title: Systematic review of adjunct therapies to improve outcomes following botulinum toxin injection for treatment of limb spasticity.
abstract: OBJECTIVE
  To determine the quality of evidence from randomized controlled trials on the efficacy of adjunct therapies following botulinum toxin injections for limb spasticity.
  
  
  METHODS
  MEDLINE, EMBASE, CINAHL, and Cochrane Central Register of Controlled Trials electronic databases were searched for English language human studies from 1980 to 21 May 2015.
  
  
  METHODS
  Randomized controlled trials assessing adjunct therapies postbotulinum toxin injection for treatment of spasticity were included. Of the 268 studies screened, 17 met selection criteria.
  
  
  METHODS
  Two reviewers independently assessed risk of bias using the Physiotherapy Evidence Database (PEDro) scale and graded according to Sackett's levels of evidence.
  
  
  RESULTS
  Ten adjunct therapies were identified. Evidence suggests that adjunct use of electrical stimulation, modified constraint-induced movement therapy, physiotherapy (all Level 1), casting and dynamic splinting (both Level 2) result in improved Modified Ashworth Scale scores by at least 1 grade. There is Level 1 and 2 evidence that adjunct taping, segmental muscle vibration, cyclic functional electrical stimulation, and motorized arm ergometer may not improve outcomes compared with botulinum toxin injections alone. There is Level 1 evidence that casting is better than taping, taping is better than electrical stimulation and stretching, and extracorporeal shock wave therapy is better than electrical stimulation for outcomes including the Modified Ashworth Scale, range of motion and gait. All results are based on single studies.
  
  
  CONCLUSIONS
  There is high level evidence to suggest that adjunct therapies may improve outcomes following botulinum toxin injection. No results have been confirmed by independent replication. All interventions would benefit from further study.
authors.affiliation: Department of Medicine, University of British Columbia, Vancouver, BC, Canada Rehabilitation Research Program, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada patricia.mills@vch.ca.
authors.forename: Patricia Branco
authors.initials: PB
authors.lastname: Mills
authors.affiliation: Department of Medicine, University of British Columbia, Vancouver, BC, Canada GF Strong Rehabilitation Centre, Vancouver, BC, Canada.
authors.forename: Heather
authors.initials: H
authors.lastname: Finlayson
authors.affiliation: Department of Medicine, University of British Columbia, Vancouver, BC, Canada GF Strong Rehabilitation Centre, Vancouver, BC, Canada.
authors.forename: Malgorzata
authors.initials: M
authors.lastname: Sudol
authors.affiliation: Department of Medicine, University of British Columbia, Vancouver, BC, Canada GF Strong Rehabilitation Centre, Vancouver, BC, Canada.
authors.forename: Russell
authors.initials: R
authors.lastname: O'Connor
mesh_terms: D001905:Botulinum Toxins / Q000008:administration & dosage / Q000627:therapeutic use*; D003131:Combined Modality Therapy; D004599:Electric Stimulation Therapy; D019220:High-Energy Shock Waves / Q000627:therapeutic use; D006801:Humans; D007273:Injections, Intramuscular; D009128:Muscle Spasticity / Q000188:drug therapy* / Q000534:rehabilitation; D009498:Neurotoxins / Q000008:administration & dosage / Q000627:therapeutic use; D010043:Outcome and Process Assessment, Health Care; D026741:Physical Therapy Modalities; D016032:Randomized Controlled Trials as Topic; D013165:Splints
chemical_list: D009498:Neurotoxins; D001905:Botulinum Toxins
keywords: Muscle spasticity; adjunct therapy; botulinum toxins; electric stimulation therapy