Reliability of Ashworth and Modified Ashworth Scales in Children with Spastic Cerebral Palsy

BACKGROUND Measurement of spasticity is a difficult and unresolved problem, partly due to its complexity and the fact that there are many factors involved. In the assessment of spasticity in the pediatric disabled population, methods that are easily used in practice are ordinal scales that still lack reliability. A prospective cross-sectional observational study was planned to determine the reliability of the Ashworth Scale (AS) and the Modified Ashworth Scale (MAS) in children with spastic cerebral palsy (CP). METHODS The study included 38 children with spastic diplegic CP. The mean age for the children was 52.9 months (SD: 19.6) ranging from 18 to 108 months. The functional levels of children were classified according to the Gross Motor Function Classification System. 20 children were in Level II (52.6%), 18 were in Level III (47.4%) and 9 were in Level I (23.7%). Spasticity in hip flexors, adductors, internal rotators, hamstrings, gastrocnemius were assessed by AS and MAS. Each child was assessed by three physiotherapists in two different sessions, a week apart. The intrarater reliability was determined by paired comparison of measurements for each therapist for the two assessments. Interrater reliability was determined by paired comparisons of the three therapists' measurements on the same day. The inter and intrarater reliability of the scales were evaluated by the intraclass correlation coefficient (ICC). RESULTS According to ICC scores, interrater reliability of AS and MAS varied from moderate to good. ICC scores of AS were between 0.54 and 0.78 and MAS were between 0.61-0.87. Test-retest results of AS and MAS varied from poor to good. ICC values were between 0.31 and 0.82 for AS and between 0.36 and 0.83 for MAS. CONCLUSION The interrater and intrarater reliability of AS and MAS are related to muscle and joint characters. The repetition of measurements by the same physiotherapist, and experience may not affect reliability. These scales are not very reliable and assessments of spasticity using these scales should be therefore interpreted with great caution.