The 9-Hole Peg Test detects change in Gaming trial

A big beast of the outcome measurement world has criticised our drive for self-assessment and self-monitoring in pwMS. Why? 

They suggested that the learning effect that occurs with repeated assessments will make it difficult to judge the results of a clinical trial. I disagree. Why? Surely the randomisation process between active and placebo groups will take care of learning effects?

It is clear from the spinal cord injury field that rehabilitation is essential to improve outcomes. Rats with spinal cord injury that are not given tasks to use the affected, or paralysed, limbs don’t recover function. In comparison rats who are given rehabilitation have a remarkable ability to recover function. The same applies to humans with spinal cord injury and surely to pwMS. If you don’t use it you lose it.

Contrary to the status quo we think that getting pwMS to use their hands and limbs will improve outcomes. This is why this study below of using computer games to promote recovery of upper limb function is so important. Alison in our group is currently developing a new upper limb outcome measure for pwMS. Her idea is that the outcome measure will encourage people to improve rather than remain the same or to simply watch themselves deteriorate. In other words, the outcome measure becomes the catalyst to ‘Do It and not Lose It’.

Alison is currently running an online survey to help with her project. If you have the time could you please complete the survey it takes less than 3 minutes. Thank you.

For more information on this research, please read the participant information and leave any questions in the comments field.

Jonsdottir et al. Serious games for arm rehabilitation of persons with multiple sclerosis. A randomized controlled pilot study. Mult Scler Relat Disord. 2017 Oct 28;19:25-29

OBJECTIVES: The feasibility and preliminary evidence for the efficacy of a serious games platform compared to exergame using the Wii for arm rehabilitation in persons with multiple sclerosis (MS) was investigated.

METHODS: A pilot single-blind randomized (2:1) controlled in clinical trial was carried out. Sixteen persons with MS participated (age years 56.8 (SD 12.3), MS-onset years 19.4 (SD 12.3), EDSS 6.5). Ten participants used a serious games platform (Rehab@Home) while 6 participants played with the commercial Wii platform, for four weeks (40min, 12 sessions/4 weeks). Feasibility and user experience measures were collected. Primary outcomes were the 9 Hole Peg Test (9HPT) and the Box and Block test (BBT). Secondary outcomes were the EQ-5D visual analogue scale (EQ-VAS) and the SF-12. Nonparametric analysis was used to verify changes from pre to post-rehabilitation within group and treatment effect was verified with Mann-Whitney U test. P value was set at 0.10 and clinical improvement was set at 20% improvement from baseline.

RESULTS: Serious games were perceived positively in terms of user experience and motivation. There were clinically significant improvements in arm function in the serious games group as measured by 9HPT (38-29.5s, P = 0.046, > 20%) and BBT 32-42 cubes, P = 0.19, > 20%) following the 12 gaming sessions while the exergame group did not improve on either test (9HPT 34.5-41.5s, P = 0.34; BBT 38,5 to 42 cubes, P = 0.34). Only the exergame group perceived themselves as having improved their health. There was a significant between groups treatment effect only in the perception of health (EQ-VAS) (Z = 1.93, P = 0.06) favouring the exergame group.

CONCLUSIONS: Virtual reality in a serious gaming approach was feasible and beneficial to arm function of persons with MS but motivational aspects of the approach may need further attention.


About the author

Prof G

Professor of Neurology, Barts & The London. MS & Preventive Neurology thinker, blogger, runner, vegetable gardener, husband, father, cook and wine & food lover.


  • I sincerely want the Nay Sayers to fail completely because I am convinced of the validity of 'use it or lose it' and that repeated use, or attempts to use hands and limbs is so important. In fact, I'm really angry that it's thought there's anything reasonable about this rationale, particularly when exercise the brain and body regularly is what underpins our health!

    I know my neuro physio would agree with this completely. She's told me that all too often the people she works with have been told 'they can't' or 'should not expect to be able to do xyz' by their HCP. She added that she takes a different view and has never failed to see patients achieve more than is initially anticipated.

    I currently have no difficulties with wrists, hands or fingers, but having picked up on the repeated request to touch my thumb to fingers in assessments, I decided to try and expand on this. Consequently I showed my physio that I'm now able to touch my thumb to fingers at speed, working from opposite digits – in other words, starting with thumb to little finger and thumb to forefinger on the other hand and then tapping each finger in turn, so that each thumb works opposite ways. She responded so positively and said she will share this exercise with other patients.

    Push forward Alison and ProfG with everything you're looking to achieve with regards to upper limb and hand function!

    Merry Christmas.🎄

  • It is important to be able to show that our functions are improving when they are. I recently lost, and then partially regained some hand function, I don't know if I will get the rest back yet. I just failed my DVLA medical on cognition and lost my driving licence and consequently my volunteer job. (In the same week that I fell and fractured my ankle!) I can only reapply to drive if I have medical evidence of improvement. I don't know if or how that is possible but any kind of measuring tool would be helpful. Also, sometimes it is hard to know ourselves if we are improving without the use of a monitoring system.

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