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The suitcase packing activity: A new evaluation of hand function
Journal of Hand Therapy xxx (2017) 1e7
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Journal of Hand Therapy journal homepage: www.jhandtherapy.org
Scientific/Clinical Article
The suitcase packing activity: A new evaluation of hand function Matthew L. Baumann DSc, OTR/L a, *, Jill M. Cancio OTD, OTR, CHT b, c, Kathleen E. Yancosek PhD, OTR/L, CHT c a b c
Department of Rehabilitation Medicine, Brooke Army Medical Center, Joint Base San Antonio-Ft. Sam Houston, San Antonio, TX, USA Extremity Trauma and Amputation Center of Excellence (EACE), Joint Base San Antonio-Ft. Sam Houston, San Antonio, TX, USA Center for the Intrepid, Brooke Army Medical Center, Joint Base San Antonio-Ft. Sam Houston, San Antonio, TX, USA
a r t i c l e i n f o
a b s t r a c t
Article history: Received 3 July 2016 Received in revised form 3 February 2017 Accepted 6 February 2017 Available online xxx
Study Design: Prospective, repeated-measures study. Introduction: Understanding individual hand function can assist therapists with the process of determining relevant treatment approaches and realistic therapeutic outcomes. At this point in time, a composite test that assesses both unilateral and bimanual hand function in relation to a functional activity is not available. Purpose of the Study: To establish the reliability and validity of the suitcase packing activity (SPA). Methods: An expert panel established face and content validity. Eighty healthy, English-speaking volunteers aged between 18 and 45 years were randomly assigned to either 1 or 2 sessions (test-retest reliability). Relative agreement between 2 examiners using an intraclass correlation coefficient (ICC)3,1 determined interrater reliability. Test-retest reliability was determined by using a repeated-measures analysis of variance and an ICC3,2. Concurrent validity was evaluated against 2 well-established hand evaluations using separate tests of correlational coefficients. Results: Face and content validity were established across 4 focus groups. Our results demonstrate good to excellent interrater reliability (ICC3,1 0.93) and good to excellent test-retest reliability (ICC3,2 0.83). SPA scores were moderately correlated with the 2-hand evaluations. Discussion: Through evaluating hand function during participation in a goal-directed activity (eg, packing a suitcase), the SPA exhibits promise in usefulness as a future viable outcome measure that can be used to assess functional abilities following a hand injury. Conclusion: The SPA is a valid and reliable tool for assessing bimanual and unilateral hand function in healthy subjects. Levels of Evidence: Diagnostic level II. Published by Elsevier Inc. on behalf of Hanley & Belfus, an imprint of Elsevier Inc.
Keywords: Hand function Hand therapy Hand assessment Treatment outcome Functional outcome measure Outcomes assessment
Introduction Understanding individual hand function can assist therapists with the process of determining relevant treatment approaches and realistic therapeutic outcomes.1 Research suggests that the
Disclaimer: The views expressed herein are those of the authors and do not reflect the official policy or position of Brooke Army Medical Center, the U.S. Army Medical Department, the U.S. Army Office of the Surgeon General, the Department of the Army and Department of Defense, or the U.S. government. Funding: This study was supported by the Center of the Intrepid, Brooke Army Medical Center. Ethical approval: Ethical approval was granted by the San Antonio Military Medical Center Institutional Review Board on 05OCT2015. * Corresponding author. Department of Rehabilitation Medicine, Brooke Army Medical Center, Joint Base San Antonio-Ft. Sam Houston, 423 Byrnes Drive, San Antonio, TX 78209, USA. Tel.: (502) 889 5979; fax: (210) 916 6746. E-mail address: [email protected] (M.L. Baumann).
dominant hand and nondominant hand each function differently during task performance.2 The dominant hand is used for object manipulation, whereas the nondominant hand acts to orient or stabilize the load imposed by the dominant hand.3,4 The dominant hand produces more accurate arm movements, with less energy required; and during functional movements, the dominant hand is able to anticipate the movement speed necessary before action without the need for visual feedback. The nondominant hand requires sensory feedback to adjust the speed of a movement while the given action is in progress.5,6 The dominant hand is more capable of adapting and demonstrating complex, rhythmic movement patterns when compared with the nondominant hand.7 Due to the unique functional differences in individual hand function, during the recovery process, it is imperative that rehabilitation professionals accurately and objectively quantify a patient’s dominant and nondominant hand abilities in relation to personally meaningful, everyday activities.4
0894-1130/$ e see front matter Published by Elsevier Inc. on behalf of Hanley & Belfus, an imprint of Elsevier Inc. http://dx.doi.org/10.1016/j.jht.2017.02.002
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Hand evaluation measures The importance of using standardized measurement instruments in assessing individual hand function is well recognized.8,9 This appreciation correlates with the increasing emphasis on outcome measures used within health care, which, in turn, is driven by the need for more cost-effective treatment.10 With shortened hospital stays and increased administrative pressure for productivity, hand therapists must evaluate a patient’s function quickly and accurately.11 Psychometrically, sound evaluations help assess an individual’s performance abilities across the continuum of care12 and can be used to assist in: (1) setting treatment priorities, (2) determining the effectiveness of treatment, and (3) recognizing treatments that can lead to improved client performance.13 Given the focus on outcomes in rehabilitation and the variety of ways in which measurement can be achieved, clinicians are challenged to select instruments that are most appropriate for their patient populations, setting, and objectives.1,14 Many approaches to assessing hand function exist, yet a “gold standard” functional hand assessment remains unavailable.9,15,16 A comprehensive hand assessment should reflect the actions an individual carries out daily,17 and therapists should therefore seek to relate measurement instruments to everyday living tasks.11 On average, hand therapists use 8 or more assessment tools on a daily to weekly basis to comprehend patients’ functional hand abilities.18 Different performance measures are used to evaluate the range of motion, endurance, dexterity, strength, and sensation to provide an accurate picture of hand function.8 At this point in time, a composite test that assesses both unilateral and bimanual hand function in relation to everyday functional activities is not available. The SPA In 2013, Gosling et al19 established the suitcase packing activity (SPA) to provide an accurate, objective, and composite measure of bimanual and unilateral hand function. Conceptualized to be occupation based, the SPA aims to evaluate unilateral and bimanual hand function through participation in a goal-directed activitydpacking a suitcase. A packing list with specific step-by-step instructions is provided to direct the individual in packing items into a suitcase. Fine and gross motor tasks embedded within the SPA seek to use practical, real-world activities such as folding clothes to highlight functional strengths and weaknesses. The purpose of this study was to evaluate the psychometric properties of the SPA. More specifically, this study aimed to: (1) establish the interrater and test-retest reliability of the SPA; (2) establish the face, content, and concurrent validity of the SPA; (3) compare the psychometric properties of the SPA to the Southampton Hand Assessment Procedure (SHAP), a standardized test of unilateral hand function, and to the Minnesota Manual Dexterity Test (MMDT), a standardized test of unilateral and bimanual hand function. Materials and methods Participants A convenience sample of 80 self-reported healthy, Englishspeaking, men and women volunteers between the age of 18 and 45 years were recruited from a level I trauma center in San Antonio, Texas. Subject recruitment took place between January 2016 and May 2016. Potential subjects were excluded if they reported existence of an unresolved upper extremity injury or a cognitive impairment. A healthy population was recruited to prevent the influence of confounding variables. This study was approved by the
local institutional review board; subjects received detailed information about the study and signed informed consent before participation. Phase 1: Manual development, face, and content validity A standardized procedure must exist in any evaluation process to ensure an assessment’s efficacy.20 There are no statistical means to appropriately assess an evaluation’s face and content validity. Claims of these validations are commonly made through procuring a panel of well-trained “experts” on the subject matter.21 Thus, to evaluate face and content validity of the SPA before subject recruitment, 4 separate 1-hour focus groups were held with a panel of experts. The purposes of the focus groups were to (1) critically analyze the SPA, (2) develop an objective, standardized procedure for administering the SPA, and (3) determine the assessment’s face and content validity. The expert panel consisted of 12 licensed occupational therapistsd5 of whom were certified hand therapists and 2 of whom were academics. The expert panel collectively agreed on a revised version of the SPA, and a manual for executing the revised SPA was created. To reduce the variability among test administrators, specific details regarding the arrangement of materials and testing procedures were documented. Phase 2: Data collection A prospective, repeated-measures design quantified performance of the SPA evaluation. A generic a priori power analysis was conducted with G*Power22 with a set at 0.05 for all statistical tests determined that a minimum of 78 subjects were needed. Once an individual’s eligibility and consent were confirmed, a short, nonstandardized questionnaire was given to each subject to gain details including the person’s age, gender, and hand dominance. Blocked randomization using IBM SPSS Statistical Software 22 (SPSS Inc, Chicago, IL) was used to randomly assign subjects to participate in either 1 or 2 sessions. All testing sessions occurred in a quiet, well-lit room with limited distractions present. Subjects performed the follow-up session in the same room they had performed the initial session. During the initial session, all subjects completed the SPA first, SHAP second, and MMDT third. The follow-up session, which occurred 7-14 days after the initial session, involved timed performances in each of the 3 conditions of the SPA. The choice of a 7- to 14-day interval between sessions was to avoid changes in a subject’s condition while also decreasing the risk for a direct learning effect. In this between-session interval models, similar test-retest procedures were used in other hand evaluation studies.23-25 All subjects performed each evaluation measure in a manner consistent with the established guidelines for the given assessment. A 5-minute break between performances of the SPA, SHAP, and MMDT was part of the testing protocol. All investigators were trained in the administration of the SPA, SHAP, and MMDT evaluations. While randomizing and counterbalancing the order in which investigators are assigned to subjects are recognized as best practice,21 time and scheduling conflicts among the 5 investigators prevented this process from occurring. Thus, 2 investigators were allocated to each subject based on individual availability. Once assigned to a given subject, the same 2 investigators rated all performance tasks at initial and (if applicable) follow-up sessions. Each investigator rated subject performance independently. Instruments used Suitcase Packing Activity The SPA was established to provide an accurate, objective measure of bimanual and unilateral hand function through
M.L. Baumann et al. / Journal of Hand Therapy xxx (2017) 1e7
evaluation of one’s performance in an occupation-based, goaldirected activity. All required items for test administration are provided in the SPA kit. Participants are provided a packing list with 20 step-by-step instructions on how to pack provided items into a given suitcase. The test administrator’s manual outlines the protocol for proper implementation (see Supplementary Appendix). The SPA picture board depicts exactly how the contents of the SPA are arranged on the testing table and is marked to delineate object placement for consistency across performances. Item placement promotes left, right, and forward reaching patterns. For this study, subjects were asked to perform the SPA under 3 distinct performance conditions: (1) using both hands, (2) using only the dominant hand with the nondominant hand constrained, and (3) using only the nondominant hand with the dominant hand constrained. Performance of the SPA under each condition was scored for time and accuracy. The time was recorded in seconds and accuracy was scored by subtracting 1 second for every task completed correctly. The composite score was recorded as the efficiency score. The timer was started by the subject once a performance activity session began and stopped by the subject as soon as all the required activities were completed or after 25 minutes had elapsed. On completion of each performance condition, the test administrator unpacked the suitcase and placed the SPA objects in their initial starting positions as quickly as possible. The placement of the picture board and SPA objects remained the same for all test performances. A packing list was provided to participants for use during performance of the activity. Items were listed in the order they were to be used. Southampton Hand Assessment Procedure The SHAP is a well-established, standardized measure shown to have excellent reliability and validity in assessing musculoskeletal and neurological conditions.13,26-28 The SHAP seeks to classify unilateral hand performance through participation in 26 timed activities in a standardized sequence.26 An index of functionality (IDF) score is derived from data accumulated from performance in all activities. For this study, subjects were asked to perform all SHAP tasks using their dominant hand and nondominant hand. Data for each task performance were recorded according to the SHAP’s established procedures. Minnesota Manual Dexterity Test The MMDT is a frequently administered, standardized test for determining baseline eye-hand coordination and arm-hand dexterity skills.29 The MMDT classifies hand motor skills according to precision of movement, beginning and end point of movement, and environmental stability.30 Test-retest reliability of the MMDT placing and turning subtests demonstrates good temporal stability, and the concurrent validity of the MMDT has been established by significant correlations with the Purdue Pegboard and the Box and Blocks Test.24 For this study, 2 trials of the following subtests were used: placing subtest, turning subtest, 1-hand turning and placing subtest, and 2-hand turning and placing subtest. To best assess unilateral performance, each subject was asked to perform the placing test and the 1-hand turning and placing test with the dominant hand for 2 consecutive trials and then the nondominant hand for 2 consecutive trials.
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reliability, a 2-way mixed effects model ICC3,2 for consistency between 2 sessions was used for each subject. SEM was calculated as: 1
SEM ¼ SD ð1 ICCÞ2 where SD represented the average standard deviation of parallel measurements combined, and ICC represents the reliability coefficient for that particular measurement. Minimum detectable change (MDC) was also calculated for the test-retest reliability of SPA initial and follow-up efficiency scores. MDC identifies the minimum amount of change necessary to exceed measurement error and identify true change.31 To calculate MDC values at the 95% confidence interval, the following formula was used:
MDC ¼ SEM 1:96
pffiffiffiffiffi21 2:
To determine whether there were significant differences between subjects and the scores obtained during initial and follow-up sessions, a 2-way repeated-measures analysis of variance (ANOVA) was performed. The ANOVA contained 2 “within-subject factors”: the trials and the SPA performance conditions. Between-subject factors included gender, age, hand dominance, and length of time between sessions. The Mauchly’s Test of Sphericity was used to assess the ANOVA test’s assumptions. If the assumption of sphericity was violated, the Greenhouse-Geisser correction epsilon was used to determine the P value. All results were considered to be significantly different when P .05. The concurrent validity of the SPA was examined against 2 wellestablished, standardized tests used to measure hand function: the SHAP and the MMDT. The Pearson’s product moment correlation coefficient (r) was used to assess the relationship between SPA, SHAP, and MMDT scores. The scores obtained from the SHAP, unilateral tasks of the MMDT (eg, the placing subtest and 1-hand turning and placing subtest), and unilateral SPA performance conditions (eg, dominant hand only and nondominant hand only) were compared with one another. For each unilateral test comparison, only dominant hand scores were compared with dominant hand scores, and only nondominant hand scores were compared against other nondominant hand scores. To assess bimanual hand function, only the scores obtained from the bimanual MMDT tasks (eg, the turning subtest and 2-hand turning and placing subtest) were compared against the scores obtained from the bimanual SPA performance condition. Significance level was set at P < .05 for all r calculations.21 At least a fair association ( 0.30) between SPA, SHAP, and MMDT scores was expected. Microsoft Excel 2007 (Microsoft Corporation, Redmond, WA) was used to determine SEM and MDC values for all SPA performance conditions. IBM SPSS Statistical Software 22 (SPSS Inc, Chicago, IL) was used to analyze descriptive statistics and perform all t-test, ANOVA, and reliability (ICC and r) calculations. Reliability results were interpreted based on the following criteria: ICC values 0.25 ¼ “low,” 0.25-0.50 ¼ “fair,” 0.50-0.75 ¼ “moderate to good,” and 0.75 ¼ “good to excellent.”21 Results Participants
Statistical analysis Intraclass correlation coefficient (ICC) and standard error measurement (SEM) were used to assess the interrater and test-retest reliability domains of the SPA. These domains were assessed with a significance level set at P < .05. A 2-way mixed effects model ICC3,1 for relative agreement between 2 raters was used for each subject to determine interrater reliability. To determine test-retest
Demographic characteristics of the 80 subjects are reported in Table 1. Ten percent of the subjects being left-handed fall within the normal population variance for handedness.32,33 All subjects performed the follow-up session within 7-14 days after the initial session; no subject was lost to follow-up. The mean and standard deviations of subject scores for the SHAP and MMDT performance condition are presented in Table 2.
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Table 1 Demographic characteristics of subjects Initial session data (N ¼ 80)
Total
Male
Female
Number of subjects (% of N) Age, mean (SD), y Hand dominance Right handed (% of N) Left handed (% of N)
80 (100%) 31.1 (6.9)
34 (42.5%) 33.6 (7.2)
46 (57.5%) 29.3 (6.2)
71 (88.8%) 9 (11.3%)
28 (82.4%) 6 (17.6%)
43 (93.5%) 3 (6.5%)
Follow-up session data (N ¼ 38)
Totala
Male
Female
Number of subjects (% of N) Age, mean (SD), y Hand dominance Right handed (% of N) Left handed (% of N) Average number of days between initial and follow-up sessions (range)
38 (100%) 31.3 (6.9)
17 (44.7%) 34.6 (7.6)
21 (55.3%) 28.7 (5.0)
36 (94.7%) 2 (5.3%) 9.58 (7-13)
15 (88.2%) 2 (11.8%) 10.0 (7-13)
21 (100.0%) 0 (0.0%) 9.2 (7-13)
SD ¼ standard deviation. a 100% follow-up rate.
Figure 1. SPA board with activity objects properly placed. SPA ¼ suitcase packing activity.
Face and content validity
Interrater reliability statistics are presented in Table 5. During the initial and follow-up sessions, the interrater reliability of time, accuracy, and efficiency scoring was good to excellent for 2 raters across bimanual and unilateral SPA tasks. For each condition, the absolute agreement of interrater reliability was established at ICC3,1 ¼ 1.00 (SEM ¼ 0.00) for time scores, ICC3,1 0.93 (SEM 0.04) for accuracy scores, and ICC3,1 ¼ 1.00 (SEM ¼ 0.00) for efficiency scores.
Over the course of the 4 focus groups, an iterative process of analyzing the SPA helped the expert panel to agree on the layout of activity items (Figure 1), the necessary table dimensions required for test setup, subject positioning in relation to the evaluation’s setup, the fine and gross motor tasks to be performed, scoring procedures, and the specific instructions to be given to each subject before, during, and after each performance condition. The expert panel removed, added, and modified specific tasks within the SPA in an effort to comprehensively evaluate the various components involved with bimanual and unilateral hand function. Recommendations were implemented, and a manual for executing the SPA was created (see Supplemental Appendix). At the end of the fourth session, all 12 panel members individually determined the SPA-satisfied face and content validity domains of a functional hand evaluation measure.
Interrater reliability Table 3 displays the number of testing sessions each investigator participated in. Investigators who were assigned to the role of “rater 1” for a subject’s initial session remained in the role of rater 1 for the same subject’s follow-up session. The same process was also used for the assignment of “rater 2.” The mean scores and standard deviations for rater 1 and rater 2 across all 3 SPA performance conditions are summarized in Table 4.
Table 2 SHAP and MMDT performance conditions mean scores and standard deviations for subjects (N ¼ 80) Scale
Mean (SD)
Range
SHAP DH IDF SHAP NDH IDF MMDT DH placing subtesta MMDT NDH placing subtesta MMDT turning subtesta MMDT DH OHTP subtesta MMDT NDH OHTP subtesta MMDT THTP subtesta
99.50 98.71 62.68 67.36 50.73 77.60 81.51 46.37
95-106 91-106 47.11-84.60 54.14-87.18 37.38-76.16 55.60-113.49 60.68-110.00 32.48-63.76
(2.86) (3.22) (5.94) (6.59) (6.21) (9.60) (9.53) (5.75)
DH ¼ dominant hand; MMDT ¼ Minnesota Manual Dexterity Test; NDH ¼ nondominant hand; OHTP ¼ one-hand turning and placing; SD ¼ standard deviation; SHAP ¼ Southampton Hand Assessment Procedure; THTP ¼ 2-hand turning and placing. a Mean and SD MMDT scores are across two trials.
Test-retest reliability The test-retest reliability of the efficiency scores across all 3 performance conditions was demonstrated to be good to excellent in Table 6. A significant difference was found within subjects across initial and follow-up sessions scores (F ¼ 238.67; degree of freedom (df) ¼ 1; P < .0001). A significant difference was also found within subjects across SPA performance conditions (F ¼ 261.48; df ¼ 5; P < .0001). Across all SPA performance conditions, mean differences in time scores between sessions were 56.12 seconds lower at follow-up for females and 65.23 seconds lower at follow-up for males. On average, SPA accuracy scores improved at follow-up by 0.25 points for females and 0.19 points for males. Mean differences in efficiency scores between sessions were 57.55 points lower at follow-up for females and 65.42 points lower at follow-up for males. No statistically significant differences were found between subjects for gender, age, hand dominance, and/or time between initial and follow-up sessions. Due to the high interrater reliability demonstrated between rater 1 and rater 2, only the test-retest reliability scores obtained by rater 1 are reported. Test-retest reliability for bimanual performance was demonstrated at ICC3,2 ¼ 0.83 (SEM ¼ 4.68; MDC ¼ 12.97). For dominant hand only performance, test-retest reliability was demonstrated at ICC3,2 ¼ 0.88 (SEM ¼ 4.74; MDC ¼ 13.14). Test-retest Table 3 Number of initial vs follow-up sessions completed by each investigator Investigator Investigator Investigator Investigator Investigator Investigator Total
1 2 3 4 5
Initial session
Follow-up session
78 12 10 18 42 160
37 6 3 10 20 76
To establish interrater reliability, each session was rated by 2 investigators. To establish test-retest reliability, the same 2 investigators rated the same subject’s initial and follow-up sessions.
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Table 4 SPA performance conditions mean scores and standard deviations at initial (N ¼ 80) and follow-up (N ¼ 38) sessions for 2 raters Rater Rater Rater Rater Rater
1, 2, 1, 2,
mean mean mean mean
(SD) (SD) (SD)a (SD)a
SPA bimanual time (s)
SPA bimanual accuracy
SPA bimanual efficiency
SPA DH only time (s)
SPA DH only accuracy
SPA DH only efficiency
SPA NDH only time (s)
SPA NDH only accuracy
SPA NDH only efficiency
335.19 335.19 268.42 268.42
18.90 18.95 18.89 18.95
317.18 317.15 249.53 249.47
449.91 449.91 402.34 402.34
18.11 18.03 18.52 18.60
431.80 431.88 383.82 383.74
471.83 471.83 434.32 434.32
18.28 18.36 18.31 18.39
453.55 453.46 415.92 416.00
(60.12) (60.12) (48.24) (48.24)
(0.98) (1.00) (1.03) (1.14)
(61.75) (61.76) (48.38) (48.45)
(82.22) (82.22) (75.65) (75.65)
(1.57) (1.68) (1.37) (1.17)
(82.40) (82.38) (75.70) (75.72)
(86.05) (86.05) (83.84) (83.84)
(1.72) (1.76) (1.38) (1.35)
(85.92) (86.01) (83.79) (83.72)
DH ¼ dominant hand; NDH ¼ nondominant hand; SD ¼ standard deviation; SPA ¼ suitcase packing activity. a Follow-up session data.
reliability for nondominant hand performance was demonstrated at ICC3,2 ¼ 0.88 (SEM ¼ 5.09; MDC ¼ 14.11). Concurrent validity Concurrent validity of the 3 outcome measures is shown in Table 7. There were several statistically significant correlations found between SPA and SHAP scores (8/10), SPA and MMDT scores (18/36), and SHAP and MMDT scores (3/4). The strongest significant correlation between the SHAP IDF scores and initial SPA unilateral performance scores was fair (r ¼ 0.42, P < .01). The strongest significant correlation between the SHAP IDF scores and follow-up SPA unilateral performance scores was fair (r ¼ 0.45, P < .01). Initial and follow-up SPA unilateral performance accuracy scores did not show a significant correlation to the SHAP IDF scores. The strongest significant correlation between the MMDT placing subtest scores and SPA unilateral performance scores was fair (r ¼ 0.46, P < .01). The strongest significant correlation between MMDT 1-hand turning and placing subtest scores and SPA unilateral performance scores was fair (r ¼ 0.28, P < .05). Follow-up SPA dominant handeonly performance scores did not show a significant correlation to the MMDT placing subtest scores. There were no significant correlations between follow-up SPA unilateral performance scores and the MMDT 1-hand turning and placing subtest scores. The strongest significant correlation between the MMDT turning subtest scores and SPA bimanual performance scores was fair (r ¼ 0.36, P < .01). The strongest significant correlation between Table 5 Interrater reliability coefficients for SPA scores at initial vs follow-up session (absolute agreement) Scoring condition Initial session SPA bimanual time SPA bimanual accuracy SPA bimanual efficiency SPA DH only time SPA DH only accuracy SPA DH only efficiency SPA NDH only time SPA NDH only accuracy SPA NDH only efficiency Follow-up session SPA bimanual time SPA bimanual accuracy SPA bimanual efficiency SPA DH only time SPA DH only accuracy SPA DH only efficiency SPA NDH only time SPA NDH only accuracy SPA NDH only efficiency
ICC (type 3,1)
SEM
95% confidence interval (lower bound to upper Bound)
1.00 0.95 1.00 1.00 1.00 1.00 1.00 0.98 1.00
0.00 0.02 0.00 0.00 0.00 0.00 0.00 0.02 0.00
1.00-1.00 0.93-0.97 1.00-1.00 1.00-1.00 1.00-1.00 1.00-1.00 1.00-1.00 0.98-0.99 1.00-1.00
1.00 0.95 1.00 1.00 0.93 1.00 1.00 0.98 1.00
0.00 0.03 0.00 0.00 0.04 0.00 0.00 0.01 0.00
1.00-1.00 0.91-0.98 1.00-1.00 1.00-1.00 0.86-0.96 1.00-1.00 1.00-1.00 0.95-0.99 1.00-1.00
DH ¼ dominant hand; ICC ¼ intraclass correlation; MDC ¼ minimal detectable change; NDH ¼ nondominant hand; SEM ¼ standard error of measurement; SPA ¼ suitcase packing activity.
MMDT 2-hand turning and placing subtest scores and SPA bimanual performance scores was fair (r ¼ 0.42, P < .05). All followup SPA scores for the bimanual performance condition did not show a significant correlation to the MMDT turning subtest scores. The correlations between the SHAP IDF scores and MMDT placing subtest scores were fair (r ¼ 0.34 to 0.38, P < .01). A significant correlation was noted with the nondominant hand between the SHAP IDF scores and MMDT 1-hand turning and placing subtest scores. This correlation was fair (r ¼ 0.40, P < .01).
Discussion Due to the wide range of physical and psychosocial factors involved with an upper extremity injury, it is important for hand therapists to quickly and accurately assess a patient’s functional capacities.34 This study established the validity and reliability of a new, objective, and composite measure of bimanual and unilateral hand function. Through evaluating hand function during participation in a goal-directed activity, the SPA exhibits promise in usefulness as a future viable outcome measure that can be used to assess functional ability after hand injury. A standardized procedure for administering the SPA was developed, and an expert panel concluded that the SPA comprehensively assessed unilateral and bimanual hand function. The SPA demonstrated good to excellent interrater reliability (ICC 0.93), good to excellent test-retest reliability (ICC 0.83), and acceptable concurrent validity (several statistically significant fair correlations between SPA vs SHAP [8/10]; SPA vs MMDT [18/36]). The SPA took approximately 2 minutes for each investigator to setup, and subjects on average completed each performance condition in less than 8 minutes. The present study results demonstrate that the SPA’s interrater and test-retest correlation coefficients to be very high for bimanual and unilateral performance conditions.35 When considering these data, involvement of study investigators in the conceptual refinement of the SPA may have aided in the high reliability results. Therefore, a future study may be warranted to examine interrater reliability of a group of raters not involved with the development of the SPA. Table 6 Test-retest reliability coefficients for SPA efficiency scores rater 1 vs rater 2 (consistency) Scoring Condition SPA bimanual Rater 1 Rater 2 SPA DH only Rater 1 Rater 2 SPA NDH only Rater 1 Rater 2
ICC (type 3,2)
SEM
95% confidence interval (lower bound-upper bound)
MDC
0.83 0.83
4.68 4.68
0.68-0.91 0.68-0.91
12.97 12.97
0.88 0.88
4.74 4.74
0.76-0.94 0.77-0.94
13.14 13.14
0.88 0.88
5.09 5.09
0.77e0.94 0.77e0.94
14.11 14.11
DH ¼ dominant hand; ICC ¼ intraclass correlation; MDC ¼ minimal detectable change; NDH ¼ nondominant hand; SEM ¼ standard error of measurement; SPA ¼ suitcase packing activity.
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Table 7 Correlation coefficients for SPA, SHAP, and MMDT scores Scale
SHAP DH IDF
SHAP NDH IDF
SHAP DH IDF SHAP NDH IDF Initial SPA DH time Initial SPA DH accuracy Initial SPA DH efficiency Initial SPA NDH time Initial SPA NDH accuracy Initial SPA NDH efficiency Initial SPA bimanual time Initial SPA bimanual accuracy Initial SPA bimanual efficiency Follow-up SPA DH time Follow-up SPA DH accuracy Follow-up SPA DH efficiency Follow-up SPA NDH time Follow-up SPA NDH accuracy Follow-up SPA NDH efficiency Follow-up SPA bimanual time Follow-up SPA bimanual accuracy Follow-up SPA bimanual efficiency
d d .41b .06 .41b d d d d d d
d d d d d .42b .13 .41b d d d
.45b .20 .45b d d d d d d
d d d .42b .03 .42b d d d
MMDT NDH placing subtest
MMDT turning subtest
MMDT DH 1-hand turning and placing subtest
MMDT NDH 1-hand turning and placing subtest
MMDT 2-hand turning and placing subtest
.34b d .36b .23a .36b d d d d d d
d .38b d d d .39b .09 .39b d d d
d d d d d d d d .33b .01 .36b
.21 d .28a .24a .28a d d d d d d
d .40b d d d .28a .05 .28b d d d
d d d d e d d d .32b .11 .35b
.28 .07 .28 d d d d d d
d d d .45b .01 .46b d d d
d d d d d d .26 .10 .26
.22 .28 .23 d d d d d d
d d d .23 .01 .23 d d d
d d d d d d .42b .05 .42b
MMDT DH placing subtest
DH ¼ dominant hand only; MMDT ¼ Minnesota Manual Dexterity Test; NDH ¼ nondominant hand only; SHAP ¼ Southampton Hand Assessment Procedure; SPA ¼ suitcase packing activity. a Significance at the 0.05 level (2 tailed). b Correlation is significant at the 0.01 level (2 tailed).
The concurrent validity data analyses demonstrated several statistically significant fair correlations between SPA, SHAP, and MMDT performance conditions. The relatively weak correlations between the assessments were not surprising. Due to the lack of a criterion standard for hand evaluation measures, it cannot be assumed that different assessments produce comparable clinical data.8 Due to the absence of a benchmark standard, the concurrent validity of the SHAP had not been established before this study.26 In this study, a statistically significant fair negative correlation between the unilateral SPA performance conditions and the SHAP IDF scores was observed. This negative correlation makes statistical sense as lower efficiency scores for the SPA indicate better functioning and higher IDF scores for the SHAP indicate better functioning. In the present study, a statistically significant fair negative correlation was also found between SHAP IDF scores and unilateral MMDT subtest scores. The findings of a fair positive correlation between most SPA and MMDT scores provide results consistent with the findings of a previous study comparing a dexterity evaluation against a functional performance evaluation.36 In addition, it is important to note that when the concurrent validity of the MMDT was originally evaluated against 2 other dexterity measures known to be reliable and valid: the Box and Blocks Test37 and Purdue Pegboard Test38; the strongest relationship between a MMDT subtest and another test was only considered “moderate to good” (r ¼ 0.67; P < .0001).24 Despite evaluating seemingly similar aspects of hand function, the variation in implementation proved difficult for test results to be highly correlated. Although only fair correlations were achieved between the evaluations used in this study, it is important to interpret obtained results relative to the assessments used. Greater than 95 is normal range for SHAP IDF scores with lower scores suggesting a decreased level of function.27 In the present study, mean subject SHAP IDF scores for dominant and nondominant hand performance were above normal range as previously reported in the literature.26 When considering MMDT subtest scores for healthy individuals (calculating means from
a previous study’s data), mean dominant hand MMDT placing subtest scores have been established at 76.70 seconds (SD ¼ 8.25), mean nondominant hand MMDT placing subtest scores have established at 79.65 seconds (SD ¼ 9.50), and mean MMDT turning subtest scores have been established at 62.00 seconds (SD ¼ 8.60).24 All subjects in the present study achieved lower mean scores across the same number of trials in each of these MMDT subtests. Considering these data, in this study, self-reported healthy subjects achieved “normal” results according to each test’s established procedures as demonstrated in existing literature.24 Thus, it could be suggested that the fair correlations between outcome measures might be due to the lack of a criterion standard for evaluating hand function. Perhaps, each test variable approach to assessing hand function makes it difficult for test results to correlate strongly with one another. Study limitations Several study limitations warrant consideration. The study recruited a convenience sample of self-reported healthy subjects. A sample size involving a nonhealthy clinical population would increase the variability and overall generalizability of the results. Second, the 2-way repeated-measures ANOVA found a significant difference within subjects across individual performance trials. This indicates that the SPA has an inherent learning effect after initial performance. Implementing additional follow-up sessions could help identify when a level of redundancy can be reached for subject scores under each SPA performance condition. Third, subjects were not randomized to the 3 SPA performance conditions (eg, using both hands, using only the dominant hand, using only the nondominant hand), which could have an influence on the overall performance scores obtained. Another limitation pertains to how the SPA does not readily identify specific pinch, grasp, and in-hand manipulation skills. Individual strengths/deficits are noted during SPA performance based on the goal-directed, occupation-based activities that one can or cannot complete. Although many argue that best practice for any evaluation involves assessing one’s occupational
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performance (function),12 others might contend that evaluations should be more reductionist in nature and focus on specific prehensile abilities. Finally, the interpretations of the MDC are limited. Future studies are needed to determine what specific score change relative to the MDC is necessary for clinically important improvement vs deterioration. Future research Future research is warranted to establish normative data stratified for gender, age, and hand dominance. Future research could also examine differences based on SPA performance while standing vs sitting. Although difficult to establish in relation to hand function, construct validity could be explored in future research. Conclusion The SPA is a simple, low-cost, valid, and reliable tool for assessing bimanual and unilateral hand function in self-reported healthy subjects. Face and content validity of the SPA have been established, and administration has been standardized. The SPA demonstrates good to excellent interrater reliability, good to excellent test-retest reliability, and acceptable concurrent validity. Upon further development and establishment of normative data, the SPA may provide a unique, functional continuous-task evaluation. The SPA shows promise in contributing to evidence-based practice by providing a quality, composite measure of hand function. Acknowledgments The authors would like to thank Catrinna R. Amorelli, DSc, OTR/L, Lindsay K. Sposato, DSc, OTR/L, and Joshua A. Springer, DSc, OTR/L for their unwavering commitment to this project as associate investigators. The authors wish to acknowledge and thank Kristin de Guzman, DSc, OTR/L and Ariel Gosling, DSc, OTR/L for their initial work on the SPA. They also thank Christopher A. Rábago, PT, PhD for his mentorship with this study’s statistical data analysis. References 1. Skirven T, Osterman AL, Fedorczyk JM, Amadio PC. Rehabilitation of the Hand and Upper Extremity. 6th ed. Philadelphia, PA: Elsevier; 2011. 2. Duff SV, Sainburg RL. Lateralization of motor adaptation reveals independence in control of trajectory and steady-state position. Exp Brain Res. 2007;179(4): 551e561. 3. Kimmerle M, Mainwaring L, Borenstein M. The functional repertoire of the hand and its application to assessment. Am J Occup Ther. 2003;57(5):489e498. 4. Yancosek KE. Management of dominant upper extremity injuries: a survey of practice patterns. J Hand Ther. 2012;25(1):79e87. quiz 88. 5. Sainburg RL, Duff SV. Does motor lateralization have implications for stroke rehabilitation? J Rehabil Res Dev. 2006;43(3):311e322. 6. Yancosek KE. Injury-induced hand dominance transfer. Lexington, KY: University of Kentucky; 2010. 7. de Poel HJ, Peper CL, Beek PJ. Intentional switches between bimanual coordination patterns are primarily effectuated by the nondominant hand. Motor Control. 2006;10(1):7e23. 8. Lindner HY, Natterlund BS, Hermansson LM. Upper limb prosthetic outcome measures: review and content comparison based on International Classification of Functioning, Disability and Health. Prosthet Orthot Int. 2010;34(2):109e128. 9. Yancosek KE, Howell D. A narrative review of dexterity assessments. J Hand Ther. 2009;22(3):258e269. quiz 270. 10. Holm MB. The 2000 Eleanor Clarke Slagle Lecture. Our mandate for the new millennium: evidence-based practice. Am J Occup Ther. 2000;54(6):575e585.
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11. Gonzalez Meng V, Rowson J, Yoxall A. Analyzing finger interdependencies during the Purdue Pegboard Test and comparative activities of daily living. J Hand Ther. 2016 [Epub ahead of print]. 12. Law M, Baum C, Dunn W. Occupational performance assessment. In: Occupational Therapy: Performance, Participation, and Wellbing. Thorofare: Slack Incorporated; 2005:338e370. 13. Wright F. Measurement of functional outcome with individuals who use upper extremity prosthetic devices: current and future directions. J Prosthet Orthot. 2006;18(2):46e56. 14. Rudman D, Hannah S. An instrument evaluation framework: description and application to assessments of hand function. J Hand Ther. 1998;11(4):266e277. 15. Cary I, Adams J. A comparison of dominant and non-dominant function in both right- and left-handed individuals using the Southampton Hand Assessment Procedure (SHAP). Br J Hand Ther. 2003;8(1):4e10. 16. Resnik LPTP, Borgia MMS. Reliability and validity of outcome measures for upper limb amputation. J Prosthet Orthot. 2012;24(4):192e201. 17. Grice KO. The use of occupation-based assessments and intervention in the hand therapy setting - A survey. J Hand Ther. 2015;28(3):300e305. quiz 306. 18. Weinstock-Zlotnick G, Bear-Lehman J. How therapists specializing in hand therapy evaluate the ability of patients to participate in their daily lives: An exploratory study. J Hand Ther. 2015;28(3):261e268. 19. deGusman K, Gosling A, Yancosek K. The Suitcase Packing Activity: A functional evaluation of unilateral and bilateral upper extremity motion. Waco, TX: Unpublished Doctoral Thesis: Baylor University; 2013. 20. Fess EE. Documentation: essential elements of an upper extremity assessment battery. Rehabil Hand Surg Ther. 1995;1:185e214. 21. Portney L, Watkins M. Foundation of Clinical Research: Applications to Practice. 3rd ed. Upper Saddle River, NJ: Pearson Prentice Hall; 2009. 22. Faul F, Erdfelder E, Land A, Buchner A. G*Power 3: A flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav Res Methods. 2007;39(2):175e191. 23. Platz T, Pinkowski C, van Wijck F, Kim IH, di Bella P, Johnson G. Reliability and validity of arm function assessment with standardized guidelines for the Fugl-Meyer Test, Action Research Arm Test and Box and Block Test: a multicentre study. Clin Rehabil. 2005;19(4):404e411. 24. Desrosiers J, Rochette A, Hebert R, Bravo G. The Minnesota Manual Dexterity Test: reliability, validity and reference values studies with healthy elderly people. Can J Occup Ther. 1997;64(5):270e276. 25. Desrosiers J, Bravo G, Hebert R, Dutil E, Mercier L. Validation of the Box and Block Test as a measure of dexterity of elderly people: reliability, validity, and norms studies. Arch Phys Med Rehabil. 1994;75(7):751e755. 26. Light C, Chappell P, Kyberd P. Establishing a standardized clinical assessment tool of pathologic and prosthetic hand function: normative data, reliability, and validity. Arch Phys Med Rehabil. 2002;83:776e783. 27. Kyberd P, Murgia A, Gasson M, Tjerks T, Metcalf C. Case studies to demonstrate the range of applications of the Southampton Hand Assessment Procedure. Br J Occup Ther. 2009;72(5):212e218. 28. Adams J, Hodges K, Kujawa J, Metcalf C. Test-retest reliability of the Southampton Assessment Procedure. Int J Rehabil Res. 2009;32:S18. 29. van de Ven-Stevens LA, Munneke M, Terwee CB, Spauwen PH, van der Linde H. Clinimetric properties of instruments to assess activities in patients with hand injury: a systematic review of the literature. Arch Phys Med Rehabil. 2009;90(1): 151e169. 30. Complete Minnesota Manual Dextery Test: Examiner’s Manual. Lafayette, IN: Lafayette Instrument Company; 1998-2012. 31. Wyrwich KW, Tierney WM, Wolinsky FD. Further evidence supporting an SEMbased criterion for identifying meaningful intra-individual changes in healthrelated quality of life. J Clin Epidemiol. 1999;52(9):861e873. 32. Llaurens V, Raymond M, Faurie C. Why are some people left-handed? An evolutionary perspective. Philos Trans R Soc Lond B Biol Sci. 2009;364(1519): 881e894. 33. Faurie C, Schiefenhvel W, leBomin S, Billiard S, Raymond M. Variation in the frequency of left-handedness in traditional societies. Curr Anthropol. 2005;46(1):142e147. 34. Cooper C. Fundamentals of hand therapy: Clinical reasoning and treatment guidelines for common diagnoses of the upper extremity. St. Louis, MO: Elsevier Health Sciences; 2013. 35. Munro B. Statistical methods for health care research. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2005. 36. Lin KC, Chuang LL, Wu CY, Hsieh YW, Chang WY. Responsiveness and validity of three dexterous function measures in stroke rehabilitation. J Rehabil Res Dev. 2010;47(6):563e571. 37. Cromwell FS. Occupational Therapist’s Manual for Basic Skills Assessment or Primary Pre-vocational Evaluation. Pasadena, CA: Fair Oaks Print. Company; 1965. 38. Tiffin J, Asher EJ. The Purdue Pegboard: Norms and studies of reliability and validity. J Appl Psychol. 1948;32(3):234.
Contents lists available at ScienceDirect
Journal of Hand Therapy journal homepage: www.jhandtherapy.org
Scientific/Clinical Article
The suitcase packing activity: A new evaluation of hand function Matthew L. Baumann DSc, OTR/L a, *, Jill M. Cancio OTD, OTR, CHT b, c, Kathleen E. Yancosek PhD, OTR/L, CHT c a b c
Department of Rehabilitation Medicine, Brooke Army Medical Center, Joint Base San Antonio-Ft. Sam Houston, San Antonio, TX, USA Extremity Trauma and Amputation Center of Excellence (EACE), Joint Base San Antonio-Ft. Sam Houston, San Antonio, TX, USA Center for the Intrepid, Brooke Army Medical Center, Joint Base San Antonio-Ft. Sam Houston, San Antonio, TX, USA
a r t i c l e i n f o
a b s t r a c t
Article history: Received 3 July 2016 Received in revised form 3 February 2017 Accepted 6 February 2017 Available online xxx
Study Design: Prospective, repeated-measures study. Introduction: Understanding individual hand function can assist therapists with the process of determining relevant treatment approaches and realistic therapeutic outcomes. At this point in time, a composite test that assesses both unilateral and bimanual hand function in relation to a functional activity is not available. Purpose of the Study: To establish the reliability and validity of the suitcase packing activity (SPA). Methods: An expert panel established face and content validity. Eighty healthy, English-speaking volunteers aged between 18 and 45 years were randomly assigned to either 1 or 2 sessions (test-retest reliability). Relative agreement between 2 examiners using an intraclass correlation coefficient (ICC)3,1 determined interrater reliability. Test-retest reliability was determined by using a repeated-measures analysis of variance and an ICC3,2. Concurrent validity was evaluated against 2 well-established hand evaluations using separate tests of correlational coefficients. Results: Face and content validity were established across 4 focus groups. Our results demonstrate good to excellent interrater reliability (ICC3,1 0.93) and good to excellent test-retest reliability (ICC3,2 0.83). SPA scores were moderately correlated with the 2-hand evaluations. Discussion: Through evaluating hand function during participation in a goal-directed activity (eg, packing a suitcase), the SPA exhibits promise in usefulness as a future viable outcome measure that can be used to assess functional abilities following a hand injury. Conclusion: The SPA is a valid and reliable tool for assessing bimanual and unilateral hand function in healthy subjects. Levels of Evidence: Diagnostic level II. Published by Elsevier Inc. on behalf of Hanley & Belfus, an imprint of Elsevier Inc.
Keywords: Hand function Hand therapy Hand assessment Treatment outcome Functional outcome measure Outcomes assessment
Introduction Understanding individual hand function can assist therapists with the process of determining relevant treatment approaches and realistic therapeutic outcomes.1 Research suggests that the
Disclaimer: The views expressed herein are those of the authors and do not reflect the official policy or position of Brooke Army Medical Center, the U.S. Army Medical Department, the U.S. Army Office of the Surgeon General, the Department of the Army and Department of Defense, or the U.S. government. Funding: This study was supported by the Center of the Intrepid, Brooke Army Medical Center. Ethical approval: Ethical approval was granted by the San Antonio Military Medical Center Institutional Review Board on 05OCT2015. * Corresponding author. Department of Rehabilitation Medicine, Brooke Army Medical Center, Joint Base San Antonio-Ft. Sam Houston, 423 Byrnes Drive, San Antonio, TX 78209, USA. Tel.: (502) 889 5979; fax: (210) 916 6746. E-mail address: [email protected] (M.L. Baumann).
dominant hand and nondominant hand each function differently during task performance.2 The dominant hand is used for object manipulation, whereas the nondominant hand acts to orient or stabilize the load imposed by the dominant hand.3,4 The dominant hand produces more accurate arm movements, with less energy required; and during functional movements, the dominant hand is able to anticipate the movement speed necessary before action without the need for visual feedback. The nondominant hand requires sensory feedback to adjust the speed of a movement while the given action is in progress.5,6 The dominant hand is more capable of adapting and demonstrating complex, rhythmic movement patterns when compared with the nondominant hand.7 Due to the unique functional differences in individual hand function, during the recovery process, it is imperative that rehabilitation professionals accurately and objectively quantify a patient’s dominant and nondominant hand abilities in relation to personally meaningful, everyday activities.4
0894-1130/$ e see front matter Published by Elsevier Inc. on behalf of Hanley & Belfus, an imprint of Elsevier Inc. http://dx.doi.org/10.1016/j.jht.2017.02.002
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Hand evaluation measures The importance of using standardized measurement instruments in assessing individual hand function is well recognized.8,9 This appreciation correlates with the increasing emphasis on outcome measures used within health care, which, in turn, is driven by the need for more cost-effective treatment.10 With shortened hospital stays and increased administrative pressure for productivity, hand therapists must evaluate a patient’s function quickly and accurately.11 Psychometrically, sound evaluations help assess an individual’s performance abilities across the continuum of care12 and can be used to assist in: (1) setting treatment priorities, (2) determining the effectiveness of treatment, and (3) recognizing treatments that can lead to improved client performance.13 Given the focus on outcomes in rehabilitation and the variety of ways in which measurement can be achieved, clinicians are challenged to select instruments that are most appropriate for their patient populations, setting, and objectives.1,14 Many approaches to assessing hand function exist, yet a “gold standard” functional hand assessment remains unavailable.9,15,16 A comprehensive hand assessment should reflect the actions an individual carries out daily,17 and therapists should therefore seek to relate measurement instruments to everyday living tasks.11 On average, hand therapists use 8 or more assessment tools on a daily to weekly basis to comprehend patients’ functional hand abilities.18 Different performance measures are used to evaluate the range of motion, endurance, dexterity, strength, and sensation to provide an accurate picture of hand function.8 At this point in time, a composite test that assesses both unilateral and bimanual hand function in relation to everyday functional activities is not available. The SPA In 2013, Gosling et al19 established the suitcase packing activity (SPA) to provide an accurate, objective, and composite measure of bimanual and unilateral hand function. Conceptualized to be occupation based, the SPA aims to evaluate unilateral and bimanual hand function through participation in a goal-directed activitydpacking a suitcase. A packing list with specific step-by-step instructions is provided to direct the individual in packing items into a suitcase. Fine and gross motor tasks embedded within the SPA seek to use practical, real-world activities such as folding clothes to highlight functional strengths and weaknesses. The purpose of this study was to evaluate the psychometric properties of the SPA. More specifically, this study aimed to: (1) establish the interrater and test-retest reliability of the SPA; (2) establish the face, content, and concurrent validity of the SPA; (3) compare the psychometric properties of the SPA to the Southampton Hand Assessment Procedure (SHAP), a standardized test of unilateral hand function, and to the Minnesota Manual Dexterity Test (MMDT), a standardized test of unilateral and bimanual hand function. Materials and methods Participants A convenience sample of 80 self-reported healthy, Englishspeaking, men and women volunteers between the age of 18 and 45 years were recruited from a level I trauma center in San Antonio, Texas. Subject recruitment took place between January 2016 and May 2016. Potential subjects were excluded if they reported existence of an unresolved upper extremity injury or a cognitive impairment. A healthy population was recruited to prevent the influence of confounding variables. This study was approved by the
local institutional review board; subjects received detailed information about the study and signed informed consent before participation. Phase 1: Manual development, face, and content validity A standardized procedure must exist in any evaluation process to ensure an assessment’s efficacy.20 There are no statistical means to appropriately assess an evaluation’s face and content validity. Claims of these validations are commonly made through procuring a panel of well-trained “experts” on the subject matter.21 Thus, to evaluate face and content validity of the SPA before subject recruitment, 4 separate 1-hour focus groups were held with a panel of experts. The purposes of the focus groups were to (1) critically analyze the SPA, (2) develop an objective, standardized procedure for administering the SPA, and (3) determine the assessment’s face and content validity. The expert panel consisted of 12 licensed occupational therapistsd5 of whom were certified hand therapists and 2 of whom were academics. The expert panel collectively agreed on a revised version of the SPA, and a manual for executing the revised SPA was created. To reduce the variability among test administrators, specific details regarding the arrangement of materials and testing procedures were documented. Phase 2: Data collection A prospective, repeated-measures design quantified performance of the SPA evaluation. A generic a priori power analysis was conducted with G*Power22 with a set at 0.05 for all statistical tests determined that a minimum of 78 subjects were needed. Once an individual’s eligibility and consent were confirmed, a short, nonstandardized questionnaire was given to each subject to gain details including the person’s age, gender, and hand dominance. Blocked randomization using IBM SPSS Statistical Software 22 (SPSS Inc, Chicago, IL) was used to randomly assign subjects to participate in either 1 or 2 sessions. All testing sessions occurred in a quiet, well-lit room with limited distractions present. Subjects performed the follow-up session in the same room they had performed the initial session. During the initial session, all subjects completed the SPA first, SHAP second, and MMDT third. The follow-up session, which occurred 7-14 days after the initial session, involved timed performances in each of the 3 conditions of the SPA. The choice of a 7- to 14-day interval between sessions was to avoid changes in a subject’s condition while also decreasing the risk for a direct learning effect. In this between-session interval models, similar test-retest procedures were used in other hand evaluation studies.23-25 All subjects performed each evaluation measure in a manner consistent with the established guidelines for the given assessment. A 5-minute break between performances of the SPA, SHAP, and MMDT was part of the testing protocol. All investigators were trained in the administration of the SPA, SHAP, and MMDT evaluations. While randomizing and counterbalancing the order in which investigators are assigned to subjects are recognized as best practice,21 time and scheduling conflicts among the 5 investigators prevented this process from occurring. Thus, 2 investigators were allocated to each subject based on individual availability. Once assigned to a given subject, the same 2 investigators rated all performance tasks at initial and (if applicable) follow-up sessions. Each investigator rated subject performance independently. Instruments used Suitcase Packing Activity The SPA was established to provide an accurate, objective measure of bimanual and unilateral hand function through
M.L. Baumann et al. / Journal of Hand Therapy xxx (2017) 1e7
evaluation of one’s performance in an occupation-based, goaldirected activity. All required items for test administration are provided in the SPA kit. Participants are provided a packing list with 20 step-by-step instructions on how to pack provided items into a given suitcase. The test administrator’s manual outlines the protocol for proper implementation (see Supplementary Appendix). The SPA picture board depicts exactly how the contents of the SPA are arranged on the testing table and is marked to delineate object placement for consistency across performances. Item placement promotes left, right, and forward reaching patterns. For this study, subjects were asked to perform the SPA under 3 distinct performance conditions: (1) using both hands, (2) using only the dominant hand with the nondominant hand constrained, and (3) using only the nondominant hand with the dominant hand constrained. Performance of the SPA under each condition was scored for time and accuracy. The time was recorded in seconds and accuracy was scored by subtracting 1 second for every task completed correctly. The composite score was recorded as the efficiency score. The timer was started by the subject once a performance activity session began and stopped by the subject as soon as all the required activities were completed or after 25 minutes had elapsed. On completion of each performance condition, the test administrator unpacked the suitcase and placed the SPA objects in their initial starting positions as quickly as possible. The placement of the picture board and SPA objects remained the same for all test performances. A packing list was provided to participants for use during performance of the activity. Items were listed in the order they were to be used. Southampton Hand Assessment Procedure The SHAP is a well-established, standardized measure shown to have excellent reliability and validity in assessing musculoskeletal and neurological conditions.13,26-28 The SHAP seeks to classify unilateral hand performance through participation in 26 timed activities in a standardized sequence.26 An index of functionality (IDF) score is derived from data accumulated from performance in all activities. For this study, subjects were asked to perform all SHAP tasks using their dominant hand and nondominant hand. Data for each task performance were recorded according to the SHAP’s established procedures. Minnesota Manual Dexterity Test The MMDT is a frequently administered, standardized test for determining baseline eye-hand coordination and arm-hand dexterity skills.29 The MMDT classifies hand motor skills according to precision of movement, beginning and end point of movement, and environmental stability.30 Test-retest reliability of the MMDT placing and turning subtests demonstrates good temporal stability, and the concurrent validity of the MMDT has been established by significant correlations with the Purdue Pegboard and the Box and Blocks Test.24 For this study, 2 trials of the following subtests were used: placing subtest, turning subtest, 1-hand turning and placing subtest, and 2-hand turning and placing subtest. To best assess unilateral performance, each subject was asked to perform the placing test and the 1-hand turning and placing test with the dominant hand for 2 consecutive trials and then the nondominant hand for 2 consecutive trials.
3
reliability, a 2-way mixed effects model ICC3,2 for consistency between 2 sessions was used for each subject. SEM was calculated as: 1
SEM ¼ SD ð1 ICCÞ2 where SD represented the average standard deviation of parallel measurements combined, and ICC represents the reliability coefficient for that particular measurement. Minimum detectable change (MDC) was also calculated for the test-retest reliability of SPA initial and follow-up efficiency scores. MDC identifies the minimum amount of change necessary to exceed measurement error and identify true change.31 To calculate MDC values at the 95% confidence interval, the following formula was used:
MDC ¼ SEM 1:96
pffiffiffiffiffi21 2:
To determine whether there were significant differences between subjects and the scores obtained during initial and follow-up sessions, a 2-way repeated-measures analysis of variance (ANOVA) was performed. The ANOVA contained 2 “within-subject factors”: the trials and the SPA performance conditions. Between-subject factors included gender, age, hand dominance, and length of time between sessions. The Mauchly’s Test of Sphericity was used to assess the ANOVA test’s assumptions. If the assumption of sphericity was violated, the Greenhouse-Geisser correction epsilon was used to determine the P value. All results were considered to be significantly different when P .05. The concurrent validity of the SPA was examined against 2 wellestablished, standardized tests used to measure hand function: the SHAP and the MMDT. The Pearson’s product moment correlation coefficient (r) was used to assess the relationship between SPA, SHAP, and MMDT scores. The scores obtained from the SHAP, unilateral tasks of the MMDT (eg, the placing subtest and 1-hand turning and placing subtest), and unilateral SPA performance conditions (eg, dominant hand only and nondominant hand only) were compared with one another. For each unilateral test comparison, only dominant hand scores were compared with dominant hand scores, and only nondominant hand scores were compared against other nondominant hand scores. To assess bimanual hand function, only the scores obtained from the bimanual MMDT tasks (eg, the turning subtest and 2-hand turning and placing subtest) were compared against the scores obtained from the bimanual SPA performance condition. Significance level was set at P < .05 for all r calculations.21 At least a fair association ( 0.30) between SPA, SHAP, and MMDT scores was expected. Microsoft Excel 2007 (Microsoft Corporation, Redmond, WA) was used to determine SEM and MDC values for all SPA performance conditions. IBM SPSS Statistical Software 22 (SPSS Inc, Chicago, IL) was used to analyze descriptive statistics and perform all t-test, ANOVA, and reliability (ICC and r) calculations. Reliability results were interpreted based on the following criteria: ICC values 0.25 ¼ “low,” 0.25-0.50 ¼ “fair,” 0.50-0.75 ¼ “moderate to good,” and 0.75 ¼ “good to excellent.”21 Results Participants
Statistical analysis Intraclass correlation coefficient (ICC) and standard error measurement (SEM) were used to assess the interrater and test-retest reliability domains of the SPA. These domains were assessed with a significance level set at P < .05. A 2-way mixed effects model ICC3,1 for relative agreement between 2 raters was used for each subject to determine interrater reliability. To determine test-retest
Demographic characteristics of the 80 subjects are reported in Table 1. Ten percent of the subjects being left-handed fall within the normal population variance for handedness.32,33 All subjects performed the follow-up session within 7-14 days after the initial session; no subject was lost to follow-up. The mean and standard deviations of subject scores for the SHAP and MMDT performance condition are presented in Table 2.
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Table 1 Demographic characteristics of subjects Initial session data (N ¼ 80)
Total
Male
Female
Number of subjects (% of N) Age, mean (SD), y Hand dominance Right handed (% of N) Left handed (% of N)
80 (100%) 31.1 (6.9)
34 (42.5%) 33.6 (7.2)
46 (57.5%) 29.3 (6.2)
71 (88.8%) 9 (11.3%)
28 (82.4%) 6 (17.6%)
43 (93.5%) 3 (6.5%)
Follow-up session data (N ¼ 38)
Totala
Male
Female
Number of subjects (% of N) Age, mean (SD), y Hand dominance Right handed (% of N) Left handed (% of N) Average number of days between initial and follow-up sessions (range)
38 (100%) 31.3 (6.9)
17 (44.7%) 34.6 (7.6)
21 (55.3%) 28.7 (5.0)
36 (94.7%) 2 (5.3%) 9.58 (7-13)
15 (88.2%) 2 (11.8%) 10.0 (7-13)
21 (100.0%) 0 (0.0%) 9.2 (7-13)
SD ¼ standard deviation. a 100% follow-up rate.
Figure 1. SPA board with activity objects properly placed. SPA ¼ suitcase packing activity.
Face and content validity
Interrater reliability statistics are presented in Table 5. During the initial and follow-up sessions, the interrater reliability of time, accuracy, and efficiency scoring was good to excellent for 2 raters across bimanual and unilateral SPA tasks. For each condition, the absolute agreement of interrater reliability was established at ICC3,1 ¼ 1.00 (SEM ¼ 0.00) for time scores, ICC3,1 0.93 (SEM 0.04) for accuracy scores, and ICC3,1 ¼ 1.00 (SEM ¼ 0.00) for efficiency scores.
Over the course of the 4 focus groups, an iterative process of analyzing the SPA helped the expert panel to agree on the layout of activity items (Figure 1), the necessary table dimensions required for test setup, subject positioning in relation to the evaluation’s setup, the fine and gross motor tasks to be performed, scoring procedures, and the specific instructions to be given to each subject before, during, and after each performance condition. The expert panel removed, added, and modified specific tasks within the SPA in an effort to comprehensively evaluate the various components involved with bimanual and unilateral hand function. Recommendations were implemented, and a manual for executing the SPA was created (see Supplemental Appendix). At the end of the fourth session, all 12 panel members individually determined the SPA-satisfied face and content validity domains of a functional hand evaluation measure.
Interrater reliability Table 3 displays the number of testing sessions each investigator participated in. Investigators who were assigned to the role of “rater 1” for a subject’s initial session remained in the role of rater 1 for the same subject’s follow-up session. The same process was also used for the assignment of “rater 2.” The mean scores and standard deviations for rater 1 and rater 2 across all 3 SPA performance conditions are summarized in Table 4.
Table 2 SHAP and MMDT performance conditions mean scores and standard deviations for subjects (N ¼ 80) Scale
Mean (SD)
Range
SHAP DH IDF SHAP NDH IDF MMDT DH placing subtesta MMDT NDH placing subtesta MMDT turning subtesta MMDT DH OHTP subtesta MMDT NDH OHTP subtesta MMDT THTP subtesta
99.50 98.71 62.68 67.36 50.73 77.60 81.51 46.37
95-106 91-106 47.11-84.60 54.14-87.18 37.38-76.16 55.60-113.49 60.68-110.00 32.48-63.76
(2.86) (3.22) (5.94) (6.59) (6.21) (9.60) (9.53) (5.75)
DH ¼ dominant hand; MMDT ¼ Minnesota Manual Dexterity Test; NDH ¼ nondominant hand; OHTP ¼ one-hand turning and placing; SD ¼ standard deviation; SHAP ¼ Southampton Hand Assessment Procedure; THTP ¼ 2-hand turning and placing. a Mean and SD MMDT scores are across two trials.
Test-retest reliability The test-retest reliability of the efficiency scores across all 3 performance conditions was demonstrated to be good to excellent in Table 6. A significant difference was found within subjects across initial and follow-up sessions scores (F ¼ 238.67; degree of freedom (df) ¼ 1; P < .0001). A significant difference was also found within subjects across SPA performance conditions (F ¼ 261.48; df ¼ 5; P < .0001). Across all SPA performance conditions, mean differences in time scores between sessions were 56.12 seconds lower at follow-up for females and 65.23 seconds lower at follow-up for males. On average, SPA accuracy scores improved at follow-up by 0.25 points for females and 0.19 points for males. Mean differences in efficiency scores between sessions were 57.55 points lower at follow-up for females and 65.42 points lower at follow-up for males. No statistically significant differences were found between subjects for gender, age, hand dominance, and/or time between initial and follow-up sessions. Due to the high interrater reliability demonstrated between rater 1 and rater 2, only the test-retest reliability scores obtained by rater 1 are reported. Test-retest reliability for bimanual performance was demonstrated at ICC3,2 ¼ 0.83 (SEM ¼ 4.68; MDC ¼ 12.97). For dominant hand only performance, test-retest reliability was demonstrated at ICC3,2 ¼ 0.88 (SEM ¼ 4.74; MDC ¼ 13.14). Test-retest Table 3 Number of initial vs follow-up sessions completed by each investigator Investigator Investigator Investigator Investigator Investigator Investigator Total
1 2 3 4 5
Initial session
Follow-up session
78 12 10 18 42 160
37 6 3 10 20 76
To establish interrater reliability, each session was rated by 2 investigators. To establish test-retest reliability, the same 2 investigators rated the same subject’s initial and follow-up sessions.
M.L. Baumann et al. / Journal of Hand Therapy xxx (2017) 1e7
5
Table 4 SPA performance conditions mean scores and standard deviations at initial (N ¼ 80) and follow-up (N ¼ 38) sessions for 2 raters Rater Rater Rater Rater Rater
1, 2, 1, 2,
mean mean mean mean
(SD) (SD) (SD)a (SD)a
SPA bimanual time (s)
SPA bimanual accuracy
SPA bimanual efficiency
SPA DH only time (s)
SPA DH only accuracy
SPA DH only efficiency
SPA NDH only time (s)
SPA NDH only accuracy
SPA NDH only efficiency
335.19 335.19 268.42 268.42
18.90 18.95 18.89 18.95
317.18 317.15 249.53 249.47
449.91 449.91 402.34 402.34
18.11 18.03 18.52 18.60
431.80 431.88 383.82 383.74
471.83 471.83 434.32 434.32
18.28 18.36 18.31 18.39
453.55 453.46 415.92 416.00
(60.12) (60.12) (48.24) (48.24)
(0.98) (1.00) (1.03) (1.14)
(61.75) (61.76) (48.38) (48.45)
(82.22) (82.22) (75.65) (75.65)
(1.57) (1.68) (1.37) (1.17)
(82.40) (82.38) (75.70) (75.72)
(86.05) (86.05) (83.84) (83.84)
(1.72) (1.76) (1.38) (1.35)
(85.92) (86.01) (83.79) (83.72)
DH ¼ dominant hand; NDH ¼ nondominant hand; SD ¼ standard deviation; SPA ¼ suitcase packing activity. a Follow-up session data.
reliability for nondominant hand performance was demonstrated at ICC3,2 ¼ 0.88 (SEM ¼ 5.09; MDC ¼ 14.11). Concurrent validity Concurrent validity of the 3 outcome measures is shown in Table 7. There were several statistically significant correlations found between SPA and SHAP scores (8/10), SPA and MMDT scores (18/36), and SHAP and MMDT scores (3/4). The strongest significant correlation between the SHAP IDF scores and initial SPA unilateral performance scores was fair (r ¼ 0.42, P < .01). The strongest significant correlation between the SHAP IDF scores and follow-up SPA unilateral performance scores was fair (r ¼ 0.45, P < .01). Initial and follow-up SPA unilateral performance accuracy scores did not show a significant correlation to the SHAP IDF scores. The strongest significant correlation between the MMDT placing subtest scores and SPA unilateral performance scores was fair (r ¼ 0.46, P < .01). The strongest significant correlation between MMDT 1-hand turning and placing subtest scores and SPA unilateral performance scores was fair (r ¼ 0.28, P < .05). Follow-up SPA dominant handeonly performance scores did not show a significant correlation to the MMDT placing subtest scores. There were no significant correlations between follow-up SPA unilateral performance scores and the MMDT 1-hand turning and placing subtest scores. The strongest significant correlation between the MMDT turning subtest scores and SPA bimanual performance scores was fair (r ¼ 0.36, P < .01). The strongest significant correlation between Table 5 Interrater reliability coefficients for SPA scores at initial vs follow-up session (absolute agreement) Scoring condition Initial session SPA bimanual time SPA bimanual accuracy SPA bimanual efficiency SPA DH only time SPA DH only accuracy SPA DH only efficiency SPA NDH only time SPA NDH only accuracy SPA NDH only efficiency Follow-up session SPA bimanual time SPA bimanual accuracy SPA bimanual efficiency SPA DH only time SPA DH only accuracy SPA DH only efficiency SPA NDH only time SPA NDH only accuracy SPA NDH only efficiency
ICC (type 3,1)
SEM
95% confidence interval (lower bound to upper Bound)
1.00 0.95 1.00 1.00 1.00 1.00 1.00 0.98 1.00
0.00 0.02 0.00 0.00 0.00 0.00 0.00 0.02 0.00
1.00-1.00 0.93-0.97 1.00-1.00 1.00-1.00 1.00-1.00 1.00-1.00 1.00-1.00 0.98-0.99 1.00-1.00
1.00 0.95 1.00 1.00 0.93 1.00 1.00 0.98 1.00
0.00 0.03 0.00 0.00 0.04 0.00 0.00 0.01 0.00
1.00-1.00 0.91-0.98 1.00-1.00 1.00-1.00 0.86-0.96 1.00-1.00 1.00-1.00 0.95-0.99 1.00-1.00
DH ¼ dominant hand; ICC ¼ intraclass correlation; MDC ¼ minimal detectable change; NDH ¼ nondominant hand; SEM ¼ standard error of measurement; SPA ¼ suitcase packing activity.
MMDT 2-hand turning and placing subtest scores and SPA bimanual performance scores was fair (r ¼ 0.42, P < .05). All followup SPA scores for the bimanual performance condition did not show a significant correlation to the MMDT turning subtest scores. The correlations between the SHAP IDF scores and MMDT placing subtest scores were fair (r ¼ 0.34 to 0.38, P < .01). A significant correlation was noted with the nondominant hand between the SHAP IDF scores and MMDT 1-hand turning and placing subtest scores. This correlation was fair (r ¼ 0.40, P < .01).
Discussion Due to the wide range of physical and psychosocial factors involved with an upper extremity injury, it is important for hand therapists to quickly and accurately assess a patient’s functional capacities.34 This study established the validity and reliability of a new, objective, and composite measure of bimanual and unilateral hand function. Through evaluating hand function during participation in a goal-directed activity, the SPA exhibits promise in usefulness as a future viable outcome measure that can be used to assess functional ability after hand injury. A standardized procedure for administering the SPA was developed, and an expert panel concluded that the SPA comprehensively assessed unilateral and bimanual hand function. The SPA demonstrated good to excellent interrater reliability (ICC 0.93), good to excellent test-retest reliability (ICC 0.83), and acceptable concurrent validity (several statistically significant fair correlations between SPA vs SHAP [8/10]; SPA vs MMDT [18/36]). The SPA took approximately 2 minutes for each investigator to setup, and subjects on average completed each performance condition in less than 8 minutes. The present study results demonstrate that the SPA’s interrater and test-retest correlation coefficients to be very high for bimanual and unilateral performance conditions.35 When considering these data, involvement of study investigators in the conceptual refinement of the SPA may have aided in the high reliability results. Therefore, a future study may be warranted to examine interrater reliability of a group of raters not involved with the development of the SPA. Table 6 Test-retest reliability coefficients for SPA efficiency scores rater 1 vs rater 2 (consistency) Scoring Condition SPA bimanual Rater 1 Rater 2 SPA DH only Rater 1 Rater 2 SPA NDH only Rater 1 Rater 2
ICC (type 3,2)
SEM
95% confidence interval (lower bound-upper bound)
MDC
0.83 0.83
4.68 4.68
0.68-0.91 0.68-0.91
12.97 12.97
0.88 0.88
4.74 4.74
0.76-0.94 0.77-0.94
13.14 13.14
0.88 0.88
5.09 5.09
0.77e0.94 0.77e0.94
14.11 14.11
DH ¼ dominant hand; ICC ¼ intraclass correlation; MDC ¼ minimal detectable change; NDH ¼ nondominant hand; SEM ¼ standard error of measurement; SPA ¼ suitcase packing activity.
6
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Table 7 Correlation coefficients for SPA, SHAP, and MMDT scores Scale
SHAP DH IDF
SHAP NDH IDF
SHAP DH IDF SHAP NDH IDF Initial SPA DH time Initial SPA DH accuracy Initial SPA DH efficiency Initial SPA NDH time Initial SPA NDH accuracy Initial SPA NDH efficiency Initial SPA bimanual time Initial SPA bimanual accuracy Initial SPA bimanual efficiency Follow-up SPA DH time Follow-up SPA DH accuracy Follow-up SPA DH efficiency Follow-up SPA NDH time Follow-up SPA NDH accuracy Follow-up SPA NDH efficiency Follow-up SPA bimanual time Follow-up SPA bimanual accuracy Follow-up SPA bimanual efficiency
d d .41b .06 .41b d d d d d d
d d d d d .42b .13 .41b d d d
.45b .20 .45b d d d d d d
d d d .42b .03 .42b d d d
MMDT NDH placing subtest
MMDT turning subtest
MMDT DH 1-hand turning and placing subtest
MMDT NDH 1-hand turning and placing subtest
MMDT 2-hand turning and placing subtest
.34b d .36b .23a .36b d d d d d d
d .38b d d d .39b .09 .39b d d d
d d d d d d d d .33b .01 .36b
.21 d .28a .24a .28a d d d d d d
d .40b d d d .28a .05 .28b d d d
d d d d e d d d .32b .11 .35b
.28 .07 .28 d d d d d d
d d d .45b .01 .46b d d d
d d d d d d .26 .10 .26
.22 .28 .23 d d d d d d
d d d .23 .01 .23 d d d
d d d d d d .42b .05 .42b
MMDT DH placing subtest
DH ¼ dominant hand only; MMDT ¼ Minnesota Manual Dexterity Test; NDH ¼ nondominant hand only; SHAP ¼ Southampton Hand Assessment Procedure; SPA ¼ suitcase packing activity. a Significance at the 0.05 level (2 tailed). b Correlation is significant at the 0.01 level (2 tailed).
The concurrent validity data analyses demonstrated several statistically significant fair correlations between SPA, SHAP, and MMDT performance conditions. The relatively weak correlations between the assessments were not surprising. Due to the lack of a criterion standard for hand evaluation measures, it cannot be assumed that different assessments produce comparable clinical data.8 Due to the absence of a benchmark standard, the concurrent validity of the SHAP had not been established before this study.26 In this study, a statistically significant fair negative correlation between the unilateral SPA performance conditions and the SHAP IDF scores was observed. This negative correlation makes statistical sense as lower efficiency scores for the SPA indicate better functioning and higher IDF scores for the SHAP indicate better functioning. In the present study, a statistically significant fair negative correlation was also found between SHAP IDF scores and unilateral MMDT subtest scores. The findings of a fair positive correlation between most SPA and MMDT scores provide results consistent with the findings of a previous study comparing a dexterity evaluation against a functional performance evaluation.36 In addition, it is important to note that when the concurrent validity of the MMDT was originally evaluated against 2 other dexterity measures known to be reliable and valid: the Box and Blocks Test37 and Purdue Pegboard Test38; the strongest relationship between a MMDT subtest and another test was only considered “moderate to good” (r ¼ 0.67; P < .0001).24 Despite evaluating seemingly similar aspects of hand function, the variation in implementation proved difficult for test results to be highly correlated. Although only fair correlations were achieved between the evaluations used in this study, it is important to interpret obtained results relative to the assessments used. Greater than 95 is normal range for SHAP IDF scores with lower scores suggesting a decreased level of function.27 In the present study, mean subject SHAP IDF scores for dominant and nondominant hand performance were above normal range as previously reported in the literature.26 When considering MMDT subtest scores for healthy individuals (calculating means from
a previous study’s data), mean dominant hand MMDT placing subtest scores have been established at 76.70 seconds (SD ¼ 8.25), mean nondominant hand MMDT placing subtest scores have established at 79.65 seconds (SD ¼ 9.50), and mean MMDT turning subtest scores have been established at 62.00 seconds (SD ¼ 8.60).24 All subjects in the present study achieved lower mean scores across the same number of trials in each of these MMDT subtests. Considering these data, in this study, self-reported healthy subjects achieved “normal” results according to each test’s established procedures as demonstrated in existing literature.24 Thus, it could be suggested that the fair correlations between outcome measures might be due to the lack of a criterion standard for evaluating hand function. Perhaps, each test variable approach to assessing hand function makes it difficult for test results to correlate strongly with one another. Study limitations Several study limitations warrant consideration. The study recruited a convenience sample of self-reported healthy subjects. A sample size involving a nonhealthy clinical population would increase the variability and overall generalizability of the results. Second, the 2-way repeated-measures ANOVA found a significant difference within subjects across individual performance trials. This indicates that the SPA has an inherent learning effect after initial performance. Implementing additional follow-up sessions could help identify when a level of redundancy can be reached for subject scores under each SPA performance condition. Third, subjects were not randomized to the 3 SPA performance conditions (eg, using both hands, using only the dominant hand, using only the nondominant hand), which could have an influence on the overall performance scores obtained. Another limitation pertains to how the SPA does not readily identify specific pinch, grasp, and in-hand manipulation skills. Individual strengths/deficits are noted during SPA performance based on the goal-directed, occupation-based activities that one can or cannot complete. Although many argue that best practice for any evaluation involves assessing one’s occupational
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performance (function),12 others might contend that evaluations should be more reductionist in nature and focus on specific prehensile abilities. Finally, the interpretations of the MDC are limited. Future studies are needed to determine what specific score change relative to the MDC is necessary for clinically important improvement vs deterioration. Future research Future research is warranted to establish normative data stratified for gender, age, and hand dominance. Future research could also examine differences based on SPA performance while standing vs sitting. Although difficult to establish in relation to hand function, construct validity could be explored in future research. Conclusion The SPA is a simple, low-cost, valid, and reliable tool for assessing bimanual and unilateral hand function in self-reported healthy subjects. Face and content validity of the SPA have been established, and administration has been standardized. The SPA demonstrates good to excellent interrater reliability, good to excellent test-retest reliability, and acceptable concurrent validity. Upon further development and establishment of normative data, the SPA may provide a unique, functional continuous-task evaluation. The SPA shows promise in contributing to evidence-based practice by providing a quality, composite measure of hand function. Acknowledgments The authors would like to thank Catrinna R. Amorelli, DSc, OTR/L, Lindsay K. Sposato, DSc, OTR/L, and Joshua A. Springer, DSc, OTR/L for their unwavering commitment to this project as associate investigators. The authors wish to acknowledge and thank Kristin de Guzman, DSc, OTR/L and Ariel Gosling, DSc, OTR/L for their initial work on the SPA. They also thank Christopher A. Rábago, PT, PhD for his mentorship with this study’s statistical data analysis. References 1. Skirven T, Osterman AL, Fedorczyk JM, Amadio PC. Rehabilitation of the Hand and Upper Extremity. 6th ed. Philadelphia, PA: Elsevier; 2011. 2. Duff SV, Sainburg RL. Lateralization of motor adaptation reveals independence in control of trajectory and steady-state position. Exp Brain Res. 2007;179(4): 551e561. 3. Kimmerle M, Mainwaring L, Borenstein M. The functional repertoire of the hand and its application to assessment. Am J Occup Ther. 2003;57(5):489e498. 4. Yancosek KE. Management of dominant upper extremity injuries: a survey of practice patterns. J Hand Ther. 2012;25(1):79e87. quiz 88. 5. Sainburg RL, Duff SV. Does motor lateralization have implications for stroke rehabilitation? J Rehabil Res Dev. 2006;43(3):311e322. 6. Yancosek KE. Injury-induced hand dominance transfer. Lexington, KY: University of Kentucky; 2010. 7. de Poel HJ, Peper CL, Beek PJ. Intentional switches between bimanual coordination patterns are primarily effectuated by the nondominant hand. Motor Control. 2006;10(1):7e23. 8. Lindner HY, Natterlund BS, Hermansson LM. Upper limb prosthetic outcome measures: review and content comparison based on International Classification of Functioning, Disability and Health. Prosthet Orthot Int. 2010;34(2):109e128. 9. Yancosek KE, Howell D. A narrative review of dexterity assessments. J Hand Ther. 2009;22(3):258e269. quiz 270. 10. Holm MB. The 2000 Eleanor Clarke Slagle Lecture. Our mandate for the new millennium: evidence-based practice. Am J Occup Ther. 2000;54(6):575e585.
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