Special communication| Volume 99, ISSUE 9, P1917-1926, September 2018

Clinical Assessment of Spasticity in People With Spinal Cord Damage: Recommendations From the Ability Network, an International Initiative

Published:February 09, 2018DOI:


      A thorough assessment of the extent and severity of spasticity, and its effect on functioning, is central to the effective management of spasticity in persons with spinal cord damage (SCD). These individuals however do not always receive adequate assessment of their spasticity. Inadequate assessment compromises management when the effect of spasticity and/or need for intervention are not fully recognized. Assessment is also central to determining treatment efficacy. A barrier to spasticity assessment has been the lack of consensus on clinical and functional measures suitable for routine clinical practice. To extend on existing work, a working group of the Ability Network identified and consolidated information on possible measures, and then synthesized and formulated findings into practical recommendations for assessing spasticity and its effect on function in persons with SCD. Sixteen clinical and functional measures that have been used for this purpose were identified using a targeted literature review. These were mapped to the relevant domains of the International Classification of Functioning, Disability and Health to assess the breadth of their coverage; coverage of many domains was found to be lacking, suggesting a focus for future work. The advantages, disadvantages, and usefulness of the measures were assessed using a range of criteria, with a focus on usefulness and feasibility in routine clinical practice. Based on this evaluation, a selection of measures suitable for initial and follow-up assessments are recommended. The recommendations are intended to have broad applicability to a variety of health care settings where people with SCD are managed.


      List of abbreviations:

      ICF (International Classification of Functioning, Disability and Health), PROM (patient-reported outcome measure), SCATS (Spinal Cord Assessment Tool for Spastic Reflexes), SCD (spinal cord damage), SCIM (Spinal Cord Independence Measure), WISCI (Walking Index for Spinal Cord Injury)
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        • Burns A.S.
        • Lanig I.
        • Grabljevec K.
        • et al.
        Optimizing the management of disabling spasticity following spinal cord damage: the Ability Network-an international initiative.
        Arch Phys Med Rehabil. 2016; 97: 2222-2228
        • Adams M.M.
        • Hicks A.L.
        Spasticity after spinal cord injury.
        Spinal Cord. 2005; 43: 577-586
        • Pandyan A.D.
        • Gregoric M.
        • Barnes M.P.
        • et al.
        Spasticity: clinical perceptions, neurological realities and meaningful measurement.
        Disabil Rehabil. 2005; 27: 2-6
        • World Health Organisation (WHO)
        Towards a common language for Functioning, Disability and Health: ICF.
        WHO, Geneva2002
      1. Spinal Cord Injury Research Evidence (SCIRE). Outcome measures toolkit. Available at: Accessed March 19, 2018.

        • Hsieh J.T.
        • Wolfe D.L.
        • Miller W.C.
        • Curt A.
        Spasticity outcome measures in spinal cord injury: psychometric properties and clinical utility.
        Spinal Cord. 2008; 46: 86-95
        • Akman M.N.
        • Bengi R.
        • Karatas M.
        • Kilinc S.
        • Sozay S.
        • Ozker R.
        Assessment of spasticity using isokinetic dynamometry in patients with spinal cord injury.
        Spinal Cord. 1999; 37: 638-643
        • Aydin G.
        • Tomruk S.
        • Keles I.
        • Demir S.O.
        • Orkun S.
        Transcutaneous electrical nerve stimulation versus baclofen in spasticity: clinical and electrophysiologic comparison.
        Am J Phys Med Rehabil. 2005; 84: 584-592
        • Benz E.N.
        • Hornby T.G.
        • Bode R.K.
        • Scheidt R.A.
        • Schmit B.D.
        A physiologically based clinical measure for spastic reflexes in spinal cord injury.
        Arch Phys Med Rehabil. 2005; 86: 52-59
        • Bravo-Esteban E.
        • Taylor J.
        • Abian-Vicen J.
        • et al.
        Impact of specific symptoms of spasticity on voluntary lower limb muscle function, gait and daily activities during subacute and chronic spinal cord injury.
        Neurorehabilitation. 2013; 33: 531-543
        • Cardenas D.D.
        • Ditunno J.F.
        • Graziani V.
        • et al.
        Two phase 3, multicenter, randomized, placebo-controlled clinical trials of fampridine-SR for treatment of spasticity in chronic spinal cord injury.
        Spinal Cord. 2014; 52: 70-76
        • Carty A.
        • McCormack K.
        • Coughlan G.F.
        • Crowe L.
        • Caulfield B.
        Alterations in body composition and spasticity following subtetanic neuromuscular electrical stimulation training in spinal cord injury.
        J Rehabil Res Dev. 2013; 50: 193-202
        • Casale R.
        • Glynn C.J.
        • Buonocore M.
        Reduction of spastic hypertonia in patients with spinal cord injury: a double-blind comparison of intravenous orphenadrine citrate and placebo.
        Arch Phys Med Rehabil. 1995; 76: 660-665
        • Chu V.W.
        • Hornby T.G.
        • Schmit B.D.
        Effect of antispastic drugs on motor reflexes and voluntary muscle contraction in incomplete spinal cord injury.
        Arch Phys Med Rehabil. 2014; 95: 622-632
        • Dhindsa M.S.
        • Merring C.A.
        • Brandt L.E.
        • Tanaka H.
        • Griffin L.
        Muscle spasticity associated with reduced whole-leg perfusion in persons with spinal cord injury.
        J Spinal Cord Med. 2011; 34: 594-599
        • Finnerup N.B.
        • Grydehoj J.
        • Bing J.
        • et al.
        Levetiracetam in spinal cord injury pain: a randomized controlled trial.
        Spinal Cord. 2009; 47: 861-867
        • Hagenbach U.
        • Luz S.
        • Ghafoor N.
        • et al.
        The treatment of spasticity with Delta9-tetrahydrocannabinol in persons with spinal cord injury.
        Spinal Cord. 2007; 45: 551-562
        • Kapadia N.
        • Masani K.
        • Catharine Craven B.
        • et al.
        A randomized trial of functional electrical stimulation for walking in incomplete spinal cord injury: effects on walking competency.
        J Spinal Cord Med. 2014; 37: 511-524
        • Kumru H.
        • Benito J.
        • Murillo N.
        • et al.
        Effects of high-frequency repetitive transcranial magnetic stimulation on motor and gait improvement in incomplete spinal cord injury patients.
        Neurorehabil Neural Repair. 2013; 27: 421-429
        • Kumru H.
        • Murillo N.
        • Samso J.V.
        • et al.
        Reduction of spasticity with repetitive transcranial magnetic stimulation in patients with spinal cord injury.
        Neurorehabil Neural Repair. 2010; 24: 435-441
        • Lechner H.E.
        • Feldhaus S.
        • Gudmundsen L.
        • et al.
        The short-term effect of hippotherapy on spasticity in patients with spinal cord injury.
        Spinal Cord. 2003; 41: 502-505
        • Livshits A.
        • Rappaport Z.H.
        • Livshits V.
        • Gepstein R.
        Surgical treatment of painful spasticity after spinal cord injury.
        Spinal Cord. 2002; 40: 161-166
        • Murillo N.
        • Kumru H.
        • Vidal-Samso J.
        • et al.
        Decrease of spasticity with muscle vibration in patients with spinal cord injury.
        Clin Neurophysiol. 2011; 122: 1183-1189
        • Pooyania S.
        • Ethans K.
        • Szturm T.
        • Casey A.
        • Perry D.
        A randomized, double-blinded, crossover pilot study assessing the effect of nabilone on spasticity in persons with spinal cord injury.
        Arch Phys Med Rehabil. 2010; 91: 703-707
        • Priebe M.M.
        • Sherwood A.M.
        • Thornby J.I.
        • Kharas N.F.
        • Markowski J.
        Clinical assessment of spasticity in spinal cord injury: a multidimensional problem.
        Arch Phys Med Rehabil. 1996; 77: 713-716
        • Reichenfelser W.
        • Hackl H.
        • Hufgard J.
        • Kastner J.
        • Gstaltner K.
        • Gfohler M.
        Monitoring of spasticity and functional ability in individuals with incomplete spinal cord injury with a functional electrical stimulation cycling system.
        J Rehabil Med. 2012; 44: 444-449
        • Sadowsky C.L.
        • Hammond E.R.
        • Strohl A.B.
        • et al.
        Lower extremity functional electrical stimulation cycling promotes physical and functional recovery in chronic spinal cord injury.
        J Spinal Cord Med. 2013; 36: 623-631
        • Sherwood A.M.
        • Graves D.E.
        • Priebe M.M.
        Altered motor control and spasticity after spinal cord injury: subjective and objective assessment.
        J Rehabil Res Dev. 2000; 37: 41-52
        • Skold C.
        • Lonn L.
        • Harms-Ringdahl K.
        • et al.
        Effects of functional electrical stimulation training for six months on body composition and spasticity in motor complete tetraplegic spinal cord-injured individuals.
        J Rehabil Med. 2002; 34: 25-32
        • Tamburella F.
        • Scivoletto G.
        • Molinari M.
        Somatosensory inputs by application of KinesioTaping: effects on spasticity, balance, and gait in chronic spinal cord injury.
        Front Hum Neurosci. 2014; 8: 367
        • Akpinar P.
        • Atici A.
        • Ozkan F.U.
        • et al.
        Reliability of the Modified Ashworth Scale and Modified Tardieu Scale in patients with spinal cord injuries.
        Spinal Cord. 2017; 55: 944-949
        • Skold C.
        • Levi R.
        • Seiger A.
        Spasticity after traumatic spinal cord injury: nature, severity, and location.
        Arch Phys Med Rehabil. 1999; 80: 1548-1557
        • Gajdosik R.L.
        • Bohannon R.W.
        Clinical measurement of range of motion. Review of goniometry emphasizing reliability and validity.
        Phys Ther. 1987; 67: 1867-1872
        • Ashworth B.
        Preliminary trial of carisoprodol in multiple sclerosis.
        Practitioner. 1964; 192: 540-542
      2. Spinal Cord Injury Research Evidence (SCIRE). Outcome measures:spasticity. Available at: Accessed March 19, 2018.

        • Tardieu G.S.S.
        • Delarue R.
        Research on a technique for measurement of spasticity [French]..
        Rev Neurol (Paris). 1954; 91: 143-144
        • Morris S.
        Ashworth and Tardieu Scales: their clinical relevance for measuring spasticity in adult and paediatric neurological populations.
        Phys Ther Rev. 2002; 7: 53-62
        • Pandyan A.D.
        • Johnson G.R.
        • Price C.I.
        • Curless R.H.
        • Barnes M.P.
        • Rodgers H.
        A review of the properties and limitations of the Ashworth and modified Ashworth Scales as measures of spasticity.
        Clin Rehabil. 1999; 13: 373-383
        • Haugh A.B.
        • Pandyan A.D.
        • Johnson G.R.
        A systematic review of the Tardieu Scale for the measurement of spasticity.
        Disabil Rehabil. 2006; 28: 899-907
        • Fleuren J.F.
        • Voerman G.E.
        • Erren-Wolters C.V.
        • et al.
        Stop using the Ashworth Scale for the assessment of spasticity.
        J Neurol Neurosurg Psychiatry. 2010; 81: 46-52
        • Penn R.D.
        • Savoy S.M.
        • Corcos D.
        • et al.
        Intrathecal baclofen for severe spinal spasticity.
        N Engl J Med. 1989; 320: 1517-1521
        • Akpinar P.
        • Atici A.
        • Ozkan F.U.
        • Aktas I.
        • Kulcu D.G.
        • Kurt K.N.
        Reliability of the Spinal Cord Assessment Tool for spastic reflexes.
        Arch Phys Med Rehabil. 2017; 98: 1113-1118
        • Nordmark E.
        • Anderson G.
        Wartenberg pendulum test: objective quantification of muscle tone in children with spastic diplegia undergoing selective dorsal rhizotomy.
        Dev Med Child Neurol. 2002; 44: 26-33
        • Hanley M.A.
        • Jensen M.P.
        • Ehde D.M.
        • et al.
        Clinically significant change in pain intensity ratings in persons with spinal cord injury or amputation.
        Clin J Pain. 2006; 22: 25-31
        • Berg K.O.
        • Wood-Dauphinee S.L.
        • Williams J.I.
        • Maki B.
        Measuring balance in the elderly: validation of an instrument.
        Can J Public Health. 1992; 83 Suppl 2: S7-S11
        • Blum L.
        • Korner-Bitensky N.
        Usefulness of the Berg Balance Scale in stroke rehabilitation: a systematic review.
        Phys Ther. 2008; 88: 559-566
        • Jackson A.B.
        • Carnel C.T.
        • Ditunno J.F.
        • et al.
        Outcome measures for gait and ambulation in the spinal cord injury population.
        J Spinal Cord Med. 2008; 31: 487-499
        • Podsiadlo D.
        • Richardson S.
        The timed “Up & Go”: a test of basic functional mobility for frail elderly persons.
        J Am Geriatr Soc. 1991; 39: 142-148
        • van Hedel H.J.
        • Wirz M.
        • Dietz V.
        Assessing walking ability in subjects with spinal cord injury: validity and reliability of 3 walking tests.
        Arch Phys Med Rehabil. 2005; 86: 190-196
        • Scivoletto G.
        • Tamburella F.
        • Laurenza L.
        • Foti C.
        • Ditunno J.F.
        • Molinari M.
        Validity and reliability of the 10-m walk test and the 6-min walk test in spinal cord injury patients.
        Spinal Cord. 2011; 49: 736-740
        • Ditunno Jr., J.F.
        • Ditunno P.L.
        • Graziani V.
        • et al.
        Walking index for spinal cord injury (WISCI): an international multicenter validity and reliability study.
        Spinal Cord. 2000; 38: 234-243
        • Ditunno J.F.
        • Scivoletto G.
        • Patrick M.
        • Biering-Sorensen F.
        • Abel R.
        • Marino R.
        Validation of the walking index for spinal cord injury in a US and European clinical population.
        Spinal Cord. 2007; 46: 181-188
        • Keith R.A.
        • Granger C.V.
        • Hamilton B.B.
        • Sherwin F.S.
        The functional independence measure: a new tool for rehabilitation.
        Adv Clin Rehabil. 1987; 1: 6-18
        • Catz A.
        • Itzkovich M.
        • Agranov E.
        • Ring H.
        • Tamir A.
        SCIM–spinal cord independence measure: a new disability scale for patients with spinal cord lesions.
        Spinal Cord. 1997; 35: 850-856
        • Catz A.
        • Itzkovich M.
        • Agranov E.
        • Ring H.
        • Tamir A.
        The spinal cord independence measure (SCIM): sensitivity to functional changes in subgroups of spinal cord lesion patients.
        Spinal Cord. 2001; 39: 97-100
        • Itzkovich M.
        • Gelernter I.
        • Biering-Sorensen F.
        • et al.
        The Spinal Cord Independence Measure (SCIM) version III: reliability and validity in a multi-center international study.
        Disabil Rehabil. 2007; 29: 1926-1933
        • Itzkovich M.
        • Tamir A.
        • Philo O.
        • et al.
        Reliability of the Catz-Itzkovich Spinal Cord Independence Measure assessment by interview and comparison with observation.
        Am J Phys Med Rehabil. 2003; 82: 267-272
        • Catz A.
        • Itzkovich M.
        • Tesio L.
        • et al.
        A multicenter international study on the Spinal Cord Independence Measure, version III: Rasch psychometric validation.
        Spinal Cord. 2007; 45: 275-291
        • Ware J.E.
        • Snow K.K.
        • Kosinski M.
        • Gandek B.
        SF-36® health survey manual and interpretation guide.
        New England Medical Center, The Health Institute, Boston1993
      3. EQ-5D.
        (Available at:) (Accessed March 19, 2018)