Coin Test: A Complementary Examination for Assessing Upper Extremity Function in Cervical Myelopathy

Abstract

Study Design

A prospective observational study.

Objectives

To explore the potential utility of the Coin Test as a valuable tool for assessing and diagnosing cervical spondylotic myelopathy (CSM).

Methods

In the first cohort, 36 patients with balance issues were assessed for CSM using the new Coin Test. In the second cohort, the Coin Test and mJOA scores were compared in 36 CSM patients before and 6 weeks after surgery.

Results

Among the 36 patients with balance problems who failed tandem gait test, 15 out of 16 (94%) CSM patients failed the Coin Test. The other 20 patients (56%) without CSM completed the Coin Test successfully but failed the tandem gait test for various reasons. The Coin Test demonstrated high specificity (100%) and sensitivity (94%) for diagnosing CSM in patients who failed tandem gait test. In the second cohort, the mJOA score improved significantly from 12 to 15 6 weeks postoperatively, and the Coin Test completion time decreased from 29.5 seconds to 16.4 seconds postoperatively (P < 0.0001). Higher mJOA scores correlate with better performance (shorter time) on the Coin Test, both at baseline and 6 weeks post-surgery.

Conclusion

The Coin Test is a useful tool for evaluating hand fine motor and sensory function in CSM patients with high specificity. It also can serve as a tool for assessing surgical outcomes in patients with CSM.

Keywords

cervical spondylotic myelopathy tandem gait coin test upper extremity function neurologic condition

Introduction

Cervical spondylotic myelopathy (CSM) stands as a significant global health concern, representing a primary cause of non-traumatic spinal cord dysfunction.^1,2 This multifaceted condition presents a diverse array of motor, sensory, and autonomic deficits, often posing a diagnostic challenge of considerable complexity. While magnetic resonance imaging (MRI) has traditionally served as the gold standard for cervical stenosis diagnosis,^3,4 its high cost renders it less than ideal for widespread screening of cervical myelopathy. Moreover, occasional disparities between radiographic findings and patients’ symptomatic experiences emphasize the need for supplementary clinical assessments.⁵

In the pursuit of heightened diagnostic precision, numerous clinical tests have emerged to distinguish CSM from other pathologies (Table 1). A thorough clinical evaluation should encompass assessments of upper motor neuron function, including the examination of hyperreflexia, Babinski and Hoffman signs, motor and sensory performance, as well as gait analysis.⁶ Despite these thorough efforts, the challenge of accurately diagnosing CSM persists, largely due to the inherent limitations of current clinical tests, characterized by their modest sensitivity and potential overlap with manifestations of other conditions closely resembling CSM.

Table 1.

The Available Clinical Tests Used to Diagnose Cervical Myelopathy in Clinical Practice.

Test	Description	Positive Sign	Sensitivity (%)	Specificity (%)	+ Likelihood Ratio
Hoffman sign	With the patient standing/sitting the physician stabilizes the PIP joint of the middle finger and applies a “flicking” stimulus	Test elicits flexion of the index finger or thumb	44 - 94	49 - 90	4.9
Inverted supinator sign	With the patient seated, the examiner relaxes the patients forearm and applies a force from a reflex hammer to the styloid process at the attachment of the brachioradialis tendon	Test elicits hyperactive finger flexion instead of brachioradialis reflex	51 - 61	72 - 99	29.1
Grip and release test	The patient flexes and extends fingers as fast as possible in a 10 second period	Test shows less than 20 grip and release cycles	61 - 96	66 - 88	___
Finger escape sign	Patient holds fingers extended and adducted	Deviation of ulnar digits into abduction	48 - 55	100	___
Sustained clonus	The patient sits with feet off the ground, the clinician applies a quick stretch to the achilles tendon with rapid passive dorsiflexion of the ankle	Ankle “beats” in and out of dorsiflexion for at least three beats	11 - 35	96 - 100	5.4
Babinski sign	With the patient supine, the clinician applies a stimulus to the plantar aspect of the foot (lateral to medial, heel to metatarsal) with a blunt ended point	Toes curl into extension instead of flexion	7 - 53	92 - 100	4.0
Gait dysfunction	Clinician assesses the patient’s gait and balance	Gait ataxia, patient takes slower, or wider steps to compensate	85-95	60-80	3.4
Biceps hyperreflexia	Examiner elicits biceps reflex with reflex hammer	Hyper-reflexive flexion at the elbow	18 - 44	71 - 96	4.8
Pectoralis hyperreflexia	Examiner stimulates the pectoralis tendon in the deltopectoral groove with a reflex hammer	Hyperreflexive shoulder adduction and internal rotation	84	97	___
Achilles hyperreflexia	Examiner elicits the achilles tendon reflex with a reflex hammer	Hyperreflexive plantar flexion	15 - 26	81 - 96	7.8
Quadriceps hyperreflexia	Examiner elicits the patellar tendon reflex with a reflex hammer	Hyperreflexive knee extension	33 - 94	76 - 97	6.9
Suprapatellar tendon reflex	Examiner stimulates the suprapatellar tendon of the quadriceps	Hyperreflexive knee extension or hip flexion	22 - 56	33 - 97	0.8 – 6.9

Early signs of CSM include gait instability and fine motor dysfunction.^7-10 The tandem gait examination, commonly employed in diagnosing neurological and vestibular disorders, including myelopathy,^11,12 is hampered by its low specificity. Various pathologies can influence tandem gait, and it mainly evaluates lower extremity function.

The only available test to assess upper extremity function is the 10-second grip-and-release test, often referred to as the “myelopathy hand” test, which uniquely evaluates hand dexterity.^13,14 However, this test has notable limitations: it relies heavily on the subjective assessment of the examiner and does not effectively measure fine motor movements or sensory function, which are critical, as many patients with cervical myelopathy experience hand numbness. Thus, an easy and objective modality to measure fine motor and sensory function and coordination of upper extremity is urgently needed.

To address these critical limitations, we introduce the “Coin Test” as a novel diagnostic tool for evaluating upper extremity function in patients with CSM. This test requires a well-controlled coordination and directional movement of the arm and fingers. In this simple yet insightful assessment, patients are instructed to stack five penny coins on a flat surface—a seemingly straightforward task with profound diagnostic significance. While unaffected individuals typically perform with ease, CSM patients often encounter significant challenges, highlighting impairments in fine motor movements and sensory functions. The elegance of the Coin Test lies in its ability to illuminate subtle difficulties experienced by individuals with CSM in a practical, clinically relevant manner.

This pilot study includes two cohorts of patients and has two aims. Cohort 1 and Aim 1: To explore whether the Coin Test, when used in conjunction with the Tandem Gait Test, increases the specificity of cervical myelopathy diagnosis. Cohort 2 and Aim 2: To evaluate whether the Coin Test can serve as a tool for assessing surgical outcomes in patients with cervical myelopathy. Overall, this study aims to explore the potential utility of the Coin Test as a valuable tool for assessing, screening, and diagnosing cervical myelopathy, highlighting its promise as a practical and objective addition to the diagnostic toolkit.

Methods

Patient Recruitment: Cohort 1

A pilot study was conducted following the Institutional Review Board approval, involving 36 consecutive patients from October 2022 to August 2023, all presenting with symptoms of lower back pain or leg pain, but the clinical history and examinations raised concerns for cervical myelopathy due to balance issues and inability to perform Tandem gait. MRIs were ordered to evaluate myelopathy. Additionally, all patients underwent the novel Coin Test with their dominant hand. Their performances were video-recorded and timed. Neurologist consultations were sought for patients presenting with neuropathic symptoms, and reasons for inability to perform Tandem gait were evaluated. Control groups consisted of patients with cervical spondylosis but without cervical stenosis or dominant side radiculopathy confirmed by MRI.

Cohort 2

Another pilot study was conducted following the Institutional Review Board approval, involving 36 consecutive patients diagnosed with CSM from January 2023 to December 2023. CSM diagnosis was established based on clinical symptoms and the presence of cervical stenosis with or without myelomalacia on MRI studies. Prior to surgery, all patients took the new Coin Test, and the test was repeated 6 weeks after surgery, which included anterior cervical discectomy and fusion or laminoplasty. The modified Japanese Orthopaedic Association (mJOA) questionnaire was conducted at the same time points for assessment.

Coin Test (Figure 1)

The Coin Test involves placing a stack of five-penny coins randomly on a level tabletop, equidistant from the participant. Subjects are instructed to move one coin at a time, using their dominant hand, to create another stack. The goal is to transfer all five pennies to a new stack in the shortest time possible, maintaining precision and controlled movement. The entire process is video recorded to provide an objective measure for assessment, timing, and documentation. The time taken by the participant to complete the task is carefully measured using a stopwatch or digital timer, crucial for evaluating the speed and efficiency of their fine motor skills in diagnosing CSM. Participants are assessed based on time to completion, accuracy, and manual control by two investigators.

Figure 1.

Illustration of the Coin Test. Patients are instructed to use their dominant hand to move a stack of coins and create a new stack approximately 5 cm (2 inches) away. The procedure is designed to evaluate hand sensation, coordination and dexterity.

Statistical Analysis

Continuous data are presented as mean and categorical data as number (percentage, %). Two-sided P < 0.05 was considered statistically significant, and calculated by One-way ANOVA followed with Dunnett’s using Prism 9. Data that support the findings of this study are available from the corresponding author upon reasonable request.

Results

For normal controls, the average time to complete the Coin Test was 10.15 seconds, with two standard deviations of 4.06 seconds. Therefore, we considered a completion time longer than 15 seconds to be abnormal.

In the first cohort, they were patients with the concern of myelopathy as they could not perform the Tandem gait test. In order to evaluate hand dexterity function, the Coin Test was performed in addition to Tandem gait test. The average age of patients was 69 years (range: 59 - 89), with females comprising 42% of the cohort. Among the 36 patients, only 16 (44%) had CSM, which hindered their ability to perform Tandem gait and the Coin Test, except for one patient (6%) who passed the Coin Test with a completion time of 12 seconds (Figure 2). The remaining 20 patients (56%) without CSM failed Tandem gait test but successfully passed the Coin Test (Figure 2). Among these 20 patients, 12 (60%) had lumbar stenosis. The remaining 8 patients (40%) failed Tandem gait test due to different factors such as advanced age, diabetes, peripheral neuropathy, minor stroke, obesity, thoracic stenosis, and multiple sclerosis, highlighting the diverse array of factors contributing to Tandem gait impairments in these cases. The sensitivity of the Coin Test for CSM patients who failed Tandem gait was 94% with a specificity of 100% (Table 2).

Figure 2.

Diagnoses for patients with failed Tandem gait.

Table 2.

Sensitivity and Specificity of the Coin Test to Diagnose CSM Among the Patients Who Failed Tandem Gait.

Coin Test	CSM	Non-CSM
Failed	15	0
Pass	1	20
Sensitivity	94%
Specificity	100%

Case example 1 without CSM (failed Tandem gait test but passed the Coin Test)

A 75-year-old male complained of left leg numbness and poor balance following a L5/S1 posterior fusion at an outside hospital in 2017. He could not perform Tandem gait test but successfully completed the Coin Test in 10 seconds. Clinical assessment revealed a positive Hoffman’s sign and a negative Babinski’s test. However, hyporeflexia was observed in both bilateral upper and lower extremities. Lumbar spine MRI revealed severe stenosis at L2/3 and moderate to severe stenosis at L3/4 (Figures 3(A) and (B)). Cervical and thoracic spine MRIs were ordered to evaluate myelopathy, which showed no high-grade stenosis (Figures 3(C) and (D)). Neurology electromyography study indicated inactive left L3/4 radiculopathy, with no evidence of large fiber polyneuropathy. Lumbar decompression surgery at L2/3 and L3/4 resulted in markedly improved balance and capability to perform Tandem gait.

Figure 3.

Case example 1. A 75-year-old male exhibits a failed tandem gait yet successfully passes the coin test. (A) and (B): sagittal and axial MRI images of the lumbar spine, revealing severe stenosis at the L2/3 level. (C) and (D): sagittal cuts of the cervical and thoracic spine, demonstrating an absence of high-grade stenosis in these regions.

Case example 2 with CSM (failed both Tandem gait and Coin tests)

A 68-year-old male presented with lower back and bilateral leg pain for 1 year as well as balance problems. X-rays revealed grade 1 L4/5 spondylolisthesis, and MRI showed L4/5 stenosis (Figures 4(A) and (B)). Unable to perform the tandem gait test, he also could not complete the Coin Test (Supplemental video 1). His Hoffman’s test was negative on both sides. He exhibited hyperreflexia in the upper extremities and hyporeflexia in the lower extremities. A subsequent MRI of the cervical spine revealed C5-7 stenosis. Following anterior cervical discectomy and fusion (ACDF) surgery at C5-7, his Coin Test performance remarkably improved, completing it in 26 seconds (Supplemental video 2).

Figure 4.

Case example 2. Depicting a 68-year-old male experiencing bilateral leg pain, this figure corresponds to examinations revealing both failed tandem gait and coin test. (A): a lumbar lateral X-ray, indicating grade 1 L4/5 spondylolisthesis. (B): an MRI of the lumbar spine, confirming stenosis at the L4/5 level. (C): an MRI of the cervical spine, uncovering moderate to severe stenosis at C5/6 and C6/7. (D): a lateral cervical spine X-ray post-anterior cervical discectomy and fusion (ACDF) at C5-7.

In the second Cohort of 36 patients with CSM, the average age of patients was 67 years (range: 49 - 82), with females comprising 50% of the cohort. Among the 36 patients, the mJOA score improved from 12 to 15 6 weeks postoperatively (P < 0.0001). Five patients could not complete Coin Test before surgery, but could complete the Coin Test successfully from 17 to 35 seconds after surgery. For the rest 31 patients, the time to complete the Coin Test decreased from 29.5 econds preoperatively to 16.4 seconds 6 weeks postoperatively (P < 0.0001) (Figure 5). Additionally, higher mJOA scores correlate with better performance (shorter time) on the Coin Test, both at baseline and 6 weeks post-surgery (Figure 6).

Figure 5.

mJOA scores and time (seconds) to complete the Coin Test for patients with CSM before and 6-week after surgery. The mJOA score improved from 11 to 15 6 weeks postoperatively (P < 0.0001). The time to complete the Coin Test decreased from 33.7 seconds preoperatively to 15.6 seconds 6 weeks postoperatively (P < 0.0001).

Figure 6.

The time taken to perform the Coin Test correlates significantly with modified Japanese Orthopaedic Association (mJOA) scores. (A) negative correlation between mJOA scores and the time required to complete the Coin Test is observed both pre-operatively (A) and 6 weeks post-operatively (B). The green solid lines represent the linear regression line, while the dotted green lines indicate the standard deviation.

Discussion

Our study presents initial findings on the Coin Test, a new tool for evaluating hand dexterity in patients with CSM.

Shortcoming of Tandem Gait Test and Current CSM Exams

In the clinic, when a patient exhibits difficulty performing the Tandem gait test and presents with balance issues similar to those observed in cohort 1, our standard protocol involves ordering an MRI of the cervical spine to rule out Cervical Spondylotic Myelopathy (CSM). Harrop et al¹⁵ 2010 conducted a retrospective analysis of 103 patients evaluated for cervical degeneration to determine the utility of various physical examination findings in CSM. In their cohort of patients with CSM, they found the following prevalence of symptoms: gait abnormality (91%), any hyperreflexia (85%), lower extremity hyperreflexia (81%), upper extremity hyperreflexia (67%), Hoffman sign (83%), and Babinski reflex (44%). Gait dysfunction remains one of the most significant hallmarks of this condition but is significantly limited by a specificity of 60%–80% in the literature, as numerous pathologies can affect Tandem gait.¹⁶ As shown in our current study, only 44% of patients who could not perform Tandem gait were diagnosed with cervical CSM. The remaining 56% had a variety of pathologies, including thoracic stenosis, lumbar stenosis, diabetes, neuropathy, obesity, aging, stroke, and multiple sclerosis (Figure 2), all of which can impact a patient’s ability to perform the Tandem Gait test.

A. Location of the neuropathology: If the brain, cervical or thoracic spinal cord, or lumbar nerves are compressed, patients may exhibit gait changes. The Coin Test, which evaluates hand function, is only affected by brain and cervical pathologies. As shown in our results (Figure 2), one patient with thoracic stenosis and twelve patients with lumbar stenosis failed the Tandem Gait test but passed the Coin Test. This suggests that the Coin Test can help localize neurological pathology to the cervical level or above.

B. Lumbar pathology: Degenerative lumbar diseases can induce biomechanical impairments in spinal muscles, leading to inefficient gait patterns and a decline in walking quality and capacity.¹⁷ These conditions affect the Tandem Gait test but not the Coin Test.

C. Age: The ability to maintain a tandem stance and walk typically starts to diminish around age 45 ¹³, with a marked decline observed with advancing age and disability. Interestingly, age does not appear to be a significant confounding factor for the Coin Test, although we did find that age affects tandem gait performance. For example, the average age in cohort 1 was 69 years, and we noted at least one patient (age 81) who failed the tandem gait test due to age-related factors but passed the Coin Test, as she did not have cervical stenosis.

D. Diabetic neuropathy: Diabetic neuropathy also affects tandem gait. It typically affects the lower extremities more than the upper extremities. This condition often begins in the feet and legs and can progress to the hands and arms as it advances. This pattern, known as “stocking-glove” distribution, is characteristic of diabetic peripheral neuropathy, where the longest nerves are affected first.¹⁸ Therefore, individuals with diabetic neuropathy usually experience symptoms such as pain, tingling, and numbness in their feet and legs before these symptoms appear in their hands and arms. In our cohort 1, two patients could not perform Tandem gait due to severe diabetes neuropathy, but they had no problems with Coin Test.

Combination of CSM Exams

Many studies have investigated the validity and utility of clinical tests for diagnosing CSM.^7,8,19 Cook et al. (2009) examined the reliability and diagnostic accuracy of seven physical exam maneuvers for CSM²⁰. They found that combining these tests did not yield improved accuracy compared to single tests used in isolation. However, selected combinations of clinical findings, such as gait deviation, Hoffman’s test, inverted supinator sign, Babinski test, and age >45 years, were effective in ruling out and ruling in CSM.²¹

Tandem Gait Plus the Coin Test

Tandem gait test primarily focuses on evaluating lower extremity function. By incorporating the Coin Test, which assesses both motor and sensory functions of the upper extremities, we may achieve a more accurate diagnostic evaluation for CSM. In our study, remarkably, all 20 patients (56%) without CSM but experiencing Tandem gait difficulty successfully passed the Coin Test, highlighting its potential as a complementary assessment tool to diagnose CSM. Conversely, with the exception of one patient (6%), all CSM patients failed the Coin Test. This leads us to believe that integrating the Tandem gait assessment (reflective of lower extremity function) with the Coin Test (evaluating upper extremity function both fine motor and sensation) enhances both sensitivity and specificity in diagnosing CSM. If a patient with balance issues cannot perform the Tandem Gait test but can do the Coin Test, they are unlikely to have cervical myelopathy. If they fail both tests, they almost certainly have cervical myelopathy.

Surgical Outcome Evaluation

The modified Japanese Orthopaedic Association (mJOA) score stands as a widely accepted clinical scoring system for evaluating the severity of cervical myelopathy.^14,22 This comprehensive scoring system assesses various clinical parameters, including upper and lower extremity motor function, upper extremity sensory function, and bladder function.⁶ However, the mJOA score is not tangible.

From the cohort 2 study, we showed that the Coin Test could be also used as a tool to evaluate the outcome of a procedure. We observed a significant improvement in the mJOA score from 12 to 15, and a notable reduction in the time taken to perform the coin test from 29 seconds to 16 seconds (Figure 5). Notably, five patients who could not complete Coin Test regained the capability to finish the Coin Test within 17 to 35 seconds. These patients were tested multiple times preoperatively, but consistently failed to complete the test, excluding the possibility of repetition improvement. Furthermore, patients with better mJOA scores got a greater performance in the Coin Test (Figure 6). This suggests that we can utilize this simple Coin Test to evaluate surgical outcomes in CSM treatment. Previously, Hassanzadeh et al. (2021) demonstrated that compared to controls, CSM patients exhibited slower, shorter, and broader gait patterns, with significantly increased compensatory angular momentum in various planes to maintain dynamic balance.²³ Furthermore, gait parameters improved post-surgery. However, gait analysis necessitates specialized equipment, technology, and trained personnel, whereas any health care professional or even patients themselves can administer the Coin Test.

Limitations

Several limitations are inherent in this pilot study. First, the Coin Test was exclusively administered to patients unable to perform Tandem gait in cohort 1, limiting its assessment scope. To comprehensively establish the specificity and sensitivity of the Coin Test itself for cervical myelopathy, it is imperative to evaluate a broader spectrum of patients, including those with cervical pathology who can and cannot perform Tandem gait. For example, patients with severe cervical radiculopathy, especially C6 radiculopathy on the dominant side affecting thumb and index, might has difficulty with Coin Test. Additionally, conditions such as brain pathology, rheumatoid arthritis, hand contracture, severe carpal tunnel disease, peripheral neuropathy, or other neurological disorders and long fingernails may affect the Coin Test. This necessitates the implementation of a clinical trial involving a substantial number of participants. This preliminary study serves as a foundation for conducting a power analysis, and we are actively recruiting at least 500 patients with neck symptoms, both with and without myelopathy, to better define the sensitivity and specificity of the Coin Test for diagnosing cervical myelopathy. Second, while improved Coin Test performance was observed following surgical decompression, the long-term effects require further investigation. A longitudinal analysis is essential to capture sustained changes over an extended period. Third, we only performed the Coin Test with the patients’ dominant hand. Non-dominant hand may show more differences for patients with myelopathy. Lastly, the current reliance on the time taken to complete the Coin Test as the primary parameter warrants expansion. Future research should encompass additional metrics such as accuracy, instances of dropping coins, hand shaking, and the inadvertent picking up of two coins instead of one, ensuring a more comprehensive and nuanced evaluation of hand dexterity.

Advantages

Several key advantages make our proposed novel Coin Test as a promising diagnostic tool for CSM, thereby enhancing our ability to understand and address the complexities of CSM. The Coin Test (hand sensation and fine motor function) plus Tandem gait (lower extremity motor function) demonstrates an extraordinary level of specificity, approaching 100%. This remarkable attribute ensures that the test reliably identifies individuals with impaired hand dexterity and sensation, thereby aiding in precise diagnosis and treatment planning. We routinely inquire about buttoning difficulty in patients with cervical stenosis, but this measure is often subjective and difficult to quantify. Unlike the Coin Test, which utilizes standardized coins (pennies) that are readily available, a buttoning test would require uniform button sizes and buttonholes to ensure consistency, which complicates its implementation. One of the most compelling aspects of the Coin Test is its accessibility. It requires no specialized training for examiners and can be conducted by a wide range of health care professionals, from specialists to primary care physicians. Moreover, it is sufficiently simple for patients to perform with appropriate guidance. This simplicity enhances the assessment process, making it widely available for use across diverse clinical settings. Furthermore, the materials needed for the test, that is penny coins, are ubiquitous and easily obtainable. We used pennies in our study. This simplicity streamlines the implementation of the test into routine clinical evaluations, eliminating barriers to its adoption. Beyond its diagnostic utility, the Coin Test has the potential to serve as a valuable outcome measure for assessing the effectiveness of surgical interventions in patients with CSM. By quantifying changes in hand dexterity post-surgery, it provides a tangible metric for evaluating treatment success and tailoring rehabilitation strategies.

Supplemental Material

Footnotes

Acknowledgements

We thank all patients who participated in this study and the spine clinic staff for assisting in patient assessing.

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.

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 the NIH; R01AR078888-01A1, R21 AR078547, R21AR082052.

Ethical Statement

ORCID iD

Xudong J. Li

Supplemental Material

Supplemental material for this article is available online.

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Supplementary Material

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