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S. Gomez Argüello1,2, M. Ostolaza2, D.A. Felici2, E.H.M. Lockhart1,2, A. Mendelevich3, J. Abudarham2
1Universidad Maimonides, Kinesiología y Fisiatría, Ciudad Autonoma de Buenos Aires, Buenos Aires, Argentina, 2Departamento de Ciencias de la Salud, Kinesiología y Fisiatría, Universidad Nacional de La Matanza, San Justo, Buenos Aires, Argentina, 3Facultad de Ciencias de la Salud, Kinesiología, Universidad de Mendoza, Mendoza, Mendoza, Argentina
Background: Post-stroke spasticity (P-SS) is a common and disabling sensory-motor disorder. P-SS leading to poor quality of life and limitations in activities of daily living. The botulinum toxin type A (BoNT-A) injection is an effective therapeutic modality to reduce temporally the focal spasticity. This could provide a window period where physical therapy (PT) could improve gains during rehabilitation. However the PT effectiveness following BoNT-A injections remains unclear.
Purpose: Review the effectiveness of PT modalities following botulinum toxin type A injection to decrease spasticity and activities limitations and improve motor functions in adults with post-stroke spasticity.
Methods: Control trials (CT) databases and registries were searched up to April 19, 2019 in MEDLINE, the Cochrane Central Register of Controlled Trials, LILACS, SciELO, PEDro, REHABDATA, ClinicalTrials.gov, World Health Organization International Clinical Trials Registry Platform, Australian New Zealand Clinical Trials Registry, ISRCTN Registry, EU Clinical Trials Register, Stroke Trials Registry, Dissertation abstracts, National Research Register, UK Clinical Research Network Portfolio Database and Open Gray. Reference lists, texts and other reviews were also searched, and expert authors were contacted.
Randomized and non-randomized CT were included. The intervention in the experimental group was one or more PT modalities after the BoNT-A injections compared with a control group with BoNT-A alone or BoNT-A plus placebo PT or BoNT-A plus at least one PT modality of the experimental group. Participants had to be over 18 years old with P-SS. Any outcome measure used was considered to assess efficacy of antispastic treatments. Two authors independently selected the trials, extracted data and assessed risk of bias, using the Cochrane Handbook, and assessed the methodological quality using GRADE.
Randomized and non-randomized CT were included. The intervention in the experimental group was one or more PT modalities after the BoNT-A injections compared with a control group with BoNT-A alone or BoNT-A plus placebo PT or BoNT-A plus at least one PT modality of the experimental group. Participants had to be over 18 years old with P-SS. Any outcome measure used was considered to assess efficacy of antispastic treatments. Two authors independently selected the trials, extracted data and assessed risk of bias, using the Cochrane Handbook, and assessed the methodological quality using GRADE.
Results: Six CT with 219 participants were included. The risk of bias assessment showed that 40.5% of the domains were unclear risk, 59.5% were low risk, and a single domain from one study was high risk. Also the studies obtained low methodological quality. All studies used different types and dosages of PT modalities. Two articles used Bont-A plus electrical stimulation (ES) in the upper limb. One of them reached an improvement in a daily life activity, however the other did not show benefits in the Modified Ashworth Scale (MAS). Other two studies used Bont-A plus ankle foot orthoses (AFO) and found improvements in several outcome measures. One trial enhanced passive ankle dorsiflexion range of motion following Bont-A plus taping. Another study used Bont-A plus home self-rehabilitation program showing significant difference in walking outcome measures.
Conclusion(s): Up to the search date, there is insufficient high-quality evidence to generalize about the effect of PT interventions during and after the BoNT-A effect in adults with P-SS. We have found low quality evidence for the use of Bont-A plus AFO, taping, home self-treatment and ES.
Implications: There are some PT modalities that had favorable effects in adults with P-SS. The high risk of bias and the low methodological quality generate doubts about their real effect. New trials with high methodological quality should be implemented to reduce the risk of bias in final results.
Funding, acknowledgements: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Keywords: stroke, spasticity, botulinum toxin
Topic: Neurology: stroke
Did this work require ethics approval? No
Institution: Universidad Maimonides
Committee: Comité de Ética de la Investigación de la Universidad Maimónides
Reason: because this study does not use any intervention in human subjects, nor does it involve their participation.
All authors, affiliations and abstracts have been published as submitted.
