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		A Letter Released to Physicians on July 3, 2006 Botox Does Not Weaken Muscles in Post-Stroke Spasticity Cases Botulinum toxin works by blocking acetylcholine release at the neuromuscular junction and causing flaccid paralysis of targeted muscles for months. Until very recently, doctors reasonably believed that injections of botulinum toxin A (BTX-A) would weaken spastic muscles in stroke survivors. To the surprise of the researchers involved, two separate studies have shown the opposite to be true. BTX-A improves strength in cases of post-stroke spasticity. Pandyan et al recruited 14 subjects with unilateral, elbow spasticity secondary to a stroke.^1 Among their measurements were grip strength and isometric elbow strength. They provided single injections to three different muscles in the affected arm. Contrary to the stated expectations of the researchers, both grip strength and elbow strength improved. Subjects also saw a reduction in spasticity as measured by EMG and an improvement in function. Pandyan speculates that the BTX-A treatments caused optimization of motor control as the treatments reduced spasticity, resulting in an improved ability to produce force. In a separate placebo controlled study, Simpson et al recruited 39 patients with increased wrist and elbow flexor tone post-stroke.^2 They were randomly assigned to single treatments of BTX-A at 75, 150, and 300 units. The 75-unit dose improved grip strength when measured at weeks 6 and 16, but the higher doses did not affect grip strength. Up to 30% of stroke survivors suffer with disabling spasticity. Post-stroke spasticity is characterized by increased muscle tone and resistance to movement. The increased stiffness contributes to fatigue by forcing stroke survivors to expend much more energy to perform basic activities. Complications of inadequately controlled spasticity include pain, contractures, and decubiti. Neal Taub, MD, ABPM&R provides BTX-A antispasmodic treatments and post-stroke rehabilitation at his private practice in Charlotte. As a physiatrist, Dr. Taub works on specific complaints or goals, and leaves patients under the general care of referring practitioners. If your patients include stroke survivors who may benefit from focal antispasmodic treatments or post-stroke rehabilitation, Please tell your patients about Neal S. Taub, MD, physiatrist.
		References Pandyan AD, Vuadens P, van Wijck FM, et al. Are we underestimating the clinical efficacy of botulinum toxin (type A)? Quantifying changes in spasticity, strength and upper limb function after injections of Botox to the elbow flexors in a unilateral stroke population. Clin Rehabil 2002; 16 (6); 654-60. Simpson DM, Alexander DN, O’Brien CF, et al. Botulinum toxin type A in the treatment of upper extremity spasticity: a randomized double-blind, placebo-controlled trial. Neurology 1996; 46: 1306-10.
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