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Thread: American Spinal Injury Association (ASIA) Impairment Scale

  1. #81
    hello,

    my cousin was in an auto accident on 11-30-08 and she fractured her c2. the doctors have said that there is spinal cord swelling and a piece of the vertebrae is in the spinal canal, but they have decided not to do surgery on it. the spinal cord has not been severed only "stretched." Does stretched mean contusion? they have labeled her as an ASIA A and i understand the chances of recovery... they are enough to keep hope alive.
    she has started having patchy sensation to touch, but i am unsure about pain sensation, as far down as her legs. I am not sure what dermatome in the legs but any sensation would be below the neurological level of injury. What could this mean in the long run? Does being labeled as an A change how doctors treat the injury? Is there anything that can be done at this early stage that would help?

    i also want to thank you for what you do here. Your dedication is noble and i greatly respect you for all the knowledge you have imparted on me through this thread.

  2. #82
    Senior Member Leo's Avatar
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    hello bantered,

    real sorry about your cousin

    which center is she in?

    it's very early in her injury so time for improvment.
    http://justadollarplease.org/

    2010 SCINet Clinical Trial Support Squad Member

    "You kids and your cures, why back when I was injured they gave us a wheelchair and that's the way it was and we liked it!" Grumpy Old Man

    .."i used to be able to goof around so much because i knew Superman had my back. now all i've got is his example -- and that's gonna have to be enough."

  3. #83
    thanks leo,

    she is at memorial hermman in houston... it is a level 1 trauma center and they are equiped to deal with this type of injury.

  4. #84
    I saw this thread and did a pub-med search on the ASIA scale. Below is an abstract on the ASIA scale and improved documentation/examination of autonomic function. I believe this is important area of recovery that is often overlooked. Personally, I believe that aggressive rehabilitation improves autonomic function but this improvement is all to often labeled "not functional". I disagree with this mind set to say the least.


    Spinal Cord. 2008 Oct 28.

    International standards to document remaining autonomic function after spinal cord injury.

    Alexander MS, Biering-Sorensen F, Bodner D, Brackett NL, Cardenas D, Charlifue S, Creasey G, Dietz V, Ditunno J, Donovan W, Elliott SL, Estores I, Graves DE, Green B, Gousse A, Jackson AB, Kennelly M, Karlsson AK, Krassioukov A, Krogh K, Linsenmeyer T, Marino R, Mathias CJ, Perkash I, Sheel AW, Shilero G, Schurch B, Sonksen J, Stiens S, Wecht J, Wuermser LA, Wyndaele JJ.

    University of Alabama, Birmingham, AL, USA.

    Study design:Experts opinions consensus.Objective:To develop a common strategy to document remaining autonomic neurologic function following spinal cord injury (SCI).Background and Rationale:The impact of a specific SCI on a person's neurologic function is generally described through use of the International Standards for the Neurological Classification of SCI. These standards document the remaining motor and sensory function that a person may have; however, they do not provide information about the status of a person's autonomic function.Methods:Based on this deficiency, the American Spinal Injury Association (ASIA) and the International Spinal Cord Society (ISCoS) commissioned a group of international experts to develop a common strategy to document the remaining autonomic neurologic function.Results:Four subgroups were commissioned: bladder, bowel, sexual function and general autonomic function. On-line communication was followed by numerous face to face meetings. The information was then presented in a summary format at a course on Measurement in Spinal Cord Injury, held on June 24, 2006. Subsequent to this it was revised online by the committee members, posted on the websites of both ASIA and ISCoS for comment and re-revised through webcasts. Topics include an overview of autonomic anatomy, classification of cardiovascular, respiratory, sudomotor and thermoregulatory function, bladder, bowel and sexual function.Conclusion:This document describes a new system to document the impact of SCI on autonomic function. Based upon current knowledge of the neuroanatomy of autonomic function this paper provides a framework with which to communicate the effects of specific spinal cord injuries on cardiovascular, broncho-pulmonary, sudomotor, bladder, bowel and sexual function.Spinal Cord advance online publication, 28 October 2008; doi:10.1038/sc.2008.121.

    http://www.ncbi.nlm.nih.gov/pubmed/1...ubmed_RVDocSum
    “As the cast of villains in SCI is vast and collaborative, so too must be the chorus of hero's that rise to meet them” Ramer et al 2005

  5. #85

    Question Reliability and validity og ASIA scale?

    Hi Wise..

    I am writing with a question about the validity and reliability of the ASIA score scale...

    I am writing a research proposal using the ASIA scale as one of the important outcome measures. I have searched for litterature to find information on the reliability and validity but can not really find anything... do you think you could help me with this? Any articles that has tested this??

    Best regards,

    Barbro Walther-Zhang

  6. #86
    Quote Originally Posted by Barbrowz View Post
    Hi Wise..

    I am writing with a question about the validity and reliability of the ASIA score scale...

    I am writing a research proposal using the ASIA scale as one of the important outcome measures. I have searched for litterature to find information on the reliability and validity but can not really find anything... do you think you could help me with this? Any articles that has tested this??

    Best regards,

    Barbro Walther-Zhang
    Barbro,

    What do you mean by the ASIA score scale? Are you referring to the motor and sensory score? The ASIA Classification is frequently called the ASIA Impairment Scale (AIS). You are clearly not searching properly. Here are some references:

    1. Lemay JF and Nadeau S (2010). Standing balance assessment in ASIA D paraplegic and tetraplegic participants: concurrent validity of the Berg Balance Scale. Spinal Cord 48: 245-50. Institut de readaptation Gingras-Lindsay de Montreal, Montreal, Quebec, Canada. jf.lemay@umontreal.ca. STUDY DESIGNS: Longitudinal and correlational study with repeated measures. OBJECTIVES: The aim of this study was to test the concurrent validity of the Berg Balance Scale (BBS) for a spinal cord injury (SCI) population. PARTICIPANTS: A total of 32 individuals with an ASIA D SCI walking 10 m independently, with or without walking assistive devices. SETTING: An intensive rehabilitation center in Montreal, Canada. METHODS: Subjects were evaluated on the BBS, the Walking Index for Spinal Cord Injury (WISCI II), the Spinal Cord Injury Functional Ambulation Inventory (SCI-FAI), the 10-m walk test (10MWT) and the Timed Up and Go (TUG). Individuals were reassessed during rehabilitation when progressing to a device providing less support or to unassisted gait. RESULTS: All walking tests were highly correlated with the BBS (0.714<Rs<0.816, P<or=0.01). A significant ceiling effect was found on the BBS, the WISCI and on most subsections of the SCI-FAI. Assistive devices used for walking relate well to the BBS score (Spearman's rho 0.714, P<0.01). CONCLUSION: The BBS is an appropriate assessment of standing balance for individuals with SCI. Complementary evaluation with the 10MWT or the 2MWT is recommended to supplement the ceiling effect on the BBS.
    2. van Middendorp JJ, Hosman AJ, Pouw MH and Van de Meent H (2009). Is determination between complete and incomplete traumatic spinal cord injury clinically relevant? Validation of the ASIA sacral sparing criteria in a prospective cohort of 432 patients. Spinal Cord Spine Unit, Department of Orthopaedics, Radboud University Nijmegen Medical Centre, Orthopaedie, Nijmegen, Gelderland, The Netherlands. Study design:Prospective multicenter longitudinal cohort study.Objective:To validate the prognostic value of the acute phase sacral sparing measurements with regard to chronic phase-independent ambulation in patients with traumatic spinal cord injury (SCI).Setting:European Multicenter Study of Human Spinal Cord Injury (EM-SCI).Methods:In 432 patients, acute phase (0-15 days) American Spinal Injury Association (ASIA)/International Spinal Cord Society neurological standard scale (AIS) grades, ASIA sacral sparing measurements, which are S4-5 light touch (LT), S4-5 pin prick (PP), anal sensation and voluntary anal contraction; and chronic phase (6 or 12 months) indoor mobility Spinal Cord Independence Measure (SCIM) measurements were analyzed. Calculations of positive and negative predictive values (PPV/NPV) as well as univariate and multivariate logistic regressions were performed in all four sacral sparing criteria. The area under the receiver-operating characteristic curve (AUC) ratios of all regression equations was calculated.Results:To achieve independent ambulation 1-year post injury, a normal S4-5 PP score showed the best PPV (96.5%, P<0.001, 95% confidence interval (95% CI): 87.9-99.6). Best NPV was reported in the S4-5 LT score (91.7%, P<0.001, 95% CI: 81.6-97.2). The use of the combination of only voluntary anal contraction and the S4-5 LT and PP sensory scores (AUC: 0.906, P<0.001, 95% CI: 0.871-0.941) showed significantly better (P<0.001, 95% CI: 0.038-0.128) discriminating results in prognosticating 1-year independent ambulation than with the use of currently used distinction between complete and incomplete SCI (AUC: 0.823, P<0.001, 95% CI: 0.781-0.864).Conclusions:Out of the four sacral sparing criteria, the acute phase anal sensory score measurements do not contribute significantly to the prognosis of independent ambulation. The combination of the acute phase voluntary anal contraction and the S4-5 LT and PP scores, predicts significantly better chronic phase-independent ambulation outcomes than the currently used distinction between complete and incomplete SCI.Sponsorship:This study was granted by 'Acute Zorgregio Oost' and the 'Internationale Stiftung fur Forschung in Paraplegie (IFP)'.Spinal Cord advance online publication, 26 May 2009; doi:10.1038/sc.2009.44.
    3. Savic G, Bergstrom EM, Frankel HL, Jamous MA and Jones PW (2007). Inter-rater reliability of motor and sensory examinations performed according to American Spinal Injury Association standards. Spinal Cord 45: 444-51. National Spinal Injuries Centre, Stoke Mandeville Hospital, Buckinghamshire Hospitals NHS Trust, Aylesbury, Bucks, UK. STUDY DESIGN: Prospective observational. AIM: To examine inter-rater reliability of motor and sensory examinations performed according to American Spinal Injury Association (ASIA) standards. SETTING: National Spinal Injuries Centre, Stoke Mandeville Hospital, Buckinghamshire Hospitals NHS Trust, UK. MATERIAL AND METHOD: Results of ASIA motor and sensory examinations performed by two experienced examiners on 45 patients with spinal cord injury (SCI) were compared. RESULTS: Total ASIA scores showed very strong correlation between the two examiners, with Pearson correlation coefficients and intraclass correlation coefficients exceeding 0.96, P<0.01 for total motor, light touch and pin prick scores. The agreement for individual muscle testing of the 10 ASIA key muscles showed substantial agreement for majority of muscles, with the weighted Kappa coefficient range 0.649-0.993, P<0.05. The overall agreement in assignment of manual muscle testing grades (0-5) was 82% on the right and 84% on the left, with the strongest agreement for grade '0' and the weakest for grade '3'. The unweighted Kappa coefficient for agreement in motor and sensory levels ranged from 0.68 to 0.78 (P<0.01). There was no difference in ASIA impairment grades derived from the two examiners' results. CONCLUSIONS: Our study results showed very good levels of agreement in ASIA clinical examinations between two experienced examiners. The established degree of variability due to inter-rater differences should be taken into account in study design of clinical trials with more than one assessor..
    4. Marino RJ and Graves DE (2004). Metric properties of the ASIA motor score: subscales improve correlation with functional activities. Arch Phys Med Rehabil 85: 1804-10. Department of Rehabilitation Medicine, Jefferson Medical College of Thomas Jefferson University, Philadelphia, PA 19107, USA. Ralph.marino@jefferson.edu. OBJECTIVE: To apply item response theory (IRT) methods to neurologic and functional scales to determine the value of using American Spinal Injury Association (ASIA) motor subscores and ability estimates, rather than total ASIA motor scores, to predict motor FIM instrument scores. DESIGN: Secondary analysis of prospectively collected data. SETTING: Model Spinal Cord Injury Systems centers. PARTICIPANTS: People with traumatic spinal cord injury (SCI) (N=4338) discharged from inpatient rehabilitation between January 1, 1994, and March 31, 2003. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Total discharge motor FIM scores, FIM subscale scores, and IRT-derived ability estimates of motor FIM scores. RESULTS: Use of separate ASIA upper-extremity and lower-extremity motor scores improved prediction of motor FIM scores over that of total ASIA motor score (R(2) for motor FIM score, .71 vs .59). Use of IRT-based ability estimates derived by applying a 2-parameter graded response model to the raw scores, however, did not improve prediction of motor FIM scores above that of the ASIA motor subscale scores. CONCLUSIONS: Consistent with the metric properties of the ASIA motor score, and with recent models of disablement, impairment in SCI is more accurately characterized by using separate ASIA upper- and lower-extremity motor scores than by using a single motor score. Use of subscores for impairment should improve prediction of functional abilities and enhance more complex models of disability.
    5. Yonenobu K, Abumi K, Nagata K, Taketomi E and Ueyama K (2001). Interobserver and intraobserver reliability of the japanese orthopaedic association scoring system for evaluation of cervical compression myelopathy. Spine (Phila Pa 1976) 26: 1890-4; discussion 1895. Department of Orthopaedic Surgery, Osaka University Medical School, Suita, Japan. yonenobu-k@umin.ac.jp. STUDY DESIGN: The inter- and intraobserver reliabilities of an assessment scale for cervical compression myelopathy were examined statistically. This scoring system consists of seven categories: motor function of fingers, shoulder and elbow, and lower extremity; sensory function of upper extremity, trunk and lower extremity; and function of the bladder. It evaluates the severity of myelopathy by allocating points based on degree of dysfunction in each category. OBJECTIVES: To determine the inter- and intraobserver reliabilities of the revised scoring system (17 - 2 points) for cervical compression myelopathy proposed by the Japanese Orthopedic Association. SUMMARY OF BACKGROUND DATA: Several scales to assess clinical outcome from treatment of cervical compression myelopathy have been proposed. Most of these scales include items evaluated by observers. However, no system, including the Japanese Orthopedic Association scoring system, has yet been validated in terms of interobserver reliability. METHODS: From five different university hospitals, 10 spine surgery specialists, 10 orthopedic surgeons who had just passed the board examination of the Japanese Orthopedic Association, and 13 residents in the first or second year of orthopedic residency programs were chosen. The participants in this study were 29 patients with myelopathy secondary to ossification of the posterior longitudinal ligament selected from five participating university hospitals. Several surgeons interviewed each patient twice at intervals of 1 to 6 weeks. Inter- and intraobserver reliabilities of the total score for all categories were evaluated by the intraclass correlation coefficient. The extension of the kappa coefficient of Kraemer also was calculated for each category to assess reliability of multivariate categorical data. RESULTS: The interobserver reliability of the total score for the first interview (intraclass correlation coefficient = 0.813) and the intra- and interobserver reliabilities of the total score (intraclass correlation coefficient = 0.826) were high. The level of experience and the hospital slightly affected the reliability of the Japanese Orthopedic Association scoring system. The kappa values for intraobserver data generally were high in each category, whereas the kappa values for interobserver data were relatively low for the categories of shoulder-elbow motor function and lower extremity sensory function. CONCLUSIONS: The inter- and intraobserver reliabilities of the Japanese Orthopedic Association scoring system for cervical myelopathy were high, suggesting that this system is useful for assessment of cervical myelopathy in comparative studies of treatment.
    6. Saboe LA, Darrah JM, Pain KS and Guthrie J (1997). Early predictors of functional independence 2 years after spinal cord injury. Arch Phys Med Rehabil 78: 644-50. Physical Therapy Services, Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada. OBJECTIVE: To determine: (1) how well factors measured at admission to an acute care facility predict functional independence measure (FIM) scores, use of personal care assistance, and wheelchair ownership 2 years after traumatic spinal cord injury (SCI); (2) the extent that factors measured during inpatient stay add to these predictions; and (3) if FIM scores differ through use of assistance and wheelchair ownership 2 years after SCI. DESIGN: Prospective, longitudinal. SETTING: Tertiary care acute, rehabilitation hospitals and home settings. PATIENTS: One hundred sixty SCI admissions. MAIN OUTCOME MEASURES: FIM, use of personal care assistance (yes/no), and wheelchair ownership (manual/electric/none) 2 years after SCI. RESULTS: Year 2 FIM scores were highly correlated (> or = .68) to the ASIA admission and discharge light touch, pin prick, and motor scores. Admission neurological status and age accounted for 65% of year 2 FIM score variance. Adding hospital events and the discharge ASIA motor score increased prediction to 76% of the variance. A separate regression model using only year 2 neurological scores and age accounted for 73% of the total FIM variance. Discriminant function analysis indicated 86% correct classification regarding use of personal care assistance and 88% correct classification of wheelchair ownership. Using a separate cross-validation sample, overall classification accuracy for assistance was 80% and wheelchair ownership 67%. FIM scores were significantly lower in assistance users (78 +/- 24) than nonusers (120 +/- 8) and were significantly different between wheelchair ownership groups: manual (103 +/- 21), electric (61 +/- 15), and none (125 +/- 2). CONCLUSIONS: Late disability can be predicted using early impairment measures. The FIM prediction from variables measured during the early treatment phase was as good as prediction based on concurrent measures.
    7. El Masry WS, Tsubo M, Katoh S, El Miligui YH and Khan A (1996). Validation of the American Spinal Injury Association (ASIA) motor score and the National Acute Spinal Cord Injury Study (NASCIS) motor score. Spine (Phila Pa 1976) 21: 614-9. Midlands Centre for Spinal Injuries, Robert Jones & Agnes Hunt Orthopaedic and District Hospital. STUDY DESIGN: In this study the motor scores of 62 consecutive acute spinal cord-injured patients were retrospectively reviewed. OBJECTIVE: The reliability of the American Spinal Injury Association and National Acute Spinal Cord Injury Study motor scores, compared with the conventional motor scores, was retrospectively assessed. SUMMARY OF BACKGROUND DATA: The reliability of the American Spinal Injury Association and National Acute Spinal Cord Injury Study scores has not as yet been confirmed. METHODS: Sixty-two consecutive adult patients admitted within 7 days of acute spinal cord injury between April, 1983, and September, 1992, were evaluated. The motor deficit percentage and the motor recovery percentage of each of the American Spinal Injury Association and the National Acute Spinal Cord Injury Study motor scores were compared with those of the conventional motor score. From the initial and final motor score, the motor deficit percentage and motor recovery percentage were calculated. There were 38 patients with cervical and thoracic lesions, 12 patients with dorso-lumbar lesions, and 12 patients with lower lumbar lesions. The average follow-up period was 41 months. RESULTS: Both the American Spinal Injury Association motor score and the National Acute Spinal Cord Injury Study motor score were representative of the conventional motor score for the evaluation of the motor deficit percentage and the motor recovery percentage in all levels (P < 0.0001). The differences in all correlation coefficients between the American Spinal Injury Association motor score and the National Acute Spinal Cord Injury Study motor score were not statistically significant in all levels and in every group. CONCLUSIONS: The American Spinal Injury Association and National Acute Spinal Cord Injury Study motor scores can both be used for the neurological quantification of motor deficit and motor recovery.

  7. #87
    s dawson, I moved and answered your post concerning your sister at
    http://sci.rutgers.edu/forum/showthread.php?t=157203

    Wise.

  8. #88
    Quote Originally Posted by Kitten View Post
    One thing that is not clear to me in the ASIA scale is the importance of anal/rectal sensation and/or control. Why is this so important? It seems that classifying injuries based on the amount of sensory/motor function below the injury site would be the most important factors.
    Kitten,

    The definition of "complete" spinal cord injury is to have some spinal level below which there is no voluntary motor function and no sensation. Since S4/5 is the lowest spinal level, if you do not have sphincter function or anal sensation, this means that you have at least one level below which you are "complete". It turns out that this definition is very effective. All people with so-called "complete" spinal cord injuries should not have sacral sparing. It turns out that the prognosis of a person with sacral sparing early after injury is very different from a person without sacral sparing. Over 90% of the former can recover unassisted walking within a year while less than 10% of the latter will recover unassisted walking.

    The ASIA classification system is not all that meaningful if the AIS (Asia Impairment Scale) is used alone. The classification includes the neurological level (defined as the lowest contiguous segmental level of the spinal that has "intact" more and sensory function), the motor scores from 10 muscles on each side of the body, and pinprick and light touch scores of each dermatome from C4 through S4/5. For example, one should just say I am AIS A (ASIA Impairment Scale A). You would add that you are <insert whatever your level is> and, if you are a doctor describing the ASIA classification, you would add the motor, touch, and pinprick scores as well. It is a way of standardizing how clinicians describe a person with spinal cord injury.

    In 1990, when I co-chaired (with John Ditunno) the committee that helped define the ASIA classification, we added the FIM score to the ASIA Classification. This is a observer based functional motor scoring system that gives an idea of the independence of the person. ASIA will probably shift over to a new measure of independence that is more specific for spinal cord injury called SCIM (Spinal Cord Independence Measure). Like, ASIA includes several syndromes of spinal cord injury, including the Anterior Spinal Syndrome, the Posterior Spinal Syndrome, and the Brown Secquard Syndrome.

    The ASIA Classification is still weak in the following respects.
    • It does not measure trunk function, stability or posture.
    • It does not measure bladder or bowel function.
    • It does not measure spasticity.
    • It does not measure neuropathic pain.
    • It does not measure walking.
    • It does not measure sexual function.
    • It does not note the presence of absence of decubiti, thrombophlebitis, autonomic dysreflxia, and the means by which the person is voiding urine, breathing, or ambulation.



    Wise.

  9. #89
    Quote Originally Posted by Wise Young View Post

    The definition of "complete" spinal cord injury is to have some spinal level below which there is no voluntary motor function and no sensation. Since S4/5 is the lowest spinal level, if you do not have sphincter function or anal sensation, this means that you have at least one level below which you are "complete". It turns out that this definition is very effective. All people with so-called "complete" spinal cord injuries should not have sacral sparing. It turns out that the prognosis of a person with sacral sparing early after injury is very different from a person without sacral sparing. Over 90% of the former can recover unassisted walking within a year while less than 10% of the latter will recover unassisted walking.

    ..........

    Wise.
    Wise,
    that you know, what % of people with SCI are examinated according to the ASIA scale after entering in an hospital with SCI?

    I was examiated (kind of) properly just after 2.5 months and it seams to me that docs don't really care about the ASIA examiantion, but hopefully I am not a standard case.

    Paolo
    The airport runway is the most important mainstreet in any town - Norm Crabtree

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