Treatment of spasticity of the lower limb after a stroke

The Rehabilitation Service of the Marqués de Valdecilla University Hospital in collaboration with 23 Spanish hospitals and a neurology service has conducted a prospective real-life observational study (Real World Evidence) on the functional improvement of botulinum toxin type A injection in patients with lower limb spasticity after having suffered a stroke. This study is part of the research line “Effectiveness of treatment with botulinum toxin in post-stroke spasticity” that the Rehabilitation Service of the Marqués de Valdecilla University Hospital has been carrying out for 15 years.


Multiple Class I studies have shown that botulinum toxin is safe and effective in the treatment of spasticity of the lower limb but there is still little data on the results of active function. Most studies focus their results on deficit improvement (muscle tone or joint balance). However, the objectives of the rehabilitation programs cover different fields of the International Classification of Functioning, Disability and Health, such as activity, participation, quality of life and environmental factors. These factors are often the most important for the patient and his caregiver.

The objective of this study published in European Neurology has been to evaluate the acquisition of specific objectives focused on each patient, agreed with him and his caregiver, in the treatment of spasticity of the lower limb after a stroke, with a botulinum toxin type A cycle , used according to the usual clinical practice of each center. For this, the GAS (Goal Attainment Scaling) scale was used, a validated method to define personalized objectives and quantify progress towards those defined objectives. To date, this type of Real – World Evidence study in the application of GAS in treatment with botulinum toxin had only been performed in the spasticity of the upper limb.

This study is the first of its kind using the GAS scale in post-stroke spasticity of the lower limb. As secondary objectives, the improvement in standardized mobility and walking scales has been assessed as the 10-meter walking test.

The results obtained have shown a high range of acquisition of primary and secondary objectives using the GAS scale. However, two negative predictive factors for the achievement of the objectives have been identified: the high time of evolution of spasticity and the pattern of knee stiffness. The results of the rest of the scales used have also been improved. Specifically, the walking speed in the 10-meter walking test improved 6 cm / second a month after the injection and 5 cm / seconds 3 – 5 months after the intervention.

Ref. Botulinum Toxin Type A Improves Function According to Goal Attainment in Adults with Poststroke Lower Limb Spasticity in Real Life Practice. López de Munain L, Valls-Solé J, Garcia Pascual I, Maisonobe P; on behalf of the VALGAS investigators group. Eur Neurol. 2019 Nov 14:1-8. doi: 10.1159/000503172. [Epub ahead of print]