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Symptom led research


Management of spasticity

Spasticity is the unwanted over activity of muscles in those with damage to their brain or spinal cord. It can be exacerbated by other external factors such as poor position or pain. Spasticity is a common symptom in people who have hemiparesis caused by stroke, brain injury or other neurological conditions, and results in reduced function of the affected limb.

The main treatment aims for upper limb focal (arm) spasticity are to improve passive function (to make it easier to care for the limb) or to restore active function when possible or management of symptoms such as pain. The main focal treatment options are physical therapy (including physiotherapy) and Botulinum toxin type A (BoNT-A).

Dr Stephen Ashford and Professor Lynne Turner-Stokes have explored the role of BoNT-A in the management of the spastic hemiplegic shoulder and identified common achievable goals for treatment. This has led to systematic processes for goal setting and evaluation for upper limb spasticity intervention using Goal Attainment Scaling (Ashford and Turner-Stokes 2006; Turner-Stokes et al. 2010; Turner-Stokes et al. 2012).

Work has also identified that BoNT-A injection of the proximal upper limb, with combined therapy, produced a reduction in spasticity, and an improvement in passive function and pain. Management of upper limb spasticity should therefore include evaluation and, if necessary, treatment of the shoulder girdle and proximal musculature (Ashford and Turner-Stokes 2008).

The researchers further tested the combination of physical therapy and Botulinum toxin in an open label prospective cohort study with 58 patients conducted in a two-centre specialist spasticity management settings in London. This showed that passive function was improved following BoNT administration and physical therapy intervention by 8 weeks and that this was maintained at 16 weeks despite the physiological effects of the BoNT gradually reducing over this time period.

The role of individual physical therapy interventions in generating and maintaining passive function gains following spasticity management with BoNT warrants further exploration.

A major component of this work has been the development of outcome evaluation systems to be applied alongside the GAS method (Turner-Stokes et al. 2012; Turner-Stokes et al. 2012).  These have included development of an upper limb spasticity evaluation index for use in a large international cohort study by Dr Ashford and Professor Turner-Stokes.

This development work has been supported by an earlier cohort study which has been led by Professor Turner-Stokes (Turner-Stokes et al. 2013).  In addition, a patient reported outcome measure (PROM) for arm function following spasticity intervention has been developed and tested – the Arm Activity measure (ArmA) (Ashford et al. 2008; Ashford et al. 2013; Ashford et al. 2013; Ashford andTurner-Stokes 2013). 

Further work funded through an NIHR Clinical Lectureship award to Dr Ashford has now started to develop a similar evaluation system for leg spasticity and begin to consider costing models in this area of intervention.


Ashford, S., Slade, M., Malaparade, F. and Turner-Stokes, L. (2008).
Evaluation of functional outcome measures for the hemiparetic upper limb: a systematic review
Journal of Rehabilitation Medicine 40(9): 787-795.
Ashford, S., Slade, M. and Turner-Stokes, L. (2013).
Conceptualisation and development of the Arm Activity measure (ArmA) for assessment of activity in the hemiparetic arm.
Disability and Rehabilitation Early Online: 1–6 DOI: 10.3109/09638288.2012.743602.
Ashford, S., Slade, M. and Turner-Stokes, L. (2013).
Initial psychometric evaluation of the Arm Activity Measure (ArmA): a measure of activity in the hemiparetic arm.
Clinical Rehabilitation iFirst 1-6. DOI:10.3109/09638288.2012.743602.
Ashford, S. and Turner-Stokes, L. (2006).
Goal attainment for spasticity management using botulinum toxin.
Physiotherapy Research International 11(1): 24-34.
Ashford, S. and Turner-Stokes, L. (2008).
Management of shoulder and proximal upper limb spasticity using botulinum toxin and concurrent therapy interventions: A preliminary analysis of goals and outcomes.
Disability and Rehabilitation 31: 220-226.
Ashford, S. and Turner-Stokes, L. (2013).
Systematic Review of Upper-limb Function Measurement Methods in Botulinum Toxin Intervention for Focal Spasticity.
Physiotherapy Research International
Turner-Stokes, L., Baguley, I., De Graaff, S., Katrak, P., Davies, L., McCrory, P. and Hughes, A. (2010).
Goal attainment scaling in the evaluation of treatment of upper limb spasticity with botulinum toxin: A secondary analysis from a double-blind placebo-controlled randomised clinical trial.
Journal of Rehabilitation Medicine 42: 81-89.
Turner-Stokes, L., Fheodoroff, K., Jacinto, J., Maisonobe, P. and Zakine, B. (2013).
The Upper Limb International Spasticity Study II.
British Medical Journal Open.
Turner-Stokes, L., Williams, H. and Ashford, S. (2012).
A UK pilot for a large international prospective cohort analysis of the use of Botulinum Toxin A (BoNT-A) in upper limb spasticity.
Physical Medicine & Rehabilitation 2(9): S190-S119.
Turner-Stokes, L., Ashford, S., De Graaff, S. and Baguley, I. (2012).
The GAS-eous tool - a framework for evaluation of outcome in upper limb spasticity.
Neurorehabilitation and Neural Repair 26(6): 695-804 (poster 649).
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