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OBJECTIVES: To evaluate the reliability of a new scale, the Triple Spasticity Scale (TSS), for assessing spasticity in stroke, through measurement of affected elbow flexors and ankle plantar flexors of hemiplegic patients with stroke, and to compare the new scale with commonly used scales.
Main outcome measures: TSS, Modified Ashworth Scale (MAS) and Modified Tardieu Scale (MTS). CONCLUSION: The TSS has good test-retest reliability and inter-rater reliability in measurement of muscle tone.
Correspondence address: Fang Li, Department of Rehabilitation, Huashan Hospital, Fudan University, Shanghai, China. The TS has been regarded as a better option than the AS for assessing spasticity (9), as it measures and compares the muscle reaction (known as dynamic muscle length or angle difference) to passive stretch at both slow and fast speeds, which agrees more closely with Lancea€™s definition (21). Spasticity is considered to be a segmental reflex elicited by muscle stretch, which is processed abnormally in related cord segments, ultimately generating excessive drive on segmental alpha motor neurones that innervate the very muscles being stretched (28). The CSI was used to measure spasticity in patients with stroke and cerebral palsy (11, 30). A total of 71 post-stroke hemiplegic inpatients admitted to our hospital were included in the study.
The TSS and MAS were rated by 1 physiatrist and 1 physiotherapist, both of whom were trained in applying these 2 scales. Elbow and plantar flexors were chosen for testing because flexed elbow and equinus foot are common patterns of UMNS in the upper and lower limbs (4). The meaning of the overall score was interpreted based on clinical experience as mild (0a€“2), moderate (3a€“5), or severe spasticity (6a€“8) in the muscles in which clonus could not be elicited.
The assessments of TSS by 2 raters were used to determine the inter-rater reliability of the scale. Seventy-one patients with a mean age of 62 years (50 males, 21 females) were included in the study. The results for the inter-rater reliability and intra-rater reliability are shown in Table V. This new scale provides an alternative for measuring spasticity, which avoids some of the shortcomings of previous scales.
The mechanism of abnormal processing is complicated, such that the stretch resistance from neural components may have different sources. An earlier version of the CSI includes 3 subsections: tendon jerks and clonus were scored to measure phasic stretch reflex excitability, whereas resistance to manual stretch was scored to measure tonic stretch reflex excitability.
The patientsa€™ demographic and clinical variables, including age, gender, time since stroke, paretic side, and lesion type (ischaemic or haemorrhagic), are shown in Table I. Before the start of the study, the raters were instructed about the measurements and study procedures by a professor, to ensure that the definitions were uniformly understood. The elbow flexors and ankle plantar flexors of each participant were assessed twice (test and re-test) with the TSS and MAS by rater 1 (the physiatrist). Participants rested for 10 min in the supine position, arms by their sides and head in a neutral position.
The meaning of the overall score was interpreted based on clinical experience as mild (0a€“3), moderate (4a€“6), or severe spasticity (7a€“10) in the muscles in which clonus could be elicited.
The assessments by 1 rater (the physiatrist) 1 day apart were used to determine the test-retest reliability. Positive signs are spasticity, spastic co-contraction, associated reactions, enhanced primitive reflexes and spastic dystonia (1).

The validity of the MAS in terms of spasticity assessment is questionable, as it does not address the velocity-dependent phenomenon, but is a sum of neural and non-neural components to passive movement (12a€“14). For example, primary endings of the muscle spindle are known to be velocity sensitive, but secondary spindle endings have static length sensitivity (29), which may generate resistance to passive stretch. A modified version of the CSI includes only 2 subsections: tendon jerks and resistance to stretch (30). The objective of this study was to design a new scale, the Triple Spasticity Scale (TSS), to evaluate spasticity in 3 ways, while attempting to avoid the shortcomings of previous scales.
All of the participants fulfilled the following inclusion criteria: hemiparesis due to a unilateral single clinical stroke, with at least 1 positive sign of upper motor neurone syndrome (exaggerated tendon jerks, spasticity, co-contraction, associated reaction and increased flexor reflex) and able to give informed consent.
The therapist examined the patient approximately 30 min after the doctora€™s first measurement. The correlation was analysed either between the TSS and MAS, or between the TSS and the R1a€“R2 of the MTS.
The test-retest and inter-rater score distribution of the TSS of the study population are shown in Table III.
Spasticity is characterized by a velocity-dependent increase in the excitability of tonic and phasic muscle stretch reflexes (2). However, a significant positive correlation has been found between the AS scores and neural components in stroke patients, whereas no consistent correlation has been found between AS scores and non-neural components (6). The MTS is unique in assessing spasticity, and the dynamic muscle length of MTS is in agreement with the dynamic stretch reflex threshold (DSRT), which is a laboratory measurement of spasticity (9).
The CSI used in neurological patients has shown validity and good reliability for measurement of spasticity (31, 32). The aim of this comprehensive scale is to use threshold and supra-threshold resistance measures together to provide an insight into spasticity, scoring the severity of the spasticity so as to make it comparable. When performing the stretch of the elbow flexors, the assessor kept the subjecta€™s arm in a neutral position. In addition, the correlation between the increased resistance (r1a€“r2, subsection 1) and dynamic muscle length (R1a€“R2, subsection 3) was also analysed. Descriptive statistics of the TSS characteristics measured by rater 1 are shown in Table IV.
The defining characteristic of enhanced tonic muscle stretch reflexes is excessive resistance of the muscle to passive stretch, whereas hyperactivity of phasic stretch reflexes refers to exaggerated tendon jerks and clonus. However, the MTS does not address passive resistance created by neural components when comparing the angle difference. A further aim is to investigate the inter-rater and intra-rater reliability of the TSS in measuring spasticity and to analyse the relationships between TSS and MAS, and between TSS and MTS, by using an adequate sample of patients with hemiplegia. When performing the stretch of the plantarflexors, the assessor kept the subjecta€™s knee extended and controlled inversion of their ankle.
The rater compares the resistance between the 2 stretches according to his or her subjective perception and then scores the increased portion (r1a€“r2). The single measures of intraclass correlation coefficient (ICC) were chosen as the test statistic of reliability (ICC; 2-way random, absolute agreement). The ICC of the elbow flexors could not be calculated because the clonus had not been elicited in the muscles. Clonus is characterized by repetitive, rhythmic contractions observed in one or more muscles of a single limb segment or multiple limb segments (3).

In addition, the reliability of MTS in both paediatric and adult populations is inconclusive (15, 16, 24a€“27). First, although the resistance to manual stretch applied by a rater at a moderate speed is closely related to the clinical concept of muscle tone, the CSI does not address the velocity-dependent phenomenon. In designing the study protocol, factors influencing stretch reflex were taken into account so as to minimize their effects.
The study was approved by the local research ethics committee of the hospital and all participants provided informed written consent. In addition, patients were measured during their initial assessment by 1 physiatrist and 1 physio­therapist (inter-rater). The ICC reflected both the degree of correspondence and the degree of agreement between the scorings. Secondly, tendon reflex may not be easily elicited from some overactive muscles in the common patterns of upper motor neurone dysfunction. Muscle tone, referring to resistance to passive stretch, has neural and non-neural components (5).
Non-neural resistance is caused by inertia, elasticity and viscosity of the body part that is moved (6). Several studies have shown that the muscle properties are altered following central nervous system lesions (7, 8). The rater then moves the joint as rapidly as possible in the same direction and through the same arc, and the angle of muscle reaction is recorded as R1 (24). Resistance coming from muscle depends on the length of the muscle and the rate of change of muscle length.
The length-dependent components are proportional to coefficients termed elasticity (or stiffness) (9).
Dynamic muscle length is the angle difference between R1 and R2 (R1a€“R2), which is converted into 5 grades in the TSS described in Table II. The velocity-dependent components are proportional to coefficients termed viscosity (or damping) (9).
According to the measurement in the normal population, the full range of motion of elbow and ankle joints in the patients were regarded as 150A° and 60A° (34), respectively. Measurement of spasticity should be aimed at neural components, rather than non-neural components that are usually not velocity-dependent (viscosity is an exception; however, it may be less in stroke patients than in controls (6)). Participants rest in the same standardized position as described for the MAS when performing the stretch. Previous measurements were often criticised if they did not address the velocity-dependence of the stretch reflex, as spasticity is a velocity-dependent phenomenon.
It is important to assess spasticity precisely so as to evaluate the effectiveness of different treatments and to choose the best option for each patient. For instance, patients with dominant neural components should be considered for treatment aimed at reducing the exaggerated stretch reflex, such as botulinum neurotoxin injection, whereas those with dominant non-neural components may benefit from other strategies, such as casting or stretch.

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