Reliability of the Spinal Cord Assessment Tool for Spastic Reflexes

Accepted Manuscript Reliability of the Spinal Cord Assessment Tool for Spastic Reflexes Pinar Akpinar, MD, Arzu Atici, MD, Feyza U. Ozkan, MD, Assoc Prof, Ilknur Aktas, MD, Assoc Prof, Duygu G. Kulcu, MD, Assoc Prof, Kubra Neslihan Kurt, MD PII:

S0003-9993(16)31144-3

DOI:

10.1016/j.apmr.2016.09.119

Reference:

YAPMR 56692

To appear in:

ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION

Received Date: 7 June 2016 Revised Date:

1 September 2016

Accepted Date: 13 September 2016

Please cite this article as: Akpinar P, Atici A, Ozkan FU, Aktas I, Kulcu DG, Kurt KN, Reliability of the Spinal Cord Assessment Tool for Spastic Reflexes, ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION (2016), doi: 10.1016/j.apmr.2016.09.119. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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Running head: Reliability of the SCATS Title: Reliability of the Spinal Cord Assessment Tool for Spastic Reflexes

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Pinar AKPINAR MD¹, Arzu ATICI MD¹, Feyza U. OZKAN MD, Assoc Prof¹, Ilknur AKTAS MD, Assoc Prof¹, Duygu G. KULCU MD, Assoc Prof², Kubra Neslihan KURT, MD¹ ¹Department of Physical Medicine and Rehabilitation, Fatih Sultan Mehmet Education and

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Research Hospital, Istanbul, Turkey

²Department of Physical Medicine and Rehabilitation, Haydarpasa Numune Education and

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Research Hospital, Istanbul, Turkey

Informed consent was obtained from the participants and all procedures were conducted in accordance with the Helsinki Declaration of 1975 and approved by the local Institutional Cinical Research Ethical Committee (Fatih Sultan Mehmet Education and Research Hospital).

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There is no conflict of interest in this study. Corresponding author: Pinar Akpinar

Department of Physical Medicine and Rehabilitation

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Fatih Sultan Mehmet Education and Research Hospital, Istanbul Adress: Fatih Sultan Mehmet Egitim ve Arastırma Hastanesi. Fiziksel Tıp ve

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Rehabilitasyon Klinigi H blok. Atasehir. Istanbul / Turkiye Email address: [email protected] Phone number: +905057877442 Reprints are not avaible from the authors

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ACCEPTED MANUSCRIPT Reliability of the Spinal Cord Assessment Tool for Spastic Reflexes

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Objective: To assess the reliability of the Spinal Cord Assessment Tool for Spastic Reflexes

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(SCATS).

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Design: Observational reliability study of the SCATS .

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Setting: Inpatient rehabilitation unit at an education and research hospital.

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Participants: This study included 47 subjects between the ages of 18 and 88 years with spinal

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cord injury, American Spinal Injury Association (ASIA) impairment scale grades from A to D

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with spasticity, and at least 6 months post injury.

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Interventions: Not applicable.

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Main outcome measures: Inter-rater and test-retest reliability of the SCATS.

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Results: The SCATS had substantial to almost perfect inter-rater agreement (κ=0.669-1.000)

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between the 2 physiatrists. Test-retest agreement of the SCATS was also substantial to almost

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perfect (κ=0.614-1.000) as well. There was a significant correlation between the SCATS

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clonus scores and the Modified Ashworth scores of the hip, knee, and ankle. No correlation

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was found between SCATS extensor spasm scores and Modified Ashworth scores. The

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SCATS flexor spasm scores were only correlated significantly with the ankle plantar flexor

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Modified Ashworth scores (p<0.05).

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Conclusion: The SCATS is a reliable tool for assessing spasm activity and spastic hypertonia

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in patients with spinal cord injury.

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Reliability of the Spinal Cord Assessment Tool for Spastic Reflexes (SCATS)

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Keywords: clonus; extensor spasm; flexor spasm; spinal cord injury; spastic reflexes;

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spasticity

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ASIA

American Spinal Injury Association

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MAS

Modified Ashworth Scale

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PSFS

Penn Spasm Frequency Scale

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SCATS

Spinal Cord Assessment Tool for Spastic Reflexes

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spinal cord injury

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Spasticity is a common sensorimotor symptom complex seen in people with spinal cord injury

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(SCI). Spasticity was initially suggested by Lance as "muscle hypertonicity," 1 but was later

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acknowledged to include the positive and negative features of the upper motor neuron

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syndrome such as exaggerated tonic and phasic stretch reflexes, flexor and extensor spasms,

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clonus, spastic dystonia, reduced motor function, and weakness.2 The freshly established

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Ability Network which is an international initiative, organized to optimize the management of

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disabling spasticity following SCI; it has proposed a consensus on the definitions of

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spasticity. 3 The group recommends adoption of the definition by Padyan: “disordered sensori-

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motor control, resulting from an upper motor neuron lesion, presenting as intermittent or

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sustained involuntary activation of muscles.”4 The Ability Network suggests that spasticity

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does not result exclusively from hyper-excitability of the stretch reflex. The group focuses on

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the motor control and the symptoms experienced by those living with spasticity.

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It is important to measure spasticity to decide the most effective management option. The

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Modified Ashworth Scale (MAS) is the most widely used scale for subjective clinical

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assessment of spasticity, but it mainly measures one component, that is, the increased muscle

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tone.5 Spastic motor behavior in SCI includes stretch reflex excitability and hyperexcitable

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interneuronal reflexes involving multiple joints. The Penn Spasm Frequency Scale (PSFS)

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was developed to assesses the patient's perception of spasm frequency but it does not

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differentiate between the types of the spasms elicited. 6

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Clonus, flexor, and extensor spasms are commonly seen in patients with SCI.7,8 There is

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disinhibition of the existing normal reflex activity. An exaggerated propriospinal phasic

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stretch reflex causes clonus. Clonus is a low-frequency rhythmic oscillation observed in 1 or

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more limb segments. Electrophysiologically, it represents short-duration electrical activity of

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involved muscles that occurs at a frequency of 3 to 8 Hz.9 Flexor spasms are coordinated

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flexion movements of the leg at multiple joints triggered by noxious or non-noxious

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cutaneous stimuli. Release of primitive reflexes, such as positive support reaction, causes

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extensor spasms. Extensor spasms are multijoint extension movements of the leg, usually

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originated by sensory signals from the hip proprioceptors.10

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Benz et al. developed a clinical measure for the assessment of spasms and spastic hypertonia

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in SCI: the Spinal Cord Assessment Tool for Spastic Reflexes (SCATS).10 The SCATS

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assesses the severity of the 3 spasticity components, clonus, flexor, and extensor spasm. As it

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differentiates between the 3 distinct types of spastic motor behaviors in SCI, it may serve as a

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guide for the management of spastic hypertonia. Benz et al. determined concurrent validity by

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using a correlation analysis of kinematic and electromyographic signals with SCATS

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measurements. Validation of the SCATS with the Ashworth Scale and PSFS yielded variable

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results.10 To use a scale confidently, reliability, validation, and responsiveness are required.

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Gourab et al. conducted a preliminary study about the inter-rater reliability of the SCATS in

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2013. Five physical therapists estimated the SCATS scores in 9 SCI subjects. The testers’

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scores were in moderate agreement.11 There have been no studies utilizing a greater number

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of subjects that have assessed the reliability of the SCATS thus far. We aimed to assess the

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reliability of the SCATS and to evaluate the relationship with the MAS and PSFS for further

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validation.

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Methods

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Study Participants

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Forty-seven subjects between the ages of 18 and 88 years with SCI were recruited from the

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inpatient rehabilitation unit of an education and research hospital. Initially, 50 subjects were

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planned to be included but 2 were excluded because of early discharge from the hospital and 1

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was unwilling to participate in the study.

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American Spinal Injury Association (ASIA) impairment scale grades from A to D with

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spasticity and at least 6 months post-injury were included in the study. All patients were in a

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stable drug program, there was no initiation or dose change of oral anti spasticity-drug

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treatment within 30 days, and no botulinum toxin injections were administered less than 90

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days before the assessment. Exclusionary criteria included multiple central nervous system

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lesion sites, the presence of significant complications that affect spasticity (such as decubitus

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ulcer, heterotopic ossification, urinary tract infection, and any other infection), and inability to

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give informed consent. Informed consent was obtained, and all procedures were conducted in

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accordance with the Helsinki Declaration of 1975 and approved by the local Institutional

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Clinical Research Ethical Committee.

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Instruments

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The SCATS was developed by Benz et al.10 to measure the spastic motor behavior in SCI.

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The SCATS is split into 3 subscales, clonus, flexor, and extensor spasms, measured with a

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score of 0 to 3 (see Appendix 1). Clonus is measured by rapid passive dorsiflexion of the

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ankle. The duration of each clonic burst was timed and scored as follows: 0, when there was

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no reaction; 1, when the duration was less than 3 seconds; 2, when clonus persisted between

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3 to 10 seconds; and 3, when clonus lasted longer than 10 seconds. Rapid passive dorsiflexion

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of the ankle was repeated 3 times if there was no reaction at the first time. 10

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SCATS flexor spasm was measured by applying a pinprick stimulus to the medial arch of the

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foot when the knee and hip were extended. The degree of spasm was scored as follows: 0,

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when there was no reaction to stimulus; 1, when there was less than 10° flexion at the hip and

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knee, or extension of the big toe; 2, when there was 10° to 30° flexion of the hip and knee;

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and 3, when there was greater than 30° hip and knee flexion. Pinprick stimulus was repeated 3

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times if there was no reaction to stimulus.10

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The SCATS extensor spasm was measured by positioning the tested lower extremity with an

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angle of 90° to 110° hip and knee flexion and suddenly extending both joints while the

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contralateral limb was extended. The duration of visible quadriceps muscle contraction was

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measured by observing the superior displacement of the patella. The degree of spasm was

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measured as follows: 0, when there was no contraction in the quadriceps muscle; 1, when

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there was contraction less than 3 seconds; 2, when there was persistent contraction for 3 to 10

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seconds; and 3, when contraction lasted longer than 10 seconds . The test was repeated 3

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times if there was no reaction at the first time.10 Also, refer to the demonstration video at:

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http://www. eng.mu.edu/inerl/SCATS.html (used with the permission of the Benz et al).

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The MAS is the most frequently used clinical measurement of spasticity. It is a 5- point scale

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that subjectively assesses the muscle tone. MAS scores were collected from the right hip

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adductor and extensor muscles, right knee extensor and flexor muscles, and right plantar

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flexor muscles of the subjects. According to the recommendations of Padyan et al.

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patients were assessed lying supine, the upper limbs parallel to the trunk in a neutral position,

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and the lower limbs parallel to one another (one exception is the assessment of knee extensors

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at the prone position).

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The PSFS was created to measure the effectiveness of intrathecal baclofen in the treatment of

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spasticity in patients with SCI.6 It is a self-reported measure with items on 5-point scales that

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assesses a patient's perception of spasticity frequency. The PSFS measures the number of

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spasms experienced by patients within a 1-h period. We used the PSFS to measure spasm

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frequency.

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Reliability and Convergent Validity

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Inter-rater agreement was investigated simultaneously by 2 experienced physiatrists with

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, all

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standardization of the SCATS assessment, testers undertook a training session before the

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initiation of the study. During training, an instructional video10,11 was watched and SCATS

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assessment was practiced.

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All patients were assessed lying supine, the upper limbs parallel to the trunk in a neutral

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position. If there was no reaction to the stimulus the first time, the sub-scale was repeated 3

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times, and the assessment was then completed. Scores of the examinations were blinded

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between the testers. There was a 20-minute break between each testers’ examination to

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minimize the effect of 1 assessment on the other.

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Test-retest agreement was investigated by re-testing each subject using the same positions, at

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the same time period of the day, 1 week apart by 1 physiatrist. The MAS was assessed and

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the PSFS was conducted by the same physiatrist as the first round. Correlations between the

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SCATS, MAS, and PSFS scores were investigated for the evaluation of the convergent

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validity.

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Analyses

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Statistical analyses were performed using the IBM SPSS Statistics 22 software package

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(Turkey). Data are presented as mean ± standard deviation. To assess the inter-rater and test-

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retest agreement kappa statistics were calculated. We used the criteria of Landis and Koch13 to

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interpret kappa values: <0.0= poor; 0.00 to 0.20= slight; 0.21 to 0.40= fair; 0.41 to 0.60=

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moderate; 0.61 to 0.80= substantial; 0.81 to 1.00= almost perfect. Spearman’s rank correlation

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coefficient was used to identify the relationship of the SCATS with the MAS and PSFS.

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Patient Demographics

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The mean age of subjects with SCI, 17 females (36.2%) and 30 males (63.48%), was

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44.19±14.52 years. The total duration of SCI was 6|–197 months. Twenty-one of the 47

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subjects were taking antispasticity medication. Demographic information and concomitant

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medication history of the participants are listed in Table 1. With regard to the ASIA

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impairment scale, 12 subjects (25.5%) were classified as grade A, 6 (12.8%) as grade B, 11

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(23.4%) as grade C, and 18 (38.3%) as grade D. With regard to the neurological level, 15

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were cervical (31.9% ), 23 were thoracic (49%), and 9 were lumbosacral (19.1%). The most

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frequent etiologies of SCI were falls and traffic accidents consecutively.

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Inter-Rater and Test-Retest Reliability

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The test-retest kappa-coefficients ranged from 0.614 to 1.000 (SD=0.08), which demonstrates

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a substantial to almost perfect agreement (Table 2).

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The inter-rater agreement measures were slightly higher than those for test-retest agreement,

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and the kappa values ranged from 0.669 to 1.000 (p<0.01) between 2 physiatrists. Inter-rater

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kappa values are shown in Table 2.

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Releationship Between the Scales (Convergent Validity)

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Figures 1, 2, and 3 show the percentage of subjects with different levels of MAS, SCATS,

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and PSFS, respectively.

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The MAS in all muscle groups significantly correlated with the SCATS clonus scores. The

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SCATS flexor spasm scores only significantly correlated with the MAS score of the ankle

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plantar flexor muscles. There were no significant correlations between the SCATS extensor

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spasm scores and any of the MAS scores (Table 3).

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Moreover, no significant correlation was observed between the SCATS scores and the PSFS

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ratings (Table 3).

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Discussion

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This is the first study to investigate the reliability of the SCATS with a large number of

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subjects. Our results demonstrated good inter-rater agreement and test-retest agreement. One

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important factor for the high agreement was using well-trained experienced testers and

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standardized SCATS. Our results also showed higher inter-rater agreement than test-retest

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agreement. The reason for the lower test-retest agreement could be because the 2 tests were

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performed 1 week apart as spasticity could change with time. We also found correlations to

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some extent with the MAS, but no significant correlation with the PSFS. As Benz et al.

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established the validity of SCATS earlier, the lack of consistent correlations between the

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SCATS and PSFS indicates differences in the manifestations of self-reporting and clinician-

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based reports across this subject population.

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It is important to use the most appropriate tool to assess the different patterns of spasticity.

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The SCATS was developed to measure spasms and spastic hypertonia in SCI.10 It also

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assesses the extent and severity of spasticity. The SCATS is an appropriate tool that

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distinguishes between different types and severity of spastic reflexes in SCI. The SCATS is

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an easy-to-administer tool. It can be administered during a home visit or at a hospital, but

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should be administered by a trained clinician.

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Correlation of the SCATS scores with MAS, the most frequently used clinical assessment

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scale, revealed different results compared to those of the Benz et al.’ study. In our study,

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SCATS clonus scores are significantly correlated to the MAS in all muscle groups. SCATS

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extensor spasm scores are not correlated significantly with any of the MAS scores, whereas

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extensor spasms are significantly correlated with the MAS scores in the Benz et al.’s study. In

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contrast, clonus scores correlate to a lesser extent in the Benz et al.’s study.10 One reason for

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the different results could be the different percentage of extensor spasms and clonus in the 2

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study groups. In our study, there were very few subjects with extensor spasms (Figure 2).

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Also, the MAS scores of knee flexor and extensor muscles were mostly at grade 0 in our

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study.

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Another point is that the MAS assesses the velocity-dependent aspect of spasticity across a

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single joint and does not estimate the multijoint flexor and extensor spasms. It is important to

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recognize that the MAS does not represent the entire picture of spasticity in subjects with SCI.

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Also, studies that examined the reliability of the MAS have yielded conflicting

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results.14,15,16,17 The SCATS is a more comprehensive clinical scale that may have advantages

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over the MAS, because it measures multijoint spastic motor behaviors in SCI. As we showed

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in our study, inter-rater agreement and test-retest agreement scores of the SCATS were good.

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The SCATS can be used reliably in this patient population.

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Comparison of the SCATS with the PSFS revealed no significant correlation with clonus

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scores in our study. In the Benz et al.’s study, there was a significant correlation between the

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SCATS clonus scores and the PSFS ratings. There was no significant correlation between

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SCATS flexor and extensor spasm scores and the PSFS ratings in both studies. The PSFS

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assesses spasm frequency as perceived by the patient, but does not differentiate between the

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types of spasms elicited. The PSFS is a self-reported scale and the SCATS is an examiner-

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based clinical tool. Priebe et al. found no correlation between the PSFS and clinical

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assessments.18 It is particularly noteworthy that there is a difference between self-reporting

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measures of spasticity and the clinical examination. The subject’s perception of his or her

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own condition could be unsound, or the elements of spasticity evaluated in the physical

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examination do not represent what is important to people with spasticity caused by SCI.

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Considering of our results, the SCATS may serve as a complementary tool to self-report

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scales in SCI.

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It is suggested that spasticity intervention trials should include objective, subjective, and

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functional assessments.19 The multidimensional nature of spasticity should be considered

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when selecting outcome measures for spasticity.20 Flexor and extensor spasms should be

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assessed clinically in patients with SCI, and the SCATS serves as a good tool for it.

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The effective use of outcome measures is important for clinical care. A spasticity outcome

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measurement tool must adequately assess the functional activities that spasticity may impact.

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Bravo-Esteban et al. investigated the impact of specific symptoms of spasticity on voluntary

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lower limb muscle function, gait, and daily activities during subacute and chronic SCI. They

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found that subjects with incomplete SCI and hypertonia showed loss of voluntary flexor

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muscle activity, while extensor spasms contributed strongly to loss of gait function.21 Spasms

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usually cause discomfort on stable body position, changing position, interfere with transfers,

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and may hinder activities of daily living in patients with motor complete SCI. For instance,

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extensor spasms may force a patient out of a wheelchair.22 The successful early diagnosis and

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management of involuntary spasms would be expected to further preserve and promote

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adaptive motor function during subacute SCI neurorehabilitation.23 As a result, diagnosis of

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spasm activity is necessary to develop a more effective neurorehabilitation treatment strategy.

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Thus, at present, the SCATS serves a useful tool for assessing spasm activity.

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Study Limitations

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Subjects in our study population had low grades of MAS at the hip extensor, knee extensor,

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and knee flexor muscles (Figure 1). Extensor spasm scores of the SCATS were 0 in almost all

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subjects (Figure 2). The cause of

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agreement of the SCATS at the extensor spasm scores could be the low extensor spasm scores

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of the subjects in our study.

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almost perfect (κ=1.000) inter-rater and test-retest

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Conclusions

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The SCATS fills a need for a clinical measurement tool to assess spasm activity in patients

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with SCI. It provides good inter-rater agreement and test-retest agreement in the measurement

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of spastic hypertonia in SCI. Further research is needed to determine the responsiveness of the

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SCATS.

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Acknowledgements

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The authors would like to thank the patients who participated in the research.

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This research did not receive any specific grants from funding agencies in the public,

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commercial, or not-for-profit sectors.

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19- Priebe M. Assessment of Spinal Cord Injury Spasticity in Clinical Trials. Topics in Spinal Cord Injury Rehabilitation 2006;11:3:69-77. DOI: 10.1310/82XL-W79K-

334

V6K2-DCWG

EP

333

20- Hsieh JT, Wolfe DL, Miller WC, Curt A. Spasticity outcome measures in spinal cord

336

injury: psychometric properties and clinical utility. Spinal Cord 2008;46(2):86-95.

337 338

AC C

335

PMID: 17909559 DOI: 10.1038/sj.sc.3102125.

21- Bravo-Esteban E, Taylor J, Abián-Vicén J, Albu S, Simón-Martínez C, Torricelli

339

D, Gómez-Soriano J. Impact of specific symptoms of spasticity on voluntary lower

340

limb muscle function, gait and daily activities during subacute and chronic spinal cord

341

injury. NeuroRehabilitation 2013;33(4):531-43. DOI: 10.3233/NRE-131000.

16

ACCEPTED MANUSCRIPT 342

22- Fleuren JF, Voerman GE, Snoek GJ, Nene AV, Rietman JS, Hermens HJ. Perception

343

of lower limb spasticity in patients with spinal cord injury. Spinal Cord 2009;

344

47(5):396-400. DOI: 10.1038/sc.2008.153.

345

23- Gómez-Soriano J, Castellote JM, Pérez-Rizo E, Esclarin A, Taylor JS. Voluntary ankle flexor activity and adaptive coactivation gain is decreased by spasticity during

347

subacute spinal cord injury. Experimental Neurology 2010;224(2):507-16. DOI:

348

10.1016/j. expneurol.2010.05.014.

SC

349

M AN U

350

351 352

357 358 359 360 361 362 363

EP

356

AC C

355

TE D

353 354

RI PT

346

17

ACCEPTED MANUSCRIPT 364 365 366

368 369

Table 1: Demographics and characteristics of participants

SC

370

RI PT

367

M AN U

371 372

Table 2: Inter-Rater and Test-Tetest Agreement of the SCATS

373

**Significant at p<0.01.

TE D

374

Table 3: Correlation of the SCATS with the MAS and the PSFS

376

r: Spearman’s Rho correlation coefficient. *Significant at p<0.05. **Significant at p<0.01.

AC C

377

EP

375

378

Figure 1: Percentage of the Subjects with Different Grades of MAS .

379

The figure shows the distribution of the MAS grades based on the location of the muscle

380

group. The vertical axis shows percentages of the subjects.

381 382

Figure 2: Percentage of Subjects with Different scores of SCATS .

18

ACCEPTED MANUSCRIPT 383

The figure shows the different scores of the SCATS with different colors. The vertical

384

axis shows percentages of the subjects.

385

Figure 3: Percentage of Subjects with Different Levels of the PSFS .

387

The figure shows the different levels of the PSFS. The vertical axis shows percentages of

388

the subjects.

RI PT

386

SC

389

Appendix 1 (Summarized from Benz EN, Hornby TG, Bode RK, Scheidt RA, Schmit BD. A

391

physiologically based clinical measure for spastic reflexes in spinal cord injury.Arch Phys

392

Med Rehabil. 2005 Jan; 86(1): 52-9)

AC C

EP

TE D

M AN U

390

ACCEPTED MANUSCRIPT Spinal Cord Assessment Tool for Spastic Reflexes (SCATS) Clonus: Quantified in response to rapid dorsiflexion of the ankle. 0 No reaction

RI PT

1 Mild: clonus maintained < 3 s 2 Moderate: clonus persists 3 to 10 s

SC

3 Severe: clonus persists >10 seconds

Flexor Spasms: Measured by applying a pinprick stimulus to the medial arch with the knee

M AN U

and hip extended straight. 0 No reaction

1 Mild: < 10° flexion at the hip and knee, or extension of the big toe

TE D

2 Moderate; 10° to 30° flexion at the hip and knee 3 Severe: > 30° hip and knee flexion

Extensor Spasms: measured by positioning the tested lower extremity with an angle of 90° to

EP

110° hip and knee flexion, and suddenly extending both joints while the contralateral limb was extended. The duration of visible quadriceps muscle contraction was measured by observing

AC C

the superior displacement of the patella. 0 No reaction

1 Mild: contraction maintained < 3 s 2 Moderate: contraction persists 3 to 10 s 3 Severe: contraction persists >10 s

ACCEPTED MANUSCRIPT Tetraplegia

Paraplegia

47

15

32

year

44.19

44.47

44.06

(range)

(18-88)

(25-68)

(18-88)

43.96

40.53

45.56

(6-197)

(6-103)

(6-197)

17 /30

6 /9

11 /21

12 (25.5%)

6 (40%)

6 (18.8%)

1 (6.7%)

2 (6.3%)

n Mean age

Mean time post injury month (range) Women/Men Etiology n/%

Traffic accidents

3 (6.4%)

M AN U

Violence

RI PT

Total

SC

Characteristics

Falls Diving Toumor Sports

18 (38.3%)

3 (20%)

15 (46.9%)

2 (4.3%)

2 (13.3%)

0 (0%)

6 (12.8%)

1 (6.7%)

5 (15.6%)

6 (12.8%)

2 (13.3%)

4 (12.5%)

Baclofen

15

7

8

medication

Tizanidine

4

2

2

Diazepam

2

1

1

AC C

EP

TE D

Spasticity

ACCEPTED MANUSCRIPT Inter-rater agreement Test-retest agreement Kappa

Clonus

0.854**

0.759**

Flexsor spasm

0.669**

0.614**

Extensor spasm

1.000**

1.000**

AC C

EP

TE D

M AN U

SC

Kappa

RI PT

SCATS

ACCEPTED MANUSCRIPT MAS hip

MAS hip

MAS knee

MAS knee MAS ankle

adductor

extensor

flexor

extensor

flexor

muscles

muscles

muscles

muscles

muscles

r

r

r

r

0.369

0.709**

0.406**

0.356

0.102

0.257

0.279

0.054

0.059

0.150

clonus

flexor

SCATS extensor

0.115

AC C

EP

TE D

spasm

M AN U

spasm

0.754**

0.208

0.393*

0.066

0.250

0.058

SC

SCATS

0.142

r

RI PT

SCATS

r

PSFS

ACCEPTED MANUSCRIPT

Hip extensor muscles 0

1

1+

2

3

Knee extensor muscles 4

AC C

EP

TE D

M AN U

Grades

Knee flexor muscles

Ankle plantar flexor muscles

SC

Hip adductor muscles

RI PT

100.0 90.0 80.0 70.0 60.0 50.0 40.0 30.0 20.0 10.0 0.0

Subjects

%

MAS

ACCEPTED MANUSCRIPT

SCATS 120.0 100.0

RI PT

%

80.0 60.0 40.0

SC

0.0 Clonus 0

Flexor spasm 1 2 3

EP

TE D

M AN U

Scores

AC C

Subjects

20.0

Extensor spasm

ACCEPTED MANUSCRIPT

PSFS 100 90 80 70

RI PT

%

60 50 40

10 0

Scores 0

2

3

EP

TE D

M AN U

1

SC

20

AC C

Subjects

30

4