[Management of neurogenic bladder patients in France: a survey carried out by the French-speaking neurourology study group (GENULF)]. / Prise en charge des patients ayant une vessie neurologique en France: une enquête du groupe d'études de neuro-urologie de langue française (GENULF).

OBJECTIVE: To design and run a survey aiming at investigating urologists' and physiatrists' clinical practices in France when managing neurogenic bladder patients. PATIENTS AND METHODS: Three thousand one hundred and eighty questionnaires were sent to the members of four French societies involved in treating neurogenic bladder dysfunction. Questions were focused on consultations, clinical follow-up and patient management. RESULTS: Two hundred and seventy-four urologists and 109 physiatrists completed the questionnaire. The frequency of systematic follow-up differed between urologists (6 months) and physiatrists (12 months). Upper urinary tract imaging and systematic urodynamic follow-up were usually performed yearly. The latter was carried out by 56% urologists and 83% physiatrists. Urinary retention was essentially treated by intermittent catheterization. Less than 15% of urologists and physiatrists were treating bacteriuria. Symptomatic urinary infections were treated for 11 to 12 days (men) and for 8 to 9 days (women). To treat their patients, both specialists used self-catheterization education and botulinum toxin A injections. CONCLUSION: Our survey showed differences in approach between urologists and physiatrists in the management of patients with neurogenic bladder dysfunction. Their clinical practice was most of the time in line with national and international guidelines.

Clinical tools for assessing balance disorders.

Three main issues have to be addressed by the examination of a patient complaining from balance disorders: physiopathology and aetiology, severity and consequences, and evolution. A precise clinical analysis must be then conducted, including close anamnesis and clinical examination, with scale measurements depending on the objectives. Daily consequences can be assessed by the Dizziness Handicap Inventory, which considers a large field of daily activities. The International Classification of Functioning evaluates activities and participation, influence of environmental factors, and quality of life. Then, patient's examination aims at objectifying and measuring the balance disorder. Quantified measurement is possible even in a simple doctor's office. Clinical scales for balance assessment should be used for a standardized assessment and to allow comparison of different subjects. Although the Tinetti test is the most-widely used in older people, it is quite approximate. The Berg Balance Scale has also been first validated in older people, it is rather easy to use, but uncertainty between two close scores is frequent. The Timed Up-and-Go Test is the simplest one and probably the most reliable. The Unipodal Stance Testing is also a simple test and a good predictor of fall. The Functional Ambulation Classification focuses attention on the physical support needed by the patient during walking. The Postural Assessment Scale for Stroke Patients (PASS) is easy to use after a recent stroke. Instrumental analysis by means of static and dynamic platforms, often coupled together with accelerometers or video, can be used to complete the clinical examination. Its main interest is to contribute to give insight into physiologic and pathologic mechanisms underlying the postural trouble.

[Texts ruling activity in nursing homes and rehabilitation institutions in France, from the 9th March 1956 decree to the 17th April 2008 decrees. Part of physical medicine and rehabilitation]. / Les textes réglementant l'activité en soins de suite et de réadaptation du décret du 9 mars 1956 aux décrets du 17 avril 2008. Place de la médecine physique et de réadaptation.

In France, inpatient care is provided in three different sectors: "medicine, surgery and obstetrics", "follow-up care and rehabilitation" (soins de suite et de réadaptation=SSR) and "long-term care". Physical medicine and rehabilitation is involved mainly in SSR. As of April 2008, there are new regulations aiming to improve prior texts, to implement rules that will be identical for public and private sectors and to prepare for the new payment-by-the-act funding system (in place of the prior global funding). Now, all SSR structures have a common general basis in terms of purpose and means and specific rules for various specialties. For example, coordination of a multidisciplinary team in specialized facilities dealing with musculoskeletal and nervous system disorders must be conducted by a physical medicine and rehabilitation (PMR) specialist. Patient admission criteria still need to be defined, as does the assessment of therapeutic objectives. The expertise of SSR facilities is recognized by the possibility of direct admission from home for ambulatory patients. Nevertheless, many specifics are missing in these new decrees. These specifications will be elaborated on a regional basis, in future endeavours within regional healthcare organizations.

Influence of subjective visual vertical misperception on balance recovery after stroke.

BACKGROUND: Subjective visual vertical (SVV) perception can be perturbed after stroke, but its effect on balance recovery is not yet known. AIM: To evaluate the influence of SVV perturbations on balance recovery after stroke. METHODS: 28 patients (14 with a right hemisphere lesion (RHL) and 14 with a left hemisphere lesion (LHL)) were included, 5 were lost to follow-up. SVV perception was initially tested within 3 months after stroke, then at 6 months, using a luminous line, which the patients adjusted to the vertical position in a dark room. Mean deviation (V) and uncertainty (U), defined as the standard deviation of the SVV, were calculated for eight trials. Balance was initially assessed by the Postural Assessment Scale for Stroke (PASS), and at 6 months by the PASS (PASS6), a force platform (lateral and sagittal stability limits (LSL6 and SSL6)), the Rivermead Mobility Index (RMI6) and gait velocity (v6). Functional outcome was also assessed by the Functional Independence Measure at 6 months (FIM6). RESULTS: The scores for balance and for FIM6 were related to the initial V value: PASS6 (p = 0.01, tau = -0.38); RMI6 (p = 0.002, tau = -0.48), LSL6 (p = 0.06, tau = -0.29), SSL6 (p = 0.004, tau = -0.43), v6 (p = 0.01, tau = -0.36) and FIM6 (p = 0.001, tau = -0.49), as well as to the initial U value: PASS6 (p = 0.03, tau = -0.32), RMI6 (p = 0.02, tau = -0.35), SSL6 (p = 0.005, tau = -0.43) and FIM6 (p = 0.01, tau = -0.38). CONCLUSIONS: Initial misperception of verticality was related to a poor score for balance after stroke. This relationship seems to be independent of motricity and neglect. Rehabilitation programmes should take into account verticality misperceptions, which could be an important factors influencing balance recovery after stroke.

Difference between individuals with left and right hemiparesis in the effect of gluteus medius vibration on body weight shifting.

OBJECTIVE: To test the effect of gluteus medius (GM) vibration on the reduction of asymmetric body weight distribution in individuals with hemiparesis (HP) at two stages of postural recovery. METHODS: The effects of GM vibration according to the shift of the body weight (%Shift) onto the paretic leg during GM vibration were registered while standing on a force-platform in 40 HP (19 left and 21 right; mean age 54.7±10.6years, mean time after stroke 2.0±1.3months), as soon as they could stand without assistance and 4 to 6 weeks later, and in 40 control subjects (mean age 54.7±10.5years). RESULTS: Without vibration, baseline body weight (BW) distribution was characterized by underloading of the paretic limb (mean BW on the paretic limb 37.2%±13.1%). At the early stage of balance recovery, % shift toward the paretic limb induced by GM vibration differed significantly between left and right HP (P=0.049) and between left HP and controls (C) (P=0.022) and was related to BW asymmetry (r=0.437, P=0.004). Later, GM vibration reduced asymmetric BW distribution in most HP and no difference was found between left and right HP and between left and C. CONCLUSION: At an advanced stage of postural recovery, GM vibration could help encourage HP to put weight on the affected limb. Interestingly, a behavioral difference was initially observed between right and left HP that could probably be explained by a different strategy due to the baseline severity of the BW asymmetry.

Evolution of subjective visual vertical perturbation after stroke.

OBJECTIVE: The perception of visual verticality is often perturbed after stroke and might be an underlying component of imbalance. The aim of this study was to describe the evolution of visual vertical (VV) perturbation and to investigate the factors affecting it. METHODS: Thirty patients with hemiplegia after a single hemispheric stroke (17 left lesioned [LL] and 13 right lesioned [RL]) were studied. Visual verticality was tested within 45 days of stroke, and then at 3 and 6 months. Subjects sat in a dark room and adjusted a luminous rod to the vertical position. The differences between patients' adjustments and vertical were calculated. The effects on VV evolution of the side, size, type, and location of the lesion were tested. RESULTS: Sixty percent of the recent stroke patients had an initial inaccurate perception of verticality, and 39% of these patients recovered during the 1st 3 months after stroke. The evolution of VV tilt depended on the side of the lesion (P = 0.01), with better recovery in LL patients. None of the other factors studied affected VV normalization. CONCLUSIONS: The poorer recovery of vertical perception after right-side stroke might be due to the predominant role of the right hemisphere in spatial cognition, and might be involved in the poorer recovery of balance after stroke in RL patients.

Postural visual dependence after recent stroke: assessment by optokinetic stimulation.

INTRODUCTION: This study was conducted to assess visual dependence of postural control early after stroke. DESIGN: Case control study. SETTING: A Physical Medicine and Rehabilitation Department. METHOD: Twenty-five patients impaired by severe hemiplegia due to a recent first stroke, were examined. Fourteen had a right and 11 a left hemispheric lesion. There were aged 52+/-13 years, time since stroke was 30+/-12 days. Patients' data were compared to data for 25 healthy subjects. Sitting posture was assessed on a dynamic balance, using two parameters: frontal plane displacement of the centre of pressure under optokinetic stimulation (OKS), and the total length of centre of pressure displacement for the stability reaction. On the basis of 90th percentile control data, patients' behaviour was classified as totally visuo independent (VI), totally visuo dependent (VD) or mixed. RESULTS: Body tilt under OKS was greater in patients than controls. No control subject was totally VD, 19 subjects were totally VI. Four patients were totally VD and only six were VI. The only clinical parameter linked to the effect of OKS was the sensitivity impairment. Overall patients with visuospatial neglect were the most perturbed, but two were totally visuo independent. DISCUSSION AND CONCLUSION: Assessment of postural variations in sitting under OKS is proposed for estimating visual dependence early after stroke. Individual reactions are more important than mean group reactions. Visual dependence is not solely due to neurological impairment, implying that previous physiological behaviour may be involved. Knowledge of these characteristics may affect rehabilitation programmes.

Fatigue after stroke.

OBJECTIVES: To examine the phenomenon of fatigue after stroke and to review the knowledge about frequency, consequences, associated factors, physiopathology and treatment. MATERIALS AND METHOD: Medline was systematically searched with the following keywords: stroke, fatigue, sleep disorders, exercise, and rehabilitation. All relevant articles found in the references were screened as well. RESULTS AND DISCUSSION: Fatigue is a common complaint after stroke and occurs in 39-72% of stroke survivors. Some studies show a severe functional impact of this symptom as well as a high mortality rate. Available evidence concerning associated factors is limited, but fatigue is clearly multifactorial. Some studies show that limited exercise capacity, increased gait energy cost, sleep-disordered breathing and sleep disorders can be related to physical fatigue. Other studies show a link between fatigue and depression. The existence of primary fatigue is still controversial. Treatment must follow a diagnostic approach. Treadmill training, among other treatments, improves fitness reserve and lowering of the energy cost of hemiparetic gait, which could be useful in relieving fatigue.

[Visual dependence after recent stroke]. / Dépendance visuelle après accident vasculaire cérébral récent.

INTRODUCTION: After chronic stroke, inability to use pertinent somatosensory or vestibular information have been described. The aim of the study was to determine whether visual dependence occurred early after stroke before rehabilitation. METHOD: Thirty patients with recent hemiplegia (16 right and 14 left hemispheric stroke) performed the rod and frame test (RFT). Patients were asked to adjust the rod to the vertical position under 3 conditions: basically, with a frame tilted 18 degrees to the right and then with the frame tilted to the left. Bias in each condition (mean, SD) was recorded and compared to adjustments of the rod by 23 controls. Motor control, sensibility, functional level (functional independence measure), age, neglect, and then balance by the postural assessment scale for stroke were assessed. RESULTS: Fifty-six per cent (17/30) of patients but only 26% of controls were influenced by the tilt of the frame on the 2 sides (visual dependence). No correlation was found between visual dependence and the characteristics of the patients. DISCUSSION: Many patients with recent hemiplegia seem to rely on visual input. The mechanisms of such visual dependence are discussed. Rehabilitation programs should take into account the possible impairment of sensory organisation and should include exercises to be performed under visual disturbances.

The effect of optokinetic and galvanic vestibular stimulations in reducing post-stroke postural asymmetry.

OBJECTIVE: To investigate the postural effect of 2 types of sensory stimulation in patients with a left hemispheric lesion (LHL) or right hemispheric lesion (RHL) compared with controls. METHODS: 35 patients (18 LHL, 17 RHL) and 27 controls (mean age 54.1 years), with a mean delay post-stroke of 3.0 months were enrolled. Subjects stood on a force platform and were stimulated on the left and right side by optokinetic (Okn) and galvanic vestibular (Gv) stimulation. Lateral displacement following stimulation toward the right and left directions was calculated as the mean position of the centre of pressure (CP) during the stimulation period minus the mean position at rest. RESULTS: Postural asymmetry was reduced in LHL and RHL patients. CP displacement was higher in cases of left-sided stimulation in the RHL group compared with control subjects and LHL patients (respectively 2.8 and 2.4 times higher, group effect, p<0.001, group × direction of stimulation interaction, p=0.007). The magnitude of displacement under Okn significantly correlated with Gv in all cases (ρ=0.635, p<0.001). CONCLUSIONS: Both GV and Okn stimulations can modulate hemiparetic's CP and their postural effects are correlated. SIGNIFICANCE: Results support a high level cortical postural effect of sensory stimulation on supramodal spatial network.

An Automated Recording Method in Clinical Consultation to Rate the Limp in Lower Limb Osteoarthritis.

For diagnosis and follow up, it is important to be able to quantify limp in an objective, and precise way adapted to daily clinical consultation. The purpose of this exploratory study was to determine if an inertial sensor-based method could provide simple features that correlate with the severity of lower limb osteoarthritis evaluated by the WOMAC index without the use of step detection in the signal processing. Forty-eight patients with lower limb osteoarthritis formed two severity groups separated by the median of the WOMAC index (G1, G2). Twelve asymptomatic age-matched control subjects formed the control group (G0). Subjects were asked to walk straight 10 meters forward and 10 meters back at self-selected walking speeds with inertial measurement units (IMU) (3-D accelerometers, 3-D gyroscopes and 3-D magnetometers) attached on the head, the lower back (L3-L4) and both feet. Sixty parameters corresponding to the mean and the root mean square (RMS) of the recorded signals on the various sensors (head, lower back and feet), in the various axes, in the various frames were computed. Parameters were defined as discriminating when they showed statistical differences between the three groups. In total, four parameters were found discriminating: mean and RMS of the norm of the acceleration in the horizontal plane for contralateral and ipsilateral foot in the doctor's office frame. No discriminating parameter was found on the head or the lower back. No discriminating parameter was found in the sensor linked frames. This study showed that two IMUs placed on both feet and a step detection free signal processing method could be an objective and quantitative complement to the clinical examination of the physician in everyday practice. Our method provides new automatically computed parameters that could be used for the comprehension of lower limb osteoarthritis. It may not only be used in medical consultation to score patients but also to monitor the evolution of their clinical syndrome during and after rehabilitation. Finally, it paves the way for the quantification of gait in other fields such as neurology and for monitoring the gait at a patient's home.

[Evolution of the concepts concerning rehabilitation treatment for hemiplegic patients]. / Evolution des concepts en rééducation du patient hémiplégique.

INTRODUCTION: The author attempts to show the evolution of the ideas guiding the rehabilitation treatment of motricity disorders after a vascular or traumatic brain lesion. METHOD: Expert opinion based on an uncomprehensive review of the literature, from the databases Reedoc and Medline and from the Institut Lionnois library in Nancy and the Charcot library in Paris. RESULTS AND DISCUSSION: Many theories and techniques have been proposed. The modern history of this rehabilitation treatment has been marked by a period that stressed control of the abnormal motricity characterizing central motor disorders, sometimes too exclusively. The development of evidence-based medicine in the 1980s undermined certain dogmas. At the same time, the advent of cerebral imaging technology confirmed clinical observations and hypotheses concerning cerebral plasticity. Today, the rehabilitation treatment of these motor disorders uses notions of learning; the diversity and complementarity of the exercises, which must be task-oriented; relative earliness and intensity of therapy; close interactions between sensitivity and motricity; and different concepts as mental imagery, the perception of verticality, or muscle strengthening. CONCLUSION: To its well-known preventive and palliative roles, rehabilitation treatment has now added a curative role. All the concepts applied today are not new, but the spirit of their application is new. Because we are sure that neurological recovery can be improved, no idea can be rejected at the outset; its effect must be demonstrated. Among the numerous ideas presently proposed, future studies will define the best ones, for the most suitable patient, at the best time.

[Evaluation of the disabilities of hemiplegic patients]. / Evaluation des incapacités fonctionnelles chez le patient hémiplégique: mise au point.

OBJECTIVES: To identify and describe the most useful functional disability scales for assessing post-stroke hemiplegic patients and those used largely in clinical trials. METHODS: A literature review of Medline about the functional parameters for balance, gait and mobility, upper extremity functional abilities, and activities of daily living. The metrologic properties of the scales were specified as were their clinical use. RESULTS: Thirty-three scales were evaluated and classified into five categories: balance (6 scales), gait and mobility (4), upper limb function (11), global motricity scales (5) and independence in activities of daily living (7). DISCUSSION AND CONCLUSION: Many functional scales are useful for assessing post-stroke hemiplegic patients. To assess balance, the Postural Assessment Stroke Scale and Berg Balance Scale are the most interesting. The Functional Ambulation Classification and the Timed Up and Go Test are the most relevant to assess gait and mobility. The Action Research Arm Test is largely used to assess upper limb functional abilities. The Functional Independence Measure and the Barthel Index are largely used to assess independence in activities of daily living.

Motor strategies of postural control after hemispheric stroke.

After stroke, the causes of balance disorders include motor disorders, sensory loss, perceptual deficits and altered spatial cognition. This review focuses on motor strategies for postural control after stroke. Weight-bearing asymmetry, smaller surface of stability, increased sway, body tilting and sometimes pushing syndrome are observed. Weakness and sensory impairments account only for some of these disturbances; altered postural reactions and anticipated postural adjustments as well as abnormal synergistic muscular activation play an important part. These disorders are often linked to cognitive impairments (visuospatial analysis, perception of verticality, use of sensory information, attention, etc.), which explain the preeminent disorders of postural control seen with right rather than left-hemisphere lesions. Most of the motor changes are due to an impaired central nervous system but some could be considered adaptive behaviors. These changes have consequences for rehabilitation and need further studies for building customized programs based on the motor comportment of a given patient.

Walking with eyes closed is easier than walking with eyes open without visual cues: The Romberg task versus the goggle task.

BACKGROUND: The Romberg test, with the subject standing and with eyes closed, gives diagnostic arguments for a proprioceptive disorder. Closing the eyes is also used in balance rehabilitation as a main way to stimulate neural plasticity with proprioceptive, vestibular and even cerebellar disorders. Nevertheless, standing and walking with eyes closed or with eyes open in the dark are certainly 2 different tasks. We aimed to compare walking with eyes open, closed and wearing black or white goggles in healthy subjects. METHODS: A total of 50 healthy participants were randomly divided into 2 protocols and asked to walk on a 5-m pressure-sensitive mat, under 3 conditions: (1) eyes open (EO), eyes closed (EC) and eyes open with black goggles (BG) and (2) EO, EO with BG and with white goggles (WG). Gait was described by velocity (m·s(-1)), double support (% gait cycle), gait variability index (GVI/100) and exit from the mat (%). Analysis involved repeated measures Anova, Holm-Sidak's multiple comparisons test for parametric parameters (GVI) and Dunn's multiple comparisons test for non-parametric parameters. RESULTS: As compared with walking with EC, walking with BG produced lower median velocity, by 6% (EO 1.26; BG 1.01 vs EC 1.07 m·s(-1), P=0.0328), and lower mean GVI, by 8% (EO 91.8; BG 66.8 vs EC 72.24, P=0.009). Parameters did not differ between walking under the BG and WG conditions. CONCLUSION: The goggle task increases the difficulty in walking with visual deprivation compared to the Romberg task, so the goggle task can be proposed to gradually increase the difficulty in walking with visual deprivation (from eyes closed to eyes open in black goggles).

Age and cerebral infarction: a postmortem study of 77 cases of cerebral infarcts in the middle cerebral artery territory.

Adverse effect of age on ischemic stroke short-term mortality was reported in some studies and attributed either to more frequent extracerebral causes of death or to an increased severity of ischemia in the aged brain. Relationship between age, size of infarcts, and causes of death were studied in 77 consecutive patients who died from infarction in the middle cerebral artery territory. Area of infarcts was assessed by planimetry, and results were expressed as an index of infarcted area. No significant relationship was found between age and the size of infarcts, the cause of death, or the interval from stroke to death. These results do not support the hypothesis of an increased severity of ischemia in the aged brain.

[Isolated sensory deficiency caused by infarction in the region of the anterior choroidal artery]. / Déficit sensitif isolé par infarctus dans le territoire de l'artère choroïdienne antérieure.

A patient presented with a pure left sensory deficit of sudden onset. CT scan showed a small capsular infarct in the anterior choroidal artery territory involving the superior thalamic peduncle in the posterior limb of the internal capsule.

[Effect of diabetes mellitus and blood glucose on the size of cerebral infarction and causes of death. Neuropathological study of 77 cases of infarction in the sylvian artery area]. / Influence du diabète et de la glycémie sur la taille des infarctus cérébraux et les circonstances du décès. Etude neuropathologique de 77 infarctus sylviens.

The influence of diabetes mellitus and hyperglycemia on cerebral infarction has been studied on 77 patients who died of infarcts in the territory of the middle cerebral artery. The size of the infarcts was assessed by transferring the surface of the infarcted area onto 8 schematic drawings corresponding to 8 brain slices and measuring this surface by means of a planimeter. An infarction volume index (IVI) was calculated by measuring the ratio of the infarcted area to the theoretical area of the middle cerebral artery territory on the 8 slices. The causes of death were assessed by full post-mortem examination. There was no statistically significant difference in size of infarcts and causes of death between diabetics and non-diabetics. However, the stroke-to-death interval was shorter (p = 0.05) in non-diabetic patients. It appears from this study that diabetes mellitus has no deleterious effect on cerebral infarction. Equally, there were non statistically significant differences in size of infarcts, stroke-to-death interval and causes of death between patients with and without hyperglycemia.

[Pharmacology and upper limb poststroke spasticity: a review. International Society of Prosthetics and Orthotics]. / Spasticité du membre supérieur après AVC, traitements pharmacologiques. Revue.

OBJECTIVES: The present study, conducted for the consensus conference "Orthotic management of stroke patients", organized by the International Society of Prosthetics and Orthotics, on September 2003, reviews the pharmacological, general, or local treatments available for post-stroke upper-limb spasticity. METHOD: A search of the international literature in the Medline and the Reedoc data banks for papers related to post-stroke upper-limb spasticity. Each paper was given a rating of A, B, or C (in term of quality) according to the instructions of the organization committee. RESULTS: General pharmacological treatments such as use of baclofen, tizanidine and dantrolene, regional treatments such as intrathecal baclofen, and local treatments with use of chemical neurolysis and alcohol or phenol are recommended for conditions described in papers with a grade of B. Neuromuscular blockade with botulinum toxin is recommended for conditions described in papers with a grade of A. DISCUSSION/CONCLUSION: Despite a satisfactory grade of recommendation, general pharmacological treatments are limited by adverse events and lack of evidence of functional benefit. Intrathecal baclofen should be discussed for upper-limb spasticity, but further studies are needed before its use can be recommended. The place of chemical neurolysis with use of alcohol or phenol should be evaluated with surgical neurotomy and botulinum toxin therapy. The use of botulinum toxin is the only treatment supported by scientific results, but many questions remain about the site of injection, how to improve efficacy and influence on neurological recovery.

[Post stroke hemiplegia: lower limb benefit from botulinum toxin (review)]. / Hémiplégie vasculaire: membre inférieur et toxine botulique (Revue).

OBJECTIVE: To clarify the conditions governing the use of botulinum toxin (BTX) for post-stroke lower limb spastic disorders: indications, choice of muscles, doses, and duration of efficacy. METHOD: Review of the international literature using the Medline and the Reedoc data banks. RESULTS: Seven controlled studies were reviewed, including in particular 2 studies vs placebo and one vs phenol, 7 open studies or case series closely related to this topic and 4 open studies partly dedicated to it. The usefulness of BTX for the treatment of equinovarus has been demonstrated. The main muscles to be treated are the soleus, gastrocnemius and tibialis posterior. The treatment proposed for toe clawing is BTX injection into the flexor digitorum longus and flexor hallucis longus, and for great toe permanent extension, injection of the extensor hallucis longus. The quadriceps femoris, the tibialis anterior or the hamstrings have only be treated in isolated cases. When the treatment is effective, its benefit may last for more than 6 months. DISCUSSION: A few controlled trials have demonstrated the efficacy of BTX for post stroke lower limb spasticity. The results of all the controlled and open trials argue in favor of its efficacy, but this still requires more thorough analysis. CONCLUSION: Botulinum toxin has a place together with other local treatments for post-stroke spasticity, but a precise guide to its use, especially its dosage, and it's effectiveness compared to that of other treatments, need further study.