Upper Extremity Function in Individuals With Paraplegia: Relationships Between Endurance, Performance, and Symptoms

ASIA Scale

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The most sensitive method for evaluating a patient with spinal cord injury is a standardized physical examination. The International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI), developed by the American Spinal Injury Association (ASIA) and also endorsed by the International Spinal Cord Society (ISCoS), has become the most widely used standardized clinical assessment and classification method worldwide in recent years.

6-Minute Pegboard and Ring Test (6PBRT)

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Unsupported functional arm exercise capacity was assessed using the 6-Minute Pegboard and Ring Test (6PBRT). During the 6PBRT, patients sat in front of a board with two bars placed at individual shoulder height and width, with two additional bars positioned 20 cm above these, each holding ten rings. Participants were asked to practice by placing several rings before the test began. They were then instructed to move the rings as quickly as possible from the lower holes to the upper holes and back again for 6 minutes. Standardized encouragement was given every minute during the test. Systolic blood pressure (SBP), diastolic blood pressure (DBP) were measured using an aneroid sphygmomanometer (Erka, Bad Tölz, Germany), while heart rate (HR) and oxygen saturation (SpO2) were monitored with a pulse oximeter (Nonin Palmsat® 2500 series, Plymouth, MN, USA) both before and after the test. Perceived dyspnea, general fatigue, and arm fatigue were recorded using the Modified Borg Scale (mBS/0-10

PURDUE PEGBOARD TEST

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After injuries, limitations in functional activities requiring fine motor skills that are commonly used in daily life have created the need to assess this function. The Purdue Pegboard Test, which evaluates fine motor skills, has become established in the healthcare field. It is suitable for assessing hand functions. The test consists of 5 subtests. One of these includes only a mathematical total score, while in the other 4 subtests, the individual actively performs tasks: Placing pins with the dominant hand (for 30 seconds) Placing pins with the non-dominant hand (for 30 seconds) Placing pins with both hands simultaneously (for 30 seconds) Mathematical total Placing pins, washers, and nuts (for 60 seconds) The test score is the total number of pins or pins, washers, and nuts placed at the end of the allotted time.

DASH Questionnaire

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The Disabilities of the Arm, Shoulder, and Hand Questionnaire (DASH) was developed in 1994 by the American Academy of Orthopaedic Surgeons (Hudak et al., 1996) to evaluate functional status and symptoms by focusing on physical function in upper extremity injuries. The DASH questionnaire consists of three sections. The first section contains 30 questions; 21 questions assess the patient's difficulty during daily living activities, 5 questions evaluate symptoms (pain, activity-related pain, tingling, stiffness, weakness), and the remaining 4 questions assess social function, work, sleep, and patient confidence. This first section determines the patient's Function/Symptom (DASH-FS) score. According to the DASH questionnaire results, a score between 0 and 100 is obtained for each section (0 = no disability, 100 = maximum disability).

Grip Strength

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For the assessment of grip strength, the Jamar hand dynamometer (Fabrication Enterprises, New York, USA) was used, which is recommended by the American Society of Hand Therapists and is widely recognized in the literature for its high validity and reliability; therefore, it is considered the gold standard. Measurements were taken with the participant seated in an upright, supported position, with the elbow flexed at 90°, the arm adducted to the trunk, and the forearm in a neutral position. Assessments were performed three times for both the dominant and non-dominant hands, with a one-minute rest period between each measurement. The mean value of the three trials was recorded in kilograms-force (kgF) for both the affected and unaffected sides. In the interpretation of the results, the percentage of normative values based on age and gender was used.

Functional Independence Measure (FIM)

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The Functional Independence Measure (FIM) is a widely used assessment tool developed to evaluate the level of functional independence in individuals with physical disabilities. It consists of 18 items, grouped under two major domains: motor (13 items) and cognitive (5 items). The motor domain includes self-care, sphincter control, mobility, and locomotion, while the cognitive domain evaluates communication and social cognition. Each item is scored on a 7-point ordinal scale, where: 1 = total assistance required, 7 = complete independence. The total FIM score ranges from 18 to 126, with higher scores indicating greater functional independence. FIM is commonly used in rehabilitation settings to track patient progress, evaluate treatment effectiveness, and plan discharge and follow-up care.

Assessment of Physical Activity Level: Physical Activity Scale for Individuals with Physical Disabilities (PASIPD)

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The Physical Activity Scale for Individuals with Physical Disabilities (PASIPD) is a 13-item self-report questionnaire assessing daily activities, household tasks, and occupational roles over the past 7 days. It includes activities such as leisure-time exercise, sports, household chores, caregiving, and work-related tasks. Participants report the frequency (never to often) and duration (\<1 hour to \>4 hours/day) of each activity. The total score is calculated by multiplying the average time spent on each activity by its corresponding MET value. Item 1 is not scored and is intended for familiarization only.