What does the
clinical acceptance as a measure of spasticity of central or
Ashworth scale really
measure and are
instrumented
measures more valid
and precise?
Diane L Damiano* PhD PT;
Jeffrey M Quinlivan ME;
Bryan F Owen MS;
Patricia Payne BS PT;
Karen C Nelson MD;
Mark F Abel MD, University of Virginia, Department of
Orthopaedics, Charlottesville, VA, USA.
*Correspondence to first author at Washington University,
Human Performance Laboratory/Barnes-Jewish Hospitals,
4555 Forest Park Parkway, St. Louis, MO 63108, USA.
E-mail: dld6830@bjc.org
This study aimed to explore the limitations of the Ashworth
scale for measuring spasticity. An isokinetic dynamometer to
quantify resistance to passive stretch and surface EMG was
used to verify if a stretch response occurred and, if so, at what
joint angle. The authors sought to determine which
components of passive resistance (magnitude, rate of change,
onset angle of stretch, or velocity dependence) were most
related to Ashworth scores and which were related to motor
function in cerebral palsy (CP). Twenty-two individuals with
spastic CP (11 males, 11 females; mean age 11.9 years, SD 4.3)
and a comparison group of nine children without CP (four
males, five females; mean age 11.3 years, SD 2.5)participated
in the study. The group with CP included those with a
diagnosis of spastic diplegia, hemiplegia, or quadriplegia,
distributed across Gross Motor Functional Classification
Levels. Procedures included: (1) clinical assessment at the
knee joint, (2) functional assessments, and (3) isokinetic
assessment of passive resistance torque in hamstrings and
quadriceps at three velocities. EMG data were recorded
simultaneously to identify stretch responses. Detecting stretch
responses using the Ashworth scale compared with
instrumented measures showed near complete agreement at
extremes of the scale, with marked inconsistencies in mid-
range values. Ashworth scores were correlated with
instrumented measures, particularly for the quadriceps, with
higher correlations to the rate of change in resistance
(stiffness) and onset angle of stretch than to peak resistance
torque. Those with greater resistance tended to have poorer
function with isokinetic relations typically stronger.
112 Developmental Medicine & Child Neurology 2002, 44: 112118
The Ashworth scale (Ashworth 1964) has gained widespread
peripheral origin. Its use is also reported frequently in clinical
trials documenting changes in spasticity throughout the
course of a disease or as a result of an intervention. The classic
description had the examiner rate the amount of tone felt as a
limb was moved passively through its arc of motion (Table I).
Later modifications incorporated an estimation of how soon
in the motion, and how much during the motion, the resis-
tance was felt (Bohannon and Smith 1987). To our knowl-
edge, how this added specification may have affected the
validity of the scale for measuring spasticity has not been
addressed. An observed tendency for scores to cluster in the
mid-ranges has led some authors to spread out the middle
portion of the scale (Bohannon and Smith 1987). However,
poorer reliability may accompany the greater discriminatory
ability of this modification (Pandyan et al. 1999). Despite its
shortcomings and lack of consensus in the exact scoring, the
Ashworth scale with all of its variants remains the standard
with which other measures of spasticity are compared.
The clinical import of the Ashworth scale has not been well
established and is, in part, enmeshed in the controversy as to
whether spasticity has a significant or causal relationship with
motor performance (Sahrmann 1977). Ashworth scores are
consistently reduced in cerebral palsy (CP) after surgical inter-
ventions designed specifically to reduce spasticity (McLaughlin
et al. 1998, Butler et al. 2000). However, ordinal scales such as
the Ashworth may lack precision and sensitivity for measuring
and detecting smaller degrees of, or changes in spasticity. Even
though the Ashworth scale purportedly gauges the degree of
spasticity, which by definition is a heightened response to
stretch that is velocity dependent (Lance 1980), the test is per-
formed at a single, although moderately brisk, speed. Even
more importantly, the Ashworth scale does not quantify spas-
ticity exclusively, if at all; rather, it measures passive resistance
to motion that may or may not be caused by a heightened
stretch response. In order to develop a more valid and quanti-
tative measure of spasticity, or to identify components of spas-
ticity or resistance more precisely, multiple biomechanical
and electrophysiological methods have been developed.
These methods include, but are not limited to, H-reflex test-
ing (Angel and Hoffman 1963), quantification of deep tendon
reflexes (Zhang et al. 2000) and clonus (Hidler and Rymer
1999), resonant frequency tests (Price et al. 1991), ramp and
hold tests (Katz and Rymer 1989), pendulum tests (Bajd and
Vodonik 1984, Fowler et al. 2000), and instrumented torque
measurements during passive motion at preset velocities
(Broberg and Grimby 1983, Firoozbakhsh et al. 1993,
Engsberg et al. 1996, Perell et al. 1996, LaMontagne et al. 1998,
Akman et al. 1999, Damiano et al. 2001a). Each of these meth-
ods varies in the degree of expertise and special equipment
required, the neural or peripheral component measured, the
joints that can be tested, the reliability of the measurements,
and the correlation of the parameters obtained with clinical
and functional measures. Multiple reports have been pub-
lished describing, validating, and comparing these measures
in a variety of patient populations (Katz et al. 1992, Skinner
1992, Sehgal and McGuire 1998).
In this investigation, the goal was to determine the validity
of the Ashworth scale by using an isokinetic dynamometer to
quantify resistance to passive stretch in knee flexion and
extension, and EMG recording to verify if a stretch response
occurred and, if so, at what joint angle. Furthermore, we want-
ed to compare the multiple parameters quantified through
instrumentation, such as magnitude of resistance, change in
resistance with angle, onset angle of stretch, and velocity
dependency of each of these parameters, with those obtained
by the Ashworth scale, and also to relate each of these impair-
ment measures to validated functional scales. We chose to
employ an isokinetic device instead of other instrumented
a absence of stretch responses. We hypothesized that the severity
150
100
Angle
measures because this method closely simulates the Ashworth
scale; its use has been reported as reliable and valid in several
populations and it is clinically accessible (Broberg and Grimby
1983, Firoozbakhsh et al. 1993, Perell et al. 1996, Damiano et
al. 2001a). In this protocol, the isokinetic device was used to
move the knee joint passively at three preset velocities through
the arc of motion in flexion and extension while resistance
torque was measured and EMG data were also recorded to ver-
ify the state of muscle activation including the presence or
of the Ashworth scores would be directly related to the magni-
tude and rate of change in resistance torque and to an earlier
angle of onset of the stretch response. We further projected
that both clinical and instrumented measures would be related

to functional severity in CP.

50

0
Method
PARTICIPANTS

50 0 A total of 31 individuals gave their consent to participate in

0 1 1 2 2 3
this study including 22 (11 males, 11 females) patients with
Time (s)
spastic CP and a comparison group of nine (four males, five
females) normally developing children. The mean age for
the children included here with CP was 11.9 years (SD 4.3 ) and
EMG

Table I: Original Ashworth scale

Score Description

0 No increase in tone
0 0 1 1 2 2 3 1 Slight increase in tone giving a catch when the limb is
Time (s) moved in flexion or extension
b 2 More marked increase in tone but limb easily flexed
3 Considerable increase in tone, passive movement difficult
150
4 Limb rigid in flexion or extension

100
Angle

50
Table II: Number of participants with CP per Gross Motor
0 Functional Classification System (GMFCS) level

GMFCS level Number of children

500 0 1 1 2 2 3
I 1
Time (s)
II 10
III 8
IV 0
V 3
EMG

Table III: Number of muscle groups with or without identified

stretch responses listed by Ashworth score
0 0 1 1 2 2 3
Time (s) Ashworth score (+) Stretch () Stretch

Figure 1: (a) absence and (b) presence of hamstring stretch
response. Top portion of each figure shows position
(uppermost lines) data from passive knee trials. Up-slope of
position graph = flexion; down-slope = extension. Lower
portion is EMG data for hamstrings which shows no activity
in (a), but in (b) a consistent and prolonged stretch response
that begins during extension is seen.
0 1 0
1 1 9
2 6 7
3 9 4
4 4 0
5 3 0
Bold, result inconsistent with isokinetic/EMG assessment.

Precision of Ashworth Scale and Instrumented Measures Diane L Damiano et al. 113
for the comparison group of nine children without CP the
mean age was 11.3 years (SD 2.5). Participants were recruited
as part of a preoperative protocol for patients undergoing
orthopaedic or neurosurgical procedures. Inclusion criteria
were: no major surgery within the past 6 months, the ability to
fit anatomically on the isokinetic device, and the ability to
comply with instructions. Any participant who assisted the
passive motion (determined by EMG) in at least one direction
was also eliminated from the study, as this would distort the
resistance torque calculations.
PROCEDURES
Clinical and functional assessments
All individuals participated in a clinical assessment of spasticity

Table IV: Correlation of knee extensor (KE) and knee flexor (KF) Ashworth scores with
isokinetic parameters in participants with CP

Correlations /s n KE Ashworth (rho) KF Ashworth (rho)

Resistance torque 30 22 0.64 ns

Resistance torque 60 22 0.53 ns
Resistance torque 120 22 0.59 ns
Stiffness 30 22 0.58 ns
Stiffness 60 22 0.56 ns
Stiffness 120 22 0.73 0.56
Onset angle 30 10Q/14H 0.80 ns
Onset angle 60 10Q/14H ns ns
Onset angle 120 10Q/14H ns 0.58

Q, quadricep stretch response; H, hamstring stretch response.

a a
0.3
0.8
0.25
Resistance torque in ft-lbs/lbs

0.7
Comparison
Slope of torque by angle

0.6 Comparison 0.2

ASH1
0.5 ASH1 ASH2
ASH2 0.15
0.4 ASH3
ASH3
0.3 0.1 ASH4
ASH4
ASH5
0.2 ASH5
0.05
0.1
0
0

b b
0.24 0.5
Resistance torque in ft-lbs/lbs

0.2
Slope of torque by angle

0.4

0.16
0.3
0.12
0.2
0.08

0.04 0.1

0 0
Figure 3: Rate of change in resistance or slope of resistance
Figure 2: Resistance torque in ft-lbs/lbs plotted by Ashworth
torque by angle (TXA) curve plotted by Ashworth scores for
scores for (a) quadriceps during knee flexion and (b)
(a) quadriceps during knee flexion and (b) hamstrings
hamstrings during knee extension at 120/s.
during knee extension at 120/s.

114 Developmental Medicine & Child Neurology 2002, 44: 112118

including Ashworth score, Ely test (or Duncan-Ely; Gage 1992),
and deep tendon reflexes. The Ashworth scale used was similar
to the classic one (Ashworth 1964; see Table I) with the excep-
tion here that scores were shifted so that a 0 score indicated
when resistance was less than normal. The Ely test is used to
assess rectus spasticity during rapid passive knee flexion while
the patient is prone. For those in the CP group, knee joint
range of motion, selective control of knee flexion and exten-
sion, and the Gross Motor Function Measure (GMFM; Russell
et al. 1989) were also assessed. The parent/caregiver accompa-
nying the child or adolescent completed the Parent Baseline
Form of the Pediatric Outcomes Data Collection Instrument
(Daltroy 1998).
Passive isokinetic and EMG assessments
Surface EMG electrodes (Noraxon USA Inc, Scottsdale, AZ,
USA) were placed over the quadriceps and hamstrings mus-
cles. The child was seated on the isokinetic device (System 3
Pro; Biodex Medical Systems, Shirley, NY, USA) in a semi-
reclining position with the hip joint angle at 60 of flexion.
The left leg was the tested leg, except for three patients with
right hemiplegia on whom the right leg was tested. Passive
isokinetic testing of the knee at 30, 60, and 120/s was per-
formed. EMG and resistance torque data were collected
simultaneously at a sampling rate of 1200 Hz (Datapac 2000;
RUN Technologies, Laguna Hills, CA, USA).
DATA ANALYSIS
For clarification, knee extensor Ashworth scores indicate
a across Gross Motor Functional Classification Levels (Palisano
60
50
40 ASH0
ASH2
30
ASH3
20 ASH5
10
0 a grade of 1 in either the knee flexor or extensor Ashworth
b
120
100
80 ASH1
ASH2
60 ASH3
ASH4
40 ASH5
20
0 Lying and Rolling
Figure 4: Onset angle in degrees of knee flexion plotted by
Ashworth scores for (a) quadriceps during knee flexion and
(b) hamstrings during knee extension at 120/s.
Precision of Ashworth Scale and Instrumented Measures Diane L Damiano et al. 115
resistance from the quadriceps during knee flexion and knee
flexor Ashworth scores indicate resistance from the ham-
strings during knee extension. Similarly, resistance torque
and stiffness in the quadriceps refers to isokinetic measure-
ments during passive knee flexion and during knee exten-
sion for the hamstring values.
Resistance joint torque was measured in ft-lb/lbs, the limb
weight was removed and the torque was normalized by body
weight. Peak resistance torque was the measure of magni-
tude. In addition, resistance torque was plotted against joint
angle for the isokinetic part of the range and the slope of this
line was computed and used as a measure of stiffness (see
Glossary in Appendix).
EMG data were used to identify the state of muscle activa-
tion during the passive trials, i.e. whether the muscles were
quiescent or whether a stretch response was consistently evi-
dent in the antagonist. Figure 1 illustrates the EMG response
to passive knee motion for a child without a stretch response
in either muscle (Fig. 1a) and a child with a stretch response
in the hamstrings muscles during knee extension (Fig.1b).
Participants were categorized by whether or not they demon-
strated hamstrings or quadriceps stretch responses. Onset
angle was also recorded for each trial where a stretch response
was identified by finding the angle equivalent of the EMG
onset. Changes in stiffness, peak resistance, and onset angle
with velocity (values from 120/s trials values from 30/s tri-
als) were also quantified to evaluate the velocity dependency
of each parameter.
Spearmans rho and Pearsons r procedures were used to
examine correlations between variable pairs.
Results
The group with CP included those with a diagnosis of spastic
diplegia, hemiplegia, or quadriplegia, with the distribution
et al. 1997) shown in Table II.
No individual in the comparison group showed a stretch
response at any of the velocities tested. Of the 22 children with
CP, 14 demonstrated stretch responses in the hamstrings, 10
had stretch responses in the quadriceps, seven had these in
both muscles, and five had these in neither muscle. We first
examined the predictive value of the Ashworth scale in detect-
ing or failing to detect stretch responses compared with the
isokinetic examination (Table III). Of the 10 muscles assigned
Table V: Spearmans correlation of knee extensor (KE)
Ashworth scores and functional measures in those with CP
Correlations KE Ashworth (rho)
POSNA Global Function Scale 0.48
Upper Extremity 0.52
Transfers and Basic Mobility 0.61
Gross Motor Function Measure TOTAL 0.68
0.63
Sitting 0.66
Crawling and Kneeling 0.63
Standing 0.58
Walk, Run and Jump 0.57
score, only one child was shown to have a stretch response in
the hamstrings during the isokinetic/EMG tests. That same
child had been assigned 0 for the quadriceps Ashworth score,
yet had also demonstrated a stretch response in that muscle.
Of the 13 muscles assigned an Ashworth score of 2, six had
identifiable stretch responses. Of the 13 muscles assigned
Ashworth scores of 3, nine had stretch responses. Finally, of
the seven muscles assigned scores of 4 or 5, all seven had evi-
dence of stretch responses on the isokinetic/EMG evaluation.
RESISTANCE TORQUE, STIFFNESS, AND ONSET ANGLE BY ASHWORTH
A clear gradient was apparent in the mean resistance (Figs 2a
and b) and stiffness values (Figs 3a and b) as Ashworth scores
increased. Onset angle of the stretch response tended to
occur sooner in the motion in those with higher Ashworth
scores (Figs 4a and b). In all patients, the EMG response,
once initiated, continued throughout the motion.
RELATIONS BETWEEN ASHWORTH SCORES AND QUANTITATIVE
MEASURES
Significant correlations tended to be in the weak to moderate
range with the quadriceps measurements showing typically
higher and more consistent relations (see Table IV).
CORRELATION WITH FUNCTION
Knee extensor Ashworth scores were significantly related to
the functional scores (Table V) while knee flexor Ashworth
scores were not. Instrumented measures for both muscle
groups had significant relationships with the functional mea-
sures as shown in Tables VI and VII. However, the correla-
tions with the hamstrings tended to be lower and/or more
sporadic than those seen for the quadriceps. An inverse cor-
relation between change in hamstring stiffness and the
Global Function Scale score was found (r=0.51) with a
greater change across velocity related to poorer ability.
OTHER INTERIMPAIRMENT CORRELATIONS
Knee extensor Ashworth scores and quadriceps stiffness at
all three velocities were related to the Ely test (r=0.45 for
Ashworth; r=0.67 to 0.77 for stiffness). The knee flexor
Ashworth score and hamstring stiffness were inversely relat-
Table VI: Pearsons correlation of Gross Motor Function
Measure (GMFM) total and Global Function Scale Score
(GLOBAL) of Pediatrics Outcomes Data Collection
Instrument with instrumented passive motion tests for
quadriceps muscle group
Correlation/s GMFM (r) GLOBAL (r)
Resistance torque 30 0.58 0.45
Resistance torque 60 0.53 0.47
Resistance torque 120 ns ns
Stiffness 30 0.76 0.54
Stiffness 60 0.73 0.63
Stiffness 120 0.70 ns
Onset angle 30 0.85 ns
Onset angle 60 ns ns
Onset angle 120 ns ns
ns, not statistically significant at p<0.05.
116 Developmental Medicine & Child Neurology 2002, 44: 112118
ed to passive knee extension (r=0.48 for Ashworth; r=0.51
to 0.59 for stiffness) indicating that greater resistance in the
hamstrings is associated with more restricted muscle lengths.
Only three children with CP demonstrated increased knee jerk
responses (greater than 3/5) on tendon tap. Each of those
children also demonstrated a stretch response during the
knee extension isokinetic tests with a knee flexor Ashworth
score of 4 in two children and 3 in one child, despite the fact
that no correlation was found between tendon reflexes and
Ashworth scores. Isolated control of the hamstrings (graded
from 0 for no control, 1 if they could initiate the movement
with the hip in extension or complete it while flexing the hip,
and 2 if they could complete the movement without flexion
at the hip) was inversely related to resistance torque in the
quadriceps (rho=0.48), indicating that greater active con-
trol in the hamstrings was associated with lower passive
resistance in the antagonist.
Discussion
Lance (1981) described spasticity in a clinical sense as, the
sensation of resistance felt as one manipulates a joint
through a range of motion, with the subject attempting to
relax (p 128). However, our investigation corroborated pre-
vious reports showing that increased resistance in CP can be
from intrinsic stiffness, or altered muscle properties in the
absence of EMG activity, from stretch responses that cause an
involuntary muscle activation, or from both factors com-
bined (Katz and Rymer 1989, Dietz and Berger 1995). Several
of the children with CP showed no stretch responses in one
or more of the muscle groups and no one in the control
group showed a stretch response at either joint at any of the
angular velocities tested. While stretch responses can be
detected in normal muscles, the threshold velocity needed
to elicit these is much greater than those employed here
(Fellows et al. 1994). A protocol designed to increase the
angular velocity incrementally until a stretch response can
be elicited in all participants may more clearly differentiate
responses in CP versus non-CP muscles.
It was apparent in this sample that the magnitude of resis-
tance in patients with identifiable stretch responses can
reach much higher levels, particularly at faster velocities,
than typically seen in those without stretch responses.
Table VII: Pearsons correlation of Gross Motor Function
Measure (GMFM) total and Global Function Scale Score
(GLOBAL) of Pediatrics Outcomes Data Collection
Instrument with parameters from instrumented tests for
hamstrings muscle group
Correlations/s GMFM (r) GLOBAL (r)
Resistance torque 30 ns ns
Resistance torque 60 ns ns
Resistance torque 120 ns ns
Stiffness 30 0.60 ns
Stiffness 60 0.57 ns
Stiffness 120 0.52 ns
Onset angle 30 ns ns
Onset angle 60 ns ns
Onset angle 120 ns ns
However, patients may exist in whom the magnitude of the
spastic response is very small or the magnitude of passive
stiffness alone is fairly high. Patients assigned Ashworth
scores in the mid-ranges of resistance yet who had passive
stiffness alone could be incorrectly judged to have mild to
moderate spasticity and, consequently, may be treated
inappropriately. It is also possible that the degree of spastic-
ity could be overestimated, even when present, which could
also adversely affect treatment outcomes. In the absence of
EMG verification, evaluating patients at different velocities
may help to distinguish passive stiffness alone from reflex
stiffness (spasticity); however, the Ashworth scale is only
performed at a single velocity. Therefore, instrumented
devices or other clinical methods, such as the newly revised
Tardieu Scale (Boyd and Graham 1999) that gauge resis-
tance at several speeds may be more useful, especially in
more equivocal cases.
As Ashworth scores and isokinetic tests both measure
resistance to passive stretch, it is logical to assume that they
would be correlated. Stiffness, rather than the magnitude of
resistance, appeared to have higher, more consistent correla-
tions with the Ashworth scores. Factors such as differences in
the position of the patient during the tests (supine versus sit-
ting), position of adjacent limbs (hip flexing and extending
throughout versus being in a statically flexed position of 60),
differences in velocities, and potentially different levels of
anxiety or fatigue across conditions may explain why these
relations were not stronger than those shown here.
The Ashworth scale, as well as more quantitative measures
of spasticity or resistance, has value beyond the impairment
level if scores are shown to relate to functional performance.
As CP is a multifaceted disorder and as evidence disputes the
primacy of spasticity in disrupting voluntary motor function,
relationships between spasticity indicators and function in
this investigation were hypothesized to be weak. An earlier
multicenter investigation on the relationships between
impairment function and disability in ambulatory children
with CP showed that Ashworth scores were weakly correlat-
ed with functional measures (Damiano and Abel 2000).
Correlations reported here in a different data set support
the previous finding but are even higher. This difference is
most likely due to the greater variation in this sample which
also included children with quadriplegia. Correlation pro-
cedures are very sensitive to the range of values, and if the
sample is fairly homogeneous quite different results may be
found from those reported in more variable samples. We
believe that sampling differences across studies may explain
many of the discrepancies reported in the literature on
whether or not spasticity is related to function in CP or in
other CNS disorders. It is also possible that spasticity, like
cocontraction, must reach a certain level before it begins to
impair function (Damiano 1993); therefore, the fact that this
study included those with higher levels of resistance may
help to explain these results. Instrumented measures tended
to have greater correlations with function than the Ashworth
scale, which may be due to greater objectivity, precision, or
range of values resulting from this method. Future investiga-
tions will focus on the relative sensitivity of isokinetic mea-
sures compared with the Ashworth scores in detecting
change in passive resistance as a result of interventions. We
will also continue to explore other confounding or colinear
factors that may be distorting the correlations reported here,
Precision of Ashworth Scale and Instrumented Measures Diane L Damiano et al. 117
such as restrictions in muscle length, and uncovering the
mechanism by which spasticity, a passive phenomenon, dis-
rupts voluntary muscle activation (Damiano et al. 2001a,b)
and motor performance.
Conclusions
A standard rehabilitation device, an isokinetic dynamometer,
can be used to quantify validly resistance torque during pas-
sive joint motion. In this investigation, the instrumented
measures tended to have stronger relationships with func-
tion than the current clinical standard, the Ashworth scale.
Passive resistance to motion, as measured clinically and with
instrumentation, shows a consistent direct relationship with
validated measures of function in CP.
Accepted for publication 1st August 2001.
Acknowledgements
This work was supported by funding from the National Institutes of
Health (R29HD36516), United Cerebral Palsy Educational and
Research Foundation, and Medtronics Neurological.
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Appendix

GLOSSARY OF TERMS
Spasticity. Consistent with the traditional physiologic
definition (Lance 1980), this is defined here as the presence
of a stretch response during passive muscle stretch at an
angular velocity of 120/s or less, as indicated by a consistent
EMG response in the muscle group being stretched.

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