Nine Hole Peg Test (NHPT)

Overview

We conducted a literature search to identify all relevant publications on the psychometric properties of the Nine-Hole Peg Test (NHPT) in two different populations – healthy normal subjects and individuals with stroke. We identified seven. The results of these suggest that the NHPT may be a reliable, valid and responsive measure in clients with stroke. In clients with acute stroke, the NHPT needs to be used carefully due to the possibility of floor effects.

In a literature review, Croarkin, Danoff, and Barnes (2004) identified the level of evidence for nine upper extremity motor function tests. The level of evidence was established based on the total number of psychometric properties addressed in studies of each test. Compared to the Action Research Arm Test (Lyle, 1981), Chedoke-McMaster Stroke Assessment (Gowland, VanHullenaar & Torresin et al., 1995), Fugl-Meyer Sensorimotor Assessment (Fugl-Meyer, Jääskö, Leyman, Olsson & Steglind, 1975), Modified Motor Assessment Chart (Lindmark & Hamrin, 1988), Motor Assessment Scale (Carr, Shepherd, Nordholm & Lynne, 1985), Motor Club Assessment (Ashburn, 1982), Motricity Index (Demeurisse, Demol & Rolaye, 1980) et Rivermead Motor Assessment (Lincoln & Leadbitter, 1979),the NHPT was found to have the greatest number of psychometric properties supported, with studies on intra-rater reliability, inter-rater reliability, convergent validity and predictive validity.

Floor/Ceiling Effects

Jacob-Lloyd, Dunn, Brain, and Lamb (2005) examined the ceiling and floor effects of the NHPT in 50 persons with stroke. Participants were assessed twice within a 6 month interval. The first assessment was at hospital discharge. In this study, participants were scored based on the cutoff of 100 seconds. Those who took more than 100 seconds to complete the test were scored as 0. At discharge, the NHPT demonstrated an adequate floor effect, with less than 20 % of the participants scoring the minimal value. After 6 months, the number of participants scoring the minimal value decreased with the NHPT still demonstrating an adequate floor effect.

Sunderland, Trinson, Bradley, and Langton-Hewer (1989) examined the presence of a floor effect in 31 participants with stroke. Assessments were performed at four points in time: admission, 1, 3 and 6 months post-stroke. Participants were given 50 seconds to complete the test. Those who were not able to complete the test within this time limit were scored as 0. Initially, the NHPT demonstrated a poor floor effect of 65% but decreased at the 6 month follow up.
Note: No values were provided by the authors for the 6 month follow-up.

Reliability

NOTE: A number of the publications on reliability reviewed below used statistical analyses such as Pearson’s correlation coefficient that are not considered the analyses of preference for testing reliability and may artificially inflate reliability coefficients. Future studies should examine the reliability of the NHPT using ICC or Kappa statistics.

Test-retest:
No studies were identified examining the test-retest reliability of the NHPT.

Intra-rater:
Heller, Wade, Wood, Sunderland, Hewer, and Ward (1987) examined the intra-rater reliability of the NHPT, Frenchay Arm Test (Heller et al., 1987), Finger Tapping Rate (Lezak, 1983), and Grip Strength (Mathiowetz, Kashman, Volland, Weber, Dowe, & Rogers, 1985) in 10 patients with chronic stroke. Participants were re-assessed with a 2-week interval by the same rater. In this study, results describe the range of reliability of the four measures mentioned above, and values for each individual measure were not provided. Spearman rho correlation coefficient was excellent (ranging for all four measures from r = 0.68 to 0.99).
Note: Although is not possible to discern the exact value for the NHPT`s reliability, all values were considered excellent and statistically significant, suggesting that the NHPT may be reliable with stable stroke clients.

Mathiowetz, Weber, Kashman, and Volland (1985) examined the intra-rater reliability of the NHPT in 26 healthy female young adults. Participants were re-assessed with a 1-week interval by the same rater. The Pearson correlation coefficient showed excellent agreement (r = 0.69) for the right hand and adequate agreement (r = 0.43) for the left.

Grice et al. (2003) reproduced the Mathiowetz et al. (1985) study in order to estimate the intra-rater reliability of the NHPT, after its design was slightly modified. In the Mathiowetz and associates’ study, the NHPT equipment was composed of a wooden board for the holes and a wooden square container for the pegs. The NHPT equipment was then modified to a plastic board with a shallow round dish as container, at the end of the board. Pearson correlation coefficient for the new NHPT was reported as adequate (r = 0.46; r = 0.44) for the right and left hand, respectively.

Inter-rater:
Heller et al. (1987) examined the inter-rater reliability of the NHPT, Frenchay Arm Test (Heller et al., 1987), Finger Tapping Rate (Lezak, 1983), and Grip Strength (Mathiowetz et al., 1985) in 10 patients with chronic stroke. Participants were assessed twice within a week by two different raters. Spearman rho correlation coefficients were excellent (ranging for all four measures from r = 0.75 to 0.99).
Note: in this study, individual values for each measure were not provided. Although is not possible to discern the exact value for the NHPT`s reliability, all values were considered excellent.

Mathiowetz et al. (1985) examined the inter-rater reliability of the NHPT in 26 healthy young female adults. Participants were evaluated simultaneously and independently by two raters. Pearson correlation coefficients showed excellent agreement (r = 0.97; r = 0.99) for the right and left hand, respectively.

Grice et al (2003) reproduced Mathiowetz et al. (1985) study to estimate the inter-rater reliability of the new NHPT. Pearson correlation coefficients showed excellent agreement (r = 0 .98; r = 0.99) for the right and left hand, respectively.

Validity

Content:
Not available.

Criterion:
Concurrent:
Sunderland et al. (1989) estimated the sensitivity of the NHPT, the Motor Club Assessment (Ashburn, 1982) and the Motricity Index (Demeurisse et al., 1980) by comparing them to the Frenchay Arm Test (Heller et al., 1987), as the gold standard, in 31 participants with acute stroke. The NHPT had the lowest sensitivity with 27% of the cases incorrectly classified. The most sensitive measure, with 0% of cases misclassified, was the Motricity Index.

Lin, Chuang, Wu, Hsieh and Chang (2010) compared the concurrent validity of the NHPT, Action Research Arm Test (ARAT) and Box and Block Test (BBT) for evaluating hand dexterity in 59 patients with stroke. The Fugl-Meyer Assessment of Sensorimotor Recovery After Stroke (FMA), Motor Activity Log (MAL) and Stroke Impact Scale (SIS) were also administered to assess the concurrent validity of the NHPT, ARAT and BBT. Using Spearman rank correlation coefficient, the NHPT, ARAT and BBT were found to have adequate to excellent correlations at pre-treatment (ranging from rho=-0.55 to -0.80) and post-treatment (ranging from rho=-0.57 to -0.71). In addition, the ARAT and BBT were found to have adequate correlations with the FMA, MAL and SIS (ranging from rho=0.31 to -0.59); however, the NHPT had only poor to adequate correlations with the FMA and MAL (ranging from rho=-0.16 to -0.33); and adequate to excellent correlations with the SIS (ranging from rho=-0.58 to -0.66). When considering both the results of responsiveness and validation components of the study, the ARAT and BBT are believed to be more appropriate than the NHPT for evaluating dexterity.

Predictive:
Sunderland et al. (1989) examined whether the NHPT, Motor Club Assessment (Ashburn, 1982) and Motricity Index (Demeurisse et al., 1980) were able to predict functional outcomes at six months after stroke measured by the Frenchay Arm Test (Heller et al., 1987). Predictive validity of the NHPT was examined in 31 participants with acute stroke. Assessments were performed at four points in time: admission, 1, 3 and 6 months post-stroke. The NHPT administered at 1 month did not predict functional outcomes at 6 months. The best predictor of functional outcomes at 6 months was the Motricity Index.

Construct:
Convergent/Discriminant:
Parker, Wade, and Hewer (1986) tested the construct validity of the NHPT by comparing the NHPT to the Motricity Index (Demeurisse et al., 1980) in 187 persons with stroke. The correlation between NHPT and Motricity Index was excellent (r = 0.82).

Known groups:
No studies have examined known groups’ validity of the NHPT.

Responsiveness

Jacob-Lloyd et al. (2005) examined the responsiveness of the NHPT in 50 persons with stroke. Participants were assessed twice within a 6 month interval. The first assessment was at hospital discharge. Effect sizes were calculated using Wilcoxon signed rank test. Although the author reported a large effect size in this study, no reference values were provided. The NHPT was more likely to detect change than the Motricity Index (Demeurisse et al., 1980).

Lin, Chuang, Wu, Hsieh and Chang (2010) evaluated the responsiveness of the NHPT, the Action Research Arm Test (ARAT) and Box and Block Test (BBT) for evaluating hand dexterity in 59 patients with subacute stroke (< 6-months) and Brunnstrom stage IV to VI for proximal and distal upper extremity function. Patients were randomly assigned to receive constraint-induced therapy, bilateral arm training or control treatment and received 2 hours of therapy, 5 days per week for 3 weeks. Assessments were performed at baseline and 3 weeks. Using Standardized Response Mean (SRM) to calculate responsiveness, the NHPT, ARAT and BBT were all found to have moderate SRM (0.64 0.79, 0.74 respectively), indicating sensitivity for detecting change in hand dexterity. When considering both the results of responsiveness and validation components of the study, the ARAT and BBT are believed to be more appropriate than the NHPT for evaluating dexterity.

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