Why we should systematically assess, control and report somatosensory impairments in BCI-based motor rehabilitation after stroke studies.

The neuronal loss resulting from stroke forces 80% of the patients to undergo motor rehabilitation, for which Brain-Computer Interfaces (BCIs) and NeuroFeedback (NF) can be used. During the rehabilitation, when patients attempt or imagine performing a movement, BCIs/NF provide them with a synchronized sensory (e.g., tactile) feedback based on their sensorimotor-related brain activity that aims at fostering brain plasticity and motor recovery. The co-activation of ascending (i.e., somatosensory) and descending (i.e., motor) networks indeed enables significant functional motor improvement, together with significant sensorimotor-related neurophysiological changes. Somatosensory abilities are essential for patients to perceive the feedback provided by the BCI system. Thus, somatosensory impairments may significantly alter the efficiency of BCI-based motor rehabilitation. In order to precisely understand and assess the impact of somatosensory impairments, we first review the literature on post-stroke BCI-based motor rehabilitation (14 randomized clinical trials). We show that despite the central role that somatosensory abilities play on BCI-based motor rehabilitation post-stroke, the latter are rarely reported and used as inclusion/exclusion criteria in the literature on the matter. We then argue that somatosensory abilities have repeatedly been shown to influence the motor rehabilitation outcome, in general. This stresses the importance of also considering them and reporting them in the literature in BCI-based rehabilitation after stroke, especially since half of post-stroke patients suffer from somatosensory impairments. We argue that somatosensory abilities should systematically be assessed, controlled and reported if we want to precisely assess the influence they have on BCI efficiency. Not doing so could result in the misinterpretation of reported results, while doing so could improve (1) our understanding of the mechanisms underlying motor recovery (2) our ability to adapt the therapy to the patients' impairments and (3) our comprehension of the between-subject and between-study variability of therapeutic outcomes mentioned in the literature.

Association between prism adaptation and auditory cues on spatial navigation in individuals with unilateral neglect.

BACKGROUND: Unilateral neglect is common among right-hemispheric stroke individuals and also concerns the auditory modality. Prism adaptation can improve auditory extinction during a dichotic listening task, but its effect during an ecological task has not been studied. OBJECTIVE: The main objective was to evaluate whether lateralized cueing before and after prism adaptation improved virtual spatial navigation of stroke individuals with visual and auditory unilateral neglect. Secondary objectives were to assess spatial memory and obtain a better understanding of the mechanism of the cueing treatment by using an eye-tracker. METHODS: We included 22 stroke individuals with left visual and auditory neglect, 14 individuals without neglect, and 12 healthy controls. After a familiarization task, participants underwent 3 evaluation sessions. Participants were first passively shown a path that they had then to actively reproduce by using a joystick. A path with lateralized beeping sounds indicating direction and a path without any sounds were followed in a randomized order. After prism adaptation, the participants followed a third path with lateralized beeping sounds. The time of navigation and number of trajectory mistakes were recorded. After navigation, spatial memory was assessed. Additionally, an eye-tracker was used during the navigation period. RESULTS: The navigational performance of participants with neglect was significantly better with than without auditory cues, especially after prism adaptation. With auditory cues, participants without neglect reached the navigational performance of healthy controls. The spatial memory of individuals with neglect was significantly lower with auditory cues. Eye-tracking analyses showed that participants with neglect made more saccades and looked longer at the right-square angles in the absence of auditory cues. CONCLUSIONS: This study demonstrates the positive effect of auditory cues in virtual spatial navigation of individuals with visual and auditory neglect and the potentiation of the help of cues after prism adaptation.

New factors that affect quality of life in patients with aphasia.

BACKGROUND: Aphasia severity is known to affect quality of life (QoL) in stroke patients, as is mood disorders, functional limitations, limitations on activities of daily life, economic status and level of education. However, communication limitation or fatigue has not been explored in this specific population. OBJECTIVE: We aimed to investigate whether these factors were associated with QoL in patients with aphasia after stroke. METHODS: Patients with aphasia were included from April 2014 to November 2017 after a first stroke and were followed for 2 years post-stroke. QoL was assessed at follow-up by the French Sickness Impact Profile 65 (SIP-65). We explored predictors such as mood disorders, communication impairment, fatigue, limitations on activities of daily life, and aphasia severity in addition to socio-demographic factors. RESULTS: We included 32 individuals (22 men; mean age 60.7 [SD 16.6] years) with aphasia after a first stroke. Poor QoL as assessed by the SIP-65 was significantly associated (Pearson correlations) with increased severity of aphasia initially (P=0.008) and at follow-up (P=0.01); increased communication activity limitations at follow-up (P<0.001); increased limitations on activities of daily life at baseline (P=0.008) and follow-up (P<0.001); increased fatigue at follow-up (P=0.001); and increased depression symptoms at follow-up (P=0.001). On multivariable analysis, QoL was associated with communication activity limitations, limitations on activities of daily life, fatigue and depression, explaining more than 75% of the variance (linear regression R2=0.756, P<0.001). The relative importance in predicting the variance was 32% for limitations on activities of daily life, 21% fatigue, 23% depression and 24% communication activity limitations. CONCLUSION: Aphasia severity, mood disorders and functional limitations may have a negative effect on QoL in patients with aphasia. Also, for the first time, we show that fatigue has an important impact on QoL in this population. Specific management of this symptom might be beneficial and should be explored in future studies.

Post-stroke follow-up: Time to organize.

BACKGROUND/OBJECTIVE: General practitioners (GPs) are pivotal in the organization of the entire post-stroke management system. This study aimed to examine the sequelae of chronic post-stroke patients and to assess whether the medical follow-up organized by GPs is truly in accordance with current recommendations and patients' clinical needs. METHODS: This was an observational study including chronic post-stroke patients after a first stroke. Their post-stroke follow-ups (visits to GPs and specialist doctors) were compared with guidelines and with clinical needs as evaluated through a number of questionnaires. RESULTS: Overall, 53.2% of patients visited a neurologist as recommended and, although 49.4% had neuropsychiatric consequences, only 6.3% visited a psychiatrist. Similarly, while 34.2% had significant post-stroke disability, only 6.3% saw a rehabilitation physician. CONCLUSION: Taking into account not only cardiovascular prevention, but all post-stroke consequences, medical follow-ups as organized by GPs were not in accordance with recommendations and failed to take advantage of the currently available multidisciplinary resources required to improve patients' needs.

Dysexecutive disorders and their diagnosis: A position paper.

Although executive function disorders are among the most prevalent cognitive impairments a consensus on diagnostic criteria has yet to be reached. With a view to harmonizing these criteria, the present position paper (i) focuses on the main dysexecutive disorders, (ii) examines recent approaches in both the behavioral and cognitive domains, (iii) defines diagnostic boundaries for frontal syndrome, (iv) reports on the frequency and profile of the executive function disorders observed in the main brain diseases, and (v) proposes an operationalization of diagnostic criteria. Future work must define the executive processes involved in human adaptive behavior, characterize their impairment in brain diseases, and improve the management of these conditions (including remediation strategies and rehabilitation).

Are visual cues helpful for virtual spatial navigation and spatial memory in patients with mild cognitive impairment or Alzheimer's disease?

OBJECTIVE: To evaluate whether visual cues are helpful for virtual spatial navigation and memory in Alzheimer's disease (AD) and patients with mild cognitive impairment (MCI). METHOD: 20 patients with AD, 18 patients with MCI and 20 age-matched healthy controls (HC) were included. Participants had to actively reproduce a path that included 5 intersections with one landmark at each intersection that they had seen previously during a learning phase. Three cueing conditions for navigation were offered: salient landmarks, directional arrows and a map. A path without additional visual stimuli served as control condition. Navigation time and number of trajectory mistakes were recorded. RESULTS: With the presence of directional arrows, no significant difference was found between groups concerning the number of trajectory mistakes and navigation time. The number of trajectory mistakes did not differ significantly between patients with AD and patients with MCI on the path with arrows, the path with salient landmarks and the path with a map. There were significant correlations between the number of trajectory mistakes under the arrow condition and executive tests, and between the number of trajectory mistakes under the salient landmark condition and memory tests. CONCLUSION: Visual cueing such as directional arrows and salient landmarks appears helpful for spatial navigation and memory tasks in patients with AD and patients with MCI. This study opens new research avenues for neuro-rehabilitation, such as the use of augmented reality in real-life settings to support the navigational capabilities of patients with MCI and patients with AD. (PsycINFO Database Record

Influence of non-contextual auditory stimuli on navigation in a virtual reality context involving executive functions among patients after stroke.

BACKGROUND: Topographical disorientation is frequent among patients after a stroke and can be well explored with virtual environments (VEs). VEs also allow for the addition of stimuli. A previous study did not find any effect of non-contextual auditory stimuli on navigational performance in the virtual action planning-supermarket (VAP-S) simulating a medium-sized 3D supermarket. However, the perceptual or cognitive load of the sounds used was not high. OBJECTIVE: We investigated how non-contextual auditory stimuli with high load affect navigational performance in the VAP-S for patients who have had a stroke and any correlation between this performance and dysexecutive disorders. METHODS: Four kinds of stimuli were considered: sounds from living beings, sounds from supermarket objects, beeping sounds and names of other products that were not available in the VAP-S. The condition without auditory stimuli was the control. The Groupe de réflexion pour l'évaluation des fonctions exécutives (GREFEX) battery was used to evaluate executive functions of patients. RESULTS: The study included 40 patients who have had a stroke (n=22 right-hemisphere and n=18 left-hemisphere stroke). Patients' navigational performance was decreased under the 4 conditions with non-contextual auditory stimuli (P<0.05), especially for those with dysexecutive disorders. For the 5 conditions, the lower the performance, the more GREFEX tests were failed. Patients felt significantly disadvantaged by the non-contextual sounds sounds from living beings, sounds from supermarket objects and names of other products as compared with beeping sounds (P<0.01). Patients' verbal recall of the collected objects was significantly lower under the condition with names of other products (P<0.001). Left and right brain-damaged patients did not differ in navigational performance in the VAP-S under the 5 auditory conditions. CONCLUSIONS: These non-contextual auditory stimuli could be used in neurorehabilitation paradigms to train patients with dysexecutive disorders to inhibit disruptive stimuli.

The effect of contextual auditory stimuli on virtual spatial navigation in patients with focal hemispheric lesions.

Topographical disorientation is a frequent deficit among patients suffering from brain injury. Spatial navigation can be explored in this population using virtual reality environments, even in the presence of motor or sensory disorders. Furthermore, the positive or negative impact of specific stimuli can be investigated. We studied how auditory stimuli influence the performance of brain-injured patients in a navigational task, using the Virtual Action Planning-Supermarket (VAP-S) with the addition of contextual ("sonar effect" and "name of product") and non-contextual ("periodic randomised noises") auditory stimuli. The study included 22 patients with a first unilateral hemispheric brain lesion and 17 healthy age-matched control subjects. After a software familiarisation, all subjects were tested without auditory stimuli, with a sonar effect or periodic random sounds in a random order, and with the stimulus "name of product". Contextual auditory stimuli improved patient performance more than control group performance. Contextual stimuli benefited most patients with severe executive dysfunction or with severe unilateral neglect. These results indicate that contextual auditory stimuli are useful in the assessment of navigational abilities in brain-damaged patients and that they should be used in rehabilitation paradigms.

Improvement of Navigation and Representation in Virtual Reality after Prism Adaptation in Neglect Patients.

Prism adaptation (PA) is responsible for an expansion of sensori-motor after-effects to cognitive domains for patients with spatial neglect. One important question is whether the cognitive after-effects induced by PA may also concern higher aspects of spatial cognition, such as navigation and topographic memory, which are critical in everyday life. The aim of this study was to assess whether multiple sessions of right PA can affect navigation and topographic memory. Seven right brain-damaged (RBD) patients with chronic neglect were included. We used a virtual supermarket named VAP-S which is an original paradigm, similar to the "shopping list test" during which patients had to purchase items from a list of eight products. Furthermore, in order to assess generalization of PA effects on constructing a spatial map from virtual information, each participant was then asked to draw the map of the virtual supermarket from memory. Regarding navigation performance, significant results were obtained: session duration reduction, fewer numbers of pauses and omissions, more items purchased on the left side and more items purchased over all. A long-lasting effect was noted, up to one month after PA. The representational task performance was also significantly increased for map drawing, with a reduction of the right shift of the symmetry axis of the map, more items drawn on the left side of maps and over all, and more items correctly located on the map. Some of these effects lasted for at least 7 days. These results suggest an expansion of PA benefit to a virtual environment. Crucially, the cognitive benefits induced by PA were noted for complex spatial cognition tasks required in everyday life such as navigation and topographic memory and this improvement was maintained for up to 1 month.

Language features in the acute phase of poststroke severe aphasia could predict the outcome.

BACKGROUND: Aphasia recovery remains difficult to predict initially in particular for the most severe cases. The features of impaired verbal communication which are the basis for cognitive-linguistic diagnosis and treatment could be part of prediction of recovery from aphasia. AIM: This study investigated whether some components of language screening in the acute phase of stroke are reliable prognostic factors for language recovery in the post-acute phase. DESIGN: Monocentric prospective study. SETTING: University hospital stroke unit. POPULATION: Eighty-six patients aged between 21 and 92 years (mean=67.4, SD=15.3) were admitted after a first left hemisphere stroke with aphasia and were consecutively included. METHODS: Language assessment was performed in the acute phase and 3 months post-stroke with the LAnguage Screening Test (LAST) and the Aphasia Severity Rating Scale (ASRS) of the Boston Diagnostic Aphasia Examination (BDAE). Severe aphasia was defined as ASRS<3. Good recovery was defined as an ASRS≥4. Language scores and other potential predictors of recovery were analysed by comparing groups of patients with good versus poor recovery and as predictors of change with multiple regression approaches. RESULTS: LAST Total score as well as all the individual items of LAST, NIHSS and ASRS measured in the acute phase significantly differentiated good and poor recovery from aphasia at three months for all aphasic patients and for the most severe cases. In multivariable analyses the repetition score of LAST at the acute phase was significantly associated with the delta of ASRS between the acute phase and 3 months after the stroke reflecting changes in symptom severity. CONCLUSIONS: For patients with initial severe aphasia, word repetition from a language screening task seems to be a more relevant predictor of recovery than initial severity to enrich the prognosis of poststroke aphasia recovery three month after a stroke. These findings show the importance of phonological perception and production as well as speech motor components in the recovery of language. These linguistic aspects of the assessment seem more relevant than severity for prediction in the acute phase. CLINICAL REHABILITATION IMPACT: These findings could improve aphasia management pathway for people with severe aphasia and their families and minimize the evidence-practice gap for speech pathologists.

The Behavioral and Cognitive Executive Disorders of Stroke: The GREFEX Study.

BACKGROUND: Many studies have highlighted the high prevalence of executive disorders in stroke. However, major uncertainties remain due to use of variable and non-validated methods. The objectives of this study were: 1) to characterize the executive disorder profile in stroke using a standardized battery, validated diagnosis criteria of executive disorders and validated framework for the interpretation of neuropsychological data and 2) examine the sensitivity of the harmonization standards protocol proposed by the National Institute of Neurological Disorders and Stroke and Canadian Stroke Network (NINDS-CSN) for the diagnosis of Vascular Cognitive Impairment. METHODS: 237 patients (infarct: 57; cerebral hemorrhage: 54; ruptured aneurysm of the anterior communicating artery (ACoA): 80; cerebral venous thrombosis (CVT): 46) were examined by using the GREFEX battery. The patients' test results were interpreted with a validated framework derived from normative data from 780 controls. RESULTS: Dysexecutive syndrome was observed in 88 (55.7%; 95%CI: 48-63.4) out of the 156 patients with full cognitive and behavioral data: 40 (45.5%) had combined behavioral and cognitive syndromes, 29 (33%) had a behavioral disorder alone and 19 (21.6%) had a cognitive syndrome alone. The dysexecutive profile was characterized by prominent impairments of initiation and generation in the cognitive domain and by hypoactivity with disinterest and anticipation loss in the behavioral domain. Cognitive impairment was more frequent (p = 0.014) in hemorrhage and behavioral disorders were more frequent (p = 0.004) in infarct and hemorrhage. The harmonization standards protocol underestimated (p = 0.007) executive disorders in CVT or ACoA. CONCLUSIONS: This profile of executive disorders implies that the assessment should include both cognitive tests and a validated inventory for behavioral dysexecutive syndrome. Initial assessment may be performed with a short cognitive battery, such as the harmonization standards protocol. However, administration of a full cognitive battery is required in selected patients.

Effect of submental sensitive transcutaneous electrical stimulation on virtual lesions of the oropharyngeal cortex.

OBJECTIVE: The aim of this study was to assess the effect of submental sensitive transcutaneous electrical stimulation (SSTES) on pharyngeal cortical representation after the creation of an oropharyngeal cortical virtual lesion in healthy subjects. METHODS: Motor-evoked potential amplitude of the mylohyoid muscles was measured with transcranial magnetic stimulation (TMS), the oropharyngeal cortex was mapped by cartography, and videofluoroscopic parameters of swallowing function were measured before and after SSTES (at the end of SSTES [0 min] and at 30 and 60 min), after the creation of a cortical virtual lesion (repetitive TMS, 1 Hz, 20 min on the dominant swallowing hemisphere). RESULTS: Nine subjects completed the study. After 20 min of SSTES, motor-evoked potential amplitude increased (P<0.05), as did swallow reaction time after repetitive TMS, as seen on videofluoroscopy, which was reversed after electrical stimulation. On cortical mapping, the number of points with a cortical response increased in the dominant lesioned hemisphere (P<0.05), remaining constant at 60 min (P<0.05). CONCLUSION: SSTES may be effective for producing cortical plasticity for mylohyoid muscles and reverses oropharyngeal cortical inhibition in healthy subjects. It could be a simple non-invasive way to treat post-stroke dysphagia.

Executive Functions Deficits After Severe Traumatic Brain Injury: The GREFEX Study.

OBJECTIVE: To assess the sensitivity of traditional neuropsychological tests and of a behavioral inventory of executive disorders in a large sample of patients with chronic severe traumatic brain injury. METHODS: A total of 112 patients were compared with 780 healthy controls from a larger database. The GREFEX battery included 7 widely used tests and the Behavioral Dysexecutive Syndrome Inventory (proxy rating). A previously described statistical methodology was used, controlling for age, education, and gender. Summary scores were computed and performance was dichotomized on the basis of 5th percentile cutoffs from controls' z scores. RESULTS: The frequency of cognitive impairment was high (55.4%) but lower than that of behavioral changes (81.5%). Double dissociations were observed between cognitive and behavioral assessments. Behavioral changes exhibited larger effect-sizes as compared with cognitive impairments. Logistic regression analysis showed that 3 cognitive tests (verbal fluency, Stroop reading, and Trail Making Test-B) and 3 behavior z scores (hypoactivity, anticipation, and hyperactivity) best discriminated patients from controls. CONCLUSION: Behavioral changes were more frequent and severe than cognitive deficits, at least as assessed with traditional testing. The present results also suggest that a shortened battery may provide a rapid screening method with reasonable sensitivity to detect deficits of executive functions in patients with severe traumatic brain injury.

A cost-utility analysis of sacral anterior root stimulation (SARS) compared with medical treatment in patients with complete spinal cord injury with a neurogenic bladder.

BACKGROUND CONTEXT: Sacral anterior root stimulation (SARS) and posterior sacral rhizotomy restores the ability to urinate on demand with low residual volumes, which is a key for preventing urinary complications that account for 10% of the causes of death in patients with spinal cord injury with a neurogenic bladder. Nevertheless, comparative cost-effectiveness results on a long time horizon are lacking to adequately inform decisions of reimbursement. PURPOSE: This study aimed to estimate the long-term cost-utility of SARS using the Finetech-Brindley device compared with medical treatment (anticholinergics+catheterization). STUDY DESIGN/SETTINGS: The following study design is used for the paper: Markov model elaborated with a 10-year time horizon; with four irreversible states: (1) initial treatment, (2) year 1 of surgery for urinary complication, (3) year >1 of surgery for urinary complication, and (4) death; and reversible states: urinary calculi; Finetech-Brindley device failures. PATIENT SAMPLE: The sample consisted of theoretical cohorts of patients with a complete spinal cord lesion since ≥1 year, and a neurogenic bladder. OUTCOME MEASURES: Effectiveness was expressed as quality adjusted life years (QALYs). Costs were valued in EUR 2013 in the perspective of the French health system. METHODS: A systematic review and meta-analyses were performed to estimate transition probabilities and QALYs. Costs were estimated from the literature, and through simulations using the 2013 French prospective payment system classification. Probabilistic analyses were conducted to handle parameter uncertainty. RESULTS: In the base case analysis (2.5% discount rate), the cost-utility ratio was 12,710 EUR per QALY gained. At a threshold of 30,000 EUR per QALY the probability of SARS being cost-effective compared with medical treatment was 60%. If the French Healthcare System reimbursed SARS for 80 patients per year during 10 years (anticipated target population), the expected incremental net health benefit would be 174 QALYs, and the expected value of perfect information (EVPI) would be 4.735 million EUR. The highest partial EVPI is reached for utility values and costs (1.3-1.6 million EUR). CONCLUSIONS: Our model shows that SARS using Finetech-Brindley device offers the most important benefit and should be considered cost-effective at a cost-effectiveness threshold of 30,000 EUR per QALY. Despite a high uncertainty, EVPI and partial EVPI may indicate that further research would not be profitable to inform decision-making.

Do patients with traumatic brain injury learn a route in the same way in real and virtual environments?

UNLABELLED: An increasing number of studies address the use of virtual environments (VE) in the cognitive assessment of spatial abilities. However, the differences between learning in a VE and a real environment (RE) remain controversial. PURPOSE: To compare the topographical behavior and spatial representations of patients with traumatic brain injury navigating in a real environment and in a virtual reproduction of this environment. METHODS: Twenty-seven subjects with moderate to severe traumatic brain injury were consecutively included and allocated to one of two groups. The subjects were taught the same route in either the virtual environment or the real environment and had to recall it twice immediately after learning the route and once after a delay. At the end of these sessions, the subjects were asked to complete three representational tests: a map test, a map recognition test recognition and a scene arrangement test. RESULTS: No significant difference was found between the two groups with regards to demographics, severity of brain injury or episodic memory. As a main result, the number of error rates did not significantly differ between the real and virtual environment [F (1, 25) = 0.679; p = 0.4176)]. Scores on the scene arrangement test were higher in the real environment [U = 32.5; p = 0.01]. CONCLUSIONS: Although spatial representations probably differ between the real and virtual environment, virtual reality remains a trusty assessment tool for spatial abilities.

Safety and self-reported efficacy of botulinum toxin for adult spasticity in current clinical practice: a prospective observational study.

OBJECTIVE: To determine the safety and the self-reported efficacy of botulinum toxin injections for adult spasticity in current clinical practice. DESIGN: A prospective observational study. SUBJECTS: A total of 406 adult patients with focal spasticity received of 1136 series botulinum toxin injections at Bordeaux University Hospital from January 2007 to December 2009. METHODS: Adverse events following botulinum toxin injections were reported. Their severity and the therapeutic efficacy of botulinum toxin injections were estimated with a four-point self-reporting scale (0 to 3). Latency and duration of adverse events and subjective improvement were also noted. RESULTS: The data of 640 series of injections were analyzed. Forty-six (7.2%) adverse events were reported, of which 36 (78%) were local. There were 18 (39%) cases of local muscular weakness with an average duration of 30.0 (SD 38.2) days, and an average severity score of 1.0 (SD 0.97). Among systemic adverse events, there were 8 (17%) cases of excessive fatigue without global muscular weakness and 2 (4%) cases of transitory generalized muscular weakness. The average subjective improvement score was 1.89 (SD 0.97) and was higher for upper, than for lower, limbs (P=0.007). CONCLUSION: Self-reported adverse events following botulinum toxin injections in spasticity are rare, often benign and of short duration in current clinical practice. Botulinum toxin is considered effective by patients in treating spasticity of the upper and lower limbs.

Botulinum toxin treatment in neurological practice: how much does it really cost? A prospective cost-effectiveness study.

Botulinum toxin (BTA) is a safe and effective therapeutic tool for many neurological conditions but few studies have investigated its real cost in neurological practice. We evaluated the daily cost of botulinum toxin type A (BTA) treatment through a cost effectiveness analysis alongside a prospective study of BTA injections at a French University Hospital over a 2-year follow-up period. The data of 3,108 BTA injections performed in 870 adult patients presenting with dystonia, facial hemispasm, or spasticity were entered in the database. Patients were questioned at each visit about the subjective effectiveness of the previous injection. The daily cost of BTA treatment was calculated as the ratio of each session's cost (including all additional costs) to the duration of subjective efficacy. The subjective rating of efficacy duration was 17.3 ± 7.7 weeks for facial hemispasm, 15.4 ± 7.7 for blepharospasm, 14.3 ± 6.7 for cervical dystonia, 14.5 ± 7.8 and 14.1 ± 7.4 weeks for upper and lower limb spasticity, respectively. The daily cost of BTA injections was 0.57 ± 0.20 for facial hemispasm, 0.95 ± 0.30 for blepharospasm, 2.85 ± 0.86 for cervical dystonia, 3.38 ± 1.49 and 3.62 ± 1.81 for upper and lower limb spasticity, respectively. When associated costs were considered, the daily cost of BTA injections was clearly increased (45-93%) in limb spasticity or rigidity but remained only modestly increased (15-37%) in other indications. These results obtained in a large cohort of patients show that BTA treatment has a low daily cost for a long-lasting effect, with a daily cost/benefit ratio that greatly depends on the indications.