Validity of HAMIS: A Test of Hand Mobility

in Scleroderma

Gunnel Sandqvist and Mona Eklund

Objective. Hand Mobility in Scleroderma (HAMIS) between the patients and the healthy individuals for
is a hand function test for persons who have sys- all items except these two.
temic sclerosis (scleroderma). The purpose of Conclusion. HAMIS has a demonstrated concur-
HAMIS is to obtain an estimation of the hand mo- rent validity compared with ROM and skin score,
bility that is precise enough to detect limitation of and it showed a good ability to discriminate between
motion at the same time as it indicates the ability to healthy individuals and persons with scleroderma,
use the hand in daily occupations. The aim of this although a lack of variation in the items measuring
study was to test psychometric properties of the pronation and supination inferred worse psychomet-
HAMIS, and the following aspects of HAMIS were ric properties for these two items.
examined: 1) the applicability of HAMIS, 2) concur-
rent validity, and 3) discriminating ability.
Methods. Forty-five patients with scleroderma INTRODUCTION
were assessed for range of motion (ROM), HAMIS,
and skin thickness. In addition, 15 healthy individ- Systemic sclerosis (SSc), or scleroderma, is a dis-
uals completed HAMIS. order of connective tissue characterized by indura-
Results. The applicability of HAMIS was good for tion and thickening of the skin, Raynaud’s phenom-
items assessing finger and thumb mobility and mod- enon, and a potential involvement of a wide range of
erate for items assessing mobility of the wrist and the internal organs (1). Based on the extent of skin in-
volvement, two forms of SSc may be distinguished:
forearm. The relationships of HAMIS to ROM and
limited systemic sclerosis (lSSc) and diffuse sys-
skin score were statistically significant for all items
temic sclerosis (dSSc). Skin induration and joint and
except for pronation and supination of the forearm.
muscle involvement often lead to a progressive re-
There were also statistically significant differences
duction in range of motion that is the major cause of
rehabilitative problems. Ninety percent of SSc pa-
tients report loss of hand grasp ability. Factors such
Supported by grants from the Swedish Rheumatism Associa-
tion. as puffy fingers, calcium deposits, and wrist exten-
Gunnel Sandqvist, MSc, OTR, Department of Rheumatology, sion reduction have been identified as risk factors for
Lund University Hospital, Lund, Sweden, and Department of later development of severe levels of hand disability
Clinical Neuroscience, Division of Occupational Therapy, Lund (2). There are many aspects of hand function, such as
University, Lund, Sweden; and Mona Eklund, Assistant Professor, anatomical integrity, mobility, muscle strength, sen-
PhD, OTR, Department of Clinical Neuroscience, Division of Oc- sation, grasp patterns, precision and accuracy, coor-
cupational Therapy, Lund University, Lund, Sweden.
dination and dexterity, unilateral and bilateral tasks,
Address correspondence to Gunnel Sandqvist, MSc, OTR, De-
partment of Rheumatology, Lund University Hospital, S-221 85 activities of daily living (ADL) tasks, and motivation
Lund, Sweden. (3). Several of these aspects, including mobility, are
Submitted for publication February 9, 2000; accepted in revised important to patients with SSc. Early hand deformi-
form July 27, 2000. ties that occur in SSc are loss of flexion of the meta-
© 2000 by the American College of Rheumatology. carpophalangeal (MCP) joints, loss of extension of

382 0893-7524/00/$5.00
Arthritis Care and Research Validity of HAMIS 383

the proximal interphalangeal (PIP) joints, loss of PATIENTS AND METHODS

thumb abduction, opposition, and flexion, and fi-
nally loss of wrist motion in all planes. These typical Subjects. The test population comprised 45 con-
hand deformities contribute to functional disability secutively selected patients (40 women and 5 men)
in varying degrees, and because of the nature of the who were hospitalized for 3 days for routine control
disease the primary goal in treatment of the hand at the department of rheumatology at a university
therefore is to maintain maximal range of motion (4). hospital in southern Sweden. The sample included
Mobility in the hand can be assessed in various all patients in routine control during 7 months. Their
ways, such as measurements of range of motion age ranged from 22 to 74 years (median age 53 years),
(ROM), using a goniometer and a ruler, or with a and the range of duration of illness was 1 to 17 years
performance index. A performance index does not (median duration 4 years). Two patients had sus-
imply a testing of movements of isolated joints but pected SSc, 33 patients had lSSc, and 9 patients had
gives an indication of the individual’s ability to use dSSc. For one patient the specified diagnosis was not
the hand skillfully in the activities of daily living (5). recorded. Fifteen healthy volunteers (14 women and
Occupational therapists, framing function within the 1 man) recruited from the hospital staff served as a
context of everyday activities, often find perfor- comparison group. Their ages ranged from 36 to 62
mance indexes more suitable in estimating function. years (median age 48 years). Forty-two individuals
Development and adoption of methods to quantify in the patient group were right dominant and 3 were
and longitudinally follow scleroderma’s impact on left dominant. In the comparison group all individ-
functional capacity, self-assessment, quality of life, uals were right dominant. These data were collected
psychological well-being, and overall health would during the same period as the patient data.
enhance both clinical trials and routine patient
Measurements. Three measures were employed:
care (6). A new hand function test, Hand Mobility
the ROM test using a goniometer and a ruler,
in Scleroderma (HAMIS), was devised in order to
HAMIS, and assessment of skin thickness by means
reflect the mobility of the scleroderma hand in an
of manual palpation (skin score).
easy way and to reflect specific impairments, e.g.,
ROM test. The ROM test followed the procedure
swelling (7). HAMIS is a performance index in-
described by the American Academy of Orthopaedic
spired by the hand function tests Signals of Func-
Surgeons (9), but some modifications were made.
tional Impairment (SOFI) (5) and Keitel Function
Therefore, the procedure used in this study will be
Test (KFT) (8). The different performance areas of
described in detail. Range of motion was measured
HAMIS are composed of different-sized grips and
as follows: Flexion deficits of digits 2 through 5 were
different movements, all related to tools and move- defined in 2 ways: 1) distance in millimeters from
ments that are part of performance of daily occu- the distal point of the digit to the flat of the hand,
pations, and it includes all movements assessed in which denominates the deficit of flexion, and 2)
an ordinary ROM-measured hand mobility test. A distance in millimeters from the distal palmar crease
performance index for evaluation of ROM is suit- to the point in the flat of the hand where the digit
able for patients with SSc since it is mostly the ended up, thus denominating the proximal flexion of
skin tightness that has an effect on the mobility, the palmar crease. Extension deficits of digits 2
and the ability of flexion and extension of the through 5 were measured with the forearm in a zero
fingers is often the same for all fingers. HAMIS was position and the ulnar side of the hand resting on the
developed with the purpose of obtaining an esti- bottom of a box. The back surface of the hand flat
mate of the function of the hand that is precise was quite close to one side of the box, and the dis-
enough to detect limitation of motion at the same tance between the nail bed of the extended fingers
time as it indicates the ability to use the hand in and the box was recorded in millimeters. The volar
daily occupations. HAMIS has turned out to be a abduction of the thumb was measured as the dis-
reliable instrument (7), and the aim of the present tance in millimeters between the fingertips of digits
study was to further test psychometric properties 1 and 2. Furthermore, extension deficits in PIP, flex-
of HAMIS. The following aspects of HAMIS were ion in MCP 1 and IP, volar flexion of the wrist, dorsal
examined: 1) the applicability of HAMIS, 2) con- extension of the wrist, pronation of the forearm, and
current validity, and 3) discriminating ability, as supination of the forearm followed the procedure
indicated by comparisons between patients with described by the American Academy of Orthopaedic
SSc and healthy individuals. Surgeons (9).
384 Sandqvist and Eklund Vol. 13, No. 6, December 2000

HAMIS. HAMIS is a performance index that con- Table 1. Range of motion among the patients (n ⫽ 45)
sists of 9 items (7) assessing the movements included
Median (range) Normal
in an ordinary range of motion test, i.e., finger flexion
and extension, abduction of the thumb, dorsal exten- Finger
sion and volar flexion of the wrist, and pronation Deficit of flexion, digits 2–5, mm 0.00 (0–45) 0.0*
and supination of the forearm. It also assesses the Proximal flexion of the palmar crease,
ability to make a thumb pincer grip and to make digits 2–5, mm 20.00 (0–40) 0.2†
finger abduction. The different performance areas of Deficit of extension, digits 2–5, mm 1.25 (0–41) 0.3†
HAMIS are composed of different-sized grips and Thumb
different movements, all related to tools and move- Abduction, mm 130.00 (65–170) 156.0†
ments that are part of daily occupations. For further Flexion of MCP 1 ⫹ IP, degrees§ 90.00 (30–125) 140.0*
description, see Sandqvist and Eklund (7). Each ex- Wrist/forearm
ercise is graded on a 0 –3 scale, where 0 corresponds Volar flexion, degrees 57.50 (0–80) 80.0*
to normal function and 3 denotes that the individual Dorsal flexion, degrees 60.00 (20–90) 70.0*
Pronation, degrees 90.00 (60–92) 90.0*
is unable to perform the task. Supination, degrees 90.00 (70–90) 90.0*
Skin score. The skin was assessed according to
Skin score
the modified Rodnan skin score technique, which
Skin score fingers 2.00 (0–3) 0‡
has acceptable inter- and intra-observer reliability
Skin score hand 1.00 (0–2) 0‡
(10). The present study assessed only the skin score Skin score arm 1.00 (0–3) 0‡
on the fingers, dorsally on the hand, and on the
* Standards from American Academy of Orthopaedic Surgeons (ref. 9).
forearm. The scale step was 0 ⫽ normal, 1 ⫽ mild † Scores of a healthy group included in a previous study by Sandqvist (ref.
skin thickness, 2 ⫽ moderate skin thickness, and 3 ⫽ 11).
‡ The normal skin constitutes the reference point and is set to 0.
severe skin thickness with inability to pinch the skin § MCP ⫽ metacarpophalangeal; IP ⫽ interphalangeal.
into a fold.

Procedure. The assessments with ROM and

HAMIS were made in connection with the routine association between scores on HAMIS and ROM, the
control by an occupational therapist (GS). First the patients were grouped according to their HAMIS
ROM test was performed, followed by administra- scores on each item. All patients who scored 0 on an
tion of HAMIS. A physician made the assessments of item formed one subgroup, those who scored 1
skin thickness. formed another, and so on. Eight different groupings
were done— one for each HAMIS item where there
Analyses. All the measures were performed on was a corresponding ROM item. Subsequently, the
both hands, but this report describes the evaluation Kruskal-Wallis H test was used to determine
on the patients’ dominant hand. To estimate whether whether any differences were obtained between
HAMIS is a relevant test for patients with SSc and these HAMIS subgroups on the corresponding ROM
does not reach a floor or ceiling effect, an applicabil- scores.
ity analysis for HAMIS was performed by examining Discriminating ability for HAMIS was examined
the frequency distribution of scores obtained for the by testing for differences between the patient group
different items. For the estimation of concurrent va- and the comparison group of the 15 volunteers, us-
lidity, two strategies were used. First, relationships ing the Mann-Whitney U test. The ability of HAMIS
between HAMIS and ROM, and between HAMIS and to detect the patient group as well as the healthy
skin score, were calculated by means of Spearman’s individuals was further assessed by means of a for-
rank correlation coefficient. The finger abduction ward stepwise logistic regression analysis. Data were
item of HAMIS was not included in this analysis analyzed by means of the SPSS software package,
since finger abduction was not measured in the ROM version 8.5 (SPSS, Chicago, IL).
test. Finger flexion according to the ROM test was
assessed in two ways as mentioned above: flexion
deficit and proximal flexion of the palmar crease. RESULTS
The HAMIS finger flexion item assesses an ability
that reflects a combination of these 2 measurements, Hand function in the investigation group. Range
and this HAMIS item was therefore correlated with of motion for the dominant hand is shown in Table
the summary of the 2 measurements of finger flexion 1. The patients’ pronation and supination of the
in the ROM test. Second, in order to further test the forearm were almost normal, while the flexion abil-
Arthritis Care and Research Validity of HAMIS 385

Table 2. The distribution of scores (0 –3) on HAMIS for Table 3. Spearman’s rank correlations between the
the patient group (n ⫽ 45) patients’ HAMIS and ROM scores

0 1 2 3 Total HAMIS ROM rs P value

Finger Finger
Flexion 15 16 10 4 45 Flexion Deficit of flexion ⫹ 0.79 0.000
Extension 12 24 5 4 45 proximal flexion of the
Abduction 19 21 5 45 palmar crease, mm
Extension Deficit of extension, 0.80 0.000
Thumb
digits 2–5, mm
Abduction 33 9 1 2 45
Pincer grip 29 12 4 45 Thumb
Abduction Abduction, digit 1, mm ⫺0.62 0.000
Wrist/forearm
Pincer grip Flexion of MCP 1 and IP, ⫺0.48 0.001
Volar flexion 31 13 1 45 degrees*
Dorsal extension 35 10 45
Pronation 44 1 45 Wrist/forearm
Supination 27 18 45 Volar flexion Volar flexion, degrees ⫺0.50 0.001
Dorsal extension Dorsal flexion, degrees ⫺0.40 0.008
Pronation Pronation, degrees 0.05 0.802
Supination Supination, degrees ⫺0.34 0.059
ity of fingers and thumb, extension of the fingers, and * MCP ⫽ metacarpophalangeal; IP ⫽ interphalangeal.
volar flexion of the wrist were more affected.

Applicability. HAMIS’ relevance and its ability to

avoid the floor or ceiling effect for patients with SSc high functioning according to the respective mea-
are demonstrated in Table 2, which shows the dis- sures.
tribution of the patients’ scores on the different items Table 4 shows correlations between HAMIS and
of HAMIS. The most widely spread distribution of skin score. There were no statistically significant
scores concerned the items “finger flexion” and “fin- correlations for pronation and supination of the fore-
ger extension.” Scores above 0 were obtained for all arm, but all the other HAMIS items were positively
items, and for the items “finger flexion,” “finger ex- associated with skin score.
tension,” and “thumb abduction” all scores were Statistically significant differences were found be-
represented, while there was just one score above 0 tween the HAMIS groupings on finger flexion (P ⫽
for the item “pronation of the forearm.” Three pa- 0.000), finger extension (P ⫽ 0.000), finger abduction
tients had totally normal HAMIS. Two of these also (P ⫽ 0.008), thumb abduction (P ⫽ 0.001), pincer
had normal ROM, while the third patient had abnor- grip of the thumb (P ⫽ 0.006), volar flexion of the
mal ROM concerning finger flexion and extension. wrist (P ⫽ 0.004), and dorsal extension of the wrist
According to HAMIS, the patients’ range of motion (P ⫽ 0.009). This indicates that the variation in ROM
was more limited in the fingers, and the patients’
mobility in pronation was almost normal. The
healthy individuals in the comparison group ob- Table 4. Spearman’s rank correlations between the
tained score 0 for all items, except for finger flexion patients’ HAMIS and skin score
(where one individual obtained score 1) and supina-
HAMIS Skin score rs P value
tion (where two individuals scored 1).
Finger
Concurrent validity. Table 3 shows the correla- Flexion Fingers 0.60 0.000
tions between the patients’ HAMIS scores and their Extension Fingers 0.52 0.000
ROM scores. The correlation was statistically signif- Abduction Fingers 0.47 0.001
icant for all items except pronation and supination Thumb
of the forearm. As indicated above, a low HAMIS Abduction Fingers 0.31 0.038
score denotes high functioning, and the same condi- Pincer grip Fingers 0.36 0.016
tion goes for finger flexion and finger extension in Wrist/forearm
ROM. However, for the remaining ROM items the Volar flexion Hand 0.33 0.029
opposite is true, i.e., a high score indicates a high Dorsal extension Hand 0.36 0.015
Pronation Hand 0.23 0.13
level of functioning. Thus, all the statistically signif- Supination Hand ⫺0.01 0.93
icant correlations indicated associations between
386 Sandqvist and Eklund Vol. 13, No. 6, December 2000

scores within each grouping was less than the vari- these items is that they might separate patients with
ation between the groups. No statistically significant dSSc from those with lSSc, which was not investi-
differences were found on pronation of the forearm gated in this study because of the low number of
(P ⫽ 0.80) or on supination of the forearm (P ⫽ 0.06). patients with dSSc. The pronation and supination
should in the first place be related to skin score of the
Discriminating ability. Differences on HAMIS be- hand and arm, but this study could not demonstrate
tween healthy individuals and persons with sclero- such a correlation (Table 4), possibly because there
derma were used as indicators of the discriminating were too few patients with skin score 2 and 3.
ability of HAMIS. There were statistically significant A disease-specific test should reflect the symp-
differences on finger flexion (P ⫽ 0.000), finger ex- toms of the disease (12). HAMIS fulfills this demand
tension (P ⫽ 0.000), finger abduction (P ⫽ 0.000), since the correlations between HAMIS and skin
thumb abduction (P ⫽ 0.027), pincer grip of the score were statistically significant for all items ex-
thumb (P ⫽ 0.008), volar flexion of the wrist (P ⫽ cept pronation and supination. The skin was more
0.015), and dorsal extension of the wrist (P ⫽ 0.047). thickened on the fingers, the ROM was more limited
The differences were not statistically significant on on the fingers than on the wrist, and the HAMIS
pronation of the forearm (P ⫽ 0.56) and supination of pointed to a substantial functional limitation of the
the forearm (P ⫽ 0.06). The ability of HAMIS to fingers. This is in agreement with other studies, in-
distinguish patients with SSc from healthy individ- dicating that the most commonly affected functions
uals was further tested through a logistic regression are finger flexion, finger extension, and abduction of
analysis (P ⫽ 0.0002), which resulted in the exten- the thumb (4,13,14). The results from the logistic
sion item as the only variable in the solution. This regression analysis, that finger extension as a single
item predicted 100% of the healthy individuals and item could separate the patients from the healthy
73% of the patients in the correct groups.
group, further underscored the fact that SSc is a
disease that largely affects finger mobility.
The patients’ ROM was very good in this study.
DISCUSSION
This explains why some of the HAMIS items almost
reached a floor effect, i.e., many of the patients
This study demonstrated some good psychometric
reached score 0. An explanation for the patients’
properties of HAMIS. It was found to be a valid test
good ROM could be that to a great extent they had
and to have good ability to discriminate patients
received treatment early in the course of the disease
with SSc from healthy individuals. There are times
when HAMIS can replace the ROM test, e.g., to fol- and they were well informed about the importance
low scleroderma’s impact over time on the ability to of hand exercise. Melvin and colleagues recom-
move the hand, in surveying scleroderma patients’ mended early treatment to prevent permanent limi-
ability to move the hand, and as a help when plan- tation of range of motion (4). Because there was a
ning exercise programs. However, if there is need for tendency towards a floor effect on some of the items,
a very careful and precise followup of treatment, an the applicability of HAMIS has not been fully estab-
ROM test is more exact and ought to be used. HAMIS lished, and the instrument needs to be tested on a
is a performance index that estimates mobility in the sample with larger variation in hand function.
context of performance, not on the level of degrees or HAMIS’ ability to discriminate between patients
millimeters, and it is therefore not sensitive enough and healthy individuals was good despite the pa-
to record the very small variations detected in the tients’ good range of motion in the hand. This indi-
ROM test. cates that HAMIS is sensitive even for relatively
No correlations were found between HAMIS and small limitations of ROM, but further studies com-
ROM with respect to pronation and supination, prising patients with greater variations of ROM are
which deviated from the result pattern of significant needed in order to estimate floor and ceiling effects.
correlations found regarding the other items. The The aim of HAMIS is to reflect the mobility of the
reason for this was probably that the patients’ range fingers, the wrist, and the forearm. There are of
of motion in pronation and supination was good. course other aspects of hand function that are of
The HAMIS items “pronation” and “supination” importance, e.g., dexterity. Many patients with SSc
will still be kept in the instrument, because these complain of fumbling, often caused by thickening of
items make the test complete for all movement lines, the skin, and this also has a great influence on the
and they are important when using the hand in ac- performance of daily occupations. A more complete
tivities of daily living. Another argument for keeping estimation of the hand function of patients with SSc
Arthritis Care and Research Validity of HAMIS 387

should therefore consist of assessment of both mo- 4. Melvin JL. Rheumatic disease in the adult and child:
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