Botulinum Toxin: From Poison to Possible Treatment for Spasticity in Spinal Cord Injury.

Botulism has been known for about three centuries, and since its discovery, botulinum toxin has been considered one of the most powerful toxins. However, throughout the 20th century, several medical applications have been discovered, among which the treatment of spasticity stands out. Botulinum toxin is the only pharmacological treatment recommended for spasticity of strokes and cerebral palsy. Although its use as an adjuvant treatment against spasticity in spinal cord injuries is not even approved, botulinum toxin is being used against such injuries. This article describes the advances that have been made throughout history leading to the therapeutic use of botulinum toxin and, in particular, its application to the treatment of spasticity in spinal cord injury.

Treatment of spasticity in spinal cord injury with botulinum toxin.

CONTEXT: Spasticity is one of the most frequent complications in spinal cord injury (SCI), and is routinely managed with oral pharmacologic therapy. Botulinum toxin (BT) is not accepted as a treatment for spasticity in SCI in Spain but may be used in certain cases of focal distribution. OBJECTIVE: To report the results with BT for treatment of spasticity in SCI. DESIGN AND SETTING: Descriptive retrospective study conducted at a specialist SCI rehabilitation center in Spain, covering patients first treated from 2012 through 2014, and successfully followed up for a minimum of 1 year. Data were collected on the following variables: demographic and SCI characteristics (level and grade); nature of spasticity, e.g. tone, distribution, spasms, articular involvement and pain; function; application of BT; tolerance and adverse reactions. RESULTS: The study covered 90 patients, predominantly male with incomplete injuries. Improvement in tone as measured by the modified Ashworth scale was a mean of 1.17 points. Goniometric improvement was achieved in 65.6% and improvement in pain in 38.9% of cases. There were no adverse side-effects. Patients with focal spasticity showed a significantly greater improvement in tone (P < 0.0001). The earlier the BT injection, the greater the improvement in goniometric performance (P < 0.006) and pain (P < 0.033), with the best results being obtained within the first 6 months of clinical course. ASIA D injuries showed a greater improvement in tone (P < 0.0001). CONCLUSIONS: BT can be both an effective treatment for focal spasticity in SCI and a good coadjuvant for oral treatments in generalized spasticity.

Short-Term Outcomes of Interdisciplinary Hip Fracture Rehabilitation in Frail Elderly Inpatients.

OBJECTIVE: To investigate short-term outcomes of an interdisciplinary rehabilitation program for elderly inpatients who underwent surgical treatment for hip fractures. METHODS: This is a prospective cohort study of fifty older inpatients who were admitted to a geriatric rehabilitation unit. Clinical and functional outcomes were assessed at admission, at discharge, and one month postdischarge. RESULTS: Patients mean age was 84.1 ± 4.7 years. Proportions of study population with risk factors of frailty were cognitive impairment (64%), Charlson comorbidity index > 1 (72%), and protein malnutrition (59.2%). Before fracture, Barthel median was 90 (IQR 85, 100), and functional ambulation classification (FAC) score was ≥ 4 for 90% of study participants. One month after concluding rehabilitation, Barthel median was 80, 1 month postdischarge FAC ≥ 4 - prefracture FAC ≥ 4 mean change was - 8% (95% CI, -21.5%, 3.4%), and average for gait speed was 0.48 ± 0.18 m/s (95% CI, 0.43, 0.54). Significant correlation was found between admission Barthel score and 1 month postdischarge Barthel score (ρ= 0.27, p=0.05), and between prefracture FAC score and FAC score 1 month postdischarge (ρ = 0.57, p = 0.05). According to regression analysis, age, cognitive status, prefracture Barthel, prefracture FAC, type of surgery, and length of stay were associated with short-term recovery outcomes. CONCLUSION: An early interdisciplinary rehabilitation management was insufficient to recover prefracture functional status. Future studies should investigate the best therapeutic strategies to optimize functional recovery, according to clinical and prefracture frail conditions of these patients.

Mirror therapy for distal radial fractures: A pilot randomized controlled study.

To investigate the efficacy of mirror therapy in reducing pain and disability in patients with distal radial fractures. Pilot randomized controlled study. Twenty-two patients with closed distal radial fracture. Patients were randomly assigned to experimental (= 11) or control (= 11) groups. Researchers were blinded to group allocation. Both groups received conventional physiotherapy. In addition, the experimental group had 15 sessions of mirror therapy (a daily session, 30 min). The control group received the same amount of conventional occupational therapy. Assessment was made from baseline to post-treatment. Pain was measured on a visual analogue scale (VAS). Active wrist extension and Quick-DASH (Disabilities of Arm, Shoulder and Hand) were used to assess functional recovery. Pain, disability, and range of motion improved for both groups after intervention. No significant post-treatment differences were found between groups in Quick-DASH (= 0.409), active wrist extension (= 0.191) and VAS scores (= 0.807). There was no significant difference in active wrist extension between groups. Mirror therapy was not superior to conventional occupational therapy in reducing pain and disability.

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