Skip to main content

Thank you for visiting You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Article
  • Published:

Classification of upper-limb dysfunction severity and prediction of independence in activities of daily living after cervical spinal-cord injury


Study design

Prospective observational study.


Classification of spinal-cord injury and prediction of independence in activities of daily living (ADL) based on performance evaluations such as upper-limb function have not been reported. Therefore, this study aimed to establish a severity classification and calculate cutoff values for independence in ADL using the Capabilities of Upper Extremity Test (CUE-T) for individuals with cervical spinal-cord injury (CSCI).


A spinal-cord injury rehabilitation center in Japan.


This study included individuals with subacute CSCI. Collected data included the CUE-T and Spinal Cord Independence Measure III (SCIM III) scores. The severity classification was used for the hierarchical cluster analysis using the CUE-T. The cutoff values of CUE-T scores for independence in ADL were calculated using an adjustment model with logistic regression analysis. The dependent variable was binary (independent/non-independent) for each SCIM III Self-care item, and the independent variable was CUE-T.


A total of 71 participants were included in the analysis. The severity of upper-limb dysfunction was classified into four categories using CUE-T. Significant differences in upper-limb function and ADL were observed between clusters. The cutoff values for CUE-T score for independence in ADL ranged from 37 to 91 points. All cutoff values showed good results in the internal validation, sensitivity analysis.


This study determined the severity of upper limb function in CSCI and the cutoff values of CUE-T scores for independence in ADL. These results may help set criteria and goals for interventions in the clinical and research fields.



This is a preview of subscription content, access via your institution

Access options

Buy this article

Prices may be subject to local taxes which are calculated during checkout

Fig. 1: Characteristics of the individual subtests of the four severity classifications.
Fig. 2: Diagram combining severity classification and cutoff values.

Similar content being viewed by others

Data availability

The datasets generated during and/or analyzed during the current study are not publicly available because participants in this study did not consent to sharing their data publicly, but are available from the corresponding author on reasonable request.


  1. Golestani A, Shobeiri P, Sadeghi-Naini M, Jazayeri SB, Maroufi SF, Ghodsi Z, et al. Epidemiology of traumatic spinal cord injury in developing countries from 2009 to 2020: a systematic review and meta-analysis. Neuroepidemiology. 2022;56:219–39.

    Article  PubMed  Google Scholar 

  2. Miyakoshi N, Suda K, Kudo D, Sakai H, Nakagawa Y, Mikami Y, et al. A nationwide survey on the incidence and characteristics of traumatic spinal cord injury in Japan in 2018. Spinal Cord. 2021;59:626–34.

    Article  PubMed  Google Scholar 

  3. Simpson LA, Eng JJ, Hsieh JTC, Wolfe DL. The health and life priorities of individuals with spinal cord injury: a systematic review. J Neurotrauma. 2012;29:1548–55.

    Article  PubMed  Google Scholar 

  4. Anderson KIMD. Targeting recovery: priorities of the spinal cord-injured population. J Neurotrauma. 2004;21:1371–83.

    Article  PubMed  Google Scholar 

  5. Lu X, Battistuzzo CR, Zoghi M, Galea MP. Effects of training on upper limb function after cervical spinal cord injury: a systematic review. Clin Rehabil. 2015;29:3–13.

    Article  PubMed  Google Scholar 

  6. Jones LAT, Bryden A, Wheeler TL, Tansey KE, Anderson KD, Beattie MS, et al. Considerations and recommendations for selection and utilization of upper extremity clinical outcome assessments in human spinal cord injury trials. Spinal Cord. 2018;56:414–25.

    Article  PubMed  Google Scholar 

  7. Lena E, Baroncini I, Pavese C, Musumeci G, Volini S, Masciullo M, et al. Reliability and validity of the international standards for neurological classification of spinal cord injury in patients with non-traumatic spinal cord lesions. Spinal Cord. 2022;60:30–6.

    Article  PubMed  Google Scholar 

  8. Marino RJ, Sinko R, Bryden A, Backus D, Chen D, Nemunaitis GA, et al. Comparison of responsiveness and minimal clinically important difference of the capabilities of upper extremity test (CUE-T) and the graded redefined assessment of strength, sensibility and prehension (GRASSP). Top Spinal Cord Inj Rehabil. 2018;24:227–38.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Marino RJ, Patrick M, Albright W, Leiby BE, Mulcahey M, Schmidt-Read M, 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;91:478–86.

    Article  PubMed  Google Scholar 

  10. Marino RJ, Kern SB, Leiby B, Schmidt-Read M, Mulcahey MJ. Reliability and validity of the capabilities of upper extremity test (CUE-T) in subjects with chronic spinal cord injury. J Spinal Cord Med. 2015;38:498–504.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Woytowicz EJ, Rietschel JC, Goodman RN, Conroy SS, Sorkin JD, Whitall J, et al. Determining levels of upper extremity movement impairment by applying a cluster analysis to the fugl-meyer assessment of the upper extremity in chronic stroke. Arch Phys Med Rehabil. 2017;98:456–62.

    Article  PubMed  Google Scholar 

  12. Chen G, Lin T, Wu M, Cai G, Ding Q, Xu J, et al. Effects of repetitive transcranial magnetic stimulation on upper-limb and finger function in stroke patients: a systematic review and meta-analysis of randomized controlled trials. Front Neurol. 2022;13:940467.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Fujita T, Sato A, Yamamoto Y, Otsuki K, Tsuchiya K, Tozato F. Motor function cutoff values for independent dressing in stroke patients. Am J Occup Ther. 2016;70:7003290010p1–7.

    Article  PubMed  Google Scholar 

  14. Fujita T, Sato A, Tsuchiya K, Ohashi T, Yamane K, Yamamoto Y, et al. Relationship between grooming performance and motor and cognitive functions in stroke patients with receiver operating characteristic analysis. J Stroke Cerebrovasc Dis. 2017;26:2828–33.

    Article  PubMed  Google Scholar 

  15. Hasegawa T, Uchiyama Y, Uemura K, Harada Y, Sugiyama M, Tanaka H. Physical impairment and walking function required for community ambulation in patients with cervical incomplete spinal cord injury. Spinal Cord. 2014;52:396–9.

    Article  CAS  PubMed  Google Scholar 

  16. Kirshblum S, Snider B, Eren F, Guest J. Characterizing natural recovery after traumatic spinal cord injury. J Neurotrauma. 2021;38:1267–84.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Fawcett JW, Curt A, Steeves JD, Coleman WP, Tuszynski MH, Lammertse D, et al. Guidelines for the conduct of clinical trials for spinal cord injury as developed by the ICCP panel: Spontaneous recovery after spinal cord injury and statistical power needed for therapeutic clinical trials. Spinal Cord. 2007;45:190–205.

    Article  CAS  PubMed  Google Scholar 

  18. Van Middendorp JJ, Hosman AJF, Pouw MH, Van De Meent H. ASIA impairment scale conversion in traumatic SCI: is it related with the ability to walk? A descriptive comparison with functional ambulation outcome measures in 273 patients. Spinal Cord. 2009;47:555–60.

    Article  PubMed  Google Scholar 

  19. Marino RJ, Thomas Jefferson University: Capabilities of Upper Extremity Test (CUE-T) v1.1 (Jul 2016)—Training Video. 2024.

  20. ASIA and ISCoS International Standards Committee. The 2019 revision of the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI)-what’s new? Spinal Cord. 2019;57:815–7.

    Article  Google Scholar 

  21. Catz A, Itzkovich M, Tesio L, Biering-Sorensen F, Weeks C, Laramee MT, et al. A multicenter international study on the Spinal Cord Independence Measure, version III: Rasch psychometric validation. Spinal Cord. 2007;45:275–91.

    Article  CAS  PubMed  Google Scholar 

  22. Becker S, Bode M, Brockmann K, Gasser T, Michaelis K, Solbrig S, et al. Cognitive-driven activities of daily living impairment as a predictor for dementia in Parkinson disease: a longitudinal cohort study. Neurology. 2022;99:E2548–60.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Peball M, Krismer F, Knaus HG, Djamshidian A, Werkmann M, Carbone F, et al. Non-motor symptoms in Parkinson’s disease are reduced by nabilone. Ann Neurol. 2020;88:712–22.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  24. Terluin B, Eekhout I, Terwee CB. The anchor-based minimal important change, based on receiver operating characteristic analysis or predictive modeling, may need to be adjusted for the proportion of improved patients. J Clin Epidemiol. 2017;83:90–100.

    Article  PubMed  Google Scholar 

  25. Rosas S, Hughes RT, Farris M, Lee H, McTyre ER, Plate JF, et al. Cartilage oligomeric matrix protein in patients with osteoarthritis is independently associated with metastatic disease in prostate cancer. Oncotarget. 2019;10:4776–85.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Dolnicar S, Grün B, Leisch F, Schmidt K. Required sample sizes for data-driven market segmentation analyses in tourism. J Travel Res. 2014;53:296–306.

    Article  Google Scholar 

  27. Sandhaug M, Andelic N, Vatne A, Seiler S, Mygland A. Functional level during sub-acute rehabilitation after traumatic brain injury: course and predictors of outcome. Brain Inj. 2010;24:740–7.

    Article  PubMed  Google Scholar 

  28. Mateo S, Roby-Brami A, Reilly KT, Rossetti Y, Collet C, Rode G. Upper limb kinematics after cervical spinal cord injury: a review. J Neuroeng Rehabil. 2015;12:9.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Fujita T, Nagayama H, Sato A, Yamamoto Y, Yamane K, Otsuki K, et al. Hierarchy of dysfunction related to dressing performance in stroke patients: a path analysis study. PLoS One. 2016;11:e0151162.

    Article  PubMed  PubMed Central  Google Scholar 

Download references


The authors would like to express their gratitude to the staff at Chiba Rehabilitation Center for their help with data collection and other activities. We are grateful to Editage ( for their English language editing.

Author information

Authors and Affiliations



All authors were involved in the research design and preparation of this manuscript. Kazumasa Jimbo, Kousuke Takahama, Tomohiro Yoshimura, Honoka Shiba, Taichi Yasumori, and Naohisa Kikuchi were strongly involved in data collection at the Chiba Rehabilitation Center and in creating the data collection manual. Kazumasa Jimbo, Kazuhiro Miyata, Hiroshi Yuine, and Hideki Shiraishi were strongly involved in the post-collection data analysis.

Corresponding author

Correspondence to Kazumasa Jimbo.

Ethics declarations

Competing interests

The authors declare no competing interests.

Ethical approval

This study was approved by the ethical review committees of the Ibaraki Prefectural University of Health Sciences (approval number 1036) and Chiba Rehabilitation Center (approval number, medical 4-6) based on the Declaration of Helsinki. Participants were informed about the study in writing and were provided with an opt-out option. We certify that all applicable institutional and government regulations concerning the ethical use of human volunteers were followed during the course of this research.

Additional information

Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary information

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Jimbo, K., Miyata, K., Yuine, H. et al. Classification of upper-limb dysfunction severity and prediction of independence in activities of daily living after cervical spinal-cord injury. Spinal Cord (2024).

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • DOI:


Quick links