In standard therapy for injuries to the hand and upper extremity, therapists primarily pay attention to client-factor details such as strength, range of motion and sensation of the body part, with little focus on how deficits in those areas affect the client's life.
My stance has always been that when a therapist chooses first to understand how the condition is affecting the clients' ability to engage in meaningful and relevant occupations, she can easily establish goals that match the client's needs and drive the occupation-based approach. There are assessment tools that can facilitate this approach, including the Canadian Occupational Performance Measure (COPM) and the Disabilities of Arm, Shoulder and Hand Assessment (DASH).
Recently, I learned of a new tool that should become standard in all occupation-based hand therapists' toolboxes. The Manual Ability Measure-36 (MAM-36) was created by occupational therapist Dr. Christine Chen and colleagues. The assessment was originally described in 2005 in the Journal of Hand Surgery (British and European Volume), when it was called the Manual Ability Measure-16. The authors of the article examined the psychometric properties of the tool and concluded that (a) in as few as 16 items, the MAM can separate patients with hand conditions into several levels of manual abilities, and (b) correlations exist between manual abilities (as measured through the tool), physical function and general sense of well being.
The tool consists of two parts: a client demographic sheet, and a self-report task list consisting of items that clients rate on a 4-point scale based upon their perceived ability to complete the task. The rating scale ranges from 1, "cannot do," to 4, "easy." The zero option indicates "almost never do (even prior to condition)." Initially, the tool had 83 items; these were reduced using statistical modeling methodology also known as the Rasch measurement model. It was originally pilot-tested with patients who had hand/UE injuries. Since the time of the original pilot study, the MAM has been validated with several other patient populations using the current 36-item version (36 items out of the 83-item item bank). Dr. Chen recently added a visual analog pain scale and a column to indicate if a task is being completed with the opposite hand.
Compared to other tools, the MAM-36 takes a more positive wellness stance and looks at function versus dysfunction. The client scores higher when higher levels of function are present; other tools, such as the DASH, focus on what the client cannot do and therefore yield higher scores for higher levels of dysfunction.
Several articles have further supported the validity and reliability of the MAM-36. Recent articles also support the use of the MAM-36 for assessing the functional abilities of clients experiencing conditions other than the typical musculoskeletal conditions of the hand and upper extremity. Studies have looked at use of the MAM-36 with clients experiencing residual weakness and dysfunction due to CVA, as well as clients with diminished strength, sensation and coordination secondary to multiple sclerosis. This broader focus makes the tool an excellent choice for not only the orthopedic-based hand clinic, but for general occupational therapy clinics as well.
I find it most interesting that clients with chronic conditions have reported greater functional ability than those with more acute conditions. The authors speculate that clients who realize their condition is permanent are more likely to adopt adaptations and compensations; those with acute injuries experience greater degrees of dysfunction but with the belief that the condition is temporary; they also may have been told to rest their hands during the time of healing.
Scholars researching the strength of the MAM also found, through interviewing study participants, that the reasons for difficulties with certain tasks vary greatly based on the diagnosis and the individual. For example, clients have varying degrees of ability to independently compensate for their loss of factor-level hand skills; some compensate easily using techniques and strategies; others do not. Some readily use an unaffected hand and consider tasks easy to do; others do not. Those who must use a stronger hand to operate an assistive walking device such as a cane do not report an easy time with many tasks due to the need to manage the cane and complete the task simultaneously.
Therapists can learn much by using the MAM-36 in the hand rehabilitation clinic. The overall function of the client and changes over time can be easily discerned through the scoring of this psychometrically sound tool. Following the assessment, the therapist should interview the client to inquire about factors that are creating dysfunction. This can lead to a focus on environmental modifications and other compensations/adaptations that can immediately enhance occupational engagement. The client and OT also can explore other contextual factors, such as additional causes for dysfunction; these may be overlooked when therapists rely on reductionist assessments that only look at neuromusculoskeletal client factors.
Dr. Chen is very interested in working with occupational therapy practitioners who can assist her with data collection as she continues to validate and explore uses for this exceptional tool. Contact her at email@example.com.
Debbie Amini, EdD, OTR/L, CHT, is director of the occupational therapy assistant program at Cape Fear Community College in Wilmington, NC. A 1983 graduate of Quinnipiac University, Hamden, CT, she has been a clinical occupational therapist specializing in hand therapy for 19 years. Readers may reach her at 910-362-7096, by e-mail at firstname.lastname@example.org or through ADVANCE at email@example.com.