Validity and responsiveness of the Simple Test for Evaluating Hand Function

Abstract

Introduction

Despite widespread use of the Simple Test for Evaluating Hand Function, we were unable to find studies to affirm the validity and responsiveness in patients with trauma and inflammatory diseases. The aim of this study was to demonstrate the criterion validity and responsiveness of the Simple Test for Evaluating Hand Function, a tool which is widely used in Japan.

Methods

Thirty patients between the ages of 20 and 82 years with distal radius fracture (n = 10), and cervical spondylosis myelopathy (n = 20) were included in this study. Concurrent validity was tested by examining the correlation between Simple Test for Evaluating Hand Function, the Purdue Pegboard Test, and the Disabilities of the Arm, Shoulder and Hand questionnaire. In addition, standardized response means were calculated to compare the responsiveness of the Simple Test for Evaluating Hand Function with Purdue Pegboard Test and Disabilities of the Arm, Shoulder and Hand.

Results

The correlation coefficient between Simple Test for Evaluating Hand Function and Purdue Pegboard Test was 0.70, and the correlation between Simple Test for Evaluating Hand Function and Disabilities of the Arm, Shoulder and Hand was −0.55 (p < 0.05). Standardized response mean shows that the Simple Test for Evaluating Hand Function (0.69) is more responsive than the Purdue Pegboard Test (0.53), and less responsive than Disabilities of the Arm, Shoulder and Hand (0.97).

Conclusions

The Simple Test for Evaluating Hand Function demonstrates concurrent validity and responsiveness as a performance based assessment of dexterity in patients with distal radius fracture and cervical spondylosis. We conclude that the Simple Test for Evaluating Hand Function could be used as a measure of dexterity or clinical change after therapy intervention. The Purdue Pegboard Test may be used for patients with an occupation that requires integrated fine motor skills and bimanual activity, whereas the Simple Test for Evaluating Hand Function may be more suitable for patients who use a variety of unilateral grips such as pinch and span. The Simple Test for Evaluating Hand Function and Disabilities of the Arm, Shoulder and Hand can complement each other when measuring someone’s activity and participation level.

Keywords

Simple Test for Evaluating Hand Function Purdue Pegboard Test Disabilities of the Arm Shoulder and Hand validity responsiveness

Introduction

Comprehensive evaluation of hand function is very important in hand therapy since the choice of therapy and assessment of therapy results are dependent on hand function. The therapist must rely on three broad approaches to hand assessment. According to the International Classification of Functioning, Disability, and Health (ICF), these components are described as body functions and structures (e.g. range of motion), activities (e.g. dexterity), and participation (e.g. work).¹ Activity is defined as “the execution of a task or action by an individual,” and participation is defined as “the person’s involvement in a life situation.” Activities include fine hand use, for example, “performing the coordinated actions of handling objects, picking up, manipulating and releasing them using one’s hand, fingers.”²

Dexterity in particular, which is defined as “the skillful and controlled manipulation of a tool or an object by the fingers,”^3,4 is considered essential for successfully performing tasks of daily living, work, school, play, and leisure.^5,6 As such, in a comprehensive assessment of upper extremity function, dexterity is an important component. Numerous measurement instruments have been developed to conduct this evaluation via performance tests. Specifically, five performance tests have been developed for all types of hand injuries:⁷ the Jebsen Taylor Hand Function Test (JTT),^8,9 Functional Dexterity Test (FDT),^10,11 NK Hand Dexterity Test (NKHDT),^12,13 Purdue Pegboard Test (PPT),^14,15 and Southampton Hand Assessment Procedure (SHAP).¹⁶ Standardized outcome instruments must demonstrate reliability, validity, and responsiveness to detect change after an intervention.¹⁷ Reliability is the ability to obtain the same scores at different time points when no change is expected; it is often tested by test–retest analysis. Validity is the ability to measure an outcome precisely, and one method of doing so is to make a comparison with a reference standard (or an instrument that has been previously validated). Responsiveness is the ability of a test to detect clinical change, which is typically measured by effect size or standardized response mean (SRM). Previous studies investigating these characteristics have reported that the JTT should not be used to judge the therapeutic effect before and after surgery due to concerns with its responsiveness and validity.¹⁸ Furthermore, there are no measurement tools that satisfy all the clinimetric properties such as reliability, validity, and responsiveness.¹⁹

In Japan, the Simple Test for Evaluating Hand Function (STEF) is widely used. STEF was developed in 1969 by Kaneko, an occupational therapist and its rating system was put to practical use in 1986.²⁰ This test scores the time taken to moving 10 objects of different shapes and sizes to predetermined places. The time taken is determined for each examination, and scores from 1 to 10 points are allocated accordingly. The reliability of this test was reported by Kaneko, who is a developer of such performance tests.²¹ Additionally, the validity of STEF is highly correlated with the Action Research Arm Test, which is widely used for diseases such as stroke.²² With respect to hand surgery, a correlation was found between STEF and the Disabilities of the Arm, Shoulder and Hand (DASH)²³ and with range of wrist motion in patients with distal radius fracture and other wrist joint diseases.²⁴

The aim of this study was to demonstrate the criterion validity and responsiveness of the STEF. We hypothesized that there would be a moderately strong correlation between STEF and PPT, and that the responsiveness of the STEF would be greater than PPT.

Methods

To measure the criterion validity and responsiveness of the STEF, we collected data from a prospective cohort of patients. In 1 year from January 2016, we recruited patients diagnosed with either distal radius fracture or cervical spondylosis from the Kanazawa Medical University Hospital. The inclusion criteria were that the patients should be older than 20 years and had no previous surgery. Patients were excluded from the analysis if they had a medical history of rheumatoid arthritis, osteoarthritis of digits of the hands, or serious complications. Evaluation of the STEF was conducted by three therapists with 4 to 10 years of experience in hand therapy. In addition, this study was conducted under the supervision of a certified hand therapist of the Japan Hand Therapy Society. Cervical spondylosis myelopathy patients were evaluated preoperatively and up to discharge (the period from surgery to discharge was average 1 month, range 2 weeks to 2 months). Distal radius fracture patients were evaluated postoperatively and up to 3 months postoperatively.

This study was approved by the Kanazawa Medical University Hospital Expert Committee on University Research Ethical Evaluation. Verbal and written information was given to all patients and all patients gave written consent before assessment.

Outcome measures

The PPT was developed in 1948 by Joseph Tiffin, an industrial psychologist at Purdue University. It is used to evaluate and train skills in the movement of hands, fingers, and arms. It is an assessment involving insertion of a pin with a length of 25 mm, 3 mm in diameter within a predetermined length of time into a board on which 25 holes are arranged vertically.²⁵

The DASH is a 30-item patient-rated questionnaire of upper extremity disability and symptoms. Each question has five response choices, ranging from “no difficulty or no symptom” to “unable to perform activity or very severe symptom.” It includes items on the degree of difficulty when performing various physical activities, the effect of the upper extremity problems on social activities, work and sleep, severity of each of the symptoms of pain, activity-related pain, tingling, weakness, and stiffness, and the psychological effect on self-image.²⁶

The STEF is a measurement tool developed as a means to evaluate the accuracy, smoothness, speed, and dexterity of voluntary movement in the upper extremity. It is composed of 10 different tasks involving 58 objects that also enable the evaluation of various grip patterns such as precision grip and power grip. The STEF consists of a rectangular board and 10 different tasks. The test board has a diameter of 40 cm × 80 cm and a height of 3.5 cm. The 10 objects are No. 1 (large ball), No. 2 (middle sphere), No. 3 (large rectangle), No. 4 (neutral direction), No. 5 (wooden disk), No. 6 (small cube), No. 7 (cloth), No. 8 (gold disc), No. 9 (small ball), and No. 10 (pin) (see Figures 1 and 2 and Table 1).

Figure 1.

Instrument of the Simple Test for Evaluating Hand Function.

Figure 2.

Instrument of the Simple Test for Evaluating Hand Function.

Table 1.

Contents (In the case of the right hand).

Items	Contents
No. 1 (large ball) DIA 6.8 cm, 80 g	Move five large balls in A to B
No. 2 (middle ball) DIA 4.0 cm, 15 g	Move six middle balls in C to A
No. 3 (large rectangle) 10 × 10 × 5 cm³, 200 g	Move five large rectangles in B to A
No. 4 (neutral direction) 3.5 × 3.5 × 3.5 cm³, 15 g	Move six neutral directions in A to D
No. 5 (wooden disk) DIA 3.1 cm, THK 1.1 cm, 5 g	Move six wooden discs in E to D
No. 6 (small cubic) 1.5 × 1.5 × 1.5 cm³, 2 g	Move six cubic cubes in F to D
No. 7 (cloth) 9.0 × 7.0 cm² vinyl cloth	Flip six cloths in the center of the table
No. 8 (gold disk) DIA 2.0 cm, THK 2.0 mm, 3 g	Move six golden disks in C to G
No. 9 (small ball) DIA 6.0 mm, 2 g	Move six small balls in G to D
No. 10 (pin) DIA 3.0 mm, LG 4.2 cm	Move six pins in C to H

DIA: Diameter, THK: Thickness, LG: Length.

STEF user’s guide

The items necessary for conducting the examination are the STEF, an examination table, the assessor handbook, a stopwatch, and writing instruments. The distance between the patient and the desk is set such that the patient’s hands are reasonably placed at the start position. The examiner gives the following instructions: “We will check the speed of hand movement. Please perform this test as quickly as you can, doing so in a comfortable manner.” At the start of the test, the hand is placed at the center as shown in Figure 3. The test is started using a signal of “Ready, go.,” and the stopwatch is stopped when the last object is placed in the intended position. All subtests have a time limit, and it is necessary to stop the assessment if the patient exceeds the time limit. If the patient drops an object or places it in the wrong place, the examiner should restart the subtest. However, if the patient fails on the third attempt, the examiner should record the subtest as “Incomplete.” The STEF is available from SAKAI Medical Co. Ltd., Japan.

Figure 3.

Posture under examination. The subject is in the chair sitting position and the elbow joint is bent 90° and placed in the center of the examination table.

STEF scoring

The examiner uses the stopwatch to measure the time taken for each subtest from start to finish, and the duration is written in the score profile field (Table 2). If the measured time on the right hand of assessment No. 1 is 9.6 s, the score is seven points. Each subtest has a full score of 10, and the entire test has a full score of 100. A total score based on 1205 persons aged 3 to 80 years or more is calculated as an index by age class.²¹

Table 2.

Scoring profile field.

	Hands (R/L)	Time limit(s)	10	9	8	7	6	5	4	3	2	1
No. 1	R	30	5.9	7.7	9.5	11.3	13.1	14.9	16.7	18.5	20.3	30.0
No. 1	L	30	6.5	8.6	10.7	12.8	14.9	17.0	19.1	21.2	23.3	30.0
No. 2	R	30	5.3	7.1	8.9	10.7	12.5	14.3	16.1	17.9	19.7	30.0
No. 2	L	30	5.6	7.4	9.2	11.0	12.8	14.6	16.4	18.2	20.0	30.0
No. 3	R	40	8.7	11.4	14.1	16.8	19.5	22.2	24.9	27.6	30.3	40.0
No. 3	L	40	9.5	12.5	15.5	18.5	21.5	24.5	27.5	30.5	33.5	40.0
No. 4	R	30	8.3	10.7	13.1	15.5	17.9	20.3	22.7	25.1	27.5	30.0
No. 4	L	30	8.7	11.1	13.5	15.9	18.3	20.7	23.1	25.5	27.9	30.0
No. 5	R	30	6.3	8.4	10.5	12.6	14.7	16.8	18.9	21.0	23.1	30.0
No. 5	L	30	7.0	9.4	11.8	14.2	16.6	19.0	21.4	23.8	26.2	30.0
No. 6	R	30	7.2	9.3	11.4	13.5	15.6	17.7	19.8	21.9	24.0	30.0
No. 6	L	30	7.7	9.8	11.9	14.0	16.1	18.2	20.3	22.4	24.5	30.0
No. 7	R	30	6.1	8.2	10.3	12.4	14.5	16.6	18.7	20.8	22.9	30.0
No. 7	L	30	6.8	9.2	11.6	14.0	16.4	18.8	21.2	23.6	26.0	30.0
No. 8	R	60	10.2	13.5	16.8	20.1	23.4	26.7	30.0	33.3	36.6	60.0
No. 8	L	60	11.7	15.9	20.1	24.3	28.5	32.7	36.9	41.1	45.3	60.0
No. 9	R	60	12.4	17.5	22.6	27.7	32.8	37.9	43.0	48.1	53.2	60.0
No. 9	L	60	13.1	18.5	23.9	29.3	34.7	40.1	45.5	50.9	56.3	60.0
No. 10	R	70	15.4	21.1	26.8	32.5	38.2	43.9	49.6	55.3	61.0	70.0
No. 10	L	70	16.5	22.2	27.9	33.6	39.3	45.0	50.7	56.4	62.1	70.0

Data analysis

We examined the relationship between the total STEF scores and the PPT and DASH scores by Pearson’s correlation coefficient. Analyses were performed using Statistical Package for the Social Sciences (SPSS), version 18 (SPSS, Inc., Chicago, IL, USA), and the significance level was set to 5%.

SRMs were calculated to assess responsiveness to clinical change as a result of therapy (mean change in score divided by the standard deviation of the score change).

Results

Thirty patients between the ages of 20 and 82 years with cervical spondylosis myelopathy or distal radius fracture were included in this study. Their demographic details are summarized in Table 3.

Table 3.

Diagnosis of patients in the evaluation study.

Diagnosis	No. of patients	Age	Gender	Dominance
Distal radius fracture	10	66.3 ± 19.2	F:8, M:2	D:4, N:6
Cervical spondylosis	20	70.4 ± 6.6	F:9, M:11	D:11, N:9
Total	30	69.0 ± 12.1	F:17, M:13	D:15, N:15

A moderately strong positive correlation coefficient was observed between the STEF and PPT (r = 0.70) (Figure 4) and moderate negative correlation between STEF and DASH scores (r = −0.55) (Figure 5).

Figure 4.

Result of correlation analysis between the STEF and PPT (n = 30, p < 0.05). STEF: Simple Test for Evaluating Hand Function; PPT: Purdue Pegboard Test.

Figure 5.

Result of correlation analysis between the STEF and DASH (n = 30, p < 0.05). STEF: Simple Test for Evaluating Hand Function; DASH: Disability of the Arm, Shoulder and Hand questionnaire.

Table 4 summarizes the mean change scores in STEF, PPT, and DASH and SRM for the affected hand. A larger SRM is seen for the DASH compared with the STEF and PPT. However, the STEF is more responsive than the PPT.

Table 4.

Responsiveness of the STEF, PPT, and DASH.

	Average	SD	SRM
STEF	2.3	3.3	0.69
PPT	1.6	3.0	0.53
DASH	13.9	14.3	0.97

SD: standard deviation; SRM: standard response mean; STEF: Simple Test for Evaluating Hand Function; PPT: Purdue Pegboard Test; DASH: Disability of the Arm, Shoulder and Hand questionnaire.

Discussion

Traditionally, outcome assessment in hand therapy has been focused on measuring range of motion, grip strength, and sensation. However, the focus has shifted in the 21st century towards assessing health at the activity and participation level.^27,28 As such measurement of activities comprise 20% of the therapist’s time and are ranked as the most critical aspect of daily practice, it is important to consider measurement tools.²⁹ Dexterity is closely related to activity limitations^5,6 and is evaluated through performance tests. Despite the fact that many performance tests have been developed internationally, there are no measurement tools that satisfy all the clinimetric properties.¹⁹

The PPT is one of the most commonly used dexterity measurement tools.³⁰ We chose to use the PPT and DASH as opposed to other hand specific measures of disability for several reasons. First, the PPT has demonstrated to have good inter-rater reliability, content validity, and construct validity.^31,32 In addition, at present, the PPT is recommended because it involves both bilateral and unilateral hand use and has a broader age range of normative data. The DASH has also demonstrated good reliability, validity, and responsiveness.³³ It is the most extensively studied tool and has the most supporting evidence for good clinimetric quality. Therefore, we attempted to clarify its relevance by analyzing the correlation between STEF, a test that is commonly performed in Japan, and the PPT and DASH tests that are used internationally.

Correlation analysis of STEF and PPT showed moderate correlation. The STEF includes the task of manipulating a pin with the thumb, index finger, and middle finger, similar to the PPT. However, the STEF consists of subtests with objects of different sizes and shapes, includes tasks using digits ranging from the thumb to little finger, and incorporates activities requiring anterior and posterior rotation of the forearm. It is possible that the specific demands of these subtests explain the moderate correlation. In recent years, analysis of hand movement has advanced with three-dimensional motion analysis. It has been reported that hand movement in various activities of daily living (ADL) and hand movement during PPT performance are different.³⁴ Therefore, PPT does not account for hand dysfunction that affects ADL. Conversely, STEF incorporates various grip patterns. Moreover, several reports have indicated a correlation between STEF and ADL.³⁵ Correlation analysis of STEF and DASH showed a moderate negative correlation as well. This was similar to the study using STEF in distal radius fractures. It was thus suggested that evaluation of dexterity by STEF can estimate performance, which is a person’s perception of what he or she actually does in a real life environment. However, the STEF and DASH measure different concepts such as activities and participation. We suggest that the STEF and DASH can complement each other in the evaluation of activities and participation limitations.

The responsiveness of the STEF (SRM, 0.69) was found to be higher than that of the PPT (SRM, 0.53), but less than that of the DASH (SRM, 0.97). Gay et al.³⁶ reported that after carpal tunnel release, the DASH showed moderate sensitivity to change at 6 weeks and good sensitivity at 12 weeks (SRM, 1.13). In addition, McDermid and Tottenham³⁷ reported that the DASH demonstrated responsiveness after 3 months (N = 60: 24 wrist problems, 36 hand problems) and SRM was 1.37. These reports and our results suggest that the DASH is responsive in a wide range of hand conditions. In contrast, the responsiveness of the PPT was low, and there have been no reports supporting PPT for responsiveness. One possible reason is that the task of PPT in hand trauma patients may be too difficult.

Study limitations

In this study, the correlation and responsiveness between STEF and PPT, and STEF and DASH was calculated for patients with trauma or inflammatory disease of the hand and cervical spondylosis myelopathy. However, the sample size was small and included a variety of etiologies. A further limitation is that we did not compare the correlation of the STEF with other performance tests such as the Nine Hole Peg Test or SHAP. Future research should explore the concurrent validity of the STEF with the PPT and DASH in specific hand conditions such as distal radius fracture or carpal tunnel syndrome and using larger samples.

Conclusions

In this study, the validity of STEF is demonstrated by moderately strong correlation between STEF and PPT, and STEF and DASH. The responsiveness of the STEF was found to be greater than that of the PPT, but less than that of the DASH. We conclude that the STEF could be used as measure of dexterity or clinical change after therapy intervention.

Footnotes

Acknowledgements

We would like to thank both Katsumi Inoue and Norio Kawahara for their assistance and guidance in this research.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Informed consent

Written informed consent was obtained from all patients for their anonymized information to be published in this article.

Ethical approval

Ethnical approval to report this case series was obtained from Kanazawa Medical University Hospital Expert Committee on University Research Ethical Evaluation (109).

Guarantor

SN.

Contributorship

SO and HI researched literature and conceived the study. AK and SN were involved in protocol development, gaining ethical approval, patient recruitment and data analysis. KI and KK wrote the first draft of the manuscript. All authors reviewed and edited the manuscript and approved the final version of the manuscript.

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