Project Manual

on
Jebson-Taylor Hand Function Test
(Indian Context)
 Chirag Sejwal | Sneha
Bachelors Of Occupational Therapy
5th Semester (2022-23)
Contents
[Link] TOPIC
1. Introduction
2. Items
3. Indications
4. Contraindications
5. Cost
6. References
7. Scoring Sheet
8. Original Publication “An Objective and Standardised Test of Hand
Function”
9. Other Articles
Introduction
The Jebsen–Taylor Hand Function Test (JTHFT) of 1969 is likely to be one of
the most widely used standardized tests of hand function performance in clinical
and research investigations. The primary role of the JTHFT is to measure
impairment and evaluate the effectiveness of treatment in a variety of hand
disorders by utilizing tasks that simulate functional manual activities.
The assessment was designed to produce quantitative scores on standardized
tasks that cover the wide range of manual functions generally required by daily
living. It was designed to give an objective measurement of a broad range of
populations by age and gender norms and is usable with the dominant and non-
dominant hand.
The JTHFT has found extensive use in neurological and musculoskeletal
disorder patients. The use has been evidenced in assessing and monitoring
disorder development in conditions such as Parkinson's disease, cerebral palsy,
stroke, and brain injury.
Its widespread application is emphasized in the literature, with more than 135
publications identifying it as a reliable tool for measuring upper limb function.
The JTHFT has also been piloted in specific populations, such as muscular
dystrophy, where it effectively measured timed performance and demonstrated
high construct validity, internal consistency, and inter-rater reliability.
In addition, it has been shown to have great worth as an instrument in assessing
functional capacity in ambulatory and non-ambulatory patients, particularly in
the case of degenerative disease, in identifying upper limb deficits and
contrasting the impact of therapy intervention.

Definition
Jebsen–Taylor Hand Function Test (JTHFT) is an objective and quantitative test
instrument used to measure functional hand capacity in a patient through a
broad range of activities of daily living involving hands.
The JTHFT involves seven separate subtests, with each assessing time to
perform typical hand-related activities involving writing, card handling, and
object lifting.
Taking normative measurements from healthy control individuals, quantitative
values are derived using this test, allowing the clinician to estimate the level of
hand functionality or handicap. The test is easily performed using minimal
equipment and can be used by both clinical and research environments to record
improvement after various types of treatment, including surgery, physical
treatment, or use of a brace.

Test Items
Seven test items were designed to be representative of various hand activities.
Each of these was administered in such a way that the items were standardized
and an objective measurement of performance was obtained. These test items
included:
1. Writing a short sentence
2. Turning over 3" by 5” inch cards
3. Picking up small objects and placing in container
4. Stacking checkers
5. Simulated eating
6. Moving empty large cans
7. Moving weighted large cans

Fig 1. Two-rupee coin Fig 2. Bottle Cap Fig 3. Paper Clips

Fig 4. Kidney Beans (Rajma)

Fig 5. Tin Cans Fig 6. Black ball point pen

Fig 7. 4 Carrom men

Test Procedures
Each subtest was specially constructed to be administered in the same way to all
subjects. The results are objectively quantified using a stopwatch. This allows
for a variety of potential scores.
Subjects sit on an 18-inch-high chair at a 30-inch-high table in a well-lit room.
Questions are answered after instructions to be sure that the subject has proper
understanding.
The subtests are always given in the same sequence, nondominant hand first for
all tasks.

Subtest – I (Writing)
Procedure –
The subject is given a black ball-point pen and four 8-by-11-inch sheets of
unruled white paper fastened, one on top of the other, to a clip board. The
sentence to be copied has 24 letters and is of third-grade reading difficulty.
The sentence is typed in all capital letters and centered on a 5-by-8-inch index
card. The card is presented with the type and face down on a bookstand. After
the articles are arranged to the comfort of the subject, the card is turned over by
the examiner with an immediate command to begin. The item is timed from the
word “go” until the pen is lifted from the paper at the end of the sentence. The
item is repeated with the dominant hand using a new sentence.
Instructions –
"Do you require glasses for reading? If so, put them on. Take this pen in your
left hand and arrange everything so that it is comfortable for you to write with
your left hand. On the other side of this card (indicate) is a sentence. When I
turn the card over and say 'Go,' write the sentence as quickly and as clearly as
you can using your left hand. Write, do not print. Do you understand? Ready?
Go."
For Dominant Hand –
"All right, now repeat the same thing, only this time using your right hand. I've
given you a different sentence. Are you ready? Go."
Subtest – II [Card Turning (Simulated Page Turning)]
Procedure –
Five 3-by-5-inch index cards, ruled on one side only, are placed in a horizontal
row 2 inches apart on the desk in front of the patient. Each card is oriented
vertically, 5 inches from the front edge of the desk. This distance is indicated on
the side edge of the desk with a piece of tape.
Timing is from the word "Go" until the last card is turned over. No accuracy of
placement after turning is necessary. The item is repeated with the dominant
hand.
Instructions –
"Place your left hand on the table please. When I say 'Go,' use your left hand to
turn these cards over one at a time as quickly as you can, beginning with this
one (indicate card to extreme right). You may turn them over in any way that
you wish and they need not be in a neat pattern when you finish. Do you
understand? Ready? Go."
For Dominant Hand –
"Now the same thing with the right hand beginning with this one (indicate
extreme left card). Ready? Go."

Subtest – III (Small Common Objects)

Procedure –
An empty 1-pound coffee can is placed directly in front of the subject, 5 inches
from the front edge of the desk. Two 1-inch paper clips (oriented vertically),
two regular-sized bottle caps (each 1-inch in diameter, placed with the inside of
the cap facing up), and two United States pennies are placed in a horizontal row
to the left of the can. The paper clips are to the extreme left and the pennies,
nearest the can. The objects are 2 inches apart.
Timing is from the word "Go" until the sound of the last object striking the
inside of the can is heard. The item is repeated with the dominant hand. The
layout for the dominant hand is a mirror image of the one described, with the
objects to the right of the can.
Instructions –
"Place your left hand on the table please. When I say 'Go,' use your left hand to
pick up these objects one at a time and place them in the can as fast as you can
beginning with this one (indicate paper clip on the extreme left). Do you
understand? Ready? Go."
For Dominant Hand –
"Now the same thing with the right hand beginning here (indicate paper clip
now on the extreme right). Ready? Go."

Subtest – IV (Simulated Feeding)

Procedure –
Five kidney beans of approximately 5/8-inch length are placed on a board*
clamped to the desk in front of the subject 5 inches from the front edge of the
desk. The beans are oriented to the left of center, parallel to and touching the
upright of the board 2 inches apart. An empty 1-pound coffee can is placed
centrally in front of the board. A regular teaspoon is provided.
Timing is from the word "Go" until the last bean is heard hitting the bottom of
the can. The item is repeated with the dominant hand; the beans being placed to
the right of center.
Instructions –
"Take the teaspoon in your left hand please. When I say 'Go,' use your left hand
to pick up these beans one at a time with the teaspoon and place them in the can
as fast as you can beginning with this one (indicate bean on the extreme left).
Do you understand? Ready? Go."
For Dominant Hand –
"Now the same thing with the right hand here (indicate bean on the extreme
right). Ready? Go."

Subtest – V (Checkers)
Procedure –
Four standard-sized (1-1/4 inch diameter) red wooden checkers are placed in
front of and touching a board* clamped to the desk in front of the subject, 5
inches from the front edge of the desk. The checkers are oriented to each side of
the center in a 0000 configuration.
Timing is from the word "Go" until the fourth checker makes contact with the
third checker. The fourth checker need not stay in place. The item is repeated
with the dominant hand.
Instructions –
"Place your left hand on the table please. When I say 'Go,' use your left hand to
stack these checkers on the table in front of you as fast as you can like this, one
on top of the other (demonstrate). You may begin with any checker. Do you
understand? Ready? Go."
For Dominant Hand –
"Now the same thing with the right hand. Ready? Go."

Subtest – VI (Large Light Objects)

Procedure –
Five empty No. 303 cans are placed in front of a board* clamped to the desk in
front of the subject 5 inches from the front edge of the desk. The cans are
spaced 2 inches apart with the open end of the can facing down.
Timing is from the word "Go" until the fifth can has been released. The item is
repeated with the dominant hand.
Instructions –
"Place your left hand on the table please. When I say 'Go,' use your left hand to
stand these cans on the board in front of you, like this (demonstrate). Begin with
this one (indicate can on extreme left). Do you understand? Ready? Go."
For Dominant Hand –
"Now the same thing with the right hand beginning here (indicate extreme right
can). Ready? Go."

Subtest – VII (Large Light Objects)

Procedure –
Five full (1 pound) No. 303 cans are placed in front of a board* clamped to the
desk in front of the subject 5 inches from the front edge of the desk. The cans
are spaced 2 inches apart.
Timing is from the word "Go" until the fifth can has been released. The item is
repeated with the dominant hand.
Instructions –
"Now do the same thing with these heavier cans. Place your left hand on the
table. When I say 'Go,' use your left hand to stand these cans on the board as
fast as you can. Begin here (indicate can on extreme left). Do you understand?
Ready? Go."
For Dominant Hand –
"Now the same thing with your right hand beginning here (indicate can on far
right). Ready? Go."

*A wooden board 4-1/2 inches long, 11-1/4 inches wide and 3/4-inch thick was secured to the desk
with a “C” clamp. The front edge (3/4-inch thickness) of the board was marked at 1/4-inch intervals
for easy reference when placing objects. A center pole (metal rod, 20 inches long, 2 inches high, and
1/2-inch wide) was glued to the board 4-5/8 inches from the front and 2 inches from the front of the
board. This is for a secretary-type chair with upright side and back rail. The front of the center upright
should be marked at 2-inch intervals and at 1-1/2 inch from each end for convenience in placing
objects
Indications & Contraindications
The Jebsen-Taylor Hand Function Test (JTHFT) is extensively employed in
clinical practice and research for measuring fine and gross motor functions of
the hand for everyday activities.
The standardized test is an imitation of activities of daily living and is very
suitable for the measurement of functional hand use across diverse populations.
The indications for employing the JTHFT are presented below.
• Indications
1. Neurological Rehabilitation:
The JTHFT is widely applied to rehabilitation patients following
neurological injuries or illness. These include patients in rehabilitation
for strokes, traumatic brain injury, and spinal cord injuries, especially
those with cervical segments C6–C7, where impairments of hand
functioning are common.
The test allows clinicians to quantitatively measure hand function,
monitor progress over time, and modify interventions accordingly.

2. Rheumatologic and Orthopaedic Conditions:

This is observed in conditions like rheumatoid arthritis, osteoarthritis,
and carpal tunnel syndrome, in which symptoms like hand pain,
stiffness, or structural deformities can restrict activities of daily living.
The JTHFT is helpful in measuring the impact of these conditions on
hand functioning and can be utilized pre- and post-treatment (e.g.,
surgery, splinting, or drug therapy).

3. Developmental and Paediatric Disorders:

In cerebral palsy or congenital hand deformities, the test may give a
functional view of the ability of the child to carry out daily activities
with his or her hands.
It is best suited for older kids who can be instructed and carry out
coherent tasks.

4. Functional Decline with Aging:

The JTHFT is a valuable tool to utilize within geriatric evaluations to
determine age-related deterioration in fine motor function. Its
application is particularly valuable for earlier detection of functional
impairment that can hinder the independence of elderly individuals.
 5. Hand Dominance and Hand Dexterity Test:
The test assesses both the dominant and non-dominant hand and
therefore is beneficial in the detection of unilateral deficits and
bilateral hand function comparison.

6. Pre- and Post-Intervention Evaluation:

The JTHFT serves as an effective tool in evaluating the effectiveness
of surgery, physical and occupational therapy, or the use of prosthetics
and orthotics.

7. Clinical Research and Functional Outcome Studies:

It is widely used in clinical trials and tests to assess hand function and
determine the effectiveness of new treatments or rehabilitation.

Although the JTHFT is very useful and non-invasive in nature, there are some
conditions or situations that may make the test unsuitable or lead to inaccurate
results. The contraindications are mostly concerned with the subject's capacity
to understand or physically perform the test as desired.
• Contraindications
1. Severe Cognitive or Communication Impairments:
Individuals with severe dementia, serious intellectual disabilities,
aphasia, or serious psychiatric illness can find it difficult to follow
directions for a test or to maintain attention on tasks.
Its evaluation requires active participation and frequent use, which is
not possible in such population groups.

2. Severe Upper Limb Paralysis or Flaccidity:

Patients exhibiting complete motor paralysis of the upper limb, as in
the case of very severe cerebrovascular accidents or severe
amyotrophic lateral sclerosis, will not be able to initiate or complete
the assessment tasks.
In such a scenario, performing the analysis could not only yield wrong
results but may even cause frustration or fatigue of the subject.

3. Acute Pain or Inflammation:

Patients with severe hand injury, recent surgery or inflammatory flare
reactions (e.g., active inflammatory rheumatoid arthritis) cannot
 perform repetitive work with their hand without pain, or risk having
tissues damaged.
Testing must be delayed until the acute illness has resolved.

4. Pre-school children (under 6 years old):

The test was designed for children and adults. Its use may not be
suitable for children under the age of 6 years because of their short
attention span, immature motor function, and inability to comprehend
instructions.

5. Behavioural or Emotional Instability:

Individuals with agitation, impulsivity, or non-compliance related to
psychological or neurological disorders cannot be relied upon to
conduct the test.

6. Severe Visual Impairment

The JTHFT involves visual direction (e.g., identifying and handling
objects), individuals with severe visual impairment can be anticipated
to be incapable of carrying out the test tasks as designed, unless
accommodations are provided as needed.

Cost of making
[Link] Item Cost
01. Stopwatch (Mobile Phone) ₹0
02. Black ballpoint pen ₹20
03. White A4 sized sheet ₹12
04. Print cost ₹50
05. Tin Cans ₹200
06. Paper clips ₹30
07. Bottle caps ₹20
08. Two Rupee Coins ₹4
09. Rajma (Kidney Beans) ₹10
10. Tea Spoon ₹20
11. Checkers ₹100
12. Scissor ₹50
13. Glue ₹20
14. Wooden planks ₹500
15. Construction of the JT Board ₹200
16. C Clamps ₹300
 17. Card Board Box ₹30
18. Salt for weights ₹56
TOTAL ₹1622

References
1. Araneda, R., Ebner‐Karestinos, D., Paradis, J., Saussez, G., Friel, K. M.,
Gordon, A. M., & Bleyenheuft, Y. (2019). Reliability and responsiveness
of the Jebsen‐Taylor Test of Hand Function and the Box and Block Test for
children with cerebral palsy. Developmental Medicine & Child Neurology,
61(10), 1182–1188. [Link]
2. Artilheiro, M. C., Fávero, F. M., Caromano, F. A., De Souza Bulle
Oliveira, A., Carvas, N., Voos, M. C., & De Sá, C. D. S. C. (2017).
Reliability, validity and description of timed performance of the Jebsen–
Taylor Test in patients with muscular dystrophies. Brazilian Journal of
Physical Therapy, 22(3), 190–197.
[Link]
3. Jebsen, R. H., Taylor, N., Trieschmann, R. B., Trotter, M. J., & Howard, L.
A. (1969). An objective and standardized test of hand function. PubMed,
50(6), 311–319. [Link]
4. O’Sullivan, S. B., Schmitz, T. J., & Fulk, G. (2019). Physical
rehabilitation. F.A. Davis.
5. Sears, E. D., & Chung, K. C. (2009). Validity and responsiveness of the
Jebsen–Taylor Hand Function test. The Journal of Hand Surgery, 35(1),
30–37. [Link]
 HHS Public Access
Author manuscript
J Hand Surg Am. Author manuscript; available in PMC 2015 April 07.
Author Manuscript

Published in final edited form as:

J Hand Surg Am. 2010 January ; 35(1): 30–37. doi:10.1016/[Link].2009.09.008.

Validity and Responsiveness of the Jebsen-Taylor Hand

Function Test
Erika Davis Sears, MD1 and Kevin C. Chung, MD, MS2
1Resident Physician, Section of Plastic Surgery, Department of Surgery, The University of
Michigan Health System; Ann Arbor, MI
2Professor of Surgery, Section of Plastic Surgery, Department of Surgery, The University of
Author Manuscript

Michigan Health System; Ann Arbor, MI

Abstract
Purpose—The aim of this study is to demonstrate the validity and responsiveness of the Jebsen-
Taylor Hand Function Test (JTT) in measuring hand function in patients undergoing hand surgery.

Methods—A prospective cohort of patients with the following conditions: (1) rheumatoid
arthritis (n=37), (2) osteoarthritis (n=10), (3) carpal tunnel syndrome (n=18), and (4) distal radius
fracture (n=46), were evaluated preoperatively and at 9 – 12 months follow-up. The JTT and
Michigan Hand Outcomes Questionnaire (MHQ) were administered. Correlation and receiver
operating characteristic (ROC) analysis were performed to evaluate the validity of the JTT as a
measure of disability. Effect size and standardized response means (SRM) were calculated to
Author Manuscript

determine responsiveness.

Results—Correlation studies revealed poor correlation of the JTT to MHQ total scores and
subsets that relate to hand function. Patients with high MHQ scores generally perform well on the
JTT; however, patients with good JTT scores do not necessarily have high MHQ scores. ROC
curves for each condition show that the change in JTT total score had poor ability to discriminate
between high and low MHQ score subjects, with area under the curve (AUC) of 0.52 – 0.66 for
each of the conditions. Effect size and SRM for all states showed greater responsiveness with the
MHQ for each condition when compared to JTT.

Conclusions—We found poor correlation between the change in JTT and absolute JTT scores
after surgery when compared to change in MHQ and absolute MHQ scores. In addition, the JTT
has poor discriminant validity based on the MHQ as a reference. This study showed that the time
Author Manuscript

to complete activities does not correlate well with patient reported outcomes. We conclude that the
JTT should not be used as a measure of disability or clinical change after surgical intervention.

Type of Study—Prospective cohort

Level of Evidence—Level III

Corresponding author and reprint requests sent to: Kevin C. Chung, MD, MS, Section of Plastic Surgery, The University of Michigan
Health System, 1500 E. Medical Center Drive, 2130 Taubman Center, SPC 5340, Ann Arbor, MI 48109-5340 Phone: 734-936-5885,
Fax: 734-763-5354, kecchung@[Link].
 Sears and Chung Page 2
Author Manuscript

Keywords
hand surgery outcomes; Jebsen-Taylor Test (JTT); Michigan Hand Outcomes Questionnaire
(MHQ); responsiveness; validity

In the current era of the outcomes movement, many more tools are available to assess
outcomes in the field of hand surgery (1). One such outcomes tool is the Jebsen-Taylor
Hand Function Test (JTT) (2), which was proposed in 1969 to assess impairment and the
effectiveness of treatment for hand conditions. This test was created to provide quantitative
measurements of standardized tasks to assess broad aspects of hand function commonly
used in everyday activities. Norms for age and sex were developed (2). Seven subsets of the
test represent a broad spectrum of hand function, which includes writing, turning over 3x5
inch cards (to simulate page turning), picking up small common objects, simulated feeding,
Author Manuscript

stacking checkers, picking up large light objects, and picking up large heavy objects. To
evaluate patient performance, each subset is timed and can be compared to the established
norms. The JTT has been widely used in the clinical and research setting. By conducting a
Medline literature search of all articles with “Jebsen” in the title or abstract, we found more
than 135 papers published using this test as one of the outcomes tools. Nearly half of these
papers have been published in the last three years, signaling the increasing application of
this test. These papers include conditions such as stroke, spinal cord injury, cerebral palsy,
multiple sclerosis, hand and wrist fractures, carpal tunnel syndrome, osteoarthritis, and
rheumatoid arthritis (3-11).

Standardized outcomes instruments must demonstrate reliability, validity, and

responsiveness to detect change after an intervention (12). Reliability is the ability to obtain
consistent measurements at different points in time given similar patient characteristics.
Author Manuscript

Reliability is often tested by test-retest analysis. Validity is the ability of an instrument to

measure what is intended. Validity can be measured in a variety of quantitative and
qualitative manners. One method to establish validity is to compare a new instrument to a
“gold standard” or previously established instrument that has been validated to measure a
specific characteristic. Responsiveness is the ability of a test to detect clinical change.
Responsiveness is typically measured by effect size or standardized response mean. These
calculations are described in detail in the methods section. It is important that outcomes
measures are reliable, give results that evaluate what is intended, and are able to detect
clinically significant change. Instruments that are easy to use and administer are also ideal.
Jebsen and Taylor’s original article (2) and several subsequent studies have demonstrated
the reliability of this instrument (5, 10, 13). However, despite its widespread use, we were
unable to find studies beyond the original article to affirm the validity of the JTT as a
Author Manuscript

measure of hand function when performing the aforementioned Medline literature search.

Hand function tests vary in the amount of time and clinical support staff needed for their
administration. In our experience, considerable effort is needed to administer the JTT.
Patients spend on average 15 minutes to complete the test, while staff members must also
spend an equivalent amount of time with the patient to administer the test. In a busy hand
surgery practice, using the test as a regular tool to assess hand function can be quite time and

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 Sears and Chung Page 3

resource consuming. Given the effort and money that is invested in the administration of the
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JTT, it is important that clinicians trust this instrument to contribute valid clinical data.

The specific aims of this study are to 1) evaluate the validity of the JTT as a measure of
disability and 2) evaluate the responsiveness of the JTT in measuring hand function in
patients undergoing hand surgery for a variety of conditions, including rheumatoid arthritis,
osteoarthritis, distal radius fracture, and carpal tunnel syndrome. We aim to determine the
validity of using this test to assess disability because the JTT is often used in the literature as
a measure of the ability of patients to perform activities of daily living (ADLs) (2, 5, 14-16).
In addition, we will determine whether the JTT is a responsive measure of global hand
function in patients with varying degree of disability resulting from a variety of common
diseases.

MATERIALS AND METHODS

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Study Design
Data were collected from a prospective cohort of patients (17-20) with the following
conditions: (1) rheumatoid arthritis (RA) (2) osteoarthritis (3) carpal tunnel syndrome and
(4) distal radius fracture, to measure the validity and responsiveness of the JTT. Patients
were evaluated preoperatively (except in the case of patients with distal radius fractures) and
at follow-up period up to one-year postoperatively. Sixty-seven patients with rheumatoid
arthritis were evaluated preoperatively before undergoing silicone metacarpophalangeal
arthroplasty. Forty patients were evaluated at one year postoperatively. Twenty-five patients
with thumb carpometacarpal (CMC) osteoarthritis were evaluated at baseline before
undergoing trapeziectomy with abductor pollicis longus suspension arthroplasty. Eleven
patients were evaluated at one year follow-up. Ninety-three patients with carpal tunnel
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syndrome were evaluated at baseline before carpal tunnel release. Fifty-four patients were
evaluated at mean follow-up of 9 months with a range of 5 to 30 months. One hundred eight
patients with distal radius fractures were evaluated at 3 months status post injury. Sixty-five
patients were re-evaluated at one year status post open reduction and internal fixation. The
goal of treatment for all conditions was to treat the underlying pathology and improve hand
function.

The JTT and Michigan Hand Outcomes Questionnaire (MHQ) domains were measured
preoperatively and at the final follow-up period as part of the research protocol for our
outcomes studies. Patients were excluded from analysis if they did not complete both the
MHQ and JTT and if they were not available at both baseline and follow-up evaluations.
Thirty-seven rheumatoid arthritis patients, 46 distal radius patients, 18 carpal tunnel patients,
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and 10 thumb osteoarthritis patients remained for analysis.

The MHQ is a 37-question, hand-specific outcomes instrument (21) with six domains: (1)
overall hand function, (2) activities of daily living (ADL), (3) pain, (4) work performance,
(5) aesthetics, and (6) patient satisfaction. Each domain except for work is assessed
separately on each hand, with a total score reported for each hand. The MHQ is self-
administered and takes approximately 15 minutes to complete. The MHQ has shown to be a
reliable, valid, and responsive instrument to measure outcomes of hand and upper limb

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conditions (22-26) and has been used concomitantly with the JTT in the four clinical studies
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outlined in this project. Several hand specific patient-rated outcomes instruments are
available for use. The MHQ was chosen for its unique ability to perform analyses based on
overall hand function as well as based on separate domains related to ability to perform
activities (ADL, work performance, and hand function subsets). Each domain is assigned a
score, thus we are able to determine the effect that domains have on overall hand function
and its relation to the JTT. Due to the ability of the test to score each hand individually, the
affected hand that underwent surgery is evaluated separate from the contralateral hand. This
allows us to better determine the effect of the intervention on hand function. Similarly, all
JTT subsets except for writing were evaluated separately for each hand in all patients.

Data Analysis
Data analysis was performed using STATA Data Analysis and Statistical Software (STATA,
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version 10, StataCorp, College Station, TX). All data analysis were performed on each
cohort of patients (carpal tunnel, rheumatoid arthritis, thumb osteoarthritis, distal radius
fracture) separately. Data from the hand that was operated on was assessed separately from
the contralateral hand, with the data presented in this study being the affected side only.
Paired t-tests were performed to detect significance of change of the JTT and the MHQ
scores from baseline to the final follow-up period. Construct validity of the JTT as a
measure of disability was evaluated by generating scatterplots and using Pearson’s
correlation of JTT scores compared to the MHQ domains. In addition to comparing JTT to
the total MHQ score, the JTT score was evaluated against MHQ domains of function, ADLs,
and work performance, as the test is frequently used as a measure of patient’s ability to
perform ADLs.

Analyses with receiver operating characteristic (ROC) curves were performed to compare
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the ability of the JTT score to discriminate among patients who rate hand function as being
good or poor as assessed by the MHQ. ROC curves measure the ability of a test to predict
the outcome of a “reference standard” comparison test that has a dichotomous variable. In
this case, the ROC curves are used to determine the ability of the JTT to discriminate against
positive and negative patient outcomes using the MHQ as the reference comparison. For this
study, positive outcome or normal state of function using MHQ was judged having a score
>75. Whereas a negative outcome or abnormal state of function was judged as having a
score ≤75. ROC curves are generated by varying the cutoff point of a test that makes an
outcome positive or negative. The sensitivity and 1-specificity (false positive) are plotted
based on the predicted outcome for that given cutoff point compared to the reference
standard. For example, a cutoff point of 30 seconds for the JTT will set an abnormal state as
having a score ≥30 seconds and normal state as having a score <30 seconds. The accuracy of
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predicting normal and abnormal states is compared to the accuracy of the MHQ in
determining normal and abnormal state based on having a score greater than or less than 75.
A true positives and false positive are determined and represent one point on the ROC curve.
The cutoff point, which determines positive and negative outcomes are varied across the
entire spectrum of possible JTT scores and this generates a point for every cutoff, which in
turn creates the entire ROC curve. The curve has the ability to tell what JTT cutoff points
have ideal sensitivity and specificity. ROC curves have a corresponding area under the curve

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(AUC) which represents the probability that the JTT will rank a randomly chosen positive
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MHQ instance higher than a randomly chosen negative MHQ instance. The higher the AUC,
the better the test is at predicting positive and negative outcomes based on the reference
standard. For example, for a curve to have an AUC of 1.0, the curve must have 100%
sensitivity and 0% false positives at each point, thus an ideal test. An AUC of 0.5 means that
the test has a 50% probability in predicting positive and negative outcomes when compared
to the reference standard. This is the same as random guessing and would be a poor test. In
general, tests with AUC of 0.75 or greater are considered to have useful discriminative
ability (27).

ROC curves were generated to determine whether change in JTT scores had the ability to
discriminate among patients that had significant change in MHQ scores after surgery;
likewise, ROC curves were generated to compare the ability of absolute JTT scores to
distinguish among patients with abnormal absolute MHQ scores preoperatively and
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postoperatively. Specifically, ROC curves were plotted for each condition to determine
whether JTT change scores could discriminate against patients that had greater than a 20-
point change in the MHQ score. ROC curves were also plotted for each condition to
determine whether the absolute JTT score could discriminate against patients that had MHQ
scores >75 (normal state).

Standardized response mean (SRM) and effect size are measures of responsiveness to
clinical change as a result of treatment. Standardized response mean is calculated as the
mean change divided by the standard deviation of the change scores. Alternatively, effect
size is calculated as mean change divided by the standard deviation of the mean at baseline.
SRM and effect size were calculated to evaluate the responsiveness of JTT and MHQ to
clinical change at final follow-up compared to baseline for all four clinical conditions.
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RESULTS
Total JTT and MHQ and their respective subsets are reported for the affected hand in Table
1. If patients had bilateral disease, the score is reported for the hand in which the patient
underwent surgery. Table 1 shows that patients with each of the four conditions saw a
statistically significant change in mean total MHQ score postoperatively. Patients with RA,
osteoarthritis of the thumb basilar joint, and carpal tunnel syndrome experienced similar
mean change after surgery of approximately 16 – 20 points. Patients with distal radius
fractures had a mean change of 11 points from 3 months after surgery to 1 year
postoperatively. Patients with RA and distal radius fractures saw statistically significant
change in total JTT scores at 1 year follow-up, whereas no statistically significant change in
JTT score was seen postoperatively for patients after carpal tunnel release and treatment of
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thumb osteoarthritis. Thus, patients that have improvement in MHQ score after surgery do
not always have a similar improvement in JTT.

Comparison of the change in total MHQ and JTT scores postoperatively show poor
correlation between the two studies as demonstrated in Table 2, with Pearson’s correlation
coefficient of 0.19 in patients with RA, 0.04 in patients with osteoarthritis, and 0.36 in
patients with distal radius fractures. There is moderate correlation of change in total MHQ

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 Sears and Chung Page 6

and JTT scores for patients with carpal tunnel syndrome, with a correlation coefficient of
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0.59. Correlation between absolute scores at final follow-up is also poor in patients with RA,
osteoarthritis, and distal radius fractures. Again, patients with carpal tunnel syndrome have
moderate correlation in absolute MHQ and JTT scores. Comparing JTT scores to MHQ
subsets that assess function, ADLs, and work, there is no improvement in the measure of
correlation coefficients. Similarly, correlation to the patient satisfaction subset of the MHQ
is also poor in patients with RA, osteoarthritis, and distal radius fractures (range correlation
coefficient 0.10 – 0.30), and has moderate correlation in patients with carpal tunnel
syndrome (correlation coefficient 0.56). Scatterplots were evaluated to further evaluate the
relationship between the two hand function tests to provide qualitative rationale of their poor
correlation. Closer examination of the scatterplots of absolute MHQ and JTT scores, as seen
in Figure 1, show that at higher ends of the scale (MHQ >80), JTT score is in or near normal
range of established norms, which is approximately 16.8 – 51 seconds depending on
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dominance of hand and age group tested (2). This relationship is seen similarly within all of
the conditions examined. Figure 1 also shows that data within JTT scores in the range of
established norms have a large span of MHQ scores, with some patients having very poor
MHQ scores, which is similarly seen in all four patient conditions. A similar phenomenon
can be seen comparing total JTT scores to individual subsets of the MHQ questionnaire.
However, Figure 1 also demonstrates that patients with abnormal JTT (>50) more reliably
have poor MHQ scores. The correlation studies demonstrate that many of the conditions
showed poor correlation to the MHQ total scores and subsets that relate to ability to use the
hand (work, function, ADL). Patients with high MHQ scores generally perform well on the
JTT, and patients with poor JTT generally scored poorly on MHQ. However, patients with
good JTT scores have quite a variety of MHQ scores with many having very low scores.

ROC analysis shows that the change in JTT score and absolute JTT score had poor ability to
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differentiate patients with positive and negative outcomes as measured by the MHQ. Table 3
demonstrates ROC curves that test discriminate ability of the change in JTT total score have
area under the curve (AUC) of 0.52 – 0.66 for each of the four conditions. Likewise Table 4
shows poor discriminate ability of the absolute JTT score to detect patients with MHQ >75
as having a positive outcome in all conditions except distal radius fractures. Patients at
follow-up with RA, osteoarthritis, and carpal tunnel syndrome had AUC values of 0.48, 0,
and 0.65 respectively, with 95% confidence intervals that show no statistically significance
difference when compared to random guessing. The distal radius follow-up group AUC was
0.76, which had a statistically significant difference when compared to random guessing.
The ROC analyses show that the JTT cannot reliably predict positive patient-reported
outcome as assessed by the MHQ.
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Table 5 demonstrates greater effect size and standardized response means with MHQ for
each condition when compared to JTT for all conditions, indicating less ability of the JTT to
detect clinical change compared to the MHQ.

Because of the loss of a fraction of patients at follow-up, our analysis includes only patients
at baseline and follow-up who were able to complete both tests and who were available at
both time points. However, we had concern that excluding some patients may have bias on
the overall result. Thus, we repeated the data analysis using all available data at baseline and

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 Sears and Chung Page 7

follow-up. This analysis included some patients who were able to only complete one of the
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tests and included some patients who may have been lost to follow-up. These patients were
originally excluded from the analysis. We found that the overall results are similar. Both the
JTT and the MHQ have the same statistical significance at baseline and follow-up, with the
change of MHQ after surgery being statistically significant for all conditions and the change
in JTT being statistically significant for RA and distal radius fracture patients only.
Correlation coefficients were similar, with poor correlation coefficients between the JTT and
MHQ with the exception of the carpal tunnel cohort, which had moderate correlation. ROC
analysis for the change in JTT was identical, as the analysis is only performed on patients
that have scores obtained at both points in time. ROC analysis for the absolute JTT score
showed that only the distal radius cohort had area under the curve (AUC) results that had
95% confidence intervals outside the range of random guessing (0.5). This was similar to the
results obtained with the prior analysis. Effect size and standardized response means also
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continue to be greater for the MHQ for all patient cohorts compared to the JTT with the
reanalysis.

DISCUSSION
Hand function can be evaluated with respect to impairment, which would include
abnormalities in measures such as range of motion, grip strength, and other performance
tests. Alternatively, hand function can also be represented by patient-rated disability, or
limitations in physical activities, such as activities of daily living. The MHQ is a measure of
disability. We chose to use the MHQ as opposed to other hand-specific measures of
disability, such as the Disabilities of the Arm, Shoulder, and Hand (DASH) Questionnaire
for several reasons (28). We used the MHQ as a measure of disability because of its ability
to assess each hand separately. This allows one to determine whether the injured hand and
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dominance of the hand has an overall effect on outcomes. We are also able to assess the
effect that patient satisfaction, pain, work, function, ADLs, and aesthetics each have on
overall hand related outcomes.

The JTT has been utilized in the literature as a measure of both impairment and disability.
While the JTT has been shown to be a valid measure of impairment in some conditions (6,
29, 30), other studies have demonstrated poor correlation between the JTT and hand
function measures obtained from patient-centered questionnaires (5, 19, 24, 31). In the
assessment of outcomes, it is important to be aware of the specific disability or impairment
that tools are intended to evaluate and whether what is being measured is important to
patients and physicians. Despite multiple studies that have demonstrated reliability of the
JTT, little has been done to evaluate its validity as a measure of ADLs and hand function,
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while some studies would suggest that it is poorly responsive to clinical change (32, 33).
Similar conclusions were found in this study. We found that correlation coefficients
comparing total JTT scores to total MHQ scores and individual subsets relating to function
are poor among patients with several different hand conditions. The JTT had poor ability to
discriminate among patients reporting high functioning MHQ scores (>75) and large change
in MHQ scores (>20). Lastly, we found that the JTT had less responsiveness to change
compared to the patient-centered MHQ questionnaire.

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 Sears and Chung Page 8

The JTT is a performance-based quantitative evaluation based on patients’ ability to perform

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seven tests, measured in time. Time is used as a measure of dexterity and efficiency of
movement; however, this study has shown that time to complete activities does not relate
well to patient reported outcomes. JTT not only correlates poorly with MHQ, but also
correlates poorly with other measures of patient-reported outcomes (5, 19, 24, 31, 33-36). A
study by Bovend’Eerdt et al. (5) compared the JTT against the nine-hole peg test, also a
timed measure of hand function, which showed excellent correlation between the two timed
tests, but no significant correlation for the two timed tests and the University of Maryland
Arm Questionnaire for Stroke (a patient-reported outcome questionnaire). This study gives
further evidence of poor correlation of a timed hand function test with patient-reported
outcomes.

We found that the JTT does not relate well to patient satisfaction or their perception of their
hand function. In other words, the validity of the JTT in measuring disability is uncertain.
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Patients with JTT scores within the range of established norms have a wide variety of MHQ
scores ranging from high to poor functioning levels. Patient reported questionnaires are
better at identifying poor hand function and are more sensitive to change after treatment. It
is possible that performance tests that focus on the quality of completing a series of tasks
may be better than the time it takes to complete the tasks. The speed of performing tasks is
likely of varying importance to individual patients, which may explain some of the
variability of scores when comparing the JTT to the MHQ. Some patients may complete an
activity within range of established norms, but may be bothered by pain or feeling of
clumsiness of movement. Other patients may not care about the time it takes to complete an
activity, but whether or not they are able to complete the activity at all. Discordance between
the two tests may also relate to the fact that the MHQ also includes characteristics such as
pain, satisfaction, and aesthetics that are likely not captured in the JTT. In addition
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disagreement can be related to the possible lesser sensitivity to change of the JTT. Thus, for
application in clinical practice, the JTT is not practical because it is able to identify some,
but not all patients who report poor hand function.

When using hand function tests in research or routine clinical use, it is important for
clinicians to know precisely what the tool is measuring, and that it is reliable, valid, and
responsive. The JTT has been used in the literature as a measure of impairment and
disability. We found that the JTT does not correlate well to patient-reported outcomes of
disability, including patient satisfaction and domains that relate to work, function, and
activities of daily living as assed by the MHQ. Similarly the JTT is not as sensitive as the
patient-reported responses obtained from the MHQ in detecting change after hand surgery.
This study demonstrates discordance of the JTT and MHQ patient-reported outcomes for
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four conditions, which strengthens our conclusion that the JTT is a poor indicator of patient
improvement after surgery. Based on our results, we conclude that clinicians should not use
the JTT alone to assess efficacy of treatments in hand surgery nor to evaluate ability of
patients to perform activities of daily living.

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 Sears and Chung Page 9

Acknowledgments
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Supported in part by a grant from the National Institute of Arthritis and Musculoskeletal and Skin Diseases (R01
AR047328) and a Midcareer Investigator Award in Patient-Oriented Research (K24 AR053120) (to Dr. Kevin C.
Chung).

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Figure 1.
Scatterplot of Jebsen-Taylor Test (JTT) versus Michigan Hand Outcomes Questionnaire
(MHQ) score in RA patients at 1 year follow-up
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 Sears and Chung Page 12

Table 1

Comparison of mean Michigan Hand Outcomes Questionnaire (MHQ) and Jebsen-Taylor Test (JTT) scores at
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baseline and final follow-up

MHQ JTT

n MHQ SD P JTT SD P
(seconds)

RA
Baseline 37 41 19 51 15

1 year 37 61 22 <0.0001 44 16 0.005

Distal Radius
3 months 46 79 15 33 8

1 year 46 90 13 <0.0001 30 7 0.0006

Carpal Tunnel
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Baseline 18 51 19 39 14

Postop* 18 67 23 <0.0008 40 33 0.87

CMC Arthritis
Baseline 10 48 16 45 18

1 year 10 69 20 0.02 33 4 0.07

RA = rheumatoid arthritis; CMC = carpometacarpal; SD = standard deviation

*
post-operative follow-up ranges average 9 months, range 5-30 months
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Table 2

Correlation of Jebsen-Taylor Test (JTT) score to Michigan Hand Outcomes Questionnaire (MHQ) total score
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and MHQ subsets

Correlation

JTT/MHQ JTT/MHQ JTT/Function JTT/ADL JTT/Work JTT/Satisf

Change Total

RA
Baseline −0.43 −0.50 −0.50 −0.47 −0.39

1 year 0.19 −0.27 −0.27 −0.41 −0.18 −0.10

Distal Radius
3 months −0.38 −0.27 −0.25 −0.49 −0.20

12 months 0.36 −0.30 −0.13 −0.22 −0.29 −0.30

Carpal Tunnel
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Baseline −0.32 −0.43 −0.51 −0.03 −0.09

Postop* 0.59 −0.63 −0.69 −0.68 −0.38 −0.56

CMC Arthritis
Baseline −0.66 −0.62 −0.74 −0.61 −0.60

12 months 0.04 0.20 0.18 0.13 0.11 0.19

Satisf = MHQ satisfaction domain; ADL = MHQ activities of daily living domain; RA = rheumatoid arthritis; CMC = carpometacarpal
*
post-operative follow-up ranges average 9 months, range 5-30 months
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Table 3

ROC (AUC) analysis for Jebsen-Taylor Test (JTT) discriminant ability in patients with Michigan Hand
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Outcomes Questionnaire (MHQ) change >20

ROC Analysis MHQ Change >20

n AUC 95% CI

RA
1 year 37 0.52 0.32 - 0.71

Distal Radius
1 year 46 0.59 0.38 - 0.81

Carpal Tunnel
9 months 18 0.66 0.40 - 0.93

CMC Arthritis
1 year 10 0.58 0.17 - 0.99
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ROC = receiver operating characteristic; AUC = area under the curve; CI = confidence interval; RA = rheumatoid arthritis; CMC =
carpometacarpal
*
post-operative follow-up ranges average 9 months, range 5-30 months
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Table 4

ROC (AUC) analysis for Jebsen-Taylor Test (JTT) discriminant ability in patients with Michigan Hand
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Outcomes Questionnaire (MHQ) score >75

ROC Analysis MHQ >75

n AUC 95% CI

RA
Baseline 37 0.78 0.49 - 1.0

1 year 37 0.48 0.29 - 0.67

Distal Radius
3 months 46 0.71 0.54 - 0.87

12 months 46 0.76 0.62 - 0.91

Carpal Tunnel
Baseline 18 0.56 0.24 - 0.89
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Postop* 18 0.65 0.38 - 0.93

CMC Arthritis
Baseline 21 ** **

12 months 10 0.00 0 - 0.63

ROC = receiver operating characteristic; AUC = area under the curve; CI = confidence interval; RA = rheumatoid arthritis; CMC =
carpometacarpal
*
post-operative follow-up ranges average 9 months, range 5-30 months
**
unable to perform the analysis because there is no area under the curve
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Table 5

Effect size (ES) and standardized response mean (SRM) at final follow-up for Michigan Hand Outcomes
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Questionnaire (MHQ) and Jebsen-Taylor Test (JTT)

MHQ JTT

ES SRM ES SRM

RA 1.05 1.07 0.47 0.49

Distal Radius 0.74 0.91 0.35 0.54

Carpal Tunnel 0.84 0.96 0.05 0.04

CMC Arthritis 1.30 0.93 0.67 0.66

RA = rheumatoid arthritis; CMC = carpometacarpal

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J Hand Surg Am. Author manuscript; available in PMC 2015 April 07.
Brazilian Journal of Physical Therapy 2018;22(3):190---197

Brazilian Journal of
Physical Therapy
[Link]

ORIGINAL RESEARCH

Reliability, validity and description of timed

performance of the Jebsen---Taylor Test in patients
with muscular dystrophies
Mariana Cunha Artilheiro a,∗ , Francis Meire Fávero b , Fátima Aparecida Caromano a ,
Acary de Souza Bulle Oliveira b , Nelson Carvas Junior c , Mariana Callil Voos a ,
Cristina dos Santos Cardoso de Sá d

a
Universidade de São Paulo (USP), Faculdade de Medicina (FMUSP), São Paulo, SP, Brazil
b
Universidade Federal de São Paulo (UNIFESP), Departamento e Neurologia/Neurocirurgia, Departamento de Neurologia Clinica,
São Paulo, SP, Brazil
c
Instituto de Assistência Médica (IAMSPE), Programa de Pós-Graduação em Ciências da Saúde, São Paulo, SP, Brazil
d
Universidade Federal de São Paulo (UNIFESP), Departamento de Ciências do Movimento Humano, Santos, SP, Brazil

Received 15 February 2017; accepted 18 September 2017

Available online 8 December 2017

KEYWORDS Abstract
Muscular dystrophies; Background: The Jebsen---Taylor Test evaluates upper limb function by measuring timed perfor-
Upper extremity; mance on everyday activities. The test is used to assess and monitor the progression of patients
Physical therapy; with Parkinson disease, cerebral palsy, stroke and brain injury.
Disability evaluation Objectives: To analyze the reliability, internal consistency and validity of the Jebsen---Taylor Test
in people with Muscular Dystrophy and to describe and classify upper limb timed performance
of people with Muscular Dystrophy.
Methods: Fifty patients with Muscular Dystrophy were assessed. Non-dominant and dominant
upper limb performances on the Jebsen---Taylor Test were filmed. Two raters evaluated timed
performance for inter-rater reliability analysis. Test---retest reliability was investigated by using
intraclass correlation coefficients. Internal consistency was assessed using the Cronbach alpha.
Construct validity was conducted by comparing the Jebsen---Taylor Test with the Performance
of Upper Limb.
Results: The internal consistency of Jebsen---Taylor Test was good (Cronbach’s ˛ = 0.98). A very
high inter-rater reliability (0.903---0.999), except for writing with an Intraclass correlation coef-
ficient of 0.772---1.000. Strong correlations between the Jebsen---Taylor Test and the Performance
of Upper Limb Module were found (rho = −0.712).

∗ Corresponding author at: Programa de Pós-Graduação em Ciências da Reabilitação, Faculdade de Medicina, Universidade de São Paulo,

Rua Cipotânea, 51, CEP: 05360-000 São Paulo, SP, Brazil.

E-mail: artilheiro.m@[Link] (M.C. Artilheiro).

[Link]
1413-3555/© 2017 Associação Brasileira de Pesquisa e Pós-Graduação em Fisioterapia. Published by Elsevier Editora Ltda. All rights reserved.
Jebsen---Taylor Test for muscular dystrophies 191

Conclusion: The Jebsen---Taylor Test is a reliable and valid measure of timed performance for
people with Muscular Dystrophy.
© 2017 Associação Brasileira de Pesquisa e Pós-Graduação em Fisioterapia. Published by Elsevier
Editora Ltda. All rights reserved.

Introduction in boys with DMD and considered as a sensitive method to

assess DMD progression. However, measurement properties
New pharmacological and therapeutic interventions during were not tested and people with other types of MD were not
the past three decades contributed to a longer survival evaluated.19
of people with Muscular Dystrophy (MD).1,2 Therefore, the We hypothesized that Jebsen---Taylor Test would generate
number of non-ambulatory people with upper limb dysfunc- accurate measures20 of upper limb motor function in people
tion has increased, as has the demand for more accurate with MD. First, we aimed to analyze the reliability, inter-
assessment protocols.2 The lack of instruments to quantify nal consistency and validity of Jebsen---Taylor Test in people
upper limb functional impairments is a challenge faced by with Muscular Dystrophy. Second, we aimed to describe and
health professionals who work with people with MD.3 classify upper limb timed performance in people with MD.
Some tests evaluate upper limb motor function in MD or
specifically in Duchenne Muscular Dystrophy (DMD), but none Methods
evaluate timed performance. The Brooke Scale classifies
upper limb active movements in DMD and Becker muscular
Experimental design
dystrophy (BMD) with a six-point scale.4 However, Brooke
Scale did not quantify functional performance. Dimension 3
This was an observational study using a cross-sectional
of the Motor Function Measure (MFM) has six items referring
design approved by the Universidade Federal de São Paulo
to upper limb function.5 However, in people with less severe
(UNIFESP) Ethics Committee (process 132---193), São Paulo,
MD, the Motor Function Measure might not detect early stage
SP, Brazil.
disabilities and might show scoring ceiling effects. ABILHAND
questionnaire points to the subject’s perception of diffi-
culty performing activities of daily living involving upper Participants
limb functions.6 ABILHAND classifies the tasks as fully or
partially performed, or not performed at all. Upper limb All participants who submitted to clinical and therapeutic
performance is inferred according to the subject’s report treatment by the Brazilian Association of Muscular Dys-
and not specifically tested. The Performance of Upper Limb trophies (ABDIM) were invited to participate (80 people).
Test assesses shoulder, elbow and hand functions in DMD. They had their diagnosis of DMD, BMD, fascioscapulohumeral
Four items of this scale measure timed performance only as dystrophy (FSH), limb-girdle muscular dystrophy (LGMD) or
additional qualitative information, with no impact on the Myotonic Dystrophy type 1 (MD1) confirmed by DNA analysis.
total score.7 Parents/legal guardians signed the consent form.
Timed performance is an accurate functional measure in Two participants were excluded due to having associated
people with DMD.8,9 This evaluation strategy has been used neurological diseases, three were excluded due to participa-
in DMD for functional performance of the lower limbs, for tion refusal by participants/parents/legal guardians, three
example, the six-minute walk test,10 in the North Star Ambu- were excluded due to unavailability, eight were excluded
latory Assessment11 and in the Functional Evaluation Scale due to severe cognitive impairment (i.e. scoring lower than
for Duchenne Muscular Dystrophy.12 The Jebsen---Taylor Test 11 on the Mini-Mental State Examination).21---23 In a previ-
evaluates upper limbs timed performance in seven subtests ous pilot study,22 we observed that a cut-point of 10 points
that represent everyday activities, such as writing, turning (instead of eighteen) could be considered for DMD people.
cards, picking up objects or beans with a spoon, stacking Fourteen participants were excluded due to the absence of
checkers, and picking up light or heavy cans. The subtests upper limb function (i.e. severe cases, bed restricted). The
assess the distal and proximal upper limb performance. minimum upper limb function required to participate in this
Materials are standardized and have low-cost. Assessment study was the ability to grasp objects and not just the pres-
requires about 35 min.13 ence of an active muscle contraction in the hands and fingers
The Jebsen---Taylor Test was translated and cross- without function. Therefore, participants who were not able
culturally adapted into Brazilian Portuguese and showed to grasp objects were excluded.
excellent intra and inter-rater reliability in people with The 50 participants included in this study were diagnosed
stroke, cerebral palsy and Parkinson disease.14---17 Scores are with DMD (72%), LGMD (16%), BMD (6%), MD1 (4%) and FSH
determined by timed performance on functional activities, (2%). In the total sample, 18 (36%) were ambulatory and 32
which differentiates this test from others. The test has nor- (64%) were non-ambulatory. The sample size was calculated
mative data for healthy people18 and was previously applied to achieve 80% power with alpha error of 5% and expected
192 M.C. Artilheiro et al.

intraclass correlation coefficients (ICC) of 0.99714 using the 12 films corresponding to the non-dominant and dominant
ICC Sample Size Package. Thus, the sample size required for attempts by the participants of each six subtests of the
this study was 49 individuals. Jebsen---Taylor Test. Fifteen days after the first assessment,
Two raters participated in this study. Both were physi- the participants were reevaluated by Rater 2.
cal therapists who worked with patients with neuromuscular The validation process was conducted by comparing the
diseases. One of the raters had a master’s degree and three Jebsen---Taylor Test with the test used to assess upper limb
years of clinical MD experience (Rater 1) and the other had function in DMD: the Performance of Upper Limb Module.7
a PhD degree and 15 years of MD clinical experience (Rater Participants were evaluated with Performance of Upper
2). One of the raters (Rater 1) had previously worked with Limb Module in one session. The same positioning adopted
the Jebsen---Taylor Test. to the Jebsen---Taylor Test was used, but only the dominant
upper limb was tested (in accordance with Performance of
Upper Limb Module testing procedures).
Procedures

Participants were evaluated using the Mini-Mental State

Statistical analysis
Examination,21 to screen for cognitive impairment. Then,
hand dominance assessment24 and the Vignos Scale25 for The hypothesis of normal distribution was tested using the
strength and functional measurement were performed to Shapiro---Wilk test. Descriptive data analysis was performed
classify the participants. The analysis of hand dominance to characterize the sample. Tests were run on the R Program
was performed by asking and observing the preferred hand (Windows version 3.3.2). The level of significance of 5% was
during the manipulation of everyday objects such as scissors, adopted.30
comb, toothbrush and pencil.24 The Vignos Scale indicated Inter-rater reliability analysis included two evaluations
the clinical grading of people with neuromuscular diseases of each film by Raters 1 and 2. The analysis was run using
(from 1 to 10; 1 for subtle changes in posture or gait and 10 ICC for two-way models and their respective 95% confidence
for bedridden patients).25 Based on Vignos Scale score, The intervals. Very low reliability was considered if the ICC was
sample was subdivided into ambulatory (Vignos score 1---6) below 0.25, low reliability if between 0.26 and 0.49, mod-
and non-ambulatory (Vignos score 7---10) to describe timed erate if between 0.50 and 0.69, high if between 0.70 and
performance. 0.89 and very high reliability when ICC was higher than 0.90.
The Jebsen---Taylor subtests were administered in the Mann---Whitney tests evaluated the differences between the
following sequence: 1: writing; 2: turning over cards; 3: medians of timed performances measured by the two Raters
picking up small common objects; 4: simulating feeding; and compared the timed performances of ambulatory and
5: stacking checkers; 6: picking up large light objects. The non-ambulatory participants.
sequence, instructions, tasks and materials followed the The internal consistency of the total score of the
norms previously validated in Brazilian Portuguese.13,14 The Jebsen---Taylor Test was evaluated using Cronbach’s alpha.
Jebsen---Taylor Test was applied to people with MD in a pre- The classification of the timed performance using the Vig-
vious pilot study.26 Based on those results, we improved nos scores of ambulatory and non-ambulatory participants
the application protocol of the Test and set the inclu- was shown in percentiles. We classified the timed perfor-
sion/exclusion criteria of the present study. mance as very good (below 20%), good (20---40%), moderate
Participants were assessed individually. They performed (40---60%), bad (60---80%) and very bad (above 80%). The sam-
the subtests seated in their wheelchair or on a chair that ple was subdivided in DMD and other types of MD (FSH, MD1,
allowed the correct positioning of the hips, knees and BMD and LGMD).
ankles, each flexed at approximately 90◦ . A table with an To test the validity of the Jebsen---Taylor Test, Spearman
adjustable height was used to keep the participants elbows correlation coefficients verified the relationships between
at approximately 90◦ flexion, considered to be the most the subtests and the domains of the Performance of Upper
comfortable position for the subject during the test. Each Limb Module.
subtest was performed using the non-dominant upper limb,
and then with the dominant upper limb.13 Time was mea- Results
sured with a mechanical stopwatch as commonly used in
clinical practice. All trials were filmed from the left and Sample characteristics are displayed in Table 1.
right sides using a digital camera on a tripod located approx- Participants with severe upper limb disability (scored as
imately two meters from the subject. The researcher asked 7---8 on the Vignos Scale) showed difficulty during subtests
participants to perform the Jebsen---Taylor Test in a comfort- 3 and 4, which required inserting objects or beans into the
able time to simulate the real condition of the task.27 can. In these cases, subtests 3 and 4 were considered com-
The two raters read the Brazilian Portuguese instructions plete when six small objects or five beans were placed on
for the Jebsen---Taylor Test. They then watched films of the the table, near the can.
patients performing the subtests and discussed the scoring
of the Jebsen---Taylor Test for 8 h.28 The raters were blinded
about participants data and they had no access to partici- Measurement properties analysis
pants’ charts. The raters collected data separately, during
the same similar time period (i.e. in the same week). They The internal consistency of the total score of the
watched the videos on different computers in different labo- Jebsen---Taylor Test was good (Cronbach’s alpha = 0.98).
ratories, but using similar equipment.29 Each rater analyzed To calculate reliability, each Rater analyzed 12 films
Jebsen---Taylor Test for muscular dystrophies 193

Table 1 Sample characteristics: mean and standard deviation of Muscular Dystrophy type, sex, upper limb dominance, age,
Vignos Scale score and Mini-Mental State Examination score of 50 subjects with 5 Types of Muscular Dystrophy.
Muscular Dystrophy type N (%) Sex Dominance Age Vignos MMSE
FSH 1 (2%) 1F 1R 19 7 29
MD1 2 (4%) 1 M/1 F 2R 22.5 (16.26) 1 22 (5.65)
BMD 3 (6%) 3M 3R 25 (1.73) 6 (3.05) 28 (4.04)
LGMD 8 (16%) 7 M/1 F 7 R/1 L 24.5 (9.16) 7 (2.42) 28.5 (0.74)
DMD 36 (72%) 36 M 31 R/5 L 13 (4.18) 7 (2.25) 27 (6.73)
FSH, Facioscapulohumeral Muscular Dystrophy; MD1, Myotonic Dystrophy type 1; BMD, Becker muscular dystrophy; LGMD, limb-girdle
muscular dystrophy; DMD, Duchenne Muscular Dystrophy; N, number; M, male; F, female; R, right; L, left; Vignos, Vignos Scale score;
MMSE, Mini-Mental State Examination score.

Table 2 Jebsen---Taylor Test subtests 1---6. Means and 95% confidence intervals (95% CI), means standard errors (SE) and intraclass
correlation coefficients (ICC) of inter-rater reliability analysis for 50 subjects with 5 types of Muscular Dystrophy.

CV Rater 1 (N = 50) Rater 2 (N = 50) p-value ICC 95% CI SEM CV Rater 1 CV Rater 2
1 ND 0.67 92.13 (8.80) 86.87 (7.88) 0.66 0.772 [0.632, 0.864] 4.20 0.68 0.64
1 D 1.09 63.53 (9.85) 63.48 (9.86) 0.98 1.000 [1.000, 1.000] 0.00 1.10 1.10
2 ND 0.59 13.24 (9.11) 13.23 (1.10) 100 0.998 [0.997, 0.999] 0.41 0.59 0.59
2 D 0.66 11.87 (1.06) 12.04 (1.07) 0.91 0.997 [0.994, 0.998] 0.06 0.63 0.63
3 ND 1.18 23.71 (3.96) 24.35 (4.40) 0.91 0.983 [0.971, 0.991] 0.52 1.18 1.28
3 D 1.01 18.91 (2.71) 17.92 (2.31) 0.78 0.903 [0.836, 0.944] 0.84 1.01 0.91
4 ND 1.42 41.3 (8.30) 42.35 (8.45) 0.93 0.999 [0.998, 0.999] 0.26 1.42 1.41
4 D 1.37 30.77 (5.98) 31.15 (6.08) 0.96 0.999 [0.998, 0.999] 0.19 1.37 1.38
5 ND 0.91 12.58 (1.63) 12.88 (1.63) 0.90 0.997 [0.995, 0.998] 0.09 0.91 0.90
5 D 0.84 9.24 (1.10) 9.37 (1.09) 0.93 0.992 [0.986, 0.995] 0.10 0.84 0.83
6 ND 1.02 18.77 (2.71) 19.02 (2.74) 0.92 0.999 [0.999, 1.000] 0.09 1.02 1.02
6 D 0.95 13.75 (1.85) 14.03 (1.93) 0.92 0.995 [0.992, 0.997] 0.13 0.95 0.98
p-value ≤0.05; ICC, intraclass correlation coefficient (ICC); 95% CI, 95% confidence interval; SEM, standard error of measurement; CV,
coefficient of variation (standard deviation/mean); ND, non-dominant upper limb; D, dominant upper limb.

correspondent to the non-dominant and dominant limb A significant difference was found between ambulatory
attempts of each of the six subtests of the Jebsen---Taylor (n = 7) and non-ambulatory (n = 7) participants with other
Test. ICC values, 95% of confidence interval and standard MD types: non-ambulatory participants showed longer times
error of the means of inter-rater reliability are displayed on non-dominant and dominant upper limbs performances
in Table 2. Subtests showed very high inter-rater reliabil- on subtests 2, 3, and 6. They also differed in dominant
ity of subtests performed with both non-dominant and upper limb performance of subtest 5: a higher median was
dominant limbs, except for the non-dominant upper limb observed in non-ambulatory participants (Table 4).
attempt on subtest 1, which showed high inter-rater reli- Ambulatory (n = 36) and non-ambulatory (n = 11) partici-
ability (Table 2). Therefore, High agreement was observed pants with DMD had their timed performance classified as
between the evaluations of Raters 1 and 2. The correlations very good, good, moderate, bad or very bad. Non-dominant
between shoulder, elbow and wrist domains of the Perfor- and dominant upper limb performances on each subtest are
mance of Upper Limb Module and the Jebsen---Taylor subtests displayed in Table 5.
(i.e. validation analysis) are demonstrated in Table 3.

Discussion
Timed performance analysis
The present study described upper limb timed performance
Timed performance of ambulatory and non-ambulatory par- and analyzed the reliability, internal consistency and validity
ticipants with DMD (n = 36) and other MD types (FSH, MD1, of the Jebsen---Taylor Test in people with Muscular Dystro-
BMD and LGMD; n = 14) is described in Table 4. phy. The good measurement properties found indicated that
The median time to the non-dominant and dominant timed performance could be used to measure the progres-
limb performances on each subtest are shown. A signifi- sion of muscle weakness14 and upper limb motor function
cant difference was found between ambulatory (n = 11) and in participants with MD. The Jebsen---Taylor Test was pre-
non-ambulatory (n = 25) DMD participants: non-ambulatory viously applied in people with DMD by Hiller and Wade,19
participants showed longer times on non-dominant and who identified that short times were indicators of upper
dominant upper limb performances on subtests 2---4 and 6 limb muscles preservation, internal consistency, reliability
(Table 4). and validity. The times on the Jebsen---Taylor Test were cor-
194 M.C. Artilheiro et al.

Table 3 Spearman correlation coefficients between the Performance of Upper Limb (PUL) Module domains (i.e. shoulder, elbow
and wrist) and the Jebsen---Taylor Test subtests (JTT) (1---6) for 50 subjects with 5 types of Muscular Dystrophy.

PUL PUL PUL PUL

Shoulder Elbow Wrist Total
JTT 1 −0.143 −0.156 −0.190* −0.129
Writing
JTT 2 −0.644** −0.677** −0.717** −0.751***
Turning over cards
JTT 3 −0.685** −0.686** −0.821*** −0.816***
Picking up small objects
JTT 4 −0.666** −0.725*** −0.755*** −0.780***
Simulating feeding
JTT 5 −0.700** −0.670** −0.760*** −0.791***
Stacking checkers
JTT 6 −0.736** −0.746** −0.867*** −0.854***
Picking up large objects
JTT −0.587* −0.642* −0.722** −0.712**
Total
PUL, Performance of Upper Limb; JTT, Jebsen---Taylor Test.
* p < 0.05.
** p < 0.01.
*** p < 0.001.

Table 4 Descriptive statistics of the Jebsen---Taylor Test for 50 ambulatory and non-ambulatory participants with Duchenne
Muscular Dystrophy (DMD) and 4 other Muscular Dystrophy types (MD).a

Ambulatory DMD (N = 11) Non-ambulatory DMD (N = 25) p-value

Median P25 P75 Min Max Median P25 P75 Min Max
1 ND 86.45 74.65 100.25 28.13 145.80 74.23 65.00 101.10 47.81 296.60 0.69
1 D 52.23 34.32 66.86 21.56 193.50 40.20 31.43 69.30 15.60 295.40 0.88
2 ND 9.46 5.32 12.33 3.28 35.20 14.28 12.68 19.30 5.85 30.20 0.00
2 D 9.09 5.94 11.79 3.19 14.40 14.09 9.46 15.60 5.41 43.30 0.01
3 ND 8.53 6.79 12.52 5.63 30.20 22.16 13.28 28.50 7.53 122.60 0.00
3 D 9.38 6.38 11.73 5.06 15.70 14.22 12.26 32.80 8.45 94.30 0.00
4 ND 10.19 6.52 14.39 5.06 19.60 26.78 16.34 73.50 9.46 234.60 0.00
4 D 9.54 8.12 11.27 6.29 16.10 18.54 12.09 35.50 7.46 133.60 0.00
5 ND 10.00 6.81 13.3 2.25 23.30 11.05 9.23 14.00 2.69 40.20 0.37
5 D 7.84 5.42 9.92 1.87 12.60 9.46 8.75 12.20 3.75 34.40 0.13
6 ND 7.38 5.22 8.82 4.22 13.30 18.00 11.37 35.90 5.59 69.90 0.00
6 D 7.28 6.22 8.41 3.28 12.40 12.47 9.35 22.60 5.39 37.30 0.00

Ambulatory MD (N = 7) Non-ambulatory MD (N = 7) p-value

Median P25 P75 Min Max Median P25 P75 Min Max
1 ND 48.47 36.78 53.34 24.09 131.69 58.09 46.66 65.9 36.97 140.9 0.23
1 D 21.45 19.46 22.21 13.60 89.99 22.75 19.35 32.3 12.72 49.6 0.56
2 ND 6.21 5.12 7.01 3.41 9.03 8.15 7.41 23.6 5.94 31.4 0.04
2 D 5.67 4.62 6.00 4.31 6.31 8.78 6.80 17.2 5.38 23.3 0.01
3 ND 7.16 6.64 8.87 6.44 14.78 14.47 10.61 61.7 7.90 126.7 0.04
3 D 6.61 6.15 8.23 5.62 11.68 13.63 9.59 39.4 7.40 78.6 0.01
4 ND 10.72 10.07 17.72 9.31 28.81 18.75 13.35 89.4 10.37 281.5 0.11
4 D 9.59 7.87 14.64 7.25 24.22 18.44 13.41 81.7 8.47 214.0 0.11
5 ND 3.16 2.94 3.78 1.92 5.85 6.10 3.90 36.6 2.44 57.7 0.14
5 D 2.40 1.99 2.78 1.29 4.59 5.94 4.62 10.8 2.03 45.9 0.02
6 ND 5.28 4.86 5.45 4.53 10.03 11.06 8.12 53.2 5.12 86.8 0.01
6 D 4.56 4.35 5.62 4.14 12.69 12.14 7.72 25.6 5.38 83.3 0.01
P25, 25th percentile; P75, 75th percentile; min, minimum; max, maximum; ND, non-dominant upper limb; D, dominant upper limb.
a Includes FSH, MD1, BMD, LGMD types of MD.
Jebsen---Taylor Test for muscular dystrophies 195

Table 5 Classification of the non-dominant and dominant upper limb timed performance on the Jebsen---Taylor Test (JTT) of
36 ambulatory and non-ambulatory participants with Duchenne Muscular Dystrophy.
JTT subtest scores Non-dominant Dominant

Ambulatory (N = 11) Non-ambulatory (N = 25) Ambulatory (N = 11) Non-ambulatory (N = 25)

Very good <73 <58 29 <28
Good 73---76 58---71 29---44 28---34
1 Moderate 76---92 71---90 44---52 34---65
Bad 92---106 90---170 52---70 65---143
Very bad >106 >170 >70 >143
Very good <4 <12.3 <5 <9
Good 4---7 12---13 5---7 9---13
2 Moderate 7.31---9.6 13---15 7---10 13---14
Bad 9.6---12 15---20 10---12 14---16
Very bad >12 >20 >12 >16
Very good <6 <12 <6 <12
Good 6---8 12---18 6---8 12---13
3 Moderate 8---10 18---24 8---10 13---16
Bad 10---13 24---35 10---13 16---35
Very bad >13 >35 >13 >35
Very good <6 <14 <7 <12
Good 6---9 14---20 7---9 12---16
4 Moderate 9---14 20---39 9---10 16---24
Bad 14---15 39---80 10---11 24---43
Very bad >15 >80 >11 >43
Very good <4 <7 <5 <7
Good 4---9 7---11 5---7 7---9
5 Moderate 9---12 11---13 7---9 9---10
Bad 12---14 13---15 9---10 10---13
Very bad >14 >15 >10 >13
Very good <5 <11 <6 <9
Good 5---7 11---16 6---7 9---11
6 Moderate 7---8 16---20 7---8 11---14
Bad 8---9 20---37 8---9 14---25
Very bad >9 >37 >9 >25

related to the Performance of Upper Limb Module scores. Participants could perform all subtests of the
Considering that the Performance of Upper Limb Module Jebsen---Taylor Test and did not demonstrate any pain
is the standard assessment for upper limb function, the or discomfort during the procedures. Subtest 1 (i.e. writing)
Jebsen---Taylor Test could be considered valid for measur- was previously considered unsuitable for people with DMD,
ing timed performance. A previous pilot study also found because it might be influenced by cognitive and/or learning
a strong correlation between the Jebsen---Taylor Test and difficulties, often associated with MD, mainly DMD.19 The
Performance of Upper Limb Module.31 present study showed that this activity could be used with
The Jebsen---Taylor Test showed high ICC values, which people with DMD (and other types of MD), as long as the
reflected high agreement between raters. For ICC calcula- subjects could read and write. The assessment of writing,
tion, the variation between participants was divided by the which has motor and cognitive demands, is important for
total variation, which included the variation between par- better understanding of upper limb function. Subtests 3 and
ticipants and the not intended variation (i.e. ‘‘error’’). As 4 required adaptations for people with severe upper limb
the study design involved the evaluation of time by means disability (i.e. scored as 7---8 on the Vignos Scale). They
of filming, the authors believe the error was lower. The were asked to place the six small objects or the five beans
coefficients of variation varied from 0.59 to 1.42. Many high on the table, near the can, instead of inserting objects or
values were found to be due to the variation of the perfor- beans into the can.
mance of each participant and not due to the variation of the All DMD participants and non-ambulatory MD partici-
instrument or rater. Even though the participants showed pants showed increased times to perform subtests of the
high variability in the tests, the raters had high agreement Jebsen---Taylor Test in comparison with the normative data.18
and the test showed good internal consistency. However, ambulatory MD participants exhibited similar
196 M.C. Artilheiro et al.

times when performing the non-dominant and the dominant of timed performance provides normative data for clinical
attempts of subtests 2, 3, 5 and 6 compared to controls. DMD practice and research. Timed performance is a reliable mea-
non-ambulatory participants showed higher times in turning sure for upper limb function in this population.
over cards, picking up small objects, simulating feeding, and
picking up large light objects. For the other MD type groups,
non-ambulatory participants showed longer times in tur- Conflicts of interest
ning over cards, picking up small objects, stacking checkers,
and picking up large light objects. Therefore, these tasks The authors declare no conflicts of interest
were more sensitive in detecting differences in upper limb
performance, as they showed increased times even in less
severe participants. Very few biomarkers involving upper References
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