CHU Lille, Neurorehabilitation Unit, 59000 Lille, France; Université Lille, INSERM UMR-S-1172, Lille Neuroscience and Cognition, 59000 Lille, France.
AP-HP, Hôpital Pitié-Salpêtrière, 75013 Paris, France.
Ann Phys Rehabil Med. 2022 Mar;65(2):101544. doi: 10.1016/j.rehab.2021.101544. Epub 2021 Nov 13.
Adjunct therapies (ATs) may further improve outcomes after botulinum toxin injections in spastic patients, but evidence was unclear in previous systematic reviews.
To assess the efficacy of non-pharmacological ATs in spastic adults according to the International Classification of Functioning, Disability and Health and build an expert consensus-based on a Delphi process.
Four electronic databases were searched up to May 2020 for reports of comparative trials of non-pharmacologic ATs after botulinum toxin injections in spastic adults. Then, 25 French experts participated in a two-round Delphi process to build recommendations on the use of ATs.
We included 32 studies (1202 participants, median 32/study) evaluating the effects of physical agents (n=9), joint posture procedures (JPPs, n=11), and active ATs (n=14), mainly after stroke. The average quality of articles was good for randomised controlled trials (median [interquartile range] PEDro score=7 [6-8]) but moderate (n=2) or poor (n=2) for non-randomised controlled trials (Downs & Black checklist). Meta-analysis was precluded owing to the heterogeneity of ATs, control groups and outcome measures. There is evidence for the use of JPPs except low-dose manual stretching and soft posture techniques. Continuous postures (by taping or casting) are recommended; discontinuous postures (by orthosis) may be preferred in patients with active function. Device-free or device-assisted active ATs may be beneficial in the mid-term (>3months after botulinum toxin injections), particularly when performed at a high-intensity (>3h/week) as in constraint-induced movement therapy. Self-rehabilitation remains understudied after a focal treatment, but its interest is highlighted by the experts. The use of physical agents is not recommended.
JPPs and active ATs (device-assisted or device-free) may further improve impairments and activities after botulinum toxin injections. Further studies are needed to better define the best strategies for ATs as a function of the individual treatment goals, participation and quality of life.
PROSPERO (CRD42018105856).
辅助疗法（ATs）可能会进一步改善痉挛患者肉毒毒素注射后的疗效，但之前的系统评价结果并不明确。
根据国际功能、残疾和健康分类评估非药物性 ATs 在痉挛成人中的疗效，并通过 Delphi 流程建立基于专家共识的推荐意见。
检索了截至 2020 年 5 月关于肉毒毒素注射后非药物性 ATs 在痉挛成人中应用的比较试验报告，共纳入 32 项研究（1202 例患者，研究中位数 32 例），评价了物理治疗（n=9）、关节姿势处理（JPPs，n=11）和主动 ATs（n=14）的效果，主要针对脑卒中患者。文章的平均质量对于随机对照试验来说较好（中位数[四分位间距] PEDro 评分为 7 [6-8]），但对于非随机对照试验来说为中等（n=2）或差（n=2）（Downs 和 Black 清单）。由于 ATs、对照组和结局测量的异质性，无法进行荟萃分析。JPPs 的使用证据充分，但不包括低剂量手法拉伸和软性姿势技术。连续姿势（通过贴扎或石膏固定）推荐使用；间断姿势（通过矫形器）可能更适合具有主动功能的患者。无器械或器械辅助的主动 ATs 在肉毒毒素注射后 3 个月以上（中期）可能有益，尤其是像强制性运动疗法那样高强度（每周>3 小时）。局部治疗后，自我康复的研究较少，但专家强调了其重要性。不推荐使用物理治疗。
JPPs 和主动 ATs（器械辅助或无器械）可能会进一步改善肉毒毒素注射后的功能障碍和活动能力。需要进一步研究，以更好地确定 ATs 的最佳策略，具体取决于个人的治疗目标、参与度和生活质量。
PROSPERO（CRD42018105856）。
