Age and Ageing 1995:24108112 Upperextremity Motor Coordination of Healthy Elderly People JOHANNE DESROSIERS, REJEAN HEBERT, GINA BRAVO, ELISABETH DUTIL Summary Motor coordination is an important prerequisite to adequate upperextremity performance. With the ageing of the population, more and more elderly people are at risk of acquiring upperextremity motor incoordination following sensorimotor deficit. The main objective of the study was to develop normative data on upperextremity motor coordination for elderly people. Three hundred and sixty subjects aged 60 and over were randomly selected and evaluated with the Finger Nose Test. The results revealed a linear decline in the performance of this test with age. Younger, more active and subjectively healthier subjects presented better motor coordination. Some differences were found between sexes and sides. The normative data will help clinicians to identify pathological reduction in motor coordination in an elderly population. Introduction Motor coordination is essential to adequate upperextremity performance. Coordination can be defined as the ability to produce a controlled, accurate and rapid movement [1]. Coordination results from the muscles working harmoniously together in the execution of movements [2]. Bourbonnais et al. [3] integrated these elements in their definition: 'the ability of a given subject to activate the appropriate muscles for the execution of a purposeful movement in an accurate and effective manner'. Good coordination depends not only on muscular work but also on sensory information and body scheme [1, 4]. Coordination is mainly under cerebellar control but it can be affected by many other components of the central nervous system, such as the pyramidal and extrapyramidal systems [5]. According to Poirier [6], coordination is a prerequisite to good manual dexterity. Several methods of measuring motor coordination have been developed using sophisticated laboratory instruments [5], but few of them are used in clinical rehabilitation settings. Clinical quantitative methods used to evaluate motor coordination are mainly tapping tasks [79] and tracking tasks [10]. Usually, upperextremity motor coordination is evaluated by observing patient performance during the execution of accurate, fast and repeated movements of the arm. The FingerNose Test is an example of such a test [5, 11]. Two main variations of the FingerNose Test are used in clinical settings. One consists of the subject repetitively touching his/her nose as fast as possible and fully extending the arm in front of him/herself. The second variation of this test consists of the subject alternately touching his/her nose and another target such as the examiner's finger. In clinical coordination assessment, the two main criteria considered are the speed and the quality of movements (presence of tremor and dysmetria). Swaine and Sullivan [12] studied the reliability of the Finger Nose Test in adults with traumatic brain injury. They concluded that therapists demonstrated poor reliability in assessing the presence of tremor and dysmetria. However, for the time of execution related to the speed of movements, intrarater reliability was estimated at 0.97 for the right side and 0.99 for the left and interrater reliability at 0.92 and 0.91 respectively. Swaine and Sullivan [13] explored the relationship between clinical and instrumental measures of motor coordination with traumatically braininjured subjects. They concluded that, although meaningful correlations were observed, these two methods of testing do not measure the same dimensions but are complementary. However, in clinical settings, instrumental measures are less available and therefore rarely used by clinicians. Some authors have reported that motor coordination is affected by age [7, 14 16]. Women are usually better coordinated than men [7, 15] or no difference is observed between the sexes [16]. In previous research, the dominant hand scored better [7,15] except the male subjects of Potvin et al. [14] who obtained better scores in the nondominant hand. The aforementioned studies involved different tests, methods and age groups which may contribute to the observed differences. All used convenience samples which might not be representative of the normal elderly population.
UPPEREXTREMITY MOTOR COORDINATION 109 With the ageing of the population, more and more elderly people are at risk of acquiring upperextremity sensorimotor impairments such as incoordination. It is important to be familiar with normal ageing in order to identify pathological changes. However, an all too familiar problem in geriatrics is the absence of normative data. The main objective of the present study was to develop normative data on upperextremity motor coordination of the elderly. Secondly, we wanted to analyse whether differences existed between the sexes and between the performance of the two upper limbs. Finally, we wanted to explore potential relationships between good motor coordination and some personal variables such as anthropometries, prior occupational activity, current activity level and selfperceived health. Methods Subjects: A random sample of 360 subjects aged 60 and over, stratified for age (60 69, 7079, 80 and over) and sex, was drawn from the electoral pool of the city of Sherbrooke (Quebec, Canada). Located 100 miles east of Montreal, Sherbrooke is a town of some 76 000 inhabitants, of whom nearly 17% are over 60. Each subject was first contacted by mail and then by telephone to verify eligibility criteria and the subject's willingness to participate in the study. The eligibility criteria were: lucidity, independence in activities of daily living, adequate eyesight and absence of impairment affecting upperlimb function. When a subject refused or was not eligible, another subject was selected until 60 subjects were enrolled per stratum. People who refused to participate in the study even though eligible were asked to reply to a general information telephone questionnaire in order to estimate refusal bias. Questions asked covered age, dominance, height, weight, current activity level and selfperceived health. Each subject was evaluated at the Upper Limb Functional Measurement Laboratory at the Centre de recherche en gerontologie et geriatrie of the Hopital D'Youville de Sherbrooke. Subjects' dominance was evaluated with the Edinburgh Handedness Inventory [17]. Procedure: This research was part of a comprehensive study of elderly upperlimb performance. The assessment procedure began with an interview in order to collect data potentially related to upperextremity performance. These variables were height (cm), weight (kg), hand size (cm), previous work characteristics (active vs. sedentary, high use vs. low use of upper extremities, high vs. low upperextremity strength required, high vs. lowfinedexterity required), selfperceived health (excellent, good, fair, poor), current activity level (very active, active, slightly active, sedentary) and frequency of current manual activities (very often, often, sometimes, seldom/never). The FingerNose Test was the fourth test administered in the evaluation battery, immediately following the Box and Block Test [18], the Purdue Pegboard [19] and the TEMPA [20, 21]. Although the FingerNose Test is frequently used in clinical settings, there is no standardized protocol universally accepted by clinicians. A standardized protocol was therefore developed in order to increase the reliability of the measure. Subjects were seated on a regular height chair without armrests, in front of a wall and positioned with nose 45 cm from a horizontal target. This target was a red circle 2 cm in diameter that could be moved on a vertical axis according to the height of the subject. With their index finger, the subjects were asked to touch nose and target alternately as fast as possible during a 20second period. If the target was not touched in an accurate manner, this nosetarget movement was not recorded so that accuracy of movement could not be sacrificed in order to increase speed of execution. The dominant side was evaluated first. The score recorded was the number of complete nose target repetitions achieved within the allowed time. The subjects were assessed by occupational therapists. Statistical analyses: Means, standard deviations and range values are reported for each sex in three different age groups (6069, 7079, 80 + ). The t test or x 2 were used to compare individuals who participated in the study and those who refused. Simple regression analyses were done in order to determine predicted values and their 95% confidence intervals for women and men according to their age. These intervals for a subject are calculated in this way: Y ± [S(b)] 2 (age age) 2 } where Y is the predicted value; MSE (mean square of the error) a measure of the adequacy of the model; n the size of the sample and S(b) the standard error of the coefficient of the age. Multiple stepwise regression analysis was also performed in order to determine the influence of several independent variables on the performance of a subject on the Finger Nose Test (dependent variable). Results Three hundred and sixty subjects aged 60 94 years (X 73.9) participated in the study. The mean age was 74.1 (SD 8.2) for women and 73.3 (SD 7.8) for men. The participation rate of randomly sampled subjects was 78% (74% for women and 82% for men). Individuals who refused to participate were comparable to those who accepted in terms of age (p = 0.47), dominance (p = 0.83), height (p = 0.06), weight (p = 0.11), sex (p = 0.06), current activity level (0.21) and selfperceived health (p = 0.19). Most of the subjects (91.7%) were righthanded with only, as expected, 6.1% lefthanded and 2.2% ambidextrous. Because of the small number of subjects who were not righthanded, the results were analysed without considering dominance. Table I presents the results of the FingerNose Test for women and men by age group. A higher score implies a better performance. As expected, there is a significant linear decline in motor coordination with age (r=0.52, p< 0.0001). Considering all subject scores, significant differences were found between men and women for the left side (t = 2.66, p= 0.0081), with men being more skilled, while no differences were found on the right side (t = 1.86, p= 0.063). However, analysis by age group (6069, 7079 and 80 + ) indicates that the difference is mainly due to the 70 79 group where men presented higher scores on both sides (p = 0.0277 on the right and p= 0.0075 on the left). No difference between sexes was observed in the 6069 and ^80yearold groups. In addition, the right side of this predominantly righthanded sample was significantly better than the left (t = 4.17, p< 0.0001).
J. DESROSIERS ET AL. Table I. Normative data for women and men on the FingerNose Test (n= 360; 60 per group) (number of complete nose target movements during 20second period) Age group (years) Women 6069 (X = 64.7) 7079 (X = 73.9) 80 + (X = 83.5) Men 6069 (X = 65.0) 7079 (X = 73.4) 80 + (X = 82.9) 30 25 20 15 Mean (SD) range Right hand 24.1 (3.5) 1731 21.1 (4.4) 1234 19.0(3.3) 1028 24.3 (3.8) 1535 22.8 (3.8) 1430 19.6 (4.0) 1029 Left hand 23.2(3.6) 1633 20.6 (4.3) 1134 18.5(3.3) 1228 24.2 (4.1) 1536 22.6(3.7) 1630 19.1 (4.1) 1234 Number of nosetarget movements in 20 seconds Normative data for all scores obtained on the Finger Nose Test by women and men according to age group are presented in Figures 1 and 2. Clinicians can use these figures to compare the performance of their elderly patients to the norms. The same results are presented in Table II as formulae derived from simple regression analyses for calculating the expected scores (predicted value) of women and men on the Finger Nose Test according to their age. Multiple stepwise regression analyses indicate that, among measured variables, three independent variables are significantly related to FingerNose Test scores: age, selfperceived health and current activity level, which explain about 32% of the variance. The younger the subjects, the more they estimate their health to be good or excellent, and the more active they are, the better their upperextremity motor coordination score. Discussion The main objective of this study was to measure the upperextremity motor coordination of elderly people in order to develop normative data for a standardized test used in clinical settings: the FingerNose Test. The sample used was randomly selected from an electoral list and the high participation rate (78%) suggests good representation of the population from which it was drawn. Furthermore, statistical analyses in, Right»ld«Loft»ld«,, Right sldd Lafi tide,, Right»lda Loft ild«, 8069 years 7076 yean 80 years + Age groups J Mean i 2 sd Figure 1. Normative data for upperextremity motor coordination measured by the FingerNose Test for women.
UPPEREXTREMITY MOTOR COORDINATION Number of nosetarget movements in 20 seconds 30 25 20 15 m I Right tide Left «ld«, I 6069 years Mean i 2 id! Right tide Left side, 7079 years Age groups I Right side L«tt»kla, 80 yaars + Figure 2. Normative data for upperextremity motor coordination measured by the Finger Nose Test for men. indicated no significant difference between those who refused and those who accepted in terms of specific variables. Therefore, the norms developed in this study should be representative of an elderly population. This study confirms the results of Kjerland [15], Potvin et al. [14], Bornstein [7] and Verkek et al. [16] that upperlimb motor coordination declines with age. Contrary to these studies which were composed of young and old subjects, our sample was exclusively composed of elderly people. Also, this study included a large number of very old people (120 subjects aged 80 and over) who are often not considered in research protocols. In the present study, sex was associated with coordination, but only in a specific age group. Indeed, men aged 7079 obtained better scores on both sides than women. These results are not consistent with data from other studies [7, 15] done with tapping tests in which women presented better scores than men. Assessing 113 subjects aged 1469, Verkek et al. [16] did not find any difference between sexes. How can we explain the superiority of men over women in this particular 70 79 age group and not in the others? The study sample is representative from the population in which it was selected, which eliminates selection bias. Information bias should also not be considered, since all information was collected uniformly. A cohort bias may however be present here. Indeed, people of 60, 70 and 80 years are different in their living experiences and in their activities which could influence motor coordination. Globally for all subjects, scores are significantly higher on the right side than on the left but these statistical differences are small and do not appear clinically important. When analyses are done by age and sex group, the differences are still present, but only for women in the three age groups. No differences are observed between scores on the right and left sides for men. Because of the wide age stratum (10 years) and of the linear reduction of motor coordination with age, the use of predictive formulae (Table II) produces more precise estimates than the use of the mean and the standard Table II. Predictive equations and 95% confidence interval of the Finger Nose Test for women and men, in relation to age Upper extremity Women Right Left Men Right Left Predictive equations 41.80.28 (age) 7.2 40.0 0.26 (age) 7.2 43.3 0.29 (age) 7.3 45.5 0.32 (age) 7.4 Variability of the estimated score R 2 0.28 0.25 0.26 0.29 Example: The right FingerNose Test score expected for a woman aged 78 is: 41.80.28 (78)= 20 nosetarget movements in 20second period. Variability associated with this score is 7.2. Therefore, the 95% confidence interval around the score expected for a woman of that age is given by (12.8, 27.2).
J. DESROSIERS ET AL. deviation (Table I). Finally, multiple regression analyses suggest that three independent variables may explain the upperextremity motor coordination scores of the subjects in the study. Age is the variable which explains most of the variance, following by selfperceived health and current activity level. These results confirm the importance of being and staying active in order to maintain good upperextremity performance. This study has some limitations. First, the majority of the sample being righthanded, these norms should be used with caution for lefthanded people. Second, the crosssectional design of the study can introduce a cohort bias, people born at the beginning of the century having not lived through the same events and in the same conditions as the younger ones, which might influence their coordination. However, this design does not have an impact on the quality of normative data. Finally, these norms consider the speed of execution of movements of ablebodied people. In the clinical setting, we must also consider the quality of the movements in order to plan treatment. Motor coordination is an important prerequisite to good upperextremity performance. This study demonstrated that ageing is associated with the speed used to execute the Finger Nose Test. Although a cohort bias may be present in this crosssectional study, the normative data presented can be used by clinicians in geriatric rehabilitation settings in order to differentiate between real coordination deficits and the normal reduction of this skill with age. Acknowledgements The authors thank the 360 subjects who agreed to participate in this study. They also thank Daniel Bourbonnais, Associate Professor at the Ecole de readaptation of the Universite de Montreal, and Carmen Moliner, occupational therapist, for their revision of the manuscript. 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Arch Phys Med Rehabil 1994;75:7515. 19. Desrosiers J, Hebert R, Bravo G, Dutil E. The Purdue Pegboard test: normative data for people aged 60 and over. Disabil Rehabil (in press). 20. Desrosiers J, Hebert R, Dutil E, Bravo G. Development and reliability of an upper extremity function test for the elderly: the TEMPA. Can J Occup Ther 1993;60:916. 21. Desrosiers J, Hebert R, Dutil E, Bravo G, Mercier L. Validity of the TEMPA: a measurement instrument for upper extremity performance. Occup Ther J Res 1994;14:26781. Authors' addresses J. Desrosiers, R. Hebert, G. Bravo Centre de recherche en gerontologie et geriatrie, Hopital D'Youville de Sherbrooke, 1036 Belvedere Sud, Sherbrooke (Quebec) J1H4C4 Canada E. Dutil Ecole de readaptation, Universite de Montreal, Canada Received 13 June 1994