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Introduction In patients taking warfarin, the level of anticoagulation status using the International Normalized Ratio (INR) is one consideration before botulinum toxin type-A (BoNTA) injections; however, there is wide diversity in physician approaches and preferences in using INR status and the INR cut-off values to determine suitability of anticoagulated patients for BoNTA injections. There is no standard approach for treating spasticity with BoNTA injections in patients who are on warfarin or direct anticoagulants (DOACs). Objective: Our objective was to review the challenges in the use of BoNTA in patients who are receiving anticoagulants and to present highlights of the Canadian Delphi Study on the management of anticoagulated patients with limb spasticity. Methods We present a hypothetical case of a patient with focal spasticity who is also receiving anticoagulants. Results The results when injecting BoNTA in anticoagulated patients were as follows: 1) BoNTA injections should not be withheld purely because a patient is anticoagulated and other factors need to be considered. 2) A 25G (or higher) needle should be used when injecting into the deepleg compartment muscles. 3) The INR level ≤3.5 should be used when injecting the deep posterior leg compartment muscles. 4) The concern regarding bleeding when using DOACs remain the same as with warfarin when INR is in the therapeutic range. 6) The dose and scheduling of DOACs need not be altered prior to BoNTA injections. Conclusions The Canadian consensus statements assist clinicians by providing a framework for consideration to navigate the challenges when injecting BoNTA in anticoagulated patients with spasticity.

BACKGROUND Adjunct therapies are nonpharmacological treatments used with botulinum toxin (BoNT) injection that may improve spasticity outcomes. It has been suggested that physicians consider adjunct therapies as a part of comprehensive spasticity management. It is unclear which adjunct therapies are used by physicians in clinical practice. OBJECTIVE To determine physician practice patterns and perceptions of use of adjunct therapies following BoNT injection for limb spasticity. DESIGN Cross-sectional national survey of current clinical practice using a 22-item questionnaire developed by the authors. SETTING Not applicable. PARTICIPANTS Survey respondents were physicians actively administering BoNT injections for limb spasticity management across Canada (N = 48). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Types of adjunct therapies used by physicians; physician opinions on barriers to adjunct therapy use, patient preferences, and future research priorities. RESULTS Most physicians prescribe home stretching programs, home active exercise programs, and splinting; however, many physicians perceive that these same adjunct therapies are unwanted by patients. A minority of physicians prescribe electrical stimulation (ES), transcutaneous electrical nerve stimulation (TENS), casting, and extracorporeal shockwave therapy; financial limitations and perceived lack of evidence were identified as barriers to their use. Significantly more physicians practicing in academic settings compared with nonacademic, community, and private practice settings used functional ES (59% vs 11%) and TENS (41% vs 0%) as adjunct therapies (P

Background: Passive leg cycling is an important clinical tool available for rehabilitation after spinal cord injury (SCI). Passive cycling can be used to derive exercise-related benefits in patients with poor motor control. There have been a number of studies examining the effects of passive cycling on a variety of outcomes. There is need for a systematic assessment of the cycling parameters and the associated clinical changes in cardiovascular, neuromuscular, and musculoskeletal outcomes after passive cycling. Objectives: To assess the effectiveness of passive leg cycling interventions on cardiovascular, neuromuscular, and musculoskeletal outcomes post SCI, and to describe intensity, duration, and type of passive leg cycling post SCI. Methods: PRISMA guided systematic review of literature based on searches in the following databases: PubMed/MEDLINE, PEDro, EMBASE, Cochrane Library, and Google Scholar. Peer-reviewed publications that were written in English were included if they described the effects of a single session or multiple sessions of passive leg cycling in persons post SCI. Results: Eleven papers were included: two were randomized controlled trials (RCTs), one was a crossover trial, and the rest were pre-post single-group designs. Three studies (including two RCTs) reported statistically significant benefits of multiple sessions of passive cycling on leg blood flow velocity, spasticity, reflex excitability and joint range of motion, and markers of muscle hypertrophy. About half of the single session studies showed statistically significant improvement in acute responses. Conclusion: Multiple sessions of passive leg cycling showed benefits in three categories – cardiovascular, musculoskeletal, and neurological – with medium to large effect sizes.

Purpose: Goal Attainment Scaling (GAS) is used to assess functional gains in response to treatment. Specific characteristics of the functional goals set by individuals receiving botulinum toxin type A (BoNTA) injections for spasticity management are unknown. The primary objectives of this study were to describe the characteristics of the goals set by patients before receiving BoNTA injections using the International Classification of Functioning, Disability and Health (ICF) and to determine whether the pattern of spasticity distribution affected the goals set. Methods: A cross-sectional retrospective chart review was carried out in an outpatient spasticity-management clinic in Toronto. A total of 176 patients with a variety of neurological lesions attended the clinic to receive BoNTA injections and completed GAS from December 2012 to December 2013. The main outcome measures were the characteristics of the goals set by the participants on the basis of ICF categories (body functions and structures, activity and participation) and the spasticity distribution using Modified Ashworth Scale scores. Results: Of the patients, 73% set activity and participation goals, and 27% set body functions and structures goals (p0.05). Conclusion: Our results show that patients receiving BoNTA treatment set a higher percentage of activity and participation goals than body functions and structures goals. Goal classification was not affected by type of spasticity distribution or type of UMN disorder.

Purpose: The purpose of this study was to estimate the interrater reliability of the Modified Ashworth Scale (MAS) using consistent movement speeds guided by a metronome when measuring wrist flexor and ankle plantar flexor spasticity in patients with an upper motor neuron (UMN) lesion. The MAS has been found to have inconsistent interrater reliability for scoring the degree of spasticity. Method: This quantitative cross-sectional pilot study occurred in the outpatient spasticity clinic of a community rehabilitation hospital. Participants were a convenience sample of 20 patients with UMN lesions receiving botulinum toxin type A injections for focal spasticity. For each of the muscle groups tested, different pairs of evaluators scored spasticity on the MAS at a velocity of 130° per second. Evaluators were physical therapy students trained by an experienced physical therapist in MAS assessment. Weighted κ values were calculated to measure interrater reliability for each muscle group. Results: The weighted κ values for the wrist flexors and ankle plantar flexors were, respectively, moderate (κw = 0.54; 95% CI: 0.21, 0.87) and slight (κw = 0.08; 95% CI: −0.34, 0.50). Conclusion: Using consistent movement velocity, novice evaluators were able to score spasticity with reasonable interrater reliability when assessing the wrist flexors but not the ankle plantar flexors.

The purpose of this study was to assess the prevalence of compartment syndrome or major bleeding episodes and compare compartment syndrome, patient and intervention characteristics in 110 patients with stroke (treated with Warfarin, new oral anticoagulants, antiplatelet, or no anticoagulants) treated for spasticity in deep leg compartment muscles with botulinum toxin injections [onabotulinumtoxinA (n = 77); incobotulinumtoxinA (n = 33)]. We reviewed 674 injection cycles (range 1–25 cycles per patient) and found no cases of compartment syndrome in any patient groups.

Objective:The adverse events (AEs) with botulinum toxin type-A (BoNTA), used for indications other than spasticity, are widely reported in the literature. However, the site, dose, and frequency of injections are different for spasticity when compared to the treatment for other conditions and hence the AEs may be different as well. The objective of this study was to summarize the AEs reported in Canada and systematically review the AEs with intramuscular botulinum toxin injections to treat focal spasticity.Methods: Data were gathered from Health Canada (2009-2013) and major electronic databases.Results: In a 4 year period, 285 AEs were reported. OnabotulinumtoxinA (n=272 events): 68% females, 53% serious, 18% hospitalization, and 8% fatalities. The type of AEs reported were – muscle weakness (19%), oropharyngeal (14%), respiratory (14%), eye related (8%), bowel/bladder related (8%), and infection (5%). IncobotulinumtoxinA (n=13): 38% females, 62% serious, and 54% hospitalization. The type of AEs reported were – muscle weakness (15%), oropharyngeal (15%), respiratory (38%), eye related (23%), bowel/bladder related (15%), and infection (15%). Commonly reported AEs in the literature were muscle weakness, pain, oropharyngeal, bowel/bladder, blood circulation, neurological, gait, and respiratory problems.Conclusion:While BoNTA is useful in managing spasticity, future studies need to investigate the factors that can minimize AEs. A better understanding of the underlying mechanisms of the AEs can also improve guidelines for BoNTA administration and enhance outcomes.

Purpose: To describe the nature, extent, and impact of spasticity; determine factors that are perceived to influence its severity; and examine the relationship between time since diagnosis and impact of spasticity on daily activities in people with stroke and multiple sclerosis (MS) who are receiving botulinum toxin injection treatments. Methods: After a cross-sectional telephone survey, descriptive statistics and correlations were analyzed separately for the stroke and MS groups. Results: A total of 29 people with stroke and 10 with MS were surveyed. Both groups perceived increased spasticity with outdoor cold (69% stroke, 60% MS), muscle fatigue (59% stroke, 80% MS), and mental stress (59% stroke, 90% MS). No statistically significant correlations were found between time since diagnosis and perceived impact of spasticity on function in the stroke (r=0.07, p=0.37) or MS (r=0.16, p=0.33) groups. The MS group experienced bilateral and more severe perception of spasticity in the legs than the stroke group and identified more factors as worsening their spasticity (p

Background. Balance impairments, falls, and spasticity are common after stroke, but the effect of spasticity on balance control after stroke is not well understood.Methods. In this cross-sectional study, twenty-seven participants with stroke were divided into two groups, based on ankle plantar flexor spasticity level. Fifteen individuals with high spasticity (Modified Ashworth Scale (MAS) score of ≥2) and 12 individuals with low spasticity (MAS score Results. The high spasticity group demonstrated greater ML COP velocity, trunk roll velocity, trunk roll velocity frequency amplitude at 3.7 Hz, and trunk roll velocity frequency amplitude at 4.9 Hz, particularly in the eyes closed condition (spasticitybyvisioninteraction). ML COP MPF was greater in the high spasticity group.Conclusion. Individuals with high spasticity after stroke demonstrated greater impairment of balance control in the frontal plane, which was exacerbated when vision was removed.

Spasticity and clonus are common clinical signs of upper motor neuron lesions poststroke. Intramuscular botulinum toxin-A injections have been shown to reduce spasticity and to improve quality of life. Upper extremity clonus can have a significant impact upon activities of daily living and can pose challenges to comfort, self-care, hygiene, and appearance. Although less common than in the ankle, it is important to understand how upper extremity clonus management may be beneficial to patients presenting with this finding. The majority of previous reports have focused on management of clonus in the lower extremity, but very few have addressed the management of upper extremity clonus. We present a case of poststroke upper extremity clonus with marked improvements following intramuscular botulinum toxin-A injections.

Objective The aims of this study were to systematically identify and summarize the literature examining the impact of physiologic and psychologic triggers on spasticity and discuss the evidence supporting various types of triggers. Design PubMed, EMBASE, CINAHL, and PEDro databases were searched using specific keyword combinations. Only studies using clinical tests or self-reports of spasticity were included. Results A total of 1152 articles were scanned for relevance, and of 44 relevant articles, 24 were reviewed. Pregnancy, posture, cold, circadian rhythm, and skin conditions increased spasticity and were measured using objective clinical tests. Self-reports of spasticity suggest that triggers such as bowel- and bladder-related issues, menstrual cycle, mental stress, and tight clothing can all increase spasticity. No literature evidence of increase in spasticity in response to heterotopic ossification, hemorrhoids, deep vein thrombosis, fever, and sleep patterns was found. Conclusions Although self-reports indicate a strong possibility of increasing spasticity, without objective examination, the true effects of these triggers on spasticity remain inconclusive. Most studies reviewed here were performed in the spinal cord injury population; therefore, it is not known whether these triggers induce similar effects in persons with other neurologic etiologies.

Botulinum toxin, frequently used to manage focal limb spasticity, has been reported to affect both extrafusal and intrafusal fibers of the injected muscle. Since most studies have used spinal reflexes, it is difficult to isolate the intrafusal effects from extrafusal and central effects. In a paper by On et al. [7], both stretch and H-reflexes were used to examine the intrafusal effects of botulinum toxin injections. Revisiting the data from On et al. [7] presented a unique opportunity to describe a novel method of measuring the effect of botulinum toxin-A on muscle spindle activity in patients with spasticity. H-reflex, maximum M-wave, and Achilles tendon reflex were serially assessed in ten patients with stroke pre-, 2, 4, and 12 weeks post-botulinum. In order to assess the intrafusal effects, we subtracted the %change in H-reflex amplitude from baseline (representing extrafusal and central effects) from the %change in Achilles tendon reflex amplitude from baseline (representing intrafusal, extrafusal and central effects). Using this formula, our results suggest that botulinum induces significant chemodenervation of the intrafusal muscle fibers (33% decreases). Intrafusal effects were greatest at 2 weeks, but tapered off by 12 weeks post-botulinum (p0.017). We found a significant positive correlation between the intrafusal effects of botulinum toxin and changes in modified Ashworth scale. Our method of assessing the effects of botulinum toxin shows significant effect on intrafusal fibers, which correlates with clinical manifestation of spasticity. Future studies need to investigate ways to maximize intrafusal effects and minimize extrafusal effects of botulinum therapy.

To understand physician preferences and bleeding complication rates of intramuscular botulinum neurotoxin type A injections for spasticity management in anticoagulated patients, questionnaires were mailed to 138 physicians across Canada. The international normalized ratio comfort range for injections was

Fung S, Phadke CP, Kam A, Ismail F, Boulias C. Effect of topical anesthetics on needle insertion pain during botulinum toxin type A injections for limb spasticity. Objective To compare pain perception using 3 anesthetics (eutectic mixture of local anesthetics [EMLA], vapocoolant spray, and ice) compared with a control (no anesthetic) during botulinum toxin type A (BTX-A) injections for lower limb spasticity. Design A placebo-controlled, single-blinded study where each study patient served as their own control. Setting Spasticity clinic. Participants Subjects (N=30) with ankle spasticity who visited the clinic for BTX-A injections in the gastrocnemius muscle were consecutively sampled. Intervention The gastrocnemius muscle was divided into 4 quadrants and 1 of the 3 different anesthetic agents was applied to each quadrant with 1 quadrant using no anesthetic, control. Main Outcome Measures Numerical Rating Scale (NRS) and the Wong-Baker FACES scale. Results Pain perception using the NRS and FACES scale was significantly lower using ice and EMLA compared with control and spray conditions ( P Conclusions Pain relief offered by EMLA and ice was comparable, suggesting that ice is a more convenient option because of brief application time (compared with EMLA). Spray may have made the patients more sensitive to pain and alternative approaches for using vapocoolant should be considered.

Objective: To assess the prevalence of pain in adults with spasticity and to assess the association between the subjective experience of pain and spasticity.Design: Cross-sectional study.Setting: outpatient spasticity management clinic of a rehabilitation centre.Patients: Patients with upper motor neuron lesions and spasticity (n=131) were recruited.Methods:We assessed pain intensity and location, relationship between spasticity and pain perception, and perception of pain relief from botulinum toxin type-A (BoNTA) injections. Main outcome measures: Pain perception rated on a 10-point numerical rating scale and pain quality.Results:65% of the patients with spasticity reported presence of pain and 60% described it as an aching pain. More patients reported pain with movement (34%) compared to rest (21%). There was a statistically poor correlation between the severity of pain and spasticity (r=0.16; p>0.05). Most patients (80%) believed that their pain was related to spasticity and 62% reported that BoNTA injections decreased their pain.Conclusions:The high incidence of pain noted within our sample suggests that physicians may have to consider pain management as part of spasticity treatment. Participants reported that their pain was related to their spasticity, and that it decreased after BoNTA treatment. Further study is needed to explore the relationships between objective measures of spasticity and pain.

Purpose: In this case report, we describe the type and duration of a physical therapy and botulinum toxin type A (BoNTA) intervention directed at lower limb spasticity and the gait and balance improvement in a patient post-stroke. Treatment of focal spasticity with BoNTA intramuscular injections combined with physical therapy is recommended by rehabilitation experts. However, the optimal type and duration of physical therapy intervention to optimize any functional gains that follow chemodenervation induced by BoNTA has not been established. Method: One individual with chronic stroke who received BoNTA injections for upper and lower extremity spasticity was included. Physical therapy intervention consisted of 45- to 60-min sessions twice weekly for 12 weeks, based on the Bobath–neurodevelopmental therapy approach, and an activity-based home program. Results: After BoNTA injections and physical therapy, the patient made clinically significant improvements in balance and gait speed and became more independent with his ambulation. Conclusions: This case report demonstrates that physical therapy after BoNTA injections can result in significant functional improvements for individuals with spasticity after chronic stroke that may not be possible with BoNTA injections alone.

Although falls, balance impairment, and spasticity are common post-stroke, their interrelationship remains unclear. We review the literature for a) a relationship between spasticity and balance and b) the effect of botulinum toxin injections on balance. Electronic databases were searched based on two criteria: a) studies assessing balance in subjects with spasticity and b) studies examining the effect of botulinum toxin on balance. The primary findings were a) balance is impaired in subjects with spasticity, but only one study assessed relationship between spasticity and balance; and b) four studies reported that balance improves following botulinum treatment for limb spasticity. Persons with spasticity demonstrate impaired balance, but the correlation between spasticity and balance has not been adequately assessed in the literature. Evidence for balance changes following botulinum toxin is weak because of lack of randomization, control group comparison, objective balance assessment measures, and standard clinical scales.

Subscapularis muscle spasticity is commonly treated with botulinum toxin injections; however, there are challenges in determining optimal injection sites within the muscle. The purpose of this study was to document the intramuscular innervation patterns of the subscapularis (1) to determine how the muscle is neuromuscularly partitioned and (2) to identify a strategy for botulinum toxin injection based on neuromuscular partitioning. In 50 formalin-embalmed cadaveric specimens, the extramuscular and intramuscular innervation was (1) serially dissected, digitized, and reconstructed in 3 dimensions (n=7); or (2) serially dissected and photographed (n=43). Intramuscular innervation patterns were compared among specimens to identify neuromuscular partitions. Variation was observed in the number (2-5) and origin of extramuscular nerve branches to the subscapularis. Despite variation in extramuscular innervation, the intramuscular innervation was consistent. Based on intramuscular innervation patterns, the subscapularis had 3 neuromuscular partitions (superior, middle, inferior) in 78% of specimens, and 2 partitions (superior, inferior) in 22% of specimens. The superior and middle partitions were most commonly innervated by branch(es) from the posterior cord, and the inferior partition by branch(es) from the axillary nerve. Injection of botulinum toxin into each partition may help to optimize results in the treatment of shoulder spasticity, and may be achieved by a combination of medial and inferior approaches. Clinical studies are required to determine whether the combination approach is more effective than any single approach and whether the number of partitions injected correlates with clinical outcomes.

Background It is difficult to compare the dosage of botulinum toxin between different neurologic conditions because of the different methods of reported dosages. Botulinum toxin is used to manage spasticity in variety of neurologic conditions, and it is important for clinicians to know whether there are differences in the dosage injected on the basis of the etiology of spasticity. Objective To determine whether the type of neural lesion influences the dosage of botulinum toxin required to manage spasticity. Design Retrospective chart review. Setting Review of patients who visited an outpatient spasticity clinic. Participants We assessed medical charts from 99 patients with stroke, multiple sclerosis (MS), and cerebral palsy (CP) (n = 33 for each etiology). We collected information such as age, gender, weight, time of lesion, total dosage (per person, per limb, per muscle), injection location, and injections cycles. Interventions None. Main Outcome Measurements OnabotulinumtoxinA dose – total dose in one leg was calculated as a sum of the units of the toxin injected in all the leg muscles. Results Total dose of toxin injected was 161 ± 19 (mean ± standard error of mean) in patients with stroke, 175 ± 13 in patients with CP, and 225 ± 18 in patients with MS. The total dose in the legs (normalized to body weight; units/kg) was significantly different between the 3 groups (stroke, CP, MS; P = .001). Subsequent post-hoc tests revealed that total dose in the legs of patients with MS was significantly greater (88%) than patients with stroke ( P = .001). Hip adductors and hamstrings were injected most commonly in MS and CP, but toe muscles were commonly injected in patients with stroke, whereas plantar flexors were evenly injected all 3 patient groups. Conclusion In our practice, we found that treating spasticity in people with MS required the greatest dose of botulinum toxin, followed by CP and then stroke.

To examine effectiveness of botulinum toxin therapy (BoNT), accurate quantification of the neurological component of underlying spasticity is needed.Systematically identify and summarize literature on neurophysiological methods to test the effectiveness of BoNT, discuss methodological aspects, and recommend best techniques for clinical and research settings.Electronic databases were searched using specific keywords. Reviews and reference lists were hand-checked to find relevant studies. Studies in adults with focal limb spasticity were included.Over 300 articles were scanned for relevance, and a list of 90 relevant articles was made. After excluding reviews and studies in healthy controls or non-spasticity related BoNT, 22 articles were reviewed. Neurophysiological techniques included electromyography (EMG; n = 11), electrical nerve stimulation (n = 13), transcranial magnetic stimulation (TMS; n = 1), functional magnetic resonance imaging (fMRI; n = 1), reflex threshold (n = 4), Achilles tendon reflex (n = 1), reflex latency (n = 1).Maximum M-wave amplitude (M-max) and stretch reflex threshold techniques were successfully used to measure the neurophysiological effects of BoNT and have high test-retest reliability. EMG techniques require effective magnitude normalization techniques and establishing test-retest reliability.Serial electrical nerve stimulation can be incorporated into clinical practice to assist in follow-up. We recommend using M-max and stretch reflex threshold techniques to assess the neurophysiological effects.

Objective: To assess the effect of spasticity and cognitive dual-task (counting backwards) on gait variability and gait asymmetry in adults with neurological disorders. High gait variability and gait asymmetry seen in patients with neurological lesions can increase falls risk. Whether spasticity and additional cognitive loads contribute to gait variability and gait asymmetry is not known. Design: Prospective cross-sectional study. Setting: Outpatient clinic. Participants: NZ43; 24 males 19 females; mean age 52 19 years; stroke (nZ21), multiple sclerosis (nZ7), acquired brain injury (nZ4), spinal cord injury (nZ3), cerebral palsy (nZ4), other (nZ4). Interventions: Not applicable. Main Outcome Measure(s): 1) Gait variability index (GVI; 3 muscles with modified Ashworth scale (MAS) score 2, 3) Spatio-temporal gait asymmetry (higher-to-lower parameter ratio; values >1 indicate asymmetry). Participants completed 2 trials each of single-task walking and dual-task walking at preferred speed on a GAITRite walkway. Results: GVI value was significantly higher in the low-spasticity (78 15) compared to the high-spasticity group (70 14; p