Article Text

Download PDFPDF
Stop using the Ashworth Scale for the assessment of spasticity
  1. J F M Fleuren1,2,
  2. G E Voerman1,3,4,
  3. C V Erren-Wolters1,
  4. G J Snoek1,2,
  5. J S Rietman1,2,5,
  6. H J Hermens1,6,
  7. A V Nene1,2
  1. 1
    Roessingh Research and Development, Enschede, The Netherlands
  2. 2
    Rehabilitation Centre Het Roessingh, Enschede, The Netherlands
  3. 3
    Scientific Institute for Quality of Healthcare, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
  4. 4
    Department of Health Technology and Services Research, Faculty of Business, Public Administration and Technology, Twente University, Enschede, The Netherlands
  5. 5
    Faculty of Engineering Technology, Twente University, Enschede, The Netherlands
  6. 6
    Faculty of Electrical Engineering, Mathematics and Computer Science, Twente University, Enschede, The Netherlands
  1. Correspondence to J F M Fleuren, Roessingh Research and Development, PO Box 310, 7500 AH Enschede, The Netherlands, j.fleuren{at}


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.

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


  • See Editorial Commentary, p 2

  • Competing interests None.

  • Ethics approval The study was approved by the medical ethics committee of the Rehabilitation Centre.

  • Patient consent Obtained.

  • Provenance and Peer review Not commissioned; externally peer reviewed.

Linked Articles