Randomized, placebo-controlled trial of incobotulinumtoxina for upper-limb post-stroke spasticity.

INTRODUCTION: Efficacy and safety of incobotulinumtoxinA in post-stroke upper-limb spasticity were studied. METHODS: Subjects randomized 2:1 to incobotulinumtoxinA (fixed dose 400 U) or placebo, with fixed doses for the primary target clinical pattern (PTCP; flexed elbow, 200 U; flexed wrist, 150 U; clenched fist, 100 U). Doses for non-primary patterns were flexible within predefined ranges. RESULTS: At week 4, incobotulinumtoxinA led to larger improvements in PTCP Ashworth scale (AS) scores than placebo [least-squares mean change ± standard error: -0.9 ± 0.06 (n = 171) vs. -0.5 ± 0.08 (n = 88); P < 0.001], and more subjects were PTCP AS responders (≥1-point improvement) with incobotulinumtoxinA (69.6%) than with placebo (37.5%; P < 0.001). Investigator's Global Impression of Change confirmed superiority of incobotulinumtoxinA vs. placebo (P = 0.003). IncobotulinumtoxinA was associated with functional improvements, as demonstrated in responder rates for Disability Assessment Scale principal target at week 4 (P = 0.007). Adverse events were mainly mild/moderate, and were reported by 22.4% (incobotulinumtoxinA) and 16.8% (placebo) of subjects. CONCLUSIONS: IncobotulinumtoxinA significantly improved upper-limb spasticity and associated disability, and was well-tolerated.

Vitamin D deficiency: implications in the rehabilitation setting.

OBJECTIVE: Vitamin D deficiency, which can result from inadequate sun exposure, dietary intake, or problems with absorption, is rarely documented in the rehabilitation literature. Most likely, it is rarely thought of by the rehabilitation profession. This is problematic because vitamin D deficiency can present as musculoskeletal pain, which is commonly seen in both outpatient clinics and inpatient rehabilitation units. The populations with the greatest risk include the homebound elderly, people with pigmented skin, people with cultural and social avoidance of the sun, people who live in wintertime in climates above and below latitudes of 35 degrees, and people with gastrointestinal malabsorption. DESIGN: The review was done using PubMed, Ovid, and MDConsult using the search terms pain, chronic pain, musculoskeletal pain, vitamin D deficiency, and osetomalacia. The search revealed 107 articles and was narrowed down to 51 articles that focused on vitamin D deficiency and its musculoskeletal manifestations. RESULTS: A direct correlation was noted between vitamin D deficiency and musculoskeletal pain. At-risk populations are not acquiring enough vitamin D through sun exposure, and the current recommended daily allowances from dietary sources including supplements are too low to compensate for this lack of sun exposure. Treatment of vitamin D deficiency produced an increase in muscle strength and a marked decrease in back and lower-limb pain within 6 mos. CONCLUSION: Vitamin D deficiency should be included in the differential diagnosis in the evaluation of musculoskeletal pain complaints in the rehabilitation setting, and treatment of any identified deficiency should be considered a potentially important component of the treatment regimen.

The use of atypical antipsychotics in traumatic brain injury.

The use of antipsychotic medication in treating individuals with traumatic brain injury (TBI) has been controversial. Much of the caution derives from animal studies (and limited human data) with regard to typical antipsychotics. Of note, however, is that similar assumptions have been made about the newer generation of atypical antipsychotics as well. Because these agents have different mechanisms of action as well as different neurotransmitter targets, this may very well be unwarranted. In this article, mechanisms of action of typical and atypical antipsychotics are discussed, with particular attention paid to their use in TBI. Indications and contraindications are presented, and recommendations are made for the responsible prescribing of antipsychotic medications after TBI.