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F - Reaching, Grasping and Manipulation

Current Practice: Specialized Assessment of Upper Limb Function in Individuals with SCI Assessment of upper limb function in SCI rehabilitation is undertaken using multiple approaches to measure different constructs at the impairment, activity or participation levels. These measures are often used for different purposes, and to test different outcomes.2 As seen in Figure 2.0 (top portion of figure), all sites use the International Standards of Neurological Classification of Spinal Cord Injury (ISNCSCI) that account for upper limb motor function and sensation (with the exclusion of the palmar surface of the hand). Eleven of 12 sites use the Functional Independence Measure (FIM) and three of 12 sites, the Spinal Cord Independence Measure (SCIM). Both FIM and SCIM incorporate upper limb function, in the context of activities of daily living. The Canadian Occupational Performance Measure (COPM) – designed to detect change in an individual’s self-perception of occupational performance, over time – is used in only one site. The bottom portion of Figure 2.0 illustrates the paucity and heterogeneity of psychometrically robust upper limb assessments in use. Given the importance of upper extremity function to individuals with tetraplegia, the frequency of formal assessment is concerning. With the exception of the Jensen, the rest of the ten upper limb assessments (many of which incorporate reaching, grasping and manipulation), are formally used in two or less sites, making it very difficult to measure patient outcomes comprehensively, over time and across sites. Most of the measures are not specific to SCI, and with the uniqueness of the sensorimotor deficits and the therapeutic interventions, this is problematic when defining best practice. Figure 2.0 Frequency of sites reporting routine use of global asesments Figure 2.0 with upper limb elements (top ), and sites reporting routine use of specific hand function asesments (bottom ). 0 2 4 6 8 10 12 ASIA FIM SCIM COPM Jebson GRASSP Grasp-release Fugl-Meyer Jaymar or JMAR TRI-HFT Motor Activity Log Nine Hole Ahauja Hand Function Test Functional Observation Smith Hand Function Evaluation Number of Sites (n= 12) The Graded and Redefined Assessment of Strength, Sensibility and Prehension (GRASSP),2,3 a new upper limb measure developed specifically for assessment of impairment of the upper limb for individuals with tetraplegia, is being tested for responsiveness and Minimal Clinical Important Difference (MCID), in four SCI rehabilitation sites in Canada and six, in Europe. Results from the study will be important to determine its use as a routine clinical assessment as part of occupational therapy or physical therapy best practice. Details about GRASSP can be found at www.sci-grassp.org. Current Practice: Therapeutic Approaches for Upper Limb Rehabilitation in Individuals with SCI In all 12 E-Scan sites, current upper limb rehabilitation includes splinting, muscle strengthening and tone reduction as part of standard practice, as well as the use of functional activities that require enhanced postural and motor control (Figure 3.0). Important indicators regarding patient outcomes, based on these interventions, have been documented in detail, in the upper limb chapter of Spinal Cord Injury Rehabilitation Evidence (SCIRE).4 SCIRE chapter authors state that “Restorative therapy interventions need to be associated with meaningful change in functional motor performance and incorporate technology that is available in the clinic and at home”. Without formally measuring specific upper limb functional outcomes, both outside the rehabilitation setting and longitudinally, the evidence for effectiveness of the multitude of approaches will elude rehabilitation service providers and funders. It is clear that FIM and SCIM are insufficient to characterize the upper limb functions important to individuals with tetraplegia, particularly in the neurorecovery phase. Both the Toronto Rehab Hand Function Test (TRI-HFT) and the GRASSP measure show potential for addressing this void. A combination of the key elements in these measures would likely suffice, but this issue requires additional item reduction and psychometric validation. Figure 3.0 Frequency of the use of aproaches to upper limb rehabilitation 0 2 4 6 8 10 12 Posture Sitting Strengthening Core Stabilization - Shoulder Strengthen Upper Limbs ROM - Normalize Shoulder, Elbow, Wrist, Hand Standing - Reaching Tone Reduction Activity-based Training Arm Ergometry Splinting Neurodevelopmental Approach Training Sensory Motor Training Bobath Training Forced Use/Bimanual Training/Massed Practice Methods Surgical Tendon Transfers FES Training to Address Sensory Motor Recovery FES Arm Ergometry FES Neuroprosthetic Training Number of Sites with Onsite Services 70 CAPTURING CAPACITY IN CANADIAN SCI REHABILITATION


F - Reaching, Grasping and Manipulation
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