Does botulinum toxin improve the function of the patient with spasticity after stroke? Toxina botulínica proporciona melhora funcional em pacientes com espasticidade secundária a acidente vascular cerebral?

Post-stroke spasticity is an important cause of disability in adults, due to muscle hyperactivity, which results in limb stiffness and muscle spasm. The prognosis for these patients depends on several features such as early management and adequate physical therapy to avoid muscle shortening, pain, and their consequences. Although several papers have shown that intramuscular injections of botulinum toxin type A (BT-A) decreases spasticity in post-stroke patients, few authors have demonstrated functional improvement after this therapy. In order to assess if individualized BT-A injections improves upper limb function in post-stroke spastic patients, we prospectively followed 20 consecutive patients of 18 years of age or more with spastic hemiparesis secondary to stroke. Fulg-Meyer scale modified for upper limbs, measure of functional independence (MFI), Ashworth modified scale, and goniometry were applied in the beginning of the investigation and in the 16th and 32nd weeks. BT-A was applied at baseline and in the 16th week. All subjects were submitted to rehabilitation therapy. All patients showed improvement according to Ashworth modified scale and increase in the range of motion, which were sustained until the 32nd week (p<0.05). The assessment of the first three parameters of the Fulg-Meyer scale and the evaluations of the motor part of the Functional Independence Measure showed statistically improvement until the end of the study. We conclude that proper choice of muscles and individualized doses of BT-A can improve function in selected post-stroke patients.<br>Espasticidade secundária a acidente vascular cerebral (AVC) é importante causa de incapacidade em adultos. O prognóstico para estes pacientes depende de vários fatores como tratamento precoce e terapia física adequada, evitando encurtamento muscular, dor e outras conseqüências. Vários estudos têm demonstrado que aplicacões intramusculares de toxina botulínica do tipo A (TxB-A) reduzem a espasticidade após AVC, entretanto poucos autores observaram melhora funcional de membros superiores com esta terapêutica. Para determinar se aplicações individualizadas de TxB-A melhoram a função no membro superior espástico de pacientes com hemiparesia secundária a AVC, acompanhamos 20 pacientes com história de AVC entre 6 meses e 5 anos. A escala de Fulg-Meyer para membros superiores, a medida de independência funcional, a escala modificada de Ashworth e goniometria foram aplicadas no início da investigação, na 16ª e 32ª semanas. TxB-A foi aplicada no início do estudo e na 16ª semana e todos os participantes foram tratados adicionalmente com fisioterapia. Observamos melhora na escala de Ashworth e aumento na amplitude de movimento em todos os pacientes até a 32ª semana (p<0.05). A análise dos 3 primeiros parâmetros da escala de Fulg-Meyer e a parte motora da MIF mostraram melhora estatisticamente significante até o final do estudo. Concluímos que a escolha adequada dos músculos e doses individualizadas de TxB-A melhoram a função em pacientes com espasticidade pós-AV

The efficacy of Botulinum Toxin A on improving ease of care in the upper and lower limbs: A systematic review and meta-analysis using the Grades of Recommendation, Assessment, Development and Evaluation approach

OBJECTIVES: A systematic review and meta-analysis using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach; evaluating Botulinum Toxin type A efficacy on improving ease of care in the upper/lower limb. DATA SOURCES: Pubmed, Cinahl, Amed, Embase and Cochrane databases. English Language. Search to July 2014. REVIEW METHODS: All randomized, placebo controlled trials on adults with difficulty in caring for the upper/lower limb resulting from spasticity of any origin and treated with a single dose of Botulinum Toxin A. Evidence quality was assessed by GRADE. RESULTS: A total of 32 studies were reviewed. Meta-analysis was carried out on 11 upper limb and three lower limb studies. Evidence quality for the upper limb was moderate. A significant result for Botulinum Toxin A was found at four to 12 weeks for the upper limb (SMD 0.80, CI 0.55, 1.06, p < 0.0001). The effects were maintained for up to six months (SMD 0.48, CI 0.34, 0.62, p < 0.0001). Evidence quality was very low for the lower limb. Meta-analysis was only possible for global assessment of benefit. No significant effect was found. (PATIENT: RR 1.37 CI (0.94, 2.00) p = 0.11; clinician: RR 1.06 (0.84, 1.34) p = 0.60.) CONCLUSION: Botulinum Toxin A improves ease of care in the upper limb for up to six months. No conclusion can be drawn for the lower limb