Assessment for Tactile Perception in Children With Cerebral Palsy

Abstract

Importance: Impaired tactile perception frequently accompanies motor deficits in children with cerebral palsy (CP). Assessing tactile perception precisely for children with CP remains challenging because of a lack of assessments with robust psychometric evidence or standard procedures.

Objective: To develop a standardized assessment tool, the Tactile Perceptual Test (TPT), for measuring tactile perception in children with CP and to examine its psychometric properties.

Design: Observational study design.

Setting: University research laboratory and medical center.

Participants: Children with CP (n = 100) and typical development (TD; n = 50).

Outcomes and Measures: The TPT includes four subtests measuring stereognosis, roughness, hardness, and heaviness. Three comparator instruments, Semmes–Weinstein monofilaments, Two-Point Discrimination, and the stereognosis subtest of the Revised Nottingham Sensory Assessment, were used for convergent validity.

Results: Good test–retest reliability was confirmed for all of the TPT subtests. The values of minimal detectable change were acceptable. Moderate correlations between the TPT and comparator instruments were found, as expected. For known-groups validity, the significant difference was confirmed between children with CP and those with TD.

Conclusions and Relevance: The TPT is a reliable and valid measure for multiple subdomains of tactile perception in children with CP. This tactile assessment may help clarify tactile performance to provide appropriate, precise interventions.

What This Article Adds: The TPT measures tactile perception in children with CP. It has four subdomains of tactile perception that could facilitate prioritization of tactile treatment of specific subdomains and thereby aid in the provision of appropriate interventions.

This study examines the psychometric properties of a standardized assessment tool, the Tactile Perceptual Test, for measuring tactile performance in children with cerebral palsy and for designing appropriate occupational therapy interventions.

Cerebral palsy (CP) is a common physical disability in childhood, with a prevalence of 2 to 3 per 1,000 live births (Oskoui et al., 2013). Clinicians dedicate considerable time and resources to manage motor functions. Although motor impairments are obvious problems and are always targeted in treatment, impaired tactile function often accompanies motor deficits (Auld, Boyd, et al., 2012b; Dan, 2020). Tactile function—localizing and experiencing the various qualities of touch—provides fundamental information for movements, especially in tasks requiring precise motor control (e.g., manual dexterity; Cooper et al., 1995). Over half of children with CP are reported to have impaired tactile function (Cooper et al., 1995; Dan, 2020). Because tactile impairment is correlated with manual dexterity and further affects the performance of daily activities, investigating tactile function is critical when considering rehabilitation approaches for children with CP (Taylor et al., 2018).

Tactile function includes tactile registration and tactile perception (Auld et al., 2011; Dan, 2020). Tactile registration is defined as the initial detection of stimuli. Measures of tactile registration (e.g., the Semmes–Weinstein monofilaments; SWM) have been developed for children with CP (Auld, Ware, et al., 2012; Kuo et al., 2016). Tactile perception is defined as the ability to understand, interpret, and give meaning to the sensory stimulus of an object’s spatial, temporal, and textural characteristics (Auld et al., 2011). The Two-Point Discrimination (TPD) and stereognosis measurements have often been used to represent the spatial domain of tactile perception, whereas the AsTex^® (Miller et al., 2009) or measurements of roughness and hardness have been used to examine modality-specific tactile perception. Currently, the precise assessment and description of tactile perception for children with CP is challenging because of a lack of assessments with robust psychometric evidence or standard procedures (Auld & Johnston, 2018; Taylor et al., 2018). According to previous systematic reports, 40% to 90% of children with CP have deficits in tactile perception (Auld et al., 2014). This wide range may be explained by previous studies having identified tactile impairments with different methodologies and having used various assessment tools for different tactile domains. These inconsistent findings entail limitations for the existing tactile perception measures for children with CP.

First, the existing measures of tactile perception for children with CP are incomplete. To date, only deficits in stereognosis and roughness have been reported in children with CP (Wingert et al., 2008). The frequently used standardized assessments include Boyd’s, Cooper’s, and Klingel’s stereognosis tests (Auld et al., 2011; Cooper et al., 1995; Kuo et al., 2016); the functional Tactile Object Recognition Test (fTORT; Taylor et al., 2018); and the AsTex (Miller et al., 2009). However, other important domains of tactile perception (e.g., hardness or heaviness) that are frequently measured in adults (Dannenbaum et al., 2002; Hsu et al., 2013) remain underreported for children with CP.

Second, investigations of the psychometric properties of existing tactile assessments have been either insufficient or imperfect. For stereognosis, only the reliabilities of Boyd’s, Cooper’s, and Klingel’s methods have been examined in children with CP. The reliabilities of Cooper’s and Klingel’s tests were acceptable (>.78; Cooper et al., 1995; Klingels et al., 2010), whereas Boyd’s test demonstrated a large magnitude of measurement error (Auld, Ware, et al., 2012). In addition, only the construct validity and responsiveness of the fTORT have been investigated (Taylor et al., 2018), and only the test–retest reliability of the AsTex roughness test—intraclass correlation (ICC) = .42—has been confirmed in children with CP (Auld, Ware, et al., 2012). No standardized assessment of tactile perception has been reported to have both sound reliability and good validity in children with CP.

Third, the methodologies for measuring specific tactile perception are not standardized across different studies. For example, in Boyd’s stereognosis test, participants need to recognize daily objects randomly chosen from a set of testing items by the examiner (Auld et al., 2011; Kuo et al., 2016). Children might receive different testing items, so inconsistent item difficulties might lead to large measurement errors. In addition, the AsTex has demonstrated poor test–retest reliability in children with CP (Auld, Ware, et al., 2012). The original AsTex requires participants to actively slide a finger along a surface to discriminate roughness, and it has demonstrated sound reliability in adults (Miller et al., 2009). However, in Auld’s study (Auld, Ware, et al., 2012), the examiner guided the children’s fingers to provide passive sensory input. This modification of the manner of measurement from active to passive touch might lead to poor reliability. Because tactile quality relies heavily on gathering information through active hand exploration, active touch may be a better way to transmit tactile input (Hsu et al., 2013).

Proper interaction between the sensory and motor systems is essential for adequate control of voluntary movement. Thus, it is necessary to develop a standardized assessment for measuring tactile perception in children with CP. The purposes of this study were to develop a new standardized tactile perceptional test—the Tactile Perception Test (TPT)—with four subdomains (stereognosis, roughness, hardness, and heaviness) and an adequate measurement manner (active touch) for children with CP and to examine its psychometric properties, including the test–retest reliability, minimal detectable change (MDC), convergent validity, and known-groups validity.

Method

Study Design and Participants

In this study, we investigated the reliability and validity of a newly developed test, the TPT. To estimate the test–retest reliability, we administered the TPT to 50 children with CP twice within 2 wk. To assess the TPT’s convergent validity, we recruited 100 children with CP. Finally, tactile perceptual data from 100 children with CP and 50 children with typical development (TD) were used to assess the known-groups validity. The inclusion criteria for the CP group were as follows: (1) ages 5–12 yr; (2) a diagnosis of CP; (3) no excessive muscle tone (a Modified Ashworth Scale score ≤2 at any joint of the upper limb); and (4) no history of injections of botulinum toxin type A or operations on the upper extremity within 6 mo. The children with TD were matched by age and recruited through advertisement fliers. Children were excluded if they could not understand or follow the test instructions. Both hands of all participants were tested. Written informed assent and consent were obtained from the children and parents, respectively. Institutional review board approval was obtained from the study sites.

Development of the Tactile Perception Test

The TPT includes four subtests: stereognosis, roughness, hardness, and heaviness. Each child was asked to place one hand within the testing box to explore items actively, without visual input. The dominant hand was measured first, followed by the nondominant hand. To reduce the motor demands, the items selected for testing were daily objects familiar to the child, and testing items were placed on or close to the child’s radial fingers (Auld, Ware, et al., 2012). During the practice trial, children were instructed to manipulate the sample items with visual input until they understood how to perform the task. During the experimental trial, children explored the items without visual or verbal feedback. The four subtests were implemented in a random order, and the reference and testing items were all presented randomly. It takes approximately 20 min to complete the TPT. To prevent fatigue, short breaks were allowed between subtests.

Stereognosis

Both daily objects and geometric blocks, common items in previous studies, were included in this study (Auld, Boyd, et al., 2012b; Cooper et al., 1995; Wingert et al., 2008). Considering that all potential testing items in the stereognosis subtest might be redundant and could not reflect their difficulty levels directly, a process of item confirmation and deduction was implemented first. Ten daily objects (a pen, button, paper clip, cotton swab, spoon, comb, table tennis ball, screw, bead block, and square key) and eight geometric blocks (a circle, triangle, square, rectangle, pentagon, star, cross, and flower) were chosen as a comprehensive item pool for item deduction. To reduce the influences of memory of past experience and mental representation, we introduced the 18 testing items to the participants before the test implementation, and a set of testing items was placed within the participant’s visual field to allow naming or pointing as responses. The responses were marked as correct (score = 1) or incorrect (score = 0).

We conducted Mokken scale analysis (MSA), one form of nonparametric item response theory, first for item deduction (Van der Ark, 2012). Using the mokken package (Version 3.0.6) in R (R Core Team, 2016), we analyzed the scores for both hands of all participants. In MSA, three assumptions of the monotone homogeneity model—unidimensionality, local independence, and monotonicity—were examined first. Once they were confirmed, the advanced model, the double monotonicity model (DMM), could be tested. The DMM requires the additional assumption of invariant item ordering (IIO), which indicates that items can be arranged in order of difficulty (Van der Ark, 2012). The detailed definitions and criteria of the assumptions of the MSA are listed in Table A.1 in the Supplemental Appendix (available online with this article at https://research.aota.org/ajot). The reliability of a Mokken scale is reported with the latent class reliability coefficient (LCRC), which should be ≥.7 to represent a reliable scale (Van der Ark et al., 2011).

Table 1.

Mokken Analysis Results of the Retained Items in the Stereognosis Subtest

Item	M	Item H (H_i )
Spoon	.94	.91
Circle	.93	.84
Cotton swab	.91	.83
Pen	.89	.84
Paper clip	.86	.87
Flower	.82	.88
Pentagon	.74	.87
Cross	.57	.84

Note. Scale H = .86. Monotonicity for all items = 0. Items for which the crit statistic is <40 does not violate the assumption of monotonicity.

Finally, eight items (a spoon, circle, cotton swab, pen, paper clip, flower, pentagon, and cross) passed all assumptions of the MSA, were retained, and were listed in order of difficulty for the stereognosis subtest (Table 1). The eight-item stereognosis subtest demonstrated strong scalability (H = 0.86), which indicated unidimensionality, and no items violated local independence or monotonicity. The observed IIO was high (H^T = 0.72), supporting the hierarchical item ordering. The LCRC was .93, indicating that the eight-item stereognosis subtest was reliable. Thus, the final stereognosis subtest included eight items with scores ranging from 0 (unable to identify any items) to 8 (able to identify all items).

Roughness Perception

For this subtest, we used sandpaper surfaces of different roughness grades adhered to the surface of disks (90-mm diameter, 5-mm thickness). The mean particle sizes of the sandpaper surfaces were 162, 100, 52, 46, 35, 26, 22, 18, and 10 µm. Larger mean particle sizes were perceived as rougher. The coarsest sandpaper (162 µm) and the finest sandpaper (10 µm) were used in a practice trial, in which a child was asked to discriminate which one was rougher. During the experimental trials, the child was first asked to distinguish which of the two sandpaper surfaces—the initial sandpaper (35 µm) or the reference sandpaper (10 µm)—was rougher. If the response was correct, sandpaper with the next smaller mean particle size (26 µm) was presented for comparison with the reference sandpaper (10 µm) in the next trial. The trial would stop when the child chose the wrong one or was unable to discriminate the two particle sizes (e.g., the child reported “I don’t know” or “I can’t tell the difference between the two”). If the response was incorrect, increasingly larger mean particle sizes (46, 52, 100, and 162 µm) would be presented one by one for comparison with the reference sandpaper until the child could discriminate them correctly. The minimum threshold that the children could discriminate was recorded. Each child was tested three times with identical testing procedures, and the median of the thresholds of three trials was used for analysis. The scores of this subtest ranged from 0 (unable to discriminate between 162 µm and 10 µm) to 8 (able to discriminate between 18 µm and 10 µm).

Hardness Perception

Pieces of foam with different hardness levels (Asker F durometer readings of 5, 35, 40, 60, 65, 70, 75, 86, and 89; 10 cm × 10 cm × 5 cm) were used for this subtest. Materials with higher Asker F readings are perceived as harder. The hardest foam (Asker F of 89) and the softest foam (Asker F of 5) were used in a practice trial. The child was asked to discriminate which piece of foam was harder. During the experimental trials, the child was first asked to discriminate which of the two pieces of foam was harder: the initial-level (Asker F of 65) piece or the reference-level (Asker F of 89) piece. The subsequent procedures to identify the minimum threshold were the same as those used in the roughness perception subtest. The scores for this subtest ranged from 0 (unable to discriminate between Asker F of 5 and Asker F of 89) to 8 (able to discriminate between Asker F of 86 and Asker F of 89).

Heaviness Perception

Cans of different weights (110, 115, 120, 125, 130, 135, 140, 145, and 150 g; 45 mm × 70 mm) were used for this subtest. The heaviest can (150 g) and the lightest can (110 g) were used in a practice trial. The child was asked to actively lift and hold the cans. During the experimental trial, the child first needed to discriminate which of the two cans was heavier: the initial-weight can (125 g) or the reference-weight can (150 g). The subsequent procedures to find the minimum threshold were the same as those described earlier. The scores for this subtest ranged from 0 (unable to discriminate between 110 g and 150 g) to 8 (able to discriminate between 145 g and 150 g).

Comparator Instruments

We investigated the TPT’s convergent validity by using four sensory tests that are commonly used with children who have CP: the SWM (Bell-Krotoski et al., 1995), the Static and Moving Two-Point Discrimination tests (sTPD and mTPD, respectively; Dellon et al., 1987), and the stereognosis subtest of the Revised Nottingham Sensory Assessment (rNSA; Wu et al., 2016).

Data Analysis

Descriptive statistics were calculated for each variable for children with TD and children with CP. We examined test–retest reliability with ICCs(3,2). The MDC with a 95% confidence level (MDC₉₅) was also calculated. The MDC₉₅ values were calculated by the following formula: ${MDC}_{95} = S E M \times 1.96 \times \sqrt{2} = S D \times \sqrt (1 - ICC) \times 1.96 \times \sqrt{2},$ where SD is the pooled standard deviation.

We examined convergent validity by using Spearman’s rank correlation coefficients between the scores for each subtest of the TPT and the comparator instruments (SWM, TPD, and rNSA). It was expected that all subdomains of the TPT would have at least low to moderate correlations with all comparator instruments. To investigate the known-groups validity, we examined the differences in tactile perception in the nondominant hands between children with TD and children with CP, using the Mann–Whitney U test.

Results

The demographic characteristics of the participants are listed in Table 2. The ICC values were high for all subtests of the TPT (.90–.94), indicating sufficient reliability for individual comparisons. The MDC₉₅ values for the four subtests ranged from 0.87 to 1.77 for children with CP. These MDC₉₅ values for all subtests were less than 30%, indicating acceptable random measurement error (Smidt et al., 2002).

Table 2.

Descriptive Information of the Participants

Variable	CP (n = 100)	TD (n = 50)	p
Age, mo, M (SD)	103.10 (31.24)	109.95 (24.64)	.15^a
Gender			.82^b
Male	52	27
Female	48	23
Dominant hand			.00^b
Right	61	46
Left	39	4
Type
Hemiplegia	55
Quadriplegia	25
Diplegia	20
MACS level
I	46
II	41
III	10
IV	3

Note. CP = cerebral palsy; MACS = Manual Ability Classification System; TD = typical development.

Independent t test.

χ² test.

For validity, Table 3 provides the correlations between the TPT and comparator instruments for children with CP. All correlations were significant, which met our expectations (rs = .28–.80). Relatively high coefficients were observed between the stereognosis subtest and all comparator instruments. For the known-groups validity, significant differences were found for all four subtests between children with TD and children with CP (Table 4).

Table 3.

Reliability and Validity of the Tactile Perception Test in Children with Cerebral Palsy

TPT Subdomain	Reliability		Validity^a
TPT Subdomain	MDC₉₅ (%)	ICC [95% CI]	SWM	sTPD	mTPD	rNSA
Stereognosis	1.46 (18)	.94 [.90–.97]	−.60	−.71	−.75	.80
Roughness	1.53 (19)	.90 [.81–.94]	−.39	−.47	−.42	.57
Hardness	0.87 (11)	.94 [.89–.96]	−.42	−.50	−.48	.56
Heaviness	1.77 (22)	.92 [.86–.96]	−.28	−.36	−.36	.59

Note. CI = confidence interval; ICC = intraclass correlation coefficient; MDC₉₅ = minimal detectable change; mTPD = Moving Two-Point Discrimination; rNSA = Revised Nottingham Sensory Assessment; sTPD = Static Two-Point Discrimination; SWM = Semmes–Weinstein monofilaments.

For all values under the Validity heading, p < .05.

Table 4.

Comparisons of the Nondominant Hand Between Children With Cerebral Palsy and Children With Typical Development

Variable	NondominantHand		Mann–WhitneyU Test
Variable	CP	TD	z	p
Stereognosis			−7.11	<.001
Range	0–8	7–8
Mdn	7	8
Roughness			−5.12	<.001
Range	0–8	7–8
Mdn	8	8
Hardness			−4.23	<.001
Range	0–8	7–8
Mdn	8	8
Heaviness			−7.04	<.001
Range	0–8	5–8
Mdn	5	8

Note. CP = cerebral palsy; TD = typical development.

Discussion

In this study, we developed the TPT to measure multiple subdomains of tactile perception—namely, stereognosis, roughness, hardness, and heaviness—in children with CP. The TPT demonstrated good test–retest reliability and reasonable MDC₉₅, indicating that the assessment score is stable over a 2-wk interval. For the stereognosis subtest, the ICC was excellent (ICC = .94). Compared with those of previous studies (ICCs =.75–.86; Auld, Ware, et al., 2012; Klingels et al., 2010), this result appears to support our use of consistent testing items instead of random selection to improve the reliability of results. Furthermore, the ICC for roughness in this study (ICC = .90) was also more satisfactory than those of previous studies (.18–.59; Auld, Ware, et al., 2012). This finding also supports our view that tactile perception should be measured actively. The MDC₉₅ values calculated in this study provide reference values to indicate true change scores on the TPT for intervention programs. The MDC₉₅ values showed that change scores of 2 points in the stereognosis, roughness, and heaviness subdomains and 1 point in the hardness subdomain can be considered to indicate true changes, given the 95% confidence level. Thus, children will need to improve by approximately 1 to 2 points in each subdomain to present true improvement. However, the results showed a ceiling effect for children with CP with the Manual Ability Classification System (MACS; Eliasson et al., 2006) Level I (22% for stereognosis, 33% for roughness, and 38% for hardness subtests), implying that the MDC₉₅ values should be used cautiously in children with CP with MACS Level I and that items of greater difficulty are needed for this population. Moreover, the heaviness subtest yielded lower scores than the other subtests, indicating that the items for heaviness are relatively difficult for children to perform. The lack of a ceiling effect for the heaviness subtest implies the adequacy of the difficulty level. Together with the previous results regarding ceiling effects, refinement of the difficulty levels across the different subtests is suggested for future studies.

For convergent validity, all subdomains of the TPT were significantly correlated with the existing standardized tests, supporting its adequate external validity. For stereognosis, the correlation coefficients with other spatial perception tests were relatively higher (rs = .71–.80) than those for other subdomains of the TPT (rs = .36–.59). These results are consistent with our expectation and those of previous studies (Auld, Boyd, et al., 2012b), because stereognosis, TPD, and rNSA are all spatial perception measurements. It is interesting that the correlation coefficients between the TPT and the tactile perception tests (rNSA, sTPD, and mTPD) were higher than those between the TPT and the tactile registration test (SWM). These findings provide evidence that the TPT measures tactile perception; they also indicate that tactile registration and tactile perception are related but separate concepts (Auld et al., 2011). In addition, the known-group validity was confirmed in children with CP; their scores on all subtests of the TPT were lower than those of children with TD. This result supports that the TPT has good known-groups validity to discriminate the affected extremities of children with CP.

The unique value of this study was the selection and ranking of stereognosis items using the MSA model, which provided at least three advantages. First, from a practical perspective, the final test needs only eight items to determine stereognosis performance. This time-saving feature makes the TPT clinically friendly. Second, the eight-item stereognosis subdomain of the TPT showed good unidimensionality, confirming the precise measurement of stereognosis. All items measured the same factor; thus, the item scores can be summed to reflect stereognosis ability. Third, the difficulty level of each stereognosis item can be ordered by mean item scores, which would benefit clinicians and researchers. The order of difficulty (from easy to difficult) was confirmed to be as follows: spoon, circle, button, cotton swab, pen, paper clip, flower, pentagon, and cross. Items with similar difficulty levels were removed, and only those with the best fit were retained. This finding might help busy clinicians to identify adequate and nonredundant items and to arrange the order conveniently.

Several limitations of this study warrant consideration. First, a convenience sample was used. Most of the children with CP (87%) in this study had mild to moderate hand function impairments, with MACS levels of I to II. This might limit the generalizability of the study results to children with CP with severe motor impairments. More children with a wider range of MACS levels should be recruited in future studies. Second, to complete the TPT, children need to understand abstract concepts such as heaviness; hence, it might not be appropriate for and should be used cautiously with those with cognitive impairments. Third, all participants were allowed to engage in active exploration during the TPT to facilitate the transmission of tactile input, so it is difficult to separate the relative contribution of tactile perception from simultaneous components such as proprioception, motor function, and musculoskeletal performance (Auld, Boyd, et al., 2012a). Although strategies to control object familiarization and location were applied to reduce the motor demands, a future study including proprioceptive tests is suggested to investigate the impact of proprioception on active tactile perception tests.

Implications for Occupational Therapy Practice

The results of this study have the following clinical implications for occupational therapy practice:

▪ The TPT is a reliable, valid, and clinically friendly assessment—developed with the subdomains stereognosis, roughness, hardness, and heaviness—that has the potential to be included in regular evaluation to design precise interventions for children with CP.

▪ Each subdomain of the TPT has good reliability and validity, suggesting that occupational therapists can use the individual scores of those tactile perceptional subdomains to understand tactile performance and to design adequate interventional programs.

▪ After selecting items by MSA, occupational therapists could choose only the final eight items to determine stereognosis performance in children with CP.

Conclusion

The TPT is a reliable, valid standardized functional tactile perception test for children with CP. The item difficulties of the stereognosis subtest are provided to enhance clinical feasibility. For both researchers and clinicians, the TPT is recommended for use along with the SWM to fully capture tactile function in terms of registration and perception. The TPT is a comprehensive tactile assessment that could facilitate prioritization of tactile treatment of specific subdomains and thereby aid in the provision of appropriate interventions.

Supplemental Material

Supplemental Appendix

Supplementary material for Assessment for Tactile Perception in Children With Cerebral Palsy

Supplementary material, sj-pdf-1-aot-10.5014_ajot.2023.050106.pdf for Assessment for Tactile Perception in Children With Cerebral Palsy by Kai-Jie Liang, Hao-Ling Chen, Kuo-Lun Huang, Ting-Ming Wang, Jeng-Yi Shieh and Tien-Ni Wang in The American Journal of Occupational Therapy

Footnotes

Acknowledgments

Kai-Jie Liang, Hao-Ling Chen, and Kuo-Lun Huang contributed equally to this work. We thank the children and their families for participating in this study. This project was supported in part by the Ministry of Science and Technology (MOST 107-2314-B-002-049-MY3 to Tien-Ni Wang and MOST 107-2628-E-002-004-MY3 to Hao-Ling Chen).

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