Barriers and facilitators to physical activity participation among community-dwelling physically inactive individuals after stroke: a qualitative exploratory study.

Physical activity has been shown to reduce the risk for first-ever stroke as well as recurrent stroke with positive effects on almost all known modifiable risk factors. However, the perceived barriers and facilitators for engaging in physical activity have been insufficiently studied and may differ between cultures. Therefore, the aim of this study was to explore the perceptions of community-dwelling physically inactive individuals with stroke about barriers and facilitators to their participation in physical activity. This qualitative study included two focus groups of ten individuals with stroke classified as physically inactive based on accelerometer recordings. A semi-structured set of questions was posed in each focus group session and the transcripts were analysed using thematic analysis. The results revealed three main themes and subthemes: individual factors (physical impairments, psychological factors, spirituality), interaction with the family (attitudes of family members/close community) and social and environmental factors (hobbies, lack of or presence of facilities, the use of orthosis). We conclude that physical activity participation is affected by a multitude of factors as well as cultural differences. Thus, interventions aimed at increasing participation in physical activity after stroke should not only be planned according to individual clinical characteristics but also take into account a range of personal-to-social factors, including cultural differences.

Best Practice Recommendations for Dysphagia Management in Intensive Care Unit (ICU): A Delphi Study from Multidisciplinary Experts in Turkey.

There is no study about all aspects of oropharyngoesophageal (OPE) dysphagia from diagnosis to follow-up in a multidisciplinary manner in the world. In order to close this gap, we aimed to create a recommendation study that can be used in clinical practice, addressing all aspects of dysphagia in the ICU in detail with the opinion of experienced multidisciplinary experts. This recommendation paper was generated by a multidisciplinary team, using the seven-step process and a three-modified Delphi round via e-mail. Firstly, 15 open-ended questions were created, and then detailed recommendations including general principles, management, diagnosis, rehabilitation, and follow-up were created with the answers from these questions, Each recommendation item was voted on by the experts as overall consensus (strong recommendation), approaching consensus (weak recommendation), and divergent consensus (not recommended).In the first Delphi round, a questionnaire consisting of 413 items evaluated with a scale of 0-10 was prepared from the opinions and suggestions given to 15 open-ended questions. In the second Delphi round, 55.4% were accepted and revised suggestions were created. At the end of the third Delphi round, the revised suggestion form was approved again and the final proposals containing 133 items were created. This study includes comprehensive and detailed recommendations, including a broad perspective from diagnosis to treatment and follow-up, as detailed as possible, for management of dysphagia in patients with both oropharyngeal- and esophageal-dysphagia in ICU.

Validity and reliability of selective control of upper extremity scale (SCUES) in patients with chronic stroke.

PURPOSE: The aim of this study is to investigate the validity and reliability of the Selective Control of Upper Extremity Scale (SCUES) in patients with stroke. MATERIALS AND METHODS: Forty-two patients with stroke aged 18-75 years, were included in the study. Patients were video-recorded while SCUES was administered. The videos were scored to determine the intrarater and inter-rater reliability. Fugl Meyer Assessment of Upper Extremity (FMA-UE), Box and Block test (BBT) and Brunnstrom Stages of Motor Recovery were measured to evaluate validity of SCUES. Spearman correlation analysis was used to assess the validity of SCUES. Intraclass correlation coefficient (ICC), Kappa (κ) and weighted Kappa (κw) were calculated to determine intrarater and inter-rater reliability. RESULTS: There were significant positive high correlations between SCUES and FMA-UE and BBT and Brunnstrom upper extremity proximal and distal values (rho = 0.944, p = 0.01; rho = 0,875, p = 0.01; rho = 0.84, p = 0.01, rho = 0.82, p = 0.01; respectively) showing validity of SCUES. The ICC value of inter-rater reliability of SCUES was 0,99 (%95 CI: 0,989-0,997, p = 0,001) showing excellent reliability. κ and κ w values for inter-rater and intrarater reliability of individual SCUES items were above 0.7 indicating excellent reliability. ICC of SCUES and FMA-UE indicated excellent intrarater reliability (ICC = 0,99; %95 CI: 0,989-0,997, p = 0,001; ICC = 0.943; %95 CI: 0.9-0.97, p = 0,0001, consecutively). CONCLUSIONS: SCUES showed similar validity and reliability with FMA-UE and SCUES can be used in the evaluation of upper extremity selective motor control in patients with stroke.

The Selective Control of Upper Extremity Scale (SCUES) stands out from existing outcome assessment tools for upper extremity motor control in stroke patients by enabling the evaluation of various quantifiers of selective motor function.SCUES assesses not only the accompanying movements of the trunk or additional joints beyond the targeted joint but also the presence of mirror movements, along with assessing the limited dynamic range of motion.SCUES appears valid and reliable in patients with stroke, indicating its potential use in evaluating upper extremity selective motor control and assessing the outcomes of interventions aimed at enhancing selective motor control.

Delayed radiation-induced motor neuron syndrome: A case report.

BACKGROUND: Delayed radiation-induced motor neuron syndrome (DRIMNS) is an atypical motor neuron disorder that develops months or years after radiation therapy. In this study we present a case of DRIMNS that developed forty years after radiotherapy and to discuss differential diagnoses. CASE PRESENTATION: A 56-year-old male patient was admitted to our clinic with complaints of increasing difficulty in walking for the past year. He had a history of operation and radiotherapy due to testicular tumor. Electroneuromyography (ENMG) and thoracic, lumbosacral, plexus and pelvic magnetic resonance imaging (MRI) were performed considering radiculopathy, plexopathy and motor neuron disease in the differential diagnosis. MRIs revealed no abnormality. Needle EMG of lower extremity and lumbar paraspinal muscles revealed fibrillation and positive sharp waves concomitant with fasciculations and reduced recruitment suggesting anterior horn cell/root involvement. DRIMNS was considered rather than motor neuron disease based on the long duration of symptoms with slow progressive course and history of radiotherapy to the pelvic region. CONCLUSION: DRIMNS is a rare entity that should be considered in the differential diagnosis of lower extremity muscle weakness in a patient with a history of malignancy and radiotherapy. EMG findings are very valuable in making the diagnosis together with the clinical picture.

Ultrasound-Guided Suprascapular Nerve Block at Suprascapular Notch-Do We Really Target Suprascapular Notch or Not? Where Is Our Real Target?

Ultrasound (US)-guided suprascapular nerve block (SSNB) is a widely used procedure and while describing the US-guided SSNB in the suprascapular notch, the suprascapular fossa is often visualized and injection is performed in that location. Although it can be done in both location, to inject the right area, the terminology should be settled and the visualization of these areas which are unclear and confusing in the literature should be clarified. In this sense, we showed the course of the nerve on a cadaver and briefly describe a protocol to correctly visualize the suprascapular notch with US.

Validity, inter-rater reliability, and feasibility of the Chelsea Physical Assessment Tool for assessing physical function in post-acute COVID-19 patients: A cross-sectional study.

BACKGROUND: Various tools have been created to measure physical function during intensive care unit (ICU) stay and after ICU discharge, but those have not been validated in coronavirus 2019 (COVID-19) patients. There is a need for a reliable, valid and feasible tool to define the rehabilitation needs of post-ICU COVID-19 patients entering the acute wards and then rehabilitation clinics. OBJECTIVE: This study aims to investigate the validity, inter-rater reliability and feasibility of Chelsea Physical Assessment Tool (CPAx) in assessing the functional status of COVID-19 patients after discharge from the ICU. METHODS: Demographic and clinical characteristics of the patients were recorded. Patients were evaluated using the modified Medical Research Council (MRC) dyspnea scale, Functional Oral Intake Scale, Glasgow Coma Scale, CPAx, Barthel Index, Katz Index and MRC sum score, measurements of grip strength obtained by dynamometer, the 5 time sit-to-stand test and 30 seconds and sit-to-stand test. CPAx and the other functional assessment tools were administered to 16 patients within 48 hours following ICU discharge. For inter-rater reliability, another physiatrist independently re-assessed the patients. MRC sum score, Barthel and Katz indexes were used to assess construct validity of CPAx. The discriminative validity of CPAx was determined by its ability to differentiate between patients with and without ICU acquired muscle weakness based on MRC sum score. The intra-class correlation coefficients (ICC) were calculated to determine inter-rater reliability for total scores of the functional assessment tools. Cohen's Kappa (κ) coefficient and weighed Kappa (κw) were calculated to determine inter-rater reliability of individual CPAx items. Ceiling and flooring effects were calculated by percentage frequency of lowest or highest possible score achieved. The number and percentages of the patients who were able to complete each tool were calculated to assess feasibility. The CPAx score was strongly correlated with MRC sum score (rho: 0.83), Barthel Index (rho: 0.87) and Katz Index (rho: 0.89) (p< 0.001) showing construct validity. Area under the ROC curve demonstrated that cut off score for CPAx was ⩽ 12 to discriminate patients with MRC sum score < 48, with a sensitivity and a specificity of 100% and 63%, respectively (AUC = 0.859, p< 0.001). ICC was high for CPAx, MRC sum score, Barthel and Katz indexes, Glasgow Coma Scale, and hand grip strength measurement, with the highest value observed for CPAx (ICC, 0.96; 95% confidence interval (CI), 0.71-0.98). κ and κw analysis showed good to excellent inter-rater reliability for individual CPAx items. No floor or ceiling effect was observed at CPAx while floor effect was observed at Barthel Index scores (25%) and Katz Index scores (37.5%). All patients could be evaluated using CPAx while less were physically able to complete the 5 time sit-to-stand, 30 seconds sit-to-stand tests (n= 4) and MRC sum score (n= 14). CONCLUSION: CPAx is a valid, reliable, and feasible tool to assess the physical functional state in COVID-19 patients following discharge from the ICU.

Musculoskeletal complaints and associated factors in school children aged between 6 and 13 years in Istanbul during the COVID-19 pandemic: A cross-sectional study.

BACKGROUND: Following the first COVID-19 cases in Turkey, face-to-face education was ceased after March 16, 2020 until the end of the educational year (i.e. June 19, 2020) and education was substituted remotely due to confinement. OBJECTIVE: This study aims to investigate the frequency of musculoskeletal complaints in school-age children and associated risk factors including reduced physical activity, increased screen time and poor ergonomics conditions in school-age children during the pandemic. METHODS: This cross-sectional study included parents or guardians of 960 students aged between 6-13 years old with a non-randomized sampling. A survey was administered consisting of 65 items related with sociodemographic characteristics of the children and family, online education hours, technological device(s) used, screen time, type of physical activity, presence of musculoskeletal problems and poor ergonomics conditions such as incorrect sitting posture. RESULTS: Logistic regression results demonstrated that age, excess weight gain, total daily screen time, smartphone use, incorrect sitting posture were associated with musculoskeletal complaints. CONCLUSION: The long-term closure of schools due to the pandemic may have led to an increase in musculoskeletal complaints in 6-13 years old children, based on the factors identified in this study, which were excess weight gain, increased screen time and incorrect sitting posture. These findings might help education and health authorities to develop strategies to improve musculoskeletal health of children especially in emergencies such as the pandemic.

A case report of lumbosacral plexopathy in a patient with a history of sacral chordoma and radiotherapy: Will the detection of myokymia on the EMG help to solve the case?1.

BACKGROUND: When a patient with a prior history of malignancy and radiotherapy develops progressive weakness as a presentation of plexus involvement, the differential diagnosis usually rests between radiation-induced plexopathy and invasion from recurrent tumor. The presence of myokymic discharges is helpful in differentiating radiation-induced from neoplastic plexopathy. OBJECTIVE: To present a case report of a patient with chordoma, a locally aggressive tumor, who was diagnosed with recurrent tumor accompanied by the occurrence of myokymia in needle electromyographic examination. METHOD: A 55-year-old male patient with a history of chordoma and radiotherapy presented to our outpatient clinic with complaints of foot drop, and impaired walking for two months. His latest magnetic resonance imaging (MRI) which was performed three months earlier did not show recurrence. Upon electromyographic evaluation, myokymia, the pathognomic electromyography abnormal wave for radiation plexopathy was detected supporting a diagnosis of radiation plexitis rather than recurrent neoplastic invasion. One month later he presented with more severe pain and was re-evaluated by an MRI, on which a mass was detected indicating relapse. CONCLUSION: With this case report, we would like to emphasize that the behaviour of the tumor should be considered and imaging should be repeated when tumors display aggressive or recurrent behaviour.

The caregiver burden of informal caregivers for stroke patients with and without dysphagia: A multi-center, cross-sectional study in Türkiye.

Objectives: The aim of this study was to investigate the caregiver burden (CB) of informal caregivers for stroke survivors with and without dysphagia and to assess the relationship between the CB levels of informal caregivers for stroke survivors with dysphagia, patients' swallowing-related quality of life (QoL), and patients' stroke-specific QoL. Patients and methods: This multi-center, prospective, cross-sectional study included a total of 120 stroke patients (76 males, 44 females; mean age: 61.1±12.3 years; range, 19 to 86 years) between October 2019 and 2020. Of the patients, 57 had dysphagia and 63 had no dysphagia. The Functional Oral Intake Scale (FOIS) was used to classify the degree of functional dietary limitation caused by each patient's swallowing impairment. Patients and caregivers completed the Eating Assessment Tool (EAT-10), Swallowing Quality of Life (SWQoL) questionnaire, Stroke Impact Scale (SIS), and the Zarit Caregiver Burden Interview (ZBI). Results: The CB levels were higher in those caring for stroke patients with dysphagia than in those caring for stroke patients without dysphagia. Caregiver burden was found to be associated with patients' swallowing-related QoL and stroke-related QoL. Significant predictors of high CB scores (F=2.55, R2=0.59; p=0.007) were being an employed caregiver (B=17.48, p=0.003), being a caregiver with high school (B=-19.6, p=0.03), and secondary school (B=-16.28, p=0.02) educational status, being son, daughter (B=30.63, p=0.007) or other relative of the patient (B=20.06, p=0.01), lower FOIS stage (B=-3.14, p=0.011), lower SWQoL (B=0.52, p=0.009) and lower SIS (B=-0.37, p=0.04) scores. Conclusion: Caregivers of stroke patients with dysphagia suffer from a higher CB than those without dysphagia. In stroke patients with dysphagia, swallowing-related QoL is associated with the QoL levels of stroke patients and the CB levels of their caregivers. Employment status, educational status of caregiver, caregiver's relativity to the patient, FOIS stage, swallowing and stroke related QoL of the patients are factors related to burden levels of caregivers of stroke patients with dysphagia. These results may help health professionals to understand dysphagia as an essential source of CB and consider it, while planning treatments.

Assessment of the relationship between rectus femoris cross-sectional area and knee extension strength in the prosthesis users with transtibial amputation: A case-control study.

Objectives: This study aims to investigate cross-sectional area of the amputated-limb rectus femoris compared to the intact-limb and controls and to determine its correlation with functional strength and walking tests in prosthesis users with transtibial amputation. Patients and methods: Between October 2018 and April 2019, a total of 14 prosthesis users (12 males, 2 females; mean age: 47.1±16.2 years; range, 26 to 73 years) who met the inclusion criteria, and 14 age-, sex-, and dominancy-matched able-bodied controls (12 males, 2 females; mean age: 47.1±16.2 years; range, 26 to 73 years) were included in this case-control study. Cross-sectional area of rectus femoris (CSA-RF) was evaluated bilaterally by two independent examiners. Knee extension strength was measured bilaterally by using a handheld dynamometer. Functional strength and walking were assessed by Step-Up-Over and Walk-Across tests of the NeuroCom Balance Master® device. Results: The CSA-RF was found to be reduced in amputated-limb compared to the intact-limb and able-bodied controls (p<0.01). In the prosthesis users, the cross-sectional area difference between both limbs rectus femoris muscles was shown to be correlated with actual and functional knee extension strength, step length, and walking speed (p<0.05). Intra- and inter-observer reliability of CSA-RF on both sides were found to be good to excellent (intraclass correlation coefficient: 0.856-0.936). Conclusion: Ultrasonographic measurement of CSA-RF is a valid and reliable tool to assess the functional strength and walking in the prosthesis users with unilateral transtibial amputation.

Psychosocial problems and cognitive functions in children with spina bifida.

Objectives: This study aims to assess psychosocial functioning in relation to lesion level and ambulatory status in children with spina bifida (SB) and compare them to their peers. Patients and methods: Between March 2013 and May 2013, a total of 31 patients with SB (11 males, 20 females; mean age: 9.4 years; range, 6 to 14.7 years) and 36 typically developing peers (16 males, 20 females; mean age: 9.8 years; range, 6.5 to 14.8 years) were included in the study. All participants were assessed using a semi-structured psychiatric diagnostic interview via the Kiddie Schedule for Affective Disorders and Schizophrenia Present and Lifetime Version (K-SADS-PL), Wechsler Intelligence Scale for Children-Revised (WISC-R), Behavioral Rating Inventory of Executive Functions (BRIEF) parent form, Social Responsiveness Scale (SRS), and Aberrant Behavior Checklist (ABC). Results: In the SB group, the rate of psychiatric disorders was significantly higher (p=0.001) and the SRS scores and the planning and organizational components of the executive function were higher than their peers (p=0.02 and p=0.007, respectively). The psychiatric diagnosis rate, BRIEF, and SRS total scores did not significantly differ according to lesion level and ambulatory status. The BRIEF initiate and organization of materials subtest scores and ABC scores were significantly lower at high lesion levels (p=0.02, p=0.02, and p=0.02, respectively) and non-community walkers (p=0.002, p=0.03, and p=0.003, respectively). Conclusion: Psychiatric disorders, impairment in social responsiveness, and planning and organization components of the executive function are prevalent in children with SB with no intellectual disabilities, compared to their peers. Therefore, psychosocial counseling and multidisciplinary follow-up for SB patients seem to be beneficial.

Characteristics of sit-to-stand movement are associated with trunk and lower extremity selective control in children with cerebral palsy: a cross-sectional study.

Even though the effect of several factors on sit-to-stand (STS) performance of children with CP has been previously explored, the potential role of lower extremity selective control, trunk control and sitting function on the performance of STS has not been examined. This study aimed to investigate the association of trunk control and lower extremity selective motor control with STS performance in children with CP. We recruited 28 children with CP aged between 4 and 10 years whose Gross Motor Function Classification System levels were I and II and 32 age-matched typically developing (TP) children. Trunk control, sitting function, selective control of the lower extremities and STS were evaluated with Trunk Control Measurement Scale (TCMS), sitting section of Gross Motor Function Measure-88 (GMFM-88), Selective Control Assessment of the Lower Extremity (SCALE) and the STS outcomes of a force platform [weight transfer time, rising index, and center of gravity (COG) sway velocity], respectively. In all evaluations, children with CP demonstrated lower scores than TD children. A moderate correlation was found between total scores of TCMS, GMFM-88 sitting section scores and COG sway velocity during STS and a fair correlation between SCALE total scores and COG sway velocity in the CP group ( r = -0.51, r = -0.52, r = -0.39, respectively). A fair correlation was found between SCALE total scores and the weight transfer time during STS in children with CP ( r = -0.39). Based on these results, improving trunk and lower extremity selective control may enhance STS performance in children with CP.

Pediatric dysphagia overview: best practice recommendation study by multidisciplinary experts.

BACKGROUND: Currently, there is no comprehensive and multidisciplinary recommendation study covering all aspects of pediatric dysphagia (PD). This study aimed to generate PD management recommendations with methods that can be used in clinical practice to fill this gap in our country and in the world, from the perspective of experienced multidisciplinary experts. METHODS: This recommendation paper was generated by a multidisciplinary team, using the seven-step process and a three-round modified Delphi survey via e-mail. First, ten open-ended questions were created, and then detailed recommendations including management, diagnosis, treatment, and follow-up were created with the answers from these questions. Each recommendation item was voted on by the experts as overall consensus (strong recommendation), approaching consensus (weak recommendation) and divergent consensus (not recommended). RESULTS: In the 1st Delphi round, a questionnaire of 414 items was prepared based on the experts' responses to ten open-ended questions. In the 2nd Delphi round, 59.2% of these items were accepted as pre-recommendation. In the 3rd Delphi round, 62.6% of 246 items were accepted for inclusion in the proposals. The final version recommendations consisted of 154 items. CONCLUSIONS: This study includes comprehensive and detailed answers for every problem that could be posed in clinical practice for the management of PD, and recommendations are for all pediatric patients with both oropharyngeal and esophageal dysphagia.

Best Practice Recommendations for Geriatric Dysphagia Management with 5 Ws and 1H.

BACKGROUND: Dysphagia is a geriatric syndrome. Changes in the whole body that occur with aging also affect swallowing functions and cause presbyphagia. This condition may progress to oropharyngeal and/or esophageal dysphagia in the presence of secondary causes that increase in incidence with aging. However, no study has been published that provides recommendations for use in clinical practice that addresses in detail all aspects of the management of dysphagia in geriatric individuals. This study aimed to answer almost all potential questions and problems in the management of geriatric dysphagia in clinical practice. METHODS: A multidisciplinary team created this recommendation guide using the seven-step and three-round modified Delphi method via e-mail. The study included 39 experts from 29 centers in 14 cities. RESULTS: Based on the 5W and 1H method, we developed 216 detailed recommendations for older adults from the perspective of different disciplines dealing with older people. CONCLUSION: This consensus-based recommendation is a useful guide to address practical clinical questions in the diagnosis, rehabilitation, and follow-up for the management of geriatric dysphagia and also contains detailed commentary on these issues.

Interrater Reliability, Acceptability, and Practicality of Real-Time Video Pediatric Gait, Arms, Legs, and Spine for Musculoskeletal Assessment of Children During Telemedicine Visits.

BACKGROUND/OBJECTIVE: With the COVID-19 (coronavirus disease 2019) pandemic, telemedicine applications gained momentum, and clinicians tried to develop various musculoskeletal examination methods to be used in telemedicine visits. The aim of this study is to investigate the interrater reliability, acceptability, and practicality of the real-time video Pediatric Gait, Arms, Legs, and Spine (v-pGALS) assessment used in the evaluation during the telemedicine visit. METHODS: The study was designed as cross-sectional. Twenty school-aged children who presented to outpatient clinics with musculoskeletal complaints were included. For interrater reliability, the children were evaluated by face-to-face examination with v-pGALS, and then the child was reevaluated by another physiatrist with real-time evaluation (online video call) with the help of a parent. For acceptability, the time taken and the discomfort caused were evaluated by patients/parents with the smiley face visual analog scale, whereas to assess practicality, the ratio of completeness to duration of examination completion was recorded. RESULTS: κ coefficient of the agreement was found to be 0.88 between the results of the face-to-face examination and online video examination, suggesting very good agreement between the 2 raters. Acceptability of v-pGALS by parents and patients was high; 60% of children and 80% of parents found the duration of examination acceptable, and 70% of the patients and 95% of parents reported no discomfort caused by examination. The duration of face-to-face examination was 5.75 ± 1.29 minutes, whereas the duration of online examination was 15.81 ± 4.9 minutes. CONCLUSIONS: Video pGALS is a reliable, acceptable, and practical examination system that can be used for musculoskeletal assessment of children in telemedicine visits.

Best Practice Recommendations for Stroke Patients with Dysphagia: A Delphi-Based Consensus Study of Experts in Turkey-Part I: Management, Diagnosis, and Follow-up.

Dysphagia is one of the most common and important complications of stroke. It is an independent marker of poor outcome after acute stroke and may become chronic after the acute period and continues to affect all aspects of the patient's life. Patients with stroke may encounter any of the medical branches in the emergency room or outpatient clinic, and as in our country, there may not be specialists specific for dysphagia, such as speech-language pathologists (SLP), in every hospital. This study aimed to raise awareness and create a common opinion of medical specialists for stroke patients with dysphagia. This recommendation paper has been written by a multidisciplinary team and offers 45 recommendations for stroke patients with dysphagia. It was created using the eight-step Delphi round via e-mail. This study is mostly specific to Turkey. However, since it contains detailed recommendations from the perspective of various disciplines associated with stroke, this consensus-based recommendation paper is not only a useful guide to address clinical questions in practice for the clinical management of dysphagia in terms of management, diagnosis, and follow-up, but also includes detailed comments for these topics.

Pros and cons of botulinum toxin injection therapy in cerebral palsy: A qualitative study exploring caregivers' perspective.

BACKGROUND: To describe and understand the experiences and beliefs of caregivers of children with cerebral palsy following botulinum toxin injection. METHODS: A descriptive case study approach with focus group interviews was employed. A semi-structured questionnaire was conducted to collect data. Twenty-one caregivers of children (3-13 years old) with cerebral palsy were recruited with a maximum variation sampling strategy to gain insight through different perspectives. Qualitative analysis with verbatim transcripts was analysed using a thematic approach. FINDINGS: Four themes emerged from qualitative analyses: acceptance of diagnosis, perceptions about treatment, caregivers' experiences with the health environment, and feelings and thoughts after the treatment. CONCLUSIONS: This study highlights caregivers' requests for information about the possible long-term effect of botulinum toxin, as well as information and support to provide the best rehabilitation programme immediately after injection.