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European Journal of Physical and Rehabilitation Medicine 2014 October;50(5):525-32


language: English

Management of stroke patients submitted to botulinum toxin type A therapy: a Delphi survey of an Italian expert panel of specialist injectors

Franceschini M. 1, Iocco M. 2, Molteni F. 3, Santamato A. 4, Smania N. 5

1 Department of Rehabilitation, IRCCS San Raffaele-Pisana, Rome, Italy; 2 P&RM Unit, Medical & Surgical Sciences Department, “Magna Graecia” University, Catanzaro, Italy; 3 H.Valduce, Villa Beretta, Costa Masnaga (LC), Italy; 4 Department of Physical Medicine and Rehabilitation, “OORR Hospital”, University of Foggia, Italy; 5 Neuromotor and Cognitive Rehabilitation Research Centre, Department of Neurological, Neuropsychological, Morphological and Movement Sciences, University of Verona, Italy


BACKGROUND: Spasticity is a common disabling symptom of several neurological conditions including stroke. Botulinum toxin type A (BTX-A) injection represents the gold standard therapy for focal spasticity. Post-stroke management of patients receiving BTX-A therapy has been variously investigated, but general agreement on how and when to implement rehabilitation is lacking.
AIM: To perform a national survey of experts on the most appropriate rehabilitation procedures after BTX-A therapy for the focal treatment of spasticity.
DESIGN: The study employed the Delphi technique through the COSMO project (Consensus on Post-Injection Management in Post-stroke Spasticity).
METHODS: Italian neurologists and physiatrists with experience in BTX-A therapy were selected to participate in the survey. Their anonymous opinions on key issues in treatment strategies in post-stroke spasticity were collected in three sequential rounds facilitated by a web platform. Consensus on a given issue was defined as agreed opinion by at least 66% of the survey participants.
RESULTS: In all, 44 Italian experts were involved. Positive consensus was reached on the need to start rehabilitation during the first week after BTX-A injection therapy, with a rehabilitation program comprising both stretching combined with electrical stimulation and exercise therapy. Functional surgery may be considered only after 12-24 months in cases of BTX-A therapy failure. The use of commercial or custom-made orthoses in selected cases was recommended. The appropriate time interval between two BTX-A injections is 3-6 months, and clinical assessment should be performed 1 month after injection.
CONCLUSION: The results of this national survey confirm that clinical experts on the use of BTX-A therapy for spasticity after stroke agree on the need to initiate rehabilitation treatment immediately after BTX-A injection: muscle stretching exercises, eventually combined with neuromuscular electrical stimulation, may enhance the effect of BTX-A therapy. Outcome after BTX-A therapy should be assessed at repeated follow-up visits.
CLINICAL REHABILITATION IMPACT: This expert panel survey can provide guidance for clinicians in the assessment of patients treated with BTX-A therapy.

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