CHAPTER 12
Functional Tests

ELAINE EWING FESS, MS, OTR, FAOTA, CHT*

“Rule #1: When you get a bizarre finding, first question the test.”^†

Communication is the underlying rationale for requiring good assessment procedures. The acquisition and transmission of knowledge, both of which are fundamental to patient treatment and professional growth, are enhanced through development and use of a common professional language based on strict criteria for functional assessment instrument selection. The use of “home-brewed,” functional evaluation tools that are inaccurate or not validated is never appropriate since their baseless data may misdirect or delay therapy intervention. The purpose of this chapter is twofold: (1) to define functional measurement terminology and criteria and (2) to review current upper extremity functional assessment instruments in relation to accepted measurement criteria. It is not within the scope of this chapter to recommend specific test instruments. Instead, readers are encouraged to evaluate the instruments used in their practices according to accepted instrument selection criteria,1 keeping those that best meet the criteria and discarding those that do not.

Instrumentation Criteria

Standardized functional tests, the most sophisticated of assessment tools, are statistically proven to measure accurately and appropriately when proper equipment and procedures are used. The few truly standardized tests available in hand/upper extremity rehabilitation are limited to instruments that evaluate hand coordination, dexterity, and work tolerance. Unfortunately, not all functional tests meet all of the requirements of standardization.

Primary Requisites

Reliability defines the accuracy or repeatability of a functional test. In other words, does the test measure consistently between like instruments; within and between trials; and within and between examiners? Statistical proof of reliability is defined through correlation coefficients. Describing the “parallelness” between two sets of data, correlation coefficients may range from +1.0 to −1.0. Devices that follow National Institute of Standards and Technology (NIST) standards, for example, a dynamometer, usually have higher reliability correlation coefficients than do tests for which there are no governing standards. When prevailing standards such as those from NIST exist for a test, use of human performance to establish reliability is unacceptable. For example, you would not check the accuracy of your watch by timing how long it takes five people to run a mile and then computing the average of their times. Yet, in the rehabilitation arena, this is essentially how reliability of many test instruments has been documented.2

Once a test’s instrument reliability is established, inter-rater and intrarater reliability are the next steps that must be confirmed. Although instrument reliability is a non-negotiable prerequisite to defining rater reliability, researchers and commercial developers often ignore this critical step, opting instead to move straight to establishing rater reliability with its less stringent, human performance-based paradigms.³ The fallacy of this fatal error seems obvious, but if a test instrument measures consistently in its inaccuracy, it can produce misleadingly high rater reliability scores that are completely meaningless. For example, if four researchers independently measure the length of the same table using the same grossly inaccurate yardstick, their resultant scores will have high inter-rater and intrarater reliability so long as the yardstick consistently maintains its inherent inaccuracies and does not change (Fig. 12-1). Unfortunately, this scenario has occurred repeatedly with clinical and research assessment tools, involving mechanical devices and paper-and-pencil tests alike.

Equipment criteria are essential to the reliability and validity of a functional assessment test instrument. Unless absolutely identical in every way, the paraphernalia constituting a standardized test must not be substituted for or altered, no matter how similar the substituted pieces may be. Reliability and validity of a test are determined using explicit equipment. When equipment original to the test is changed, the test’s reliability and validity are rendered meaningless and must be reestablished all over again. An example, if the wooden checkers in the Jebsen Taylor Hand Function Test are replaced with plastic checkers, the test is invalidated.4

Administration, scoring, and interpretation instructions provide procedural rules and guidelines to ensure that testing processes are exactingly conducted and that grading methods are fair and accurate. The manner in which functional assessment tools are employed is crucial to accurate and honest assessment outcomes. Test procedure and sequence must not vary from that described in the administration instructions. Deviations in recommended equipment procedure or sequence invalidate test results. A cardinal rule is that assessment instruments must not be used as therapy practice tools for patients. Information obtained from tools that have been used in patient training is radically skewed, rendering it invalid and meaningless. Patient fatigue, physiologic adaptation, test difficulty, and length of test time may also influence results. Clinically this means that sensory testing is done before assessing grip or pinch; rest periods are provided appropriately; and if possible, more difficult procedures are not scheduled early in testing sessions. Good assessment technique should reflect both test protocol and instrumentation requirements. Additionally, directions for test interpretation are essential. Functional tests have specific application boundaries. Straying beyond these clearly defined limits leads to exaggeration or minimization of inherent capacities of tests, generating misguided expectations for staff and patients alike. For example, goniometric measurements pertain to joint angles and arcs of motion. They, however, are not measures of joint flexibility or strength.

Although, not a primary instrumentation requisite, a bibliography of associated literature is often included in standardized test manuals. These references contribute to clinicians’ better appreciation and understanding of test development, purpose, and usage.

Secondary Requisites

Normative data are drawn from large population samples that are divided, with statistically suitable numbers of subjects in each category, according to appropriate variables such as hand dominance, age, sex, occupation, and so on. Many currently available tests have associated so-called normative data, but they lack some or, more often, all of the primary instrumentation requisites, including reliability; validity; purpose statement; equipment criteria; and administration, scoring, and interpretation instructions. Regardless of how extensive a test’s associated normative information may be, if the test does not meet the primary instrumentation requisites, it is useless as a measurement instrument.5

Tertiary Options

Sensitivity, a statistical measure, defines the proportion of correctly identified positive responses in a subject population. In other words, sensitivity tells, in terms of percentages, how good a test is at properly identifying those who actually have the diagnosis (Fig. 12-2).⁶ The mnemonic “SnNout” is often associated with Sensitivity, indicating that a Negative test result rules out the diagnosis.⁷ As an example, out of a population of 50, if a test correctly identifies 15 of the 20 people who have the diagnosis and who test positive (TP), the sensitivity of the instrument is 75.0% (TP/[TP + FN] = sensitivity %).*

Specificity, also a statistical measure, defines the proportion of negative results that are correctly identified in a subject population. Specificity, in the form of a percentage, tells how good a test is at correctly identifying those who do not have the diagnosis (see Fig. 12-2).⁶ “SpPin,” the mnemonic associated with Specificity, designates that a Positive test result rules in the diagnosis.⁷ If out of the same example population of 50 subjects, the test correctly identifies 12 of 30 people who do not have the diagnosis who test negative (TN), the specificity of the test is 40.0% (TN/[TN + FP] = specificity %).^†

Predictive values define the chances of whether positive or negative test results will be correct. A positive predictive value looks at the true positives and false positives a test generates and defines the odds of a positive test being correct in terms of a percentage.⁶ Using the examples previously mentioned, 18 of 33 positive test results were true positives (pink), resulting in a positive predictive value of 54.5%. Conversely, a negative predictive value specifies, in terms of percentage, the chances of a negative test result being correct by looking at the true negatives and false negatives it generates. In the previous example, 12 of 17 negative test results were true negatives (blue), for a 70.6% negative predictive value. The advantage of predictive values is that they change as the prevalence of the diagnosis changes. Loong’s 2003 article, “Understanding sensitivity and specificity with the right side of the brain” is an excellent reference for students and those who are new to these concepts.⁶

It is important to remember that sensitivity, specificity, and predictive values have higher accuracy when test instruments meet the primary instrumentation requisites addressed earlier in this section. If a test measures inconsistently or inappropriately, or if instrumentation equipment or procedural guides are disregarded, the test’s respective sensitivity, specificity, and predictive value percentages are compromised.

Additional Considerations

Scale refers to the basic measurement unit of an instrument. Scale should be suitably matched to the intended clinical application. For example, if a dynamometer measures in 10-pound increments and a patient’s grip strength increases by a half a pound per week, it would take 20 weeks before the dynamometer would register the patient’s improvement. The dynamometer in this example is an inappropriate measurement tool for this particular clinical circumstance because its scale is too gross to measure the patient’s progress adequately.

Range involves the scope or breadth of a measurement tool, in other words, the distance between the instrument’s beginning and end values. The range of an instrument must be appropriate to the clinical circumstance in which it will be used. For example, the majority of dynamometers used in clinical practice have a range from 0 to 200 pounds and yet, grip scores of many patients in rehabilitation settings routinely measure less than 30 pounds. Furthermore, the accuracy of most test instruments is diminished in the lowest and highest value ranges. This means that clinicians are assessing clients grip strength using the least accurate, lower 15% of available dynamometer range. With 85% of their potential ranges infrequently used, current dynamometers are ill suited to acute rehabilitation clinic needs. However, these same dynamometers are well matched to work-hardening situations where grip strengths more closely approximate the more accurate, midrange values of commercially available dynamometers.

Standardized Tests Versus Observational Tests

Computerized Assessment Instruments

Computerized assessment tools must meet the same primary measurement requisites as noncomputerized instruments. Unfortunately, both patients and medical personnel tend to assume that computer-based equipment is more trustworthy than noncomputerized counterparts. This naive assumption is erroneous and predisposed to producing misleading information. In hand rehabilitation, some of the most commonly used noncomputerized evaluation tools have been or are being studied for instrument reliability and validity (the two most fundamental instrumentation criteria). However, at the time of this writing, none of the computerized hand evaluation instruments have been statistically proven to have intrainstrument and interinstrument reliability compared with NIST criteria. Some have “human performance” reliability statements, but these are based on the fatally flawed premise that human normative performance is equivalent to gold-standard NIST calibration criteria.2-3,5 Who would accept the accuracy of a weight set that had been “calibrated” by averaging 20 “normal” individuals’ abilities to lift the weights? Human performance is not an acceptable criterion for defining the reliability (calibration) of mechanical devices, including those used in upper extremity rehabilitation clinics.

Furthermore, one cannot assume that a computerized version of an instrument is reliable and valid because its noncomputerized counterpart has established reliability. For example, although some computerized dynamometers have identical external components to those of their manual counterparts, internally they have been “gutted” and no longer function on hydraulic systems. Reliability and validity statements for the manual hydraulic dynamometer are not applicable to the “gutted” computer version. Even if both dynamometers were hydraulic, separate reliability and validity data would be required for the computerized instrument.

The inherent complexity of computerized assessment equipment makes it difficult to determine instrument reliability without the assistance of qualified engineers, computer experts, and statisticians. Compounding the problem, stringent federal regulation often does not apply to “therapy devices.” Without sophisticated technical assistance, medical specialists and their patients have no way of knowing the true accuracy of the data produced by computerized therapy equipment.

Instrumentation Summary

Although many measurement instruments are touted as being “standardized,” most lack even the rudimentary elements of statistical reliability and validity,8,9 relying instead on normative statements such as means or averages. These norm-based tests lack even the barest of instrumentation requisites, meaning they cannot substantiate their consistency of measurement nor their ability to measure the entity for which they were designed. Because relatively few evaluation tools fully meet standardization criteria, instrument selection must be predicated on satisfying as many of the previously mentioned requisites as possible.¹⁰ Hand/upper extremity assessment tools vary in their levels of reliability and validity according to how closely their inherent properties match the primary instrumentation requisites.

As consumers, medical specialists must require that all assessment tools have appropriate documentation of reliability and validity at the very least. Furthermore, “data regarding reliability [and validity]^‡ should be available and should not be taken at face value alone; just because a manufacturer states reliability studies have been done, or a paper concludes an instrument is reliable, does not mean the instrument or testing protocol meets the requirements for scientific design.”¹¹ Purchasing and using assessment tools that do not meet fundamental measurement requisites limits potential at all levels, from individual patients to the scope of the profession.

Functional Assessment Instruments

Handedness

Handedness is an essential component of upper extremity function. Traditionally, the patient self-report is the most common method of defining hand preference in the upper extremity rehabilitation arena. Although hand preference tests with established reliability and validity have been used by psychologists to delineate cortical dominance for several decades,12,13 knowledge of these tests by surgeons and therapists is relatively limited. Recent studies show that the Waterloo Handedness Questionnaire (WHQ),^13-15 a 32-item function-based survey with high reliability and validity, more accurately and more extensively defines hand dominance (Fig. 12-3) than does the patient self-report.^16-17 The WHQ is inexpensive, simple and fast to administer, easy to score, and patients respond positively to it, welcoming its user-friendly format and explicitness of individualized results. Better definition of handedness is important to clinicians and researchers alike, in that it improves treatment focus and outcomes on a day-to-day basis, and, through more precise research studies, it eventually enhances the professional body of knowledge. (Also see the Grip Assessment section of this chapter.)

Hand Strength

Grip Assessment

Grip strength is most often measured with a commercially available hydraulic Jamar dynamometer (Fig. 12-4), although other dynamometer designs are available.^18-22 Developed by Bechtol²³ and recommended by professional societies,^24-26 the Jamar dynamometer has been shown to be a reliable test instrument,²⁷ provided calibration is maintained and standard positioning of test subjects is followed.^28-34

In an ongoing instrument reliability study, of over 200 used Jamar and Jamar design dynamometers evaluated by the author, 51% passed the requisite +0.9994 correlation criterion compared with NIST F-tolerance test weights (government certified high-caliber test weights). Of these (0.9994 and above), 27% needed minor faceplate adjustments to align their read-out means with the mean readings of the standardized test weights. Of 30 brand new dynamometers, 80% met the correlation criterion of +0.9994. Interestingly, two Jamar dynamometers were tested multiple times over more than 12 years with less than a 0.0004 change in correlation, indicating that these instruments do maintain their calibration if carefully used and stored.35

Test procedure is important. In 1978 and 1983, the American Society for Surgery of the Hand recommended that the second handle position be used in determining grip strength and that the average of three trials be recorded.^24,36 In contrast to the recommended mean of three grip trials, one maximal grip is reported to be equally reliable in a small cohort study.³⁷ Deviation from recommended protocol should be undertaken with caution in regard to the mean-of-three-trials criterion, which is commonly utilized in research studies. More information is needed before adopting the one-trial method.

Of importance is the concept that grip changes according to size of object grasped. Normal adult grip values for the five consecutive handle positions consistently create a bell-shaped curve, with the first position (smallest) being the least advantageous for strong grip, followed by the fifth and fourth positions; strongest grip values occur at the third and second handle positions.^23,38 If inconsistent handle positions are used to assess patient progress, normal alterations in grip scores may be erroneously interpreted as advances or declines in progress. Fatigue is not an issue for the three-trial test procedure, but may become a factor when recording grip strengths using all five handle positions (total of 15 trials with 3 trials at each position).³⁹ A 4-minute rest period between handle positions helps control potential fatigue effect.⁴⁰ Although a 1-minute rest between sets was reported to be sufficient to avoid fatigue, this study was conducted using a dynamometer design instrument whose configuration is different from that of the Jamar dynamometer.⁴¹ Percent of maximal voluntary contraction (MVC) required is also important in understanding normal grip strength and fatigue.⁴² For example it is possible to sustain isometric contraction at 10% MVC for 65 minutes without signs of muscle fatigue.⁴³ Although Young⁴⁰ reported no significant difference in grip scores between morning and night, his data collection times were shorter compared to those of other investigators who recommend that time of day should be consistent from trial to trial.^23,44

Better definition of handedness directly influences grip strength. Using the WHQ, Lui and Fess found a consistent polarization pattern with greater differences between dominant and nondominant grip strengths in normal subjects with WHQ classifications of predominantly left or right preference versus those who were ambidextrous or with slight left or right preferences. This polarization pattern was especially apparent in the second Jamar handle position.⁴⁵

Norms for grip strength are available,^46-49 but several of these studies involve altered Jamar dynamometers or other types of dynamometers.^50-54 Independent studies refute the often cited 10% rule for normal subjects,⁵⁵ with reports finding that the minor hand has a range of equal to or stronger than the major hand in up to 31% of the normal population.^54,56,57 The “10% rule” also is not substantiated when the WHQ is used to define handedness.⁴⁵ Grip has been reported to correlate with height, weight, and age,^23,54,56,58 and socioeconomic variables such as participation in specific sports or occupations also influence normal grip.^59,60 Grip strength values lower than normal are predictive of deterioration and disability in elderly populations.^61-67 It is important to note that the Mathiowetz normative data reported for older adults⁴⁸ may be “up to 10 pounds lower than they should be.”⁶⁸ A 2005 meta-analysis by Bohannon and colleagues that combined normative values from 12 studies that used Jamar dynamometers and followed American Society of Hand Therapists (ASHT) recommended testing protocols may be the most useful reference for normative data to date.⁶⁹ In a 2006 study, Bohannon and coworkers also conducted a meta-analysis for normative grip values of adults 20 to 49 years of age.⁷⁰

Although grip strength is often used clinically to determine sincerity of voluntary effort, validity of its use in identifying submaximal effort is controversial, with studies both supporting^71-76 and refuting its appropriateness.^77-82 Niebuhr⁸³ recommends use of surface electromyography in conjunction with grip testing to more accurately determine sincerity of effort. The rapid exchange grip test,^84,85 a popular test for insincere effort, has been shown to have problems with procedure and reliability;^86,87 and even with a carefully standardized administration protocol, its validity is disputed due to low sensitivity and specificity.^86,88,89

Hand grip strength is often an indicator of poor nutritional status. Unfortunately, the majority of these studies have been conducted using grip instruments other than the Jamar or Jamar-like dynamometers.^90-93 Furthermore, very few of these studies address calibration methods, rendering their results uncertain.

Bowman and associates reported that the presence or absence of the fifth finger flexor digitorum superficialis (FDS) significantly altered grip strength in normal subjects, with grip strength of the FDS-absent group being nearly 7 pounds less than the FDS-common group, and slightly more than 8 pounds less than the FDS-independent group.⁹⁴

The Jamar’s capacity as an evaluation instrument, the effects of protocol, and the ramification of its use have been analyzed by many investigators over the years with mixed, and sometimes conflicting, results. Confusion is due in large part to the fact that the vast majority of studies reported have relied on nonexistent, incomplete, or inappropriate methods for checking instrument accuracy of the dynamometers used in data collection. A second and more recent development is the ability to better define handedness using the WHQ. Scientific inquiry is both ongoing and progressive as new information is available. Although past studies provide springboards and directions, it is important to understand that all grip strength studies need to be reevaluated using carefully calibrated instruments and in the context of the more accurate definition of handedness provided by the WHQ.

Other grip strength assessment tools need to be ranked according to stringent instrumentation criteria, including longitudinal effects of use and time. Although spring-load instruments or rubber bulb/bladder instruments (Fig. 12-5) may demonstrate good instrument reliability when compared with corresponding NIST criteria, both these categories of instruments exhibit deterioration with time and use, rendering them inaccurate as assessment tools.

Pinch Assessment

Reliability of commercially available pinchometers needs thorough investigation. Generally speaking, hydraulic pinch instruments are more accurate than spring-loaded pinchometers (Fig. 12-6). A frequently used pinchometer in the shape of an elongated C with a plunger dial on top is, mechanically speaking, a single large spring, in that its two ends are compressed toward each other against the counter force of the single center C spring. This design has inherent problems in terms of instrument reliability.⁹⁵

Three types of pinch are usually assessed: (1) prehension of the thumb pulp to the lateral aspect of the index middle phalanx (key, lateral, or pulp to side); (2) pulp of the thumb to pulps of the index and long fingers (three-jaw chuck, three-point chuck); and (3) thumb tip to the tip of the index finger (tip to tip). Lateral is the strongest of the three types of pinch, followed by three-jaw chuck. Tip to tip is a positioning pinch used in activities requiring fine coordination rather than power. As with grip measurements, the mean of three trials is recorded, and comparisons are made with the opposite hand. Better definition of handedness via the WHQ improves understanding of the relative value of dominant and nondominant pinch strength. Cassanova and Grunert96 describe an excellent method of classifying pinch patterns based on anatomic areas of contact. In an extensive literature review, they found more than 300 distinct terms for prehension. Their method of classification avoids colloquial usage and eliminates confusion when describing pinch function.

Sensibility Function

Of the five hierarchical levels of sensibility testing ([1] autonomic/sympathetic response, [2] detection, [3] discrimination, [4] quantification, and [5] identification),97,98 only the final two levels include functional assessments. (See Chapter 11 for details regarding testing in the initial three levels.) At this time no standardized tests are available for these two categories although their concepts are used frequently in sensory reeducation treatment programs. However, several observation-based assessments are used clinically.

Quantification is the fourth hierarchical level of sensory capacity. This level involves organizing tactile stimuli according to degree. A patient may be asked to rank several object variations according to tactile properties, including, but not limited to, roughness, irregularity, thickness, weight, or temperature. An example of a quantification level functional sensibility assessment, Barber’s series of dowel rods covered with increasingly rougher sandpapers requires patients to rank the dowel rods from smoothest to roughest with vision occluded. For more detail, the reader is referred to Barber’s archived chapter on the companion Web site of this text.

Identification, the final and most complicated sensibility level, involves the ability to recognize objects through touch alone.

The Moberg Picking-Up Test is useful both as an observational test of gross median nerve function and as an identification test. Individuals with median nerve sensory impairment tend to ignore or avoid using their impaired radial digits, switching instead to the ulnar innervated digits with intact or less impaired sensory input, as they pick up and place small objects in a can. This test is frequently adapted to assess sensibility identification capacity by asking patients, without using visual cues, to identify the small objects as they are picked up. A commercially available version of the Moberg Picking-Up Test is available. Currently, the Moberg is an observational test only. It meets none of the primary instrumentation requisites, including proof of reliability and validity; and for most of the noncommercial versions that are put together with a random assortment of commonly found small objects, it lacks even the simplest of equipment standards.

Daily Life Skills

The Flinn Performance Screening Tool (FPST)99 is important because of its excellent test–retest reliability (92% of the items: Kendall’s τ > 0.8 and 97% agreement); and because it continues to be tested and upgraded over time (Fig. 12-7). The FPST allows patients to work independently of the evaluator in deciding what tasks they can and cannot perform. The fact that this test is not influenced by the immediate presence of an administrator is both important and unusual. Busy clinicians may prejudge or assume patient abilities based on previous experience with similar diagnoses; and some patients hesitate to disclose personal issues. With the FPST, the potential for therapist bias is eliminated and issues such as patient lack of disclosure due to social unease is reduced. Patients peruse and rank the cards on their own without extraneous influence. The FPST consists of three volumes of over 300 laminated daily activity photographs that have been tested and retested for specificity and sensitivity of task. Volume 1 assesses self-care tasks; volume 2 evaluates home and outside activities; volume 3 relates to work activities. This test represents a major step toward defining function in a scientific manner.

Manual Dexterity and Coordination

Tests that assess dexterity and coordination are available in several levels of difficulty, allowing selection of instruments that best suit the needs and abilities of individual patients. As noted earlier, when using a standardized test instrument, it is imperative not to deviate from the method, equipment, and sequencing described in the test instructions. Test calibration, reliability, and validity are determined using very specific items and techniques, and any change in the stipulated pattern renders resultant data invalid and meaningless. Using a standardized test as a teaching or training device in therapy also excludes its use as an assessment instrument, due to skewing of data.

Jebsen Taylor Hand Function Test

Of the tests available, the Jebsen Taylor Hand Function Test100 requires the least amount of extremity coordination, is inexpensive to assemble, and is easy to administer and score. The Jebsen consists of seven subtests: (1) writing, (2) card turning, (3) picking up small objects, (4) simulated feeding, (5) stacking, (6) picking up large lightweight objects, and (7) picking up large heavy objects. Originally developed for use with patients with rheumatoid arthritis,^100,101 the Jebsen has been used to assess aging adults,¹⁰² hemiplegic persons,¹⁰³ children,¹⁰⁴ and patients with wrist immobilization,¹⁰⁵ among others. Jebsen norms are categorized according to maximum time, hand dominance, age, and gender.¹⁰⁶ Rider and Lindon⁴ report a statistically significant difference in times with substitution of plastic checkers for the original wooden ones, and a trend of faster times with use of larger paper clips than originally described, invalidating the test. Equipment for standardized tests cannot be substituted or altered from that of the original test unless the test is restandardized completely with the new equipment. Capacity to measure gross coordination makes the Jebsen test an excellent instrument for assessing individuals whose severity of impairment precludes use of many other coordination tests, which often require very fine prehension patterns. The Jebsen is commercially available, but, before being used, this commercial format must be assessed thoroughly to ensure that it meets the original equipment standards and procedures.

Minnesota Rate of Manipulation Tests

Purdue Pegboard Test

Requiring prehension of small pins, washers, and collars, the Purdue Pegboard Test107 evaluates finer coordination than the two previous dexterity tests. Subcategories for the Purdue are (1) right hand, (2) left hand, (3) both hands, (4) right, left, and both, and (5) assembly. Normative data are presented in categories based on gender and job type: male and female applicants for general factory work, female applicants for electronics production work, male utility service workers, among others. Normative data are also available for 14- to 19-year-olds¹⁰⁸ and for ages 60 and over.¹⁰⁹ Reddon and colleagues¹¹⁰ found a learning curve for some subtests when the Purdue was given five times at weekly intervals, reinforcing the concept that standardized tests should not be used as training devices for patients.

In terms of psychomotor taxonomy, all of the previously described tests assess activities that are classified as skilled movements, with the exception of the Jebsen’s task of picking up small objects with a spoon. Skilled movements involve picking up and manipulation of objects using finger–thumb interaction. At this level, tool usage is not involved in the testing process. In contrast, compound adaptive skills, the next higher psychomotor level, incorporates tool use, a more difficult proficiency.

Crawford Small Parts Dexterity Test

O’Connor Peg Board Test

The O’Connor Peg Board111 test also requires use of tool manipulation to place small pegs on a board.

Nine-Hole Peg Test

Work Hardening

Valpar Component Work Samples

Baltimore Therapeutic Equipment Work Simulator

The Baltimore Therapeutic Equipment Work Simulator (BTEWS) employs static and dynamic modes to produce resistance to an array of tools and handles that are inserted into a common exercise head. Although the basic concept of this machine is innovative and the static mode has been shown to be accurate with high reliability correlation coefficients, the dynamic mode has problems producing consistent resistance. Coleman and coworkers found the dynamic mode resistance to vary widely both within machines and between machines, making the Work Simulator inappropriate for assessment when consistent resistance is required (Fig. 12-8).^112-114 Because of the fluctuating and unpredictable dynamic mode resistance changes, which are not accurately reflected by the computer printout (Figs. 12-9 and 12-10), caution should be used in allowing patients with acute injuries, geriatric patients, pediatric patients, patients with inflammatory problems such as rheumatoid arthritis, patients with unstable vascular systems, or patients with impaired sensibility to exercise on this machine. Longitudinal pre-BTEWS and post-BTEWS volumetric measurements may be helpful in identifying patients whose inflammatory response to working in the Work Simulator dynamic mode may be progressively increasing.

Interestingly, a review of reliability studies involving the Work Simulator identifies a pattern that is all too often found with mechanical rehabilitation devices, in that multiple studies were conducted and reported using human performance to establish its reliability as an assessment instrument.^115-121 Human performance is not an appropriate indicator of accuracy or calibration for mechanical devices using NIST criteria. Furthermore, the recommended method for “calibrating” Work Simulators involves a static process of weight suspension that is incongruous with assessing dynamic mode resistance. Later, when a team of engineers evaluated the consistency of resistance of the dynamic mode according to NIST standards and employing an appropriate dynamic measurement method, reliability and accuracy of the dynamic mode were found to be seriously lacking.¹¹³

A second-generation “work simulator,” the BTE Primus, is currently on the market, along with similar machines from other companies. The Primus drops the terminology of “static” and “dynamic” modes, opting instead for isometric, isotonic, and isokinetic resistance and continuous passive motion modes. No NIST-based reliability information for the modes in which patients work against preset resistances is available for any of these second-generation machines including the Primus.^122-125 Before the Primus may be used as an assessment instrument, or for that matter, a treatment tool, the Coleman and associates¹¹³ engineering methods used to evaluate the BTEWS should be employed to fully identify the consistency of resistance produced by its resistance modes. Unfortunately, the Coleman and associates NIST-based engineering study of the BTEWS is not included in the Primus operator’s manual bibliography.

Assessment of a patient’s potential to return to work is based on a combination of standardized and observational tests, knowledge of the specific work situation, insight into the patient’s motivational and psychological resources, and understanding of the complexities of normal and disabled hands and upper extremities in general. Although its importance has been acknowledged in the past, vocational assessment of the patient with an upper extremity injury is now given a higher priority in most of the major hand rehabilitation centers throughout the country. Treatment no longer ends with achievement of skeletal stability, wound healing, and a plateau of motion and sensibility. This shift in emphasis has been the result, in large part, of the contributions of the Philadelphia Hand Center.

Patient Satisfaction

Testing patient satisfaction has become an integral part of rehabilitation endeavors.126,127 Just as other test instruments must meet primary instrumentation requisites, so too must patient satisfaction assessment tools,^128-130 which are often in the format of patient self-report questionnaires.

Current symptom or satisfaction tools used in evaluating patients with upper extremity injury or dysfunction include the Medical Outcomes Study 36-Item Health Survey (SF-36), the Upper Extremities Disabilities of Arm, Shoulder, and Hand (DASH),^131-150 the Quick DASH, and the Michigan Hand Outcomes Questionnaire (MHQ).^151,152 In contrast to the DASH instruments, the MHQ takes into consideration the important factors of hand dominance and hand/upper extremity cosmesis.^151-160 These assessment tools have been extensively tested and meet all the primary instrumentation requisites. They are also available in many languages.

Diagnosis-Specific Tests of Function

Rheumatoid Arthritis

In contrast to these sophisticated coordination tests is the ubiquitous use of sphygmomanometers to assess grip strength. Despite a 1999 engineering report by Unsworth and colleagues¹⁶¹ that found “bags of different diameter and volume were seen to give statistically different pressure readings when squeezed by the same subjects,” the blood pressure cuff remains a common tool for evaluating grip strength in contemporary rheumatoid arthritis literature.

Stroke

The Wolf Motor Function Test (WMFT)162-171 assesses motor function in adults with hemiplegia due to stroke or traumatic brain injury. Although the original WMFT had 21 tasks, the adapted WMFT is shortened to 15 functional tasks and “includes items that cover a range of movements that can be evaluated within a realistic time period for both clinical and research purposes.” Ranging from 0.86 to 0.99, the WMFT-15 has good inter-rater, intrarater agreement, internal consistency, and test–retest reliability. A video demonstration of the WMFT may be found at www.youtube.com/watch?y=SIJK88NdZM.

Used in constraint-induced movement therapy, the original Motor Activity Log (MAL)^172-176 was designed as a structured interview to assess how hemiparetic poststroke individuals use their more involved upper extremity in real-world activities. The MAL is divided into two components: amount of use (AOU) and quality of movement (QOM), during activities of daily living. The MAL is “internally consistent and relatively stable in chronic stroke patients not undergoing intervention.” However, its longitudinal construct validity is in doubt. The Motor Activity Log-14, a shortened version of the MAL, corrects many of the inconsistencies of the original MAL.¹⁷⁴

Carpal Tunnel Syndrome

The Severity of Symptoms and Functional Status in Carpal Tunnel Syndrome questionnaire is an outcomes tool that was developed specifically to assess carpal tunnel syndrome symptoms177-183 using a combination of impairment assessment tools, patients’ self-reports of their symptoms, and their abilities to accomplish a few specific functional tasks that are problematic for those suffering from median nerve compression at the wrist.

Summary

Evaluation with instruments that measure accurately and truthfully allows physicians and therapists to correctly identify hand/upper extremity pathology and dysfunction, assess the effects of treatment, and realistically apprise patients of their progress. Accurate assessment data also permit analysis of treatment modalities for effectiveness, provide a foundation for professional communication through research, and eventually influence the scope and direction of the profession as a whole. Because of their relationship to the kind of information obtained, assessment tools should be chosen carefully. The choice of tools directly influences the quality of individual treatment and the degree of understanding between hand specialists. Criteria exist for identifying dependable instruments for accurate measurement when used by different evaluators and from session to session. Unless the results of a “home-brewed” test are statistically analyzed, the test is tried on large numbers of normal subjects, and the results are analyzed again, it is naïve to assume that such a test provides meaningful information. In the future, currently utilized tools may be better understood through checking their reliability and validity levels with bioengineering technology,176 and statisticians may be of assistance in devising protocols that will lead to more refined and accurate information. We as hand specialists have a responsibility to our patients and our colleagues to continue to critique the instruments we use in terms of their capacities as measurement tools. Without assessment, we cannot treat, we cannot communicate, and we cannot progress.

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* The author receives no compensation in any form from products discussed in the chapter.

† Weinstein, S. 50 Years of somatosensory research. J Hand Ther. 1993;6(1):113.

* TP, number of true positives; FN, number of false negatives.

† TN, number of true negatives; FP, number of false positives.

‡ Author insert.