OnabotulinumtoxinA Injection for Poststroke Upper-Limb Spasticity: Guidance for Early Injectors From a Delphi Panel Process
Abstract Background OnabotulinumtoxinA reduces muscle hypertonia associated with poststroke spasticity (PSS). PSS manifests as several common postures. Objective To define treatment paradigms for PSS upper-limb common postures. Design Modified Delphi method. Setting Expert panel. Participants Ten in...
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Published in | PM & R Vol. 9; no. 2; pp. 136 - 148 |
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Main Authors | , , , , , , , , , |
Format | Journal Article |
Language | English |
Published |
United States
01.02.2017
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Subjects | |
Online Access | Get full text |
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Summary: | Abstract Background OnabotulinumtoxinA reduces muscle hypertonia associated with poststroke spasticity (PSS). PSS manifests as several common postures. Objective To define treatment paradigms for PSS upper-limb common postures. Design Modified Delphi method. Setting Expert panel. Participants Ten injectors experienced in the treatment and clinical research of PSS (physiatrists and neurologists) were invited to participate in the Delphi panel. Methods The Delphi panel reviewed an electronic worksheet with PSS upper-limb postures to define onabotulinumtoxinA treatment paradigms (Round 1). During Round 2, panel members discussed in person Round 1 results and voted until consensus (≥66% agreement). Recommendations were geared toward those with new or early injection experience. Main Outcome Measurements Expert consensus on onabotulinumtoxinA treatment parameters for PSS including muscles to inject, dose per muscle and posture, and treatment adjustments for suboptimal response. Results For each posture, consensus was reached on targeted subsets of muscles. Doses ranged for individual muscles (10-100 U) and total doses per posture (50-200 U). An onabotulinumtoxinA dilution 50 U/mL (2:1 dilution ratio) was considered most appropriate; dilution ratios of 1:1 to 4:1 may be appropriate in some circumstances. The majority (89%) of panel members would increase the dose and/or the number of muscles treated for a suboptimal response to onabotulinumtoxinA. The panel identified 3 common aggregate upper-limb postures: (1) adducted shoulder + flexed elbow + pronated forearm + flexed wrist + clenched fist; (2) flexed elbow + pronated forearm + flexed wrist + clenched fist; and (3) flexed wrist + clenched fist. The recommended starting dose per aggregate was 300 U, 300 U, and 200 U, with a total maximum dose of 400 U, 400 U, and 300 U, respectively. Localization guidance techniques were considered essential for all postures. Conclusions Consensus on common muscles and onabotulinumtoxinA treatment paradigms for postures associated with upper-limb PSS was achieved via a modified Delphi method. The purpose of this analysis is to educate early onabotulinumtoxinA injectors rather than provide an evidence-based review. |
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Bibliography: | Disclosures outside this publication: honoraria for consulting, research, speakers bureaus, Allergan, Ipsen, Merz, US WorldMeds Disclosures outside this publication: consultancy and research grant support, Allergan, Merz, and Ipsen Disclosures related to this publication: personal fees, Allergan (author was a member of the Delphi panel) Disclosures outside this publication: honoraria and grants, Allergan and Merz Disclosure outside this publication: other, Allergan (speaker and consultant fees) Disclosures outside this publication: grants, Allergan and Ipsen Disclosures outside this publication: grants, Allergan, Mertz, and Ipsen; speaking honoraria, Allergan Disclosures related to this publication: personal fees, Allergan Disclosures outside this publication: grants, Allergan and Merz Disclosures related to this publication: grant and personal fees, Allergan Disclosures outside this publication: grants and personal fees, Ipsen, Medtronic, Merz; grant, Concert; other relationships, Vanderbilt University receives income from grants or contracts with Allergan, Ipsen, Lundbeck, Medtronic, Merz, and US WorldMeds for research or educational programs led by Dr Charles. Dr Charles receives income from the Alliance for Patient Access, Allergan, AstraZeneca, Concert, Ipsen, and Medtronic, and US WorldMeds for consulting services Disclosures outside this publication: personal fees and non‐financial support, Allergan and Ipsen Disclosures outside this publication: grants, Mertz, US WorldMeds, Lundbeck, Teva; personal fees, Allergan, Mertz, Ipsen, US WorldMeds, UCB Pharma, Lundbeck, Impax, Teva; non‐financial support, Allergan, Mertz, Ipsen, US WorldMeds, UCB Pharma, Lundbeck, Impax, Teva ObjectType-Article-1 SourceType-Scholarly Journals-1 ObjectType-Feature-2 content type line 23 |
ISSN: | 1934-1482 1934-1563 |
DOI: | 10.1016/j.pmrj.2016.06.016 |