Using kinematics to re-define the pull test as a quantitative biomarker of the postural response in normal pressure hydrocephalus patients

Samuel Daly, Jacob T Hanson, Vibha Mavanji, Amy Gravely, James Jean, Alec Jonason, Scott Lewis, James Ashe, John M. Looft, Robert A. McGovern

Research output: Contribution to journalArticlepeer-review

2 Scopus citations


Quantitative biomarkers are needed for the diagnosis, monitoring and therapeutic assessment of postural instability in movement disorder patients. The goal of this study was to create a practical, objective measure of postural instability using kinematic measurements of the pull test. Twenty-one patients with normal pressure hydrocephalus and 20 age-matched control subjects were fitted with inertial measurement units and underwent 10–20 pull tests of varying intensities performed by a trained clinician. Kinematic data were extracted for each pull test and aggregated. Patients participated in 103 sessions for a total of 1555 trials while controls participated in 20 sessions for a total of 299 trials. Patients were separated into groups by MDS-Unified Parkinson’s Disease Rating Scale (MDS-UPDRS) pull test score. The center of mass velocity profile easily distinguished between patient groups such that score increases correlated with decreases in peak velocity and later peak velocity onset. All patients except those scored as “3” demonstrated an increase in step length and decrease in reaction time with increasing pull intensity. Groups were distinguished by differences in the relationship of step length to pull intensity (slope) and their overall step length or reaction time regardless of pull intensity (y-intercept). NPH patients scored as “normal” on the MDS-UPDRS scale were kinematically indistinguishable from age-matched control subjects during a standardized perturbation, but could be distinguished from controls by their response to a range of pull intensities. An instrumented, purposefully varied pull test produces kinematic metrics useful for distinguishing clinically meaningful differences within hydrocephalus patients as well as distinguishing these patients from healthy, control subjects.

Original languageEnglish (US)
Pages (from-to)791-802
Number of pages12
JournalExperimental Brain Research
Issue number3
StatePublished - Mar 2022

Bibliographical note

Funding Information:
This work was supported in part by MnDRIVE, a collaboration between the University of Minnesota and the State of Minnesota.

Publisher Copyright:
© 2022, This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply.


  • Hydrocephalus
  • Perturbation
  • Postural instability
  • Reaction time
  • Step response
  • Biomechanical Phenomena
  • Hydrocephalus, Normal Pressure/diagnosis
  • Humans
  • Postural Balance/physiology
  • Biomarkers
  • Parkinson Disease/diagnosis

PubMed: MeSH publication types

  • Journal Article


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