ABILHAND

Evidence Reviewed as of before: 17-06-2012
Author(s): Annabel McDermott, OT
Editor(s): Nicol Korner-Bitensky, PhD OT

Purpose

The ABILHAND is a semi-structured item-response questionnaire that measures manual ability according to an individual’s perceived difficulty performing daily bimanual tasks.

In-Depth Review

Purpose of the measure

The ABILHAND is an interview-based assessment tool that measures a patient’s perceived difficulty using his/her hands to perform manual activities in daily life. The ABILHAND assesses active function of the upper limbs. The tool measures an individual’s ability to perform bimanual tasks, regardless of strategies used to complete the task (Ashford et al., 2008; Penta et al., 1998)

Available versions

The ABILHAND was originally developed by Penta et al. (1998) as a 56-item, 4-level questionnaire of unimanual and bimanual ability for patients with rheumatoid arthritis. The original ABILHAND was intended to measure rehabilitation outcomes and to provide guidelines for goal setting in treatment planning (Gustafsson et al., 2004). Penta et al. (2001) found that patients with stroke were able to complete unimanual activities with the unaffected limb, regardless of hand dominance, whereas bimanual tasks were more difficult. Accordingly, a version was developed specifically for patients with stroke that only included bimanual items, as well as two alternate unimanual’ activities that require skillful use of the affected hand (cutting nails, filing nails). Penta et al. (2001) also reviewed the 4-level scoring criterion (impossible, very difficult, difficult, easy) and found that patients rarely used the very difficult’ score. This indicated that the two intermediate scoring criteria (very difficult, difficult) were not sufficiently differentially distinct. Accordingly, the stroke version of the ABILHAND was developed with a 3-level scoring criterion (impossible, any difficulty, easy).

Other impairment-specific versions were subsequently created with modified item sets and levels. Each version of the ABILHAND has its own Rasch-derived item difficulty calibrations that rely on computerized algorithms to obtain the patient’s overall measure from his/her responses (Simone et al., 2011).

Features of the measure

Items:

The ABILHAND is an inventory of 23 bimanual activities (from most difficulty to least difficult):

  1. Hammering a nail
  2. Threading a needle
  3. Peeling potatoes with a knife
  4. Cutting own nails
  5. Wrapping up gifts
  6. Filing own nails
  7. Cutting meat
  8. Peeling onions
  9. Shelling hazel nuts
  10. Opening a screw-topped jar
  11. Fastening zipper of jacket
  12. Tearing open pack of chips
  13. Buttoning up a shirt
  14. Sharpening a pencil
  15. Spreading butter on a slice of bread
  16. Fastening a snap
  17. Buttoning up trousers
  18. Taking the cap off a bottle
  19. Opening mail
  20. Squeezing toothpaste on a toothbrush
  21. Pulling up the zipper of trousers
  22. Unwrapping a chocolate bar
  23. Washing hands

Scoring:

The patient is asked to rate his/her perceived difficulty performing items without help, according to the following scoring criteria:

  • 0 = impossible
  • 1 = difficult
  • 2 = easy

Tasks that the patient has not performed in the past 3 months are not scored and are encoded as missing responses.

The ABILHAND was developed using the Rasch measurement model, which provides a method to convert the ordinal raw score into a linear measure on a unidimensional scale. Item scores are entered into the WINSTEPS computer program, and raw ordinal data is converted to linear measures expressed in logits (log-odds probability units). The total score is scaled along a unidimensional continuum with 0 at the centre of the scale, whereby the higher the logit number, the greater the patient’s perceived ability (Gustafsson et al., 2004).

What to consider before beginning:

Users should note that self-estimated measures (i.e. when scores are not based on clinician observation of performance) are subject to overestimation or underestimation of actual performance, depending on motivation and cognitive skills (Penta et al. 2001).

Clinicians should consider patient factors such as self-esteem, insight, vision, hearing, language and cognitive function prior to administering the ABILHAND (Gustafsson et al., 2004).

Mpofu & Oakland (2010) advise caution when using the ABILHAND to measure improvements in impairment of the affected upper limb after stroke rehabilitation. The ABILHAND does not take into consideration the arm used to perform a task or compensatory strategies employed to complete the task. Accordingly, improvement in scores may be based on use of compensatory strategies rather than on improvement in the affected arm.

Time:

The ABILHAND takes 10 to 30 minutes to administer (Ashford et al., 2008; Connell et al., 2012).

Training requirements:

No training requirements have been specified for the ABILHAND, although administration by a clinician is recommended (Ashford et al., 2008).

Equipment:

The ABILHAND is a semi-structured questionnaire that does not require specific equipment, however the WINSTEPS computer program is required to process raw scores.

Client suitability

Can be used with:

  • Individuals with chronic stroke
  • Individuals with rheumatoid arthritis
  • Individuals with systemic sclerosis

Should not be used with:

  • Due to the subjective nature of the patient’s reports, this measure should not be used with individuals with severe cognitive deficits (Penta et al., 2001).
  • The ABILHAND may not be suitable for use with patients with aphasia or apraxia (Gustafsson et al., 2004).

In what languages is the measure available?

  • French
  • English
  • Dutch
  • Italian
  • Swedish

Summary

What does the tool measure? Manual ability of the upper extremity.
What types of clients can the tool be used for? The ABILHAND can be used with, but is not limited to, patients with stroke.
Is this a screening or assessment tool? Assessment
Time to administer 10-30 minutes
Versions
  • AH-RA for rheumatoid arthritis (46 items, 4 levels)
  • AH-RA revised version (27 items, 3 levels)
  • ABILHAND-ULA for upper limb amputees (22 items; 4 levels)
  • SSC-adapted ABILHAND for systemic sclerosis (26 items, 3 levels)
  • ABILHAND – neuromuscular age-independent version (22 items)
  • ABILHAND-Kids (21 items)
Other Languages French, English, Swedish, Dutch, Italian
Measurement Properties
Reliability Internal consistency:
– Order of difficulty of items has been confirmed by Rasch analysis.
– One study reported a high item reliability index.
– One study reported high person separation reliability.

Test-retest:
No studies have reported on the test-retest reliability of the ABILHAND.

Intra-rater:
No studies have reported on the intra-rater reliability of the ABILHAND.

Inter-rater:
No studies have reported on the inter-rater reliability of the ABILHAND.

Validity Content:
– One study reported that the 23 items of the ABILHAND define a common continuum of manual ability, and items are coherent with the overall questionnaire and contribute to the measurement of manual ability.
– One study examined stability of item difficulty of the ABILHAND and found that item hierarchy was substantially retained across different groupings (impairment, age, sex, ability).
– One study reported that scores explained 84% of observed variance. The main factor across the residuals explained only 11.4% of the residual variance (1.8% of the total variance).

Criterion:
Concurrent:
One study examined the concurrent validity of the ABILHAND among patients with chronic upper limb impairment resulting from conditions including stroke and reported adequate correlations with the Box and Block Test, Jamar handgrip and Purdue pegboard test, and an adequate negative correlation with the Nine Hole Peg Test.

Predictive:
No studies have reported on the predictive validity of the ABILHAND.

Construct:
Convergent/Discriminant:
No studies have reported on the convergent/discriminant validity of the ABILHAND.

Known Groups:
– One study reported highly significant differences in ABILHAND scores between patients with tetraparesis, hemiparesis, other neurological impairments (multiple sclerosis, Parkinson’s disease, ataxia) and healthy subjects.
– One study reported no correlation between ABILHAND scores and country, age, sex, time since stroke, affected side, lesion site or tactile sensitivity; poor correlation with grip strength and manual dexterity of the unaffected limb; poor negative correlation with depression; adequate correlation with grip strength and manual dexterity of the affected limb; and excellent correlation with upper limb motricity.

Floor/Ceiling Effects No studies have reported on the floor/ceiling effects of the ABILHAND.
Does the tool detect change in patients?
  • No studies have reported on the responsiveness of the ABILHAND.
  • One study reported that the ABILHAND demonstrates 92% sensitivity and 80% specificity at a lower cutoff score of 80/100.
Acceptability The ABILHAND is non-invasive and quick to administer. The items are considered reflective of real-life activities (i.e. ecologically valid).
Feasibility The ABILHAND is portable and is suitable for administration in various settings. The assessment is quick to administer and requires minimal specialist equipment or training.
How to obtain the tool? The ABILHAND is available in Penta, M., Tesio, L., Arnould, C., Zancan, A., & Thonnard, J-L. (2001). The ABILHAND questionnaire as a measure of manual ability in chronic stroke patients: Rasch-based validation and relationship to upper limb impairment. Stroke, 32, 1627-34

Psychometric Properties

Overview

A literature search was conducted to identify all relevant publications on the psychometric properties of the ABILHAND. While additional studies have been conducted on other ABILHAND versions, this review specifically addresses the psychometric properties of the 23-item stroke version of the ABILHAND, unless otherwise specified. Two studies were identified.

Floor/Ceiling Effects

No studies have reported on the floor or ceiling effects of the ABILHAND. However, given the hierarchical relationship of items, lower-level tasks of the ABILHAND may be susceptible to floor effects (Ashford et al., 2008).

Reliability

Internal consistency:

Penta et al. (2001) examined the internal consistency of the original 56-item ABILHAND in a sample of 103 patients with chronic stroke using Rasch analysis and reported high reliability (Rasch separation reliability=0.90; person separation reliability=0.90). The authors examined the stability of the scale through differential item functioning (DIF) tests among 12 subgroups: sex (male/female); country (Belgium/Italy); age (< 60/≥ 60), affected side (dominant/nondominant); delay since stroke (< 2 years/≥ 2 years), level of depression, dexterity and manual ability of the unaffected limb, grip strength, dexterity and sensitivity of the affected limb, and motricity of the affected limb. The difficulty hierarchy of the ABILHAND was uniformly perceived by patients with chronic stroke.

Simone et al. (2011) examined the internal consistency of the ABILHAND in a sample of 126 patients with chronic upper limb impairment resulting from stroke (n=83), multiple sclerosis (n=17), peripheral or cerebellar ataxia (n=13), spinal cord lesion (n=10) or Parkinson’s disease (n=3), and 24 health subjects. The ABILHAND demonstrated high reliability (item reliability index=0.94; Cronbach’s alpha=0.99). All items of the ABILHAND fit the Rasch model satisfactorily. There were at least 4 strata of statistically different measures, indicating that variance across scores did not reflect randomness. The authors also examined stability of item difficulty through differential item functioning (DIF) by comparing 4 different groupings of the sample pool: impairment (hemiparesis vs. other); age (≤ 69 vs. > 69); sex (male vs. female); and ability (above median vs. below median). There was a very moderate DIF across the grouping criteria, whereby item hierarchy was substantially retained for all subgroups: impairment (1 outlier: buttoning a shirt); sex (6 outliers: fastening a snap, shelling hazel nuts, hammering a nail, wrapping up gifts, peeling potatoes, spreading butter); age (4 outliers: threading a needle, wrapping up gifts, spreading butter, fastening a snap); and ability (2 outliers: sharpening a pencil, cutting meat).

Test-retest:

No studies have reported on the test-retest reliability of the ABILHAND.

Intra-rater:

No studies have reported on the intra-rater reliability of the ABILHAND.

Inter-rater:

No studies have reported on the inter-rater reliability of the ABILHAND. Note, however that inter-rater reliability is less necessary because administration of the ABILHAND does not rely on clinician-observation of patient performance.

Validity

Content:

Penta et al. (2001) examined the measure of perceived difficulty of the ABILHAND in a sample of 103 patients with chronic stroke. Item distribution ranged from 1.72 to -2.18 logits. All items fit the Rasch model and the 23 items define a common continuum of manual ability. All point measure correlation coefficients (RPM) were positive, indicating that all items are coherent with the overall questionnaire and contribute to the measurement of manual ability. Although fit statistics indicated that most activities adequately measure recovery of manual ability in chronic stroke, 1 item obtained an outlier outfit value (buttoning up a shirt, mean square=1.64), and four items obtained outlier infit values (cutting meat, mnsq=0.69; shelling hazel nuts, mnsq=1.33; tearing open a packet of chips, mnsq=1.22; sharpening a pencil, mnsq=0.65).

Penta et al. (2001) examined the content validity of the ABILHAND by comparing the ranking of item difficulty with expert opinion of four occupational therapists regarding the involvement of the affected hand in each activity. The following classifications were used: (1) the item does not require the affected limb, if it is broken down into several unimanual sequences; (2) the task requires the affected upper limb to stabilize an object but does not involve any fingers; and (3) the task requires precision grip, grip strength, dexterity or any digital activity from the affected side. Findings indicate that more difficult items also tend to require a greater degree of use of the affected limb, whereas easier items do not require the use of the affected limb.

Simone et al. (2011) examined the validity of the ABILHAND in a sample of 126 patients with chronic upper limb impairment resulting from stroke (n=83), multiple sclerosis (n=17), peripheral or cerebellar ataxia (n=13), spinal cord lesion (n=10) or Parkinson’s disease (n=3), and 24 health subjects. Modeled scores explained 84% of observed variance. The main factor across the residuals explained only 11.4% of the residual variance (1.8% of the total variance).

Criterion:

Concurrent:

Simone et al. (2011) compared the concurrent validity of the ABILHAND, Jamar handgrip, Box and Block Test (BBT), Purdue pegboard test and Nine Hole Peg Test (NHPT) in a sample of 126 patients with chronic upper limb impairment resulting from stroke, multiple sclerosis, sensory or cerebellar ataxia, spinal cord lesion or Parkinson’s disease, and 24 healthy subjects, using Pearson’s r. Adequate correlations were found between the ABILHAND and the Jamar handgrip (r=0.377, p=0.001), BBT (r=0.481, p=0.000) and the Purdue pegboard test (r=0.493, p=0.000), and an adequate negative correlation was found between the ABILHAND and the NHPT (r=-0.370, r=0.007).

Predictive:

No studies have reported on the predictive validity of the ABILHAND.

Construct:

Convergent/Discriminant:

No studies have reported on the convergent/discriminant validity of the ABILHAND.

Known Group:

Penta et al. (2001) examined the relationship of the ABILHAND measures to other demographic and clinical variables in a sample of 103 patients with chronic stroke, using univariate ANOVA and correlation coefficients (Mann-Whitney U test, Kruskal-Wallis H tests, Spearman p, Pearson r). Tests revealed no significant differences in ABILHAND measures according to demographic indexes of country (Belgium/Italy), sex or age. Clinical variables such as time since stroke, affected side (dominant/nondominant), lesion site and tactile sensitivity of either limb (measured using the Semmes-Weinstein tactile sensation test) were not significantly related to ABILHAND measures. There was a poor correlation between ABILHAND measures and grip strength (Jamar handgrip, R=0.242, P<0.014) and manual dexterity (Box and Block Test, R=0.248, P=0.012) of the unaffected limb, and a poor negative correlation with depression (Geriatric Depression Scale, p=-0.213, P=0.030). ABILHAND measures demonstrated an adequate correlation with grip strength (R=0.562, P<0.001) and manual dexterity (R=0.598, P<0.001) of the affected limb, and an excellent correlation with upper limb motricity (Brunnstrom upper limb motricity test, p=0.730, P<0.001). Results showed a direct relationship between ABILHAND measures of manual ability and impairment on the affected side, where more complex combinations of manual dexterity without/without grip strength and/or upper limb motricity impairment correlated with higher manual disability.

Simone et al. (2011) examined the known-group validity of the ABILHAND in a sample of 126 patients with chronic upper limb impairment resulting from stroke, multiple sclerosis, sensory or cerebellar ataxia, spinal cord lesion or Parkinson’s disease, and 24 healthy subjects, using Kruskal-Wallis test. Highly significant differences (P<0.001) were found between patients with tetraparesis, hemiparesis, other neurological impairments (multiple sclerosis, Parkinson’s disease, ataxia) and control participants.

Responsiveness

Simone et al. (2011) reported a satisfactory match between the distribution of item difficulty levels and patients’ ability levels. The average ability of healthy controls vs. patients with chronic upper limb impairment resulting from stroke, multiple sclerosis, sensory or cerebellar ataxia, spinal cord lesion or Parkinson’s disease was 89 (standard error=8) vs. 63 (standard error=17).

Sensitivity & Specificity:

Simone et al. (2011) examined the sensitivity and specificity of the ABILHAND in a sample of 126 patients with chronic upper limb impairment resulting from stroke, multiple sclerosis, sensory or cerebellar ataxia, spinal cord lesion or Parkinson’s disease, and 24 healthy subjects. An “impairment-normality” cut-off was computed through logistic regression and a lower cut-off score of 80/100 is proposed for healthy controls (area under ROC curve=0.9097, p<0.05). This allowed correct classification of patients vs. healthy controls with a 92% sensitivity rate and 80% specificity rate, whereby 82% of the sample was correctly classified.

References

  • Ashford, S., Slade, M., Malaprade, F., & Turner-Stokes, L. (2008). Evaluation of functional outcome measures for the hemiparetic upper limb: a systematic review. Journal of Rehabilitation Medicine, 40, 787-95.
  • Connell, L.A. & Tyson, S.F. (2012). Clinical reality of measuring upper-limb ability in neurological conditions: a systematic review. Archives of Physical Medicine and Rehabilitation, 93, 221-8.
  • Gustafsson, S., Sunnerhagen, K.S, & Dahlin-Ivanoff, D. (2004). Occupational therapists’ and patients’ perceptions of ABILHAND, a new assessment tool for measuring manual ability. Scandinavian Journal of Occupational Therapy, 11, 107-17.
  • Mpofu, E. & Oakland, T. (2010). Rehabilitation and Health Assessment: Applying ICF Guidelines. New York: Springer Publishing Company.
  • Penta, M., Tesio, L., Arnould, C., Zancan, A., & Thonnard, J-L. (2001). The ABILHAND questionnaire as a measure of manual ability in chronic stroke patients: Rasch-based validation and relationship to upper limb impairment. Stroke, 32, 1627-34.
  • Simone, A., Rota, V., Tesio, L., & Perucca, L. (2011). Generic ABILHAND questionnaire can measure manual ability across a variety of motor impairments. International Journal of Rehabilitation and Research, 34, 131-40.

See The Measure

How to obtain the ABILHAND:

The ABILHAND is available in Penta, M., Tesio, L., Arnould, C., Zancan, A., & Thonnard, J-L. (2001). The ABILHAND questionnaire as a measure of manual ability in chronic stroke patients: Rasch-based validation and relationship to upper limb impairment. Stroke, 32, 1627-34.

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