Access to Focal Spasticity Care: A Cross Canada Survey of Physiatrists

Multidisciplinary collaborative consensus statement on the barriers and solutions to care access, patient and caregiver support, and clinical capacity and capability for patients with spasticity

BACKGROUND

There is evidence that patients with spasticity are not receiving adequate care. Identifying the unmet needs of patients with spasticity is essential to develop services and treatment strategies to better support this population This is an effort to identify challenges related to treatment of spasticity and provide the springboard for the implementation of identified solutions.

OBJECTIVE

To identify the main barriers to spasticity care and identify potential solutions.

DESIGN

Delphi process.

SETTING

Expert panel.

PARTICIPANTS

A total of 35 participants with diverse experience and knowledge related to spasticity care were invited and 29 attended an in-person 2022 Spasticity Summit hosted by the American Academy of Physical Medicine and Rehabilitation.

METHODS

The expert panel participated in a presummit survey to identify the main potential barriers to spasticity care. During the in-person meeting the panel initially worked in small groups and then as whole to reach consensus through the Delphi process. The panel also completed a postsummit survey.

RESULTS

Several barriers to spasticity care and potentials solutions were identified. Consensus was reached for the top three barriers and potential solutions (>50% and >75%, respectively). Top barriers included the need for a document listing all the challenges related to access of care for spasticity, increased caregiver and community awareness of spasticity, and education of clinicians regarding patient needs. Top solutions to barriers included increasing the number of providers who treat spasticity, enhancing patient and caregiver education, and developing and publishing a consensus guidance statement.

CONCLUSIONS

Consensus was achieved on the top three barriers to spasticity care and potential solutions. The purpose of this analysis is to pave the way for further development of solutions to improve the care of patients with spasticity.

Canadian Physicians' Use of Intramuscular Botulinum Toxin Injections for Shoulder Spasticity: A National Cross-Sectional Survey

Spasticity of the upper extremity can result in severe pain, along with many complications that can impair a patient's activities of daily living. Failure to treat patients with spasticity of the upper limb can result in a decrease in the range of motion of joints and contracture development, leading to further restriction in daily activities. We aimed to investigate the practice patterns of Canadian physicians who utilize Botulinum toxin type-A (BoNT-A) injections in the management of shoulder spasticity. 50 Canadian Physical Medicine and Rehabilitation (PM&R) physicians completed a survey with an estimated completion rate of (36.23%). The demographics of the survey participants came from a variety of provinces, clinical settings, and patient populations. The most common muscle injected for shoulder adduction and internal rotation spasticity was the pectoralis major, this was followed by latissimus dorsi, pectoralis minor, subscapularis and teres major. Injection of BoNT-A for problematic post-stroke shoulder spasticity was common, with (81.48%) of participants responding that it was always or often used in their management of post-stroke spasticity (PSS). Dosing of BoNT-A demonstrated variability for the muscle injected as well as the type of toxin used. The goals of the patients, caregivers, and practitioners were used to help guide the management of these patients. As a result, the practice patterns of Canadian physicians who treat shoulder spasticity are varied, due to numerous patient factors. Future studies are needed to analyze optimal treatment patterns, and the development of algorithms to standardize care.

Canadian Physicians' Use of Perioperative Botulinum Toxin Injections to Spastic Limbs: A Cross-sectional National Survey

Objective

To investigate the practice patterns of Canadian physicians who use perioperative botulinum toxin (BoNT) injections to improve surgical outcomes on spastic limbs.

Design

A cross-sectional national survey composed of an invitation email and an 18-item questionnaire was disseminated by a national physical medicine and rehabilitation (PMR) society to 138 physician members involved in spasticity management.

Setting

Not applicable.

Participants

Twenty-five percent of the participants (N=34) fully completed the survey.

Interventions

Not applicable.

Main Outcome Measures

Participants completed an online questionnaire that examined the practice patterns and surgical outcomes associated with perioperative BoNT injections.

Results

The majority (n=21; 84%) of Canadian physicians who inject BoNT perioperatively to improve outcomes of surgeries performed on spastic limbs are specialists in PMR practicing in academic settings. Most respondents (74%) used BoNT injections for perioperative treatment for patients with limb spasticity undergoing surgery. Of those surveyed, 65% of physicians used BoNT preoperatively, 21% used BoNT intraoperatively, and 24% used BoNT postoperatively.Of the physicians who performed BoNT injections preoperatively, 6% performed BoNT injections 7 to 12 weeks preoperatively, 32% performed BoNT injections 4 to 6 weeks preoperatively, 47% performed BoNT injections 2 to 3 weeks preoperatively, and 15% performed BoNT injections 0 to 1 week preoperatively. The majority of physicians (85%) responded that injecting BoNT perioperatively may improve a patient's surgical outcome and all of the participants (100%) stated that BoNT did not contribute to any perioperative complications or adverse effects. Qualitative responses emphasized that successful outcomes from the perioperative BoNT were linked to enhanced collaboration with surgeons and that more research is needed to determine the optimal timing of perioperative BoNT.

Conclusion

Canadian physicians, mostly PMR specialists, administer perioperative BoNT to improve outcomes of surgeries performed on spastic limbs. The optimal timing for perioperative BoNT was suggested to be 2 to 3 weeks before the surgery by 47% of survey respondents. All participating physicians responded that perioperative BoNT did not contribute to any known perioperative complications or adverse events. This study highlights the importance of conducting more robust research to better understand optimal timing for perioperative BoNT injection, enhancing collaboration between physicians and surgeons, and increasing awareness of perioperative BoNT when planning for surgeries on spastic limbs.