The use of botulinum toxin for spasticity in people with spinal cord injury: a scoping review.

[INTRODUCTION] This review synthesizes the literature on botulinum toxin (BoNT) for spasticity in spinal cord injury (SCI), with attention to definitions, treatment goals, outcome measures, injection protocols, and efficacy.

[EVIDENCE ACQUISITION] Systematic searches of MEDLINE, Embase, CENTRAL, Scopus, and PEDro were conducted from 1995 to May 2025, supplemented by grey literature, trial registries, citation tracking, and expert consultation. Eligible studies investigated intramuscular BoNT in adults with SCI-related spasticity; other neurological conditions were excluded. No restrictions on design, setting, or geography were applied. Two reviewers independently screened records and extracted data using piloted templates.

[EVIDENCE SYNTHESIS] Thirty-five studies (1995-2025) from 17 countries were included: 14 case reports/series, 10 observational studies, 2 retrospective cohorts, 2 randomized controlled trials, 1 crossover trial, 1 quasi-experimental study, and 5 systematic reviews. Most did not define spasticity; when reported, Lance's definition predominated, although Pandyan's is recommended in SCI. Goal setting was rarely described and seldom involved patients. Outcome measures primarily addressed impairment (e.g., Modified Ashworth Scale, passive range of motion), with limited attention to function or quality of life. BoNT protocols varied in toxin type, dose, target muscles, and use of guidance, and injection details were frequently underreported. Evidence of efficacy was weak: only three experimental studies were identified, all limited by small samples, lack of SCI-specific analyses, or incomplete reporting.

[CONCLUSIONS] Evidence on BoNT for SCI-related spasticity is scarce, heterogeneous, and methodologically weak. Future research should adopt consensus definitions, involve patients in goal setting, apply SCI-specific outcomes, and report protocols transparently to guide practice.