title: Management of shoulder and proximal upper limb spasticity using botulinum toxin and concurrent therapy interventions: a preliminary analysis of goals and outcomes.
abstract: OBJECTIVE
  To explore the role of Botulinum Toxin type A (BoNT-A) in the management of the spastic hemiplegic shoulder and identify the common achievable goals for treatment.
  
  
  METHODS
  Set in a regional spasticity management service in the UK, a prospective observational cohort study was undertaken. Patients (n = 16) were receiving BoNT-A (Dysport) injection and concurrent therapy for spasticity of the shoulder girdle or proximal upper limb following stroke/other acquired brain injury. Mean age 54.5 (SD 15.7) years. Mean time since injury: 15.7 months. Functional goals for intervention were determined through agreement with the patient or their carers using Goal Attainment Scaling (GAS). Evaluation of spasticity (Modified Ashworth Scale), pain (numbered graphic rating scale) and three standard passive function tasks (washing, dressing and positioning) were also undertaken.
  
  
  RESULTS
  Sixteen weeks post-injection, significant improvements were identified in spasticity (Z = -3.535, p <0.0001), pain (Z = -1.942, p = 0.052) and passive function (Z = -3.172, p = 0.002). GAS scores had improved in all but one subject, with goals either achieved or over-achieved.
  
  
  CONCLUSIONS
  BoNT-A injection of the proximal upper limb, with combined therapy, produced a reduction in spasticity, improvement in passive function and pain. Management of upper limb spasticity should include evaluation and, if necessary treatment, of the shoulder girdle and proximal musculature.
authors.affiliation: Regional Rehabilitation Unit, Northwick Park Hospital and Department of Palliative Care, Policy and Rehabilitation, School of Medicine, King's College London, UK. Stephen.Ashford@nwlh.nhs.uk
authors.forename: Stephen
authors.initials: S
authors.lastname: Ashford
authors.forename: Lynne
authors.initials: L
authors.lastname: Turner-Stokes
mesh_terms: D019274:Botulinum Toxins, Type A / Q000627:therapeutic use*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009128:Muscle Spasticity / Q000188:drug therapy* / Q000503:physiopathology; D009465:Neuromuscular Agents / Q000627:therapeutic use*; D010147:Pain Measurement; D011446:Prospective Studies; D020127:Recovery of Function; D016896:Treatment Outcome; D034941:Upper Extremity / Q000503:physiopathology*
chemical_list: D009465:Neuromuscular Agents; D019274:Botulinum Toxins, Type A