Introduction: Upper 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 methods: We 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.
Results: A 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.
Conclusions: This 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.
Keywords: botulinum toxin; clinical practices; shoulder muscles; spasticity; survey.
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