1.1 accidents has increased by 3,781 cases or

1.1 Background of the study

Hand is the most influential and powerful parts the upper limb in
daily life. An injury to hand can affect a person’s overall well-being and
health-status. Hence, work-related hand injury may be life
changing for the injured person.

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is the most common anatomical site of the body to be injured at any place of
work due to its location and usage. Amina, Muhammad, Aziz and Othman (2015)
were define that hand injury is characterized by injury occurring distal to
proximal wrist crease as well as soft tissue injury to the forearm and fractures
of the carpal bones, distal radius and ulna. Injury in the hand can cause
functional problem in activities in daily living (Mckandawire, Boot,
Braithwaite & Patterson, 2002).


to Bureau of Labor Statistics, during 2013, more
than 1,000,000 hand injuries occurred in the United States alone and the hand
injuries required a median of five days before returning to work. As
cited by Mostafa, Sayed and Osman (2014) revealed that the incidence of injury
at work involved hand were treated in hospital emergency department in United
Stated States affecting 1,080,00 workers every year. Similarly reported by The
National Electronic Injury Surveillance System, the most common anatomic sites
injured and were treated in hospital emergency department were fingers and
hands in United States (Barton, 1989).


local statistics provided from Malaysian Social Security Organization (SOCSO)
Annual Report (2016), the number reported accidents has increased by 3,781
cases or 6.02% to 66,618 cases compared to 62,837 cases in 2015. Number of
accidents that involved upper limb, specifically fingers is the highest with
total 7,159 cases followed by the hand, wrist and forearm with total 4,851
cases, 1,105 cases and 326 cases respectively. The majority of hand injuries
occurred four percents more in male than female in 2016.


Hand is the significant part of the body used by the worker to
operate tools or machinery (Bell et al., 2011). According to the Malaysian
Department of Occupational Safety and Health (DOSH), work-related injuries
until October 2017 occur mostly in sector such as manufacturing, construction
and agriculture.

A worker with hand injury suffer reduced hand functions including
grip and pinch strength, fine motor skill, dexterity, decreased range of motion
(ROM) in involved hand (Chang et al., 2011). As the result, the hand deficits affected
by hand injury can cause upper limb disability to perform activities of daily
living (ADL).

As it known that, hand functions after hand injury was
traditionally evaluated by using objective measures to identify impairments (Karnezis
& Fragkiadakis, 2002). However,
in a study by Macdermid, Richard, Donner & Bellamy (2000) found that those
objectives measure only may not reflect overall level of function and
performance to use the injured hand in everyday life. The Disability of Arm,
Shoulder and Hand (DASH) is the activity-level outcome questionnaire which
proved by the World Health Organization (WHO) model of health that able to
measure subjective impairments and activity limitation, as well as
participation restrictions in ADL (Wong et al., 2007).  Thus, it is important to assess not only the
impairments but also to determine how the impairments will impact the daily

With the current limited literature regarding the fine motor skill
and level of disability after hand injuries, this study will focus on to
determine the relationship between fine motor skill and level of disability
based on DASH score among adult workers with hand injuries. This study also
determine whether demographic characteristic of worker with hand injuries such
as gender, age, race, hand dominance, occupation status and history of injury are
related to level of disability as previous study provided insufficient data
regarding those variables.





1.2 Problem Statement

of the previous studies proved that factor relating hand functions such as grip
strength, pinch strength and also demographic characteristics on level of
disability are significantly related to each other. However, there is
inadequate data regarding the correlation of fine motor skill and the level of
disability based on DASH score which may affecting the performance of hand among
adult worker population with hand injuries.


1.3 Research questions

There were specific four questions to answer in this study:

What is the level of fine motor skill among adult workers with hand

What is the level of disability in adult workers with hand

What is the association between demographic characteristics and
DASH score?

What is the magnitude of relationship between fine motor skill and
DASH score?


1.4 Aim of study

The main aim of this study was to investigate the
relationship between fine motor skill and DASH score among adult workers with hand injuries.


1.5 Objectives of study

To determine the level of fine motor skill among adult workers with
hand injuries.

To determine the level of disability in adult workers with hand

To investigate the association between demographic characteristics
(gender, age, race, hand dominance, occupation status and history of injury)
and DASH score.

To examine the magnitude of relationship between fine motor skill
and DASH score.




1.6 Hypotheses

Fine motor skill and DASH score.

There is no association between fine motor skill and DASH score.

There is association between fine motor skill and DASH score.


Demographic characteristics and DASH score.

There is no association between demographic characteristics and DASH score.

There is association between demographic characteristics and DASH score.


1.6 Significant of the study

This study offers the opportunity to understand hand fine motor
skill among adult workers with hand injuries and the association between fine
motor skill using Purdue Pegboard Test (PPT) and level of hand performance
assessed by DASH. It is also useful and enhances occupational therapists’
understanding of the participants’ on how they perceived their disability and
to detect and level of function.

The result of
this study basically could be helpful for occupational therapist to promote the
proper assessment of hand injuries and to assist in effective treatment
planning process and intervention during hand injury rehabilitation.

Besides, this study is can embrace the core concept of occupational
therapists’ roles in hand rehabilitation by grounding the true identity of our
profession and incorporating the aspects of level of functioning in everyday
activities rather than solely focusing on the specific hand deficits.

2: Literature Review

Fine motor skill is used interchangeably with dexterity. The hand
fine motor skill is important for one to perform delicate movement and to
engage in daily activities such as writing, grasping or handling object,
eating, grooming, buttoning and working (Backman et al., 1992; Williams et al,
1982; as cited in Sahin et al., 2017).

Fine motor skill was defined as the ability to use hand skillfully
characterized by fine and voluntary movement in task that required to
manipulating small object (Yancosek &
Howell, 2009; Weintraub, Gilmour-Grill, & Weiss, 2010). It was also
a synchronization of small muscles in the hands and fingers as well the eyes
that work together to provide coordination (Cuffaro, 2011). According to
Wiesendanger & Serrien (2001) stated that speed, force and dexterity are
among basic physiological mechanism in order a normal person to manipulate

Fine motor skill is one of the hand functions that paramount in
hand evaluation of neuromotor function of the hand, which involves integration
of motor and sensory function. There are many performance-based standardized
assessments which developed to assess hand fine motor skill include the Jebsen-
Tailor Hand Functional Test (JTHFT) (Jebsen, Taylor, Trieschmann, Trotter &
Howard, 1969),  the Functional Dexterity
Test (FDT) (Aaron & Jansen, 1992), the Purdue Pegboard Test (PPT) (Tiffin
& Asher, 1948), the Box AND Block Test (BBT) (Mathiowetz, Volland, Kashman,
& Weber, 1985), the NK Hand Dexterity Board (NKHDT) (Turgeon, McMerDermid,
& Roth,1999) and the Nine-hole Peg Test (NHPT) (Mathiowtz, Weber, Kashman,
& Volland, 1985). All these assessments can be used to assess the hand fine
motor skill in both neurological and musculoskeletal disorder.


2.1 Fine motor
skill and Performance of Hand in Daily Activities

The measure of hand impairments in hand condition such as grip
strength, pinch strength, fine motor skills or dexterity was linked to The
International Classification of Functioning, Disability and Health (ICF)
component of body function (World Health Organization, 2015). Although there
has been many literature studied the relationship between hand impairments and
how it can impact the activity limitation however,  the literature on changes specifically in
hand fine motor skills on performance in daily life in people with hand injury
was lacking.

In a study on patients with polymyositis and dermatomyositis, the patients
with reduced hand grip strength and dexterity also demonstrated activity
limitation according to the DASH (Regardt, 2014). Recent
study by Malcus et al., (2015) found that 42
percent of patients with systemic lupus erythematosus experienced hand problem reported interference with
performance of daily activities. He and his colleagues also stated that the
most affected area was productivity while the least affected was self care. In
that study, pain, fumbling and reduced grip strength were the most significant


2.2 Factor affecting fine motor skill


Abundant research has been testified the factor such as age, gender,
dominant hand and finger thickness affecting the fine motor skill on health
people (Wang et al., 2014; Bryden & Roy, 2005; Peters & Champagnaro,
1996; Peters, Servos & Day, 1990; Martin et., 2015). While the other study
on 242 patients with distal radius fracture (DRF) from Bobos (2016) found that age
and gender was determine as significant predictor for fine motor skill.




Increasing age was
proved positively correlate with poor hand function skill (Michimata et
al,2008; Wang et al., 2014).  In previous
studies by Michimata et al., (2008) and Sartorio et al., (2013) stated that
people older than 50 years found to be worse in fine motor skill compared to
younger people.


Similar with a study by
Wang et al., (2014) also revealed that fine motor skill that measured based on
NHPT in younger people was better than in older people, as expected. Moreover,
the result of recent study also showed that net
time of Functional Dexterity Test (FDT) was significantly higher in higher age
group. For ages 20-39 years, ages 40-59 years and older than 60 years, the net
time were 24 seconds, 27 seconds and 37 seconds respectively (Sahin et al.,


This is because, both
motor and sensory function in older people have reduced with increasing age
(Desrosiers et al., 1999). Reduced motor and sensory function in fine motor
skill are characterized by slower, less nimble and less smooth, less
coordinated and less control performances (Martin et al., 2015).





Many research has shown that gender was associated with
fine motor skill score measured with different type of assessments (Peters
& Campagnaro, 1996; Mathiowetz et al.,1985; Bryden & Roy, 2005;
Amirjani et al, 2007; Wang et al., 2014; Ng et al, 1999).


In a study comparing gender difference using PPT, the result
revealed that women have better performance of hand fine motor skill compared
to men (Peters & Campagnaro, 1996). There are also few studies that
consistently reported female were performing much better in Grooved Pegboard
Test (GPT) (Bryden & Roy, 2005), NHPT (Wang et al., 2014), Moberg Pick-Up
Test (MPUT) (Amirjani et al., 2007) and Box and Block Test (BBT) (Mathiowetz et
al, 1985).


However in a study by Bobos (2016), he was comparing
the ability of individual with (DRF) to manipulate object against time using NK
Hand Dexterity Test (NKHDT). He discovered that men had better score time than
women. According to size of objects in NKHDT, men also
manipulate large and medium objects faster in the 3 to 6-month period after



Dominant hand


Dominant hand has been reported manipulate faster in hand fine
motor skill tests (Bryden & Roy, 2005; Michimata et al., 2008; and Wang et
al., 2014 as cited in Sahin et al., 2017).


Two studies examined the relation of hand dominance with fine motor
skills using FDT among children and adult separately. Gogola et al., (2013)
found that children performed 0.09 pegs/ second faster in dominant hand than
non-dominant hand. While in a cross sectional study of healthy adult
population, dominant hand also reported score better compared to non-dominant
hand despite in of all age group (Sahin et al.,2017).




Finger thickness


the findings of the study by Peters and Campagnaro
(1996), they found that males show better
performance for holding thick pegs, whereas females show better performance for holding thin pegs. In that study,
when the pegs are held with tweezers, the
difference between males and females was no
longer significant because the tweezers minimized the effect of finger thickness as the determining factor.
On the other hand, Peters et al., (1990) as cited in Sahin et al., (2017) found a negative
correlation between test performance and finger size for both genders and
suggested that finger thickness is associated with the test result.


The later
study was conducted with GPT so that the result was more comparable to the

Bryden and Roy (2005) found that females performed 7 seconds
faster in the GPT. The interesting finding explained by the fact that males
usually have thicker fingers while the women have thinner fingers.



Chapter 3: Methodology

3.1 Study design

This study was conducted using
cross-sectional study because it is quick, easy and cheap to conduct and
researcher was able to collect data in short period of time (Sedgwick, 2014). This
study do not involved experimental procedure and no variables are manipulated
by the researcher therefore, there will be no loss to follow up because
participants were interviewed and assessed only once.

In addition, correlation study was used to
see whether the two variables in this study are related and it provided
predictions of relationship between those two variables as well. Therefore, the
data collected will be used to predict the relationship between fine motor
skill, level disability and demographic characteristics among adult workers
with hand injuries.


3.2 Participants

Participants were eligible to participate in the study if they met
with all the inclusion criteria. Participants were adult workers aged between
18 to 60 years old either male or female. Participants presented with
unilateral injury to the bone, tendon, and nerve or combined from hand up to
forearm were also included. Participants were fully informed about the
procedure and informed consent was signed by all participants once the
participants read the Participant Information and Consent form which provided
during the early data procedure.

Participants were excluded if the
participants presented with multiple injuries or other than hand injuries, hand
deficits due to neurological and medical problem, peripheral neuropathy,
cumulative trauma disorder injury, sprain or strain injury and diagnosed with
psychological illness or dementia.




3.3 Sampling method

Power calculation for this study was performed using G-power
software. A total of 115 participants recruited in this study had shown
reliable results allowing credible conclusion to be made at p<0.05 significant difference. Purposive sampling method was used to recruit the participants which all recruited participants were selected based on inclusion criteria. Thus none of the participants were excluded from the study.   3.4 Setting Data collection took place from March to April 2018 at Occupational Therapy Department in five different general hospitals in Malaysia: (1) Hospital Taiping, Perak; (2) Hospital Raja Perempuan Zainab II, Kota Bharu; (3) Hospital Sultanah Bahiyah, Alor Setar; (4) Hospital Sulatanah Nora Ismail, Batu Pahat; and (5) Hospital Sultan Haji Ahmad Shah, Temerloh.   3.5 Data collection procedures 3.5.1 Demographic Characteristics Demographic characteristics were collected by using a brief questionnaire comprised of few questions such as participants age (18 to 60 years old), gender (male or female), race (Malay, Indian or Chinese), dominant hand (left or right), occupation status (sector, type of occupation, type of company, employment status and return to work status) and history of injury (diagnosis, injured hand, location of injury, range of motion limitation, date of injury, duration of injury, cause of injury, sensation and health service received). These demographic characteristics were obtained at the beginning of data collection process. Then it will be followed by Purdue Pegboard Test and DASH. The demographic characteristics collected will be used to find out whether these demographic characteristics were associated with DASH score. 3.5.2 Instrumentation (a) Purdue Pegboard Test (PPT) The PPT was proved by many literatures as a reliable and valid instrument used to assess fine motor skill which reflects the quality and speed of performance of the hand (Amirjani, Ashworth, Olson, Morhart & Chan, 2011). PPT also has been ranked as the most three assessments of dexterity by systematic reviews studied by Causby, Reed, McDonnell, & Hiller (2014) due to its reliability and validity as well as its fewer confounding variables such as age, gender and handedness. PPT was developed by a psychologist, named Dr. Joseph Tiffin from Purdue University in 1948. It was initially used to measure fine motor skill or dexterity of assembly workers (Tiffin & Asher, 1948). Currently, it has been widely used mainly for hand rehabilitation and research purposes. In this study, Purdue Pegboard Model #32020 was used. There are 25 pins, in each far right and far left cup of the pegboard, 20 collars and 40 washers. For the participants whose right handed, collars should be inside the cup to the right of centre of pegboard while washers are inside the cup to the left of centre of pegboard. In contrast, the location of collars and washers are reversed for the left- handed participants. As explained in the study by Tiffin and Asher (1948) there are four subtests in PPT. The first three subtests, participants are required to place one pin at a time into a pegboard hole as fast as possible with the dominant hand followed by non-dominant hand and both hands within 30 seconds. In the fourth subtest, the participants required to pick up a pin with right hand. While the participants place the pin into the top hole, the left hand needed to pick up a washer. As soon as the pin had been placed, put the washer over the pin. Then, participants pick up collar and washer using right and left hand respectively and placed it over the previous pin and washer. The complete first assembly consisted of a pin, a washer, a collar and a washer. Similarly, participants repeat the same step of assembly to the next hole. This test was continues until 60 seconds. For each subtests, participants were allowed to practice. The score of PPT was calculated by adding the number of pin, collar or washer placed into the hole of pegboard during three trials of each subtests. The averages value of the three trials then were calculated and used as the data analysis.   (b) Disability of the Arm, Shoulder and Hand (DASH) The DASH questionnaire was developed in 1996 by the collaboration of Institute of Work and Health, the Council of Musculoskeletal Specialty Societies and the American Academy of Orthopaedic Surgeons (Hudak et al., 1996 as cited in Smith et al., 2012). It is a self-administered questionnaire intended to assess level of disability after injuries to the upper limb.  It consists of 30-items with six domains; daily activities, symptoms, social functions, work functions, sleep and confidence (Dowrick et al, 2006). The participants rated the each item using a five-point scale. A total score is ranging from 0 indicates no disability to 100 indicates severe disability of upper limb. This questionnaire took approximately 5 minutes to complete. The DASH has been known to its excellent validity with Cronbach alpha of 0.96, reliability with a Pearson correlation of 0.96 as well as its extensively used in clinical practice (Van de Ven-Stevens, 2016). To date, DASH questionnaire also has been translated into 50 languages including Bahasa Malaysia.     3.5 Data analysis All data was statistically analysed  by using SPSS software version 23.0 statistical software. All the parameters were analysed with significance level of p<0.05 and confidence interval of 95%. The descriptive statistics was  presented as frequency, mean and standard deviation. The exploratory data analysis then carried out using Shapiro-Wilk in the form of Normal Q-Q plot for each set of data which mean to confirm the normal distribution of data collected. Therefore, parametric tests were used to calculate the data. Independent t-test was used to compare mean of gender, dominant hand and injured hand from the demographic characteristics data to evaluate its association with DASH score. The relationship of variables between fine motor skill, age, race, occupation status and history of injury with DASH score were analyzed using Pearson Correlation Coefficients and bivariate ANOVA with significance set at p<0.05 to testing the hypothesis.   3.6 Ethical consideration Ethical approval from Faculty of Health Sciences of University of Teknology Malaysia (UiTM) has been obtained in order to conduct this study. Ethic Application Form, Subjects Information Sheet and Consent Form had completed by the researcher. Approval to collect data in the hospital and screen medical records pertaining to details of diagnosis has been granted by Malaysia Ministry of Health through National Medical Research Register (NMMR) ethics committee. Hence, the ethical aspect of research was followed very strictly during this research. The participation in this study was voluntary by means participants were give full autonomy whether to or not to involve in this study. In the subjects information sheet and consent form, researcher had stated the brief introduction of study, purpose of study, study procedures, benefits of study, study risk (if any) and confidentiality. All information collected from the participants was appropriately taken with the knowledge of the participants and their expressed willingness and informed consent A consent form was signed by all the participants before participating in this study. Confidentiality and anonymity of the participants was guaranteed to ensure privacy of their information.