Knee position sense: does the time interval at the target angle affect position accuracy?

Knee proprioception four months after anterior cruciate ligament reconstruction: Impact of limb dominance, anterolateral procedure, and association with readiness to return to sport

BACKGROUND

Knee proprioception may be compromised after anterior cruciate ligament reconstruction (ACLR), but associated factors and impact remain unclear. This study evaluated knee proprioception 4 months after primary ACLR, compared with healthy controls, and explored the impacts of leg dominance, anterolateral procedures (AEAPs), and their association with psychological readiness to return to sports.

METHODS

This prospective cohort study included 30 ACLR participants and 20 healthy controls. Isokinetic testing measured knee strength and proprioception, using passive joint position sense (JPS1: detection, JPS2: repositioning) and kinesthesia (threshold to detection of passive motion). At 8 months, ACLR participants completed the ACL-RSI scale to assess psychological readiness to return to sports.

RESULTS

At 4 months postoperative, kinesthesia was better in the operated limb than the non-operated limb (p = 0.008), but position sense did not differ significantly. There were no significant differences in kinesthesia or position sense between ACLR participants and controls. The operated limb had worse JPS2 if the ACLR was on the non-dominant side. Proprioception was unaffected by AEAPs, and only repositioning showed a moderate, non-significant correlation with ACL-RSI (r = -0.377).

CONCLUSION

At 4 months post-ACLR, kinesthesia improved in the operated leg; dominance influenced position sense, highlighting the need for personalized rehabilitation.

Smartphone Proprioception for Ankle Navigation (SPAN): Reliability and Effect of Position Exposure Time

This study investigated ankle discriminative acuity and performance and measurement consistency for tests undertaken with different joint position exposure times (PETs). Twenty-four participants were tested using a novel Smartphone Proprioception for Ankle Navigation (SPAN) under four PETs, i.e., 0.25s, 0.5s, 0.75s and 1s, delivered in a random sequence, and then re-tested within one week. The results indicated a PET main effect (F = 10.12, p = 0.004, partial ƞ2 = 0.14), and limb preference main effect (F = 5.39, p = 0.03, partial ƞ2 = 0.19), without significant interactions (p > 0.05). Ankle proprioception improved with prolonged PET, with the non-dominant side outperforming the dominant side. A PET of 0.25s showed good to excellent reliability, with intraclass correlation coefficients (ICCs) of 0.897 (95%CI: 0.761, 0.955) and 0.885 (95%CI: 0.736, 0.951), with standard errors of measurements (SEM) between 0.030 and 0.035, and minimum detectable change at 90% (MDC90) between 0.070 and 0.082, compared to poor to moderate reliability at the other three longer PETs (ICCs =0.352-0.736). The findings suggested the prolongation of PET can improve ankle proprioceptive performance but can amplify the inter-occasion variability, likely due to increased cognitive analysis with longer stimulus sampling. SPAN may thus be a cost-effective and accessible apparatus for clinical practice.

Test-Retest Reliability of a Passive Joint Position Sense Test After ACL Reconstruction: Influence of Direction, Target Angle, Limb, and Outcome Measures

Background:

The joint position sense (JPS) is an element of proprioception and defined as an individual’s ability to recognize joint position in space. The JPS is assessed by measuring the acuity of reproducing a predetermined target angle. The quality of psychometric properties of knee JPS tests after anterior cruciate ligament reconstruction (ACLR) is uncertain.

Purpose/Hypothesis:

The purpose of this study was to evaluate the test-retest reliability of a passive knee JPS test in patients who underwent ACLR. We hypothesized that the passive JPS test would produce reliable absolute error, constant error, and variable error estimates after ACLR.

Study Design:

Descriptive laboratory study.

Methods:

Nineteen male participants (mean age, 26.3 ± 4.4 years) who had undergone unilateral ACLR within the previous 12 months completed 2 sessions of bilateral passive knee JPS evaluation. JPS testing was conducted in both the flexion (starting angle, 0°) and the extension (starting angle, 90°) directions in the sitting position. The absolute error, constant error, and variable error of the JPS test in both directions were calculated at 2 target angles (30° and 60° of flexion) by using the angle reproduction method for the ipsilateral knee. The standard error of measurement (SEM), smallest real difference (SRD), and intraclass correlation coefficients (ICCs) with 95% Cis were calculated.

Results:

ICCs were higher for the JPS constant error (operated and nonoperated knee, 0.43-0.86 and 0.32-0.91, respectively) compared with the absolute error (0.18-0.59 and 0.09-0.86, respectively) and the variable error (0.07-0.63 and 0.09-0.73, respectively). The constant error of the 90°-60° extension test showed moderate to excellent reliability for the operated knee (ICC, 0.86 [95% CI, 0.64-0.94]; SEM, 1.63°; SRD, 4.53°), and good to excellent reliability for the nonoperated knee (ICC, 0.91 [95% CI, 0.76-0.96]; SEM, 1.53°; SRD, 4.24°).

Conclusion:

The test-retest reliability of the passive knee JPS tests after ACLR varied depending on the test angle, direction, and outcome measure (absolute error, constant error, or variable error). The constant error appeared to be a more reliable outcome measure than the absolute error and the variable error, mainly during the 90°-60° extension test.

Clinical Relevance:

As constant errors have been found reliable during the 90°-60° extension test, investigating these errors—in addition to absolute and variable errors—to reflect bias in passive JPS scores after ACLR is warranted.

The Clinical Benefits of a Dynamic vs. Static Component as Part of a Comprehensive Warm-Up for Recreational Sports Players with Clinical Histories of Hamstring Injuries: A Randomized Clinical Trial

Background: Few previous studies have analyzed the effects of certain specific static and dynamic warm-up components on recreational sports players with a previous hamstring injury. Therefore, the aim of this study was to analyze changes in some modifiable and external risk factors after (immediately and in a follow-up assessment after 10 min) a static or dynamic warm-up program on recreational sports players with a previous hamstring injury. Methods: A total of 62 participants were randomized into 2 groups: static warm-up (SW) (n = 31) or dynamic warm-up (DW) (n = 31). Range of movement (RoM), perceived pain, the pressure−pain threshold, and joint position sense were assessed at baseline, immediately after the intervention and 10 min afterwards. The intervention for the SW (hot pack procedures in both hamstring muscles) lasted 20 min. The DW intervention consisted of a running exercise performed on a treadmill for 10 min. Results: Both groups showed statistically significant changes (p ≤ 0.05) in the primary outcomes (perceived pain and the pressure−pain threshold) at the three measurement times (this was also true for RoM for the SW group, with statistically significant differences only between times from the baseline to the 10-min follow-up; p ≤ 0.05, d = 0.23). The intra-group secondary outcome showed no statistically significant changes (p > 0.05) in both groups (except for the period from the baseline−immediately after in the DW group; p ≤ 0.05, d = 0.53). The comparison between groups showed no statistically significant differences for any of the variables analyzed. (p ≥ 0.05). Conclusion: The present findings suggest that both specific warm-up modalities seem to positively influence perceived pain on stretching and the pressure threshold; however, the significant reduction in the joint repositioning error and the larger effect sizes observed in the DW group suggest that this method has a greater beneficial impact in recreational sports players with clinical histories of hamstring injuries.

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 a Novel Proprioceptive Rehabilitation Device on Shoulder Joint Position Sense, Pain and Function

Background and Objectives: Shoulder disorders are associated with pain, restricted range of motion and muscular strength, moderate disability and diminished proprioception. This study aimed to compare the effectiveness of an innovative technology-supported and a classical therapist-based proprioceptive training program in addition to conventional physiotherapy, on joint position sense (JPS), pain and function, in individuals with different musculoskeletal shoulder disorders, such as rotator cuff tear, subacromial impingement syndrome and superior labrum anterior and posterior tear. The innovative element of the proprioceptive training programme consists of the use of the Kinesimeter, a device created for both training and assessing shoulder JPS. Materials and Methods: The shoulder JPS test and the DASH outcome questionnaire were applied to fifty-five individuals (28 females, 27 males, mean age 56.31 ± 6.75), divided into three groups: 17 in the conventional physiotherapy group (control group); 19 in the conventional physiotherapy + classical proprioceptive training program group (CPT group); and 19 in the conventional physiotherapy + innovative proprioceptive training program group (KPT group). Assessments were performed before and after a four-week rehabilitation program, with five physiotherapy sessions per week. Results: When baseline and post-intervention results were compared, the value of the shoulder JPS and DASH outcome questionnaire improved significantly for the KPT and CPT groups (all p < 0.001). Both KPT and CPT groups showed statistically significant improvements in JPS, pain and function, compared to the control group which received no proprioceptive training (all p < 0.05). However, the KPT group showed no significant benefits compared to the CPT group. Conclusions: Our findings indicate that using the Kinesimeter device as a novel, innovative proprioceptive training tool has similar effects as the classical proprioceptive training programs among individuals with different non-operated musculoskeletal shoulder disorders such as: rotator cuff tear, subacromial impingement syndrome, and superior labrum anterior and posterior tear.

Effect of Load, Angle, and Contraction Type on Clinically Assessed Knee Joint Position Sense

CONTEXT

Proprioception is an individual's awareness of body position in 3-dimensional space. How proprioceptive acuity changes under varying conditions such as joint position, load, and concentric or eccentric contraction type is not well understood. In addition, a limitation of the variety of techniques to assess proprioception is the lack of clinically feasible methods to capture proprioceptive acuity. The purpose of this study was to implement a readily available instrument, a smartphone, in the clinical evaluation of knee active joint position sense and to determine how joint angle, joint loading, and quadriceps contraction type affect an individual's active joint position sense.

DESIGN

Cross-over study.

METHODS

Twenty healthy, physically active university participants (10 women and 10 men: 21.4 [2.0] y; 1.73 [0.1] m; 70.9 [14.3] kg) were recruited. Individuals were included if they had no neurological disorder, no prior knee surgery, and no recent knee injury. The participants were given a verbal instruction to locate a target angle and then were tasked with reproducing the target angle without visual or verbal cues. An accelerometer application on a smartphone was used to assess the angle to the nearest tenth of a degree. Three variables, each with 2 levels, were analyzed in this study: load (weighted and unweighted), contraction type (eccentric and concentric), and joint position (20° and 70°). A repeated-measures analysis of variance was conducted to assess the within-subjects factors of load, contraction, and position.

RESULTS

A significant difference of 0.50° (0.19°) of greater error with eccentric versus concentric contraction (P = .02) type was identified. In addition, a significant interaction was found for contraction × position, with a mean increase in error of 0.98° (0.33°) at the 20° position when contracting eccentrically (P = .03).

CONCLUSIONS

Contraction type, specifically eccentric contraction at 20°, showed significantly greater error than concentric contraction. This suggests that, during eccentric contractions of the quadriceps, there may be decreased proprioceptive sensitivity compared with concentric contractions.

Recent Ankle Injury, Sport Participation Level, and Tests of Proprioception

OBJECTIVE

Assessing the effects of ankle injury and sport participation level on ankle proprioceptive sensitivity using a joint position reproduction (JPR) test and an inversion movement extent discrimination test.

DESIGN

Cross-sectional.

SETTING

Biomechanics lab.

PARTICIPANTS

Forty-five student athletes ages 21-30 (mean = 24.8 y).

MAIN OUTCOME MEASURES

Participants were tested for ankle inversion sensitivity using 2 devices; movement reproduction error was obtained from JPR in a non-weight-bearing (N-WB) state at 10° and 15° of inversion, and an ankle proprioceptive sensitivity score was obtained from the active movement extent discrimination apparatus (AMEDA), representing the ability to differentiate 5 inversion movement extents between 10.5° and 14.5°, with testing in both N-WB and weight-bearing (WB) states.

RESULTS

For the 34 athletes with no ankle injury in the previous 12 months, the sensitivity scores achieved on the AMEDA were significantly higher (P < .01) than those for the 11 athletes with ankle injury, and the injury effect was significantly greater in WB (P = .01). In JPR testing, the 2.96° error of reproduction for athletes with no recent ankle injury was not significantly different from the 3.36° error for those with ankle injury (P = .46). Correlation of current sport participation level with JPR showed less error for higher-level performers (r = .49, P = .001) but no significant relationship to WB or N-WB AMEDA scores (both P > .61). WB AMEDA scores were significantly higher for athletes who had competed at a higher level of sport competition when <18 years old (r = -.57, P < .001).

CONCLUSIONS

Previous ankle sprains affected proprioceptive scores on the WB AMEDA and N-WB AMEDA tests, indicating the sensitivity of the AMEDA movement discrimination test to the effects of ankle injury. The correlation between JPR scores and current level of sport participation suggests the sensitivity of the JPR test to current ankle use.

Development of supine and standing knee joint position sense tests

OBJECTIVES

We aimed to assess the test-retest reliability of a supine and standing knee joint position sense (JPS) test, respectively, and whether they discriminate knees with anterior cruciate ligament (ACL) injury from asymptomatic knees.

DESIGN

Repeated measures and cross-sectional.

SETTING

Research laboratory.

PARTICIPANTS

For test-retest reliability, 24 persons with asymptomatic knees. For discriminative analysis: 1) ACLR - 18 persons on average 23 months after unilateral ACL reconstruction, 2) CTRL - 23 less-active persons, and 3) ATHL - 21 activity level-matched athletes.

MAIN OUTCOME MEASURES

Absolute error (AE) and variable error (VE).

RESULTS

Test-retest reliability was generally highest for AE of the standing test (ICC 0.64-0.91). Errors were less for the standing compared to the supine test across groups. CTRL had greater knee JPS AE (P = 0.005) and VE (P = 0.040) than ACLR. ACLR knees showed greater VE compared to the contralateral non-injured knees for both tests (P = 0.032), albeit with a small effect size (η_p² = 0.244).

CONCLUSIONS

Our standing test was more reliable and elicited lesser errors than our supine test. Less-active controls, rather than ACLR, produced significantly greater errors. Activity level may be a more predominant factor than ACLR for knee JPS ∼2 years post-reconstruction.

Immediate effects of neurodynamic nerve gliding versus static stretching on hamstring neuromechanical properties

PURPOSE

We investigated the immediate effects of neurodynamic nerve gliding (ND) on hamstring flexibility, viscoelasticity, and mechanosensitivity, compared with traditional static stretching (ST).

METHODS

Twenty-two physically active men aged 21.9 ± 1.9 years were divided randomly into two equal intervention groups using ST or ND. An isokinetic dynamometer was used to measure the active knee joint position sense, perform passive knee extension, record the passive extension range of motion (ROM) and the passive-resistive torque of hamstrings. Stiffness was determined from the slope of the passive torque-angle relationship. A stress relaxation test (SRT) was performed to analyze the viscoelastic behavior of the hamstrings. The passive straight leg raise (SLR) test was used to evaluate hamstring flexibility.

RESULTS

A significant interaction was observed for ROM and passive ultimate stiffness, reflected by an increase in these indicators after ND but not after SD. SLR increased significantly in both groups. After ST, a significantly faster initial stress relaxation was observed over the first 4 s. than after ND. There was no significant change in the active knee joint position sense.

CONCLUSIONS

ND provided a slightly greater increase in hamstring extensibility and passive stiffness, possibly by decreasing nerve tension and increasing strain in connective tissues than ST. The ST mostly affected the viscoelastic behavior of the hamstrings, but neither intervention had a significant impact on proprioception.

Assessing the concurrent validity and reliability of an iPhone application for the measurement of range of motion and joint position sense in knee and ankle joints of young adults

OBJECTIVE

To analyze the concurrent validity and reliability of an iPhone application for assessing range of motion (ROM) and joint position sense (JPS) in ankle and knee joints.

DESIGN

Cross-sectional study.

SETTING

Sport laboratory.

PARTICIPANTS

Twenty healthy and physically active volunteers.

INTERVENTIONS

All participants performed a ROM and a JPS test in ankle and knee joints, which were simultaneously evaluated with photo-analysis and the iPhone application.

MAIN OUTCOMES MEASURES

A total of 80 angles were obtained with the iPhone app and the photo-analysis and compared for concurrent validity. Reliability was evaluated through re-scoring of images with the iPhone app by two different testers.

RESULTS

Very high correlation was observed between both methods for ankle and knee ROM and knee JPS (r > 0.90), and high correlation for ankle JPS (r = 0.71-0.90), while Bland-Altman plots showed absolute agreement for all the variables. Inter- and intra-tester reliability was perfect for all the variables (ICC > 0.81), except for the inter-tester reliability of ankle JPS, which was substantial (ICC = 0.61-0.81).

CONCLUSIONS

This new iPhone application is valid and reliable for measuring ankle and knee ROM and JPS, although special attention is needed during ankle evaluation to avoid errors.

Effects of Kinesio taping of the knee on proprioception, balance, and functional performance in patients with anterior cruciate ligament rupture: A retrospective case series

To investigate whether Kinesio tape (KT) application improves proprioception, balance, and functional performance in patients with anterior cruciate ligament rupture (ACLr).This retrospective analysis included 48 male patients with surgically-untreated ACLr who attended the Sports Medicine and Rehabilitation Center, Qingdao Municipal Hospital, China between June 2017 and June 2018. KT was applied to induce a detoning effect on the quadriceps muscle and toning effect on the ischiocrural muscles. Proprioception, balance, and functional performance were assessed before and 1 and 7 days after KT application using the Lysholm scale, anteroposterior shift of the tibia (APST), active angle reproduction test (AART), modified star excursion balance test (mSEBT), and single-hop distance (SHD).KT resulted in significant improvements in Lysholm scale at 1 day (83.00 [6.50] vs. 76.00 [5.25], P < .001) and APST (8.00 [2.00] vs. 10.00 [2.00] mm, P < .001), AART (3.00 [1.00] vs. 4.00 [1.75] degrees, P < .001), SEBT (96.08 [6.62] vs. 83.92 [7.31] %, P < .001) and SHD (120.96 [6.94] vs. 106.46 [9.03] %, P < .001) at 3 hours (median [interquartile range]). However, significant deficits remained when compared with the healthy side. Except for mSEBT posterolateral direction, those effects were maintained at 7 days.KT has benefits in people with ACLr but cannot fully compensate for functional deficits. KT could be used to assist knee strengthening during rehabilitation.