Composite Spasticity Index (CSI)

Purpose

The Composite SpasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
Index (CSI) provides a clinical measure of spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
that can be used with patients with hemiparesis following strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

In-Depth Review

Purpose of the measure

The Composite SpasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
Index (CSI) s a measure of upper and lower extremity spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
that is suitable for use with patients with hemiparesis following strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More.

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 SpasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
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 spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
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 spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
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 spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
, which is defined by the following levels according to clinical experience:

0 – 9 = mild spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.

10 – 12 = moderate spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.

13 – 16 = severe spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.

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 SpasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
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 spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
; scores of 5 – 9 indicate moderate spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
; and a score of 10 or greater indicates severe spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
(Jobin & Levin, 2000; Scholtes et al., 2006).

Client suitability

Can be used with:

• Patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More (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?	SpasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
What types of clients can the tool be used for?	Patients with hemiparesis following strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More as well as cerebral palsy and spinal cord injury.
Is this a screeningTesting for disease in people without symptoms. or assessment tool?	Assessment
Time to administer	Not reported
Versions	Composite SpasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke. Index Modified Composite SpasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke. Index
Other Languages	N/A
Measurement Properties
ReliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of “true” variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to “noise” in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .	Internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. More: Two studies examined the internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. More of the CSI: one study reported an excellent correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation. between the total spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke. score and resistance to passive stretch and clonus; one study reported adequate internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. More using Cronbach’s coefficient alpha. Test-retest: One study reported excellent test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society). of the CSI; one study reported excellent test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society). of the Composite SpasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke. Scale. Intra-rater: No studies have reported on the intra-rater reliabilityThis is a type of reliability assessment in which the same assessment is completed by the same rater on two or more occasions. These different ratings are then compared, generally by means of correlation. Since the same individual is completing both assessments, the rater’s subsequent ratings are contaminated by knowledge of earlier ratings. of the CSI. Inter-rater: No studies have reported on the inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept. of the CSI.
ValidityThe degree to which an assessment measures what it is supposed to measure.	Content: One study reported that the three items of the CSI are relevant to assess spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke. in strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More. Criterion: Concurrent: Three studies have reported on the concurrent validityTo validate a new measure, the results of the measure are compared to the results of the gold standard obtained at approximately the same point in time (concurrently), so they both reflect the same construct. This approach is useful in situations when a new or untested tool is potentially more efficient, easier to administer, more practical, or safer than another more established method and is being proposed as an alternative instrument. See also “gold standard.” of the CSI: two studies reported excellent negative relationships between clinical spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke. 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 validityA form of criterion validity that examines a measure’s ability to predict some subsequent event. Example: can the Berg Balance Scale predict falls over the following 6 weeks? The criterion standard in this example would be whether the patient fell over the next 6 weeks. of the CSI. Construct: Convergent/Discriminant: Two studies examined the convergent validityA type of validity that is determined by hypothesizing and examining the overlap between two or more tests that presumably measure the same construct. In other words, convergent validity is used to evaluate the degree to which two or more measures that theoretically should be related to each other are, in fact, observed to be related to each other. of the Composite SpasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke. Index and the Fugl-Meyer Assessment (FMA). One study found an excellent negative correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation. using Spearman rank-order statistics, whereas the other study found no significant relationships between the two measures using Pearson product moment correlationThe most commonly used method of computing a correlation coefficient between variables that are linearly related. Pearson’s r is a measure of association which varies from -1 to +1, with 0 indicating no relationship (random pairing of values) and 1 indicating perfect relationship statistics. One study examined the convergent validityA type of validity that is determined by hypothesizing and examining the overlap between two or more tests that presumably measure the same construct. In other words, convergent validity is used to evaluate the degree to which two or more measures that theoretically should be related to each other are, in fact, observed to be related to each other. of the Composite SpasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke. Scale with other measures using Spearman correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation. coefficients and reported an adequate negative correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation. between ankle plantar flexor spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke. 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 gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety. parameters (velocity, cadence and step length and stance time of the unaffected leg). Known Group: One study examined known groups validityKnown groups validity is a form of construct validation in which the validity is determined by the degree to which an instrument can demonstate different scores for groups know to vary on the variables being measured. of the Composite SpasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke. Scale and reported a significant difference in spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke. between patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More and healthy elderly subjects.
Floor/Ceiling Effects	No studies have examined the floor or ceiling effects of the CSI in clients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.
SensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also “Specificity.” / SpecificitySpecificity refers to the probability that a diagnostic technique will indicate a negative test result when the condition is absent (true negative).	No studies have reported on the sensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also “Specificity.” or specificitySpecificity refers to the probability that a diagnostic technique will indicate a negative test result when the condition is absent (true negative). of the CSI.
Does the tool detect change in patients?	No studies have formally examined the responsivenessThe ability of an instrument to detect clinically important change over time. of the CSI.
Acceptability	The CSI is commonly used in the assessment of spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke. in adults. It is an acceptable measure of spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke. in strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.
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 SpasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
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 strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More. Four studies reported on the psychometric properties of the CSI; one study that reported on the psychometric properties of the Composite SpasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
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 strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More. However, it is unlikely that this tool would be appropriate for floor and ceiling evaluation.

Reliability

Internal ConsistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. More:
Levin & Hui-Chan (1993) administered the CSI over three trials with 10 patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More and hemiparesis and 7 healthy subjects. Data was calculated using Pearson correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
coefficients and was provided for two of three trials. The total spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
score had an excellent correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order 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 correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order 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 consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. More of the CSI with 19 adults with acute to chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More. Internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. More 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 reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
of the CSS in 10 healthy elderly adults and 10 patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More and reported excellent test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
using Intraclass Correlation Coefficient (ICC)Intraclass correlation (ICC) is used to measure inter-rater reliability for two or more raters. It may also be used to assess test-retest reliability. ICC may be conceptualized as the ratio of between-groups variance to total variance. (ICC = 0.97 and 0.80 for affected and unaffected limbs, respectively, of patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More; ICC = 0.80 for both left and right limbs of health adults).

Levin & Hui-Chan (1993) assessed the test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
of the CSI in 10 patients with spastic hemiparesis and strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More over three testing occasions and reported excellent test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
(r = 0.87) using Intraclass CorrelationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
Coefficients (ICC).

Intra-rater:
No studies have examined the intra-rater reliabilityThis is a type of reliability assessment in which the same assessment is completed by the same rater on two or more occasions. These different ratings are then compared, generally by means of correlation. Since the same individual is completing both assessments, the rater’s subsequent ratings are contaminated by knowledge of earlier ratings.
of the CSI.

Inter-rater:
No studies have examined the inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
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 spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
. In a sample with 19 patients with acute to chronic strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More, 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 spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
in strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More.

Criterion :

Concurrent :
Levin et al. (2000) examined the correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
between clinical spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
and the stretch reflex threshold range for elbow flexor and extensor muscles in 12 patients with hemiparetic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More, using Spearman rank order statistics. An excellent negative correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
was found between clinical spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
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 spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
from hemiparetic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More have more severe limitations in the range in which flexor and extensor stretch reflex thresholds can be regulated. There was also an excellent negative correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order 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 spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
with values of static stretch reflex thresholds in elbow flexors, using Pearson Product Moment correlationThe most commonly used method of computing a correlation coefficient between variables that are linearly related. Pearson’s r is a measure of association which varies from -1 to +1, with 0 indicating no relationship (random pairing of values) and 1 indicating perfect relationship
statistics. Clinical spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
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 spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
(CSI) and static stretch reflex excitability alone (r = -0.652, p<0.05). These results indicate validityThe degree to which an assessment measures what it is supposed to measure.
for quantification of spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
in elbow flexors (Jobin & Levin, 2000).

Levin & Hui-Chan (1993) examined the correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
between clinical spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
and altered reflex function in 10 patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More 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 inhibitionThe ability to suppress automatic actions that are inappropriate in a given context that interfere with a certain behavior (Grieve & Gnanasekaran, 2008)
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 validityA form of criterion validity that examines a measure's ability to predict some subsequent event. Example: can the Berg Balance Scale predict falls over the following 6 weeks? The criterion standard in this example would be whether the patient fell over the next 6 weeks.
of the CSI when used with patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More.

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 gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
parameters (velocity, cadence and step length and stance time of the affected and unaffected legs), using Spearman correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
coefficients. An

Levin et al. (2000) found an excellent negative correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
between clinical spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
and the Fugl-Meyer Assessment (FMA) (r=-0.86, p<0.005), using Spearman rank order statistics.

Levin & Feldman (1994) compared clinical spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
(measured using the CSI) and the FMA, using Pearson product moment correlationThe most commonly used method of computing a correlation coefficient between variables that are linearly related. Pearson’s r is a measure of association which varies from -1 to +1, with 0 indicating no relationship (random pairing of values) and 1 indicating perfect relationship
statistics. No significant relationships were seen between clinical spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
and clinical motor function.

Known groups:
Ng & Hui-Chan (2005) investigated the known-group validityThe degree to which an assessment measures what it is supposed to measure.
of the CSS in 10 healthy elderly subjects and 11 patients with chronic strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More. Ankle plantar flexor spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
, measured by the CSS, was significantly higher in the affected leg of patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More than the mean scores of both legs in healthy elderly subjects (p<0.001). Within the group of patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More, ankle plantar flexor spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
was significantly higher in the affected leg than the unaffected leg (p<0.001).

Responsiveness

The responsivenessThe ability of an instrument to detect clinically important change over time.
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 spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
in 13 patients with spastic hemiparesis following strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More. 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 spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
among patients who received TENS (at 2 weeks treatment only), and a significant difference in spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
between patients who received TENS and the control group who received placebo stimulation (p<0.05).

SensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also “Specificity.”
/ SpecificitySpecificity refers to the probability that a diagnostic technique will indicate a negative test result when the condition is absent (true negative).
:
No studies have reported on the sensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also “Specificity.”
or the specificitySpecificity refers to the probability that a diagnostic technique will indicate a negative test result when the condition is absent (true negative).
of the CSI when used with patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

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 SpasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
Index.