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How to diagnose post-stroke spasticity (PSS)

Diagnosis and treatment of PSS during the first 3 months post-stroke may benefit patients in their aim for a full recovery5,6

It is possible to identify the functional risk factors that may contribute to the development of chronic spasticity.

The PSS risk classification tool has been developed by a panel of experts and AbbVie to help spasticity patients get the timely treatment they need

The Post-Stroke Spasticity Classification System was created with the assistance of a group of international experts in the field of PSS, utilising both published risk factors and their own clinical experience. 

The development of this material was funded by AbbVie.

This tool is recommended by experts in the field of stroke rehabilitation and neurorehabilitation to be used when evaluating patients who have had a stroke, ideally within the first 12 weeks post-stroke. However, it can still be used at other timepoints. It is recommended that this screening tool is used during regular follow-up visits after a stroke, to identify and manage symptoms of post-stroke spasticity.

Possible additional risk factors for the development of post-stroke spasticity include:

  • smoking (defined as current and past smokers)9,18
  • left-sided stroke9
  • enhanced manual activities prior to the stroke9

This tool is based on the clinical expertise of Dr Rhoda Allison, Dr Ganesh Bavikatte, Professor Philippe Marque, Associate Professor Barry Rawicki, Dr Maria Matilde de Mello Sposito, Dr Paul Winston and Professor Jörg Wissel.

*Mildly increased muscle stiffness = MAS 1 or +1; moderately = MAS 2; markedly = MAS 3; severe = MAS 4.‡19 Measured using the Fugl-Meyer Upper Extremity Scale.10,11 Based on the clinical expertise of the expert panel. §Muscle contractions should be differentiated from contractures. Visual inattention includes hemianopsia, scotoma or visual neglect. **Can be measured with the Barthel Index (low score) and EQ-5D (low score).9

CT: computerised tomography; EQ-5D: EuroQol-5D; MAS: Modified Ashworth Scale; MDT: multidisciplinary team; MRI: magnetic resonance imaging; PSS: post-stroke spasticity.

BOTOX® (botulinum toxin type A) is indicated for the treatment of focal spasticity including:20

  • wrist and hand disability due to upper limb spasticity associated with stroke in adults
  • ankle and foot disability due to lower limb spasticity associated with stroke in adults


  1. Allergan. Data on file. INT/0423/2016
  2. Aurora S K, Winner P et al. OnabotulinumtoxinA for treatment of chronic migraine: pooled analyses of the 56-week PREEMPT clinical program. Headache 2011;51(9):1358-1373
  3. Blumenfeld A M, Stark R J et al. Long-term study of the efficacy and safety of OnabotulinumtoxinA for the prevention of chronic migraine: COMPEL study. J Headache Pain 2018;19(1):13
  4. Allergan. Data on file. 014
  5. Stinear C, Ackerley S et al. Rehabilitation is initiated early after stroke, but most motor rehabilitation trials are not: a systematic review. Stroke 2013;44(7):2039-2045.
  6. Rosales RL, Efendy F et al. Botulinum toxin as early intervention for spasticity after stroke or non-progressive brain lesion: A meta-analysis. J Neurol Sci. 2016;371:6-14.
  7. Ward A B. Long-term modification of spasticity. J Rehabil Med 2003(41 Suppl):60-65
  8. Sunnerhagen K S. Predictors of spasticity after stroke. Curr Phys Med Rehabil Rep 2016;4:182-185
  9. Wissel J, Verrier M et al. Post-stroke spasticity: predictors of early development and considerations for therapeutic intervention. PM&R 2015;7(1):60-67
  10. Fugl-Meyer A R, Jaasko L et al. The post-stroke hemiplegic patient. 1. a method for evaluation of physical performance. Scand J Rehabil Med 1975;7(1):13-31
  11. Opheim A, Danielsson A et al. Early prediction of long-term upper limb spasticity after stroke: part of the SALGOT study. Neurology 2015;85(10):873-880
  12. Wissel J, Ward A B et al. European consensus table on the use of botulinum toxin type A in adult spasticity. J Rehabil Med 2009;41(1):13-25
  13. Wilkinson D, Sakel M et al. Patients with hemispatial neglect are more prone to limb spasticity, but this does not prolong their hospital stay. Arch Phys Med Rehabil 2012;93(7):1191-1195
  14. de Jong L D, Hoonhorst M H et al. Arm motor control as predictor for hypertonia after stroke: a prospective cohort study. Arch Phys Med Rehabil 2011;92(9):1411-1417
  15. Nijland R H, van Wegen E E et al. Presence of finger extension and shoulder abduction within 72 hours after stroke predicts functional recovery: early prediction of functional outcome after stroke: the EPOS cohort study. Stroke 2010;41(4):745-750
  16. National Institute for Health and Care Excellence (NICE). Clinical guideline 162. Stroke rehabilitation in adults, 12 June 2013. Available at: Accessed January 2023
  17. Duncan P W, Zorowitz R et al. Management of adult stroke rehabilitation care: a clinical practice guideline. Stroke 2005;36(9):e100-143
  18. Leathley M J, Gregson J M et al. Predicting spasticity after stroke in those surviving to 12 months. Clin Rehabil 2004;18(4):438-443
  19. Bohannon RW and Smith MB. Interrater reliability of a modified Ashworth scale of muscle spasticity. Phys Ther 1987;67(2):206-207
  20. BOTOX® Summary of Product Characteristics. Available at: Accessed January 2023

Please refer to the BOTOX® Summary of Product Characteristics for further information on adverse events, contraindications and special warnings and precautions for use.


Date of preparation: January 2023. UK-BTX-220203.