Multiple sclerosis (MS) is a degenerative disease of the central nervous system and is a common neurological disorder among the young adult population (Karussis, 2014). Residual scarring along the central nervous system and associated loss of brain volume can result in loss of sensation, visual deficits, and ataxic movements of the upper and lower extremities. The diagnosis of MS typically occurs during the most productive time of an adult's life, with onset usually occurring between 18 and 50 years (Buchanan et al., 2009). Quality of life is compromised through disruption of vocational, social, and family life (Naci et al., 2010). The effects of MS on neuromuscular functioning limit the performance of activities within daily occupations, such as work and school tasks, and activities of daily living, such as self-care and home maintenance. Management of basic activities of daily living (BADLs) can minimize the effects of MS and create a more independent life within the home and community (Månsson & Lexell, 2004). The general symptoms of MS appear to affect occupational performance (Lexell, 2009); however, the effect of MS on fine motor skills and occupational task performance has not been examined.
Buchanan et al. (2009) detailed the symptoms of MS that influence functional abilities, but no research has been done on the effect of fine motor status on age-appropriate occupations, such as vocational skills and home management, self-care, and leisure tasks (i.e., gardening, crafts) among young adults with MS.
Fine motor changes are among the early symptoms of MS (Buchanan et al., 2009). Young adults with MS may have gross motor or fine motor issues that prevent them from engaging in occupations for self-care, productivity, and leisure tasks. Misinterpretation of poor performance at work or home as a result of motor deficits may lead to decreased competence and can affect self-confidence, especially for the younger population (MacAllister et al., 2007).
Lexell (2009) found that people with MS have limitations of occupational performance based on the type of activity and the necessary skills. Specific limitations are based on the type of MS and the area of occupational performance. The ability to perform BADLs may decrease as the disease progresses (Finlayson et al., 1998; Månsson & Lexell, 2004).
Many occupations, such as BADLs and independent activities of daily living, require a combination of upper extremity strength and coordination. If function is compromised, people may have difficulty with simple tasks within daily occupations, such as opening and closing objects, manipulating writing tools or utensils, and dressing and grooming themselves.
Gross motor muscle weakness typically occurs along with fine motor weakness, and both are common in people with MS, with 80% to 90% reporting weakness, coordination issues, and spasticity contributing to functional limitations (Finlayson et al., 1998; Gorniak et al., 2014). Coordination with appropriate synchronization of fingertip pressure is necessary for the successful performance of BADLs (Gorniak et al., 2014). Inability to coordinate fine motor movements and forces may lead to dropping or slipping of objects and inability to perform BADLs that require fine motor skills (Gorniak et al., 2014). Squillace et al. (2016) reported that adolescents with MS showed less right hand two-point pinch strength compared with a healthy control group.
Gorniak et al. (2014) investigated kinesthetic deficits when performing tasks that require bilateral activities and measured the overall time it took adults with MS and healthy control subjects to perform common BADLs. They found that (a) task times were longer for people with MS, (b) task time was influenced by the type of task and the kinetics used to complete it, (c) grip force when completing tasks was significantly less among adults with MS than among the healthy control group, and (d) people with MS showed differences between grip and load forces exerted on handheld objects (Gorniak et al., 2014). These findings suggest that a person with MS may lose dexterous abilities that require bilateral or typical functioning for finer BADL tasks, such as fastening clothes or writing.
Previous studies reported fine motor weakness among those with MS (Julian et al., 2013; Squillace et al., 2015). Tal-Saban et al. (2014) suggested a link between motor coordination and the effect of symptoms on level of function at some point in the progression of disease. Squillace et al. (2015) found significant differences in dexterity between adolescents with MS and an age- and gender-matched control group, as measured by the Purdue Pegboard Test (PPBT) and the Nine-Hole Peg Test. A study of adults with MS found that difficulty with BADLs was linked to problems with manual dexterity and fine motor skills (Kierkegaard et al., 2012).
The occupations of young adults in their prevocational life and into adulthood require higher levels of motor skills to manipulate writing or work tools. Delays in these skills can result in a need for accommodations for productivity and management of age-appropriate skills (Case-Smith & Exner, 2015).
This study investigated a relationship between fine motor skills and performance and satisfaction with occupations and the role of hand dominance and speed in satisfaction with the performance of tasks among young adults with MS. We hypothesized that young adults with MS will have fine motor deficits that affect their occupations, resulting in dissatisfaction with their occupational performance in self-identified problem areas.
Design and Rationale
A correlational research design was used. We measured the fine motor status of young adults with MS with the Purdue Pegboard Test (PPBT) and the Grooved Pegboard Test (GPBT). We measured the level of perceived performance and satisfaction with occupational tasks in young adults with MS with an adapted Canadian Occupational Performance Measure (COPM) (Law et al., 2014). The instrument was adapted to indicate tasks that require fine motor skills and was used to measure participants' perception of their occupational performance and satisfaction with their performance.
Participants were a convenience sample of patients from private outpatient neurological and support groups located within a large metropolitan region. They included 11 men and 29 women who were 18 to 30 years old. All had a diagnosis of MS. The definition of young adult varies and includes individuals ranging from 15 to 40 years (Walker-Harding et al., 2017). Our focus was on the young adult population because of the early stages of neurological symptoms that occur at a younger age. The transition to adulthood involves growing responsibilities at work, at school, and in the family.
The study protocol was approved by two institutional review boards. Recruitment flyers were distributed to clinics, support groups, and community-based MS organizations. Clinics distributed information about the study to patients who met the inclusion criteria. Patients who expressed interest in volunteering to participate contacted the investigator and were screened for inclusion. Included in the study were men and women who were 18 to 30 years and had no history of neurological or physical impairment; had an Expanded Disability Status Scale score of 6.0 or less; retained some self-care abilities; had experienced no exacerbation within the last 1 to 2 months to avoid acute confounding factors (i.e., existing MS symptoms of fatigue and weakness); and expressed an average level of independence on initial screening. Participants were excluded from the study if they were younger than 18 years or older than 30 years; had previous physical or neurological impairments that could affect the study results; had a score of 6.5 or greater on the Expanded Disability Status Scale (Tarver, 2015); required maximum assistance with self-care and mobility tasks; were recently discharged from inpatient care; had active exacerbation of symptoms; or had frequent exacerbations.
We conducted a brief standardized cognitive screening with the Symbol Digit Modalities Test (SDMT) (Smith, 1991) to rule out cognitive impairments that would make individuals ineligible to participate. A normative Z score of greater than −3.0 or the oral test indicates sufficient cognitive functioning (Smith, 1991).
The PPBT and GPBT measure fine motor movements of the hands and digits, digital dexterity, and fine motor bilateral coordination (Zakzanis, 2000) that are necessary for proficiency in occupational performance. The PPBT consists of 50 pegs, 40 collars, and 40 washers. The PPBT measures performance in four conditions: preferred hand, nonpreferred hand, both hands, and assembly. Participants were seated at a table within reach of far right and far left cups containing 25 pegs each, for a total of 50 pegs. Washers and collars were located in the center cup; therefore, participants who preferred the right hand would take washers from the cup nearest to the far right cup, and those who preferred the left hand would take washers from the cup closest to the far left cup (Lafayette Instrument, 2015).
The PPBT was selected as an assessment because of its test-retest reliability correlation with a single trial use. A single trial for this study was preferred to avoid fatigue or weakness after two or three trials. A follow-up assessment was performed with the GPBT, which requires speed. Test-retest reliability ranged from 0.60 to 0.76 for a single trial and 0.82 to 0.91 for three trials (Lafayette Instrument, 2015; Tiffin & Asher, 1948). Gallus and Mathiowetz (2003) used the PPBT with people with MS and found that with a one-trial administration of the PPBT, test-retest reliability coefficients ranged from 0.85 to 0.90 for two trials and from 0.92 to 0.96 for three trials, which suggests that one trial is sufficient for people with MS. Intercorrelation scores were obtained from a large group and showed low scores ranging from 0.41 to 0.50, which may indicate that each test of the PPBT may be used as a predictor of finger dexterity or manipulation speed (Lafayette Instrument, 2015).
The GPBT assesses manipulative dexterity and involves a board with 25 randomly designed slots and pegs with a matching design for the slots (Trites, 2007). The pegs must be maneuvered and manipulated to fit into lock-and-key-shaped designated spaces (Lafayette Instrument, 2002). The GPBT was selected because it requires speed, dexterity, and visual motor skills that are required for many BADLs. A major strength of the GPBT is that it requires more complex visual motor coordination than other pegboard tests because of the randomly positioned slots that require the key-like peg to be rotated for an exact fit (Trites, 2007). We did not measure the visual motor component of the GPBT, but used it as an observational behavior. The GPBT is a timed test, recorded in seconds, that scores each hand on three areas of performance: total time, total number of drops, and total number of pegs placed correctly (Lafayette Instrument, 2002). The GPBT has been found to be a reliable and dependable measure of manual dexterity. Retest reliability for the dominant hand is p < .01 and r = 0.74, and for the nondominant hand, r = 0.72 (Yancosek & Howell, 2009). Validity has been shown to be excellent, with established criterion, construct, discriminant, face, and content validity (Trites, 2007). In a comparison study of tests of manual dexterity, Wang et al. (2011) found high coefficients for test-retest reliability for the GPBT (range, 0.85–0.91) for the right and left hands.
The COPM was used to collect participant self-reports of performance within three subcategories: self-care, productivity, and leisure. Participants identified their most important occupations and indicated perceived satisfaction and problems with their performance within each area. Instead of using the COPM as a clinical outcome measure for interventions, we used it to identify performance patterns in fine motor skills, satisfaction, and problem areas for young adults with MS. The authors of the COPM gave permission to adapt the items for this study only (C. DeCola, personal communication, October, 4, 2016). The original three categories of the COPM included examples of subcategory activities for the participant to rate. For this study, the investigator provided categories that required dexterous or fine motor skills. For example, items listed under the main category of self-care included applying makeup, shaving, and managing fasteners. For this study, the COPM was used to discover performance patterns in fine motor skills, satisfaction, and problem areas for young adults with MS.
The COPM has acceptable test-retest reliability at 1- to 2-week intervals, ranging from 0.63 to 0.89 for performance and 0.76 to 0.88 for satisfaction (Law et al., 2014). Content, criterion, and construct validity also have been evaluated for the COPM. Content validity is supported through national and international recognition of the use of the tool, client centeredness, and the influence of the environment on performance. The COPM has shown criterion validity through successful identification of problems with occupational performance across age groups. The foundational beliefs of occupational therapy provide for the construct validity of the COPM (Law et al., 2014). This instrument has been found to be a valid measure of occupational performance after several investigations (Law et al., 2014). Lexell (2009) used the COPM in a two-part study of engagement in occupations among people with MS. They found that participants perceived more than 350 items of occupations as difficult to perform (Lexell, 2009).
Participants were informed about the study from nurse practitioners at the participating neurological outpatient clinics. Clients who expressed interest in participating were provided with our contact information or gave us permission to contact them. Participants were given the option of meeting at the clinic, at a library, or in their home. At the start of testing, the informed consent form was reviewed. Data collection began with administration of the Symbol Digit Modalities Test, followed by the quantitative measures, the PPBT, GPBT, and COPM. Participants took approximately 10 minutes to complete the PPBT, 5 to 8 minutes to complete the GPBT, and 25 minutes to complete the COPM, for a total time of approximately 45 minutes for the quantitative components of the study.
Raw scores on the PPBT and the GPBT were compared to established mean norms based on age and hand dominance. The PPBT mean norms were derived from the mean performance of healthy young adults with a mean of one trial per subtest (Lafayette Instrument, 2015). The GPBT scores were then categorized based on level of performance into a slow group and a fast group (Lafayette Instrument, 2015). Findings were compared with normative data for the PPBT preferred and nonpreferred hand manipulation, both hands, and assembly subtests and GPBT completion time.
The adapted COPM, a measure created to reflect tasks that require fine motor skills, included three main categories: self-care, productivity, and leisure. The subcategories for self-care were personal care and community management. The subcategories for productivity were paid and unpaid work, household management, and school. Finally, the subcategories for leisure included quiet recreation, active recreation, and socialization. These categories totaled 34 separate items.
To measure differences between perceived performance and satisfaction with occupations and fine motor skills status, an independent two-sample t test was performed. All analyses were performed with IBM SPSS Statistics Grad Pack Base 24 data analysis software. Spearman's correlation analysis was conducted to determine whether there was a relationship among the PPBT, GPBT subtests, and COPM satisfaction and performance findings. The goal of the correlation analysis was to determine the direction of the relationship between fine motor status and perceived performance and satisfaction with occupations.
Of the 40 participants, 29 were women (72%) and 11 were men (27%). In addition, 35 (88%) were right handed, and all 5 left-handed participants were women. All participants scored below the mean performance norms on the preferred, nonpreferred, and assembly subtests, according to PPBT means. In contrast, for both hands, 7 (63%) of the 11 men and 22 (75%) of the 29 women scored above the mean performance for young adults. The overall average score for both hands was above the mean performance for both genders. The PPBT scores for both hands were calculated by adding the right and left side scores to achieve a “both hand total score,” possibly resulting in higher scores, but not necessarily better manipulative skills.
At the start of the assessment, participants were asked to rank the 34 COPM items according to the occupations they perceived as most problematic (Table 1).
Problematic Occupations Identified on the Adapted Canadian Occupational Performance
A difference was found in the distribution of occupations among subcategory items. Among the 34 COPM items, 8 were rated as the most important problematic occupations (Figure 1). Occupations that involve the manipulation of objects or writing tools accounted for 63% of the most frequently identified problems.
Most frequently perceived problem occupations among young adults with multiple sclerosis.
During the adapted COPM interview, participants rated the importance of activities within the subcategories of personal care, community management, paid and unpaid work, household management, school, quiet recreation, active recreation, and socialization. The scale ranged from 1 to 10, with 1 representing not important at all and 10 representing extremely important (Law et al., 2014).
Next participants were asked to choose five of the problems that they rated as most important (Law et al., 2014). They were then asked to complete a self-evaluation of their current performance and their satisfaction in each area (Law et al., 2014). A rating of 1 indicates inability to perform the task and a rating of 10 indicates ability to perform the task extremely well. Participants then rated their satisfaction with their performance, with a rating of 1 indicating that they were not satisfied and a rating of 10 indicating that they were extremely satisfied. The higher the score, the higher the participant's performance and satisfaction.
Table 2 shows total perceived performance and satisfaction ratings. Mean performance ratings were in the average range. Satisfaction ratings were lower than performance ratings and were lowest in the areas of school and active recreation tasks. Overall perceived performance scores were higher than perceived satisfaction scores within the average and high ranges.
Average Ratings of Problematic Occupations
An independent two-sample t test found no significant differences between GPBT and COPM performance and satisfaction. A marginally significant difference (p = .051) was found between hand dominance of the GPBT fast and slow groups and perceived performance, suggesting that speed does not affect perceived satisfaction with the dominant or nondominant hand and that speed leads to differences in perception of performance with the dominant hand. No statistically significant relationship was found between hand dominance and speed or satisfaction with performance of tasks.
The effect size for the dominant hand for both the fast and slow groups on the GPBT and COPM was 0.65 for performance and 0.63 for satisfaction, indicating a large difference in the distribution of scores between groups. The effect size for the nondominant hand and COPM was 0.37 for satisfaction, indicating a medium practical difference in the distribution of scores between the variables, and that for COPM was 0.112 for performance, indicating a small difference in the distribution of scores.
Spearman's correlation analysis found a moderate relationship among the preferred (0.470), nonpreferred (0.468), and assembly (0.424) subtests of the PPBT and the satisfaction component of the COPM. A weak correlation was found with the nonpreferred hand and performance (0.359) and assembly subtests of the PPBT and the performance (0.350) component of the COPM. A weak correlation also was found between the GPBT dominant subtest and the COPM satisfaction (0.377) component. Table 3 shows the relationships between components of the PPBT, GPBT, and COPM performance and satisfaction.
Correlations Among PPBT Subtest, GPBT, and COPM Satisfaction and Performance Scores
Participants perceived greater satisfaction with performance when they had improved fine motor skills of the dominant hand. As coordination improved with the PPBT assembly subtest, perceived satisfaction and performance increased.
The 40 participants ranked the COPM items according to their perceived most problematic occupations affected by fine motor issues. Of the 34 items, 8—typing, note taking, manipulating objects, writing, cleaning house, managing fasteners, shaving, and applying makeup—were rated as the most important problematic occupations. Occupations involving the manipulation of objects or writing tools accounted for 63% of the most frequently identified problems.
Participants rated fine motor skills related to productivity at work, school, and home as the most important. These findings are consistent with the expected occupational roles of this population with their performance as a student and employee. Participants rated performance higher than satisfaction. Low satisfaction ratings within the home, work, and school problem areas suggest that fine motor issues interfere with tasks that are very important to daily productivity.
Low PPBT and GPBT individual and assembly performance and speed scores explain why participants reported that writing, typing, manipulating small objects, and performing household duties were the most problematic. People with MS and other neurological disorders have fine motor deficits that affect manual dexterity while performing daily tasks (Gorniak et al., 2014). Activities of daily living involved with self-care, productivity, and leisure require coordination of hand movements to manipulate objects or tools. When tasks require one hand, or if one hand is slower than the other, the task will be difficult to perform.
Participants reported frequently dropping objects or experiencing low hand strength as a common symptom during and after an exacerbation. Impaired fine motor skills or coordination, including a tendency to drop objects, decreased intrinsic hand strength, and limited ability to manipulate tools, can decrease the ability to perform daily tasks that require fine motor skills (Gorniak et al., 2014). Krishnan and Jaric (2008) found lower scores for task performance and coordination, as measured with static and dynamic manipulation grip tool devices. These findings agreed with previous reports (Lexell, 2009) indicating that fine motor testing is important in identifying changes in performance over time for people with MS.
The hypothesis that young adults with MS would have low satisfaction with performance involving fine motor skills was confirmed and corroborated previous findings (Gorniak et al., 2014; Lexell, 2009; Lexell et al., 2006, 2014; Tal-Saban et al., 2014). Gorniak et al. (2014) found a correlation between impaired upper extremity movements and the perception of overall functional ability among those with MS. In this study, young adults with MS were unsatisfied with their performance on 34 age-related tasks involving fine motor skills that are required for self-care, productivity, and leisure. These findings are consistent with those of Lexell (2009), who found that people with MS have problems with self-care and household tasks and that many need financial and practical help to manage daily life. Tal-Saban et al. (2014) found a relationship between motor coordination and the effect of the symptoms of MS on daily functioning.
The finding that 35% of participants scored their perceived performance higher than their perceived satisfaction indicates that they believed that they could perform tasks but were not satisfied with the way they completed them. This finding is consistent with the conclusions of Lexell et al. (2006), who found similar ratings of perceived difficulty in chosen occupations and unsatisfactory performance.
The occupations that were most frequently identified and scored low on satisfaction were shaving and applying makeup, printing, writing or typing letters, manipulating small objects, performing household care, and managing fasteners. These are core occupations that require fine motor skills. This finding is consistent with the work of Lexell et al. (2014) that showed that in a group of 43 people with MS, the most frequently reported problems were in the areas of self-care (63%) and productivity (24%). On a scale of 1 to 10, participants rated their perceived satisfaction an average of 3.03 for self-care and 4.15 for productivity.
In our study, only 3 of the 40 participants rated both performance and satisfaction as high (10), regardless of their lower fine motor scores. One participant indicated that she was satisfied with her performance on tasks, regardless of the degree to which fine motor symptoms limited performance. Despite poor performance, her optimism may be explained as satisfaction with completing the task, regardless of how it was completed, such as with the use of grasping compensation.
Implications for Occupational Therapy Practice
Occupational therapists have an important role in addressing the effects of fine motor deficits on the occupations of young adults with MS. With use of the Occupational Therapy Performance Framework (American Occupational Therapy Association, 2014), occupational therapists have a point of reference in understanding the effect of fine motor skills of young adults with MS and the meaningful occupations they perform.
In addressing fine motor deficits for this population, specific task-related goals and interventions within self-care, productivity, and leisure activities that use specific fine motor skills can improve occupational performance during BADLs. Intervention sessions, including digital exercises and functional tasks requiring digital strength and manipulative skills, are helpful in maintaining the fine motor skills needed for successful occupational outcomes. In addition, occupational therapists can create environmental adaptations to allow more independent and functional occupational lives. These interventions provide the foundation for improved satisfaction with occupational performance.
Future research is needed to explore fine motor skills and their effect on the occupations of young adults with MS. Research should explore the symptoms of MS that affect the performance of occupations, such as fatigue, cognitive and visual issues, and psychosocial problems. Several studies have evaluated the occupations, performance, and participation of people with MS (Lexell, 2009; Lexell et al., 2006, 2014), but limited research has linked fine motor skills and occupations of those with MS, specifically, young adults with MS. Future research on the fine motor skills of young adults in relation to their occupations using a randomized controlled trial with a larger population may confirm these findings. Future studies using the COPM in its entirely may increase understanding of the performance and satisfaction of all occupations. Further research on the effect of problematic fine motor skills on psychosocial factors among young adults with MS would be beneficial for occupational therapists in developing treatment plans.
This study had limitations. It used a modified version of the COPM that focused exclusively on items requiring fine motor performance. Despite an acceptable power analysis, this study had a small convenience sample that was drawn from local neurological clinics.
This study showed that young adults with MS have low scores on individual manipulation and coordination subtests on the PPBT and slow speed on the GPBT. Scores for perceived performance on the COPM were relatively higher than scores for perceived satisfaction, indicating that although participants could perform tasks, they were not necessarily satisfied with their performance. Statistically significant correlations were found between perceived performance and satisfaction scores and components of the PPBT and GPBT, but no significant correlations were found with perceived performance and dominant or non-dominant hand on the GPBT. This may be the result of overall higher scores on the performance component of the test.
Young adults 18 to 30 years old were selected for this study because of the developmental changes that occur during this time of life. Although the problems that were chosen were individual to each participant, this study found that young adults with MS can perform most tasks, but they would prefer to perform the task better. This finding is particularly important for those beginning a new career, already involved in their career, caring for their family and children, and maintaining independence. Young adults with MS perceive difficulties with occupations that are affected by their fine motor status.
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Problematic Occupations Identified on the Adapted Canadian Occupational Performance
|Self-care||Personal care (n = 31)||Managing nails (n = 1)
Opening containers (n = 3)
Performing general dressing tasks (n = 4)
Managing fasteners (n = 11)
Shaving/applying makeup (n = 12)|
|Community management (n = 14)||Paying bills (n = 4)
Handling money (n = 7)
Shopping (n = 3)|
|Productivity||Performing paid/unpaid work (n = 24)||Learning new tasks (n = 7)
Managing responsibilities (n = 13)
Preparing resume (n = 4)|
|Household management (n = 37)||Preparing food (n = 7)
Cleaning housea (n = 14)
Washing dishes (n = 5)
Doing laundry (n = 4)
Performing minor house repairs (n = 5)
Providing child care (n = 2)|
|School (n = 54)||Manipulating objects (n = 14)
Drawing/cutting/pasting (n = 5)
Printing/writing (n = 17)
Taking notes (n = 10)
Doing homework (n = 8)|
|Leisure||Quiet recreation (n = 14)||Knitting/sewing (n = 1)
Participating in hobbies/collectionsb (n = 6)
Engaging in creative arts (n = 1)
Playing cards/board games (n = 3)
Manipulating media tools (n = 3)|
|Active recreation (n = 13)||Caring for pets (n = 3)
Dining out (using utensils) (n = 5)
Driving car (manipulating door and knobs) (n = 5)|
|Socialization (n = 20)||Using telephone (n = 2)
Hosting parties (n = 2)
Writing (typing) lettersc (n = 16)|
Average Ratings of Problematic Occupations
|Occupation||n (%)||Performance rating||Satisfaction rating|
| Personal care||31 (69)||6.4 (average)||5.3 (average)|
| Community management||14 (31)||7.6 (average)||6.8 (average)|
| Total times items chosen||45|
| Paid/unpaid work||24 (21)||7.0 (average)||6.1 (average)|
| Household management||37 (32)||6.5 (average)||5.4 (average)|
| School||54 (47)||6.7 (average)||4.9 (low)|
| Total times items chosen||115|
| Quiet recreation||14 (30)||7.9 (average)||5.9 (average)|
| Active recreation||13 (28)||6.1 (average)||4.2 (low)|
| Socialization||20 (42)||6.8 (average)||5.4 (average)|
| Total times items chosen||47|
|Average||6.9 (average)||4.4 (low)|
Correlations Among PPBT Subtest, GPBT, and COPM Satisfaction and Performance Scores
|Pegboard||Satisfaction (r)||Performance (r)|
|PPBT (both hands)||0.204||0.168|