A 67-year-old woman was diagnosed with a complex regional pain syndrome, primarily in the upper left limb, that was attributable to hemorrhagic right hemisphere stroke. The patient showed spastic upper limb monoplegia, spastic equinovarus foot, trunk push syndrome and left lateral shift of the center of mass with global postural instability induced by the asymmetric postural attitude. She had difficulty in maintaining a vertical position and her ability to walk, either assisted or with a walking aid, was impaired. At initial examination, she had been undergoing physiotherapy for at least 2 months post-stroke, which consisted of postural control exercises, gait training, and passive and active upper and lower limb kinesis. She was receiving anti-spastic therapy (baclofen and pregabalin).
Initial clinical evaluation consisted of an assessment of: upper and lower left limb spasticity [modified Ashworth scale (MAS)]; grading of pain [visual analog scale (VAS)]; trunk control capacity in specific motor performances [trunk control test (TCT)]; upper and lower limb motor function [motricity index (MI)]; visual gait analysis (VGA) performed while walking barefoot over a distance of 12 meters, grading initial foot contact during the stance phase (normal heel strike=0; flat foot=1; toe then heel=2; mild toewalking=3; marked toe-walking=4; change of one grade was considered clinically significant); gait velocity, determined by dividing the distance of a walkway (10 meters) by the time the patient needed to cross it at maximum speed, with supervisor and without using gait help. Five days after the initial evaluation, the patient underwent an injection session with Xeomin®. Xeomin® was reconstituted with saline to a final concentration of 50 IU/mL. The total dose administered was 400 IU, in accordance with published guidelines for the management of spasticity.20
The muscles to be injected were identified using surface anatomy and the doses injected in the different muscles are given in . Injections were administered under sterile conditions using standardized techniques. Physiotherapy, as described previously, was performed during and after the injection session. In addition, electrical surface stimulation of the injected muscles was performed two times per day for 3 days, and daily application of a dynamic palmar and elbow extension orthosis for 4 days.
Doses of Xeomin® administered to individual muscles.
One week and 1 month after the injection session, the patient was examined again by the same physician. Three measurements of each clinical parameter or gait velocity were performed at each examination and the mean value was calculated to quantify the effect of treatment with Xeomin®. After a one-way analysis of variance (ANOVA) of our results, only a descriptive review of the therapy outcome can be given.
Clinical examination performed before and after Xeomin® administration demonstrated its efficacy at reducing spasticity in the upper and lower limbs, decreasing the MAS 1.3- and 1.7-fold, respectively, at 1 month after treatment (A). In the upper limb, a marked amelioration in pain intensity was observed, reflected by a 3-fold reduction in VAS after 1 month (B), an improvement of comparatively greater magnitude than that observed in spasticity. Trunk postural attitude and paraxial muscle recruitment were enhanced after Xeomin® treatment as seen by an increased TCT (C). Recovery of motor function of the left upper limb was reflected by an increased MI after 1 month (D), although motor function of the lower limb was not affected. Better left foot contact during the gait cycle also followed administration of Xeomin®, with significant VGA score reduction after 1 month (E). Walking speed increased after treatment (F). None of the adverse events most frequently associated with botulinum toxin treatment (headache, dysphagia, and weakness) were observed after the treatment. Flu-like symptoms, which have been reported for other botulinum preparations, were also not reported with the use of Xeomin®.
Figure 1 Clinical and functional measurements before, 1 week, and 1 month after Xeomin® administration. A) Spasticity (Modified Ashworth Scale [MAS]); B) Pain (visual analog scale [VAS]); C) Trunk control capacity (TCT); D) Motricity index (MI); E) Visual (more ...)