Occupational therapists recently gained a new task-oriented, patient-centered hand function assessment tool called the Manual Ability Measure.

“It is easy, it is functional, it is quick and I love it,” said Anissa E. Hill, OTR, MOT, senior OT for outpatient services at the University of Texas MD Anderson Cancer Center in Houston, who uses it with oncology patients after surgery or those with neuropathy.

MAM consists of 20 questions in which the therapist asks the patient about the relative difficulty the person has completing specific tasks. Examples include opening a medicine bottle, clipping nails, cutting meat, tying shoes, writing and turning a key in a door lock. The therapist then uses a conversion table to score the results.

Christine C. Chen, OTR/L, ScD, FAOTA, associate professor in clinical occupational therapy at Columbia University College of Physicians and Surgeons in New York, developed MAM as an intake assessment tool that also could be used to set treatment goals and to monitor progress. “My tool measures disability rather than impairment,” Chen said.

In developing a plan of care, MAM can be used with other tools that determine grip or finger strength or assess range of motion or coordination. “This complements other assessments,” Chen said. “It gives you a more global function, a more comprehensive picture.”

MAM’s development

After working as an OT for a number of years, Chen realized what mattered most to patients was their ability to do the things that were important to them. She began developing MAM in 1999 while completing her post-doctoral education with Carl V. Granger, MD, a faculty member at the University of Buffalo (N.Y.) School of Medicine and Biomedical Sciences, and creator of the Functional Independence Measure used in rehab facilities.

“It was concise assessment, but the items were so global, I felt it did not tell the story,” said Chen, who approached Granger about developing a tool that would address only upper-extremity functioning. Granger approved of her idea. At first, Chen developed a 36-question tool, validated it and then pared it down to 20 questions. Chen used Rasch Analysis for statistical modeling, which considers an item’s difficulty and a person’s ability.

While some tools had been developed to measure hand function in patients with specific conditions, such as arthritis or carpal tunnel syndrome, Chen has validated MAM in patients with acute injuries, such as fractures, and chronic conditions. She recently began testing it with neurological conditions, including stroke, multiple sclerosis and spinal cord injuries and found it useful in these populations.

MAM differs from the Disabilities of the Arm, Shoulder and Hand Outcome Measure in that it does not include symptoms and has fewer questions.

Tool’s usefulness

MAM can be used when admitting a new patient in any practice setting — acute care, home health or outpatient rehabilitation. Hill estimated it takes two to 10 minutes to administer, depending on whether she has to set up a task and let the patient try it during a session. She has found MAM not only gets patients discussing their functional levels but also prompts them to try things they may not have attempted at that point in their recovery.

MAM can be used at the item level or to evaluate entire hand function. “The way it is scored, they can use it to set clinical goals,” Chen said. She recommended asking what the patient wants to work on and focusing on those concerns.

At scheduled follow-up dates, such as four or six weeks, the therapist can administer MAM again. If the therapy improves the function, the patient’s response to the difficulty of that item on the tool will change. “If they use it correctly, they can see where patients trend and the weaknesses,” Chen said. “They can use the hierarchically arranged difficulty to see whether the patient achieved the easier items and what the treatment goal will be — the next most difficult item, for example.”

Chen said MAM becomes less sensitive for a chronic condition, because after weeks or months, patients learn to adapt. The impaired hand becomes a “helping hand” rather than a performing hand. At that point, the patient likely will report less difficulty completing the task.

Although Chen said MAM can serve as a great outcome measure, she fears insurance companies will use it to deny coverage if the tool’s global score does not indicate improvement. She suggested therapists focus on increased function on certain tasks if that scenario occurs. “They can say ‘the patient couldn’t perform 15 out of 20 items, but now out of the 15 items, seven or eight of them they can do with ease.’” Chen said. “That’s evidence.”

Put into practice

Therapists are just beginning to learn about MAM and incorporate it into their practices. But Chen said she fears unless the tool becomes a performance measure required by regulatory agencies, similar to pain scales, OTs may just consider it one more task.

Amy Matthews, OTR/L, OTD, vice chair in the department of occupational therapy and an assistant professor at the School of Pharmacy and Health Professions at Creighton University in Omaha, Neb., recently learned about MAM and is considering adding it to the curriculum in her rehabilitation assessment course. She called MAM well-studied but said some therapists may find it faster just to question the patient.

Matthews also pointed out that outpatient therapists tend to follow a medical model and focus on factors such as strength or range of motion. “We should be using more things, but they take time.”

But Mathews said MAM’s list of everyday tasks could spur helpful discussions. “You can get a good idea from talking to the patients about which of the tasks they can or cannot do,” she said.

Matthews voiced concern that MAM does not ask the patient to rate the importance of each task. And the MAM does not allow the therapist to evaluate how well the patient performs the task — it’s purely the patient’s perception, she said.

“But the thing I like about it is it will get patients talking about some of the things they don’t think about, like buttering bread or loading a CD into a drive,” Matthews said. “It will get them thinking and talking about how this injury has affected their lives.”

Debra Anscombe Wood is a freelance writer.