Progress in Rehabilitation Medicine
Online ISSN : 2432-1354
ISSN-L : 2432-1354
Combined Extracorporeal Shock Wave Therapy and Botulinum Toxin Injection for Spasticity in the Acute Phase of Spinal Cord Injury: A Case Report
Maiko Nishimura, Risa Harada, Takumi Hirabayashi, Yuka Muranaka, Toshiki Usui, Mariko Nagase, Ryoga Kashima, Wataru Saho, Ryo Yoshikawa, Yoshitada Sakai
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Keywords: case-based evidence, early mobilization, motor impairment, multimodal therapy, neuromodulation
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2025 Volume 10 Article ID: 20250038

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ABSTRACT

Background: No standard treatment has been established for acute-phase spasticity after spinal cord injury (SCI). This case report demonstrates the impact of combining extracorporeal shock wave therapy (ESWT) and botulinum toxin administration on mobilization in the acute phase of SCI-associated spasticity.

Case: A man aged in his 50s was admitted to our hospital following a bicycle collision with an automobile. The patient was diagnosed with a non-ossifying cervical SCI without radiographic abnormality. Spasticity in both lower limbs impaired the patient’s ability to perform a standing movement and maintain a stable position. Considering the necessity of spasticity management, ESWT and botulinum toxin injection were administered.

Discussion: Range of motion (ROM) and Modified Ashworth Scale (MAS) score of the lower limbs, as well as the standing posture, were evaluated. After radical ESWT and botulinum toxin injection, both ROM and MAS improved. The patient gained the ability to maintain a standing position with the assistance of only one person and was able to sit stably without assistance.

Conclusions: The administration of ESWT and botulinum toxin injection during the acute care hospital stay for spasticity may be beneficial for promoting early mobilization.

INTRODUCTION

Spasticity is a consequence of upper motor neuron syndrome and a sensory-motor control disorder characterized by a velocity-dependent increase in muscle tone and exaggerated tendon jerks.1) Approximately two-thirds of patients develop spasticity after spinal cord injury (SCI). Spasticity requiring treatment for more than 1 year is more common in cervical injuries classified as American Spinal Injury Association Impairment Scale (AIS) B or C.2)

In addition to physical therapy, botulinum toxin injection is frequently used to treat spasticity. Botulinum toxins inhibit acetylcholine release by cleaving essential presynaptic proteins at the neuromuscular junction after neuronal uptake, thereby reducing muscle contraction.3) The use of extracorporeal shock wave therapy (ESWT), a noninvasive and effective treatment for localized musculoskeletal conditions,4) has become more frequent in the treatment of spasticity. Studies have demonstrated its effectiveness in improving Modified Ashworth Scale (MAS) score in patients with chronic stroke.5) Most patients with SCI develop spasticity within 1 month of onset and remain in the chronic phase.6) However, there is no standard treatment for acute-phase spasticity, with only case reports of botulinum toxin available.7) For ESWT, only limited cases have been reported in chronic SCI,8,9) and no use has been reported in the subacute or acute phases. We report the use of radial ESWT (rESWT) and botulinum toxin administration, combined with physical and occupational therapy, for the treatment of spasticity in the acute phase of SCI.

CASE

A man in his 50s was admitted to a university hospital following a bicycle collision with an automobile. He presented with sensory loss and muscle weakness in both the upper and lower limbs. T2-weighted magnetic resonance imaging revealed a high-signal area at C4-C5 of the cervical spine (Fig. 1). The patient was diagnosed with non-ossifying cervical SCI without radiographic abnormality; he was referred to the rehabilitation department 3 days after the injury.

Fig. 1.

Sagittal view of T2-weighted cervical spine MRI showing a high-signal area at C4-C5.

At the initial physical examination, Manual Muscle Testing (MMT) scores were (right/left): trapezius, 5/5; deltoid, 5/5; biceps brachii, 5/5; triceps brachii, 2/3; wrist extension, 2/3; wrist flexion, 2/3; finger extension, 1/3; finger flexion, 1/3; iliopsoas, 2/2; quadriceps femoris, 2/2; hamstrings, 2/2; and tibialis anterior, 1/5. MAS scores were (right/left): elbow extension, 0/0; wrist dorsiflexion, 0/0; finger extension, 0/0; hip flexion, 2/2; knee extension, 2/2; knee flexion, 3/2; and ankle dorsiflexion, 3/3. The neurological injury level was determined as C5, and the AIS classification was C. The Functional Independence Measure (FIM) score was 48, with the following subscores: self-care, 6; sphincter control, 2; transfers, 3; locomotion, 2; communication, 14; and social cognition, 21. Rehabilitation therapy was initiated 4 days after the injury. The orthopedic surgeon restricted the patient to a head-up position of at least 60 degrees with a cervical collar. Range of motion (ROM) and muscle-strengthening exercises were initiated in the supine position.

Seven days after the injury, posterior C3-C7 decompression and fixation were performed. Rehabilitation therapy was initiated 3 days after the operation (10 days after the injury) (Fig. 2). Mobilization was initiated by elevating the head. After confirming the absence of hypotension or subjective symptoms such as discomfort, the patient gradually progressed to sitting at the edge of the bed and then to standing. However, spasticity in both lower limbs, with intermittent strong muscle hypertonia in the direction of knee flexion, impaired the ability to stand and maintain stability. The following MMT scores were recorded for the lower limbs: iliopsoas, 2/4; quadriceps femoris, 2/2; hamstrings, 2/2; and tibialis anterior, 2/5. ROM and MAS results for the lower limbs are shown in Table 1.

Fig. 2.

Postoperative plain cervical spine X-ray images. (a) Anteroposterior view, (b) lateral view. Seven days after the injury, posterior C3-C7 decompression and fixation were performed.

Table 1. Progression of ROM and MAS in lower limbs

MeasurementSideAfter surgery
(day 10)		After rESWT
(day 28)		After botulinum toxin injection
(day 33)
ROM (°)
 Hip flexionRight9090100
Left9090100
 Hip extensionRight000
Left000
 Hip abductionRight5510
Left10515
 Knee flexionRight140140140
Left145145145
 Knee extensionRight−10−10−5
Left000
 Ankle dorsiflexionRight−20−10−5
Left−5−50
MAS
 Hip flexionRight333
Left321+
 Knee extensionRight333
Left321+
 Ankle dorsiflexionRight443
Left442

rESWT was initiated 17 days after injury for spasticity using the Swiss DolorClast Smart20 system (Electro Medical Systems, Nyon, Switzerland). A pressure of 2.5 bar was applied at 12 Hz to treat each muscular area. A total of 500 shots were administered to each hamstring and 1000 shots to each ankle plantar flexor bilaterally, twice a week before physical therapy. After rESWT, the standing movement temporarily became smoother but remained unstable because of equinus foot from lower-limb spasticity. The ROM and MAS results after rESWT are shown in Table 1.

To further manage spasticity, a botulinum toxin injection was administered 28 days after the injury, with a total dose of 200 units of incobotulinumtoxin A. The target muscles and injection doses were (right/left) (U): semitendinosus, 40/20; gastrocnemius, 60/40; and flexor digitorum longus, 20/20. After botulinum toxin injection, the frequency of knee flexion hypertonia decreased, and ankle dorsiflexion limitation was reduced. The patient was able to place both heels on the floor, and although assistance was still required, could maintain a stable standing position. The ROM and MAS results after botulinum toxin injection are shown in Table 1. Before transfer, the FIM score was 53, with the following subscores: self-care, 10; sphincter control, 2; transfers, 4; locomotion, 2; communication, 14; and social cognition, 21. The patient was transferred to a rehabilitation hospital 34 days after the injury.

Considering that the patient was unable to write because of finger paralysis, written consent was obtained from a surrogate. Given that this case report presents only treatments provided for clinical purposes, with no interventions performed for research, ethics committee approval was deemed unnecessary.

DISCUSSION

In the acute phase of SCI, the focus of treatment is on respiratory management, blood pressure control, and other critical aspects, with limited reports on spasticity.10) In this case, spasticity hindered mobilization, thereby prompting treatment. When evaluating spasticity improvement, the effects of natural recovery and physical and occupational therapy cannot be fully separated from those of rESWT and botulinum toxin injection. This limitation is unavoidable in rehabilitation and applies to the present report.

ESWT is thought to enhance nitric oxide (NO) production, which contributes to reducing spasticity. NO facilitates the formation of neuromuscular junctions, neurotransmission, memory formation, and synaptic plasticity.5) In addition, the high-energy waves of ESWT may affect muscle mechanical properties by disrupting actin–myosin cross-bridges, thereby reducing muscle contraction.11)

rESWT can improve MAS scores in patients with chronic and subacute stroke.5,12) Although rESWT has been reported in chronic SCI,8,9) its application in the acute phase has not been documented. The optimal parameters of rESWT have not been established, and findings vary across studies. Typically, pressure may range from 1.5 to 3.0 bar, frequency may range from 4 to 12 Hz, and pulses per muscle may reach 2000.11,13,14) In this case, rESWT was delivered at 2.5 bar and 12 Hz, with 500 shots/1000 shots per muscle. Pressure and frequency were determined based on previous reports.11,13,14) Although many studies have employed 1500–2000 shots, no application in acute SCI has been reported. Therefore, a relatively lower number of shots was applied for safety.

In this patient, adding rESWT to physical therapy facilitated smoother standing. However, severe spasticity of the ankle plantar flexors let to persistent equinus foot and an unstable standing position. To enhance spasticity management, botulinum toxin was also administered.

Botulinum toxin has been shown to reduce spasticity and improve MAS scores in patients with SCI and stroke.15,16) In subacute stroke, it reduces the incidence of spasticity and contracture without negatively impacting functional recovery,17) and in acute stroke with upper limb impairment, functional improvements have also been reported.18) In addition, combining botulinum toxin with ESWT has been shown to reduce spasticity and improve motor function in stroke patients.11) However, in acute SCI, existing reports are limited to case studies on botulinum toxin use for the upper limbs.7)

In the present case, we treated spasticity in a patient with acute SCI based on these findings. In Japan, botulinum toxin is rarely administered in convalescent rehabilitation wards because of reimbursement constraints. Therefore, treatment was provided at our university hospital during hospitalization. Figure 3 shows treatment progress and changes in ROM and MAS for ankle dorsiflexion. After rESWT, ROM improved, but MAS did not. Following botulinum toxin injection, both ROM and MAS improved. A comparison of standing positions during treatment is presented in Fig. 4. At the initiation of rehabilitation, two-person assistance was required to maintain standing. After rESWT, knee extension improved, and the center of gravity shifted forward. Slight improvement in ankle ROM facilitated this shift, whereas reduced hamstring hypertonia enabled greater quadriceps output. Following botulinum toxin injection, heel contact was achieved, allowing the patient to stand with only one-person assistance. Muscle hypertonia in the hamstrings and ankle plantar flexors was further reduced, decreasing the frequency of strong episodic hypertonia in knee flexion and enabling heel contact on the floor. At the initiation of rehabilitation, sitting was unstable and the patient required assistance to maintain a seated position. However, by the time of patient transfer, the patient could sit stably without assistance. Administering rESWT and botulinum toxin during acute care for spasticity, which hindered early mobilization, allowed more effective physical therapy and facilitated mobilization.

Fig. 3.

Clinical course with serial ROM and MAS assessments of ankle dorsiflexion. After rESWT, ROM improved, but MAS did not. Following botulinum toxin injection, both ROM and MAS improved. PT, physical therapy; OT, occupational therapy.

Fig. 4.

Photographs of standing training at different times during therapy. (a) After the operation (10 days after injury), two-person assistance was required to maintain a standing position. (b) After rESWT (21 days after injury), knee extension improved, and the center of gravity shifted forward. (c) After botulinum toxin injection (33 days after injury), heel contact on the floor was achieved, allowing the patient to maintain a standing position with only one-person assistance.

In previous studies on stroke and SCI, rESWT was most effective in cases with MAS scores below 4.9,13) In the present case, rESWT slightly reduced hamstring hypertonia with MAS 3, whereas no improvement was observed in the ankle plantar flexors with MAS 4. Although rESWT has been associated with changes in cell membrane permeability and NO production,19) the mechanisms underlying its antispastic effects remain unclear. rESWT may be useful for moderate spasticity; however, in severe cases where passive movement is nearly impossible, combined use of botulinum toxin may be necessary.

A limitation of this report, as mentioned earlier, is that the improvements in ROM, MAS, and motor function may not necessarily be attributable to rESWT and botulinum toxin, but rather to the natural course of recovery or to physical and occupational therapy. In this case, although ROM and MAS improved and the need for assistance in initiating and maintaining standing decreased, the patient still required help, and assessments such as the Standing Balance Scale and the Timed Up-and-Go test could not be performed. Furthermore, improvements in FIM were primarily attributed to the removal of activity restrictions, with the impact limited to a 1-point increase in the transfer item. Nevertheless, the reduction in required assistance was evident, and although the effect on measurable test items was small, the benefits of spasticity treatment for patients aiming at functional recovery are substantial. In addition, although orthotic devices can promote early mobilization, financial constraints precluded this patient from obtaining a custom orthosis. Combining orthotic therapy might have resulted in more effective outcomes.

CONCLUSION

For spasticity in the acute phase of SCI, combining rESWT and botulinum toxin administration alongside physical and occupational therapy enabled early mobilization and effective training during acute hospitalization. Administering rESWT and botulinum toxin during acute care for spasticity, which hinders mobilization, may be beneficial for promoting early recovery.

ACKNOWLEDGMENTS

The authors thank Editage (www.editage.com) for English language editing.

CONFLICTS OF INTEREST

The authors declare no conflict of interest.

REFERENCES
 
© 2025 The Japanese Association of Rehabilitation Medicine

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