Management of Spasticity Revisited

Laura A. Graham

Disclosures

Age Ageing. 2013;42(4):435-441. 

In This Article

Assessment for Aggravating Factors

It is important to identify and remove any irritant which may lead to increase in tone (Table 1).

Physical examination should include full documentation of the pattern of neurology and consideration as to whether this fits with the history. The presence of soft tissue shortening and limitations of joint range of movement should also be noted. Testing of power in the affected limb is important in identifying whether spasticity treatment will be likely to improve function. Further acute investigations (such as CT scan to exclude further stroke or hydrocephalus) may be required if there is a change in neurological signs. Skin inspection is important, both to identify triggering factors and to protect hygiene in compromised skin creases (for example, claw hand and elbow flexor pattern after stroke). Mobile patients should have an examination of barefoot gait.

Outcome Measures

Standardised measures before and after treatment are a crucial component of the assessment process and should ideally include measures of impairment, activity limitation and participation, as well as completion of the patient's own goals which can be formally measured using goal attainment scaling.[11]

Impairment Measures. Spasticity is most often measured using the Modified Ashworth scale or Tardieu scales, although both have drawbacks. Ashworth scales are quick to administer but have limited validity and reliability, whereas the Tardieu scale is too complex and time-consuming to use in day-to-day clinical practice.[12]

Goniometry is used to measure the angle of range of movement across a joint, or tape measurements can record changes. Visual analogue scales for pain and stiffness, including vertical or symbol-based scales which may be more appropriate for those with communication difficulties or cognitive impairment, are also useful.

Activity Limitation. Measures may be used which reflect the pattern of limb involvement. The Frenchay arm test, Action research arm test or nine hole PEG test are suggested tools for assessing upper limb spasticity.[10] The Arm Activity Measure[10] is a useful practical tool which reflects daily activities and can be easily used in clinic.

Simple standard lower limb measures include the 10-m or 6-min walking distance, or video recording of gait. Detailed gait analysis if available may be appropriate for more complex cases.[10]

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