I BOT_FOT II_Hand Function Notes_Dr. Punita V. Solanki_April 2024.pdf

First (I) Year BOT. Subject/Course: Fundamentals of Occupational Therapy II
S. No. 7: Hand Function and Evaluation Methods
Lecture Notes by Dr. Punita V. Solanki. Professor & Incharge. April 2024
DYPU School of Occupational Therapy Nerul, Navi Mumbai. Dr. Punita V. Solanki Page 1 of 12
Course Syllabus: D Y Patil Deemed to be University School of Occupational Therapy
Bachelors of Occupational Therapy (BOT) Program 2021-2022
Year: First (I) Year BOT
Subject/Course: Fundamentals of Occupational Therapy II
Section (S. No.) 7: Hand Function and Evaluation Methods
Contents (Level 1) (Hours: 05)
1. Functional Anatomy of Hand
2. Prehension and Grasp Patterns
3. Grip and Pinch Strength
4. Functional Evaluation of Hand
5. Oedema Assessment
6. In-Hand Manipulation
References
1) Occupational Therapy for Physical Dysfunction. Catherine A. Trombly. 4th
Edition 1997
Chapter 6: Evaluation of Biomechanical and Physiological Aspects of Motor Performance.
Page No’s: 106-107, 150-152.
2) Occupational Therapy for Physical Dysfunction. Catherine A. Trombly, Mary Vining
Radomski. 5th
Edition 2002. Chapter 4: Assessing Abilities and Capacities: Range of Motion,
Strength and Endurance. Page No’s: 81-82, 128-130 & Chapter 42: Hand Impairments. Page
No’s: 931-937. & 7th
Edition 2014. Section II Assessment of Occupational Function: Chapter
7: 7 Assessing Abilities and Capacities: Range of Motion, Strength, and Endurance. Page
No.: 226-231.
3) Occupational Therapy: Practice Skills for Physical Dysfunction. Lorraine Williams
Pedretti, Mary Beth Early. 5th
Edition 2001 Chapter 31: Orthotics. Page No’s: 531-540 &
Chapter 44: Hand and Upper Extremity Injuries. Page No’s: 841-843 & 7th
Edition 2013 &
8th
Edition 2018
4) Willard and Spackman’s Occupational Therapy. Helen L. Hopkins & Helen D. Smith. 8th
Edition 1993 Chapter 18: Functional Restoration: Section 4: Hand Rehabilitation. Page No’s:
678-684. Willard and Spackman's Occupational Therapy by Elizabeth Blesedell Crepeau,
Ellen S. Cohn and Barbara A Boyt Schell. 11th
Edition 2009 and 13th
Edition 2019. [Unit V:
Client Factors and Occupational Performance.]

5) Joint Structure and Function: A Comprehensive Analysis. Cynthia C. Norkin, Pamela K.
Levangie. 2nd
Edition 1998 Chapter 9: Wrist and Hand Complex. Page No.: 290-296.
5th
Edition 2011. Chapter 9. The Wrist and Hand Complex. Page No.: 343-349.
Functional Anatomy of Wrist and Hand
Wrist Complex (Radiocarpal Joint Structure) is formed by the radius and radio-ulnar disk
proximally and by the scaphoid, lunate and triquetrum distally. Wrist complex is a biaxial
joint with 2 degrees of freedom of motion. The hand consists of 5 digits; or 4 fingers and a
thumb. Each digit has a carpometacarpal (CMC) joint and a metacarpophalangeal (MCP)
joint. The fingers each have two interphalangeal (IP) while the thumb has only one. There are
19 bones distal to the carpals and 19 joints that make up the hand complex. While there are
structural similarities between the joints of the fingers and the joints of the thumb, function
differs significantly enough that the fingers shall be examined separately from the thumb.
Figure 1: Anatomy of Right Wrist and Hand: Dorsal/Posterior & Ventral/Anterior Surface
The Functional Position of the Wrist and Hand is:
1) Wrist complex in slight extension (20°) and slight ulnar deviation (10°).
2) Fingers moderately flexed at the MCP joints (45°), slightly flexed at the PIP joints (30°)
and slightly flexed at the DIP joints and thumb in opposition.
The wrist position optimizes the power of the finger flexors so that hand closure or all hand
functions can be accomplished with the least possible effort.

Figure 2: Functional position of the hand: wrist extension and ulnar deviation with moderate
flexion of the metacarpophalangeal and interphalangeal joints of the finger and thumb.
Prehension and Grasp Patterns
Prehension: is defined as a position of the hand that allows finger and thumb contact and
facilitates manipulation of objects. These are of three types:
a) Lateral Prehension (Pad to Lateral Pinch).
b) Palmar Prehension (Pad to Pad Pinch or Palmar Pinch or Three Jaw Chuck).
c) Tip Prehension (Tip to Tip Pinch).
a) Lateral Prehension (Pad to Lateral Pinch): In lateral prehension the pad of the thumb is
positioned to contact the radial side of either the middle or distal phalanx of the index finger.
Most commonly this pattern of prehension is used in holding an eating utensil and holding
and turning a key.
Figure 3: Pad-To-Side Prehension
b) Palmar Prehension (Pad to Pad Pinch or Palmar Pinch or Three Jaw Chuck): In
Palmar prehension the thumb is positioned in opposition to the index and long fingers. The

important component of motion in this pattern is thumb rotation, which allows for pad-to-pad
opposition. This prehension pattern is used in lifting objects from a flat surface such as paper,
in holding small objects as pen, beads, small grains etc and in tying a shoe lace or a bow.
Figure 4: Pad-To-Pad Prehension
c) Tip Prehension (Tip to Tip Pinch): In tip prehension the IP joint of the thumb and the
DIP and PIP joints of the finger are flexed to facilitate tip to tip prehension. These motions
are necessary to pick up a pin or a coin. Once a pin is in the hand, tip prehension will be
converted to palmar prehension to provide more skin surface area to retain a small object.
Figure 5: Tip-To-Tip Prehension
Grasp: is defined as a position of the hand that facilitates contact of an object against the
palm and the palmar surface of the partially flexed digits and the thumb is involved in all
types of grasps except that of hook grasp. These are of following types:
a) Cylindrical Grasp
b) Spherical Grasp

c) Hook Grasp
d) Intrinsic Plus Grasp
e) Lateral Prehension
a) Cylindrical Grasp: Cylindrical grasp the most common static grasp pattern is used to
stabilize objects against the palm and the fingers, with the thumb acting as an opposing force.
This pattern is assumed for grasping a hammer, pot handle, drinking glass or the handhold on
a walker or a crutch.
Figure 6: Cylindrical Grasp
b) Spherical Grasp: Also called ball grasp, this pattern is assumed for holding a round
object such as a ball or apple. It differs from cylindrical grasp primarily in the positioning of
the fourth and fifth digits. In spherical grasp the two ulnar digits are supported in greater
extension to allow a more open hand posture whereas in cylindrical grasp the two ulnar
metacarpals are held in greater flexion.
Figure 7: Spherical Grasp

c) Hook Grasp: Hook grasp is the only prehension pattern that does not include the thumb to
supply opposition. The MCP joints are held in extension and the DIP and PIP joints are held
in flexion of all the four digits. This is the attitude the hand assumes when holding the handle
of a shopping bag, a pail or a briefcase.
Figure 8: Hook Grasp
d) Intrinsic Plus Grasp: Intrinsic plus grasp is characterized by the positioning of all the
MCP joints of the fingers in flexion, the DIP and PIP joints in full extension and the thumb in
opposition to the third and fourth fingers. This pattern is used in grasping and holding large
flat objects such as books, folders, files or plates etc.
Figure 9: Intrinsic Plus Grasp
e) Lateral Prehension: Lateral prehension is a unique form of grasp. Contact occurs between
two adjacent fingers. Lateral prehension is included here as a form of power grip because
lateral grip involves the static holding of an object that is then moved by the more proximal

joints of the upper extremity. Although not a “powerful” grip, neither is lateral prehension
used to manipulate objects in the hand. It is generally typified by the holding of a cigarette.
Figure 10: Lateral Prehension
Grip and Pinch Strength: The standard methods of measurement are recommended by the
American Society of Hand Therapists (ASHT) 1981 & 1992. The subject should be seated
with his shoulder adducted and neutrally rotated, elbow flexed at 90°, the forearm in neutral
position and the wrist in 0° to 30° extension and between 0° to 15° of ulnar deviation. The
hip and knees when seated should be at 90° of flexion with feet flat on the ground. Three
trials are taken of each hand with a 2–3-minute rest between trials and the score is the
average of the three trials.
Grip Strength Assessment
a) Jamar Dynamometer (Set at the second position from all of 5 positions as per ASHT): It is
a reliable, valid and an accurate method of grip strength assessment.
Test-retest reliability of this method using the Jamar hydraulic dynamometer was found to be
0.88; interrater reliability (two raters, same time) was 0.99. Interrater (two raters, same time)
reliability of averaged B & L pinch meter scores was 0.98, and test–retest reliability was
0.81.
b) Vigorimeter: is an acceptable alternative hand strength measuring device which is
commercially available for patients whose diagnoses contraindicate stress on joints and or
skin.
c) Adapted Sphygmomanometer: is an alternative method of grip strength measurement used
for rheumatoid arthritis patients.

d) The power grip attachment of the Baltimore Therapeutic Equipment (BTE) Work
Simulator.
Clinical Impression: It is recommended that a change in score of at least 6 kg (13 pounds) is
considered to be clinically significant.
In right-handed individuals, the dominant side is typically 10% stronger than the
nondominant side, although lefthanded individuals typically demonstrate equal strength
bilaterally.
Pinch Strength Assessment (All 3 types): is tested using a pinch gauge or a pinch meter.
The pinch gauge made by B and L Engineering has been found to be the most accurate. As
with the grip dynamometer, three successive trials should be obtained and compared
bilaterally.
These instruments are calibrated and set at 0 to start. The readings are noted in kilograms or
pounds. Three trials are taken and average of the 3 trials is recorded. A pause of 2-4 minutes
is allowed in between trials whilst assessment.
Figure 11: Grip and Pinch Strength Assessment
Functional Evaluation of Hand
Hand evaluation includes general physical examination of hand for pain, tenderness, wounds,
scars etc, assessment of range of motion, manual muscle strength testing, oedema assessment,
grip and pinch strength measurement, sensibility, dexterity and hand function.

Dexterity Measurement
Dexterity requires hand ROM, hand strength, and sensation in order to manipulate objects.
Individuals who lack full hand motion and function often complain about their inability to
manipulate objects for writing, fastening clothing, or turning a key in a car or door.
Sensibility: The Semmes Weinstein monofilaments are used to assess pressure threshold.
The two-point discriminator is used to assess density of receptors for two-point
discrimination. Dellon’s modification of Moberg Pickup test is a functional hand function test
for assessment of sensations.
Dexterity and Hand Function Tests
a) Jebson Taylor Hand Function test.
b) Purdue Pegboard test.
c) Minnesota Rate of Manipulation test (MRMT).
d) Crawford’s Small Parts Dexterity test.
e) Box and Block test.
f) Nine Hole Peg test.
g) O’Connor’s Dexterity test.
Oedema Assessment: Oedema is an abnormal accumulation of interstitial fluid beneath the
skin, or in one or more cavities of the body. Hand volume is measured to assess the presence
of extracellular or intracellular edema.
Methods of Assessment of Oedema are:
1) Clinical assessment
2) Volumetric measures by Volumeter.
3) Circumferential measures by circumference tape or jeweller’s ring size standards or an
external calliper.
Clinical Assessment
Clinically oedema may be classified into two types: pitting and non-pitting oedema.
Pitting edema appears early and can be recognized as a bloated swelling that creates a pitted
appearance when pressed. Pitting may be more pronounced on the dorsal surface, where the

venous and lymphatic systems provide return of fluid to the heart. Whereas in non-pitting
oedema there is no pitted appearance when pressed.
Figure 12: Pitting Oedema
Volumetric Measure by Volumeter: Volumetric measures document changes in the mass of
a body part by use of water displacement. It is most often used to measure hand oedema. The
voltmeter has been shown to be accurate to 10 ml, when used in a prescribed manner. It
consists of a water vessel with a spill over spout near the top of the water level and a
graduated beaker.
The evaluation is performed as follows:
1) A plastic voltmeter is filled and allowed to empty into a large beaker until the water
reaches the spout level. The beaker is then emptied and dried thoroughly.
2) The patient is instructed to immerse the hand in the plastic voltmeter, being careful to keep
the hand in the mid position.
3) The hand is lowered until it rests gently between the middle and ring fingers on the dowel
rod. It is important that the hand not press onto the rod.
4) The hand remains still until no more water drips into the beaker.
5) The water is poured into a graduated cylinder or a beaker. The cylinder or a beaker is
placed on a level surface and a reading is made in millilitres.
An oedematous hand displaces more water than an unswollen hand so that a lower reading is
considered an improvement. Sitting or standing significantly affects the scores of volumetric
measurements so it is important to standardize the administration procedure.

Figure 13: Volumetric Measurement of Oedema
Circumferential Measures by Circumference Tape or Jeweller’s Ring Size Standards or
An External Calliper: is a method of assessing oedema of an individual finger or a joint.
Circumferential measurement is quick to perform and provides a good alternative when it is
not possible to use a voltmeter. Be consistent with measuring tape, placement and tension. An
external calliper is an alternative method of assessing smaller diameter areas. Again,
consistent instrument placement and tension are important for maintaining accuracy.
With circumferential measurements, it is essential to measure at exactly the same place from
test to test. Using anatomic landmarks can assist in the placement, such as over the third digit
PIP joint or 5 cm proximal to the ulnar styloid.
Figure 14: Circumferential Measurement of Oedema
A second method of measuring edema of the whole hand is the figure-of-eight technique.
This method is based on the understanding that edema of the hand tends to collect more

dorsally. Using a ¼ -inch wide tape measure with the wrist in neutral and fingers adducted,
the tape is started at the medial aspect of the wrist just distal to the ulnar styloid. The tape is
then run across the volar surface of the wrist to the most distal point of the radial styloid and
then run diagonally across the dorsum of the hand to the fifth MP joint. The tape is then run
across the heads of the metacarpals to the second MP joint and then back across the dorsum
of the hand to the starting point. The measurement recorded is the distance measured by the
tape in centimetres
Precautions for Edema Measurements
Immersing the hand in water is sometimes contraindicated, such as with open wounds or skin
conditions, immediately postoperatively, with percutaneous pinning and external fixation
devices, healing skin grafts, and suspicion of infection. It is also inappropriate if having the
extremity in the dependent position during testing significantly increases pain and edema or if
spasticity or paralysis impacts the measurement
In-Hand Manipulation
In-hand manipulation is the ability to move an object in hand using only your thumb and
fingers. In-hand manipulation skills are linked to developing more efficient fine motor skills
and writing skills.
There are 3 different skill sets for in-hand manipulation: translation, rotation and shift.
Translation: Translation is the ability to move an object from your palm to your fingertips.
These are: finger-to-palm and palm-to-finger translations and these can be with or without
stabilization.
Rotation: Rotation is the ability to turn an object using the pads of your fingers.
There are three types of rotation: simple, complex and complex with stabilization. Simple is
when you twist open or close a lid on a container. Complex rotation is when you turn an
object over to the other side. For example, flipping a coin from heads to tails or rotating a
pencil heads.
Shift: Shifting is the ability to move an object using only your fingertips in a forward or
backward motion.

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