Franceschini M, Iocco M, Molteni F, Santamato A, Smania N
Department of Rehabilitation IRCCS San Raffaele-Pisana, Rome, Italy -
Eur J Phys Rehabil Med. 2014 Oct;50(5):525-33. Epub 2014 Jun 19.
Spasticity is a common disabling symptom of several neurological conditions including stroke. Botulinum toxin type A (BTX-A) injection represents the gold standard therapy for focal spasticity. Post-stroke management of patients receiving BTX-A therapy has been variously investigated, but general agreement on how and when to implement rehabilitation is lacking.
To perform a national survey of experts on the most appropriate rehabilitation procedures after BTX-A therapy for the focal treatment of spasticity.
The study employed the Delphi technique through the COSMO project (Consensus on Post-Injection Management in Post-stroke Spasticity).
Italian neurologists and physiatrists with experience in BTX-A therapy were selected to participate in the survey. Their anonymous opinions on key issues in treatment strategies in post-stroke spasticity were collected in three sequential rounds facilitated by a web platform. Consensus on a given issue was defined as agreed opinion by at least 66% of the survey participants.
In all, 44 Italian experts were involved. Positive consensus was reached on the need to start rehabilitation during the first week after BTX-A injection therapy, with a rehabilitation program comprising both stretching combined with electrical stimulation and exercise therapy. Functional surgery may be considered only after 12-24 months in cases of BTX-A therapy failure. The use of commercial or custom-made orthoses in selected cases was recommended. The appropriate time interval between two BTX-A injections is 3-6 months, and clinical assessment should be performed 1 month after injection.
The results of this national survey confirm that clinical experts on the use of BTX-A therapy for spasticity after stroke agree on the need to initiate rehabilitation treatment immediately after BTX-A injection: muscle stretching exercises, eventually combined with neuromuscular electrical stimulation, may enhance the effect of BTX-A therapy. Outcome after BTX-A therapy should be assessed at repeated follow-up visits.
This expert panel survey can provide guidance for clinicians in the assessment of patients treated with BTX-A therapy.
痉挛是包括中风在内的几种神经系统疾病常见的致残症状。A型肉毒毒素（BTX-A）注射是局灶性痉挛的金标准治疗方法。接受BTX-A治疗的中风后患者的管理已得到广泛研究，但对于如何以及何时实施康复治疗尚未达成普遍共识。
针对BTX-A治疗局灶性痉挛后最合适的康复程序进行全国性专家调查。
本研究通过COSMO项目（中风后痉挛注射后管理共识）采用德尔菲技术。
选择有BTX-A治疗经验的意大利神经科医生和物理治疗师参与调查。在一个网络平台的协助下，分三轮收集他们对中风后痉挛治疗策略关键问题的匿名意见。对某一问题达成共识的定义为至少66%的调查参与者达成一致意见。
共有44名意大利专家参与。就BTX-A注射治疗后第一周内开始康复治疗达成了积极共识，康复计划包括拉伸联合电刺激和运动疗法。仅在BTX-A治疗失败的情况下，12 - 24个月后才考虑进行功能手术。建议在特定病例中使用商业或定制的矫形器。两次BTX-A注射之间的适当时间间隔为3 - 6个月，注射后1个月应进行临床评估。
这项全国性调查的结果证实，使用BTX-A治疗中风后痉挛的临床专家一致认为，BTX-A注射后应立即开始康复治疗：肌肉拉伸运动，最终联合神经肌肉电刺激，可能会增强BTX-A治疗的效果。BTX-A治疗后的结果应在多次随访中进行评估。
该专家小组调查可为临床医生评估接受BTX-A治疗的患者提供指导。
