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Correspondence and reprint requests to Kathleen E. Yancosek, PhD, OTR/L, CHT, 15 Kansas St, Bldg #42, United States Army Institute of Environmental Medicine, Natick, MA 01760.
To describe current practice patterns in hand therapy to 1) gain insights into beliefs of certified hand therapists (CHTs) related to initiating a hand dominance transfer, 2) describe CHTs’ clinical decision-making strategies, and 3) describe research priorities related to hand dominance transfer in hand therapy.
Participants
Five hundred sixty-three members of the American Society of Hand Therapists.
Methods
The online Internet survey contained 30 questions related to four categories: 1) demographics of clinicians, 2) beliefs about hand dominance transfer, 3) clinical strategies and decision making, and 4) a research agenda related to hand dominance transfer. Data were sorted, compiled, and analyzed descriptively.
Results
Respondents were primarily occupational therapists working as full-time staff therapists treating between nine and 15 patients per day with orthopedic injuries to the dominant upper extremity caused by trauma. The overwhelming majority of respondents (92.7%) believed that motivation is a factor in the success of the hand dominance transfer. Most respondents (83%) do not directly initiate a hand dominance transfer. The number one reason (64%) for not initiating a dominance transfer is that CHTs believe that their patients will regain full recovery of injured hand over time. If a transfer is initiated, the number one task addressed is handwriting (62%); the most commonly recommended piece of adaptive equipment was the handsfree can opener (63.8%); 72% educate on the risk of overuse injury to the noninjured (intact) limb. Most respondents agreed or strongly agreed that more research needs to be done related to hand dominance transfer, specifically related to return to work rates, interventions using virtual reality, and assessments using neuroimaging technologies.
Level of Evidence
3b.
Injury-induced hand dominance transfer (I-IHDT) is a forced shift of hand dominance after injury.
The transfer to the nondominant hand is imposed on a person after an insult to the central or peripheral nervous systems or musculoskeletal systems. Persons with unilateral dexterity loss of the dominant limb face a double-impact injury: they are left in a functional state of single-handedness and they are at a neuromotor disadvantage because of losing the stronger,
Because of this, I-IHDT is an area of concern for certified hand therapists (CHTs) who provide rehabilitation services to persons with upper limb injuries.
Background
The body of literature related to the management of dominant hand injuries
is limited. Therefore, questions remain as to how and when to best facilitate a hand dominance transfer. Currently, it is likely that CHTs rely on the following treatment approaches: 1) direct rehabilitation to the significantly injured side or, in case of amputation, instruction in the replacement of function with a prosthesis, 2) augmenting the functional loss with adaptive equipment/teach one-handed performance of motor skills, 3) training the contralateral (previously nondominant) limb to assume dominant hand functions (speed, dexterity, strength, endurance), or 4) a hybrid of treatment approaches.
There are innate differences in hand function influenced by hand dominance.
Although most activities are accomplished bimanually, the dominant hand acts as the more dexterous main executor, whereas the nondominant hand acts as supporter.
The EFFUL (Evaluation of Function in the Flail Upper Limb) system. A ranking score system to measure improvement achieved by surgical reconstruction and rehabilitation.
Dominant hand dexterity loss may be temporary (immobilization due to bone or soft-tissue injuries) or permanent (e.g., amputation, brachial plexus injury, hemiparesis, or complex regional pain syndrome).
Severity and specificity of neglect-like symptoms in patients with complex regional pain syndrome (CRPS) compared to chronic limb pain of other origins.
The purpose of this descriptive report is to describe current practice patterns in hand therapy for the management of injuries affecting the dominant upper extremity. The specific objectives were to 1) gain insights into the beliefs of CHTs related to initiating a hand dominance transfer in patients with dominant upper extremity injuries, 2) describe CHTs’ clinical decision-making strategies related to management of I-IHDT, and 3) describe possible research priorities related to hand dominance transfer in hand therapy.
Methodology
Design and Participants
Descriptive findings from this study resulted from an online Internet survey. Approval for the study was obtained from the local office of research quality control. An e-mail invitation to participate in the survey was sent to 2,547 (national and international) members of the American Society of Hand Therapists (ASHT).
Procedure
Potential respondents had seven days to access the survey Web site via a personal identification number (PIN) that was provided in the e-mail. Based on PIN access tracking, on day 14, a reminder e-mail was sent to those ASHT members who had not responded to the survey.
The survey was developed by the author as part of a university course in Clinical and Translational Science. The survey was pilot tested with five therapists at a large academic medical center and with five therapists at a professional meeting in 2010. Feedback from the pilot contributed to rewording of questions to improve clarity and obtain information on the time required to complete the survey.
The survey included 30 questions related to four categories: 1) demographics of clinicians, 2) beliefs about hand dominance transfer, 3) clinical strategies and decision making, and 4) a research agenda related to hand dominance transfer. Data were sorted, compiled, and analyzed descriptively. After primary analysis, data were sorted into two groups and examined. Group 1 represented those CHTs who direct and initiate hand dominance transfer, and group 2 represented those who do not directly initiate hand dominance transfer. Data are herein described and presented as frequency distributions. Differences between group 1 and group 2 are presented in the final Results section of this article.
Results
Category 1: Demographics of Respondents
The survey was successfully received by 2,526 ASHT members (21 surveys were returned because of erroneous e-mail addresses). There were 563 respondents (a 22% response rate). Eighty-six percent of respondents were occupational therapists (OTs), 29% had more than ten years of clinical experience, and 60% had more than 20 years of experience. Eighty-nine percent of respondents reported spending greater than 75% of their workday treating clients with upper extremity injuries, and 7% reported spending greater than 50% of their workday treating clients with upper extremity injuries. The primary category type of injury the respondents treated was 99% orthopedic (neuromusculoskeletal) and 1% neurological. The primary cause of injury was trauma (49.7%), followed by cumulative trauma/repetitive stress (31.4%), sports/activity injury (14.2%), metabolic (3.7%), and less than 1% for autoimmune or congenital. Seventy-nine percent of respondents reported that more than half of the patients they treat have an injury to their dominant upper extremity.
When asked about current work setting, more than half of respondents reported working in an outpatient clinic (Figure 1). Less than 10% selected “Other” and described other as industry, research, or academic setting, physician-owned practice, Veteran Affairs Medical Center, deployed military setting, and pediatric clinic. Figure 1 also shows the respondents’ various roles, the different types of work setting and schedules, and the average number of patients seen per day. Most respondents work as full-time staff therapists in outpatient clinics, treating between nine and 15 patients per day.
Figure 1Description of work setting, role, schedule, and patients seen per day of respondents.
More than half (53.1%) of respondents agreed or strongly agreed that adults with traumatic amputations of all or part of the dominant hand must undergo hand dominance transfer because most prostheses do not allow for a sophisticated array of fine sensorimotor abilities. Similarly, 54.8% agreed or strongly agreed that adults with traumatic amputation of all or part of the dominant hand will experience a hand dominance transfer differently than clients with a physically intact but nonfunctional limb (such as those with a brachial plexus avulsion injury).
Respondents were asked to comment (Yes, No, or Unsure) on whether they believed that various factors improve a client’s ability to transfer hand dominance. Figure 2 shows that most CHTs agreed (i.e., selected “Yes”) that motivation, intact cognition, and work demands are factors that contribute to initiating a hand dominance transfer. Likewise, there was strong agreement (i.e., selected “No”) that race, social status, and gender are factors that do not contribute to a hand dominance transfer. The factor that received the highest percentage of answers of “Unsure” was culture. See Figure 2 for the comprehensive list of factors presented to respondents.
Figure 2Responses to the question “In your experience, what factors improve a client’s ability to transfer hand dominance?” presented as percent of respondents who answered “yes,” “no,” or “unsure” to each factor.
In this section of the survey, four respondents selected “other.” One respondent wrote that his or her belief is that if a patient can translate an object from the palm to the fingertips, that is a “sign” of a positive prognosis for recovery of dominant hand functions. One respondent wrote that clients would not want to work on hand dominance transfer until all the recovery was maximized in the injured limb. Two respondents wrote that working on hand dominance transfer would slow down the recovery of function in the injured limb.
Category 3: Clinical Strategies and Decision Making
Respondents selected “Yes” or “No” to each of four possible methods of evaluating hand dominance: 540 respondents selected “Yes” to Ask client to report dominant hand, 128 respondents selected “Yes” to Observation of movement, one respondent selected “Yes” to Laterality quotient instrument, and 68 selected “Yes” to Compare right to left scores on a standardized strength or motor assessment.
When asked whether or not they directly initiate hand dominance transfer when working with a client who has a dominant hand injury, 83% selected “No.” Reasons for not initiating a hand dominance transfer were the following: 1) Most of my clients will regain full function of the dominant hand (64%), 2) I have limited time with my clients and choose to focus that time on recovery of the injured hand (21%), 3) I assume the client has been slowly transferring hand dominance throughout his/her recovery time frame (18%), and 4) There is no standard protocol to follow (9%). If a hand dominance transfer is initiated, the most common factors reported to influence a clinician’s decision as to the best time were 1) prognosis/injury severity, 2) client’s functional level, and 3) client’s request.
Twelve functional dexterity tasks were presented to CHTs (Figure 3), and when asked which fine motor tasks they address in a hand dominance transfer intervention, therapists most commonly selected handwriting (62%). Some respondents checked the “Other” box and wrote in the following tasks that they use to address a loss of dominant hand function: driving, using a phone, house cleaning, shoveling snow, raking, and computer mouse use.
Figure 3Response to the question “When working with a client with a dominant hand injury do you directly address the following fine motor, functional dexterity tasks in your hand dominance transfer program?” presented as percent of respondents who answered “yes,” “no,” or “depends” to each task.
Twelve examples of adaptive equipment were presented to respondents (Figure 4). Results indicated that the three most commonly recommended were 1) handsfree can opener, 2) rocker knife, and 3) button hook. Related to the timing of recommending or issuing adaptive equipment, most respondents (43%) wait several weeks to see how much hand function returns before making a recommendation; other respondents make recommendations immediately (14%); wait only several days (27%); or make no recommendations at all (16%). Most respondents reportedly do not directly initiate a hand dominance transfer; however, 72% educate their clients about the increased risk to the noninjured (intact/sound) limb.
Figure 4Response to the question “When you are working with a client who has a unilateral injury, do you provide or recommend the following adaptive equipment?” presented as percent of respondents who answered “yes,” “no,” or “unfamiliar” to each piece of equipment.
Most respondents (69.4%) agreed or strongly agreed that research funding and resources should be provided to more fully investigate hand dominance transfer in injured adults. Seventy-six percent of respondents agreed or strongly agreed that 1) rehabilitation scientists should investigate the factors that help facilitate a successful hand dominance transfer and 2) clinical care pathways should be developed to assist therapists in facilitating hand dominance transfer in injured adult clients. Seventy-one percent (71.2%) agree or strongly agree that neuroimaging techniques should be used to examine the changes in the brain after peripheral injuries that permanently impair dominant hand function. Eighty percent (80.4%) agreed or strongly agreed that rehabilitation scientists should investigate the return to work rates of those who lose dominant hand function. Sixty-six percent (66.3%) agreed or strongly agreed that rehabilitation scientists should investigate virtual reality interventions to assist clients with hand dominance transfer (Figure 5).
Figure 5Responses to statements about topics that rehabilitation scientists should investigate with each statement listed.
Group 1 reported directly initiating hand dominance transfer (N=98), and group 2 reportedly did not (N=465). Data were converted to percentages and compared; differences greater than 10% were considered meaningful and are herein described. The demographics of the two groups were similar, except that group 1 reported seeing more patients injured from trauma (58.2%) than group 2 (48.0%). When it came to recommending adaptive equipment, group 1 was more familiar with all of the equipment, with the exception of the Knork™, and recommended or provided more equipment than group 2, but no group difference was greater than 10%.
Group 1 was more likely to select “Yes” in using the following tasks as part of their rehabilitation care plan: handwriting (group 1: 73% and group 2: 60%), work tasks (group 1: 60% and group 2: 50%), and oral hygiene (group 1: 54% and group 2: 41%). Group 1 was more certain in their responses as to whether or not they believed certain factors influenced hand dominance transfer as reflected in a lower percentage of selecting “Unsure” as a response. However, the differential spread between group 1 and group 2 was only greater than 10% in two instances, namely, group 1 selected “Yes” more often for visual perceptual ability (group 1: 78.6% and group 2: 66.2%) and youth (group 1: 69.4% and group 2: 57.6%) being relevant factors in hand dominance transfer.
Discussion
The demographics of survey respondents closely match the proportion of OTs to physical therapists (PTs) of the CHT population: 85% OT to 15% PT.
The respondents reported treating mostly orthopedic, upper extremity injuries from trauma (acute and cumulative) to the dominant limb. These results support research findings from other studies that found that 1) cumulative trauma disorders are more prevalent in dominant extremities
The second section of the survey revealed beliefs of respondents relating to hand dominance transfer. Due to a lack of a standardized protocol for I-IHDT, the actions of CHTs are predominantly predicated on their beliefs about hand dominance and the role it plays in recovery of function. Most CHTs felt that hand dominance transfer was necessary after amputation of a dominant hand, rather than relying on limited dexterity function of the currently available prostheses. This belief aligned with their belief that patients with upper limb amputation would experience hand dominance transfer differently than those with injured, but attached, upper limbs. Perhaps this conviction relates to sentiments of respondents who wrote that patients may not want to work on hand dominance transfer until maximum recovery was reached in the injured limb and that working on the transfer would somehow slow down functional return in the injured limb. This concern revolves around the argument that if the therapist facilitates a rapid return to function and one-handed independence (modified independence), then the patient may withdraw from the treatment plan set out for actual restoration of function in the injured limb or perhaps abandon the use of a prosthesis.
Respondents were strongly united in their belief that “motivation” was a driving force in a successful hand dominance transfer. Motivation is a difficult construct to operationalize and quantify, but when studied, motivation appears to influence participation in rehabilitation as well as outcomes.
Surprisingly, for nine of 15 factors presented, greater than 25% of respondents selected “unsure.” This indecisiveness could be interpreted to mean that respondents do not have enough information from the field of hand therapy or that they were unsure about using other knowledge from general rehabilitation theories to apply to this specific question related to the transfer of hand dominance. That slightly more than one-third of respondents were unsure of cultural implications of hand dominance transfer brings to light a relevant concern, namely, that there may be cultural reasons why a right-handed person may “resist” becoming left-hand dominant. For example, left-handedness has many stereotypes in different societies: “linkisch” (German) means “maladroit or clumsy;” “sinister” (Latin) means “disastrous and unlucky;” “mancino” (Italian) means deceitful, maimed, or dishonest.”
In the section of the survey related to clinical strategies and decision making, although 76% agreed or strongly agreed that a clinical practice guideline (CPG) should be established, less than 10% selected “no protocol” for their reason for not initiating a hand dominance transfer. In other words, respondents support the establishment of a CPG, but the absence of one is not deterring their attention from dominance transfer interventions, when called for. This is likely a reflection of a highly experienced group of CHTs who responded to this survey, with 60% of respondents reporting having more than 20 years of experience.
Respondents who initiate hand dominance transfer cited prognosis/injury severity, client’s functional level, and client’s request for such therapy as factors that influence their decision. These reasons closely align with previous research. For example, Walsh et al.
used patient surveys and chart reviews at two regional hand centers to try to determine what type of hand injuries led to a change of hand dominance. They categorized injuries to one of four diagnostic groups: 1) peripheral nerve injury, 2) revascularization or replantation, 3) multiple digit flexor tendon injury, and 4) crush injury. They further categorized the patients by the zones of injury. Their findings suggested that nerve involvement was a key indicator in the patients’ need for switching hand dominance. Results suggested that more complex tasks with dexterity requirements were more difficult to switch to the nondominant hand (writing, drawing, and cutting with scissors). These authors suggested that therapists consider anatomical level of the injury, diagnosis, and the complexity of the transferring task when dealing with a patient with a traumatic hand injury. Eggers and Mennen
The EFFUL (Evaluation of Function in the Flail Upper Limb) system. A ranking score system to measure improvement achieved by surgical reconstruction and rehabilitation.
discussed the phenomenon of hand dominance transfer as a product of functional adaptation to accomplish ADLs when motion and sensation are traumatically lost in the “main executor” arm and hand after brachial plexopathies. They suggest that skilled actions beyond those of an 8-year-old child require extensive deliberate practice to facilitate dominance transfer because of necessary proficiency, speed, and agility.
Most respondents selected handwriting as the task addressed in a hand dominance transfer. The link between handwriting and hand dominance is not unexpected because hand dominance is often solely defined by the hand used for writing.
Furthermore, despite handwriting being a basic skill learned early in life, it is purported to be the highest form of unilateral hand dexterity skill attained by the general population. Two compelling characteristics of handwriting capture the essence of both dexterity and hand dominance. First, dexterity generally implies an interaction with a tool or object needed to accomplish a goal, and handwriting captures the hand’s interface with a commonly encountered tool and accomplishes a goal. Second, handwriting captures the hand’s unique link to the brain for planning and executing purposeful movements,
thereby providing a link between the peripheral manifestation of dexterity and the more central origin of dominance in the brain. Monitoring dexterity development in the previously nondominant hand, through handwriting performance improvements, becomes a strategy for tracking motor control changes that represent the necessary learning of hand dominance transfer.
Relationships among biomechanical ergonomic factors, handwriting product quality, handwriting efficiency, and computerized handwriting process measures in children with and without handwriting difficulties.
Other tasks that respondents wrote in the “other” category that relate language to hand dominance were using a phone and using a computer mouse.
Because loss of dominant hand dexterity impairs performance of ADLs, 84% of the respondents recommend adaptive equipment. This is consistent with the description of Chan and LaStayo
of management of mutilating hand injuries, where they recommend early instruction in ADLs, specifically if a dominant hand is injured. Another indication of the collective consciousness of restoration of independence was that 72% of respondents reported educating their clients about the increased risk to the noninjured (intact/sound) limb, meaning that the therapists were aware of the loss of independence should the intact limb succumb to an overuse injury. These results demonstrate an overall awareness and attentiveness to providing holistic care of patients facing I-IHDT.
The final section of the survey sought to gain insight into CHTs’ desire for a research agenda related to hand dominance transfer. There was strong agreement for additional inquiry in this area, including development of a CPG. Respondents agreed that efforts should direct investigation to elucidate factors that help facilitate hand dominance transfer, explore virtual reality as an intervention, use neuroimaging technologies to “observe” the transfer, and examine return to work as a meaningful outcome. These results reflect current practice trends toward sophisticated analysis in research using advancements in neuroimaging studies. Recent research is beginning to examine the benefits of bilateral arm training versus, or paired with, unilateral (affected) arm training.
When comparing groups 1 and 2, the subtle difference was that group 1 was more committed in their answers. Specifically, across the survey categories, group 1 selected “Unsure,” “Unfamiliar,” and “Depends” fewer times than group 2. Because of the overall similarity in demographics, beliefs, and reported practice patterns of all respondents, perhaps the correct conclusion to be drawn is that the decisiveness of group 1 corresponds to their answering “Yes” to whether they directly initiate a hand dominance transfer rather than a difference in the approach to addressing hand dominance transfer after hand injury.
Limitations
Despite having more than 500 respondents, this study is limited by the 22% response rate, and therefore, generalization is cautioned to that of a demographic similar to the 22% of ASHT population who did respond. Another limitation is that one survey question did not specify if the hand function loss was temporary or permanent; that the loss was permanent was implied but caused confusion for at least one respondent who e-mailed the primary investigator. Another potential limitation, which was pointed out by another respondent through e-mail to the investigator, was the wording of the question “In your best estimation, what is the percentage of clients you treat with injuries to the dominant upper extremity?” The respondent who e-mailed suggested that this question should have asked respondents to reference the last five patients treated for upper extremity injuries. This concern speaks to the general risk in survey research of relying on the accuracy of memories of respondents.
Conclusion
The results demonstrate that most CHTs (76%) feel there is a need for a CPG to be established and available for CHTs. Current practice patterns related to hand dominance transfer include 1) addressing functional dexterity tasks (handwriting) to improve nondominant hand function, 2) recommending/providing adaptive equipment, and 3) educating on risk for an overuse injury to their intact/uninjured limb.
Acknowledgment
The author would like to thank Dr. C.A. Strohbach for editorial assistance with this article.
References
Yancosek K.E.
Mullineaux D.R.
Stability of handwriting performance following injury-induced hand dominance transfer in adults: a pilot study.
The EFFUL (Evaluation of Function in the Flail Upper Limb) system. A ranking score system to measure improvement achieved by surgical reconstruction and rehabilitation.
Severity and specificity of neglect-like symptoms in patients with complex regional pain syndrome (CRPS) compared to chronic limb pain of other origins.
Relationships among biomechanical ergonomic factors, handwriting product quality, handwriting efficiency, and computerized handwriting process measures in children with and without handwriting difficulties.
Disclaimer: The opinions or assertions contained herein are the private views of the author and are not to be construed as official or as reflecting the views of the Army or the Department of Defense.
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