Development of Reaching, Grasping & Manipulation indicators to advance the quality of spinal cord injury rehabilitation: SCI-High Project

Figures & data

Figure 1 Driver diagram for the RG&M Domain. The Impairment Branch is common to all 11 SCI-High Domains. The red items shown in the diagram represent the aim of the indicators. *Thicker black lines on the Technology branch reflect the greater volume of evidence supporting NMES and FES. UEMS: Upper-Extremity Motor Score, LEMS: Lower-Extremity Motor Score, NLI: Neurological Level of Injury, AIS: ASIA Impairment Scale, HR: Heart Rate, BP: Blood Pressure; FES: Functional Electrical Stimulation, AMES: Assisted Movement with Enhanced Sensation, Bioness Inc., NMES: Neuromuscular Electrical Stimulation, SARA System: Smart Assistive Reacher Arm (SARA) System, SRS System: Stimulus Router System, MeCFES: Myoelectrical Controlled Functional Electrical Stimulation, and PNSS/rTMS: Peripheral Nerve Somatosensory Stimulation System/repetitive Transcranial Magnetic Stimulation.

Table 1 Description of the therapeutic constructs underlining the RG&M practices which informed indicator development.

Prevention Therapy Concept

Prevention of injury or complications focuses on regional trauma, joint deformity, co-contractions, muscle imbalance, spasticity, contracture, shoulder subluxation, shoulder elbow or wrist overuse injury, overstretching of the finger flexor tendons and hyperextension of the metacarpophalangeal joints. Optimizing seating stability focuses on selecting the most appropriate, ergonomic wheelchair and seating system; promoting an optimal seated posture and stabilization for trunk stability and upper extremity needs; optimizing techniques and performance during wheelchair propulsion and related skills (e.g. pressure relief, transfers); and functional activities.

Neurorestorative Therapy Concept

Neurorestoration is a process to promote, restore, or maintain the integrity of the neurological functions by using neurorestorative strategies, including physical, chemical, biological, and surgical interventions, or any other kinds of intervention that bring about structural and/or functional restoration simultaneously.^Citation75 Functional recovery is the typical objective of neurorestorative therapies. Neurorestorative therapies in the context of the RG&M Domain will focus on restoring, promoting, or maintaining the sensorimotor integrity of the upper extremity which has been compromised secondary to the traumatized/diseased spinal cord by employing therapeutic techniques that may improve joint range of motion, strength and/or coordination to allow for progression with activity-based therapies with the ultimate goal of maximizing functional recovery.

Figure 2 RG&M structure indicator tool.

Figure 3 Alphabetical list of therapeutic activities intended to facilitate Reaching, Grasping & Manipulation outcomes. This table was modified from Ozelie et al., 2012⁷³ with feedback from Lyndhurst Centre OTs and PTs and RG&M Working Group Members.

Table 2 Systematic search of outcomes related to reaching, grasping and manipulation.

Measurement Tool	Scale
Functional Independence Measure (FIM)^Citation76,Citation77	Number of Items=18, 13 motor and 5 socio-cognitive subscales, scored from 1 (total dependence) to 7 (total independence)
Graded Redefined Assessment of Strength, Sensibility and Prehension (GRASSP)^Citation36	Sensation: Number of Items=3 locations for dorsal and 3 locations for palmar side of each hand-scored from 0 to 4 Strength: Number of Items=10 arm & hand muscle for each arm scored from 0 to 5 Prehension: Number of Items=3 grasping, 6 prehension tasks for each arm divided to prehension ability subscale scored from 0 to 4 and prehension performance subscale scored from 0 to 5
Grasp Release Test (GRT)^Citation78,Citation79	Number of Items=6, Subjects grasp, move and release six different objects as many times as possible in three 30-s trials for each object. Three objects have to be manipulated with palmar grasp and three objects with lateral grasp. The number of attempts, completions and failures are registered.
Quadriplegia Index of Function (QIF)^Citation80	Number of Items=37, the functional performance categories are scored on a 5-point scale from 0 (dependent) to 4 (independent)
Spinal Cord Independence Measure (SCIM)^Citation62,Citation81	Number of Items=19, Item response categories vary from item to item; ranging from 0–2 to 0-15, Scores are derived by adding up the items producing a total score (0 to 100) and/or subscale scores (self-care: 0-20; respiration and sphincter management: 0-40; mobility 0-40)
Toronto Rehabilitation Institute Hand Function Test (TRI-HFT)^Citation82	Number of Items=14, 10 manipulation items, using palmar and lateral pinch grasp scored from 1 to 7, where each item is scored in each of the 3 positions except the mug and the zip lock bag which are not scored in supination. 4 Strength Items, using items with dynamometers to measure lateral grip force and circular grip force, Strength test is scored using Newtons
The Van Lieshout Test Short Version (VLT-SV)^Citation83,Citation84	Number of Items=10, scored on a 6-point scale from 0 (task was not possible) to 5 (highest level of accomplishment), Individual item scores take into account the 1) ability to complete the task; 2) behavioral quality of performance (e.g./accuracy of task completion); and 3) independence in performing the task without using external support (e.g./assistance of the contralateral arm)

Table 3 Minimal data set of reaching, grasping and manipulation indicators.

Indicator	Denominator	Type	Measurement
Number of OTs and PTs with specialized certification, education, training and/or work experience in upper extremity intervention and therapy related to RG&M	Total number of therapists participating in upper extremity therapy service provision at each site per FY*	Structure	Annual
Total hours of received upper extremity therapies related to RG&M and the proportion of this time (in hours) allocated to neurorestorative therapy during the rehabilitation length of stay	Number of individuals with tetraplegia**	Process	Rehabilitation discharge
GRASSP Strength Subscore	Number of individuals with tetraplegia**	Outcome - Baseline	Rehabilitation admission +/−72 weekday hours
SCIM Self-Care subscore (patient interview)	Number of individuals with tetraplegia**	Outcome - Baseline	Rehabilitation admission+/−72 weekday hours
GRASSP Strength Subscore	Number of individuals with tetraplegia**	Outcome - Intermediary	Rehabilitation discharge
SCIM Self-Care subscore (patient interview)	Number of individuals with tetraplegia**	Outcome - Intermediary	Prior to rehab discharge
SCIM Self-Care subscore (patient interview)	Number of individuals with tetraplegia**	Outcome - Final	18 months post-rehab admission

*FY: fiscal year; GRASSP: Graded Redefined Assessment of Strength, Sensation and Prehension measure; SCIM: Spinal Cord Independence Measure; AIS: American Spinal Injury Association Impairment Scale. **Individuals living with injuries or disease with a neurological level of injury between C1-T1 and AIS category between A-D and who received RG&M therapy. Implementation considerations: The structure indicator is collected annually at each participating site; the process indicator is collected daily for each individual receiving RG&M therapies; 3) the outcome indicators are captured at baseline, rehabilitation discharge, and 18-months post-rehabilitation admission. Baseline assessment should occur within seven days of admission to inpatient rehabilitation.

Figure 4 Illustration of the intersection between rehabilitation discharge (red vertical line) and the slope of change in upper extremity motor scores (MS). The red dotted line represents the median rehabilitation length of stay in Canada.⁷⁴ The recovery timeline graph was adapted from Burns and Ditunno, 2001,⁷¹ displaying functional motor recovery in individuals with C6 tetraplegia with an initial MS at the C5 myotome. Solid and dotted black lines depict modeled data resulting from individuals with different motor scores.

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