Effectiveness of botulinum toxin treatment for upper limb spasticity after stroke over different ICF domains: a systematic review and meta-analysis

Publication date: Available online 21 February 2019

Source: Archives of Physical Medicine and Rehabilitation

Author(s): Aukje Andringa, Ingrid van de Port, Erwin van Wegen, Johannes Ket, Carel Meskers, Gert Kwakkel

Abstract

Objective

To provide a comprehensive overview of reported effects and scientific robustness of botulinum toxin (BoNT) treatment regarding the main clinical goals related to post-stroke upper limb spasticity, using the ICF classification.

Data sources

Embase.com, PubMed, Wiley/Cochrane Library, and Ebsco/CINAHL were searched from inception up to 16 May 2018.

Study Selection

Randomized controlled trials comparing upper limb BoNT injections with a control intervention in stroke patients were included. A total of 1212 unique records were screened by two independent reviewers. Forty trials were identified, including 2718 stroke patients.

Data Extraction

Outcome data were pooled according to assessment timing (i.e. 4-8 and 12 weeks after injection), and categorized into six main clinical goals (i.e. spasticity-related pain, involuntary movements, passive joint motion, care ability, arm and hand use, and standing and walking performance). Sensitivity analyses were performed for the influence of study and intervention characteristics, involvement of pharmaceutical industry, and publication bias.

Data Synthesis

Robust evidence is shown for the effectiveness of BoNT in reducing resistance to passive movement, as measured with the (Modified) Ashworth Score, and improving self-care ability for the affected hand and arm after intervention (p<0.005) and at follow-up (p<0.005). In addition, robust evidence is shown for the absence of effect on 'arm-hand capacity' at follow-up. BoNT significantly reduced 'involuntary movements', 'spasticity-related pain', and 'carer burden', and improved 'passive range of motion', while no evidence was found for 'arm and hand use' after intervention.

Conclusions

In view of the robustness of current evidence, no further trials are needed to investigate BoNT for its favourable effects on resistance to passive movement of the spastic wrist and fingers, and on self-care. No trials are needed to further confirm the lack of effects of BoNT on arm-hand capacity, whereas additional trials are needed to establish the suggested favourable effects of BoNT on other 'body functions' which may result in clinically meaningful outcomes at 'activity' and 'participation' levels.

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