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Subject of the scale: Spinal cord injury

International Classification for Surgery of the Hand in Tetraplegia (ICSHT - Giens)


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The International Classification for Surgery of the Hand in Tetraplegia (ICSHT) was presented in 1978, in its first version, at the 1st International Conference on Surgical Rehabilitation of the Upper Limb in Tetraplegic Patients in Edinburgh (Scotland) [1] then reworked, almost definitively, in 1984. This was the Giens classification ratified at the 2nd conference in Giens (France) [2].

More than 30 years ago the Giens classification became the reference tool to describe residual neuromotor resources and establish the surgical strategy on the tetraplegic upper limb. It is presented under 2 areas of evaluation:

1) The motor evaluation: This makes it possible to rank the upper limb from 0 to 10 according to the active residual muscles below the elbow which can be transferred. It assumes that the muscle is scored at least 4/5 MRC to enable classification in the corresponding group. It is the characterisation of group 3 which is the most difficult because the distinction of the strength of each of the ECR (extensor carpi radialis longus and brevis) is sometimes subject to discussion.

It is agreed that other key muscles, not classified, must be taken into account: the triceps brachii, biceps brachii, deltoideus posterior, pectoralis major clavicularis and latissimus dorsi.

1) The sensitive evaluation: This relies on a 2-point discriminative sensitivity test applied to the pad of the thumb and the index finger. The discriminative sensitivity is thus considered as intact if 2 points are discriminated at a distance ? 10mm. In this case, or in the opposite case, the mention Cutaneous Cu+/Cu- is applied.

Lastly, the existence or absence of spasticity (Sp+/Sp-) and visual substitution (Ocular O+/O-) complete the description of the upper limb.

For example, the upper right limb may be classified 4, Sp+, Cu+ and O+ and the upper left limb 5, Sp-, Cu+ and O+. Some authors add the concept of T+ or T- and P+ or P- depending on whether or not, respectively, the triceps brachii and the pectoralis major clavicularis are present.

In routine practice, only the motor examination is really taken into account in the surgical strategy.

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Psychometric properties:


Psychometric properties



Face validity

[1] [2]

Content validity


Criterion validity

Concurrent validity


Predictive validity


Construct validity

Convergent validity


Divergent validity


Discriminant validity
(sensitivity and distinctiveness)



Intra-rater reliability


Inter-rater reliability




Internal consistency (alpha)




General comment on reliability:

The metrological qualities of the ICSHT have never been studied as such.
They rely on the properties of the motor examination undertaken in compliance with MRC (Medical Research Council) recommendations and those of the 2-point discrimination test.

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Inaugural references:

[1] McDowell CL, Moberg EA, Smith AG. International conference on surgical rehabilitation of the upper limb in tetraplegia. J Hand Surg Am. 1979 Jul;4(4):387-90. PubMed PMID: 38273.

[2] McDowell CL, Moberg EA, House JH. Proceedings: Second international conference on surgical rehabilitation of the upper limb in tetraplegia. J Hand Surg [Am]. 1986; 11: 604–608.

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