Spasticity Assessment in Cerebral Palsy

  • Lynn Bar-OnEmail author
  • Jaap Harlaar
  • Kaat Desloovere
Living reference work entry


Spasticity is an important, but not the only, component contributing to the increased joint resistance experienced by children with spastic cerebral palsy. Conventional clinical spasticity scales, based on physical examination of the passive muscle, are easy to apply in pediatric populations. Unfortunately, these have low reliability and are unable to differentiate between the different components of joint hyper-resistance. To correctly differentiate spasticity from other neural and non-neural contributions, instrumented assessments that integrate electrophysiological and biomechanical measures are required. In the last 15 years, great advancements in clinically applicable, instrumented assessments were made. However, the translation from research to clinical setting is lagging behind. Simple, yet accurate, instrumented assessments are expected to greatly advance clinical practice in terms of treatment planning based on etiological classification and subsequent outcome evaluation. In addition, the transfer of the research findings to functional outcome would require to extend our research agenda to include assessments of hyperreflexia in the active muscle. Altogether these instrumented methods are not only needed to classify different aspects of joint hyper-resistance but will also provide further insight into its pathophysiology enabling the development of future treatment options for children with spastic cerebral palsy.


Cerebral palsy Spasticity Electromyography Hyper-resistance Instrumented assessment 


  1. Bar-On L, Aertbeliën E, Molenaers G et al (2012a) Comprehensive quantification of the spastic catch in children with cerebral palsy. Res Dev Disabil 34:386–396Google Scholar
  2. Bar-On L, Aertbeliën E, Wambacq H et al (2012b) A clinical measurement to quantify spasticity in children with cerebral palsy by integration of multidimensional signals. Gait Posture 38:141–147CrossRefPubMedGoogle Scholar
  3. Bar-On L, Aertbeliën E, Molenaers G et al (2014a) Instrumented assessment of the effect of botulinum toxin-A in the medial hamstrings in children with cerebral palsy. Gait Posture 39:17–22CrossRefPubMedGoogle Scholar
  4. Bar-On L, Aertbeliën E, Molenaers G et al (2014b) Manually-controlled instrumented spasticity assessments: a systematic review of psychometric properties. Dev Med Child Neurol 56:932–950CrossRefPubMedGoogle Scholar
  5. Bar-On L, Aertbeliën E, Molenaers G, Desloovere K (2014c) Muscle activation patterns when passively stretching spastic lower limb muscles of children with cerebral palsy. PLoS One 9:e91759CrossRefPubMedPubMedCentralGoogle Scholar
  6. Bar-On L, Desloovere K, Molenaers G et al (2014d) Identification of the neural component of torque during manually-applied spasticity assessments in children with cerebral palsy. Gait Posture 40:346–351CrossRefPubMedGoogle Scholar
  7. Bar-On L, Molenaers G, Aertbeliën E et al (2014e) The relation between spasticity and muscle behavior during the swing phase of gait in children with cerebral palsy. Res Dev Disabil 35:3354–3364CrossRefPubMedGoogle Scholar
  8. Bar-On L, Van Campenhout A, Desloovere K et al (2014f) Is an instrumented spasticity assessment an improvement over clinical spasticity scales in assessing and predicting the response to integrated botulinum toxin-A treatment in children with cerebral palsy? Arch Phys Med Rehabil 95:515–523CrossRefPubMedGoogle Scholar
  9. Bar-On L, Aertbeliën E, Molenaers G, Desloovere K (2015) The type of spasticity predicts botulinum toxin-A treatment outcome in children with cerebral palsy. Gait Posture 42:S91. ESMACCrossRefGoogle Scholar
  10. Biering-Sørensen F, Nielsen JB, Klinge K (2006) Spasticity-assessment: a review. Spinal Cord 44: 708–722CrossRefPubMedGoogle Scholar
  11. Bohannon RW, Smith MB (1987) Interrater reliability of a modified Ashworth scale of muscle spasticity. Phys Ther 67:206–207CrossRefPubMedGoogle Scholar
  12. Boyd RN, Graham HK (1999) Objective measurement of clinical findings in the use of botulinum toxin type A for the management of children with cerebral palsy. Eur J Neurol 6:23–35CrossRefGoogle Scholar
  13. Burke D, Wissel J, Donnan GA (2013) Pathophysiology of spasticity in stroke. Neurology 80:S20CrossRefPubMedGoogle Scholar
  14. Burridge J, Wood D, Hermens H et al (2005) Theoretical and methodological considerations in the measurement of spasticity. Disabil Rehabil 27:69–80CrossRefPubMedGoogle Scholar
  15. Calota A, Levin MF (2009) Tonic stretch reflex threshold as a measure of spasticity: implications for clinical practice. Top Stroke Rehabil 16:177–188CrossRefPubMedGoogle Scholar
  16. Chung SG, van Rey E, Bai Z et al (2008) Separate quantification of reflex and nonreflex components of spastic hypertonia in chronic hemiparesis. Arch Phys Med Rehabil 89:700–710CrossRefPubMedGoogle Scholar
  17. Crenna P (1998) Spasticity and “spastic” gait in children with cerebral palsy. Neurosci Biobehav Rev 22: 571–578CrossRefPubMedGoogle Scholar
  18. de Gooijer-van de Groep KL, de Vlugt E, de Groot JH et al (2013) Differentiation between non-neural and neural contributors to ankle joint stiffness in cerebral palsy. J Neuroeng Rehabil 10:81CrossRefPubMedPubMedCentralGoogle Scholar
  19. de Vet HC, Terwee CB, Ostelo RW et al (2006) Minimal changes in health status questionnaires: distinction between minimally detectable change and minimally important change. Health Qual Life Outcomes 4:54CrossRefPubMedPubMedCentralGoogle Scholar
  20. de Vlugt E, de Groot JH, Schenkeveld KE et al (2010) The relation between neuromechanical parameters and Ashworth score in stroke patients. J Neuroeng Rehabil 7:35CrossRefPubMedPubMedCentralGoogle Scholar
  21. Delp S, Anderson FC, Arnold AS et al (2007) OpenSim: open-source software to create and analyze dynamic simulations of movement. IEEE Trans Biomed Eng 54:1940–1950CrossRefPubMedGoogle Scholar
  22. Flamand VH, Massé-Alarie H, Schneider C (2013) Psychometric evidence of spasticity measurement tools in cerebral palsy children and adolescents: a systematic review. J Rehabil Med 45:14–23CrossRefPubMedGoogle Scholar
  23. Fleuren JFM, Voerman GE, Erren-Wolters CV et al (2010) Stop using the Ashworth scale for the assessment of spasticity. J Neurol Neurosurg Psychiatry 81:46–52CrossRefPubMedGoogle Scholar
  24. Fosang AL, Galea MP, McCoy AT et al (2003) Measures of muscle and joint performance in the lower limb of children with cerebral palsy. Dev Med Child Neurol 45:664–670CrossRefPubMedGoogle Scholar
  25. Galiana L, Fung J, Kearney R (2005) Identification of intrinsic and reflex ankle stiffness components in stroke patients. Exp Brain Res 165:422–434CrossRefPubMedGoogle Scholar
  26. Gäverth J, Eliasson A-C, Kullander K et al (2014) Sensitivity of the NeuroFlexor method to measure change in spasticity after treatment with botulinum toxin A in wrist and finger muscles. J Rehabil Med 46:629–634CrossRefPubMedGoogle Scholar
  27. Gholami S, Ansari NN, Naghdi S et al (2017) Biomechanical investigation of the modified Tardieu scale in assessing knee extensor spasticity poststroke. Physiother Res Int 23:e1698CrossRefGoogle Scholar
  28. Graham HK, Aoki KR, Autti-Rämö I et al (2000) Recommendations for the use of botulinum toxin type A in the management of cerebral palsy. Gait Posture 11:67–79CrossRefPubMedGoogle Scholar
  29. Haberfehlner H, Maas H, Harlaar J et al (2016) Knee moment-angle characteristics and semitendinosus muscle morphology in children with spastic paresis selected for medial hamstring lengthening. PLoS One 11:e0166401CrossRefPubMedPubMedCentralGoogle Scholar
  30. Harlaar J, Becher JG, Snijders CJ, Lankhorst GJ (2000) Passive stiffness characteristics of ankle plantar flexors in hemiplegia. Clin Biomech 15:261–270CrossRefGoogle Scholar
  31. Hasson F, Keeney S, McKenna H (2000) Research guidelines for the Delphi survey technique. J Adv Nurs 32:1008–1015PubMedGoogle Scholar
  32. Haugh AB, Pandyan AD, Johnson GR (2006) A systematic review of the Tardieu scale for the measurement of spasticity. Disabil Rehabil 28:899–907CrossRefPubMedGoogle Scholar
  33. Jamshidi M, Smith AW (1996) Clinical measurement of spasticity using the pendulum test: comparison of electrogoniometric and videotape analyses. Arch Phys Med Rehabil 77:1129–1132CrossRefPubMedGoogle Scholar
  34. Jansen K, De Groote F, Aerts W et al (2014) Altering length and velocity feedback during a neuro-musculoskeletal simulation of normal gait contributes to hemiparetic gait characteristics. J Neuroeng Rehabil 11:78CrossRefPubMedPubMedCentralGoogle Scholar
  35. Jethwa A, Mink J, Macarthur C et al (2010) Development of the hypertonia assessment tool (HAT): a discriminative tool for hypertonia in children. Dev Med Child Neurol 52:e83–e87CrossRefPubMedGoogle Scholar
  36. Kalsi G, Fry NR, Shortland AP (2016) Gastrocnemius muscle–tendon interaction during walking in typically-developing adults and children, and in children with spastic cerebral palsy. J Biomech 49: 3194–3199CrossRefPubMedGoogle Scholar
  37. Kamper DG, Schmit BD, Rymer WZ (2001) Effect of muscle biomechanics on the quantification of spasticity. Ann Biomed Eng 29:1122–1134CrossRefPubMedGoogle Scholar
  38. Klingels K, Demeyere I, Jaspers E et al (2012) Upper limb impairments and their impact on activity measures in children with unilateral cerebral palsy. Eur J Paediatr Neurol 16:475–484CrossRefPubMedGoogle Scholar
  39. Lamontagne A, Malouin F, Richards CL (2001) Locomotor-specific measure of spasticity of plantarflexor muscles after stroke. Arch Phys Med Rehabil 82:1696–1704CrossRefPubMedGoogle Scholar
  40. Lance J (1980) Symposium synopsis. In: Feldman RG, Young RR, Koella WPE (eds) Spasticity: disordered motor control. Yearbook medical, Chicago, pp 485–494Google Scholar
  41. Lindberg PG, Gäverth J, Islam M et al (2011) Validation of a new biomechanical model to measure muscle tone in spastic muscles. Neurorehabil Neural Repair 25:617–625CrossRefPubMedGoogle Scholar
  42. Malhotra S, Pandyan AD, Day CR et al (2009) Spasticity, an impairment that is poorly defined and poorly measured. Clin Rehabil 23:651–658CrossRefPubMedGoogle Scholar
  43. Mathewson MA, Chambers HG, Girard PJ et al (2014) Stiff muscle fibers in calf muscles of patients with cerebral palsy lead to high passive muscle stiffness. J Orthop Res 32:1667–1674CrossRefPubMedGoogle Scholar
  44. Meinders M, Price R, Lehmann JF, Questad KA (1996) The stretch reflex response in the normal and spastic ankle: effect of ankle position. Arch Phys Med Rehabil 77:487–492CrossRefPubMedGoogle Scholar
  45. Meyer GA, Lieber RL (2011) A nonlinear model of passive muscle viscosity. J Biomech Eng 133:91007–91001CrossRefPubMedCentralGoogle Scholar
  46. Morris SL, Williams G (2018) A historical review of the evolution of the Tardieu scale. Brain Inj 32:665–669CrossRefPubMedGoogle Scholar
  47. Musampa NK, Mathieu PA, Levin MF (2007) Relationship between stretch reflex thresholds and voluntary arm muscle activation in patients with spasticity. Exp Brain Res 181:579–593CrossRefPubMedGoogle Scholar
  48. Nielsen JB, Petersen NT, Crone C, Sinkjaer T (2005) Stretch reflex regulation in healthy subjects and patients with spasticity. Neuromodulation 9:49–57CrossRefGoogle Scholar
  49. Pandyan AD, Price CI, Rodgers H et al (2001) Biomechanical examination of a commonly used measure of spasticity. Clin Biomech (Bristol, Avon) 16:859–865CrossRefGoogle Scholar
  50. Pandyan A, Gregoric M, Barnes M et al (2005) Spasticity: clinical perceptions, neurological realities and meaningful measurement. Disabil Rehabil 27:2–6CrossRefPubMedGoogle Scholar
  51. Pandyan AD, Van Wijck FMJ, Stark S et al (2006) The construct validity of a spasticity measurement device for clinical practice: an alternative to the Ashworth scales. Disabil Rehabil 28:579–585CrossRefPubMedGoogle Scholar
  52. Pennati GV, Plantin J, Borg J, Lindberg PG (2016) Normative NeuroFlexor data for detection of spasticity after stroke: a cross-sectional study. J Neuroeng Rehabil 13:30CrossRefPubMedPubMedCentralGoogle Scholar
  53. Platz T, Eickhof C, Nuyens G, Vuadens P (2005) Clinical scales for the assessment of spasticity, associated phenomena, and function: a systematic review of the literature. Disabil Rehabil 27:7–18CrossRefPubMedGoogle Scholar
  54. Sanger TD, Delgado MR, Gaebler-Spira D et al (2003) Classification and definition of disorders causing hypertonia in childhood. Pediatrics 111:e89–e97CrossRefPubMedGoogle Scholar
  55. Schwartz MH, Rozumalski A, Trost JP (2008) The effect of walking speed on the gait of typically developing children. J Biomech 41:1639–1650CrossRefPubMedGoogle Scholar
  56. Sheean G (2008) Neurophysiology of spasticity. In: Barnes M, Johnson G (eds) Upper motor neurone syndrome and spasticity. Clinical management and neurophysiology, 2nd edn. Cambridge University Press, Cambridge, pp 9–54CrossRefGoogle Scholar
  57. Sinkjaer T, Magnussen I (1994) Passive, intrinsic and reflex-mediated stiffness in the ankle extensors of hemiparetic patients. Brain 117:355–363CrossRefPubMedGoogle Scholar
  58. Sloot LH, Van Den Noort JC, Van Der Krogt MM et al (2015a) Can treadmill perturbations evoke stretch reflexes in the calf muscles? PLoS One 10:e0144815CrossRefPubMedPubMedCentralGoogle Scholar
  59. Sloot LH, van der Krogt MM, de Gooijer-van de Groep KL et al (2015b) The validity and reliability of modelled neural and tissue properties of the ankle muscles in children with cerebral palsy. J Neuroeng Rehabil 42:7–15Google Scholar
  60. Sloot LH, Bar-On L, van der Krogt MM et al (2016) Motorized versus manual instrumented spasticity assessment in children with cerebral palsy. Dev Med Child Neurol 59:145–151CrossRefGoogle Scholar
  61. Tardieu G, Shentoub S, Delarue R (1954) A la recherche d’une technique de mesure de la spasticite imprime avec le periodique. Neurologique 91:143–144Google Scholar
  62. Van Campenhout A, Bar-On L, Aertbeliën E et al (2014) Can we unmask features of spasticity during gait in children with cerebral palsy by increasing their walking velocity? Gait Posture 39:953–957CrossRefPubMedGoogle Scholar
  63. van den Noort JC, Scholtes VA, Becher JG, Harlaar J (2010) Evaluation of the catch in spasticity assessment in children with cerebral palsy. Arch Phys Med Rehabil 91:615–623CrossRefPubMedGoogle Scholar
  64. van den Noort J, Bar-On L, Aertbeliën E et al (2017) European consensus on the concepts and measurement of the pathophysiological neuromuscular responses to passive muscle stretch. Eur J Neurol 24:981–e38CrossRefPubMedGoogle Scholar
  65. van der Krogt MM, Doorenbosch CAM, Becher JG, Harlaar J (2009) Walking speed modifies spasticity effects in gastrocnemius and soleus in cerebral palsy gait. Clin Biomech (Bristol, Avon) 24:422–428CrossRefGoogle Scholar
  66. van der Krogt MM, Doorenbosch CAM, Becher JG, Harlaar J (2010) Dynamic spasticity of plantar flexor muscles in cerebral palsy gait. J Rehabil Med 42:656–663CrossRefPubMedGoogle Scholar
  67. Voerman G, Gregorič M, Hermens H (2005) Neurophysiological methods for the assessment of spasticity: the Hoffmann reflex, the tendon reflex, and the stretch reflex. Disabil Rehabil 27:33–68CrossRefPubMedGoogle Scholar
  68. Willerslev-Olsen M, Lorentzen J, Sinkjaer T, Nielsen JB (2013) Passive muscle properties are altered in children with cerebral palsy before the age of 3 years and are difficult to distinguish clinically from spasticity. Dev Med Child Neurol 55:617–623CrossRefPubMedGoogle Scholar
  69. Willerslev-Olsen M, Andersen JB, Sinkjaer T, Nielsen JB (2014) Sensory feedback to ankle plantar flexors is not exaggerated during gait in spastic children with cerebral palsy. J Neurophysiol 111:746–754CrossRefPubMedGoogle Scholar
  70. Wood D, Burridge J, Van Wijck F et al (2005) Biomechanical approaches applied to the lower and upper limb for the measurement of spasticity: a systematic review of the literature. Disabil Rehabil 27:19–33CrossRefPubMedGoogle Scholar
  71. Wu Y-N, Ren Y, Goldsmith A et al (2010) Characterization of spasticity in cerebral palsy: dependence of catch angle on velocity. Dev Med Child Neurol 52:563–569CrossRefPubMedGoogle Scholar
  72. Zhao H, Wu Y-N, Hwang M et al (2011) Changes of calf muscle-tendon biomechanical properties induced by passive-stretching and active-movement training in children with cerebral palsy. J Appl Physiol 111:435–442CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Rehabilitation SciencesKU LeuvenLeuvenBelgium
  2. 2.Department of Rehabilitation Medicine, Laboratory for Clinical Movement Analysis, MOVE Research Institute AmsterdamVU University Medical CenterAmsterdamThe Netherlands
  3. 3.Department of Biomechanical EngineeringDelft University of TechnologyDelftThe Netherlands

Section editors and affiliations

  • Freeman Miller
    • 1
  1. 1.AI DuPont Hospital for ChildrenWilmingtonUSA

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