30ournal of Neurology, Neurosurgery, and Psychiatry 1 996;61:30-35

Use of botulinum toxin in stroke patients withsevere upper limb spasticity

B B Bhakta, J A Cozens, JM Bamford, M A Chamberlain

Rheumatology andRehabilitationResearch Unit,University of Leeds,36 Clarendon Road,Leeds LS2 9NZ, UKB B BhaktaJ A CozensM A ChamberlainDepartment ofNeurology, St JamesUniversity Hospital,Beckett Street, Leeds,UKJM BamfordCorrespondence to:Dr B B Bhakta,Rheumatology andRehabilitation ResearchUnit, University of Leeds,36 Clarendon Road, LeedsLS2 9NZ UK.

Received 6 October 1995and in revised form12 January 1996Accepted 23 February 1996

AbstractObjectives-Spasticity can contribute topoor recovery of upper limb functionafter stroke. This is a preliminary evalua-tion of the impact of botulinum toxintreatment on disability caused by upper

limb spasticity after stroke.Methods-Seventeen patients with severe

spasticity and a non-functioning arm

were treated with intramuscular botu-linum A neurotoxin (median age at treat-ment 54'5 years; median time betweenonset of stroke and treatment 1-5 years).Baseline and assessments two weeks aftertreatment were compared to assess effi-cacy. The duration of improvement indisability was documented. Outcomemeasures used were: passive range ofmovement at the shoulder, elbow, wrist,and fingers; modified Ashworth scale toassess spasticity of biceps and forearmfinger flexors; an eight point scale toassess the degree of difficulty experiencedby the patient or carer for each functionalproblem defined before treatment; thepresence of upper limb pain. The biceps,forearm finger flexors, and flexor carpiulnaris were treated with intramuscularbotulinum toxin. Up to a total dose of400-1000 mouse units (MU) of Dysport(Speywood) or 100-200 MU of BOTOX®(Allergan) was used in each patient.Results-Functional problems reportedby the patients before treatment were dif-ficulty with cleaning the palm, cutting fin-gernails, putting the arm through a

sleeve, standing and walking balance,putting on gloves, and rolling over in bed.Hand hygiene improved in 14 of 17patients; difficulty with sleeves improvedin four of 16; standing and walking bal-ance improved in one of four; shoulderpain improved in six of nine; wrist painimproved in five of six. Passive range ofmovement at shoulder, elbow, and wristimproved after treatment. Benefit was

noted within two weeks and lasted one to11 months. No adverse effects occurred.Conclusion-This preliminary study sug-

gests that intramuscular botulinum toxinis a safe and effective treatment forreducing disability in patients with severe

upper limb spasticity.

(7 Neurol Neurosurg Psychiatry 1996;61:30-35)

Keywords: botulinum toxin; spasticity; stroke

Despite considerable rehabilitation effort, theprognosis for recovery of upper limb functionafter stroke remains poor. Of patients with aninitially paralysed arm, only 4% to 5% regainnormal function and up to 28% experience norecovery.' Because upper limb function isessential for many tasks of daily living, impair-ment contributes to reduced quality of life andincreases dependence. Even in patients withcomplete arm paralysis, spasticity can be animportant contributor to disability, by causingpain or interfering with hygiene and dressing.The mainstays of conventional treatment

for severe upper limb spasticity include phys-iotherapy and systemic medication (baclofenand dantrolene). Despite these treatments,many patients remain disabled due to thespasticity. Moreover, the amount of systemicantispastic medication required may causeadverse drug reactions such as drowsiness. Inaddition, unwanted generalised muscle weak-ness may further increase disability-forexample, reduction in ability to transfer orstand because of loss of tone in the hip andknee extensor muscles. To avoid these sys-temic effects local treatment with phenolicnerve and motor point blocks have been usedin patients with severe upper limb spasticity.2Although this treatment can be effective, itmay cause dysaesthesia and local tissue necro-sis in the treated arm. This treatment is cur-rently not recommended for upper limbspasticity when sensation is preserved.

Intramuscular botulinum toxin A offers thepossibility of local treatment of spasticitywithout affecting sensation. It is an estab-lished treatment for squint,3 blepharospasm,4hemifacial spasm,5 torticollis,6 and focal dys-tonias.7 More recently, it has been used totreat limb spasticity after stroke, traumaticbrain injury, and multiple sclerosis.8"Botulinum toxin irreversibly blocks the releaseof acetylcholine from the nerve endings at theneuromuscular junction. Unlike alcohol andphenol nerve blocks, it has a selective actionon motor nerves without affecting sensorynerve conduction. Preserved perception is anintegral part of maximising motor recoveryafter stroke and therefore treatments thatdo not cause sensory disturbance have a theo-retical advantage over non-specific local treat-ments.The aims of this open pilot study were: (1) to

identify the disabilities experienced by patientsas a consequence of severe upper limb spastic-ity after stroke, (2) to assess the impact oftreatment with botulinum toxin on impair-ments and disabilities using a new patient

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defined assessment, (3) to establish the safetyof treatment in this group of patients.

Materials and methodsAfter stroke the resultant upper limb impair-ments and disabilities vary considerably.Therefore, to make a meaningful assessmentof the impact of botulinum toxin, we treated arelatively homogeneous population. Patientswere recruited according to the following cri-teria: (1) stroke was the cause of the impair-ments, (2) severe upper limb spasticity wasaffecting self care and had not been improvedby conventional treatment such as physiother-apy, systemic antispastic medication, and useof orthoses, (3) there was absence of usefulupper limb movement, (4) no previous localantispastic treatment had been used, and (5)informed consent was obtained.

COHORTSeventeen patients (eight men, nine women)were recruited. Nine patients had right hemi-plegia. None of the patients had significantlanguage problems which affected compre-hension of the outcome assessments used inthis study. Median age at onset of stroke was54-5 (range 16.3-68.5) years. Median timebetween onset of stroke and treatment withbotulinum toxin was 1-5 (range 0O3-42 5)years. Fourteen patients had complete upperlimb paralysis. The remaining three had slightvoluntary muscle activity but the resultingmovement was not functionally useful. Inthese patients, the upper limb assumed aflexed posture at rest as a result of severe spas-ticity.

ASSESSMENTSBefore treatment and two weeks after treat-ment assessments of impairment and disabilitywere made. Patients were followed up untilthey reported loss of initial functional benefit.Some patients were having physiotherapy forother disability problems such as mobility andseating. Treatment for these concurrent prob-lems remained unaltered during this study.

TREATMENTThe treatment consisted of a single course of

intramuscular botulinum toxin to the bicepsbrachii, flexor digitorum profundus, flexordigitorum superficialis, and flexor carpiulnaris. The rationale for injecting these mus-cles is based on the clinical observation of theresting position of the upper limb in thesepatients. Spasticity in the biceps musclecaused the elbow to assume a flexed positionin 15 of 17 patients. In all patients there wasflexion at the proximal interphalangeal andmetacarpophalangeal joints as well as flexionof the wrist related to spasticity of the flexordigitorum superficialis. Flexor digitorum pro-fundus spasticity accounted for the flexion atthe distal interphalangeal joints in 16 of 17patients. In six of 17 patients the resting wristposition was not only flexed but also ulnardeviated suggesting that the flexor carpiulnaris was also involved. These muscles werelocalised by standard anatomical landmarks asused in needle EMG. Standard dilutions ofbotulinum toxin in normal saline as recom-mended in the drug information leaflets wereused. During the course of this study thepreparation of botulinum toxin available to uschanged. Initially Dysport (Speywood) andsubsequently BOTOX5 (Allergan) was used.The potency of both preparations is measuredusing a bioassay: one mouse unit (MU) is themedian lethal intraperitoneal dose for onemouse. The potency of the BOTOXt mouseunit and the Dysport mouse unit differ.Although there is no established ratio ofpotencies it is believed that I MU ofBOTOXtis equivalent to about 4-5 MU of Dysport.10In the present study, this equivalence ratio wasused to maintain similar doses of botulinumtoxin received by the patients. Dysport wasused at a dilution of 500 MU in 2-5 ml of nor-mal saline. BOTOXt was used at a dilution of100 MU in 2-5 ml. Table 1 shows the doses ofbotulinum toxin given to each muscle in eachpatient. Although the Ashworth scale wasused to judge spasticity before treatment, therewas a ceiling effect in some patients. This wasparticularly evident when rating spasticity inthe forearm finger flexors, as all the patientsfell into the highest category. Therefore inaddition to the Ashworth grading, the dosegiven to individual muscles was based on clini-cal impression of spasticity, which was judged

Table 1 Doses of botulinum toxin used in each muscle

Time between Dose of botulinum toxin used (MU) FunctionalAge at onset stroke and benefit after

Patient of stroke (y) treatment (y) Drug Biceps FDP FDS FCU Total dose treatment

1 53-5 0-4 Dysport 400 300 300 0 1000 Absent2 61-1 1-4 Dysport 200 100 100 100 500 Present3 47 4 1 1 Dysport 200 200 100 0 500 Present4 59-8 1 0 Dysport 200 150 100 0 450 Present5 42 0 5-0 Dysport 200 100 100 100 500 Present6 54-5 1 0 Dysport 200 100 100 100 500 Present7 31 5 11 2 Dysport 400 100 150 100 750 Present8 42 0 3 8 Dysport 100 150 150 0 400 Present9 47 6 1-5 Dysport 100 125 125 125 475 Present10 58-4 0 9 Dysport 200 100 100 100 500 Present11 43 1 0-6 Dysport 0 150 150 200 500 Present12 16 3 42 6 BOTOX® 80 50 50 0 180 Present13 68 5 10.0 BOTOX® 100 50 50 0 200 Present14 59-0 4-0 BOTOX® 0 50 50 0 100 Present15 55-0 3-5 BOTOX® 50 50 50 0 150 Absent16 58 8 2-0 BOTOX® 70 30 50 0 150 Absent17 60 9 0-3 BOTOX® 50 30 50 0 130 Present

FDP = flexor digitorum profundus; FDS - flexor digitorum superficialis; FCU = flexor carpi ulnaris.

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by the passive resistance to movement of thewrist, fingers, and elbow. The total dose perpatient did not exceed 1000 MU of Dysport or200 MU of BOTOXR.

MEASURING IMPAIRMENTThe modified Ashworth grading" was used toclinically assess spasticity of the biceps brachiiand the forearm finger flexors.

Range of passive joint movement at theshoulder, elbow, and wrist was measured byprotractor goniometry. There is no scale thatallows easy recording of the finger position inthese patients. A five point scale was thereforedevised to record finger position at rest and atmaximal passive finger extension. The scalingwas determined by the number of the asses-sor's fingers that could be easily inserted intothe subject's palm. The patient's fingers weredeemed to be fully extended when four fingerscould be placed on to the palm of the handwithout difficulty and fully flexed when evenone finger could not be easily inserted into thepalm (no fingers-fully closed; one finger-1/4open; two fingers-1/2 open; three fingers-3/4 open; four fingers-fully open). Thedegree of finger flexion was rated with thewrist in its resting position of palmar flexion.

Initially we attempted to use a visual ana-logue scale to determine the severity of painbut this was later abandoned as these patientshad difficulty in completing the scale.Subsequently the presence and location ofpain were recorded at rest and on passivemovement of the arm before and after treat-ment. Any change in pain reported by thepatient was documented.

MEASURING DISABILITYOur preliminary experience found the Barthelindex'2 to be insensitive to change in disabilityreported by patients. Therefore a patientdefined goals assessment was designed to mea-sure individual changes at the disability level,using specific self care problems selected bypatients. An item bank of self care activitieshad been developed by an open interview withthe patients. The patient or the carerdescribed the areas of difficulty with self carethat they considered were related to spasticityin the arm. For each of these identified prob-lems, the patient rated the degree of difficultyon a four point scale (1 = no difficulty; 2 = alittle difficulty; 3 = moderate difficulty; 4 = agreat deal of difficulty) before and after treat-ment. The carer completed the rating scale ifthe patient did not perform the identified selfcare task independently. This allowed docu-mentation of any change in the carer's "effort"needed for a particular activity.

STATISTICAL ANALYSISDescriptive data is given for changes in thefunctional assessments, the scoring of passiverange of finger movement, and change in painbefore and after treatment. Student's t test wasused to detect significant change in the rangeof joint movement. Wilcoxon non-parametricanalysis was used to analyse changes in spastic-ity as graded by the modified Ashworth scale.

ResultsIMPAIRMENTSBefore treatment, 16 of 17 patients had a modi-fied Ashworth rating of biceps spasticity of atleast 4. All patients had a modified Ashworthgrading of 5 for spasticity of the forearm fingerflexors. There was a significant improvement inthe grading of biceps spasticity after treatment(pretreatment median score 5, range 2-5; post-treatment median score 3, range 2-4; P =0 001). There was also a significant improve-ment in the grading of forearm finger flexorspasticity after treatment (pretreatment medianscore 5, range all 5; post-treatment medianscore 4, range 2-5; P = 0-005). It is notablethat four out of seven patients reportedimprovement in self care despite no change inthe Ashworth grading of forearm finger flexorspasticity.The mean range of passive shoulder abduc-

tionor adduction was 650 before treatment.The mean improvement after treatment was17° (95% confidence interval (95% CI) 7 2-26 4; P = 0 002), with four of the 17 patientshaving at least a 300 improvement in this range.The mean range of passive shoulder flexion andextension was 870 before treatment. The meanimprovement after treatment was 170 (95% CI-3-33; P = 0 09) with five out of 17 patientshaving at least a 300 improvement in this range.The mean range of passive elbow flexion andextension was 1130 before treatment. Themean improvement after treatment was 160(95% CI 7 2-28-8; P = 0 04) with three out of17 patients having at least a 300 improvementin this range. Before treatment, nine out of 17patients had a clinically fixed flexion deformity atthe elbow (mean flexion deformity, 430; rangeof flexion deformity 10°-80°). After treatment,the elbow could be fully passively extended infour out of these nine patients. The mean rangeof passive wrist dorsiflexion and palmar flexionwas 600 before treatment. The mean improve-ment after treatment was 310 (95% CI 20-1-43 4; P < 0 001) with nine out of 17 having atleast a 300 improvement in this range aftertreatment. In six out of 17 patients the wristcould not be passively dorsiflexed beyond neu-tral before treatment. After treatment in fourout of these six patients passive dorsiflexionbeyond neutral was possible.

Before treatment, 14 out of 17 patients hadflexed fingers at rest preventing easy insertionof one finger into the palm (fig 1) with none

Figure 1 Finger position of hemiplegic hand at rest,before, and after treatment.

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Table 2 The effect of botulinum toxin treatment on the functional difficulties reported bypatients or their carers

No ofpatientsNo ofpatients No ofpatients No with becomingreporting dependent on improvement independentdifficulty with carerfor the ) 2 grades of their carer

Type of activity the activity activity of difficulty for the activity

Cleaning palm ofaffected hand 17/17 13/17 13/17 5/13

Cutting finger nails ofaffected hand 17/17 13/17 10/17 2/13

Putting affected arm throughthe sleeve of shirt or coat 16/17 11/16 4/16 2/11

Standing balance 4/17 - 1/4Walking balance 3/17 - 0/3 -

Cleaning the armpit ofaffected arm 2/17 2/2 1/2 0/2

Putting glove onaffected hand 1/17 0/1 0/1 -

Tuming in bed 1/17 0/1 0/1

having sufficient range of passive extension ofthe fingers to allow easy placement of four fin-gers on the palm. After treatment not onlycould at least one finger be easily inserted intothe palm in 10 out of these 14 patients but alsoin 10 of the 17 patients full passive extension ofthe fingers was possible allowing easy place-ment of four fingers on the palm.

Shoulder pain on passive movement wasreported by nine out of 17 (53%) patientsbefore treatment. After treatment six out ofthese nine patients reported improvement,with complete resolution of shoulder pain intwo patients. Elbow pain on passive move-ment was reported by three out of 17 patientsbefore treatment. After treatment, all reportedimprovement in elbow pain. Wrist pain onpassive movement was reported by six out of17 patients before treatment. After treatment,this improved in five out of the six patients.

DISABILITIESTable 2 shows the activities that patientsreported difficulty with before treatment. This

.~~~~~~s.a~

Figure 3 Degree ofdifficulty puttinghemiplegic arm throughsleeves before and aftertreatment.

cr :I e- -C

table also shows the number of patients thatwere dependent on their carers for each partic-ular activity. All 17 patients had reported diffi-culty with cleaning the palm and cutting thefinger nails of the affected hand; 13 weredependent on their carer to carry out theseactivities. Sixteen of 17 had difficulty withputting the arm through the sleeve of a shirtor coat, and one in 17 had difficulty puttingon gloves. Three patients who could walkthought that spasticity in their arm causedelbow flexion while walking and this affectedbalance.

Overall, 14 of 17 patients reported somefunctional benefit after treatment with botu-linum toxin. Table 2 shows the number ofpatients who improved two or more levels ofdifficulty after treatment. To illustrate reduc-tion in dependence on the carer for the activi-ties described, figs 2 and 3 show the changesin difficulty with hand hygiene and putting thearm through sleeves in patients who weredependent on their carers for these activitiesbefore treatment. Five out of 13 patients whowere initially dependent on their carer to carryout hand hygiene became independent.Similarly two out of 11 patients who dependedon the carer to put their affected arm throughthe sleeve of a shirt or coat became indepen-dent.

FOLLOW UPIn the 14 patients who reported functionalbenefit, an effect was apparent two to threedays after treatment. Three patients whoreported benefit at two weeks after treatmentfailed to attend for continued follow up. In theremaining 11 patients, functional improve-ment lasted between four weeks and 47 weeks.Sensation in both arms was clinically assessedbefore and after treatment and no change wasnoted. No adverse effects, such as flu-likesymptoms and swallowing difficulties, werereported by any of the patients

.e:ratne DiscussionPr Sst - t rSec.a e r

- To fully assess the impact of local treatmentfor spasticity not only do changes in impair-ment have to be measured (for example,change in range of joint movement, clinicalgrading of spasticity, and pain), but also theeffects of treatment on disability. A prelimi-nary study of the use of botulinum toxin instroke patients with upper limb spasticity by

cil>tnCIE9K Hesse et all' showed that certain self care

activities such as hand hygiene did improve;however, little measurable effect was recordedon standardised functional assessments. We

;^il;)think that this disappointing conclusion arose'''J111!Ie&e .ES through the use of global assessments of motor

r-tr-ea--trnier- impairment and disability (Rivermead motor

PoC,, s-eatrnet score'4 and Barthel index'2) which are rela-

tively insensitive to the type of improvementreported by patients. Moreover, the secondaryeffects of spasticity such as shoulder, elbow, or

wrist joint pain (with consequent sleep distur-bance and depression) may be poorly reflectedin the impairment or disability scores used.

t)i erJ-de 1laC - m+ Although local treatment may be effective, it is

Figure 2 Degree ofdifficulty with handhygiene before and aftertreatment.

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often difficult to quantify improvement ifglobal assessments of function such as theBarthel index are used.

Patient defined goal assessments provide analternative to the standard global assessmentsto quantify change in specific functional abil-ity. The scale used in this study is based on theMACTAR ' which has been used to assess dis-ability in rheumatoid arthritis. The resultsshow that this scale can detect change in thedegree of difficulty experienced by patients orcarers in specific functional tasks. Althoughformal validation of this instrument is needed,the changes in difficulty reported by patientsor carers nevertheless suggest that botulinumtoxin may have a role in reducing specificupper limb disabilities. In addition, attainmentof independence in certain aspects of self careas defined by the patient (for example, handhygiene, putting affected arm through sleeves)can be achieved and are detected using thisinstrument.

Periarticular pain was also improved insome patients after treatment. Relief of severespasticity of the biceps and forearm fingerflexor muscles, and increased mobility of thejoints are likely to contribute to pain reliefafter treatment. During this study, we alsofound that determining the amount of fixedshortening (contracture) in spastic musclescan be difficult as shown by improvement inrange of passive elbow movement in patientswho were previously considered to have a"fixed" flexion deformity.As well as the local beneficial effects men-

tioned, improvement also occurred distant tothe site of injection, as shown by the improve-ment in range of shoulder movement andrelief of shoulder pain. Possible explanationsfor this improvement include: (1) local diffu-sion of toxin across fascial planes as occursafter its use in torticollisl" and (2) systemiceffects. In vitro studies have shown retrogradeaxonal flow of botulinum toxin'7 along thenerve fibre suggesting that spinal mechanismsmay also be involved in the distant effect.'8

There is risk of unwanted muscle weaknessafter botulinum toxin treatment. This ismainly related to local diffusion of toxin acrossmuscle fascial boundaries although systemictoxin spread should not be excluded.Significant clinical adverse effects (dysphagia)can occur when botulinum toxin is used forthe treatment of torticollis. This effect mainlyrelates to the close proximity of the treatedmuscles to those involved in swallowing. Nosuch problems were reported in the patientstreated in this study, indicating that total dosesup to 1000 MU of Dysport and 200 MU ofBOTOXR may be safely given for upper limbspasticity.

Previous studies with botulinum toxin intorticollis suggest that the treatment effectusually lasts between three and six months. Inthis preliminary study some patients had func-tional benefit after treatment that apparentlyoutlasted the "drug effect". Patient 9 (table 1)had continued functional benefit which lasted47 weeks. We think that the prolonged treat-ment effect was related to a vigorous self exer-

cise programme instituted by the patient her-self. It was sometimes difficult to control forself initiated exercise programmes, as thepatients who noticed improvement tended tocarry out arm mobilisation exercises. This sug-gests that botulinum toxin may offer a windowof opportunity to allow a passive mobilisationexercise programme to be instituted to main-tain functional gains made after treatment.Clearly we need to explore this phenomenonfurther to capitalise on functional benefitgained after this treatment. It might beexpected that the greatest impact would occurif botulinum toxin treatment was given earlierafter stroke rather than later. Four out of 17patients were treated within one year of strokeonset. One patient reported no reduction indisability. The other three patients had func-tional benefit lasting between four and 16weeks. Three out of 17 patients were treatedmore than 10 years after their stroke and allshowed benefit lasting between six and 10weeks. Although from these limited data it isnot possible to conclude that early treatment islikely to be more efficacious, we suspect thatbotulinum toxin has a role in the rehabilitationof the spastic upper limb during the earlystages of rehabilitation as an adjunct to physio-therapy and occupational therapy, particularlywhen spasticity hinders arm function inpatients with active upper limb movement.

This preliminary open study suggests thatbotulinum toxin is a safe and effective treat-ment for spasticity in this group of patients.Upper limb disability and pain can bereduced. Distant beneficial effects are alsofound. Validation of the patient oriented goalassessment is being carried out so that morerobust statistical analysis can be applied. Arandomised placebo controlled study isplanned. There is clearly a need to measurespasticity more accurately and relate it to diffi-culty with specific activities including selfcare. Also, activities that cause increases inupper limb spasticity, such as walking andwheelchair propulsion, need to be exploredfurther.

1 Gowland C. Management of hemiplegic upper limb. In:Brandstater ME, Basmajian JV, eds. Stroke rehabilitatioon.Baltimore: Williams and Wilkins, 1987:217-45.

2 Skeil DA, Barnes MP. The local treatment of spasticity.Clin Rehabil 1994;8:240-6.

3 Scott AB. Botulinum toxin injection of eye muscles to cor-rect strabismus. Tranis Am Ophthalmol Soc 1981;79:734-70.

4 Scott AB, Kennedy RA, Stubbs HA. Botulinum toxininjection as a treatment for blepharospasm. ArchOphthalmol 1985;103:347-50.

5 Flanders M, Chin D, Boghen D. Botulinum toxin: pre-ferred treatment for hemifacial spasm. Eur Neurol 1993;33;316-9.

6 Anderson TJ, Rivest J, Stell R, et al. Botulinum toxin treat-ment of spasmodic torticollis. _7 R Soc Med 1992;85:524-9.

7 Jankovics J. Botulinum toxin in movement disorders.Current Opinions in Neurology 1994;7:358-66.

8 Das TK, Park DM. Effect of treatment with botulinumtoxin on spasticity. Postgrad Med_ 1989;65:208-10.

9 Snow BJ, Tsui JK, Bhatt MH, Varelas M, Hashimoto SA,Calne DB. Treatment of spasticity with botulinum toxin:a double blind study. Ann Neurol 1990;28:512-5.

10 Borodic GE. Botulinum toxin potency: a mystery resolvedby the median paralysis unit. 7 R Coll Phys 1994;87:571-2.

11 Bohannon RW, Smith MB: Interrater reliability of a modi-fied Ashworth scale of muscle spasticity. Phys Ther 1987;67:206-7.

12 Mahoney Fl, Barthel DW. Functional evaluation: theBarthel index. MD Med 37 1965;14:61-5.

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13 Hesse S, Friedrich H, Domasch C, Mauritz K. Botulinumtoxin therapy for upper limb flexor spasticity: preliminaryresults. J Rehabil Sci 19925:98-101.

14 Lincoln N, Leadbitter D. Assessment of motor function instroke patients. Physiotherapy 1979;65:48-51.

15 Tugwell P, Bombardier C, Buchanan WW, GoldsmithCH, Grace E, Hanna B. The MACTAR patient prefer-ence disability questionnaire-an individualised func-tional priority approach for assessing improvement inphysical disability in clinical trials in rheumatoid arthritis.J Rheumatol 1987;14:446-5 1.

16 Borodic GE, Joseph M, Fay L, Cozzolino D, Ferrante R.Botulinum toxin A for the treatment of spasmodic torti-collis: dysphagia and regional toxin spread. Head Neck1990;12:392-8.

17 Weigand H, Erdmann G, Wellhoner HH. '5I-labelled botu-linum A neurotoxin: pharmocokinetics in cats, afterintramuscular injection. Naunyn Schmiedebergs ArchPharmacol 1976,292: 161-5.

18 Gamer CG, Strube A, Witt TN, Gasser T, Oetal WH.Time course of distant effects of local injections of botu-linum toxin. Mov disord 1993;8:33-7.

I suppose sciatica can be regarded as part of the neu-rologist's remit. Bennett is probably describing an SIroot syndrome. Many treatment options have beenadvanced for back pain. That used on Grigory appearsremarkably successful-perhaps the fact that the secretmedicine was laced with vodka had something to dowith it!

Laurence Sterne, 1759, The life and opinions ofTristram Shandy gentlemanAnd how goes it with Thy Concubine-thy wife-andthy little ones o' both sides? And when did you hearfrom the old gentleman and Lady-your sister, aunt,uncle and cousins-I hope they have got better of theircolds, coughs, claps, tooth-aches, fevers, stranguries,sciaticas, swellings, and sore eyes.

Fydodor Dostoyevsky, 1880, The brothers KaramazovAnd she treats Grigory with this secret medicine ofhers three times a year, Sir, every time his lumbagogets so bad that he can't move, just as though he wasparalyzed, Sir. Yes, Sir, three times a year. When thishappens, she takes a towel, dips it in the infusion andrubs his back with it for half an hour, till it's bone dryand goes quite red and swollen. Then what's left over inthe bottle she gives him to drink with a special prayer,Sir. Not all of it, though, for she leaves a drop or twoover for herself, seeing as how it's such a rare occasion,Sir, and she drinks it, too. And both being strictly tee-total, Sir, they just drops off and they sleeps verysoundly for a very long time. When Grigory wakes up,he's almost always well after it, but when Marfa wakes

up she always has a headache from it, Sir ...

But quite unexpectedly Grigory woke up in thenight, lay awake thinking for a moment and, though heimmediately felt a sharp pain in the small of his back,sat up in bed.

Edith Wharton, 1911, Ethan Frome"Mr Hale? Why, yes, you'll find him down home now.He ain't going to his work this forenoon. He woke upwith a touch o' lumbago, and I just made him put onone of old Dr Kidder's plasters and set right up intothe fire."

Arnold Bennet, 1911, Hilda LesswaysShe had three genuine complaints, rheumatism, sciat-ica, and neuritis; they were all painful. The latest andworst was the neuritis, which had attacked her inthe wrist, producing swollen joints that had to befomented with hot water ...On the previous day she had been sitting on the cold

new oilcloth of the topmost stairs, minutely instructinga maid in the craft of polishing banisters. And the nextmorning an attack of acute sciatica had supervened.For a trifling indiscretion Sarah was thus condemnedto extreme physical torture. Hilda had found her rigidon the bed. She suffered the severest pain in the small ofthe back and all down the left leg.

G D PERKINRegional Neurosciences Centre,

Charing Cross Hospital,Fulham Palace Road,London W6 8RF, UK

NEUROLOGY IN LITERATURE

Sciatica

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