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Saccadic Adaptation in Children / Salman et al 1031

Original Article

Interrater Reliability of Modified Ashworth Scale


and Modified Tardieu Scale in Children With
Spastic Cerebral Palsy
Winnie Ka Ling Yam, FHKAM (Paediatrics); Milan So Mei Leung, PDipPT

ABSTRACT

Resistance to passive movement in children with spastic cerebral palsy was assessed by two raters using the Modified
Ashworth Scale and the Modified Tardieu Scale. Four muscle groups in the lower limbs were tested using a standardized
procedure. Interrater reliability of the scales was evaluated by the intraclass correlation coefficient. Seventeen children,
with a mean age of 7 years 9 months, were included. Two children were rated twice. The intraclass correlation
coefficients of both scales were low and did not reach the acceptable limit of 0.75. Caution should be used when these
scales are applied. (J Child Neurol 2006;21:10311035; DOI 10.2310/7010.2006.00222).

Some of our results were presented at the 2004 annual meeting of the
Society of Hong Kong Child Neurology and Developmental Paediatrics,
Hong Kong and at the 2004 annual meeting of the Hong Kong Paediatric
Received May 7, 2005. Received revised Sept 26, 2005, and Nov 13, 2005. Society, Hong Kong.
Accepted for publication Dec 11, 2005. Address correspondence to Dr Winnie Ka Ling Yam, Department of
From the Departments of Paediatrics and Adolescent Medicine (Dr Yam), Paediatrics and Adolescent Medicine, Alice Ho Miu Ling Nethersole
and Physiotherapy (Ms Leung) Alice Ho Miu Ling Nethersole Hospital, Hospital, Chuen On Road, Tai Po, Hong Kong SAR, China. Tel: 852-2689-
Hong Kong SAR, China. 2286; fax: 852-2689-2096; e-mail: wklyam@hotmail.com.

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1032 Journal of Child Neurology / Volume 21, Number 12, December 2006

Numerous modalities of treatment to reduce muscle spasticity and Andersson showed that there was no significant correla-
have arisen in recent years. To assess the outcome of these tion of parameters in the pendulum test with the Modified
interventions, accurate and reliable instruments should be used. Ashworth Scale.8 Using three-dimensional movement analysis,
The Modified Ashworth Scale and the Modified Tardieu Scale are Mackey et al found poor intrarater reliability of the Modified
two clinical rating scales that are often used for outcome Tardieu Scale in assessing the biceps of 10 hemiplegic children.9
measurement (Table 1).1,2 Traditionally, the Modified Ashworth In summary, the results on the reliability of both scales remain
Scale was widely used, but the Modified Tardieu Scale was equivocal and there is a need for further study to address this
recently proposed as a more reliable clinical tool.2 The reliability important issue.
of the Modified Ashworth Scale has been tested in adults with Our study aimed at investigating the interrater reliability of
stroke, intracranial lesions, and traumatic brain injury.1,35 The the Modified Ashworth Scale and the Modified Tardieu Scale in
reliability of the Modified Tardieu Scale in adults has not been children with cerebral palsy. The importance of our study rested
reported. For the pediatric population, data on the reliability of in providing an opportunity to examine whether Fosang et als
either scale are even more limited and inconclusive.69 Boyd et al results7 could be replicated. It had been shown that the reliability
determined the intrarater reliability of these scales in the context of the Modified Ashworth Scale varied between different patient
of a randomized clinical trial of botulinum toxin in children.2 groups, between different muscle groups, and between different
Adductor tone (with the hips and knees flexed and then with the testing protocols; therefore, our study would clarify whether the
hips and knees extended) of the placebo group was assessed on reliability of the Modified Tardieu Scale showed similar
two occasions. Comparison was made between the mean scores findings.1,35
of the Modified Ashworth Scale and the Modified Tardieu Scale In contrast to Fonsang et als protocol,7 we believed that the
on 16 limbs. No statistical significance was found between the hip adductors and ankle plantar flexors should be tested in two
two means. The authors concluded that there was good positions owing to their anatomic consideration. With the hips
intrarater reliability. Fosang et al tested the reliability of the and knees extended, spasticity contributed by the adductor
two scales on 18 children with cerebral palsy.7 The hip adductors magnus, adductor longus, adductor brevis, gracilis, and medial
(with the hip and the knee in extension), hamstrings, and hamstrings would be assessed. With the hips extended and the
gastrocnemius were tested. The interrater reliability, calculated knees flexed, contribution from the gracilis and medial ham-
by the intraclass correlation coefficient, ranged between 0.27 strings could be distinguished from the rest of the hip adductors.
and 0.56 for the Modified Ashworth Scale and 0.55 and 0.74 If spasticity of the gracilis and medial hamstrings was present,
for the Modified Tardieu Scale. Testretest reliability, calculated the hips could not be abducted to a wider range than that
by the intraclass correlation coefficient, ranged between 0.21 achieved with the knees extended. For the ankle plantar flexors,
and 0.82 for the Modified Ashworth Scale and 0.38 and 0.93 for spasticity contributed by the gastrocnemius would be assessed
the Modified Tardieu Scale. Using the Wartenberg pendulum when the knee was extended, whereas the soleus would be
test on the quadriceps of 20 spastic diplegic children, Nordmark assessed when the knee was flexed. The gracilis, medial

Table 1. Modified Ashworth Scale and Modified Tardieu Scale

Grade Description
Modified Ashworth Scale
0 No increase in muscle tone
1 Slight increase in muscle tone, manifested by a catch, followed by minimal resistance at the end of range of motion when the part
is moved in flexion or extension/abduction or adduction, etc
1+ Slight increase in muscle tone, manifested by a catch, followed by minimal resistance throughout the remainder (less than half) of
the range of motion
2 More marked increase in muscle tone through most of the range of motion, but the affected part is easily moved
3 Considerable increase in muscle tone; passive movement is difficult
4 Affected part is rigid in flexion or extension (eg, abduction or adduction)
Modified Tardieu Scale
Quality of muscle reaction
0 No resistance throughout the course of the passive movement
1 Slight resistance through the course of passive movement; no clear catch at a precise angle
2 Clear catch at a precise angle, interrupting the passive movement, followed by release
3 Fatiguable clonus (, 10 s when maintaining the pressure) appearing at a precise angle
4 Unfatiguable clonus (.10 s when maintaining the pressure) at a precise angle
5 Joint immovable
Joint angles
Measure relative to the position of minimal stretch of the muscle (corresponding to angle zero) for all joints except the hip, where it is relative
to the resting anatomic position (eg, angle zero corresponds to the ankle at 90 deg and the hip at midline)
R1 Angle of muscle reaction
R2 Angle of full range of motion (passive range of motion)

Definition of velocities used


V1 As slow as possible (slower than the natural drop of the limb segment under gravity)
V2 Speed of the limb segment falling under gravity
V3 As fast as possible (faster than the rate of the natural drop of the limb segment under gravity)
Adapted from Bohannon and Smith and Boyd et al.1,2

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Interrater Reliability of Modified Ashworth and Tardieu Scales in Spastic Cerebral Palsy / Yam and Leung 1033

hamstrings, and gastrocnemius muscles crossed two joints, Instrument and Testing Position
whereas the other hip adductors and soleus muscles crossed The Modified Ashworth Scale and the Modified Tardieu Scale were used.
only one joint. Muscles that crossed two joints were particularly The Modified Ashworth Scale is a 6-point rating scale for gauging muscle
prone to development of spasticity and contracture. resistance to passive movement.10 The Modified Tardieu Scale is another
Differentiating the contributions of spasticity from the different 6-point rating scale for describing the quality of muscle reaction. In
muscle groups enabled subsequent interventions to target the addition, two angles (R1 and R2) were determined in the Modified
appropriate muscles. Therefore, we believed that these muscles Tardieu Scale. The angle of muscle reaction (R1) was defined as the point
groups should be tested individually. in the joint range in which a velocity-dependent catch or clonus was felt
Fosang et al tested the interrater reliability of the Modified during a quick stretch of the muscle. The angle of full range of motion
Ashworth Scale score, the Modified Tardieu Scale score, and R2. (R2) was equivalent to the passive range of motion. The difference
We believed that the interrater reliability of R1 and R2 2 R1 between the two angles (R2 2 R1) represented the dynamic component.9
should also be examined because of their important clinical Both R1 and R2 were measured relative to the neutral position or resting
implications. It had been proposed that when the muscle was anatomic position of the joints. The neutral position at the ankle joint
stretched to the R1 position, muscle spasticity came into action. (corresponding to angle zero) was the position with the ankle at 90
When the muscle was stretched to the R2 position, the degrees to the lower leg. A negative value would be given if the ankle
viscoelasticity of the soft tissues and joints and the component could not be dorsiflexed beyond angle zero. The resting anatomic
of contracture might come into play. Thus, the R2 2 R1 value position at the hip joint was defined as the thigh being at zero degrees to
indicated the level of spasticity in the joint.9 Botulinum toxin the trunk. A negative value would be given if the hip could not be
injection might be useful in children with a large R2 2 R1 because abducted beyond the resting position. The limbs were moved as fast as
there was a higher degree of spasticity. On the other hand, surgical possible in obtaining R1 and moved slowly to its end range in obtaining
intervention might be more appropriate in those with a small R2 2 R2.
R1 because of the higher degree of contracture. Four muscle groups in each lower limb were tested. These included
The reasons for the low reliability in other studies included hip adductors with the knee extended, hip adductors with the knee
low variability or a limited range of scores, extraneous factors, flexed, ankle plantar flexors with the knee extended, and ankle plantar
and scoring methods.4 In designing our study protocol, these flexors with the knee flexed. Starting positions and velocities adopted in
factors were specifically attended to so as to minimize the effects. testing the muscles were standardized (Table 2). The head of the child
was maintained neutral to avoid eliciting asymmetric tonic neck reflex.
METHOD This abnormal reflex, which was common in children with cerebral palsy,
might interfere with the muscle tone. The adductors were tested with
Participants both hips and knees in full extension. Then the adductors were tested
Children were recruited from the departments of Physiotherapy and with the hips in full extension and the knees in 90-degree flexion. The legs
Paediatrics and Adolescent Medicine in Alice Ho Miu Ling Nethersole were moved from the neutral position to the maximal abducted position
Hospital, Hong Kong. Convenience sampling was used. Children with without any concomitant pelvic movement. To minimize any pelvic
spastic cerebral palsy were included. Different topographic distributions movement, both lower limbs were moved together. The ankle plantar
(hemiplegia, diplegia, monoplegia, triplegia, and quadriplegia) of cerebral flexors with the knee extended were tested by moving the ankle from
palsy were allowed. This ensured that a wide range of muscle tone was maximal plantar flexion to maximal dorsiflexion. The ankle plantar
included for evaluation of both ends of the scales. Children were excluded if flexors were tested again with the knee flexed. The hindfoot was
they suffered from other types of cerebral palsy (such as dyskinetic, ataxic, maintained in the neutral position to avoid calcaneal valgus or varus. The
and mixed types) or if parental consent could not be obtained. The Ethics raters moved the limbs three times to grade the tone and the joint ranges.
Committee of the Hospital Authority, Hong Kong, approved the study. Data on the Modified Ashworth Scale score, Modified Tardieu Scale
score, and two Modified Tardieu Scale angles (R1 and R2) were collected
for each muscle group. Both lower limbs of each child were assessed.
Raters
Two raters, including a pediatrician (rater 1) and a physiotherapist (rater
2), scored each child. Both raters had more than 10 years of experience in Procedure
handling children with cerebral palsy and were familiar with both scales. When the children came for their physical therapy session, they were
To ensure adherence to the methodology, a meeting was held before invited to participate in the study if they fulfilled the inclusion criteria.
commencement of the study to clarify the procedure and to distribute Assessment was done by the two raters during the same 2-hour physical
written guidelines. The two scales and instructions were also included in therapy session of the child. The raters performed the assessment
the recording form so that raters might refer to them. However, no independently, and there was at least a 5-minute rest between the two
extensive training or standardization was done to resemble the usual assessments. The order of assessment and the sequence of muscle testing
clinical practice in which the scales would be used. by the two raters were random. Testing was performed when the child

Table 2. Starting Joint Positions and Velocities

Muscle Group Starting Joint Position Velocity


Hip adductors, knee flexed Hips extended, knees flexed by 90 deg V3 for R1
Hip adductors, knee extended Hips and knees extended V1 for R2
Ankle plantar flexors, knee extended Knee fully extended
Ankle plantar flexors, knee flexed Knee flexed by 90 deg

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1034 Journal of Child Neurology / Volume 21, Number 12, December 2006

was emotionally stable because muscle tone might be affected by fear or was for the hip adductors, for which the scores were
anxiety. The results were entered into a separate recording sheet for each concentrated near the lower end. No child reported any pain
rater so that each rater determined the result without being aware of the during the testing procedure.
results from the other rater. The results for the interrater reliability are shown in Table 4.
Intraclass correlation coefficients for the Modified Ashworth
Data Analysis Scale ranged between 0.41 and 0.73, whereas those for the
Measurements by different raters on the same child at the same time Modified Tardieu Scale ranged between 0.22 and 0.71. Intraclass
were used to determine the interrater reliability. The interrater reliability correlation coefficients for R1 ranged between 0.37 and 0.71, for
was calculated for the Modified Ashworth Scale scores, Modified Tardieu R2 between 0.17 and 0.74, and for R2 2 R1 between 0.40 and 0.69.
Scale scores, and R1, R2, and R2 2 R1. For nominal and ordinal data,
such as the Modified Ashworth Scale score and the Modified Tardieu DISCUSSION
Scale score, reliability should be tested with kappa statistics. Quadratic
weighing for kappa statistics was commonly recommended. When such a Although Fosang et al concluded that the interrater reliability of
weighting system was used, the weighted kappa would be equivalent to the Modified Tardieu Scale was better than that of the Modified
the intraclass correlation coefficient.11 For continuous data, such as R1, Ashworth Scale, none of the interrater intraclass correlation
R2, and R2 2 R1, the reliability should be tested with the intraclass coefficients (of the Modified Ashworth Scale score or the
correlation coefficient.12 Therefore, the intraclass correlation coefficient Modified Tardieu Scale score) in their study reached the
was chosen as the test statistic. Data were analyzed using SPSS (SPSS acceptable level of 0.75.7 Our results showed a similar finding.
Inc, Chicago, IL). The two-way mixed-consistency model of intraclass The interrater intraclass correlation coefficients of passive range
correlation coefficient was used. The intraclass correlation coefficient of motion (equivalent to R2 in our study) ranged between 0.63
reflected both the degree of correspondence and the degree of agreement and 0.78 for hip abduction, popliteal angle, and ankle dorsiflex-
between the ratings. The closer the intraclass correlation coefficient ion in Fosang et als study. We did not test the popliteal angle in
result was to 1, the better the agreement was between raters. Good our study, but the interrater intraclass correlation coefficients of
reliability was generally defined as an intraclass correlation coefficient $ R1, R2, and R2 2 R1 for hip adductors or ankle plantar flexors
0.75.12 did not reach 0.75.
Some common reasons for low interrater reliability were
RESULTS specifically addressed in our study. Our results in Table 3 did not
support a limited range of scores as a reason for low reliability.
Seventeen children with a mean age of 7 years 9 months (range 3 Extraneous factors, such as the emotional status of the child or
years 6 months15 years 11 months) were included. Seven of the pain, could contribute to the variability.10 The emotional
children were male, and 10 were female. Eleven children had instability of the child had been eliminated by specific instruc-
spastic diplegic cerebral palsy, two had left hemiplegic cerebral tions in our testing procedure, and no child reported any pain. To
palsy, and four had triplegic cerebral palsy. Nine of the children improve scoring methods, strict standardization of the position
belonged to level I in the Gross Motor Function Classification and procedure was used in our study. The starting limb position,
System, five to level II, and three to level III. Two children were neutral positioning of the head, and the number and velocity of
rated twice. These second ratings were done 1 week after the testing movement were specified to reduce variability arising
first and after botulinum toxin had been given. Because the from reflex excitability and viscoelasticity of soft tissues and
current study involved interrater reliability only, the second joints.10 However, it would be interesting to undertake further
ratings for these two children were also included for analysis. studies to see if another standardization (eg, preceding activities,
The Modified Ashworth Scale and Modified Tardieu Scale scores interval between testing movements, force used, external
were distributed across the entire scales (Table 3). Exception standardization with three-dimensional movement analysis)

Table 3. Score Distribution of the Modified Ashworth Scale and the Modified Tardieu Scale

Hip Add, KF Hip Add, KE Ankle PF, KE Ankle PF, KF

Grade Rater 1 Rater 2 Rater 1 Rater 2 Rater 1 Rater 2 Rater 1 Rater 2


Modified Ashworth Scale
0 20 17 19 15 13 18 7 10
1 4 6 2 7 1 3 5 14
1+ 1 2 0 0 1 0 3 0
2 5 11 5 14 3 2 10 3
3 8 2 12 2 9 8 10 9
4 0 0 0 0 11 7 3 2
Modified Tardieu Scale
0 20 17 19 15 14 14 8 10
1 2 8 0 11 0 5 1 1
2 16 13 19 12 11 10 14 16
3 0 0 0 0 3 0 11 7
4 0 0 0 0 1 6 4 4
5 0 0 0 0 9 3 0 0
Hip Add 5 hip adductors; KE 5 knee extended; KF 5 knee flexed; PF 5 plantar flexors.

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Interrater Reliability of Modified Ashworth and Tardieu Scales in Spastic Cerebral Palsy / Yam and Leung 1035

Table 4. Interrater Agreement on the Modified Ashworth Scale and the Modified Tardieu Scale

Intraclass Correlation Coefficient (95% Confidence Interval)

Muscle Group Modified Ashworth Scale Modified Tardieu Scale R1 R2 R2 2 R1


Hip adductors, knee 0.41 (0.110.64) 0.66 (0.440.81) 0.71 (0.510.84) 0.74 (0.550.85) 0.53 (0.260.72)
flexed
Hip adductors, knee 0.73 (0.540.85) 0.71 (0.510.84) 0.71 (0.500.84) 0.53 (0.250.72) 0.69 (0.480.83)
extended
Ankle plantar flexors, 0.56 (0.300.74) 0.22 (20.110.50) 0.55 (0.290.74) 0.17 (20.150.46) 0.40 (0.090.63)
knee extended
Ankle plantar flexors, 0.46 (0.160.67) 0.44 (0.150.67) 0.37 (0.060.61) 0.36 (0.050.61) 0.53 (0.260.73)
knee flexed
R1 5 angle of muscle reaction; R2 5 angle of full range of motion.

might improve the reliability.4,13 To resemble the clinical setting, tools for assessing poststroke spasticity. Arch Phys Med Rehabil
we distributed written guidelines and included the scales and 1999;80:10131016.
instructions in the recording forms. Further studies should be 6. Boyd RN, Graham HK: Objective measurement of clinical
findings in the use of botulinum toxin type A for the management
performed to identify what type of training to raters might
of children with cerebral palsy. Eur J Neurol 1999;6(Suppl 4):
increase the interrater reliability of the scale. S23S35.
In summary, the interrater reliability of the Modified 7. Fosang AL, Galea MP, McCoy AT, et al: Measures of muscle and
Ashworth Scale and the Modified Tardieu Scale was low. joint performance in the lower limb of children with cerebral
Caution should be used in applying these scales in the palsy. Dev Med Child Neurol 2003;45:664670.
assessment of lower limb muscle tone for children with cerebral 8. Nordmark E, Andersson G: Wartenberg pendulum test: Objective
palsy. As these scales remained important in the clinical setting, quantification of muscle tone in children with spastic diplegia
further studies should be undertaken to identify ways to improve undergoing selective dorsal rhizotomy. Dev Med Child Neurol
2002;44:2633.
their reliability. These scales might remain useful if intrarater
reliability could be documented.10 9. Mackey AH, Walt SE, Lobb G, Stoot NS: Intraobserver
reliability of the Modified Tardieu Scale in the upper limb
of children with hemiplegia. Dev Med Child Neurol 2004;46:
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