Clinical Briefs

By Louis Kuritzky, MD

Injection of Botulinum Toxin for Wrist and Finger Spasticity after a Stroke

Post-stroke spasticity in the hands and wrists is potentially particularly disabling in that it may complicate basic essential daily activities like dressing, washing, and eating. There is a paucity of information about the role of botulinum toxin (BOT) on functional outcome in post-stroke spastic disorders.

Brashear and colleagues studied patients (n = 126) with post-stroke spasticity of the upper extremity. In addition to an overall global assessment, functional disability outcomes measured were hygiene, dressing, limb position, and pain. Each patient selected one of these 4 end points as their personal "principal target," though all parameters were measured for all subjects. Most patients selected "dressing" as the principle target, but more than one quarter chose limb position. Patients received a single set of 4-5 injections in wrist and finger muscles, or placebo. Outcomes were measured at 4, 6, 8, and 12 weeks.

More than twice as many persons who received BOT than those who received placebo achieved improvement in their primary target. For functional disability, BOT recipients’ improvements (at least 1 point on an 8-point scale) were again superior to placebo (83% vs 53%). The physician’s global assessment score was significantly higher for BOT at all follow-up visits. No serious adverse events were seen in either group.

Statistically significant and clinically meaningful improvements in upper extremity function are seen as early as 1 week after BOT injections and are maintained for at least 12 weeks. 

Brashear A, et al. N Engl J Med. 2002;346:395-400.

Prescribed Exercise in People with Fibromyalgia

The treatment offered for fibromyalgia (FMG)—typically consisting of analgesics, NSAIDs, and antidepressants, alone or in combination—often provides suboptimal efficacy. Although some trials of exercise have suggested a favorable effect on FMG, their widespread applicability to the ambulatory setting has been limited by underpowered study groups and provision of specialized exercise plans administered in hospitals by health professionals with special expertise in this field.

Richards and Scott investigated the effect of aerobic exercise (treadmill walking or exercise bicycles) or stretching/relaxation activities. Twice-weekly classes of aerobic activities began with two 6-minute sessions and were advanced as tolerated to 2 25-minute sessions over a 12-week observation period. The primary outcome was self-rated global impression, rated on a 7-point scale, with 1 being "very much worse" and 7 being "very much better." Only persons with a score of 6 or greater were considered responders.

The 108 participants were highly disabled at baseline, with a mean SF-36 score greater than 3 SD below normal, and two thirds were receiving disability benefits.

At 3 months, a statistically significantly greater portion of exercise subjects were responders than relaxation subjects (35% vs 18%). This beneficial effect was still measurable at 12 months. A substantial number of individuals were noncompliant: specifically, only 53% of subjects attended at least one third of the exercise classes. Accordingly, the authors do suggest that future investigation should evaluate methods to enhance compliance with exercise, given the favorable effects demonstrated in this trial. 

Richards SCM, Scott DL. BMJ. 2002; 325:185-187.

Risk of Diabetes Among Patients with Schizophrenia

The advent of newer anti- psychotic agents for schizophrenia has broadened the clinician’s therapeutic palette, with the additional benefit of fewer extrapyramidal adverse effects. Nonetheless, this pharmacotherapeutic evolution has introduced a different panel of adverse effects, such as weight gain, dyslipidemia, glucose perturbations, and cardiac toxicities. This study draws upon a very large database from 400 British general practice sites, including 3.5 million patients. The primary outcome was the quantification of risk of new onset diabetes in schizophrenic subjects who received newer antipsychotics, ie, olanzapine and risperidone.

Cases were defined as having been newly diagnosed with the diabetes at least 3 months after the beginning of the study period. Comparators were controls that did not have a diagnosis of diabetes. Study subjects were further classified as those receiving "conventional" antipsychotics or "newer" antipsychotics (olanzapine, risperidone).

Among 19,637 persons with schizophrenia from the study population, 451 cases of incident diabetes were discerned. Compared with matched controls, the odds ratio for diabetes among users of olanzapine was increased almost 6-fold, and was more than 4-fold greater than patients who had received "conventional" agents. There was no significant increase in risk for persons who took risperidone. Koro and colleagues conclude that the metabolic consequences of antipsychotics merit consideration by clinicians. 

Koro CE, et al. BMJ. 2002;325:243.

Dr. Kuritsky, Clinical Assistant Professor, University of Florida, Gainesville, is Associate Editor of Internal Medicine Alert.