How could robotic training and botolinum toxin be combined in chronic post stroke upper limb spasticity? A pilot study

Abstract

Background: Spasticity has a role of primary importance in functional motor recovery of upper limb after a stroke. The widespread intervention is the botulinum toxin neurolysis, however robotic training could have a role as useful addition to this conventional therapy.

Aim: The aim of this study was to verify how the combination of a short robotic training and chemical neurolysis reduces spasticity and improves function in chronic post-stroke patients.

Design: Prospective single blind randomized controlled clinical trial.

Setting: Post-stroke outpatients.

Population: Fifteen chronic post-stroke outpatients with severe upper limb spastic paresis.

Methods: Two experimental groups underwent ten sessions of robotic training, alone (Group A) or with Botulinum toxin neurolysis (Group B). Evaluation of motor function with Fugl Meyer Upper Limb Assessment Scale (FMA) and Box & Block Test (B&B), disability with Functional Indipendence Measure (FIM), spasticity with Modified Ashworth Scale (MAS), and the Quality of Life (Euro-Qol) and muscular recruitment pattern with dynamic surface electromyography were carried out before and after the interventions.

Results: Both groups showed improvement in FMA (Group A 8.25 and Group B 5.29). Higher improvement in B&B was detected in the group A (2.62 versus 0,14 in Group B). MAS was improved more in the Group B (-0,86 versus -0,14 in Group A). In both groups, sEMG showed a reduction of co-contractions and an increase of agonist muscles recruitment during the reaching movement and the robotic exercises.

Conclusion: The demonstrated improvement in motor function and in muscular activation pattern suggests how a short robotic training could be effective in chronic post-stroke spasticity of upper limb and in less severe spasticity the only robotic treatment could be effective.

Clinical rehabilitation impact: With the limits of small sample, the results showed some equivalence between these two approaches with respect to motor recovery and spasticity reduction suggesting that the cost effectiveness of each treatment may have an important role in this choice.