SCIENTIFIC/CLINICAL ARTICLE
JHT READ FOR CREDIT ARTICLE #133.
A Narrative Review of Dexterity Assessments
Katie E. Yancosek, MS, OTR/L, CHT
Department of Rehabilitation Sciences, University of
Kentucky, Lexington, Kentucky
Dana Howell, PhD, OTD, OTR/L
Eastern Kentucky University, Richmond, Kentucky
This article is a comparison of the psychometric
properties (reliability and validity) and other charac-
teristics (cost, administration time, and year of publi-
cation) of commercially available adult dexterity
assessments used in research and clinical practice for
adults. Dexterity is defined as ‘‘fine, voluntary move-
ments used to manipulate small objects during a spe-
cific task’’1 and is typically an integral part of a
thorough evaluation of the hand. An examination of
dexterity provides a unique way of evaluating the neu-
romotor function of the entire hand because sensation
and intrinsic hand strength combine to produce the
manipulative skills that facilitate dextrous move-
ments. Dexterity may be further described by two re-
lated terms—manual dexterity, which is the ability to
handle objects with the hand and fine motor dexterity,
which refers to in-hand manipulations as separate
skills from the gross motor grasp and release skills as-
sociated with manual dexterity.1 The results of assess-
ments for both manual and fine motor dexterity may be
This article was not adapted from a presentation at a meeting and
no grant monies are associated with its execution.
Correspondence and reprint requests to Katie E. Yancosek, MS, OTR/
L, CHT, 923 Forest Lake Drive, Lexington, KY 40515; e-mail:
<Kathleen.yancosek@us.army.mil>.
0894-1130/$ e see front matter. Published by Hanley & Belfus, an
imprint of Elsevier Inc.
doi:10.1016/j.jht.2008.11.004
258 JOURNAL OF HAND THERAPY
ABSTRACT
Narrative Review:
This article is a narrative review of the psychometric properties
(reliability and validity) and other characteristics (cost, time to
administer, and year of publication) of commercially available
manual and finger dexterity assessments used for adults in
the United States. Complete research articles related to dexterity
assessments were gathered from online database searches and
individually critiqued for scientific rigor based on reliability
and validity. Articles relating to 14 dexterity assessments were re-
viewed. All but three tools had established reliability, seven tools
had all five forms of validity established, and two had only face
and content validity. The results of this review provide information
to those interested in fine motor skill acquisition, impairment, or
functional recovery after injury. Therapists may use this informa-
tion to choose the best assessment instrument to evaluate a pa-
tient’s recovery of function over time. This review adds to the
evidence-based, best-practice literature related to assessment and
outcome measurements of patients with limited dexterity function
participating in rehabilitation.
J HAND THER. 2009;22:258–70.
used to quantify and predict both ability and disability
by gauging a person’s speed and quality of movement
as the hand interfaces with objects and tools related to
self-care, work, or leisure pursuits.2 A study conducted
by Williams et al.3 demonstrated that dexterity was the
best predictor of independence in activities of daily liv-
ing (ADL) within a cohort of geriatric females.
Outcome measures related to dexterity are impor-
tant to detect clinically significant changes in an
injured patient population, to provide vocational
placement recommendations, to assess patients after
a work-related injury as part of a functional capacity
evaluation (FCE), to provide evidence of (dys)func-
tion in workman’s compensation cases, and to eval-
uate and compare dexterity levels among various
injured and uninjured populations.4 Assessing dex-
terity is critical because dexterity is a central compo-
nent of hand function. Currently, over 20 different
dexterity assessments are available. According to
Rudman and Hannah,5 selection of an appropriate
assessment is often based on a variety of factors,
including financial and time costs; availability, famil-
iarity, or practicality; and applicability to a given
patient or research population. Importantly, they
note that attention should also be directed toward
the psychometric soundness of the assessment
instrument, which is the focus of this article.
BACKGROUND
Reliability and validity make up an assessment’s
psychometric properties. Validity refers to an asses-
sment’s ability to accurately measure the construct it
seeks to measure. Reliability refers to an assessment’s
ability to reproduce similar results with sequential
administrations.6 There are three types of reliability.
They are commonly referred to, and therefore most
often recognized and understood, by the methods
used to examine them. The first type of reliability is
called stability. The familiar method is to collect
testeretest data on an instrument given by one exam-
iner at two different times. It is reported by a stability
coefficient such as Pearson’s r. Stability is commonly
known as intrarater reliability. The second type of
reliability is called internal consistency. The two famil-
iar methods to examine internal consistency are a
split-half technique and a Cronbach’s alpha.6 In these
methods, the researcher is asking if items on an instru-
ment ‘‘consistently’’ measure the same concept. In the
split-half technique, the outcomes of the instrument
are divided and compared for consistent results. In
the Cronbach’s alpha method, each item is separately
compared with others, looking for the degree of corre-
lation between items. The third type of reliability is
equivalence. The familiar method is to compare score
results obtained by two examiners administering the
same test. Equivalence is commonly known as ‘‘inter-
rater’’ reliability. It should be noted that stability
(intrarater reliability) of an assessment must be estab-
lished before equivalence (interrater reliability) be-
cause stability means the instrument is dependable
in measuring a construct over time. Similarly, reliabil-
ity of an instrument must precede validity.6
Validity is related to how true an assessment is in
capturing the construct it seeks to measure.5,6 There
are five types of validity. The first type of validity,
which is the simplest type, is face validity. It describes
how the instrument appears to measure the con-
struct. The second type of validity is content
validity—it explores if an instrument captures all
the meaningful elements of a construct. Face validity
can be ascertained by an amateur, whereas content
validity should be established by a subject matter ex-
pert. The third type of validity is construct validity.
This is how logical an instrument is in measuring a
concept. Construct validity can be established
through divergent and convergent methods of evalu-
ating how well an instrument measures a theory or
construct; however, it can never be truly proved but
rather disproved. The fourth type of validity is dis-
criminate validity. This is a type of validity that seeks
to explore how well an instrument can discriminate
between groups of people. The final type of validity
is criterion validity. It seeks to establish a relationship
between the assessment and another factor (crite-
rion). There are two methods of establishing criterion
validity. As with reliability types, the data collection
and comparison methods often serve as names for
criterion validity. The methods (names) are concur-
rent and predictive validity. In concurrent validity,
data are collected at the same time (concurrently)
and assessment scores are compared to examine cor-
relation. In predictive validity, data are collected first
on the test instrument and then later on another
assessment and compared for correlation.
The purpose of this review is to compare dexterity
assessments based on published research related to
the tests’ reliability, validity, and other factors, includ-
ing cost, availability, time to administer, and bilateral
hand use.
METHODS
A critical review was conducted by one reviewer
using the method proposed by Wright et al.7 The re-
search question was ‘‘What are the psychometric prop-
erties of commercially available, adult dexterity
assessments in the United States?’’ Before searching
the evidence, a research protocol was created that spec-
ified inclusion and exclusion criteria. Only English-
language studies, Level 2b or higher on the hierarchy
of evidence, that examined the psychometric proper-
ties of adult, commercially available dexterity assess-
ments were included. Level 2b evidence was selected
because it is the level of investigation associated with
exploratory cohort studies that provide meaningful re-
sults, which are more generalizable compared with
case studies.8 Exclusion criteria were set as pediatric
and geriatric studies, non-English studies, client self-
assessment questionnaires related to hand use, and
dexterity assessments that are unavailable for purchase
or replication within the United States. Additionally,
dexterity assessments were excluded if the review
failed to find any literature on the instrument.
The literature was searched with a date range from
1920 to 2007. The databases that were individually
searched through EBSCOHost portal included the
following: Medline, PubMed, CINAHL, PsychINFO,
and Pre-CINAHL. Google Scholar was also searched.
Terms used in each database search included the
following: dexterity OR coordination AND adult
AND assessment OR instrument OR evaluation,
AND psychometric properties AND therapy assess-
ment. The databases were also searched using spe-
cific names of the dexterity assessments found in a
textbook on physical dysfunction rehabilitation.9
Lastly, the reference citations of the studies obtained
were examined to find additional studies to include
in the review.
Data were extracted and placed into a matrix to
provide a detailed description of the sample (size,
JulyeSeptember 2009 259
sex, and population), study purpose, analysis, and A total of 67 research studies related to the 14 as-
statistical results. These data provide a comprehen- sessments were found, 40 of which met the inclusion
sive overview based on available literature related to criteria. Research related to the reliability and valid-
each dexterity assessment. ity of each assessment, and a history of the research
done to date, is presented in Table 3. Because of the
vast amount of data uncovered in this review, the fol-
RESULTS lowing narrative is an overview of each assessment
instrument and the details of the statistical findings
Fourteen dexterity assessments were identified from each study are placed in Table 3.
that met the inclusion criteria. Table 1 provides a
summary of the number of published research stud-
ies found per dexterity assessment and the subse- NARRATIVE DISCUSSION OF
quent types of reliability and validity established. TEST-SPECIFIC RESULTS
Table 2 includes information about each assessment
such as the original publication date of the instru- Box and Block Test
ment, vendor, and cost, whether or not the test as-
The Box and Block test (BBT) is a measure of manual
sesses bilateral hand use, tool use, manual versus
dexterity that requires repeatedly moving 1-inch blocks
finger dexterity (or both), and the time taken to
from one side of a box to another in 60 seconds.
administer the test.
Mathiowetz et al.10 first provided normative data on a
large sample size from a seven-county sample in the
Milwaukee area. Additionally, four other Level 2b
studies on this assessment were examined.10e13 Three
TABLE 1. Summary of Subgroup Analysis Based on Each studies were completed on patient populations that
Dexterity Assessment
established validity of use with various diagnoses. The
Numbers of BBT shows very high interrater and testeretest
Studies
with Level reliability (intraclass correlation coefficient
Dexterity 2b or . Established Established [ICC] ¼ 0.99). All studies were well designed, free
Assessment Evidence Reliabilitya Validityb of bias, and demonstrate reliability and validity of the
BBT.
BBT 5 RET, INTER CR, CON,
DIS, F, CNT
Crawford 1 F, CNT Crawford Small Parts Dexterity Test
Small Parts
FDT 1 RET, INTER CR, CON, The Crawford Small Parts Dexterity Test is a timed
DIS, F, CNT
Grooved 2 RET F, CNT
test of both manual and finger dexterity that requires
Pegboard use of tweezers and a screwdriver for a series of tasks
JHFT 2 RET CR, CON, on an assembly plate. Although this test has face
DIS, F, CNT validity, and presumably content validity, the litera-
MMDT 2 RET CR, CON, F ture is void of studies establishing solid psychometric
MRMT 6 IC, RET CR, CON,
DIS, F, CNT
properties on this instrument. Only one Level 2b
Moberg Pick- 4 INTER CR, CON, study was found; the purpose of that study by
Up Test DIS, F, CNT Burger14 was to question the original reference values
NHP 3 RET, INTER CR, F, CNT because changes had been made in the testing mate-
O’Connor 1 DIS, F, CNT rials and yet the normative data were not reassessed.
FDT
PP 6 RET CR, CON,
This study used a small convenience sample of
DIS, F, CNT healthy volunteers to evaluate differences between
SODA 3 IC, RET CR, CON, F, scores on the two test versions. There was not a statis-
CNT tically significant difference between Part I of the test,
WMFT 4 INTER, IC CR, CON, but there was a large difference (t ¼ 5.5, p , 0.001) in
DIS, F, CNT
Part II. This assessment is therefore in need of reeval-
BBT ¼ Box and Block test; FDT ¼ Functional Dexterity Test; uation for psychometric soundness.
JHFT ¼ JebseneTaylor Test of Hand Function; MMDT ¼ Minne-
sota Manual Dexterity Test; MRMT ¼ Minnesota Rate of Manipu-
lation Test; NHP ¼ Nine-Hole Peg Test; FDT ¼ Finger Dexterity Functional Dexterity Test
Test; PP ¼ Purdue Pegboard; SODA ¼ Sequential Occupational
Therapy Dexterity Assessment; WMFT ¼ Wolf Motor Function The Functional Dexterity Test (FDT) is a timed
Test.
a
RET ¼ retest; INTER ¼ interrater; IC ¼ internal consistency. measure of manual dexterity that involves turning
b
CR ¼ criterion; CON ¼ construct, DIS ¼ discriminate, F ¼ face, sixteen wooden pegs over and reinserting them into
CNT ¼content. the pegboard. It was constructed over a 20-year period

260 JOURNAL OF HAND THERAPY

 TABLE 2. Properties of Dexterity Assessments
Assesses
Dexterity Bilateral Hand Time to Manual, Fine
Assessment Year Published Available From Use Cost Administer (min) Dexterity, or Both
BBT 1985 Sammons Preston N $189.95 5 M
Crawford small 1949 Harcourt Y $567.00 30 B
parts assessment
FDT 2003 North coast medical N $127.95 5 M
JHFTa 1969 Sammons Preston N $289.95 30 B
MMDT 1991 Lafayette Y $200.00 30 M
Instrument Co.,
MRMT 1946, updated Best priced Y $247.49 30 M
in 1957, 1969 products, Inc.,
Moberg Pick-Up 1958 Not Available for N N/A 5 B
Test purchase but
reproducible
NHP 1971 Sammons Preston N $72.95 5 F
O’Connor Tweezer 1958 Lafayette N $105.00 5 B
FDTa Instrument Co.,
PP 1948 Lafayette N $110.00 8e10 F
Instrument Co.,
SODAa 1996, short version Not available but Y N/A SODA ¼ 30 and B
in 1999 reproducible SODA-S ¼ 15
WMFT 2001 Not available for Y N/A 30e45 M
purchase but
reproducible
BBT ¼ Box and Block test; FDT ¼ Functional Dexterity Test; JHFT ¼ JebseneTaylor; MMDT ¼ Minnesota Manual Dexterity Test;
MRMT ¼ Minnesota Rate of Manipulation Test; NHP ¼ Nine-Hole Peg Test; FDT ¼ Finger Dexterity Test; PP ¼ Purdue Pegboard;
SODA ¼ Sequential Occupational Therapy Dexterity; WMFT ¼ Wolf Motor Function Test; M ¼ Manual dexterity, F ¼ Finger Dexterity,
B ¼ Both.
a
Test incorporates evaluation of tool use. Eating utensils and writing instruments are considered tools.

by many therapists at Texas Woman’s University and
several unpublished articles have been written on its
development and utility. The first and only published
study available for review was the original article.15
This article shared the summative data collected on
the assessment and provided reference values based
on age and hand dominance. Intrarater reliability
was shown to be excellent (ICC ¼ 0.91) and construct
validity was established. Further validation of the test
is recommended by the study’s authors.
Grooved Pegboard
The Grooved Pegboard is a unique dexterity as-
sessment in that each peg has a ridge on one side and
therefore must be oriented correctly to fit into a hole
on the pegboard. This lock-and-key feature of the peg
and pegboard necessitates visual attention to task
and thumb and index finger manipulation of the peg.
This feature makes it a test of interest to many
investigators and clinicians.16 Because the Grooved
Pegboard is one part of neuropsychological batteries,
only two Level 2b studies16,17 were found that solely
examined the assessment’s psychometric properties.
Bryden and Roy16 investigated the influence of gen-
der and hand dominance on manual dexterity, and
also provided normative data for the performance
of 153 healthy adult subjects. The study also provides
an alternate use for the test by providing normative
data on the amount of time it takes to remove the
grooved pegs from the holes. The authors suggest
that this method of test administration could be
used as a motor speed assessment, although no
attempt was made to validate it with another estab-
lished assessment of motor speed. A study by Ruff
and Parker17 used the Grooved Pegboard with 360
healthy adults to establish gender- and age-specific
reference values, as well as to provide evidence of
retest reliability at a statistically significant level of
p , 0.01. Both studies on the Grooved Pegboard are
robust studies with adequate sample sizes, sound
methodologies, and similar findings related to
gender and hand dominance on dexterity.
JebseneTaylor Test of Hand Function
The JebseneTaylor Test of Hand Function (JHFT)
assesses both fine and manual finger dexterity through
seven timed subtests related to functional tasks, such as
picking up common objects, eating, and writing. This
instrument was developed in 1969 by Jebsen et al.18
Two Level 2b studies18,19 were reviewed on the JHFT,
including the original normative data that were col-
lected on 300 healthy and 60 impaired individuals
across the age span. This original study established re-
liability, validity, and reference values based on age.
The second Level 2b study19 established criterion va-
lidity (r ¼ 0.635, p , 0.01) with 18 traumatic spinal
cord injured patients by correlating the scores on the
JHFT to scores on the KleineBell ADL scale.

JulyeSeptember 2009 261

 TABLE 3. Summary of Literature on Available Dexterity Assessment

262
Number and
Dexterity Sex of
Assessment Authors Year Subjects Population Purpose Statistical Results
BBT Svensson and Hager-Ross11 2006 N ¼ 20; 11F, 9M Adults with CharcoteMariee Establish reliability with Retest ICC for right
Tooth disease patient population hand ¼ 0.95, left hand ¼ 0.96
Platz et al.12 2005 N ¼ 56 Neurologically Interrater reliability ICCs and Spearman rho
impaired adults testeretest reliability, all . 0.95
construct validity between
Fugl-Meyer test, ARA,
and BBT
Desrosiers et al.13 1994 N ¼ 35 healthy adults, N ¼ 34 Patients older than 60 yr with Establish reference values, ICC ¼ 0.89 and 0.97, validity
impaired adults, N ¼ 104 and without UE impairment construct validity, and matched with ARA using
impaired adults (for the reliability Pearson r ¼ 0.80 and 0.82

JOURNAL OF HAND THERAPY

construct validity test), and
N ¼ 360 (for the norming)
Goodkin et al.26 1988 N ¼ 228 Patients with MS Compared BBT and NHP Correlation between BBT and
with typical MS disability NHP, r ¼ 0.70
ratings
Mathiowetz et al.10 1985 N ¼ 628; 318F, 310M Volunteers from 7 different Interrater reliability Interrater reliability Pearson
(age range 20e94) counties in Milwaukee area r ¼ 1.00 for right hand and
r ¼ 0.999 for left hands
Crawford small parts Burger14 1985 N ¼ 24 Healthy adults Establish reliability between Paired t tests showed no
two versions of the difference on Part I of the test
assessment instrument t ¼ 0.5 but differences were
found on part II t ¼ 5.5,
p , 0.001
FDTa Aaron and Stegnik Jensen15 2003 N ¼ 339. Study based on 5 Students, workers, uninjured Establish validity, reliability Interrater reliability
different combined studies and injured hands of hand reference values ICC ¼ 0.82e0.93, intrarater
therapy patients reliability ICC ¼ 0.91
Grooved pegboard Bryden and Roy16 2005 N ¼ 153; 106F, 47M Healthy college students Establish reliability of a new F values were significant at
administration method p , 0.001 level
Ruff and Parker17 1993 N ¼ 360 Healthy adults from 3 Evaluated changes with hand Age, education, and gender
geographical locations dominance, gender, differences were noted,
education, and age p , 0.01. Reliability: Pearson
r coefficient dominant hand
r ¼ 0.72 and nondominant
hand r ¼ 0.74
JHFT Lynch and Bridle19 1989 N ¼ 18 Traumatic SCI patients Compare JebseneTaylor to Pearson r ¼ 0.635, p , 0.01
KleineBell ADL Scale for
construct validity
Jebsen et al.18a 1969 N ¼ 300 (30F and 30M in age 300 Healthy adults Establish reference values for 7 Pearson coefficient for retest
categories 20e29, 30e39, and 60 patients subtests according to age and reliability r ¼ 0.60e0.99,
40e49, 50e59, and 60e94) gender; establish Good discriminate validity
discriminate validity with using SDs: patients were
patient population greater than 2 SD away from
normative reference values
 MMDT Surrey et al.20 2003 N ¼ 223 Examine the difference in t-Tests were statistically
performance on the MRMT significant at the p , 0.001 for
and the MMDT placing and turning subtests
and for overall scores
Desrosiers et al.27 1997 N ¼ 247 Healthy elderly Establish criterion validity by ICC ¼ 0.79e0.87 for retest
comparing MMDT with reliability; ICC between
MRMT (N ¼ 45), BBT, and PP MMDT and MRMT ¼ 0.85e
testeretest reliability 0.95; ICC with BBT ¼ 0.63
(N ¼ 35); establish retest and ICC with PP ¼ 0.67
reliability
MRMT Surrey et al.20 2003 N ¼ 223 College students and airline Examine the difference in t-Tests were statistically
passengers performance on the MRMT significant at the p , 0.001 for
and the MMDT placing and turning subtests
and for overall scores
Maiden and Dyson21 1997 N ¼ 25 15 Healthy subjects, 10 injured Establish reliability of Pearson r ¼ 0.95
clients assessment instrument
between standing and sitting
conditions
Clopton et al.22 1984 N ¼ 90; 36F, 54M College students Establish reliability of Scores between standing and
assessment administration sitting did not differ at the
between standing and sitting p ¼ , 0.05 level
conditions
Gloss and Wardle23 1982 N ¼ 118; 22F, 96M Adults with permanent hand Establish predictive validity by Pearson r ¼ 0.266e0.814
impairment correlating scores
between MRMT and
disability rating
Shanthamani24 1978 N ¼ 60; 22F, 38M Government factory workers Establish predictive validity by Pearson r ¼ 0.50
correlating performance
scores with gender,
education, and field
experience
Drussell25 1959 N ¼ 32; 9F, 22M Adults with cerebral palsy who Establish criterion validity of Pearson’s r ¼ 0.68
worked in manual labor jobs the MRMT (placing subtest
in Los Angeles only) with the USES
Moberg Pick-Up Amirjani et al.29 2007 N ¼ 116; 87 F, 29M Healthy subjects in 3 groups: Establish reference values Age had a significant impact
Test ages 20e39 (N ¼ 34) 40e59 based on age, gender, and on performance (p , 0.01);
(N ¼ 35), 60 and older hand dominance vision had a significant
(N ¼ 47) impact on performance
(p , 0.05); and females were
faster compared with men
(p , 0.05)
Jerosch-Herold30 2003 N ¼ 23; 4F, 19M Median nerve lac/repair Establish validity by measuring Cohen’s d effect size ¼ 0.80
the assessment instrument’s
responsiveness to clinical
change
Ng et al.31 N ¼ 100; 47F, 53M Healthy adult volunteers from Establish reference values Paired t-tests between visual
a variety of occupations based on gender and hand status, hand dominance, and
dominance; interrater genders: all results were
reliability tested on 14 of 100 significant with p , 0.01.

JulyeSeptember 2009 263

subjects Pearson’s coefficient for
interrater reliability, r ¼ 0.60
(Continued on next page)
 Table 3 (continued)

264
Number and
Dexterity Sex of
Assessment Authors Year Subjects Population Purpose Statistical Results
28a
Moberg 1958 Design a measure as a
functional sensory test
NHP Svensson and Hager-Ross11 2006 N ¼ 20; 11F, 9M Swedish adults with Charcote Establish reliability of test with
Retest ICC for right
MarieeTooth disease patients hand ¼ 0.99, left hand ¼ 0.80
Grice et al.34 2003 N ¼ 25 (for reliability tests) and College students and Establish interrater reliability,
Pearson r: Right: r ¼ 0.984, left:
N ¼ 703; 389F, 314M for community volunteers retest reliability, and r ¼ 0.993. Testeretest
norming (ages 21e71 yr) normative reference values reliability Pearson r
coefficient: right r ¼ 0.459,
left r ¼ 0.442
Mathiowetz et al.10a 1985 N ¼ 644 26 female OT students, and 618 Establish reference values, Concurrent validity: right:

JOURNAL OF HAND THERAPY

volunteers concurrent validity with the Pearson r ¼ 0.61 left:
PP, and reliability (retest and Pearson r ¼ 0.53; retest
interrater) reliability: right r ¼ 0.69, left
r ¼ 0.43; interrater reliability:
right r ¼ 0.97, left r ¼ 0.99
O’Connor FDT Gloss and Wardle37 1981 N ¼ 96; 18F, 78M Adults with permanent UE Establish predictive validity by Pearson r ¼ 0.69 for disability
impairment correlating on O’Connor FDT and 0.88 for ADL subscale
and disability rating and
ADL subscale
PP Gallus and Mathiowetz2 2003 N ¼ 25; 22F, 3M Patients with MS Examine retest reliability for ICC for 1 trial ¼ 0.850.90, ICC
1 and 3 trial administration for 3 trial ¼ 0.920.96
methods
Buddenberg et al.38 2003 N ¼ 47; 33F, 14M College Students Examine retest reliability for ICC for 1 trial ¼ 0.370.70, ICC
1 and 3 trial administration for 3 trial ¼ 0.81.89
methods
Maiden and Dyson21 1997 N ¼ 25 Healthy adults and 10 injured Positive correlation Pearson r ¼ 0.95
clients
Hamm and Curtis39 1980 N ¼ 340; 164F, 176M Candidates for vocational Establish reference values for a All Z tests were statistically
rehabilitation clinical population; significant p , 0.05. Authors
performed correlation recommend using clinical
analysis using Z tests (on reference values
means) between 1968 norms
and clinical sample
Shanthamani24 1979 N ¼ 60; 22F, 38M Government factory workers Establish validity correlation of Pearson r ¼ 0.80
performance with gender
and education
Tiffin et al. 1948 N ¼ 7814; 4530F, 3284M College students, veterans, and Establish reference values, Pearson r ¼ 0.60e0.76 for 1-trial
industrial job applicants retest reliability and validity scores, and r ¼ 0.82e0.91 for
3-trial scores (estimates
extrapolated by Spearmane
Brown prophecy formula)
 SODA Van Lankeveld et al.43 1999 N ¼ 109; 62F, 42M Establish reliablity (internal Cronbach’s alpha; SODA ¼ 0.91,
consistency) SODA-S ¼ 0.81 HAQ VAS
pain correlation between
Sollerman hand function and
SODA r ¼ 0.79 and r ¼ 0.75 for
SODA & VAS and r ¼ 0.052
for SODA and self-reported
disability
O’Connor et al.42 1999 N ¼ 25; 14F, 11M Adults with RA being seen at Establish validity and Retest Pearson r ¼ 0.93,
outpatient rehabilitation reliability (interrater and intrarater Pearson r ¼ 0.78
center in Australia retest)
Van Lankeveld et al.41 1996 N ¼ 109 Adults with RA Establish validity and retest Pearson’s r ¼ 0.71 for
and interrater reliability correlation with ROM and
(reliability done on N ¼ 22) grip, Pearson’s r ¼ 0.65 with
Dutch health status
questionnaire, Pearson’s
r ¼ 0.41 with VAS for pain,
Pearson’s r ¼ 0.34 for disease
status using disease
assessment score. Retest
reliability r ¼ 0.93 interrater
reliability r ¼ 0.78
WMFT Morris et al.45 2001 N ¼ 24 Adults after stroke with motor Establish interrater and retest Interrater reliability, ICC ¼ 0.97
impairment reliability, establish reliability and 0.88; retest reliability
(internal consistency) ICC ¼ 0.90 and 0.95 for
performance time and
functional ability score,
respectively. Internal
consistency was .0.86 for both
test administrations
Wolf et al.46 2001 N ¼ 38 19 adults after stroke, 19 health Establish interrater and retest ICC ¼ 0.95e0.99
controls reliability, establish criterion
validity with FMA and
construct validity with
control case
Wolf et al.47 2005 N ¼ 229 Adults after sroke (3e9 months Establish criterion and ICC ¼ 0.97e0.99
poststroke) construct validity with FMA
Hui Yung Ang 2006 N ¼ 45; 29F, 16M Adults after stroke Establish construct validity Spearman’s rho correlation
and Wai Kwong48 between FMA, FIM, coefficients all .0.896. No
Brunnstrom’s recovery correlation found with FIM
stages, and scale (numbers not given)
BBT ¼ Box and Block test; ICC ¼ intraclass correlation coefficient; UE ¼ upper extremity; MS ¼ multiple sclerosis; NHP ¼ Nine-Hole Peg Test; FDT ¼ Functional Dexterity Test; JHFT ¼ Jebsene
Taylor Test of Hand Function; SCI ¼ spinal cord injured; ADL ¼ activities of daily living; SD ¼ standard deviation; MMDT ¼ Minnesota Manual Dexterity Test; MRMT ¼ Minnesota Rate of
Manipulation Test; USES ¼ United States Employment Services Descriptive Rating Scale; PP ¼ Purdue Pegboard; FMA ¼ Fugl-Meyer Motor Assessment; SODA ¼ Sequential Occupational
Therapy Dexterity Assessment; RA ¼ rheumatoid arthritis; ROM ¼ range of motion; ARA = Action Research Arm Test; FIM ¼ Functional Independence Measure; SODA-S ¼ SODA-Short
form; HAQ ¼ Health Assessment Questionnaire; VAS ¼ Visual Analogue Scale.
ICC, Pearson r, Spearman’s Rho, and Cohen’s d all estimate correlation and effect of variables in relationship to one another.
Interpreting correlation coefficients: .0.8 ¼ large correlation, .0.5 ¼ moderate correlation, and .0.2 ¼ small correlation.
aOriginal article on assessment instrument.

JulyeSeptember 2009 265

Minnesota Rate of Manipulation Test
The Minnesota Rate of Manipulation Test (MRMT)
and the Minnesota Manual Dexterity Test (MMDT)
are two versions of a similar assessment tool. The
MRMT is no longer produced but can be purchased
through Internet sources. Both versions consist of five
timed subtests that assess manual dexterity needed
to turn and/or place 60 short, round blocks with one
or both hands. A distinction between the two ver-
sions is that MRMT contains two boards, whereas
MMDT uses a single board. Six Level 2b studies20e25
were reviewed on the MRMT and two on the
MMDT.26,27 Both assessments have undergone
research to establish reliability and all five types of
validity. However, Surrey et al.20 raise legitimate con-
cern for the use of the MMDT based on their results
that revealed significant differences in scores
between the placing and turning subtests between
the two test versions (p , 0.001). Furthermore, they
point out that the MMDT uses the normative values
and instructions established for the 1957 version of
the MRMT. Given their findings, research to establish
new norms and evaluate psychometric properties
should be done related to the currently available
version of the MMDT.
Moberg Pick-Up Test
The Moberg Pick-Up Test is a timed measure of both
manual and fine motor dexterity that involves picking
up 12 small items. It was first described by Moberg in
1958.28 It was originally designed as a functional sen-
sory test of the hand, but adequately captures the re-
lated components of object manipulation and offers
a valuable score of vision-occluded dexterity. In addi-
tion to the original, descriptive article, three Level 2b
studies were reviewed.28e30 In 1999, Ng et al.31 exam-
ined 100 healthy adults with the Moberg Pick-Up Test.
They established reference values; however, 53% of
their subjects ranged from ages 20 to 29 years. They
demonstrated a statistically significant influence
(p , 0.01) of gender and hand dominance on dexter-
ity. Fourteen of the 100 subjects were randomly re-
tested by an additional examiner. The interrater
correlations were statistically significant at the
p , 0.01 level. Based on the limitations of the Ng
et al. study, Amirjani et al.29 conducted a study in
Canada with a minimum of 34 healthy subjects in
one of three age categories—young (20e39 yr),
middle aged (40e59 yr), and old (60þ yr). This study
provided reference values based on age, gender, hand
dominance, and eyes open and closed testing condi-
tions. The final study30 reviewed on the Moberg was
of 23 patients who had undergone median nerve lac-
eration and repair. The study established
discriminate validity of the Moberg by demonstrating
its ability to be responsive to clinical change. The
266 JOURNAL OF HAND THERAPY
Moberg test is not available for purchase, but can be
reproduced using the provided specifications.
Nine-Hole Peg Test
The Nine-Hole Peg (NHP) Test is a timed measure
of fine dexterity and involves placing and removing
nine pegs in a pegboard. Three studies were re-
viewed on the NHP. The NHP was first described by
Kellor et al.32 in 1971. The study provided normative
references based on a sample of 250 subjects. There
was a description of the test pegboard and the pegs
but no description of the container. No reliability or
validity was reported until Mathiowetz et al.33 con-
ducted new research in Wisconsin with a large
sample of volunteers. This study examined validity
of the test through a comparison with the Purdue
Pegboard (PP) test. The results showed a moderate
correlation between the two assessments. In 2003,
Grice et al.34 used a sample of college students and
community volunteers to establish new reference
values and evaluate reliability. Both reviewed studies
used large samples and provided reference values
based on gender and age. A Swedish study examined
the use of the NHP within a small sample of patients
with CharcoteMarieeTooth Syndrome, the retest
reliability was found to be high (ICC ¼ 0.99).11
O’Connor Finger Dexterity Test
The O’Connor Finger Dexterity Test (FDT) is a
timed test of both manual and fine dexterity that
dates back to 1926. It involves manipulating and
placing small pins, three at a time, into 100 small
holes of a pegboard. The original test construction
and validation were published in the testing manual,
but results were not published in a scholarly journal.
The test is also available in a modified version that
includes the use of tweezers to place a single pin in a
hole of the pegboard. Both tests are used today for
screening job applicants for various jobs that require
fine finger and tweezer dexterity skills35,36 but only
one Level 2b study was found that examined psycho-
metric properties.37 This study correlated the scores
on the O’Connor FDT with disability ratings and
ADL subscale scores on the disability rating. The
sample was 96 adults with permanent impairment
to the upper extremity. The Pearson correlation rat-
ings were 0.69 and 0.88 for the disability rating and
the ADL subscale, respectively. These results repre-
sent moderate to high correlation and therefore dem-
onstrate good-to-excellent predictive validity. No
Level 2b studies were found on the tweezer version
of the O’Connor dexterity assessment. Based on lim-
ited data to support either assessment instrument,
caution should be taken when considering these
instruments.
Purdue Pegboard
The Purdue Pegboard (PP) is a test of fine dexterity
that has been widely used in both clinical and research
settings.2 This assessment involves a series of four
subtests that consist of placing small pins into holes
on a pegboard and assembling pins and washers.
Including the original article on this assessment, six
Level 2b studies were reviewed.2,15,20,38e40 Validity
and reliability are well established through abundant
research in healthy and patient populations. The orig-
inal reference values from 1948 were obtained on the
large sample (N ¼ 7,814) of college students, veterans,
and industrial applicants and were revised in 1968 for
specific personnel selection tasks, such as electronics
production, general factory work, and assembly
jobs. Reference values have also been established for
clinical populations in subsequent studies. The stud-
ies that examined retest reliability found better results
with the three-trial administration.
Sequential Occupational Therapy Dexterity
Assessment
The Sequential Occupational Therapy Dexterity
Assessment (SODA) is a test specifically designed
for patients with rheumatoid arthritis (RA) that in-
volves ten bilateral and two unilateral tasks. This is a
unique dexterity assessment because it does not use
time as a measure of performance but rather evaluates
the quality of movement. It measures both manual
and fine dexterity. It was introduced in 1996 in the
Netherlands.41 Three Level 2b studies were reviewed.
The SODA was used in an RA patient population in
Australia to assess validity and reliability.42 In 1999,
a shortened version was created using the original
study population to correlate findings and establish
validity.43 This study demonstrated a correlation coef-
ficient of 0.93 (high) between the SODA and the
revised, shortened version, SODA-S. All studies dem-
onstrated criterion validity by showing high correla-
tion with other established and acceptable measures
of disease and pain.
Wolf Motor Function Test
The Wolf Motor Function Test (WMFT), formerly
called the Emory Motor Test44 is a functional dexter-
ity test that has been shown to be reliable and valid
within acute and subacute stroke patient popula-
tions. It is a measure of manual dexterity that requires
completion of six upper extremity movements and
nine functional tasks; both segments are timed.
There were four Level 2b studies reviewed45e48 that
collectively demonstrate reliability and validity of
use within a stroke population. When criterion and
construct validity were evaluated, the ICC values
ranged between 0.97 and 0.99 (high).47
DISCUSSION
This critical review of dexterity assessments and
research related to the psychometric soundness of
these instruments yielded information essential to
those interested in patients with dexterity limitations.
Three of the reviewed assessments (the MRMT, PP,
and BBT) demonstrated solid psychometric proper-
ties through evidence from more than five Level 2b
studies. Six studies collectively established reliability
as well as criterion, construct, discriminate, and con-
tent validity of the MRMT and PP, whereas five Level
2b studies established reliability and all types of
validity of the BBT. Based on these results, the BBT
and MRMT are recommended as assessments of
choice to evaluate manual dexterity, and the PP is
recommended to assess fine finger dexterity. Because
the BBT evaluates unilateral dexterity, the MRMT
evaluates bilateral manual dexterity, and the PP eval-
uates fine finger dexterity, clinicians and researchers
need to further consider the specific needs of a patient
population or a given research investigation before
selecting an assessment tool.
Three of the reviewed assessments, the O’Connor
FDT, Grooved Pegboard, and Crawford Small Parts,
should be used cautiously. These three assessments
had few published studies examining their reliability
or validity, which limited examination to the original
research data and suggests a need for additional
research to evaluate these instruments.
Several assessments in this review have unique
characteristics that may also influence a clinician’s
decision to select an assessment. The Moberg serves
as the only assessment that incorporates a visually
blinded testing condition. The Grooved Pegboard is
unique for its additional obstacle of having a ridge on
the side of each peg and thereby demanding high levels
of visual attention. The WMFT is used specifically for
evaluating stroke patients, and the SODA is used
specifically for patients with RA. The SODA is also
the only test that does not measure dexterity perfor-
mance based on time. Another separation among the
assessments is those that require the use of tweezers.
These assessments are the O’Connor Tweezer
Dexterity Assessment and the Crawford Small Parts.
These two assessments, however, have no established
reliability data, and should undergo evaluation before
continued use by clinicians or researchers.
LIMITATIONS
Both authors established criteria for data extraction
at the start of the review; however, only one reviewer
searched the literature and extracted data. Another
notable limitation is that this review focused only on
adult dexterity assessments, to the exclusion of pedi-
atric and geriatric assessment tools. Further
JulyeSeptember 2009 267
investigation into assessments specific to these pop-
ulations is warranted. Finally, perhaps the pervasive
reliance on technology, such as computers, cellular
telephones, pagers, I-pods, and MP3 players has
affected baseline dexterity values in all populations.
Dexterity abilities may have improved radically due
to the increased use, or declined based on the auto-
mation of work processes that were previously reliant
on manual skills. Either way, research is needed to
update the reference values of all 14 assessments from
those values established in the 1900s. Additionally,
research exploring how dexterity assessments are
used across clinical practice is necessary. The sam-
pling methods of studies related to dexterity hand
function assessments need not be limited to conve-
nience samples, as they were in most of the studies
presented in this review, given the increasing profes-
sional network connections and the use of Internet
and other technologies.
CONCLUSIONS
This review summarized decades of research done
on commercially available dexterity assessments. The
focus was on the psychometric properties and other
defining characteristics of dexterity assessments with
the goal of helping clinicians and researchers make
informed selections of appropriate dexterity assess-
ment instruments to compliment a full evaluation of
the function of the upper limb. The MRMT, PP, and
BBT demonstrated solid psychometric properties
through evidence from more than five Level 2b stud-
ies. The BBT and MRMT are therefore recommended
as assessments of choice to evaluate manual dexterity,
and the PP is recommended to assess fine finger
dexterity. This review highlighted psychometric
soundness as a critical factor in decisions regarding
selection of a dexterity assessment. This review may
also provoke new research ideas based on gaps in the
literature or the changing needs of therapy fields.
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JulyeSeptember 2009 269
 JHT Read for Credit
Quiz: Article # 133

Record your answers on the Return Answer Form
found on the tear-out coupon at the back of this
issue. There is only one best answer for each
question.
#1. The design of this study is
a. an RCT
b. a case series
c. a systematic review
d. a narrative review
#2. The study primarily evaluates tests of
a. hand function
b. digital strength
c. finger dexterity
d. digital sensibility
#3. The authors refer to the following as psychomet-
ric properties of testing instruments
a. validity and reliability
b. sensitivity and specificity
c. positive and negative predictive values
d. selectivity and reactivity
#4. The research design was based on data extracted
from
a. manufacturers’ printed instructions
b. a review of a series of articles from the
literature
c. questionnaires returned by CHTs
d. interviews of patients at the conclusion of their
treatment (discharge from service)
#5. The authors recommend the following test(s) for
their psychometric properties
a. Jebsen Hand Function Test
b. BBT, MRMT, and PP
c. Sollerman Hand Function Test
d. Moberg Pick Up Test and the 9 Hole Peg Board
When submitting to the HTCC for re-certification,
please batch your JHT RFC certificates in groups
of 3 or more to get full credit.

270 JOURNAL OF HAND THERAPY