Background: Spasticity following a stroke occurs in about 30% of patients. The mechanisms underlying this disorder, however, are not well understood.Method: This review aims to define spasticity, describe hypotheses explaining its development after a stroke, give an overview of related neuroimaging studies as well as a description of the most common scales used to quantify the degree of spasticity and finally explore which treatments are currently being used to treat this disorder.Results: The lack of consensus is highlighted on the basis of spasticity and the associated absence of guidelines for treatment, use of drugs and rehabilitation programmes.Conclusions: Future studies require controlled protocols to determine the efficiency of pharmacological and non-pharmacological treatments for spasticity. Neuroimaging may help predict the occurrence of spasticity and could provide insight into its neurological basis.

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Spasticity after stroke: Physiology, assessment and treatment

Objective: To assess and to compare the reliability of the Modified Tardieu Scale with the Modified Ashworth Scale in patients with severe brain injury and impaired consciousness.Design: Cross-sectional observational comparison study.Setting: An early rehabilitation centre for adults with neurological disorders.Subjects: Thirty patients with impaired consciousness due to severe cerebral damage of various aetiologies.Measurement protocol: Four experienced physical therapists rated each patient in a randomized order once daily for two consecutive days. Shoulder, elbow, wrist, hip, knee and ankle spasticity were assessed by the use of Modified Tardieu Scale and Modified Ashworth Scale data collection procedures.Main outcome measures: Test - retest and inter-rater reliability (k=kappa value) of the Modified Tardieu Scale and the Modified Ashworth Scale.Results: The test-retest reliability of the Modified Ashworth Scale was moderate to good (k = 0.47-0.62) and of the Modified Tardieu Scale moderate to very goo...

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Reliability of the Modified Tardieu Scale and the Modified Ashworth Scale in adult patients with severe brain injury: a comparison study

Purpose: To characterise clinical assessment methods for spasticity and/or its functional consequences in clinical patient populations at risk to suffer from spasticity. Method: Systematic literature search and manual-based two-step review process of psychometric properties of clinical assessment scales for spasticity and associated phenomena, as well as of functional scales with an association with spasticity. Reviewed psychometric properties included internal consistency, interrater, intrarater as well as retest reliability, construct validity, ecological validity, and responsiveness. Results: Until May 2003 electronic database searches established a reference pool of 4151 references of which 90 references contributed to the review objectives. An additional 20 references were identified by an informal reference search. Twenty-four clinical scales that assess spasticity and/or related phenomena as well as 10 scales for 'active function' and three scales for 'passive function' with an association with spa...

Clinical scales for the assessment of spasticity, associated phenomena, and function: a systematic review of the literature

Measurement of spasticity is a difficult and unresolved problem, partly due to its complexity and the fact that there are many factors involved. In the assessment of spasticity in the pediatric disabled population, methods that are easily used in practice are ordinal scales that still lack reliability. A prospective cross-sectional observational study was planned to determine the reliability of the Ashworth Scale (AS) and the Modified Ashworth Scale (MAS) in children with spastic cerebral palsy (CP). The study included 38 children with spastic diplegic CP. The mean age for the children was 52.9 months (SD: 19.6) ranging from 18 to 108 months. The functional levels of children were classified according to the Gross Motor Function Classification System. 20 children were in Level II (52.6%), 18 were in Level III (47.4%) and 9 were in Level I (23.7%). Spasticity in hip flexors, adductors, internal rotators, hamstrings, gastrocnemius were assessed by AS and MAS. Each child was assessed by three physiotherapists in two different sessions, a week apart. The intrarater reliability was determined by paired comparison of measurements for each therapist for the two assessments. Interrater reliability was determined by paired comparisons of the three therapists' measurements on the same day. The inter and intrarater reliability of the scales were evaluated by the intraclass correlation coefficient (ICC). According to ICC scores, interrater reliability of AS and MAS varied from moderate to good. ICC scores of AS were between 0.54 and 0.78 and MAS were between 0.61–0.87. Test-retest results of AS and MAS varied from poor to good. ICC values were between 0.31 and 0.82 for AS and between 0.36 and 0.83 for MAS. The interrater and intrarater reliability of AS and MAS are related to muscle and joint characters. The repetition of measurements by the same physiotherapist, and experience may not affect reliability. These scales are not very reliable and assessments of spasticity using these scales should be therefore interpreted with great caution.

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Reliability of Ashworth and Modified Ashworth Scales in Children with Spastic Cerebral Palsy

The Modified Ashworth Scale (MAS) is a clinical scale used to assess muscle spasticity. While the evidence indicates that the reliability of the MAS is better in the upper limb and in certain distal muscle groups, no investigation has compared the effect of limbs and muscle groups on the MAS reliability. This study aimed to evaluate the effect of limb and muscle group on the reliability of the MAS in patients with spastic hemiplegia. Thirty subjects with upper and lower limb muscle spasticity were recruited for this trial. Two female experienced physiotherapists participated in this examination of reliability, and rated each patient in a randomized order in a single session. For the intrarater reliability, the second rater repeated the test 1 week later. Shoulder adductor, elbow flexor, wrist flexor, hip adductor, knee extensor, and ankle plantar flexor were tested on the hemiplegic side. Results demonstrated moderate inter (kappa=0.514, SE=0.046, p < 0.001) and intrarater (kappa=0.590, SE=0.051, p<0.001) reliability. For the inter and intrarater reliability, the agreement obtained for the upper and lower limb was similar. In the upper limb, the agreement between raters on the distal wrist flexor was significantly higher than the agreement on the proximal shoulder adductor. In the lower limb, there was a similar agreement between raters on the distal ankle plantar flexor and proximal hip adductor. For within rater, the agreement on the proximal and distal muscles of both limbs was not statistically significant. The Modified Ashworth Scale had moderate reliability. The limbs had no effect on the reliability. The agreement on distal wrist flexor in the upper limb was significantly higher between rater than in the proximal shoulder adductor. The agreement obtained with the MAS was not good, which questions the validity of the measurements.

Michael Corcoran

Papers

Inter- and intrarater reliability of the Ashworth Scale and the Disability Assessment Scale in patients with upper-limb poststroke spasticity.