Validation of the Santa Casa Evaluation of Spasticity Scale
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Article
Arq Neuropsiquiatr 2010;68(1):56-61
Validation of the Santa Casa
Evaluation of Spasticity Scale
Karina Pavan1, Bruna Eriko Matsuda Marangoni1,
William Akira Lima Shimizu2 , Sheila Evangelista Mattos2,
Paula Pereira Ferrari2, Silvia Regina Gomes Martins2, Sergio Lianza3
Abstract
Spasticity is a clinical condition that has negative repercussions on function. A scale capable
of quantifying the severity and impact of an injury is fundamental to the rehabilitation
process. The objective of this study was to retest and validate the Santa Casa evaluation of
spasticity scale, a descriptive assessment of activities of daily living, transfers and locomotion.
We analyzed spasticity and functional status in 97 hemiparetic patients. With statistical
significance (pSanta Casa spasticity scale: validation
Arq Neuropsiquiatr 2010;68(1) Pavan et al.
mobile, making transfers, maintaining personal hygiene passive movement22. The muscle groups evaluated were
and locomoting20. The Ashworth scale, created by Bry- the elbow flexors and the knee extensors.
an Ashworth in 196421, and the modified Ashworth scale The FIM is an 18-item scale that quantifies incapac-
(MAS), devised by Bohannon and Smith in 1987, are sim- ity based on six functional conditions (self-care, sphinc-
ple instruments employed to quantify muscle resistance ter control, mobility, locomotion, communication and so-
to passive movement, the latter being more sensitive22,23. cial cognition), the score ranging from 18 to 126 points25.
One instrument used in evaluating and quantifying in- In the present study, this scale was used as a self-report
capacity is the Functional Independence Measure (FIM), questionnaire and could therefore be referred to as an
a scale created for use in the United States and validat- oral FIM.
ed for use in Brazil24,25. In 1990, Lianza et al. created the The SCESS is designed to quantify the impact that
Santa Casa scale26, an instrument designed to measure spasticity has on functional status in terms of the perfor-
the degree of spasticity and determine its repercussions mance of activities of daily living and transfers, as well as
on functional performance. Although easily applied, the locomotion, the score ranging from 1 to 5.
scale presented little sensitivity. The SCESS is a modified version of the Santa Casa
Spasticity and its consequences constitute a great scale. The alterations to the Santa Casa scale were made
challenge, for patients as well as for physical therapists. after discussions between the researchers and the prin-
Therefore, it is fundamental to have, at the outset of the cipal author of the scale. The resulting modified version
rehabilitation process, an instrument that quantifies the (the SCESS) was applied in the evaluation of the patients
degree of spasticity and its impact on function. In view of in the current sample.
this, we have modified the Santa Casa scale, using the new To determine the reliability of the SCESS, an initial
name Santa Casa evaluation of spasticity scale (SCESS) to evaluation (test) was followed by a second evaluation (re-
designate the modified version. test) one week later, both evaluations being performed by
The objective of the present study was to test and val- the same observer (rater) and inter-rater reliability being
idate the SCESS. determined. The MAS and the FIM were applied, togeth-
er with the SCESS, only in the initial evaluation. The MAS
METHOD and the FIM were used in order to draw correlations be-
The study sample consisted of 97 hemiparetic patients tween their efficiency and that of the scale put forth for
with spasticity treated in the Rehabilitation Sector of the validation (the SCESS). The SCESS was used in order to
Santa Casa de Misericórdia de São Paulo, Brazil. evaluate muscle tone and functional status based on the
The following inclusion criteria were applied: being performance of certain activities, which were divided into
at least 14 years of age; having received a clinical diag- two categories: upper limbs– including activities of daily
nosis related to acquired brain injury, such as CVA, ce- living (feeding oneself, dressing, donning clothing acces-
rebral tumour, craniocerebral trauma or multiple sclero- sories and maintaining personal hygiene) and practical ac-
sis; presenting proportionate or disproportionate topo- tivities (writing, operating household appliances and using
graphic distribution of hemiparetics; being treated in the home electronics); and lower limbs – the capacity to walk
Rehabilitation Sector of the Santa Casa Sisters of Mer- a certain distance with or without the aid of a parallel bar.
cy Hospital of São Paulo; and having given written in- Analysis of variance was observed in the association
formed consent. between the scale and aspects such as age, genre, type of
We excluded patients who had been submitted to se- injury and topography. Evaluation of reliability (internal
lective chemical neurolysis, such as botulinum toxin type consistency and stability) was tested by analyzing the co-
A or phenol, within the preceding six months, as well as efficient of reliability, with the model test-retest, and the
those who were wheelchair-bound, those treated with an- value of Cronbach alpha. The validation was established
tispasticity agents and those with severe cognitive deficits. by the linear correlation between the results for each area
The study design was approved by the Ethics in Research and results in the measures chosen as the gold standard
Committee of the Hospital. Subsequently (from April to for that area measured by Pearson correlation coefficient.
November of 2007), data were collected by two evalua- The statistical significance used was pSanta Casa spasticity scale: validation
Pavan et al. Arq Neuropsiquiatr 2010;68(1)
In terms of the ability to evaluate the upper limbs, the Table 1. Characteristics of the patients (n=97) by analysis of variance.
correlations between the SCESS and the MAS and the Age (years)
FIM are shown in Table 3. Mean±SD 52.10±15.362
Table 4 shows how the SCESS correlates with the Gender, n (%)
MAS and the FIM, in terms of the ability to evaluate the Male 59 (60.8)
lower limbs. Female 38 (39.2)
Data related to the test-retest (inter-rater) reliability Duration of injury (months)
Mean±SD 45.22±52.697
of the SCESS are shown in Table 5.
Clinical diagnosis, n (%)
Cerebrovascular accident 86 (88.7)
DISCUSSION
Other 11 (11.3)
Injury to the CNS that involves the cortico-reticulo-
Topographic diagnosis, n (%)
bulbo-spinal pathway results in altered muscle tone and
Left-hemisphere paresis 47 (48.5)
reduced activity of the musculoskeletal system, which has Right-hemisphere paresis 50 (51.5)
repercussions for functional capacity5,13-17. SD: standard deviation.
The leading cause of neurological dysfunction in the
adult population is CVA27, which results in a number of
incapacitating conditions. One such condition is spastic- Table 2. Associations between the variables and the scale by
ity, which should be appropriately evaluated in order im- analysis of variance.
prove the functional prognosis for CVA patients20. In the SCESS*
present study, CVA was the most prevalent etiology, be- Age pSanta Casa spasticity scale: validation
Arq Neuropsiquiatr 2010;68(1) Pavan et al.
Table 4. Interscale correlations related to the lower limbs Pearson’s correlation.
SCESS*
100% capable 75% capable 50% capable 25% capableSanta Casa spasticity scale: validation
Pavan et al. Arq Neuropsiquiatr 2010;68(1)
movement to fast muscle, unlike the SCESS which mea- ing items, thereby indicating the sensitivity of the scale.
sures the spastic condition of the functional condition. This is of great importance when the principal objective
Therefore, a low or no resistance to the muscle during is clinical follow-up evaluation, since it makes it possible
passive motion assessment with MAS may also mean a to determine the quality of the rehabilitation program, as
plegia thus a condition unfavorable to the SCESS features. well as that of the treatment facility itself25. In this case,
Certain aspects evaluated in the FIM, such as sphinc- factors such as age, gender, topography and time of inju-
ter control, communication and social cognition, were ry become important for monitoring and directing the
unaffected by the degree of spasticity, which, in our opin- process of rehabilitation.
ion, indicates that the SCESS presents low sensitivity. It is common for instruments designed to quanti-
The SCESS is a scale that is applied by observing the fy physical incapacity to be used in place of those that
performance of activities of daily living and locomotion. specifically evaluate muscle strength, muscle tone and
Therefore, it is more specific than is the FIM for activities range of movement in order to determine the degree to
that are affected by spasticity (Table 3). In Table 4, which which the upper and lower limbs are impaired, the for-
presents data on functional status of the lower limbs, the mer type of instrument often lacking sensitivity48. That
results cited above can be seen. is what prompted us to modify the original Santa Casa
There was a statistically significant correlation be- scale. Since they perform different functions and are ap-
tween the FIM and the SCESS, despite the different strat- plied in different skills, we evaluated the upper and lower
egies used in their application. This is likely due to the in- limbs separately, which is important to assessing the true
fluence that motor and musculoskeletal aspects have on status of the patients. The SCESS presented good sensi-
communication skills, social cognition and sphincter con- tivity for this purpose.
trol, although further studies should be conducted in or- There is no instrument designed to determine the
der to increase knowledge of these variables that are so influence that spasticity has of functional capacity, and
important to the rehabilitation process. there is therefore no gold standard with which to draw
Table 3 shows that there were some patients who pre- comparisons, a difficulty also encountered by Riberto et
sented total independence in the self-care domain of the al. in validating the FIM25. Therefore, we used scales that
FIM and yet were found to haveSanta Casa spasticity scale: validation
Arq Neuropsiquiatr 2010;68(1) Pavan et al.
11. Brin MF. Treatment of spasticity using local injections of botulinum toxin. 30. Carroll D. The disability in hemiplegia caused by cerebrovascular disease: se-
Skills Workshop Series Seattle: American Academy of Neurology, 1995. rial study of 98 cases. J Chron Dis 1962;13:179-188.
12. O’Brien CF, Gormley ME, Winkler PA, Yablon AS. Fisiologia y tratamiento de 31. Bourestom NC. Predictors of long-term recovery in cerebrovascular disease.
la espasticidad. Deerfield: Discovery International, 1996. Arch Phys Med Rehabil 1967;48:415-419.
13. Young RR. Physiologic and pharmacologic approaches on spasticity. In: 32. Adams GF, Merrett JD. Prognosis and survival in the aftermath of hemiple-
Scheimberg L, Shahani BT (Eds). Neurologic rehabilitation. Philadelphia: Neu- gia. Br Med J 1996;312:5222-5226.
rologic Clinics, WB Saunders 1987;5:529-539. 33. Kaste M, Waltimo O. Prognosis of patients with middle cerebral artery occlu-
14. Meythaler JM. Concept of spastic hypertonia. Phys Med Rehabil Clin N Am sion. Stroke 1976;7:482-485.
2001;12:725-735. 34. Anderson TP, Bourestom N, Greenberg FR, Hildyard VG. Predictive factors in
15. Hinderer S, Gupto S. Functional outcomes measures to asses interventions stroke rehabilitation. Arch Phys Med Rehabil 1974;55:545-553.
for spasticity. Arch Phys Med Rehabil 1996;77:1083-1089. 35. Andersen AL, Hanvik LJ, Brown JR. A statistical analysis of rehabilitation in
16. Mall V, Heinen F, Linder M, et al. Treatment of cerebral palsy with botulin- hemiplegia. Geriatrics 1950;5:24-218.
ium toxin A: functional benefit and reduction of disability. Pediatr Rehabil 36. Mills VM, DiGenio M. Functional differences in patients with left or right cere-
1997;1:235-1237. brovascular accidents. Phys Ther 1983;63:481-488.
17. Quagliato EMAB. Toxina botulínica A no tratamento da espasticidade em par- 37. Denes G, Semenza C, Stoppa E, Lis A. Unilateral spatial neglect and recovery
alisia cerebral: aspectos práticos. In: Souza AMC, Ferraretto I (eds). São Paulo: from hemiplegia: follow-up study. Brain 1982;105:543-552.
Memnon; 1998:38-46. 38. Cramer SC. Editorial comment – spasticity after stroke: what’s the catch?
18. Teive HG, Zonta M, Kumagai Y. Tratamento espasticidade. Arq Neuropsiquiatr Stroke 2004;35:139-140.
1998;56:852-858. 39. Nakhostin-Ansari N, Naghdi S, Moammeri H, Jalaie S. A comparative study
19. Bobath B. Adult hemiplegia: evaluation and treatment, 3rd Ed. London: Hei- on the inter-rater reliability of the Ashworth Scales in assessment of spastic-
nemann Medical, 1990. ity. Acta Med Iranica 2006;44:246-250.
20. Jongbloed L. Prediction of function after stroke: a clinical review. Stroke 40. Mehrholz J, Wagner K, Meibne D, Grundmann K, Zange C. Reliability of the
1986;17:765-776. Modified Tardieu scale and the modified Ashworth scale in adult patients
21. Ashworth B. Preliminary trial of carisprodol in multiple sclerosis. Practitioner with severe brain injury: a comparison study. Clin Rehabil 2005;19:751-759.
1964;192:540-543. 41. Haas BM, Bergstrom E, Jamous A, Bennie A. The interrater reliability of the
22. Bohannon RW, Smith MB. Interrater reliability of modified Ashworth scale of original and of the modified Ashworth scale for the assessment of spasticity
muscle spasticity. Phys Ther 1987;67:206-207. in patients with spinal cord injury. Spinal Cord 1996;34:560-564.
23. Brashear A, Zafonte R, Corcoran M, et al. Inter- and intrarater reliability of the 42. Pandyan AD, Price CI, Barnes MP, Johnson GR. A biomechanical investigation
Ashworth scale and the disability assessment scale in patients with upper- into the validity of the modified Ashworth Scale as a measure of elbow spas-
limb poststroke spasticity. Arch Phys Med Rehabil 2002;83:1349-1354. ticity. Clin Rehabil 2003;17:290-293.
24. Granger CV, Hamilton BB, Keith RA, Zielezny M, Sherwin FS. Advances in func- 43. Morris S. Ashworth and Tardieu scales: their clinical relevance for measuring
tional assessment for medical rehabilitation. Topics in Geriatric Rehabilitation spasticity in adult and paediatric neurological populations. Phys Ther Rev
1986;1:59-74. 2002;7:53-62.
25. Riberto M, Miyazaki MH, Jucá SSH, Sakamoto H, Pinto PPN, Battistella LR. Val- 44. Dombovy M L. Rehabilitation and the course of recovery after stroke. In: Whis-
idação Brasileira da Medida de Independência Funcional. Acta Fisiatr 2004; nant JP (Ed). Stroke: populations, cohorts and clinical trials. Oxford, England
11:72-76. Butterworth-Heinemann 1993:218-237.
26. Lianza S, Pavan K, Rosseto R, Mekaru D, Wojciechowski. Avaliação da Incapaci- 45. Newton, RA. Contemporary issues and theories of motor control: assessment
dade. In: Lianza S (ed). Medicina de Reabilitação. 3 ed. Rio de Janeiro: Guana- of moviment and balance, In: Umphred DA (Ed). Neurological rehabilitation,
bara-Koogan 2007:10-25. 4 ed. St Louis, Mosby-Year Book; 1995:81.
27. Arnadottir SA, Mercer VS. Effects of footwear on measurements of balance 46. Kusoffsky A, Wadell I, Nilsson BY. The relationship between sensory impair-
and gait in women between the ages of 65 and 93 Years. Phys Ther 2000; ment and motor recovery in patients with hemiplegia. Scand J Rehab Med
80:17-27. 1982;14:27-32.
28. Rankin J. Cerebral vascular accidents in patients over the age of 60 progno- 47. Fugl-Meyer AR. Post-stroke hemiplegia assessment of properties. Scand J Re-
sis. Scottish Med J 1957;2:200-215. hab Med 1981;7:85-93.
29. Bruell JH, Simon J. Development of objective predictors of recovery in hemi- 48. Duncan PW, Goldstein LB, Horner RD, et al. Similar motor recovery of upper
plegic patients. Arch Phys Med Rehabil 1960;41:564-569. and lower extremities after stroke. Stroke 1994;23:1181-1188.
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