The use of botulinum toxin type A in the management of adult-onset focal spasticity: a survey of Australian allied health professionals

The barriers and facilitators to satisfaction with botulinum neurotoxin treatment in people with cervical dystonia: a systematic review

Background

Cervical dystonia (CD) is an isolated, focal, idiopathic dystonia affecting the neck and upper back. CD is usually treated by botulinum neurotoxin (BoNT) injections into the dystonic muscles; however, about 20% of people will discontinue BoNT therapy. This systematic review aimed to determine the barriers to satisfaction and facilitators that could improve satisfaction with BoNT therapy for people with CD.

Methods

A database search for journal articles investigating satisfaction with BoNT treatment in CD identified seven qualitative studies and one randomised controlled trial. Results were grouped into “direct” and “indirect” barriers and facilitators.

Results

The most reported direct barrier to satisfaction with BoNT was treatment non-response, reported by up to 66% of participants. Other direct barriers included negative side effects, early wearing-off of treatment effect and inexperience of the treating physician. Indirect barriers included limited accessibility to treatment (including cost) and personal choice. Direct facilitators of satisfaction with BoNT included relief of symptoms and flexible re-treatment intervals. Indirect facilitators included easy accessibility to treatment.

Conclusions

Despite BoNT having a discontinuation rate of only 20%, it appears a much greater proportion of people with CD are dissatisfied with this treatment. As BoNT is currently the main treatment offered to people with CD, efforts to improve treatment response rates, reduce side effects and make treatment more flexible and readily available should be adopted to improve the quality of life for people with CD.

Supplementary information

The online version contains supplementary material available at 10.1007/s10072-022-06114-8.

Botulinum Neurotoxin-A Injection in Adult Cervical Dystonia and Spastic Paresis: Results From the INPUT (INjection Practice, Usage and Training) Survey

Botulinum toxin-A (BoNT-A) is an effective treatment for cervical dystonia (CD) and spastic paresis (SP), but it requires in-depth knowledge of anatomy and injection techniques. The Ixcellence Network® is an educational programme to provide neurology, neuropaediatrics, and physical medicine and rehabilitation (PMR) specialists with access to best clinical practices and innovations regarding SP and CD management with BoNT-A. To assess the benefits of such educational programmes and identify unmet needs, a multidisciplinary scientific committee designed INPUT (INjection Practice, Usage & Training), an international multicentric survey describing training and practices among this trained and experienced population. A self-completed questionnaire was sent online to 553 trainees and 14 trainers from the Ixcellence Network®. Among the 131 respondents, 92% specialized in PMR (48%) or neurology (44%), with a mean experience of 15.5 years in their clinical fields and 10.9 years of BoNT-A injection. Most of them (98%) reported having received training before performing their first BoNT-A injection and attending specific courses on how to perform it without any instrumental guidance (76%), and with ultrasound (73%), electrical stimulation (44%) or electromyography (41%). In terms of practices, 92% of respondents reported using at least one guidance technique while injecting, with ultrasound being the most used technique (48%). Attending specific courses was significantly associated with greater self-confidence and use, e.g. for injection with ultrasound, mean self-confidence, on a scale from 1 (not confident) to 10 (fully confident), was 7.9 for trained respondents (vs 4.0 for untrained respondents, p < 0.001) of whom 70% stated that they used this technique regularly or systematically (vs. 11% of untrained healthcare professionals (HCPs), p < 0.0001). Moreover, 84% of respondents reported having trained colleagues, residents or fellows through theoretical (70%) or practical teaching in individuals (80%) or in small groups (65%). Overall, 86% of respondents reported a notable increase over the past 5 years of the number of patients treated with BoNT-A. INPUT is the first international survey describing training and practices in SP and CD management of physicians who attended a dedicated educational programme. The results highlighted the importance of training for self-confidence, and the use of specific techniques and new approaches.

Practice Patterns of Physicians Using Adjunct Therapies with Botulinum Toxin Injection for Spasticity: A Canadian Multicenter Cross-Sectional Survey

BACKGROUND

Adjunct therapies are nonpharmacological treatments used with botulinum toxin (BoNT) injection that may improve spasticity outcomes. It has been suggested that physicians consider adjunct therapies as a part of comprehensive spasticity management. It is unclear which adjunct therapies are used by physicians in clinical practice.

OBJECTIVE

To determine physician practice patterns and perceptions of use of adjunct therapies following BoNT injection for limb spasticity.

DESIGN

Cross-sectional national survey of current clinical practice using a 22-item questionnaire developed by the authors.

SETTING

Not applicable.

PARTICIPANTS

Survey respondents were physicians actively administering BoNT injections for limb spasticity management across Canada (N = 48).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Types of adjunct therapies used by physicians; physician opinions on barriers to adjunct therapy use, patient preferences, and future research priorities.

RESULTS

Most physicians prescribe home stretching programs, home active exercise programs, and splinting; however, many physicians perceive that these same adjunct therapies are unwanted by patients. A minority of physicians prescribe electrical stimulation (ES), transcutaneous electrical nerve stimulation (TENS), casting, and extracorporeal shockwave therapy; financial limitations and perceived lack of evidence were identified as barriers to their use. Significantly more physicians practicing in academic settings compared with nonacademic, community, and private practice settings used functional ES (59% vs 11%) and TENS (41% vs 0%) as adjunct therapies (P < .05). Research priorities included determining the effectiveness of immediate postinjection application of adjunct therapies (eg, injected muscle activation with ES or stretching) and nutraceuticals.

CONCLUSIONS

Canadian physicians frequently use adjunct therapies in combination with BoNT injection to treat spasticity. Financial and time constraints are identified as barriers to implementation of adjunct therapies that are currently supported by research, and patient preferences may also affect compliance. Future research should focus on adjunct therapies that overcome these barriers.

Intensive therapy after botulinum toxin in adults with spasticity after stroke versus botulinum toxin alone or therapy alone: a pilot, feasibility randomized trial

Background

Botulinum toxin-A is provided for adults with post-stroke spasticity. Following injection, there is a variation in the rehabilitation therapy type and amount provided. The purpose of this study was to determine if it is feasible to add intensive therapy to botulinum toxin-A injections for adults with spasticity and whether it is likely to be beneficial.

Methods

Randomized trial with concealed allocation, assessor blinding, and intention to treat analysis. Thirty-seven adults (n = 3 incomplete or lost follow-up) with spasticity in the upper or lower limb were allocated to one of three groups: experimental group received a single dose of botulinum toxin-A plus an intensive therapy for 8 weeks, control group 1 received a single dose of botulinum toxin-A only, and control group 2 received intensive therapy only for 8 weeks. Feasibility was measured by examining recruitment, intervention (adherence, acceptability, safety), and measurement. Benefit was measured as goal achievement (Goal Attainment Scale), upper limb activity (Box and Block Test), walking (6-min walk test) and spasticity (Tardieu scale), at baseline (week 0), immediately after (week 8), and at three months (week 12).

Results

Overall recruitment fraction for the trial was 37% (eligibility fraction 39%, enrolment fraction 95%). The 26 participants allocated to receive intensive rehabilitation attended 97% of clinic-based sessions (mean 11 ± 2 h) and an averaged 58% (mean 52 ± 32 h) of prescribed 90 h of independent practice. There were no study-related adverse events reported. Although participants in all groups increased their goal attainment, there were no between-group differences for this or other outcomes at week 8 or 12.

Conclusion

Providing intensive therapy following botulinum toxin-A is feasible for adults with neurological spasticity. The study methods are appropriate for a future trial. A future trial would require 134 participants to detect a between-group difference of 7 points on Goal Attainment Scale t-scores with an alpha of 0.05 and power of 80%.

Trial registration

ACTRN12612000091808. Registered 18/01/2012, retrospective

Upper limb spasticity management for patients who have received Botulinum Toxin A injection: Australian therapy practice

BACKGROUND/AIM

To describe Australian physiotherapy and occupational therapy practice for patients who receive upper-limb Botulinum Toxin-A (BoNT-A).

METHOD

Anonymous online survey asking about practice experience. Convenience sample of 128 BoNT-A experienced occupational therapists and physiotherapists.

RESULTS

The primary work setting was multidisciplinary inpatient or outpatient rehabilitation services where therapists had automatic referral to BoNT-A patients. Patients expected BoNT-A to improve functional movement, reduce hypertonicity, increase passive range, reduce pain, improve appearance and hand hygiene. Most patients were injected in multidisciplinary public hospital clinics and had median 2 pre-injection (range 0-30) and 8 post-injection (range 0-50) therapy sessions. Biceps, flexor digitorum profundus/superficialis and brachoradialis were most frequently injected. Injectors used therapist assessment information to select sites 68% of the time; only 44% of services had assessment protocols. Standardised therapy assessments examined motor performance, pain and function in that order of frequency. The greater the awareness and perceived relevance of an assessment the more often therapists used it. All therapists set goals, most collaboratively, and these mirrored patient expectations. The most common treatments were stretch, task-specific functional training, strength training and home programmes.

CONCLUSION

While trends in Australian assessment, goals and treatment practice were observed, greater consistency could be achieved if therapy practice guidelines existed. The gap is exacerbated by the absence of Australian BoNT-A organisation and process of care spasticity management guidelines. This creates an environment where practice variability is inevitable. Recommendations to improve local service quality are made.

A systematic review protocol to evaluate the psychometric properties of measures of function within adult neuro-rehabilitation

BACKGROUND

Spasticity in the upper limb is common after acquired brain impairment and may have a significant impact on the ability to perform meaningful daily activities. Traditionally, outcome measurement in spasticity rehabilitation has focused on impairment, however, improvements in impairments do not necessarily translate to improvements in an individual's ability to perform activities or engage in life roles. There is an increasing need for outcome measures that capture change in activity performance and life participation.

METHODS/DESIGN

We will conduct a systematic review of the psychometric properties of instruments used to measure upper limb functional outcomes (activity performance and participation) in patients with spasticity. Assessments (n = 27) will be identified from a recently published systematic review of assessments that measure upper limb function in neurological rehabilitation for adults with focal spasticity, and a systematic review of each assessment will then be conducted. The databases MEDLINE, CINAHL and EMBASE will be searched from inception. Search strategies will include the name of the assessment and the COnsensus-based Standards for the selection of health status Measurement INstruments (COSMIN) published search strategy for identifying studies of measurement properties. The methodological rigour of the testing of the psychometric quality of instruments will be undertaken using the Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) checklist. International Classification of Functioning, Disability and Health (ICF) definitions of impairment, activity and participation will be used for content analysis of items to determine the extent to which assessments are valid measures of activity performance and life participation. We will present a narrative synthesis on the psychometric properties and utility of all instruments and make recommendations for assessment selection in practice.

DISCUSSION

This systematic review will present a narrative synthesis on the psychometric properties and utility of assessments used to evaluate function in adults with upper limb focal spasticity. Recommendations for assessment selection in practice will be made which will aid clinicians, managers and funding bodies to select an instrument fit for purpose. Importantly, appropriate assessment selection will provide a mechanism for capturing how applicable to everyday life the outcomes from individualised rehabilitation programs for the upper limb really are.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42014013190.

Botulinum neurotoxin type A versus punctal plug insertion in the management of dry eye disease

Purpose:

To compare the efficacies of punctal plug insertion and Botulinum toxin injection in dry eye disease not responding to topical medications.

Materials and Methods:

A non-controlled randomized clinical trial of two parallel groups of 60 dry eye patients seen in the clinic not responding to topical medications were divided into two groups. One group received punctal plugs and the other group received Botulinum toxin injections to prevent lacrimal tear drainage.

Results:

Of a total of 36 patients with a mean age of 44.5 years who received punctal plugs, 50% of them experienced improvements in the clinical manifestations of their disease. 12/36 (33.3%) developed plug extrusion, and 6/36 (16.7%) patients developed conjunctival erosions with irritation that necessitated plug removal within one week of insertion. A total of 24 patients with a mean age of 47.5 years received injections of Botulinum toxin. Of these, 83.3% had improvement in all of the clinical manifestations of dry eye. 4/24 (16.7%) had no improvement in the degrees to which they experienced foreign body sensations, 33.3% reported shampoo entering the eye while showering. All of the patients who received Botulinum toxin injections were satisfied with the results of their treatment, whereas only 72.3% of the patients who received punctal plugs were satisfied with their results.

Conclusion:

Botulinum neurotoxin A injections can be a very good alternative to punctal plugs in improving the clinical manifestations of dry eye disease They are associated with the development of fewer and milder complications and with higher levels of patient satisfaction.

The process of developing a non-medical (advanced allied health) botulinum toxin A prescribing and injecting model of care in a public rehabilitation setting

Objective The aim of this paper was to describe the process undertaken to develop a non-medical (advanced allied health extended role) botulinum toxin A prescription and injection project for adults with upper and lower limb spasticity secondary to an acquired brain injury. The hypertonicity clinic in the present study was located in a metropolitan public hospital in Queensland where multidisciplinary services are provided by a rehabilitation specialist and an advanced occupational therapist and physiotherapist. Methods The process of developing the model included establishing potential benefits for the role extension project and documentation of a project plan. Results Project outcomes included the development of a relevant governance structure, a research evidence-based project evaluation framework, a draft research ethics application, delineation of the key eligibility criteria and competencies required for physiotherapist and occupational therapist prescribers, and a final project report. Conclusion Non-medical prescribing has the potential to increase patient access to botulinum toxin A injection for the management of focal spasticity. A process that supports early patient engagement, extensive consultation with relevant stakeholders, a strong governance structure, a high-quality research project and a long lead time may maximise the potential for successful completion of advanced allied health role extension projects, including prescription and injection of botulinum toxin A. What is known about the topic? Non-medical prescribing has been recommended as a strategy for facilitating responsive health care and addressing health workforce shortages in Australia and overseas. What does this paper add? A detailed description of the process used to develop a non-medical prescribing and injecting project within a public hospital rehabilitation unit, as well as an analysis of the facilitators and barriers to progression. What are the implications for practitioners? A process that supports early patient engagement, extensive consultation with relevant stakeholders, a strong governance structure, a high-quality research project and a long lead time may maximise the potential for successful completion of advanced allied health role extension projects, including prescription and injection of botulinum toxin A.