title: Constraint-Induced Movement Therapy After Injection of Botulinum Toxin Type A for a Patient With Chronic Stroke: One-Year Follow-up Case Report.
abstract: OBJECTIVE
  Spasticity, an aspect of upper motor neuron syndrome, is a widespread problem in patients with stroke. To date, no study has reported the long-term (up to 1 year) outcomes of botulinum toxin (BTX) injection in combination with constraint-induced movement therapy in patients with chronic stroke. In this case report, the long-term (1 year) effects of the combination of BTX type A injection and constraint-induced movement therapy on spasticity and arm function in a patient with chronic stroke and arm paresis are described.
  
  
  METHODS
  The patient was a 66-year-old man who had had an infarction in the right posterior limb of the internal capsule 4 years before the intervention. At screening, the patient was not able to voluntarily extend his interphalangeal or metacarpophalangeal joints beyond the 10 degrees required for constraint-induced movement therapy. From 12 days after BTX type A injection, the patient received 5 hours of constraint-induced movement therapy for 10 weekdays.
  
  
  RESULTS
  All outcome measures (Modified Ashworth Scale, Fugl-Meyer Assessment, Action Research Arm Test, and amount of use scale of the Motor Activity Log) improved substantially over the 1-year period (before intervention to 1 year after intervention). Repeat BTX type A injections were not necessary because muscle tone and arm function did not worsen during the observation period.
  
  
  CONCLUSIONS
  The improved arm function may have reflected improvements in volitional movements and coordination or speed of movements in the paretic arm as a result of a reduction in spasticity, a reduction of learned nonuse behaviors, or use-dependent plasticity after the combination of BTX type A injection and constraint-induced movement therapy. In addition, the possibility of an influence of the passage of time or the Hawthorne effect cannot be ruled out. If this approach proves useful in future controlled studies, it may reduce the rising medical costs of the treatment of stroke.
authors.affiliation: S. Amano, OTR, MS, Department of Rehabilitation, The Hospital of Hyogo College of Medicine, Hyogo, Japan.
authors.forename: Satoru
authors.initials: S
authors.lastname: Amano
authors.affiliation: T. Takebayashi, OTR, MS, Department of Rehabilitation, The Hospital of Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo 663-8501, Japan. takshi77@hyo-med.ac.jp.
authors.forename: Takashi
authors.initials: T
authors.lastname: Takebayashi
authors.affiliation: K. Hanada, OTR, Department of Rehabilitation, The Hospital of Hyogo College of Medicine.
authors.forename: Keisuke
authors.initials: K
authors.lastname: Hanada
authors.affiliation: A. Umeji, OTR, Department of Rehabilitation, The Hospital of Hyogo College of Medicine.
authors.forename: Atsushi
authors.initials: A
authors.lastname: Umeji
authors.affiliation: K. Marumoto, MD, PhD, Hyogo Prefectural Rehabilitation Hospital at Nishi-Harima, Tatsuno, Hyogo, Japan.
authors.forename: Kohei
authors.initials: K
authors.lastname: Marumoto
authors.affiliation: K. Furukawa, MD, Department of Rehabilitation Medicine, The Hyogo College of Medicine.
authors.forename: Keiko
authors.initials: K
authors.lastname: Furukawa
authors.affiliation: K. Domen, MD, PhD, Department of Rehabilitation Medicine, The Hyogo College of Medicine.
authors.forename: Kazuhisa
authors.initials: K
authors.lastname: Domen
mesh_terms: D000368:Aged; D019274:Botulinum Toxins, Type A / Q000627:therapeutic use*; D002908:Chronic Disease; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D009128:Muscle Spasticity / Q000209:etiology / Q000628:therapy*; D009465:Neuromuscular Agents / Q000627:therapeutic use*; D010291:Paresis / Q000209:etiology / Q000628:therapy*; D026741:Physical Therapy Modalities; D012149:Restraint, Physical; D020521:Stroke / Q000150:complications / Q000628:therapy*; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D009465:Neuromuscular Agents; D019274:Botulinum Toxins, Type A