• The lower extremity motor score (LEMS) is a subscale of the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) that assesses lower extremity muscle strength.
  • Previous research suggests that individual UEMS or LEMS scores alone (rather than total ISNCSCI scores) better predict upper limb or lower limb function (Marino & Graves, 2004; Graves, 2006).

Clinical Considerations

  • The score range is 0–5 for each of 5 key muscles (hip flexors, knee extensors, ankle dorsi-flexors, long toe extensors and ankle plantar flexors) of each leg, with a maximum score of 50.

ICF Domain

Body Function ▶ Neuromusculoskeletal & Movement-related Functions and Structures

Administration

  • Clinician-administered.
  • The LEMS, along with the ISNCSCI exam, should be performed in the supine position (except for the rectal examination that can be performed side-lying) to ensure scores collected are standard and comparable.
  • During each myotome / muscle group testing, the assessor should start the assessment in “grade 3” by default. Depending on the performance of the patient in each test, then the assessor will move forward to Grade 4-5 or Grade 0-2. Please refer to the worksheet to see the patient positions and testing procedures for each muscle group and grade.

Number of Items

10 locations (myotomes) (5 on each side of the body):

  • L2 – hip flexors
  • L3 – knee extensors
  • L4 – ankle dorsiflexors
  • L5 – long toe extensors
  • S1 – ankle plantarflexors

Equipment

N/A

Scoring

Each myotome is rated from 0 to 5:

  • Grade 0 = Total paralysis
  • Grade 1 = Palpable or visible contraction
  • Grade 2 = Active movement, full range of motion (ROM) with gravity eliminated
  • Grade 3 = Active movement, full ROM against gravity
  • Grade 4 = Active movement, full ROM against gravity and moderate resistance in a muscle specific position
  • Grade 5 = (Normal) active movement, full ROM against gravity and full resistance in a functional muscle position expected from an otherwise unimpaired person

The maximum score is 50.

Languages

ISNCSCI Worksheet is available in many languages: https://asia-spinalinjury.org/isncsci-worksheet-now-available-in-other-languages/

Training Required

Training is mandatory. The International Standards Training e-Learning Program (InSTeP) is a five-module course (including basic anatomy, sensory examination, motor examination, anorectal examination, and scoring, scaling, and the AIS classification) designed to enable clinicians to perform accurate and consistent SCI neurological examinations of individuals with SCI. Visit ASIA-SpinalInjury.org for more information.

Availability

Measurement Property Summary

# of studies reporting psychometric properties: 8

Interpretability

MCID:

  • MID by injury level and severity:
    • Cervical B = 2.35
    • Cervical C = 2.45
    • Cervical D = 1.5
    • Thoracic A = 0.44
    • Thoracic B = 1.75
    • Thoracic C = 2.12
    • Thoracic D = 1.31
    • Lumbar A = 2.26
    • Lumbar B = 2.08
    • Lumbar C = 1.73
    • Lumbar D = 1.71
  • Effect size-based estimate for small/large changes in LEMS scores:
    • Cervical B = 0/0
    • Cervical C = 2.36/5.9
    • Cervical D = 1.84/4.6
    • Thoracic A/B = 0/0
    • Thoracic C = 1.72/4.3
    • Thoracic D = 1.44/3.6
    • Lumbar A = 1.92/4.8
    • Lumbar B = 1.88/4.7
    • Lumbar C = 1.58/3.95
    • Lumbar D = 1.52/3.8

(Scivoletto et al. 2013; n=661; 440 males; mean age: 50.35 years; 233 ASIA A, 67 ASIA B, 158 ASIA C, 142 ASIA D; mean (SD) time since injury = 51.6(36.8) days)
SEM: not established in SCI
MDC: not established in SCI
Smallest Real Difference: 1.3

(Tester et al. 2016; n=72, 57 males, 15 females; mean age: 36 years; median time since injury: 0.7 years; ASIA A-D)

Typical values

Mean (SD) LEMS scores Admission to Discharge:

  • Cervical B = 0(0) to 11.5(16.6)
  • Cervical C = 19.4(11.8) to 37.3(12.7)
  • Cervical D = 39.2(9.2) to 44.8(6.5)
  • Thoracic A = 0(0) to 0.76(3.1)
  • Thoracic B = 0(0) to 10.3(12.4)
  • Thoracic C = 14.6(8.6) to 27.4(12.3)
  • Thoracic D = 34.6(7.2) to 40.8(5.8)
  • Lumbar A = 6.6(9.6) to 11.9(12.8)
  • Lumbar B = 6.9(9.4) to 14.4(11.3)
  • Lumbar C = 16.3(7.9) to 28.7(9.4)
  • Lumbar D = 36.6(7.6) to 41.6(9.4)

(Scivoletto et al. 2013; n=661; 440 males; mean age: 50.35 years; 233 ASIA A, 67 ASIA B, 158 ASIA C, 142 ASIA D; mean (SD) time since injury = 51.6(36.8) days)

Reliability – High

  • Internal consistency is High for the LEMS (Cronbach’s a = 0.995)

(Lena et al. 2021; n=140, 92 males, 48 females; mean (SD) age: 60 (16) years; 30 cervical, 78 thoracic, 32 lumbar; ASIA A-D)

  • Inter-rater reliability is High for the LEMS (r = 0.986; ICC = 0.98)

(Lena et al. 2021; n=140, 92 males, 48 females; mean (SD) age: 60 (16) years; 30 cervical, 78 thoracic, 32 lumbar; ASIA A-D)
(Marino et al. 2008; n=16; 16 examiners; 10 males; 5 complete tetraplegia, 5 motor incomplete tetraplegia, 5 complete paraplegia, 1 motor incomplete paraplegia; only test performed in incomplete SCI)

Validity – Moderate to High

  • High correlation with the Walking Index for Spinal Cord Injury (WISCI) in people with SCI:
    • 3 months: r = 0.85
    • 6 months: r = 0.85
    • 12 months: r = 0.88

(Ditunno et al. 2007; N = 146 (114M, 32F); Mean age = 32 years (range 16 – 69 years); Incomplete spinal cord injury patients who had a Functional Independence Measure locomotor score for walking of < 4 on entry.)

  • Moderate correlation with the Gait Deviation Index for Spinal Cord Injury (SCI-GDI): r = 0.638

(Sinovas-Alonso et al. 2023; n=85, 50 participants without SCI, 35 adults with incomplete SCI)

  • Moderate correlation with SCIM mobility subscore: r = 0.666, p<0.001

(Lena et al. 2021; n=140, 92 males, 48 females; mean (SD) age: 60 (16) years; 30 cervical, 78 thoracic, 32 lumbar; ASIA A-D)

  • High correlation with 6 Minute Walk Test (6MWT): r = 0.7 (0.64-0.76)
  • High correlation with 10 Meter Walk Test (10MWT): r = 0.69 (0.63-0.75)
  • High correlation with the Modified Functional Reach: r = 0.81 (0.77-0.85)
  • High correlation with Berg Balance Scale (BBS): r = 0.79 (0.74-0.85)
  • High correlation with the Neuromuscular Recovery Scale (NRS) Overall Phase and Summary Score: r = 0.70-0.80

(Harkema et al. 2016; n=152; 123 male; mean age: 36 years; 43 ASIA A, 21 ASIA B, 39 ASIA C, 49 ASIA D; median (range) time post-SCI: 0.9 (0.1-45.2) years)

  • Moderate to High correlations with self-selected WISCI level, self-selected WISCI speed, max WISCI level, and max WISCI speed: r = 0.509-0.717 (p<0.05)

(Burns et al. 2011; n=41, tetraplegia; ASIA A-D; chronic SCI)
(Morganti et al. 2005; n=200; 184 males; mean age: 50.4 years; 84 ASIA A, 19 ASIA B, 129 ASIA C, 52 ASIA D; mean (SD) time since injury: 56.9(43.9) days)

Responsiveness

  • Effect size: Not established in SCI.
  • Standardized Response Means: LEMS Standardized Response Means after Locomotor Training:
    • All individuals: 0.23
    • AIS-A/B: -0.10
    • AIS-C: 0.72
    • AIS-D: 0.16

(Harkema et al. 2016; n=152; 123 male; mean age: 36 years; 43 ASIA A, 21 ASIA B, 39 ASIA C, 49 ASIA D; median (range) time post-SCI: 0.9 (0.1-45.2) years)

Floor/Ceiling Effect

53% of participants at floor (score 0)

(Marino & Graves 2004; n=4338, 3443 males; 854 complete tetraplegia, 1464 incomplete tetraplegia, 1195 complete paraplegia, 825 incomplete paraplegia, 2049 ASIA A, 511 ASIA B, 655 ASIA C, 1123 ASIA D; median (IQR) time since injury = 15 (9-28) days)

Reviewers

Dr. Janice Eng, Dr. Carlos L. Cano-Herrera, Matthew Querée

Date Last Updated

31 December 2024

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: 149-57. doi: 10.1177/1545968310376756.
https://pubmed.ncbi.nlm.nih.gov/21239706/

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: 181-8. doi: 10.1038/sj.sc.3102071.
https://pubmed.ncbi.nlm.nih.gov/17502878/

Graves DE, Frankiewicz RG, Donovan WH. Construct validity and dimensional structure of the ASIA motor scale. J Spinal Cord Med. 2006; 29: 39-45. doi: 10.1080/10790268.2006.11753855.
https://pubmed.ncbi.nlm.nih.gov/16572564/

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 Neurotrauma. 2016; 33: 2181-2190. doi: 10.1089/neu.2015.4213.
https://pubmed.ncbi.nlm.nih.gov/27071494/

Marino RJ, Graves DE. Metric properties of the ASIA motor score: subscales improve correlation with functional activities. Arch Phys Med Rehabil. 2004; 85: 1804-10. doi: 10.1016/j.apmr.2004.04.026.
https://pubmed.ncbi.nlm.nih.gov/15520975/

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: 166-70. doi: 10.1080/10790268.2008.11760707.
https://pubmed.ncbi.nlm.nih.gov/18581663/

Morganti B, Scivoletto G, Ditunno P, Ditunno JF, Molinari M. Walking index for spinal cord injury (WISCI): criterion validation. Spinal Cord. 2005; 43: 27-33. doi: 10.1038/sj.sc.3101658.
https://pubmed.ncbi.nlm.nih.gov/15520841/

Lena E, Baroncini I, Pavese C, Musumeci G, Volini S, Masciullo M, Aiachini B, Fizzotti G, Puci MV, Scivoletto G. Reliability and validity of the international standards for neurological classification of spinal cord injury in patients with non-traumatic spinal cord lesions. Spinal Cord. 2022; 60: 30-36. doi: 10.1038/s41393-021-00675-9.
https://pubmed.ncbi.nlm.nih.gov/34326462/

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: 373-84
https://pubmed.ncbi.nlm.nih.gov/23486305/

Sinovas-Alonso I, Herrera-Valenzuela D, de-Los-Reyes-Guzmán A, Cano-de-la-Cuerda R, Del-Ama AJ, Gil-Agudo Á. Construct Validity of the Gait Deviation Index for People With Incomplete Spinal Cord Injury (GDI-SCI). Neurorehabil Neural Repair. 2023; 37: 705-715. doi: 10.1177/15459683231206747.
https://pubmed.ncbi.nlm.nih.gov/37864467/

Tester NJ, Lorenz DJ, Suter SP, Buehner JJ, Falanga D, Watson E, Velozo CA, Behrman AL, Michele Basso D. Responsiveness of the Neuromuscular Recovery Scale During Outpatient Activity-Dependent Rehabilitation for Spinal Cord Injury. Neurorehabil Neural Repair. 2016; 30: 528-38. doi: 10.1177/1545968315605181.
https://pubmed.ncbi.nlm.nih.gov/26359344/

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