title: Occurence and Clinical Predictors of Spasticity After Ischemic Stroke Reliability of potential clinical measures of muscle tone in the elbows of patients after stroke. Validation of portable muscle tone measurement device for quantifying velocity-dependent properties in elbow spasticity. The correlation between Modified Ashworth Scale scores and the new index of alpha motoneurones excitability in post-stroke patients. Inter-rater reliability of the Modified Modified Ashworth Scale as a clinical tool in measurements of post-stroke elbow flexor spasticity. The relation between Ashworth scale scores and the excitability of the α motor neurones in patients with post-stroke muscle spasticity Is stroke the most common cause of disability? Ashworth Scales are unreliable for the assessment of muscle spasticity The unreliability of clinical measures of muscle tone: implications for stroke therapy.
abstract: Background and Purpose — There is currently no consensus on ( 1 ) the percentage of patients who develop spasticity after ischemic stroke , ( 2 ) the relation between spasticity and initial clinical findings after acute stroke , and ( 3 ) the impact of spasticity on activities of daily living and health-related quality of life . Methods — In a prospect i ve cohort study , 301 consecutive patients with clinical signs of central paresis due to a first-ever ischemic stroke were examined in the acute stage and 6 months later . At both times , the degree and pattern of paresis and muscle tone , the Barthel Index , and the EQ-5D score , a st and ardized instrument of health-related quality of life , were evaluated . Spasticity was assessed on the Modified Ashworth Scale and defined as Modified Ashworth Scale > 1 in any of the examined joints . Results — Two hundred eleven patients ( 70.1 % ) were reassessed after 6 months . Of these , 42.6 % ( n=90 ) had developed spasticity . A more severe degree of spasticity ( Modified Ashworth Scale ≥3 ) was observed in 15.6 % of all patients . The prevalence of spasticity did not differ between upper and lower limbs , but in the upper limb muscles , higher degrees of spasticity ( Modified Ashworth Scale ≥3 ) were more frequently ( 18.9 % ) observed than in the lower limbs ( 5.5 % ) . Regression analysis used to test the differences between upper and lower limbs showed that patients with more severe paresis in the proximal and distal limb muscles had a higher risk for developing spasticity ( P≤0.001 ) . Spasticity of the upper and lower limb was more frequent in patients with hemihypesthesia than in patients without sensory deficits ( P≤0.001 ) . Patients with spasticity showed a lower Barthel Index and EQ-5D score compared with the group without spasticity . Conclusions — Spasticity was present in 42.6 % of patients with initial central paresis . However , severe spasticity was relatively rare . Predictors for the development of spasticity were a severe degree of paresis and hemihypesthesia at stroke onset OBJECTIVES This study investigated the reliability of  joint resting position ( EJP ) , resistance to passive movement ( ERM ) , and the angle of appearance of the resistance ( EAR )  as measures of muscle hypertonus of elbow flexors in patients after stroke . Previously , similar measures had been found reliable when applied to measuring shoulder and wrist hypertonus in patients after stroke . METHOD Forty-five subjects with stroke were r and omly selected from occupational therapy admissions at two rehabilitation centers .  Tone of elbow flexors was measured twice at the same sitting by two examiners . EJP and EAR were measured with a goniometer , and ERM was measured with a resistance rating scale .  Correlations were calculated between first and second measurements by center and by high tone and poor upper extremity function subgroups ( with correction for multiple correlations ) to determine reliability . RESULTS Each of the three measures was highly reliable as demonstrated by a high correlation in at least one of the subgroups ( Center 1 : EJP , r = .964 for high tone subgroup ; ERM , r = .789 , EAR , r = .902 , both in poor upper extremity function subgroup ; and Center 2 : EJP , r = .892 , ERM , r = .938 , both in poor upper extremity function subgroup ; EAR , r = .666 for all subjects ; all p values < .05 ) . Correlations were especially high when data for subjects with high upper extremity function were eliminated . CONCLUSION Reliability of these three methods of measuring upper extremity muscle tone enhances their usefulness as well as therapists ' confidence in their judicial application The objective of this study is to develop a portable device for quantifying the velocity-dependent properties of spastic elbow muscles .  Based on a motor-driven system , validation tests of the portable system such as accuracy and response of sensors were first examined . Furthermore , simulated modules ( inertia , damper and spring ) as well as elbow joints ( 15 control and 15 hemiplegic subjects ) were manually stretched under four different frequencies ( 1/3 , 1/2 , 1 and 3/2 Hz ) through 60 degrees range of motion . Joint resistance and displacement during sinusoidal stretch were collected for further analysis . Two quantitative parameters ( i.e. , viscous components under each frequency and averaged viscosity across four frequencies ) were derived to estimate the velocity-dependent properties of elbow joint . Tests of simulated modules confirm the manual stretch protocol and data analysis are valid in estimating the velocity-dependent component during a sinusoidal stretch . Compared to normal control , viscous component in each stretch frequency and averaged viscosity were significantly higher in subjects with spasticity ( P < 0.001 ) . The viscous component and averaged viscosity were found highly correlated with the modified Ashworth scale . These findings suggest that measurements of viscous component and averaged viscosity during manual sinusoidal stretching using the portable device could be clinical ly useful in evaluating spasticity The  Modified Ashworth Scale ( MAS ) is currently a widely used clinical scale to evaluate muscle spasticity . However , it lacks reliability and the validity , of the MAS as a clinical measure of muscle spasticity has been challenged . The aim of the present study was to examine the validity of the MAS in patients with wrist flexor spasticity after stroke by using the Hslope/Mslope ( Hslp/Mslp ) ratio as the new index of alpha motoneuron excitability . Twenty-seven adult patients ( 14 women and 13 men ) with first ever stroke result ing in hemiplegia with a mean ( SD , range ) age of 57.9 ( 11.6 , 37 - 75 ) were included in the study . The main outcome measures were the  MAS for the clinical assessment of spasticity , and the Hslp/Mslp for the neurophysiological evaluation . There was not a significant correlation between the  MAS scores and Hslp/Mslp ratio ( r = 0.38 , p > 0.05 ) . The mean of the Hslp/Mslp did not show a hierarchical increase with the  MAS scores . The findings indicate that the MAS is not a valid and ordinal level measure of muscle spasticity Patients with neurological conditions may be affected by spasticity . The Modified Modified Ashworth Scale ( MMAS ) is a clinical tool used to measure spasticity . The purpose of the present study was to investigate the inter-rater reliability of the MMAS during the assessment of elbow flexor spasticity in adult patients with post-stroke hemiplegia . Twenty-one adult patients with stroke ( 5 women , 16 men ) with a median age of 60 years ( interquartile range , 47 - 68 ) were tested . Elbow flexors on the affected side were examined . Inter-rater reliability for two inexperienced raters was very good . The weighted Kappa value was 0.81 ( St and ard Error = 0.097 , 95 % CI : 0.62 - 1.00 , p = 0.0002 ) . The weighted percentage agreement was 97.4 % . The agreement between raters occurred mostly on score 1 ( 38.1 % ) followed by score 0 ( 23.8 % ) . The MMAS yielded reliable measurements between raters when used on patients post-stroke with elbow flexor spasticity Background : The  modified Ashworth scale ( MAS )  is the most widely used method for assessing muscle spasticity in clinical practice and research . However , the validity of this scale has been challenged . Objectives : To compare the MAS with objective neurophysiological tests of spasticity . Methods : The MAS was recorded in patients with post-stroke lower limb muscle spasticity and correlated with the excitability of the α motor neurones . The latter was evaluated by measuring the latency of the Hoffmann reflex ( H reflex ) and the ratio of the amplitude of the maximum H reflex ( Hmax ) to that of the compound action motor potential of the soleus muscle ( Mmax ) . Results : Data on 24 r and omly recruited patients were analysed . Patients were divided into two groups according to their MAS score : 14 had a MAS score of 1 ( group A ) and 10 scored 2 ( group B ) . The two groups were comparable with respect to age and sex , but in group A there was a longer period since the stroke . The H reflex latency was reduced and the Hmax : Mmax ratio was increased in both groups . The Hmax : Mmax ratio values were higher for group B but the differences were not statistically significant . Conclusions : There is a relation between the  MAS  scores and α motor neurone excitability , although it is not linear . This suggests that the MAS measures muscle hypertonia rather than spasticity BACKGROUND It is widely stated that stroke is the most common cause of severe disability . We aim ed to examine whether this cl aim is supported by any evidence . METHODS We conducted secondary analysis of the Office of National Statistics 1996 Survey of Disability , United Kingdom . This was a multistage stratified r and om sample of 8683 noninstitutionalized individuals aged between 16 and 101 years , mean 62 years , response rate 83 % ( n = 8816 ) . The outcome used was the Office of Population Censuses and Surveys severity scale for disability . Odds ratios and population -attributable fractions were calculated to examine the associations between diagnoses and disability . RESULTS Logistic regression modelling suggests that , after adjustment for comorbidity and age , those with stroke had the highest odds of reporting severe overall disability ( odds ratio 4.88 , 95 % confidence interval [ CI ] 3.37 - 6.10 ) . Stroke was also associated with more individual domains of disability than any of the other conditions considered . Adjusted population -attributable fractions were also calculated and indicated that musculoskeletal disorders had the highest population -attributable fraction ( 30.3 % , 95 % CI 26.2 - 34.1 ) followed by mental disorders ( 8.2 % , 95 % CI 6.9 - 9.5 ) and stroke ( 4.5 % , 95 % CI 3.6 - 5.3 ) . CONCLUSION Stroke is not the most common cause of disability among the noninstitutionalized United Kingdom population . However , stroke is associated with the highest odds of reporting severe disability . Importantly , stroke is associated with more individual domains of disability compared with other conditions and might be considered to be the most common cause of complex disability Ashworth  Scales  are the most widely used tests to assess the severity of muscle spasticity . These scales offer qualitative and subjective information ; consequently , there are issues concerning validity and reliability . This article presents the results of a study comparing interrater reliability of the original and of the modified Ashworth Scales for measuring muscle spasticity in elbow flexors . Fifteen patients with hemiplegia ( nine men and six women ) with a median age of 52 years ( interquartile range , 28–64 ) participated in this study . Two physiotherapists rated the muscle tone of elbow flexors according to ratings criteria of the  Ashworth and the  modified Ashworth Scales . Kappa values for the original Ashworth  and the modified Ashworth Scales were 0.17 ( SE = 0.21 ; p = 0.41 ) and 0.21 ( SE = 0.12 ; p = 0.08 ) , respectively . The scales showed similar levels of reliability ( χ2 = 0.0285 , df = 1 , p = 0.7 ) . The Ashworth Scales  are not reliable for the assessment of muscle spasticity . In the absence of interrater reliability , the validity of the measurements may also be question ed BACKGROUND the central tenet of the neurofacilitatory approach to stroke therapy is that muscle tone needs to be normal before normal movement can occur . A reliable clinical measure of the full spectrum of muscle tone is needed to test : ( i ) the purported relationship between muscle tone , other motor impairments and disability , and ( ii ) the effectiveness of stroke therapy to restore movement . AIM the purpose of the study was to test the inter-rater reliability of clinical categorization of muscle tone ( spastic/normal/flaccid ) and also a visual analogue scale with anchor points of ' lowest tone possible ' ( score 0 ) and ' highest tone possible ' ( score 100 ) . METHODS four independent raters assessed  tone  of  elbow flexors and knee extensors of 14 stroke rehabilitation in patients using the categorical scale . Six independent raters assessed tone of elbow flexors and knee extensors of 25 chronic stroke patients and two healthy volunteers using the visual analogue scale . All assessment orders were r and omized . RESULTS both scales were unreliable , with K coefficients for the categorical scale ranging from -0.046 to 0.56 for the categorical scale , and intra-class correlation coefficients for the visual analogue scale of 0.595 for elbow flexors and 0.451 for knee extensors . Assessment order effects for the visual analogue scale were non-significant for elbow flexors ( P= 0.545 ) and knee extensors ( P= 0.911 ) . CONCLUSIONS these results , and those of earlier studies , suggest that clinical measures of muscle tone are consistently unreliable . Systematic investigation of the therapy rationale for planning and evaluating treatment is required before relevant clinical measures can be developed
target: None of the review ed measurement tools demonstrated satisfactory results for all psychometric properties evaluated , and the majority lacked evidence concerning validity and absolute reliability .
  This systematic review found limited evidence to support the use of most of clinical measures of spasticity for people post-stroke .
  This review identified various clinical measures of spasticity that have been investigated in people after stroke .
background: PURPOSE To identify and appraise the literature on clinical measures of spasticity that has been investigated in people after stroke .