the development and leader-

ship of these International Consensus Statements,

including: Professor H. Kerr Graham; Professor John

Olver; Associate Professor Victor S.C. Fung; Associate

Professor Barry Rawicki; Dr Barbara J. Singer and

Dr Iona Novak. The authors gratefully acknowledge

Dr Stephen de Graaff for the review of this paper.

Table 6 Frequency of therapy post-injection

Study Therapy frequency Level of evidence*

Hesse S et al. Clin Rehabil.

1998;12(5):381–8 [44]

ES for ½ hr per session, three sessions per day for 3 days following BoNT-A

injections

II

Giovannelli M et al. Clin Rehabil.

2007; 21: 331–337 [43]

Daily physiotherapy for 15 consecutive days after injection. Patients received

therapy to maintain muscle length through passive or active exercise, and

stretching regimen on injected area (40 min each session): soft movements of

joints with short pauses at final position and reciprocal movements

II

Carda S et al. Clin Rehabil

2005;19:621–626 [84]

Adhesive taping worn 24-h/day for 6 days and checked daily III

Thermoplastic palmar splint positioned for maximal stretching in conjunction with

daily stretching exercises and electrical stimulation of injected muscles for 5 days.

Total daily time required for this treatment was about 90 min. In addition,

60 min was required for splint modelling during 1st day

Levy CE et al. Am J Phys Med

Rehabil 2007;86:696–706 [45]

Exercise therapy commenced within 1 week of BONT-A treatment. Its intensity

was 1 h, 3· per week, duration 4 wks

III

Subjects who met eligibility criteria for CIMT at the conclusion of exercise therapy

(4-wks post-injection) were then entered into a 2-wk course of CIMT. CIMT

consisted of 6 h of intensive upper-limb training 5 days/wk for 2 wks

Rodriquez AA et al. Am J Phys Med

Rehabil 2000; 79: 44–47 [85]

Stretch using a short-hand �weight-bearing� orthosis for 1 min 5 times/day and on

hands and knees (3-point) 5–10 min/day. All subjects used a wrist-hand

antispasticity ball orthosis for night use. After stretching, subjects participated in

self-directed training of voluntary finger and wrist extension as appropriate to

their level of active extension (implied daily; frequency and total amount of

therapy not reported)

IV

Sun SF et al. Physical Therapy 86

(10):1387–1397 [86]

4-wk modified CIMT programme: 2 h of training each day three times weekly and

�told to wear the restraint as long as possible and for at least 5 h of his waking

hours per day during the study period�

V

Denham SP. American Journal of

Occupational Therapy 2008;61:473–

479 [87]

Occupational therapy began the day following injection, and was scheduled 3·week for 6 weeks, then 2· week for 6 weeks. Following one-on-one therapy, the

participant was started on a functional home programme for 6 weeks including

overnight splint wear, daily passive stretching and AROM exercises followed by a

minimum of three functional activities

V

*Level of evidence refers specifically to the level of evidence supporting the therapy intervention, not the BoNT-A comparison. Thus, the therapy

protocol provided in conjunction with BoNT-A in a BoNT-A RCT would be classified as being level III (case series) if there was not a control

group who received BoNT-A without therapy.



The Cerebral Palsy Institute also gratefully

acknowledges the unrestricted educational grant

received from Allergan to support the project. It should

be noted that no authors were provided with any funds

to participate in the project. Funds were solely used for

independent project management and professional

editing from an independent medical writer. A project

charter was developed by the Cerebral Palsy Institute

and independent project officer based on a literature

review of International Consensus Statements. As part

of this charter, Allergan had no access to the manu-

scripts at any point throughout the project duration

and had no right of scientific veto. Authors were

recruited to the project using the following criteria: had

published research on BoNT or the associated adjunc-

tive therapies; were from varying professions repre-

senting the team typically involved with a patient for

this indication of BoNT; were preferentially from

varying countries and continents; had experience of

using different preparations of BoNT so as to minimize

potential sources of bias; had experience working with

children and adults; and were willing to volunteer to

work in a multi-disciplinary author team. Potential

authors were excluded if they were or had ever been

employees of any of the BoNT pharmaceutical

companies.

Conflicts of interest

Barry Snow has acted as a paid consultant to Allergan

by attending an advisory board on the use of botulinum

toxin for headache. Lynne Turner Stokes has received

honoraria and consultancy fees from Ipsen Ltd relating

to research and clinical use of Botulinum Toxin, some

of which are referred to in this work.

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