The Role of Botulinum Toxin Type-A in Spasticity: Research Trends from a Bibliometric Analysis.

Botulinum toxin type-A (BoNT-A) has emerged as a key therapeutic agent for the management of spasticity. This paper presents a comprehensive bibliometric and visual analysis of research concerning BoNT-A treatment of spasticity to elucidate current trends and future directions in this research area. A search was conducted in the Web of Science database for articles focused on the use of BoNT-A in spasticity published between 2000 and 2022. We extracted various metrics, including counts of publications and contributions from different countries, institutions, authors, and journals. Analytical methods in CiteSpace were employed for the examination of co-citations, collaborations, and the co-occurrence of keywords. Our search yielded 1489 publications. Analysis revealed a consistent annual increase in research output. The United States, United Kingdom, and Italy were the leading contributors. The top institution in this research was Assistance Publique Hopitaux, Paris. The journal containing the highest number of relevant publications was Toxins. Key frequently occurring keywords were 'stroke', 'cerebral palsy', 'adult spasticity', and 'upper extremity'. This study identified 12 clusters of keywords and 15 clusters of co-cited references, indicating the main focus areas and emerging themes in this field. This study comprehensively analyzed and summarized trends in BoNT-A research in the field of spasticity over the past 22 years.

May Spasticity-Related Unpleasant Sensations Interfere with Daily Activities in People with Stroke and Traumatic Brain Injury? Secondary Analysis from the CORTOX Study.

Background/Objectives: This study examined the impact of spasticity-related unpleasant sensations (pain, heaviness, stiffness) on various domains of the International Classification of Functioning, Disability, and Health (ICF) and psychosocial well-being in individuals affected by stroke or traumatic brain injury (TBI). The primary aim is to explore how these sensations affect daily activities, participation, and overall quality of life, guided by the comprehensive framework of the ICF. Methods: Utilizing a secondary analysis of data from a cohort undergoing Botulinum toxin type-A treatment for spasticity post-stroke or TBI, we developed and administered an ad-hoc questionnaire focusing on ICF domains such as body function, activities and participation, and psychosocial aspects such as mood, relationship, social life, motivation, and sleep quality. Spearman rho correlation was applied to assess the relationship between unpleasant sensations and functional as well as psychosocial outcomes among 151 participants. Results: This study identified significant correlations between the severity of unpleasant sensations and limitations in daily functioning, particularly in activities of daily living and mobility. Furthermore, an impactful association was identified between increased unpleasant sensations and deterioration in psychosocial well-being, notably in mood and sleep quality. Conclusions: These findings advocate for a person-centered approach in spasticity management, emphasizing the integration of sensory impairment strategies into rehabilitation to enhance functional outcomes and quality of life. Such an approach aims to improve functional outcomes and enhance the quality of life for individuals experiencing spasticity post-stroke or TBI. Future directions include targeted interventions to alleviate these sensations, support better rehabilitation results and improve patient experiences.

Anatomical landmarks for ultrasound-guided rectus femoris diagnostic nerve block in post-stroke spasticity.

Introduction/Purpose: To determine the location of the rectus femoris (RF) motor branch nerve, as well as its coordinates with reference to anatomical and ultrasound landmarks. Methods: Thirty chronic stroke patients with stiff knee gait (SKG) and RF hyperactivity were included. The motor nerve branch to the RF muscle was identified medially to the vertical line from anterior superior iliac spine and the midpoint of the superior margin of the patella (line AP) and vertically to the horizontal line from the femoral pulse and its intersection point with the line AP (line F). The point of the motor branch (M) was located with ultrasound, and nerve depth and subcutaneous tissue thickness (ST) were calculated. Results: The coordinates of the motor branch to the RF were 2.82 (0.47) cm medially to the line AP and 4.61 (0.83) cm vertically to the line F. Nerve depth and subcutaneous tissue thickness were 2.71 (0.62) cm and 1.12 (0.75) cm, respectively. Conclusion: The use of specific coordinates may increase clinicians' confidence when performing RF motor nerve block. This could lead to better decision-making when assessing SKG in chronic stroke patients.

Rehabilitation interventions for glioma patients: a mini-review.

Glioma is a group of tumors that originate from glial cells within the central nervous system and comprise 27% of all tumors and 80% of malignant tumors. With remarkable progress in surgical practices, chemotherapy, and radiation therapy, patients with glioma are experiencing greater survival times, which means they need more rehabilitative care. In fact, people with this condition may experience a variety of symptoms that can affect their functions and drastically reduce their quality of life. In fact, patients suffering from glioma has a distinctive symptom complex highlighting the requirement for customized care. Growing evidence shows that rehabilitation therapy can improve the functional prognosis and quality of life of glioma patients. However, there is limited evidence of the success of rehabilitation protocols designed specifically for individuals with glioma. It is essential to determine the most comprehensive rehabilitation programs as well as the sufficient resources, dosage, and duration. The goal of this mini-review was to classify and map rehabilitation interventions used to treat multiple disabling sequalae in individuals affected by glioma. We aim to provide a comprehensive overview of the rehabilitation protocols used for this population, so that clinicians have a guide to support treatment and an inspiration for further research. This document is intended to be a reference point for professionals involved in the management of adult patients with gliomas. Further exploration is needed to form improved care models for recognizing and addressing functional restrictions in this population.

Sensor-Based Rehabilitation in Neurological Diseases: A Bibliometric Analysis of Research Trends.

BACKGROUND: As the field of sensor-based rehabilitation continues to expand, it is important to gain a comprehensive understanding of its current research landscape. This study aimed to conduct a bibliometric analysis to identify the most influential authors, institutions, journals, and research areas in this field. METHODS: A search of the Web of Science Core Collection was performed using keywords related to sensor-based rehabilitation in neurological diseases. The search results were analyzed with CiteSpace software using bibliometric techniques, including co-authorship analysis, citation analysis, and keyword co-occurrence analysis. RESULTS: Between 2002 and 2022, 1103 papers were published on the topic, with slow growth from 2002 to 2017, followed by a rapid increase from 2018 to 2022. The United States was the most active country, while the Swiss Federal Institute of Technology had the highest number of publications among institutions. Sensors published the most papers. The top keywords included rehabilitation, stroke, and recovery. The clusters of keywords comprised machine learning, specific neurological conditions, and sensor-based rehabilitation technologies. CONCLUSIONS: This study provides a comprehensive overview of the current state of sensor-based rehabilitation research in neurological diseases, highlighting the most influential authors, journals, and research themes. The findings can help researchers and practitioners to identify emerging trends and opportunities for collaboration and can inform the development of future research directions in this field.

Sensor based assessment of turning during instrumented Timed Up and Go Test for quantifying mobility in chronic stroke patients.

BACKGROUND: Turning may be particularly challenging for stroke patients leading to decreased mobility and increased functional restriction. Timed up and go instrumentation using a simple technology in the clinical context could allow for the collection of both traditional and potentially more discriminatory variables in turning ability. AIM: Determine whether the speed turning metrics obtained by a single inertial sensor are suitable for differentiating between stroke patients with varying levels of mobility and disability. DESIGN: Cross-sectional study. SETTING: Outpatients setting. POPULATION: Chronic stroke patients. METHODS: A total of 48 chronic stroke patients and 23 healthy controls were included. Stroke patients were divided in two groups based on the total iTUG score: an impaired mobility (> 20 seconds) and an available mobility (<20 seconds) group. All subjects performed an instrumented Timed Up and Go (iTUG) wearing a single IMU sensor on the lower back. Time of subcomponents of the timed up and go test and kinematic parameters of turning were quantified. Other clinical outcomes were: 10 meters walk test, Functional Ambulation Categories Scale (FAC), the Rivermead Mobility Index (RMI), Modified Rankin Scale and the Saltin-Grimby Physical Activity Level Scale (SGPALS). RESULTS: There were significant differences (P<0.01) in iTUG phases and turning speeds among groups. Low to strong significant correlations were found between measures derived from the turning speeds and clinical measures. The area under the curve (AUC) of Receiver Operating Characteristic (ROC) turning speeds was demonstrated to be able to discriminate (AUC: 0.742-0.912) from available to impaired stroke patients. CONCLUSIONS: This study provides evidence that turning speeds during timed up and go test are accurate measures of mobility and capable of discriminating stroke patients with impaired mobility from those with normal mobility. CLINICAL REHABILITATION IMPACT: The turning metrics are related to impairment and mobility in chronic stroke patients; hence they are important to include during clinical evaluation and may assist in creating a customized strategy, assess potential treatments, and effectively organize recovery.

Reference theories and future perspectives on robot-assisted rehabilitation in people with neurological conditions: A scoping review and recommendations from the Italian Consensus Conference on Robotics in Neurorehabilitation (CICERONE).

BACKGROUND: Robot-based treatments are developing in neurorehabilitation settings. Recently, the Italian National Health Systems recognized robot-based rehabilitation as a refundable service. Thus, the Italian neurorehabilitation community promoted a national consensus on this topic. OBJECTIVE: To conceptualize undisclosed perspectives for research and applications of robotics for neurorehabilitation, based on a qualitative synthesis of reference theoretical models. METHODS: A scoping review was carried out based on a specific question from the consensus Jury. A foreground search strategy was developed on theoretical models (context) of robot-based rehabilitation (exposure), in neurological patients (population). PubMed and EMBASE® databases were searched and studies on theoretical models of motor control, neurobiology of recovery, human-robot interaction and economic sustainability were included, while experimental studies not aimed to investigate theoretical frameworks, or considering prosthetics, were excluded. RESULTS: Overall, 3699 records were screened and finally 9 papers included according to inclusion and exclusion criteria. According to the population investigated, structured information on theoretical models and indications for future research was summarized in a synoptic table. CONCLUSION: The main indication from the Italian consensus on robotics in neurorehabilitation is the priority to design research studies aimed to investigate the role of robotic and electromechanical devices in promoting neuroplasticity.

Reasons and Determinants of BoNT-A Treatment Discontinuation in Patients Living with Spasticity: A 10-Year Retrospective Analysis.

BACKGROUND: The present study aimed to evaluate the reasons and determinants of BoNT-A discontinuation in patients with stroke, multiple sclerosis, spinal cord injury, and traumatic brain injury. METHODS: It is a retrospective study of 56 discontinuer patients treated with botulinum toxin between January 2011 and December 2021. Discontinuation rates and their predictors were estimated using Kaplan-Meier, Log rank test, and Cox's regression method of analyses. RESULTS: The mean age was 56.54 years, 53.57% were affected by post-stroke spasticity, 17.86% by spinal cord injury, 12.5% and 16.07% by traumatic brain injury and multiple sclerosis, respectively. The median discontinuation time was 5 months. The main reason for discontinuation were logistic problems (37%) and orthopedic surgeries or intrathecal baclofen (27%). Discontinuers were more likely to have severe spasticity (R = 1.785), have no pain (HR = 1.320), no access to rehabilitation services (HR = 1.402), and have cognitive impairment (HR = 1.403). CONCLUSIONS: The main reasons for discontinuation are related to logistic issues (due to distance or the absence of an adequate caregiver) and surgical interventions for spasticity, including intrathecal baclofen. It is crucial to identify possible predictors of discontinuation to improve the effectiveness of a multidisciplinary management. The study confirms the crucial role of rehabilitation and caregivers in achieving better long-term outcomes.

Ultrasonographic Evaluation of Three Approaches for Botulinum Toxin Injection into Tibialis Posterior Muscle in Chronic Stroke Patients with Equinovarus Foot: An Observational Study.

Spastic equinovarus (SEV) foot deformity is commonly observed in patients with post-stroke spasticity. Tibialis posterior (TP) is a common target for botulinum toxin type-A (BoNT-A) injection, as a first-line treatment in non-fixed SEV deformity. For this deep muscle, ultrasonographic guidance is crucial to achieving maximum accuracy for the BoNT-A injection. In current clinical practice, there are three approaches to target the TP: an anterior, a posteromedial, and a posterior. To date, previous studies have failed to identify the best approach for needle insertion into TP. To explore the ultrasonographic characteristics of these approaches, we investigated affected and unaffected legs of 25 stroke patients with SEV treated with BoNT-A. We evaluated the qualitative (echo intensity) and quantitative (muscle depth, muscle thickness, overlying muscle, subcutaneous tissue, cross-sectional area) ultrasound characteristics of the three approaches for TP injection. In our sample, we observed significant differences among almost all the parameters of the three approaches, except for the safety window. Moreover, our analysis showed significant differences in cross-sectional area between treated and untreated. Advantages and disadvantages of each approach were investigated. Our findings can thus provide a suitable reference for clinical settings, especially for novice operators.

Transcranial Direct Current Stimulation Combined with Botulinum Neurotoxin Type A Injections for Treatment of Upper Limb Intention Tremor in Multiple Sclerosis: A Case Report.

Upper limb intention tremor is a common cause of disability in multiple sclerosis (MS). Transcranial direct current stimulation (tDCS) is an emerging form of brain stimulation used to improve sensorimotor impairments in many neurological disorders. Here, we describe a combined therapeutic approach with botulinum neurotoxin type A (BoNT-A) and tDCS for the treatment of upper limb tremor in a patient with MS. We administered a cathodal tDCS 15 days after the injections of BoNT-A. Both post-injection and post-stimulation evaluation revealed a considerable improvement of the tremor. This approach positively affected the patient's activities of daily living. Our case report shows a safe and beneficial effect of tDCS in the treatment of action tremor in MS especially as a possible adjunctive synergic treatment with BoNT-A injections.

Effectiveness of robotic balance training on postural instability in patients with mild Parkinson's disease: A pilot, single blind, randomized controlled trial.

OBJECTIVE: To examine whether tailored robotic platform training could improve postural stability compared with conventional balance treatment in patients with mild Parkinson's disease.  Design: Randomized single-blind pilot study. SUBJECTS: Twenty-two patients with mild Parkinson's disease (Hoehn and Yahr scale; HandY 1-2). METHODS: Patients were randomly assigned to an experimental group for robotic balance training and to a control group for conventional balance training. Each patient received 20 treatments (45 min/session, 5 times/week). Blinded evaluations were conducted before and after the treatment and 1 month post-treatment. Primary outcome measures were Mini BESTest, and Berg Balance Scale; secondary outcome measures were 10-Meter Walk Test, Five Times Sit to Stand Test, and Parkinson's Disease Questionnaire 39. RESULTS: Primary outcome measures in patients in both the experimental and control groups improved significantly after the balance treatment. Similar results were found for all the secondary outcome measures. The experimental group performed significantly better than the control group at both post-intervention and follow-up evaluation in the primary outcomes (p < 0.05). No significant differences be-tween groups were found in secondary outcomes. CONCLUSION: Robot-assisted balance training may be a promising tool to improve postural stability in patients with mild Parkinson's disease.

Localized muscle vibration in the treatment of motor impairment and spasticity in post-stroke patients: a systematic review.

INTRODUCTION: During the last decades, many studies have been carried out to understand the possible positive effects of vibration therapy in post-stroke rehabilitation. In particular, the use of localized muscle vibration (LMV) seems to have promising results. The aim of this systematic review was to describe the use of LMV in post-stroke patients to improve motor recovery, reducing spasticity and disability in both upper and lower limb. EVIDENCE ACQUISITION: A search was conducted on PubMed, Scopus, Pedro and REHABDATA electronic database. Only randomized controlled trials have been included, excluding no-localized vibratory treatments and other pathological conditions. Fourteen studies met the inclusion criteria and were included in this review. EVIDENCE SYNTHESIS: Collectively, the studies involved 425 stroke patients. Most studies included chronic stroke patients (ten) and treated only the upper limb (eleven). There is evidence that LMV therapy is effective in reducing spasticity and improving motor recovery, especially when associated with conventional physical therapy. CONCLUSIONS: LMV may be a feasible and safe tool to be integrated into traditional and conventional neurorehabilitation programs for post-stroke patients to reduce spasticity. Analysis of the available clinical trials do not allow us to indicate vibration therapy as effective in functional motor recovery, despite some studies showed encouraging results. Further studies, with larger size of homogeneous patients and with a shared methodology are needed to produce more reliable data, especially on the lower limb.

Discontinuation of botulinum neurotoxin type-A treatment during COVID-19 pandemic: an Italian survey in post stroke and traumatic brain injury patients living with spasticity.

BACKGROUND: The COVID-19 pandemic has affected health-care systems worldwide, including the outpatient spasticity care with botulinum neurotoxin toxin type A (BoNT-A). AIM: The aim of this study was to investigate the impact of discontinuation of BoNT-A treatment on patients living with spasticity during the COVID-19 quarantine. DESIGN: A multicentric cross-sectional study. SETTING: Outpatients setting. POPULATION: Patients with spasticity after stroke and traumatic brain injury treated with BoNT-A. METHODS: A phone-based survey was conducted from March to May, 2020. Based on the International Classification of Functioning, Disability and Health (ICF), an ad hoc questionnaire CORTOX (CORonavirus TOXin survey) was developed to investigate patients' experiences following the discontinuation of their usual treatment for spasticity due to the lockdown and its implication on their health perception. It assessed patients' condition and explored different ICF domains related to spasticity: unpleasant sensations, mobility, self-care, facilitators and psychosocial factors. The sum of those represented the CORTOX score (Max 142). The questionnaire also collected data about the impact of COVID-19 on patients' wellbeing (mood, sleep, relationships, community life, motivation). RESULTS: A total of 151 participants completed the survey. Most participants (72.2%) experienced a worsening in perceived spasticity, 53% got worse in independence and 70.9% had a negative impact on quality of life. The mean CORTOX score was 52.85±27.25, reflecting a perceived worsening in all ICF domains investigated. Moderate to strong correlations were found between different sub-scores of the questionnaire and severity of spasticity (P<0.001). COVID-19 psychosocial related factors were associated with loss of independence (P<0.05) but only mood was associated with worsening of spasticity (P<0.001). The lack of rehabilitation therapy was significantly associated with the worsening of independence but not with the worsening of spasticity. Finally, respondents reported that BoNT-A was useful to their condition and should not be discontinued. CONCLUSIONS: The discontinuation of BoNT-A treatment was associated with worsening of activities and participation and perceived spasticity. COVID-19 related problems and rehabilitation showed an association with loss of independence. CLINICAL REHABILITATION IMPACT: This study will provide useful information in the field of spasticity management using a patient's centred approach, with consistent quantitative and qualitative information.

Combined Effects of Isokinetic Training and Botulinum Toxin Type A on Spastic Equinus Foot in Patients with Chronic Stroke: A Pilot, Single-blind, Randomized Controlled Trial.

Botulinum toxin A (BoNT-A) has been shown effective for poststroke lower limb spasticity. Following injections, a wide range of multidisciplinary approach has been previously provided. The purpose of this pilot, single-blind, randomized controlled trial was to determine whether BoNT-A combined with a regime of a four-week ankle isokinetic treatment has a positive effect on function and spasticity, compared with BoNT-A alone. Secondly, the validity of the use of an isokinetic dynamometer to measure the stretch reflex at the ankle joint and residual strength has been investigated. Twenty-five chronic stroke patients were randomized to receive combined treatment (n = 12; experimental group) or BoNT-A alone (n = 13; control group). Outcome measures were based on the International Classification of Functioning, Disability and Health. An isokinetic dynamometer was also used for stretch reflex and strength assessment. Patients were evaluated at baseline (t0), after five (t1) and eight weeks after the injection (t2). The experimental group reported significantly greater improvements on lower limb spasticity, especially after eight weeks from baseline. Gait speed (10-m walk test) and walking capacity (6-min walking test) revealed statistically significantly better improvement in the experimental than in control group. Peak resistive ankle torque during growing angular velocities showed a significant reduction at the higher velocities after BoNT-A injections in the experimental group. Peak dorsiflexor torque was significantly increased in the experimental group and peak plantarflexor torque was significantly decreased in control group. Alternative rehabilitation strategies that combine BoNT-A and an intense ankle isokinetic treatment are effective in reducing tone and improving residual strength and motor function in patients with chronic hemiparesis.