Does botulinum toxin treatment improve upper limb active function?

• Published in: Annals of physical and rehabilitation medicine 2019-07, Vol.62 (4), p.234-240
• Main Authors: Levy, Jonathan, Molteni, Franco, Cannaviello, Giovanni, Lansaman, Thibaud, Roche, Nicolas, Bensmail, Djamel
• Format: Article
• Language: English
• Subjects: Arm; Botulinum toxin; Botulinum Toxins, Type A - therapeutic use; Clinical Trials as Topic; Hand Strength; Humans; Life Sciences; Muscle Spasticity - drug therapy; Muscle Spasticity - rehabilitation; Neuromuscular Agents - therapeutic use; Outcome; Patient Care Planning; Recovery of Function; Rehabilitation; Spasticity; Stroke; Treatment Outcome; Upper limb
• ISSN: 1877-0657; 1877-0665
• DOI: 10.1016/j.rehab.2018.05.1320

•There is no evidence of grasp activity improvement resulting from reducing upper-limb spasticity with botulinum toxin injection.•When goals are correctly set, they are achieved in most cases.•Goals related to passive function or impairment are more frequently achieved.•The better the underlying motor control, the higher the functional expectations.•The selection of less disabled patients, repeated injections, extended assessment time and combined therapies may help demonstrate the functional effects of botulinum toxin injections on upper-limb spasticity. Spasticity following lesions of the central nervous system such as stroke is a major cause of impairment and disability, especially when it affects the upper limb, and can be focally relieved by intramuscular injections of botulinum toxin (BT). Functional improvements of the affected upper limb after a BT focal treatment remain controversial. We aimed to assess the functional effects of BT treatment on upper-limb spasticity in the literature, identify flaws and deficiencies in proving these effects and propose leads for future trials. We searched the MEDLINE and Cochrane databases for trials, reviews and meta-analyses assessing the effect of BT injection in upper-limb spasticity. This was a non-systematic narrative review, and the selection of articles was based on the authors’ expertise. The review focused on stroke-related spasticity and disability. Patients’ therapeutic targets involved use of the disability assessment scale (DAS) or goal attainment scale (GAS). Impairments and passive function goals prevailed for active function and participation and were more frequently achieved for the former than the latter. Meta-analyses showed no to mild effect sizes for improvement in upper-limb function but failed to show higher and/or better use of the paretic upper limb in activities of daily living after BT injection. BT injections for impairment and passive function are related to improved kinematic parameters; however, the relation between relief of spasticity and improved upper-limb activity has not been established. Possible explanations for the lack of functional effect in studies are first, disability is mainly due to muscle weakness rather than spasticity, so patients with the best underlying motricity may benefit the most from BT injections; second, assessment methods may not be adapted to screen eligible patients; third, most studies’ endpoints were at 4 to 12 weeks after a single injection, but rep