What are the goals for BoNT-A treatment of spasticity?

Updated: Jun 28, 2019
  • Author: Krupa Pandey, MD; Chief Editor: Stephen A Berman, MD, PhD, MBA  more...
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Even though BoNT-A is a focal treatment, untreated muscles may benefit from the disruption of the synergy patterns that often replace isolated muscle control. Increased range of motion, reduction in spasms, ease of caregiving, and reduced pain are primary goals leading to improved function and quality of life. Treatment begins with mutually agreed upon goals and expectations, a treatment plan that addresses all the clinical issues.

Generally, there is an inverse relationship between spasticity and voluntary motor control. Patients with severe spasticity often have less voluntary movement than patients with mild spasticity. Underlying motor control, strength, and coordination should be assessed to project the functional results of reducing spasticity. Since reduction of spasticity in patients with poor selective motor control may not provide mobility, treatment goals of improving positioning, caregiving, or comfort may be more appropriate.

Patients with cognitive deficits may not be able to take full advantage of their reduced spasticity; treatment aimed at easing their care or pain may be more beneficial. Patients with painful spasms or contracture often experience significant pain relief after treatment with BoNT-A.

In the upper limb, patterns of spasticity that may improve specifically from botulinum toxin include an adducted and internally rotated shoulder, flexed elbow, pronated forearm, flexed wrist, thumb-in-palm, and clenched fist. [33, 34] In the lower extremity, botulinum toxin injections may particularly improve spasticity causing flexed hip, flexed knee, adducted thighs, stiff (ie, extended) knee, equinovarus foot, and striatal toe. Outcomes should be evaluated by subjective and objective clinical measures, including rating scales and videotape recordings that clearly reflect defined goals and objectives.

In summary, common functional goals with neurolysis using the botulinum toxins (or phenol or alcohol) include improving gait, hygiene, and ADLs; easing pain and care; and decreasing spasm frequency. Technical objectives are to promote tone reduction and to improve range of motion and joint position. Once begun, treatment is evaluated constantly; follow-up is crucial to gauge the response and to fine-tune muscle selection and dose as necessary.

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