Inter- and intrarater reliability of goniometry and hand held dynamometry for patients with subacromial impingement syndrome

The reliability and concurrent validity of goniometric and visual estimation in participants with unilateral shoulder pain

INTRODUCTION

The Constant-Murley Score (CMS) uses universal goniometry (UG), and the Shoulder Functional Reach Score (SFRS) uses visual estimation (VE). The CMS has validity challenges, and the SFRS has been critiqued for using VE. This study sought to determine the reliability and concurrent validity of VE when compared to the UG for shoulder flexion and abduction. Differences between symptomatic and asymptomatic shoulder and expert and novice raters were also explored.

METHODS

Participants were included if they were at least 18 years old with unilateral, symptomatic shoulder pain, with no post-surgical contraindications. All conditions were randomized, and raters were blinded.

RESULTS

The intertester reliability for UG had Intraclass Correlation Coefficient (ICC) values of 0.76-0.91 at visit one. VE had ICC values that ranged from 0.87 to 0.92 at visit one. VE test-retest reliability had ICC values from 0.81 to 0.94. At visit one, concurrent validity was demonstrated by rho values from 0.84 to 0.89. There were statistically significant differences between the shoulders (P ≤ 0.0448), and there were no differences between the raters (P ≥ 0.0960).

DISCUSSION

UG and VE of active shoulder flexion and abduction are reliable and concurrently valid. Additionally, there were differences between symptomatic and asymptomatic shoulders, and there were no differences between novice and expert raters.

CONCLUSION

The SFRS may be reliable and valid for measuring shoulder motion using VE within and between treatment sessions. Future research should examine this in larger, more diverse participant populations.

The effect of kinesio® tape on scapulothoracic joint kinematics in young healthy participants

INTRODUCTION

The purpose of this study was to investigate the effects of Kinesio® tape on scapulothoracic joint kinematics during humerothoracic elevation and lowering in asymptomatic participants.

METHOD

Sixteen males and 24 females participated in data collection using the Polhemus G4 3D electromagnetic motion capture system. Dominant shoulder kinematics were collected while the participant performed three repetitions of elevation in the frontal, sagittal, and scapular planes. Initial data collection occurred with and subsequent data collection without Kinesio® tape. Scapular upward rotation and posterior tilting were compared between the two conditions between 30 and 90 degrees of elevation.

RESULTS

During abduction elevation, participants demonstrated 3.40° more posterior tilting (p = 0.001), and 2.58° less upward rotation (p = 0.006) with Kinesio® tape. During lowering in the scapular plane, participants demonstrated 2.05° less downward rotation (p = 0.008) with Kinesio® tape.

DISCUSSION

People with subacromial impingement and multidirectional instability demonstrate decreased upward rotation. People with subacromial impingement also demonstrate decreased posterior tilting. Posterior tilting differences found during elevation as well as upward rotation differences found during lowering in this study indicate Kinesio® tape may be beneficial to patients with impingement or multidirectional instability.

CONCLUSION

Kinesio® tape significantly alters scapulothoracic kinematics during humerus to trunk elevation. The clinical significance of this remains to be investigated.

The Intrarater and Interrater Reliability and Validity of Universal Goniometer, Digital Inclinometer, and Smartphone Application Measuring Range of Motion in Patients with Total Knee Arthroplasty

Objectives

The aim of this study was to investigate the intrarater and interrater reliability and validity of range of motion measurements obtained with a universal goniometer, digital inclinometer, and smartphone application in patients with total knee arthroplasty.

Methods

Range of motion of the knee joint was measured by two examiners with a universal goniometer, digital inclinometer, and a smartphone application. Data were obtained from 51 knees of 27 patients at postoperative 6 months. Two measurements made by the first examiner were compared to assess interrater reliability, and measurements from both examiners were compared to assess intrarater reliability. Statistical analysis was performed using intraclass correlation coefficient (ICC) and Spearman's rho values.

Results

With all three methods, active and passive knee flexion range of motion measurements showed high intrarater and interrater reliability (ICC = 0.749-0.949). Concurrent validity analysis also demonstrated statistically significant, moderate to strong correlation among the three methods (r = 0.775-0.941).

Conclusion

The universal goniometer, digital inclinometer, and smartphone application were all found to be reliable and valid assessment tools in clinical practice for patients with total knee arthroplasty.

Closing-wedge Osteotomies: Can We Do and Teach Better?

BACKGROUND

Wedge osteotomies are ubiquitous in pediatric orthopaedics and limb deformity surgery; however, there is no universally preferred methodology for these procedures. This study aims to determine the relative accuracy and effectiveness of several measuring and marking methods to guide best practices for wedge-shaped osteotomies in long bones.

METHODS

An observational cohort study was completed. Orthopaedic residents (postgraduate years 1 to 5) completed 30-degree wedge osteotomies on a sawbone (Pacific Research Lab) femur utilizing a standard oscillating saw under 3 measuring conditions: (1) no measurement tool, (2) 30-degree triangle, and (3) goniometer, in combination with 2 different marking methods: (1) marking pen or (2) pin placement. Demographic characteristics and osteotomy performance (quality, completion time, and accuracy) were assessed. Quality was ranked as perfect (1), mild step-off (2), or gross surface irregularity (3). Multivariate regressions and analysis of variance were performed comparing demographics, osteotomy performance, and measuring methods.

RESULTS

Twenty-four residents were included for analysis; 6 were female (25%). Female sex was independently associated with longer completion time when evaluating all combined scenarios (138 vs. 99 s, P =0.003) without differences in surface quality or angle accuracy. There were no significant associations between measuring technique and accuracy or surface quality, but use of the goniometer and the triangle both were associated with significantly longer completion time compared with no visual aid ( P =0.002 and 0.007). When controlling for measuring technique, use of the pen as a marking technique had significantly shorter completion times ( P <0.001), higher surface quality ( P <0.001), and better accuracy ( P <0.001) than guide pins.

CONCLUSIONS

We recommend the use of a marking pen in combination with the surgeon's preferred measuring guide to optimize trainees' performance of closing wedge osteotomies. Future research is necessary to corroborate these findings in a higher fidelity setting, such as a cadaveric study. Further, while male residents complete wedge osteotomies quicker than female residents, quality and accuracy are comparable among trainees. Slower pace should not be conflated with poor performance but rather should inform effective intraoperative teaching for diverse trainees.

External to internal glenohumeral strength ratio in non-traumatic rotator cuff pathologies

Background and study aims

A correct agonist -antagonist strength relationship for shoulder external and internal rotation is necessary for functional stability of the shoulder. This strength relationship is described by the ratio of external to internal strength (ER/IR).The aim of this stydy is to produce comparative data as regards the ER/IR ratio in subjects with different non-traumatic rotator cuff diseases.

Design and setting

A cross-sectional study in an outpatient clinic in a tertiary care university hospital.

Methods

In 55 subjects with rotator cuff disease (confirmed by physical examination and assessed by ultrasound and magnetic resonance arthrography), the ER/IR ratio of the shoulder was isometrically measured with a hand-held dynamometer and compared with values pertaining to the unaffected shoulder of the same individuals.

Results

The mean ER/IR values in the overall group were 0.89 (SD 0.18) and 0.94 (SD 0.22) for the affected and unaffected shoulders, respectively. The ratio was 0.87 (SD 0.23) in patients with subdeltoid bursitis, 0.88 (SD 0.16) in rotator cuff tendinopathy and 0.87 (SD 0.22) in patients with rotator cuff tears.

Conclusions

The ER/IR ratio appears to be similar between the affected and unaffected shoulders of subjects with nontraumatic cuff pathologies.

Interpositional scaffold anchor rotator cuff footprint tear repair: excellent survival, healing, and early outcomes

PURPOSE

Shoulder function limitation duration after a full-thickness rotator cuff tendon (RCT) tear may influence post-repair healing and outcomes. A suture anchor was developed to improve footprint repair fixation and healing through biological fluid delivery and scaffold augmentation. The primary multicenter study objective was to evaluate RCT repair failure rate based on 6-month MRI examination, and device survival at 1-year follow-up. The secondary objective was to compare the clinical outcomes of subjects with shorter- and longer-term shoulder function limitation duration.

METHODS

Seventy-one subjects (46 men) with moderate-to-large RCT tears (1.5-4 cm), at a median 61 years of age (range = 40-76), participated in this study. Pre-repair RCT tear location/size and 6-month healing status were confirmed by an independent radiologist. Subjects with shorter- (Group 1: 17.8 ± 21 days, n = 37) and longer-term (Group 2: 185.4 ± 89 days, n = 34) shoulder function limitation durations were also compared over 1 year for active mobility, strength, American Shoulder and Elbow Surgeon's Shoulder Score (ASES score), Veterans RAND 12 Item Health Survey (VR-12), and visual analog scale (VAS) pain and instability scores.

RESULTS

Three of the 52 subjects [5.8%] who underwent 6-month MRI experienced a re-tear at the original RCT footprint repair site. By the 1-year follow-up, overall anchor survival was 97%. Although Group 2 displayed lower ASES and VR-12 scores pre-repair (ASES = 40.1 ± 17 vs. 47.9 ± 17; VR-12 physical health (PH) = 37.2 ± 9 vs. 41.4 ± 8) (p ≤ 0.048), at 3-month post-RCT repair (ASES = 61.3 ± 19 vs. 71.3 ± 20; VR-12 PH = 40.8 ± 8 vs. 46.8 ± 9) (p ≤ 0.038), and at 6-month post-RCT repair (ASES = 77.4 ± 18 vs. 87.8 ± 13; VR-12 PH = 48.9 ± 11 vs. 54.0 ± 9) (p ≤ 0.045), by 1-year post-RCT repair, groups did not differ (n.s.). Between-groups VR-12 mental health score differences were not evident at any time period (n.s.). Shoulder pain and instability VAS scores also did not differ (n.s.), displaying comparable improvement between groups from pre-RCT repair to 1-year post-RCT repair. Groups had comparable active shoulder mobility and strength recovery at each follow-up (n.s.).

CONCLUSION

At 6-month post-RCT repair, only 3/52 of patients [5.8%] had a footprint re-tear, and at 1-year follow-up, overall anchor survival was 97%. Use of this scaffold anchor was associated with excellent early clinical outcomes regardless of shoulder function impairment duration.

LEVEL OF EVIDENCE

II.

Intra- and interrater reliability of belt-stabilized hand-held dynamometer in scapular protraction strength tests in individuals with shoulder pain

PURPOSE

Scapular protraction strength can be evaluated using a hand-held dynamometer (HHD). However, it is necessary to measure the reliability of HHD in individuals with shoulder pain and to minimize the limitations related to the evaluator and the low methodological quality cited in previous studies. This study assessed, with methodological enhancement, the intra- and interrater reliability of belt-stabilized HHD in the assessment of scapular protraction strength in individuals with shoulder pain.

METHOD

Fifty individuals with unilateral symptoms of subacromial pain syndrome (20 men, aged 40.5 ± 15.3 years) were evaluated in two sessions using the belt-stabilized HHD for maximum isometric strength of scapular protraction with the individual in the sitting and supine positions. Reliability values were obtained using the intraclass correlation coefficient with the standard error of measurement (SEM and %SEM) and the minimal detectable change (MDC).

RESULTS

The intra- and interrater HHD reliability were excellent for all measurements ranging from 0.88 to 0.96 (SEM = 2.0-4.0 kg; %SEM 12 to 17; MDC = 6-11 kg).

CONCLUSION

Belt-stabilized HHD is reliable for the assessment of scapular protraction strength in individuals with subacromial pain syndrome in both the sitting and supine positions.

Grip and shoulder strength correlation with validated outcome instruments in patients with rotator cuff tears

HYPOTHESIS/BACKGROUND

The ability to better define preoperatively the extent of rotator cuff (RC) dysfunction is desired. The study's purpose was to prospectively examine the relationships between absolute and percentage loss (affected compared to unaffected) of grip and shoulder strength, and RC dysfunction.

METHODS

Forty-seven consecutive patients with proven RC tears participated in this study. Prior to surgery, bilateral strengths of grip, shoulder abduction, and shoulder external rotation (ER) were measured with a handheld dynamometer, and subjective outcome measures were gathered. RC tear size was determined via arthroscopy. Patient-reported outcomes were gathered on the day of the examination or via e-mail following initial evaluation. Descriptive statistics, difference analysis, and correlation coefficients (reported as either direct or negative) were used to analyze data. Grip, abduction and ER strengths, and percentage loss of grip, abduction, and ER strengths (percentage loss affected vs. unaffected), and tear size were analyzed in relation to all of the scores on selected subjective outcome measurement tools. The P value was set at .05.

RESULTS

Fair direct correlations were found between grip strength and the Veterans RAND 12-Item Health Survey (VR-12) mental health scores, ER strength and Simple Shoulder Test (SST), abduction strength, and both the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) function score and SST score. Abduction and ER strengths were also found to possess a fair direct correlation. Fair negative correlations were found between the ASES function score and each of the following: percentage loss of abduction strength, percentage loss of ER strength, and tear size in centimeters. Another fair negative correlation was found between the Single Assessment Numerical Evaluation (SANE) score and tear size in centimeters.

DISCUSSION

Our findings suggest that as shoulder strength decreases, ipsilateral shoulder RC dysfunction increases. Grip strength was not related to shoulder RC dysfunction.

CONCLUSION

Grip strength was not found to correlate with RC tears. Those with decreased abduction and ER strengths and low ASES scores should be considered more likely to have an RC tear.

A Novel Rehabilitation Program Using Neuromuscular Electrical Stimulation (NMES) and Taping for Shoulder Pain in Swimmers: A Protocol and Case Example

In-pool return to swim protocols have been described for swimmers returning from being deactivated from swimming due to a shoulder injury who have full shoulder strength. Many swimmers actively participate in swim practice and competition with shoulder pain and experience deficits in performance. There are multiple reported risk factors associated with shoulder pain among swimmers, including training errors and physical impairments. These include pool and dry-land training errors, weakness in the scapular stabilizers and rotator cuff, and muscle tightness. A need exists for dry-land rehabilitation programs for impairments common to swimmers that can be performed in a traditional outpatient physical therapy setting. The purpose of this clinical commentary is to present a protocol using neuromuscular electrical stimulation (NMES), taping, strengthening, and stretching to address impairments that are common among swimmers while allowing continued active participation in practice and competition.

LEVEL OF EVIDENCE

Level 5.

Massage for Combat Injuries in Veteran with Undisclosed PTSD: a Retrospective Case Report

INTRODUCTION

Massage has shown promise in reducing symptoms related to dissociation and anxiety that can exacerbate chronic pain and suffering. The combat wounded, veteran population is increasing and requires a multidisciplinary approach for comprehensive treatment. This case study examines massage therapy use to improve veteran combat injury rehabilitation and recovery experience through purposive, retrospective, and comprehensive SOAP note review.

METHODS

A 31-year-old White male received seven, 60-min, full body massages for combat related shoulder injury complications incurred approximately six years before presentation. The right shoulder sustained a broken humeral head and complete dislocation during a defensive maneuver in a life-threatening attack. This case study utilized data from three different assessments: goniometric measurements for shoulder range of motion, observation and documentation for environmental comfort behaviors, and client self-report for treatment goal attainment. Six weekly, full body, 60-min massages were completed sequentially. A follow-up 60-min treatment was completed at Week 8. Treatment to the injured area included focused trigger point therapy, myofascial release, and proprioceptive neuromuscular facilitation to the neck, shoulder, and chest.

RESULTS

Total percent change for active flexion, extension, abduction, adduction, internal rotation, and external rotation were 12.5, 150, 40, 167, 14.3, and 0%, respectively. Total percent change for passive flexion, extension, abduction, adduction, internal rotation, and external rotation were 63.6, 350, 66.7, 450, 133, and 77.8%, respectively. Environmental comfort behaviors were reduced. Client treatment goals were attained.

CONCLUSIONS

Massage therapy provided meaningful benefit to a combat injury for a veteran with PTSD.

Measurement properties of handheld dynamometry for assessment of shoulder muscle strength: A systematic review

Like any assessment tool, handheld dynamometry (HHD) must be valid and reliable in order to be meaningful in clinical practice and research. To summarize the evidence of measurement properties of HHD for the assessment of shoulder muscle strength. Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, EMBASE, and PEDro were searched up to February 2020. Inclusion criteria were studies (a) evaluating HHD used on the glenohumeral joint, (b) evaluating measurement properties, and (c) included individuals ≥ 18 years old with or without shoulder symptoms. Exclusion criteria were studies (a) including patients with neurologic, neuromuscular, systemic diseases, or critical illness or bed-side patients and (b) that did not report the results separately for each movement. In total, 28 studies with 963 participants were included. The reliability results showed that 98% of the intraclass correlation coefficient (ICC) values were ≥0.70. The measurement error showed that the minimal detectable change in percent varied from 0% to 51.0%. The quality of evidence was high or moderate for the majority of movements and type of reliability examined. Based on the evidence of low or very low quality of evidence, the convergent validity and discriminative validity of HHD were either sufficient, indeterminate, or insufficient. The reliability of HHD was overall sufficient, and HHD can be used to distinguish between individuals on the group level. The measurement error was not sufficient, and evaluation of treatment effect on the individual level should be interpreted with caution.

The Reliability and Validity of Wearable Inertial Sensors Coupled with the Microsoft Kinect to Measure Shoulder Range-of-Motion

Background: Objective assessment of shoulder joint active range of motion (AROM) is critical to monitor patient progress after conservative or surgical intervention. Advancements in miniature devices have led researchers to validate inertial sensors to capture human movement. This study investigated the construct validity as well as intra- and inter-rater reliability of active shoulder mobility measurements using a coupled system of inertial sensors and the Microsoft Kinect (HumanTrak). Methods: 50 healthy participants with no history of shoulder pathology were tested bilaterally for fixed and free ROM: (1) shoulder flexion, and (2) abduction using HumanTrak and goniometry. The repeat testing of the standardised protocol was completed after seven days by two physiotherapists. Results: All HumanTrak shoulder movements demonstrated adequate reliability (intra-class correlation (ICC) ≥ 0.70). HumanTrak demonstrated higher intra-rater reliability (ICCs: 0.93 and 0.85) than goniometry (ICCs: 0.75 and 0.53) for measuring free shoulder flexion and abduction AROM, respectively. Similarly, HumanTrak demonstrated higher intra-rater reliability (ICCs: 0.81 and 0.94) than goniometry (ICCs: 0.70 and 0.93) for fixed flexion and abduction AROM, respectively. Construct validity between HumanTrak and goniometry was adequate except for free abduction. The differences between raters were predominately acceptable and below ±10°. Conclusions: These results indicated that the HumanTrak system is an objective, valid and reliable way to assess and track shoulder ROM.

Electrical interferential current stimulation versus electrical acupuncture in management of hemiplegic shoulder pain and disability following ischemic stroke-a randomized clinical trial

Background

Hemiplegic Shoulder Pain (HSP) is among common complications occurring after stroke leading to disability. This study was conducted to compare the effects of electrical Interferential Current stimulation (IFC) and Electrical Acupuncture (EAC) on pain intensity, range of motion, and functional ability in patients with HSP and also comparing the two modalities regarding improvement of above indices.

Methods

In this randomized clinical trial, 46 patients with HSP caused by ischemic stroke were recruited and assigned into 2 groups. Conventional exercise trainings were applied for both groups. Group A received additional IFC with medium frequency of 4000 HZ, and Group B received additional EAC two times a week for a total of 10 sessions. Pain severity, daily function, and shoulder Range of Motion (ROM) were evaluated using Visual Analogue Scale (VAS), Shoulder Pain and Disability Index (SPADI), and goniometry, respectively before and 5 weeks after the treatment.

Results

Both groups showed relative improvement in pain severity, SPADI score, and its subscales, and also active and passive shoulder ROM after the treatment. However, IFC group compared to EAC group had higher mean changes of active ROM in abduction (28.00 ± 3.81 vs. 12.25 ± 2.39) and functional subscale of SPADI (11.45 ± 1.88 vs. 5.80 ± 1.66) after the treatment. On the contrary, EAC group showed higher percentage of VAS changes (46.14 ± 6.88 vs. 34.28 ± 5.52), indicating better pain improvement compared to IFC group. Other parameters did not show significant difference between two groups.

Conclusion

Both IFC and EAC caused short term improvement in functional state, increased motion, and decreased pain in patients with HSP. Although pain control was more evident in acupuncture group, IFC resulted in better effects on function and active ROM of abduction, and seems to have higher efficacy.

Trial registration

This clinical trial was registered in the Iranian Registry of Clinical Trials at 2016-07-16 with a registry number of IRCT201602153217N10.

Contralateral Muscle Imbalances and Physiological Profile of Recreational Aerial Athletes

BACKGROUND

Aerial fitness is quickly gaining popularity; however, little is known regarding the physiological demands of aerial athletes. The purpose of the study was to examine contralateral muscle imbalances, compare dominant versus non-dominant hamstrings-to-quadriceps (H:Q) ratios, and to establish a physiological profile of recreational aerial athletes.

METHODS

Thirteen aerialist women visited a local aerial studio to participate in a data collection session to examine isometric levels of upper and lower body strength, muscle endurance, flexibility, balance, and cardiovascular fitness.

RESULTS

No significant differences were found between dominant and non-dominant hand grip strength (p = 0.077), dominant and non-dominant isometric knee flexion (p = 0.483), dominant and non-dominant isometric knee extension (p = 0.152), or dominant and non-dominant isometric H:Q ratios (p = 0.102). In addition, no significant difference was found between isometric dominant H:Q ratio and the widely-used value of 0.60 (p = 0.139). However, isometric non-dominant H:Q ratio was significantly lower than the 0.60 criterion (p = 0.004). Aerial athletes demonstrated to have excellent flexibility, balance, cardiorespiratory fitness, and average strength.

CONCLUSIONS

Aerial fitness may be another recreational activity that could be used to maintain higher levels of flexibility, balance, cardiorespiratory fitness, and strength. Aerialists may want to consider focusing on strengthening the lower body and balancing the hamstrings and quadriceps muscle strength.