Evaluation of Hand Functions in Hemodialysis Patients

Abstract

Background and aims. Patients with end stage renal disease (ESRD) have many musculoskeletal abnormalities, including hand dysfunction. The Sollerman test evaluates hand grip function in daily activities. The relationships between Sollerman test (dominant hand) with Duruoz's Hand Index (DHI), Health Assessment Questionnaire (HAQ), and Beck Depression Inventory (BDI) tests have not been investigated previously. The aims of this study are to evaluate hand grip function using the Sollerman test in hemodialysis (HD) patients, correlate this test with other measures evaluating hand function or psychosocial status, and investigate factors that can affect Sollerman test. Methods. One-hundred twenty HD patients (64 male, 56 female, mean age 51 ± 1.4 years, mean duration of HD therapy 5.3 ± 3.7 years) were included in this study. The HAQ, DHI, and BDI scores were determined by standard techniques. All patients underwent the Jamar grip test and Sollerman test for the dominant (D) and non-dominant hand (ND). Results. We found a positive correlation between Sollerman test (dominant hand) with Sollerman test-ND, Jamar-D, and Jamar-ND tests. There were negative correlations between Sollerman test with age, HAQ, BDI, and DHI tests. Conclusions. The relationships between Sollerman test (dominant hand) with DHI, HAQ, and BDI tests have not been investigated previously. This study showed the correlations between the Sollerman test (dominant hand) and other tests (either positive or negative). Psychosocial problems can affect hand functions.

Keywords:

• hemodialysis
• hand
• function
• depression
• disability

INTRODUCTION

Chronic kidney disease (CKD) is a common health problem.[1] The prevalence of CKD is 10.9% in the United States.[2] There is an increasing incidence and prevalence of patients with end-stage renal disease (ESRD) requiring renal replacement therapy worldwide.

Recent developments in dialysis technology increased patient survival and quality of life in dialysis patients having end stage renal disease; however, dialysis patients have a decreased quality of life compared to healthy controls.[3] Psychological, neurological, and musculoskeletal problems are common in dialysis patients.[4],[5] Hand function abnormalities can affect quality of life in hemodialysis patients.[6] The Sollerman test, JAMAR grip strength test, and Duruoz's Hand Index (DHI) are tests assessing hand functions. Health Assessment Questionnaire (HAQ), and Beck Depression Inventory (BDI) evaluate quality of life and depression, respectively.

The aims of this study are to evaluate hand grip function using the Sollerman test in hemodialysis (HD) patients; correlate this test with other measures, such as the JAMAR grip strength test, Health Assessment Questionnaire, Duruoz's Hand Index, and Beck Depression Inventory; and investigate some factors that can affect Sollerman test.

MATERIALS AND METHODS

One-hundred twenty patients (64 male, 56 female, mean age 51 years, range 17–79) who received hemodialysis in two centers participated in the study. The study was approved by Medical School Ethical Committee. Mean duration of HD treatment was 5.3 years (range 0.5–23 years). All patients had HD treatment thrice weekly, each lasting four hours.

The patients’ age, gender, marital status, hand dominance, duration of kidney disease, etiology of kidney disease, details of renal replacement therapy (type, duration, previous), vascular access localization, history of vascular access creation, and routine laboratory examination findings were investigated.

Exclusion criteria for all subjects were inflammatory arthritis, clinical findings related to peripheral neuropathy or amyloidosis, restricted hand motion due to skin lesions and contractures, upper limb amputation or arthroplasty, wrist surgery or trauma, severe malnutrition, current use of antidepressant drugs, and history of psychiatric disorders. None of the patients had venous catheters for hemodialysis.

Sollerman and JAMAR grip tests were done for dominant and non-dominant hands.[7],[8] The Health Assessment Questionnaire, Duruoz's Hand Index, and Beck Depression Inventory scores were determined by standard techniques.[9–11]

Hand grip function was analyzed by the Sollerman test using 20 different daily life activities of hand. Points are assigned to each item on a five-level scale (zero to four); the final score is the sum of all items. Scores range from 0 to 80. A normal dominant hand should have a score of 80. Normal non-dominant hand score is between 78 and 80, and scores under 78 are considered as abnormal.[7]

JAMAR (JA Preston Corp, Ontario, Canada) grip test is performed in the sitting position while the shoulder is adducted, elbow flexed to ninety degrees, and forearm and wrist in neutral position. The test was performed three times, and the highest score was recorded as kilograms of force.

The Beck Depression Inventory (BDI) is a 21-item instrument designed to assess the severity of depression in adults (0–63). Each consists of 21 questions scaled in Likert format. Subjects are asked to rate themselves on a 0 to 3 spectrum (0 = least, 3 = most), with a score range of 0 to 63 and the total score being the sum of all items. The high scores show increased depression of the subjects (cut off value: 17).[11] Hisli et al.[12] evaluated the validation and reliability of this test in patients of our country. We have used this modified version of the form.

Duruoz's test has 18 questions evaluating the activities of daily life. After the completion of the questionnaire, the subjects receive a score between zero to five, where zero indicates the ability to do the activity and five indicates the inability to perform the activity.[10]

The Health Assessment Questionnaire (HAQ) consists of 20 questions that investigate the degree of difficulty during the performance of an activity of daily living (0 = no difficulty, 1 = some difficulty; 2 = much difficulty; 3 = unable to do). The test measures the performance of daily living in 8 different areas: dressing, arising, eating, walking, hygiene, reaching, gripping and errands and chores. The final score ranges from 0 to 3.0, where a higher score indicates a higher degree of disability.[9] Kucukdeveci et al. adapted the Turkish version of the Health Assessment Questionnaire.[13] We have used the modified version of the test.

The Mann Whitney U, Students’ t-, and chi square tests were used for statistical analysis and a p value less than 0.05 was considered as statistically significant. Results are expressed as mean ± standard error of mean.

RESULTS

The Sollerman test of dominant hand was abnormal in 83 of the 120 (69%) patients. The relationships between Sollerman test and various parameters are shown in Table 1. Older patients had a more common abnormal Sollerman test. Diabetic nephropathy and marital status (being married) were significantly associated with abnormal Sollerman test. Mean HAQ, DHI, and BDI test scores were higher in patients having an abnormal dominant hand Sollerman test. There was a positive correlation between dominant hand Sollerman and JAMAR grip tests.

Table 1 Sollerman test and various parameters

	Sollerman test(dominant hand)
Parameter	Normal	Abnormal	p
Age (years)	40 ± 2	56 ± 2	0.001
Gender			0.616
Male	21	43
Female	16	40
Primary kidney disease			0.020
Diabetic nephropathy	2	19
Other diseases	35	64
Marital status			0.001
Married	21	70
Single/widowed/divorced	16	13
Duration of hemodialysis treatment (years)	6 ± 0.4	5. ± 0.4	0.441
Nondominant hand Sollerman test			0.001
Normal	37	0
Abnormal	14	69
Dominant hand JAMAR grip test (kg)	21 ± 1.0	15 ± 1.0	0.001
HAQ score	3.48 ± 0.85	16.33 ± 1.25	0.001
DHI score	3.9 ± 1.1	20.3 ± 2.0	0.001
BDI score	9.2 ± 1.1	17 ± 1.0	0.001
Parathormone (pg/mL)	271.2 ± 4	196.8 ± 3	0.141
Hemoglobin (gr/dL)	10.4 ± 0.2	10.2 ± 0.1	0.430
Urea reduction rate	0.6 ± 0.1	0.6 ± 0.01	0.720

Results are expressed as mean ± standard error of mean.

Abbreviations: HAQ = Health Assessment Questionnaire, DHI = Duruoz's Hand Index, BDI = Beck Depression Inventory.

DISCUSSION

Neurological and musculoskeletal problems such as mixed motor and sensory polyneuropathy and diffuse muscle weakness arise in patients having CKD. The retention of uremic toxins and inadequate dialysis are probable causes of neurological problems. Effective dialysis leads to improvement of uremic neuropathy, but subclinical manifestation can be detected in more than half of dialysis patients. The number of studies evaluating hand function in hemodialysis patients is limited.[6],[10],[11]

The Sollerman hand function test analyzes the grip function by using 20 different daily life activities of hand. The eight main grip tips are tested in the following proportions: pulp pinch 20%, lateral pinch 20%, tripod pinch 10%, five finger pinch 15%, diagonal volar grip 15%, transverse volar grip 14%, spherical volar grip 4%, and extension grip 2%. The Sollerman test is a very objective test and may illustrate the deficiency of the exact function of the daily life activity of the hand both to the patient and physician. Therefore, the Sollerman test allows the right, objective, and most useful treatment and rehabilitation plan of the hand.[7]

There seems to be only one study evaluating hand grip function using the Sollerman test in HD patients. Limaye et al.[14] evaluated hand function in 35 hemodialysis patients. They found that the Sollerman score correlated poorly with age and significantly with HAQ score, duration of hemodialysis, Visual Analog Scala-Function (VAS-F), and JAMAR grip test score. They also found that Sollerman scores were highly correlated between dominant and non-dominant arms.

There are some differences in our study:

1. our study included 120 patients;

2. we investigated the correlation between the Sollerman test with Beck Depression Inventory (BDI) and Duruoz's Hand Index (DHI); and

3. we found that some factors, such as diabetes mellitus and marital status, can affect the Sollerman test.

Duruoz's Hand Index evaluates hand functions subjectively. Thirty-seven patients emphasized abnormal functions such as opening and closing a zipper, picking up coins, etc. in DHI,[10] but the Sollerman test was normal in 16 of the 37 patients, which indicated that some patients were unaware of their ability. The patients experience some hand functions.

It has been demonstrated that a significant amount of patients who undergo hemodialysis have increased the risk of having some depression.[15],[16] The depression state of these patients may lead to increase morbidity and mortality. Likewise, we found that the level of the depression score was significantly correlated with impaired hand function according to the Sollerman test.

We suggest that psychosocial problems can affect hand functions, that some patients are unaware of their ability, and that the Sollerman test is a useful test to evaluate hand functions. Regular assessment of hand functions can improve quality of life in hemodialysis patients.