title: OnabotulinumtoxinA for Lower Limb Spasticity: Guidance From a Delphi Panel Approach.
abstract: BACKGROUND
  OnabotulinumtoxinA is approved for the treatment of upper and lower limb spasticity in adults. Guidance on common postures and onabotulinumtoxinA injection paradigms for upper limb spasticity has been developed via a Delphi Panel; however, similar guidance for lower limb spasticity has not been established.
  
  
  OBJECTIVE
  To define a clinically recommended treatment paradigm for the use of onabotulinumtoxinA for each common posture among patients with poststroke lower limb spasticity (PSLLS) and to identify the most common PSLLS aggregate postures.
  
  
  METHODS
  Clinical experts provided insight regarding onabotulinumtoxinA treatment for PSLLS using an adaptation of the Delphi consensus process.
  
  
  METHODS
  Delphi panel.
  
  
  METHODS
  Ten expert clinicians in neurology and physical medicine and rehabilitation who treat PSLLS.
  
  
  METHODS
  A minimum of 2 rounds of anonymous voting occurred for each recommendation until consensus was reached (≥66% agreement). The first round was conducted via a survey; the second round was an in-person meeting.
  
  
  METHODS
  Reached consensus on muscle selection for injection, overall and per-muscle dose of onabotulinumtoxinA, number of injection sites/muscle, onabotulinumtoxinA dilution, and use of localization techniques. The most common PSLLS postures were reviewed. Recommendations were tailored toward injectors with less experience.
  
  
  RESULTS
  Consensus was reached on targeted subsets of muscles for each posture. Doses ranged from 20 to 150 U for individual muscles and 50 to 300 U for limb postures. OnabotulinumtoxinA dilution 50 U/mL (2:1 ratio) was considered most appropriate but varied based on muscles selected (range, 2:1-4:1). Experts agreed that localization techniques for muscle identification during injection for all postures would be useful. For suboptimal response to injection, all panel members would increase the dose, and the majority (89%) would increase the number of treated muscles. The panel identified 3 common aggregating lower limb postures: (1) equinovarus foot and flexed toes; (2) extended knee and plantar flexed foot/ankle; and (3) plantar flexed foot/ankle and flexed toes. The recommended starting doses for each aggregate posture were 400 U, 400 U, and 300 U, respectively.
  
  
  CONCLUSIONS
  The modified Delphi panel process provided consensus on common muscles and corresponding onabotulinumtoxinA treatment paradigms for postures associated with PSLLS that can be used for guidance in optimizing care delivery.
  
  
  METHODS
  V.
authors.affiliation: MossRehab Gait and Motion Analysis Laboratory, MossRehab Gait and Motion Analysis Laboratory, 60 Township Line Rd, Elkins Park, PA 19027(∗). Electronic address: aesquena@einstein.edu.
authors.forename: Alberto
authors.initials: A
authors.lastname: Esquenazi
authors.affiliation: Spasticity and Dystonia Clinic, 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/Movement Disorders, Loma Linda University School of Medicine, Loma Linda, CA(¶).
authors.forename: Khashayar
authors.initials: K
authors.lastname: Dashtipour
authors.affiliation: Department of Veterans Affairs and University of California San Francisco School of Medicine, San Francisco, CA(#).
authors.forename: Glenn D
authors.initials: GD
authors.lastname: Graham
authors.affiliation: Department of Physical Medicine and Rehabilitation, 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 R
authors.initials: IR
authors.lastname: Odderson
authors.affiliation: Kansas City Bone and Joint Clinic, Overland Park, KS(‡‡).
authors.forename: Atul T
authors.initials: AT
authors.lastname: Patel
authors.affiliation: Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY(§§).
authors.forename: David M
authors.initials: DM
authors.lastname: Simpson
mesh_terms: D000328:Adult; D019274:Botulinum Toxins, Type A / Q000008:administration & dosage*; D003697:Delphi Technique; D004305:Dose-Response Relationship, Drug; D004334:Drug Administration Schedule; D005260:Female; D006801:Humans; D007273:Injections, Intramuscular; D035002:Lower Extremity / Q000503:physiopathology; D008297:Male; D009128:Muscle Spasticity / Q000188:drug therapy* / Q000209:etiology / Q000503:physiopathology; D017410:Practice Guidelines as Topic; D018570:Risk Assessment; D012720:Severity of Illness Index; D020521:Stroke / Q000150:complications* / Q000175:diagnosis; D000071939:Stroke Rehabilitation / Q000379:methods; D016896:Treatment Outcome
chemical_list: D019274:Botulinum Toxins, Type A