Modified Ashworth

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

Description Original Ashworth Scale:

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

Modified Ashworth Scale:

 Similar to Ashworth, but adds a 1+ scoring category to indicate resistance through less
than half of the movement (Bohannon & Smith, 1987)

Scoring  0 No increase in muscle tone

 1 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+ Slight increase in muscle tone, manifested by a catch, followed by minimal resistance
throughout the remainder (less than half) of the ROM
 2 More marked increase in muscle tone through most of the ROM, but affected part(s)
easily moved
 3 Considerable increase in muscle tone, passive movement difficult
 4 Affected part(s) rigid in flexion or extension

ICF Domain Body Structure

Time to Administer < 5 minutes
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
 Traumatic Brain Injury
 Stroke
 Spinal Cord Injury
 Multiple Sclerosis

Test-retest Reliability Modified Ashworth Scale

Acute 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)

 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)

Chronic 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
 Modified Ashworth

since injury 14.1 months)

 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

Interrater/Intrarater Modified Ashworth Scale

Acute Stroke: (Blackburn et al, 2002)

Reliability
 Adequate intrarater reliability. Agreement ranged from 57.5% (Kendall Tau-b = .44) to
85% (Kendall Tau-b = .66)
 Poor interrater reliability. Agreement ranged from 50% (Kendall Tau-b = .20) to 42.5%
(Kendall Tau-b = .16)
o 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.

Patients with severe cerebral damage: (Mehrholz et al, 2005)

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

Patients with central nervous system lesions: (Bohannon & Smith, 1987, n = 30, mean age = 59.3
(17.6) years)

 Excellent interrater reliability between two experienced raters (Kendall's tau: .847, p
< .001)

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

 Adequate interrater reliability (r =.727) for plantar flexor spasticity

Chronic 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)

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

Acute SCI: (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)

 Adequate interrater reliability (ICC = 0.56)

Original Ashworth Scale:

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

 Adequate intra-rater Reliability (across 10 raters)

Elbow Wrist Fingers Thumb

Overall weighted K .668 .740 .740 .680
p .998 .972 1.000 .985
 Adequate to excellent interrater reliability (depending on joint

Mean of evaluations 1 and 2 (Kendall W)

 Modified Ashworth

Elbow Wrist Fingers Thumb

.765 .598 .792 .611
Criterion Validity Modified Ashworth Scale
Traumatic Brain Injury: (Allison & Abraham, 1995, n = 34, mean age = 30.4 years)

(Predictive/Concurrent)
 Adequate concurrent validity with:
o Timed toe tapping (r = -.042)
o Reflex Threshold Angle (r = .49)
o H-reflex during dorsiflexion (r = .47)
o H-wave during vibration (r = .39)

Construct Validity Modified Ashworth Scale:

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

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

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

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

Content Validity Theoretical basis of the Modified Ashworth Scale:

Implicit assumptions: (Pandyan et al, 1999)

 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.

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)