Management of stroke patients submitted to botulinum toxin type A therapy: a Delphi survey of an Italian expert panel of specialist injectors.

BACKGROUND: 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. AIM: To perform a national survey of experts on the most appropriate rehabilitation procedures after BTX-A therapy for the focal treatment of spasticity. DESIGN: The study employed the Delphi technique through the COSMO project (Consensus on Post-Injection Management in Post-stroke Spasticity). METHODS: 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. RESULTS: 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. CONCLUSION: 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. CLINICAL REHABILITATION IMPACT: This expert panel survey can provide guidance for clinicians in the assessment of patients treated with BTX-A therapy.

A quantitative approach in the treatment of hemiplegic patients using an electropneumatic platform.

Exercise is the central feature in the rehabilitative treatment of hemiplegic patients. In cognitive rehabilitation, great importance is attributed to the recovery of a sufficient number of proprioceptive channels before expecting the patient to regain voluntary control. The PERM [Piattaforma (Platform), Elettropneumatica (Electropneumatic) per (for) Riabilitazione (Rehabilitation) Motoria (Motor)] is a new device that can be used in the treatment of the lower limbs to provide the patient with controlled and quantifiable mechanical stimuli, thus enabling the therapist to adopt a more rigorous approach to treatment even in the very early stages of rehabilitation. Alternatively, the system can be used in a different operating mode as a normal biofeedback system capable of displaying on-screen the extent to which voluntary load has been transferred to the lower limb.

The management of 138 psoriatic arthritic patients.

Clinical experience obtained in the management of 138 patients of psoriatic arthritis is reported. The correct recognition of arthritic subtype (according to Moll and Wright classification) always resulted essentially in the choice of the therapy. Our programme included rehabilitative, pharmacologic and surgical approaches. Our data suggest that psoriatic arthritis is a mild articular disease when compared to other affections such as rheumatoid arthritis or ankylosing spondylitis. Notwithstanding an accurate therapeutical programme, it is necessary to control atypical cases which not infrequently can occur.