{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,21]],"date-time":"2026-08-21T09:23:05Z","timestamp":1787304185184,"version":"build-2736575974"},"reference-count":26,"publisher":"MDPI AG","issue":"8","license":[{"start":{"date-parts":[[2026,8,21]],"date-time":"2026-08-21T00:00:00Z","timestamp":1787270400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Toxins"],"abstract":"<jats:p>Post-stroke spasticity may interfere with function and rehabilitation and contribute to pain, contracture, care burden, and disability. Botulinum toxin type A is an established focal treatment for post-stroke spasticity, but it is often introduced in the chronic phase, when persistent involuntary muscle overactivity may coexist with secondary musculoskeletal complications. This opinion paper critically examines whether early treatment with botulinum toxin should be considered a myth or an emerging clinical reality. Current evidence from meta-analyses, randomized trials, observational cohorts, and pooled analyses was reviewed with particular attention to treatment timing, treatment triggers, functional outcomes, and prevention of secondary complications. The literature supports the clinical usefulness of earlier treatment in appropriately selected patients, particularly for reducing focal involuntary muscle overactivity and resistance to passive movement, delaying symptomatic progression, slowing contracture development, and reducing pain-related complications. However, a consistent additional effect on active motor recovery has not been demonstrated, and evidence for participation and long-term functional independence remains less definitive. Moreover, \u201cearly\u201d is heterogeneously defined across studies, ranging from the first weeks to the first year after stroke. We therefore propose moving from a rigid time-based concept of \u201cearly\u201d treatment toward timely, target- and goal-guided intervention, integrating botulinum toxin with rehabilitation when a clinically relevant and modifiable focal neural treatment target emerges. To operationalize this concept, we propose a pragmatic set of clinical variables including the neural treatment target, its clinical impact and trajectory, passive musculoskeletal status, pain and care burden, motor recovery context, rehabilitation goals, and patient priorities.<\/jats:p>","DOI":"10.3390\/toxins18080356","type":"journal-article","created":{"date-parts":[[2026,8,21]],"date-time":"2026-08-21T08:14:01Z","timestamp":1787300041000},"page":"356","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Early Treatment of Post-Stroke Spasticity with Botulinum Toxin Type A: Myth or Reality?"],"prefix":"10.3390","volume":"18","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-3558-8276","authenticated-orcid":false,"given":"Alessandro","family":"Picelli","sequence":"first","affiliation":[{"name":"Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37134 Verona, Italy"},{"name":"Department of Neurosciences, University Hospital of Verona, 37126 Verona, Italy"},{"name":"Canadian Advances in Neuro-Orthopedics for Spasticity Consortium (CANOSC), Kingston, ON K7K 1Z6, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rita","family":"Di Censo","sequence":"additional","affiliation":[{"name":"Department of Neurosciences, University Hospital of Verona, 37126 Verona, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7630-1887","authenticated-orcid":false,"given":"Nicola","family":"Smania","sequence":"additional","affiliation":[{"name":"Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37134 Verona, Italy"},{"name":"Department of Neurosciences, University Hospital of Verona, 37126 Verona, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4242-8497","authenticated-orcid":false,"given":"Valentina","family":"Varalta","sequence":"additional","affiliation":[{"name":"Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37134 Verona, Italy"},{"name":"Department of Neurosciences, University Hospital of Verona, 37126 Verona, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5930-5974","authenticated-orcid":false,"given":"Mirko","family":"Filippetti","sequence":"additional","affiliation":[{"name":"Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37134 Verona, Italy"},{"name":"Canadian Advances in Neuro-Orthopedics for Spasticity Consortium (CANOSC), Kingston, ON K7K 1Z6, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,8,21]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"431","DOI":"10.1016\/j.rehab.2018.04.004","article-title":"Onset, time course and prediction of spasticity after stroke or traumatic brain injury","volume":"62","author":"Sunnerhagen","year":"2019","journal-title":"Ann. 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