Anand Pandyan

A review of the properties and limitations of the Ashworth and modified Ashworth Scales as measures of spasticity

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 passive movement, but not spasticity. The modified Ashworth Scale (MAS) will need to be treated as a nominal level measure of resistance to passive movement until the ambiguity between the ‘1’ and ‘1+’ grades is resolved. The reliability of the scales is better in the upper limb. The AS may be more reliable than the MAS. There is a need to standardize methods to apply these scales in clinical practice and research.

Spasticity: Clinical perceptions, neurological realities and meaningful measurement

The aim of this paper is to review briefly our understanding of the phenomenon of spasticity based in current evidence.

Electrical Stimulation of Wrist Extensors in Poststroke Hemiplegia

BACKGROUND AND PURPOSE It has been suggested that cyclic neuromuscular electrical stimulation (ES) may enhance motor recovery after stroke. We have investigated the effects of ES of the wrist extensors on impairment of wrist function and on upper-limb disability in patients being rehabilitated after acute stroke. METHODS We recruited 60 hemiparetic patients (mean age, 68 years) 2 to 4 weeks after stroke into a randomized, controlled, parallel-group study comparing standard rehabilitation treatment with standard treatment plus ES of wrist extensors (3 times 30 minutes daily for 8 weeks). Isometric strength of wrist extensors was measured using a device built for that purpose. Upper-limb disability was assessed with use of the Action Research Arm Test (ARAT). Observations were continued for 32 weeks (24 weeks after the finish of ES or the control intervention phase). RESULTS The change in isometric strength of wrist extensors (at an angle of 0 degrees extension) was significantly greater in the ES group than the control group at both 8 and 32 weeks (P=0.004, P=0.014 by Mann Whitney U test). At week 8 the grasp and grip subscores of the ARAT increased significantly in the ES group compared with that in the control group (P=0.013 and P=0.02, respectively); a similar trend was seen for the total ARAT score (P=0.11). In the subgroup of 33 patients with some residual wrist extensor strength at study entry (moment at 0 degrees extension >0), the ARAT total score had increased at week 8 by a mean of 21.1 (SD, 12.7) in the ES group compared with 10.3 (SD, 9.0) in the control group (P=0.024, Mann Whitney U test); however, at 32 weeks the differences between these 2 subgroups were no longer statistically significant. CONCLUSIONS ES of the wrist extensors enhances the recovery of isometric wrist extensor strength in hemiparetic stroke patients. Upper-limb disability was reduced after 8 weeks of ES therapy, with benefits most apparent in those with some residual motor function at the wrist. However, it is not clear how long the improvements in upper-limb disability are maintained after ES is discontinued.

A systematic review and synthesis of the quantitative and qualitative evidence behind patient-centred goal setting in stroke rehabilitation

Objective: To map out from the literature the nature, extent and effects of application of patient-centred goal setting in stroke rehabilitation practice. Design: Systematic review. Data sources: A search was conducted in the Cochrane (Wiley), AMED, Medline (EBSCO), Embase, Sports discuss, Medline (Ovid) and CINAHL databases. Secondary search based on references from the preliminary search was undertaken. Review methods: Quantitative and qualitative studies that included aspects of patient-centredness and goal setting in stroke patients from 1980 to June 2010 were collected. Studies were scrutinized for relevance and quality based on published methodology. The findings were synthesized by aggregating the themes from the qualitative studies and relating them to relevant findings from the quantitative studies. Results: Eighteen qualitative and eight quantitative and one mixed method study conducted in stroke rehabilitation services ranging from acute to community rehabilitation were included. Themes that emerged were related to perceptions of patients and professionals regarding patient-centredness, nominal adoption of this concept, consequences of discrepancies in the perceptions and practice, related ethical conflicts, challenges to application and strategies to improve its application. The effects of following patient-centred goal-setting practice have been studied mostly with weak methodologies and studies show some benefit with psychological outcomes. Conclusion: Patient-centred goal setting is minimally adopted in goal-setting practice due to various barriers. Since the effects of incorporating this concept have not been evaluated rigorously it is suggested that further research is essential to investigate its effect on patient outcomes.

A systematic review of the Tardieu Scale for the measurement of spasticity

Background. The Tardieu Scale has been suggested a more appropriate clinical measure of spasticity than the Ashworth or modified Ashworth Scales. It appears to adhere more closely to Lances definition of spasticity as it involves assessment of resistance to passive movement at both slow and fast speeds. Objective. To review the available literature in which the Tardieu Scale has been used or discussed as a measure of spasticity, with a view to determining its validity and reliability. Study design. A systematic review of all literature found related to the Tardieu Scale (keywords: Tardieu scale, spasticity) from Pubmed and Ovid databases, including medline, CINAHL, EMBASE, Journals at Ovid full text, EBM reviews and Cochrane database of systematic reviews. Hand searching was also used to track the source literature. Conclusions. In theory, we can acknowledge that the Tardieu Scale does, in fact, adhere more closely to Lances definition of spasticity. However, there is a dearth of literature investigating validity and reliability of the scale. Some studies have identified the Tardieu Scale to be more sensitive than other measures, to change following treatment with botulinum toxin. Further studies need to be undertaken to clarify the validity and reliability of the scale for a variety of muscle groups in adult neurological patients.

A biomechanical investigation into the validity of the modified Ashworth Scale as a measure of elbow spasticity

Objective: To investigate the criterion validity of the modified Ashworth Scale. Population: Volunteers from a stroke population admitted to a district general hospital stroke unit diagnosed with a first ever stroke less than 26 weeks previously. Outcome measures: Resistance to passive movement about the elbow was simultaneously quantified (biomechanically) and graded (modified Ashworth Scale). Passive range of movement and peak instantaneous velocity during passive movement were also measured. Analysis: Criterion validity was investigated as convergent construct validity (using the Spearmans correlation coefficient) and concurrent validity (using analysis of variance). Results: One hundred measurements were taken on 63 subjects. Correlation between the modified Ashworth Scale and resistance to passive movement was 0.511. Resistance to passive movement and velocity showed significant differences between the modified Ashworth score of ‘0’ and a modified Ashworth score greater than ‘0’ (p < 0.01). There were no significant differences between MAS ‘1’, ‘1+’ and ‘2’. Resistance to passive movement in the impaired arm was significantly higher than in the nonimpaired arm (p < 0.01). Conclusion: The modified Ashworth Scale does not provide a valid measure of spasticity at lower grades but it may provide a measure of resistance to passive movement.

Electrical stimulation for preventing and treating post-stroke shoulder pain: a systematic Cochrane review

Background: Shoulder pain after stroke is common and disabling. The optimal management is uncertain, but electrical stimulation (ES) is often used to treat and prevent pain. Objectives: The objective of this review was to determine the efficacy of any form of surface ES in the prevention and/or treatment of pain around the shoulder at any time after stroke. Search strategy: We searched the Cochrane Stroke Review Group trials register and undertook further searches of Medline, Embase and CINAHL. Contact was established with equipment manufacturers and centres that have published on the topic of ES. Selection criteria: We considered all randomized trials that assessed any surface ES technique (functional electrical stimulation (FES), transcutaneous electrical nerve stimulation (TENS) or other), applied at any time since stroke for the purpose of prevention or treatment of shoulder pain. Data collection and analysis: Two reviewers independently selected trials for inclusion, assessed trial quality and extracted the data. Main results: Four trials (a total of 170 subjects) fitted the inclusion criteria. Study design and ES technique varied considerably, often precluding the combination of studies. Population numbers were small. There was no significant change in pain incidence (odds ratio (OR) 0.64; 95% CI 0.19–2.14) or change in pain intensity (standardized mean difference (SMD) 0.13; 95% CI –1.0–1.25) after ES treatment compared with control. There was a significant treatment effect in favour of ES for improvement in pain-free range of passive humeral lateral rotation (weighted mean difference (WMD) 9.17; 95% CI 1.43–16.91). In these studies ES reduced the severity of glenohumeral subluxation (SMD –1.13; 95% CI –1.66 to –0.60), but there was no significant effect on upper limb motor recovery (SMD 0.24; 95% CI –0.14–0.62) or upper limb spasticity (WMD 0.05; 95% CI –0.28–0.37). There did not appear to be any negative effects of electrical stimulation at the shoulder.

Biomechanical approaches applied to the lower and upper limb for the measurement of spasticity: a systematic review of the literature.

Purpose: To review and characterise biomechanical approaches for the measurement of spasticity as one component of the upper motor neurone syndrome. Method: Systematic literature searches based on defined constructs and a four-step review process of approaches used or described to measure spasticity, its association with function or associated phenomena. Most approaches were limited to individual joints and therefore, to reflect this trend, references were grouped according to which body joint(s) were investigated or whether it addressed a functional activity. For each joint, references were further sub-divided into the types of measurement method described. Results: A database of 335 references was established for the review process. The knee, ankle and elbow joints were the most popular, perhaps reflecting the assumption that they are mono-planar in movement and therefore simpler to assess. Seven measurement methods were identified: five involving passive movement (manual, controlled displacement, controlled torque, gravitational and tendon tap) and two involving active movement (voluntary and functional). Generally, the equipment described was in an experimental stage and there was a lack of information on system properties, such as accuracy or reliability. Patient testing was either by cohort or case studies. The review also conveyed the myriad of interpretations of the concept of spasticity. Conclusions: Though biomechanical approaches provide quantitative data, the review highlighted several limitations that have prevented them being established as an appropriate method for clinical application to measure spasticity.

Effects of electrical stimulation on flexion contractures in the hemiplegic wrist

Objective: To study the effects of electrical stimulation (ES) on flexion contractures in the hemiplegic wrist. Design: The investigation was carried out following an OFF (two weeks with rehabilitation only) - ON (two weeks with ES treatment and rehabilitation) - OFF (two weeks rehabilitation only) fixed protocol. Setting: A stroke ward and an outpatient stroke service. Subjects: Eleven hemiplegic subjects with reduced range of extension and increased resistance to passive movement at the wrist. Main measure: Quantitative measures of the hemiplegic posture at the wrist, passive range of extension and resistance to passive extension of the wrist. Measurements were taken at the start of the study and then at two-weekly intervals. Two extra measurements were taken at the end of the ON period. Results: Following two weeks treatment with ES the posture of the wrist improved and the passive range of extension increased. However, there were no significant changes in the resistance to passive movement. These benefits appeared largely to be lost two weeks after ES was discontinued. Conclusions: Short-term ES gives temporary improvements in contractures at the wrist in poststroke hemiplegia.

Contractures in the post-stroke wrist: a pilot study of its time course of development and its association with upper limb recovery

Background: Contractures are common in a stroke population, yet there is little information on the time course of development. Objectives: Investigate quantitatively changes associated with contracture formation in an acute stroke population. Study design: Longitudinal study on 22 subjects who were 2–4 weeks post stroke. Outcome measures: Contractures were assessed by quantifying the resting posture, resistance to passive movement and passive range of movement. Upper limb function was measured using the Action Research Arm Test and the Nine-Hole Peg Test. Active range of extension, wrist extension strength (isometric), grip strength and neglect were also measured. Repeated measures: Following an initial assessment, repeated measurements were taken at 4, 8, 20 and 32 weeks after recruitment. Results: Two distinct subgroups, one capable of some functional movement (F group; 8 subjects) and another which was not (NF group; 14 subjects), were identified at the start of the study. The NF group showed changes associated with contracture formation at the wrist, i.e., reduction in the passive range of movement, an increase in resistance to passive movement and a worsening of the flexion posture. Changes were observed from the time of recruitment even though neglect improved. The F group showed improvements in upper limb function and there was no evidence to support contracture formation. Conclusions: Subjects most prone to contracture formation were those who showed no signs of early functional recovery (2–4 weeks after the stroke). Changes consistent with adaptive shortening were seen from week 4 of the study period.