Perspective of an International Online Patient and Caregiver Community on the Burden of Spasticity and Impact of Botulinum Neurotoxin Therapy: Survey Study

How many stroke survivors develop problematic spasticity requiring pharmacological therapy? An international (Europe and USA) observational study protocol

INTRODUCTION

Current care plans for stroke survivors typically focus on acute management, resulting in many stroke survivors being discharged to their communities without adequate follow-up, despite their often experiencing significant post-stroke complications, such as post-stroke spasticity (PSS). While studies have explored the incidence and prevalence of PSS, little is known about how early PSS develops and how many stroke survivors develop 'problematic' PSS that would benefit from pharmacological treatment.

METHODS AND ANALYSIS

EPITOME is a prospective, international, observational, epidemiological study of participants (aged 18-90 years) who develop paresis within days 3-14 of a first-ever stroke that occurred within the past 4 weeks. Participants at sites across seven different countries are monitored remotely at 2 weeks and 1, 2, 3, 6, 9 and 12 months post-stroke to detect the possible onset of PSS using the Post-stroke Spasticity Monitoring Questionnaire (PSMQ). If the PSMQ indicates the possible presence of PSS, participants undergo a full in-clinic assessment to confirm the presence of PSS. For participants with confirmed PSS, the severity and distribution of spasticity is documented, and the investigator assesses whether the participant has spasticity that could benefit from pharmacological therapy. Participants without clinically confirmed PSS return to remote monitoring.

ETHICS AND DISSEMINATION

Ethics approval was obtained in all seven participating countries. Results will be published at international meetings and in an international peer-reviewed journal. Lay summaries will be prepared to accompany the primary paper and will also be provided to study participants.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov NCT06055725.

A survey on the short to medium-term satisfaction of neurological patients treated by functional surgery for the correction of limb deformities

OBJECTIVES

Functional surgery (FS) is often used to correct congenital or acquired deformities in neurological patients. Along with functional results, short- and medium-term patient satisfaction should always be considered a key goal of surgery and rehabilitation. The aim of this study is to assess the short to medium-term satisfaction of patients who underwent FS and its correlation with perceived improvements.

METHODS

Invitation to an anonymous online survey was sent via e-mail to all neurological adult patients or caregivers of children who underwent lower or upper limb FS over the 2018-2020 period. The survey investigated patients' satisfaction with the surgery and the variation in pain, ADLs, level of independence, body image, self-esteem, social interaction skills, participation in social events, leisure activities and sports, and use of orthoses or walking aids. Descriptive data analysis was performed. Correlations were assessed using Kendall's tau.

RESULTS

122 out of 324 adults and 53 out of 163 children's caregivers filled out the questionnaire, with a response rate approaching 40%. Eighty-three percent of adult respondents and 87% of the children's caregivers were satisfied or very satisfied in the short and medium terms and reported their expectations had been met. Satisfaction was significantly correlated (p < 0.01) with improvements in functional abilities, social participation, self-esteem, and pain reduction. Half of the adults and 40% of children stopped using their orthoses or replaced them with lighter ones. Dissatisfaction and worsened conditions were reported by <10% of the respondents.

CONCLUSION

According to patients and caregivers, FS was satisfactory in the short and medium terms, following improvements in all the ICF domains for most patients.

Effect of transcutaneous spinal direct current stimulation on spasticity in upper motor neuron conditions: a systematic review and meta-analysis

STUDY DESIGN

A systematic review and meta-analysis of clinical trials.

OBJECTIVES

To determine the effect of non-invasive transcutaneous spinal direct current stimulation (tsDCS) on spasticity, activity limitations and participation restrictions in various upper motor neuron diseases.

METHODS

Six databases including CINAHL plus, Cochrane CENTRAL, Embase, MEDLINE, SCOPUS and Web of Science were searched for the relevant records from January 2008 to December 2022. Two reviewers independently selected and extracted data on spasticity, activity limitations and participation restrictions. The risk of bias was evaluated using the PEDro scale while the GRADE approach established the certainty of the evidence.

RESULTS

Eleven studies were identified of which 5 (45.5%) were rated as having a low risk of bias and 8 (72.7%) were meta-analyzed. The meta-analyses did not show any significant differences between cathodal (SMD = -0.67, 95% CI = -1.50 to 0.15, P = 0.11, I2 = 75%, 6 RCTs) or anodal (SMD = 0.11, 95% CI = -0.43 to -0.64, p = 0.69, I2 = 0%, 2 RCTs) and sham tsDCS for spasticity. There was also no significant difference between active and sham tsDCS for activity limitations (SMD = -0.42, 95% CI = -0.04 to 0.21, p = 0.2, I2 = 0%, 2 RCTs) and participation restrictions (MD = -8.10, 95% CI = -18.02 to 1.82, p = 0.11, 1 RCT).

CONCLUSIONS

The meta-analysis of the available evidence provides an uncertain estimate of the effect of cathodal tsDCS on spasticity, activity limitation and participation restriction. It might be very helpful, or it may make no difference at all. However, considering the level of the evidence and the limitation in the quality of the majority of the included studies, further well-designed research may likely change the estimate of effect.

TRIAL REGISTRATION

PROSPERO CRD42021245601.

A Cost-Effectiveness and Budget Impact Analysis of AbobotulinumtoxinA in Greece

This study aimed to assess the cost-effectiveness of abobotulinumtoxinA (aboBoNT-A) plus Best Supportive Care (BSC) compared with BSC alone for managing limb spasticity in adult patients in Greece, as well as to conduct a budget impact analysis of the introduction of aboBoNT-A in the Greek healthcare system compared to onabotulinumtoxinA (onaBoNT-A). Clinical studies were utilized to extract data on drug efficacy and patients' utility, while cost data were collected from Greek sources. The results of the study showed that aboBoNT-A plus BSC was a cost-effective treatment option for both upper and lower limb spasticity in adult patients compared to BSC. Additionally, introducing aboBoNT-A into the Greek healthcare system resulted in cost savings in pharmaceutical spending over a 5-year period. The findings suggest that incorporating aboBoNT-A into the Greek healthcare system could improve patient access to treatment and healthcare resource efficiency, as it is a more economical option compared to onaBoNT-A.

A UK Single-Center, Retrospective, Noninterventional Study of Clinical Outcomes and Costs of Two BotulinumtoxinA Treatments for Limb Spasticity

Service model changes at the North Staffordshire Rehabilitation Centre (UK) included switching spasticity treatment from onabotulinumtoxinA (onaBoNT-A) to abobotulinumtoxinA (aboBoNT-A). This noninterventional, retrospective, longitudinal study (NCT04396704) describes the clinical and economic outcomes in toxin-naive adults with spasticity who received onaBoNT-A (Cohort 1; 2015-2017) or aboBoNT-A (Cohort 2; 2017-2019). Outcomes included Goal Attainment Scale T (GAS-T) score, treatment satisfaction, quality of life (QoL; EQ-5D visual analog scale [VAS] score), and treatment costs. Adverse events were recorded for Cohort 2. Cohort 1 included 60 patients (mean [standard deviation] dose, 206.0 [98.8] U); Cohort 2 included 54 patients (753.7 [457.3] U). Mean (95% confidence interval) GAS-T scores for Cohorts 1 and 2 were 43.1 (39.3-46.9) and 47.8 (43.7-51.9) at Week 6, and 43.2 and 44.3 at Week 12, respectively. In both cohorts most patients were satisfied with treatment. At Week 12, QoL had not changed in Cohort 1 but had improved in Cohort 2 (EQ-5D VAS, -5). Mean estimated per-patient costs (in 2021) for Cohorts 1 and 2 were £315.56 and £249.25, respectively, at Week 6, and £343.20 and £273.21, respectively, at Week 12. Fifteen non-treatment-related serious adverse events and two deaths were recorded. These data may warrant a larger prospective study powered to compare outcomes of aboBoNT-A and onaBoNT-A.

Botulinum toxin use in patients with post-stroke spasticity: a nationwide retrospective study from France

Background

Current guidelines recommend intramuscular botulinum toxin type A (BoNT-A) injection as first-line treatment for spasticity, a frequent and impairing feature of various central nervous system (CNS) lesions such as stroke. Patients with spasticity commonly require BoNT-A injections once every 3 to 4 months. We conducted a nationwide, population-based, retrospective cohort study, using the French National Hospital Discharge Database (PMSI), to describe BoNT-A use for spasticity in clinical practice in France between 2014 and 2020. The PMSI database covers the whole French population, corresponding to over 66 million persons.

Methods

We first searched the PMSI database for healthcare facility discharge of patients who received BoNT-A injections between 2014 and 2020, corresponding to the first set. For each BoNT-A-treated patient, we identified the medical condition for which BoNT-A may have been indicated. Another search of the PMSI database focused on patients admitted for acute stroke between 2014 and 2016 and their spasticity-related care pathway (second set). Overall, two subpopulations were analysed: 138,481 patients who received BoNT-A injections between 2014 and 2020, and 318,025 patients who survived a stroke event between 2014 and 2016 and were followed up until 2020.

Results

Among the 138,481 BoNT-A-treated patients, 53.5% received only one or two BoNT-A injections. Most of these patients (N = 85,900; 62.0%) received BoNT-A because they had CNS lesions. The number of patients with CNS lesions who received ≥1 BoNT-A injection increased by a mean of 7.5% per year from 2014 to 2019, but decreased by 0.2% between 2019 and 2020, corresponding to the COVID-19 outbreak. In stroke survivors (N = 318,025), 10.7% were coded with post-stroke spasticity, 2.3% received ≥1 BoNT-A injection between 2014 and 2020, and only 0.8% received ≥3 injections within the 12 months following BoNT-A treatment initiation, i.e., once every 3 to 4 months.

Conclusion

Our analysis of the exhaustive PMSI database showed a suboptimal implementation of BoNT-A treatment recommendations in France. BoNT-A treatment initiation and re-administration are low, particularly in patients with post-stroke spasticity. Further investigations may help explain this observation, and may target specific actions to improve spasticity-related care pathway.

Validity of Accelerometer-Based Sensor System for Muscle Tightness Estimation through Vibration on the Upper Limb

Spasticity is a condition that profoundly impacts the ability to perform everyday tasks. However, its diagnosis requires trained physicians and subjective evaluations that may vary depending on the evaluator. Focal vibration of spastic muscles has been proposed as a non-invasive, pain-free alternative for spasticity modulation. We propose a system to estimate muscular tightness based on the propagation of elastic waves in the skin generated by focal vibration of the upper limb. The developed system generates focalized displacements on the biceps muscle at frequencies from 50 to 200 Hz, measures the vibration acceleration on the vibration source (input) and the distant location (output), and extracts features of ratios between input and output. The system was tested on 5 healthy volunteers while lifting 1.25 - 11.25 kg weights to increase muscle tone resembling spastic conditions, where the vibration frequency and weight were selected as explanatory variables. An increase in the ratio of the root mean squares proportional to the weight was found, validating the feasibility of the current approach to estimating muscle tightness.Clinical Relevance- This work presents the feasibility of a vibration-based system as an alternative method to objectively diagnose the degree of spasticity.

Symptom burden, management and treatment goals of people with MS spasticity: Results from SEEN-MSS, a large-scale, self-reported survey

BACKGROUND

Spasticity occurs frequently in people with multiple sclerosis (PwMS) and may affect non-physical aspects of life. However, there is a paucity of data assessing the full impact of spasticity in PwMS.

OBJECTIVE

This survey of PwMS and spasticity (PwMSS) was undertaken to understand the impact of spasticity in physical, functional, emotional, and social domains.

METHODS

SEEN-MSS (Symptoms and Emotions Exploration Needed in Multiple Sclerosis Spasticity), an online survey, was developed in collaboration with three US-based MS organizations (conducted February-April 2021).

RESULTS

Survey was completed by 1,177 PwMSS, 78% female, mean age 56.8yrs, 16.8yrs from MS diagnosis, 11.5yrs with spasticity. Considering day-to-day goals of treatment, respondents reported that managing symptoms(46%) was nearly as important as slowing disease progression(54%). Most reported spasticity was a constant reminder of their MS. Participants reported that spasticity limited daily activities (92%), caused pain (92%), impaired sleep (89%) and negatively impacted emotional well-being (87%). Spasticity fostered a sense of dependence (61%), isolation (40%), decline in self-confidence (75%), self-image (70%), and social connection (62%).

CONCLUSIONS

Spasticity has wide-reaching negative impacts on multiple aspects of life, causing substantial burden for PwMSS. Results emphasize the need to fully understand the burden of spasticity and addressing individual needs of PwMSS.

Experiences of patients with poststroke spasticity throughout a botulinum toxin treatment cycle: Results from a prospective ethnographic study

This study was conducted to capture the experience of patients with poststroke spasticity (PSS) throughout one botulinum neurotoxin A (BoNT-A) treatment cycle. The REBOT study (NCT03995524) was a prospective, observational ethnographic study conducted in France, Italy, the UK, and the USA. It combined a mixed-method ethnography (including semi-structured qualitative interviews within a week of a BoNT-A injection) with completion of a longitudinal quantitative patient-reported outcome questionnaire and sharing of video and images, both reported weekly over a 12–14-week period throughout the BoNT-A treatment cycle. The study recruited 30 adult patients with PSS who were receiving BoNT-A treatment. The most commonly used BoNT-A product was onabotulinumtoxinA (Botox^®), which was administered to 21 patients (70%), whereas two patients (6.7%) received abobotulinumtoxinA (Dysport^®) and seven patients (23.3%) did not specify the BoNT-A medication that they received. Patients reported a high, continuous burden of PSS, with spasms, sleeping difficulties, stiffness, and pain being the most commonly reported symptoms. In line with an observed waning effect of BoNT-A injections, spasticity symptoms initially were improved at Weeks 4–6 after injection but reemerged after 9–11 weeks. Treatment satisfaction levels decreased over the BoNT-A treatment cycle, as reflected by the worsening of symptoms and the need to self-medicate and consult a physician. The psychological impact of PSS was high. Patients acknowledged the benefits of BoNT-A treatment but wished for more individualized treatment plans with flexible dosing and injection intervals. Additionally, only 10% of patients reported that they had a trusting relationship with their physician and believed that their needs were considered by those managing their PSS. To our knowledge, this was the first ethnographic study in patients with PSS who were treated with BoNT-A. This ethnographic approach to patient surveys complements traditional research methods and allows improved identification of patients' unmet needs by capturing their weekly experience of treatment. The findings of this study confirm previous observations of the diminishing effectiveness of BoNT-A injections between treatment sessions, highlighting the need for agents with a longer duration of action and/or a more flexible treatment pattern that allows for more frequent injections.

Patients' Perspectives About the Treatment They Receive for Cardiovascular Diseases and Mental Disorders: Web-Based Survey Study

Background

Noncommunicable disease (NCD)–related deaths account for 71% of deaths worldwide. The World Health Organization recently developed a global action plan to address the impact of NCDs, with the goal of reducing the number of premature NCD-related deaths to 25% by the year 2025. Appropriate therapeutic adherence is critical for effective disease management; however, approximately 30%-50% of patients with an NCD do not comply with disease management activities as prescribed. Web-based patient communities can represent platforms from which specific information on patients’ perception of treatment adherence can be gathered outside of a clinical trial setting.

Objective

This study aims to better understand patients’ perspectives regarding therapeutic adherence and iatrogenic risk in 2 major groups of NCDs for which poor disease management can have fatal consequences: cardiovascular diseases and mental disorders. Therapeutic adherence, motivational factors, patients’ awareness and perception of iatrogenesis, and treatment tools used by patients were assessed.

Methods

A web-based survey was performed among patients with cardiovascular diseases or mental disorders or both conditions who were registered on the French Carenity platform, a web-based community in which patients with an NCD can share experiences and receive support and information. The study inclusion criteria were defined as follows: diagnosis of cardiovascular disease or mental disorder or both conditions (self-declared), age ≥18 years, residence in France, registration on the French Carenity platform, and ongoing pharmaceutical treatment for the condition. Patients who met the inclusion criteria were then invited to complete a self-administered web-based questionnaire that included questions addressing therapeutic adherence and iatrogenic risk.

Results

A total of 820 patients were enrolled in the study, including patients with cardiovascular diseases (403/820, 49.2%), patients with mental disorders (292/820, 35.6%), and patients with both cardiovascular diseases and mental disorders (125/820, 15.2%). The mean age of the participants was 55.2 (SD 12.7) years. We found that 82.8% (679/820) of patients experienced adverse effects of medication. Patients tended to perceive themselves to be more adherent than they actually were; a significant number of patients disregarded their prescription and stopped or interrupted medication without consulting with a doctor. Patients with cardiovascular diseases were nearly twice as adherent as patients with a mental disorder (P≤.001). Adherence was significantly associated with gender (P≤.001), age (P≤.001), and treatment complexity (P≤.001). Finally, for each disease type, 3 patient profiles were identified, which provide interesting insight for improving therapeutic adherence and adjustment strategies specifically according to patient behavior.

Conclusions

This study provides insight into the perspectives of patients receiving therapy for cardiovascular diseases or mental disorders or both conditions, which could help improve the management of NCDs and prevent premature death. Our study also shows that web-based patient platforms provide new opportunities to improve disease management by understanding patients’ experiences.

Revisiting Spasticity After Stroke: Clustering Clinical Characteristics for Identifying At-Risk Individuals

Purpose

To collectively identify the clinical characteristics determining the risk of developing spasticity after stroke.

Patients and Methods

A cross-sectional study was conducted at a single rehabilitation outpatient clinic from June to December 2019. Inclusion criteria were stroke duration of over four weeks, aged 18 years and above. Exclusion criteria were presence of concurrent conditions other than stroke that could also lead to spasticity. Recruited patients were divided into “Spasticity” and “No spasticity” groups. Univariate analysis was deployed to identify significant predictive spasticity factors between the two groups followed by a two-step clustering approach for determining group of characteristics that collectively contributes to the risk of developing spasticity in the “Spasticity” group.

Results

A total of 216 post-stroke participants were recruited. The duration after stroke (p < 0.001) and the absence of hemisensory loss (p = 0.042) were two significant factors in the “Spasticity” group revealed by the univariate analysis. From a total of 98 participants with spasticity, the largest cluster of individuals (40 patients, 40.8%) was those within less than 20 months after stroke with moderate stroke and absence of hemisensory loss, while the smallest cluster was those within less than 20 months after severe stroke and absence of hemisensory loss (21 patients, 21.4%).

Conclusion

Analyzing collectively the significant factors of developing spasticity may have the potential to be more clinically relevant in a heterogeneous post-stroke population that may assist in the spasticity management and treatment.

Guided Self-rehabilitation Contracts Combined With AbobotulinumtoxinA in Adults With Spastic Paresis

BACKGROUND AND PURPOSE

Guided self-rehabilitation contracts (GSCs) are a diary-based rehabilitation strategy, wherein specific muscles are identified for prescription of high-load, home self-stretching techniques. We assessed the effect of GSCs combined with simultaneous upper limb (UL) and lower limb (LL) abobotulinumtoxinA injections on composite active range of motion (CXA) in adults with chronic spastic paresis.

METHODS

This was an international, prospective, single-arm, open-label study (ENGAGE, NCT02969356). Personalized GSCs were monitored by phone every other week, alongside 2 consecutive abobotulinumtoxinA injections (1500 U) across UL and LL, over 6 to 9 months. Primary outcomes were responder rates (CXA improvement ≥35° [UL] or ≥5° [LL]) at week 6 cycle 2. Secondary outcomes were active function (UL: Modified Frenchay Scale [MFS]; LL: 10-m barefoot maximal walking speed [WS]) and quality of life (12-item Short Form Health Survey, SF-12).

RESULTS

Of the 153 treated participants, 136 had primary endpoint data; 72.1% (95% confidence interval [CI], 64.0-78.9) were responders. Mean (SD) CXA changes from baseline to last study visit were +49.3° (63.4) for UL and +20.1° (27.6) for LL. Mean (95% CI) changes from baseline to week 12 cycle 2 were +0.55 (0.43-0.66) in MFS, +0.12 m/s (0.09-0.15) for WS, and +4.0 (2.8-5.2) for SF-12 physical scores. In the safety population (n = 157), 49.7% of participants reported treatment-emergent adverse events (AEs); 12.1% reported 25 serious AEs.

DISCUSSION AND CONCLUSIONS

GSC combined with simultaneous UL and LL abobotulinumtoxinA injections led to improvements in CXA and function in both limbs, and quality-of-life physical scores. These results suggest the beneficial effect of combined GSC and abobotulinumtoxinA therapy in the management of spastic paresis.Video Abstract available for more insight from the authors (see the Supplementary Video, available at: http://links.lww.com/JNPT/A346).