Management of shoulder and proximal upper limb spasticity using botulinum toxin and concurrent therapy interventions: A preliminary analysis of goals and outcomes

Purpose. To explore the role of Botulinum Toxin type A (BoNT-A) in the management of the spastic hemiplegic shoulder and identify the common achievable goals for treatment. Method. Set in a regional spasticity management service in the UK, a prospective observational cohort study was undertaken. Patients (n=16) were receiving BoNT-A (Dysport) injection and concurrent therapy for spasticity of the shoulder girdle or proximal upper limb following stroke/other acquired brain injury. Mean age 54.5 (SD 15.7) years. Mean time since injury: 15.7 months. Functional goals for intervention were determined through agreement with the patient or their carers using Goal Attainment Scaling (GAS). Evaluation of spasticity (Modified Ashworth Scale), pain (numbered graphic rating scale) and three standard passive function tasks (washing, dressing and positioning) were also undertaken. Results. Sixteen weeks post-injection, significant improvements were identified in spasticity (Z=-3.535, p 0.0001), pain (Z=-1.942, p=0.052) and passive function (Z=-3.172, p=0.002). GAS scores had improved in all but one subject, with goals either achieved or over-achieved. Conclusions. BoNT-A injection of the proximal upper limb, with combined therapy, produced a reduction in spasticity, improvement in passive function and pain. Management of upper limb spasticity should include evaluation and, if necessary treatment, of the shoulder girdle and proximal musculature.