1. health and fitness
2. disorders

Research Report
Reliability of the Scores for the Finger-to-Nose Test
in ~ d u l t swith Traumatic Brain Injury
Background and Purpose. The purpose of this study was to determine the intrarater and interrater reliability of measurements of three clinicalfeatures of coordination based o n the perfomnce of the '~nger-tonose"test. Subjects. Thirtyseven persons with traumatic brain injury (26 male, 11 female), aged 17 to G4
years @=29.1, SD=9.9),participated in the study. Mdbocis. Each subject's pHorrnance was videotaped and evaluated for the right and left upper extremities (CIEs)
(two trials each) with respect to thefollowing vanables: time of execution, degree of
dysmetria, and degree of tremor @our-pointordinal ratings). One year later,jive
mpmener1ced
physcal therapists (including the orig2'nal investigator) independently
rated each patient's videotaped pe?ji~nnancein the same manner as described
above. Remlis. Intraclm correlation coeficients (ICC[3,1])for intrarater reliability
were .971 and .986 and ICCs for interrater reliability were ,920and ,913for nght
and lefr UEs, respectively,for the time of execution. A generalized ffippa statistic of
.54 was calcuhted for the scoring of dymtria (both UEs), and Kappa stat&&
calculatedfor the scoring of tremor were .18 and .31for right and left UEs, respectively. Interrater reliability was lowerfor the scoring of these vanables and varied
from .36 to .40for dysmetria andfrom .27 to .26for tremor (nght and left UEs,
respectively). C d u s l o n and Dascusston. These results indicate that physical
tberapkts demonstrate low reliability in assesment of the presence of dysmetria and
~revwrusing videotaped pe&nmnces of thejinger-to-nose test. The results suggest,
b o w e ~that
~ , therapkts reliably measure the time of execution of this test. gthe
limitations associated with therapists' capacityfor objective measurement of subjecby establishment of more deJnitive scartive phenomena cannot be overcome (e,
ing cn'tma for the measures of dysmeria and tremor), tben therapisa should seek
alternative methods of evaluation of UE coordination. [SwaineBR, Sulliuan SJ
Reliability of the scoresfor the finger-tonose test in adults with traumatic brain
injury. Phys Tber. 1333;73:71-78.]
Bonnle R Swalne
S John Sullhran
Key Words: Coordination, Reliability, Tests and measurements, Traumatic brain
injury.
BR Swaine, FT,is a student in the Doctor of Biomedical Sciences Program, L'Ecole d e Readaptstion, Facultk d e Medeane, UniversitC de Montreal, Montreal, Quebec, Canada H3C 3J7. Address all
correspondence to Ms Swaine at Centre de Recherche, Institut d e Readaptation de Montreal, 6300
Darlington Ave, Montreal, Quebec, Canada H3S ZJ4.
SJ Sullivan, PhD, is Associate Professor, Department of Exercise Science, Concordia University, 7141
Sherbrooke St W,Montreal, Quebec, Canada H3G 1MS; Researcher, Centre de Recherche, Institut
d e Readaptation d e Montreal; and Adjunct Professor, L'Ecolc de Readaptation, Facult6 de Medecine,
Universite de Montreal.
This study was approved by the institutional review boards of the Institut de Readaptation de Montreal, the Centre de Readaptation Lucie Bruneau, and the Centre de Rkadaptation Estrie Inc.
This project was Funded in part by the Societe de L'Assurance Automobile du Quebec and the
Fonds de la Recherche en Sante du Quebec. Ms Swaine was supported by the Fonds Pour la Formation de Chercheurs et L'Aide a la Recherche.
This article was submitted January 30, 1 9 2 , and was accepted September 28, 1992.
Physical Therapy /Volume 73, Number 2Pebruar-y 1993
Coordination disturbances are only
one of the clinical manifestations of
the complex motor disorders affecting
persons with traumatic brain injury
PI).Disturbances in coordination
among this population are frequent14
and can severely compromise motor
function. The documentation of coordination disturbances (eg, the inability
to execute smooth, accurate, and
controlled movementss) forms an
integral part of the assessment of
sensorimotor function in the population of patients with TBI.
71 / 17
Clinicians usually assess coordination
disturbances by observation, noting
the quality of movements performed
by the patient. Instrumented, quantitative methods have recently been used
to measure coordination in patient
populations with varied neurologic
disorders. These methods include
tracking tasks,6,7 reciprocal tapping
tasks? and kinematic analysis.9 A traditional and long-standing method of
the measurement of upper-extremity
WE) coordination, however, consists
of the clinician observing the patient's
performance during the "finger-tonose" testlo and noting certain characteristics of the movement such as
time of execution and presence or
absence of dysmetria and tremor. The
time of execution of this test can be
recorded using a stopwatch. Dysmetria is characterized as an impaired
ability to judge the force and range of
a movement; tremor refers to an
involuntary oscillatory movement.5
Information regarding the degree of
dysmetria and tremor is usually
scored using ordinal rating scales and
is heavily dependent on the clinician's
judgment.
Although the protocol for recording
results from the finger-to-nose test
may vary among institutions and individual clinicians, the literature indicates that it is used routinely in the
clinical setting and can perhaps be
identified as the "gold standard" measure of UE coordination.5~10J~
The use
of ordinal rating scales such as those
used in the finger-to-nose test has
recently been questioned, however,
because of their reliability and sensitivity limitations.12
Recently, Mayo et all3 examined the
interrater reliability of several clinical
measures (including the finger-tonose test) from a standard neurophysical evaluation. Four experienced
physical therapists rated the finger-tonose test performances of 18 adults
with neurological impairment (including 16 patients with TBI). The degree
of agreement among raters was found
to be 49.7% for dysmetria and 76%
on the scoring of tremor; each variable was evaluated using a three-point
ordinal rating scale. Kappa statistics
calculated for dysmetria and tremor
were .17 and .08, respectively, indicating "poor" interobserver agreement.
The authors did not, however, examine the reliability of the timed measure of this test, nor did they examine
intrarater reliability. We believe,
therefore, that further research must
be conducted to fully examine both
the intrarater and interrater reliability
of this clinical measure of coordination in persons with TBI.
The purpose of this study was to
determine the intrarater and interrater reliability of the scoring system
used by experienced physical therapists who independently rated the
videotaped performances of the
finger-to-nose test among persons
with TBI.
subjects who consented to be filmed.
Subjects ranged in age from 17 to
64 years @=29.1, SD=9.9). The duration of coma varied considerably
among subjects, ranging from 1 to
135 days @=38.2, SD=32.7), as did
the time elapsed since the subjects'
injury, ranging from 3 to 117 months
@=34.0, SD=30.9).
Raters
Five physical therapists (including the
original investigator [BRS]) participated as raters in this study. All raters,
except the original investigator, were
recruited from a neurology team of a
physical therapy department within a
Montreal rehabilitation center. The
raters, each with between 4 and
15 years @=10.8,SD=4.5) of clinical
experience in the treatmeni of patients who have neurological impairment, were all very familiar with the
application of the finger-to-nose test
in persons with TBI.
Method
Equipment and Procedure
Subjects
Thirty-seven persons with TBI
(26 male, 11 female) participated in
the study. The sample was one of
convenience, with subjects recruited
from three different rehabilitation
centers* on the basis of the diversity
of the levels of severity of sensorimotor deficits. Inclusion criteria were
(1) an adequate UE motor function
(suficient active range of motion and
voluntary movement) to perform the
finger-to-nose test with at least one
UE and (2) sufficient comprehension
of simple verbal commands. The
protocol for this study was approved
by each institution from which the
subjects were recruited (and the data
were collected). Informed consent to
be filmed was obtained from all
subjects.
The data analyzed in this study represent a subset of data (n=37) from a
previously published study14 (n =40).
The present study included only those
'The Institut de Rkadaptation de Montreal, the Ceritre d e Readaptation Lucie Bruneau, and the
Centre d e Readaptation Estrie Inc.
The finger-to-nose test was administered to all subjects during a previous
study conducted approximately 1 year
before the current study.'* At that
time, subjects were instructed to perform the finger-to-nose test in the
typical clinical manner. With his or
her eyes open, each subject began the
test with an arm extended in front of
the body at shoulder level. The subject then flexed the elbow, touched
his or her nose as accurately as possible, and returned the arm to the fully
extended position. The need for both
speed and accuracy of performance
was emphasized to the subjects. Subjects performed the task with each UE
whenever possible (two trials with
each arm). The total time for the
completion of five complete cycles of
movement was recorded using a
stopwatch. In addition, the degree of
both dysmetria and tremor observed
during the movement was recorded
for each LlE. These variables were
rated on separate four-point ordinal
scales using the following criteria:
3=normal performance or the absence of a deficit, 2=slight deficit,
Physical Therapy /Volume 73, Number 2/February 1993
1=moderate deficit, and 0 =severe
deficit.
Each subject's performance (two trials
for each UE) was videotaped while
the investigator administered and
scored the test. The subject was videotaped from a lateral view so that
the rater could clearly observe
whether subjects accurately touched
their finger to their nose. The videotaped performances were then analyzed 1 year later by the original investigator and by four other physical
therapists.
Rater trainlng. No specific training
of the therapists was conducted. Prior
to the viewing of the videotape, however, the raters participated in a brief
orientation session consisting of the
presentation of the evaluation form,
the scoring protocol, and the procedure for the rating session. The scaring system (ordinal rating scales) was
provided for all raters on a printed
sheet. The rating scales were undefined for dysmetria and tremor because they are typically not defined
when using this clinical test. The
variable time of execution (for each
trial), however, was defined for the
raters as the time for the completion
of five complete cycles of movement.
A cycle began with the arm extended
in front of the body at shoulder level,
included the flexion of the elbow so
as to bring the index finger to touch
the nose, and finished with the return
of the arm to the fully extended position. During this session, the therapists were also given time to practice
and become comfortable with the
manipulation of their stopwatches.
lntrarater scoring procedure. The
original investigator scored the subjects' performances (two trials) on the
finger-to-nose test using the previously described procedure on two
different occasions: (1) during the
original data collection and (2) during
the viewing of the videotaped performances 1 year later. This rater did not
review any of the previous scores
collected 1 year earlier, prior to the
viewing of the videotape a year later.
The videotaped performances were
presented in such a way that the order of subjects tested differed from
that in the original data collection.
Therefore, for the analysis of intrarater reliability with 1 year between
tests, there was one examiner.
lnterrater scoring procedure. The
videotape was viewed at the Institut
de Readaptation de Montreal during
two 1-hour sessions. Each subject's
videotaped performance was presented to the group of five raters
(including the original investigator).
The raters scored each subject's performance (two trials for each UE)
simultaneously and independently
and did not consult with each other
during or after the evaluations. The
raters were given the opportunity to
review a particular segment of the
videotaped performance only if necessary. The total time for the completion of five complete cycles of movement and the degree of both
dysmetria and tremor observed during the movement performed by each
UE (two trials for each UE) were
recorded by each therapist using the
scoring system described earlier.
Data Analysis
This study sought to determine the
reliability of measurements obtained
by the "typical" user of the test. It was
assumed that the typical therapist (in
terms of years of clinical experience)
knows how to skillfully score this test;
therefore, this session did not include
a training demonstration with examples of a performance characterizing
each of the four ratings. Likewise,
therapists were not given the opportunity to view any videotaped performances prior to beginning the rating
procedure.
The generalized Kappa statistic was
chosen to determine the intrarater
and interrater reliability of the measurements of dysmetria and tremor.
This statistic, developed by Cohen,l5 is
a coefficient of agreement (among
two or more raters) for categorical
data that corrects for chance agreement. Kappa values less than .OO have
been characterized arbitrarily as indicating "poor" agreement, values between .OO and .20 have been characterized as indicating "slight"
Physical Therapy/Volume 73, Number 2/February 1993
agreement, and those between .21
and .40 are said to represent "fair"
agreement. Kappa values between .41
and .60 have been characterized as
"moderate," those between .61 and
.80 have been characterized as "substantial," and values greater than .81
are said to indicate "almost perfect"
agreement.16
Although Kappa was the preferred
statistic, agreement was also described
as the total percentage of subjects in
which both of a pair of raters agreed
on the score. The agreement among
rater pairs, however, does not indicate the degree of reliability that can
be attained.
In order to establish the intrarater
and interrater agreement for the measurement of "time of execution" (interval data), intraclass correlation
coefficients (ICC[3,1.])were calculated.
This particular model was used with
the assumption that judges are considered fixed effects1' as the selection
procedure of raters did not meet the
requirements of randomness. Tests of
significance using an F test were performed at the .O1 level.
lntrarater agreement. Intrarater
agreement for this study was determined by having the same person
(BRS) measure the same three variables on two different occasions. The
patients' scores obtained by the original investigator were compared with
those recorded 1 year later from the
videotaped performances of the
finger-to-nose test.
lnterrater agreement. In order to
assess the interrater agreement
among the pairs of raters for the
scoring of dysmetria and tremor,
generalized Kappa coefficients were
calculated for each of the 10 possible
pairs of raters (for trials 1 and 2) and
are reported as average values across
all possible pairs.
Results
The distributions of the data from the
finger-to-nose test for the 37 subjects
are shown in Tables 1 and 2. Only
data for right-sided performances
-
Table I. Descriptive Characteristics and Distributions of Data Obtained with the
Finger-to-Nose Test When the Same Rater Evaluated Each Subject (N=37) on Two
Dzyerent Occasionsa
Number of Obsewatlonsb
Varlable
Trial 1
Trlal 2
Dysmetria
O=severe
3=normal
Tremor
(trials 1 and 2) are presented because
the distributions for right- and leftsided performances were very similar.
Reported in Table 1 are the distributions of the combined data obtained
when the same rater (BRS) measured
the same three variables on two different occasions for each of the
37 subjects (maximum of 74 obsemtions). For example, the scores for all
subjects from trial 1 on the first testing occasion (test) have been combined with the scores from trial 1 on
the second testing occasion (retest)
1 year later, and likewise for trial
2. Not all subjects could perform the
finger-to-nose test with their right UE;
therefore, only data from 67 performances are presented.
Time of execution (s)
X
SD
Range
-
"Right-sided performances only.
'percentage of evaluations shown in parentheses.
Table 2.
Descriptive Characteristics and Distributions of Data Obtained with the
Finger-to-Nose Test When Five Raters Evaluated Each Subject (N=37)"
Number of Obsewatlonsb
Varlable
Dysmetria
O=severe
1=moderate
2=slight
3 =normal
Trlal 1
Trlal 2
In general, scores for dysmetria and
tremor did not vary greatly among the
subjects. The majority of subjects
tested were scored as having normal
performances when dysmetria
(>55% of the subjects) and tremor
(92.5% of the subjects) were evaluated. This scoring, however, creates a
distribution problem that makes our
use of the Kappa statistic problematic, because the Kappa corrects for
chance agreement. Mean times of
execution of the finger-to-nose test
were 4.98 and 4.58 seconds for trials
1 and 2, respectively, with the range
of times being similar for both trials.
Furthermore, the distribution of the
scores did not vary over the two
trials. This finding may indicate that
this particular rater consistently
judged subjects as having the same
degree of dysmetria or tremor while
performing each trial, o r that the
subjects' performance was indeed
consistent over the two trials.
Tremor
O=severe
1 =moderate
2=slight
3=normal
Time of execution (s)
X
SD
Range
"Right-sided performances only.
'percentage of evaluations shown in parentheses.
20 / 74
The distribution of scores obtained
when the five raters evaluated each of
the 37 subjects, for a maximum of
185 possible observations, is shown in
Table 2. Different numbers of observations were recorded for individual
variables and trials. These differences
were due to either a subject's inability
to perform both trials of the finger-tonose test with the right UE or a therapist's inability to rate a particular
subject. Although the variability of
Physical Therapy /Volume 73, Number 2Pebruary 1993
1
-
Table 3. Intrarater Reliability Coeficients
Mean
Kappa"
Percentage of
Agreement
Varlable
ICC(3,1)b
Dysmetria
RC
72
Ld
78
Tremor
R
90.5
L
89.5
Tables 3 and 4 present the results of
three indexes of agreement-percentage of agreement, Kappa statistic, and
ICC-for the three variables (ie, degree of dysmetria, degree of tremor,
and time of execution). The values for
these indexes of agreement were
originally calculated with the data
from each trial; however, the values
reported here represent the mean of
the values from both trials for each
UE. For simplicity, data are presented
separately for the intrarater and interrater reliabilities.
Time of execution (s)
lntrarater Agreement
R
L
aMean Kappa represents the mean of the Kappa coefficients calculared for trials 1 and 2.
b~<.005.
'R=right upper extremity.
d ~ = l e f tupper extremity.
scores exceeds that found for the data
obtained by the same rater (Tab. I),
scores for dysmetria and tremor still
did not vary greatly among the subjects. This finding again makes interpretation of values obtained with the
Kappa, a statistic that corrects for
chance agreement, problematic, with
an uneven distribution likely as chance
agreement increases. A greater degree
of variability was found for the scoring
-
Table 4.
of the presence of dysmetria, with only
45.9% (trial 1) and 48.8% (trial 2) of
the subjects being scored as having
normal performances. The majority of
subjects (74.6% and 81.3% for trials
1 and 2, respectively) were scored as
having normal performances when
tremor was evaluated. Consistency
between tnals was again very high.
lnterrater Agreement
Interrater Reliability Coeficients
Varlable
Percentage of
Agreement
Percentage of agreement was 72% or
higher for the scoring of dysmetria
and tremor (Tab. 3). In general,
Kappa values for the scoring of dysmetria were higher than those for
tremor, indicating moderate agreement on the scoring of dysmetria but
only slight to fair agreement on the
scoring of tremor. This result, however, may also be a factor of the differences in distribution for the scores
on the two variables. Both ICCs were
above .95 for time of execution and
were determined to be significant
(PC ,005).
Mean
Kappa"
ICC(3,l)b
Percentage of agreement among the
five raters exceeded 62% (Tab. 4).
Kappa statistics for the scoring of
dysmetria were again slightly higher
than those for tremor but indicated
only fair agreement for both variables.
All ICCs were above .89 for time of
execution and were significant
(PC .005).
Dysmetria
RC
62.9
Ld
68.2
Tremor
R
78.6
L
80.8
Time of execution (s)
R
L
aMean Kappa represents the mean of the Kappa coefficients calculated for trials 1 and 2
b~<.005.
'R=right upper extremity.
d ~ = l e f tupper extremity.
Physical Therapy /Volume 73, Number 2/February 1993
Discussion
Generally, the Kappa coefficients
(agreement statistic) indicated that the
five therapists did not agree well on
the scoring of dysmetria and tremor.
In contrast, agreement was somewhat
higher when the same therapist (intrarater) evaluated these variables on
two different occasions. The greatest
agreement among raters was observed in the assessment of the time
of execution of the finger-to-nose test,
with both intrarater and interrater
reliability being very high. As expected, the scoring of the qualitative
aspects of the performance was more
difficult than the recording of the
quantitative measurement of time. It
should be noted, however, that there
was not an equal representation of all
observations and, because Kappa corrects for chance agreement, our reliability coefficients may be low, reflecting not poor reliabhty but rather the
poor distribution of observations.
These results are similar to those
reported elsewhere.l3 Interrater
agreement (Kappa) for the assessment
of dysmetria and tremor remained
low. Because most observations of
tremor were normal, however, the
Kappa values really d o not accurately
reflect reliability. The agreement of
these measures improved slightly (by
.20 for tremor) when the team of
raters consisted of therapists practicing within the same rehabilitation
setting. In the previous study, both
the raters and the subjects were
drawn from two different rehabilitation centers and one acute care setting. Another difference, perhaps also
contributing to the improved reliability, is the nature of the sample. In the
present study, the sample was restricted to only subjects with TBI and
in particular to those who were in the
later stages of the physical rehabilitation process. It is perhaps noteworthy
that in this study, in which a slightly
higher agreement was obtained, a
four-point rating scale was used (as
opposed to a three-point scale). The
choice of the four-point scale was
predicated by the clinical protocol
used by the therapists participating in
the study.
There may be several reasons for the
slight to moderate reliability (Kappa)
reported for the variables of dysmetria and tremor. A number of causes
of low reliability have been discussed
by Rothstein18 and include those attributable to (1) the person administering the test, (2) the instrument
itself, or (3) the characteristics of the
subject(s) being tested. We will address each of these causes as they
pertain to this study.
First, in this study, the same person
administered the finger-to-nose test to
all 37 subjects, thereby introducing a
constant source of error. Five different raters, however, scored (one aspect of the administration of the test)
each performance. The purpose of
this study was not to determine the
reliability of scores on the finger-tonose test among physical therapists
who had specialized training in its
application and to conclude that expert users of the test can obtain reliable measurements. Instead, its purpose was to determine the reliability
of scores on the finger-to-nose test for
assessing the ability of the "typical"
user of the test. The typical therapist
(in terms of years of experience)
knows how to skillfully perform this
test and frequently uses this measure
of coordination in his or her clinical
practice.
We assumed that the raters from this
study, by virtue of their training and
clinical experience, had the necessary
skills to score the finger-to-nose test.
Perhaps the raters had difficulty noting the deficits from the videotaped
performances (a method that they are
not familiar with), or they misinterpreted the scoring criteria because
the criteria were not sufficiently defined. Furthermore, the interrater
agreement may perhaps be different
among therapists with less clinical
experience in the treatment and evaluation of patients who have TBI. Likewise, the reliability reported in this
article may have been overestimated,
because the five therapists were recruited from the same physical therapy department (sample of convenience). The results might perhaps
have been quite d8erent if the raters
had been selected from a number of
rehabilitation centers.
A second possible cause of the low
reliability relates to the instrument
itself. The finger-to-nose test uses
ordinal rating scales to evaluate the
presence of dysmetria and tremor,
thereby providing an appreciation of
the qualitative nature of the movement performed by the patient. Descriptors such as "moderate deficit,"
however, lack precision and conse-
quently may not be sensitive to small
and perhaps meaningful changes in
patient ~tatus.5~~9
These descriptors are
vague and could, in theory, be based
on more definitive criteria that might
improve the reliability of the scores
on the finger-to-nose test (eg, number
of times the subject misses touching
his or her nose).
A probable cause of the low reliability
in this study (and a limitation) was
restrictions in observed scale variability. The values of the Kappa statistic
depend on the prevalence of the
scores over all subjects.20When the
proportion of observed values is
heavily skewed toward one of the
scale values (Tabs. 1 and 2), Kappa
values can be quite low, even with
little rater error. If the percentage of
agreement is high and Kappa is relatively low, then a restriction in the
distribution of judgments is a likely
explanation for the low reliability. For
example, for the rating of tremor
(Tabs. 3 and 4), low Kappa values
were associated with a high percentage of agreement, indicating that the
raters were observing subjects with
little or no presence of tremor consistently and were in fact agreeing on
that score.
Attempts were made to obtain a sample of subjects with a diversity of
levels of severity of sensorimotor
deficits. We expected our sample to
be similar to those reported in the
literature,21122 in which at least 33% of
the subjects presented "cerebellar
syndromes" and coordination deficits.
As measured by the finger-to-nose
test, however, only a small percentage
(maximum of 6%) of our sample was
judged by the five therapists as having
moderate and severe coordination
deficits. In actuality, the sample may
have been composed of a greater
percentage of subjects with coordination deficits, but the deficits were not
identified using the finger-to-nose
test.
The use of video recordings has provided an alternative method for the
examination of interrater reliability
i~sues.~3.~*
Furthermore, by eliminating the intertest interval (when estab-
Physical Therapy /Volume 73, Number 2Pebruary 1993
lishing intrarater reliability), no
change in the variables to be measured can occur, and the measurement obtained on the second occasion is not influenced by the first
measurement. Such an approach has
allowed the examination of the reliability of the scoring protocol of the
finger-to-nose test-the focus of this
report. This approach, however, does
not necessarily allow generalizations
to the traditional test-retest situation
in which the test is administered and
scored on two occasions. In addition,
the use of videotaping permits a number of therapists to observe and score
a performance without disturbing the
patient. Patients with TBI may not
perform optimally while being observed by a team of raters.
Cllnlcal lmpllcatlons
The resi~ltsof this study provide some
important information regarding the
amount of error associated with the
measurement of coordination using
the finger-to-nose test. Therapists can
now better interpret the measurements associated with the finger-to
nose test in view of the reliability
associated with it. In turn, therapists
may then be able to make more appropriate inferences or judgments
regarding patient progress in coordination performances or treatment
intervention. Therapists should realize, however, that the Kappas reported in this study may be underestimating reliability because of the
distribution problems we discussed.
Therapists should be encouraged in
learning that they can reliably measure the time of execution of the
finger-t:o-nosetest using a stopwatch.
The reliable data obtained with this
method offer therapists, and possibly
third-party payers, important information regarding a particular dimension
of performance (eg, speed of movement) in coordination deficits and its
resolution in patients with TBI. Improvement in this aspect of performance, however, may not necessarily
reflect an improvement in the overall
coordination abilities of a patient,
because the accuracy of performance
may be sacrificed for the increased
speed of movement.
Knowing the limitations of the fingerto-nose test should prompt therapists
to seek more objective and quantitative methods for evaluating coordination performances. Computerized
methods for the measurement of
coordination are currently available to
therapist~,~5326
and the relationship
between this method and the standard clinical finger-to-nose test has
recently been established.14
Suggestions for Further
Research
We suggest that if therapists continue
to use the finger-to-nose test to measure UE coordination among patients
with TBI, efforts should be made to
establish clearer scoring criteria for
the rating of dysmetria and tremor.
The need for accuracy criteria for the
timed measure, for example, is clearly
evident.
The results of this study d o not allow
generalizations to other patient populations, and therapists cannot assume a
similar level of reliability in other
patient groups.18If therapists wish to
know the reliability of data obtained
with the fmger-tonose test among
other patient populations, further
research must be conducted. Additional research with patients who have
TBI is also needed. Before the reliability of scores in patients with TBI can
be understood, a study must be conducted in which the Kappa values are
not influenced by the types of distribution problems we encountered.
Physical therapists appeared to demonstrate low reliability (intrarater and
interrater) for scoring the presence of
dysmetria and tremor during the
videotaped performances of the
finger-to-nose test. The therapists,
however, reliably measured the time
of execution of this test (using a stopwatch). These results suggest a need
to establish more definitive scoring
criteria in order to improve the reliability of these measures. Therapists
Physical Therapy /Volume 73, Number 2February 1993
should be aware of the amount of
error associated with the measurements from the finger-to-nose test and
should be very cautious with interpretations of this test in the population of
patients with TBI.
Acknowledgments
We thank Linda Pezzi for her valuable
assistance during the interrater reliability rating session. We also thank
Helen Corriveau, PT, Maria Carangelo,
PT, Christine Chessex, PT, and Felicia
Guama, PT, for their participation in
the scoring part of this study and
Ginette Gravel for her assistance with
the statistical analysis.
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can enjoy-ln one volume-the wisdom of those who have
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Physical Therapy/Volume 73, Number 2February 1993