American Spinal Injury Association Impairment Scale (AIS): International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI)

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Tool Description

  • The ASIA (American Spinal Injury Association) Impairment Scale (AIS), based on the Frankel scale, is a clinician-administered scale used to classify the severity (completeness) of injury in individuals with SCI. It identifies sensory and motor levels indicative of the highest spinal level demonstrating “unimpaired” function. Preservation of function in the sacral segments (S4-S5) is a key for determining the AIS grade.
  • 5 point ordinal scale, based on the Frankel scale, classifies individuals from A” (complete SCI) to “E” (normal sensory and motor function):

A: Complete. No sensory or motor function is preserved in the sacral segments S4-S5.
B: Sensory incomplete. Sensory but not motor function is preserved below the neurological level and includes the sacral segments S4-S5 (light touch, pin prick at S4-S5 or deep anal pressure), AND no motor function is preserved more than three levels below the motor level on either side of the body.
C:  Motor incomplete. Motor function is preserved below the neurological level and more than half of key muscle functions below the single neurological level of injury (NLI) have a muscle grade less than 3.
D: Motor incomplete. Motor function is preserved below the neurological level and at least half of key muscle functions below the NLI have a muscle grade of 3 or greater.
E: Normal. If sensation and motor function as tested with the ISNCSCI are graded as normal in all segments, and the patient had prior deficits, then the AIS grade is E. Someone without an initial SCI does not receive an AIS grade.

  • AIS scores are considered essential when classifying persons with SCI as to their neurological status. AIS scores are routinely collected in administrative databases such the Model Systems and CIHI National Rehabilitation Reporting System.

ICF Domain:

Body Function – Subcategory: Neuromusculoskeletal & Movement-related Functions and Structures.

Number of Items:

Twenty-eight dermatomes are assessed bilaterally using pinprick and light touch sensation and 10 key muscles are assessed bilaterally with manual muscle testing. The results are summed to produce overall sensory and motor scores and are used in combination with evaluation of anal sensory and motor function as a basis for the determination of AIS classification.

Brief Instructions for Administration & Scoring

Administration:

  • clinician-administered; clinical examination conducted to test whether sensation is 0-absent; 1-impaired or 2-normal.
  • Muscle function is rated from 0-total paralysis to 5-normal (active movement, full ROM against significant resistance).
  • The presence of anal sensation and voluntary anal contraction are assessed as a yes/no.
  • Time to administer can range from 10 minutes to 1 hour.

Equipment: No special equipment is required - only 1 clean pin for the Sensory (Pin Prick) exam.

Scoring:

The AIS is scored on a 5 point ordinal scale from A (sensory & motor complete SCI) to E (normal sensory and motor function).
On the ISNCSCI, Sensory scores rated 0 (sensation absent), 1 (impaired) and 2 (normal) for each dermatome. Light Touch & Pin Prick each scored out of 112 (28 locations bilaterally with a max score of 2 at each location).
Muscle function rated 0 (total paralysis) to 5 (active movement, full ROM against significant resistance) for each myotome. UEMS & LEMS each scored out of 50; ASIA Motor Score scored out of 100.
The presence of anal sensation and voluntary anal contraction are assessed as a yes/no.
Results can be entered into www.isncscialgorithm.com to calculate the key scores for neurological classification.

Interpretability

MCID: Reported in Scivoletto et al. 2013; n=661, mean time since injury = 51.6 days:

  • For Total Sensory Score = 5.19;
  • For Total Motor Score = 4.48;
  • Upper Extremity Motor Score = 2.72;
  • Lower Extremity Motor Score = 3.66

SEM: Reported in Furlan et al. 2008 based on data from Kirshblum et al. 2004

  • Mean (SD) ASIA motor score at 1 year post-injury: 45.2 (22.8)
  • Mean (SD) ASIA motor score at 5 years post-injury: 46.6 (23.3)

MDC:

  • Total Motor Score*: 1.87
    Total Sensory Score: 3.87

Standard Error of Measurement:

  • Total Motor Score* = 0.67
    Total Sensory Score = 1.40
    (Scivoletto, et al. 2013; n=661, 478 males; mixed injury types; mean (SD) time since injury = 51.6(36.8) days)
    *ASIA Motor Score

Typical Values - Mean (SD) Scores:

  • ASIA motor at 1 year post-injury: 45.2 (22.8); ASIA motor at 5 years post-injury: 46.6 (23.3)(Kirshblum et al., 2004; N=559 from Model SCI Systems Database; traumatic SCI; reported in Furlan et al., 2008)

Languages:

English

Training Required:

Training is mandatory.

Availability:

Instructions for administration, training manual and scoring form available from:
http://asia-spinalinjury.org/wp-content/uploads/2016/02/International_Stds_Diagram_Worksheet.pdf

Online ISNCSCI calculator: www.isncscialgorithm.com

Video: https://www.scireproject.com/outcome-measures/video/how-to

Clinical Considerations

  • This is an internationally recognized standard that is widely used for research and clinical purposes. Its development and continued evolution are well grounded in expert clinical consensus thereby ensuring high content validity.
  • The exam is generally well tolerated although sensory testing for those with severe hypersensitivity may be uncomfortable and testing for anal sensation/voluntary contraction can result in the stimulation of a bowel movement.
  • The test may pose a significant clinician/patient burden unless the clinician is experienced and well-practiced in the test.
  • Preservation of function in the sacral segments (S4-S5) is key for determining the AIS.

Measurement Property Summary

# of studies reporting psychometric properties: 37

Reliability:

  • High Inter-rater Reliability:
    ASIA Motor Score: ICC = 0.999
    ASIA Light Touch: ICC = 0.997
    ASIA Pin Prick: ICC = 0.988
    (Savic et al. 2007; n=45, 38 males; mixed injury types; 3 months to 43 years post-SCI)
  • High Intra-rater Reliability:
    ASIA UEMS: ICC = 0.98
    ASIA Light Touch: ICC = 0.99
    ASIA Pin Prick: ICC = 0.99
    (Marino et al. 2008; n = 16 patients, n = 16 examiners, 10 male patients; mixed injury type; acute SCI)

Validity:

  • High correlation with Quadriplegia index of function (QIF):ASIA Motor = 0.91ASIA Light Touch = 0.64ASIA Pin Prick = 0.65Moderate to High correlation with Functional Independence Measure (FIM):ASIA Motor = 0.91ASIA Light touch = 0.58ASIA Pin Prick = 0.55(Yavuz et al. 1998; n=29, 20 males; tetraplegia; mean (range) time since injury = 20 (2-72) weeks)Moderate to High correlation with 6 Minute Walk Test (6MWT):ASIA Motor = 0.64ASIA Motor (UEMS) = 0.24ASIA Motor (LEMS) = 0.70

    Moderate to High correlation with 10 Meter Walk Test (10MWT):

    ASIA Motor = 0.63

    ASIA Motor (UEMS) = 0.24

    ASIA Motor (LEMS) = 0.69

    Moderate to High correlation with Berg Balance Scale (BBS):

    ASIA Motor = 0.75

    ASIA Motor (UEMS) = 0.30

    ASIA Motor (LEMS) = 0.79

    (Harkema et al. 2016; N=152, 123 male; mixed injury type; median (range) time post-SCI = 0.9 (0.1-45.2) years)

Responsiveness:

Effect Size:
ASIA UEMS: 0.69-1.29
ASIA Light Touch: -0.08-0.30
(Velstra et al. 2015; n=74, 51 males; mixed injury types; acute SCI at study enrollment, measured 1,3,6,12 months post-SCI)
Standardized Response Mean:
ASIA Motor: 0.33
ASIA Motor (UEMS): 0.38
ASIA Motor (LEMS): 0.23
(Post locomotor training; breakdown by AIS levels available in research summary; Harkema et al. 2016; N=152, 123 male; mixed injury type; median (range) time post-SCI = 0.9 (0.1-45.2) years)

Floor/ceiling effect:

Floor/Ceiling Effect:
ASIA UEMS:
42% of subjects at ceiling (score 50)

ASIA LEMS:
53% of subjects at floor (score 0)
(Marino & Graves 2004; n=4338, 3443 males; mixed injury types; median (IQR) time since injury = 15 (9-28) days)

Reviewers

Dr. Vanessa Noonan, Jeremy Mak, John Zhu, Kyle Diab, Matthew Querée

Date Last Updated:

Nov 1, 2016

Download the measure

Download Worksheet:
Instructions for administration, training manual and scoring form available from: www.asia-spinalinjury.org

Video

Scoring

The AIS is scored on a 5 point ordinal scale from A (sensory & motor complete SCI) to E (normal sensory and motor function).
On the ISNCSCI, Sensory scores rated 0 (sensation absent), 1 (impaired) and 2 (normal) for each dermatome. Light Touch & Pin Prick each scored out of 112 (28 locations bilaterally with a max score of 2 at each location).
Muscle function rated 0 (total paralysis) to 5 (active movement, full ROM against significant resistance) for each myotome. UEMS & LEMS each scored out of 50; ASIA Motor Score scored out of 100.
The presence of anal sensation and voluntary anal contraction are assessed as a yes/no.
Results can be entered into www.isncscialgorithm.com to calculate the key scores for neurological classification.

Equipment Needed

ASIA/ISNCSCI:

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