Statement of the Rehabilitation Medicine Society of Australia and New Zealand for the therapeutic use of botulinum toxin A in spasticity management.

The Rehabilitation Medicine Society of Australia and New Zealand advocates the safe, effective and evidence-based use of botulinum toxin type A for spasticity management. The process requires appropriate training, alongside considerable knowledge and skills, to maximise efficacy. The processes before and after injection contribute to effectiveness. The gold standard of managing spasticity is for assessment by a multidisciplinary specialist team, deriving patient-centric goals, and designing an injection protocol to match these goals. The patient and/or carers are considered part of the decision-making team. Postinjection therapy and measurement of goal achievement are highly recommended as part of the wider holistic approach to management. The Society believes treatment failures can be minimised by following clear clinical guidelines.

A systematic review: efficacy of botulinum toxin in walking and quality of life in post-stroke lower limb spasticity.

BACKGROUND: Improved walking is one of the highest priorities in people living with stroke. Post-stroke lower limb spasticity (PSLLS) impedes walking and quality of life (QOL). The understanding of the evidence of improved walking and QOL following botulinum toxin (BoNTA) injection is not clear. We performed a systematic review of the randomized control trials (RCT) to evaluate the effectiveness of BoNTA injection on walking and QOL in PSLLS. METHODS: We searched PubMed, Web of Science, Embase, CINAHL, ProQuest Thesis and Dissertation checks, Google Scholar, WHO International Clinical Trial Registry Platform, ClinicalTrials.gov , Cochrane, and ANZ and EU Clinical Trials Register for RCTs looking at improvement in walking and QOL following injection of BoNTA in PSLLS. The original search was carried out prior to 16 September 2015. We conducted an additional verifying search on CINHAL, EMBASE, and MEDLINE (via PubMed) from 16 September 2015 to 6 June 2017 using the same clauses as the previous search. Methodological quality of the individual studies was critically appraised using Joanna Briggs Institute's instrument. Only placebo-controlled RCTs looking at improvement in walking and QOL were included in the review. RESULTS: Of 2026 records, we found 107 full-text records. Amongst them, we found five RCTs qualifying our criteria. No new trials were found from the verifying search. Two independent reviewers assessed methodological validity prior to inclusion in the review using Joanna Briggs Institute's appraisal instrument. Two studies reported significant improvement in gait velocity (p = 0.020) and < 0.05, respectively. One study showed significant improvement in 2-min-walking distance (p < 0.05). QOL was recorded in one study without any significant improvement. Meta-analysis of reviewed studies could not be performed because of different methods of assessing walking ability, small sample size with large confidence interval and issues such as lack of power calculations in some studies. Findings from our systematic and detailed study identify the need for a well-designed RCT to adequately investigate the issues highlighted. CONCLUSIONS: This review could not conclude there was sufficient evidence to support or refute improvement on walking or QOL following BoNTA injection. Reasons for this are discussed, and methods for future RCTs are developed.

Effectiveness of botulinum toxin type A on gait and quality of life in adult post-stroke patients with lower limb spasticity: a systematic review protocol.

REVIEW QUESTION/OBJECTIVE: The objective of this review is to examine the current best available evidence on the effectiveness of botulinum toxin type A on gait (velocity and distance) and quality of life (QoL) in adult post-stroke patients with lower limb spasticity.More specifically, this review aims to determine the effectiveness of botulinum toxin type A on adult post-stroke patients with lower limb spasticity in relation to.

Botulinum toxin for foot dystonia in patients with Parkinson's disease having deep brain stimulation: A case series and a pilot study.

BACKGROUND: Six patients with Parkinson's disease with deep brain stimulation who were experiencing disabling foot dystonia were referred to the spasticity clinic for a trial of botulinum toxin. The foot and ankle muscles were injected with onabotulinum toxin (Botox) to determine the effects on foot dystonia, pain and lower limb functional outcomes. DESIGN: Case series. SUBJECTS/PATIENTS: Six patients with Parkinson's disease with deep brain stimulation experiencing disabling foot dystonia. METHODS: Dystonic foot and ankle muscles were identified and injected with 250-400 units botulinum toxin and re-coded pre- and 3 weeks post-injection with the Burke Fahn Marsden Dystonia score, visual analogue score of pain, Unified Parkinson's Disease Rating Scale (UPDRS) - lower limb score, Timed up and Go test (TUG), 6-Minute Walk Test (6MWT), gait velocity, cadence in an instrumented walkway, and Goal Attainment Scale (GAS). RESULTS: Three weeks after botulinum toxin injection, significant improvements were noted in dystonia, pain, UPDRS, 6MWT, gait velocity, and cadence. Five out of 6 patients improved on the TUG test. Patients also reported improvements in their GAS goals. CONCLUSION: Botox injection significantly improved foot dystonia, pain and lower limb functional outcomes in patients with Parkinson's disease with deep brain stimulation.

Rethinking diagnoses in rehabilitation: An educational case series.

OBJECTIVE: To review the diagnosis of patients transferred to rehabilitation unit. DESIGN: Case series. SUBJECTS: Five patients with functional decline were transferred from an acute care setting in a tertiary hospital to the rehabilitation unit. METHODS: Full clinical evaluation and clinical reasoning were applied in addition to multidisciplinary care. Functional outcome and discharge destination were noted in each case. RESULTS: All patients had a new diagnosis that evolved during their stay in the rehabilitation unit in addition to their existing conditions. The new diagnosis helped to direct their future treatment programme. Four patients had good outcomes; they gained significant functional independence and were discharged home. One patient had an adverse outcome. CONCLUSION: In addition to multidisciplinary care, it is important to review the medical diagnosis in the rehabilitation unit. Diagnostic errors can have profound effect on the lives of patients with already existing impairments. Rehabilitation physicians should avoid making assumptions or diagnostic biases, and reapply clinical reasoning especially in the care of individuals with functional decline in rehabilitation.

Patients living with cancer - the role of rehabilitation.

BACKGROUND: Patients are surviving longer with cancer due to early detection and improvements in treatment. With longer survival, quality of life becomes very important. While improvements in treatment add years to the life of patients diagnosed with cancer, rehabilitation can add life to those years. OBJECTIVE: This article highlights the role rehabilitation can play in enhancing the quality of life for patients living with cancer. DISCUSSION: There are an increasing number of cancer survivors, creating the imperative to look beyond just survival. Potentially remediable problems may include pain, deconditioning and functional impairments. Patients with cancers of the breast, head and neck, musculoskeletal, central nervous system and peripheral nervous system, prostate, and metastatic cancer of the spine may particularly benefit from rehabilitation. Active engagement of oncologists, palliative medicine, general practitioners and rehabilitation specialists can be useful to assist in the rehabilitation needs of patients. In appropriate situations, patients with cancer should be offered rehabilitation services if they are likely to benefit.

Sacroiliac joint pathologies in low back pain.

OBJECTIVE: The study describes the clinical spectrum of patients with low back pain due to sacroiliac joint (SIJ) involvement with the proposition of a diagnostic scheme. METHODS: In this retrospective review, 61 patients with SIJ pain (unilateral or bilateral) greater than six weeks duration were evaluated by pain history, clinical examination including SIJ provocative tests, laboratory investigations and skeletal imaging. RESULTS: Fifty two patients (M: F, 31:21) were diagnosed to have specific SIJ pathologies amongst 61 patients presenting between 2002 to 2004. Forty patients (65%) were diagnosed with rheumatic conditions - ankylosing spondylitis (AS) - 21, undifferentiated spondyloarthropathy (UspA) - 11, psoriatic arthropathy (PS) - 5, reactive arthropathy (ReA) - 1 and juvenile spondyloarthropathy (JS)-2. Non rheumatic conditions were involved in 12 patients (20%) - osteitis condensus ilii (OCI) - 4, osteomalacia - 2, tuberculosis - 2, pyogenic arthritis - 1, pregnancy related sacroiliac joint pain - 2 and malignancy in 1 patient. The diagnosis could not be confirmed in 9 patients (15%). CONCLUSIONS: Medical history, clinical examination including SIJ tests, plain radiography and laboratory investigations were helpful in diagnosing SIJ pathology in 39% cases (n = 24), 46% (n = 28) needed CT or MRI. A diagnostic scheme of dividing the SIJ pathologies into rheumatic and non-rheumatic conditions was helpful in evaluating patients with suspected SIJ pathologies.

Genu recurvatum in hemophilia: a case report.

Hemorrhages in the musculoskeletal system of patients with hemophilia give rise to a number of disabilities requiring rehabilitative measures. The knee is the most commonly affected joint. Recurrent hemorrhages in the knee joint can cause arthropathy and flexion deformity. The current literature does not reveal development of genu recurvatum from repeated hemorrhages. This report presents a patient with hemophilia who developed a genu recurvatum deformity. We have discussed the clinical presentation, probable cause, and the management of the patient, and have included a brief review of the epidemiology of this deformity along with management options.

Study of hand function in a group of shoe factory workers engaged in repetitive work.

BACKGROUND: Work related hand and wrist musculoskeletal disorders are well known. The contributing factors could be repetitive movements, forceful work and awkward posture. It is not known how these movements affect grip or pinch strength and other functional aspects of the hand. AIMS: To study a group of shoe factory workers doing repetitive thumb and wrist movements for prevalence of musculoskeletal disorders and consequence on grip and pinch strength, two-point discrimination and perceived disability. METHODS: 39 shoe factory workers who put straps into 900 to 1000 pairs of rubber sandals per day and 29 hospital clerks as a control group were evaluated for musculoskeletal disorders, grip and pinch strength, two-point discrimination and perceived disability (by questionnaire). Proportions were compared by chi squared or Fisher Exact test and quantitative outcome by t-test or multiple linear regressions. RESULTS: Common musculoskeletal diseases of thumb/wrist were absent among shoe factory workers as in the clerks. Increased two-point discrimination over thumb (p=0.01, right; p=0.02, left) and a clear trend for reduced pinch strength between thumb and index finger (p=0.06, right; p=0.07, left) were noted compared to clerks after adjusting for years on the job. Perceived disabilities included pain and localised dermal thickening over the thumb. DISCUSSION: No case of carpal tunnel syndrome or hand/wrist tendinitis was detected among workers doing highly repetitive thumb/wrist movement. Pinch strength decreased and two-point discrimination was adversely affected while grip strength remained unaffected. The main perceived disabilities of pain and skin changes over the thumb adversely affected their day-to-day life.