Full Length Article| Volume 35, ISSUE 4, P581-589, October 2022

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The Neurological Hand Deformity Classification: Construct validity, test-retest, and inter-rater reliability

Published:March 29, 2021DOI:


      • The NHDC is a valid measure of the construct of hand deformity.
      • Test-retest reliability coefficients demonstrate that the NHDC is stable between repeat administrations.
      • Inter-rater reliability coefficients demonstrate that the NHDC can be used reliably by raters.
      • It is recommended that the NHDC is used to classify hand deformity in children with cerebral palsy.



      The Neurological Hand Deformity Classification (NHDC) is an impairment-based tool that classifies hand deformity into one of two ordinal scales: flexion or extension deformities. Classification is made from live observation or from recorded video footage. Differentiation between the levels is determined by wrist position and wrist and finger movement.


      To examine aspects of validity and reliability of the NHDC.

      Study design

      A measurement study design.


      Data from a convenience sample of 127 children with cerebral palsy, 66 males: 61 females, ranging in age from 8 months to 15 years, across all Manual Ability Classification System levels I to V, were analyzed. Construct validity was assessed by testing predetermined hypotheses of relationships between the NHDC and measures of body function and activity measures with observed performance using the Chi Squared Test of Independence and Spearman Correlation Coefficient. Test-retest and inter-rater reliability were assessed by calculating agreement between repeated measures and paired raters using weighted kappa and Cohen's kappa with 95% confidence intervals.


      Predicted hypotheses for the NHDC were met in nine of 10 Spearman's rho correlations with body structure measures and in 2 of 7 correlations with activity measures. Test-retest for flexion deformities: κw = 0.84; 95% CI 0.70-0.98; and extension deformities: κ = 1.0; 95% CI 1.0-1.0 was good to excellent; inter-rater reliability for flexion deformities: κw = 0.76; 95% CI 0.67-0.85; and extension deformities κ = 0.75; 95% CI 0.43-1.0 was moderate to excellent.


      Expected relationships between the NHDC and other measures, stability between repeated measures and acceptable between-rater agreement supports confidence classifying hand deformity in children with cerebral palsy with the NHDC.



      ABILHAND (ABILHAND-Kids questionnaire), AROM (Active range of motion), Box and Blocks (Box and block test of manual dexterity), COSMIN (COnsensus-based Standards for the selection of health Measurement Instruments), CP (Cerebral Palsy), DPA (Dynamic positional analysis), ICF (International Classification of Functioning, Disability and Health), iWHOT (Infant wrist hand orthosis trial), MACS (Manual Ability Classification System), MAS (Modified Ashworth Scale), MIT (Minimizing Impairment Trial), MTS (Modified Tardieu Scale), NHDC (Neurological Hand Deformity Classification), PEDI-CAT (The Pediatric Evaluation of Disability – Computer Aided Test), PROM (Passive range of motion), SHUEE (Shriner's Hospital Upper Extremity Evaluation)
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      JHT Read for Credit

      Quiz: # 900

      Record your answers on the Return Answer Form found on the tear-out coupon at the back of this issue or to complete online and use a credit card, go to There is only one best answer for each question.
      • # 1.
        The NHDC distinguishes between
        • a.
          neurological and orthopedic causes of deformities
        • b.
          open and closed hand deformities
        • c.
          flexion and extension deformities
        • d.
          supination and pronation deformities
      • # 2.
        Construct validity was tested using the
        • a.
          Spearman Correlation Coefficient and the Chi Squared Test of Independence
        • b.
          two ICCs
        • c.
          an ANOVA and an ICC
        • d.
          none of the above
      • # 3.
        Cohen's Kappa was used to assess
        • a.
        • b.
        • c.
          intra-rater reliability
        • d.
          inter-rater reliability
      • # 4.
        The measurement study followed __________ guidelines
        • a.
          Philadelphia Children's Hospital
        • b.
        • c.
        • d.
      • # 5.
        Validity and reliability analyses gave the investigators confidence in the use of the NHDC as a classification tool
        • a.
          not true
        • b.
      When submitting to the HTCC for re-certification, please batch your JHT RFC certificates in groups of 3 or more to get full credit.