Abstract
Study design:
A retrospective audit of assessor accuracy using the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) in three multicentre randomised controlled trials (SCIPA: Spinal Cord Injury and Physical Activity) spanning 2010–2014 with standards revised in 2011.
Objectives:
To investigate assessor accuracy of neurological classification after spinal cord injury.
Setting:
Australia and New Zealand.
Methods:
ISNCSCI examinations were undertaken by trained clinicians prior to randomisation. Data were recorded manually and ISNCSCI worksheets circulated to panels, consensus reached and worksheets corrected. An audit team used a 2014 computerised ISNCSCI algorithm to check manual worksheets. A second audit team assessed whether the 2014 computerised algorithm accurately reflected pre- and post-2011 ISNCSCI standards.
Results:
Of the 208 ISNCSCI worksheets, 24 were excluded. Of the remaining 184 worksheets, 47 (25.5%) were consistent with the 2014 computerised algorithm and 137 (74.5%) contained one or more errors. Errors were in motor (30.1%) or sensory (12.4%) levels, zone of partial preservation (24.0%), motor/sensory scoring (21.5%), ASIA Impairment Scale (AIS, 8.3%) and complete/incomplete classification (0.8%). Other difficulties included classification when anal contraction/sensation was omitted, incorrect neurological levels and violation of the ‘motor follows sensory rule in non-testable myotomes’ (7.4%). Panel errors comprised corrections that were incorrect or missed or incorrect changes to correct worksheets.
Conclusion:
Given inaccuracies in the manual ISNCSCI worksheets in this long-term clinical trial setting, continued training and a computerised algorithm are essential to ensure accurate scoring, scaling and classification of the ISNCSCI and confidence in clinical trials.
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References
Galea MP, Dunlop SA, Marshall R, Clark J, Churilov L . Early exercise after spinal cord injury ('Switch-On'): study protocol for a randomised controlled trial. Trials 2015; 16: 7.
Harvey LA, Dunlop SA, Churilov L, Hsueh Y-SA, Galea MP . Early intensive hand rehabilitation after spinal cord injury (‘Hands On’): a protocol for a randomised controlled trial. BioMed Central 2011; Trials 2011 12: 14.
Fehlings MG, Theodore N, Harrop J, Maurais G, Kuntz C, Shaffrey CI et al. A phase I/IIa clinical trial of a recombinant Rho protein antagonist in acute spinal cord injury. J Neurotrauma 2011; 28: 787–796.
Fehlings MG, Vaccaro A, Wilson JR, Singh A, W Cadotte D, Harrop JS et al. Early versus delayed decompression for traumatic cervical spinal cord injury: results of the Surgical Timing in Acute Spinal Cord Injury Study (STASCIS). PLoS ONE 2012; 7: e32037.
Kirshblum SC, Waring Waring, Biering-Sorensen F, Burns SP, Johansen M et al International Standards for the Neurological Classification of Spinal Cord Injury, Revised 20158th edn, American Spinal Injury Association: Atlanta, GA, USA. 2015.
Galea MP, Dunlop SA, Davis GM, Nunn A, Geraghty T, Hsueh Y-sA et al. Intensive exercise program after spinal cord injury (‘Full-On’): study protocol for a randomized controlled trial. BioMed Central 2013; Trials 2013 14: 291.
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.
Kirshblum S, Waring W 3rd . Updates for the International Standards for Neurological Classification of Spinal Cord Injury. Phys Med Rehabil Clin N Am 2014; 25: 505–517 vii.
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.
Waring WP 3rd, 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.
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.
Donovan WH, Brown DJ, Ditunno JF Jr, Dollfus P, Frankel HL . Neurological issues. Spinal Cord. 1997; 35: 275–281.
Furlan JC, Fehlings MG, Tator CH, Davis AM . Motor and sensory assessment of patients in clinical trials for pharmacological therapy of acute spinal cord injury: psychometric properties of the ASIA Standards. J Neurotrauma 2008; 25: 1273–1301.
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.
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.
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, Bergstrom EM, 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.
Curt A, Van Hedel HJ, Klaus D, Dietz V, Group E-SS. Recovery from a spinal cord injury: significance of compensation, neural plasticity, and repair. J Neurotrauma 2008; 25: 677–685.
Kirshblum SC, Biering-Sorensen F, Betz R, Burns S, Donovan W, Graves DE et al. International Standards for Neurological Classification of Spinal Cord Injury: cases with classification challenges. J Spinal Cord Med 2014; 37: 120–127.
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: 373–384.
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.
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.
Schuld C, Wiese J, Franz S, Putz C, Stierle I, Smoor I et al. Effect of formal training in scaling, scoring and classification of the International Standards for Neurological Classification of Spinal Cord Injury. Spinal Cord 2013; 51: 282–288.
Marshall R, Clark JM, Dunlop SA, Galea MP The International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI): Consensus between Clinicians and Expert examiners [Abstract]. Conference Proceedings, 53rd International Spinal Cord Society (ISCoS) Annual Scientific Meeting, 2014. [Abstract]. In press 2014.
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, Li Pi, Shan R, Marino RJ . A web-based computer program to determine the ASIA impairment classification. Spinal Cord 2010; 48: 100–104.
Schuld C, Wiese J, Hug A, Putz C, Hedel HJ, 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.
Rick Hansen Institute. ISNCSCI Algorithm http://www.isncscialgorithm.com/. International Spinal Cord Society 2014.
Walden K, Belanger LM, Biering-Sorensen F, Burns SP, Echeverria E, Kirshblum S et al. Development and validation of a computerized algorithm for International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI). Spinal Cord 2015; 54: 197–203.
Marino R, Barros T, Biering-Sorensen F, Burns SP, Donovan WH, Graves D et al International standards for neurological classification of spinal cord injury. J Spinal Cord Med 2003; 26 (Suppl 1): S50–S56.
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.
Acknowledgements
The work was funded by the Transport Accident Commission (Victorian Neurotrauma Initiative), the Lifetime Care and Support Authority NSW, the Australian Government National Health and Medical Research Council (APP1002347 and APP1028300) and the Neurotrauma Research Program (Western Australia).
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Armstrong, A., Clark, J., Ho, D. et al. Achieving assessor accuracy on the International Standards for Neurological Classification of Spinal Cord Injury. Spinal Cord 55, 994–1001 (2017). https://doi.org/10.1038/sc.2017.67
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DOI: https://doi.org/10.1038/sc.2017.67
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