SCIENTIFIC/CLINICAL ARTICLE
JHT READ
FOR
CREDIT ARTICLE #133.
A Narrative Review of Dexterity Assessments
Katie E. Yancosek, MS, OTR/L, CHT
Department of Rehabilitation Sciences, University of
Kentucky, Lexington, Kentucky
Dana Howell, PhD, OTD, OTR/L
Eastern Kentucky University, Richmond, Kentucky
This article is a comparison of the psychometric
properties (reliability and validity) and other characteristics (cost, administration time, and year of publication) of commercially available adult dexterity
assessments used in research and clinical practice for
adults. Dexterity is defined as ‘‘fine, voluntary movements used to manipulate small objects during a specific task’’1 and is typically an integral part of a
thorough evaluation of the hand. An examination of
dexterity provides a unique way of evaluating the neuromotor function of the entire hand because sensation
and intrinsic hand strength combine to produce the
manipulative skills that facilitate dextrous movements. Dexterity may be further described by two related terms—manual dexterity, which is the ability to
handle objects with the hand and fine motor dexterity,
which refers to in-hand manipulations as separate
skills from the gross motor grasp and release skills associated with manual dexterity.1 The results of assessments for both manual and fine motor dexterity may be
This article was not adapted from a presentation at a meeting and
no grant monies are associated with its execution.
Correspondence and reprint requests to Katie E. Yancosek, MS, OTR/
L, CHT, 923 Forest Lake Drive, Lexington, KY 40515; e-mail:
<Kathleen.yancosek@us.army.mil>.
0894-1130/$ e see front matter. Published by Hanley & Belfus, an
imprint of Elsevier Inc.
doi:10.1016/j.jht.2008.11.004
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JOURNAL OF HAND THERAPY
ABSTRACT
Narrative Review:
This article is a narrative review of the psychometric properties
(reliability and validity) and other characteristics (cost, time to
administer, and year of publication) of commercially available
manual and finger dexterity assessments used for adults in
the United States. Complete research articles related to dexterity
assessments were gathered from online database searches and
individually critiqued for scientific rigor based on reliability
and validity. Articles relating to 14 dexterity assessments were reviewed. All but three tools had established reliability, seven tools
had all five forms of validity established, and two had only face
and content validity. The results of this review provide information
to those interested in fine motor skill acquisition, impairment, or
functional recovery after injury. Therapists may use this information to choose the best assessment instrument to evaluate a patient’s recovery of function over time. This review adds to the
evidence-based, best-practice literature related to assessment and
outcome measurements of patients with limited dexterity function
participating in rehabilitation.
J HAND THER. 2009;22:258–70.
used to quantify and predict both ability and disability
by gauging a person’s speed and quality of movement
as the hand interfaces with objects and tools related to
self-care, work, or leisure pursuits.2 A study conducted
by Williams et al.3 demonstrated that dexterity was the
best predictor of independence in activities of daily living (ADL) within a cohort of geriatric females.
Outcome measures related to dexterity are important to detect clinically significant changes in an
injured patient population, to provide vocational
placement recommendations, to assess patients after
a work-related injury as part of a functional capacity
evaluation (FCE), to provide evidence of (dys)function in workman’s compensation cases, and to evaluate and compare dexterity levels among various
injured and uninjured populations.4 Assessing dexterity is critical because dexterity is a central component of hand function. Currently, over 20 different
dexterity assessments are available. According to
Rudman and Hannah,5 selection of an appropriate
assessment is often based on a variety of factors,
including financial and time costs; availability, familiarity, or practicality; and applicability to a given
patient or research population. Importantly, they
note that attention should also be directed toward
the psychometric soundness of the assessment
instrument, which is the focus of this article.
BACKGROUND
Reliability and validity make up an assessment’s
psychometric properties. Validity refers to an assessment’s ability to accurately measure the construct it
seeks to measure. Reliability refers to an assessment’s
ability to reproduce similar results with sequential
administrations.6 There are three types of reliability.
They are commonly referred to, and therefore most
often recognized and understood, by the methods
used to examine them. The first type of reliability is
called stability. The familiar method is to collect
testeretest data on an instrument given by one examiner at two different times. It is reported by a stability
coefficient such as Pearson’s r. Stability is commonly
known as intrarater reliability. The second type of
reliability is called internal consistency. The two familiar methods to examine internal consistency are a
split-half technique and a Cronbach’s alpha.6 In these
methods, the researcher is asking if items on an instrument ‘‘consistently’’ measure the same concept. In the
split-half technique, the outcomes of the instrument
are divided and compared for consistent results. In
the Cronbach’s alpha method, each item is separately
compared with others, looking for the degree of correlation between items. The third type of reliability is
equivalence. The familiar method is to compare score
results obtained by two examiners administering the
same test. Equivalence is commonly known as ‘‘interrater’’ reliability. It should be noted that stability
(intrarater reliability) of an assessment must be established before equivalence (interrater reliability) because stability means the instrument is dependable
in measuring a construct over time. Similarly, reliability of an instrument must precede validity.6
Validity is related to how true an assessment is in
capturing the construct it seeks to measure.5,6 There
are five types of validity. The first type of validity,
which is the simplest type, is face validity. It describes
how the instrument appears to measure the construct. The second type of validity is content
validity—it explores if an instrument captures all
the meaningful elements of a construct. Face validity
can be ascertained by an amateur, whereas content
validity should be established by a subject matter expert. The third type of validity is construct validity.
This is how logical an instrument is in measuring a
concept. Construct validity can be established
through divergent and convergent methods of evaluating how well an instrument measures a theory or
construct; however, it can never be truly proved but
rather disproved. The fourth type of validity is discriminate validity. This is a type of validity that seeks
to explore how well an instrument can discriminate
between groups of people. The final type of validity
is criterion validity. It seeks to establish a relationship
between the assessment and another factor (criterion). There are two methods of establishing criterion
validity. As with reliability types, the data collection
and comparison methods often serve as names for
criterion validity. The methods (names) are concurrent and predictive validity. In concurrent validity,
data are collected at the same time (concurrently)
and assessment scores are compared to examine correlation. In predictive validity, data are collected first
on the test instrument and then later on another
assessment and compared for correlation.
The purpose of this review is to compare dexterity
assessments based on published research related to
the tests’ reliability, validity, and other factors, including cost, availability, time to administer, and bilateral
hand use.
METHODS
A critical review was conducted by one reviewer
using the method proposed by Wright et al.7 The research question was ‘‘What are the psychometric properties of commercially available, adult dexterity
assessments in the United States?’’ Before searching
the evidence, a research protocol was created that specified inclusion and exclusion criteria. Only Englishlanguage studies, Level 2b or higher on the hierarchy
of evidence, that examined the psychometric properties of adult, commercially available dexterity assessments were included. Level 2b evidence was selected
because it is the level of investigation associated with
exploratory cohort studies that provide meaningful results, which are more generalizable compared with
case studies.8 Exclusion criteria were set as pediatric
and geriatric studies, non-English studies, client selfassessment questionnaires related to hand use, and
dexterity assessments that are unavailable for purchase
or replication within the United States. Additionally,
dexterity assessments were excluded if the review
failed to find any literature on the instrument.
The literature was searched with a date range from
1920 to 2007. The databases that were individually
searched through EBSCOHost portal included the
following: Medline, PubMed, CINAHL, PsychINFO,
and Pre-CINAHL. Google Scholar was also searched.
Terms used in each database search included the
following: dexterity OR coordination AND adult
AND assessment OR instrument OR evaluation,
AND psychometric properties AND therapy assessment. The databases were also searched using specific names of the dexterity assessments found in a
textbook on physical dysfunction rehabilitation.9
Lastly, the reference citations of the studies obtained
were examined to find additional studies to include
in the review.
Data were extracted and placed into a matrix to
provide a detailed description of the sample (size,
JulyeSeptember 2009 259
sex, and population), study purpose, analysis, and
statistical results. These data provide a comprehensive overview based on available literature related to
each dexterity assessment.
RESULTS
Fourteen dexterity assessments were identified
that met the inclusion criteria. Table 1 provides a
summary of the number of published research studies found per dexterity assessment and the subsequent types of reliability and validity established.
Table 2 includes information about each assessment
such as the original publication date of the instrument, vendor, and cost, whether or not the test assesses bilateral hand use, tool use, manual versus
finger dexterity (or both), and the time taken to
administer the test.
TABLE 1. Summary of Subgroup Analysis Based on Each
Dexterity Assessment
Numbers of
Studies
with Level
2b or .
Evidence
Established
Reliabilitya
Established
Validityb
BBT
5
RET, INTER
Crawford
Small Parts
FDT
1
CR, CON,
DIS, F, CNT
F, CNT
1
RET, INTER
Grooved
Pegboard
JHFT
2
RET
2
RET
MMDT
MRMT
2
6
RET
IC, RET
Moberg PickUp Test
NHP
O’Connor
FDT
PP
4
INTER
3
1
RET, INTER
6
RET
SODA
3
IC, RET
WMFT
4
INTER, IC
Dexterity
Assessment
CR, CON,
DIS, F, CNT
F, CNT
CR, CON,
DIS, F, CNT
CR, CON, F
CR, CON,
DIS, F, CNT
CR, CON,
DIS, F, CNT
CR, F, CNT
DIS, F, CNT
CR, CON,
DIS, F, CNT
CR, CON, F,
CNT
CR, CON,
DIS, F, CNT
BBT ¼ Box and Block test; FDT ¼ Functional Dexterity Test;
JHFT ¼ JebseneTaylor Test of Hand Function; MMDT ¼ Minnesota Manual Dexterity Test; MRMT ¼ Minnesota Rate of Manipulation Test; NHP ¼ Nine-Hole Peg Test; FDT ¼ Finger Dexterity
Test; PP ¼ Purdue Pegboard; SODA ¼ Sequential Occupational
Therapy Dexterity Assessment; WMFT ¼ Wolf Motor Function
Test.
a
RET ¼ retest; INTER ¼ interrater; IC ¼ internal consistency.
b
CR ¼ criterion; CON ¼ construct, DIS ¼ discriminate, F ¼ face,
CNT ¼content.
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JOURNAL OF HAND THERAPY
A total of 67 research studies related to the 14 assessments were found, 40 of which met the inclusion
criteria. Research related to the reliability and validity of each assessment, and a history of the research
done to date, is presented in Table 3. Because of the
vast amount of data uncovered in this review, the following narrative is an overview of each assessment
instrument and the details of the statistical findings
from each study are placed in Table 3.
NARRATIVE DISCUSSION OF
TEST-SPECIFIC RESULTS
Box and Block Test
The Box and Block test (BBT) is a measure of manual
dexterity that requires repeatedly moving 1-inch blocks
from one side of a box to another in 60 seconds.
Mathiowetz et al.10 first provided normative data on a
large sample size from a seven-county sample in the
Milwaukee area. Additionally, four other Level 2b
studies on this assessment were examined.10e13 Three
studies were completed on patient populations that
established validity of use with various diagnoses. The
BBT shows very high interrater and testeretest
reliability
(intraclass
correlation
coefficient
[ICC] ¼ 0.99). All studies were well designed, free
of bias, and demonstrate reliability and validity of the
BBT.
Crawford Small Parts Dexterity Test
The Crawford Small Parts Dexterity Test is a timed
test of both manual and finger dexterity that requires
use of tweezers and a screwdriver for a series of tasks
on an assembly plate. Although this test has face
validity, and presumably content validity, the literature is void of studies establishing solid psychometric
properties on this instrument. Only one Level 2b
study was found; the purpose of that study by
Burger14 was to question the original reference values
because changes had been made in the testing materials and yet the normative data were not reassessed.
This study used a small convenience sample of
healthy volunteers to evaluate differences between
scores on the two test versions. There was not a statistically significant difference between Part I of the test,
but there was a large difference (t ¼ 5.5, p , 0.001) in
Part II. This assessment is therefore in need of reevaluation for psychometric soundness.
Functional Dexterity Test
The Functional Dexterity Test (FDT) is a timed
measure of manual dexterity that involves turning
sixteen wooden pegs over and reinserting them into
the pegboard. It was constructed over a 20-year period
TABLE 2. Properties of Dexterity Assessments
Dexterity
Assessment
BBT
Crawford small
parts
FDT
JHFTa
MMDT
MRMT
Moberg Pick-Up
Test
NHP
O’Connor Tweezer
FDTa
PP
SODAa
WMFT
Year Published
Available From
1985
1949
Sammons Preston
Harcourt
assessment
2003
North coast medical
1969
Sammons Preston
1991
Lafayette
Instrument Co.,
1946, updated
Best priced
in 1957, 1969
products, Inc.,
1958
Not Available for
purchase but
reproducible
1971
Sammons Preston
1958
Lafayette
Instrument Co.,
1948
Lafayette
Instrument Co.,
1996, short version Not available but
in 1999
reproducible
2001
Not available for
purchase but
reproducible
Assesses
Bilateral Hand
Use
Cost
Time to
Manual, Fine
Administer (min) Dexterity, or Both
N
Y
$189.95 5
$567.00 30
M
B
N
N
Y
$127.95 5
$289.95 30
$200.00 30
M
B
M
Y
$247.49 30
M
N
N/A
5
B
N
N
$72.95 5
$105.00 5
F
B
N
$110.00 8e10
F
Y
N/A
Y
N/A
SODA ¼ 30 and
SODA-S ¼ 15
30e45
B
M
BBT ¼ Box and Block test; FDT ¼ Functional Dexterity Test; JHFT ¼ JebseneTaylor; MMDT ¼ Minnesota Manual Dexterity Test;
MRMT ¼ Minnesota Rate of Manipulation Test; NHP ¼ Nine-Hole Peg Test; FDT ¼ Finger Dexterity Test; PP ¼ Purdue Pegboard;
SODA ¼ Sequential Occupational Therapy Dexterity; WMFT ¼ Wolf Motor Function Test; M ¼ Manual dexterity, F ¼ Finger Dexterity,
B ¼ Both.
a
Test incorporates evaluation of tool use. Eating utensils and writing instruments are considered tools.
by many therapists at Texas Woman’s University and
several unpublished articles have been written on its
development and utility. The first and only published
study available for review was the original article.15
This article shared the summative data collected on
the assessment and provided reference values based
on age and hand dominance. Intrarater reliability
was shown to be excellent (ICC ¼ 0.91) and construct
validity was established. Further validation of the test
is recommended by the study’s authors.
Grooved Pegboard
The Grooved Pegboard is a unique dexterity assessment in that each peg has a ridge on one side and
therefore must be oriented correctly to fit into a hole
on the pegboard. This lock-and-key feature of the peg
and pegboard necessitates visual attention to task
and thumb and index finger manipulation of the peg.
This feature makes it a test of interest to many
investigators and clinicians.16 Because the Grooved
Pegboard is one part of neuropsychological batteries,
only two Level 2b studies16,17 were found that solely
examined the assessment’s psychometric properties.
Bryden and Roy16 investigated the influence of gender and hand dominance on manual dexterity, and
also provided normative data for the performance
of 153 healthy adult subjects. The study also provides
an alternate use for the test by providing normative
data on the amount of time it takes to remove the
grooved pegs from the holes. The authors suggest
that this method of test administration could be
used as a motor speed assessment, although no
attempt was made to validate it with another established assessment of motor speed. A study by Ruff
and Parker17 used the Grooved Pegboard with 360
healthy adults to establish gender- and age-specific
reference values, as well as to provide evidence of
retest reliability at a statistically significant level of
p , 0.01. Both studies on the Grooved Pegboard are
robust studies with adequate sample sizes, sound
methodologies, and similar findings related to
gender and hand dominance on dexterity.
JebseneTaylor Test of Hand Function
The JebseneTaylor Test of Hand Function (JHFT)
assesses both fine and manual finger dexterity through
seven timed subtests related to functional tasks, such as
picking up common objects, eating, and writing. This
instrument was developed in 1969 by Jebsen et al.18
Two Level 2b studies18,19 were reviewed on the JHFT,
including the original normative data that were collected on 300 healthy and 60 impaired individuals
across the age span. This original study established reliability, validity, and reference values based on age.
The second Level 2b study19 established criterion validity (r ¼ 0.635, p , 0.01) with 18 traumatic spinal
cord injured patients by correlating the scores on the
JHFT to scores on the KleineBell ADL scale.
JulyeSeptember 2009 261
262
JOURNAL OF HAND THERAPY
1988
1985
Goodkin et al.26
Mathiowetz et al.10
1993
1989
1969
Ruff and Parker17
Lynch and Bridle19
Jebsen et al.18a
JHFT
N ¼ 153; 106F, 47M
2005
Bryden and Roy16
Grooved pegboard
N ¼ 300 (30F and 30M in age
categories 20e29, 30e39,
40e49, 50e59, and 60e94)
N ¼ 18
N ¼ 360
N ¼ 339. Study based on 5
different combined studies
Aaron and Stegnik Jensen15 2003
N ¼ 24
N ¼ 628; 318F, 310M
(age range 20e94)
FDTa
1985
1994
Desrosiers et al.13
N ¼ 35 healthy adults, N ¼ 34
impaired adults, N ¼ 104
impaired adults (for the
construct validity test), and
N ¼ 360 (for the norming)
N ¼ 228
N ¼ 56
2005
Platz et al.12
Year
N ¼ 20; 11F, 9M
Authors
Number and
Sex of
Subjects
Svensson and Hager-Ross11 2006
Crawford small parts Burger14
BBT
Dexterity
Assessment
300 Healthy adults
and 60 patients
Traumatic SCI patients
Healthy adults from 3
geographical locations
Students, workers, uninjured
and injured hands of hand
therapy patients
Healthy college students
Healthy adults
Volunteers from 7 different
counties in Milwaukee area
Patients with MS
Patients older than 60 yr with
and without UE impairment
Adults with CharcoteMariee
Tooth disease
Neurologically
impaired adults
Population
Purpose
Compare JebseneTaylor to
KleineBell ADL Scale for
construct validity
Establish reference values for 7
subtests according to age and
gender; establish
discriminate validity with
patient population
Establish reliability of a new
administration method
Evaluated changes with hand
dominance, gender,
education, and age
Establish validity, reliability
reference values
Establish reliability between
two versions of the
assessment instrument
Compared BBT and NHP
with typical MS disability
ratings
Interrater reliability
Establish reliability with
patient population
Interrater reliability
testeretest reliability,
construct validity between
Fugl-Meyer test, ARA,
and BBT
Establish reference values,
construct validity, and
reliability
TABLE 3. Summary of Literature on Available Dexterity Assessment
Pearson coefficient for retest
reliability r ¼ 0.60e0.99,
Good discriminate validity
using SDs: patients were
greater than 2 SD away from
normative reference values
Interrater reliability Pearson
r ¼ 1.00 for right hand and
r ¼ 0.999 for left hands
Paired t tests showed no
difference on Part I of the test
t ¼ 0.5 but differences were
found on part II t ¼ 5.5,
p , 0.001
Interrater reliability
ICC ¼ 0.82e0.93, intrarater
reliability ICC ¼ 0.91
F values were significant at
p , 0.001 level
Age, education, and gender
differences were noted,
p , 0.01. Reliability: Pearson
r coefficient dominant hand
r ¼ 0.72 and nondominant
hand r ¼ 0.74
Pearson r ¼ 0.635, p , 0.01
Correlation between BBT and
NHP, r ¼ 0.70
ICC ¼ 0.89 and 0.97, validity
matched with ARA using
Pearson r ¼ 0.80 and 0.82
Retest ICC for right
hand ¼ 0.95, left hand ¼ 0.96
ICCs and Spearman rho
all . 0.95
Statistical Results
JulyeSeptember 2009 263
Moberg Pick-Up
Test
MRMT
MMDT
2003
1997
1984
1982
1978
1959
2007
Surrey et al.20
Maiden and Dyson21
Clopton et al.22
Gloss and Wardle23
Shanthamani24
Drussell25
Amirjani et al.29
Ng et al.31
2003
1997
Desrosiers et al.27
Jerosch-Herold30
2003
Surrey et al.20
N ¼ 100; 47F, 53M
N ¼ 23; 4F, 19M
N ¼ 116; 87 F, 29M
N ¼ 32; 9F, 22M
N ¼ 60; 22F, 38M
N ¼ 118; 22F, 96M
N ¼ 90; 36F, 54M
N ¼ 25
N ¼ 223
N ¼ 247
N ¼ 223
(Continued on next page)
t-Tests were statistically
significant at the p , 0.001 for
placing and turning subtests
and for overall scores
Healthy elderly
Establish criterion validity by
ICC ¼ 0.79e0.87 for retest
comparing MMDT with
reliability; ICC between
MRMT (N ¼ 45), BBT, and PP
MMDT and MRMT ¼ 0.85e
testeretest reliability
0.95; ICC with BBT ¼ 0.63
(N ¼ 35); establish retest
and ICC with PP ¼ 0.67
reliability
College students and airline
Examine the difference in
t-Tests were statistically
passengers
performance on the MRMT
significant at the p , 0.001 for
and the MMDT
placing and turning subtests
and for overall scores
15 Healthy subjects, 10 injured Establish reliability of
Pearson r ¼ 0.95
clients
assessment instrument
between standing and sitting
conditions
College students
Establish reliability of
Scores between standing and
assessment administration
sitting did not differ at the
between standing and sitting
p ¼ , 0.05 level
conditions
Adults with permanent hand
Establish predictive validity by Pearson r ¼ 0.266e0.814
impairment
correlating scores
between MRMT and
disability rating
Government factory workers
Establish predictive validity by Pearson r ¼ 0.50
correlating performance
scores with gender,
education, and field
experience
Adults with cerebral palsy who Establish criterion validity of
Pearson’s r ¼ 0.68
worked in manual labor jobs
the MRMT (placing subtest
in Los Angeles
only) with the USES
Healthy subjects in 3 groups:
Establish reference values
Age had a significant impact
ages 20e39 (N ¼ 34) 40e59
based on age, gender, and
on performance (p , 0.01);
(N ¼ 35), 60 and older
hand dominance
vision had a significant
(N ¼ 47)
impact on performance
(p , 0.05); and females were
faster compared with men
(p , 0.05)
Median nerve lac/repair
Establish validity by measuring Cohen’s d effect size ¼ 0.80
the assessment instrument’s
responsiveness to clinical
change
Healthy adult volunteers from Establish reference values
Paired t-tests between visual
a variety of occupations
based on gender and hand
status, hand dominance, and
dominance; interrater
genders: all results were
reliability tested on 14 of 100
significant with p , 0.01.
subjects
Pearson’s coefficient for
interrater reliability, r ¼ 0.60
Examine the difference in
performance on the MRMT
and the MMDT
Moberg
Authors
1981
2003
2003
1997
1980
1979
1948
Gloss and Wardle37
Gallus and Mathiowetz2
Buddenberg et al.38
Maiden and Dyson21
Hamm and Curtis39
Shanthamani24
Tiffin et al.
O’Connor FDT
PP
N ¼ 7814; 4530F, 3284M
N ¼ 60; 22F, 38M
N ¼ 340; 164F, 176M
N ¼ 25
N ¼ 47; 33F, 14M
N ¼ 25; 22F, 3M
N ¼ 96; 18F, 78M
N ¼ 644
Design a measure as a
functional sensory test
Establish reliability of test with
patients
Establish interrater reliability,
retest reliability, and
normative reference values
Purpose
Statistical Results
Retest ICC for right
hand ¼ 0.99, left hand ¼ 0.80
Pearson r: Right: r ¼ 0.984, left:
r ¼ 0.993. Testeretest
reliability Pearson r
coefficient: right r ¼ 0.459,
left r ¼ 0.442
26 female OT students, and 618 Establish reference values,
Concurrent validity: right:
volunteers
concurrent validity with the
Pearson r ¼ 0.61 left:
PP, and reliability (retest and
Pearson r ¼ 0.53; retest
interrater)
reliability: right r ¼ 0.69, left
r ¼ 0.43; interrater reliability:
right r ¼ 0.97, left r ¼ 0.99
Adults with permanent UE
Establish predictive validity by Pearson r ¼ 0.69 for disability
impairment
correlating on O’Connor FDT
and 0.88 for ADL subscale
and disability rating and
ADL subscale
Patients with MS
Examine retest reliability for
ICC for 1 trial ¼ 0.850.90, ICC
1 and 3 trial administration
for 3 trial ¼ 0.920.96
methods
College Students
Examine retest reliability for
ICC for 1 trial ¼ 0.370.70, ICC
1 and 3 trial administration
for 3 trial ¼ 0.81.89
methods
Healthy adults and 10 injured
Positive correlation
Pearson r ¼ 0.95
clients
Candidates for vocational
Establish reference values for a All Z tests were statistically
rehabilitation
clinical population;
significant p , 0.05. Authors
performed correlation
recommend using clinical
analysis using Z tests (on
reference values
means) between 1968 norms
and clinical sample
Government factory workers
Establish validity correlation of Pearson r ¼ 0.80
performance with gender
and education
College students, veterans, and Establish reference values,
Pearson r ¼ 0.60e0.76 for 1-trial
industrial job applicants
retest reliability and validity
scores, and r ¼ 0.82e0.91 for
3-trial scores (estimates
extrapolated by Spearmane
Brown prophecy formula)
1985
NHP
Mathiowetz et al.10a
N ¼ 20; 11F, 9M
Population
2003
1958
Year
Grice et al.34
28a
Number and
Sex of
Subjects
Swedish adults with Charcote
MarieeTooth disease
N ¼ 25 (for reliability tests) and College students and
N ¼ 703; 389F, 314M for
community volunteers
norming (ages 21e71 yr)
Dexterity
Assessment
JOURNAL OF HAND THERAPY
Svensson and Hager-Ross11 2006
Table 3 (continued)
264
JulyeSeptember 2009 265
N ¼ 229
N ¼ 45; 29F, 16M
1996
2001
2001
2005
2006
Van Lankeveld et al.41
Morris et al.45
Wolf et al.46
Wolf et al.47
Hui Yung Ang
and Wai Kwong48
N ¼ 38
N ¼ 24
N ¼ 109
N ¼ 25; 14F, 11M
1999
O’Connor et al.42
N ¼ 109; 62F, 42M
1999
Van Lankeveld et al.43
Establish interrater and retest
reliability, establish reliability
(internal consistency)
Establish validity and
reliability (interrater and
retest)
Establish validity and retest
and interrater reliability
(reliability done on N ¼ 22)
19 adults after stroke, 19 health Establish interrater and retest
controls
reliability, establish criterion
validity with FMA and
construct validity with
control case
Adults after sroke (3e9 months Establish criterion and
poststroke)
construct validity with FMA
Adults after stroke
Establish construct validity
between FMA, FIM,
Brunnstrom’s recovery
stages, and scale
Adults after stroke with motor
impairment
Adults with RA being seen at
outpatient rehabilitation
center in Australia
Adults with RA
Establish reliablity (internal
consistency)
Spearman’s rho correlation
coefficients all .0.896. No
correlation found with FIM
(numbers not given)
ICC ¼ 0.97e0.99
Pearson’s r ¼ 0.71 for
correlation with ROM and
grip, Pearson’s r ¼ 0.65 with
Dutch health status
questionnaire, Pearson’s
r ¼ 0.41 with VAS for pain,
Pearson’s r ¼ 0.34 for disease
status using disease
assessment score. Retest
reliability r ¼ 0.93 interrater
reliability r ¼ 0.78
Interrater reliability, ICC ¼ 0.97
and 0.88; retest reliability
ICC ¼ 0.90 and 0.95 for
performance time and
functional ability score,
respectively. Internal
consistency was .0.86 for both
test administrations
ICC ¼ 0.95e0.99
Cronbach’s alpha; SODA ¼ 0.91,
SODA-S ¼ 0.81 HAQ VAS
pain correlation between
Sollerman hand function and
SODA r ¼ 0.79 and r ¼ 0.75 for
SODA & VAS and r ¼ 0.052
for SODA and self-reported
disability
Retest Pearson r ¼ 0.93,
intrarater Pearson r ¼ 0.78
BBT ¼ Box and Block test; ICC ¼ intraclass correlation coefficient; UE ¼ upper extremity; MS ¼ multiple sclerosis; NHP ¼ Nine-Hole Peg Test; FDT ¼ Functional Dexterity Test; JHFT ¼ Jebsene
Taylor Test of Hand Function; SCI ¼ spinal cord injured; ADL ¼ activities of daily living; SD ¼ standard deviation; MMDT ¼ Minnesota Manual Dexterity Test; MRMT ¼ Minnesota Rate of
Manipulation Test; USES ¼ United States Employment Services Descriptive Rating Scale; PP ¼ Purdue Pegboard; FMA ¼ Fugl-Meyer Motor Assessment; SODA ¼ Sequential Occupational
Therapy Dexterity Assessment; RA ¼ rheumatoid arthritis; ROM ¼ range of motion; ARA = Action Research Arm Test; FIM ¼ Functional Independence Measure; SODA-S ¼ SODA-Short
form; HAQ ¼ Health Assessment Questionnaire; VAS ¼ Visual Analogue Scale.
ICC, Pearson r, Spearman’s Rho, and Cohen’s d all estimate correlation and effect of variables in relationship to one another.
Interpreting correlation coefficients: .0.8 ¼ large correlation, .0.5 ¼ moderate correlation, and .0.2 ¼ small correlation.
aOriginal article on assessment instrument.
WMFT
SODA
Minnesota Rate of Manipulation Test
The Minnesota Rate of Manipulation Test (MRMT)
and the Minnesota Manual Dexterity Test (MMDT)
are two versions of a similar assessment tool. The
MRMT is no longer produced but can be purchased
through Internet sources. Both versions consist of five
timed subtests that assess manual dexterity needed
to turn and/or place 60 short, round blocks with one
or both hands. A distinction between the two versions is that MRMT contains two boards, whereas
MMDT uses a single board. Six Level 2b studies20e25
were reviewed on the MRMT and two on the
MMDT.26,27 Both assessments have undergone
research to establish reliability and all five types of
validity. However, Surrey et al.20 raise legitimate concern for the use of the MMDT based on their results
that revealed significant differences in scores
between the placing and turning subtests between
the two test versions (p , 0.001). Furthermore, they
point out that the MMDT uses the normative values
and instructions established for the 1957 version of
the MRMT. Given their findings, research to establish
new norms and evaluate psychometric properties
should be done related to the currently available
version of the MMDT.
Moberg Pick-Up Test
The Moberg Pick-Up Test is a timed measure of both
manual and fine motor dexterity that involves picking
up 12 small items. It was first described by Moberg in
1958.28 It was originally designed as a functional sensory test of the hand, but adequately captures the related components of object manipulation and offers
a valuable score of vision-occluded dexterity. In addition to the original, descriptive article, three Level 2b
studies were reviewed.28e30 In 1999, Ng et al.31 examined 100 healthy adults with the Moberg Pick-Up Test.
They established reference values; however, 53% of
their subjects ranged from ages 20 to 29 years. They
demonstrated a statistically significant influence
(p , 0.01) of gender and hand dominance on dexterity. Fourteen of the 100 subjects were randomly retested by an additional examiner. The interrater
correlations were statistically significant at the
p , 0.01 level. Based on the limitations of the Ng
et al. study, Amirjani et al.29 conducted a study in
Canada with a minimum of 34 healthy subjects in
one of three age categories—young (20e39 yr),
middle aged (40e59 yr), and old (60þ yr). This study
provided reference values based on age, gender, hand
dominance, and eyes open and closed testing conditions. The final study30 reviewed on the Moberg was
of 23 patients who had undergone median nerve laceration and repair. The study established
discriminate validity of the Moberg by demonstrating
its ability to be responsive to clinical change. The
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JOURNAL OF HAND THERAPY
Moberg test is not available for purchase, but can be
reproduced using the provided specifications.
Nine-Hole Peg Test
The Nine-Hole Peg (NHP) Test is a timed measure
of fine dexterity and involves placing and removing
nine pegs in a pegboard. Three studies were reviewed on the NHP. The NHP was first described by
Kellor et al.32 in 1971. The study provided normative
references based on a sample of 250 subjects. There
was a description of the test pegboard and the pegs
but no description of the container. No reliability or
validity was reported until Mathiowetz et al.33 conducted new research in Wisconsin with a large
sample of volunteers. This study examined validity
of the test through a comparison with the Purdue
Pegboard (PP) test. The results showed a moderate
correlation between the two assessments. In 2003,
Grice et al.34 used a sample of college students and
community volunteers to establish new reference
values and evaluate reliability. Both reviewed studies
used large samples and provided reference values
based on gender and age. A Swedish study examined
the use of the NHP within a small sample of patients
with CharcoteMarieeTooth Syndrome, the retest
reliability was found to be high (ICC ¼ 0.99).11
O’Connor Finger Dexterity Test
The O’Connor Finger Dexterity Test (FDT) is a
timed test of both manual and fine dexterity that
dates back to 1926. It involves manipulating and
placing small pins, three at a time, into 100 small
holes of a pegboard. The original test construction
and validation were published in the testing manual,
but results were not published in a scholarly journal.
The test is also available in a modified version that
includes the use of tweezers to place a single pin in a
hole of the pegboard. Both tests are used today for
screening job applicants for various jobs that require
fine finger and tweezer dexterity skills35,36 but only
one Level 2b study was found that examined psychometric properties.37 This study correlated the scores
on the O’Connor FDT with disability ratings and
ADL subscale scores on the disability rating. The
sample was 96 adults with permanent impairment
to the upper extremity. The Pearson correlation ratings were 0.69 and 0.88 for the disability rating and
the ADL subscale, respectively. These results represent moderate to high correlation and therefore demonstrate good-to-excellent predictive validity. No
Level 2b studies were found on the tweezer version
of the O’Connor dexterity assessment. Based on limited data to support either assessment instrument,
caution should be taken when considering these
instruments.
Purdue Pegboard
DISCUSSION
The Purdue Pegboard (PP) is a test of fine dexterity
that has been widely used in both clinical and research
settings.2 This assessment involves a series of four
subtests that consist of placing small pins into holes
on a pegboard and assembling pins and washers.
Including the original article on this assessment, six
Level 2b studies were reviewed.2,15,20,38e40 Validity
and reliability are well established through abundant
research in healthy and patient populations. The original reference values from 1948 were obtained on the
large sample (N ¼ 7,814) of college students, veterans,
and industrial applicants and were revised in 1968 for
specific personnel selection tasks, such as electronics
production, general factory work, and assembly
jobs. Reference values have also been established for
clinical populations in subsequent studies. The studies that examined retest reliability found better results
with the three-trial administration.
This critical review of dexterity assessments and
research related to the psychometric soundness of
these instruments yielded information essential to
those interested in patients with dexterity limitations.
Three of the reviewed assessments (the MRMT, PP,
and BBT) demonstrated solid psychometric properties through evidence from more than five Level 2b
studies. Six studies collectively established reliability
as well as criterion, construct, discriminate, and content validity of the MRMT and PP, whereas five Level
2b studies established reliability and all types of
validity of the BBT. Based on these results, the BBT
and MRMT are recommended as assessments of
choice to evaluate manual dexterity, and the PP is
recommended to assess fine finger dexterity. Because
the BBT evaluates unilateral dexterity, the MRMT
evaluates bilateral manual dexterity, and the PP evaluates fine finger dexterity, clinicians and researchers
need to further consider the specific needs of a patient
population or a given research investigation before
selecting an assessment tool.
Sequential Occupational Therapy Dexterity
Assessment
The Sequential Occupational Therapy Dexterity
Assessment (SODA) is a test specifically designed
for patients with rheumatoid arthritis (RA) that involves ten bilateral and two unilateral tasks. This is a
unique dexterity assessment because it does not use
time as a measure of performance but rather evaluates
the quality of movement. It measures both manual
and fine dexterity. It was introduced in 1996 in the
Netherlands.41 Three Level 2b studies were reviewed.
The SODA was used in an RA patient population in
Australia to assess validity and reliability.42 In 1999,
a shortened version was created using the original
study population to correlate findings and establish
validity.43 This study demonstrated a correlation coefficient of 0.93 (high) between the SODA and the
revised, shortened version, SODA-S. All studies demonstrated criterion validity by showing high correlation with other established and acceptable measures
of disease and pain.
Wolf Motor Function Test
The Wolf Motor Function Test (WMFT), formerly
called the Emory Motor Test44 is a functional dexterity test that has been shown to be reliable and valid
within acute and subacute stroke patient populations. It is a measure of manual dexterity that requires
completion of six upper extremity movements and
nine functional tasks; both segments are timed.
There were four Level 2b studies reviewed45e48 that
collectively demonstrate reliability and validity of
use within a stroke population. When criterion and
construct validity were evaluated, the ICC values
ranged between 0.97 and 0.99 (high).47
Three of the reviewed assessments, the O’Connor
FDT, Grooved Pegboard, and Crawford Small Parts,
should be used cautiously. These three assessments
had few published studies examining their reliability
or validity, which limited examination to the original
research data and suggests a need for additional
research to evaluate these instruments.
Several assessments in this review have unique
characteristics that may also influence a clinician’s
decision to select an assessment. The Moberg serves
as the only assessment that incorporates a visually
blinded testing condition. The Grooved Pegboard is
unique for its additional obstacle of having a ridge on
the side of each peg and thereby demanding high levels
of visual attention. The WMFT is used specifically for
evaluating stroke patients, and the SODA is used
specifically for patients with RA. The SODA is also
the only test that does not measure dexterity performance based on time. Another separation among the
assessments is those that require the use of tweezers.
These assessments are the O’Connor Tweezer
Dexterity Assessment and the Crawford Small Parts.
These two assessments, however, have no established
reliability data, and should undergo evaluation before
continued use by clinicians or researchers.
LIMITATIONS
Both authors established criteria for data extraction
at the start of the review; however, only one reviewer
searched the literature and extracted data. Another
notable limitation is that this review focused only on
adult dexterity assessments, to the exclusion of pediatric and geriatric assessment tools. Further
JulyeSeptember 2009 267
investigation into assessments specific to these populations is warranted. Finally, perhaps the pervasive
reliance on technology, such as computers, cellular
telephones, pagers, I-pods, and MP3 players has
affected baseline dexterity values in all populations.
Dexterity abilities may have improved radically due
to the increased use, or declined based on the automation of work processes that were previously reliant
on manual skills. Either way, research is needed to
update the reference values of all 14 assessments from
those values established in the 1900s. Additionally,
research exploring how dexterity assessments are
used across clinical practice is necessary. The sampling methods of studies related to dexterity hand
function assessments need not be limited to convenience samples, as they were in most of the studies
presented in this review, given the increasing professional network connections and the use of Internet
and other technologies.
CONCLUSIONS
This review summarized decades of research done
on commercially available dexterity assessments. The
focus was on the psychometric properties and other
defining characteristics of dexterity assessments with
the goal of helping clinicians and researchers make
informed selections of appropriate dexterity assessment instruments to compliment a full evaluation of
the function of the upper limb. The MRMT, PP, and
BBT demonstrated solid psychometric properties
through evidence from more than five Level 2b studies. The BBT and MRMT are therefore recommended
as assessments of choice to evaluate manual dexterity,
and the PP is recommended to assess fine finger
dexterity. This review highlighted psychometric
soundness as a critical factor in decisions regarding
selection of a dexterity assessment. This review may
also provoke new research ideas based on gaps in the
literature or the changing needs of therapy fields.
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JulyeSeptember 2009 269
JHT Read for Credit
Quiz: Article # 133
Record your answers on the Return Answer Form
found on the tear-out coupon at the back of this
issue. There is only one best answer for each
question.
#1. The design of this study is
a. an RCT
b. a case series
c. a systematic review
d. a narrative review
#2. The study primarily evaluates tests of
a. hand function
b. digital strength
c. finger dexterity
d. digital sensibility
#3. The authors refer to the following as psychometric properties of testing instruments
a. validity and reliability
b. sensitivity and specificity
c. positive and negative predictive values
270
JOURNAL OF HAND THERAPY
d. selectivity and reactivity
#4. The research design was based on data extracted
from
a. manufacturers’ printed instructions
b. a review of a series of articles from the
literature
c. questionnaires returned by CHTs
d. interviews of patients at the conclusion of their
treatment (discharge from service)
#5. The authors recommend the following test(s) for
their psychometric properties
a. Jebsen Hand Function Test
b. BBT, MRMT, and PP
c. Sollerman Hand Function Test
d. Moberg Pick Up Test and the 9 Hole Peg Board
When submitting to the HTCC for re-certification,
please batch your JHT RFC certificates in groups
of 3 or more to get full credit.