BioMed Central

Page 1 of 8
(page number not for citation purposes)
BMC Musculoskeletal Disorders
Research article Open Access
Reliability of Ashworth and Modifed Ashworth
Scales in Children
with Spastic Cerebral Palsy
Akmer Mutlu*, Ayse Livanelioglu and Mintaze erem
!unel
Address" #acette$e %niversity, &aculty of #ealth 'ciences, (e$artment of Physical )hera$y and
Reha*ilitation, +,1++, 'aman$azari, Ankara,
)urkey
-mail" Akmer Mutlu* . akmer/hacette$e0edu0tr1 Ayse Livanelioglu . alivanelioglu/yahoo0com1
Mintaze erem !unel . mintaze/hacette$e0edu0tr
* Corres$onding author
Abstract
Background Measurement of s$asticity is a di2cult and unresolved $ro*lem, $artly due
to its
com$le3ity and the fact that there are many factors involved0 4n the assessment of
s$asticity in the
$ediatric disa*led $o$ulation, methods that are easily used in $ractice are ordinal scales
that still
lack relia*ility0 A $ros$ective cross.sectional o*servational study 5as $lanned to
determine the
relia*ility of the Ash5orth 'cale 6A'7 and the Modi8ed Ash5orth 'cale 6MA'7 in children
5ith
s$astic cere*ral $alsy 6CP70
Methods )he study included 98 children 5ith s$astic di$legic CP0 )he mean age for the
children
5as :;0< months 6'(" 1<0,7 ranging from 18 to 1+8 months0 )he functional levels of
children 5ere
classi8ed according to the !ross Motor &unction Classi8cation 'ystem0 ;+ children 5ere in
Level
44 6:;0,=7, 18 5ere in Level 444 6>?0>=7 and < 5ere in Level 4 6;90?=70 '$asticity in hi$
@e3ors,
adductors, internal rotators, hamstrings, gastrocnemius 5ere assessed *y A' and MA'0
-ach child
5as assessed *y three $hysiothera$ists in t5o diAerent sessions, a 5eek a$art0 )he
intrarater
relia*ility 5as determined *y $aired com$arison of measurements for each thera$ist for
the t5o
assessments0 4nterrater relia*ility 5as determined *y $aired com$arisons of the three
thera$istsB
measurements on the same day0 )he inter and intrarater relia*ility of the scales 5ere
evaluated *y
the intraclass correlation coe2cient 64CC70
Results According to 4CC scores, interrater relia*ility of A' and MA' varied from
moderate to
good0 4CC scores of A' 5ere *et5een +0:> and +0?8 and MA' 5ere *et5een +0,1C+08?0
)estretest
results of A' and MA' varied from $oor to good0 4CC values 5ere *et5een +091 and +08;
for A' and *et5een +09, and +089 for MA'0
Conclusion )he interrater and intrarater relia*ility of A' and MA' are related to muscle
and Doint
characters0 )he re$etition of measurements *y the same $hysiothera$ist, and e3$erience
may not
aAect relia*ility0 )hese scales are not very relia*le and assessments of s$asticity using
these scales
should *e therefore inter$reted 5ith great caution0
Background
'$asticity is one feature of an u$$er motor neurone syndrome
that may aAect functionality, limit daily living
activities and diminish Euality of life in children 5ith
Pu*lished" 1+ A$ril ;++8
BMC Musculoskeletal Disorders ;++8, !">> doi"1+0118,F1>?1.;>?>.<.>>
Received" ;> Gcto*er ;++?
Acce$ted" 1+ A$ril ;++8
)his article is availa*le from" htt$"FF5550*iomedcentral0comF1>?1.;>?>F<F>>
H ;++8 Mutlu et al1 licensee IioMed Central Ltd0
)his is an G$en Access article distri*uted under the terms of the Creative Commons Attri*ution License
6htt$"FFcreativecommons0orgFlicensesF*yF;0+7,
5hich $ermits unrestricted use, distri*ution, and re$roduction in any medium, $rovided the original 5ork is
$ro$erly cited0
BMC Musculoskeletal Disorders ;++8, !">> htt$"FF5550*iomedcentral0comF1>?1.;>?>F<F>>
Page ; of 8
(page number not for citation purposes)
s$astic Cere*ral Palsy 6CP7 J1.:K0 )he assessment of s$asticity
is im$ortant in order to determine eAectiveness of
treatment on s$asticity and to $lan medical or surgery
a$$lications and also to measure the regulation of tonus,
to decide on $hysiothera$y goals, and to encourage the
children and their families0
#o5ever the measurement of s$asticity is a di2cult and
unresolved $ro*lem, $artly due to its com$le3ity and the
fact that there are many factors involved J,K0 )here are
many diAerent assessment methods for s$asticity varying
from clinical ordinal scales to com$le3 electrical or
orthotic eEui$ments0
-lectro$hysiologic tests, electromyogra$hy, dynamic @e3iometer,
s$asticity measurement system, $endulum test
and isokinetic dynamometer are all 8ne e3am$les from
$u*lished literature although these methods are limited
for clinical use0 )hey are mostly used for research studies
and it is hard to elicit coo$eration in children J;,,.11K0 4n
the assessment of s$asticity, methods that are easily used
in $ractice are1 measuring the resistance of s$astic muscles
to Euantify muscle tone such as the Ash5orth 'cales 6A'7,
the Modi8ed Ash5orth 'cales 6MA'7, the )ardieu 'cale
and the Modi8ed )ardieu 'cale 6M)'70 )he Ash5orth
'cale and MA' measure s$asticity and are a$$lied manually
to determine the resistance of muscle to $assive
stretching 6)a*le 470 )he )ardiue and Modi8ed )ardieu
'cales are measured at 9 diAerent velocities 6L1, L;, and
L970 Iy moving the lim* at diAerent velocities, the
res$onse to stretch can *e more easily gauged since the
stretch re@e3 res$onds diAerently to velocity0 J8,<,1;.1<K0
)he A', MA', )ardieu and Modi8ed )ardieu 'cales are
commonly used in children 5ith CP J;+,;1K0
)he a$$lication of ordinal scales indicates that they still
lack relia*ility and have some limitations in measuring
s$asticity0 )he scales oAer Eualitative and su*Dective information,
concerning validity and relia*ility J<,;;,;9K0
)he A' and MA' need no eEui$ment1 they are easily and
commonly used in the clinic J;,8,<,;>.;,K0 #o5ever,
these scales have some disadvantages *ecause they are not
standardized, stimulus is not 5ell controlled, and also
they have no relia*ility and validity for all muscle grou$s0
)hey are not easily used statistically as they include
numerical values J;,9,8,<,1,,;?K0
4n the study conducted *y Iohannon and 'mith, the relia*ility
of A' in el*o5 @e3ors in $atients 5ith stroke 5as
assessed and found relia*le J8K0 )he relia*ility of A' ve
MA' is *etter in the u$$er lim*0 )he relia*ility of lo5er
e3tremities has controversial results and has demonstrated
lo5 relia*ility in children 5ith s$astic CP in a fe5
studies $u*lished J;,1,,;?K0 Cla$ton et al0 investigated
the interrater and intrarater relia*ility of MA' in el*o5
@e3ors, hi$ adductors, Euadrice$s, hamstrings, gastrocnemius
and soleus of 1? children 5ith hy$ertonus0 -l*o5
@e3ors and hamstrings had good 4CC values of interrater
relia*ility 5hile $oor interrater relia*ility in other muscles
5as o*served0 #amstrings had good intrarater relia*ility
5hile the other muscles had moderate relia*ility J;8K0
&osang et al0 investigated relia*ility of MA', $assive range
of motion 6PRGM7 and M)' in 1, children 5ith CP0 All
measurements 5ere re$eated t5ice *y si3 raters0 )he interrater
relia*ility for PRGM and M)' $rovided acce$ta*le
intra class correlation coe2cient values, *ut the results for
MA' 5ere lo5er J1<K0 4n the studies analyzing the relia*ility
of A', 'ehgal re$orted that A' had a limited and lo5
relia*ility0 Pandyan et al0 found that interrater relia*ility
of A' should *e addressed and Irashear et al found
MgoodM inter and interrater relia*ility results of A' in
$atients 5ith stroke J;;,;<,9+K0 Nam and Leung investigated
the relia*ility of MA' and M)' in children 5ith
s$astic CP0 )he intraclass correlation coe2cients of *oth
scales 5ere lo5 and did not reach the acce$ta*le limit of
+0?:0 Caution should *e used 5hen these scales are
a$$lied J91K0
A' and MA' are common to clinical $ractice and are freEuently
used0 As the relia*ility of *oth scales are not de8nite
and there are fe5 studies on younger children, 5e
$lanned to conduct this study0 )here is no study in the
$u*lished literature investigating the relia*ility of A' and
MA' together in younger children 5ith CP0 )he $ur$ose
of our study 5as to assess the intra and interrater relia*ility
of the A' and MA', and to e3amine the relia*ility of
*oth scales in the lo5er e3tremities in children 5ith s$astic
CP0
Methods
Procedure
)he study received ethical a$$roval from #acette$e %niversity
-thics Committee and all $arents of the children
5ere informed a*out the study and their consent 5as
o*tained0 A $ros$ective cross.sectional o*servational
study 5as conducted on the lo5er lim*s of 98 s$astic
di$legic children 6?, lo5er lim*s in all7 5hose $arents
had given consent, and 5ho had the inclusion criteria and
5ere a*le to com$lete the study0 -ight out of 98 children
could not $artici$ate in the second assessment session as
9 children dis$layed an3iety and could not co$e 5ith
measurement, : children 5ere living out of the city and
5ere not a*le to attend t5ice0 )herefore the intrarater relia*ility
5as assessed in 9+ children0
)he study included 11 girls, ;? *oys, a total of 98 children
5ith s$astic di$legic CP0 )he mean age for the children
5as :;0< months 6'(" 1<0,7 ranging from 18 to 1+8
months0 )he functional level of $artici$ants 5as classi8ed
BMC Musculoskeletal Disorders ;++8, !">>
htt$"FF5550*iomedcentral0comF1>?1.;>?>F<F>>
Page 9 of 8
(page number not for citation purposes)
according to the !ross Motor &unction Classi8cation 'ystem
6!M&C'7, ;+ children 5ith CP 5ere in Level 44
6:;0,=7, 18 5ere in Level 444 6>?0>=7 and < 5ere in Level
4 6;90?=7 J9;K0 Level 4 re$resents the children 5ho can
5alk 5ithout restrictions *ut have limitations in more
advanced gross motor skills0 Level 44 re$resents those 5ho
can 5alk 5ithout restrictions *ut have limitations 5alking
outdoors and in the community0 Level 444 re$resents those
5ho can 5alk 5ith assistive mo*ility devices *ut 5ith limitations
in 5alking outdoors and in the community0
4nclusion criteria for the study 5ere1 6i7 '$astic di$legic
ty$e of CP1 6ii7 having had no ortho$edic surgery, Iotulinium
to3in inDection1 6iii7 having had no oral or intratheceal
myorela3ant drugs1 6iv7 having had no severe
limitations in $assive range of motion at lo5er e3tremities
and 6v7 having had no mental retardation0 -ach child 5as
assessed *y three $hysiothera$ists in t5o diAerent sessions
a 5eek a$art0 )he intrarater relia*ility 5as determined
*y a $aired com$arison of the measurements for
each thera$ist *et5een the t5o assessments0 )he interrater
relia*ility 5as determined *y a $aired com$arison of the
measurements of the three thera$ists on the same day0
)he full time e3$erience of the $artici$ating $hysiothera$ists
6A,I,C7 5as 1,, 1;, 9 years as 5ell as 1>, 8, 9 years in
$ediatric reha*ilitation res$ectively0 All of the measurements
5ere taken in the su$ine $osition, the head $osition
5as in midline and the resting lim* $osition 5as
neutral 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 muscles
J8,<,;9K0 )he muscle grou$s tested 5ere hi$ @e3ors,
adductors 6knee e3tended7, internal rotators of hi$, hamstrings
and $lantar @e3ors 6knee e3tended7, 6)a*le 170
A $ilot study 5as $erformed to reach an agreement among
the $hysiothera$ists a*out the scoring of A' and MA', the
$ositioning of the $atient and also for agreement on
s$eed of movement, num*er of re$etitions of movement
$er Doint, and the order of testing for the muscles in the
lo5er e3tremities0 Gne re$etition 5as done $er Doint0 )he
three $hysiothera$ists agreed on an o$timum s$eed0
Assessments 5ere $erformed *y the three $hysiothera$ists
6A, I, C7 in the same order, in a Euiet room 5hen the $artici$ants
5ere calm and rela3ed0 )he order of testing for
the muscles 5ere as follo5s" hi$ @e3ors, adductors, internal
rotators, hamstrings and $lantar @e3ors0 )he $hysiothera$ists
tried to $erform the assessments 5ithout
causing any discomfort0 -ach $hysiothera$ist 5as assisted
*y the same fourth $hysiothera$ist 5ho did not $erform
any measurement and only hel$ed maintain the $ositions
of the su*Dects and recorded the scores0 Assessments 5ere
$erformed and measured only once in the same session
due to the nature of s$asticity and a 9+.minute interval
$eriod *et5een the assessments 5as added in order to
eliminate stretch re@e3es occurring in the $revious measurement
and not to aAect the follo5ing measurements0
)he interval $eriod *et5een t5o assessment sessions 5as
? days in order not to kee$ the initial records in mind0
'cores from the right and left sides of the *ody 5ere com*ined
for the same muscle and data from all raters 5ere
collected0 Partici$ants 5ere assessed *y using A' and MA'
J8,<K0
Statistical analysis
Oe handled each lo5er e3tremity of the child as a se$erate
case and therefore diAerent results of the right and left leg
of a child did not aAect each other0 )he intraclass correlations
coe2cient 64CC7 5as used to assess the intra and
interrater relia*ility of A' and MA'0 &leiss and Cohen suggest
that 4CC is the mathematical eEuivalent of the
5eighted a$$a for ordinal data, *ut it can also assess relia*ility
for more than t5o raters at a time and for diAerent
num*ers of raters for each su*Dect J99K0 )he 4CC can *e
used for ordinal data 5ith eEual distance *et5een intervals
J9>K0 MA' and A' scores 5ere considered ordinal and
"able # Descriptions of Ashworth and Modifed Ashworth
Scales
Ashworth Scale
+ Po increase in tone
1 'light increase in tone giving catch 5hen the lim* is moved in @e3ion
and e3tension
; More marked increase in tone, *ut lim* is easily @e3ed
9 Considera*le increases in tone, $assive movement di2cult
> Lim* rigid in @e3ion or e3tension J1?K0
Modifed Ashworth Scale
+ Po increase in muscle tone
1 'light increase in muscle tone, manifested *y a catch and release or
*y minimal resistance at the end of the range of motion 5hen the
aAected
$art6s7 is6are7 moved in @e3ion or e3tension
1Q 'light increase in muscle tone, manifested *y a catch follo5ed *y
minimal resistance through the remainder of the range of motion *ut
the
aAected $art6s7 is6are7 easily moved0
; More marked increase in muscle tone through most of the range of
movement, *ut the aAected $art6s7 is easily moved0
9 Considera*le increases in muscle tone, $assive movement di2cult
> AAected $art6s7 is 6are7 rigid in @e3ion or e3tension
BMC Musculoskeletal Disorders ;++8, !">>
htt$"FF5550*iomedcentral0comF1>?1.;>?>F<F>>
Page > of 8
(page number not for citation purposes)
a value of 10: for MA' 5as assigned to ratings of 1Q to
maintain eEual intervals J;;K0 )he <:= con8dence interval
6C47 5as used to determine the statistical signi8cance0
)he clinical signi8cance 5as de8ned as $oor for an 4CC
*elo5 +0:+, moderate for +0:+ to +0?:, and good for +0?:
or higher J9>K0 )he soft5are used for all calculations 5as
'P'' 110+1 for Oindo5s0
Results
)he A' and MA' scores of the mean value, the minimum
and ma3imum values of A' and MA' are $resented in
)a*le ;0
Interrater Reliability of AS
4CC scores of A' results demonstrated good relia*ility for
the 8rst and second measures of hi$ internal rotators
64CC" +08+, +0?87, the 8rst measure of hamstrings 64CC"
+0?87 and only the second measure of hi$ @e3ors 64CC"
+0?,70 Moderate relia*ility 5as found for the 8rst and second
measures of hi$ adductors 5ith knee e3tended 64CC"
+0,8, +0?;7 and $lantar @e3ors 5ith knee e3tended 64CC"
+0:?, +0:>7, the 8rst measure of hi$ @e3ors 64CC" +0?+7
and only for the second measure of hamstrings 64CC"
+0,<7 6)a*le 970
"able $ Distribution of Results of Ashworth Scale and Modifed
Ashworth Scale
AS%OR"& SCA'( MOD)*)(D AS&%OR"& SCA'(
Muscles Measurement P) Mean Lalue Min.Ma3 Mean Lalue Min.Ma3
#i$ &le3ors &irst A 1 +C9 ; +C>
I 1 +C9 1 +C>
C 1 +C; 1 +C9
'econd A 1 +C9 ; +C>
I 1 1C; 1 1C;
C 1 +C; 1 +C9
#i$ &irst A ; +C9 ; +C>
Adductors 6nee e3tended7 I 1 1C; ; 1C9
C 1 1C; ; 1C9
'econd A ; +C; ; +C9
I 1 1C; ; 1C9
C 1 1C9 ; 1C>
#i$ 4nternal Rotators &irst A 1 +C; ; +C9
I 1 +C; 1 +C9
C 1 +C; ; +C9
'econd A 1 +C; 1 +C9
I 1 +C; 1 +C9
C 1 +C; ; +C9
#amstrings &irst A ; 1C9 9 1C>
I ; 1C9 9 1C>
C ; 1C9 ; 1C>
'econd A ; 1C9 9 1C>
I ; 1C9 9 ;C>
C ; 1C9 9 1C>
Plantar &le3ors 6nee e3tended7 &irst A ; 1C9 9 1C>
I ; 1C9 9 1C>
C ; +C9 ; +C>
'econd A ; 1C9 9 1C>
I ; 1C; 9 1C>
C ; 1C9 9 1C>
min" minimum maks" ma3imum
BMC Musculoskeletal Disorders ;++8, !">>
htt$"FF5550*iomedcentral0comF1>?1.;>?>F<F>>
Page : of 8
(page number not for citation purposes)
Interrater Reliability of MAS
MA' results indicated good relia*ility for the 8rst and second
measures of hamstrings 64CC" +0?,, +0?97 and adductors
64CC" +089, +08?7, the 8rst measure of hi$ internal
rotators 64CC" +08>70 Moderate relia*ility 5as found for
the 8rst and second measures of hi$ @e3ors 64CC" +0?1,
+0?>7 and gastrocnemius 64CC" +0,>, +0,87, the second
measure of hi$ internal rotators 64CC" +0,17 and hamstrings
64CC" +0?97 6)a*le 970
Intrarater Reliability of AS
Among three raters, the A' intrarater 4CC scores 5ere
found to *e ranging from $oor to good 64CC" +091C+08;70
)he lo5est relia*ility 5as +091 *et5een the adductor
measurements of rater C and the highest relia*ility 5as
+08; *et5een the hamstring measurements of rater C0 All
scores of raters are demonstrated in )a*le >0
Intrarater Reliability of MAS
)he scores 5ere $oor to and good 64CC" +09,C+08970 )he
lo5est relia*ility 5as +09, *et5een the hi$ internal rotator
measurements of rater A and the highest relia*ility 5as
"able + )nterrater Reliability of Ashworth and Modifed
Asworth Scales
)nterrater Reliability ,!-. Confdence )nter/al0
Muscle Measure1ent 2 AS&%OR"& MOD)*)(D AS%OR"&
#i$ &le3ors &irst ?,
?, +0?+ 6+0:?C+08+7 +0?1 6+0:8C+0817
?,
'econd ,+
,+ +0?, 6+0,>C+08:7 +0?> 6+0,+C+0897
,+
#i$ Adductors 6nee e3tended7 &irst ?,
?, +0,8 6+0:>C+0?<7 +089 6+0?:C+0887
?,
'econd ,+
,+ +0?; 6+0:?C+08;7 +08? 6+081C+0<;7
,+
#i$ 4nternal Rotators &irst ?,
?, +08+ 6+0?+C+08,7 +08> 6+0??C+08<7
?,
'econd ,+
,+ +0?8 6+0,?C+08,7 +0,1 6+0>+C+0?:7
,+
#amstrings &irst ?,
?, +0?8 6+0,8C+08:7 +0?, 6+0,:C+08>7
?,
'econd ,+
,+ +0,< 6+0:;C+08+7 +0?9 6+0:<C+0897
,+
Plantar &le3ors 6nee e3tended7 &irst ?,
?, +0:? 6+0>:C+0,87 +0,> 6+0:;C+0?>7
?,
'econd ,+
,+ +0:> 6+09<C+0,?7 +0,8 6+0:,C+0?87
,+
BMC Musculoskeletal Disorders ;++8, !">>
htt$"FF5550*iomedcentral0comF1>?1.;>?>F<F>>
Page , of 8
(page number not for citation purposes)
+089 *et5een the hi$ @e3or measurements of rater C0 )he
intrarater 4CC scores of MA' are demonstrated in )a*le :0
Discussion
4n the assessment of s$asticity in children 5ith s$astic CP,
a num*er of ordinal scales such as A', MA' and )ardieu
and M)' are commonly used J;+,91,9:K0 )here is no
study in the $u*lished literature investigating the relia*ility
of A' and MA' together in younger children 5ith CP,
therefore 5e undertook this study0 )o our kno5ledge, this
is the 8rst study investigating the intra and interrater relia*ility
of A' and MA' in children 5ith s$astic CP0 A' and
MA' measure resistance to $assive movement and therefore
measure hy$ertonia J9,K0
4n this study, relia*ility in hi$ @e3ors, adductors, internal
rotators, hamstrings and gastrocnemius muscle grou$s in
children 5ith s$astic CP 5ere investigated0 )he interrater
relia*ility scores of *oth A' and MA' 5ere ranged from
moderate to good and the intrarater relia*ility scores
ranged considera*ly from $oor to good0
Larious factors may aAect the measurement results of relia*ility0
Ohile investigating the relia*ility of scales, related
Doints, anatomic and *iomechanical characteristics of
muscle grou$s as 5ell as interrater and intrarater change
and *iological change should *e taken into consideration
J9?K0 Prie*e et al determined that lo5 relia*ility results of
ordinal scales are related to $ro*lems 5hich occur during
the measurement of s$asticity as 5ell as the environment
and general condition of the $atient J1?K0
4n order to eliminate these negative factors in our study,
an a$$ro$riate environment regulation, the comfort of
the children, the rela3ation of the children, and interval
$eriods *et5een measurements 5ere $rovided0 Iesides,
due to its nature, s$asticity is sensitive to $assive stretching
and velocity may aAect clinical features0 As $assive
stretching is considered to aAect the follo5ing measurement
results, measurements 5ere re$eated once on t5o
diAerent days of the study0 )o minimize the disadvantage
of the stretching of the s$astic muscle, fast stretching 5as
avoided0 )he measurement criteria 5ere standardized *y a
$ilot study $reviously0 )he $hysiothera$ists $erformed
measurements in the same order and gave *reaks *et5een
the measurement of the testers in order to avoid the eAect
of stretching0
4n our study, the 4CC scores of interrater relia*ility ranged
from +0:> to +08+ and the intrarater relia*ility from +091
to +08;, the gastrocnemius muscle had the lo5est value in
A', and the interrater relia*ility of MA' 5as *et5een
+0,>C+08?, 5hile the intrarater relia*ility 5as *et5een
+0>1C+0890 4t may *e that there is a relation to A' and
MA'0 Oe 5ere not sur$rised to see that the inter relia*ility
5as higher than the intratester relia*ility0 )his con8rms
that these scales should *e inter$reted 5ith great caution
and indicates that even the same rater has the $ossi*ility
of making an error0 )he re$etition of measurements *y the
same $hysiothera$ist, and e3$erience may not aAect relia*ility
as 5e mentioned in the conclusion of our study0
Although the interrater relia*ility of A' and MA' 5ere
similar in our study, the intrarater relia*ility of MA' had
"able 3 )ntrarater Reliability of Ashworth Scale
)ntrarater Reliability ,!-. Confdence )nter/al0 24 56
7ariable tested A B C
#i$ &le3ors +0,1 6+0>;C+0?>7 +0>> 6+0;1C+0,;7 +0:8 6+098C+0?;7
#i$ Adductors 6nee e3tended7 +0?9 6+0:<C+0897 +0,9 6+0>,C+0?,7 +091
6+0+,C+0:;7
#i$ 4nternal Rotators +0,+ 6+0>;C+0?>7 +098 6+01:C+0:87 +0:< 6+09<C
+0?97
#amstrings +0>< 6+0;?C+0,,7 +0,? 6+0:+C+0?87 +08; 6+0?;C+08<7
!astrocnemius +0>? 6+0;:C+0,>7 +0>; 6+018C+0,+7 +0>9 6+0;+C+0,;7
"able - )ntrarater Reliability of Modifed Ashworth Scale
)ntrarater Reliability ,!-. Confdence )nter/al0 24 56
7ariable tested A B C
#i$ &le3ors +0?> 6+0,1C+08>7 +0>9 6+0;+C+0,17 +089 6+0?>C+08<7
#i$ Adductors 6nee e3tended7 +0?> 6+0,+C+0897 +0,; 6+0>9C+0?:7 +0?8
6+0,:C+08,7
#i$ 4nternal Rotators +09, 6+01;C+0:,7 +0>1 6+018C+0,+7 +0?, 6+0,9C
+08:7
#amstrings +0:, 6+09,C+0?17 +0:> 6+099C+0,<7 +0,< 6+0:>C+08+7
!astrocnemius +0:, 6+09,C+0?17 +0?+ 6+0:>C+08+7 +0,8 6+0:1C+0?<7
BMC Musculoskeletal Disorders ;++8, !">>
htt$"FF5550*iomedcentral0comF1>?1.;>?>F<F>>
Page ? of 8
(page number not for citation purposes)
higher scores than the intrarater relia*ility of A'0 )his
result may arise from the common use of MA' in $ractice
*y raters 5ho had e3$erience in $ediatric $hysiothera$y0
&osang stated that MA' had *etter intrarater relia*ility
com$ared to interrater relia*ility and it should only *e
used *y a single rater for the same $artici$ant rather than
diAerent raters J1<K0 )he interrater relia*ility 5as higher
than the intrarater relia*ility of our MA' results 5hen
com$ared to the results of the study conducted *y &osang
and Cla$ton0 )his may *e due to the lo5 num*er of raters
in our study J1<,;8K0
)he mean value of MA' 5as +08? for the intertester relia*ility
of adductor muscles and +0,8 for the intertester relia*ility
of $lantar @e3ors0 Nam and Leung investigated the
interrater relia*ility of MA' and M)' for hi$ adductors
and $lantar @e3ors in children 5ith s$astic CP0 )heir
results sho5ed that the intraclass correlation coe2cients
of *oth scales 5ere lo5 and did not reach the acce$ta*le
limit of +0?:0 Oe had similar results in the $lantar @e3ors
although they 5ere diAerent in the adductors0
Gur result for the adductor muscles may *e related to the
la5s of $hysics0 Po5er and load arm of these muscle
grou$s are longer com$ared to those of the $lantar @e3ors0
4n addition, the range of motion of the adductor muscle
grou$s is greater than that of the $lantar @e3ors0 )hese
may $rovide a higher relia*ility of the adductor muscles0
)here are fe5 studies e3amining the relia*ility of A' and
MA' in one single study, ho5ever recent studies have
focused on the relia*ility of MA' J1<,;8K0
)here have *een studies focusing on the relia*ility of A'
and MA' on the adult $o$ulation0 #aas et al used A' and
MA' for assessing lo5er e3tremity s$asticity in 99 adult
$ara$legic $atients and found A' to *e more relia*le than
MA' J98K0 Ansari et al assessed 5rist s$asticity *y A' and
MA' in $atients 5ith stroke and re$orted no diAerence for
the interrater relia*ility *et5een A' and MA' J9<K0 Relia*ility
scales are also aAected from the assessed muscles
and $ersonal characteristics of su*Dects0 -ase in mani$ulation
as 5ell as su$$orting the lo5er e3tremities in children
and the range of motion ca$a*ility due to the muscle
grou$ 5hich is assessed are the $ro*a*le characteristics
mentioned a*ove J8,;;,;8K0 Also, our sam$le grou$ consisted
of children 5ho are younger than those of most
sam$le grou$s 5ith CP0 )herefore, this could have
aAected our results0 Nounger kids 5ould *e easier to move
due to smaller lim*s 6es$ecially for the $ro3imal muscles
5hich are addressed *rie@y7 *ut 5ould *e harder to test
due to reasons of adherence since they are so young0
Conclusion
Pevertheless, recent studies on this issue may guide future
studies0 )he interrater and intrarater relia*ility of A' and
MA' are related to muscle and Doint characters0 )he re$etition
of measurements *y the same $hysiothera$ist, and
e3$erience may not aAect relia*ility0 )hese scales are not
very relia*le and assessments of s$asticity using these
scales should *e therefore inter$reted 5ith great caution0
&uture research studies are reEuired to analyze factors
aAecting relia*ility in children 5ith CP0
Con8ict of interest
)he author6s7 declare that they have no com$eting interests0
Authors9 contributions
AM carried out study design, data collection, statistical
analysis, data inter$retation, manuscri$t $re$aration, literature
search0 AL $artici$ated study design, data collection,
statistical analysis, data inter$retation, manuscri$t
$re$aration, M! $artici$ated study design, data collection,
statistical analysis, manuscri$t $re$aration, literature
search0
Acknowledge1ents
)his study 5as a $art of M'c )hesis su*mitted to #acette$e %niversity0
)his study 5as $resented as a $oster $resentation in 19th and
1:thAnnual
Meeting -uro$ean Academy of Childhood (isa*ility 6-AC(7 in
!ote*org,
'5eden and Gslo, Por5ay0
References
10 Perin I" Physical therapy for the child with cerebral palsy: 4n
Pediatric Physical Therapy -dited *y" )ecklin R'0 Philadel$hia" RI
Li$$incott
Com$any1 1<8<",8.1+:0
;0 -ngs*erg RR, Glree ', Ross 'A, Park )'" ;uantitati/e clinical
1easure of spasticity in children with Cerebral Palsy: Arch
Phys Med Rehabil 1<<,, <<:<>.:<<0
90 'kinner 'R" Direct 1easure1ent of spasticity: 4n The Diplegic
Child !"aluation and Management -dited *y" 'ussman M(0 Rosemont"
American Academy of Grtho$aedic 'urgeon1 1<<;"91.>>0
>0 Ross 'A, -ngs*erg RR" Relationships between spasticity=
strength= gait= and the >M*M?55 in persons with spastic
diplegia cerebral palsy: Arch Phys Med Rehabil ;++?,
@@111>.11;+0
:0 -ngs*erg RR, Ross 'A, Collins (R, Park )'" Predicting functional
change fro1 preinter/ention 1easures in selecti/e dorsal
rhiAoto1y: # $eurosurg ;++?, #65;8;.;8?0
,0 atz R), Rovai !P, Irait C, Rymer OS" ObBecti/e Cuantifcation
of spastic hypertonia Correlation with clinical fndings: Arch
Phys Med Rehabil 1<<;, <+99<.9>?0
?0 Al*right AL" Cerebral Palsy and 1o/e1ent disorders: # Child
$eurol 1<<,, ##;<.9,0
80 Iohannan RO, 'mith MI" )nterrater reliability of a 1odifed
ashworth scale of 1uscle spasticity: Phys Ther 1<8?, 5<;+,.;+?0
<0 !regson RM, Leathley M, Moore AP, 'harma A, 'mith )L, Oatkins
CL" Reliability of the tone assess1ent scale and the 1odifed
ashworth scale as clinical tools for assessing poststroke
spasticity:
Arch Phys Med Rehabil 1<<<, @61+19.1+1,0
1+0 Cha*al C, 'ch5id #A, Raco*son L" "he dyna1ic 8eDo1eter An
instru1ent for the obBecti/e e/aluation of spasticity:
Anesthesiol
1<<1, <3,+0,+<.,1;0
110 Gtis RC, Root L, Pamilla RR, roll MA" Bio1echanical
1easure1ent
of spastic plantar8eDors: De" Med Child $eurol 1<89,
$-,+.,,0
Pu*lish 5ith BioMed Central and every
scientist can read your 5ork free of charge
%BioMed Central &ill be the most signi'cant de"elopment for
disseminating the results of biomedical research in our lifetime(%
'ir Paul Purse, Cancer Research %
Nour research $a$ers 5ill *e"
availa*le free of charge to the entire *iomedical community
$eer revie5ed and $u*lished immediately u$on acce$tance
cited in Pu*Med and archived on Pu*Med Central
yours T you kee$ the co$yright
'u*mit your manuscri$t here"
htt$"FF5550*iomedcentral0comFinfoF$u*lishingUadv0as$
BioMedcentral
BMC Musculoskeletal Disorders ;++8, !">>
htt$"FF5550*iomedcentral0comF1>?1.;>?>F<F>>
Page 8 of 8
(page number not for citation purposes)
1;0 #augh AI, Pandyan A(, Rohnson !R" A syste1atic re/iew of the
"ardieu Scale for the 1easure1ent of spasticity: Disabil Rehabil
;++,, $@8<<.<+?0
190 Mehrholz R, Oagner , Meissner (, !rundmann , Sange C, och R,
Pohl M" Reliability of the Modifed "ardieu Scale and the
Modifed
Ashworth Scale in adult patients with se/ere brain
inBury a co1parison study: Clin Rehabil ;++:, #!?:1.?:<0
1>0 OahlEuist !4" (/aluation and pri1ary 1anage1ent of
spasticity:
$urse Practitioner 1<8?, #$;?.9;0
1:0 #arris 'R, 'mith L#, ruko5ski L" >onio1etric reliability for a
child with spastic Cuadriplegia: # Pediatr )rthop 1<8:, -9>8.9:10
1,0 Price R, IDornson &, Lehmann R&, McLaughlin R&, #ays RM"
;uantitati/e
1easure1ent of spasticity in children with cerebral
palsy: De"elopmental Medicine * Child $eurol 1<<1, ++,<0:8:.:<:0
1?0 Prie*e MM, 'her5ood AM, )horn*y R4, haras P&, Marko5ski R"
Clinical asses1ent of spasticity in spinal cord inBury A
1ultidi1ensional
proble1: Arch Phys Med Rehabil 1<<,, <<?19.?1,0
180 Ash5orth I" Preli1inary trial of carisoprodol in 1ultiple
sclerosis:
Practitioner 1<,>, #!$:>+.:>;0
1<0 &osang AL, !alea MP, McCoy A), Reddihough (', 'tory 4"
Measures
of 1uscle and Boint perfor1ance in the lower li1b of children
with Cerebral Palsy: De" Med Child $eurol ;++9, 3-,,>.,?+0
;+0 Mackey A#, Oalt '-, Lo** !, 'tott P'" )ntraobser/er reliability
of the 1odifed "ardieu scale in the upper li1b of children
with he1iplegia: De" Med Child $eurol ;++>, 35;,?.;?;0
;10 'chein*erg A, #all , Lam L), GB&laherty '" Oral baclofen in
children
with cerebral palsy a double?blind cross?o/er pilot
study: # Paediatr Child +ealth ;++,, 3$?1:.?;+0
;;0 Pandyan A(, Rohnson !R, Price C4, Curless R#, Iarnes MP, Rodgers
#" A re/iew of the properties and li1itations of the Ashworth
and 1odifed Ashworth Scales as 1easures of spasticity:
Clin Rehabil 1<<<, #+9?9.9890
;90 (amiano (L, Vuinlivan RM, G5en I&, Payne P, Pelson C, A*el M&"
%hat does the Ashworth Scale really 1easure and are
instru1ented 1easures 1ore /alid and preciseE De" Med
Child $eurol ;++;, 3311;.1180
;>0 Noung RR" Spasticity A re/iew: $eurology 1<<>, 33,## Supp
!01;.;+0
;:0 atz R), Rymer OS" Spastic hypertonia Mechanis1s and
1easure1ent: Arch Phys Med Rehabil 1<8<, <61>>.1::0
;,0 Allison 'C, A*raham L(" Correlation of Cuantitati/e 1easures
with the 1odifed ashworth scale in the assess1ent of
plantar 8eDor spasticity in patients with trau1atic brain
inBury: # $eurol 1<<:, $3$,<<.?+,0
;?0 Lin RP, Iro5n R, Irotherstone R" Assess1ent of spasticity in
he1iplegic cerebral palsy: )) Distal lower?li1b re8eD
eDcitability
and function: De" Med Child $eurol 1<<>, +5;<+.9+90
;80 Clo$ton P, (utton R, &eatherston ), !rigs*y A, Mo*ley R, Melvin R"
)nterrater and intrarater reliability of the 1odifed ashworth
scale in children with hypertonia: Pediatr Phys Ther ;++:,
#<;,8.;?>0
;<0 'ehgal P, Mc!uire RR" Beyond Ashworth: (lectrophysiologic
Cuantifcation of spasticity: Phys Med Rehabil Clin $ Am 1<<8,
!<><.<?<0
9+0 Irashear A, Safonte R, Corcoran M, !alvez.Rimenez P, !racies RM,
!ordon M&, McAfee A, Ru2ng , )hom$son I, Oilliams M, Lee C#,
)urkel C" )nter?and intrarater reliability of the ashworth scale
and the disability assess1ent scale in patients with upperli1p
poststroke spasticity: Arch Phys Med Rehabil ;++;,
@+19><.19:>0
910 Nam OL, Leung A'M" )ntrerrater reliability of 1odifed
asworth Scale and 1odifed tardieu scale in children with
spastic cerebral palsy: # Child $eurol ;++,, $#1+91.1+9:0
9;0 Palisano R, Rosen*aum P, Oalter ', Russell (, Oood -, !alu$$i I"
De/elop1ent and reliability of a syste1 to classify gross
1otor function in children with Cerebral Palsy: De" Med Child
$eurol 1<<?, +!;1>.;;90
990 &leis RL, Cohen R" "he eCui/alence of weighted kappa and the
intraclass correlation coeFcient as 1easures of reliability:
!duc Psychol Mat 1<?9, ++,19.,1<0
9>0 Portney L, Oatkins M" ,oundations of Clinical research Applications
to
Practice PR, %'A" Prentice #all #ealth1 ;+++0
9:0 Oallen MA, GB@aherty 'R, Oaugh MC" *unctional outco1es of
intra1uscular botulinu1 toDin type A in the upper li1bs of
children with cerebral palsy a phase )) trial: Arch Phys Med
Rehabil ;++>, @-1<;.;++0
9,0 GB(5yer PR, Ada L, Peilson P(" Spasticity and 1uscle
contracture
following stroke: Brain 1<<,, ##!1?9?.1?><0
9?0 -llaszi5 M, Noung 'L, Oood*ury M!, &leld &" Statistical
1ethodology
for the concurrent assess1ent of interrater and intrarater
reliability Gsing gonio1etric 1easure1ents as an
eDa1ple: Phys Ther 1<<>, <3???.?880
980 #aas IM, Iergstrom -, Ramous A, Iennie A" )nterrater reliability
of the original and of the 1odifed ashworth scale for the
assess1ent of spasticity in patients with spinal cord inBury:
-pinal Cord 1<<,, +3:,+.:,>0
9<0 Ansari PP, Paghdi ', Moammeri #, Ralaie '" Ashworth scales are
unreliable for the assess1ent of the 1uscle spasticity:
Physiother
Theor Pract ;++,, $$,+011<.1;:0
Pre?publication history
)he $re.$u*lication history for this $a$er can *e accessed
here"
htt$"FF5550*iomedcentral0comF1>?1.;>?>F<F>>F$re$u*