Synergic use of botulinum toxin injection and radial extracorporeal shockwave therapy in Multiple Sclerosis spasticity

Background and aim In Multiple Sclerosis(MS)spasticity worsen patient′s quality of life.Botulinum NeuroToxin TypeA(BoNT-A)is extensively used in focal spasticity,frequently combined with physical therapies.Radial extracorporeal shock waves(rESW)were already used in association with BoNT-A.Considering that loss of efficacy and adverse events are determinants of BoNT-A treatment interruption,this study aimed to evaluate the possibility to prolong BoNT-A′s effect by using rESW in MS focal spasticity.Methods Sixteen MS patients with spasticity of triceps surae muscles were first subjected to BoNT-A therapy and,four months later,to 4 sections of rESWT.Patients were evaluated before,30,90 days after the end of the treatments,by using Modified Ashworth Scale(MAS),Modified Tardieu Scale(MTS)and kinematic analysis of passive and active ankle ROM.Results BoNT-A determined a significant reduction of spasticity evaluated by MAS with a reduction of positive effects after 4months(P<0.05);MTS highlighted the efficacy only 90 days after injection(P<0.05).rESWT decreased MAS values at the end and 30 days later the treatment(P<0.01);MTS values showed instead a prolonged effect(P<0.01).BoNT-A determined a gain of passive and active ankle ROM,persisting along with treatment and peaking the maximum value after rESWT(P<0.05).Conclusions rESWT can prolong BoNT-A effect inducing significant reduction of spasticity and improvement in passive and active ankle ROM in MS patients.The use of rESWT following BoNT-A injection is useful to avoid some limitations and to prolong the therapeutic effects of BoNT-A therapy.