Is an instrumented spasticity assessment an improvement over clinical spasticity scales in assessing and predicting the response to integrated botulinum toxin type a treatment in children with cerebral palsy? Comprehensive quantification of the spastic catch in children with cerebral palsy. Efficacy of coupling repetitive transcranial magnetic stimulation and physical therapy to reduce upper-limb spasticity in patients with stroke: a randomized controlled trial. Dimensionality and construct validity of the Fugl-Meyer Assessment of the upper extremity. The relation between Ashworth scores and neuromechanical measurements of spasticity following stroke Analysis and Comparison of the Psychometric Properties of Three Balance Measures for Stroke Patients Psychometric properties of the sensory scale of the Fugl-Meyer Assessment in stroke patients Clinical assessment of hand motor performance after acquired brain injury with dynamic computerized hand dynamometry: construct, concurrent, and predictive validity. A comparison of goal attainment scaling and the Canadian occupational performance measure for paediatric rehabilitation research Reliability of the Fugl-Meyer assessment for testing motor performance in patients following stroke. Regulation of stretch reflex threshold in elbow flexors in children with cerebral palsy: a new measure of spasticity. Focal muscle vibration in the treatment of upper limb spasticity: a pilot randomized controlled trial in patients with chronic stroke. Comparative assessment of therapeutic response to physiotherapy with or without botulinum toxin injection using diffusion tensor tractography and clinical scores in term diplegic cerebral palsy children Reliability of elbow stretch reflex assessment in chronic post-stroke hemiparesis Alterations in body composition and spasticity following subtetanic neuromuscular electrical stimulation training in spinal cord injury. Evaluation of the psychometric properties of the upper limb subscales of the Motor Assessment Scale using a Rasch analysis model. Validation of portable muscle tone measurement device for quantifying velocity-dependent properties in elbow spasticity.
OBJECTIVE To compare responsiveness and predictive ability of clinical and instrumented spasticity assessment s after botulinum toxin type A ( BTX ) treatment combined with casting in the medial hamstrings ( MEHs ) in children with spastic cerebral palsy ( CP ) . DESIGN Prospect i ve cohort study . SETTING Hospital . PARTICIPANTS Consecutive sample of children ( N=31 ; 40 MEH muscles ) with CP requiring BTX injections . INTERVENTION Clinical and instrumented spasticity assessment s before and on average ± SD 53±14 days after BTX . MAIN OUTCOME MEASURES Clinical spasticity scales included the Modified Ashworth Scale and the Modified Tardieu Scale . The instrumented spasticity assessment integrated biomechanical ( position and torque ) and electrophysiological ( surface electromyography ) signals during manually performed low- and high-velocity passive stretches of the MEHs . Signals were compared between both stretch velocities and were examined pre- and post-BTX . Responsiveness of clinical and instrumented assessment s was compared by percentage exact agreement . Prediction ability was assessed with a logistic regression and the area under the receiver operating characteristic ( ROC ) curves of the baseline parameters of responders versus nonresponders . RESULTS Both clinical and instrumented parameters improved post-BTX ( P≤.005 ) ; however , they showed a low percentage exact agreement . The baseline Modified Tardieu Scale was the only clinical scale predictive for response ( area under the ROC curve=0.7 ) . For the instrumented assessment , baseline values of root mean square ( RMS ) electromyography and torque were better predictors for a positive response ( area under the ROC curve=.82 ) . Baseline RMS electromyography remained an important predictor in the logistic regression . CONCLUSIONS The instrumented spasticity assessment showed higher responsiveness than the clinical scales . The amount of RMS electromyography is considered a promising parameter to predict treatment response In clinical setting s , the spastic catch is judged subjectively . This study assessed the psychometric properties of objective parameters that define and quantify the severity of the spastic catch in children with cerebral palsy ( CP ) . A convenience sample of children with spastic CP ( N=46 ; age range : 4 - 16 years ) underwent objective spasticity assessment s. High velocity , passive stretches were applied to the gastrocnemius ( GAS ) and medial hamstrings ( MEH ) .  Muscle activity was measured with surface electromyography ( sEMG ) , joint angle characteristics using inertial sensors and reactive torque using a force sensor . To test reliability , a group of 12 children were retested after an average of 13 ± 9 days . The angle of spastic catch ( AOC ) was estimated by three biomechanical definitions : joint angle at ( 1 ) maximum angular deceleration ; ( 2 ) maximum change in torque ; and ( 3 ) minimum power . Each definition was checked for reliability and validity . Construct and clinical validity were evaluated by correlating each AOC definition to the averaged root mean square envelope of EMG ( RMS-EMG ) and the Modified Tardieu Scale ( MTS ) . Severity categories were created based on selected parameters to establish face validity . All definitions showed moderate to high reliability . Significant correlations were found between AOC3 and the MTS of both muscles and the RMS-EMG of the MEH , though coefficients were only weak . AOC3 further distinguished between mild , moderate and severe catches . Objective parameters can define and quantify the severity of the spastic catch in children with CP . However , a comprehensive underst and ing requires the integration of both biomechanical and RMS-EMG data OBJECTIVE To assess the efficacy of inhibitory repetitive transcranial magnetic stimulation ( rTMS ) for decreasing upper-limb muscle tone after chronic stroke . DESIGN A r and omized sham-controlled trial with a 4-week follow-up . SETTING Research hospital . PARTICIPANTS Patients with stroke ( N=20 ) with poststroke upper limb spasticity . INTERVENTIONS The experimental group received rTMS to the primary motor cortex of the unaffected side ( 1500 pulses ; 1Hz ; 90 % of resting motor threshold for the first dorsal interosseous muscle ) in 10 sessions , 3d/wk , and physical therapy ( PT ) . The control group received sham stimulation and PT . MAIN OUTCOME MEASURES Modified Ashworth scale ( MAS ) , upper-extremity Fugl-Meyer assessment , FIM , range of motion , and stroke-specific quality -of-life scale . All outcomes were measured at baseline , after treatment ( postintervention ) , and at a 4-week follow-up . A clinical ly important difference was defined as a reduction of ≥1 in the MAS score . RESULTS Friedman test revealed that PT is efficient for significantly reducing the upper limb spasticity of patients only when it is associated with rTMS . In the experimental group , 90 % of the patients at postintervention and 55.5 % at follow-up showed a decrease of ≥1 in the MAS score , representing clinical ly important differences . In the control group , 30 % of the patients at postintervention and 22.2 % at follow-up experienced clinical ly meaningful changes . There were no differences between the groups at any time for any of the other outcome measures , indicating that both groups demonstrated similar behaviors over time for all variables . CONCLUSIONS rTMS associated with PT can be beneficial in reducing poststroke spasticity . However , more studies are needed to clarify the clinical changes underlying the reduction in spasticity induced by noninvasive brain stimulations OBJECTIVE To investigate the dimensionality and construct validity of the Fugl-Meyer Assessment of the upper extremity by using Rasch analysis . DESIGN Secondary analysis of pooled data from 2 existing data sets : a r and omized therapeutic exercise clinical trial and a cohort longitudinal study of stroke recovery . SETTING University research center . PARTICIPANTS A total of 512 subjects , ages 69.8+/-11.1 years , who were 0 to 145 days poststroke . INTERVENTIONS Not applicable . MAIN OUTCOME MEASURES Dimensionality was examined with principal components analysis and Rasch item-fit statistics . The Rasch-derived item hierarchy was examined for consistency with the expected course of poststroke upper-extremity recovery suggested by the reflex-hierarchical conceptual model underlying the assessment . RESULTS Factor loadings and item infit statistics suggested that the 3 reflex items were empirically disconnected from other assessment items . The reflex items were removed . The modified 30-item assessment showed a unidimensional structure . The Rasch-item-difficulty order was not consistent with the expected item order . CONCLUSIONS The items testing resting-state reflexes may threaten the assessment 's dimensionality . With reflex items removed , the assessment is a unidimensional measure of volitional movement . The Rasch-generated item-difficulty order challenges the hierarchical structure implied by the instrument 's underlying conceptual framework Background Spasticity is a common impairment that follows stroke , and it results typically in functional loss . For this reason , accurate quantification of spasticity has both diagnostic and therapeutic significance . The most widely used clinical assessment of spasticity is the modified Ashworth scale ( MAS ) , an ordinal scale , but its validity , reliability and sensitivity have often been challenged . The present study addresses this deficit by examining whether quantitative measures of neural and muscular components of spasticity are valid , and whether they are strongly correlated with the MAS . Methods We applied abrupt small amplitude joint stretches and Pseudor and om Binary Sequence ( PRBS ) perturbations to both paretic and non-paretic elbow and ankle joints of stroke survivors . Using advanced system identification techniques , we quantified the dynamic stiffness of these joints , and separated its muscular ( intrinsic ) and reflex components . The correlations between these quantitative measures and the MAS were investigated . Results We showed that our system identification technique is valid in characterizing the intrinsic and reflex stiffness and predicting the overall net torque . Conversely , our results reveal that there is no significant correlation between muscular and reflex torque/stiffness and the MAS magnitude . We also demonstrate that the slope and intercept of reflex and intrinsic stiffnesses plotted against the joint angle are not correlated with the MAS . Conclusion Lack of significant correlation between our quantitative measures of stroke effects on spastic joints and the clinical assessment of muscle tone , as reflected in the MAS suggests that the MAS does not provide reliable information about the origins of the torque change associated with spasticity , or about its contributing components Background and Purpose — This study compared the psychometric properties of 3 clinical balance measures , the  Berg Balance Scale ( BBS ) , the Balance subscale of the Fugl-Meyer test ( FM-B ) , and the Postural Assessment Scale for Stroke Patients ( PASS ) , in stroke patients with a broad range of neurological and functional impairment from the acute stage up to 180 days after onset . Methods — One hundred twenty-three stroke patients were followed up prospect ively with the 3 balance measures 14 , 30 , 90 , and 180 days after stroke onset ( DAS ) . Reliability ( interrater reliability and internal consistency ) and validity ( concurrent validity , convergent validity , and predictive validity ) of each measure were examined . A comparison of the responsiveness of each of the 3 measures was made on the basis of the entire group of patients and 3 separate groups classified by degree of neurological severity . Results — The FM-B and BBS showed a significant floor or ceiling effect at some DAS points , whereas the PASS did not show these effects . The BBS , FM-B , and PASS all had good reliability and validity for patients at different recovery stages after stroke . The results of effect size demonstrated fair to good responsiveness of all 3 measures within the first 90 DAS but , as expected , only a low level of responsiveness at 90 to 180 DAS . The PASS was more responsive to changes in severe stroke patients at the earliest period after stroke onset , 14 to 30 DAS . Conclusions — All 3 measures tested showed very acceptable levels of reliability , validity , and responsiveness for both clinicians and research ers . The PASS showed slightly better psychometric characteristics than the other 2 measures Objective : To examine the psychometric properties of the sensory scale of the Fugl-Meyer Assessment ( FMA-S ) in stroke patients with a broad range of neurological and functional impairment at times from 14 to 180 days after stroke . Subjects : A total of 176 first stroke patients consecutively admitted to a university based medical centre . Design : This prospect i ve , longitudinal investigation was based on data collected at 14 , 30 , 90 and 180 days after stroke . Main outcome measures : Reliability ( inter-rater reliability and internal consistency ) , validity ( convergent and predictive validity ) and responsiveness of the FMA-S  were examined . Results : The inter-rater agreement of the total score of the FMA-S was excellent , with an intraclass correlation coefficient of 0.93 . The Cronbach 's alphas of the FMA-S at four time points after stroke ranged from 0.94 to 0.98 , indicating excellent internal consistency . However , the FMA-S showed a significant ceiling effect ( more than 44.4 % of the subjects achieving the highest score ) , poor to moderate inter-rater reliability for light touch items ( weighted kappa ranging from 0.30 to 0.55 ) , low to moderate validity ( Spearman 's rho ranging from 0.29 to 0.53 ) , and low to moderate responsiveness ( st and ardized response mean ranging from 0.27 to 0.67 ) at different post-stroke stages of recovery . Conclusions : The psychometric properties of the FMA-S in measuring sensory function do not support its clinical use in stroke patients . Further studies on methods to improve the psychometric properties of the FMA-S are needed OBJECTIVE To assess the construct , concurrent , and predictive validity of dynamic computerized h and dynamometry . DESIGN Prospect i ve correlational study between dynamometry and functional upper limb performance . SETTING Hospital outpatient spasticity clinics . PARTICIPANTS Adults with upper motor neuron syndrome affecting the upper limb after acquired brain injury ( ABI ) ( n=38 ; median age , 50 y ; range , 18 - 81 y ) and healthy adult control participants ( n=27 ; median age , 37 y ; range , 22 - 62 y ) . INTERVENTION Not applicable . MAIN OUTCOME MEASURES  Dynamic computerized dynamometry elements of h and performance ( isometric force , force velocity , isometric grip work , contraction and relaxation duration ) and the Action Research Arm Test . RESULTS Motor elements of h and performance objective ly measured by the dynamic computerized dynamometry protocol achieved moderate to good validity when correlated with st and ardized measures of functional h and performance . Dynamic computerized dynamometry identified clear differences in h and performance between participants with and without ABI . Within the ABI group , dynamic computerized h and dynamometry achieved fair to moderate predictive validity with regards to whether a participant would be referred for botulinum toxin A injections . CONCLUSIONS This study provides support for the construct , concurrent , and predictive validity of the dynamic computerized dynamometry protocol Purpose : To investigate the relative utility of Canadian Occupational Performance Measure ( COPM ) ( adapted for children ) and Goal Attainment Scaling ( GAS ) as outcome measures for paediatric rehabilitation . Methods : A two-group pre – post design investigated the impact of a 3-month programme . Forty-one children with spastic hemiplegic cerebral palsy ( mean 3.9 years ; GMPM level 1 ; 21 boys , 10 girls ) were r and omized to occupational therapy only and occupational therapy plus one Botulinum Toxin A injection .  The latter was considered a ‘ proven ’ intervention for the purpose of this instrumentation study . Intervention impact was investigated using GAS and COPM .  Instrument sensitivity , convergent validity , goal /problem profiles and administration were evaluated . Results : Both instruments were sensitive to within group change and detected significant between group change . Likert scale coding for GAS scores was more sensitive than the traditional weighted GAS or COPM . Different constructs were measured by each instrument .  COPM was more time efficient in training , development and administration . Conclusion : Study aim , logistic and re source factors should guide the choice of COPM and /or GAS instruments as both are sensitive to change with a proven intervention and both evaluate different constructs BACKGROUND AND PURPOSE The purpose of this study was to establish the interrater reliability of assessment s made with the Fugl-Meyer evaluation of physical performance in a rehabilitation setting . SUBJECTS Twelve patients ( 7 male , 5 female ) , aged 49 to 86 years ( mean = 66 ) , who had sustained a cerebrovascular accident participated in the study . All patients were admitted consecutively to a rehabilitation center and were between 6 days and 6 months poststroke . METHODS Three physical therapists , each with more than 10 years of experience , assessed the patients in a r and omized and balanced order using this assessment . The therapists st and ardized the assessment approach prior to the study but did not discuss the procedure once the study began . RESULTS The overall reliability was high ( overall intraclass correlation coefficient = .96 ) , and the intraclass correlation coefficients for the subsections of the assessment varied from .61 for pain to .97 for the upper extremity . CONCLUSION AND DISCUSSION The relative merits of using the Fugl-Meyer assessment as a research tool versus a clinical assessment for stroke are discussed The tonic stretch reflex threshold in children with cerebral palsy ( CP ) was measured to determine its test-retest reliability and its concurrent validity as a potential measure of spasticity . Fourteen children with spastic CP aged 6 to 18 years were tested on three separate occasions for clinical spasticity and stretch reflex thresholds of affected elbow flexors .  Electromyographic ( EMG ) recordings were obtained by surface electrodes for elbow flexors and extensors during mechanical displacements of the passive joint towards extension . Displacements were produced by a torque motor at seven velocities which r and omly varied from trial to trial . EMG activity was measured in the stretched flexor muscles to determine threshold angles and velocities for each velocity of stretch . These were plotted on a velocity-angle-phase diagram and regression analysis was used to determine the static stretch reflex threshold for each participant . The measure showed good test-retest reliability for the group ( ICC 0.73 , p<0.001 ) whereas a significant correlation between the measure and the clinical spasticity scale was not found . This technique is a potential outcome variable for measuring the efficacy of treatments aim ed at decreasing spasticity in children with CP OBJECTIVE To examine the clinical effect of repetitive focal muscle vibration ( rMV ) on the motor function of the upper extremity 1 month after treatment in patients with chronic stroke . DESIGN We performed a pilot r and omized controlled trial using a double-blind , parallel-group study design . SETTING Medical center . PARTICIPANTS Patients with chronic stroke ( N=49 ) . INTERVENTIONS Patients r and omly assigned to the study group ( SG ) received rMV , while patients in the control group ( CG ) received a placebo vibratory treatment . The patients and the clinical examiner were blind to the intervention . MAIN OUTCOME MEASURES The primary endpoint was an improvement of more than .37 points on the Functional Ability Scale of the Wolf Motor Function Test ( WMFT FAS ) . The Modified Ashworth Scale and the visual analog scale were the secondary outcome measures . All measures were administered before the treatment ( t0 ) and 1 week ( t1 ) and 1 month ( t2 ) after the treatment . RESULTS Twenty-eight patients were allocated to the SG and 21 to the CG . The analysis of variance for repeated measurements revealed a significant difference in the expression of the WMFT FAS score over time only in the SG ( P=.006 ) . The treatment was successful for 7 ( 33 % ) of 21 patients recruited in the SG and for 2 ( 13 % ) of 15 patients recruited in the CG . The relative risk was 2.5 ( 95 % confidence interval , .60 - 10.39 ) , and the number needed to treat was 5 . The Wilcoxon test showed a statistically significant difference between t0 and t2 in the SG ( P=.02 ) . No adverse event was observed in the 2 groups . CONCLUSIONS Our results suggest that rMV treatment of the upper limb may improve the functional ability of chronic stroke patients , but a larger , multicenter , r and omized controlled study is needed The present study was to compare the effects of combined therapy [ botulinum ( BTX ) plus physiotherapy ] with physiotherapy alone using diffusion tensor imaging ( DTI ) derived fractional anisotropy ( FA ) values of motor and sensory fiber bundles and clinical grade of the disability to see the value of BTX in term children with spastic diplegic cerebral palsy ( CP ) . Clinical ly diagnosed 36 children participated in the study . All these children were born at term , and had no history of seizures . The study was r and omly categorized into two groups : group I ( n=18 ) - physiotherapy alone and group II ( n=18 ) - physiotherapy plus BTX injection . Quantitative diffusion tensor tractography on all these children was performed on motor and sensory fiber bundles on baseline as well as after 6months of therapy . Motor function and clinical grade s were also measured by gross motor function measures ( GMFM ) scale on both occasions . We observed significant change in FA value in motor and sensory fiber bundle as well as in GMFM scores at 6months compared to baseline study in both the groups . However , delta change and relative delta change in FA values of sensory and motor fiber bundle as well as GMFM score between group I and group II was statistically insignificant . We conclude that addition of BTX to physiotherapy regimen does not influence the outcome at 6months with similar insult in children with term diplegic spastic CP . This information may influence management of diplegic CP especially in developing countries , where BTX is beyond the reach of these children OBJECTIVE To establish reliability of quantitative measures of elbow joint spastic hypertonia in post-stroke hemiparesis . METHODS Nine subjects with post-stroke hemiparesis ( mn duration : 42 months ) were tested on three separate days . Biceps brachii and brachioradialis EMG were recorded during passive ramp- and -hold extensions applied at seven speeds between 30 and 210 degrees /s . EMG burst duration , onset position threshold , and burst intensity were used to evaluate reflex activity . Torque at 40 degrees of elbow flexion was used as a mechanical indicator of spastic hypertonia . RESULTS Across speeds ICCs were consistent , means ranged between 0.63 and 0.85 . Thus , relative reliability was fair to excellent for all parameters . Absolute reliability , determined using st and ard error of measurement expressed as a percentage of the mean score ( % SEM ) , improved at higher speeds ( > or = 120 degrees/s ) . CONCLUSIONS These results establish reliability of reflex and mechanical measures of elbow spastic hypertonia post-stroke . The data demonstrate greater reflex detection at high speeds , indicating greater potential to document meaningful changes in these distinct aspects of spastic hypertonia following intervention . SIGNIFICANCE Based on findings of this study , reliability was demonstrated using four parameters of reflex EMG and torque indicating measurement consistency across sessions . These observations motivate determination of requisite effect sizes for clinical trials that evaluate treatment outcome The objective of this prospect i ve cohort study was to investigate alterations in body composition variables and spasticity following subtetanic neuromuscular electrical stimulation ( NMES ) training in an adult population with spinal cord injury ( SCI ) . Fourteen sedentary adults with SCI ( thoracic [T]4-T11 ; American Spinal Injury Association Impairment Scale A/B ; time since injury : 10.17 + /- 11.17 yr ) were recruited from the National SCI data base .  Four adhesive electrodes ( 175 cm2 each ) were placed bilaterally on the proximal and distal quadriceps and hamstrings muscle groups and subtetanic contractions were elicited using a h and held NMES device .  Lean body mass ( LBM ) and other body composition variables were measured using dual-energy X-ray absorptiometry . Spasticity was measured using the Spinal Cord Assessment Tool for Spastic Reflexes ( SCATs ) and visual analog scales . Verbal and written feedback was obtained to subjectively evaluate spasticity . LBM and spasticity measurements were taken before and after an 8 wk NMES training program in order to assess change . A statistically significant increase in lower-limb LBM , i.e. , muscle tissue ( p > 0.001 ) , and a reduction in SCATs ( p < 0.001 ) score , indicating reduced spasticity , was observed . Subjective responses were positive . Improvements in body composition and SCATs scores indicate that subtetanic NMES training elicits favorable responses and may have important clinical implication s for an SCI population OBJECTIVES To apply Rasch analysis to evaluate the psychometric properties of the composite score of the 3 upper limb subscales of the Motor Assessment Scale ( UL-MAS ) when administered in the acute/subacute phase post-stroke . DESIGN Prospect i ve data collection of UL-MAS scores . PARTICIPANTS Eighty Eighty individuals a mean of 64.8 days ( st and ard deviation 53.3 ; range 4 - 193 days ) following the onset of unilateral stroke . METHODS All UL-MAS test items were administered in 30 participants assessed longitudinally over 3 occasions , and in 50 participants assessed on a single occasion . These 140 observations were pooled to be evaluated using Rasch analysis . RESULTS With the elimination of the wrist radial deviation test item , the UL-MAS demonstrated uni-dimensionality with no significant test item response bias . The test item difficulty hierarchy was vali date d in the Upper Arm and H and Movements subscales , but not in the Advanced H and Activities subscale . The acceptable floor ( 14 % ) and ceiling ( 9 % ) effects and the high Person Separation Reliability Index ( 0.96 ) indicated that the scale was appropriately targeted to discriminate statistically between groups of acute/subacute stroke participants with differing upper limb motor recovery . CONCLUSION The findings support the psychometric properties of the composite UL-MAS score in this clinical population The objective of this study is to develop a portable device for quantifying the velocity-dependent properties of spastic elbow muscles .  Based on a motor-driven system , validation tests of the portable system such as accuracy and response of sensors were first examined . Furthermore , simulated modules ( inertia , damper and spring ) as well as elbow joints ( 15 control and 15 hemiplegic subjects ) were manually stretched under four different frequencies ( 1/3 , 1/2 , 1 and 3/2 Hz ) through 60 degrees range of motion . Joint resistance and displacement during sinusoidal stretch were collected for further analysis . Two quantitative parameters ( i.e. , viscous components under each frequency and averaged viscosity across four frequencies ) were derived to estimate the velocity-dependent properties of elbow joint . Tests of simulated modules confirm the manual stretch protocol and data analysis are valid in estimating the velocity-dependent component during a sinusoidal stretch . Compared to normal control , viscous component in each stretch frequency and averaged viscosity were significantly higher in subjects with spasticity ( P < 0.001 ) . The viscous component and averaged viscosity were found highly correlated with the modified Ashworth scale . These findings suggest that measurements of viscous component and averaged viscosity during manual sinusoidal stretching using the portable device could be clinical ly useful in evaluating spasticity
Parameters that integrated electrophysiological signals with joint movement characteristics were best able to quantify spasticity .
There were conflicting results regarding biomechanical-based parameters that quantify the resistance to passive stretch .
AIM The first aim of this study was to systematic ally review and critically assess manually controlled instrumented spasticity assessment methods that combine multidimensional signals .
The second aim was to extract a set of quantified parameters that are psychometrically sound to assess spasticity in a clinical setting .