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Rehab Measures: Nine-Hole Peg Test

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Nine-Hole Peg Test Instructions 

Title of Assessment

Nine-Hole Peg Test 

Acronym

NHPT

Instrument Reviewer(s)

Initially reviewed by the Rehabilitation Measures Team in 2010; Updated with references for the MS population by Hang Nguyen, SPT and Claire Mysliwy, SPT in 2011; Updated with references for the PD population by Suzanne O'Neal, PT, DPT, NCS and the PD EDGE task force of the Neurology Section of the APTA in 2/2013

Summary Date

1/22/2014 

Purpose

Measures finger dexterity

Description

  • Administered by asking the client to take the pegs from a container, one by one, and place them into the holes on the board, as quickly as possible
  • Participants must then remove the pegs from the holes, one by one, and replace them back into the container
  • The board should be placed at the client's midline, with the container holding the pegs oriented towards the hand being tested
  • Only the hand being evaluated should perform the test
  • Hand not being evaluated is permitted to hold the edge of the board in order to provide stability
  • Scores are based on the time taken to complete the test activity, recorded in seconds
    • Alternative scoring - the number of pegs placed in 50 or 100 seconds can be recorded. In this case, results are expressed as the number of pegs placed per second
  • Stopwatch should be started from the moment the participant touches the first peg until the moment the last peg hits the container

Area of Assessment

Dexterity; Upper Extremity Function 

Body Part

Upper Extremity 

ICF Domain

Body Function; Activity 

Domain

Motor 

Assessment Type

Observer 

Length of Test

05 Minutes or Less 

Time to Administer

< 1 minute

Number of Items

Equipment Required

  • Board (wood or plastic): with 9 holes (10 mm diameter, 15 mm depth), placed apart by 32 mm (Mathiowetz et al, 1985; Sommerfeld et al., 2004) or 50 mm (Heller, Wade, Wood, Sunderland, Hewer, & Ward, 1987)
  • A container for the pegs: square box (100 x 100 x 10 mm) apart from the board or a shallow round dish at the end of the board (Grice et al, 2003)
  • 9 pegs (7 mm diameter, 32 mm length) (Mathiowetz et al, 1985)
  • A stopwatch

Training Required

None required

Type of training required

No Training 

Cost

Free 

Actual Cost

Cost of materials only

Age Range

Adult: 18-64 years; Elderly adult: 65+ 

Administration Mode

Paper/Pencil 

Diagnosis

Acquired Brain Injury; Stroke 

Populations Tested

  • Brain Injury
  • Stroke
  • Parkinson's Disease

Standard Error of Measurement (SEM)

Stroke:

(Chen et al, 2009; n = 62; age 61 (9.9) years; median of 8 months post-stroke; authors used a mean of 3 trials to calculate mean and SD, Acute and Chronic Stroke)

  • SEM = 29 seconds

Parkinson's Disease:

(Earhart et al, 2011; n = 262; mean age = 67.7 (9.2) years; disease duration = 6.2 (4.8) years; average Hoehn & Yahr Stage = 2.3 (range 1 - 4)

  • SEM = 1.02 seconds for dominant hand; 0.82 seconds for nondominant hand

Minimal Detectable Change (MDC)

Stroke
(Chen et al, 2009, Acute and Chronic Stroke)
  • MDC = 32.8 seconds
  • Percentage change = 54%

Parkinson's Disease:

(Earhart et al, 2011)

  • MDC = 2.6 seconds for dominant hand; 1.3 seconds for non dominant hand

Minimally Clinically Important Difference (MCID)

Not Established

Cut-Off Scores

Not Established

Normative Data

Healthy Sample Norms
(Grice et al, 2003; n = 703 healthy adults; age range = 21 - 70+ years, Healthy Sample Norms)
 
Mean and Standard Deviation of Male (n = 314) & Female Participant's (n = 389)
Male
Age
n
mean -right
mean -left
SD -right
SD -left
21–25
41
16.41
17.5
1.65
1.73
26–30
32
16.88
17.84
1.89
2.22
31–35
31
17.54
18.47
2.70
2.94
36–40
32
17.71
18.62
2.12
2.30
41–45
30
18.54
18.49
2.88
2.42
46–50
30
18.35
19.57
2.47
2.69
51–55
25
18.9
19.84
2.37
3.10
56–60
25
20.90
21.64
4.55
3.39
61–65
24
20.87
21.60
3.50

2.98

66–70
14
21.23
22.29
3.29
3.71
71+
25
25.79
25.95
5.60
4.54
All Male
314
18.99
19.79
3.91
3.66
Female
21–25
43
16.04
17.21
1.82
1.55
26–30
33
15.90
16.97
1.91

1.77

31–35
32
16.69
17.47
1.70

2.13

36–40
35
16.74
18.16
1.95
2.08
41–45
37
16.54
17.64
2.14
2.06
46–50
45
17.36
17.96
2.01
2.30
51–55
42
17.38
18.92
1.88
2.29
56–60
31
17.86
19.48
2.39
3.26
56–60
31
17.86
19.48
2.39
3.26
61–65
29
18.99
20.33
2.18
2.76
66–70
31
19.90
21.44
3.15
3.97
71+

31

22.49

24.11

6.02

5.66

All Female

389

17.67

18.91

3.17

3.44

 

Multiple Sclerosis:

(Erasmus et al, 2001)

Standard Values for Health Controls (n = 140)
Mean
SD
Median
2% point
98% point
Dominant Side
9HPT (s)
17.81
2.17
17.80
13.33
23.03
Tapping rate (1/s)
5.68
0.78
5.73
3.76
7.59
Median of speed (mm/s)
31.5
14.4
28.2
11.2
71.6
Constancy of speed
2.04
0.26
1.90
1.80
2.90
Mean drawing error (mm)
1.46
0.31
1.39
0.97
2.30
0.0-0.2 Hz power (mm^2)
-0.1
2.5
-0.2
-2.9
5.3
0.2-2.0 Hz power (mm^2)
1.1
5.6
-0.1
-8.1
21.7
2-10 Hz power (mm^2)
0.53
0.32
0.48
0.22
2.01
Non-dominant side
9HPT (s)
18.49
2.26
18.20
14.04
24.22
Tapping rate (1/s)
5.00
0.72
5.03
3.24
6.46
Median of speed (mm/s)
31.1
14.1
28.7
10.7
72.0
Constancy of speed
2.01
0.21
2.00
1.80
2.63
Mean drawing error (mm)
1.56
0.39
1.51
0.96
2.58
0.0-0.2 Hz power (mm^2)
-0.2
1.9
-0.3
-2.6
3.9
0.2-2.0 Hz power (mm^2)
1.0
3.9
0.6
-5.9
14.0
2-10 Hz power (mm^2)
0.58
0.40
0.50
0.19
1.59

Median of Values for Patients with Predominant CULA, UMNS with and without spasticity and SDUL (better hand/worse hand)
Symptomatic Group
CULA
UMNS spasticity
UMNS w/o spasticity
SDUL
NHPT (s)
45.1/73.4b
34.1/47.6b
38.5/58.5b
25.3/31.7a
Tapping rate (1/s)
3.3/2.6b
3.6/2.3b
3.7/2.8b
4.4/4.2b
Speed (mm/s)
39.0/42.7
39.7/37.3
44.2/36.3
55.4/54.9
Constancy of Speed
2.2/2.4
2.1/2.1
2.1/2.3
2.0/2.1
Drawing error (mm)
3.3/4.1b
2.8/3.2
2.5/2.6
2.5/2.9
0.0-0.2 Hz power
(mm^2)
0.76/1.47
0.49/0/70
0.53/0.54
0.58/0.46
0.2-2.0 Hz power
(mm^2)
7.8/15.9
8.2/8.7
6.3/9.1
6.3/6.3
2-10 Hz power
(mm^2)
1.7/6.6b
0.9/1.6
0.9/1.2
0.6/0.8a
P<0.01; Significance of difference between better and worse hand: a P<0.05; b P<0.001

Stroke:

(Beebe and Lang, 2009; mean age = 56.9 (10.2), times since stroke onset = 18.6 (5.6) days, Acute Stroke)

Normative Data:
1 month
3 months
6 months
ARAT
26.4 (23.9)
39.5 (19.7)
41.3 (20.8)
Grip Strength (kg)
9.2 (9.6)
14.0 (10.3)
15.4 (11.4)
9HPT (sec)
88.8 (40.2)
67.8 (41.7)
60.8 (39.7)
SIS: Hand function

19.9 (28.0)

48.4 (32.7)
43.9 (34.2)
9HPT = 9-Hole Peg Test
SIS = Stroke Impact Scale-Hand

Parkinson's Disease:

(Earhart et al, 2011)

9-Hole Peg Test Scores by Hoehn & Yahr Stage
Modified H&Y Stage
Dominant Hand Means (s) +SD
Non-Dominant Hand (s) Means +SD
1 (n = 12)
23.5 (5.6)
23.5 (5.2)
1.5 (n = 4)
23.4 (3.2)
31.2 (10.1)
2 (n = 112)
26.6 (6.6)
27.5 (6.4)
2.5 (n = 62)
34.3 (22.5)
34.4 (12.9)
3 (n = 52)
36.7 (16.4)
36.8 (13.4)
4 (n = 15)
43.3 (15.9)
47.9 (15.9)

Test-retest Reliability

Stroke:
(Chen et al, 2009, Acute and Chronic Stroke)
  • Excellent test-retest reliability for entire group (ICC = 0.85)
  • Adequate test-retest reliability for individuals with hand spasticity (ICC = 0.64)
  • Excellent test-retest reliability for individuals without hand spasticity (ICC = 0.86)

Parkinson's Disease:

(Earhart et al, 2011)

  • Excellent test retest reliability (ICC = 0.88 for dominant hand and ICC = 0.91 for nondominant hand)

Healthy Adulats:

(Wang et al 2011; n = 305; mean age = 32 (26); age range = 3 - 85 years)

  • Excellent test retest reliability (ICC = 0.95 for right hand, ICC = 0.92 for left hand)

Interrater/Intrarater Reliability

Healthy Adults:

(Grice et al, 2003, Healthy Adults)

  • Excellent interrater reliability for the right hand (r = 0.984)
  • Excellent interrater reliability for the left hand (r = 0.993)

Multiple Sclerosis:

(Erasmus et al, 2001, Multiple Sclerosis)

Test Quality: Reliability, External Validity and Specificity of 9HPT, tapping, drawing error and 2-10 Hz power
Test
9HPT
Tapping Rate
Drawing Precision
2-10 Hz Power
(a) Rank correlation coefficients of test results between 2 consecutive days
Better Hand
0.923
0.843
0.900
0.937
Worse Hand 0.862 0.525 0.862 0.924

(Cohen et al, 2000)

Intrarater and Interrater Reliability of the MS Functional Composite (MSFC) (9HPT is a part of the MSFC)
Testing sessions
ICC
1-6
0.88
1 vs 2
0.93
2 vs 3
0.83
3 vs 4
0.97
4 vs 5
0.97*
5 vs 6
0.95**
7 vs 8
0.96
* Intrarater reliability; ** Interrater reliability; ICC = intraclass correlation coefficient

Stroke: (Heller et al, 1987; n = 56; mean age = 72 (9.9) years; assessed < 3 months post-stroke, Acute Stroke)

  • Adequate to excellent intrarater reliability (r = 0.68 to 0.99)
  • Excellent interrater reliability (r = 0.75 to 0.99)

Internal Consistency

Not Established

Criterion Validity (Predictive/Concurrent)

Stroke:

(Sunderland et al, 1989; n = 38; mean age = 67, Acute Stroke)

  • Poor concurrent validity with Frenchay Arm Test: 27% of cases incorrectly classified
  • Poor predictive validity: NHPT administered at 1 month did not predict functional outcomes at 6 months post stroke

 (Keh-chung et al, 2010; n = 59; mean age = 55.50(11.66), Stroke Rehabilitation)

  • Adequate correlation with Stroke Impact Scale Hand function domain at pretreatment (p = 0.58)
  • Excellent correlation with Stroke Impact Scale Hand function domain at posttreatment (p = -0.66)
  • Adequate to excellent concurrent validity with Box and Block Test and Action Research Arm Test at pretreatment (p = -0.55 to -0.80) and posttreatment (p = -0.57 to -0.71)
  • Poor correlations with Fugl-Meyer Assessment and Motor Activity Log at pretreatment (p = -0.16 to -0.27) and postreatment (p = -0.18 to -0.33)

Healthy Adults:

(Wang et al, 2011)

  • Adequate correlation with the Purdue Pegboard test (p = -0.74 to -0.75)
  • Excellent correlation with the Bruininks-Oseretsky Test of Motor Proficiency (p = -0.87 to -0.89)

Construct Validity (Convergent/Discriminant)

Stroke:
(Parker et al, 1986; 2 weeks, 3 & 6 months post onset, Acute Stroke)
  • Excellent convergent validity with Motricity Index (r = 0.82)

Content Validity

Not Established

Face Validity

Not Established

Floor/Ceiling Effects

Stroke:

(Jacob-Lloyd et al, 2005; n = 50)

  • Participants assessed twice, first at discharge (Time 1) and then 6 months post-discharge (Time 2)
  • Each assessment used a 100 second cut-off with assessment times that exceeded 100 seconds receiving a score of 0
  • Time 1 (discharge): adequate floor effects with less than 20% of participants received the minimum score
  • Time 2 (6 months post-discharge): fewer participants received the lowest possible score

(Sunderland et al, 1989; n = 31, Acute Stroke)

  • Poor floor effects at the initial assessment but improved at 6 months post-stoke
  • Participants were assessed 4 times: at admission and 1, 3 and 6 months post-stroke
  • 50 second cut-score (with three trials for each hand)
  • Participants not able to complete the assessment in 50 seconds were given a score of 0

Responsiveness

Stroke:

(Demeurisse et al, 1980; n = 50, Stroke)

  • NHPT may be more sensitive to change than the Motricity Index
  • Participant was assessed twice in a 6 month period; once prior to discharge and again within 6 months of discharge
  • Large effect sizes were reported, but no values were provided


(Beebe and Lang, 2009, Acute Stroke)

Responsiveness:
1–3 months
1–6 months
Grip
0.50
0.65
Pinch
0.52
0.56
ARAT
0.55
0.63
9HPT
0.52
0.66
SIS-Hand
1.02
0.86
Responsiveness was calculated using the single population effect size method. Values closer to 1.00 = more responsive to change. Low responsiveness < 0.20; moderate responsiveness < 0.50, and high responsiveness < 0.80

Professional Association Recommendations

Recommendations from the Neurology Section of the American Physical Therapy Association’s StrokEDGE Taskforce, MSEDGE Taskforce, SCI EDGE Taskforce, and the TBI EDGE Taskforce are listed below. These recommendations were developed by a panel of research and clinical experts using a modified Delphi process.

 

For detailed information about how recommendations were made, please visit:  http://www.neuropt.org/go/healthcare-professionals/neurology-section-outcome-measures-recommendations

 

Abbreviations:

HR

Highly Recommend

R

Recommend

LS / UR

Reasonable to use, but limited study in target group  / Unable to Recommend

NR

Not Recommended

 

Recommendations for use based on acuity level of the patient:

 

Acute

(CVA < 2 months post)

(SCI < 1 month post)

Subacute

(CVA 2 to 6 months)

(SCI 3 to 6 months)

Chronic

(> 6 months)

StrokEDGE

NR

R

R

 

Recommendations based on level of care in which the assessment is taken:

 

Acute Care

Inpatient Rehabilitation

Skilled Nursing Facility

Outpatient

Rehabilitation

Home Health

StrokEDGE

NR

R

R

R

R

MS EDGE

HR

HR

HR

HR

HR

 

Recommendations based on EDSS Classification:

 

EDSS 0.0 – 3.5

EDSS 4.0 – 5.5

EDSS 6.0 – 7.5

EDSS 8.0 – 9.5

MS EDGE

HR

HR

HR

R

 

Recommendations for entry-level physical therapy education and use in research:

 

Students should learn to administer this tool? (Y/N)

Students should be exposed to tool? (Y/N)

Is this tool appropriate for use in intervention research studies? (Y/N)

StrokEDGE

No

Yes

Yes

MS EDGE

Yes

Yes

Yes

Considerations

  • Sensitive to practice effects
  • 3 to 4 administrations have been recommended prior to the baseline assessment
Do you see an error or have a suggestion for this instrument summary? Please e-mail us!

Bibliography

Beebe, J. A. and Lang, C. E. (2009). "Relationships and responsiveness of six upper extremity function tests during the first six months of recovery after stroke." J Neurol Phys Ther 33(2): 96-103. Find it on PubMed

Chen, H. M., Chen, C. C., et al. (2009). "Test-retest reproducibility and smallest real difference of 5 hand function tests in patients with stroke." Neurorehabil Neural Repair 23(5): 435-440. Find it on PubMed

Cohen, J. A., Fischer, J. S., et al. (2000). "Intrarater and interrater reliability of the MS functional composite outcome measure." Neurology 54(4): 802-806. Find it on PubMed

Demeurisse, G., Demol, O., et al. (1980). "Motor evaluation in vascular hemiplegia." Eur Neurol 19(6): 382-389. Find it on PubMed

Earhart, G. M., Cavanaugh, J. T., et al. (2011). "The 9-hole PEG test of upper extremity function: average values, test-retest reliability, and factors contributing to performance in people with Parkinson disease." J Neurol Phys Ther 35(4): 157-163. Find it on PubMed

Erasmus, L. P., Sarno, S., et al. (2001). "Measurement of ataxic symptoms with a graphic tablet: standard values in controls and validity in Multiple Sclerosis patients." Journal of Neuroscience Methods 108(1): 25-37. Find it on PubMed

Heller, A., Wade, D. T., et al. (1987). "Arm function after stroke: measurement and recovery over the first three months." Journal of Neurology, Neurosurgery and Psychiatry 50(6): 714-719. Find it on PubMed

Jacob-Lloyd, H., Dunn, O., et al. (2005). "Effective measurement of the functional progress of stroke clients." The British Journal of Occupational Therapy 68(6): 253-259.

Lin, K., Chuang, L., et al. (2010). "Responsiveness and validity of three dexterous function measures in stroke rehabilitation." Journal of Rehabilitation Research and Development 47(6): 563-571.

Mathiowetz, V., Kashman, N., et al. (1985). "Grip and pinch strength: normative data for adults." Arch Phys Med Rehabil 66(2): 69-74. Find it on PubMed

Oxford Grice, K., Vogel, K. A., et al. (2003). "Adult norms for a commercially available Nine Hole Peg Test for finger dexterity." American Journal of Occupational Therapy 57(5): 570-573. Find it on PubMed

Parker, V. M., Wade, D. T., et al. (1986). "Loss of arm function after stroke: measurement, frequency, and recovery." Int Rehabil Med 8(2): 69-73. Find it on PubMed

Sommerfeld, D. K., Eek, E. U., et al. (2004). "Spasticity after stroke: its occurrence and association with motor impairments and activity limitations." Stroke 35(1): 134-139. Find it on PubMed

Sunderland, A., Tinson, D., et al. (1989). "Arm function after stroke. An evaluation of grip strength as a measure of recovery and a prognostic indicator." British Medical Journal 52(11): 1267.

Wang, Y. C., Magasi, S. R., et al. (2011). "Assessing dexterity function: a comparison of two alternatives for the NIH Toolbox." Journal of Hand Therapy 24(4): 313-320; quiz 321. Find it on PubMed

 

 

 

Year published

1971 

Instrument in PDF Format

Yes 
Approval Status Approved 
 
Attachments
Created at 10/30/2010 11:36 AM  by Dawood Ali 
Last modified at 1/22/2014 3:12 PM  by Jason Raad