Discussion
stroke, post-stroke spasticity, spasticity
STROKE
We have previously demonstrated that the early use of botulinum toxin reduced
spasticity and contractures after stroke and that the effects lasted for
approximately 12 weeks.This indicates that the early use of botulinum toxin for post-stroke spasticity can
be cost-saving to the NHS when assessed in terms of gain in the activity of daily
living (Barthel Index) and arm function (total Action Research Arm Test). This
result contrasts with previously reported cost-effectiveness data that suggested
that the base case incremental cost-effectiveness ratio for botulinum toxin type A
plus therapy was £93,500.The previous study measured response to treatment using the Modified
Ashworth Score (an invalidated measure of spasticity),The previous study treatment was initiated in patients who are likely to
have established spasticity and/or contractures (mean time to treatment
46 weeks post-stroke).The previous study primarily focused on improving function using a
combination of therapy and botulinum toxinIn the current study, all patients had an Action Research Arm Test of 0
to 2 at injection,This study is the first randomised-controlled study using botulinum toxin early to
analyse the potential cost-effectiveness of trying to manage contractures. It
provides data that suggests that the perceived expense of botulinum toxin early
after a stroke before any contractures have developed may help reduce health costs
longer term. Clinicians, often subconsciously, make decisions based on the cost of
treatment on a daily basis. This is a form of rationing services which clinicians
are often unaware they make. It is uncomfortable for clinicians who want to be
patient-centred but must balance this ideal, with remaining service-centred to
ensure patient flow through their service. We hope that this study helps to ease
just one of the many cost-based treatment decisions that clinicians must make.Treating spasticity early, in stroke patients at risk of contractures, with botulinum
toxin does not lead to a significant increase in cost associated with managing these
patients. Future-powered studies should now focus on the long-term
cost-effectiveness associated with treatment involving botulinum toxin and ensure
all social costs are included to allow for a more meaningful result.