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Evaluating and improving care

Upper limb function

Development of tools to assess function in the spastic upper limb

Through related work the need for further assessment of upper limb function has been identified. Assessing functional gain is problematic for three reasons. Firstly the goals for treatment vary widely (Sheean 2001). Secondly in some cases treatment is aimed at restoring motor control leading to independent function (termed ‘active function’). Thirdly in other cases, where paralysis is more severe, the goals for intervention may be to improve the ease of caring for the person - maintaining hygiene or ease of dressing for example (termed ‘passive function’). The management of spasticity also includes physiotherapy to stretch the affected muscles and where possible to promote motor control through practice of tasks, and is therefore further complicated by incorporating more than one intervention.

While functional scales, which include a standardised task battery, are useful for comparison of different patient groups, they may not reflect accurately the individual goals of each patient, and user-focused outcomes are increasingly regarded as critical to the demonstration of success. There is therefore a need to develop functional outcome measurement tools to use alongside approaches such as Goal Attainment Scaling, which assess both active and passive function from the ecological perspective of the "patient".

Main Projects


Arm Activity Measure

Work has been undertaken including a two systematic reviews, identify pre-existing tools, which may be valuable in this area of outcome measurement. Current research outputs include:Patient Reported Outcome Measure (PROM) questionnaire:The Arm Activity Measure (ArmA)Development of upper limb proformas for outcome evaluationSystems for recording therapy intervention (physiotherapy and occupational therapy)Development of costing models for lower limb spasticity intervention 

Associated reaction scale

A tool has been designed to rate the phenomenon of associated reactions in individuals with arm spasticity. Spasticity in the arm can be accompanied by flexion of the elbow and internal rotation at the shoulder, which is associated with physical effort and is therefore, termed an associated reaction. 

The associated reaction scale is designed to be used by raters who have clinical experience of the phenomena. Further work is planned evaluating the utility of the tool in both the research and clinical practice environments.



Turner-Stokes L, Ashford S, Jacinto J, Maisonobe P, Balcaitiene J & Fheodoroff K. (2016) Impact of integrated upper limb spasticity management including botulinum toxin A on patient-centred goal attainment: rationale and protocol for an international, prospective, longitudinal cohort study (ULIS III), BMJ Open; 6:e011157.

Ashford S, Jacinto J, Fheodoroff K & Turner-Stokes L. (2016) Common goal areas in the treatment of upper limb spasticity: a multicentre analysis, Clinical Rehabilitation. 30(6) 617–622, DOI: 10.1177/0269215515593391.

Fheodoroff  K, Ashford S, Jacinto J, Maisonobe P, Balcaitiene J & Turner-Stokes L. (2015) Factors influencing goal attainment in patients with post-stroke upper limb spasticity following treatment with botulinum toxin A in real-life clinical practice: sub-analyses from the Upper Limb International Spasticity (ULIS)-II Study. Toxins. 7, 1192-1205; doi:10.3390/toxins7041192


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