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BioMed CentralPage 1 of 8(page number not for citation purposes)

BMC Musculoskeletal DisordersResearch article Open Access

Reliability of Ashworth and Modied AshworthScales in Childrenwith Spastic Cerebral PalsyAkmer Mutlu*, Ayse Livanelioglu and Mintaze erem!unelAddress" #acette$e %niversity, &aculty of #ealth 'ciences, (e$artment of Physical )hera$y andRehailitation, +1++, 'aman$azari, Ankara,

)urkey-mail" Akmer Mutlu* . akmer/hacette$e0edu0tr Ayse Livanelioglu . alivanelioglu/yahoo0comMintaze erem !unel . mintaze/hacette$e0edu0tr* Corres$onding author

AbstractBackground Measurement of s$asticity is a di2cult and unresolved $rolem, $artly dueto itscom$le3ity and the fact that there are many factors involved0 4n the assessment ofs$asticity in the$ediatric disaled $o$ulation, methods that are easily used in $ractice are ordinal scalesthat stilllack reliaility0 A $ros$ective cross.sectional oservational study 5as $lanned todetermine thereliaility of the Ash5orth 'cale 6A'7 and the Modied Ash5orth 'cale 6MA'7 in children5iths$astic cereral $alsy 6CP70Methods)he study included 98 children 5ith s$astic di$legic CP0 )he mean age for thechildren

5as :;0< months 6'(" 1


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Conclusion)he interrater and intrarater reliaility of A' and MA' are related to muscleand Dointcharacters0 )he re$etition of measurements y the same $hysiothera$ist, and e3$eriencemay notaect reliaility0 )hese scales are not very reliale and assessments of s$asticity usingthese scalesshould e therefore inter$reted 5ith great caution0

Background'$asticity is one feature of an u$$er motor neurone syndromethat may aect functionality, limit daily livingactivities and diminish Euality of life in children 5ithPulished" 1+ A$ril ;++8BMC Musculoskeletal Disorders ;++8, !">> doi"1+0118F1>?1.;>?>.>Received" ;> Gctoer ;++?Acce$ted" 1+ A$ril ;++8

)his article is availale from" htt$"FF5550iomedcentral0comF1>?1.;>?>F>H ;++8 Mutlu et al licensee IioMed Central Ltd0

)his is an G$en Access article distriuted under the terms of the Creative Commons Attriution License6htt$"FFcreativecommons0orgFlicensesFyF;0+7,5hich $ermits unrestricted use, distriution, and re$roduction in any medium, $rovided the original 5ork is$ro$erly cited0

BMC Musculoskeletal Disorders ;++8, !">> htt$"FF5550iomedcentral0comF1>?1.;>?>F>

Page ; of 8(page number not for citation purposes)s$astic Cereral Palsy 6CP7 J1.:K0 )he assessment of s$asticity

is im$ortant in order to determine eectiveness oftreatment on s$asticity and to $lan medical or surgerya$$lications and also to measure the regulation of tonus,to decide on $hysiothera$y goals, and to encourage thechildren and their families0#o5ever the measurement of s$asticity is a di2cult andunresolved $rolem, $artly due to its com$le3ity and thefact that there are many factors involved JK0 )here aremany dierent assessment methods for s$asticity varying

from clinical ordinal scales to com$le3 electrical ororthotic eEui$ments0-lectro$hysiologic tests, electromyogra$hy, dynamic @e3iometer,s$asticity measurement system, $endulum testand isokinetic dynamometer are all ne e3am$les from$ulished literature although these methods are limitedfor clinical use0 )hey are mostly used for research studiesand it is hard to elicit coo$eration in children J;,.11K0 4nthe assessment of s$asticity, methods that are easily usedin $ractice are measuring the resistance of s$astic musclesto Euantify muscle tone such as the Ash5orth 'cales 6A'7,the Modied Ash5orth 'cales 6MA'7, the )ardieu 'caleand the Modied )ardieu 'cale 6M)'70 )he Ash5orth'cale and MA' measure s$asticity and are a$$lied manuallyto determine the resistance of muscle to $assivestretching 6)ale 470 )he )ardiue and Modied )ardieu'cales are measured at 9 dierent velocities 61, ;, and970 Iy moving the lim at dierent velocities, the


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res$onse to stretch can e more easily gauged since thestretch re@e3 res$onds dierently to velocity0 J8,


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used0 As the reliaility of oth scales are not deniteand there are fe5 studies on younger children, 5e$lanned to conduct this study0 )here is no study in the$ulished literature investigating the reliaility of A' andMA' together in younger children 5ith CP0 )he $ur$ose

of our study 5as to assess the intra and interrater reliailityof the A' and MA', and to e3amine the reliaility ofoth scales in the lo5er e3tremities in children 5ith s$asticCP0MethodsProcedure)he study received ethical a$$roval from #acette$e %niversity-thics Committee and all $arents of the children5ere informed aout the study and their consent 5asotained0 A $ros$ective cross.sectional oservationalstudy 5as conducted on the lo5er lims of 98 s$astic

di$legic children 6? lo5er lims in all7 5hose $arentshad given consent, and 5ho had the inclusion criteria and5ere ale to com$lete the study0 -ight out of 98 childrencould not $artici$ate in the second assessment session as9 children dis$layed an3iety and could not co$e 5ithmeasurement, : children 5ere living out of the city and5ere not ale to attend t5ice0 )herefore the intrarater reliaility5as assessed in 9+ children0)he study included 11 girls, ;? oys, a total of 98 children5ith s$astic di$legic CP0 )he mean age for the children5as :;0< months 6'(" 1?1.;>?>F>Page 9 of 8(page number not for citation purposes)according to the !ross Motor &unction Classication 'ystem6!M&C'7, ;+ children 5ith CP 5ere in Level 446:;0=7, 18 5ere in Level 444 6>?0>=7 and < 5ere in Level4 6;90?=7 J9;K0 Level 4 re$resents the children 5ho can5alk 5ithout restrictions ut have limitations in moreadvanced gross motor skills0 Level 44 re$resents those 5ho

can 5alk 5ithout restrictions ut have limitations 5alkingoutdoors and in the community0 Level 444 re$resents those5ho can 5alk 5ith assistive moility devices ut 5ith limitationsin 5alking outdoors and in the community04nclusion criteria for the study 5ere 6i7 '$astic di$legicty$e of CP 6ii7 having had no ortho$edic surgery, Iotuliniumto3in inDection 6iii7 having had no oral or intrathecealmyorela3ant drugs 6iv7 having had no severe


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limitations in $assive range of motion at lo5er e3tremitiesand 6v7 having had no mental retardation0 -ach child 5asassessed y three $hysiothera$ists in t5o dierent sessionsa 5eek a$art0 )he intrarater reliaility 5as determinedy a $aired com$arison of the measurements for

each thera$ist et5een the t5o assessments0 )he interraterreliaility 5as determined y a $aired com$arison of themeasurements of the three thera$ists on the same day0)he full time e3$erience of the $artici$ating $hysiothera$ists6A,I,C7 5as 1, 1;, 9 years as 5ell as 1>, 8, 9 years in$ediatric rehailitation res$ectively0 All of the measurements5ere taken in the su$ine $osition, the head $osition5as in midline and the resting lim $osition 5asneutral e3ce$t the hi$ e3ternal rotation measurement,taken in the sitting $osition0 )he scores for A' and MA'5ere determined according to the level of resistance during

the $assive movement of the antagonist musclesJ8,


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collected0 Partici$ants 5ere assessed y using A' and MA'J8,K0 MA' and A' scores 5ere considered ordinal and"able # Descriptions of Ashworth and Modied AshworthScales

Ashworth Scale+ o increase in tone1 'light increase in tone giving catch 5hen the lim is moved in @e3ionand e3tension; More marked increase in tone, ut lim is easily @e3ed9 Considerale increases in tone, $assive movement di2cult> Lim rigid in @e3ion or e3tension J1?K0Modifed Ashworth Scale+ o increase in muscle tone1 'light increase in muscle tone, manifested y a catch and release ory minimal resistance at the end of the range of motion 5hen the

aected$art6s7 is6are7 moved in @e3ion or e3tension1Q 'light increase in muscle tone, manifested y a catch follo5ed yminimal resistance through the remainder of the range of motion uttheaected $art6s7 is6are7 easily moved0; More marked increase in muscle tone through most of the range ofmovement, ut the aected $art6s7 is easily moved09 Considerale increases in muscle tone, $assive movement di2cult> Aected $art6s7 is 6are7 rigid in @e3ion or e3tensionBMC Musculoskeletal Disorders ;++8, !">>

htt$"FF5550iomedcentral0comF1>?1.;>?>F>Page > of 8(page number not for citation purposes)a value of 10: for MA' 5as assigned to ratings of 1Q tomaintain eEual intervals J;;K0 )he


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or higher J9>K0 )he soft5are used for all calculations 5as'P'' 110+1 for Oindo5s0Results)he A' and MA' scores of the mean value, the minimumand ma3imum values of A' and MA' are $resented in

)ale ;0Interrater Reliability o AS4CC scores of A' results demonstrated good reliaility forthe rst and second measures of hi$ internal rotators64CC" +08+, +0?87, the rst measure of hamstrings 64CC"+0?87 and only the second measure of hi$ @e3ors 64CC"+0?70 Moderate reliaility 5as found for the rst and secondmeasures of hi$ adductors 5ith knee e3tended 64CC"+08, +0?;7 and $lantar @e3ors 5ith knee e3tended 64CC"+0:?, +0:>7, the rst measure of hi$ @e3ors 64CC" +0?+7and only for the second measure of hamstrings 64CC"

+0I 1 +9 1 +>C 1 +; 1 +9'econd A 1 +9 ; +>I 1 1; 1 1;C 1 +; 1 +9

#i$ &irst A ; +9 ; +>Adductors 6nee e3tended7 I 1 1; ; 19C 1 1; ; 19'econd A ; +; ; +9I 1 1; ; 19C 1 19 ; 1>#i$ 4nternal Rotators &irst A 1 +; ; +9I 1 +; 1 +9C 1 +; ; +9'econd A 1 +; 1 +9I 1 +; 1 +9

C 1 +; ; +9#amstrings &irst A ; 19 9 1>I ; 19 9 1>C ; 19 ; 1>'econd A ; 19 9 1>I ; 19 9 ;>C ; 19 9 1>Plantar &le3ors 6nee e3tended7 &irst A ; 19 9 1>


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I ; 19 9 1>C ; +9 ; +>'econd A ; 19 9 1>I ; 1; 9 1>C ; 19 9 1>

min" minimum maks" ma3imumBMC Musculoskeletal Disorders ;++8, !">>htt$"FF5550iomedcentral0comF1>?1.;>?>F>Page : of 8(page number not for citation purposes)Interrater Reliability o MASMA' results indicated good reliaility for the rst and secondmeasures of hamstrings 64CC" +0?, +0?97 and adductors64CC" +089, +08?7, the rst measure of hi$ internalrotators 64CC" +08>70 Moderate reliaility 5as found forthe rst and second measures of hi$ @e3ors 64CC" +0?1,

+0?>7 and gastrocnemius 64CC" +0>, +087, the secondmeasure of hi$ internal rotators 64CC" +017 and hamstrings64CC" +0?97 6)ale 970Intrarater Reliability o ASAmong three raters, the A' intrarater 4CC scores 5erefound to e ranging from $oor to good 64CC" +091+08;70)he lo5est reliaility 5as +091 et5een the adductormeasurements of rater C and the highest reliaility 5as+08; et5een the hamstring measurements of rater C0 Allscores of raters are demonstrated in )ale >0Intrarater Reliability o MAS

)he scores 5ere $oor to and good 64CC" +09+08970 )helo5est reliaility 5as +09 et5een the hi$ internal rotatormeasurements of rater A and the highest reliaility 5as"able + )nterrater Reliability of Ashworth and ModiedAsworth Scales)nterrater Reliability ,!-. Condence )nter/al0Muscle Measure1ent 2 AS&%OR"& MOD)*)(D AS%OR"i$ &le3ors &irst ?? +0?+ 6+0:?+08+7 +0?1 6+0:8+0817?'econd +

+ +0? 6+0>+08:7 +0?> 6+0++0897+#i$ Adductors 6nee e3tended7 &irst ?? +08 6+0:>+0?


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#i$ 4nternal Rotators &irst ?? +08+ 6+0?++087 +08> 6+0??+08 6+0:;+0?>7?'econd +

+ +0:> 6+09?1.;>?>F>Page of 8(page number not for citation purposes)+089 et5een the hi$ @e3or measurements of rater C0 )heintrarater 4CC scores of MA' are demonstrated in )ale :0Discussion4n the assessment of s$asticity in children 5ith s$astic CP,a numer of ordinal scales such as A', MA' and )ardieu

and M)' are commonly used J;+,91,9:K0 )here is nostudy in the $ulished literature investigating the reliailityof A' and MA' together in younger children 5ith CP,therefore 5e undertook this study0 )o our kno5ledge, thisis the rst study investigating the intra and interrater reliailityof A' and MA' in children 5ith s$astic CP0 A' andMA' measure resistance to $assive movement and thereforemeasure hy$ertonia J9K04n this study, reliaility in hi$ @e3ors, adductors, internalrotators, hamstrings and gastrocnemius muscle grou$s inchildren 5ith s$astic CP 5ere investigated0 )he interrater

reliaility scores of oth A' and MA' 5ere ranged frommoderate to good and the intrarater reliaility scoresranged consideraly from $oor to good0arious factors may aect the measurement results of reliaility0Ohile investigating the reliaility of scales, relatedDoints, anatomic and iomechanical characteristics ofmuscle grou$s as 5ell as interrater and intrarater changeand iological change should e taken into consideration


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J9?K0 Priee et al determined that lo5 reliaility results ofordinal scales are related to $rolems 5hich occur duringthe measurement of s$asticity as 5ell as the environmentand general condition of the $atient J1?K04n order to eliminate these negative factors in our study,

an a$$ro$riate environment regulation, the comfort ofthe children, the rela3ation of the children, and interval$eriods et5een measurements 5ere $rovided0 Iesides,due to its nature, s$asticity is sensitive to $assive stretchingand velocity may aect clinical features0 As $assivestretching is considered to aect the follo5ing measurementresults, measurements 5ere re$eated once on t5odierent days of the study0 )o minimize the disadvantageof the stretching of the s$astic muscle, fast stretching 5asavoided0 )he measurement criteria 5ere standardized y a$ilot study $reviously0 )he $hysiothera$ists $erformed

measurements in the same order and gave reaks et5eenthe measurement of the testers in order to avoid the eectof stretching04n our study, the 4CC scores of interrater reliaility rangedfrom +0:> to +08+ and the intrarater reliaility from +091to +08;, the gastrocnemius muscle had the lo5est value inA', and the interrater reliaility of MA' 5as et5een+0>+08?, 5hile the intrarater reliaility 5as et5een+0>1+0890 4t may e that there is a relation to A' andMA'0 Oe 5ere not sur$rised to see that the inter reliaility5as higher than the intratester reliaility0 )his conrms

that these scales should e inter$reted 5ith great cautionand indicates that even the same rater has the $ossiilityof making an error0 )he re$etition of measurements y thesame $hysiothera$ist, and e3$erience may not aect reliailityas 5e mentioned in the conclusion of our study0Although the interrater reliaility of A' and MA' 5eresimilar in our study, the intrarater reliaility of MA' had"able 3 )ntrarater Reliability of Ashworth Scale)ntrarater Reliability ,!-. Condence )nter/al0 24 567ariable tested A B C#i$ &le3ors +01 6+0>;+0?>7 +0>> 6+0;1+0;7 +0:8 6+098+0?;7

#i$ Adductors 6nee e3tended7 +0?9 6+0:+0?7 +0916+0++0:;7#i$ 4nternal Rotators +0+ 6+0>;+0?>7 +098 6+01:+0:87 +0:< 6+09< 6+0;?+07 +0? 6+0:++0?87 +08; 6+0?;+08? 6+0;:+0>7 +0>; 6+018+0+7 +0>9 6+0;++0;7"able - )ntrarater Reliability of Modied Ashworth Scale)ntrarater Reliability ,!-. Condence )nter/al0 24 56


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7ariable tested A B C#i$ &le3ors +0?> 6+01+08>7 +0>9 6+0;++017 +089 6+0?>+08 6+0++0897 +0; 6+0>9+0?:7 +0?86+0:+087#i$ 4nternal Rotators +09 6+01;+0:7 +0>1 6+018+0+7 +0? 6+09

+08:7#amstrings +0: 6+09+0?17 +0:> 6+099+0+08+7!astrocnemius +0: 6+09+0?17 +0?+ 6+0:>+08+7 +08 6+0:1+0??1.;>?>F>Page ? of 8(page number not for citation purposes)higher scores than the intrarater reliaility of A'0 )hisresult may arise from the common use of MA' in $racticey raters 5ho had e3$erience in $ediatric $hysiothera$y0&osang stated that MA' had etter intrarater reliaility

com$ared to interrater reliaility and it should only eused y a single rater for the same $artici$ant rather thandierent raters J1


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MA' in $atients 5ith stroke and re$orted no dierence forthe interrater reliaility et5een A' and MA' J9


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;0 -ngserg R, Glree ', Ross 'A, Park )'" ;uantitati/e clinical1easure of spasticity in children with Cerebral Palsy:ArchPhys Med Rehabil 1


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BMC Musculoskeletal Disorders ;++8, !">>htt$"FF5550iomedcentral0comF1>?1.;>?>F>Page 8 of 8(page number not for citation purposes)1;0 #augh AI, Pandyan A(, ohnson !R" A syste1atic re/iew of the

"ardieu Scale for the 1easure1ent of spasticity: Disabil Rehabil;++, $@8


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Child $eurol ;++;, 3311;.1180;>0 Noung RR" Spasticity A re/iew: $eurology 1


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9?0 -llaszi5 M, Noung 'L, Ooodury M!, &leld &" Statistical1ethodologyfor the concurrent assess1ent of interrater and intraraterreliability Gsing gonio1etric 1easure1ents as anea1ple: Phys Ther 1?1.;>?>F>F$re$u

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