Graded Redefined Assessment Of Strength, Sensibility And Prehension Research Articles

Nerve transfer for upper extremity reanimation in people with spinal cord injury: A 2-year follow-up case series

Objective To describe the 2-year functional outcomes of nerve transfer (NT) for upper extremity reanimation. Study Design A prospective case series. Setting A highly specialized rehabilitation hospital for spinal cord injury (SCI) in Italy. Intervention Upper limb nerve transfer (32 NTs, 15 upper limbs). Participants Twelve male individuals with traumatic SCI (AIS A or B, neurological level from C4 to C7) were enrolled; 24-month follow-up data were available for 11. Outcome measures We evaluated the strength recovery of recipient muscles through the Medical Research Council (MRC) Scale for Muscle Strength. Upper limb function and independence were assessed with the Graded Redefined Assessment of Strength Sensibility and Prehension (GRASSP) test version 1 and the Spinal Cord Independent Measure III (SCIM III). Patient satisfaction was also evaluated. Results After 24 months, median MRC scores (range) were: triceps 2 (1–2); extensor digitorum communis 3 (1–4); extensor pollicis longus 2.5 (1–4); flexor digitorum profundus 2 (0–4); flexor pollicis longus 2 (0–4). No complication occurred. GRASSP prehension ability and prehension performance total scores significantly improved at 24 months from 1 (0–4) to 2 (0–7) and from 1 (0–8) to 5 (0–-22), respectively. The SCIM III self-care sub-scale score improved at 24-month follow-up (p = 0.009). This study has important limitations, including a limited generalizability of the results and a small sample size that does not allow definitive conclusions to be drawn. A large multicenter prospective study is needed to confirm our findings. Conclusions NT represents a functional surgery option with few complications for the resuscitation of upper limbs in persons with tetraplegia.

DiSCIoser: unlocking recovery potential of arm sensorimotor functions after spinal cord injury by promoting activity-dependent brain plasticity by means of brain-computer interface technology: a randomized controlled trial to test efficacy

BackgroundTraumatic cervical spinal cord injury (SCI) results in reduced sensorimotor abilities that strongly impact on the achievement of daily living activities involving hand/arm function. Among several technology-based rehabilitative approaches, Brain-Computer Interfaces (BCIs) which enable the modulation of electroencephalographic sensorimotor rhythms, are promising tools to promote the recovery of hand function after SCI. The “DiSCIoser” study proposes a BCI-supported motor imagery (MI) training to engage the sensorimotor system and thus facilitate the neuroplasticity to eventually optimize upper limb sensorimotor functional recovery in patients with SCI during the subacute phase, at the peak of brain and spinal plasticity. To this purpose, we have designed a BCI system fully compatible with a clinical setting whose efficacy in improving hand sensorimotor function outcomes in patients with traumatic cervical SCI will be assessed and compared to the hand MI training not supported by BCI.MethodsThis randomized controlled trial will include 30 participants with traumatic cervical SCI in the subacute phase randomly assigned to 2 intervention groups: the BCI-assisted hand MI training and the hand MI training not supported by BCI. Both interventions are delivered (3 weekly sessions; 12 weeks) as add-on to standard rehabilitation care. A multidimensional assessment will be performed at: randomization/pre-intervention and post-intervention. Primary outcome measure is the Graded Redefined Assessment of Strength, Sensibility and Prehension (GRASSP) somatosensory sub-score. Secondary outcome measures include the motor and functional scores of the GRASSP and other clinical, neuropsychological, neurophysiological and neuroimaging measures.DiscussionWe expect the BCI-based intervention to promote meaningful cortical sensorimotor plasticity and eventually maximize recovery of arm functions in traumatic cervical subacute SCI. This study will generate a body of knowledge that is fundamental to drive optimization of BCI application in SCI as a top-down therapeutic intervention, thus beyond the canonical use of BCI as assistive tool.Trial registrationName of registry: DiSCIoser: improving arm sensorimotor functions after spinal cord injury via brain-computer interface training (DiSCIoser). Trial registration number: NCT05637775; registration date on the ClinicalTrial.gov platform: 05-12-2022.

Student Competition (Technology Innovation) ID 1972228

Background Upper limb rehabilitation after cervical spinal cord injury is vital for regaining independence. Hand function assessments are critical for upper limb rehabilitation, but are unable to accurately reflect performance in the individual’s home environment. Video from wearable cameras (egocentric video), paired with deep learning, can assess hand function during activities of daily living (ADLs) at home. Previous studies have focused on analyzing quantitative aspects of hand usage, but there has yet to be a study that uses deep neural networks to assess the quality of hand usage from egocentric video. Objective To train a deep neural network to predict hand function assessment scores from egocentric video. Methods The dataset used contained egocentric videos of ADLs performed by 17 participants with AIS grades from A-D in a home simulation laboratory. Tasks were annotated with scores adapted from the Graded Redefined Assessment of Strength Sensibility and Prehension (GRASSP). The annotated video was then used to train and validate a SlowFast neural network to predict GRASSP scores, using leave-one-subject-out cross validation. Model performance was evaluated by mean absolute error, accuracy, and F1 score. The model was optimized with a hyperparameter sweep. Results The top performing model demonstrated a mean absolute error of 0.52±0.19, an accuracy of 0.55±0.14, and F1 score of 0.55±0.16, on an ordinal scale from 1 to 5. Conclusion These results demonstrate that automated assessment of hand function is possible by applying deep learning to egocentric video. Future work should expand the model to larger datasets with more variability.

Grasp Analysis in the Home Environment as a Measure of Hand Function After Cervical Spinal Cord Injury

Background Following a spinal cord injury, regaining hand function is a top priority. Current hand assessments are conducted in clinics, which may not fully represent real-world hand function. Grasp strategies used in the home environment are an important consideration when examining the impact of rehabilitation interventions. Objective The main objective of this study is to investigate the relationship between grasp use at home and clinical scores. Method We used a previously collected dataset in which 21 individuals with spinal cord injuries (SCI) recorded egocentric video while performing activities of daily living in their homes. We manually annotated 4432 hand-object interactions into power, precision, intermediate, and non-prehensile grasps. We examined the distributions of grasp types used and their relationships with clinical assessments. Results Moderate to strong correlations were obtained between reliance on power grasp and the Spinal Cord Independence Measure III (SCIM; P < .05), the upper extremity motor score (UEMS; P < .01), and the Graded Redefined Assessment of Strength Sensibility and Prehension (GRASSP) Prehension (P < .01) and Strength (P < .01). Negative correlations were observed between the proportion of non-prehensile grasping and SCIM (P < .05), UEMS (P < .05), and GRASSP Prehension (P < .01) and Strength (P < .01). Conclusion The types of grasp types used in naturalistic activities at home are related to upper limb impairment after cervical SCI. This study provides the first direct demonstration of the importance of hand grasp analysis in the home environment.

Transcutaneous Cervical Spinal Cord Stimulation Combined with Robotic Exoskeleton Rehabilitation for the Upper Limbs in Subjects with Cervical SCI: Clinical Trial.

(1) Background: Restoring arm and hand function is a priority for individuals with cervical spinal cord injury (cSCI) for independence and quality of life. Transcutaneous spinal cord stimulation (tSCS) promotes the upper extremity (UE) motor function when applied at the cervical region. The aim of the study was to determine the effects of cervical tSCS, combined with an exoskeleton, on motor strength and functionality of UE in subjects with cSCI. (2) Methods: twenty-two subjects participated in the randomized mix of parallel-group and crossover clinical trial, consisting of an intervention group (n = 15; tSCS exoskeleton) and a control group (n = 14; exoskeleton). The assessment was carried out at baseline, after the last session, and two weeks after the last session. We assessed graded redefined assessment of strength, sensibility, and prehension (GRASSP), box and block test (BBT), spinal cord independence measure III (SCIM-III), maximal voluntary contraction (MVC), ASIA impairment scale (AIS), and WhoQol-Bref; (3) Results: GRASSP, BBT, SCIM III, cylindrical grip force and AIS motor score showed significant improvement in both groups (p ≤ 0.05), however, it was significantly higher in the intervention group than the control group for GRASSP strength, and GRASSP prehension ability (p ≤ 0.05); (4) Conclusion: our findings show potential advantages of the combination of cervical tSCS with an exoskeleton to optimize the outcome for UE.

Differences in sensorimotor and functional recovery between the dominant and non-dominant upper extremity following cervical spinal cord injury.

Post hoc analysis of prospective multi-national, multi-centre cohort study. Determine whether cerebral dominance influences upper extremity recovery following cervical spinal cord injury (SCI). A multi-national subset of the longitudinal GRASSP dataset (n = 127). Secondary analysis of prospective, longitudinal multicenter study of individuals with cervical SCI (n = 73). Study participants were followed for up to 12 months after a cervical SCI, and the following outcome measures were serially assessed - the Graded Redefined Assessment of Strength, Sensibility, and Prehension (GRASSP) and the International Standards for the Neurological Classification of SCI (ISNCSCI), including upper extremity motor and sensory scores. Observed recovery and relative (percent) recovery were then determined for both the GRASSP and ISNCSCI, based on change from initial to last available assessment. With the exception of prehension performance (quantitative grasping) following complete cervical SCI,there were no significant differences (p < 0.05) for observed and relative (percent) recovery, between the dominant and non-dominant upper extremities, as measured using GRASSP subtests, ISNCSCI motor scores and ISNCSCI sensory scores. Despite welldocumented differences between the cerebral hemispheres, cerebral dominance appears to play a limited role in upper extremity recovery following acute cervical SCI.

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.

CMAP Scan Examination of the First Dorsal Interosseous Muscle After Spinal Cord Injury.

The study assessed motor unit loss in muscles paralyzed by spinal cord injury (SCI) using a novel compound muscle action potential (CMAP) scan examination. The CMAP scan of the first dorsal interosseous (FDI) muscle was applied in tetraplegia (n = 13) and neurologically intact (n=13) subjects. MScanFit was used for estimating motor unit numbers in each subject. The D50 value of the CMAP scan was also calculated. We observed a significant decrease in both CMAP amplitude and motor unit number estimation (MUNE) in paralyzed FDI muscles, as compared with neurologically intact muscles. Across all subjects, the CMAP (negative peak) amplitude was 8.01 ± 3.97 mV for the paralyzed muscles and 16.75 ± 3.55 mV for the neurologically intact muscles (p < 0.001). The CMAP scan resulted in a MUNE of 59 ± 37 for the paralyzed muscles, much lower than 108 ± 21 for the neurologically intact muscles (p < 0.001). No significant difference in D50 was observed between the two groups (p= 0.2). For the SCI subjects, there was no significant correlation between MUNE and CMAP amplitude, or any of the clinical assessments including pinch force, grip force, the Graded Redefined Assessment of Strength, Sensibility and Prehension (GRASSP) score, and SCI duration (p > 0.05). The findings provide an evidence of motor unit loss in the FDI muscles of individuals with tetraplegia, which may contribute to weakness and other hand function deterioration. The CMAP scan offers several practical benefits compared with the traditional MUNE techniques because it is noninvasive, automated and can be performed within several minutes.

A suite of automated tools to quantify hand and wrist motor function after cervical spinal cord injury

BackgroundCervical spinal cord injury (cSCI) often causes chronic upper extremity disability. Reliable measurement of arm function is critical for development of therapies to improve recovery after cSCI. In this study, we report a suite of automated rehabilitative tools to allow simple, quantitative assessment of hand and wrist motor function.MethodsWe measured range of motion and force production using these devices in cSCI participants with a range of upper limb disability and in neurologically intact participants at two time points separated by approximately 4 months. Additionally, we determined whether measures collected with the rehabilitative tools correlated with standard upper limb assessments, including the Graded Redefined Assessment of Strength, Sensibility, and Prehension (GRASSP) and the Jebsen Hand Function Test (JHFT).ResultsWe find that the rehabilitative devices are useful to provide assessment of upper limb function in physical units over time in SCI participants and are well-correlated with standard assessments.ConclusionsThese results indicate that these tools represent a reliable system for longitudinal evaluation of upper extremity function after cSCI and may provide a framework to assess the efficacy of strategies aimed at improving recovery of upper limb function.

A single-subject study of robotic upper limb training in the subacute phase for four persons with cervical spinal cord injury.

Study designSingle-subject design, standard training (“B”) compared with Robotic training (“C”).ObjectivesTo explore the impact of robotic training on upper limb function, activities of daily living (ADL) and training experience in subacute tetraplegic inpatients.SettingInpatient subacute Norwegian spinal cord injury (SCI) unit.MethodsFour participants (C4–7, AIS A-C) completed 11 sessions of robotic training using a passive robotic exoskeleton (Armeo Spring®). Descriptive statistics and visual analyses were used for comparing standard occupational therapy and robotic training. Outcome measures included the Spinal Cord Independence Measure (SCIM-III), the Graded Redefined Assessment of Strength Sensibility and Prehension (GRASSP), and a questionnaire.ResultsAll of the participants exhibited an increase in assessments of upper limb function (GRASSP-total) right side (0.4%–61.2%), and all except for one participant (−8%) showed an increase on their left side (20.9%–106.2%). Three out of four participants had improvements in ADL function SCIM-III (ranging from 5.6% to 46.7%). Results demonstrated improvements during the robotic intervention period in five out of 28 measurements. The participants enjoyed the exercise, and found it motivating and relevant to their injury (median ranged from 3.5 to 6.5 on a 0–7 scale).ConclusionsThree out of four participants improved upper limb function and ADL independence, but the study could not confirm that improvements were due to the robotic intervention. The participants enjoyed the robotic training and found it relevant to their injury.

Clinical Outcomes from a Multi-Center Study of Human Neural Stem Cell Transplantation in Chronic Cervical Spinal Cord Injury

Human neural stem cell transplantation (HuCNS-SC®) is a promising central nervous system (CNS) tissue repair strategy in patients with stable neurological deficits from chronic spinal cord injury (SCI). These immature human neural cells have been demonstrated to survive when transplanted in vivo, extend neural processes, form synaptic contacts, and improve functional outcomes after experimental SCI. A phase II single blind, randomized proof-of-concept study of the safety and efficacy of HuCNS-SC transplantation into the cervical spinal cord was undertaken in patients with chronic C5-7 tetraplegia, 4-24 months post-injury. In Cohort I (n = 6) dose escalation from 15,000,000 to 40,000,000 cells was performed to determine the optimum dose. In Cohort II an additional six participants were transplanted at target dose (40,000,000) and compared with four untreated controls. Within the transplant group, there were nine American Spinal Injury Association Impairment Scale (AIS) B and three AIS A participants with a median age at transplant of 28 years with an average time to transplant post-injury of 1 year. Immunosuppression was continued for 6 months post-transplant, and immunosuppressive blood levels of tacrolimus were achieved and well tolerated. At 1 year post-transplantation, there was no evidence of additional spinal cord damage, new lesions, or syrinx formation on magnetic resonance (MR) imaging. In summary, the incremental dose escalation design established surgical safety, tolerability, and feasibility in Cohort I. Interim analysis of Cohorts I and II demonstrated a trend toward Upper Extremity Motor Score (UEMS) and Graded Redefined Assessment of Strength, Sensibility, and Prehension (GRASSP) motor gains in the treated participants, but at a magnitude below the required clinical efficacy threshold set by the sponsor to support further development resulting in early study termination.

Decreased white matter fractional anisotropy is associated with poorer functional motor skills following spinal cord injury: a pilot study.

Prospective cross-sectional study OBJECTIVES: The objective of this study was to assess associations between white matter changes and functional motor markers including grip strength and prehension in the upper limb. Single Center Imaging Study, in Vancouver Canada. Diffusion tensor imaging produced FA (Fractional Anisotropy) maps of the brain for participants with SCI (n = 7) and controls (n = 6). These FA maps were analyzed using tract-based spatial statistics. Correlations between the FA values (of the genu of the corpus callosum, the left superior longitudinal fasciculus and the right anterior thalamic radiation) of the SCI group and functional outcomes (grip strength, Graded Redefined Assessment of Strength, Sensibility and Prehension (GRASSP)) were assessed. Significant differences (p < 0.05) were found between the FA values of the controls and the SCI group in two white matter clusters, with lower values in the SCI group. Strong correlations were found between the FA values of the identified clusters and the age of SCI participant, and the right GRASSP Quantitative Prehension and right total GRASSP score. This preliminary data suggests that decreased FA in the genu of the corpus callosum may be a biomarker for functional motor ability of the upper limb with higher FA indicating better ability. Further research needs to be done to determine if other white matter tracts are also associated with strength and use of the hand following SCI. The International Collaboration on Repair Discoveries (operating grant) and Canada Research Chair Program (for JJE) provided support for this research.

Evaluation of the Capabilities of Upper Extremity Test (CUE-T) in Children With Tetraplegia.

Background: The Capabilities of Upper Extremity Test (CUE-T) is a spinal cord injury (SCI)-specific instrument based on the CUE Questionnaire (CUE-Q). Objective: To evaluate the psychometric properties of CUE-T in children with cervical SCI and determine the lowest age appropriate for test administration. Method: In this repeated measures multicenter study, 39 youths, mean age 12.3 years and mean time post injury 5.14 years, completed two administrations of the CUE-T. Test-retest reliability, internal consistency, and known groups validity were measured. Concurrent and discriminant validity were measured against previously validated measures: CUE-Q, Graded Redefined Assessment of Strength, Sensibility and Prehension (GRASSP), Spinal Cord Independence Measure (SCIM) III, SCIM III-Self Care (SCIM-SC), and SCIM-Mobility. Results: The CUE-T scores demonstrated strong test-retest reliability (ICC ≥ 0.95), strong internal consistency (α ≥ 0.90), and acceptable individual item agreement (κ ≥ 0.49). The hand subscale had better scores (p < .05) for the motor incomplete versus complete known groups, and the arm, hand, and side subscales had better scores (p < .05) for higher versus lower strength groups. The CUE-T had strong concurrent validity with the CUE-Q (r = 0.85-0.87), GRASSP (r = 0.78-0.90), and SCIM-SC (r = 0.70) and moderate-to-weak correlation with the total SCIM (r = 0.65) and SCIM-Mobility (r = 0.51). Children older than 6 years with mature grasp patterns were able to complete the CUE-T. Conclusion: The CUE-T scores are reliable and valid for use in children with cervical SCI older than 6 years of age.

Evaluation of the graded redefined assessment of strength, sensibility and prehension (GRASSP) in children with tetraplegia.

Psychometric study. To validate the GRASSP in pediatric SCI populations and establish the lower age of test administration. United States: Pennsylvania, Maryland, Illinois, Michigan, California, Texas. Mean, SD and range of scores were calculated and examined for known-group differences. Test-retest reliability was measured by the intra-class correlation, concurrent validity of the GRASSP against the SCIM, SCIM-SS, and the CUE-Q was measured by the Spearman correlation. GRASSP scores differed between participants with motor complete and incomplete injuries (p = <0.0001-0.036). Test-retest reliability was strong (ICC = 0.99). Weak correlation with the total SCIM (r = 0.33-0.66), and moderate to strong correlation with the SCIM-SC (r = 37-0.70) and CUE-Q (r = 0.40-0.84). Results support the validity of the GRASSP and provide evidence that the scores are reliable when administered to children. The GRASSP sensory and strength subtests are recommended for children beginning at 6 years of age, and the GRASSP prehension performance/ability subtest for children beginning at 8 years of age. Normative data are needed for the performance components of the GRASSP.

Predicting task performance from upper extremity impairment measures after cervical spinal cord injury.

Automated sensor-based assessments of upper extremity (UE) function after cervical spinal cord injury (SCI) could provide more detailed tracking of individual recovery profiles than is possible with existing assessments, and optimize the delivery and assessment of new interventions. The design of reliable automated assessments requires identifying the key variables that need to be measured to meaningfully quantify UE function. An unanswered question is to what extent measures of sensorimotor impairment can quantitatively predict performance on functional tasks. The objective was to define the predictive value of impairment measures for concurrent functional task performance in traumatic cervical SCI, as measured by the Graded Redefined Assessment of Strength, Sensibility and Prehension (GRASSP). Retrospective analysis. A data set of 138 GRASSP assessments was analyzed. The Strength and Sensation modules were used as measures of impairment, whereas the concurrent Prehension Performance module was used as the surrogate measure of function. Classifiers were trained to predict the scores on each of the six individual tasks in the Prehension Performance module. The six scores were added to obtain a total score. The Spearman's ρ between predicted and actual total Prehension Performance scores was 0.84. Predictions using both the Strength and Sensation scores were not found to be superior to predictions using the Strength scores alone. Measures of UE motor impairment are highly predictive of functional task performance after cervical SCI. Automated sensor-based assessments of UE motor function after SCI can rely on measuring only impairment and estimating functional performance accordingly.

Responsiveness, Sensitivity, and Minimally Detectable Difference of the Graded and Redefined Assessment of Strength, Sensibility, and Prehension, Version 1.0

As spinal cord injury (SCI) trials begin to involve subjects with acute cervical SCI, establishing the property of an upper limb outcome measure to detect change over time is critical for its usefulness in clinical trials. The objectives of this study were to define responsiveness, sensitivity, and minimally detectable difference (MDD) of the Graded Redefined Assessment of Strength, Sensibility, and Prehension (GRASSP). An observational, longitudinal study was conducted. International Standards of Neurological Classification of SCI (ISNCSCI), GRASSP, Capabilities of Upper Extremity Questionnaire (CUE-Q), and Spinal Cord Independence Measure (SCIM) were administered 0-10 days, 1, 3, 6, and 12 months post-injury. Standardized Response Means (SRM) for GRASSP and ISNCSCI measures were calculated. Longitudinal construct validity was calculated using Pearson correlation coefficients. Smallest real difference for all subtests was calculated to define the MDD values for all GRASSP subtests. Longitudinal construct validity demonstrated GRASSP and all external measures to be responsive to neurological change for 1 year post-injury. SRM values for the GRASSP subtests ranged from 0.25 to 0.85 units greater than that for ISNCSCI strength and sensation, SCIM-SS, and CUE-Q. MDD values for GRASSP subtests ranged from 2-5 points. GRASSP demonstrates good responsiveness and excellent sensitivity that is superior to ISNCSCI and SCIM III. MDD values are useful in the evaluation of interventions in both clinical and research settings. The responsiveness and sensitivity of GRASSP make it a valuable condition-specific measure in tetraplegia, where changes in upper limb neurological and functional outcomes are essential for evaluating the efficacy of interventions.

Predictive Value of Upper Limb Muscles and Grasp Patterns on Functional Outcome in Cervical Spinal Cord Injury

Objective. To determine which single or combined upper limb muscles as defined by the International Standards for the Neurological Classification of Spinal Cord Injury (ISNCSCI); upper extremity motor score (UEMS) and the Graded Redefined Assessment of Strength, Sensibility, and Prehension (GRASSP), best predict upper limb function and independence in activities of daily living (ADLs) and to assess the predictive value of qualitative grasp movements (QlG) on upper limb function in individuals with acute tetraplegia. Method. As part of a Europe-wide, prospective, longitudinal, multicenter study ISNCSCI, GRASSP, and Spinal Cord Independence Measure (SCIM III) scores were recorded at 1 and 6 months after SCI. For prediction of upper limb function and ADLs, a logistic regression model and unbiased recursive partitioning conditional inference tree (URP-CTREE) were used. Results. Logistic regression and URP-CTREE revealed that a combination of ISNCSCI and GRASSP muscles (to a maximum of 4) demonstrated the best prediction (specificity and sensitivity ranged from 81.8% to 96.0%) of upper limb function and identified homogenous outcome cohorts at 6 months. The URP-CTREE model with the QlG predictors for upper limb function showed similar results. Conclusion. Prediction of upper limb function can be achieved through a combination of defined, specific upper limb muscles assessed in the ISNCSCI and GRASSP. A combination of a limited number of proximal and distal muscles along with an assessment of grasping movements can be applied for clinical decision making for rehabilitation interventions and clinical trials.

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.

Outcome of the upper limb in cervical spinal cord injury: Profiles of recovery and insights for clinical studies

BackgroundImproved appreciation of recovery profiles of sensory and motor function as well as complex motor functions (prehension) after cervical spinal cord injury (SCI) will be essential to inform clinical studies to consider primary and secondary outcome measures for interventions and the optimization of dosing and timing of therapies in acute and chronic SCI.Objectives(1) To define the sensory, motor, and prehension recovery profiles of the upper limb and hand in acute cervical SCI and (2) to confirm the impact of AIS severity and conversion on upper limb sensorimotor recovery.MethodsAn observational longitudinal cohort study consisting of serial testing of 53 patients with acute cervical SCI was conducted. International Standards of Neurological Classification of Spinal Cord Injury, Graded Redefined Assessment of Strength Sensibility and Prehension (GRASSP), Capabilities of Upper Extremity (CUE-Q) Questionnaire, and Spinal Cord Independence Measure III (SCIM-III) were administered at 0–10 days, 1, 3, 6, and 12 months.AnalysisChange over time was plotted using mean and standard deviation of the total and subgroups of the sample.ResultsIndividuals with traumatic tetraplegia show distinct patterns of recovery. Factors that distinguish homogeneous subgroups of the sample are: severity of injury (level of injury, completeness) at baseline and conversion from a complete to an incomplete injury.ConclusionsIn cervical SCI, clinical recovery can be assessed using standardized measures that distinguish levels of activity and impairment. Specific recovery profiles of the upper limb over the 1-year timecourse provide new insights and opportunity for combined analysis of recovery profiles for different clinical assessment tools of upper limb function which are meaningful to inform the design of study protocols.

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.