Measures of adult hand function: Arthritis Hand Function Test (AHFT), Grip Ability Test (GAT), Jebsen Test of Hand Function, and The Rheumatoid Hand Functional Disability Scale (The Duruöz Hand Index [DHI])

Authors


ARTHRITIS HAND FUNCTION TEST (AHFT)

General Description

Purpose

The Arthritis Hand Function Test (AHFT) is an 11-item performance based test designed to measure hand strength and dexterity.

Content

The items include grip and pinch strength, pegboard dexterity, lacing a shoe and tying a bow, fastening/unfastening 4 buttons, fastening/unfastening 2 safety pins, cutting putty with a knife and fork, manipulating coins into a slot, lifting a tray of tin cans, and pouring a glass of water.

Developer/contact information

Catherine Backman and Hazel Mackie. Arthritis Hand Function Test Manual (1997) can be ordered for $25.00 US Funds from School of Rehabilitation Sciences, University of British Columbia, T325-2211 Wesbrook Mall, Vancouver, British Columbia, V6T2B5 Canada.

Versions

One.

Number of items in scale

11 items.

Subscales

There are 4 subscales: Strength, Applied Strength, Dexterity, and Applied Dexterity.

Populations

Developmental/target

Adults with rheumatoid arthritis (RA), osteoarthritis (OA), and systemic sclerosis (SSc).

Other uses

None.

WHO ICF Components

Activity limitation.

Administration

Method

Items are administered in order on the scoring worksheet in the manual. Right and left hands are tested separately for the strength and dexterity items. The applied dexterity and applied strength items are performed using both hands.

Training

Test is not difficult to administer or score. Manual provides specific instructions.

Time to administer/complete

20 minutes.

Equipment needed

Sphygmomanometer, pinch meter, 9-hole pegboard, shoe, button board, 2 safety pins, theraplast, plate, knife and fork, coins, box, wooden tray, 12 cans of soup, pitcher, glass, 1,000 ml container, measuring cup, dycem, stopwatch. All items can be stored in a 24-inch suitcase for portability.

Cost/availability

Test manual purchased from authors. Pinchmeter and theraplast must be ordered from an adapted equipment catalogue for around $250. Equipment such as the pegboard, coin box, putty guide, and tray must be fabricated. Other equipment is easily available from a discount store. A cheap suitcase is helpful to transport items. In total, the entire cost (including support staff time to assemble) according to one of the authors is approximately $500.

Scoring

Responses

Scale

Varies by subscale.

Score range

Grip strength range 0–300 mm Hg, pinch strength range 0–30 kg, applied strength range for cans 0–12 cans, applied strength range for pouring water is 0–2,000 ml, dexterity range is 0 – undetermined number of seconds.

Interpretation of scores

Scores can be transferred to a Hand Function Profile sheet matched for age and sex. This profile provides a summary and compares the scores to the norms.

Method of scoring

Grip strength is measured in mm Hg while pinch strength is measured in kg. Dexterity and applied dexterity items are timed in seconds. Applied strength is number of cans lifted and volume of water lifted in the pitcher in ml.

Time to score

5 minutes.

Training to score

None needed.

Training to interpret

No training is needed to interpret scores.

Norms available

Norms for both men and women are reported in the manual

Psychometric Information

Reliability

Interrater reliability

In RA, intraclass correlation coefficient (ICC) ranged from 0.89 to 1.0 between 2 independent observers rating 20 subjects (1). In OA, ICC ranged from 0.99 to 1.0 between 2 independent observers rating 26 subjects (4). In SSc, ICC ranged from 0.99 to 1.0 between 2 independent observers rating 20 subjects (5)

Test-retest reliability

In RA, 20 subjects were tested twice within 2 weeks (ICC 0.53–0.96) (1–3). In OA, 26 subjects were tested twice within 2 weeks (ICC 0.74–0.96) (4). In SSc, 20 subjects were tested twice within 2 weeks (ICC 0.80–0.97) (5).

Validity

Content or face validity

Items were developed based on a systemic review of other hand function tests. Items reviewed by 5 occupational therapists who judged the final items to be clear and important unilateral and bilateral tasks

Concurrent validity

Healthy controls: 395 healthy adult volunteers were administered the Nine-hole pegboard test and items from the Applied Dexterity section of the AHFT. Correlations ranged from 0.32 to 0.60. In RA 20 subjects were evaluated with the AHFT and the Jebsen Hand Function Test (JHFT). Correlations between the AHFT and scores on the JHFT were 0.61–0.64 for the right hand scores and 0.02–0.08 for left hand scores (1). ICC was 0.71 between scores on the AHFT and the dexterity subscale of the Arthritis Impact Measurement Scale (AIMS) (1).

In OA 26 subjects were evaluated with the AHFT and self-reports of physical activities of daily living (PADL) and instrumental activities of daily living (IADL). Correlations between the AHFT and PADL scores ranged from 0.40 to 0.69 and between the AHFT and IADL scores ranged from 0.46 to 0.75 (4). In SSc 20 subjects with SSc were evaluated with the AHFT and the Health Assessment Questionnaire (HAQ) and the physical component of the AIMS2. Correlations ranged from 0.32 to 0.73 with the HAQ and from 0.19 to 0.69 with the AIMS2 (5).

Sensitivity/responsiveness to change

None reported.

Comments and Critique

The majority of hand function tests assess only one aspect of function such as strength or dexterity, only unilateral tasks and do not include functional tasks. The AHFT is a performance-based test that measures both unilateral and bilateral functional tasks. Thus, numerous items are needed. However, most are easily available and fit into a 24-inch suitcase. The test had adequate psychometric properties for RA, OA, and SSc. Predictive validity and responsiveness to change have not been documented. There is no summative total score, which is a disadvantage when using in research since numerous correlations or comparisons must be made for each of 11 items and not just one score.

References

1.(Original) Backman C, Mackie H, Harris J. Arthritis hand function test: Development of a standardized assessment tool. Occup Ther J Res 1991;11:246–256.

2.Backman C, Cork S, Gibson D, Parsons J. Assessment of hand function: the relationship between pegboard dexterity and applied dexterity. Can J Occup Ther 1992;59:208–13.

3.Backman C, Mackie H. Arthritis hand function test: Inter-rater reliability among self-trained raters. Arthritis Care Res 1995;8:10–5.

4.Backman C, Mackie H. Reliability and validity of the Arthritis Hand Function test in adults with osteoarthritis. Occup Ther J Res 1997;17:55–67.

5.Poole JL, Gallegos M, O'Linc S. Reliability and validity of the Arthritis Hand Functional Test in adults with systemic sclerosis (scleroderma). Arthritis Care Res 2000;13:69–73.

GRIP ABILITY TEST (GAT)

General Description

Purpose

The Grip Ability Test (GAT) is a modification of a general test of hand function based on activities of daily living, the Grip Function Test. It is intended to be a simple and rapid test of hand function.

Content

Putting a sock over one hand, putting a paper clip on an envelope, and pouring water from a jug.

Developer/contact information

Berit Dellhag and Anders Bjelle. Berit Dellhag, PhD, OTR, Department of Rheumatology, Sahlgrenska University Hospital, S-413 45, Goteborg, Sweden.

Versions

One.

Number of items in scale

There are 3 items in test.

Subscales

None.

Populations

Developmental/target

People with rheumatoid arthritis.

Other uses

None.

WHO ICF Components

Activity limitation.

Administration

Method

Performance-based test. Person is timed performing each of the 3 items according to standardized instructions (1).

Training

None needed.

Time to administer/complete

Can take from 10 seconds to 2–3 minutes. The authors do not state any time limits.

Equipment needed

A 25-cm of Tubigrip elasticized tubular bandage (7.5 cm wide for women and 10 cm wide for men), metal paper clip (30 × 10 mm), envelope (11.5 cm × 16 cm), one liter water jug with handle, cup (2 dl), stopwatch.

Cost/availability

A 10 m-roll of tubigrip = $55.00 available from hand therapy catalogs.

Scoring

Responses

Scale

Number of seconds to complete.

Score range

Range is from 5–6 seconds to 2–3 minutes.

Interpretation of scores

A GAT score of <20 seconds is considered normal. Higher scores mean decreased hand function.

Method of scoring

Each item is timed in seconds and the times are summed to yield a total GAT score.

Time to score

Scoring is immediate. The times for the 3 tasks are summed which takes less than 1 minute.

Training to score

None needed.

Training to interpret

None needed.

Norms available

No.

Psychometric Information

Reliability

Internal consistency

Cronbach's alpha calculated from testing 52 subjects was 0.65 (1). Intraobserver reliability was r = 0.99 (1). Interobserver reliability for 2 observers rating 20 subjects was r = 0.95 (1).

Validity

Content validity

Items selected from the Grip Function Test to represent 4 grip types (1).

Concurrent validity

Scores from the GAT correlated with scores on the Health Assessment Questionnaire (r = 0.53; P < 0.001), grip strength (r = 0.29; P < 0.05), self-estimated hand function (r = 0.42; P < 0.01), pain with nonresisted motion (r = 0.33; P < 0.05), pain with resisted motion (r = 0.46; P < 0.001), stiffness (r = 0.32; P < 0.001), and the Keital functional test (r = 0.42; P < 0.01) (1).

Construct validity

Known groups validity: all items discriminated between persons with RA and controls (P < 0.001) (1). Changes in the GAT scores correlated with change in HAQ scores (r = 0.42; P < 0.01) (2). Subjects with low GAT scores displayed normal or increased safety margins in grip force and the load at the point where an object begins to slip out of the fingers compared to healthy controls, whereas subjects who had higher GAT scores exhibited lower safety margins (3).

Sensitivity/responsiveness to change

Total scores on the GAT (P < 0.001) and items scores (P < 0.01, 0.01, and 0.05, respectively) were sensitive to change after a hand training program (1). A 5-year followup study reported GAT scores were significantly worse in women and significantly better in men (2).

Comments and Critique

The GAT is a simple and rapid test of hand function that does not require much equipment or training. All of the psychometric studies and research using this test have been done by one of the developers of the test. The GAT has not been validated with other standardized performance based tests of hand function. No reliability or validity studies have been done on persons with other forms of arthritis.

References

1.(Original) Dellhag B, Bjelle A. A grip ability test for use in rheumatology practice. J Rheumatol 1995;41:138–63.

2.Dellhag B, Bjelle A. A five-year followup of hand function and activities of daily living in rheumatoid arthritis. Arthritis Care Res 1999;2:33–41.

3.Dellhag B, Hosseini N, Bremell T, Ingvarsson PE. Disturbed grip function in women with rheumatoid arthritis. J Rheumatol 2001;28:2624–33.

JEBSEN TEST OF HAND FUNCTION

General Description

Purpose

The purpose of the test is to assess broad aspects of hand function commonly used in activities of daily living using standardized tasks.

Content

Tasks are representative of various hand activities such as writing, turning pages, feeding and picking up small, large, light, and heavy objects.

Developer/contact information

A description on how to construct the test is in Jebsen et al (1). Test kit can be ordered from Sammons Preston, An AbilityOne Company, P.O. Box 5071, Bolingbrook, IL 60440-5071 (Telephone: 1-800-323-5547) for approximately $210.

Versions

Homemade and commercially made.

Number of items in scale

Seven tasks each performed by the non-dominant and dominant hands

Subscales

There are 7 subscales: writing, turning over 3 by 5 inch cards (simulated page turning), picking up small common objects, simulated feeding, stacking checkers, picking up large light cans, picking up large heavy cans.

Populations

Developmental/target

Children, over 6 years of age, and adults who have impairments in the hand(s).

Other uses

Stroke, rheumatoid arthritis, quadriplegia, older adults, Duchenne muscular dystrophy, myelomeningocele.

WHO ICF Components

Activity limitation.

Administration

Method

Items are administered in order using standardized instructions: writing, card turning, picking up small common objects, simulated feeding, stacking checkers, picking up large light and heavy objects. For each item, the non-dominant hand is tested first and then the dominant.

Training

No training is needed to administer this test. Instructions are included in the test kit; however, the original Jebsen et al (1) manuscript provides clearer instructions.

Time to administer/complete

Total time is 10–15 minutes but can be variable depending on the level of disability in the subjects. Younger children ages 6–7 may take up to 20 minutes (2).

Equipment needed

Table and chair, pencil, stopwatch, common objects (paper, pencil, clipboard, index cards, coffee can, pennies, paper clips, bottle caps, kidney beans, spoon, wooden board, C-clamp, wooden checkers, tape). A kit is available that includes all items complete with a carrying bag.

Cost/availability

It is difficult to obtain wooden checkers. Thus, it may be easier to purchase the test from Sammons Preston for $210.00.

Scoring

Responses

Scale

Scales for all items are times in seconds.

Score range

Variable depending on disability.

Interpretation of scores

Subscale scores can be compared to the normative tables according to age and sex. The longer the time required to complete the subscales, the more disability a person has.

Method of scoring

Each subscale is scored by recording the amount of time it takes the person to complete each task. Scores can be summed to obtain a total score.

Time to score

Minimal.

Training to score

None needed.

Training to interpret

None needed.

Norms available

Norms for both adults (1) and children (2) exist for the hand-made version but not the commercially-available version.

Psychometric Information

Reliability

Intrarater

Reliability was established by having one rater test 25 people with RA on successive days (r = 0.82) (3).

Interrater

Reliability was established by having 2 raters time and score 25 people with RA (r = 0.91) (3). In another study, interrater reliability was established by having 2 raters simultaneously time and score 5 subjects who were over 60 years of age. ICCs ranged from 0.82 to 1.00 (4).

Test-retest reliability

In the original study, 26 adult subjects with stable hand disorders were tested at 2 points in time (r = 0.60–0.99) (1). Later, 5 subjects over 60 years of age were also tested at 2 points in time (r = 0.84–0.85) (3). The stability of the Jebsen over 3 sessions using 20 healthy women showed that subjects performed faster on each successive session; however, only writing and simulated feeding showed a significant difference (5). To establish test-retest reliability in children, 20 children with stable hand disorders were tested at 2 points in time, 4–10 days apart (r = 0.87–0.99) (2).

Validity

Concurrent validity

In patients with RA the scores on the Jebsen correlated significantly with scores on the AIMS dexterity items (r = 0.43), the AIMS activities of daily living items (r = 0.47), the AIMS household activity items (r = 0.58), grip strength (r = 0.56) and the HAQ (r = 0.37) (3). All of the subscales except writing correlated with the HAQ (r = 0.49–0.55) and joint deformity (r = 0.38–0.63) (6). None of the subscales correlated with pain (6).

Subjects (128) were compared stacking wood (standardized) versus plastic (unstandardized) checkers and picking up 1-inch (standardized) versus 1 1/4-inch (unstandardized) paper clips. Times were significantly faster for the wood checkers than plastic checkers but not for the paper clips (7).

Discriminative validity

The Jebsen was shown to discriminate between subjects with and without different physical disabilities (1,3). However, the mean times were not statistically significantly different between older subjects with OA (8), compared to the norms reported by Jebsen et al (1).

Sensitivity/responsiveness to change

No studies available.

Comments and Critique

The Jebsen Test of Hand Function has been used to measure hand function in persons with a wide range of diagnoses ranging from normal aging to arthritis and stroke. The test is easy and quick to administer and can yield subtest scores or an overall score. The norms should be revised using the commercially available version of the test. Content validity has been questioned by Mathiowetz (9) who reported that page turning and simulated feeding do not duplicate the actual tasks. In addition, the hands are tested separately, yet many task of daily living are bilateral, i.e., tying a bow, buttoning. More studies assessing the validity and sensitivity of the test are needed.

References

1.(Original) Jebsen RH, Taylor N, Trieschmann RB, Trotter MJ, Howard LA. An objective and standardized test of hand function. Arch Phys Med Rehab 1969;50:311–9.

2.Taylor N, Sand PL, Jebsen RH. Evaluation of hand function in children. Arch Phys Med Rehabil 1973;54:129–35.

3.Vliet Vlieland TPM, van der Wijk TP, Jolie IMM, Zwinderman AH. Determinants of hand function in patients with rheumatoid arthritis. J Rhematol 1996;23:835–40.

4.Hackel ME, Wolfe GA, Band SM, Canfield JS. Changes in hand function in the aging adult as determined by the Jebsen Test of Hand Function. Phys Ther 1992;72:373–7.

5.Stern EB. Stability of the Jebsen-Taylor Hand Function Tests across three test sessions. Am J Occup Ther 1992;46:647–9.

6.Sharma S, Schumacher HR, McLellan AT. Evaluation of the Jebsen Hand Function Test for use in patients with rheumatoid arthritis. Arthritis Care Res 1994;7:16–9.

7.Rider B, Linden C. Comparison of standardized and non-standardized administration of the Jebsen Hand Function Test. J Hand Ther 1988;1:121–3.

8.Labi MLC, Gresham GE, Rathey UK. Hand function in osteoarthritis. Arch Phys Med Rehabil 1982;63:438–40.

9.Mathiowetz V. Role of physical performance component evaluations in occupational therapy functional assessment. Am J Occup Ther 1993;47:225–30.

THE RHEUMATOID HAND FUNCTIONAL DISABILITY SCALE (THE DuruÖz Hand Index [DHI])

General Description

Purpose

The purpose of this self-report scale is to measure functional ability in the hand.

Content

The questions ask how much difficulty the person has performing 18 tasks without the help of any assistive device. Kitchen tasks include holding a bowl, a plate full of food, pouring liquid, cutting meat, and peeling fruit. Dressing items include buttoning and opening/closing a zipper. Hygiene items include squeezing a tube of toothpaste and holding a toothbrush. Office items include two writing tasks. Items in the “Other” category include turning a doorknob, cutting with scissors, and turning a key in a lock.

Developer/contact information

Tuncay Duruöz, MD, Celal Bayar University Medical School, Physical Medicine and Rehabilitation, Manisd, Turkey.

Versions

French and English.

Number of items in scale

18 items.

Subscales

Kitchen (8 items), Dressing (2 items), Hygiene (2 items), Office (2 items) and Other (4 items).

Populations

Developmental/target

Rheumatoid arthritis, osteoarthritis, scleroderma.

Other uses

None.

WHO ICF Components

Activity limitation.

Administration

Method

Either the physician or client can complete the scale.

Training

None required.

Time to administer/ complete

Less than 3 minutes.

Equipment needed

The scale and a pencil.

Cost/availability

No cost. Available in Duruöz et al (1) article. Copy available at the Arthritis Care & Research Website at http://www.interscience.wiley.com/jpages/0004-3591:1/suppmat/index.html.

Scoring

Responses

Scale

Items are scored on a Likert scale from 0 (done without difficulty) to 5 (impossible to do).

Score range

Total score range from 0 to 90. Scores for Kitchen subscale range from 0 to 40.

Scores for Dressing, Hygiene, Office subscales range from 0 to 10. Scores for Other range from 0 to 20.

Interpretation of scores

A higher score indicates greater disability or more difficulty whereas a lower score indicates less disability or difficulty.

Method of scoring

Scores for each item are summed to yield subscale scores, and scores from the subscales are summed to yield a total score.

Time to score

Less than 1 minute.

Training to score

None.

Training to interpret

None.

Norms available

No.

Psychometric Information

Reliability

RA

Intrarater reliability established by having the same rater interview 25 subjects 2 times 24 hours apart; ICC 0.97 (1). Interrater reliability was established by having 2 raters interview 68 subjects at 24 hour intervals. The ICC was 0.96 (1).

OA

Interrater reliability was established by administering the scale 2 times within 1 hour to 41 subjects. The ICC was 0.96 (2).

SSc

Test-retest reliability was established by administering the scales 2 times 1 week apart. Peasons r = 0.96 (3).

Validity

Content or face

Validity was determined by collecting a list of hand activity questions from published indices. The questions were divided into 5 categories and given to 10 subjects. These subjects added other items and evaluated items for clarity. It was then administered to 102 subjects. Questions that were “never done” by more than 5% of subjects were eliminated yielding 18 items (1).

Criterion referenced validity

In RA, scores on the DHI were correlated with scores on a visual analog scale for functional handicap (rs = 0.77) (1). In SSc, scores on the DHI were correlated with scores on the Arthritis Hand Function Tests (r = 0.92–0.94) (3).

Convergent validity

In RA, scores on the DHI correlated with scores on the Revel functional index (rs = 0.91) and the Hand functional index (rs = 0.58) (1). In OA, scores on the DHI correlated with scores on the Revel Functional Index (rs = 0.86), the Dreiser functional index (rs = 0.87), and a visual analog scale to assess perceived disability (rs = 0.67).

Sensitivity/responsiveness to change

Sensitivity in RA

55 subjects completed the scale 2 times approximately 15 months apart. Changes in scores correlated with subject perceived handicap (rs = 0.58) but had little correlation with disease activity measures (rs = 0.19–0.34) (4).

The responsiveness of the DHI after surgery was assessed by testing 52 subjects who were going to have wrist and/or finger surgery 48 hours before the surgery and at least 6 months after surgery. DHI scores significantly improved at the send visit (P < 0.0001) (5).

Sensitivity in OA

51 subjects completed the scale 2 times approximately 5 months apart. Changes in scores correlated with subjects overall assessment (rs = 0.47) (2). The scale also discriminated between those who improved and those who deteriorated (P < 0.0001) (2).

Comments and Critique

The DHI seems to be a promising scale for use in rheumatology research. It is quick to administer and does not require any training or special equipment. Adequate reliability and validity have been established for persons with RA and OA, although all of the studies are from the same institution. The DHI has not been validated with other standardized performance-based tests of hand function. Preliminary reliability and validity studies have been done with persons with SSc.

Appendix

 

Table  . Summary Table of Adult Hand Function Measures*
Measure/scaleContentMeasure outputsNumber of itemsResponse formatMethod of adminis-trationTime for adminis-trationValidated populationsPsychometrics
ReliabilityValidityRespon-siveness
  • *

    RA = rheumatoid arthritis; OA = osteoarthritis; SSc = systemic sclerosis.

Arthritis Hand Function TestHand strength and dexterity4 subscales (strength, dexterity, applied strength, applied dexterity) that can be compared to normative data11TimedPerformance test20 minutesRA OA SScExcellentGoodNot noted
Grip Ability TestSimple test based on hand activities used in daily tasks (e.g., pouring water, put paper clip on envelop)Scores on 3 items, plus total score3TimedPerformance test2–3 minutesRAGoodLimited  informationNot noted
Jebsen Test of Hand FunctionItems represent hand activities used in daily tasks (e.g., writing, picking up small objects, picking up light and heavy cans)7 subscale scores that can be compared to normative tables7TimedPerformance test10–15 minutesRA, OAGoodAcceptableNot noted
Rheumatoid Hand Function Disability Scale (DHI)Functional ability in the hand4 subscales (Kitchen tasks, Dressing, Hygiene, Office, Other), plus total score186 point Likert Scale (0–5)Self-report3 minutesRA OA SScExcellentGoodGood

Ancillary