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Asia (American Spinal Injury Association) Chart

Asia Chart

The American Spinal Injury Association (ASIA) impairment scale describes a person’s functional impairment as a result of a SCI. This scale indicates how much sensation a person feels after light touch and a pinprick at multiple points on the body and tests key motions on both sides of the body.

ASIA measures:

  • NEUROLOGICAL LEVEL
  • SENSORY LEVEL
  • MOTOR LEVEL
  • SENSORY SCORE (pinprick and light touch)
  • MOTOR SCORE
  • ZONE OF PARTIAL PRESERVATION

Components of the Test

Main Parts of Examination

1) Manual Muscle Power Testing

2) Light Touch sensation

3) Pinprick Sensation

The lowest level of Motor Control

– Voluntary Anal Contraction

Lowest level of Sensation

– Deep Anal Pressure

Explaining the examination to your PATIENTS

This is not a fun exam

  • Uncomfortable
  • Confusing
  • Requires patience

Timing of the Examination

  • The initial examination should be done in EMERGENCY DEPARTMENT for Traumatic Spinal Cord Injury
  • Attempt to determine the motor level, sensory level, completeness of injury, and AIS score
  • However, it is difficult to obtain complete and reliable results in ED
  • Traumatic Brain Injury
  • Pain
  • Respiratory Failure
  • Shock
  • Cognitive Changes
  • Drugs

Sensory

Key point in each of the 28 dermatomes (from C2 to S4-S5) on the right and left sides.

Two aspects of sensation are examined:

  • Light touch
  • Pinprick (sharp-dull discrimination)

Asia Chart

LIGHT TOUCH

  • Wisp cotton
  • Applied lightly.
  • Stroke across skin. Not exceed 1 cm
  • Done with eyes close

PIN PRICK

  • Standard safety pin
  • Pointed end for sharpness
  • Rounded end for dullness
  • Apply light pressure without moving the pin after the point of contact

Asia Chart

Sensory Test of Anal Region

  • S4-S5 dermatome
  • Perianal Sensation
  • Deep Anal Sensation

Sensory Grading

0 =absent

1= impaired (partial or altered appreciation including hyperesthesia)

2=normal

NT = not testable

Sensory grading

Sensory grading

Sensory grading

Anal Exam

Very Important Part to Test!

Voluntary Anal Contraction

-Insert a finger into the rectum, and ask the patient to contract the anus (like holding in a BM), and release. Repeat several times to confirm voluntary contraction

Deep Anal Pressure

-With the finger still in the rectum, ask the patient which direction you are applying pressure- towards the head, towards the feet, towards the right side, or left side.

Should show consistent differentiation between directions

 Use Gloves and Lube

Motor

Key Muscles Functions

  • 10 paired myotomes
  • Upper Limb C5-T1
  • Lower Limb L2-S1

Represent each respective spinal cord segment

spinal cord segment

Manual Muscle Testing Grading

Manual Muscle Testing Grading

Positioning for motor examination

  • Neutral position for Grade 3 testing
  • Strategically eliminate gravity for Grade 2 testing
  • When testing for Grades 4 and 5, the muscle is positioned in a manner that partially activates the muscles
  • The patient is instructed to maintain that position
  • C6 Wrist in full extension

C5-Biceps

C5-Biceps

C6-Wrist Extensor

C6-Wrist Extensor

C7-Triceps

C7-Triceps

C8-Finger Flexors (DIP)

C8-Finger Flexors (DIP)

T1-Small Finger Abductor

T1-Small Finger Abductor

L2-Hip Flexors

L2-Hip Flexors

L3-Quadriceps

L3-Quadriceps

L4-Dorsiflexors

L4-Dorsiflexors

L5-Great Extensor Toe

L5-Great Extensor Toe

S1-Plantar Flexors

S1-Plantar Flexors

ASIA Impairment Scale Classification

1) Determine sensory level for right and left side

  • The lowest level with a 2 (normal) for both pinprick and light touch where every level higher also 2
  • The sensory level may be different on the left and right sides

Sensory level for right and left side

2) Determine motor levels for the right and left sides

  • The lowest level where the muscle grade is at least a 3, with all muscles above graded as a 5
  • In regions where there is no myotome to test, the motor level is presumed to be the same as the sensory level.

Motor levels for the right and left sides

3) Determine the neurological level of injury

  • The highest level of the 4 individual levels

Neurological level of injury

4) Determine whether the injury is Complete or incomplete. If complete AIS Grade = A

1) Defined by the presence/absence of sacral sparing

2) If NO voluntary anal contraction AND all S4-5 sensory scores are 0 AND there is NO deep anal pressure then the injury is complete

3) NOOOON Sign

NOOOON Sign

4) Determine ASIA impairment Scale grade

  • A = Complete.
  • B = Sensory incomplete.
  • C = Motor incomplete.
  • D = Motor incomplete.
  • E=Normal.

5) Determine ASIA impairment Scale grade

A = Complete.

B = Sensory incomplete.

C = Motor incomplete.

D = Motor incomplete.

E = Normal.

6) If A is ruled out, is the injury Motor incomplete?

(Do they get out of “B”???)

– Preservation of motor function is defined by

  • Presence of voluntary anal contraction

OR

  • Motor movement greater than three levels below the motor level on that side of the body

– (may use non-key muscle groups)

– If both of these are absent, AIS Grade = B

Test non key muscles

Test non key muscles

 7) If B is ruled out, how incomplete is the motor function?

– Are at least half of the key muscles below the neurological level of injury graded 3 or better?

– If no, AIS Grade = C

– If yes, AIS Grade = D

AIS Grade

About Authors

Dr. Muhammad Mahmood Ahmad is a Spinal as well as an Orthopedic Surgeon with over 14 years of experience currently practicing at Razia Saeed Hospital, Multan.