The Reliability of an Instrumented Device for Measuring Components of the Star Excursion Balance Test

Background

The Star Excursion Balance Test (SEBT) is a dynamic test that requires strength, flexibility, and proprioception and has been used to assess physical performance, identify chronic ankle instability, and identify athletes at greater risk for lower extremity injury. In order to improve the repeatability in measuring components of the SEBT, the Y Balance Test™ has been developed.

Objective

The purpose of this paper is to report the development and reliability of the Y Balance Test™.

Methods

Single limb stance excursion distances were measured using the Y Balance Test™ on a sample of 15 male collegiate soccer players. Intraclass Correlation Coefficients (ICC) were used to determine the reliability of the test.

Results

The ICC for intrarater reliability ranged from 0.85 to 0.91 and for interrater reliability ranged from 0.99 to 1.00. Composite reach score reliability was 0.91 for intrarater and 0.99 for interrater reliability.

Discussion

This study demonstrated that the Y Balance Test™ has good to excellent intrarater and interrater reliability. The device and protocol attempted to address the common sources of error and method variation in the SEBT including whether touch down is allowed with the reach foot, where the stance foot is aligned, movement allowed of the stance foot, instantaneous measurement of furthest reach distance, standard reach height from the ground, standard testing order, and well defined pass/fail criteria.

Conclusion

The Y Balance Test™ is a reliable test for measuring single limb stance excursion distances while performing dynamic balance testing in collegiate soccer players.     

ASSOCIATIONS BETWEEN THREE CLINICAL ASSESSMENT TOOLS FOR POSTURAL STABILITY

Study Design:

Clinical Measurement, Correlation, Reliability

Objectives:

To assess the relationship between the Single Leg Balance (SLB), modified Balance Error Scoring System (mBESS), and modified Star Excursion Balance (mSEBT) tests and secondarily to assess inter-rater and test-retest reliability of these tests.

Background:

Ankle sprains often result in chronic instability and dysfunction. Several clinical tests assess postural deficits as a potential cause of this dysfunction; however, limited information exists pertaining to the relationship that these tests have with one another.

Methods:

Two independent examiners measured the performance of 34 healthy participants completing the SLB Test, mBESS test, and mSEBT at two different time periods. The relationship between tests was assessed using the Pearson Correlation and Fisher''s Exact Tests. Inter-rater and test-retest reliability were assessed using the intraclass correlation coefficient (ICC) and Kappa statistics.

Results:

A significant correlation (r = -0.35) was observed between the mSEBT and the mBESS. Fisher''s Exact Test showed a significant association between the SLB Test and mBESS (P = .048), but no association between the SLB and mSEBT (P = 1.000). Inter-rater reliability was excellent for the mSEBT and fair for the mBESS (ICCs of .91 and .61 respectively). Excellent agreement was observed between raters for the SLB test (k = 1.00). Test-retest reliability was excellent for the mSEBT (ICC = 0.98) and fair for the mBESS (ICC = 0.74). There was poor test-retest agreement for the SLB test (k = .211).

Conclusion:

There was a significant relationship observed between the SLB Test, mBESS test, and mSEBT: however; strength of association measures showed limited overlap between these tests. This suggests that these tests are interrelated but may not assess equal components of postural stability.     

Reliability,validity, and responsiveness of the Balance Evaluation Systems Test (BESTest) in individuals with multiple sclerosis

Background

The Balance Evaluation Systems Test (BESTest) measures various aspects of postural control, but little data exist in persons with multiple sclerosis (MS). The purpose of this study was to determine the psychometrics of the BESTest in MS.

MEASURING FITNESS IN FEMALE GYMNASTS: THE GYMNASTICS FUNCTIONAL MEASUREMENT TOOL

Purpose/Background:

A reliable and valid method of measuring and monitoring a gymnast''s total physical fitness level is needed to assist female gymnasts in achieving healthy, injury-free participation in the sport. The Gymnastics Functional Measurement Tool (GFMT) was previously designed as a field-test to assess physical fitness in female competitive gymnasts. The purpose of this study was to further develop the GFMT by establishing a scoring system for individual test items and to initiate the process of establishing the test-retest reliability and construct validity of the GFMT.

Methods:

A total of 105 competitive female gymnasts ages 6-18 underwent testing using the GFMT. Fifty of these subjects underwent re-testing one week later in order to assess test-retest reliability. Construct validity was assessed using a simple regression analysis between total GFMT scores and the gymnasts'' competition level to calculate the coefficient of determination (r²). Test-retest reliability was analyzed using Model 1 Intraclass correlation coefficients (ICC). Statistical significance was set at the p<0.05 level.

Results:

The relationship between total GFMT scores and subjects'' current USAG competitive level was found to be good (r² = 0.60). Reliability testing of the GFMT total score showed good test-retest reliability over a one week period (ICC=0.97). Test-retest reliability of the individual component items was good (ICC = 0.80-0.92).

Conclusions:

The results of this study provide initial support for the construct validity and test-retest reliability of the GFMT.     

FEASIBILITY AND RELIABILITY OF DYNAMIC POSTURAL CONTROL MEASURES IN CHILDREN IN FIRST THROUGH FIFTH GRADES

Purpose/Background:

Although dynamic postural control is a prerequisite to the development of fundamental movement skills in children, few studies have examined the feasibility and reliability of assessment techniques that measure dynamic postural control in youth under 13 years of age. Therefore, the purpose of this study was to determine the feasibility and reliability of the Lower Quarter Y Balance Test (YBT‐LQ) in children and to examine the reproducibility of these measures across developmental periods of childhood.

Methods:

188 subjects in first through fifth grades (age = 6.9 to 12.1 yr) performed the YBT‐LQ on two occasions in a field‐based setting. Reach distances and cumulative score (sum of 3 directions) were measured and analyzed using intraclass correlation coefficients (ICC). Sub‐cohorts of 14 and 8 subjects were used to assess inter‐rater reliability within‐session and between‐session, respectively.

Results:

The overall ICC was moderate‐to‐good for the anterior (right=0.82; left=0.82), posteromedial (right=0.77; left=0.75), and posterolateral (right 0.80; left=0.77) reach directions. The combined ICC was also moderate‐to‐good for children in grades 1 (0.71), 2 (0.74), 3 (0.84), 4 (0.82), and 5 (0.79). Typical error values for right and left limbs were less than 10% of the mean for all reach measures across all grades. Interrater reliability within session (ICC > 0.995) and between sessions (0.907 ≤ ICC ≤ 0.974) were both excellent. No unexpected responses or injury occurred during testing.

Conclusions:

These findings indicate that the YBT‐LQ is a feasible and reproducible measure of dynamic postural control in children in first through fifth grades.

Level of Evidence:

2b     

Relationships among the Y balance test,Berg Balance Scale,and lower limb strength in middle-aged and older females

Background:

Older females have less dynamic postural control and muscle strength than do middle-aged females. Aging-related strength losses may limit balancing performance.

Objective:

The purpose of this study was to investigate the ability of the Y Balance Test (YBT) and lower limb strength to discriminate between females in 2 age groups, the relationship between YBT distance and the Berg Balance Scale (BBS), and the degree to which performance on YBT distance is related to lower limb strength in middle-aged and older females.

Method:

The 40 healthy, independently active females were divided into 2 groups: older and middle-aged. The participants underwent measurements of YBT distance using the YBT, maximal muscular strength of the lower limbs using a handheld dynamometer, and the BBS.

Results:

The YBT distance in 3 directions and lower limb muscle strength for both lower limbs were significantly lower in the older adults than in the middle-aged group. A moderate correlation but insignificant correlation was found between the YBT composite distance and the BBS score. In the older females, YBT distance was significantly positively correlated with strength of the knee flexor and hip abductor. In the middle-aged group, YBT distance was significantly positively correlated with strength of the knee flexor and hip extensor.

Conclusions:

Performance on the YBT was influenced by the strength of lower limb. We suggested that YBT can be used to alternative as a measurement of dynamic balance. Proper training programs for older people could include not only strengthening exercises but also YBT performance to improve balance.     

5-Repetition Sit-to-Stand Test in Subjects With Chronic Stroke: Reliability and Validity

Mong Y, Teo TW, Ng SS. 5-repetition sit-to-stand test in subjects with chronic stroke: reliability and validity.

Objectives

To examine the (1) intrarater, interrater, and test-retest reliability of the 5-repetition sit-to-stand test (5-repetition STS test) scores, (2) correlation of 5-repetition STS test scores with lower-limb muscle strength and balance performance, and (3) cut-off scores among the 3 groups of subjects: the young, the healthy elderly, and subjects with stroke.

Design

Cross-sectional study.

Setting

University-based rehabilitation center.

Participants

A convenience sample of 36 subjects: 12 subjects with chronic stroke, 12 healthy elderly subjects, and 12 young subjects.

Interventions

Not applicable.

Main Outcome Measures

5-Repetition STS test time scores; hand-held dynamometer measurements of hip flexors, and knee flexors and extensors; ankle dorsiflexors and plantarflexors muscle strength; Berg Balance Scale (BBS); and limits of stability (LOS) test using dynamic posturography.

Results

Excellent intrarater reliability of intraclass correlation coefficient (ICC) (range, .970-.976), interrater reliability (ICC=.999), and test-retest reliability (ICC range, .989-.999) were found. Five-repetition STS test scores were also found to be significantly associated with the muscle strength of affected and unaffected knee flexors (ρ=-.753 to -.830; P<.00556) of the subjects with stroke. No significant associations were found between 5-repetition STS test and BBS and LOS tests in subjects with stroke. Cut-off scores of 12 seconds were found to be discriminatory between healthy elderly and subjects with stroke at a sensitivity of 83% and specificity of 75%.

Conclusions

The 5-repetition STS test is a reliable measurement tool that correlates with knee flexors muscle strength but not balance ability in subjects with stroke.     

ULTRASOUND IMAGING MEASUREMENT OF THE TRANSVERSUS ABDOMINIS IN SUPINE,STANDING, AND UNDER LOADING: A RELIABILITY STUDY OF NOVICE EXAMINERS

Background

Military personnel and first responders (police and firefighters) often carry large amounts of gear. This increased load can negatively affect posture and lead to back pain. The ability to quantitatively measure muscle thickness under loading would be valuable to clinicians to assess the effectiveness of core stabilization treatment programs and could aid in return to work decisions. Ultrasound imaging (USI) has the potential to provide such a measure, but to be useful it must be reliable.

Purpose

To assess the intrarater and interrater reliability of measurements of transversus abdominis (TrA) and internal oblique (IO) muscle thickness conducted by novice examiners using USI in supine, standing, and with an axial load.

Study Design

Prospective, test‐retest study

Methods

Healthy, active duty military (N=33) personnel were examined by two physical therapy doctoral students (primary and secondary ultrasound technicians) without prior experience in USI. Thickness measurements of the TrA and IO muscles were performed at rest and during a contraction to preferentially activate the TrA in three positions (hook‐lying, standing, and standing with body armor). Percent thickness changes and intraclass correlation coefficients (ICC) were calculated.

Results

Using the mean of three measurements for each of the three positions in resting and contracted muscle states, the intrarater ICC (3,3) values ranged from 0.90 to 0.98. The interrater ICC (2,1) values ranged from 0.39 to 0.79. The ICC values of percent thickness changes were lower than the individual ICC values for all positions and muscle states.

Conclusion

There is excellent intrarater reliability of novice ultrasound technicians measuring abdominal muscle thickness using USI in three positions during the resting and contracted muscle states. However, interrater reliability of two novice technicians was poor to fair, so additional training and experience may be necessary to improve reliability.

Level of Evidence

2b     

Assessing Electronic Note Quality Using the Physician Documentation Quality Instrument (PDQI-9)

Objective

To refine the Physician Documentation Quality Instrument (PDQI) and test the validity and reliability of the 9-item version (PDQI-9).

Methods

Three sets each of admission notes, progress notes and discharge summaries were evaluated by two groups of physicians using the PDQI-9 and an overall general assessment: one gold standard group consisting of program or assistant program directors (n = 7), and the other of attending physicians or chief residents (n = 24). The main measures were criterion-related validity (correlation coefficients between Total PDQI-9 scores and 1-item General Impression scores for each note), discriminant validity (comparison of PDQI-9 scores on notes rated as best and worst using 1-item General Impression score), internal consistency reliability (Cronbach’s alpha), and inter-rater reliability (intraclass correlation coefficient (ICC)).

Results

The results were criterion-related validity (r = –0.678 to 0.856), discriminant validity (best versus worst note, t = 9.3, p = 0.003), internal consistency reliability (Cronbach’s alphas = 0.87–0.94), and inter-rater reliability (ICC = 0.83, CI = 0.72–0.91).

Conclusion

The results support the criterion-related and discriminant validity, internal consistency reliability, and inter-rater reliability of the PDQI-9 for rating the quality of electronic physician notes. Tools for assessing note redundancy are required to complement use of PDQI-9. Trials of the PDQI-9 at other institutions, of different size, using different EHRs, and incorporating additional physician specialties and notes of other healthcare providers are needed to confirm its generalizability.     

FUNCTIONAL PERFORMANCE TESTING OF THE HIP IN ATHLETES: A SYSTEMATIC REVIEW FOR RELIABILITY AND VALIDITY

Purpose/Background:

The purpose of this study was to systematically review the literature for functional performance tests with evidence of reliability and validity that could be used for a young, athletic population with hip dysfunction.

Methods:

A search of PubMed and SPORTDiscus databases were performed to identify movement, balance, hop/jump, or agility functional performance tests from the current peer-reviewed literature used to assess function of the hip in young, athletic subjects.

Results:

The single-leg stance, deep squat, single-leg squat, and star excursion balance tests (SEBT) demonstrated evidence of validity and normative data for score interpretation. The single-leg stance test and SEBT have evidence of validity with association to hip abductor function. The deep squat test demonstrated evidence as a functional performance test for evaluating femoroacetabular impingement. Hop/Jump tests and agility tests have no reported evidence of reliability or validity in a population of subjects with hip pathology.

Conclusions:

Use of functional performance tests in the assessment of hip dysfunction has not been well established in the current literature. Diminished squat depth and provocation of pain during the single-leg balance test have been associated with patients diagnosed with FAI and gluteal tendinopathy, respectively. The SEBT and single-leg squat tests provided evidence of convergent validity through an analysis of kinematics and muscle function in normal subjects. Reliability of functional performance tests have not been established on patients with hip dysfunction. Further study is needed to establish reliability and validity of functional performance tests that can be used in a young, athletic population with hip dysfunction.

Level of Evidence:

2b (Systematic Review of Literature)     

Reliability and Validity of a Partial Weight Bearing Measure of Lower Extremity Performance

Background

Methods of measuring lower extremity function is limited for those with partial weight bearing (PWB) status in early phases of a lower extremity rehabilitation program.

Objectives

The purpose of this study was to measure intra-rater reliability of two lower extremity PWB performance measures using an incline exercise apparatus and to evaluate the concurrent validity and responsiveness to change of these two measures.

Methods

Thirty-seven adult patients with lower extremity injuries were measured on two PWB measures (PWB20 and PWB30) of lower extremity performance as well as several common measures of LE function. After initial testing, subjects were asked to return for retesting, following four to six weeks of rehabilitation intervention. Reliability of the data from the measures was tested using intraclass correlation coefficients (ICC); validity was based on bivariate correlations of the measures. The minimal detectable change (MDC) value and limb symmetry index (LSI) were used to study the responsiveness of the PWB measures.

Results

The ICC for the PWB20 and PWB30 were 0.95 and 0.98, respectively. The bivariate correlations of the PWB20 with stair climbing and walking speed were greater than those of the PWB30. Correlations ranged from r = 0.49 to 0.72 between the PWB measures and the functional measures. For most patients, their change in score between initial testing and follow-up exceeded the MDC; the LSI improved for all patients.

Conclusion

Using the incline apparatus yielded reliable PWB data. In addition, performance on the PWB measures correlated fairly well with common measures of function.     

THE RELIABILITY AND CONCURRENT VALIDITY OF SHOULDER MOBILITY MEASUREMENTS USING A DIGITAL INCLINOMETER AND GONIOMETER: A TECHNICAL REPORT

Purpose/Aim:

This study investigated the intrarater reliability and concurrent validity of active shoulder mobility measurements using a digital inclinometer and goniometer.

Materials/Methods:

Two investigators used a goniometer and digital inclinometer to measure shoulder flexion, abduction, internal and external rotation on 30 asymptomatic participants in a blinded repeated measures design.

Results:

Excellent intrarater reliability was present with Intraclass Correlation Coefficients (ICC- 3,k) for goniometry ≥ 0.94 and digital inclinometry ≥ 0.95. The concurrent validity between goniometry and digital inclinometry was good with ICC (3,k) values of ≥ 0.85. The 95% limits of agreement suggest that the difference between these two measurement instruments can be expected to range from 2° to 20°.

Conclusions:

The results cautiously support the interchangeable use of goniometry and digital inclinometer for measuring shoulder mobility measurements. Although reliable, clinicians should consider the 95% limits of agreement when using these instruments interchangeably as clinically significant differences are likely to be present.

Level of evidence:

2b     

Measurement properties and feasibility of clinical tests to assess sit-to-stand/stand-to-sit tasks in subjects with neurological disease: a systematic review

Background

Subjects with neurological disease (ND) usually show impaired performance during sit-to-stand and stand-to-sit tasks, with a consequent reduction in their mobility levels.

Objective

To determine the measurement properties and feasibility previously investigated for clinical tests that evaluate sit-to-stand and stand-to-sit in subjects with ND.

Method

A systematic literature review following the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) protocol was performed. Systematic literature searches of databases (MEDLINE/SCIELO/LILACS/PEDro) were performed to identify relevant studies. In all studies, the following inclusion criteria were assessed: investigation of any measurement property or the feasibility of clinical tests that evaluate sit-to-stand and stand-to-sit tasks in subjects with ND published in any language through December 2012. The COSMIN checklist was used to evaluate the methodological quality of the included studies.

Results

Eleven studies were included. The measurement properties/feasibility were most commonly investigated for the five-repetition sit-to-stand test, which showed good test-retest reliability (Intraclass Correlation Coefficient:ICC=0.94-0.99) for subjects with stroke, cerebral palsy and dementia. The ICC values were higher for this test than for the number of repetitions in the 30-s test. The five-repetition sit-to-stand test also showed good inter/intra-rater reliabilities (ICC=0.97-0.99) for stroke and inter-rater reliability (ICC=0.99) for subjects with Parkinson disease and incomplete spinal cord injury. For this test, the criterion-related validity for subjects with stroke, cerebral palsy and incomplete spinal cord injury was, in general, moderate (correlation=0.40-0.77), and the feasibility and safety were good for subjects with Alzheimer''s disease.

Conclusions

The five-repetition sit-to-stand test was used more often in subjects with ND, and most of the measurement properties were investigated and showed adequate results.     

Validity of the Community Balance and Mobility Scale in Community-Dwelling Persons After Stroke

Knorr S, Brouwer B, Garland SJ. Validity of the Community Balance and Mobility Scale in community-dwelling persons after stroke.

Objectives

To examine the convergent validity, sensitivity to change, floor and ceiling effects of the Community Balance and Mobility Scale (CB&M) in community-dwelling stroke survivors. The secondary objective was to determine the correlations between the CB&M and lower-limb motor recovery and strength.

Design

Validity study.

Setting

Two university-based research centers.

Participants

Community-dwelling persons after stroke (N=44; 24 men, 20 women; mean age, 62.6±12.6y). Baseline measures were taken 3 months after the onset of stroke (98.6±52.6d); participants were reassessed 8 months poststroke (246.8±57.2d).

Interventions

Not applicable.

Main Outcome Measures

CB&M, Berg Balance Scale (BBS), Timed Up & Go (TUG), Chedoke McMaster Stroke Assessment (CMSA) Impairment Inventory for leg and foot, concentric bilateral isokinetic strength of the lower-limb flexor and extensor muscle groups using a dynamometer. The magnitude of the associations and the standardized response means (SRMs) among the CB&M, BBS, and TUG were used to examine the convergent validity and sensitivity to change, respectively.

Results

Moderate to high convergent validities (ρ=.70 to .83, P<.001) were observed among the CB&M, BBS, and TUG. The CB&M was moderately correlated with the CMSA leg and foot scores (ρ=.61 and .63, respectively, P<.001) and the paretic limb strength (ρ=.67, P<.001). The CB&M demonstrated the greatest ability to detect change between the baseline and follow-up assessments (SRM=.83).

Conclusions

The CB&M is valid and sensitive to change in assessing functional balance and mobility in ambulatory stroke survivors with moderate to mild neurologic impairments.     

THE RELIABILITY,MINIMAL DETECTABLE CHANGE AND CONSTRUCT VALIDITY OF A CLINICAL MEASUREMENT FOR IDENTIFYING POSTERIOR SHOULDER TIGHTNESS

Purpose/Background:

Posterior shoulder tightness (PST) has been implicated in the etiology of numerous shoulder disorders. Therefore, clinicians and researchers must have a reliable and valid method for quantifying PST. The purpose of this study was to investigate the interrater reliability, minimal detectable change at the 90% confidence interval (MDC₉₀) and construct validity of an inclinometric measurement designed to quantify PST.

Methods:

Two investigators each performed sidelying PST measurements on the non-dominant shoulder of 45 asymptomatic participants in a blinded repeated measures design. Upon completion of the PST measurements, one rater assessed active internal and external rotation for the validity component of the investigation.

Results:

Interrater reliability using an intraclass correlation coefficient (ICC) model 2,k was good (ICC 5 0.90). The MDC₉₀ indicated that a change of greater than or equal to 9 degrees would be required to be 90% certain that a change in the measurement would not be the result of inter-trial variability or measurement error. Construct validity was evaluated using active internal rotation for convergence and external rotation for discrimination. Construct validity was supported by a good to excellent relationship between PST and internal rotation (r 5 0.88) and by an inverse relationship between PST and external rotation (r 5 20.07).

Conclusion:

The sidelying procedure described in this investigation appears to be a reliable and valid means for quantifying PST when strict measurement protocols are adhered to. An advantage of this procedure lies in the ability to control scapular position to ensure motion is limited to the glenohumeral joint. Moreover, the use of inclinometry provides an absolute angle of tightness that may be used for intersubject comparison, documenting change, and to determine reference values. Clinicians and researchers should consider the MDC values presented when interpreting change values during subsequent measurement sessions.     

RELIABILITY OF AND THE RELATIONSHIP BETWEEN ULTRASOUND MEASUREMENT AND THREE CLINICAL ASSESSMENTS OF HUMERAL TORSION

Purpose/Background:

Differences in humeral torsion have been observed between overhead athletes and non‐athletes. Although humeral torsion may be an adaptive process for athletic performance, it may be associated with injury. Methods for measuring humeral torsion have consisted of radiography, computer tomography, and ultrasound imaging. However, diagnostic imaging may be costly and not available to all clinicians. The implementation of clinical assessments may be an alternative way to measure humeral torsion. Before clinical measures can be recommended, these assessments need to be evaluated for validity and reliability of each test. The purpose of this study was to assess the intratester and intertester reliability of three clinical tests, intratester reliability of ultrasound measures, and the validity of each clinical test to ultrasound measures.

Methods

Thirty participants (male: 12, female: 18; age: 20±2 years; height: 174.24±9.35 cm; mass: 70.53±11.06 kg; body mass index: 23.13±2.47 kg/m²; years in sport: 9±4 years) with experience in overhead sports were assessed for humeral torsion, bilaterally. Humeral torsion was assessed using musculoskeletal ultrasound by a single assessor, and using three separate clinical assessments by two independent assessors. Clinical assessments included the angle of rotation during both the bicipital tuberosity palpation with the shoulder abducted at 90 degrees (Palp90) or 45 degrees (Palp45), and the angle of external rotation during horizontal adduction (HADD).

Results

Intratester reliability for the ultrasound measure was good (ICC=0.907), along with intratester reliability for both assessors across each clinical assessment (ICC''s > 0.769). Poor to moderate reliability was observed between assessors for each clinical assessment (ICC=0.256 Palp90, ICC=0.419 Palp45, ICC=0.243 HADD. Only the Palp90 measure had a fair but significant (r=0.326, p=0.011) relationship with ultrasound measures.

Conclusion

Individual assessors can achieve reliable ultrasound, bicipital tuberosity palpation and HADD values across multiple trials; however, these measures are not consistent between assessors. Additionally, only one clinical test had a fair but significant relationship with ultrasound measures. Improved testing procedures may be needed to increase between assessor reliability and strength of relationships to ultrasound measures. Current application of clinical assessments to measure humeral torsion is limited.

Level of Evidence:

3b; Grade of Recommendation C     

RELIABILITY,COMPARABILITY, AND VALIDITY OF FOOT INVERSION AND EVERSION STRENGTH MEASUREMENTS USING A HAND-HELD DYNAMOMETER

Background

There are conflicting results with respect to the validity and reliability of lower extremity strength measurements using a hand-held dynamometer (HHD) in the healthy population. Previous studies exploring foot inversion and eversion strength using a HHD were carried out with predominantly clinically affected participants in different positions. The question arises whether HHD measurements of isometric foot inversion and eversion strength performed with participants in different positions are valid, reliable and comparable and can be used alternatively.

Purpose

The aims of this study were to investigate: a) the intra- and inter-tester reliability of measurements of foot inversion and eversion strength in different participant positions using a belt-stabilized HHD; b) the comparability of results obtained in different positions; and c) the concurrent validity of the aforementioned measurements using an isokinetic dynamometer.

Methods

Thirty adults (12 females and 18 males; mean age 22.5 ± 3.9 years) volunteered to participate in this study. Maximal isometric foot inversion and eversion torques (Nm) were measured with participants lying supine, sitting with knees extended and lying on their side using a belt-stabilized HHD. Measurements were performed independently by two physiotherapists over two days and were repeated using an isokinetic dynamometer. Validity and intra- and inter-tester reliability were determined using the intra-class correlation coefficient (ICC). A two-way ANOVA (p < 0.05) and post-hoc tests with Bonferroni correction were used to compare data from different positions. Bland-Altman plots were used to demonstrate the range of error and difference between HHD and isokinetic measurements.

Results

Intra-tester reliability for inversion and eversion torques was fair to excellent in all positions (ICC = 0.598–0.828). Excellent inter-tester reliability was found for eversion torques in all positions (ICC = 0.773–0.860). For inversion torques, inter-tester reliability was fair to excellent (ICC = 0.519–0.879). ICC values of 0.205 to 0.562 indicated a low to fair concurrent validity. A significant difference was observed between the torques of the supine and side-lying positions as well as sitting and side-lying positions (p < 0.05). Bland-Altman plots showed that the mean of the differences for inversion and eversion torques deviates considerably from zero, indicating that measurements with the HHD in the three positions produce lower values compared to using the isokinetic dynamometer.

Conclusions

Inversion and eversion strength measurements with subjects in different positions using HHD seem to be reliable, but consistently underestimated torque output when compared with measurements using isokinetic dynamometry. While the HHD outcomes measured in supine and sitting positions seem to be comparable, those measured in supine/sitting and side-lying positions differed.

Level of Evidence

Diagnostic study, Level 3     

Manual Ability Classification System (MACS): reliability between therapists and parents in Brazil

BACKGROUND:

The Manual Ability Classification System (MACS) has been widely used to describe the manual ability of children with cerebral palsy (CP); however its reliability has not been verified in Brazil.

OBJECTIVE:

To establish the inter- and intra-rater reliability of the Portuguese-Brazil version of the MACS by comparing the classifications given by therapists and parents of children with CP.

METHOD:

Data were obtained from 90 children with CP between the ages of 4 and 18 years, who were treated at the neurology and rehabilitation clinics of a Brazilian hospital. Therapists (an occupational therapist and a student) classified manual ability (MACS) through direct observation and information provided by parents. Therapists and parents used the Portuguese-Brazil version of the MACS. Intra- and inter-rater reliability was obtained using unweighted Kappa coefficient (k) and intra-class correlation coefficient (ICC). The Chi-square test was used to identify the predominance of disagreements in the classification of parents and therapists.

RESULTS:

An almost perfect agreement resulted among therapists [K=0.90 (95% CI 0.83-0.97); ICC=0.97 (95%CI 0.96-0.98)], as well as with intra-rater (therapists), with Kappa ranging between 0.83 and 0.95 and ICC between 0.96 and 0.99 for the evaluator with more and less experience in rehabilitation, respectively. The agreement between therapists and parents was fair [K=0.36 (95% CI 0.22-0.50); ICC=0.79 (95% CI 0.70-0.86)].

CONCLUSIONS:

The Portuguese version of the MACS is a reliable instrument to be used jointly by parents and therapists.     

AN INITIAL EVALUATION OF THE BTRACKS BALANCE PLATE AND SPORTS BALANCE SOFTWARE FOR CONCUSSION DIAGNOSIS

Background

As recently dictated by the American Medical Society, balance testing is an important component in the clinical evaluation of concussion. Despite this, previous research on the efficacy of balance testing for concussion diagnosis suggests low sensitivity (∼30%), based primarily on the popular Balance Error Scoring System (BESS). The Balance Tracking System (BTrackS, Balance Tracking Systems Inc., San Diego, CA, USA) consists of a force plate (BTrackS Balance Plate) and software (BTrackS Sport Balance) which can quickly (<2 min) perform concussion balance testing with gold standard accuracy.

Purpose

The present study aimed to determine the sensitivity of the BTrackS Balance Plate and Sports Balance Software for concussion diagnosis.

Study Design

Cross-Sectional Study

Methods

Preseason baseline balance testing of 519 healthy Division I college athletes playing sports with a relatively high risk for concussions was performed with the BTrackS Balance Test. Testing was administered by certified athletic training staff using the BTrackS Balance Plate and Sport Balance software. Of the baselined athletes, 25 later experienced a concussion during the ensuing sport season. Post-injury balance testing was performed on these concussed athletes within 48 of injury and the sensitivity of the BTrackS Balance Plate and Sport Balance software was estimated based on the number of athletes showing a balance decline according to the criteria specified in the Sport Balance software. This criteria is based on the minimal detectable change statistic with a 90% confidence level (i.e. 90% specificity).

Results

Of 25 athletes who experienced concussions, 16 had balance declines relative to baseline testing results according to the BTrackS Sport Balance software criteria. This corresponds to an estimated concussion sensitivity of 64%, which is twice as great as that reported previously for the BESS.

Conclusions

The BTrackS Balance Plate and Sport Balance software has the greatest concussion sensitivity of any balance testing instrument reported to date.

Level of Evidence

Level 2 (Individual cross sectional diagnostic study)