A synthesis and appraisal of clinical practice guidelines, consensus statements and Cochrane systematic reviews for the management of focal spasticity in adults and children

The Modified Ashworth and Modified Tardieu Scales differ in their classification of lower limb spasticity

ObjectiveTo investigate agreement in spasticity classification between the Modified Ashworth Scale (MAS) and the Modified Tardieu Scale (MTS) when performed on four lower limb muscles in adults following neurological injury.DesignObservational trial.SettingInpatient and outpatient neurological rehabilitation unit.ParticipantsNinety adults with lower limb spasticity.Main MeasuresNinety participants underwent a spasticity assessment of their hamstrings at 40° and 90° of hip flexion, quadriceps, gastrocnemius and soleus using the MAS and MTS. Assessment findings were dichotomised into spastic (MAS ≥ 1 or MTS X ≥ 2) or not spastic (MAS = 0 or MTS X ≤ 1) categories. To evaluate agreement, 2 × 2 contingency tables were generated to calculate positive, negative and overall agreement. Statistical association was calculated using the Fisher's Exact Test.ResultsThe MAS classified the presence of spasticity more frequently than the MTS. The proportion of trials with agreement in spasticity classifications according to both scales and their Fishers exact test were hamstrings at 90° hip flexion (17.6%; p = 0.009); hamstrings at 40° hip flexion (75.0%; p = 0.166); quadriceps (67.1%; p = 0.020); gastrocnemius (77.9%; p = 0.586); and soleus (67.8%; p = 0.113).ConclusionThe MAS and MTS demonstrated a level of disparity in their classification of lower limb spasticity across all four muscles, particularly the more proximal muscle groups.

A randomized, double-blind, placebo-controlled trial of DaxibotulinumtoxinA for Injection for the treatment of upper limb spasticity in adults after stroke or traumatic brain injury

BACKGROUND

Intramuscular injection of botulinum toxin type A is a first-line pharmacotherapy for adults with upper limb spasticity (ULS). However, reemergence of symptoms within 12 weeks of treatment is common and longer-lasting treatments are needed.

OBJECTIVE

To evaluate the efficacy and safety of three doses of DaxibotulinumtoxinA for Injection (DAXI) for treatment of ULS in adults with stroke or traumatic brain injury.

INTERVENTION

Intramuscular injections of placebo (N = 24), DAXI 250 U (N = 22), DAXI 375 U (N = 19), or DAXI 500 U (N = 18) to the suprahypertonic muscle (SMG) and other muscle groups.

DESIGN

Randomized, double-blind, placebo-controlled study.

SETTING

Twenty-six study centers across the United States.

PARTICIPANTS

Eighty-three adult patients with ULS were randomly assigned to each treatment group and followed for up to 36 weeks.

OUTCOME MEASURES

Co-primary endpoints were the Modified Ashworth Scale (MAS) score change from baseline in the designated SMG and Physician Global Impression of Change (PGIC) at Week 6.

RESULTS

The mean changes from baseline in MAS score for the designated SMG for placebo and the DAXI 250 U, 375 U, and 500 U groups were -0.6, -0.9, -0.9, and -1.8, respectively, at Week 4 and -0.8, -0.9, -1.0, and -1.5, respectively, at Week 6. Statistically significant improvement in MAS score compared with placebo was reported only for the 500 U dose (Week 4: p < .001; Week 6: p = .049). Significant improvements in PGIC ratings compared with placebo were reported for DAXI 375 U (p = .015) and DAXI 500 U (p = .009) at Week 4 but not for any DAXI doses at Week 6. All DAXI doses were well tolerated with no trend toward more adverse events with increased dose.

CONCLUSION

Results from this Phase 2 study indicate that DAXI 500 U is effective and well tolerated for treatment of adults with ULS.

Is Whole-Body Cryostimulation Useful in Modulating Spasticity in Adults with Cerebral Palsy? A Case Study

Background: This case study investigates the effect of a five-session whole-body cryostimulation (WBC) cycle on a 55-year-old female patient with cerebral palsy (CP) and lower limb spasticity (LLS) with a typical diplegic gait pattern. CP is a common physical disability characterized by motor impairments, including spasticity, which significantly impacts mobility and quality of life. The current treatments for spasticity often have limited efficacy and considerable side effects, making alternative therapies like WBC an area of interest. Methods: The patient underwent a 10-day inpatient rehabilitation program integrated with five WBC sessions at -110 °C for 2 min. The treatment effects were assessed immediately before and after the five WBC sessions using the Ashworth Scale, Fugl-Meyer Assessment, H-reflex test, and gait analysis. Psychosocial outcomes were measured with the SF-36, WHO-5, PSQI, ESS, and BDI questionnaires. Results: Immediately after the WBC cycle, gait analysis showed increased walking speed (0.48 to 0.61 m/s left; 0.49 to 0.57 m/s right) and step length (0.30 to 0.38 m left; 0.30 to 0.35 m right). The H/M ratio in the H-reflex test improved, indicating a better neuromuscular efficiency. Psychosocial assessments revealed a 42.5% reduction in pain and a 24% improvement in overall quality of life and well-being. Discussion and Conclusions: The objective improvements in gait parameters and neuromuscular modulation, along with the subjectively reported enhancements in functional abilities, highlight the potential of WBC as a valuable addition to rehabilitation strategies for this population. Further research is needed to confirm these findings and assess long-term outcomes.

Hamstring spasticity assessment: does the hip flexion angle impact outcomes?

PURPOSE

Hamstring spasticity is prevalent following neurological injury. The standardized assessment involves passive knee extension, in a position of 90° hip flexion. This creates passive insufficiency of the muscle and lacks ecological validity for walking, whereby the hip typically flexes to a maximum of 40° during swing phase, while the knee extends. This study compared assessment outcomes when completed in 40° and 90° hip flexion.

METHODS

The Modified Ashworth Scale and Modified Tardieu Scale, were performed on 35 adults with a neurological condition. Each participant was assessed by three assessors, resulting in 105 trials at 40° and 90°.

RESULTS

There was a significant increase in the proportion of trials rated as spastic using the Modified Ashworth Scale (p=.012, phi=.27), and Modified Tardieu Scale (p<.001, phi=.36), and the severity of spasticity using the Modified Ashworth Scale (p<.001, effect size (ES)=.50), and Modified Tardieu Scale (p<.001 ES=.47), at 90° hip flexion. The angle of reaction occurred 32° earlier at 90° hip flexion (p<.001, ES = 1.61).

CONCLUSIONS

Completing hamstring assessments in 40° hip flexion may reduce the passive insufficiency and improve the ecological validity of assessment, for walking. This may assist in the selection of patients requiring intervention, when their goal relates to walking.

The Effect of Botulinum Neurotoxin-A (BoNT-A) on Muscle Strength in Adult-Onset Neurological Conditions with Focal Muscle Spasticity: A Systematic Review

Botulinum neurotoxin-A (BoNT-A) injections are effective for focal spasticity. However, the impact on muscle strength is not established. This study aimed to investigate the effect of BoNT-A injections on muscle strength in adult neurological conditions. Studies were included if they were Randomised Controlled Trials (RCTs), non-RCTs, or cohort studies (n ≥ 10) involving participants ≥18 years old receiving BoNT-A injection for spasticity in their upper and/or lower limbs. Eight databases (CINAHL, Cochrane, EMBASE, Google Scholar, Medline, PEDro, Pubmed, Web of Science) were searched in March 2024. The methodology followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and was registered in the Prospective Register of Systematic Reviews (PROSPERO: CRD42022315241). Quality was assessed using the modified Downs and Black checklist and the PEDro scale. Pre-/post-injection agonist, antagonist, and global strength outcomes at short-, medium-, and long-term time points were extracted for analysis. Following duplicate removal, 8536 studies were identified; 54 met the inclusion criteria (3176 participants) and were rated as fair-quality. Twenty studies were analysed as they reported muscle strength specific to the muscle injected. No change in agonist strength after BoNT-A injection was reported in 74% of the results. Most studies' outcomes were within six weeks post-injection, with few long-term results (i.e., >three months). Overall, the impact of BoNT-A on muscle strength remains inconclusive.

To what extent are guidelines used in spasticity clinics? A qualitative study of facilitators and barriers to spasticity guideline implementation

OBJECTIVE

To determine the common understanding of focal muscle spasticity guidelines amongst clinicians working in spasticity clinics. To examine the facilitators and barriers to their implementation as well as their influence on clinic processes.

DESIGN

A qualitative study based on a phenomenological approach.

SETTING

Online videoconferencing platform.

PARTICIPANTS

Sixteen experienced multi-disciplinary clinicians providing specialised care across 12 spasticity clinics in Victoria, Australia.

INTERVENTION

Observational.

MAIN MEASURES

Two independent reviewers performed line by line coding of transcripts. Reflexive thematic analysis was undertaken with themes/subthemes inductively derived.

RESULTS

Seven key themes emerged. First, knowledge of specific guideline recommendations was low amongst some clinicians. Second, there is a lack of health service resources to support guideline implementation. Third, a limited evidence base for guidelines affected clinicians' willingness to implement the recommendations. Fourth, peer support was highly valued but opportunities to collaborate were limited. Fifth, a large amount of intrinsic motivation and personal time was required from clinicians to successfully implement guideline recommendations. Sixth, the standardisation of clinic processes was one way in which clinicians felt they could better align their clinical practice to guidelines. Lastly, guidelines overall had a moderate influence on spasticity clinic processes.

CONCLUSIONS

Knowledge of recommendations varied but, overall, guidelines had an influence on clinic processes and staff perceptions across the state-wide services. Health service resources, limited evidence for guideline recommendations and time constraints were considered barriers to spasticity guideline implementation. Multi-disciplinary expertise and teamwork, the individual's motivation to change and inter-clinic collaboration were considered to be the facilitators.

Botulinum toxin A injection for post-stroke upper limb spasticity and rehabilitation practices from centers across Asian countries

Purpose

Describe real-life practice and outcomes in the management of post-stroke upper limb spasticity with botulinum toxin A (BoNT-A) in Asian settings.

Methods

Subgroup analysis of a prospective, observational study (NCT01020500) of adult patients (≥18 years) with post-stroke upper limb spasticity presenting for routine spasticity management, including treatment with BoNT-A. The primary outcome was goal attainment as assessed using goal-attainment scaling (GAS). Patients baseline clinical characteristics and BoNT-A injection parameters are also described.

Results

Overall, 51 patients from Asia were enrolled. Rates of comorbid cognitive and emotional problems were relatively low. Patients tended to have more severe distal limb spasticity and to prioritize active over passive function goals. Most (94.1%) patients in the subgroup were treated with abobotulinumtoxinA. For these patients, the median total dose was 500 units, and the most frequently injected muscles were the biceps brachii (83.3%), flexor carpi radialis (72.9%), and flexor digitorum profundus (66.7%). Overall, 74.5% achieved their primary goal and the mean GAS T score after one treatment cycle was 56.0 ± 13.0, with a change from baseline of 20.9 ± 14.3 (p < 0.001). The majority (96.1%) of Asian patients were rated as having improved.

Conclusion

In the Asian treatment setting, BoNT-A demonstrated a clinically significant effect on goal attainment for the real-life management of upper limb spasticity following stroke.

Clinical presentation of patients with lower limb spasticity undergoing routine treatment with botulinum toxin: baseline findings from an international observational study

OBJECTIVE

Describe how people with lower limb spasticity present for treatment in routine clinical practice.

METHODS

Prospective, observational study (Clinicaltrials.gov: NCT04050527) of ambulatory adult patients (≥ 18 years) with unilateral lower limb spasticity (able to take ≥ 5 steps with or without assistance) presenting for routine spasticity management, including treatment with abobotulinumtoxinA.

RESULTS

The study population included 430 adults with lower limb spasticity. Despite their relatively young age (mean ± standard deviation 53.7 ± 13.9 years), only 20% of patients were employed. Most patients had an acquired brain injury due to cerebrovascular disease; 84.1% reported having concomitant upper limb spasticity. Using the Leg Activity Measure, most patients reported no or only mild difficulties in performing hygiene/positioning tasks, while 80.7% had at least mild difficulty with indoor ambulation and 90.5% had at least mild difficulty with walking outdoors. Sensory, communication and/or cognitive impairments were also common. At the first treatment cycle, 50.7% of patients set active function primary goals, including locomotion transferring or standing.

CONCLUSION

These observations highlight the complexity of presentation that must be considered when setting treatment goals for lower limb spasticity and emphasize the types of impairment and activity (functional) limitations that treating teams may expect to encounter in their patients and should cover in their initial and follow-up assessments.

Focal muscle spasticity has little impact on muscle power for walking in people with Traumatic Brain Injury

BACKGROUND

Spasticity is prevalent following Traumatic Brain Injury. 'Focal' muscle spasticity has been defined as spasticity affecting a localised muscle group, but it's impact on gait kinetics remains unclear. The aim of this study was to investigate the relationship between focal muscle spasticity and gait kinetics following Traumatic Brain Injury.

METHODS

Ninety-three participants attending physiotherapy for mobility limitations following Traumatic Brain Injury were invited to participate in the study. Participants underwent clinical gait analysis and were grouped depending on the presence or absence of focal muscle spasticity. Kinetic data was obtained for each sub-group, and participants were compared to healthy controls.

FINDINGS

Hip extensor power generation at initial contact, hip flexor power generation at terminal stance, and knee extensor power absorption at terminal stance were all significantly increased, and ankle power generation was significantly reduced at push-off when comparing Traumatic Brain Injury to healthy control populations. There were only two significant differences between participants with and without focal muscle spasticity, hip extensor power generation at initial contact was increased (1.53 vs 1.03 W/kg, P < .05) for those with focal hamstring spasticity, and knee extensor power absorption in early stance was reduced (-0.28 vs -0.64 W/kg, P < .05) for those with focal rectus femoris spasticity. However, these results should be interpreted with caution as the sub-group of participants with focal hamstring and rectus femoris spasticity was small.

INTERPRETATION

Focal muscle spasticity had little association with abnormal gait kinetics in this cohort of independently ambulant people with Traumatic Brain Injury.

Long-Term Spasticity Management in Post-Stroke Patients: Issues and Possible Actions-A Systematic Review with an Italian Expert Opinion

Spasticity is a well-known motor dysfunction occurring after a stroke. A group of Italian physicians' experts in treating post-stroke spasticity (PSS) reviewed the current scientific evidence concerning the state-of-the-art clinical management of PSS management and the appropriate use of botulinum toxin, aiming to identify issues, possible actions, and effective management of the patient affected by spasticity. The participants were clinicians specifically selected to cover the range of multidisciplinary clinical and research expertise needed to diagnose and manage PSS. When evidence was not available, the panel discussed and agreed on the best way to manage and treat PSS. To address the barriers identified, the panel provides a series of consensus recommendations. This systematic review provides a focused guide in the evaluation and management of patients with PSS and its complications. The recommendations reached by this panel of experts should be used by less-experienced doctors in real life and should be used as a guide on how to best use botulinum toxin injection in treating spasticity after a stroke.

Effectiveness of physical therapy interventions on post-stroke spasticity: An umbrella review

BACKGROUND

Post-stroke spasticity is often one of the primary impairments addressed in rehabilitation. However, limited guidance exists on the effectiveness of physical therapy (PT) interventions for post-stroke spasticity.

OBJECTIVE

To evaluate the quality of evidence of PT interventions for post-stroke spasticity.

METHODS

Ovid (Medline), Cochrane Library, CINAHL, Scopus, PEDro, and PROSPERO were searched to identify reviews based on the following criteria: 1) published between 2012 and 2021, 2) participants older than 18 years old, 3) post-stroke spasticity, 4) PT interventions, 5) clinical or neurophysiological measures of spasticity as primary outcomes. Assessment of Multiple Systematic Reviews 2 and the Grades of Recommendations Assessment, Development, and Evaluation assessed methodological quality.

RESULTS

Eight articles were included in the analysis. No high-quality evidence was found. Moderate quality evidence exists for transcutaneous electrical nerve stimulation, neuromuscular electrical stimulation, resistance training, and lower extremity ergometer training with or without functional electrical stimulation. Low quality evidence exists for dynamic stretching, botulinum toxin with constraint-induced movement therapy, and static stretching using positional orthoses.

CONCLUSION

Findings suggest that PT should prioritize a combination of active strategies over passive interventions, but further studies are needed prioritizing analyses of the movement system in managing post-stroke spasticity in conjunction with medical therapies.

Do randomised controlled trials evaluating functional outcomes following botulinum neurotoxin-A align with focal spasticity guidelines? A systematic review

PURPOSE

The impact of botulinum neurotoxin-A (BoNT-A) on functional outcomes when managing focal muscle spasticity remains unclear. It is possible that randomised controlled trial (RCT) design and/or reporting may be a contributing factor. The objective of this review was to determine the extent to which RCTs evaluating functional outcomes following BoNT-A align with focal spasticity guidelines.

MATERIALS AND METHODS

RCTs published from 2010 were included if they targeted focal spasticity, included BoNT-A, randomised a physical intervention to the upper/lower limb, or the primary outcome(s) related to the activity/participation domains of the International Classification of Functioning, Disability, and Health. Data extraction and quality appraisal using the Modified PEDro and Modified McMasters Tool were performed independently by two reviewers. General research practices were also extracted such as compliance with therapy reporting guidelines.

RESULTS

Fifty-two RCTs were eligible. Individualised goal setting was uncommon (25%). Six studies (11.5%) included multi-disciplinary management, and five (9.6%) included patient/caregiver education. Four studies (7.7%) measured outcomes beyond 6 months. The Median Modified PEDro score was 11/15.

CONCLUSIONS

Alignment with focal spasticity guidelines in RCTs was generally low. Our understanding of the impact of focal spasticity management on functional outcomes may be improved if RCT design aligned more closely with guideline recommendations.IMPLICATIONS FOR REHABILITATIONThe influence of BoNT-A on improved functional outcomes is yet to be determined.Individualised goal setting with a multi-disciplinary team is uncommon in an RCT design, despite it being a key guideline recommendation.Given the long-term nature of spasticity management, guidelines recommend short as well as long-term reviews following intervention however RCTs rarely assess beyond 6 months.

Association of Lower Limb Focal Spasticity With Kinematic Variables During Walking in Traumatic Brain Injury

BACKGROUND AND PURPOSE

Focal muscle spasticity is defined as spasticity that affects a localized group of muscles. It is prevalent in many adult-onset neurological conditions, yet the relationship of focal muscle spasticity with walking remains unclear. Therefore, the aim of this study was to determine the relationship of focal muscle spasticity with the kinematics of walking in traumatic brain injury (TBI).

METHODS

Ninety-one participants with TBI underwent clinical gait analysis and assessment of focal lower limb muscle spasticity in a prospective cross-sectional study. A matched group of 25 healthy controls (HCs) were recruited to establish a reference dataset. Kinematic data for each person with and without focal muscle spasticity following TBI were compared with the HC cohort at a matched walking speed.

RESULTS

The TBI and HC cohorts were well matched. Only those with focal hamstring muscle spasticity walked significantly different to those without. They had significantly greater knee flexion (23.4° compared with 10.5°, P < 0.01) at initial contact. There were no other significant differences in kinematic variables between those with and without focal muscle spasticity. There was no significant association between focal muscle spasticity and walking speed.

DISCUSSION AND CONCLUSIONS

Focal muscle spasticity and abnormal kinematics whilst walking were common in this cohort of people with TBI. However, focal muscle spasticity had little relationship with kinematic variables, and no significant relationship with walking speed. This finding has implications for the treatment of focal muscle spasticity to improve walking following TBI. Focal muscle spasticity had little relationship with kinematic variables and walking speed in this cohort of people with TBI who could walk without assistance.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A381).

Clinical practice guidelines and consensus statements for antenatal oral healthcare: An assessment of their methodological quality and content of recommendations

OBJECTIVES

To review the content of recommendations within antenatal oral healthcare guidance documents and appraise the quality of their methodology to inform areas of development, clinical practice, and research focus.

METHOD

A systematic search of five electronic databases, Google search engine, and databases from relevant professional and guideline development groups published in English, developed countries, and between 2010 and 2020 was undertaken to identify guidance documents related to antenatal oral healthcare. Quality of documents was appraised using the Appraisal of Guidelines Research and Evaluation II tool, and a 3-step quality cut-off value was used. Inductive thematic analysis was employed to categories discreet recommendations into themes.

RESULTS

Six guidelines and one consensus statement were analysed. Two documents developed within Australia scored ≥60% across five of the six domains of the quality appraisal tool and were recommended for use. Four documents (developed in the United States and Canada) were recommended for use with modifications, whilst one document (developed in Europe) was not recommended. A total of 98 discreet recommendations were identified and demonstrated considerable unanimity but differed in scope and level of information. The main content and number of recommendations were inductively categorised within the following clinical practice points: risk factor assessments (n = 2), screening and assessment (n = 10), pre-pregnancy care (referral, n = 1), antenatal care (health education and advice, n = 14; management of nausea and vomiting, n = 7; referral, n = 2), postnatal care (health education and advice, n = 1; anticipatory guidance, n = 6), documentation (n = 4), coordinated care (n = 4), capacity building (n = 6), and community engagement (n = 1).

CONCLUSION

The methodological rigour of included guidance documents revealed areas of strengths and limitations and posit areas for improvement. Further research could centre on adapting antenatal oral healthcare guidelines and consensus statements to local contexts. More high-quality studies examining interventions within antenatal oral healthcare are needed to support the development of recommendations.

Emerging Concepts and Evidence in Telematics Novel Approaches or Treatments for Spasticity Management After Botulinum Injection

There is a strong recommendation for the use of intramuscular botulinum toxin in patients with persistent or progressive spasticity affecting one or more joints and who have an identifiable therapeutic target. After a botulinum toxin injection, a stretching intervention improves the results of the treatment, and it should be performed by patients and/or caregivers after being trained by a therapist. Adherence to this recommendation remains low once the therapist stops following the patient. The COVID-19 pandemic has increased the use of telemedicine with different approaches to treat patients. There has been an increased use of motivational applications, with virtual reality software and real-life videos, which provide a gaming experience that increases adherence. There are programs with synchronous telehealth exercises guided by physical therapists or software with sensor-based technology that shows the range of motion (ROM) and strength of the muscles of a particular joint. These new approaches to patient follow-up appear to increase adherence to exercise because they need to be “watched and controlled” is achieved.

Healthcare needs, expectations, utilization, and experienced treatment effects in patients with hereditary spastic paraplegia: a web-based survey in the Netherlands

BACKGROUND

We aimed to identify healthcare needs, expectations, utilization, and the experienced treatment effects in a population of Dutch patients with hereditary spastic paraplegia (HSP).

METHODS

We distributed an online questionnaire among 194 adult persons with HSP in the Netherlands, of which 166 returned a fully completed version. After applying predefined exclusion criteria, 109 questionnaires from persons with pure HSP were analysed.

RESULTS

Healthcare needs and expectations were primarily focused on the relief of muscle stiffness and reduction of balance and gait impairments (65-80%), but many participants also expressed needs regarding relief of non-motor symptoms (e.g. pain, fatigue), emotional problems, impaired sleep and self-care capacity, and participation problems (> 60%). Remarkably, despite these frequent needs, relatively few participants (< 33%) expected to be able to improve in these additional domains. Rehabilitation physicians and physiotherapists were more frequently consulted than neurologists and occupational therapists, respectively. Physiotherapy was the most often proposed non-pharmacological intervention (85%), followed by orthopedic footwear (55%) and splints (28%). Approximately one third of the participants was never offered any pharmacological (spasmolytic) treatment. Spasmolytic oral drugs, injections, and intrathecal baclofen were given to 41%, 26%, and 5% of the participants, respectively. Independent of the type of pharmacological intervention, 35-46% of these participants experienced decreased spastiticy and improved general fitness. Other experienced effects differed per type of intervention.

CONCLUSIONS

Based on this web-based survey in the Netherlands, there seems to be ample room for improvement to meet and attune the healthcare needs and expectations of people with HSP concerning both their motor and non-motor symptoms and functional limitations. In addition, the provision of adequate information about non-pharmacological and pharmacological interventions seems to be insufficient for many patients to allow shared decision making. These conclusions warrant a more pro-active attitude of healthcare providers as well as an interdisciplinary approach for a substantial proportion of the HSP population, also involving professionals with a primary occupational and/or psychosocial orientation.

Goal analysis in patients with limb spasticity treated with incobotulinumtoxinA in the TOWER study

PURPOSE

To map spasticity-related goals using the International Classification of Functioning, Disability and Health (ICF) linking rules, and review goal syntax to direct future goal setting.

MATERIALS AND METHODS

1633 treatment goals, set during the TOWER study, were linked to the ICF framework and EQ-5D domains. Goals were mapped independently by two investigators with expertise in ICF linking rules.

RESULTS

In total, 1630 (99.8%) goals could be mapped to the ICF (inter-rater agreement on the main ICF category 96.1%). Most goals (80.2%) were mapped to a single ICF category and were related to activities/participation (54.9%). 170 (10.4%) goals were related to general tasks and activities, such as positioning, stretching, and strengthening. In total, 1072 goals (65.6%) mapped to the EQ-5D domains (inter-rater agreement 90.8%). Analysis of the goal syntax highlighted the need to include a verb in patient-centered goals to direct active behavior.

CONCLUSIONS

The ICF offers a broad framework for setting patient-centered, easily understandable goals for patients with spasticity, including goals related to (guided) self-management activities. This analysis sheds new light on patient needs and could direct future goal-driven botulinum toxin spasticity treatment focused on enabling patients to better manage activity limitations imposed by their body function impairments.Trial registration: NCT01603459 registered with ClinicalTrials.gov (https://clinicaltrials.gov/ct2/show/NCT01603459).Implications for RehabilitationThe ICF offers a broad framework for setting patient-centered, easily understandable goals for patients with spasticity.ICF domains that include general tasks and demands can be used to establish goals relating to (guided) self-management of spasticity.An ICF-based goal-setting framework may increase the comparability of clinical data across studies.