The research, published in Frontiers in Neurology by a team at Paracelsus Medical University and the Christian Doppler University Hospital, tackles a stubborn gap in routine care. Post-stroke spasticity affects between roughly 4 and 42.6 percent of stroke survivors depending on when they are assessed, and patients with severe initial arm weakness are at particularly high risk, with up to 46 percent developing spastic hypertonia within the first year. Left untreated, abnormal muscle tone can lead to contractures, pain syndromes, skin breakdown and lasting losses in independence. Despite effective therapies being available, studies from France and elsewhere have documented widespread underuse of botulinum toxin, especially among older, multimorbid patients whose competing medical problems can obscure the functional toll of rigid, clenched muscles.

The Salzburg team, led by Melanie Rudelstorfer and Richard Friedrich Radlberger, reasoned that the missing link might not be treatment capacity but detection. Physicians spend limited time at the bedside, while nurses, physiotherapists and occupational therapists observe patients continuously during washing, dressing and mobilization. If these professionals could reliably flag candidates for specialist evaluation, the referral pipeline to botulinum toxin therapy might finally match the true prevalence of the disorder.

To test that idea, the researchers conducted a prospective, two-phase, single-center study of 124 patients treated across neurology and geriatric wards, two neurological rehabilitation units and a long-term care facility between April and October 2025. The participants had a median age of 72 years, ranging from 20 to 94, and just under half were men. Stroke was the most common admission diagnosis, accounting for 33.1 percent of cases, followed by traumatic causes such as fractures, traumatic brain injury and paraplegia at 30.6 percent, with a mixed group of infections, internal medicine conditions and multiple sclerosis making up most of the remainder.

In the first phase, the researchers deployed an existing instrument called the Spastic Movement Disorder Decision Tree, or SMD-DT. This algorithmic tool combines the Modified Ashworth Scale for grading muscle tone, the Medical Research Council scale for muscle strength, and the Spasticity-Associated Arm Pain Scale into a structured pathway for judging whether a patient’s spasticity is clinically relevant and might warrant treatment. Nurses, physiotherapists and occupational therapists each applied the decision tree independently, blinded to one another’s results, and their judgments were compared against the assessment of an experienced neurologist, who served as the reference standard.

The results revealed a striking dependence on context and professional background. On a neurological rehabilitation unit, where staff regularly manage complex spasticity cases, agreement with the neurologist was excellent: physiotherapists and nurses each achieved a Cohen’s kappa of 1.00, meaning perfect agreement, while occupational therapists reached 0.79. But on a geriatric ward, where referrals for botulinum toxin were infrequent and staff had less neurological exposure, the decision tree faltered. Occupational therapists still managed substantial agreement at kappa 0.65 and physiotherapists reached 0.46, but nurses dropped to 0.28, a level classified as fair and not statistically significant in that sample. All professional groups showed a sensitivity of 0.67 in the geriatric setting, meaning a third of true cases slipped past them.

That failure proved instructive. Rather than abandoning nurse-led screening, the researchers convened an interprofessional meeting between nursing staff and a botulinum toxin-experienced neurologist to understand why the scales-based tool did not translate to everyday nursing workflows. Out of that consensus came the Salzburg Nursing Questionnaire, or SNQ, a radically simplified instrument built around three practical questions drawn from the caregiver’s perspective: Does the nurse need physical strength to overcome the patient’s tense posture during personal care, for example at the genital area, armpits or during catheter changes? Is pain perceived during mobilization, such as dressing or hygiene? And are there skin injuries like macerations or ulcerations caused by the tense posture, for instance on palms, elbows or armpits? A single yes triggers a referral recommendation, and the questionnaire is designed to be completed after morning care, requiring no formal rating scales at all.

The second phase put the SNQ through its paces in independent cohorts to avoid training effects. On a second neurological rehabilitation unit with 28 patients, the questionnaire achieved a kappa of 0.61 against the physician’s referral recommendation, with a sensitivity of 1.00, meaning every true case was caught, and a specificity of 0.96, with only one false positive. The more dramatic result came from an independent long-term care facility specializing in multiple sclerosis and vegetative state patients, where the SNQ achieved both sensitivity and specificity of 1.00 relative to the neurologist’s recommendation for botulinum toxin treatment. In other words, three yes-or-no questions answered by nurses during routine care matched the judgment of a spasticity expert without missing a single candidate.

The authors are careful to frame these numbers within the study’s limitations. It was a single-center investigation with modest sample sizes, producing wide confidence intervals, and the reference standard rested on the clinical judgment of one neurologist rather than fully operationalized criteria, since no objective benchmark exists for botulinum toxin indication. The SMD-DT also focuses primarily on the upper limbs, potentially overlooking patients whose spasticity affects only the legs, a blind spot the SNQ avoids because it applies regardless of body region. The SNQ itself has not yet undergone formal psychometric validation, and the authors emphasize that assessments of construct validity, test-retest reliability and external validation in further cohorts remain pending before widespread implementation.

Even so, the study carries a message that resonates well beyond Salzburg: screening instruments are not one-size-fits-alls, and their diagnostic performance is inseparable from who applies them and where. Algorithm-based tools built on formal scales may excel in therapy-oriented disciplines like physiotherapy and occupational therapy, particularly in rehabilitation settings, whereas simplified, function-oriented checklists are better matched to the realities of nursing workflows outside specialized neurology. A differentiated, profession-specific screening strategy, the authors argue, could finally close the notorious gap between how common spasticity is and how rarely it is treated, transforming bedside observations made while washing and dressing a patient into timely referrals for a therapy that can relieve pain, ease caregiving and preserve independence. An English translation of the questionnaire is provided for international readers, though the original German version was used in the study and the translation has not been formally validated.

Subject of Research: Interprofessional screening tools for detecting candidates for botulinum toxin therapy in spastic movement disorders

Article Title: Improving detection of candidates for botulinum toxin therapy in spasticity: an interprofessional screening approach

Article References: Rudelstorfer, M., Mayr-Pirker, B., Trinka, E., Iglseder, B., & Radlberger, R. F. (2026). Improving detection of candidates for botulinum toxin therapy in spasticity: an interprofessional screening approach. Frontiers in Neurology, 17, Article 1939701. https://doi.org/10.3389/fneur.2026.1939701

Image Credits: AI Generated

DOI: 10.3389/fneur.2026.1939701

Keywords: botulinum toxin, spasticity, post-stroke spasticity, nursing questionnaire, screening, neurorehabilitation, diagnostic accuracy, interprofessional care, geriatrics, movement disorders, referral, Salzburg Nursing Questionnaire