A review of the properties and limitations of the Ashworth and modified Ashworth Scales as measures of spasticity
TL;DR: The application of both scales would suggest that confusion exists on their characteristics and limitations as measures of spasticity, and there is a need to standardize methods to apply these scales in clinical practice and research.
Abstract: Background: The Ashworth Scale and the modified Ashworth Scale are the primary clinical measures of spasticity. A prerequisite for using any scale is a knowledge of its characteristics and limitations, as these will play a part in analysing and interpreting the data. Despite the current emphasis on treating spasticity, clinicians rarely measure it.Objectives: To determine the validity and the reliability of the Ashworth and modified Ashworth Scales.Study design: A theoretical analysis following a structured literature review (key words: Ashworth; Spasticity; Measurement) of 40 papers selected from the BIDS-EMBASE, First Search and Medline databases.Conclusions: The application of both scales would suggest that confusion exists on their characteristics and limitations as measures of spasticity. Resistance to passive movement is a complex measure that will be influenced by many factors, only one of which could be spasticity. The Ashworth Scale (AS) can be used as an ordinal level measure of resistance to pa...
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TL;DR: The standardized guidelines assured comparability of test administration and scoring across clinical facilities and provided information that was not identical to information from the Hemispheric Stroke Scale or the Modified Barthel Index.
Abstract: Objectives: To establish: (1) inter-rater and test–retest reliability of standardized guidelines for the Fugl-Meyer upper limb section, Action Research Arm Test and Box and Block Test in patients with paresis secondary to stroke, multiple sclerosis or traumatic brain injury and (2) correlation between these arm motor scales and more general measures of impairment and activity limitationDesign: Multicentre cohort studySetting: Three European referral centres for neurorehabilitationSubjects: Thirty-seven stroke, 14 multiple sclerosis and five traumatic brain injury patientsMain measures: Scores of the Fugl-Meyer Test (arm section), Action Research Arm Test, and Box and Block Test derived from video informationResults: All three motor tests showed very high inter-rater and test–retest reliability (ICC and rho for main variables>095) Correlation between the motor scales was very high (rho>092) Motor scales correlated moderately highly with the Hemispheric Stroke Scale, a measure of impairment (rho=0
717 citations
TL;DR: Findings indicate that the focus on spasticity in stroke rehabilitation is out of step with its clinical importance, and careful and continual evaluation to establish the cause of the patient’s disabilities is essential before a decision is made on the most proper rehabilitation approach.
Abstract: Background and Purpose— There is no consensus concerning the number of patients developing spasticity or the relationship between spasticity and disabilities after acute stroke. The aim of the present study was to describe the extent to which spasticity occurs and is associated with disabilities (motor impairments and activity limitations). Methods— Ninety-five patients with first-ever stroke were examined initially (mean, 5.4 days) and 3 months after stroke with the Modified Ashworth Scale for spasticity; self-reported muscle stiffness; tendon reflexes; Birgitta Lindmark motor performance; Nine Hole Peg Test for manual dexterity; Rivermead Mobility Index; Get-Up and Go test; and Barthel Index. Results— Of the 95 patients studied, 64 were hemiparetic, 18 were spastic, 6 reported muscle stiffness, and 18 had increased tendon reflexes 3 months after stroke. Patients who were nonspastic (n=77) had statistically significantly better motor and activity scores than spastic patients (n=18). However, the correlat...
671 citations
TL;DR: The TUG scores were reliable, were able to differentiate the patients from the healthy elderly subjects, and correlated well with plantarflexor strength, gait performance, and walking endurance in subjects with chronic stroke.
580 citations
University of British Columbia1, Craig Hospital2, University of Cambridge3, University of California, San Diego4, Thomas Jefferson University5, Imperial College London6, University of Toronto7, Miami Project to Cure Paralysis8, National Institutes of Health9, University of Queensland10, Acorda Therapeutics, Inc.11, University of California, Los Angeles12, Baylor College of Medicine13, Robert Jones and Agnes Hunt Orthopaedic Hospital14, Keio University15
TL;DR: An international panel reviewed the methodology for clinical trials of spinal cord injury (SCI), and provided recommendations for the valid conduct of future trials, and focused on outcome measures that are relevant toclinical trials of experimental cell-based and pharmaceutical drug treatments.
Abstract: An international panel reviewed the methodology for clinical trials of spinal cord injury (SCI), and provided recommendations for the valid conduct of future trials. This is the second of four papers. It examines clinical trial end points that have been used previously, reviews alternative outcome tools and identifies unmet needs for demonstrating the efficacy of an experimental intervention after SCI. The panel focused on outcome measures that are relevant to clinical trials of experimental cell-based and pharmaceutical drug treatments. Outcome measures are of three main classes: (1) those that provide an anatomical or neurological assessment for the connectivity of the spinal cord, (2) those that categorize a subject's functional ability to engage in activities of daily living, and (3) those that measure an individual's quality of life (QoL). The American Spinal Injury Association impairment scale forms the standard basis for measuring neurologic outcomes. Various electrophysiological measures and imaging tools are in development, which may provide more precise information on functional changes following treatment and/or the therapeutic action of experimental agents. When compared to appropriate controls, an improved functional outcome, in response to an experimental treatment, is the necessary goal of a clinical trial program. Several new functional outcome tools are being developed for measuring an individual's ability to engage in activities of daily living. Such clinical end points will need to be incorporated into Phase 2 and Phase 3 trials. QoL measures often do not correlate tightly with the above outcome tools, but may need to form part of Phase 3 trial measures.
496 citations
TL;DR: Investigation of the frequency of balance disability; to characterize different levels of disability; and to identify demographics, stroke pathology factors, and impairments associated with balance disability found subjects with the most severe balance disability had more severe strokes, impairments, and disabilities.
Abstract: Background and Purpose. Balance disability is common after stroke, but there is little detailed information about it. The aims of this study were to investigate the frequency of balance disability; to characterize different levels of disability; and to identify demographics, stroke pathology factors, and impairments associated with balance disability.
Subjects. The subjects studied were 75 people with a first-time anterior circulation stroke; 37 subjects were men, the mean age was 71.5 years (SD=12.2), and 46 subjects (61%) had left hemiplegia.
Methods. Prospective hospital-based cross-sectional surveys were carried out in 2 British National Health Service trusts. The subjects’ stroke pathology, demographics, balance disability, function, and neurologic impairments were recorded in a single testing session 2 to 4 weeks after stroke.
Results. A total of 83% of the subjects (n=62) had a balance disability; of these, 17 (27%) could sit but not stand, 25 (40%) could stand but not step, and 20 (33%) could step and walk but still had limited balance. Subjects with the most severe balance disability had more severe strokes, impairments, and disabilities. Weakness and sensation were associated with balance disability. Subject demographics, stroke pathology, and visuospatial neglect were not associated with balance disability.
Discussion and Conclusion. Subjects with the most severe balance disability had the most severe strokes, impairments, and disabilities. Subject demographics, stroke pathology, and visuospatial neglect were not associated with balance disability. [Tyson SF, Hanley M, Chillala J, et al. Balance disability after stroke. Phys Ther . 2006;86:30–38.]
465 citations
References
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Book•
01 Jan 1956
TL;DR: This is the revision of the classic text in the field, adding two new chapters and thoroughly updating all others as discussed by the authors, and the original structure is retained, and the book continues to serve as a combined text/reference.
Abstract: This is the revision of the classic text in the field, adding two new chapters and thoroughly updating all others. The original structure is retained, and the book continues to serve as a combined text/reference.
35,552 citations
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01 Jan 1990
TL;DR: In this paper, the authors present a tour of categorical data analysis for Contingency Tables and Logit and Loglinear models for contingency tables, as well as generalized linear models for Matched Pairs.
Abstract: Two--Way Contingency Tables. Three--Way Contingency Tables. Generalized Linear Models. Logistic Regression. Loglinear Models for Contingency Tables. Building and Applying Logit and Loglinear Models. Multicategory Logit Models. Models for Matched Pairs. A Twentieth--Century Tour of Categorical Data Analysis. Appendix. Table of Chi--Squared Distribution Values for Various Right--Tail Probabilities. Bibliography. Indexes.
7,062 citations
TL;DR: The relationship between the raters' judgments was significant and the reliability was good, and it is believed these results to be positive enough to encourage further trials of the modified Ashworth scale for grading spasticity.
Abstract: We undertook this investigation to determine the interrater reliability of manual tests of elbow flexor muscle spasticity graded on a modified Ashworth scale. We each independently graded the elbow flexor muscle spasticity of 30 patients with intracranial lesions. We agreed on 86.7% of our ratings. The Kendall's tau correlation between our grades was .847 (p less than .001). Thus, the relationship between the raters' judgments was significant and the reliability was good. Although the results were limited to the elbow flexor muscle group, we believe them to be positive enough to encourage further trials of the modified Ashworth scale for grading spasticity.
4,788 citations
"A review of the properties and limi..." refers methods in this paper
...…was initially developed as a simple clinical tool to test the efficacy of an anti-spastic drug in patients with multiple sclerosis,12 but later Bohannon and Smith (1987)13 modified the original scale by adding an additional category, a 1+ falling between 1 and 2, with the aim of increasing…...
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Book•
23 Nov 1987
TL;DR: The design of experiments, analysis of the means of small samples using the t-c Distribution, and selection of the statistical method for clinical measurement and the structure of human populations are reviewed.
Abstract: Introduction The design of experiments Sampling and observational studies Summarizing data Presenting data Probability The Normal Distribution Estimation, standard error, and confidence intervals Significance tests Analysis of the means of small samples using the t-c Distribution Choosing the statistical method Clinical measurement Mortality statistics and the structure of human populations Solutions to exercises.
2,245 citations
Book•
01 Jan 1980
TL;DR: In this article, the multivariate normal distribution is used for principal component analysis and multivariate analysis of covariance and related topics, as well as multi-dimensional scaling and cluster analysis.
Abstract: Part One. Multivariate distributions. Preliminary data analysis. Part Two: Finding new underlying variables. Principal component analysis. Factor analysis. Part Three: Procedures based on the multivariate normal distribution. The multivariate normal distribution. Procedures based on normal distribution theory. The multivariate analysis of variance. The multivariate analysis of covariance and related topics. Part Four: Multi-dimensional scaling and cluster analysis. Multi-dimensional scaling. Cluster analysis.
1,856 citations