• The upper extremity motor score (UEMS) is a subscale of the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) that assesses upper extremity muscle strength.
  • Previous research suggests that individual UEMS or LEMS scores alone (rather than total ISNCSCI scores) better predict upper limb or lower limb function (Marino & Graves, 2004; Graves, 2006).

Clinical Considerations

  • The score range is 0–5 for each of 5 key muscles (elbow flexors, wrist extensors, elbow extensors, long finger flexors, and small finger abductor) of each arm, with a maximum score of 50.

ICF Domain

Body Function ▶ Neuromusculoskeletal & Movement-related Functions and Structures

Administration

  • Clinician-administered.
  • The UEMS, along with the ISNCSCI exam should be performed in the supine position (except for the rectal examination that can be performed side-lying) to ensure scores collected are standard and comparable.
  • During each myotome / muscle group testing, the assessor should start the assessment in “grade 3” by default. Depending on the performance of the patient in each test, then the assessor will move forward to Grade 4-5 or Grade 0-2. Please refer to the worksheet to see the patient positions and testing procedures for each muscle group and grade.

Number of Items

10 locations (myotomes) (5 on each side of the body):

  • C5 – elbow flexors
  • C6 – wrist extensors
  • C7 – elbow extensors
  • C8 – long finger flexors
  • T1 – small finger abductor

Equipment

N/A

Scoring

Each myotome is rated from 0 to 5:

  • Grade 0 = Total paralysis
  • Grade 1 = Palpable or visible contraction
  • Grade 2 = Active movement, full range of motion (ROM) with gravity eliminated
  • Grade 3 = Active movement, full ROM against gravity
  • Grade 4 = Active movement, full ROM against gravity and moderate resistance in a muscle specific position
  • Grade 5 = (Normal) active movement, full ROM against gravity and full resistance in a functional muscle position expected from an otherwise unimpaired person

The maximum score is 50.

Languages

ISNCSCI Worksheet is available in many languages: https://asia-spinalinjury.org/isncsci-worksheet-now-available-in-other-languages/

Training Required

Training is mandatory. The International Standards Training e-Learning Program (InSTeP) is a five-module course (including basic anatomy, sensory examination, motor examination, anorectal examination, and scoring, scaling, and the AIS classification) designed to enable clinicians to perform accurate and consistent SCI neurological examinations of individuals with SCI. Visit ASIA-SpinalInjury.org for more information.

Availability

Measurement Property Summary

# of studies reporting psychometric properties: 1

Interpretability

MCID:

  • MID by injury level and severity:
    • Cervical A = 2.91
    • Cervical B = 2.1
    • Cervical C = 2.42
    • Cervical D = 1.9
  • Effect size-based estimate for small/large changes in UEMS scores:
    • Cervical A = 2.94/7.35
    • Cervical B/C = 2.32/5.8
    • Cervical D = 2.18/5.45

(Scivoletto et al. 2013; n=661; 440 males; mean age: 50.35 years; 233 ASIA A, 67 ASIA B, 158 ASIA C, 142 ASIA D; mean (SD) time since injury = 51.6(36.8) days)

SEM: not established in SCI

MDC: 2.0

(Marino et al. 2008; n=16; 16 examiners; 10 males; 5 complete tetraplegia, 5 motor incomplete tetraplegia, 5 complete paraplegia, 1 motor incomplete paraplegia)

Smallest Real Difference: 1.3

(Tester et al. 2016; n=72, 57 males, 15 females; mean age: 36 years; median time since injury: 0.7 years; ASIA A-D)

Typical values

Mean (SD) UEMS scores Admission to Discharge:

  • Cervical A = 19.3(14.7) to 23.6(14.4)
  • Cervical B = 19.05(11.6) to 28(9.3)
  • Cervical C = 23.8(11.6) to 37(12.6)
  • Cervical D = 35.4(10.9) to 41.2(7.9)

(Scivoletto et al. 2013; n=661; 440 males; mean age: 50.35 years; 233 ASIA A, 67 ASIA B, 158 ASIA C, 142 ASIA D; mean (SD) time since injury = 51.6(36.8) days)

Reliability – High

  • Internal consistency is High for the UEMS (Cronbach’s a = 0.995)

(Lena et al. 2021; n=140, 92 males, 48 females; mean (SD) age: 60 (16) years; 30 cervical, 78 thoracic, 32 lumbar; ASIA A-D)

  • Inter-rater reliability is High for the UEMS (r = 0.931; ICC = 0.98)

(Lena et al. 2021; n=140, 92 males, 48 females; mean (SD) age: 60 (16) years; 30 cervical, 78 thoracic, 32 lumbar; ASIA A-D)
(Marino et al. 2008; n=16; 16 examiners; 10 males; 5 complete tetraplegia, 5 motor incomplete tetraplegia, 5 complete paraplegia, 1 motor incomplete paraplegia; only test performed in incomplete SCI)

Validity – Moderate to High

  • Moderate correlation with SCIM self-care subscore: r = 0.407, p<0.001

(Lena et al. 2021; n=140, 92 males, 48 females; mean (SD) age: 60 (16) years; 30 cervical, 78 thoracic, 32 lumbar; ASIA A-D)

  • High correlation with the Duruöz Hand Index (DHI): r = -0.80, p = 0.001

(Misirlioglu et al. 2016; n=40; mean age: 35.6 years; duration of injury: 116.7 years)

  • High correlation with the Capabilities of Upper Extremity Test (CUE-T): r = 0.83-0.91

(Marino et al. 2015; n=50, 36 males, 14 females; mean age: 48.1 years; ASIA A-D)
(Marino et al. 2012; n=30, 23 males, 7 females; mean age: 44.8 years; chronic SCI; complete and incomplete SCI)

  • High correlation with the Revised CUE-Q total (at admission and at discharge): r = 0.70-0.89

(Oleson & Marino 2014; n=46, 42 males, 4 females; median age: 44 years; ASIA A-D)

  • High correlations with the GRASSP Strength subscale (at 1-, 3-, 6-, and 12-months post-injury): r = 0.89-0.96

(Kalsi-Ryan et al. 2016; N =53 (48M, 5F); Mean (SD) age 49.6 (15.6); All acute SCI, 0-10 days post-injury; AIS-A/B/C/D: 11/5/16/21; Level of injury: 51 cervical, 2 thoracic) 

  • High correlation with the short-form QIF: r = 0.824

(Marino & Goin 1999; n=95, 85 males, 10 females; mean (SD) age: 31.2 (13.2) years; tetraplegia)

  • Moderate correlation with the Neuromuscular Recovery Scale (NRS) Overall Phase and Summary Score: r = 0.41-0.49

(Harkema et al. 2016; n=152; 123 male; mean age: 36 years; 43 ASIA A, 21 ASIA B, 39 ASIA C, 49 ASIA D; median (range) time post-SCI: 0.9 (0.1-45.2) years)

  • High correlation with the FIM: r = 0.741

(Marino et al. 2008; n=154; mean age: 37 years; chronic SCI; ASIA A-D)

Responsiveness

  • Effect size: 0.69-1.29

(Velstra et al. 2015; n=74; 51 males; mean age: 49 years; at one month: 18 ASIA A, 12 ASIA B, 10 ASIA C, 34 ASIA D; acute SCI at study enrollment, measured 1,3,6,12 months post-SCI)
(Oleson & Marino 2014; n=46, 42 males, 4 females; median age: 44 years; ASIA A-D

  • Standardized Response Means: 0.38

(Post locomotor training; breakdown by AIS levels available in research summary; Harkema et al. 2016; n=152; 123 male; mean age: 36 years; 43 ASIA A, 21 ASIA B, 39 ASIA C, 49 ASIA D; median (range) time post-SCI: 0.9 (0.1-45.2) years)

Floor/Ceiling Effect

42% of participants at ceiling (score 50)

(Marino & Graves 2004; n=4338, 3443 males; 854 complete tetraplegia, 1464 incomplete tetraplegia, 1195 complete paraplegia, 825 incomplete paraplegia, 2049 ASIA A, 511 ASIA B, 655 ASIA C, 1123 ASIA D; median (IQR) time since injury = 15 (9-28) days)

Reviewers

Dr. Janice Eng, Dr. Carlos L. Cano-Herrera, Matthew Querée

Date Last Updated

31 December 2024

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https://pubmed.ncbi.nlm.nih.gov/16572564/

Harkema SJ, Shogren C, Ardolino E, Lorenz DJ. Assessment of Functional Improvement without Compensation for Human Spinal Cord Injury: Extending the Neuromuscular Recovery Scale to the Upper Extremities. J Neurotrauma. 2016; 33: 2181-2190. doi: 10.1089/neu.2015.4213.
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Lena E, Baroncini I, Pavese C, Musumeci G, Volini S, Masciullo M, Aiachini B, Fizzotti G, Puci MV, Scivoletto G. 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: 30-36. doi: 10.1038/s41393-021-00675-9.
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Marino RJ, Graves DE. Metric properties of the ASIA motor score: subscales improve correlation with functional activities. Arch Phys Med Rehabil. 2004; 85: 1804-10. doi: 10.1016/j.apmr.2004.04.026.
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Marino RJ, Jones L, Kirshblum S, Tal J, Dasgupta A. Reliability and repeatability of the motor and sensory examination of the international standards for neurological classification of spinal cord injury. J Spinal Cord Med. 2008; 31: 166-70. doi: 10.1080/10790268.2008.11760707.
https://pubmed.ncbi.nlm.nih.gov/18581663/

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. doi: 10.1179/2045772314Y.0000000272.
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Marino RJ, Patrick M, Albright W, Leiby BE, Mulcahey M, Schmidt-Read M, Kern SB. Development of an objective test of upper-limb function in tetraplegia: the capabilities of upper extremity test. Am J Phys Med Rehabil. 2012 ;91(6):478-86. doi: 10.1097/PHM.0b013e31824fa6cc.
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Oleson CV, Marino RJ. Responsiveness and concurrent validity of the revised capabilities of upper extremity-questionnaire (CUE-Q) in patients with acute tetraplegia. Spinal Cord. 2014; 52: 625-8. doi: 10.1038/sc.2014.77.
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Velstra IM, Curt A, Frotzler A, Abel R, Kalsi-Ryan S, Rietman JS, Bolliger M. Changes in Strength, Sensation, and Prehension in Acute Cervical Spinal Cord Injury: European Multicenter Responsiveness Study of the GRASSP. Neurorehabil Neural Repair. 2015; 29: 755-66. doi: 10.1177/1545968314565466.
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