Measurement properties of visual rating of postural orientation errors of the lower extremity - A systematic review and meta-analysis

Lower extremity movement quality in professional team sport athletes: Inter-rater agreement and relationships with quantitative results from the corresponding pattern

BACKGROUND

Adequate movement control and quality can be prerequisite functions for performance of the lower extremity. The purposes of our work were 1) to explore the agreement of an efficient test battery assessing qualitative movement execution and 2) to determine its consistency with quantitative performance tests from the corresponding movement pattern.

METHODS

The participants were professional male association football players competing in the first German Bundesliga. They performed four movement quality tests (Single-limb balance squat, Balance forward hop, Balance side hop, Balance 90° rotation hop) and the corresponding performance tests (Y-balance test, Forward hop for distance, Side hop test, Square hop test). Qualitative tests were judged by two experienced raters; the ratings were compared to determine inter-rater agreement using Kappa statistics. The relationship with the quantitative tests was determined using Spearman's rank correlations.

RESULTS

Thirty participants (19 to 33 years old) were included in this study. We found an at least substantial level of agreement (Cohen's Kappa, 0.64-0.84) with an excellent percentage of exact (83-93%) agreement between the two raters for the movement quality tests. Our findings revealed that the quantitative test results are only slightly related to the movement quality outcomes (ρ(27) <|0.3| and P > 0.2).

CONCLUSIONS

Consequently, the qualitative test results provide unique information and complement corresponding quantitative performance tests in professional football athletes. Their observational judgement of foot position, lower limb alignment and upper body control in sagittal, frontal, and transverse planes is agreeable.

Evaluation of hop test movement quality to enhance return to sport testing. A cross-sectional study

Introduction

Return to Sport tests with functional hop tests are often used to decide when a person is ready to return to sport after an anterior cruciate ligament (ACL) injury. Poor movement quality, such as knee valgus, hip adduction and hip internal rotation is considered a risk factor for ACL injury. However, it is unclear whether existing tests adequately cover the aspect of movement quality. This study aims to investigate whether there is a relationship between the calculated limb symmetry index (LSI) of hop tests as an indication of performance and the total score of the "Quality First" assessment (movement quality). The second aim is to examine the reliability of the newly developed "Quality First" assessment for evaluating movement quality in hop tests.

Methods

The cross-sectional study recruited 34 patients with an ACL reconstruction. The vertical hop, single-leg hop for distance, and side hop tests were performed and recorded. The video recordings were assessed using the "Quality First" assessment. The Spearman correlation coefficient was calculated using the LSI and the "Quality First" total score. Intraclass correlation coefficients (ICC) and standard error of measurements (SEM) were used to calculate intra- and interrater reliability. In addition, the minimal detectable change (MDC) was determined.

Results

The correlation test between the LSI and the "Quality First" total score showed no correlation for all three jumps (r = -0.1-0.02/p-value = 0.65-0.93). The interrater reliability of the "Quality First" assessment showed fair to good reliability (ICC2: 0.45-0.60), with SEM ranging from 1.46 to 1.73 and the MDC from 4.06 to 4.8. Intrarater reliability was good to excellent (ICC3: 0.73-0.85), with SEM values ranging from 0.89 to 1.09 and the MDC from 2.47 to 3.01.

Conclusion

The quality of movement, measured with the "Quality First" assessment, indicated no correlation with the calculated LSI from jump performance, therefore movement quality should also be examined in Return to Sport tests. The "Quality First" assessment shows fair to good reliability when used by different raters. When used multiple times by the same rater, the assessment has good to excellent reliability.

Prevention of Secondary Injury after Anterior Cruciate Ligament Reconstruction: Relationship between Pelvic-Drop and Dynamic Knee Valgus

(1) Background: Optimal neuromuscular, Lumbo-Pelvic-Hip Complex, and lower extremity control are associated with decreased risk factors for secondary anterior cruciate ligament (ACL) injury. This study aimed to analyze any asymmetries and malalignments in the Lumbo-Pelvic-Hip Complex and the lower limbs at 6 months after ACL reconstruction (ACLR). (2) Methods: We conducted an exploratory retrospective observational single-center study in patients during the outpatient postoperative rehabilitation program at ICOT (Latina, Italy). From January 2014 to June 2020, 181 patients were recruited, but only 100 patients (86 male 28 ± 0.6 years, 178 ± 0.5 height; 14 female 24 ± 2.0 years, 178 ± 3.0 height) were eligible for the inclusion criteria and studied 6 months after ACL reconstruction surgery. (3) Statistical analysis: Student's t-tests and Pearson's product-moment correlation coefficient were used to determine significant differences between affected and non-affected limbs and variables' association. (4) Results: The study shows a decrease in neuromuscular control of the Lumbo-Pelvic-Hip Complex and dynamic adaptive valgus of the knee at 6 months after ACLR (mean difference between pathological and healthy limb of dynamic adaptive valgus was -10.11 ± 8.19° 95% CI -14.84 to -9.34; mean value was 16.3 ± 6.8° 95% CI 14.04 to 18.55 for healthy limb and 4.2 ± 3.1° 95% CI 3.15 to 5.21 for pathological limb, p < 0.0001). The results also showed a relationship between dynamic adaptive valgus and contralateral pelvic drop (r = 0.78, 95% CI 0.62 to 0.88, magnitude of correlation very large). (5) Conclusions: The analysis showed an associative correlation between decreased postural control of the pelvic girdle and dynamic adaptive valgus of the knee in 38% of patients; this study highlights the usefulness of the Single-Leg Squat Test (SLST) as a clinical/functional assessment to evaluate the rehabilitation process and as a preventive tool to reduce the risk of second ACL injuries during the return to sport.

Visual assessment of movement quality: a study on intra- and interrater reliability of a multi-segmental single leg squat test

Background

The Single Leg Squat test (SLS) is a common tool used in clinical examination to set and evaluate rehabilitation goals, but there is not one established SLS test used in the clinic. Based on previous scientific findings on the reliability of the SLS test and with a methodological rigorous setup, the aim of the present study was to investigate the intra- and interrater reliability of a standardised multi-segmental SLS test.

Methods

We performed a study of measurement properties to investigate the intra- and interrater reliability of a standardised multi-segmental SLS test including the assessment of the foot, knee, pelvis, and trunk. Novice and experienced physiotherapists rated 65 video recorded SLS tests from 34 test persons. We followed the Quality Appraisal for Reliability Studies checklist.

Results

Regardless of the raters experience, the interrater reliability varied between “moderate” for the knee variable (ĸ = 0.41, 95% CI 0.10–0.72) and “almost perfect” for the foot (ĸ = 1.00, 95% CI 1.00–1.00). The intrarater reliability varied between “slight” (pelvic variable; ĸ = 0.17, 95% CI -0.22-0.55) to “almost perfect” (foot variable; ĸ = 1.00, 95% CI 1.00–1.00; trunk variable; ĸ = 0.82, 95% CI 0.66–0.97). A generalised kappa coefficient including the values from all raters and segments reached “moderate” interrater reliability (ĸ = 0.52, 95% CI 0.43–0.61), the corresponding value for the intrarater reliability reached “almost perfect” (ĸ = 0.82, 95% CI 0.77–0.86).

Conclusions

The present study shows a “moderate” interrater reliability and an “almost perfect” intrarater reliability for the variable all segments regardless of the raters experience. Thus, we conclude that the proposed standardised multi-segmental SLS test is reliable enough to be used in an active population.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13102-021-00289-x.

Reliability and validity of a novel Kinect-based software program for measuring a single leg squat

Background

The Single leg squat (SLS) is a movement screening test widely used in clinical settings. The SLS is highly subjective in its nature. Objective measures, such as 3D-motion analyses, are seldom used in daily clinical work. An interactive, Kinect-based 3D-movement analysis system, the Qinematic™, is proposed to be easily used in clinical settings to assess the SLS. The aim of this study was to establish the test-retest reliability and construct validity of Qinematic™ for assessing the SLS. A further aim was to identify angles of medial knee displacement, to summarise the discriminative ability of the SLS measured by Qinematic™.

Methods

We performed a test-retest reliability study (n = 37) of the SLS using Qinematic™ and a construct validity study, in which Qinematic™ data were compared with visual assessment of video-recorded SLS.

Results

Three variables (left knee down, right knee up and down) reached “substantial reliability” (ICC = 0.64–0.69). One variable, “left knee up”, showed a significant difference between the two test occasions (T1–6.34°, T2 0.66°, p = 0.013, ICC = 0.50), and “poor absolute reliability” was seen for all variables (SEM = 9.04–10.66, SDC = 25.06–29.55). A moderate agreement between the visual assessment and Qinematic™ data for various knee angles was shown (Kappa = 0.45–0.58). The best discriminative ability of the SLS was found at a knee angle of 6° (AUC = 0.82, sensitivity = 0.86, specificity = 0.78, PPV = 0.58, NPV = 0.94).

Conclusions

Qinematic™ shows a poor absolute reliability, and a substantial relative reliability, in measuring a SLS at the way down. This indicates that Qinematic™ should not be recommended for the use on an individual level, but it can possibly be used on a group level. The merged results of the construct validity study indicate that Qinematic™ at 6° of medial displacement can identify subjects with a knee over foot position. In summary, the use of the Qinematic™ net trajectory angle, which estimates the “line of best fit” cannot be recommended to assess a knee medial to foot position and should be reconsidered.

Visual assessment of movement quality in the single leg squat test: a review and meta-analysis of inter-rater and intrarater reliability

Single leg squat (SLS) is a common tool used in clinical examination to set and evaluate rehabilitation goals, but also to assess lower extremity function in active people.

Is poor proprioception associated with worse movement quality of the knee in individuals with anterior cruciate ligament deficiency or reconstruction?

[Purpose] To investigate the association between proprioception and a knee medial to foot position during weight-bearing activities in patients with anterior cruciate ligament reconstruction and anterior cruciate ligament deficiency. [Participants and Methods] Thirty-eight patients with anterior cruciate ligament reconstruction and 13 patients with anterior cruciate ligament deficiency aged 18–40 years were included. Proprioception was assessed by knee kinesthesia measured by the threshold to detection of passive motion. Movement quality was assessed by visual observation of the position of the knee in relation to the foot during the mini squat, the single-leg hop for distance, and the cross-over hop for distance. [Results] In patients with anterior cruciate ligament deficiency, worse kinesthesia was significantly associated with a knee medial to foot position during the single-leg hop for distance. No statistically significant associations were observed between kinesthesia and a knee medial to foot position during the three tasks in patients with anterior cruciate ligament reconstruction. [Conclusion] Poor proprioception may be associated with worse movement quality of the knee in patients with anterior cruciate ligament deficiency, but not in patients with anterior cruciate ligament reconstruction. Differences in sensorimotor function between patients with reconstructed and non-reconstructed anterior cruciate ligament should be considered in training and rehabilitation regimens aiming to enhance performance and prevent further injuries in these patients.

Agreement between test procedures for the single-leg hop for distance and the single-leg mini squat as measures of lower extremity function

Background

Different test procedures are often used within performance-based measures, causing uncertainty as to whether results can be compared between studies. Thus, the aim of this study was to assess agreement between different test procedures for the single-leg hop for distance (SLHD) and the single-leg mini squat (SLMS), respectively, two commonly used tasks for assessing deficiency in lower extremity muscle function.

Methods

Twenty-three participants (20–42 years) with lower extremity injury performed the SLHD with arms free and with arms behind back, and the Limb Symmetry Index (LSI; injured leg divided by uninjured and multiplied by 100) was calculated. Another group of 28 participants (mean 18–38 years) performed five SLMSs at a pre-defined speed and maximum number of SLMSs during 30 seconds, and were visually observed and scored as either having a knee-over-foot or a knee-medial-to-foot position (KMFP).

Results

No systematic difference between test procedures for the LSI of the SLHD was noted (p=0.736), Cohen’s kappa = 0.42. The Bland & Altman plot showed wide limits of agreement between test procedures, with particularly poor agreement for participants with abnormal LSI (<90%). Ten participants were scored as having a KMFP during five SLMSs at a predefined speed, while five had a KMFP during maximum number of SLMSs during 30 seconds (p=0.063, Cohen’s kappa = 0.56).

Conclusions

The moderate agreement between the two test procedures for the SLHD and the SLMS, respectively, indicate that results from these different test procedures should not be compared across studies. SLHD with arms behind back, and five SLMSs at a pre-defined speed, respectively, were the most sensitive procedures to detect individuals with poor functional performance.