Special communication| Volume 97, ISSUE 6, SUPPLEMENT , S169-S181, June 2016

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.


      List of abbreviations:

      COPM (Canadian Occupational Performance Measure), GRASSP (Graded Redefined Assessment of Strength, Sensibility and Prehension), GRT (Grasp and Release test), ICF (International Classification of Functioning, Disability and Health), PWI (Personal Wellbeing Index), ROM (range of motion)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Sinnott K.A.
        • Dean S.
        Choosing appropriate measures.
        Hosp Med. 2005; 66: 205-209
        • Post M.W.
        Outcome measurement.
        in: Chhabra H. ISCoS textbook on comprehensive management of spinal cord injuries. Wolters Kluwer (India), New Delhi2015: 918-928
        • Dunn J.A.
        • Hay-Smith E.J.
        • Keeling S.
        • Sinnott K.A.
        Decision-making about upper limb tendon transfer surgery by people with tetraplegia for more than 10 years.
        Arch Phys Med Rehabil. 2016; 97: S88-S96
        • Bryden A.
        • Sinnott K.
        • Mulcahey M.
        Innovative strategies for improving upper extremity function in persons with tetraplegia and considerations in measuring functional outcomes.
        Top Spinal Cord Inj Rehabil. 2005; 10: 75-93
        • Moberg E.
        Surgical treatment for absent single-hand grip and elbow extension in quadriplegia. Principles and preliminary experience.
        J Bone Joint Surg Am. 1975; 57: 196-206
        • McDowell C.L.
        • Moberg E.
        • House J.H.
        The Second International Conference on Surgical Rehabilitation of the Upper Limb in Tetraplegia (quadriplegia).
        J Hand Surg Am. 1986; 11: 604-608
        • Hentz V.R.
        • Brown M.
        • Keoshian L.A.
        Upper limb reconstruction in quadriplegia: functional assessment and proposed treatment modifications.
        J Hand Surg Am. 1983; 8: 119-131
        • Mulcahey M.J.
        • Hutchinson D.
        • Kozin S.H.
        Assessment of the upper limb in tetraplegia: considerations in evaluation and outcomes research.
        J Rehabil Res Dev. 2007; 44: 91-102
        • Velstra I.M.
        • Ballert C.S.
        • Cieza A.
        A systematic literature review of outcome measures for upper extremity function using the International Classification of Functioning, Disability, and Health as reference.
        PM R. 2011; 3: 846-860
        • van Tuijl J.H.
        • Janssen-Potten Y.J.
        • Seelen H.A.
        Evaluation of upper extremity motor function tests in tetraplegics.
        Spinal Cord. 2002; 40: 51-64
        • 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
        • Sinnott K.A.
        • Dunn J.A.
        • Rothwell A.G.
        • Hall A.S.
        • Post M.W.
        The development of the NZ upper limb surgery registry for tetraplegia.
        Spinal Cord. 2014; 52: 611-615
        • Dunn J.A.
        • Sinnott K.A.
        • Bryden A.M.
        • Connolly S.J.
        • Rothwell A.G.
        Measurement issues related to upper limb interventions in persons who have tetraplegia.
        Hand Clin. 2008; 24 (v): 161-168
        • World Health Organization
        International Classification of Functioning, Disability and Health: ICF.
        World Health Organization, Geneva2001
        • Wuolle K.S.
        • Van Doren C.L.
        • Thrope G.B.
        • Keith M.W.
        • Peckham P.H.
        Development of a quantitative hand grasp and release test for patients with tetraplegia using a hand neuroprosthesis.
        J Hand Surg Am. 1994; 19: 209-218
        • Marino R.J.
        • Goin J.E.
        Development of a short-form quadriplegia index of function scale.
        Spinal Cord. 1999; 37: 289-296
        • Carroll D.
        A quantitative test of upper extremity function.
        J Chronic Dis. 1965; 18: 479-491
        • Spooren A.I.
        • Janssen-Potten Y.J.
        • Post M.W.
        • Kerckhofs E.
        • Nene A.
        • Seelen H.A.
        Measuring change in arm hand skilled performance in persons with a cervical spinal cord injury: responsiveness of the Van Lieshout Test.
        Spinal Cord. 2006; 44: 772-779
        • Marino R.J.
        • Shea J.A.
        • Stineman M.G.
        The Capabilities of Upper Extremity Instrument: reliability and validity of a measure of functional limitation in tetraplegia.
        Arch Phys Med Rehabil. 1998; 79: 1512-1521
        • 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: 82-87
        • Wangdell J.
        • Friden J.
        Satisfaction and performance in patient selected goals after grip reconstruction in tetraplegia.
        J Hand Surg Eur Vol. 2010; 35: 563-568
        • Wangdell J.
        • Friden J.
        Performance of prioritized activities is not correlated with functional factors after grip strength reconstruction in tetraplegia.
        J Rehabil Med. 2011; 43: 626-630
        • Wangdell J.
        • Friden J.
        Activity gains after reconstruction of elbow extension in patients with tetraplegia.
        J Hand Surg Am. 2012; 37: 1003-1010
        • Wangdell J.
        • Carlsson G.
        • Friden J.
        From regained function to daily use: experiences of surgical reconstruction of grip in people with tetraplegia.
        Disabil Rehabil. 2014; 36: 678-684
        • Wangdell J.
        • Carlsson G.
        • Friden J.
        Enhanced independence: experiences after regaining grip function in people with tetraplegia.
        Disabil Rehabil. 2013; 35: 1968-1974
        • Cummins R.A.
        • Eckersley R.
        • Pallant J.
        • van Vugt J.
        • Misajon R.
        Developing a national index of subjective wellbeing: the Australian Unity Wellbeing Index.
        Soc Indic Res. 2003; 64: 159-190
        • Geyh S.
        • Fellinghauer B.A.
        • Kirchberger I.
        • Post M.W.
        Cross-cultural validity of four quality of life scales in persons with spinal cord injury.
        Health Qual Life Outcomes. 2010; 8: 94
        • Fekete C.
        • Boldt C.
        • Post M.
        • Eriks-Hoogland I.
        • Cieza A.
        • Stucki G.
        How to measure what matters: development and application of guiding principles to select measurement instruments in an epidemiologic study on functioning.
        Am J Phys Med Rehabil. 2011; 90: S29-S38
        • Lamb D.W.
        • Chan K.M.
        Surgical reconstruction of the upper limb in traumatic tetraplegia. A review of 41 patients.
        J Hand Surg Br. 1983; 65: 291-298
        • Cieza A.
        • Geyh S.
        • Chatterji S.
        • Kostanjsek N.
        • Ustün B.
        • Stucki G.
        ICF linking rules: an update based on lessons learned.
        J Rehabil Med. 2005; 37: 212-218
        • Kalsi-Ryan S.
        • Curt A.
        • Fehlings M.G.
        • Verrier M.C.
        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: 34-46
        • Gresham G.E.
        • Labi M.L.
        • Dittmar S.S.
        • Hicks J.T.
        • Joyce S.Z.
        • Stehlik M.A.
        The quadriplegia index of function (QIF): sensitivity and reliability demonstrated in a study of thirty quadriplegic patients.
        Paraplegia. 1986; 24: 38-44
        • Dunn J.A.
        Upper limb surgery outcomes for tetraplegia.
        in: Rehabilitation. Massey, Palmerston North1998
        • Kalsi-Ryan S.
        • Verrier M.
        A synthesis of best evidence for the restoration of upper-extremity function in people with tetraplegia.
        Physiother Can. 2011; 63: 474-489
        • Kalsi-Ryan S.
        • Wilson J.
        • Yang J.M.
        • Fehlings M.G.
        Neurological grading in traumatic spinal cord injury.
        World Neurosurg. 2013; 82: 509-518
        • Sinnott K.A.
        • Brander P.
        • Siegert R.J.
        • Rothwell A.G.
        • De Jong G.
        Life impacts following reconstructive hand surgery for tetraplegia.
        Top Spinal Cord Inj Rehabil. 2009; 15: 90-97
        • Kalsi-Ryan S.
        • Curt A.
        • Verrier M.C.
        • Fehlings M.G.
        Development of the Graded Redefined Assessment of Strength, Sensibility and Prehension (GRASSP): reviewing measurement specific to the upper limb in tetraplegia.
        J Neurosurg Spine. 2012; 17: 65-76
        • Kalsi-Ryan S.
        • Beaton D.
        • Curt A.
        • Popovic M.R.
        • Verrier M.C.
        • Fehlings M.G.
        Outcome of the upper limb in cervical spinal cord injury: profiles of recovery and insights for clinical studies.
        J Spinal Cord Med. 2014; 37: 503-510
        • Velstra I.M.
        • Curt A.
        • Frotzler A.
        • et al.
        Changes in strength, sensation, and prehension in acute cervical spinal cord injury: European Multicenter Responsiveness Study of the GRASSP.
        Neurorehabil Neural Repair. 2015; 29: 755-766
        • Mulcahey M.
        • Smith B.
        • Betz R.
        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: 41-46
        • Biering-Sørensen F.
        • Bryden A.
        • Curt A.
        • et al.
        International spinal cord injury upper extremity basic data set.
        Spinal Cord. 2014; 52: 652-657
        • Post M.W.
        • Van Lieshout G.
        • Seelen H.A.
        • Snoek G.J.
        • Ijzerman M.J.
        • 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: 763-771
        • Spooren A.I.
        • Arnould C.
        • Smeets R.J.
        • Bongers H.M.
        • Seelen H.A.
        Improvement of the Van Lieshout hand function test for tetraplegia using a Rasch analysis.
        Spinal Cord. 2013; 51: 739-744
        • Spooren A.I.
        • Arnould C.
        • Smeets R.J.
        • Snoek G.
        • Seelen H.A.
        Reference values for the transformed Van Lieshout hand function test for tetraplegia.
        Spinal Cord. 2013; 51: 745-749
        • Backus D.
        • Cordo P.
        • Gillott A.
        • Kandilakis C.
        • Mori M.
        • Raslan A.M.
        Assisted movement with proprioceptive stimulation reduces impairment and restores function in incomplete spinal cord injury.
        Arch Phys Med Rehabil. 2014; 95: 1447-1453
        • Franke A.C.
        • Snoek G.J.
        • de Groot S.
        • Nene A.V.
        • Spooren A.I.
        • Post M.W.
        Arm hand skilled performance in persons with a cervical spinal cord injury–long-term follow-up.
        Spinal Cord. 2013; 51: 161-164
        • Oleson C.V.
        • Marino R.J.
        Responsiveness and concurrent validity of the revised Capabilities of Upper Extremity-Questionnaire (CUE-Q) in patients with acute tetraplegia.
        Spinal Cord. 2014; 52: 625-628
        • McColl M.A.
        • Paterson M.
        • Davies D.
        • Doubt L.
        • Law M.
        Validity and community utility of the Canadian Occupational Performance Measure.
        Can J Occup Ther. 2000; 67: 22-30
        • Wressle E.
        • Marcusson J.
        • Henriksson C.
        Clinical utility of the Canadian Occupational Performance Measure–Swedish version.
        Can J Occup Ther. 2002; 69: 40-48
        • Eyssen I.C.
        • Beelen A.
        • Dedding C.
        • Cardol M.
        • Dekker J.
        The reproducibility of the Canadian Occupational Performance Measure.
        Clin Rehabil. 2005; 19: 888-894
        • Wressle E.
        • Samuelsson K.
        • Henriksson C.
        Responsiveness of the Swedish version of the Canadian Occupational Performance Measure.
        Scand J Occup Ther. 1999; 6: 84-89
        • Carpenter L.
        • Baker G.A.
        • Tyldesley B.
        The use of the Canadian occupational performance measure as an outcome of a pain management program.
        Can J Occup Ther. 2001; 68: 16-22
        • Veehof M.M.
        • Sleegers E.J.
        • van Veldhoven N.H.
        • Schuurman A.H.
        • van Meeteren N.L.
        Psychometric qualities of the Dutch language version of the Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH-DLV).
        J Hand Ther. 2002; 15: 347-354
        • Bourke J.A.
        • Hay-Smith E.J.
        • Snell D.L.
        • DeJong G.
        Attending to biographical disruption: the experience of rehabilitation following tetraplegia due to spinal cord injury.
        Disabil Rehabil. 2014; 14: 1-8
        • Lau A.D.
        • Cummins R.
        • McPherson W.
        An investigation into the cross-cultural equivalence of the Personal Wellbeing Index.
        Soc Indic Res. 2005; 72: 403-430
        • Johanson M.E.
        • Murray W.M.
        The effect of task demand on pinch force magnitude in subjects with spinal cord injury.
        J Neurol Phys Ther. 2007; 31: 197-198
        • Curtin M.
        Development of a tetraplegic hand assessment and splinting protocol.
        Paraplegia. 1994; 32: 159-169
        • Johanson M.E.
        • Murray W.M.
        The unoperated hand: the role of passive forces in hand function after tetraplegia.
        Hand Clin. 2002; 18: 391-398
        • Helliwell P.
        • Howe A.
        • Wright V.
        Functional assessment of the hand: reproducibility, acceptability, and utility of a new system for measuring strength.
        Ann Rheum Dis. 1987; 46: 203-208
        • Mathiowetz V.
        • Weber K.
        • Volland G.
        • Kashman N.
        Reliability and validity of grip and pinch strength evaluations.
        J Hand Surg Am. 1984; 9: 222-226
        • Rudhe C.
        • van Hedel H.J.
        Upper extremity function in persons with tetraplegia: relationships between strength, capacity, and the Spinal Cord Independence Measure.
        Neurorehabil Neural Repair. 2009; 23: 413-423
        • Smaby N.
        • Johanson M.E.
        • Baker B.
        • Kenney D.E.
        • Murray W.M.
        • Hentz V.R.
        Identification of key pinch forces required to complete functional tasks.
        J Rehabil Res Dev. 2004; 41: 215-224
        • Flood-Joy M.
        • Mathiowetz V.
        Grip-strength measurement: a comparison of three Jamar dynamometers.
        OTJR. 1987; 7: 235-243
        • Haward B.M.
        • Griffin M.J.
        Repeatability of grip strength and dexterity tests and the effects of age and gender.
        Int Arch Occup Environ Health. 2002; 75: 111-119
        • Velstra I.M.
        • Bolliger M.
        • Tanadini L.G.
        • et al.
        Prediction and stratification of upper limb function and self-care in acute cervical spinal cord injury with the graded redefined assessment of strength, sensibility, and prehension (GRASSP).
        Neurorehabil Neural Repair. 2014; 28: 632-642
        • Wangdell J.
        • Bunketorp-Käll L.
        • Koch-Borner S.
        • Fridén J.
        Early active rehabilitation after grip reconstructive surgery in tetraplegia.
        Arch Phys Med Rehabil. 2016; 97: S117-S125
        • Oess N.P.
        • Curt A.
        The advanced appreciation of upper limb rehabilitation in cervical spinal cord injury.
        in: Dietz V. Nef T. Rymer W.Z. Neurorehabilitation technology. Springer, New York2012: 191-218
      1. Connolly S, Mehta S, Foulon BL, Teasell RW, Aubut JL. Upper limb rehabilitation following spinal cord injury. Spinal Cord Injury Research Evaluation. 2010. Available at: Accessed June 22, 2015.

        • Marino R.J.
        • Patrick M.
        • Albright W.
        • et al.
        Development of an objective test of upper-limb function in tetraplegia: the capabilities of upper extremity test.
        Am J Phys Med Rehabil. 2012; 91: 478-486
        • Carswell A.
        • McColl M.A.
        • Baptiste S.
        • Law M.
        • Polatajko H.
        • Pollock N.
        The Canadian Occupational Performance Measure: a research and clinical literature review.
        Can J Occup Ther. 2004; 71: 210-222
        • Post M.W.
        • Charlifue S.
        • Biering-Sørensen F.
        • et al.
        Development of the International Spinal Cord Injury Activities and Participation Basic Data Set.
        Spinal Cord. 2015 Oct 20; ([Epub ahead of print])