Definition, Assessment and Treatment of Spasticity According to Physiotherapists and Occupational Therapists in Flanders, Belgium: A Cross-sectional Qualitative Study.

The questionnaire will be distributed online using the REDCAP data collection system on social media platform, via mail and Linkedin. Official representative groups (occupational therapists and physiotherapists) will be contacted to distribute the Questionnaire QR-code or link to their members.

Participants will be first asked for their consent and informed this study followed all the European GDPR guidelines.

The included respondent group consisted of Dutch-speaking Belgian adults with a degree in physiotherapy or occupational therapy, who completed the full online questionnaire on spasticity. Respondents who did not meet these criteria or who did not confirm the informed consent, were excluded. Experience in the work field was not a requirement to participate in this study. The researchers chose to only include fully completed questionnaires, even if a partially completed questionnaire had some relevant information to process. This was done to be consistent in the number of responses and the data analysis. It is also not known why a respondent chose to stop without filling out all the questions.

In Belgium, occupational therapy is offered as a three-year bachelor's program. Physical therapy, which was originally a three-year bachelor's degree as well, became an academic program of four years in 1998 and was subsequently extended to a five-year master's program in 2002.

Recruitment was carried out by sharing the questionnaires URL link and QR-code on social media and with professional associations for PTs and OTs in Flanders (Axxon and ergotherapie-belgium.be). Additionally, the questionnaire was distributed by email to personal contacts of the researchers, all of whom hold qualifications in physiotherapy or occupational therapy.

To ensure anonymity, each respondent was assigned a chronological identification number, which made it impossible to identify the respondents from the data collected. The data was only processed by the researchers for the purpose of answering the research question in this study. Participation was completely voluntary, and respondents could terminate filling out the questionnaire at any moment without consequences for them. Respondents did not receive a personal benefit for completing the questionnaire. Respondents were also not automatically notified of the results from this study.

Questionnaire and outcome variables The questionnaire was made through 'Research Electronic Data Capture Platform' (REDCAP), which is a secure, online software platform that is in accordance with the General Data Protection Regulation (GDPR). Before filling out the questionnaire, respondents had to provide informed consent.

The questionnaire is based on the work of Blanchette et al. (2017) and consisted of five sections. Because respondents consisted of PTs and OTs in Flanders, which is the Dutch speaking part of Belgium, the questionnaire was created in Dutch. But since this study will be compiled in English, all questions and answers were translated (attachment 1, table 5).

The first section consists of eight questions on the sociodemographic characteristics of the respondents: profession, gender, age (open-ended question), years of experience in the work field, percentage of neurological patients (NPs) in the respondent's clientele, work environment, specialization and highest level of education. For work environment and specialization there was an 'others' option. If there was no appropriate option listed for that respondent, they could fill this in themselves through an open-ended question. These variables were used to categorize respondents into different groups for further analysis.

The second section is about the interpretation and definition of spasticity and was added compared to the questionnaire of Blanchette et al. (2017). First, respondents were asked to describe spasticity in an open-ended question. To mitigate potential bias in responses to the open-ended question, respondents were required to complete this question before gaining access to the multiple-choice question. This consisted of five definitions - originally formulated by Lance (1980), Young (1994), Pandyan et al. (2005), Dressler et al. (2018) and Li et al. (2021) - or 'none of the above', where they had to indicate which one they preferred.

The evaluation of spasticity was questioned through multiple-choice questions in the third section. First, four multiple-choice questions were shown, namely: 'Who is responsible for the evaluation of spasticity?', 'When does it need to take place?', 'How important is the use of validated and reliable assessment methods?', and 'Which assessment methods do you use to evaluate spasticity?'. For the first and fourth answer there was also an option for 'others' if the respondent wanted to add something. For the fourth question, indicating multiple answers was possible. Next, there was a question about how satisfied the respondent is with six listed measurement tools (range of motion (ROM), clonus, modified Ashworth scale (MAS), modified Tardieu scale (MTS), deep tendon reflexes, functional scales). For each tool they could choose between 'not at all satisfied', 'not satisfied', 'satisfied' or 'very satisfied'.

Finally, there was a section consisting of one multiple-choice question regarding the preferred treatment of spasticity. Here, indicating multiple options was also accepted and 'others' was also possible. However, this section was not shown if the respondent indicated that they do not work with NPs.

Questions are as followed:

Therapist Questionnaire Therapist Sociodemographic Characteristics

1. Profession

• Occupational Therapist
• Physiotherapist
• Trained in both professions

1. Gender

• Male
• Female
• Unknown

1. Age __________________________________
2. How many years of experience do you have in clinical practice overall?

• Less than 1 year
• Approximately 1 to 3 years
• Between 4 and 10 years
• More than 10 years

1. What percentage of your clientele consists of neurological patients?

• None
• Less than 30% Therapist Questionnaire
• 31% - 75%
• More than 75%

1. How would you best describe your work environment? (multiple answers possible)

• Hospital
• Rehabilitation center
• Institute
• Private practice
• Medical-pedagogical institute for children
• Mental health institute
• School
• University
• University college
• Home care
• Other: _____________________________

1. What is your current field of work? (multiple answers possible)

• Neurology
• Orthopedics
• Pediatrics
• Pulmonology
• Physical Activity
• Sports
• Geriatrics Therapist Questionnaire
• Psychiatry

1. Highest level of professional education

• Master's degree
• Bachelor's degree

1. What is your area of specialization?

• Neurology
• Orthopedics/Sports
• Pediatrics
• Geriatrics
• Physical Activity
• Other: _____________________________ Interpretation and Definition of Spasticity

1. How would you describe spasticity? __________________________________________
2. Which of the following definitions of spasticity seems most appropriate to you?

• [ ] Spasticity is a motor disorder characterized by a velocity-dependent increase in tonic stretch reflexes...
• [ ] A motor disorder due to abnormal intraspinal processing of primary afferent input.
• [ ] Impaired sensorimotor control from an upper motor neuron lesion causing involuntary muscle activation.
• [ ] Involuntary muscle hyperactivity in the presence of central paresis, including various components. Therapist Questionnaire
• [ ] A speed- and length-dependent increase in resistance due to hyperexcitable pathways.
• [ ] None of the above Evaluation of Spasticity

1. Which healthcare provider should be responsible for evaluating spasticity?

• Physician
• Physiotherapist
• Occupational Therapist
• Nurse
• Other: _____________________________

1. When should the evaluation/testing take place?

• At intake
• After 3 weeks
• At hospital discharge (returning home)
• Periodically
• During rehabilitation

1. How important is it to use validated and reliable measurement tools for spasticity?

• Very important
• Important
• Neutral
• Unimportant Therapist Questionnaire
• Not important at all

1. Which of the following measurement tools do you use to evaluate spasticity?

• Range of Motion
• Modified Ashworth Scale
• Deep Tendon Reflexes
• Functional Scales
• Ashworth Scale
• Torque Measurements
• Modified Tardieu Scale
• Clinical Score of Tone
• Spasm Frequency Scale
• Composite Spasticity Index
• Clonus Scale
• Pendulum Test
• EMG
• Other: _____________________________

1. How satisfied are you with the following measurement tools?

• Tool | Not at all | Not satisfied | Satisfied | Very satisfied |
• Range of Motion | [ ] | [ ] | [ ] | [ ] |
• Clonus | [ ] | [ ] | [ ] | [ ] |
• Modified Ashworth Scale | [ ] | [ ] | [ ] | [ ] | Therapist Questionnaire
• Modified Tardieu Scale | [ ] | [ ] | [ ] | [ ] |
• Deep Tendon Reflex | [ ] | [ ] | [ ] | [ ] |
• Functional Scales | [ ] | [ ] | [ ] | [ ] | Treatment of Spasticity

1. How do you currently treat spasticity?

• Long-term stretching
• Long-term ice application
• Sensory-level stimulation (TENS)
• Motor-level stimulation
• Vibration
• Splinting
• Positioning
• Traction
• Other: _____________________________