BACKGROUND: Spasticity is a common feature in patients with disruptions in corticospinal pathways. However, the term is used ambiguously. Here, spasticity is defined as enhanced velocity-dependent stretch reflexes and placed within the context of deforming spastic paresis encompassing other forms of muscle overactivity. OBJECTIVE: This scoping review aims at evaluating the clinimetric quality of clinical outcome assessments (COAs) for spasticity across different pathologies and to make recommendations for their use. METHODS: A literature search was conducted to identify COAs used to assess spasticity. An international expert panel evaluated the measurement properties in the included COAs. Recommendations were based on the MDS-COA program methodology based on three criteria: if the COA was (1) applied to patients with spastic paresis, (2) used by others beyond the developers, and (3) determined to be reliable, valid, and sensitive to change in patients with spasticity. RESULTS: We identified 72 COAs of which 17 clinician-reported outcomes (ClinROs) and 6 patient-reported outcomes (PROs) were reviewed. The Tardieu Scale was the only ClinRO recommended for assessing spasticity. One ClinRO-Composite Spasticity Index-and two PROs-Spasticity 0-10 Numeric Rating Scale and 88-Item Multiple Sclerosis Spasticity Scale-were recommended with caveats. The Ashworth-derived COAs were excluded after evaluation due to their focus on muscle tone rather than spasticity, as defined in this review. CONCLUSIONS: The Tardieu Scale is recommended for assessing spasticity, and two PROs are recommended with caveats. Consistent terminology about the various types of muscle overactivity is necessary to facilitate their assessment and treatment. © 2024 The Author(s). Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.

BIOTN Laboratory EA 7377 BIOTN Université Paris Est Créteil Créteil France

CIBERNED Institute of Health Carlos 3 Madrid Spain

Department of Medicine University of Alberta Edmonton Alberta Canada

Department of Neurological Sciences Rush University Medical Center Chicago Illinois USA

Department of Neurology and Centre of Clinical Neuroscience 1st Faculty of Medicine Charles University Prague Czech Republic

Department of Neurology General University Hospital Prague Prague Czech Republic

Department of Neurology P J Šafárik University Košice Slovakia

Department of Neurology University Hospital of L Pasteur Košice Slovakia

Department of Physical Medicine and Rehabilitation CHU UCL Namur Site Godinne Yvoir Belgium

Division of Physical Medicine and Rehabilitation Glenrose Rehabilitation Hospital Edmonton Alberta Canada

Faculty of Medicine and Surgery Research Center for Health Sciences and Dept Of Neuroscience University of Santo Tomas Manila Philippines

Jefferson Moss Magee Rehabilitation Philadelphia Pennsylvania USA

Movement Disorders Unit Neurology Department Hospital Universitario Instituto de Investigación Sanitaria 12 de Octubre Madrid Spain

National Centre of Epidemiology Institute of Health Carlos 3 Madrid Spain

Neurology and Psychosomatic at Wittenbergplatz Berlin Germany

Parkinson's Disease and Movement Disorders Clinic Division of Neurology Department of Medicine The Ottawa Hospital Research Institute Ottawa Ontario Canada

Service de Neurorééducation Université de Corse Centre Hospitalier de Bastia Bastia France

Service de Rééducation Neurolocomotrice Hôpitaux Universitaires Henri Mondor Assistance publique Hôpitaux de Paris Créteil France

University of Ottawa Brain and Mind Institute Ottawa Ontario Canada

University of Potsdam Potsdam Germany

Zobrazit více v PubMed

Gracies JM. Coefficients of impairment in deforming spastic paresis. Ann Phys Rehabil Med 2015;58(3):173–178. PubMed

Gracies JM. Pathophysiology of spastic paresis. II: emergence of muscle overactivity. Muscle Nerve 2005;31(5):552–571. PubMed

Baude M, Nielsen JB, Gracies JM. The neurophysiology of deforming spastic paresis: a revised taxonomy. Ann Phys Rehabil Med 2019;62(6):426–430. PubMed

Katz RT. Rymer WZJAopm, rehabilitation. Spastic hypertonia: Mech Meas 1989;70(2):144–155. PubMed

Li S, Francisco GE. Current concepts in assessment and management of spasticity. In: Wilson RRP, ed. Stroke Rehabilitation. St. Louis, Missouri: Elsevier; 2019:133–154.

Mosso A. Description d'un myotonomètre pour étudier la tonicité des muscles chez l'hommne. Arch ital de biol 1896;3:1–36.

Smith AE, Martin DS, Garvey PH, Fenn WO. A dynamic method for measurement of muscle tonus in man. J Clin Invest 1930;8(4):597–622. PubMed PMC

Pandyan AD, Gregoric M, Barnes MP, Wood D, Van Wijck F, Burridge J, et al. Spasticity: clinical perceptions, neurological realities and meaningful measurement. Disabil Rehabil 2005;27(1–2):2–6. PubMed

Lance JWFR, Young RR, Koeller C. Spasticity: Disorder of Motor Control. Chicago, IL: Year Book Medical; 1980:485–494.

Li S, Francisco GE, Rymer WZ. A new definition of poststroke spasticity and the interference of spasticity with motor recovery from acute to chronic stages. Neurorehabil Neural Repair 2021;35(7):601–610. PubMed

Gracies J‐MA K, Biering‐Sørensen B, Dewald JPA, et al. For the Spasticity Study Group of the International Movement Disorders Society. Spastic Paresis: Treatable Movement Disorder. Submitted to Movement Disorders Journal; 2024.

Ashworth B. Preliminary trial of Carisoprodol in multiple sclerosis. Practitioner 1964;192:540–542. PubMed

Pandyan AD, Price CI, Barnes MP, Johnson GR. A biomechanical investigation into the validity of the modified Ashworth scale as a measure of elbow spasticity. Clin Rehabil 2003;17(3):290–293. PubMed

Pandyan AD, Price CI, Rodgers H, Barnes MP, Johnson GR. Biomechanical examination of a commonly used measure of spasticity. Clin Biomech (Bristol, Avon) 2001;16(10):859–865. PubMed

Bakheit AM, Maynard VA, Curnow J, Hudson N, Kodapala S. The relation between Ashworth scale scores and the excitability of the alpha motor neurones in patients with post‐stroke muscle spasticity. J Neurol Neurosurg Psychiatry 2003;74(5):646–648. PubMed PMC

Patrick E, Ada L. The Tardieu scale differentiates contracture from spasticity whereas the Ashworth scale is confounded by it. Clin Rehabil 2006;20(2):173–182. PubMed

Fleuren JF, Voerman GE, Erren‐Wolters CV, Snoek GJ, Rietman JS, Hermens HJ, et al. Stop using the Ashworth scale for the assessment of spasticity. J Neurol Neurosurg Psychiatry 2010;81(1):46–52. PubMed

Skorvanek M, Goldman JG, Jahanshahi M, Marras C, Rektorova I, Schmand B, et al. Global scales for cognitive screening in Parkinson's disease: critique and recommendations. Mov Disord 2018;33(2):208–218. PubMed

Holmefur M, Aarts P, Hoare B, Krumlinde‐Sundholm L. Test‐retest and alternate forms reliability of the assisting hand assessment. J Rehabil Med 2009;41(11):886–891. PubMed

Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics 1977;33(1):159–174. PubMed

Terwee CB, Bot SD, de Boer MR, van der Windt DA, Knol DL, Dekker J, et al. Quality criteria were proposed for measurement properties of health status questionnaires. J Clin Epidemiol 2007;60(1):34–42. PubMed

Husted JA, Cook RJ, Farewell VT, Gladman DD. Methods for assessing responsiveness: a critical review and recommendations. J Clin Epidemiol 2000;53(5):459–468. PubMed

Carr JH, Shepherd RB, Nordholm L, Lynne D. Investigation of a new motor assessment scale for stroke patients. Phys Ther 1985;65(2):175–180. PubMed

Fugl‐Meyer AR, Jääskö L, Leyman I, Olsson S, Steglind S. The post‐stroke hemiplegic patient. 1. A method for evaluation of physical performance. Scand J Rehabil Med 1975;7(1):13–31. PubMed

Merkel SI, Voepel‐Lewis T, Shayevitz JR, Malviya S. The FLACC: a behavioral scale for scoring postoperative pain in young children. Pediatr Nurs 1997;23(3):293–297. PubMed

Gracies JM, Marosszeky JE, Renton R, Sandanam J, Gandevia SC, Burke D. Short‐term effects of dynamic lycra splints on upper limb in hemiplegic patients. Arch Phys Med Rehabil 2000;81(12):1547–1555. PubMed

Levin MF, Hui‐Chan CW. Relief of hemiparetic spasticity by TENS is associated with improvement in reflex and voluntary motor functions. Electroencephalogr Clin Neurophysiol 1992;85(2):131–142. PubMed

Farrar JT, Troxel AB, Stott C, Duncombe P, Jensen MP. Validity, reliability, and clinical importance of change in a 0‐10 numeric rating scale measure of spasticity: a post hoc analysis of a randomized, double‐blind, placebo‐controlled trial. Clin Ther 2008;30(5):974–985. PubMed

Hobart JC, Riazi A, Thompson AJ, Styles IM, Ingram W, Vickery PJ, et al. Getting the measure of spasticity in multiple sclerosis: the multiple sclerosis spasticity scale (MSSS‐88). Brain 2006;129(Pt 1):224–234. PubMed

Snow BJ, Tsui JK, Bhatt MH, Varelas M, Hashimoto SA, Calne DB. Treatment of spasticity with botulinum toxin: a double‐blind study. Ann Neurol 1990;28(4):512–515. PubMed

Love S, Gibson N, Smith N, Bear N, Blair E. Interobserver reliability of the Australian spasticity assessment scale (ASAS). Dev Med Child Neurol 2016;58(Suppl 2):18–24. PubMed

Bleck EE. Orthopaedic Management in Cerebral Palsy. London: Mac Keith; 1987.

Jethwa A, Mink J, Macarthur C, Knights S, Fehlings T, Fehlings D. Development of the hypertonia assessment tool (HAT): a discriminative tool for hypertonia in children. Dev Med Child Neurol 2010;52(5):e83–e87. PubMed

Boyd RN, Graham HK. Objective measurement of clinical findings in the use of botulinum toxin type A for the management of children with cerebral palsy. Eur J Neurol 1999;6(S4):s23–s35.

Boyd RNBS, Ballieu CE, Graham HK. Validity of a clinical measure of spasticity in children with cerebral palsy in a double‐blinded randomized controlled clinical trial, abstract. Dev Med Child Neurol 1998;40:7.

Benz EN, Hornby TG, Bode RK, Scheidt RA, Schmit BD. A physiologically based clinical measure for spastic reflexes in spinal cord injury. Arch Phys Med Rehabil 2005;86(1):52–59. PubMed

Bates B. A Guide to Physical Examination and History Taking. 5th ed. Philadelphia: Lippincott; 1991.

Hallett M. NINDS myotatic reflex scale. Neurology 1993;43(12):2723. PubMed

Li F, Wu Y, Xiong L. Reliability of a new scale for measurement of spasticity in stroke patients. J Rehabil Med 2014;46(8):746–753. PubMed

Priebe MM, Sherwood AM, Thornby JI, Kharas NF, Markowski J. Clinical assessment of spasticity in spinal cord injury: a multidimensional problem. Arch Phys Med Rehabil 1996;77(7):713–716. PubMed

Worley JS, Bennett W, Miller G, Miller M, Walker B, Harmon C. Reliability of three clinical measures of muscle tone in the shoulders and wrists of poststroke patients. Am J Occup Ther 1991;45(1):50–58. PubMed

Takeuchi N, Kuwabara T, Usuda S. Development and evaluation of a new measure for muscle tone of ankle plantar flexors: the ankle plantar flexors tone scale. Arch Phys Med Rehabil 2009;90(12):2054–2061. PubMed

Stam J, van Crevel H. Reliability of the clinical and electromyographic examination of tendon reflexes. J Neurol 1990;237(7):427–431. PubMed

Jobin A, Levin MF. Regulation of stretch reflex threshold in elbow flexors in children with cerebral palsy: a new measure of spasticity. Dev Med Child Neurol 2000;42(8):531–540. PubMed

Drefus LC, Clarke S, Resnik K, Koltsov J, Dodwell ER, Scher DM. The root‐Ely modified test of rectus Femoris spasticity has reliability in individuals with cerebral palsy. HSS J: Musculoskeletal J Hospital Special Surg 2018;14(2):143–147. PubMed PMC

Scholtes VA, Dallmeijer AJ, Knol DL, Speth LA, Maathuis CG, Jongerius PH, et al. Effect of multilevel botulinum toxin a and comprehensive rehabilitation on gait in cerebral palsy. Pediatr Neurol 2007;36(1):30–39. PubMed

Barnes S, Gregson J, Leathley M, Smith T, Sharma A, Watkins C. Development and inter‐rater reliability of an assessment tool for measuring muscle tone in people with hemiplegia after a stroke. Physiotherapy 1999;85(8):405–409.

Marsico P, Frontzek‐Weps V, van Hedel HJA. Velocity dependent measure of spasticity: reliability in children and juveniles with neuromotor disorders. J Pediatr Rehabil Med 2021;14(2):219–226. PubMed

Wartenberg R. Pendulousness of the legs as a diagnostic test. Neurology 1951;1(1):18–24. PubMed

Barker S, Horton M, Kent RM, Tennant A. Development of a self‐report scale of spasticity. Top Stroke Rehabil 2013;20(6):485–492. PubMed

Milinis K, Tennant A, Mills RJ, Al‐Chalabi A, Burke G, Dick DJ, et al. Development and validation of spasticity index‐amyotrophic lateral sclerosis. Acta Neurol Scand 2018;138(1):47–54. PubMed

Gracies JM, Bayle N, Vinti M, Alkandari S, Vu P, Loche CM, et al. Five‐step clinical assessment in spastic paresis. Eur J Phys Rehabil Med 2010;46(3):411–421. PubMed

Gracies JM, Esquenazi A, Brashear A, Banach M, Kocer S, Jech R, et al. Efficacy and safety of abobotulinumtoxinA in spastic lower limb: randomized trial and extension. Neurology 2017;89(22):2245–2253. PubMed PMC

Winston P, Mills PB, Reebye R, Vincent D. Cryoneurotomy as a percutaneous mini‐invasive therapy for the treatment of the spastic limb: case presentation, review of the literature, and proposed approach for use. Arch Rehab Res Clin Transl 2019;1(3–4):100030. PubMed PMC

Gracies JM, Burke K, Clegg NJ, Browne R, Rushing C, Fehlings D, et al. Reliability of the Tardieu scale for assessing spasticity in children with cerebral palsy. Arch Phys Med Rehabil 2010;91(3):421–428. PubMed

Baude M, Loche CM, Gault‐Colas C, Pradines M, Gracies JM. Intra‐ and inter‐raters reliabilities of a stepped clinical assessment of chronic spastic paresis in adults. Ann Phys Rehabil Med 2015;58:e4–e5.

Singh P, Joshua AM, Ganeshan S, Suresh S. Intra‐rater reliability of the modified Tardieu scale to quantify spasticity in elbow flexors and ankle plantar flexors in adult stroke subjects. Ann Indian Acad Neurol 2011;14(1):23–26. PubMed PMC

Akpinar P, Atici A, Ozkan FU, Aktas I, Kulcu DG, Sarı A, et al. Reliability of the modified Ashworth scale and modified Tardieu scale in patients with spinal cord injuries. Spinal Cord 2017;55(10):944–949. PubMed

Ansari NN, Naghdi S, Hasson S, Rastgoo M, Amini M, Forogh B. Clinical assessment of ankle plantarflexor spasticity in adult patients after stroke: inter‐and intra‐rater reliability of the modified Tardieu scale. Brain Inj 2013;27(5):605–612. PubMed

Pradines M, Baude M, Marciniak C, Francisco G, Gracies JM, Hutin E, et al. Effect on passive range of motion and functional correlates after a long‐term lower limb self‐stretch program in patients with chronic spastic paresis. PM R 2018;10(10):1020–1031. PubMed

Pradines M, Poitou T, Gál O, Hoskovcová M, Bayle N, Baude M, et al. Where is the zero of Tardieu for proximal trans‐joint lower limb muscles? The relevance for the estimation of muscle shortening and weakness. Front Neurol 2023;14:1–4. PubMed PMC

Van't Veld RC, Flux E, van Oorschot W, Schouten AC, van der Krogt MM, van der Kooij H, et al. Examining the role of intrinsic and reflexive contributions to ankle joint hyper‐resistance treated with botulinum toxin‐a. J Neuroeng Rehabil 2023;20(1):19. PubMed PMC

Pradines M, Ghedira M, Portero R, Masson I, Marciniak C, Hicklin D, et al. Ultrasound structural changes in triceps Surae after a 1‐year daily self‐stretch program: a prospective randomized controlled trial in chronic hemiparesis. Neurorehabil Neural Repair 2019;33(4):245–259. PubMed

Bhadane MY, Gao F, Francisco GE, Zhou P, Li S. Correlation of resting elbow angle with spasticity in chronic stroke survivors. Front Neurol 2015;6:183. PubMed PMC

Chan CWY. Motor and sensory deficits following a stroke: relevance to a comprehensive evaluation. Physiother Can 1986;38:29–34.

Calota A, Levin MF. Tonic stretch reflex threshold as a measure of spasticity: implications for clinical practice. Top Stroke Rehabil 2009;16(3):177–188. PubMed

Goulet C, Arsenault AB, Bourbonnais D, Laramée MT, Lepage Y. Effects of transcutaneous electrical nerve stimulation on H‐reflex and spinal spasticity. Scand J Rehabil Med 1996;28(3):169–176. PubMed

Levin MF, Selles RW, Verheul MH, Meijer OG. Deficits in the coordination of agonist and antagonist muscles in stroke patients: implications for normal motor control. Brain Res 2000;853(2):352–369. PubMed

Levin MF, Hui‐Chan C. Are H and stretch reflexes in hemiparesis reproducible and correlated with spasticity? J Neurol 1993;240(2):63–71. PubMed

Ng SS, Hui‐Chan CW. The timed up & go test: its reliability and association with lower‐limb impairments and locomotor capacities in people with chronic stroke. Arch Phys Med Rehabil 2005;86(8):1641–1647. PubMed

Nadeau S, Arsenault AG, Gravel D, Lepage Y, Bourbonnais D. Analysis of the spasticity index used in adults with a stroke. Can J Rehab 1998;11:219–220.

Anwar K, Barnes MP. A pilot study of a comparison between a patient scored numeric rating scale and clinician scored measures of spasticity in multiple sclerosis. NeuroRehabilitation 2009;24(4):333–340. PubMed

Tsai S, Blackburn J, Gaebler‐Spira D. Validation of the 0–10 numeric rating scale measure of spasticity in children with cerebral palsy. J Pediatr Neurol 2016;14: (01):12–16.

Patti F, Messina S, Solaro C, Amato MP, Bergamaschi R, Bonavita S, et al. Efficacy and safety of cannabinoid oromucosal spray for multiple sclerosis spasticity. J Neurol Neurosurg Psychiatry 2016;87(9):944–951. PubMed PMC

Stampacchia G, Rustici A, Bigazzi S, Gerini A, Tombini T, Mazzoleni S. Walking with a powered robotic exoskeleton: subjective experience, spasticity and pain in spinal cord injured persons. NeuroRehabilitation 2016;39(2):277–283. PubMed

Rodic SZ, Knezevic TI, Kisic‐Tepavcevic DB, Dackovic JR, Dujmovic I, Pekmezovic TD, et al. Validation of the Serbian version of multiple sclerosis spasticity scale 88 (MSSS‐88). PLoS One 2016;11(1):e0147042. PubMed PMC

Henze T, von Mackensen S, Lehrieder G, Zettl UK, Pfiffner C, Flachenecker P. Linguistic and psychometric validation of the MSSS‐88 questionnaire for patients with multiple sclerosis and spasticity in Germany. Health Qual Life Outcomes 2014;12:119. PubMed PMC

Freeman J, Gorst T, Ofori J, Marsden J. Evaluation of the multiple sclerosis spasticity scale 88: a short report. Rehab Process Outcome 2019;8:1–4. PubMed PMC

Knežević T, Rodić SZ, Foti C, Nikolić‐Drulović J, Dujmovic I, Konstantinović LM. Subscale Correlations between MSSS‐88 and PRISM Scales in Evaluation of Spasticity for Patients with Multiple Sclerosis. Srpski arhiv za celokupno lekarstvo 2017;145(9‐10):481–485.

Ottonello M, Pellicciari L, Centonze D, Foti C, Pistarini C, Albensi C, et al. The cross‐cultural adaptation and psychometric validation of the MSSS‐88 for use in Italian patients with multiple sclerosis. Disabil Rehabil 2019;41(4):465–471. PubMed

Lecharte T, Gross R, Nordez A, Le Sant G. Effect of chronic stretching interventions on the mechanical properties of muscles in patients with stroke: a systematic review. Ann Phys Rehabil Med 2020;63(3):222–229. PubMed

Gross R, Verduzco‐Gutierrez M, Draulans N, Zimerman M, Francisco GE, Deltombe T. Module 3: Surg Manag Spasticity. Journal of the International Society of Physical and Rehabilitation Medicine 2022;5(Suppl 1):S38–S49.

Deltombe T, Wautier D, De Cloedt P, Fostier M, Gustin T. Assessment and treatment of spastic equinovarus foot after stroke: guidance from the Mont‐Godinne interdisciplinary group. J Rehabil Med 2017;49(6):461–468. PubMed

Simpson DM, Hallett M, Ashman EJ, Comella CL, Green MW, Gronseth GS, et al. Practice guideline update summary: botulinum neurotoxin for the treatment of blepharospasm, cervical dystonia, adult spasticity, and headache. Rep the Guid Dev Subcommittee Am Acad Neurol 2016;86(19):1818–1826. PubMed PMC

Biering‐Soerensen B, Stevenson V, Bensmail D, Grabljevec K, Martínez Moreno M, Pucks‐Faes E, et al. European expert consensus on improving patient selection for the management of disabling spasticity with intrathecal baclofen and/or botulinum toxin type a. J Rehabil Med 2022;54:1–13. PubMed PMC

Wissel J, Ward AB, Erztgaard P, Bensmail D, Hecht MJ, Lejeune TM, et al. European consensus table on the use of botulinum toxin type a in adult spasticity. J Rehabil Med 2009;41(1):13–25. PubMed

Cramer SC, Sur M, Dobkin BH, O'Brien C, Sanger TD, Trojanowski JQ, et al. Harnessing neuroplasticity for clinical applications. Brain 2011;134(Pt 6):1591–1609. PubMed PMC

Winstein C, Varghese R. Been there, done that, so what's next for arm and hand rehabilitation in stroke? NeuroRehabilitation 2018;43(1):3–18. PubMed

Gracies JM, Francisco GE, Jech R, Khatkova S, Rios CD, Maisonobe P. Guided self‐rehabilitation contracts combined with AbobotulinumtoxinA in adults with spastic paresis. J Neurol Phys Ther: JNPT 2021;45(3):203–213. PubMed PMC

Bohannon RW, Smith MB. Interrater reliability of a modified Ashworth scale of muscle spasticity. Phys Ther 1987;67(2):206–207. PubMed

Ansari NN, Naghdi S, Younesian P, Shayeghan M. Inter‐ and intrarater reliability of the modified modified Ashworth scale in patients with knee extensor poststroke spasticity. Physiother Theory Pract 2008;24(3):205–213. PubMed

Haas BM, Bergström E, Jamous A, Bennie A. 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 1996;34(9):560–564. PubMed

Platz T. Personal Communication about REPAS Via Email; 2023.

Deltombe T, Decq P, Mertens P, Gustin T. Does fascicular neurotomy have long‐lasting effects? J Rehabil Med 2007;39(5):421–422. PubMed