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:

  • Ansari, Naghdi, Hasson, Azarsa & Azarnia (2008)
  • Boyd & Graham (1999);
  • Gracies et al. (2000);
  • Haugh, Pandyan & Johnson (2006);
  • Morris (2002); and
  • Patrick & Ada (2006).
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