Figure 1
American Spinal Injury Association (ASIA) sensory key points. Reprinted by permission from ASIA. ASIA. International Standards for Neurological Classification of Spinal Cord Injury, revised 2002. Chicago (IL): ASIA; 2002. C = cervical, L = lumbar, S = sacral, T = thoracic.
Source publication
This article was presented at the Premeeting Workshop on Outcome Measures at the American Spinal Injury Association (ASIA) Annual Scientific Meeting in Dallas, Texas, in May 2005. The article summarizes preliminary findings of three quantitative sensory tests that were evaluated as part of the International Spinal Research Trust Clinical Initiative...
Context in source publication
Context 1
... each of the three tests (electrical, vibration, and thermal PTs), normative values and reproducibility of the technique were established in control subjects before per- forming the test in the patients with SCI. Wherever possi- ble, stimuli were applied over American Spinal Injury Association (ASIA) sensory key points or, at least, within ASIA dermatomes (Figure 1). All patients also had a clinical neurological examination and classification per- formed according to ASIA standards [13][14] so that the QST results could be correlated with clinical sensory examination results. Consistent with ASIA standards, clinical sensory level was determined separately for the right and left sides of the body and defined as the most caudal spinal segment with normal sensory function for both sensory modalities (i.e., pinprick and light touch). ...
Similar publications
Context/Objective: Spinal Cord Injury (SCI) patients face unique identity challenges associated with physical limitations, higher comorbid depression, increased suicidality and reduced subjective well-being. Post-injury identity is often unaddressed in subacute rehabilitation environments where critical physical and functional rehabilitation goals...
Citations
... However, care should be exercised when considering this conclusion, given the small number of participants tested. Our results echo those of previous studies that have shown that EPTs in individuals with SCI were significantly higher than control participants [24,25,[28][29][30][31]. ...
Study design
Observational, cohort study.
Objectives
(1) Determine the feasibility and relevance of assessing corticospinal, sensory, and spinal pathways early after traumatic spinal cord injury (SCI) in a rehabilitation setting. (2) Validate whether electrophysiological and magnetic resonance imaging (MRI) measures taken early after SCI could identify preserved neural pathways, which could then guide therapy.
Setting
Intensive functional rehabilitation hospital (IFR).
Methods
Five individuals with traumatic SCI and eight controls were recruited. The lower extremity motor score (LEMS), electrical perceptual threshold (EPT) at the S2 dermatome, soleus (SOL) H-reflex, and motor evoked potentials (MEPs) in the tibialis anterior (TA) muscle were assessed during the stay in IFR and in the chronic stage (>6 months post-SCI). Control participants were only assessed once. Feasibility criteria included the absence of adverse events, adequate experimental session duration, and complete dataset gathering. The relationship between electrophysiological data collected in IFR and LEMS in the chronic phase was studied. The admission MRI was used to calculate the maximal spinal cord compression (MSCC).
Results
No adverse events occurred, but a complete dataset could not be collected for all subjects due to set-up configuration limitations and time constraints. EPT measured at IFR correlated with LEMS in the chronic phases ( r = −0.67), whereas SOL H/M ratio, H latency, MEPs and MSCC did not.
Conclusions
Adjustments are necessary to implement electrophysiological assessments in an IFR setting. Combining MRI and electrophysiological measures may lead to better assessment of neuronal deficits early after SCI.
... Despite its somewhat subjective nature, Quantitative Sensory Testing (QST) has been well investigated in patients with SCI. The test uses thermal, electrical and vibratory stimuli administered at different dermatomes to detect the pain thresholds (Savic et al., 2007;Boakye et al., 2012). The assessment of pain intensity is often performed using questionnaires and self-reported scales. ...
Pain is a significant problem in diseases affecting the spinal cord, including demyelinating disease. To date, studies have examined the reliability of clinical measures for assessing and classifying the severity of spinal cord injury (SCI) and also to evaluate SCI-related pain. Most of this research has focused on adult populations and patients with traumatic injuries. Little research exists regarding pediatric spinal cord demyelinating disease. One reason for this is the lack of reliable and useful approaches to measuring spinal cord changes since currently used diagnostic imaging has limited specificity for quantitative measures of demyelination. No single imaging technique demonstrates sufficiently high sensitivity or specificity to myelin, and strong correlation with clinical measures. However, recent advances in diffusion tensor imaging (DTI) and magnetization transfer imaging (MTI) measures are considered promising in providing increasingly useful and specific information on spinal cord damage. Findings from these quantitative imaging modalities correlate with the extent of demyelination and remyelination. These techniques may be of potential use for defining the evolution of the disease state, how it may affect specific spinal cord pathways, and contribute to the management of pediatric demyelination syndromes. Since pain is a major presenting symptom in patients with transverse myelitis, the disease is an ideal model to evaluate imaging methods to define these regional changes within the spinal cord. In this review we summarize (1) pediatric demyelinating conditions affecting the spinal cord; (2) their distinguishing features; and (3) current diagnostic and classification methods with particular focus on pain pathways. We also focus on concepts that are essential in developing strategies for the detection, monitoring, treatment and repair of pediatric myelitis.
... For this purpose, quantitative sensory testing (QST), dermatomal SSEPs (dSSEPS), and contact heat evoked potentials (CHEPs) have been investigated. 108 Quantitative Sensory Testing (QST) 109,110 involves administration of three types of stimuli to determine the threshold of detection of electrical, thermal and vibratory stimuli at the ASIA key sensory points in different dermatomes. This testing is based on the subject's report of perception differing from EP testing that measures evoked signals. ...
... In a prospective evaluation of an SCI cohort, QST was more sensitive than the standard neurological testing. 109 When combined, the three modalities (electrical/light touch, temperature and vibration) test both the dorsal column (light touch and vibration) and spinothalamic (temperature) sensory inputs. The stimuli are very reproducible and are selected to assess both small unmyelinated afferents and also larger myelinated afferents. ...
The preservation of functional neural tissue after spinal cord injury (SCI) is the basis for spontaneous neurological recovery. Some injured patients in acute phase have more potential for recovery than others. This fact is problematic for the construction of clinical trials because enrollment of subjects with variable recovery potential makes it difficult to detect effects, requires large sample sizes, and risks Type II errors. In addition, the current methods to assess injury and recovery are non-quantitative and not very sensitive. It is likely that therapeutic combinations will be necessary to cause substantially improved function after SCI, thus we need highly sensitive techniques to evaluate changes in motor, sensory, autonomic and other functions. We review several emerging neurophysiological techniques with high sensitivity. Quantitative methods to evaluate residual tissue sparing after severe acute spinal cord injury (SCI) have not entered widespread clinical use. This reduces the ability to correlate structural preservation with clinical outcome following SCI resulting in enrollment of subjects with varying patterns of tissue preservation and injury into clinical trials. We propose that the inclusion of additional measures of injury severity, pattern, and individual genetic characteristics may enable stratification in clinical trials to making the testing of therapeutic interventions more effective and efficient. New imaging techniques to assess tract injury and demyelination and methods to quantify tissue injury, inflammatory markers, and neuroglial biochemical changes may improve the evaluation of injury severity, correlation with neurological outcome and measure the effects of treatment more robustly than is currently possible. The ability to test such a multimodality approach will require a high degree of collaboration between clinical and research centers and government research support. When the most informative of these assessments is determined it may be possible to identify patients with substantial recovery potential, improve selection criteria and conduct more efficient clinical trials.
... Since then we have contributed to the validation of the International Standards for Neurological Classification of Spinal Cord injury 52 and development of some new, more precise methods of quantifying the level and density of spinal cord lesions, 53 as part of the International Spinal Research Trust (ISRT) funded studies of physiological [54][55][56] and clinical outcome measures. [57][58][59][60] AGEING AND SURVIVAL Together with the Northwest Regional Spinal Injuries Centre, Southport, UK, and in collaboration with Craig Hospital, Englewood, CO, USA, we have undertaken a longitudinal study on Ageing with SCI in order to provide information on health, functional ability and psychosocial wellbeing in persons with long-term spinal cord injury. 61 In 1990, when the study started, all participants had been injured more than 20 years previously. ...
This Ludwig Guttmann Lecture was presented at the 2012 meeting of the International Spinal Cord Society in London. It describes the contribution of Stoke Mandeville Hospital to the field of spinal cord injuries. Dr Ludwig Guttmann started the Spinal Unit at Stoke Mandeville Hospital in 1944 and introduced a novel, comprehensive method of care, which included early admission, prevention and treatment of spinal cord injury related complications, active rehabilitation and social reintegration. Soon a dedicated specialist team was assembled and training of visitors was encouraged, some of whom went on to start their own spinal units. Research went hand in hand with clinical work, and over the years more than 500 scientific contributions from Stoke Mandeville have been published in peer reviewed journals and books. Guttmann introduced sport as a means of physical therapy, which soon lead to organised Stoke Mandeville Games, first national in 1948, then international in 1952 and finally the Paralympic Games in 1960. Stoke Mandeville is regarded as the birthplace of the Paralympic movement, and Guttmann was knighted in 1966. Stoke Mandeville is also the birthplace of the International Medical Society of Paraplegia, later International Spinal Cord Society, which was formed during the International Stoke Mandeville Games in 1961, and of the Society's medical journal Paraplegia, later Spinal Cord, first published in 1963. Guttmann's followers have continued his philosophy and, with some new developments and advances, the present day National Spinal Injuries Centre at Stoke Mandeville Hospital provides comprehensive, multidisciplinary acute care, rehabilitation and life-long follow-up for patient with spinal cord injuries of all ages.Spinal Cord advance online publication, 9 October 2012; doi:10.1038/sc.2012.109.
... For clinical applications, such as monitoring the treatment and rehabilitation processes following a surgery, a more quantitative and objective way for the diagnosis of spinal cord injury is required. In recent years, some encouraging investigations have been carried out for this purpose by assessing the thermal [3] and electrical perception threshold [4, 5]. However, these techniques require patient's feedback, hence cannot be effectively used for noncooperative and unconscious patients. ...
In our previous study, we have demonstrated that analyzing the skin impedances measured along the key points of the dermatomes might be a useful supplementary technique to enhance the diagnosis of spinal cord injury (SCI), especially for unconscious and noncooperative patients. Initially, in order to distinguish between the skin impedances of control group and patients, artificial neural networks (ANNs) were used as the main data classification approach. However, in the present study, we have proposed two more data classification approaches, that is, support vector machine (SVM) and hierarchical cluster tree analysis (HCTA), which improved the classification rate and also the overall performance. A comparison of the performance of these three methods in classifying traumatic SCI patients and controls was presented. The classification results indicated that dendrogram analysis based on HCTA algorithm and SVM achieved higher recognition accuracies compared to ANN. HCTA and SVM algorithms improved the classification rate and also the overall performance of SCI diagnosis.
... Those authors (Nicotra and Ellaway, 2006) found normal warm detection thresholds one to two dermatomes immediately above the lesion level. Therefore, it could be that warm threshold abnormalities could be found in dermatomes clinically defined as normal in some subjects with cSCI or iSCI, but may not be a generalized finding (Nicotra and Ellaway, 2006;Savic et al., 2007). ...
... Defrin et al. (1999), found an elevation in heat pain threshold above the level of injury in SCI subjects with pain and functionally complete spinal transection. However no changes in heat pain threshold were reported by Wasner et al. (2008), above level (in the face) or by Finnerup et al. (2007), and by Savic et al. (2007), at SCI level. The different result in psychophysical measures between those studies might be due to the selection of subjects, pain characteristic, and methodological differences which were used in each study. ...
... However, this may not be an easy task, as many attempts have been made to develop sensitive, accurate and reliable thoracic sensory assessment paradigms that can be easily performed with a minimum of equipment and training. [23][24][25][26][27][28] Conclusion Our analysis of thoracic AIS-A SCI may be helpful for investigators planning clinical trials of new therapeutic interventions for SCI. The best available option for tracking neurological recovery in thoracic cord segments remains the neurological level or the pin-prick sensory level. ...
Retrospective, longitudinal analysis of sensory, motor and functional outcomes from individuals with thoracic (T2-T12) sensorimotor complete spinal cord injury (SCI).
To characterize neurological changes over the first year after traumatic thoracic sensorimotor complete SCI.
A dataset of 399 thoracic complete SCI subjects from the European Multi-center study about SCI (EMSCI) was examined for neurological level, sensory levels and sensory scores (pin-prick and light touch), lower extremity motor score (LEMS), ASIA Impairment Scale (AIS) grade, and Spinal Cord Independence Measure (SCIM) over the first year after SCI.
AIS grade conversions were limited. Sensory scores exhibited minimal mean change, but high variability in both rostral and caudal directions. Pin-prick and light touch sensory levels, as well as neurological level, exhibited minor changes (improvement or deterioration), but most subjects remained within one segment of their initial injury level after 1 year. Recovery of LEMS occurred predominantly in subjects with low thoracic SCI. The sensory zone of partial preservation (ZPP) had no prognostic value for subsequent recovery of sensory levels or LEMS. However, after mid or low thoracic SCI, ≥3 segments of sensory ZPP correlated with an increased likelihood for AIS grade conversion.
The data suggest that a sustained deterioration of three or more thoracic sensory levels or loss of upper extremity motor function are rare events and may be useful for tracking the safety of a therapeutic intervention in early phase acute SCI clinical trials, if a significant proportion of study subjects exhibit such an ascent.
... Although neurophysiological measures of body function/structure have not shown promise in some acute studies, 45 they may have value in persons with chronic SCI. 55 Quantitative sensory 56,57 and motor testing procedures also offer promise of greater precision. Recent advances in neuroimaging of SCI hold promise for development of anatomical/physiological surrogates of the severity of injury for use in clinical trials. ...
The need to determine the beneficial effect of the treatment of spinal cord injury (SCI) requires clearly defined standardized measures of the severity of injury and how well the function is restored. Improved neurological recovery should be linked to increased capacity to perform tasks such as walking, reaching and grasping, which results in meaningful gains in mobility and self-care. Measurements of recovery, capacity, mobility and self-care are the outcomes used to determine the benefits from the treatment and have evolved over the last century with contributions by the mentors and protégés of Sir Ludwig Guttmann, whom we honor today. Randomized clinical trials in the past 20 years have taught us many lessons as to which outcome measures have the greatest validity and reliability. The International Standards for Neurological Classification of SCI have become the clinical gold standard for measurement of severity, but would benefit from pathophysiological surrogates to better understand the mechanisms of recovery. Measurements of walking capacity have emerged as valid/reliable/responsive and upper extremity measures are in development, which help distinguish neurological improvement from rehabilitation adaptation. Performance of self-care and mobility has been linked to capacity and severity outcomes. In addition, new partnerships between clinical trial entities, professional societies, industry and federal agencies should facilitate identification of priorities and uniformity of measurement standards. Our ultimate goal is to improve the quality of life of those individuals with SCI whom we serve, but we must focus our investigative efforts carefully, systematically and rigorously as clinical scientists.
... [1][2][3] The need for improved and more sensitive outcome measures for SCI clinical trials has been emphasized repeatedly. [4][5][6][7] This is especially true of therapeutic clinical trials that, for safety reasons, may target patients with thoracic lesion, where current clinical assessment tools are not sensitive enough to detect minor neurological changes. The EPT test was developed with this in mind. ...
Prospective longitudinal experimental study.
The aim of this study was to assess the sensitivity to change of the electrical perceptual threshold (EPT) test during the longitudinal monitoring of neurological changes in patients with incomplete spinal cord injury (SCI).
National Spinal Injuries Centre, Stoke Mandeville Hospital, Buckinghamshire Hospitals NHS Trust, Buckinghamshire, UK.
Perceptual threshold to 3 Hz cutaneous electrical stimulation was measured in 11 patients with incomplete SCI at selected American Spinal Injuries Association (ASIA) sensory key points on four occasions. The first three measurements were performed within a 5-day period (baseline) and the fourth measurement (follow-up) at least 9 months later. The results were tested for statistical significance and the effect sizes were calculated.
There were no significant differences between the EPT results of the three baseline assessments. When the mean baseline and follow-up EPT results were compared, there were no significant differences in EPT values above the sensory level of lesion, but a significant difference (reduction in threshold values) was found at and below the level of SCI, with medium and large effect sizes, respectively.
The EPT test showed good sensitivity to change in dermatomes at and directly below the sensory level of the SCI. This makes it a potentially useful quantitative sensory instrument for detecting changes in sensory function during longitudinal monitoring of patients with SCI.
... In order to diagnose and assess the level of SCI, clinical neurological examination technique has been widely used by clinicians for years. However, in recent years, a few studies were carried out to assess the level and severity of SCI in quantitative manner [8, 9, 13, 15, 16]. Main motivation of these studies was the relative subjectivity of clinical neurological examination in the assessment and monitoring of neurological changes in patients with SCI [11]. ...
The purpose of this study was to develop a quantitative skin impedance test that could be used to diagnose spinal cord injury (SCI) if any, especially in unconscious and/or non-cooperative SCI patients. To achieve this goal, initially skin impedance of the sensory key points of the dermatomes (between C3 and S1 bilaterally) was measured in 15 traumatic SCI patients (13 paraplegics and 2 tetraplegics) and 15 control subjects. In order to classify impedance values and to observe whether there would be a significant difference between patient and subject impedances, an artificial neural network (ANN) with back-propagation algorithm was employed. Validation results of the ANN showed promising performance. It could classify traumatic SCI patients with a success rate of 73%. By assessing the experimental protocols and the validation results, the proposed method seemed to be a simple, objective, quantitative, non-invasive and non-expensive way of assessing SCI in such patients.
