Using a Delphi Panel to Identify a Treatment Paradigm for Injecting Botulinum Toxin to Treat Common Postures in Post-Stroke Upper Limb Spasticity (P5.167)

OBJECTIVE: To define a clinically-recommended treatment paradigm using onabotulinumtoxinA for upper-limb common postures resulting from post-stroke spasticity (PSS). BACKGROUND: OnabotulinumtoxinA reduces muscle hypertonia associated with PSS; however, clinicians may not recognize many of the treatable common postures associated with PSS or may not be comfortable injecting onabotulinumtoxinA due to limited experience with this intervention. DESIGN/METHODS: Ten clinical experts participated in a modified Delphi panel process, consisting of 2-3 rounds of voting using anonymous feedback until reaching clinical consensus (蠅66[percnt] agreement). The panel identified the most common upper-limb postures associated with PSS that would be candidates for onabotulinumtoxinA treatment, then defined a treatment paradigm particularly appropriate for inexperienced injectors for the 1) muscle selection for onabotulinumtoxinA injection, 2) dose for each muscle and overall dose for each posture, and 3) use of localization techniques (eg, EMG, electrical stimulation, ultrasound). RESULTS: The panel identified 3 common aggregating upper-limb postures in PSS: 1) adducted shoulder, flexed elbow, pronated forearm, flexed wrist, and clenched fist; 2) flexed elbow, pronated forearm, flexed wrist, and clenched fist; and 3) flexed wrist and clenched fist. An onabotulinumtoxinA dilution 50 U/mL (2:1 dilution ratio [range, 1:1-4:1]) was considered most appropriate. Recommended starting doses for each aggregate were 300U, 300U, and 200U, with total maximum doses of 400U, 400U, and 300U, respectively. Doses for individual muscles ranged from 10-100U. In collaboration with the patient, existing or desired limb function or care activity were important considerations when determining the postures and treatment doses. Localization techniques for muscle identification were considered essential for all postures. CONCLUSIONS: The modified Delphi panel provided consensus on 3 aggregate common upper-limb postures associated with PSS and corresponding treatment paradigms for injecting onabotulinumtoxinA. Study Supported by: Allergan Disclosure: Dr. Simpson has received personal compensation for activities with NeurogesX, Eli Lilly & Company, AstraZeneca, Allergan, Inc., ViroMed, Pfizer Inc., Astellas Pharma, Ipsen, and Merz Pharma as a consultant and/or speaker. Dr. Patel has received personal compensation for activities with Allergan, Inc. as an advisory board member. Dr. Alfaro has received personal compensation for activities with Allergan as an advisor and/or consultant. Dr. Ayyou has received personal compensation for activities with Allergan. Dr. Charles has received personal compensation for activities with Allergan, Ipsen, Medtronic, Inc., and the Alliance for Patient Access. Dr. Dashtipour has received personal compensation for activities with Teva, Allergan, Ipsen, Merz Pharma, Solstice Neurosciences, and Lundbeck Research USA, Inc. as a scientific advisory board member and/or speaker. Dr. Esquenazi has received research support from Allergan, Inc. and Ipsen. Dr. Graham has received personal compensation for activities with D-Pharm, Ltd. and Allergan, Inc. as a consultant and/or advisory board member. Dr. McGuire has received personal compensation for activities with Allergan, Inc. and Merz Pharma. Dr. Odderson has received personal compensation for activities with Allergan, Inc. as a consultant and/or speaker.