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RehabMeasures Instrument

Nine-Hole Peg Test

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Purpose

The Nine-Hole Peg Test (9-HPT) is a standardized, quantitative assessment used to measure finger dexterity.

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Instrument Details

Acronym 9-HPT ; NHPT

Area of Assessment

Dexterity
Upper Extremity Function

Assessment Type

Observer

Administration Mode

Paper & Pencil

Cost

Free

Cost Description

Cost of materials: $23-$35

Diagnosis/Conditions

  • Brain Injury
  • Stroke Recovery

Key Descriptions

  • 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 (pegs/s)
  • Stopwatch should be started from the moment the participant touches the first peg until the moment the last peg hits the container.

Number of Items

1

Equipment Required

  • Wood or plastic board with 9 holes (10 mm diameter, 15 mm depth), placed 32 or 50 mm apart
  • A container for the pegs: square box (100 x 100 x 10 mm) away from the board. Or, a shallow round dish at the end of the board
  • 9 pegs (7 mm diameter, 32 mm length)
  • Stopwatch

Time to Administer

1-3 minutes

Required Training

No Training

Age Ranges

Adult

18 - 64

years

Elderly Adult

65 +

years

Instrument Reviewers

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; Updated in 2019 by Bridget Hahn, OTD, OTR/L, Hannah Dau, OTS, Natasha Irani, OTS, and Mallory Schrier, OTS

Body Part

Upper Extremity

ICF Domain

Body Function
Activity

Measurement Domain

Motor

Professional Association Recommendation

Recommendations for use of the instrument from the Neurology Section of the American Physical Therapy Association’s Multiple Sclerosis Taskforce (MSEDGE), Parkinson’s Taskforce (PD EDGE), Spinal Cord Injury Taskforce (PD EDGE), Stroke Taskforce (StrokEDGE), Traumatic Brain Injury Taskforce (TBI EDGE), and Vestibular Taskforce (Vestibular EDGE) 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) 

(Vestibular < 6 weeks post)

Subacute

(CVA 2 to 6 months)

(SCI 3 to 6 months)

Chronic

(> 6 months)

(Vestibular > 6 weeks post)

StrokEDGE

NR

R

R

 

Recommendations Based on Parkinson Disease Hoehn and Yahr stage: 

 

I

II

III

IV

V

PD EDGE

R

R

R

R

NR

 

 

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

 

Acute Care

Inpatient Rehabilitation

Skilled Nursing Facility

Outpatient

Rehabilitation

Home Health

MS EDGE

HR

HR

HR

HR

HR

StrokEDGE

NR

R

R

R

R

 

 

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)

Appropriate for use in intervention research studies? (Y/N)

Is additional research warranted for this tool (Y/N)

MS EDGE

Yes

Yes

Yes

Yes

PD EDGE

Yes

Yes

No

Not reported

StrokEDGE

No

Yes

Yes

Not reported

Considerations

  • Sensitive to practice effects
  • 3 to 4 administrations have been recommended prior to the baseline assessment
  • Should be used with caution in patients with low or high disability levels

 

Do you see an error or have a suggestion for this instrument summary? Please e-mail us!

Stroke

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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

Minimal Detectable Change (MDC)

Stroke: 

(Chen et al, 2009, Acute and Chronic Stroke)

  • MDC = 32.8 seconds 
  • Percentage change = 54%

Normative Data

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

 

 

 

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)

Chronic Stroke:

(Ekstrand, Lexell, & Brogårdh, 2016; n=45 [n=39 for more affected hand]; mean age (SD) = 65 (7) years; disease duration (SD) = 44 (28) months)

  • Excellent test-retest reliability (ICC = 0.99 for more affected hand; ICC = 0.93 for less affected hand)

Interrater/Intrarater Reliability

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

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 post-treatment (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 post-treatment (p = -0.57 to -0.71)
  • Poor correlations with Fugl-Meyer Assessment and Motor Activity Log at pretreatment (= -0.16 to -0.27) and post-treatment (p = -0.18 to -0.33)

(Lin, Chuang, Wu, Hsieh, & Chang, 2010; n=59; mean age (SD) = 55.5 (11.66) years; mean disease duration (SD) = 16.14 (13.95) months)

  • Excellent concurrent validity with Box and Block Test pretreatment and posttreatment (Spearman’s rho = -0.80 and -0.71, respectively)
  • Adequate concurrent validity with the Action Research Arm Test pretreatment and posttreatment (Spearman’s rho = -0.55 and -0.57, respectively)
  • Adequate concurrent validity with the Stroke Impact Scale Hand Function Domain pretreatment (Spearman’s rho = -0.58)
  • Excellent concurrent validity with the Stroke Impact Scale Hand Function Domain posttreatment (Spearman’s rho = -0.66)
  • Poor concurrent validity with the Fugl-Meyer Assessment pretreatment and posttreatment (Spearman’s rho = -0.27 and -0.18, respectively)

Chronic Stroke:

(Tobler-Ammann et al., 2016; n=31; mean age = 62.7 (15.1) years; disease duration= 51.1 (82) months; German sample)

  • Poor concurrent validity with Virtual Peg Insertion Test (Spearman’s rho = -0.23 to -0.31)

Construct Validity

Stroke: 

(Parker et al, 1986; 2 weeks, 3 & 6 months post onset, Acute Stroke)

  • Excellent convergent validity with Motricity Index (r = 0.82)

(Johansson and Häger, 2019; stroke group n=30, control group n=41; stroke group mean age = 69 (9) years, control group mean age = 66 (12); stroke group disease duration= 22 (17) months)

  • Adequate discriminant validity between the stroke group and control group (r ≥ 0.32)
  • Adequate convergent validity with time to complete the Fugl Meyer Assessment (Spearman’s rho = 0.38 to 0.70)

Chronic Stroke:

(Ekstrand, Lexell, and Brogårdh, 2016)

  • Excellent convergent validity with Modified Sollerman Hand Function Test with the more affected hand (Spearman’s rho =  -0.68)
  • Adequate convergent validity with Box and Block Test for more affected hand (rho = -0.57) and less affected hand (rho = -0.47)
  • Adequate convergent validity with Modified Sollerman Hand Function Test (rho =  -0.48) and Box and Block Test (rho = -0.44) for the less affected hand

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:
(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

 

 

 

(Lin, Chuang, Wu, Hsieh, & Chang, 2010)

  • Moderate responsiveness to change of UL function 6 months after stroke from pretreatment to post-treatment (SRM = 0.64, Z-value = 4.77)

Parkinson's Disease

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Standard Error of Measurement (SEM)

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

 

(Proud, Bilney, Miller, Morris & McGinley, 2019, n=30; mean age (SD) = 67.1 (9.5) years; disease duration (SD) = 6.4 (4.5) years; median HY score = 2.0) 

  • SEM for ON* group (n = 26) = 2.04 seconds for dominant hand; 2.33 seconds for nondominant hand; 2.35 seconds for more affected hand, 2.12 for less affected hand
  • SEM for EOD* group (n = 25): 2.66 seconds for dominant hand; 2.04 seconds for nondominant hand; 2.15 seconds for more affected hand; 2.52 seconds for less affected hand
  • *Note: The period during which medication is working effectively is called ON time; the period during which medication is at end of dose is called EOD time

Minimal Detectable Change (MDC)

Parkinson's Disease:

(Earhart et al, 2011)

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

(Proud, Bilney, Miller, Morris & McGinley, 2019)

  • MDC for ON group (n=26) = 5.65 seconds for dominant hand; 6.46 for nondominant hand; 6.51 seconds for more affected hand; 5.88 seconds for less affected hand
  • MDC for EOD group (n=25) = 7.37 seconds for dominant hand; 5.65 for nondominant hand; 5.96 seconds for more affected hand; 7.01 seconds for less affected hand

Normative Data

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)

 

 (Proud, Bilney, Miller, Morris & McGinley, 2019)

Modification and Subtest

Wk 1 Mean (SD)
(n=27)

Wk 2 Mean (SD)

(n=26 On, n=25 EOD)

On

 

 

Dom

25.40 (5.06)

24.22 (3.76)

NonDom

25.90 (4.35)

27.23 (4.14)

MAH

26.57 (4.61)

26.45 (4.60)

LAH

24.77 (4.64)

25.08 (3.75)

OFF

 

 

Dom

24.92 (5.22)

25.41 (5.23)

NonDom

27.25 (4.70)

26.78 (4.64)

MAH

26.75 (4.98)

26.78 (4.89)

LAH

25.48 (5.14)

25.46 (4.98)

Note: CI = confidence interval; Dom = dominant hand; EOD = end of dose; ICC = intraclass correlation coefficient; LAH = less affected hand; MAH = more affected hand; MDC = minimal detectable change; Nondom = nondominant hand; SD = standard deviation; SEM = standard error of measurement

Test/Retest Reliability

Parkinson's Disease:

(Earhart et al, 2011)

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

(Proud, Bilney, Miller, Morris & McGinley, 2019)

  • Adequate test-retest reliability: (ICC = 0.70-0.81)

 

Interrater/Intrarater Reliability

Parkinson’s Disease:

(Proud, Bilney, Miller, Morris & McGinley, 2019)

  • Excellent interrater reliability: (ICC > 0.99)

Non-Specific Patient Population

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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 Participants (n = 314):

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


Mean and Standard Deviation of Female Participant's (n = 389):

 

Age

n

mean -right

mean -left

SD -right

SD -left

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

 

Test/Retest Reliability

Healthy Adults:

(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 (= 0.993)

Criterion Validity (Predictive/Concurrent)

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)

Multiple Sclerosis

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Standard Error of Measurement (SEM)

Multiple Sclerosis (Hervault, Balto, Hubbard and Motl, 2017; n=69; mean age (SD) = 50.5 (8.9) years; mean disease duration (SD) = 14.4 (10.5) years)

  • SEM for Non-Dominant Hand (NDH): 2.69s
  • SEM for Dominant Hand (DH): 1.58s

Minimal Detectable Change (MDC)

Multiple Sclerosis (Hervault, Balto, Hubbard and Motl, 2017)

  • MDC for NDH: 7.46s (29.1%)
  • MDC for DH: 4.38s (19.4%)

Cut-Off Scores

Multiple Sclerosis (Lamers et al., 2015; n=105; mean age (SD) = 53.7 (11.1) years; disease duration = 17.93 (11.18 years); mean EDSS score = 6.5 (IQR = 5.1-7.5))

  • Score greater than 0.27 pegs per second (33.3 s total) indicates severe hand dysfunction

Normative Data

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

 

 

 

 

 

(Lamers et al., 2015)

  • Mean (SD) Score = 0.25 (0.12) pegs/s for Total Group (n = 105)
  • Mean (SD) Score = 0.16 (0.07) pegs/s for Low-Dexterity Subgroup (n = 51)
  • Mean (SD) Scores = 0.34 (0.06) pegs/s for High-Dexterity Subgroup (n = 54)

(Hervault, Balto, Hubbard and Motl, 2017)

  • NDH Time 1 Mean (SD) = 26.04 s (11.7)
  • NDH Time 2 (1 week later) Mean (SD) = 25.10 s (10.0)
  • DH Time 1 Mean (SD): 22.9 s (6.3)
  • DH Time 2 (1 week later) Mean (SD): 22.3 s (6.9)

Test/Retest Reliability

Multiple Sclerosis:

(Hervault, Balto, Hubbard and Motl, 2017)

  • Excellent test-retest reliability (ICC = 0.947 for NDH, ICC = 0.937 for DH)

Interrater/Intrarater Reliability

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

 

 

(Rosti-Otajarvi et al., 2008; n=10; mean age= 42.3 (7.4) years; disease duration= 12.2 (7.5) years)

  • Excellent interrater reliability (ICC=.98)
  • Excellent intrarater reliability (ICC=.98) 

Internal Consistency

Multiple Sclerosis:

Predictive Validity

(Tijsma, Vister, Hoang & Lord, 2016; n=210; age range = 20-74 years)

  • Adequate predictive validity of 9HPT at predicting choice stepping reaction time (CSRT) related to balance and falls (R2=0.449).

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  

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