[ARTICLE] Does the Finger-to-Nose Test measure upper limb coordination in chronic stroke? – Full Text

Abstract

Background

We aimed to kinematically validate that the time to perform the Finger-to-Nose Test (FNT) assesses coordination by determining its construct, convergent and discriminant validity.

Methods

Experimental, criterion standard study. Both clinical and experimental evaluations were done at a research facility in a rehabilitation hospital. Forty individuals (20 individuals with chronic stroke and 20 healthy, age- and gender-matched individuals) participated.. Both groups performed two blocks of 10 to-and-fro pointing movements (non-dominant/affected arm) between a sagittal target and the nose (ReachIn, ReachOut) at a self-paced speed. Time to perform the test was the main outcome. Kinematics (Optotrak, 100Hz) and clinical impairment/activity levels were evaluated. Spatiotemporal coordination was assessed with slope (IJC) and cross-correlation (LAG) between elbow and shoulder movements.

Results

Compared to controls, individuals with stroke (Fugl-Meyer Assessment, FMA-UE: 51.9 ± 13.2; Box & Blocks, BBT: 72.1 ± 26.9%) made more curved endpoint trajectories using less shoulder horizontal-abduction. For construct validity, shoulder range (β = 0.127), LAG (β = 0.855) and IJC (β = −0.191) explained 82% of FNT-time variance for ReachIn and LAG (β = 0.971) explained 94% for ReachOut in patients with stroke. In contrast, only LAG explained 62% (β = 0.790) and 79% (β = 0.889) of variance for ReachIn and ReachOut respectively in controls. For convergent validity, FNT-time correlated with FMA-UE (r = −0.67, p < 0.01), FMA-Arm (r = −0.60, p = 0.005), biceps spasticity (r = 0.39, p < 0.05) and BBT (r = −0.56, p < 0.01). A cut-off time of 10.6 s discriminated between mild and moderate-to-severe impairment (discriminant validity). Each additional second represented 42% odds increase of greater impairment.

Conclusions

For this version of the FNT, the time to perform the test showed construct, convergent and discriminant validity to measure UL coordination in stroke.

Background

Upper-limb (UL) coordination deficits are commonly observed in neurological patients (e.g., cerebellar ataxia, stroke, etc.). In healthy subjects, goal-directed movement requires synchronized interaction (coordination) between multiple effectors [1, 2, 3]. Characterizing UL coordination, however, is challenging for clinicians and researchers because of lack of consensus regarding its definition (e.g., see [4, 5, 6, 7]). Nevertheless, definitions usually describe coordinated movement as involving specific patterns of temporal (timing between joints) and spatial (joint movement pattern) variability [1, 2, 8]. However, trajectory formation differs for reaches made in a body-centered frame of reference (egocentric) compared to those relying on mapping of extrinsic space and visuo-motor transformations [9, 10] made away from the body (exocentric). Thus, coordination can be defined as the skill of adjusting temporal and spatial aspects of joint rotations according to the task [11].

Damage to descending pathways due to stroke can lead to movement deficits defined at two levels. At the end-effector level (e.g. hand), variables describe movement performance (time, straightness, smoothness, precision), whereas at the interjoint level, variables describe movement quality (joint ranges of motion, interjoint coordination) [12]. These variables may be affected differently for egocentric and exocentric movements.

Although it is widely recognized that training can improve performance of functional tasks even years after a stroke [13], a valid tool for the measurement of coordination has not yet been established. In healthy individuals, coordinated movements are described in terms of spatial variables, related to the positions of different joints or body segments in space and/or temporal variables, related to the timing between movements of joints/segments during the task [1]. Consideration of task specificity is important in characterizing coordination. In addition, movement may be affected by abnormal stereotypical UL movement synergies and concomitant reduction in kinematic redundancy [10, 14] as well as deficits reducing both movement performance and quality [15, 16].

In clinical practice, coordination is assumed to be measured by the time to perform alternating movements with different end effectors (e.g., supination/pronation of the forearm, sliding the heel up and down the anterior aspect of the shin). Another task commonly used to assess coordination is the Finger-to-Nose test (FNT) [17, 18]. In the standard neurological exam [19], the individual alternately touches their nose and the evaluator’s stationary or moving finger while lying supine, sitting or standing. In the Fugl-Meyer UL Assessment (FMA-UL) [18], the FNT is objectively measured as the difference in time to alternately touch the knee and nose five times between the more- and less-affected arm on a 0 to 2 point scale. Aside from FNT-time, two other features of endpoint performance, arm trajectory straightness/smoothness (tremor) and precision (dysmetria), are estimated qualitatively [18] for a total of six points.

However, the construct validity of FNT-time as an UL coordination measure in individuals with stroke has not been established using detailed kinematic assessment, where construct validity is defined as the degree to which experimentally-determined and theoretical definitions match [20]. For clinicians to use FNT as part of the UL assessment, this assumption must be verified along with its convergent and discriminant validity.

The study objectives were to determine construct, convergent and discriminant validity of FNT-time to measure UL coordination in individuals with chronic stroke using kinematic analysis. We characterized movement parameters during performance of FNT between healthy and stroke subjects. We also related FNT outcomes (time, trajectory straightness, precision) to UL impairment severity and activity limitations. We hypothesized that FNT-time would 1) be related to interjoint coordination measures (construct validity); 2) be correlated with other measures of UL impairment and/or activity limitations (convergent validity); and 3) discriminate between levels of UL impairment (discriminant validity). Preliminary data have appeared in abstract form [21].

Continue —> Does the Finger-to-Nose Test measure upper limb coordination in chronic stroke? | Journal of NeuroEngineering and Rehabilitation | Full Text

 

Fig. 1 a Experimental set up illustrating marker placement and examples of endpoint displacement for finger-to-nose test. Subject sat with one arm partially extended, index finger fully extended and target placed at 90% arm-length at eye-level. The task was to touch the target and then the nose accurately 10 times at a self-paced speed; b Examples of 10 trials of endpoint (tip of index finger) displacement over time. First row–healthy subject moving endpoint at self-paced speed; Second row–healthy subject moving endpoint at a slower speed and Third row–Stroke subject moving endpoint a self-paced speed

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