Brain Injury, December 2008; 22(13–14): 1007–1012

The Modified Tardieu Scale for the measurement of elbow flexor

spasticity in adult patients with hemiplegia

NOUREDDIN NAKHOSTIN ANSARI1, SOOFIA NAGHDI1, SCOTT HASSON2,

MOHAMMAD HASAN AZARSA1, & SOMAYE AZARNIA1
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1
Faculty of Rehabilitation, Tehran University of Medical Sciences, Iran and 2Physical Therapy Department
Angelo State University, San Angelo, TX, USA

(Received 28 May 2008; revised 22 September 2008; accepted 6 October 2008)

Abstract
Primary objective: To investigate the inter-rater reliability of the Modified Tardieu Scale (MTS) in the measurement of
elbow flexor muscle spasticity in patients with adult hemiplegia.
For personal use only.

Research design: A cross-sectional study to examine the agreement between two raters on elbow flexor muscle spasticity using
Modified Tardieu Scale.
Interventions: Not applicable.
Methods and procedures: Thirty patients (21 men, nine women) with an age range of 21–79 years (mean ¼ 54.9; SD ¼ 15.7)
were tested. Two inexperienced raters assessed the elbow flexor muscle spasticity in the affected side during the same
session. The order of assessments by the two raters was randomized. The main outcome measure was dynamic component
of spasticity (R2–R1). Reliability was also calculated for MTS scores, angle of muscle reaction (R1), and passive range of
motion (R2).
Main outcomes and results: The ICC for R2–R1 was 0.72. The ICC for MTS scores, R1 and R2 were 0.74, 0.74 and 0.56,
respectively.
Conclusions: The Modified Tardieu Scale did not provide acceptable high inter-rater reliability in the measurement of
muscle spasticity in patients with hemiplegia when used by raters of limited experience.

Keywords: Spasticity, Modified Tardieu Scale, inter-rater reliability, hemiplegia

Introduction While debate continues over the pathophysiology

There is no precise definition for spasticity [1].
However, a generally accepted and most often cited
definition characterize it as [2]: ‘a velocity dependent
increase in tonic stretch reflex with exaggerated
tendon jerks, resulting from the hyperexcitability of
the stretch reflex’ [2]. Stroke, spinal cord injuries,
multiple sclerosis, cerebral palsy, and traumatic
brain injury can cause spasticity, which is a major
source of disability in many patients with these
conditions. The prevalence of spasticity among
different patients has been reported between 35–
85% [3–6].
of spasticity, stretch reflex has been stated as the
major neural circuit in producing spasticity [7, 8].
Any change in inhibitory and excitatory descending
pathways controlling spinal reflex activity result in
hyperexcitability of the stretch reflex [9, 10].
However, clinical features of the patient with
upper motor neuron dysfunction indicate that
both reflex hyperexcitability and mechanical stiff-
ness contribute to increased resistance to passive
stretch [7, 11–14]. If untreated, spasticity can
cause pain, abnormal posture, difficulty in move-
ment, deformity, contractures leading to limited

Correspondence: Dr Noureddin Nakhostin Ansari, Faculty of Rehabilitation, Tehran University of Medical Sciences, Enghelab Ave, Pitch-e-shemiran, 11498,
PO Box: 11155-1683, Tehran, Iran. Fax: þ98 21 77882009. E-mail: nakhostin@sina.tums.ac.ir
ISSN 0269–9052 print/ISSN 1362–301X online ß 2008 Informa Healthcare Ltd.
DOI: 10.1080/02699050802530557
 1008 N. N. Ansari et al.
active and passive joint mobility and functional
limitations [8, 15, 16].
The measurement of spasticity using valid and
reliable tools is important to assess the outcome of
interventions. The most commonly used scales,
which are the Ashworth [17] and the modified
Ashworth scales [18], have recently been questioned
as valid and reliable tools [19–21]. The Ashworth
Scales are criticized as they just measure resistance
to passive movement [22, 23] and are unable to
differentiate between the reflex and peripheral
components [24]. The Tardieu scale has been
recently suggested as a suitable and reliable alter-
native for use in the measurement of muscle
spasticity [24–27]. This scale, originally developed
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by Tardieu et al. [28] and later modified by Held
and Pierrot-Deseilligny [29], has been further
modified by Boyd and Graham [30] as the
Modified Tardieu Scale (MTS). The MTS uses
standardized procedures to measure quality of
muscle reaction at specified velocities (i.e. fast
stretch, speed of the limb segment falling under
gravity, and slow controlled motion) [30, 31].
During the fast stretch maneouvre the particular
angle at which ‘catch’ occurs from hyperactive
For personal use only.
stretch reflex is called R1, also known as angle of
muscle reaction. During the slow controlled man-
eouvre, passive range of motion (PROM) is assessed
and is called R2 and represents the muscle length at
rest and is recorded as an angle [30]. The difference
between the two measures is R2–R1 or the dynamic
component of spasticity and is more important than
the single measures of R1 and R2 [30, 31]. A large
and small difference between R1 and R2 is
suggestive of spasticity and muscle contracture,
respectively [8, 30].
The published literature is lacking on the relia-
bility of the MTS in adult patients with spasticity.
A study by Mehrholz et al. [32] compared the
reliability of the MTS with the Modified Ashworth
Scale (MAS) in adult patients with severe brain
injury and found significantly higher test–re-test
and inter-rater reliability for MTS. The inter-rater
reliability of both scales was poor-to-moderate.
Most of the studies conducted on the reliability of
the MTS have been with children. Boyd et al. [27]
examined the validity and reliability of the MTS and
the MAS in children with cerebral palsy (CP).
They demonstrated good intra-rater reliability for
the MTS.
Fosang et al. [33] assessed the reliability of the
MTS and the MAS in a group of 18 children with CP.
The authors showed acceptable inter-rater reliability
for MTS and PROM, but highly variable intra-rater
reliability (range: 0.55–0.78 for time 1, 0.58–0.73 for
time 2). There was a large variability in the magnitude
of PROM measurements with different raters and
a disparity of repeated measurements for the same
rater.
Mackey et al. [34], in the measurement of biceps
spasticity in 10 children with hemiplegia CP, found
poor intra-observer reliability for MTS. The median
error in measured angle within one session was 3–5 .
The median absolute differences in joint angle
ranged from 4–13 , with errors of 25–30 at V3.
Five patients had an R2–R1 equal to or greater than
15 and three had an inter-sessional difference of
more than 20 . They concluded that the R2–R1 may
have limited value in measurement of muscle
spasticity.
In an investigation conducted by Yam and Leung
[35] to evaluate the inter-rater reliability of the MTS
and MAS, four muscle groups in the lower limbs
of children with spastic CP were examined. They
demonstrated low reliability for both tools and
concluded that these scales should be used with
caution.
There is a scarcity of publications regarding the
reliability of the MTS, with only one study in adult
patients. Considering the need to perform inter-rater
and intra-rater reliability studies of modified Tardieu
scale, the present study was performed to examine
the inter-rater reliability of the MTS in the measure-
ment of elbow flexor muscle spasticity in adult
patients with hemiplegia.
Methods and procedures
Study design
A cross-sectional study was used to examine the
agreement between two raters on elbow flexor
muscle spasticity using Modified Tardieu Scale.
Patients
Adult patients attending the physiotherapy clinics of
rehabilitation faculty (Tehran University of Medical
Sciences, Iran) were asked to participate in the
study. Inclusion criteria were: (1) age 18;
(2) hemiplegia of at least 1 month duration caused
by an upper motor neuron lesion; and (3) ability to
understand instructions. Exclusion criteria were:
(1) history of joint trauma, joint pain and surgery;
(2) taking anti-spasticity drugs; and (3) non-consent.
The study was approved by the Research Council
of Rehabilitation Faculty, Tehran University of
Medical Sciences. Informed verbal consent was
obtained.
Raters
The raters were two physiotherapy (PT) students;
one male and one female. When the study com-
menced, they had completed their final year of
 Spasticity assessment with modified Tardieu scale
education for the bachelor’s degree in PT. No formal
training or workshop on the MTS was conducted for
them. However, the procedure and the measuring
instrument was explained and demonstrated to them
by the first author in a 45 minute session.
Procedure
Age, gender, aetiology, affected side and duration
of disease were recorded. The two raters examined
each patient in a single session and the order of
testing between them was randomized. The raters
were blinded to each other’s results. Before data
collection, subjects were at rest in their beds for at
least 5 minutes.
The data collection procedure described in detail
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elsewhere was followed [30–33, 36]. Patients were in
sitting position on a chair, shoulder in adduction,
and were asked to remain calm and to relax the arm
completely. The procedure consisted of measuring
PROM for R2 at a stretching velocity of V1, grading
the quality of muscle reaction at the stretching
velocity of V2; and measuring R1 for the angle of
muscle reaction. The rater measured first the R2
with speed of V1 using a standard goniometer
For personal use only.
(Sammons Preston, Health Co, USA). One rater
positioned and measured the elbow PROM while
the other rater held the positioned limb. For PROM
measurement, a standard method was used [37].
The end position was elbow extension (180 denotes
full extension). One side of the goniometer was
covered to ensure blinding the raters. The value
was read from the other side of the goniometer. The
measuring raters recorded their results and no
discussion was allowed between the ‘measurer’ and
‘holder’. The Modified Tardieu Scale quality of
muscle reaction ranging from 0–4 (Table I) was then
rated at the V2 stretching velocity. Only one passive
movement was permitted for rating spasticity [19].
The point of spasticity-provoked ‘catch’ was
Table I. Modifid Tardieu Scale.*
Grade Description
0 No resistance throughout the course of the
passive movement
1 Slight resistance throughout the course of the
passive movement, with no clear catch at
precise angle
2 Clear catch at precise angle, interrupting the
passive movement, followed by release
3 Fatigable clonus (<10 seconds when main-
taining pressure) occurring at precise
angle
4 Infatigable clonus (>10 seconds when
maintaining pressure) occurring at precise
angle
*Boyd and Graham [30].
1009
measured as the MTS angle of reaction (R1) with
the above-mentioned goniometer and using the same
blinding procedure, if quality of muscle reaction
score was 2 or higher. The R1 was equal to R2, if the
patient scored ‘0’ or ‘1’. The test was repeated by the
second rater after a period of 10 minutes and the role
of the raters as ‘measurer’ and ‘holder’ was reversed.
Statistical analysis
Data were analysed using SPSS (V11.5). The one-
way random effects model (people effect random) of
intraclass correlation coefficient (ICC) was used.
The inter-rater reliability was calculated for the
Modified Tardieu Scale scores and R1, R2 and R2–
R1. For the Modified Tardieu Scale scores, the ICC
was also used as the weighted kappa with quadratic
weighting would be equivalent to the intraclass
correlation coefficient. The ICC values were inter-
preted as follows: 0.00–0.39 (low), 0.40–0.59
(moderate), 0.60–0.79 (moderately high) and
0.80–1.00 (high) [38]. Paired t-test was used to
analyse the difference between raters for measures
of R1, R2 and R2–R1.
Main outcomes and results
Thirty adult patients with hemiplegia with a mean
age of 54.9 years (SD 15.7, range 21–79), consisting
of 21 men and nine women and 19 right and 11 left
hemiplegics were included in the study. The mean
time since brain injury was 24.8 months (SD 21.5,
range 1–86). The diagnoses were stroke (n ¼ 26),
intracerebral haemorrhage (n ¼ 3) and traumatic
brain injury (n ¼ 1).
Table II shows the reliability results and the mean
and range for MTS measures for each of the raters.
While the ICC values for R1 and R2–R1 were
moderately high, the ICC value for R2 was
moderate. Mean absolute differences in measure-
ments of the elbow joint angle (R2) and catch angle
(R1) between raters were 6.7 (range 0–20; 95% CI
4.8–8.6) and 18.6 (range 0–87; 95% CI 11.5–25.7),
respectively. Mean absolute difference of R2–R1
between raters was 17.4 (range 0–93; 95% CI
9.7–25.2). Paired t-test demonstrated no significant
difference between raters for R1, R2 and R2–R1
( p > 0.05).
Inter-rater reliability for the MTS scores was
moderately high. The MTS scores for quality of
muscle reaction ranged between 0–2. None of the
raters scored ‘3’ or ‘4’ for any subjects. The raters
showed agreement for scores ‘2’ (19 patients), ‘1’
(3 patients), and ‘0’ (1 patient), respectively. The
disagreement was observed between the grades ‘0’
and ‘1’ (4 patients) and ‘1’ and ‘2’ (3 patients),
respectively (Table III).
 1010 N. N. Ansari et al.

Table II. The results for measurements of R1, R2 and R2–R1.

MTS measures M (SD) Range 95% CI ICC (95% CI), p-value

R1 Rater 1 118.57 (33.28) 80–173

Rater 2 112.93 (41.07) 60–180 106.34–125.16 0.74 (0.52–0.87), p < 0.001
R2 Rater 1 166.37 (7.84) 143–178
Rater 2 165.63 (10.13) 140–180 163.73–168.27 0.56 (0.26–0.76), p ¼ 0.0004
R2–R1 Rater 1 47.80 (33.29) 0–88
Rater 2 52.70 (39.98) 0–105 41–59.5 0.72 (0.50–0.86), p < 0.001

R1: Angle of muscle reaction; R2: passive range of motion; R2–R1: dynamic component or spasticity.

Table III. Agreement between raters for quality of [39, 40]. The speed of movement used in this study
muscle reaction of Modified Tardieu Scale (n ¼ 30). for measuring spasticity was V2. Mehrholz et al. [32]
Rater 2 used V3 for stretching elbow flexors. The V3 speed
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of movement for quantifying the muscle reaction is

Rater 1 0 1 2 3 4 Total not recommended for elbow flexors [30, 31]. The
0 1 0 0 1 literature suggests different speeds (V2 or V3) for
1 4 3 1 8 passive stretch of different muscles groups [30, 31].
2 0 2 19 21 The joint angle and the degree of muscle reaction
3 both are velocity dependent [26]. Thus, it may be
4
more appropriate to use a single fast velocity (V3) for
Total 5 5 20 30
muscle groups to achieve a spastic catch.
Intraclass correlation coefficient (ICC) ¼ 0.74, 95% Clonus can usually be generated by rapid passive
Confidence Interval: 0.53–0.87. stretch of muscles [39]. Therefore, the velocity used
For personal use only.

for stretching of muscle in the present study did not

Discussion
To the authors’ knowledge, this is the first report on
the inter-rater reliability of all MTS measures in an
adult population with hemiplegia. The reliability
for MTS scores did not reach high level. The reason
may be that the raters were inexperienced. Neither
had they been trained for using the scale before
the study commenced, nor did they have sufficient
experience in handling patients with hemiplegia and
measuring muscle spasticity. In the study by
Mehrholz et al. [32], despite participation of
experienced physical therapists, moderate-to-very
good reliability for various muscle groups were
found. There was not consistent good reliability
observed over all muscle groups. Although experi-
ence and training in the assessment of muscle
spasticity may increase the reliability, these results
raise questions about the validity of the MTS. The
scale has been stated to be simple to utilize for rating
spasticity [25]; so a high agreement was expected for
quality of muscle reaction between raters.
A limited range of scores was selected by the
raters. A full spectrum of MTS scores was also not
achieved in the study by Mehrholz et al. [32]. The
grades of ‘3’ and ‘4’ were not scored in the present
study. One reason may be the velocity used for
passive stretching of muscle. The spasticity is
velocity dependent [2] and with increase in stretch
velocity, resistance to passive movement increases
appear to be fast enough to elicit clonus. However,
clonus can not be evoked in all muscles [26].
Clonus, although related to spasticity, is a separate,
excess symptom that differs from spasticity [25, 26].
Setting the presence of clonus as the highest level of
spasticity in MTS reduces the quality of the muscle
reaction as nominal data and questions the validity
of the scale [25]. The reason for absence of scores ‘3’
and ‘4’ in the assigned scores may be that the clonus
is an independent phenomenon. The most agree-
ment was found for assigned score of ‘2’. This may
indicate that the MTS may provide more reliable
measurements with spastic muscles. A study with
inclusion of patients having the whole grades on the
scale is warranted to test this hypothesis.
Results from this study showed moderate and
moderately high reliability for R2 and R1, respec-
tively, despite the fact that the raters were assisting
each other which is not the same level of indepen-
dent measurement when raters are truly blinded.
In order to measure R2 and R1 reliably, sufficient
training and practice to the raters might be needed
[33]. The raters in the present study were not given
such training. The aim was for the situation to
resemble the clinical context, where newly trained
physical therapists may be asked to examine these
types of patients. The measurement differences
between these raters for R2 and R1 were high,
which is in agreement with previous studies report-
ing large variability in the magnitude of angular
measurements [33, 34]. The amount of experience
 Spasticity assessment with modified Tardieu scale
of the raters and the degree preparation to use the
scale might be factors that played roles in this study.
In previous investigations, the level of reliability was
unchanged by training and experience, such that
the participation of experienced raters [32, 33, 35],
more training sessions [32], training workshop [33]
and familiarity with scale [35] did not improve the
reliability. Therefore, the problem may be that
the scale itself is not suitable for the clinical use.
These raters explained that the differences in the
degree of patients’ muscle spasticity and the postur-
ing of the limb might have contributed to moderate
reliability for R2, as these could have affected the
goniometry (aligning the arms of the goniometer
with the bony landmarks). Hence, the manual
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measurement of joint angles for R2 and R1 is likely
to be variable due to factors influencing the raters.
Raters also reported that the level of spasticity and
relaxation of some patients had changed between
trials.
Kilgour et al. [41], despite the participation of
experienced physical therapists in the study, found
significant errors in measurements. The difficulty
in determination of end range positioning has been
shown as a significant source of error in the
For personal use only.
measurement of joint angles [41]. It is therefore
important to establish the reliability of passive range
of motion in adult patients with spastic hemiplegia
and the acceptable magnitude of differences in joint
angle measurements between raters and within rater.
The variation in R1 measurements between raters
could be due to difficulty in accurate determination
of angle of catch. In a study to examine the validity
of the MAS, Pandyan et al. [21] found the ability
of the rater in identifying of the catch angle to be
unreliable. For patients with an MTS score of ‘2’,
differences of up to 40 for R1 were obtained. The
variations in R1 can be due to disagreement between
grades ‘1’ and ‘2’ or higher. The disagreement
between the score of 1 and 2 was found for three
patients in the current study which produced R1
errors of 67 , 50 and 87 . The variations in
R1 could also be due to errors in the measurement
of the end range for R2. Any difference between
raters for R2 end range can vary the R1 for patients
scored ‘0’ and ‘1’ by raters. This study observed an
R1 difference with a range of 2–17 . One possible
interpretation for R1 variations may be that the
R1 measurement is dependent upon the degree of
quality of muscle reaction to be 2 or higher.
Therefore, the second passive stretch of the muscle
for measuring catch angle (R1) might have changed
the angle of catch. Even one stretch can decrease
spasticity [22].
In the present study, the MTS measure of R2–R1
was not highly reliable, but highly variable (though
not statistically significant) between raters of limited
1011
experience, which suggests caution when using the
MTS. Previous reports have shown great variability
for R2–R1 [34, 41], so that the authors cast doubt
on the usefulness and the ability of the MTS for
measuring spasticity.
Conclusion
The current study did not find high inter-rater
reliability for R2–R1 measures of the Modified
Tardieu Scale. The other measures of the scale did
not reach the acceptable level of high reliability, as
well. Wide variations were noted in the measure-
ments of R1, R2 and R2–R1 between raters. Further
investigations are needed for the MTS before it is
suggested to be used commonly in the clinic and for
research purposes.
Acknowledgements
We are grateful to patients participating in this study.
Declaration of interest: The authors report no
conflicts of interest. The authors alone are respon-
sible for the content and writing of the paper.
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