Article

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.
CI - Copyright (c) 2017 American Academy of Physical Medicine and Rehabilitation.
Published by Elsevier Inc. All rights reserved.

Langue : ANGLAIS