Correlation of three different knee joint position sense measures

Physical Therapy in Sport 11 (2010) 81e85

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Physical Therapy in Sport journal homepage: www.elsevier.com/ptsp

Original research

Correlation of three different knee joint position sense measures Dayanand Kiran a, *, Mary Carlson a, Daniel Medrano b, Darla R. Smith b a b

Physical Therapy Program, University of Texas at El Paso, 1101, N Campbell Street, El Paso 79902, USA Department of Kinesiology, University of Texas at El Paso, El Paso 79902, USA

a r t i c l e i n f o

a b s t r a c t

Article history: Received 17 March 2010 Received in revised form 27 May 2010 Accepted 7 June 2010

Objective: The purpose of this study was to investigate correlation during concurrent measurement among three knee joint position sense (JPS) measures in sitting position and between two measures in standing position. Methods: Isokinetic dynamometer, electrogoniometer, and two dimensional (2D) video analysis were used for measuring knee JPS. The JPS was measured both in sitting and standing positions. All three measures were employed concurrently to measure knee JPS in sitting position; however, only the electrogoniometer and 2D video analysis were concurrently used in the standing position. The knee JPS was recorded in sitting position at 15 , 30 , and 45 and in standing at high, mid and low knee flexion positions. Results: The results of the study suggest excellent correlation (0.94e0.98) between the electrogoniometer and 2D video analysis measures in standing position. In sitting position, good to excellent correlation (0.63e0.92) was found between the isokinetic dynamometer and electrogoniometer; however, fair to good correlation was found between 2D video analysis and either of the two measures (electrogoniometer [0.52e0.57] and isokinetic dynamometer [0.41e0.63]. Conclusion: Either 2D video or an electrogoniometer may be used to measure JPS in standing position; however, in sitting position 2D video should not be used if the camera is required to be placed at 10 from the plane of motion. Ó 2010 Elsevier Ltd. All rights reserved.

Keywords: Joint position sense Electrogoniometer Isokinetic dynamometer Two dimensional video analysis Correlation

1. Introduction Proprioception is the umbrella term for kinesthesia and joint position sense (JPS). JPS refers to the awareness of joint position in space and is mediated through various receptors called mechanoreceptors (Grob, Kuster, Higgins, Lloyd, & Yata, 2002). These receptors are located in the joint capsule, ligaments, menisci, musculotendinous unit, and skin (Kavounoudias, Roll, & Roll, 2001; Lephart, Pincivero, & Rozzi, 1998). Poor proprioception is suggested as a risk factor for the development of functional inability in patients with knee osteoarthritis (Sharma, Cahue, Song, Hayes, Pai, & Dunlop, 2003). The deterioration of proprioception results in increased postural sway, decreased balance, increased risk of falls and changes in gait patterns (Bergin, Bronstein, Murray, Sancovic, & Zeppenfeld, 1995; Manchester, Woollacott, Zederbauer-Hylton, & Marin, 1989; Tinetti & Speechley, 1989). The changes in proprioception not only affect

* Corresponding author. Tel.: þ1 915 747 7218; fax: þ1 915 747 8211. E-mail addresses: [email protected] (D. Kiran), [email protected] (M. Carlson), [email protected] (D. Medrano), [email protected] (D.R. Smith). 1466-853X/$ e see front matter Ó 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.ptsp.2010.06.002

the function of older adults but also have impact on the younger population, especially with anterior cruciate ligament (ACL) injuries. Proprioception is important in the prevention of injuries as reduced proprioception is one of the factors contributing to injury in the knee, particularly the ACL. Although the causes of ACL injury are multi-factorial, poor proprioception is one of the key causative factors (Beynnon & Johnson, 1996; Griffin et al., 2000; Taimela, Kujala, & Osterman, 1990). Additionally, the restoration of a fully functional knee joint after ACL injury depends on regaining proprioception as an important component (Aune, Holm, Risberg, Jensen, & Steen, 2001; Friden, Roberts, Ageberg, Walden, & Zatterstrom, 2001). Therefore, proprioception appears not only important for the prevention of ACL injuries, but also for regaining full function after ACL reconstruction. ACL injuries can be treated with reconstruction surgery where the patellar tendon or the hamstring tendon is used as a graft to replace the torn ACL ligament. Although reconstruction is successful in regaining joint stability, the recovery of proprioceptive function remains debatable (Henriksson, Ledin, & Good, 2001). MacDonald, Hedden, Pacin, and Sutherland (1996) reported no significant improvement in proprioceptive deficits in patients 31 months after ACL reconstruction by measuring

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kinesthesia. However, Reider et al. (2003) reported a significantly improved level of proprioception by measuring JPS in an ACL reconstructed knee after six months of rehabilitation when compared with the contralateral limb. Furthermore, Hopper, Creagh, Formby, Goh, Boyle, and Strauss (2003) reported no significant difference in knee proprioception after 12e16 months of ACL reconstruction by measuring JPS. Reider et al. (2003) used an electrogoniometer to measure the JPS, however, Hopper et al. (2003) used Peak Motus motion measurement to measure the knee JPS. The results regarding proprioceptive function may be contradictory not only due to differences in measurement methods but also due to use of different equipment to measure the proprioception. Early measurement of JPS used a modified Thomas splint with a Pearson knee piece or a copper frame with a motor and a calibrated scale (Barrett, 1991; Corrigan, Cashman, & Brady, 1992). These measurements were subjected to a high degree of intertester variability as the joint angle was visually estimated. Many studies have used the isokinetic dynamometer, electrogoniometer, or 2D video analysis to measure JPS (Birmingham et al., 1998; Hopper et al., 2003; Reider et al., 2003). Although all three measures of JPS have been used separately, no studies have established if concurrent measurement will result in similar values of JPS. Additionally, most of the studies tested JPS in non-weight bearing conditions while functional activities are performed in weight bearing conditions. It logically follows that JPS should be tested in weight bearing conditions in order to simulate functional activities. Therefore, this study aimed to determine if three JPS measures (isokinetic dynamometer, electrogoniometer, and 2D video analysis) produced equivalent results. 2. Methods 2.1. Participants A group (convenience sampling) of 30 participants (male and female), ages 18e25 years with no history of injury or surgery to the knee, were recruited from the university student population. The number of participants was decided based on previous studies (Grob et al., 2002; Reider et al., 2003) on proprioception in ACL injuries. The inclusion criteria for the study were (a) current enrollment at the university and (b) participation in sports-related activities at least three times a week. The participation in sports activities was required so that everybody could be at a similar level of proprioception. The exclusion criteria were (a) any history of injury, pain, or swelling of the knee in the previous year and (b) any history of medical problems which could limit proprioception. All the inclusion and exclusion criteria were determined by the participants’ answers on a health questionnaire form. Approval of the proposal from the university’s ethical review board was obtained prior to data collection. All the participants were asked to sign an informed consent form.

2.3. Sitting measurement 2.3.1. Calibration of electrogoniometer The Penny and Giles ‘M’ series twin axis electrogoniometer (Penny þ Giles, UK) was used to measure JPS. It measures the potential difference between the two endblocks, and converts the difference in potential to the respective joint angle. Before data collection, calibration of the electrogoniometer was done using VICON Motus Motion System (VMMS) version 8.5 (Peak Performance Technologies, Inc. CO, USA) and a universal goniometer. One endblock of the electrogoniometer was placed on the fixed and the other on the movable arm of the universal goniometer for the calibration (see Fig. 1). The movable arm was rotated in 10 increments, and the corresponding voltages were recorded from the VMMS. Further, the following equation was obtained by plotting a graph (R2 ¼ 0.99) between the recorded voltage (x) and the angle (y) to which the universal goniometer arm was moved:

AngleðyÞ ¼ 88:118x þ 261:09

This equation was used to calculate the knee joint angle during JPS testing. 2.3.2. Calibration of the video camera A JVC camera (Victor Company of Japan, Japan) was used for recording the video for the measurement of JPS by VMMS. Before testing, the calibration of the camera’s spatial field was done by VMMS using a 0.50 m 0.325 m frame with reflective markers at each corner. 2.3.3. Testing procedure The participants were asked to sit on the isokinetic dynamometer system 3 (Biodex Medical Systems, Shirley, New York) chair with their trunks secured to the chair after calibrating the system as per manufacturer’s guidelines. The endblocks of the goniometer were placed on the lateral aspect of the dominant limb knee joint. To measure the knee angle by 2D video analysis, the reflective markers were placed on the thigh, lateral knee joint line, and lateral malleolus. The thigh marker was placed slightly forward and downward to the greater trochanter after placing the other two markers. All the markers were ensured to be in one line and in the same plane in knee extended position. Additionally, the reflective marker at the knee joint was stemmed to bring all three markers in one plane. The placement of the endblocks and the reflective markers were held constant throughout the experiment in sitting and standing position.

2.2. Procedures Three measures were taken concurrently in sitting position: isokinetic dynamometer, 2D video analysis, and electrogoniometer. However, only two measures were taken concurrently in standing position: 2D video analysis and electrogoniometer. A practice test was given to familiarize the participant with the procedure before testing. The order of the testing in sitting or standing positions was determined randomly.

(1)

Fig. 1. Placement of elctrogonometer endblocks.


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Participants were seated with the knee flexed to 90 on the isokinetic dynamometer chair with eyes covered (Fig. 2). Testing positions of 15 , 30 , and 45 were selected on the isokinetic dynamometer protocol (Birmingham et al., 1998). The three test positions were tested in the order of 15 , 30 , and 45 as the dynamometer protocol does not permit random selection. The researcher asked the participant to move the knee from the starting position to the angle being demonstrated by the dynamometer and then to return the knee to the starting position. The participants were asked to remember each demonstrated position and then return the knee joint to the demonstrated position. The participants indicated the reproduction of the knee angle to the demonstrated position by pressing a switch at the appropriate angle. The measurements from camera and electrogoniometer were also recorded by the VMMS at each corresponding demonstrated and reproduced position. An error angle between the demonstrated and the reproduced position was considered for analysis of JPS. 2.4. Standing measurement The calibration and placement of the endblocks of the electrogoniometer was the same as it was in the sitting position. However, the camera’s spatial field was recalibrated by using VMMS and 1.83 m 0.92 m frame with reflective markers at each corner. 2.4.1. Testing procedure The participants were asked to stand with maximum weight on the test limb and with eyes covered (Fig. 3). The foot of the nontested leg was touching the floor for stability only. They were asked to flex the knee to a randomly determined position of around 0 e45 of knee flexion. We considered the test position high, mid and low when the knee was flexed around 15 , 30 , and 45 respectively. The participants were asked to remember the demonstrated position and return to a standing position. They were then asked to place the knee joint in the demonstrated position. Both the demonstrated and reproduced positions were recorded by the electrogoniometer and the camera for the analysis (Hopper et al., 2003; Reider et al., 2003). 2.5. Research design The research design was a prospective within subject’s design that used concurrent measurement and random ordering of the JPS

Fig. 3. Placement of reflective markers and endblocks for measurement of JPS in standing.

tests. The independent variables were the testing procedures with three levels (electrogoniometer, isokinetic dynamometer, and 2D video analysis), and testing positions with two levels (sitting and standing). The dependent variable, joint position sense, was measured in degrees. 2.6. Data analysis We conducted all planned comparisons using SPSS 15.0 statistical software. First of all, we examined all the variables for distributional assumptions and potential outliers using frequency analysis and histograms. Following these analyses, descriptive statistics were reported including means and standard deviations for continuous variables (JPS score). 3. Results Thirty healthy participants (13 females and 17 males) with no history of injury in the lower limb were tested on their dominant limb. Three trials of demonstrated and reproduced testing were done at each position and the average absolute error values are presented in Table 1. For the knee position at 15 only two absolute

Table 1 presents the descriptive statistics of absolute error of the knee joint position sense with the mean, standard deviation, minimum and maximum values (in degrees) in sitting and standing position. Test Equipment position

Minimum Maximum Mean error error

Isokinetic dynamometer

1 1 0.67 0.27 0.53 0.26 0.14 0.27 0.14

10 8 12 7.30 7.10 8.53 6.54 7.07 5.59

4.68 3.85 3.90 3.24 2.90 3.42 2.91 2.72 2.31

2.21 1.90 2.55 1.63 1.61 2.04 1.65 1.49 1.47

Standing Electrogoniometer High Mid Low 2D video analysis High Mid Low

0.31 1.2 0.35 0.34 0.98 0.31

9.01 9.15 8.77 8.67 8.21 7.26

3.34 3.85 3.57 3.49 3.58 3.24

2.33 2.07 2.1 2.24 2.00 1.99

Sitting

Fig. 2. Placement of reflective markers and endblocks for measurement of JPS in sitting position.

Measured position

15 30 45 Electrogoniometer 15 30 45 2D video analysis 15 30 45

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errors were averaged due to loss of data. In the sitting position, the mean absolute errors measured by the isokinetic dynamometer were 4.68 (SD 2.21), 3.85 (SD 1.90), and 3.90 (SD 2.55) degrees in the 15 , 30 and 45 test positions respectively. The mean absolute errors measured by the electrogoniometer in the same positions were 3.24 (SD 1.63), 2.90 (SD 1.61), and 3.42 (SD 2.04) degrees. The 2D video analysis mean absolute measures of the knee JPS were 2.91 (SD 1.65), 2.72 (SD 1.49), and 2.31 (SD 1.47) degrees in the similar test positions. In the standing position, the mean absolute errors measured by electrogoniometer were 3.34 (SD 2.33), 3.85 (SD 2.07), and 3.57 (SD 2.10) degrees in the high-, mid-, and lowtest positions respectively. In the same test positions, the mean absolute errors measured by 2D video analysis were 3.49 (SD 2.24), 3.58 (SD 2.00), and 3.24 (SD 1.99) degrees. To assess the concurrent reliability the correlations between average absolute error angles of two measurement techniques were determined at each position in both sitting (Table 2) and standing (Table 3). Excellent correlation (0.94e0.98) in the standing knee measurements is noted at each joint position between the electrogoniometer and the 2D video analysis. However, good to excellent level of correlation (0.63e0.92) is present between the electrogoniometer and isokinetic dynamometer measurements at all three of the positions in sitting. Furthermore, fair to good correlation (0.41e0.63) is present between the two dimensional video and either of the other two measures (electrogoniometer and isokinetic dynamometer measurements).

4. Discussion Although knee joint position sense (JPS) has been measured by different equipment in the research literature, the correlation among the measures has not been studied. The present study aimed to evaluate if the concurrent measures of the knee JPS by the three measures (isokinetic dynamometer, electrogoniometer, and 2D video analysis) were highly correlated. These measures have been used by numerous researchers for several years (Birmingham et al., 1998; Hopper et al., 2003; Reider et al., 2003). Further, we tested the reliability of the measures in both sitting and standing positions since both positions were used in the research literature. In the standing position, we found excellent correlation (0.94e0.98) between the electrogoniometer and 2D video analysis measurement (Fleiss, 1981). The excellent correlation in standing position appeared to be due to the minimal level of error in measurement of joint angles by 2D video analysis when the camera was placed at 90 from the plane of motion. Additionally, the analysis of the measures of JPS in standing suggests that neither measure is better than the other, as both measures had equivalent

Table 3 presents the inter-correlations between all the test positions in standing. Equipment

Measured position

Electrogoniometer High

2D video analysis High

Mid

Low

0.98 (r2 ¼ 0.96)

Mid

0.96 (r2 ¼ 0.92)

Low

0.94 (r2 ¼ 0.88)

values of JPS. Therefore, researchers may use either measure during knee JPS measurement in standing position with confidence. In the standing measurements, we were able to place the camera close to a 90 position; however, in sitting position measurement the placement of the camera at 90 was not possible due to the isokinetic dynamometer arm blocking the camera’s visual field. Therefore, we had to place the camera at an angle of 10 where the dynamometer could not obstruct the visibility of the reflective markers. In this study, we found that in the sitting position the correlation between the measures of the isokinetic dynamometer and the electrogoniometer was in the range of 0.63e0.92 within the different tested positions. However, the correlation between the measures of isokinetic dynamometer and the 2D video analysis or between the 2D video analysis and the electrogoniometer was in the range of 0.41e0.63 or 0.52e0.57 respectively. The fair to good correlation between 2D video analysis and either of the other two measures appeared to be due to the inability of the VICON Motus motion system (VMMS) to measure joint angles accurately when the camera position was close to 10 from the plane of motion. In a previous study, (Kiran, Carlson, Medrano, & Smith, 2010), we reported increased error when the camera was placed at 5 e10 from the plane of motion. Therefore, the increased error in JPS measurement by 2D video analysis could be the reason for the fair to good correlation between 2D video analysis measure and isokinetic dynamometer or electrogoniometer measure. However, when the camera was positioned perpendicular to the plane of motion, the 2D video analysis measures were highly correlated with the electrogoniometer measures as evidenced by the standing JPS correlation values. Further studies may be done to discern the correlation between concurrent JPS measurements by the electrogoniometer and the 2D video analysis in the sitting position. The correlation between the electrogoniometer and the isokinetic dynamometer in the sitting position ranged from 0.63 to 0.92 with an increase in correlation from 15 knee flexion to 45 knee flexion position. The differential in correlation in these positions may be due to more skin movement in the thigh in a fully

Table 2 presents the inter-correlations between all the positions in sitting. Equipment

Measured position

2D video analysis

Isokinetic dynamometer

15

0.41 (r2 ¼ 0.17)

15

30

Electrogoniometer 30

15 30 45

15

30

45

0.63 (r2 ¼ 0.40) 0.80 (r2 ¼ 0.64)

0.53 (r2 ¼ 0.28)

45 Electrogoniometer

45

0.63 (r2 ¼ 0.40) 0.55 (r2 ¼ 0.30) 0.52 (r2 ¼ 0.27) 0.57 (r2 ¼ 0.32)

0.92 (r2 ¼ 0.85)


extended position than in a flexed position. Kuo, Tully, and Galea (2008) reported displacement of skin markers in the lateral thigh during hipe knee flexion in sitting position. The measurement of the joint angle by electrogoniometer depends on the change in voltage between the two endblocks. The differential skin movement in the thigh from extension to flexion of the knee may interfere with the change in voltage between the two endblocks, yielding altered JPS measurement values. Further research may be done to find out the accuracy of electrogoniometer measures at different degrees of knee flexion angle. Additionally, research may be done to discover the amount of skin movement throughout the knee range of motion. The future study may also include correlation in sitting position of knee JPS measures by an electrogoniometer and 2D video analysis with a camera perpendicular to the plane of motion. In conclusion, since excellent correlation between 2D video analysis and electrogoniometer was found, either electrogoniometer or 2D video analysis may be used in the standing position to measure JPS; if the camera is placed perpendicular to the plane of motion. Accordingly, either isokinetic dynamometer or electrogoniometer may be used to measure knee JPS in sitting position as the correlation between those two measures was good to excellent. However, in sitting position, the correlation of the 2D video analysis and either of the other two measures was only fair to good. Therefore, the selection of 2D video analysis to measure knee JPS in sitting position with the camera placed at 10 from the plane of movement should be avoided. Acknowledgements The research was funded by College of Health Sciences, the University of Texas at El Paso. Conflict of interest None. Ethical statement The study was approved by the University of Texas at El Paso review board (88060-4). References Aune, A. K., Holm, I., Risberg, M. A., Jensen, H. K., & Steen, H. (2001). Four-strand hamstring tendon autograft compared with patellar tendon-bone autograft for anterior cruciate ligament reconstruction. A randomized study with two-year follow-up. The American Journal of Sports Medicine, 29(6), 722e728.

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