RESUMO
The aim was to investigate if botulinum toxin type A (BTx-A) associated with physical therapy is superior to physical therapy alone in post stroke spasticity. A randomized, double-blinded controlled trial was performed in a rehabilitation unit on Northeastern, Brazil. Patients with post stroke spasticity were enrolled either to BTx-A injections and a pre-defined program of physical therapy or saline injections plus physical therapy. Primary endpoint was functional performance evaluated through time up and go test, six minutes walking test and Fugl-Meyer scale for upper limb. Secondary endpoint was spasticity improvement. Confidence interval was considered at 95%. Although there was a significant decrease in upper limbs flexor tonus (P<0.05) in the BTx-A group, there was no difference regarding functional performance after 9 months of treatment. When analyzing gait speed and performance, both groups showed a significant improvement in the third month of treatment, however it was not sustained over time. Although BTx-A shows superiority to improve muscle tone, physical therapy is the cornerstone to improve function in the upper limbs of post stroke patients.
RESUMO
Post-stroke spasticity is an important cause of disability in adults, due to muscle hyperactivity, which results in limb stiffness and muscle spasm. The prognosis for these patients depends on several features such as early management and adequate physical therapy to avoid muscle shortening, pain, and their consequences. Although several papers have shown that intramuscular injections of botulinum toxin type A (BT-A) decreases spasticity in post-stroke patients, few authors have demonstrated functional improvement after this therapy. In order to assess if individualized BT-A injections improves upper limb function in post-stroke spastic patients, we prospectively followed 20 consecutive patients of 18 years of age or more with spastic hemiparesis secondary to stroke. Fulg-Meyer scale modified for upper limbs, measure of functional independence (MFI), Ashworth modified scale, and goniometry were applied in the beginning of the investigation and in the 16th and 32nd weeks. BT-A was applied at baseline and in the 16th week. All subjects were submitted to rehabilitation therapy. All patients showed improvement according to Ashworth modified scale and increase in the range of motion, which were sustained until the 32nd week (p<0.05). The assessment of the first three parameters of the Fulg-Meyer scale and the evaluations of the motor part of the Functional Independence Measure showed statistically improvement until the end of the study. We conclude that proper choice of muscles and individualized doses of BT-A can improve function in selected post-stroke patients.
Assuntos
Atividades Cotidianas , Toxinas Botulínicas Tipo A/administração & dosagem , Espasticidade Muscular/tratamento farmacológico , Fármacos Neuromusculares/administração & dosagem , Acidente Vascular Cerebral/complicações , Adulto , Análise de Variância , Relação Dose-Resposta a Droga , Feminino , Humanos , Injeções Intramusculares , Masculino , Pessoa de Meia-Idade , Espasticidade Muscular/etiologia , Espasticidade Muscular/reabilitação , Exercícios de Alongamento Muscular , Estudos Prospectivos , Amplitude de Movimento Articular , Reabilitação do Acidente Vascular Cerebral , Resultado do Tratamento , Extremidade SuperiorRESUMO
Post-stroke spasticity is an important cause of disability in adults, due to muscle hyperactivity, which results in limb stiffness and muscle spasm. The prognosis for these patients depends on several features such as early management and adequate physical therapy to avoid muscle shortening, pain, and their consequences. Although several papers have shown that intramuscular injections of botulinum toxin type A (BT-A) decreases spasticity in post-stroke patients, few authors have demonstrated functional improvement after this therapy. In order to assess if individualized BT-A injections improves upper limb function in post-stroke spastic patients, we prospectively followed 20 consecutive patients of 18 years of age or more with spastic hemiparesis secondary to stroke. Fulg-Meyer scale modified for upper limbs, measure of functional independence (MFI), Ashworth modified scale, and goniometry were applied in the beginning of the investigation and in the 16th and 32nd weeks. BT-A was applied at baseline and in the 16th week. All subjects were submitted to rehabilitation therapy. All patients showed improvement according to Ashworth modified scale and increase in the range of motion, which were sustained until the 32nd week (p<0.05). The assessment of the first three parameters of the Fulg-Meyer scale and the evaluations of the motor part of the Functional Independence Measure showed statistically improvement until the end of the study. We conclude that proper choice of muscles and individualized doses of BT-A can improve function in selected post-stroke patients.
Espasticidade secundária a acidente vascular cerebral (AVC) é importante causa de incapacidade em adultos. O prognóstico para estes pacientes depende de vários fatores como tratamento precoce e terapia física adequada, evitando encurtamento muscular, dor e outras conseqüências. Vários estudos têm demonstrado que aplicacões intramusculares de toxina botulínica do tipo A (TxB-A) reduzem a espasticidade após AVC, entretanto poucos autores observaram melhora funcional de membros superiores com esta terapêutica. Para determinar se aplicações individualizadas de TxB-A melhoram a função no membro superior espástico de pacientes com hemiparesia secundária a AVC, acompanhamos 20 pacientes com história de AVC entre 6 meses e 5 anos. A escala de Fulg-Meyer para membros superiores, a medida de independência funcional, a escala modificada de Ashworth e goniometria foram aplicadas no início da investigação, na 16ª e 32ª semanas. TxB-A foi aplicada no início do estudo e na 16ª semana e todos os participantes foram tratados adicionalmente com fisioterapia. Observamos melhora na escala de Ashworth e aumento na amplitude de movimento em todos os pacientes até a 32ª semana (p<0.05). A análise dos 3 primeiros parâmetros da escala de Fulg-Meyer e a parte motora da MIF mostraram melhora estatisticamente significante até o final do estudo. Concluímos que a escolha adequada dos músculos e doses individualizadas de TxB-A melhoram a função em pacientes com espasticidade pós-AVC