Measurement properties of the short version of the Van Lieshout test for arm/hand function of persons with tetraplegia after spinal cord injury

[Predictors of upper limbs' function in patients with cervical tetraplegia]

Patients with traumatic cervical injury of the spinal cord show clinical symptoms of tetraplegia. Furthermore, the motor function of the upper limbs is a key function for such patients, because it has a significant impact on the quality of life. One of the components of the definition of rehabilitation potential is the identification of the possible functions' ceiling and compliance of the patient's current condition with known model characteristics.

OBJECTIVE

The aim of the study is to determine the predictors of upper limb functional motor activity in patients in the late period after spinal cord injury (SCI).

MATERIAL AND METHODS

The study included 190 patients with SCI: 151 men and 49 women. The mean age of patients was 30.0±12.9 years, the age of SCI - 1.9 [0.60; 5.40] years, in 93% of cases SCI was traumatic. Patients were classified using the ASIA International Neurological Standard. Upper limb function was evaluated using a short version of the Van Lushot Test (VLT). Stimulation electroneuromyography (SENMG) from the median and ulnar nerves was performed. The distribution at the motor level (ML) was as follows: C4-C6 - 117 patients; C7-D1 - 73 patients; depending on the severity of injury (SI): type A and B - 132 patients; upper limb motor score (ASIAarm) was 25.0±12.2, on VLT - 38.3±20.9. The factor loading of 10 factors was evaluated simultaneously in a linear discriminant analysis, the cut-off point was 20 and 40 scores on VLT (25 and 50% on the International Classification of Functioning, Disability and Health without the domain «balance»).

RESULTS

According to SENMG, denervation changes were detected in 15% of median and in 23% of ulnar nerves. The rank significance for the VLT threshold of 20 scores was: ASIA_arm - 100, functional tenodesis (FT) - 91, ML - 73, SI - 18; the classification tree had one branching at the ASIA_arm point of 17.3 score. The rank significance for the threshold of 40 scores was: ASIA_arm - 100, ML - 59, SI - 50, FT - 28, M response from the median nerve - 5; the classification tree had one branching at the ASIA_arm point of 26.9 score. The results of multivariate linear regression analysis confirmed the highest factor loading of ML predictor, motor score for upper limb (ASIA_arm) in both cases (R=0.67, R₂=0.45, F=38.0, p=0.00 and R=0.69, R₂=0.47; F=42.0, p=0.00, respectively).

CONCLUSION

In the late period after a spinal injury the leading predicative value for functional motor activity has the motor score of ASIA for the upper limb. The ASIA score more than 27 scores is the prediction of moderate and mild impairments, and less than 17 - severe impairments.

Preliminary evaluation of the reliability and validity of the 3D printed Toronto Rehabilitation Institute-Hand Function Test in individuals with spinal cord injury

OBJECTIVE

The study objectives were to evaluate the inter-rater and intra-rater reliability; and criterion and construct validity of the 3D printed Toronto Rehabilitation Institute -Hand Function Test (3D TRI-HFT) in individuals with spinal cord injury (SCI).

DESIGN

Observational study.

SETTING

Inpatient Rehabilitation Hospital.

PARTICIPANTS

Four individuals with subacute and three individuals with chronic SCI.

INTERVENTIONS

Reliability and validity of the 3D TRI-HFT was assessed within two interventional studies.

OUTCOME MEASURES

Participants performed the 3D TRI-HFT, Graded Redefined Assessment of Strength, Sensibility and Prehension (GRASSP), Functional Independence Measure (FIM) and the Spinal Cord Independence Measure (SCIM) at baseline, after 20 and 40 sessions of therapy and at six month follow-up from baseline. 3D TRI-HFT assessments were graded at the time of performance and re-graded from the video recordings for purpose of reliability testing. Validity testing was done by comparing the scores on 3D TRI-HFT with the scores on the GRASSP, and the FIM and SCIM self care sub-scores.

RESULTS

The 3D TRI-HFT had high intra-rater and inter-rater reliability in sub-acute and chronic SCI with ICC values exceeding 0.99. Moderate to strong correlations were found between 3D TRI-HFT object manipulation scores and the FIM and SCIM self care sub-scores, with r values in the range of 0.7-0.8. Strong correlations were found between the various components of GRASSP and the 3D TRI-HFT, with r values exceeding 0.9.

CONCLUSIONS

The 3D TRI-HFT is a reliable and valid measure to assess unilateral hand gross motor function in individuals with SCI.

[Patient-centered approach using COPM, GAS scores in medical rehabilitation of patients with tetraplegia after spinal cord injury]

OBJECTIVE

To study the efficacy of the patient- and task-oriented approach and specific therapeutic exercises (TE) for the arms in patients after spinal cord injury at the cervical level.

MATERIAL AND METHODS

The study included 119 patients with a history of spinal injury of more than one year. They were divided into three demographically comparable groups. Group 1 patients (control) received standard of care: TE, physiotherapeutic treatment, social adaptation (SA), and massage; Group 2-standard of care and specific TE for the arms as part of the SA; Group 3-the same as Group 2 combined with the patient- and task-oriented approach (patient-selected activities were trained). Outcomes were assessed at the beginning (T₁), end (T₂), and at 1 year (T₃) after a 30-day medical rehabilitation course.

RESULTS

No statistically significant differences between the groups in demographic, neurological (ISCSCI score), motor (FIMm, VLT scores), psychological parameters (depression, anxiety), quality of life (WHOQOL-BREF score) before the medical rehabilitation (T₁) were observed. At the end of the medical rehabilitation course (T₂), the increase in functional scores was 6.0±5.4 points of FIMm score, 6.0±4.6 points of VLT score in group 1; 8.0±7.6 points of FIMm score, 7.0±7.1 points of VLT score in group 2; 9.0±6.9 points of FIMm score, 8.0±7.6 points of VLT in group 3. Significant differences were found between groups 1 and 2 and 3 on the domains of «finger I» (13.6±9.64 points vs. 15.2±9.40 and 15.3±9.21 points respectively), «fingers II-V» (9.4±6.76 points vs. 11.3±6.41 and 11.6±6.76 points respectively) of VLT score; between groups 3 and 1 on the domains «self-care» (25.9±9.67 points vs. 23.1±9.8 points), «transfer» (11.7±6.21 points vs. 10.6±6.1 points) of the FIMm score, and also the group 3 patients had a higher quality of life by 3.0±1.8 points. At delayed follow-up (T₃-T₂), no changes of the FIMm and VLT scores were detected within groups. In group 3, 69% of problems were identified in self-care (COPM); subjective assessment of functional improvement for COPM (T₂-T₁) was as follows: «performance» 4.7±1.27 points, «satisfaction» 3.8±1.63 points; for GAS the T-score at the end of rehabilitation was 1.3±0.55 points, and the greatest significance of change was noted for COPM under «performance» (ES=0.73), with the correlation coefficient between FIMm and COPM being 0.55 and 0.63 for «performance» and «satisfaction» domains, respectively.

CONCLUSION

Patient- and task-oriented approach implemented by using COPM questionnaire and GAS score together with specific TE for arms is an effective method of motor medical rehabilitation of patients with posttraumatic cervical tetraplegia. This approach improves their quality of life, while parameters of subjective scores (COPM, GAS) have the same sensitivity in comparison with the conventional motor scores (FIMm, VLT).

Recovery of Distal Arm Movements in Spinal Cord Injured Patients with a Body-Machine Interface: A Proof-of-Concept Study

BACKGROUND

The recovery of upper limb mobility and functions is essential for people with cervical spinal cord injuries (cSCI) to maximize independence in daily activities and ensure a successful return to normality. The rehabilitative path should include a thorough neuromotor evaluation and personalized treatments aimed at recovering motor functions. Body-machine interfaces (BoMI) have been proven to be capable of harnessing residual joint motions to control objects like computer cursors and virtual or physical wheelchairs and to promote motor recovery. However, their therapeutic application has still been limited to shoulder movements. Here, we expanded the use of BoMI to promote the whole arm's mobility, with a special focus on elbow movements. We also developed an instrumented evaluation test and a set of kinematic indicators for assessing residual abilities and recovery.

METHODS

Five inpatient cSCI subjects (four acute, one chronic) participated in a BoMI treatment complementary to their standard rehabilitative routine. The subjects wore a BoMI with sensors placed on both proximal and distal arm districts and practiced for 5 weeks. The BoMI was programmed to promote symmetry between right and left arms use and the forearms' mobility while playing games. To evaluate the effectiveness of the treatment, the subjects' kinematics were recorded while performing an evaluation test that involved functional bilateral arms movements, before, at the end, and three months after training.

RESULTS

At the end of the training, all subjects learned to efficiently use the interface despite being compelled by it to engage their most impaired movements. The subjects completed the training with bilateral symmetry in body recruitment, already present at the end of the familiarization, and they increased the forearm activity. The instrumental evaluation confirmed this. The elbow motion's angular amplitude improved for all subjects, and other kinematic parameters showed a trend towards the normality range.

CONCLUSION

The outcomes are preliminary evidence supporting the efficacy of the proposed BoMI as a rehabilitation tool to be considered for clinical practice. It also suggests an instrumental evaluation protocol and a set of indicators to assess and evaluate motor impairment and recovery in cSCI.

[Upper limb motor and functional recovery in patients with tetraplegia]

OBJECTIVE

To study the recovery of the upper limb motor function and functional independence in patients with cervical spinal cord injury.

MATERIAL AND METHODS

The study included 49 patients with subacute tetraplegia, mean age 33±14.8 years, 42 men and 7 women, admitted to the Preodolenie Rehabilitation Center. The follow-up was up to 2 years. The clinical and functional states were assessed after 3, 6, 12 and more than 12 months after spinal injury, using the ASIA neurological standard scale, the motor subscale of Functional Independence Scale (FIM) and short form of Van Lieshout Test (VLT). All patients received continuous rehabilitation courses that included physiotherapy, occupational therapy, social support, psychological rehabilitation.

RESULTS

Upper limb motor recovery occurred in the first 6 months after spinal cord injury at 5±3.9 points (ASIA), while in 49% patients motor level decreased by one segment of the spinal cord, in 8% patients completeness of spinal cord injury improved. The improvement of functional independence was found during the first 12 months: according to FIM, in the period of 3-6 months by 18±11.1 points, in the period of 6-12 months by 8±8.1 points; according to VLT in the period of 3-6 months by 19±14.4 points, in the period of 6-12 months by 5.6±6.02 points.

CONCLUSIONS

Upper limb motor recovery mostly occurs in the first 6 months while the functional independence improvement lasts during the first 12 months after a spinal cord injury.

Internal consistency and validity of the Italian version of the Jebsen-Taylor hand function test (JTHFT-IT) in people with tetraplegia

STUDY DESIGN

Psychometric study.

OBJECTIVES

This study aimed to evaluate the internal consistency and validity of the Italian version of the Jebsen-Taylor hand function test (JTHFT-IT) in people with tetraplegia.

SETTING

Italian spinal units.

METHODS

Psychometric properties of the JTHFT-IT were assessed following international guidelines. The internal consistency was examined using Cronbach's alpha coefficient. Pearson's correlation coefficient was calculated for the concurrent validity of JTHFT-IT with a dynamometer, while the construct validity was calculated in comparison to that of the Van Lieshout test short version in Italian (VLT-SV-IT).

RESULTS

The test was administered to 48 right-hand dominant people with tetraplegia. Cronbach's alpha calculation resulted in a value of 0.96 for the right hand and 0.94 for the left hand. In terms of the validity of the scale, the Pearson's correlation, as measured in relation to the VLT-SV-IT and dynamometer, showed statistically significant results (range for the correlation coefficient of between -0.96 and -0.12, p < 0.05).

CONCLUSIONS

The findings of this study support the internal consistency and validity of the JTHFT-IT and its use among a population with cervical SCI as a measure of hand functionality.

Development of Reaching, Grasping & Manipulation indicators to advance the quality of spinal cord injury rehabilitation: SCI-High Project

OBJECTIVE

To describe the development of structure, process, and outcome indicators aimed to advance the quality of Reaching, Grasping & Manipulation (RG&M) rehabilitation for Canadians living with spinal cord injury or disease (SCI/D).

METHOD

Upper extremity rehabilitation experts developed a framework of indicators for evaluation of RG&M rehabilitation quality. A systematic search of the literature identified potential upper extremity indicators that influence RG&M outcomes. A Driver diagram summarized factors influencing upper extremity outcomes to inform the selection of structure and process indicators. Psychometric properties, clinical utility, and feasibility of potential upper extremity measures were considered when selecting outcome indicators.

RESULTS

The selected structure indicator is the number of occupational and physical therapists with specialized certification, education, training and/or work experience in upper extremity therapy related to RG&M at a given SCI/D rehabilitation center. The process indicator is the total hours of upper extremity therapies related to RG&M and the proportion of this time allocated to neurorestorative therapy for each individual with tetraplegia receiving therapy. The outcome indicators are the Graded Redefined Assessment of Strength, Sensation and Prehension (GRASSP) strength and Spinal Cord Independence Measure III (SCIM III) Self-Care subscores implemented at rehabilitation admission and discharge, and SCIM III Self-Care subscore only at 18 months post-admission.

CONCLUSION

The selected indicators align with current practice, will direct the timing of routine assessments, and enhance the volume and quality of RG&M therapy delivered, with the aim to ultimately increase the proportion of individuals with tetraplegia achieving improved upper extremity function by 18 months post-rehabilitation.

Validation and cross-cultural adaptation of the Van Lieshout test in an Italian population with cervical spinal cord injury: a psychometric study

STUDY DESIGN

Psychometric study.

OBJECTIVE

To assess the reliability and validity of the Italian-translated and adapted version of the Van Lieshout test (VLT) in a population of people with cervical spinal cord injury (C-SCI).

SETTING

Multicenter study in multiple hospitals in Italy.

METHODS

The original scale was translated from English to Italian according to international guidelines. The internal consistency, test-retest reliability, and responsiveness of the Italian version of the VLT (IT-VLT) were examined. The IT-VLT was administered to 50 individuals with C-SCI, and its construct and convergent validity were evaluated using Pearson correlation coefficients with the Italian version of the Spinal Cord Injury Measure version III (SCIM III).

RESULTS

All psychometric properties of the IT-VLT showed significant values, including the Cronbach's α, which was 0.95 (left hand) and 0.94 (right hand). Furthermore, the test-retest reliability showed an intraclass correlation coefficient of 0.89, 0.81, and 0.87 for the right hand, left hand, and total value, respectively. The Pearson correlation coefficient of the IT-VLT and the Italian version of the SCIM III showed all significant results r = 0.559 (p < 0.01). The IT-VLT score improved significantly during in-patient rehabilitation In fact the mean (95% CI) change between T0 and T1 was - 13.2 ± 28.6 (- 21.38; - 5.10).

CONCLUSIONS

The IT-VLT was a reliable and a valid outcome measure for assessing hand function in the Italian population with C-SCI. The present study lays the grounds to investigate the psychometric properties of the short version of the IT-VLT.

The Graded and Redefined Assessment of Strength, Sensibility, and Prehension Version 2 Provides Interval Measure Properties

The Graded and Redefined Assessment of Strength, Sensibility and Prehension (GRASSP) is a valid, reliable, and responsive outcome measure to evaluate upper limb function in individuals with tetraplegia. GRASSP generates ordinal total scores; therefore, applicability as an interval level measurement requires testing of its measurement properties. This study examined the metric characteristics with Rasch Analysis to derive interval level scales of the respective GRASSP subtests. The GRASSP was recorded within 10 days, and at 1, 3, 6, and 12 months after cervical spinal cord injury (SCI). Rasch analysis was performed for each GRASSP subscale to assess the following metric assumptions: absence of local item dependency (LID), unidimensionality, monotonicity, item and model fit, reliability, and absence of differential item functioning (DIF) for side (left and right) and examination stage. If these assumptions could not be met, adjustments were undertaken to achieve a good fit to the Rasch model. Seventy-seven individuals with cervical SCI were included (n = 154 arms). Stacking the data for the side (left and right) resulted in a total of 614 observations, which were based on the repeated measurements. With minor adjustments, the GRASSP subscales showed good reliability, item fit, and ordered response options. Local item dependencies were found in the strength and sensibility subscales. Redundancies among some measurement items allowed shortening of the subscales without reasonable loss of reliability. Absence of DIF for the examination stage supported robustness of the subscales over time. The modified GRASSP, now Version 2, subtest scores can be applied as interval level measurements, and the reduction of items within subscales allows for shorter assessment times in clinical studies without degrading metric properties.

Robot-assisted arm assessments in spinal cord injured patients: a consideration of concept study

Robotic assistance is increasingly used in neurological rehabilitation for enhanced training. Furthermore, therapy robots have the potential for accurate assessment of motor function in order to diagnose the patient status, to measure therapy progress or to feedback the movement performance to the patient and therapist in real time. We investigated whether a set of robot-based assessments that encompasses kinematic, kinetic and timing metrics is applicable, safe, reliable and comparable to clinical metrics for measurement of arm motor function. Twenty-four healthy subjects and five patients after spinal cord injury underwent robot-based assessments using the exoskeleton robot ARMin. Five different tasks were performed with aid of a visual display. Ten kinematic, kinetic and timing assessment parameters were extracted on joint- and end-effector level (active and passive range of motion, cubic reaching volume, movement time, distance-path ratio, precision, smoothness, reaction time, joint torques and joint stiffness). For cubic volume, joint torques and the range of motion for most joints, good inter- and intra-rater reliability were found whereas precision, movement time, distance-path ratio and smoothness showed weak to moderate reliability. A comparison with clinical scores revealed good correlations between robot-based joint torques and the Manual Muscle Test. Reaction time and distance-path ratio showed good correlation with the “Graded and Redefined Assessment of Strength, Sensibility and Prehension” (GRASSP) and the Van Lieshout Test (VLT) for movements towards a predefined position in the center of the frontal plane. In conclusion, the therapy robot ARMin provides a comprehensive set of assessments that are applicable and safe. The first results with spinal cord injured patients and healthy subjects suggest that the measurements are widely reliable and comparable to clinical scales for arm motor function. The methods applied and results can serve as a basis for the future development of end-effector and exoskeleton-based robotic assessments.

Robot-assisted task-oriented upper extremity skill training in cervical spinal cord injury: a feasibility study

STUDY DESIGN

Prospective multiple case study.

OBJECTIVES

To test (1) the feasibility of haptic robot technology (Haptic Master (HM)) use to improve arm-hand function (AHF) and arm-hand skill performance (AHSP) in persons with a cervical spinal cord injury (C-SCI), (2) inventory participants' motivation and expectation to work with the robot technology used and (3) to descriptively report the results in individual cases.

SETTING

Rehabilitation Centre.

METHODS

Five C-SCI patients were trained for 6 weeks, 3 days per week, 60 min per day. Therapists filled out the Usefulness, Satisfaction and Ease-of-use questionnaire (USE). The Intrinsic Motivational Inventory (IMI) and credibility and expectancy questionnaire (CEQ) were filled out by participants. Performance at activity level was gauged using the Van Lieshout test for AHF in Tetraplegia and the Spinal Cord Independence Measure. Function level was gauged using muscle strength testing and the International Classification for Surgery of the Hand in Tetraplegia.

RESULTS

As to the feasibility of the application of haptic robot technology, the mean USE score was 65%. Mean IMI and CEQ results were 67% and 60%, respectively. Participants were motivated to train with the HM. All participants rated credibility higher than expectations regarding the improvement. In the current patients, little progress was demonstrated at the International Classification of Functioning, Disability and Health function and the activity level.

CONCLUSION

It is feasible to train C-SCI persons with the HM. Therapists report that working with the HM is easy to learn and easy to perform. Usability of the HM may be improved. Further research is needed to assess in which group of C-SCI and at which stage of rehabilitation HM training may be most beneficial.

Changes in Strength, Sensation, and Prehension in Acute Cervical Spinal Cord Injury

Objective. To investigate the internal and external responsiveness and recovery profiles of the Graded Redefined Assessment of Strength, Sensibility, and Prehension (GRASSP) instrument in revealing changes in upper limb function within the first year following cervical spinal cord injury (SCI). Method. A European prospective, longitudinal, multicenter study assessing the GRASSP at 1, 3, 6, and 12 months after cervical SCI. Subtests of GRASSP were compared to the upper extremity motor (UEMS) and light touch scores (LT) according to the International Standards of Neurological Classification of Spinal Cord Injury (ISNCSCI), the Spinal Cord Independence Measure self-care subscore (SCIM-SS), as well as a clinician-rated outcome measure (CROM) of clinical relevance. Data were analyzed for GRASSP responsiveness and recovery rate over time. Results. Seventy-four participants entered the study. GRASSP subtests proved responsive (standardized response mean [SRM] ranged from 0.79 to 1.48 for strength, 0.50 to 1.03 for prehension, and 0.14 to 0.64 for sensation) between all examination time points. In comparison, UEMS and LT showed lower responsiveness (SRM UEMS ranged from 0.69 to 1.29 and SRM LT ranged from 0.30 to −0.13). All GRASSP subtests revealed significant, moderate-to-excellent correlations with UEMS, LT, and SCIM-SS at each time point, and changes in GRASSP subtests were in accordance with the CROM. GRASSP prehension and motor recovery was largest between 1 and 3 months. Conclusion. The GRASSP showed excellent responsiveness, detecting distinct changes in strength and prehension relating to the severity of cervical SCI. It detected clinically significant changes complimentary to the ISNCSCI and SCIM-SS assessments.

Assisted movement with proprioceptive stimulation reduces impairment and restores function in incomplete spinal cord injury

OBJECTIVE

To test whether treatment with assisted movement with enhanced sensation (AMES) using vibration to the antagonist muscle would reduce impairments and restore upper limb function in people with incomplete tetraplegia.

DESIGN

Prospective, pre-post study.

SETTING

Laboratory and rehabilitation hospital.

PARTICIPANTS

We recruited 15 arms from 10 individuals (8 men; mean age, 40.5 y; mean years postspinal cord injury [SCI], 3) with chronic, incomplete tetraplegia.

INTERVENTION

Two or three 20-minute sessions per week over 9 to 13 weeks (25 sessions total) on the AMES device, which combines repeated movement with targeted vibration to the antagonist muscle.

MAIN OUTCOME MEASURES

Strength and active motion tests on the AMES device; International Standards for the Neurological Classification of SCI (ISNCSCI) motor and sensory examinations; Modified Ashworth Scale (MAS); grasp and release test (GRT); Van Lieshout Test (VLT); and Capabilities of Upper Extremity questionnaire (CUE).

RESULTS

The AMES strength test scores improved significantly in metacarpophalangeal flexion (P=.024) and extension (P=.007) and wrist flexion (P=.001) and extension (P<.000). The AMES active motion scores improved in the hand (P=.001) and wrist (P=.001). The MAS and ISNCSCI scores remained unchanged, whereas the GRT scores increased (P=.025). Post hoc analysis showed a trend from pre- to posttreatment (P=.068) and a significant change from pretreatment to 3-month follow-up (P=.046). There was no significant change in the VLT (P=.951) or the CUE (P=.164). Five of the 10 participants reported a return of sensation to the digits after the first, second, or third treatment session.

CONCLUSIONS

People with chronic, incomplete tetraplegia may experience improvements in impairments and function after treatment on a device combining assisted movement and proprioceptive stimulation. Further investigation is warranted.

Prediction and Stratification of Upper Limb Function and Self-Care in Acute Cervical Spinal Cord Injury With the Graded Redefined Assessment of Strength, Sensibility, and Prehension (GRASSP)

Background. There is inherent heterogeneity within individuals suffering from cervical spinal cord injury (SCI), and early prediction of upper limb function and self-care is challenging. As a result, considerable uncertainty exists regarding the prediction of functional outcome following cervical SCI within 1 year of injury. Objective. To evaluate the value of Graded Redefined Assessment of Strength, Sensibility, and Prehension (GRASSP) in predicting upper limb function and self-care outcomes in individuals with cervical SCI. Method. A prospective longitudinal multicenter study was performed. Data from the GRASSP, the Spinal Cord Independence Measure (SCIM III), and the American Spinal Injury Association (ASIA) Impairment Scale were recorded at 1, 6, and 12 months after cervical SCI. For prediction of functional outcome at 6 and 12 months, a logistic regression model, receiver operating characteristics (ROC), and unbiased recursive partitioning conditional inference tree (URP-CTREE) were used with 8 different predictor variables. Results. Logistic regression analysis, ROC analysis, and URP-CTREE all revealed that the strength subtest within GRASSP is the strongest predictor for upper limb function and self-care outcomes. URP-CTREE provides useful information on the distribution of different outcomes in acute cervical SCI and can be used to predict cohorts with homogeneous outcomes. Conclusion. The GRASSP at 1 month can accurately predict upper limb function and self-care outcomes even in a heterogeneous group of individuals across a wide spectrum of neurological recovery. The application of URP-CTREE can reveal the distribution of outcome categories and, based on this, inform trial protocols with respect to outcomes analysis and patient stratification.

A noninvasive neuroprosthesis augments hand grasp force in individuals with cervical spinal cord injury: the functional and therapeutic effects

Objectives. The primary purpose of this study was to evaluate myoelectrically controlled functional electrical stimulation (MeCFES) for enhancing the tenodesis grip in people with tetraplegia. The second aim was to estimate the potential number of candidates for the MeCFES device. The application of MeCFES provides the user with direct control of the grasp force as opposed to triggered FES systems. Methods. Screening 253 medical records of C5 to C7 spinal cord injury resulted in 27 participants who trained activities of daily living for 12 × 2 hours, using the MeCFES. Hand function was evaluated by the Action Research Arm Test (ARAT). Primary outcome was the ARAT change score with/without the device, before/after the intervention period. Secondary outcome was the number of positive or clinically relevant change scores with respect to the cohort. Results. The MeCFES improved hand test score in 63% of the subjects at first application. Training resulted in a significant therapeutic effect, which resulted in an overall increase of hand function in 89% of the participants and 30% experienced a clinically relevant change (6 points or more). Conclusions. Clinical relevance was found both as an assistive aid and as a therapeutic tool in rehabilitation. The therapeutic effect deserves further investigation in clinical studies.

Arm hand skilled performance in persons with a cervical spinal cord injury--long-term follow-up

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To assess development of arm hand skilled performance (AHSP) during and after in-patient rehabilitation in persons with cervical spinal cord injury (CSCI) and to determine factors that influence the outcome.

SETTING

Eight rehabilitation centres in the Netherlands with specialised spinal cord injury departments.

METHODS

AHSP was assessed using the Van Lieshout test (VLT) in persons admitted with recent CSCI. Assessment was carried out at the beginning (t1), after 3 months (t2), at the end (t3) of in-patient rehabilitation, and 1 and 5 years thereafter (t4, t5). Multilevel regression analysis was performed to determine development of AHSP and associations between AHSP and age, gender, motor completeness, lesion level (high or low CSCI), motor scores of upper extremity (MSUE), and pain in the tested arm.

RESULTS

Fifty-five participants were included with mean age 38 years (range 18–64). There were 73% male, 80% had high CSCI (C3–C6) and 69% had motor complete lesion. Scores of VLT improved significantly during in-patient rehabilitation (mean: t1=25; t3=33) (P=0.005), scores remained unchanged at 1 year (t4=32) and 5 years (t5=32) (P=0.903) after in-patient rehabilitation. Motor completeness, MSUE and pain were significantly related to the VLT score (P<0.001, P<0.001, P=0.015, respectively). Age, gender and lesion level had no significant relationship.

CONCLUSION

AHSP improved during in-patient rehabilitation. It was then stable during the next 5 years after discharge. Persons with an incomplete lesion, high MSUE and no pain in the tested arm perform best on the VLT.

Development of the Graded Redefined Assessment of Strength, Sensibility and Prehension (GRASSP): reviewing measurement specific to the upper limb in tetraplegia

OBJECT

Primary outcome measures for the upper limb in trials concerning human spinal cord injury (SCI) need to distinguish between functional and neurological changes and require satisfying psychometric properties for clinical application.

METHODS

The Graded Redefined Assessment of Strength, Sensibility and Prehension (GRASSP) was developed by the International GRASSP Research and Design Team as a clinical outcome measure specific to the upper limbs for individuals with complete and incomplete tetraplegia (that is, paralysis or paresis). It can be administered across the continuum of recovery after acute cervical SCI. An international multicenter study (involving centers in North America and Europe) was conducted to apply the measure internationally and examine its applicability.

RESULTS

The GRASSP is a multimodal test comprising 5 subtests for each upper limb: dorsal sensation, palmar sensation (tested with Semmes-Weinstein monofilaments), strength (tested with motor grading of 10 muscles), and prehension (distinguishes scores for qualitative and quantitative grasping). Thus, administration of the GRASSP results in 5 numerical scores that provide a comprehensive profile of upper-limb function. The established interrater and test-retest reliability for all subtests within the GRASSP range from 0.84 to 0.96 and from 0.86 to 0.98, respectively. The GRASSP is approximately 50% more sensitive (construct validity) than the International Standards of Neurological Classification of SCI (ISNCSCI) in defining sensory and motor integrity of the upper limb. The subtests show concurrence with the Spinal Cord Independence Measure (SCIM), SCIM self-care subscales, and Capabilities of Upper Extremity Questionnaire (CUE) (the strongest concurrence to impairment is with self-perception of function [CUE], 0.57-0.83, p < 0.0001).

CONCLUSIONS

The GRASSP was found to demonstrate reliability, construct validity, and concurrent validity for use as a standardized upper-limb impairment measure for individuals with complete or incomplete tetraplegia. Responsiveness (follow-up from onset to 1 year postinjury) is currently being tested in international studies (in North America and Europe). The GRASSP can be administered early after injury, thus making it a tool that can be administered in acute care (in the ICU), rehabilitation, and outpatient clinics.

Upper Extremity Function in Persons with Tetraplegia: Relationships Between Strength, Capacity, and the Spinal Cord Independence Measure

Objective. To quantify the relationship between the Spinal Cord Independence Measure III (SCIM III), arm and hand muscle strength, and hand function tests in persons with tetraplegia. Methods. A total of 29 individuals with tetraplegia (motor level between cervical 4 and thoracic 1; sensory-motor complete and incomplete) participated. The total score, category scores, and separate items of the SCIM III were compared to the upper extremity motor score (UEMS), an extended manual muscle test (MMT) for 11 upper extremity muscles, and 6 functional capacity tests of the hand. Spearman's correlation coefficients ( rs) and regression analyses were performed. Results. The SCIM III sum score correlated well with the sum scores of the 3 tests ( rs ≥ .76). The SCIM III self-care category correlated better with the tests ( rs ≥ .80) compared to the other categories ( r s ≤ .72). The SCIM III self-care item “grooming” highly correlated with muscle strength and hand capacity items ( rs ≥ .80). A combination of hand muscle tests and the key grasping task explained over 90% of the variability in the self-care category scores. Conclusions. The SCIM III self-care category reflects upper extremity performance as it contains especially useful and valid items that relate to upper extremity function and capacity tests.

Feasibility of a classification system for physical therapy, occupational therapy, and sports therapy interventions for mobility and self-care in spinal cord injury rehabilitation

OBJECTIVE

To test the feasibility of a classification system developed to record the contents of treatment sessions intended to improve mobility and self-care by persons with a spinal cord injury (SCI) in clinical rehabilitation.

DESIGN

Descriptive study.

SETTING

Three Dutch SCI facilities.

PARTICIPANTS

Participants (N=36) as well as physical therapists (n=20), occupational therapists (n=14), and sports therapists (n=2).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Questionnaires to assess the clarity of the classification system, time needed to record 1 treatment session, and the distribution of categories and interventions. The classification system consisted of 28 categories at 3 levels of functioning: basic functions (eg, muscle power), basic activities (eg, transfers), and complex activities (eg, walking and moving around outside).

RESULTS

Therapists used 1625 codes to record 856 treatment sessions of 142 patients. For 93% of the treatment sessions, the coding caused little or no doubt. The therapists were able to classify 86.3% of the treatment sessions within 3 minutes. The classification system was rated as useful and easy to use.

CONCLUSIONS

The findings support the suitability of our classification system as a tool to record the contents of SCI treatment sessions in different settings and by different therapists.

Development of a classification of physical, occupational, and sports therapy interventions to document mobility and self-care in spinal cord injury rehabilitation

OBJECTIVE

To describe the development of a classification for therapeutic activities in clinical spinal cord injury (SCI) rehabilitation.

DESIGN

Descriptive study including a modified Delphi consensus method.

SETTING

Specialized SCI units of 10 rehabilitation facilities.

PARTICIPANTS

Thirty physical therapists, occupational therapists, and sports therapists from 10 Dutch and Flemish SCI centers.

MAIN OUTCOME MEASURES

Identification of the levels, categories, and interventions; level of agreement among experts with (1) definitions, (2) terminology, (3) relevance, and (4) completeness of the classification (consensus considered sufficient if 80% or more agree).

RESULTS

The classification comprises three levels of functioning: basic functions, basic activities, and complex activities. The three levels comprise 28 categories within which interventions are listed. Sufficient consensus was obtained for the definitions of the three levels (range, 87%-100%). Percentages of consensus for the terminology used and the completeness of the categories ranged from 75% to 100%. The perceived relevance of the categories for everyday work varied per discipline.

CONCLUSION

A potentially useful classification was developed to record clinical treatment sessions in physical therapy, occupational therapy, and sports therapy for persons with SCI. The classification is currently being tested in ongoing research.

Measurement issues related to upper limb interventions in persons who have tetraplegia

Measurement of upper limb function in persons with tetraplegia poses significant issues for clinicians and researchers. It is crucial that measures detect the small but significant improvements in hand function that may or may not occur as a result of our interventions. Before determining how we measure changes from upper limb interventions, we must establish what outcomes are of greatest interest, and for whom. Many issues have an impact on both the measurement and interpretative process.

Assessment of upper extremity muscle function in persons with tetraplegia

The objective was to investigate the actual level of muscle function impairment in tetraplegic persons and, inextricably related to this, the possibilities to compensate function loss using new muscle coalitions. In this cross-sectional group study, 20 persons with a cervical spinal cord injury (SCI) at segmental levels C5C6 or C7C8 and 10 control persons participated. Activity from 21 upper extremity and trunk muscles was recorded during standardised gross upper extremity task performance. No substantial differences in main activation patterns were found between C7C8 and control subjects. In contrast, main activation patterns in C5C6 persons showed an absence of selectivity, which may be explained by the participants activating every controllable muscle in an attempt to perform maximally. In order to identify more intricate differences in muscle activation between control and C7C8 persons a fine motor function task may be necessary. Muscle activation patterns during arm task performance were stable in all three groups.

Measuring change in arm hand skilled performance in persons with a cervical spinal cord injury: responsiveness of the Van Lieshout Test

OBJECTIVES

To asses whether the Van Lieshout Test (VLT) is responsive to measure changes in arm hand skilled performance (AHSP) over time during active rehabilitation in persons with cervical spinal cord injury (C-SCI) and in different subgroups of persons with C-SCI according to lesion completeness and to lesion level.

STUDY DESIGN

Longitudinal cohort study.

SETTING

Spinal Cord Injury Units in eight rehabilitation centres across the Netherlands.

METHODS

In the present study, data from a national SCI cohort study are used. Data from the VLT, the Grasp Release Test (GRT), the Functional Independence Measure (FIM) and the Quadriplegia Index of Function (QIF) were recorded at three moments during active rehabilitation: at the start of active rehabilitation (t1), 3 months after t1 (t2) and at discharge (t3). Data have been analysed using three responsiveness measures, that is, the standardized response mean, the effect size and comparison of test scores measured at different times.

RESULTS

The VLT is responsive for the intervals t1-3, t1-2 and t2-3. The VLT can be used to measure changes in AHSP in persons with a C-SCI with an American Spinal Injury Association Impairment Scale (AIS) A or B score or an AIS C or D score, as well as in persons with a C3-C6 lesion or a C7-T1 lesion. The responsiveness of the VLT is significantly correlated to the GRT, but not to the FIM and the QIF.

CONCLUSION

The VLT is responsive in measuring changes in AHSP during rehabilitation in persons with C-SCI.