Goal attainment for spasticity management using botulinum toxin

AAPM&R consensus guidance on spasticity assessment and management

BACKGROUND

The American Academy of Physical Medicine and Rehabilitation (AAPM&R) conducted a comprehensive review in 2021 to identify opportunities for enhancing the care of adult and pediatric patients with spasticity. A technical expert panel (TEP) was convened to develop consensus-based practice recommendations aimed at addressing gaps in spasticity care.

OBJECTIVE

To develop consensus-based practice recommendations to identify and address gaps in spasticity care.

METHODS

The Spasticity TEP engaged in a 16-month virtual meeting process, focusing on formulating search terms, refining research questions, and conducting a structured evidence review. Evidence quality was assessed by the AAPM&R Evidence, Quality and Performance Committee (EQPC), and a modified Delphi process was employed to achieve consensus on recommendation statements and evidence grading. The Strength of Recommendation Taxonomy (SORT) guided the rating of individual studies and the strength of recommendations.

RESULTS

The TEP approved five recommendations for spasticity management and five best practices for assessment and management, with one recommendation unable to be graded due to evidence limitations. Best practices were defined as widely accepted components of care, while recommendations required structured evidence reviews and grading. The consensus guidance statement represents current best practices and evidence-based treatment options, intended for use by PM&R physicians caring for patients with spasticity.

CONCLUSION

This consensus guidance provides clinicians with practical recommendations for spasticity assessment and management based on the best available evidence and expert opinion. Clinical judgment should be exercised, and recommendations tailored to individual patient needs, preferences, and risk profiles. The accompanying table summarizes the best practice recommendations for spasticity assessment and management, reflecting principles with little controversy in care delivery.

Two-year prospective cohort of intensive care survivors enrolled on a digitally enabled recovery pathway focussed on individualised recovery goal attainment

BACKGROUND

Despite substantial evidence documenting physical, psychological, and cognitive problems experienced by intensive care unit (ICU) survivors, few studies explore interventions supporting recovery after hospital discharge. Individualised recovery goal setting, the standard of care across many rehabilitation areas, is rarely used for ICU survivors. Digital health technologies may help to address current service fragmentation and gaps. We developed and implemented a digital ICU recovery pathway using the aTouchaway e-health platform.

OBJECTIVES

The objective of this study was to explore recovery barriers and challenges; recovery goals set and achieved; self-reported patient outcomes; and healthcare costs of patients enrolled on a 12-week digital ICU recovery pathway after hospital discharge.

METHODS

We conducted a prospective observational single-centre cohort study (June 2021 to May 2023) at a 90-bed tertiary critical care service in London, UK. We enrolled adults ventilated for ≥3 days who were able to participate in recovery activities. We ascertained baseline recovery challenges and identified recovery goals and achievement over 12 weeks. We collected patient-reported outcomes at 2-4, 12-14, 26-28 weeks and healthcare utilisation monthly for 28 weeks.

RESULTS

We enrolled 105 participants (35% of eligible patients). Common rehabilitation challenges were standing balance (60%), walking indoors (56%), and washing (64%) and dressing (47%) abilities. Of 522 home recovery goals, 63% weekly, 48% monthly, and 38% aspirational goals were achieved. Most goals related to self-care: ability to move outside (91 goals, 55% achieved) and inside (45 goals, 47% achieved) the home and community access (65 goals, 48% achieved). Nottingham Extended Activities of Daily Living Scale scores improved from timepoints 1 to 2 (median [interquartile range]: 15 [7, 19] versus 19 [15, 21], P = 0.01). Total healthcare costs were £240,017 (median [interquartile range] cost per patient: £784 [£125, £4419]).

CONCLUSIONS

This study found multiple ongoing functional deficits, challenges achieving recovery goals, and limited improvements in self-reported outcomes, with moderate healthcare costs after hospital discharge indicate substantial ongoing rehabilitative needs.

Botulinum toxin type A inhibits M1 macrophage polarization by deactivation of JAK2/STAT1 and IκB/NFκB pathway and contributes to scar alleviation in aseptic skin wound healing

The non-neuronal and non-muscular effects of botulinum toxin type A (BTXA) on scar reduction has been discovered. This study was designed to investigate the effects of BTXA on macrophages polarization during the early stage of skin repair. A skin defect model was established on the dorsal skin of SD rats. BTXA was intracutaneous injected into the edge of wound immediately as the model was established. Histological examinations were performed on scar samples. Raw 264.7 was selected as the cell model of recruited circulating macrophages, and was induced for M1 polarization by LPS. Identify the signaling pathways that primarily regulated M1 polarization and respond to BTXA treatment. Application of BTXA at early stage of injury significantly reduced the scar diameter without delaying wound closure. BTXA treatment improved fiber proliferation and arrangement, and inhibited angiogenesis in scar granular tissue. The number of M1 macrophages and the levels of pro-inflammation were decreased after treated with BTXA in scar tissues. LPS activated JAK2/STAT1 and IκB/NFκB pathways were downregulated by BTXA, as well as LPS induced M1 polarization. At early stage of skin wound healing, injection of BTXA effectively reduced the number of M1 macrophages and the levels of pro-inflammatory mediators which contributes to scar alleviation. BTXA resisted the M1 polarization of macrophages induced by LPS via deactivating the JAK2/STAT1 and IκB/NFκB pathways.

Effects of Goal Management Training on self-efficacy, self-esteem, and quality of life for persons with schizophrenia spectrum disorders

Persons with schizophrenia often show executive dysfunction assessed with both subjective (self-report) and objective (neuropsychological tests) measures. In a recent randomized controlled trial (RCT), subjective executive functioning in everyday life was improved following Goal Management Training (GMT). The aim of the current study is to investigate the potential of GMT to improve secondary well-being outcomes from that RCT, including self-esteem, self-efficacy, and quality of life in persons with schizophrenia spectrum disorders. Since well-being is frequently lower in persons with schizophrenia compared to healthy individuals, further knowledge about well-being as an outcome after cognitive remediation may have implications for clinical treatment. Sixty-five participants were randomly assigned to GMT (n = 31) or a waiting list control condition (n = 34). Assessments were conducted at baseline (T1), immediately after the intervention (T2-5 weeks), and at six-month follow-up (T3). Measures included the Rosenberg Self-Esteem Scale, the Perceived Quality of Life Scale, and the General Self-Efficacy Scale. Results were analyzed using a linear mixed model analysis for repeated measures. There were no significant effects of GMT on self-esteem or quality of life. Only the GMT group showed a significant increase in self-efficacy that was most evident at six months follow-up, F(1, 34) = 10.71, p = 0.002, d = 0.71. Improved self-efficacy was found to correlate significantly with a reduction in perceived executive dysfunction in an exploratory post hoc analysis. Our findings demonstrate the potential of GMT in improving self-efficacy in schizophrenia Clinical trial registration:https://clinicaltrials.gov, NCT03048695.

Patient-reported benefits from nabiximols treatment in multiple sclerosis-related spasticity exceed conventional measures

Aim: This prospective, multicenter, open-label, noninterventional 12-week study investigated the effectiveness and tolerability of add-on nabiximols oromucosal spray (Sativex®) in the real-world setting in Germany. Patients & methods: The main analysis set comprised 51 adult patients (49 nabiximols responders) with multiple sclerosis (MS) spasticity. Results: The mean overall goal attainment scale score (primary outcome measure) increased by 46% from baseline to week 12 (35.2 vs 51.4; p < 0.001). Mean gait speed was improved by 23% at 4 and 12 weeks. Clinically meaningful improvements in mean 0-10 numerical rating scale scores for spasticity, pain, sleep quality and urinary bladder dysfunction were recorded at 4 and 12 weeks. Conclusion: Nabiximols is a useful therapeutic option for patients with MS spasticity.

Digital solutions and the future of recovery after critical illness

PURPOSE OF REVIEW

Digital technologies may address known physical and psychological barriers to recovery experienced by intensive care survivors following hospital discharge and provide solutions to care fragmentation and unmet needs. The review highlights recent examples of digital technologies designed to support recovery of survivors of critically illness.

RECENT FINDINGS

Despite proliferation of digital technologies supporting health in the community, there are relatively few examples for intensive care survivors. Those we identified included web-based, app-based or telemedicine-informed recovery clinics or pathways offering services, including informational resources, care planning and navigation support, medication reconciliation, and recovery goal setting. Digital interventions supporting psychological recovery included apps providing adaptive coping skills training, mindfulness, and cognitive behavioural therapy. Efficacy data are limited, although feasibility and acceptability have been established for some. Challenges include difficulties identifying participants most likely to benefit and delivery in a format easily accessible to all, with digital exclusion a resultant risk.

SUMMARY

Digital interventions supporting recovery comprise web or app-based recovery clinics or pathways and digital delivery of psychological interventions. Understanding of efficacy is relatively nascent, although several studies demonstrate feasibility and acceptability. Future research is needed but should be mindful of the risk of digital exclusion.

Comparison of traditional outcome measures and self-assessed goal achievement in patients treated surgically for benign prostatic hyperplasia

PURPOSE

To determine self-assessed goal achievement (SAGA) outcomes in men treated surgically for lower urinary tract symptoms (LUTS) due to benign prostatic obstruction (BPO) and compare them to the traditional outcome measures.

METHODS

Single-center analysis of prospective database of men undergoing surgical treatment of LUTS/BPO at a single institution between July 2019 and March 2021. We assessed individual goals, traditional questionnaires, and functional outcomes prior to treatment, and at first follow-up after 6-12 weeks. We compared SAGA outcomes 'overall goal achievement' and 'satisfaction with treatment' to subjective and objective outcomes using Spearman's rank correlations (rho).

RESULTS

A total of sixty-eight patients completed the individual goal formulation prior to surgery. Preoperative goals varied between different treatments and individuals. IPSS correlated with 'overall goal achievement' (rho = - 0.78, p < 0.001) and 'satisfaction with treatment' (rho = - 0.59, p < 0.001). Similarly, the IPSS-QoL was correlated with overall goal achievement (rho = - 0.79, p < 0.001) and satisfaction with treatment (rho = - 0.65, p < 0.001). No correlation was seen between SAGA outcomes and functional outcomes Qmax and PVR.

CONCLUSIONS

SAGA represents a uniquely patient-specific outcome measure. Our study is, to our knowledge, the first to assess patient-specific goals prior to surgery and examine SAGA outcomes following treatment in men suffering from LUTS/BPO. The correlation of SAGA outcomes with IPSS and IPSS-QoL highlight the importance of this well-established questionnaire. Functional outcomes do not necessarily reflect patient's goals and may rather be considered physician-directed outcomes.

Moderators of metacognitive strategy training for executive functioning in early schizophrenia and psychosis risk

Goal Management Training (GMT) improved self-reported executive functioning in a recent randomized, controlled trial in early intervention for psychosis participants. Little is known about the mechanism for this benefit, so this study investigates objectively measured executive function, the difference between subjective and objective executive function, independent living and employment status as potential moderators of efficacy of GMT. Baseline scores from 81 participants (GMT n = 39 vs Treatment-as-usual; TAU n = 42) were analyzed in a linear mixed model analysis for repeated measures as predictors of improvement on the self-reported Behavior Rating Inventory of Executive Function-Adult version (BRIEF-A) immediately and 30 weeks after GMT. Potential moderators were scores from objective measures of executive functioning, discrepancy between subjective and objective measures, independent living and employment status. Discrepancy was assessed by comparing four clusters of participants with differing patterns of scores. The effect of GMT remained significant regardless of initial objective executive functioning at baseline. Those with higher subjective complaints at baseline in two clusters with (i) both objective and subjective executive dysfunction, and (ii) mostly subjective executive dysfunction experienced greater change after treatment. Living arrangements or participation in education or work did not significantly moderate the effects of GMT. Poor performance on neuropsychological tasks is not an obstacle to making use of GMT, but further knowledge is needed about the benefits of strategy training for individuals with a combination of poor performance with few subjective complaints.

A person-centered approach to home and community-based services outcome measurement

In the United States, over 2.5 million people with disabilities are recipients of supports through the Center for Medicare and Medicaid Services (CMS) Home and Community-Based Services (HCBS) program. Recent decades have seen a growing focus on providing HCBS in a person-centered manner thereby supporting outcomes that are both important for and to the person. HCBS outcome measurement, however, has not kept pace with advancements in person-centered thinking as it relates to providing supports to people with disabilities. The concept of person-centered outcome measurement has been inadequately defined and is frequently misunderstood including by those in the measurement field. The authors first operationally define person-centered measurement and establish its importance within the context of HCBS and the recent CMS's Final Settings Rule. The important role that person-centered measurement has to play in quality improvement efforts in this area is then explored. A discussion is subsequently provided as to the challenges that are faced in person-centered measurement specific to the disability field. In addition to further conceptualizing and defining this form of measurement, recommendations are provided for moving the field forward.

A randomized controlled trial of Goal Management Training for executive functioning in schizophrenia spectrum disorders or psychosis risk syndromes

BACKGROUND

Executive functioning is essential to daily life and severely impaired in schizophrenia and psychosis risk syndromes. Goal Management Training (GMT) is a theoretically founded, empirically supported, metacognitive strategy training program designed to improve executive functioning.

METHODS

A randomized controlled parallel group trial compared GMT with treatment as usual among 81 participants (GMT, n = 39 versus Wait List Controls, n = 42) recruited from an early intervention for psychosis setting. Computer generated random allocation was performed by someone independent from the study team and raters post-intervention were unaware of allocation. The primary objective was to assess the impact of GMT administered in small groups for 5 weeks on executive functioning. The secondary objective was to explore the potential of the intervention in influencing daily life functioning and clinical symptoms.

RESULTS

GMT improved self-reported executive functioning, measured with the Behavior Rating Inventory of Executive Function - Adult version (BRIEF-A), significantly more than treatment as usual. A linear mixed model for repeated measures, including all partial data according to the principle of intention to treat, showed a significant group x time interaction effect assessed immediately after intervention (post-test) and 6 months after intervention (follow-up), F = 8.40, p .005, r .37. Improvement occurred in both groups in objective executive functioning as measured by neuropsychological tests, functional capacity, daily life functioning and symptoms of psychosis rated by clinicians. Self-reported clinical symptoms measured with the Symptoms Check List (SCL-10) improved significantly more after GMT than after treatment as usual, F = 5.78, p .019, r .29. Two participants withdrew due to strenuous testing and one due to adverse effects.

CONCLUSIONS

GMT had clinically reliable and lasting effects on subjective executive function. The intervention is a valuable addition to available treatment with considerable gains at low cost.

TRIAL REGISTRATION

Registered at clinicaltrials.gov NCT03048695 09/02/2017.

Goal-Setting in Multiple Sclerosis-Related Spasticity Treated with Botulinum Toxin: The GASEPTOX Study

Spasticity is one of the most disabling symptoms in multiple sclerosis (MS). Botulinum toxin injection (BTI) is a first-line treatment for focal spasticity. There is a lack of evidence of a functional improvement following BTI in MS-related spasticity. To describe goal-setting for BTI in MS, and evaluate the degree of attainment, using goal attainment scaling (GAS) 4-to-6 weeks after injection session, a one-year multi-center retrospective observational study assessing goal-setting and achievement during BTI session in spastic patients with MS was set up. Following the GAS method, patients and their physicians set up to three goals and scored their achievement 4 to 6 weeks thereafter. Commonly used goals from three centers were combined into a standardized list and 125 single BTI sessions were analyzed. The most frequent goals regarded lower limb (LL) impairments (equinovarus foot, toe claw) or locomotion (stability, walking distance, clinging) and accounted for 89.1%, versus 10.9% for upper limb (UL), mostly for mild-to-moderate MS. Overall, goals were frequently achieved (85.77%) mainly when related to gait and mobility rather than hygiene and ease of care. This study gives an overview on the most frequent, relevant, and achievable goals to be set in real-life practice of BTI for spasticity management in MS.

Quality of life impacts and wider benefits following upper limb surgery for spasticity management

Background/Aims

A new, collaborative, multidisciplinary clinic for the management of people with upper limb spasticity and contracture was established between two healthcare trusts. The aim of this study was to determine the perceived benefits to patients of this new clinic and of upper limb surgery, where performed.

Methods

A service evaluation of a collaborative upper limb surgical assessment clinic for patients with complex problems of their upper limbs as a result of spasticity was undertaken. Questionnaires were distributed to 21 patients who attended the clinic in its first year (December 2017–2018), with follow-up focus groups. A rough cost–benefit review was undertaken.

Results

Patients highlighted benefits in both passive and active care tasks. They chose outcome measures that they felt were most useful to measure these benefits and coproduced multimedia information resources. The cost–benefit review indicated that a break-even point could be reached in as little as 1 year.

Conclusions

The team has gained a broad perspective of potential impacts on the patient and their carers, as well as future service development and research options.

[Impact of integrated upper limb spasticity management including repeat botulinum toxin type A (BoNT-A) injections on patient-centred goal attainment in real-life practice: results from the prospective, observational Upper Limb International Spasticity cohort study (ULIS-III) in a Russian subpopulation]

OBJECTIVE

To assess the longitudinal attainment of patient-centred and function related goals after integrated spasticity management including repeated cycles of botulinum toxin A type A (BoNT-A) injections in real life settings over a period of 2 years. The article presents analysis of the results within the subpopulation of patients from Russia.

MATERIAL AND METHODS

This international, multicentre, observational, prospective, longitudinal cohort study (registered at clinicaltrials.gov as NCT02454803) included patients ≥18 years old with upper-limb spasticity of any aetiology in whom a decision had already been made to inject any BoNT-A formulation commercially available in the Russi. The treatment outcomes were evaluated using the Upper Limb Spasticity Index, which combines the patient-centred Goal Attainment Scaling (GAS) with a set of targeted standardised measures to assess the neurological impairment. The extent of functional impairment was assessed using the DAS.

RESULTS

168 Russian patients from 7 sites with a mean age of 49.8 years participated in the study. The Russian subpopulation had some differences from the overall study population in baseline characteristics of patients and injection practices of BoNT-A treatment. During the study period, the majority of Russian patients received AboBoNT-A (Dysport) injections - 142 (85%) patients at cycle 1, while OnaBoNT-A (Botox) was used in 14 (8%) patients, and IncoBoNT-A (Xeomin) - in 12 (7%) patients. Higher doses of AboBoNT-A were observed compared to the overall population, mean doses of AboBoNT-A between cycles 1 and 4 were 909-934 U in the Russian patients and 814-859 U in the overall population. In general, patients of the Russian subpopulation successfully achieved their treatment goals. The mean cumulated GAS T-score over the study was 51.1±3.0, marginally exceeding the same parameter in the overall population (49.5±5.9). Across the 6 goal domains, cumulated GAS T-scores in Russian subpopulation were highest for the goals related to passive function and pain relief, with mean scores of 51.8±4.2 and 51.6±4.8, respectively. In the overall population cumulated GAS T-scores were highest for involuntary movements (mean 50.5±5.6) and pain relief (mean 50.4±6.2). The lowest GAS T-scores were for the treatment goals related to active function in both Russian subpopulation and overall population, the mean scores were 48.3±5.5 and 46.6±7.4 respectively. The study results also showed significant improvement in in terms of reduction of muscle tone according to MAS (Modified Ashworth Scale) and the extent of functional impairment according to DAS (Disability Assessment Scale).

CONCLUSIONS

The results of this subgroup analysis on patients from Russia showed high effectiveness of repeated cycles of BoNT-A injections as part of the integrated upper limb spasticity management conducted in real life settings, both in terms of reduction of muscle tone and correction of functional impairment, which contributes to the successful achievement of the treatment goals. The right choice of individual patient-centred treatment goals and methods for assessing their achievement are important components of the treatment and rehabilitation process for patients with spastic paresis of the upper limb.

BoNT-A for Post-Stroke Spasticity: Guidance on Unmet Clinical Needs from a Delphi Panel Approach

There is extensive literature supporting the efficacy of botulinum toxin (BoNT-A) for the treatment of post-stroke spasticity, however, there remain gaps in the routine management of patients with post-stroke spasticity. A panel of 21 Italian experts was selected to participate in this web-based survey Delphi process to provide guidance that can support clinicians in the decision-making process. There was a broad consensus among physicians that BoNT-A intervention should be administered as soon as the spasticity interferes with the patients' clinical condition. Patients monitoring is needed over time, a follow-up of 4-6 weeks is considered necessary. Furthermore, physicians agreed that treatment should be offered irrespective of the duration of the spasticity. The Delphi consensus also stressed the importance of patient-centered goals in order to satisfy the clinical needs of the patient regardless of time of onset or duration of spasticity. The findings arising from this Delphi process provide insights into the unmet needs in managing post-stroke spasticity from the clinician's perspective and provides guidance for physicians for the utilization of BoNT-A for the treatment of post-stroke spasticity in daily practice.

Effect of nabiximols on Goal Attainment Scale scores in patients with treatment-resistant multiple sclerosis spasticity

Background: Nabiximols oromucosal spray (Sativex^®) is an approved add-on treatment option for moderate-to-severe treatment-resistant multiple sclerosis (MS) spasticity. Materials & methods: This prospective, observational, noninterventional, 3-month follow-up pilot study assessed the evolution of patient-selected goal attainment scale (GAS) item scores and of MS spasticity and associated symptoms during nabiximols treatment. Results: In the full analysis set (n = 21), the mean (SD) overall unweighted GAS score increased from 32.1 (3.4) at baseline to 43.6 (14.6) at month 3 (p = 0.0060), constituting a clinically meaningful change. Slight improvements were observed in MS spasticity and most associated symptoms. Nabiximols improved walking ability and was well tolerated. Conclusion: The study provides proof-of-concept that GAS methodology can be applied to MS management in daily practice.

Discontinuation of botulinum neurotoxin type-A treatment during COVID-19 pandemic: an Italian survey in post stroke and traumatic brain injury patients living with spasticity

BACKGROUND

The COVID-19 pandemic has affected health-care systems worldwide, including the outpatient spasticity care with botulinum neurotoxin toxin type A (BoNT-A).

AIM

The aim of this study was to investigate the impact of discontinuation of BoNT-A treatment on patients living with spasticity during the COVID-19 quarantine.

DESIGN

A multicentric cross-sectional study.

SETTING

Outpatients setting.

POPULATION

Patients with spasticity after stroke and traumatic brain injury treated with BoNT-A.

METHODS

A phone-based survey was conducted from March to May, 2020. Based on the International Classification of Functioning, Disability and Health (ICF), an ad hoc questionnaire CORTOX (CORonavirus TOXin survey) was developed to investigate patients' experiences following the discontinuation of their usual treatment for spasticity due to the lockdown and its implication on their health perception. It assessed patients' condition and explored different ICF domains related to spasticity: unpleasant sensations, mobility, self-care, facilitators and psychosocial factors. The sum of those represented the CORTOX score (Max 142). The questionnaire also collected data about the impact of COVID-19 on patients' wellbeing (mood, sleep, relationships, community life, motivation).

RESULTS

A total of 151 participants completed the survey. Most participants (72.2%) experienced a worsening in perceived spasticity, 53% got worse in independence and 70.9% had a negative impact on quality of life. The mean CORTOX score was 52.85±27.25, reflecting a perceived worsening in all ICF domains investigated. Moderate to strong correlations were found between different sub-scores of the questionnaire and severity of spasticity (P<0.001). COVID-19 psychosocial related factors were associated with loss of independence (P<0.05) but only mood was associated with worsening of spasticity (P<0.001). The lack of rehabilitation therapy was significantly associated with the worsening of independence but not with the worsening of spasticity. Finally, respondents reported that BoNT-A was useful to their condition and should not be discontinued.

CONCLUSIONS

The discontinuation of BoNT-A treatment was associated with worsening of activities and participation and perceived spasticity. COVID-19 related problems and rehabilitation showed an association with loss of independence.

CLINICAL REHABILITATION IMPACT

This study will provide useful information in the field of spasticity management using a patient's centred approach, with consistent quantitative and qualitative information.

The Effect of a Rehabilitation Specific Gaming Software Platform to Achieve Individual Physiotherapy Goals in Children with Severe Spastic Cerebral Palsy: A Randomized Crossover Trial

Cerebral palsy (CP) is the most common cause of permanent neurological disabilities in children. Many children require long-term daily physiotherapy (PT), and videogaming is a promising tool to increase motivation in rehabilitation. The short- and medium-term effects of an intervention with rehabilitation specific videogames were evaluated on individually defined therapy goals, gross motor function, and motivation. Thirty-two children with bilateral spastic CP, Gross Motor Function Classification level III-IV, and 6-15 years were randomized into an intervention group (regular PT and gaming) or a control group (regular PT), followed by a crossover. The effects of both training periods (each 12 weeks) were compared using the Goal Attainment Scale (GAS), Trunk Control Measurement Scale (TCMS), Pediatric Balance Scale (PBS), Gross Motor Function Measure-88 (GMFM-88), and Dimensions of Mastery Motivation Questionnaire (DMQ). After 3 months follow-up, children were retested using the GMFM, TCMS, and PBS. The GAS change scores were significantly higher after the intervention compared to the control period (8.5 and 2.4, P < 0.001). The change scores for standing exercises (3.85 and 0.22, P = 0.04) and dynamic sitting balance (5.9 and -1.7, P < 0.001) were also significantly higher. After 3 months follow-up the results did not persist. A combined approach of regular PT and rehabilitation specific gaming showed significant effects on individually defined therapy goals, dynamic sitting balance, and standing exercises. However, the lack of persistent effect indicates that continuous individual goal-oriented PT with the addition of gaming is needed.

Real-life outcomes in spasticity management: features affecting goal achievement

BACKGROUND/OBJECTIVE

Spasticity is a complex and common condition but there is a lack of 'real-world' data on goal setting and spasticity treatment, as well as identifying those features that might be associated with goal achievement. Our aim was to provide such data.

METHODS

Prospective attenders at a multi-disciplinary spasticity clinic over 2 years followed for consecutive appointments. Patient demographics and doses of botulinum toxin injected were documented. Main outcome was achievement of a primary goal but secondary goals were also recorded. Independent variables were examined for association to the outcome.

RESULTS

A total of 606 goals were set in 224 patients. The majority (75.2%) were achieved with similar levels across active (72.5%), passive (75.7%) and pain (78.6%) goals. However, in terms of the primary goal, active primary goals were achieved less frequently (59.7%) than non-active primary goal (74.2%). A logistic regression confirmed that this was the only independent variable associated with primary goal achievement. The majority of patients (61.6%) required changes to their treatment between appointments, irrespective of time since diagnosis, age or aetiology.

CONCLUSIONS

Most goals set in spasticity clinic can be achieved irrespective of type of goal. However, active goals may be harder to accomplish when they are set as a primary goal. This may reflect the desire of individuals to prioritise a desirable goal rather than one that is achievable. While goal setting is important in the management of spasticity patients, very few patient or treatment factors are associated with outcome prediction. Further work needs to identify features that may predict successful outcome.

A Pilot Study of Two Different Constraint-Induced Movement Therapy Interventions in Children With Hemiplegic Cerebral Palsy After Botulinum Toxin Injection During Preschool Education

Introduction: To establish a pilot study on applying two low dose (40 h) constraint-induced movement therapy (CIMT) interventions in children with hemiplegic cerebral palsy (CP) after botulinum toxin (BoNT-A) injection during preschool education. Methods: Five children with spastic CP (mean age: 5.31 years; Gross Motor Function Classification System level I and II) undergoing regular BoNT-A injections and rehabilitation programs were included. Participants were randomly allocated to one of two CIMT programs (40 h): a 2-week 4-hours/day CIMT program and a 4-week 2-hours/day CIMT program. One CIMT program was performed 1 month after a BoNT-A injection, and then the second program was implemented with the next injection. The outcomes were measured by changes in Goal Attainment Scaling (GAS), the grasp and Visual-Motor Integration (VMI) test in Peabody-Developmental Motor Scales (PDMS), the self-care scale on the Functional Skill Scale, and the Caregiver Assistance in Chinese Version of Pediatric Evaluation of Disability Inventory (PEDI-C), Anxiety and Oppositional Defiance Problems of Achenbach System of Empirically-Based Assessment before and after the CIMT interventions, and at every 2 months' follow-up thereafter. Results: The mean age of the participants was 5.31 years, BMI was 16.7 (kg/m²), VIQ was 86.4 ± 8.5, and dose of BoNT-A injection in the upper limb was 42 ± 26.6 units. Grasp, VMI, and self-care on the Functional Skill Scale were significantly better in the 4-week 2-hours/day CIMT program (p < 0.001, p = 0.001, p < 0.001). GAS, grasp, VMI, two 2 self-care scales of PEDI were significantly improved after the CIMT programs, and improvement continued for up to 4 months after the programs. There was no clinical evidence showing changes in the scores for anxiety and oppositional defiance problems during the study period. Conclusions: The preliminary findings, although limited, suggest a potential therapeutic role for the school-based CIMT program after BoNT-A injection. The 4-week 2-hours/day CIMT program might be better than a 2-week 4-hours/day program in terms of self-care and hand function when performed in kindergarten in this pilot study. Furthermore, this pilot study provides valuable information; therefore, it is crucial to include more CP children and blinded assessors for hand function and ADL in the future study.

The Leg Activity measure, a new measure of passive and active function and impact on quality of life; informing goal setting and outcome evaluation in leg spasticity

PURPOSE

Application of the Leg Activity measure in acquired brain injury spasticity intervention to identify areas for goal setting prior to treatment, document the treatments applied and evaluate outcome.

METHODS

A prospective cohort from three specialist spasticity management centres was used. Primary outcome measures were, Leg Activity Measure, Modified Ashworth Scale and Goal Attainment Scaling - light. Measurement was completed at baseline, 6 and 12 weeks. The Leg-Therapy recording Schedule was used to record physical therapy intervention.

RESULTS

Participants (n = 64) included had a mean age of 51 (18-84) years, half (n = 32) were men. Significant changes were demonstrated over the 12-week period in MAS (X^r2 = 35.4; p < 0.001), the Leg Activity passive function scale (X^r2 = 32.2; p < 0.001) (e.g., improved ease of dressing, hygiene) and Leg Activity impact on quality of life scale (Xr2 = 32.2; p < 0.001). No change was identified in the Leg Activity active function scale. Goal achievement was demonstrated at 6 weeks and further improved at 12 weeks (Xr2 = 65.7; p < 0.001) and was associated with change in the relevant scale. Physical interventions were captured at each time-point.

DISCUSSION

Significant gains in passive-function and quality-of-life were recorded by the Leg Activity measure scales at 6 weeks, and at 12 weeks post-injection in the context of on-going physical treatment, primarily by self-management.Implications for rehabilitationThe Leg Activity measure is able to detected changes in passive function and impact on quality of life.Measurement of change in active function is also likely to be detected, but was not seen in the cohort studied.The Leg Activity measure was effective in this study in identifying problem areas to enable setting of treatment goals and planning of treatment intervention.

Psychometric evaluation of the leg activity measure (LegA) for outcome measurement in people with brain injury and spasticity

PURPOSE

The aim of this study is to evaluate the properties of the Leg Activity measure according to COnsensus-based Standards for the selection of health Measurement INstruments.

METHOD

Participants were assessed at baseline, one day, 6 weeks and 12 weeks, following treatment for leg spasticity with botulinum toxin and physical interventions.

RESULTS

In stage 1, 64 participants were recruited to evaluate the initial psychometric properties of Leg Activity measure. In stage 2, 100 additional participants were recruited, to evaluate the scaling properties. Total sample of 164 participants was used. Construct validity was supported for "passive function", "active function" and "impact on quality of life". Cronbach's alpha was 0.86, 0.97 and 0.87 respectively for the scales. Item level test-retest agreement ranged from 91-97% (Kappa 0.75-0.95). Following treatment for spasticity (n = 64), the Leg Activity measure "passive function" and "impact on life" scales were responsive to change. Principal components analysis confirmed the constructs and a unidimensional Rasch Partial Credit Model was subsequently established for each scale. Transformation to an interval scale was achieved. Using the ordinal-to-interval conversion tables, parametric statistical analysis may be used.

CONCLUSION

The study provides support for the Leg Activity measure being valid, reliable and responsive.Implications for rehabilitationThe Leg Activity measure is the only published self-report measure in the current literature that addresses passive and active function as well as impact on quality of life, of the paretic leg in a comprehensive manner.The initial evaluation of Leg Activity measure psychometric properties, in relation to the COnsensus-based Standards for the selection of health Measurement INstruments checklist and Medical Outcomes Trust Quality Criteria, supports its measurement properties for clinical and research use.The Leg Activity measure as a valid, reliable and responsive tool for the evaluation of treatment in leg spasticity including condition specific (spasticity) quality-of-life.

[Treatment goals in patients with post-stroke upper limb spasticity following injection of botulinum toxin A : Results of the German-Austrian subgroup of the ULIS-II study]

BACKGROUND

The ULIS-II was an international cohort study (NCT01020500) evaluating current treatment of upper limb spasticity in post-stroke adult patients with botulinum toxin A (BoNT-A) in real-life practice.

OBJECTIVE

Post hoc analysis to compare current management of post-stroke adult patients regarding goal setting and attainment with BoNT-A in Germany (D) and Austria (A) with the full cohort of ULIS-II.

MATERIAL AND METHODS

The ULIS-II was a global, open-label, prospective, multicenter observational study with 2 visits conducted in 84 centers worldwide. A total of 468 patients aged ≥18 years with post-stroke upper limb spasticity were included. The primary outcome measure was the responder rate defined as achievement of a goal attainment scale (GAS) score of 0, 1 or 2 after 1 cycle of BoNT-A.

RESULTS

A total of 57 patients from D/A were included in the efficacy analysis. The number of patients in D/A and the full cohort achieving the primary (78.9% vs. 79.6%) and secondary treatment goal (76.8% vs. 75.6%), respectively, was comparable. Deviating from the full cohort, the most common primary treatment goal in D/A was related to impairment (33.3%). Compared to baseline there was a marked reduction in concomitant therapies at the follow-up visit after 3-5 months in the D/A group: patients receiving oral anti-spastic medication 61.4% vs. 40.4%, positioning 50.9% vs. 36.8% and splinting 43.9% vs. 31.6%. Injection control techniques were less frequently used in the D/A group compared to the global study cohort (electrical stimulation: 26.3% vs. 45.8% and electromyography: 12.3% vs. 29.2%). No adverse events were documented in the D/A cohort.

CONCLUSION

A single injection of BoNT-A in adult patients with post-stroke spasticity of the arm led to a high response rate of approximately 80% in both cohorts. The BoNT-A injections in post-stroke adult patients contributed to an improvement in the daily life of patients and their carers beyond simple reduction of muscle tone or spasticity.

Effects of a 6-month self-rehabilitation programme in addition to botulinum toxin injections and conventional physiotherapy on limitations of patients with spastic hemiparesis following stroke (ADJU-TOX): protocol study for a randomised controlled, investigator blinded study

INTRODUCTION

Home-based self-rehabilitation programmes combined with botulinum toxin injections (BTIs) appear to be a relevant approach to increase the recommended intensive rehabilitation of patients with spasticity following a stroke. The literature highlights a lack of evidence of beneficial effects of this adjuvant therapy to reduce limitations of patients with stroke. The aim of this study is to assess the effects of a 6-month self-rehabilitation programme in adjunction to BTI, in comparison with BTI alone, to reduce limitations of patients with spasticity following a stroke.

METHODS AND ANALYSIS

220 chronic patients will participate to this multicentre, prospective, randomised, controlled, assessor blinded study. All patients will benefit from two successive BTI (3 months apart), and patients randomised in the self-rehabilitation group will perform in adjunction 6 months of self-rehabilitation at home. All patients continue their conventional physiotherapy. The main outcome is the primary treatment goal (PTG), which will be determined jointly by the patient and the medical doctor using Goal Attainment Scaling. Impairments and functions, quality of life, mood and fatigue will be assessed. Botulinum toxin will be injected into the relevant muscles according to the PTG. Patients in the self-rehab group will be taught the self-rehabilitation programme involving respectively 10 min of stretching, 10 min of strengthening and 10 min of task-oriented exercises, corresponding to their PTG. Compliance to the self-rehabilitation programme will be monitored.

ETHICS AND DISSEMINATION

Patients will sign written informed consent. Ethical approval was obtained from ethics committee. The results will be disseminated in a peer-reviewed journal and presented at international congresses. The results will also be disseminated to patients.

TRIAL REGISTRATION NUMBER

NCT02944929.

Effect of the neuro-orthopedic surgery for spastic equinovarus foot after stroke: a prospective longitudinal study based on a goal-centered approach

BACKGROUND

Neuro-orthopedic surgery is recognized as an effective treatment to improve walking capacity in case of spastic equinovarus foot. However, the effect of surgery on the 3 domains of the International Classification of Functioning, Disability and Health (ICF) has never been studied.

AIM

The aim of this study was to assess the efficacy of the neuro-orthopedic surgery for spastic equinovarus foot after stroke based on a goal-centered approach and on the 3 domains of the International Classification of Functioning, Disability and Health (ICF).

DESIGN

Prospective, single blind, case-series, intervention study (before-after trial) with a 1-year follow-up.

SETTING

University Hospital of Mont-Godinne.

POPULATION

Eighteen hemiplegic patients with spastic equinovarus foot.

METHODS

A selective tibial neurotomy and/or an Achille tendon lengthening, and/or a tibialis anterior tendon transfer were performed to correct a disabling SEF. The primary outcome measure was the goal attainment scale. The secondary outcome measures included body function and structure (spasticity, strength, range of motion, pain, gait speed, ankle kinematics), activities (walking aids, functional ambulation category, functional walking category, ABILOCO) and social participation and quality of life (Satispart-Stroke, SF-36) assessment before and 2 months and 1 year after surgery.

RESULTS

An increase in the goal attainment scale score, in the body function and activity/participation domains of the ICF, a decrease in triceps spasticity and pain, an increase in ankle range of motion and gait speed, an improvement in equinus and a reduction in walking aids were observed.

CONCLUSIONS

This study confirms the efficacy of the neuro-orthopedic surgical treatment of spastic equinovarus foot after stroke to improve walking capacities and to achieve personal goals in the body function and activity/participation domains of the ICF.

CLINICAL REHABILITATION IMPACT

In case of post-stroke spastic foot, a personalized neuro-orthopedic surgical program including neurotomy, tendon lengthening and/or transfer improves patient-centered goals in the different domains of the ICF.

Botulinum Toxin A for Spastic Trismus Due to Brain Stem Encephalitis in a Pediatric Intensive Care Setting: A Unique Case Report

Injection of botulinum toxin A to masseter and temporalis muscles improved mouth opening and facilitated suction and oral care in a child with spastic trismus. This is the first such report in a 3.5-year-old child on mechanical ventilator in pediatric intensive care unit setting.

Goal Attainment Scaling for haemophilia (GAS-Hēm): testing the feasibility of a new patient-centric outcome measure in people with haemophilia

INTRODUCTION

To address the need for a patient-reported outcome that can measure clinically and personally meaningful change in people with haemophilia (PwH) on prophylaxis, an approach based on Goal Attainment Scaling (GAS) was developed: the GAS-Hēm.

AIM

To establish real-world feasibility of GAS-Hēm in PwH.

METHODS

Patients aged 5-65 years were enroled from four North American centres for a 12-week study. The primary outcome was the proportion of participants who completed GAS-Hēm interviews at baseline, 6 and 12 weeks. GAS-Hēm scores were obtained by subject- and clinician-rated goal attainment at Weeks 6 and 12, and compared with quality of life (QoL) measures and annualized bleed rate (ABR) for construct validity. Goals were evaluated qualitatively for content validity. Responsiveness was calculated using standardized response means (SRM).

RESULTS

Forty-two participants set 63 goals. Participants preferred to define (37/63) their own goals or further individualize (23/63) from the GAS-Hēm menu. Thirty of the 37 self-defined goals were matched to goals on the GAS-Hēm menu. The most common goal areas were: weight, exercise and nutrition (n = 17); leisure activities (n = 8); and joint problems (n = 7). Both participant- and clinician-rated GAS-Hēm scores at 6 weeks (n = 40) and 12 weeks (n = 41) demonstrated satisfactory goal attainment (SRM [subject-rated] at 12 weeks for adult and paediatric groups was 1.25 and 1.16, respectively). Correlations of GAS-Hēm scores with QoL measures and ABR were uniformly small.

CONCLUSION

GAS-Hēm was feasible and tapped constructs not captured by ABR or QoL measures.

Categorisation of goals set using Goal Attainment Scaling for treatment of leg spasticity: a multicentre analysis

Background: Goal-classification of person-centred goals, using Goal Attainment Scaling for leg spasticity treatment. Methods: The study was conducted in two phases: phase I, a retrospective review to evaluate categories of goal set in routine clinical practice. Findings were used to design a goal classification system. Phase II, a multi-centre study to confirm the goal categories. Goals set (n = 270) were analysed from data collected at three centres in the UK (one centre for phase I). Goal categories were mapped onto the domains of the World Health Organisation, International Classification of Functioning Disability and Health. Results: One hundred and twenty seven participants were recruited in two cohorts: phase I: 63; phase II: 64. Goal categories using both cohorts were assigned to two domains, each subdivided into three key goal categories: Domain 1: body structure impairment 121 (44%): (a) pain/discomfort 34 (12%), (b) involuntary movements 20 (7%), and (c) range of movement/contracture prevention 67 (25%). Domain 2: activity function 149 (56%): (a) passive function (ease of caring for the affected limb) n = 89 (33%), (b) active function (transfers) 26 (10%), and (c) active function (mobility) 27 (10%), other n = 7 (3%). Conclusions: Patients individual leg spasticity goals can be grouped into six categories and two domains, which will assist clinicians, patients and cares in setting and evaluating goals in practice. Implications for Rehabilitation Six goal areas used in clinical goal setting for leg spasticity management were identified, under the two domains: (1) body structure impairment: pain, involuntary movements, and range of movement and (2) activities/function: passive function (ease of caring), active function - transfers or standing and active function - mobility. Categorisation of goals is consistent on repeated evaluation and across different clinical services. Using clinical goals for leg spasticity treatment is an effective method to identify treatment priorities.

Botulinum toxin use in rehabilitation clinics: a survey to highlight differences and similarities

Spasticity is a complex condition and its management is multifaceted, involving physical therapies as well as interventions with botulinum toxin. There is currently no standard for best practice and also wide variation in spasticity service set-ups and the background of clinicians involved in treatment. This could potentially cause large differences in practice. The aim of this survey was to attempt to identify some of the common elements of service delivery as well as highlight any significant variations in service models. It was hoped that the results would assist healthcare professionals working with toxins to gauge or improve their own service provision in the light of any findings. A survey of 48 botulinum toxin experts was conducted at a national conference in the UK. Questions included (i) numbers of patients referred and diagnostic groups, (ii) staff composition of each clinic, (iii) methods of spasticity assessment, (iv) outcome measures and treatment goals commonly used and (v) follow-up arrangements. There were broad areas of agreement between experts such as methods of assessment of spasticity, treatment, injection guidance and follow-up arrangements. However, there were differences in diagnostic groups seen, staff composition and in outcome measurement across a wide range of clinic settings. There are considerable variations in practice between toxin experts. This survey may help practitioners identify areas of improvement in their services or explore alternative service arrangements.

Goal Attainment Scaling in Individuals with Upper Limb Spasticity Post Stroke

Focusing on rehabilitation goals is an effective approach for improving function in individuals with spasticity after stroke. The objectives of this study were to examine and map goals of post-stroke individuals with spasticity using the Goal Attainment Scale (GAS) and International Classification of Functioning, Disability and Health (ICF), and to evaluate the impact of botulinum toxin A (BoNTA) on occupational performance based on the type of rehabilitation goals. Thirty-one patients were recruited from an outpatient spasticity management clinic. Each patient set one goal, was injected with BoNTA in their spastic upper limb muscles and received standard rehabilitation services twice a week for four weeks. Twenty-seven participants achieved the expected level, and four exceeded the expected level of their rehabilitation goals. Fifty-five percent of the goals were related to Activity/Participation, and 45% of the goals were categorized in the Body Structures and Function domain of the ICF. Fifteen goals focused on positioning, while 16 goals focused on (independent) activities of daily living (ADL/IADL). Both the positioning and ADL/IADL groups experienced a reduction in MAS following the administration of BoNTA. The positioning group was older and more impaired. Mapping goals to ICF identifies specific targets for intervention, establishes a common language within the interdisciplinary team and contextualizes the ways disability impacts goals. This study is limited by a relatively small sample size and absence of a functional measure. Further studies can explore the development of goal/item banks to advance the use of GAS for spasticity management. Copyright © 2016 John Wiley & Sons, Ltd.

Impact of integrated upper limb spasticity management including botulinum toxin A on patient-centred goal attainment: rationale and protocol for an international prospective, longitudinal cohort study (ULIS-III)

OBJECTIVES

Describe the rationale and protocol for the Upper Limb International Spasticity (ULIS)-III study, which aims to evaluate the impact of integrated spasticity management, involving multiple botulinum toxin A (BoNT-A) injection cycles and concomitant therapies, on patient-centred goal attainment. Outline novel outcome assessment methods for ULIS-III and report initial evaluation data from goal setting in early stages of the study.

DESIGN

Large international longitudinal cohort study of integrated upper limb spasticity management, including BoNT-A.

PARTICIPANTS AND SETTING

ULIS-III is a 2-year study expected to enrol >1000 participants at 58 study centres across 14 countries.

INTERVENTIONS

The study design is non-interventional and intended to reflect real-life clinical practice. It will describe injection practices and additional treatment strategies, and record clinical decision-making in a serial approach to long-term spasticity management.

OUTCOME MEASURES

ULIS-III will use a goal-directed approach to selection of targeted standardised measures to capture the diversity of presentation, goals and outcomes. ULIS-III will implement the Upper Limb Spasticity Index, a battery of assessments including a structured approach to goal attainment scaling (Goal Attainment Scaling-Evaluation of Outcomes for Upper Limb Spasticity tool), alongside a limited set of standardised measures, chosen according to patients' selected goal areas. Concomitant therapy inputs, patient satisfaction with engagement in goal setting, health economic end points and health-related quality of life data will also be captured.

RESULTS OF INITIAL EVALUATION OF GOAL QUALITY

Recruitment started in January 2015. By June 2015, 58 sites had been identified and initial data collected for 79 patients across 13 sites in 3 countries. Goal setting data were quality-checked and centres rated on the basis of function-related and Specific, Measurable, Achievable, Realistic, Timed (SMART) characteristics of goal statements. Overall, 11/13 centres achieved the highest rating (A++).

CONCLUSIONS

ULIS-III will provide valuable information regarding treatment of and outcomes from real-life upper limb spasticity management worldwide.

TRIAL REGISTRATION NUMBER

NCT02454803; Pre-results.

Detecting change in patient outcomes in a rural ambulatory rehabilitation service: the responsiveness of Goal Attainment Scaling and the Lawton Scale

Objective The Wagga Wagga Ambulatory Rehabilitation Service (WWARS) clinicians felt the Australian Modified Lawton’s Instrumental Activities of Daily Living Scale (Lawton Scale) was unresponsive to changes detected in many patients following their individualised programs. This study examined the performance of the Goal Attainment Scaling (GAS) concomitantly with the Lawton Scale in ambulatory rehabilitation patients. Methods Consecutive patients (n = 83) of WWARS were evaluated pre and post treatment with the Lawton Scale and GAS. The statistical properties, particularly responsiveness, of the scales were compared. Results Statistically significant change (P < 0.001) was observed following treatment on both the Lawton Scale and GAS. Mean GAS scores changed by 38.7% compared with 8.3% for the Lawton Scale. GAS demonstrated a greater effect size (Cliff’s δ) of 1.67 (95% confidence interval 1.51–1.91) than the Lawton Scale 0.83 (95% confidence interval 0.57–0.94). In 33.7% of patients, the Lawton Scale was invariant but improved with GAS. Conclusions GAS was a more responsive measure than the Lawton Scale in rural ambulatory rehabilitation patients. Consequently, GAS is recommended as a performance outcome measure in the evaluation of ambulatory rehabilitation services to supplement standardised outcome measures such as the Lawton Scale. What is known about the topic? GAS has been shown to be more responsive in detecting changes in patient outcomes than the original Lawton’s Instrumental Activities of Daily Living Scale when assessing the requirements of the elderly for geriatric services and for people with acquired brain injury undergoing cognitive rehabilitation. Its responsiveness in patients with greater casemix diversity, such as those found in rural ambulatory rehabilitation services, remains uncertain. What does this paper add? This study demonstrates GAS is more responsive than the Lawton Scale for detecting clinically meaningful change in a rural Australian ambulatory rehabilitation service delivering programs to people with heterogeneous goals. What are the implications for practitioners? GAS facilitates the delivery of patient-centred care, accommodates the heterogeneity of patient-centred goals for evaluation, and better measures goal-achievement. Global standardised measures such as the Lawton Scale may be useful for the comparison of differing patient populations, but a weakness is they may not capture the individualised goals valued by each patient seen in rehabilitation. Consequently, GAS should be considered as an additional outcome measure in the evaluation of ambulatory rehabilitation services in assessing program effectiveness and possibly for service comparison. Furthermore, ongoing training and support in GAS application should be provided to ensure the maintenance of accurate goal setting and scaling.

Frequency and characteristics of goal attainment following BoNT-A injection for management of spasticity

PURPOSE

To determine which Goal Attainment Scale (GAS) goals are commonly achieved in patients with upper limb and/or lower limb spasticity following Botulinum Neurotoxin Type A (BoNT-A) injection.

METHOD

Adults who attended a Spasticity Management Clinic for upper and/or lower limb BoNT-A injection were included in this prospective cohort study. Goals were set by participants and/or carers in conjunction with the therapist using the GAS, prior to injection and reviewed at one month following the injection. Three out of the five categories of goals were passive. Goals were categorised into: mobility/transfers, pain/comfort, upper limb use, hygiene, and cosmesis. The number of responders for the GAS total score, and in each of the GAS categories, was calculated.

RESULTS

Sixty-seven participants were recruited (mean age 51 ± 16 years; range 18-85), 70% had a stroke. Responders for mobility and transfer goals were further post injury or disease onset than non-responders (median 5.9 vs. 1.2 years, p = 0.03). Clients with stroke were less likely than other participants to achieve mobility and transfer goals (p = 0.02). There was a trend for those who achieved mobility and transfer goals to be younger (mean 49 years vs. 55 years, p = 0.06). Although active goals are more commonly identified, passive goals were more likely to be achieved.

CONCLUSIONS

Although active goals are commonly identified by people with spasticity, passive goals were more likely to be achieved following BoNT-A injection. A long duration of spasticity does not preclude patients from achieving mobility and transfer goals. Non-stroke participants were more likely to achieve mobility and transfer goals. Implications for Rehabilitation Patients with chronic spasticity should be considered for BoNT-A as clinically meaningful outcomes can be achieved. When spasticity is present in multiple muscles, the GAS can be an assistive tool to guide clinicians in determining which muscles are a priority for injection, because the client will be more motivated to improve those specific goals. Although carers and patients are more willing to set active goals, these are more difficult to achieve possibly because follow up intervention or independent practise is required.

[The study of the efficacy of Botulinum toxin type A in patients with poststroke upper-limb spasticity ULIS-II: an analysis of Russian patients]

AIM

To assess the efficacy of Botulinum toxin type A (BoNT-A) injections in routine practice.

MATERIAL AND METHODS

An international, post-marketing, multi-center, observational, prospective, longitudinal study included patients ≥18 years with poststroke upper-limb spasticity in whom a decision to inject BoNT-A had already been made, and who had no previous treatment with BoNT-A or BoNT-B within the last 12 weeks. The responder rate was assessed by the patient-centered goal attainment scaling (GAS).

RESULTS AND CONCLUSION

The study included 7 Russian research centers (41 patients). Sixteen patients (39%) received BoNT-A injections prior to entering the study. During the treatment, 29 patients (70.7%) received dysport injections; 2 (4.9%) botox injections, 8 (19.5%) xeomin injections and 2 (4.9%) other BoNT-A agents. The primary treatment goals were successfully attained in 87.8%, secondary treatment goals in 88.3%. An improvement in passive function as primary goal and as secondary goal were achieved in 100%, in the range of movement in 94.9%, pain reduction in 82.4%, improvement in active function of the upper limb in 76.5%, reduction in involuntary movements (associated reactions) in 83.3% of cases. Investigators' global assessment of benefits revealed that 97.6% of patients showed positive effects from BoNT-A injections. Pateitnts' assessment of global benefits was slightly lower - 90,2% of patients reported positive treatment effects When assessed by patients, the rate of global benefits was 90.2%. Botulinum-toxin therapy is an effective treatment option. In the vast majority of patients, it allows both for reduction in muscle tone and functional benefits that could improve quality of life of the patients.

Common goal areas in the treatment of upper limb spasticity: a multicentre analysis

Objective:

We aimed to develop a goal classification of individualised goals for spasticity treatment incorporating botulinum toxin intervention for upper limb spasticity to under-pin a more structured approach to future goal setting.

Design:

Individualised goals for spasticity treatment incorporating botulinum toxin intervention for upper limb spasticity ( n=696) were analysed initially from four studies published in 2008-2012, spanning a total of 18 centres (12 in the UK and 6 in Australia). Goals were categorised and mapped onto the closest matching domains of the WHO International Classification of Functioning. Confirmatory analysis included a further 927 goals from a large international cohort study spanning 22 countries published in 2013.

Results:

Goal categories could be assigned into two domains, each subdivided into three key goal areas: Domain 1: symptoms/impairment n=322 (46%): a. pain/discomfort n=78 (11%), b. involuntary movements n=75 (11%), c. range of movement/contracture prevention n=162 (23%). Domain 2: Activities/function n=374 (54%): a. passive function (ease of caring for the affected limb) n=242 (35%), b active function (using the affected limb in active tasks) n=84 (12%), c. mobility n=11 (2%). Over 99% of the goals from the large international cohort fell into the same six areas, confirming the international applicability of the classification.

Conclusions:

Goals for management of upper limb spasticity, in worldwide clinical practice, fall into six main goal areas.

Factors influencing goal attainment in patients with post-stroke upper limb spasticity following treatment with botulinum toxin A in real-life clinical practice: sub-analyses from the Upper Limb International Spasticity (ULIS)-II Study

In this post-hoc analysis of the ULIS-II study, we investigated factors influencing person-centred goal setting and achievement following botulinum toxin-A (BoNT-A) treatment in 456 adults with post-stroke upper limb spasticity (ULS). Patients with primary goals categorised as passive function had greater motor impairment (p < 0.001), contractures (soft tissue shortening [STS]) (p = 0.006) and spasticity (p = 0.02) than those setting other goal types. Patients with goals categorised as active function had less motor impairment (0.0001), contracture (p < 0.0001), spasticity (p < 0.001) and shorter time since stroke (p = 0.001). Patients setting goals for pain were older (p = 0.01) with more contractures (p = 0.008). The proportion of patients achieving their primary goal was not impacted by timing of first-ever BoNT-A injection (medium-term (≤1 year) vs. longer-term (>1 year)) post-stroke (80.0% vs. 79.2%) or presence or absence of severe contractures (76.7% vs. 80.6%), although goal types differed. Earlier BoNT-A intervention was associated with greater achievement of active function goals. Severe contractures impacted negatively on goal achievement except in pain and passive function. Goal setting by patients with ULS is influenced by impairment severity, age and time since stroke. Our findings resonate with clinical experience and may assist patients and clinicians in selecting realistic, achievable goals for treatment.

Management of spasticity revisited

Spasticity is common after stroke and other neurological conditions and causes considerable limitations of movement, activities of daily living and participation. Interaction with other components of the upper motor neurone syndrome (UMNS) and the heterogeneity of patients' presentations together with limited tools for outcome measurement have hampered the production of randomised controlled trial data for management strategies. Specialist multi-disciplinary goal-centered management programmes are the mainstay of treatment. Pharmacological therapies have limited effect, and physical and positional management are crucial. Targeted intramuscular botulinum toxin injection is now the most popular pharmacological treatment. Intrathecal therapies also play a lesser role. A team approach and holistic assessment are essential to beneficial outcomes.

Results from the Upper Limb International Spasticity Study-II (ULISII):a large, international, prospective cohort study investigating practice and goal attainment following treatment with botulinum toxin A in real-life clinical management

OBJECTIVE

To describe real-life practice and person-centred outcomes in the treatment of poststroke upper limb spasticity with botulinum toxin A (BoNT-A).

DESIGN

Observational, prospective study.

SETTING

84 secondary care centres in 22 countries.

PARTICIPANTS

456 adults (≥18 years) with poststroke upper limb spasticity treated with one cycle of BoNT-A.

METHODS/OUTCOMES

Muscle selection, BoNT-A preparation, injection technique and timing of follow-up were conducted according to routine practice for each centre.

PRIMARY OUTCOME

achievement of the patient's primary goal for treatment using goal-attainment scaling (GAS). Measurements of spasticity, standardised outcome measures and global benefits were also recorded.

RESULTS

The median number of injected muscles was 5 (range 1-15) and the most frequently injected muscles were the long finger flexors, followed by biceps and brachioradialis. The median (range) follow-up time was 14 (2.6 to 32.3) weeks. The common primary treatment goals were passive function (132 (28.9%)), active function (104 (22.8%)), pain (61 (13.4%)), impairment (105 (23%)), involuntary movement (41 (9%)) and mobility (10 (2.2%)). Overall, 363 (79.6%) (95% CI 75.6% to 83.2%) patients achieved (or overachieved) their primary goal and 355 (75.4%) (95% CI 71.2% to 79.2%) achieved their secondary goal. Mean (SD) change from baseline in GAS T-scores was 17.6 (11.0) (95% CI 16.4 to 18.8; p<0.001). GAS T-scores were strongly correlated with global benefit and other standard measures (correlations of 0.38 and 0.63, respectively; p<0.001).

CONCLUSIONS

BoNT-A demonstrated a clinically significant effect on goal attainment for the real-life management of upper-limb spasticity following stroke. The study confirms the feasibility of a common international data set to collect systematic prospective data, and of using GAS to capture person-centred outcomes relating to passive and active functions and to pain.

REGISTRATION

ClinicalTrials.gov identifier: NCT01020500.

Feasibility of video clip analysis on effect of botulinum toxin-A injection for post-stroke upper limb spasticity

Existing functional evaluation tools do not accurately reveal the improved function following botulinum toxin A (BTX-A) injection for post-stroke upper limb spasticity. With the aim of developing an alternate method of measuring functional improvement following BTX-A injection, this study tested the feasibility, validity and reliability of video clip analysis performed by the clinicians. Seventy-nine patients administered BTX-A due to post-stroke upper limb spasticity, were retrospectively evaluated using video clip analysis. Pre- and post-injection video clips recorded at 1-month intervals were randomly allocated and sent to three blinded physician evaluators who were asked to choose the one that seemed more improved in terms of hand motion and associated upper limb reaction during gait. The three physicians chose the post-injection video clip as depicting improved hand motion (82.3%, 79.7%, and 72.2%) and associated upper limb reaction during gait (73.4%, 70.9%, and 70.9%). Kappa and intraclass correlation coefficient as a measure of interrater reliability among the three physicians was 0.86 and 0.79 for the hand, and 0.92 and 0.92 for associated upper limb reaction during gait, respectively. The percent overall agreement of the physicians was 78.1% and 71.7% for hand function and associated upper limb reaction, respectively. Retrospective pre- and post-BTX-A injection video clip analyses is a clinically feasible alternative method to evaluate the improvement following BTX-A injection for post-stroke upper limb spasticity, especially in busy clinical practice setting.

Systematic review of upper-limb function measurement methods in botulinum toxin intervention for focal spasticity

BACKGROUND AND PURPOSE

This paper aimed to select studies evaluating botulinum toxin (BoNT) intervention applied for upper-limb spasticity and from these identify outcome measures that are a) applicable in the hemiparetic upper limb and b) include evaluation of functional outcome in the context of everyday real-life activities.

METHODS

A systematic search was used to identify peer-reviewed papers evaluating BoNT intervention for focal spasticity management in the upper limb. From these papers, outcome evaluation methods were identified, which attempted to capture 'active function' improvement (functional use of the hand and/or arm) or passive function improvement (care for the affected limb, for example to maintain hygiene and dress or support the arm).

RESULTS

The search yielded 411 studies. Seventy papers were identified following a final review of the abstracts as potentially including evaluation of functional outcome (active and/or passive function). Following the review of the papers, a total of 22 studies contained specific methods for evaluating functional outcome in the upper limb.

DISCUSSION

Three different patient-focused methods to evaluate functional outcome following focal spasticity intervention using BoNT have been identified: 1) use of patient report of upper-limb items (including the Leeds Adult Spasticity Impact Scale and the Disability Assessment Scale), 2) use of a composite measure of function incorporating functional items and 3) Goal Attainment Scaling. None of these methods fully address evaluation of functional outcome in this context but may go some way to recording these improvements. An alternative or complementary measure, recently published, is the Arm Activity Measure for evaluation of active and passive function in this context. The Arm Activity Measure addresses active and passive function changes from the perspective of patients and carers and has been developed for application in this context.