Ashworth Scale / Modified Ashworth Scale (AS/MAS)

1. Abstract

The Ashworth Scale (AS) and its refined successor, the Modified Ashworth Scale (MAS), represent the premier clinical measurement instruments utilized worldwide across clinical neurology, physiatry, physical therapy, and neurorehabilitation to quantify muscle spasticity and hypertonia. Originally conceptualized by Bryan Ashworth in 1964 to assess the therapeutic efficacy of pharmacological agents in multiple sclerosis, the scale was later refined by Richard W. Bohannon and Melissa B. Smith in 1987. Bohannon and Smith introduced a discrete intermediate grade (“1+”) to address perceived insensitivity in capturing the classic “catch-and-release” phenomenon and low-grade resistance occurring in early-to-mid range of motion. The resulting 6-point ordinal instrument evaluates the resistance encountered by an examiner during the passive manual elongation of an affected limb through its anatomical arc of motion over approximately a one-second velocity profile (“one thousand one”).

The scale measures an underlying continuum spanning from absolute flaccidity or normal physiological passive resistance (Grade 0) to unyielding joint ankylosis and rigidity (Grade 4). Despite widespread adoption in clinical trials targeting pharmacotherapies such as botulinum neurotoxin type A, intrathecal baclofen, and oral antispasticity medications, the psychometric properties of the AS and MAS have ignited substantial academic debate. While the MAS demonstrates moderate-to-substantial intra-rater and inter-rater reliability in specific muscle groups—most notably the elbow flexors, wrist flexors, and ankle plantarflexors—its construct validity remains complex. Methodological investigations utilizing simultaneous surface electromyography (sEMG) and kinematic biomechanical torque sensors reveal that the scale captures an amalgamation of neural velocity-dependent stretch reflex hyperexcitability alongside non-neural biomechanical alterations, including muscle contracture, thixotropy, tendon stiffness, and joint connective tissue remodeling. Modern metric evaluations via Rasch analysis and non-parametric item response frameworks have highlighted ordinal-interval conversion discrepancies, ceiling and floor vulnerabilities, and inconsistent category boundary discrimination between Grade 1 and Grade 1+. This paper provides an exhaustive, academically rigorous review of the AS and MAS, detailing their theoretical architecture, neurophysiological constructs, psychometric parameters, structural factor characteristics, and standardized administration protocols.

2. Keywords

Modified Ashworth Scale, Ashworth Scale, spasticity, hypertonia, neurorehabilitation, stroke rehabilitation, upper motor neuron syndrome, muscle tone, psychometrics, inter-rater reliability

3. Authors

The original Ashworth Scale was authored by Bryan Ashworth, MD, FRCP, who served as a Consultant Neurologist at the Department of Neurology, Royal Infirmary of Edinburgh, and University of Edinburgh, Scotland, United Kingdom. Dr. Ashworth published the initial clinical rating rubric in 1964 during investigational pharmacotherapy trials evaluating carisoprodol in patients with severe spasticity secondary to multiple sclerosis.

The Modified Ashworth Scale (MAS) was developed and empirically standardized by Richard W. Bohannon, PT, DPT, PhD, FAPTA, FAHA, and Melissa B. Smith, PT, MS. At the time of the instrument’s revision and primary psychometric validation in 1987, both authors were affiliated with the Department of Physical Therapy, School of Allied Health, University of North Carolina at Chapel Hill, and the Department of Physical Therapy at North Carolina Memorial Hospital in Chapel Hill, North Carolina, United States. Dr. Richard W. Bohannon has held distinguished academic professorships in physical therapy and kinesiology at the University of Connecticut (Storrs, CT) and Campbell University (Buies Creek, NC). Inquiries regarding historical developmental protocols are typically directed through institutional physical therapy departments or major biomedical repositories cataloging neurorehabilitation assessment methodologies.

4. Purpose

The primary purpose of the Ashworth Scale and Modified Ashworth Scale is to grade, monitor, and standardize the clinical assessment of muscle spasticity and velocity-dependent resistance to passive stretch in individuals experiencing upper motor neuron (UMN) lesions. Spasticity is a prevalent secondary impairment resulting from cerebrovascular accidents (stroke), traumatic brain injuries, spinal cord injuries, multiple sclerosis, cerebral palsy, and hypoxic-ischemic encephalopathies. Clinical assessment is vital because elevated muscle tone can lead to profound functional limitations, progressive soft-tissue contractures, joint subluxations, hygiene difficulties, chronic musculoskeletal pain, and secondary limitations in activities of daily living (ADLs) such as dressing, bathing, and independent locomotion.

In pharmacological and clinical research, the AS and MAS serve as cardinal efficacy endpoints for antispasticity interventions. Regulatory approvals for intramuscular chemodenervation agents (such as onabotulinumtoxinA, abobotulinumtoxinA, incobotulinumtoxinA, and rimabotulinumtoxinB), systemic oral spasmolytics (such as baclofen, tizanidine, dantrolene sodium, and clonazepam), and continuous neurosurgical intrathecal infusions rely on MAS score reductions as an established clinical metric. The scale provides clinicians and investigators with a standardized ordinal system to track treatment effects over time, adjust dosage schedules, and gauge the need for physical and occupational therapeutic modalities.

Beyond drug trials, the MAS is deployed in clinical neurorehabilitation to guide individualized goal attainment, orthotic prescription, splinting regimens, serial casting, and surgical decision-making (e.g., selective dorsal rhizotomy, neurotomy, or tendon-lengthening surgeries). Theoretically, the scale aims to bridge subjective physical examination findings with structured clinical staging. While laboratory-grade biomechanical dynamometry and multichannel electromyography supply quantitative physiological readouts, they require specialized equipment, extensive calibration, and computational signal processing, rendering them impractical for everyday bedside examinations. The MAS addresses this clinical need by offering a rapid, non-invasive, cost-free clinical index that can be executed in under two minutes per joint without specialized apparatus.

5. Psychological and Neurophysiological Construct

The operational construct evaluated by the AS and MAS is clinical spasticity, historically embedded within the broader diagnostic rubric of hypertonia. In 1980, neurologist James W. Lance established the classic physiological definition of spasticity: “a motor disorder characterized by a velocity-dependent increase in tonic stretch reflexes (muscle tone) with exaggerated tendon jerks, resulting from hyperexcitability of the stretch reflex, as one component of the upper motor neuron syndrome.” Clinically, this definition identifies velocity-dependent passive resistance as the cardinal manifestation of spasticity.

Within the cognitive and perceptual evaluation performed by the administering clinician, the construct splits into distinct phenomenological and biomechanical dimensions:

• The “Catch-and-Release” Phenomenon: Represents an abrupt, transient resistance felt during rapid passive mobilization of the target muscle, followed by a perceptible release of tension. Neurophysiologically, this phenomenon corresponds to the recruitment of hyperexcitable Group Ia and Group II spindle afferents triggering an exaggerated monosynaptic and polysynaptic stretch reflex, which is subsequently terminated or attenuated by non-reciprocal polysynaptic inhibition, Golgi tendon organ (Ib) activation, or biomechanical decoupling of cross-bridges.
• Low-End Terminal Resistance (Grade 1): Manifested as a minimal, fleeting resistance or a catch occurring at the terminal end-range of motion, when the muscle approaches maximum structural elongation. In this grade, reflex excitability is recruited only under conditions of high physiological muscle fascicle strain.
• Early-to-Mid Arc Catch with Continued Resistance (Grade 1+): Characterized by an initial catch occurring earlier in the trajectory of movement, followed by modest, palpable resistance across less than half of the remaining range of motion. This grade reflects heightened fusimotor sensitivity and earlier recruitment of dynamic reflex thresholds.
• Marked Movement Resistance Through Most of the Arc (Grade 2): Palpable resistance persisting across more than 50% of the movement trajectory. At this stage, passive joint movement remains comparatively effortless for the clinician to complete, despite unambiguous resistance throughout the stroke. This reflects a convergence of hyperactive tonic stretch reflexes and early passive structural stiffness of the muscle-tendon complex.
• Severe Hypertonic Resistance (Grade 3): Pronounced resistance where passive joint movement is accomplished only with deliberate, substantial effort by the clinician. Here, active neuromuscular reflex hyperexcitability is typically confounded by biomechanical soft tissue changes, including non-enzymatic collagen cross-linking, loss of sarcomeres in series, and increased intramuscular perimysial connective tissue density.
• Rigidity and Complete Ankylosis (Grade 4): The affected anatomical segment is fixed in an unyielding posture of flexion, extension, abduction, or adduction, preventing movement across the joint. In Grade 4, neurogenic spasticity has often yielded to structural myostatic contracture, joint capsular fibrosis, and soft-tissue shortening.

A key construct-related challenge is that the clinician’s hand cannot distinguish pure velocity-dependent neurogenic stretch reflex resistance from passive non-neural biomechanical resistance. Biomechanical muscle properties—such as thixotropy (the history-dependent viscosity of resting actin-myosin cross-bridges), extracellular matrix remodeling, titin filament stiffening, and tendon aponeurosis slack reduction—register subjectively to the examiner as resistance to passive motion. Consequently, modern psychometric consensus emphasizes that the Ashworth Scale and Modified Ashworth Scale measure overall resistance to passive movement rather than isolated reflex-mediated spasticity.

6. Theoretical Framework

The theoretical framework underlying the AS and MAS integrates concepts from neurophysiology, motor control, biomechanics, and clinical measurement theory. The central premise relies on the pathophysiological sequelae of the upper motor neuron syndrome. Disruption of descending corticospinal and reticulospinal tracts disturbs the delicate equilibrium between descending supraspinal inhibition and excitation within the spinal cord.

Under healthy conditions, the dorsal reticulospinal tract (originating in the ventromedial medullary reticular formation and driven by motor cortical inputs) exerts a potent inhibitory influence over spinal reflex arcs. Damage to cortical motor fields or their efferent projections disinhibits the medial reticulospinal tract (originating in the pontine reticular formation) and the vestibulospinal tract. This imbalance yields a hyperexcitable alpha motor neuron pool, reduced presynaptic inhibition of Group Ia afferents, diminished recurrent inhibition via Renshaw cells, and attenuated reciprocal inhibition between antagonist muscle groups. Consequently, when a clinician mobilizes a limb passively, the physiological muscle spindle stretch triggers an uninhibited, synchronous discharge of spinal motor units, producing elevated tone.

Equally critical to the theoretical architecture is the biomechanical model of soft-tissue rheology. When skeletal muscle remains chronically paretic and immobilized, muscle remodeling occurs rapidly. In accordance with the sliding filament theory and muscle plastic remodeling concepts, sustained joint shortening triggers the loss of sarcomeres in series, changes in muscle fascicle angle, accumulation of advanced glycation end-products, and progressive interstitial fibrosis. Therefore, the passive resistance modeled by the MAS is governed by an equation of joint passive torque:

τ_total = τ_inertia + τ_viscosity(θ′) + τ_elasticity(θ) + τ_reflex(θ, θ′)
where τ represents torque, θ represents joint angle, and θ′ denotes angular velocity.

From a psychometric measurement theory perspective, the Ashworth Scale and Modified Ashworth Scale are conceptualized as clinician-reported outcome (ClinRO) measures governed by classical sensory threshold detection. The examiner acts as a biomechanical transducer, sensing resisting force via cutaneous mechanoreceptors, joint position proprioceptors, and tendinous Golgi tendon organs in their own hands, while standardizing the velocity of displacement. The clinician’s perceptual system converts this continuous resistive torque profile into one of six discrete, structured ordinal categories. This introduces psychometric vulnerabilities related to clinician subjective thresholds, inter-examiner variation in passive movement velocity, and non-uniform category boundaries.

7. Validity

The validation of the AS and MAS has been the subject of extensive empirical inquiry, examining construct, convergent, discriminant, and predictive validity.

Construct and Convergent Validity: Convergent validity has been evaluated by correlating MAS scores against neurophysiological markers and laboratory biomechanical measures. Multiple studies have assessed correlations between MAS ratings and the electromyographic Hoffman reflex (H-reflex), specifically the maximum H-reflex to maximum M-wave ratio (H_max/M_max), which indexes spinal motor neuron excitability. Findings demonstrate modest to low correlations (typically ranging from r = 0.20 to 0.45), indicating that the scale does not reflect purely isolated spinal reflex excitability. When compared against biomechanical dynamometry (isokinetic dynamometers measuring passive resistive torque at controlled velocities, such as 30°/s, 60°/s, and 120°/s), convergent validity coefficients improve substantially, with Spearman rank correlations (r_s) ranging from 0.52 to 0.78 in the elbow flexors and ankle plantarflexors. These findings substantiate that the MAS validly measures total passive mechanical resistance at the joint, although its sensitivity to purely neurogenic components remains modest.

Discriminant Validity: Discriminant validity has been tested by comparing MAS scores against clinical measures of active motor performance, such as voluntary muscle force (measured via the Medical Research Council scale), active range of motion, and motor dexterity tests (e.g., Fugl-Meyer Assessment motor domain, Action Research Arm Test). Research demonstrates weak-to-negligible correlations (r = -0.10 to -0.32) between MAS reductions and functional dexterity improvements. This divergence confirms that the MAS discriminates between involuntary hypertonia and voluntary active neuromuscular recruitment; reduction in passive muscle tone does not automatically yield proportional improvements in voluntary functional dexterity.

Predictive and Criterion Validity: The predictive validity of the MAS is evident in longitudinal studies monitoring post-stroke recovery and pharmacotherapy response. Baseline MAS scores ≥ 2 in hemiparetic wrist and finger flexors during early subacute stroke predict the development of structural contractures at six months post-stroke with sensitivity exceeding 80%. In clinical intervention trials, the MAS reliably demonstrates significant sensitivity to change following intramuscular administration of botulinum toxin type A, yielding mean score decreases of 1 to 2 grades that correlate with improvements in ease of passive hygiene care, reduction in spasm frequency, and reductions in subjective pain.

8. Reliability

The reliability of the Ashworth Scale and Modified Ashworth Scale has been scrutinized across diverse clinical cohorts, muscle groups, and research settings. Because the MAS produces ordinal categorical data, psychometrically rigorous evaluations employ unweighted or weighted kappa (κ) statistics, Kendall’s tau (τ), or Intraclass Correlation Coefficients (ICC) using two-way random-effects models.

Inter-Rater Reliability: In their foundational 1987 investigation, Bohannon and Smith evaluated 30 stroke patients with upper extremity spasticity, reporting an inter-rater agreement of 86.7% and a Kendall’s τ of 0.847 (p < 0.001) for the elbow flexors when evaluated by two physical therapists. Subsequent multi-center investigations have presented more nuanced outcomes. Gregson and colleagues (1999, 2000) evaluated inter-rater reliability in post-stroke populations across multiple muscle groups, identifying weighted kappa (κ_w) values ranging from 0.53 to 0.74 for the elbow flexors, wrist flexors, and knee extensors, reflecting moderate to good reliability. However, lower extremity muscles—particularly the hip adductors and ankle plantarflexors—routinely exhibit lower inter-rater agreement, with κ_w values frequently dipping into the fair-to-poor range (0.35 to 0.55). Blackburn and colleagues (2002) corroborated this in the lower limbs of stroke patients, demonstrating unweighted kappa coefficients as low as 0.21 to 0.42 for the gastrocnemius-soleus complex.

Intra-Rater (Test-Retest) Reliability: Intra-rater reliability is consistently higher than inter-rater reliability. Clinicians testing the same patient across short temporal windows (e.g., separated by 1 to 4 hours to minimize biological fluctuation) typically achieve substantial-to-excellent reproducibility. Reported intra-rater ICCs range between 0.68 and 0.90 for upper limb muscles and 0.60 to 0.82 for lower limb muscles. Brashear and colleagues (2002) established substantial intra-rater reliability for wrist flexors (κ_w = 0.75) and elbow flexors (κ_w = 0.71) in a standardized multicenter trial protocol.

Sources of Measurement Error: Reliability is challenged by several clinical and environmental variables, including:

• Inconsistent velocity of passive movement across examiners, as deviating from the one-second standard directly alters velocity-dependent tone.
• Examiner stabilization technique and variations in patient starting position (e.g., supine versus seated postures, which alter vestibular and tonic neck reflex inputs).
• Ambient room temperature and secondary patient states, such as emotional stress, bladder fullness, or concurrent cutaneous pain, all of which alter sympathetic output and spinal reflex gains.
• Repeated passive mobilization producing a transient “warming-up” or thixotropic loosening effect, where subsequent repetitions yield lower passive resistance than the initial stretch.

9. Factor Analysis and Structural Dimensionality

Because the Ashworth Scale and Modified Ashworth Scale are single-item observational grading rubrics applied across individual anatomical joints, standard multi-item exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) are generally applied to multi-joint assessment batteries rather than to an isolated muscle reading. When clinicians administer the MAS across a standardized anatomical profile (e.g., evaluating shoulder internal rotators, elbow flexors, wrist flexors, hip adductors, knee flexors, and ankle plantarflexors), factor analytic techniques have been deployed to explore whether spasticity reflects a unidimensional systemic construct or distinct anatomical sub-dimensions.

Structural evaluations using principal component analysis and EFA in stroke and cerebral palsy cohorts generally identify a two-factor or three-factor latent structure. These factors naturally separate into upper extremity hypertonia (loading heavily on elbow, wrist, and finger flexors; factor loadings > 0.75) and lower extremity hypertonia (loading heavily on quadriceps, hamstrings, and gastrocnemius; factor loadings > 0.70). These empirical findings confirm that post-stroke spasticity does not distribute uniformly across the central nervous system; rather, it clusters along functional and anatomical segmental boundaries governed by differential corticospinal versus bulbospinal reticulospinal projection damage.

Modern psychometric literature has applied Rasch measurement models and Item Response Theory (IRT) to examine the structural validity and scaling properties of the MAS. Rasch analysis demonstrates significant challenges within the MAS category structure:

• Disordered Thresholds: Multiple Rasch investigations (e.g., Pandyan et al., 1999; Preissner et al., 2006) demonstrate that category “1+” often displays disordered thresholds. Clinicians experience difficulty distinguishing reliably between Grade 1 (minimal resistance at the end-range of motion) and Grade 1+ (minimal resistance through less than half of the range of motion). The probability curves for these categories frequently overlap, indicating that they do not represent distinct, monotonically increasing strata of hypertonia.
• Non-Equidistant Intervals: The psychological and physical jump between Grade 2 and Grade 3 (where movement becomes difficult) is considerably larger than the step between Grade 0 and Grade 1, violating the assumptions of interval measurement. Parametric statistical computations (such as calculating arithmetic means and standard deviations) on raw MAS scores violate metric assumptions, and Rasch-transformed interval-level logit scores are recommended for rigorous mathematical modeling.
• Scale Unidimensionality: When applied to a single limb segment, Rasch fit statistics (infit and outfit mean squares between 0.70 and 1.30) indicate adequate fit to a unidimensional model of passive joint resistance, confirming that the scale captures a coherent clinical construct, despite its non-linear scaling increments.

10. Instrument / Measurement Tool

The Modified Ashworth Scale is an observational, performance-based clinical rating system. It requires no specialized diagnostic hardware, relying entirely on the clinician’s physical mobilization of the patient’s joint. The structured specifications of the instrument are detailed below:

• Instrument Type: Clinician-Reported Outcome (ClinRO) / Standardized Performance-Based Clinical Rating Scale.
• Target Respondent: Administered by trained healthcare professionals (physiatrists, neurologists, physical therapists, occupational therapists, rehabilitation nurses) to pediatric or adult patients with neurological conditions.
• Number of Items: Single-item ordinal assessment per target muscle group; routinely administered across multiple bilateral joints to assemble a comprehensive spasticity profile.
• Administration Time: Approximately 1 to 2 minutes per muscle group; 10 to 15 minutes for a full-body bilateral screening.
• Equipment Required: Standard clinical examination plinth/bed; goniometer (optional, to verify precise joint angular limits).
• Patient Preparation and Instructions:
  • The patient is positioned comfortably in a supine posture. If supine positioning is contraindicated or impossible due to structural contractures, the alternative position (e.g., seated, semi-recumbent) must be maintained consistently across longitudinal evaluations.
  • The patient is explicitly instructed to remain completely relaxed, avoid active voluntary movement, and minimize vocalization or breath-holding during the test.
  • The extremity to be examined is placed in a neutral, relaxed position. Testing should ideally precede strenuous active motor therapy to avoid exercise-induced hypertonia spikes.
• Examiner Biomechanical Procedure:
  • The examiner stabilizes the proximal joint segment with one hand while cradling the distal segment with the other.
  • The joint is initially mobilized through its available passive range of motion at a slow velocity to assess baseline range, joint integrity, and identify any mechanical pain.
  • To test spasticity in a muscle that primarily flexes a joint (e.g., biceps brachii), the examiner starts with the joint in a position of maximal flexion and rapidly extends the joint to maximal extension over approximately one second (audibly or mentally timed by counting “one thousand one”).
  • To test spasticity in a muscle that primarily extends a joint (e.g., triceps brachii, quadriceps), the examiner starts with the joint in a position of maximal extension and rapidly flexes it to maximal flexion over approximately one second.
  • The stretch maneuver should not be repeated more than twice successively to avoid the thixotropic “release” effect, which transiently reduces tone upon consecutive mobilizations.
• Scoring and Transformation Rules:
  • The resistance felt across the arc is scored using the 6-point ordinal continuum: 0, 1, 1+, 2, 3, or 4.
  • For parametric statistical analysis in scientific research, the categorical grade “1+” is commonly mathematically coded as 1.5 (or recoded into a 0 to 5 continuous integer format: 0=0, 1=1, 1+=2, 2=3, 3=4, 4=5). However, researchers are cautioned that this recoding does not convert ordinal observations into linear interval-level data.

11. Permissions, Fee, and Test Year

The original Ashworth Scale was developed and published in 1964 by Dr. Bryan Ashworth in the journal Preliminary Communications / The Lancet. The Modified Ashworth Scale was refined and published in 1987 by Dr. Richard W. Bohannon and Melissa B. Smith in the journal Physical Therapy (the official journal of the American Physical Therapy Association). Both foundational formulations were placed directly in the scholarly public domain through their initial publications.

No licensing fees, commercial royalties, or formal administrative user permissions are required to utilize, reproduce, or clinically implement the Ashworth Scale or Modified Ashworth Scale in standard clinical practice, academic education, or investigator-initiated clinical trials. The scale rubrics, clinical instructions, and scoring criteria are accessible worldwide across medical literature. When deploying the instrument in published scientific research, formal bibliographic attribution to Ashworth (1964) and/or Bohannon and Smith (1987) is required under standard academic citation ethics.

12. References

Ashworth, B. (1964). Preliminary trial of carisoprodol in multiple sclerosis. The Lancet, 283(7329), 373–374. https://doi.org/10.1016/S0140-6736(64)92461-7

Blackburn, M., van Vliet, P., & Mockett, S. P. (2002). Reliability of measurements obtained with the modified Ashworth scale in the lower extremities of people with stroke. Physical Therapy, 82(1), 25–34. https://doi.org/10.1093/ptj/82.1.25

Bohannon, R. W., & Smith, M. B. (1987). Interrater reliability of a modified Ashworth scale of muscle spasticity. Physical Therapy, 67(2), 206–207. https://doi.org/10.1093/ptj/67.2.206

Brashear, A., Zafonte, R., Corcoran, M., Galvez-Jimenez, N., Gracies, J. M., Gordon, M. F., Elovic, E., Yablon, S., Turkel, C., & Gallagher, C. (2002). Inter- and intrarater reliability of the Ashworth Scale and the Disability Assessment Scale in patients with upper-limb poststroke spasticity. Archives of Physical Medicine and Rehabilitation, 83(10), 1349–1354. https://doi.org/10.1053/apmr.2002.35334

Gregson, J. M., Leathley, M., Moore, A. P., Sharma, A. K., Smith, T. L., & Watkins, C. L. (1999). Reliability of the Tone Assessment Scale and the modified Ashworth scale as clinical tools for assessing poststroke spasticity. Archives of Physical Medicine and Rehabilitation, 80(9), 1013–1016. https://doi.org/10.1016/S0003-9993(99)90053-9

Gregson, J. M., Leathley, M. J., Moore, A. P., Smith, T. L., Sharma, A. K., & Watkins, C. L. (2000). Reliability of measurement of muscle tone and muscle power in stroke patients. Age and Ageing, 29(3), 223–228. https://doi.org/10.1093/ageing/29.3.223

Haas, B. M., Bergström, E., Jamous, A., & Bennie, A. (1996). The inter rater reliability of the original and of the modified Ashworth scale for the assessment of spasticity in patients with spinal cord injury. Spinal Cord, 34(9), 560–564. https://doi.org/10.1038/sc.1996.100

Lance, J. W. (1980). Symposium synopsis. In R. G. Feldman, R. R. Young, & W. P. Koella (Eds.), Spasticity: Disordered Motor Control (pp. 485–494). Year Book Medical Publishers.

Pandyan, A. D., Johnson, G. R., Price, C. I., Curless, R. H., Barnes, M. P., & Rodgers, H. (1999). A review of the properties and limitations of the Ashworth and modified Ashworth scales as measures of spasticity. Clinical Rehabilitation, 13(5), 373–383. https://doi.org/10.1191/026921599677595404

Preissner, K. L., Schmeler, M. R., & Schein, R. M. (2006). Psychometric properties of the Modified Ashworth Scale: A critical review. Physical & Occupational Therapy in Geriatrics, 24(4), 57–74. https://doi.org/10.1080/J148v24n04_04

13. Items of the Scale