| NIH Toolbox for assessment of neurological and behavioral function |
the nih toolbox: setting a standard for biomedical research.
- Hodes, Richard, Insel, Thomas, Landis, Story. Pages: S1
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nih toolbox for assessment of neurological and behavioral function.
- Gershon, Richard, Wagster, Molly, Hendrie, Hugh, MB, ChB, Fox, Nathan, Cook, Karon, Nowinski, Cindy, MD, PhD. Pages: S2-S6
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input on nih toolbox inclusion criteria: surveying the end-user community.
- Nowinski, Cindy, MD, PhD, Victorson, David, Debb, Scott, Gershon, Richard. Pages: S7-S12
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Objective: The NIH Toolbox is intended to be responsive to the needs of investigators evaluating neurologic and behavioral function in diverse settings. Early phases of the project involved gathering information and input from potential end users.Methods: Information was collected through literature and instrument database reviews, requests for information, consensus meetings, and expert interviews and integrated into the NIH Toolbox development process in an iterative manner.Results: Criteria for instrument inclusion, subdomains to be assessed, and preferences regarding instrument cost and length were obtained. Existing measures suitable for inclusion in the NIH Toolbox and areas requiring new measure development were identified.Conclusion: The NIH Toolbox was developed with explicit input from potential end users regarding many of its key features.(C)2013 American Academy of Neurology
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using the nih toolbox in special populations: considerations for assessment of pediatric, geriatric, culturally diverse, non-english-speaking, and disabled individuals.
- Victorson, David, Manly, Jennifer, Wallner-Allen, Kathleen, Fox, Nathan, Purnell, Christy, Hendrie, Hugh, MB, ChB, Havlik, Richard, Harniss, Mark, Magasi, Susan, Correia, Helena, Gershon, Richard. Pages: S13-S19
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Background: In order to develop health outcomes measures that are relevant and applicable to the general population, it is essential to consider the needs and requirements of special subgroups, such as the young, elderly, disabled, and people of different ethnic and cultural backgrounds, within that population.Methods: The NIH Toolbox project convened several working groups to address assessment issues for the following subgroups: pediatric, geriatric, cultural, non-English-speaking, and disabled. Each group reviewed all NIH Toolbox instruments in their entirety.Results: Each working group provided recommendations to the scientific study teams regarding instrument content, presentation, and administration. When feasible and appropriate, instruments and administration procedures have been modified in accordance with these recommendations.Conclusion: Health outcome measurement can benefit from expert input regarding assessment considerations for special subgroups.(C)2013 American Academy of Neurology
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gustation assessment using the nih toolbox.
- Coldwell, Susan, Mennella, Julie, Duffy, Valerie, Pelchat, Marcia, Griffith, James, Smutzer, Gregory, Cowart, Beverly, Breslin, Paul, Bartoshuk, Linda, Hastings, Lloyd, Victorson, David, Hoffman, Howard. Pages: S20-S24
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The NIH Toolbox for Assessment of Neurological and Behavioral Function (NIH Toolbox) is a set of brief measures for the assessment of cognitive function, emotional health, motor function, and sensory function for use in clinical trials and in epidemiologic and longitudinal studies. Gustatory perception is assessed as 1 of 6 areas of sensory function. A team of 11 scientists with expertise in taste perception selected 2 gustatory measures, 1 of which can be used in young pediatric populations. The measure selected for young pediatric populations assesses sucrose (sweet) taste preference and can also be used across the age span of 5 to 85 years. For adult populations, the selected measure is a regional test, which assesses variability in perceived intensity of quinine hydrochloride (bitter) when applied to the tongue tip as well as perceived with the whole mouth. The team also recommends the regional test for assessing other tastants, such as sodium chloride (salty). Validation studies have demonstrated that the measures modified for the NIH Toolbox correlate with more traditional assessments, and can identify known population differences in gustation.(C)2013 American Academy of Neurology
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vestibular function assessment using the nih toolbox.
- Rine, RoseMarie, Schubert, Michael, Whitney, Susan, Roberts, Dale, Redfern, Mark, Musolino, Mark, Roche, Jennica, Steed, Daniel, Corbin, Bree, Lin, Chia-Cheng, Marchetti, Greg, Beaumont, Jennifer, Carey, John, Shepard, Neil, Jacobson, Gary, Wrisley, Diane, Hoffman, Howard, Furman, Gabriel, Slotkin, Jerry. Pages: S25-S31
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Objective: Development of an easy to administer, low-cost test of vestibular function.Methods: Members of the NIH Toolbox Sensory Domain Vestibular, Vision, and Motor subdomain teams collaborated to identify 2 tests: 1) Dynamic Visual Acuity (DVA), and 2) the Balance Accelerometry Measure (BAM). Extensive work was completed to identify and develop appropriate software and hardware. More than 300 subjects between the ages of 3 and 85 years, with and without vestibular dysfunction, were recruited and tested. Currently accepted gold standard measures of static visual acuity, vestibular function, dynamic visual acuity, and balance were performed to determine validity. Repeat testing was performed to examine reliability.Results: The DVA and BAM tests are affordable and appropriate for use for individuals 3 through 85 years of age. The DVA had fair to good reliability (0.41-0.94) and sensitivity and specificity (50%-73%), depending on age and optotype chosen. The BAM test was moderately correlated with center of pressure (r = 0.42-0.48) and dynamic posturography (r = -0.48), depending on age and test condition. Both tests differentiated those with and without vestibular impairment and the young from the old. Each test was reliable.Conclusion: The newly created DVA test provides a valid measure of visual acuity with the head still and moving quickly. The novel BAM is a valid measure of balance. Both tests are sensitive to age-related changes and are able to screen for impairment of the vestibular system.(C)2013 American Academy of Neurology
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olfactory assessment using the nih toolbox.
- Dalton, Pamela, PhD, MPH, Doty, Richard, Murphy, Claire, Frank, Robert, Hoffman, Howard, Maute, Christopher, Kallen, Michael, PhD, MPH, Slotkin, Jerry. Pages: S32-S36
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The human olfactory system provides us with information about our environment that is critical to our physical and psychological well-being. Individuals can vary widely in their ability to detect, recognize, and identify odors, but still be within the range of normal function. Although several standardized tests of odor identification are available, few specifically address the issues in testing very young children, most of whom are likely to be unfamiliar with many of the odor stimuli used in adult tests and have limited ability to read and identify labels to select among choices. Based on the format of the San Diego Odor Identification Test and the delivery system of the University of Pennsylvania Smell Identification Test, we developed 2 versions of an odor identification test using standardized odor stimuli in a scratch-and-sniff format in which participants match 5 (children) or 9 (adults) odors to pictures representing the odor source. Results from normative testing and validation showed that for most participants, the test could be completed in 5 minutes or less and that the poorer performance among the youngest children and the elderly was consistent with data from tests with larger numbers of items. Expanding on the pediatric version of the test with adult-specific and public health-relevant odors increased the ecological validity of the test and facilitated comparisons of intraindividual performance across developmental stages.(C)2013 American Academy of Neurology
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vision assessment using the nih toolbox.
- Varma, Rohit, MD, MPH, McKean-Cowdin, Roberta, Vitale, Susan, Slotkin, Jerry, Hays, Ron. Pages: S37-S40
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Vision is a sensation that is created from complex processes and provides us with a representation of the world around us. There are many important aspects of vision, but visual acuity was judged to be the most appropriate vision assessment for the NIH Toolbox for Assessment of Neurological and Behavioral Function, both because of its central role in visual health and because acuity testing is common and relatively inexpensive to implement broadly. The impact of visual impairments on health-related quality of life also was viewed as important to assess, in order to gain a broad view of one's visual function. To test visual acuity, an easy-to-use software program was developed, based on the protocol used by the E-ETDRS. Children younger than 7 years were administered a version with only the letters H, O, T, and V. Reliability and validity of the Toolbox visual acuity test were very good. A 53-item vision-targeted, health-related quality of life survey was also developed.(C)2013 American Academy of Neurology
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somatosensation assessment using the nih toolbox.
- Dunn, Winnie, Griffith, James, Morrison, M., Tracy OTD, R, Tanquary, Jennifer, Sabata, Dory, OTD, OTR, Victorson, David, Carey, Leeanne, Gershon, Richard. Pages: S41-S44
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Touch sensation is one element of sensory function. As such, somatosensation is one of the sensory domains included in the NIH Toolbox, which is an assessment battery for measuring a range of human functions including emotional health, sensation, cognition, and motor function. We evaluated a variety of methods for inclusion in the NIH Toolbox main battery. In a convenience sample of 409 participants, we evaluated aspects of kinesthesia, pain, and tactile discrimination. We present results on these measures across the lifespan and discuss implications for future studies that use the NIH Toolbox and these measures.(C)2013 American Academy of Neurology
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audition assessment using the nih toolbox.
- Zecker, Steven, Hoffman, Howard, Frisina, Robert, Dubno, Judy, Dhar, Sumitrajit, Wallhagen, Margaret, PhD, GNP-BC, AGSF, FAAN, Kraus, Nina, Griffith, James, Walton, Joseph, Eddins, David, Newman, Craig, Victorson, David, Warrier, Catherine, Wilson, Richard. Pages: S45-S48
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The NIH Toolbox project has assembled measurement tools to assess a wide range of human perception and ability across the lifespan. As part of this initiative, a small but comprehensive battery of auditory tests has been assembled. The main tool of this battery, pure-tone thresholds, measures the ability of people to hear at specific frequencies. Pure-tone thresholds have long been considered the "gold standard" of auditory testing, and are normally obtained in a clinical setting by highly trained audiologists. For the purposes of the Toolbox project, an automated procedure (NIH Toolbox Threshold Hearing Test) was developed that allows nonspecialists to administer the test reliably. Three supplemental auditory tests are also included in the Toolbox auditory test battery: assessment of middle-ear function (tympanometry), speech perception in noise (the NIH Toolbox Words-in-Noise Test), and self-assessment of hearing impairment (the NIH Toolbox Hearing Handicap Inventory Ages 18-64 and the NIH Toolbox Hearing Handicap Inventory Ages 64+). Tympanometry can help differentiate conductive from sensorineural pathology. The NIH Toolbox Words-in-Noise Test measures a listener's ability to perceive words in noisy situations. This ability is not necessarily predicted by a person's pure-tone thresholds; some people with normal hearing have difficulty extracting meaning from speech sounds heard in a noisy context. The NIH Toolbox Hearing Handicap Inventory focuses on how a person's perceived hearing status affects daily life. The test was constructed to include emotional and social/situational subscales, with specific questions about how hearing impairment may affect one's emotional state or limit participation in specific activities. The 4 auditory tests included in the Toolbox auditory test battery cover a range of auditory abilities and provide a snapshot of a participant's auditory capacity.(C)2013 American Academy of Neurology
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pain assessment using the nih toolbox.
- Cook, Karon, Dunn, Winnie, PhD, OTR, Griffith, James, Morrison, M., Tanquary, Jennifer, Sabata, Dory, OTD, OTR, Victorson, David, Carey, Leeanne, MacDermid, Joy, BScPT, MSc, Dudgeon, Brian, PhD, OTR, Gershon, Richard. Pages: S49-S53
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Objective: Pain is an important component of health and function, and chronic pain can be a problem in its own right. The purpose of this report is to review the considerations surrounding pain measurement in the NIH Toolbox, as well as to describe the measurement tools that were adopted for inclusion in the NIH Toolbox assessment battery.Methods: Instruments to measure pain in the NIH Toolbox were selected on the basis of scholarly input from a diverse group of experts, as well as review of existing instruments, which include verbal rating scales, numerical rating scales, and graphical scales.Results: Brief self-report measures of pain intensity and pain interference were selected for inclusion in the core NIH Toolbox for use with adults. A 0 to 10 numerical rating scale was recommended for measuring pain intensity, and a 6-item Patient Reported Outcome Measurement Information System (PROMIS) short form for measuring pain interference. The 8-item PROMIS Pediatric Pain Interference measure was recommended as a supplemental measure. No specific measure was recommended for measuring pain intensity in children.Conclusions: Core and supplemental measures were recommended for the NIH Toolbox. Additional measures were reviewed for investigators who seek tools for measuring pain intensity in pediatric samples.(C)2013 American Academy of Neurology
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cognition assessment using the nih toolbox.
- Weintraub, Sandra, Dikmen, Sureyya, Heaton, Robert, Tulsky, David, Zelazo, Philip, Bauer, Patricia, Carlozzi, Noelle, Slotkin, Jerry, Blitz, David, Wallner-Allen, Kathleen, Fox, Nathan, Beaumont, Jennifer, Mungas, Dan, Nowinski, Cindy, MD, PhD, Richler, Jennifer, Deocampo, Joanne, Anderson, Jacob, Manly, Jennifer, Borosh, Beth, Havlik, Richard, Conway, Kevin, Edwards, Emmeline, Freund, Lisa, King, Jonathan, Moy, Claudia, Witt, Ellen, Gershon, Richard. Pages: S54-S64
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Cognition is 1 of 4 domains measured by the NIH Toolbox for the Assessment of Neurological and Behavioral Function (NIH-TB), and complements modules testing motor function, sensation, and emotion. On the basis of expert panels, the cognition subdomains identified as most important for health, success in school and work, and independence in daily functioning were Executive Function, Episodic Memory, Language, Processing Speed, Working Memory, and Attention. Seven measures were designed to tap constructs within these subdomains. The instruments were validated in English, in a sample of 476 participants ranging in age from 3 to 85 years, with representation from both sexes, 3 racial/ethnic categories, and 3 levels of education. This report describes the development of the Cognition Battery and presents results on test-retest reliability, age effects on performance, and convergent and discriminant construct validity. The NIH-TB Cognition Battery is intended to serve as a brief, convenient set of measures to supplement other outcome measures in epidemiologic and longitudinal research and clinical trials. With a computerized format and national standardization, this battery will provide a "common currency" among researchers for comparisons across a wide range of studies and populations.(C)2013 American Academy of Neurology
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motor assessment using the nih toolbox.
- Reuben, David, Magasi, Susan, McCreath, Heather, Bohannon, Richard, EdD, PT, Wang, Ying-Chih, PhD, OT, Bubela, Deborah, PhD, PT, Rymer, William, MD, PhD, Beaumont, Jennifer, Rine, Rose, Marie PT, PhD, Lai, Jin-Shei, PhD, OTR, Gershon, Richard. Pages: S65-S75
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Motor function involves complex physiologic processes and requires the integration of multiple systems, including neuromuscular, musculoskeletal, and cardiopulmonary, and neural motor and sensory-perceptual systems. Motor-functional status is indicative of current physical health status, burden of disease, and long-term health outcomes, and is integrally related to daily functioning and quality of life. Given its importance to overall neurologic health and function, motor function was identified as a key domain for inclusion in the NIH Toolbox for Assessment of Neurological and Behavioral Function (NIH Toolbox). We engaged in a 3-stage developmental process to: 1) identify key subdomains and candidate measures for inclusion in the NIH Toolbox, 2) pretest candidate measures for feasibility across the age span of people aged 3 to 85 years, and 3) validate candidate measures against criterion measures in a sample of healthy individuals aged 3 to 85 years (n = 340). Based on extensive literature review and input from content experts, the 5 subdomains of dexterity, strength, balance, locomotion, and endurance were recommended for inclusion in the NIH Toolbox motor battery. Based on our validation testing, valid and reliable measures that are simultaneously low-cost and portable have been recommended to assess each subdomain, including the 9-hole peg board for dexterity, grip dynamometry for upper-extremity strength, standing balance test, 4-m walk test for gait speed, and a 2-minute walk test for endurance.(C)2013 American Academy of Neurology
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emotion assessment using the nih toolbox.
- Salsman, John, Butt, Zeeshan, Pilkonis, Paul, Cyranowski, Jill, Zill, Nicholas, Hendrie, Hugh, MB, ChB, Kupst, Mary, Kelly, Morgen, Bode, Rita, Choi, Seung, Lai, Jin-Shei, PhD, OTR, Griffith, James, Stoney, Catherine, Brouwers, Pim, Knox, Sarah, Cella, David. Pages: S76-S86
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One of the goals of the NIH Toolbox for Assessment of Neurological and Behavioral Function was to identify or develop brief measures of emotion for use in prospective epidemiologic and clinical research. Emotional health has significant links to physical health and exerts a powerful effect on perceptions of life quality. Based on an extensive literature review and expert input, the Emotion team identified 4 central subdomains: Negative Affect, Psychological Well-Being, Stress and Self-Efficacy, and Social Relationships. A subsequent psychometric review identified several existing self-report and proxy measures of these subdomains with measurement characteristics that met the NIH Toolbox criteria. In cases where adequate measures did not exist, robust item banks were developed to assess concepts of interest. A population-weighted sample was recruited by an online survey panel to provide initial item calibration and measure validation data. Participants aged 8 to 85 years completed self-report measures whereas parents/guardians responded for children aged 3 to 12 years. Data were analyzed using a combination of classic test theory and item response theory methods, yielding efficient measures of emotional health concepts. An overview of the development of the NIH Toolbox Emotion battery is presented along with preliminary results. Norming activities led to further refinement of the battery, thus enhancing the robustness of emotional health measurement for researchers using the NIH Toolbox.(C)2013 American Academy of Neurology
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norming plans for the nih toolbox.
- Beaumont, Jennifer, Havlik, Richard, Cook, Karon, Hays, Ron, Wallner-Allen, Kathleen, Korper, Samuel, Lai, Jin-Shei, Nord, Christine, Zill, Nicholas, Choi, Seung, Yost, Kathleen, Ustsinovich, Vitali, Brouwers, Pim, Hoffman, Howard, Gershon, Richard. Pages: S87-S92
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Objective: The NIH Toolbox for Assessment of Neurological and Behavioral Function (NIH Toolbox) is a comprehensive battery of brief assessment tools. The purpose of this article is to describe plans to establish normative reference values for the NIH Toolbox measures.Methods: A large sample will be obtained from the US population for the purpose of calculating normative values. The sample will be stratified by age (ages 3-85 years), sex, and language preference (English or Spanish) and have a total sample size of at least 4,205. The sample will include a minimum of 25-100 individuals in each targeted demographic and language subgroup.Results: Norming methods will include poststratification adjustment calculated using iterative proportional fitting, also known as raking, so that the weighted sample will have the same distribution on key demographic variables as the US population described in the 2010 Census.Conclusions: As with any set of norms, users should be mindful of the reference population and make conclusions consistent with the limitations of normative sampling, since it is not a probability-based sample. However, the NIH Toolbox norming study has been designed to minimize bias and maximize representativeness and precision of estimates. The availability of a 'toolbox' of normed measures will be an important foundation for addressing critical research questions in neurologic and behavioral health.(C)2013 American Academy of Neurology
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