Does preconditioning with serial casting prior to abobotulinumtoxinA injection improve outcomes in the rehabilitation of post-stroke wrist and finger flexor spasticity?

Post-stroke spasticity (PSS) affects up to 48% of stroke survivors, with disabling forms in about 18%. In the upper limb, 95% of cases show a flexor-dominant pattern. Botulinum toxin A (BoNT-A) is the treatment of choice, but adjunctive strategies such as serial casting may be used to enhance outcomes. To evaluate whether serial casting prior to abobotulinumtoxinA (AboBoNT-A) injections improves the reduction of wrist and finger flexor spasticity in subacute stroke survivors. In this prospective, randomized, two-center trial, 27 stroke patients with moderate wrist and finger flexor spasticity were allocated to one of two groups: SC + BoNT-A group (Group 1): serial casting for two weeks prior to AboBoNT-A injection (n = 14). BoNT-A group (Group 2): standard treatment with AboBoNT-A alone (n = 13). Both groups participated in an eight-week inpatient neurorehabilitation program. Spasticity and joint stiffness were assessed using the Modified Ashworth Scale (MAS) and the Modified Tardieu Scale (MTS). Additional validated outcome measures for stroke rehabilitation were also employed, including the passive Range of Motion (PROM), Wolf Motor Function Test (WMFT), Grip Strength, Barthel Index, Visual Analogue Scale for pain (VAS), and Stroke Impact Scale (SIS). Both groups showed improvements after BoNT-A. In the SC + BoNT-A group, MAS scores decreased and remained stable during follow-up. In the BoNT-A group, a recurrence of muscle stiffness was observed at week 6. Serial casting prior to BoNT-A was associated with a trend toward more sustained reduction of spasticity, but superiority over BoNT-A alone was not statistically confirmed.