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 Disability and Rehabilitation

ISSN: 0963-8288 (Print) 1464-5165 (Online) Journal homepage: http://www.tandfonline.com/loi/idre20

Using the international classification of

functioning to examine the impact of trigger finger

Danit Langer, Adina Maeir, Michael Michailevich, Yael Applebaum & Shai
Luria

To cite this article: Danit Langer, Adina Maeir, Michael Michailevich, Yael Applebaum & Shai
Luria (2016): Using the international classification of functioning to examine the impact of
trigger finger, Disability and Rehabilitation, DOI: 10.3109/09638288.2015.1137980

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 DISABILITY AND REHABILITATION, 2016
http://dx.doi.org/10.3109/09638288.2015.1137980

RESEARCH PAPER

Using the international classification of functioning to examine the impact of

trigger finger
Danit Langera, Adina Maeira, Michael Michailevichb, Yael Applebauma and Shai Luriac
a
School of Occupational Therapy, Hadassah and Hebrew University, Jerusalem, Israel; bDepartment of Orthopaedic, Sherutay Briut Clalit,
Jerusalem, Israel; cDepartment of Orthopedic Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel

ABSTRACT ARTICLE HISTORY

Purpose To evaluate the impact of trigger finger (TF) on hand motor function, activity and Received 9 June 2015
participation (A&P) and quality of life (QOL), and to evaluate the association between personal Revised 20 November 2015
factors (age and gender, disease severity) and body functions (dexterity and strength) with A&P and Accepted 30 December 2015
Downloaded by [The University of British Columbia] at 05:17 12 March 2016

QOL in patients with TF. Methods Sixty-six patients with TF (study group) and 66 healthy Published online 29 January
volunteers (control group) participated in the study. TF symptoms were graded using the Quinnell 2016
classification. A&P was evaluated using the Disabilities of Arm Shoulder and Hand questionnaire
KEYWORDS
and the QOL using the World Health Organization Quality of Life questionnaire. Dexterity was Disability; dexterity; grip
evaluated using the Functional Dexterity Test and the Purdue Pegboard Test; hand strength was strength; hand function;
evaluated using the Jamar Dynamometer and Pinch Gauge. Results The comparisons between the quality of life; stenosing
study and control groups revealed significant differences in all measures. The study group reported flexor tenosynovitis
lower perceived QOL, A&P and reduced hand strength and dexterity. Hierarchical regression analyses
revealed that (a) the severity of TF contributed significantly to the explained variance of QOL, while
demographics and hand functioning did not; (b) demographics, TF severity and hand function all
contributed significantly to the explained variance of A&P. Conclusion The findings of the study point
to the importance of addressing the functional implications and QOL of individuals with TF.

ä IMPLICATIONS FOR REHABILITATION

 Although trigger finger is considered to be a mild hand pathology, it has a wide-ranging impact
on hand functioning, daily activities and quality of life.
 Clinicians should include assessments of these outcomes in the treatment of individuals with
trigger finger.
 Treatment efficacy should be evaluated with International Classification of Functioning
outcomes, and not limited to symptomatology.

Introduction fingers flexor tendons commonly occurs at the fibro-

Normal function of the hand is an important factor in a
person’s ability to independently engage in daily
activities and occupations.[1,2] Despite the fact that
hand injuries and disorders are frequent, their conse-
quences are often underestimated in clinical practice.[3]
Clinicians and researchers in the field of hand therapy
tend to focus on body functions and body structures
(anatomical and physiological aspects), with less empha-
sis placed on activities (execution of tasks or actions),
participation (involvement in life situations) and quality
of life (QOL).[4,5] The current research focused on the
specific health condition of trigger finger (TF).
TF, also called the stenosing flexor tenosynovitis, is a
common hand pathology in adulthood. Triggering of the
osseous tunnel formed by the metacarpal neck and the
first annular pulley. The initial complaints associated
with TF are pain over the A1 pulley or clicking. Without
treatment, there may be a gradual worsening of
symptoms to severe pain and locking of the digit in
flexion.[6,7] TF is one of the most common diseases seen
in hand surgery clinics and is the fourth leading cause of
referral to these clinics.[8–10] It is characterized by pain,
swelling and clicking of a digit during flexion or
extension.[11] The incidence of TF is 28:100 000 per
year or a lifetime risk of 2.6% in the general population,
but it increases to 10% in the diabetic population.[12,13]
The mean age of onset for TF is 58 years, and it is
diagnosed in women two to six times more frequently
than in men.[7] In recently published guidelines for the

CONTACT Danit Langer dlanger10@gmail.com School of Occupational Therapy, Mount Scopus, POB 24026, Jerusalem 91240, Israel
ß 2016 Taylor & Francis
 2 D. LANGER ET AL.
management of TF, experts agreed on the following
methods: orthotics, corticosteroid injections and surgical
treatment. When planning a treatment regimen, they
recommended considering the severity and duration of
the disease, as well as previous treatment.[14]
The literature describes the symptoms of TF, but there
is a lack of reference to the broader consequences of this
pathology. Furthermore, treatment efficacy studies
measure change in symptoms as the primary outcome
measure, and do not include measures of functional
status and QOL. Thus, the reported efficacy of orthotics
on symptom resolution in the short term was 66–92%
[6,11,15,16] and 87% in the long term [17]; and the
efficacy of corticosteroid injections on symptom reso-
lution in the long term was 45–69%.[18–20]
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The World Health Organization (WHO) adopted the
International Classification of Function (ICF) as an
‘‘international language’’ and as a model for evaluation
and measurement of health.[21] The ICF provides a
broad perspective on the implications of health condi-
tions that addresses the interaction between the elem-
ents of body systems and structures, activity and
participation (A&P) in life roles and contextual factors
(environmental factors and personal factors).[21] Rose
et al. [4] conducted a literature review to determine the
frequency of the use of the ICF classification in the hand
therapy literature. They found that the literature fre-
quently referred to body structures and body functions,
and much less frequently to A&P and environmental
components. Unfortunately, no change was found in the
frequency of use of these concepts over the years,
despite the growing place the ICF framework occupies in
the health care system. The authors stressed the need
for hand therapy research that will incorporate all
components of the ICF framework.[4] Adopting this
point of view will enhance the provision of more
comprehensive rehabilitation services that address the
whole person in their environment. Based on our clinical
experience, we suggest that although TF is considered a
minor health disorder by medical professionals, it bears
substantial limitations on the individuals that live with it.
Therefore, the focus of the present study was to evaluate
the impact of TF from a bio-psycho-social perspective
using the ICF as the theoretical framework for the study.
The usefulness and the advantages of the ICF have
been reported in several studies.[22–26] To make the ICF
applicable for clinical practice core sets have been
developed for different health conditions that provide a
specific list of ICF categories to describe the implications
of a defined condition.[3,22] The ICF core sets for
Hand Conditions (HC) have been adopted at the
International ICF Consensus Conference which convened
in Switzerland in 2009 comprising of (1) the
Comprehensive ICF Core Set consisting of 117 categories
to cover all aspects of function potentially relevant to
individuals with HC and (2) the Brief ICF Core Set
consisting of 23 categories from the comprehensive ICF
Core Set that serves as a minimal standard to describe a
patient function. The HC core sets could serve as useful
tools to guide research and practice in the assessment of
a patient function in clinical studies, clinical encounters
and multi-professional evaluation.[3] The Brief Core Set
for HC guided the domains to be examined in the
current study of individuals with TF.
In summary, the current study was motivated by the
high prevalence of TF in hand rehabilitation and the
paucity of knowledge regarding the broad conse-
quences of this condition. Despite the consideration
that TF is a relatively ‘‘minor’’ hand condition, clinical
experience leads us to question this claim, considering
client complaints of prolonged functional disability due
to this condition. Therefore, we chose the ICF in order to
study the consequences of the condition beyond
symptoms and body functions. This line of research
bears significance for the practice of hand rehabilitation
for individuals with TF and, in general, for all hand
related conditions, since this discipline is reported to
address a narrower scope of outcomes than those
recommended by the WHO.[4,21]
The goals of the study were to (a) evaluate the impact
of TF on motor function, A&P and QOL; (b) evaluate the
associations between personal factors and body func-
tions with A&P and QOL in people with TF.
Methods
Recruitment and participants
One hundred and fifty patients with TF that presented to
the clinics of two hand surgeons between 1 March 2012
and 30 April 2013 were invited to participate in the
study. Sixty-six patients agreed to participate.
Consenting participants inclusion criteria were adult
patient (age 18 years or greater) with a diagnosis of one
or more digits or thumb with TF of a Quinnell grade one
or higher (refer to Figure 1 for distribution of affected
digits). The exclusion criteria were upper extremity
trauma in the preceding year, known neurological
deficits, known cognitive deficits. Informed consent
was obtained from all participants in the study.
The research group was matched with healthy partici-
pants according to age and gender. A control group
of 66 healthy participants was recruited using a
convenience sample. The demographic and clinical
data of the patients and healthy participants were
recorded.

Figure 1. Distribution of trigger finger digits.
Instruments
Disabilities of the Arm Shoulder and Hand (DASH) was
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developed in order to describe the disability experi-
enced by people with upper-limb disorders and also to
monitor changes in symptoms and function over time.
The questionnaire consists of 30 questions related to
physical function, social function and different symp-
toms. Each item has five response options. The scores for
all items are then used to calculate a scale score ranging
from 0 (no disability) to 100 (most severe disability).
There are two additional parts with four questions that
are relevant for people that engage in sports, music and
work.[27] These parts were not included in the present
study. Many studies have examined the properties of the
DASH and found the questionnaire to have sound
psychometric properties.[27,28]
World Health Organization Quality of Life (WHOQOL-
BREF) questionnaire is the short version of the WHOQOL-
100. The questionnaire consists of 26 questions that are
divided into four areas: physical, psychological, social
and environmental and overall quality of life and general
health.[29,30] The WHOQOL-BREF is described in the
literature as having very good psychometric
properties.[29,31]
The Functional Dexterity Test (FDT) tool is suitable for
the adult population, 20–70 years old, with various
injuries to the upper limb. The FDT gives information
regarding the patients’ ability to use their hands for
functional tasks requiring a dynamic 3-jaw chuck grasp
pattern. It is made of a square wooden pegboard with 16
pegs. The examiner documents the time required to turn
over all the pegs. Execution time is measured on each
hand separately. The FDT was found to have good inter-
rater and good test re-test reliability.[32,33]
Purdue Pegboard Test (PPT) was developed in 1948, in
order to assess manual dexterity and precision of
applicants for industrial work. Since then, the PPT has
been used in rehabilitation and in research.[34] The PPT
includes four sub-tests: participants are asked to place
metal pins, one at a time, into a row of pegboard holes
TF, HAND FUNCTION, QOL, ACTIVITY AND PARTICIPATION 3
first with the dominant hand, then with the non-
dominant hand, followed by placing pairs of pins with
both hands simultaneously. In the fourth and final
subtest, a pin, washer, collar, and second washer are
assembled in an operation requiring both hands.[35]
Jamar Dynamometer (JD) was designed to measure
gross power fist grip and is considered to be the most
accurate test for this skill. The American Society of Hand
Therapists (ASHT) recommended the use of this tool for
the assessment of grip strength.[36] Psychometric
testing found good inter-rater reliability and high test
re-test reliability.[37,39]
Pinch Gauge (PG) by B & L Engineering Co was
designed to measure the strength of pinch grip of the
fingers used in daily activities. The Pinch Gauge is
considered to be the most accurate tool for the assess-
ment of pinch strength. Psychometric testing found good
inter-rater reliability and high test re-test reliability.[36]
Numerical Pain Rating Scale (NRS): The NRS is a scale
with 11 degrees, reflecting the subjective intensity of
pain experienced by a person during the preceding day
or the previous week.[39] The pain scale can be
administered verbally or by using a visual scale.[40]
The Quinnell grading system is used to assess clinical
severity of TF. According to this classification, TF fingers
are rated as follows: 0, normal movement of the digit; 1,
uneven movement; 2, actively correctable locking of the
digit; 3, passively correctible locking; and grade 4
represents fixed deformity.[41]
Ethical considerations
The study protocol was approved by the Institutional
Helsinki committee. Informed oral and written consent
was obtained from all participants.
Procedure
Informed consent was obtained by hand surgeons. The
hand functioning assessments and questionnaires were
administered by experienced occupational therapists to
participants immediately after their visit with the doctor.
Healthy participants were administered the same assess-
ment protocol.
Statistical procedures
Results were analyzed using SPSS 20 (SPSS Inc., Chicago,
IL). Prior to main hypotheses testing, group comparisons
were performed in order to rule out extraneous factors
(demographics and background clinical data) that might
influence the results. An independent sample t-test was
used to compare age between the TF groups with the
 4 D. LANGER ET AL.

control group. A Chi-square analysis was used to Table 1. Demographic and clinical data: comparison of TF and
compare gender, hand dominance presence of add- healthy groups.
itional health conditions and vocation between groups TF (n ¼ 66) Control (n ¼ 66)
(Table 1). Mean (SD) Mean (SD) t(df) p
Since the instruments for dexterity (FDT & PPT), Age 60.14 (11.34) 58.60 (11.55) 0.772(130) 0.663
strength (JD & PG) and QOL have multiple subtests, we Pain 5.48 (2.41)
Gender n (%) n (%) Chi2 p
conducted a principal components factor analysis. The Male 21 (32) 23 (35) 0.136 0.712
results for all subtests of the FDT and PPT produced 1 Female 45 (68) 43 (65)
Dominance
factor eigenvalue ¼3.7 which explained 61.8% of the Right 58 (88) 57 (86) 0.068 0.795
variance of these dexterity sub tests representing global Left 8 (12) 9 (14)
Affected Hand
dexterity function (factor loadings for each sub test are Dominant 37 (57)
presented in Table 2). A principal components factor Non Dominant 18 (27)
Both 11 (16)
analysis was conducted for right and left hand JD and PG Clinical grade
produced 1 factor, eigenvalue ¼3.03 which explained 1 12 (18)
2 45 (68)
76% of the variance of these sub tests, representing
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3 9 (14)
global hand strength (Table 2). A principal components Additional medical conditionsa
Yes 35 (53) 27 (41) 1.947 0.163
factor analysis conducted for the four domains of No 31 (47) 39 (59)
WHOQOL-BREF produced 1 factor, eigenvalue ¼2.96 Vocation
which explained 74% of the variance of sub tests, High manual strain 11 (18) 6 (9) 3.426 0.331
Low manual strain 36 (58) 36 (55)
representing global QOL (Table 2). These factors are Retired 10 (16) 16 (24)
presented as z scores (ranging from 3 to 3; mean ¼ 0) Unemployed 5 (8) 8 (12)
were used for further data analysis and will be referred TF: trigger finger.
a
Additional medical conditions reported were diabetes, cardiovascular
to as dexterity hand strength and QOL, respectively. disease, osteoarthritis, carpal tunnel syndrome, and musculoskeletal
An independent sample t-test was conducted to disorder not in upper extremity.
compare QOL, disability (as measured using the DASH),
dexterity and hand strength between TF and control
Table 2. Loadings for each sub-test used to form the factor of
groups. Pearson’s correlation was used to determine the
global dexterity function, hand strength and quality of life.
relationship between variables of interest and outcome
Global dexterity function
variables among the TF group. Multivariate analysis was
FDT DH FDT NDH PPT DH PPT NDH PPT BH PPT assembly
used to determine the explanatory model for TF health 0.608 0.672 0.845 0.841 0.905 0.805
outcome. Multiple linear hierarchical regressions were
computed using the DASH and global health-related Global hand strength
QOL factor as the dependent variables and personal
JD DH JD NDH PG DH PG NDH
factors (age and gender), disease severity (Quinnell 0.859 0.845 0.892 0.886
grade), hand strength and dexterity as the independent
Global quality of life
variables. According to the ICF model, a hierarchical
stepwise analysis was used to calculate the explanatory Physical Psychological Social Environmental
power of the independent personal and impairment 0.806 0.890 0.838 0.903
variables on the dependent variable. To do this, the FDT, functional dexterity test; PPT, Purdue Pegboard Test JD, Jamar
following variables were entered into the model in three dynamometer; DH, dominant hand; NDH, non-dominant hand; BH, both
hands.
blocks: block 1 personal factors (age and gender); block
2 disease severity (Quinnell grade) and block 3 impair-
ment variables (hand strength and dexterity). moderate significant correlations between all measures
(Table 4).
Both hierarchical regression models are presented in
Results
Table 5. Regarding the first model with QOL as the
The comparisons between the study and control groups dependent variable, all the independent variables
revealed significant differences in measures of QOL, together explained 24.1% of the variance in QOL (overall
disability, hand strength and dexterity. The TF group F¼ 3.368, p ¼ 0.010). The hierarchical analyses revealed
reported a lower perceived QOL and higher levels of that block 2, comprising the disease severity variable
disability. They also had reduced hand strength and significantly contributed to the R-square change (12%),
dexterity in comparison with the control group (Table 3). whereas the other blocks, comprising personal factors,
Results from the univariate correlation analysis revealed hand strength and dexterity, were not significant.
 TF, HAND FUNCTION, QOL, ACTIVITY AND PARTICIPATION 5

Table 3. Mean difference in disability, QOL, dexterity and hand strength between the TF group and controls.
TF group Control group 95% CI of the difference
Mean (SD) Mean (SD) t df p Effect Size Lower Upper
QoL QOL 0.33 (0.88) 0.31 (1.02) 3.8 126 0.001 0.733 0.31 0.98
Disability 35.8 (21.29) 8.00 (10.62) 9.2 95 0.001 0.967 32.78 21.15
Dexterity 0.35 (0.93) 0.34 (0.95) 4.2 128 0.001 1.442 0.37 1.02
Strength 0.37 (0.92) 0.37 (0.94) 4.5 129 0.001 0.795 0.42 1.06
TF: trigger finger.

addressing the functional implications and QOL of

Table 4. Correlation results among disability, QOL, hand individuals with TF.
strength and dexterity. Regarding the body functions of dexterity and hand
QOL Strength Dexterity strength, we found that individuals with TF scored
Disability 0.310** 0.457** 0.365** significantly lower than healthy controls. These findings
QOL 0.310* 0.390**
Strength 0.363**
could be partially explained by the affected digits among
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the majority of study participants which involved the

*p ¼ 0.05.
**p ¼ 0.01.
Regarding the second model with disability as the
dependent variable, all the independent variables
together explained 42.4% of the variance in disability
(overall F ¼ 8.377, p ¼ 0.001). The hierarchical analyses
revealed that all three blocks each contributed signifi-
cantly to the R-square change.
Discussion
The aim of the present study was to describe the impact
of TF, using the ICF as a theoretical framework and the
Brief Core Set for HC to select the domains to be
examined. The study demonstrated that TF has consid-
erable functional implications that need to be incorpo-
rated into future rehabilitation research and practice.
Participants reported a lower QOL, more restrictions in
A&P and more impairment in body functions than the
control group. These findings suggest that clinical
practice adhere to ICF guidelines, whereby evaluation
and treatment outcomes incorporate broad health
consequences, beyond the symptoms of TF.
The impact of TF on QOL was not reported in previous
studies, but several studies have reported an adverse
impact of other hand conditions on QOL, such as hand
osteoarthritis, carpal tunnel syndrome (CTS) and tendin-
itis.[42–45] The results of the present study showed a
similar trend, demonstrating that TF albeit a relatively
‘‘minor’’ hand condition has similar implications on
health-related QOL. Furthermore, the TF group also
reported higher levels of disability in comparison to
controls. These results are in line with a recent
study, using the QuickDASH, that found functional
differences among the clinical grades of TF.[12] Taken
together, these findings point to the importance of
radial side and is more involved in dexterity. In addition,
non-specific mechanisms of pain, fear and disuse which
may occur with TF may compromise the overall func-
tioning of the hand. To the best of our knowledge, these
findings have not been reported previously. A similar
trend of decreased hand strength and dexterity has been
found among people with other upper extremity
musculo-skeletal disorders, such as rheumatoid arthritis,
osteoarthritis and CTS.[46–48]
The moderate correlations that were found among
body functions, A&P and QOL demonstrate that these
components of the ICF model in TF have some degree of
shared variance, yet each component represents unique
phenomenon, relevant for understanding the implica-
tions of TF. Considering the importance of A&P and QOL
as rehabilitation outcomes, we sought to identify factors
that contribute to their variance. Results of regression
analyses revealed that the severity of TF contributed
significantly to the explained variance of QOL, while
personal factors and hand functioning did not add
unique significant variance. Previous studies reported
conflicting results regarding hand functioning and QOL
among post-stroke participants. McEwen, Mayo, Wood–
Dauphinee [49] found that dexterity could explain 22%
of physical health related QOL, while the other found no
association between the two.[50] Regarding A&P we
found that each of the three blocks of the model,
personal factors, disease severity as well as hand
function, contributed significantly to the explained
variance of the DASH. Importantly, hand function
contributed an additional 23% to the overall explained
variance, beyond that accounted for by disease severity.
These findings are similar to previous reports that
physical impairments (grip strength, dexterity and
range of motion) explained 25% of the variance in
patient-reported disability in a cohort of distal radius
fractures.[51]
 6 D. LANGER ET AL.
Table 5. Hierarchical multiple regression results for QOL and disability.
QOL
Step Variable last step R2 change
1 Age 0.085 0.047
Gender 0.037
2 Disease severity 0.227 0.119
3 Strength 0.178 0.076
Dexterity 0.248
*p50.05.
**p50.01.
The findings of this study that hand function can
explain a substantial portion of variance in A&P
(measured by the DASH) but not in QOL could be
attributed to the difference between these two import-
ant outcomes. A&P represents daily function which has
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been shown to be related to hand function,[1,2]
while QOL is a much broader health outcome which
may not be directly impacted by hand function, yet be
impacted by other mediating variables. The severity
of TF pathology was found to significantly explain
QOL variance which might be understood by the course
of TF pathology, whereby in many cases, symptoms
(if left untreated) gradually worsen over time. Therefore,
it is possible that the relationship of TF severity and
QOL could be attributed to a prolonged period
of disruption in daily living in individuals with more
severe TF, which in turn affects psychological and
physical well-being. This hypothesis requires further
investigation.
Overall, the findings of this study have important
implications for understanding the impact of TF on this
patient population. The broad outcomes of A&P and
QOL as well as hand function need to be evaluated
in order to provide comprehensive treatment accord-
ing to WHO standards. This is especially pertinent
due to recent studies documenting the insufficient
use of broad outcome measures among hand
therapists,[4,5,52,53]
Limitations and recommendations
The present study did not address environmental factors
that are part of the ICF model. We failed to recruit TF
participants with Quinnell grade 4 and the distribution
of participants among the TF grades was not equal.
Despite the fact that no significant differences were
found between the groups in the rates of additional
health conditions, specific health conditions, such as
diabetes (found in 15% of TF group and 7% of controls),
may have influenced the findings. Larger samples will
enable further study of relationships between variables
representing the different components of the ICF in
order to investigate mediating/moderating factors that
Disability
F change Last step R2 change F change
1.369 0.448** 0.138 4.815*
0.085
7.832** 0.048 0.058 4.236*
2.643 0.442** 0.228 11.251**
0.348**
impact participation and quality of life among individ-
uals with TF and other hand pathologies.
Conclusion
This study demonstrated the impact of TF on hand
functioning, activities of daily living and QOL. These
findings are noteworthy because TF is usually discussed
in terms of symptoms and treatment is evaluated
primarily by symptoms reduction. This study described
the implications of TF using the ICF framework and
demonstrated that even a relatively minor hand condi-
tion may have an impact on all domains of this model
when compared to healthy participants (excluding
environmental factors), stressing the importance of
incorporating this framework in hand therapy practice.
The findings of this study could serve as a basis for
developing interventions that target meaningful out-
comes for individuals with TF.
Disclosure statement
The authors report that they have no conflicts of interest.
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