Botulinum toxin type A infiltration in spasticity and cervical dystonia. Muscle morphology: an overlooked factor.

INTRODUCTION: Botulinum toxin type A is used to treat spasticity and dystonia. However, its relationship with muscle morphology has not been studied. The action mechanism of botulinum toxin is based on the inhibition of acetylcholine release. Therefore, larger doses of toxin would be needed to treat larger muscles. This study aims to establish whether there is a discrepancy between muscle morphology and the botulinum toxin doses administered. METHODS: We dissected, and subsequently measured and weighed, muscles from the upper and lower limbs and the head of a fresh cadaver. We consulted the summary of product characteristics for botulinum toxin type A to establish the recommended doses for each muscle and calculated the number of units infiltrated per gramme of muscle. RESULTS: Different muscles present considerable morphological variability, and the doses of botulinum toxin administered to each muscle are very similar. We observed great variability in the amount of botulinum toxin administered per gramme of muscle, ranging from 0.3 U/g in the biceps femoris to 14.6 U/g in the scalene muscles. The mean dose was 2.55 U/g. The doses administered for nearly all lower limb muscles were below this value. CONCLUSIONS: There are significant differences in morphology between the muscles of the lower limbs, upper limbs, and head, but similar doses of botulinum toxin are administered to each muscle. These differences result in great variability in the number of units of botulinum toxin administered per gramme of muscle.

Incidence of falls in long-stay hospitals: risk factors and strategies for prevention.

INTRODUCTION: Falls are a major health problem in elderly institutionalised patients, due to the associated high morbidity and mortality rates and the impact on future quality of life. OBJECTIVE: To analyse the incidence and patient profile for falls, and to identify potential causes and effects. We also assess the efficacy of intervention in selected patients in preventing further falls. METHODS: We performed a prospective study at a long-term care centre for 12 months. Data were collected via fall reports. The falls committee drafted a monthly data collection form. RESULTS: A total of 155 falls were recorded in 80 patients, with 40% presenting more than one fall. Patients aged over 70 years accounted for 84.5% of falls; 42.7% of patients are able to walk independently; 55.5% of falls occurred in the bedroom; 74.8% of patients had been prescribed sedatives or psychoactive, or antihypertensive drugs; 27.7% of falls were due to loss of balance and 22.5% were due to patients performing an activity for which they did not have the capacity. Fractures occurred in 1.9% of patients. CONCLUSIONS: Patients aged over 70 years, walking independently, receiving sedatives or psychoactive or antihypertensive drugs, and with history of falls were at greatest risk. The majority of falls occurred in the bedroom. Physiotherapy interventions were highly effective in cases selected by the falls committee.

Neurorehabilitation in the times of Covid-19: insights from the Spanish Neurorehabilitation Society (SENR).

The entire world is experiencing an unprecedented global health crisis and Spain has been one of the most heavily affected countries within Europe. Unexpected rapid changes and reorganization of medical services that occurred during the pandemic lead to an impact in the practice of neurorehabilitation. The idiosyncrasies typical of neurorehabilitation management, specially in acute facilities, that makes it susceptible as a vector of dissemination of Covid but also because of the need of finding new wards and intensive care units for Covid patients, the interventions in neurorehabilitation has suffered enormous changes. There is a need for rethinking the future to treat a new wave of patients with neurorehabilitation necessities such as those recovering from Covid 19 with neurological sequelae but also of those neurorehab patients who were unable to access the health system during the locke down period. This article is intended to invite to reflect on and discuss the redesign of our current neurorehabilitation plans after the experience on the Covid 19 pandemic.

Neurorrehabilitación del ictus en España, comparativa con Europa / Comparison of stroke neurorehabilitation in Spain and in Europe

No disponible

Incidence of falls in long-stay hospitals: risk factors and strategies for prevention. / Incidencia de caídas en el hospital de larga-media estancia. Factores de riesgo y estrategias para la prevención.

INTRODUCTION: Falls are a major health problem in elderly institutionalised patients, due to the associated high morbidity and mortality rates and the impact on future quality of life. OBJECTIVE: To analyse the incidence and patient profile for falls, and to identify potential causes and effects. We also assess the efficacy of intervention in selected patients in preventing further falls. METHODS: We performed a prospective study at a long-term care centre for 12 months. Data were collected via fall reports. The falls committee drafted a monthly data collection form. RESULTS: A total of 155 falls were recorded in 80 patients, with 40% presenting more than one fall. Patients aged over 70 years accounted for 84.5% of falls; 42.7% of patients are able to walk independently; 74.8% of patients had been prescribed sedatives or psychoactive, or antihypertensive drugs; 55.5% of falls occurred in the bedroom; 27.7% of falls were due to loss of balance and 22.5% were due to patients performing an activity for which they did not have the capacity. Fractures occurred in 1.9% of patients. CONCLUSIONS: Patients aged over 70 years, walking independently, receiving sedatives or psychoactive or antihypertensive drugs, and with history of falls were at greatest risk. The majority of falls occurred in the bedroom. Physiotherapy interventions were highly effective in cases selected by the falls committee.

La rehabilitación del ictus en las mujeres / Stroke rehabilitation in women

No disponible

Poststroke checklist: un cuestionario para detectar las necesidades de rehabilitación después del ictus / The poststroke checklist: a questionnaire to detect rehabilitation needs after stroke

Introducción. El Poststroke checklist (PSC) es un cuestionario breve y fácil de usar que pretende estandarizar el seguimiento de los pacientes con ictus crónico y asegurar el acceso a intervenciones de rehabilitación basadas en la evidencia. El objetivo de este trabajo es describir la metodología seguida para elaborar el cuestionario y su validación preliminar. Material y métodos. Se describe la elaboración del PSC original y de la versión en castellano (retrotraducción y adaptación al lenguaje clínico local). Se realizó una validación preliminar para evaluar su comprensibilidad en 20 pacientes con ictus de más de 6 meses de evolución (tiempo de latencia de respuesta y grado de comprensión de cada ítem). Por último, se evaluó la satisfacción de los pacientes con el PSC en cuanto a la capacidad de identificar los problemas que afectaban su vida después del ictus. Resultados. El tiempo medio de respuesta fue < 2 seg para todas las preguntas del PSC. Respecto a la interpretación del cuestionario, la comprensión fue buena para la mayoría de pacientes. La comprensión fue parcial en la pregunta sobre movilidad en 5 pacientes, actividades de la vida diaria, comunicación, cognición y vida tras el ictus en 4 y sobre espasticidad en 3. Solo un paciente no comprendió la cuestión sobre prevención secundaria. Los 20 pacientes se mostraron satisfechos con el cuestionario. Conclusiones. El PSC es una herramienta de uso rápido y comprensible para los pacientes, y puede ser útil para detectar necesidades de rehabilitación a largo plazo después de un ictus (AU)

Introduction. The Poststroke checklist (PSC) is a short, easy-to-use questionnaire, intended to facilitate a standardized approach to identifying long-term problems in stroke survivors and ensure access to evidence-based rehabilitation interventions. The aim of this study was to describe the methodology used to develop the questionnaire and its preliminary validation. Material and methods. The development of the original PSC and the Spanish version (back-translation and adaptation to the local clinical language) is described. Preliminary validation was performed to assess its comprehensibility in 20 stroke patients over a 6-month period (latency of response and degree of understanding of each item). Finally, patients’ satisfaction with the PSC regarding its ability to identify problems affecting their lives after stroke was evaluated. Results. The average response time was < 2 sec for all questions in the PSC. Concerning the interpretation of the questionnaire, understanding was good for most patients. Understanding was partial in the question on mobility in 5 patients, activities of daily living, communication, cognition and life after stroke in 4, and spasticity in 3. Only one patient did not understand the question on secondary prevention. The 20 patients were satisfied with the questionnaire. Conclusions. The PSC is a brief tool that is easily understood by patients and could be useful for detecting long term needs after stroke and to facilitate appropriate referrals (AU)

An international study of the quality of national-level guidelines on driving with medical illness.

BACKGROUND: Medical illnesses are associated with a modest increase in crash risk, although many individuals with acute or chronic conditions may remain safe to drive, or pose only temporary risks. Despite the extensive use of national guidelines about driving with medical illness, the quality of these guidelines has not been formally appraised. AIM: To systematically evaluate the quality of selected national guidelines about driving with medical illness. DESIGN: A literature search of bibliographic databases and Internet resources was conducted to identify the guidelines, each of which was formally appraised. METHODS: Eighteen physicians or researchers from Canada, Australia, Ireland, USA and UK appraised nine national guidelines, applying the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument. RESULTS: Relative strengths were found in AGREE II scores for the domains of scope and purpose, stakeholder involvement and clarity of presentation. However, all guidelines were given low ratings on rigour of development, applicability and documentation of editorial independence. Overall quality ratings ranged from 2.25 to 5.00 out of 7.00, with modifications recommended for 7 of the guidelines. Intra-class coefficients demonstrated fair to excellent appraiser agreement (0.57-0.79). CONCLUSIONS: This study represents the first systematic evaluation of national-level guidelines for determining medical fitness to drive. There is substantive variability in the quality of these guidelines, and rigour of development was a relative weakness. There is a need for rigorous, empirically derived guidance for physicians and licensing authorities when assessing driving in the medically ill.

Capacidad de conducción tras un ictus: evaluación y recuperación / Driving ability after a stroke: evaluation and recovery

Introducción: La habilidad para conducir después de un ictus ha sido reconocida por muchos autores como un indicador de independencia y se asocia de forma significativa con una reintegración social adecuada. Sin embargo, no queda claro quién y cómo debe valorarse la capacidad de conducción de un individuo que ha sufrido un ictus. El proceso neurorrehabilitador es capaz de obtener mejorías en los pacientes que han sufrido un ictus y, por lo tanto, un paciente puede volver a estar capacitado para conducir tras un tratamiento neurorrehabilitador adecuado. El objetivo de este artículo es realizar una revisión de la literatura, con el fin de poner de manifiesto la evidencia actual respecto a los métodos de evaluación de la capacidad para conducir y de aquellas intervenciones llevadas a cabo para recuperar la capacidad de conducir. Desarrollo: Se llevó a cabo una búsqueda de la literatura de diferentes bases de datos entre 1993 y 2011. Se analizaron de forma individual los estudios realizados sobre la base de los métodos de evaluación de la capacidad de conducir y de intervención neurorrehabilitadora. Conclusiones: Se debe valorar de forma apropiada a todos los pacientes con un ictus en los que existen dudas sobre su capacidad de conducir. La forma adecuada de valorar a estos pacientes según la literatura es mediante una valoración multidisciplinar que determine quién está capacitado para someterse a un test en carretera. Los ejercicios de neurorrehabilitación existentes pueden mejorar la capacidad de conducir de los pacientes con ictus

Introduction: The ability to drive after a stroke has been recognised by many authors as a sign of independence and it is closely associated with proper social reintegration. However, it remains unclear how the driving ability of an individual who has suffered a stroke should be evaluated, and by whom. Neurorehabilitation can produce improvements in patients who have suffered a stroke, and patients may therefore be able to resume driving at the end of an appropriate neurorehabilitation programme. The aim of this article is to present a literature review in order to highlight current evidence regarding methods for assessing driving ability and therapeutic methods applied in order to recover a patient's ability to drive. Development: A literature search was performed in different databases for the period between 1993 and 2011. Studies were analysed individually based on methods for assessing driving ability and neurorehabilitation measures. Conclusions: If there are any doubts regarding stroke patients’ ability to drive, patients should be assessed appropriately. The proper way to assess these patients according to the literature is by employing a multidisciplinary evaluation to determine who is able to take a road test. Neurorehabilitation exercises currently in use may be able to improve driving ability in stroke patients

Escleritis necrotizante c-ANCA positivo y esclerosis múltiple compatible con Wegener ocular: tratamiento con rituximab / C-ANCA positive necrotising scleritis and multiple sclerosis compatible with ocular Wegener: treatment with rituximab

CASO CLÍNICO: Paciente diagnosticada de escleritis necrotizante c-ANCA+, seudotumor orbitario y posible esclerosis múltiple; en 2003 realizó tratamiento con ciclofosfamida oral y esteroides con respuesta parcial. Entre 2005-2010 sufrió episodios oculares autolimitados. En 2010 se realizó un primer trasplante escleral, con mala evolución. Se inició tratamiento con rituximab y se realizó segundo injerto con buena evolución. A los 12 meses no se observaron cambios en resonancia magnética y el segundo injerto cicatrizó. DISCUSIÓN: La enfermedad de Wegener con afectación limitada a la órbita y/o el ojo es una entidad poco frecuente. La anatomía patológica, analítica de sangre, clínica y buena respuesta al tratamiento son clave para su diagnóstico

CASE REPORT: A patient diagnosed with necrotizing scleritis, c-ANCA + an orbital pseudotumour, and possible multiple sclerosis in 2003 was treated with oral cyclophosphamide and steroids with partial response. Between 2005-2010 she suffered self-limited episodes. In 2010 a first scleral transplant was performed with poor outcome. She was treated with rituximab, and a second graft was performed with good results. At 12 months there was no change in magnetic resonance and the second graft healed. DISCUSSION: Wegener's disease with limited involvement of the orbit and/or the eye is a rare condition. The histopathology, blood analysis, symptoms and good response to treatment are the key to its diagnosis

Driving ability after a stroke: evaluation and recovery.

INTRODUCTION: The ability to drive after a stroke has been recognised by many authors as a sign of independence and it is closely associated with proper social reintegration. However, it remains unclear how the driving ability of an individual who has suffered a stroke should be evaluated, and by whom. Neurorehabilitation can produce improvements in patients who have suffered a stroke, and patients may therefore be able to resume driving at the end of an appropriate neurorehabilitation programme. The aim of this article is to present a literature review in order to highlight current evidence regarding methods for assessing driving ability and therapeutic methods applied in order to recover a patient's ability to drive. DEVELOPMENT: A literature search was performed in different databases for the period between 1993 and 2011. Studies were analysed individually based on methods for assessing driving ability and neurorehabilitation measures. CONCLUSIONS: If there are any doubts regarding stroke patients' ability to drive, patients should be assessed appropriately. The proper way to assess these patients according to the literature is by employing a multidisciplinary evaluation to determine who is able to take a road test. Neurorehabilitation exercises currently in use may be able to improve driving ability in stroke patients.

[C-ANCA positive necrotising scleritis and multiple sclerosis compatible with ocular Wegener: treatment with rituximab]. / Escleritis necrotizante c-ANCA positivo y esclerosis múltiple compatible con Wegener ocular: tratamiento con rituximab.

CASE REPORT: A patient diagnosed with necrotizing scleritis, c-ANCA+ an orbital pseudotumour, and possible multiple sclerosis in 2003 was treated with oral cyclophosphamide and steroids with partial response. Between 2005-2010 she suffered self-limited episodes. In 2010 a first scleral transplant was performed with poor outcome. She was treated with rituximab, and a second graft was performed with good results. At 12 months there was no change in magnetic resonance and the second graft healed. DISCUSSION: Wegener's disease with limited involvement of the orbit and/or the eye is a rare condition. The histopathology, blood analysis, symptoms and good response to treatment are the key to its diagnosis.

«Tiempo es cerebro», ¿solo en la fase aguda del ictus? / "Time is brain": only in the acute phase of stroke?

Introducción y objetivo: El ictus representa en España la primera causa de muerte por entidades específicas en mujeres, la primera causa de invalidez en los adultos y supone un enorme coste tanto humano como económico. En los últimos años se han producido avances importantes tanto en el tratamiento de la fase aguda como en el proceso neurorrehabilitador; sin embargo, continúa sin quedar claro cuál es el momento óptimo en el que debe iniciarse la neurorrehabilitación después de un ictus y cuáles son las consecuencias de retrasar este inicio. El objetivo de este estudio es comprobar el efecto que supone cada día de retraso en el inicio de la neurorrehabilitación en la recuperación funcional y su influencia en la tasa de institucionalización al alta.Métodos: Estudio retrospectivo en el que se incluyeron los pacientes ingresados entre abril de 2005 y septiembre de 2008, en la Unidad de Neurorrehabilitación de Ictus (UNRHI) del Hospital Parkwood (Universidad de Western Ontario, Canadá). Se obtuvo la edad, la puntuación FIM al ingreso y al alta, los días entre la aparición del ictus y el ingreso en la Unidad de Neurorrehabilitación y el destino al alta.Resultados: Después de ajustar por edad y FIM al ingreso, se encontró una asociación estadísticamente significativa entre la mejoría funcional de los pacientes (ganancia de FIM) y el retraso por cada día en comenzar la rehabilitación. Existe una correlación estadísticamente significativa entre el retraso en iniciar esta terapia y el grado de institucionalización al alta. Conclusiones: Por cada día que se retrase el inicio del tratamiento neurorrehabilitador empeora el pronóstico funcional de los pacientes al alta. Este retraso se relaciona también con una mayor tasa de institucionalización al alta (AU)

Introduction and objective: In Spain, stroke is the leading cause of death in women as well as the leading cause of disability in adults. This translates into a huge human and economic cost. In recent years there have been significant advances both in the treatment of acute stroke and in the neuro-rehabilitation process; however, it is still unclear when the best time is to initiate neurorehabilitation and what the consequences of delaying treatment are. To test the effect of a single day delay in the onset of neurorehabilitation on functional improvement achieved, and the influence of that delay in the rate of institutionalisation at discharge.Methods: A retrospective study of patients admitted to Parkwood Hospital's Stroke Neurorehabilitation Unit (UNRHI) (University of Western Ontario, Canada) between April 2005 and September 2008 was performed. We recorded age, Functional Independence Measurement (FIM) score at admission and discharge, the number of days between the onset of stroke and admission to the Neurorehabilitation Unit and discharge destination. Results: After adjustment for age and admission FIM, we found a significant association between patient functional improvement (FIM gain) and delay in starting rehabilitation. We also observed a significant correlation between delay in initiating therapy and the level of institutionalisation at discharge. Conclusions: A single day delay in starting neurorehabilitation affects the functional prognosis of patients at discharge. This delay is also associated with increased rates of institutionalisation at discharge (AU)

Hombro doloroso hemipléjico en pacientes con ictus: causas y manejo / Painful hemiplegic shoulder in stroke patients: causes and management

Introducción: El hombro doloroso hemipléjico es frecuente después de un ictus. Su aparición conlleva además del dolor, una limitación para las actividades de la vida diaria, así como para la participación en programas específicos de neurorrehabilitación. Todo este conjunto determina un peor resultado funcional. El buen manejo de los pacientes puede reducir tanto la frecuencia de aparición de hombro doloroso, como la intensidad del mismo, mejorando así el pronóstico funcional.Desarrollo: Entre los años 1980 y 2008 se llevó a cabo una búsqueda de la literatura en diferentes bases de datos. La evaluación de los artículos se realizó con el sistema de puntuación PEDro. Se establecieron 5 niveles de evidencia para obtener las conclusiones.Conclusiones: La subluxación del hombro, ocurre de manera precoz tras el ictus y se asocia con subluxación de la articulación del hombro y con espasticidad (subescapular y pectoral mayor principalmente). Los cabestrillos previenen la subluxación del hombro. Es preferible realizar movimientos con un menor rango de movimiento y sin agresividad, para evitar la aparición del hombro doloroso. La inyección de corticoides no mejora el dolor ni el rango de movimiento de los pacientes hemipléjicos, mientras que la toxina botulínica combinada con fisioterapia parece reducir el dolor del hombro hemipléjico (AU)

Introduction: The hemiplegic shoulder pain is common after a stroke. Its appearance brings pain and limits daily living activities as well as participation in specific Neuro-rehabilitation programs. All this leads to a worse functional outcome. Good management of patients can reduce both the frequency and intensity of shoulder pain, improving functional outcome.Development: We conducted a literature search of various databases between 1980 and 2008. The articles were evaluated using the PEDro scoring system. Five evidence levels were established for the conclusions.Conclusions: Shoulder subluxation, occurs at an early stage after stroke and is associated with subluxation of the shoulder joint and spasticity (mainly subscapularis and pectoralis). Slings prevent subluxation of the shoulder. It is preferable to move within a lower range of motion and without aggression to prevent the occurrence of shoulder pain. The injection of corticosteroids does not improve pain and range of motion in hemiplegic patients, while botulinum toxin combined with physical therapy appears to reduce hemiplegic shoulder pain (AU)

Assessing the impact of thrombolysis on progress through inpatient rehabilitation after stroke: a multivariable approach.

BACKGROUND: Acute administration of tissue plasminogen activator has been shown to improve immediate and long-term patient recovery after ischaemic stroke. Yet, despite widespread clinical application, many patients who receive acute tissue plasminogen activator still require inpatient rehabilitation. AIMS AND HYPOTHESIS: This study aimed to examine the effect of tissue plasminogen activator administration on recovery among patients requiring inpatient rehabilitation after stroke in Ontario, Canada. It was hypothesized that after covariate adjustment, administration of tissue plasminogen activator would be associated with accelerated progress through inpatient rehabilitation. METHODS: Acute and rehabilitation data were retrieved from the Registry of the Canadian Stroke Network and the National Rehabilitation Reporting System for all ischaemic stroke patients admitted to an acute facility and a rehabilitation unit between July 1, 2003 and March 31, 2008. Patients were divided into two groups: those who received tissue plasminogen activator and those who were medically eligible but did not receive tissue plasminogen activator. Three rehabilitation progress indicators were compared between groups: Functional Independence Measure gain, active length of stay, and discharge destination. Indicators were modelled using multivariable generalized linear models or logistic regression as appropriate. RESULTS: Patients who received tissue plasminogen activator experienced shorter active lengths of stay (log estimate ± standard error: -0·04 ± 0·01 days), and were slightly more likely to be discharged home compared to controls (adjusted odds ratio 1·35, 95% confidence interval 1·004-1·82). No differences were noted on Functional Independence Measure gain during rehabilitation. CONCLUSION: Results suggest that tissue plasminogen activator may contribute to accelerated progress through inpatient rehabilitation; however, there is no evidence to suggest that it contributes to greater functional improvement as measured by the Functional Independence Measure.

[Painful hemiplegic shoulder in stroke patients: causes and management]. / Hombro doloroso hemipléjico en pacientes con ictus: causas y manejo.

INTRODUCTION: The hemiplegic shoulder pain is common after a stroke. Its appearance brings pain and limits daily living activities as well as participation in specific Neuro-rehabilitation programs. All this leads to a worse functional outcome. Good management of patients can reduce both the frequency and intensity of shoulder pain, improving functional outcome. DEVELOPMENT: We conducted a literature search of various databases between 1980 and 2008. The articles were evaluated using the PEDro scoring system. Five evidence levels were established for the conclusions. CONCLUSIONS: Shoulder subluxation, occurs at an early stage after stroke and is associated with subluxation of the shoulder joint and spasticity (mainly subscapularis and pectoralis). Slings prevent subluxation of the shoulder. It is preferable to move within a lower range of motion and without aggression to prevent the occurrence of shoulder pain. The injection of corticosteroids does not improve pain and range of motion in hemiplegic patients, while botulinum toxin combined with physical therapy appears to reduce hemiplegic shoulder pain.

["Time is brain": only in the acute phase of stroke?]. / «Tiempo es cerebro¼, ¿solo en la fase aguda del ictus?

INTRODUCTION AND OBJECTIVE: In Spain, stroke is the leading cause of death in women as well as the leading cause of disability in adults. This translates into a huge human and economic cost. In recent years there have been significant advances both in the treatment of acute stroke and in the neuro-rehabilitation process; however, it is still unclear when the best time is to initiate neurorehabilitation and what the consequences of delaying treatment are. To test the effect of a single day delay in the onset of neurorehabilitation on functional improvement achieved, and the influence of that delay in the rate of institutionalisation at discharge. METHODS: A retrospective study of patients admitted to Parkwood Hospital's Stroke Neurorehabilitation Unit (UNRHI) (University of Western Ontario, Canada) between April 2005 and September 2008 was performed. We recorded age, Functional Independence Measurement (FIM) score at admission and discharge, the number of days between the onset of stroke and admission to the Neurorehabilitation Unit and discharge destination. RESULTS: After adjustment for age and admission FIM, we found a significant association between patient functional improvement (FIM gain) and delay in starting rehabilitation. We also observed a significant correlation between delay in initiating therapy and the level of institutionalisation at discharge. CONCLUSIONS: A single day delay in starting neurorehabilitation affects the functional prognosis of patients at discharge. This delay is also associated with increased rates of institutionalisation at discharge.

Does the treatment of spastic equinovarus deformity following stroke with botulinum toxin increase gait velocity? A systematic review and meta-analysis.

While botulinum toxin-A (BT-A) has been used to treat lower-limb focal spasticity successfully, its effect on characteristics of gait has not been well defined. The objective of this systematic review was to establish the treatment effect associated with the use of BT-A for equinovarus to improve gait velocity following stroke, using a meta-analytic technique. Relevant studies were identified through a literature search encompassing the years 1985 to November 2009. Studies were included if (i) the sample was composed of adult subjects recovering from either first or subsequent stroke, presenting with spastic equinovarus deformity of the ankle preventing full active dorsiflexion, and (ii) subjects who received BT-A were compared with subjects who had received a placebo, or (iii) in the absence of a placebo-controlled condition, subject had received BT-A and was assessed before and after treatment. A standardized mean difference (SMD) ± standard error and 95% confidence interval (CI) for gait velocity between the treatment and control group was calculated for each study, using Hedges's g, and the results pooled. Eight trials, five randomized controlled trials, and three single group intervention studies were included. Data representing 228 subjects were available for pooled analysis. Treatment with BT-A was associated with a small improvement in gait velocity (Hedge's g = 0.193 ± 0.081; 95% CI: 0.033 to 0.353, P < 0.018) representing an increase of 0.044 meters/s. The use of BT-A for lower-limb post-stroke equinovarus because of spasticity was associated with a small, but statistically significant increase in gait velocity.