Alberto Esquenazi1, Abraham Alfaro2, Ziyad Ayyoub3, David Charles4, Khashayar Dashtipour5, Glenn D Graham6, John R McGuire7, Ib R Odderson8, Atul T Patel9, David M Simpson10. 1. MossRehab Gait and Motion Analysis Laboratory, MossRehab Gait and Motion Analysis Laboratory, 60 Township Line Rd, Elkins Park, PA 19027(∗). Electronic address: aesquena@einstein.edu. 2. Spasticity and Dystonia Clinic, Bacharach Institute for Rehabilitation, Pomona, NJ(†). 3. Rancho Los Amigos National Rehabilitation Center, Downey, CA; David Geffen School of Medicine, University of California, Los Angeles, CA; Western University of Health Sciences, Pomona, CA(‡). 4. Department of Neurology, Vanderbilt University, Nashville, TN(§). 5. Department of Neurology/Movement Disorders, Loma Linda University School of Medicine, Loma Linda, CA(¶). 6. Department of Veterans Affairs and University of California San Francisco School of Medicine, San Francisco, CA(#). 7. Department of Physical Medicine and Rehabilitation, Medical College of Wisconsin, Milwaukee, WI(∗∗). 8. Department of Rehabilitation Medicine, University of Washington, Seattle, WA(††). 9. Kansas City Bone and Joint Clinic, Overland Park, KS(‡‡). 10. Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY(§§).
Abstract
BACKGROUND: OnabotulinumtoxinA is approved for the treatment of upper and lower limb spasticity in adults. Guidance on common postures and onabotulinumtoxinA injection paradigms for upper limb spasticity has been developed via a Delphi Panel; however, similar guidance for lower limb spasticity has not been established. OBJECTIVE: To define a clinically recommended treatment paradigm for the use of onabotulinumtoxinA for each common posture among patients with poststroke lower limb spasticity (PSLLS) and to identify the most common PSLLS aggregate postures. DESIGN: Clinical experts provided insight regarding onabotulinumtoxinA treatment for PSLLS using an adaptation of the Delphi consensus process. SETTING: Delphi panel. PARTICIPANTS: Ten expert clinicians in neurology and physical medicine and rehabilitation who treat PSLLS. METHODS: A minimum of 2 rounds of anonymous voting occurred for each recommendation until consensus was reached (≥66% agreement). The first round was conducted via a survey; the second round was an in-person meeting. MAIN OUTCOME MEASUREMENTS: Reached consensus on muscle selection for injection, overall and per-muscle dose of onabotulinumtoxinA, number of injection sites/muscle, onabotulinumtoxinA dilution, and use of localization techniques. The most common PSLLS postures were reviewed. Recommendations were tailored toward injectors with less experience. RESULTS: Consensus was reached on targeted subsets of muscles for each posture. Doses ranged from 20 to 150 U for individual muscles and 50 to 300 U for limb postures. OnabotulinumtoxinA dilution 50 U/mL (2:1 ratio) was considered most appropriate but varied based on muscles selected (range, 2:1-4:1). Experts agreed that localization techniques for muscle identification during injection for all postures would be useful. For suboptimal response to injection, all panel members would increase the dose, and the majority (89%) would increase the number of treated muscles. The panel identified 3 common aggregating lower limb postures: (1) equinovarus foot and flexed toes; (2) extended knee and plantar flexed foot/ankle; and (3) plantar flexed foot/ankle and flexed toes. The recommended starting doses for each aggregate posture were 400 U, 400 U, and 300 U, respectively. CONCLUSION: The modified Delphi panel process provided consensus on common muscles and corresponding onabotulinumtoxinA treatment paradigms for postures associated with PSLLS that can be used for guidance in optimizing care delivery. LEVEL OF EVIDENCE: V.
BACKGROUND: OnabotulinumtoxinA is approved for the treatment of upper and lower limb spasticity in adults. Guidance on common postures and onabotulinumtoxinA injection paradigms for upper limb spasticity has been developed via a Delphi Panel; however, similar guidance for lower limb spasticity has not been established. OBJECTIVE: To define a clinically recommended treatment paradigm for the use of onabotulinumtoxinA for each common posture among patients with poststroke lower limb spasticity (PSLLS) and to identify the most common PSLLS aggregate postures. DESIGN: Clinical experts provided insight regarding onabotulinumtoxinA treatment for PSLLS using an adaptation of the Delphi consensus process. SETTING: Delphi panel. PARTICIPANTS: Ten expert clinicians in neurology and physical medicine and rehabilitation who treat PSLLS. METHODS: A minimum of 2 rounds of anonymous voting occurred for each recommendation until consensus was reached (≥66% agreement). The first round was conducted via a survey; the second round was an in-person meeting. MAIN OUTCOME MEASUREMENTS: Reached consensus on muscle selection for injection, overall and per-muscle dose of onabotulinumtoxinA, number of injection sites/muscle, onabotulinumtoxinA dilution, and use of localization techniques. The most common PSLLS postures were reviewed. Recommendations were tailored toward injectors with less experience. RESULTS: Consensus was reached on targeted subsets of muscles for each posture. Doses ranged from 20 to 150 U for individual muscles and 50 to 300 U for limb postures. OnabotulinumtoxinA dilution 50 U/mL (2:1 ratio) was considered most appropriate but varied based on muscles selected (range, 2:1-4:1). Experts agreed that localization techniques for muscle identification during injection for all postures would be useful. For suboptimal response to injection, all panel members would increase the dose, and the majority (89%) would increase the number of treated muscles. The panel identified 3 common aggregating lower limb postures: (1) equinovarus foot and flexed toes; (2) extended knee and plantar flexed foot/ankle; and (3) plantar flexed foot/ankle and flexed toes. The recommended starting doses for each aggregate posture were 400 U, 400 U, and 300 U, respectively. CONCLUSION: The modified Delphi panel process provided consensus on common muscles and corresponding onabotulinumtoxinA treatment paradigms for postures associated with PSLLS that can be used for guidance in optimizing care delivery. LEVEL OF EVIDENCE: V.
Authors: Alberto Esquenazi; Ganesh Bavikatte; Daniel S Bandari; Wolfgang H Jost; Michael C Munin; Simon Fuk Tan Tang; Joan Largent; Aubrey Manack Adams; Aleksej Zuzek; Gerard E Francisco Journal: PM R Date: 2021-01-11 Impact factor: 2.298