Incidence estimate and guideline-oriented treatment for post-stroke spasticity: an analysis based on German statutory health insurance data

Background: Spasticity after stroke has been internationally recognized as an important health problem causing impairment of mobility, deformity, and pain. The aim of this study was to assess the frequency of first-ever and recurrent stroke and of subsequent spastic and flaccid paresis. Factors influencing the development of spasticity were analyzed. A further major aim was to provide a "real-life" assessment of the treatment of spasticity in Germany and to discuss this in view of the treatment recommended by German and international clinical guidelines. Methods: The database used in this study comprised a cohort of 242,090 insurants from a large statutory health insurance fund in the federal state of Hesse, Germany. A first hospital discharge diagnosis in 2009 with any of the International Classification of Diseases, Tenth Revision (ICD-10) codes I60-I64 was used to identify patients with acute stroke (hemorrhage and ischemic). These patients were followed up six months after stroke to monitor whether they developed spastic or flaccid paresis (hospital or ambulatory care diagnoses ICD-10 code G81-G83 [excluding G82.6/G83.4/G83.8]). For patients with spastic paresis after stroke the spasticity treatment was analyzed for a six-month period (physiotherapy, oral muscle relaxants, intrathecal baclofen, and botulinum toxin). Results: Standardized to the population of Germany, 3.7 per 1000 persons suffered a stroke in 2009 (raw 5.2/1000). Of all surviving patients, 10.2% developed spasticity within 6 months. Cox regression revealed no significant influence of patient age, gender, morbidity (diabetes, hypertensive diseases, ischemic heart diseases) or type of stroke on development of spasticity. 97% of surviving patients with spasticity received physiotherapy (inpatient care 89%, ambulatory care 48%). Oral muscle relaxants were prescribed to 13% of the patients. No patient received intrathecal baclofen or botulinum toxin. Conclusion: Claims data enabled analysis of the occurrence of stroke and post-stroke spasticity. These data provide insight into real-life treatment for spasticity in Germany. The proportion of patients who receive physiotherapy, which is the international guideline-recommended basic therapy after transition into ambulatory care, can be improved on. Botulinum toxin as an international guideline-based treatment option for focal spasticity has not been implemented in practice in Germany as yet.