Botulinum toxin therapy for treatment of spasticity in multiple sclerosis: review and recommendations of the IAB-Interdisciplinary Working Group for Movement Disorders task force.
Dressler D, Bhidayasiri R, Bohlega S, Chahidi A, Chung TM, Ebke M, Jacinto LJ, Kaji R, Koçer S, Kanovsky P, Micheli F, Orlova O, Paus S, Pirtosek Z, Relja M, Rosales RL, Sagástegui-Rodríguez JA, Schoenle PW, Shahidi GA, Timerbaeva S, Walter U, Saberi FA.Abstract
Botulinum toxin (BT) therapy is an established treatment of spasticity due to stroke. For multiple sclerosis (MS) spasticity this is not the case. IAB-Interdisciplinary Working Group for Movement Disorders formed a task force to explore the use of BT therapy for treatment of MS spasticity. A formalised PubMed literature search produced 55 publications (3 randomised controlled trials, 3 interventional studies, 11 observational studies, 2 case studies, 35 reviews, 1 guideline) all unanimously favouring the use of BT therapy for MS spasticity. There is no reason to believe that BT should be less effective and safe in MS spasticity than it is in stroke spasticity. Recommendations include an update of the current prevalence of MS spasticity and its clinical features according to classifications used in movement disorders. Immunological data on MS patients already treated should be analysed with respect to frequencies of MS relapses and BT antibody formation. Registration authorities should expand registration of BT therapy for spasticity regardless of its aetiology. MS specialists should consider BT therapy for symptomatic treatment of spasticity.
Spasticity (increased muscle tone anywhere in the body) affects around 74% of PwMS experience it (bearing in mind that there are no accurate figures for this); of which 47% are classified as Ashworth score >/=2 (i.e. marked increase in tone but able to move the affected limbs easily; Barnes MP (2003) Spasticity in multiple sclerosis. Neurorehabil Neural Repair 17:66–70).Spasticity is defined as a "motor disorder characterized by a velocity-dependent increase in tonic stretch reflexes with exaggerated tendon jerks resulting from hyperexcitability of the stretch reflex".
In my books spasticity is a definite low low for those I review in clinic, overshadowing any improvements, or status quo achieved in other problem areas. I have recently been looking into the application of botox in spasticity management and this literature summary demonstrates that it has a role in management. This needs to be done before contractures arise, wherein the spastic postures become fixed and botox would be ineffective.
The IAB-Interdisciplinary Working Group for Movement Disorders state in this review that there is robust evidence to support the use of botox in MS spasticity, quoting 3 randomised controlled trials (Table 1, see below) and 3 interventional studies (Table 2, see below), and therefore are overwhelmingly in favor of botox use. In practical terms botox is only available in specialist centres and has high reimbursement costs for the health service (i.e. expensive). However, more clinicians and PwMS need to be aware of it as a potential option in MS managment. Figure 1 is a management algorithm from the Royal College of Physicians for adults with spasticity.
Table 1. Randomised controlled trials retrieved from PubMed for the current literature search
Study
|
Design
|
Methods
|
Results
|
|---|---|---|---|
Snow et al. [62]
|
RCT
|
9 pts with hip-adductor spasticity due to MS
Ashworth scale, hygiene scale
Botox 400MU
|
BT reduces Ashworth and hygiene scales
|
Grazko et al. [25]
|
RCT
|
4 pts with leg spasticity, 1 pt with arm spasticity due to MS
Ashworth scale
8 pts with rigidity
|
BT reduces Ashworth scale
|
Hyman et al. [29]
|
RCT
|
74 pts with hip-adductor spasticity due to MS
knee distance, pain score, hygiene score, spasm frequency
adverse effects
Dysport 500MU/1000MU/1500MU
|
Dysport reduces hip spasticity
no clear dose effect
adverse effects
|
RCT randomised, placebo-controlled trial, pt/pts patient/patients, BT botox
Table 2. Interventional Studies retrieved from PubMed for the current literature search
Study
|
Design
|
Methods
|
Result
|
|---|---|---|---|
Giovannelli et al. [23]
|
Parallel groups investigator blinded
|
38 pts with MS spasticity
control/BT/BT and physiotherapy groups
Ashworth scale, visual analogue scale
|
BT improves both dimensions, better effect in BT and physiotherapy group
|
Barnes et al. [4]
|
Parallel groups investigator blinded
|
192 pts with upper limb spasticity
1% due to MS
dilution 20/50MU/ml
disability scale, Ashworth scale
Xeomin®
|
No dilution effect
|
Paolini et al. [48]
|
Parallel groups
|
42 pts with MS spasticity
role of vibration in BT therapy
|
BT therapy and vibration improve spasticity
|
BT botulinum toxin, pt/pts patient/patients, MS multiple sclerosis
Figure 1 Management strategy for adults with spasticity (Royal College of Physicians)
