title: Botulinum toxin a, evidence-based exercise therapy, and constraint-induced movement therapy for upper-limb hemiparesis attributable to stroke: a preliminary study.
abstract: OBJECTIVE
  To determine whether the combination of botulinum toxin A (BTX-A) treatment for the upper limb and a 4-wk course of exercise therapy could improve motor function sufficiently to allow those with poststroke hemiparesis and spasticity to achieve the minimal motor criteria (MMC) to be enrolled in constraint-induced movement therapy (CIMT), and to determine the feasibility of enrolling participants into CIMT if they meet MMC after treatment with a combination of BTX-A plus exercise therapy.
  
  
  METHODS
  Twelve individuals received BTX-A and exercise therapy for 1 hr/day, three times per week, for 4 wks. Those who met MMC were enrolled in 2 wks of CIMT, and the rest received a home exercise program. Outcome measures included the Ashworth Scale, Wolf Motor Function Test (WMFT), the Motor Activity Log (MAL), the Box and Blocks Test (BBT), and the upper-extremity subtest of the Fugl-Meyer Assessment of Motor Function (FM-UE).
  
  
  RESULTS
  Ashworth Scale scores declined from a mean score of 2.0-1.2 (P = 0.01). Four of 12 subjects were able to achieve MMC (P = 0.026). CIMT participants improved in the BBT, the MAL, and the WMFT compared with their own baseline. Gains achieved during CIMT receded by week 24 as spasticity returned.
  
  
  CONCLUSIONS
  BTX-A plus exercise therapy shows potential to improve function for those with severe hand paresis and spasticity after stroke. Those who meet MMC may initially realize further modest gains through CIMT. However, gains are likely to recede as spasticity returns. Adding medications or modifying the therapy protocol to include activities such as functional neuromuscular stimulation or robotic training may yield a more potent effect.
authors: Physical Medicine and Rehabilitation Service, North Florida/South Georgia Veterans Health Service, Gainesville, Florida 32608, USA.
authors: Charles E
authors: CE
authors: Levy
authors: Clare
authors: C
authors: Giuffrida
authors: Lorie
authors: L
authors: Richards
authors: Sam
authors: S
authors: Wu
authors: Sandy
authors: S
authors: Davis
authors: Steven E
authors: SE
authors: Nadeau
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D019274:Botulinum Toxins, Type A / Q000627:therapeutic use*; D003131:Combined Modality Therapy; D005081:Exercise Therapy / Q000379:methods; D006225:Hand; D006801:Humans; D008875:Middle Aged; D009128:Muscle Spasticity / Q000534:rehabilitation; D009465:Neuromuscular Agents / Q000627:therapeutic use*; D010291:Paresis / Q000534:rehabilitation*; D000071939:Stroke Rehabilitation; D014836:Volition
chemical_list: D009465:Neuromuscular Agents; D019274:Botulinum Toxins, Type A