Towards a Clinical Measurement of Spasticity?

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REVIEW PAPER

Towards a Clinical Measurement of Spasticity? BeFnhUNlMEUUU JLesley Crow Key Words Spasticity, measurement, assessment, impairment, disability,

musde tone.

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The need for reliable and valid evaluation appears universal for the measuring of outcome. Such measurements can then sometimes also be used to demonstrate effective treatment, satisfy contract partners (purchasers and providers) as well as patients, and contribute to maintain or even improve professional standards. Some areas of clinical practice, however, may be easier to evaluate than others.

W i implementation of the Government‘s document ‘ ~ e a ~ t h ot the Nation’ lhere appearstobeanincreased need for objec- The measurement of spasticity is complex and tive evaluation and quantification of outcome in rehabilitation. difficult but the literature identifies a need to spastrcity is a dinical feature and a physiological phenomenon that hasoften beenconsbmdcomplex and difficult to measure. obtain a quantitative measurement of spasticity Hawever, the Meraturnh a s h i i e d the needfor aquantitative (Pederson, 1969;Jones et al, 1982;Katz and measurementdthis impairmentcaused by an increase in musde Rymer, 1989;Leslie et al, 1992).Methods of treattone within the clinlcal setting. The development ot such a meaeurementhasbeenaffeuedbyaladcof. ofthe ment have been accepted too often without critical evaluation of their effectiveness (Burry, Undmm. ofspastidty.Avarietyofmeasumts for spasticity are available and can be divided into subjective 1972)and too little effort has been applied to the mBBsuRM1Bnt8 (suchastendonjerks. rating scalasandessocidevelopment of reliable measurements (Wade, ated reactions) and objective measurements (including EMG, 1992).Difficulties arise in areas where objective pendulum tests and isokinetic measurements) but few are actually used. The measurementof spasticity is seen as part measurements are not readily available or when ofthe overall 888888mBn1process and it is proposed that more they are difficult to apply to the clinical setting. energy should be devoted to evaluating the reliability and validity of already existing dinical BssBssment scales.

Introduction The Govenunent highlighted in its document The Health of the Nation’ (DOH,1990)the need for effective measures of outcome from health care. An important element of demonstrating the value of a certain treatment intervention by any health care professional is to measure its effectiveness. This may be done either by indirect measurements of functional ability or by direct measurements of impairment. Measurement can also help to establish diagnosis, prognosis, severity and treatment outcome (Wade, 1992). Objectiveand subjective measurements have been described by Rothstein (19851,with objective meaemementa considered more precise and less affected by the pereons taking the measurement and showing reliability between testers. Subjective measurements are not denied a role in clinical practice or evaluation although they tend to be based more on clinical impressions (Rothstein, 1985).However, they can generate data on a nominal or ordinal scale which would allow for statistical analysis of the results. Objective measurements tend to generate data on a intervalhati0 level of measurement and potentially more robust statistical tests can be applied.

A measurement of spasticity will need to be based largely on the mechanisms underlying the phenomenon, but there appears to be a lack of understanding or agreement about these mechanisms. Spasticity is generally described as a motor . disorder characterised by a velocity-dependent increase in muscle tone with exaggerated tendon jerks (Lance, 1980). Further clinical features may include a loss of dexterity (Landau, 1980) and an impairment of postural control, mobility and function (Dimitrijevic, 1985). The main suggested mechanisms include changes to the intrinsic properties of the the muscle itself (Dietz and Berger, 1984),increased excitability of alpha motor neurones and /or gamma motor neurones (Rushworth, 1980; PierrotDeseilligny, 1985; Dimitrijevic, 1985), alterations in recurrent inhibition (Shefner et al, 1992; Pierrot-Deseilligny, 19851, abolition of presynaptic inhibition (Lance and Burke, 1974)and plastic adaptive changes in the CNS (Kidd et al, 1992).Therefore, a measurement of spasticity will also need to reflect what exactly is being measured. Some clinicians choose to use outcome measures which reflect levels of spasticity more indirectly. Examples of such measurements are global activity of daily living (ADL)scales such as the Barthel index (Mahoney and Barthel, 1965)or

more specific motor ability scales such as the Electromyognm Bf-menb (EMO) Motor Club Assessment Form (Ashburn, 1982). The functional assessment would then U h t Despite increasing support for the use of EMG aa a meam of biofeedbacL for the rehabilitationof the more general disability c a u d by epeeticity spastic states (Crowet al, 1969) the usefulnem and other factors. However, a direct and immeof EMG in the measurement of spasticity has not diate effect of spasticity may in fact be better been conf'irmedby the literature (Lehmann et d, reflected by a direct measurement of the impair- 1989). Accurate recordings of muscle activity ment caused. This may not be a general outcome may be possible on a one-off basis, but the repeat measure but provide specific information on the reliability is generally poor, owing to the uee subtle changes of muscle tone. of surfacehkin electrodes which can never be This review focuses on measurements used by reapplied with precision on the same location. physiotherapists or useful to physiotherapists in Better accuracy can be achieved with indwellthe clinical setting. The clinical setting relates ing electrodes but this has significant ethical to direct patient managementftreatment where implications within a clinical setting. Another simple and often mobile measurement tools can shortcoming of EMG lies in its inability to disbe used. This setting is distinct from an experi- tinguish between voluntary or conscious muecle mental setting where there is a more specifid activity and the spontaneous firing of spastic critical need for research and evaluation tools. muscle (Tepavac et d,1992). Measurement tools relevant to the experimental setting will therefore only find a brief mention Pendulum T e d (WartenbergTed) here. Despite reported limitations (Heerkenset d, This test w e e a specific form of stretch by 1994), the World Health Organisation definitions allowing the weight of the lower limb to simulate of disability and impairment will be used in the a stretch to the knee extensor muscles. It context of this paper: measures resistance to passive stretch biomechanically (Bajd and Bowman, 1982). The 'An impairment is any loss or abnormality of psychological, physiological or anatomical structure or measured leg is dropped from 111 extension and function' (WHO, 1980, page 45). allowed to swing freely with the patient lying in a supine position. The ewinge are recorded with an 'A disability is any restriction or lack (resulting from electrogoniometer (Bajd and Vodovnic, 1984), impairment) of ability to perform an activity in the sometimes also with EMG measurements manner or within the range considered normal for a (DeSouza and Musa, 1987) which again raises human being' (WHO, 1980, page 143). questions of reliability. Several authors describe the Wartenberg pendulum test as a reliable measurement of spasticity (Bohannon, 1981; Katz A Review of the Literature et a2 1992; Leslie et al, 1992) and it appears The literature offers a variety of alternatives for to provide a quantifiable measurement of the measuring spasticity but no single one of these resistance of muscle to passive stretch but thie seems to be widely used (Katzet al, 1992; Tepavac resistance could be due to factore other than spa% et al, 1992). This has been confirmed by a recent ticity. This includes changes in the mechanical survey (Haas, 1994) which indicated that health properties of the muecle tissue due to disuse (Katz care professionals did not measure spasticity and Rymer, 1989)A further limitation is that the although it was regarded as an important issue. test has only ever been used on spasticity of the The overview of measurements of spasticity will quadriceps muscle in the lower limb and doee not be divided into those applicable to the clinical appear to be suitable for other muscle group. setting and those used in the research setting

Isokinetic Meaaaremenb, Eliciting Stretch Measurement of Spasticity using Reflexes v i a Torque Generatore Laboratory Tools As indicated earlier it is not the main focus of this These methods quantify changes in phasic and paper to review more complex laboratory tools available for the quantification of spasticity. However, it is important to know that such tools are available and that they may be used in the clinical setting to evaluate treatment of spasticity; the complexity and the cost of these tools make them seem more appropriate for a research setting. Tools under this category can also be the Yardstick for validating more subjective but clinically applicable measurements.

tonic reflex activity of a spastic muscle (Katz and Rymer, 1989). Spastic muscle with an increase in tonic stretch reflexes will increase the resistance to passive stretch. Limbs fixed to a torque gpnerator are beingmoved to quantify the amount of torque (amount of force induced by moving the limb over a certain angle) and/or threshold (the angle where an increase in EMG activity or torque can be measured). Many studies ( s i b et d,1994; Lehmam et al, 1989; Meyer and Adorjani, 1980)

using torque generators also use EMG to quanti@ muscle tone with the above-mentioned problems. A number of authors describe a variety of devices (Seib et al, 1994;Firoozbalthsh et al, 1993;Katrak et al, 1992;Walsh, 1992;Katz and Rymer, 1989;Norton et al, 1972;Jones et al, 1982) Many of the above authors have performed reliability studies and have demonstrated good inter-rater reliability. Some apparatus appears to be able to overcome the problem of interference of mechanical muscle properties and measure only the increase in muscle tone (Seib et al, 1994).

ElectrophysiologicalTesting Since reflexes are heightened in spasticity, attempts to q u a n t e the excitability of the motor pool should be a prime target for investigation. The most frequently described reflex is the so called Hoffmann reflex (H-reflex). This is a monosynaptic reflex associated with large afferent IA fibres (Delwaide, 1985). It can be elicited in a variety of muscles but the soleus muscle is mostly used for this technique (Delwaide, 1985)A sufiiciently high stimulus produces the H-reflex and a subsequent motor response or movement of the stimulated muscle. The ratio of H-reflex and motor response has been described as an indicator for the quantification of spasticity (Delwaideet al, 1980)but has also found many critics (Katz et al, 1992;Katz and Ryman, 1989;Pederson, 1969). Katz and Rymer in a review in 1989 concluded that this test demonstrates little correlation with clinicalfindings.

Measurement of Spasticity Using Simple Clinically Applicable Tools Measurements and tools under this category have been described in the literature and appear to be simple enough to be applicable for the day-to-day assessment of spasticity which physiotherapists and other health care professionals may find useful. This paper will introduce the measurements and review their validity and reliability as they have been described.

Ratinglscalee Rating scales appear to be the simplest way to assess spasticity. The resistance of the muscle to passive stretch is the basis for the establishment of rating scales. A tester moves an affected limb and rates or categorises the resistance felt. As indicated earlier, resistance to passive movement may be due to changes in the properties of the muscle as well as due to spasticity. As the resistance to stretch is dependent on the velocity a t which the joint is moved, a standard velocity would be required to ensure a t least some reliability of measurements. Several of these scales are

described,but the modified Ashworth scale, established by Bohannon and Smith (19871,is the only scale which has been evaluated (Wade, 1992)and has shown inter-rater reliability in subsequent studies by Sloan et a1 (19921 and by Bodin and Morris (1991).However, doubts about the appropriateness of the statistical analysis in these studies have been raised (Haas, 1994)and only further work may confirm or otherwise if the scale is truly reliable. Katz et a1 (1992)and Jones et a1 (1982)feel that such scales provide only subjective information and make evaluation of therapy d S cult and open to error. A three-category scale (mild/moderate/severe spasticity) is widely used by physiotherapists but is unreliable with large inter-rater errors ( DeSouza and Musa, 1987).The information gained through rating scales might only be qualitative, but ‘they are at present the yardstick against which newer and more exact methods must be compared’ (Katz and Rymer, 1989). It could be argued that more objective measurements should be the yardstick for evaluating more subjective measurements.

Hand-held Myometers Two devices described under Werent names also use the resistance of muscle to passive stretch as their basis for measurement (Chabal et al, 1991). A study by Maloulin et a1 (1989)used a commercially available myometer of the type which is generally used for the evaluation of muscle strength. Myometers in the quantification of muscle strength have been found valid and of reasonable reliability (Bohannon, 1986; Bohannon and Andrews, 1987).Measurements are taken via a force transducer which produces a digital read-out of the resistance produced by the spastic muscle. For the evaluation of spasticity, the myometer demonstrated good intra-rater reliability when used in the upper and lower limb and good inter-rater reliability in the upper limb. However, the inter-rater reliability was poor for measurements of plantar flexor spasticity. This is consistent with an inter-rater reliability study utilising the modified Ashworth rating scale High levels of training may (Sloan et ~2,1992). have contributed to the good reliability but the myometer appears at least to be worthy of further investigation. If reliability is confirmed in subsequent studies then myometers could offer quantifiable measurements which would be superior to rating scales but still fairly simple and inexpensive. Chabal et a1 (1991)designed an apparatus which appears to be similar t o a myometer and also incorporates a goniometer. This apparatus was used in the evaluation of antispasticity drug treatment. The authors make claims for the apparatus to be reliable but fail to report results of statistical tests.

m Tendon Jerks This method uses the heightened reflexes in spasticity as the basis for evaluation. Eliciting the reflex in a number of tendons is a common clinical and bedside test which is generally easy to administer. But it provides a clinical impression which is highly subjective and it would be essential to supply a reproducible stimulus and measure the degree of deflection (Burry,1972). Attempta have been made to provide such a reproducible stimulus. Jones and Mulley (1982)describe a device but found that the readings were not clinically applicable and the apparatus was too complex. It appears then that the use of tendon jerks in their simplest form are not reliable and any attempts of standardising the test makes the method too complex for the clinical setting.

phenomenon of spasticity and therefore may contribute to disability rather than represent a direct impairment. Associated reactione appear closely related to activity and effort on the part of the patient and both seem dif€idtto quantify. This would be essential if associated reactions were used in a measurement of spasticity, ae in a study by Dvir and Panturih (1993)and were compared with isokinetic meaeurements. The authors fail to report statistical correlations between the two measurements. Associated reactions were evaluated using goniometry to measure differences in joint position before and after a specifiedmovement. The use of associated reactions in the measurement of spasticity appears of limited value at present.

Patient Selfsvalaation of Spaeticity

Indirect Measurement of Spasticity Little work has been reported of the use of Performance and Functional Measurements patients’ own imprewions of their spasticity. Haaa Spasticity can affect dexterity and functional activities and changes in the functional ability of the patient may indicate changes in level of spasticity. There are a number of valid and reliable measurements of functional ability available (Wade, 1992)but there are conflictingopinions as to their validity in measuring spasticity. The Oswestry scale (Goff, 1976)grades the effect of spasticity on isolated active movements but no reliability studies have been carried out (DeSouza and Musa, 1987).Katz and Rymer (1989)feel that functional measurements provide a ‘useful parameter of activities of daily living‘ but do not reflect spasticity per se. Functional tests may be useful in demonstrating changes in spasticity (Pederson, 19691,and Burry (1972)even postulates that simple functional tests may turn out to be the most reliable parameters of spasticity. Future research may include correlations between a clinical measurement scale and functional outcome measures to test this hypothesis. It has been mentioned before that functional performance measurements are an indirect measure and are also described as global disability measures (Wade, 1992) and as such differ fiom a direct measurement of spasticity which attempts to measure the impairment. It still remains to be seen if functional measurements can detect small subtle changes in muscle tone. Associated Reactions These are o h n linked to effort and &bath (1990) describes them as indicators of spasticity. Associated reactions in hemiplegia were defined by Davies (1985)as abnormal reflex movements of the affected side which would duplicate the typical stereotyped spastic pattern in the arm and leg. Asmciated reactions appear to be an indirect

(1994)reports a survey in which some clinicians propose the use of patient self-evaluation in s p ticity measurement. Seib et aZ(1994)describe the use of a ‘subjective spasticity assessment form’ with a scale from -4 to +4. No studies of reliability or validity of this scale have been reported. Further work with self-evaluation is required and studies to correlate findings with reliable and valid measurements of spasticity are still to be done.

Conclusions and Recommendationn Patient handling will usually give an experienced physiotherapist useful information and an impression of the level of spasticity for treatment and management purposes. However, this impression is only subjective and of very limited validity or reliability. Many physiotherapiste are now attempting to record their findings in a way that is useful, a t least to themselves. Unfortunately such records are individually defined and used and therefore only of benefit in a local setting with limited standardisation or evaluation. Measurement of spasticity should be seen ae part of the overall assessment of a patient; but since spasticity is an impairment a direct measurement of this phenomenon must be used. An increaee in muscle tone and exaggerated reflexes are characteristic for spasticity. Objective measurements such as the pendulum test, isokinetic measurements and physiological measurements attempt to measure these phenomena directly. Although there is some success in providing reliable and valid measurement tools such as the pendulum test and isokinetic measurements, they are not suitable for the day-to-day evaluation of spasticity in the clinical setting. Measurement tools and

scales which are suitable for the clinical setting are available and some of these claim to be reliable but further work is necessary.However, the more sophisticated and reliable laboratory tools should be able to provide the yardstick required to evaluate these scales. The health service and professional practice have moved on. The popular spasticity scale of mi1dJmoderatelsevere no longer appears to be good enough. More energy should be devoted to evaluate the Ashworth scale with appropriate statistical analysis and for a variety of pathologies. The use of myometers may also offer some hope of a simple instrument capable of delivering numerid data for the quantificationof spasticity. At this stage there is no need to reinvent the wheel or another spasticity scale. Patients' perceptions of their own level of spasticity could also be of value and inclusion of these in a spasticity scale might warrant further exploration. Functional assessment sales such as the Barthel Index are inappropriate measurements for spasticity, since they evaluate the functional ability and disability of a patient and not any of the phenomena seen in spasticity. The need for the developmentof a clinically applicable measurement tool for spasticity has been recognieed. All health care professionalsare challenged to practise what they believe in. In the case of the measurement of spasticity it appears that it ia time to progress from the desire to measure spasticity to the evaluation of available clinical measurement tools.

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Thanks to Jo Atkins and Jean Colbum from Oxford Brookes University, school of Health Care Studies, and to Difys Bayes from the University of Brighton, Department of Mathematical sdences, fur their advice, aupportandencouragement.

Authorr Bemhenl M Haas BA MCSP Is a senior lecturer at the University of Brighton, Oeparlmenl of Occupational Therapy and

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J Lesley Crow MSe MCSP Cert Ed (FEfHE) is a former senior leebreratnleuniiof~.schodofphysktherapy. This artide was receivedon July 27,1994. and accepted on May 30.199!j.

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WCPT-EUROPUCSP CONGRESS September 12-1 5,1996

CONGRESS THEATRE, DEVONSHIRE PARK CENTRE EASTBOURNE

Physiotherapy for Best Effect Fdlowingonfromthefirsf hisMysuccessfulm - E Congressheld m copenhasenin 1994, the chartered societyofphysiotheraw is d e l i to be hostingthis second eventwhiiwill be held in a m j m 3 b with its ownAnnual Congress. The WCPT-E Congress will be broad besed, and will kmk at the clinicaleffedive~~~%ofphysiotheraw .The a3ntralthemehssbeendividedinco~lolaucingarees forwhiiabaradsareinvited:

*oukomea O a k r l c d m *Raamrch oselvkeaccmdmm * - ~ w ~ d . v d O p n r m t ( ~ ) Clinicld g u # d b wd StaldMs *Rdocd. The programme will begin each day with a broadbased keynote address on the theme for the day selected from the above. Itwill then break down into concurrent abstract presentations on spedfic dinical topics, but maintaining a link with the day’s broad

theme. Papers are invited on all aspects of physiotherapyto coinddewiththeabovetheme.Fonnsforthesubmission of an abstract paper are available from the charteredsodetyofphysiolheraw*-telephone or write to the CSP Events unit. lel0171-3066621, fax 0171-3066611.