asia chart

ASIA CHART PRESENTER: DR SITI NADIAH MD SABRI SUPERVISOR: DR CHUA LI SHUN

Most accurate way to document impairment in a person with a SCI is by performing a standardized neurological examination, as endorsed by the International Standards for Neurological Classification of SCI Patients



Components Main Parts of Lowest Level of Lowest Level of of the Test Examination Motor Control Sensation • LT sensation • Voluntary Anal • PP sensation Contraction • Deep Anal • Manual (VAC) Pressure (DAP) muscle power testing

Sensory SENSORY GRADING Exam 0 Absent 1 Impaired (partial or altered appreciation • Face used as the reference point (cheek) including hyperesthesia) 2 Normal • Performed separately for NT Not testable LT & PP

Light Touch Cotton Apply 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 pin after point of contact

Pin Exam Grade 1: ability to Grade 0: cannot distinguish distinguish sharp from dull, the sharp from the dull however, the sensation is aspect of the safety pin qualitatively different as compared to the face (less sharp or hyperesthetic)

Level Description of Key Points for Sensory Testing C2 1 cm lateral to Occipital Protuberance C3 Supraclavicular Fossa at Midclavicular Line C4 Over Acromioclavicular Joint C5 Lateral Side Antecubital Fossa just Proximal to Elbow Crease C6 Dorsal Surface of Proximal Phalanx of the Thumb C7 Dorsal Surface of Proximal Phalanx of the Middle Finger C8 Dorsal Surface of Proximal Phalanx of the Little Finger T1 Medial Side Antecubital Fossa, just Proximal to Medical Epicondyle of Humerus

T2 Apex of Axilla T3 Midclavicular Line and 3rd Intercostal Space T4 Midclavicular Line and 4th Intercostal Space at Nipple Line T5 Midclavicular Line and 5th Intercostal Space Midway between T4 & T6 T6 Midclavicular Line and 6th Intercostal Space at the level of Xiphisternum T7 Midclavicular Line and 7th Intercostal Space Midway between T6 & T8 - Quarter Distance between Level Xiphisternum & Umbilicus T8 Midclavicular Line and 8th Intercostal Space Midway between T6 & T10- Half Distance between Level Xiphisternum & Umbilicus T9 Midclavicular Line and 9th Intercostal Space Midway between T8 & T10 - Three Quarters Distance between Level Xiphisternum & Umbilicus T10 Midclavicular Line and 10th Intercostal Space at the Level of Umbilicus T11 Midclavicular Line and 11th Intercostal Space Midway between T10 & T12 - Midway between Level of Umbilicus & Inguinal Ligament T12 Midclavicular Line Over Midpoint Inguinal Ligament L1 Midway between Sensory Point at T12 & L1

L2 Anterior-Medial Thigh at the Midpoint drawn connecting Midpoint of Inguinal Ligament & Medial Femoral Condyle L3 Medial femoral Condyle above the Knee L4 Medial Malleolus L5 Dorsal Foot at 3rd Metatarsal Phalangeal Joint S1 Lateral Aspect of Calcaneus S2 Midpoint of Popliteal Fossa S3 Over Ischial Tuberosity or Infragluteal Fold S4 - 5 Perianal Area < 1cm Lateral to Mucocutaneous Junction

• S3 • Over the ischial tuberosity or intragluteal • S4/S5 • In the perianal area, <1cm lateral to the mucocutaneous junction

Sensory Level • Determined by performing an examination of the key sensory points within each of 28 dermatomes on each side of body (right & left) • The most caudal level where sensation for LT & PP are both graded as 2 (normal) for both sides of the body

Motor Exam • Conducted using conventional manual muscle testing technique 0 Total paralysis 1 Palpable or visible contraction 2 Active movement, gravity eliminated 3 Active movement, against gravity 4 Active movement, against some resistance 5 Active movement, against full resistance NT Not testable

Not Testable • Contracture • If a muscle’s range is limited by contracture that exceeds 50% of the normal ROM • Spasticity • Pain • Cast

































Motor Level • Determined by examining a key muscle function within each of 10 myotomes on each side of the body • Defined by the lowest key muscle function that has a grade of at least 3 providing the key muscle functions represented by segments above are intact (5)

Neurological level of injury (NLI) Most caudal level, at which both motor and sensory modalities are intact on both sides of the body

• In cases where there is no key muscle level available (i.e cervical levels at and above C4, T2-L1, and sacral levels below S2), the NLI is that which corresponds to the sensory level

Sacral sparing Sensory or motor function in the sacral segments, S4-5 • Sensory function = S4-5 dermatome or DAP • Motor function = VAC

• With finger still in rectum, ask patient w you are applying pressure – towards he left side VAC DAP

ASIA Impairment Scale A Complete No sensory or motor function is preserved in the sacral segments S4-5 B Sensory Incomplete Sensory but not motor function is preserved below the neurological level and includes the sacral segments S4-5 AND no motor function is preserved more than 3 levels below the motor level on either side of the body

C Motor Incomplete Motor function is preserved at the most caudal sacral segments for VAC OR the patient meets criteria for sensory incomplete status, and has some sparing of motor function more than 3 levels below the ipsilateral motor level on either side of the body For AIS C- less than half of key muscle functions below the single NLI have a muscle grade ≥ 3 D Motor Incomplete Motor incomplete status as defined above, with at least half (or more) of key muscles functions below the single NLI have a muscle grade ≥ 3 E Normal If sensation and motor function as tested with ISNCSCI are graded as normal in all segments, and the patient had prior deficits

Steps in Classification Determine sensory levels for right and left sides Determine motor levels for right and left sides Determine the neurological level of injury (NLI) Determine whether the injury is Complete or Incomplete Determine ASIA Impairment Scale (AIS) Grade

Zone of Partial Preservation The extent of preserved functions below the sensory and motor levels & an important predictor of neurological recovery i.e. dermatomes and myotomes caudal to respective sensory and motor levels that remain partially innervated

ZPP.. 2019 Updates Motor ZPP Sensory ZPP Motor ZPPs are now defined and should be documented in all cases including patients Sensory ZPP on a given side is defined in the absence of sensory function in S4-5 (LT, PP) with incomplete injuries with absent VAC *Tip – doesn’t apply e.g. if AIS C where VAC is present on this side as long as DAP is not present *Tip – think about e.g. AIS B, where…left and right pr(rectal) finding is different

• In cases with present DAP, sensory ZPPs on both sides are not defined and should be noted as “not applicable (NA)” • Tip – DAP has no left or right (see the AIS form to recall….) • In cases with absent DAP, a sensory ZPP can be defined on one side (assuming also absent LT and PP sensation in S4-5 on this side) • While it may not necessarily be applicable (and should be noted as “NA”) on the other side if there is present LT or PP at S4-5 • (If you think about this….if it’s not absent then it will not be incomplete injury and therefore will be an A and ZPP is applicable in A ...)

It only applies if…’No’