American Spinal Injury Association (ASIA) Impairment Scale - Page 5

Wise Young · 04-11-2004, 09:15 PM

mattc, I apologize for the double negative in the statement... please read it again: "Less than half of the muscles have a score of three or greater"... means that half or more of the muscles have scores less than 3. Wise.

Wise Young · 04-11-2004, 09:30 PM

Sherman, for most of my career, I have been arguing against applying the label of "complete" to people. It is inappropriate scientifically, clinically, and psychologically. We know that

1. Scientifically, absence of function below the injury site does not mean absence of axons or connections, only that there is not sufficient connections to reach a threshold for activity.

2. Clinically, as many as 20-25% of people with so-called "complete" spinal cord injury and particularly when treated with methylprednisolone become "incomplete" over time (i.e. convert from ASIA A to ASIA B or C).

3. Psychologically, the label of "complete" injury becomes a self-fulfilling prophecy. People who believe that they will not recover will not only not try to recover but deny the possibility of recovery.

Regarding your level... it depends on the neurological findings. That is why I keep asking you what sensation and motor function you have. When you say that your last normal sensation is at vertebral level T12, that does not make sense. Use the dermatomal map below and figure out your sensory level is. And please, figure out your motor level. Can you feel down to your knees... if so, your sensory level may be at L3, for example.

Meg1 · 04-12-2004, 05:10 PM

Like many others I am trying to understand how to figure out the ASIA score of Dennis, C5 diagnosed as complete.

He seems like a classic C5 in terms of function, but does have some sensation below level of injury on the right side, not the same as pre-SCI, but some - down to his toes.

My question on ASIA rating has to do with the fact he knows when he has to have a BM and can feel when it happens, and also can 'feel' when he has his suppository as part of his BP.

Does this mean he may not be complete? And possibly ASIA B, not ASIA A?

Thanks Wise,
Meg

SCI-Nurse · 04-12-2004, 05:16 PM

The injury is named after the lowest segment with NORMAL SENSATION
&
A MUSCLE GRADE OF 3 OR BETTER

So if someone has movement at C5 with a grade 3 or better, but not below this, they would be called C5 even if they have have normal sensation. The fact that he has bowel and bladder (and genital???) sensation, even if not normal, would indicate an ASIA B at least, since this requires some sensation below the level of injury that includes the peri-anal (around the anus) sensation.

(KLD)

Wise Young · 04-12-2004, 06:41 PM

KLD, thanks very much for pointing that out. A muscle grade of 3 is considered normal for a segment because almost all muscles are shared between two segments. Therefore, if the C5 dermatome has normal sensation and the biceps (which is innervated by C5 and C6) is a grade 3 or better, the person has a C5 injury level.

Meg, I agree with KLD. The fact that Dennis can feel a suppository being placed suggests that he has rectal and anal sensation. If he can (and it is not just some indirect feeling) feel touch or pinprick around his anus, this would mean that he is an ASIA B. This is also consistent with his having feeling down to his toes on the right side. He may even be an ASIA C if he has voluntary motor function that is more than one segment below his neurological level. This is where the ASIA classification system is vague. The original scale developed by Hans Frankel, called the Frankel scale, upon which the ASIA scale is partly based, the C classification is assigned only if there is non-useful motor function in some leg muscle. The ASIA scale does not distinguish between arms and legs muscles. Therefore, if Dennis gets back finger movements (C8), this would mean that he would be considered an ASIA C.

Christopher Reeve started off as an ASIA A with a C2 neurological level. At about 2 years after injury, he began to notice that he can feel a suppository inserted during his bowel routine. Over time, he became so sensitive that this would bother him and they had to use lidocaine jelly when they did his routine. His son Will also noticed that he could attract his father's attention when he slapped his father's hand. So, Christopher was at least an ASIA B. Over 3-5 years, he continued to get back more sensory function so that he has sensation over perhaps as much as 3/4 of his body, down to his knees. In addition, he found that he could shrug his shoulders, move his left index finger, and voluntarily move his hip flexors sufficiently to lift a 5-pound weight with either leg in a swimming pool. He, however, still cannot move his biceps. Therefore, Christopher currently has a C4 neurological level and an ASIA C classification.

Wise.

Meg1 · 04-13-2004, 05:16 AM

Thanks for the reply Wise. I am truthfully not sure of the muscle grade, as far as I know a test has never been done on the grade. He does have some sensation down to his toes - he could feel my daughter playing with his toes about two months post (he was not looking and noticed her doing it). His biceps do work, triceps are very trace. No finger movement. Wrist flexors are working well on the right, but trace on the left.

He does need lidocane during his BP, not sure about pin prick though, again I do not know that this test has ever been done. He has not been in a pool yet, he did he inpatient and now outpatient therapy at Kessler, but has not 'been invited' to go swimming yet.

Thanks again for the quick reply and all your hard work.

Meg

SCI-Nurse · 04-13-2004, 03:25 PM

A grade 3 muscle is one that will move the designated joint through its full range of motion against gravity, but will not take resistance.

Here is a handout that I use when teaching new staff that you may find helpful. This can be combined with the sensory dermatome chart below posted by Dr. Young:

Meg1 · 04-13-2004, 06:14 PM

What determines complete vs. incomplete?

Wise Young · 04-13-2004, 08:20 PM

meg, ASIA A is "complete". Everything else is "incomplete". Wise.

antiquity · 04-13-2004, 09:33 PM

Incomplete = touch/pin prick anal sensation, some motor/sensory preservation below injury level.
Complete = no touch/pin prick anal sensation, may or may not have motor/sensory preservation below injury level.

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04-11-2004, 09:15 PM	#41
Wise Young Administrator Join Date: Jul 2001 Location: New Brunswick, NJ, USA Posts: 37,972	mattc, I apologize for the double negative in the statement... please read it again: "Less than half of the muscles have a score of three or greater"... means that half or more of the muscles have scores less than 3. Wise.

04-11-2004, 09:30 PM	#42
Wise Young Administrator Join Date: Jul 2001 Location: New Brunswick, NJ, USA Posts: 37,972	Sherman, for most of my career, I have been arguing against applying the label of "complete" to people. It is inappropriate scientifically, clinically, and psychologically. We know that 1. Scientifically, absence of function below the injury site does not mean absence of axons or connections, only that there is not sufficient connections to reach a threshold for activity. 2. Clinically, as many as 20-25% of people with so-called "complete" spinal cord injury and particularly when treated with methylprednisolone become "incomplete" over time (i.e. convert from ASIA A to ASIA B or C). 3. Psychologically, the label of "complete" injury becomes a self-fulfilling prophecy. People who believe that they will not recover will not only not try to recover but deny the possibility of recovery. Regarding your level... it depends on the neurological findings. That is why I keep asking you what sensation and motor function you have. When you say that your last normal sensation is at vertebral level T12, that does not make sense. Use the dermatomal map below and figure out your sensory level is. And please, figure out your motor level. Can you feel down to your knees... if so, your sensory level may be at L3, for example.

04-12-2004, 05:10 PM	#43
Meg1 Senior Member Join Date: Sep 2003 Posts: 225	Like many others I am trying to understand how to figure out the ASIA score of Dennis, C5 diagnosed as complete. He seems like a classic C5 in terms of function, but does have some sensation below level of injury on the right side, not the same as pre-SCI, but some - down to his toes. My question on ASIA rating has to do with the fact he knows when he has to have a BM and can feel when it happens, and also can 'feel' when he has his suppository as part of his BP. Does this mean he may not be complete? And possibly ASIA B, not ASIA A? Thanks Wise, Meg

04-12-2004, 05:16 PM	#44
SCI-Nurse Moderator Join Date: Jul 2001 Location: USA Posts: 41,301	The injury is named after the lowest segment with NORMAL SENSATION & A MUSCLE GRADE OF 3 OR BETTER So if someone has movement at C5 with a grade 3 or better, but not below this, they would be called C5 even if they have have normal sensation. The fact that he has bowel and bladder (and genital???) sensation, even if not normal, would indicate an ASIA B at least, since this requires some sensation below the level of injury that includes the peri-anal (around the anus) sensation. (KLD)

04-12-2004, 06:41 PM	#45
Wise Young Administrator Join Date: Jul 2001 Location: New Brunswick, NJ, USA Posts: 37,972	KLD, thanks very much for pointing that out. A muscle grade of 3 is considered normal for a segment because almost all muscles are shared between two segments. Therefore, if the C5 dermatome has normal sensation and the biceps (which is innervated by C5 and C6) is a grade 3 or better, the person has a C5 injury level. Meg, I agree with KLD. The fact that Dennis can feel a suppository being placed suggests that he has rectal and anal sensation. If he can (and it is not just some indirect feeling) feel touch or pinprick around his anus, this would mean that he is an ASIA B. This is also consistent with his having feeling down to his toes on the right side. He may even be an ASIA C if he has voluntary motor function that is more than one segment below his neurological level. This is where the ASIA classification system is vague. The original scale developed by Hans Frankel, called the Frankel scale, upon which the ASIA scale is partly based, the C classification is assigned only if there is non-useful motor function in some leg muscle. The ASIA scale does not distinguish between arms and legs muscles. Therefore, if Dennis gets back finger movements (C8), this would mean that he would be considered an ASIA C. Christopher Reeve started off as an ASIA A with a C2 neurological level. At about 2 years after injury, he began to notice that he can feel a suppository inserted during his bowel routine. Over time, he became so sensitive that this would bother him and they had to use lidocaine jelly when they did his routine. His son Will also noticed that he could attract his father's attention when he slapped his father's hand. So, Christopher was at least an ASIA B. Over 3-5 years, he continued to get back more sensory function so that he has sensation over perhaps as much as 3/4 of his body, down to his knees. In addition, he found that he could shrug his shoulders, move his left index finger, and voluntarily move his hip flexors sufficiently to lift a 5-pound weight with either leg in a swimming pool. He, however, still cannot move his biceps. Therefore, Christopher currently has a C4 neurological level and an ASIA C classification. Wise.

04-13-2004, 05:16 AM	#46
Meg1 Senior Member Join Date: Sep 2003 Posts: 225	Thanks for the reply Wise. I am truthfully not sure of the muscle grade, as far as I know a test has never been done on the grade. He does have some sensation down to his toes - he could feel my daughter playing with his toes about two months post (he was not looking and noticed her doing it). His biceps do work, triceps are very trace. No finger movement. Wrist flexors are working well on the right, but trace on the left. He does need lidocane during his BP, not sure about pin prick though, again I do not know that this test has ever been done. He has not been in a pool yet, he did he inpatient and now outpatient therapy at Kessler, but has not 'been invited' to go swimming yet. Thanks again for the quick reply and all your hard work. Meg

04-13-2004, 06:14 PM	#48
Meg1 Senior Member Join Date: Sep 2003 Posts: 225	What determines complete vs. incomplete?

04-13-2004, 08:20 PM	#49
Wise Young Administrator Join Date: Jul 2001 Location: New Brunswick, NJ, USA Posts: 37,972	meg, ASIA A is "complete". Everything else is "incomplete". Wise.

04-13-2004, 09:33 PM	#50
antiquity Moderator Join Date: Jul 2001 Posts: 14,540	Incomplete = touch/pin prick anal sensation, some motor/sensory preservation below injury level. Complete = no touch/pin prick anal sensation, may or may not have motor/sensory preservation below injury level.