Dexterity Training

Description of Intervention

Dexterity is a complex concept that is difficult to measure and define. One of the best available definitions of dexterity is "a subset of hand function pertaining to the coordination of voluntary movement to accomplish an actual or simulated functional goal/task accurately, quickly, resourcefully and adapting to environment or change." Good dexterity indicates that a person can grasp and manipulate objects with total control and without giving conscious thought to the performance of these tasks, while poor dexterity means the person has difficulty making precise and intricate movements with their hands and fingers.¹

Impaired dexterity is common after many conditions that affect the hands or wrist, most of which are of either musculoskeletal or neurologic origin.^1,2 For example, a finger sprain or fracture can render that digit unusable, which can severely interfere with the entire hand’s ability to execute careful manual tasks in daily life. In neurologic conditions like Parkinson’s disease (PD) and multiple sclerosis (MS), the loss of manual dexterity can prevent a patient from performing many activities of daily living (ADLs) that require fine motor skills, like writing, texting, driving, typing, buttoning a shirt, tying shoes, shaking hands, or holding a utensil. This adds to the burden of these diseases and may threaten patients’ jobs and wellbeing, in some cases forcing them to require outside care to get through the day.^1,2

Other conditions that can lead to dexterity impairments are rheumatoid arthritis (RA), fibromyalgia, Dupuytren’s disease, tendinitis, and tight scars that form after burns and other injuries to the hand.^3,4 Evaluating dexterity and providing appropriate treatment for any noted deficiencies is therefore essential for hand surgeons and other healthcare providers that treat patients with hand and wrist conditions.⁵

Indications for Intervention

Poor hand dexterity may result from many causes, including traumatic injuries to the hand or wrist, overuse injuries, musculoskeletal conditions, surgical procedures, neurologic disorders, RA, fibromyalgia, or tight scars following a burn or hand injury.^1,2,4-6

Diagnosis^1,4,5,7,8

1. Ask for the patient’s medical history, including any recent injuries or surgeries.
2. If the patient reports any dexterity impairments, ask them to describe in detail which tasks and ADLs they have difficulty completing.
3. Evaluate the patient’s current use of their hands with one or more functional tests, some of which include the following (when selecting and interpreting which test(s) to use, consider the match between a dexterity test and the person's task demands):
   • Jebsen Hand Function Test
   • Functional Dexterity Test
   • Moberg Pickup Test
   • Grooved Pegboard Test
   • Box and Block Test
   • Sollerman Hand Function Test
   • 9-Hole Peg Test
   • Purdue Pegboard Test
4. If dexterity is only impaired in one hand, compare the deficits in the affected hand with that of the contralateral hand.
5. Attend to all dimensions of dexterity during the assessment (eg, document excessive movements during a timed performance-based outcome measure or note the time taken by a patient when doing informal task observations).
6. Ask if the patient has any comorbidities, including smoking, diabetes, or osteopenia.

Intervention Options

In most cases, patients with impaired dexterity should be referred to a physical or occupational therapist, where they can expect to experience improvements in dexterity with practically no risk for adverse events. Occupational therapy is intended to enable specific functions of certain body parts and is particularly appropriate for patients who struggle to complete the physical tasks required in their profession (eg, typing, using a screwdriver or hammer, painting, sewing, cutting hair).⁴

The occupational or physical therapist should then design a personalized treatment program intended to improve the patient’s dexterity, with a particular focus on the tasks and ADLs that the patient finds to be challenging.⁴ This will usually include a variety of stretching and strengthening exercises that mimic the difficult ADLs or work-specific tasks. Among the interventions that are commonly prescribed to improve dexterity are the following^2,9:

• Stress ball exercises
• Opening and closing the hands
• Pinch and grasp performance exercises
• Exercises with therapeutic putty
  • Rolling putty
  • Squeezing putty
• Wrist and hand stretches
  • Finger abduction
  • Finger adduction
  • Finger flexion
  • Finger extension
  • Finger opposition
• Finger, thumb, and hand strengthening exercises
• Work or ADL simulation training (eg, typing, using tools or utensils, buttoning a shirt, pouring a liquid into a glass)

Activities to Improve Fine Motor Coordination in Hands

These are activities to increase the coordination in your hands. Your therapist will instruct you on how often you should do each activity.

• Shuffle and deal cards.
• Trace a design with a pen.
• Make a chain of paper clips.
• Pick up small beans and put them in a cup or straw.
• Pick up hooks and eyes and put them in a medicine bottle. You can buy hooks and eyes in sewing sections of stores.
• Pick up coins and place them in a coin purse or wallet.
• Put clothes pins on the side of a cup.
• Screw and unscrew nuts and bolts.
• Pick up toothpicks with a tweezers.
• Fold, crumple or tear paper or tissue.
• String beads or macaroni on a string.
• Use an iPad or smart phone.
• Lace shoes and tie them.
• Stack coins or wrap them in coin wrappers.
• Pick up marbles and hold as many as you can in your hand.
• Play a game with small pegs or playing pieces.
• Bounce a small ball and catch it.
• Practice buttoning.
• Practice putting on and taking off jewelry, such as a watch or bracelet.
• String beads or buttons.
• Sew with needle and thread.
• Cut out coupons.

The therapist should regularly monitor the patient’s progress throughout the program, paying close attention to changes in pain levels, swelling, proprioception, and overall movement patterns. As the patient improves, the intensity, frequency, and duration of the prescribed exercises should gradually increase based on the patient’s comfort level. Exercises should progress from global to specific, and eventually finish with finger movements that involve both hands.^4,6 In some cases an orthotic device may also be prescribed to help improve dexterity.⁴