A group of clinicians from across Europe experienced in the use of botulinum toxin type A for the treatment of spasticity following acquired brain injury gathered to develop a consensus statement on best practice in managing adults with spasticity. This consensus table summarizes the current published data, which was collated following extensive literature searches, their assessment for level of evidence and discussion among the whole group. Published information is supplemented by expert opinion based on clinical experience from 16 European countries, involving 28 clinicians, who treat an average of approximately 200 patients annually, representing many thousand spasticity treatments with botulinum toxin per year.

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Background and Purpose-Spasticity is a disabling complication of stroke and different noninvasive treatments are used to reduce muscle hypertonia. Shock waves are defined as a sequence of single sonic pulses largely used in the treatment of diseases involving bone and tendon as well as muscular contractures. The effect and duration of extracorporeal shock wave therapy (ESWT) was investigated on muscle hypertonia of the hand and wrist. Methods-A total of 20 patients affected by stroke associated with severe hypertonia in upper limbs were evaluated.Placebo stimulation was performed 1 week before active stimulation in each patient. Evaluation was performed using the National Institutes of Health and Ashworth scales and video monitoring with a digital goniometer before and immediately after placebo or active stimulation. Motor nerve conduction velocity from abductor digiti minimi were recorded. Patients were monitored at 1, 4, and 12 weeks after active treatment. Results-After active ESWT, patients showed greater improvement in flexor tone of wrist and fingers compared with placebo stimulation. At the 1-and 4-week follow-up visits, a significant decrease of passive muscle tonicity was noted on muscles in all patients receiving active treatment. At 12 weeks after therapy, 10 of the 20 patients showed persistent reduction in muscle tone. There were no adverse events associated with ESWT. Key Words: extracorporeal shock wave therapy Ⅲ muscle spasticity Ⅲ rehabilitation Ⅲ shock waves Ⅲ stroke I ncrease in muscle tone in the hands and wrists is a major problem in the management of chronic hemiparetic patients and may seriously impair dressing, washing, and other activities of daily living. 1 Motor neuron syndrome in stroke patients is a collection of symptoms including motor defects, increased reflexes, and muscle hypertonia, which produce a series of complications causing changes in the rheologic components of muscles and subsequent stiffness in tendons and joints. 1 In stroke, the hypertonia in muscles is partially related to spinal hyperexcitability in addition to fibrosis and changes in connective tissues that are responsible for passive rigidity of muscles. 1 Recent studies have reported that muscular injections of botulinum toxin type A decreases muscular tone in hypertonic muscles of the hand, with improvement in the use of the upper limb and a decrease in complications. [2][3][4][5] However, in a small number of patients, the development of neutralizing antibodies can reduce the efficacy of treatment. In addition, the dosage of botulinum is not always sufficient to treat extensive and severe hypertonia in upper and lower limbs. Rehabilitation and different noninvasive treatments, particularly on the connective components, should be also considered. Conclusions-ESWTShock waves are defined as a sequence of single sonic pulses characterized by high peak pressure (100 MPa), fast pressure rise (Ͻ10 ns), and short duration (10 s). Different studies and clinical experiments have demonstrated the efficacy of shock waves ...

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Freezing of gait (FoG) is a disabling symptom associated with falls, with little or no responsiveness to pharmacological treatment. Current protocols used for rehabilitation are based on the use of external sensory cues. However, cued strategies might generate an important dependence on the environment. Teaching motor strategies without cues [i.e., action observation (AO) plus Sonification] could represent an alternative/innovative approach to rehabilitation that matters most on appropriate allocation of attention and lightening cognitive load. We aimed to test the effects of a novel experimental protocol to treat patients with Parkinson’s disease (PD) and FoG, using functional, and clinical scales. The experimental protocol was based on AO plus Sonification. 12 patients were treated with 8 motor gestures. They watched eight videos showing an actor performing the same eight gestures, and then tried to repeat each gesture. Each video was composed by images and sounds of the gestures. By means of the Sonification technique, the sounds of gestures were obtained by transforming kinematic data (velocity) recorded during gesture execution, into pitch variations. The same 8 motor gestures were also used in a second group of 10 patients; which were treated with a standard protocol based on a common sensory stimulation method. All patients were tested with functional and clinical scales before, after, at 1 month, and 3 months after the treatment. Data showed that the experimental protocol have positive effects on functional and clinical tests. In comparison with the baseline evaluations, significant performance improvements were seen in the NFOG questionnaire, and the UPDRS (parts II and III). Importantly, all these improvements were consistently observed at the end, 1 month, and 3 months after treatment. No improvement effects were found in the group of patients treated with the standard protocol. These data suggest that a multisensory approach based on AO plus Sonification, with the two stimuli semantically related, could help PD patients with FoG to relearn gait movements, to reduce freezing episodes, and that these effects could be prolonged over time.

In this study, a combined repetitive transcranial magnetic stimulation/electroencephalography (rTMS/EEG) method was used to explore the acute changes of cortical oscillatory activity induced by intermittent short trains of high-frequency (5-Hz) rTMS delivered over the left primary motor cortex (M1). We evaluated the electrophysiological reaction to magnetic stimulation during and 2-4 s after 20 trains of 20-pulses rTMS, using event-related power (ERPow) that reflects the regional oscillatory activity of neural assemblies, and event-related coherence (ERCoh) that reflects the interregional functional connectivity of oscillatory neural activity. These event-related transformations were for the upper alpha (10-12 Hz) and beta (18-22 Hz) frequency ranges, respectively. For the alpha band, threshold rTMS and subthreshold rTMS induced an ERPow increase during the trains of stimulation mainly in frontal and central regions ipsilateral to stimulation. For the beta band, a similar synchronization of cortical oscillations for both rTMS intensities was seen. Moreover, subthreshold rTMS affected alpha-band activity more than threshold rTMS, inducing a specific ERCoh decrease over the posterior regions during the trains of stimulation. For beta band, the decrease in functional coupling was observed mainly during threshold rTMS. These findings provide a better understanding of the cortical effects of high-frequency rTMS, whereby the induction of oscillations reflects the capacity of electromagnetic pulses to alter regional and interregional synaptic transmissions of neural populations.