Grasp and Release Test for Tetraplegic Hand Assessment: an update of the Grasp and Release Test.

The Grasp and Release Test (GRT) was originally developed to measure effectiveness of an implanted neuroprosthesis in people with tetraplegia. Its ease of use and lack of floor and ceiling effects culminated in recommendations for inclusion in a battery of tests to measure outcome following upper limb reconstructive surgery. However, the length of time taken to administer the GRT in a clinical setting, lack of instructions of accepted grasp patterns in the upper limb reconstructive surgery population and scoring procedures lead to differences in reporting outcomes using this measure. In order to ensure clinical utility for the upper limb reconstructive surgery population, revisions of the original test instructions have been made and are reported in this article. Further testing of the psychometric properties of the new measure are currently underway.

Research priorities to enhance life for people with spinal cord injury: a Swedish priority setting partnership.

STUDY DESIGN: Mixed-method consensus development project. OBJECTIVE: To identify the top ten research priorities for spinal cord injury (SCI). SETTING: Nationwide in Sweden in 2021-22. METHODS: The PSP process proposed by the James Lind Alliance was used. It comprises two main phases: question identification and priority selection. People living with SCI, relatives of people with SCI as well as health professionals and personal care assistants working with people with SCI were included. RESULTS: In the first phase, 242 respondents provided 431 inputs addressing potentially unanswered questions. Of these, 128 were beyond the scope of this study. The remaining 303 were merged to formulate 57 questions. The literature review found one question answered, so 56 questions proceeded to the prioritisation. In the second phase, the interim prioritisation survey, 276 respondents ranked the 56 questions. The top 24 questions then proceeded to the final prioritisation workshop, at which 23 participants agreed on the top ten priorities. CONCLUSIONS: This paper reveals issues that people living with SCI, relatives of people with SCI as well as health professionals and personal care assistants working with people with SCI find difficult to get answered. The top-priority questions for people living with SCI in Sweden concern specialist SCI care and rehabilitation, followed by a number of questions addressing physical health. Other topics, from the 56 key questions include Mental health, Ageing with SCI, Community support and personal care assistance, and Body functions. This result can guide researchers to design appropriate studies relevant to people with SCI. SPONSORSHIP: The project was funded by the Gothenburg Competence Centre for Spinal Cord Injury and the Swedish Association for Survivors of Accident and Injury (RTP).

Reproducibility, Construct Validity, and Responsiveness of the Tetraplegia Upper Limb Activities Questionnaire, TUAQ. Part 2.

OBJECTIVE: To test reliability, construct validity and responsiveness of the Tetraplegia Upper Limb Activities Questionnaire (TUAQ), a patient-reported outcome measure that assesses perceived performance and satisfaction with 10 standardized activities. DESIGN: Outcome measure psychometric evaluation. SETTING: Spinal cord injury units in 2 countries. PARTICIPANTS: Reproducibility: 47 individuals with tetraplegia. Construct validity and responsiveness: 33 individuals with tetraplegia undergoing surgery to restore hand function (N=80). INTERVENTIONS: Reproducibility: The TUAQ was completed on 2 occasions, 2 weeks apart. Construct validity and responsiveness: Participants completed the TUAQ prior to surgery and 3-12 months after hand reconstruction surgery. Internal consistency was examined using Cronbach α. Two agreement parameters were examined: the SEM and minimal detectable change with 90% confidence interval (MDC90). Construct validity was evaluated using Pearson product moment correlation against a priori hypotheses. Responsiveness was assessed using paired t tests and effect size. RESULTS: Test-retest reliability and internal consistency was high (intraclass correlation coefficient of 0.89 for performance scale and 0.88 for satisfaction, Cronbach α of 0.92 and 0.90, respectively). For agreement the SEM scores were 4.7 and 3.5, with MDC90 of 10.9 and 8.2, respectively. Responsiveness and construct validity showed sound results with no ceiling or floor effects and with large effect size (>1.05). CONCLUSIONS: The TUAQ demonstrates good psychometric properties for reliability and agreement for persons with tetraplegia and responsiveness and construct validity for surgical reconstruction of hand function for persons with tetraplegia. The TUAQ appears appropriate to be used as a patient-reported outcome measure for clinical and research purposes in this population.

Development, Internal Construct, and Unidimensionality of the Tetraplegia Upper Limb Activities Questionnaire, TUAQ. Part 1.

OBJECTIVE: This study aims to develop a patient-reported outcome measure that focuses on relevant daily activities relying on upper extremity for individuals with tetraplegia. DESIGN: Cross-sectional study. SETTING: Spinal cord injury units in 2 countries. PARTICIPANTS: Ninety-nine individuals (N=99) with C2-C8, American Spinal Injury Association Impairment Scale A-D tetraplegia, mean age 46 years, 1- 43 years post injury. INTERVENTIONS: Thirteen items included in the initial testing were chosen from 708 activity limitations identified by individuals with tetraplegia. Items were pilot tested for wording, response options, and relevance for both performance and satisfaction. Items were analyzed and reselected using exploratory factor analysis and Rasch analysis for local dependency, dimensionality, differential item functioning (DIF), threshold response, and targeting. MAIN OUTCOME MEASURES: Not applicable. RESULTS: Exploratory factor analysis supported a 2-factor solution for both performance and satisfaction. While data fit the Rasch model, there was evidence of local dependency and multiple disordered thresholds. Three items were removed because of high interitem correlation and DIF and the scale rescored to 5 response options. The remaining 10 items demonstrated fit to the Rasch model, with no local dependency, no multidimensionality, no item or person misfit, and minimal disordered thresholds. CONCLUSIONS: Results support the internal construct validity and unidimensionality of the Tetraplegia Upper Limb Activities Questionnaire (TUAQ), a 10-item, 5-response patient-reported outcome measure assessing performance and satisfaction with activities targeted to the upper extremity for individuals with tetraplegia. Further testing is required and ongoing to evaluate reliability and responsiveness of the TUAQ.

Rehabilitation After Spasticity-Correcting Upper Limb Surgery in Tetraplegia.

OBJECTIVE: To describe the early active rehabilitation concept developed for spasticity-correcting surgery in tetraplegia and to report the outcomes in grip ability and change of performance and satisfaction in patients' prioritized activities 1 year postoperatively. DESIGN: Retrospective case-control study. SETTING: Nonprofit rehabilitation unit. PARTICIPANTS: All patients who underwent surgeries for correction of spasticity in tetraplegic hands between 2009 and 2013 in the studied unit (N=37). INTERVENTIONS: Spasticity-correcting upper limb surgery with early active rehabilitation to restore grip ability in tetraplegia. MAIN OUTCOME MEASURES: Grasp and release test (GRT) and modified Canadian Occupational Performance Measure (COPM). RESULTS: All patients could accomplish the early active rehabilitation concept. The complication rate related to the treatment was low. Compared with preoperatively, all evaluated individuals experienced improvements in grasp ability and activity performance and satisfaction at 1-year follow-up. The performance in prioritized activities, as measured by the COPM, improved by 2.6 scale steps. Satisfaction with performance improved 3.0 scale steps postoperatively (n=21). The grasp ability, measured by the GRT, improved significantly, from 80 preoperatively to 111 (n=10). CONCLUSIONS: The surgery, combined with the early active rehabilitation protocol, is a reliable and safe procedure. The ability to use the hand improved, and gains were maintained at least 1 year after surgery in all patients with respect to both the objective grasp ability and patients' subjective rating of their performance and satisfaction in their prioritized activities. The procedure should therefore be considered as an adjunct to other treatments of upper limb spasticity in spinal cord injury.

Early Active Rehabilitation After Grip Reconstructive Surgery in Tetraplegia.

OBJECTIVE: To describe and evaluate the concept of early active rehabilitation after tendon transfer to restore grip function in tetraplegia. DESIGN: Retrospective cohort study. SETTING: Two nonprofit rehabilitation units in Sweden and Switzerland. PARTICIPANTS: All patients with tetraplegia who underwent tendon transfer to restore grip ability during 2009 to 2013 (N=49). INTERVENTION: Reconstructive tendon transfer surgery with early active rehabilitation to restore grip ability in tetraplegia. MAIN OUTCOME MEASURES: Grip and pinch strength, grip ability test, and outcome of prioritized activities. RESULTS: In the 49 surgeries performed, postoperative complications included 2 patients with bleeding and 2 infections related to the surgery. There were no reported ruptures or lengthening of transferred tendons. Within 24 hours after surgery, all 47 patients (100%) with finger flexion reconstruction succeeded to activate their finger flexion. All but 1 patient with reconstructed thumb flexion sucessfully activated their thumb flexion (n=40). Three weeks after surgery, all patients (100%) were able to perform basic activities of daily living, and instrumental activities of daily living were achieved by 74%. One year after surgery, the maximum grip strength in restored finger flexion was on average 6.9kg (range, 1.5-15kg; n=29). The maximum pinch strength in restored thumb flexion was on average 3.7kg (range, 1-20; n=29). On average, grip ability improved from 33 to 101 (n=19) according to the COPM. Prioritized activity limitations, as measured with the COPM, equated to an average of 3.5 steps (2.5 steps preoperatively to 6 steps postoperatively). Patients' perceived satisfaction with this improvement was 4 steps (increasing from 2 steps preoperatively to 6 steps postoperatively). CONCLUSIONS: Grip reconstructive surgery followed by early active rehabilitation can be considered a reliable procedure that leads to substantial improvements in grip and pinch strength and activity performance among patients with tetraplegia.

Rehabilitation After Posterior Deltoid to Triceps Transfer in Tetraplegia.

OBJECTIVE: To describe and evaluate the rehabilitation concept after posterior deltoid to triceps transfer in patients with tetraplegia. DESIGN: Retrospective observational study. SETTING: Rehabilitation units. PARTICIPANTS: Patients with tetraplegia who had posterior deltoid to triceps tendon transfer and had muscle strength measurements 1 year postsurgery from 2009 to 2013 (N=44). INTERVENTIONS: Posterior deltoid to triceps tendon transfer to restore elbow extension and postoperative rehabilitation. MAIN OUTCOME MEASURES: Elbow extension range of motion and muscle strength and the modified Canadian Occupational Performance Measure (COPM). RESULTS: Surgery was performed on 53 arms. No major complications (eg tendon rupture, lengthening) were reported. Muscle strength measured 1 year after surgery was on average grade 3 (out of 5) in the 53 operated arms. The ability to extend the elbow against gravity was achieved in 62% of the arms (muscle strength of grade ≥3). In patients with a preoperative elbow extension deficit (n=14), the deficit was reduced on average from 16° to 9°. The performance of the prioritized activities as measured with the COPM improved on average 2.6 scale steps, from 3.3 to 5.9. Satisfaction with the performance improved on average 3.2 scale steps, from 2.8 to 6.0. CONCLUSIONS: The posterior deltoid to triceps tendon transfer with the applied rehabilitation protocol is a safe and effective procedure. There were no tendon ruptures, and all patients were able to complete the rehabilitation protocol. The shorter restriction time after surgery allows the patient to be independent at an earlier stage of the rehabilitation and reduces hospitalization or care burden.

Measurement of Outcomes of Upper Limb Reconstructive Surgery for Tetraplegia.

Reconstructive arm/hand surgery for tetraplegia is performed to improve arm/hand function and therefore personal well-being for individuals who accept such elective surgeries. However, changes at an impairment level do not always translate into functional or quality of life changes. Therefore, multiple outcome tools should be used that incorporate sufficient responsiveness to detect changes in arm/hand function, activity and participation, and quality of life of the individuals involved. This narrative review aims to assist clinicians to choose the most appropriate tools to assess the need for reconstructive surgery and to evaluate its outcomes. Our specific objectives are (1) to describe aspects to consider when choosing a measure and (2) to describe the measures advised by an international therapist consensus group established in 2007. All advised measures are appraised in terms of the underlying construct, administration, and clinical relevance to arm/hand reconstructions. Essentially there are currently no criterion standard measures to evaluate the consequences of reconstructive arm/hand surgery. However, with judicious use of available measures it is possible to ensure the questions asked or tasks completed are relevant to the surgical reconstruction(s) undertaken. Further work in this field is required. This would be best met by immediate collaboration between 2 outcome's tool developers and by analysis of pre- and postoperative data already held in various international sites, which would allow further evaluation of the measures already in use, or components thereof.

Expected outcome for reconstructive hand surgery after spinal cord injuries related to level of injury and sex.

This retrospective, multicentre study maps grip strength and grasp ability after tendon transfer surgery in patients with tetraplegia. Data were analysed in the whole group and in subgroups stratified into the International Classification for Surgery of the Hand in Tetraplegia (ICSHT) and sex. In total, 200 arms (143 patients) had tendon transfer surgery to restore grip and pinch function, 74% were men, 42% were ICSHT group ≤3 and 58% ICSHT were group ≥4. The one-year outcome across all participants for grip strength was 5.2 kg, pinch strength 2.1 kg and a score of 108 for the Grasp and Release test. Men had significantly higher grip and pinch strength compared to women, while there was no significant difference with respect to grasp ability. ICSHT group ≥4 had significantly higher grip strength and grasp ability compared to ICSHT group ≤3, whereas no significant difference in pinch strength between ICSHT groups was seen.Level of evidence: III.

Identified needs to enhance life for people with spinal cord injury: a part of the Swedish Needs Assessment Project.

PURPOSE: To identify factors that contribute to the enhanced life of people with spinal cord injury (SCI) in Sweden. MATERIALS AND METHODS: This cross-sectional study combined workshops (n = 38) and survey data (n = 243) from people living with SCI and their relatives, health professionals, and personal care assistants working with people living with SCI. The data were first categorized using Bronfenbrenner's bioecological model, followed by a conventional content analysis. RESULTS: The factors that contribute to an enhanced life for people living with SCI are similar to those of the general population, including relationships, leisure activities, and occupation within the mesosystem. However, the unique components of the exosystem and macrosystem are specifically associated with people living with SCI. The exosystem, particularly in healthcare, plays a major role for medical reasons but also tends to obtrude and minimize the mesosystem. The macrosystem is essential, as it sets the rules that govern the actors in the other layers, creating prerequisites for meeting the needs of the mesosystem and exosystem. CONCLUSIONS: The needs that contribute to an enhanced life are multifaceted and individualized. Therefore, these systems must be flexible throughout the lifespan of individuals with SCI.

This paper reports needs that contribute to an enhanced life for people living with spinal cord injury in Sweden.The factors that contribute to an enhanced life are multifaceted and individual, and these must be considered throughout the entire life span, including getting help if secondary complications arise, aging and other life events.Individuals' willingness to take ownership is strong but requires support from the surrounding systems that can accommodate individual's unique needs.The exosystem (ea health care) plays a major role but risk to obtrude and minimize the mesosystem (individual's immediate relations).Positive attitudes toward oneself, from family members and loved ones, from health care professionals and authorities are crucial for an enhanced life.

Feasibility of using fNIRS to explore motor-related regional haemodynamic signal changes in patients with sensorimotor impairment and healthy controls: A pilot study.

BACKGROUND: While functional near-infrared spectroscopy (fNIRS) can provide insight into cortical brain activity during motor tasks in healthy and diseased populations, the feasibility of using fNIRS to assess haemoglobin-evoked responses to reanimated upper limb motor function in patients with tetraplegia remains unknown. OBJECTIVE: The primary objective of this pilot study is to determine the feasibility of using fNIRS to assess cortical signal intensity changes during upper limb motor tasks in individuals with surgically restored grip functions. The secondary objectives are: 1) to collect pilot data on individuals with tetraplegia to determine any trends in the cortical signal intensity changes as measured by fNIRS and 2) to compare cortical signal intensity changes in affected individuals versus age-appropriate healthy volunteers. Specifically, patients presented with tetraplegia, a type of paralysis resulting from a cervical spinal cord injury causing loss of movement and sensation in both lower and upper limbs. All patients have their grip functions restored by surgical tendon transfer, a procedure which constitutes a unique, focused stimulus for brain plasticity. METHOD: fNIRS is used to assess changes in cortical signal intensity during the performance of two motor tasks (isometric elbow and thumb flexion). Six individuals with tetraplegia and six healthy controls participate in the study. A block paradigm is utilized to assess contralateral and ipsilateral haemodynamic responses in the premotor cortex (PMC) and primary motor cortex (M1). We assess the amplitude of the optical signal and spatial features during the paradigms. The accuracy of channel locations is maximized through 3D digitizations of channel locations and co-registering these locations to template atlas brains. A general linear model approach, with short-separation regression, is used to extract haemodynamic response functions at the individual and group levels. RESULTS: Peak oxyhaemoglobin (oxy-Hb) changes in PMC appear to be particularly bilateral in nature in the tetraplegia group during both pinch and elbow trials whereas for controls, a bilateral PMC response is not especially evident. In M1 / primary sensory cortex (S1), the oxy-Hb responses to the pinch task are mainly contralateral in both groups, while for the elbow flexion task, lateralization is not particularly clear. CONCLUSIONS: This pilot study shows that the experimental setup is feasible for assessing brain activation using fNIRS during volitional upper limb motor tasks in individuals with surgically restored grip functions. Cortical signal changes in brain regions associated with upper extremity sensorimotor processing appear to be larger and more bilateral in nature in the tetraplegia group than in the control group. The bilateral hemispheric response in the tetraplegia group may reflect a signature of adaptive brain plasticity mechanisms. Larger studies than this one are needed to confirm these findings and draw reliable conclusions.

[Spasticity-correcting surgery can have long-lasting effects]. / Spasticitetskorrigerande kirurgi kan ge långvariga förbättringar.

Spasticity is a common secondary complication after injuries to the central nervous system (CNS). Spasticity may severely impair arm and hand function, and consequently, affect an individual's function, resulting in disabilities or limiting activities and participation. Today, there is conflicting evidence regarding the effectiveness of available spasticity treatments. The population of adults with spasticity problems due to a CNS injury is heterogenic. A multidisciplinary approach is essential in customizing treatment to individual needs. The planning of treatment should consider the remaining upper limb functions and the patient's potential to improveme. Spasticity-correcting surgery is an option that seems underutilized. This article describes a structured and standardized program for the preoperative assessment, the surgical technique and the postoperative rehabilitation of patients undergoing upper limb spasticity-correcting surgery.

Activity gains after reconstructions of elbow extension in patients with tetraplegia.

PURPOSE: Reconstruction of triceps function in persons with tetraplegia is an established surgical intervention. The purpose of this study was to investigate and evaluate patient perspective of gains in activity and satisfaction after surgical reconstruction of triceps function and subsequent rehabilitation. METHODS: We studied the effects of surgery and rehabilitation in 14 persons (19 arms) treated with deltoid-to-triceps transfer. We used Canadian Occupational Performance Measurement standards to capture the performance and satisfaction of patient-identified activity goals. Follow-up was performed at 6 and 12 months postoperatively. To make group analyses, we classified activity goals according to the International Classification of Function, Disability, and Health categories of activities and participation, as well as relative to the position of the arm in space. RESULTS: Patients reported improvement in performance after surgery, and satisfaction was rated even higher. Improvement was seen in all types of activities that patients had prioritized. No single goal was rated lower at 12 months' follow-up than before surgery. The most common activity gains were related to "driving a wheelchair" and the ability to "reach out," each of which represented 20% of expressed goals. Although "driving a wheelchair" and "moving the body" (transfers) were common goals, the smallest improvements for both performance and satisfaction after 12 months were seen in these areas. We observed the highest performance improvement in the category of "writing" and the ability to "stretch out the arm when lying down." CONCLUSIONS: Improvement in activity continues over the first year after triceps reconstruction. Complex activities continue to improve over a longer period than simpler activities. We saw the highest improvement in activities performed without the aid of gravity and activities highly dependent on coordination. Such actions are difficult to compensate for by technique or skills, and therefore elbow extension is essential for performance. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Linking Prioritized Occupational Performance in Patients Undergoing Spasticity-Correcting Upper Limb Surgery to the International Classification of Functioning, Disability, and Health.

Background: Spasticity is generally caused by damage to the spinal cord or the areas of the brain that controls movements, which poses significant limitations in occupational tasks. Objectives: The aims of the study were to (I) describe prioritized occupational performance problems (POPP) among patients who underwent upper limb spasticity-correcting surgery and map them to the International Classification of Function, Disability, and Health (ICF); (II) assess outcomes postsurgery; (III) assess whether the results are influenced by the diagnosis, gender, and residual muscle function; and (IV) assess correlation between changes in COPM and gains in grasp ability and grip strength. Methods: In this retrospective study, assessments occurred pre- and postsurgery, including the Canadian Occupational Performance Measure (COPM), grip strength, and grasp ability. POPP were transformed to prioritized occupational performance goals (POPG) during subsequent rehabilitation. Results: 60 patients with a history of spinal cord injury (SCI) (n = 42; 59%), stroke (n = 25; 34%), traumatic brain injury (TBI) (n = 4; 6%), and reason unknown (n = 1; 1%) were included, with a mean age of 57 (±13) years. Of those, 11 had bilateral surgery, generating 71 COPM forms and 320 POPG. The POPG were mapped to the ICF activity and participation chapter, most often to self-care (n = 131; 41%), domestic life (n = 68; 21%), and mobility (n = 58; 18%). COPM scores were significantly increased postsurgery, irrespective of diagnosis, gender, and muscle function. No clear correlation between COPM improvement and hand function gains was shown. Conclusion: Patients who underwent spasticity-correcting upper limb surgery identified difficulties with a wide range of occupational tasks that they considered as important to regain. Treatment-induced gains in occupational performance were significant but had no clear correlation with gains in grasp ability and hand strength. Independent of diagnosis, gender, and residual muscle function, it seems important to address the activity- and participation-specific aspects in the assessment and rehabilitation of patients.

The impact of upper limb spasticity-correcting surgery on the everyday life of patients with disabling spasticity: a qualitative analysis.

PURPOSE: The aim of this study was to explore the patient perspective of their experiences of daily life after spasticity-correcting surgery for disabling upper limb (UL) spasticity after spinal cord injury (SCI) and stroke. MATERIALS AND METHODS: Eight patients with UL spasticity resulting from SCI (n= 6) or stroke (n= 2) were interviewed 6-9 months after spasticity-correcting surgery. A phenomenographic approach was used to analyze the interviews. RESULTS: Five themes emerged from the interviews: (1) bodily changes, such as increased muscle strength, range of motion, and reduced muscle-hypertonicity; (2) improved occupational performance, facilitating tasks, mobility, and self-care; (3) regained control, explicating the perception of regaining bodily control and a more adaptable body; (4) enhanced interpersonal interactions, entailing the sense of being more comfortable undertaking social activities and personal interactions; and (5) enhanced psychological well-being, including having more energy, increased self-esteem, and greater happiness after surgery. CONCLUSIONS: The participants experienced improvements in their everyday lives, including body functions, activities, social life, and psychological well-being. The benefits derived from surgery made activities easier, increased occupational performance, allowed patients regain their roles and interpersonal interactions, and enhanced their psychological well-being.Implications for rehabilitationSpasticity-correcting surgery benefits patients by improving bodily functions, which in turn, enable gains in activities, social life, and psychological well-being.Patients' experiences of increased body functions, such as enhanced mobility and reduced muscle hypertonicity, appear to increase the sense of bodily control.The surgery can increase participation and psychological well-being, even for patients whose functional or activity level did not improve after the treatment.The benefits expressed by the individuals in this study can be used to inform, planning, and in discussion with patients and other healthcare professionals about interventions targeting spasticity.

[The combination of nerve and tendon transfers offers good possibilities for hand function in patients with cervical spinal cord injury]. / Så kan funktion i hand och arm återfås efter halsryggmärgsskada.

Regaining upper extremity function is a prioritized matter for patients with tetraplegia after a cervical spinal cord injury (cSCI). The purpose of this article is to describe the current evidence and treatment strategies for upper extremity reconstruction after cSCI at the Centre for Advanced Reconstruction of Extremities, Sahlgrenska University Hospital, Sweden. The specialized unit works in a multidisciplinary setting to optimize the care of the patient population. Preoperative planning and an individualized treatment according to the needs and abilities of the patient are considered key points to achieve the best possible outcome. The addition of nerve transfers to the established method of tendon transfers for grip reconstruction has led to increased possibilities to achieve both functional hand opening and grip. Here we present our preferred method of upper extremity reconstruction, which involves a two-staged procedure where the tendon-based grip reconstruction is preceded by nerve transfer of the supinator to posterior intraosseous nerve whenever possible. Important clinical aspects as well as future perspectives are discussed.

Arm activity measure (ArmA): psychometric evaluation of the Swedish version.

BACKGROUND: Patient Reported Outcomes Measure (PROM) are commonly used in research and essential to understand the patient experience when receiving treatment. Arm Activity Measure (ArmA) is a valid and reliable self-report questionnaire for assessing passive (section A) and active (section B) real-life arm function in patients with disabling spasticity. The original English version of ArmA has been psychometrically tested and translated into Thai. AIMS: Translate and cross-culturally adapt ArmA to Swedish language and context. Further, to evaluate the reliability, validity and sensitivity of the Swedish version of the questionnaire (ArmA-S) in patients with disabling upper limb spasticity caused by injuries to the central nervous system (CNS). MATERIALS AND METHODS: ArmA was translated and cross-culturally adapted according to established guidelines. Validity and reliability were evaluated in 61 patients with disabling spasticity. Face and content validity was evaluated by expert opinions from clinicians and feedback from patients with upper limb spasticity. Internal consistency reliability was assessed with Cronbach's alpha and test-retest reliability was assessed using the quadratic weighted kappa. RESULTS: ArmA-S was shown to be clinically feasible, with good face and content validity and no floor or ceiling effects. Internal consistency of ArmA-S was high and equivalent to ArmA; with Chronbach´s alpha coefficients values of 0.94 and 0.93 for section A and B, respectively. Test-retest reliability was good, with kappa values of 0.86 and 0.83 for section A and B, respectively. Some layout modifications of ArmA-S were made to further increase the user-friendliness, test-retest reliability, and responsiveness. CONCLUSION: ArmA-S was shown to be a reliable and valid self-report questionnaire for use in clinical practice and research to assess improvements in passive and active upper limb function in patients with disabling spasticity.

Toward Consensus in Assessing Upper Limb Muscle Strength and Pinch and Grip Strength in People With Tetraplegia Having Upper Limb Reconstructions.

OBJECTIVES: To reach agreement on standardized protocols for assessing upper limb strength and grip and pinch force for upper limb reconstructive surgery for tetraplegia. METHODS: Selected members of an expert panel composed of international therapists formed at the 2018 International Congress for Upper Limb Surgery for Tetraplegia conducted a literature review of current practice that identified gaps and inconsistencies in measurement protocols and presented to workshop attendees. To resolve discrepancies, a set of questions was presented to workshop attendees who voted electronically. Consensus was set at 75% agreement. RESULTS: For manual muscle testing, consensus was reached for using the Medical Research Council scale, without plus or minus, and the use of resistance through range when testing grade 4 and grade 5 strength. Pectoralis major and serratus anterior should be routinely tested, however there was no consensus on other shoulder muscles. Grip and pinch strength should be tested according to the American Society of Hand Therapists positioning. For grip strength, either the Jamar or Biometrics dynamometer expressed in kilograms should be used. For grip and pinch strength, three measurements should be performed at each testing. No consensus was reached on a device for pinch strength. CONCLUSION: This work is an important step to enable comparable data in the future. Further consensus methods will work toward developing more comprehensive guidelines in this population. Building international consensus for pre- and postoperative measures of function supports objective evaluation of novel therapies and interpretation of multicenter studies.

Activity gains after upper limb surgery for spasticity in patients with spinal cord injury.

Spasticity is a common and increasingly prevalent secondary complication of spinal cord injury. The aim of the study was to evaluate patient-experienced gains in prioritized activities after surgery to reduce the effects of spasticity in upper limbs in tetraplegia. The study includes evaluation of 30 operations for 27 patients performed on hypertonic tetraplegic hands during 2007-2015 using the Canadian Occupational Performance Measure. Activity performance increased at both 6 months and 12 months by a mean of 3.0 and 2.9 points, respectively. Satisfaction increased by 3.3 and 3.4, respectively. All types of activities improved, with wheelchair manoeuvring as one of the highest rated. The intervention increased prioritized activity performance and persisted at least 12 months after surgery. Patients with mild upper limb impairment showed greater improvement after surgery. After operation, patients were able to perform 71% of their prioritized activities, which they could not perform before. Patients' satisfaction with the performance was high. LEVEL OF EVIDENCE: IV.