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

Selecting Goals and Target Muscles for Botulinum Toxin A Injection Using the Goal Oriented Facilitated Approach to Spasticity Treatment (GO-FAST) Tool

The objective of this article is to introduce the GO-FAST Tool (developed by the Toxnet group) to clinicians working in the field of neurological rehabilitation, specifically post-stroke spasticity management. The concepts utilized in the Tool and described in this article can be broadly grouped into five topics: the principles of patient-centred goal-setting; an algorithm for setting SMART (specific, measurable, attainable, realistic, and timed) treatment goals; goal-related target muscles and botulinum toxin type A dose determinants; goal attainment follow-up, scoring, and interpretation; and the multimodal approach to spasticity management. The Tool can enhance clinical practice by providing guided assistance with goal-setting and target muscle selection for botulinum toxin type A treatment. It also provides support with the follow-up evaluation of goal attainment and calculation of treatment success. The Tool is designed to be used by clinicians with varying levels of expertise in the field of neurological rehabilitation and post-stroke spasticity management, from those who are new to the field to those with many years of experience. A case study is presented in the Results Section of the article to illustrate the utility of the Tool in setting SMART treatment goals in the management of patients with post-stroke spasticity.

Goal Attainment: A Clinically Meaningful Measure of Success of Botulinum Toxin-A Treatment for Lower Limb Spasticity in Ambulatory Patients

Objectives

The objectives of this study were to evaluate whether botulinum toxin type A (BoNT-A) treatment for lower limb spasticity leads to patient goal attainment and identify factors associated with positive goal attainment and to assess the effect of BoNT-A treatment on patients’ gait.

Design

Retrospective cohort study between June 2014 and February 2019.

Setting

Public outpatient spasticity clinic in a tertiary hospital.

Participants

Thirty patients (N=30; 50% female; average age, 50.5y) with lower limb spasticity of heterogenous etiologies (96.7% cerebral±spinal origin and 3.3% isolated spinal origin); 73.3% (N=22) of patients had previously received BoNT-A treatment.

Interventions

BoNT-A injection to lower limb muscles.

Main Outcome Measures

The primary outcome measure was goal attainment measured using Goal Attainment Scaling. The Modified Ashworth Scale (MAS) was used to assess spasticity. Gait was characterized by spatiotemporal parameters.

Results

Fifty-six treatment episodes were analyzed and showed that BoNT-A treatment resulted in a significant reduction in spasticity (pretreatment MAS=3.18±0.73; posttreatment MAS=2.27±0.89; P<.001) with no associated change in gait parameters. Logistic regression revealed that most patients (74.1%) achieved all of their goals, with younger patients having a high likelihood of goal attainment regardless of their gait profile identified by latent profile analysis of the gait parameters. Patients considered to have a low functioning gait profile demonstrated a significantly greater likelihood of goal attainment than patients with the other gait profiles combined (odds ratio, 45.6; 95% confidence interval, 1.3-1602.1; P=.036). Chronic spasticity and pretreatment severity of spasticity (MAS) and its reduction were not associated with likelihood of goal attainment.

Conclusions

The success and efficacy of BoNT-A treatment in improving patient perceived gait quality and reducing the negative symptoms of spasticity were best measured using Goal Attainment Scaling. The study emphasizes the importance of measuring patient goals as a clinical outcome. Gait parameters were most informative when used collectively to classify patients based on their overall gait profile, which assisted in identifying differences between patients’ likelihood of goal attainment after treatment.

Efficacy of botulinum toxin in modifying spasticity to improve walking and quality of life in post-stroke lower limb spasticity - a randomized double-blind placebo controlled study

Background

Post-stroke lower limb spasticity (PSLLS) has a prevalence of 28–37%. PSLLS can cause difficulty in walking and reduce quality of life (QOL). Post stroke spasticity impairs the ability to intervene to improve walking ability. Botulinum Toxin A (BT) is an effective intervention for focal spasticity, but its use is currently restricted in many countries by their reimbursement system stating that the evidence for improvement in walking and quality of life (QOL) is not robust for treatment in the lower limb. This randomized control trial (RCT) will investigate the effectiveness of BT in modifying spasticity, and improving functioning (mobility, walking, activities of daily living (ADL’s) and QOL.

Methods/design

A double-blind placebo-controlled trial injection will assess the effect of BT compared with a placebo (normal saline) in a sample of n = 94 patients. Following treatment of spasticity measured by Modified Ashworth Scale (MAS), the primary outcome of gait velocity will be measured by i) Gait Rite (Electronic Walkway); ii) walking by 2 Min Walk Test; iii) balance by Berg Balance Scale; mobility by iv) Timed Up and Go (TUG); v) lower limb function by ABILICO; vi) patient related goal by Goal Attainment Scale (GAS); vii) QOL by SF 12 (Rand version); viii) activities of daily living by the Functional Autonomy Measurement System (SMAF). There will be an associated health economic analysis.

Discussion

The study methodology is based on our systematic review 2026 studies, which concluded the evidence for improving mobility following use of BT to reduce spasticity was not robust. The results of this study could establish the use of BT in improving gait and lower limb function in PSLLS. This study could provide the evidence needed for reimbursement schemes to consider and changes to its funding policy for BT in PSLLS.

Trial registration

The trial is registered with the Australia New Zealand Clinical Trails Registry (ANZCTR)-ANZCTRN12617001603303. Registered 07/12/2017.

Spatiotemporal Gait Analysis and Lower Limb Functioning in Foot Dystonia Treated with Botulinum Toxin

Foot dystonia (FD) is a disabling condition causing pain, spasm and difficulty in walking. We treated fourteen (14) adult patients experiencing FD with onabotulinum toxin A injection into the dystonic foot muscles. We analyzed the spatiotemporal gait utilizing the GaitRite system pre- and 3 weeks post-botulinum toxin injection along with measuring dystonia by the Fahn–Marsden Dystonia Scale (FMDS), pain by the Visual Analog Scale (VAS) and other lower limb functional outcomes such as gait velocity, the Berg Balance Scale (BBS), the Unified Parkinson’s Disease Rating Scale–Lower Limb Score (UPDRS–LL), the Timed Up and Go (TUG) test and the Goal Attainment Scale (GAS). We found that stride length increased significantly in both the affected (p = 0.02) and unaffected leg (p = 0.01) after treatment, and the improvement in stride length was roughly the same in each leg. Similar results were found for step length (p = 0.02) with improvement in the step length differential (p = 0.01). The improvements in the lower limb functional outcomes were also significant—FMDS, VAS, TUG, and UPDRS–LL decreased significantly after treatment (all p < 0.001), and BBS (p = 0.001), GAS (p < 0.001) except cadence (p = 0.37). BT injection improved walking in foot dystonia as evidenced through gait analysis, pain and lower limb functional outcomes. Main study limitations were small sample size and lack of control.

Therapy influences goal attainment following botulinum neurotoxin injection for focal spasticity in adults with neurological conditions

OBJECTIVE

To determine whether therapy influenced goal attainment following botulinum toxin (BoNT-A) injection for focal spasticity in adults with neurological conditions.

METHODS

A prospective observational cohort study conducted in a large metropolitan spasticity clinic on adults with focal spasticity of any origin. Participants were provided with a therapy programme, designed to maximise therapeutic outcome. The primary outcome measure was Goal Attainment Scaling. To measure adherence, participants completed a therapy-recording tool each day. Goal attainment, and the rate of adherence to the therapy programme, was evaluated after 10 weeks.

RESULTS

Active indications for BoNT-A treatment made up the majority of the goals (80.30%). Goals were achieved in 43/76 cases (56.60%; 95% CI = 42.40 to 69.80%). Therapy adherence was associated with significantly greater goal attainment (OR = 1.02, p = 0.03, 95% CI = 1.00 to 1.04). Greater adherence to therapy increased the odds of goal achievement for active indications but not for passive indications, suggesting a possible statistical interaction between the indication for injection and adherence to therapy (p < 0.01).

CONCLUSION

Therapy adherence was associated with greater goal attainment. Active indications for BoNT-A were more reliant on adherence to prescribed therapy programmes than passive indications, although further investigation is required.