Editorial Note on: Spinal Cord advance online publication, 17 January 2012; doi:10.1038/sc.2011.169

To Dr's Casas-Parera, Kuchkarian, Baez and Agotegaray,

I would like to commend you for the important consideration of translation into Spanish to allow for the more widespread use of the International Standards worksheet. It is important to note that the International Standards as well as the worksheet has undergone revisions in June of 20111 that is available from the ASIA website (http://www.asia-spinalinjury.org/publications/59544_sc_Exam_Sheet_r4.pdf), and was published and is available for free download.2 In any language version, these changes and updated worksheet should be incorporated.

With regard to the addition of cord transection into the clinical syndromes, please remember that the International Standards and the ASIA Impairment Scale classification are on the basis of the clinical examination. Cord ‘transection’ is a diagnosis made by surgical observation and perhaps on radiological testing, and cannot be determined by clinical examination alone.

For manual muscle testing (MMT), under usual circumstances (non-spinal cord specific examination), the extent of the active range the patient has below a grade 3 (antigravity strength with full range of motion) is by assigning ‘pluses’ and ‘minuses’.3 For instance, if there is full range of motion with gravity eliminated about a joint and 25% of the range against gravity can be completed, the examiner may give a score of 2+. A score of 3− is given when there is active range of motion of a motor function against gravity, but between 50–99% and not through the complete range. However, in the examination in persons with SCI, pluses and minuses are not recommended and only whole numbers are used; only a patient with antigravity strength in the available range of motion can receive a grade of 3. As the definitions of the number scale on the MMT of 0–5 have been universally accepted it is beyond the scope of the International Standards Committee to change this.

I thank you for your suggestions, and will bring forward your excellent idea for the International Standards Committee to pursue translation of the Standards in to other languages.