Sensation Domain - NIH Toolbox

Supported by
NIH Toolbox
Assessment of Neurological and Behavioral Function
Sensation Domain
Howard J. Hoffman
Unveiling the NIH Toolbox
Bethesda, MD
September 10, 2012
For more information, please
visit www.nihtoolbox.org
This project is funded in whole or in part with Federal funds from the Blueprint for Neuroscience Research and the Office of Behavioral
and Social Sciences Research, National Institutes of Health, under Contract No. HHS-N-260-2006-00007-C.

I am a Federal employee with no outside
activities or conflicts of interest to disclose.
Epidemiology Program
DSP, NIDCD, NIH

Olfaction
Vestibular
Vision
Somatosensation
Audition
Gustation

Definitions – what is it?
Identification & evaluation of tools
Selection of optimal tools
► Easy, perform in 5-7 minutes by inexperienced person
► Valid, reliable measure
► The Shed – Toolbox Supplemental Measures
Create and validate during 1.5 years
Ready for norming

The ability to see and to hear contributes immeasurably
to public health and the quality of life.
Vision and hearing can affect . . .
• independence in daily life
• educational success and employment opportunities
• workplace productivity and safety
• social and mental health
Based on Healthy People 2010 statistics:
21 million (10%) U.S. adults are visually impaired &
36 million (17%) U.S. adults report trouble hearing

Definition
The ability to detect sound and use it functionally.
Toolbox Measures
Words-In-Noise (WIN): English version (Wilson, 2003) and
Spanish version (McArdle et al, 2009)
• monosyllabic, high-frequency words (e.g., red, mouse)
• 7 signal-to-babble ratios (multi-talker)
• ears tested separately, randomized order

Hearing Threshold Test – Automated Audiometry for
the NIH Toolbox (AANT)
• circumaural headphones & personal computer
• thresholds in each ear at 6 frequencies –
500, 1000, 2000, 4000, 6000, & 8000 Hertz
• validation – limited at this time
Hearing Handicap Inventory for Adults/Elderly
(HHIA/HHIE) (Newman et al, 1990)
• subject (or proxy) answers 12 questions about hearing problems
• 3-point answer scale: “Yes” / “Sometimes” / “No”
• sample question… “Does a hearing problem cause you difficulty when
listening
to the TV or radio?”
Tympanometry handheld device (Maico Otowave)

Audition (Hearing) Team
Title
Steve Zecker, Team Leader
Northwestern University
Sumit Dhar
Northwestern University
Judy Dubno
Medical University of South Carolina
David Eddins
University of South Florida
Robert Frisina, Jr.
University of South Florida
James Griffith
Northwestern University
Howard Hoffman
NIDCD, NIH
Nina Kraus
Northwestern University
Robert Margolis
University of Minnesota
David Victorson
Northwestern University
Margaret Wallhagen
University of California, San Francisco
Joseph Walton
University of South Florida
Richard Wilson
Mountain Home VA Medical Center -TN

Definition
Sense of light-derived stimuli that provides a personal
conscious representation of the environment.
Toolbox Measure
Static Visual Acuity (SVA) – central visual acuity,
computerized test
Supplemental Measure
Vision-Related Quality of Life survey (VRQOL) –
new instrument for self-reported functional impact

Static Visual Acuity (ages 3-85)
HOTV: Children 3 to 6 years: ETDRS: Ages 7 to 85 years:
► ETDRS optotype derived from the Early Treatment for Diabetic Retinopathy
Study
► Both eyes tested simultaneously to save time. Subjects asked to wear
corrective lenses for distance vision if normally worn, since focus is on
everyday functioning.
► SVA computerized software mimics ETDRS chart testing; subject sits 12.5
feet away from 19 inch computer screen.

Supplemental Measure
► Self-reported instrument (new)
► For use by adults 18-85 years of age
► Based on review of 12 existing, validated questionnaires
► 53 items selected using PROMIS method to assess 6
domains:
1) color vision
2) distance vision
3) near vision
4) ocular symptoms
5) psycho/social functioning
6) role performance
► Construct validation to NEI-VFQ

Vision Team
Title
Rohit Varma, Team Leader
University of Southern California
Eileen Birch
Retina Foundation of the Southwest
Karen Cruickshanks
University of Wisconsin
Ron Hays
University of California, Los Angeles
Christopher Johnson
University of Iowa
Paul Lee
University of Michigan
Maureen Maguire
University of Pennsylvania
Robert Massof
The Johns Hopkins University
Roberta McKean-Cowdin
University of Southern California
Cynthia Owsley
University of Alabama – Birmingham
Michael Repka
The Johns Hopkins University
Jerry Slotkin
Northwestern University
Susan Vitale
National Eye Institute, NIH
Michael Wall
University of Iowa

Balance disorders make one feel unsteady or dizzy, as if
moving, spinning, or floating, even if standing still or lying down.
Based on the 2008 National Health Interview Survey . . .
33 million (15%) U.S. adults reported dizziness/balance
problems during past year and had a 5-fold risk of falling.
► The most bothersome symptoms were reported as:
– Unsteadiness or imbalance (28%)
– Feeling lightheaded (18%)
– Feeling one is about to pass out (16%)
– Vertigo or spinning feeling (14%)
– Blurred vision when moving head (5%)
– Other (19%)
Source: Hoffman et al., Barany Society Proceedings, 2010.

Definition:
Balance sense is critical for maintaining spatial orientation
and posture. The vestibular system contributes to gaze
stabilization and balance ability.
Toolbox Measures (of inner ear vestibular
function):
Dynamic Visual Acuity (DVA) (with Vision Team) –
► Vestibulo-ocular reflex (VOR) assessed by gaze stability
Multi-Condition Standing Balance Test
(with Motor Domain Team) –
► Vestibulo-spinal system assessed by sway measures
using computerized accelerometry

DVA
headgear –
rate sensor
attached to
headband
Visual acuity
head stable
head rotating L, R @ 180 deg/sec
score = static – dynamic acuity “level”
Rate of movement
accelerometer, on head band –
controls for correct rate
Shown to be reliable and valid

Measures sway velocity –
6 conditions (45 seconds trial)
Eyes open / closed on solid floor or 4”
foam pad; tandem stance
Reliable and valid (correlated with
force plate, r = 0.77 – 0.98)
Sensitive to age and discriminated
subjects w/ vestibular hypofunction

Balance / Vestibular Team
Title
Rose Marie Rine, Team Leader
Specialty Therapy LLC, Jacksonville, FL
Marshall University, West Virginia
John Carey
The Johns Hopkins University
Howard Hoffman
NIDCD, NIH
Gary Jacobson
Vanderbilt University
Gregory Marchetti
Duquesne University
Mark Musolino
Vital Clip, Pittsburgh
Mark Redfern
University of Pittsburgh
Michael C. Schubert
The Johns Hopkins University
Neil Shepard
Mayo Clinic, Rochester, MN
Jerry Slotkin
Northwestern University
Susan Whitney
University of Pittsburgh
Diane Wrisley
Lynchburg College, VA

The senses of smell and taste monitor the intake into
the body of all the body’s nutrients.
The senses of smell and taste . . .
• determine flavor and palatability of foods and beverages,
• provide early warning of danger from toxic fumes,
smoke, spoiled food, or poisons,
• influence salt and fat consumption that contributes to chronic
illnesses and conditions (e.g., hypertension and obesity),
• provide hedonic pleasures that enhance the quality of life.
►14 million (7%) U.S. adults have impaired sense of smell
►25% of U.S. population can’t taste the “bitterness” of PTC/PROP
Sources: Bartoshuk et al., 1998; Murphy et al., 2002; Schubert et al., 2012.

Definition:
Ability to detect and identify airborne chemicals.
Function of the olfactory system in humans:
The sense of smell provides information about our environment
critical to our health and well-being. We can discriminate over
5,000 different odorant molecules.
Includes…
► ability to detect odor sensation … not assessed in the
Toolbox
► to recognize odor quality … not assessed in the Toolbox
to identify the source, i.e., name or recognize familiar odorants

Toolbox Measure
Odor identification test – scored as the percent of
correctly identified odors.
Child Version
• Lemon
• Play Doh
• Chocolate
• Bubble Gum
• Popcorn
(ages 3–9 years)
Adult Version
All items in child version plus
• Coffee
• Smoke
• Natural Gas
• Flower
(ages 10–85 years)

“Scratch and Sniff”
smell tests
◄ Toolbox Odor ID test has been
validated against the 40-item
University of Pennsylvania Smell
Identification Test (UPSIT) ▼

Familiarity (selecting pictures, not names)

Odor 9
Bubble Gum Chocolate
Flower
Natural Gas

Olfaction (Smell) Team
Title
Pamela Dalton, Team Leader Monell
Chemical Senses Center
Richard Doty
University of Pennsylvania
Robert Frank
Ohio University
Howard Hoffman
NIDCD, NIH
Julie Mennella
Monell Chemical Senses Center
Claire Murphy
San Diego State University
Jerry Slotkin
Northwestern University

Definition
Gustation is the perception of one or more of these tastes:
sweet, salty, sour, bitter, or umami (savory/brothy) from
whole mouth or regional stimulation of the tongue.
Toolbox Measures
Spatial test with NaCl and quinine; age >12 years
► suprathreshold intensity scaling, using the
general Labeled Magnitude Scale (gLMS)
Supplemental Measures
• Sucrose preference test
• PROP Taste Test – not part of the Shed

Intensity indicated using general
Labeled Magnitude Scale gLMS
1 M NaCl (salt) and
1 mM Quinine HCl (bitter)
Presented by cotton swab to tongue tip,
then whole mouth “sip, spit, and rinse”.

Gustation (Taste) Team
Title
Susan Coldwell, Team Leader
University of Washington
Linda Bartoshuk
University of Florida
Gary Beauchamp
Monell Chemical Senses Center
Paul Breslin
Monell Chemical Senses Center
Beverly Cowart
Monell Chemical Senses Center
Valerie Duffy
University of Connecticut, Storrs
James Griffith
Northwestern University
Lloyd Hastings
Osmic Enterprises, Inc., Cincinnati
Howard Hoffman
NIDCD, NIH
Julie Mennella
Monell Chemical Senses Center
Michael O’Mahony
University of California, Davis
Marci Pelchat
Monell Chemical Senses Center
Greg Smutzer
Temple University, Philadelphia

Definition
The detection, discrimination, and recognition of body
(somato) sensations (touch, proprioception, and pain)
Toolbox Measures
Self-reported pain intensity numerical rating (adult)
PROMISE Pain Interference Scales (child & adult)
Supplemental Measures
Tactile discrimination – 10 items, dominant hand
(not recommended)

Somatosensory function includes “detection,
discrimination and recognition” of pain.
Well-developed, self-reported pain measures have
been validated in a range of acute and chronic
medical conditions.
– Toolbox chose not to develop new pain measures

Adults, short form measure:
How much did pain interfere with…
► your day-to-day activities?
► work around the home?
► your ability to participate in social activities?
► your household chores?
► the things you usually do for fun?
► your enjoyment of social activities?
…………………………………………………………………………………………………………………….
Each item is scored as: 1 –“not at all”, 2 –“a little bit”,
3 –“somewhat”, 4 –“quite a bit”, 5 –“very much”

Children, PROMIS measure:
8-item subscale assesses pain impact on …
► sleep
► attention
► mobility (walking, running, standing)
► ability to have fun
► schoolwork
► affect (anger when in pain)
…………………………………………………………………………………………………………………….
Advantages: Developed using modern psychometric tools
(IRT) and tested for differential responses for boys & girls

Toolbox Pain Intensity Measures
In the past 7 days, how would you rate your pain on average?
Adults: 0-10 numerical rating scale
(0 = no pain, …,10 = worst imaginable pain)
Children: no recommendation
Toolbox Interference Measures
Adults: PROMIS Pain Interference Scale
Children: PROMIS Pediatric Pain
Interference Scale

Somatosensation–Pain Team
Title
Winnie Dunn, Team Leader
University of Kansas
Leeanne M. Carey
LaTrobe University
Lisa Connor
Washington University
Karen F. Cook
Northwestern University
Amy Darragh
Ohio State University
Brian Dudgeon
University of Washington
Richard Gershon
Northwestern University
James Griffith
Northwestern University
Howard Hoffman
NIDCD, NIH
Margo Holm
University of Pittsburgh
Partap Khalsa
NCCAM, NIH
Joy MacDermid
McMasters U
Tracy Morrison
University of Kansas
Deborah Olster
OBSSR, NIH
Linda Porter
NINDS, NIH
Roseanne Schaaf
Thomas Jefferson
University
Dory Sabata
University of Kansas
David Victorson
Northwestern
University

► Valid reliable tests of sensory sub-domains
► Computerized – easy to use
► Individually developed, thus stand alone
► Many for 3-85 years, most for >6 years

Supported by
NIH Toolbox
Assessment of Neurological and Behavioral Function
For more information
visit
www.nihtoolbox.org
This project is funded in whole or in part with Federal funds from the Blueprint for Neuroscience Research and the Office of Behavioral
and Social Sciences Research, National Institutes of Health, under Contract No. HHS-N-260-2006-00007-C.