title: Local muscle injection of botulinum toxin type a synergistically improves the beneficial effects of repetitive transcranial magnetic stimulation and intensive occupational therapy in post-stroke patients with spastic upper limb hemiparesis.
abstract: BACKGROUND
  The purpose of this study was to determine whether local injection of botulinum toxin type A (BoNT-A) into the spastic muscles has any added benefits to repetitive transcranial magnetic stimulation (RTMS)/occupational therapy (OT) in patients with spastic upper limb hemiparesis.
  
  
  METHODS
  The study subjects of 80 post-stroke patients with spastic upper limb hemiparesis (age: 60.2 ± 13.0 years, time after stroke: 55.3 ± 43.0 months), were divided into the BoNT-A plus RTMS/OT group and RTMS/OT group. BoNT-A was injected into the spastic muscles (total dose: 240 units) before RTMS/OT. The latter included 12 sessions of 40 min RTMS over the non-lesional hemisphere and 240-min intensive OT daily over 15 days. Spasticity was evaluated by the modified Ashworth scale (MAS) and the motor function of the affected upper limb was evaluated serially with Fugl-Meyer Assessment and Wolf Motor Function Tests.
  
  
  RESULTS
  Both groups showed significant improvements in spasticity and motor function. The addition of BoNT-A resulted in better improvement in FMA score and MAS of finger flexor muscles (p < 0.05).
  
  
  CONCLUSIONS
  The triple-element protocol of local injection of BoNT-A into spastic finger muscles, RTMS and intensive OT, is a promising therapeutic program for post-stroke spastic upper limb hemiparesis, although its significance should be confirmed in randomized, placebo-controlled trials.
authors.affiliation: Department of Rehabilitation Medicine, Jikei University School of Medicine, Minato-Ku, Tokyo, Japan.
authors.forename: Naoki
authors.initials: N
authors.lastname: Yamada
authors.forename: Wataru
authors.initials: W
authors.lastname: Kakuda
authors.forename: Takahiro
authors.initials: T
authors.lastname: Kondo
authors.forename: Sugao
authors.initials: S
authors.lastname: Mitani
authors.forename: Masato
authors.initials: M
authors.lastname: Shimizu
authors.forename: Masahiro
authors.initials: M
authors.lastname: Abo
mesh_terms: D019274:Botulinum Toxins, Type A / Q000008:administration & dosage*; D005240:Feasibility Studies; D005260:Female; D005385:Fingers / Q000503:physiopathology; D006801:Humans; D007273:Injections, Intramuscular; D008297:Male; D008875:Middle Aged; D009465:Neuromuscular Agents / Q000008:administration & dosage*; D009788:Occupational Therapy / Q000379:methods*; D020336:Paraparesis, Spastic / Q000209:etiology / Q000503:physiopathology / Q000534:rehabilitation*; D011446:Prospective Studies; D020127:Recovery of Function / Q000187:drug effects; D012189:Retrospective Studies; D012720:Severity of Illness Index; D020521:Stroke / Q000150:complications / Q000503:physiopathology; D000071939:Stroke Rehabilitation; D050781:Transcranial Magnetic Stimulation / Q000379:methods*; D016896:Treatment Outcome
chemical_list: D009465:Neuromuscular Agents; D019274:Botulinum Toxins, Type A