Clinical
Rehabilitation
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The Tardieu Scale differentiates contracture from spasticity whereas the Ashworth Scale is
confounded by it
Emily Patrick and Louise Ada
Clin Rehabil 2006 20: 173
DOI: 10.1191/0269215506cr922oa
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Clinical Rehabilitation 2006; 20: 173-182
The Tardieu Scale differentiates contracture from
spasticity whereas the Ashworth Scale is
confounded by it
Emily Patrick and Louise Ada School of Physiotherapy, The University of Sydney, Sydney, Australia
Received 5th January 2005; returned for revisions 21 st February 2005; revised manuscript accepted 20th June 2005.
Objective: To compare the Tardieu Scale as a clinical measure of spasticity after
stroke with the Ashworth Scale.
Design: Cross-sectional study.
Participants: Sixteen people, living in the community three years after their stroke.
Main measures: The Ashworth Scale and Tardieu Scale as well as laboratory
measures of spasticity (stretch-induced electromyographic (EMG) activity) and
contracture (maximum passive joint excursion) were collected from the affected
elbow flexors and extensors and ankle plantarflexors and dorsiflexors by three
examiners who were blinded to the results of the other measures.
Results: The percentage exact agreement (PEA) between the Tardieu Scale and a
laboratory measure of spasticity was 100% for both the elbow flexors and ankle
plantarflexors. This was significantly (P= 0.02) greater than the PEA of 63% for both
muscles between the Ashworth Scale and the same laboratory measure of
spasticity. For contracture, the PEA between the Tardieu Scale and a laboratory
measure was 94% for both the elbow flexors and the ankle plantarflexors. Pearson
correlation coefficients between the Tardieu Scale and laboratory measures of
spasticity were 0.86 for the elbow flexors and 0.62 for the ankle plantarflexors and
between the Tardieu Scale and laboratory measures of contracture were 0.89 for the
elbow flexors and 0.84 for the ankle plantarflexors.
Conclusion: In all cases that spasticity was overestimated by the Ashworth Scale,
participants had a contracture. These findings suggest that the Tardieu Scale
differentiates spasticity from contracture whereas the Ashworth Scale is
confounded by it.
Introduction
Spasticity, defined as 'a motor disorder characterised by a velocity-dependent increase in tonic
stretch reflexes ("muscle tone") with exaggerated
tendon jerks, resulting from hyperexcitability of
Address for correspondence: Louise Ada, School of Physiotherapy, Faculty of Health Sciences, The University of
Sydney, PO Box 170, Lidcombe NSW 1825, Australia.
e-mail: L.Ada(fhs.usyd.edu.au
(C
2006 Edward Arnold
(Publishers)
the stretch reflex' (ref. 1, p. 485), is one of the
impairments of an upper motor neuron lesion. It is
important for clinicians to be able to measure
spasticity so that it can be accurately identified and
the effectiveness of interventions aimed at reducing
it can be evaluated. Currently, the Ashworth Scale2
or the modified Ashworth Scale3 are the most
commonly used clinical measure of spasticity.4
However, the validity of the Ashworth Scales has
been challenged. Pandyan et al.S concluded that
Ltd
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10.1 191/0269215506cr922oa
174 E Patrick and L Ada
confusion exists regarding the characteristics of the
Ashworth Scale as a measure of spasticity. In
addition, doubts have been raised about the
validity of the Ashworth Scale after finding that
it was not comparable to laboratory measures of
spasticity. 6-9 The Ashworth Scale grades the
resistance to movement but it appears unable to
differentiate whether the cause of abnormal resistance is neural or peripheral.8- 11
Based on clinical and physiological observations, Tardieu12,13 proposed a method of measuring spasticity, from which a quantifiable scale was
constructed by Held and Pierrot-Deseilligny'4 and
this has been translated by Gracies et al.15 (see
Appendix). The broad aim of this study was to
investigate the validity of the Tardieu Scale as
a clinical measure of spasticity after stroke by
testing its content validity and comparing it
with the Ashworth Scale. The specific research
questions were:
1.3, range 1.2-5), consisting of 11 men and
5 women, and 7 right and 8 left hemiplegics
were recruited. The procedures were approved
by the institutional ethics committee and all
participants gave informed consent prior to data
collection.
Design
A cross-sectional, analytical study was undertaken, in which clinical scales were compared with
laboratory measures of spasticity and contracture,
with the latter used as the reference standard.
Measurements were performed on the affected
elbow flexors and extensors and the affected
ankle plantarflexors and dorsiflexors of each
participant. Prior to each measure, the joints
were moved slowly and passively through range
to precondition them. The participants were measured by one examiner using the Ashworth Scale, a
different examiner using the Tardieu Scale and a
third examiner collected the laboratory measures.
1) Does the Tardieu Scale identify the presence The three examiners were blinded to the results of
of spasticity more effectively than the Ash- the other measures. The order of the measures was
worth Scale after stroke?
random and all testing procedures were completed
2) Does the Tardieu Scale reflect the severity of in a single session.
spasticity more effectively than the Ashworth
Scale after stroke?
Clinical scales
3) Does the Tardieu Scale identify the presence
of contracture after stroke?
Scale
4) Does the Tardieu Scale reflect the severity of Ashworth
sat on a bed with their legs extended
Participants
contracture after stroke?
and their arms resting by their side. The trunk was
with the head in a neutral position.
Our hypothesis was that the Tardieu Scale would supported
were instructed to completely relax
Participants
be able to differentiate contracture from spasticity while their affected
elbows and ankles were pasand therefore be the more valid clinical measure of sively moved throughout
range in both directions
spasticity.
by the examiner. Spasticity was quantified according to the Ashworth Scale using the criteria for
grades 0-4 outlined by Ashworth.2
Method
Participants
Individuals who had had one stroke resulting in
hemiplegia were recruited for this study. Patients
were excluded from the study only if they were
younger than 45 or older than 85 years, or if
they had severe cognitive or language deficits
hat would interfere with the comprehension of
instructions required to participate in the study.
Sixteen participants, aged 63 years old (SD 7,
range 51-77), three years since stroke (SD
Tardieu Scale
Participants sat in the same standardized position as described for the Ashworth Scale. The
affected limbs were passively moved through range
at two velocities - first, 'as slow as possible' (VI)
and then 'as fast as possible' (V3), as described by
Held and Deseilligny14 and interpreted by the
examiner. At both velocities, the quality of the
muscle reaction to stretch (X) was assessed for
each muscle group and the angle at which the
muscle reaction occurred (Y) was measured with a
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Clinical measurement of spasticity after stroke 175
hand-held goniometer after the cessation of the
movement. Contracture was quantified by recording the angle at which the muscle reaction occurred
during the slow velocity stretch (V1). This velocity
is considered to be too slow to excite abnormal
reflex activity following stroke, therefore, the angle
recorded represents the end of range.'5 Spasticity
was quantified according to the criteria of muscle
reaction for grades 0-4 during the fast velocity of
stretch (V3). The velocity of the limb segment
falling under gravity (i.e., V2) was not used in this
study since it is not practical for most muscle
groups.
Laboratory measures
The same experimental set-up was used for
measurement of both contracture and spasticity
(Figure 1). First, participants sat at an adjustable
table in a high-backed chair, with their affected
arm in 90 degrees of shoulder flexion and the
forearm secured in a horizontal arm frame which
constrained movement to flexion and extension at
the elbow (Figure la). A potentiometer at the
axis of rotation of the arm frame measured joint
angle while a load cell (capacity 250 N; Applied
Measurement, Sydney, Australia) fixed to a handle
measured applied torque. Then, participants
were positioned in long sitting with the affected
foot secured in a foot frame that constrained
movement to plantarflexion and dorsiflexion at
the ankle (Figure lb). A potentiometer at the
axis of rotation of the arm frame measured joint
angle while a load cell (capacity 450 N) fixed to a
handle measured applied torque. Muscle activity
was measured using bipolar silver-silver chloride
surface electrodes. Electrodes were positioned
according to Basmajan and Blumenstein.'6 The
electrode impedance was kept below 5 kQ by
thorough abrading and cleaning of the skin and
the experiment proceeded only when a satisfactorily low level of background noise was achieved
(less than 10 ptV).
Contracture
Maximum passive joint excursion was measured. Participants were asked to relax with the
affected limb positioned in the frame and the
electromyograph (EMG) recording was displayed
on the computer screen to ensure that participants
remained relaxed. The relaxed limb was slowly
moved to the end of range by applying 2 Nm to
the upper limb and 10 Nm to the lower limb and
this was held for 5 s.
Spasticity
Stretch-induced muscle activity was measured.
Participants were asked to relax with the affected
limb positioned in the frame and, prior to stretching, the EMG recording was displayed on the
computer screen to ensure that muscles were
(b)
Figure 1 Set-up for the laboratory measures for the (a) upper and (b) lower limb. Three signals were collected: a
potentiometer measured joint angle, a load cell measured applied torque and electrodes measured muscle activity.
Downloaded from cre.sagepub.com at UNIV OF DELAWARE LIB on March 1, 2011
176 E Patrick and L Ada
electrically silent. The muscles were then stretched
by moving the limbs passively through range at
two velocities - fast and slow. Five ramp stretches
were recorded for each velocity in each muscle
group. In order to remove any 50 Hz line frequency
interference or low-frequency movement artefact,
the EMG was high-pass filtered (digital eighthorder Butterworth) at 80 Hz. Normally, no EMG
activity is observed when the relaxed muscles of a
neurologically normal person are stretched in this
manner. ,18 Therefore, any stretch-induced EMG
activity observed was considered to be abnormal
and indicative of spasticity. ' Figure 2 presents data
from two participants, one with spasticity and
one without. Even in the presence of severe
spasticity (Figure 2d), no evidence of stretch reflex
activity was apparent during the slow ramp stretch
(Figure 2c), confirming that the slow velocities
of stretch did not excite the stretch reflex response
in stroke.
flexion, < 130 degrees elbow flexion, or elbow extension was > 5 degrees off a straight elbow.
Data extraction
Measurement yielded five variables for each
muscle group. There were three variables for
spasticity: fast stretch-induced EMG activity, Tardieu score and Ashworth score. For the clinical
scales, spasticity was operationally defined as
being present when the scores reflected a neural
event, such as a catch occurring at a precise angle.
Therefore, spasticity was considered present in a
muscle group if the score was . 1 on the Ashworth
Scale and if the muscle reaction grade (X) during
the fast velocity stretch (V3) was . 2 on the
Tardieu Scale. For the laboratory measure, spasticity was considered to be present if, on visual
examination, a clear burst of EMG was timelocked to the maximum velocity of ramp stretch
(Figure 2d) in at least three of the five trials. In
order to quantify the severity of the spasticity in
the laboratory measure, the EMG was rectified
and integrated, and the average peak stretchinduced activity across trials was determined.
There were two variables for contracture: maximum passive joint excursion and Tardieu score
(Y at VI). Contracture was operationally defined
as being present if the angle at the end of range was
5 -10 degrees less than full range. Therefore, for
both clinical and laboratory measures, contracture
was present if end-of-range was: < 10 degrees
ankle dorsiflexion; < 25 degrees ankle plantar-
Results
Statistical analysis
In order to examine the ability of the Ashworth
and Tardieu Scales to identify the presence of
spasticity and/or contracture, the percentage
exact agreement (PEA) between laboratory and
clinical measures was calculated. The significance
of the differences in PEA was determined using
Fisher's exact P-value of the chi-square statistic
to account for small numbers in some cells. In
order to examine the ability of the Tardieu Scale
to reflect the severity of spasticity and contracture, the ordinal clinical measures of spasticity
and interval measures of contracture were correlated with the interval laboratory measures of
spasticity and contracture using the Pearson
correlation coefficient.
Spectrum of participants
For each muscle group, participants were
placed into one of four categories based on the
presence or absence of spasticity and contracture as determined by the laboratory measures
(Table 1). Only two of the four muscle groups
(elbow flexors and ankle plantarflexors) displayed
each combination of spasticity and contracture.
Therefore, only these muscle groups were subsequently analysed.
Does the Tardieu Scale identify the presence of
spasticity more effectively than the Ashworth Scale
after stroke?
In identifying the presence or absence of
spasticity in the elbow flexors, there was 100%
exact agreement between the Tardieu Scale and
the laboratory measure of spasticity (chancecorrected agreement statistic kappa = 1.0). In contrast, there was 63% exact agreement between
the Ashworth Scale and the laboratory measure
of spasticity (kappa = 0.24), showing a significantly poorer ability of this scale to correctly
identify spasticity in the elbow flexors (P = 0.02).
The percentage exact agreement between the
Tardieu Scale and the laboratory measure of
spasticity in the ankle plantarflexors was also
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Clinical measurement of spasticity after stroke 177
(a)
(b)
20
20
-oC)
0)
C
c
U)
c
-
-30
-30
250
250
CD=LL
w
c:
E
a)
CD
CD -250
(c)
-250 L
(d)
20
20
0)
w
U)
a)
CD
-0)
co
._l
c
-30
,250
250 r
0'25
a)
(I)
li JLJL 11 IIv 7 -1
(U
C20
Ct
-30
i1
s
-250
Figure 2 Muscle activity (lower traces) in response to (a) slow and (b) fast ramp stretches (upper traces) in a participant with
no spasticity. Muscle activity (lower traces) in response to (c) slow and (d) fast ramp stretches (upper traces) in a participant
with spasticity. Note the absence of reflex reaction to the slow stretch (c) even when a large reflex reaction and clonus is
present during fast stretch (d).
100% (kappa = 1.0). In contrast, the percentage
exact agreement between the Ashworth Scale and
the laboratory measure was 63% (kappa = 0.25),
showing a significantly poorer ability of this scale
to correctly identify spasticity in the ankle plantarflexors (P = 0.02).
Does the Tardieu Scale reflect the severity of
spasticity more effectively than the Ashworth Scale
after stroke?
Figure 3(a and b) illustrates the relationship
between the clinical and laboratory measures of
spasticity. In the elbow flexors, there was a strong,
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178 E Patrick and L Ada
Table 1 Spectrum of spasticity and contracture
Spasticity
Elbow flexors
Contracture
Y
N
Elbow extensors
Ankle plantarflexors
Ankle dorsiflexors
Y
N
Y
N
Y
N
Y
N
4
3
5
4
0
8
0
8
4
4
3
5
0
0
0
16
significant relationship between the grade of
muscle reaction (X) during the fast stretch (V3)
using the Tardieu Scale and peak stretch-induced
EMG activity (r = 0.86, P = 0.001). In addition,
there was a significant but moderate relationship
between the Tardieu Scale and the laboratory
measure of spasticity in the ankle plantarflexors
(r = 0.62, P = 0.01). In contrast, there was little
relationship between the Ashworth Scale and the
-
Spas(A) = 0.1 Spas(Lab) + 0.3
Spas(T) = 0.2 Spas(Lab) + 0.3
(D
8-
W
64
Spas(A) = 0.01 Spas(Lab) + 0.5
Spas(T) = 0.1 Spas(Lab) + 1
50
O
> 1210 -
a)
Does the Tardieu Scale identify the presence of
contracture after stroke?
In identifying the presence or absence of contracture in the elbow flexors, there was 94% exact
agreement between the Tardieu Scale and the
(b)
(a)
12
laboratory measure of spasticity in either the elbow
flexors (r = 0.33, P = 0.21) or ankle plantarflexors
(r=J0.15, P =0.59).
40
O
8 o,
30
0,
O
20
-
10
2
S
0
_S___
0
0
2
1
4
3
1
0
2
3
4
Clinical scale score (0-4)
(c)
(d)
cm 35
25
Cont(T) = 0.3 Cont(Lab) + 0.8
230
Cont(T) = Cont(Lab) + 2
20
a)
C) 25
15
c
L-
20
a)
.' 15
cZQ. 10
X
co
*~~~~~/
10
.
0
5
5
0
-5
0
2
4
6
8
10
12
-5
Tardieu Scale score
5
-
15
25
(deg)
Figure 3 Relations between the Tardieu score and laboratory measure (closed circles and solid line) and Ashworth score and
laboratory measure (open circle and dotted line) for (a) elbow flexor spasticity, (b) plantarflexor spasticity, (c) elbow flexor
contracture, and (d) plantarflexor contracture. Equations of the relations are included where T = Tardieu score, A = Ashworth
scores, and Lab = laboratory measures.
Downloaded from cre.sagepub.com at UNIV OF DELAWARE LIB on March 1, 2011
Clinical measurement of spasticity after stroke 179
laboratory measure of contracture (kappa =
0.88). The percentage exact agreement between
the Tardieu Scale and the laboratory measure of
contracture in the ankle plantarflexors was
also 94% (kappa = 0.88).
Does the Tardieu Scale reflect the severity of
contracture after stroke?
Figure 3(c and d) presents the relationship
between the clinical and laboratory measures of
contracture. There was a strong, significant relationship between the angle of muscle reaction (Y)
during the slow stretch (Vi) using the Tardieu
Scale and the laboratory measure of contracture in
both the elbow flexors (r = 0.89, P = 0.00 1) and
ankle plantarflexors (r = 0.84, P = 0.001).
Discussion
This is the first study to compare the Tardieu Scale
with the Ashworth Scale in people after stroke. The
results indicate that the Tardieu Scale is able to
identify the presence of spasticity more effectively
than the Ashworth Scale in both an upper and
lower limb muscle. There have been many previous
suggestions that the Ashworth Scale is not adequate as a measure of spasticity.5- 1l The moderate
percentage exact agreement between the Ashworth
Scale and laboratory measures of spasticity found
in this study is in line with previous studies
examining the validity of the Ashworth Scale
by comparing it with other clinical19'20 and
laboratory6-1 measures. The only study showing
a significant relationship between the Ashworth
Scale and laboratory measures21 used markedly
higher stretching velocities than the current study
in a group of spinal cord-injured patients.
The lack of agreement between the Ashworth
Scale and laboratory measures of spasticity in the
current study may be because the Ashworth Scale
does not exclusively measure spasticity. Experimental evidence suggests that increased resistance
to movement is not exclusively dependent on
stretch reflex activity but is also due to increased
stiffness as a result of contracture.9,22-24 Therefore,
by quantifying the resistance to passive movement,
the Ashworth Scale measures a combination of
neural and peripheral factors (i.e., it does not
differentiate spasticity from contracture). Spasticity was overestimated by the Ashworth Scale
15% of the time when compared with the laboratory measures of stretch-induced EMG activity, in
line with a previous study.6 In 100% of these
cases, participants had a contracture compared
with only 14% of the cases when spasticity was
underestimated by the Ashworth Scale. This suggests that the Ashworth Scale is confounded by
contracture.
Not only was the Tardieu Scale able to identify
the presence of spasticity, but it was also able to
identify the presence of contracture. This is most
likely because the Tardieu Scale takes into account
the main factor to which the stretch reflex is
known to be sensitive - the velocity of stretch.
This velocity-dependence of the stretch reflex has
been well established (e.g., refs 1, 24 and 25]
with several studies reporting no stretch reflex
during slow passive movements23 24262' and evidence of a threshold velocity of stretch below
which no EMG response was elicited.28'29 In the
current study, the slow stretch did not result in
stretch-induced EMG activity in any participant in
either muscle group, so that the end of the stretch
accurately reflected the end of range. This suggests,
therefore, that contracture can be validly measured
in the clinic, even in the presence of spasticity, by
moving the limb very slowly so as to not excite
hyperactive reflexes. On the other hand, during the
fast stretch, nearly half the participants exhibited
stretch-induced EMG activity in both muscle
groups which was strongly related to the grade of
the muscle reaction (X) during V3 using the
Tardieu Scale. Some researchers have proposed
that the angle of muscle reaction (Y) recorded
during V3 be used to measure the amount of
spasticity present in a muscle rather than the grade
of muscle reaction (X). 15,30 However, in the current
study, the relationship between the angle of muscle
reaction at V3 was only significantly related to the
angle at which fast stretch-induced EMG activity
occurred in the elbow flexors (r = 0.78, P = 0.04),
not in the ankle plantarflexors (r = - 0.57, P =
0.14). This suggests that the grade of muscle
reaction (X) during the fast velocity stretch (V3)
is the most appropriate measure of spasticity from
the Tardieu Scale.
Taken together, these findings suggest that the
Tardieu Scale appears to be the more valid
Downloaded from cre.sagepub.com at UNIV OF DELAWARE LIB on March 1, 2011
180 E Patrick and L Ada
Clinical
*
*
messages
Spasticity measured by the Ashworth Scale
is confounded by contracture.
The Tardieu Scale differentiates spasticity
from contracture, therefore, it is the more
valid clinical tool.
clinical tool for the measurement of spasticity
after stroke because it can differentiate spasticity
from contracture. Nevertheless, one of the limitations of the present study was that the examiners
only measured the participants using one measure. Although this meant that the examiners
were blinded to the results of the other measures,
it also means that the results could have been
confounded by examiner experience. However,
the examiners standardized the procedures beforehand and the examiner using the Ashworth
Scale had more clinical experience than the
examiner using the Tardieu Scale. Even though
the Tardieu Scale takes slightly longer to apply, it
is suggested that it be used to measure spasticity
in clinical practice, since distinguishing between
the neural and peripheral contributions to movement resistance after stroke enables intervention
to be accurately directed at the underlying
impairments.
Acknowledgements
We are grateful to Anchalee Foongchomcheay
for being the third blinded measurer in this study
and Roger Adams for his help with the statistical
analysis.
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Appendix - Tardieu Scale
Grading is always performed at the same time of day, in a constant position of the body for a given limb.
Other joints, particularly the neck, must also remain in a constant position throughout the test and
between tests. For each muscle group, reaction to stretch is rated at a specified stretch velocity with two
parameters, X and Y
Velocity of stretch
Vi: As slow as possible (minimizing stretch reflex).
V2: Speed of the limb segment falling under gravity.
V3: As fast as possible (faster than the rate of the natural drop of the limb segment under gravity).
Vl is used to measure the passive range of motion. Only V2 or V3 are used to measure spasticity.
Quality of the muscle reaction (X)
0: No resistance through the course of the passive movement.
1: Slight resistance throughout the course of the passive movement with no clear catch at a
precise angle.
2: Clear catch at a precise angle, interrupting the passive movement, followed by release.
3: Fatigable clonus (<10 s when maintaining pressure) occurring at a precise angle.
4: Unfatigable clonus ( >10 s when maintaining pressure) occurring at a precise angle.
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182 E Patrick and L Ada
Angle of muscle reaction (Y)
Measured relative to the position of minimal stretch of the muscle (corresponding to angle 0) for all
joints except hip, where it is relative to the resting anatomic position.
Adapted from
Tardieu12'13 by Held and Pierrot-Deseilligny14 and translated by Gracies et al.'5
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