{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,13]],"date-time":"2026-10-13T03:34:46Z","timestamp":1791862486807,"version":"4.3.4"},"reference-count":64,"publisher":"MDPI AG","issue":"1","license":[{"start":{"date-parts":[[2026,1,19]],"date-time":"2026-01-19T00:00:00Z","timestamp":1768780800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Ipsen PLC"},{"name":"London North West University Healthcare NHS Trust Charitable funds"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Toxins"],"abstract":"<jats:p>Improvement in passive function (i.e., ease of caring for a limb) is a common goal for treatment of spasticity in the arm with botulinum toxin. A large international, observational, 2-year longitudinal study (ULIS-III, N = 953) was conducted in real-life practice. This original secondary analysis examines whether improvement in passive function goals were met over repeated injection cycles. We report changes by cycle measured by the Passive Function sub-scale of the Arm Activity measure (ArmA-PF) and examine predictors of improvement and injection occurrence. Inclusion in this analysis was based on passive function being selected as a primary or secondary goal for one or more cycle of treatment (n = 542\/953). Goals were assessed at the start and end of each cycle using the Goal Attainment Test score and the ArmA-PF. Over all cycles of treatment, goals were set for 1641\/2187 injections (75.0%) and achieved in 1250 (76.2%). Significant improvements in ArmA-PF score were identified for at least six cycles (p &lt; 0.001) with evidence of cumulative benefit over successive cycles. This occurred regardless of patient-related baseline characteristics, with the possible exception of some relationship with injection localization techniques. In conclusion, repeated botulinum toxin injections provide significant improvement in passive function, which was sustained over repeated cycles of treatment.<\/jats:p>","DOI":"10.3390\/toxins18010051","type":"journal-article","created":{"date-parts":[[2026,1,19]],"date-time":"2026-01-19T11:35:27Z","timestamp":1768822527000},"page":"51","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":3,"title":["Longitudinal, Multi-Cycle Evaluation of Passive Function Improvement in People with Arm Spasticity Treated with Botulinum Toxin A"],"prefix":"10.3390","volume":"18","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-5541-7063","authenticated-orcid":false,"given":"Stephen A.","family":"Ashford","sequence":"first","affiliation":[{"name":"Department of Palliative Care, Policy and Rehabilitation, Cicely Saunders Institute, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King\u2019s College London, London SE5 9RS, UK"},{"name":"Regional Hyper-Acute Rehabilitation Unit, Northwick Park Hospital, London North West University Healthcare, London HA1 3UJ, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9623-9723","authenticated-orcid":false,"given":"Khan","family":"Buchwald","sequence":"additional","affiliation":[{"name":"School of Clinical Sciences, Faculty of Health and Environmental Science, Auckland University of Technology, Auckland 0627, New Zealand"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6508-5055","authenticated-orcid":false,"given":"Klemens","family":"Fheodoroff","sequence":"additional","affiliation":[{"name":"Neurorehabilitation, Gailtal-Klinik, 9620 Hermagor, Austria"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3428-2312","authenticated-orcid":false,"given":"Jorge","family":"Jacinto","sequence":"additional","affiliation":[{"name":"Centro de Medicina de Reabilita\u00e7\u00e3ode Alcoit\u00e3o, Servi\u00e7o de Reabilita\u00e7\u00e3o de adultos 3, 2649-506 Estoril, Portugal"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3075-7672","authenticated-orcid":false,"given":"Ajit","family":"Narayanan","sequence":"additional","affiliation":[{"name":"School of Engineering, Computer and Mathematical Sciences, Auckland University of Technology, Auckland 1010, New Zealand"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Richard J.","family":"Siegert","sequence":"additional","affiliation":[{"name":"Department of Psychology and Neuroscience, Faculty of Health and Environmental Science, Auckland University of Technology, Auckland 0627, New Zealand"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christian","family":"Hannes","sequence":"additional","affiliation":[{"name":"Ipsen, 81677 Munich, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3302-9462","authenticated-orcid":false,"given":"Lynne","family":"Turner-Stokes","sequence":"additional","affiliation":[{"name":"Department of Palliative Care, Policy and Rehabilitation, Cicely Saunders Institute, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King\u2019s College London, London SE5 9RS, UK"},{"name":"Regional Hyper-Acute Rehabilitation Unit, Northwick Park Hospital, London North West University Healthcare, London HA1 3UJ, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,1,19]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"74","DOI":"10.1111\/j.1468-1331.2010.03129.x","article-title":"Botulinum toxin assessment, intervention and after-care for upper limb hypertonicity in adults: International consensus statement","volume":"17","author":"Sheean","year":"2010","journal-title":"Eur. J. Neurol."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"354906","DOI":"10.1155\/2014\/354906","article-title":"Pathophysiology of spasticity: Implications for neurorehabilitation","volume":"2014","author":"Trompetto","year":"2014","journal-title":"Biomed. Res. Int."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"3329","DOI":"10.1161\/STROKEAHA.108.518563","article-title":"The prevalence of joint contractures, pressure sores, painful shoulder, other pain, falls, and depression in the year after a severely disabling stroke","volume":"39","author":"Sackley","year":"2008","journal-title":"Stroke"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"184","DOI":"10.1177\/0269215510381620","article-title":"Spasticity and contractures at the wrist after stroke: Time course of development and their association with functional recovery of the upper limb","volume":"25","author":"Malhotra","year":"2011","journal-title":"Clin. Rehabil."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"41","DOI":"10.1016\/S1836-9553(12)70071-1","article-title":"Half of the adults who present to hospital with stroke develop at least one contracture within six months: An observational study","volume":"58","author":"Kwah","year":"2012","journal-title":"J. Physiother."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"24","DOI":"10.1002\/pri.36","article-title":"Goal attainment for spasticity management using botulinum toxin","volume":"11","author":"Ashford","year":"2006","journal-title":"Physiother. Res. Int."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"799","DOI":"10.1016\/j.apmr.2008.01.007","article-title":"Repeated treatments with botulinum toxin type a produce sustained decreases in the limitations associated with focal upper-limb poststroke spasticity for caregivers and patients","volume":"89","author":"Elovic","year":"2008","journal-title":"Arch. Phys. Med. Rehabil."},{"key":"ref_8","first-page":"827","article-title":"Spastic hypertonia and movement disorders: Pathophysiology, clinical presentation, and quantification","volume":"1","author":"Sheean","year":"2009","journal-title":"Phys. Med. Rehabil."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"992","DOI":"10.1016\/S1474-4422(15)00216-1","article-title":"Safety and efficacy of abobotulinumtoxinA for hemiparesis in adults with upper limb spasticity after stroke or traumatic brain injury: A double-blind randomised controlled trial","volume":"14","author":"Gracies","year":"2015","journal-title":"Lancet Neurol."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"415","DOI":"10.1002\/mus.24776","article-title":"Randomized, placebo-controlled trial of incobotulinumtoxina for upper-limb post-stroke spasticity","volume":"53","author":"Elovic","year":"2016","journal-title":"Muscle Nerve"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"380","DOI":"10.1136\/jnnp.2008.159657","article-title":"Botulinum neurotoxin versus tizanidine in upper limb spasticity: A placebo-controlled study","volume":"80","author":"Simpson","year":"2009","journal-title":"J. Neurol. Neurosurg. Psychiatry"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"1703","DOI":"10.1016\/j.apmr.2019.01.016","article-title":"Effectiveness of Botulinum Toxin Treatment for Upper Limb Spasticity Poststroke Over Different ICF Domains: A Systematic Review and Meta-Analysis","volume":"100","author":"Andringa","year":"2019","journal-title":"Arch. Phys. Med. Rehabil."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"13","DOI":"10.2340\/16501977-0303","article-title":"European consensus table on the use of botulinum toxin type A in adult spasticity","volume":"41","author":"Wissel","year":"2009","journal-title":"J. Rehabil. Med."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"1818","DOI":"10.1212\/WNL.0000000000002560","article-title":"Practice guideline update summary: Botulinum neurotoxin for the treatment of blepharospasm, cervical dystonia, adult spasticity, and headache: Report of the Guideline Development Subcommittee of the American Academy of Neurology","volume":"86","author":"Simpson","year":"2016","journal-title":"Neurology"},{"key":"ref_15","unstructured":"Ashford, S.A., and Turner-Stokes, L. (2018). Spasticity in Adults: Management Using Botulinum Toxin. National Guidelines, Royal College of Physicians. [2nd ed.]."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"845","DOI":"10.1136\/jnnp.2006.103341","article-title":"Treatment of shoulder pain in spastic hemiplegia by reducing spasticity of the subscapular muscle: A randomised, double blind, placebo controlled study of botulinum toxin A","volume":"78","author":"Yelnik","year":"2007","journal-title":"J. Neurol. Neurosurg. Psychiatry"},{"key":"ref_17","first-page":"771","article-title":"Botulinum treatment of spasticity: Why is it difficult to show a functional benefit?","volume":"14","author":"Sheean","year":"2001","journal-title":"Trauma Rehabil."},{"key":"ref_18","unstructured":"Ashford, S. (2023). Spasticity: When and How to Treat the Clinical Problem in Neurological Rehabilitation. Physical Management for Neurological Conditions, Elsevier. [5th ed.]."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"jrm42605","DOI":"10.2340\/jrm.v57.42605","article-title":"Muscle selection and dosing in patients undergoing treatment with abobotulinumtoxinA for lower limb spasticity in real world practice","volume":"57","author":"Ashford","year":"2025","journal-title":"J. Rehabil. Med."},{"key":"ref_20","first-page":"100","article-title":"Turner-StokesAnalysis of Goal Setting and Physical Treatment for Focal Spasticity Following Stroke or Other Brain Injury","volume":"19","author":"Ashford","year":"2024","journal-title":"Int. J. Stoke."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"560","DOI":"10.1212\/WNL.94.15_supplement.560","article-title":"An International, Multicenter, Observational, Longitudinal Study to Assess the Effectiveness of AbobotulinumtoxinA Injections for Adult Lower Limb Spasticity: The AboLiSH Study (560)","volume":"94","author":"Esquenazi","year":"2020","journal-title":"Neurology"},{"key":"ref_22","first-page":"S698","article-title":"Identifying and Managing Spasticity in Neurological Shoulder Dysfunction","volume":"39","author":"Hoad","year":"2024","journal-title":"Mov. Disord."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"44","DOI":"10.1016\/S0885-3924(00)00146-9","article-title":"Management of spasticity associated pain with botulinum toxin A","volume":"20","author":"Wissel","year":"2000","journal-title":"J. Pain. Symptom Manag."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"jrm00133","DOI":"10.2340\/16501977-2770","article-title":"Assessing the effectiveness of upper-limb spasticity management using a structured approach to goal-setting and outcome measurement: First cycle results from the ULIS-III Study","volume":"53","author":"Jacinto","year":"2021","journal-title":"J. Rehabil. Med."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"jrm00157","DOI":"10.2340\/16501977-2801","article-title":"Longitudinal goal attainment with integrated upper limb spasticity management including repeat injections of botulinum toxin A: Findings from the prospective, observational Upper Limb International Spasticity (ULIS-III) cohort study","volume":"53","author":"Jacinto","year":"2021","journal-title":"J. Rehabil. Med."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"443","DOI":"10.1007\/BF01530764","article-title":"Goal attainment scaling: A general method of evaluating comprehensive mental health programmes","volume":"4","author":"Kiresuk","year":"1968","journal-title":"Community Ment. Health J."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"362","DOI":"10.1177\/0269215508101742","article-title":"Goal attainment scaling in rehabilitation; a practical guide","volume":"23","year":"2009","journal-title":"Clin. Rehabil."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"253","DOI":"10.1080\/096020199389365","article-title":"Goal Attainment Scaling in Rehabilitation 9(3\u20134)","volume":"9","author":"Malec","year":"1999","journal-title":"Neuropsychol. Rehabil."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"352","DOI":"10.1177\/0269215508101741","article-title":"Writing SMART rehabilitation goals and achieving goal attainment scaling: A practical guide","volume":"23","author":"Botell","year":"2009","journal-title":"Clin. Rehabil."},{"key":"ref_30","doi-asserted-by":"crossref","unstructured":"Siegert, R.J., and Levack, W. (2014). Goal Attainment Scaling (GAS) in adult neurorehabilitation. Rehabilitation Goal Setting: Theory Practice Evidence, Taylor and Francis.","DOI":"10.1201\/b17166"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"661","DOI":"10.1080\/09602011.2014.901228","article-title":"Goal attainment scaling in brain injury rehabilitation: Strengths, limitations and recommendations for future applications","volume":"24","author":"Grant","year":"2014","journal-title":"Neuropsychol. Rehabil."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"jrm6498","DOI":"10.2340\/jrm.v55.6498","article-title":"Goal Attainment Scaling in rehabilitation: An educational review providing a comprehensive didactical tool box for implementing Goal Attainment Scaling","volume":"55","author":"Villepinte","year":"2023","journal-title":"J. Rehabil. Med."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"617","DOI":"10.1177\/0269215515593391","article-title":"Common goal areas in the treatment of upper limb spasticity: A multicentre analysis","volume":"30","author":"Ashford","year":"2016","journal-title":"Clin. Rehabil."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"1412","DOI":"10.1212\/WNL.0000000000208540","article-title":"Longitudinal Goal Attainment Across Four Consecutive Botulinum Toxin Treatment Cycles in Adults with Upper Limb Spasticity (P7-4.001)","volume":"104","author":"Jacinto","year":"2025","journal-title":"Neurology"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"1583","DOI":"10.1080\/09638280701618828","article-title":"Goal attainment scaling: Current methodological challenges","volume":"29","author":"Tennant","year":"2007","journal-title":"Disabil. Rehabil."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"1","DOI":"10.3310\/hta14260","article-title":"BoTULS: A multicentre randomised controlled trial to evaluate the clinical effectiveness and cost-effectiveness of treating upper limb spasticity due to stroke with botulinum toxin type A","volume":"14","author":"Shaw","year":"2010","journal-title":"Health Technol. Assess."},{"key":"ref_37","unstructured":"Royal College of Physicians, and British Society of Rehabilitation Medicine, The Chartered Society of Physiotherapy, Association of Chartered Physiotherapists in Neurology and the Royal College of Occupational Therapists (2009). Spasticity in Adults: Management Using Botulinum Toxin\u2014National Guidelines, Royal College of Physicians, Clinical Effectiveness and Evaluation Unit."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"1513","DOI":"10.3109\/09638288.2012.743602","article-title":"Conceptualisation and development of the Arm Activity measure (ArmA) for assessment of activity in the hemiparetic arm","volume":"35","author":"Ashford","year":"2013","journal-title":"Disabil. Rehabil."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"728","DOI":"10.1177\/0269215512474942","article-title":"Initial psychometric evaluation of the Arm Activity Measure (ArmA): A measure of activity in the hemiparetic arm","volume":"27","author":"Ashford","year":"2013","journal-title":"Clin. Rehabil."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"138","DOI":"10.4103\/jisprm.jisprm_47_19","article-title":"ULIS (Upper Limb International Spasticity), a 10-year Odyssey: An international, multicentric, longitudinal cohort of person-centered spasticity management in real-life practice","volume":"2","author":"Fheodoroff","year":"2019","journal-title":"J. Int. Soc. Phys. Rehabil. Med."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"e011157","DOI":"10.1136\/bmjopen-2016-011157","article-title":"Impact of integrated upper limb spasticity management including botulinum toxin A on patient-centred goal attainment: Rationale and protocol for an international prospective, longitudinal cohort study (ULIS-III)","volume":"6","author":"Ashford","year":"2016","journal-title":"BMJ Open"},{"key":"ref_42","doi-asserted-by":"crossref","unstructured":"Matak, I., B\u00f6lcskei, K., Bach-Rojecky, L., and Helyes, Z. (2019). Mechanisms of Botulinum Toxin Type A Action on Pain. Toxins, 11.","DOI":"10.3390\/toxins11080459"},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"e002771","DOI":"10.1136\/bmjopen-2013-002771","article-title":"Results from the Upper Limb International Spasticity Study-II (ULIS-II): A large, international, prospective cohort study investigating practice and goal attainment following treatment with botulinum toxin A in real-life clinical management","volume":"3","author":"Fheodoroff","year":"2013","journal-title":"BMJ Open"},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"309","DOI":"10.1179\/016164109X12478302362734","article-title":"Long-term treatment of spasticity with botulinum toxin type A: An analysis of 1221 treatments in 137 patients","volume":"32","author":"Mohammadi","year":"2010","journal-title":"Neurol. Res."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"245","DOI":"10.1002\/mus.25721","article-title":"Effects of repeated abobotulinumtoxinA injections in upper limb spasticity","volume":"57","author":"Gracies","year":"2018","journal-title":"Muscle Nerve"},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"fcaa201","DOI":"10.1093\/braincomms\/fcaa201","article-title":"When can maximal efficacy occur with repeat botulinum toxin injection in upper limb spastic paresis?","volume":"3","author":"Gracies","year":"2021","journal-title":"Brain Commun."},{"key":"ref_47","first-page":"1120","article-title":"Individualized OnabotulinumtoxinA Treatment for Upper Limb Spasticity Resulted in High. Clinician- and Patient-Reported Satisfaction: Long-Term. Observational Results from the ASPIRE Study","volume":"12","author":"Francisco","year":"2020","journal-title":"Phys. Med. Rehabil."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"504","DOI":"10.2340\/16501977-1817","article-title":"Functional goal achievement in post-stroke spasticity patients: The BOTOX\u00ae Economic Spasticity Trial (BEST)","volume":"46","author":"Ward","year":"2014","journal-title":"J. Rehabil. Med."},{"key":"ref_49","first-page":"24","article-title":"Predictors of real-world response in adults treated with botulinumtoxin-A for upper limb spasticity","volume":"7","author":"Fheodoroff","year":"2024","journal-title":"J. Int. Soc. Phys. Rehabil. Med."},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"535","DOI":"10.1002\/mus.20284","article-title":"Pathophysiology of spastic paresis. I: Paresis and soft tissue changes","volume":"31","author":"Gracies","year":"2005","journal-title":"Muscle Nerve"},{"key":"ref_51","first-page":"CD007455","article-title":"Stretch for the treatment and prevention of contractures (Review)","volume":"1","author":"Harvey","year":"2017","journal-title":"Cochrane Database Syst. Rev."},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"1027","DOI":"10.1113\/JP272767","article-title":"New perspectives in the development of muscle contractures following central motor lesions","volume":"4","author":"Pingel","year":"2017","journal-title":"J. Physiol."},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"88","DOI":"10.1191\/0269215503cr587oa","article-title":"Contractures in the post-stroke wrist: A pilot study of its time course of development and its association with upper limb recovery","volume":"17","author":"Pandyan","year":"2003","journal-title":"Clin. Rehabil."},{"key":"ref_54","doi-asserted-by":"crossref","first-page":"5885","DOI":"10.1080\/09638288.2025.2472988","article-title":"Understanding development of contractures in people with stroke: Formulation of a logic-model to inform care and prevention","volume":"47","author":"Ashford","year":"2025","journal-title":"Disabil. Rehabil."},{"key":"ref_55","first-page":"395","article-title":"Developing occupational therapy (OT) and physiotherapy (PT) splinting guidelines for the prevention and correction of contractures in adults with neurological dysfunction","volume":"29","author":"Kilbride","year":"2015","journal-title":"Clin. Rehabil."},{"key":"ref_56","doi-asserted-by":"crossref","first-page":"234","DOI":"10.1016\/j.rehab.2018.05.1320","article-title":"Does botulinum toxin treatment improve upper limb active function?","volume":"62","author":"Levy","year":"2019","journal-title":"Ann. Phys. Rehabil. Med."},{"key":"ref_57","doi-asserted-by":"crossref","first-page":"731","DOI":"10.1177\/0269215514555036","article-title":"The efficacy of Botulinum Toxin A on improving ease of care in the upper and lower limbs: A systematic review and meta-analysis using the Grades of Recommendation, Assessment, Development and Evaluation approach","volume":"29","author":"Baker","year":"2014","journal-title":"Clin. Rehabil."},{"key":"ref_58","doi-asserted-by":"crossref","unstructured":"Turner-Stokes, L., Buchwald, K., Ashford, S.A., Fheodoroff, K., Jacinto, J., Narayanan, A., and Siegert, R.J. (2025). Pain Reduction with Repeated Injections of Botulinum Toxin A in Upper Limb Spasticity: A Longitudinal Analysis from the ULIS-III Study. Toxins, 17.","DOI":"10.3390\/toxins17030117"},{"key":"ref_59","doi-asserted-by":"crossref","first-page":"S15","DOI":"10.1016\/j.toxicon.2020.11.371","article-title":"Worldwide clinician survey on practice patterns and perceptions on use of adjunct therapies following botulinum toxin injection for limb spasticity","volume":"190","author":"Deltombe","year":"2021","journal-title":"Toxicon"},{"key":"ref_60","doi-asserted-by":"crossref","first-page":"252","DOI":"10.1016\/j.rehab.2019.06.001","article-title":"French clinical guidelines for peripheral motor nerve blocks in a PRM setting","volume":"62","author":"Yelnik","year":"2019","journal-title":"Ann. Phys. Rehabil. Med."},{"key":"ref_61","doi-asserted-by":"crossref","first-page":"8515","DOI":"10.1080\/09638288.2021.2011437","article-title":"Do randomised controlled trials evaluating functional outcomes following botulinum neurotoxin-A align with focal spasticity guidelines? A systematic review","volume":"44","author":"Sutherland","year":"2022","journal-title":"Disabil. Rehabil."},{"key":"ref_62","doi-asserted-by":"crossref","first-page":"509","DOI":"10.1080\/09638288.2020.1769207","article-title":"A synthesis and appraisal of clinical practice guidelines, consensus statements and Cochrane systematic reviews for the management of focal spasticity in adults and children","volume":"44","author":"Williams","year":"2022","journal-title":"Disabil. Rehabil."},{"key":"ref_63","first-page":"65","article-title":"A Simple Sequentially Rejective Multiple Test Procedure","volume":"6","author":"Holm","year":"1979","journal-title":"Scand. J. Stat."},{"key":"ref_64","doi-asserted-by":"crossref","first-page":"726","DOI":"10.2105\/AJPH.86.5.726","article-title":"Adjusting for multiple testing when reporting research results: The Bonferroni vs Holm methods","volume":"86","author":"Mikel","year":"1996","journal-title":"Am. J. Public Health"}],"container-title":["Toxins"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2072-6651\/18\/1\/51\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,1,21]],"date-time":"2026-01-21T08:54:47Z","timestamp":1768985687000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2072-6651\/18\/1\/51"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,1,19]]},"references-count":64,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2026,1]]}},"alternative-id":["toxins18010051"],"URL":"https:\/\/doi.org\/10.3390\/toxins18010051","relation":{},"ISSN":["2072-6651"],"issn-type":[{"value":"2072-6651","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,1,19]]}}}