Search

To identify the impact of upper limb spasticity on stroke survivors by linking their shared experience to the International Classification of Functioning, Disability, and Health (ICF).Ten community dwelling adults with a chronic stroke and spasticity, who had completed an upper limb rehabilitation trial participated in semi-structured interviews. Data were analysed using content analysis and linked to the ICF Comprehensive Core Set for stroke using standard linking rules.Four hundred and thirty-nine meaningful concepts eligible for linking were identified. The majority (Half of the Comprehensive Core Set categories for stroke were relevant, but to adequately capture experience an additional eight were needed. The ICF category profile may be unique to our participants or may suggest further research is needed to determine if additions to core set categories are required.Implications for rehabilitationOur ICF mapping demonstrated that the Brief Core Set for stroke was not sufficient to capture the range of experience for stroke survivors with upper limb spasticity, instead the Comprehensive Core Set for stroke supplemented with eight clinical-cohort specific second-level-categories should be used.Our findings suggest that rehabilitation may better reflect lived experience if it focuses on Body Function (Chapters 1, 2, 4, 7), Activity and Participation (Chapters 1-9), and Environment (Chapters 1, 2, 3, 5) because Body Structure was rarely mentioned in this or previous post-stroke ICF mapping research.

Background It is common for people with persistent spasticity due to a stroke to receive an injection of botulinum toxin-A in the upper limb, however post-injection intervention varies. Aim To determine the long-term effect of additional upper limb rehabilitation following botulinum toxin-A in chronic stroke. Method An analysis of long-term outcomes from national, multicenter, Phase III randomised trial with concealed allocation, blinded measurement and intention-to-treat analysis was carried out. Participants were 140 stroke survivors who were scheduled to receive botulinum toxin-A in any muscle(s) that cross the wrist because of moderate to severe spasticity after a stroke greater than 3 months ago, who had completed formal rehabilitation and had no significant cognitive impairment. Experimental group received botulinum toxin-A plus 3 months of evidence-based movement training while the control group received botulinum toxin-A plus a handout of exercises. Primary outcomes were goal attainment (Goal Attainment Scale) and upper limb activity (Box and Block Test) at 12 months (ie, 9 months beyond the intervention). Secondary outcomes were spasticity, range of motion, strength, pain, burden of care, and health-related quality of life. Results By 12 months, the experimental group scored the same as the control group on the Goal Attainment Scale (MD 0 T-score, 95% CI -5 to 5) and on the Box and Block Test (MD 0.01 blocks/s, 95% CI -0.01 to 0.03). There were no differences between groups on any secondary outcome. Conclusion Additional intensive upper limb rehabilitation following botulinum toxin-A in chronic stroke survivors with a disabled upper limb is not more effective in the long-term. Trial Registration ACTRN12615000616572 (12/06/2015).

Supplemental Digital Content is available in the text., Background and Purpose— The aim of this trial was to determine the effect of additional upper limb rehabilitation following botulinum toxin-A for upper limb activity in chronic stroke. Methods— We conducted a multicenter phase III randomized trial with concealed allocation, blinded measurement, and intention-to-treat analysis. One hundred forty stroke survivors who were scheduled to receive botulinum toxin-A in any muscle(s) that cross the wrist because of moderate to severe spasticity after a stroke >3 months ago, who had completed formal rehabilitation and had no significant cognitive impairment. Experimental group received botulinum toxin-A plus evidence-based movement training while the control group received botulinum toxin-A plus a handout of exercises. Primary outcomes were goal attainment (Goal Attainment Scaling) and upper limb activity (Box and Block Test) at 3 months (end of intervention). Secondary outcomes were spasticity, range of motion, strength, pain, burden of care, and health-related quality of life. Results— In terms of goal attainment, the experimental group scored the same (mean difference, 2 T-score [95% CI, −2 to 7]) as the control group on the Goal Attainment Scale. In terms of upper limb activity, by 3 months the experimental group moved blocks at the same speed (mean difference, 0.00 blocks/s [95% CI, −0.02 to 0.01]) as the control group on the Box and Block Test. There were no differences between groups on any secondary outcome except strength, in favor of the experimental group (mean difference, 1.4 kg [95% CI, 0.2–2.7]). Conclusions— Findings suggest that additional intensive upper limb rehabilitation following botulinum toxin-A in chronic stroke survivors with a disabled upper limb is not effective. Registration— URL: https://www.clinicaltrials.gov. Unique identifier: ACTRN12615000616572.

To determine which Goal Attainment Scale (GAS) goals are commonly achieved in patients with upper limb and/or lower limb spasticity following Botulinum Neurotoxin Type A (BoNT-A) injection.Adults who attended a Spasticity Management Clinic for upper and/or lower limb BoNT-A injection were included in this prospective cohort study. Goals were set by participants and/or carers in conjunction with the therapist using the GAS, prior to injection and reviewed at one month following the injection. Three out of the five categories of goals were passive. Goals were categorised into: mobility/transfers, pain/comfort, upper limb use, hygiene, and cosmesis. The number of responders for the GAS total score, and in each of the GAS categories, was calculated.Sixty-seven participants were recruited (mean age 51 ± 16 years; range 18-85), 70% had a stroke. Responders for mobility and transfer goals were further post injury or disease onset than non-responders (median 5.9 vs. 1.2 years, p = 0.03). Clients with stroke were less likely than other participants to achieve mobility and transfer goals (p = 0.02). There was a trend for those who achieved mobility and transfer goals to be younger (mean 49 years vs. 55 years, p = 0.06). Although active goals are more commonly identified, passive goals were more likely to be achieved.Although active goals are commonly identified by people with spasticity, passive goals were more likely to be achieved following BoNT-A injection. A long duration of spasticity does not preclude patients from achieving mobility and transfer goals. Non-stroke participants were more likely to achieve mobility and transfer goals. Implications for Rehabilitation Patients with chronic spasticity should be considered for BoNT-A as clinically meaningful outcomes can be achieved. When spasticity is present in multiple muscles, the GAS can be an assistive tool to guide clinicians in determining which muscles are a priority for injection, because the client will be more motivated to improve those specific goals. Although carers and patients are more willing to set active goals, these are more difficult to achieve possibly because follow up intervention or independent practise is required.

To determine whether gait and mobility measures are responsive to change following botulinum toxin (BoNT) injections in adults with lower limb spasticity.Independently ambulant adults who attended a spasticity clinic for lower limb BoNT injections were eligible to participate. The 10 m walk test (shoes on and off), timed up and go test and 6-min walk test were performed before injection and 1 month later. Participants completed a global rating of change scale (GRCS) at follow up. Comparisons were made between participants' ratings of change and change in walking performance. Effect sizes (ES) and standard error of measurement (SEM) were calculated for each outcome.Thirty-nine patients (22 female, 17 male; mean age 51 ± 12 years; range 26-74 years) with a median spasticity duration of 53 months participated. Statistically significant changes were found in all gait and mobility measures at 1 month following injection. All ES were small (0.2) and SEM for each measure was large. The global rating of change scale (GRCS) indicated that 66% of participants perceived that their walking had improved. However, there was a significant relationship between GRCS and performance on walking tests for the 10 m walk test with shoes off (p = 0.01) and timed up and go test (p = 0.02) only.Commonly used walking tests may not be responsive to change following BoNT injection. The small ES suggest that BoNT has a modest effect on walking ability. Tests of walking performance may not be sufficient to capture all clinically relevant changes in walking ability following BoNT injection of the lower limb.