American Spinal Injury Association (ASIA) Scale & Exam

OT Dude Academy’s Free NBCOT® Exam Prep Course Spinal Cord Injury (SCI) American Spinal Injury Association (ASIA) Scale & Exam

The ASIA Exam was developed by the American Spinal Injury Association (ASIA) as a universal tool to define and describe the extent and severity of a client’s spinal cord injury. The ASIA scale informs practice for future rehabilitation needs. It is comprised of a sensory and motor assessment of the left and right sides of the body. The ASIA Exam was recently updated in 2019.1  Ideally, the ASIA scale is completed within 72 hours of the initial injury. To perform the test, the patient should be lying in supine, except for the rectal examination. This is to ensure consistency across tests.2 

ASIA Impairment Scale (AIS)

  • A = Complete. Complete lack of motor and sensory function below the level of injury (including the anal area)
  • B = Sensory Incomplete. Some sensations below the level of the injury (including anal sensation)
  • C = Motor Incomplete. Some muscle movement is spared below the level of injury, but 50 percent of the muscles below the level of injury cannot move against gravity.
  • D = Motor Incomplete. Most (more than 50 percent) of the muscles that are spared below the level of injury are strong enough to move against gravity.
  • E = Normal. All neurlogic function has returened.3 

Muscle Function Grading

  • 0 = Total paralysis
  • 1 = palpable or visible contraction
  • 2 = active movement, full ROM with gravity eliminated
  • 3 = active movement, full ROM against gravity
  • 4 = active movement, full ROM against gravity, and moderate resistance
  • 5 = (normal) active movement, full ROM against gravity, and full resistance
  • 5* = (normal) active movement, full ROM against gravity and sufficient resistance to be considered normal if identified inhibiting factors, e.g, pain, disuse, were not present
  • NT = Not testable, e.g., immobilization, severe pain, amputation, contracture > 50% of normal ROM

Sensory Grading

  • 0 = Absent
  • 1 = Altered, hypo- or hypersensitivity
  • 2 = Normal
  • NT = Not testable

Steps in Classification

  1. Determine sensory levels for the right and left sides.
  2. Determine motor levels for the right and left sides.
  3. Determine the neurological level of injury (NLI)
  4. Determine whether the injury is complete or incomplete.
  5. Determine ASIA Impairment Scale (AID) Grade using the flowchart.4 

Deep Anal Pressure (DAP)

Patient is in the lateral position. After wearing gloves, the finger that will be used in the examination is lubricated. The lubricated finger is inserted 2-3 cm into the anus in adult patients but less in children. Deep anal pressure is tested by applying slight pressure on the anorectal wall with the index finger or by squeezing the anus between the thumb and index finger. Deep anal pressure is evaluated as “yes” or “none”.5 6 

Voluntary Anal Contraction

In voluntary anal contraction, the presence of repeatable voluntary contraction of the external anal sphincter around the examiner’s finger is evaluated. The patient is asked to squeeze the index finger in the anal channel with the external anal sphincter. The result of voluntary anal contraction examination is recorded as “yes” or “no”.5 6 

Classification of Incomplete SCI

  • Brown-Sequard Syndrome
  • Anterior Cord Syndrome
  • Posterior Cord Syndrome
  • Conus Medullaris Syndrome
  • Cauda Equina Syndrome
  1. ASIA and ISCoS International Standards Committee. The 2019 revision of the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI)-What’s new? Spinal Cord. 2019 Oct;57(10):815-817.[↩]
  2. Burns S, Biering-Sørensen F, Donovan W, Graves D, Jha A, Johansen M, Jones L, Krassioukov A, Kirshblum, Mulcahey MJ, Schmidt Read M, Waring W. International Standards for Neurological Classification of Spinal Cord Injury, Revised 2011. Top Spinal Cord Inj Rehabil 2012;18(1):85-99.[↩]
  3. Shepard Center. (n.d.). ASIA/ISCoS Exam and Grade. Retrieved from https://www.spinalinjury101.org/details/asia-iscos[↩]
  4. ASIA. ISNCSCI Scoring Outlines and ASIA Impairment Scale (AIS[↩]
  5. 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:
    535-46.[↩][↩]
  6. Gündüz B, Erhan B. Omurga-omurilik yaralanmalarında klinik ve muayene ve sınıflama. In: Hancı M, Erhan B, editors. Omurga ve Omurilik Yaralanmaları. İnter Tıp Yayınevi, İzmir, 2013. p.207-20.[↩][↩]
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