Botulinum toxin type-A (BoNTA) and dynamic wrist-hand orthoses versus orthoses alone for the treatment of spastic-paretic upper extremity in chronic stroke patients


Purpose: The purpose of this study was to investigate the potential functional improvement of the spastic-paretic upper extremity of individuals with chronic hemiparesis when using a dynamic wrist-hand orthosis with and without concurrent botulinum toxin type-A (BoNTA) injections into the spastic upper extremity muscles. Methods: A three-year retrospective chart review was conducted on all stroke patients referred to out-patient occupational therapy for an upper extremity rehabilitation program, which included use of a dynamic wrist-hand orthosis (DWHO). Three charts documented concurrent treatment with a DWHO + BoNTA. Eleven charts documented DWHO use without concurrent BoNTA treatment. Pre- and post-intervention outcome measure scores were compared between the two groups. Pre- and post-interven- tion scores were also analyzed irrespective of treatment group. Results: Although improvement approached significance on three of the documented outcome measures when comparing the DWHO + BoNTA and DWHO groups, no statistically significant changes were found. A significant difference (p < 0.05) however, was found between the pre- and post-intervention scores irrespective of treatment group in 13 of 14 of the outcome measures documented. Conclusions: Further research with a larger sample size is suggested to assess the combined effect of using a dynamic wrist-hand orthosis and BoNTA injections into the spastic upper extremity muscles of individuals with chronic hemiparesis post stroke.

Share and Cite:

Pooyania, S. and Semenko, B. (2014) Botulinum toxin type-A (BoNTA) and dynamic wrist-hand orthoses versus orthoses alone for the treatment of spastic-paretic upper extremity in chronic stroke patients. Open Journal of Therapy and Rehabilitation, 2, 12-18. doi: 10.4236/ojtr.2014.21003.

Conflicts of Interest

The authors declare no conflicts of interest.


[1] Evidence based review of stroke rehabilitation. (2013).
[2] Van Peppen, R.P.S., Kwakkel, G., Wood-Dauphinee, S., Hendriks, H.J.M., Van der Wees, P.J. and Dekker, J. (2004) The impact of physical therapy on functional outcomes after stroke: What’s the evidence? Clinical Rehabili-tation, 18, 833-862.
[3] Oujamaa, L., Relave, I., Froger, J., Mottet, D. and Pelissier, J. (2009) Rehabilitation of arm function after stroke. Literature review. Annals of Physical and Rehabil Medicine, 52, 269-293.
[4] Thielman, G.T., Dean, C.M. and Gentile, A.M. (2004) Rehabilitation of reaching after stroke: Task-related training versus progressive resistive exercise. Archives of Physical Medicine and Rehabilitation, 10, 1613-1618.
[5] Greenwood, R.J., Barnes, M.P., McMillan, T.M. and Ward, C.D. (2003) Handbook of neurological rehabilitation. 2nd Edition, Psychology Press, New York.
[6] Hallett, M. (2001) Plasticity of the human motor cortex and recovery from stroke. Brain Research Reviews, 36, 169-174.
[7] Nelles, G., Jentzen, W., Jueptner, M., Muller, S. and Diener, H.C. (2001) Arm training induced brain plasticity in stroke studied with serial positron emission tomography. NeuroImage, 13, 1146-1154.
[8] Classen, J., Liepert, J., Wise, S.P., Hallett, M. and Cohen, L.G. (1998) Rapid plasticity of human cortical movement representation induced by practice. Journal of Neurophysiology, 79, 1117-1123.
[9] Westlake, K. and Byl, N. (2013) Neural plasticity and implications for hand rehabilitation after neurological insult. Journal of Hand Therapy, 26, 87-92.
[10] Lindsay, M.P., Gubitz, G. and Bayley, M. (2010) Canadian best practice recommendations for stroke care. Canadian Stroke Strategy Best Practices and Standards Writing Group, Ottawa.
[11] Wolf, S.L., Winstein, C.J., Miller, J.P., Taub, E., Uswatte, G., Morris, D., et al. (2006) Effect of constraint-induced movement therapy on upper extremity function 3 to 9 months after stroke: The EXCITE randomized clinical trial. JAMA, 296, 2095-2104.
[12] Shi, Y.X., Tian, J.H., Yang, K.E. and Zhao, Y. (2011) Modified constraint-induced movement therapy versus traditional rehabilitation in patients with upper-extremity dysfunction after stroke: A systematic review and metaanalysis. Archives of Physical Medicine and Rehabilitation, 92, 972-982.
[13] Taub, E., Uswatte, G., Bowman, M., Mark, V., Delgado, A., Bryson, C., et al. (2013) Constraint-induced movement therapy combined with chronic stroke patients with plegic hands: A case series. Archives of Physical Medicine and Rehabilitation, 94, 86-94.
[14] Taub, E., Uswatte, G., King, D.K., Morris, D., Crage, J.E. and Chatterjee, A. (2006) A placebo-controlled trial of constraint-induced movement therapy for upper extremity after stroke. Stroke, 37, 1045-1049.
[15] Page, S.J., Levine, P. and Leonard, A.C. (2005) Modified constraint-induced therapy in acute stroke: A randomized controlled pilot study. Neurorehabilitation and Neural Repair, 19, 27-32.
[16] Rowe, T., Blanton, S. and Wolf, S. (2009) Long-term follow-up after constraint-induced therapy: A case report of a chronic stroke survivor. AJOT, 63, 317-322.
[17] Parker, V.M., Wade, D.T. and Langton-Hewer, R. (1986) Loss of arm function after stroke: Measurement, frequency, and recovery. International Rehabilitation Medicine, 8, 69-73.
[18] Nichols-Larsen, D., Clark, P.C., Zeringue, A., Greenspan, A. and Blanton, S. (2005) Factors influencing stroke survivors’ quality of life during subacute recovery. Stroke, 36, 1480-1484.
[19] Barry, J.G., Ross, S.A. and Woehrle, J. (2012) Therapy incorporating a dynamic wrist-hand orthosis versus manual assistance in chronic stroke: A pilot study. Journal of Neurologic Physical Therapy, 36, 17-24.
[20] Sun, S.F., Hsu, C.W., Hwang, C.W., Hsu, P.T., Wang, J.L. and Yang, C.L. (2006) Application of combined botulinum toxin type A and modified constraint-induced movement therapy for an individual with chronic upper-extremity spasticity after stroke. Physical Therapy, 86, 1387-1397.
[21] Butler, A., Blanton, S., Rowe, V. and Wolf, S. (2006) Attempting to improve function and quality of life using the FTM protocol: Case report. Journal of Neurologic Physical Therapy, 30, 148-156.
[22] Hoffman, H. and Blakey, G. (2011) New design of dynamic orthoses for neurological conditions. Neuro Rehabilitation, 28, 55-61.
[23] Jeon, H., Woo, Y., Yi, C., Kwon, O. Jung, M., Young-hee, L., et al. (2012) Effect of intensive training with a spring-assisted hand orthosis on movement smoothness in upper extremity following stroke: A pilot clinical trial. Topics in Stroke Rehabilitation 19, 320-328.
[24] Broeks, J.G., Lankhorst, G.J., Rumping, K. and Prevo, A.J. (1999) The long-term outcome of arm function after stroke: Results of a follow-up study. Disability and Rehabilitation, 21, 357-364.
[25] Evidence based research in stroke rehabilitation. (2013).
[26] Wissel, J., Ward, A.B., Erztgaard, P., Bensmail, D., Hecht, M.J., Lejeune, T.M., et al. (2009) European consensus table on the use of botulinum toxin type A in adult spasticity. Journal of Rehabilitation Medicine, 41, 13-25.
[27] Naumann, M., So, Y., Argoff, C.E., Childers, M.K., Dykstra, D.D., Gronseth, G.S., et al. (2008) Assessment: botulinum neurotoxin in the treatment of autonomic disorders and pain (an evidence based review): Report of the therapeutics and technology assessment subcommittee of the American Academy of Neurology. Neurology, 70, 1707-1714.
[28] Teasell, R., Foley, N., Pereira, S., Sequeira, K. and Miller, T. (2012) Evidence to practice: Botulinum toxin in the treatment of spasticity post stroke. Topics in Stroke Rehabilitation, 19, 115-121.
[29] Wolf, S., Milton, B., Reiss, A., Easley, K., Shenvi, N. and Clark, P. (2012) Further assessment to determine the additive effect of botulinum toxin type A on an upper extremity exercise program to enhance function among individuals with chronic stroke but extensor capability. Archives of Physical Medicine and Rehabilitation, 93, 578- 587.
[30] Sun, S.F., Hsu, C.W., Sun, H.P., Hwang, C.W., Yang, C.L. and Wang, J.L. (2010) Combined botulinum toxin type A with modified constraint-induced movement therapy for chronic stroke patients with upper extremity spasticity: A randomized controlled study. Neurorehabilitation and Neural Repair, 24, 34-41.
[31] Marciniak, C. (2011) Poststrokehypertonicity: Upper limb assessment and treatment. Topics in Stroke Rehabilitation, 18, 179-194.
[32] Sheean, G., Lannin, N.A., Turner-Stokes, L., Rawicki, B. and Snow, B.J. (2010) Botulinum toxin assessment, intervention and after-care for upper limb hypertonicity in adults: International consensus statement. European Journal of Neurology, 17, 74-93.

Copyright © 2023 by authors and Scientific Research Publishing Inc.

Creative Commons License

This work and the related PDF file are licensed under a Creative Commons Attribution 4.0 International License.