Test-Retest Reproducibility and Smallest Real Difference of 5 Hand Function Tests in Patients With Stroke

Abstract

Objective. To investigate the test-retest reproducibility and smallest real difference (SRD) of 3 hand strength tests (grip, palmar pinch, and lateral pinch) and 2 dexterity tests (the Box and Block test [BBT] and the Nine Hole Peg test [NHPT]) in patients with stroke. Methods. The 5 tests were administered on 62 stroke patients in 2 sessions, 3 to 7 days apart. The intraclass correlation coefficient (ICC) was used to determine the level of reproducibility between measurements on 2 sessions. The SRD was used to determine the extent of measurement error because of chance variation in individual patients. SRD percentage (SRD relative to mean score) was used to compare test-retest reliability across tests. We analyzed the group as a whole, then in 2 subgroups (hand spasticity vs none). Results. The test-retest reproducibility of all 5 tests was high for all the patients, with ICCs ranging from 0.85 to 0.98. The SRDs for the more/less affected hand were: 2.9/4.7 kg for the grip test; 1.2/1.3 kg for the palmar pinch test; 1.4/1.0 kg for the lateral pinch test; 5.5/7.8 blocks/minute for the BBT; and 32.8/6.2 seconds for the NHPT. Unacceptably high SRD percentages (>30%) were found for the affected hand using the NHPT (54%), palmar pinch (35%), and lateral pinch (34%). When comparing these indices for participants with spasticity versus none for all 5 tests, the ICCs were lower and the SRD and SRD percentage were higher for the spasticity group. Conclusions. All 5 tests demonstrated satisfactory test-retest reproducibility for a diverse group of patients with stroke. However, all tests showed higher levels of measurement error when performed with the more affected hand and in patients with hypertonicity of that hand. Thus, baseline and postrehabilitation change scores using these common tests of strength and dexterity must be interpreted with some caution, especially in poorly controlled clinical trials. Repeated measures ought to be incorporated to examine reliability within a trial that includes participants with a hypertonic hand.

Keywords

Hand strength Measurement Stroke rehabilitation Reliability

References

Thrasher TA , Zivanovic V. , McIlroy W. , Popovic MR Rehabilitation of reaching and grasping function in severe hemiplegic patients using functional electrical stimulation therapy. Neurorehabil Neural Repair. 2008;22: 706-715.

Weller P. , Wittsack HJ , Siebler M. , Hömberg V. , Seitz RJ Motor recovery as assessed with isometric finger movements and perfusion magnetic resonance imaging after acute ischemic stroke. Neurorehabil Neural Repair. 2006;20:390-397.

Dobkin B. Rehabilitation after stroke. N Engl J Med. 2005;352:1677-1684.

Lang C. , Beebe J. Relating movement control at 9 upper extremity segments to loss of hand function in people with chronic hemiparesis. Neurorehabil Neural Repair . 2007;21:279-292.

Turk R. , Notley SV , Pickering RM , Simpson DM , Wright PA , Burridge JH Reliability and sensitivity of a wrist rig to measure motor control and spasticity in poststroke hemiplegia. Neurorehabil Neural Repair. 2008;22: 684-696.

van der Esch M. , Steultjens M. , Ostelo RW , Harlaar J. , Dekker J. Reproducibility of instrumented knee joint laxity measurement in healthy subjects. Rheumatology ( Oxford). 2006;45:595-599.

Atkinson G. , Nevill AM Statistical methods for assessing measurement error (reliability) in variables relevant to sports medicine. Sports Med. 1998 ;26:217-238.

Patten C. , Kothari D. , Whitney J. , Lexell J. , Lum PS Reliability and responsiveness of elbow trajectory tracking in chronic poststroke hemiparesis. J Rehabil Res Dev. 2003;40:487-500.

Roebroeck ME , Harlaar J. , Lankhorst GJ The application of generalizability theory to reliability assessment: An illustration using isometric force measurements . Phys Ther. 1993;73:386-395.

10.

Schuck P. , Zwingmann C. The `smallest real difference' as a measure of sensitivity to change: A critical analysis. Int J Rehabil Res. 2003;26: 85-91.

11.

Steffen T. , Seney M. Test-retest reliability and minimal detectable change on balance and ambulation tests, the 36-item short-form health survey, and the unified Parkinson disease rating scale in people with Parkinsonism. Phys Ther. 2008;88:733-746.

12.

Schreuders TA , Roebroeck ME , Goumans J. , van Nieuwenhuijzen JF , Stijnen TH , Stam HJ Measurement error in grip and pinch force measurements in patients with hand injuries. Phys Ther. 2003;83:806-815.

13.

Chen HM , Hsieh CL , Sing Kai L. , Liaw LJ , Chen SM , Lin JH The test-retest reliability of 2 mobility performance tests in patients with chronic stroke. Neurorehabil Neural Repair. 2007;21:347-352.

14.

Bertrand AM , Mercier C. , Bourbonnais D. , Desrosiers J. , Gravel D. Reliability of maximal static strength measurements of the arms in subjects with hemiparesis. Clin Rehabil. 2007;21:248-257.

15.

Boissy P. , Bourbonnais D. , Carlotti MM , Gravel D. , Arsenault BA Maximal grip force in chronic stroke subjects and its relationship to global upper extremity function. Clin Rehabil. 1999 ;13:354-362.

16.

Croarkin E. , Danoff J. , Barnes C. Evidence-based rating of upper-extremity motor function tests used for people following a stroke. Phys Ther . 2004;84:62-74.

17.

Hammer A. , Lindmark B. Test-retest intra-rater reliability of grip force in patients with stroke . J Rehabil Med. 2003;35:189-194.

18.

Rousseaux M. , Kozlowski O. , Froger J. Efficacy of botulinum toxin a in upper limb function of hemiplegic patients. J Neurol. 2002;249:76-84.

19.

Woldag H. , Hummelsheim H. Is the reduction of spasticity by botulinum toxin a beneficial for the recovery of motor function of arm and hand in stroke patients? Eur Neurol. 2003;50:165-171.

20.

Mathiowetz V. , Volland G. , Kashman N. , Weber K. Adult norms for the Box and Block test of manual dexterity. Am J Occup Ther. 1985;39:386-391.

21.

Mathiowetz V. , Weber K. , Kashman N. , et al. Adult norms for the Nine-Hole Peg test of finger dexterity. Occup Ther J Res. 1985;5:25-38.

22.

Trombly CA , Scott AD Evaluation of motor control. In: Trombly CA , ed. Occupational Therapy for Physical Dysfunction. Baltimore, MD: Williams and Wilkins; 1989:55-71.

23.

Prince B. , Makrides L. , Richman J. Research methodology and applied statistics. Part 2: The literature search . Physiother Can. 1980;32:201-206.

24.

Goodkin DE , Hertsgaard D. , Seminary J. Upper extremity function in multiple sclerosis: improving assessment sensitivity with Box-and-Block and Nine-Hole Peg tests. Arch Phys Med Rehabil. 1988;69:850-854.

25.

Beckerman H. , Roebroeck ME , Lankhorst GJ , Becher JG , Bezemer PD , Verbeek AL Smallest real difference, a link between reproducibility and responsiveness . Qual Life Res. 2001;10:571-578.

26.

Smidt N. , van der Windt DA , Assendelft WJ , et al. Interobserver reproducibility of the assessment of severity of complaints, grip strength, and pressure pain threshold in patients with lateral epicondylitis. Arch Phys Med Rehabil. 2002;83:1145-1150.

27.

Jette AM , Tao W. , Norweg A. , Haley S. Interpreting rehabilitation outcome measurements. J Rehabil Med. 2007;39:585-590.

28.

Ketcham CJ , Rodriguez TM , Zihlman KA Targeted aiming movements are compromised in nonaffected limb of persons with stroke. Neurorehabil Neural Repair. 2007;21:388-397.

29.

Sunderland A. Recovery of ipsilateral dexterity after stroke . Stroke. 2000; 31:430-433.