title: OnabotulinumtoxinA Injection for Poststroke Upper-Limb Spasticity: Guidance for Early Injectors From a Delphi Panel Process.
abstract: OnabotulinumtoxinA reduces muscle hypertonia associated with poststroke spasticity (PSS). PSS manifests as several common postures.
  
  
  
  To define treatment paradigms for PSS upper-limb common postures.
  
  
  
  Modified Delphi method.
  
  
  
  Expert panel.
  
  
  
  Ten injectors experienced in the treatment and clinical research of PSS (physiatrists and neurologists) were invited to participate in the Delphi panel.
  
  
  
  The Delphi panel reviewed an electronic worksheet with PSS upper-limb postures to define onabotulinumtoxinA treatment paradigms (Round 1). During Round 2, panel members discussed in person Round 1 results and voted until consensus (≥66% agreement). Recommendations were geared toward those with new or early injection experience.
  
  
  
  Expert consensus on onabotulinumtoxinA treatment parameters for PSS including muscles to inject, dose per muscle and posture, and treatment adjustments for suboptimal response.
  
  
  
  For each posture, consensus was reached on targeted subsets of muscles. Doses ranged for individual muscles (10-100 U) and total doses per posture (50-200 U). An onabotulinumtoxinA dilution 50 U/mL (2:1 dilution ratio) was considered most appropriate; dilution ratios of 1:1 to 4:1 may be appropriate in some circumstances. The majority (89%) of panel members would increase the dose and/or the number of muscles treated for a suboptimal response to onabotulinumtoxinA. The panel identified 3 common aggregate upper-limb postures: (1) adducted shoulder + flexed elbow + pronated forearm + flexed wrist + clenched fist; (2) flexed elbow + pronated forearm + flexed wrist + clenched fist; and (3) flexed wrist + clenched fist. The recommended starting dose per aggregate was 300 U, 300 U, and 200 U, with a total maximum dose of 400 U, 400 U, and 300 U, respectively. Localization guidance techniques were considered essential for all postures.
  
  
  
  Consensus on common muscles and onabotulinumtoxinA treatment paradigms for postures associated with upper-limb PSS was achieved via a modified Delphi method. The purpose of this analysis is to educate early onabotulinumtoxinA injectors rather than provide an evidence-based review.
  
  
  
  V.
authors.affiliation: Department of Neurology, Icahn School of Medicine at Mount Sinai, Box 1052, New York, NY 10029(∗). Electronic address: david.simpson@mssm.edu.
authors.forename: David M
authors.initials: DM
authors.lastname: Simpson
authors.affiliation: Kansas City Bone and Joint Clinic, Overland Park, KS(†).
authors.forename: Atul T
authors.initials: AT
authors.lastname: Patel
authors.affiliation: Bacharach Institute for Rehabilitation, Pomona, NJ(‡).
authors.forename: Abraham
authors.initials: A
authors.lastname: Alfaro
authors.affiliation: Rancho Los Amigos National Rehabilitation Center, Downey, CA; David Geffen School of Medicine, University of California, Los Angeles, CA; Western University of Health Sciences, Pomona, CA(§).
authors.forename: Ziyad
authors.initials: Z
authors.lastname: Ayyoub
authors.affiliation: Department of Neurology, Vanderbilt University, Nashville, TN(¶).
authors.forename: David
authors.initials: D
authors.lastname: Charles
authors.affiliation: Department of Neurology, Loma Linda University School of Medicine, Loma Linda, CA(#).
authors.forename: Khashayar
authors.initials: K
authors.lastname: Dashtipour
authors.affiliation: MossRehab Gait and Motion Analysis Laboratory, Elkins Park, PA(‖).
authors.forename: Alberto
authors.initials: A
authors.lastname: Esquenazi
authors.affiliation: Department of Veterans Affairs, San Francisco, CA; University of New Mexico School of Medicine, Albuquerque, NM(∗∗).
authors.forename: Glenn D
authors.initials: GD
authors.lastname: Graham
authors.affiliation: Medical College of Wisconsin, Milwaukee, WI(††).
authors.forename: John R
authors.initials: JR
authors.lastname: McGuire
authors.affiliation: Department of Rehabilitation Medicine, University of Washington, Seattle, WA(‡‡).
authors.forename: Ib
authors.initials: I
authors.lastname: Odderson
mesh_terms: D065087:Acetylcholine Release Inhibitors / Q000008:administration & dosage / Q000627:therapeutic use*; D019274:Botulinum Toxins, Type A / Q000008:administration & dosage / Q000627:therapeutic use*; D003697:Delphi Technique; D006801:Humans; D007267:Injections; D009128:Muscle Spasticity / Q000188:drug therapy* / Q000209:etiology / Q000503:physiopathology*; D011187:Posture / Q000502:physiology; D020521:Stroke / Q000150:complications*; D016896:Treatment Outcome; D034941:Upper Extremity / Q000503:physiopathology*
chemical_list: D065087:Acetylcholine Release Inhibitors; D019274:Botulinum Toxins, Type A