Analyzing the Effect of Extracorporeal Shockwave Therapy after Botulinum Toxin Injection on Calf Muscle Spasticity Improvement in Patients with Multiple Sclerosis - A Randomized Clinical Trial

Abstract

Background: Spasticity is a frequent and disabling manifestation of multiple sclerosis (MS), characterized by increased muscle tone and stiffness that limit mobility and daily functioning. Effective management requires a multimodal therapeutic strategy. This randomized clinical trial evaluated the efficacy of adjunct extracorporeal shockwave therapy (ESWT) following botulinum toxin type A (BTX-A) injection in reducing calf muscle spasticity in MS patients. Materials and Methods: Twenty participants were randomly assigned to receive either BTX-A alone (n = 10) or BTX-A combined with ESWT (n = 10). Clinical outcomes, including range of motion (ROM), Modified Ashworth Scale, and pain assessed by visual analog scale (VAS), were measured at 10 days, 1 month, and 2 months post-treatment. Results: Dorsiflexion ROM showed no significant between-group difference (P = 0.807), whereas plantar-flexion ROM significantly improved in the BTX-A + ESWT group compared with BTX-A alone (P = 0.047). MAS scores declined significantly over time in both groups (P < 0.001) without intergroup difference. Pain reduction, assessed by VAS, was greater in the ESWT group, showing significant between-group differences (P = 0.02). Compared with BTX-A alone, adjunct ESWT produced greater VAS improvement at day 10 (mean difference - 0.90, 95 CI - 1.65 to - 0.15) and 1 month (-1.10, 95 CI - 1.76 to - 0.44). Conclusions: ESWT as an adjunct to BTX-A enhances pain relief and improves plantar-flexion ROM in MS-related calf spasticity compared with BTX-A alone, supporting its role as a valuable component of multimodal spasticity management.