Performance-based outcome measures of dexterity and hand function in person with hands and wrist injuries: A scoping review of measured constructs

BACKGROUND

Dexterity impairments are common and disabling. Currently, there is no consensus on an operational definition to measure dexterity.

PURPOSE

This review aims to provide an overview of constructs measured by performance-based outcome measures of dexterity and hand function (PBOMD) validated for use in persons with musculoskeletal hand and wrist conditions.

STUDY DESIGN

Scoping review, with qualitative content analysis.

METHODS

MEDLINE, Embase, CINAHL, PsycINFO were searched from inception until November 2019. Three reviewers identified studies investigating the psychometric properties of PBOMD in persons with hand and wrist conditions. Original articles and manuals of validated PBOMD were obtained. Reviewers independently extracted and performed a content analysis of constructs comparing the theoretical concepts of dexterity and function.

RESULTS

Twenty PBOMD were identified. PBOMD featured 1-57 tasks and 1-8 potential grasps patterns per tool. Description of the constructs measured indicated overlap between dexterity and hand function. In newer tools, there was a greater representation of daily activities to include domains like self-care and domestic life; and measurement of qualitative aspects of performance. Concurrently, there was less focus on mobility. The majority of identified tools (70%) used speed as the criterion evaluation of performance. None of the PBOMD evaluated dexterity associated with leisure activities or modern technologies like smartphones, nor measured the ability to adapt to changing demands when completing tasks.

CONCLUSIONS

Hand function and dexterity are imprecisely defined and operationalized in PBOMD. Dexterity is a complex construct that current PBOMD incompletely captures. PBOMD often quantified as the speed of movement, ignoring other important aspects like accommodating environmental changes during task performance. Clinicians should consider tasks included in PBOMD, the quantification method, and each PBOMD's limitations when choosing PBOMD.

Psychometric properties of the Assessment of Motor and Process Skills in patients undergoing rehabilitation following hand-related disorders

Introduction

Assessment of Motor and Process Skills (AMPS) has been proven to be a suitable measurement tool for assessing performance-based ADL ability; however, its reliability and validity have not been tested on patients with hand-related disorders.

Methods

Patients referred for outpatient hand rehabilitation were assessed with AMPS, The Canadian Occupational Performance Measure (COPM), dynamometer and goniometer at baseline and after eight weeks of hand therapy. Construct validity and responsiveness of AMPS were assessed by hypothesis testing. Construct validity was assessed by correlating the baseline score of AMPS with the baseline score of the other measurement tools. Responsiveness was assessed by correlating the change scores of each measurement tool with a Global Rating Scale.

Results

Fifty-one patients were recruited. The construct validity of AMPS indicated that the various measurement tools captured different aspects to functioning from the AMPS, as the correlations between AMPS and the other measurement tools were generally weak to low (r < 0.25 to 0.49). AMPS was less responsive than COPM when correlated with the GRS. The correlation between COPM and GRS was r = 0.62 compared with the AMPS motor, r = 0.45 and AMPS process, r = 0.33. Relative responsiveness of AMPS is similar to that of the dynamometer (r = 0.39) and goniometer (r = –0.34).

Discussion

In a sample of 51 patients, this study found that the construct validity of AMPS seemed to be moderate, while the responsiveness of AMPS seemed to be poor. However, due to the small sample size no conclusions can be made, and should be further assessed in larger studies.

An occupational perspective in hand therapy: A scoping review

Introduction

There have been calls for the occupational therapy profession to realign with its values around occupation. However, the profession faces challenges in practice areas that have historically been underpinned by a biomechanical approach, such as hand therapy. The aim of this scoping review was to describe what is known about an occupational perspective in the hand therapy literature.

Method

This scoping review utilised a recognised five-step approach. A search was conducted in four databases for papers published between 2005 and 2016. Numerical and thematic analyses were employed, using the Canadian Practice Process Framework as a theoretical framework.

Results

Fifty papers were included in the scoping review. Six themes were identified: the centrality of occupation; inconsistencies in terminology; where in the occupational therapy process?; informal discussion as a key occupational strategy; occupational therapists’ expectations of patients; and a bottom-up approach focusing on biomechanical strategies to implementing the plan.

Conclusion

Whilst there has been some integration of an occupational perspective into hand therapy literature, there are still challenges. Inconsistent terminology, the lack of an occupational perspective throughout the occupational therapy process and a bottom-up approach to interventions all demonstrate the continuing tensions between the biomechanical approach and an occupational perspective.

A service evaluation of the therapy assessments used for preoperative wrist surgery assessments within a single National Health Service Trust

Introduction

Chronic wrist joint pain is complex and often managed surgically. Where pain predominates, but function and movement are good, conservative or less invasive procedures may be preferable, such as denervation. To aid surgical selection denervation effectiveness can be predicted by a wrist assessment including nerve blocks. While much literature exists for denervation surgery no research to date has explored nerve blocks from a therapy assessment perspective. The purpose of this service evaluation was to establish current assessment practice, provide an important starting point to discuss why assessments may be selected and aid understanding of the assessment service provided.

Methods

A service evaluation was undertaken. The assessments selected by three therapists for cases referred for a preoperative wrist assessment were recorded and analysed.

Results

Fourteen participants were recruited during a five-month period. The mean age was 57.43 years (range 21–79). Two assessments were terminated to address conservative management. Of the remaining 12 participants, assessments included range of motion, cumulative and resting pain 100% (n = 12), grip and pinch strength 92% (n = 11), function 17% (n = 2) and Baltimore Therapeutic Equipment static and dynamic movements 92% (n = 11).

Conclusion

This time-limited evaluation provides insight into the varied assessments used, by therapists within a single NHS Trust, to simulate activity and/or wrist structures under stress. The assessment is a global patient-centred process which aids identification of strategies for conservative and surgical procedures including denervation surgery. Despite the small sample, trends were noted in the practices of experienced hand therapists.

The inter-rater reliability of the Smith hand function test: A South African perspective

Introduction

The Smith hand function test is a performance-based hand function assessment with limited evidence on its psychometric properties. This study was conducted to investigate the inter-rater reliability of the Smith hand function test and for consideration in a developing country context.

Methods

Twenty-two participants living in Cape Town, South Africa were selected by convenience sampling. The sample performed test–retest of the Smith hand function test items four times by four different raters. The inter-rater reliability was calculated using intraclass correlation coefficients, with 95% confidence interval, testing absolute agreement and consistency.

Results

The intraclass correlation coefficients were above 0.75 for all subtests apart from the button board test item. This item had intraclass correlation coefficients of 0.579 (agreement) and 0.577 (consistency) with a standard deviation of 3.64 s and a 0.39 s standard error of measurement.

Conclusions

The inter-rater reliability of the Smith hand function test following a test–retest design by multiple raters was good. This suggests that further psychometric studies on the Smith hand function test could be valuable for clinical hand practice.

Which assessment tools address the categories of the Brief ICF Core Set for Hand Conditions?

Introduction

The purpose of this study was to explore whether assessment tools address aspects that are relevant according to the Brief ICF Core Set for Hand Conditions (BICF-CS).

Methods

Assessment tools meant to assess functioning and/or environmental factors in adults with hand conditions were reviewed. MEDLINE and CINAHL databases, previously published reviews, the book Clinical Assessment Recommendations of the ASHT, and websites of assessment tools were used for the content comparison and linking to the 23 categories of the BICF-CS. The updated version of the linking rules was applied by two reviewers.

Results

Forty-six assessment tools, known within the areas of hand therapy and hand surgery, were linked to the 23 categories of the BICF-CS. Regarding Body functions and body structures, the categories that were most frequently addressed were b730 “Muscle power functions,” b280 “Sensation of pain,” b710 “Mobility of joint functions, ” and s730 “Structure of upper extremity. ” Regarding Activities and Participation, d440 “Fine hand use” was addressed mostly and 25 assessment tools (with a total of 146 items) were linked to this category. Regarding Environmental Factors, only one assessment tool was identified that could be linked to two categories. Fifteen points of discussion were encountered in the linking process.

Conclusions

Content comparison of 46 assessment tools revealed that 19 of the 23 categories of the BICF-CS were addressed. The environmental factors were hardly addressed.

Construct validity of the canadian occupational performance measure in participants with tendon injury and Dupuytren disease

BACKGROUND

In patient-centered practice, instruments need to assess outcomes that are meaningful to patients with hand conditions. It is unclear which assessment tools address these subjective perspectives best.

OBJECTIVE

The aim of this study was to establish the construct validity of the Canadian Occupational Performance Measure (COPM) in relation to the Disabilities of Arm, Shoulder, and Hand (DASH) questionnaire and the Michigan Hand Outcomes Questionnaire (MHQ) in people with hand conditions. It was hypothesized that COPM scores would correlate with DASH and MHQ total scores only to a moderate degree and that the COPM, DASH questionnaire, and MHQ would all correlate weakly with measures of hand impairments.

DESIGN

This was a validation study.

METHODS

The COPM, DASH questionnaire, and MHQ were scored, and then hand impairments were measured (pain [numerical rating scale], active range of motion [goniometer], grip strength [dynamometer], and pinch grip strength [pinch meter]). People who had received postsurgery rehabilitation for flexor tendon injuries, extensor tendon injuries, or Dupuytren disease were eligible.

RESULTS

Seventy-two participants were included. For all diagnosis groups, the Pearson coefficient of correlation between the DASH questionnaire and the MHQ was higher than .60, whereas the correlation between the performance scale of the COPM and either the DASH questionnaire or the MHQ was lower than .51. Correlations of these assessment tools with measures of hand impairments were lower than .46.

LIMITATIONS

The small sample sizes may limit the generalization of the results.

CONCLUSIONS

The results supported the hypotheses and, thus, the construct validity of the COPM after surgery in people with hand conditions.

Test-retest reliability and convergent validity of a computer based hand function test protocol in people with arthritis

OBJECTIVES

A computer based hand function assessment tool has been developed to provide a standardized method for quantifying task performance during manipulations of common objects/tools/utensils with diverse physical properties and grip/grasp requirements for handling. The study objectives were to determine test-retest reliability and convergent validity of the test protocol in people with arthritis.

METHODS

Three different object manipulation tasks were evaluated twice in forty people with rheumatoid arthritis (RA) or hand osteoarthritis (HOA). Each object was instrumented with a motion sensor and moved in concert with a computer generated visual target. Self-reported joint pain and stiffness levels were recorded before and after each task. Task performance was determined by comparing the object movement with the computer target motion. This was correlated with grip strength, nine hole peg test, Disabilities of Arm, Shoulder, and Hand (DASH) questionnaire, and the Health Assessment Questionnaire (HAQ) scores.

RESULTS

The test protocol indicated moderate to high test-retest reliability of performance measures for three manipulation tasks, intraclass correlation coefficients (ICCs) ranging between 0.5 to 0.84, p<0.05. Strength of association between task performance measures with self- reported activity/participation composite scores was low to moderate (Spearman rho <0.7). Low correlations (Spearman rho < 0.4) were observed between task performance measures and grip strength; and between three objects' performance measures. Significant reduction in pain and joint stiffness (p<0.05) was observed after performing each task.

CONCLUSION

The study presents initial evidence on the test retest reliability and convergent validity of a computer based hand function assessment protocol in people with rheumatoid arthritis or hand osteoarthritis. The novel tool objectively measures overall task performance during a variety of object manipulation tasks done by tracking a computer based visual target. This allows an innovative method of assessing performance than considering the time taken to complete a task or relying on subjective measures of self-reports on a limited range of objects and tasks covered. In addition, joint pain and stiffness levels before and after a manipulation task are tracked, which is lacking in other hand outcome measures. Performance measures during a broad range of object manipulation tasks relate to many activities relevant to life role participation. Therefore, task performance evaluation of common objects, utensils, or tools would be more valuable to gauge the difficulties encountered in daily life by people with arthritis. Future studies should consider a few revisions of the present protocol and evaluate a number of different objects targeting strength, fine, and gross dexterity based tasks for a broader application of the tool in arthritis populations.

Do patient-reported outcome measures capture functioning aspects and environmental factors important to individuals with injuries or disorders of the hand?

STUDY DESIGN

Qualitative study.

INTRODUCTION

Clinical outcome evaluation needs to consider the patient perspective for an in-depth understanding of functioning and disability.

PURPOSE OF THE STUDY

To explore whether patient-reported outcome measures (PROMs) used in the field of hand injuries or hand disorders, capture functioning aspects and environmental factors important to the patients.

METHODS

We performed a qualitative study and a systematic literature review. The focus group sessions were recorded, transcribed verbatim, and the identified concepts were linked to the ICF. We searched in MEDLINE for reviews, related to injuries or disorders of the hand, reporting on PROMs. We linked the items of the identified PROMs to the ICF and compared the qualitative data with the content of the PROMs.

RESULTS

Statements from 45 individuals who participated in eight focus groups were linked to 97 categories of the ICF. From 15 reviews included, eight PROMs were selected. The selected PROMs capture 34 of the categories retrieved from the qualitative data.

CONCLUSIONS

PROMs used in the context of hand injuries or hand disorders capture only in parts the functioning aspects important to the patients.

Evaluation of Non Diseased Specified Outcome Measures in Hand Injuries to Assess Activity and Participation Based on ICF Content

The objective of the study is to provide information about non disease specified outcome measures which evaluate disability in patients who have impairments in hand and upper extremity and to find the extent to which they are evaluating "disability" based on ICF hand Core Set (activity limitation and participation restriction). MEDLINE, CINAHL, GOOGLE SCHOLAR , OVID and SCIENCE DIRECT databases were systematically searched for studies on non disease specified outcome measures used to evaluate upper extremity function; only studies written in English were considered. We reviewed titles and abstracts of the identified studies to determine whether the studies met predefined eligibility criteria (eg, non disease specified out come measures used in hand injured patients). All the outcome measures which had eligibility included. After full text review ,7 non disease specified outcome measures in hand were identified. Studies were extracted, and the information retrieved from them. All the outcome measures which had incuded, were linked with ICF hand core set disability part (activity and participation). All of them only linked to 16 (42 %) components of ICF hand Core Set, which were most activity and less participation from ICF. None of the non disease specified out come measures in hand injuries cover all domains of disability from the ICF Hand Core Set.

Clinimetric evaluation of questionnaires used to assess activity after traumatic brachial plexus injury in adults: a systematic review

OBJECTIVES

To identify upper limb questionnaires used in the brachial plexus injury (BPI) literature to assess activities and to evaluate their clinimetric properties. DATA SOURCES; STUDY SELECTION;

DATA EXTRACTION

This systematic review was undertaken in 2 stages. In stage 1, 10 electronic databases and 1 Internet journal were searched for quantitative studies (ie, randomized controlled trials, comparative studies, case series, and case studies) that evaluated outcome after BPI, irrespective of language or date of publication, from date of database inception to September 2010. All outcome instruments used were extracted and classified using the International Classification of Functioning, Disability and Health framework. Questionnaires were identified that apportioned >50% of the total score to the assessment of upper limb activity. In stage 2, 4 electronic databases were searched for papers that evaluated the clinimetric properties of all identified activity questionnaires with respect to peripheral nerve injuries of the upper limb. Two independent reviewers assessed the clinimetric properties of identified questionnaires according to standardized criteria.

DATA SYNTHESIS

Stage 1 identified 4324 papers, of which 265 met the inclusion criteria. One hundred and three outcome measures were identified, the majority of which assess body function or body structure. Twenty-nine questionnaires assessed upper limb activity. Two questionnaires, the ABILHAND and Disability of the Arm, Shoulder and Hand (DASH), attributed >50% of the overall score to activity of the upper limb. The DASH had some published evidence of clinimetric properties in individuals with peripheral nerve injuries. Neither had been clinimetrically evaluated for BPI, nor met all quality criteria.

CONCLUSIONS

Day-to-day activities of the upper limb are infrequently evaluated after BPI. While attempts have been made to measure activity, there is a paucity of clinimetric evidence on activity questionnaires for individuals with BPI. We recommend that a core set of items be developed which evaluate activity, as well a body structure, body function, and participation.

Validation of the Comprehensive International Classification of Functioning, Disability and Health (ICF) Core Set for Hand Conditions

Introduction

The Comprehensive International Classification of Functioning, Disability and Health (ICF) Core Set for Hand Conditions has been developed as a tool to describe functioning in individuals with hand conditions. The purpose of this study was to validate the ICF Core Set in a multicentre study in Germany.

Methods

We conducted a cross-sectional multicentre study involving individuals with various types of hand injuries or disorders from hand trauma units and rehabilitation facilities in Germany. We performed structured patient interviews using the Comprehensive ICF Core Set for Hand Conditions to investigate whether all of its categories are necessary to describe patients' functioning. Patients additionally completed the Disabilities of the Arm, Shoulder and Hand Questionnaire (DASH).

Results

The study sample comprised 260 individuals (65% men) with a mean age of 46 years. Participants had a mean DASH score of 42.7 (22.25 SD) and a median time since injury or diagnosis of 106 days. Most frequent diagnoses were fractures at forearm, wrist and hand level. We identified patients' problems in all ICF categories of the Comprehensive ICF Core Set for Hand Conditions with a prevalence of at least 10%. Two ICF categories were perceived as missing: ‘b4352 – functions of lymphatic vessels’ and ‘b298 – sensory functions and pain, other specified – neuralgia in upper extremity’.

Discussion

The Comprehensive ICF Core Set for Hand Conditions has been validated in this national multicentre study. All of its categories could thereby be confirmed. Further validation is needed, involving different study samples in different countries worldwide.