Optimal Dose of Extracorporeal Shock Wave Therapy After Botulinum Toxin Type A Injection for Post-stroke Spasticity

Inclusion Criteria: * Male or female * Age ≥20 years * inpatients * Elbow flexor spasticity in patients, confirmed to be mainly due to biceps brachii * Modified Ashworth scale (MAS) ≥2, * At least a 3-month period from stroke, * Written informed consent has been obtained Exclusion Criteria: * Fixed contractures and/or deformities at the elbow, * Previous fractures of the paretic upper limb, * Peripheral nervous system disorders/myopathies, * Previous BTX-A treatment and/or ESWT, * Structural alterations in the soft tissue (e.g., fibrosis), * Known allergy or sensitivity to the study medication or its components * Presence of an unstable medical condition or uncontrolled systemic disease * Any medical condition that may put the patient at increased risk with exposure to botulinum toxin therapy. (ex. Myasthenia gravis, Eaton-Lambert syndrome, amyotrophic lateral sclerosis, or any other significant disease that might interface with neuromuscular function. * Bleeding tendency and/or anticoagulation therapy * Presence of infection or skin disorder at injection sites * Females were are pregnant, nursing, or are planning a pregnancy during the study * Females of child-bearing potential (including pre-menstrual woman), not using a reliable means of contraception * Participant who should be withdrawn from the study in the opinion of the investigator for any reason