European expert consensus on improving patient selection for the management of disabling spasticity with intrathecal baclofen and/or botulinum toxin type A.
Bo Biering-Soerensen, Valerie Stevenson, Djamel Bensmail and 5 others
PMID 34608495WHAT IT FOUND
European spasticity experts agreed intrathecal baclofen was favoured for adult multi-segmental or generalized spasticity after oral drugs fail, while botulinum toxin was favoured for focal or segmental spasticity.
Patient goals and shared decisions should guide treatment choice.
Key findings
01Experts reached high agreement that multi-segmental or generalized disabling spasticity refractory to oral drug treatment makes patients best candidates for intrathecal baclofen (96.1% consensus), and focal or segmental disabling spasticity makes patients ideal candidates for botulinum toxin (98.7% consensus).
02Experts recommended botulinum toxin immediately (31.2%) or not more than 3 months (49.4%) after disabling spasticity onset; for intrathecal baclofen, they recommended waiting at least 4 to 6 months (28.6%) or more than 6 months (26.0%).
03Experts agreed combined intrathecal baclofen and botulinum toxin may be considered when goals are not fully achieved with intrathecal baclofen alone in generalized or multi-segmental disabling spasticity (89.6% agreement).
STILL TO COME
How it was doneWhat they foundWhat it means for PTsWhat it means for OTs
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What it does not show
This is expert consensus and survey opinion, not a trial of patient outcomes; it cannot show that any treatment works. The final algorithm was not tested further after the survey. No randomized trials comparing intrathecal baclofen with botulinum toxin were identified, and no studies were found on combining them. Respondents were mostly physicians, with few physical therapists and nurses, so therapist perspectives may be underrepresented. The advisory board selected experts they knew, and many respondents worked in centres able to offer both treatments, which may bias agreement. Consensus could be reached when neutral answers were counted, so some agreement may be weak. Incomplete surveys and child-only clinicians were excluded; the paper applies to adults. Access, funding, and referral factors were not explored.
The easy way to misread this
Do not read the expert agreement on intrathecal baclofen or botulinum toxin as proof that either treatment improves function. This is a consensus statement about patient selection, not a tested intervention, and the paper reports no randomized trials comparing the two treatments.