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In-hand manipulation assessment instruments for children: A scoping review

Article  in  British Journal of Occupational Therapy · November 2021

DOI: 10.1177/03080226211037859

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Review

British Journal of Occupational Therapy

2021, Vol. 0(0) 1–16
In-hand manipulation assessment instruments for © The Author(s) 2021
Article reuse guidelines:
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DOI: 10.1177/03080226211037859
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Annelize Kruger, Monique Strauss, Marieta Visser 

Abstract
Aim: Accurate assessment of in-hand manipulation is imperative when treating children with fine motor delays. A clinically suitable
instrument for in-hand manipulation is required to inform the paediatric developmental and rehabilitation context. Critical evaluation
of the available instrument is required to make an informed decision and direct future research. The aim of the study was to assess the
available literature with a view to writing a scoping review on in-hand manipulation assessment instruments for children.
Methods: The Arskey and O’Malley six-stage scoping review was applied. Fifteen databases were sourced for articles published
between 1 January 1990 and 31 December 2020. After identifying 33 eligible articles that met the inclusion criteria, the data obtained
from the articles were charted.
Results: Eleven in-hand manipulation assessment instruments were identified and summarised according to (i) the constructs of in-
hand manipulation included; (ii) clinical utility aspects of applicability and practicality and (iii) psychometric properties.
Conclusion: At the time of the review, none of the instruments had comprehensively completed the instrument development process to
the point of standardisation with evaluated psychometric properties. Further research is recommended for the development of a gold
standard in-hand manipulation assessment instrument.

Keywords
In-hand manipulation, fine motor skills, children, assessment instruments, clinical utility, psychometric properties
Received: 24 March 2021; accepted: 14 July 2021

Introduction sound in-hand manipulation assessment instrument is re-

In-hand manipulation is the process of adjusting an object in
a person’s hand for more effective placement after it has been
grasped without touching another surface and considered to
be one of the most complex fine motor skills to develop
(Exner, 2006, 2010). This concept was predefined with the
foundational work of Elliot and Connolly (1984) in their
classification of intrinsic hand movements. Exner (1986) later
built on Elliott and Connolly’s work and coined the term in-
hand manipulation skills. In 2009, Pont et al. compared and
integrated these two classification systems resulting in
a modified classification system of in-hand manipulation with
the following six distinct components: (i) finger-to-palm
translation to achieve stabilisation; (ii) palm-to-finger
translation; (iii) simple shift; (iv) complex shift; (v) simple
rotation and (vi) complex rotation (Pont et al., 2009).
The impact of poor in-hand manipulation on a child’s
functioning is manifested in the proficiency and quality of
their participation in play, self-care and scholastic tasks
(Brown and Link, 2016; Case-Smith, 1995, 1996; Feder et al.,
2005). A child who is referred to a clinician is often char-
acterised as being ‘clumsy’ or having ‘messy handwriting’
(Cornhill and Case-Smith, 1996). Identifying in-hand ma-
nipulation as an underlying component (Creek, 2003; Laver
Fawcett, 2007) will enable the clinician to plan and imple-
ment an appropriate treatment plan, for which a clinically
quired. When the different in-hand manipulation components
were clarified by Pont et al. (2009), the need to develop an In-
Hand Manipulation Test (IMT) was emphasised.
The first in-hand manipulation assessment instrument
described in the literature was developed in 1986 by Exner
(1990). From 1990 to 2004, Exner published several articles
on the development of the IMT (Exner, 1990, 1993, 1997;
Miles Breslin and Exner, 1999; Smith-Zuzovsky and Exner,
2004). In 1993, Jewell and Humphry developed an Obser-
vational Protocol of In-Hand Manipulation (Humphry et al.,
1995; Jewell and Humphry, 1993). In 1997, the ‘unnamed test
of Pehoski’ for children was reported on (Pehoski et al.,
1997a, 1997b). From 1996 to 2002, Case-Smith worked on
the Test of In-hand Manipulation (TIHM), which she used to
explore the relationship between aspects of in-hand manip-
ulation and fine motor performance in children (Case-Smith,
1991, 1995, 1996, 2000, 2002; Cornhill and Case-Smith,
Department of Occupational Therapy, School of Health and Rehabilitation
Sciences, Faculty of Health Sciences, University of the Free State,
Bloemfontein, South Africa
Corresponding author:
Annelize Kruger, Department of Occupational Therapy, CR de Wet
Building, Faculty of Health Sciences, University of the Free State, 205
Nelson Mandela Drive, Bloemfontein 9300, South Africa.
Email: krugerea@ufs.ac.za
2 British Journal of Occupational Therapy 0(0)
1996). Later, in 2008, Pont et al. refined the TIHM into the
TIHM-Revised. In recent years, publications of new in-hand
manipulation assessment instruments have emerged. In 2014,
with a follow-up study in 2016, Visser et al. developed the
UFS IHM-Checklist (Visser et al., 2014, 2016). In 2015, De
Vries et al. adapted the test by Pont et al. into the Timed-
TIHM. In 2016, Raja et al. developed the Test of In-hand
Manipulation Skills (TIMS). Klymenko et al. (2018) de-
veloped an assessment tool suitable for adults. In 2019,
Kaiser and Carrascob adapted the test by Pont et al. into the
Modified In-hand Manipulation Test (TIHM-M).
Taking all these instruments into consideration, the
question arose: How do clinicians decide on what instrument
to use? An instrument evaluation process has been advised by
Laver Fawcett (2007) to ensure a good fit to the clinical
setting. A way of critically evaluating instruments is by using
the Instrument Evaluation Framework (Rudman and Hannah,
1998), the Outcome Measure Rating Form Guidelines (Law,
1987, 2004), the criteria for Test Critique (Laver Fawcett,
2007), the COSMIN-checklist (COnsensus-based Standards
for the selection of health Measurement INstruments)
(Mokkink et al., 2012) or the set of considerations proposed
by Kielhofner (2006).
Furthermore, a clinically sound assessment instrument
should also display characteristics of a systematic and
comprehensive instrument development process (Benson and
Clark, 1982; Law, 1987; Rudman and Hannah, 1998). It
should cover all the aspects of the construct being assessed,
namely, in-hand manipulation, and include evaluated psy-
chometric properties (Schoneveld et al., 2009; Van de Ven-
Stevens et al., 2009). Lastly, it should be standardised as
a norm-referenced instrument that is contextually relevant to
the intended patient population (Rudman and Hannah, 1998).
However, to date, there are no reviews that have critically
appraised and mapped out all the published in-hand ma-
nipulation assessment instruments according to an instrument
evaluation process, to determine if they do comply with all
the requirements of a sound assessment instrument. For this
reason, it is difficult to inform clinical decision-making and
practice from all the available instruments described above.
Therefore, the aim of this scoping review was to summarise
and provide a broad overview of the different in-hand ma-
nipulation assessment instruments described in the literature.
Methods
Scoping reviews are a form of knowledge synthesis suitable
to map out the literature landscape of an emerging topic. It is
useful for evidence reconnaissance, as it can provide a broad
overview of a topic and thereby identify gaps in the evidence,
clarify key concepts and report on the types of evidence that
can inform practice and direct future research (Arksey and
O’Malley, 2005; Joanna Briggs Institute, 2019a). In contrast
to a systematic review, a scoping review does not formally
assess or ‘weight’ the quality of the evidence which allows for
a greater range of studies to be included and thereby de-
termine the extent of research available (Levac et al., 2010).
The six-stage scoping review framework described by Arksey
and O’Malley (2005) was used to conduct the review.
Stage 1: Identifying the research question
The research question, as the starting point of the scoping
review, had to be sufficiently extensive to ensure a compre-
hensive coverage (Levac et al., 2010) and therefore was What
is known from the literature about paediatric in-hand ma-
nipulation assessment instruments?
Stage 2: Identifying the relevant studies
The parameters of a scoping review study must be determined
after becoming familiar with the content to ensure that a topic
is covered comprehensively (Arksey and O’Malley, 2005). A
literature search was performed in collaboration with
a medical librarian on 15 electronic databases (Academic
Search Ultimate, MEDLINE, CINAHL, APA PsycINFO,
Health Source: Nursing/Academic Edition, CAB, Master-
FILE Premier, ERIC, Health Source – Consumer Edition and
Nursing/Academic Edition, SocINDEX, Sociology Source
Ultimate SPORTDiscuss, Africa-Wide Information and Ac-
ademic Search Ultimate), as well as on Google and Google
Scholar, using a combination of the following keywords:
"in-hand manipulation", "fine motor", "handwriting",
"dexterity", "hand function", "hand therapy", "hand
injury", "hand rehabilitation", "tool", "instrument",
"outcome", "performance", "assessment", "measure-
ment", "evaluation", "psychometric", "clinimetric",
"applicable", "utility", "reliability", "validation",
"validity", "shift", "translation", "rotation", "child",
"paediatrics".
The reference lists of key publications were then con-
sulted. Articles were limited to those published in peer-
reviewed journals in English between 1 January 1990 and
31 December 2020. Eligibility was based on the inclusion
criteria that an assessment instrument had to refer to in-hand
manipulation and that the participants were children (18 years
or younger).
Stage 3: Selection of articles
The selection process, as outlined in Figure 1, shows that the
searches conducted on the electronic databases yielded 1209
abstracts, while the additional searches further contributed 63
records. Of the total of 1272 records found, 34 duplicates
were excluded. After reviewing the titles and abstracts of the
1238 records, 1186 irrelevant records were excluded. Key
journals were hand-searched, and 30 additional records were
added from these articles’ reference lists. Eligibility was
determined by reviewing the full-text of 82 records, after
which 49 records were excluded on the basis of reasons
shown in Figure 1. The remaining 33 published articles were
included in the scoping review.
Stage 4: Charting the data
The process of charting the data must provide a descriptive
and logical summary of the results (Joanna Briggs Institute,
Kruger et al.
Figure 1. Article selection process.
2019b). Eleven in-hand manipulation assessment instruments
were identified and then organised chronologically according
to the name of the instrument discussed in the article, the
number of articles published of the assessment instrument and
the articles’ detail as summarised in Table 1.
Stage 5: Collating, summarising and reporting
the results
A broad overview of the eleven in-hand manipulation as-
sessment instruments is provided according to three key
concepts. The headings of the tables were determined after
becoming familiar with the data (Arksey and O’Malley, 2005;
Levac et al., 2010). The components of in-hand manipulation
were based on the Modified System for Classification of In-
hand Manipulation (Pont et al., 2009). The parameters for
clinical utility, that were grouped under applicability and
practicality, were constructed after consulting the Test
3
Critique criteria by Laver Fawcett (2007), the Instrument
Evaluation Framework (Rudman and Hannah, 1998) and the
Outcome Measure Rating Form Guidelines (Law, 1987,
2004). The psychometric properties that had been in-
vestigated were presented in the sequence in which validity
and reliability should be tested, as proposed by Benson and
Clark (1982) in their Guide for Instrument Development and
Validation. As the COSMIN-checklist provides a quality
appraisal of the instrument’s measuring properties, it is most
applicable to be used for a systematic review (Mokkink et al.,
2012).
Stage 6: Consultation
Based on the most recent published article, 15 graduate
projects with resulting manuscripts that were unpublished had
also been conducted (Smith-Zuzovsky and Exner, 2004).
These dissertations are not available outside of the Townson
4 British Journal of Occupational Therapy 0(0)

Table 1. Overview of the publications of in-hand manipulation assessment instruments.

No. of
No. Name of the instrument Abbr. articles Authors and year of publication Country

1 In-Hand Manipulation Test – Quality IMT-Q 4 Exner (1990, 1993, 1997); Miles Breslin and Exner Ohio, USA
section (1999); Smith-Zuzovsky and Exner (2004)
2 Test of In-Hand Manipulation TIHM 6 Case-Smith (1991, 1995, 1996, 2000, 2002), Ohio, USA
Cornhill and Case-Smith (1996)
2 Feder et al. (2005); Feder et al. (2007) Quebec, Canada
1 Bazyk et al. (2009) Ohio, USA
3 Observation Protocol of In-Hand N/A 2 Jewell and Humphry (1993); North Carolina, USA
Manipulation Humphry et al. (1995)
4 Unnamed test of Pehoski N/A 3 Pehoski et al. (1997a, 1997b); Boston, USA
Denton et al. (2006)
5 Unnamed test of Bonnier N/A 1 Bonnier et al. (2006) Stockholm, Sweden
6 Test of In-Hand Manipulation – TIHM-R 3 Pont et al. (2008); Brown and Link (2016); Queensland,
Revised Dadson et al. (2020) Australia
7 Assessment of Children’s Hand Skills ACHS 6 Chien et al. (2009, 2010, 2011a, 2011b, 2012); Victoria, Australia
Chien et al. (2014)
8 University of the Free State In-Hand UFS IHM-C 2 Visser et al. (2014, 2016) Bloemfontein, South
Manipulation Checklist Africa
9 Timed-Test of In-Hand Manipulation T-TIHM 1 De Vries et al. (2015) Haren, Netherlands
10 Test of In-Hand Manipulation Skills TIMS 1 Raja et al. (2016) Sikkim, India
11 Modified In-Hand Manipulation Test TIHM-M 1 Kaiser and Carrascob (2019) Geneve, Switzerland

State University in Maryland, USA, as confirmed through
personal email communication with the medical librarian in
2018. Unfortunately, an attempt to consult with Exner, the
leading authority on in-hand manipulation who developed
both the IMT-Quality and IMT-Speed assessment instruments
as part of her doctoral degree, was unsuccessful. Visser, the
principal author of the UFS In-hand Manipulation Checklist,
provided guidance and direction in procuring and evaluating
the articles that related to in-hand manipulation. Contact with
the main author of the TIMS, Kavitha Raja, enabled the
researcher to purchase the manual, prefabricated version of
the instrument and video showing how to administer the
activities to an adult.
Results
A total of 33 eligible articles were included in the charting
process through which 11 in-hand manipulation assessment
instruments were identified (see Figure 1). The results are
reported according to the three key concepts: (i) components
of in-hand manipulation included; (ii) clinical utility and (iii)
psychometric properties.
Components of in-hand manipulation
The presence of the six in-hand manipulation components in
the instruments are reported in Table 2, with short definitions
of the components to orientate the reader. In cases where an
author made changes to the assessment instrument over the
course of the instrument’s development, the most recent
description of the assessment instrument was included in the
tables.
All the assessment instruments included a complex ro-
tation component which included the rotation task in the
unnamed test of Pehoski. This is in contradiction to Denton
et al. (2006), who referred to the movement as simple
rotation, as the movement of turning a peg aligned with the
definition and example provided as complex rotation Pont
et al. (2009). Both the IMT-Q (Smith-Zuzovsky and Exner,
2004) and the UFS IHM-C (Visser et al., 2016) included all
the in-hand manipulation components, except for a compo-
nent of shift. The unnamed test of Bonnier et al. (2006)
differed from the other assessment instruments in that it only
assessed complex shift and complex rotation. The Assess-
ment of Children’s Hand Skills (ACHS) could potentially
assess all the components of in-hand manipulation, provided
that the items chosen could elicit all the components of in-
hand manipulation and during the scoring, a distinction was
made between the complex and simple parts of the shift and
rotation tasks. Similarly, the TIMS did not distinguish be-
tween simple and complex shift component when scoring
(Raja et al., 2016), whereas the TIHM-M included an ad-
ditional item which can be classified as complex shift (Kaiser
and Carrascob, 2019).
Clinical utility
The data obtained regarding the clinical utility of instruments,
specifically their applicability and practicality, are summar-
ised in Tables 3 and 4, respectively. The applicability
(Table 3) of an instrument indicates its purpose (Rudman and
Hannah, 1998), how appropriate it is for a population group
(Kielhofner, 2006) and its accessibility (Laver Fawcett,
2007).
For the intended purpose of these instruments, eight in-
corporated an aspect of evaluation in combination with either
describing or predicting the child’s in-hand manipulation
skills. The age groups for 10 assessment instruments ranged
between the ages of two to 12 years, except for the unnamed
test of Bonnier that was designed specifically for adolescents.
The research populations for nine of the assessment instru-
ments included typical developing children, as this formed
Kruger et al. 5

Table 2. Components of in-hand manipulation included by assessment instruments.

In-hand manipulation components

Translation Translation Simple Complex Simple Complex

No. Name of the instrument Abbr. finger-palm palm-finger shift shift rotation rotation Stabilisation

1 In-Hand Manipulation IMT-Q 3 3 7 3 3 3 3 All items performed

Test – Quality section with and without
stabilisation
2 Test of In-Hand TIHM 3 3 7 7 7 3 ± Only translation items
Manipulation performed with
stabilisation
3 Observation Protocol of In- N/A 3 3 7 7 7 3 ± Only translation items
Hand Manipulation performed with
stabilisation
4 Unnamed test of Pehoski N/A 3 3 7 7 7 3 7
5 Unnamed test of Bonnier N/A 7 7 7 3 7 3 7
6 Test of In-Hand TIHM-R 3 3 7 7 7 3 ± Only translation items
Manipulation – Revised performed with
stabilisation
7 Assessment of Children’s ACHS 3 3 ± ± ± ± 7
Hand Skills
8 University of the Free State UFS IHM-C 3 3 3 7 3 3 3 All items performed
In-Hand Manipulation with and without
Checklist stabilisation
9 Timed-Test of In-Hand T-TIHM 3 3 7 7 7 3 ± Only translation items
Manipulation performed with
stabilisation
10 Test of In-Hand TIMS 3 3 ± ± 3 3 3 All items performed
Manipulation Skills with and without
stabilisation
11 Modified In-Hand TIHM-M 3 3 7 3 7 3 ± Only translation items
Manipulation Test performed with
stabilisation
The component is 3 included; 7 excluded; ± partially included.
Finger-to-palm translation: An object is moved from the fingertips and pad of the thumb into the palm of the hand in order to stabilise and store an
object in the palm of the hand (Pehoski et al., 1997b; Pont et al., 2009).
Palm-to-finger translation: An object is moved from its stabilised position in the palm to the tips of the fingers and is commonly used to retrieve an
object from storage within the palm (Pehoski et al., 1997b; Pont et al., 2009).
Simple rotation: An object is rotated through one-fourth or one-half of its axis (Raja et al., 2016) while the thumb moves independently and all the
involved fingers act as a single unit (Pont et al., 2009).
Complex rotation: An object is rotated about one or more of its axes by 180–360°, which requires independent and isolated finger movements
(Pont et al., 2009).
Simple shift: An object is moved linearly by simultaneous flexion or extension of the thumb and fingers as a single unit (Pont et al., 2009).
Complex shift: An object is moved linearly by individual finger movements, as a result of the digits being repositioned on the object (Pont et al., 2009).
Stabilisation: When one or more objects, or part of an object, is stabilised in the ulnar portion of the hand while another object or part of an object is
being manipulated by other digits, using any one of the other forms of in-hand manipulation (Pont et al., 2009).

the first stage of instrument development. Children with
various conditions and fine motor delays were included by six
of the assessment instruments, while the unnamed test of
Pehoski also included an adult controlled group (Pehoski
et al., 1997a, 1997b).
Five assessment instruments did not indicate the need for
clinician training (Bonnier et al., 2006; Case-Smith, 1996;
Humphry et al., 1995; Raja et al., 2016; Visser et al., 2016)
while it was a pre-requisite for the IMT-Q (Exner, 1993).
Training was provided to the researchers who executed the
unnamed test of Pehoski (Pehoski et al., 1997a, 1997b),
TIHM-R (Pont et al., 2008), ACHS (Chien et al., 2014) and
TIHM-M (Kasier and Carrascob, 2019). Six of the 33 articles
were closed access (Bonnier et al., 2006; Chien et al., 2011b;
Dadson et al., 2020; Feder et al., 2005, 2007; Jewell and
Humphry, 1993), which requires a clinician who is not
subscribed to the journal to buy the articles. Ten of the
instruments are available for use with permission from the
authors.
The aspects of practicality (Table 4) refer to the inclusions
of the manual (the extent that the administration and scoring
instructions and equipment requirements are standardised)
(Laver Fawcett, 2007; Rudman and Hannah, 1998), the
different administration aspects, the measurement scale used
(Kielhofner, 2006) and scorable aspects of in-hand manip-
ulation. The authors of two of the assessment instruments,
TIMS (Raja et al., 2016) and ACHS (Chien et al., 2012),
published a thorough description of the instrument as an
appendix to their articles, while the IMT-Q is not reproducible
from the articles’ descriptions (Exner, 1990, 1993; Miles
Breslin and Exner, 1999; Smith-Zuzovsky and Exner, 2004).
The remainder of the instruments included descriptions of the
instructions, tasks and equipment (Bonnier et al., 2006;
Humphry et al., 1995; Kaiser and Carrascob, 2019; Pehoski

Table 3. Applicability of the in-hand manipulation assessment instruments.
No. Name of the instrument
1 In-Hand Manipulation
Test – Quality section
2 Test of In-Hand
Manipulation
3 Observation Protocol of In- N/A
Hand Manipulation
4 Unnamed test of Pehoski
5 Unnamed test of Bonnier N/A
6 Test of In-Hand TIHM-R Predictive, 3 years 0 m– Typical children
Manipulation – Revised
7 Assessment of Children’s
Hand Skills
6
Clinical utility: Applicability
Access and source of the
Abbr. Purpose Age range Research population Inclusion/exclusion criteria Training article(s) Availability and cost
IMT-Q Descriptive 3 years 0 m– Typical children and children Inclusion: skills to follow basic Required Open access from AJOT (4/4 On request for permission
8 years with fine motor delays, directions Exclusion: articles) and use
11 m spastic diplegia and born Cognitive delays and
prematurely younger than 18 months
TIHM Descriptive, 4 years 0 m– Children with tactile None None Open access from AJOT (7/9 On request for permission
predictive 6 years defensiveness, decreased articles) Closed access and use. Equipment
11 m tactile discrimination, from Wiley Online requirements are
developmental delay, Library and POTJ (2/9 a prefabricated 9-HPTÔ
spastic diparesis cerebral articles) with prices from
palsy; Fragile X, mental publishers ranging
retardation and with from US$38–73
moderate fine motor
delays
Descriptive, 2 years 0 m– Typical children None None Open access from AJOT (1/2 On request for permission
evaluative 7 years article) Closed access and use
11 m from Taylor & Francis
Online (1/2 article)
N/A Descriptive, 3 years 0 m– Typical children and adults None Researchers were Open access from AJOT (3/3 On request for permission
evaluative 6 years as a controlled group trained articles) and use
11 m
Evaluative 13 years 0 m– Children with hemiplegic Inclusion: Children with None Closed access from Taylor On request for permission
18 years cerebral palsy hemiplegic cerebral palsy & Francis Online (1/1 and use
11 m article)
Exclusion: significant Researchers were Open access from AJOT and On request for permission
evaluative 7 years 0 m impairment of vision, trained in a 2-h BJOT (2/3 articles) and use. Equipment
hearing, motor, or workshop Closed access from requirements are
cognitive skills and no Wiley Online Library (1/3 a prefabricated 9-HPTÔ
psychosocial, behavioural, articles) with 5 pegs with prices
learning, or intellectual from publishers
problems and/or ranging from US$38–73
insufficient understanding
of English to complete the
test
ACHS Predictive, 2 years 0 m– Typical children, children None Researchers were Open access from Wiley Appendix in the article. On
evaluative 12 years with disabilities trained over 2 Online Library, AJOT, request for permission
11 m days (12 h in BJOT and Journal of and use
total). Rehabilitation Medicine
Recommends (5/6 articles) Closed
‘self-learning’ access from
training ScienceDirect
(1/6 article)
British Journal of Occupational Therapy 0(0)
(continued)
Table 3. Continued.
Clinical utility: Applicability

Access and source of the

Kruger et al.

No. Name of the instrument Abbr. Purpose Age range Research population Inclusion/exclusion criteria Training article(s) Availability and cost
8 University of the Free State UFS Descriptive 4 years 0 m– Typical children Exclusion: Physical, cognitive None Open access from Scielo On request for permission
In-Hand Manipulation IHM-C 7 years or emotional disabilities as South Africa (2/2 and use
Checklist 11 m a result of autism, cerebral articles)
palsy or attention deficit
disorder
9 Timed-Test of In-Hand T-TIHM Predictive, 5 years 0 m– Typical children with good Exclusion: Limiting medical Researchers were Open access from Wiley On request for permission
Manipulation evaluative 6 years and poor paper-and- diagnosis or visual or trained Online Library (1/1 and use. Equipment
11 m pencil task performance auditory impairment article) requirements are
a prefabricated 9-HPTÔ
with prices ranging
from US$38–73 from
publishers
10 Test of In-Hand TIMS Descriptive, 3 years 6 m– Typical children, CP, Exclusion: Any history of None Open access from Appendix in the article.
Manipulation Skills evaluative 9 years 6 m developmental upper limb surgery, severe International Journal of Publisher (US$80)
coordination disorder, sensory loss (auditory or Health & Allied Sciences
down syndrome visual) or unable to (1/1 article)
understand test
instructions
11 Modified In-Hand TIHM-M Predictive, 6 years 6 m– Typical children Inclusion: Child is in grade Researchers were Open access from Iranian On request for permission
Manipulation Test evaluative 9 years 6 m level according to age trained Rehabilitation Journal and use. Equipment
Exclusion: No physical or (1/1 article) requirements are
developmental disorder a prefabricated 9-HPTÔ
with prices ranging
from US$38–73 from
publishers
AJOT – American Journal of Occupational Therapy; POTJ – Physical and Occupational Therapy Journal; BJOT – British Journal of Occupational Therapy.
Descriptive: Description of the person’s current functional status with a focus on identifying strengths and limitations. Often used to provide baseline data for treatment planning and clinical decision-making (Rudman
and Hannah, 1998).
Predictive: Undertaken in order to predict the future ability or state of a client or to predict a specific outcome in the future. (Rudman and Hannah, 1998).
Evaluative: Used to detect a change in functioning over time and undertaken to monitor a client’s progress during rehabilitation and to determine the effectiveness of the intervention. (Rudman and Hannah, 1998).
7
 8

Table 4. Practicality aspects of in-hand manipulation assessment instruments.

Clinical utility: Practicality

Administration Scorable aspects

Frequency
Name of the Number Time Measuring Quality of Additional of Time to Item(s)
No. instrument Abbr. Manual inclusions Method of items required Hand(s) scale movement movements movement complete dropped

1 In-Hand Manipulation IMT-Q Articles contain insufficient Formal 55 15–20 min Only dominant Ordinal 3 5-point rating scale (0 = 3 Six substitution 7 7 ± Additional
Test – Quality section information. Formal mechanistic hand scale no in-hand manipulation pattern(s) not specified observation,
manual in the process of tasks and 4 = smooth, efficient were scored number of
development and reported movement and uses the drops
to contain detailed distal finger pads) recorded but
instructions, with not scored
presentation, scoring and
interpretation instructions.
2 Test of In-Hand TIHM Instructions and presentation Formal mechanistic 5 Not Only dominant Ordinal scale 7 3 Counted and scored the 7 3 Scored in 3 Counted and
Manipulation described in articles. No tasks specified hand. Actively times the peg was seconds scored
scoring sheet or discourage non- stabilised on another
interpretation of results dominant hand surface
provided. Equipment
requirements are
a prefabricated.
3 Observation Protocol N/A Standardised materials and Formal mechanistic 13 Not Only dominant Ordinal 7 3 Alternative 3 3 Scored in 3 Counted
In-Hand instructions, also scoring and functional specified hand scale manipulation Frequency seconds for and
Manipulation sheet described in the tasks strategies not scored functional scored
article. No specific specified, recorded tasks
instructions or
interpretation of the
results provided.
4 Unnamed test of N/A Instructions and presentation Formal mechanistic 5 10 min Only dominant Ordinal 3 3-point rating scale (1 = 7 7 3 Scored in 3 Counted and
Pehoski described in articles. No tasks hand. Actively scale mature; 3 = immature) seconds for scored for
scoring sheet or discourage non- rotation task rotation task
interpretation of results dominant hand
provided.
5 Unnamed test of N/A No specific instructions Formal mechanistic 3 Not Only non-dominant Ordinal scale 3 5-point rating scale for 7 7 7 7
Bonnier available. Scoring tasks specified hand. Actively rotation and shift tasks
described in the article. No restrain non-
interpretation of scores affected/
provided. dominant hand
6 Test of In-Hand TIHM-R Instructions and presentation Formal mechanistic 3 5–7 min Only dominant Ordinal scale 3 3-point scale (0 = no IHM 3 Counted and scored the 7 3 Scored in 3 Counted and
Manipulation – described in articles. No tasks hand. Actively skills used, 1 = IHM used times the peg was seconds scored
Revised scoring sheet or discourage non- less than 50% of the stabilised on an
interpretation of results dominant hand time, 2 = IHM used more external surface
provided. Equipment than 50% of the time)
requirements are
a prefabricated 9-HPTÔ.
7 Assessment of ACHS Description of test items and Informal Functional 22 20–30 min Not specified Ordinal scale 3 6-point scale 7 7 7 7
Children’s Hand scoring published in the tasks
Skills appendix. No
standardised materials,
methods, or test settings
required. Formal manual
in the process of
development (predicted
cost US$70).
British Journal of Occupational Therapy 0(0)

(continued)
Table 4. Continued.
Clinical utility: Practicality

Administration Scorable aspects

Kruger et al.

Frequency
Name of the Number Time Measuring Quality of Additional of Time to Item(s)
No. instrument Abbr. Manual inclusions Method of items required Hand(s) scale movement movements movement complete dropped

8 University of the Free UFS Instructions and presentation Formal 8 10–15 min Only dominant hand Nominal scale 3 Two 3 Scored specified as 7 7 ± Additional
State In-Hand IHM-C described in articles. No mechanistic categories: stabilise against body observation,
Manipulation scoring sheet or tasks (i) Successful and surface; rotate not scored
Checklist interpretation of results completion with body; use both hands;
provided. Photo of or without fixation of arm; change
equipment requirements compensation hands; rotate the wrist
included. (ii) No compensatory
methods used
9 Timed-Test of In-Hand T- Instructions and presentation Formal mechanistic 3 5–7 min Only dominant hand Ordinal scale 7 ± Additional observation if 7 3 Scored best ± Additional
Manipulation TIHM described in articles. No tasks an external surface was attempt out observation,
scoring sheet or used but not scored of two in not scored
interpretation of results seconds
provided. Equipment
requirements are
a prefabricated 9-HPTÔ
10 Test of In-Hand TIMS Instructions, equipment and Formal mechanistic 47 15–20 min Only right-hand Ordinal scale 3 4-point rating scale (0 = ± Additional observation 7 7 3 Counted and
Manipulation Skills presentation published in tasks No manipulation within could be noted, but not scored but
the appendix. Manual can the hand noticeable, scored not included
be purchased (US$80) hand is used only to in the final
grasp; 3 = object score
manipulated smoothly
and quickly within the
hand, using the distal
finger pads
predominantly)
11 Modified In-Hand TIHM-M Instructions and presentation Formal mechanistic 5 Not Only dominant Ordinal scale 3Raw scores ranged from 3 Stabilised on external 7 3Informal 3 Scored per
Manipulation Test and scoring of each task tasks specified hand 0-5 or 0-2 for the shift surface, no contact of untimed item and
described in articles. No task the peg with thumb trial, included in
scoring sheet or (translation tasks). followed by final quality
interpretation of results Stick angled at ≥45° on two-timed, score
provided. Equipment more than half of the formal trials.
requirements are similar distance or did not Scored best
to 9-HPTÔ with reach the marked line attempt in
descriptions. An additional at the end of the stick seconds
dowel stick was included with a tolerance of 1 cm
(description included). (shift task)

Scoring aspect is either 3 scored, 7 not included in scoring, ± noted as an observation only.
9
10
et al., 1997b; Raja et al., 2016; Visser et al., 2016), with the
UFS IHM-C being the only one to include a photographic
image of the equipment (Visser et al., 2016). The TIHM,
TIHM-R, T-TIHM and TIHM-M are all pegboard-based
assessment instruments using the 9-Hole Pegboard Test
(9-HPTÔ) equipment (Case-Smith, 2002; Kaiser and
Carrascob, 2019; Pont et al., 2008; Van Hartingsveldt
et al., 2015), which is commercially available. The exact
scoring sheet and interpretation of the results, along with the
instructions, are available in the respective published ar-
ticles but are incomplete to be classified as a standardised
manual (Bonnier et al., 2006; Humphry et al., 1995; Kaiser
and Carrascob, 2019; Pehoski et al., 1997a, 1997b; Raja
et al., 2016; Visser et al., 2016).
A formal administration approach was proposed by the
guidelines of 10 instruments, except for ACHS that followed
an informal and naturalistic approach (Chien et al., 2009).
Functional tasks were also included by the ACHS (Chien
et al., 2009) and partially by the Observational Protocol of In-
hand Manipulation, which included tasks such as fastening
a button, eating with a spoon or brushing teeth (Chien et al.,
2009; Humphry et al., 1995). Mechanistic tasks used by the
remaining instruments referred to either structured test items
such as the pegboard with a specific goal verbalised (Case-
Smith, 2002; De Vries et al., 2015; Pehoski, et al., 1997a;
1997b; Pont et al., 2008; Visser et al., 2016) or ‘games’ that
were structured to ensure that the movement was elicited and
repeated for optimal scoring (Bonnier et al., 2006; Exner
1993; Humphry et al. 1995; Raja et al., 2016; Visser et al.,
2016).
The four fundamental levels of measurement scales used
in assessment instruments are nominal, ordinal, interval and
ratio (Kielhofner 2006; Laver Fawcett, 2007). Ten of the
assessment instruments used ordinal scales, which are the
numerical values that represent the performance of the child
on a continuum and either refer to a rating scale or a timed
score (Laver Fawcett, 2007). The UFS IHM-C used
a nominal scale, as two categories were used during the
scoring (Visser et al., 2016). The quality of the movement
was often scored on a rating scale ranging from a 3-point
(Pehoski et al., 1997a; Pont et al., 2008) to a 6-point scale
(Chien et al., 2009). Additional movements were referred to
by some authors as substitution patterns (Miles Breslin and
Exner, 1999), compensatory methods (Visser et al., 2016) or
alternative manipulation strategies (Humphry et al., 1995).
These movements by the child referred to those other than
the identified in-hand manipulation pattern that would be
most efficient for that specific activity (Humphry et al.,
1995), which could indicate immaturity of the developed
skill (Pehoski, et al., 1997a; Pont et al., 2009; Visser et al.,
2016).
The frequency with which the correct in-hand manipu-
lation movement pattern was used by the child was only
scored by the Observational Protocol of In-hand Manipula-
tion (Humphry et al., 1995). Recording the time to complete
an item was scored in seconds by six of the assessment in-
struments. Scoring the exact number of times an object was
dropped per item was scored by six of the assessment in-
struments, while three others included it as an additional
British Journal of Occupational Therapy 0(0)
observation (De Vries et al., 2015; Smith-Zuzovsky and
Exner, 2004; Visser et al., 2016).
Psychometric properties
The psychometric properties reported in the eligible articles
are summarised in Table 5. In addition to the five components
proposed by Benson and Clark (1982), inter-rater and intra-
rater reliability, as well as the assessment instruments’ re-
sponsiveness to change, were included as these were important
aspects for predictive and evaluative instruments (Rudman and
Hannah, 1998).
The item selection process, the first part of constructing an
instrument, was performed by means of different methods.
These methods included either reviewing the literature and
non-standardised activities (Bonnier et al., 2006; Visser et al.,
2014), selecting the tasks based on Exner’s Classification of
In-hand Manipulation (Bonnier et al., 2006), considering
items that were familiar and easily available to the target
group (Raja et al., 2016) or consulting with parents and
teachers to determine what functional tasks of a child were
important to them (Humphry et al., 1995). Content validity,
the recommended second step in instrument development
(Benson and Clark, 1982) was only performed for the IMT-Q
(Exner, 1993), ACHS (Chien et al., 2012) and TIMS (Raja
et al., 2016).
Retest reliability was evaluated for seven of the assess-
ment instruments, with all reporting acceptable levels of
reliability, except the TIMH-R (Pont et al., 2008). Notably,
the fourth and fifth steps, namely, internal consistency, and
criterion validity, had not been investigated by any of the
authors (Brown and Link 2016; Feder et al., 2007). Construct
validity had been determined for half of the assessment in-
struments, with acceptable levels of validity, apart from the
translation activities of the TIMH-R (Pont et al., 2008).
Inter-rater reliability was evaluated for most assessment
instruments with acceptable levels. The intra-rater reliability
was determined for only the ACHS and found to be adequate
(Chien et al., 2014). Responsiveness to change was only
investigated for the TIMS after providing 15 children with
various hand dysfunctions with 15 days of 25-min in-
tervention sessions (Raja et al., 2016).
Discussion
The research on eleven in-hand manipulation instruments
identified from 33 eligible articles, published in seven dif-
ferent countries over a period of 30 years, confirms that in-
hand manipulation is pertinent to paediatric therapists in both
developed and developing countries.
Components of in-hand manipulation
None of the instruments incorporated all the components of
in-hand manipulation in a manner that was easily differen-
tiated during the presentation and scoring of the tasks. The
ACHS (Chien et al., 2009) and TIMS (Raja et al., 2016)
include tasks or activities that potentially elicit the compo-
nents but lack the scoring opportunity to distinguish between
Table 5. Psychometric properties of the in-hand manipulation assessment instruments.
Psychometric properties
Kruger et al.

Name of the Item Content Internal Criterion Responsiveness Norm/criterion

No. instrument Abbr. selection validity Retest reliability consistency validity Construct validity Inter-rater reliability Intra-rater reliability to change referenced

1 In-Hand IMT-Q 3Exner 3Exner 3Smith-Zuzovsky and 7 7 3Miles Breslin and Exner 3Miles Breslin and Exner 7 7 7
Manipulation (1990) (1993) Exner (2004); Miles (1999) r = 0.427 age (1999) ICC = 0.90
Test – Quality Breslin and Exner r = 0.433 hand preference
section (1999) ICC = ranged r = 0.258 total IMT and
from 0.84 to 0.95 for gender r = 0.433, p <
different age groups 0.01 hand preference and
total IMT
2 Test of In-Hand TIHM 3Case- 7 7 7 7 7 7 7 7 7
Manipulation Smith
(1996)
3 Observation Protocol N/A 3Jewell and 7 3Humphry et al. (1995) 7 7 7 3Jewell and Humphry 7 7 7
of In-Hand Humphry r = ranged from 0.71 to (1993) r = ranged from
Manipulation (1993) 0.94 for different test 0.91 to 0.99
items
4 Unnamed test of N/A 3Pehoski 7 7 7 7 7 3Pehoski et al. (1997a) 7 7 7
Pehoski et al. Cohen’s kappa ranged
(1997a) from 0.79 to 0.82 for
different items
5 Unnamed test of N/A 3Bonnier 7 7 7 7 7 7 7 7 7
Bonnier et al.
(2006)
6 Test of In-Hand TIHM-R 3Pont et al. 7 3Pont et al. (2008); 7 7 3Pont et al. (2008) Rasch 3Brown and Link (2016); 7 7 7
Manipulation – (2008) Brown and Link (2016) modelling used – Pont et al. (2008)
Revised ‘Inadequate’ at ‘adequate’ although with ‘Excellent’ 46 of the 100
75.86% agreement limited sensitivity to data sets were given
when two data sets performance of finger-to- exactly the same overall
overlapped palm and palm-to-finger ability measured by two
translation or more raters
7 Assessment of ACHS 3Chien et al. 3Chien 3Chien et al. (2010) 7 7 3Chien et al. (2012) Rasch 3Chien et al. (2010) 3Chien et al., (2014) 7 3Chien et al.
Children’s Hand (2009) et al. r = 0.78, p < 0.01 goodness-of-fit analysis, r = 0.63, later on ICC = ranged from (2012)
Skills (2010) r = ranged from 0.59 to improved to ICC = 0.81 0.61 to 0.93 for Intended to
0.89 (Chien et al., 2014) different be criterion
evaluations referenced
8 University of the Free UFS 3Visser 7 7 7 7 7 3Visser et al. (2016) 7 7 7
State In-Hand IHM-C et al.
Manipulation (2014;
Checklist 2016)
9 Timed-Test of In- T-TIHM 3De Vries 7 3De Vries et al. (2015) 7 7 3De Vries et al. (2015) 7 7 7 7
Hand et al. ICC = 0.71 r = 0.40 convergent
Manipulation (2015) validity with WRITIC
established

(continued)
11
 12

Table 5. Continued.
Psychometric properties

Name of the Item Content Internal Criterion Responsiveness Norm/criterion

No. instrument Abbr. selection validity Retest reliability consistency validity Construct validity Inter-rater reliability Intra-rater reliability to change referenced

10 Test of In-Hand TIMS 3Raja et al. 3Raja 3Raja et al. (2016) ICC = 7 7 3Raja et al. (2016) ICC = 3Raja et al. (2016) ICC = 0.87 7 3Raja et al. 7
Manipulation (2016) et al. ranged from 0.82 to ranged from 0.7 to 0.9 (2016)
Skills (2016) 0.95 for different items
11 Modified In-Hand TIHM-M 3 Kaiser and 7 3 Kaiser and Carrascob 7 7 7 3 Kaiser and Carrascob 7 7 7
Manipulation Test Carrascob (2019) ICC speed = (2019) ICC speed = 0.85
(2019) 0.84 ICC quality = 0.62 ICC quality = 0.87

3 Component has been researched; 7 Component has not been researched.

WRITIC = Writing Readiness Inventory Tool in Context.
Guidelines to interpret: Intraclass correlation coefficient (ICC) Poor = <0.5; moderate = 0.5–0.75; good = 0.75–0.9; excellent = >0.90 (Koo and Li, 2016).
Pearson’s correlation coefficient (r) Weak = ±0.1–0.3; average = ±0.3–0.5; strong = 0.5–1.0.
1. Content validity: The degree to which the items in an instrument represent the domain being measured (Schoneveld et al., 2009).
2. Test-retest reliability: The stability of an instrument over time. Repeated scores in a short time period should be similar (Schoneveld et al., 2009).
3. Internal consistency: The degree to which items measure different aspects of the same attribute and nothing else (Schoneveld et al., 2009).
4. Criterion validity: The extent to which the results of an instrument relate to a measure of a similar construct, has demonstrated reliability and validity (Rudman and Hannah, 1998).
5. Construct validity: The degree to which test items measure a theoretical construct and is able to perform as theorised (Laver Fawcett, 2007).
6. Inter-rater reliability: The extent to which an instrument produces consistent scores when used by different raters (Rudman and Hannah, 1998).
7. Intra-rater reliability: The extent to which an instrument produces consistent scores when used by the same rater (Rudman and Hannah, 1998).
8. Responsiveness to change: The exactness of a measure and extent to discriminate differing amounts of a variable and its ability to measure change (Laver Fawcett, 2007).
British Journal of Occupational Therapy 0(0)
Kruger et al.
the simple and complex components of shift and rotation,
while the IMT-Q (Smith-Zuzovsky and Exner, 2004), UFS
IHM-Checklist (Visser et al., 2016) and TIHM-M (Kaiser and
Carrascob, 2019) excluded either the components of simple
or complex shift. This inconsistency of discriminating be-
tween the more discreet components of shift stems from
Exner’s Classification for In-hand Manipulation (1990) that
only refers to shift as one component.
However, the Modified Classification of In-hand Manipu-
lation proposed by Pont et al. (2009) has further conceptualised
all the components by providing comprehensive definitions
with examples and therefore recommended that future instru-
ments should base their item selection process on this model.
It is noteworthy that the articles reviewed that had been
published after 2009 did not integrate (De Vries et al., 2015)
or adjust their instruments’ items to clearly reflect both simple
and complex shift (Chien et al., 2012; Raja et al., 2016; Visser
et al., 2016). A possible reason for this might be that the tasks
included by these instruments are too complex to observe and
score simple and complex shift or rotation separately. For
example, the assessment of simple shift can either be based on
the desired action (e.g. fingers are flexed and extended in
unison) or the child’s performance of an activity (e.g. the
fingers push a key into a hole) or during a functional task (e.g.
the child opens up a lock), but specific instructions are needed
to guide the assessor to distinguish between what must be
scored as ‘each aspect demands an evaluation of both quality
and speed of execution’ (Pont et al., 2009: 3).
Clinical utility
In this study, the multi-dimensional term of clinical utility
referred to the instrument’s applicability and practicality to
acknowledge the clinical factors that influence a clinician’s
choice of instrument (Smart, 2006). Reassuringly the age
group of four- to six-year-old children were included by the
majority of the instruments which is the age group that cor-
responds with the rapid development spur of in-hand ma-
nipulation (Pehoski, 2006; Visser et al., 2014, 2016) and relates
to the development of a child’s pre-writing and writing skills
(Van Hartingsveldt et al., 2011). In contrast, the limited in-
clusion of younger and older children in the instruments was
concerning. Detecting in-hand manipulation delays is impor-
tant both for children as early as the age of 1 year, when in-hand
manipulation starts to develop (Pehoski, 2006), as well as
children aged 12 years and older who are required to display
mature in-hand manipulation skills, although not at the same
speed as that of an adult (Exner, 2010).
The design of the tasks in the current instruments relies on
the child to wait for the instructions and understand how to
use the objects to reach the goal. This can make the as-
sessment of a young child challenging. Developmentally,
children from the age of 1 year to 18 months engage pre-
dominantly in imitation and ‘pretend’ games, using objects
relevant to the situation (e.g. using a spoon or drinking cup).
The ability to use simple tools whilst linking steps together
and performing multiple related actions together develop
until the age of two (e.g. shape blocks and hammering). Up to
the age of 3 years, children participate in more tasks that
13
require object manipulation and combine actions into entire
play scenarios (e.g. dressing a doll to put into bed). If an
instrument is not specifically developed to incorporate these
developmental stages of a child, the assessment of a child’s
in-hand manipulation is understandably difficult. For an older
child, the simplicity of the tasks required for good engage-
ment of a four- to six-year-old might not pique their interest
(Case-Smith, 2006). Therefore, it would be important to
adjust the presentation and goal of the task to be appropriate
for an adolescent, which is possible when comparing to other
formal handwriting assessments that include the age range of
nine to 17 years, that is, Detailed Assessment of Speed of
Handwriting (DASH) (Simons and Probst, 2014).
The majority of instruments present mechanistic tasks in
a formal manner to a small age range and highlight that few
instruments were developed with the intention to be adjustable
for different age groups. Should these instruments be extended
to younger or older children, either a floor or ceiling effect may
occur, when the child scores the minimum or maximum of the
test, respectively, and consequently, the instrument does not
display the full deficit or extent of a child’s ability (Laver
Fawcett, 2007). In comparison, the ACHS (Chien et al., 2009)
is flexible and allows the assessor to choose up to three from 22
functional activities to assess the hand function of the child.
However, the chosen activities, albeit age-appropriate, may
not demonstrate all six constructs of in-hand manipulation
and therefore may provide insufficient information on the
child’s in-hand manipulation skills.
The limited availability of the instruments and training
may influence the extent to which the instruments are used
(Smart, 2006). As the ordinal scale used by most instruments
are prone to subject bias (Laver Fawcett, 2007), training
clinicians to administer and observe the subtle in-hand ma-
nipulation movements is vital. Training by means of video
recordings has been proposed (CHSA Hub, 2016; Exner,
1993) but not yet implemented. The benefits of training
a clinician to make detailed observations have been shown to
also improve the inter-rater reliability of an instrument (Van
Jaarsveld et al., 2012).
None of the instruments are yet commercially available
and still rely on the clinician to self-fabricate the equipment
and scoring forms from the articles’ descriptions. It therefore
poses the danger that clinicians either incorrectly apply the
directions from the article, misinterpret the results, or do not
assess in-hand manipulation at all as this task can appear too
daunting. Should the clinician solely rely on clinical ob-
servations, or on more accessible ‘grey’ literature proposed
on the internet, they run the risk of grounding clinical de-
cisions on subjective and scientifically unsound information.
In both cases, it can at best result in poor service delivery, or at
worst, harmfully mislabel a child, provide unnecessary and
expensive services, or fail to identify and treat the existing
problem (Laver Fawcett, 2007; Smith- Zuzovsky and Exner,
2004; Stewart, 2010).
Psychometric properties
From the overview provided, it is evident that the reliability
and validity aspects of the instruments still require further
14
research. The purpose of the different instruments was not
clearly specified and consequently classified according to the
definitions from the Instrument Evaluation Framework
(Rudman and Hannah, 1998). As a result, the most important
psychometric properties corresponding to the purpose of the
instruments was not evaluated. Further research is warranted;
however, any changes made to an instrument by the clinician
or future researchers should be done with caution, as Laver
Fawcett (2007: 24) warns that ‘once the standard procedure
for test administration and scoring has been changed, even in
a small way, the reliability and validity of that part if the test or
test item can no longer be guaranteed’. Overall, the results
showed a need for further refinement of the proposed in-
struments into more comprehensive and standardised in-
struments with evaluated psychometric properties. The
COSMIN-checklist can be used by future researchers to
determine the quality and extent of research on the psy-
chometric properties of measuring instruments (Mokkink
et al., 2012).
Limitations
This review only included published articles up to 31 De-
cember 2020, and although an extensive search was con-
ducted on the available databases to ensure a broad
representation of the literature, grey literature and the review
of the physical end-product of the instruments itself were not
compared. Hence, the instruments were not compared to each
other as different instrument development processes and
models were used by the different researchers. Lastly, the
quality of psychometric evidence was not compared, as
would be the case with a systematic review, and consequently,
this scoping review ‘cannot determine whether particular
studies provide robust or generalizable findings’ (Arksey and
O’Malley, 2005: 27).
Recommendations
The landscape of the available in-hand manipulation as-
sessment instruments described in published literature has
been mapped out, while identifying gaps to be addressed by
future research. From this evidence, the following recom-
mendations are proposed:
Firstly, it is recommended that an instrument be consistent
with the Modified Classification System of In-hand Manip-
ulation (Pont et al., 2009) and ensured that all in-hand ma-
nipulation components are included, that clear observation
and scoring guidelines accompany the instrument.
Secondly, it is recommended that an in-hand manipulation
instrument must consider the different clinical utility aspects.
Tasks and items should be adjustable for different age groups
(i.e. object size amounts and speed requirements). Training in
the use of the instrument should be provided, either at un-
dergraduate or postgraduate levels. Postgraduate training can
be performed by means of workshops, webinars or interactive
video recordings that illustrate how to observe and score the
different movements of each task according to the age
groups. Standardisation of instrument’s administration and
scoring manuals are imperative, along with either criterion
British Journal of Occupational Therapy 0(0)
or norm-referenced interpretation. The standardised manual
with a prefabricated toolkit must be commercially available
or from accessible publishers, at a reasonable cost, to
prevent illegal copying and self-fabrication of instruments
without permission.
Finally, future collaboration and coordinated research
efforts are advised to attain a gold standard paediatric as-
sessment instrument for in-hand manipulation. It is impera-
tive that researchers follow an instrument development
process and evaluate relevant psychometric properties re-
quired for a sound assessment instrument.
Conclusion
This scoping review reports on eleven in-hand manipulation
assessment instruments described in the published literature
with reference to the different constructs of in-hand manip-
ulation, clinical utility and the psychometric properties of
each instrument. The results indicate that there is currently no
instrument with proof of comprehensive instrument de-
velopment, an account of clinical utility and evaluated
psychometric properties. Future research should aim at de-
veloping new or refining existing assessment instruments. A
sound in-hand manipulation instrument could assist clinicians
to identify and appropriately treat children with problems in
this area of fine motor skills.
Key findings
• We presented a critical appraisal of the current published in-
hand manipulation assessment instruments for children
that determined the degree of compliance with the re-
quirements of a sound assessment instrument.
• Eleven instruments were identified as having limitations in
comprehensively assessing in-hand manipulation, ac-
counted clinical utility, proof of instrument development
and evaluated psychometric properties.
• Research is recommended for the refinement or development
of in-hand manipulation assessment instruments.
What the study has added
This study provided a broad overview and critical evaluation
of the eleven in-hand manipulation assessment instruments
for children that inform clinical practice and guide future
research based on the gaps identified.
Acknowledgements
The authors thank Dr. Daleen Struwig, medical writer/editor, Faculty of
Health Sciences, UFS, for technical and editorial preparation of the
manuscript and Annamarie du Preez, Assistant Director: Library and
Information Services, Frik Scott Library, Faculty of Health Sciences,
UFS, for assistance with the literature search on electronic databases.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the
research, authorship, and/or publication of this article.
Kruger et al.
Funding
The author(s) disclosed receipt of the following financial support for the
research, authorship, and/or publication of this article: This work was
supported by a master’s degree bursary from the University of the Free
State, Postgraduate Services.
Contributorship
This article was developed from an original article submitted by AK as
part of her dissertation (Master’s in Occupational Therapy at the Uni-
versity of the Free State). MS and MV were study supervisors and as-
sisted with the writing of the article. All authors reviewed and edited the
manuscript and approved the final version of the manuscript.
ORCID iD
Marieta Visser  https://orcid.org/0000-0002-8825-4683
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