Shoulder Proprioception: A Review

The purpose of this review is to provide a comprehensive resource for shoulder proprioception assessment and its integration into clinical decision making as well as targeted rehabilitation protocols. Data for this review were acquired from peer-reviewed articles from computerized online databases, namely PubMed and Medline, published between 1906 and 2021. The development of digital/smart phone goniometers can improve shoulder joint range of motion (ROM) measurements and demonstrate comparable measurement accuracy to the universal standard goniometer. The inclinometer offers a portable and cost-effective method for measuring shoulder joint angles and arcs of motion in the vertical plane. Two types of dynamometers, the computerized isokinetic machine and the handheld hydraulic dynamometer, are reliable tools for objective shoulder rotator cuff strength assessment. Motion analysis systems are highly advanced modalities that create three-dimensional models of motion arcs using a series of cameras and reflective beads, offering unparalleled precision in shoulder proprioception measurement; however, they require time-consuming calibration and skilled operators. Advancements in wearable devices and compact mobile technology such as iPhone applications may make three-dimensional motion analysis more affordable and practical for outpatient settings in the future. The complex interplay between proprioception and shoulder dysfunction is not fully understood; however, shoulder proprioception can likely both contribute to and be caused by shoulder pathology. In patients with rotator cuff tears, glenohumeral osteoarthritis, and shoulder instability, clinicians can track proprioception to understand a patient's disease progression or response to treatment. Finally, rehabilitation programs targeting shoulder proprioception have shown promising initial results in restoring function and returning athletes to play.

Validation of a novel clinical tool for monitoring distal limb stiffness

Objective

To validate a novel technique to measure limb stiffness in a clinical setting.

Animals

Three horses and three ponies owned by the Royal Veterinary College.

Procedures

Limb stiffness indices for both forelimbs were first derived using the gold standard of kinematic analysis. Using the same animals, limb stiffness indices were then calculated using portable floor scales to record weight and an electrogoniometer to record changes in metacarpophalangeal joint angle. The two techniques were then assessed for correlation and repeatability.

Results

The repeatability of limb stiffness measurement using the novel clinical tool was considered to be good based on a small coefficient of variation (5.70%). The correlation of limb stiffness as derived by both methods was high (r = 0.78, p < 0.01). Limb stiffness was positively correlated with the mass of the subject (r = 0.85, p < 0.01), with heavier horses having greater limb stiffness.

Clinical relevance

This study has compared a novel method to measure distal forelimb stiffness non-invasively in a clinical setting to kinematic analysis in six equids. It has demonstrated that limb stiffness increases in a linear fashion with body mass consistent with the role of forelimbs providing energy storage. Because in vivo limb stiffness has been shown previously to alter with injury to the superficial digital flexor tendon, it is hypothesized that this technique will offer a practical technique for the clinician to assess limb stiffness in clinical cases. Further study will be necessary to determine its clinical usefulness in such cases.

Validity and Reliability of Inertial Measurement Units in Active Range of Motion Assessment in the Hip Joint

Measuring joint range of motion has traditionally occurred with a universal goniometer, inclinometer, or expensive laboratory systems. The popularity of the inertial measurement unit (IMU) is growing, enabling the small and even single portable device to measure the range of motion. Until now, they were not used to assess hip joint range of motion. Our study aimed to check the validity of IMUs in assessing hip range of motion and compare them to other measurement devices-universal goniometer and inclinometer. Twenty participants completed three hip movements (flexion in standing and prone internal and external rotation) on both hips. Two testers independently assessed each movement with a goniometer, digital inclinometer, and IMU at different time points. To assess the agreement of active hip ROM between devices, Intraclass Correlation Coefficient (ICC) and Bland-Altman analysis were used. Furthermore, inter-rater and intra-rater reliability were also assessed by using ICC and Bland-Altman analysis. Limits of agreement (LOA) were calculated using Bland-Altman plots. The IMU demonstrated good to excellent validity (ICC: 0.87-0.99) compared to the goniometer and digital inclinometer, with LOAs < 9°, across all tested movements. Intra-rater reliability was excellent for all devices (ICC: 0.87-0.99) with LOAs < 7°. However, inter-rater reliability was moderate for flexion (ICC: 0.58-0.59, LOAs < 22.4) and poor for rotations (ICC: -0.33-0.04, LOAs < 7.8°). The present study shows that a single inertial measurement unit (RSQ Motion, RSQ Technologies, Poznan, Poland) could be successfully used to assess the active hip range of motion in healthy subjects, comparable to other methods accuracy.

Reliability and Validity of a Smartphone Device and Clinical Tools for Thoracic Spine Mobility Assessments

Quantifying thoracic spine mobility with reliable and valid tools is a challenge for clinicians in practice. The aim of this study is to determine the reliability and validity of a smartphone device, bubble inclinometer and universal goniometer to quantify the static kyphotic curve and active range of motion of the thoracic spine. A total of 17 participants (mean age = 23.7 ± 2.3 years) underwent repeated measurements with three raters, on three separate days performing the lumbar-locked trunk rotation, standing full extension, standing full flexion, standing relaxed curve and seated trunk rotation assessments. Mostly "Good" to "Excellent" intra-rater (ICC ranging from 0.624 to 0.981) and inter-reliability (ICC ranging from 0.671 to 0.968) was achieved with the smartphone and clinical tools. "Excellent" validity (ICC ranging from 0.903 to 0.947) with the smartphone was achieved during lumbar-locked trunk rotation and standing relaxed curve assessment. "Good" validity (ICC ranging from 0.836 to 0.867) of the smartphone was achieved during the seated trunk rotation. The Samsung s9+ smartphone with the iSetSquare mobile application is a reliable and valid tool to use for clinical assessments assessing thoracic spine mobility.

Reliability Analysis of In-person and Virtual Goniometric Measurements of the Upper Extremity

Background

Virtual healthcare has forced clinicians to modify or eliminate parts of the musculoskeletal evaluation such as motion assessment. Although acceptable to excellent levels of in-person goniometric reliability is achievable, reliability of virtual assessments is unknown.

Purpose

To determine if similar upper extremity goniometric measurements could be obtained in-person and virtually.

Study Design

Reliability study; classroom setting.

Methods

Publicly recruited sample over 18 years of age with no upper extremity injuries. Each subject was tested in a standing position with dominant arm facing the clinicians to visualize the landmarks for goniometer placement. Flexion and extension of the shoulder, elbow and wrist were measured. Prior to performing in-person goniometric measurements for each joint, an image was captured of each pre-determined joint position using a mobile device with a camera. This image represented the screenshot on a virtual platform. Four clinicians performed in-person measurements twice during the same session on each subject. The following week clinicians measured virtual images using the same techniques. Inter-rater and intra-rater reliability were determined via intraclass correlation coefficients (ICC).

Results

Inter-rater reliability for five of the six in-person (ICC≥0.81) and virtual measurements (ICC≥0.78 ) were classified as excellent. In-person wrist extension (ICC=0.60) and virtual wrist flexion (ICC=0.65) were classified as good. Intra-rater reliability for individual clinicians were between good and excellent for the in-person measurements (ICC:0.61-0.96) and virtual measurements (ICC:0.72-0.97). There were a greater number of excellent ICC values for the virtual measurements (90%) compared to in-person measurements (70%). There were statistically significant differences between in-person and virtual sessions for five of six measurements (p≤0.006). Only elbow extension did not differ between sessions (p=0.966).

Conclusion

Virtual assessment compared to goniometric measurements showed good to excellent inter- and intra-rater reliabilities (ICC > 0.60), which suggests clinicians can utilize goniometry either in person or on a virtual platform.

Level of Evidence

3b©The Author(s).

Accuracy of a Smartphone Software Application Compared With a Handheld Goniometer for Measuring Shoulder Range of Motion in Asymptomatic Adults

Background

Typically, shoulder range of motion (ROM) measurements are performed in a clinic setting, where physicians, physical therapists (PTs), and occupational therapists make use of a goniometer.

Purpose

To determine the accuracy of a smartphone-based ROM software application (app) in assessing active shoulder ROM and compare the measurements with traditional goniometry as measured by a PT.

Study Design

Cohort study (diagnosis); Level of evidence, 2.

Methods

This prospective, nonblinded study was conducted at a single institution with adult asymptomatic participants with full active ROM of both shoulders. Participants were enrolled between June 1 and 15, 2021. Each participant self-assessed their active shoulder ROM using the PeerWell smartphone app. A single PT concurrently measured each participant's active shoulder ROM using a handheld universal goniometer. Bilateral shoulder ROM (forward flexion, abduction [AB], external rotation, internal rotation [IR], and extension) was measured 2 times for each participant. Interrater reliability between the smartphone app and PT measurements as well as intrarater reliability for each method of measurement were assessed using the intraclass correlation coefficient (ICC), and limits of agreement were analyzed for the difference in measurement methods.

Results

Data were analyzed for 60 shoulders (30 right, 30 left) from 30 participants (mean age, 31.4 ± 11.7 years; 73% female). The interrater reliability between the 2 methods was excellent for all movements (ICCs, 0.90-0.96). For all movements except shoulder AB, the mean difference in the measurements between the 2 methods was <1.3°; the mean difference in AB ROM was 2.08°. For all movements except IR, both PTs and the app showed excellent intrarater reliability (ICCs >0.90); for IR, good intrarater reliability (ICC ≥0.75) was observed.

Conclusion

The PeerWell smartphone app provided measurements comparable with manual measurements taken by a PT using a goniometer. These data provide evidence that the smartphone app is a reliable and valid tool for measuring shoulder ROM and show promise for measuring and monitoring patient ROM remotely.

Video-based Goniometer Applications for Measuring Knee Joint Angles during Walking in Neurological Patients: A Validity, Reliability and Usability Study

Easy-to-use evaluation of Range Of Motion (ROM) during walking is necessary to make decisions during neurological rehabilitation programs and during follow-up visits in clinical and remote settings. This study discussed goniometer applications (DrGoniometer and Angles - Video Goniometer) that measure knee joint ROM during walking through smartphone cameras. The primary aim of the study is to test the inter-rater and intra-rater reliability of the collected measurements as well as their concurrent validity with an electro-goniometer. The secondary aim is to evaluate the usability of the two mobile applications. A total of 22 patients with Parkinson's disease (18 males, age 72 (8) years), 22 post-stroke patients (17 males, age 61 (13) years), and as many healthy volunteers (8 males, age 45 (5) years) underwent knee joint ROM evaluations during walking. Clinicians and inexperienced examiners used the two mobile applications to calculate the ROM, and then rated their perceived usability through the System Usability Scale (SUS). Intraclass correlation coefficients (ICC) and correlation coefficients (corr) were calculated. Both applications showed good reliability (ICC > 0.69) and validity (corr > 0.61), and acceptable usability (SUS > 68). Smartphone-based video goniometers could be used to assess the knee ROM during walking in neurological patients, because of their acceptable degree of reliability, validity and usability.

Estimation of wettability of topical fluoride gel on anterior and posterior teeth: An in vitro study

The surface area determination has a vital role in measuring the properties of liquid and solid substances. Fluoride is a potent remineralizing agent of the teeth. The surface area is measured using a goniometer. The main aim of this study is to estimate the wettability of topical fluoride gel on the anterior and posterior teeth surfaces. Topical acidulated phosphate fluoride (APF) gel was taken in small quantities. Anterior and posterior teeth were collected, and their superficial unaltered enamel sections were used as the surface where the contact angle (CA) is determined. The surface wettability is determined using Ossila goniometer to measure CA. Each stage was mounted on a mechanical stage of the goniometer. A calibrated microsyringe was used to dispense drops of the APF gel over the surface of the specimen Group A (anterior tooth cut section) and Group B (posterior tooth cut section). This procedure is repeated for all specimen samples. The mean of CAs of the anterior teeth (88.41°) was greater when compared with the mean of posterior teeth (80.36°) CA. P value found using the paired t-test of SPSS software is found to be 0.271 (>0.05), hence statistically not significant. The greater the CA, the lower is the degree of wettability on the teeth surfaces. The mean CA of the topical fluoride APF gel on the anterior tooth surface is greater when compared to the posterior tooth surface. This signifies that greater wettability is seen on posterior tooth surfaces.

Visual Joint Angle Assessment: Does Accuracy Improve with a Higher Level of Orthopaedic Surgery Training?

INTRODUCTION

The purpose of this study was to evaluate the accuracy of visual joint angle assessments by orthopaedic surgery trainees amongst various levels of training.

METHODS

Sagittal plane photographs of several joints at various angles were distributed to trainees within an orthopaedic residency program. Joint angles were estimated and compared to those obtained with a goniometer. Inter-and intra-rater reliability and ANOVA were conducted to assess differences between groups.

RESULTS

Twenty trainees were studied. The percent error for knee measurements differed at 23.1%, 26.2% and 11.1% for the PGY 2-3, PGY 4-5 and PGY 6 groups, respectively (P=0.024). Percentage error for ankles showed the greatest variability at 69.7-96.3%. Intra-rater reliabilities for all visual joint angle assessment were similar amongst groups.

CONCLUSIONS

Visual joint angle assessments vary amongst trainees, with PGY 6s most accurately identifying knee joint angles. Visual assessment is inaccurate compared to goniometric measurements, thus limiting visual measurements during patient encounters.

Validation of a new Equinometer device for measuring ankle range of motion in patients with cerebral palsy: An observational study

The goniometer is the gold-standard measurement tool of ankle range of motion (ROM). However, several studies have questioned its inter- and intra-rater reliability. Therefore, we conducted this validation study to assess the reliability of a different tool, named Equinometer, as a measurement device of ankle ROM in addition to comparing the reproducibility of their results.Sixteen healthy individuals were included. They underwent both goniometer and Equinometer measurements in knee extension and 90° knee flexion (Silfverskjöld Test). Three raters reported the values of dorsiflexion (DF) and plantarflexion (PF) in each session using both measurement tools. Intra-rater reliability was assessed between 2 raters on another study group of 24 participants. Intraclass correlation coefficients were used to determine the reliability of the used device.The age of study subjects ranged from 22 to 85 years. Fifty percent were males, and the right ankle joint was the most examined side (68.75%). In terms of DF and PF during knee extension and flexion, our analysis revealed that the measurements recorded by the Equinometer were equivalent to the goniometer. Of note, the intra-rater reliability of the Equinometer was excellent for both DF and PF assessment during both knee flexion and extension (Intraclass correlation coefficient ranged from 0.90 to 0.98), with minimal mean differences from goniometer measurements. Subgroup analysis based on age did not reveal any significant differences (P > .05).Given the high intra-rater correlations of the Equinometer, we suggest that it is reliable and precise in recording ankle ROM in outpatient clinics, particularly to obtain reproductive, comparable and unbiased data from different observers.

Evaluation of a New Simplified Inertial Sensor Method against Electrogoniometer for Measuring Wrist Motion in Occupational Studies

Wrist velocity is an important risk factor for work-related musculoskeletal disorders in the elbow/hand, which is also difficult to assess by observation or self-reports. This study aimed to evaluate a new convenient and low-cost inertial measurement unit (IMU)-based method using gyroscope signals against an electrogoniometer for measuring wrist flexion velocity. Twelve participants performed standard wrist movements and simulated work tasks while equipped with both systems. Two computational algorithms for the IMU-based system, i.e., IMU_norm and IMU_flex, were used. For wrist flexion/extension, the mean absolute errors (MAEs) of median wrist flexion velocity compared to the goniometer were <10.1°/s for IMU_norm and <4.1°/s for IMU_flex. During wrist deviation and pronation/supination, all methods showed errors, where the IMU_norm method had the largest overestimations. For simulated work tasks, the IMU_flex method had small bias and better accuracy than the IMU_norm method compared to the goniometer, with the MAEs of median wrist flexion velocity <5.8°/s. The results suggest that the IMU-based method can be considered as a convenient method to assess wrist motion for occupational studies or ergonomic evaluations for the design of workstations and tools by both researchers and practitioners, and the IMU_flex method is preferred. Future studies need to examine algorithms to further improve the accuracy of the IMU-based method in tasks of larger variations, as well as easy calibration procedures.

Validation of an on-screen application-based measurement of shoulder range of motion over telehealth medium

BACKGROUND

Shoulder range-of-motion (ROM) assessment is vital for the follow-up evaluation of operated patients and for the outcome-based research studies. The aim of this study was to investigate the accuracy and reliability of a remote on-screen application (app)-based method of shoulder ROM measurement through a telehealth medium.

MATERIALS AND METHODS

A consultant shoulder surgeon, a board-certified orthopedic resident, and a graduate medical doctor served as the examiners. The cohort consisted of 24 healthy volunteers and 16 symptomatic patients with expected shoulder ROM deficits. Shoulder ROM was first examined physically using a goniometer in the clinic and then over Zoom remote conferencing using the protractor extension app of the Chrome browser.

RESULTS

Instrument validity was examined by comparing the goniometer method with the protractor app-based method of the expert shoulder consultant using Bland-Altman analysis. It showed only minor mean differences between the healthy volunteers and the patients in elevation (2.0° and 5.0°, respectively), abduction (2.0° and 3.0°, respectively), external rotation with the elbow adducted (1.9° and 0.2°, respectively), external rotation with the elbow abducted at 90° (0.4° and 4°, respectively), and internal rotation with elbow abducted at 90° (2.3° and 1.2°, respectively), with limits of agreement that were below the well-established minimal clinically important difference values. The intraclass correlation coefficient (ICC) values varied between 0.83 and 0.96 for the volunteers and between 0.90 and 0.98 for the patients, indicating excellent correlation between the 2 methods. The interobserver reliability between 2 examiners for the protractor app-based method as evaluated by ICC scores was excellent; it ranged between 0.86 and 0.98 for the volunteers and between 0.88 and 0.99 for the patients. Comparison of the protractor app-based method with the gold-standard goniometer method for the resident and the graduate doctor showed excellent ICC values.

CONCLUSION

A protractor app-based method of measuring shoulder ROM over a telehealth medium is accurate and reliable compared with a clinical goniometer method. This validated method can be used during remote telehealth consultation with significant benefits of saving patients travel and time during the COVID-19 (coronavirus disease 2019) pandemic and even later.

Assessment of shoulder range of motion using a commercially available wearable sensor-a validation study

BACKGROUND

Our study aims to validate a commercially available inertial measurement unit (IMU) system against a standard laboratory-based optical motion capture (OMC) system for shoulder measurements in a clinical context.

METHODS

The validation analyses were conducted on 19 healthy male volunteers. Twelve reflective markers were placed on each participant's trunk, scapula and across the arm and one IMU was attached via a self-adhesive strap on the forearm. A single tester simultaneously collected shoulder kinematic data for four shoulder movements: flexion, extension, external rotation, and abduction. Agreement between OMC system and IMU measurements was assessed with Bland-Altman analyses. Secondary analysis included mean biases, root mean square error (RMSE) analysis and Welch's t-test.

RESULTS

Bland-Altman limits of agreement (LoA) exceeded the acceptable range of mean difference for 95% of the population (-22.27°, 11.31°). The mean bias showed high levels of agreement within 8° for all four movements. More than 60% of participants demonstrated mean bias less than 10° between methods. Statistically significant differences were found between measurements for abduction (P<0.001) and flexion (P=0.027) but not for extension and external rotation (P≥0.05).

CONCLUSIONS

Our study shows preliminary evidence for acceptable accuracy of a commercially available IMU against an OMC system for assessment of shoulder movements by a single tester. The IMU also exhibits similar whole degree of error compared to a standard goniometer with potential for application in remote rehabilitation.

Reconstruction of the Image Metric of Periodic Structures in an Opto-Digital Angle Measurement System

Measurement of the object angular position and its change is one of the important tasks in measurement technique. Our method is based on determination of the angular position of a 2D periodical optical pattern (2D mark) at the object, captured by the sensor of a digital camera. System performance can be frustrated by errors in determination of the spot coordinates on the camera sensor; by the presence of lens aberrations; by deviations from the parallelism of the pattern planes and the camera sensor; and by differences between the actual spots positions and the ideal grid. In the paper we discuss the effect of these errors and the way to correct or eliminate them. We have developed the mathematical routine and the corresponding numerical codes for correction of the said errors. The code and the routine we checked in a real experiment. It has shown that the correction decreases the standard deviation in 15 times.

Feasibility and reliability of a web-based smartphone application for joint position measurement

Objective

Measurement of joint angles is usually performed using a simple goniometer, which can often be time-consuming and inaccurate, however smartphones can measure angles, this technology could be used to measure joint position. Studies of smartphone applications for this purpose lack consistency and homogeneity. The aim of the current study is to analyse the reliability and accuracy of 3 inertial motion unit-based smartphone applications for goniometric measurement, using 3 different industry standards as external controls.

Methods

In the first 2 phases of the study, measurements of angles between 90° and 165° (simulating knee extension) using 3 smartphone applications were analysed against the 3 industry standards. In the third phase, the smartphone’s raw data was individually analysed against a digital inclinometer across the x, y and z axes.

Results and conclusion

Results from the 3 phases of this study indicate a high degree of reliability and validity of the applications compared with the industry standards, with no clinically significant deviations. Thus, this technology could be used in a clinical setting. However, further clinical research, focussing on joint motions with greater than a single degree of freedom, is required before the use of such applications for joint position measurement in clinical practice.

An Inertial Measurement Unit-Based Wireless System for Shoulder Motion Assessment in Patients with Cervical Spinal Cord Injury: A Validation Pilot Study in a Clinical Setting

Residual motion of upper limbs in individuals who experienced cervical spinal cord injury (CSCI) is vital to achieve functional independence. Several interventions were developed to restore shoulder range of motion (ROM) in CSCI patients. However, shoulder ROM assessment in clinical practice is commonly limited to use of a simple goniometer. Conventional goniometric measurements are operator-dependent and require significant time and effort. Therefore, innovative technology for supporting medical personnel in objectively and reliably measuring the efficacy of treatments for shoulder ROM in CSCI patients would be extremely desirable. This study evaluated the validity of a customized wireless wearable sensors (Inertial Measurement Units-IMUs) system for shoulder ROM assessment in CSCI patients in clinical setting. Eight CSCI patients and eight healthy controls performed four shoulder movements (forward flexion, abduction, and internal and external rotation) with dominant arm. Every movement was evaluated with a goniometer by different testers and with the IMU system at the same time. Validity was evaluated by comparing IMUs and goniometer measurements using Intraclass Correlation Coefficient (ICC) and Limits of Agreement (LOA). inter-tester reliability of IMUs and goniometer measurements was also investigated. Preliminary results provide essential information on the accuracy of the proposed wireless wearable sensors system in acquiring objective measurements of the shoulder movements in CSCI patients.

Validity and reliability of smartphone inclinometer applications for measurement of elbow range of motion in paediatric patients

PURPOSE

Precise measurement of elbow range of motion (ROM) post-injury or surgery forms an important part of determining prognosis and the need for further intervention. Clinicians are increasingly incorporating smartphone use in our medical practice; we sought to determine if a smartphone goniometer application is a valid and reliable tool for assessment of elbow ROM in the paediatric patient, compared to visual and goniometer assessment.

METHODS

In total, 20 paediatric patients (40 elbows) between six and 15 years of age with an elbow or forearm injury were included in this prospective series. Elbow flexion, extension, pronation and supination were measured independently by two orthopaedic clinicians. Measurements were taken from injured as well as unaffected side using a standardized technique, first with visual estimation and then using a universal goniometer (UG) and smartphone goniometer application Angle Meter via Google Play store (Smart Tool Factory, Istanbul, Turkey).

RESULTS

There was excellent interobserver reliability for all three modalities, with average intraclass correlation coefficient (ICC) values greater than 0.90. Visual estimation had the lowest average ICC of 0.92, compared to 0.97 for UG and smartphone. Overall, there was excellent intraobserver reliability between the smartphone application and the gold standard UG for all elbow movements with ICCs ranging between 0.98 to 0.99 and mean absolute difference ranging from 1.1 ± 1.0° to 2.6 ± 1.9°. The smartphone application showed superior agreement over visual estimation when compared to the gold standard UG with lower mean differences and 95% limits of agreement (LOA) falling within 10°.

CONCLUSIONS

Our study demonstrates that a smartphone application is a valid and reliable assessment tool for measurement of elbow ROM in paediatric patients, and better than visualization alone.

LEVEL OF EVIDENCE

III.

Effects of joint capsular release on range of motion in patients with frozen shoulder

BACKGROUND

A thickened joint capsule is believed to be one of the most specific manifestations of and the primary restraint against range of motion (ROM) in frozen shoulders. The purpose of this study was to evaluate the relationship among ROMs under general anesthesia before surgery and the effects of each joint capsular release on ROM.

METHODS

ROM was measured using a goniometer with scapular fixation. Arthroscopic pan-capsular release was performed with the patient in the beach-chair position in the following order: (1) rotator interval, (2) coracohumeral ligament, (3) superior capsule, (4) middle glenohumeral ligament, (5) anterior inferior glenohumeral ligament, and (6) posterior inferior glenohumeral ligament. ROMs in forward flexion (FF), lateral elevation (LE), external rotation with the arm at the side (ER1), external rotation at 90° of LE (ER2), internal rotation at 90° of LE (IR2), horizontal flexion, external rotation at 90° of FF (ER3), and internal rotation at 90° of FF (IR3) were evaluated before and after each release.

RESULTS

A total of 32 consecutive shoulders were included. After each capsular release, the ROM recovered; the final ROM was significantly greater on the affected side than on the unaffected side. Significant correlations were found between FF and LE, FF and ER1, ER1 and ER2, ER1 and ER3, ER2 and ER3, and IR2 and IR3 on both sides, regardless of surgery.

CONCLUSION

Each segment of the joint capsule affected ROM in all directions, supporting the need for whole-joint capsular release; ROM was significantly greater on the affected side than on the unaffected side after surgery.

Shoulder Strength and Range of Motion Between Collegiate Pitchers and Position Players in Baseball

Baseball is a sport that places excessive strain on the shoulder complex caused from repetitive overhead throws. In the sport of baseball, shoulder strength and range of motion (ROM) are paramount for success on the field. The purpose of this study was to determine strength and ROM differences between collegiate baseball pitchers and position players. It was hypothesized that pitchers would have higher strength and ROM values, due to the volume of throwing a pitcher performs. A total of nine collegiate baseball pitchers and position players (n = 18) volunteered for the study (age = 20.94 ± 1.21 years, height = 183.42 ± 4.74 cm, and mass = 89.56 ± 10.76 kg). Shoulder strength was measured using a Humac Norm isokinetic dynamometer at 180ºsec-1 and 300ºsec-1 and ROM was measured using a goniometer. All participants completed a five-minute warm-up at 50 rpm on an upper body ergometer. Following the warm-up, passive internal and external ROM were measured for the throwing (dominant) arm. No statistical differences were found in external ROM (p = 0.319), internal ROM (p = 0.258), external peak torque @180ºsec-1 (p = 0.467), internal peak torque @180ºsec-1 (p = 0.156), external peak torque @300ºsec-1 (p = 0.225), or internal peak torque @300ºsec-1 (p = 0.137). The findings indicate similar isokinetic strength and flexibility in the throwing shoulder of collegiate athletes who perform repeated overhead throwing motions. Thus, in this study the player's baseball position (pitchers vs. position player) did not influence throwing shoulder strength and ROM characteristics.

Accuracy of an electrogoniometer relative to optical motion tracking for quantifying wrist range of motion

Methods for capturing wrist range of motion (RoM) vary in complexity, cost, and sensitivity. Measures by manual goniometer, though an inexpensive modality, provide neither dynamic nor objective motion data. Conversely, optical motion capture systems are widely used in three-dimensional scientific motion capture studies but are complex and expensive. The electrogoniometer bridges the gap between portability and objective measurement. Our study aims to evaluate the accuracy of a 2 degree of freedom electrogoniometer using optical motion capture as the reference for in vivo wrist motion. First, a mechanical system constructed from two plastic pipes and a universal joint mimicked a human wrist to assess the inherent accuracy of the electrogoniometer. Simulations of radial/ulnar deviation (R/U), flexion/extension (F/E) and circumduction were evaluated. Second, six subjects performed three RoM tasks of R/U deviation, F/E, and circumduction for evaluation of the in vivo accuracy. Bland-Altman analysis quantified the accuracy. The mechanical experiment reported greater accuracy than the in vivo study with mean difference values less than ±1°. The in vivo accuracy varied across RoM tasks, with mean differences greatest in the F/E task (7.2°). Smaller mean differences values were reported in the R/U deviation task (-0.8°) and the circumduction task (1.2°).

Smartphone Application with Virtual Reality Goggles for the Reliable and Valid Measurement of Active Craniocervical Range of Motion

Objective: This study aimed to determine the intra-rater and inter-rater reliability and validity of a hybrid device, combining virtual reality goggles, a magnetometer and an inclinometer application for smartphones, to measure craniocervical range. Summary of Background Data: Accurate evaluation of craniocervical range of motion is important for early detection of certain diseased conditions and monitoring the progress of interventions. The universal goniometer is widely used for the measurement but it requires experienced practitioners. Whether a combination of virtual reality goggles and smartphone applications can provide the same or better performance compared with the goniometer is still unknown. Methods: Forty-one healthy adults from the department of physical medicine and rehabilitation were recruited for craniocervical range examination (flexion, extension, side-bending to the right or left and rotating to the right or left) by using the hybrid device and universal goniometer. Using the hybrid device, repeated measurements were performed twice by a primary rater and once by a second rater. The primary rater also conducted a measurement using the universal goniometer in the same cohort. The intra-rater and inter-rater reliability (intra-class correlation coefficient (ICC)) were calculated using the two-way random effect model, whereas the validity was examined by the Pearson correlation coefficient and Bland-and-Altman plot. The interval between the first and second sessions of the measurement for intra-rater reliability was set at 30 min. Results: Excellent intra-rater (ICC ≥ 0.925) and inter-rater (ICC ≥ 0.880) reliability was noted for the hybrid device. The minimal detectable changes from intra-observer and inter-observer comparisons ranged between 4.12° and 7.42° in all six directions. The Bland-and-Altman plot revealed small mean differences (≤1.68°) between the hybrid device and universal goniometer. Both instruments had highly correlated measurements of craniocervical motion (r values ≥ 0.918). Conclusion: For healthy participants, excellent intra-rater and inter-rater reliability was noted for the hybrid device, and the measurements were consistent with the universal goniometer measurements. Future studies are needed to examine whether the device can perform similarly for patients with neck disorders.

The Measurement Methods of Movement and Grip Strength in Children with a Previous Upper Extremity Fracture: A Comparative, Prospective Research

BACKGROUND AND AIMS

Decreased range of motion of the elbow and forearm and decreased grip strength are potential findings following a childhood upper extremity fracture. Clinical follow-up is essential because spontaneous improvement is seen several months after the injury. Freehand measuring with a goniometer and hydraulic dynamometer is used to evaluate clinical result. The new methods are justified in avoiding human typewriting errors, thus improving patient safety. Nevertheless, their feasibility in child patients is unknown. This study aimed to evaluate congruence between the computer-assisted and the free-hand measuring methods.

MATERIALS AND METHODS

A total of 59 children with a previous supracondylar humerus fracture were clinically examined by means of free-hand (transparent goniometer and hydraulic dynamometer; Jamar, Lafayette Ltd.) and computer-assisted (E-Link System Packages, Biometrics Ltd.) methods. The range of motion and grip strength were measured separately using both methods. Agreement between the measurements was evaluated using the Bland-Altman method.

RESULTS

The results between the two methods were incongruent and the differences between measurements increased along with the mean of measurements in all categories except elbow extension. Rotational range of motions were smaller and grip strength was weaker while measuring with the computer-assisted method. The mean discrepancy was 0.97° (95% confidence interval = -2.46 to 0.53) for elbow extension and 7.97° (95% confidence interval = 6.60-9.33) for elbow flexion.

CONCLUSIONS

Grip strength is used to evaluate impairment of hand function. The study method showed slightly lower results in grip strength. Range of motion is essential when evaluating the outcome of supracondylar humerus fracture, while >10° of change in elbow range of motion associate with impaired function. As compared with the gold-standard goniometer, the methods were not congruent. However, all differences were under 10° and probably beyond clinical importance. Because of its advantages in recording the outcomes to electronical charts, the computer-assisted method is recommended option in performing the follow-up of complicated pediatric supracondylar humerus fractures.

Monitoring Methods of Human Body Joints: State-of-the-Art and Research Challenges

The world's population is aging: the expansion of the older adult population with multiple physical and health issues is now a huge socio-economic concern worldwide. Among these issues, the loss of mobility among older adults due to musculoskeletal disorders is especially serious as it has severe social, mental and physical consequences. Human body joint monitoring and early diagnosis of these disorders will be a strong and effective solution to this problem. A smart joint monitoring system can identify and record important musculoskeletal-related parameters. Such devices can be utilized for continuous monitoring of joint movements during the normal daily activities of older adults and the healing process of joints (hips, knees or ankles) during the post-surgery period. A viable monitoring system can be developed by combining miniaturized, durable, low-cost and compact sensors with the advanced communication technologies and data processing techniques. In this study, we have presented and compared different joint monitoring methods and sensing technologies recently reported. A discussion on sensors' data processing, interpretation, and analysis techniques is also presented. Finally, current research focus, as well as future prospects and development challenges in joint monitoring systems are discussed.

Utility of the iPhone 4 Gyroscope Application in the Measurement of Wrist Motion

BACKGROUND

Measurement of wrist range of motion (ROM) is important to all aspects of treatment and rehabilitation of upper extremity conditions. Recently, gyroscopes have been used to measure ROM and may be more precise than manual evaluations. The purpose of this study was to evaluate the use of the iPhone gyroscope application and compare it with use of a goniometer, specifically evaluating its accuracy and ease of use.

METHODS

A cross-sectional study evaluated adult Caucasian participants, with no evidence of wrist pathology. Wrist ROM measurements in 306 wrists using the 2 methods were compared. Demographic information was collected including age, sex, and occupation. Analysis included mixed models and Bland-Altman plots.

RESULTS

Wrist motion was similar between the 2 methods. Technical difficulties were encountered with gyroscope use. Age was an independent predictor of ROM.

CONCLUSIONS

Correct measurement of ROM is critical to guide, compare, and evaluate treatment and rehabilitation of the upper extremity. Inaccurate measurements could mislead the surgeon and harm patient adherence with therapy or surgeon instruction. An application used by the patient could improve adherence but needs to be reliable and easy to use. Evaluation is necessary before utilization of such an application. This study supports revision of the application on the iPhone to improve ease of use.

Effects of moving cupping therapy on hip and knee range of movement and knee flexion power: a preliminary investigation

Cupping therapy has become more popular in the sports setting because of its simplicity in application, minimal adverse effects, and reduction in pain and muscle tenderness, yet there is little research on its effectiveness for range of movement and power.Objectives: The primary aim of this study was to investigate if a single session of moving cupping to the posterior aspect of the lower limb effects hip and knee range of movement and knee flexion power. The secondary aim was to consider participants' views and perceptions of moving cupping therapy.Methods: Twenty-one healthy participants (12 male and 9 female) aged between 19 and 31 years volunteered to take part in the study. All participants received 15 min of moving cupping therapy to their dominant posterior lower extremity. Hip and knee range of movement and knee flexion isokinetic power measurements were taken prior to and immediately after the moving cupping intervention. Participants also completed a questionnaire based on their experience and perceptions of cupping.Results: Results showed a significant increase (p = <.05) in hip and knee range of movement measurements by 7% in the straight leg raise and 4% in a popliteal angle test. However, no significant changes were seen in the knee flexion power measures. Data from the questionnaire suggest that despite moving cupping being reported as 'uncomfortable' it is considered acceptable.Discussion: Moving cupping therapy may have short-term changes to range of movement but not power, though the limitations of this study mean that rigorous studies are required before the effectiveness of moving cupping can be determined.

Assessment of Shoulder Range of Motion Using a Wireless Inertial Motion Capture Device-A Validation Study

(1) Background: Measuring joint range of motion has traditionally occurred with a universal goniometer or expensive laboratory based kinematic analysis systems. Technological advances in wearable inertial measurement units (IMU) enables limb motion to be measured with a small portable electronic device. This paper aims to validate an IMU, the 'Biokin', for measuring shoulder range of motion in healthy adults; (2) Methods: Thirty participants completed four shoulder movements (forward flexion, abduction, and internal and external rotation) on each shoulder. Each movement was assessed with a goniometer and the IMU by two testers independently. The extent of agreement between each tester's goniometer and IMU measurements was assessed with intra-class correlation coefficients (ICC) and Bland-Altman 95% limits of agreement (LOA). Secondary analysis compared agreement between tester's goniometer or IMU measurements (inter-rater reliability) using ICC's and LOA; (3) Results: Goniometer and IMU measurements for all movements showed high levels of agreement when taken by the same tester; ICCs > 0.90 and LOAs < ±5 degrees. Inter-rater reliability was lower; ICCs ranged between 0.71 to 0.89 and LOAs were outside a prior defined acceptable LOAs (i.e., > ±5 degrees); (4) Conclusions: The current study provides preliminary evidence of the concurrent validity of the Biokin IMU for assessing shoulder movements, but only when a single tester took measurements. Further testing of the Biokin's psychometric properties is required before it can be confidently used in routine clinical practice and research settings.

Influence of Wrist Position on the Metacarpophalangeal Joint Motion of the Index Through Small Finger

BACKGROUND

The metacarpophalangeal joints exhibit range of motion that is influenced by wrist position. Synergistic motion occurs between the wrist and the metacarpophalangeal joints with different static wrist positions affecting joints' motion capability. The aim of this study was to determine how different wrist positions influence the active range of motion of the index through small finger metacarpophalangeal joints.

METHODS

The active range of motion of the index through small finger metacarpophalangeal joints of 31 healthy subjects was measured in flexion/extension and radial/ulnar deviation in 5 different flexion/extension wrist positions, using biaxial electrogoniometers.

RESULTS

There was a difference in range of motion of all fingers depending on the wrist position. The minimum metacarpophalangeal joint range of motion was found in 80° wrist extension, the maximum in neutral wrist position. For the index finger, flexion/extension was 84.7° (±8.6°) to 25.9° (±10.2°) and radial/ulnar deviation was 32.1° (±11.3°) to 22.6° (±12.8°). For the middle finger, flexion/extension was 84.8° (±8.5°) to 25.9° (±10.1°) and radial/ulnar deviation 28.8° (±11.1°) to 22.1° (±8.9). The fourth finger showed a range of motion for flexion/extension of 87.2° (±11.5°) to 22.8° (±11.6°) and radial/ulnar deviation of 8.1° (±5.8°) to 32.3° (±12.4°). The highest range of motion was measured at the fifth finger with flexion/extension of 84.0° (±8.6°) to 32.1°(±16.8°) and radial/ulnar deviation of 15.1° (±12.9°) up to 54.6° (±18.7°).

CONCLUSIONS

The range of motion of the index through small finger metacarpophalangeal joints was significantly influenced by wrist position. The highest metacarpophalangeal joint range of motion of all fingers was conducted in neutral wrist positions. Apart from ergonomic implications, we conclude that metacarpophalangeal joint motion should be assessed under standardized wrist positions.

The C0-C2 axial rotation test: normal values, intra- and inter-rater reliability and correlation with the flexion rotation test in normal subjects

OBJECTIVES

Impairment in upper cervical spine mobility is associated with cervicogenic headache severity and disability. Measures of such mobility include the flexion-rotation test (FRT), which requires full cervical flexion and may be influenced by lower cervical spine dysfunction. The C0-C2 axial rotation test also evaluates upper cervical mobility but normal values and reliability have not been reported. Our objective is to determine normal values, and intra-rater and inter-rater reliability of the C0-C2 axial rotation test.

METHODS

Two therapists independently evaluated the FRT and C0-C2 axial rotation test with an iPhone compass application on 32 asymptomatic subjects with mean age 40.53 (SD 11.64) years on two occasions. Measurement procedures were standardized; and order of testing randomized.

RESULTS

For the FRT and C0-C2 axial rotation test reliability was high (ICC > 0.88). For rater one, Mean range to the left during the FRT and C0-C2 axial rotation test was 45.0° (6.04) and 14.43° (2.94), respectively, while range to the right was 44.6° (6.57) and 15.44° (2.68). For the FRT and C0-C2 axial rotation test the standard error of measurement was at most 2°, while the minimum detectable change was at most 4°. A strong positive correlation exists between the FRT and C0-C2 axial rotation test (r = 0.84, P < 0.01).

DISCUSSION

The range recorded during the C0-C2 axial rotation test and FRT have high levels of reliability when evaluated using an iPhone. The strong correlation between the FRT and C0-C2 axial rotation test indicate that both may be measuring similar constructs, but each test needs to be referenced to normal values.

A Novel Setup and Protocol to Measure the Range of Motion of the Wrist and the Hand

The human hand is important for the performance of activities of daily living which are directly related to quality of life. Various conditions, such as Duchenne muscular dystrophy (DMD) can affect the function of the human hand and wrist. The ability to assess the impairment in the hand and the wrist by measuring the range of motion (ROM), is essential for the development of effective rehabilitation protocols. Currently the clinical standard is the goniometer. In this study we explore the feasibility and reliability of an optical sensor (Leap motion sensor) in measuring active hand/wrist ROM. We measured the hand/wrist ROM of 20 healthy adults with the goniometer and the Leap motion sensor, in order to check the agreement between the two methods and additionally, we performed a test-retest of the Leap motion sensor with 12 of them, to assess its reliability. The results suggest low agreement between the goniometer and the leap motion sensor, yet showing a large decrease in measurement time and high reliability when using the later. Despite the low agreement between the two methods, we believe that the Leap motion sensor shows potential to contribute to the development of hand rehabilitation protocols and be used with patients in a clinical setting.

Visual Estimation of Dupuytren's Flexion Contractures-A Prospective Comparative Trial

Purpose

Surgeons and resident physicians in a clinic setting often visually estimate Dupuytren flexion contractures of the hand to follow disease progression and decide on management. No previous study has compared visual estimates with a standardized instrument to ensure measurement reliability.

Methods

Consecutive patients consulted for Dupuytren flexion contractures of the hand had individual joint contractures estimated in degrees (°) by both a resident physician and staff surgeon. Estimates were compared with goniometer measurements to generate intraclass correlation coefficients (ICCs), and residents and surgeons were compared based on their accuracy.

Results

Twenty-eight patients enrolled in this study, which provided a total of 80 hand joints for analysis. Resident physicians achieved an ICC of 0.42, which indicates poor reliability. The hand surgeon achieved an ICC of 0.86, which indicates high reliability. The surgeon also had better accuracy than the residents.

Conclusion

Hand surgeons should be mindful of the limitations of visual estimates of Dupuytren flexion contractures, particularly when conducted by trainees. Joint angle measurements taken for the purposes of research should be done with a goniometer at minimum.

Experimental Comparison of the Clinical Measurement of Ankle Joint Dorsiflexion and Radiographic Tibiotalar Position

Clinical measurement of ankle dorsiflexion is typically used to diagnose limited ankle range of motion. Controversy and a lack of clarity continue regarding the most accurate clinical method of measuring ankle joint dorsiflexion and the effect that the foot position (supinated, neutral, pronated) has on the true tibiotalar position. We investigated the effects of supinated, neutral and pronated foot positions on the clinical dorsiflexion measurements in 50 healthy subjects and compared these results to the radiographic measurement of tibiotalar joint position with the ankle maximally dorsiflexed in each of the 3 foot positions. Interrater reliability was confirmed to be adequate among the 3 clinicians of varied skill levels. Radiographic measurements of the tibiotalar position showed very little change in each of the 3 foot positions, with a total difference of 0.35° between supination and pronation. However, we found a mean difference of 14° of dorsiflexion in the clinical measurements between the pronated and supinated foot position, with a 9.08° difference between the neutral and supinated positions. Motion of the foot between the neutral and supinated positions introduced an additional source of potential error from the measurement technique when using the neutral position as the standard, which has been recommended in the past. We recommend a supinated foot position as a more reliable foot position for measuring the clinical ankle joint range of motion and propose it as a potential standard.

Hydroxyapatite and Self-Assembling Peptide Matrix for Non-Oxidizing Tooth Whitening

OBJECTIVES

The aim of this combined in vitro and in vivo study was to evaluate the efficacy of tooth whitening using a mixture of Self- Assembling Peptide Matrix (SAPM) and hydroxyapatite (HA).

METHODS

The mixture was applied on stained bovine teeth, and the tooth color was measured using a spectrophotometer; mean changes in L*a*b values between measurements were expressed as DE. Additionally, the nature of the surface layer was investigated by ATRFTIR and EDX. The optical changes due to the additional surface layer were measured using a goniometer. Finally, a proof-of-concept clinical study was performed investigating the mixture of SAPM+HA.

RESULTS

The results verified that the SAPM remained on the tooth surface and acted as a temporary adhesive to attach the HA particles to the tooth surface. Further, the optical changes due to the additional surface layer indicated a diffuse reflection to be the origin of the optical whitening. Lastly, the mixture of SAPM+HA showed significant and visible whitening after one application, increasing throughout the first week of home application (DE = 4.9 ± 3.3) and remaining stable for 30 days (DE = 4.8 ± 3.6).

CONCLUSIONS

The combination of SAPM+HA particles caused optical whitening based on diffuse reflection by the HA particles on the tooth surface. The whitening effect and its magnitude observed in vitro were also seen in vivo.

Effect of Yoga Based Lifestyle Intervention on Patients With Knee Osteoarthritis: A Randomized Controlled Trial

Objective: To investigate the effect of integrated approach of yoga therapy (IAYT) intervention in individual with knee Osteoarthritis. Design: Randomized controlled clincial trail. Participants: Sixty-six individual prediagnosed with knee osteoarthritis aged between 30 and 75 years were randomized into two groups, i.e., Yoga (n = 31) and Control (n = 35). Yoga group received IAYT intervention for 1 week at yoga center of S-VYASA whereas Control group maintained their normal lifestyle. Outcome measures: The Falls Efficacy Scale (FES), Handgrip Strength test (left hand LHGS and right hand RHGS), Timed Up and Go Test (TUG), Sit-to-Stand (STS), and right & left extension and flexion were measured on day 1 and day 7. Results: There were a significant reduction in TUG (p < 0.001), Right (p < 0.001), and Left Flexion (p < 0.001) whereas significant improvements in LHGS (p < 0.01), and right extension (p < 0.05) & left extension (p < 0.001) from baseline in Yoga group. Conclusion: IAYT practice showed an improvement in TUG, STS, HGS, and Goniometer test, which suggest improved muscular strength, flexibility, and functional mobility. CTRI Registration Number: http://ctri.nic.in/Clinicaltrials, identifier CTRI/2017/10/010141.

Developmental pattern of tibiofemoral angle in healthy north-east Indian children

PURPOSE

Physiological range of tibiofemoral angle (TFA) is poorly defined and may lead to unnecessary therapeutic interventions. Studies on TFA developmental pattern suggest that racial and ethnic differences are present; children in north-east India who have not yet been studied need to be evaluated.

PATIENTS AND METHODS

Cross-sectional study of clinical TFA, intermalleolar distance and intercondylar distance in 1020 healthy north-east Indian children aged from 2 to 18 years was done. Height, weight and body mass index were also recorded.

RESULTS

At two years of age the mean TFA was valgus. The values reached a peak of 8.55° (standard deviation (SD) 1.01) valgus at seven years of age. The TFA then gradually stabilised to 3.18° (SD 1.18) valgus by 18 years of age. There was no significant difference in TFA between male and female patients.

DISCUSSION

The present study is the largest and only the third such study on Indian children and the first on healthy northeast Indian children. By the end of two years most children had valgus angulation. This, along with the peak angulation observed, was similar to most of the other studies. The age at peak angulation and subsequent stabilisation of valgus angulation varied greatly among children of different origins, especially non-Indian children.

CONCLUSIONS

Data can be used to identify children who require further follow-up/evaluation and can serve as guidelines during deformity correction and future studies. The development of TFA in this cohort is not different from other children of India but differs from children of other ethnic origins.

Effect of head posture on tooth contacts in dentate and complete denture wearers using computerized occlusal analysis system

Purpose:

The purpose of the study was to assess and compare the occlusal contacts in dentate and edentulous patients wearing complete denture with varying head posture.

Materials and Methods:

Ad hoc sampling of 30 subjects (15 dentate and 15 edentulous) based on inclusion and exclusion criteria was done. Subjects were divided into two groups: dentate and edentulous. Each group was further divided into two subgroups based on two head postures-upright 90° and ventroflexed 30°. For recording of every posture, a new sensor was used, and the subject was asked to clench on the sensor in maximum intercuspation position at the two head postures.

Results:

Data were summarized as mean ± standard error and compared by Student's t-test using SPSS software (windows version 17.0 IBM corporation, New York, USA). A statistically significant correlation between head posture and contact area was found in dentate and denture wearers, i.e., tooth contact area varies with head posture.

Conclusion:

It was concluded that the occlusal contacts vary at different head posture in dentate as well as in denture wearers. With ventroflexion, the number of tooth contact decreased as compared to upright-erect position in both groups. Clinical implication - since the number of tooth contacts varies with varying head postures, it is recommended that the balancing of the contacts should be done at varying head postures.

Measuring the effects of structural turnout suits on firefighter range of motion and comfort

Range of motion (ROM) can be restricted by wearing stiff and bulky clothing. This is particularly true of firefighter suits that are constructed using fabric layers to provide thermal protection from fire. This study developed an evaluation technique to quantify the loss of mobility associated with wearing firefighters' protective suits that were deliberately selected to represent similar ergonomic design features. The ROM of 10 firefighters was measured using electro-goniometers attached to their bodies while they wore uniforms and a reference outfit, and performed specific movements. The most restrictive uniform is the Bulky suit that contained additional layers of materials in sleeves and on the knees. The Traditional Suit was more ROM restrictive than Ergonomic. The subjective evaluation of suits supported the objective assessments provided by the electro-goniometers. A 3-D body scanning technique was employed to establish a correlation between the bulkiness of firefighter outfits and subject ROM. Practitioner Summary: This study presents a methodology for measurements of range of motion (ROM) in firefighters wearing personal protective equipment (PPE). Even small differences in designs of PPE may impact firefighters' ROM, which can be detected by electro-goniometers providing measurements if they are attached along the joint to measure limb angular movement.

Electromagnetic bone segment tracking to control femoral derotation osteotomy-A saw bone study

Correction of rotational gait abnormalities is common practice in pediatric orthopaedics such as in children with cerebral palsy. Femoral derotation osteotomy is established as a standard treatment, however, different authors reported substantial variability in outcomes following surgery with patients showing over- or under-correction. Only 60% of the applied correction is observed postoperatively, which strongly suggests intraoperative measurement error or loss of correction during surgery. This study was conducted to verify the impact of error sources in the derotation procedure and assess the utility of a newly developed, instrumented measurement system based on electromagnetic tracking aiming to improve the accuracy of rotational correction. A supracondylar derotation osteotomy was performed in 21 artificial femur sawbones and the amount of derotation was quantified during the procedure by the tracking system and by nine raters using a conventional goniometer. Accuracy of both measurement devices was determined by repeated computer tomography scans. Average derotation measured by the tracking system differed by 0.1° ± 1.6° from the defined reference measurement . In contrast, a high inter-rater variability was found in goniometric measurements (range: 10.8° ± 6.9°, mean interquartile distance: 6.6°). During fixation of the osteosynthesis, the tracking system reliably detected unintentional manipulation of the correction angle with a mean absolute change of 4.0° ± 3.2°. Our findings show that conventional control of femoral derotation is subject to relevant observer bias whereas instrumental tracking yields accuracy better than ±2°. The tracking system is a step towards more reliable and safe implementation of femoral correction, promising substantial improvements of patient safety in the future. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:1106-1112, 2017.

Data Collection and Analysis Using Wearable Sensors for Monitoring Knee Range of Motion after Total Knee Arthroplasty

Total knee arthroplasty (TKA) is the most common treatment for degenerative osteoarthritis of that articulation. However, either in rehabilitation clinics or in hospital wards, the knee range of motion (ROM) can currently only be assessed using a goniometer. In order to provide continuous and objective measurements of knee ROM, we propose the use of wearable inertial sensors to record the knee ROM during the recovery progress. Digitalized and objective data can assist the surgeons to control the recovery status and flexibly adjust rehabilitation programs during the early acute inpatient stage. The more knee flexion ROM regained during the early inpatient period, the better the long-term knee recovery will be and the sooner early discharge can be achieved. The results of this work show that the proposed wearable sensor approach can provide an alternative for continuous monitoring and objective assessment of knee ROM recovery progress for TKA patients compared to the traditional goniometer measurements.

Validity and Reliability of 2 Goniometric Mobile Apps: Device, Application, and Examiner Factors

CONTEXT

Smartphones are being used in a variety of practice settings to measure joint range of motion (ROM). A number of factors can affect the validity of the measurements generated. However, there are no studies examining smartphone-based goniometer applications focusing on measurement variability and error arising from the electromechanical properties of the device being used.

OBJECTIVE

To examine the concurrent validity and interrater reliability of 2 goniometric mobile applications (Goniometer Records, Goniometer Pro), an inclinometer, and a universal goniometer (UG).

DESIGN

Nonexperimental, descriptive validation study.

SETTING

University laboratory.

PARTICIPANTS

3 physical therapists having an average of 25 y of experience.

MAIN OUTCOME MEASURES

Three standardized angles (acute, right, obtuse) were constructed to replicate the movement of a hinge joint in the human body. Angular changes were measured and compared across 3 raters who used 3 different devices (UG, inclinometer, and 2 goniometric apps installed on 3 different smartphones: Apple iPhone 5, LG Android, and Samsung SIII Android). Intraclass correlation coefficients (ICCs) and Bland-Altman plots were used to examine interrater reliability and concurrent validity.

RESULTS

Interrater reliability for each of the smartphone apps, inclinometer and UG were excellent (ICC = .995-1.000). Concurrent validity was also good (ICC = .998-.999). Based on the Bland-Altman plots, the means of the differences between the devices were low (range = -0.4° to 1.2°).

CONCLUSIONS

This study identifies the error inherent in measurement that is independent of patient factors and due to the smartphone, the installed apps, and examiner skill. Less than 2° of measurement variability was attributable to those factors alone. The data suggest that 3 smartphones with the 2 installed apps are a viable substitute for using a UG or an inclinometer when measuring angular changes that typically occur when examining ROM and demonstrate the capacity of multiple examiners to accurately use smartphone-based goniometers.

Accuracy of patient-reported range of elbow motion

BACKGROUND

Patient-reported outcome meaures (PROMs) not only provide valuable insights into subjective indices of joint health, but also may provide limited objective information about range of motion (ROM). We sought to evaluate the accuracy of patient-reported range of elbow motion compared to measured ROM.

METHODS

Sixty clinic patients were recruited, of whom 26 had elbow pathologies and 34 had pathologies other than at the elbow joint. Each patient independently estimated ROM for extension, flexion, pronation and supination before this was measured by a clinician using a universal goniometer, with the mean being the gold standard.

RESULTS

We found that patients' ROM estimates were significantly different from measured ROM (p < 0.00001 at 95% confidence interval). There was no statistically significant difference between elbow pathology and non-elbow pathology patients' estimated ROM.

CONCLUSIONS

There was great disparity between patient-estimated and measured ROM, although estimates of patients with known elbow pathology did not demonstrate any significant difference from their healthy counterparts. These differences may be too great for patient-estimated range of motion to be used as a reliable tool for assessing outcomes.

Interrater and Intrarater Reliability and Validity of 3 Measurement Methods for Shoulder-Position Sense

CONTEXT

Joint-position sense (JPS) plays a critical role in the stability of shoulder joint. Restoration of JPS is essential to improve rehabilitation outcomes in individuals with shoulder injury. However, the number of affordable and reliable shoulder-JPS measurement methods for everyday clinical practice is limited.

OBJECTIVE

To estimate reliability and validity of 3 simple shoulder-JPS measurement methods.

DESIGN

Cross-sectional study.

PARTICIPANTS

25 healthy men and women.

MAIN OUTCOME MEASURE

Absolute-error scores of JPS in 3 ranges of shoulder flexion (low, mid, and high), measured with a laser pointer, an inclinometer, and a goniometer in 2 separate sessions (48 h apart).

RESULTS

Overall interrater and intrarater intraclass correlation coefficients were .86 and .78 for the laser pointer, .67 and .70 for the inclinometer, and .60 and .50 for the goniometer, respectively. There was excellent reliability in the low range for the laser pointer and inclinometer methods, but fair to good and poor reliability in mid- and high ranges, respectively. All methods showed strong validity.

CONCLUSION

The laser pointer and inclinometer JPS measurement methods are reliable and can be used by clinicians during rehabilitation of shoulder injuries.

Validity and Reliability of the Achillometer(®): An Ankle Dorsiflexion Measurement Device

Limited ankle dorsiflexion is closely related to important foot and ankle pathologies. Various measurement devices and methods have been examined, but these have demonstrated limited validity and reliability. The purpose of the present study was to assess the validity and intra- and interobserver reliability of the Achillometer(®). A total of 22 consecutive subjects with ankle or foot pathologies and 39 healthy participants were included. All participants were measured using the goniometer and the Achillometer(®), a portable device used to assess ankle dorsiflexion in the weightbearing position with knee in extension. The intraclass correlation coefficient, standard error of the mean, and minimal detectable change were determined. The goniometer and Achillometer(®) revealed high intraobserver reliability coefficients with an intraclass correlation coefficient of 0.88 (standard error of the mean 1.49, minimal detectable change 4.12) and 0.85 (standard error of the mean 1.57, minimal detectable change 4.34), respectively. The interobserver reliability of both measurement techniques ranged from 0.63 to 0.67. The Achillometer(®) showed a strong correlation with the goniometer for both observers. In conclusion, the Achillometer(®) is a valid measurement device to assess ankle dorsiflexion range of motion in the weightbearing position with an extended knee in a heterogeneous population. The device has good intraobserver and moderate interobserver reliability and measurement properties comparable to those of the goniometer.

Goniometer Measurements of Oral Labial Angle and Evaluation of Oral Motor Reflexes in Preterm Infants: Comparison to Findings in Term Infants

To date, no study has evaluated changes in oral labial angle as preterm infants mature. The main purpose of this study was to document goniometer measurements of the labial angle of the mouth in preterm infants, to assess changes with development, to compare to findings in healthy term infants, and also evaluate oral motor reflexes in these groups. Seventy-eight preterm infants and 45 healthy term infants were recruited for the prospective study. Labial angle was assessed via goniometer, and oral motor reflexes and the volume of milk ingested were evaluated. There was significant difference between term and preterm infants' labial angles (P < .01). The distribution of preterm infants' angles were similar to term infants' by 36 to 40 weeks' postmenstrual age. Goniometer measurements of the oral labial angle may reveal oral motor performance in preterm infants and may be relevant for feeding skills assessment in this group of infants.

The validity and reliability of a new instrumented device for measuring ankle dorsiflexion range of motion

PURPOSE/BACKGROUND

A restriction in ankle dorsiflexion range of motion (ROM) has been linked to several clinical manifestations such as metatarsalgia, heel pain, nerve entrapment, ankle joint equinus, patellar and ankle injuries. The purpose of the present study was to examine the validity and reliability of the Leg Motion system for measuring ankle dorsiflexion ROM.

STUDY DESIGN

Descriptive repeated-measures study.

METHODS

Twenty-six healthy male university students were recruited to test the reliability of the Leg Motion system, which is a portable tool used for assessment of ankle dorsiflexion during the weight-bearing lunge test. The participants were tested two times separated by two weeks and measurements were performed at the same time of the day by the same single rater. To test the validity of the Leg Motion system, other maximal ankle dorsiflexion ROM assessments (goniometer, inclinometer and measuring tape) were measured in a single session (i.e., the first test session) during the weight-bearing lunge position using a standard goniometer, a digital inclinometer and a measuring tape measure with the ability to measure to the nearest 0.1 cm.

RESULTS

Paired t-tests showed the absence of significant differences between right and left limb measurements of dorsiflexion in all tests. Mean values ± standard deviations were as follows: Leg Motion test (left 11.6cm±3.9; right 11.9cm ±4.0), tape measure (left 11.6cm±4.0; right 11.8cm±4.2), goniometer (left 40.6º±5.2; right 40.6º±5.2), and digital inclinometer (left 40.0º±5.8; right 39.9º±5.6). The Leg Motion composite values (i.e., average of the two legs) showed a significant (p<0.05) positive correlation with the tape measure (r=0.99), with the goniometer (r=0.66), and with the digital inclinometer (r=0.72).

CONCLUSIONS

The results of the present study provide evidence to support the use of the Leg Motion system as a valid, portable, and easy to use alternative to the weight-bearing lunge test to assess ankle dorsiflexion ROM in healthy participants.

LEVEL OF EVIDENCE

2b.

Range of motion assessment of the shoulder and elbow joints using a motion sensing input device: a pilot study

BACKGROUND

Motion sensing input devices could provide a practical and low-cost alternative method for repeated range of motion measurements. This study aimed to assess the reliability, accuracy and time requirements of a motion sensing input device (Microsoft Kinect) for ROM measurements comparing it with goniometer based measurements and subjective estimation.

MATERIAL AND METHODS

Full ROM was measured in 14 shoulder and elbow joints using the different methods. The order was randomly selected and each movement was measured twice. The results were recorded in degrees and the time measured in seconds.

RESULTS

In general, there was a poor to moderate agreement between the Kinect system compared to the goniometer. There was a good agreement between the goniometer-based and the subjective technique. The Kinect-based technique showed excellent test-retest reliability.

CONCLUSION

The Kinect system showed good test-retest reliability, but lower accuracy compared to goniometer-based measurements. Improvements in patient positioning and measurement protocol standardization must be made before its implementation in clinical practice.

Is the Kinect system suitable for evaluation of the hip joint range of motion and as a screening tool for femoroacetabular impingement (FAI)?

BACKGROUND

In the clinical evaluation of femoroacetabular impingement (FAI), there is a lack of quantitative, reliable and informative assessment methods for the overall functional capability of an individual.

OBJECTIVE

We compared clinical and radiological measurements of the hip joint with a new methodology based on the concept of 3-dimensional reachable workspace using Microsoft Kinect.

METHODS

We assessed the correlation between the alpha angle of Nötzli on full-length radiographs and the clinical internal rotation. We evaluated the accuracy of joint positions and angles of the hip between the Kinect system and clinical examination including range of motion (ROM).

RESULTS

The results of our clinical trial with 24 study participants showed a significant difference between normal internal rotation (> 21°) and reduced internal rotation (⩽ 21°) in comparison to the radiological alpha angle of Nötzli (P=0.026). The acquired reachable Kinect data demonstrated a moderate agreement between the Kinect and clinical examination (correlation coefficients between 0.230 and 0.375).

CONCLUSIONS

The findings suggest that a higher grade alpha angle of Nötzli accompanies reduced clinical internal rotation. The Kinect system provides reliable results of hip ROM. However, further test series must be performed for the application of Kinect in the clinical evaluation of FAI.

Validation of an innovative method of shoulder range-of-motion measurement using a smartphone clinometer application

BACKGROUND

An accurate and reliable measurement of shoulder range of motion (ROM) is important in the evaluation of the shoulder. A smartphone digital clinometer application is a potentially simpler method for measuring shoulder ROM. The goal of this study was to establish the reliability and validity of shoulder ROM measurements among varying health care providers using a smartphone clinometer application in healthy and symptomatic adults.

METHODS

An attending surgeon, fellow, resident, physician assistant, and student served as examiners. Bilateral shoulders of 24 healthy subjects were included. Fifteen postoperative patients served as the symptomatic cohort. Examiners measured ROM of each shoulder, first using visual estimation and then using a goniometer and smartphone clinometer in a randomized fashion.

RESULTS

The interobserver reliability among examiners showed significant correlation, with average intraclass correlation coefficient [ICC(2,1)] values of 0.61 (estimation), 0.69 (goniometer), and 0.80 (smartphone). All 5 examiners had substantial agreement with the gold standard in healthy subjects, with average ICC(2,1) values ranging from 0.62 to 0.79. The interobserver reliability in symptomatic patients showed significant correlation, with average ICC(2,1) values of 0.72 (estimation), 0.79 (goniometer), and 0.89 (smartphone). Examiners had excellent agreement with the gold standard in symptomatic patients, with an average ICC(2,1) value of 0.98.

CONCLUSION

The smartphone clinometer has excellent agreement with a goniometer-based gold standard for measurement of shoulder ROM in both healthy and symptomatic subjects. There is good correlation among different skill levels of providers for measurements obtained using the smartphone. A smartphone-based clinometer is a good resource for shoulder ROM measurement in both healthy subjects and symptomatic patients.

Measuring shoulder external and internal rotation strength and range of motion: comprehensive intra-rater and inter-rater reliability study of several testing protocols

BACKGROUND

Shoulder range of motion (ROM) and strength measurements are imperative in the clinical assessment of the patient's status and progression over time. The method and type of assessment varies among clinicians and institutions. No comprehensive study to date has examined the reliability of a variety of procedures based on different testing equipment and specific patient or shoulder position. The purpose of this study was to establish absolute and relative reliability for several procedures measuring the rotational shoulder ROM and strength into internal (IR) and external (ER) rotation strength.

METHODS

Thirty healthy individuals (15 male, 15 female), with a mean age of 22.1 ± 1.4 years, were examined by 2 examiners who measured ROM with a goniometer and inclinometer and isometric strength with a hand-held dynamometer (HHD) in different patient and shoulder positions. Relative reliability was determined by intraclass correlation coefficients (ICC). Absolute reliability was quantified by standard error of measurement (SEM) and minimal detectable change (MDC). Systematic differences across trials or between testers, as well as differences among similar measurements under different testing circumstances, were analyzed with dependent t tests or repeated-measures analysis of variance in case of 2 or more than 2 conditions, respectively.

RESULTS

Reliability was good to excellent for IR and ER ROM and isometric strength measurements, regardless of patient or shoulder position or equipment used (ICC, 0.85-0.99). For some of the measurements, systematic differences were found across trials or between testers. The patient's position and the equipment used resulted in different outcome measures.

CONCLUSIONS

All procedures examined showed acceptable reliability for clinical use. However, patient position and equipment might influence the results.

Agreement between visual and goniometric assessments of adductor and popliteal angles in infants

CONTEXT

Amiel-Tison method is a commonly used technique for assessing tone and neurological status of infants. There is a paucity of data on the reliability of visual assessment of angles, a component of this method.

SUBJECTS AND METHODS

We compared the visual and the goniometric assessment of adductor and popliteal angles in infants with hypertonia and neurologically normal controls. A total of 16 infants with hypertonia and 15 normal infants underwent blinded assessment of the adductor and popliteal angles.

STATISTICAL ANALYSIS

The mean and standard deviation for the difference between visual and goniometric measurements were calculated for popliteal and adductor angles.

RESULTS

The mean differences between visual and goniometric measurements for the popliteal angle were 4.94 (SD3.40) and 8.73 (SD6.10) degrees for the cases and controls respectively. Similarly, the values for adductor angle measurements were 8.94 (SD8.23) and 14.47 (SD8.47) degrees respectively.

CONCLUSION

The deviation of visual assessment from goniometric measurement was found to be less for popliteal angle measurement as compared to adductor angle measurements. It was note-worthy that the difference was less for the measurements of children with spasticity.

Validity and reliability of a new ankle dorsiflexion measurement device

BACKGROUND

The assessment of the maximum ankle dorsiflexion angle is an important clinical examination procedure. Evidence shows that the traditional goniometer is highly unreliable, and various designs of goniometers to measure the maximum ankle dorsiflexion angle rely on the application of a known force to obtain reliable results. Hence, an innovative ankle dorsiflexion measurement device was designed to make this measurement more reliable by holding the foot in a selected posture without the application of a known moment.

OBJECTIVES

To report on the comprehensive validity and reliability testing carried out on the new device.

METHODS

Following validity testing, four different trials to test reliability of the ankle dorsiflexion measurement device were performed. These trials included inter-rater and intra-rater testings with a controlled moment, intra-rater reliability testing with knees flexed and extended without a controlled moment, intra-rater testing with a patient population, and inter-rater reliability testing between four raters of varying experience without controlling moment. All raters were blinded.

STUDY DESIGN

A series of trials to test intra-rater and inter-rater reliabilities.

RESULTS

Intra-rater reliability intraclass correlation coefficient was 0.98 and inter-rater reliability intraclass correlation coefficient (2,1) was 0.953 with a controlled moment. With uncontrolled moment, very high reliability for intra-tester was also achieved (intraclass correlation coefficient = 0.94 with knees extended and intraclass correlation coefficient = 0.95 with knees flexed). For the trial investigating test-retest reliability with actual patients, intraclass correlation coefficient of 0.99 was obtained. In the trial investigating four different raters with uncontrolled moment, intraclass correlation coefficient of 0.91 was achieved.

CONCLUSIONS

The new ankle dorsiflexion measurement device is a valid and reliable device for measuring ankle dorsiflexion in both healthy subjects and patients, with both controlled and uncontrolled moments, even by multiple raters of varying experience when the foot is dorsiflexed to its end of range of motion.

CLINICAL RELEVANCE

An ankle dorsiflexion measuring device has been designed to increase the reliability of ankle dorsiflexion measurement and replace the traditional goniometer. While the majority of similar devices rely on application of a known moment to perform this measurement, it has been shown that this is not required with the new ankle dorsiflexion measurement device and, rather, foot posture should be taken into consideration as this affects the maximum ankle dorsiflexion angle.