The Advanced Appreciation of Upper Limb Rehabilitation in Cervical Spinal Cord Injury



The nature of an upper limb function impairment following a cervical spinal cord injury (SCI) is bilateral and rather symmetric, which increases the impact of the injury on the independence and quality of life of the affected patient. Therefore, this disorder is very different from stroke and other damages within the peripheral nervous system. Physical training therapy is of high clinical importance in patients with a cervical SCI so as to increase neural plasticity, and thereby improve motor recovery. New rehabilitation therapies based on robots, passive workstations, and functional electrical stimulation (FES) systems have been developed. However, the overall clinical value of these new technology-based therapies in SCI patients needs to be evaluated. Different methods can be used to test or describe the condition of the upper limb function before and after a novel physical training therapy session. We present a detailed functional classification of the hand that can distinguish different levels of impairment with typical impacts on activities of daily living. In consequence, changes between these levels (improvement or deterioration) can be considered clinically meaningful. In addition, upper limb function following SCI can be assessed with measures of capacity and performance, as well as surrogates (electrophysiological and biomedical recordings). While performance tests target on clinically relevant changes by assessing activities related to daily life (i.e., hand function), measures of capacity and surrogates focus on detailed functions (motor and sensory scores, conduction velocity) that do not necessarily correlate with clinically meaningful changes. Nevertheless, capacity tests and surrogates can detect subtle changes induced by interventions that might be missed by clinical measures.


Tetraplegia Upper limb function Rehabilitation Assessment Clinically meaningful improvement 


  1. 1.
    Anderson KD. Targeting recovery: priorities of the spinal cord-injured population. J Neurotrauma. 2004;21(10):1371–83.PubMedCrossRefGoogle Scholar
  2. 2.
    Snoek GJ, Ijzerman MJ, Hermens HJ, Maxwell D, Biering-Sorensen F. Survey of the needs of patients with spinal cord injury: impact and priority for improvement in hand function in tetraplegics. Spinal Cord. 2004;42:526–32.PubMedCrossRefGoogle Scholar
  3. 3.
    Waters RL, Adkins RH, Yakura JS, Sie I. Motor and sensory recovery following complete tetraplegia. Arch Phys Med Rehabil. 1993;74:242–7.PubMedGoogle Scholar
  4. 4.
    Krebs HI, Hogan N, Aisen ML, Volpe BT. Robot-aided neurorehabilitation. IEEE Trans Rehabil Eng. 1998;6(1):75–87.PubMedCrossRefGoogle Scholar
  5. 5.
    Nef T, Guidali M, Riener R. ARMin III – arm therapy exoskeleton with an ergonomic shoulder actuation. Appl Bionic Biomech. 2009;6(2):127–42.CrossRefGoogle Scholar
  6. 6.
    Micera S, Carrozza MC. A simple robotic system for neurorehabilitation. Auton Robots. 2005;19:271–84.CrossRefGoogle Scholar
  7. 7.
    Sanchez RJ, Liu J, Rao S, et al. Automating arm movement training following severe stroke: functional exercises with quantitative feedback in a gravity-reduced environment. IEEE Trans Neural Syst Rehabil Eng. 2006;14(3):378–89.PubMedCrossRefGoogle Scholar
  8. 8.
    Kowalczewski J. Upper extremity neurorehabilitation. Ph.D. dissertation, Department of Medicine, Alberta University, Alberta; 2009.Google Scholar
  9. 9.
    Popovic MR, Keller T. Modular transcutaneous functional electrical stimulation system. Med Eng Phys. 2005;27:81–92.PubMedCrossRefGoogle Scholar
  10. 10.
    Popovic MR, Curt A, Keller T, Dietz V. Functional electrical stimulation for grasping and walking: indications and limitations. Spinal Cord. 2001;39:403–12.PubMedCrossRefGoogle Scholar
  11. 11.
    American Spinal Injury Association. International standards for neurological classification of spinal cord injury. Chicago: American Spinal Injury Association (ASIA); 2002. p. 1–24.Google Scholar
  12. 12.
    Catz A, Itzkovich M, Agranov E, Ring H, Tamir A. SCIM – spinal cord independence measure: a new disability scale for patients with spinal cord lesions. Spinal Cord. 1997;35:850–6.PubMedCrossRefGoogle Scholar
  13. 13.
    Catz A, Itzkovich M, Steinberg F, et al. The Catz-Itzkovich SCIM: a revised version of the spinal cord independence measure. Disabil Rehabil. 2001;23(6):263–8.PubMedCrossRefGoogle Scholar
  14. 14.
    Catz A, Itzkovich M, Tesio L, et al. A multicenter international study on the spinal cord independence measure, version III: Rasch psychometric validation. Spinal Cord. 2007;45:275–91.PubMedCrossRefGoogle Scholar
  15. 15.
    Fattal C. Critical review of the evaluation of the results of upper limb functional surgery in tetraplegia since 50 years. Ann Réadap Méd Phys. 2004;47:30–47.CrossRefGoogle Scholar
  16. 16.
    Buck M, Beckers D. Rehabilitation bei Querschnittlähmung. Berlin/Heidelberg: Springer-Verlag, Inc.; 1993. p. 288–94.CrossRefGoogle Scholar
  17. 17.
    Nigst H. Band 3 Operationen an Tetraplegikern. In: Buck-Gramcko D, Nigst H, editors. Motorische Ersatzoperationen der Oberen Extremität. Stuttgart: Hippokrates-Verlag; 1991. p. 11–8.Google Scholar
  18. 18.
    Moberg E. Surgical treatment for absent single-hand grip and elbow extension in quadriplegia. J Bone Joint Surg. 1975;57-A(2):196–206.Google Scholar
  19. 19.
    McDowell CL, Moberg EA, Smith AG. International conference on surgical rehabilitation of the upper limb in tetraplegia. J Hand Surg. 1979;4(4):387–90.Google Scholar
  20. 20.
    McDowell CL, Moberg EA, House JH. The second international conference on surgical rehabilitation of the upper limb in tetraplegia (quadriplegia). J Hand Surg. 1986;11-A(4):604–8.Google Scholar
  21. 21.
    MacAvoy MC, Green DP. Critical reappraisal of medical research council muscle testing for elbow flexion. J Hand Surg. 2007;32-A(2):149–53.Google Scholar
  22. 22.
    Freehafer AA, Vonhaam E, Allen V. Tendon transfers to improve grasp after injuries of the cervical spinal cord. J Bone Joint Surg. 1974;56-A(5):951–9.Google Scholar
  23. 23.
    Hentz VR, Brown M, Keoshian LA. Upper limb reconstruction in quadriplegia: functional assessment and proposed treatment modifications. J Hand Surg. 1983;8(2):119–31.Google Scholar
  24. 24.
    Edgerton VR, Roy RR. Robotic training and spinal cord plasticity. Brain Res Bull. 2009;78:4–12.PubMedCrossRefGoogle Scholar
  25. 25.
    Girgis J, Merrett D, Kirkland S, Metz GA, Verge V, Fouad K. Reaching training in rats with spinal cord injury promotes plasticity and task specific recovery. Brain. 2007;130:2993–3003.PubMedCrossRefGoogle Scholar
  26. 26.
    Lo AC, Guarino PD, Richards LG, et al. Robot-assisted therapy for long-term upper-limb impairment after stroke. N Engl J Med. 2010;362:1772–83.PubMedCrossRefGoogle Scholar
  27. 27.
    Staubli P, Nef T, Klamroth-Marganska V, Riener R. Effects of intensive arm training with the rehabilitation robot ARMin II in chronic stroke patients: four single-cases. J Neuroeng Rehabil. 2009;6(46):1–10.Google Scholar
  28. 28.
    Colombo R, Pisano F, Micera S, et al. Assessing mechanisms of recovery during robot-aided neurorehabilitation of the upper limb. Neurorehabil Neural Repair. 2008;22:50–63.PubMedGoogle Scholar
  29. 29.
    Housman SJ, Scott KM, Reinkensmeyer DJ. A randomized controlled trial of gravity-supported, computer-enhanced arm exercise for individuals with severe hemiparesis. Neurorehabil Neural Repair. 2009;23(5):505–14.PubMedCrossRefGoogle Scholar
  30. 30.
    GRASSP Version 1.0 [user’s guide]. Toronto: Axal Inc; 2008.Google Scholar
  31. 31.
    Kalsi-Ryan S, Curt A, Fehlings MG, Verrier MC. Assessment of the hand in tetraplegia using the graded redefined assessment of strength, sensibility and prehension (GRASSP): impairment versus function. Top Spinal Cord Inj Rehabil. 2009;14(4):34–46.CrossRefGoogle Scholar
  32. 32.
    Post MW, Van Lieshout G, Seelen HA, Snoek GJ, Ijzerman MJ, Pons C. Measurement properties of the short version of the Van Lieshout test for arm/hand function of persons with tetraplegia after spinal cord injury. Spinal Cord. 2006;44:763–71.PubMedCrossRefGoogle Scholar
  33. 33.
    Fattal C. Motor capacities of upper limbs in tetraplegics: a new scale for the assessment of the results of functional surgery on upper limbs. Spinal Cord. 2004;42:80–90.PubMedCrossRefGoogle Scholar
  34. 34.
    Land NE, Odding E, Duivenvoorden HJ, Bergen MP, Stam HJ. Tetraplegia hand activity questionnaire (THAQ): the development, assessment of arm/hand function-related activities in tetraplegic patients with a spinal cord injury. Spinal Cord. 2004;42:294–301.PubMedCrossRefGoogle Scholar
  35. 35.
    Rogers JC, Figone JJ. Traumatic quadriplegia: follow-up study of self-care skills. Arch Phys Med Rehabil. 1980;61:316–21.PubMedGoogle Scholar
  36. 36.
    Law M, Baptiste S, McColl M, Opzoomer A, Polatajko H, Pollock N. The Canadian Occupational Performance Measure: an outcome measure for occupational therapy. Can J Occup Ther. 1990;57(2):82–7.PubMedGoogle Scholar
  37. 37.
    Kalsi-Ryan S, Beaton D, Curt A, Duff S, Popovic MR, Rudhe C, Fehlings MG, Verrier MC. J Neurotrauma. 2011 Aug 12. [Epub ahead of print]Google Scholar
  38. 38.
    Thorsen R, Ferrarin M, Spadone R, Figo C. Functional control of the hand in tetraplegics based on residual synergistic EMG activity. Artif Organs. 1999;23(5):470–3.PubMedCrossRefGoogle Scholar
  39. 39.
    Marino RJ, Shea JA, Stineman MG. The capabilities of upper extremity instrument: reliability and validity of a measure of functional limitation in tetraplegia. Arch Phys Med Rehabil. 1998;79(December):1512–71.PubMedCrossRefGoogle Scholar
  40. 40.
    Sollerman C, Ejeskär A. Sollerman hand function test: a standardized method and its use in tetraplegic patients. Scand J Plast Reconstr Surg Hand Surg. 1995;29:167–76.PubMedCrossRefGoogle Scholar
  41. 41.
    Stroh KS, Van Doren CL, Thrope GB, Keith MW, Peckham PH. Development of a quantitative hand grasp and release test for patients with tetraplegia using a hand neuroprosthesis. J Hand Surg. 1994;19-A(2):209–18.Google Scholar
  42. 42.
    Mulcahey MJ, Smith BT, Betz RR. Psychometric rigor of the Grasp and Release test for measuring functional limitation of persons with tetraplegia: a preliminary analysis. J Spinal Cord Med. 2004;27(1):41–6.PubMedGoogle Scholar
  43. 43.
    Vanden BA, Van Laere M, Hellings S, Vercauteren M. Reconstruction of the upper extremity in tetraplegia: functional assessment, surgical procedures and rehabilitation. Paraplegia. 1991;29:103–12.CrossRefGoogle Scholar
  44. 44.
    Wolf SL, Lecraw DE, Barton LA, Jann BB. Forced use of hemiplegic upper extremities to reverse the effect of learned nonuse among chronic stroke and head-injured patients. Exp Neurol. 1989;104:125–32.PubMedCrossRefGoogle Scholar
  45. 45.
    Wolf SL, Catlin PA, Ellis M, Archer LA, Morgan B, Piacentino A. Assessing Wolf motor function test as outcome measure for research in patients after stroke. Stroke. 2001;32:1635–9.PubMedCrossRefGoogle Scholar
  46. 46.
    Gowland C, Stratford P, Ward M, et al. Measuring physical impairment and disability with the Chedoke-McMaster stroke assessment. Stroke. 1993;24:58–63.PubMedCrossRefGoogle Scholar
  47. 47.
    Gowland CA. Staging motor impairment after stroke. Stroke. 1990;21 Suppl 9:II19–21.PubMedGoogle Scholar
  48. 48.
    Lyle RC. A performance test for assessment of upper limb function in physical rehabilitation treatment and research. Int J Rehabil Res. 1981;4(4):483–92.PubMedCrossRefGoogle Scholar
  49. 49.
    Fugl-Meyer AR, Jääskö L, Leyman I, Olsson S, Steglind S. The post-stroke hemiplegic patient. A method for evaluation of physical performance. Scand J Rehabil Med. 1975;7:13–31.PubMedGoogle Scholar
  50. 50.
    Sanford J, Moreland J, Swanson LR, Stratford PW, Gowland C. Reliability of the Fugl-Meyer assessment for testing motor performance in patients following stroke. Phys Ther. 1993;73:447–54.PubMedGoogle Scholar
  51. 51.
    Duncan PW, Propst M, Nelson SG. Reliability of the Fugl-Meyer assessment of sensorimotor recovery following cerebrovascular accident. Phys Ther. 1983;63:1606–9.PubMedGoogle Scholar
  52. 52.
    Berglund K, Fugl-Meyer AR. Upper extremity function in hemiplegia. A cross-validation study of two assessment methods. Scand J Rehabil Med. 1986;18:155–7.PubMedGoogle Scholar
  53. 53.
    Hudak PL, Amadio PC, Bombardier C, UECG. Development of an upper extremity outcome measure: the DASH (Disabilities of the Arm, Shoulder, and Hand). Am J Ind Med. 1996;29:602–8.PubMedCrossRefGoogle Scholar
  54. 54.
    Jester A, Harth A, Germann G. “Disability of arm, shoulder and hand”-Fragebogen. Trauma Berufskrankh. 2008;10 Suppl 3:381–3.CrossRefGoogle Scholar
  55. 55.
    Cup EH, Scholte op Reimer WJ, Thijssen MC, van Kuyk-Minis MA. Reliability and validity of the Canadian Occupational Performance Measure in stroke patients. Clin Rehabil. 2003;17:402–9.PubMedCrossRefGoogle Scholar
  56. 56.
    Jebsen RH, Taylor N, Trieschmann RB, Trotter MJ, Howard LA. An objective and standardized test of hand function. Arch Phys Med Rehabil. 1969;50:311–9.PubMedGoogle Scholar
  57. 57.
    Davis Sears E, Taylor N, Chung KC. Validity and responsiveness of the Jebsen-Taylor hand function test. J Hand Surg. 1969;35-A:30–7.Google Scholar
  58. 58.
    Fleishman EA. The structure and measurements of physical fitness. Englewood Cliffs: Prentice-Hall, Inc.; 1964. p. 23–4.Google Scholar
  59. 59.
    Gloss DS, Wardle MG. Use of the Minnesota rate of manipulation test for disability evaluation. Percept Mot Skills. 1982;55:527–32.PubMedCrossRefGoogle Scholar
  60. 60.
    Holser P, Fuchs E. Box and Block test. In: Occupational therapists manual for basic skills assessment: primary prevocational evaluation. Pasadena: Fair Oaks Printing Company; 1960. p. 29–31.Google Scholar
  61. 61.
    Desrosiers J, Bravo G, Hébert R, Dutil E, Mercier L. Validation of the Box and Block test as a measure of dexterity of elderly people: reliability, validity, and norms studies. Arch Phys Med Rehabil. 1994;75:751–5.PubMedGoogle Scholar
  62. 62.
    Mathiowetz V, Volland G, Kashman N, Weber K. Adult norms for the Box and Block test of manual dexterity. Am J Occup Ther. 1985;39(1):386–91.PubMedCrossRefGoogle Scholar
  63. 63.
    van de Ven-Stevens LA, Munneke M, Terwee CB, Spauwen PH, van der Linde H. Clinimetric properties of instruments to assess activities in patients with hand injury: a systematic review of the literature. Arch Phys Med Rehabil. 2009;90:151–69.PubMedCrossRefGoogle Scholar
  64. 64.
    Rousson V, Gasser T, Seifert B. Assessing intrarater, interrater and test-retest reliability of continuous measurements. Stat Med. 2002;21:3431–46.PubMedCrossRefGoogle Scholar
  65. 65.
    MacKenzie CL, Iberall T. The grasping hand. In: Advances in psychology. Amsterdam: North-Holland; 1994. p. 370.Google Scholar
  66. 66.
    Iberall T. Human prehension and dexterous robot hands. Int J Robot Res. 1997;16(3):285–99.CrossRefGoogle Scholar
  67. 67.
    Schlesinger G. Der mechanische Aufbau der kunstlichen Glieder. In: Ersatzglieder und Arbeitshilfen. Berlin: Springer; 1919.Google Scholar
  68. 68.
    Light CM, Chappell PH, Kyberd PJ. Establishing a standardized clinical assessment tool of pathologic and prosthetic hand function: normative data, reliability, and validity. Arch Phys Med Rehabil. 2002;83:776–83.PubMedCrossRefGoogle Scholar
  69. 69.
    Napier JR. The prehensile movements of the human hand. J Bone Joint Surg. 1956;38-B(4):902–13.Google Scholar
  70. 70.
    Cutkosky MR. On grasp choice, grasp models, and the design of hands for manufacturing tasks. IEEE Trans Robot Aut. 1989;5(3):269–79.CrossRefGoogle Scholar
  71. 71.
    Kvien TK, Heiberg T, Hagen KB. Minimal clinically important improvement/difference (MCII/MCID) and patient acceptable symptom state (PASS): what do these concepts mean? Ann Rheum Dis. 2007;66(Suppl III):iii40–1.PubMedCrossRefGoogle Scholar
  72. 72.
    Perng JK, Fisher B, Hollar S, Pister KS. Accelerating sensing glove. In: Proceedings of the IEEE Wear Comp International Symposium. San Francisco; 1999. p. 178–80.Google Scholar
  73. 73.
    Ansuini C, Santello M, Tubaldi F, Massaccesi S, Castiello U. Control of hand shaping in response to object shape perturbation. Exp Brain Res. 2007;180:85–96.PubMedCrossRefGoogle Scholar
  74. 74.
    Simone LK, Sundarrajan N, Elovic EP, et al. Measuring finger flexion and activity trends over a 25 hour period using a low-cost wireless device. In: Proceedings of the IEEE EMBS International Conference, New York; 2006. p. 6281–4.Google Scholar
  75. 75.
    Vanello N, Hartwig V, Tesconi M, et al. Sensing glove for brain studies: design and assessment of its compatibility for fMRI with a robust test. IEEE/ASME Trans Mechatron. 2008;13(3):345–54.CrossRefGoogle Scholar
  76. 76.
    Dipietro L, Sabatini AM, Dario P. A survey of glove-based systems and their applications. IEEE Trans Syst Man Cyber. 2008;38(4):461–82.CrossRefGoogle Scholar

Copyright information

© Springer-Verlag London Limited 2012

Authors and Affiliations

  1. 1.Spinal Cord Injury CenterUniversity of Zurich, Balgrist University HospitalZurichSwitzerland

Personalised recommendations