1 1 2 3 4 5 6 7 8

The Tetraplegia Hand Measure (THM)

A New Measurement Approach of the Hand for Individuals with Cervical Spinal Cord Injury (SCI): The Tetraplegia Hand Measure (THM) Sukhvinder Kalsi-Ryan, MSc, BSc. PT.1,3,6 Dorcas Beaton, PhD, MSc, BSc.OT.2,3,7,8 Michael G. Fehlings, PhD, MD.5,6 David Mikulis, MD.4,6 Molly C.Verrier, MHSc., Dip POT.1,3,8

9 1Dept. of Physical Therapy, 2Dept. of Occupational Therapy, 3Graduate Dept. of Rehabilitation 10 11 12 13 14 15 16 17 18 19 20 21 22 Science, 4Dept. of Medical Imaging, 5Dept. of Surgery, Faculty of Medicine, University of Toronto, 6Spinal Program, Krembil Neuroscience Centre, University Health Network, 7St. Michaels Hospital, 8Toronto Rehabilitation Institute, 9Institute of Work and Health. Running Title: The Tetraplegia Hand Measure (THM) Sukhvinder Kalsi-Ryan Graduate Department of Rehabilitation Science, University of Toronto Rehabilitation Sciences Building 500 University Ave. 10th Floor Toronto, ON, M5T 1W5 P: 416-946-8546 F: 416-946-8561 Email: sukhvinder.kalsi-ryan@uhn.on.ca

23Key Words: tetraplegia, measurement, hand function, sensory motor impairment, assessment 24 25This work was supported by the Toronto Rehabilitation Institute Student Scholarship Fund and 26The Ontario Neurotrauma Foundation.

1 1Mini Abstract 2 3

The Tetraplegia Hand Measure (THM)

A New Measurement Approach of the Hand for Individuals with Cervical Spinal Cord Injury (SCI): The Tetraplegia Hand Measure (THM)

4A multiple domain approach for measurement of hand function for individuals with tetraplegia 5(CO-T1) was developed. The THM was subjected to clinical utility and feasibility testing in a 6cross sectional sample of 30 subjects. The THM was found to have clinical utility, feasibility, 7and sensitivity in the full range of individuals with tetraplegia. The THM provided a detailed 8profile of integrated sensorimotor hand function with potential for longitudinal applications. 9Key Points: 10 11 12 13 14 15 16 17 18 19 20 21 22 23 The Tetraplegia Hand Measure (THM) was developed based on a theoretical framework and a sensorimotor hand function construct specific to the cervical SCI population. The THM is a battery which consists of five tests which have clinical utility and are feasible to use with the tetraplegic population. The THM defines hand impairment in relationship to dermatomes and myotomes and has greater sensitivity than the ASIA impairment scale.

1 1 2

The Tetraplegia Hand Measure (THM) A New Measurement Approach of the Hand for Individuals with Cervical Spinal Cord Injury (SCI): The Tetraplegia Hand Measure (THM)

3Study Design. A sensorimotor hand function construct was used to develop the THM. Existing 4measures: Semmes Weinstein Monofilaments (SWM), Vibration Sense-256 cps (VIB), Static 5Two Point Discrimination (S2PD), Dynamometry (DYN), Manual Muscle Testing (MMT), and 6the Modified Sollerman Hand Function Test (MSHFT) were aggregated to measure hand 7impairment. The THM was tested on a sample (n=30, 13 complete and 17 incomplete) to 8determine the clinical utility, feasibility, and compare the results with the American Spinal Injury 9Associations International Standards of Neurological Classification of Spinal Cord Injury 10(ASIA). 11Objective. The aim of this study was to develop a multi-domain approach for the measurement 12of hand function for individuals with tetraplegia (CO to T1) which would provide a detailed 13profile of integrated sensorimotor hand function at a time point and longitudinally. 14Summary of Background Data. Hand function is of critical importance to independence and 15quality of life for individuals with tetraplegia. Measurement strategies sensitive to subtle but 16important change in hand function for tetraplegia are not yet well developed. An approach of 17measurement that is sensitive and responsive, and that can be used to assess the extensive 18variability of sensory and motor changes post injury is required. 19Results. The THM was deemed feasible and clinically useful with minor modifications which 20entailed the refinement of the sensory test locations and elimination of dynamometry. The THM 21determined differences within individuals and between groups (C5 to T1), that were otherwise 22defined by the ASIA impairment scale as the same.

The Tetraplegia Hand Measure (THM)

1Conclusions. The THM is a sensitive multi-domain approach for measurement of hand function 2and has utility to evaluate the varying presentations, after cervical spinal cord injury. 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23

1 1Introduction

The Tetraplegia Hand Measure (THM)

2The state of residual upper extremity function is a critical determinant of independence for 3individuals with tetraplegia. Indeed a recent survey found that fifty percent of tetraplegics rated 4the potential to regain arm and hand function as most important to enhancing their quality of life 5(1). Furthermore, the impaired upper limb function in tetraplegics is reflected in lifetime care costs 6of approximately 1 million dollars. The high cost is partly related to the additional burden of care 7provision(2). As a result of the emphasis placed on upper extremity function by the population and 8society, and the increasing potential for recovery secondary to the increased proportion of 9individuals with incomplete SCI (3), intense interest has been generated in the development of 10new therapies for improving or preserving hand function. Therapeutic interventions such as: 11Functional Electrical Stimulation (FES) (4), neuroprosthetics (5-8), and reconstructive surgery by 12way of tendon transfer (9-12) are examples of interventional methods currently being developed to 13partially restore hand function. Moreover, neuroprotective and neuroregenerative strategies 14currently being tested may have the potential to significantly impact hand function. However, 15measurement approaches to determine the efficacy are lagging. Some of the new methods of 16treatment are useful for individuals with minimal (weak passive tenodesis) or no existing hand 17function and often enhance tenodesis and lateral key pinch grasps (force generation and 18endurance), enabling individuals to enhance their ability to perform specific activities of daily 19living. Existing assessment approaches usually measure one very specific function such as grasp 20force, magnitude and duration (13, 14). However, force values for grasp do not reflect subtle 21neurological changes that may give an individual the ability to perform a more optimal 22movement pattern. Measuring hand function post injury is complex, and dependent on multiple 23factors such as the interplay between the sensory and motor aspects of movement.

The Tetraplegia Hand Measure (THM)

1The American Spinal Injury Associations International Standards of Neurological Classification 2of Spinal Cord Injury (ASIA) 15 is the current gold standard to assess recovery after SCI, but is 3a relatively insensitive measure of hand function. Thus, there is a critical need for an outcome 4measure that is sensitive and responsive to change and which can be used to assess the extensive 5variability of sensory and motor changes post injury for both tracking the natural history of 6recovery and, the response of individuals receiving treatment. Sollerman and Ejeskar did attempt 7to measure hand function in the tetraplegic population. The attempt had limited success as the 8Sollerman Hand Function Test (SHFT) was designed with a construct for normal hand function. 9Small modifications to the SHFT would have made the measure more specific to the SCI 10population. Therefore, the purpose of the study was to develop a new measurement approach that 11would provide a detailed profile of integrated sensorimotor hand function for individuals with 12complete and incomplete tetraplegia (CO-T1). 13Materials and Methods 14Outcome Measure Development. Most of the measures or tests used to date with the SCI 15population have been developed for and validated on other populations such as the Functional 16Independence Measure (FIM) 16, grip and pinch dynamometry 17, and the Sollerman Hand 17Function Test 18. These tests were based on constructs specific to the population for which the 18measures were developed. A theoretical framework was developed for the THM which 19represented three components that contribute to normal and abnormal hand function. Functional 20Capacity, Neurophysiological Mechanisms, and Pathology are important for Sensorimotor Hand 21Function (Figure 1). It was assumed that the capacity of the hand to function is reliant on 22postural control and supporting motions of the arm. Therefore, the functional substrates, 23neurophysiological mechanisms, and pathology were considered in the development of the

The Tetraplegia Hand Measure (THM)

1measure, however, not entirely accommodated for in the structure of the measure. The THM was 2designed to be specific to the hand by integrating the four domains of the construct of 3Sensorimotor Hand Function (SMHF): Primary Sensation, Integrated Sensation, Primary Motor, 4and Integrated Motor Function. To accomplish a goal oriented task, one must have the ability to 5perceive (primary sensation), distinguish input (integrated sensation), use this information to 6generate a force (primary motor) and then grade and sequence a coordinated force(s) (integrated 7motor function) to produce a fluent movement, such as a grasp. 8A multi-domain construct can elucidate the impairing domain (sensory and/or motor or both), 9otherwise known as the source of the functional deficit(s), and determine how these domains 10relate to overall function. Identifying the source of the functional impairment is important to 11develop targeted therapeutic interventions. Therefore, the THM was designed a) to measure 12natural recovery b) and to assess the efficacy of therapeutic interventions. 13Six tests were selected based on three criteria: measurement accuracy of the parameter of the 14domains, reliability greater than 0.80, and availability of well established literature and 15normative data Table 1. The SHFT was modified to be more specific to the tetraplegic 16population and renamed the Modified Sollerman Hand Function Test (MSHFT). The new 17measurement approach consisted of a battery of six tests called the Tetraplegia Hand Measure 18(THM) reflecting the four domains of SMHF. The measure was designed to capture all 19components and possibilities of grasp function. 20Recruitment. The research assistant and/or the treating physical therapists/occupational 21therapists identified potential participants from the inpatient and outpatient Spinal Cord Injury 22Rehabilitation Programs at the Toronto Rehabilitation Institute (Lyndhurst Site) and the Spinal 23Program, Krembil Neuroscience Centre at the Toronto Western Hospital. A flyer was also posted

The Tetraplegia Hand Measure (THM)

1so that interested individuals could volunteer for the study. Once identified, potential subjects 2were screened, asked to participate, informed about the study, and asked to provide consent by 3the research assistant. 4Procedure. Ethical approval for this study was granted by the University of Toronto, Toronto 5Rehabilitation Institute, and University Health Network Research Ethics Boards. Individuals 6were included if they were tetraplegic (injury CO to TI/level of lesion, C4 to T1 as classified by 7the ASIA), ASIA classification A, B, C, or D, 18 to 90 years of age, medically stable, and able to 8give informed consent. Individuals were excluded if they had a moderate to severe brain injury 9or any other condition other than SCI affecting upper limb sensorimotor function. Subject charts 10were reviewed to gather demographics of age, gender, injury date, and dominance. An ASIA 11assessment was performed on each subject. The THM was administered on each subject, in a 12quiet and well lit room. 13Data Analysis. All data were analyzed using SPSS. The analysis strategies were directed to three 14objectives: 15 16 17 18 1. To determine whether all six tests of the THM were able to represent the whole (CO T1) cervical SCI population (possess clinical utility). 2. To determine if the THM classifies hand function in individuals with tetraplegia. 3. To determine if the domains are inter-related and reflected the construct of SMHF.

19To determine if the six tests represented the whole cervical SCI population, frequency 20distributions of ASIA sensory and motor scores and THM data were reviewed for similarities. 21Sensitivity of the THM was tested by comparing data from the left and right sides using Pearson 22and Spearman Correlation coefficients to determine within individual differences. A method for 23reporting sensation and motor ability by hand specific dermatomes and myotomes was

The Tetraplegia Hand Measure (THM)

1developed. Findings for both the sensory tests and MMT were reported as dermatome (C6, C7, 2C8) and myotome (C6, C7, C8, T1) levels. To analyze the quantitative sensory data, a method of 3coding and mapping was derived to establish a level of sensation for each modality the sensation 4was reported as a dermatome distribution for each modality separately. Figure 2 illustrates the 5diagram used for mapping the response levels for all three tests. Response levels for SWM, 6S2PD and VIB were collapsed as per Table 3, and then all test locations for each sensory test 7were mapped. Points representing normal, impaired, and absent sensation were counted and 8summed, a dermatome for each test was determined based on the normal responses. The THM 9findings were then compared to ASIA sensory levels to determine sensitivity of the THM. The 10results of the MMT were presented as myotomes
(23)

. A grade 3 in 50% of the muscles

11innervated by a particular motor level was assigned to the corresponding myotome. A grade 2 or 123 in less than 50% of the muscles of a motor level assigned a + sign to the above myotome. This 13method of summarizing data for muscle strength is useful for clinicians and researchers looking 14for detail regarding the motor ability of the hand which is lacking in the ASIA. The ASIA motor 15level of C7 defines an individual with elbow extension of grade 3 or more. However, this is not 16enough information to elaborate whether the individual has any metacarpal phalangeal extension, 17which is meaningful to those treating or studying the hand. The THM motor levels represented 18the subjects differently the findings were then compared to ASIA motor levels. Finally a 19descriptive comparison between the sensory and motor domains and the integrated motor domain 20of the THM was conducted to establish the importance of a sensitive multi domain measure. 21ASIA motor upper extremity subscores, were used for all analysis as they were considered to be 22more specific than the ASIA total motor scores22. 23Results

The Tetraplegia Hand Measure (THM)

1Five of the six tests in the THM were deemed to have clinical utility for the cervical SCI 2population. Clinical utility was demonstrated by the ability of SWM, VIB, S2PD, MMT and the 3MSHFT to assess the whole range of the sample and classify the sample according to 4dermatomes and myotomes. Dynamometry was deemed not clinically useful or feasible to 5remain in the THM, as it was only successfully tested with 7/30 individuals. 6The THM demonstrated greater sensitivity than the ASIA sensory and motor scores with respect 7to defining differences between the left and right sides. The differences in left and right sides 8could be detected even when ASIA testing did not demonstrate asymmetry. Table 2 presents the 9number of significant (moderate correlation (0.400 < r < 0.799 with a p<0.05) and high 10correlation (r > 0.800 with a p<0.05)) relationships between left and right sides for each item in 11each test. The three sensory tests and the MSHFT displayed more asymmetry than the other tests 12within the THM. When the known asymmetric individuals (according to ASIA sensory and 13motor) were removed from the sample separately, SWM and MSHFT scores continued to 14demonstrate asymmetry between sides. With the asymmetrical individuals removed, the number 15of significant relationships between sides was still low (particularly the sensory modalities) 16indicating less similarity than expected between left and right sides. Therefore, the results of the 17tests within the THM define an individuals sensory and motor impairments with greater 18sensitivity than the ASIA sensory and motor scores. 19Sensory mapping was analyzed by grouping the sample according to ASIA sensory levels, right 20and left, and incomplete and complete. Hands were represented individually, separated into 21ASIA sensory level (ie. C5, C6, C7, C8), and by completeness (ie. creating two C5 groups one 22complete and one incomplete).

10

The Tetraplegia Hand Measure (THM)

1The method of sensory quantification rendered a dermatome for each sensory modality for every 2individual. Table 4 presents the findings which show differences between individuals in the same 3ASIA level. Individuals also presented with different impairment levels for the different sensory 4modalities. Table 4 also summarizes the THM myotomes and compares them to the ASIA motor 5levels and demonstrates increased sensitivity of the motor assessment. Again the findings show 6differences between individuals in the same levels as defined by ASIA. Individuals with 7incomplete injuries show a greater variation than complete individuals with respect to sensory 8and motor differences. Table 5 presents the ASIA levels, THM dermatomes/myotomes and the 9MSHFT scores for all 30 subjects. Subjects were placed in order of MSHFT scores. Table 5 is an 10example of how THM results define the individual with a sensory, motor and functional 11component - multi-domain method. For example subject one in Table 5 presents with a THM 12sensory level of C5, a THM motor level of C6+, and a functional score (MSHFT) of 20/45. 13These three scores define the individuals impairment and functional level specific to the hand. 14Individuals with similar THM motor levels would be expected to present with the same MSHFT 15scores. However, subject 14 and 30 have varying dermatomes which is the source of the 16functional impairment for subject 14. Subject 21 and 22 have very similar MSHFT (difference of 17one point) scores however, differ from one another with respect to the THM motor level. The 18functional tasks do not differentiate these two individuals, however, the individual domains do. It 19would be assumed that a poor score on the functional tasks would be significantly affected by the 20motor ability and to a lesser degree by the sensation. However, subject 14 has the best possible 21motor ability and a very poor score on the MSHFT (should be 40 or greater). When comparing 22the individual domains, there is evidence poor sensation limits the ability to function. The THM

11

The Tetraplegia Hand Measure (THM)

1renders a different set of data than the ASIA for individuals with tetraplegia, demonstrates 2sensitivity, and delineates the source of the functional impairment, as can be seen in Table 5. 3Discussion 4Alternative approaches used to measure hand function in SCI are limited, as they are designed to 5measure capacity or overall function, where the changes in function can not be directly related to 6neurological change. Therefore, the construct with multiple domains designed for the THM was 7useful in developing a measure that captured impairments and deficits specific for individuals 8with tetraplegia. As a result the THM has the ability to assess in detail hand function for the 9whole tetraplegic population across the continuum of recovery. A multiple domain construct is 10useful in that it allows for the provision of information for sensation and motor function 11separately as well as combined sensorimotor function. How the individual domains influence 12combined functions is vitally important particularly for the intricacies of hand tasks. Having 13comprehensive information about the components of a hand task, such as a grasp, may help 14determine why some individuals grasp better than others, despite the same SCI impairments and 15classifications (ASIA impairment scale). The ASIA impairment scale is a classification measure 16and was designed to discriminate the whole SCI population. Therefore, the THM is an 17appropriate extension to define the hand in greater detail. 18The THM includes five of the proposed tests, which were feasible to use with the whole 19population. Further development will investigate the replacement of a force measure. The THM 20was found to be a sensitive assessment of sensory, motor and functional impairment and revealed 21differences within individuals and between individuals despite being grouped according to the 22ASIA impairment scale. The advantages of the THM are that it provides specific sensory, motor, 23and hand function impairment information which is not captured in the current ASIA

12

The Tetraplegia Hand Measure (THM)

1classification and impairment scale; providing a detailed sensory, motor, and functional profile 2of individuals with tetraplegia. The THM can determine the status of impairment and function 3cross-sectionally and longitudinally which is important for the study of outcomes with the SCI 4population. 5This new method of quantifying, scoring and reporting sensory and motor data specific to the 6hand will provide the required tool for future study. In addition a more detailed assessment of 7quantifiable sensation will allow researchers to track change over time to detect small 8improvements and can be used in future work to determine to what degree sensation of the hand 9is related to a repertoire of movements and grasp. The impact of small improvements in 10sensation (more than one type) and motor control are still unknown. One of the disadvantages of 11the THM is that it has not yet been tested for reliability, construct validity, and responsiveness. 12In summary the THM is a new measurement strategy, specific to tetraplegic hand function, 13shows sensitivity to small differences in sensation and motor function, and provides a 14methodology for reporting specific to the dermatomes and myotomes of the hand. The THM 15shows promise for use in clinical settings as a discriminative and evaluative measure. As for 16research purposes, further development for reliability, validity, and responsiveness are 17warranted. Our work is now focused on reliability and validity testing prior to applying the 18measure to other populations such as the cervical spondylotic myelopathy group. 19 20 21 22 23 1. Anderson KD. Targeting recovery: priorities of the spinal cord-injured population. J Neurotrauma 2004; 21(10): 1371-83.

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The Tetraplegia Hand Measure (THM) 2. DeVivo MJ. Causes and costs of spinal cord injury in the United States. Spinal Cord 1997; 35(12): 809-13. 3. Sekhon L, Fehlings MG. Epidemiology, Demographics, and Pathophysiology of Acute Spinal Cord Injury. Spine 2001; 26(24S): S2-S12. 4. Mangold S, Keller T, Curt A, et al. Transcutaneous functional electrical stimulation for grasping in subjects with cervical spinal cord injury. Spinal Cord 2005; 43(1): 1-13. 5. Inmann, A, Haugold, M. Implementation of natural sensory feedback in a portable control system for a hand grasp neuroprosthesis. Med Eng Phys 2004; 26(6): 449-58. 6. Muclcahey MJ, Betz RR, Kozin SH, et al. Implantation of the Freehand System during initial rehabilitation using minimally invasive techniques. Spinal Cord 2004; 42(2): 14655. 7. Taylor P, Esnouf J, Hobby J. The functional impact of the Freehand System on tetraplegic hand function. Clinical results. Spinal Cord 2002; 40(11): 560-6. 8. Prochazka A, Gauthier M, Wieler M, et al. The bionic glove: an electrical stimulator garment that provides controlled grasp and hand opening in quadriplegia. Arch Phys Med Rehabil 1997; 78(6): 608-14. 9. Cizmar I, Wendsche P, Brychta P, et al. Reconstruction of functional handgrip in traumatic tetraplegiacase study. Acta Chir Plast 2004; 45(4): 119-23. 10. Rothwell AG, Sinnott K.A, Mohammed KD, et al. Upper limb surgery for tetraplegia: a 10-year re-review of hand function. J Hand Surg 2003; 28(3): 489-97. 11. Meiners T, Abel R, Lindel K, Improvement in activities of daily living following functional hand surgery for treatment of lesions to the cervical spinal cord: self assessment by patients. Spinal Cord 2003; 40(11): 574-80.

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The Tetraplegia Hand Measure (THM) 12. Lo IK, Turner R, Connolly S, et al. The outcome of tendon transfers for C6-spared quadriplegics. J Hand Surg 2003; 23(2): 156-61. 13. Mulcahey M.J, 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 Medicine 2004; 27(1): 41-6. 14. Inmann, A. & Haugold, M. (2001). An instrumented object for evaluation of lateral hand grasp during functional tasks. J Med Eng Technol, 25(5): 207-11. 15. Marino RJ, Barros T, Biering-Sorensen F, et al. International Standards for Neurological Classification of Spinal Cord Injury. Sixth Edition 2004. 16. Keith RA, Granger CV, Hamilton BB, et al. The functional independence measure: a new tool for rehabilitation. Adv Clin Rehabil; 1987; 1, 6-18. 17. Mathiowetz V, Weber K, Volland G, et al. Reliability and validity of girp and pinch strength evaluations. J Hand Surg 1984; 9(2): 69-74. 18. Sollerman, C. & Ejeskar, A. Sollerman hand Function Test: A Standardized Method and its Use in Tetraplegic Patients. Scandinavian Journal of Plastic and Reconstructive Hand Surgery 1995; 29: 167 176. 19. Mackin E, Callahan A, Skiver T, Schneider L, Osterman A. Hunter-Mackin-Callahan Rehabilitation of the Hand and Upper Extremity, Fifth Edition. St. Louis, Missouri: Mosby, 2002. 20. Novak CB, MacKinnon SE, Kelly L. Correlation of Two-Point Discrimination and Hand Function Following Median Nerve Injury. Annals of Plastic Surgery 1993; 31: 495-98. 21. Brandsma JW, Schreuders TA, Birke JA, Piefer A Oostendorp R. J Hand Ther 1995; 8(3): 185-90.

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The Tetraplegia Hand Measure (THM) 22. Marino RJ, Graves DE. Metric Properties of the ASIA Motor score: Subscales improve correlations with functional activites. Arch Phys Med Rehabil 2004; 11: 1804-1810. 23. Moore KL. Clinically Oriented Anatomy 2nd Edition. Baltimore: Williams and Wilkins, 1985: 728-44.

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The Tetraplegia Hand Measure (THM)

1Table 1. Rationale for Selection and Inclusion of Tests in the Tetraplegia Hand Measure CONSTRUCT SENSORIMOTOR HAND FUNCTION Domain Parameter Test Normative Assigned Selected Data Primary Sensation Integrated Sensation Primary Motor Light Touch SWM (19) Yes CRITERIA Reliability Established in Literature for SCI (19) 0.965 No

Cortical Sensation Strength Force

VIB (20) S2PD (20) MMT (21) DYN(17)

Yes

0.982(20) 0.989(20) 0.880(21) 0.9910.999(17) 0.980(18)

No

Yes (wrist) Yes

No

Integrated Motor 2

Grasp Patterns

MSHFT (18)

No

Yes(*)

3SWM Semmes Weinstein Monofilaments 4S2PD Static Two Point Discrimination 5DYN Dynamometry

VIB Vibration Sense MMT Manual Muscle Testing

MSHFT Modified Sollerman Hand Function Test

6* - Sollerman and Ejeskar in 1995 made an attempt at validating the SHFT on the SCI population

17

The Tetraplegia Hand Measure (THM)

1Table 2. Prevalence of Left and Right Symmetry for Sensation/Motor/Integrated Motor Function of Hands Test - Items 2 ASIA Subscores (n = 4) 3SWM Test Locations (n = 414) VIB Test Locations (n = 5) 5S2PD Test Locations (n = 7) Dynamometry Grips (n = 4) MMT Muscles (n = 28) 7MSHFT Tasks (n = 10) 6 8Classification of Spinal Cord Injury 10ASIA Subscores ASIA Total, Asia Motor Total, ASIA UE Motor Score, ASIA Sensory Total 11THM Tetraplegia Hand Measure 12VIB Vibration Sense 13DYN Dynamometry SWM Semmes Weinstein Monofilaments MMT Manual Muscle Testing 3/5 6/7 4/4 28/28 7/10 4/5 7/7 not compared not compared not compared not compared not compared 4/4 28/28 8/10 Number of significant relationships between left and right variables
for whole sample n=30 without Sensory Asymmetric Individuals n=25 without Motor Asymmetric Individuals n=23

ASIA - American Spinal Injury Associations International Standards of Neurological

4/4 4/14

4/4 6/14

4/4 not compared

S2PD Static Two Point Discrimination

MSHFT Modified Sollerman Hand Function Test

18

The Tetraplegia Hand Measure (THM)

1Table 3. Collapsed Response Levels for Sensory Mapping 2 Collapsed Response Level VIB * Normal Normal = 2 Impaired Impaired = 1 No Response Absent = 0 3 5SWM Semmes Weinstein Monofilaments 6S2PD Static Two Point Discrimination

SWM * 0.080 g/F, 0.217 g/F 2.35 g/F, 4.19 g/F, 279.4 g/F No response

S2PD 5 mm, 8 mm 12 mm,15 mm No response

VIB Vibration Sense

7* - Response levels of these two tests were collapsed to agree with VIB response levels 8 9 10 11 12 13

19

The Tetraplegia Hand Measure (THM)

1Table 4: ASIA Sensory and Motor Levels with associated 2SWM, VIB, S2PD and MMT levels for the right side, n=30. ASIA Sensory Level C4 C4 n =1 C5 C6 C7 C8 C5 C4 n =11 C5 C6 C7 C8 C6 C4 n =6 C5 C6 C7 C8 C7 C4 n =5 C5 C6 C7 C8 C8 n =4 C4 T1 n =2 C5 S5 n =3 C6 C7 C8 SWM C I VIB C I S2PD C I 1 1 1 1 4 1 2 1 1 1 1 3 2 1 1 1 2 4 1 1 C5 n =4 2 2 1 C6 n =8 2 1 3 2 1 2 3 C7 n =7 C5 C6 C7 C8 T1 C5 C6 C7 C8 T1 C5 C6 C7 C8 T1 C5 C6 C7 C8 T1 C5 C6 C7 C8 T1 3 1+ ASIA Motor Level MMT C I

1 1 2

2 3

1+ 2+

1 1+ 2 1 1+ 2

1 1 2 1 3 3 2

1 1 1 2 1 1 1 1 2 1 5 1

1 1 1 1 1 4 1

C8 n =0

T1 n =3 L3 n=1 S5 n= 7

1+ 1 8

20

The Tetraplegia Hand Measure (THM)

1I - incomplete subjects, C - complete subjects, SWM Semmes Weinstein 2Monofilaments VIB Vibration Sense S2PD Static Two Point Discrimination

3MMT Manual Muscle Testing

MSHFT Modified Sollerman Hand Function Test

4+ - refer to analysis section where + sign signifies more than reported myotome

21

The Tetraplegia Hand Measure (THM)

1Table 5: ASIA Sensory and Motor Levels, SWM Dermatomes, MMT Myotomes and 2Modified Sollerman Hand Function Test Scores. Class ASIA Sensory ASIA Motor Right ASIA Score S/M 23/10 56/11 106/35 18/9 16/6 16/8 16/11 26/11 16/7 16/9 24/15 18/6 26/7 72/39 16/14 20/14 24/14 20/14 28/21 28/11 64/30 18/9 62/27 25/26 28/43 106/50 17/24 104/50 106/50 24/31 Hand SWM Dermatome Hand MMT Myotome C6+ C6 C7+ C6 C6 C6 C5+ C6 C6 C5+ C5+ C6 C6 T1 C6 C8+ C7 C6 T1 C6+ T1 C6+ T1 T1 C8 T1 T1 T1 T1 T1 MSHFT Score

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 3

C B D A A A C A A A A A B C A B A A A B D B C D C D C D D C

C5 C8 C6 C6 C5 C5 C5 C7 C5 C5 C7 C5 C7 T1 C5 C6 C6 C6 C8 C7 S5 T2 C4 C5 C8 S5 C5 S5 S5 C7

C5 C7 S1 C6 C5 C6 C6 C6 C5 C6 C7 C5 C6 S1 C7 C7 C7 C7 T1 C6 L3 C7 S1 C6 S1 S1 C5 S5 S1 T1

C5 C7 C7 C5 C6 C6 C7 C6 C6 C5 C7 C6 C5 C5 C6 C7 C7 C7 C7 C6 C6 C6 C6 T1 C6 C5 C5 C6 C5 C8

20 20 22 23 23 23 24 26 26 26 27 29 29 29 29 30 30 31 35 36 37 38 40 40 40 41 43 45 45 45

4SWM Semmes Weinstein Monofilaments

22

1 1VIB Vibration Sense

The Tetraplegia Hand Measure (THM) S2PD Static Two Point Discrimination MSHFT Modified Sollerman Hand Function Test

2MMT Manual Muscle Testing

3Figure 1. Theoretical Framework for the Assessment of Hand Impairment in 4Individuals with Tetraplegia 5 6 7 8 9 10 11 SENSORIMOTOR HAND FUNCTION Primary Sensation Integrated Sensation Primary Motor Integrated Motor
Functional Substrates -Intent to Move -Supporting Mechanisms -Postural Control -Stabilizers -Sensory -Motor Neurophysiological Mechanisms -Plasticity/Adaptation -Motor Learning -Motor Control -Motor Planning Pathology/Recovery -Spinal Cord Injury -Reorganization -Maladaptive Recovery

12 13 14 15Figure 2: Sensory Mapping Diagram for Coding of Multi-Modality Sensation 16 17 18 19 20 C6 21 22 23 C8 C7

Semmes Weinstein Monofilaments Static 2 Point Discrimination Vibration Sense

23

1 1 2C6 , C7, C8 dermatome distribution

The Tetraplegia Hand Measure (THM)

C8

24