Disability and Rehabilitation

ISSN: 0963-8288 (Print) 1464-5165 (Online) Journal homepage: http://www.tandfonline.com/loi/idre20

Validity and test–retest reliability of a measure of hand sensibility and manual dexterity in people with multiple sclerosis: the ReSense test Alon Kalron, Michal Greenberg-Avrahami & Anat Achiron To cite this article: Alon Kalron, Michal Greenberg-Avrahami & Anat Achiron (2015) Validity and test–retest reliability of a measure of hand sensibility and manual dexterity in people with multiple sclerosis: the ReSense test, Disability and Rehabilitation, 37:10, 914-920, DOI: 10.3109/09638288.2014.948128 To link to this article: http://dx.doi.org/10.3109/09638288.2014.948128

Published online: 06 Aug 2014.

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Date: 05 November 2015, At: 19:09

http://informahealthcare.com/dre ISSN 0963-8288 print/ISSN 1464-5165 online Disabil Rehabil, 2015; 37(10): 914–920 ! 2014 Informa UK Ltd. DOI: 10.3109/09638288.2014.948128

ASSESSMENT PROCEDURES

Validity and test–retest reliability of a measure of hand sensibility and manual dexterity in people with multiple sclerosis: the ReSense test

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Alon Kalron1,2, Michal Greenberg-Avrahami2, and Anat Achiron2 1

Department of Physical Therapy, Tel-Aviv University, Tel-Aviv, Israel and 2Multiple Sclerosis Center, Sheba Medical Center, Tel-Hashomer, Israel

Abstract

Keywords

Purpose: To evaluate the concurrent validity and reliability of the ReSense tool, a new clinical test aimed at determining sensory and functional deficits of the hand in people with multiple sclerosis (PwMS). Methods: Study participants included 90 PwMS, 58 women, characterized by significant sensory symptoms in one or both hands. Thirty healthy subjects, 19 women, served as controls. The ReSense evaluation tool measures the ability to perceive and recognize texture and spatial properties of specific elements. ReSense scores were compared with the two-point discrimination (2PD), Semmes–Weinstein monofilament (SWM), Nine-Hole Peg Test (9-HPT), Box and Block Test (BBT) and the Functional dexterity (FDT) tests. Results: The Cronbach alpha value for the ReSense test for PwMS was 0.84. The ReSense was significantly correlated with the 9-HPT; Pearson’s R ¼ 0.44 and FDT; Pearson’s R ¼ 0.35. Significant correlations were demonstrated between the ReSense score to SWM and 2PD. The strongest correlation was found with the 2PD performed on the dominant hand; Pearson’s R ¼ 0.55. Conclusions: The ReSense is a valid tool developed for testing sensing properties of the hand in PwMS. We believe that the sensitivity and specificity values of this tool will assist the clinician to formulate decisions related to rehabilitation management of his/her patient.

Hand, motor skills, multiple sclerosis, resense test History Received 18 January 2014 Revised 23 June 2014 Accepted 21 July 2014 Published online 6 August 2014

ä Implication for Rehabilitation   

The ReSense, a valid and reliable tool was developed for testing sensing properties of elements with hand manipulation in the clinic. The ReSense test score was significantly correlated with scores of manual dexterity and traditional sensibility tests. A continuous scale such as the ReSense test may provide clinicians with more precise information relating to hand performance in PwMS than traditional sensory tools.

Introduction Multiple sclerosis (MS) is a neurologic disease affecting an estimated 2.5 million adults worldwide and is the most common disabling neurological disease in young adults. MS is primarily diagnosed between ages 20 and 50 [1]; is two to three times more common in women than men [2] and results in demyelination and axonal loss in the central nervous system (CNS) [3]. During the course of the disease, approximately three out of four people with MS (PwMS) encounter upper limb dysfunction and somatosensory deficits including both proprioceptive and cutaneous input [4]. Consequently, a substantial number experience a negative impact on vital activities of daily living (ADL), e.g. eating or toileting [5], resulting in dependence and a reduced quality of life [6].

Address for correspondence: Alon Kalron, PhD, PT, Physical Rehabilitation Research Unit, Multiple Sclerosis Center, Sheba Medical Center, Tel-Hashomer, Israel. Tel: 972-9-9512726; 972-52-2436839 (Mobile). E-mail: [email protected]

Hands serve both executive and perceptual functions based on the biomechanical advantages of opposable thumbs and rich mechanoreceptors in the skin of grasping digits [7]. In order to produce smooth and timely manipulation of objects, both the internal presentation (based on previous experience) and peripheral sensory information affects the control strategy [8]. Thus, sensory function plays a critical role in the functional use of hands. Accordingly, it is essential for clinicians to assess sensory function in an objective, accurate and timely manner for PwMS who suffer sensory disturbances of the hand. Several studies have demonstrated the restorative potential of the hand in PwMS resulting from motor training programs [9,10], multidisciplinary treatment [11], robot-assisted arm training [12] and sensory retraining [13]. To date, several measuring tools have been used to quantify perception and discriminative sensation in the hands of people suffering from neurological impairments. The most common include the two-point discrimination (2PD) and SemmesWeinstein monofilament (SWM) tests. Traditional tests used to determine upper limb function and manual dexterity in clinical

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settings include the Nine-Hole Peg Test (9-HPT) [14], Box and Block Test (BBT) [15], Action Research Arm Test [16] and Fugl–Meyer test [16]. It is worth noting that although these tests are well established for clinical and research evaluation needs, they still have several limitations. For instance, the conventional SWD and 2PD assessment tools contain few weaknesses. Firstly, the stimulus applied by the examiner to the cutaneous surface is highly subjective [17]. Secondly, these tests are applied in a passive manner, i.e. voluntary hand movement is not permitted [18]. Previous studies have reported diminished transmission of tactile input in addition to difficulty in efficiently acquiring sensory data when sensory input is applied under passive touch conditions [19,20]. Additionally, the 9-HPT also has certain faults; it is sensitive to practice effects and has been found to have poor floor effects at the initial assessment of stroke survivors [21]. Active perception is defined as a measurement technique incorporating proprioceptive and tactile input information through intended movements [20]. This approach consists of a two-stage sequence, a general grasping stage and a more precise exploratory process to efficiently extract the objects underlying properties [22,23]. Specifically, the hand uses motor capabilities to greatly extend its tactile resolution [24]. A previous experiment showed that healthy people could classify the shapes of objects correctly with active exploration but could not properly identify them through passive touch [25]. Therefore, it is not surprising that the results of traditional sensory tests for an injured hand correspond little with the hand function [26,27]. Consequently, new exploratory procedures have been strongly recommended to assess hand sensibility and manual dexterity. Although, several tests based on actively sensing the properties of objects have been developed [28,29], it is questionable whether these tools are appropriate for the MS population. Recently, the ReSense, a new sensory measurement tool was developed at the MS Center, Sheba Medical Center in Israel. The ReSense tool is based on the active perception approach. This concept involves utilizing hand action during object contact for the purpose of shape and texture identification. The hand movements selected enables the somatosensory receptors to effectively interpret sensory characteristics of the object being explored. Object properties such as shape, texture, weight, surface compliance and temperature are reported to be the basis for object recognition [30]. Shape and texture, in particular, have been reported to influence grip and load forces during grasp and lift [31]. Thus, the ReSense test relies on definite identification of these features. Hence, the purpose of the present study was to evaluate the concurrent validity and reliability of the ReSense test tool, a clinical test aimed at reflecting sensory and functional deficits of the hand in PwMS.

Methods and materials Study participants Study participants included 90 PwMS volunteers, 58 women and 32 men, with a mean age of 45.6 (S.E. ¼ 1.3). The inclusion criteria for the MS patient group was: (1) clinically defined MS according to the revised McDonald’s criteria [32] and confirmed by an experienced neurologist; (2) significant sensory symptoms (e.g. decrease in touch or pain or position sense in the thumb and fingers) in one or both hands, confirmed by a neurological examination; and (3) good-to-normal grade muscle power of the abductor pollicis brevis muscle according to the traditional manual muscle strength testing procedures. The neurological examination concluded with an expanded disability status scale (EDSS) score. The EDSS is an accepted method of quantifying disability in MS. It is an eight-function system scale including

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motor, sensory, cerebellar, brain stem, visual, bowel and bladder, pyramidal, and others. Participants were excluded if they suffered from communication problems, emotional disturbances, prominent cognitive decline, orthopedic disorders negatively affecting hand movement, blurred vision or had relapsed during the previous three months. Thirty apparently healthy subjects, 11 men and 19 women, mean age of 42.3 (S.E. ¼ 2.5) years served as controls. The study was performed at the Department of Occupational Therapy, Multiple Sclerosis Center, Sheba Medical Center, Tel-Hashomer, Israel and was approved by the Sheba Institutional Review Board. All participating subjects signed an informed consent form. Instrumentation The ReSense evaluation tool The ReSense evaluation tool measures the ability to perceive and recognize object forms by utilizing cues taken from texture, size and spatial properties. The tool contains 18 tactile stimulation elements constructed from plastic pieces. Mean dimensions of each element is 2 cm  2 cm  0.5 cm. Elements are equally subdivided into three subgroups. Elements 1 to 6 are differentiated by geometrical shapes. Shapes include quadrangular, triangle, circular, heart, flower and a plus sign. Elements 1 to 6 are identical in terms of coating texture; all are characterized by a smooth surface. Elements 7 to12 are differentiated by coating texture characteristics. Textures include immersed dots, protrusive dots, straight lines, wavy lines, mini squares and smooth surfaces. The geometrical shapes of elements 7 to 12 are identical, all quadrangular. Elements 13 to18 are mixtures of the previous subgroups. Namely, each element was different in terms of geometrical shapes and coating texture (e.g. triangle with straight lines, heart shape with wavy lines, etc.). ReSense tactile elements are shown in Figure 1. ReSense testing procedure Before formal data collection, an initial familiarization phase was carried out by an occupational therapist specialized in MS rehabilitation. Subjects performed two trial demonstrations with the sample objects, which varied in geometrical shape and texture similar to the test objects. Following familiarization, the formal test was executed. Subjects were instructed to sit upright with their hands comfortably supported on the table and only use the first three digits of one hand to handle the tactile elements. The test was performed with eyes open; however, a curtain was positioned in front of them to block their view. Elements were separately manipulated by each hand, the dominant hand first. During test, no information was provided as to the success rates. The test comprised three phases performed in consecutive order: (1) Stereognosis test: A box (15  15  4 cm) containing the cubic elements was placed in front of the participant, the curtain prevented viewing the cubic elements. Elements 1 to 6 were randomly placed inside the box. The subject was then instructed to pick up an element and sense its geometrical properties. Participants were encouraged to identify and name the shape of the element. Time for identification was limited to 15 s. The subject randomly continued to pick up the next object and follow the same rule. The first phase was completed when the last element was handled. (2) Texture differentiation test: The setup and procedures were similar to the stereognosis test. Elements 7 to 12 were placed

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Figure 1. ReSense tactile elements.

in the box. The subject was instructed to pick up a cube and sense its texture. Participants were encouraged to identify and name the texture properties of the element. Time for identification was limited to 15 s. The subject continued to randomly pick up the next object and follow the same rule. The second phase was completed when the last element was handled. (3) Stereognosis and texture differentiation test (combination phase): The third phase was performed with elements 12 to 18. Participants were encouraged to identify both texture and geometrical properties within the 15-s time frame. A score was provided for each test component. Three points were awarded for a correct identification during the stereognosis test. Two points were awarded for a correct identification during the texture differentiation test. A single point was provided for correct recognition during the third phase of the test. Consequently, a total score was calculated. A perfect score of 36 (18 + 12 + 6) was awarded for precise identification of all 18 element tactile characteristics within the time frame. The scoring system was determined on the basis of a preliminary observational phase and interviews with healthy subjects who had trained with the ReSense tool. A consultant group consisting of three occupational therapists and two neurologists specialized in PwMS interpreted the information. The expert group classified three phases as easy, moderate or hard. A consensus approach was used for decision-making. The stereognosis phase was ranked as the easiest followed by texture identification. It was quite clear that the combination phase was the most challenging. In order for the total score to reflect the different test phase difficulties, it was decided to credit the easiest task with a higher grade (3 points) and the reverse for hardest task (1 point). The rationale was that failure on a relatively difficult task should impact the total score less compared to a situation where failure was observed on an easier task. Experimental protocol The primary aim of the study was to examine the concurrent validity of the ReSense test. Therefore, ReSense test scores were compared to traditional hand sensibility, manual dexterity and upper limb function tests. In addition, ReSense scores of the MS

group were compared to those of the healthy controls. In order to assess test–retest reliability, healthy participants and 30 of the 90 MS participants were examined 7–14 days after the initial examination. During each session, hand sensibility, manual dexterity and the ReSense tests were performed in random order. All measurements were performed by a single occupational therapist in both assessment sessions. (1) Sensory evaluation: The 2PD test was used to determine tactile sensation [33]. Light-touch and pressure-sensation thresholds were determined using the SWM [34]. These measurements are standardized tests commonly used in research and sensory evaluation of peripheral and central nerve lesions and are usually used as a criterion standard of touch–pressure threshold and tactile sensation. Normal hand thresholds points for the SWM test ranged from 1.65 to 2.83. Regarding the 2PD, a healthy person should be able to recognize two points separated by as little as 2–4 mm on the finger pads [35]. The two sensory tests were performed on the anterior aspect of the finger pads. A modified 4, 2 and 1 stepping algorithm [36] was employed to evaluate the threshold point. The subjects were seated and blindfolded. The monofilaments test began with a 4.17 filament; the two-point discrimination test with a 5 mm distance gap. Depending on the subject’s response, the changes in stimulus intensity/distance gap were rendered in three increments until a change in their response was observed and a turnaround point reached. Changes were then made in two increments until another turnaround point, at which point all stimuli was presented into one increment. The tactile sensation threshold was determined as the lightest filament experienced 450% of the time. In the same manner, the two-point discrimination threshold was determined as the smallest distance gap recognized 450% of the time. For each location tested, the examiner performed two null trials randomly placed throughout the algorithm. If the subject responded to both null trials at any given location, the test was halted and the subject reinstructed. The final score, given separately for both the monofilaments test and the twopoint discrimination test, was calculated as the total sum of the separate thresholds presented by each digit. (2) 9-Hole Peg Test (9-HPT): The 9-HPT is a brief, standardized, quantitative test of upper extremity function [33]. A small,

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shallow container holding nine pegs and a wood or plastic block containing nine empty holes is placed on the table. When the start command is given, a stopwatch is activated and the patient proceeds to pick up the nine pegs, one at a time, as quickly as possible, and place them into the nine holes. Once they are in the holes, the patient removes them as quickly as possible, one at a time, returning them to the shallow container. The total time to complete the task is recorded. A normal result in healthy adults (aged 40 to 50) is 18 s [37]. (3) Box and Block test (BBT): The box and blocks test examines manual dexterity [38]. Wooden blocks are placed in a wooden box with two equally sized compartments separated by a 15.2 cm high divider. The subject is required to single handedly grasp one block at a time, carry it over the partition and then release it on the opposite side. The subject is given 60 s to complete the test. The number of blocks transferred to the other side is then counted. Normal results in healthy adults (aged 40 to 50) are 80 cubes transferred in one minute [39]. (4) Functional dexterity test (FDT): The FDT is a square pegboard with 16 holes and 16 pegs. Using a stopwatch, the examiner measures the amount of time that it takes for the subject to turn over all the pegs on the board, as quickly as possible, using one hand at a time. The FDT has shown excellent reliability in measuring fine finger dexterity [40]. Statistical analyses Descriptive statistics were used to describe a mean and standard error (S.E.) of the dependent variables; the results of demographic and clinical data, traditional sensibility, manual dexterity and the ReSense tests. An independent t-test was used to compare the performance between MS and control groups regarding the ReSense test. The Kolmogorov–Smirnov test was used to examine the normality of the distribution. The reliability of the ReSense for MS participants and healthy controls was analyzed by the Cronbach alpha test. Concurrent validity of the ReSense was determined by the Pearson’s R correlation between the ReSense score and the scores from traditional hand sensibility and manual dexterity tests. Correlation coefficients 0.35 are generally considered to represent low or weak correlations, 0.36 to 0.67 modest or moderate correlations, and 0.68 to 1.0 strong or high correlations with r coefficients 0.90 very high correlations [41]. A receiver operating characteristic (ROC) curve was constructed using sensitivity and specificity values of the ReSense test scores, differentiating between the MS and healthy groups. All analyses were performed using IBM SPSS statistics software (Version 21.0 for Windows, SPSS Inc., Armonk, NY). All reported p values were two-tailed. The level of significance was set at p50.05.

Results Mean disease duration of PwMS in our study was 11.4 years (S.E. ¼ 1.0). Neurological impairment, as indexed by the neurologist-derived EDSS was 5.2 (S.E. ¼ 0.2). Eighty-two participants (90% of the sample) were right-handed dominant. No significant differences were observed between the MS and healthy groups in terms of age and gender ratio. PwMS scored significantly lower in the ReSense tests compared to their healthy counterparts. This finding was demonstrated for both dominant [25.3 (S.E. ¼ 0.8) versus 33.1 (S.E. ¼ 1.2); p50.001] and non-dominant hands [22.9 (S.E. ¼ 0.8) versus 32.3 (S.E. ¼ 1.1); p50.001]. Demographic, clinical variables and ReSense test scores of the study population are reported in Table 1.

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Table 1. Descriptive characteristics of study participants. Mean (S.E.) Variables Age (years) Gender Male Female Ratio M/F Hand dominance Rt Lt Ratio Rt/Lt EDSS Disease duration (years) ReSense score (Range 0–36) Dominant hand Non-dominant hand

MS (n ¼ 90)

Healthy (n ¼ 30

p Value

45.6 (1.3)

42.3 (2.5)

0.65

32 58 0.56

11 19 0.58

0.79

82 8 10.3 5.2 (0.2) 11.4 (1.0)

27 3 9 – –

0.67 – –

25.3 (0.8) 22.9 (0.8)

33.1 (1.2) 32.3 (1.1)

40.001 40.001

In all traditional sensory and manual dexterity measurements, PwMs performed poorly using the non-dominant hand compared to the dominant hand. Details are provided in Table 2. Test–retest reliability The Cronbach alpha values of the ReSense test for the healthy controls were 0.91, 0.87 for the dominant and non-dominant hands, respectively. Scores for the MS participants were 0.85 and 0.83 for the dominant and non-dominant hands, respectively. These results indicate that the test was consistent for repeat trials with both hands among the healthy and PwMS. Correlation between the ReSense test and traditional hand sensibility and manual dexterity tests The ReSense was negative moderately correlated with two (out of three) manual dexterity tests. Correlation between the ReSense to 9-HPT and FDT was 0.44 and 0.35, respectively. Correlation scores were similar regarding dominant and nondominant hands. No significant correlations were observed between the ReSense to BBT. Regarding the traditional sensibility tests, negative moderate correlations were demonstrated between the ReSense score to SWM and 2PD. The strongest correlation was found with the 2PD performed on the dominant hand. Correlation scores between traditional sensory and manual dexterity tests to the ReSense test are detailed in Table 3. ROC curve ROC curves based on the ReSense test score were executed according to the dominant (Figure 2) and non-dominant hand (Figure 3). The results collected from the dominant hand, the area under the curve c-statistic was 0.891 (95% CI, 0.82–0.94), indicated a good overall grouping ability. The optimal criterion value for classification between PwMS and healthy participants was set at 27, sensitivity ¼ 74.73 (95% CI, 64.5–83.3), specificity ¼ 96.8 (95% CI, 83.2–99.5), positive likelihood ratio ¼ 23.16, negative likelihood ratio ¼ 0.26; p50.0001. According to results collected from the non-dominant hand, the area under the curve c-statistic was 0.894 (95% CI, 0.82–0.94). The optimal criterion value for classification between PwMS and healthy participants was set at 30, sensitivity ¼ 86.75 (95% CI, 77.5–93.2), specificity ¼ 77.4 (95% CI, 58.9–90.4), positive likelihood ratio ¼ 3.84, negative likelihood ratio ¼ 0.17; p50.0001.

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Table 2. Hand sensibility and manual dexterity measurements of the MS participants. Mean (S.E.) Variable

Dominant

9-HPT (s) BBT (no) FDT (s) SWM finger 1 (mm) SWM finger 2 (mm) SWM finger 3 (mm) 2PD finger 1 (mm) 2PD finger 2 (mm) 2PD finger 3 (mm) ReSense (0–36)

43.7 46.9 88.2 3.33 3.27 3.30 5.07 4.92 5.08 25.3

(3.0) (1.3) (5.5) (0.05) (0.05) (0.05) (0.24) (0.20) (0.25) (0.8)

Non-dominant 32.1 39.5 66.7 3.56 3.49 3.56 6.17 6.07 6.54 22.9

(1.2) (1.3) (4.9) (0.08) (0.07) (0.08) (0.35) (0.29) (0.34) (0.8)

Mean difference (95% CI) 11.6 7.4 21.5 0.23 0.21 0.26 1.10 1.15 1.46 2.6

(6.5, 16.8) (5.0, 9.7) (10.3, 16.8) (0.14, 0.33) (1.2, 0.31) (0.15, 3.65) (0.48, 1.72) (0.65, 1.65) (0.80, 2.11) (4.0, 0.8)

p Value 40.001 40.001 40.001 40.001 40.001 40.001 40.001 40.001 40.001 0.001

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9-HPT, Nine-hole peg test; BBT, Box and Block test; FDT, Functional dexterity test; SWM, Semmes–Weinstein monofilament test; 2PD, Two-point discrimination test.

Table 3. Correlation between results of the ReSense and traditional sensibility and manual dexterity tests for PwMS. ReSense Variable 9-HPT (s) BBT (No) FDT (s) SWM finger 1 (mm) SWM finger 2 (mm) SWM finger 3 (mm) 2PD finger 1 (mm) 2PD finger 2 (mm) 2PD finger 3 (mm)

Dominant b

0.43 0.15 0.34a 0.37a 0.34a 0.40b 0.58b 0.52b 0.56b

Non-dominant 0.44b 0.26 0.36a 0.46b 0.46b 0.44b 0.39a _0.35a 0.36a

a

Correlation is significant at 0.05 level. Correlation is significant at 0.01 level. 9-HPT, Nine-hole peg test; BBT, Box and Block test; FDT, Functional dexterity test; SWM, Semmes–Weinstein monofilament test; 2PD, Two-point discrimination test.

b

Figure 3. ROC curves based on the ReSense test score according to the non-dominant hand.

Discussion

Figure 2. ROC curves based on the ReSense test score according to the dominant hand.

In this study, we tested the concurrent validity and reliability of the ReSense test. High Cronbach alpha values indicated good test–retest reliability for both healthy and MS groups. These results are similar to those presented by Hsu et al. [28] and Williams [29], although they examined similar sensory testing tools on patients suffering from carpal tunnel syndrome and stroke, respectively. In the present study, according to the area under the curve formulated in the ROC analysis, the ReSense test was proven diagnostically accurate. Compared to healthy participants, PwMS scored on average 25% less in both hands. Cut scores of 27 and 30 for the dominant and no-dominant hand, respectively, were found to discriminate between PwMS who suffer from hand deficits and the healthy controls. We assume that a continuous scale like the ReSense may provide clinicians with more precise information relating to performance than dichotomous or categorical scales. We hope that the clinician will use the sensitivity and specificity values in combination with other evaluation data to formulate decisions related to rehabilitation management of his/her patient.

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The ReSense score had moderately to good correlations (Pearson’s R ranged from 0.3 to 0.6) with the traditional hand sensibility (SWM and 2PD) and manual dexterity tests (9-HPT and FDT), with the exception of the BBT test. The latter could be explained by the fact that in contrast with other manual dexterity tests, the BBT requires sufficient range of movement and strength of the elbow and shoulder joints. We assume that because active detection of tactile elements through hand manipulation does not involve to a high extent the proximal joints of the upper limb, the ReSense scores were not correlated to those of the BBT. Correlation analysis findings support the primary aim of this study, that the ReSense test is a test of sensation and manual dexterity of the hand in the MS population. Nevertheless, the different correlation values are difficult to explain. If we divide the tests into two groups, pure sensory tests (SWM and 2PD) and manual dexterity tests (9-HPT and FDT), we can argue that the ReSense test reflects, to a better extent, the sensory properties of the hand. This argument is logically acceptable due to the nature of the ReSense test. The tool was developed to evaluate the ability to detect definite characteristics of specific elements relying on kinesthetic and sensory information from the movement of the thumb and fingers. Hand properties such as strength and force, are probably less vital for this purpose. Nevertheless, an effective test of hand abilities should provide as much information as possible as to hand functionality. The fact that a single test, the ReSense, reflects both sensory and manual dexterity components strengthens the importance of this test for the MS population. Both arms were separately analyzed because it was hypothesized that hand dominance may affect performance on outcome measurements including the ReSense test. Results of the traditional tests demonstrated that the non-dominant hand of the MS group performed significantly worse on all tests compared with the dominant hand. The ReSense test results reached a similar conclusion. PwMS scored an average 10% less with their non-dominant hand compared to the dominant hand. Differences between dominant and non-dominant hand performance revealed in our study are in agreement with Lamers et al. [42], who examined, perceived and actual arm performance in 30 wheelchair-bound MS patients and observed a clear significant difference between the dominant and non-dominant hand in favor of the dominant hand.

Limitations Study limitations: (a) the ReSense test measures only two aspects of haptics (shape and texture); therefore, it does not provide information relating to other haptic components (temperature, weight, size). There is a chance that an addition of other haptic components to the tool would have increased its sensitivity of sensory hand function; (b) hand impairment may be due to the sum of multiple components. Potential factors include tremor, spasticity and fatigue. In this context, the present study did not take into account all potential risk factors. Nevertheless, the exact contribution of these factors on sensory hand function is still unclear; (c) there is a possibility that the neurological examination performed by the neurologist for eligibility into the trial missed subtle cases of sensory impairment. Consequently, there is a chance that only those patients with severe sensory deficits were included in the study.

Conclusions This study evaluated the validity and reliability of the ReSense tool for testing sensing properties of elements with hand manipulation in the clinic. Future studies should examine whether the measurements of the tool is sensitive to changes in sensibility

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and hand function in PwMS undergoing different treatment strategies. Moreover, it is important to examine the ability of the ReSense test to discriminate between different levels of sensory impairment of the hand (e.g. mild, moderate, severe). Finally, we assume that the ReSense test is an appropriate tool for other pathologies characterized by hand impairments (e.g. stroke survivors, carpal tunnel syndrome), nevertheless future studies are needed in order to confirm this assumption.

Declaration of interest The authors report no declaration of interest.

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Validity and test-retest reliability of a measure of hand sensibility and manual dexterity in people with multiple sclerosis: the ReSense test.

To evaluate the concurrent validity and reliability of the ReSense tool, a new clinical test aimed at determining sensory and functional deficits of t...
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