More Progress -- Numbers Going UP!

In addition to quantifiable and documented proof that I've had an increase in motor function, Dr. Becker's evaluation report presented evidence of a return in sensory function, as well.

Much like motor function, the ASIA exam also scores sensory function, however, on a different scale. Light touch and pin-prick (pain) sensation are graded, at each of the 28 key sensory points, as follows:

Sensory Grading Scale
0 = absent sensation
1 = impaired sensation
2 = normal sensation

The official ASIA exam form provides guidelines on where key sensory points for each level are located. It also does a nice job of delineating exactly to where the nerve roots of each vertebral level corresponds to the body.

This (right) is what I like to call the ASIAn Man. Perhaps a modern Vitruvian – only illustrating a different standard of measure. Each area on the ASIAn Man is labeled with the vertebral level that determines its sensory function – i.e., C4 is labeled as such because the nerve roots that carry nerve impulses back and forth to that area of the body insert just below the C4 vertebra.

The black dots in each area indicates its key sensory point – i.e., the spot that is tested with the sharp/light stimulus.

The response to each is graded and recorded on a chart, much like the chart used for scoring the motor function of the exam. The maximum score for each side is 56, for a total of 112 possible points. (If you have no neurological damage, you would score 112.)

There are typically two rows to the following chart - one for upper extremities (C-2 to T-8), one for lower extremities (T-9 to S4/5) - but, my second row is all zeros, and that's rather depressing, so we'll stick with the upper extremities. For now. ;)

My initial evaluation exam resulted in these scores:

Sensory exam, pin-prick

05/06/08

	C2	C3	C4	C5	C6	C7	C8	T1	T2	T3	T4	T5	T6	T7	T8
R	2	2	2	0	0	0	0	0	0	0	0	0	0	0	0	6
L	2	2	2	0	0	0	0	0	0	0	0	0	0	0	0	6

That's grade 2, or "normal", sensory function down to C-4. It's fairly typical, as C-4 is my level of injury. So, that's a grand total of 12.

After just over two months in therapy, my exam score was:

Sensory exam, pin-prick

10/07/08

	C2	C3	C4	C5	C6	C7	C8	T1	T2	T3	T4	T5	T6	T7	T8
R	2	2	2	0	0	0	0	0	0	0	0	0	0	0	0
L	2	2	2	0	0	0	0	1	0	0	0	0	0	0	0

Another lonely 1 in the left column, surrounded by zeros. I am, however, undaunted by what might appear to be a negligible development because the promising part is not so much in the number itself, but the colum it stands in – T-1. That is the exciting part! If there is communication down to T-1, then there is hope for all the zeros between it and C-4. And, if I'm able to recover that one connection after 17 years, then there's hope for all the zeros that come after it.

My light touch scores, which were already higher than pin prick, made a more significant jump.

Sensory exam, light touch

05/06/08

	C2	C3	C4	C5	C6	C7	C8	T1	T2	T3	T4	T5	T6	T7	T8
R	2	2	2	1	0	0	0	0	0	0	0	0	0	0	0	7
L	2	2	2	1	0	0	0	0	0	1	1	0	0	0	0	9

That's a total of 16. Just as is evident in my motor function, my left side is stronger.

After two months in therapy, my sensory function scored:

Sensory exam, light touch

10/07/08

	C2	C3	C4	C5	C6	C7	C8	T1	T2	T3	T4	T5	T6	T7	T8
R	2	2	2	0	0	0	0	0	1	1	0	0	0	0	0	8
L	2	2	2	1	0	0	0	1	0	2	1	0	0	0	0	11

And that is a total of 19. I'm very excited at all the numbers popping up down in the T level -- not to mention thrilled with what I'm now able to feel. For example, I can now sense hot and cold on my upper left arm, a few inches lower than I was previously able to feel. I can feel the stim on the back of my right shoulder, just below my scapular -- both the muscle contraction and the electrode being placed on my skin, neither of which I could sense in September.

If we can return, for a moment, to our ASIAn friend, you can see how my light touch scores translate over:

There are a few discrepancies between the two sets of results (e.g., there was presence of impaired sensation at right C-5 in May that did not manifest in October). Based solely on my own experience, I believe it is because sometimes, where my sensation is impaired, I have difficulty discerning between sensations. In some places,well below any levels that are scored on the ASIA exam, I can feel pressure, but no skin sensation. In other areas, I can feel something has touched me, but I don't feel the sharpness of the pin. So, it's often difficult to say, since I can't see what's going on and my sensory perception is not 100 percent.

Over all, my ASIA scores have gone from 12 and 16 to 13 and 19 on pin prick and light touch, respectively. We're heading in the right diection!

The ASIA scale and the cervical spine

C-4 ASIA B (incomplete) was the diagnosis arrived at in May 2008, during my initial evaluation at the Kennedy-Krieger Institute, and it was my first spark of hope.
The American Spinal Injury Association (ASIA) Impairment Scale is the method by which doctors can classify an injury in uniform and unambiguous terms. Its parameters provide guidelines by which to determine whether an injury is complete (no motor/sensory function below the level of injury) or incomplete (some degree of motor/sensory function present below the level of injury). The scale ranges from A to E, with A indicating the most impairment and E indicating no impairment.

A = Complete: No motor or sensory function is preserved in the sacral segments S4-S5.

B = Incomplete: Sensory but not motor function is preserved below the neurological level and includes the sacral segments S4-S5.

C = Incomplete: Motor function is preserved below the neurological level, and more than half of key muscles below the neurological level have a muscle grade less than 3.

D = Incomplete: Motor function is preserved below the neurological level, and at least half of key muscles below the neurological level have a muscle grade of 3 or more.

E = Normal: Motor and sensory function are normal.

The C-4 designation indicates an injury at the fourth vertebra of the cervical spine. Nerve roots, which insert at each level of the spine, correspond to different parts of the body, thus where the injury is located on the spine determines what level of functionality the injured person will have. The nerve roots of the cervical spine and corresponding levels are:

C3 - an injury at this level or above will result in respirator dependence
C4 - shoulders, diaphragm, weak biceps
C5 - biceps, deltoids, some wrist
C6 - wrist, thumb
C7 - triceps, fingers

My initial injury was C-5/6, but that's another story for another day. Suffice it to say, when I left primary care, five weeks after the accident, and went to rehab, my injury level was at C4, and that's where it is today.

In the first few months post-injury, there was some debate as to whether my injury was complete or incomplete, but after I came home from rehab doctors told me it was in fact complete (or, ASIA A), and I'd come to accept that. So, ASIA B was news to me.

It was my first spark of hope, but also the first indication of what I'd had wrong all these years. Everything I knew about SCI has been turned upside down. All the definites have become maybes, all the impossibles, possible.