Poster 6: International Standards for Neurological Classification of Spinal Cord Injury: Inter-Rater Agreement and Guidelines for Use with Children and Youths

Abstract

Objective: To report the results of interrater agreement of the International Standards for Neurological Classification of Spinal Cord Injury (ISCSCI) motor, sensory and anorectal examinations in children\youths. Design: Prospective cross-sectional multi-center reliability study. Participants: 210 children\youth with chronic spinal cord injury (SCI). Interventions: Four repeated measures of the ISCSCI motor, sensory and anorectal examinations administered by seven raters. Main Outcomes: Intraclass correlation coefficients (ICC) and confidence intervals (CI) were calculated for inter-rater agreement for motor, sensory and anorectal scores based on age at exam, level of injury and injury severity. Results: Among 210 children, 29 were unable to understand test instructions due to age. The remaining 179 children were a mean age of 14.5 years, had sustained their SCI at a mean age of 10 years and were an average of 4.9 years since injury. When examined for the entire sample, interrater agreement for motor/sensory exams and anorectal responses was good (ICC and lower 95% CI values ≥0.88). Agreement was equally high for motor/sensory exams when examined as a function of age at exam, type of injury and American Spinal Injury Association Impairment Scale (AIS). In contrast, agreement for anal sensation was poor (ICC=0.49) for AIS grade A (N=99) and poor for both anal sensation (ICC=0.59) and contraction (ICC=0.49) for AIS grade B (N=36). For AIS grade C\D (n=44) anal sensation and contraction was good (ICC=0.82) to high (ICC=O0.98) but lower CI values were poor (≥0.48). Conclusions: Motor\sensory examinations have utility for children as young as six years with good-high agreement. In contrast, reliability of the anorectal examination is poor with children with AIS grade A\B. Further validation of the anorectal examination is warranted; caution in interpretation and use is recommended. The Neurological Standards cannot be applied to children under six years of age and even children as old as 8 years may have difficulty understanding test instructions.