Stop using the Ashworth scale for the assessment of spasticity

Aim: Many studies have been performed on the methodological qualities of the (modified) Ashworth Scale but overall these studies seem inconclusive. The aim of this study was to investigate the construct validity and inter-rater reliability of the Ashworth Scale (AS) for the assessment of spasticity in the upper and lower extremities. Method: A cross-sectional study on spasticity in the elbow flexors (part 1) and knee extensors (part 2) was carried out. In both parts AS was assessed while muscle activity and resistance were recorded simultaneously in patients with upper motor neuron syndrome. Each patient was measured by three raters. Results: 30 patients participated, 19 in each part of the study. For elbow flexor muscles, AS was not significantly associated with electromyographic parameters, except for rater 2 (rho= 0.66, p<0.01). A significant moderate association was found with resistance (0.54 <= rho <= 0.61, p<0.05). For knee extensors, AS scores were moderately associated with muscle activity (0.56 <= rho <= 0.66, p<0.05) and also with resistance (0.55 <= rho <= 0.87, p<0.05). The intraclass correlation coefficient for absolute agreement was 0.58 for elbow flexors and 0.63 for knee extensors. In linear mixed model analysis, the factor rater appeared to be highly associated with AS. Conclusion: The validity and reliability of the AS is insufficient to be used as a measure of spasticity.