Brain Advance Access originally published online on November 9, 2005
Brain 2006 129(1):224-234; doi:10.1093/brain/awh675
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Getting the measure of spasticity in multiple sclerosis: the Multiple Sclerosis Spasticity Scale (MSSS-88)
1 Peninsula Medical School, Plymouth, 2 Neurological Outcome Measures Unit, Institute of Neurology, London, UK and 3 School of Education, Murdoch University, Perth, Western Australia
Correspondence to: Dr Jeremy Hobart, Senior Lecturer and Honorary Consultant Neurologist, Department of Clinical Neuroscience, Peninsula Medical School, Room N16 ITTC Building, Tamar Science Park, Davy Road, Plymouth, Devon PL6 8BX, UK E-mail: Jeremy.Hobart{at}pms.ac.uk
Spasticity is most commonly defined as an inappropriate, velocity dependent, increase in muscle tonic stretch reflexes, due to the amplified reactivity of motor segments to sensory input. It forms one component of the upper motor neuron syndrome and often leads to muscle stiffness and disability. Spasticity can, therefore, be measured through electrophysiological, biomechanical and clinical evaluation, the last most commonly using the Ashworth scale. None of these techniques incorporate the patient experience of spasticity, nor how it affects people's daily lives. Consequently, we set out to construct a rating scale to quantify the perspectives of the impact of spasticity on people with multiple sclerosis. Qualitative methods (in-depth patient interviews and focus groups, expert opinion and literature review) were used to develop a conceptual framework of spasticity impact, and to generate a pool of items with the potential to convert this framework into a rating scale with multiple dimensions. This item pool was administered, in the form of a questionnaire, to a sample of people with multiple sclerosis and spasticity. Guided by Rasch analysis, we constructed and validated a rating scale for each component of the conceptual framework. Decisions regarding item selection were based on the integration and assimilation of seven specific analyses including clinical meaning, ordering of thresholds, fit statistics and differential item functioning. The qualitative phase (17 patient interviews, 3 focus groups) generated 144 potential scale items and a conceptual model with eight components addressing symptoms (muscle stiffness, pain and discomfort and muscle spasms,), physical impact (activities of daily living, walking and body movements) and psychosocial impact (emotional health, social functioning). The first postal survey was sent to 272 people with multiple sclerosis and had a response rate of 88%. Findings supported the development of scales for each component but demonstrated that five item response options were too many. The 144-item questionnaire, reformatted with four-item response options, was administered with four validating instruments to an independent sample of 259 people with multiple sclerosis (response rate 78%). From the responses, an 88-item instrument with eight subscales was developed that satisfied criteria for reliable and valid measurement. Correlations with other measures were consistent with predictions. The 88-item Multiple Sclerosis Spasticity Scale (MSSS-88) is a reliable and valid, patient-based, interval-level measure of the impact of spasticity in multiple sclerosis. It has the potential to advance outcomes measurement in clinical trials and clinical practice, and provides a new perspective in the clinical evaluation of spasticity.
Key Words: spasticity measurement; multiple sclerosis; Multiple Sclerosis Spasticity Scale (MSSS-88); quality of life measurement; Rasch analysis
Abbreviations: ADL = activities of daily living; FAMS = Functional Assessment in Multiple Sclerosis; MSSS-88 = Multiple Sclerosis Spasticity Scale; MSIS-29 = Multiple Sclerosis Impact Scale
Received March 30, 2005. Revised September 30, 2005. Accepted October 4, 2005.
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