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Assessing muscle tone is critical for several movement disorders, such as Parkinson's disease and dystonia. Clinicians can evaluate muscle tone by observing the patient's gait and station and evaluating rapid alternating movements and point-to-point movements. The Modified Ashworth Scale (MAS) is a widely accepted clinical tool used to measure muscle tone and spasticity, which is a velocity-dependent increase in muscle stretch reflexes. MAS involves assigning a grade of spasticity from 0-4 based on the resistance to passive movement of a joint or muscle. However, it has been criticised for its poor inter and intra-rater reliability. The original Ashworth Scale, which the MAS is based on, was designed to assess the effectiveness of anti-spasticity drugs on patients with multiple sclerosis.
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What You'll Learn
The Modified Ashworth Scale
The MAS is used to assess the resistance experienced during passive range of motion, which does not require any instrumentation and is quick to perform. It is performed by extending the patient's limb first from a position of maximal possible flexion to maximal possible extension (the point at which the first soft resistance is met). The MAS is then assessed while moving from extension to flexion. The MAS assigns a grade of spasticity by moving a joint/muscle through a high-velocity quick stretch.
The MAS has been utilised in various populations, including stroke, spinal cord injury, multiple sclerosis, cerebral palsy, traumatic brain injury, paediatric hypertonia, and central nervous system lesions. It is widely used in research and clinical practice to evaluate the efficacy of pharmacologic and rehabilitation interventions for the treatment and management of spasticity.
Despite its popularity, the MAS has been criticised for its poor inter and intra-rater reliability, particularly in the assessment of spasticity in the lower limb. The MAS may only be measuring resistance to passive movement, thus providing a limited assessment of spasticity. It is also unable to differentiate between the various factors contributing to resistance to passive stretch.
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Upper extremity tone
The modified Ashworth scale is the most widely accepted clinical tool for measuring muscle tone and spasticity. It grades muscle spasticity on a scale from 1 to 3, with 1 being a slight increase in muscle tone and 3 being a considerable increase, making passive movement difficult. The scale is used to assess the resistance experienced during passive range of motion and does not require any instrumentation, making it quick and easy to perform in a clinical setting. However, it may not be entirely psychometrically sound, and there are criticisms regarding its poor inter and intra-rater reliability.
Spasticity can vary in severity, ranging from a mild feeling of muscle tightness to severe, painful, and uncontrollable stiffness and spasms. It can affect daily activities such as dressing, bathing, and hygiene tasks, and if left untreated, can lead to contractures, bone fractures, joint dislocation, and infections. Physiotherapy and occupational therapy can help manage spasticity by focusing on upper extremity stretching, strengthening, and training to improve range of motion and function. Local injections of botulinum toxin (Botox) or phenol can also be used to selectively reduce muscle tone and improve comfort and positioning.
To assess upper extremity tone, a clinician will take a muscle through passive movements, such as bending the elbow or knee, and observe the resistance to movement. They may also evaluate coordination by observing the patient's gait and station, as well as rapid alternating movements and point-to-point movements. The patient should be able to turn their hand from prone to supine rapidly and smoothly and perform finger-to-nose testing accurately and without tremors. These assessments help distinguish between different types of increased muscle tone, such as rigidity, dystonia, and spasticity, and guide appropriate treatment interventions.
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Lower extremity tone
The lower extremities can also be tested by rapidly flexing the thigh after instructing the patient to let the leg flop. The sudden flexion of the thigh raises the knee. Another maneuver is to shake the forearm and observe the floppiness of the hand's movements at the wrist.
The Ashworth scale is the most widely used assessment tool to measure resistance to limb movement in a clinical setting, although it is unable to distinguish between the neural and non-neural components of increased tone. The Modified Ashworth Scale scores exhibited better reliability when measuring upper extremities than lower. This scale quantifies muscle spasticity by assessing the response of the muscle to stretch applied at specified velocities.
Muscle strength testing can also be used to evaluate weakness and differentiate true weakness from imbalance or poor endurance. Commonly tested muscles in the lower extremity include the hip flexors, knee extensors, dorsiflexors, great toe extensors, and plantar flexors.
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Gait abnormalities
There are several types of gait abnormalities. A lurching gait is common among people affected by paralysis or weakness of the gluteus area, causing a slow and long stride. A hemiplegic gait is caused by a lesion in the central nervous system, resulting in unilateral weakness and spasticity, and the patient has to circumduct their leg to prevent their foot from dragging on the ground. A neuropathic gait, or high-steppage gait, is caused by weakness of the muscles in the distal limb, resulting in foot drop and a high-stepping gait to prevent the toes from dragging on the floor. An antalgic gait is caused by pain, resulting in a reduced stance phase on the affected leg and a limping appearance.
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Muscle strength
The most commonly accepted method of evaluating muscle strength is the Medical Research Council Manual Muscle Testing scale. This method involves testing key muscles from the upper and lower extremities against the examiner’s resistance and grading the patient’s strength on a 0 to 5 scale accordingly. Commonly tested muscles include the shoulder abductors, elbow flexors, elbow extensors, wrist extensors, finger flexors, hip flexors, and knee extensors.
Functional testing often provides a better picture of the relationship between strength and disability. As the patient does various maneuvers, deficiencies are noted and quantified as much as possible (e.g., the number of squats done or steps climbed). Rising from a squatting position or stepping onto a chair tests proximal leg strength; walking on the heels and on tiptoes tests distal strength. Pushing with the arms to get out of a chair indicates quadriceps weakness.
When performing formal muscle testing, it is important to observe the patient performing the tests and assess the muscle strength on a scale from 0 to 5. General principles for examining muscle strength include encouraging maximal effort, stabilizing the joint, and isolating the muscle group across one joint. It is also important to compare one side of the body to the other and look for patterns of weakness.
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Frequently asked questions
The Modified Ashworth Scale (MAS) is the most universally accepted clinical tool used to measure muscle tone. It is a revised version of the original Ashworth Scale that measures spasticity in patients with lesions to the central nervous system.
The main challenge is to distinguish among the main subtypes of increased muscle tone: rigidity, dystonia, and spasticity. Another challenge is that the assessment of muscle tone is critical to several movement disorders, such as Parkinson's disease and dystonia.
The general principles for examining muscle strength include encouraging maximal effort, stabilizing the joint, and isolating the muscle group across one joint. It is also important to compare one side to the other and look for patterns of weakness.
