International standards for neurological classification of spinal cord injury: training effect on accurate classification.

OBJECTIVE: To evaluate the accuracy and agreement of International Standards for Neurological Classification of Spinal Cord Injury (ISCSCI) classification and to determine the effectiveness of formal training for pediatric clinicians. STUDY POPULATION: Participants (N = 28) in a formal 90-minute classification training session. OUTCOME MEASURE: Pre/post-training examination of 10 case examples of a variety of neurological classifications.
RESULTS: Regardless of years of experience with the ISCSCI, a statistically significant improvement (P < 0.05) in classification was achieved after formal training. Before training, 27% (539 of 1,960) of the questions were answered incorrectly. After training, the percentage of incorrect classifications decreased to 11% (198 of 1,960) incorrect (P < 0.05). After training, the percentage of incorrect motor level classifications decreased by 23% (42% to 19% incorrect; P< 0.05). Post-training improvements were also demonstrated (P< 0.05) in classifying sensory levels (9% to 3% incorrect), neurological levels (31% to 6% incorrect), and severity of injury (9% to 0% incorrect). After training, reductions in classification errors (P < 0.05) were demonstrated in American Spinal Injury Association (ASIA) Impairment Scale (AIS) A (from 20% to 7%), B (50% to 11%), C (71% to 46%), and D (63% to 16%).
CONCLUSIONS: This study demonstrated the benefits of formal, standardized training for accurate classification of the ISCSCI. Effective training programs must emphasize the guidelines and decision algorithms used to determine motor level and ASIA AIS designations because these remained problematic after training and are often a concern of patients/parents and are primary endpoints in clinical trials for neurological recovery.