4
Japanese Journal of Comprehensive Rehabilitation Science (2017)

Original Article

Improvement in Disability Assessment Scale after Botulinum toxin A
treatment for upper limb spasticity
Kenta Fujimura, OTR, BS,1 Hitoshi Kagaya, MD, DMSc,2 Hisae Onaka, OTR,3
Yuki Okochi, OTR,3 Masayuki Yamada, OTR, MS,1 Toshio Teranishi, RPT, PhD,1
Yoshikiyo Kanada, RPT, DMSc,1 Eiichi Saitoh, MD, DMSc2
Faculty of Rehabilitation, School of Health Sciences, Fujita Health University, Toyoake, Aichi, Japan
Department of Rehabilitation Medicine I, School of Medicine, Fujita Health University, Toyoake, Aichi, Japan3
Department of Rehabilitation, Fujita Health University Hospital, Toyoake, Aichi, Japan1
2

ABSTRACT
Fujimura K, Kagaya H, Onaka H, Okochi Y, Yamada
M, Teranishi T, Kanada Y, Saitoh E. Improvement in
Disability Assessment Scale after Botulinum toxin A
treatment for upper limb spasticity. Jpn J Compr
Rehabil Sci 2017; 8: 4-9.
Objective: We investigated the effect of botulinum
toxin type A for upper limb spasticity on activities ofdaily living using the Disability Assessment Scale(DAS).
Methods: The subjects were 47 patients who received
botulinum therapy for upper limb spasticity. They
were assessed before administration and 2, 6, and 12
weeks after administration by using the DAS, theModified Ashworth Scale (MAS), and upper-limbrelated parameters from the Fugl-Meyer Assessment(FMA).
Results: DAS scores for hygiene, dressing, and limb
position improved significantly 2 and 6 weeks afteradministration (p < 0.05), but there was no significant
change in pain. MAS scores exhibited significant
improvement 2, 6, and 12 weeks after administration,and the total scores for FMA upper-limb parameters
exhibited significant improvement 2 and 6 weeks afteradministration (p < 0.05).
Conclusion: Botulinum therapy contributes to improving
not only the spasticity itself, but also to improving
difficulties in activities of daily living associated withupper limb spasticity.
Key words: spasticity, BoNT-A, activities of daily
Correspondence: Kenta Fujimura, OTR, BS
Faculty of Rehabilitation, School of Health Sciences, Fujita
Health University, 1-98 Dengakugakubo, Kutsukake-cho,
Toyoake, Aichi 470-1192, Japan.
E-mail: fujimura@fujita-hu.ac.jp
Accepted: December 21, 2016.
No conflicts of interest or research funds are provided inthis research.
©Kaifukuki Rehabilitation Ward Association 2017
doi.org/10.11336/jjcrs.8.4

living, upper limb function, Disability Assessment
Scale
Introduction
Spasticity is one of the positive symptoms of
cerebrovascular disease and other upper motor neuron
diseases. Approximately 20% of all first-time stroke
patients exhibit spasticity 1-2 weeks, 3 months, and18 months after the stroke, and spasticity is reported to
become more severe over time [1]. Spasticity not only
diminishes voluntary control of the upper and lower
limbs on the affected side and their function level, butalso impedes the performance of rehabilitation withthe aim of improving motor paralysis. Upper limb
spasticity tends to occur predominantly in the flexor
muscles, in many cases causing the limb to adopt anabnormally flexed position. This impairs the patient’s
ability to perform many activities of daily living(ADL), including maintaining hand hygiene by handwashing and wiping, changing clothes, standing up,
and walking. In terms of appearance, posture and limb
position are also poor. Spasticity thus gives a strong
impact.
Botulinum toxin type A (BoNT-A) is widely used in
the treatment of spasticity. In addition to the Barthel
Index (BI) and the Functional Independence Measure(FIM) for evaluating overall ADL, the 8-Item
Disability Scale [2] and the Disability Assessment
Scale (DAS) [3] can be used to evaluate the effect ofupper limb spasticity on ADL performance. The BI
and FIM are scales for evaluating the level of
independence in ADL, but since it is unclear whether
the affected or unaffected side is used in performing
actions, they cannot be described as simply measuring
impaired ability due to spasticity. The 8-Item Disability
Scale is an evaluation tool developed to measure theeffect of upper limb spasticity using a four-point scale
to assess eight parameters – cleaning the palm, cutting
Jpn J Compr Rehabil Sci Vol 8, 2017

Fujimura K et al.: Improvement in DAS after Botulinum toxin A treatment for upper limb spasticity 5

the fingernails, putting the paretic arm through a sleeve,cleaning under the armpit, cleaning around the elbow,
standing balance, walking balance, and the ability toperform an upper limb physiotherapy exercise programat home. Although this assessment does reflect upper
limb spasticity, it does not take into account issues suchas abnormal limb position, and the results may also beaffected by other factors related to physical ability
besides upper limb spasticity. The DAS is anotherevaluation tool developed to measure disability
associated with upper limb spasticity in patients withthis condition. The evaluation parameters include
some that reflect hand washing and changing clothes
as part of ADL, and others related to abnormal limb
position and pain associated with spasticity. Patientsare evaluated in an interview format, enabling the severityof the disability to be assessed (Table 1). Most studies
involving DAS evaluations before and after BoNT-A
administration [4-17] have focused on one treatment
target from among the four DAS parameters. Simpson etal. [7] reported that DAS scores improved significantly 6
weeks after BoNT-A administration in 19 patients whochose limb position as the target out of a total of 60 cases.
Kaji et al. [9] also found that DAS scores improved
significantly after BoNT-A administration in 51 patients
who chose limb position and 31 who chose dressing
actions as the targets out of a total of 109 cases. Other
studies, however, only recorded the fact that target
parameters improved, without indicating the specificparameters. Spasticity may cause more than one
disability, and it is unclear whether or not it isappropriate to select only a single target parameter toassess the severity of the disability. A study by
Marciniak et al. [18] evaluated all four DAS parametersin 10 patients treated with BoNT-A and 11 who were
given a placebo. They found a significantly greater
improvement in hygiene four weeks after treatment
among those in the BoNT-A group compared with theplacebo group, as well as a similar trend of improved
ability to execute dressing. The objective of the present
study was to evaluate the disabilities associated withupper limb spasticity using all four DAS parameters,

and to identify their characteristics and changes overtime.
Methods
The study subjects were 47 patients who underwent
BoNT-A treatment between January 2012 and June 2014
for upper limb spasticity resulting from cerebrovasculardamage. The subjects comprised 27 men and 20 women,with mean age of 56 years (19-76 years). The spasticity
was caused by cerebral infarction in 17 cases, cerebral
hemorrhage in 29, and subarachnoid hemorrhage in 1.
The mean time from onset until BoNT-A administration
was 1,552 days (median 1,337 days, range 117-5,610
days).
Difficulties in ADL were assessed by using the
DAS. Spasticity was assessed according to the
Modified Ashworth Scale (MAS) [19], with evaluationof the shoulder adductor, elbow flexor, forearm
pronator, wrist flexor, finger proximal interphalangeal(PIP) joint flexor, and thumb interphalangeal (IP) joint
flexor muscles. Motor function was assessed in termsof the total Fugl-Meyer Assessment upper extremity(FMA-U/E) score [20] and its subscales (A: shoulder/elbow/forearm; B: wrist; C: fingers; D: coordination/
speed). Assessments were performed four times,
specifically, before treatment and 2, 6, and 12 weeks
after treatment. Written consent was obtained from thepatients at each assessment.
Statistical Analysis
DAS, MAS, and FMA-U/E scores at 2, 6, and 12
weeks after BoNT-A administration were comparedwith those before administration. A comparison
between the pretreatment DAS parameters was also
performed. The Wilcoxon signed rank test, correctedby the Bonferroni method, was used for comparisons.
The statistical software used was SPSS Statistics
Version 21 (IBM), with p < 0.05 regarded as significant.

Table 1. Disability Assessment Scale (DAS) [3].
Interview with each patient to determine the extent of functional impairment according to the following scale:
0: No disability.
1: Mild disability (noticeable but does not significantly interfere with normal activities).
2: Moderate disability (normal activities require increased effort and/or assistance).
3: Severe disability (normal activities limited).
HygieneDressing
Limb position
PainThe extent of maceration, ulceration, and/or palmar infection; palm and hand cleanliness;ease of cleaning; ease of nail trimming; and the degree of interference caused by hygienerelated disability in the patient’s daily life.
The difficulty or ease with which the patient could put on clothing (e.g., shirt, jacket, gloves)and the degree of interference caused by dressing-related disability in the patient’s daily life.
The amount of abnormal position of the upper limb.
The intensity of pain or discomfort related to upper limb spasticity.
Jpn J Compr Rehabil Sci Vol 8, 2017

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Fujimura K et al.: Improvement in DAS after Botulinumtoxin A treatment for upper limb spasticity

Results
The muscles treated with BoNT-A were thepectoralis major in 24 patients, the biceps brachii in
31, the brachialis in 5, the brachioradialis in 1, thetriceps brachii in 1, the pronator teres in 6, the flexor
carpi radialis in 38, the flexor carpi ulnaris in 37, thepalmaris longus in 1, the flexor digitorum profundus in4, the flexor digitorum superficialis in 45, and theflexor pollicis longus in 23. A dose of 15-100 units
was administered to each muscle.
Before BoNT-A administration, the number of patientswith a DAS score of 0 (no disability) was 20 (42.6%) for
hygiene, 15 (31.9%) for dressing, 15 (31.9%) for limb
position, and 32 (68.1%) for pain. The corresponding
numbers for those with a DAS score of 3 (severe
disability) were 11 (23.4%) for hygiene, 5 (10.6%) for
dressing, 11 (23.4%) for limb position, and 0 (0.0%) for
pain. A comparison between the different parameters
before BoNT-A administration showed that comparedwith pain, the level of disability was significantly higher
for hygiene (p = 0.001), dressing (p < 0.001), and limb
position (p < 0.001). Figure 1 shows the changes in DAS
parameters over time after BoNT-A administration.
Improvements in hygiene (p = 0.006, p = 0.030), dressing(p = 0.001, p = 0.003), and limb position (p < 0.001, p =0.003) were evident at 2 and 6 weeks after administration.
However, at 12 weeks after administration, there was no
significant difference compared with the scores before
administration. There was no significant change in pain

at any point after administration compared with before
administration.
MAS scores for the shoulder adductor and elbow flexor
muscles improved significantly at 2 weeks (p < 0.001) and6 weeks (p = 0.001) after BoNT-A administration.
Significant improvement in the scores for the forearm
pronator, wrist flexor, finger PIP joint flexor, andthumb IP joint flexor muscles was evident at 2, 6, and12 weeks after administration (Table 2).
Total FMA-U/E scores improved significantly at 2
and 6 weeks after BoNT-A administration (p = 0.003,
p = 0.002). There was no significant difference between
the score at 12 weeks after administration and the scorebefore administration. Subscale A (shoulder/elbow/
forearm) scores improved significantly at 2 and 6 weeks
after BoNT-A administration (p = 0.003, p = 0.002).
Subscale B (wrist) scores tended to improve 2 weeks
after BoNT-A administration (p = 0.056) and improved
significantly 6 weeks after administration (p = 0.009).
There was no improvement in the scores for Subscale C(hand) and Subscale D (coordination/speed) (Table 3).
Discussion
DAS, MAS, and FMA-U/E scores all improved
significantly after BoNT-A treatment of upper limbs
with spasticity. DAS assessment prior to BoNT-A
administration revealed that approximately 60% of thepatients exhibited disability in terms of hygiene,
approximately 70% in terms of dressing and limb(*p < 0.05, **p < 0.01)
Figure 1. Changes in DAS.
Improvements in hygiene, dressing, and limb position were evident at 2 and 6 weeks afteradministration. There was no significant change in pain at any point after administrationcompared with before administration (Wilcoxon signed rank test with Bonferroni correction).
Jpn J Compr Rehabil Sci Vol 8, 2017

Fujimura K et al.: Improvement in DAS after Botulinum toxin A treatment for upper limb spasticity 7

Table 2. Changes in MAS.
BeforeMedian 25%
Shoulder adductors
Elbow flexors
Forearm pronators
Wrist flexors
Finger PIP joint flexors
Thumb IP joint flexors

1+
2
1+
2
2
1+

1
1
1
1+
1+
1

2 weeks
75%

Median 25%

2
2
2
3
2
1+

1**
1**
1**
1**
1**
1**

1
1
0
1
1
0

6 weeks

12 weeks

75%

Median 25%

75%

Median 25%

75%

1+
1+
1+
1+
1+
1

1+**
1+**
1**
1+**
1+**
1**

1+
1+
1+
1+
1+
1+

1+
1+
1*
1+**
1+**
1**

1+
2
1+
2
2
1+

1
1
0
1
1
0

1
1
1
1
1
1

Wilcoxon signed rank test with Bonferroni correction. *p < 0.05, **p < 0.01.
Percentages indicate percentile.

Table 3. Changes in FMA-U/E.

Total score
Subscale A score
Subscale B score
Subscale C score
Subscale D score

Before2 weeks

6 weeks

12 weeks21.9±12.0
15.4±7.0
1.2±2.2
5.1±4.3
0.2±0.7

23.0±11.7**
16.6±7.0**
1.6±2.6
4.7±3.3
0.2±0.723.9±11.3*
16.9±6.5**
1.7±2.7*
5.1±3.3
0.2±0.923.2±12.2
16.0±6.9
1.5±2.5
5.6±4.1
0.2±0.8

Wilcoxon signed rank test with Bonferroni correction. Mean±SD.
*p < 0.05, **p < 0.01.
position, and approximately 30% in terms of pain.
Among the studies that have provided a breakdown of
DAS target items [4-10, 12, 14, 16, 17], a large proportion
selected dressing or limb position as the targets, andonly around 10% chose pain as the target. In this study,
spasticity impaired the dressing actions and limb
position in a large proportion of patients, and a few
patients complained of spasticity-associated pain.
With respect to severity, the DAS score was 3 (severe
disability) for hygiene and limb position in over 20%of the cases. Pain was milder than the other threeparameters. In terms of changes over time in spastic
muscles after treatment with BoNT-A, the other threeparameters exhibited significant improvement at 2 and 6
weeks after administration. The assessment of hygiene,
one of the categories evaluated by DAS, includes not
only active movements by the spastic upper limb but
also whether or not the spastic hand can be washedusing the hand on the unaffected side. In particular,
severe paralysis in the functions of the peripheral areasof the upper limbs was apparent in our subjects in thisstudy, as evidenced by the mean scores of 1.2 ± 2.2 for
Subscale B and 5.1 ± 4.3 for Subscale C of the FMAU/E evaluation prior to administration, making it
highly likely that actions were performed by theunaffected hand. The improvements at 2 and 6 weeks
after BoNT-A administration may therefore have been
due to the alleviation of spasticity of the elbow, wrist,and finger flexor muscles, which would have bothmade it easier to hold the arm with the elbow extended
during hand washing and improved the finger grip,
making these movements easier. The limb positionparameter of the DAS evaluates the physical, mental,
and social effects of abnormal positioning of the arm.
Synergic movements of the flexor muscles predominate
in severely spastic upper limbs, which frequently
adopt the Wernicke-Mann posture with bent elbows
and curled-up fingers. Alleviating spasticity of theflexor muscles of the upper limbs thus directly
improves abnormal limb positioning. The dressing
parameter of the DAS evaluates the ease of changing a
dress or shirt and the effect of spasticity on the actions
involved. Generally speaking, the actions entailed inpassing the arm on one side through a sleeve when
getting dressed require shoulder flexion and abductionand elbow extension movements. Passing the opposite
arm through the other sleeve then requires abductionof the other arm, pulling the clothing with a sufficientdegree of tension to enable the arm to pass smoothly
through the sleeve. A patient with a spastic upper limbthat tends to adopt an abnormally flexed position may
thus have particular difficulty in performing dressing
actions when changing clothes. Whether or not thepatient is capable of voluntary movements of theshoulder and elbow may also constitute an importantfactor in the performance of these actions. BoNT-A
administration may therefore have made dressing
actions easier not only by reducing the spasticity of theupper limb extensor muscles, but also by improving
the function of the central part of the upper limb
expressed in Subscale A of the FMA-U/E. Increasing
the number of opportunities for active movement of
the upper limbs may also have improved the patients’abilities to perform dressing actions, leading to further
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Fujimura K et al.: Improvement in DAS after Botulinumtoxin A treatment for upper limb spasticity

improvement at 6 weeks after administration comparedwith at 2 weeks. In terms of the active movement
aspect, hand washing actions in hygiene may also be
assumed to involve active movements of the wrist andfingers. However, as severe paralysis of the peripheral
areas of the upper limbs was apparent in our study
subjects before administration, with a mean score of
5.1 ± 4.3 on Subscale C of the FMA-U/E, as shown in
Table 3, voluntary movements may not have increased
because no improvement in motor function wasachieved after the reduction in spasticity. Possible
reasons for the absence of improvement in these threeparameters at 12 weeks after administration may
include spasticity of the elbow flexor muscles, which
would have made it difficult to perform the actions
involved in hand washing and passing the arms
through sleeves while dressing that entail holding theelbow in an extended position. With respect to pain,
approximately 70% of our subjects had a DAS score of
0 (no disability) for this parameter before administration
while approximately 20% had a score of 1 (milddisability). No significant improvement was obtained
because most of our subjects were already mild cases inthis respect.
MAS scores, which express the severity of spasticity,
all improved significantly 2 weeks and 6 weeks after
the treatment of spastic muscles with BoNT-A. Our
study thus showed a similar effect of BoNT-A
administration in reducing spasticity to that alreadyreported in other studies [21-23].
Total FMA-U/E scores and scores for Subscale A
improved significantly 2 and 6 weeks after administration.
On the other hand, scores for Subscale B improved
significantly at 6 weeks, while exhibiting a tendency toimprove at 2 weeks. Several previous studies have shownthat FMA-UE scores are improved by concentrated
practice after BoNT-A administration [24-27]. Takekawa
et al. [24] reported that if patients were instructed tocarry out exercises independently at home afteradministration, scores for Subscales A and B improved
greatly 1, 3, and 6 months later, and scores for Subscale
D also improved after 3 and 6 months. In the present
study, we did not implement consistent instruction orintervention regarding rehabilitation or independent
exercises after BoNT-A administration. The subjects,
however, did continue to perform exercises afteradministration in settings such as outpatient rehabilitation
at our hospital or another clinic, day care, and homerehabilitation visits, achieving significant improvementcomparable with that seen in previous studies. In
particular, the improvement in Subscale A, which
expresses the function of the central part of the upper
limbs, made a major contribution to the improvement
in total score. This may have been because ofsignificant improvements in the spasticity of theshoulder abductor, elbow flexor, and forearm pronatormuscles, or because the subjects’ score of 15.4 ± 7.0
for Subscale A of the FMA-U/E before administration
Jpn J Compr Rehabil Sci Vol 8, 2017

meant that at least some voluntary movement waspossible. At 12 weeks after administration, the spasticityof the shoulder abductor and elbow flexor muscles wasin the process of returning to its pre-administrationlevel, eliminating the significant improvement in the
Subscale A score and the total score. Subscale B wasassessed with the elbow held at 90º flexion orcompletely extended. In the 12-week evaluation, thisscore must therefore have been affected at least
somewhat by the increased spasticity of the elbow
flexor muscles. Subscale C, which expresses thefunction of the peripheral parts of the upper limbs,
exhibited more severe paralysis prior to BoNT-A
administration. BoNT-A administration thus did not
result in improved motor function due to reduced
spasticity.
The limitations of this study include the fact that themuscles treated and the dose administered were
determined by agreement between the doctor andpatient, meaning that injection locations and doses
were not necessarily consistent. Since the maximum
dose that can be administered to the upper limb is 240
units in Japan, the dose may not have been sufficient.
In addition, as injections were delivered to multiple
muscles, we were unable to investigate which of themuscles that received injections contributed to
improving the DAS scores. However, our results did
demonstrate that approximately 60-70% of thepatients with upper limb spasticity suffered fromdisabilities in hygiene, dressing, and limb position.
Hygiene and limb position disabilities in particularwere more severe. BoNT-A administration significantly
improved difficulties in ADL as well as spasticity.
Further studies are required to ascertain the specificcausal relationship between muscle spasticity and
ADL disabilities, as well as the improvement of these
difficulties by multiple administration of BoNT-A.

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