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Determining Severity: Spasticity Assessments

Assessment of spasticity should encompass physical, functional, and quality of life measures. These should be done from the clinician's, patient's, and caregiver's perspectives. The overactive muscles or muscle groups should be identified and the effect of spasticity on all aspects of patient function, including mobility, employment, and activities of daily living (ADLs), should be determined. Tone, mobility, strength, balance, endurance, pain, quality of life, and the need, if any, for assistive devices should all be considered.1-4

Since spasticity is difficult to quantify, clinical severity scales are useful, including:2

  • Ashworth Scale/Modified Ashworth Scale
  • Physician's Rating Scale
  • Spasm Frequency Scale

An office visit may not provide an adequate picture of overall severity of spasticity. Evaluation and assessment for several hours, at specific times of the day, or over a course of weeks may be necessary.

Assessment of a patient’s function and quality of life are also important to determine since severe spasticity is based on functional limitations and comfort. Knowing if a patient has severe spasticity will ultimately guide treatment and help determine treatment outcomes.

Note that this is not a complete list of all available assessment tools used to evaluate spasticity, its impact on patients, or its severity. Depending on the cause of the spasticity specific assessment tools may be employed.

Note that patient assessments employ both clinician- and patient-reported tools. It is important to keep in mind that the intensity of spasticity should take into account the clinician’s, patient’s, and caregiver’s perspectives.8 A patient’s self-report may be a more accurate reflection of problematic or severe spasticity.9 That is, severe spasticity is best described as how problematic the spasticity is to the patient or caregiver rather than just a numerical rating on a spasticity assessment measure.8

  1. Reeves S, Lambeth K. Chapter 15: The role of physical and occupational therapy in the evaluation and management of spasticity. In: Brashear A, Elovic E, eds. Spasticity: Diagnosis and Management. 2nd ed. New York, NY: Demos Medical Publishing, LLC, 2016.
  2. Walker HW, Hon AJ, Kirschblum S. Chapter 23: Spasticity due to disease of the spinal cord: pathophysiology, epidemiology, and treatment. In: Brashear A, Elovic E, eds. Spasticity: Diagnosis and Management. 2nd ed. New York, NY: Demos Medical Publishing, LLC, 2016.
  3. Ivanhoe CB, Durand Sanchez AV. Chapter 4: Ancillary findings associated with spasticity. In: Brashear A, Elovic E, eds. Spasticity: Diagnosis and Management. 2nd ed. New York, NY: Demos Medical Publishing, LLC, 2016.
  4. Elovic E. Chapter 5: Measurement tools and treatment outcomes in patients with spasticity. In: Brashear A, Elovic E, eds. Spasticity: Diagnosis and Management. 2nd ed. New York, NY: Demos Medical Publishing, LLC, 2016.
  5. Tilton A, Miller D. Chapter 28: Evaluation, treatment, planning, and nonsurgical treatment of cerebral palsy. In: Brashear A, Elovic E, eds. Spasticity: Diagnosis and Management. 2nd ed. New York, NY: Demos Medical Publishing, LLC, 2016.
  6. Shah A. Maitin I. Chapter 24: Spasticity due to multiple sclerosis: epidemiology, pathophysiology, and treatment. In: Brashear A, Elovic E, eds. Spasticity: Diagnosis and Management. 1st ed. New York, NY: Demos Medical, 2016.
  7. Baude M, Gracies JM. Chapter 6: Techniques and scales for measuring spastic paresis. In: Brashear A, Elovic E, eds. Spasticity: Diagnosis and Management. 2nd ed. New York, NY: Demos Medical Publishing, LLC, 2016.
  8. Saulino M, Ivanhoe CB, McGuire JR, et al. Best practices for intrathecal baclofen therapy: patient selection. Neuromodulation. 2016;19(6):607-615.
  9. McGuire JR. Chapter 2: Epidemiology of spasticity in the adult and child. In: Brashear A, Elovic E, eds. Spasticity: Diagnosis and Management. 2nd ed. New York, NY: Demos Medical Publishing, LLC, 2016.

Visual Analog Scale (VAS)3

The VAS instrument measures characteristics or attitudes (eg, pain) from a patient’s perspective with values that range across a continuum from none to an extreme amount. The VAS tool is usually a horizontal line that is anchored by word descriptions at each end of the 100 mm length, and the score is determined by measuring in millimeters from the left side to the point on the line marked by the patient.3

Gross Motor Functional Classification System5

The Gross Motor Functional Classification System (GMFCS) is a tool that determines level of function as shown in the levels outlined below.5

Gross Motor Function Classification System

Level I

Walks and runs independently

Level II

Walks independently

Level III

Walks with assistance

Level IV

Stands for transfer

Level V

Absent head control and sitting balance

Adapted from Reference 5: Tilton A, Miller D. Chapter 28: Evaluation, treatment, planning, and nonsurgical treatment of cerebral palsy. In: Brashear A, Elovic E, eds. Spasticity: Diagnosis and Management. 2nd ed. New York, NY: Demos Medical Publishing, LLC, 2016.

Ashworth Scale/Modified Ashworth Scale (MAS)4

The MAS is a subjective scale that measures passive activity. A score of 0 to 4 is assigned by the examiner based on the amount of increased resistance perceived while moving the patient’s joint through its available range of motion. The MAS is an attempt to strengthen the Ashworth Scale, first published in 1964, with a more reliable scale, particularly when evaluating the wrist and elbow. Importantly, the Ashworth Scale and MAS are well known, easy to perform, and have a history of use for evaluating spasticity and management outcomes in both clinical trials and practice.4

Ashworth Scale4 Modified Ashworth Scale4
Score Description Score Description
0 No increase in muscle tone 0 No increase in muscle tone
1 Slight increase in muscle tone manifested at end of range of motion 1 Slight increase in muscle tone manifested by a catch and release at end of range of motion
2 More marked increase in tone through most of the range of motion but joint easily moved 1+ Slight increase in muscle tone, manifested by a catch followed by minimal resistance throughout the remainder (less than ¼) of the range of motion
3 Considerable increase in muscle tone; passive movement is difficult 2 More marked increase in tone through most of the range of motion but joint easily moved
4 Affected part is rigid in flexion or extension 3 Considerable increase in muscle tone; passive movement is difficult
4 Affected part is rigid in flexion or extension

Functional Independence Measure4

The Functional Independence Measure (FIM) is a commonly used instrument that assesses a person’s ability to perform 18 subjective items. In other words, it is used to assess activity limitations. Items are graded between 1 (dependent) and 7 (totally independent). Items that are evaluated by the FIM include self-care, mobility, eating, grooming, dressing, toileting, transfers, walking, and stair climbing. It is often used in the rehabilitation setting.4

Expanded Disability Status Scale (EDSS)6

This ordinal scale ranges from 0 to 10 and evaluates disability in people with MS through 8 functional systems (visual, pyramidal, cerebellar, brainstem, sensory, bowel and bladder function, cognition, mental, and other). In addition, the EDSS measures a patient’s ambulation and reliance on an assistive device. A 0 score indicates no disability and 10 is death due to MS. In general, 0 to 4.0 means a patient is ambulatory and does not need assistance. A score of 4.0-7.5 means there is a dependence on an assistive device with limited ability to walk a short distance. A score of 6.0 or greater means there is reliance on a single-point cane, while a patient’s ability to transfer from a wheelchair to bed results in scores 7.5 to 10.0.6

Sickness Impact Profile (SIP)3

The SIP measures quality of life by evaluating body care and movement, social interaction, mobility, communication, emotional behavior, household management, alertness, and ambulation.3

The Stroke-Adapted SIP30
Body Care and Movement
  1. I make difficult moves with help (eg, getting into or out of cars, bathtubs)
  2. I move my hands or fingers with some limitation or difficulty
  3. I get in and out of bed or chairs by grasping something for support or using a cane or walker
  4. I have trouble getting shoes, socks, or stockings on
  5. I get dressed only with someone’s help
Social Interaction
  1. I show less interest in other people’s problems (eg, I don’t listen when they tell me about their problems, don’t offer to help)
  2. I often act irritable to those around me (eg, snap at people, give sharp answers, criticize easily)
  3. I show less affection
  4. I am doing fewer social activities with groups of people
  5. I talk less to those around me
Mobility
  1. I stay home most of the time
  2. I am not going into town
  3. I do not get around in the dark or in unlit places without someone’s help
Communication
  1. I carry on a conversation only when very close to the other person or looking at him/her
  2. I have difficulty speaking (eg, get stuck, stutter, stammer, slur my words)
  3. I do not speak clearly when I am under stress
Emotional Behavior
  1. I say how bad or useless I am (eg, I am a burden on others)
  2. I laugh or cry suddenly
  3. I act irritable and inpatient with myself (eg, talk badly about myself, swear at myself, blame myself for things that happen)
  4. I get sudden frights
Household Management
  1. I am not doing any of the maintenance or repair work that I would usually do in my home or yard
  2. I am not doing any of the shopping that I would usually do
  3. I am not doing any of the housecleaning that I would usually do
  4. I am not doing any of the clothes washing that I would usually do
Alertness Behavior
  1. I am confused and start several actions at a time
  2. I make more mistakes than usual
  3. I have difficulty doing activities involving concentration and thinking
Ambulation
  1. I do not walk up or down hills
  2. I get around only by using a walker, crutches, cane, walls, or furniture
  3. I walk more slowly
Adapted from Reference 3: Ivanhoe CB, Durand Sanchez AV. Chapter 4: Ancillary findings associated with spasticity. In: Brashear A, Elovic E, eds. Spasticity: Diagnosis and Management. 2nd ed. New York, NY: Demos Medical Publishing, LLC, 2016.

Tardieu Scale7

This scale is used in children with cerebral palsy. It is a scale that evaluates resistance and muscle stretch by measuring the degree of angles of movement (from 0 at the position of minimal stretch) to assess passive soft tissue extensibility and the functional muscle length for each tested muscle group. This is done by exerting the slowest and strongest possible stretch on the muscle groups and associated soft tissue (eg, fascia, tendons, ligaments) to move the limb segment as far as possible without causing pain or jeopardizing soft tissue integrity. The scale also evaluates the response of tested muscles to their own stretch (spasticity) by stretching the muscles group as fast as possible without catch.7

Tardieu Scale: Grading
Spasticity Angle (Threshold) Angle of arrest at slow speed (XVI) minus angle of catch at fast speed (XV3)
Spasticity Grade (Gain)
  1. No resistance throughout passive movement
  2. Slight resistance throughout passive movement
  3. Clear catch at precise angle, interrupting passive movement, followed by release
  4. Fatigable clonus (<10 seconds when maintaining pressure) occurring at a precise angle, followed by release
  5. Unfatigable clonus (<10 seconds when maintaining pressure) occurring at a precise angle
    • Catch without release: 0 if XVI = XV3; “unrateable” spasticity otherwise
    • Catch with “minimal” release: graded 2 if XV3 consistent and consistently less than XVI
    • Angle 0˚= position of minimal stretch of the tested muscle
    • For grades 0 and 1, spasticity angle X=0˚ by definition
Adapted from Reference 7: Baude M, Gracies JM. Chapter 6: Techniques and scales for measuring spastic paresis. In: Brashear A, Elovic E, eds. Spasticity: Diagnosis and Management. 2nd ed. New York, NY: Demos Medical Publishing, LLC, 2016.

36-item Short-Form Health Survey (SF-36)

This patient-reported outcomes tool is a generic tool that measures quality of life through 36 survey items. The survey evaluates vitality, physical functioning, bodily pain, general health perceptions, emotional functioning, social functioning, and mental health.

Penn Spasm Frequency Scale (PSFS)2

The Penn Spasm Frequency Scale (PSFS) is one of the most commonly used scales to measure how frequently spasticity or spasm occurs. This scale was created to measure the effectiveness of intrathecal baclofen therapy (ITB Therapy℠) for patients with spasticity of spinal origin. The scale measures the number of spasms within a 1-hour period.2

Penn Spasm Frequency Score
0 No spasms
1 Mild spasms induced by stimulation
2 Infrequent spasms occurring less than once per hour
3 Spasms occurring more than once per hour
4 Spasms occurring more than 10 times per hour
Adapted from Reference 2: Walker HW, Hon AJ, Kirschblum S. Chapter 23: Spasticity due to disease of the spinal cord: pathophysiology, epidemiology, and treatment. In: Brashear A, Elovic E, eds. Spasticity: Diagnosis and Management. 2nd ed. New York, NY: Demos Medical Publishing, LLC, 2016.

Important Safety Information for Lioresal® Intrathecal (baclofen injection)

Abrupt discontinuation of intrathecal baclofen, regardless of the cause, has resulted in sequelae that include high fever, altered mental status, exaggerated rebound spasticity, and muscle rigidity, that in rare cases has advanced to rhabdomyolysis, multiple organ-system failure and death.

Prevention of abrupt discontinuation of intrathecal baclofen requires careful attention to programming and monitoring of the infusion system, refill scheduling and procedures, and pump alarms. Patients and caregivers should be advised of the importance of keeping scheduled refill visits and should be educated on the early symptoms of baclofen withdrawal. Special attention should be given to patients at apparent risk (e.g. spinal cord injuries at T-6 or above, communication difficulties, history of withdrawal symptoms from oral or intrathecal baclofen). Consult the technical manual of the implantable infusion system for additional postimplant clinician and patient information (see WARNINGS).

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For more information, including BOXED WARNING, refer to Lioresal® Intrathecal (baclofen injection) prescribing information.