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Botulinum Toxin: Advancing Treatments for Spasticity
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Botulinum Toxin: Advancing Treatments for Spasticity

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

Deadline for manuscript submissions: 30 June 2026 | Viewed by 6047

Special Issue Editors

Prof. Dr. Sheng Li

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Guest Editor
Department of Physical Medicine and Rehabilitation, University of Texas Health Science Center – Houston, Houston, TX 77030, USA
Interests: spasticity; motor recovery; neuromodulation; neuropathic pain; neurorehabilitation
Special Issues, Collections and Topics in MDPI journals
Prof. Dr. Ping Zhou

E-Mail
Guest Editor
Faculty of Biomedical and Rehabilitation Engineering, University of Health and Rehabilitation Sciences, Qingdao 266071, China
Interests: biomedical signal processing; motor unit; EMG; neuromuscular electrophysiology; neurorehabilitation; myoelectric control
Special Issues, Collections and Topics in MDPI journals
Prof. Dr. Rajiv Reebye

E-Mail Website
Guest Editor
Division of Physical Medicine & Rehabilitation, University of British Columbia, Vancouver, BC V6T 1Z4, Canada
Interests: botulinum toxin, spasticity management, ultrasound assessment, neurorehabilitation

Special Issue Information

Dear Colleagues,

Botulinum toxin (BoNT) has become the main treatment for spasticity of cerebral and spinal origins, such as stroke, brain injury, spinal cord injury, cerebral palsy, and multiple sclerosis. Although its efficacy in spasticity reduction has been established, especially in limb spasticity, BoNT treatment should be customized for individual patients to achieve the best possible clinical outcome.

For this Special Issue of Toxins, we welcome submissions of original research, case series, perspectives, and comprehensive reviews related to factors that can influence clinical decision making and clinical outcomes in BoNT treatment, including, but not limited to, the following:

  • How to set realistic and achievable goals in BoNT treatment;
  • How to optimize treatment plans if goals are not achieved;
  • Appropriate and additional target muscle selection in upper and lower limb focal spasticity treatment, as the clinical manifestations of spasticity are heterogenous, and the selection of target muscles should consider joint abnormality and the resultant kinetic malalignment, especially in the lower limb;
  • Exploring the adjunct therapies that can best optimize BoNT treatment effects, such as electrical stimulation, extracorporeal shock waves, or exoskeleton treatment;
  • Whether early BoNT treatment can facilitate neuroplasticity and facilitate functional recovery;
  • The effects of BoNT treatment on spastic muscles;
  • The importance of the use of ultrasound to help enhance the delivery of BoNT into spastic muscles, given that these muscles show some changes;
  • The monitoring of spastic muscles over time and after the chronic use of BoNT-A treatment;
  • How to assess and differentiate these effects via electromyographic and sonographic assessment;
  • Whether artificial intelligent models can predict BoNT treatment outcomes and guide and improve BoNT treatment.  

Prof. Dr. Sheng Li
Prof. Dr. Ping Zhou
Prof. Dr. Rajiv Reebye
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 250 words) can be sent to the Editorial Office for assessment.

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 toxin
  • spasticity
  • spastic muscles
  • electromyography (EMG)
  • ultrasound
  • neurorehabilitation

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Published Papers (4 papers)

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Research

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13 pages, 639 KB  
Article
Early Intervention of Hemiplegic Shoulder Pain in the Context of Post-Stroke Shoulder Spasticity: A Canadian Cross-Sectional Survey
by Farris Kassam, Fraser MacRae, Linden Lechner, Heather Dow, Ève Boissonnault, Fiona Huang and Paul Winston
Toxins 2026, 18(5), 228; https://doi.org/10.3390/toxins18050228 - 12 May 2026
Viewed by 417
Abstract
Objectives: To investigate current Canadian physicians’ practice patterns of treating upper limb post-stroke spasticity (PSS) and hemiplegic shoulder pain (HSP) acutely after a stroke. In addition, by examining Canadian physicians’ diagnostic capabilities, time till treatment, minimum criteria to begin treatment, mechanisms of treatment, [...] Read more.
Objectives: To investigate current Canadian physicians’ practice patterns of treating upper limb post-stroke spasticity (PSS) and hemiplegic shoulder pain (HSP) acutely after a stroke. In addition, by examining Canadian physicians’ diagnostic capabilities, time till treatment, minimum criteria to begin treatment, mechanisms of treatment, targeting of muscles, and benefits and adverse effects of treatment, we aim to learn about areas of improvement to optimize PSS management for Canadians. Design: The present study was a cross-sectional survey, polling practicing Canadian physicians. Results: A total of 17 physicians completed the survey, all PM&R specialists, save one neurologist. Four provinces were represented in the responses. Participants had, on average, over ten years of experience managing post-stroke spasticity in outpatient and inpatient clinics. All 17 perform botulinum neurotoxin A (BoNT-A) injections for HSP associated with PSS. Most participants reported that they will begin BoNT-A treatments 2–3 weeks post-stroke, most commonly targeting the pectoralis major, subscapularis, and latissimus dorsi. Participants reported the mean median dosage they use as onabotulinum toxin A (169.12 units, SD = 73.70), incobotulinum toxin A (178.13 units, SD = 65.75), and abobotulinum toxin A (470.83 units, SD = 171.17). For injection guidance, participants responded that they use ultrasound for the largest percentage of their caseload, followed by electromyography, then electrical stimulation, then palpation. Very seldom did participants use palpation alone. Conclusions: From the limited sample included in analyses, the Canadian physicians respondents seem to be treating HSP and associated PSS with variable strategies. Further research is required to align dosages, targets, and guidance strategies as they vary considerably. Full article
(This article belongs to the Special Issue Botulinum Toxin: Advancing Treatments for Spasticity)
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16 pages, 280 KB  
Article
Good Clinical Practices for the Management of Post-Stroke Spasticity with BoNT-A: A Delphi-Based Approach from the Italian Expert Group
by Alessio Baricich, Carmelo Chisari, Paolo De Blasiis, Marzia Millevolte, Alessandro Picelli, Andrea Santamato, Patrizia Maria Caglioni and Franco Molteni
Toxins 2026, 18(2), 94; https://doi.org/10.3390/toxins18020094 - 11 Feb 2026
Viewed by 1175
Abstract
Background: Post-stroke spasticity (PSS) is a common complication in stroke survivors, significantly impairing functional recovery and quality of life. Despite its prevalence, Italy lacks national guidelines or structured good clinical practice documents, resulting in heterogeneous clinical management. Methods: An Italian Delphi study was [...] Read more.
Background: Post-stroke spasticity (PSS) is a common complication in stroke survivors, significantly impairing functional recovery and quality of life. Despite its prevalence, Italy lacks national guidelines or structured good clinical practice documents, resulting in heterogeneous clinical management. Methods: An Italian Delphi study was conducted to establish expert-based recommendations for PSS management. A panel of 93 rehabilitation medicine specialists and neurologists, each with over 5 years of experience in PSS management with botulinum toxin A (BoNT-A), participated in two rounds of voting on 47 statements drafted and approved by seven Key Opinion Leaders (KOLs), recognized for their national and international expertise. Consensus was defined as ≥75% of respondents answering ‘strongly agree’ or ‘somewhat agree’. Results: In Round 1, consensus was reached for 90% of statements; five items did not achieve the threshold. After revision and a second round, consensus was achieved for all items, including consideration of lesion site in clinical management and the role of adjuvant post-injection interventions. The panel’s heterogeneity ensured broad representativeness. Conclusion: This Delphi study provides the first structured Italian expert recommendations for PSS management. Full consensus was reached in all 47 statements and in the Symptoms domain, particularly regarding pain, stiffness and heaviness, which highlights the importance of a structured framework to support consistent, individualized care. By standardizing patient assessment, treatment planning, and follow-up strategies, these findings provide a practical reference for clinicians. Full article
(This article belongs to the Special Issue Botulinum Toxin: Advancing Treatments for Spasticity)
12 pages, 438 KB  
Article
Early Botulinum Toxin Type A Injection May Improve Motor Recovery in Patients with Post-Stroke Spasticity: A Secondary Analysis from a Longitudinal Cohort Study
by Alessandro Picelli, Andrea Santamato, Michela Cosma, Alessio Baricich, Carmelo Chisari, Marzia Millevolte, Cristina Del Prete, Ilenia Mazzù, Rita Di Censo, Nicola Smania and Mirko Filippetti
Toxins 2025, 17(11), 558; https://doi.org/10.3390/toxins17110558 - 13 Nov 2025
Cited by 3 | Viewed by 2261
Abstract
Spasticity after stroke impairs motor control, delays recovery, and reduces quality of life. Botulinum toxin type A is the first-line treatment, but it is often administered in the chronic phase, potentially limiting its impact on rehabilitation. Emerging evidence suggests that earlier treatment may [...] Read more.
Spasticity after stroke impairs motor control, delays recovery, and reduces quality of life. Botulinum toxin type A is the first-line treatment, but it is often administered in the chronic phase, potentially limiting its impact on rehabilitation. Emerging evidence suggests that earlier treatment may enhance recovery, though functional benefits remain uncertain. We conducted a secondary analysis of a multicenter, open-label, longitudinal cohort study to investigate whether the timing of the first botulinum toxin type A injection influences outcomes in post-stroke patients naïve to this treatment. All participants received botulinum toxin injections combined with conventional rehabilitation. Assessments were performed at baseline and at 4, 12, and 24 weeks post-injection. The primary outcome was muscle tone; secondary outcomes included motor strength, sensorimotor recovery, and global disability. Statistical analyses used mixed-effects models and trend tests. Patients treated within 90 days of stroke onset showed greater reductions in spasticity at 4 and 12 weeks compared with later treatment. Despite having more severe baseline impairments, early treated patients demonstrated faster and more pronounced improvements in upper-limb strength, sensorimotor recovery, and global disability. Early toxin administration is associated with enhanced reduction in spasticity and improved motor recovery, particularly in patients with severe initial deficits. Full article
(This article belongs to the Special Issue Botulinum Toxin: Advancing Treatments for Spasticity)
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Review

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10 pages, 826 KB  
Review
Botulinum Toxin Treatment of Stiff Person Syndrome—A Critical Review and Update
by Ava Grace Tohidian, Samira Marie Comtesse, Shahroo Etemadmoghadam and Bahman Jabbari
Toxins 2026, 18(3), 130; https://doi.org/10.3390/toxins18030130 - 5 Mar 2026
Viewed by 1144
Abstract
Stiff person syndrome (SPS) is an autoimmune disorder with muscle stiffness and spasms, for which current therapies provide incomplete relief. Botulinum neurotoxin (BoNT) has been explored as an adjunctive symptomatic treatment. The aim of this review was to critically evaluate the clinical evidence [...] Read more.
Stiff person syndrome (SPS) is an autoimmune disorder with muscle stiffness and spasms, for which current therapies provide incomplete relief. Botulinum neurotoxin (BoNT) has been explored as an adjunctive symptomatic treatment. The aim of this review was to critically evaluate the clinical evidence for BoNT therapy in SPS. Using Medline, Scopus and Google Scholar, we identified nine reports that were published up to 1 January 2026. English articles and articles with information on study type, type/dose of BoNT and treatment results were included. One study was double-blind and placebo-controlled, one was retrospective and seven were single-case reports, comprising 46 patients. Open-label trials used botulinumtoxin-A (Botox, Dysport or Xeomin), while the blind study applied abobotulinumA (Dysport). All but one study (a case report) demonstrated motor improvement and a reduction in painful spasms associated with patient satisfaction. Reported doses ranged from 300 to 800 units for onabotulinumtoxinA and incobotulinumtoxinA and from 700 to 1000 units for abobotulinumtoxinA. The literature highlights the need for randomized clinical trials in larger cohorts, with careful selection of dose, injection sites, and adjunct physiotherapy, as well as an evaluation of early BoNT therapy in SPS. The novelty of this review lies in its critical synthesis of reported data and inclusion of most recent reports. Full article
(This article belongs to the Special Issue Botulinum Toxin: Advancing Treatments for Spasticity)
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