EVALUATING CHANGE IN CLINICAL STATUS: RELIABILITY AND MEASURES OF AGREEMENT FOR THE ASSESSMENT OF GLENOHUMERAL RANGE OF MOTION

Objectives:

To evaluate intra-rater and inter-rater reliability and measurement error in glenohumeral range of motion (ROM) measurements using a standard goniometer.

Study design:

17 adult subjects with and without shoulder pathology were evaluated for active and passive range of motion. Fifteen shoulder motions were assessed by two raters to determine reliability. The intra-class correlation coefficients (ICC) were calculated and examined to determine if reliability of ICC ≥ 0.70 existed. The standard error of measurement (SEM) and the minimal clinical difference (MCD) were also calculated.

Results:

Thxe criterion reliability was achieved in both groups for intra-rater reliability of standing AROM abduction; supine AROM and PROM abduction, flexion, external rotation at 0° abduction; and for inter-rater reliability of supine AROM and PROM abduction, external rotation at 0° abduction. The SEM ranged from 4°-7° for intra-rater and 6°-9° for inter-rater agreement on movements that achieved the criterion reliability. The MCD ranged from 11°-16° for a single evaluator and 14°-24° for two evaluators.

Conclusions:

Assessment of AROM and PROM in supine achieves superior reliability. The use of either a single or multiple raters affects the number of movements that achieved clinically meaningful reliability. Some movements consistently did not achieve the criterion and may not be the best movements to monitor treatment outcome.     

CONCURRENT VALIDITY AND RELIABILITY OF 2D KINEMATIC ANALYSIS OF FRONTAL PLANE MOTION DURING RUNNING

Purpose:

Three‐dimensional motion analysis is the “gold standard” for evaluating kinematic variables during treadmill running. However, its use is limited by temporal and financial restraints. Therefore, the purpose of this study was to assess the concurrent validity and reliability of 2D video analysis for frontal plane kinematic variables during treadmill running.

Methods:

Twenty‐four healthy male and female collegiate cross‐country runners completed a running protocol at a self‐selected speed. Frontal plane kinematic data were collected using 3D and 2D motion analysis systems. Variables of interest included contralateral pelvic drop (CPD), peak hip adduction angle (HADD), and peak knee abduction angle (KABD). Pearson Product Correlation Coefficients were used to determine the relationship between the 3D and 2D systems for each variable. Intra‐Class Correlation Coefficients (ICC) were used to assess intra‐rater reliability of the user of the 2D software.

Results:

The 2D testing method demonstrated excellent intra‐rater reliability for peak HADD (ICCs: 0.951‐0.963), peak CPD (0.958‐0.966), and peak KABD (ICCs: 0.955‐0.976). Moderate correlations between 2D and 3D measures of HADD on the left (0.539; p=0.007) and the right (0.623; p=0.001) and peak KABD on the left (0.541; p=.006) lower extremity were found. No statistically significant correlation of CPD was found between the 2D and 3D systems. The 2D measure of CPD had a strong correlation to the 2D assessment of HADD on both the left (0.801; p=0.0001) and the right (0.746; p=0.0001) extremity.

Conclusion:

These findings and the ease of data capture using 2D software provide support for the utility of 2D video analysis in the evaluation of frontal plane variables, specifically HADD.

Level of evidence:

2B     

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     

Reliability of different methodologies of infrared image analysis of myofascial trigger points in the upper trapezius muscle

BACKGROUND:

Infrared thermography is recognized as a viable method for evaluation of subjects with myofascial pain.

OBJECTIVE:

The aim of the present study was to assess the intra- and inter-rater reliability of infrared image analysis of myofascial trigger points in the upper trapezius muscle.

METHOD:

A reliability study was conducted with 24 volunteers of both genders (23 females) between 18 and 30 years of age (22.12±2.54), all having cervical pain and presence of active myofascial trigger point in the upper trapezius muscle. Two trained examiners performed analysis of point, line, and area of the infrared images at two different periods with a 1-week interval. The intra-class correlation coefficient (ICC_2,1) was used to assess the intra- and inter-rater reliability.

RESULTS:

With regard to the intra-rater reliability, ICC values were between 0.591 and 0.993, with temperatures between 0.13 and 1.57 °C for values of standard error of measurement (SEM) and between 0.36 and 4.35 °C for the minimal detectable change (MDC). For the inter-rater reliability, ICC ranged from 0.615 to 0.918, with temperatures between 0.43 and 1.22 °C for the SEM and between 1.19 and 3.38 °C for the MDC.

CONCLUSION:

The methods of infrared image analyses of myofascial trigger points in the upper trapezius muscle employed in the present study are suitable for clinical and research practices.     

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     

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     

RELIABILITY OF TWO METHODS OF CLINICAL EXAMINATION OF THE FLEXIBILITY OF THE HIP ADDUCTOR MUSCLES

Background

An inadequate level of flexibility of the adductor muscles is one of the most critical risk factors for chronic groin pain and strains. However, measurement methods of adductor muscle flexibility are not well defined.

Purpose

To determine the inter‐session reliability of the biarticular and monoarticular adductor muscle flexibility measures obtained from passive hip abduction with the knee flexed over the edge of the plinth test (PHA) and the passive hip abduction test at 90° of hip flexion (PHA_90°).

Study design

Clinical Measurement Reliability study.

Methods

Fifty healthy recreational athletes participated in this study. All participants performed the PHA and PHA_90° on four different occasions, with a two‐week interval between testing sessions. Reliability was examined through the change in the mean between consecutive pairs of testing sessions (ChM), standard error of measurement expressed in absolute values (SEM) and as a percentage of the mean score (%SEM), minimal detectable change at 95% confidence interval (MDC₉₅), and intraclass correlation coefficients (ICC_2,k).

Results

The findings showed negligible or trivial ChM values for the two adductor flexibility measures analyzed (<2°). Furthermore, the SEM and MDC₉₅ were 2.1° and 5.9° and 2.2° and 6.2° for the measures obtained from the PHA and PHA_90°, respectively, with %SEM scores lower than 5% and ICC scores higher than 0.90.

Conclusion

The findings from this study suggest that the adductor muscle flexibility measures analyzed have good to excellent inter‐session reliability in recreational athletes. Thus, clinicians can be 95% confident that an observed change between two measures larger than 5.9° and 6.2° for the flexibility measures obtained from the PHA and PHA_90°, respectively, would indicate a real change in muscle flexibility.

Level of evidence

2     

THE RELIABILITY OF REHABILITATIVE ULTRASOUND IMAGING IN THE MEASUREMENT OF INFRASPINATUS MUSCLE FUNCTION IN THE SYMPTOMATIC AND ASYMPTOMATIC SHOULDERS OF PATIENTS WITH UNILATERAL SHOULDER IMPINGEMENT SYNDROME

Background:

Rehabilitative ultrasound Imaging (RUSI) is increasingly used in the management of musculoskeletal conditions as it provides an objective measure of muscle function while being less invasive than needle electromyography. While research has documented the ability to reliably measure trunk muscles in patients with back pain, no study to date has used RUSI to quantify infraspinatus muscle function in patients with shoulder impingement syndrome (SIS).

Hypothesis/Purpose:

The purpose of this study was to examine the intra‐rater and inter‐rater reliability of measuring infraspinatus muscle thickness with RUSI and to compare such measures during resting versus contracted muscle states and in the symptomatic versus asymptomatic shoulders in patients with SIS.

Study Design:

Cross‐sectional, measurement study

Methods:

Fifty‐two participants with unilateral SIS underwent a standard baseline examination to include RUSI of the infraspinatus muscle bilaterally. Images were acquired at rest and during a submaximal isometric contraction, by two novice examiners. The isometric contraction was elicited by having prone participants externally rotate their shoulder from a position of 90° abduction into a dynamometer and hold a static force of 20 mmHg (approximately 20‐30% maximal voluntary contraction). Images were captured using a standardized placement of the transducer placed just inferior to the spine of the scapula along the medial scapular border and measured off‐line using Image J software (V1.38t, National Institutes of Health, Bethesda, Maryland).

Results:

Estimates (ICCs) for thickness measurements ranged between 0.96 and 0.98 for intra‐rater reliability and between 0.87 and 0.92 for inter‐rater reliability. Reliability was substantially lower (ICC = 0.43 to 0.79) for calculations of percent thickness change. The infraspinatus muscle was significantly thicker when contracted (19.1mm) than during rest (16.2mm) in both shoulders (p < 0.001). There was also a statistically significant interaction between contraction state and shoulder (p = 0.026), indicating that the change in thickness that occurred during contraction was significantly smaller in the symptomatic shoulder than in the asymptomatic shoulder.

Conclusion:

RUSI measurements of infraspinatus muscle thickness appear to be highly reliable, both within the same examiner and between different examiners, in patients with SIS. Moreover, such measurements were different in rested and contracted states of the infraspinatus, as well as, between the symptomatic and asymptomatic shoulders of patients with unilateral SIS.

Level of evidence:

Level 2     

RELIABILITY AND VALIDITY OF FUNCTIONAL PERFORMANCE TESTS IN DANCERS WITH HIP DYSFUNCTION

Study Design:

Quasi-experimental, repeated measures.

Purpose/Background:

Functional performance tests that identify hip joint impairments and assess the effect of intervention have not been adequately described for dancers. The purpose of this study was to examine the reliability and validity of hop and balance tests among a group of dancers with musculoskeletal pain in the hip region.

Methods:

Nineteen female dancers (age: 18.90±1.11 years; height: 164.85±6.95 cm; weight: 60.37±8.29 kg) with unilateral hip pain were assessed utilizing the cross-over reach, medial triple hop, lateral triple hop, and cross-over hop tests on two occasions, 2 days apart. Test-retest reliability and comparisons between the involved and uninvolved side for each respective test were determined.

Results:

Intra-class correlation coefficients for the functional performance tests ranged from 0.89-0.96. The cross-over reach test had a SEM of 2.79 cm and a MDC of 7.73 cm. The medial and lateral triple hop tests had SEM values of 7.51 cm and 8.17 cm, and MDC values of 20.81 cm and 22.62 cm, respectively. The SEM was 0.15 seconds and the MDC was 0.42 seconds for the cross-over hop test. Performance on the medial triple hop test was significantly less on the involved side (370.21±38.26 cm) compared to the uninvolved side (388.05±41.49 cm); t₍₁₈₎ = −4.33, p<0.01. The side-to-side comparisons of the cross-over reach test (involved mean=61.68±10.9 cm; uninvolved mean=61.69±8.63 cm); t₍₁₈₎ = −0.004, p=0.99, lateral triple hop test (involved mean=306.92±35.79 cm; uninvolved mean=310.68±24.49 cm); t₍₁₈₎ = −0.55, p=0.59, and cross-over hop test (involved mean=2.49±0.34 seconds; uninvolved mean= 2.61±0.42 seconds; t₍₁₈₎ = −1.84, p=0.08) were not statistically different between sides.

Conclusion:

The functional performance tests used in this study can be reliably performed on dancers with unilateral hip pain. The medial triple hop test was the only functional performance test with evidence of validity in side-to-side comparisons. These results suggest that the medial triple hop test may be a reliable and valid functional performance test to assess impairments related to hip pain among dancers.

Level of Evidence:

3b. Non-consecutive cohort study     

CONCURRENT VALIDITY OF DIGITAL INCLINOMETER AND UNIVERSAL GONIOMETER IN ASSESSING PASSIVE HIP MOBILITY IN HEALTHY SUBJECTS

Background:

Hip range of motion is an important component in assessing clinical orthopedic conditions of the hip, low back and lower extremities. However it remains unclear as to what constitutes the best tool for clinical measurement. The purpose of this study was to investigate the concurrent validity of passive range of motion (ROM) measurements of hip extension and hip internal and external rotation using a digital inclinometer and goniometer.

Design:

Criterion Standard

Setting:

Clinical research laboratory

Participants:

30 healthy subjects without pain, radicular symptoms or history of surgery in the low back or hip regions.

Main Outcome Measures:

Passive hip range of motion for extension, hip internal rotation and hip external rotation. A digital inclinometer and universal goniometer were utilized as the tools for comparisons between measurements.

Results:

There was a statistically significant difference (p < 0.05) between the goniometer and digital inclinometer in measured hip ROM except for measurements of right hip external rotation (p > 0.05). The mean difference between the goniometer and digital inclinometer in left hip extension, internal rotation and external rotation were 3.5°, 4.5° and 5.0° respectively. The mean difference between the two devices in right hip extension, internal rotation and external rotation were 2.8°, 4.2° and 2.6° respectively. On average, the difference between the goniometer and digital inclinometer in extension was 3.2°, internal rotation was 4.5° and external rotation was 3.8°. The digital inclinometer had greater measurement during EXT and ER. Furthermore, there was no statistically significant difference (p > 0.05) in hip ROM between the left and right side for either goniometric or digital inclinometer measurements.

Conclusions:

This results of this study indicate that a significant difference exists between the two devices in all measurements with exception of right hip extension. The differences were noted to be between 3–5 degrees for all planes measured. These findings suggest that caution should be used if these two devices are to be used interchangeably to quantify passive hip range of motion in either clinical practice or when comparing studies that utilize different instruments.

Level of Evidence:

2b     

Increased left ventricular torsion in hypertrophic cardiomyopathy mutation carriers with normal wall thickness

Background

Increased left ventricular (LV) torsion has been observed in patients with manifest familial hypertrophic cardiomyopathy (HCM), and is thought to be caused by subendocardial dysfunction. We hypothesize that increased LV torsion is already present in healthy mutation carriers with normal wall thickness.

Methods

Seventeen carriers with an LV wall thickness <10 mm, and seventeen age and gender matched controls had cardiovascular magnetic resonance (CMR) cine imaging and tissue tagging. LV volumes and mass were calculated from the cine images. LV torsion, torsion rate, endocardial circumferential strain and torsion-to-endocardial-circumferential-shortening (TECS) ratio, which reflects the transmural distribution in contractile function, were determined using tissue tagging.

Results

LV volumes, mass and circumferential strain were comparable between groups, whereas LV ejection fraction, torsion and TECS-ratio were increased in carriers compared to controls (63 ± 3% vs. 60 ± 3%, p = 0.04, 10.1 ± 2.5° vs. 7.7 ± 1.2°, p = 0.001, and 0.52 ± 0.14°/% vs. 0.42 ± 0.10°/%, p = 0.02, respectively).

Conclusions

Carriers with normal wall thickness display increased LV torsion and TECS-ratio with respect to controls, which might be due to subendocardial myocardial dysfunction. As similar abnormalities are observed in patients with manifest HCM, the changes in healthy carriers may be target for clinical intervention to delay or prevent the onset of hypertrophy.     

Reliability of the Balance Evaluation Systems Test (BESTest) and BESTest sections for adults with hemiparesis

BACKGROUND:

The Balance Evaluation Systems Test (BESTest) was recently created to allow the development of treatments according to the specific balance system affected in each patient. The Brazilian version of the BESTest has not been specifically tested after stroke.

OBJECTIVE:

To evaluate the intra- and inter-rater reliability and concurrent and convergent validity of the total score of the BESTest and BESTest sections for adults with hemiparesis after stroke.

METHOD:

The study included 16 subjects (61.1±7.5 years) with chronic hemiparesis (54.5±43.5 months after stroke). The BESTest was administered by two raters in the same week and one of the raters repeated the test after a one-week interval. Intraclass correlation coefficient (ICC) was calculated to assess intra- and interrater reliability. Concurrent validity with the Berg Balance Scale (BBS) and convergent validity with the Activities-specific Balance Confidence scale (ABC-Brazil) were assessed using Pearson''s correlation coefficient.

RESULTS:

Both the BESTest total score (ICC=0.98) and the BESTest sections (ICC between 0.85 and 0.96) have excellent intrarater reliability. Interrater reliability for the total score was excellent (ICC=0.93) and, for the sections, it ranged between 0.71 and 0.94. The correlation coefficient between the BESTest and the BBS and ABC-Brazil were 0.78 and 0.59, respectively.

CONCLUSIONS:

The Brazilian version of the BESTest demonstrated adequate reliability when measured by sections and could identify what balance system was affected in patients after stroke. Concurrent validity was excellent with the BBS total score and good to excellent with the sections. The total scores but not the sections present adequate convergent validity with the ABC-Brazil. However, other psychometric properties should be further investigated.     

Reproducibility of the six-minute walk test and Glittre ADL-test in patients hospitalized for acute and exacerbated chronic lung disease

Background:

The 6-minute walk test (6MWT) and the Glittre ADL-test (GT) are used to assess functional capacity and exercise tolerance; however, the reproducibility of these tests needs further study in patients with acute lung diseases.

Objectives:

The aim of this study was to investigate the reproducibility of the 6MWT and GT performed in patients hospitalized for acute and exacerbated chronic lung diseases.

Method:

48 h after hospitalization, 81 patients (50 males, age: 52±18 years, FEV₁: 58±20% of the predicted value) performed two 6MWTs and two GTs in random order on different days.

Results:

There was no difference between the first and second 6MWT (median 349 m [284-419] and 363 m [288-432], respectively) (ICC: 0.97; P<0.0001). A difference between the first and second tests was found in GT (median 286 s [220-378] and 244 s [197-323] respectively; P<0.001) (ICC: 0.91; P<0.0001).

Conclusion:

Although both the 6MWT and GT were reproducible, the best results occurred in the second test, demonstrating a learning effect. These results indicate that at least two tests are necessary to obtain reliable assessments.     

Regional assessment of left ventricular torsion by CMR tagging

Purpose

To introduce a standardized method for calculation of left ventricular torsion by CMR tagging and to determine the accuracy of torsion analysis in regions using an analytical model.

Methods

Torsion between base and apex, base and mid, and mid and apex levels was calculated using CSPAMM tagging and Harmonic Phase tracking. The accuracy of torsion analysis on a regional basis (circumferential segments and transmural layers) was analyzed using an analytical model of a deforming cylinder with a displaced axis of rotation (AoR). Regional peak torsion values from twelve healthy volunteers calculated by the described method were compared to literature.

Results

The deviation from the analytical torsion per % AoR-displacement (of the radius) was 0.90 ± 0.44% for the circumferential segments and only 0.05% for the transmural layers. In the subjects, circumferentially, anterolateral torsion was larger than inferior (12.4 ± 3.9° vs. 5.0 ± 3.3°, N.S.). Transmurally, endocardial torsion was smaller than epicardial (7.5 ± 1.3° vs. 8.0 ± 1.5°, p < 0.001).

Conclusion

Variability in the position of the AoR causes a large variability in torsion in circumferential segments. This effect was negligible for global torsion, and torsion calculated in transmural layers. Results were documented for the healthy human heart and are in agreement with data from literature.     

RELIABILITY AND ACCURACY OF A GONIOMETER MOBILE DEVICE APPLICATION FOR VIDEO MEASUREMENT OF THE FUNCTIONAL MOVEMENT SCREEN DEEP SQUAT TEST

Background/Purpose

The squat is a fundamental movement of many athletic and daily activities. Methods to clinically assess the squat maneuver range from simple observation to the use of sophisticated equipment. The purpose of this study was to examine the reliability of Coach''s Eye (TechSmith Corp), a 2‐dimensional (2D) motion analysis mobile device application (app), for assessing maximal sagittal plane hip, knee, and ankle motion during a functional movement screen deep squat, and to compare range of motion values generated by it to those from a Vicon (Vicon Motion Systems Ltd) 3‐dimensional (3D) motion analysis system.

Methods

Twenty‐six healthy subjects performed three functional movement screen deep squats recorded simultaneously by both the app (on an iPad [Apple Inc]) and the 3D motion analysis system. Joint angle data were calculated with Vicon Nexus software (Vicon Motion Systems Ltd). The app video was analyzed frame by frame to determine, and freeze on the screen, the deepest position of the squat. With a capacitive stylus reference lines were then drawn on the iPad screen to determine joint angles. Procedures were repeated with approximately 48 hours between sessions.

Results

Test‐retest intrarater reliability (ICC_3,1) for the app at the hip, knee, and ankle was 0.98, 0.98, and 0.79, respectively. Minimum detectable change was hip 6°, knee 6°, and ankle 7°. Hip joint angles measured with the 2D app exceeded measurements obtained with the 3D motion analysis system by approximately 40°. Differences at the knee and ankle were of lower magnitude, with mean differences of 5° and 3°, respectively. Bland‐Altman analysis demonstrated a systematic bias in the hip range‐of‐motion measurement. No such bias was demonstrated at the knee or ankle.

Conclusions

The 2D app demonstrated excellent reliability and appeared to be a responsive means to assess for clinical change, with minimum detectable change values ranging from 6° to 7°. These results also suggest that the 2D app may be used as an alternative to a sophisticated 3D motion analysis system for assessing sagittal plane knee and ankle motion; however, it does not appear to be a comparable alternative for assessing hip motion.

Level of Evidence

3     

RELIABILITY OF THREE MEASURES OF ANKLE DORSIFLEXION RANGE OF MOTION

Purpose/Background:

A variety of methods exist to measure ankle dorsiflexion range of motion (ROM). Few studies have examined the reliability of a novice rater. The purpose of this study was to determine the reliability of ankle ROM measurements using three different techniques in a novice rater.

Methods:

Twenty healthy subjects (mean±SD, age=24±3 years, height=173.2±8.1 cm, mass=72.6±15.2 kg) participated in this study. Ankle dorsiflexion ROM measures were obtained in a weight-bearing lunge position using a standard goniometer, digital inclinometer, and a tape measure using the distance-to-wall technique. All measures were obtained three times per side, with 10 minutes of rest between the first and second set of measures. Intrarater reliability was determined using an intraclass correlation coefficient (ICC_2,3) and associated 95% confidence intervals (CI). Standard error of measurement (SEM) and the minimal detectable change (MDC) for each measurement technique were also calculated.

Results:

The within-session intrarater reliability (ICC_2,3) estimates for each measure are as follows: tape measure (right 0.98, left 0.99), digital inclinometer (right 0.96; left 0.97), and goniometer (right 0.85; left 0.96). The SEM for the tape measure method ranged from 0.4–0.6 cm and the MDC was between 1.1–1.5 cm. The SEM for the inclinometer was between 1.3–1.4° and the MDC was 3.7–3.8°. The SEM for the goniometer ranged from 1.8–2.8° with an MDC of 5.0–7.7°.

Conclusions:

The results indicate that reliable measures of weight-bearing ankle dorsiflexion ROM can be obtained from a novice rater. All three techniques had good reliability and low measurement error, with the distance-to-wall technique using a tape measure and inclinometer methods resulting in higher reliability coefficients (ICC_2,3=0.96 to 0.99) and a lower SEM compared to the goniometer (ICC_2,3=0.85 to 0.96).

Level of Evidence:

2b     

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     

Feasibility of common carotid artery point of care ultrasound in cardiac output measurements compared to invasive methods

Background

Cardiac output (CO) measurement in the intensive care unit (ICU) requires invasive devices such as the pulmonary artery (PA) catheter or arterial waveform pulse contour analysis (PCA). This study tests the accuracy and feasibility of point of care ultrasound (POCUS) of the common carotid artery to estimate the CO non-invasively and compare it to existing invasive CO measurement modalities.

Methods

Patients admitted to the surgical and cardiothoracic ICU in a tertiary university-affiliated academic center during a 4-month period, with invasive hemodynamic monitoring devices for management, were included in this cohort study. Common carotid artery POCUS was performed to measure the CO and the results were compared to an invasive device.

Results

Intensivists and ICU fellows, using ultrasound of the common carotid artery, obtained the CO measurements. Images of the Doppler flow and volume were obtained at the level of the thyroid gland. Concurrent CO measured via invasive devices was recorded. The patient cohort comprised 36 patients; 52 % were females. The average age was 59 ± 13 years, and 66 % were monitored via PCA device and 33 % via PA catheter. Intraclass correlation coefficient (ICC) analysis demonstrated almost perfect correlation (0.8152) between measurements of CO via ultrasound vs. invasive modalities. The ICC between POCUS and the invasive measurement via PCA was 0.84 and via PA catheter 0.74, showing substantial agreement between the ultrasound and both invasive modalities.

Conclusions

Common carotid artery POCUS offers a non-invasive method of measuring the CO in the critically ill population.