Shoulder Spasticity Treatment With Botulinum Toxin: A Nationwide Cross-Sectional Survey of Clinical Practices.

introductionUpper limb spasticity can be responsible for several complications (e.g., pain, spasms, contractures, deformity, decreased or lost motor control), which can have a negative impact on functional independence and the quality of life of patients. Chemodenervation with botulinum toxin type A (BoNT-A) is a first-line treatment of focal spasticity in the upper limb (UL). However, shoulder muscles were not included in the classical pivotal BoNT-A studies, leaving a knowledge gap regarding the application of intra-muscular BoNT-A in the spasticity management of this anatomical area compared with the arm and forearm. MATERIALS AND

methodsWe conducted a descriptive cross-sectional nationwide online survey of the current Portuguese clinical practices for BoNT-A injections treating shoulder spasticity. Data were collected regarding the patient's spasticity cause, shoulder muscles treated, BoNT-A doses, guidance methods used, primary goal domains, treatment effectiveness, adverse effects, and recommendation of adjuvant therapy.

resultsA total of 33 physical medicine and rehabilitation physicians were surveyed. Most of the surveyed doctors (90.91%; n = 30) identified post-stroke spasticity as the major condition for the use of BoNT-A injections in their clinical practice. The most frequently injected muscles for patterns that included shoulder adduction and internal rotation were the pectoralis major (100%; n = 33), subscapularis (93.94%; n = 31), latissimus dorsi (54.55%; n = 18), and teres major (24.24%; n = 8). In patterns including shoulder extension, the posterior deltoid (75.76%; n = 25), the long head of the triceps brachii (66.67%; n = 22), and the latissimus dorsi (48.48%; n = 16) were the most frequently targeted muscles. The primary goals of treatments were improvements in passive function (96.97%; n = 32), pain (84.85%; n = 28), active function (45.45%; n = 15), and range of motion (39.39%; n = 13). The overall impression of therapeutic efficacy was "good" (60.61%; n = 20), and adverse drug reactions were considered "very rare" (84.85%; n = 28) and "mild" (93.94%; n = 31). Ultrasound was used "always" and "most times" in 66.67% (n = 22) of cases. The maximum BoNT-A doses per muscle were lower than those in previously reported studies. Conventional kinesiotherapy was "always" recommended as adjuvant therapy after BoNT-A by 66.67% (n = 22) of physiatrists.

conclusionsThis study provides the first nationwide Portuguese description of "real-life" clinical practices concerning the use of BoNT-A for shoulder spasticity. The selection of goal domains aligned with international results, and the targeted muscles were relatively similar. The use of ultrasound was high, and the maximum BoNT-A doses per muscle were lower than those in other reported clinical practices. The providers reviewed indicated high safety satisfaction with using BoNT-A for shoulder spasticity. Further development of clinical guidelines to standardize practices may be useful.