High Early Burden of Post-Stroke Spasticity and Persistent Treatment Gaps in Structured Follow-up Care

Technical Summary: High Early Burden of Post-Stroke Spasticity and Persistent Treatment Gaps in Structured Follow-up Care

Problem Statement
Post-stroke spasticity (PSS) is a frequent and disabling motor complication that significantly impairs functional recovery, quality of life, and increases healthcare costs. While approximately 25–40% of stroke survivors develop clinically relevant spasticity within the first year, real-world data regarding the implementation of guideline-recommended antispastic treatments—specifically botulinum toxin type A (BoNT-A)—within structured follow-up programs is limited. Despite BoNT-A being recommended as a first-line treatment for focal PSS, its utilization remains low in routine care, potentially due to limited outpatient screening, delayed recognition, restricted access to specialized treatment, and fragmented referral pathways.

Methodology
This prospective cohort study was conducted within the SOS-Care program, a structured post-stroke follow-up initiative in Dresden, Germany, designed to provide coordinated outpatient care for 12 months post-discharge.

• Population: The study focused on patients with persistent motor deficits (defined as ≥1 point in motor items of the NIHSS at discharge) following ischemic stroke or intracerebral hemorrhage. Patients with pre-stroke functional dependence, severe cognitive impairment, or those receiving palliative care were excluded.
• Screening and Assessment: Systematic spasticity screening was integrated into the follow-up protocol. Assessments occurred at predefined intervals (3 and 12 months post-stroke onset).
  • Clinical Spasticity: Evaluated using the Modified Ashworth Scale (MAS) across 12 joint regions (shoulder, elbow, wrist, hip, knee, ankle). Clinically relevant spasticity was defined as a MAS score ≥2 in at least one joint.
  • Patient-Reported Outcomes: The Zorowitz Spasticity Screening Tool was administered to assess functional impairment.
  • Treatment Tracking: Antispastic treatments (physiotherapy, occupational therapy, oral medication, BoNT-A) were recorded. The "implementation gap" for BoNT-A was defined as the proportion of patients with a documented treatment recommendation who had not initiated therapy.
• Statistical Analysis: Multivariable logistic regression was employed to identify predictors of clinically relevant PSS within 12 months, adjusting for age, sex, stroke type, and discharge disability scores (mRS or NIHSS).

Key Results

• Prevalence and Timing: Among patients with persistent paresis and available follow-up data, clinically relevant spasticity (MAS ≥2) was observed in 72.7% (40/55) over the cumulative 12-month period.
  • At 3 months, 64.2% (34/53) of patients exhibited clinically relevant spasticity.
  • At 12 months, 56.5% (26/46) exhibited clinically relevant spasticity.
  • When considering any increase in muscle tone (MAS >0), prevalence was even higher (92.7% cumulative).
• Predictors: In multivariable analysis, disability at discharge (measured by mRS) was the only independent predictor of clinically relevant spasticity within 12 months. Each one-point increase in mRS was associated with a 2.62-fold increase in the odds of developing spasticity (OR 2.62, 95% CI 1.45–4.75). Age, sex, and stroke type (hemorrhagic vs. ischemic) were not significant predictors.
• Treatment Implementation Gap: Despite systematic screening and structured follow-up, the translation of recommendations into therapy was nearly absent.
  • At 3 months, BoNT-A was recommended for 11.8% of patients with clinically relevant spasticity; zero patients initiated therapy.
  • At 12 months, BoNT-A was recommended for 26.9% of affected patients; zero patients initiated therapy.
  • While physiotherapy and occupational therapy were frequently documented (96.2% and 80.8% respectively at 12 months), the specific guideline-recommended focal treatment (BoNT-A) was not implemented for any patient with a documented recommendation.

Key Contributions and Significance
The study provides novel real-world evidence regarding the burden and management of PSS within a structured care framework.

1. High Early Burden: The research confirms that clinically relevant PSS occurs early (within 3 months) and affects a substantial majority of stroke survivors with persistent motor deficits, often persisting through the first year.
2. Identification of a Critical Care Gap: The primary contribution is the documentation of a near-complete implementation gap for BoNT-A therapy. The study demonstrates that even within a program featuring active case management and systematic screening, the mere identification of treatment needs does not guarantee the initiation of evidence-based outpatient care.
3. Systemic Barriers: The findings suggest that barriers to PSS management extend beyond under-recognition. The lack of therapy initiation despite documented recommendations points to systemic issues such as limited availability of experienced injectors, administrative hurdles, and fragmented referral pathways between rehabilitation, primary care, and specialist services.
4. Implications for Post-Stroke Care: The authors conclude that modern post-stroke care models must evolve beyond the prevention of recurrent vascular events. To address disabling long-term sequelae like spasticity, structured programs must integrate not only detection mechanisms but also robust, accessible pathways for referral and specialized treatment implementation.

The study acknowledges limitations including its single-center design, potential selection bias due to program participation, and reliance on MAS as the primary assessment tool. However, its prospective design and detailed characterization of real-world treatment patterns offer clinically relevant insights into the disconnect between clinical guidelines and outpatient practice.