*2.2.3 Assessment of resistance to passive movement, including assessment of the full range of motion and contracture identification*

Trunk and limb spasms are evaluated in this step. This assessment is usually performed using the Modified Ashworth scale. However, it may fail to distinguish


**Table 1.** *Medical Research Council (MRC) grading of muscle strength.*


**Table 2.**

daily life should be considered as well. These assessments should also be carried out in the follow-up visits. In some references, it is recommended to perform the assessments by a professional in this area in a multidisciplinary visit with a team of specialists and clinicians instead of assessments by different specialists in several visits. The assessment consists of two parts: history and physical examination.

*Neurostimulation and Neuromodulation in Contemporary Therapeutic Practice*

The ultimate goal of assessment of history is to provide a thorough history that encompasses the impact of the disease on the patient's communications and interactions with the environment and also covers all aspects of the disease. Therefore, the provision of a checklist is recommended (Appendix 1). In addition to the suggested questions, the answers to these two questions are very important in history taking and should be included in the treatment plan: Does the spasticity contribute to improving your performance? And is this spasticity a local problem or

For observation, it is recommended to evaluate the items of posture, alignment, presence of spontaneous spasms, seating if applicable, movement patterns when moving (e.g., walking, transferring or picking up objects), and pressure sores. However, observation alone is not enough and outcome measurements (Appendix 2) such as timed 10-meter walk test and goniometry are useful.

The grading scale of the Medical Research Council (MRC) (**Table 1**) can be used to assess both weakness and spasticity. However, its application in severe to mod-

*2.2.3 Assessment of resistance to passive movement, including assessment of the full range*

Trunk and limb spasms are evaluated in this step. This assessment is usually performed using the Modified Ashworth scale. However, it may fail to distinguish

2 Active movement with gravity eliminated

4 Active movement against gravity and resistance

*2.2.2 Assessment of active movement, including range of motion and muscle strength*

The physical examination involves three steps, as follows.

**2.1 History**

a generalized one?

*2.2.1 Observation*

**2.2 Physical examination**

erate spasticity is difficult.

**Table 1.**

**88**

*of motion and contracture identification*

**Grade Definition** 0 No contraction

5 Normal power

*Medical Research Council (MRC) grading of muscle strength.*

1 Flicker of contraction only

3 Active movement against gravity

*Recommendations to standardize the measurement of the Ashworth scale.*

between neuronal and non-neuronal causes of spasticity [1]; thus, the items addressed in **Table 2** should be noted to avoid misinterpretation [2]. It is effective to use the Tardiu scale [3] to differentiate between the neuronal component and the non-neuronal one because of the evaluation at different velocities [4]; however, it is more time-consuming than the Ashworth test. It should be noted that the suggested tests are specified for spasticity evaluation in limbs, and if one of the patient's chief complaints is trunk spasticity, the verbal or visual analog scales can be used as well as measuring the distance between two fixed points on the trunk in fast and slow trunk flexions by using a tape.

It is important to use outcome measures in clinical evaluation; however, it is always challenging to maintain a balance between test simplicity and speed with its reliability and validity [5], so different tests and methods have been suggested with respect to the disease diagnosis. In this book, we recommend the outcome measure of the National Hospital of Neurology and Neurosurgery (NHNN) in London with a few modifications [2], which is typically used for patients with moderate to severe spasticity (Appendix 2).

When the assessment is over and the treatment plan is being outlined, any physician should ask himself an important question: "why should I treat this spasticity?" and the more important question is "what are the patient's expectations of this treatment?" So the ultimate goal should be discussed with the patients and their caregivers to expect a realistic outcome. Since these goals are different for each patient, the following desires can be addressed: sitting comfortably in a wheelchair, adequate and comfortable night sleep, easier catheterization for bladder drainage, etc.

Different algorithms [6–8] have been developed for the evaluation of and therapeutic approach to spasticity; one of the most applied of them has been developed by Stevenson et al. [2] and is presented in **Figure 1**.

**Figure 1.** *Therapeutic approach to spasticity.*
