Lack of systematic approach to assessing adult lower limb spasticity: A systematic review

Ms Stella Kravtsov1, Dr Ettie Ben-Shabat2, Dr  Corey  Joseph1, Dr Anna  Murphy1

1Monash Health, 2Alfred Health,

Background: Spasticity may adversely affect function and may be treated with Botulinum Toxin A (BoNT-A) injections, which are muscle specific and costly. The efficacy of BoNT-A injections depends on the accuracy of the assessment. Spastic muscles are selected based on differential resistance to rapid and slow muscle lengthening, and its manifestation in function. Such assessment is often conducted prior to instrumental gait analyses. We examined the clinical assessment of adults’ lower leg spasticity, in studies of instrumental gait analysis.

Method: Searches were conducted to identify studies where adult participants with lower limb spasticity were assessed with instrumental gait analyses. Databases: Medline, EMBASE, CINAHL, AMED, Cochrane and PEDro. Data was examined for the spasticity assessment tools used, and the muscles tested.


Thirty-seven studies were included. Spasticity was assessed with the:

  • Modified Ashworth Scale n=32
  • Modified Tardieu Scale n=5
  • Duncan-Ely test n=3
  • Levin & Hui-Chan Spasticity Index n=1
  • Spasticity Index based on EMG n=1
  • Multiple measurements n=5

Muscle assessed were:

  1. “Ankle plantar-flexors” n=11,
  2. “Triceps Surae” n=11,
  3. Gastrocnemius n=5,
  4. Soleus n=2,
  5. Tibialis-Posterior n=1,
  6. Rectus-Femoris n=5,
  7. Quadriceps n=9,
  8. Hamstrings n=6,
  9. Unspecified muscles n=4

In most studies muscles were tested in functional groups:

  • Ankle Plantar-Flexors (muscles 1-5) n=25
  • Knee extensors (muscles 6+7) n=14
  • Knee flexors (muscle 8) n=6
  • Two or 3 muscle groups n=12

Discussion: The Modified Ashworth Scale is commonly used for assessing spasticity, despite its lack of differentiation between resistance to rapid and slow muscle lengthening. Plantar-flexors were the muscle group most frequently tested, often with no attempts to differentiate between individual muscles. Knee extensors were tested infrequently, which is surprising considering the prevalence of stiff knee gait. Against expectations, spasticity assessment in instrumental gait analysis studies is poorly reported. Spasticity assessment is best conducted comprehensively (all possible muscle groups) and systematically (muscle specific).

Biography: To be confirmed

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