Reference Manual for the e ASIA. International Standards for Neurological ANERIGIN SPINAL INJURY ASSOCIATION age . Classification of Spinal Cord Injury Endorsed by the INTERNATIONAL MEDICAL SOCIETY OF PARAPLEGIA Supported by ‘the Christopher Reeve Paralysis Foundationfefeace Mano fr the intationa standards or Newall Cstiaon of Seal Cord in (Re 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,‘elerence Marva forthe intentional standards for Nerloglal Casio of pa Cond nary te. 2003) Table of Contents Preface i 1. Introduction pel Ralph J. Marino, M.D. IL _ Neurological Assessment: Sensory Examination pe7 Frederick M. Maynard, Jr, M.D.; revised by Michael Priebe, M.D. TI. Neurological Assessment: Motor Examination, peal Williams H. Donovan, M.D. IV. Scoring, Scaling and Classification pe 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. V1. Metric Properties of the International Standards for ps 68 Neurological Classification of Spinal Cord Injury, Implications for Research Use Daniel Graves, Ph.D., Ralph J. Marino, M.D. Appendices A, Sample Data Forms - Blank pg Al B. Sample Data Forms - Completed pg BI ‘Video 1 is 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 If and II. Video Ils 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.Aefeace Manual theintratonal Standards for Nelo Ciasicatn of Spal or inary (ev 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.ference Manual for he nteratonl Standards fo NeurlgialCaseation of spinal Crd nu Re. 2003) ‘The Neurological Standards Committee of the American Spinal Injury Association Ralph J. Marino, M.D., Chairman and Editor ‘Tarcisio Barros, MD. Fin Biering-Sorensen, M.D. Stephen P. Burns, M.D. William Donovan, MD. Daniel Graves, Ph.D. Michael Haak, MD. 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, MD.,Ph.D., Co-Chairman William H. Donovan, M.D., Editor Frederick M. Maynard, Jr, M.D,, Editor Burton H. Lane, MEd., Media Consultant Byron Hamilton, M.D., Consultant Inder Perkash, MD., 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, M.D. Robert L. Waters, M.D. Jack E. Wilberger, M.D. Reviewers: Michelle Cohen, Ph.D. Gerald J. Herbison, M.D. Barbara E. Wolff, M.Ed.Reference Manual forthe Internationa Standards fo Neola Casicaton of Sia Cor jy ex 2003) Chapter I Introduction This manual and companion videotapes provide support for users of ISCSCI. The primary goal for ISCSCT 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 ISCSC1 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 ISCSCI 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 Il and III describe and illustrate in great detail the sensory and motor components of the neurological examination of patients with SCL. 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. 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 per! Ivoducion 1Reference Manual fo the ntematoal Standart for Neuroglia of Sela Crd ny fee. 2003) 2 Chapter ntoducton teflected 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) A minimum 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 fo: the Intemational tndars for Neri Cassiano pina Cord ry 2003), Surgery (AOS), 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. C. Innovations ISCSCI-92 incorporated several major additions and modifications to previous ASIA standards: Chapter dnroducton 3Aeference Manual the Internat tndars for Newologis Clason of Sal Crd ny Oe. 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, ¢.g., NASCIS, optional testing of a few muscles was added to ISCSCL-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 totoducton~ foleence Manual fr he Intemational Standards for Newell Cassicaton of Sia Crd ny Rev. 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 35, 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-$5, 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 or 5). The ISCSCI-2000 booklet clarified a number of items: ‘+ Motor incomplete: prior definitions of motor incomplete injuries {AIS C or D) were ambiguous. The current definition is-’To be motor - incomplete an individual must be incomplete (sacral sparing) and have 7 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 commitiee felt that there was insufficient evidence to endorse this instrument over other functional assessment instruments for SCI. Chapter sarodictioneference Mana forthe nterationa tnd fo Netlog Caseaton of pina ord ny ex 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, 50 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/TID, 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) ARandomized 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. I Neurotrauma, 8 Suppl 1:547-52. Daniels L, & Worthingham C. (1972) Muscle Testing: Techniques of Manwal - 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 | IngedutonAelerence Manual for the errata! Stands for Newlogal Casita of Spl Cord ny 2003) Chapter II Neurological Assessment: 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 area 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 functional 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 ISCSCT has important limitations and that several areas need further research. Chapa tI Neweloga Assessment: The Sensory Examination 7Aeferece Manual othe intetina tnd for Nevelogicl Ciassficston of Spinal Cordray Re 2003) B. 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 dermatornal 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, or 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. Arrecommended 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 Chapter Newall Asessment The Sensory Examinationefrece Man fr he Interior Standards fr Newco Csticaton of Spinal Crd nu (eu 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 ot 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 Chop) Neurologic Assessment The Sensory Exambation 9a feferene Manva fr the ntaonal Sanda fo Newlin of spa Cord nu (Rev 2005. - ‘The key sensory point (or alternate point) is unavailable for testing, because of casting, lacerations, bums, dressings or amputation. 3. Sharp/Dull Discrimination a, Method standard 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, 7 nor-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 itis conchided 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 7 0 Absent: Patient has no feeling of being touched with either the sharp or dull ends of the pin. 10 Chapter Neurological asesement: The Sensory xanination{eference Manu othe ternational Standards fr Neural Chstiato of Spinal Coty Rev. 2005) _ figure 1. C2 One cm lateral to the occipital protuberance at the base of the skull. An alternate key point is at least 4 3 cm. behind the ear. C3 See figure 5. C4 Over the acromio-clavicular joint. 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. NI (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. 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 S4-5 dermatome). The recommended method of testing is by doing a digital examination. The patient is asked to describe any sensory awareness, including 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). a Chapters Neurologic Assessment The Sensory Examination 11Aeference Manual othe intenatonal standards fr NewolgicCssfiaton of pial Corny Re 2003. figure 2 C3. On the lateral (radial) side of the antecubital fossa just proximal 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 7 phalanx of the middle finger. CB. On the dorsal surface of the proximal phalanx of the little finger. 12 Chapter Meurolpcal Asasment Te Sensor ExaminationAsference Manu for he IntestonalStardad for Neural lsat of Sil Crd ny Ro. 2003) figure 4. T1 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, 13. At the midclavicular line and the 2 third intercostal space, found by palpating the anterior chest to locate 2 the third rib and the corresponding third intercostal space below it. © o™ ‘Té 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 supraclavicular fossa TS At the midclavicular line and the fifth intercostal space, located midwoay between the level of the nipples and the level of the xiphisternum. T6 At the midclavicular line, located at the level of the xiphisternuam. 7 At the midelavicular tine, 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. 19 At the midclavicular line, located at three quarters of the distance between the level of the xiphisternur ‘and the level of the umbilicus. TIO At the midclavicular line, located at the level of the umbilicus. Chapter eurolagialAsesent The Sensor Examination 13Reference Manual or te ntemtina tndads fo Neurologic Cassication of Spinal Crd nye. 2003) figure 6, - TI1 At the midclavicular line, midwony between the level of 7 the umbilicus and the inguinal ligament, noe $F eno T12 At the midclavicular line, over the midpoint of the Tue eTu inguinal ligament. me em L1_ Midway between the key sensory points for T12 and 12. 12 On the anterior-medial thigh, midwoay on a line between a the midpoint of the inguinal ligament and the medial ue [)\ eu ; ‘femoral condyle above the knee. Re en figure 7. 13. At the medial femoral condyle above the knee. 14 Chapter Neurological Assesment The Sensor Examinationfleece Manual fr he nematic! Sandor for Neurological lessen of prl Cord ry (Rev 2003) figure 8. 1A Over the medial malleolus. 5 On the dorsum of the foot at the third metatarsal phalangeal joint. figure 9. S1_On the lateral side of the heel 82. In the popliteal fossa of the knee at the midpoint. Chapter il Neuologa! Assessment The Sensory Exaninatin 15fefeence Manual forthe temas Standards fr Newolagal Castleton of Spl Cord inure: 203) figure 10. $3 Over the ischial tuberosity. 84/5 In the perianal area, less ‘thar one cmt. lateral to the ‘mucocutaneous junction, S/S 53 C. Optional Sensory Testing 1. Joint Movement Appreciation ‘a. 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, actoss 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. Itis 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 it ewlegical Assent: The Sensory ExaminationAefrence Manual for he ternational Sanda for Mewleicl Cassia of Sal Crd ny le 2003) », 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; (8 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. NT (Not Testable): Patient is unable to understand and follow directions. or ‘The joint is unavailable for testing because of casting, lacerations, ‘burns, 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 Newologia Assessment: The Sesoy Examination 17eference Manual forthe teat tndas for NewologiclCasfcatin of pal Cord ny Ge. 2003) 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 patients 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 Newropical Asessment The Sensor Examinationfelerence Manual far the itematlonal tarda Newrogkal Cassiano pal Cod ij Rv 2003) D. Questions and Answers + How do you score a patient with absent sensation in the T1 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. Its 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 orin 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. (Capt Neurological Assessment: The Sens Examination 19eference Manual the ltematonal Sanda for Newoonal Clsticaton of Spl Crd nu Re, 208) 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 (i.e, 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 fel something, however he/she is unable to distinguish this feeling from that of the dull end of the pin. Is this scored O 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 (eg., the sharp end feels “sharper” than the dull end), then score pinprick as 1, impaired. Ifnot, then score pinprick as 0, absent. E, References Austin GM. (1972) The Spinal Cord: Basic Aspects and Surgical Considerations, 2nd ed. Springfield, Il: Thomas. 20 Chapter Newoogial Assessment: The Sensory Examination- feferance Manu for he nteraton! Studer fr Newroogka lsat of Spinal Crd nary (Re. 203) Chapter Ill 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 ISCSCI The key muscles to be tested in the motor examination and their corresponding spinal cord roots or segments are: C5 Elbow flexors C6 Wrist extensors C7 Elbow extensors CB Finger flexors (distal phalanx of middle finger) T1 Finger abductors (little finger) L2 Hip flexors 13 Knee extensors LA 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 NewologkalAsesment The Moo Examination 21sleence Manalfor the ntemationa Sanda fr Neuronal Chsiicaton of Spinal Crd nay (Re. 203) (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 itis 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 DeL.isa (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. 1A 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 itis 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 HewrlogicalAssessment: The Moto Examinationfeference Manval fr the Iterations! tna fo Newark lsicaton of snl Cod ia ev 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 itis 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. NI (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 (e.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). Itis important to try to document whether the weakness of a key muscle under these circumstances is due toa 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 ot 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 tl Mewologial Assesment The Motor Examination 23oference Manual fo the Intemational Staaf: Newoosicl Cassia of Spal Cord ry ev 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 Mevlopal Assesment The Moto Examination‘efrence Manual fo the Inertial Sanders for Netlog Casation of Sil Cord ry Re. 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 superficial. + 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 T8, 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, brachi - 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. Chapel Neurol! Asesment The Motor Examination 75eforece Manual or th ternational Standards for Newall Csticatn of Sina Cord ny Rev. 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. Examiner 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 It Newologa! Assessment The Moto ExaminationReference Manual forthe Intemational tnd for Neola lsiation of Spiral Cor iy (ex 2003), 2. Wrist extensors (extensor carpi radialis longus and brevis - C6 myotome) . Grades 0, 1, and 2 ‘esting 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 fully flexed. Examiner action: 7 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. . ‘hope! NewrologialAssesmment The Mot Eanination 27fafeence Marval rte teat! Standards for Newco 2 Casticeon of Spinal Cord jr er 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 act ‘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 Newoopial Assesment The Motor Examinationefeence Maus! forthe ternational Sond for Heol Chsscatn of pal Cord ny ev. 2003) 3, Elbow extensors (triceps - C7 myotome) cont. Grade 2 ‘esting 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 it Neurotol Assessment: The Motr Examination 29Reference Manor he interatonal tnd for Neurol Casati of Spinal Cord ny Re. 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 1 phalanx of the middle finger (flexor digitorum profundus - 8 myotome) Grades 0,1, and 2 Testing position: we 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 Chopteril_Newelogical Assessment The Motor Exainatonfefeence Maal forthe intematonal Standards for Nelo sexton of Spinal Crd nu Re. 2005) 4, Finger flexor to the distal phalanx of the middle finger (flexor digitorum profundus - €B 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. y —F | Examiner action: ‘Ask the patient to resist the ‘examiner's push and try to extend the DIP joint. Patient action: | Same as above. CheperIewolopal Assessment The Motor amination 31eference Manual fo th Inrational Standards fr Neuronal Clsiicaton of Spal Cod nu (a, 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. Exansiner 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 Neurologic! Assessment The Mot Examinationfefeence Manual rte International Standards for Newrcancal Chsstcaton of Spinal Cor nay ex 2005) 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. 6. Hip Flexors (iliopsoas - L2 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 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 MewoloalAssessment: The Motor Examination 33ference Manual for he nterationl Standards fe Neurological Casicaton of Sil Crd nay (ie. 2005) 6. Hip 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°. wt VIN V) 23a Le 34 Chapter sewologal Asessman: The Motor Exomistonerence Manual fr the intentional Standards for Neola Clsthatin of Spina Cord nay (Re 2003) 6. Hip Flexors (iliopsoas - 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: 7 ‘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 MewolgalAsesoment: The Mota Examination 35Reference Maal ote Intemational Sandan for Merlo lsat of Spina or injury ev. 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 NewologkalAsessment The Motor Examinationeference Manual forthe ntematonal Standard fr Newco Csifiaton of Sal Cord ny Ga. 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 - La 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 action: Attempt to dorsiflex the ankle. (Chapter europa Assesment The Motor Examination 377 Aeference Maal for he nemtonl Sanda for NewrlopcalCsiiation of eral Cord ary ev. 2005) 8. Ankle dorsiflexors (tibialis anterior - L4 myotome) cont, 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 dorsifiex the ankle. Grade 3 ‘Testing position: The hip is in the same position as grades 0-1, - except itis 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 Newoiogie Assessment: The Motor ExaminationReference Manl fr the International Sunda or Newologis Clasico of Sinl Cod nur (Re. 2003) 8. 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. 9. Long toe extensors (extensor hallucis longus - 15 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 Neurologtal Assesment: The Motor Baminaton 33Bseence Manual the Intemational Sadar for Nerlaga Cafe of Sinl Cord ry ev. 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 Chapel Newelegal Assessment The Mota ExaminationAeference Maal forthe Intestinal Stands Nawolgkal Clstiaton of Spel Cord jury Re. 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 it Neuronal Assent The Motor xaminaton 41Reference Manual fo: the intematonal tro Nevelogical Caseaon of Spinal Cord Iu Re, 2003) 10. Ankle plantar flexors (gastrocnemius, soleus - = 51 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 Chapterit_Mewologal Assesment: The Motar Examination~ eference Manual othe tational Stands for Newoegkcal Csseaton of pal Cod iy ev 2003) a . 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 Cé (and possibly some C5). In a patient with a motor level above C5, itis 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 T11. 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 | Newologal assesment The Motor Examination 43fleece Mal or the iteration tandards for Neurol Clascatn of pla Cord ny (Re. 2005) + 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 ifthe range is limited by contracture or spasticity? Ifa muscle’s range is limited by contracture, and the contracture limits Tess 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). Af 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. (44 Chapter Neurologia Assesment The Meter aminationAefeence Mos! fr the intenatlona Standards for NeurolgialCesscatn of pina Cord ny Oe. 2005) © 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, itis 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, Sth Edition, pp. 112-189, 241-338. Philadelphia: Seunders, ‘Yashon D. (1986) Spinal Injury, 2nd Edition, pp. 13-17. Norwalk, CT: Appleton-Century-Crafts. Chapter it Neurotol Assessment: The Motor Examination 48Reference Manual othe Intemational standart for Neola! Casscston of Spinal Cord nary ev 2003) Chapter IV Scoring, Scaling and Classification A. Overview ‘The neurological assessment, which includes the motor and sensory examinations described in Chapters Il 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, itis 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, i.e., 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. 4% Chapter Scoring, Sang and Casscationeforence Maal rte intratona Standards for Neurological Casicaton of pial Cor Inj 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 I}) 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 7 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 17 are hyperesthetic; but the patient cannot distinguish between pin prick and dill 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 S4-5 (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, Sang and Chsstation 47Aolernce Meal rte Intemational Saar for Neweloglal Clascaton of pina Cor jury ev 2003) 48 Chapter Scoing Scag and stationfefeence Manual othe nemauoal Standart for Wawona Clasico of Spinal Crd ny (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 IIL 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 subjects 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 ISCSCI-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 -T1 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 cof motion with gravity eliminated, earning a grade of 2. Ankle dorsifiexors, 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, Chapter V-Scoring Scaling and Clsticaon 49Reference Manual forthe Inmatonl Standards for Newroogc lascato of Spinal Cod inure. 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), 2 8 m 3 a YEE BRABQR ecco oconee ‘Motor Score: C. Neurological Levels ‘The rationale for determining the neurological level was first established Dy 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. Sirice the prediction of self care and ambulation is usually based on the motor level (Long, 1955; Welch, 11986), use of a single neurological level where there is a difference between motor and sensory levels may be misleading in predicting functional activities (Marino R) et al. 1995). Symmetry occurs 80% of the time or more, based on single neurological levels (Stover, et.al, 1995). 50 Chapter Sern, Scaing and ClsicatonBefeence Man for the Inematonl Sadar for Neola Claecaion of Spinal Cord in Rex 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 itis 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 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 east 3 or 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 Copter WV Scoring, Scaling and sion 51elerence Manual othe Intraoral Sanda fr Newcagal Casticaton of pnal Cord iy (Rex 203) ‘one muscle group (i.e., 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, ifa muscle has at least a grade of 3, itis 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, ie,, C1 to C4, T2 to L1, and S2 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 1 on the right, and the remaining muscles are graded 0. The motor level is C6 on. the left side, as Cé 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 3or 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 Scoring Scag and Casscation