500 Section - Botulinum Toxin Type A Combined with Robot-Assisted Therapy for Post-Stroke Spasticity: A Systematic Review

Wednesday, May 20, 2026

6:00 PM - 7:30 PM PT

Presenting Author/Autor expositor(s)

SS

Stefania Spina, PhD

Medical Doctor
Azienda Ospedaliera Universitaria Foggia
Foggia, Puglia, Italy

Co-Author(s)

aS

andrea Santamato, Prof., MD

Full Professor
Foggia University
Foggia, Puglia, Italy
SF

Salvatore Facciorusso, MD

Medical Doctor
Azienda Ospedaliera Universitaria Foggia
SAN GIOVANNI ROTONDO, Puglia, Italy

Objectives : Post-stroke spasticity interferes with motor control and functional recovery. Botulinum toxin type A (BoNT-A) reduces focal hypertonia, while robot-assisted therapy (RAT) delivers intensive, task-specific training. Their combination may facilitate motor recovery, but clinical evidence remains inconsistent.
The aim is evaluate the efficacy and safety of BoNT-A combined with RAT in post-stroke spasticity and to assess the influence of RAT timing after injection on clinical outcomes.

Design: A systematic review of randomized controlled trials was conducted. PubMed, Scopus, Web of Science, and clinical trial registries were searched up to April 2025. Eligible trials enrolled adults with upper- or lower-limb post-stroke spasticity and compared BoNT-A + RAT with BoNT-A + conventional therapy or RAT alone. Risk of bias was assessed using the Cochrane RoB 2 tool.

Results: Seven randomized controlled trials (n = 229) were included (four upper-limb, three lower-limb). All studies reported significant within-group reductions in spasticity following BoNT-A (Modified Ashworth Scale), with no consistent additional spasticity reduction attributable to RAT. In contrast, all lower-limb trials demonstrated superior functional outcomes with combined therapy, including improvements in gait speed (10-Meter Walk Test), walking endurance (6-Minute Walk Test), balance (Berg Balance Scale), and mobility (Timed Up and Go). Upper-limb studies showed comparable improvements in motor impairment (Fugl–Meyer Assessment) across active interventions. One trial suggested that initiating RAT approximately four weeks after BoNT-A injection resulted in greater motor and kinematic improvements than earlier initiation. Overall risk of bias was judged as “some concerns,” primarily due to lack of blinding, small sample sizes, and heterogeneity in outcome assessment. No serious adverse events related to combined treatment were reported.

Conclusion: BoNT-A combined with RAT is safe and appears particularly effective for enhancing lower-limb functional recovery after stroke. The timing of RAT initiation may influence outcomes and warrants confirmation in larger, methodologically robust trials.