Objectives To investigate current Canadian physicians' practice patterns of treating upper limb post stroke spasticity (PSS) and hemiplegic shoulder pain (HSP) acutely after a stroke. In addition, by examining Canadian physicians' diagnostic capabilities, time till treatment, minimum criteria to begin treatment, mechanisms of treatment, targeting of muscles, and benefits and adverse effects of treatment, we aim to learn about areas of improvement to optimize PSS management for Canadians. Design The present study was a cross-sectional survey, polling practicing Canadian physicians. Results 17 physicians completed the survey, all PM&R specialists, save one neurologist. Four provinces were represented in the responses. Participants had, on average, over ten years of experience managing post stroke spasticity in outpatient and inpatient clinics. All 17 perform botulinum neurotoxin A (BoNT-A) injections as a first line treatment for HSP associated with PSS. Most participants reported that they will being BoNT-A treatments 2-3 weeks post stroke, most commonly targeting the pectorals major, subscapularis, and latissimus dorsi. Participants reported the median dosage they would inject for each of onabotulinum toxin A (169.12 units, SD = 73.70), incobotulinum toxin A (178.13 units, SD = 65.75), and abobotulinum toxin A (470.83 units, SD = 171.17). For injection guidance, participants responded that they use ultrasound for the largest percentage of their caseload, followed by electromyography, then electrical stimulation, then palpation. Very seldom did participants use palpation alone. Conclusions From the limited sample included in analyses, Canadian physicians seem to be treating HSP and associated PSS with BoNT-A injections as first line treatments. Further research is required to align dosages, targets, and guidance strategies as they vary considerably.
Stroke is a major public health issue as it is the second largest cause of death, with an annual global mortality rate of 5.5 million people. Spasticity is a common sequela following stroke that presents in up to 43% of patients. It is defined as “involuntary muscle hyperactivity in the presence of central paresis. The involuntary muscle hyperactivity can consist of spasticity sensu strictu, of rigidity, of dystonia and of spasms or a mixture of those elements”. Management of post stroke spasticity (PSS) can be particularly challenging as the onset of PSS can appear acutely following a stroke or present later in the management of chronic stroke. Since effective treatment is based on early recognition and intervention, physicians must constantly be aware of its presentation to reduce progression and improve patient outcomes. In addition to spasticity, hemiplegic shoulder pain (HSP) is a common condition that also results after stroke. Like PSS, the onset of HSP can be acute, with 17% of patients experiencing HSP within 1 week. Just like in PSS, early intervention can reduce the risk of contracture and maximize recovery. The pathology of HSP can be multifaceted; it can include mechanical factors such as weakness, muscle imbalance and bicipital tendonitis, and neurological factors including paralysis, altered sensation, neurological pain and the main contributor of HSP, spasticity. Since PSS and HSP are so intimately connected, this paper’s objective is to investigate current Canadian physicians’ practice patterns of treating upper limb PSS and HSP acutely after a stroke. In addition, by examining Canadian physicians’ diagnostic capabilities, time till treatment, minimum criteria to begin treatment, mechanisms of treatment, targeting of muscles, and benefits and adverse effects of treatment, we aim to learn about areas of improvement to optimize spasticity management for Canadians.
The participants in this study were licensed Canadian physicians who treat PSS and HSP. In all, 17 participants completed the survey. Prospective participants were excluded if they neglected to continue the survey beyond providing demographic information, were practicing in countries other than Canada, or were allied health professionals other than physicians. Of the 17 participants, all were physical medicine and rehabilitation specialists save one neurologist. Four provinces were represented by the survey respondents, seven reported that they are practicing in Ontario, four in British Columbia, three in Alberta, and three in Quebec. The sample had a mean of 10.18 (SD = 6.06) years treating HSP and 10.59 (SD = 6.18) years treating PSS.
Participants were asked to rank the most common causes of HSP in their practices. Overall, the highest ranked cause was stroke (weighted score = 172, mean score = 1.7), followed very closely by spasticity (weighted score = 170, mean score = 3.4). Next most important were adhesive capsulitis (weighted score = 152, mean score = 3.9) and rotator cuff pathology (weighted score = 144, mean score = 2.9). When asked about the ability to accurately differentiate the cause of HSP being PSS as opposed to other etiologies, only four stated that they could confidently isolate the etiology with between 80%-100% certainty. The respondents indicated that the clinical signs and symptoms that would most shift their pre test probability towards HSP being due to spasticity over other causes were flexor patterning in the upper limb (13 participants), limitation of shoulder abduction (11 participants), limitation of shoulder external rotation (10 participants), pain on passive movement (9 participants), and pain on active movement (5 participants).
All 17 of the study participants reported that they perform BoNT-A injections for HSP treatment associated with shoulder spasticity. They reported that they use BoNT-A as a first line treatment for spastic upper extremities for a mean 64.18% (SD = 28.57%) of their patients. Participants reported the minimum MAS rating at which they would consider administering BoNT-A injections in the shoulder at a median of 2 (IQR = [1,2]), and they would consider beginning treatment less than a week post stroke (1 participant), 7-14 days after stroke (5 participants), 15-21 days after stroke (9 participants), 22 days - 1 month after stroke (2 participants). The most commonly treated muscles for PSS were pectoralis major (17 participants), subscapularis (11 participants), latissimus dorsi (10 participants). Also mentioned were pectoralis minor (6 participants), teres major (4 participants), deltoid (2 participants), coracobrachialis (1 participant), and biceps brachii (1 participant). Participants reported the median dosage they would inject for each of onabotulinum toxin A (169.12 units, SD = 73.70), incobotulinum toxin A (178.13 units, SD = 65.75), and abobotulinum toxin A (470.83 units, SD = 171.17).
While performing BoNT-A injections, participants reported that they use ultrasound guidance for the highest proportion of their injections at 60.88% (SD = 38.25%). They estimated using electromyography for a mean 58.21% (SD = 35.93%) of their injections. They also reported using electric stimulation a mean 34% (SD = 33.68%) and manual palpation 29.54% (SD = 41.93%) of the time. They reported using manual palpation only just 4.94% (SD = 8.57%) of the time. Correlational analysis of the participants’ reported guidance technique preferences was conducted using data from all participants who reported the rate at which they use each guidance technique probed (zeros included) for a total of 12 participants considered. There was a strong, significant negative correlation in the rate at which clinicians used EMG guidance, and US guidance (pearson r = -0.84, p = 0.0006) indicating that participants who used US guidance frequently used EMG more rarely and vise-versa; no other correlations were significant.
For adjuncts, participants reported that on average, the most commonly used treatments were stretching (73.12%, SD = 34.01), active exercise programs (67.12%, SD = 26.38), and explicit referral to physiotherapy (65.41%, SD = 23.21). Barriers to survey respondents seeking adjunct treatments included clinician-based time constraints (10 participants), risk of adverse events (4 participants), lack of evidence (3 participants), patient preference (2 participants).
From the limited sample included in analyses, Canadian physicians seem to treat HSP and PSS with BoNT-A injections as first line treatments. Further research is required to align dosages, targets, and guidance strategies.
COI Unless noted below there are none. Fraser A. MacRae, BS – Disclosed travel support and investigator role in clinical trial (Pacira)
