4/23/2017

“ASIA Exam”
International Standards for
• The exam now referred to as the
Neurological Classification of Spinal International Standards exam
Cord Injury • Patients are classified according to the ASIA
Michael Kryger, MD Impairment Scale (AIS)
SCI Fellow • Combined efforts from
Current Concepts in Spinal Cord Injury Medicine – ASIA: American Spinal Injury Association
Conference – ISCOS: International Spinal Cord Society
April 29, 2017

International Standards The ASIA Form

• Last Revised booklet in
2011, 7th edition
• Worksheet revised 2013

Components of the Test Explaining the exam to your Patients

• Three Main Parts to the Exam: • This is NOT a fun exam- it is
– Strength Testing
uncomfortable, confusing and requires
– Light Touch Sensation
– Pinprick Sensation patience
• Lowest Level of motor control: • So explaining to the patient why we do it is
– Voluntary Anal Contraction important!
• Lowest Level of Sensation:
– Deep Anal Pressure

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What not to say: Explaining the exam to your Patients

• “Let’s do this test- it’s for a research • This test will help us determine where your
spinal cord was injured
database and makes the world a better
• It might be different than what was seen on
place!” the MRI or CT Scan
• These patients have just gone through • This is the main test we use to determine
significant traumas- they may not care what level your injury was, how severe it was,
and a rough idea of what we could expect for
about helping the greater good. recovery

Explaining the exam to your Patients Timing of the Exam

• Plus, not only can we use past data to • Initial exam in ER documents traumatic SCI
– Apply appropriate interventions
predict how you will do, if you would like, – Attempt to determine motor level, sensory level,
completeness of injury and AIS score
we can add your exam to a research • Difficult to obtain a complete and reliable exam in ER
database so that future people can benefit • Comorbidities: TBI, Respiratory failure, pain, illicit
like you will drugs, shock, cognitive changes, etc
• 72 hour exam may be better for prediction of recovery

Manual Muscle Testing Grading

Manual Muscle Testing

Strength Grade Description

5/5 Full Strength, Full ROM
Provides some strength against resistance for full
4/5
ROM
3/5 Can perform movement against gravity for full ROM
Can perform movement with gravity eliminated for
2/5
full ROM
Some muscle activity (Palpable or visible), but
1/5
unable to move against gravity
0/5 No muscle activity detected

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Manual Muscle Testing:

Positioning for Motor Exam
Other considerations
• The grade must be achieved with full range of motion • Neutral positioning for Grade 3 testing
at the given resistance level • Strategically eliminate gravity for Grade 2 testing
– (ie moving 25% of ROM against gravity does not earn you a 3/5) – Maintain that position for Grade 1 or 0 testing
• 5* indicates that you would expect a muscle to be 5/5 • When testing for grade 4 or 5, the muscle is positioned in a
strength if there was no SCI-related limiting factor (like manner that partially activates the muscle
a fracture, or pain limiting motion) – Patient is instructed to maintain that position
• NT for limbs that you are not certain of 5/5 strength, – Examples:
but could not be tested due to pain/casting/fracture • C6 – wrist in full extension
etc. • L2 – Hip flexed to 90 degrees
• Refer to Motor exam guides on ASIA website for detailed
• No pluses or minuses! positioning for each myotome

C5- Biceps C6- Wrist Extensors

Gravity Eliminated Against Resistance Gravity Eliminated Against Resistance

Against Gravity Against Gravity

C7- Triceps C8- Finger Flexors (FDP-DIP)

Gravity Eliminated Against Resistance

Gravity Eliminated Against Gravity/ Against Resistance

Against Gravity

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T1- Finger Flexors (FDP-DIP) L2- Hip Flexors

Gravity Eliminated Against Resistance

Gravity Eliminated Against Gravity/ Against Resistance

Against Gravity

L3- Quadriceps L4- Dorsiflexors

Gravity Eliminated Against Resistance

Gravity Eliminated Against Gravity/ Against Resistance

Against Gravity

L5- Great Toe Extensor S1- Plantarflexors

Gravity Eliminated
Against Resistance

Gravity Eliminated Against Gravity/ Against Resistance

Against Gravity

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Motor Exams Pearls and Pitfalls Motor Exams Pearls and Pitfalls
• Patient must be supine for testing • Beware compensatory muscle relaxation
• Move the joints through ROM prior to MMT – Elbow extension mimicked by biceps relaxation
to rule out any pain, spasticity , or – Relaxation of great toe flexors
contracture which might effect motor scores – Palpate the muscle to verify contraction
• Stabilize above and below the join tested to • Consider substituting isometric muscle
prevent muscle substitution contractions in persons with unstable spine
– Supination for Wrist extension – Avoid hip flexion in persons with lesion T8 and below
– Elbow extension by external shoulder rotation as this may increase kyphotic stress on L-spine

Non-key Muscle Groups

• Shoulder movement (C5) except shrug Light-touch Sensation
• Elbow Supination (C5)
• Elbow pronation (C6)
• Wrist Flexion (C6)
– Etc... See ASIA Form
• These become important when assigning AIS
Grade

Light-touch Sensation
Pinprick Sensation

• Use a cotton swab with the top fluffed out

• Use the face as comparison

Grade Description
2 Normal Sensation
1 Abnormal Sensation (hyper or hypo -esthesia)
0 Absent Sensation
NT Not Testable

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Pinprick Sensation Sensation Pearls and Pitfalls

• Use a Safety Pin- cover = dull, pin =sharp • Eyes should be closed for sensory testing
• Use the face as comparison • Tell the patient not to guess
Grade Description • If a patient can not accurately distinguish
2 Normal- can distinguish sharp/dull, and sharp is sharp/ dull on their face then the sensory
equivalent to face
exam is Not Testable
1 Can distinguish sharp/dull, and sharp is less than
or sharper than face • If there is concern for guessing, each point
0 Cannot distinguish sharp/dull (<80%) should be tested 10 times.
NT Not Testable – An accurate response is required 8/10 times

Sensation Pearls and Pitfalls Brief Overview of Dermatomes

• If a patient has abnormal sensation at C2 but
intact sensation on the face, then the person
is given a sensory level of C1
• Dermatomes can be graded as Not Testable if
factors are present which inhibit normal
testing
– Hairy chest, burn, peripheral neuropathy,
wrapping, etc.

Brief Overview of Dermatomes Brief Overview of Dermatomes

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Anal Exam Anal Exam

• Very Important Part to test!
• Voluntary Anal Contraction-
• Don’t forget dermatomes at this point too:
– Insert finger into rectum, and ask patient to contract anus (like
holding in a BM), and release. Repeat several times to confirm
voluntary contraction
• Deep Anal Pressure-
– With finger still in rectum, ask patient which direction you are
applying pressure- towards head, towards feet, towards right
side or towards left side.
– Should show consistent differentiation between directions
• Use Gloves and Lube

Scoring the ASIA Exam Scoring the ASIA Exam

2) Separate motor scores are calculated for the UE and LE

1) Each vertical column is added for a column total for motor and sensory

Scoring the ASIA Exam

3) Separate total scores are calculated for LT and PP ASIA Impairment Scale Classification
1. Determine sensory levels for right & left sides
– The lowest level with a 2 (normal) for both pinprick
and light touch where every level higher is also 2
• The sensory levels may be different on the left
and right sides

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AIS Classification AIS Classification

2. Determine motor levels for right and left sides. 3. Determine the Neurological Level of Injury
– The lowest level where the muscle grade is at least a – The highest level of the four individual levels
three, with all muscles above graded as a 5
– In regions where there is no myotome to test, the
motor level is presumed to be the same as the
sensory level

AIS Classification AIS Classification

4. Determine whether the injury is Complete or 5. Determine ASIA Impairment Scale (AIS) Grade
Incomplete. If complete AIS Grade = A A = Complete
– Defined by presence/absence of sacral sparing
– If NO voluntary anal contraction AND all S4-5 sensory
B = Sensory Incomplete (ie Motor Complete)
scores are O AND there is NO deep anal pressure then C = Motor Incomplete
injury is COMPLETE
– NOOOON Sign D = Motor Incomplete
N O O O O N
E = Normal

AIS Classification Non-key muscle groups

6. If A is ruled out, is the injury Motor incomplete?
(Do they get out of “B”???)
– Preservation of motor function is defined by
• Presence of voluntary anal contraction
OR
• Motor movement greater than three levels below
the motor level on that side of the body
– (may use non-key muscle groups)
– If both of these are absent, AIS Grade = B

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AIS Classification Zone of Partial Preservation

6. If B is ruled out, how incomplete is the motor • Only defined for AIS A COMPLETE lesions
function? – Lowest dermatome and myotome on either side with
- Are at least half of the key muscles below any preserved function (even if abnormal)
the neurological level of injury graded 3 or
better?
- If no, AIS Grade = C
- If yes, AIS Grade = D

You’re ready to do an ASIA Exam! References

• American Spinal Injury Association. International Standards for
Neurological Classification of Spinal Cord Injury, revised 2011;
Atlanta GA.
• American Spinal Injury Association:
http://www.asia-spinalinjury.org/
– ISNCSCI Exam Sheet
– Motor Exam Guide
– Sensory Exam Guide
• Online ASIA Exam calculator:
http://isncscialgorithm.azurewebsites.net/

Examples...