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 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.
for use with patients with neurological conditions. When using the Tardieu Scale or MTS, 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.
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 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 patients with neurological conditions. The Tardieu Scale and MTS quantify 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.
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 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.
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 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.
(Morris, 2002).

The ability of the Ashworth Scales to 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.
has been questioned and some publications suggest that they measure abnormal tone or resistance to passive stretch rather than 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.
because they do not take into account the velocity-dependent component 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.
. 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 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.
(Paulis, Horemans, Brouwer & Stam, 2011).

Available versions

Tardieu et al. (1954) first suggested the technique 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.
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 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.
.

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 (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 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 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.
.

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 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 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 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.
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 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?	The MTS can be used with, but is not limited to 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.
Is this a screeningTesting for disease in people without symptoms. 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
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: No studies have examined the internal constency of the MTS 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. Test-retest: One study examined 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 Tardieu Scale and found 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 both inertial sensors and goniometry. Intra-rater: Two studies 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 MTS and reported adequate to excellent 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. using kappa statistics. Inter-rater: One study 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 Tardieu Scale using inertial sensors and goniometry. Adequate to excellent 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. was found using goniometry and inertial sensors respectively, as calculated 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.. Two studies 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 MTS and reported poor to adequate 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. using kappa and ICC.
ValidityThe degree to which an assessment measures what it is supposed to measure.	Content: No studies have examined the content validityRefers to the extent to which a measure represents all aspects of a given social concept. Example: A depression scale may lack content validity if it only assesses the affective dimension of depression but fails to take into account the behavioral dimension. of the Tardieu Scale or the MTS 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. Criterion: Concurrent: No studies have examined 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 Tardieu Scale or the MTS 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. Predictive: No studies have examined 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 Tardieu Scale or the MTS 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. Construct: Convergente/Discriminant: 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 Tardieu Scale and reported 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 Tardieu Scale and electromyography (EMG) measurements 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. and contracture. Known Group: No studies have examined the 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 Tardieu Scale or MTS 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 examined 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.” /specificity of the Tardieu Scale or MTS 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.
Floor/Ceiling Effects	No studies have examined the floor or ceiling effects of the Tardieu Scale or MTS 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.
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 Tardieu Scale or MTS. However, the Tardieu Scale was found to be sensitive enough to detect change in patients undergoing treatment for 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 one study.
Acceptability	The MTS 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 children. In adults, it has been suggested to be a more accurate and 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 . 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. 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 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. 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 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.

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:
No studies have reported on the internal constancy of the Tardieu Scale or the MTS 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.

Test-rested:
Paulis et al. (2011) evaluated and compared 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 Tardieu Scale measurements using goniometry and inertial sensors (IS). Two therapists each assessed 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 elbow flexors in 13 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 using goniometry and IS, on two separate occasions (30 minutes apart). 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 Tardieu Scale as calculated 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. 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 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).
when both goniometry and IS were used.

Intra-rater:
Mehrholz, Wagner, Meibner, Grundmann, and Zange (2005) investigated 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 MTS and the Modified Ashworth Scale in 30 clients with severe cerebral damage resulting from 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 (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 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 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 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 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 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 MTS in 91 patients with subacute 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. 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 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.
using the MTS). 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 MTS, as calculated 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., 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 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 MTS and the Modified Ashworth Scale in 30 clients with severe cerebral damage resulting from 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 (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 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.
, 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 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 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 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 MTS in 30 patients with hemiplegiaComplete paralysis of the arm, leg, and trunk on one side of the body that results from damage to the parts of the brain that control muscle movements. Hemiplegia is not a progressive condition, nor is it a disease. caused by 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 (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 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 MTS measures, as calculated 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., 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 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.
.

Paulis et al. (2011) evaluated and compared 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 Tardieu Scale measurements using goniometry and inertial sensors (IS). Two therapists each assessed 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 elbow flexors in 13 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 on two separate occasions (30 minutes apart). 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 Tardieu Scale using IS, as calculated 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., was excellent (0.84), whereas 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.
using goniometry was only adequate (0.66). 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 passive range of motion (ROM) using IS was excellent and equivalent to goniometry (ICC=0.89 for both). 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 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 validityRefers to the extent to which a measure represents all aspects of a given social concept. Example: A depression scale may lack content validity if it only assesses the affective dimension of depression but fails to take into account the behavioral dimension.
of the Tardieu Scale or the MTS 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.

Criterion:

Concurrent:
No 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 Tardieu Scale or the MTS 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.

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 Tardieu Scale or the MTS 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:
Patrick and Ada (2006) evaluated 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 Tardieu Scale by comparing it to the Ashworth Scale and electromyography (EMG) measurements 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.
and contracture in 16 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. Correlations were calculated using Fisher exact test and 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. The Tardieu Scale was found to have excellent agreement with EMG for detecting 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.
(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 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.
(kappa = 0.24 for elbow flexors and kappa = 0.25 for ankle plantar flexors). In addition, there was 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 Tardieu Scale and EMG measurement 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 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 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 Ashworth Scale and EMG measurements 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 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 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 differentiate between 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 contracture in the upper and lower extremities than the Ashworth Scale.

Known groups:
No studies have reported on the 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 Tardieu Scale or the MTS 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.

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 Tardieu Scale or the MTS 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.

Responsiveness

Gracies et al. (2000) assessed the short-term effects of dynamic lycra splints on 16 patients with upper extremity hemiplegiaComplete paralysis of the arm, leg, and trunk on one side of the body that results from damage to the parts of the brain that control muscle movements. Hemiplegia is not a progressive condition, nor is it a disease. caused by 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 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 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 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 responsivenessThe ability of an instrument to detect clinically important change over time.
of the Tardieu Scale was not formally assessed in this study, the scale was sensitive enough to detect a decrease 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.
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).