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Botulinum Toxin in Neuro-Rehabilitation: Expanding Horizons in Spasticity and Beyond
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Botulinum Toxin in Neuro-Rehabilitation: Expanding Horizons in Spasticity and Beyond

A special issue of Toxins (ISSN 2072-6651). This special issue belongs to the section "Bacterial Toxins".

Deadline for manuscript submissions: 31 January 2026 | Viewed by 5436

Special Issue Editors

Dr. Stefano Tamburin

E-Mail Website
Guest Editor
Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37100 Verona, Italy
Interests: pain; neurodegenerative disorders; movement disorders; neurorehabilitation
Special Issues, Collections and Topics in MDPI journals
Dr. Alessandro Picelli

E-Mail Website
Guest Editor
Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37100 Verona, Italy
Interests: botulinum toxins; muscle spasticity; movement disorders; rehabilitation; ultrasound
Special Issues, Collections and Topics in MDPI journals
Dr. Mirko Filippetti

E-Mail Website
Guest Editor
Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37100 Verona, Italy
Interests: botulinum toxins; muscle spasticity; pain; movement disorders; rehabilitation; ultrasound

Special Issue Information

Dear Colleagues,

This Special Issue, titled “Botulinum Toxin in Neuro-Rehabilitation: Expanding Horizons in Spasticity and Beyond”, will explore the evolving role of botulinum neurotoxin in neuro-rehabilitation practices. Current research highlights botulinum neurotoxin’s therapeutic potential beyond its traditional applications in managing spasticity, focusing on its effects on pain management, quality of life and other relevant outcomes in various neurological conditions characterized by spasticity. However, significant challenges remain, including optimizing dose, achieving better goals, developing strategies to pinpoint spasticity earlier and treating it sooner.

This Special Issue is devoted to all the above themes, with a particular focus on the fields of neurology, neurorehabilitation and pain medicine. Randomized controlled trials, original reports, innovative and informative case studies or series, systematic reviews and meta-analyses in human populations, as well as experimental studies in animal models, are all welcome.

Dr. Stefano Tamburin
Dr. Alessandro Picelli
Dr. Mirko Filippetti
Guest Editors

Manuscript Submission Information

Manuscripts should be submitted online at www.mdpi.com by registering and logging in to this website. Once you are registered, click here to go to the submission form. Manuscripts can be submitted until the deadline. All submissions that pass pre-check are peer-reviewed. Accepted papers will be published continuously in the journal (as soon as accepted) and will be listed together on the special issue website. Research articles, review articles as well as short communications are invited. For planned papers, a title and short abstract (about 100 words) can be sent to the Editorial Office for announcement on this website.

Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a double-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. Toxins is an international peer-reviewed open access monthly journal published by MDPI.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 2700 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

  • botulinum neurotoxin
  • neurology
  • neurorehabilitation
  • Parkinson’s disease
  • rehabilitation
  • dystonia
  • movement disorders
  • pain
  • stroke
  • spasticity

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Published Papers (4 papers)

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Research

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21 pages, 1391 KiB  
Article
Botulinum Neurotoxin A-Induced Muscle Morphology Changes in Children with Cerebral Palsy: A One-Year Follow-Up Study
by Charlotte Lambrechts, Nathalie De Beukelaer, Ines Vandekerckhove, Ineke Verreydt, Anke Andries, Francesco Cenni, Ghislaine Gayan-Ramirez, Kaat Desloovere and Anja Van Campenhout
Toxins 2025, 17(7), 327; https://doi.org/10.3390/toxins17070327 - 27 Jun 2025
Viewed by 172
Abstract
Botulinum neurotoxin type A (BoNT-A) is widely used to reduce spasticity in children with cerebral palsy. Despite its therapeutic benefits, incomplete muscle recovery has been observed post-treatment. This study evaluated longitudinal BoNT-A effects on muscle morphology over one year in children with CP [...] Read more.
Botulinum neurotoxin type A (BoNT-A) is widely used to reduce spasticity in children with cerebral palsy. Despite its therapeutic benefits, incomplete muscle recovery has been observed post-treatment. This study evaluated longitudinal BoNT-A effects on muscle morphology over one year in children with CP (n = 26, mean age: 5.19 years ± 3.26). Three-dimensional freehand ultrasound assessed medial gastrocnemius muscle volume (MV), muscle belly length (ML), cross-sectional area (CSA), and echo intensity (EI) at baseline and at 3, 6, and 12 months post-BoNT-A. Z-score normalization accounted for natural muscle growth. Linear mixed models analyzed muscular changes over time, and repeated-measures ANOVA compared muscle parameters to an age- and severity-matched control group (n = 26, mean age: 4.98 ± 2.15) at one-year follow-up. MV exhibited a declining trend at 3 (p = 0.005), 6 (p = 0.003), and 12 months (p = 0.007), while ML remained unchanged throughout follow-up (p = 0.95). The initially reduced CSA at 6 months (p = 0.0005) recovered at one year, and EI increased only at 3 months post-BoNT-A (p < 0.0001). At one-year follow-up, there was a trend for reduced growth rate (MV/month) (p = 0.035) in the intervention group, whereas the control group exhibited an increased muscle growth (p = 0.029). These findings suggest distinct recovery timelines for CSA and ML, which may explain the incomplete MV recovery and highlight substantial interindividual variation in recovery processes. Full article
(This article belongs to the Special Issue Botulinum Toxin in Neuro-Rehabilitation: Expanding Horizons in Spasticity and Beyond)
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Review

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27 pages, 6659 KiB  
Review
The Elias University Hospital Approach: A Visual Guide to Ultrasound-Guided Botulinum Toxin Injection in Spasticity: Part II—Proximal Upper Limb Muscles
by Marius Nicolae Popescu, Claudiu Căpeț, Cristina Beiu and Mihai Berteanu
Toxins 2025, 17(6), 276; https://doi.org/10.3390/toxins17060276 - 31 May 2025
Viewed by 584
Abstract
Ultrasound-guided botulinum toxin type A (BoNT-A) injections play a critical role in the management of upper limb spasticity. This is the second part of ‘The Elias University Hospital Approach: A Visual Guide to Ultrasound-Guided Botulinum Toxin Injection in Spasticity’ and it focuses on [...] Read more.
Ultrasound-guided botulinum toxin type A (BoNT-A) injections play a critical role in the management of upper limb spasticity. This is the second part of ‘The Elias University Hospital Approach: A Visual Guide to Ultrasound-Guided Botulinum Toxin Injection in Spasticity’ and it focuses on the proximal upper limb muscles, complementing the first part, which addressed the distal upper limb muscles. This guide provides a detailed analysis of ultrasound anatomy, clinical relevance, and injection strategies for the latissimus dorsi, teres major, subscapularis, pectoralis major, pectoralis minor, deltoid, triceps brachii, biceps brachii, brachialis, and brachioradialis. Using the Elias University Hospital (EUH) model, it presents a structured approach to BoNT-A administration, ensuring precision, safety, and optimal outcomes in spasticity management. To enhance clinical application, this guide incorporates a wide array of high-quality ultrasound images and dynamic videos, offering a comprehensive and practical understanding of scanning techniques, anatomical structures, and injection procedures. This second part of the series serves as an essential reference for clinicians, aligning with the first installment to provide a complete and systematic approach to ultrasound-guided BoNT-A therapy for upper limb spasticity. Full article
(This article belongs to the Special Issue Botulinum Toxin in Neuro-Rehabilitation: Expanding Horizons in Spasticity and Beyond)
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27 pages, 6183 KiB  
Review
The Elias University Hospital Approach: A Visual Guide to Ultrasound-Guided Botulinum Toxin Injection in Spasticity: Part I—Distal Upper Limb Muscles
by Marius Nicolae Popescu, Claudiu Căpeț, Cristina Beiu and Mihai Berteanu
Toxins 2025, 17(3), 107; https://doi.org/10.3390/toxins17030107 - 26 Feb 2025
Cited by 3 | Viewed by 1618
Abstract
Post-stroke spasticity significantly impairs upper limb function and quality of life. Ultrasound-guided botulinum toxin-A (BoNT-A) injections have become a cornerstone of management, enhancing precision and safety. This paper offers a comprehensive guide for clinicians on ultrasound-guided BoNT-A injections for distal upper limb muscles. [...] Read more.
Post-stroke spasticity significantly impairs upper limb function and quality of life. Ultrasound-guided botulinum toxin-A (BoNT-A) injections have become a cornerstone of management, enhancing precision and safety. This paper offers a comprehensive guide for clinicians on ultrasound-guided BoNT-A injections for distal upper limb muscles. Each muscle is detailed in terms of its role in spasticity management, ultrasound identification with key anatomical landmarks, clinical relevance, and injection strategies. Motor points, traditionally identified through anatomical studies or electromyography (EMG), are precisely localized using a musculoskeletal ultrasound by targeting the point of maximum muscle thickness, often corresponding to the motor point. The authors present their clinical method, developed at Elias University Hospital (EUH), to refine BoNT-A injection practices. This approach enhances efficacy, reduces dosage requirements, and improves patient outcomes. The paper also explores unique ultrasound characteristics of spastic muscles, such as their relationship with peripheral nerves, adjacent vascular and muscular structures, and intra- and intermuscular fascia, to guide clinicians in targeting functional muscle tissue. This guide is illustrated with representative ultrasound images and clinical diagrams and provides practical insights into anatomical relationships and injection techniques. Part I focuses on distal upper limb muscles, with Part II addressing proximal upper limb muscles. Full article
(This article belongs to the Special Issue Botulinum Toxin in Neuro-Rehabilitation: Expanding Horizons in Spasticity and Beyond)
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Other

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6 pages, 241 KiB  
Opinion
Does the Diffusion Profile Differ Between Botulinum Toxin Type a Formulations? Implications for the Management of Post-Stroke Spasticity
by Alessandro Picelli, Stefano Tamburin, Rita Di Censo, Nicola Smania and Mirko Filippetti
Toxins 2024, 16(11), 480; https://doi.org/10.3390/toxins16110480 - 7 Nov 2024
Viewed by 2583
Abstract
Botulinum toxin type A is a first-line treatment for post-stroke spasticity, with selective action at nerve endings and minimal effects beyond the injection site. However, concerns about potential adverse reactions due to toxin diffusion and spread can significantly influence physicians’ therapeutic decisions in [...] Read more.
Botulinum toxin type A is a first-line treatment for post-stroke spasticity, with selective action at nerve endings and minimal effects beyond the injection site. However, concerns about potential adverse reactions due to toxin diffusion and spread can significantly influence physicians’ therapeutic decisions in managing post-stroke spasticity. Current evidence shows that while the main formulations of botulinum toxin type A have different molecular weights and sizes, they do not exhibit differing diffusion profiles. Instead, the key factors determining botulinum toxin type A diffusion and spread in post-stroke spasticity management are the dose (i.e., the actual amount of 150 kDa neurotoxin protein injected), dilution, and injection volume. Other injection-related factors, such as the needle gauge and injection speed, have also been suggested to have a secondary influence on botulinum toxin type A diffusion and spread. The needs of patients with post-stroke spasticity may vary, and depending on treatment goals, botulinum toxin type A diffusion and spread can be something to avoid or may offer therapeutic benefits by reaching a greater number of nerve terminals in the target muscle, enhancing the toxin’s effect. These factors should be carefully evaluated in spasticity clinics. Full article
(This article belongs to the Special Issue Botulinum Toxin in Neuro-Rehabilitation: Expanding Horizons in Spasticity and Beyond)
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