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• W1982506654 abstract "HomeStrokeVol. 42, No. 7Letter by Munin et al Regarding Article, “Botulinum Toxin for the Upper Limb After Stroke (BoTULS) Trial: Effect on Impairment, Activity Limitation, and Pain” Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBLetter by Munin et al Regarding Article, “Botulinum Toxin for the Upper Limb After Stroke (BoTULS) Trial: Effect on Impairment, Activity Limitation, and Pain” Michael C. Munin, MD, Douglas J. Weber, PhD and Elizabeth R. Skidmore, PhD, OTR/L Michael C. MuninMichael C. Munin Search for more papers by this author , Douglas J. WeberDouglas J. Weber Search for more papers by this author and Elizabeth R. SkidmoreElizabeth R. Skidmore Search for more papers by this author Originally published2 Jun 2011https://doi.org/10.1161/STROKEAHA.111.621219Stroke. 2011;42:e412Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2011: Previous Version 1 To the Editor:We read the article by Shaw et al1 with great interest. Their trial examined whether abobotulinumtoxinA and task practice therapy could improve upper limb function after spastic hemiparesis more than therapy alone in controls based on changes in the Action Research Arm Test (ARAT).1 There are several points that may explain why the investigators saw only improvements in patient-rated basic upper limb functional activities rather than observed ARAT scores in treated subjects.When injecting botulinum toxin, the clinicians used surface localization to identify forearm muscles instead of more accurate guidance from ultrasound with electromyography or nerve stimulation. We demonstrated that ultrasound guidance during botulinum toxin injections is more accurate than surface localization when targeting forearm muscles that have a complex pattern of overlapping anatomy with superficial and deep layers.2 Using ultrasound guidance, muscles with several bellies (eg, flexor digitorum superficialis) can be administered doses individually to target specific spastic patterns in each belly. Confirmation of accurate drug placement can be attained by targeting end plate regions or visually ensuring that the injectate stays within fascial borders, and not by assuming that local diffusion of toxin would be sufficient for delivery.The methodology was also hindered by using low median doses of abobotulinumtoxinA between 200 and 300 total units. In previous upper limb stroke spasticity studies, mean doses ranged between 500 and 1000 units.3 The majority of subjects had spasticity affecting the shoulder, elbow, wrist, and hand, indicating that many muscles required treatment. Although up to 9 different muscles could be injected based on clinical assessment, the median reported dose per individual muscle was ≈100 units, meaning that only a few muscles were injected during a session. Because functional improvement was the primary outcome of this trial, inaccurate placement of toxin combined with suboptimal dosing of limited numbers of muscles may explain why the intervention group did not show improvement in ARAT relative to controls.The Botulinum Toxin for the Upper Limb After Stroke study enrolled a majority of subjects with very low, if any, distal hand function at baseline (ARAT score, 0–3). Participants in the Botulinum Toxin for the Upper Limb After Stroke trial with some retained active upper limb function (ARAT score, 4–56) were more likely to experience a predefined successful outcome compared to the larger number of participants with no retained upper limb function (ARAT score, 0–3). Therefore, with severe baseline weakness in a majority of subjects, it is not surprising that botulinum toxin injections that block neuromuscular transmission and cause selective muscle weakening did not improve active functional movement as measured by the ARAT.Measuring upper limb function is clearly more difficult than studying a more precisely defined construct like blood pressure. The authors of the article1 note that ≈30% of subjects had improved ARAT scores at 3 months, although toxin injections did not affect this relationship. Our findings also demonstrated a gain in ARAT scores at 3 months in subjects administered a combination of onabotulinumtoxinA and task practice training, with and without functional electric stimulation.4 In the Botulinum Toxin for the Upper Limb After Stroke trial, significantly more abobotulinumtoxinA patients had improvement in subject-reported daily tasks, like opening the palm for cleaning and cutting nails and putting an arm through a coat sleeve. These findings indicate that different measures give us different information about the effectiveness of interventions on upper limb function and pose the question, which measures are best for measuring changes in upper limb spasticity after stroke? We appreciate the investigators' contribution to the literature with this large, multicenter, randomized trial, and we hope that our comments further the discussion.Michael C. Munin, MDDouglas J. Weber, PhD Department of Physical Medicine and Rehabilitation University of Pittsburgh School of Medicine Pittsburgh, PAElizabeth R. Skidmore, PhD, OTR/L Department of Occupational Therapy University of Pittsburg School of Medicine Pittsburgh, PADisclosureNone.FootnotesStroke welcomes Letters to the Editor and will publish them, if suitable, as space permits. Letters must reference a Stroke published-ahead-of-print article or an article printed within the past 3 weeks. The maximum length is 750 words including no more than 5 references and 3 authors. Please submit letters typed double-spaced. Letters may be shortened or edited. Include a completed copyright transfer agreement form (available online at http://stroke.ahajournals.org and http://submit-stroke.ahajournals.org). References 1. Shaw LC, Price CI, van Wijck FM, Shackley P, Steen N, Barnes MP; on behalf of the BoTULS Investigators. Botulinum Toxin for the Upper Limb After Stroke (BoTULS) trial: Effect on impairment, activity limitation, and pain. Stroke. 2011; 42:1371–1379.LinkGoogle Scholar2. Henzel MK, Munin MC, Niyonkuru C, Skidmore ER, Weber DJ, Zafonte RD. Comparison of surface and ultrasound localization to identify forearm flexor muscles for botulinum toxin injections. PMR. 2010; 2:642–646.CrossrefMedlineGoogle Scholar3. Bakheit AM, Fedorova NV, Skoromets AA, Timerbaeva SL, Bhakta BB, Coxon L. The beneficial antispasticity effect of botulinum toxin type A is maintained after repeated treatment cycles. J Neurol Neruosurg Psychiatry. 2004; 75:1558–1561.CrossrefMedlineGoogle Scholar4. Weber DJ, Skidmore ER, Niyonkuru C, Chang CL, Huber LM, Munin MC. Cyclic functional electrical stimulation does not enhance gains in hand grasp function when used as an adjunct to onabotulinumtoxinA and task practice therapy: a single-blind, randomized controlled pilot study. Arch Phys Med Rehabil. 2010; 91:679–686.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited ByShaw L, Barnes M and Rodgers H (2011) Response to Letter by Munin et al Regarding Article, “Botulinum Toxin for the Upper Limb After Stroke (BoTULS) Trial: Effect on Impairment, Activity Limitation, and Pain”, Stroke, 42:7, (e413-e413), Online publication date: 1-Jul-2011. July 2011Vol 42, Issue 7 Advertisement Article InformationMetrics © 2011 American Heart Association, Inc.https://doi.org/10.1161/STROKEAHA.111.621219PMID: 21636823 Originally publishedJune 2, 2011 PDF download Advertisement SubjectsRehabilitation" @default.
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