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The Focal Spasticity Index

Focal Spasticity Index

Goal analysis from four large international studies has identified six common categories for treatment goals [1], which are listed in Table 1. More recently a structured framework has been developed for use in spasticity management – the Focal Spasticity Index.

Table 1: Treatment goals

Principal ICF domains

Key goal areas (ICF codes)

Domain 1:

Symptoms and impairment

  1. Pain/discomfort/stiffness (b280, b780, b134)

  2. Involuntary movements (b760, b765)

  3. Impairment (prevention of contractures) (b710, b735)

Domain 2:


(Active and Passive function)

  1. Passive function (caring for the affected limb), (d520)

  2. Active function (using the affected limb in some motor task) (d430, d440, d445)

  3. Mobility (d415, d450)


  • Cosmesis (improving body image)

  • Facilitation of therapy

Key: ICF= International Classification of Functioning, Disability and Health

The Focal Spasticity Index (FSI) includes both patient-reported and clinician-rated elements. Developed originally in the context of upper limb intervention [2], the approach as now been adapted to encompass outcome evaluation in both upper and lower limb spasticity.

  • The FSI comprises a structured approach to GAS together with severity indicators and confounders to recovery, and a limited set of standardised measures determined by the selected goal areas of treatment for any given patient.

  • The key components of the FSI are listed in Table 2.

 Table 2: Components of the Focal Spasticity Index


Measurement tools

A. Severity and confounders to recovery

(History and examination)

  •   Duration of spasticity (months)

  •   Distribution and severity of spasticity (Modified Ashworth Scale)

  •   Soft tissue contractures (Loss of range)

  •   Severity of underlying impairment (Neurological Impairment Set)

B. Goals for treatment

  •   Individual goal attainment scaling using GAS light

  •   Goals negotiated between patient and team, categorised within one or more of the six main goal areas:

    • Domain 1
  1.   Pain

  2.   Involuntary movements

  3.   Impairment (prevention of contractures)

    • Domain 2

  1.   Passive function

  2.   Active function

  3.   Mobility

  •   Recommended measures used to define goal parameters, selected according to the chosen goal area(s) e.g.

    • Pain: Rating out of 10 (Verbal rating, NGRS or SPIN)
    • Ease of care: Rating out of 10 (Verbal rating, NGRS)
    • Involuntary movement – Carry angle, spasm frequency or Upper limb Associated Reaction Rating Scale [3]
    • Mobility: 10m walking speed

C.   Standardised measures – recommended for all patients where   relevant / possible


Function - passive and active

  • Upper limb: Arm Activity Measure (ArmA)
  • Lower limb: Leg Activity Measure (LegA)


Global benefits

  • Patient reported: Global benefit scale (-2 to +2)

  • Clinician reported: Global benefit scale (-2 to +2)

  • Quality of life: The Spasticity-related Quality of Life tool (SQol-6D)

MAS = Modified Ashworth Scale; NIS = Neurological Impairment Scale; NGRS
= Numbered Graphic Rating Scale; SPIN = Scale of Pain Intensity

Severity indicators and confounders to recovery

These data are collected by clinicians. The section includes:

  • Basic demographic characteristics to define the population (e.g. age, gender, aetiology).

  • Distribution and severity of the spasticity. Spasticity is a focal condition which may affect the whole upper limb – or just the proximal or distal part of it. Its severity and distribution will affect the types of goals for treatment. Despite its acknowledged limitations [4], the Modified Ashworth Scale (MAS) [5] is included as the most widely used measure of spasticity in clinical practice.

  • Factors that may confound outcome include neurological impairments within the affected limb(s) (e.g. motor control, sensory loss, neglect) and general impairments (e.g. deficits in cognition, behaviour, communication, and mood) which may limit the individual’s ability to engage successfully in rehabilitation and achievement of their set goals. These are captured using the Neurological Impairment Set adapted for spasticity [2].

Individual goal attainment scaling

The FSI incorporates a structured approach to goal attainment scaling using the GAS-light. Goals are categorised within one of the six main goal areas. ‘SMART’ (i.e. specific, measurable, achievable, realistic and timed) goal statements are drawn up with reference to recommended measures (or ‘goal parameters’) wherever possible. This supports the collection of standardised measures alongside GAS, but the burden of data collected is reduced as only the measures relevant to the chosen goal categories are recorded for each patient.

For example, if pain reduction is a goal for treatment, the SMART goal statement may refer to a pain rating out of 10 – eg ‘To reduce spasticity-related pain from 8/10 to 4/10 within 6 weeks’.

Clinicians should be aware however, that patients with cognitive/communication deficits may have difficulty reporting their symptoms. A number of tools have been developed to facilitate pain reporting, such as the numbered graphic rating scale or the Scale of Pain Intensity (SPIN) [6].

Standardised measures

The Arm Activity measure (ArmA) and Leg Activity measure (LegA) are patient-reported tools that are recommended as standardised measures to capture changes in passive and active function in the upper and lower limb respectively.

The clinician and patient rating of global benefit of the intervention are recommended to reflect overall change following intervention.

Increasingly, quality of life measures are required by commissioners to capture health utility and cost-effectiveness. General health utility and quality of life measures are shown to be insensitive to change following focal interventions for spasticity. A specific health utility tool to capture spasticity-related quality of life (the SQoL6D) is currently undergoing evaluation, but there is insufficient evidence as yet to recommend its general use.


The Focal Spasticity Index


[1] Ashford S, Fheodoroff K, Jacinto J, Turner-Stokes L. Common goal areas in the treatment of upper limb spasticity: A multicentre analysis. Clinical Rehabilitation 2016;30:617-22.

[2] Turner-Stokes L, Ashford, S, Jacinto, J, Maisonobe, P, Balcaitiene, J & Fheodoroff, K. 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 2016;6.

[3] MacFarlane A, Turner-Stokes L, De Souza L. The associated reaction rating scale: a clinical tool to measure associated reactions in the hemiplegic upper limbClinical Rehabilitation 2002;16:726-35.

[4] Mehrholz J, Wagner K, Meissner D, al. e. Reliability of the modified Tardieu scale and the modified Ashworth scale in adult patients with severe brain injury: a comparison study. Clinical Rehabilitation 2005:751-9.

[5] Pandyan A D, Johnson G R, Price C I M, Curless R H, Barnes M P. A review of the properties and limitations of the Ashworth and modified Ashworth Scales as measures of spasticity. Clinical Rehabilitation 1999;13:373–83.

[6] Jackson D, Horn S, Kersten P, Turner-Stokes L. Development of a pictorial scale of pain intensity for patients with communication impairments: initial validation in a general population Clinical Medicine 2006;6:580-5.

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