Reference Manual for the e@ ASIA. International Standards AMERIGAN SPINAL INJURY ASSOCIATION for Neurological Classification of Spinal Cord Injury Endorsed by the INTERNATIONAL MEDICAL SOCIETY OF PARAPLEGIA Supported by the Christopher Reeve Paralysis Foundationfeference Manual forthe Intemational Standards for Neurological Cassficaton of Spinal Cord Injury (Rev. 2003) Copyright © 2003 American Spinal Injury Association (ASIA). This package is intended for the express use of training professionals in the.use of the “International Standards for Neurological Classification of Spinal Cord Injury.” No part of this publication may be modified, reproduced, stored in a retrieval system, or transmitted in any form or by any means (electronic, photocopying, recording or otherwise) without prior written permission of ASIA. Alll rights reserved. Contact Lesley M. Hudson, M.A. at: lesley_hudson@shepherd.org, or by FAX at 404-355-1826 to obtain permission to reprint from this document. Published by the American Spinal Injury Association, Chicago, Illinois, 2003,Reference Mana forthe Intemational Standard for Neuologla Classification of Spinal Cord In (eu 2003) Table of Contents I Preface i Introduction pg Ralph J. Marino, M.D. Neurological Assessment: Sensory Examination ps7 Frederick M. Maynard, Jr., M.D.; revised by Michael Priebe, M.D. Neurological Assessment: Motor Examination pg 2 William H. Donovan, M.D. Scoring, Scaling and Classification pg 46 John F. Ditunno, Jr., M.D.; revised by William H. Donovan, M.D. Reliability and Validity of the International Standards of pg 61 Classification of Spinal Cord Injury Stephen P. Burns, M.D. Metric Properties of the International Standards for pg 68 Neurological Classification of Spinal Cord Injury, Implications for Research Use Darel Graves, Ph.D., Ralph J. Marino, M.D. Appendices ‘A. Sample Data Forms - Blank pg Al B. Sample Data Forms - Completed pg BI Video Iis entitled “The Neurological Exam for Patients With Spinal Cord Injury” TRT.2:30. This video contains the complete neurological examination on a normal subject and relates to Chapters Il and Il Video Il is entitled “The Neurological Exam for Patients With Spinal Cord Injury: An Interactive Tutorial” TRT:24.00. This video contains the examination of a tetraplegic and a paraplegic subject and relates to Chapter IV and Appendices Aand B.Reference Manval oth Intnatonal Standards fo NewologiclCasfiation of Spinal Cord injury (Rev. 2003) Preface Since the first edition of the Reference Manual was published in 1994, the Neurological Standards Committee of the American Spinal Injury Association has received numerous comments from clinicians and researchers. As a result of this input, the International Standards for the Classification of Spinal Cord Injury (ISCSCI) booklet, “the Standards”, has been revised, first in 1996, and again in 2000. Additionally, use of the Standards has provided new information on the reliability and validity of the component and aggregate measures contained therein. Finally, advances in measurement theory have resulted in newer methods to evaluate the properties of measurement scales, and more sophisticated procedures for using the scales in research. For all these reasons, a second edition of the Reference Manual was deemed necessary. This edition seeks to update the ‘examination and classification instructions to conform to the current ISCSCI booklet. It will also review the current status of the psychometric properties of the Standards. In the current edition of the Reference Manual, Chapter 1 has been updated to review the key modifications in the Standards since the first edition of this manual. The sensory and motor examinations (Chapters 2 and 3) have not changed, although minor modifications have been made in the text and figures in order to enhance clarity. The section on “Scoring, Scaling and Classification” has had more extensive changes to reflect those made in the ISCSCI over the years. The chapter on “Reliability” has been completely rewritten, and the chapter on “Research Usage” has been replaced by one on the metric properties of the Standards. As was noted in the ISCSCI-2000 booklet, the Functional Independence Measure (FIM) has been dropped from the Standards. Therefore, the chapter describing the FIM has been removed. Finally, references have been included at the end of each chapter, eliminating the need for a bibliography chapter in this edition of the Reference Manual. We are indebted to the original Committee that produced the first edition of the Reference Manual and the accompanying videotapes. We wish to thank all those who have sent us their questions, comments, and suggestions. We hope that this manual will assist those who use the International Standards to achieve consistent assessments and uniform classifications of spinal cord injury, which in turn will advance our knowledge and enhance our ability to care for individuals who sustain spinal cord injuries.Aeference Manual forth International Standards fr Neurological Casication of Spinal Cord Injury (Rex 2003) I Standards Committee of the American Spinal Injury Association Ralph J. Marino, M.D., Chairman and Editor Tarcisio Barros, M.D. Fin Biering-Sorensen, M.D. Stephen P. Burns, M.D. William Donovan, M.D. Daniel Graves, Ph.D. Michael Haak, M.D. Lesley Hudson, M.A. Michael Priebe, M.D. ‘March, 2003 Original Committee Members and Contributors: John F. Ditunno, Jt, M-D., Chairman and Editor Wise Young, M.D., Ph.D., Co-Chairman William H. Donovan, M.D., Editor Frederick M. Maynard, Jr., M.D., Editor Burton H. Lane, M.Ed., Media Consultant Byron Hamilton, M.D., Consultant Inder Perkash, M-D., Consultant Margaret Brown, Ph.D., Managing Editor Lynn Phillips Bryant, Scientific Editor Advisory Committee: Michael B. Bracken, Ph.D. Graham Creasey, M.D. Thomas B. Ducker, M.D. Samuel L. Stover, M.D. Charles H. Tator, MD. Robert L. Waters, M.D. Jack E. Wilberger, MD. Reviewers: Michelle Cohen, Ph.D. Gerald J. Herbison, M.D. Barbara E. Wolff, M.Ed.Reference Manual for the Intemational Standard fo Neurological Classification of Spinal Cod nu [Rex 2003) Chapter I Introduction A. Overview This manual and companion videotapes provide support for users of ISCSCI. The primary goal for ISCSCI is to establish a minimal clinical data base that can be reliably obtained by all clinicians and researchers through performance of a practical examination in a variety of settings, from emergency care through rehabilitation and follow-up care. The purpose of these materials is to provide training for clinicians and investigators working in spinal cord injury in order to assure a high degree of accuracy and reliability in the application of ISCSCI in neurological examinations, and in subsequent scoring, scaling and classification. In addition, the manual offers the rationale for specific approaches adopted within ISCSCI and for the methods of examination selected. The learner is expected to comprehend thoroughly the definitions in the ISCSCI booklet and then use the manual and videotapes to learn the recommended standards for examining patients, Achieving a high level of skill in using ISCSCT in patient examinations is based on practice and on reliability testing of examiners in clinical settings. However, to use data obtained in the examination for scoring, scaling and classification requires a greater depth of understanding of the rationale, particularly if applied to investigative work. This manual is organized to support the learning of basic examination techniques, as well as application to scoring, scaling and classification. Chapter I provides background to the creation of ISCSCI and highlights the points at which revisions have been made. Chapters II and III describe and illustrate in great detail the sensory and motor components of the neurological examination of patients with SCI. Chapter IV discusses the scoring of data and classifying the injury; it provides clinical examples illustrating typical and atypical cases. Chapter V summarizes research regarding the reliability and the validity of the standard neurological assessment. Chapter VI reviews other psychometric properties of the scales in the Standards, particularly the motor score, and the implications concerning use of the data in research. B, Background For more than a quarter of a century, it has been clear that the adoption of a standard approach to assessment and classification of the severity of spinal cord injury is needed (Michaelis, 1969). Severity of injury is primarily Chapter! Invoduction 1Reference Manual forthe Intemational tanda for Neurological Clsifcatn of Spal Crd Inj ie. 2003) 2 Chapter! Invoducion reflected in the extent of paralysis and loss of sensation, as well as in the reduced ability to perform activities of daily life. Motor and sensory losses are quantified in measures of impairment, while losses in daily life functioning are assessed using measures of disability. Together, these measures - of impairment and disability - can be used to predict clinical ‘outcomes and to monitor gains following spinal cord injury. The importance of clinical outcome measures has been emphasized in justifying efficient hospital care and in multi-center clinical trials (Walker, 1991). Aminimum data set that is valid, precise and reliable is essential to multi- center clinical trials. Such measures have been used in multi-center studies, which include prognosis of motor recovery in the upper extremities of tetraplegic subjects, based on increase of muscle strength and motor levels (Ditunno et al., 1992); and the effects of drug intervention in SCI, based on improvement in motor and sensory scores (Bracken, 1990; 1991) The momentum necessary for the development of ISCSCI has come from several sources. Under the leadership of Samuel Stover, M.D. in 1982 and the National Database for the Model SCI Centers, ASIA adopted its first standards. The impetus at that time came from the need to develop greater precision in the definition of neurological levels and the extent of incomplete injury, and to achieve more consistent and reliable data among the centers participating in the National Database. This led to the adoption of key muscles and key sensory points to be tested in the neurological assessment. Because of continued discrepancies amongst clinicians and investigators, William H. Donovan, M.D. in 1989-90 led an ASIA committee that further refined the precision in the determination of levels, further defined key muscles and sensory points, and clarified the zone of partial preservation and Frankel grades. ISCSCI emerged primarily from needs highlighted by the publication of the results of the multi-center (NASCIS) trials of methylprednisolone (Bracken et al,, 1990, 1991), which showed lack of agreement between muscles used for motor scores by the National Acute Spinal Cord Injury Study (NASCIS) centers, the SCI National Database centers and the existing ASIA standards. ‘The committee members who worked on ISCSCI-92 brought a variety of viewpoints into the deliberations. They have had extensive clinical experience in the classification of SCI, have led in the development of assessment and classification methods, and have applied such methods to multi-center trials. Members represent a variety of disciplines: physical medicine and rehabilitation, neurological surgery, orthopedic surgery, and epidemiology; and organizations: American Academy of OrthopedicReference Manual forthe intemational Standards for NewrloaiclCasiication of Spinal Crd nur (Rev. 2003) Surgery (AAOS), American Academy of Physical Medicine and Rehabilitation (AAPM&R), American Association of Neurological Surgeons (AANS), American Association for Surgery and Trauma (AAST), American College of Epidemiology, American Congress of Rehabilitation Medicine (ACRM), American Congress of Surgery (ACS), American Spinal Injury Association (ASIA), Congress of Neurological Surgery (CNS), International Spinal Cord Society (ISCoS) [formerly International Medical Society of Paraplegia (IMSOP)], Joint Section on Neurotrauma and Critical Care of AANS/CNS, and The Neurotrauma Society. The face validity of ISCSCI is based on a process that included lengthy discussion within the committee of definitions and procedures to develop consensus in several face-to-face meetings and phone conferences. The discussion was based on both clinical experience and research results. Input to the committee was broadened beyond the organizations and disciplines directly represented by its members through extensive organizational contacts and presentations of the standards at a wide variety of meetings and through journal publications. These efforts tapped into numerous health professional networks in addition to those of physicians, including physical therapists, occupational therapists, nurses and others. All written comments were circulated to members of the committee and are responded to in several of the chapters of this manual. ‘The manual and videotapes were developed through a similar process of ‘committee meetings and telephone conferences. A training consultant from ‘Thomas Jefferson University Hospital, Mr. Burton Lane, assisted the committee and scripted the videotapes with input from and review by the committee members. The draft video of the neurological examination was shown for comment at national meetings (American Academy of Neurology, 1993; American Spinal Injury Association, 1993) and international meetings (IMSOP, Ghent, 1993; Japanese PM&R Society, 1993; Second International Neurotrauma Society, Glasgow, 1993). Editorials and manuscripts were published in major journals, and multiple presentations by committee members were made before specialty societies, Through all of these means, the committee sought validation of ISCSCI and of the techniques /rationale incorporated into the manual and videotapes. innovations ISCSCI-92 incorporated several major additions and modifications to previous ASIA standards: Chapter! induction 3foference Manual forthe Intemational Standards for Neurological Clsifation of Spinal Crd Injury (Rex. 2003) ‘+ Assessment of disability had not previously been included as part of the standard assessment. The focus originally had been upon measuring impairment alone, without also assessing the impact of SCI on the individual's daily life functioning. ISCSCI-92 recommended the use of the Functional Independence Measure (FIM) as a complement to the motor and sensory assessment of neurological status. This recommendation was withdrawn with the 2000 revision of the ISCSCI. ‘* The definition of complete /incomplete injury was modified. This innovation is further discussed in Chapter IV, Section D. * Modifications were made in some of the key muscles and key sensory points. ‘+ The scoring of the sensory examination to produce a sensory score was new to ISCSCI-92. * Scores reflecting right and left sensory and motor levels were separately derived. ‘+ The definition of the zone of partial preservation was modified to reflect preservation of some function over more than three segments ‘+ The modified Frankel scale of the previous standards was modified again, and is now referred to as the ASIA Impairment Scale. ‘+ The visual schemas used in the prior booklet to illustrate the clinical syndromes were eliminated, as the committee felt that several studies raised questions about their validity. + To maintain continuity and compatibility with other databases, e.g., NASCIS, optional testing of a few muscles was added to ISCSCI-92. * The testing of position sense and deep pain were added as optional tests. In addition to these changes in the standards, a key innovation in the "how" of the neurological assessment has been incorporated into this manual and supporting videotapes. Most significantly, the position for testing motor function recommended here and in the videotapes differs from what is recommended in standard texts (e.g,, Daniels and Worthingham, 1972). Because ISCSCI is applied to patients with spinal cord injuries who typically must be tested in the supine position, especially in the initial period following injury (necessary for proper immobilization of the spine), 4 Chapter! Invoduetionfoference Manual forthe Intemational Standards fo Newoogial Chssication of Spinal Cord injury Re. 2003) this manual recommends that all testing for motor function be conducted with the patient in the supine position. For example, this manual recommends that the plantar flexors be tested in the supine position, even for grades 3-5, which is not the position Daniels and Worthingham. recommend for testing this muscle for its functional correlation. However, the committee chose an approach that would best (ie., most reliably and validly) reflect change in the neurological status of the patient ~ the supine position allows consistent application over time, from the acute through follow-up points of assessment. Superior methods may be developed over time based on research, but the recommendations herein are based on consensus, given our current knowledge. This innovation is further discussed in Chapter II. D. Revisions of ISCSCI The ISCSCI-96 booklet contained the following changes: * Clarification that where myotomes are not clinically testable, ie. C1-C4, T2-L1, and $2-S5, the motor level is presumed to be the same as the sensory level. * Change in instructions for manual muscle test scoring and motor level determination. A muscle is graded normal (5) if it is felt to be fully innervated, even if inhibiting factors such as pain or hypertonicity limit full effort by the patient. The motor level is then the lowest key muscle that has a grade of at least 3, providing the key muscles above that level are judged to be normal. (5) (formerly 4 ot 5). ‘The ISCSCI-2000 booklet clarified a number of items: * Motor incomplete: prior definitions of motor incomplete injuries (AIS C of D) were ambiguous. The current definition is-"To be motor incomplete an individual must be incomplete (sacral sparing) and have either voluntary anal sphincter contraction or motor function preserved more than three levels below the motor level.” * Zone of Partial Preservation (ZPP): revised instructions to indicate that the caudal extent of partially innervated segments should be recorded rather than the number of segments. * Functional Independence Measure (FIM™): the FIM™ was removed from the Standards because the committee felt that there was insufficient evidence to endorse this instrument over other functional assessment instruments for SCL Chapter! nvoduction 5Aeference Manual othe Intemational Standards for Neurological lasiication of Spinal Cord I ev. 2003) Reference Manual, 2nd Edition In the second edition of the reference manual, the committee: * Updated the manual to reflect changes made to the Standards since the first edition was published in 1994. * Removed the clinical syndromes from chapter 4 and the Neurological Examination form. While the Committee recognizes that the syndromes are often useful clinically, the descriptions are imprecise and overlap, so that patients often have characteristics of more than one syndrome. The clinical syndromes are not required for classification, and had been included previously because of widespread clinical use. ‘+ Added fields to the neurological examination form for 1) Patient name/ID, 2) Date of examination, 3) Examiner. Added a block for comments by the examiner. This is useful to explain scores of NT (not testable) or other unusual findings that would influence classification. E. References Bracken MB, Shepard MJ, Collins WE, Holford TR et al. (1990) A Randomized Controlled Trial of Methylprednisolone or Naloxone in the ‘Treatment of Acute Spinal Cord Injury. N Engl J Med, 332:1405-1411. Bracken MB. (1991) Treatment of Acute Spinal Cord Injury With Methylprednisolone: Results of a Multicenter, Randomized Clinical Trial. J Neurotrauma, 8 Suppl 1:547-52. Daniels L, & Worthingham C. (1972) Muscle Testing: Techniques of Manual Examination, 3rd ed. Philadelphia: Saunders. Ditunno JF, Stover SL, Freed MM, Ahn JH. (1992) Motor Recovery of the Upper Extremities in Traumatic Quadriplegia: A Multicenter Study. Arch Phys Med Rehabil, 73:431-436. Michaelis LS. (1969) International Inquiry on Neurological Terminology and Prognosis in Paraplegia and Tetraplegia. Paraplegia, 7: 1-5. Walker MD. (1991) Acute Spinal Cord Injury. N Engl J Med; 324:1885-88. 6 Chapter! invodutionReference Manual forthe Intemational Standards for Hewologial Caslcaton of pina Crd injury ev. 2003). Chapter II Neurological Assessmen: The Sensory Examination A Introduction In ISCSCI, the sensory examination is sub-divided into required and optional components. The required elements are those necessary to obtain sensory levels and sensory scores, and to determine complete /incomplete degree of neurologic impairment. The optional elements of the exam do not contribute to scoring, scaling and classification. However, they are recommended as part of the comprehensive evaluation of patients with spinal cord injury for purposes of clinical management. ‘Two sensory modalities, sharp /dull (pin prick) discrimination and light touch appreciation, were chosen for required testing because they reflect transmission of information through different tracts of the spinal cord, and they can be readily tested in all segmental cutaneous areas (dermatomes) of the body. In addition, testing for appreciation of deep pressure in the anal atea is required for final confirmation of a complete injury classification among patients with absent sharp /dull discrimination and absent light touch appreciation in the perirectal area (S4-5 dermatomes), For purposes of uniformity among examiners (inter-rater reliability), testing of each sensory modality is performed using a standard method in specified body locations, known as key sensory points. Results of testing are recorded using standardized definitions for grades (or levels) of appreciation/ discrimination. These key sensory points, standard methods and definitions of grades used in the required testing are discussed in the next section. Testing of joint movement appreciation and appreciation of deep pressure elsewhere in the body are deemed optional. The committee believes they are clinically useful in comprehensive management for prediction of fanctional extremity use, in the case of joint movement appreciation; and possibly for prediction of neurological recovery, in the case of deep pressure appreciation. However, the committee recognizes the need for prospective study to validate and clarify the hypothesized clinical predictive utility of these tests. Optional testing is also discussed below. The final section of this chapter discusses several important questions raised during field review of ISCSCI and of drafts of this manual. They are included, among other reasons, to emphasize the committee's awareness that ISCSCI has important limitations and that several areas need further research. Chapter Neurological Assesment The Sensory Examination 7Reference Manu forthe Intemational Standards for Newoogical lassfiation of Spinal Cod ur Re. 2003) Required Testing 1. Key Sensory Points ‘Twenty-eight (28) specific skin locations, referred to as key sensory points, are recommended in the testing of sharp /dull discrimination and light touch appreciation (see Sections 2 and 3 below). The committee's rationale for selecting these locations is twofold. First, each respective key sensory point represents a dermatomal area found in a majority of dermatomal body maps in the most widely recognized anatomy references. Secondly, each sensory point could readily and reliably be located in relation to bony anatomical landmarks to improve inter-rater reliability. The dermatomal map adopted in ISCSCI was adapted from Austin (1972), based upon the committee's consensus that it most accurately reflected each member's clinical experience with spinal cord injured patients. When a key sensory point is unavailable for testing because of casting, laceration, dressings, ot amputation, any spot within the recommended dermatome (see Figure 1 in the ISCSCI booklet) may be used as an alternate testing location. It is recommended that a notation be made when an alternate location is used. A recommended practical sequence to follow for the sensory ‘examination is to begin with sharp /dull discrimination testing in dermatomes where there is suspected impairment and to proceed in a cephalad direction until a patient reports a change toward normal (sharpness). This technique allows an examiner to quickly locate the body region in which the level of neurological impairment will be found. The examiner will then need to proceed with careful testing for sharp/dull discrimination grading and light touch appreciation at the specified key sensory points for dermatomes in the impaired region. Asking patients to compare their appreciation of sensory modalities on the corresponding right and left key sensory points may also be useful for grading specific dermatomes. Figures 1 through 10 illustrate the locations of key sensory points, and captions describe the locations verbally, including important relationships to anatomical landmarks. 8 Chapler il Newoegcal Assessment: The Sensry ExaminationReference Manual forthe lernatinal Standards ae Neurological Clacton of Spinal Cord Inu (Rev. 2003) 2. Light Touch Appreciation a. Method The recommended testing instrument is a tapered wisp of cotton, pulled. off a cotton ball or off a cotton-tipped applicator stick. The cotton is applied by lightly and briefly stroking it across the skin, moving over a distance not to exceed 1 cm. Substitute instruments ~ a finger tip, piece of tissue or dull end of a safety pin ~- may be used, but should be noted accordingly. After briefly explaining the procedure to the patient, the examiner touches the patient’s face on the cheek with the cotton wisp. Patients are asked to state when they are touched and where, to determine that the patient is able to follow directions and to appreciate light touch in an area of the body with normal sensation. Testing is done with the patient's eyes closed or vision blocked. The patient is asked to remember the feeling of being touched by cotton on the cheek as a normal frame of reference. In examining the patient, each key sensory point (see Section 1, above) is tested in turn. At each key point, the patient is asked to state when they experience being touched. For those who do appreciate light touch at the tested location, they are asked to state whether the feeling is the same as on the face. They are touched again on the face, as needed, to remind them of the normal light touch feeling. After each key sensory point is tested, a grade is recorded, applying the definitions below. b. Grading 0 Absent: Patient does not correctly and reliably report being touched. 1 Impaired: Patient correctly reports being touched, but describes the feeling as different than on the face (greater, lesser or otherwise different). 2 Normal: Patient correctly reports being touched, and describes the feeling as the same as on the face. NT (Not testable): Patient is unable to reliably appreciate light touch when tested on the face. or Chapter II Neurological Assesment: The Sensory Eainaton 9Reference Manual fr the Intemational Standards fr Neurological Casfication of Spinal Crd nur (Re. 2003) The key sensory point (or alternate point) is unavailable for testing because of casting, lacerations, burns, dressings or amputation. 3. Sharp/Dull Discrimination a. Method Astandard safety pin is used. The pin is to be opened and straightened out. The pointed end is used to test for sharpness and the rounded end for dullness. After briefly explaining the procedure to the patient, the examiner ‘touches the patient's face on the cheek, alternating the blunt and pointed ends of the pin, to determine that the patient is able to follow directions and to distinguish between sharpness /dullness in an area of the body with normal sensation. Testing is done with the patient’s eyes closed or vision blocked. In examining the patient, each key sensory point (see Section 1, above) is tested in turn. At each key sensory point, the blunt and pointed ends of the pin are alternately placed on the skin. Whether using the dull or pointed end, light pressure is applied without moving the pin after point of contact. The patient is asked to state when they have been touched and whether the feeling is sharp or dull. After repeated touching with alternate ends of the pin, the examiner must decide if the patient can correctly discriminate between sharp and dull with reliability at that location. It is important to alternate between sharp and dull in an irregular, non-predictable pattern in order to minimize the potential for accurate guessing. In questionable cases, 8 out of 10 correct answers is suggested as a standard for accuracy that reduces the probability of correct guessing to less than .05. If it is concluded that a patient can reliably discriminate at a location, the examiner again touches the sharp end of the pin on the face. The patient is asked whether the sharpness felt in the two locations (the face and the tested location) is essentially the same or is different. After each key sensory point is tested, a grade is recorded, applying the definitions below. b. Grading 0 Absent: Patient has no feeling of being touched with either the sharp or dull ends of the pin. 10 Chapter Neurolagical Assessment: The Sensory ExaminationAelerence Manual forthe Intemational Standards for Neurological Clsifcaton of pial Cord inj Re. 2003) or Patient does not reliably distinguish between the sharp and dull ends of the pin. 1 _ Impaired: Patient reliably distinguishes between the sharp and dull ends of the pin, but states that the intensity of sharpness is different (greater or lesser) in the location being tested, compared to the feeling of sharpness on his/her face. 2. Normal: Patient reliably distinguishes between the sharp and dull ends of the pin and states that the intensity is the same in the tested location as on the face. NT (Not testable): Patient is unable to reliably distinguish sharp /dull ends of the pin when tested on the face. or The key sensory point (or alternate points) is unavailable for testing because of casting, lacerations, burns, dressings or amputation. 4, Deep Anal Sensation The presence of deep anal sensation can occasionally be the only evidence of a clinically incomplete SCI. Therefore, careful testing for deep anal sensation is required when patients have absent sharp /dull discrimination and light touch appreciation in the perirectal area (the key sensory points for the 4-5 dermatome). The recommended method of testing is by doing a digital examination. The patient is asked to describe any sensory awareness, inchiding feelings of touch and /or pressure, when firm pressure with the digit is placed on the rectal walls. Deep anal sensation is recorded as present or absent (yes or no). figure 1. C2. One cm lateral to the occipital protuberance at the base of the skull. An alternate key point is atleast 3m. behind the ear. C3. See figure 5. C4 Over the acromio-clavicular joint. Chapter Neurological Assessment: The Sensory Examination 11{ference Manual othe Intemational Standards for NerlogicalCasfation of Spinal Cord inj (Re: 2003) figure 2. C5. On the lateral (radial) side of the antecubital fossa just proximsal to the elbow. figure 3. C6. On the dorsal surface of the proximal phalanx of the thumb. C7 On the dorsal surface of the proximal phalanx of the middle finger. C8_On the dorsal surface of the proximal phalanx of the little finger. 12. Chapter Neurological Assessment: The Senso ExaminationReference Manual forthe Intemational Stand for Neurological Classfcaton of Spina ord nur ev. 2003) figure 4. Tl On the medial (ulnar) side of the antecubital fossa, just proximal to the medial epicondyle of the humerus. T2_ At the apex of the axilla TS At the midclavicular line and the third intercostal space, found by palpating the anterior chest to locate the third rib and the corresponding third intercostal space below it. T4 At the midclavicular line and the fourth intercostal space, located at the level of the nipples. Clinical Tips: When sensory loss begins at, or just above, the nipples, careful sensory testing at key points on the upper limbs is essential. figure 5. C3. At the apex of the supra-clavicular fossa. TS At the midclavicular line and the fifth intercostal space, located midway between the level of the nipples and the level of the xiphisternum. 16 At the midclavicular line, located at the level of the xiphisternum. T7 At the midclavicular line, located at one quarter the distance between the level of the xiphisternum and the level of the umbilicus. TS At the midclavicular line, located at one half the distance between the level of the xiphisternum and the level of the umbilicus. 9 At the midclavicular line, located at three quarters of the distance between the level of the xiphisternum ‘and the level of the umbilicus. T10 At the midclavicular line, located at the level of the umbilicus. are Chapter I Neurological Assessment: The Sensor Examination 13Reference Manual fr te Intemational Standards fr Neurological Clasication of pina Cod iar (Re. 2003) figure 6. THI At the midclavicular line, midway between the level of the umbilicus and the inguinal ligament. T12 At the midclavicular line, over the midpoint of the inguinal ligament. Li Midway between the key sensory points for T12 and L2. 12 On the anterior-medial thigh, midway on a line between the midpoint of the inguinal ligament and the medial {femoral condyle above the knee. Toe Tle Te lie e710 em em eu ew figure 7. BX 13. Af the medial femoral condyle above _|\° the knee, 14 Chapter Newragicl Assessment: The Sensory ExaminationReference Manval forth intematonal Standards for Neurological asieation of Spinal Crd Ir (Rew. 2003) figure 8. 14 Over the medial malleolus. L5 On the dorsum of the foot at the third metatarsal phalangeal joint. figure 9. S1_ On the lateral side of the heel. S2__ In the popliteal fossa of the knee at the midpoint. Chapter il Neurological Assessment: The Sensory Examination 15Reference Manual forthe Intemational Standards fr Neurological Casieation of Spinal Con nur (ev. 2003) figure 10. $3 Over the ischial tuberosity. S4/5 In the perianal area, less than one om. lateral to the mucocutaneous junction. C. Optional Sensory Testing 1. Joint Movement Appreciation 4, Rationale for Testing Impaired appreciation of joint movement is thought by SCI clinicians to be correlated with limited functional use of the corresponding body parts, across patients with similar muscular strength for moving the joint. Nevertheless, available empirical data are inadequate to substantiate this impression. The committee recognizes the need for research to validate the clinical utility of this test. It is not a required component, as joint movement appreciation has not been observed to be present in the absence of any light touch appreciation or sharp /dull discrimination; thus, testing of joint movement appreciation is not necessary for classification of neurological level or degree of impairment. 16 Chapter Neurological Assessment: The Sensory ExaminationReference Manual for the international standards or Newrogial Clasification of Spinal Cord jury Ge. 2003) b. Method Appreciation of movement of key body joints is tested by supporting the proximal body part and then holding the body part being moved on the medial and lateral sides while the joint is moved in alternate directions. Joint movement should begin from the mid-position of a joint’s range of motion. Testing is done with the patient's eyes closed or vision blocked. ‘As each joint is moved, the patient is asked to state when movement is. perceived and the direction of the movement (up/down, towards/away). At each location, the examiner should repeat the joint movement several times in each direction, covering a different degree of the joint’s range of motion with each repetition. © Grading 0 Absent: Patient is unable to correctly report joint movement; (6 of 10 or more) on large movements of the joint. 1 Impaired: Patient consistently is correct (8 of 10 answers are correct) only on large movements of the joint; a majority of the answers are incorrect (8 of 10, or more) on small movements of the joint (10 degrees or less) 2 Normal: Patient consistently is correct (8 of 10 answers are correct) ‘on both small (10 degrees or less) and large movements of joint. NI (Not Testable): Patient is unable to understand and follow directions or The joint is unavailable for testing because of casting, lacerations, bums, dressings or amputation. d. Testing Locations The following joints are recommended for standard testing: * Wrist © Thumb, at the interphalangeal joint * Little finger, at the proximal interphalangeal joint © Knee © Ankle © Great toe, at the interphalangeal joint Chapter Neurological Assessment: The Sensory Examination 17feference Manual for the International Standards for NewlogicalCasfication of Spinal Cord injury (Re. 203) 2. Deep Pressure Appreciation a. Rationale for Testing The presence of deep pressure sensation in the distal limbs of an acute SCI patient with otherwise complete sensory loss in these limbs has been observed by experienced clinicians often to precede or herald recovery of sensory and/or motor functioning. Since some sensory appreciation from a deep pressure stimulus is always reported by patients with impaired or normal light touch appreciation and /or sharp/dull discrimination, testing for deep pressure appreciation is only recommended for patients in whom the sensory modalities are graded 0 (absent). b. Method Deep pressure sensation is tested using the examiner’s index finger. The examiner’s thumb can be used when testing a distal phalanx. Very firm pressure is placed on the skin for 3 - 5 seconds at each location tested. A firm surface is required on the opposing side of the body location being tested. ‘The examiner first explains the procedure and applies pressure on the patient's chin as a reference feeling for deep pressure, and to establish that the patient can reliably participate in the examination. Testing is done with the patient's eyes closed or vision blocked. The patient is given pressure over each point tested and is asked to indicate when pressure is felt. The patient also is asked to describe any feelings when pressure is not being applied in order to assess the reliability of the patient's reports. Grading 0 Absent: Patient experiences no feeling when pressure is applied. 1 Present: Patient reliably reports some feeling when pressure is applied. d, Testing Locations The following points are recommended for standard testing: ‘© Wrist, on the styloid prominence of the radius * Thumb, on the dorsal distal phalanx (nailbed) © Little finger, on the dorsal distal phalanx (nailbed) * Ankle, on the medial malleolus ‘+ Great toe, on the dorsal distal phalanx (nailbed) * Small toe, on the dorsal distal phalanx (nailbed) 18 Chapter Neurological Assessment The Sensory EmnatonReference Manual forthe iteration Standards fr Newologcal Clasiication of Spinal Crd injury (Re. 2003) Questions and Answers * How do you score a patient with absent sensation in the TI and T2 dermatomes and some sensation at the key sensory point for T3? ‘The T3 dermatome is perhaps the most difficult to isolate. Considerable individual variation exists in the descent of the supraclavicular nerves down the anterior-superior chest region. These nerves originate from the C4 nerve roots and traverse the cervical plexus. It is recommended that the T3 dermatome be scored as absent in the case described here if there is no sensation at the level of the nipples. It is also recommended that the skin be pulled upward over the chest, and that the anterior ribs be palpated in order to be certain of the anatomical location of the key sensory point, which is tested on the overlying skin. Verification of the location of the T3 and T4 intercostal spaces by palpation rather than by referencing the nipple lines only is often’ necessary in obese individuals or in women with large breasts. ‘© Why are two-point discrimination and other objective tests of various sensibilities not recommended for routine testing? The primary goal for ISCSCI is to establish a minimal clinical data base that can be reliably obtained by all clinicians and researchers through performance of a practical examination in a variety of settings, from ‘emergency care through rehabilitation and follow-up care. The ‘committee is aware of and strongly endorses the International Classification for the Tetraplegic Upper Limb, which is based on the work of Drs. Moberg, Ejeskar and Dahloff, and has been endorsed by several international societies and conferences on the surgical rehabilitation of the upper limb in the patient with tetraplegia. These methods of sensory testing are essential for the clinical evaluation of a tetraplegic hand prior to reconstructive surgery, and are likely to be superior to the sensory methods of ISCSCI for prognostication of upper limb function, The committee also recognizes many newer objective methods for quantifying sensibilities of the hand, such as the Semmes-Weinstein monofilament test. However, these methods cannot be readily and routinely employed in the clinical arena and consequently have not been recommended in ISCSCI. Chapter Neurological Assessment: The Sensory Examination 19feference Manual forthe Intemational Standards fr Neurological lslicaton of Spinal Crd inary Rew. 2003) * Why is joint movement appreciation, rather than joint position sensation, recommended? The committee is of the opinion that these sensibilities probably have equal value for the clinician desiring simple information on intactness of proprioceptive sensation. Testing of joint movement appreciation probably is easier to perform uniformly and it is easier to obtain cooperation of patients in a stressful situation (ie., after acute SCI). Joint movement appreciation probably reflects information from cutaneous and muscular receptors (e.g., muscle spindles), with little contribution from joint afferents that probably provide joint position sensation. However, information about joint position and joint movement is probably transmitted to the brain in the same tracts (or region) of the spinal cord. ‘+ _ In testing for pinprick sensation with the sharp end of the pin, the patient is able to feel something, however he/she is unable to distinguish this feeling from that of the dull end of the pin. Is this scored 0 or 1? In this part of the examination, you are testing for appreciation of sharpness, not any sensation. Therefore, if the patient cannot distinguish between sharp and dull sensation, pinprick sensation should be scored as absent (0). ‘+ In testing for pinprick sensation in an area of abnormal sensation, the patient reports a feeling of sharpness when touched with the sharp end of the safety pin. However, he/she also reports that the dull end of the pin feels sharp. How is this dermatome scored? In this case, it is important to determine whether or not the patient can distinguish between being touched by the sharp and dull end of the pin. If the patient can distinguish (e.g., the sharp end feels “sharper” than the dull end), then score pinprick as 1, impaired. If not, then score pinprick as 0, absent. E, References Austin GM. (1972) The Spinal Cord: Basic Aspects and Surgical Considerations, 2nd ed. Springfield, : Thomas. 20 Chapter I Newolagical Assessment: The Sensory ExaminationReference Manual forthe Intemational Standards fot Nevoloical Classification of Spinal Cord ny (Rev. 2003) Chapter II! Neurological Assessment: The Motor Examination A. Introduction As was true of the sensory examination, ISCSCI recommends required and optional components in the motor examination. The required muscles {key muscles) are those that contribute to the motor score and the motor level. The other muscles tested, although clinically important, are viewed as optional in that they do not contribute to the motor scores or levels. B, Required Testing 1. Key Muscles In contrast to the sensory examination, only certain levels or segments of the spinal cord are accessible to motor testing. For purposes of determining a motor level and recording a motor score that has some predictive value with respect to function, accurate testing is only available for the muscles located on the extremities or appendicular skeleton. Muscles located on the axial skeleton cannot be graded using the six-point scale recommended in ISCSCL The key muscles to be tested in the motor examination and their corresponding spinal cord roots or segments are: C5 Elbow flexors C6 Wiist extensors C7 Elbow extensors C8 Finger flexors (distal phalanx of middle finger) TI Finger abductors (little finger) L2 Hip flexors L3 Knee extensors L4 Ankle dorsiflexors L5 Long toe extensor $1 Ankle plantar flexors The committee selected these key muscles bearing in mind three important concerns: (1) a muscle function or action was needed to represent each of the respective spinal cord segments listed, (2) each muscle function or action had to have functional significance, and Chapter | Newelogial Assessment The Motor Examination 21Reference Manual forthe international Standards for Neurological Cassiication of Spina Cord nur Re. 2003) (3) each representative muscle function or action had to be adequately accessible to examination in the supine position. The committee felt that testing in the supine position was the only approach allowing a valid ‘comparison of a patient's scores obtained during the acute period to those obtained during the rehabilitation and follow-up phases of care. The position of the body must be identical at all testing junctures, particularly when one considers the effect that position and tone may have upon recruitment of muscles affected by spasticity. An example of localization is the committee's selection of the elbow flexors as the key muscle action that best represents the C5 spinal segment. The principle elbow flexor is the biceps/brachialis muscle, and it is innervated by two spinal nerves: C5 and C6. Most muscles have multiple spinal segment innervation, but the committee chose by consensus those muscles innervated primarily by two segments. By consensus the most rostral segment was assigned for every key muscle. The rationale for this is discussed in the ISCSCI booklet (pp. 15-18). In sum, if two segments innervate one muscle, then a grade of 3 or better will indicate that the proximal of the two segments is to be regarded as normal if the next most rostral key muscle action is normal. References used to determine the key muscles include Hollingshead (1981), Yashon (1986) and DeLisa (1993). 2. Grading Because a more accurate, clinically applicable method of force measurement of the key muscles is not currently available, the traditional six-point manual muscle testing scale is used: 0 No visible or palpable muscle contraction is noted in the muscle being examined. 1 A visible or palpable contraction is noted in the muscle being examined. 2 The muscle is able to move, at least once, the part of the extremity to which it is inserted through a full range of motion (or the maximum available range of motion), in the position in which gravity is eliminated. 3 The muscle is able to move, at least once, the part of the extremity to which it is inserted through a full range of motion (or the maximum available range of motion), in the position in which gravity must be overcome. 22 Chapter! Neurological Assessment: The Motor ExaminationReference Manual forthe Inteatonl Standards for Newologial Clsiction of Spinal Cor Injury (Rev. 2003) 4 The muscle is able to move, at least once, the part of the extremity to which it is inserted through a full range of motion (or the maximum available range of motion), and in addition, provides some resistance against the efforts of the examiner to oppose it. 5 The muscle is able to move, at least once, the part of the extremity to which it is inserted through a full range of motion (or the maximum available range of motion), and to the examiner’s judgment, exerts a normal amount of resistance against the efforts of the examiner to oppose it. 5* The muscle is able to exert, in the examiner's judgment, a sufficient resistance to consider the muscle capable of “normal” resistance if identifiable inhibiting factors were not present. NT (Not testable) The patient is unable to reliably exert the effort required to move the muscle or the muscle is unavailable because of immobilization of the extremity, pain on effort or amputation. Note: When a key muscle tests as Grade 5, it can be presumed to be fully innervated by the contributions from two segments of the spinal cord (c.g, the elbow flexors are innervated from C5 and C6). Clinical conditions do arise, however, when a key muscle does not test as a Grade 5 even though it is fully innervated. Conditions such as pain and disuse will affect the muscle’s ability to produce a normal (Grade 5) contraction. Such an affected muscle, even though fully innervated, may test less than 5 (most often 4). It is important to try to document whether the weakness of a key muscle under these circumstances is due to a loss of innervation or is simply a reflection of inhibiting factors such as pain or disuse. While it might seem intuitively more appropriate to grade the muscle as it actually tests rather than what it would test if the inhibiting factors were not present, doing it that way has proved to be a significant problem for clinicians and data recorders alike in the determination of the motor level. The ISCSCI standards state “The motor level is defined by the lowest key muscle that has a grade of at least 3, providing the key muscles represented by segments above that level are judged to be normal (Grade 5).” If a muscle function or action was graded as less than 5 when it was in fact normally innervated, it would obscure the determination of the motor level. After considerable discussion, the standards committee felt that the examiner was the best person to determine whether or not a muscle that tested less than normal was in fact really fully innervated. If that muscle is felt by the examiner to be fully innervated, even though there are conditions Chapter ll Newologial Assessment: The Motor Examination 73ference Manu forthe Intemational Standards for Newogica lssfcation of Spinal Cord Injury (Re 2003) present which inhibit a full contraction, the examiner may choose to grade that muscle as a 5. However, the examiner is asked to place an asterisk (*) after that 5 to indicate that inhibiting factors were present. If the examiner feels, however, that he/she cannot be certain of what the innervation status of the muscle is under these circumstances, the muscle should be graded as NT. 3. Method of Examination This chapter and the videotapes illustrate by drawings and narrative description the position for testing each key muscle. Video I demonstrates the examination of each muscle function or action in a non-disabled subject; Video II demonstrates examination of select muscles for function or action in spinal cord injured subjects. The assumption in this manual and in the videos is that examiners have some previous knowledge of muscle testing. Consequently, it must be emphasized that testing according to ISCSCI often departs from the testing standards recommended in texts such as Daniels and Worthingham (1972). According to ISCSCI, testing of muscles must always be done with the patient in the supine position — a major departure from the sitting, standing, sidelying and prone positions incorporated into standard approaches to testing. For ease of recording and remembering the results of testing, the clinician should examine the key muscles sequentially on one side of the body, beginning with C5, and then repeat the same procedure on the opposite side, Attempts need not be made, however, to examine each key muscle for each grade above. Instead, if the muscle appears on inspection to be normal, place the extremity in the position pictured for Grade 5 in the accompanying sketches. If Grade 5 is found to be unobtainable, the examiner should work down the scale. Alternatively, if the muscle appears paralyzed or significantly affected, the extremity should be placed in the position shown for Grades 0 and 1; the examiner then works up the scale. The sketches in this section show the positions used for all of the muscle grades for each of the key muscle actions /functions. The following points will facilitate the examination: © Elbow flexion and extension. For both of these muscles, when checking Grade 2, sufficient flexion of the humerus must be permitted to allow the forearm to clear and slide over the chest and abdomen. 24 Chapter Newoegica Assessment The Motor ExaminationReference Manual othe International Standard fr Neurological Clasiication of Spinal Coed nur Rew, 2003) Flexor digitorum profundus. When checking for Grades 1-3, the wrist must be stabilized so that passive movement caused by dorsiflexion of the wrist is not misinterpreted as voluntary movement of the distal phalanx (ie. tenodesis grip movement). When checking for Grades 4 and 5, proximal phalanges must be stabilized as well, to avoid misinter- pretation of distal phalanx movement caused by contraction of the hand intrinsics or the flexor digitorum superficialis. + Hip flexors. For Grade 1, the examiner is actually palpating the more superficial hip flexors, ie., sartorius and rectus femoris rather than the iliopsoas. The insertion of the latter is too deep to be seen or felt when the iliopsoas possesses only Grade 1 strength. When examining a patient with an acute traumatic lesion below TS, the hip should not be allowed to flex passively or actively beyond 90 degrees. Flexion beyond 90 degrees may place too great a kyphotic stress on the lumbar spine. © Plantar flexors. Checking for Grades 3-5 is significantly different from what is described in standard texts. This departure was required for examining patients in the supine position, which, as stated previously, is necessary to insure valid comparison of scores over time. 1. Elbow flexors (biceps, brachialis - C5 myotome) Grades 0, 1, and 2 ‘Testing position: The shoulder is in internal rotation and adducted. ‘The forearm is resting on the abdomen. The elbow is 30° from full extension. The wrist is in neutral pronation- supination and just below the navel. Examiner action: Support the forearm. Palpate the flexors. Ask the patient to bring the hand to his nose. Patient action: Attempt to fully flex the elbow. Chapter Newrlogzal Assessment The Motor Examination 25Reference Manual forthe Intemational Standards for Neurological lesifcaton of Spinal Cord ry Re. 2003) 1. Elbow flexors (biceps, brachialis - 5 myotome) cont. Grade 3 Testing position: The shoulder is in neutral rotation, adducted, and in neutral flexion-extension. The elbow is fully extended, and the hand is supinated. Examtiner action: Ask the patient to flex the elbow. Patient action: Attempt to fully flex the elbow. Grades 4 and 5 Testing position: The shoulder is in neutral rotation, adducted, and in neutral flexion-extension. The elbow is flexed to 90°, and the hand is supinated. Examiner action: Ask the patient to flex the elbow. Pull against the volar aspect of the patient's wrist while bracing the shoulder. Patient action: Attempt to fully flex the elbow. 26 Chapter il Newrologial Assessment: The Motor ExaminationReference Manual forthe nemational Standards for Neurological Classification of Spinal Cord ry (ev 2003) 2. Wrist extensors (extensor carpi radialis longus and brevis - C6 myotome) Grades 0, 1, and 2 Testing position: The shoulder is in internal rotation, adducted, and in neutral flexion-extension. The elbow is in full extension. ‘The wrist is in neutral pronation-supination and fally flexed. Examiner action: Support the forearm. Palpate the extensors, and ask the patient to dorsiflex the wrist. Patient action: Attempt to fully extend the wrist. Grade 3 Testing position: The shoulder is in neutral rotation, adducted, and in. neutral flexion-extension. ‘The elbow is fully extended, and the wrist fully pronated and flexed. Examiner action: Support the wrist. Ask the patient to dorsiflex the wrist. Patient action: Attempt to fully extend the wrist. Chapter Newologal Assessment The Motor Examination 27Reference Manual forthe Intemational Standards fr Nevolgcal Casication of Spinal Cord ny (Rex 2003) 2. Wrist extensors (extensor carpi radialis longus and brevis - C6 myotome) cont. Grades 4 and 5 Testing position: Same as grade 3 position, except the wrist is at 90°, fully extended. Examiner action: Ask the patient to resist the examiner’s pull. Pull down on the hand in the direction of palmar flexion and ulnar deviation, (Note: you are testing the radial wrist extensors, so direction of force applied by examiner should be angled toward the ulnar side of the wrist rather than directly downward.) Patient action: Attempt to fully extend the wrist. 3. Elbow extensors (triceps - C7 myotome) Grades 0 and 1 Testing position: The shoulder is in internal rotation and adducted. The forearm is resting on the abdomen. The elbow is 30° from full extension. The wrist is in neutral pronation-supination. Examiner action: Support the forearm. Palpate the extensors. Ask the patient to straighten the arm. Patient action: ‘Attempt to fully extend the arm. 28 Chapter Newologleal Assessment The Motor ExaminetionReference Manual forthe nteratonal Standards fr NewololalClasication of Spinal Cord nr (Rev. 2003) 3. Elbow extensors (triceps - C7 myotome) cont. Grade2 Testing position: ‘The shoulder is the same as above. The elbow is fully flexed. Examiner action: Support the arm and ask the patient to straighten it, Patient action: Attempt to fully extend the arm. Grade 3 Testing position: The shoulder is in neutral rotation, adducted, and at 90° flexion. The elbow is flexed, and the hand is by the ear. Examiner action: Support the arm and ask the patient to straighten it. Patient action: Attempt to fully extend the arm. Chapter Il Newologcal Assessment: The Motor Examination 29Reference Manual for the International tandas for NewoogislClasfcation of Spinal Cod nury (ev. 2003) 3. Elbow extensors (triceps - C7 myotome) cont. Grades 4 and 5 Testing position: Same as grade 3, except the elbow is at 45° from full extension. Examiner action: ‘Ask the patient to resist the examiner’s push by trying to straighten the arm. The examiner tries to flex the elbow. Patient action: Attempt to fully extend the arm. 4. Finger flexor to the distal phalanx of the middle finger (flexor digitorum profundus - C8 myotome) Grades 0, 1, and 2 Testing position: The shoulder is in neutral rotation, adducted, and in neutral flexion-extension. The elbow is fully extended. The wrist is in neutral pronation-supination and neutral flexion-extension. The metacarpal phalangeal and proximal interphalangeal joints are extended. Examiner action: Stabilize the wrist in neutral with the MP and PIP joints extended. Palpate flexors and ask the patient to flex the DIP joint. Patient action: Attempt to flex the DIP joint. 30 Chapter Neurological Assesment: The Mtor ExaminationAeference Manual for the international Standard for Neurological Clsifcation of pial Cord jury Re. 2003) 4, Finger flexor to the distal phalanx of the middle finger (flexor digitorum profundus - C8 myotome) cont. Grade 3 Testing position: The shoulder and elbow are the same, and the wrist is fully supinated. Examiner action: Same as above. Patient action: Same as above. Grades 4 and 5 Testing position: ‘The same as grade 3, except the DIP is fully flexed. Examiner action: Ask the patient to resist the examiner's push and try to extend the DIP joint. Patient action: Same as above. Chapter Neurological Assessment The Motor Examination 31Reference Manual forthe Intemational tandrds for Neurological laslfaton of Spinal Cord jury (Re. 2003) 5. Small finger abductors (abductor digiti minimi - T1 myotome) Grades 0, 1, and 2 Testing position: The shoulder is in internal rotation, adducted, and in neutral flexion-extension. The elbow is in full extension. The wrist is in full pronation and neutral flexion-extension. The MP, PIP, and DIP joints are fully extended. Examiner action: Press down lightly on the back of the hand and palpate the abductor. Ask the patient to move the little finger away from the fourth finger. Patient action: Attempt to abduct the little finger. Grade 3 Testing position: The shoulder is in neutral rotation, adducted, and at 15° flexion. The elbow is at 90° flexion, and the wrist is pronated and in neutral flexion-extension. Examiner action: Support the hand and ask the patient to abduct the little finger. Patient action: Attempt to abduct the little finger. 32 Chapter It Mewologial Asessment: The Motor ExaminationReference Manual for the Intemational Standard fer Neurological Casiication of Spinal Cord ny Rev. 2003) 5. Small finger abductors (abductor digiti minimi - T1 myotome) cont. Grades 4 and 5 Testing position: Same as grades 0-2, except the little finger is fully abducted. Examiner action: ‘Ask the patient to resist as the examiner pushes the little finger against the abduction. Patient action: Attempt to keep the little finger abducted. ip Flexors psoas - L2 myotome) (i Grades 0 and 1 Testing position: The hip is in neutral rotation, neutral adduction /abduction and 15° from full extension. The knee is 15° from full extension, Examiner action: Support the thigh to eliminate friction. Palpate distal to the anterior superior iliac spine. Ask the patient to flex the thigh. Patient action: Attempt to flex the thigh. Chapter It eurlogical Assessment The Motor Examination 33Reference Manual forthe Intemational Standards for Neurological Clasiicaton of Spinal Cord nu (Re 2003) Flexors (iliopsoas - L2 myotome) cont. Grade 2 Testing position: The hip is in external rotation, at 45° flexion. The knee is flexed at 90°. Examiner action: Support the leg and ask the patient to flex the thigh. Patient action: Attempt to flex the thigh away from the body. Grade 3 Testing position: The hip is in neutral rotation, neutral adduction /abduction and flexion /extension. The knee is fully extended. Examiner action: Ask the patient to fully flex the hip and to keep the foot from dragging on the bed. Do not allow flexion beyond 90° when examining acute thoraco-lumbar and lumbar injuries. Support the leg. Patient action: Attempt to bring the hip to full 90°. 34 Chapter il Neurological Assessment: The Motor ExaminationReference Manual for the international Standard or Neurological hsicaton of Spinal Cod ny (Rex 2003) Hip Flexors jopsoas - L2 myotome) cont. Grades 4 and 5 Testing position: Same as grade 3, except the hip is flexed to 90°. Examiner action Ask the patient to resist the examiner's push. The examiner tries to extend the hip while bracing the hip on the opposite side. Patient action: Attempt to keep the hip at full 90°, Clinical Tip: __In the acute spine injury period, when the spine may be unstable/painful, it may only be possible to test hip flexor muscle strength isometrically. Using, the testing position for Grade 3 (above), the examiner places a hand on the patient's thigh just above the knee. Ask the patient to lift the leg straight off the bed and resist the patient's movement. The examiner's judgement is required to grade the force as 2 through 5. 7. Knee extensors (quadriceps - L3 myotome) Grades 0 and 1 Testing position: The hip is in neutral rotation, neutral adduction /abduction and 15° from full extension. The knee is 15° from full extension. ‘Examiner action: Support knee to isolate the muscle and palpate the extensors. Ask the patient to extend the knee. Patient action: Attempt to extend the knee. Clinical Tip: Asking the patient to push the entire leg backward (down) may better elicit trace contraction in the quadriceps. Chapter Neurlgial Assessment The Motor Examination 35Reference Manual forthe Intemational Standards for Neurological Classification of Spinal Cord Injury (Re 2003) 7. Knee extensors (quadriceps - L3 myotome) cont. Grade 2 Testing position: The hip is in external rotation, at 45° flexion. The knee is flexed at 90°. Examiner action: Support the leg and ask the patient to straighten the knee. Patient action: Attempt to straighten the knee. Grade 3 Testing position: The hip is in the same position as grades 0-1, and the knee is partially flexed. Examiner action: Place arm under the tested knee and grasp the other knee. This causes the tested knee to flex. Ask the patient to straighten the knee. Patient action: Attempt to straighten the knee. 36 Chapter Newologica Assessment The Motor Examinationference Manual forthe itemationa standard for Newrolgial Clsifcaton of Spinal Crd injury (Re, 2003 7. Knee extensors (quadriceps - L3 myotome) cont. Grades 4 and 5 ‘Testing position: Same as grade 3, except the knee is 15° from full extension. Examiner action: Place arm under the tested knee and grasp the other knee. Push down on the leg just proximal to the ankle and ask the patient to straighten the knee. Patient action: Attempt to straighten the knee. 8. Ankle dorsiflexors (tibialis anterior - L4 myotome) Grades 0 and 1 Testing position: The hip is in neutral rotation, neutral adduction /abduction flexion/extension. The knee is fully extended. The ankle is slightly plantar flexed. Examiner action: Palpate the dorsiflexors. Ask the patient to bring the foot toward the knee. Patient acti Attempt to dorsiflex the ankle. Chapter Newrolgial Assesment: The Motor Examination 37Reference Manual forthe nerational Standards for Neurological Clasticaton of Spinal Cord nu (Re. 2003) Ankle dorsiflexors L4 myotome) Grade 2 Testing position: The hip is in external rotation, 45° abduction. The knee is flexed at 90°, and the ankle is fully plantar flexed. Examiner action: Ask the patient to bring the foot toward the knee. Patient action: Attempt to dorsiflex the ankle Grade 3 Testing position The hip is in the same position as grades 0-1, except it is slightly flexed, as is the knee. Examiner action: Ask the patient to bring the foot toward the knee. Patient action: Attempt to bring the foot toward the knee 38 Chapter I Neurological Assessment The Motor ExaminationReference Manual forthe International Standards fr Newologcl Clasfiation of Spinal Cord injury (Rex 2003) Ankle dorsiflexors (tibialis anterior - L4 myotome) cont. Grades 4 and 5 Testing position: Same as grade 3, except the ankle is fully dorsiflexed. Examiner action: Push against the dorsiflexed ankle and ask the patient to resist the push, Patient action: Attempt to resist the push, Long toe extensors (extensor hallucis longus - L5 myotome) Grades 0 and 1 Testing position: The hip is in neutral rotation, neutral adduction /abduction, and flexion extension. The knee is fully extended. The ankle is in partial plantar flexion. Examiner action: Palpate the extensor of the long toe. Ask the patient to bring the toe toward the knee. Patient action: Attempt to bring the toe toward the knee. Chapter lil Newrologkal Assessment: The Motor Examination 39Aeference Mansa forthe Intemational Standards for Nowoloical lesan of Spinal Cor jury (eu 2003) 9. Long toe extensors (extensor hallucis longus - L5 myotome) cont. Grade 2 Testing position: The hip is in external rotation, 45° abduction. The knee is flexed at 90°, and the ankle is in neutral plantar/dorsi- flexion. The big toe is in full plantar flexion, Examiner action: ‘Ask the patient to bring the toe toward the knee. Patient action: Attempt to bring the toe toward the knee. Grade 3 ‘Testing position: The hip is in the same position as grades 0-1, except it and the knee are slightly flexed. Examiner action: Ask the patient to bring the toe toward the knee. Patient action: Attempt to bring the toe toward the knee. 40. Chapter it neurological Assessment: The Motor Examinationfeference Manual forthe Iteational Standards or Neurological Clasicaton of Spinal Cord nur ev. 2003) 9. Long toe extensors (extensor hallucis longus - L5 myotome) cont. Grades 4 and 5 Testing position: Same as grade 3, except the toe is fully extended. Examiner action: Push against the toe and ask the patient to resist the push. Patient action: Attempt to resist the push. 10. Ankle plantar flexors (gastrocnemius, soleus - $1 myotome) Grades 0, 1, and 2 Testing position: The hip is in external rotation, at 45%flexion. The knee is flexed at 90°. Examiner action: Palpate the plantar flexors. Ask the patient to press down, with the foot. Patient action: Attempt to plantar flex the foot. Chapter | Neurological Asessment The Motor Examination 41Reference Manual forthe Intemational Standards or Newologlal Clsicaton of Spinal Cor nu (ex. 2003) 10. Ankle plantar flexors (gastrocnemius, soleus - $1 myotome) cont, Grade 3 Testing position: The hip is in neutral rotation and flexed to 45°, and the knee is fully flexed. The foot is resting on a firm surface. Examiner action: Ask the patient to lift the heel off the surface. Patient action: Attempt to lift the heel. Grades 4 and 5 ‘Testing position: Same as grades 0-1, except the ankle is fully plantar flexed. Examiner action: Push against the flexed foot and ask the patient to resist the push. Patient action: Attempt to maintain plantar flexion. 42 Chapter Neurologic Assessment: The Motor EvamiatonReference Manual forthe international Standards fr Newlogical Casati of Spina Cord injury Rev. 2003) C. Optional Testing Testing of the following muscles, while not useful for obtaining a motor score, is frequently helpful in confirming the involvement of both sensory and motor modalities in the regions of the spinal cord from which they arise. Because some of these muscles are not muscles of the appendicular skeleton, they cannot be tested as described above. The diaphragm. Innervation is from C3 and C4 (and possibly some C5). In a patient with a motor level above C5, it is important to know whether the diaphragm is affected and if so, to what extent. While clinical criteria such as the physical examination and the measurement of vital capacity provide important information in that regard, it is often helpful to examine the diaphragm under fluoroscopy to determine the extent of involvement. Movement of the hemidiaphragm two or more inter-spaces generally is an indicator of normal function on that side. Deltoids. Innervation is from C5-6, (and possibly some C4). Testing of these muscles in the traditional way is difficult in a supine patient because of the necessity for the patient to be sitting to determine whether there is antigravity strength (Grade 3). Nevertheless, they are important muscles for the upper extremity with respect to function as they provide a major contribution to the function of reach. The abdominal muscles. The abdominal muscles are innervated by multiple segments, from T6 through T12. For lesions located between these segments, a disparity of innervation exists between the muscles above and below the umbilicus. Those upper muscles that are still innervated will contract better than those below the umbilicus, and the umbilicus will, therefore, move rostrally when the patient is asked to flex the head and neck. This phenomena, called Beevor's sign, is most strikingly positive in patients with lesions at T9 through TI1 Hip adductors. Innervation is from L2 and L3. While these muscles are also difficult to grade in a supine patient, they are important muscles to examine because they are frequently the first muscles to return in a patient who is destined to convert from motor complete to motor incomplete in the lower extremities. Subtle contractions of these muscles can be determined by palpating the tendon of the adductor longus which is, the most superficial of the adductor group as it originates from the pubic ramus. Chapter Newological Assessment: The Motor Examination 43Aeference Manual forthe Intemational Standards for Neurological Cassfcation of Spinal Cor Injury (ev. 2003) + Hamstrings. Because of the plurisegmental innervation of these muscles, they are not useful for the determination of a motor level. It is also not possible to test these muscles properly in the supine position. Nevertheless, these muscles are also felt by some to be a potential harbinger of more substantial return of motor function to the lower extremity in the recently injured spinal cord patient D. Questions and Answers * Would it be acceptable to test the patient for follow-up examinations in the standard position, since the spine is stabilized at that point and risk has been removed? To allow valid comparison of the patient's impairment level over time, the examination must be done consistently. Muscle strength, for this, reason, must be tested in the same position at all points of testing, * Because the ankle plantar flexors cannot be tested ideally in the supine position, can an alternative muscle be substituted, for example, the toe flexors? ‘The committee recommended that alternative muscles not be substituted, particularly in research studies, unless the alternative can be shown to represent the same spinal segment and is comparable in its functional significance. * How do you grade a muscle if the range is limited by contracture or spasticity? If a muscle’s range is limited by contracture, and the contracture limits less than 25 - 50 percent of the range, then the muscle is to be graded through its available range subject to the same criteria of the 0-5 scale which applies to any other muscle. If the contracture exceeds the 50 percent of the normal range of motion, the muscle is to be listed as. Not Testable (NT). If the range is limited by spasticity, every effort should be made to relax the muscle and the subject so that spasticity is not triggered during the examination. If the spasticity is so severe as to prohibit placing the extremity in the desired position, or the spasticity sets off uncontrollable clonic activity, the muscle is to be classified as NT. 46 Chapter Neurological Asessment: The Motor Examinationfeference Manual forthe nestional Standards for Neurological Clason of Splnal Cord injury ev. 2003) + Does one use the “break test” in evaluating muscle resistance? The committee felt that the “break test” as such should not be the criteria which distinguishes Grade 4 from Grade 5. Grade 4 is simply a reflection of a muscle’s ability to take a moderate amount of force but less than what would be considered normal for that muscle. It is difficult to specify exactly how much force should be defined as “moderate.” It is also difficult to define how much force must be used to “break” muscles of different sizes, e.g, for the abductor digiti V versus the gastroc-soleus. ‘* How does the examiner grade the hip flexor muscles in the presence of pain and/or instability due to a thoracolumbar fracture? Pain may be elicited upon testing of this muscle due to its proximity to and origins from the thoracolumbar spine. If the pain is too severe when the leg is placed in the appropriate position, precluding accurate testing, then the muscle is to be classified as NT. The same principle applies if a fracture exists in the appendicular skeleton so that the examiner's ability to test a specific muscle on that limb is impaired. © Can pluses or minuses be used as gradients of whole numbers? The committee realizes that individual centers and individual clinicians may at times wish to use a finer grading scale than the 0-5 six-point scale given above. However, for purposes of inter-rater reliability, it is recommended that only whole numbers be used when comparing data from one institution to another. References Daniels L, & Worthingham C. (1972) Muscle Testing: Techniques of Manual Examination, 3rd ed. Philadelphia: Saunders. DeLisa JA, Gans, GM. (1993) Rehabilitation Medicine: Principles and Practice, 2nd Edition, pp. 74-89. Philadelphia: Lippincott. Hollingshead WH, Jenkins DB. (1981) Functional Anatomy of the Limbs and Back, 5th Edition, pp. 112-189, 241-338. Philadelphia: Saunders. Yashon D. (1986) Spinal Injury, 2nd Edition, pp. 13-17. Norwalk, CT: Appleton-Century-Crafts. ‘Chapel Neurological Assessment The Motor Examination 4Reference Manual forthe Intemational Standards for Nouoogcal Clsifcation of Spinal Cord iy Re. 2003) Chapter IV Scoring, Scaling and Classification A. Overview ‘The neurological assessment, which includes the motor and sensory examinations described in Chapters II and III, forms the data base for: the determination of the motor and sensory scores; the neurological levels; the completeness of neurological loss; the zone of partial preservation; the ASIA Impairment Scale score; and clinical syndromes. As was noted in Chapter I, the skills required for reliable examination differ from those required for scoring, scaling and classification. Reliable sensory and motor testing is achieved through practice, especially in diverse clinical settings and with patients with different types of lesions. Accuracy of examination is the necessary first step in accurate scoring, scaling and classification, However, the latter also requires thorough understanding of the definitions of neurological levels, complete and incomplete lesions, the zone of partial preservation, the ASIA Impairment Scale and clinical syndromes. Scoring skills differ from testing skills, and reliability studies support this conclusion (see Chapter V), (Cohen, ME, 1998). In complicated cases, it is difficult to achieve agreement in classification among experts, (Donovan, 1997). This is probably because classification requires the highest level of interpretation of the examination obtained by testing. This chapter provides an introduction to scoring methods, with questions raised and examples other than in the videos used to illustrate a variety of points. The two patients examined in Video II provide the data used in this chapter to demonstrate techniques of scoring. B. Scoring Motor and sensory scores are important end points for determining change, ice., improvement, lack of improvement, or deterioration of neurological function over time. For clinical purposes, the motor score provides a rapid method of communicating change. For research purposes, such as ‘multi-center clinical trials, motor and sensory scores serve as end points to demonstrate effectiveness of interventions. However, there is controversy over the use of summed scores for evaluating changes in function, particularly when there are baseline differences in groups. See chapter VI for further information. 446 ChapterlV. Scoring Scaling and Clssieatonfeference Manual forthe International Standards for Neurological lasiation of Spinal Cord Injury Re. 2003) 1. Sensory Scoring To calculate the sensory score, each of the key sensory points on both sides of the body must be given a grade of 0 2 (using the scale discussed in Chapter II) on both of the testing modalities (pin prick and light touch). Normal sensation for each modality is reflected in a grade of 2 for each of the 28 key points tested on each side of the body, resulting in a score of 56 for each side of the body, and a total score of 112 for the modality in question. The sensory score cannot be calculated if any required key sensory point is not tested. Clinical judgement is emphasized as the major determining factor when distinguishing between grades, and reliability testing between examiners and examinations is essential. Alternative sites must be carefully defined when adopted in research studies. Case 1 In the patient with tetraplegia, the sensory findings (see Table 1a) are symmetrical for light touch and pin prick. C2 - C4 are normal for both testing modalities, but impaired for both in the C5 dermatome, on both sides. No sensation is found distal to C5. Consequently, the sensory score for light touch is 14, and for pin prick is also 14. Case 2 With this patient, the calculation is more difficult because the injury is incomplete, and the scoring for light touch is different than for pin prick sensation. Light touch sensation is preserved to some extent in all, dermatomes (C2 - $4-5). In addition, multiple dermatomes below T7 are hyperesthetic; but the patient cannot distinguish between pin prick and dull sensation, and is consequently graded 0 in those dermatomes. For calculating the light touch sensory score (see Table 1b), the findings are symmetrical, with normal sensation in 13 dermatomes (C2 - T6), and impaired light touch sensation from 17 through $4-5 (15 dermatomes). The score for each side is 41, with a total light touch sensory score of 82. In calculating the pin prick sensory score, the findings are also symmetrical, with normal sensation in 12 dermatomes (C2 - T5) and impaired pin prick sensation in 2 dermatomes. The 14 dermatomes distal to T7 are graded as 0, since the patient cannot distinguish dull from sharp. The total pin prick sensory score is 52. Chapter Scoring Scating and asian 47Aeference Manual for the Iteatonl Standards fr Nevoloica Classica of Spinal Crd nur (Rew. 2003) gy eI kg fg Pin Prick Light Touch Case 2 Pin Prick Light Touch Case 1 a 3 ct cs 6 cs TL T2 T4 15 Te 7 18 To Tm m2 lu 13 0) SL S45 Scores: =82 7+7=14 41441 Light Touch Pin Prick =52 26 +26 14 72+7 48. Chapter IV Scoring Scaling and CssitctionAefrence Manual forthe Intemational Standard for NewroogclCasiication of Spinal Cord nj Re. 2003), 2 Motor Scoring To calculate the motor score, each of the ten key muscles on both sides of the body is given a grade of 0 - 5, using the scale described in Chapter Ill. Normal strength is reflected in a grade of 5 for each muscle, resulting in a score of 25 for each extremity, 50 for each side of the body, and 100 for all extremities. The motor score cannot be calculated if any required muscle is not tested. The motor examinations for the two patients featured in Video II will be reviewed and scored below. See Appendix B for completed scoring sheets of these two cases. Case 1 The motor examination of the patient with tetraplegia in Video II will be discussed first. The scoring of this patient is relatively straightforward, as the subject’s muscle weakness follows the common pattern of complete injury. Both elbow flexors are normal strength and receive a grade of 5. The wrist extensor on the right side has normal strength and also receives a grade of 5. However, the left wrist is weak and provides only moderate resistance, receiving a grade of 4. The elbow extensors are weaker. The left side moves through the defined range of motion, with gravity eliminated, and receives a grade of 2; but the right side is unable to move through the defined range and receives a grade of 1. No voluntary movement is found in the finger flexors or small finger abductors. This is also the case in the lower extremities. The muscle grades for each of the muscles tested are indicated in Table 2a, which is similar to the scoring chart in ISCSCL-92. The total motor score for this patient is 22, based on the summation across all muscles, most of which were graded 0. Case 2 The key muscles of the upper extremity test normal on each side; therefore, C5 - Tl key muscles each receive a grade of 5 for a score of 25 for each side. The muscles of the lower extremity show asymmetry. Hip flexors on the right and left are able to give normal resistance and receive a grade of 5. The right knee extensor also gives normal resistance, receiving a grade of 5; the left knee extensor can only go through a range of motion with gravity eliminated, earning a grade of 2. Ankle dorsiflexors, however, are weak; but the right side provides moderate resistance and receives a grade of 4, while the left side extends against gravity and receives a grade of 3. Long toe extensors give resistance against gravity and receive a grade of 3. Ankle plantar flexors do not provide resistance against gravity (by lifting the heel completely off the bed), whereas they can flex the ankle when gravity is eliminated; therefore, ChapterV Scoring, Scaling and Clsiication 49Reference Manual forthe Intemational Standards for Neurological lasifcation of Spinal Cor injury Rex. 2003) they receive a grade of 2. The motor score is calculated by adding the grades of each muscle tested (see Table 2b), achieving a total of 84 (50 for upper extremities, plus 19 lower right and 15 for lower left) coco oo one 5 Motor Score: n+d 22 CC. Neurological Levels The rationale for determining the neurological level was first established by Long (1955) when he related self-care and mobility in SCI to specific neurological levels. Virtually all texts today relate self-care and ambulation activities to the neurological level. In ISCSCI, the neurological level is determined for the right and left side, and motor and sensory functions; based upon the examination findings for the key sensory points and key muscles. Therefore, four separate levels are possible, and a single level is designated only when levels are symmetrical and equal for motor and sensory functions. Motor and sensory levels are the same in only 25-30 percent of complete injuries, and the motor level may be two or three levels below the sensory level at one year post injury. Sinice the prediction of self care and ambulation is usually based on the motor level (Long, 1955; Welch, 1986), use of a single neurological level where there is a difference between motor and sensory levels may be misleading in predicting functional activities (Marino RJ et al. 1995). Symmetry occurs 80% of the time or more, based on single neurological levels (Stover, et.al., 1995). 50 chapter V Scoring Scaling and CasatiReference Manual for the Internationa Standards foe NeutlagalCasication of Spinal Cord nut Re. 2003) 1, Sensory Level The sensory level is the most caudal normally innervated dermatome for both pin prick and light touch sensation, or the dermatome below which sensory defects exist. This is determined by a grade of 2 (normal) in all dermatomes from C2 to the segment that has an abnormal dermatome score of less than 2 for either light touch or pin prick. The normal dermatome immediately above the dermatome with impaired or absent light touch or pin prick is the sensory level. Since the right and left sides may differ, the sensory level should be determined for each side. Case 1 The patient with tetraplegia (see Table 1a) has normal light touch and pin sensation in C2 - C4. C5 shows impaired light touch and pin prick sensation bilaterally. C6 and all distal dermatomes have absent sensation in both modalities. The sensory level is C4 since it is the most caudal dermatome with normal pin prick and light touch sensation. The right and left sensory levels are the same since the findings are symmetric. Case 2 The patient with paraplegia (see Table 1b) has normal light touch sensation in dermatomes C2 - T6, with normal pin prick sensation in C2-T5, The sensory level is TS, as this is the most caudal dermatome that is normal for both testing modalities and all dermatomes above i) this level are normal. The findings, again, are symmetric; therefore, the right and left sensory levels are the same. 2. Motor Level The motor level is the most caudal, normal or intact innervated spinal nerve or the segment below which motor deficits exist. As stipulated in ISCSCI, the key muscle representing this segment must be a grade of at least 3 ot better to be considered intact, provided the next most rostral key muscle tests as normal. The rationale for this convention and for limiting key muscles to one spinal segment is as follows: Just as each segmental nerve (root) innervates more than one muscle, most muscles are innervated by more than one nerve segment (usually two segments; see Figure). Therefore, the assigning of one muscle or Chopter IV Soring Scaling and Cssifation 51Aeference Manual forthe itemationl Standards fr Newel Clasiation of Spinal Crd Ir Re. 2003), ‘one muscle group (ie., the key muscle) to represent a single spinal nerve segment is a simplification, used with the understanding that in any muscle the presence of innervation by one segment and the absence of innervation by the other segment will result in a weakened muscle. By convention, if a muscle has at least a grade of 3, it is considered to have intact innervation by the more rostral of the innervating segments. In determining the motor level, the next most rostral key muscle must test as 5, since it is assumed that the muscle will have both of its two innervating segments intact. For example, if no activity is found in the C7 key muscle and the C6 muscle is graded as 3, then the motor level for he tested side of the body is C6, providing the C5 muscle is graded 5. The examiner's judgment is relied upon to determine whether a muscle that tests as less than normal (5) may in fact be fully innervated. This may occur when full effort from the patient is inhibited by factors such as pain, positioning and hypertonicity or when weakness is judged to be due to disuse. If any of these or other factors impede standardized muscle testing, the muscle should be graded as not testable (NT). However, if these factors do not prevent the patient from performing a forceful contraction and the examiner's best judgment is that the muscle would test normally (5) were it not for these factors, it may be graded as 5. In summary, the motor level (the lowest normal motor segment which may differ by side of body) is defined by the lowest key muscle that has a grade of at least 3, providing the key muscles represented by segments above that level are judged to be normal (5). For those myotomes that are not clinically testable by a manual muscle exam, i., Cl to C4, T2 to L1, and 82 to $5, the motor level is presumed to be the same as the sensory level. If the sensation for a segment is normal, motor function for that segment is considered normal; if sensation is impaired, motor function is considered impaired. Case 1 This patient (see Table 2a) has normal strength in the elbow flexors (C5). The wrist extensors (C6) receive a grade of 4 on the left and 5 on the right. The left C6 segment represents a normal spinal segment since the segment rostral to it, ie., the elbow flexor (C5), on the left has normal strength; and the left wrist extensor is at least a grade 3 (in fact, a grade 4), The elbow extensor (C7) received a grade of 2 on the left and 1on the right, and the remaining muscles are graded 0. The motor level is C6 on the left side, as C6 is the most caudal spinal segment that is normal. Although the left wrist extensor is not normal on muscle testing (grade 4), by ISCSCI convention it represents a normal segment because it is grade 3 or better. The motor level on the right side is also C6 because the right wrist extensor tests normal (grade 5) and the next caudal muscle, the right elbow extensor, is grade 1 (which is not grade 3 or better). 52 chapter IV Scoring Scaling and Clssicationfeference Manual othe International Standards for Neola lasiicaton of Spinal Cod Ij (Re. 2003) Case 2 This patient (see Table 2b) has normal strength in the five key muscles of the upper extremities and in the hip flexors (L2) and in the right knee extensor (L3). The left knee extensor is grade 2. The right ankle dorsiflexor (L4) received a grade of 4 and the left a grade of 3. The long toe extensors (L5) received a grade of 3. The ankle plantar flexors (S1) received a grade of 2. Despite these finding in the lower extremities, the motor level follows the sensory level because the sensory level exists in a segment where the muscles representing that myotome cannot be tested, ie. T5. Since the motor level follows the sensory level when the sensory level is in such a location (e.g., from T2 to L1), the motor level is T5. The preservation of motor function below this level is a manifestation of incompleteness. This influences the ASIA Impairment Scale but not the motor level. D. Incomplete/Complete Injuries and the Zone of Partial Preservation Acomplete injury is defined as the absence of sensory and motor function in the lowest sacral segment. This definition was chosen on the basis of a study by Waters et al. (1991), which reported that fewer tetraplegic patients converted from complete to incomplete injury status at one to two years follow-up, using this definition, compared to the prior definition. The prior definition classified an individual as incomplete if sensory or motor fanction extended more than three segments below the neurological level (ASIA Standards, 1989) An incomplete injury is defined as partial preservation of sensory and/or motor function in the lowest sacral segment ($4-5). Sacral sensation includes sensation at the anal mucocutaneous junction as well as deep anal sensation. The test of motor function is the presence of voluntary contraction of the external anal sphincter upon digital examination. The zone of partial preservation (ZPP) is used only with complete injuries, and refers to those dermatomes and myotomes caudal to the neurological level that remain partially innervated. The most caudal segment with some sensory or motor function defines the extent of the sensory or motor ZPP, respectively, and should be recorded for the right and left sides. In Case 1, no sensation or motor function is found in dermatomes from C6 to $4.5; this is classified as a complete lesion. C2 - C4 is normal for sensation but CS is impaired, so the sensory ZPP is C5 for both right and left sides, The motor ZPP is C7 for both sides since C2 - C6 spinal segments are intact and the C7 key muscle (elbow extensor) is less than grade 3. Chapter V Scrng Scaling and Classification 53Aelerence Manual forthe Intemational Standards for Neurological Clsficaton of Spinal Cord Injury (Rev 2003) In Case 2, the lesion is incomplete, because sensation for light touch is partially intact through the lowest sacral segment (S4-5). The ZPP is not recorded in an incomplete injury. E, The ASIA Impairment Scale (AIS) (modified from Frankel) This scale, formerly known as the Frankel Grades or Scale, has been modified so many times over the years that the committee chose to change the name in 1992. The first modification was the clarification of the words “useful” and “non-useful” for grades D and C. In ISCSCI, for ASIA Impairment Scale D (AIS D), at least half of key muscles below the neurological level must be grade 3 or better. ‘The second modification was the change in definition of a complete lesion and the zone of partial preservation. Since the new definition of a complete lesion allows the zone of partial preservation to be greater than three segments, the only segment required with absent motor and sensory function is S4-5. The following definitions are used in grading the degree of impairment: A= Complete. No sensory or motor function is preserved in the sacral segments S4-S5. B= Incomplete. Sensory but not motor function is preserved below the neurological level and includes the sacral segments S4-$5. C= Incomplete. Motor function is preserved below the neurological level, and more than half of key muscles below the neurological level have a muscle grade less than 3 (Grades 0-2). D = Incomplete. Motor function is preserved below the neurological level, and at least half of key muscles below the neurological level have a muscle grade greater than or equal to 3. E = Normal. Sensory and motor function are normal. Note: For an individual to receive a grade of C or D, he/she must be incomplete, that is, have sensory or motor function in the sacral segments, S455. In addition, the individual must have either (1) voluntary anal sphincter contraction or (2) sparing of motor function more than three levels below the motor level. St Chapter WV Scoring Scaling and ChssficaionReference Manual for the Intemational Standards fo Nevolog Casfcation of Spina Cord Injury Rev. 2003) In Case 1, the patient with a complete lesion is classified on the ASIA Impairment Scale as an A. In Case 2, the patient has at least half of the key muscles below the level of the lesion (T5) graded 3 or better. The sensory level is T5. The motor level follows the sensory level and is also TS. This represents the neurological level for the classification of impairment since this is the most caudal intact level. Four of the key muscles in the right leg and three in the left leg are grade 3 or better. Since seven of ten key muscles are “at least half,” the patient is classified as AIS D. F. Steps in Classification The following order is recommended in determining the classification of individuals with SCI. 1. Determine sensory levels for right and left sides. 2. Determine motor levels for right and left sides. Note: in regions where there is no myotome to test, the motor level is presumed to be the same as the sensory level. 3. Determine the single neurological level Note: this is the lowest segment where motor and sensory function is normal on both sides, and is the most cephalad of the sensory and motor levels determined in steps 1 and 2. 4, Determine whether the injury is Complete or Incomplete (sacral sparing). 5. Determine ASIA Impairment Scale Grade: a. Is injury incomplete? NO, AIS=A. Record ZPP. b. If YES, is injury motor incomplete? NO, AIS=B (Yes=voluntary anal sphincter or motor function more than three levels below the motor level on a given side.) c. If YES, are atleast half of the key muscles below the (single) neurological level graded 3 or better? NO, AIS=C d. IFyes, AIS=D. Chapter Scoring Scaling and Cassificaton 55feference Manual forthe Inerational Standards for Neurological Classification of Spinal Cod injury (eu. 2003) e. Ifsensation and motor function is normal in all segments, AIS=E. Note: AIS E is used in follow up testing when an individual with a documented SCI has recovered normal function. If at initial testing no deficits are found, the individual in neurologically intact; the ASIA Impairment Scale does not apply. G. Questions 1. What is the motor level in the following case examples given the grades of the following key muscles and a sensory level of C6? a. elbow flexor 5, wrist extensor 5, elbow extensor 5, flexor digitorum profundus 0, fifth finger abductor 0. Answer: ‘The motor level is C7 since the lowest key muscle with a grade of at least 3, with the next muscle rostral to it testing normal (Grade 5), is the elbow extensor. b. elbow flexor 5, wrist extensor 3, elbow extensor 3, flexor digitorum profundus 0, fifth finger abductor 0 Answer: The motor level is C6 because the wrist extensor is the lowest muscle to test at least 3 with the next rostral muscle testing normal (grade 5). ©. Elbow flexor 5, wrist extensor 5, elbow extensor 5, flexor digitorum profundus 4, abductor digitum quinti 4, all lower limb key muscles 4. Answer: The motor level is C8 because the flexor digitorum profundus is the lowest key muscle to test at least 3 with the next most rostral key muscle testing normal (Grade 5). 53% Chapter Scoring, Scaling and Classificationfeference Manual for he international Standards for Neurological Clsifikatlon of Spinal Cord nay (Rev. 2003) 2. What is the motor level in the following case of an acute lumbar injury with back pain? The patient has sustained an L1 burst fracture, and CT reveals a bilateral paraspinal hematoma. On muscle testing flexion of the hip is painful, and the hip flexes only 30°. When the thigh is supported by the examiner, however, the patient is able to exert a strong, isometric contraction that can be palpated in the accessory hip flexor muscle (sartorius, rectus femoris). Further, when the hip is placed in the position of 90°, and the patient is asked to resist extension, a brief burst of resistive force is felt which gives way instantaneously due to pain. The quadriceps tests as Grade 5, the anterior tibialis Grade 3, and the extensor hallucis Grade 1, the gastrocnemius Grade 1 Answer: In this case the hip flexors are almost certainly fully innervated, even though they do not test as a Grade 5. The examiner is justified in giving the hip flexors a Grade 5* and therefore the motor level would be LA. If the examiner felt uncertain about the decision, he/she should give the hip flexor the grade of NT. In that case, a designation of the motor level for that side of the body should be deferred. 3. What is the motor level in the following example? Sensory modalities are normal on the right and left at C2, C3 and on the left at C4. Sensory modalities are diminished on the right at C4 and at C5 bilaterally. All sensation is absent below C5. Key muscle motor testing is as follows: Elbow Flexors 3 on the right, 4 on the left, Wrist Extensors 1 on the right, 2 on the left. All muscles below wrist extensors 0. Answer: The right motor level is C3 and the left motor level is C5. This is arrived at by following the rule in ISCSCI-00 that the key muscle representing the motor level must be a grade of at least 3, provided the next most rostral muscle tests as normal. Additionally, sensory testing is used when the myotome is not clinically testable by a manual muscle exam. Therefore on the right side, since the C4 dermatome test is abnormal, it is assumed that the C4 myotome is Chapter Scoring Scaling and Cessation $7Aeference Manual forthe Intemational Standard or Neurological Clsslicaton of Spinal Cord nu Ge 2003) also impaired. Therefore the right motor level is C3. On the left side, the C4 dermatome tests as normal so the C4 myotome is considered normal. As a result, the left motor level is C5, since C5’s key muscle tests at least 3 (in this case, actually 4). 4, What is the motor level in the following example? The sensory modalities are normal to T12, diminished at L1-L2, and absent in all segments below L2. All muscles in the upper extremity are normal. They key muscles in the lower extremity are as follows: Hip Flexors, Grade 3; Quadriceps, Grade 1; Anterior Tibialis, Grade Extensor Hallucis Longus, Grade 0; Gastrocnemius, Grade 0. There is no sacral sparing of sensory or motor function. Answer: The motor level is T12 because the rule states that when the sensory level is located in a segment where no key muscle at that segment exists, the motor level follows the sensory level. Because this injury is complete (AIS A), a sensory zone of partial preservation (ZPP) exists, extending to L2. Similarly, a motor ZPP exists, extending to L3. 1.2 cannot be said to be the motor level in this case because one cannot know what the status of the muscles innervated by L1 are because they cannot be tested. Only those muscles innervated by T12 can be presumed normal (even though not testable) because the T12 sensory segment is normal. Since we do not know what gtade the muscles innervated by L1 are (they cannot be tested), the requirements of the rule that in order for the motor level to be L2, the next most rostral level (L1) key muscle must test as 5, cannot be met. 5. AC7 patient has a sensory incomplete lesion, with absence of all key muscles below the level except for voluntary anal sphincter contraction. What is this patient's AIS? Answer: The patient has an AIS grade C. AIS B implies the absence of all motor power below the level of the lesion. Therefore, the presence of voluntary contraction of any muscle, even non-key muscles more than 3 segments below the motor level indicates an AIS grade C. Caution should be taken, however, when the anal sphincter is interpreted as having voluntary power, because the patient can at times mimic a voluntary contraction by bearing down. 538 Chapter V Scoring Scaling and CssifcationReference Manual forthe Intemational standards for Newelogial lasiicaton of Spina or nary (Re. 2003, In addition, care must be taken not to mistake reflex contractions for voluntary. When in doubt, the patient should be scored as not having voluntary power. It should be noted that voluntary contraction of the anal sphincter is by itself, sufficient to classify any SCI patient as motor incomplete. 6. A patient has intact sensation through L2, with impaired sensation below this level including the sacral segments $4-5. Upper extremity strength is normal. In the lower extremities on the right side strength is as follows: L2-4, L3-3, 141, 15-0, S1-0. On the left, strength is: L2-5, 13-4, L4-2, 15-0, $1-0. There is no voluntary anal sphincter contraction. What is this patient’s AIS? Answer: AIS B - the motor level for this patient is L2 on the right and L3 on the left. In order to be classified as an ASIA C, motor function must extend more than 3 levels caudal to the motor level. Therefore, the patient would have to have voluntary motor function extending into the S1 myotome and/or the anal sphincter in order to be considered an AIS C. 7. A patient with a cervical injury has normal sensation to C7. There is diminished sensation for light touch, and absent pin prick below C7 while deep anal sensation is present. The key muscles on both right and left test grade 5 from C5 through C7, C8 is 3, T1 is 1, L2 is 2, L3 is 4 and L4 is 1. LS is 1on the left but 4 0n the right and S1 is 4 bilaterally. Voluntary anal contraction is present. What is the ASIA impairment scale grade? Answer: The sensory level for this patient is C7. The motor level is C8. In order to determine whether the patient has an AIS C vs. D grade, the standards say “...at least half of the key muscles below the neurologic level have a muscle grade greater than or equal to 3” in order to be classified as a D. Since C7 is the neurologic level in this case, there are 14 key muscles below the neurologic level. Exactly one half of these key muscles are at least grade 3. Therefore this patient is an AIS D. ChapterV Scoring Sealing and Cssifcation 59Reference Manual othe Intemational Standards fo NevolagalCalication of Spinal Cor Injury (ev. 2003) H. References ASIA. (1989) Standards for Neurological Classification of Spinal Injury Patients. American Spinal Injury Association; Chicago. Cohen ME, Ditunno JE Jr., Donovan WH, Maynard FM, Jr. (1998) A test of the 1992 International Standards for Neurological and Functional Classification of Spinal Cord Injury. Spinal Cord;36(8):554-60. Donovan WH, Brown DJ, Ditunno JF, Jr, Dollfus P, Frankel HL. (1997) ‘Neurological issues. Spinal Cord;35(5):275-81 Frankel HL, Hancock DO, Hyslop G, et al. (1969) The value of postural reduction in the initial management of closed injuries of the spine with para- plegia and tetraplegia. Paraplegia; 7(3): 179-192. Long CC, Lawton EB. (1955) Functional Significance of Spinal Cord Lesion Level. Arch Phys Med Rehabil; 46:249-55. Marino RJ, Rider-Foster D, Maissel G, Ditunno JF. (1995) Superiority of motor level over single neurological level in categorizing tetraplegia. Paraplegia; 33:510-3, Stover SL, DeLisa JA, Whiteneck GG, eds. (1995) Spinal Cord Injury: Clinical Outcomes from the Model Systems. Gaithersburg, MD: Aspen Publishers. Waters RL, Adkins RH, & Yakura JS. (191) Definition of Complete Spinal Cord Injury. Paraplegia; 29: 573-581. Welch RD, Lobley SJ, O'Sullivan SB, Freed MM. (1986) Functional Independence in Quadriplegia: Critical Levels. Arch Phys Med Rehabil; 67(4):235-40. 6 Chaper IV Scoring. Scaling and CassfeationReference Mandal fo th inteationa Standards fer Neurological Clsiication of pial Cod jury eu. 2003) Chapter V_ Reliability and Validity of the International Standards for Classification of Spinal Cord Injury A. Introduction The necessity of having uniform Standards for neurologic classification of spinal cord injury (SCI) is described in detail elsewhere in this, manual. In order for the Standards to serve these purposes for clinicians and researchers, they must have both reliability and validity. In this context, reliability refers to the consistency of results when the examination and classification are performed either by two different examiners (inter-rater reliability) or by a single examiner (intra-rater reliability) on a subject with a stable neurological status across the examination episodes. Reliability of the Standards can be considered for both the examination procedure (e.g. scores determined for individual Key Muscles) and for the classification (e.g. ASIA Impairment Score or motor level). For a measurement method such as the Standards, validity is most appropriately assessed as construct validity. Contained under this category are the properties of predictive validity and concurrent validity. Since the Standards were initially developed by American Spinal Injury Association (ASIA) in 1983, they have undergone extensive modifications. When the changes over different editions of the Standards are considered individually, it is clear that nearly all were made to improve the reliability of the examination and classification procedure. Much of the research supporting the need for improving the reliability of the Standards has been published in the medical literature. Therefore, the vast majority of what has been published, much of which shows problems with the reliability of specific portions of the ‘examination or classification, is based on previous versions of the Standards, and attempts have been made through the modifications to address these shortcomings. The current body of research on reliability supports most of the content as having adequate reliability for routine use by clinicians and researchers. Those areas that still have less than acceptable reliability, such as the classification of incomplete injuries, may be addressed in the future though either a modification of the Standards or an improvement in the supporting manual used for classification. ChopterY Relay and Valdty ofthe ntenatonal Standards of Cessation of Spinal Cord jy. 61feference Manual forthe Intemational Standards for Newolola Clsifcaton of pina Crd It Re. 2003) B. Research on Reliability Reliability has been broadly defined as the "quantification of the consistency and inconsistency in examinee performance." (Feldt and Brennan, 1989) As noted above, reliability can be considered for the components of the examination as well as the neurologic classification derived from the examination. Only a limited number of studies have considered the reliability of the examination for the Standards when performed as described in the training manual. However, a larger number of studies have assessed the reliability of manual muscle testing as described in standard texts.(Hislop and Montgomery, 1995) Most of these studies have demonstrated acceptable inter-rater reliability when commonly tested muscles are assessed with standard technique and when muscles strength is scored with a 6 point (0-5) scale. (Florence et al., 1992) When muscle strength is graded with + and - sub-grades, or when less commonly studies muscles such as gluteus medius are assessed, greater inter-rater variability in grading has been demonstrat- ed.(Frese at al., 1987) Jonssen et al. (2000) assessed the reliability of the examination in 23 predominantly incomplete subjects. Two physicians and two physical therapists performed the examinations, and a training session was held in the middle of the study to attempt to improve agree- ment between examiners. Motor scores showed good or very good agreement following the mid-study training procedure for the majority of individual Key Muscles. However, that study did not state whether motor testing was performed using the testing techniques specified in the prior edition of this Reference Manual. (Donovan, 1994) For sensory scores in individual dermatomes, agreement as measured with kappa improved after the rater met mid-study to discuss technique, but scores remained in the fair to poor range. Most studies that have assessed the examination component of the Standards have assessed composite scores derived from summating individual motor or sensory scores from the examination. Cohen and Bartko (1994) evaluated the 1992 Standards and reported excellent inter- and intra-rater reliability for total pin, touch , and motor scores. Intra-class correlation coefficients for these ranged from 0.96 to 0.99. Scores for light touch in subjects with incomplete injures showed less reliability than the other measures, and this was thought to be due to variability in testing technique. Following that study, a standardized method for performing the sensory exam was recommended in the first edition of this manual.(Maynard 1994) A later study involving primarily subjects with motor-complete SCI also reported excellent intra-rater reliability for these composite motor and sensory scores, with highest reliability for the ASIA motor score.(Clifton et al., 1996) 62 Chapter Relbity and Vay ofthe International Standard of Oasification of Spina Cord IniuryReference Manual forthe ntemational Standards for Neurological Clsiicatlon of Spinal Cord ur Rev. 2003) ‘The majority of research on reliability of the Standards has assessed the classification that examiners make when given a hypothetical examination. One of the earliest studies to assess this was published by Donovan et al (1990). In that study, the 1987 edition of the Standards was assessed using 5 cases that were classified by 15 experts and 16 clinicians. Multiple areas showed poor inter-rater agreement, including dermatomes, Frankel scores, and neurological level. Subsequent to this study, a number of revisions were proposed for the Standards, such as the definition of Key Sensory Points for testing of sensation within each dermatome and the development of the ASIA Impairment Scale score. Priebe and Waring (1991) assessed the original Standards and the 1989 modification of the Standards in 15 physicians with 5 cases. This study showed that use of the modified Standards improved agreement with the gold standard classification for Frankel score, motor level, sensory level, and zone of injury. Classification of thoracic motor levels was identified as a persisting problem area. The recommendation from these investigators that standardized training methods be developed was in part responsible for development of the first edition of this manual. Cohen and Bartko (1994) evaluated classification in a study of 29 physical therapists and nurses participating in a study of a pharmacologic agent to treat acute SCL AIS was found to have good inter- and intra-rater, reliability (ICC .72 and .84, respectively), although reliability was poor (ICC .13-.20) for incomplete tetraplegia and paraplegia. However, neurologic levels showed only fair to good inter-rater reliability, with ICC for sensory ranging .32 to 45 and ICC for motor ranging .54 to .72. ‘The investigators noted that the raters had not received training in classification of neurological levels and had not been required to do so during the drug trial. Thus they concluded that training in classification would be required to achieve inter-rater reliability. Cohen et al. (1998) later assessed the effect of training on the reliability of classification of neurological levels and AIS using the 1992 Standards. 106 professionals were provided with two examinations: one subject with complete tetraplegia and one with incomplete paraplegia. After classifying oth cases, the raters received a lecture on classification, and they then repeated their classification for the two cases. For complete tetraplegia, the proportion with correct classification (when compared to the criterion standard provided by the investigators) increased slightly, but classification prior to the lecture was correct for the majority of items. For incomplete paraplegia the percent correct improved substantially, but for some parts of the classification the majority of raters remained incorrect. Chapter Relay and Vality ofthe ntematiena Standards of Cessation of Spinal Cord Injury. 62Reference Manual forthe Interatonal Standards fr Neurological Clasiication of Spinal Cord ny (Re 2003) The investigators concluded that additional training was needed, and that motor level classification when grade 4 muscles are present required a revision of definitions. Donovan et al. (1997) assessed the reliability of classification using a group of internationally recognized experts on neurological classification Even this group of experts disagreed over some aspects of classification. Problems remained with sensory level determination and how to score muscles if pain inhibits effort. An attempt was made to address both of these problem areas in the 1996 revision of the Standards. . Research on Validity Validity has been broadly defined as "an inductive summary of both the existing evidence for and the potential consequences of score interpretation and use."(Messick, 1989) .Many studies are available that support the predictive and concurrent validity of the Standards, and some of these will be briefly reviewed here. Some of these studies were not designed to specifically address the validity of the Standards; rather, investigators appear to have considered them the best available and widely recognized measure of neurologic function in SCI, and thus its, predictive or concurrent validity has been compared to that of other measures such as motor evoked potentials.(Curt et al., 1998) No alternate “gold standard” representation for the neurologic examination and classification is available for determination of criterion validity. Due to the process by which the Standards were developed and the components of the neurologic exam that are assessed to determine classification, the Standards can also be considered to have face validity. Predictive validity is defined as "the extent to which an individual's future level on the criterion is predicted from prior test performance." (Messick, 1989) A number of studies have assessed the predictive validity of components of the Standards for neurologic examinations performed shortly after SCI. Crozier et al. (1991) found that in patients with Frankel B classification at 72 hours post-injury, recovery of ambulation was significantly more likely if pin sensation was partially or completely preserved below the level of injury. Similar findings have been reported subsequently by other investigators.(Katoh et al., 1996) Patients with ASIA D tetraplegia at 72 hours post-injury are likely to recover independent ambulation irrespective of age; in contrast, age affects prognosis in those with ASIA C tetraplegia, with a much less favorable prognosis for those age 50 years or greater.(Burns et al., 1997) The validity of the motor scores in predicting upper and lower limb {64 Chapter Refit and Valdty of the Inemational Standards of Cassifcation of Spinal Cod IryReference Manual forthe Intemational Standard for Neurclogkcal hssfiation of pial Cod jury (Rex 2003) function have been assessed and compared with various electrophysiologic studies. In general, the scores showed prognostic value equal to or superior to the electrophysiologic examination. In a study of 36 patients with acute tetraplegia, Curt et al., (1998) found the upper extremity motor score at 25 days post-injury to be significantly correlated with upper limb function, and total motor score was significantly correlated with ambulatory status, at 6 months post-injury. Motor-evoked potentials were found to have slightly lower correlations with outcome in that study. Concurrent validity has been defined as "the extent to which the test scores estimate an individual's present standing on the criterion. (Messick, 1989) The concurrent validity of motor scores and neurological levels in relation to functional tasks has been assessed by a number of investigators. This relationship has been assessed for hand function in motor-complete tetraplegic subjects by Marino and coworkers (1995). Both the UEMS and motor levels were found to be highly correlated with a measure of self-feeding ability, with a lower correlation found between single neurological level and feeding ability. In patients with ASIA C tetraplegia, independence in a number of self-care tasks is more likely with an ASIA Motor Score of 30 or greater points. (Toh et al., 1998) Waters and colleagues (1994) demonstrated that motor scores are correlated. with both the metabolic cost of ambulation and the ability to maintain community-level ambulation. In 1993 Bednarczky and Sanderson compared the ASIA motor score and the Bracken scale in 30 subjects. A moderate correlation (tho=-.66) was found between these two measures. D. Conclusion Researchers have assessed the reliability of various editions of the Standards, with the majority of published studies having assessed the 1992 revision. Most of these studies have demonstrated reliability for some component of the Standards, such as ASIA motor score. However, these same studies have also found less than acceptable reliability for other components, and these findings have prompted revisions to the Standards and the development of training materials. Areas that have been problematic have included neurologic levels and the classification of motor-incomplete injuries. The validity of the Standards has been established in terms of predictive and concurrent validity for certain components of the examination and classification. Overall, the changes made with each revision of the Standards appear to have increased their reliability, and this should function to improve their validity. Future research on the reliability and validity of the Standards may uncover the need for further refinements to definitions and development of additional teaching materials. Chapter Relay and Valsty ofthe iteration Standards ofCassiication of Spinal Crd nary 65feference Manual for the Intemational Standards for Newrclgical Classification of Spinal Cord ny (Re. 2003) References Bednarczyk JH, Sanderson Dj. (1993) Comparison of functional and medical assessment in the classification of persons with spinal cord injury. J Rehabil Res Dev.;30(4):405-411. Burns SP, Golding DG, Rolle WA, Jr, Graziani V, Ditunno JF, Jr. (1997) Recovery of ambulation in motor-incomplete tetraplegia. Arch Phys Med Rehabi,;78(11):1169-1172. Clifton GL, Donovan WH, Dimitrijevic MM, et al. (1996) Omental transposition in chronic spinal cord injury. Spinal Cord.;34(4):193-203. Cohen ME, Bartko JJ. (1994) Reliability of ISCSCI-92 for neurological classification of spinal cord injury. In: American Spinal Injury Association and International Medical Society of Paraplegia, ed. Reference manual for the standards for neurologic and functional classification of spinal cord injury. Chicago: American Spinal Injury Association;59-65. Cohen ME, Ditunno JF, Jr, Donovan WH, Maynard FM, Jr. (1998) A test of, the 1992 Intemational Standards for Neurological and Functional Classification of Spinal Cord Injury. Spinal Cord.;36(8):554-560. Crozier KS, Graziani V, Ditunno JF, Jt, Herbison GJ. (1991) Spinal cord injury: prognosis for ambulation based on sensory examination in patients who are initially motor complete. Arch Phys Med Rehabil. ;72(2):119-121. Curt A, Keck ME, Dietz V. (1998) Functional outcome following spinal cord injury: significance of motor-evoked potentials and ASIA scores. Arch Phys Med Rehabil.;79:81-86. Donovan WH, Wilkerson MA, Rossi D, Mechoulam F, Frankowski RF (1990) A test of the ASIA guidelines for classification of spinal cord injuries. J Neuro Rehabs ;4:39-53, Donovan WH. (1994) Neurological assessment: motor examination. In; American Spinal Injury Association and International Medical Society of Paraplegia, ed. Reference manual for the standards for neurologic and functional classification of spinal cord injury. Chicago: American Spinal Injury Association;19-41. Donovan WH, Brown DJ, Ditunno JF, Jr, Dollfus P, Frankel HL. (1997) Neurological issues. Spinal Cord.;35(5):275-281. {66 Chapter Relay and Vali ofthe nenational Standards of Clasifcaton of Spinal Crd IryReference Manual forthe Intemational Standards for Newoagical Clsifcation of Spinal Cod injury (Rev. 2003) Feldt LS, Brennan RL. Reliability. In: Linn RL, ed. (1989) Educational ‘Measurement. 3rd edition ed. New York: Macmillan Publishing ‘Company;105-146. Frese E, Brown M, Norton BJ. (1987) Clinical reliability of manual muscle testing. Middle trapezius and gluteus medius muscles. Phys Ther.;67(7):1072-1076. Florence JM, Pandya S, King WM, et al. (1992) Intrarater reliability of manual muscle test (Medical Research Council scale) grades in Duchenne's muscular dystrophy. Phys Ther.;72(2):115-122; discussion 122-116 Hislop HJ, Montgomery J. (1995) Daniels and Worthingham’s Muscle Testing. 6th Edition ed. Philadelphia: W. B. Saunders Company. Jonsson M, Tollback A, Gonzales H, Borg J. (2000) Inter-rater reliability of the 1992 international standards for neurological and functional classification of incomplete spinal cord injury. Spinal Cord.;38(11):675-679. Katoh S, el Masry WS, Jaffray D, et al. (1996) Neurologic outcome in conservatively treated patients with incomplete closed traumatic cervical spinal cord injuries. Spine.;21(20):2345-2351. Marino RJ, Rider-Foster D, Maissel G, Ditunno JF. (1995) Superiority of motor level over single neurological level in categorizing tetraplegia. Paraplegia ;33(9)'510-513. Maynard FM, Jr. (1994) Neurological assessment: sensory examination. In: American Spinal Injury Association and International Medical Society of Paraplegia, ed. Reference manual for the standards for neurologic and functional classification of spinal cord injury. Chicago: American Spinal Injury Association;:5-17. Messick S. Validity. In: Linn RL, ed. (1989) Educational Measurement. 3rd edition ed. New York: Macmillan Publishing Company;:13-103, Priebe MM, Waring WP. (1991) The interobserver reliability of the revised American Spinal Injury Association standards for neurological classification of spinal injury patients. Am J Phys Med Rehabil.;20(5):268-270. ‘Toh E, Arima T, Mochida J, Omata M, Matsui S. (1998) Functional evaluation using motor scores after cervical spinal cord injuries. Spinal Cord.;36(7):491-46. Waters RL, Adkins R, Yakura J, Vigil D. (1994) Prediction of ambulatory performance based on motor scores derived from standards of the American Spinal Injury Association. Arch Phys Med Rehabil. ;75(7):756-760. Chapter Vly and Vali ofthe Iternatinal Standards of Cssiction of Spinal Crd uy 67feferece Manual forthe International Standards for NeurlogialClassication of Spinal Cord Inury (ev. 2003) Chapter VI_ Metric Properties of the International Standards for Neurological Classification of Spinal Cord Injury, Implications for Research Use A. Introduction In the good practice of research, the services and advice of a trained statistician are always recommended. There are four areas of research where a statistician can be invaluable, 1) research design and planning 2) sampling issues (ie., power and probabilistic sampling); 3) measurement issues; 4) and lastly quantitative analysis. All four components should be afforded equal weight in conducting scientific research. A good rule for research is to meet with your statistician early and often. Statistical methods are not the focus of this chapter. However, itis incumbent upon the researcher to fully understand the characteristics of the measures and classifications employed in the research project. The Standards for Neurological Classification of Spinal Cord Injury, first published in 1982, is a system designed to precisely classify a patient with an SCI Gtover, 1982). Since the first edition the Standards have been revised five times. The sixth edition was published in 2000 (Marino, 2000). Each revision has sought to refine the clarity of the Standards in order to increase the accuracy of definitions of level and extent of injuries ‘The core of the Standards is the standardized motor and sensory evaluation. The ASIA Motor Scale (AMS) physical examination consists of a manual muscle test of ten key muscles bilaterally, five in each upper extremity and five in each lower extremity, along with voluntary anal contraction. The key muscles in the extremities are rated on a 0 to 5 rating scale. The muscle scores are summed to yield a total motor score. Anal contraction is tested as presence or absence of voluntary contraction of the anal sphincter palpable to the examiner. The sensory examination consists of light touch (LT) and pin prick (PP) tests at defined key points of 28 dermatomes bilaterally and the presence or absence of sensation in the perianal area. The LT and PP tests are rated on a three-point scale defined as absent, impaired and normal. The ratings for each dermatome are summed to yield a LT score and a PP score. 68 Chapter Metric Properties ofthe ineaional Standards fr Neurological Casication of Spinal Cord Inu, Implications for Research UseReference Manual forthe Intemational Standards fr NewroagcalCassiation of Spinal Cord Injury (Re. 2003) The ten key muscles tested bilaterally in the ASIA motor scale do not represent an exhaustive set of the muscles innervated by the spinal cord. These ten muscles were chosen based on the pattern of innervation and the ease of testing in a clinical setting (Marino, 2000). Therefore it is essential to determine the extent to which scores from these selected muscles adequately represent the construct of motor function. The question of representative scores is less critical for the sensory scales because every identifiable dermatome is tested twice, once for light touch and once for pin prick. The Standards provide guidelines for determining classifications based on the patterns of the raw motor and sensory data. Up to fifteen indicators can be obtained from the classification for a spinal injury. These ai ) bilateral motor, sensory, and neurological levels; 2) total motor, pin prick and light touch scores; 3) completeness of injury; 4) ASIA Impairment Scale and; 5) bilateral motor and sensory zones of partial preservation (complete injuries only). ‘An important distinction to be made is between classification and measurement. Classifications are designed to describe the pattern of neurological impairment qualitatively; they are not meant to quantify the impairment, No single classification indicator can either fully describe the injury nor can it quantify the impairment. The variation of the motor score by motor level, for example, is very large as seen in Figure 1. Likewise, groups formed on the ASIA Impairment Scale rating alone would not be expected to show differences in the motor score as seen in Figure 2. However, there have been several methods proposed for classifying patients into groups for research purposes, but care should be taken when doing so. One such method has been developed based on mortality data by Coll et al. (1996). The original system proposed by Coll used the Frankel system to characterize the extent of injury. The modification employed by Graves et al. (1999) has substituted the ASIA Impairment Scale for the Frankel Classification, but is otherwise unchanged. This grouping system, depicted in Figure 3 produces groups based on the level and extent of the injury. As seen in Figure 4 the groups formed with the modified Coll system do follow the expected pattern of motor score where more severely impaired groups tend to have lower motor scores. The groups are also somewhat more homogenous. Chapter V1 Metric Properties ofthe Intemational Standards for Neurological Clasitcation of Spinal Cord nun, Implications fr Research Use 68Reference Manual forthe Intemational Standai for Newlogl lasfiaton of Spinal Crd Injury (Rev. 2003) 100 S s S 8 ASIA Motor Total Score x 8 CO C8 COS CO TO TO TOS TO7 TOO TH LOL LiS Sol $43 CM COL CO5 COS TOR TO T06 TH THO TH LO LO $02 S015 Motor Level Figure 1, Distribution of ASIA motor scores by motor level. The bar represents the interquatile range (25th-75th percentiles), the black horizontal line is the median value, and the circles and stars indicate outlier values. 70 Chapter Metric Properties of the inteationl Standards for Neurological Casification of Spinal Cord nay, pias fr Research UseReference Manual for he Intemational Standards for Neurological lsifcation of Spinal Cod Injury (ex 2003) Figure 2. Distribution of ASIA motor scores by ASIA Impairment Scale grade. The bar represents the interquartile range (25th-75th percentiles), the black horizontal line is the median value, and the circles indicate outlier values. Chopter Vi Metric Properties ofthe Inemational Standard fr Neurological Caslicatin of Spinal Cord nur, Implication for Research Use 71Aeference Manual forthe Itematonl Standards for Newological Clasfication of Spinal Cord inj Rev. 2003) Neurological ASIA Impairment Scale A Pt | Group i Fi Tr 1-08 109 T10 TA Taz L-01 Loz 3 $02 Figure 3. Modified Coll classification (Graves et al., 1999). 72 Chapter Metic Poperies ofthe ineational Standards for Neurological Casati of Seal Cord Iu, Implication for Reseach Useference Manal for the Intemational Standards for Neurological Clsscation of Spinal Cord Injury (ev. 2003) 100 152 8 8 1393 —Ous— 8 ASIA Motor Total Score J roo oes x 8 0 | Sas 132 193, 603 9 Group1 Group 2 Group 3 Group 4 Modified Coll Classification Group Figure 4. Distribution of ASIA motor scores by modified Coll classification group. The bar represents the interquartile range (25th-75th percentiles), the black horizontal line is the median value, and the circles and stars indicate outlier values. (Chapter Metric Properties ofthe Iterational Standards fer Neurological lssifcation of Spinal Cord Inuy, Implication for Research Use aReference Manual forthe Internationa Standards for Neurological lasicaton of pial Cod ny (Re 2003) B. Measurement Characteristics of the ASIA Motor and Sensory Scales This section will describe some recent research into the measurement characteristics of the ASIA Motor Scale and to a lesser extent the sensory scales. The research in this section will utilize modern Item Response Theory (IRT) techniques to overcome a few of the issues inherent in the use of the raw data in a classical sense. In order for the reader to benefit from this research a few principals of IRT need to be briefly addressed. The general concepts will be presented, with more technical details identified by smaller font size. The essential difference between modern IRT analysis and the classical reliability theory is that IRT specifies a mathematical model relating the probability of a response to the underlying ability (van der Linden & Hambleton, 1997). In classical theory there is no such specification, and all scores are linear combinations of responses. For the purposes of this discussion, the IRT model estimates one or two parameters that effect the relationship between an item response (e.g, right elbow flexor MMT score) and the underlying construct (e.g,, motor neurological function). Currently one or two parameters are estimated: (1) item difficulty, and (2) item discrimination. ‘The standardized physical examination in the Standards contains raw data that could be utilized to develop measures that will define a continuum of neurological function. Each rating from the motor and sensory examination is considered an item ‘on that test. Utilizing IRT (Samejima, 1969; Thissen, 1991) it is possible to determine the accuracy of individual items and the amount of information that they contribute to the measure developed from those items (Revicki & Cella, 1997; Hambleton, 1989; Hambleton et al, 1991; van der Linden & Hambleton, 1997; Spray, 1987; McHorney, 1997). In an IRT analysis item parameters are estimated from the data that define the relation ofthe individual ratings to the underlying continuum of neurological function. The distinguishing features of the several different IRT models are 1) the number of parameters used to define the relation between responses and the ‘underlying construct and 2) the type of data the model works with. Currently a wide array of models designed to work with dichotomous and polytomous data and estimating one, two or three parameters are widely used. The three parameters are item difficulty (b, item discrimination (a), and a pseudo-chance factor (c). The chance factor does not affect most rating scales soit will not be discussed any further. Acommonly used IRT method is Rasch Analysis (Rasch, 1960). The Rasch model is a special case of the one-parameter IRT model developed by Lord(1952). The Rasch model estimates item difficulty, and assumes that all items are equally discriminating. It is assumed that the spinal segments can be ordered according to the level of ability it requires to achieve a high rating. The difficulty is based on the likelihood of the population receiving a particular grade on a particular muscle. This simply means that it is assumed that a person with more motor ability is 74 Chapter V_Menic Propet ofthe intsmationa Standards for NewoogicalClsscaton of Spinal Cord uy, Inplkatons for Research Usefeference Manal fr the International Standards fo Neurological Clasication of Spinal Cord nur (Rev. 2003) more likely to receive a high rating on the lower segments tested. Essentially, the one-parameter IRT model states that a person’s response toa given item is related to that person’s ability and to the item difficulty, For the motor score, this means that for a person with a spinal cord injury, his or her MMT grade on a given muscle is a factor of that person’s motor function (ability) and the difficulty of the item (key muscle). This however, leads to an ability estimate that is perfectly correlated with the simple sum of the ratings regardless of the pattern of motor preservation or impairment. The one parameter model, as noted above, assumes that all items are equally discriminating. This assumption is restrictive, and can lower the amount of information that can be extracted from the raw data. The Graded Response Model is a two parameter model that estimates item discrimination in addition to item difficulty. The effect is that ability estimate in the Graded Response Model is weighted by the difficulty of the items, which is not the case for the Rasch model. ‘The model for the one parameter logistie model i elo) ROT aw ‘Where (6) is the probability of the randomly chosen person with ability @ will respond correctly toitem i; By. isthe difficulty of item i. An assumption in the one parameter model is that al ites aze equally discriminating and therefore only differ indilfcuty. This assumption leads tothe situation thatthe ability estimate produced with the one parameter model isnot weighted by the item difficulty (Lord, 1860). There wll be a perfect correlation between the rar test score and the ability estimate from the one parameter model. This isnot the case withthe two parameter model which estimates both the item difficulty and a item discrimination factor. The equal discrimination of tems isa restrictive assumption. Itis likely that items in an existing scale will not be equally discriminating. Therefore, the model to be used in this research isthe Graded Response Model (Samejima, 1968) The graded response moctel provides for the discrimination of tems to vary. The model forthe graded response models ee (0b) BO = (ebeO~b,) Chapter vi Metric Properties of the Intemational Standards fr Neurological Clssication of Spinal Cord nun, Implications for Research Use 75Reference Manual fo the Intemational standards for Neurological Caslicaton of Spinal Cod iu ev. 2003) Where P, (8) is the probability ofthe randomly chosen person with ability @ respond in category x of item ior higher; by. is the difficulty ofa response at or above the threshold between response categories x and x + 1 and is defined as the level of 8 at which the probability of a correct response reaches .5, when there is no. chance factor ais the discrimination parameter othe tem, D sa scaling factor when set othe value of 17 brings the logistic function into close alignment to the ‘normal ogive function. In a two parameter model the a parameters proportionate to the slope of the ICC. This model assumes that the response eategores ean be ordered and gives the dificult assigned to the threshold between categorie. ‘Therefore, the model provides the probability ofa response within response category x or higher. The ability estimate provided by the graded response model willbe weighted by the dificult ofthe tems thresholds (Lord, 1980) Unlike classical theory, IRT allows one to evaluate the resulting measure over the range of ability. Evaluation of individual items provides an estimate of the “information” it contains to determine ability. The more precise an item, the more information it contains. Items of different difficulty provide information about different levels of ability. Therefore, the information in a given item, determined by the “item information function” is related inversely to the measurement error of the item and directly to its ability to discriminate between levels of ability. Item information can be combined to yield a “test information function”, that indicates the reliability of the measure to determine ability over the range of ability. The metric used for this is called “Information”, and is determined continuously for levels of ability. Values above 25 are desired. Graphing Information by Ability can illustrate the information regarding ability of items, subscales and scales across the range of ability (see below). ‘The work of Bimbaum incorporated Fischer's information statistics in the two and thee parameter models (van der Linden & Hambleton, 1997). Later Samejima incorporated information statistics into the graced response model. Unlike classical theory that provides a single standard error of measurement for atest, IRT provides continuous estimate ofthe standard error over the range of @. A particular item ‘may be more precise in measuring over a specific ange of @, and therefore, provide ‘more information in that range of . Individual item information functions demonstrate the range of @ (ability) where an item provides the most information (van der Linden & Hambleton, 1997; Lord, 1980). The more elevated the information function, the more precise the measurement and the finer the discrimination between ability evelscan be made. The information function for an item using the graded response model is given by: 2 1,(@) = ——__ 2.8947, —_ O- Came [+ emp 76 Chapter VI_ Metric Propet of te Internationa Standards for Neurological Clssication of Spinal Crd Inu, plato fr Research UseReference Manal forthe international Standards for Neurological Clasiiation of Spina Cord injuty (Re 2003) ‘The elevation of item information functions for the graded response model will be related to two factors; 1) inversely related to the amount of error over the specific levels of 6; sE(6)= +_ O- Te 2) directly related to the ability of an item to discriminate between levels of 0. The information function will be maximized when: 1, + In0.5(1 + VIF Be,)) "Day ‘The combined item information functions wil then demonstrate the compete, or test information function. Ithas been determined that combining item information function to form a test information function and elevating this function above the level of 25 has litle effect on the standard error. Therefor, combining item Information functions such thatthe test information function is elevated above 25 vera broad range of @ would provide atest with minimal ecror over a wide range of abilities (Green etal, 1988). Additionally, the marginal reliability is related to the average elevation of the test information function. The reliability of a est that has an information function that is elevated over a wide range of @ willbe higher than a function thats elevated over a portion of the range of @ and depressed over the remainder C. Advantages of Item Response Theory There are at least three specific issues that IRT methods can help address in the use of the ASIA Motor Score; 1) distinguishing between distinct patterns of responses that may be lost in summation of raw rating data or the use of a one parameter model; 2) maximize the information available from the ratings by investigation of the dimensionality; 3) help alleviate distributional abnormalities. 1. Pattern Preservation ‘The pattern of neurological function and impairment following SCIis critical to understanding the prognosis and functional outcomes of rehabilitation. Using the simple summation of the raw response data, it is possible for two individual patients to have exactly the same motor score, yet have completely different Patterns of neurological function that lead to completely different rehabilitation regimens and vastly different functional outcomes. Chapter Metric Properties ofthe inerationa Standards or Neurological Classification of Spinal Cord nun, Implication for Reseorh Use 77foference Manal forthe ntemational Standards for Neurological Classification of Spinal Crd nur (Re. 2003) An example could be a patient with a central cord syndrome where ‘most function is lost in the upper extremities, while the lower extremities have nearly normal strength contrasted with a patient with complete T6 paraplegia resulting in a loss of function in the lower extremities but normal function in the upper extremities. For both patients the summated ASIA motor score could be identical. However, it is obvious that these patients would demonstrate very different patterns of neurological impairment and have very different functional abilities. This situation will occur in large data sets and is, not uncommon. ‘The summation of the individual ratings from the motor score diminishes the information contained in the pattern of ratings of individual muscles. If the raw scores lose the information in the pattern of responses, then using the one parameter or Rasch model will lose this information also. This follows from the fact that the raw scores and ability estimates from the Rasch model will be perfectly correlated. A preferred measure of neurological function would preserve information contained in the pattern of motor and sensory function so that patients with different patterns could be distinguished Defining the relation of the individual ratings to the construct of neurological function with both item difficulty and item discrimination will allow the scoring of examinations that will ‘maintain the information contained in the pattern of the ratings by differentially weighting the responses by the amount of information they contain. Utilizing the graded response model with the motor ratings it is possible to distinguish between patients with the same raw score but different patterns of ratings. Figure 5 shows two patients J.D. and DM. who demonstrate a common situation. Here is an example of two patients who have exactly the same motor score but distinctly different response patterns. The scale score listed above the raw score is calculated by allowing the raw scores to be weighted by the item difficulty. This is an example of how the two Parameter model could preserve the information contained in the response pattern that would be lost by either the raw summated score, or the one parameter model ability estimate. 78 Chapter Metric Properties ofthe Intemational Standards fer MeurlogicalCastfiaton of Spinal Cord Inu, Implatons for Research UseReference Manal or he interationa tanda for Neurological lasscation of Spinal Cod Injury ev. 2003) om vo a e fe Hi s if HH | |i en fal g tel . ey = |B EI 8 |B Hy 3 iB Ey = |e ey 5 |e fe & IB mm | fe me Scaled Score 19.08, S, a | Sesea sors (+O = Caverns] rors | ga +o CE ormone Figure 5. Muscle and motor score ratings for two hypothetical Patients with identical motor scores. 2. Dimensionality The first edition of the Reference Manual for the International Standards for Neurological and Functional Classification of Spinal Cord Injury indicates that the ASIA motor score is a continuous measure of neurological function Bracken & Holford, 1994). This statement has been misinterpreted by some to mean that this is then a unidimensional measure of neurological function. This perception has been furthered by the fact that the internal consistency of the ASIA motor score is very high (a = .932). The continuity of the ASIA motor score will be addressed in the next section. This section will address the dimensionality of the motor score. A correlation matrix of ASIA motor score items, which looks at the relationship between values of one item to values of another, reveals a pattern that artificially inflates classical internal consistency estimates (table 1). Factor analysis of the items indicates that there are in fact two distinct factors: 1) Upper consisting of the 10 upper extremity key muscles, and 2) Lower ~ consisting of the 10 lower extremity key muscles (table 2). Chapter Metric Properties ofthe Intemational Standards er Neurological lassifcation of Spinal Cord nay, mpication for Research Use 79Reference Manual forthe Iterations Standards for Newologial Classicaton of Spinal Cord injury (ex 2008) ‘An investigation into the dimensions of the ASIA Motor Score has revealed that there are two distinct dimensions contained in this scale. A correlation matrix of the 20 individual ratings in presented in Table 1. The correlation coefficients corresponding to the upper extremity ratings (bold upper left triangle) and the coefficients corresponding to the lower extremity ratings (bold lower right triangle) demonstrate that there isa high degree of interrelatedness within each of the upper and lower extremity scales(16). Iti clear that the magnitude of the correlations in the bold triangles are substantially larger than the those in the square in the upper right comer that depict the correlation between the upper to lower extremities in table 1. The high value for the Cronbach's alpha is produced by the high degree of relation within the two scales, not a high degree of relatedness ofall of the items. ‘This matrix demonstrates why the internal consistency estimates of the ASIA, ‘motor score can be very high, but yet contain two distinct factors (Schutt, 1996) Internal consistency estimates, such as Cronbach's a, will be artificially high when there are subsets of highly interrelated items, even if the individual subsets are not highly correlated, Table 1. Correlation Matrtix for ASIA Motor Score Items. 80 Chapter Vi Metric Properties ofthe inerational Standards fr Neurological Classification of Spina Cor injury, Implications for Research Use BRSeeSeRSeeB rn n aes Spey BeRbEYIYSRREAeference Manual fo the Intemational Standards for Neurol Casfcatin of Spinal Cord nur (Re. 2003) “Alpha factor analysis confirmed the existence of two factors that explained 82.9% of the variance in the 20 ratings. The eigenvalues for these factors were 8.82 and 7.77 ‘When rotated to the Varimax criterion, these factors demonstrated simple structure ‘with the ten ratings from the upper extremities forming one factor and the ten ratings from the lower extremities forming the second factor. Table 2 shows the rotated variable loadings of these factors demonstrating simple structure. Table 2. Variable Loadings For Rotated Factors Underlying The ASIA Motor Score Factor Upper Lower C05 Right 001 C06 Right 027 CO? Right 076 C08 Right 059 TOI Right 021 C05 Left -021 C06 Left 013 C07 Left 054 C08 Left 048 T01 Left 006 102 Right 901 103 Right 918 L04 Right 900 ‘L05 Right 899 S01 Right 918 L02 Left 893 03 Left 12 104 Left .900 105 Left 901 S01 Left 921 Further evidence of the two dimensional structure of the ASIA motor score can be demonstrated using the information functions. If the ASIA motor scale is indeed not a unidimensional scale, then violating the unidimensionality assumption by analyzing all items as a single scale should increase the error of measurement and thus, reduce the amount of information available from the scale. Chapter Meric Properties ofthe nemational standards for Neurological Clesscation of Spinal Cord niu, plains for Research Use 81Reference Manual for he Intemational Standars for NeutlogicalCastication of Spinal Cord Injury (Rev. 203) ‘As demonstrated in Figure 6, when the upper and lower extremity scales are analyzed separately using a graded response model, 1) the individual information functions for the two 10 item upper and lower extremity scales are elevated above the reference line at the value of 25 over a wider range of ability (q); 2) the information functions for the separate upper and lower extremity scales are elevated over a higher range of q relative to the single scale; 3) the combined information function for these two scales is elevated over a broader range of ability than is the information function when the upper and lower extremity scales are analyzed as a single scale (Graves & Frankiewicz, 2001). From a practical standpoint, this example demonstrates that using the upper and lower extremity scales as two separate scales will provide more information than will the single scale. By maintaining the two separate scales, at least some of the pattern information is preserved. 100 Uppers Lower 80 Information & 200-150 100-805 20D Ability (theta) Figure 6. Information Functions for ASIA Motor Scale 2 Chapter Metric Properties ofthe international Standards fr MewologialCssifiation of Spina Cord nay, Implications for Research Usefaference Manal forthe Intemational Standards for Neweagcal lssfcation of pial Cord uy (eu. 2003) 3. Distributional Abnormalities There are well established distributional abnormalities inherent in any large collection of ASIA motor total scores. Figure 7 depicts a typical distribution of ASIA motor total scores, this one taken from the National SCI Database (Graves et al., 1999). This distribution shows that nearly 30% of the cases have the score of 50. The majority of these cases represent persons who have sustained an SCI with preserved motor function between C05 and TO1 and motor function that does not extend to LO2. These distributional abnormalities are directly related to the raw data components of the ASIA motor score. The ASIA motor score consists of manual muscle test scores for key muscles in the upper and lower extremities. There is a gap of twelve untested spinal segments between these two sets of key muscles. Any injury that results in the termination of preserved motor function between T01 and LO1 will not be distinguished from the others (Graves & Frankiewicz, 2000). With this type of distribution the ASIA motor score can be seen as insensitive to change, and incapable of distinguishing between motor ability in approximately 30% of the cases. 1400 7 1200 | | 1000 | || e 800 E 600 | | 400 a a 200 | ee 0 qa do % % % % % % %% % % Total ASIA Motor Score Figure 7. Typical distribution of ASIA Motor Scales Chapter VI Metric Properties of he Intemational Standard for Neurological Classification of pal Cord Inuy,implicaon for Reseach Use 63Aeference Manal for the Intemational Standard for Neurological lssfcation of Spinal Cod injury (Rex. 2003) However, simply separating the upper and lower extremity rating scales will not overcome the distribution problems. In order to overcome these problems the gap must be filled in by some value that would help differentiate the patients who can not be differentiated by the motor score alone. One possible solution is to determine the extent to which substituting a scale developed from the light touch and pinprick sensory data between -02 and L-01 can serve to augment the 12 untested myotomes in the ASIA motor score. One study demonstrated that this approach may have potential (Graves & Frankiewicz, 2000). In this example data from 448 patients with complete ASIA and FIM evaluations at admission to rehabilitation and complete FIM data at discharge were included. The FIM scales were analyzed separately and weighted by item difficulty. Residual change score of Self-care and Mobility subscales during rehabilitation were then calculated for the FIM scales. The ASIA motor and sensory data were calibrated in three different scale structures: 1) as a single 20 item motor scale; 2) as Upper and lower extremity scales separately, and 3) the upper and lower extremities separate with the addition of the separately scaled sensory variable. The sensory variable is the composite of the calibrated light touch and pinprick ratings between T02 and LO1. Utilizing linear regression the incremental value of upper and lower ASIA motor scores and the sensory data for predicting self-care and mobility change during rehabilitation was determined. The results listed in Table 3 show the additional variance (R2 increment) explained for each predictor in the separate analyses. The first analyses using the single scaled ASIA motor score accounted for a total of 23.5% and 35.7% of the variance for Self-care and mobility respectively. Entering the separately scaled upper and lower extremity scores increased the explained variance to 35.8% and 44.1% for self-care and mobility respectively. Separating the upper and lower extremities also demonstrates the differential influence of upper extremity function for self-care and lower extremity function for mobility. Finally, the addition of a separately scaled sensory variable increases the explained variance to 53.2% for self-care and 46.9% for mobility. Additionally, the pattern of differential influence of upper and lower extremity function is extended with the addition of the sensory variable. The weighted linear combination of the ASIA motor ratings combined with the weighted sensory ratings did improve the prediction of functional gain during rehabilitation. 4 Chapter Metric Properties ofthe Intemational Standards for Neurological Cessation of Spinal Cor nay, Implications fr Research UseReference Manval forte Intemational Standards for Neurological Clsication of Spinal Cord Injury Re. 2003) However, the use of three weighted linear combinations is pethaps not as useful as a single index with better distributional properties. Figure 8 shows the distribution of a composite score for ASIA motor and sensory scale data that has been scored utilizing a maximum likelihood estimation program from a graded response model. By combining the sensory and motor data into a single analysis the distribution of the final score is much closer to normal than is the typical distribution illustrated in Figure 7. Table 3. Incremental Increase in prediction of Functional Gain Predictor Self Care Mobility Analysis 1 ASIA Motor Score Total 235 357 Analysis 2 Upper Extremities 328 099 Lower Extremities 057 342 Analysis 3 Upper Extremities 219 062 Sensory Variable 226 201 Lower Extremities 087 206 Chapter Metric Properties of te International standards for Neurological Clsscation of Spinal Cord Inluy, mplations fr Research Use 85Reference Manual fo the Intemational Standards fr Newloia Clssiication of Spinal Cord injury (Rev. 2003) Fe a 6% %a “ “ “ Theta Figure 8. Distribution of a Composite of Maximum Likelihood Scoring Estimates D. Conclusion ‘The International Standards for Neurological Classification of Spinal Cord Injury contain a standardized neurological evaluation that can be utilized to define measures of neurological function. However caution should be used when using this data. The measurement properties of these data need to be considered carefully before analysis, is undertaken. The use of IRT methods can reduce the influence of some of the abnormalities. 5 Chapter VI_ Metric Properties ofthe intmatonal Standards for NewologialCasiation of Spinal Crd Inu, plications for Research UseReference Manual forthe international Standards fr Newelogial lasification of Spinal Cor ny (Rex 2003) Reference List Bracken, M. B. & Holford, T. R. (1994). Research Uses of the international standards for neurological and functional classification of spinal cord injury. In American Spinal Injury Association (Ed.), Reference Manual for the International Standards for Neurological and Functional Classification of Spinal Cord Injury (pp. 67-78). Chicago, IL: American Spinal Injury Association. Coll, J., Frankel, H. L., Charlifue, S., Fraser, M., Gardner, B., Jamous, A., & Kirshnan, K. (1996). Evaluation of Homogeneity in Determining Appropriate Groupings for Mortality Risk in Spinal Cord Injury. Spinal Cord Scientific Programme and Abstracts, 21. Graves, D. E. & Frankiewicz, R. G. (2000). A Sensory Variable as Predictor of Functional Gain. Archives of Physical Medicine and Rehabilitation 81[12}, 1621. Graves, D. E. & Frankiewicz, R. G. (2001). Internal consistency does not equal unidimensionality. Archives of Physical Medicine and Rehabilitation 82[10], 1496. Graves, D. E,, Frankiewicz, R. G., & Carter, R. E. (1999). Gain in functional ability during medical rehabilitation as related to rehabilitation process indices and neurologic measures. Archives of Physical Medicine and Rehabilitation, 80, 1464-1470. Green, D. R,, Yen, W. M., & Burket, G. R. (1989). Experiences in the application of Item Response Theory in test construction. Applied Psychological Measurement, 2, 297-312. Hambleton, R. K. (1989). Principles and selected Applications of the Item Response theory. In R.L.Linn (Ed.), Educational measurement (rd ed., pp. 147-200). New York: Macmillan. Hambleton, R. K., Swaminathan, H., & Rogers, H. J. (1991). Fundamentals of Hem Response Theory, Newbury Park: California: Sage Publications. Lord, FM. (1952). A Theory of Test Scores. (1 ed.) (Vols. 7) lowa City: lowa: Psychomatric Society. Lord, F. M. (1980). Applications of Item Response Theory To Practical Testing Problems. Hillsdale, New Jersy: Lawrence Erlbaum Associates. Chapter Metric Properties ofthe Intemational Standars for Neurological Classification of Spinal Cod Inu, Implications for Research Use 87Reference Manual for he international Standards for Neurological lssfication of Spinal Cord ny (Re 2003) Marino, R. J. (2000). International Standards for the Neurological Classification of Spinal Cord Injury. (5th ed.) Chicago: American Spinal Injury Association. McHorney, C. A. (1997). Generic Health Measurement: Past Accomplishments and a Measurement Paradigm for the 21st Century. Annals of Internal Medicine, 127, 743-750. Priebe, M. M. & Waring, W. P. (1991). The interobserver reliability of the revised American Spinal Injury Association standards for neurological classification of spinal injury patients. American Journal of Physical Medicine ‘and Rehabilitation, 70, 268-270. Rasch, G. (1960). Probabilistic Models for Some Intelligence and Attainment Tests. (1 ed.) Copenhagen:Danmarks: Danmarks Paedagogiske Institut. Revicki, D. A. & Cella, D. F. (1997). Health Status Assessment for the twenty first century: Item response theory, Item banking and computer adaptive testing. Quality of Life Research, 6, 595-600. Samejima, F. (1969). Estimation of Latent Ability using a response pattern of graded scores. Psychometric Monograph, 17. Schmitt, N. (1996). Uses and Abuses of Coefficient Alpha. Psychological Assessment, 8, 350-353. Spray, J. A. (1987). Recent Developments in Measurement and Possible Applications to the Measurement of Psychomotor Behavior. Research Quarterly for Exercise and Sport, 58, 203-209. Stover, S. L. (1982). Standards for Neurological Classification of Spinal Injury Patients. Chicago: ASIA. Thissen, D. (1991). Multilog User's Guide: Multiple, Categorical Item Analysis and Test Scoring Using Item Response Theory. (1991 Version 6.0 ed.) Chicago, IL: Scientific Software, Inc. van der Linden, W. J. & Hambleton, R. K. (1997). Handbook of Modern Item Response Theory. New York, NY: Springer. 88 Chapter I_ Metric Properties ofthe Intemational Standard for Neurological Casifation of Spinal Cord ny, Implications for Research UseReference Manual for he international Standards for Neurological Casati of Spinal Cord nur (Rev. 2003) Appendix A Blank Neurological Form for PhotocopyingAeference Manual for the Intemational Standards for Neucagical Clsification of Spinal Cord Injury (Rex 2003) soe _vouaossy Ant eas ucyoury Bu Uy LOS iow paeye 29 ou PREYS na KBD) pox 8a APL Moy AL saennens Tubes ee a A = Ta ajuoiow atest its Akos hwepoosacemmucn CIT yorow isonet y CoC usosnas Nouvauasaud Co) 2343 1aN0oNt CoC usosnas aaa Te WILdivd 40 3NOZ HO 31L37dWOD 74 WwoID0710uNaN (29 2) 6) imoo fo) tnrvonrd (eu 29) guo9s Hono Hor 9 = auoos uo1on [—] =C}+| eum” guoos yw Na -CH FGP s™Mon +48. (oN) voyoenueo eu Lennon [—] es obuy on) siomnpae so6g i 20 Go0uy eyppnu jo muteud ep) SsoKay 206013 2 ‘swosuene wom 29 s105u00%9 IsuHt 9 siorey #003 ¥ 2 2 7 a saT0snW Aa ows — Hanon ‘Thor HOLOW AYNPNI GYHOSD IWNidS 40 NOILLVOISISSW19 1VDIDOTOUNAN GYVGNVLS ‘sjUeWOQ ‘ewe JOUIeXa, ‘wexy Jo a72q OWEN JuaHeference Manual for he international Standards for Neurological Csficaton of Spinal Cord Inu Re 2003) Appendix B Case Examples for Chapter IV Scoring, Scaling and ClassificationIT yorow — sass rts woot EIT orow — valde [ES] Anosnas _Nouvauasaud 2ala1dWOon| = [29] [23 ]4uosNas Tana Te sayiluva do aNoz Geese) yousanos 7 2 -worpotouna Ae (69 69) (5) 2) inom eo) uu) ayOOs HONOL HONE ]=<— MZ og, adoos uoow [2] = [a+ [also evs 0a) auoos wold Nid Co) = ZK) (onse4) uogeoues jour Auy [Kl] vi vil (f

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