Simpson David M, Patel Atul T, Alfaro Abraham, Ayyoub Ziyad, Charles David, Dashtipour Khashayar, Esquenazi Alberto, Graham Glenn D, McGuire John R, Odderson Ib
Department of Neurology, Icahn School of Medicine at Mount Sinai, Box 1052, New York, NY 10029(∗).
Kansas City Bone and Joint Clinic, Overland Park, KS(†).
PM R. 2017 Feb;9(2):136-148. doi: 10.1016/j.pmrj.2016.06.016. Epub 2016 Jun 23.
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.
A型肉毒毒素可减轻与中风后痉挛（PSS）相关的肌肉张力亢进。PSS表现为几种常见姿势。
确定PSS上肢常见姿势的治疗模式。
改良德尔菲法。
专家小组。
邀请了10名在PSS治疗和临床研究方面有经验的注射医生（物理治疗师和神经科医生）参加德尔菲小组。
德尔菲小组审查了一份包含PSS上肢姿势的电子工作表，以确定A型肉毒毒素的治疗模式（第一轮）。在第二轮中，小组成员亲自讨论第一轮结果并投票，直至达成共识（≥66%的一致意见）。建议针对那些有新的或早期注射经验的人。
就PSS的A型肉毒毒素治疗参数达成专家共识，包括注射的肌肉、每块肌肉的剂量和姿势，以及对反应欠佳的治疗调整。
对于每种姿势，就目标肌肉子集达成了共识。每块肌肉的剂量范围为（10 - 100 U），每个姿势的总剂量范围为（50 - 200 U）。50 U/mL的A型肉毒毒素稀释液（2:1稀释比例）被认为最合适；在某些情况下，1:1至4:1的稀释比例可能合适。大多数（89%）小组成员会增加剂量和/或治疗的肌肉数量，以应对A型肉毒毒素反应欠佳的情况。小组确定了3种常见的上肢综合姿势：（1）内收肩 + 屈曲肘 + 旋前前臂 + 屈曲腕 + 握拳；（2）屈曲肘 + 旋前前臂 + 屈曲腕 + 握拳；（3）屈曲腕 + 握拳。每种综合姿势的推荐起始剂量分别为300 U、300 U和200 U，最大总剂量分别为400 U、400 U和300 U。定位引导技术被认为对所有姿势都至关重要。
通过改良德尔菲法，就与上肢PSS相关姿势的常见肌肉和A型肉毒毒素治疗模式达成了共识。本分析的目的是对早期A型肉毒毒素注射医生进行培训，而非提供基于证据的综述。
V级。
