Rationale and design of a multicentre, double-blind, prospective, randomized, European and Canadian study: Evaluating patient outcomes and costs of managing adults with post-stroke focal spasticity

A person-centered approach to home and community-based services outcome measurement

In the United States, over 2.5 million people with disabilities are recipients of supports through the Center for Medicare and Medicaid Services (CMS) Home and Community-Based Services (HCBS) program. Recent decades have seen a growing focus on providing HCBS in a person-centered manner thereby supporting outcomes that are both important for and to the person. HCBS outcome measurement, however, has not kept pace with advancements in person-centered thinking as it relates to providing supports to people with disabilities. The concept of person-centered outcome measurement has been inadequately defined and is frequently misunderstood including by those in the measurement field. The authors first operationally define person-centered measurement and establish its importance within the context of HCBS and the recent CMS's Final Settings Rule. The important role that person-centered measurement has to play in quality improvement efforts in this area is then explored. A discussion is subsequently provided as to the challenges that are faced in person-centered measurement specific to the disability field. In addition to further conceptualizing and defining this form of measurement, recommendations are provided for moving the field forward.

Peony and licorice decoction fumigation treatment for strephenopodia after stroke: Study protocol for a randomized controlled pilot trial

BACKGROUND

As one of the most common functional disabilities in stroke patients with hemiplegia, poststroke strephenopodia (PSS) seriously affects the life quality of patients, and causes mental and emotional disorders. Some studies have suggested that the traditional Chinese medicine fumigation therapy could be an effective intervention method for patients with PSS. This study aims to investigate the biomechanical effect of the classic prescription peony and licorice decoction (PLD) fumigation treatment for PSS.

METHODS/DESIGN

This study is a multicenter, randomized, placebo-controlled, double blind trial. A total of 190 patients with PSS according to the inclusion criteria will be recruited in 3 centers and randomly distributed to either the intervention group or the control group in a 1:1 ratio. The intervention group will receive PLD fumigation treatment, while the control group will receive placebo fumigation treatment. All patients will receive standardized modern rehabilitation treatment according to the "Chinese Guidelines for Stroke Rehabilitation" (2011 version). The primary outcome measure is medial plantar area (Metatarsal 1+ Metatarsal 2 + Heel Medial) generating from the RSSCAN gait system. The secondary outcome measures contain the scores of clinical scales including Berg Balance Scale, Fugl-Meyer Assessment, Modified Ashworth Scale, Barthel Index, and Stroke-Specific Quality of Life Scale. All assessments will be implemented at baseline, 4 weeks after intervention and at the end of 3 months' follow-up. Intention-to-treat analysis and per-protocol analysis will be applied in this trial.

DISCUSSION

The results of this study are expected to verify the clinical effect of PLD fumigation treatment for strephenopodia after stroke, and to explore the related biomechanical mechanisms by objective evaluation parameter.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ChiCTR2000032433. Registered on 28 April 2020. http://www.chictr.org.cn/showprojen.aspx?proj=52644.

Safety of OnabotulinumtoxinA with Concomitant Antithrombotic Therapy in Patients with Muscle Spasticity: A Retrospective Pooled Analysis of Randomized Double-Blind Studies

BACKGROUND

OnabotulinumtoxinA is approved as a treatment across multiple indications. For the treatment of spasticity, onabotulinumtoxinA is injected directly into affected muscles. Intramuscular injections may result in local bleeding and related complications, especially in patients receiving anticoagulant therapy. Despite anticoagulants being commonly used, there is limited information in the medical literature regarding the safety of intramuscular medications in patients receiving oral anticoagulants. This retrospective analysis included pooled safety data from Allergan-sponsored studies evaluating onabotulinumtoxinA for the treatment of patients with muscle spasticity.

OBJECTIVE

The objective of this study was to determine the risk of bleeding complications in patients with post-stroke spasticity receiving antithrombotic therapy and intramuscular onabotulinumtoxinA.

METHODS

We conducted a retrospective analysis of pooled safety data from 16 randomized, double-blind, placebo-controlled Allergan-sponsored studies of onabotulinumtoxinA for the treatment of post-stroke upper or lower limb muscle spasticity, including adult patients with at least moderate upper or lower limb spasticity and receiving at least one dose of the study drug. Bleeding-related adverse events starting within 4 weeks of study treatment were assessed. The incidence rates of bleeding complications were compared for patients receiving classes of antithrombotic therapy vs those not receiving antithrombotic therapy and for those receiving onabotulinumtoxinA vs placebo (with or without antithrombotic therapy).

RESULTS

Of 1877 patients, 1182 received antithrombotic therapy. The overall incidence of bleeding complications was < 2%. In those receiving any antithrombotic therapy, the incidence of bleeding was 1.0% vs 1.4% (no antithrombotic therapy); after onabotulinumtoxinA, it was 0.9% for those receiving antithrombotic therapy vs 1.4% (no antithrombotic therapy), and for placebo 1.2% vs 1.4%, respectively. Subgroup results were similar.

CONCLUSIONS

No apparent increased risk of bleeding complications was observed following administration of onabotulinumtoxinA to patients receiving antithrombotic therapy. Nonetheless, patient education and careful observation of the injection site in patients receiving antithrombotic therapy remains warranted.

[Botulinum toxin in treatment of lower limb spasticity in patients with brain damage]

AIM

To develop and test a method of examination of patients with lower limb spasticity, to describe lower limb spasticity patterns in patients with brain damage and to assess the efficacy of abobotulinumtoxin A (dysport) in the rehabilitation of patients with stroke.

MATERIAL AND METHODS

Spasticity rating scales (MAS and Tardieu), the Barthel index, the Rankin scale , the Rivermead Mobility Index, the Hauser Ambulation Index, a comfortable walking test were used. Treatment satisfaction was assessed with the Visual analogue scale. Abobotulinumtoxin A (dysport) was used for treatment of lower limb spasticity.

RESULTS AND CONCLUSION

Two most common patterns (dynamic and static) were identified in patients with post-stroke spasticity and the method of testing spasticity was developed. The prevalence of spasticity in individual muscles of the lower extremity was estimated as well. An analysis of the efficacy of dysport and a sensitive analysis of the scales used in the study were carried out.

[Treatment goals in patients with post-stroke upper limb spasticity following injection of botulinum toxin A : Results of the German-Austrian subgroup of the ULIS-II study]

BACKGROUND

The ULIS-II was an international cohort study (NCT01020500) evaluating current treatment of upper limb spasticity in post-stroke adult patients with botulinum toxin A (BoNT-A) in real-life practice.

OBJECTIVE

Post hoc analysis to compare current management of post-stroke adult patients regarding goal setting and attainment with BoNT-A in Germany (D) and Austria (A) with the full cohort of ULIS-II.

MATERIAL AND METHODS

The ULIS-II was a global, open-label, prospective, multicenter observational study with 2 visits conducted in 84 centers worldwide. A total of 468 patients aged ≥18 years with post-stroke upper limb spasticity were included. The primary outcome measure was the responder rate defined as achievement of a goal attainment scale (GAS) score of 0, 1 or 2 after 1 cycle of BoNT-A.

RESULTS

A total of 57 patients from D/A were included in the efficacy analysis. The number of patients in D/A and the full cohort achieving the primary (78.9% vs. 79.6%) and secondary treatment goal (76.8% vs. 75.6%), respectively, was comparable. Deviating from the full cohort, the most common primary treatment goal in D/A was related to impairment (33.3%). Compared to baseline there was a marked reduction in concomitant therapies at the follow-up visit after 3-5 months in the D/A group: patients receiving oral anti-spastic medication 61.4% vs. 40.4%, positioning 50.9% vs. 36.8% and splinting 43.9% vs. 31.6%. Injection control techniques were less frequently used in the D/A group compared to the global study cohort (electrical stimulation: 26.3% vs. 45.8% and electromyography: 12.3% vs. 29.2%). No adverse events were documented in the D/A cohort.

CONCLUSION

A single injection of BoNT-A in adult patients with post-stroke spasticity of the arm led to a high response rate of approximately 80% in both cohorts. The BoNT-A injections in post-stroke adult patients contributed to an improvement in the daily life of patients and their carers beyond simple reduction of muscle tone or spasticity.

Categorisation of goals set using Goal Attainment Scaling for treatment of leg spasticity: a multicentre analysis

Background: Goal-classification of person-centred goals, using Goal Attainment Scaling for leg spasticity treatment. Methods: The study was conducted in two phases: phase I, a retrospective review to evaluate categories of goal set in routine clinical practice. Findings were used to design a goal classification system. Phase II, a multi-centre study to confirm the goal categories. Goals set (n = 270) were analysed from data collected at three centres in the UK (one centre for phase I). Goal categories were mapped onto the domains of the World Health Organisation, International Classification of Functioning Disability and Health. Results: One hundred and twenty seven participants were recruited in two cohorts: phase I: 63; phase II: 64. Goal categories using both cohorts were assigned to two domains, each subdivided into three key goal categories: Domain 1: body structure impairment 121 (44%): (a) pain/discomfort 34 (12%), (b) involuntary movements 20 (7%), and (c) range of movement/contracture prevention 67 (25%). Domain 2: activity function 149 (56%): (a) passive function (ease of caring for the affected limb) n = 89 (33%), (b) active function (transfers) 26 (10%), and (c) active function (mobility) 27 (10%), other n = 7 (3%). Conclusions: Patients individual leg spasticity goals can be grouped into six categories and two domains, which will assist clinicians, patients and cares in setting and evaluating goals in practice. Implications for Rehabilitation Six goal areas used in clinical goal setting for leg spasticity management were identified, under the two domains: (1) body structure impairment: pain, involuntary movements, and range of movement and (2) activities/function: passive function (ease of caring), active function - transfers or standing and active function - mobility. Categorisation of goals is consistent on repeated evaluation and across different clinical services. Using clinical goals for leg spasticity treatment is an effective method to identify treatment priorities.

Botulinum toxin therapy in patients with oral anticoagulation: is it safe?

When used therapeutically, botulinum toxin (BT) has to be injected into its target tissues. All manufacturers warn not to do so in patients with oral anticoagulation to avoid haematoma. We wanted to study the haematoma frequency (HF) in patients with anticoagulation receiving BT therapy. 32 patients (16 females, 16 males, age 69.3 ± 10.0 years) with blepharospasm (n = 6), hemifacial spasm (n = 8), post-stroke spasticity (n = 16), and cervical dystonia (n = 2) received BT therapy (needle size 27G, post-injection tissue compression) whilst on anticoagulation (anticoagulation group, AG). 32 patients matched for disease, target muscles, age, and gender received identical BT therapy without anticoagulation (control group, CG). Anticoagulation was performed with phenprocoumon. International normalised ratio (INR) at the time of BT injection was in all patients within the recommended margins of 2.0 and 3.0 (mean 2.6 ± 0.27). Overall HF was 3.0% in AG and 1.8% in CG (not significant). All hematomas occurred in blepharospasm patients (AG 5.2%, CG 2.6%, not significant) and hemifacial spasm patients (AG 3.9%, CG 2.9%, not significant). In cervical dystonia and spasticity there were no haematomas. Throughout an observation period of 4 years, none of the haematomas was surgically relevant. Haematomas are a rare complication of BT therapy, mainly occurring in periocular injections. Anticoagulation only marginally increases HF, provided INR is controlled and appropriate injection techniques are used. Surgically relevant haematomas do not occur. Interruption of oral anticoagulation to perform BT therapy is not justified.

Quality of life and costs of spasticity treatment in German stroke patients

OBJECTIVE

To gather data about the medical and non-medical health service in patients suffering from post-stroke spasticity of the upper limb and evaluate treatment effectiveness and tolerability as well as costs over the treatment period of one year.

METHODS

Prospective, non-interventional, multicenter, parallel-group study comparing effectivenessand costs of incobotulinumtoxinA (INCO) treatment (n = 118) to conventional (CON) antispastic therapy (n = 110) for upper limb spasticity after stroke in 47 clinical practices across Germany over a 1-year treatment period. IncobotulinumtoxinA was applied according to the individual treatment algorithms of each participating site and additional antispastic treatments were allowed. Primary efficacy objective was the reduction of the muscle tone measured by Ashworth scale. Responder analyses and logistic regressions were performed. Quality of life, measured by SF-12 questionnaire and functional disability were assessed. Besides calculating treatment costs, a cost-utility analysis was performed.

RESULTS

Responder rates of all muscle groups of the upper extremities were significantly higher in the treatment group (62.9-86.2 % vs. 15.5-26.9 %, p < 0.01). Total health service costs were twice as high in the INCO group, however cost-utility ratios were consistently superior compared to the control group. Lowest incremental costs were documented to improve the "physical health" dimension in quality of life.

CONCLUSION

Higher responder rates, higher increases in quality of life and superior cost-utility ratios in the BoNT/A-treatment group underline guideline recommendations for botulinum toxin A treatment in focal or segmental spasticity. Results may partially be influenced by different patient demographics or disease severity at study entry.

A systematic review to investigate the measurement properties of goal attainment scaling, towards use in drug trials

Background

One of the main challenges for drug evaluation in rare diseases is the often heterogeneous course of these diseases. Traditional outcome measures may not be applicable for all patients, when they are in different stages of their disease. For instance, in Duchenne Muscular Dystrophy, the Six Minute Walk Test is often used to evaluate potential new treatments, whereas this outcome is irrelevant for patients who are already in a wheelchair. A measurement instrument such as Goal Attainment Scaling (GAS) can evaluate the effect of an intervention on an individual basis, and may be able to include patients even when they are in different stages of their disease. It allows patients to set individual goals, together with their treating professional. However, the validity of GAS as a measurement instrument in drug studies has never been systematically reviewed. Therefore, we have performed a systematic review to answer two questions: 1. Has GAS been used as a measurement instrument in drug studies? 2: What is known of the validity, responsiveness and inter- and intra-rater reliability of GAS, particularly in drug trials?

Methods

We set up a sensitive search that yielded 3818 abstracts. After careful screening, data-extraction was executed for 58 selected articles.

Results

Of the 58 selected articles, 38 articles described drug studies where GAS was used as an outcome measure, and 20 articles described measurement properties of GAS in other settings. The results show that validity, responsiveness and reliability of GAS in drug studies have hardly been investigated. The quality of the reporting of validity in studies in which GAS was used to evaluate a non-drug intervention also leaves much room for improvement.

Conclusions

We conclude that there is insufficient information to assess the validity of GAS, due to the poor quality of the validity studies. Therefore, we think that GAS needs further validation in drug studies, especially since GAS can be a potential solution when a small heterogeneous patient group is all there is to test a promising new drug.

Trial registration

The protocol has been registered in the PROSPERO international prospective register for systematic reviews, with registration number CRD42014010619. http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42014010619.

Electronic supplementary material

The online version of this article (doi:10.1186/s12874-016-0205-4) contains supplementary material, which is available to authorized users.

OnabotulinumtoxinA Improves Pain in Patients With Post-Stroke Spasticity: Findings From a Randomized, Double-Blind, Placebo-Controlled Trial

CONTEXT

Patients with post-stroke spasticity (PSS) commonly experience pain in affected limbs, which may impact quality of life.

OBJECTIVES

To assess onabotulinumtoxinA for pain in patients with PSS from the BOTOX(®) Economic Spasticity Trial, a multicenter, randomized, double-blind, placebo-controlled trial.

METHODS

Patients with PSS (N = 273) were randomized to 22- to 34-week double-blind treatment with onabotulinumtoxinA + standard care (SC) or placebo injection + SC and were eligible to receive open-label onabotulinumtoxinA up to 52 weeks. Assessments included change from baseline on the 11-point pain numeric rating scale, proportion of patients with baseline pain ≥4 achieving ≥30% and ≥50% improvement in pain, and pain interference with work at Week 12, end of double-blind treatment, and Week 52.

RESULTS

At baseline, most patients (74.3%) experienced pain and 47.4% had pain ≥4 (pain subgroup). Mean pain reduction from baseline at Week 12 was significantly greater with onabotulinumtoxinA + SC (-0.77, 95% CI -1.14 to -0.40) than placebo + SC (-0.13, 95% CI -0.51 to 0.24; P < 0.05). Higher proportions of patients in the pain subgroup achieved ≥30% and ≥50% reductions in pain at Week 12 with onabotulinumtoxinA + SC (53.7% and 37.0%, respectively) compared with placebo (28.8% and 18.6%, respectively; P < 0.05). Reductions in pain were sustained through Week 52. Compared with placebo + SC, onabotulinumtoxinA consistently reduced pain interference with work.

CONCLUSION

This is the first randomized, placebo-controlled trial demonstrating statistically significant and clinically meaningful reductions in pain and pain interference with work with onabotulinumtoxinA in patients with PSS.

The biomechanical effect of acupuncture for poststroke cavovarus foot: study protocol for a randomized controlled pilot trial

BACKGROUND

Poststroke cavovarus foot greatly affects patients' activities of daily life and raises the risks of falls and consequent fractures. Acupuncture appears to be safe and effective in promoting motor functions and enhancing the activities of daily life among patients with poststroke cavovarus foot. The current study aims to study the biomechanical effect of acupuncture for poststroke cavovarus foot with objective outcome measurements.

METHODS/DESIGN

This is an assessor and analyst-blinded, randomized, controlled pilot study. A total of 60 eligible patients with poststroke cavovarus foot will be allocated by a 1:1 ratio into an acupuncture treatment group and a control group. Patients in the control group will receive conventional rehabilitation therapies, whereas a combination of acupuncture and conventional rehabilitation therapies will be applied in the acupuncture group. The primary outcome measures are three objective biomechanical parameters from the RSSCAN gait system: varus angle, dynamic plantar pressure distribution, and static plantar contact area. Scores of the Berg Balance Scale, the Fugl-Meyer Assessment, and the Stroke-Specific Quality of Life Scale, as well as other biomechanical parameters such as the step length and width, step time phase, and weight shifting phase will be selected as secondary outcome measurements. All assessments will be conducted at baseline, 4 weeks after the treatment course, and after a follow-up period of 3 months.

DISCUSSION

Results of the current study will provide detailed interpretations of the biomechanical effect of acupuncture for stroke rehabilitation and foundations for future larger clinical studies.

TRIAL REGISTRATION

Chinese Clinical Trial Registry: ChiCTR-IPC-15006889 (8 August 2015).

A completed audit loop of a botulinum toxin therapy service for adult spasticity

Aims:

To undertake a re-audit of all process standards relating to a multidisciplinary team spasticity service employing botulinum toxin set up in 2008, and to identify and clarify the effectiveness of the referral pathway for this service.

Methods:

A retrospective sample of 100 consecutive adult patient case notes who were treated with botulinum toxin and seen by the multidisciplinary team. This audit used the national guidelines set out by the Royal College of Physicians et al (2009) as the gold standard.

Results:

Participants (n=100; mean age=63.5 years; age range 17–86 years) had a variety of diagnoses but predominantly ischaemic stroke. Comparison of audit and re-audit data demonstrated significant improvements in 17 out of 19 service standards, which included patients reviewed by consultant, multidisciplinary team assessment, and achievement of patient goals and functional abilities.

Conclusions:

This iterative process provides practice-based evidence of the benefit of identifying the post-injection therapist prior to the injection of botulinum toxin. This re-audit also enabled further improvement of service re-design in order to reduce waiting times in future.

Common goal areas in the treatment of upper limb spasticity: a multicentre analysis

Objective:

We aimed to develop a goal classification of individualised goals for spasticity treatment incorporating botulinum toxin intervention for upper limb spasticity to under-pin a more structured approach to future goal setting.

Design:

Individualised goals for spasticity treatment incorporating botulinum toxin intervention for upper limb spasticity ( n=696) were analysed initially from four studies published in 2008-2012, spanning a total of 18 centres (12 in the UK and 6 in Australia). Goals were categorised and mapped onto the closest matching domains of the WHO International Classification of Functioning. Confirmatory analysis included a further 927 goals from a large international cohort study spanning 22 countries published in 2013.

Results:

Goal categories could be assigned into two domains, each subdivided into three key goal areas: Domain 1: symptoms/impairment n=322 (46%): a. pain/discomfort n=78 (11%), b. involuntary movements n=75 (11%), c. range of movement/contracture prevention n=162 (23%). Domain 2: Activities/function n=374 (54%): a. passive function (ease of caring for the affected limb) n=242 (35%), b active function (using the affected limb in active tasks) n=84 (12%), c. mobility n=11 (2%). Over 99% of the goals from the large international cohort fell into the same six areas, confirming the international applicability of the classification.

Conclusions:

Goals for management of upper limb spasticity, in worldwide clinical practice, fall into six main goal areas.

Gait improvement by low-dose botulinum toxin A injection treatment of the lower limbs in subacute stroke patients

[Purpose] Lower-limb spasticity after stroke may be associated with worse functional outcome. Our study aim was to establish whether a low-dose botulinum toxin A (BTX-A) injection in subacute stroke patients can improve spasticity, gait, and daily living abilities. [Subjects] Twenty-three subacute stroke patients were randomly allocated to BTX-A treatment group (11 patients) and control group (12 patients). [Methods] In the BTX-A treatment group patients, 200 units BTX-A was injected into the triceps surae (150 iu) and posterior tibial (50 iu) by electrical stimulation-guided. The patients in the control group received the same volume of placebo solution into the same injection locations. Gait analysis (step length, cadence, speed), the 6-min walking test, Fugl-Meyer Assessment (FMA) of the lower limbs, modified Ashworth scale assess (MAS) assessment of the lower limbs, surface electromyography (sEMG), and modified Barthel index (MBI) assessment were performed before and at 4,8 weeks after treatment. [Results] We found that the FMA of the low limbs and MBI were significantly improved in both groups. The gait analysis, FMA, and MBI results in the BTX-A treatment group were better than those in the control group. MAS and surface electromyography (sEMG) showed better improvement of spasticity in the treatment group. [Conclusion] Early low-dose botulinum toxin A (BTX-A) injection in subacute stroke patients into the lower-limb may improve gait, spasticity, and daily living abilities.

Multidisciplinary rehabilitation following botulinum toxin and other focal intramuscular treatment for post-stroke spasticity

BACKGROUND

Spasticity may affect stroke survivors by contributing to activity limitations, caregiver burden, pain and reduced quality of life (QoL). Spasticity management guidelines recommend multidisciplinary (MD) rehabilitation programmes following botulinum toxin (BoNT) treatment for post-stroke spasticity. However, the evidence base for the effectiveness of MD rehabilitation is unclear.

OBJECTIVES

To assess the effectiveness of MD rehabilitation, following BoNT and other focal intramuscular treatments such as phenol, in improving activity limitations and other outcomes in adults and children with post-stroke spasticity. To explore what settings, types and intensities of rehabilitation programmes are effective.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (February 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 12), MEDLINE (1948 to December 2011), EMBASE (1980 to January 2012), CINAHL (1982 to January 2012), AMED (1985 to January 2012), LILACS (1982 to September 2012), PEDro, REHABDATA and OpenGrey (September 2012). In an effort to identify further published, unpublished and ongoing trials we searched trials registries and reference lists, handsearched journals and contacted authors.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared MD rehabilitation (delivered by two or more disciplines in conjunction with medical input) following BoNT and other focal intramuscular treatments for post-stroke spasticity with placebo, routinely available local services, or lower levels of intervention; or studies that compared MD rehabilitation in different settings, of different types, or at different levels of intensity. We excluded RCTs that assessed the effectiveness of unidisciplinary therapy (for example physiotherapy only) or a single modality (for example stretching, casting, electrical stimulation or splinting only). The primary outcomes were validated measures of activity level (active and passive function) according to the World Health Organization's International Classification of Functioning, Disability and Health. Secondary outcomes included measures of symptoms, impairments, participation, QoL, impact on caregivers and adverse events.

DATA COLLECTION AND ANALYSIS

We independently selected the trials, extracted data, and assessed methodological quality using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE). Due to the limited number of included studies, with clinical, methodological and statistical heterogeneity, quantitative meta-analysis was not possible. Therefore, GRADE provided qualitative synthesis of 'best evidence'.

MAIN RESULTS

We included three RCTs involving 91 participants. All three studies scored 'low quality' on the methodological quality assessment, implying high risk of bias. All studies investigated various types and intensities of outpatient rehabilitation programmes following BoNT for upper limb spasticity in adults with chronic stroke. Rehabilitation programmes included: modified constraint-induced movement therapy (mCIMT) compared with a neurodevelopmental therapy programme; task practice therapy with cyclic functional electrical stimulation (FES) compared with task practice therapy only; and occupational, manual therapy with dynamic elbow extension splinting compared with occupational therapy only. There was 'low quality' evidence for mCIMT improving upper limb motor function and spasticity in chronic stroke survivors with residual voluntary upper limb activity, up to six months, and 'very low quality' evidence for dynamic elbow splinting and occupational therapy reducing elbow range of movement at 14 weeks. Task practice therapy with cyclic FES did not improve upper limb function more than task practice therapy alone, only at 12 weeks. No studies addressed interventions in children and those with lower limb spasticity, or after other focal intramuscular treatments for spasticity.

AUTHORS' CONCLUSIONS

At best there was 'low level' evidence for the effectiveness of outpatient MD rehabilitation in improving active function and impairments following BoNT for upper limb spasticity in adults with chronic stroke. No trials explored the effect of MD rehabilitation on 'passive function' (caring for the affected limb), caregiver burden, or the individual's priority goals for treatment. The optimal types (modalities, therapy approaches, settings) and intensities of therapy for improving activity (active and passive function) in adults and children with post-stroke spasticity, in the short and longer term, are unclear. Further research is required to build evidence in this area.

Upper limb international spasticity study: rationale and protocol for a large, international, multicentre prospective cohort study investigating management and goal attainment following treatment with botulinum toxin A in real-life clinical practice

OBJECTIVES

This article provides an overview of the Upper Limb International Spasticity (ULIS) programme, which aims to develop a common core dataset for evaluation of real-life practice and outcomes in the treatment of upper-limb spasticity with botulinum toxin A (BoNT-A). Here we present the study protocol for ULIS-II, a large, international cohort study, to describe the rationale and steps to ensure the validity of goal attainment scaling (GAS) as the primary outcome measure. METHODS AND ANALYSIS DESIGN: An international, multicentre, observational, prospective, before-and-after study, conducted at 84 centres in 22 countries across three continents.

PARTICIPANTS

468 adults presenting with poststroke upper limb spasticity in whom a decision had already been made to inject BoNT-A (5-12 consecutive participants recruited per centre).

INTERVENTIONS

Physicians were free to choose targeted muscles, BoNT-A preparation, injected doses/technique and timing of follow-up in accordance with their usual practice and the goals for treatment.

PRIMARY OUTCOME MEASURE

GAS.

SECONDARY OUTCOMES

Measurements of spasticity, standardised outcome measures and global benefits. Steps to ensure validity included: (1) targeted training of all investigators in the use of GAS; (2) within-study validation of goal statements and (3) establishment of an electronic case report form with an in-built tracking facility for separation of baseline/follow-up data.

ANALYSIS

Efficacy population: all participants who had (1) BoNT-A injection and (2) subsequent assessment of GAS. Primary efficacy variable: percentage (95% CI) achievement of the primary goal from GAS following one BoNT-A injection cycle.

ETHICS AND DISSEMINATION

This non-interventional study is conducted in compliance with guidelines for good pharmacoepidemiology practices. Appropriate ethical approvals were obtained according to local regulations. ULIS-II will provide important information regarding treatment and outcomes from BoNT-A in real-life upper limb spasticity management. The results will be published separately.

REGISTRATION

ClinicalTrials.gov identifier: NCT01020500.

[Epidemiology and clinical assessment of spasticity in multiple sclerosis]

Spasticity is a commonly seen symptom in patients with multiple sclerosis (MS). The vast majority of patients will suffer from this symptom during the course of the disease, and one- third of patients considers that spasticity contributes to a greater part of their disability. The symptom is frequently disabling. It can, however, allow some activities to be performed. Treatment of the symptom is sometimes deleterious, which is why strict assessment of the consequences of spasticity and anticipation of the outcome of antispastic treatment are necessary. Clinical scales, such as the Ashworth and Tardieu scales, are used in clinical practice. The essential element is not, however, assessment of the symptom, but its repercussions on activities of everyday life. It is important to make a list of what patients consider to be disabling situations to verify that they are truly consequences of spasticity. Considering the heterogeneity of clinical expression of spasticity in patients with MS, the use of a scale such as goal attainment scaling (GAS) can probably be totally adapted for the assessment of the effects of antispastic treatment.

Consequences of neurologic lesions assessed by Barthel Index after Botox(®) injection may be underestimated

Purpose

The aim of this study was to investigate whether the consequences of neurologic lesions are underestimated when the Barthel Index (BI) is used to assess the clinical outcome of botulinum toxin injection.

Patients and methods

The records for all in- and outpatients with various neurologic lesions (stroke, multiple sclerosis, spinal cord injury, traumatic brain injury, and so forth) who had been referred to the authors’ departments and who had received botulinum toxin type A (Botox^®) for spasticity within a 4-year period (2008–2011) were examined retrospectively. BI data were collected and analyzed.

Results

The BI score was found to have increased in follow-up assessments (P = 0.048). No correlation was found between the degree of spasticity and the BI score.

Conclusion

The specific injection of Botox in patients with neurologic lesions was not strongly correlated with a significant functional outcome according to the BI. The results of this study suggest that clinicians need to look at other measurement scales for the assessment of significant outcomes of Botox in the rehabilitation process after neurologic lesions.