Composite Spasticity Index (CSI)

Evidence Reviewed as of before: 25-04-2012
Author(s)*: Annabel McDermott, OT
Editor(s): Nicol Korner-Bitensky, PhD OT
Expert Reviewer: Mindy Levin, PhD PT

Purpose

The Composite Spasticity Index (CSI) provides a clinical measure of Spasticity that can be used with patients with hemiparesis following stroke.

In-Depth Review

Purpose of the measure

The Composite Spasticity Index (CSI) s a measure of upper and lower extremity Spasticity that is suitable for use with patients with hemiparesis following stroke.

The CSI measures the phasic stretch reflex by assessing the tendon jerk and clonus, and the tonic stretch reflex with assessment of resistance to passive movement of the limb (Calota & Levin, 2009).

Available versions

A Composite Spasticity Scale was originally proposed by Chan (1986). The CSI was subsequently developed by Levin & Hui-Chan (1992).

Features of the measure

Items:

The CSI is comprised of 3 items:

  1. Tendon jerk
  2. Resistance to passive flexion
  3. Clonus

Description of tasks:

The first item (tendon jerk) measures hyper-reflexia by applying taps to the biceps, triceps, patellar or Achilles tendon, depending on the location of the Spasticity being measured. The therapist should apply enough force to evoke a ‘maximal’ reflex jerk. This can be compared with the maximum tendon reflex elicited on the unaffected side (Chan, 1986).

The second item (resistance to passive stretch) measures hyperactivity of the tonic stretch reflex by assessing the amount of resistance felt by the examiner when the passive muscle is stretched (Chan, 1986). This item incorporates the Modified Ashworth Scale 5-point ordinal scale, which is doubly-weighted (0 to 8), and measures the magnitude of the resistance to stretch at moderate speed (> 100 degrees per second) (Levin & Hui-Chan, 1992).

The third item (clonus) assesses the number of beats of clonus at the wrist (upper limb) or ankle (lower limb) when the hand or foot is rapidly flexed by the examiner (Chan, 1986).

What to consider before beginning:

Chan (1986) advised that the presence of contractures and/or a clasp-knife reflex should be noted when assessing resistance to passive stretch. Contractures can be detected by comparing the passive ROM on the affected side with that on the unaffected side. A clasp-knife reflex can be detected by the presence of a ‘melting away’ of the resistance with increased amount of passive stretch.

The tonic stretch reflex is influenced by the initial muscle length and the velocity of stretch; accordingly, the examiner should apply passive stretch to the affected muscles at the same speed (around 100 deg/sec) and with the limb positioned in the same posture to attain similar initial muscle length on readministration (Chan, 1986).

The CSI measures the magnitude of the stretch response rather than the threshold (Calota & Levin, 2009).

Scoring and Score Interpretation:

The first and second items of the CSI (tendon jerk and resistance to passive stretch) are scored on 5-point scales. The third item (amount and duration of ankle clonus) is scored on a 4-point scale (Levin & Hui-Chan, 1992).

Tendon jerks 0 No response
1 Normal response
2 Mildly hyperactive response
3 Moderately hyperactive response
4 Maximally hyperactive response
Resistance to passive stretch* 0 No resistance (hypotonic)
2 Normal resistance
4 Mildly increased resistance
6 Moderately increased resistance
8 Maximally increased resistance
Clonus 1 Clonus not elicited
2 1-3 beats of clonus elicited
3 3-10 beats of clonus elicited
4 Sustained clonus

* Note that resistance to passive stretch is double-weighted

The second item (resistance to passive stretch) is doubly weighted, as it most closely represents hypertonus.

The patient’s total Spasticity score is calculated as the sum of scores (tendon jerk + resistance to passive stretch + clonus). The composite score is used to determine the severity of Spasticity, which is defined by the following levels according to clinical experience:

0 – 9 = mild Spasticity
10 – 12 = moderate Spasticity
13 – 16 = severe Spasticity

Time:

Time taken to perform the CSI has not been reported.

Training requirements:

There are no specific training requirements for the CSI. However, administrators should practice stretching the joint smoothly (without quick accelerations and decelerations) at a given speed to improve reproducibility of the results.

Subscales:

N/A

Equipment:

A reflex hammer is required for administration of the CSI.

Alternative Forms of the Composite Spasticity Index (CSI)

Jobin and Levin (2000) created the Modified Composite Spasticity Index to measure phasic (tendon jerks) and tonic (resistance to manual stretch) stretch reflex excitability in children with cerebral palsy. This measure does not include assessment of clonus. Accordingly, the composite score is the sum of the tendon jerk + resistance to passive stretch. Composite scores range from 1 to 12, where scores of 1 – 4 indicate mild Spasticity; scores of 5 – 9 indicate moderate Spasticity; and a score of 10 or greater indicates severe Spasticity (Jobin & Levin, 2000; Scholtes et al., 2006).

Client suitability

Can be used with:

  • Patients with stroke (Levin et al. 2000)
  • Patients with spinal cord injury (Goulet et al., 1996)
  • Children with cerebral palsy (Jobin & Levin, 2000)

Should not be used with:

  • Not specified.

In what languages is the measure available?

English

Summary

What does the tool measure? Spasticity
What types of clients can the tool be used for? Patients with hemiparesis following stroke as well as cerebral palsy and spinal cord injury.
Is this a screening or assessment tool? Assessment
Time to administer Not reported
Versions
  • Composite Spasticity Index
  • Modified Composite Spasticity Index
Other Languages N/A
Measurement Properties
Reliability Internal consistency:
Two studies examined the Internal consistency of the CSI: one study reported an excellent correlation between the total Spasticity score and resistance to passive stretch and clonus; one study reported adequate Internal consistency using Cronbach’s coefficient alpha.

Test-retest:
One study reported excellent test-retest reliability of the CSI; one study reported excellent test-retest reliability of the Composite Spasticity Scale.

Intra-rater:
No studies have reported on the intra-rater reliability of the CSI.

Inter-rater:
No studies have reported on the inter-rater reliability of the CSI.

Validity Content:
One study reported that the three items of the CSI are relevant to assess Spasticity in stroke.

Criterion:
Concurrent:
Three studies have reported on the concurrent validity of the CSI: two studies reported excellent negative relationships between clinical Spasticity and stretch reflex measures; one study reported no consistent significant correlations between the CSI and physiological measures of reflex function.

Predictive:
No studies have reported on the predictive validity of the CSI.

Construct:
Convergent/Discriminant:
Two studies examined the convergent validity of the Composite Spasticity Index and the Fugl-Meyer Assessment (FMA). One study found an excellent negative correlation using Spearman rank-order statistics, whereas the other study found no significant relationships between the two measures using Pearson product moment correlation statistics.
One study examined the convergent validity of the Composite Spasticity Scale with other measures using Spearman correlation coefficients and reported an adequate negative correlation between ankle plantar flexor Spasticity of the affected leg (measured by the CSS) and stance time of the affected leg only. No significant correlations were found between the CSS and the Timed Up and Go Test (TUG), 6 Minute Walk Test (6MWT) or other gait parameters (velocity, cadence and step length and stance time of the unaffected leg).

Known Group:
One study examined known groups validity of the Composite Spasticity Scale and reported a significant difference in Spasticity between patients with chronic stroke and healthy elderly subjects.

Floor/Ceiling Effects No studies have examined the floor or ceiling effects of the CSI in clients with stroke.
Sensitivity/ Specificity No studies have reported on the Sensitivity or Specificity of the CSI.
Does the tool detect change in patients? No studies have formally examined the responsiveness of the CSI.
Acceptability The CSI is commonly used in the assessment of Spasticity in adults. It is an acceptable measure of Spasticity in stroke.
Feasibility The time to administer the CSI has not been reported. Ease of administration and scoring is dependent on experience of the assessor.
How to obtain the tool? Click here to see the CSI.

Psychometric Properties

Overview

A literature search was conducted to identify all relevant publications on the psychometric properties of the Composite Spasticity Index (CSI). While this assessment can be used with other populations, this module addresses the psychometric properties of the measure specifically when used with patients with stroke. Four studies reported on the psychometric properties of the CSI; one study that reported on the psychometric properties of the Composite Spasticity Scale (CSS) has also been included in this review.

Floor/Ceiling Effects

No studies have reported on the floor/ceiling effects of the CSI when used with patients with stroke. However, it is unlikely that this tool would be appropriate for floor and ceiling evaluation.

Reliability

Internal Consistency:
Levin & Hui-Chan (1993) administered the CSI over three trials with 10 patients with stroke and hemiparesis and 7 healthy subjects. Data was calculated using Pearson correlation coefficients and was provided for two of three trials. The total Spasticity score had an excellent correlation with resistance to passive stretch (r = 0.94, 0.89, p<0.05) and clonus (r = 0.85, 0.86, p<0.05) but not Achilles tendon reflex. There was a significant correlation between clonus and resistance to passive stretch on one occasion (r = 0.82, p<0.05), indicating that severity of clonus varied with that of the resistance to passive stretch. There were no other significant associations between items.

Nadeau et al. (1998) measured the Internal Consistency of the CSI with 19 adults with acute to chronic stroke. Internal Consistency of the CSI, as measured using Cronbach’s coefficient alpha, was adequate (α = 0.7023).

Test-retest:
Chan (1986) advised that the examiner instructs the patient to relax when measuring resistance to passive stretch, or alternatively, for the examiner to exert the same effort from test to test. Further, the examiner should apply passive stretch to the affected muscles at the same speed and with the limb positioned in the same posture to attain similar initial muscle length on readministration.

Ng & Hui-Chan (2005) assessed the 1-week test-retest reliability of the CSS in 10 healthy elderly adults and 10 patients with chronic stroke and reported excellent test-retest reliability using Intraclass Correlation Coefficient (ICC) (ICC = 0.97 and 0.80 for affected and unaffected limbs, respectively, of patients with stroke; ICC = 0.80 for both left and right limbs of health adults).

Levin & Hui-Chan (1993) assessed the test-retest reliability of the CSI in 10 patients with spastic hemiparesis and stroke over three testing occasions and reported excellent test-retest reliability (r = 0.87) using Intraclass correlation Coefficients (ICC).

Intra-rater:
No studies have examined the intra-rater reliability of the CSI.

Inter-rater:
No studies have examined the inter-rater reliability of the CSI.

Validity

Content :

Nadeau et al. (1998) used principle component analysis to determine the extent to which each item of the CSI contributed to the concept of Spasticity. In a sample with 19 patients with acute to chronic stroke, the three items of the CSI combined into 1 factor that explained 67.9% of the total variance (eigenvalue = 2.035). This indicates that the 3 items of the CSI are relevant to assess Spasticity in stroke.

Criterion :

Concurrent :
Levin et al. (2000) examined the correlation between clinical Spasticity and the stretch reflex threshold range for elbow flexor and extensor muscles in 12 patients with hemiparetic stroke, using Spearman rank order statistics. An excellent negative correlation was found between clinical Spasticity and the static thresholds of the flexors (r=-0.75, p<0.01) and extensors (r=-0.69, p<0.05). This indicates that patients with more severe Spasticity from hemiparetic stroke have more severe limitations in the range in which flexor and extensor stretch reflex thresholds can be regulated. There was also an excellent negative correlation with the velocity dependencies of the stretch reflex thresholds of the flexor muscle (r=-0.70, p<0.05), the limitations in the ranges of reciprocal innervation (r=-0.84, p<0.01) and active joint motion (r=-0.67, p<0.05).

Levin & Feldman (1994) compared clinical Spasticity with values of static stretch reflex thresholds in elbow flexors, using Pearson Product Moment correlation statistics. Clinical Spasticity was measured using the CSI and stretch reflex thresholds were measured by static angular threshold and the slope of the relationship between the dynamic threshold angles and velocity. A significant excellent negative relationship was seen between clinical Spasticity (CSI) and static stretch reflex excitability alone (r = -0.652, p<0.05). These results indicate validity for quantification of Spasticity in elbow flexors (Jobin & Levin, 2000).

Levin & Hui-Chan (1993) examined the correlation between clinical Spasticity and altered reflex function in 10 patients with stroke and spastic hemiparesis. Physiological measurement of reflex functions included: H-reflex latency; maximal amplitude of the H-reflex as a percentage of the maximal M response (H/M ratio); amount of inhibition of the H-reflex during vibration as a percentage of the control H-reflex amplitude (Hvib/Hctl); and excitability (latency, duration, magnitude) of the soleus stretch reflex. Measures were taken over three testing days, although statistical data were provided for only two days. There were no consistent significant correlations between the CSI and physiological measures of reflex function.

Predictive:
No studies have reported on the predictive validity of the CSI when used with patients with stroke.

Construct:

Convergent/Discriminant:
Ng & Hui-Chan (2005) investigated the associations between the CSS, Timed Up and Go Test (TUG), 6 Minute Walk Test (6MWT) and other gait parameters (velocity, cadence and step length and stance time of the affected and unaffected legs), using Spearman correlation coefficients. An

Levin et al. (2000) found an excellent negative correlation between clinical Spasticity and the Fugl-Meyer Assessment (FMA) (r=-0.86, p<0.005), using Spearman rank order statistics.

Levin & Feldman (1994) compared clinical Spasticity (measured using the CSI) and the FMA, using Pearson Product Moment correlation statistics. No significant relationships were seen between clinical Spasticity and clinical motor function.

Known groups:
Ng & Hui-Chan (2005) investigated the known-group validity of the CSS in 10 healthy elderly subjects and 11 patients with chronic stroke. Ankle plantar flexor Spasticity, measured by the CSS, was significantly higher in the affected leg of patients with stroke than the mean scores of both legs in healthy elderly subjects (p<0.001). Within the group of patients with stroke, ankle plantar flexor Spasticity was significantly higher in the affected leg than the unaffected leg (p<0.001).

Responsiveness

The responsiveness of the CSI has not been formally assessed, however it has been used in several studies as a measure of within-group and between-group differences.

Levin & Hui-Chan (1992) examined the effect of repetitive low-threshold afferent stimulation (TENS) on clinical Spasticity in 13 patients with spastic hemiparesis following stroke. Patients received stimulation to the peroneal nerve for 60 minutes, 5 days a week for 3 weeks. Patients were assessed using the CSI at baseline and after 2 and 3 weeks of stimulation. The CSI detected a change in Spasticity among patients who received TENS (at 2 weeks treatment only), and a significant difference in Spasticity between patients who received TENS and the control group who received placebo stimulation (p<0.05).

Sensitivity/ Specificity:
No studies have reported on the Sensitivity or the Specificity of the CSI when used with patients with stroke.

References

  • Calota, A. & Levin, M.F. (2009). Tonic stretch reflex threshold as a measure of spasticity: Implications for clinical practice. Topics in Stroke Rehabilitation, 16(3): 177-188.
  • Chan, C.W.Y. (1986). Motor and sensory deficits following a stroke: Relevance to a comprehensive evaluation. Physiotherapy Canada, 38, 29-34.
  • Goulet, C., Arsenault, A.B., Bourbonnais, D., Laramee, M.T., & Lepage, Y. (1996). Effects of transcutaneous nerve stimulation on H-reflex and spinal spasticity. Scandinavian Journal of Rehabilitation Medicine, 28, 169-76.
  • Goulet, C., Arsenault, A.B., Bourbonnais, D., & Levin, M.F. (1994). Topographical effects of transcutaneous electrical nerve stimulation on the H-reflex of the triceps surae muscles. Journal of Electromyography & Kinesiology, 4, 116-125.
  • Jobin, A. & Levin, M. (2000). Regulation of stretch reflex threshold in elbow flexors in children with cerebral palsy: a new measure of spasticity. Developmental Medicine & Child Neurology, 42, 531-540.
  • Levin, M.F. & Feldman, A.G. (1994). The role of stretch reflex threshold regulation in normal and impaired motor control. Brain Research, 657, 23-30.
  • Levin, M.F. & Hui-Chan, C.W.Y. (1992). Relief of hemiparetic spasticity by TENS is associated with improvement in reflex and voluntary motor functions. Electroencephalography and Clinical Neurophysiology, 85, 131-142.
  • Levin, M.F., & Hui-Chan, C. (1993). Are H and stretch reflexes in hemiparesis reproducible and correlated with spasticity? Journal of Neurology, 240, 63-71.
  • Levin, M.F., Selles, R.W., Verheul, M.H.G., & Meijer, O.G. (2000). Deficits in the coordination of agonist and antagonist muscles in stroke patients: Implications for normal motor control. Brain Research, 853, 352-69.
  • Nadeau, S., Arsenault, A.G., Gravel, D., Lepage, Y., & Bourbonnais, D. (1998). Analysis of the spasticity index used in adults with a stroke. Canadian Journal of Rehabilitation, 11, 219-20.
  • Ng, S.S., & Hui-Chan, C.W. (2005). The Timed Up & Go Test: Its reliability and association with lower-limb impairments and locomotor capacities in people with chronic stroke. Archives of Physical Medicine and Rehabilitation, 86, 1641-7.
  • Scholtes, V.A.B., Becher, J.G., Beelen, A., & Lankhorst, G.J. (2006). Clinical assessment of spasticity in children with cerebral palsy: a critical review of available instruments. Developmental Medicine and Child Neurology, 48, 64-73.

See the measure

How to obtain the Composite Spasticity Index?

Click here for a copy of the Composite Spasticity Index.

Table of contents

Disability Assessment Scale (DAS)

Evidence Reviewed as of before: 19-06-2012
Author(s)*: Katie Marvin, MSc. PT
Editor(s): Annabel McDermott; Nicol Korner-Bitensky, PhD OT

Purpose

The Disability Assessment Scale (DAS) evaluates upper limb functional disability in patients with spasticity following stroke

In-Depth Review

Purpose of the measure

The Disability Assessment Scale (DAS) evaluates upper-limb functional disability in patients with spasticity following stroke. The DAS was developed as a tool that objectively evaluates functional impairment resulting from spasticity.

Available versions

None reported.

Features of the measure

Items:

  • Hand hygiene
    • Extent of palm maceration, ulceration or infection.
    • Cleanliness of the palm, ease of cleaning, nail trimming.
    • Effect of hygiene-related disability on other areas of functioning.
  • Dressing
    • Ability to dress.
    • Effect of dressing-related disability on other areas of functioning.
  • Limb position abnormality.
    • Amount of abnormal limb position.
  • Pain
    • Intensity of pain or discomfort related to upper-limb spasticity.
    • Interference with activities of daily living.

Description of tasks:

Patients are interviewed to determine the extent of functional impairment for the following 4 areas:

  • Hygiene: The rater assesses the extent of palm maceration, ulceration, or infection; cleanliness of the palm, ease of cleaning, and nail trimming; and the effect of hygiene-related disability on other areas of functioning.
  • Dressing: The rater assess the patient’s ability to dress and the effect of dressing-related disability on other areas of functioning.
  • Limb position: The rater assesses the amount of abnormal position of the limb; and
  • Pain: The rater assesses the intensity of pain or discomfort related to upper-limb spasticity and interference with activities of daily living.

Scoring and Score Interpretation:

The DAS Scale uses a 4-point rating scale according to the following criteria:

  • 0 – no disability.
  • 1 – mild disability (noticeable but does not interfere significantly with normal activities.
  • 2 – moderate disability (normal activities require increased effort and/or assistance).
  • 3 – severe disability (normal activities limited).

Time:

Not typically reported.

Training requirements:

None reported.

Subscales:

None

Equipment:

None reported.

Alternative Forms of the Disability Assessment Scale

None reported.

Client suitability

Can be used with:

  • Clients with stroke with spasticity.

Should not be used with:

  • Clients without spasticity.

Languages of the measure

None reported.

Summary

What does the tool measure? Functional disability in patients with spasticity.
What types of clients can the tool be used for? The Disability Assessment Scale can be used with, but is not limited to clients with post-strokespasticity.
Is this a screening or assessment tool? Assessment
Time to administer Not reported
Versions None
Other Languages None
Measurement Properties
Reliability Intra-rater:
One study examined the intra-rater reliability of the DAS in patients with spasticity following stroke and found adequate to excellent intra-rater reliability.

Inter-rater:
One study examined the inter-rater reliability of the DAS in patients with spasticity following stroke and found adequate to excellent inter-rater reliability.

Validity No studies have examined the Validity of the DAS.
Floor/Ceiling Effects No studies have examined the floor/ceiling effects of the DAS.
Does the tool detect change in patients? The responsiveness of the DAS has not formally been studied, however the DAS has been used to measure change in spasiticity in a clinical trial with patients with stroke.
Acceptability The DAS is one of the only tools available for evaluation of upper limb functional disability in patients with spasticity following stroke.
Feasibility There is a lack of information about the DAS, affecting ease of administration.
How to obtain the tool? See: Brashear, A., Zafonte, R., Corcoran, M., Galvez-Jimenez, N., Gracies, J-M., Gordon, M.F., et al. (2002). Inter- and Intrarater Reliability of the Ashworth Scale and the Disability Assessment Scale in patients with upper-limb poststroke spasticity. Archives of Physical Medicine Rehabilitation, 83, 1349-1351.

Psychometric Properties

Overview

A literature search was conducted to identify all relevant publications on the psychometric properties of the Disability Assessment Scale when used with patients with stroke. Only one study was identified. Further studies are required before definitive conclusions can be drawn regarding the reliability and validity of the DAS for use with patients following stroke.

Floor/Ceiling Effects

No studies were identified examining the floor/ceiling effects of the DAS.

Reliability

Internal consistency:
No studies have examined the Internal consistency of the DAS.

Test-retest:
No studies have examined the test-retest reliability of the DAS.

Intra-rater:
Brashear et al. (2002) investigated the intra-rater reliability of the DAS in nine patients with spasticity following stroke. All patients were evaluated twice on the same day by 10 trained evaluators. Inter-rater reliability, as calculated using overall weighted kappa scores, was adequate to excellent (k=0.520, 0.530, 0.775 and 0.776 for hygiene, dressing, limb position and pain respectively).

Inter-rater:
Brashear et al. (2002) investigated the Inter-rater reliability of the DAS in nine patients with spasticity following stroke. All patients were evaluated twice on the same day (at least an hour apart) by 10 trained evaluators. Inter-rater reliability, as calculated using Kendall’s W, was adequate to excellent (Kendall’s W=0.494, 0.557, 0.626 and 0.772 for dressing, limb position, hygiene, and pain respectively).

Validity

Content:

No studies have examined the content validity of the DAS.

Criterion:

Concurrent:
No studies have examined the concurrent validity of the DAS.

Predictive:
No studies have examined the predictive validity of the DAS.

Construct:

Convergent/Discriminant:
No studies have examined the convergent/discriminant validity of the DAS.

Known Groups:
No studies have examined the known groups validity of the DAS.

Sensitivity/ Specificity:

No studies have examined the sensitivity/specificity of the DAS.

Responsiveness

Brashear et al. (2002) investigated the effect of Botulinum Toxin A on arm flexor spasticity in 126 patients with stroke over a 12-week period. The DAS was administered at baseline 4, 6, 8 and 12-weeks. Although the responsiveness of the DAS was not formally assessed in this study, the scale was sensitive enough to detect an improvement in function following botox treatment.

References

  • Brashear, A., Gordon, M.F., Elovic, E., Kassicieh, V.D., Marciniak, C., Do, M., Lee, C-H, Jenkins, S. et al. (2002). Intramuscular injection of botulinum toxin for the treatment of wrist and finger spasticity after a stroke. New England Journal of Medicine, 347(6), 395-400.
  • Brashear, A., Zafonte, R., Corcoran, M., Galvez-Jimenez, N., Gracies, J-M., Gordon, M.F., et al. (2002). Inter- and Intrarater reliability of the Ashworth Scale and the Disability Assessment Scale in patients with upper-limb poststroke spasticity. Archives of Physical Medicine Rehabilitation, 83, 1349-1351.

See the measure

Further information on the DAS can be found in the following publication

Brashear, A., Zafonte, R., Corcoran, M., Galvez-Jimenez, N., Gracies, J-M., Gordon, M.F., et al. (2002). Inter- and Intrarater reliability of the Ashworth Scale and the Disability Assessment Scale in patients with upper-limb poststroke spasticity. Archives of Physical Medicine Rehabilitation, 83, 1349-1351.

Table of contents

Leeds Adult Spasticity Impact Scale (LASIS)

Evidence Reviewed as of before: 13-06-2012
Author(s)*: Annabel McDermott, OT
Editor(s): Nicol Korner-Bitensky, PhD OT

Purpose

The Leeds Adult Spasticity Impact Scale (LASIS) is a measure of passive arm function, suitable for patients with Spasticity and little or no active movement of the upper extremity.

In-Depth Review

Purpose of the measure

The Leeds Adult Spasticity Impact Scale (LASIS) is a measure of passive arm function that is administered by semi-structured interview to the patient or carer. It consists of 12 items of low difficulty that evaluate performance of daily functional tasks in the individual’s normal environment. The LASIS is useful for patients with minimal or no active movement or function but with self-care issues of the upper extremity (Ashford et al., 2008).

Available versions

The LASIS was originally published as the Patient Disability and Carer Burden Scale by Bhakta et al. (1996), which included 8 patient items and 4 carer items (Bhakta et al., 2000). The four carer items have been excluded from the current version of the LASIS.

Features of the measure

Items:

The LASIS consists of 12 items that measure passive and low-level active function.

Passive function items:

  • Cleaning the palm (affected hand)*
  • Cutting fingernails (affected hand)*
  • Cleaning the affected elbow*
  • Cleaning the affected armpit*
  • Cleaning the unaffected elbow*
  • Putting arm through coat sleeve*
  • Difficulty putting on a glove
  • Difficulty rolling over in bed
  • Doing physiotherapy exercises to arm*

Active function items:

  • Difficulty balancing in standing*
  • Difficulty balancing when walking*
  • Hold object steady, use other hand (jar)

* Items originally included in the Patient Disability and Carer Burden Rating Scale (Bhakta et al., 2000).

Scoring:

Items are rated between 0 – 4 according to the following criteria:

  • 0 = No difficulty
  • 1 = Little difficulty
  • 2 = Moderate difficulty
  • 3 = A great deal of difficulty
  • 4 = Inability to perform the activity

The total score is calculated as the sum of individual scores, divided by the total number of questions answered. This results in a total score between 0 – 4 that represent disability or carer burden (Ashford et al., 2008).

Note: As the final score does not rely on responses to all 12 items, it may not reflect actual disability or function in the arm (Ashford et al., 2008).

Description of tasks:

The LASIS is administered through semi-structured interview with the patient or carer, with regard to the patient’s performance of tasks over the past 7 days.

Time:

The LASIS takes approximately 10 minutes to administer (Ashford et al., 2008).

Training requirements:

The LASIS should be administered by a clinician (Ashford et al., 2008).

Equipment:

Equipment such as a jar may be required to validate responses.

Alternative form of the Leeds Adult Spasticity Impact Scale (LASIS)

None reported.

Client suitability

Can be used with:

  • Patients with Spasticity, including patients with stroke.

Should not be used with:

  • None reported.

Languages of the measure

No translations reported.

Summary

What does the tool measure? Passive and low-level active function of the upper limb.
What types of clients can the tool be used for? Patients with upper limb spasticity, including patients who have experienced a stroke.
Is this a screening or assessment tool? Assessment tool
Time to administer 10 minutes
Versions The LASIS was originally published as the Patient Disability and Carer Burden Scale, which included four dressing and grooming items that have been excluded from the current version of the LASIS.
Other Languages None reported
Measurement Properties
Reliability Internal consistency:
No studies have reported on the Internal consistency of the LASIS.

Test-retest:
No studies have reported on the test-retest reliability of the LASIS.

Intra-rater:
No studies have reported on the intra-rater reliability of the LASIS.

Inter-rater:
No studies have reported on the inter-rater reliability of the LASIS.

Validity Content:
No studies have reported on the content validity of the LASIS.

Criterion:
Concurrent:
No studies have reported on the concurrent validity of the LASIS.

Predictive:
No studies have reported on the predictive validity of the LASIS.

Construct:
Convergent/Discriminant:
No studies have reported on the convergent/discriminant Validity of the LASIS.

Known Groups:
No studies have reported on the known-groups Validity of the LASIS.

Floor/Ceiling Effects No studies have reported on the floor or ceiling effects of the LASIS.
Does the tool detect change in patients? No studies have reported on the sensitivity of the LASIS in patients with stroke.
Acceptability The LASIS is useful for patients with minimal or no active movement or function of the upper extremity.
Feasibility Administrative burden due to calculation of total score, but not complex.
How to obtain the tool? Further information can be found here.

Psychometric Properties

Overview

A literature search was conducted to identify all relevant publications on the psychometric properties of the Leeds Adult Spasticity Impact Scale (LASIS). At the time of publication no studies have reported on the psychometric properties of the LASIS in the stroke population.

Floor/Ceiling Effects

While no studies have investigated the floor or ceiling effects of the LASIS when used with a stroke population, it ca be anticipated that ceiling effects may exist when the LASIS is used with high-functioning patients, due to the hierarchical relationship of items (Ashford et al., 2008).

Reliability

Internal consistency:
No studies have reported on the Internal consistency of the LASIS.

Test-retest:
No studies have reported on the test-retest reliability of the LASIS.

Intra-rater:
No studies have reported on the intra-rater reliability of the LASIS.

Inter-rater:
No studies have reported on the inter-rater reliability of the LASIS.

Validity

Content:

No studies have reported on the content validity of the LASIS.

Criterion:

Concurrent:
No studies have reported on the concurrent validity of the LASIS.

Predictive:
No studies have reported on the predictive validity of the LASIS.

Construct:

Convergent/Discriminant:
No studies have reported on the convergent/discriminant validity of the LASIS.

Known Group:
No studies have reported on the known-groups validity of the LASIS.

Responsiveness

No studies have reported on the responsiveness of the LASIS.

Sensitivity/Specificity:
No studies have reported on the Sensitivity or the specificity of the LASIS.

References

  • Ashford, S., Slade, M., Malaprade, F., & Turner-Stokes, L. (2008). Evaluation of functional outcome measures for the hemiparetic upper limb: A systematic review. Journal of Rehabilitation Medicine, 40, 787-95.
  • Bhakta, B.B., Cozens, J.A., Chamberlain, M.A., & Bamford, J.M. (2000). Impact of botulinum toxin type A on disability and carer burden due to arm spasticity after stroke: a randomised double blind placebo controlled trial. Journal of Neurological Neurosurgery and Psychiatry, 69, 217-21.

See the measure

How to obtain the LASIS?

Further information can be found here.

Table of contents

Modified Ashworth Scale

Evidence Reviewed as of before: 13-07-2011
Author(s)*: Sabrina Figueiredo, BSc; Lisa Zeltzer, BSc
Editor(s): Nicol Korner-Bitensky, PhD OT; Elissa Sitcoff, BA BSc

Purpose

The Modified Ashworth Scale is considered the primary clinical measure of muscle spasticity in patients with neurological conditions. However, some publications question its ability to measure spasticity and advocate the Modified Ashworth Scale as a rating scale to measure abnormality in tone or the resistance to passive movements, since there is no clinically direct method for measuring spasticity (Gregson, Leathley, Moore, Sharma, Smith & Watkins, 1999; Pandyan, Johnson, Price, Curless, Barnes & Rodgers, 1999).

In-Depth Review

Purpose of the measure

The Modified Ashworth Scale is considered the primary clinical measure of muscle spasticity in patients with neurological conditions. However, some publications question its ability to measure spasticity and advocate the Modified Ashworth Scale as a rating scale to measure abnormality in tone or the resistance to passive movements, since there is no clinically direct method for measuring spasticity (Gregson, Leathley, Moore, Sharma, Smith & Watkins, 1999; Pandyan, Johnson, Price, Curless, Barnes & Rodgers, 1999).

Available versions

The Ashworth Scale was initially developed in the early 1960s by Bryan Ashworth, to estimate the efficacy of anti-spastic drugs in clients with Multiple Sclerosis. It is a 5-point scale, with a grade score of 0, 1, 2, 3, or 4 (Ashworth, 1964). In 1987, Bohannon and Smith added the grade “1+” and proposed slight changes on the definitions of each score in order to increase the sensitivity of the measure and facilitate scoring. The new measure was then called the Modified Ashworth Scale and is considered by many as the gold standard for measuring spasticity (Bohannon & Smith, 1987).

Features of the measure

Items:

Although there are no standardized guidelines for its use, the Modified Ashworth Scale can be applied to muscles of both the upper or lower body. The rater should extend the client’s limb from a position of maximal flexion to maximal extension until the first soft resistance is felt. Moving a client’s limb through its full range of motion should be done within one second by counting “one thousand and one” (Bohannon and Smith, 1987).

Mehlroz, Wagner, Meibner, Grundmann and Zange (2005) suggest testing of the upper limbs should take place while the client is lying supine, with the upper limbs parallel to the trunk, elbows extended, wrists in a neutral position, and the lower limbs positioned parallel to one another. Exceptions are made for the shoulder extensors, where the arm should be moved from extension to 90 degrees of flexion, and for the shoulder internal rotators, where the arm should be moved from neutral to a maximum external rotation.

For the lower limbs, Blackburn, van Vliet, and Mockett (2002) recommend that the client should be side lying. Specifically for testing the soleus muscle, the hips and knees should be positioned in 45 degrees of flexion and the ankle is moved from maximum plantar flexion to maximum dorsiflexion. For the gastrocnemius muscle, hips should be in 45 degrees of flexion with the knees in maximum extension and the ankle is moved from maximum plantar flexion to maximum dorsiflexion. For the quadriceps femoris muscle, knees and hips should be in maximal extension and the knee is moved from maximum extension to maximum flexion.

Throughout testing the client should be instructed to remain calm and relaxed, and when repeated testing is undertaken, testing should be initiated at the same time of the day to minimize possible changes in spasticity levels due to medication interaction (Bohannon and Smith, 1987).

Scoring:

The Modified Ashworth Scale is a 6-point scale. Scores range from 0 to 4, where lower scores represent normal muscle tone and higher scores represent spasticity or increased resistance to passive movement.

Specific score definitions for the Ashworth Scale and for the Modified Ashworth Scale are as follows:

>Score Ashworth Scale (Ashworth, 1964) Modified Ashworth Scale (Bohannon & Smith, 1987)
0 No increase in tone No increase in muscle tone
1 Slight increase in tone giving a catch when the limb was moved in flexion or extension Slight increase in muscle tone, manifested by a catch and release or by minimal resistance at the end of the range of motion (ROM) when the affected part is moved in flexion or extension
1+ N/A Slight increase in muscle tone, manifested by a catch, followed by minimal resistance throughout the remainder (less than half) of the ROM
2 More marked increase in tone but limb easily flexed More marked increase in muscle tone through most of the ROM, but affected parts easily moved
3 Considerable increase in tone, passive movement difficult Considerable increase in muscle tone, passive movement difficult
4 Limb rigid in flexion or extension Affected part rigid in flexion or extension

Time:

Not reported, but it will vary with the numbers of muscles being tested.

Subscales:

None

Equipment:

  • Therapy mat
  • Paper

Training:

None typically reported.

Alternative form of the Modified Ashworth Scale

  • Ashworth Scale:
    Published in 1964, the Ashworth Scale was the original measure for resistance to passive movement. It is a 5-point scale, with a grade score of 0, 1, 2, 3, or 4. The Ashworth Scale is less sensitive than the Modified Ashworth Scale (Brashear, Zafonte, Corcoran, Galvez-Jimenez, Gracies, Gordon et al., 2002).
  • Modified Modified Ashworth Scale:
    Published in 2006, the Modified Modified Ashworth Scale aims to improve the reliability of the Modified Ashworth Scale. It is a 5-point scale, where the authors omitted the grade “1+” from the Modified Ashworth Scale and slightly redefined the grade “2” (Ansari, Naghdi, Younesian, & Shayeghan, 2008). The definition for each grade is as follows:
Score Modified Modified Ashworth Scale (Ansari, Naghdi, Moammeri, Jalaie, 2006)
0 No increase in muscle tone
1 Slight increase in muscle tone, manifested by a catch and release or by minimal resistance at the end of the range of motion (ROM) when the affected part is moved in flexion or extension
2 Marked increase in muscle tone, manifested by a catch in the middle ROM, but affected part easily moved
3 Considerable increase in muscle tone, passive movement difficult
4 Affected part rigid in flexion or extension

Client suitability

Can be used with:

  • Clients with stroke.
  • Clients with other neurological impairment such as multiple sclerosis, traumatic
    brain injury, spinal cord injury.

Should not be used in:

  • To date, there is no information on restrictions for using the Modified Ashworth Scale.

In what languages is the measure available?

English

Summary

What does the tool measure? The Modified Ashworth Scale is a clinical measure of muscle spasticity or, more specifically, is a rating scale to measure tonus abnormality.
What types of clients can the tool be used for? The Modified Ashworth Scale can be used with, but is not limited to clients with stroke.
Is this a screening or assessment tool? Assessment
Time to administer Not reported, but it will vary with the number of muscle groups being tested.
Versions Ashworth Scale, Modified Ashworth Scale, Modified Modified Ashworth Scale.
Other Languages English.
Measurement Properties
Reliability Internal consistency:
No studies have examined the Internal consistency of the Modified Ashworth Scale.

Test-retest:
No studies have examined the test-retest reliability of the Modified Ashworth Scale.

Intra-rater:
Four studies have examined the intra-rater reliability of the Modified Ashworth Scale and reported adequate to excellent intra-rater reliability using kappa, weighted kappa or Kendall’s tau-b.

Inter-rater:
Eight studies examined the inter-rater reliability of the Modified Ashworth Scale and reported poor to excellent inter-rater reliability using kappa, weighted kappa, Kendall’s tau-b or Spearman’s rho.

Validity

Content:
One study examined the content validity of the Modified Ashworth Scale to gather evidence of its assumptions and reported caution is required when stating that the Modified Ashworth Scale is a measure of spasticity since evidence suggests that the resistance to passive movement is not an exclusive measure of spasticity.

Criterion:
Concurrent:
One study examined the concurrent validity of the Modified Ashworth Scale and reported a poor correlation between the Modified Ashworth Scale and surface electromyography, using Spearman’s rho.

Predictive:
No studies have examined the predictive validity of the Modified Ashworth Scale.

Construct:
Convergent:
Five studies examined the convergent validity of the Modified Ashworth Scale and reported excellent correlations between the Modified Ashworth Scale and motor performance tests (Fugl-Meyer Assessment, Box and Block test, active range of motion, grip strength) and neurophysiologic assessments (electromyography, pendulum test), adequate correlations between the Modified Ashworth Scale and measures of resistance to passive movement and neurophysiologic assessments (velocity sensitivity) and poor correlations between the Modified Ashworth Scale and pain and neurophysiologic assessments (torque), using Pearson correlation, Spearman rho correlation, kappa and Fisher exact test.

Known Groups:
Two studies examined known groups validity of the Modified Ashworth Scale and reported that the Modified Ashworth Scale is not able to distinguish between different values of H-reflex latency and different levels of stiffness, using student t-test and ANOVA.

Does the tool detect change in patients? No studies have examined the responsiveness of the Modified Ashworth Scale.
Acceptability The Modified Ashworth Scale is the primary clinical measure for spasticity.
Feasibility The time to administer the Modified Ashworth Scale has not been reported, but it will vary with the numbers of muscles being tested.
How to obtain the tool? The Modified Ashworth Scale can be obtained from its original publication: Bohannon & Smith (1987). The following publications also present the full tool described: Bakheit et al., (2003); Pandyan et al., (1999); Salter, Jutai, Teasell, Foley and Bitensky (2005).

Psychometric Properties

Overview

We conducted a literature search to identify all relevant publications on the psychometric properties of the Modified Ashworth Scale in individuals with stroke. We identified twenty studies. The Modified Ashworth Scale shows conflicting results regarding its reliability and validity.

Reliability

Note: The Modified Ashworth Scale’s reliability appears to be muscle-dependent. In general, assessments of the elbow and wrist showed better results when compared to assessments of the knee and ankle plantar muscle.

Intra-rater:
Gregson, Leathley, Moore, Sharma, Smith, and Watkins (1999) estimated the intra-rater reliability of the Modified Ashworth Scale in 32 clients with acute stroke and a median age of 74 years by measuring muscle tone at the elbow. Participants were assessed by the same rater within a 1-day interval at the same time of the day. intra-rater reliability, as calculated using weighted kappa was excellent (weighted kappa = 0.83).

Gregson, Leathley, Moore, Smith, Sharma, and Watkins (2000) evaluated the intra-rater reliability of Modified Ashworth Scale in 35 clients with acute stroke and a median age of 75 years by measuring muscle tone of flexors and extensors of the elbow, wrist, knee and ankle. Participants were assessed by the same rater within a 1-day interval at the same time of the day. intra-rater reliability, as calculated using weighted kappa was excellent for the elbow (weighted kappa = 0.83), wrist (weighted kappa = 0.88), and knee weighted kappa = 0.94) and adequate for the ankle (weighted kappa = 0.64).

Blackburn, van Vliet, and Mockett (2002) measured the intra-rater reliability of the Modified Ashworth Scale in 20 clients with acute stroke and 16 clients with chronic stroke measuring muscle tone of the gastrocnemius, soleus and quadriceps femoris. Participants were evaluated by the same rater within a 1-week interval. intra-rater reliability as calculated using Kendall’s tau-b was adequate for the Modified Ashworth Scale, (Kendall’s tau-b = 0.56) as well as for each muscle tested: gastrocnemius (Kendall’s tau-b = 0.44), soleus (Kendall’s tau-b = 0.58), and quadriceps femoris (Kendall’s tau-b = 0.66). Lower scores on the Modified Ashworth Scale showed higher levels of agreement. A score of 0 indicated that an intra-rater agreement of 60% was achieved while at score of 2 indicated only 12% of intra-rater agreement.

Mehrholz, Wagner, Meibner, Grundmann, and Zange (2005) estimated the intra-rater reliability of Modified Ashworth Scale and the Modified Tardieu Scale (MTS) in 30 clients with, either from stroke, traumatic brain injury or cerebral hypoxia by measuring muscle tone of the shoulder, elbow, wrist, hip, knee and ankle. Participants were re-assessed within a 1-day interval, at the same time of the day and position, by the same rater. intra-rater reliability, as calculated using kappa statistics were adequate for all muscles as follows: Shoulder flexor (kappa = 0.55), shoulder external rotator (kappa = 0.47), elbow flexor (kappa = 0.47), elbow extensor (kappa = 0.53), wrist flexor (kappa = 0.58), wrist extensor (kappa = 0.51), hip flexor (kappa = 0.53), hip extensor (kappa = 0.49), knee flexor (kappa = 0.52), knee extensor (kappa = 0.55), ankle extensor with knee joint flexed (kappa = 0.62), ankle extension with knee joint fully extended (kappa = 0.47). When compared with the MTS, the intra-rater reliability of the MTS was significantly higher for all muscles (P<0.05), except for the extensor and internal rotator muscles of the shoulder (P>>0.05).

Inter-rater:
Bohannon and Smith (1987) analyzed the inter-rater reliability of the Modified Ashworth Scale in 30 clients with intracranial lesions either from multiple sclerosis (n = 1), closed head injuries (n = 5) or stroke (n = 24) by measuring muscle tone of the elbow flexors. inter-rater reliability, as calculated using Kendall’s tau-b, was excellent (Kendall’s tau-b = 0.84).

Bodin and Morris (1991) estimated the inter-rater reliability of the Modified Ashworth Scale in 18 clients with stroke by measuring muscle tone at the wrist. Participants were assessed by two different raters, independently, under three different conditions: immediately after positioning, after a 90 second stretch of the flexors and after a 90 second stretch of the extensors. inter-rater reliability, as calculated using Kendall’s tau-b, was excellent (Kendall’s tau-b = 0.85) and adequate when agreement was calculated using kappa values (kappa = 0.74).

Sloan, Sinclair, Thompson, Taylor, and Pentland (1992) verified the inter-rater reliability of the Modified Ashworth Scale in 34 clients with hemiplegia secondary to stroke by assessing muscle tone of the knee flexors, elbow flexors and extensors. Participants were assessed by four raters independently. inter-rater reliability, as calculated using Spearman’s rho, ranged from adequate to excellent at the elbow (rho = 0.56 to 0.90) and from poor to excellent at the knee (rho = 0.26 to 0.62).

Gregson et al. (1999) estimated the inter-rater reliability of the Modified Ashworth Scale in 32 clients with acute stroke and a median age of 74 years by measuring muscle tone at the elbow. Participants were assessed by two different raters at approximately the same time of the day. inter-rater reliability as calculated using weighted kappa was excellent (weighted kappa = 0.84).

Gregson et al. (2000) evaluated the inter-rater reliability of the Modified Ashworth Scale in 35 clients with acute stroke and a median age of 75 years by measuring the muscle tone of flexors and extensors of the elbow, wrist, knee and ankle. Participants were assessed by two different raters at approximately the same time of the day. inter-rater reliability, as calculated using weighted kappa was excellent for the elbow (weighted kappa = 0.96), wrist (weighted kappa = 0.89) and knee (weighted kappa = 0.79) and adequate for the ankle (weighted kappa = 0.51).

Blackburn et al. (2002) measured the inter-rater reliability of the Modified Ashworth Scale in 20 clients with acute stroke and 16 clients with chronic stroke. Muscle tone of the gastrocnemius, soleus and quadriceps femoris was measured. Participants were evaluated by two different raters. inter-rater reliability of the Modified Ashworth Scale, as calculated using Kendall’s tau-b, was poor (Kendall’s tau-b = 0.06). Kendall’s tau-b ratings were also poor for the gastrocnemius (Kendall’s tau-b = 0.15), soleus (Kendall’s tau-b = 0.19), and quadriceps femoris (Kendall’s tau-b = 0.28). Agreement between raters occurred mostly at a score of 0, in which an agreement of 40.8% was achieved. Higher scores, such as a score of 2, showed 0% of agreement between raters.

Ansari, Naghdi, Moammeri, and Jalaie (2006) assessed the inter-rater reliability of the Modified Ashworth Scale in 15 clients with stroke by measuring muscle tone of the elbow flexors. Participants were assessed by two different raters. inter-rater reliability, as calculated using kappa statistics, was poor (kappa = 0.21).

Mehrholz et al. (2005) estimated the inter-rater reliability of the Modified Ashworth Scale and the Modified Tardieu Scale (MTS) in 30 clients with severe cerebral damage, either from stroke, traumatic brain injury or cerebral hypoxia by measuring muscle tone of the shoulder, elbow, wrist, hip, knee and ankle. Participants were re-assessed by four different raters. inter-rater reliability, as calculated using kappa statistics was adequate for elbow extension (kappa = 0.42) and poor for all other muscles, as follows: shoulder flexors (kappa = 0.29), shoulder external rotators (kappa = 0.16), elbow flexors (kappa = 0.33), wrist flexors (kappa = 0.34), wrist extensors (kappa = 0.30), hip flexors (kappa = 0.31), hip extensors (kappa = 0.24), knee flexors (kappa = 0.28), knee extensors (kappa = 0.35), ankle extensors with knee flexed (kappa = 0.20), and ankle extensor with knee fully extended (kappa = 0.14). When compared with the MTS, the inter-rater reliability of the MTS was significantly higher for all muscles (P<0.05) except for wrist extensor muscles (P>0.05).

Validity

Content:

Pandyan, Johnson, Price, Curless, Barnes, and Rodgers (1999) performed a literature review to gather evidence for a theoretical basis of the Modified Ashworth Scale. The implicit assumptions for the Modified Ashworth Scale appear to be that: 1) Changes in the resistance to passive movement are due to changes in spasticity; 2) Stretch mechanoreceptors in the muscle would elongate with similar velocity during repeated measures and 3) The range of movement on each joint during repeated measures is unaltered. Also, caution is required when stating that the Modified Ashworth Scale is a measure of spasticity since evidence suggests that the resistance to passive movement is not an exclusive measure of spasticity, and will vary according to the level of activity in the alpha motor neuron of agonist and antagonist muscles, the viscoelastic properties of soft tissues and joints.

Criterion:

Concurrent:
Cooper, Musa, van Deursen, and Wiles (2005) assessed the concurrent validity of the Modified Ashworth Scale by comparing it to surface electromyography as the gold standard for spasticity in 31 clients with stroke and 20 healthy individuals. A poor correlation was reported between the Modified Ashworth Scale and surface electromyography, as calculated using Spearman’s rho (rho = 0.21).

Predictive:
No studies have examined the predictive validity of the Modified Ashworth Scale.

Construct:

Convergent/Discriminant:
Katz, Rovai, Brait, and Rymer (1992) tested the convergent validity of the Modified Ashworth Scale by comparing it to the Fugl-Meyer Assessment (Fugl-Meyer, Jääskö, Leyman, Olsson, & Steglind, 1975) and objective measurements of spasticity including electromyography, torque, pendulum test, and H/M ratio in 10 clients with stroke. Correlations as calculated using Pearson correlations were excellent between the Modified Ashworth Scale and the Fugl-Meyer Assessment (r = -0.94), the electromyography (r = -0.79), and the pendulum test (r = -0.67). No significant correlations were found between the Modified Ashworth Scale, torque, and H/M ratio, and therefore their respective values were not described by the authors.

Lin and Sabbahi (1999) measured the convergent validity of the Modified Ashworth Scale by comparing it to hyperactive stretch reflex measures such as electromyography, torque response and velocity sensitivity of the stretch reflexes as well as to motor performance measures such as the Fugl-Meyer Assessment (Fugl-Meyer, Jääskö, Leyman, Olsson, & Steglind, 1975), the Box and Block test (Cromwell, 1965; Mathiowetz, Volland, Kashman, & Weber, 1985a), active range of motion and grip strength in 10 clients with chronic stroke. Correlations were calculated at two points in time using Spearman’s rho. Correlations between the Modified Ashworth Scale and motor performance measures for both day 1 and 2 were all excellent: Fugl-Meyer Assessment (rho1 = -0.83; rho2 = -0.76), Box and Block Test (rho1 = -0.83; rho2 = -0.76), active range of motion (rho1 = -0.74; rho2 = -0.62) and grip strength (rho1 = -0.86; rho2 = -0.85). With respect to the hyperactive stretch reflexes,excellent correlations were found between the Modified Ashworth Scale and electromyography of muscles at rest on day 1 (rho = 0.77) and day 2 (rho = 0.67), electromyography of active muscles at day 1 (rho = 0.77), on day 2 (rho = 0.74) and the torque of muscles at rest on day 1 (rho = 0.80). Adequate correlations were found between the Modified Ashworth Scale and velocity sensitivity on day 1 (rho = 0.52) and day 2 (rho = 0.57). Poor correlations were found between the Modified Ashworth Scale and torque of muscles at rest on day 2 (rho = -0.25) and the torque of active muscles on day 1 (rho = 0.26) and on day 2 (rho = 0.21).

Pandyan, Price, Rodgers, Barnes and Johnson (2001) estimated the convergent validity of the Modified Ashworth Scale by comparing it to biomechanical measures of resistance to passive movement of the elbow in 16 clients with acute stroke. In this study, the correlation using Kappa statistics was poor (kappa = 0.36).

Pandyan, Price, Barnes, and Johnson (2003) evaluated the convergent validity of the Modified Ashworth Scale by comparing it to a biomechanical measure of resistance to passive movement of the elbow in 63 clients with stroke. An adequate correlation was found using Spearman’s rho (rho = 0.51).

Pizzi, Carlucci, Falsini, Verdesca and Grippo (2005) estimated the convergent validity of the Modified Ashworth Scale by comparing it to neurophysiologic assessments of spasticity (H-reflex and M-response), passive range of motion of the elbow and wrist, and pain in 65 clients with stroke. Correlations were calculated using Spearman’s rho and Fisher exact test. An adequate correlation between the Modified Ashworth Scale and the neurophysiologic assessment of the wrist was found (rho = 0.40). Also, higher scores (>3) on the Modified Ashworth Scale were associated with a decrease in passive range of motion (F = 6.8). No correlation was found between pain and Modified Ashworth Scale values for either the elbow or the wrist.

Known groups:
Bakheit, Maynard, Curnow, Hudson, and Kodapola (2003) analyzed whether Modified Ashworth Scale scores were able to distinguish between individuals with higher values in the H- reflex latency and H/M ratio from those with lower values of H-reflex latency and H/M ratio in 24 clients with stroke. Known groups validity, as calculated using the student t-test, showed that the Modified Ashworth Scale is not able to distinguish between clients with lower and higher values of H-reflex latency and H/M ratio, two neurophysiologic tests for spasticity.

Kumar, Pandyan, and Sharma (2006) verified whether the Modified Ashworth Scale was able to differentiate clients with four different levels of stiffness (no stiffness, mild, moderate, and severe stiffness) in 111 clients with stroke. Known groups validity, as calculated using Analysis of Variance (ANOVA), showed that the Modified Ashworth Scale was not able to distinguish between individuals with different levels of stiffness.

Responsiveness

No studies have examined the responsiveness of the Modified Ashworth Scale.

References

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See the measure

How to obtain the Modified Ashworth Scale?

The Modified Ashworth Scale can be obtained from its original publication: Bohannon & Smith (1987).

The following publications also present the full tool described: Bakheit et al., (2003); Pandyan et al., (1999); Salter, Jutai, Teasell, Foley and Bitensky (2005).

By clicking here, you can access a video showing how to administer the assessment.

It is also available on the Shirley Ryan Ability Lab website.

Table of contents

Tardieu Scale and Modified Tardieu Scale (MTS)

Evidence Reviewed as of before: 13-07-2011
Author(s)*: Katie Marvin, MSc. (Candidate)
Editor(s): Nicol Korner-Bitensky, PhD OT; Annabel McDermott, OT

Purpose

The Tardieu Scale and Modified Tardieu Scale (MTS) are clinical measures of muscle spasticity for use with patients with neurological conditions. When using the Tardieu Scale or MTS, spasticity is quantified by assessing the muscle’s response to stretch applied at given velocities.

In-Depth Review

Purpose of the measure

The Tardieu Scale and the Modified Tardieu Scale (MTS) are clinical measures of muscle spasticity in patients with neurological conditions. The Tardieu Scale and MTS quantify spasticity by assessing the muscle’s response to stretch applied at given velocities. The quality of the muscle reaction at specified velocities and the angle at which the muscle reaction occurs are incorporated into the measurement of spasticity using the MTS (Morris, 2002).

The Ashworth Scale and the Modified Ashworth Scale are most often used clinically in the assessment of adults, however the MTS is more commonly used in the assessment of children and has been suggested to be a more accurate clinical measure of spasticity (Morris, 2002).

The ability of the Ashworth Scales to measure spasticity has been questioned and some publications suggest that they measure abnormal tone or resistance to passive stretch rather than spasticity because they do not take into account the velocity-dependent component of spasticity. The MTS compares the muscle’s resistance to passive stretch at both slow and fast speeds in order to account for the velocity-dependent characteristic of spasticity (Paulis, Horemans, Brouwer & Stam, 2011).

Available versions

Tardieu et al. (1954) first suggested the technique of spasticity measurement used in the Tardieu Scale. Held and Pierrot-Deseilligny (1969) later developed the quantifiable Tardieu Scale that was then translated into English by Gracies et al. (2000). Boyd and Graham (1999) further modified the scale as the Modified Tardieu Scale (MTS).

Features of the measure

Items:

There are no actual items to the MTS.

Description of tasks:

The examiner evaluates the muscle group’s reaction to stretch at a specified velocity with 2 parameters: X (quality of muscle reaction) and Y (angle of muscle reaction).

Velocity of stretch:

  • V1: As slow as possible (minimizing stretch reflex)
  • V2: Speed of the limb segment falling under gravity
  • V3: As fast as possible (faster than the rate of the natural drop of the limb segment under gravity)

The resulting joint angles are defined as:

  • R1 (the angle of catch following a fast velocity stretch – during either V2 or V3); and
  • R2 (passive range of motion following a slow velocity stretch – V1 – Mackey, Watt, Lobb & Stott, 2004).
  • As V1 is used to measure the passive range of motion (PROM), only V2 and V3 are used to rate spasticity.

Grading should always be performed at the same time of the day, and the limb being test should be placed in the same position for repeat testing. The MTS specifies limb placement positions for consistency (Boy & Graham, 1999; Morris 2002). Other joints, in particular the neck, must also remain in a constant position for the duration of the test and on subsequent testing.

Angle of muscle reaction (Y): Measured relative to the position of minimal stretch of the muscle (corresponding to angle) for all joints except hip, where is it relative to the resting anatomical position (Gracies, Marosszeky, Renton, Sandanam, Gandevia & Burke, 2000).

What to consider before beginning:

Test positions:

  • Upper limb – To be tested in a sitting position.
  • Lower limb – To be tested in supine position.

For further details on testing positions, please visit Morris (2002).

Scoring and Score Interpretation:

Although not described in the original Tardieu Scale, Boyd and Graham (1999) describe R1 and R2 when evaluating the reaction of the muscle. R1 is used to denote the angle at which a “catch” resulting from an overactive stretch reflex is present, and R2 denotes the angle of muscle length at rest. In the development of the MTS, Boyd and Graham suggested that the relationship between R1 and R2 is of greater importance than the individual measures of R1 and R2.

  • A large difference between R1 and R2 suggests a large dynamic component with a greater capacity for change or improvement.
  • A small difference between R1 and R2 suggests a predominantly fixed contracture in the muscle with a poorer capacity for change.

Therefore, the relationship between R1 and R2 can be used to estimate the role of neural mechanisms (spasticity) and mechanical restraint of the soft tissue when the muscle reacts to passive stretch.

Time:

Not reported, but it will vary with the numbers of muscles being tested.

Training requirements:

  • None typically reported, however, the experience of the rater has considerable influence on results (Ansari et al., 2008; Singh et al., 2011)

Subscales:

None.

Equipment:

  • Pencil or pen
  • Goniometer
  • Mat, plinth or bed

Alternative forms of the Modified Tardieu Scale

Tardieu Scale:

First developed in 1954, the Tardieu Scale has been suggested as a reliable alternative to the Ashworth Scales, as it compares the muscle’s resistance to passive stretch at both slow and fast speeds in order to account for the velocity-dependent characteristic of spasticity.

Modified Tardieu Scale:

Published in 1999, the MTS uses the same grading scale outlined in the original Tardieu Scale, however the modifications aim to standardize the testing procedure. Specific limb placement, alignment positions and procedures are described. Measures of passive range of motion are described as R2; the angle of muscle reaction (‘catch’) is described as R1; and the difference between the two measures (R2-R1) are used to help differentiate spasticity and soft-tissue restrictions (Boyd and Graham, 1999).

Score definitions for the Tardieu Scale and the MTS are provided below. Score definitions between the two measures are consistent.

Quality of muscle reaction (X):

Grade Description
0 No resistance throughout the course of the passive movement.
1 Slight resistance throughout the course of the passive movement, with no clear catch at a precise angle.
2 Clear catch at a precise angle, interrupting the passive movement, followed by a release.
3 Fatigable clonus (<10 seconds when maintaining pressure) occurring at a precise angle.
4 Infatigable clonus (>>10 seconds when maintaining pressure) occurring at a precise angle.
5 Joint is immoveable.

Client suitability

Can be used with:

  • Clients with stroke.
  • Clients with other neurological impairment such as cerebral palsy (Boyd & Graham, 1999) and traumatic brain injury (Mehrholz et al., 2005).

Should not be used with:

  • To date, there is no information on restrictions for using the Tardieu Scale or the MTS.

In what languages is the measure available?

English

Summary

What does the tool measure? The Tardieu Scale and the Modified Tardieu Scale (MTS) are clinical measures of muscle spasticity.
What types of clients can the tool be used for? The MTS can be used with, but is not limited to clients with stroke.
Is this a screening or assessment tool? Assessment
Time to administer Not reported, but it will vary with the number of muscle groups being tested.
Versions Tardieu Scale, MTS
Other Languages English
Measurement Properties
Reliability

Internal consistency:
No studies have examined the internal constency of the MTS in clients with stroke.

Test-retest:
One study examined the test-retest reliability of the Tardieu Scale and found excellent test-retest reliability using both inertial sensors and goniometry.

Intra-rater:
Two studies examined the intra-rater reliability of the MTS and reported adequate to excellent intra-rater reliability using kappa statistics.

Inter-rater:
One study examined the inter-rater reliability of the Tardieu Scale using inertial sensors and goniometry. Adequate to excellent inter-rater reliability was found using goniometry and inertial sensors respectively, as calculated using Intraclass Correlation Coefficient (ICC).

Two studies examined the inter-rater reliability of the MTS and reported poor to adequate inter-rater reliability using kappa and ICC.

Validity

Content:
No studies have examined the content validity of the Tardieu Scale or the MTS in clients with stroke.

Criterion:
Concurrent:
No studies have examined the concurrent validity of the Tardieu Scale or the MTS in clients with stroke.

Predictive:
No studies have examined the predictive validity of the Tardieu Scale or the MTS in clients with stroke.

Construct:
Convergente/Discriminant:
One study examined the convergent validity of the Tardieu Scale and reported excellent correlation between the Tardieu Scale and electromyography (EMG) measurements of spasticity and contracture.

Known Group:
No studies have examined the known groups validity of the Tardieu Scale or MTS in clients with stroke.

Sensitivity & Specificity:
No studies have examined the Sensitivity/specificity of the Tardieu Scale or MTS in clients with stroke.

Floor/Ceiling Effects No studies have examined the floor or ceiling effects of the Tardieu Scale or MTS in clients with stroke.
Does the tool detect change in patients? No studies have formally examined the responsiveness of the Tardieu Scale or MTS. However, the Tardieu Scale was found to be sensitive enough to detect change in patients undergoing treatment for spasticity in one study.
Acceptability The MTS is commonly used in the assessment of spasticity in children. In adults, it has been suggested to be a more accurate and Reliability clinical measure of spasticity than the Ashworth Scale.
Feasibility The time to administer the MTS has not been reported, but it will vary with the numbers of muscles being tested.
How to obtain the tool? The following publications present the full Tardieu Scale and/or the MTS: Ansari, Naghdi, Hasson, Azarsa & Azarnia (2008); Boyd & Graham (1999); Gracies et al. (2000); Haugh, Pandyan & Johnson (2006); Morris (2002); and Patrick & Ada (2006).

Psychometric Properties

Overview

A literature search was conducted to identify all relevant publications on the psychometric properties of the Tardieu Scale and the Modified Tardieu Scale (MTS). While this assessment can be used with various populations, this module addresses the psychometric properties of the measure specifically when used with patients with stroke. Six studies were identified.

Floor/Ceiling Effects

No studies have reported on the floor or ceiling effects of the Tardieu Scale or the MTS when used with patients with stroke.

Reliability

Internal Consistency:
No studies have reported on the internal constancy of the Tardieu Scale or the MTS when used with patients with stroke.

Test-rested:
Paulis et al. (2011) evaluated and compared the test-retest reliability of Tardieu Scale measurements using goniometry and inertial sensors (IS). Two therapists each assessed spasticity of the elbow flexors in 13 patients with stroke using goniometry and IS, on two separate occasions (30 minutes apart). test-retest reliability of the Tardieu Scale as calculated using Intraclass Correlation Coefficient (ICC) was excellent for both goniometry and IS (ICC=0.86 and 0.76 respectively). Passive range of motion (ROM) and angle of catch (AoC) data was also found to have excellent test-retest reliability when both goniometry and IS were used.

Intra-rater:
Mehrholz, Wagner, Meibner, Grundmann, and Zange (2005) investigated the intra-rater reliability of the MTS and the Modified Ashworth Scale in 30 clients with severe cerebral damage resulting from stroke (subacute), traumatic brain injury or cerebral hypoxia. Muscle tone of the shoulder, elbow, wrist, hip, knee and ankle was measured. Participants were re-assessed within a 1-day interval, at the same time of the day and position, by the same rater. The intra-rater reliability of the MTS, as calculated using kappa statistics, were adequate for shoulder flexor (kappa = 0.65), shoulder external rotator (kappa = 0.53) and knee flexor (kappa = 0.67) muscles and excellent for all other muscles as follows: elbow flexors (kappa = 0.78), elbow extensors (kappa = 0.75), wrist flexors (kappa = 0.87), wrist extensors (kappa = 0.71), hip flexors (kappa = 0.76), hip extensors (kappa = 0.72), knee flexors (kappa = 0.67), knee extensors (kappa = 0.81), ankle extensors with knee joint flexed (kappa = 0.82), ankle extensors with knee joint fully extended (kappa = 0.72). When compared with the Modified Ashworth Scale, the intra-rater reliability of the MTS was significantly higher for all muscles (P<0.05), except for the extensor and internal rotator muscles of the shoulder (P>0.05).

Singh, Joshua, Ganeshan and Suresh (2011) examined the intra-rater reliability of the MTS in 91 patients with subacute stroke. Elbow flexors and ankle plantar flexors were assessed and re-assessed within a 2-day interval, at the same time of day and position, by the same rater (rater was extensively trained in evaluation of spasticity using the MTS). The intra-rater reliability of the MTS, as calculated using Intraclass Correlation Coefficient (ICC), was excellent for all MTS measurements for both elbow flexors and ankle plantar flexors (elbow flexors: R1 ICC = 0.998, R2 ICC = 0.978, R2-R1 ICC = 0.991, MTS scores ICC = 0.847; ankle plantar flexors: R1 ICC = 0.990, R2 ICC = 0.995, R2-R1 ICC = 0.907, MTS scores ICC = 0.863).

Inter-rater:
Mehrholz et al. (2005) estimated the inter-rater reliability of the MTS and the Modified Ashworth Scale in 30 clients with severe cerebral damage resulting from stroke (subacute), traumatic brain injury or cerebral hypoxia. Muscle tone of the shoulder, elbow, wrist, hip, knee and ankle was measured. Participants were assessed by four different raters. inter-rater reliability, as calculated using kappa statistics, was adequate for shoulder flexors (kappa = 0.44), elbow flexors (kappa = 0.48), elbow extensors (kappa = 0.51), hip flexors (kappa = 0.42), knee flexors (kappa = 0.53), knee extensors (kappa = 0.44) and ankle extensors with knee fully flexed (kappa = 0.47), but poor for shoulder external rotators (kappa = 0.39), wrist flexors (kappa = 0.33), wrist extensors (kappa = 0.38), hip extensors (kappa = 0.37), ankle extensors with knee fully extended (kappa = 0.29) and elbow extensors (kappa = 0.42). When compared with the Modified Ashworth Scale, the inter-rater reliability of the MTS was significantly higher for all muscles (P<0.05) except for wrist extensor muscles (P>0.05).

Ansari, Naghdi, Hasson, Azarsa and Azarnia (2008) evaluated the inter-rater reliability of the MTS in 30 patients with hemiplegia caused by stroke (chronic) or traumatic brain injury (mean age 54.9 years). Two inexperienced raters examined the patients and were blinded to the other’s results. The inter-rater reliability of the MTS measures, as calculated using Intraclass Correlation Coefficient (ICC), were adequate (R1 ICC=0.74; R2 ICC=0.56; and R2-R1 ICC= 0.72). The authors suggested that the limited experience of the raters likely impacted the inter-rater reliability.

Paulis et al. (2011) evaluated and compared the inter-rater reliability of Tardieu Scale measurements using goniometry and inertial sensors (IS). Two therapists each assessed spasticity of the elbow flexors in 13 patients with stroke on two separate occasions (30 minutes apart). The inter-rater reliability of the Tardieu Scale using IS, as calculated using Intraclass Correlation Coefficient (ICC), was excellent (0.84), whereas the inter-rater reliability using goniometry was only adequate (0.66). The inter-rater reliability of passive range of motion (ROM) using IS was excellent and equivalent to goniometry (ICC=0.89 for both). The inter-rater reliability of the angle of catch (AoC) was excellent using IS (ICC=0.87) and adequate using goniometry (ICC=0.60).

Validity

Content:

No studies have reported on the content validity of the Tardieu Scale or the MTS when used with patients with stroke.

Criterion:

Concurrent:
No studies have reported on the concurrent validity of the Tardieu Scale or the MTS when used with patients with stroke.

Predictive:
No studies have reported on the predictive validity of the Tardieu Scale or the MTS when used with patients with stroke.

Construct:

Convergent/Discriminant:
Patrick and Ada (2006) evaluated the convergent validity of the Tardieu Scale by comparing it to the Ashworth Scale and electromyography (EMG) measurements of spasticity and contracture in 16 patients with stroke. Correlations were calculated using Fisher exact test and Pearson correlation coefficients. The Tardieu Scale was found to have excellent agreement with EMG for detecting spasticity (kappa = 1.0) and contractures (kappa = 0.88) for both the elbow flexor and ankle plantar flexor muscles. The Ashworth Scale had poor agreement with EMG for detecting spasticity (kappa = 0.24 for elbow flexors and kappa = 0.25 for ankle plantar flexors). In addition, there was an excellent correlation between the Tardieu Scale and EMG measurement of spasticity in the elbow flexor and ankle plantar flexor muscles (r = 0.86, P = 0.001; 0.62, P = 0.001 respectively), whereas there was a poor correlation between the Ashworth Scale and EMG measurements of spasticity in both the elbow flexors and ankle plantar flexors (r = 0.33, P = 0.21; r = 0.15, P = 0.59 respectively). The authors concluded that the Tardieu Scale is better able to identify spasticity and differentiate between spasticity and contracture in the upper and lower extremities than the Ashworth Scale.

Known groups:
No studies have reported on the known groups validity of the Tardieu Scale or the MTS when used with patients with stroke.

Sensitivity/ Specificity:

No studies have reported on the Sensitivity or the Specificity of the Tardieu Scale or the MTS when used with patients with stroke.

Responsiveness

Gracies et al. (2000) assessed the short-term effects of dynamic lycra splints on 16 patients with upper extremity hemiplegia caused by stroke. The treatment regime included wearing the treatment garment for 3 hours on the first day, and no use of the garment on the second day. Patients were assessed using the Tardieu Scale at the beginning and end of the 3-hour treatment on both days. A change in spasticity was detected using the Tardieu R1 (angle of catch) measurement of wrist and finger flexors when patients were re-assessed after wearing the treatment garment for 3 hours (change in mean±SD 120.8°±40.5° to 145.4°±36.9°; and 163.1°±31.5° to 169.2°±25.3° respectively), whereas no change occurred on the subsequent day when the patients did not wear the garment. Although the responsiveness of the Tardieu Scale was not formally assessed in this study, the scale was sensitive enough to detect a decrease in spasticity of the elbow and finger flexors following the application of the garment.

References

  • Ammann, C.M., Kawanami, L.M., Giratalla, M.M., Hoetmer, R.A., Rodriguez, V.J. & Munro, K.K. (2005). Choosing a spasticity outcome measure: A review for the neuromodulation clinic. University of Alberta Health Sciences Journal, 2, 29-32.
  • Boyd, R.N. & Graham, H.K. (1999). Objective measurement of clinical findings in the use of botulinum toxin type A for the management of children with cerebral palsy. European Journal of Neurology, 6 (suppl4), S23-S25.
  • Gracies, J-M., Marosszeky, J. E., Renton, R., Sandanam, J., Gandevia, S.C. & Burke, D. (2000). Short-term effects of dynamic lycra splnts on upper limb in hemiplegic patients. Archives of Physical Medicine and Rehabilitation, 81, 1547-55.
  • Haugh, A.B., Pandyan, A.D. & Johnson, G.R. (2006). A systematic review of the Tardieu Scale for the measurement of spasticity. Disability and Rehabilitation, 28(15), 899-907.
  • Mackey, A.H., Walt, S.E., Lobb, G. & Stott, N.S. (2004). Intraobserver reliability of the Modified Tardieu Scale in the upper limb of children with hemiplegia. Developmental Medicine and Child Neurology, 46, 267-272.
  • Morris, S. (2002). Ashworth and Tardieu Scales: Their clinical relevance for measuring spasticity in adult and paediatric neurological populations. Physical Therapy Reviews, 7, 53-62.
  • Patrick, E. & Alda, L. (2006). The Tardieu Scale differentiates contracture from spasticity whereas the Ashworth Scales is confounded by it. Clinical Rehabilitation, 20, 173-182.
  • Paulis, W.D., Horemans, H.L.D, Brouwer, B.S. & Stam, H.J. (2011). Excellent test-retest and inter-rater reliability for Tardieu Scale measurements with inertial sensors in elbow flexors for stroke patients. Gait & Posture, 33, 185-189.
  • Singh, P. & Joshua, A.M. (2011). Intra-rater reliability of the modified Tardieu scale to quantify spasticity in elbow flexors and ankle plantar flexors in adult stroke subjects. Annals of Indian Academy of Neurology, 14, 23-26.

See the measure

How to obtain the Tardieu Scale and the Modified Tardieu Scale (MTS)?

The following publications present the full Tardieu Scale and/or the MTS:

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