Management of stroke patients submitted to botulinum toxin type a therapy: A Delphi survey of an Italian expert panel of specialist injectors

Background. Spasticity is a common disabling symptom of several neurological conditions including stroke. Botulinum toxin type A (BTX-A) injection represents the goldstandard therapy for focal spasticity. Post-stroke management of patients receiving BTX-A therapy has been variously investigated, but general agreement on how andwhen to implement rehabilitation is lacking. Aim. To perform a national survey of experts on the most appropriate rehabilitation procedures after BTX-A therapyfor the focal treatment of spasticity. Design. The study employed the Delphi technique through the COSMO project (Consensus on Post-InjectionManagement in Post-stroke Spasticity). Methods. Italian neurologists and physiatrists with experience in BTX-A therapy were selected to participatein the survey. Their anonymous opinions on key issues in treatment strategies in post-stroke spasticity were collected in three sequential rounds facilitated by a web platform.Consensus on a given issue was defined as agreed opinion by at least 66% of the survey participants. Results. In all, 44 Italian experts were involved. Positiveconsensus was reached on the need to start rehabilitation during the first week after BTX-A injection therapy, with a rehabilitation program comprising both stretchingcombined with electrical stimulation and exercise therapy. Functional surgery may be considered only after 12-24 months in cases of BTX-A therapy failure. Theuse of commercial or custom-made orthoses in selected cases was recommended. The appropriate time interval between two BTX-A injections is 3-6 months, and clinicalassessment should be performed 1 month after injection. Conclusion. The results of this national survey confirm that clinical experts on the use of BTX-A therapy forspasticity after stroke agree on the need to initiate rehabilitation treatment immediately after BTX-A injection: muscle stretching exercises, eventually combined withneuromuscular electrical stimulation, may enhance the effect of BTX-A therapy. Outcome after BTX-A therapy should be assessed at repeated follow-up visits. Clinical Rehabilitation Impact. This expert panel survey can provide guidance for clinicians in the assessment of patients treated with BTX-A therapy