All articles are permanently available online to the public without restrictions or subscription fees. All articles are free to be used, cited, and distributed, on condition that appropriate acknowledgment is included. Authors are the copyright holders of their original contributions and grant the Canadian Online Publication Group (COPG) a license to publish the article and identify itself as the original publisher. CPOJ articles are licensed under the Creative Commons Attribution 4.0 International License. CPOJ Website: https://jps.library.utoronto.ca/index.php/cpoj/index Editorial Office: cpoj@online-publication.com ISSN: 2561-987X CPOJ is a member of, and subscribes to the principles of, the Committee on Publication Ethics (COPE). VOLUME 5, ISSUE 2 2022 LITERATURE REVIEW Carlyle K, Day S. Outcome measures used to assess hand activity in amputee and intact populations: A literature review. Canadian Prosthetics & Orthotics Journal. 2022; Volume 5, Issue 2, No.4. https://doi.org/10.33137/cpoj.v5i2.39023 https://online-publication.com/wp/ http://creativecommons.org/licenses/by/4.0/ https://jps.library.utoronto.ca/index.php/cpoj/index mailto:cpoj@online-publication.com https://publicationethics.org/about/our-organisation https://publicationethics.org/members/canadian-prosthetics-orthotics-journal https://doi.org/10.33137/cpoj.v5i2.39023 1 Carlyle K, Day S. Outcome measures used to assess hand activity in amputee and intact populations: A literature review. Canadian Prosthetics & Orthotics Journal. 2022; Volume 5, Issue 2, No.4. https://doi.org/10.33137/cpoj.v5i2.39023 LITERATURE REVIEW OUTCOME MEASURES USED TO ASSESS HAND ACTIVITY IN AMPUTEE AND INTACT POPULATIONS: A LITERATURE REVIEW Carlyle K1,2*, Day S1 1 Department of Biomedical Engineering, Faculty of Engineering, University of Strathclyde, Glasgow, United Kingdom. 2 EPSRC Centre for Doctoral Training in Prosthetics and Orthotics, University of Salford, United Kingdom. INTRODUCTION The hand is a complex structure responsible for powerful prehension and precise control. The range and adaptability achieved by the hand is due to the complex anatomical structure and precise control of movement and feedback by the central nervous system.1 Hands are capable of determining information by allowing identification of objects by their size, shape, surface, weight, texture, and thermal properties.2 Moreover, hands are crucial as terminal end- effectors in enabling people to carry out activities of daily living (ADL) and participate in society.3 They are vital for carrying out basic ADL such as feeding, dressing, and hygiene. Additionally, hands can be used as communication tools as demonstrated through the use of sign language and touch reading, and creative tools in music and dance. If the hand is incapacitated due to trauma, tumour, infection, peripheral vascular disease, or congenital anomaly, then amputation may be the result. Roughly five to six thousand amputations are undertaken in the United Kingdom each year.4 Of these amputations, roughly one fifth are upper limb amputations.5 A solution to assist those with amputation in carrying out ADL lies in prosthetic devices. It has been noted that statistics relevant to the prevalence of limb amputation and prosthetic device provision are limited and often inconsistent.6 Studies have also shown that hand prostheses prescribed to users are not reaching their OPEN ACCESS ABSTRACT BACKGROUND: The human hand is critical in assisting with activities of daily living (ADL). Amputation of the hand can affect a person physically, socially and psychologically. Knowledge of outcome measures used to assess upper limb activity of intact and amputee populations may aid in guiding research to develop applicable measurement tools specific to the amputee population. Tools could aid developments in prosthetic design and prescription, which benefit both users and healthcare researchers. OBJECTIVE(S): This literature review examined outcome measurement tools used with non-amputee and amputee populations to assess hand activity. The objectives were to identify which characteristics of hand activity are captured by currently available measurement tools. METHODOLOGY: Searches were conducted using PubMed, Cochrane and ProQuest for studies investigating hand activity for amputee and non-amputee populations. A total of 15 studies were included. PRISMA guidelines were used to assist with study selection. Data extraction and narrative synthesis were carried out. FINDINGS: A total of 32 outcome measures were found. Frequently used tools were: Box and Block Test, Swedish Disabilities of the Arm Shoulder and Hand Questionnaire, and range of motion. Studies employed a combination of 2 to 12 tools. Themes extracted were: importance of function and quality of life, the need for realistic tasks, and the need for outcome measures specific of the population. CONCLUSION: There is a gap in research surrounding outcome measurement tools used to assess hand activity in the amputee population. A combination of outcome measures are required to obtain insight into the hand activities of intact and amputee populations. Function and quality of life are important aspects to consider when describing hand activity. ARTICLE INFO Received: July 22, 2022 Accepted: December 12, 2022 Published: December 25, 2022 CITATION Carlyle K, Day S. Outcome measures used to assess hand activity in amputee and intact populations: A literature review. Canadian Prosthetics & Orthotics Journal. 2022; Volume 5, Issue 2, No.4. https://doi.org/10.33137/cpoj.v5i2.3 9023 KEYWORDS Outcome Measures, Healthcare, Amputee, Upper Limb, Amputation, Rehabilitation, Prosthetics * CORRESPONDING AUTHOR: Kirsty Carlyle, MEng Department of Biomedical Engineering, Faculty of Engineering, University of Strathclyde, Glasgow, United Kingdom. Email: kirsty.carlyle@strath.ac.uk ORCID ID: https://orcid.org/0000-0002-0291-4717 Journal Homepage: https://jps.library.utoronto.ca/index.php/cpoj/index Volume 5, Issue 2, Article No.4. 2022 https://doi.org/10.33137/cpoj.v5i2.39023 https://doi.org/10.33137/cpoj.v5i2.39023 https://doi.org/10.33137/cpoj.v5i2.39023 mailto:kirsty.carlyle@strath.ac.uk https://orcid.org/0000-0002-0291-4717 https://jps.library.utoronto.ca/index.php/cpoj/index 2 Carlyle K, Day S. Outcome measures used to assess hand activity in amputee and intact populations: A literature review. Canadian Prosthetics & Orthotics Journal. 2022; Volume 5, Issue 2, No.4. https://doi.org/10.33137/cpoj.v5i2.39023 CANADIAN PROSTHETICS & ORTHOTICS JOURNAL ISSN: 2561-987X OUTCOME MEASURES USED TO ASSESS HAND ACTIVITY Carlyle and Day, 2022 desired potential as users find them difficult to control and not fully functional.6 Despite advancements in prosthetic technology, people with amputations have significantly high rates of device rejection compared to other levels of prosthetic use.7 There are a range of devices and options available to people with amputation and their clinicians, however, more knowledge with respect to prosthetic performance may allow better prescription and design of prosthetics. Recording patient and user outcomes is a recognised means of driving further research and development of technology.8 Outcome measurement tools have been used widely in research to assess limb activity. Such tools include quantitative functional tests and qualitative questionnaires. For health practitioners, standardised outcome measure- ment tools may allow them to better prescribe treatments for their patients. This review contributes to healthcare research by reviewing the current state-of-the-art outcome measures used to assess hand activities. The review has an overarching aim of providing a basis for further research into outcome measurement tools for assessing real world use of upper limb prosthetics. The specific aim is to examine outcome measurement tools used to assess hand activities as no such review exists in the literature. The review achieves this by meeting the following objectives: • Evaluating the range of existing outcome measurement tools for intact and amputee populations when assessing hand activity • Examining and comparing various outcome measurement tools used for hand activities. METHODOLOGY Reporting findings in a non-biased, usable format aids in advancing research and informing clinical decision making in the field of prosthetics and orthotics, and related fields. Since qualitative and quantitative tools are used to report outcome measures related to hand activity, a literature review was selected as a strong approach to synthesise such data and put it into context.9 Due to the different natures of the outcome measures expected to be found in the review, a narrative synthesis was performed to summarise data.10 The literature review was conducted in accordance with PRISMA guidelines11 as shown in Figure 1. Searches were run in PubMed, Cochrane, ProQuest databases. Relevant keywords used in the search were ("outcome measures" OR "outcome measurement tool" OR "outcome measurement tools" OR "outcome measurement") AND ("hand activity" OR "hand activities" OR "hand function") AND (function* OR "quality of life" OR satisfaction) AND (amputee OR intact OR amputation) NOT (foot OR feet OR lower limb). Results were filtered to meet the following inclusion criteria: written in English, including adult human participants, published between August 2009 and August 2021. Duplicates were removed. Study titles were screened and excluded if they reported on children, measurement tools that focus on arm movement (not hands), interventions not specific to population, feasibility studies and participants with neurological conditions without involvement of healthy controls. The following types of study were excluded: systematic reviews, pilot studies, protocol developments, narrative reviews, feasibility studies and non-peer reviewed articles. Systematic reviews were excluded so the study only considered original research. Studies were included if they reported outcome measures and tools to assess adult human hand function and quality of life of unilateral upper limb amputees, bilateral upper limb amputees and the intact population. Abstracts were screened from studies which passed or remained unclear following title screening. Full texts were obtained from studies which passed or remained unclear following screening. Full text screening was then conducted. The final studies were assessed for quality using a method derived from the CASP checklists.12 This method involved applying a set of questions to each study which took into account the validity of results, risk of bias, quality of data, ethical considerations and the applicability of results in the context of the research question and study population (Table 1). Figure 1: Study selection flowchart. Records identified from databases (n = 761) Records removed before screening: Records marked as ineligible by automation tools (n = 382) Records screened (n = 379) Records excluded (n = 330) Full-text articles assessed for eligibility (n = 49) Reports excluded: - Wrong population (n = 20) - Wrong study focus (n = 6) - Live trial with no results published (n = 3) - Wrong study type (n = 3) - Wrong intervention (n = 1) - Limited data (n = 1) Studies included in this review (n = 15) Identification of studies via databases and registers Id e n ti fi c a ti o n S c re e n in g In c lu d e d https://doi.org/10.33137/cpoj.v5i2.39023 3 Carlyle K, Day S. Outcome measures used to assess hand activity in amputee and intact populations: A literature review. Canadian Prosthetics & Orthotics Journal. 2022; Volume 5, Issue 2, No.4. https://doi.org/10.33137/cpoj.v5i2.39023 CANADIAN PROSTHETICS & ORTHOTICS JOURNAL ISSN: 2561-987X OUTCOME MEASURES USED TO ASSESS HAND ACTIVITY Carlyle and Day, 2022 Ethical approval was not required to complete this review as no subject participation or handling of sensitive information were carried out. Ethics surrounding the studies included in this review were considered. All studies involving subjects and confidential information were checked to ensure quality data was collected with appropriate ethical approval. Data Analysis All outcome measures used in each study were recorded and the frequency of use of each outcome measure was noted. Modified or adapted versions of tools - such as the original DASH and QuickDASH – were grouped together. Measures which were similar in nature through describing the same variables were grouped together. Strength variables such as grip strength and precision force were grouped together to represent force control (FC). Joint angle measures were grouped together (ROM). Shape texture identification test and self-rating of tactile gnosis were grouped together (tactile gnosis/TG). Upper extremity functional scale and patient specific functional scales were grouped together (functional scales/FS). Duration of hand movements and task movement times were grouped together (temporal measures/TM). Outcome measures were also grouped into the following types: ‘functional’, ‘quality of life (QoL)’ and ‘functional and QoL’ measures. Narrative synthesis was carried out with the aid of thematic analysis to determine themes. RESULTS Following searching and screening, 15 studies were reviewed (Table 2). A data extraction table (Table 3) was used to record number of outcome measures, types of outcome measures, participant demographics and ethical considerations. Table 1: Quality appraisal checklist. Author (year) S o b u h e t a l. , (2 0 1 4 )1 3 L a w re n c e e t a l. , (2 0 1 5 )1 4 R e s n ik a n d B o rg ia ( 2 0 1 6 )1 5 R a v e h e t a l. , (2 0 1 8 )1 6 L e e e t a l. , (2 0 2 0 )1 7 E k lu n d e t a l. , (2 0 0 9 )1 8 H ru b y e t a l. , (2 0 1 9 )1 9 R e s n ik e t a l. , (2 0 2 0 )2 0 R e s n ik e t a l. , (2 0 2 0 )2 1 S p e th e t a l. , (2 0 2 0 )2 2 W a n g e t a l. , (2 0 2 1 )2 3 H ru b y e t a l. , (2 0 1 7 )2 4 d e B o e r e t a l. , (2 0 1 6 )2 5 B o u m a e t a l. , (2 0 1 8 )2 6 B e rn a rd o n e t a l. , (2 0 1 5 )2 7 Did the study address a clearly focused research question? Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Was the recruitment strategy appropriate to the aims? Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Are there any conflicts of interest? N N N N N N N Y (declared financial grant) N Y (declared financial grant) N N N N N Was there a clearly defined study protocol? Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Do the benefits of the experimental intervention outweigh the harms and costs? Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Have ethical issues been taken into consideration? Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Is there a clear statement of findings? Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Can the results be applied to the context of hand and upper limb activity? Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Does the study find anything new or useful? Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y https://doi.org/10.33137/cpoj.v5i2.39023 4 Carlyle K, Day S. Outcome measures used to assess hand activity in amputee and intact populations: A literature review. Canadian Prosthetics & Orthotics Journal. 2022; Volume 5, Issue 2, No.4. https://doi.org/10.33137/cpoj.v5i2.39023 CANADIAN PROSTHETICS & ORTHOTICS JOURNAL ISSN: 2561-987X OUTCOME MEASURES USED TO ASSESS HAND ACTIVITY Carlyle and Day, 2022 Table 2: List of included papers Authors Title Year Sobuh et al., 13 Visuomotor behaviours when using a myoelectric prosthesis 2014 Lawrence et al., 14 Outcome measures for hand function naturally reveal three latent domains in older adults: strength, coordinated upper extremity function, and sensorimotor processing 2015 Resnik and Borgia 15 Responsiveness of outcome measures for upper limb prosthetic rehabilitation 2016 Raveh et al., 16 Myoelectric prosthesis users improve performance time and accuracy using vibrotactile feedback when visual feedback is disturbed 2018 Lee et al., 17 Clip-On IMU system for assessing age-related changes in hand functions 2020 Eklund et al., 18 Hand function and disability of the arm, shoulder and hand in Charcot-Marie-Tooth disease 2009 Hruby et al., 19 Bionic upper limb reconstruction: a valuable alternative in global brachial plexus avulsion injuries-a case series 2019 Resnik et al., 20 A national survey of prosthesis use in veterans with major upper limb amputation: comparisons by gender 2020 Resnik et al., 21 Function and quality of life of unilateral major upper limb amputees: effect of prosthesis use and type 2020 Speth et al., 22 Assessment of tree-based statistical learning to estimate optimal personalized treatment decision rules for traumatic finger amputations 2020 Wang et al., 23 Application of machine learning to the identification of joint degrees of freedom involved in abnormal movement during upper limb prosthesis use 2021 Hruby et al., 24 Algorithm for bionic hand reconstruction in patients with global brachial plexopathies 2017 de Boer et al., 25 Intermanual transfer effects in below-elbow myoelectric prosthesis users 2016 Bouma et al., 26 Musculoskeletal complaints in individuals with finger or partial hand amputations in the Netherlands: a cross-sectional study 2018 Bernardon et al., 27 Bilateral hand transplantation: functional benefits assessment in five patients with a mean follow-up of 7.6 years (range 4- 13 years) 2015 Table 3: Data extraction table. Authors/ year Title Ethical Concerns? Type of Study Participant Demographics Number of Participants Intact, amputee, prosthesis user or combination Setting Self-reported, clinician observed or combination? Sobuh et al., 2014 13 Visuomotor behaviours when using a myoelectric prosthesis No quantitative intact adults and adult myoelectric prosthesis users 11 combination (intact and prosthesis user) university clinician observed Lawrence et al., 2015 14 Outcome measures for hand function naturally reveal three latent domains in older adults: strength, coordinated upper extremity function, and sensorimotor processing No quantitative healthy older adults and older adults with osteoarthritis of the CMC joint 99 intact university/rehab centre clinician observed Resnik and Borgia, 2016 15 Responsiveness of outcome measures for upper limb prosthetic rehabilitation No quasi- experiment al study adult upper limb amputees 39 amputee veterans affairs sites combination Raveh et al., 2018 16 Myoelectric prosthesis users improve performance time and accuracy using vibrotactile feedback when visual feedback is disturbed No quantitative transradial amputees using a myoelectric prosthesis with normal or corrected eyesight 12 prosthesis user laboratory combination https://doi.org/10.33137/cpoj.v5i2.39023 5 Carlyle K, Day S. Outcome measures used to assess hand activity in amputee and intact populations: A literature review. Canadian Prosthetics & Orthotics Journal. 2022; Volume 5, Issue 2, No.4. https://doi.org/10.33137/cpoj.v5i2.39023 CANADIAN PROSTHETICS & ORTHOTICS JOURNAL ISSN: 2561-987X OUTCOME MEASURES USED TO ASSESS HAND ACTIVITY Carlyle and Day, 2022 Table 3: Data extraction table (continued) Authors/ year Title Ethical Concerns? Type of Study Participant Demographics Number of Participants Intact, amputee, prosthesis user or combination Setting Self-reported, clinician observed or combination? Lee et al., 2020 17 Clip-On IMU system for assessing age- related changes in hand functions No quantitative healthy adults (aged 20-31 and 75-89) 34 intact university clinician observed Eklund et al., 2009 18 Hand function and disability of the arm, shoulder and hand in charcot- marie-tooth disease No quantitative adults with charcot marie tooth and healthy controls 60 intact hospitals/clinics combination Hruby et al., 2019 19 Bionic upper limb reconstruction: a valuable alternative in global brachial plexus avulsion injuries-a case series No quantitative adults with complete bracial plexus injury who underwent bionic reconstruction after high level upper limb amputation 5 prosthesis user university combination Resnik et al., 2020 20 A national survey of prosthesis use in veterans with major upper limb amputation: comparisons by gender No cross- sectional survey adult veterans with upper limb amputation who had been treated between 2010 and 2015 808 amputee telephone survey self-reported Resnik et al., 2020 21 Function and quality of life of unilateral major upper limb amputees: effect of prosthesis use and type No cross- sectional survey adult veterans with unilateral upper limb amputation who had been treated between 2010 and 2015 755 amputee telephone survey self-reported Speth et al., 2020 22 Assessment of tree-based statistical learning to estimate optimal personalized treatment decision rules for traumatic finger amputations No cohort study adult patients who underwent revision amputation or replantation 185 amputee various research centres combination Wang et al., 2021 23 Application of machine learning to the identification of joint degrees of freedom involved in abnormal movement during upper limb prosthesis use No quantitative adults with no upper limb disability, trained on deka bypass or body powered bypass 24 intact laboratory clinician observed Hruby et al., 2017 24 Algorithm for bionic hand reconstruction in patients with global brachial plexopathies No quantitative adults with posttraumatic global brachial plexopathies 5 prosthesis user university combination https://doi.org/10.33137/cpoj.v5i2.39023 6 Carlyle K, Day S. Outcome measures used to assess hand activity in amputee and intact populations: A literature review. Canadian Prosthetics & Orthotics Journal. 2022; Volume 5, Issue 2, No.4. https://doi.org/10.33137/cpoj.v5i2.39023 CANADIAN PROSTHETICS & ORTHOTICS JOURNAL ISSN: 2561-987X OUTCOME MEASURES USED TO ASSESS HAND ACTIVITY Carlyle and Day, 2022 Studies were published between the years 2009 and 2021. Across the studies, participants were categorised in the following populations: able bodied, able bodied using upper limb bypass equipment, upper limb prosthesis users; people with osteoarthritis, Charcot-Marie-Tooth disease, upper limb/finger/hand amputation and recipients of hand and forearm allotransplantation. Studies were conducted using intact only, intact and amputee/prosthesis user, and amputee/prosthesis user only populations. Studies involving participants with osteoarthritis and Charcot-Marie- Tooth used healthy controls, enabling their inclusion within the review. A total of 32 outcome measures were identified within the studies reviewed (Table 4). The most frequently used tools and measures, as shown in Figure 2, were the BBT (7), DASH (7), ROM (7) and FC (6). All studies used a combination of measures, ranging from 2 to 12 outcome measures assessed per study. The majority (59%) of outcome measures listed in Table 4 are functional based measures. While function-based outcome measures were more prevalent within studies, some outcome measurement tools (19%) assess both function and quality of life (Figure 3). The following quotes of relevance to the research topic were extracted from included studies: • "the most objective of the commonly used upper limb evaluation tools are based on time to perform a structured set of tasks, but use of these in isolation gives limited insight into ease of use of a prosthesis"13 • "the central question here is, what should we use to quantify hand function considering that we have so many choices of assessment tools and even more outcome measures stemming from these tools?"14 • "leaders in upper limb prosthetic rehabilitation understand the importance of choosing outcome measures that have been evaluated for persons with upper limb amputation and that are reliable, valid, and responsive to change"18 • “another important aspect in prosthetic rehabilitation research is the use of valid outcome measures"19 The following themes were derived from the papers in relation to assessing hand activity: the importance of function and quality of life, the need for realistic tasks, and the need for outcome measures specific to the population. DISCUSSION A The review depicts a range of outcome measures used to measure hand activity in amputee and intact populations. There was a clear indication that use of multiple outcome measures is optimum to evaluate hand activity. It could be true that it is difficult to select one tool due to lack of tools which bring together various aspects of hand activity such as function, pain, and satisfaction. Table 3: Data extraction table (continued) Authors/ year Title Ethical Concerns? Type of Study Participant Demographics Number of Participants Intact, amputee, prosthesis user or combination Setting Self-reported, clinician observed or combination? de Boer et al., 2016 25 Intermanual transfer effects in below-elbow myoelectric prosthesis users No case- control study myoelectric prosthesis users and controls 44 combination (intact and prosthesis user) university/rehab centre clinician observed Bouma et al., 2018 26 Musculoskeletal complaints in individuals with finger or partial hand amputations in the Netherlands: a cross- sectional study No cross- sectional study adult finger and hand amputees and healthy controls 201 combination (intact and amputee) questionnaire sent to participants self reported Bernardon et al., 2015 27 Bilateral hand transplantation: functional benefits assessment in five patients with a mean follow-up of 7.6 years No quantitative adults who underwent hand and forearm allotransplantation following trauma 5 intact (post transplantation) rehabilitation clinic combination https://doi.org/10.33137/cpoj.v5i2.39023 7 Carlyle K, Day S. Outcome measures used to assess hand activity in amputee and intact populations: A literature review. Canadian Prosthetics & Orthotics Journal. 2022; Volume 5, Issue 2, No.4. https://doi.org/10.33137/cpoj.v5i2.39023 CANADIAN PROSTHETICS & ORTHOTICS JOURNAL ISSN: 2561-987X OUTCOME MEASURES USED TO ASSESS HAND ACTIVITY Carlyle and Day, 2022 Table 4: List of outcome measures, acronyms, type and description of measures. Outcome Measure Acronym Type Description Box and Block test 28 BBT Functional Test of manual dexterity Swedish Disabilities of the Arm Shoulder and Hand Questionnaire 29 DASH Functional & QoL Self-reported measure of disability and symptoms in relation to the upper limb Range of Motion ROM Functional Measure of level of movement achieved Force Control FC Functional Measure of strength achieved Southampton Hand Assessment Procedure 30 SHAP Functional Test of hand function using abstract objects and ADL Orthotics and Prosthetics User's Survey 31 OPUS Functional & QoL Self-reported survey of outcomes and satisfaction with orthotic/prosthetic devices and services Tactile Gnosis TG Functional Ability to detect information through touch 9 Hole Peg test 32 9HPT Functional Measure of finger dexterity 36-Item Short Form Survey 33 SF-36 QoL Self-reported measure of quality of life Temporal measures TM Functional Time-based activities and tasks Edinburgh Handedness Inventory 34 EHI Functional Assessment of hand dominance Modified Action Research Arm test 35 mARAT Functional Assessment of hand function during grasp, pinch, grip and gross movements Visual Analogue Scale 36 VAS QoL Measure of severity of symptoms Trinity Amputation and Prosthetic Experience Scale 37 TAPES QoL Self-reported measure of experiences and satisfaction with regards to acquired amputation and prosthesis adjustment Veterans SF-12 Health Survey with physical and mental components 38 VR-12 Functional & QoL Self-reported measure of health Jebsen-Taylor Hand Function tests 39 JTHFT Functional Test of hand function carrying out a range of different ADL- based tasks Functional Scales FS Functional Measure of function Pain Pain QoL Assessment of patient/user pain Activity measure for upper limb amputation 40 AM-ULA Functional Measure of upper limb activity performance Michigan Hand Outcomes Questionnaire 41 MHQ Functional & QoL Self-reported measure of hand outcomes including pain, function, aesthetics, ADL, work and satisfaction Gaze Behaviour GB Functional Assessing visual responses during tasks University of New Brunswick Skill and Spontaneity tests 42 UNB-SST Functional Non-timed measure of function Prevalence of Musculoskeletal Complaints MSC QoL Self-reported indication of physical symptoms Upper extremity work demands score UEWD Functional & QoL Measure specifically related to work tasks Patient-reported work productivity PR-WP QoL Self-reported indication of level of ability to participate in work Modified Kapandji Index 43 mKI Functional Measure of hand mobility Carroll Upper Extremity Function test 44 UEFT Functional Measure of functional impairment and severity Purdue Pegboard test 45 PPT Functional Measure of gross upper limb movement and finger dexterity Self-subjective global evaluations SSGE QoL Self-reported measure of quality of life 400 Point Assessment 46 400-PA Functional Test of function in tasks, strength, mobility and handling Direct observation by therapist while performing tasks DTO Functional Clinician-researcher observing participant without using a specific measure Hand Transplantation Score System 47 HTSS Functional & QoL Measure of ability and quality of life following hand transplantation https://doi.org/10.33137/cpoj.v5i2.39023 8 Carlyle K, Day S. Outcome measures used to assess hand activity in amputee and intact populations: A literature review. Canadian Prosthetics & Orthotics Journal. 2022; Volume 5, Issue 2, No.4. https://doi.org/10.33137/cpoj.v5i2.39023 CANADIAN PROSTHETICS & ORTHOTICS JOURNAL ISSN: 2561-987X OUTCOME MEASURES USED TO ASSESS HAND ACTIVITY Carlyle and Day, 2022 Figure 2: Graph depicting number of times each outcome measure was used across the included studies. Figure 3: Pie chart showing that most outcome measures assess function, with a smaller proportion assessing QoL. The reason behind choice of tool may be due to location of the study – for example in-clinic or telephone surveys. Additionally, choice of tool may be a consequence of the fact that not all tools are validated for use in amputee populations. It is possible that researchers select tools based on personal preference rather than appropriateness. Tools involving participant-reporting of data may not reflect physical performance, thus may not be sufficient. Nonetheless, self-reported studies, which occur as surveys or interviews can attract larger sample sizes. No specific guidelines related to hand activities or therapy were highlighted within the included studies, emphasising the need for their development. There was a lack of diverse devices included in the studies with most studies involving prostheses featuring only myoelectric devices. Finally, there is limited information on outcome measures for cosmetic devices. Theme 1: The importance of function and quality of life when assessing hand activity A key theme was the value of both functional and quality of life assessments of hand activity. Despite this finding, 59% of outcome measures used were functional measures and only 22% quality of life measures. By using a combination of outcome measurement tools, the researchers were frequently able to capture functional, and quality of life data. However, there is no standard combination, or designed pairing of tools to obtain all information. This highlights the need for development of guidelines that are comparative of both contexts. While functional domains and tasks were considered repeatedly throughout studies, it is evident that these variables affect quality of life. These variables can affect ability to participate in work and social environments which subsequently attributes to an improved quality of life. Pain was another common theme found throughout studies. Pain should be considered throughout performance of various functional tasks as such tasks may conversely impair function. Presence of pain is likely to have a negative effect on quality of life. It is important to involve the participants’ self-reported outcomes of parameters such as pain to create a picture of their overall satisfaction. Nonetheless, self-reported outcomes are limited due to self- reporting bias. Outcome measures, which account for functional failures, may be advantageous in the amputee and prosthetic user population to account for actions such as failed prehension. This could provide key information about device performance as well as participant function. Theme 2: Need for realistic tasks when assessing hand activity Another major theme was the importance of ADL. Many of the functional outcome measures were used in combination with other tools to put function into context. Most of the studies investigating hand function, and the outcome measures included were structured in that the participants were given precise instructions to complete tasks. It must be noted that the ability to place pegs in a board, as required within the 9HPT and PPT, does not correlate to information about key parameters such as strength or function. Similarly this process does not correlate with the skill required to carry out typical ADL. Likewise, the BBT was one of the most frequently used measures and is simple to set up - but transferring blocks between compartments is one repetitive process which is not likely implemented in most ADL. An overlooked element is participant-led activities during assessment. In prosthetic user populations, it would be pragmatic to ask the participant to complete tasks with their prosthesis on and off to account for a range of scenarios. It should not be assumed that users wear their device consistently. Studies should include both unilateral and 19% 22%59% Ratio of function and QoL based outcome measure Function+QoL QoL Function 0 1 2 3 4 5 6 7 8 B B T D A S H R O M F C S H A P O P U S T G 9 H P T S F -3 6 T M E H I m A R A T V A S T A P E S V R -1 2 J T H F T F S P a in A M -U L A M H Q G B U N B -S S T M S C U E W D P R -W P M K I U E F T P P T S S G E 4 0 0 -P A D T O H T S S N u m b e r o f s tu d ie s u s in g o u tc o m e m e a s u re Outcome Measure FREQUENCY OF USE OF OUTCOME MEASURES https://doi.org/10.33137/cpoj.v5i2.39023 9 Carlyle K, Day S. Outcome measures used to assess hand activity in amputee and intact populations: A literature review. Canadian Prosthetics & Orthotics Journal. 2022; Volume 5, Issue 2, No.4. https://doi.org/10.33137/cpoj.v5i2.39023 CANADIAN PROSTHETICS & ORTHOTICS JOURNAL ISSN: 2561-987X OUTCOME MEASURES USED TO ASSESS HAND ACTIVITY Carlyle and Day, 2022 bilateral tasks to represent a wider range of real-life scenarios. In addition, most studies were carried out in research laboratories, clinics, and universities. This means the researcher has control within the study and this weakens the link between the hand activities and real-world applications. Shifting from basic tasks to real world object manipulation, such as turning keys or picking up a mug, would provide an extra dimension in relating clinical studies to applications in the real world. Theme 3: Need for outcome measures specific to population Different populations are known to have different key components of hand function, so the focus of functional assessment tools should be tailored to the prosthesis user population. It was also highlighted within the reviews that people value parameters differently, for example dexterity may be of more importance than strength. It would be advantageous to understand the parameters which are of importance to prosthesis users before using tools to assess hand activity. Performance-based outcome measures used to assess hand activity often compare the performance of an amputee or prosthesis user with the intact population. This is not an optimal comparison since the populations have various levels of function and goals. Low level strength is required to facilitate ADL and functional tasks, so people with amputation who may have a level of strength too low to carry out such tasks may be unable to be assessed with such tools. Also, there is a level of dexterity required for tools such as tactile gnosis assessments. If outcome measurement tools can only be used in populations with a baseline level of ability, then tools must be adapted or developed to involve people who do not satisfy this criterion. Further, many of the tools used are temporal based and therefore do not give indications into ease of use, which is an important parameter when investigating the amputee and prosthesis user populations. Another argument for using outcome measures specific to the population is that a specific measurement may alleviate the need for recruiting healthy, intact participants when researchers are interested in outcomes of amputee or prosthesis users only. Limitations A limitation of this review is that data from pilot studies, reviews and protocol development studies were not included. Therefore, outcome measures considered are not a comprehensive list. Inclusion was limited to studies published in more recent years to ensure conclusions were reflective of the current state of technology and practice. Studies which only included participants with neurological conditions were excluded to ensure the correct population was analysed. Studies which used stroke-specific tools were excluded as outcome measurement tool selection by the research may be biased towards the stroke population and thus not a true reflection of amputee or intact populations. Small sample sizes within many included studies are another limiting factor, as this restricts data available for assessment. Studies with larger sample sizes were self-reported surveys which are limited in terms of outcome measurement tools which can be used. Only one reviewer screened and selected articles for inclusion, thus presenting a potential element of bias in terms of study selection. CONCLUSION There is a definite gap in research surrounding outcome measurement tools used to assess hand activity in the amputee and prosthesis user population. Results from this review of outcome measures used in amputee and intact populations, showed that a combination of outcome measures are currently used to obtain insight into hand activities of intact and amputee populations. There are no set guidelines or recommended pairings of tools, and key information about hand activity could potentially be missed during investigations. The reason a combination of tools are used is partially because currently used outcome measurement tools are limited for use in amputee and prosthesis user populations. Some measurement tools were not validated for upper limb amputees, and some involving temporal based tasks may not have been appropriate for assessing function in prosthesis users. Additionally, combinations of tools are used because both function and quality of life measurements are deemed important. These aspects are of particular interest in amputee and prosthetic user populations where factors such as pain, social participation and satisfaction are of high importance to both the person themselves, healthcare practitioners and prosthesis developers. Tools should be developed with both functional and quality of life measurements taken into consideration as well as tasks which pose a likeness to carrying out ADL. Finally, tools should be developed specific to the population to ensure that measurements are valid, useful, and specific. ACKNOWLEDGEMENTS N/A DECLARATION OF CONFLICTING INTERESTS The Authors declare that there is no conflict of interest. AUTHORS CONTRIBUTION Kirsty Carlyle: Designed the research question and study design, conducted the literature search and study selection, writing the manuscript. Sarah Day: Designed the research question and study design, writing the manuscript. https://doi.org/10.33137/cpoj.v5i2.39023 10 Carlyle K, Day S. Outcome measures used to assess hand activity in amputee and intact populations: A literature review. Canadian Prosthetics & Orthotics Journal. 2022; Volume 5, Issue 2, No.4. https://doi.org/10.33137/cpoj.v5i2.39023 CANADIAN PROSTHETICS & ORTHOTICS JOURNAL ISSN: 2561-987X OUTCOME MEASURES USED TO ASSESS HAND ACTIVITY Carlyle and Day, 2022 SOURCES OF SUPPORT This work was supported by the UK Engineering and Physical Sciences Research Council (EPSRC) grant EP/S02249X/1 for the Centre for Doctoral Training in Prosthetics and Orthotics. ETHICAL APPROVAL Ethical approval was not needed. REFERENCES 1.Biryukova EV, Yourovskaya VZ. A Model of Human Hand Dynamics. In: Schuind F, An KN, Cooney WP, Garcia-Elias M. (eds) Advances in the Biomechanics of the Hand and Wrist. NATO ASI Series, 1994; vol 256. Springer, Boston, MA. DOI: 10.1007/978-1-4757-9107-5_11 2.Jones L, Lederman S. Human hand function. New York: Oxford, 2006. 3.Edemekong PF, Bomgaars DL, Sukumaran S, Schoo C. Activities of Daily Living. In: StatPearls [Internet]. 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