Abstract
Study Design:
Prospective, longitudinal cohort study.
Objectives:
To quantify the effect of formal training in the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) on the classification accuracy and to identify the most difficult ISNCSCI rules.
Settings:
European Multicenter Study on Human Spinal Cord Injury (EMSCI).
Methods:
EMSCI participants rated five challenging cases of full sensory, motor and anorectal examinations before (pre-test) and after (post-test) an ISNCSCI instructional course. Classification variables included sensory and motor levels (ML), completeness, ASIA Impairment Scale (AIS) and the zones of partial preservation.
Results:
106 attendees were trained in 10 ISNCSCI workshops since 2006. The number of correct classifications increased significantly (P<0.00001) from 49.6% (2628 of 5300) in pre-testing to 91.5% (4849 of 5300) in post-testing. Every attendee improved, 12 (11.3%) achieved 100% correctness. Sensory levels (96.8%) and completeness (96.2%) are easiest to rate in post-testing, while ML (81.9%) and AIS (88.1%) are more difficult to determine. Most of the errors in ML determination arise from sensory levels in the high cervical region (C2−C4), where by convention the ML is presumed to be the same as the sensory level. The most difficult step in AIS classification is the determination of motor incompleteness.
Conclusion:
ISNCSCI training significantly improves the classification skills regardless of the experience in spinal cord injury medicine. These findings need to be considered for the appropriate preparation and interpretation of clinical trials in spinal cord injury.
Similar content being viewed by others
Log in or create a free account to read this content
Gain free access to this article, as well as selected content from this journal and more on nature.com
or
References
Kirshblum SC, Burns SP, Biering-Sorensen F, Donovan W, Graves DE, Jha A et al International standards for neurological classification of spinal cord injury (revised 2011). J Spinal Cord Med 2011; 34: 535–546.
Furlan JC, Noonan V, Singh A, Fehlings MG . Assessment of impairment in patients with acute traumatic spinal cord injury: a systematic review of the literature. J Neurotrauma 2011; 28: 1445–1477.
Fawcett JW, Curt A, Steeves JD, Coleman WP, Tuszynski MH, Lammertse D et al Guidelines for the conduct of clinical trials for spinal cord injury as developed by the ICCP panel: spontaneous recovery after spinal cord injury and statistical power needed for therapeutic clinical trials. Spinal Cord 2007; 45: 190–205.
Lammertse D, Tuszynski MH, Steeves JD, Curt A, Fawcett JW, Rask C et al Guidelines for the conduct of clinical trials for spinal cord injury as developed by the ICCP panel: clinical trial design. Spinal Cord 2007; 45: 232–242.
Steeves JD, Lammertse D, Curt A, Fawcett JW, Tuszynski MH, Ditunno JF et al Guidelines for the conduct of clinical trials for spinal cord injury (SCI) as developed by the ICCP panel: clinical trial outcome measures. Spinal Cord 2007; 45: 206–221.
Tuszynski MH, Steeves JD, Fawcett JW, Lammertse D, Kalichman M, Rask C et al Guidelines for the conduct of clinical trials for spinal cord injury as developed by the ICCP panel: clinical trial inclusion/exclusion criteria and ethics. Spinal Cord 2007; 45: 222–231.
Cohen ME, Ditunno JF, Donovan WH, Maynard FM . A test of the 1992 international standards for neurological and functional classification of spinal cord injury. Spinal Cord 1998; 36: 554–560.
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: 166–170.
Savic G, Bergström 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.
Burns AS, Lee BS, Ditunno JF, Tessler A . Patient selection for clinical trials: the reliability of the early spinal cord injury examination. J Neurotrauma 2003; 20: 477–482.
Cohen ME, Sheehan TP, Herbison GJ . Content validity and reliability of the international standards for neurological classification of spinal cord injury. Topics Spinal Cord Injury Rehabil 1996; 4: 15–31.
Curt A, Schwab ME, Dietz V . Providing the clinical basis for new interventional therapies: refined diagnosis and assessment of recovery after spinal cord injury. Spinal Cord 2004; 42: 1–6.
Kirshblum SC, Waring W, Biering-Sorensen F, Burns SP, Johansen M, Schmidt-Read M et al Reference for the 2011 revision of the international standards for neurological classification of spinal cord injury. J Spinal Cord Med 2011; 34: 547–554.
Waring WP, Biering-Sorensen F, Burns S, Donovan W, Graves D, Jha A et al 2009 review and revisions of the international standards for the neurological classification of spinal cord injury. J Spinal Cord Med 2010; 33: 346–352.
Kirshblum S Difficult cases in classification of SCI. Presented at the American Paraplegia Society Meeting; 5 September 2006; Las Vegas, NV.
Chafetz RS, Vogel LC, Betz RR, Gaughan JP, Mulcahey MJ . International standards for neurological classification of spinal cord injury: training effect on accurate classification. J Spinal Cord Med 2008; 31: 538–542.
Mulcahey MJ, Gaughan J, Betz RR, Vogel LC . Rater agreement on the ISCSCI motor and sensory scores obtained before and after formal training in testing technique. J Spinal Cord Med 2007; 30 (Suppl 1): S146–S149.
Schuld C, Wiese J, Hug A, Putz C, van Hedel HJA, Spiess MR et al Computer implementation of the international standards for neurological classification of spinal cord injury for consistent and efficient derivation of its subscores including handling of data from not testable segments. J Neurotrauma 2012; 29: 453–461.
Chafetz RS, Prak S, Mulcahey MJ . Computerized classification of neurologic injury based on the international standards for classification of spinal cord injury. J Spinal Cord Med 2009; 32: 532–537.
Linassi G, Shan RLP, Marino RJ . A web-based computer program to determine the ASIA impairment classification. Spinal Cord 2010; 48: 100–104.
Acknowledgements
We thank all patients and all colleagues participating in the EMSCI network. Additionally, we thank all attendees of the ISNCSCI instructional courses for performing the pre-/post-tests and for giving valuable feedback. This work was partly funded by the International Foundation for Research in Paralegia, Zurich, Switzerland.
Author information
Authors and Affiliations
Consortia
Corresponding author
Ethics declarations
Competing interests
The authors declare no conflict of interest.
Additional information
Supplementary Information accompanies the paper on the Spinal Cord website
Supplementary information
Rights and permissions
About this article
Cite this article
Schuld, C., Wiese, J., Franz, S. et al. Effect of formal training in scaling, scoring and classification of the International Standards for Neurological Classification of Spinal Cord Injury. Spinal Cord 51, 282–288 (2013). https://doi.org/10.1038/sc.2012.149
Received:
Revised:
Accepted:
Published:
Issue date:
DOI: https://doi.org/10.1038/sc.2012.149
Keywords
This article is cited by
-
The revised zone of partial preservation (ZPP) in the 2019 International Standards for Neurological Classification of Spinal Cord Injury: ZPP applicability in incomplete injuries
Spinal Cord (2024)
-
Computer International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) algorithms: a review
Spinal Cord (2023)
-
A taxonomy for consistent handling of conditions not related to the spinal cord injury (SCI) in the International Standards for Neurological Classification of SCI (ISNCSCI)
Spinal Cord (2022)
-
Implementation of multilingual support of the European Multicenter Study about Spinal Cord Injury (EMSCI) ISNCSCI calculator
Spinal Cord (2022)
-
Theoretical and practical training improves knowledge of the examination guidelines of the International Standards for Neurological Classification of Spinal Cord Injury
Spinal Cord (2022)
