Combined botulinum toxin type A and electrical stimulation in individuals with C5–C6 and C6–C7 tetraplegia: a pilot study

Study design: Single-blind pilot study. Objectives: (1) To evaluate combined BoNT-A injection of spastic antagonistic muscles and ES of wrist extensors in order to improve hand function in incomplete cervical SCI patients. (2) To identify prognostic indicators of hand improvements, as a function of motor levels of injury. Setting: Ten incomplete asymmetric SCI tetraplegics admitted to San Camillo Hospital (Venezia, Italy), who were not able to perform automatic grasping, were enrolled in the study. A better motor level (BML) C6–C7 and worse motor level (WML) C5–C6 were assigned to take into account asymmetric motor strength. Methods: Administration of 100–200 UI BoNT-A per limb into flexor carpi radialis (FCR), extensor digitorum communis (EDC), brachial biceps (BB), and pectoralis major (PM) was performed. This was in conjunction with 6 weeks of 30-min ES sessions repeated three times a day for 6 days a week in wrist extensor muscles, and 6 weeks of 30-min hand rehabilitation for 6 days a week. Assessments included wrist Range of Motion (w-RoM), Modified Ashworth Score (MAS), Functional Independence Measure motor scores (FIM motor), and Nine Hole Peg Test (NHPT). Results: Treatments produced a significant reduction in motor spasticity (MAS) and better dexterity (NHPT) in the C6–C7 BML with respect to the WML cases (p level = 0.007; p = 0.01, respectively). FIM motor scores improved more in BML (median: 20; range 20/22) than in WML (median: 10; range 8/17). Conclusions: Hand function improvement, determined by combined BONT-A and ES, was better in C6–C7 than in C5–C6 SCI patients.