The effects of joint angle and reliability on knee proprioception

Effects of Muscular Fatigue on Position Sense in Two Phases of the Menstrual Cycle

It is generally accepted that local muscular fatigue can negatively affect position sense. Interestingly, it has been proposed that in women, position sense and neuromuscular coordination may be affected by fluctuations of estrogen and progesterone levels. The aim of this study was to examine the possible effect of localized muscle fatigue on knee joint position sense at two phases of the menses: follicular and luteal. Twenty physically active females aged 19-30 years, with normal menses, volunteered for this study. An isokinetic dynamometer was used to evaluate proprioception and perform the fatigue protocol of the knee extensors and flexors. Knee proprioception at rest and after fatigue at three knee target angles (30°, 45°, 60°) was measured. A three-way ANOVA analysis with repeated measures was performed. The results showed that the main effect of fatigue was significant, but no main effect of the menstrual cycle phase was found. Additionally, a main effect was found for the target angle (more flexed target knee joint angles were associated with larger angular error deviations). In conclusion, localized muscle fatigue can significantly reduce the accuracy of active knee joint repositioning in both the luteal and the follicular menstrual phases in young, physically active healthy women.

The effect of mechanical vibration-based stimulation on dynamic balance control and gait characteristics in healthy young and older adults: A systematic review of cross-sectional study

BACKGROUND

A good dynamic balance control and stable gait played an important role in the daily ambulation, especially for older adults with sensorimotor degeneration. This study aimed to systematically review the effects and potential mechanisms of mechanical vibration-based stimulation (MVBS) on dynamic balance control and gait characteristics in healthy young and older adults.

METHOD

Five bioscience and engineering databases, including MEDLINE via PubMed, CINAHL via EBSCO, Cochrane Library, Scopus, and Embase, were searched until September 4th, 2022. Studies published between 2000 and 2022 in English and Chinese involving mechanical vibration related to gait and dynamic balance were included. The procedure was followed via the preferred reporting items for systematic reviews and meta-analysis method. The methodological quality of included studies was assessed using the NIH study quality assessment tool for observational cohort and cross-sectional studies.

RESULTS

A total of 41 cross-sectional studies met the inclusion criteria and were included in this study. Eight studies were good-quality while 26 were moderate-quality and 7 were poor-quality. There were six categories of MVBS at various frequencies and amplitudes utilized in included studies, including plantar vibration, focal muscle vibration, Achilles tendon vibration, vestibular vibration, cervical vibration, and vibration on nail of hallux.

SIGNIFICANCE

Different types of MVBS targeting different sensory systems affected the dynamic balance control and gait characteristics differently. MVBS could be used to provide improvement or perturbation to specific sensory systems, to induce different sensory reweight strategies during gait.

A Reliability of Active and Passive Knee Joint Position Sense Assessment Using the Luna EMG Rehabilitation Robot

Joint position sense (JPS) is the awareness of joint location in space, indicating accuracy and precision of the movement. Therefore, the aim of the present study is to determine the reliability of active and passive JPS assessment regarding the knee joint. This was carried out using the Luna EMG rehabilitation robot. Further analysis assessed whether the examination of only the dominant site is justified and if there are differences between sites. The study comprised 24 healthy male participants aged 24.13 ± 2.82 years, performing sports at a recreational level. Using the Luna EMG rehabilitation robot, JPS tests were performed for the right and left knees during flexion and extension in active and passive mode, in two separate sessions with a 1-week interval. Both knee flexion and extension in active and passive modes demonstrated high reliability (ICC = 0.866-0.982; SEM = 0.63-0.31). The mean JPS angle error did not differ significantly between the right and left lower limbs (p < 0.05); however, no between-limb correlation was noted (r = 0.21-0.34; p > 0.05). The Bland-Altman plots showed that the between-limb bias was minimal, with relatively wide limits of agreement. Therefore, it was concluded that the Luna EMG rehabilitation robot is a reliable tool for active and passive knee JPS assessment. In our study, JPS angle error did not differ significantly between left and right sides; however, the slight asymmetry was observed (visible in broad level of agreement exceeding 5° in Bland-Altman plots), what may suggest that in healthy subjects, e.g., active athletes, proprioception should always be assessed on both sides.

Effects of two different stretching techniques on proprioception and hamstring flexibility: a pilot study

Aim: This study aimed to compare the immediate and long-term effect of proprioceptive neuromuscular facilitation (PNF) contract-relax-antagonist-contract (CRAC) exercises versus static stretching on proprioception and flexibility in males with hamstring shortness. Patients & methods: Knee extension angle test was used to measure flexibility and isokinetic dynamometer to evaluate proprioception. Assessments were evaluated at baseline, after first exercise and eighth week. The hamstring stretching was applied 3 days a week for 8 weeks. Results: Flexibility and position sense were similar in the immediate and long term (p > 0.05). However, the motion sense increased significantly in long term within the PNF CRAC group (p = 0.02). Conclusion: Both stretching exercises are effective for improving flexibility. Moreover, PNF CRAC improved motion sense more than static stretching in the long term. Clinical trial registration number: NCT04026646.

Validity and reliability of smartphones in measuring joint position sense among asymptomatic individuals and patients with knee osteoarthritis: A cross-sectional study

BACKGROUND

Quantifying proprioception deficit in patients with osteoarthritis (OA) may be important in evaluating treatment effectiveness. This study investigated the concurrent and known-groups validity as well as test-retest reliability of a smartphone application in assessing joint position sense (JPS) in asymptomatic individuals and patients with knee OA.

METHODS

Sixty-four knees, from 16 asymptomatic controls and 16 patients with bilateral OA, were assessed twice with a 1-week interval in between. The smartphone Goniometer Pro application and isokinetic dynamometer simultaneously quantified JPS, in terms of absolute repositioning error (RE) angle, during active and passive limb movements at selected angles.

RESULTS

Both devices showed moderate to almost perfect correlations in measuring JPS; whether active (intra-class correlation coefficient (ICC) >0.87) or passive (ICC >0.97). The mean RE angle differences between the two devices were <0.77° (passive JPS) and <2.76° (active JPS). Both devices were capable of distinguishing patients and asymptomatic controls at 55° and 80°. The smartphone showed moderate test-retest reliability of active JPS measurement (ICC = 0.51) in the two groups, similar to that of the isokinetic dynamometer (ICC = 0.62), but with a high measurement error.

CONCLUSIONS

Smartphone application is a valid alternative to the isokinetic dynamometer in assessing JPS in patients with knee OA and asymptomatic controls. The two devices could distinguish patients and asymptomatic volunteers during passive JPS measured at 55° and 80°. Both devices have moderate reliability in quantifying active JPS, but reliability results should be considered with caution.

Comparing single and multi-joint methods to detect knee joint proprioception deficits post primary unilateral total knee arthroplasty

BACKGROUND

The use of various single-joint proprioception measurements has resulted in contradictory findings after knee arthroplasty. The use of balance as a surrogate measure to assess knee proprioception post-operation has resulted in further confusion. The aim of this study was to measure single joint knee proprioception in participants after unilateral knee arthroplasty, and compares it to multi-joint balance.

METHODS

Eleven participants at 1 year after unilateral total knee arthroplasty and twelve age-matched controls were enrolled. The threshold to detect passive motion and the sensory organization test were used to measure single joint knee proprioception and multi-joint balance respectively. Two-way ANOVA and independent t-tests were used to measure differences between and within groups. Regression analysis was used to measure the association between proprioception and balance measurements.

FINDINGS

Surgical knees demonstrated significantly more deficient proprioception compared to the non-surgical knees and both knees of the control groups during flexion (P < 0.01) and extension (P < 0.05). Non-surgical knees showed similar proprioception to both knees of the control group during flexion and extension. Within the knee arthroplasty group, only deficiencies during flexion showed significant correlation with Sensory Organization Test visual ratio. No additional differences between both groups during balance measurements, nor any correlations between local joint proprioception and balance were seen.

INTERPRETATION

These findings indicate deficient surgical knee proprioception in participants one year after unilateral total knee arthroplasty. Limited associations between measurements indicate that balance may be a poor measure of single-joint proprioception.

The Effects of Cryotherapy on Knee Joint Position Sense and Force Production Sense in Healthy Individuals

The proprioceptive information received from mechanoreceptors is potentially responsible for controlling the joint position and force differentiation. However, it is unknown whether cryotherapy influences this complex mechanism. Previously reported results are not universally conclusive and sometimes even contradictory. The main objective of this study was to investigate the impact of local cryotherapy on knee joint position sense (JPS) and force production sense (FPS). The study group consisted of 55 healthy participants (age: 21 ± 2 years, body height: 171.2 ± 9 cm, body mass: 63.3 ± 12 kg, BMI: 21.5 ± 2.6). Local cooling was achieved with the use of gel-packs cooled to -2 ± 2.5°C and applied simultaneously over the knee joint and the quadriceps femoris muscle for 20 minutes. JPS and FPS were evaluated using the Biodex System 4 Pro apparatus. Repeated measures analysis of variance (ANOVA) did not show any statistically significant changes of the JPS and FPS under application of cryotherapy for all analyzed variables: the JPS’s absolute error (p = 0.976), its relative error (p = 0.295), and its variable error (p = 0.489); the FPS’s absolute error (p = 0.688), its relative error (p = 0.193), and its variable error (p = 0.123). The results indicate that local cooling does not affect proprioceptive acuity of the healthy knee joint. They also suggest that local limited cooling before physical activity at low velocity did not present health or injury risk in this particular study group.

Does proprioceptive acuity during active knee rotation in the transverse plane vary at different ranges?

BACKGROUND

Knee proprioception in the sagittal plane has been widely investigated in prospective studies, however limited information is known about proprioceptive acuity during active knee rotation and the way most commonly injured.

OBJECTIVE

To investigate whether proprioceptive acuity during active internal and external knee rotation varies at different ranges in the transverse plane.

METHODS

Healthy volunteers (N: 26) without previous injury or surgery of the knee joint participated in the study.Knee rotation proprioceptive acuity was measured using a custom-designed device. The measure of proprioceptive acuity used in this study was the just-noticeable-difference (JND). Participants actively rotated the knee at different intervals(initial, mid, and terminal internal or external rotation range) to one of four movement blocks and the magnitude of the permitted motion was judged.

RESULTS

The means of the JND for proprioceptive acuity at initial internal rotation (0.80° ± 0.06) were significantly (p< 0.002) lower than for mid (1.62° ± 0.18), and terminal (2.08° ± 0.35) internal rotation. The means of the JND for proprioceptive acuity at initial external rotation (1.16° ± 0.10) were significantly (p< 0.04) lower than for mid (1.95° ± 0.30), and terminal (1.97° ± 0.24) internal rotation.

CONCLUSIONS

Participants perceived smaller differences between active internal and external rotation movements at initial rotation range than at the mid and terminal rotation range of movement. This suggests better proprioceptive acuity at the initial rotation range of movement in the transverse plane.

Effects of acceleration training 24 weeks after anterior cruciate ligament reconstruction on proprioceptive and dynamic balancing functions

[Purpose] The present study aimed to investigate whether the effects of rehabilitation exercise performed after anterior cruciate ligament reconstruction on proprioceptive sensory and dynamic balancing functions differ between males and females. [Subjects and Methods] Eighteen subjects aged between 20-30 years enrolled in this study. The ages did not significantly differ between the males and females. The rehabilitation exercise program was performed three times per week for 12 weeks (3 months), and was initiated immediately after anterior cruciate ligament reconstruction. Thereafter, the patients visited the hospital once per week to perform rehabilitation exercise during weeks 12-24 (3-6 months), and education on self-exercise and assessments were conducted during the visits. Self-exercise was performed two times per week according to the determined program. [Results] The extension active joint position sense, extension passive joint position sense, and flexion passive joint position sense of the affected and unaffected knees did not show any interaction effects between the measurement periods or between the groups. In the case of the affected knee, the results of two-way repeated-measures analysis of variance showed no significant difference between the measurement periods or between the groups; moreover, no, interaction effects were observed between the measurement periods or between the groups. In the case of the unaffected knee, although no significant difference was observed between the measurement periods, significant differences were observed between the groups. [Conclusion] In conclusion, this study revealed that most knee rehabilitation exercise training programs can be applied to both genders during the recovery period after ACL reconstruction, except for the knee rotational feedback/feedforward function exercise that may exhibit different effects based on the gender.

Reproducibility of a knee and hip proprioception test in healthy older adults

BACKGROUND

Proprioception can be assessed by measuring joint position sense (JPS). Most studies have focused on JPS of the knee joint while literature for other joints especially for hip JPS is scarce. Although some studies have evaluated proprioception of the knee joint, the reproducibility of methods has rarely been investigated.

AIMS

To estimate intrasession reliability and agreement of an active-active JPS test for hip flexion/abduction and knee flexion in healthy older adults.

METHODS

Nineteen healthy older adults participated in this study. The proprioception of the hip (flexion and abduction) and knee (flexion) were assessed in both legs using the "active-active" reproduction technique. Intraclass correlation coefficient (ICC), standard error of measurement (SEM), and limits of agreement (LOA) were estimated for relative angular error (RE), absolute angular error (AE), and variable angular error (VE).

RESULTS

Reliability of our JPS test was substantial to almost perfect for the RE for both joints and legs (ICC values ranging from 0.75 to 0.93). We also found that the ICC values for AE were substantial for knee flexion and hip abduction of the left and right leg. The ICC results of VE showed poor reliability for hip and knee joints. SEM and LOA values for hip abduction were generally lower than for hip and knee flexion, indicating lower measurement error or more precise scores for the proprioception test of hip abduction.

CONCLUSION(S)

Proprioceptive acuity of the knee and hip joints in healthy older adults can be reliably assessed with an active-active procedure in a standing position with respect to relative and absolute error.

Effects of closed kinetic chain exercises on proprioception and functional scores of the knee after anterior cruciate ligament reconstruction

[Purpose] The purpose of this study was to examine the effect of closed kinetic chain exercises performed by an unstable exercise group (UEG) and a stable exercise group (SEG) on the knee joint, proprioception, and functional scores of patients who underwent anterior cruciate ligament (ACL) reconstruction. [Subjects] Twenty-eight patients participated in this study. The exclusion criteria were fracture or neurological disease. [Methods] The subjects were randomly assigned to one of two groups, each with 14 people. Each group took part in a 60-minute exercise program, three times a week for six weeks. [Results] The results of the clinical evaluation at 45°proprioception showed statistically significant differences between the two groups. The results of the clinical evaluation at 15°proprioception showed no statistically significant differences between the two groups. [Conclusion] The proprioception and functional scores of the patients in the UEG who underwent ACL reconstruction were superior to those in the SEG group.

A systematic review to determine the reliability of knee joint position sense assessment measures

BACKGROUND

The assessment of joint position sense (JPS) is the most widely used measurement of knee proprioceptive capability within the literature. However, it remains unclear what the most reliable method is to assess this. The purpose of this study was to determine the intra- and inter-rater reliability of the various methods used to assess knee JPS.

METHODS

A systematic review of published and unpublished literature sources was conducted up to June 2012. All studies principally assessing the reliability (intra- or inter-rater) or reproducibility of a JPS of the knee were included. The methodological quality of each study was reviewed using the Critical Appraisal Skills Programme tool.

RESULTS

A total of 18 studies were eligible, assessing the reliability of JPS with 456 knees. The reliability of four methods of JPS has been recorded: position replication using a model, image recorded angulation, electrogoniometry and dynamometry/angular motion chair. Intra-rater reliability was good for the assessment of JPS using photographs and digital images, and replicating knee position using a paper model, this was good but variable when electrogoniometry was used, and moderate but variable when assessed using dynamometry/angle motion chairs. The assessment of JPS by image recorded angulation, electrogoniometry and dynamometry/angular motion chair has demonstrated good inter-rater reliability.

CONCLUSIONS

Whilst JPS methods appear to have variable reliability, the four assessment methods should be further assessed with pathological populations such as those following patellar dislocation or anterior cruciate ligament rupture. This will better facilitate the generalisability of JPS assessment methods to inform clinical practice.

Assessing longitudinal change in coordination of the paretic upper limb using on-site 3-dimensional kinematic measurements

BACKGROUND AND PURPOSE

It is largely unknown how adaptive motor control of the paretic upper limb contributes to functional recovery after stroke. This paucity of knowledge emphasizes the need for longitudinal 3-dimensional (3D) kinematic studies with frequent measurements to establish changes in coordination after stroke. A portable 3D kinematic setup would facilitate the frequent follow-up of people poststroke. This case report shows how longitudinal kinematic changes of the upper limb can be measured at a patient's home using a portable 3D kinematic system in the first 6 months poststroke.

CASE DESCRIPTION

The outcomes of the upper-limb section of the Fugl-Meyer Motor Assessment (FMA), the Action Research Arm Test (ARAT), and 3D kinematic analyses were obtained from a 41-year-old man with a left hemispheric stroke. Three-dimensional kinematic data of the paretic upper limb were collected during a reach-to-grasp task using a portable motion tracker in 5 measurements during the first 6 months after stroke. Data from an individual who was healthy were used for comparison.

OUTCOMES

The FMA and ARAT scores showed nonlinear recovery profiles, accompanied by significant changes in kinematic outcomes over time poststroke. Specifically, elbow extension increased, forward trunk motion decreased, peak hand speed increased, peak hand opening increased, and peak hand opening occurred sooner after peak hand speed.

DISCUSSION

This case report illustrates the feasibility of frequently repeated, on-site 3D kinematic measurements of the paretic upper limb. Early after stroke, task performance was mainly driven by adaptive motor control, whereas adaptations were mostly reduced at 26 weeks poststroke. The presented approach allows the investigation of what is changing in coordination and how these changes are related to the nonlinear pattern of improvements in body functions and activities after stroke.

Proprioception in knee osteoarthritis: a narrative review

OBJECTIVE

To give an overview of the literature on knee proprioception in knee osteoarthritis (OA) patients.

METHOD

A literature search was performed and reviewed using the narrative approach.

RESULTS

(1) Three presumed functions of knee proprioception have been described in the literature: protection against excessive movements, stabilization during static postures, and coordination of movements. (2) Proprioceptive accuracy can be measured in different ways; correlations between these methods are low. (3) Proprioceptive accuracy in knee OA patients seems to be impaired when compared to age-matched healthy controls. Unilateral knee OA patients may have impaired proprioceptive accuracy in both knees. (4) Causes of impaired proprioceptive accuracy in knee OA remain unknown. (5) There is currently no evidence for a role of impaired proprioceptive accuracy in the onset or progression of radiographic osteoarthritis (ROA). (6) Impaired proprioceptive accuracy could be a risk factor for progression (but not for onset) of both knee pain and activity limitations in knee OA patients. (7) Exercise therapy seems to be effective in improving proprioceptive accuracy in knee OA patients.

CONCLUSIONS

Recent literature has shown that proprioceptive accuracy may play an important role in knee OA. However, this role needs to be further clarified. A new measurement protocol for knee proprioception needs to be developed. Systematic reviews focusing on the relationship between impaired proprioceptive accuracy, knee pain and activity limitations and on the effect of interventions (in particular exercise therapy) on proprioceptive accuracy in knee OA are required. Future studies focusing on causes of impaired proprioceptive accuracy in knee OA patients are also needed, taking into account that also the non-symptomatic knee may have proprioceptive impairments. Such future studies may also provide knowledge of mechanism underlying the impact of impaired proprioceptive accuracy on knee pain and activity limitations.

The reliability of knee joint position testing using electrogoniometry

BACKGROUND

The current investigation examined the inter- and intra-tester reliability of knee joint angle measurements using a flexible Penny and Giles Biometric electrogoniometer. The clinical utility of electrogoniometry was also addressed.

METHODS

The first study examined the inter- and intra-tester reliability of measurements of knee joint angles in supine, sitting and standing in 35 healthy adults. The second study evaluated inter-tester and intra-tester reliability of knee joint angle measurements in standing and after walking 10 metres in 20 healthy adults, using an enhanced measurement protocol with a more detailed electrogoniometer attachment procedure. Both inter-tester reliability studies involved two testers.

RESULTS

In the first study, inter-tester reliability (ICC[2,10]) ranged from 0.58-0.71 in supine, 0.68-0.79 in sitting and 0.57-0.80 in standing. The standard error of measurement between testers was less than 3.55 degrees and the limits of agreement ranged from -12.51 degrees to 12.21 degrees . Reliability coefficients for intra-tester reliability (ICC[3,10]) ranged from 0.75-0.76 in supine, 0.86-0.87 in sitting and 0.87-0.88 in standing. The standard error of measurement for repeated measures by the same tester was less than 1.7 degrees and the limits of agreement ranged from -8.13 degrees to 7.90 degrees . The second study showed that using a more detailed electrogoniometer attachment protocol reduced the error of measurement between testers to 0.5 degrees .

CONCLUSION

Using a standardised protocol, reliable measures of knee joint angles can be gained in standing, supine and sitting by using a flexible goniometer.

Test-retest reliability of knee kinesthesia in healthy adults

Background

Sensory information from mechanoreceptors in the skin, muscles, tendons, and joint structures plays an important role in joint stability. A joint injury can lead to disruption of the sensory system, which can be measured by proprioceptive acuity. When evaluating proprioception, assessment tools need to be reliable. The aim of this study was to assess the test-retest reliability of a device designed to measure knee proprioception.

Methods

Twenty-four uninjured individuals (14 women and 10 men) were examined with regard to test-retest reliability of knee kinesthesia, measured by the threshold to detection of passive motion (TDPM). Measurements were performed towards extension and flexion from the two starting positions, 20 degrees and 40 degrees knee joint flexion, giving four variables. The mean difference between test and retest together with the 95% confidence interval (test 2 minus test 1), the intraclass correlation coefficient (ICC_2,1), and Bland and Altman graphs with limits of agreement, were used as statistical methods for assessing test-retest reliability.

Results

The intraclass correlation coefficients ranged from 0.59 to 0.70 in all variables except one. No difference was found between test and retest in three of the four TDPM variables. TDPM would need to decrease between 10% and 38%, and increase between 17% and 24% in groups of uninjured subjects to be 95% confident of detecting a real change. The limits of agreement were rather wide in all variables. The variables associated with the 20-degree starting position tended to have higher intraclass correlation coefficients and narrower limits of agreement than those associated with 40 degrees.

Conclusion

Three TDPM variables were considered reliable for observing change in groups of subjects without pathology. However, the limits of agreement revealed that small changes in an individual's performance cannot be detected. The higher intraclass correlation coefficients and the narrower limits of agreement in the variables associated with the starting position of 20 degrees knee joint flexion, indicate that these variables are more reliable than those associated with 40 degrees. We, therefore, recommend that the TDPM be measured with a 20-degree starting position.

A prospective study on knee proprioception after meniscal allograft transplantation

The meniscus plays an important role in the proprioceptive ability of the knee joint. The aim of this prospective study was to assess the short-term influence of a meniscus replacement on the proprioception of the knee. Fourteen patients who had undergone a fresh meniscal allograft transplantation between May 2001 and June 2003 were tested pre-operatively and 6 months post-operatively. Disability regarding pain, stiffness and functionality of the affected knee during daily activities was measured by the Western Ontario and McMaster Universities Arthritis (WOMAC) scale. The knee joint position sense was assessed using the Biodex System 3 isokinetic dynamometer. The results of the WOMAC scale showed no significant differences concerning pain, stiffness or knee function between the pre- and post-operative condition of the knee. Assessment of the knee joint position sense at a reference point of 70 degrees of knee flexion revealed a significant improvement of the proprioception of the operated knee at 6 months after surgery compared with the pre-operative condition. The results of this study suggest that although no significant improvement of pain and functionality of the operated knee occurred at this short-term follow-up period, a meniscal allograft transplantation seems to have a significant positive effect on the joint position sense of the previously meniscectomised knee.

The effects of menstrual cycle on the knee joint position sense: preliminary study

The purpose of this study was to determine the effects of menstrual cycle on proprioception by using the active knee joint position sense test (JPST). The 19 healthy women (ages between 20 years and 27 years) who have normal regular menstrual cycle were included in the study. We applied JPSTs at two different directions throughout the three different phases of the menstrual cycle, i.e. menstrual, follicular, and early luteal in dominant knees. When we started from flexion (90 degrees ), target angles were 70 degrees , 50 degrees , and 30 degrees and we started from extension (0 degrees ), target angles were 20 degrees , 40 degrees and 60 degrees . The absolute reposition errors from the target angles have been evaluated. Results have shown that reposition errors from the target angle at 40 degrees , 50 degrees and 70 degrees of knee angles were higher in the menstrual phase than that of the follicular phase (P<0.05). In addition, higher value of reposition error from the target angle at 40 degrees was found in the menstrual phase compared to luteal phase (P<0.05). In conclusion, we have demonstrated that active JPST was significantly reduced in the menstruation period.