Reliability of Ashworth and Modified Ashworth scales in children with spastic cerebral palsy

Akmer Mutlu, Ayse Livanelioglu, Mintaze Kerem Gunel, Akmer Mutlu, Ayse Livanelioglu, Mintaze Kerem Gunel

Abstract

Background: 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).

Methods: 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).

Results: 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.

Conclusion: 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.

References

    1. Perin B. Physical therapy for the child with cerebral palsy. In: Tecklin JS, editor. Pediatric Physical Therapy. Philadelphia: JB Lippincott Company; 1989. pp. 68–105.
    1. Engsberg JR, Olree KS, Ross SA, Park TS. Quantitative clinical measure of spasticity in children with Cerebral Palsy. Arch Phys Med Rehabil. 1996;77:594–599. doi: 10.1016/S0003-9993(96)90301-9.
    1. Skinner SR. Direct measurement of spasticity. In: Sussman MD, editor. The Diplegic Child : Evaluation and Management. Rosemont: American Academy of Orthopaedic Surgeon; 1992. pp. 31–44.
    1. Ross SA, Engsberg JR. Relationships between spasticity, strength, gait, and the GMFM-66 in persons with spastic diplegia cerebral palsy. Arch Phys Med Rehabil. 2007;88:1114–1120. doi: 10.1016/j.apmr.2007.06.011.
    1. Engsberg JR, Ross SA, Collins DR, Park TS. Predicting functional change from preintervention measures in selective dorsal rhizotomy. J Neurosurg. 2007;106:282–287.
    1. Katz RT, Rovai GP, Brait C, Rymer WZ. Objective quantification of spastic hypertonia: Correlation with clinical findings. Arch Phys Med Rehabil. 1992;73:339–347. doi: 10.1016/0003-9993(92)90007-J.
    1. Albright AL. Cerebral Palsy and movement disorders. J Child Neurol. 1996;11:29–36.
    1. Bohannan RW, Smith MB. Interrater reliability of a modified ashworth scale of muscle spasticity. Phys Ther. 1987;67:206–207.
    1. Gregson JM, Leathley M, Moore AP, Sharma AK, Smith TL, Watkins CL. Reliability of the tone assessment scale and the modified ashworth scale as clinical tools for assessing poststroke spasticity. Arch Phys Med Rehabil. 1999;80:1013–1016. doi: 10.1016/S0003-9993(99)90053-9.
    1. Chabal C, Schwid HA, Jacobson L. The dynamic flexometer: An instrument for the objective evaluation of spasticity. Anesthesiol. 1991;74:609–612.
    1. Otis JC, Root L, Pamilla JR, Kroll MA. Biomechanical measurement of spastic plantarflexors. Dev Med Child Neurol. 1983;25:60–66.
    1. Haugh AB, Pandyan AD, Johnson GR. A systematic review of the Tardieu Scale for the measurement of spasticity. Disabil Rehabil. 2006;28:899–907. doi: 10.1080/09638280500404305.
    1. Mehrholz J, Wagner K, Meissner D, Grundmann K, Zange C, Koch R, Pohl M. Reliability of the Modified Tardieu Scale and the Modified Ashworth Scale in adult patients with severe brain injury: a comparison study. Clin Rehabil. 2005;19:751–759. doi: 10.1191/0269215505cr889oa.
    1. Wahlquist GI. Evaluation and primary management of spasticity. Nurse Practitioner. 1987;12:27–32. doi: 10.1097/00006205-198703000-00003.
    1. Harris SR, Smith LH, Krukowski L. Goniometric reliability for a child with spastic quadriplegia. J Pediatr Orthop. 1985;5:348–351.
    1. Price R, Bjornson KF, Lehmann JF, McLaughlin JF, Hays RM. Quantitative measurement of spasticity in children with cerebral palsy. Developmental Medicine & Child Neurol. 1991;33:585–595.
    1. Priebe MM, Sherwood AM, Thornby JI, Kharas NF, Markowski J. Clinical assesment of spasticity in spinal cord injury: A multidimensional problem. Arch Phys Med Rehabil. 1996;77:713–716. doi: 10.1016/S0003-9993(96)90014-3.
    1. Ashworth B. Preliminary trial of carisoprodol in multiple sclerosis. Practitioner. 1964;192:540–542.
    1. Fosang AL, Galea MP, McCoy AT, Reddihough DS, Story I. Measures of muscle and joint performance in the lower limb of children with Cerebral Palsy. Dev Med Child Neurol. 2003;45:664–670. doi: 10.1017/S0012162203001245.
    1. Mackey AH, Walt SE, Lobb G, Stott NS. Intraobserver reliability of the modified Tardieu scale in the upper limb of children with hemiplegia. Dev Med Child Neurol. 2004;46:267–272.
    1. Scheinberg A, Hall K, Lam LT, O'Flaherty S. Oral baclofen in children with cerebral palsy: a double-blind cross-over pilot study. J Paediatr Child Health. 2006;42:715–720. doi: 10.1111/j.1440-1754.2006.00957.x.
    1. Pandyan AD, Johnson GR, Price CI, Curless RH, Barnes MP, Rodgers H. A review of the properties and limitations of the Ashworth and modified Ashworth Scales as measures of spasticity. Clin Rehabil. 1999;13:373–383. doi: 10.1191/026921599677595404.
    1. Damiano DL, Quinlivan JM, Owen BF, Payne P, Nelson KC, Abel MF. What does the Ashworth Scale really measure and are instrumented measures more valid and precise? Dev Med Child Neurol. 2002;44:112–118. doi: 10.1017/S0012162201001761.
    1. Young RR. Spasticity: A review. Neurology. 1994;44:12–20.
    1. Katz RT, Rymer WZ. Spastic hypertonia: Mechanisms and measurement. Arch Phys Med Rehabil. 1989;70:144–155.
    1. Allison SC, Abraham LD. Correlation of quantitative measures with the modified ashworth scale in the assessment of plantar flexor spasticity in patients with traumatic brain injury. J Neurol. 1995;242:699–706. doi: 10.1007/BF00866923.
    1. Lin JP, Brown JK, Brotherstone R. Assessment of spasticity in hemiplegic cerebral palsy. II: Distal lower-limb reflex excitability and function. Dev Med Child Neurol. 1994;36:290–303.
    1. Clopton N, Dutton J, Featherston T, Grigsby A, Mobley J, Melvin J. Interrater and intrarater reliability of the modified ashworth scale in children with hypertonia. Pediatr Phys Ther. 2005;17:268–274. doi: 10.1097/01.pep.0000186509.41238.1a.
    1. Sehgal N, McGuire JR. Beyond Ashworth. Electrophysiologic quantification of spasticity. Phys Med Rehabil Clin N Am. 1998;9:949–979.
    1. Brashear A, Zafonte R, Corcoran M, Galvez-Jimenez N, Gracies JM, Gordon MF, McAfee A, Ruffing K, Thompson B, Williams M, Lee CH, Turkel C. Inter-and intrarater reliability of the ashworth scale and the disability assessment scale in patients with upper-limp poststroke spasticity. Arch Phys Med Rehabil. 2002;83:1349–1354. doi: 10.1053/apmr.2002.35474.
    1. Yam WKL, Leung ASM. Intrerrater reliability of modified asworth Scale and modified tardieu scale in children with spastic cerebral palsy. J Child Neurol. 2006;21:1031–1035. doi: 10.1177/7010.2006.00222.
    1. Palisano R, Rosenbaum P, Walter S, Russell D, Wood E, Galuppi B. Development and reliability of a system to classify gross motor function in children with Cerebral Palsy. Dev Med Child Neurol. 1997;39:214–223.
    1. Fleis JL, Cohen J. The equivalence of weighted kappa and the intraclass correlation coefficient as measures of reliability. Educ Psychol Mat. 1973;33:613–619. doi: 10.1177/001316447303300309.
    1. Portney L, Watkins M. Foundations of Clinical research: Applications to Practice. NJ, USA: Prentice Hall Health; 2000.
    1. Wallen MA, O'flaherty SJ, Waugh MC. Functional outcomes of intramuscular botulinum toxin type A in the upper limbs of children with cerebral palsy: a phase II trial. Arch Phys Med Rehabil. 2004;85:192–200. doi: 10.1016/j.apmr.2003.05.008.
    1. O'Dwyer NJ, Ada L, Neilson PD. Spasticity and muscle contracture following stroke. Brain. 1996;119:1737–1749. doi: 10.1093/brain/119.5.1737.
    1. Ellasziw M, Young SL, Woodbury MG, Fleld KF. Statistical methodology for the concurrent assessment of interrater and intrarater reliability: Using goniometric measurements as an example. Phys Ther. 1994;74:777–788.
    1. Haas BM, Bergstrom E, Jamous A, Bennie A. Interrater reliability of the original and of the modified ashworth scale for the assessment of spasticity in patients with spinal cord injury. Spinal Cord. 1996;34:560–564.
    1. Ansari NN, Naghdi S, Moammeri H, Jalaie S. Ashworth scales are unreliable for the assessment of the muscle spasticity. Physiother Theor Pract. 2006;22:119–125. doi: 10.1080/09593980600724188.

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