Spasticity Treatment Beyond Botulinum Toxins.

Botulinum toxin (BonT) is the mainstream treatment option for post-stroke spasticity. BoNT therapy may not be adequate in those with severe spasticity. There are a number of emerging treatment options for spasticity management. In this paper, we focus on innovative and revived treatment options that can be alternative or complementary to BoNT therapy, including phenol neurolysis, cryoneurolysis, and extracorporeal shock wave therapy.

Real-world analysis of botulinum toxin (BoNT) injections in post-stroke spasticity: Higher doses of BoNT and longer intervals in the early-start group.

Our primary objective was to compare early-start vs. late-start Botulinum toxin (BoNT) injections in post-stroke spasticity management. This is an IRB approved retrospective chart review of patients who were admitted for inpatient rehabilitation within 6 months after first-ever stroke between January 2014 and December 2018 and received BoNT injections within 15 months. The total dose and interval between consecutive injections were used as objective outcomes. 2367 stroke admissions were reviewed. 189 patients metinclusion criteria. 68 out of 189 patients received BoNT injections within 12 weeks after stroke (EARLY group). 20 patients in the EARLY group who received at least three cycles were included for analysis. Out of 189 patients, 47 patients were categorized into the Early- and Late-start subgroups each by time from stroke onset to first BoNT injection (1st and 4th quartiles of time distribution) for comparisons. In the EARLY group, the first interval (Mean (M) = 7.6 weeks, standard deviation (SD) = 2.14) was significantly shorter than the second interval (M = 23.7, SD = 10.41) and the third interval (M = 20.0, SD = 11.23; p < 0.05). The dose at the first cycle (M = 492 units, SD = 201.5) was significantly lower than the dose at the third cycle (M = 605, SD = 82.6). In comparison between the Early- and Late-start subgroups, the time to first BoNT injection was 6.4 weeks (range: 4.7-8.6) after stroke for the Early-start subgroup and 49.6 weeks (range: 27.4-62.3) after stroke for the Late-start subgroup. The subsequent intervals after the first injection were significantly longer in the Early-start subgroup (M = 23.1 weeks) than in the Late-start subgroup (M = 14.6 weeks) (p = 0.008). The average total dose of BoNT was significantly higher in the Early-start subgroup (M = 561.9 units, SD = 143.1) than the Late-start subgroup (M = 470.0, SD = 164.8) (p = 0.012). The findings showed that higher doses of BoNT were used in the Early-start group, and often resulted in longer intervals between subsequent injections than in the Late-start group.

Early Use of Phenol Neurolysis Likely Reduces the Total Amount of Botulinum Toxin in Management of Post-Stroke Spasticity.

The main objective was to examine practice patterns of phenol neurolysis for post-stroke spasticity management in the early stage. We performed a chart review of patients who were admitted for inpatient rehabilitation within 6 months after first-ever stroke and received phenol neurolysis within 15 months post-stroke. Out of 2,367 stroke admissions from January 2014 and December 2018, 68 patients met the criteria. 52.9% of these patients received phenol neurolysis within 12 weeks, i.e., early stage. The earliest phenol neurolysis procedure was at 19 days after stroke. On average, patients received first phenol injections at 16.3 weeks after stroke with an average dose of 7.3 ml. Most commonly injected nerves were tibial nerve motor branches (41/68), sciatic nerve motor branches (37/68), lateral pectoral nerve (16/68), medial pectoral nerve (15/68), obturator nerve (15/68) and musculocutaneous nerve (15/68). Among 68 patients, 24 received phenol only; 17 received phenol neurolysis first followed by botulinum toxin (BoNT) injections; 19 received BoNT injections first followed by phenol neurolysis; 8 received both phenol and BoNT injections at the same time. The interval from stroke to first procedure was similar between the Phenol-First group (13.3 weeks) and the BoNT-First group (12.6 weeks). The total amount of BoNT was significantly lower in the Phenol-First group (361.3 units) than in the BoNT-First group (515.8 units) (p = 0.005). The total amount of phenol was not statistically different between the Phenol-First group (5.9 ml) and the BoNT-First group (8.3 ml). The interval between the first procedure and its subsequent procedure was not statistically different between the Phenol-First group (18.3 weeks) and the BoNT-First group (10.7 weeks). These long intervals suggest that the subsequent injection (type and dose) was not planned during the first procedure. The general patterns of target areas were similar between BoNT injections and phenol neurolysis, except that phenol neurolysis rarely targeted the upper extremity distal muscles. No side effects after phenol or BoNT injections in the early stage after stroke were observed in the chart review. In summary, phenol neurolysis was started as early as 19 days after stroke. On average, patients received first phenol about 4 months after stroke with an average of 7.3 ml of phenol. Early use of phenol neurolysis likely decreases the total amount of BoNT for management of post-stroke spasticity without increased side effects.

Stroke and sarcopenia.

PURPOSE OF REVIEW: to evaluate recent scientific research studies related to the changes in skeletal muscle after stroke and the presence of sarcopenia in stroke survivors to establish its incidence and effects on function. RECENT FINDINGS: Recently published findings on stroke-related sarcopenia are limited. This might be due to changes in the consensus definition of sarcopenia. Sarcopenia in stroke patients is estimated at 14 to 54%. The presence of sarcopenia at the time of a stroke can lead to worse recovery and functional outcomes. SUMMARY: Presence of sarcopenia prior to a stroke may be more common than suspected and can lead to worse functional recovery. Clinicians should be aware of this to better identify and treat stroke-related sarcopenia. Future research should focus on larger population studies to more accurately establish correlation between stroke and sarcopenia.

Phenol Neurolysis for the Management of Shoulder Spasticity in Early Recovery From Traumatic Brain Injury: A Case Report.

This case describes a 16-year-old boy who suffered a severe traumatic brain injury. The patient gradually recovered but developed debilitating spasticity mainly in left triceps muscle, abnormal positioning of shoulder girdle complex, and shoulder pain. Phenol (6%) was injected to axillary and radial nerves under the guidance of electrical stimulation and ultrasound imaging at 10 weeks after the initial injury. After injection, triceps spasticity and shoulder pain were immediately reduced, and abnormal positions of shoulder girdle complex and elbow joint gradually returned to functional limits over 2 weeks. This case suggests that phenol neurolysis for spasticity management in early recovery could yield functional recovery.Level of Evidence: V.

Rehabilitation Needs of the Elder with Traumatic Brain Injury.

The incidence of traumatic brain injury (TBI) in older adults is increasing. As the expected life expectancy increases, there is a heightened need for comprehensive rehabilitation for this population. Elderly patients with TBI benefit from rehabilitation interventions at all stages of injury and can achieve functional gains during acute inpatient rehabilitation. Clinicians should be vigilant of unique characteristics of this population during inpatient rehabilitation, including vulnerability to polypharmacy, posttraumatic hydrocephalus, neuropsychiatric sequelae, sleep disturbances, and sensory deficits. Long-term care should include fall prevention, assessment of cognitive deficits, aerobic activity, community reintegration, and caretaker support. Life expectancy is reduced after TBI.

Centrally mediated late motor recovery after botulinum toxin injection: Case reports and a review of current evidence.

OBJECTIVE: Botulinum neurotoxin is commonly utilized in neurorehabilitation as a treatment for focal spasticity. Clinical experience has yielded observations of late motor recovery after intramuscular injection of botulinum neurotoxin, that are not readily explained by the classical mechanism of action of the neurotoxin in controlling spasticity. These findings have triggered speculation regarding a botulinum neurotoxin mediated effect at the central level after peripheral intervention. METHODS: A review of current literature reveals evidence of distant action after peripheral botulinum neurotoxin injection in affected muscles, be it in other muscles, nerves, spinal cord or the cortex. RESULTS: Plausible explanations for a centrally mediated late motor recovery after botulinum neurotoxin injection include: (i) direct action of botulinum neurotoxin at distant sites in the central nervous system, mediated by retrograde transport of the neurotoxin into the spinal cord, and (ii) cortical reorganization due to botulinum neurotoxin-induced decrease in peripheral sensory input at the local injection site. CONCLUSION: Additional research is required to further elucidate these hypotheses, as well as providing specific dosing specifications, patient selection criteria and the interplay with other therapeutic modalities necessary to promote late motor recovery.

Practice patterns for spasticity management with phenol neurolysis.

OBJECTIVE: To present practice patterns for phenol neurolysis procedures conducted for spasticity management. DESIGN: A retrospective review of 185 persons with spasticity who underwent phenol neurolysis procedures (n = 293) at an academic rehabilitation hospital and clinic. Patient demographics, concomitant spasticity treatments, and procedure relevant information were collected. RESULTS: The cohort included 71.9% males and 61.6% inpatient procedures. Neurological diagnoses included stroke (41.0%), traumatic brain injury (28.6%) and spinal cord injury (24.3%). Musculoskeletal diagnoses included spastic hemiplegia or paresis (51.3%), tetraplegia (38.4) and paraplegia (9.2%). At the time of phenol neurolysis, most patients (77.5%) received concomitant pharmacological treatments for spasticity. Injection guidance modalities included electrical stimulation and ultrasound (69.3%) or ultrasound only (27.3%). A mean of 3.48 ml of phenol were injected per nerve and 10.95 ml of phenol were used per procedure. Most commonly injected nerves included the obturator nerve (35.8%) and sciatic branches to the hamstrings and adductor magnus (27.0%). Post-phenol neurolysis assessment was recorded in 54.9% of encounters, in which 84.5% reported subjective benefit. Post-procedure adverse events included pain (4.0%), swelling and inflammation (2.7%), dysaesthesia (0.7%) and hypotension (0.7%). CONCLUSION: Phenol neurolysis is currently used to reduce spasticity for various functional goals, including preventing contractures and improving gait. Depending on the pattern of spasticity displayed, numerous peripheral nerves in the upper and lower extremities can be targeted for treatment with phenol neurolysis. Further research into its role in spasticity management, including studies exploring its cost-effectiveness and pharmacological and side-effects compared with other treatment options are needed.