Professor Dobkin has raised the following question: Does spasticity itself raise the cost of stroke care 4-fold? In our study,1 we reported a 4-fold increase in direct costs for patients with stroke with spasticity compared with patients with stroke without spasticity. We do not claim that spasticity per se is the cause of the higher costs. Instead we discuss that spasticity reflects a more severe motor disorder that is associated with disability as illustrated by the modified Ashworth Scale and the modified Rankin Scale running almost in parallel. In accordance, we believe that data might be helpful for further studies of cost-effectiveness of interventions targeting any of the components of the sensorimotor disorder poststroke. Overall, this disorder is complex and the interrelations between its components as well as their relative impact on disability even more so. Although there is increasing evidence to support the use of intramuscular botulinum toxin to reduce spasticity, the cost-effectiveness of such treatment mainly remains to be shown.
We fully agree that a modified Ashworth Scale score ≥1, or any score, is not enough for the diagnosis of a clinical problem. Instead, a comprehensive assessment of all components of the sensorimotor disorder and their relative impact on activity performance as well as on a global level is required. Indeed, disentangling the impact of spasticity is not an easy task, partially because clinically useful, valid measures are lacking, as extensively discussed. We have reported the result of 1 approach to this problem in a study indicating that at 1 year after first-ever stroke, only 4% of all patients have a clinical problem related to positive signs of the upper motor neuron syndrome.2