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Validity and reliability of palpation-digitization for non-invasive kinematic measurement – A systematic review
Manual Therapy 18 (2013) 26e34
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Systematic review
Validity and reliability of palpation-digitization for non-invasive kinematic measurement e A systematic review Divya Bharatkumar Adhia a, b, *, Melanie D. Bussey a,1, Daniel Cury Ribeiro b, c, 2, Steve Tumilty b, 3, Stephan Milosavljevic b, 4 a b c
School of Physical Education, University of Otago, Dunedin, New Zealand Centre for Physiotherapy Research, University of Otago, Dunedin, New Zealand Otago Institute of Sport and Adventure, Otago Polytechnic, Dunedin, New Zealand
a r t i c l e i n f o
a b s t r a c t
Article history: Received 6 December 2011 Received in revised form 6 June 2012 Accepted 11 June 2012
Joint kinematic assessment using an electromagnetic tracking device (EMTD) requires palpationdigitization (PD) of bony landmarks to define the anatomical axes. Errors in PD of bony landmarks can perturb the anatomical axes and affect the validity and reliability of kinematic measurements. The validity and reliability of PD for kinematic measurement needs to be explored before recommending its wider use. A systematic search of 15 electronic databases located studies assessing validity and/or reliability of PD for joint kinematic assessment. Two independent reviewers used the QUADAS and QAREL tools to assess quality of validity and reliability studies respectively. The results were synthesized qualitatively using a level of evidence approach. Eight studies satisfied the final eligibility criteria and were included in the review. The validity, intra-rater reliability and inter-rater reliability were assessed in three, seven and one study respectively. The overall level of evidence for validity of PD technique was strong with high correlation (0.80) reported by three high (60%) quality studies. The overall level of evidence for intra-rater reliability was also strong with very high ICC (0.90) and satisfactory SEM (SEM % 10%) reported by four high quality studies. However the level of evidence for inter-rater reliability was limited and needs to be addressed by future research. Ó 2012 Elsevier Ltd. All rights reserved.
Keywords: Validity Reliability Palpation-digitization Kinematics
1. Introduction Evaluation of joint kinematics is essential to musculoskeletal assessment, helping clinicians determine baseline data, monitor progress and guide appropriate implementation of treatment strategies (Smith, 1982). While clinicians often use simple noninvasive devices such as goniometers or inclinometers to measure joint kinematics, these can only assess two-dimensional motion and have reduced accuracy in measuring motion outside the sagittal plane (Ordway et al., 1997; Nussbaumer et al., 2010). Thus, it
* Corresponding author. School of Physical Education, University of Otago, Dunedin, New Zealand. Tel.: þ64 211167594. E-mail addresses: [email protected], [email protected] (D.B. Adhia), [email protected] (M.D. Bussey), daniel.cury.ribeiro@ gmail.com (D.C. Ribeiro), [email protected] (S. Tumilty), [email protected] (S. Milosavljevic). 1 Tel.: þ64 3479 8981. 2 Tel.: þ64 3479 3666. 3 Tel.: þ64 3479 5757. 4 Tel.: þ64 3479 7193. 1356-689X/$ e see front matter Ó 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.math.2012.06.004
would be advantageous to have a simple non-invasive device that allows accurate and reliable measurement of three-dimensional (3D) joint motion (An et al., 1988). Recently, electromagnetic tracking devices (EMTD) have become a popular tool for noninvasive clinical evaluation of 3D joint motion particularly in complex joints such as spine (Assink et al., 2008; Heneghan et al., 2009). The use of EMTD for joint kinematic assessment can be considered an important advancement that can have both research and clinical utility providing an ability to determine multiplanar joint kinematics and guiding appropriate implementation of treatment strategies (An et al., 1988; Bussey et al., 2004). An EMTD uses a low frequency electromagnetic field generated by a transmitter to detect 3D position and orientation of sensors fixed to body segments (Pomianowski, 2001). The arbitrary axis of the system may be converted to a meaningful anatomical joint axis using palpation-digitization (PD) of anatomical bony landmarks (Pennock and Clark, 1990; Wu et al., 2005). The PD technique involves the tester palpating the most prominent part of a bony landmark followed by physically collecting the 3D co-ordinates of the bony landmark using an electromagnetic digitizing stylus
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(sensor embedded in a pen) (Bussey et al., 2004). The 3D coordinates of sensors and digitized bony landmarks relative to the source are obtained from electronic software connected to the EMTD system; and the relative 3D movement between distal and proximal body segments is then determined using these coordinates. The PD technique of EMTD has been used in both the clinical and research environment; however it can be affected by several sources of error. Errors during a PD technique can arise from tester, subject, and procedure-related variability (Smidt et al., 1992). As bony landmarks are irregular structures (de Groot, 1997; Croce et al., 2005), the accurate and consistent palpation of bony landmarks is a primary concern while using this technique (Seffinger et al., 2004; Stochkendahl et al., 2006). Further, with some bony landmarks being more superficial than others the ability to accurately palpate may differ with anatomical location (Harlick et al., 2007). Inaccuracies in palpation of bony landmarks may result in digitization errors leading to misalignment of the anatomical axis system about which the movements are assumed to occur (e.g., the flexionextension axis of a joint coordinate system should be aligned in the medio-lateral direction) (Piazza and Cavanagh, 2000). Errors in PD of bony landmarks can affect the validity and reliability of kinematic measurements leading to misinterpretation of results (de Groot, 1997; Meskers et al., 1998; France and Nester, 2001; Croce et al., 2005; Morton et al., 2007; Langenderfer et al., 2009; Moriguchi et al., 2009). Thus, the level of evidence for validity and reliability of PD techniques for joint kinematic measurements is essential for EMTD to produce clinically meaningful results, and needs to be established before recommending its wider use. Therefore, the purpose of this research is to systematically review the literature concerning the validity and reliability of PD technique of bony landmark identification for joints kinematic assessment using EMTD.
2. Methods 2.1. Search strategy A systematic search strategy was conducted to locate studies assessing validity and/or reliability of PD for joint kinematic measurements using EMTD, in any sampled population. Three relevant subject areas; namely 1) EMTD, 2) validity and/or reliability, and 3) kinematic measurements; along with their related terms were used to perform the systematic search (Table 1). The databases were searched using combinations of keywords and specific subject headings. The Boolean operators “OR” and “AND” were used to combine the search terms within and between each of
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the three subject areas respectively. In order to cover the widest spectrum of articles, no search limits were applied to any databases. The systematic search was conducted on 1st September 2011 by the primary investigator (DBA). The following electronic databases were searched from their inception: Ovid MEDLINE, EMBASE, AMED, PubMed, Science Direct, CINAHL, Cochrane library, Scopus, SPORTDiscus, Scirus, ISI web of science and ProQuest. Supplementary searches included the following search engines: Google scholar, ProQuest Dissertation and Thesis, and WorldCat. The reference lists of review articles and of each acquired full-text manuscript were also explored to identify any publications not identified during the initial database search. Further, citations of included manuscripts were also screened to identify any relevant articles. 2.2. Eligibility criteria The articles obtained by the systematic search were exported to an EndNoteÒ library where they underwent a stepwise screening procedure for eligibility. Two independent reviewers (DBA and DCR) screened the titles, abstracts and full text of the articles for eligibility based on following criteria: 2.2.1. Inclusion criteria Type of studies: Studies were included only if measurement of validity and/or reliability was one of the primary aims of the study. Publications in any language as full text articles, theses or peer reviewed reports were included for the review. Type of participants: Studies on human participants were included for the review. No restrictions were made with respect to demographics or condition (healthy individuals/ pathological group) of participants. Type of interventions and outcome measures: The studies using the PD techniques for joint kinematics assessment using EMTD were included for the review. The studies were included only if they assessed the validity and/or reliability of PD techniques and provided validity and/or reliability statistics.
2.2.2. Exclusion criteria Biomechanical in-vitro studies Full text could not be located Letters, editorials, comments, case-studies, protocols, guidelines, conference proceedings or review articles Articles using PD that only defined the local co-ordinate system and did not assess the validity and/or reliability of PD itself.
Table 1 Search strategy: keywords and search terms used. Search terms
EMTD/related terms
Validity/reliability/related terms
Kinematic measurements/related terms
MeSH/subject terms/subject headings/CINAHL headings/Thesauras
Nil
Biomechanics, kinematics, measurement, range of motion, joint mobility, motion, movement, mechanics, kinesiology
Keywords
Polhemus, Fastrak, Isotrak, Liberty, Flock of birds, electromagnetic tracking device, electromagnetic tracking system
Reliability, reliability and validity, reproducibility, inter-rater reliability, intra-rater reliability, test retest reliability, consistency and reliability, validity, accuracy, sensitivity and specificity, precision, predictive value of tests Reliability, reproducibility, repeatability, inter-rater, intra-rater, inter-examiner, intra-examiner, inter-observer, intra-observer, inter-tester, intra-tester, validity, accuracy, sensitivity, specificity, likelihood ratio, precision
EMTD: electromagnetic tracking device, MeSH: medical subject headings.
Biomechanics, kinematics, movement, measurement, range of motion, three dimensional motion, 3D motion, 3D movement
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Assessment of validity and/or reliability of PD were not one of the primary aims of the study. Technical reports on validity and/or reliability of PD not involving human participants (e.g on Plexiglas model). In cases of uncertainty about eligibility of the manuscript on basis of title and abstract, full text of those manuscripts were screened for eligibility. In case of disagreement between two reviewers, a consensus was reached by the use of a third reviewer (MDB).
Table 2 Levels of evidence approach. Level of evidence
Criteria
Strong Moderate
Consistent findings from 3 high quality studies Consistent findings from at least 1 high quality and one or more low quality studies Consistent findings in 1 low quality studies or only 1 study available Inconsistent findings in multiple studies irrespective of study quality No studies found
Limited Conflicting No evidence
2.3. Data Extraction Two independent reviewers (DBA & DCR) extracted data from included studies using standard forms, as recommended by Lucas et al. (2010). The details included: study aims, study design, participant details, examiner details, equipment, details of assessment procedure of index test and reference standard, outcome measures, statistical techniques used, estimates of validity and reliability coefficient, conclusion and relevant methodological limitation. Any discrepancy of interpretation was resolved by discussion seeking consensus and use of third reviewer if disagreement persisted.
Reference: van Tulder et al., 2003.
2.6. Sensitivity analysis The level of evidence approach used for synthesizing the data, takes into account the number of studies, quality of studies and consistency of study outcomes (van Tulder et al., 2003). The criterion for defining high quality studies was set at 60% (van der Wurff et al., 2000; May et al., 2006; May et al., 2010). To test the effect of quality criteria on the assumptions of level of evidence, the predetermined criterion (60%) for defining studies as high quality was subjected to a change of 10% and its effect on level of evidence was determined.
2.4. Assessing quality of studies The QUADAS (Whiting et al., 2003) and QAREL (Lucas et al., 2010) scales were used to assess the quality of validity and reliability studies, respectively. These scales have demonstrated acceptable levels of content validity (good) and inter-rater reliability (k > 0.60) (Whiting et al., 2006; Lucas et al., 2010). The QUADAS and QAREL checklist consists of 14 and 11 items, respectively, and both assess the external validity, internal validity and statistical methods of the studies. Each item is equally weighted and scored as Yes, No or Unclear based on guidelines provided. The studies were considered of high quality if items in the respective checklists scored as Yes were 60% (van der Wurff et al., 2000; May et al., 2006; May et al., 2010). Each included study was scored independently by two reviewers (DBA & DCR) and disagreement was resolved by discussion or use of third reviewer (MDB). The agreement between the two reviewers for rating studies based on quality scales was calculated by percent agreement. 2.5. Data analysis and synthesis Pooling of results and meta-analysis, where appropriate, was part of the protocol for this systematic review. However, metaanalysis could not be performed due to the heterogeneous characteristics of included studies. Moreover, a subgroup analysis could not be performed due to the limited number of studies in any one joint area evaluating the same outcome variables. Hence a descriptive analysis was conducted and data were synthesized using van Tulder et al. (2003) level of evidence approach (Table 2). P-values of 0.05 as reported from paired t-test and ANOVA statistics were interpreted as indicating no significant difference between the index test and reference standard. The Intraclass Correlation Coefficient (ICC) and Pearson’s correlation coefficient was interpreted as follows: 0.00e0.29 as very low correlation, 0.30e0.49 as low correlation, 0.50e0.69 as moderate correlation, 0.70e0.89 as high correlation, 0.90 and above as very high correlation (Munro and Visintainer, 2005). The standard error of measurement (SEM%) of 10% was considered as acceptable absolute reliability. For studies that did not provide absolute reliability statistics, the SEM and SEM% were calculated if the required information was available (Beckerman et al., 2001).
3. Results 3.1. Literature search Fig. 1 displays the flow diagram, based on PRISMA guidelines (Liberati et al., 2009), of the flow of articles through the review process as approved by two reviewers. Of 2219 articles, only eight articles were identified as assessing validity (Sprigle et al., 2002), reliability (Culham and Peat, 1993; Gould, 2003; Ludewig et al., 2004; Laprade and Lee, 2005; Singh et al., 2010) or validity þ reliability (KulkarniLambore and Peat, 2000; Bussey et al., 2004). 3.2. Methodological quality 3.2.1. Validity studies The two reviewers initially disagreed on 5/42 (15.15%) of QUADAS items for the quality score of validity studies. The disagreement between the two reviewers was then resolved by discussion. All included validity studies were high quality (>60%) with quality scores ranging from 72.72% to 90.90% (Table 3). The internal validity of all the studies was high with the score of >85.00%, whereas the external validity was slightly low ranging from 50.00% to 75.00%. 3.2.2. Reliability studies Similar to QUADAS, the two reviewers initially disagreed on 7/ 77 (9.09%) (Kappa ¼ 0.77) items of the QAREL checklist for the quality score of reliability studies. The disagreement between the two reviewers was then resolved by discussion. The quality score of reliability studies ranged from 40.00% to 71.43% with 5 high quality studies (60%) and 2 low quality studies (<60%) (Table 4). The internal validity, external validity and statistical method component of the quality scale ranged from 33.34% to 75.00%, 33.34%e 66.67% and 0.00%e100% respectively. 3.3. Study characteristics 3.3.1. Validity studies The characteristics of the validity studies are displayed in Table 5. The validity of PD technique was assessed against radiography or CT scan as reference standards in healthy subjects in all
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Database specific subject headings / keywords / thesaurus
Electronic Databases (1572) : Ovid AMED (46), Ovid EMBASE (144), Ovid 4 MEDLINE (101), CINAHL (40),, Cochrane library (10), PubMed (49), ProQuest (22), Scopus (792), Science Direct (114), 5 SPORTDiscus (23), ISI Web of knowledge (205) 205) & Scirus (26). 6
Supplementary searches (647): Suppleme Google scholar scho (612), ProQuest Thesis & Dissertations (7) and OCLC World Cat (28). Dissertation
Total otal number off articles articles obtained = 22 2219 Excluded: duplicates 908 Retained aft after f er duplicates = 1311 Excluded: not no relevant (885), non-EMTD (116), in-vitro in-vitr or technical report (137), (46), non-validity or reliability (85) reviews (46)
Excluded: title and abstract screening 1269
Retained tained aft after f er title and abstract screeni screening = 42 E Excluded: PD for LCS (11), no PD (19), technical report (4) P
Excluded: full text screening 34
Retained aft after f er fu ffull ll textt sc screening reening = 8 Included: hand searching of reference list = 0 Final number off articles articles included in the review = 8
Validity alone = 1
Validity and Reliability = 2
Reliability alone = 5
Fig. 1. Flowchart of articles reviewed.
three studies. Two studies (Sprigle et al., 2002; Bussey et al., 2004) assessed the validity of PD technique for assessing pelvic kinematics, one study assessed hip kinematics (Sprigle et al., 2002) and one study assessed the metacarpo-phalangeal joint kinematics (Kulkarni-Lambore and Peat, 2000). The mean difference between the joint kinematic measures assessed using PD and the reference standard ranged from 0.34 to 8.00 (SD: 0.52 to 10.00 ). All the studies reported high (0.80) to very high (0.90) correlation, with two studies reporting no significant difference (P > 0.05) between the index and reference standard. 3.3.2. Reliability studies The reliability studies and their characteristics are displayed in Table 6. The intra-rater reliability of PD technique was assessed by 7 studies, and inter-rater reliability was assessed by 1 study. While most studies evaluated reliability in healthy population, 2 studies (Kulkarni-Lambore and Peat, 2000; Ludewig et al., 2004) also included symptomatic population. The reliability of the PD
technique was assessed for both joint range of motion (ROM) and static postural angles. The reliability of PD technique for ROM measurements was evaluated in patello-femoral, pelvis, shoulder and metacarpo-phalangeal joint, whereas for static postural angles were evaluated in the spinal and shoulder joints using respective bony landmarks. High (0.70e0.89) to very high (0.90e1.00) measures of reliability were demonstrated for PD of most of the bony landmarks for kinematic assessment of most of the joints. The ICC ranged from 0.51 to 0.99 with a mean of 0.90 and SD of 0.09, and the SEM% ranged from 1.27% to 10.25% with a mean of 4.80% and SD of 2.22%. 3.4. Level of evidence 3.4.1. Validity studies The results in Table 5 demonstrate overall strong evidence for the validity of PD technique for assessing joint kinematics. A high to very high correlation was reported by 3 high quality studies, and no
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Table 3 Quality analysis of validity studies using QUADAS tool. Questions:
Bussey et al., 2004
Sprigle et al., 2002
Kulkarni-Lambore and Peat, 2000
1. Representative sample 2. Selection criteria 3. Appropriate reference standard 4. Stability of target condition 5. Appropriate sample received reference standard 6. Same reference standard to all 7. Reference standard independent of the index test 8. Index test detailed 9. Reference standard detailed 10. Independent interpretation of index test 11. Independent interpretation of reference standard 12. Clinical data available similar to that in practice 13. Uninterpretable/intermediate test results reported 14. Withdrawals explained Internal validity (%) (Q: 3-7, 10, 11, 13, 14) External validity (%) (Q: 1, 2, 8, 9, 12) Percentage of Yes (%)
No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes NA NA NA 7/7 ¼ 100 3/4 ¼ 75.00 10/11 ¼ 90.90
No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes NA NA NA 7/7 ¼ 100 3/4 ¼ 75.00 10/11 ¼ 90.90
No No Yes Yes Unclear Yes Yes Yes Yes Yes Yes NA NA NA 6/7 ¼ 85.71 2/4 ¼ 50.00 8/11 ¼ 72.72
NA¼ not applicable.
significant difference between the PD technique and the reference standard was reported by 2 high quality studies. There was moderate evidence of PD of pelvic landmarks and limited evidence of PD of hand landmarks for assessing the pelvic and metacarpophalangeal joint kinematics, respectively. However, no evidence was found for validity of PD technique in any other segments of the body. 3.4.2. Reliability studies The results of the relative and absolute reliability statistics (Table 6) demonstrates overall strong evidence for the intra-rater and limited evidence for the inter-rater reliability, respectively. The reliability of PD procedure demonstrated strong and moderate level of evidence for joint ROM and static postural angles, respectively. A high to very high intra-rater ICC and satisfactory intra-rater SEM% of PD technique for joint ROM (3 high and 1 low quality studies) and postural angles (2 high and 1 low quality studies) assessment were reported. There was moderate evidence of intrarater reliability of PD procedure for assessing the thoracic curvatures, whereas only limited evidence was found in other joints due to an inadequate number of studies.
3.5. Sensitivity analysis The change of quality criterion for defining high quality studies from 60% to 60 10% had no effect on the overall level of evidence,
and it remained strong for both the validity and intra-reliability of PD technique. Moreover, at 70% criterion the level of evidence also remained moderate for the validity and intra-rater reliability of PD technique for pelvic and thoracic kinematics respectively. The sensitivity analysis had no effect on the limited evidence of the overall inter-rater reliability, and the validity and reliability of PD technique in other segments of the body.
4. Discussion 4.1. Summary of results The results of this systematic review demonstrate overall strong evidence for high levels of validity of PD technique for assessment of pelvic, hip and metacarpo-phalangeal joint kinematics using EMTD. The mean difference between the reference standard and the index test was least for innominate ROM assessment (0.34 0.52 ) and highest for pelvic tilt assessment (8.00 7.80 ). These discrepancies can be partly attributed to the use of PolhemusÔ EMTD, with higher static accuracy (0.76 mm), for innominate ROM assessment; when compared to the use of Flock of BirdsÔ (FOB) EMTD, with comparatively lower static accuracy (1.08 mm), for pelvic tilt assessment (Sprigle et al., 2002; Bussey et al., 2004). Further, the reference standard used for these kinematic measurements also differed (Table 5), with different techniques applied to locate bony landmarks and calculate the angles
Table 4 Quality analysis of reliability studies using QAREL tool. Questions:
Singh et al., 2010
Laprade and Lee, 2005
Bussey et al., 2004
Ludewig et al., 2004
Gould, 2003
Kulkarni-Lambore and Peat, 2000
Culham and Peat, 1993
1. Representative sample 2. Representative raters 3. Blinding (other raters) 4. Blinding (own findings) 5. Blinding (reference / disease) 6. Blinding (clinical information) 7. Blinding (additional cues) 8. Examination order varied 9. Appropriate time interval 10. Test appropriate 11. Appropriate statistics Internal validity (%) (Q:3-9) External validity (%) (Q:1-2, 10) Statistical methods (%) (Q:11) Percentage of Yes (%)
Yes Unclear NA Yes NA NA Unclear NA Yes Yes Yes 2/3 ¼ 66.67 2/3 ¼ 66.67 1/1 ¼ 100 5/7 ¼ 71.43
Yes Unclear NA Yes NA NA Unclear NA Yes Yes Yes 2/3 ¼ 66.67 2/3 ¼ 66.67 1/1 ¼ 100 5/7 ¼ 71.43
Yes Unclear NA Yes Yes NA Unclear NA Yes Yes No 3/4 ¼ 75.00 2/3 ¼ 66.67 0/1 ¼ 0.00 5/8 ¼ 62.50
Yes Unclear Unclear Yes NA Unclear Unclear Unclear Yes Yes No 2/6 ¼ 33.34 2/3 ¼ 66.67 0/1 ¼ 0.00 4/10 ¼ 40.00
Yes Unclear NA Yes NA NA Unclear NA Yes Yes Yes 2/3 ¼ 66.67 2/3 ¼ 66.67 1/1 ¼ 100 5/7 ¼ 71.43
Yes Unclear NA Yes Yes Unclear Unclear NA Yes Yes Yes 3/5 ¼ 60.00 2/3 ¼ 66.67 1/1 ¼ 100 6/9 ¼ 66.67
No Unclear NA Yes NA NA Unclear NA Yes Yes Yes 2/3 ¼ 66.67 1/3 ¼ 33.34 1/1 ¼ 100 4/7 ¼ 57.14
NA: not applicable.
72.72 ICC ¼ 0.93 Not reported 2nd, 3rd and 5th MCP joint ROM (respective metacarpal and proximal phalanx, forearm) Radiograph 5 (healthy subjects) Metacarpo-phalangeal joint angles Kulkarni-Lambore and Peat (2000)
LPSIS: left posterior superior iliac spine, RPSIS: right posterior superior iliac spine, LASIS: left anterior superior iliac spine, RASIS: right anterior superior iliac spine, PSIS: posterior superior iliac spine, ASIS: anterior superior iliac spine, MCP: metacarpo-phalangeal, ROM: range of motion, ICC: Intraclass correlation coefficient.
90.90
Pearson’s correlation, linear regression and ANOVA ICC (2,1) Pelvic tilt: >0.25 Hip angle: >0.28 Pelvic tilt and hip angle Sprigle et al. (2002)
10 (healthy subjects)
Radiograph
Pelvic tilt: 8.00 7.80 Hip angle: 4.90 10.00 0.80
Pelvic tilt: r ¼ 0.89 R2 ¼ 0.80 Hip angle: r ¼ 0.78
90.90 r ¼ 0.83 Pearson’s correlation and paired t-test >0.05 0.34 0.52
Right innominate rotation (LPSIS, RASIS, RPSIS) Left innominate rotation (RPSIS, LASIS, LPSIS) Pelvic tilt (ASIS, PSIS) Hip angle (ASIS, PSIS) Computed Tomography Scan Innominate angles Bussey et al. (2004)
6 (healthy subjects)
Joint/segment Author (year)
Table 5 Characteristics of validity studies.
Sample size (subjects)
Reference standard used
Statistics used P value Mean difference between index and reference (degrees) Outcome variables (landmarks digitized)
Validity measure
Quality score (%)
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from the reference standard. These procedural differences can affect kinematic measurements leading to discrepancies in the mean difference. The results of this review also demonstrated overall strong evidence for very high levels of intra-rater reliability of PD technique for assessment of joint ROM and postural angles using EMTD. The relative (ICC) and absolute (SEM%) reliability was least for the static humeral abduction position (ICC ¼ 0.51) and metacarpophalangeal joint ROM (SEM% ¼ 7.73e10.25%) respectively. The lower reliability noted can be attributed to non-prominence of bony landmarks used (Table 6) for assessment of these kinematic measurements; which may lead to lower consistency and higher measurement errors when compared to prominent bony landmarks (Smidt et al., 1992). Measurement errors were smaller (SEM % ¼ 1.3%) for the cranio-vertebral angles which used bony landmarks of 7th cervical vertebrae and tragus. However, marking of the bony landmark using an indelible pen before digitization would have resulted in some bias leading to increased consistency of PD trials in this study. Participant (e.g., anthropometrics), tester (e.g., training, experience, palpation skills, etc.) and procedure (bony landmarks digitized, number of trials, duration between trials, using average of trials for kinematic calculations etc.) related variability can affect the measurement errors associated with PD of bony landmarks (Smidt et al., 1992). Reliability studies included in this review differed (Table 6) in terms of participants evaluated (symptomatic/ asymptomatic), joints/segments evaluated (peripheral joints/spinal joints), bony landmarks digitized (Table 6), number of trials (1e4), duration between sessions (none to 7 days), outcome variables (static postural angles/joint ROM), EMTD used (PolhemusÔ Isotrak or Fastrak) and reliability study design (trial-to-trial/inter-day). However, the authors found no relation between these sources of variability and the reliability of PD technique. 4.2. Methodological considerations While most studies demonstrated high internal and external validity, there were some methodological limitations affecting generalizability and clinical applicability of the results. Firstly, the subjects included in most studies were young healthy adults with mean age of 35.0 17.0 years and mean BMI of 22.6 1.6 kg/m2. A healthy population is not necessarily representative of the clinical population (Whiting et al., 2003), and the bony landmarks may be difficult to palpate in obese individuals leading to higher measurement errors (Langenderfer et al., 2009). Thus the results of these studies cannot be generalized to the clinical population or other populations whose anthropometrics are disparate from the subjects included in these studies. Secondly, none of the studies described the characteristics of the testers conducting the PD procedure. Tester-related variability such as profession (student/ manual therapist/osteopath/chiropractic, etc), experience (novice/ months/years), and training can influence a tester’s palpation skills and may have a greater effect on the PD measurement errors (Harlick et al., 2007; Haneline and Young, 2009). Thus, the unknown variability of testers among these studies further limits its generalizability. Thirdly, the statistics used by some studies were inappropriate (Lucas et al., 2010) and some others failed to report the absolute measures of reliability. While the relative reliability statistic of ICC indicates the degree of relationships between two measures, the absolute reliability statistics of SEM reflects the magnitude of difference between the two measures and has more clinical applicability (Domholdt, 2005). Hence, the lack of absolute reliability statistics limits the clinical applicability of these results. Lastly, no studies reported measurement errors of individual bony landmarks and measurement error sensitivity for kinematic
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Table 6 Characteristics of reliability studies. Author (year)
Joint/segment
Reliability study design
Sample size (subjects)
No of PD trials
Outcome variables (landmarks digitized)
Statistics used
Relative reliability
Absolute reliability SEM
% SEM
Thoracic kyphosis (T1, T8, L1) Lumbar lordosis (T8, L1, L5) Lateral thoracic curvature (T1, L1) Lateral lumbar curvature (L1, L5) Patella displacement (ME, LE, GT)
ICC (3,1) and SEM
0.93 0.98 0.75 0.84 ME: 0.99 LE: 0.98 GT: 0.99 0.89
1.57 1.51 1.04 0.56 5.80 mm 5.80 mm 8.50 mm e
3.66 5.25 e e 3.39 4.97 3.39 e
0.90 e1.70
e
40.00
1.30 1.27 3.19 3.02 3.44 3.38 5.84 4.68 4.69 8.56 7.73 10.25 5.03 e
71.43
Singh et al. (2010)
Thoraco-lumbar curvature
Intra-rater (trial to trial)
52 (healthy subjects)
3
Laprade and Lee (2005)
Patello-femoral kinematics
Intra-rater (trial to trial)
10 (healthy subjects)
3
Bussey et al. (2004)
Innominate kinematics
Intra-rater (trial to trial)
15 (healthy subjects)
4
Ludewig et al. (2004)
Intra-rater (Trial to trial) Inter-rater
Gould (2003)
Postural angles and spinal curves
Testeretest (Inter-day: 24 h apart) Intra-rater (Trial to trial)
Kulkarni-Lambore and Peat (2000)
MCP joint kinematics
Culham and Peat (1993)
Spine & shoulder posture
11 (healthy or shoulder pathology) 5 (healthy or shoulder pathology) 5 (healthy or shoulder pathology)
1
Pearson’s correlation
SEM
Not reported
1.30 e4.10
1
1.90 e4.00
1
Intra-rater (Inter-day: <7 days apart)
11 (7 healthy, 4 rheumatoid patients)
1
Intra-rater (Inter-day: 1e7 days apart)
20 (healthy women)
2
Left cranio-vertebral (LT, C7) Right cranio-vertebral (RT, C7) Left shoulder-sagittal (C7, LSJ) Right shoulder-sagittal (C7, RSJ) Left shoulder-horizontal (C7, LSJ) Right shoulder-horizontal (C7, RSJ) Cervical spine curvature (C2, C7) Upper thoracic curvature (T4, T8) Lower thoracic curvature (T8, T12) 2nd, 3rd, 4th and 5th MCP joint ROM (respective metacarpal and proximal phalanx, forearm) Upper thoracic slope (T1, T3) Lower thoracic slope (T10, T12) Scapula anterior tilt (R1, IA) Humeral flexion-extension (PH, DH) Scapula abduction (R1, IA) Clavicle elevation (MC, LC) Humeral abduction (PH, DH) Scapula rotation (AA, R1, R2) Clavicle rotation (MC, LC) Humeral rotation (R1, R2, ME, LE) Scapula horizontal (T1, R1, AA, IA) Scapula vertical (T1, R1, AA, IA)
71.43
62.50
0.92
1
35 (healthy subjects)
71.43
ICC (3,1)
ICC (2,1)
ICC (2,1)
0.96 0.97 0.98 0.98 0.97 0.97 0.94 0.98 0.99 WF1: 0.85 WN1: 0.88 WE1: 0.77 WE2: 0.95 0.91 0.87 0.88 0.86 0.75 0.96 0.51 0.90 0.93 0.94 0.93 0.80
0.72 0.69 1.24 1.26 0.66 0.66 1.95 0.77 1.13 5.91 5.65 7.18 3.27 e
66.67
57.14
SEM: standard error of measurement, ICC: Intraclass correlation coefficient, T: thoracic spinous process, L: lumbar spinous process, ME: medial epicondyle, LE: lateral epicondyle, GT: greater trochanter, LPSIS: left posterior superior iliac spine, RPSIS: right posterior superior iliac spine, LASIS: left anterior superior iliac spine, RASIS: right anterior superior iliac spine, SN: sternal notch, C: cervical spinal process, XP: xiphoid process, SCJ: sternoclavicular joint, ACJ: acromio-clavicular joint, LT: left tragus, RT: right tragus, LSJ: left shoulder joint, RSJ: right shoulder joint, ROM: range of motion, MCP: metacarpo-phalangeal, WF: wrist in flexion, WN: wrist in neutral, WE: wrist in extension, R1: root of right scapula, IA: inferior angle of scapula, PH: proximal humerus, DH: humerus, MC: medial clavicle, LC: lateral clavicle, ME: medial humeral epicondyle, LE: lateral humeral epicondyle, AA: acromion angle, R2: root of left scapula, ‘e’ : could not be calculated.
D.B. Adhia et al. / Manual Therapy 18 (2013) 26e34
Clavicular kinematics during arm elevation
Right innominate rotation (LPSIS, RASIS, RPSIS) Left innominate rotation (RPSIS, LASIS, LPSIS) Clavicle ROM (SN, C7, XP, T8, SCJ and ACJ)
ICC
Quality score (%)
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measurements. Kinematic measurements of certain joints may be more sensitive to errors in one or more bony landmarks (Piazza and Cavanagh, 2000; Morton et al., 2007; Moriguchi et al., 2009), for example, error in palpation of femoral epicondyle has shown to have greater effect on the tibio-femoral and patella-femoral kinematics when compared to errors in tibial or patella landmarks (Morton et al., 2007). Although small measurement errors (SEM ¼ 0.56 to 5.91 ) were reported, the influence of the measurement error of each bony landmark on the kinematic measurement is unknown. A sensitivity analysis of the influence of the measurement errors on respective kinematic outcome variables would have further helped to strengthen the rigor of the absolute reliability statistics. 4.3. Practical implications The results of this systematic review imply that the PD technique using EMTD is a valid and reliable technique for assessment of 3D joint kinematics at least in the joints evaluated. This technique is simple, non-invasive, capable of assessing 3D joint kinematics, and can be applied to all joints in the body. Similar to several clinical tests, the kinematic joint assessment using EMTD requires palpation of the bony landmarks and can be easily adapted by clinicians (Pennock and Clark, 1990; Wu et al., 2005). In the modern era of evidence based practice, this technique of PD of bony landmarks can have high clinical utility as it can provide clinicians with objective and accurate 3D measurements of joint kinematics for baseline assessment, determine progress and improve clinical decision making. 4.4. Limitations of this review Although this review was designed based on PRISMA guidelines, some limitations need to be addressed. Firstly, we used the QUADAS and QAREL tool for assessing the quality of validity and reliability studies, respectively. As these scales are developed for assessing the quality of diagnostic accuracy and reliability studies, its applicability for assessing the quality of kinematic validity and reliability studies is unknown. However, these scales were similar to the other reviews in related areas and were appropriate for the aims of this review (van Trijffel et al., 2005; Haneline and Young, 2009). Secondly, the two reviewers assessing the methodological quality of the studies were not blinded to the authors or results of the included studies due to their familiarity with the topic. While one could argue that this may have caused reviewer bias (Stochkendahl et al., 2006), non-blinding authors has shown to have no influence on quality assessment of studies (Berlin, 1997). Thirdly, only studies that were published as full text article, thesis or peer reviewed reports, that primarily assessed the validity and/or reliability of PD technique, were included and conference proceedings were not included for the study which would have led to publication bias resulting in overestimation of the validity and/or reliability of PD technique (Song et al., 2000). Lastly, the results of the studies included in this review were synthesized qualitatively using the level of evidence approach. The use of qualitative level of evidence approach would have concealed the considerable heterogeneity that existed among the included studies (Stochkendahl et al., 2006). However, despite the heterogeneity in the study characteristics, most of the studies demonstrated high levels of validity and reliability of PD technique for joint kinematic measurements. 5. Conclusions and future recommendations The results of this systematic review demonstrate overall strong level of evidence for the validity and intra-rater reliability of PD of bony landmarks for joint kinematics assessment. A high level of
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validity and very high level of relative intra-rater reliability were demonstrated for most joint segments evaluated. The results of absolute intra-rater reliability statistics (SEM%) also demonstrated satisfactory results; however the sensitivity of these measurement errors on the outcome variables is unknown and should be undertaken by future reliability studies using PD technique. The evidence for the inter-rater reliability of PD technique for joint kinematic assessment was limited but is important for the clinical utility of this technique and therefore should be addressed by future researchers. References An KN, Jacobsen MC, Berglund LJ, Chao EYS. Application of a magnetic tracking device to kinesiologic studies. Journal of Biomechanics 1988;21(7):613e20. Assink NA, Bergman GJD, Knoester B, Winters JC, Dijkstra PU. Assessment of the cervical range of motion over time, differences between results of the flock of birds and the EDI-320: a comparison between an electromagnetic tracking sysytem and an electronic inclinometer. Manual Therapy 2008;13(5):450e5. Beckerman H, Roebroeck ME, Lankhorst GJ, Becher JG, Bezemer PD, Verbeek ALM. Smallest real difference, a link between reproducibility and responsiveness. Quality of Life Research 2001;10(7):571e8. Berlin JA. Does blinding of readers affect the results of meta-analyses? University of Pennsylvania Meta-analysis blinding study group. Lancet 1997;350(9072): 185e6. Bussey MD, Yanai T, Milburn P. A non-invasive technique for assessing innominate bone motion. Clinical Biomechanics 2004;19(1):85e90. Croce UG, Leardini A, Chiari L, Cappozzo A. Human movement analysis using stereophotogrammetry part 4: assessment of anatomical landmark misplacement and its effects on joint kinematics. Gait and Posture 2005;21(2):226e37. Culham E, Peat M. Spinal and shoulder complex posture I: measurement using the 3Space Isotrak. Clinical Rehabilitation 1993;7(4):309e18. de Groot JH. The variability of shoulder motions recorded by means of palpation. Clinical Biomechanics 1997;12(7/8):461e72. Domholdt E. Rehabilitation research- principles and applications. Philadelphia: Elsevier Saunders; 2005. pp. 85e254. France L, Nester C. Effect of errors in the identification of anatomical landmarks on the accuracy of Q angle values. Clinical Biomechanics 2001;16(8):710e3. Gould JA. Three-dimensional measurements of posture and movements of neck, shoulder and scapula. The Hong Kong Polytechnique University - Dissertations. 2003; http://hdl.handle.net/10397/3213. Harlick JC, Milosavljevic S, Milburn PD. Palpation identification of spinous processes in lumbar spine. Manual Therapy 2007;12(1):56e62. Haneline MT, Young M. A review of intraexaminer and interexaminer reliability of static spinal palpation: a literature synthesis. Journal of Manipulative and Physiological Therapeutics 2009;32(5):379e86. Heneghan NR, Hall A, Hollands M, Balanos GM. Stability and intra-tester reliability of an in vivo measurement of thoracic axial rotation using an innovative methodology. Manual Therapy 2009;14(4):452e5. Kulkarni-Lambore S, Peat M. Reliability and validity of 3space Isotrak in the measurement of metacarpophalangeal joint range. Physiotherapy Theory and Practice 2000;16(4):219e27. Langenderfer JE, Rullkoetter PJ, Mell AG, Laz PJ. A multi-subject evaluation of uncertainty in anatomical landmark location on shoulder kinematic description. Computer Methods in Biomechanics and Biomedical Engineering 2009;12(2):211e6. Laprade J, Lee R. Real-time measurement of patellofemoral kinematics in asymptomatic subjects. The Knee 2005;12(1):63e72. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gotzsche PC, Loannidis JPA, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS Medicine 2009;6:e1000100. Lucas NP, Macaskill P, Irwig L, Bogduk N. The development of a quality appraisal tool for studies of diagnostic reliability (QAREL). Journal of Clinical Epidemiology 2010;63(8):854e61. Ludewig PM, Behrens SA, Meyer SM, Spoden SM, Wilson LA. Three-dimensional clavicular motion during arm elevation: reliability and descriptive data. Journal of Orthopaedic and Sports Physical Therapy 2004;34(3):140e9. May S, Chance-Larsen K, Littlewood C, Lomas D, Saad M. Reliability of physical examination tests used in the assessment of patients with shoulder problems: a systematic review. Physiotherapy 2010;96(3):179e90. May S, Littlewood C, Bishop A. Reliability of procedures used in the physical examination of non-specific low back pain: a systematic review. Australian Journal of Physiotherapy 2006;52:91e102. Meskers CGM, Vermeulen HM, de Groot JH, van der Helm FCT, Rozing PM. 3D shoulder position measurements using a six-degree-of-freedom electromagnetic tracking device. Clinical Biomechanics 1998;13(4e5):280e92. Moriguchi CS, Carnaz L, Silva LCCB, Salasar LEB, Carrregaro RL, de Oliveria Sato T, et al. Reliability of intra- and inter-rater palpation discrepancy and estimation of its effect on joint angle measurements. Manual Therapy 2009;14(3):299e305. Morton NA, Malestsky LP, Pal S, Laz PJ. Effect of variability in anatomical landmark location on knee kinematic description. Journal of Orthopaedic Research 2007; 25(9):1221e30.
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Munro BH, Visintainer MA. Statistical methods for health care research. Philadelphia: Lippincott Williams and Wilkins; 2005. pp. 239e58. Nussbaumer S, Leunig M, Glatthorn JF, Stauffacher S, Gerber H, Maffiuletti NA. Validity and test-retest reliability of manual goniometers for measuring passive hip range of motion in femoroacetabular impingement patients. BMC Musculoskeletal Disorders 2010;11:194. Ordway NR, Seymour R, Donelson RG, Hojnowski L, Lee E, Edwards WT. Cervical sagittal range-of-motion analysis using three methods: cervical range-ofmotion device, 3Space, and radiography. Spine 1997;22(5):501e8. Pennock GR, Clark KJ. An anatomy-based coordinate system for the description of the kinematic displacements in the human knee. Journal of Biomechanics 1990; 23(12):1209e18. Piazza SJ, Cavanagh PR. Measurement of the screw-home motion of the knee is sensitive to errors in axis alignment. Journal of Biomechanics 2000;33(8): 1029e34. Pomianowski SA. 3-space electromagnetic tracking device- a useful method in an in vitro study. Acta of Bioengineering and Biomechanics 2001;3(2):49e53. Seffinger MA, Najm WI, Mishra SI, Adams A, Dickerson VM, Murphy LS, et al. Reliability of spinal palpation for diagnosis of back and neck pain. Spine 2004; 29(19):E413e25. Singh DV, Bailey M, Lee R. Biplanar measurement of thoracolumbar curvature in older adults using an electromagnetic tracking device. Archives of Physical Medicine and Rehabilitation 2010;91(1):137e42. Smidt GL, McQuade KJ, Wei S. Evaluation of the Metrecom and its use in quantifying skeletal landmark locations. Journal of Orthopaedic and Sports Physical Therapy 1992;16(4):182e8. Smith DS. Measurement of joint range e an overview. Clinics in Rheumatic Diseases 1982;8(3):523e31.
Song F, Eastwood AJ, Gilbody S, Duley L, Sutton AJ. Publication and related biases. Health Technology Assessment 2000;4(10):1e115. Sprigle S, Wootten M, Bresler M, Flinn N. Development of a noninvasive measure of pelvic and hip angles in seated posture. Archives of Physical Medicine and Rehabilitation 2002;83(11):1597e602. Stochkendahl MJ, Christensen HW, Hartvigsen J, Vach W, Haas M, Hestbaek L, et al. Manual examination of the spine: a systematic critical literature review of reproducibility. Journal of Manipulative and Physiological Therapeutics 2006; 29(6):475e85. van der Wurff P, Meyne W, Hagmeijer RHM. Clinical tests of the sacroiliac joint: a systematic methodological review. Part 2: validity. Manual Therapy 2000; 5(2):89e96. van Trijffel E, Anderegg Q, Bossuyt PMM, Lucas C. Inter-examiner reliability of passive assessment of intervertebral motion in the cervical and lumbar spine: a systematic review. Manual Therapy 2005;10(4):256e69. van Tulder M, Furlan A, Bombardier C, Bouter L. Updated method guidelines for systematic reviews in the Cochrane collaboration back review group. Spine 2003;28(12):1290e9. Whiting P, Rutjes AWS, Reitsma JB, Bossuyt PMM, Kleijnen J. The development of QUADAS: a tool for the quality assessment of studies of diagnostic accuracy included in systematic reviews. BMC Medical Research Methodology 2003;3(25):25. Whiting PF, Weswood ME, Rutjes AW, Reitsma JB, Bossuyt PNM, Kleijnen J. Evaluation of QUADAS, a tool for the quality assessment of diagnostic accuracy studies. BMC Medical Research Methodology 2006;6:9. Wu G, van der Helm FCT, Veeger HEJ, Makhsous M, Roy PV, Anglin C, et al. ISB recommendation on definitions of joint coordinate systems of various joints for reporting of human joint motion-Part II: shoulder, elbow, wrist and hand. Journal of Biomechanics 2005;38(5):981e92.
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Systematic review
Validity and reliability of palpation-digitization for non-invasive kinematic measurement e A systematic review Divya Bharatkumar Adhia a, b, *, Melanie D. Bussey a,1, Daniel Cury Ribeiro b, c, 2, Steve Tumilty b, 3, Stephan Milosavljevic b, 4 a b c
School of Physical Education, University of Otago, Dunedin, New Zealand Centre for Physiotherapy Research, University of Otago, Dunedin, New Zealand Otago Institute of Sport and Adventure, Otago Polytechnic, Dunedin, New Zealand
a r t i c l e i n f o
a b s t r a c t
Article history: Received 6 December 2011 Received in revised form 6 June 2012 Accepted 11 June 2012
Joint kinematic assessment using an electromagnetic tracking device (EMTD) requires palpationdigitization (PD) of bony landmarks to define the anatomical axes. Errors in PD of bony landmarks can perturb the anatomical axes and affect the validity and reliability of kinematic measurements. The validity and reliability of PD for kinematic measurement needs to be explored before recommending its wider use. A systematic search of 15 electronic databases located studies assessing validity and/or reliability of PD for joint kinematic assessment. Two independent reviewers used the QUADAS and QAREL tools to assess quality of validity and reliability studies respectively. The results were synthesized qualitatively using a level of evidence approach. Eight studies satisfied the final eligibility criteria and were included in the review. The validity, intra-rater reliability and inter-rater reliability were assessed in three, seven and one study respectively. The overall level of evidence for validity of PD technique was strong with high correlation (0.80) reported by three high (60%) quality studies. The overall level of evidence for intra-rater reliability was also strong with very high ICC (0.90) and satisfactory SEM (SEM % 10%) reported by four high quality studies. However the level of evidence for inter-rater reliability was limited and needs to be addressed by future research. Ó 2012 Elsevier Ltd. All rights reserved.
Keywords: Validity Reliability Palpation-digitization Kinematics
1. Introduction Evaluation of joint kinematics is essential to musculoskeletal assessment, helping clinicians determine baseline data, monitor progress and guide appropriate implementation of treatment strategies (Smith, 1982). While clinicians often use simple noninvasive devices such as goniometers or inclinometers to measure joint kinematics, these can only assess two-dimensional motion and have reduced accuracy in measuring motion outside the sagittal plane (Ordway et al., 1997; Nussbaumer et al., 2010). Thus, it
* Corresponding author. School of Physical Education, University of Otago, Dunedin, New Zealand. Tel.: þ64 211167594. E-mail addresses: [email protected], [email protected] (D.B. Adhia), [email protected] (M.D. Bussey), daniel.cury.ribeiro@ gmail.com (D.C. Ribeiro), [email protected] (S. Tumilty), [email protected] (S. Milosavljevic). 1 Tel.: þ64 3479 8981. 2 Tel.: þ64 3479 3666. 3 Tel.: þ64 3479 5757. 4 Tel.: þ64 3479 7193. 1356-689X/$ e see front matter Ó 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.math.2012.06.004
would be advantageous to have a simple non-invasive device that allows accurate and reliable measurement of three-dimensional (3D) joint motion (An et al., 1988). Recently, electromagnetic tracking devices (EMTD) have become a popular tool for noninvasive clinical evaluation of 3D joint motion particularly in complex joints such as spine (Assink et al., 2008; Heneghan et al., 2009). The use of EMTD for joint kinematic assessment can be considered an important advancement that can have both research and clinical utility providing an ability to determine multiplanar joint kinematics and guiding appropriate implementation of treatment strategies (An et al., 1988; Bussey et al., 2004). An EMTD uses a low frequency electromagnetic field generated by a transmitter to detect 3D position and orientation of sensors fixed to body segments (Pomianowski, 2001). The arbitrary axis of the system may be converted to a meaningful anatomical joint axis using palpation-digitization (PD) of anatomical bony landmarks (Pennock and Clark, 1990; Wu et al., 2005). The PD technique involves the tester palpating the most prominent part of a bony landmark followed by physically collecting the 3D co-ordinates of the bony landmark using an electromagnetic digitizing stylus
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(sensor embedded in a pen) (Bussey et al., 2004). The 3D coordinates of sensors and digitized bony landmarks relative to the source are obtained from electronic software connected to the EMTD system; and the relative 3D movement between distal and proximal body segments is then determined using these coordinates. The PD technique of EMTD has been used in both the clinical and research environment; however it can be affected by several sources of error. Errors during a PD technique can arise from tester, subject, and procedure-related variability (Smidt et al., 1992). As bony landmarks are irregular structures (de Groot, 1997; Croce et al., 2005), the accurate and consistent palpation of bony landmarks is a primary concern while using this technique (Seffinger et al., 2004; Stochkendahl et al., 2006). Further, with some bony landmarks being more superficial than others the ability to accurately palpate may differ with anatomical location (Harlick et al., 2007). Inaccuracies in palpation of bony landmarks may result in digitization errors leading to misalignment of the anatomical axis system about which the movements are assumed to occur (e.g., the flexionextension axis of a joint coordinate system should be aligned in the medio-lateral direction) (Piazza and Cavanagh, 2000). Errors in PD of bony landmarks can affect the validity and reliability of kinematic measurements leading to misinterpretation of results (de Groot, 1997; Meskers et al., 1998; France and Nester, 2001; Croce et al., 2005; Morton et al., 2007; Langenderfer et al., 2009; Moriguchi et al., 2009). Thus, the level of evidence for validity and reliability of PD techniques for joint kinematic measurements is essential for EMTD to produce clinically meaningful results, and needs to be established before recommending its wider use. Therefore, the purpose of this research is to systematically review the literature concerning the validity and reliability of PD technique of bony landmark identification for joints kinematic assessment using EMTD.
2. Methods 2.1. Search strategy A systematic search strategy was conducted to locate studies assessing validity and/or reliability of PD for joint kinematic measurements using EMTD, in any sampled population. Three relevant subject areas; namely 1) EMTD, 2) validity and/or reliability, and 3) kinematic measurements; along with their related terms were used to perform the systematic search (Table 1). The databases were searched using combinations of keywords and specific subject headings. The Boolean operators “OR” and “AND” were used to combine the search terms within and between each of
27
the three subject areas respectively. In order to cover the widest spectrum of articles, no search limits were applied to any databases. The systematic search was conducted on 1st September 2011 by the primary investigator (DBA). The following electronic databases were searched from their inception: Ovid MEDLINE, EMBASE, AMED, PubMed, Science Direct, CINAHL, Cochrane library, Scopus, SPORTDiscus, Scirus, ISI web of science and ProQuest. Supplementary searches included the following search engines: Google scholar, ProQuest Dissertation and Thesis, and WorldCat. The reference lists of review articles and of each acquired full-text manuscript were also explored to identify any publications not identified during the initial database search. Further, citations of included manuscripts were also screened to identify any relevant articles. 2.2. Eligibility criteria The articles obtained by the systematic search were exported to an EndNoteÒ library where they underwent a stepwise screening procedure for eligibility. Two independent reviewers (DBA and DCR) screened the titles, abstracts and full text of the articles for eligibility based on following criteria: 2.2.1. Inclusion criteria Type of studies: Studies were included only if measurement of validity and/or reliability was one of the primary aims of the study. Publications in any language as full text articles, theses or peer reviewed reports were included for the review. Type of participants: Studies on human participants were included for the review. No restrictions were made with respect to demographics or condition (healthy individuals/ pathological group) of participants. Type of interventions and outcome measures: The studies using the PD techniques for joint kinematics assessment using EMTD were included for the review. The studies were included only if they assessed the validity and/or reliability of PD techniques and provided validity and/or reliability statistics.
2.2.2. Exclusion criteria Biomechanical in-vitro studies Full text could not be located Letters, editorials, comments, case-studies, protocols, guidelines, conference proceedings or review articles Articles using PD that only defined the local co-ordinate system and did not assess the validity and/or reliability of PD itself.
Table 1 Search strategy: keywords and search terms used. Search terms
EMTD/related terms
Validity/reliability/related terms
Kinematic measurements/related terms
MeSH/subject terms/subject headings/CINAHL headings/Thesauras
Nil
Biomechanics, kinematics, measurement, range of motion, joint mobility, motion, movement, mechanics, kinesiology
Keywords
Polhemus, Fastrak, Isotrak, Liberty, Flock of birds, electromagnetic tracking device, electromagnetic tracking system
Reliability, reliability and validity, reproducibility, inter-rater reliability, intra-rater reliability, test retest reliability, consistency and reliability, validity, accuracy, sensitivity and specificity, precision, predictive value of tests Reliability, reproducibility, repeatability, inter-rater, intra-rater, inter-examiner, intra-examiner, inter-observer, intra-observer, inter-tester, intra-tester, validity, accuracy, sensitivity, specificity, likelihood ratio, precision
EMTD: electromagnetic tracking device, MeSH: medical subject headings.
Biomechanics, kinematics, movement, measurement, range of motion, three dimensional motion, 3D motion, 3D movement
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Assessment of validity and/or reliability of PD were not one of the primary aims of the study. Technical reports on validity and/or reliability of PD not involving human participants (e.g on Plexiglas model). In cases of uncertainty about eligibility of the manuscript on basis of title and abstract, full text of those manuscripts were screened for eligibility. In case of disagreement between two reviewers, a consensus was reached by the use of a third reviewer (MDB).
Table 2 Levels of evidence approach. Level of evidence
Criteria
Strong Moderate
Consistent findings from 3 high quality studies Consistent findings from at least 1 high quality and one or more low quality studies Consistent findings in 1 low quality studies or only 1 study available Inconsistent findings in multiple studies irrespective of study quality No studies found
Limited Conflicting No evidence
2.3. Data Extraction Two independent reviewers (DBA & DCR) extracted data from included studies using standard forms, as recommended by Lucas et al. (2010). The details included: study aims, study design, participant details, examiner details, equipment, details of assessment procedure of index test and reference standard, outcome measures, statistical techniques used, estimates of validity and reliability coefficient, conclusion and relevant methodological limitation. Any discrepancy of interpretation was resolved by discussion seeking consensus and use of third reviewer if disagreement persisted.
Reference: van Tulder et al., 2003.
2.6. Sensitivity analysis The level of evidence approach used for synthesizing the data, takes into account the number of studies, quality of studies and consistency of study outcomes (van Tulder et al., 2003). The criterion for defining high quality studies was set at 60% (van der Wurff et al., 2000; May et al., 2006; May et al., 2010). To test the effect of quality criteria on the assumptions of level of evidence, the predetermined criterion (60%) for defining studies as high quality was subjected to a change of 10% and its effect on level of evidence was determined.
2.4. Assessing quality of studies The QUADAS (Whiting et al., 2003) and QAREL (Lucas et al., 2010) scales were used to assess the quality of validity and reliability studies, respectively. These scales have demonstrated acceptable levels of content validity (good) and inter-rater reliability (k > 0.60) (Whiting et al., 2006; Lucas et al., 2010). The QUADAS and QAREL checklist consists of 14 and 11 items, respectively, and both assess the external validity, internal validity and statistical methods of the studies. Each item is equally weighted and scored as Yes, No or Unclear based on guidelines provided. The studies were considered of high quality if items in the respective checklists scored as Yes were 60% (van der Wurff et al., 2000; May et al., 2006; May et al., 2010). Each included study was scored independently by two reviewers (DBA & DCR) and disagreement was resolved by discussion or use of third reviewer (MDB). The agreement between the two reviewers for rating studies based on quality scales was calculated by percent agreement. 2.5. Data analysis and synthesis Pooling of results and meta-analysis, where appropriate, was part of the protocol for this systematic review. However, metaanalysis could not be performed due to the heterogeneous characteristics of included studies. Moreover, a subgroup analysis could not be performed due to the limited number of studies in any one joint area evaluating the same outcome variables. Hence a descriptive analysis was conducted and data were synthesized using van Tulder et al. (2003) level of evidence approach (Table 2). P-values of 0.05 as reported from paired t-test and ANOVA statistics were interpreted as indicating no significant difference between the index test and reference standard. The Intraclass Correlation Coefficient (ICC) and Pearson’s correlation coefficient was interpreted as follows: 0.00e0.29 as very low correlation, 0.30e0.49 as low correlation, 0.50e0.69 as moderate correlation, 0.70e0.89 as high correlation, 0.90 and above as very high correlation (Munro and Visintainer, 2005). The standard error of measurement (SEM%) of 10% was considered as acceptable absolute reliability. For studies that did not provide absolute reliability statistics, the SEM and SEM% were calculated if the required information was available (Beckerman et al., 2001).
3. Results 3.1. Literature search Fig. 1 displays the flow diagram, based on PRISMA guidelines (Liberati et al., 2009), of the flow of articles through the review process as approved by two reviewers. Of 2219 articles, only eight articles were identified as assessing validity (Sprigle et al., 2002), reliability (Culham and Peat, 1993; Gould, 2003; Ludewig et al., 2004; Laprade and Lee, 2005; Singh et al., 2010) or validity þ reliability (KulkarniLambore and Peat, 2000; Bussey et al., 2004). 3.2. Methodological quality 3.2.1. Validity studies The two reviewers initially disagreed on 5/42 (15.15%) of QUADAS items for the quality score of validity studies. The disagreement between the two reviewers was then resolved by discussion. All included validity studies were high quality (>60%) with quality scores ranging from 72.72% to 90.90% (Table 3). The internal validity of all the studies was high with the score of >85.00%, whereas the external validity was slightly low ranging from 50.00% to 75.00%. 3.2.2. Reliability studies Similar to QUADAS, the two reviewers initially disagreed on 7/ 77 (9.09%) (Kappa ¼ 0.77) items of the QAREL checklist for the quality score of reliability studies. The disagreement between the two reviewers was then resolved by discussion. The quality score of reliability studies ranged from 40.00% to 71.43% with 5 high quality studies (60%) and 2 low quality studies (<60%) (Table 4). The internal validity, external validity and statistical method component of the quality scale ranged from 33.34% to 75.00%, 33.34%e 66.67% and 0.00%e100% respectively. 3.3. Study characteristics 3.3.1. Validity studies The characteristics of the validity studies are displayed in Table 5. The validity of PD technique was assessed against radiography or CT scan as reference standards in healthy subjects in all
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Database specific subject headings / keywords / thesaurus
Electronic Databases (1572) : Ovid AMED (46), Ovid EMBASE (144), Ovid 4 MEDLINE (101), CINAHL (40),, Cochrane library (10), PubMed (49), ProQuest (22), Scopus (792), Science Direct (114), 5 SPORTDiscus (23), ISI Web of knowledge (205) 205) & Scirus (26). 6
Supplementary searches (647): Suppleme Google scholar scho (612), ProQuest Thesis & Dissertations (7) and OCLC World Cat (28). Dissertation
Total otal number off articles articles obtained = 22 2219 Excluded: duplicates 908 Retained aft after f er duplicates = 1311 Excluded: not no relevant (885), non-EMTD (116), in-vitro in-vitr or technical report (137), (46), non-validity or reliability (85) reviews (46)
Excluded: title and abstract screening 1269
Retained tained aft after f er title and abstract screeni screening = 42 E Excluded: PD for LCS (11), no PD (19), technical report (4) P
Excluded: full text screening 34
Retained aft after f er fu ffull ll textt sc screening reening = 8 Included: hand searching of reference list = 0 Final number off articles articles included in the review = 8
Validity alone = 1
Validity and Reliability = 2
Reliability alone = 5
Fig. 1. Flowchart of articles reviewed.
three studies. Two studies (Sprigle et al., 2002; Bussey et al., 2004) assessed the validity of PD technique for assessing pelvic kinematics, one study assessed hip kinematics (Sprigle et al., 2002) and one study assessed the metacarpo-phalangeal joint kinematics (Kulkarni-Lambore and Peat, 2000). The mean difference between the joint kinematic measures assessed using PD and the reference standard ranged from 0.34 to 8.00 (SD: 0.52 to 10.00 ). All the studies reported high (0.80) to very high (0.90) correlation, with two studies reporting no significant difference (P > 0.05) between the index and reference standard. 3.3.2. Reliability studies The reliability studies and their characteristics are displayed in Table 6. The intra-rater reliability of PD technique was assessed by 7 studies, and inter-rater reliability was assessed by 1 study. While most studies evaluated reliability in healthy population, 2 studies (Kulkarni-Lambore and Peat, 2000; Ludewig et al., 2004) also included symptomatic population. The reliability of the PD
technique was assessed for both joint range of motion (ROM) and static postural angles. The reliability of PD technique for ROM measurements was evaluated in patello-femoral, pelvis, shoulder and metacarpo-phalangeal joint, whereas for static postural angles were evaluated in the spinal and shoulder joints using respective bony landmarks. High (0.70e0.89) to very high (0.90e1.00) measures of reliability were demonstrated for PD of most of the bony landmarks for kinematic assessment of most of the joints. The ICC ranged from 0.51 to 0.99 with a mean of 0.90 and SD of 0.09, and the SEM% ranged from 1.27% to 10.25% with a mean of 4.80% and SD of 2.22%. 3.4. Level of evidence 3.4.1. Validity studies The results in Table 5 demonstrate overall strong evidence for the validity of PD technique for assessing joint kinematics. A high to very high correlation was reported by 3 high quality studies, and no
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Table 3 Quality analysis of validity studies using QUADAS tool. Questions:
Bussey et al., 2004
Sprigle et al., 2002
Kulkarni-Lambore and Peat, 2000
1. Representative sample 2. Selection criteria 3. Appropriate reference standard 4. Stability of target condition 5. Appropriate sample received reference standard 6. Same reference standard to all 7. Reference standard independent of the index test 8. Index test detailed 9. Reference standard detailed 10. Independent interpretation of index test 11. Independent interpretation of reference standard 12. Clinical data available similar to that in practice 13. Uninterpretable/intermediate test results reported 14. Withdrawals explained Internal validity (%) (Q: 3-7, 10, 11, 13, 14) External validity (%) (Q: 1, 2, 8, 9, 12) Percentage of Yes (%)
No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes NA NA NA 7/7 ¼ 100 3/4 ¼ 75.00 10/11 ¼ 90.90
No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes NA NA NA 7/7 ¼ 100 3/4 ¼ 75.00 10/11 ¼ 90.90
No No Yes Yes Unclear Yes Yes Yes Yes Yes Yes NA NA NA 6/7 ¼ 85.71 2/4 ¼ 50.00 8/11 ¼ 72.72
NA¼ not applicable.
significant difference between the PD technique and the reference standard was reported by 2 high quality studies. There was moderate evidence of PD of pelvic landmarks and limited evidence of PD of hand landmarks for assessing the pelvic and metacarpophalangeal joint kinematics, respectively. However, no evidence was found for validity of PD technique in any other segments of the body. 3.4.2. Reliability studies The results of the relative and absolute reliability statistics (Table 6) demonstrates overall strong evidence for the intra-rater and limited evidence for the inter-rater reliability, respectively. The reliability of PD procedure demonstrated strong and moderate level of evidence for joint ROM and static postural angles, respectively. A high to very high intra-rater ICC and satisfactory intra-rater SEM% of PD technique for joint ROM (3 high and 1 low quality studies) and postural angles (2 high and 1 low quality studies) assessment were reported. There was moderate evidence of intrarater reliability of PD procedure for assessing the thoracic curvatures, whereas only limited evidence was found in other joints due to an inadequate number of studies.
3.5. Sensitivity analysis The change of quality criterion for defining high quality studies from 60% to 60 10% had no effect on the overall level of evidence,
and it remained strong for both the validity and intra-reliability of PD technique. Moreover, at 70% criterion the level of evidence also remained moderate for the validity and intra-rater reliability of PD technique for pelvic and thoracic kinematics respectively. The sensitivity analysis had no effect on the limited evidence of the overall inter-rater reliability, and the validity and reliability of PD technique in other segments of the body.
4. Discussion 4.1. Summary of results The results of this systematic review demonstrate overall strong evidence for high levels of validity of PD technique for assessment of pelvic, hip and metacarpo-phalangeal joint kinematics using EMTD. The mean difference between the reference standard and the index test was least for innominate ROM assessment (0.34 0.52 ) and highest for pelvic tilt assessment (8.00 7.80 ). These discrepancies can be partly attributed to the use of PolhemusÔ EMTD, with higher static accuracy (0.76 mm), for innominate ROM assessment; when compared to the use of Flock of BirdsÔ (FOB) EMTD, with comparatively lower static accuracy (1.08 mm), for pelvic tilt assessment (Sprigle et al., 2002; Bussey et al., 2004). Further, the reference standard used for these kinematic measurements also differed (Table 5), with different techniques applied to locate bony landmarks and calculate the angles
Table 4 Quality analysis of reliability studies using QAREL tool. Questions:
Singh et al., 2010
Laprade and Lee, 2005
Bussey et al., 2004
Ludewig et al., 2004
Gould, 2003
Kulkarni-Lambore and Peat, 2000
Culham and Peat, 1993
1. Representative sample 2. Representative raters 3. Blinding (other raters) 4. Blinding (own findings) 5. Blinding (reference / disease) 6. Blinding (clinical information) 7. Blinding (additional cues) 8. Examination order varied 9. Appropriate time interval 10. Test appropriate 11. Appropriate statistics Internal validity (%) (Q:3-9) External validity (%) (Q:1-2, 10) Statistical methods (%) (Q:11) Percentage of Yes (%)
Yes Unclear NA Yes NA NA Unclear NA Yes Yes Yes 2/3 ¼ 66.67 2/3 ¼ 66.67 1/1 ¼ 100 5/7 ¼ 71.43
Yes Unclear NA Yes NA NA Unclear NA Yes Yes Yes 2/3 ¼ 66.67 2/3 ¼ 66.67 1/1 ¼ 100 5/7 ¼ 71.43
Yes Unclear NA Yes Yes NA Unclear NA Yes Yes No 3/4 ¼ 75.00 2/3 ¼ 66.67 0/1 ¼ 0.00 5/8 ¼ 62.50
Yes Unclear Unclear Yes NA Unclear Unclear Unclear Yes Yes No 2/6 ¼ 33.34 2/3 ¼ 66.67 0/1 ¼ 0.00 4/10 ¼ 40.00
Yes Unclear NA Yes NA NA Unclear NA Yes Yes Yes 2/3 ¼ 66.67 2/3 ¼ 66.67 1/1 ¼ 100 5/7 ¼ 71.43
Yes Unclear NA Yes Yes Unclear Unclear NA Yes Yes Yes 3/5 ¼ 60.00 2/3 ¼ 66.67 1/1 ¼ 100 6/9 ¼ 66.67
No Unclear NA Yes NA NA Unclear NA Yes Yes Yes 2/3 ¼ 66.67 1/3 ¼ 33.34 1/1 ¼ 100 4/7 ¼ 57.14
NA: not applicable.
72.72 ICC ¼ 0.93 Not reported 2nd, 3rd and 5th MCP joint ROM (respective metacarpal and proximal phalanx, forearm) Radiograph 5 (healthy subjects) Metacarpo-phalangeal joint angles Kulkarni-Lambore and Peat (2000)
LPSIS: left posterior superior iliac spine, RPSIS: right posterior superior iliac spine, LASIS: left anterior superior iliac spine, RASIS: right anterior superior iliac spine, PSIS: posterior superior iliac spine, ASIS: anterior superior iliac spine, MCP: metacarpo-phalangeal, ROM: range of motion, ICC: Intraclass correlation coefficient.
90.90
Pearson’s correlation, linear regression and ANOVA ICC (2,1) Pelvic tilt: >0.25 Hip angle: >0.28 Pelvic tilt and hip angle Sprigle et al. (2002)
10 (healthy subjects)
Radiograph
Pelvic tilt: 8.00 7.80 Hip angle: 4.90 10.00 0.80
Pelvic tilt: r ¼ 0.89 R2 ¼ 0.80 Hip angle: r ¼ 0.78
90.90 r ¼ 0.83 Pearson’s correlation and paired t-test >0.05 0.34 0.52
Right innominate rotation (LPSIS, RASIS, RPSIS) Left innominate rotation (RPSIS, LASIS, LPSIS) Pelvic tilt (ASIS, PSIS) Hip angle (ASIS, PSIS) Computed Tomography Scan Innominate angles Bussey et al. (2004)
6 (healthy subjects)
Joint/segment Author (year)
Table 5 Characteristics of validity studies.
Sample size (subjects)
Reference standard used
Statistics used P value Mean difference between index and reference (degrees) Outcome variables (landmarks digitized)
Validity measure
Quality score (%)
D.B. Adhia et al. / Manual Therapy 18 (2013) 26e34
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from the reference standard. These procedural differences can affect kinematic measurements leading to discrepancies in the mean difference. The results of this review also demonstrated overall strong evidence for very high levels of intra-rater reliability of PD technique for assessment of joint ROM and postural angles using EMTD. The relative (ICC) and absolute (SEM%) reliability was least for the static humeral abduction position (ICC ¼ 0.51) and metacarpophalangeal joint ROM (SEM% ¼ 7.73e10.25%) respectively. The lower reliability noted can be attributed to non-prominence of bony landmarks used (Table 6) for assessment of these kinematic measurements; which may lead to lower consistency and higher measurement errors when compared to prominent bony landmarks (Smidt et al., 1992). Measurement errors were smaller (SEM % ¼ 1.3%) for the cranio-vertebral angles which used bony landmarks of 7th cervical vertebrae and tragus. However, marking of the bony landmark using an indelible pen before digitization would have resulted in some bias leading to increased consistency of PD trials in this study. Participant (e.g., anthropometrics), tester (e.g., training, experience, palpation skills, etc.) and procedure (bony landmarks digitized, number of trials, duration between trials, using average of trials for kinematic calculations etc.) related variability can affect the measurement errors associated with PD of bony landmarks (Smidt et al., 1992). Reliability studies included in this review differed (Table 6) in terms of participants evaluated (symptomatic/ asymptomatic), joints/segments evaluated (peripheral joints/spinal joints), bony landmarks digitized (Table 6), number of trials (1e4), duration between sessions (none to 7 days), outcome variables (static postural angles/joint ROM), EMTD used (PolhemusÔ Isotrak or Fastrak) and reliability study design (trial-to-trial/inter-day). However, the authors found no relation between these sources of variability and the reliability of PD technique. 4.2. Methodological considerations While most studies demonstrated high internal and external validity, there were some methodological limitations affecting generalizability and clinical applicability of the results. Firstly, the subjects included in most studies were young healthy adults with mean age of 35.0 17.0 years and mean BMI of 22.6 1.6 kg/m2. A healthy population is not necessarily representative of the clinical population (Whiting et al., 2003), and the bony landmarks may be difficult to palpate in obese individuals leading to higher measurement errors (Langenderfer et al., 2009). Thus the results of these studies cannot be generalized to the clinical population or other populations whose anthropometrics are disparate from the subjects included in these studies. Secondly, none of the studies described the characteristics of the testers conducting the PD procedure. Tester-related variability such as profession (student/ manual therapist/osteopath/chiropractic, etc), experience (novice/ months/years), and training can influence a tester’s palpation skills and may have a greater effect on the PD measurement errors (Harlick et al., 2007; Haneline and Young, 2009). Thus, the unknown variability of testers among these studies further limits its generalizability. Thirdly, the statistics used by some studies were inappropriate (Lucas et al., 2010) and some others failed to report the absolute measures of reliability. While the relative reliability statistic of ICC indicates the degree of relationships between two measures, the absolute reliability statistics of SEM reflects the magnitude of difference between the two measures and has more clinical applicability (Domholdt, 2005). Hence, the lack of absolute reliability statistics limits the clinical applicability of these results. Lastly, no studies reported measurement errors of individual bony landmarks and measurement error sensitivity for kinematic
32
Table 6 Characteristics of reliability studies. Author (year)
Joint/segment
Reliability study design
Sample size (subjects)
No of PD trials
Outcome variables (landmarks digitized)
Statistics used
Relative reliability
Absolute reliability SEM
% SEM
Thoracic kyphosis (T1, T8, L1) Lumbar lordosis (T8, L1, L5) Lateral thoracic curvature (T1, L1) Lateral lumbar curvature (L1, L5) Patella displacement (ME, LE, GT)
ICC (3,1) and SEM
0.93 0.98 0.75 0.84 ME: 0.99 LE: 0.98 GT: 0.99 0.89
1.57 1.51 1.04 0.56 5.80 mm 5.80 mm 8.50 mm e
3.66 5.25 e e 3.39 4.97 3.39 e
0.90 e1.70
e
40.00
1.30 1.27 3.19 3.02 3.44 3.38 5.84 4.68 4.69 8.56 7.73 10.25 5.03 e
71.43
Singh et al. (2010)
Thoraco-lumbar curvature
Intra-rater (trial to trial)
52 (healthy subjects)
3
Laprade and Lee (2005)
Patello-femoral kinematics
Intra-rater (trial to trial)
10 (healthy subjects)
3
Bussey et al. (2004)
Innominate kinematics
Intra-rater (trial to trial)
15 (healthy subjects)
4
Ludewig et al. (2004)
Intra-rater (Trial to trial) Inter-rater
Gould (2003)
Postural angles and spinal curves
Testeretest (Inter-day: 24 h apart) Intra-rater (Trial to trial)
Kulkarni-Lambore and Peat (2000)
MCP joint kinematics
Culham and Peat (1993)
Spine & shoulder posture
11 (healthy or shoulder pathology) 5 (healthy or shoulder pathology) 5 (healthy or shoulder pathology)
1
Pearson’s correlation
SEM
Not reported
1.30 e4.10
1
1.90 e4.00
1
Intra-rater (Inter-day: <7 days apart)
11 (7 healthy, 4 rheumatoid patients)
1
Intra-rater (Inter-day: 1e7 days apart)
20 (healthy women)
2
Left cranio-vertebral (LT, C7) Right cranio-vertebral (RT, C7) Left shoulder-sagittal (C7, LSJ) Right shoulder-sagittal (C7, RSJ) Left shoulder-horizontal (C7, LSJ) Right shoulder-horizontal (C7, RSJ) Cervical spine curvature (C2, C7) Upper thoracic curvature (T4, T8) Lower thoracic curvature (T8, T12) 2nd, 3rd, 4th and 5th MCP joint ROM (respective metacarpal and proximal phalanx, forearm) Upper thoracic slope (T1, T3) Lower thoracic slope (T10, T12) Scapula anterior tilt (R1, IA) Humeral flexion-extension (PH, DH) Scapula abduction (R1, IA) Clavicle elevation (MC, LC) Humeral abduction (PH, DH) Scapula rotation (AA, R1, R2) Clavicle rotation (MC, LC) Humeral rotation (R1, R2, ME, LE) Scapula horizontal (T1, R1, AA, IA) Scapula vertical (T1, R1, AA, IA)
71.43
62.50
0.92
1
35 (healthy subjects)
71.43
ICC (3,1)
ICC (2,1)
ICC (2,1)
0.96 0.97 0.98 0.98 0.97 0.97 0.94 0.98 0.99 WF1: 0.85 WN1: 0.88 WE1: 0.77 WE2: 0.95 0.91 0.87 0.88 0.86 0.75 0.96 0.51 0.90 0.93 0.94 0.93 0.80
0.72 0.69 1.24 1.26 0.66 0.66 1.95 0.77 1.13 5.91 5.65 7.18 3.27 e
66.67
57.14
SEM: standard error of measurement, ICC: Intraclass correlation coefficient, T: thoracic spinous process, L: lumbar spinous process, ME: medial epicondyle, LE: lateral epicondyle, GT: greater trochanter, LPSIS: left posterior superior iliac spine, RPSIS: right posterior superior iliac spine, LASIS: left anterior superior iliac spine, RASIS: right anterior superior iliac spine, SN: sternal notch, C: cervical spinal process, XP: xiphoid process, SCJ: sternoclavicular joint, ACJ: acromio-clavicular joint, LT: left tragus, RT: right tragus, LSJ: left shoulder joint, RSJ: right shoulder joint, ROM: range of motion, MCP: metacarpo-phalangeal, WF: wrist in flexion, WN: wrist in neutral, WE: wrist in extension, R1: root of right scapula, IA: inferior angle of scapula, PH: proximal humerus, DH: humerus, MC: medial clavicle, LC: lateral clavicle, ME: medial humeral epicondyle, LE: lateral humeral epicondyle, AA: acromion angle, R2: root of left scapula, ‘e’ : could not be calculated.
D.B. Adhia et al. / Manual Therapy 18 (2013) 26e34
Clavicular kinematics during arm elevation
Right innominate rotation (LPSIS, RASIS, RPSIS) Left innominate rotation (RPSIS, LASIS, LPSIS) Clavicle ROM (SN, C7, XP, T8, SCJ and ACJ)
ICC
Quality score (%)
D.B. Adhia et al. / Manual Therapy 18 (2013) 26e34
measurements. Kinematic measurements of certain joints may be more sensitive to errors in one or more bony landmarks (Piazza and Cavanagh, 2000; Morton et al., 2007; Moriguchi et al., 2009), for example, error in palpation of femoral epicondyle has shown to have greater effect on the tibio-femoral and patella-femoral kinematics when compared to errors in tibial or patella landmarks (Morton et al., 2007). Although small measurement errors (SEM ¼ 0.56 to 5.91 ) were reported, the influence of the measurement error of each bony landmark on the kinematic measurement is unknown. A sensitivity analysis of the influence of the measurement errors on respective kinematic outcome variables would have further helped to strengthen the rigor of the absolute reliability statistics. 4.3. Practical implications The results of this systematic review imply that the PD technique using EMTD is a valid and reliable technique for assessment of 3D joint kinematics at least in the joints evaluated. This technique is simple, non-invasive, capable of assessing 3D joint kinematics, and can be applied to all joints in the body. Similar to several clinical tests, the kinematic joint assessment using EMTD requires palpation of the bony landmarks and can be easily adapted by clinicians (Pennock and Clark, 1990; Wu et al., 2005). In the modern era of evidence based practice, this technique of PD of bony landmarks can have high clinical utility as it can provide clinicians with objective and accurate 3D measurements of joint kinematics for baseline assessment, determine progress and improve clinical decision making. 4.4. Limitations of this review Although this review was designed based on PRISMA guidelines, some limitations need to be addressed. Firstly, we used the QUADAS and QAREL tool for assessing the quality of validity and reliability studies, respectively. As these scales are developed for assessing the quality of diagnostic accuracy and reliability studies, its applicability for assessing the quality of kinematic validity and reliability studies is unknown. However, these scales were similar to the other reviews in related areas and were appropriate for the aims of this review (van Trijffel et al., 2005; Haneline and Young, 2009). Secondly, the two reviewers assessing the methodological quality of the studies were not blinded to the authors or results of the included studies due to their familiarity with the topic. While one could argue that this may have caused reviewer bias (Stochkendahl et al., 2006), non-blinding authors has shown to have no influence on quality assessment of studies (Berlin, 1997). Thirdly, only studies that were published as full text article, thesis or peer reviewed reports, that primarily assessed the validity and/or reliability of PD technique, were included and conference proceedings were not included for the study which would have led to publication bias resulting in overestimation of the validity and/or reliability of PD technique (Song et al., 2000). Lastly, the results of the studies included in this review were synthesized qualitatively using the level of evidence approach. The use of qualitative level of evidence approach would have concealed the considerable heterogeneity that existed among the included studies (Stochkendahl et al., 2006). However, despite the heterogeneity in the study characteristics, most of the studies demonstrated high levels of validity and reliability of PD technique for joint kinematic measurements. 5. Conclusions and future recommendations The results of this systematic review demonstrate overall strong level of evidence for the validity and intra-rater reliability of PD of bony landmarks for joint kinematics assessment. A high level of
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validity and very high level of relative intra-rater reliability were demonstrated for most joint segments evaluated. The results of absolute intra-rater reliability statistics (SEM%) also demonstrated satisfactory results; however the sensitivity of these measurement errors on the outcome variables is unknown and should be undertaken by future reliability studies using PD technique. The evidence for the inter-rater reliability of PD technique for joint kinematic assessment was limited but is important for the clinical utility of this technique and therefore should be addressed by future researchers. References An KN, Jacobsen MC, Berglund LJ, Chao EYS. Application of a magnetic tracking device to kinesiologic studies. Journal of Biomechanics 1988;21(7):613e20. Assink NA, Bergman GJD, Knoester B, Winters JC, Dijkstra PU. 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