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Objectives: Degenerative cervical myelopathy (DCM) involves spinal cord compression, which causes neurological decline. Neurological impairment in DCM is variable and can involve complex upper limb dysfunction including loss of manual dexterity, hyper-reflexia, focal weakness, and sensory impairment. DCM can cause progressive loss of manual dexterity, reduced upper limb (UL) function and disability. The purpose of this study was to define relationships between impairment and disability of the UL and determine the impact of duration of symptoms on disease severity., Design: An observational cross-sectional study quantifying disease severity, UL impairment and disability at time of diagnosis was conducted. A second observational longitudinal cohort was studied at the time of diagnosis and 1 year later., Setting: Toronto Western Hospital, Spine Program., Subjects: The cross sectional study included 140 study subjects diagnosed with mild, moderate or severe DCM. For the longitudinal study, 61 study subjects with mild DCM were enrolled and split into two groups, one group with less than 12 months of symptom duration and more than 12 months., Main Measures: Modified Japanese Orthopaedic Assessment (mJOA); Graded Redefined Assessment of Sensation, Strength and Prehension (GRASSP); Quick Disability of the Arm, Shoulder and Hand (QuickDASH)., Results: Pearson correlation coefficients between GRASSP and QuickDASH revealed significant relationships between strength, sensation and dexterity for all patients to varying degrees. The covariate (mJOA) was significantly related to QuickDASH, indicating duration of symptoms has an important effect on UL disability in the mild severity group., Conclusions: Strength, sensation and dexterity play a defining role in disability of the UL across all severities of DCM and are discriminant measures. Duration of symptoms has a significant impact on self-perceived disability, where a longer duration in mild patients results in diminished disability, suggesting adaptation. Duration of symptoms is an important factor to consider in the treatment plan for patients with mild disease., Competing Interests: I have read the journal's policy and the authors of this manuscript have the following competing interests: Sukhvinder Kalsi-Ryan is the CEO of Neural Outcomes Consulting Inc., the company that manufactures the GRASSP. Sukhvinder Kalsi-Ryan and Michael G. Fehlings are members of the GRASSP development team, which receives licensing royalties for the GRASSP. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

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., (© The Author(s) 2015.)

Background: Upper limb function plays a significant role in enhancing independence for individuals with tetraplegia. However, there is limited knowledge about the specific input of sensorimotor deficits on upper limb function. Thus the theoretical framework designed to develop the Graded Redefined Assessment of Strength Sensibility and Prehension (GRASSP) was used as a hypothetical model to analyze the impact of impairment on function., Objective: To define the association of impairment (sensation, strength, and prehension measured by the GRASSP) to upper limb function as defined by functional measures (Capabilities of Upper Extremity Questionnaire, Spinal Cord Independence Measure)., Methods: A hypothetical model representing relationships by applying structural equation modeling was used to estimate the effect of the impairment domains in GRASSP on upper limb function. Data collected on 72 chronic individuals with tetraplegia was used to test the hypothetical model., Results: Structural equation modeling confirmed strong associations between sensation, strength, and prehension with upper limb function, and determined 72% of the variance in "sensorimotor upper limb function" was explained by the model. Statistics of fit showed the data did fit the hypothesized model. Sensation and strength influence upper limb function directly and indirectly with prehension as the mediator., Conclusions: The GRASSP is a sensitive diagnostic tool in distinguishing the relative contribution of strength, sensation and prehension to function. Thus, the impact of interventions on specific domains of impairment and related contribution on clinical recovery of the upper limb can be detailed to optimize rehabilitation programs.

With the advent of new interventions targeted at both acute and chronic spinal cord injury (SCI), it is critical that techniques and protocols are developed that reliably evaluate changes in upper limb impairment/function. The Graded Redefined Assessment of Strength Sensibility and Prehension (GRASSP) protocol, which includes five subtests, is a quantitative clinical upper limb impairment measure designed for use in acute and chronic cervical SCI. The objectives of this study were to: (1) establish the inter-rater and test-retest reliability, and (2) establish the construct and concurrent validity with the International Standards of Neurological Classification of Spinal Cord Injury (ISNCSCI), Spinal Cord Independence Measure II (SCIM), and the Capabilities of Upper Extremity Questionnaire (CUE). The study protocol included repeated administration of the GRASSP to a cross-section of individuals with tetraplegia who were neurologically stable (n=72). ISNCSCI, CUE, and SCIM assessments were also administered. Two assessors examined the individuals over a 7-day period. Reliability was tested with intra-class correlation coefficients; construct validity was established with agreement/discordance analysis between the GRASSP and ISNCSCI sensory and motor items; and concurrent validity was tested with Spearman correlation coefficients. Inter-rater and test-retest reliability for all subtests within the GRASSP were above the hypothesized value of 0.80 (0.84-0.96 and 0.86-0.98, respectively). The GRASSP is about 50% more sensitive (construct validity) than the ISNCSCI when defining sensory and motor integrity of the upper limb; the subtests showed concurrence with the SCIM, SCIM self-care subscale, and CUE. The strongest concurrence to impairment was with self-perception of function (CUE) (0.57-0.83, p<0.0001). The GRASSP was found to demonstrate reliability, construct validity, and concurrent validity for use as a standardized upper limb impairment measure for individuals with tetraplegia.

Purpose: Because upper-limb function represents overall function for individuals with tetraplegia, the restoration of upper-extremity function is exceedingly important for this population. The purpose of this review was to identify interventions that optimize upper-limb function after tetraplegia based on best available evidence., Methods: A search of MEDLINE, AMED, and PubMed with the search terms "hand function AND tetraplegia" and "upper limb function AND tetraplegia" found 384 articles. After elimination of duplicates and review of titles and abstracts, 43 studies were found to be applicable. Study quality of all applicable studies was assessed with a modified version of the Scottish Intercollegiate Guidelines Network for Cohort Studies methodology., Results: The applicable studies were organized into three categories: conventional therapies (CT), electrical stimulation therapies (ES), and surgical interventions (SI). The proportion of papers in each category that presented with sufficient methodological quality to contribute to best evidence was as follows: CT: 0/2; ES: 10/21; SI: 6/20., Conclusions: ES therapies are beneficial as assistive technologies and as therapeutic intervention in the subacute phase of recovery. SIs are suitable for individuals who meet very specific criteria for tendon-transfer surgery. Further clinical trials are warranted for ES and SI therapies to substantiate prescription of therapeutics.

BackgroundDegenerative cervical myelopathy (DCM) involves spinal cord compression, which causes neurological decline. Neurological impairment in DCM is variable and can involve complex upper limb dysfunction including loss of manual dexterity, hyperreflexia, focal weakness, and sensory impairment. The modified Japanese Orthopaedic Association (mJOA) score relies on the patients' subjective perceptions, whereas existing objective measures such as strength and sensory testing do not capture subtle changes in dexterity and function.Objective1) To characterize arm and hand function in DCM; and 2) To develop and validate Graded Redefined Assessment of Strength, Sensibility, and Prehension Version-Myelopathy (GRASSP-M), a clinical assessment that quantifies upper limb impairment.MethodsA total of 148 DCM patients (categorized into mild, moderate, and severe based on mJOA grade) and 21 healthy subjects were enrolled. A complete neurological exam, the mJOA, the QuickDASH, grip dynamometry, and the GRASSP-M were administered.ResultsStrength, sensation, and manual dexterity significantly declined with increasing DCM severity (P ≤ .05). Impairment in hand dexterity showed better discrimination between mild, moderate, and severe DCM categories than strength or sensation. The GRASSP-M was found to be both a reliable (intraclass correlation coefficient >0.75 for intra- and inter-rater reliability) and valid (with both concurrent and construct validity) tool.ConclusionThese results demonstrate that patients' subjective reporting of functional status, especially in the mild DCM category, may underrepresent the extent of functional impairment. The GRASSP-M is an objective tool designed to characterize patients' functional impairment related to the upper limb, which proves useful to diagnose and quantify mild dysfunction, monitor patients for deterioration, and help determine when patients should be treated surgically.