• The Ashworth Scale measures the effects of antispasticity drugs in individuals with multiple sclerosis (it has subsequently been adapted for other diagnoses, including SCI).
  • The Modified Ashworth Scale measures resistance during passive soft-tissue stretching and is used as a simple measure of spasticity in patients with lesions of the Central Nervous System.

Clinical Considerations

  • This measure is commonly used in the clinical setting to assess spasticity in people with SCI. However, it should be noted that spasticity is a multi-faceted construct with individual components of spasticity weakly related to each other suggesting that different clinical scales measure unique aspects of spasticity.
  • This measure assesses single-joint resistance to passive ROM or a velocity dependent stretch reflex. They do not address spasm frequency or severity, nor do they differentiate between phasic and tonic components of spasticity. Therefore, the overall construct of spasticity is best measured with an appropriate battery of tests including the Ashworth or Modified Ashworth.
  • The Ashworth and Modified Ashworth are well-tolerated by patients.
  • This measure is easily administered during routine clinic visits and doesn’t require specialized equipment.

ICF Domain

Body Function ▶ Neuromusculoskeletal & Movement-related Functions and Structures

Administration

  • Clinician-administered; both tests (Ashworth and MAS) are clinical examinations performed on a relaxed patient in the supine position.
  • The muscle is assessed by rating the resistance to passive range of motion (ROM) about a single joint.

Number of Items

Clinician/Patient may test any number of muscles affected by Spasticity.

Equipment

None

Scoring

  • Original Ashworth Scale: Tests resistance to passive movement about a joint, scores range from 0-4 with 5 choices, a score of 1 indicates no resistance, 5 indicates rigidity.
  • Modified Ashworth Scale: Similar to the Ashworth Scale but adds a 1+ scoring category to indicate resistance through less than half of the movement, scores range from 0 (no increase in muscle tone) to 4 (affected part(s) rigid in flexion or extension, with 6 choices.

Languages

English

Training Required

Requires clinical judgment and experience with spasticity.

Availability

Can be found here.

# of studies reporting psychometric properties: 18

Interpretability

MCID: not established in SCI; but in stroke, initial change in muscle tone/spasticity in response to botox treatment was approximately a 1-point decrease on the MAS scale, reflecting a clinically significant improvement.
(Shaw et al. 2010)
SEM: not established in SCI.
MDC: not established in SCI population but in a stroke population, initial change in muscle tone/spasticity in response to botox treatment was an approximately 1-point decrease on the MAS scale reflecting a clinically significant improvement.

(Shaw et al. 2010)

Reliability – Moderate to High

Moderate Inter-rater Reliability (for MAS): ICC = 0.56

(Tederko et al. 2007)

Moderate to High inter-rater reliability (MAS): Kappa: 0.531-0.774
Moderate test-retest reliability (MAS): Kappa: 0.580-0.716

(Akpinar et al. 2017)

Validity – Low to High

  • Correlation of Ashworth (hip, knee, ankle) with Spinal Cord Assessment Tool for Spastic reflexes (SCATS) (clonus, flexion, extension) was Moderate to High.
  • Correlation of Ashworth (hip, knee, ankle) with Penn Spasm Frequency Scale (PSFS) was Moderate.
Hip Knee Angle
PSFS 0.43 0.43 0.51
Hip – 0.90 0.67
Knee – – 0.77
Clonus 0.56 0.65 0.60
Flexion 0.55 0.47 0.40
Ext 0.98 0.88 0.61

(Benz et al. 2005)

  • Low correlation with Spasm Frequency Scale (SFS): ρ: -0.13 to 0.21

(Baunsgaard et al. 2016; n=31; 20 males; mean age: 48.3 + 20.2 years; 18 ASIA A/B/C, 13 ASIA D)

Responsiveness

With intrathecal baclofen treatment, Ashworth scores were found to significantly decrease (P<.0001).

(Penn et al. 1989; Gianino et al. 1998; Aydin et al. 2005; Boviatsis et al. 2005)

Floor/Ceiling Effect

In a group of MS or SCI patients: with intrathecal baclofen treatment, Ashworth scores were found to significantly decrease.

(Boviatsis et al. 2005)

Typical Values

Score Distributions (SD):

  • Score 0: 25.7%
  • Score 1: 34.0%
  • Score 2: 23.7%
  • Score 3: 16.5%

(Sherwood et al. 2000)

Reviewer

Jane Hsieh, Dr. Carlos L. Cano-Herrera

Date Last Updated

31 December 2024

Akpinar P, Atici A, Ozkan FU, Aktas I, Kulcu DG, Sarı A, Durmus B. Reliability of the Modified Ashworth Scale and Modified Tardieu Scale in patients with spinal cord injuries. Spinal Cord. 2017 Oct;55(10):944-949. https://pubmed.ncbi.nlm.nih.gov/28485384/

Ashworth B. Preliminary trial of carisoprodol in multiple sclerosis. Practitioner 1964;192:540-542.
http://www.ncbi.nlm.nih.gov/pubmed/14143329

Aydin G, Tomruk S, Keles I, Demir SO, Orkun S. Transcutaneous electrical nerve stimulation versus baclofen in spasticity: clinical and electrophysiologic comparison. Am J Phys Med Rehabil 2005; 84: 584-492.
http://www.ncbi.nlm.nih.gov/pubmed/16034227

Benz EN, Hornby TG, Bode RK, Scheidt RA, Schmit BD. A physiologically based clinical measure for spastic reflexes in spinal cord injury. Arch Phys Med Rehabil 2005;86:52-59.
http://www.ncbi.nlm.nih.gov/pubmed/15640989

Baunsgaard CB, Nissen UV, Christensen KB, Biering-Sørensen F. Modified Ashworth scale and spasm frequency score in spinal cord injury: reliability and correlation. Spinal Cord. 2016 Sep;54(9):702-8. https://pubmed.ncbi.nlm.nih.gov/26857270/

Boviatsis EJ, Kouyialis AT, Korfias S, Sakas DE. Functional outcome of intrathecal baclofen administration for severe spasticity. Clinical Neurology and Neurosurgery, 2005; 107: 289-295.
http://www.ncbi.nlm.nih.gov/pubmed/15885386

Craven BC, Morris AR. Modified Ashworth scale reliability for measurement of lower extremity spasticity among patients with SCI. Spinal Cord, 2010; doi:10.1038/sc.2009.107.
http://www.ncbi.nlm.nih.gov/pubmed/19786977

Haas BM, Bergstrom E, Jamous A, Bennie A. The inter rater reliability of the original and of the modified Ashworth scale for the assessment of spasticity in patients with spinal cord injury. Spinal Cord 1996;34:560-564.
http://www.ncbi.nlm.nih.gov/pubmed/8883191

Lechner HE, Frotzler A, Eser P. Relationship between self- and clinically rated spasticity in spinal cord injury. Arch Phys Med Rehabil 2006;87:15-19.
http://www.ncbi.nlm.nih.gov/pubmed/16401432

Lee KC, Carson L, Kinnin E, Patterson V. The Ashworth scale: a reliable and reproducible method of measuring spasticity. Neurorehabilitation and Neural Repair, 1989; 3:205-209.
http://nnr.sagepub.com/content/3/4/205.abstract

Mishra C, Ganesh GS. Inter-rater reliability of modified modified Ashworth scale in the assessment of plantar flexor muscle spasticity in patients with spinal cord injury. Physiother Res Int. 2014;19(4):231-7.
http://www.ncbi.nlm.nih.gov/pubmed/24619735

Penn RD, Savoy SM, Corcos D, Latash M, Gottlieb G, Parke B, Kroin JS. Intrathecal baclofen for severe spinal spasticity. New England Journal of Medicine, 1989; 320(23): 1517-1521.
http://www.ncbi.nlm.nih.gov/pubmed/2657424

Priebe MM, Sherwood AM, Thornby JI, Kharas NF, Markowski J. Clinical assessment of spasticity in spinal cord injury: a multidimensional problem. Arch Phys Med Rehabil 1996; 77:713-716.
http://www.ncbi.nlm.nih.gov/pubmed/8670001

Sherwood AM, Graves DE, Priebe MM. Altered motor control and spasticity after spinal cord injury: subjective and objective assessment. Journal of Rehabilitation Research and Development, 2000; 37 (1): 41-52.
http://www.ncbi.nlm.nih.gov/pubmed/10847571

Skold C, Harms-Ringdahl K, Hultling C, Levi R, Seiger A. Simultaneous Ashworth measurements and electromyographic recordings in tetraplegic patients. Arch Phys Med Rehabil, 1998; 79: 959-65.
http://www.ncbi.nlm.nih.gov/pubmed/9710170

Skold C. Spasticity in spinal cord injury: self- and clinically rated intrinsic fluctuations and intervention-induced changes. Arch Phys Med Rehabil 2000;81:144-149.
http://www.ncbi.nlm.nih.gov/pubmed/10668766

Sinovas-Alonso I, Herrera-Valenzuela D, de-Los-Reyes-Guzmán A, Cano-de-la-Cuerda R, Del-Ama AJ, Gil-Agudo Á. Construct Validity of the Gait Deviation Index for People With Incomplete Spinal Cord Injury (GDI-SCI). Neurorehabil Neural Repair. 2023 Oct;37(10):705-715. https://pubmed.ncbi.nlm.nih.gov/37864467/

Smith AW, Jamshidi M, Lo SK. Clinical measurement of muscle tone using a velocity-corrected modified Ashworth scale. Am J Phys Med Rehabil, 2002; 81: 202-206.
http://www.ncbi.nlm.nih.gov/pubmed/11989517

Tederko P, Krasuski M, Czech J, Dargiel A, Garwacka-Jodzis I, Wojciechowska A. Reliability of clinical spasticity measurement in patients with cervical spinal cord injury. Ortopedia Traumatologia Rehabilitacja, 2007; 5(6): Vol 9, 467-483.
http://www.ncbi.nlm.nih.gov/pubmed/18026067

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