ClinicSpeak: hand training trial

We should shift our focus away from the legs to the hands in progressive MS. #ClinicSpeak #MSBlog #MSResearch

“The following study is remarkable in two ways; firstly, you can do a rater-blinded randomised trials of a physical therapy and secondly, it focuses on hand function and not walking. Upper limb function is the elephant in the room. We are also focused on lower limb function and mobility that we forget how important hand function is for maintaining quality of life. MS is many disease rolled into one and when someone with MS tells you they are losing hand function (buttons, writing, eating, drinking, laces, self-catheterisation, transferring, etc.) you begin to realise how this impacts on their quality of life. I personally think that in progressive MS trials we should shift our focus away from the lower limb function as a primary outcome and focus on hand and upper limb function. I am sure if we do this we will have a better chance of showing that there is a role for DMTs in progressive MS. For those of you who are noticing a fall-off in upper limb and hand function you should let your neurologist or nurse specialist know about it so that you can be referred for the most appropriate therapy.”

Epub: Kamm et al. Home-based training to improve manual dexterity in patients with multiple sclerosis: A randomized controlled trial. Mult Scler. 2015 Jan 26. pii: 1352458514565959. 

BACKGROUND: Impaired manual dexterity is frequent and disabling in MSers, affecting activities of daily living (ADL) and quality of life.

OBJECTIVE: We aimed to evaluate the effectiveness of a standardized, home-based training program to improve manual dexterity and dexterity-related ADL in MSers.

METHODS: This was a randomized, rater-blinded controlled trial. Thirty-nine MSers acknowledging impaired manual dexterity and having a pathological Coin Rotation Task (CRT), Nine Hole Peg Test (9HPT) or both were randomized 1:1 into two standardized training programs, the dexterity training program and the theraband training program. MSers trained five days per week in both programs over a period of 4 weeks. Primary outcome measures performed at baseline and after 4 weeks were the CRT, 9HPT and a dexterous-related ADL questionnaire. Secondary outcome measures were the Chedoke Arm and Hand Activity Inventory (CAHAI-8) and the JAMAR test.

RESULTS: The dexterity training program resulted in significant improvements in almost all outcome measures at study end compared with baseline. The theraband training program resulted in mostly non-significant improvements.

CONCLUSION: The home-based dexterity training program significantly improved manual dexterity and dexterity-related ADL in moderately disabled MS patients. Trial Registration NCT01507636.

About the author

Prof G

Professor of Neurology, Barts & The London. MS & Preventive Neurology thinker, blogger, runner, vegetable gardener, husband, father, cook and wine & food lover.


  • It would be really useful to know what the dexterity training consisted of! Good that dexterity can be improved without resorting to medicaiotn.

  • The interesting thing I have found with my (so far) relatively mild loss of hand function is that it affects things that require intentional hand/finger movements/coordination such as for turning pages of books, food preparation, sewing, playing music etc, whereas typing has not suffered so much – maybe because after some 35+ years of using a keyboard it is more of an automatic collection of movements (can still do around 50 wpm, but there are a few more transposed characters than there used to be…)

    What is a worry for the future though is that although I could still be quite independent if my legs get quite a bit worse and I had to rely on crutches or a wheelchair, if my hands give up the ghost then I'm stuffed.

    I'm certainly in agreement about the shortcomings in focussing on lower limb function, but not entirely in agreement with focussing on upper limbs instead. What is needed to a greater extent is focussing on the whole person and their functioning, including QoL. So once again, that wretched EDSS will fail to tell it like it is.

    A couple of questions:
    Which part of the brain controls hand/arm movements?
    Is hand/arm function affected less by spinal lesions than legs/bladder/bowels?
    If so, does this mean that the brain's neuro-plasticity has a better chance of helping with improving hand/arm function and dexterity through programs such as the one used in this study?

    • I completely agree with your comment about there needing to be a holistic view of the MS'er when capturing the impact of the disease on our bodies. It's unclear who EDSS is designed to inform / help as it's way too blunt a measure that's primarily focussed on lower limb function to be of real benefit to MSers, medical professionals or employers.

      I've had increasing upper limb problems and using a stick is becoming more and more difficult because of hand and arm issues. The public are much less aware of upper limb disabilities and I often get dirty looks etc in supermarkets because I struggle with packing shopping and getting my card out to pay. Keying in my pin is impacted by a small tremor and I have problems opening jars, packets and blister packed tablets.

      My physiotherapist referred me to Podiatry for foot problems but there doesn't appear to be a similar specialist team for hand issues, despite the increasing impact the latter is having on me. So like some of the earlier comments I'd like to know what the hand therapy consisted of.

    • I guess the EDSS is just the refelction of an aera. In the 60-80's MS was mostly associated with walking problems and wheelchairs. Everyone could see it and no one could deny it.

      So it was just a consequence and a reflection of this "what you can see"-aera.

      Nowadays we enter the "what you can't see"-aera. And the EDSS should really pay tribute to this. EDSS 3.5-7.0 ist mostly focused on walking.

      But: if your hands/arms don't work you can't even use a wheelchair or crutches!

By Prof G



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