Use of Botulinum Toxin for Limb Immobilization for Rehabilitation in Rats with Experimental Stroke.

Motor rehabilitation strategies after unilateral stroke suggest that the immobilization of the healthy, unimpaired limb can promote the functional recovery of a paretic limb. In rodents, this has been modeled using casts, harnesses, and other means of restricting the use of the non-paretic forelimb in models of experimental stroke. Here, we evaluated an alternative approach, using botulinum toxin injections to limit the function of the non-paretic forelimb. Adult male rats were subjected to permanent ligation of the left distal middle cerebral artery, resulting in right forelimb paresis. The rats were then subjected to: (1) no treatment; (2) botulinum toxin injections 1 day post stroke; or (3) cast placement 5 days post stroke. Casts were removed after 5 weeks, while the botulinum toxin injection effectively immobilized subjects for approximately the same duration. Rats with bilateral forelimb impairment due to the stroke plus casting or botulinum injections were still able to feed and groom normally. Both immobilization groups showed modest recovery following the stroke compared to those that did not receive immobilization, but the casting approach led to unacceptable levels of animal stress. The botulinum toxin approach to limb immobilization had both advantages and disadvantages over traditional physical limb immobilization. The major advantage was that it was far less stress-inducing to the subject animals and appeared to be well tolerated. A disadvantage was that the paresis took roughly 10 weeks to fully resolve, and any degree of residual paresis could confound the interpretation of the behavioral assessments.

Efficacy of individualized homeopathic medicines in treatment of post-stroke hemiparesis: A randomized trial.

BACKGROUND: Hemiparesis is a serious motor impairment following stroke and affecting around 65% of stroke patients. This trial attempts to study the efficacy of individualized homeopathic medicines (IHMs) in comparison with identical-looking placebos in treatment of post-stroke hemiparesis (PSH) in the mutual context of standard physiotherapy (SP). METHODS: A 3-months, open-label, randomized, placebo-controlled trial (n = 60) was conducted at the Organon of Medicine outpatient departments of National Institute of Homoeopathy, West Bengal, India. Patients were randomized to receive IHMs plus SP (n = 30) or identical-looking placebos plus SP (n = 30). Primary outcome measure was Medical Research Council (MRC) muscle strength grading scale; secondary outcomes were Stroke Impact Scale (SIS) version 2.0, Modified Ashworth Scale (MAS), and stroke recovery 0-100 visual analogue scale (VAS) scores; all measured at baseline and 3 months after intervention. Group differences and effect sizes (Cohen's d) were calculated on intention-to-treat sample. RESULTS: Although overall improvements were higher in the IHMs group than placebos with small to medium effect sizes, the group differences were statistically non-significant (all P>0.05, unpaired t-tests). Improvement in SIS physical problems was significantly higher in IHMs than placebos (mean difference 2.0, 95% confidence interval 0.3 to 3.8, P = 0.025, unpaired t-test). Causticum, Lachesis mutus, and Nux vomica were the most frequently prescribed medicines. No harms, unintended effects, homeopathic aggravations or any serious adverse events were reported from either group. CONCLUSION: There was a small, but non-significant direction of effect favoring homeopathy against placebos in treatment of post-stroke hemiparesis. TRIAL REGISTRATION: CTRI/2018/10/016196; UTN: U1111-1221-7664.

Severe Hyperkalemia Masquerading as Acute Ischemic Stroke: A Case Report.

Severe hyperkalemia usually presents as cardiac or neurologic manifestations. We report a case of a 63-year-old Caucasian woman, who was admitted to Namazi Hospital, affiliated with Shiraz University of Medical Sciences (Shiraz, Iran) in August 2019. The patient suffered from left-sided weakness and slurred speech for one hour prior to admission. Initially, the patient was treated for acute ischemic stroke, and an intravenous recombinant tissue plasminogen activator (IV-rTPA) was prescribed. However, further investigations showed severe hyperkalemia. Hemiparesis and slurred speech improved significantly with appropriate management of hyperkalemia. To the best of our knowledge, this is the first case of hyperkalemia masquerading as acute ischemic stroke without evidence of concomitant central nervous system malignancies, large vessel atherosclerosis, or recreational drug abuse. Stroke mimics due to hyperkalemia should be considered in any patient with simultaneous sudden onset of focal neurologic deficits and tall peaked T waves, particularly in the context of renal failure and a history of potassium-sparing drug use.

Continuous Tissue Plasminogen Activator Infusion Using a Minimally Invasive Irrigating Catheter for the Treatment of Intraparenchymal Hemorrhage Within the Basal Ganglia: Case Reports.

BACKGROUND AND IMPORTANCE: Intraparenchymal hemorrhage (IPH) is a debilitating and highly morbid type of stroke with limited effective treatment modalities. Minimally invasive evacuation with tissue plasminogen activator (rt-PA) has demonstrated promise for mortality/functional improvements with adequate clot volume reduction. In this study, we report 2 cases of continuous rt-PA infusion using a closed circuit, dual lumen catheter, and irrigation system (IRRAflow) for IPH treatment. CLINICAL PRESENTATION: A 55-year-old man was admitted for acute onset left hemiparesis; he was found to have right basal ganglia IPH. He was treated with continuous rt-PA irrigation using the IRRAflow device, at a rate of 30 mL/h for 119 hours, with a total volume reduction of 87.8 mL and post-treatment volume of 1.2 mL. At 3-month follow-up, he exhibited a modified Rankin score of 4 and improved hemiparesis. A 39-year-old woman was admitted for acute onset left facial droop, left hemianopsia, and left hemiparesis; she was diagnosed with a right basal ganglia IPH. She was treated with drainage and continuous rt-PA irrigation at 30 mL/h for 24 hours, with a total hematoma volume reduction of 41 mL and with a final post-treatment volume of 9.1 mL. At 3-month follow-up, she exhibited a modified Rankin score of 3 with some improvement in left hemiparesis. CONCLUSION: Continuous rt-PA infusion using a minimally invasive catheter with saline irrigation was feasible and resulted in successful volume reduction in 2 patients with IPH. This technique is similar to the Minimally Invasive Surgery Plus rt-PA for Intracerebral Hemorrhage Evacuation (MISTIE) approach but offers the potential advantages of less breaks in the sterile circuit, continuous intracranial pressure monitoring, and may provide more efficient clot lysis compared with intermittent bolusing.

Effects of Citrus depressa Hayata Fruit Extract on Thigh Muscles Mass and Composition in Subacute Stroke Patients: A Double-Blind, Randomized, Controlled Pilot Trial.

Objective: This pilot study evaluated the effects of Citrus depressa Hayata fruit extract (CFEx) on thigh muscle cross-sectional area (CSA) and composition in subacute stroke patients with hemiparesis who were undergoing rehabilitation. Design and Intervention: This double-blinded, placebo-controlled, randomized pilot trial included 40 subacute stroke patients with moderate-to-severe hemiparesis, and they were randomly assigned to receive CFEx or placebo supplements for 12 weeks. The thigh muscle CSA was measured by computed tomography as total muscle area defined by Hounsfield units (HU) values of -29 to 150 HU. The total muscle area was divided into muscle area with fat infiltration and normal muscle area to evaluate muscle composition (-29 to 29 and 30 to 150 HU, respectively). Results: At baseline, the total muscle area and normal muscle area in the paretic thigh were lower than those in the nonparetic thigh. The nonparetic normal muscle area was significantly higher in the CFEx group than in the placebo group at 12 weeks, whereas the total muscle area was not different. Conclusions: The thigh muscle CSA and composition in the paretic side have already deteriorated in patients with moderate-to-severe hemiparesis at the subacute stroke stage. CFEx supplementation during rehabilitation might improve the nonparetic thigh muscle composition in subacute stroke patients. Findings of this study are needed to be verified by a large-scale randomized trial since this study was a pilot study with a small sample size. Trial registration: UMIN Clinical Trial Registry (UMIN ID: UMIN000012902).

Prevesicular herpes zoster lumbar radiculopathy with transient motor paresis: A case report.

RATIONALE: Herpes zoster frequently causes dermatomal vesicular rash accompanied by severe neuralgia, and reaching a differential diagnosis may be challenging before the appearance of the vesicular rash. PATIENT CONCERNS: A 40-year-old male patient visited the emergency department with a complaint of sudden onset motor weakness and ipsilateral radiating neuralgia to the Lt. thigh. He had suffered from chickenpox during childhood. DIAGNOSES: No skin lesion was present at the initial visit. The reverse Straight Leg Raise test was negative. Magnetic resonance imaging showed asymmetrically swollen dorsal root ganglion with Gadolinium enhancement. The vesicular rash that appeared on the sixth day after the symptom onset led to the diagnosis of herpes zoster. INTERVENTIONS: Antiviral agent of valacyclovir (1000 mg t.i.d.) was administered for 7 days. OUTCOMES: The patient recovered from motor weaknesses by 2 weeks from the onset of the symptom. Mild degree post-herpetic neuralgia recovered by 2 months. LESSONS: A high index of suspicion is necessary to differentiate early herpes zoster radiculitis before the appearance of vesicular rash from compressive radiculopathy. In L2-3 ipsilateral radiating pain along the dermatome or myotome, the absence of reverse Straight Leg Raise sign may be a possible factor in differentiating herpes zoster radiculitis from compressive radiculopathy.

The Effect of Repeated abobotulinumtoxinA (Dysport®) Injections on Walking Velocity in Persons with Spastic Hemiparesis Caused by Stroke or Traumatic Brain Injury.

BACKGROUND: Botulinum toxin (BoNT) injections were shown to improve muscle tone of limbs in patients with spasticity. However, limited data are available regarding the effects of repeated BoNT injections on walking ability. OBJECTIVE: To assess changes in walking velocity (WV), step length, and cadence under different test conditions after repeated treatment with abobotulinumtoxinA (aboBoNT-A; Dysport) in spastic lower limb muscles. DESIGN: Secondary analysis of an open-label, multiple-cycle extension (National Clinical Trials number NCT01251367) to a phase III, double-blind, randomized, placebo-controlled, single-treatment cycle study, in adults with chronic hemiparesis (NCT01249404). SETTING: Fifty-two centers across Australia, Belgium, the Czech Republic, France, Hungary, Italy, Poland, Portugal, Russia, Slovakia, and the United States. PATIENTS: 352 Ambulatory adults (18-80 years) with spastic hemiparesis and gait dysfunction caused by stroke or traumatic brain injury, with a comfortable barefoot WV of 0.1 to 0.8 m/s. INTERVENTIONS: Up to four aboBoNT-A treatment cycles, administered to spastic lower limb muscles. MAIN OUTCOME MEASUREMENTS: Changes from baseline in comfortable and maximal barefoot and with shoes WV (m/s), step length (m/step), and cadence (steps/minutes). RESULTS: At Week 12 after four injections, WV improved by 0.08 to 0.10 m/s, step length by 0.03 to 0.04 m/step, and cadence by 3.9 to 6.2 steps/minutes depending on test condition (all P < .0001 to .0003 vs baseline). More patients (7% to 17%) became unlimited community ambulators (WV ≥0.8 m/s) across test conditions compared with baseline, with 39% of 151 patients classified as unlimited community ambulators in at least one test condition and 17% in all four test conditions. CONCLUSIONS: Clinically meaningful and statistically significant improvements in WV, step length, and cadence under all four test conditions were observed in patients with spastic hemiparesis after each aboBoNT-A treatment cycle.

Extraocular Muscle Palsy in Patients with Chronic Orbital Myositis.

BACKGROUND: Orbital myositis (OM) is a subgroup of idiopathic orbital inflammation. It can involve single or multiple extraocular muscles and result in restriction or paresis of extraocular muscles. METHOD: We reported two unusual cases of extraocular muscle paresis in the fibrotic stage of chronic OM and reviewed the literature related to this finding. RESULTS: The first case was of a 38-year-old woman with chronic OM with large-angle right eye exotropia and right medial rectus paresis. She received a botulinum A toxin injection into the right lateral rectus muscle as a first treatment, but it was unsuccessful in correcting her deviation. Subsequently, she underwent two strabismus surgeries, which successfully resolved her diplopia in primary gaze. The second case was of a 35-year-old woman with chronic OM and left lateral rectus palsy, which was managed with a botulinum A toxin injection. CONCLUSION: OM can cause extraocular muscle palsy in the chronic fibrotic stage of the disease.

Effect of treating elbow flexor spasticity with botulinum toxin injection and adjunctive casting on hemiparetic gait parameters: A prospective case series.

OBJECTIVE: To investigate changes in hemiparetic gait parameters after treatment of elbow flexor spasticity with botulinum neurotoxin (BoNT) injection and adjunctive casting. DESIGN: Prospective case series. SUBJECTS: Ten participants with spasticity secondary to acquired brain injury (8 stroke, 2 traumatic brain injury). INTERVENTIONS: Participants received BoNT injections for their spastic elbow flexors under ultrasound guid-ance. Two weeks post-injection, an elbow stretching cast was applied for 1 week. OUTCOME MEASURES: Assessments using the Modified Ashworth Scale (MAS), Tardieu scale V1 angle of arrest at slow speed and V3 angle of catch at fast speed, 2-min walk test (2MWT), Edinburgh Gait Score scale (EGS) and video gait analysis for step-length symmetry were conducted pre-BoNT injection (t0) and at cast removal (t1). Goal attainment scale (GAS) was used to assess changes in spasticity and gait 3 months post-injection (t2). RESULTS: At t1, participants showed a mean increase of 16.7° (p < 0.01) on the Tardieu Scale V3 and a mean reduction of 0.5 points on the MAS (p < 0.05). There was also a mean reduction on EGS of 2.7 points (p < 0.05), and a mean increase on 2MWT of 3.1 m (p < 0.05). On the GAS, all participants report-ed impro-ved gait at t2 and 80% reported a decrease in spasticity. CONCLUSION: Combining BoNT injection with casting for treatment of elbow flexor spasticity without treat-ing the lower limb may improve hemiparetic gait parameters.

Efficacy of botulinum toxin A for the treatment of hemiparesis in adults with chronic upper limb spasticity.

INTRODUCTION: this study aimed to evaluate the effectiveness of botulinum toxin A (BoNT-A) injection in hemiparetic patients with chronic spasticity in the upper limb resulting from stroke or traumatic brain injury. METHODS: we conducted a retrospective study including 45 patients seen, in our department of Physical Medicine and Rehabilitation, between January 2014 and December 2016. All patients received an injection of BoNT-A (Dysport, 100 U/ml). Affected upper-extremity muscles could be injected as per the investigator's discretion to a maximum total dose of 1000 U. We evaluated muscle tone using Modified Ashworth Scale (MAS). Functional disability was assessed using Modified Frenchay Scale (MFS), Nine Hole Peg Test (NHPT) and Barthel Index (BI). Quality of life (QoL) was assessed using the 36-Item Short Form Health Survey (SF-36). The achievement of treatment goal was assessed by the Goal Attainment Scaling (GAS). RESULTS: patients decreased their MAS score over the first and the third months (p<0.05). MFS showed improvement at 1 month after injection with a median change from baseline of 8 (range: 1-16; p<0.001). The change from baseline ranged from 0 to 5 points for NHPT at 1 month after injection (p< 0.001). This functional improvement was maintained to 3 months. Improvements in Barthel Index was observed at 3 months with a median change from baseline of 5 points (range 0-15; p<0.001). The mean change from baseline of SF-36 score was 4.77 ± 3.39 (p<0.001). The mean GAS T-score was 47.04 ±7.78 (median 50, IQR 7.7), giving a mean (SD) change from baseline of 25.36 ± 8.46 (95% CI 22.82 to 27.90; p <0.001). Binary logistic regression was used to identify the independent factors predicting a favorable functional outcome of Bon-T treatment. It showed that neglect was independent predictive factor treatment failure (p=0.009, OR=3.2) while previous injection of BoNT-A was an independent predictive factors of treatment success (p=0.009, OR=0.3). CONCLUSION: our study showed a good response to BoNT-A injection delivered in the management of chronic upper limb spasticity resulting from stroke or traumatic brain injury. It demonstrated its outcome in improving muscle tone, function and QoL. It also showed that the majority of patients achieved their goal as defined at the start of the treatment, mainly for patients who received previous injection of BoNT-A.

Motor recovery of hemiparetic leg by improvement of limb-kinetic apraxia in a chronic patient with traumatic brain injury: A case report.

RATIONALE: Limb-kinetic apraxia (LKA), a kind of apraxia, means the inability to perform precise and voluntary movements of extremities resulting from injury of the premotor cortex (PMC) or the corticofugal tract (CFT) from the PMC. Diagnosis of LKA is made by observation of movements without specific assessment tools. PATIENT CONCERNS: A 44-year-old male underwent conservative management for traumatic intracerebral hemorrhage in the left basal ganglia and subarachnoid hemorrhage due to a pedestrian-car crash. When he was admitted to the rehabilitation department of a university hospital after 41 months after onset, he presented with right hemiparesis (Medical Research Council (MRC): shoulder abductor; 3, elbow flexor; 3, finger extensor; 0, hip flexor; 2- [range: 30°], knee extensor; 1 and ankle dorsiflexor; 3-). In addition, he exhibited slow, clumsy, and mutilated movements when performing movements of his right ankle. DIAGNOSES: The patient was diagnosed as traumatic brain injury (TBI). INTERVENTIONS: Clinical assessments and DTI were performed at 41 and 44 months after onset. During three months, rehabilitative therapy was performed including dopaminergic drugs (pramipexole 2.5 mg, ropinirole 2.5 mg, and amantadine 300 mg, and carbidopa/levodopa 75 mg/750 mg). OUTCOMES: The right leg weakness slowly recovered during 3 months, until 44 months after the initial injury (MRC: shoulder abductor, 3; elbow flexor, 3; finger extensor, 0; hip flexor, 3; knee extensor, 3; and ankle dorsiflexor, 3+). The fiber number of the right corticospinal tract (CST) was decreased on 44-month diffusion tensor tractography (DTT) (1319) compared with 41-month DTT (1470) and the left CST was not reconstructed on both DTTs. The fiber number of both CRTs were decreased on 44-month DTT (right: 1547, left: 698) than 41-month DTT (right: 3161, left: 1222). LESSONS: A chronic patient with TBI showed motor recovery of the hemiparetic leg by improvement of LKA after rehabilitation. This results have important implications for neurorehabilitation.

Postintravenous immunoglobulin stroke in a toddler with Down syndrome: a diagnostic challenge.

Children with Down syndrome have a higher risk of stroke. Similarly, intravenous immunoglobulin (IV Ig) is also known to cause a stroke. We reported a 3-year-old boy with Down syndrome who presented with severe pneumonia and received IV Ig. He developed right hemiparesis 60 hours after the infusion. Blood investigations, echocardiography and carotid Doppler did not suggest vasculitis, thrombophilia or extracranial dissection. Brain computerised tomography (CT) showed acute left frontal and parietal infarcts. Initial magnetic resonance angiography (MRA) of cerebral vessels showed short segment attenuations of both proximal middle cerebral arteries and reduction in the calibre of bilateral supraclinoid internal carotid arteries. The boy was treated with enoxaparin and aspirin. He only had partial recovery of the hemiparesis on follow-up. A repeat MRA 13 months later showed parenchymal collateral vessels suggestive of moyamoya disease. We recommend imaging the cerebral vessels in children with a high risk of moyamoya before giving IV Ig.

Composite active range of motion (CXA) and relationship with active function in upper and lower limb spastic paresis.

OBJECTIVE: The aim of this study is to evaluate a novel composite measure of active range of motion (XA) and determine whether this measure correlates with active function. DESIGN: Post hoc analysis of two randomized, placebo-controlled, double-blind studies with open-label extensions exploring changes in active function with abobotulinumtoxinA. SETTING: Tertiary rehabilitation centers in Australia, Europe, and the United States. SUBJECTS: Adults with upper (n = 254) or lower (n = 345) limb spastic paresis following stroke or brain trauma. INTERVENTIONS: AbobotulinumtoxinA (⩽5 treatment cycles) in the upper or lower limb. MAIN MEASURES: XA was used to calculate a novel composite measure (CXA), defined as the sum of XA against elbow, wrist, and extrinsic finger flexors (upper limb) or soleus and gastrocnemius muscles (lower limb). Active function was assessed by the Modified Frenchay Scale and 10-m comfortable barefoot walking speed in the upper limb and lower limb, respectively. Correlations between CXA and active function at Weeks 4 and 12 of open-label cycles were explored. RESULTS: CXA and active function were moderately correlated in the upper limb (P < 0.0001-0.0004, r = 0.476-0.636) and weakly correlated in the lower limb (P < 0.0001-0.0284, r = 0.186-0.285) at Weeks 4 and 12 of each open-label cycle. Changes in CXA and active function were weakly correlated only in the upper limb (Cycle 2 Week 12, P = 0.0160, r = 0.213; Cycle 3 Week 4, P = 0.0031, r = 0.296). Across cycles, CXA improvements peaked at Week 4, while functional improvements peaked at Week 12. CONCLUSION: CXA is a valid measure for functional impairments in spastic paresis. CXA improvements following abobotulinumtoxinA injection correlated with and preceded active functional improvements.

Efficacy and Safety of AbobotulinumtoxinA for the Treatment of Hemiparesis in Adults with Lower Limb Spasticity Previously Treated With Other Botulinum Toxins: A Secondary Analysis of a Randomized Controlled Trial.

OBJECTIVE: To examine the safety and efficacy of abobotulinumtoxinA in patients previously treated with botulinum toxin type A (BoNT-A) products other than abobotulinumtoxinA. DESIGN: Secondary analysis from a phase 3, double-blind, single-cycle, randomized, placebo-controlled study. SETTING: Fifty-two centers (11 countries). PATIENTS: Adults with spastic hemiparesis were randomized (1:1:1) to receive abobotulinumtoxinA 1000 U, 1500 U, or placebo in their affected lower limb. MAIN OUTCOME MEASUREMENTS: Muscle tone (6-point Modified Ashworth Scale [MAS], 0-5) for the gastrocnemius-soleus complex (GSC); proportion of MAS responders (≥1-point improvement); angle of catch (XV3 ) and spasticity grade (Y) for the GSC and soleus. Assessments were at weeks 1, 4, and 12 post-injection. Only descriptive statistics are presented. RESULTS: Of 388 patients, 84 received previous BoNT-A treatment (abobotulinumtoxinA 1000 U: N = 30; abobotulinumtoxinA 1500 U: N = 28; placebo: N = 26). At week 4, mean (SD) changes in MAS score in the GSC were - 0.8 (1.1), -0.9 (1.0), and - 0.4 (0.7) for abobotulinumtoxinA 1000 U, 1500 U, and placebo, respectively. Greater MAS responder rates were observed for abobotulinumtoxinA versus placebo at all time points. Mean (SD) changes (week 4) for abobotulinumtoxinA 1000 U, 1500 U, and placebo for XV3 were: GSC, 8° (21), 6° (10) and 1° (7); soleus, 11° (21), 5° (9) and 0° (8), respectively; for Y: GSC, -0.4 (0.7), -0.6 (0.8) and - 0.0 (0.9); soleus, -0.5 (0.7), -0.5 (0.7) and - 0.1 (0.6), respectively. Safety data and adverse events were consistent with the overall known profile of abobotulinumtoxinA. CONCLUSIONS: Patients previously treated with other BoNT-As showed improved muscle tone and spasticity at week 4 following abobotulinumtoxinA injection versus placebo. These findings suggest that abobotulinumtoxinA, at the recommended doses, has a good safety and efficacy profile in adults with lower limb spasticity who were previously treated with other BoNT-A products.

Effects on walking of simultaneous upper/lower limb abobotulinumtoxina injections in patients with stroke or brain injury with spastic hemiparesis.

OBJECTIVE: To compare walking speed in patients with spastic hemiparesis who received abobotulinumtoxinA either in the lower limb or simultaneously in both the lower and upper limbs. DESIGN: Post hoc analysis from a phase 3 study of abobotulinumtoxinA (Dysport®, NCT01251367). PATIENTS: Adult patients with spastic hemiparesis causing gait dysfunction. METHODS: Comfortable barefoot walking speed over 10 m was evaluated in patients receiving lower limb vs lower and upper limb injections over ≤4 treatment cycles; 1,000 U or 1,500 U in lower limb for cycle 1/2; optional upper limb injections from cycle 3 (500 U: upper limb, 1,000 U: lower limb). RESULTS: Mean (standard deviation; SD) lower limb cycle 3/4 doses were lower in the lower plus upper limb group vs lower limb only (1,000 U (SD 50), 1,000 U (SD 50) vs 1,380 U (SD 210), 1,360 U (SD 220). Baseline comfortable barefoot walking speed was similar between groups. Changes at cycle 3 week 4, in m/s, were: lower and upper limb: +0.063 (SD 0.131); lower limb only: +0.078 (SD 0.114), and cycle 4 week 4: lower and upper limb: +0.086 (SD 0.166); lower limb only: +0.086 (SD 0.123). CONCLUSION: Simultaneous lower and upper limb abobotulinumtoxinA treatment does not hamper improvement in walking speed compared with lower limb treatment alone. Thus, physicians may split the 1,500 U abobotulinumtoxinA dose as needed to best treat patients with spastic paresis.