Effectiveness of an Interprofessional Approach to the Treatment of Spasticity With Botulinum Toxin & Non-pharmacological Therapies

The Goal Attainment Scale (GAS) is a tool to formulate and measure personalized rehabilitation goals on all ICF levels. In this model the following 5-point rating is used:

• 2 much better than defined
• 1 better than defined 0 SMART formulated goal is achieved

• 1 baseline status unchanged
• 2 worsening of baseline status

LegA: It is a valid and reliable tool, which measures change in passive and active function of the lower limb due to spasticity related impairment and the impact of these on quality of life. It is a patient or carer-rated outcome measure with 33 items relating to clinically relevant goals from the patient or carer's point of view. It is a 5 point Likert scale with 0 = no difficulties/ not at all and 4 = not able to do/ extremly.

Spasticity-related quality of life (SQoL-6D) provides an overall picture of spasticity-related health status following focal treatment of upper limb spasticity. As a valid, reliable and responsive measure of spasticity-related quality of life, the SQoL is designed to record those dimensions that relate to the chosen goal areas. There are six dimensions of the SQoL-6D:

• Reduction of pain and discomfort
• Control of spasms and other involuntary movements
• Maintaining the range of upper limb movements
• Passive function: ease of caring for the affected limb
• Active function - using the affected limb in activities
• Mobility/ balance. Each dimension is assessed using a five-level scale ranging from 0 to 4, whereas 0 = no difficulties and 4 = extremly hard/ not able to do

ArmA: It is a valid and reliable tool, which measures changes in passive and active function in the upper limb due to spasticity related impairment. It is a patient or carer rated outcome measure with 20 items relating to clinically relevant goals from the patient or carer's point of view. It is a 5-point Likert scale with 0 = no difficulties and 4 = not able to do.

LegA: It is a valid and reliable tool, which measures change in passive and active function of the lower limb due to spasticity related impairment and the impact of these on quality of life. It is a patient or carer-rated outcome measure with 33 items relating to clinically relevant goals from the patient or carer's point of view. It is a 5 point Likert scale with 0 = no difficulties and 4 = not able to do.

MAS: The MAS measures the severity of spasticity and is a six-point ordinal scale (0 - no difficulty, 4 - unable to do task) with an additional point at +1 (slight increase in muscle tone). The MAS therefore provides a single score to represent spasticity. It has moderate reliability but is widely used in clinical practice due to ease of application.

mTS: The mTS is a reliable measure which quantifies spasticity by assessing the muscle response to different stretch velocities (movements at fast and slow speed passive movement) and by determining the spasticity angle. Additionally, the quality of muscle reaction regarding resistance, clonus or contracture is noted. It is a 5-point ordinal scale with 0=no resistance and 4=clonus > 10sec.

Muscle strength will be tested manually by the examiner following the Medical Research Council (MRC) as a valid tool. The scale is an ordinal scale and ranges from 0-5 whereas grade 0 to 3 has the highest reliability and with score 0 (no strength at all) to 5 (maximum strength).

For conscious patients the Numeric Pain Rating Scale (NRS) will be used. This scale measures the subjective intensity of pain. It is an 11-point scale scored from 0-10, whereas 0 = no pain and 10 = the most intense pain imaginable. It is described having a good sensitivity.

The Zürich Observation Pain Assessment (ZOPA) is used to external assessment of pain in people with cognitive and/ or conscious impairments in the field of neurosurgery and neurology. The instrument consists of a defined pool of items (behavioural characteristics) and is divided into four categories with a total of 13 subcategories. It provides information about the presence of pain and not about the perceived pain quality. The scale is assessed in various dimensions (e.g. facial expressions, posture, verbal expressions), with each dimension being rated on a five-point scale from 0 (no expression) to 4 (highest degree of pain).

The behavioural pain assessment tool for patients in minimal conscious state will be used for the included patients at the Royal Hospital for Neuro-disability. It is a structured framework for recording and monitoring behaviours that may denote experience of pain in patients with prolonged disorders of consciousness. 7 items will be observed by a health-professional and then scored from 0 to 2. Whereas 0 means normal behaviour and 2 means a strong sign which can indicate stronger pain.