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594

Quantitative Clinical Measure of Spasticity in Children With


Cerebral Palsy
Jack R. Engsberg, Phi), Kenneth S. Olree, MS, Sandy A. Ross, MHSPT, T. S. Park, MD
ABSTRACT. Engsberg JR, Olree KS, Ross SA, Park TS. administered to children with cerebral palsy to minimize or
Quantitative clinical measure of spasticity in children with cere- eliminate the influence of spasticity.8-m Methods to quantify the
bral palsy. Arch Phys Med Rehabil 1996;77:594-9. various types of spasticity include the Modified Ashworth scale,
electromyography (EMG), deep tendon reflex tests, and resis-
Objective: This investigation developed an objective mea- tance-to-motion t e s t s . I-4'9'tH4 Of these four methods for as-
sure to quantify the degree of spasticity. sessing spasticity only the Modified Ashworth scale is regularly
Design: Specifications included a single variable that inte- used in a clinical setting] ~ The Modified Ashworth Scale in-
grated key elements characterizing spasticity: velocity, range of volves manually moving a limb through the range of motion to
motion, and resistance to passive motion. A dynamometer at passively stretch specific muscle groups. The scale permits a
a children's hospital quantified the passive resistance of the rapid assessment of the degree of spasticity about many joints.
hamstrings to knee extension for a range of motion at 4 different However, although its use is widespread in clinical and research
speeds for the prospective descriptive investigation. settings for assessing spasticity, it remains a basically subjective
Patients: A convenience sample of six children with able measure recorded in ordinal data.l ~ As a consequence, its relia-
bodies and 17 children with spastic diplegic cerebral palsy vol- bility has been called into question. 15
unteered. In contrast to the Modified Ashworth scale, the remaining
Data Processing: Torque-angle data were processed to calcu- three methods for assessing the degree of spasticity are objective
late the work done by the machine on the children for each measures. These tests, however, have limitations that prevent
speed and then determine the slope of the work-velocity curves. them for being used regularly in a clinical setting. EMG has
This slope was considered to be the measure of spasticity and been used to examine muscle activity in spastic adults and
it was hypothesized that children with cerebral palsy would have children undergoing selective dorsal rhizotomy surgery] 2A6Al-
a greater slope than children with able bodies. An independent t though it provides insight into the activity of the muscle, the
test determined whether a significant difference existed between methods are difficult to use clinically. The EMG signal is highly
groups (p < .05). dependent on the techniques used to record them (eg, electrode
Results: Torque-angle data for children with able bodies indi- type, electrode placement) and on the muscle under examina-
cated little change in passive resistance as a function of speed. tion? Further, the relationship between EMG and muscle force
Similar data for children with cerebral palsy indicated larger is not easily quantified.
resistive torques with increasing speed. Slope from the work- Deep tendon reflex tests apply an impact load to a specific
velocity data was close to zero for children with able bodies tendon and measure EMG, leg displacements, force, or accelera-
[.003 J/(°/sec)], while the corresponding slope for children with l i o n s . 4'13'17 Custom-made devices have been developed to stan-
cerebral palsy was approximately 10 times greater [.031 J/(°/ dardize the impact to the tendon] 7 Nevertheless, these devices
sec)] and significantly different (p < .05).
may not be applicable to other tendons, and the generalization
Conclusion: The slope of the work-velocity data integrates of results to other joints is unknown.
three major components characterizing spasticity, it is a single
Resistance-to-motion tests seem to fail into two types. Both
number that can easily be evaluated and interpreted in a clinical types assess resistance to motion with dynamometers; one type
setting, and it utilizes a machine that is available at many cen- measures the resistance during small oscillations and the other
ters. measures resistance over a large range of m o t i o n . 9'14']839 In both
© 1996 by the American Congress of Rehabilitation Medicine cases the tests are not regularly used in a clinical setting. Some
and the American Academy of Physical Medicine and Rehabili- of these tests require custom-made equipment not available to
tation many centers. 14'~9Some do not provide information that can be
easily understood and interpreted by the clinician. TM Often the
MAJOR IMPAIRMENT in cerebral palsy is spasticity.
A Clinically, the term spasticity is often used to refer to a
number of impairments, including muscle hypertonia, ~'2 hyper-
device is not applicable to a variety of joints or muscles, t'4'w
The purpose of this investigation was to develop a method
to quantify the degree of spasticity that would be useful in the
active deep tendon reflex,3 clonus, 4 and velocity-dependent re- clinical setting. Priorities for this method included equipment
sistance to passive stretch. 5-7 Many surgical and therapeutic pro- that was available to many centers, ease of operation, applicabil-
cedures are performed, and many pharmacological drugs are ity to a variety of joints and muscles, and simple but meaningful
results. To maintain both clinical and mechanical relevance, and
From the Motion Analysis Laboratory, Department of Neurosurgery, St. Louis to maximize simplicity of results, spasticity was characterized
Children's Hospital (Dr. Engsberg, Mr. Olree, Ms. Ross, Dr. Park) and Washing- as a velocity-dependent resistance to passive stretch. 5-7
ton University School of Medicine (Dr. Engsberg, Dr. Park), St. Louis, MO.
Submitted for publication June 27, 1995. Accepted in revised form December
14, 1995. METHODS
No commercial party having a direct or indirect interest in the subject matter
of this article has or will confer a benefit upon the authors or upon any organization For this prospective, descriptive investigation, a convenience
with which the authors are associated. sample of six children with able bodies (mean age 9 years,
Reprint requests to Jack R. Engsberg, PhD, Director, Motion Analysis Labora- range 4 to 17; 2 boys, 4 girls; mean mass 34.5kg, SD 17.9) and
tory, St. Louis Children's Hospital, One Children's Place, St. Louis, MO 63110.
© 1996 by the American Congress of Rehabilitation Medicine and the American
17 children with spastic diplegie cerebral palsy (mean age 10
Academy of Physical Medicine and Rehabilitation years, range 4 to 16; 8 boys, 9 girls; mean mass 32.3kg, SD
0003-9993/96/7706-357453.00/0 14.6) were tested. The children with able bodies were recruited

Arch Phys Med Rehabil Vol 77, June 1996


SPASTICITY MEASURE IN CHILDREN WITH CP, Engsberg 595

through parents within the hospital community or were siblings


of children visiting the hospital. The children with cerebral
palsy had been referred to the motion analysis laboratory for 0- .......... " ................
other testing by an orthopedic surgeon or were scheduled to
undergo a selective dorsal rhizotomy the following day and
were referred to the laboratory by a neurosurgeon. The clinical _2J
diagnosis of spastic diplegic cerebral palsy was made by the
referring physician. Only children who were large enough to fit v

comfortably on the test equipment and who would presumably


cooperate were approached for participation. All parents and
children who were asked to participate consented. Each child -6"

and/or parent was informed about the project and gave informed
consent. In each child with an able body only one leg was -8"
tested. Attempts were made to test both legs of the children
with cerebral palsy, but if a child became tired, bored, or unco- Knee Flexed ] IKnee Extended
operative, only one leg was tested. Initial efforts at determining -lC
-7o -~o -~o 4o -5o -~o -10 1'o ~o 30
the reliability of the measure were accomplished by testing KinCem Angle (degrees)
two children at two different times after their selective dorsal
rhizotomy surgery. One child was tested at 34 and 41 weeks Fig 1. Quantification of the work done (torque × angular displacement)
after surgery and a second child was tested at 10 and 21 months by the KinCom machine on one subject at one speed (shaded area). The
after surgery. boundaries for the a r e a were the torque-angle curve, the zero torque line,
and the end range of motion (about 12°). A work value was calculated for
The KinCom dynamometer~can move the passive leg through each of the four speeds for each child. Inertial and gravitational effects
a range of motion at a specified speed, measuring the force have been accounted for in the torque values.
applied to a support arm during the motion. Each child sat on
the KinCom with stabilization straps across the distal aspect of
the thigh and pelvis. The child was supported at his or her back The force data from each child were downloaded to a personal
and was capable of maintaining an upright position. The axis computer in which the weight of the leg and foot due to gravity,
of the KinCom was aligned with the knee axis of the child. The estimated to be 5.8% of total body weight, was partialled out
leg of the child was attached to the support arm by securing in a custom computer program. 2° The acceleration of the leg
the leg against a tibia pad with Velcro straps. A fixed laboratory from a motionless position to a constant angular velocity pro-
coordinate system was established by moving the lever arm to duced a torque component in the data that was unwanted. As
a horizontal position (0°). Torques were calculated by inputting would be expected this component was increased as both the
the distance of the tibia pad from the rotation axis of the ma- speed of the test and the mass of the leg and foot increased.
chine. These inertial effects were removed by modeling the accelera-
Before conducting the spasticity tests, the anatomic range tion component as an underdamped second-order system and
of motion limits for knee extension or hamstring length were subtracting it from the torque values.2~
established for each child. The starting position for the test was The areas quantifying the work done (ie, fT*d0 where T =
approximately 60 ° below the horizontal, although this position Torque and dO is a small angular displacement measured in
was decreased to 50 ° if substantial quadriceps resistance existed. radians) by the machine on the child were calculated using the
A special feature of the KinCom was used to determine the trapezoid rule. The boundaries for the areas were the torque-
limits for knee extension. This feature caused the machine to angle curve, the zero torque line, and the end range of motion
stop if a preset force (ie, termination force) was reached. Ini- (fig 1). Four areas quantifying work were determined for each
tially, the machine was set to take the knee of the child beyond child for the given speeds (ie, 10°, 30°, 60 °, 90°/sec). Linear
its physiological limits. To prevent this from happening a low regression was used to determine the line of best fit for these
termination force value was programmed into the machine to four areas as a function of speed. The slope of the linear regres-
stop the test. The end range of extension motion was determined sion line was considered to be the measure of spasticity. It was
by assigning a speed of 10°/sec to the KinCom and engaging hypothesized that the children with able bodies would have
the passive mode. The child was instructed not to help the lever slopes close to zero because they have no velocity-dependent
arm move and remain as relaxed as possible as the leg rotated resistance to stretch and the children with cerebral palsy would
from a flexed to an extended position. The end range of motion have slopes greater than zero because they do have a velocity-
for knee extension was determined and recorded by gradually dependent resistance to stretch.
increasing the termination force until the child felt uncomfort- Because not all children wit~l cerebral palsy had both legs
able, the pelvis began to rotate posteriorly, or the knee began tested, the single leg tested was used in the analysis (n = 6).
to rise. The final termination force values were converted to In the cases where both legs were tested, a single leg from each
torques for each child and ranged between 6 and 20Nm. To child was randomly chosen for analysis (n = 11). A chi-squared
insure the safety of the child an adult closely observed the tests test was performed to determine if the distribution of the slopes
and held a button that, if pressed, would stop the test. for the children with cerebral palsy were significantly different
The spasticity tests were then conducted. These tests were from a normal distribution. Since no significant difference was
similar to the previous one except that the end range of exten- found (p < .01) an independent t test was used to determine if
sion motion was used to stop the tests instead of a termination a significant difference existed between the slopes for the two
force value. The starting angle remained at approximately 60 ° groups of children (p < .05).
below the horizontal. The termination force was increased from
its preset value to assure that the end range of motion was
achieved. Tests for knee extension were conducted at speeds of RESULTS
10°, 30°, 60 °, and 90°/sec, and the resistive torque was continu- Torque-angle data for a typical child with an able body indi-
ously monitored during the trials. cated very little change in resistive torque as a function of speed

Arch Phys Med Rehabil Vol 77, June 1996


596 SPASTICITY MEASURE IN CHILDREN WITH CP, Engsberg

2 Table 1: Work Done by the KinCom Machine on Childrens' Knees


Work (Joules)
0 Subjects 10°/sec 30°/sec 60°/see 90°/sec

Able body (n = 6) 2.81 2.78 2.91 3.04


-2- SD 2.48 2.35 2.12 2.11
Cerebral palsy (n = 17) 2.81 3.82 4.22 5.52
E SD 1.92 2.40 2,30 3.04
z
-4 Means and standard deviations for the work done (ie, torque x angular
O
displacement) by the KinCom machine on knees of the children with
F-- cerebral palsy and the children with able bodies at 4 speeds of knee
-8" extension in the upright position. The work remained relatively constant
regardless of the speed for the children with able bodies. In contrast,
I to dens the work for the children with cerebral palsy increased as thespeed
-8" increased.

Knee Flexed } [ Knee Extended


-10 crossed the 0 torque line and the magnitude of the resistive
-70-60 -50 -40 -30 -20 -10 1'0 20 30
KinCorn Angle (degrees) torque throughout the range of motion.
The slope (Joules/(°/sec)) of the linear regression line for
Fig 2, Results of the passive resistance tests for a typical child with an work values as a function of velocity (table 1) for the children
able body (girl, age 7 years, mass 26kg). Very little difference existed
with able bodies was very close to zero (.0031, SD = .009),
between curves regardless of the speed of knee extension, indicating
little relationship between resistance and speed through the range of whereas the corresponding slope for the children with cerebral
motion. Inertial and gravitational effects have been accounted for in the palsy was approximately 10 times greater (.033, SD = .019)
torque values. (fig 4). These slopes were significantly different (p < .05). The
repeat testing of the two groups of children after selective dorsal
because all curves were essentially the same (fig 2). In addition, rhizotomy surgery indicated small differences compared to the
differences between the children with cerebral palsy and those
the ordering of the curves according to magnitude did not pro-
gressively increase or decrease. In contrast, similar data for a with able bodies (fig 5).
typical child with cerebral palsy indicated larger resistive tor-
DISCUSSION
ques with an increase in speed (fig 3). An extensor torque (ie,
positive value) existed for about the first 20° to 25 ° of motion The purpose of this investigation was to develop a method
for both groups of children, The presence of the extensor torque to quantify the degree of spasticity that would be useful in the
before a flexor torque was common in most children. clinical setting. Priorities for this method included equipment
The work done (fig 1) by the machine on the knees of the that was available to many centers, ease of operation, applicabil-
children with able bodies remained relatively constant for the ity to a variety of joints and muscles, and simple but meaningful
four speeds, whereas the work done on the children with cere- results. To maintain both clinical and mechanical relevance and
bral palsy increased as the velocity increased (table 1). There to maximize simplicity of results, spasticity was characterized
was an 8% increase from the slow speed to the fast speed in as a velocity-dependent resistance to passive stretch. 5-7
the children with able bodies and a 96% increase from slow to A number of limitations are associated with this investigation.
fast for the children with cerebral palsy. The standard deviations The tests for spasticity measure the resultant torque about the
were relatively large for both groups of children. This was knee joint. This resultant joint torque is the sum of all the
because of the variability in both the point at which the curves

...'"
0

-2- ...-"

o , ..,'""

-4- o
E-
,.."*
-6-
ml

-6-

[ K ~ _T~Kn~eeExtended I ~ ,,g/-~
-10 2
-70 -60 -50 -40 -30 -20 -10 0 10 20 30 0 1'0 2'0 ~o 4o 10 ~0 #0 do $0 lO0
KinComAngle(degrees) Velocity of Knee Extension(degrees/s)

Fig 3. Results of the passive resistance tests for a typical child with Fig 4. Work done by the KinCom machine on the children with cerebral
spastic diplegic cerebral palsy (girl, age 12 years, mass 39kg}. In contrast palsy and on the children with able bodies presented in table 1 and
to the results presented in figure 2, this test showed an increase in plotted as a function of velocity. Linear regression lines are included
resistance corresponding to an increase in speed of knee extension, re- with their slopes. The slope for the children with cerebral palsy was
flecting the velocity-dependent resistance to stretch characteristic of approximately 10 times greater than the corresponding slope for the
children with cerebral palsy. Inertial and gravitational effects have been children with able bodies. The slopes were significantly different (Cere-
accounted for in the torque values. bral palsy slope [---] - .033; able body slope [ - - | = .0031),

Arch Phys Med Rehabil Vol 77, June 1996


SPASTICITY MEASURE IN CHILDREN WITH CP, Engsberg 597

0.03 The present investigation focuses solely on knee joint exten-


sion. The KinCom is capable of performing the same functions
at many other joints of the body besides the knee (eg, ankle,
elbow, hip). It is thus a relatively straightforward process to
"~
CD
0.02 adapt the methods presented here to other joints.
Spasticity has been characterized by muscle hypertonia, ~2
hyperactive deep tendon reflexes,3 clonus,4 and velocity-depen-
0.01 A dent resistance to passive stretch. 5-7The characterization chosen
for this investigation was velocity-dependent resistance to pas-
..~ A sive stretch. It was chosen because it was not only clinically
0.00 A relevant but also contained three elements that were fundamen-
r~ tal to mechanical engineering principals. These key elements
were stretch, resistance, and velocity. The stretch was related
-0.01 to an angular joint range of motion, the resistance to the torque
Patients about the joint, and the velocity to the rate of angular change
of the joint. Further, the torque and angular range of motion
Fig5. Preliminary test-retest results for two children with cerebral palsy. values could be combined into the common mechanical term,
One child was tested at 34 and 41 weeks after surgery and a second
child was tested at 10 and 21 months after surgery. The difference be-
work (ie, fT*d0). The simple statistical technique of linear re-
tween the repeat testing was far smaller than the differences between gression permitted the creation of the single variable, slope,
the averages for the children with cerebral palsy and those with able for quantifying spasticity. The ability to relate the variables
bodies ([], children with able bodies; A, children with cerebral palsy; A to fundamental mechanical and statistical principals was very
SDR posttests at 7-week interval; A, SDR posttests at 14-week interval).
important because the validity of the measure was impossible
to assess. No "gold standard" exists from which to make a
comparison.22Therefore it was reasoned that the measure would
individual torques that can occur about a joint (eg, agonist and
antagonistic muscles). The present investigation did not deter- be valid if it quantified the key elements of its characterization.
The Modified Ashworth scale is the only measure for spas-
mine these individual contributions to the resultant joint torque.
ticity that is presently being used in a clinical settingJ ~ The
This limits to some degree the interpretation of the results if,
scale permits a rapid assessment of many joints, but it does not
for example, during the spasticity tests for the hamstrings there
directly assess any velocity component associated with spas-
was torque generated by the quadriceps. This quadriceps torque
ticity, it only records ordinal data, and its reliability has been
would assist the machine in its movement to full extension and
questionedJ ~ Like the measure presented in the current investi-
produce a resultant joint torque that would underestimate the
gation its validity cannot be compared to a "gold standard."2z
hamstring passive resistive torque. The extensor torque with the
It also cannot be considered as a "gold standard." Nevertheless,
knee in a flexed position at the start of the tests for the children
the Modified Ashworth scale was used to assess some of the
with cerebral palsy (fig 3) was probably related to the passive
children recruited for this investigation (n = 12). A correlation
muscle elements of the quadriceps. The collection of EMG data
between it and the measure of the present investigation was
from the muscles crossing the knee would have aided in the
quite low (r = .28). Further review indicated that the Ashworth
understanding of this condition, although it would not have assessments were made by five different physical therapists. No
permitted any additional quantification of torque because the interrater reliability was appraised. It has been reported that the
relationship between EMG and torque is difficult to determine. mean interrater correlation between three practitioners assessing
Regardless, EMG equipment was not available while this inves- the degree of spasticity at the knee was .45. ~ It was concluded
tigation was being conducted. that additional work was required to make a more realistic
The estimation of the mass of the leg and foot due to gravity comparison between the two measures.
was 5.8% of total body massJ 4 This calculation was based on Reliability of the measurement is a key factor in determining
measurements taken from adults and it should be noted that its utility. A thorough assessment of the reliability of the mea-
children may have a slightly different percentage. It should also sure presented in this investigation has not yet been completed.
be noted that this estimation does not affect the results of the The majority of the children tested were seen the day before
measure for spasticity because a change in mass estimation of their selective dorsal rhizotomy surgery. This preoperation day
the leg and foot would only shift the torque-angle curves (eg, was filled with numerous other commitments related to the
figs 2 and 3) up or down. Since this shift would be the same surgery, thus preventing the children from being accessible for
for all speeds, it would alter the work done by the KinCom on repeat testing. Further, most of the children were not from the
the child by proportional amounts, thus producing the same surrounding area and could not be expected to bear the expense
slope (ie, our measure for spasticity). A more accurate estimate of arriving a day early for repeat testing. It was fortunate, how-
of the mass of the leg and foot would become critical if the ever, that one child had to retm'n to the hospital 7 weeks after
data from figures 2 and 3 were used in another manner. For his 8-month postoperative visit and a second child could be
example, if the average of the four work values was to be used retested at his 2-year follow-up visit. The length of time between
as an estimate of spastic hypertonia, then a vertical shift in the repeat testing and the small differences compared with the dif-
curves would become important. A shift up or down would ference between the children with cerebral palsy and those with
increase or decrease the value of this measure. able bodies are encouraging results for good reliability of the
The KinCom angles presented in figures 2 and 3 quantify the measure. Additional work is required to confirm or refute these
angular orientation of the KinCom lever arm and not the knee preliminary results.
joint angle of the child. An offset between the lever arm and It is important to note that the present investigation did not
the leg existed. A lever arm-leg angular relationship was not attempt to separate the resistive torque into that attributed to
essential to the investigation and, therefore, not determined for the active and passive components of muscleJ 4 This is a limita-
all children. However, the offset has been estimated to be be- tion of the investigation because such information would be
tween 10° and 15°. quite valuable. However, such a separation was not part of

Arch Phys Med Rehabil Vol 77, June 1996

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