• Ian J Baguley, Melissa T Nott, Lynne Turner-Stokes, Stephen De Graaff, Pesi Katrak, Paul McCrory, Monica de Abadal, and Andrew Hughes.
• Westmead Hospital and The University of Sydney, Australia. ian.baguley@swahs.health.nsw.gov.au
• J Rehabil Med. 2011 Nov 1; 43 (11): 1032-7.

BackgroundLimited empirical information exists regarding botulinum toxin-A injector decision-making practices for adult upper limb post-stroke spasticity. The design of most studies prevents such an assessment, as injection sites and dosage are mandated by researcher protocols. This contrasts to usual injector practices, where individualized decision-making is the standard of care.DesignSecondary data analysis from an Australian randomized controlled trial of 90 adults with upper limb post-stroke spasticity where experienced clinicians followed their standard clinical injecting practice rather than a mandated injection regimen.MethodsClinicians were hypothesized to tailor their injection practices according to the subject's degree of spasticity and/or the type of functional gain desired. Hypothesis testing was conducted using non-parametric analysis.ResultsMuscle selection and botulinum toxin-A dosage were not significantly associated with spasticity severity or with patient-identified goals. Between-site differences in injection practices suggested that injector beliefs, rather than patient characteristics, were the dominant feature driving botulinum toxin-A injection strategy for post-stroke upper limb spasticity.ConclusionThis result looks into the "black box" of rehabilitation, revealing significant variation in injector beliefs. Findings suggest that further scientific work is required to maximize the efficacy of botulinum toxin-A injections in post-stroke upper limb spasticity management.

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