Nine Hole Peg Test (NHPT)

Evidence Reviewed as of before: 09-06-2011
Author(s): Sabrina Figueiredo, BSc
Editor(s): Lisa Zeltzer, MSc OT; Nicol Korner-Bitensky, PhD OT; Elissa Sitcoff, BA BSc

Purpose

The Nine Hole Peg Test (NHPT) was developed to measure finger dexterity, also known as fine manual dexterity. It can be used with a wide range of populations, including clients with stroke. Additionally, the NHPT is a relatively inexpensive test and can be administered quickly.

In-Depth Review

Purpose of the measure

The Nine Hole Peg Test (NHPT) was developed to measure finger dexterity, also known as fine manual dexterity. It can be used with a wide range of populations, including clients with stroke. Additionally, the NHPT is a relatively inexpensive test and can be administered quickly.

The NHPT should be used in association with other upper extremity performance tests, in order to estimate upper limb function with more accuracy.

Available versions

The NHPT was first introduced by Kellor, Frost, Silberberg, Iversen, and Cummings in 1971. In 1985, norms for the NHPT in healthy individuals were established by Mathiowetz, Weber, Kashman, and Volland.

Features of the measure

Items:

The NHPT is composed of a square board with 9 pegs. At one end of the board are holes for the pegs to fit in to, and at the other end is a shallow round dish to store the pegs. The NHPT is administered by asking the client to take the pegs from a container, one by one, and placing them into the holes on the board, as quickly as possible. Clients must then remove the pegs from the holes, one by one, and replace them back into the container. In order to practice and register baseline scores, the test should begin with the unaffected upper limb. 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. The hand not being evaluated is permitted to hold the edge of the board in order to provide stability (Mathiowetz et al., 1985; Sommerfeld, Eek, Svensson, Holmqvist, & Arbin, 2004).

Scoring:

Clients are scored based on the time taken to complete the test activity, recorded in seconds. The stopwatch should be started from the moment the participant touches the first peg until the moment the last peg hits the container. (Grice, Vogel, Le, Mitchell, Muniz, & Vollmer, 2003; Mathiowetz et al., 1985).

Mathiowetz et al. (1985) reported that on average, healthy male adults complete the NHPT in 19.0 seconds (SD 3.2) with the right hand, and in 20.6 seconds (SD 3.9) with the left hand. For healthy female adults, the NHPT was completed in 17.9 seconds (SD 2.8) and 19.6 seconds (SD 3.4) with the right and left hand, respectively.

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 (Jacob-Lloyd, Dunn, Brain, & Lamb, 2005; Sunderland, Trinson, Bradley, & Langton-Hewer, 1989).

Time:

Not typically reported. Norms indicated above indicate approximate testing times in normals.

Subscales:

None

Equipment:

The standardized equipment consists of:

  • A board, in 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. Initially the container was a square box (100 x 100 x 10 mm) apart from the board. The most current container is 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).
  • Stopwatch.

Training:

None typically reported.

Alternative forms of the Nine Hole Peg Test

None.

Client suitability

Can be used with:

  • Clients with stroke.
  • Clients should have a satisfactory level of upper limb fine motor skills as they must be able to pick up the pegs to complete the test.

Should not be used in:

  • The NHPT cannot be used with clients who have severe upper extremity impairment.
  • The NHPT cannot be used with clients with severe cognitive impairment.
  • Scoring with an upper time limit of 50 or 100 seconds requires caution especially in the acute post-stroke period due to the possibility of floor effects (Jacob-Lloyd et al., 2005; Sunderland et al.,1989).

In what languages is the measure available?

There are no official translations of the NHPT.

Some publications from Netherlands, Japan and Sweden have used the NHPT as an outcome measure, which shows its use in languages other than English. (Dekker, Van Staalduinem, Beckerman, Van der Lee, Koppe, & Zondervan, 2001; Hatanaka, Koyama, Kanematsu, Takahashi, Matsumoto, & Domen, 2007; Sommerfeld et al., 2004).

Summary

What does the tool measure? Finger dexterity.
What types of clients can the tool be used for? The NHPT can be used with, but is not limited to clients with stroke.
There are no restrictions when administering it to clients with chronic stroke. With clients with acute stroke the mode of scoring should be observed in order to avoid floor effects.
Is this a screening or assessment tool? Assessment
Time to administer The amount of time it takes to administer the NHPT has not been reported and it will vary according to the client’s impairment or the mode of scoring.
Versions There are no alternative versions.
Other Languages There are no official translations.
Measurement Properties
Reliability
  • No studies have examined the internal consistency of the NHPT.
  • Three studies have examined the intra-rater reliability of the NHPT. Both reported excellent intra-rater reliability and one reported adequate intra-rater reliability using correlation coefficients. One study used Spearman rho and the two others, Pearson correlation.
  • Three studies have examined the inter-rater reliability of the NHPT and reported excellent inter-rater reliability using correlation coefficients. One study used Spearman rho and the two others, Pearson correlation.
Validity

Criterion:

Concurrent:

Two studies have examined the concurrent validity of the NHPT. The first study examined the sensitivity of the NHPT comparing it to the Frenchay Arm Test as the gold standard and reported that NHPT has a low sensitivity, with 27% of misclassified results. The second study examined the concurrent validity of the NHPT and reported adequate to excellent correlation with the Box and Block Test (BBT) and the Action Research Arm Test (ARAT) at pre and post-treatment.

Predictive:

One study has examined predictive validity and reported that NHPT is not able to predict functional outcomes after six months of stroke.

Construct:

Convergent:

One study has examined convergent validity of the NHPT and reported excellent correlations between the NHPT and the Motricity Index using Pearson correlation coefficients.

Floor/Ceiling Effects

Two studies have examined floor effects of the NHPT. In both studies, clients were scored based on a cutoff of 50 or 100 seconds. Participants not able to complete the test within this time were scored as 0. In both studies, at earlier phases of the stroke, floor effects were poor or adequat. After six months of stroke the floor effects were adequate.

Does the tool detect change in patients? Two studies have examined the ability to detect change of the NHPT and reported that the NHPT is able to detect change.
Acceptability The NHPT should not be used clients with severe upper extremity impairment and those who are not able to pick up the pegs.
Feasibility

The administration of the NHPT is quick and simple, however it requires standardized equipment.

One study has examined the feasibility of the NHPT and reported that, on average, 52% of clients with acute stroke were not able to perform the NHPT (Jacob-Lloyd et al., 2005).

How to obtain the tool?

The NHPT instructions can be obtained in the study by Mathiowetz et al., (1985). Also, a version of the measure can be obtained from the publication by Wade (1992). Davis et al. (1999) reported the most used standardized equipments for NHPT in the United States are produced by Smith and Nephew Rehabilitation, Inc. and Sammons Preston.

Standardized equipment can be obtained at the website: http://www.sammonspreston.com/Supply/Product.asp?Leaf_Id=A8515

Psychometric Properties

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

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.

References

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  • Carr, J.H., Shepherd, R.B., Nordholm, L., & Lynne, D. (1985). Investigation of a new motor assessment scale for stroke patients. Physical Therapy, 65, 175- 180.
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  • Davis, J., Kayser, J., Matlin, P., Mower, S., & Tadano, P. (1999). Nine hole peg tests – are they all the same? Occupational Therapy Practice, 4, 59-61.
  • Dekker, C.L., Van Staalduinem, A.M., Beckerman, H., Van der Lee, J.H., Koppe, P.A., & Zondervan, R.C.J. (2001). Concurrent validity of instruments to measure upper extremity performance: the action research arm test; the nine hole peg test and the motricity index. Nederlands Tijdscrift Voor Fysiotherapie, 111(15), 110- 115.
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See The Measure

How to obtain the NHPT?

The NHPT instructions can be obtained in the study by Mathiowetz et al. (1985) and Wade (1992).

Davis, Kayser, Matlin, Mower, and Tadano (1999) reported that the most commonly used standardized equipment for the NHPT in the United States are produced by both Smith and Nephew Rehabilitation, Inc., and Sammons Preston.

Standardized equipment can be obtained at the website: http://www.sammonspreston.com/Supply/Product.asp?Leaf_Id=A8515

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