title: A simulation of hand impairments: effects on upper extremity function and implications toward medical impairment rating and disability determination.
abstract: OBJECTIVE
  To determine whether simulation of significant impairment of the hand will have a predictable impact on degree of functional loss at the wrist and hand.
  
  
  METHODS
  Single subject repeat measures using before-after trial comparisons and healthy volunteer subjects.
  
  
  METHODS
  Occupational therapy section of a large academic medical center.
  
  
  METHODS
  Twenty adult volunteer student subjects from an occupational therapy education (OTE) department were included. All were between ages 18 and 43 years, right hand dominant, and in excellent general health. There were 19 women and 1 man, reflecting gender distribution of the OTE student body.
  
  
  METHODS
  A simulated fusion of the carpometacarpal (CMC) joint of the thumb was achieved by immobilization in an individually fabricated splint designed to maximally restrict motion at the first CMC joint. Impairment ratings (baseline vs splinted) according to the AMA Guides were obtained by Greenleaf testing, and upper extremity function was quantitatively assessed before and after splinting.
  
  
  METHODS
  Measures of upper extremity function included grip and pinch strength, wrist torque, and speed of performance on the Valpar Small Tools test, Jebsen Hand Function test, and an exploratory measure, the Functional Life Activity Test (FLAT).
  
  
  RESULTS
  Significant impairments were achieved for all subjects after splinting and according to Greenleaf testing. Splinting resulted in significant reductions in grip and pinch strength, wrist torque, and significant slowing of performance on the Valpar, Jebsen, and FLAT tests. Regressions of degree of impairment on degree of functional loss after splinting, and according to each of the above measures, were not significant.
  
  
  CONCLUSIONS
  Impairment of the hand was simulated to a mild-to-moderate degree as measured according to the AMA Guides. This imposed significant reductions in motion at key joints of the wrist and hand as well as significant reductions in grip and pinch strength and wrist torque. A corresponding and significant slowing of performance on a variety of measures of upper extremity function of an industrial and nonindustrial nature was also seen. However, and for the first time, correlation and regression reveals that it is not possible to predict degree of functional loss attributable to degree of impairment for the hand. It thus appears that, for mild-to-moderate clinical impairments, the associated impairment rating is a poor estimator of functional loss at the hand and should be used cautiously, if at all, as a criterion for disability determination.
authors.affiliation: Department of Rehabilitation Medicine, University of Kansas Medical Center, Kansas City, USA.
authors.forename: R D
authors.initials: RD
authors.lastname: Rondinelli
authors.forename: W
authors.initials: W
authors.lastname: Dunn
authors.forename: K M
authors.initials: KM
authors.lastname: Hassanein
authors.forename: C A
authors.initials: CA
authors.lastname: Keesling
authors.forename: S C
authors.initials: SC
authors.lastname: Meredith
authors.forename: T L
authors.initials: TL
authors.lastname: Schulz
authors.forename: N J
authors.initials: NJ
authors.lastname: Lawrence
mesh_terms: D000203:Activities of Daily Living; D000293:Adolescent; D000328:Adult; D004185:Disability Evaluation; D005260:Female; D005384:Finger Joint / Q000503:physiopathology; D006230:Hand Injuries / Q000503:physiopathology / Q000534:rehabilitation*; D006801:Humans; D008297:Male; D016544:Patient Simulation; D016059:Range of Motion, Articular; D014955:Wrist Joint / Q000503:physiopathology