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Rehab Measures: Ashworth Scale / Modified Ashworth Scale

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Title of Assessment

Ashworth Scale / Modified Ashworth Scale

Link to instrument

Modified Ashworth Scale Instructions (other languages below)

Purpose

  • Originally developed to assess the effects of antispasticity drugs on spasticity in Multiple Sclerosis
  • Modified Ashworth: measures spasticity in patients with lesions of the Central Nervous System

Acronym

AS / MAS

Instrument Reviewer(s)

Initially reviewed by the Rehabilitation Measures Team; Updated by Phyllis Palma PT, DPT and Christopher Newman PT, MPT, NCS and the SCI EDGE task force of the Neurology section of the APTA in 9/2012; Updated with references for the TBI population by Irene Ward, PT, DPT, NCS and the TBI EDGE task force of the Neurology Section of the APTA in 2012; Updated with references for Pediatrics and Cerebral Palsy by Anna Wetzel, SPT, Brian Baranyi, SPT, and Stephanie Johnson, SPT in 11/2012.

Summary Date

26 04 2013

Description

Original Ashworth Scale:

  • Tests resistance to passive movement about a joint with varying degrees of velocity
    • Scores range from 0-4, with 5 choices
    • A score of 1 indicates no resistance and 5 indicates rigidity

Modified Ashworth Scale :

  • Similar to Ashworth, but adds a 1+ scoring category to indicate resistance through less than half of the movement. Thus scores range from 0-4, with 6 choices (Bohannon & Smith, 1987)

Score

Ashworth Scale (1964)

Modified Ashworth Scale Bohannon & Smith (1987)

0 (0)

No increase in tone

No increase in muscle tone

1 (1)

Slight increase in tone giving a catch when the limb was moved in flexion or extension

Slight increase in muscle tone, manifested by a catch and release or by minimal resistance at the end of the range of motion when the affected part(s) is moved in flexion or extension

1+ (2)

Slight increase in muscle tone, manifested by a catch, followed by minimal resistance throughout the reminder (less than half) of the ROM (range of movement)

2 (3)

More marked increase in tone but limb easily flexed

More marked increase in muscle tone through most of the ROM, but affected part(s) easily moved

3 (4)

Considerable increase in tone - passive movement difficult

Considerable increase in muscle tone passive, movement difficult

4 (5)

Limb rigid in flexion or extension

Affected part(s) rigid in flexion or extension

ICF Domain

Body Structure, Body Function

Time to Administer

< 5 minutes, dependent upon the number of muscles/joints tested

Number of Items

AS uses a 5 point scale (range 0 to 4); MAS uses 6 point scale (range 0 to 4)

Equipment Required

Mat Table

Training Required

None

Actual Cost

Free

Populations Tested

  • Adults and children with lesions of the Central Nervous System
  • Cerebral Palsy
  • Multiple Sclerosis
  • Pediatric Hypertonia
  • Spinal Cord Injury
  • Stroke
  • Traumatic Brain Injury

Standard Error of
Measurement (SEM)

Not Established

Minimal Detectable
Change (MDC)

Stroke:

(Shaw et al, 2010; n = 333; adults with upper limb spasticity at the shoulder, elbow, wrist or hand and reduced upper limb function due to stroke more than 1 month previously.)

  • Response to Botox: the magnitude of initial change in muscle tone/spasticity was approximately a one-point decrease on the MAS which reflects a clinically significant improvement.

Minimally Clinically
Important Difference (MCID)

Not Established

Cut-Off Scores

Not Established

Normative Data

Not Established

Test-retest Reliability

Modified Ashworth Scale

Children with Cerebral Palsy:

(Mutlu et al, 2008; n = 38; mean age = 52.9 (19.6) months, Children with CP)

  • Poor to Excellent test-retest reliability (ICC = 0.36-0.83)

(Fosang at al, 2003; n = 18; mean age = 6.4 years, Children with CP)

  • Adequate to excellent test-retest reliability for hamstrings (ICC = 0.66-0.80)
  • Poor to adequate test-retest reliability for calf (ICC = 0.21-0.72)
  • Adequate to excellent test-retest reliabilty for hip adductors (ICC = 0.59-0.82)

SCI:

(Tederko et al, 2007, n = 30; 5 = unable to sit up, 14 = adapted to sitting position, 11 patients = adapted to standing position or able to walk; mean age = 33.9 (range = 17-65); mean time since injury 14.1 months, Chronic SCI)

  • Adequate reliability for individual muscle groups (ICC = 0.56), however the MAS may be a more appropriate measure of global muscle tone.
  • The reliability of muscle tone assessments were weaker among younger patients
  • Joint contractures decreased the reliability of the MAS

Stroke:

(Gregson et al, 2000; n = 32; median age = 74 years; median Barthel score = 8; median time since onset = 40 (IQR = 19 - 78) days. Blackburn et al, 2002; n = 32; mean age = 76.1 (7.89) years; assessed 12 weeks post-stroke, Acute Stroke)

  • Excellent intra-rater reliability for elbow (kw = 0.84) (Gregson et al, 1999)
  • Adequate intra-rater reliability for elbow (kw = 0.77 – 0.84); ankle (kw = 0.59 – 0.64); wrist (kw = 0.80 – 0.88) and knee (kw = 0.77 – 0.94) (Gregson et al, 2000)
  • Adequate intra-rater reliability in the lower extremity of 73.3% (Kendall tau-b = 0.567) (Blackburn et al, 2002)

Traumatic Brain Injury:

  • Adequate test-retest reliability for the Shoulder, elbow, wrist, hip, knee and ankle (kappa = 0.47-0.62) (Mehrholz et al, 2005)
  • Excellent test-retest for the ankle (r = 0.82; k = 0.422) (Allison et al, 1996)

Interrater/Intrarater

  Reliability

Modified Ashworth Scale:

Patients with central nervous system lesions:

(Bohannon & Smith, 1987, n = 30, mean age = 59.3 (17.6) years, patients with centeral nervous system lesions)

  • Excellent interrater reliability between two experienced raters (Kendall's tau = 0.847, p < 0.001)

Patients with severe cerebral damage:

(Mehrholz et al, 2005, patients with severe cerebral damage)

  • Poor to adequate Inter-rater reliability (kappa = 0.16 to 0.42)

SCI:

(Haas et al, 1996, n = 30, mean age = 40.3 years, mean time since injury = 17.23 months; Frankel Grade A = 18, B = 3, C = 2, D = 6, E = 1, Chronic SCI)

  • Poor to adequate interrater reliability depending on the muscle group (Kappa = 0.21 to 0.61)

(Craven et al, 2010, n = 20, C5-T10, AIS A-D > 12 months, Chronic SCI)

  • Inter-rater reliability was poor to adequate (Kappa < 0.6) for all muscle groups
  • Inter-session reliability for a single rater was adequate (0.4 < ICC < 0.75) for all muscle groups
  • MAS not reliable as an intrarater tool for all raters, and showed poor inter-rater and adequate inter-session reliability.
  • MAS has poor reliability for determining lower extremity spasticity between raters (interrater) or over time (intersession)

(Toderko et al, 2007; n = 30 (16 complete & 14 with incomplete); mean age = 33.9 (14.7) years; time since injury = 4-66; rated by 6 independent observers, Acute SCI)

  • Adequate interrater reliability (ICC = 0.56)

Stroke:

(Blackburn et al, 2002, Acute Stroke)

  • Adequate intrarater reliability. Agreement ranged from 57.5% (Kendall Tau-b = 0.44) to 85% (Kendall Tau-b = 0.66)
  • Poor interrater reliability. Agreement ranged from 50% (Kendall Tau-b = 0.20) to 42.5% (Kendall Tau-b = 0.16)
    • The authors concluded that the MAS was a reliable measurements for lower limb assessments made by a single rater, with highest agreement at the grade of 0. However, reliability between examiners was poor

TBI:

(Allison et al, 1996, n = 30, mean age = 28.3 (10.8) years; mean time since injury = 56 (48.4) months, Chronic TBI)

  • Adequate interrater reliability (r = 0.727) for plantar flexor spasticity

Original Ashworth Scale:

Children with Cerebral Palsy:

(Mutlu, 2008, Children with CP)

  • Excellent interrater reliability for measures hamstrings (ICC = 0.76, 0.73)
  • Excellent interrater reliability for measures of hip adductors (ICC = 0.83, 0.87)
  • Adequate to excellent interrater reliability for measure of hip internal rotators (ICC = 0.61, 0.84)
  • Adequate interrater reliability for measures of hip flexors (ICC = 0.71, 0.74)
  • Adequate interrater reliability for measures of gastrocnemius (ICC = 0.64, 0.68)
  • Poor to excellent intrarater reliability:
    • Lowest intrarater reliability found for hip internal rotators (ICC = 0.36)
    • Highest intrarater reliability found for hip flexors (ICC = 0.83)
  • Authors concluded that assessments of spasticity using the Modified Ashworth Scale are not very reliable for this population and should be used with caution

 (Fosang, 2003, Children with CP)

  • Hamstrings
    • Poor to adequate interrater reliability (ICC = 0.37-0.48)
    • Adequate to Excellent intrarater reliability (ICC = 0.66-0.80)
  • Calf
    • Poor to Adequate interrater reliability (ICC: 0.27-0.45)
    • Poor to Adequate intrarater reliability (ICC: 0.21-0.70)
  • Adductors
    • Adequate interrater reliability (ICC = 0.54-0.56)
    • Adequate intrarater reliability (ICC = 0.59-0.72)

(Yam, 2005; n = 17, mean age=7.9 years, Children with CP)

  • Poor to adequate interrater reliability for hip adductors, knee flexed (ICC = 0.41)
  • Adequate interrater reliability for hip adductors, knee extended (ICC = 0.73)
  • Adequate interrater reliability for ankle plantarflexors, knee extended (ICC = 0.56)
  • Adequate interrater reliability for ankle plantarflexors, knee flexed (ICC = 0.46)
  • The authors caution the use of this test in this population due to none of the measures possessing excellent interrater reliability (ICC > 0.75)

Pediatric Hypertonia:

(Clopton, 2005; n = 17, mean age = 7 years, Pediatric Hypertonia)

  • Excellent interrater relibility for elbow flexors and hamstrings (ICC > 0.75)
  • Poor to adequate interrater reliability for other muscles (ICC < 0.50)
    • Lower than clinically acceptable
  • Excellent intrarater reliability for hamstrings (ICC > 0.75)
  • Adequate intrarater reliability for other muscles (ICC 0.50-0.75)
    • Potentially lower than clinically acceptable

Stroke:

(Kaya et al, 2011, n = 64, mean age = 60.5 (11.9) years; mean time since stroke = 15.7 (10.2) weeks, Stroke)

  • Excellent for both MAS and MMAS, with weighted kappa values of 0.868 and 0.892
  • MAS and MMAS have very good inter-rater reliability for assessment of poststroke elbow flexor spasticity
  • Neither scale is superior to grade spasticity in patients with hemiplegia for this particular muscle group

(Brashear et al, 2002, n = 10, mean age = 59.9 (16.17) years, Chronic Stroke)

  • Adequate intrarater reliability (across 10 raters)

Elbow
Wrist
Fingers
Thumb
Overall weighted K
0.668
0.740
0.740
0.680
p

0.998

0.972

1.000

0.985

  • Adequate to excellent interrater reliability (depending on joint) 

Mean of evaluations 1 and 2 (Kendall W)
Elbow
Wrist
Fingers
Thumb
0.765
0.598
0.792
0.611

TBI:

(Ansari et al., n = 15; mean age of 57.3 (14.4) years. They had brain injury on average of 33.3 (26.2) months earlier, Chronic TBI)

  • Adequate: the weighted Kappa (kappaw) values were calculated for reliability. The kappaw was 0.61 (adequate) for elbow flexor and 0.78 (excellent) for wrist flexor. Results support the adequate to excellent interrater reliability of the MMAS for persons with upper limb spasticity

Internal Consistency

Not Established

Criterion Validity

(Predictive/Concurrent)

Modified Ashworth Scale:

 

Children with Children:

(Alhusani, 2010; n = 27, mean age = 7 (1.9) years, Children with CP)

  • Percentage of Exact Agreement with lab measurement (stretch-induced electromyographic activity) in identifying spasticity
    • 81.5% non-significant fair agreement (K = 0.24)
    • P = 0.057 non-significant
  • Pearson Correlation with lab measurement to identify the severity of spasticity
    • R = 0.009 not a significant correlation
    • P = 0.7 not a significant correlation

Traumatic Brain Injury:

(Allison & Abraham, 1995, n = 34, mean age = 30.4 years, TBI)

  • Adequate concurrent validity with:
    • Timed toe tapping (r = -0.042)
    • Reflex Threshold Angle (r = 0.49)
    • H-reflex during dorsiflexion (r = 0.47)
    • H-wave during vibration (r = 0.39)

Construct Validity

(Convergent/Discriminant)

Modified Ashworth Scale:

SCI:

(Smith et al, 2002; n = 22; 14 quadriplegia (3 incomplete), 8 paraplegia (1 incomplete); mean age = 33.4 (12.5) years, SCI)

  • Excellent: Correlation with the Wartenberg Pendulum Test & MAS (r = -0.69)

Stroke:

(Katz 1992, n = 10; Lin & Sabbahi, 1999, n = 10, mean age = 59 (4) years, Chronic Stroke)

  • Excellent convergent validity with:
    • Fugl-Meyer (r = -0.94)
    • Electromyography (r  = -0.79)
    • Box-Block Test (r  = -0.83)
    • Active Range of Motion (r  = -0.74)
    • Grip Strength (r = -0.86)
    • Pendulum test (r = -0.67)

Content Validity

Theoretical basis of the Modified Ashworth Scale:

Implicit Assumptions:

(Pandyan et al, 1999, Implicit Assumptions)

  • Changes in the resistance to passive movement are due to changes in spasticity
  • Stretch mechanoreceptors in the muscle would elongate with similar velocity during repeated measures
  • Range of movement on each joint during repeated measures is unaltered

These authors suggested:

  • Caution is required when stating that the Modified Ashworth Scale is a measure of spasticity
  • Evidence suggests that the resistance to passive movement is not an exclusive measure of spasticity
  • Resistance will vary according to the level of activity in the alpha motor neuron of agonist and antagonist muscles, the viscoelastic properties of soft tissues and joints.

Stroke:

(Hong Min, 2012; n = 21; mean age = 58.0 (13.9) years; mean time post stroke = 32.2 (7.3) days, Stroke)

Adequate Spearman Correlation Coefficient between MAS and amplitude of biceps T-reflex (0.464 and 0.573 for two different raters)

Face Validity

Not Established

Floor/Ceiling Effects

Not Established

Responsiveness

Not Established

Professional Association Recommendations

Recommendations for use of the instrument from the Neurology Section of the American Physical Therapy Association’s Multiple Sclerosis Taskforce (MSEDGE), Parkinson’s Taskforce (PD EDGE), Spinal Cord Injury Taskforce (PD EDGE), Stroke Taskforce (StrokEDGE), Traumatic Brain Injury Taskforce (TBI EDGE), and Vestibular Taskforce (VEDGE) are listed below. These recommendations were developed by a panel of research and clinical experts using a modified Delphi process.

 

For detailed information about how recommendations were made, please visit:  http://www.neuropt.org/go/healthcare-professionals/neurology-section-outcome-measures-recommendations

 

Abbreviations:

HR

Highly Recommend

R

Recommend

LS / UR

Reasonable to use, but limited study in target group  / Unable to Recommend

NR

Not Recommended

 

Recommendations for use based on acuity level of the patient:

 

Acute

(CVA < 2 months post)

(SCI < 1 month post)

(Vestibular < 6 months post)

Subacute

(CVA 2 to 6 months)

(SCI 3 to 6 months)

Chronic

(> 6 months)

SCI EDGE

NR

NR

NR

StrokEDGE

R

R

R

 

Recommendations based on level of care in which the assessment is taken:

 

Acute Care

Inpatient Rehabilitation

Skilled Nursing Facility

Outpatient

Rehabilitation

Home Health

StrokEDGE

R

R

R

R

R

 

Recommendations for entry-level physical therapy education and use in research:

 

Students should learn to administer this tool? (Y/N)

Students should be exposed to tool? (Y/N)

Appropriate for use in intervention research studies? (Y/N)

Is additional research warranted for this tool (Y/N)

SCI EDGE

No

No

No

Not reported

StrokEDGE

No

Yes

Yes

Not reported

Ashworth Scale, Modified

Recommendations for use of the instrument from the Neurology Section of the American Physical Therapy Association’s Multiple Sclerosis Taskforce (MSEDGE), Parkinson’s Taskforce (PD EDGE), Spinal Cord Injury Taskforce (PD EDGE), Stroke Taskforce (StrokEDGE), Traumatic Brain Injury Taskforce (TBI EDGE), and Vestibular Taskforce (VEDGE) are listed below. These recommendations were developed by a panel of research and clinical experts using a modified Delphi process.

 

For detailed information about how recommendations were made, please visit:  http://www.neuropt.org/go/healthcare-professionals/neurology-section-outcome-measures-recommendations

 

Abbreviations:

HR

Highly Recommend

R

Recommend

LS / UR

Reasonable to use, but limited study in target group  / Unable to Recommend

NR

Not Recommended

 

Recommendations for use based on acuity level of the patient:

 

Acute

(CVA < 2 months post)

(SCI < 1 month post)

(Vestibular < 6 months post)

Subacute

(CVA 2 to 6 months)

(SCI 3 to 6 months)

Chronic

(> 6 months)

SCI EDGE

LS

LS

LS

 

Recommendations based on level of care in which the assessment is taken:

 

Acute Care

Inpatient Rehabilitation

Skilled Nursing Facility

Outpatient

Rehabilitation

Home Health

MS EDGE

UR

UR

UR

UR

UR

TBI EDGE

LS

R

R

R

R

 

Recommendations based on SCI AIS Classification:

 

AIS A/B

AIS C/D

SCI EDGE

LS

LS

Recommendations for use based on ambulatory status after brain injury:

 

Completely Independent

Mildly dependant

Moderately Dependant

Severely Dependant

TBI EDGE

N/A

N/A

N/A

N/A

 

Recommendations based on EDSS Classification:

 

EDSS 0.0 – 3.5

EDSS 4.0 – 5.5

EDSS 6.0 – 7.5

EDSS 8.0 – 9.5

MS EDGE

UR

UR

UR

UR

 

Recommendations based on vestibular diagnosis

 

Peripheral

Central

Benign Paroxysmal Positional Vertigo (BPPV)

Other

  Recommendations for entry-level physical therapy education and use in research:

 

Students should learn to administer this tool? (Y/N)

Students should be exposed to tool? (Y/N)

Appropriate for use in intervention research studies? (Y/N)

Is additional research warranted for this tool (Y/N)

MS EDGE

No

No

No

Yes

SCI EDGE

No

Yes

No

Not reported

TBI EDGE

Yes

Yes

Yes

Not reported

Considerations

    • Adequate training is required to ensure inter-rater reliability
    • Reliability differs from muscle to muscle
    • Assessment technique must be standardized
    • Some critics question the validity of the Ashworth scale and Modified Ashworth Scale in measuring spasticity. It may be a description of resistance to passive movement. Therefore, measuring only one aspect of spasticity, not a comprehensive assessment. (Salter et al, 2005)
    • It was concluded that the Ashworth scale is of limited use in the assessment of spasticity in the lower limb of patients with SCI
    • The Ashworth scale produces a global assessment of the resistance to passive movement of an extremity, not just stretch-reflex hyperexcitability. Specifically, the Ashworth score is likely to be influenced by non-contractile soft tissue properties, by persistent muscle activity (dystonia), by intrinsic joint stiffness, and by stretch reflex responses (Kamper et al., 2001)
    • Ambiguity of wording and lack of standardized procedures limit the scale’s usefulness for comparison across studies as well as reliability
    • The Modified Ashworth scale does not comply with the concept of spasticity (a velocity-dependent increase in muscle tone) (Scholtes, 2007)
    • The Modified Ashworth Scale measures muscle tone intensity at one, unspecified, velocity which can make comparisons difficult (Scholtes, 2007)

Translated Modified Ashworth Scale:

Chinese (simplified): http://www.haodf.com/zhuanjiaguandian/liubaoqiong_1077075591.htm

French:
http://www.cofemer.fr/UserFiles/File/ECH.1.2.2.Asworth.pdf

German:
http://www.patientensicherheit.ch/dms/de/themen/3126_sturz_testbeschreibung_chedoke_master_d/Testbeschreibung%20chedoke%20MC%20Master.pdf

Italian (p103):
http://www.iss.it/binary/publ/cont/08-39%20web.1233562284.pdf

Japanese (p2):
https://www.jstage.jst.go.jp/article/jkpt/12/0/12_1/_pdf

Korean:
http://blog.naver.com/PostView.nhn?blogId=3c273&logNo=10000521558

Spanish (p40):
http://www.tdx.cat/bitstream/handle/10803/3840/nml1de1.pdf;jsessionid=1CF6D8957E26C2A044019951FEBF24F2.tdx2?sequence=1

These translations, and links to them, are subject to the Terms and Conditions of Use of the Rehab Measures Database. RIC is not responsible for and does not endorse the content, products or services of any third-party website, and does not make any representations regarding its quality, content or accuracy. If you would like to contribute a language translation to the RMD, please contact us at rehabmeasures@ric.org.

Do you see an error or have a suggestion for this instrument summary? Please e-mail us!

Bibliography

Alhusaini, A. A., Dean, C. M., et al. (2010). "Evaluation of spasticity in children with cerebral palsy using Ashworth and Tardieu Scales compared with laboratory measures." J Child Neurol 25(10): 1242-1247. Find it on PubMed

Allison, S. and Abraham, L. (1995). "Correlation of quantitative measures with the modified Ashworth scale in the assessment of plantar flexor spasticity in patients with traumatic brain injury." Journal of neurology 242(10): 699-706. Find it on PubMed

Allison, S., Abraham, L., et al. (1996). "Reliability of the Modified Ashworth Scale in the assessment of plantarflexor muscle spasticity in patients with traumatic brain injury." International Journal of Rehabilitation Research 19(1): 67. Find it on PubMed

Ansari, N. N., Naghdi, S., et al. (2009). "Assessing the reliability of the Modified Modified Ashworth Scale between two physiotherapists in adult patients with hemiplegia." NeuroRehabilitation 25(4): 235-240.

Blackburn, M., van Vliet, P., et al. (2002). "Reliability of measurements obtained with the modified Ashworth scale in the lower extremities of people with stroke." Physical Therapy 82(1): 25. Find it on PubMed

Bohannon, R. and Smith, M. (1987). "Interrater reliability of a modified Ashworth scale of muscle spasticity." Physical Therapy 67(2): 206. Find it on PubMed

Brashear, A., Zafonte, R., et al. (2002). "Inter-and intrarater reliability of the Ashworth Scale and the Disability Assessment Scale in patients with upper-limb poststroke spasticity* 1." Archives of physical medicine and rehabilitation 83(10): 1349-1354. Find it on PubMed

Clopton, N., Dutton, J., et al. (2005). "Interrater and intrarater reliability of the Modified Ashworth Scale in children with hypertonia." Pediatr Phys Ther 17(4): 268-274. Find it on PubMed

Craven, B. C. and Morris, A. R. (2010). "Modified Ashworth scale reliability for measurement of lower extremity spasticity among patients with SCI." Spinal Cord 48(3): 207-213. Find it on PubMed

Fosang, A. L., Galea, M. P., et al. (2003). "Measures of muscle and joint performance in the lower limb of children with cerebral palsy." Dev Med Child Neurol 45(10): 664-670. Find it on PubMed

Gregson, J., Leathley, M., et al. (1999). "Reliability of the Tone Assessment Scale and the modified Ashworth scale as clinical tools for assessing poststroke spasticity." Archives of physical medicine and rehabilitation 80(9): 1013-1016. Find it on PubMed

Gregson, J., Leathley, M., et al. (2000). "Reliability of measurement of muscle tone and muscle power in stroke patients." Age and Ageing 29(3): 223. Find it on PubMed

Haas, B., Bergström, E., et al. (1996). "The inter rater reliability of the original and of the modified Ashworth scale for the assessment of spasticity in patients with spinal cord injury." Spinal Cord 34(9): 560-564. Find it on PubMed

Hsieh, J. T., Wolfe, D. L., et al. (2008). "Spasticity outcome measures in spinal cord injury: psychometric properties and clinical utility." Spinal Cord 46(2): 86-95. Find it on PubMed

Kamper, D. G., Schmit, B. D., et al. (2001). "Effect of muscle biomechanics on the quantification of spasticity." Ann Biomed Eng 29(12): 1122-1134. Find it on PubMed 

Katz, R., Rovai, G., et al. (1992). "Objective quantification of spastic hypertonia: correlation with clinical findings." Archives of physical medicine and rehabilitation 73(4): 339. Find it on PubMed

Kaya, T., Karatepe, A. G., et al. (2011). "Inter-rater reliability of the Modified Ashworth Scale and modified Modified Ashworth Scale in assessing poststroke elbow flexor spasticity." Int J Rehabil Res 34(1): 59-64. Find it on PubMed

Lin, F. and Sabbahi, M. (1999). "Correlation of spasticity with hyperactive stretch reflexes and motor dysfunction in hemiplegia." Archives of physical medicine and rehabilitation 80(5): 526-530. Find it on PubMed

Mehrholz, J., Wagner, K., et al. (2005). "Reliability of the Modified Tardieu Scale and the Modified Ashworth Scale in adult patients with severe brain injury: a comparison study." Clinical rehabilitation 19(7): 751. Find it on PubMed

Min, J. H., Shin, Y.-I., et al. (2012). "The Correlation between Modified Ashworth Scale and Biceps T-reflex and Inter-rater and Intra-rater Reliability of Biceps T-reflex." Annals of Rehabilitation Medicine 36(4): 538-543.

Mutlu, A., Livanelioglu, A., et al. (2008). "Reliability of Ashworth and Modified Ashworth scales in children with spastic cerebral palsy." BMC Musculoskelet Disord 9: 44. Find it on PubMed

Pandyan, A., Johnson, G., et al. (1999). "A review of the properties and limitations of the Ashworth and modified Ashworth Scales as measures of spasticity." Clinical rehabilitation 13(5): 373. Find it on PubMed

Remy-Neris, O., Tiffreau, V., et al. (2003). "Intrathecal baclofen in subjects with spastic hemiplegia: assessment of the antispastic effect during gait." Arch Phys Med Rehabil 84(5): 643-650. Find it on PubMed

Salter, K., Jutai, J., et al. (2005). "Issues for selection of outcome measures in stroke rehabilitation: ICF body functions." Disability & Rehabilitation 27(4): 191-207. Find it on PubMed

Salter, K., Jutai, J. W., et al. (2005). "Issues for selection of outcome measures in stroke rehabilitation: ICF Body Functions." Disabil Rehabil 27(4): 191-207. Find it on PubMed

Scholtes, V. A., Becher, J. G., et al. (2007). "Clinical assessment of spasticity in children with cerebral palsy: a critical review of available instruments." Developmental Medicine & Child Neurology 48(1): 64-73.

Shaw, L., Rodgers, H., et al. (2010). BoTULS: a multicentre randomised controlled trial to evaluate the clinical effectiveness and cost-effectiveness of treating upper limb spasticity due to stroke with botulinum toxin type A, Prepress Projects.

Tederko, P., Krasuski, M., et al. (2007). "Reliability of clinical spasticity measurements in patients with cervical spinal cord injury." Ortop Traumatol Rehabil 9: 467-483. Find it on PubMed

Yam, W. K. and Leung, M. S. (2006). "Interrater reliability of Modified Ashworth Scale and Modified Tardieu Scale in children with spastic cerebral palsy." J Child Neurol 21(12): 1031-1035. Find it on PubMed

Link to instrument

Modified Ashworth Scale Instructions (other languages below)

NIDRR
The contents of this database were developed under a grant from the Department of Education, NIDRR grant number H133B090024 (PI: Allen Heinemann, PhD).  However, the content does not necessarily represent the policy of the Department of Education, and you should not assume endorsement by the Federal Government.  
 
 

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