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Botulinum Toxin Type A for the Treatment of Lower Limb Spasticity after Stroke

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Abstract

Post-stroke lower limb spasticity impairs balance and gait leading to reduced walking speed, often increasing wheelchair use and caregiver burden. Several studies have shown that appropriate treatments for lower limb spasticity after stroke include injections of botulinum toxin type A (BoNT-A), phenol or alcohol, surgical correction and a rehabilitation program. In the present article, we review the safety and effectiveness of BoNT-A for the treatment of lower limb spasticity after stroke, with a focus on higher doses of BoNT-A. The cumulative body of evidence coming from the randomized clinical trials and open-label studies selected in the article suggest BoNT-A to be safe and efficacious in reducing lower limb spasticity after stroke. Studies of high doses of BoNT-A also showed a greater reduction of severe post-stroke spasticity. In stroke survivors with spasticity of the ankle plantar-flexor muscles, a combined approach between surgery and BoNT-A can be indicated. However, controversy remains about improvement in motor function relative to post-stroke spasticity reduction after BoNT-A treatment.

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References

  1. Simpson DM, Gracies JM, Graham HK, Miyasaki JM, Naumann M, Russman B, Simpson LL, So Y. Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Assessment: Botulinum neurotoxin for the treatment of spasticity (an evidence-based review): report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. 2008;70:1691–8.

  2. Wissel J, Ward AB, Erztgaard P, Bensmail D, Hecht MJ, Lejeune TM, Schnider P, Altavista MC, Cavazza S, Deltombe T, Duarte E, Geurts AC, Gracies JM, Haboubi NH, Juan FJ, Kasch H, Katterer C, Kirazli Y, Manganotti P, Parman Y, Paternostro-Sluga T, Petropoulou K, Prempeh R, Rousseaux M, Slawek J. European consensus table on the use of botulinum toxin type A in adult spasticity. J Rehabil Med. 2009;41:13–25.

    Article  Google Scholar 

  3. Sheean GL. Botulinum treatment of spasticity: why is it so difficult to show a functional benefit? Curr Opin Neurol. 2001;14:771–6.

    Article  CAS  Google Scholar 

  4. Deltombe T, Wautier D, De Cloedt P, Fostier M, Gustin T. Assessment and treatment of spastic equinovarus foot after stroke: guidance from the Mont-Godinne interdisciplinary group. J Rehabil Med. 2017;49:461–8.

    Article  Google Scholar 

  5. Ward AB. Managing spastic foot drop after stroke. Eur J Neurol. 2014;21:1053–4.

    Article  Google Scholar 

  6. Boudarham J, Hameau S, Pradon D, Bensmail D, Roche N, Zory R. Changes in electromyographic activity after botulinum toxin injection of the rectus femoris in patients with hemiparesis walking with a stiff-knee gait. J Electromyogr Kinesiol. 2013;23:1036–43.

    Article  CAS  Google Scholar 

  7. Carda S, Bertoni M, Zerbinati P, Rossini M, Magoni L, Molteni F. Gait changes after tendon functional surgery for equinovarus foot in patients with stroke: assessment of temporo-spatial, kinetic, and kinematic parameters in 177 patients. Am J Phys Med Rehabil. 2009;88:292–301.

    Article  Google Scholar 

  8. Farina S, Migliorini C, Gandolfi M, Bertolasi L, Casarotto M, Manganotti P, Fiaschi A. Smania N Combined effects of botulinum toxin and casting treatments on lower limb spasticity after stroke. Funct Neurol. 2008;23:87–91.

    PubMed  Google Scholar 

  9. Carda S, Invernizzi M, Baricich A, Cisari C. Casting, taping or stretching after botulinum toxin type A for spastic equinus foot: a single-blind randomized trial on adult stroke patients. Clin Rehabil. 2011;25:1119–27.

    Article  Google Scholar 

  10. Baricich A, Carda S, Bertoni M, Maderna L, Cisari C. A single-blinded, randomized pilot study of botulinum toxin type A combined with non-pharmacological treatment for spastic foot. J Rehabil Med. 2008;40:870–2.

    Article  Google Scholar 

  11. Perera S, Mody SH, Woodman RC, Studenski SA. Meaningful change and responsiveness in common physical performance measures in older adults. J Am Geriatr Soc. 2006;54:743–9.

    Article  Google Scholar 

  12. Slavinski J, Pradon D, Bensmail D, Roche N, Zory R. Energy cost of obstacle crossing in stroke patients. Am J Phys Med Rehab. 2014;93:1044–50.

    Article  Google Scholar 

  13. Podsiadlo D, Richardson S. The timed up and go: a test of basic functional mobility for frail elderly persons. J Am Geriat Soc. 1991;39:142–8.

    Article  CAS  Google Scholar 

  14. Das TK, Park DM. Effect of treatment with botulinum toxin on spasticity. Postgrad Med J. 1989;65:208–10.

    Article  CAS  Google Scholar 

  15. Simpson DM, Hallett M, Ashman EJ, Comella CL, Green MW, Gronseth GS, Armstrong MJ, Gloss D, Potrebic S, Jankovic J, Karp BP, Naumann M, So YT, Yablon SA. Practice guideline update summary: botulinum neurotoxin for the treatment of blepharospasm, cervical dystonia, adult spasticity, and headache: Report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology. 2016;86:1818–26.

    Article  CAS  Google Scholar 

  16. Albanese A. Terminology for preparations of botulinum neurotoxins: what a difference a name makes. JAMA. 2011;305:89–90.

    Article  CAS  Google Scholar 

  17. Santamato A, Panza F. Benefits and risks of non-approved injection regimens for botulinum toxins in spasticity. Drugs. 2017;77:1413–22.

    Article  CAS  Google Scholar 

  18. Dressler D, Mander GJ, Fink K. Equivalent potency of Xeomin® and Botox®. Mov Disord. 2008;1(23 suppl):S20–1.

    Google Scholar 

  19. Dressler D, Mander G, Fink K. Measuring the potency labelling of onabotulinumtoxinA (Botox®) and incobotulinumtoxinA (Xeomin®) in an LD50 assay. J Neural Transm. 2012;119:13–5.

    Article  CAS  Google Scholar 

  20. Odergren T, Hjaltason H, Kaakkola S, Solders G, Hanko J, Fehling C, Marttila RJ, Lundh H, Gedin S, Westergren I, Richardson A, Dott C, Cohen H. A double blind, randomised, parallel group study to investigate the dose equivalence of Dysport and Botox in the treatment of cervical dystonia. J Neurol Neurosurg Psychiatry. 1998;64:6–12.

    Article  CAS  Google Scholar 

  21. Frevert J. Content of botulinum neurotoxin in Botox®/Vistabel®, Dysport®/Azzalure®, and Xeomin®/Bocouture®. Drugs RD. 2010;10:67–73.

    Article  Google Scholar 

  22. Wein T, Esquenazi A, Jost WH, Ward AB, Pan G, Dimitrova R. OnabotulinumtoxinA for the treatment of post-stroke distal lower-limb spasticity: a randomized trial. PM R. 2018. https://doi.org/10.1016/j.pmrj.2017.12.006 (Epub ahead of print).

  23. Gracies JM, Esquenazi A, Brashear A, Banach M, Kocer S, Jech R, Khatkova S, Benetin J, Vecchio M, McAllister P, Ilkowski J, Ochudlo S, Catus F, Grandoulier AS, Vilain C, Picaut P. International AbobotulinumtoxinA adult lower limb spasticity study group. efficacy and safety of abobotulinumtoxinA in spastic lower limb: randomized trial and extension. Neurology. 2017;89:2245–53.

  24. Pittock SJ, Moore AP, Hardiman O, Ehler E, Kovac M, Bojakowski J, Al Khawaja I, Brozman M, Kanovský P, Skorometz A, Slawek J, Reichel G, Stenner A, Timerbaeva S, Stelmasiak Z, Zifko UA, Bhakta B, Coxon E. A double-blind randomised placebo-controlled evaluation of three doses of botulinum toxin type A (Dysport) in the treatment of spastic equinovarus deformity after stroke. Cerebrovasc Dis. 2003;15:289–300.

    Article  CAS  Google Scholar 

  25. Kaji R, Osako Y, Suyama K, Maeda T, Uechi Y, Iwasaki M. Botulinum toxin type A in post-stroke lower limb spasticity: a multicenter, double-blind, placebo-controlled trial. J Neurol. 2010;257:1330–7.

    Article  CAS  Google Scholar 

  26. Burbaud P, Wiart L, Dubos JL, Gaujard E, Debelleix X, Joseph PA, Mazaux JM, Bioulac B, Barat M, Lagueny A. A randomised, double blind, placebo-controlled trial of botulinum toxin in the treatment of spastic foot in hemiparetic patients. J Neurol Neurosurg Psychiatry. 1996;61:265–9.

    Article  CAS  Google Scholar 

  27. Johnson CA, Burridge JH, Strike PW, Wood DE, Swain ID. The effect of combined use of botulinum toxin type A and functional electric stimulation in the treatment of spastic drop foot after stroke: a preliminary investigation. Arch Phys Med Rehabil. 2004;85:902–9.

    Article  Google Scholar 

  28. Dunne JW, Gracies JM, Hayes M, Zeman B, Singer BJ, Multicentre Study Group. A prospective, multicentre, randomized, double-blind, placebo-controlled trial of onabotulinumtoxinA to treat plantarflexor/invertor overactivity after stroke. Clin Rehabil. 2012;26:787–97.

  29. Hesse S, Lücke D, Malezic M, Bertelt C, Friedrich H, Gregoric M, Mauritz KH. Botulinum toxin treatment for lower limb extensor spasticity in chronic hemiparetic patients. J Neurol Neurosurg Psychiatry. 1994;57:1321–4.

    Article  CAS  Google Scholar 

  30. Santamato A, Micello MF, Panza F, Fortunato F, Pilotto A, Giustini A, Testa A, Fiore P, Ranieri M, Spidalieri R. Safety and efficacy of incobotulinum toxin type A (NT 201-Xeomin) for the treatment of post-stroke lower limb spasticity: a prospective open-label study. Eur J Phys Rehabil Med. 2013;49:483–9.

    CAS  PubMed  Google Scholar 

  31. Mancini F, Sandrini G, Moglia A, Nappi G, Pacchetti C. A randomised, double-blind, dose-ranging study to evaluate efficacy and safety of three doses of botulinum toxin type A (Botox) for the treatment of spastic foot. Neurol Sci. 2005;26:26–31.

    Article  CAS  Google Scholar 

  32. Pimentel LH, Alencar FJ, Rodrigues LR, Sousa FC, Teles JB. Effects of botulinum toxin type A for spastic foot in post-stroke patients enrolled in a rehabilitation program. Arq Neuropsiquiatr. 2014;72:28–32.

    Article  Google Scholar 

  33. Picelli A, Bonetti P, Fontana C, Barausse M, Dambruoso F, Gajofatto F, Girardi P, Manca M, Gimigliano R, Smania N. Is spastic muscle echo intensity related to the response to botulinum toxin type A in patients with stroke? A cohort study. Arch Phys Med Rehabil. 2012;93:1253–8.

    Article  Google Scholar 

  34. Picelli A, Tamburin S, Bonetti P, Fontana C, Barausse M, Dambruoso F, Gajofatto F, Santilli V, Smania N. Botulinum toxin type A injection into the gastrocnemius muscle for spastic equinus in adults with stroke: a randomized controlled trial comparing manual needle placement, electrical stimulation and ultrasonography-guided injection techniques. Am J Phys Med Rehabil. 2012;91:957–64.

    Article  Google Scholar 

  35. Tok F, Balaban B, Yaşar E, Alaca R, Tan AK. The effects of onabotulinum toxin A injection into rectus femoris muscle in hemiplegic stroke patients with stiff-knee gait: a placebo-controlled, nonrandomized trial. Am J Phys Med Rehabil. 2012;91:321–6.

    Article  Google Scholar 

  36. Roche N, Boudarham J, Hardy A, Bonnyaud C, Bensmail B. Use of gait parameters to predict the effectiveness of botulinum toxin injection in the spastic rectus femoris muscle of stroke patients with stiff knee gait. Eur J Phys Rehabil Med. 2015;51:361–70.

    CAS  PubMed  Google Scholar 

  37. Hameau S, Bensmail D, Robertson J, Boudarham J, Roche N, Zory R. Isokinetic assessment of the effects of botulinum toxin injection on spasticity and voluntary strength in patients with spastic hemiparesis. Eur J Phys Rehabil Med. 2014;50:515–23.

    CAS  PubMed  Google Scholar 

  38. Riley PO, Kerrigan DC. Torque action of two-joint muscles in the swing period of stiff-legged gait: a forward dynamic model analysis. J Biomech. 1998;31:835–40.

    Article  CAS  Google Scholar 

  39. Sung DH, Bang HJ. Motor branch block of the rectus femoris: its effectiveness in stiff-legged gait in spastic paresis. Arch Phys Med Rehabil. 2000;81:910–5.

    Article  CAS  Google Scholar 

  40. Goldberg SR, Anderson FC, Pandy MG, Delp SL. Muscles that influence knee flexion velocity in double support: implications for stiff knee gait. J Biomech. 2004;37:1189–96.

    Article  Google Scholar 

  41. Caty GD, Detrembleur C, Bleyenheuft C, Deltombe T, Lejeune TM. Effect of simultaneous botulinum toxin injections into several muscles on impairment, activity, participation, and quality of life among stroke patients presenting with a stiff knee gait. Stroke. 2008;39:2803–8.

    Article  CAS  Google Scholar 

  42. Rousseaux M, Daveluy W, Kozlowski O, Allart E. Onabotulinumtoxin-A injection for disabling lower limb flexion in hemiplegic patients. NeuroRehabilitation. 2014;35:25–30.

    PubMed  Google Scholar 

  43. Yelnik AP, Colle FM, Bonan IV, Lamotte DR. Disabling overactivity of the extensor hallucis longus after stroke: clinical expression and efficacy of botulinum toxin type A. Arch Phys Med Rehabil. 2003;84:147–9.

    Article  Google Scholar 

  44. Suputtitada A. Local botulinum toxin type A injections in the treatment of spastic toes. Am J Phys Med Rehabil. 2002;81:770–5.

    Article  Google Scholar 

  45. Royal College of Physicians. Guidance to good practice. Guidelines for the use of botulinum toxin (BTX) in the management of spasticity in adults. London: Royal College of Physicians; 2002.

  46. Baricich A, Picelli A, Santamato A, Carda S, de Sire A, Smania N, Cisari C, Invernizzi M. Safety profile of high-dose botulinum toxin type A in post-stroke spasticity treatment. Clin Drug Investig. 2018. https://doi.org/10.1007/s40261-018-0701-x (Epub ahead of print).

  47. Baricich A, Grana E, Carda S, Santamato A, Cisari C, Invernizzi M. High doses of onabotulinumtoxinA in post-stroke spasticity: a retrospective analysis. J Neural Transm (Vienna). 2015;122:1283–7.

    Article  CAS  Google Scholar 

  48. Hesse S, Jahnke MT, Luecke D, Mauritz KH. Short-term electrical stimulation enhances the effectiveness of Botulinum toxin in the treatment of lower limb spasticity in hemiparetic patients. Neurosci Lett. 1995;201:37–40.

    Article  CAS  Google Scholar 

  49. Santamato A, Panza F, Ranieri M, Frisardi V, Micello MF, Filoni S, Fortunato F, Intiso D, Basciani M, Logroscino G, Fiore P. Efficacy and safety of higher doses of botulinum toxin type A NT 201 free from complexing proteins in the upper and lower limb spasticity after stroke. J Neural Transm. 2013;120:469–76.

    Article  CAS  Google Scholar 

  50. Santamato A, Panza F, Intiso D, Baricich A, Picelli A, Smania N, Fortunato F, Seripa D, Fiore P, Ranieri M. Long-term safety of repeated high doses of incobotulinumtoxinA injections for the treatment of upper and lower limb spasticity after stroke. J Neurol Sci. 2017;378:182–6.

    Article  CAS  Google Scholar 

  51. Ramirez-Castaneda J, Jankovic J, Comella C, Dashtipour K, Fernandez HH, Mari Z. Diffusion, spread, and migration of botulinum toxin. Mov Disord. 2013;28:1775–83.

    Article  CAS  Google Scholar 

  52. Bhatia KP, Münchau A, Thompson PD, Houser M, Chauhan VS, Hutchinson M, Shapira AH, Marsden CD. Generalised muscular weakness after botulinum toxin injections for dystonia: a report of three cases. J Neurol Neurosurg Psychiatry. 1999;67:90–3.

    Article  CAS  Google Scholar 

  53. Baizabal-Carvallo JF, Jankovic J, Pappert E. Flu-like symptoms following botulinum toxin therapy. Toxicon. 2011;58:1–7.

    Article  CAS  Google Scholar 

  54. Roche N, Schnitzler A, Genet FF, Durand MC, Bensmail D. Undesirable distant effects following botulinum toxin type A injection. Clin Neuropharmacol. 2008;31:272280.

    Article  Google Scholar 

  55. Pickett A. Dysport: pharmacological properties and factors that influence toxin action. Toxicon. 2009;54:683–9.

    Article  CAS  Google Scholar 

  56. Ward AB, Wissel J, Borg J, Ertzgaard P, Herrmann C, Kulkarni J, Lindgren K, Reuter I, Sakel M, Säterö P, Sharma S, Wein T, Wright N, Fulford-Smith A. Functional goal achievement in post-stroke spasticity patients: the BOTOX® Economic Spasticity Trial (BEST). J Rehabil Med. 2014;46:504–13.

    Article  Google Scholar 

  57. Leach E, Cornwell P, Fleming J, Haines T. Patient centered goal-setting in a subacute rehabilitation setting. Disabil Rehabil. 2010;32:159–72.

    Article  Google Scholar 

  58. Sunnerhagen KS, Francisco GE. Enhancing patient–provider communication for long-term post-stroke spasticity management. Acta Neurol Scand. 2013;128:305–10.

    CAS  PubMed  Google Scholar 

  59. Baricich A, Cosenza L, Sandrini G, Paolucci S, Morone G, Santamato A, Baricich A, Cosenza L, Sandrini G, Paolucci S, Morone G, Santamato A. Development of a patient-centered questionnaire for post-stroke spasticity assessment: a reliability study. Funct Neurol. 2018;33:113–5.

  60. Rosales RL, Kong KH, Goh KJ, Kumthornthip W, Mok VC, Delgado-De Los Santos MM, Chua KS, Abdullah SJ, Zakine B, Maisonobe P, Magis A,Wong KS. Botulinum toxin injection for hypertonicity of the upper extremity within 12 weeks after stroke: a randomized controlled trial. Neurorehabil Neural Repair. 2012;26:812–21.

  61. Fietzek UM, Kossmehl P, Schelosky L, Ebersbach G, Wissel J. Early botulinum toxin treatment for spastic pes equinovarus—a randomized double-blind placebo-controlled study. Eur J Neurol. 2014;21:1089–95.

    Article  CAS  Google Scholar 

  62. Tao W, Yan D, Li JH, Shi ZH. Gait improvement by low-dose botulinum toxin A injection treatment of the lower limbs in subacute stroke patients. J Phys Ther Sci. 2015;27:759–62.

    Article  Google Scholar 

  63. Kirazli Y, On AY, Kismali B, Aksit R. Comparison of phenol block and botulinus toxin type A in the treatment of spastic foot after stroke: a randomized, double-blind trial. Am J Phys Med Rehabil. 1998;77:510–5.

    Article  CAS  Google Scholar 

  64. Rousseaux M, Buisset N, Daveluy W, Kozlowski O, Blond SM. Comparison of botulinum toxin injection and neurotomy in patients with distal lower limb spasticity. Eur J Neurol. 2008;15:506–11.

    Article  CAS  Google Scholar 

  65. Bollens B, Gustin T, Stoquart G, Detrembleur C, Lejeune T, Deltombe T. A randomized controlled trial of selective neurotomy versus botulinum toxin for spastic equinovarus foot after stroke. Neurorehabil Neural Repair. 2013;27:695–703.

    Article  Google Scholar 

  66. Picelli A, Dambruoso F, Bronzato M, Barausse M, Gandolfi M, Smania N. Efficacy of therapeutic ultrasound and transcutaneous electrical nerve stimulation compared with botulinum toxin type A in the treatment of spastic equinus in adults with chronic stroke: a pilot randomized controlled trial. Top Stroke Rehabil. 2014;21(Suppl 1):S8–16.

    Article  Google Scholar 

  67. Wu T, Li JH, Song HX, Dong Y. Effectiveness of botulinum toxin for lower limbs spasticity after stroke: a systematic review and meta-analysis. Top Stroke Rehabil. 2016;23:217–23.

    Article  Google Scholar 

  68. Baker JA, Pereira G. The efficacy of Botulinum Toxin A for limb spasticity on improving activity restriction and quality of life: a systematic review and meta-analysis using the GRADE approach. Clin Rehabil. 2016;30:549–58.

    Article  Google Scholar 

  69. Gupta AD, Chu WH, Howell S, Chakraborty S, Koblar S, Visvanathan R, Cameron I, Wilson D. A systematic review: efficacy of botulinum toxin in walking and quality of life in post-stroke lower limb spasticity. Syst Rev. 2018;7:1.

    Article  Google Scholar 

  70. Stoquart GG, Detrembleur C, Palumbo S, Deltombe T, Lejeune TM. Effect of botulinum toxin injection in the rectus femoris on stiff-knee gait in people with stroke: a prospective observational study. Arch Phys Med Rehabil. 2008;89:56–61.

    Article  Google Scholar 

  71. Hutin E, Pradon D, Barbier F, Gracies JM, Bussel B, Roche N. Lower limb coordination in hemiparetic subjects: impact of botulinum toxin injections into rectus femoris. Neurorehabil Neural Repair. 2010;24:442–9.

    Article  Google Scholar 

  72. Robertson JV, Pradon D, Bensmail D, Fermanian C, Bussel B, Roche N. Relevance of botulinum toxin injection and nerve block of rectus femoris to kinematic and functional parameters of stiff knee gait in hemiplegic adults. Gait Posture. 2009;29:108–12.

    Article  Google Scholar 

  73. Chan J, Winter A, Palit M, Sturt R, Graaff SD, Holland AE. Are gait and mobility measures responsive to change following botulinum toxin injections in adults with lower limb spasticity? Disabil Rehabil. 2013;35:959–67.

    Article  Google Scholar 

  74. Baricich A, Picelli A, Molteni F, Guanziroli E, Santamato A. Post-stroke spasticity as a condition: a new perspective on patient evaluation. Funct Neurol. 2016;31:179–80.

    CAS  PubMed  PubMed Central  Google Scholar 

  75. Picelli A, Bonetti P, Fontana C, Barausse M, Dambruoso F, Gajofatto F, Tamburin S, Girardi P, Gimigliano R, Smania N. Accuracy of botulinum toxin type A injection into the gastrocnemius muscle of adults with spastic equinus: manual needle placement and electrical stimulation guidance compared using ultrasonography. J Rehabil Med. 2012;44:450–2.

    Article  Google Scholar 

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Authors and Affiliations

  1. Physical Medicine and Rehabilitation Section, “OORR Hospital”, University of Foggia, Viale Pinto, 71100, Foggia, Italy

    Andrea Santamato, Nicoletta Cinone, Sara Letizia, Luigi Santoro & Maurizio Ranieri

  2. “Fondazione Turati” Rehabilitation Centre, Vieste, Foggia, Italy

    Andrea Santamato

  3. Neurodegenerative Disease Unit, Department of Basic Medical Sciences, Neuroscience and Sense Organs, University of Bari “Aldo Moro”, Bari, Italy

    Francesco Panza & Madia Lozupone

  4. Department of Clinical Research in Neurology, Center for Neurodegenerative Diseases and the Aging Brain, University of Bari “Aldo Moro”, “Pia Fondazione Cardinale G. Panico”, Tricase, Lecce, Italy

    Francesco Panza

  5. Geriatric Unit, Fondazione IRCCS “Casa Sollievo della Sofferenza”, San Giovanni Rotondo, Foggia, Italy

    Francesco Panza

  6. Institute of Neurology, Catholic University of Sacred Heart, Rome, Italy

    Antonio Daniele

  7. Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy

    Antonio Daniele

  8. Department of Neurosciences, Biomedicine and Movement Sciences, Neuromotor and Cognitive Rehabilitation Research Center, University of Verona, Verona, Italy

    Alessandro Picelli

  9. Neurorehabilitation Unit, Department of Neurosciences, Hospital Trust of Verona, Verona, Italy

    Alessandro Picelli

  10. Health Sciences Department, Università del Piemonte Orientale, Novara, Italy

    Alessio Baricich

  11. Department of Neuro-Rehabilitation IRCCS, Casa Sollievo della Sofferenza, San Giovanni Rotondo, Foggia, Italy

    Domenico Intiso

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  1. Andrea Santamato
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Andrea Santamato, Nicoletta Cinone, Francesco Panza, Sara Letizia, Luigi Santoro, Madia Lozupone, Antonio Daniele, Alessandro Picelli, Alessio Baricich, Domenico Intiso, and Maurizio Ranieri have no conflicts of interest that are directly relevant to the content of this study.

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Santamato, A., Cinone, N., Panza, F. et al. Botulinum Toxin Type A for the Treatment of Lower Limb Spasticity after Stroke. Drugs 79, 143–160 (2019). https://doi.org/10.1007/s40265-018-1042-z

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