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Development of a patient-centered questionnaire

for post-stroke spasticity assessment:
a reliability study

i
al
Alessio Baricich, MD, PhDa Introduction

on
Lucia Cosenza, MDa
Giorgio Sandrini, MDb Globally, stroke is the second cause of death and the
Stefano Paolucci, MDc second leading cause of disability-adjusted life-years
(Kassebaum et al., 2016). The direct and indirect costs of
Giovanni Morone, MD, PhDc
this disease are considerable, especially in view of the

zi
Andrea Santamato, MDd
neurological, psychiatric and medical complications that
Nicoletta Cinone, MDd may ensue (McGuire and Harvey, 1999).
Elisabetta Peri, Eng, PhDe Spasticity, the most frequent complication, is characterized

na
Alessandro Picelli, MD, PhDf by increased velocity-dependent muscle tone and stretch
Marco Invernizzi, MD, PhDa reflexes, due to upper motor neuron damage. The
Giorgio Ferriero, MD, PhDe presence of this type of complication is associated with a
four-fold increase in health care costs (Lundström et al.,
2010). Spasticity, highly heterogeneous in terms of its

r
aHealth Sciences Department, University of Piemonte clinical manifestations and timing of onset, is present ap-

te
Orientale, Novara, Italy proximately in 46% of patients 12 months after stroke
bDepartment of Brain and Behavioral Sciences, Univer- (Sommerfeld et al., 2012). Stroke survivors with spasticity
sity of Pavia, Pavia, Italy often develop secondary deformities of the limbs,
In
cIRCSS “Santa Lucia” Foundation, Rome, Italy disability and pain that limits their ability to perform basic
dDepartment of Physical Medicine and Rehabilitation, activities of daily living (ADLs): it has been reported that
OORR Hospital, University of Foggia, Foggia, Italy between 25 and 74% of 50 million stroke survivors
eMaugeri Spa SB Clinical Scientific Institute, IRCSS, require some kind of assistance or are completely
Pavia (PV) Italy dependent on a caregiver following the ictal event
ni

fNeuromotor and Cognitive Rehabilitation Research (Veerbeek et al., 2011). Abnormal postures and soft
Centre, University of Verona, Verona, Italy tissue alterations lead to the onset of musculoskeletal
nociceptive pain, establishing a vicious cycle of pain and
io

hypertonia (Harrison and Field, 2015).

Correspondence to: Lucia Cosenza The focal approach in the treatment of spasticity, based
E-mail: luc.csnz@gmail.com on injection of botulinum toxin, acts through two me-
chanisms: reduction of muscle contractions, due to
iz

inhibition of acetylcholine release at the neuromuscular

Summary junction (Barnes, 2003), and an antinociceptive action
(Rosales et al., 1996).
Ed

In the emerging scenario of patient-centered medi-
cine, it is becoming increasingly important to involve
patients in the management of chronic diseases. The
rehabilitation field currently has no assessment tool
for evaluating the functional impact of post-stroke
spasticity on activities of daily living.
IC
However, unjustified treatment with botulinum toxin could
impair functional performance. This occurs as a result of
reduction of the compensatory effect of the hypertonia,
which is associated with a considerable loss of strength
(Sunnerhagen et al., 2013).
Hypertonia reduction, although the most immediate index

The aim of this study was to identify a tool to fill this
gap.
The “Spasticity Questionnaire in Real Life” (SPQR)
was administered, twice, to 39 patients with post-
stroke spasticity.
C
of a good treatment from the clinical point of view, is often
not an adequate measure of therapeutic efficacy. Indeed,
it is also essential to consider patient satisfaction,
measured in terms of reduced interference of spasticity

with ADLs, or absence of such interference.

Statistical analysis showed internal consistency and
reliability of the questionnaire, with values greater
than 0.96 and 0.76, respectively. These results show
that the SPQR is a promising tool for evaluating the
©
In clinical practice there are various assessment tools
available for evaluating spasticity in a static condition.
However, clinicians and researchers still have no tool at
their disposal for assessing the extent to which post-

functional impact of post-stroke spasticity.
KEY WORDS: botulinum toxin type A, muscle spasticity,
patient-centered care, patient outcome assessment,
stroke.
stroke spasticity (PSS) impacts on functional tasks or on
ADLs. Instrumental evaluation of spasticity is also
currently incomplete: while current clinical instruments
are able to identify muscle activation patterns in a
dynamic context, there is no means of identifying the
impact of spasticity and the presence of pain in «static»

Functional Neurology 2018;33(2):113-115 113