Diagnosis and assessment

Patient Journey.

People with spasticity are usually oriented to multiple healthcare settings, which differ significantly in their treatment aims. In stroke or intensive care units and other hospital wards the main focus is the patient’s survival. After this acute phase the focus shifts towards the rehabilitation and general care of the patient. If the patient is sent to a nursing home, however, only basic care is generally provided.

Post-stroke spasticity is usually diagnosed and treated at rehabilitation centers, where many experts, such as rehabilitation specialists, occupational therapists, physical therapists, speech therapists, psychologists, social workers and nurses work together to provide patients with different treatment options.

The patient journey from diagnosis to assessment

Diagnosis.

Diagnosis of spasticity is mainly based on clinical evaluation that should include:

  • Clinical history
  • Physical examination
  • Evaluation of stretch reflexes (e.g., deep tendon reflexes, involuntary muscle contractions provoked by stretching the muscle with a tap on the tendon that connects the muscle to a bone)
  • Assessment of passive and active motion
  • Function, e.g., toileting, eating, sleeping, dressing, sitting, standing or walking

A proper assessment of the individual’s clinical and neurological status is critical in developing an effective treatment plan with achievable goals.

A proper assessment of the individual’s clinical and neurological status is critical in developing an effective treatment plan with achievable goals.

Spasticity is suspected based on a history of a neurological disorder and on a specific abnormal posture. Then, it is confirmed if the patient shows an increased resistance to passive movements that increases with speed and typical positioning of the limbs, due to increased muscle tone. The diagnosis is not complicated for rehabilitation specialists but unfortunately a lot of other specialists are not trained and thus don’t recognized the symptoms or when they do so, don’t see the potential benefit of an adapted treatment.

The features of spasticity should be assessed individually for each patient, with the focus on three main areas:

  • The overall motor difficulties
  • The ability to control the muscles
  • How muscle stiffness and any contractures worsen the functional problems

The clinical pattern is of particular interest as it helps to identify the muscles affected by spasticity and thus to determine an appropriate treatment.

The most common diagnostic tools are:

  • Nerve blocks: local transient anesthesia of nerve(s) to evaluate the involvement of muscles in a specific spastic pattern

Electromyography: to evaluate activity of muscles while the patient performs a movement or a task via external electrodes


Assessment scales are used to evaluate the severity of spasticity and response to treatment:

  • Severity of spasticity: Ashworth Scale, Modified Ashworth Scale and Tardieu Scale
  • Disability: Disability Assessment Scale and Functional Ambulation Classification Scale
  • Carer Burden Scale
  • Goal Attainment Scale

Other scales can be used to quantify the consequences of spasticity on everyday activities, like the Disability Assessment Scale, which determines the functional impairment associated with spasticity; the Carer Burden Scale, which evaluates the impact of spasticity on physical carer burden or the Functional Ambulation Scale, which evaluates the gait dependence.

  • Assessment of resistance to stretching when a limb is passively moved
  • Quantitative determination of muscle tone
  • Widely used in spasticity patients
  • Rates muscle tone using a 5-point scale (0 to 4)
  • Examines independence and ambulation abilities

  • This scale is a modification of Ashworth Scale to differentiate mild and moderate spasticity
  • Rates muscle tone using a 6-point scale

  • The Disability Assessment Scale determines functional impairment, limb position and pain
  • The Disability Assessment Scale consists of four functional domains each of them rated by the patient on a 0 to 3 scale:
    • Hygiene
    • Dressing
    • Limb position
    • Pain
  • To calculate the overall score the four domain ratings have to be added, obtaining a final score between 0 and 12

  • Examines independence and ambulation abilities
  • Patients are rated based on their most independent level of function and ability to ambulate
  • Assessed by the physician on a 6-point scale:
    • Level 0 = No functional ambulation
    • Level 1 = Ambulator-dependent for physical assistance, with high dependency
    • Level 2 = Ambulator-dependent for physical assistance, with low dependency
    • Level 3 = Ambulator-dependent for supervision
    • Level 4 = Ambulator-independent (level surfaces only)
    • Level 5 = Ambulator-independent

  • Measures impact of upper limb spasticity on the physical carer burden
  • The Carer Burden Scale consists of four items:
    • Cleaning the palm
    • Cutting the fingernails
    • Cleaning the armpit
    • Putting the affected arm through a sleeve
  •  Each item is rated by the carer on a 0 (no carer burden) to 4  (maximum carer burden) point scale at its most difficult day over the preceding week
  • To calculate the overall score, all the item ratings have to be added and divided by the number of items answered ((∑ item rating)/number of items answered)

  • The Goal Attainment Scale aims at defining goals that are realistic and measurable
  • Each patient and healthcare team identifies two personal and realistic goals for each of the treated limbs at each botulinum toxin injection visit
  • The importance and difficulty for each goal are also defined
  • The physicians rate the Goal Attainment Scale score for each injection cycle at the next injection visit using a 5-point scale:
    • -2 = a lot less than expected
    • -1 = a little less than expected
    • 0 = expected level of achievement
    • +1 = a little better than expected
    • +2 = a lot better than expected


A multidisciplinary team can help you with treating spasticity

How can spasticity be treated?

MULTI-MODAL APPROACH FOR SPASTICITY TREATMENT.

The treatment of adult with spasticity should be provided by a multidisciplinary team employing a shared-care approach. A variety of treatment options is available and clinical experience has shown that a multi-modal approach has many benefits.

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Your questions around spasticity

FAQs

FREQUENTLY ASKED QUESTIONS.

Here you will find the most frequently asked questions (FAQs). We will be updating this section periodically.

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