A practical guide to optimizing the benefits of post-stroke spasticity interventions with botulinum toxin A: An international group consensus.

This consensus paper is derived from a meeting of an international group of 19 neurological rehabilitation specialists with a combined experience of more than 250 years (range 4-25 years; mean 14.1 years) in treating post-stroke spasticity with botulinum toxin A. The group undertook critical assessments of some recurring practical challenges, not yet addressed in guidelines, through an exten-sive literature search. They then discussed the results in the light of their individual clinical experience and developed consensus statements to present to the wider community who treat such patients. The analysis provides a comprehensive overview of treatment with botulinum toxin A, including the use of adjunctive therapies, within a multidisciplinary context, and is aimed at practicing clinicians who treat patients with post-stroke spasticity and require further practical guidance on the use of botulinum toxin A. This paper does not replicate information published elsewhere, but instead aims to provide practical advice to help optimize the use of botulinum toxin A and maximize clinical outcomes. The recommendations for each topic are summarized in a series of statements. Where published high-quality evidence exists, the recommendations reflect this. However, where evidence is not yet conclusive, the group members issued statements and, in some cas-es, made recommendations based on their clinical experience.

Neurolysis: A Brief Review for a Fading Art.

The key to the successful treatment of patients with spasticity is contingent on choosing appropriate interventions tailored to meet the needs, goals, and specific presentation of each patient. For the clinician attempting to address the focal manifestations of hypertonia without surgical intervention, there have been 2 primary options: neurolysis or chemodenervation. Before the introduction of the botulinum toxins, neurolysis was the only focal spasticity treatment option available to the previous generation of physical medicine and rehabilitation practitioners.

Assessing competency in spasticity management: a method of development and assessment.

This project endeavored to create an educational module including methodology to instruct physical medicine and rehabilitation residents in the evaluation and appropriate treatment of patients with spasticity and other sequelae of the upper motor neuron syndrome. It further sought to verify acquired competencies in spasticity management through objective evaluation methodology. A physical medicine and rehabilitation board-certified physician with 10 yrs clinical experience in spasticity management trained 16 residents using a standardized competency-based module. Assessment tools developed for this program address the basic competencies outlined by the Accreditation Council for Graduate Medical Education. The 16 residents successfully demonstrated proficiency in every segment of the evaluation module by the end of the Postgraduate Year 3 spasticity management rotation. Objective measures compared resident scores on an institution-specific standardized test administered before and after training. Resident proficiency in the skills and knowledge pertaining to spasticity management was objectively verified after completion of the standardized educational module. Validation of the assessment tool is evidenced by significantly improved postrotational institution-specific standardized test scores (mean pretest score, 61.1%; mean posttest score, 95.4%) as well as oral testing. In addition, the clinical development tool was validated by residents being individually observed performing skills and deemed competent by a board-certified physical medicine and rehabilitation physician specializing in spasticity management. The standardized educational module and evaluation methodology provide a potential framework for the definition of baseline competency in the clinical skill area of spasticity management.