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
  • No studies have examined the internal consistency of the Modified Ashworth Scale.
  • No studies have examined the test-retest reliability of the Modified Ashworth Scale.
  • 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.
  • 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.

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