Composite Spasticity Index (CSI)

Objective[edit | edit source]

Example of upper limb spasticity

The Composite Spasticity Index (CSI) is used for the quantification of spasticity in hemiparetic limbs.[1]

Intended Population[edit | edit source]

It is intended for use in patients with stroke[1], spinal cord injury and cerebral palsy[2].

Method of Use[edit | edit source]

The CSI has three components:

  1. Tendon jerk
  2. Resistance to passive flexion
  3. Clonus

1. Tendon jerk[edit | edit source]

The biceps, triceps, patellar, or Achilles tendon can be tested. Ensure sufficient force is used while tapping the tendon so as to elicit a 'maximal' reflex jerk and compare the result with the unaffected limb.[1]

0 No response
1 Normal response
2 Mildly hyperactive response
3 Moderately hyperactive response
4 Maximally hyperactive response

2. Resistance to passive stretch[edit | edit source]

The resistance felt during this test allows the examiner to evaluate the hyperactivity of the tonic stretch reflex. The stretch must be performed at moderate speed (>100 degrees per second).[1]

Note the presence of contractures and/or a clasp-knife response before examination[2].

0 No resistance (hypotonic)
2 Normal resistance
4 Mildly increased resistance
6 Moderately increased resistance
8 Maximally increased resistance

This item is doubly weighted due to its close relation to hypertonus.

3. Clonus[edit | edit source]

On rapid flexion of the wrist or ankle, the examiner notes the number of beats of clonus (if present).[1]

1 Clonus not elicited
2 1-3 beats of clonus elicited
3 3-10 beats of clonus elicited
4 Sustained clonus

Interpretation[edit | edit source]

The composite score (sum of scores from each component) is used to ascertain the severity of spasticity.[1]

0-9 Mild
10-12 Moderate
13-16 Severe

Evidence[edit | edit source]

Reliability[edit | edit source]

The CSI has excellent test-retest reliability (r = 0.87)[3].

Validity[edit | edit source]

The CSI is valid for the examination of spasticity in elbow flexors[4]. A meta analysis supports that CSI scores correlate with upper limb function[5]. For the lower limb, the CSI was found not to have concurrent validity when assessed against the Wisconsin Gait Scale or the Gait Abnormality Rating Scale for patients with hemiplegia[6].

Responsiveness[edit | edit source]

The responsiveness of the CSI has not been studied.

Links[edit | edit source]

A copy of the outcome measure can be found here.

References[edit | edit source]

  1. 1.0 1.1 1.2 1.3 1.4 1.5 Calota A, Levin MF. Tonic stretch reflex threshold as a measure of spasticity: implications for clinical practice. Top Stroke Rehabil. 2009 May-Jun;16(3):177-88.
  2. 2.0 2.1 Stroke Engine. Composite Spasticity Index. Available from:,patients%20with%20hemiparesis%20following%20stroke (Accessed 21/08/2022)
  3. Levin MF, Hui-Chan CW. Conventional and acupuncture-like transcutaneous electrical nerve stimulation excite similar afferent fibers. Arch Phys Med Rehabil. 1993 Jan;74(1):54-60.
  4. Levin MF, Feldman AG. The role of stretch reflex threshold regulation in normal and impaired motor control. Brain Res. 1994 Sep 19;657(1-2):23-30.
  5. Francis HP, Wade DT, Turner-Stokes L, Kingswell RS, Dott CS, Coxon EA. Does reducing spasticity translate into functional benefit? An exploratory meta-analysis. J Neurol Neurosurg Psychiatry. 2004 Nov;75(11):1547-51
  6. Lu X, Hu N, Deng S, Li J, Qi S, Bi S. The reliability, validity and correlation of two observational gait scales assessed by video tape for Chinese subjects with hemiplegia. J Phys Ther Sci. 2015 Dec;27(12):3717-21.