title: Rehabilitation therapies after botulinum toxin-A injection to manage limb spasticity: a systematic review.
abstract: BACKGROUND
  Botulinum toxin A (BoNT-A) injections are increasingly used to treat muscle spasticity and are often complemented by adjunctive rehabilitation therapies; however, little is known about the effect of therapy after injection.
  
  
  OBJECTIVE
  The aim of this study was to identify and summarize evidence on rehabilitation therapies used after BoNT-A injections to improve motor function in adults with neurological impairments.
  
  
  METHODS
  Searches were conducted in PubMed, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL, National Research Register, metaRegistry of Controlled Trials, PEDro, and OTseeker.
  
  
  METHODS
  Randomized and quasi-randomized controlled trials were considered for inclusion. Participants with neurological impairments received BoNT-A to treat focal spasticity in limbs, with rehabilitation interventions provided to experimental groups only. Primary outcome measures were joint mobility, function of the affected limb, and spasticity. Eleven studies with 234 participants, most of whom had stroke, were included in the review.
  
  
  METHODS
  Two reviewers extracted study details and data.
  
  
  RESULTS
  Methodological quality was rated using the PEDro scale. Both fixed-effects and random-effects models were used to calculate effect size.
  
  
  RESULTS
  Studies were of variable quality: 3 were poor (PEDro score 1 to 4), and 8 were moderate (PEDro score 6 to 7). No study investigated effects for longer than 24 weeks (6 months). Included trials presented 9 therapy types, including ergometer cycling, electrical stimulation, stretch (casting, splinting, taping, or manual or exercise-induced stretch), constraint-induced movement therapy, task-specific motor training, and exercise programs. Statistical findings suggest that combined therapy and BoNT-A is slightly more effective than BoNT-A alone.
  
  
  CONCLUSIONS
  Evidence relating to impact of adjunct therapy is available, but the heterogeneity of studies limits the opportunity to demonstrate overall impact. Researchers need to consider the benefits of greater consistency in study approaches and measures so that meaningful evaluations of overall adjunct therapy effects can be made.
authors: B.Z. Kinnear, BAppSc(OT), Faculty of Social Sciences, University of Wollongong, Wollongong, New South Wales, Australia. Mailing address: School of Health and Society, Illawarra Health & Medical Research Institute, University of Wollongong, Northfields Avenue, Wollongong, New South Wales, 2522 Australia. bkinnear@hammond.com.au biancakinnear@hotmail.com.
authors: Bianca Z
authors: BZ
authors: Kinnear
authors: N.A. Lannin, PhD, BSc(OT), GradDip, Department of Occupational Therapy, La Trobe University, and Occupational Therapy Department, Alfred Health Melbourne, Victoria, Australia.
authors: Natasha A
authors: NA
authors: Lannin
authors: A. Cusick, PhD, BAppSc(OT), MA(Psych), MA(Interdisc Stud), PhD, Faculty of Social Sciences, University of Wollongong.
authors: Anne
authors: A
authors: Cusick
authors: L.A. Harvey, BAppSc, GradDipAppSc(ExSpSc), MAppSc, PhD, Rehabilitation Studies Unit, Kolling Institute, Sydney Medical School/Northern, University of Sydney, New South Wales, Australia.
authors: Lisa A
authors: LA
authors: Harvey
authors: B. Rawicki, MB, BS, FAFRM, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia.
authors: Barry
authors: B
authors: Rawicki
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D019274:Botulinum Toxins, Type A / Q000627:therapeutic use*; D003131:Combined Modality Therapy / Q000379:methods; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009128:Muscle Spasticity / Q000188:drug therapy* / Q000534:rehabilitation*; D009465:Neuromuscular Agents / Q000627:therapeutic use*; D026741:Physical Therapy Modalities
chemical_list: D009465:Neuromuscular Agents; D019274:Botulinum Toxins, Type A