Shriners Hospital Upper Extremity Evaluation Research Articles

Outcomes Associated with a Single Joystick-Operated Ride-on-Toy Navigation Training Incorporated into a Constraint-Induced Movement Therapy Program: A Pilot Feasibility Study

Our research aims to evaluate the utility of joystick-operated ride-on-toys (ROTs) as therapeutic adjuncts to improve upper extremity (UE) function in children with hemiplegic cerebral palsy (HCP). This study assessed changes in affected UE use and function following a three-week ROT navigation training incorporated into an existing constraint-induced movement therapy (CIMT) camp in 11 children (3-14 years old) with HCP. We report changes in scores on the standardized Shriners Hospital Upper Extremity Evaluation (SHUEE) from pretest-to-posttest and changes from early-to-late sessions in percent time spent by the affected arm in: (a) "moderate-to-vigorous activity", "light activity" and "no activity" bouts based on accelerometer data and (b) "independent", "assisted", and "no activity" bouts based on video data. We also explored relationships between standardized measures and training-specific measures of affected UE activity. We found small-to-medium improvements in the SHUEE scores. Between 90 and 100% of children also showed medium-to-large improvements in affected UE activity from early-to-late sessions using accelerometers and small improvements via video-based assessments. Exploratory analyses suggested trends for relationships between pretest-posttest and training-specific objective and subjective measures of arm use and function. Our pilot data suggest that single joystick-operated ROTs may serve as motivating, child-friendly tools that can augment conventional therapies such as CIMT to boost treatment dosing, promote affected UE movement practice during real-world navigation tasks, and ultimately improve functional outcomes in children with HCP.

Can the Shriners Hospital Upper Extremity Evaluation (SHUEE) Detect Change in Dynamic Position and Spontaneous Function of the Upper Limb in People With Hemiplegic Cerebral Palsy?

The Shriners Hospital Upper Extremity Evaluation (SHUEE) is a video-based measure designed to assess upper extremity function in people with cerebral palsy (CP). The SHUEE completes both dynamic positional analysis (DPA; position during functional activities) and spontaneous functional analysis (spontaneous use of the involved limb). Although the SHUEE has been suggested as a measure for planning upper limb interventions and evaluating outcomes, limited evidence of its ability to detect change exists. Thus, this study aimed to describe responsiveness of the SHUEE to detect change after orthopaedic surgery. In this Institutional Review Board-approved retrospective cohort study, we identified children with CP who were administered SHUEE on≥2 encounters. We formed pairs of initial and follow-up visits between temporally adjacent visits. Pairs were assigned to a surgery or non-surgery group based on intervening upper limb orthopaedic surgery. We compared differences in baseline SHUEE scores between groups and differences in temporally adjacent SHUEE scores within groups using Welch unequal variances t tests and paired t tests, respectively. Nineteen people (7 female) with hemiplegic CP had≥2 SHUEE assessments; Manual Ability Classification System levels I (3), II (8), III (7), IV (1); Gross Motor Function Classification System levels I (10), II (7), IV (2); mean age at baseline 11.9 (5.1 to 19.1) years; and follow-up at 13.4 (5.5 to 19.7) years. Six people had≥2 visits leading to 14 surgical pairs and 10 non-surgical pairs. At baseline, DPA of the wrist and forearm were significantly lower in the surgical group ( P <0.05). At follow-up, no significant difference between the groups existed in DPA measures ( P >0.05). After surgical intervention, there was a significant change in overall and wrist DPA ( P <0.05). The DPA measures demonstrated responsiveness to expected positional changes in the arm after orthopaedic surgery in people with CP. The SHUEE was useful in identifying abnormal segmental alignment pre-surgically and documenting changes in alignment postoperatively. As orthopaedic surgery does not address limb neglect or bimanual ability, spontaneous functional analysis scores were as expected-unchanged. Level III, retrospective cohort study.

Comparison of outcome between operative treatment and constraint-induced movement therapy for forearm and wrist deformities in cerebral palsy. A randomized controlled trial

Several treatment strategies for upper extremity deformities in cerebral palsy have been studied for their effectiveness in terms of function and quality of life. There are a few comparative studies between nonoperative and operative management for upper extremity deformities. This study aimed to compare the outcomes between conservative methods using constraint-induced movement therapy (CIMT) and operative methods using pronator teres rerouting, flexor carpi ulnaris transfer to extensor carpi radialis brevis (FCU transfer to ECRB) and fractional lengthening in cerebral palsy patients with forearm pronation and wrist flexion contracture. A total of 19 participants aged 7-15 years were randomized to either CIMT or surgery. The primary endpoint was changes in Shriners Hospital Upper Extremity Evaluation (SHUEE) functional score. Secondary endpoints comprised range of motion, Volkmann’s angle, and the Pediatric Outcomes Data Collection Instrument (PODCI). At 1-year follow-up, there was no significant difference between the nonoperative and operative groups in any SHUEE dimensions, range of motion or PODCI. However, there was significant improvement in Volkmann’s angle in the operative group compared to the CIMT group: CIMT = 11.11 ± 9.92, surgery = -13.00 ± 4.72: p = 0.04 (95% CI = 1.68-46.54). Operative treatment provided more improvement in wrist posture, represented by Volkmann’s angle, in cerebral palsy patients. However, SHUEE, range of motions and PODCI were comparable between the CIMT and operative groups.

Evaluation of a Customized 3D Printed ORGAN-Hand Orthotic Device for Unilateral Cerebral Palsy: a Pilot Study.

To achieve intensive activity-based and goal-directed rehabilitation for unilateral cerebral palsy (UCP), several static and functional upper limb orthoses have been used but with limited robust evidence-base. The current pilot study evaluated the feasibility and efficacy of a customized 3D-printed orthotic device in children with UCP. The attainment of a prespecified goal and Shriners Hospital Upper Extremity Evaluation (SHUEE) at 3 and 6 mo were the efficacy measures. Of the 14 screened children, 5 (median age: 7.9 y; 3 boys) were included. The 3-mo follow-up could be completed for 3 children while 6-mo follow-up could be completed for 1 child. Rest could not be assessed due to pandemic restrictions. Although none attained set goals till the last follow-up, all 3 children (at 3-mo follow-up) showed improvement in SHUEE scores without any significant safety concerns. Further studies on 3D-printed orthosis in UCP are the need of the hour.

The Dynamic Thumb-in-Palm Pattern in Children with Spastic Cerebral Palsy and Its Effects on Upper Limb Function.

The thumb-in-palm (TIP) pattern is one of the most common upper limb deformities in cerebral palsy (CP). This study was designed to investigate the effect of the dynamic TIP pattern on upper limb function in children with spastic CP. This prospective observational study included a total of 106 children with CP with dynamic TIP. The House TIP classification while grasping small or large objects, Melbourne Assessment of Unilateral Upper Limb Function (MUUL), Shriners Hospital Upper Extremity Evaluation (SHUEE), Zancolli classification for wrist–finger flexor deformity, and degree of swan neck deformity were assessed. Type I was the most common and highest functioning House TIP classification type. However, there were no significant differences in upper arm function between types II, III, and IV. The three components of the SHUEE showed stronger association with MUUL than House TIP and Zancolli classifications. After multivariable analysis, functional use of the wrist–finger and the thumb played a more significant role than the dynamic alignment of the thumb. In conclusion, the House TIP classification is useful to describe the TIP pattern. The SHUEE thumb assessment is a useful tool for reflecting upper arm function. The upper arm function was related more with the associated wrist flexor deformity than dynamic TIP.

Validity and reliability of the Turkish versions of Assessment of Children's Hand Skills and Children's Hand-Skills Ability Questionnaire in children with hemiplegic cerebral palsy.

Assessment of Children's Hand Skills (ACHS) and Children's Hand-Skills Ability Questionnaire (CHSQ) are interconnected hand skills assessment tools that together contain parent questionnaire and observational assessment. With this quality, ACHS and CHSQ enable the therapist to obtain information about the child's real-life performances as well as to conduct a clinical observational assessment. The purpose of this study was to investigate the validity and reliability of the Turkish versions of ACHS and CHSQ in children with hemiplegic cerebral palsy (HCP). A total of 112 children with HCP between 2 and 12 years of age were included. All participants were subjected to ACHS, CHSQ, Shriners Hospital Upper Extremity Evaluation (SHUEE) and ABILHAND-Kids. Convergent construct validity was investigated through analysing the relationship between ACHS and SHUEE and between CHSQ and ABILHAND-Kids. Discriminative construct validity was investigated through analysing the differences between genders for CHSQ and ACHS. For reliability, test-retest interclass correlation coefficient (ICC) and internal consistency Cronbach's alpha were calculated and analysed. ACHS showed very strong relationships with SHUEE's spontaneous functional analysis (r = 0.86) and grip-release function (r = 0.86) parameters with a strong relationship with positional dynamic analysis (r = 0.78). CHSQ's leisure (r = 0.80), school/education (r = 0.75) and activities of daily living (r = 0.76) domains showed strong relationships with the ABILHAND-Kids. There was no difference between genders for ACHS and all domains of CHSQ (p > 0.05). All domains and total score of ACHS and CHSQ had perfect test-retest reliability (ICC > 0.90). ACHS had perfect internal consistency (Cronbach's α = 0.98); CHSQ had very high internal consistency (Cronbach's α = 0.84). The Turkish versions of ACHS (ACHS-TR) and CHSQ (CHSQ-TR) are valid and reliable hand skills assessment tools in children with HCP.

Surgery for the Pronated Forearm and Flexed Wrist in Children with Cerebral Palsy.

There is no consensus in the literature on how best to manage wrist flexion and forearm pronation deformities in children with cerebral palsy (CP). The aim of this research was to come up with a treatment algorithm for the surgical management of such cases. Children with CP who underwent upper limb surgery between 2009 and 2016 at a single centre and by a single lead surgeon were reviewed retrospectively. Movement analysis and Shriners Hospital Upper Extremity Evaluation (SHUEE) data collected pre- and post-operatively. Thirteen patients were recruited. Most patients underwent a flexor carpi ulnaris (FCU) to extensor carpi radialis brevis (ECRB) transfer, with or without pronator teres (PT) re-routing, and finger flexor or elbow flexor releases. Mean increase in active range of supination was 40.8° (p = 0.002) and wrist extension 28.9° (p = 0.004). The mean increase in dynamic positional analysis (part of the SHUEE) was 25.4% (of which 40.3% was due the increases in wrist function and 16.8% due to forearm function). The loss of wrist flexion was not significant (p = 0.125). The mean follow-up was 14months (range 9-21). To tackle both a pronation and flexion deformity, the authors favour performing a FCU to ECRB transfer in isolation if there is active supination to neutral; if active supination is short of neutral, then a FCU to ECRB with a PT release and possible re-routing performed. A treatment algorithm is proposed. IV.

BRAZILIAN VERSION OF THE SHRINERS HOSPITAL UPPER EXTREMITY EVALUATION (SHUEE): TRANSLATION, CULTURAL ADAPTATION, AND EVALUATION OF PSYCHOMETRIC PROPERTIES.

ABSTRACTObjective: To validate the upper limb assessments tool, Shriners Hospital Upper Extremity Evaluation (SHUEE), for individuals with hemiplegic cerebral palsy in the Brazilian population.Methods: Validation study to translate and culturally adapt the Manual and the instrument. The psychometric properties evaluated were reliability and convergent validity. Reliability was determined by internal consistency (Cronbach’s α coefficient), ceiling and floor effect, sensitivity to changes, and intra- and interobserver agreement. Convergent validity was performed using the Pediatric Motor Activity Log, the self-care scale of the Pediatric Evaluation of Disability Inventory, and the Manual Ability Classification System.Results: We evaluated 21 individuals with hemiplegic cerebral palsy, with a mean age of 8.7±4.0 years. After the instrument was translated, there was no need for cultural adaptation. The total Cronbach’s α coefficient was 0.887 (95% confidence interval [95%CI] 0.745-0.970). We calculated sensitivity to changes in five subjects who underwent treatment with Botulinum Toxin Type A and physical therapy, with a significant difference between pre- and post-treatment evaluations in the Spontaneous Functional Analysis and Dynamic Positional Analysis. Convergent validity showed a significant correlation of the Spontaneous Functional Analysis and Dynamic Positional Analysis with the scales evaluated. All items of SHUEE presented high intra- and interobserver agreement.Conclusions: The results revealed that the Brazilian version of the SHUEE demonstrated good reliability and convergent validity, suggesting that it is an adequate and reliable tool for individuals with hemiplegic cerebral palsy in the Brazilian population.

Effects of upper extremity surgery on activities and participation of children with cerebral palsy: a systematic review.

AimTo evaluate and synthesize the evidence for effects of upper extremity surgery (UES) on activities and participation of children and adolescents with cerebral palsy (CP).MethodThe databases MEDLINE, Embase, and PsycINFO were searched for publications up to September 2018. Studies included were comparative studies with or without concurrent comparison groups or case series with pretest/posttest outcomes with a minimal sample size of 10 participants; those that reported the effects of UES with a follow‐up time of at least 5 months; those including patients diagnosed with CP aged up to 20 years; and those that used a validated activity‐based instrument. Risk of bias was assessed using the ROBINS‐I (Risk Of Bias In Non‐randomised Studies ‐ of Interventions) tool and quality assessment was performed using the Grading of Recommendations Assessment, Development and Evaluation.ResultsTwelve studies, involving 310 children and adolescents, were included. The ability and perception of the patient to use the hand(s) and perform activities (measured with the Shriners Hospital Upper Extremity Evaluation, Assisting Hand Assessment, and House Functional Classification) improved significantly after UES. The quality of evidence was very low for each of the activity outcomes of interest.InterpretationThe very low evidence prohibits recommendations on the use of UES to guide clinical practice. More high‐quality comparative studies are needed to obtain better insight into the effects of UES on activities and participation.What this paper adds Low quality of evidence for effects of upper extremity surgery (UES) on activities and participation.Limited evidence for improvement in activities and participation after UES.

An Assessment of the Applicability of Shriners Hospital Upper Extremity Evaluation as a Decision-making Tool and Outcome Measure in Upper Limb Cerebral Palsy in Indian Children.

Background:The aim of this study was to assess the applicability and performance of the Shriners Hospital Upper Extremity Evaluation (SHUEE) and to determine its usefulness in clinical decision-making and as an outcome measure with reference to Indian children suffering from cerebral palsy.Materials and Methods:The SHUEE videos of 40 children with cerebral palsy with spastic hemiplegia or asymmetrical diplegia were analyzed and scored. Seven children had undergone upper extremity surgery based on a preoperative evaluation. All seven had a postoperative evaluation. Pre- and postoperative scores were compared. Intra- and interobserver reliability was assessed. The level of familiarity and comfort of the children with the assigned tasks was gauged.Results:Analysis of the scores revealed that patients could be categorized into three discrete groups based on the modified House scores and Spontaneous Functional Analysis (SFA) scores, which helps in identifying the patients who would benefit from surgical intervention. In the seven children who were operated, there was a mean increase in the postoperative SFA (2.97, P = 0.259), Dynamic Positional Analysis (3.15, P = 0.229) and Grasp/Release Analysis (4.96, P = 0.334) scores, though the differences were not statistically significant. There was excellent intraobserver (r - 0.98) and interobserver reliability (r - 0.97, 0.96) based on the intraclass correlation coefficient. The children were familiar with the assigned tasks and were not duly uncomfortable while attempting to perform them.Conclusions:SHUEE is a useful modality to assess upper limb function in Indian children with cerebral palsy, and can be used as a decision-making tool and mode of documentation.

Can the Shriners Hospital Upper Extremity Evaluation (SHUEE) detect change in dynamic position and spontaneous function of the upper limb in youth with unilateral cerebral palsy?

Can the Shriners Hospital Upper Extremity Evaluation (SHUEE) detect change in dynamic position and spontaneous function of the upper limb in youth with unilateral cerebral palsy?

Brazilian version of the Shriners Hospital Upper Extremity Evaluation (SHUEE): cultural adaptation and evaluation of psychometric properties

Brazilian version of the Shriners Hospital Upper Extremity Evaluation (SHUEE): cultural adaptation and evaluation of psychometric properties

SHUEE on the evaluation of upper limb in cerebral palsy.

OBJECTIVE: To demonstrate the use of the tool for evaluation of spastic upper limb SHUEE (Shriners Hospital Upper Extremity Evaluation) in the evaluation of upper limb in cerebral palsy (CP) and its ability to detect changes after surgical treatment of identified deformities. METHODS: 19 patients with spastic hemiplegic CP had their upper limb evaluated by SHUEE. Five patients underwent surgical treatment of deformities detected and performed the test at one year postoperatively. RESULTS: The mean age was 9.02 years old; 18 patients were classified as level I GMFCS and one patient as level II. At baseline, the mean spontaneous functional analysis was 59.01; dynamic positional analysis was 58.05 and grasp-and-release function, was 91.21. In the postoperative period the scores were, respectively, 65.73, 69.62 and 100, showing an improvement of 3.5% in the spontaneous functional analysis and of 44.8% in dynamic positional analysis. CONCLUSIONS: SHUEE is a tool for evaluation of spastic upper limb in cerebral palsy that helps in the specific diagnosis of deformities, indication of treatment and objective detection of results after surgical treatment. Level of Evidence IV, Case Series.

Tendon transfer surgery in upper-extremity cerebral palsy is more effective than botulinum toxin injections or regular, ongoing therapy.

For children with upper-extremity cerebral palsy (CP) who meet standard indications for tendon transfer surgery, we hypothesized that surgical treatment would result in greater functional improvement than treatment with botulinum toxin injections or regular, ongoing therapy. Thirty-nine children with upper-extremity CP, who were four to sixteen years of age and surgical candidates for the transfer of the flexor carpi ulnaris to the extensor carpi radialis brevis, pronator teres release, and extensor pollicis longus rerouting with adductor pollicis release, were prospectively assigned, either randomly (twenty-nine patients) or by patient/family preference (ten patients), to one of three treatment groups: surgical treatment (Group 1); botulinum toxin injections (Group 2); or regular, ongoing therapy (Group 3). Seven centers participated. Assessment measurements included active range of motion, pinch and grip strength, stereognosis, and scores as measured with eight additional functional or patient-oriented outcome instruments. Thirty-four patients (twenty-five randomized and nine from the patient-preference arm) were evaluated twelve months post-treatment as the study cohort. For the primary outcome of the Shriners Hospital Upper Extremity Evaluation (SHUEE) dynamic positional analysis (DPA), significantly greater improvement was seen in Group 1 than in the other two groups (p < 0.001). Improvements in SHUEE DPA reflected improved supination and wrist extension during functional activities after surgical treatment. Group 1 showed more improvement in the Pediatric Quality of Life Inventory (PedsQL) CP module domain of movement and in the Canadian Occupational Performance Measure (COPM) score for satisfaction than Groups 2 and 3. Both Groups 1 and 3 showed more improvement in pinch strength than did Group 2. For children with upper-extremity CP who were candidates for standard tendon transfer, surgical treatment was demonstrated to provide greater improvement, of modest magnitude, than botulinum toxin injections or regular, ongoing therapy at twelve months of follow-up for the SHUEE DPA, the PedsQL CP module domain of movement, and COPM satisfaction.

Constraint-induced movement therapy (CIMT) for young children with cerebral palsy: Effects of therapeutic dosage

To compare effects of 2 dosage levels of constraint-induced movement therapy (CIMT) for children with hemiplegic cerebral palsy (CP). We hypothesized that high-dosage CIMT would produce larger benefits than moderate-dosage. Three sites enrolled a total of 18 children (6 children per site from 3-6 years) with unilateral CP. Children were randomly assigned to CIMT for 21 days for either 6 hours/day (high-dosage=126 hours) or 3 hours/day (moderate-dosage=63 hours); both groups wore a long-arm cast. Evaluators (blind to dosage) assessed children 1-week prior, then 1-week and 1-month after treatment with the Assisting Hand Assessment (AHA), The Quality of Upper Extremity Skills Test (QUEST) Dissociated Movement and Grasp sections, the Shriners Hospital Upper Extremity Evaluation (SHUEE), and the Pediatric Motor Activity Log (PMAL). All children responded well to casting and received the full intended dosage. Both groups showed statistically significant gains on the AHA, QUEST, SHUEE, and PMAL. Effect sizes ranged from 0.36-0.79. Overall, both groups showed comparable improvements at 1-week and 1-month post-treatment. Pediatric CIMT at both moderate and high dosages produced positive effects across multiple reliable, valid outcome measures. The findings refuted the hypothesis of differential dosage benefits. Future research should address long-term effects, enroll larger and more diverse samples, and assess lower dosages to ascertain a minimal-efficacy threshold.

Forced-use, Without Therapy, in Children With Hemiplegia

Forced use (FU) is an emerging treatment for children with hemiplegic cerebral palsy (CP). It involves constraining the unaffected arm and no additional treatment of the affected arm. Our study examined a new approach to FU in children with hemiplegic CP: that is, restraint of the unaffected limb and no rehabilitation. Ten children with hemiplegic CP aged between 5 and 9 years were compared with 10 control children (aged between 5 and 8 y). All participants were classified as MACS level II.The FU group wore a fixed cast, on the unaffected arm for 21 consecutive days, and, such as the control group, did not receive any physical therapy.All participants were assessed by the Melbourne Assessment of Unilateral Upper Limb Function and the Shriners Hospital Upper Extremity Evaluation. A statistically significant increase in both the functional scales was already apparent after cast removal and was maintained during follow-ups. The total Melbourne Assessment of Unilateral Upper Limb Function percentage score increased significantly to 9.5% and 12.3% on 3-week and 3-month follow-up examinations, respectively (P<0.05). A statistically significant increase was observed in 2 of the 3 parts of the Shriners Hospital Upper Extremity Evaluation: spontaneous use (P<0.05) and the ability of the involved limb to grasp and release (G/R) (P<0.05). These preliminary results suggest that FU without rehabilitation improves the spontaneous use and function of the affected upper limb. In children with hemiplegia, this approach may be an economically viable means of upper limb treatment that has no side effects. Therapeutic Level III. See Instructions to Authors for complete description of level of evidence.

Upper limb activity measures for 5‐ to 16‐year‐old children with congenital hemiplegia: a systematic review

This systematic review aimed to compare the validity, reliability, evaluative validity, and clinical utility of upper limb activity measures for children aged 5 to 16 years with congenital hemiplegia. Electronic databases were searched to identify assessments that measure upper limb activity available for use and for which published validity and reliability data for the population are obtainable. Assessment items were coded according to the International Classification of Functioning, Disability and Health (ICF) categories to determine if at least 35% of the assessment items fell within the activity component of the ICF. Assessments that met these criteria were included in the review. Thirty-eight measures were identified, and five met the inclusion criteria. The best measure of unimanual capacity was the Melbourne Assessment of Unilateral Upper Limb Function (MUUL); however, the Shriners Hospital Upper Extremity Evaluation (SHUEE) and the Quality of Upper Extremity Skills Test (QUEST) could also be considered, depending on the type of information required. The performance-based measure of bimanual upper limb activity in children with hemiplegia with the best psychometric properties was the Assisting Hand Assessment (AHA). The ABILHAND-Kids is a parent-report, performance-based questionnaire with excellent clinical utility and psychometric properties. Clinicians may choose to use more than one of these measures to detect changes in unimanual or bimanual upper limb activity.

Surgical Management of Thumb Deformity in Children With Hemiplegic-type Cerebral Palsy

Evidence-based clinical decision-making for the surgical management of thumb deformities in children with cerebral palsy is difficult, primarily because of a lack of consensus with respect to assessment of thumb alignment and function. We have used the Shriners Hospital Upper Extremity Evaluation, a validated assessment tool, to determine the outcome after thumb reconstruction surgery in these children. The goals of this study were to determine the relationship between static and dynamic assessments of the thumb before surgery, the outcomes with respect to static and dynamic alignments of the thumb after soft tissue and skeletal surgery, and the relationship between preoperative spontaneous functional use of the involved extremity (indicative of the magnitude of neurologic impairment) and the change in thumb dynamic alignment after surgery. A retrospective case series was performed, consisting of 33 children with hemiplegic-type cerebral palsy who had undergone surgical reconstruction of the thumb between 1998 and 2006. All children had preoperative and postoperative Shriners Hospital Upper Extremity Evaluation analyses performed (mean time to follow-up was 2 y and 2 mo). Static modified House scale of thumb alignment, dynamic thumb positional analysis, and the spontaneous functional use of the involved extremity were compared and contrasted. Dynamic thumb alignment was significantly worse than static thumb alignment (P=0.0005). Comparable improvements were achieved in both static and dynamic thumb alignment after surgical thumb reconstruction (P=0.6242). Optimal outcome was achieved more frequently in the static alignment (82% of cases) than in the dynamic alignment (61% of cases). There was poor correlation between the spontaneous use of the involved extremity before surgery and the changes in thumb dynamic alignment after surgery (Pearson correlation coefficient 0.1554, P=0.39). Static thumb alignment is not a good predictor of dynamic function, and interventions designed to improve function should focus on the assessment of dynamic thumb alignment. Improvements in both static and dynamic alignment of the thumb are possible after reconstructive surgery (consisting of muscle release, tendon transfer, and skeletal stabilization), regardless of the degree or density of underlying neurologic impairment.