• 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.

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.

ICF Domain

Body Function ▶ Neuromusculoskeletal & Movement-Related Functions and Structures.


  • 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.

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.


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


  • 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 or ais.emsci.org to calculate the key scores for neurological classification.



Training Required

Training is mandatory


Instructions for administration, training manual and scoring form available from: https://asia-spinalinjury.org/international-standards-neurological-classification-sci-isncsci-worksheet/

Online ISNCSCI calculator: www.isncscialgorithm.com

# of studies reporting psychometric properties: 37


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).


  • 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)


  • 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)


  • High correlation with Quadriplegia index of function (QIF):
    ASIA Motor = 0.91
    ASIA Light Touch = 0.64
    ASIA Pin Prick = 0.65
  • Moderate to High correlation with Functional Independence Measure (FIM):
    ASIA Motor = 0.91
    ASIA Light touch = 0.58
    ASIA 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 = 0.64
    ASIA Motor (UEMS) = 0.24
    ASIA 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)


  • 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

    42% of subjects at ceiling (score 50)
    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)


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

Date Last Updated

1 November 2016

Aidinoff E, Benjamini Y, Galili T, Polliack T, Front L, Bluvshtein V, Itzkovich M, Hart J, Catz A. Non-linear formulas for the spinal cord injury ability realization measurement index. Spinal Cord. 2012;50(4):324-7. http://www.ncbi.nlm.nih.gov/pubmed/22124345

American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury, revised 2002. 2002. Chicago, IL, American Spinal Injury Association.

Blaustein DM, Zafonte R, Thomas D, Herbison GJ, Ditunno JF. Predicting recovery of motor complete quadriplegic patients. 24 hour v 72 hour motor index scores. Am J Phys Med Rehabil 1993;72: 306-311.

Burns AS, Delparte JJ, Patrick M, Marino RJ, Ditunno JF. The reproducibility and convergent validity of the walking index for spinal cord injury (WISCI) in chronic spinal cord injury. Neurorehabil Neural Repair. 2011;25(2):149-57.

Catz A, Greenberg E, Itzkovich M, Bluvshtein V, Ronen J, Gelernter I. A new instrument for outcome assessment in rehabilitation medicine: Spinal cord injury ability realization measurement index. Arch Phys Med Rehabil. 2004;85(3):399-404.

Cifu DX, Seel RT, Kreutzer JS, McKinley WO. A multicenter investigation of age-related differences in lengths of stay, hospitalization charges, and outcomes for a matched tetraplegia sample. Arch Phys Med Rehabil 1999; 80: 733-40.

Cohen ME, Ditunno JF, Jr., Donovan WH, Maynard FM, Jr. A test of the 1992 International Standards for Neurological and Functional Classification of Spinal Cord Injury. Spinal Cord 1998;36:554-560.

Cohen ME, Sheehan TP, Herbison GJ. Content validity and reliability of the International Standards for Neurological Classification of Spinal Cord Injury. Top Spinal Cord Inj Rehabil 1996;1:15-31.

Curt A, Keck ME, Dietz V. Functional outcome following spinal cord injury: significance of motor-evoked potentials and ASIA scores. Arch Phys Med Rehabil 1998; 79: 81-86.

Ditunno JF, Barbeau H, Dobkin BH, Elashoff R, Harkema S, Marino RJ, Hauck WW, Apple D, Basso DM, Behrman A, Deforge D, Fugate L, Saulino M, Scott M, Chung J; Spinal Cord Injury Locomotor Trial Group. Validity of the walking scale for spinal cord injury and other domains of function in a multicenter clinical trial. Neurorehabil Neural Repair. 2007;21(6):539-50.

Ditunno JF, Scivoletto G, Patrick M, Biering-sorensen F, Abel R, Marino R. Validation of the walking index for spinal cord injury in a US and European clinical population. Spinal Cord. 2008;46(3):181-8.

El Masry WS, Tsubo M, Katoh S, El Miligui Y, Khan A. Validation of the American Spinal Injury Association (ASIA) Motor Score and the National Acute Spinal Cord Injury Study (NASCIS) Motor Score. Spine, 1996; 21(5): 614-619.

Fattal C. Motor capacities of upper limbs in tetraplegics: a new scale for the assessment of the results of functional surgery on upper limbs. Spinal Cord, 2004; 42: 80-90.

Frankel HL, Hancock DO, Hyslop G, Melzak J, Michaelis LS, Ungar GH, Vernon JD, Walsh JJ. The value of postural reduction in the initial management of closed injuries of the spine with paraplegia and tetraplegia. Paraplegia 1969;7:179-192.

Fujiwara T, Hara Y, Akaboshi K, Chino N. Relationship between shoulder muscle strength and functional independence measure (FIM) score among C6 tetraplegics. Spinal Cord. 1999;37(1):58-61.

Graves DE, Frankiewicz RG, Donovan WH. Construct validity and dimensional structure of the ASIA motor scale. J Spinal Cord Med 2006;29:39-45.

Harkema SJ, Shogren C, Ardolino E, Lorenz DJ. Assessment of functional improvement without compensation for human spinal cord injury: extending the Neuromuscular Recovery Scale to the upper extremities. J Neurotraum 2016. Ahead of print. doi:10.1089/neu.2015.4213.

Hasegawa T, Uchiyama Y, Uemura K, Harada Y, Sugiyama M, Tanaka H. Physical impairment and walking function required for community ambulation in patients with cervical incomplete spinal cord injury. Spinal Cord. 2014;52(5):396-9.

Johnston MV, Diab ME, Kim SS, Kirshblum S. Health literacy, morbidity, and quality of life among individuals with spinal cord injury. J Spinal Cord Med. 2005;28(3):230-40.

Jonsson M, Tollback A, Gonzales H, Borg J. Inter-rater reliability of the 1992 international standards for neurological and functional classification of incomplete spinal cord injury. Spinal Cord 2000;38:675-679.

Kalsi-ryan S, Beaton D, Ahn H, et al. Responsiveness, Sensitivity, and Minimally Detectable Difference of the Graded and Redefined Assessment of Strength, Sensibility, and Prehension, Version 1.0. J Neurotrauma. 2016;33(3):307-14.

Kirshblum S, Millis S, Mckinley W, Tulsky D. Late neurologic recovery after traumatic spinal cord injury. Arch Phys Med Rehabil. 2004;85(11):1811-7.

Lazar RB, Yarkony GM, Ortolano D, Heinemann AW, Perlow E, Lovell L, Meyer PR. Prediction of functional outcome by motor capability after spinal cord injury. Arch Phys Med Rehabil 1989;70:819-822.

Marino RJ, Graves DE. Metric properties of the ASIA motor score: subscales improve correlation with functional activities. Arch Phys Med Rehabil 2004;85:1804-1810.

Marino RJ, Jones L, Kirshblum S, Tal J, Dasgupta A. Reliability and repeatability of the motor and sensory examination of the international standards for neurological classification of spinal cord injury. J Spinal Cord Med. 2008;31(2):166-70.

Marino RJ, Kern SB, Leiby B, Schmidt-read M, Mulcahey MJ. Reliability and validity of the capabilities of upper extremity test (CUE-T) in subjects with chronic spinal cord injury. J Spinal Cord Med. 2015;38(4):498-504.

Marino RJ, Patrick M, Albright W, Leiby BE, Mulcahey M, Schmidt-Read M, Kern SB. Development of an objective test of upper-limb function in tetraplegia: the capabilities of upper extremity test. Am J Phys Med Rehabil. 2012;91(6):478-86.

Marino RJ, Shea JA, Stineman MG. The Capabilities of Upper Extremity instrument: reliability and validity of a measure of functional limitation in tetraplegia. Arch Phys Med Rehabil. 1998;79(12):1512-21.

Morganti B, Scivoletto G, Ditunno P, Ditunno JF, Molinari M. Walking index for spinal cord injury (WISCI): criterion validation. Spinal Cord. 2005;43(1):27-33.

Oleson CV, Marino RJ. Responsiveness and concurrent validity of the revised capabilities of upper extremity-questionnaire (CUE-Q) in patients with acute tetraplegia. Spinal Cord. 2014;52(8):625-8.

Ovechkin AV, Vitaz TW, Terson de paleville DG, Mckay WB. Quality of residual neuromuscular control and functional deficits in patients with spinal cord injury. Front Neurol. 2013;4:174.

Priebe MM, Waring WP. The interobserver reliability of the revised American Spinal Injury Association standards for neurological classification of spinal injury patients. Am J Phys Med Rehabil 1991;70:268-270.

Rudhe C, Van hedel HJ. Upper extremity function in persons with tetraplegia: relationships between strength, capacity, and the spinal cord independence measure. Neurorehabil Neural Repair. 2009;23(5):413-21.

Saboe LA, Darrah JM, Pain KS, Guthrie J. Early predictors of functional independence 2 years after spinal cord injury. Arch Phys Med Rehabil. 1997;78(6):644-50.

Savic G, Bergstrom EMK, Frankel HL, Jamous MA, Jones PW. Inter-rater reliability of motor and sensory examinations performed according to American Spinal Injury Association standards. Spinal Cord, 2007; 45: 444-451.

Scivoletto G, Glass C, Anderson KD, Galili T, Benjamin Y, Front L, Aidinoff E, Bluvshtein V, Itzkovich M, Aito S, Baroncini I, Benito-Penalva J, Castellano S, Osman A, Silva P, Catz A. An international age- and gender-controlled model for the Spinal Cord Injury Ability Realization Measurement Index (SCI-ARMI). Neurorehabil Neural Repair. 2015;29(1):25-32.

Scivoletto G, Tamburella F, Laurenza L, Molinari M. Distribution-based estimates of clinically significant changes in the International Standards for Neurological Classification of Spinal Cord Injury motor and sensory scores. Eur J Phys Rehabil Med. 2013;49(3):373-84.

Sisto SA, Lorenz DJ, Hutchinson K, Wenzel L, Harkema SJ, Krassioukov A. Cardiovascular status of individuals with incomplete spinal cord injury from 7 NeuroRecovery Network rehabilitation centers. Arch Phys Med Rehabil. 2012;93(9):1578-87.

Tester NJ, Lorenz DJ, Suter SP, et al. Responsiveness of the Neuromuscular Recovery Scale During Outpatient Activity-Dependent Rehabilitation for Spinal Cord Injury. Neurorehabil Neural Repair. 2016;30(6):528-38.

van Hedel HJ, Wirz M, Curt A. Improving walking assessment in subjects with an incomplete spinal cord injury: responsiveness. Spinal Cord. 2006;44(6):352-6.

van Middendorp JJ, Hosman AJF, Pouw MH, EM-SCI Study Group, and Van de Meent H. ASIS impairment scale conversion in traumatic SCI: is it related with the ability to walk? A descriptive comparison with functional ambulation outcome measures in 273 patients. Spinal Cord 2009; 47: 555-560.

Velstra IM, Bolliger M, Krebs J, Rietman JS, Curt A. Predictive Value of Upper Limb Muscles and Grasp Patterns on Functional Outcome in Cervical Spinal Cord Injury. Neurorehabil Neural Repair. 2016;30(4):295-306.

Velstra IM, Curt A, Frotzler A, Abel R, Kalsi-Ryan S, Rietman JS, Bolliger M. Changes in Strength, Sensation, and Prehension in Acute Cervical Spinal Cord Injury: European Multicenter Responsiveness Study of the GRASSP. Neurorehabil Neural Repair. 2015;29(8):755-66.

Yavuz N, Tezyurek M, Akyuz M. A comparison of two functional tests in quadriplegia: the quadriplegia index of function and the functional independence measure. Spinal Cord, 1998; 36: 832-837.