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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

Not Free

Cost Description

$70-135; Purchase through different vendors.

CDE Status

Not a CDE -- last searched 6/28/2023.

Diagnosis/Conditions

  • Brain Injury Recovery
  • Stroke Recovery

Populations

Stroke
Pediatric Disorders
Parkinson's Disease
Non-Specific Patient Population
Multiple Sclerosis
Mixed Populations

Key Descriptions

  • The Nine-Hole Peg Test is administered by asking the client to take the pegs from a container, one by one, and place them into 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.
  • The hand not being evaluated is permitted to hold the edge of the board to provide stability.
  • Scores are based on the time taken to complete the 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)
  • Alternative scoring for children: the number of pegs placed divided by the time it took the child to place the pegs before they lost interest in continuing. Results are expressed as the number of pegs 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

Or until the child discontinues the assessment.

Required Training

No Training

Age Ranges

Preschool Children

2 - 5

years

Child

6 - 12

years

Adolescent

13 - 17

years

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.

Updated in 2021 by Tierza Clerc, Kim Villarreal, Morgan Williams, and Ivan Rodriguez (Master of Occupational Therapy students) and Danbi Lee, PhD, OTD, OTR/L.

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.

Recommendations for the use of the instrument from NINDS CDE Status for children’s populations: Duchenne Muscular Dystrophy (DMD), Becker Muscular Dystrophy (BMD), Spinal Muscular Atrophy (SMA), Cerebral Palsy (CP), Congenital Muscular Dystrophy (CMD), Multiple Sclerosis (MS), Friedreich’s Ataxia.

For detailed information about how recommendations were made, please visit:  

 

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.
  • There are different types of pegboards, and norms may change, so you must ensure you are using a nine-hole pegboard (Rolyan 9-Hole Peg Test and other 9-hole pegboards) and not a different one with a different layout (e.g., Grooved Pegboard Test).

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, & Brog?rdh, 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 (r = 0.68 to 0.99) 
  • Excellent interrater reliability (r = 0.75 to 0.99)

Criterion Validity (Predictive/Concurrent)

Concurrent validity:

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 (p = -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

Convergent 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 H?ger, 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 Brog?rdh, 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 Adults: 

(Grice et al, 2003; n = 703; 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

 

Healthy Children: (Poole et al., 2005; N = 406; 47.5% male, 52.5% female; right handed n = 369, left handed n = 47; age range = 4-19 years)

Normative data for male participants:

Age range (years)

n

Mean seconds, dominant hand

SD

Mean seconds, non-dominant hand

SD

4-5

27

                  29.8

3.8

                    34.5

5.9

6-7

25

                  25.5

6.0

                    28.5

6.6

8-9

23

                  19.9

3.9

                    21.7

4.3

10-11

24

                  18.9

4.1

                    20.2

3.3

12-13

25

                  18.0

2.5

                    18.4

2.6

14-15

25

                  18.0

2.7

                    18.6

1.8

16-17

21

                  16.9

2.0

                    17.1

2.4

18-19

23

                  16.1

1.6

                    16.7

1.2

Normative data for female participants:

Age range (years)

n

Mean seconds, dominant hand

SD

Mean seconds, non-dominant hand

SD

4-5

21

                  30.2

6.3

                    33.2

6.2

6-7

23

                  22.5

2.3

                    25.9

5.2

8-9

26

                  18.7

1.9

                    21.2

3.2

10-11

21

                  16.7

3.4

                    19.0

3.1

12-13

24

                  17.1

1.8

                    18.1

2.2

14-15

25

                  16.8

2.4

                    18.1

1.8

16-17

43

                  15.8

1.9

                    17.1

1.8

18-19

30

                  16.1

2.1

                    17.4

2.0

 

Healthy Children: (Wang et al., 2011; N = 340; age range = 3-13 years (n = 119))

 

Age (years)

n

Mean (SD) seconds with right hand

Mean (SD) seconds with left hand

3-4

19

          32.8 (6.5)

          39.0 (7.6)

5-6

30

          25.0 (3.9)

          26.9 (4.1)

7-9

29

          19.9 (3.4)

          20.7 (2.7)

10-13

41

          17.0 (2.0)

          18.2 (2.5)

 

Healthy Children: (Smith et al., 2000; N = 542; 52.9% male, 47.1% female; right-handed n = 483; left-handed n = 59)

Normative data for male participants with dominant hand:

Age (years)

n

Mean (seconds)

SD

5

29

28.03

3.54

6

74

23.96

3.28

7

59

21.70

2.30

8

52

20.70

2.02

9

38

18.85

2.27

10

35

17.40

1.94

 

Normative data for female participants with dominant hand:

Age (years)

n

Mean (seconds)

SD

5

38

25.43

3.92

6

47

22.43

3.62

7

55

20.95

2.46

8

39

19.80

2.75

9

38

18.21

1.75

10

38

18.13

2.05

 

Normative data for male participants with non-dominant hand:

Age (years)

n

Mean (seconds)

SD

5

29

31.41

4.25

6

74

26.59

4.00

7

59

24.93

3.41

8

52

22.27

2.59

9

38

20.68

2.21

10

35

20.16

2.25

 

Normative data for female participants with non-dominant hand:

Age (years)

n

Mean (seconds)

SD

5

38

29.08

3.27

6

47

26.23

3.87

7

55

23.78

2.50

8

39

22.35

2.43

9

38

20.57

2.47

10

38

19.85

2.23

 

Percentiles for male participants with dominant hand:

Age (years)

5th

10th

25th

50th

75th

90th

95th

5

33.3

32.6

31.6

27.4

26.0

23.3

22.7

6

29.6

28.6

26.1

23.2

22.2

20.1

19.5

7

25.5

24.6

23.1

21.6

20.1

18.8

17.9

8

23.8

23.0

22.2

20.4

19.2

18.3

17.8

9

22.9

22.2

20.0

18.9

17.4

16.2

15.7

10

22.1

20.2

18.1

17.2

16.3

14.7

14.6

 

Percentiles for female participants with dominant hand:

Age (years)

5th

10th

25th

50th

75th

90th

95th

5

34.1

28.6

26.9

24.6

22.8

22.1

21.0

6

28.4

26.3

24.2

22.3

20.2

18.2

17.6

7

25.9

23.9

22.0

20.7

19.5

18.4

17.6

8

25.3

23.9

20.8

19.8

18.2

17.1

15.5

9

20.9

20.4

19.6

18.0

17.1

16.2

14.8

10

20.9

20.7

19.1

18.1

16.7

16.1

15.2

 

Percentiles for male participants with non-dominant hand:

Age (years)

5th

10th

25th

50th

75th

90th

95th

5

38.2

36.5

33.5

31.1

27.9

26.2

25.9

6

33.6

32.4

28.9

25.4

24.3

22.1

21.4

7

30.5

29.5

27.7

24.5

22.6

20.3

19.3

8

26.8

25.7

23.8

22.1

20.9

19.1

18.9

9

24.5

25.2

22.6

20.2

19.4

18.3

17.5

10

24.7

23.2

21.5

20.0

18.4

17.5

17.1

 

Percentiles for female participants with non-dominant hand:

Age (years)

5th

10th

25th

50th

75th

90th

95th

5

33.8

33.0

31.7

29.1

26.9

24.7

24.0

6

32.2

30.9

29.1

26.2

23.6

21.3

19.7

7

29.2

26.9

25.3

23.6

21.5

21.2

20.4

8

27.3

25.6

23.3

21.5

20.7

19.9

19.6

9

24.5

23.5

21.8

20.6

19.1

17.4

17.1

10

23.9

23.4

21.7

19.1

18.3

17.2

17.0

Test/Retest Reliability

Healthy Subjects: (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)

 

Healthy Children: (Wang et al., 2011; N = 53; retest completed within 2 weeks) 

  • Excellent test-retest reliability (ICC = .95 for right hand; ICC = .92 for left hand)

 

Healthy Children: (Smith et al., 2000; N = 503; retest between 4-6 weeks)

  • Adequate test-retest reliability (ICC = 0.81 for dominant hand; ICC = 0.79 for non-dominant hand)

Interrater/Intrarater Reliability

Healthy Adults: (Grice et al, 2003; n = 703; age range = 21-71+) 

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

 

Healthy Children: (Poole et al., 2005; N = 20)

  • Excellent interrater reliability: (ICC = 0.98 for dominant hand; ICC = 0.96 for the non-dominant hand)

 

Healthy Children: (Smith et al., 2000; N = 522; urban = 416 students, two occupational therapists, seven public schools; rural = 106 students, an occupational therapist and a teacher, three public schools)

  • Excellent interrater reliability between two occupational therapists (ICC = 0.99 for dominant hand; ICC = 0.99 for non-dominant hand)
  • Excellent interrater reliability between occupational therapist and teacher (ICC = 0.99 for dominant hand; ICC = 0.99 for non-dominant hand)

Criterion Validity (Predictive/Concurrent)

Concurrent Validity:

Healthy Adults: (Wang et al, 2011; n = 120)

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

Healthy Children: (Wang et al., 2011; n = 120)

  • Excellent concurrent validity with BOT (r = -0.89 for right hand and r = -0.87 for left hand)

 

Healthy Children: (Smith et al., 2000; n = 236; ages 6, 8, & 10 years)

  • Excellent concurrent validity with the Purdue Pegboard Test. (r = -0.80 for the dominant hand; r = -0.74 for the non-dominant hand)

 

Healthy Children: (Rosenblum et al., 2003; N = 47; age range = 5-6 years)

  • Excellent correlation between 9HPT and rotational hand tasks scores (r = 0.53-0.69)
  • Excellent correlation between 9HPT and translational hand tasks score (r = 0.75)

 

Predictive Validity:

Healthy Children: (Van Hartingsveldt et al., 2015; n = 119 in kindergarten, n = 109 retested after 1 year; age range = 5-6 years)

  • Adequate predictive validity of the 9HPT on good writing readiness between testing in kindergarten and first grade (r = ?0.40, p < 0.001)

Construct Validity

Convergent Validity:

Healthy Children: (De Vries et al., 2015; N = 119; 43 poor writers, 76 good writers; mean age = 70.4 months)

  • Adequate convergent validity with the Timed-TIHM (Spearman’s rho = 0.40)
  • Adequate convergent validity with Writing Readiness Inventory Tool in Context (WRITIC; Spearman’s rho = 0.40)

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) 

Criterion Validity (Predictive/Concurrent)

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).

Pediatric Disorders

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Responsiveness

Upper Extremity Impairments: (Tarakci et al, 2020; N = 92; juvenile idiopathic arthritis (n = 43); cerebral palsy (n = 30); brachial plexus birth injury (n = 19); pre- and post-outcomes taken after two different interventions; Turkish sample)

  • The 9HPT detected a small change (d = 0.10) after Leap Motion Controller-based training (LMCBT) and a small change (d = 0.08) after conventional treatment.

Mixed Populations

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Normative Data

Mixed Populations: (McKay et al., 2017; n = 1,000; mean (SD) = 20.4 (6.4))

Reference values for the 9-Hole Peg Test by age group and sex (seconds)

Age Group (years)

Male (mean (SD), n)

Female (mean (SD), n)

3-9

28.8 (9.2), 70

28.5 (12.6), 70

10-19

19.1 (2.4)a, 80

18.0 (2.7), 80

20-59

18.3 (2.6)a, 200

16.9 (2.2), 200

60+

22.4 (5.5)a, 150

20.4 (3.7), 150

aSignificant sex differences, p < 0.01

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.   

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. 

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. 

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

De vries, L., Van Hartingsveldt, M. J., Cup, E. H., Nijhuis-van der Sanden, M. W., & de Groot, I. J. (2015). Evaluating fine motor coordination in children who are not ready for handwriting: Which test should we take? Occupational Therapy International, 22(2), 61–70. https://doi.org/10.1002/oti.1385

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. 

Ekstrand, E., Lexell, J., & Brog?rdh, C. (2016). Test?Retest Reliability and Convergent Validity of Three Manual Dexterity Measures in Persons With Chronic Stroke. The Journal of injury, function, and rehabilitation, 8(10).

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. 

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. 

Hervault, M., Balto, J. M., Hubbard, E. A., & Motl, R. W. (2017). Reliability, precision, and clinically important change of the Nine-Hole Peg Test in individuals with multiple sclerosis. International Journal of Rehabilitation Research, 40(1), 91-93.

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. 

Johansson, G.M., & H?ger, C.K. (2019). A modified standardized nine hole peg test for valid and reliable kinematic assessment of dexterity post-stroke. Journal of NeuroEngineering and Rehabilitation. 16(1), 8.

Lamers, I., Cattaneo, D., Chen, C. C., Bertoni, R., Van Wijmeersch, B., & Feys, P. (2015). Associations of upper limb disability measures on different levels of the International Classification of Functioning, Disability and Health in people with multiple sclerosis. Physical therapy, 95(1), 65-75.

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). "Adult norms for the Nine Hole Peg Test Of Finger Dexterity." OTJR: Occupation, Participation and Health, 5(1): 24-38.

McKay, M.J., Baldwin, J.N., et al. (2017). Reference values for developing responsive functional outcome measures across the lifespan. Neurology, 88, 1512-1519. 

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. 

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. 

Poole, J. L., Burtner, P. A., Torres, T. A., McMullen, C. K., Markham, A., Marcum, M. L., Anderson, J.B, & Qualls, C. (2005). Measuring dexterity in children using the Nine-hole Peg Test. Journal of Hand Therapy, 18(3), 348-351. https://doi.org/10.1197/j.jht.2005.04.003

Proud, E. L., Bilney, B., Miller, K. J., Morris, M. E., & McGinley, J. L. (2019). Measuring hand dexterity in people with Parkinson’s disease: Reliability of pegboard tests. American Journal of Occupational Therapy, 73(4), 1-8.

Rosenblum, S., Josman, N. (2003). The relationship between postural control and fine manual dexterity. Physical & Occupational Therapy in Pediatrics, 23(4), 47-60. https://doi.org/10.1080/J006v23n04_04

Smith, Y. A., Hong, E., & Presson, C. (2000). Normative and validation studies of the Nine-hole Peg Test with children. Perceptual and Motor Skills, 90(3), 823-843. https://doi.org/10.2466/pms.2000.90.3.823

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. 

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. 

Tarakci, E., Arman, N., Tarakci, D., & Kasapcopur, O. (2020). Leap Motion Controller–based training for upper extremity rehabilitation in children and adolescents with physical disabilities: A randomized controlled trial. Journal of Hand Therapy, 33(2), 220-228. https://doi.org/10.1016/j.jht.2019.03.012

Tijsma, M., Vister, E., Hoang, P., & Lord, S. R. (2017). A simple test of choice stepping reaction time for assessing fall risk in people with multiple sclerosis. Disability and rehabilitation, 39(6), 601-607.

Tobler-Ammann, B.C., De bruin, E.D., Fluet, M.C., Lambercy, O., De Bie, R.A., & Knols, R.H. 2016. Concurrent validity and test-retest reliability of the virtual peg insertion test to quantify upper limb function in patients with chronic stroke. Journal of NeuroEngineering and Rehabilitation. 13(1), 116.

Van Hartingsveldt, M. J., Cup, E. H.C., de Groot, I.J.M., Nijhuis-van der Sanden, M.W.G. (2014). Writing readiness inventory tool in context (WRITIC): Reliability and Convergent Validity. Australian Occupational Therapy Journal, 61, 102-109.  

Van Hartingsveldt, M. J., Cup, E. H.C., Hendriks, J.C.M., De Vries, L., de Groot, I.J.M., Nijhuis-van der Sanden, M.W.G. (2015). Predictive validity of kindergarten assessment on handwriting readiness. Research in Developmental Disabilities, 36, 114-124. https://doi.org/10.1016/j.ridd.2014.08.014

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. 

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