Name: a standardized method for measurement of elbow kinesthesia
Uploaded: 2020-10-10T15:00:00
Description: Watch this Scientific Journal Video about A Standardized Method for Measurement of Elbow Kinesthesia at JoVE.com

The authors would like to thank Dr. Jon Nelson for technical support of EMG and electrogoniometer equipment used here.

The Institutional Review Board at The College of St. Scholastica has approved the study under which this protocol was developed and tested.
1. Fabrication of the visual screen
<ol>
	<li>Cut the &#190; inch (1.9 cm) diameter PVC pipe into various lengths: two 30 inch (76.2 cm) pieces (screen base); two 8 inch (20.3 cm) pieces (screen base); one 44 inch (111.8 cm) piece (vertical screen support); and one 32 inch (81.3 cm) piece (screen fabric holder).</li>
	<li>Place an end cap on one end of e...

<ol>
	<li>Coderre, A. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Assessment+of+upper-limb+sensorimotor+function+of+subacute+stroke+patients+using+visually+guided+reaching.">Assessment of upper-limb sensorimotor function of subacute stroke patients using visually guided reaching.</a> Neurorehabilitation and Neural Repair. 24 (6), 528-541 (2010).</li><li>Dukelow, S. P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Quantitative+assessment+of+limb+position+sense+following+stroke.">Quantitative assessment of limb position sense following stroke.</a> Neurorehabilitation and Neural Repair. 24 (2), 178-187 (2010).</li><li>Semrau, J. A., Herter, T. M., Scott, S. H., Dukelow, S. P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+identification+of+kinesthetic+deficits+after+stroke.">Robotic identification of kinesthetic deficits after stroke.</a> Stroke. 44 (12), 3414-3421 (2013).</li><li>Meyer, S., Karttunen, A. H., Thijs, V., Feys, H., Verheyden, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=How+do+somatosensory+deficits+in+the+arm+and+hand+relate+to+upper+limb+impairment,+activity,+and+participation+problems+after+stroke?+A+systematic+review.">How do somatosensory deficits in the arm and hand relate to upper limb impairment, activity, and participation problems after stroke? A systematic review.</a> Physical Therapy. 94 (9), 1220-1231 (2014).</li><li>Desrosiers, J., Bourbonnais, D., Bravo, G., Roy, P. M., Guay, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Performance+of+the+'unaffected'+upper+extremity+of+elderly+stroke+patients.">Performance of the 'unaffected' upper extremity of elderly stroke patients.</a> Stroke. 27 (9), 1564-1570 (1996).</li><li>Carey, L. M., Matyas, T. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Frequency+of+discriminative+sensory+loss+in+the+hand+after+stroke+in+a+rehabilitation+setting.">Frequency of discriminative sensory loss in the hand after stroke in a rehabilitation setting.</a> Journal of Rehabilitation Medicine. 43 (3), 257-263 (2011).</li><li>Konczak, J., Krawczewski, K., Tuite, P., Maschke, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+perception+of+passive+motion+in+Parkinson's+disease.">The perception of passive motion in Parkinson's disease.</a> Journal of Neurology. 254 (5), 655 (2007).</li><li>Van Deursen, R. W. M., Simoneau, G. 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J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Proprioceptive+acuity+assessment+via+joint+position+matching:+from+basic+science+to+general+practice.">Proprioceptive acuity assessment via joint position matching: from basic science to general practice.</a> Physical Therapy. 90 (8), 1176-1184 (2010).</li><li>Juul-Kristensen, B., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Test-retest+reliability+of+joint+position+and+kinesthetic+sense+in+the+elbow+of+healthy+subjects.">Test-retest reliability of joint position and kinesthetic sense in the elbow of healthy subjects.</a> Physiotherapy Theory and Practice. 24 (1), 65-72 (2008).</li><li>Deshpande, N., Connelly, D. M., Culham, E. G., Costigan, P. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Reliability+and+validity+of+ankle+proprioceptive+measures.">Reliability and validity of ankle proprioceptive measures.</a> Archives of Physical Medicine and Rehabilitation. 84 (6), 883-889 (2003).</li><li>Boerboom, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Validation+of+a+method+to+measure+the+proprioception+of+the+knee.">Validation of a method to measure the proprioception of the knee.</a> Gait &amp; Posture. 28 (4), 610-614 (2008).</li><li>Nagai, T., Sell, T. C., Abt, J. P., Lephart, S. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Reliability,+precision,+and+gender+differences+in+knee+internal/external+rotation+proprioception+measurements.">Reliability, precision, and gender differences in knee internal/external rotation proprioception measurements.</a> Physical Therapy in Sport. 13 (4), 233-237 (2012).</li><li>Refshauge, K. M., Chan, R., Taylor, J. L., McCloskey, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Detection+of+movements+imposed+on+human+hip,+knee,+ankle+and+toe+joints.">Detection of movements imposed on human hip, knee, ankle and toe joints.</a> The Journal of Physiology. 488 (1), 231-241 (1995).</li><li>Portney, L. G., Watkins, M. 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L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+Simple+Non-invasive+Method+for+Temporary+Knockdown+of+Upper+Limb+Proprioception.">A Simple Non-invasive Method for Temporary Knockdown of Upper Limb Proprioception.</a> Journal of Visualized Experiments. (133), e57218 (2018).</li><li>Proske, U., Tsay, A., Allen, T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Muscle+thixotropy+as+a+tool+in+the+study+of+proprioception.">Muscle thixotropy as a tool in the study of proprioception.</a> Experimental Brain Research. 232 (11), 3397-3412 (2014).</li><li>Wise, A. K., Gregory, J. 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D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Age-related+decline+in+proprioception.">Age-related decline in proprioception.</a> Clinical Orthopaedics and Related Research. (184), 208-211 (1984).</li><li>Pai, Y. C., Rymer, W. Z., Chang, R. 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The presented protocol describes how to measure elbow TDPM in a standardized fashion using a common CPM machine to provide the passive movement. Across 20 healthy participants the average elbow TDPM measurement was found to be similar to the average value identified in previous studies using other TDPM measuring setups7,19,32, and produced reliable results across testing sessions. TDPM of the ipsilesional elbow among the eight p...

Proprioceptive information is an important contributor to the control of human movement. Proprioceptive deficits accompany a wide range of neurologic conditions such as stroke1,2,3,4,5,6, Parkinson&#8217;s disease7, and sensory neuropathies8. Orthopedic injuries such as ligament and muscle tears have also been shown to reduce proprioceptive function9. The construct of proprioception is often tested in clinical outcome measures via detection of provider-applied small alterations in finger or toe position10,11,12,13,14. Such measures produce relatively coarse measurements: &#8220;absent&#8221;, &#8220;impaired&#8221;, &#8220;normal&#8221;12. While sufficient for detection of gross proprioceptive impairments, laboratory mechanical testing methods are required to precisely measure subtle proprioceptive impairments14,15,16.
Researchers and clinicians often divide proprioception into submodalities for measurement. The most commonly investigated submodalities of proprioception are joint position sense (JPS) and kinesthesia, typically defined as the sense of movement3,16,17. Joint position sense is often tested via active matching tasks, where individuals replicate a reference joint angle18,19. Kinesthesia is commonly measured using the threshold to detection of passive movement (TDPM), whereby a participant&#8217;s limb is passively moved slowly, with the participant indicating the point at which movement is first detected16,17,19. Measurement of TDPM typically requires use of specialized equipment to provide the slow passive movement and denote the point of detection17.
Valid and reliable results have been found at different joints using TDPM methods9,16,19,20,21,22. However, there is considerable variation in TDPM equipment and methods, creating a challenge for comparison of findings across studies16,17. Laboratories often develop their own limb movement and measurement devices, or use expensive commercial devices and software16. Passive movement speeds also vary; movement speed is known to affect detection thresholds7,16,23. A standardized, easily reproducible method capable of quantifying TDPM across a range of impairment levels is needed. Because the anatomy and physiology of each joint differs, protocols should be joint specific19. The protocol outlined here is specific to the elbow joint. However, the methods of this protocol may be useful to establish protocols for other joints.
To increase generalizability across sensorimotor research laboratories, the preferred apparatus for providing the passive movement for elbow TDPM testing would be commercially available at an affordable cost. To this end, an elbow continuous passive movement (CPM) machine (available speed range 0.23&#176;/s &#8211; 2.83&#176;/s) was chosen to produce the motorized, consistent motion. CPM machines are commonly found in rehabilitation hospitals and medical supply stores and can be rented or borrowed to reduce research costs. Additional equipment requirements include items commonly found in sensorimotor laboratories (i.e., electrogoniometer and electromyography (EMG) sensors), and hardware stores (e.g., PVC pipe, string and tape).
Two different groups were tested to explore the measurement properties of this TDPM protocol: healthy adults and adults with chronic stroke. For the adults with chronic stroke, the ipsilesional (i.e., less affected) arm was tested. Kinesthetic sense in the ipsilesional elbow in adults with chronic stroke may appear normal with clinical testing, but impaired when evaluated using quantitative laboratory methods5,15. This example illustrates the importance of developing and using sensitive and precise measures of somatosensory impairment and makes this a useful population for testing purposes. For validation of this protocol, we used the known groups method24. We compared TDPM to another quantitative measure of kinesthesia, the Brief Kinesthesia Test (BKT). The BKT has been shown to be sensitive to ipsilesional upper limb impairment post stroke25. The tablet-based version (tBKT) was used in this study because it is the same test as the BKT, administered on a tablet with more trials. The tBKT has been shown to be stable in one-week test-retest measurement and sensitive to proprioceptive knockdown26. It was hypothesized that the elbow TDPM and tBKT outcomes would be correlated as sensorimotor control of the elbow contributes to BKT performance26.
The purpose of this paper is to outline a standardized method of measuring elbow TDPM that is reproducible using common equipment. Data is presented regarding reliability and initial validity testing of the method, as well as feasibility of use for persons with no known pathology, and those who were hypothesized to have mild somatosensory impairment.

<table>
	<tbody>
		<tr>
			<td>3/4 inch diameter PVC pipe</td>
			<td>Charlotte Pipe</td>
			<td></td>
			<td>Pipe to be cut into lengths of: 30 inches/76.2 cm (x2); 8 inches/20.3 cm (x2); 44 inches/111.8 cm (x1); 32 inches/81.3 cm (x1).</td>
		</tr>
		<tr>
			<td>3/4 inch diameter PVC pipe end caps (x3)</td>
			<td>Charlotte Pipe</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>45&#176; PVC elbow (x1)</td>
			<td>Charlotte Pipe</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>90&#176; PVC elbows (x2)</td>
			<td>Charlotte Pipe</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Athletic tape</td>
			<td>3M</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Delsys acquisition software (EMGworks)</td>
			<td>Delsys</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Double-sided tape</td>
			<td>3M</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Duct tape</td>
			<td>3M</td>
			<td></td>
			<td>Used to assist in removal of dead skin cells on participant&#39;s skin prior to EMG sensor placement.</td>
		</tr>
		<tr>
			<td>Elbow Continuous Passive Motion (CPM) Machine</td>
			<td>Artromot</td>
			<td></td>
			<td>Chattanooga Artromot E2 Compact Elbow CPM; Model 2038</td>
		</tr>
		<tr>
			<td>Electrogoniometer</td>
			<td>Biometrics, Ltd</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Flour sack dishcloths (x2)</td>
			<td>Room Essentials</td>
			<td></td>
			<td>Fabric used for creation of visual screen.</td>
		</tr>
		<tr>
			<td>Handheld external trigger switch</td>
			<td>Qualisys</td>
			<td></td>
			<td>Trigger switch used for electrogoniometer event marking.</td>
		</tr>
		<tr>
			<td>Hearing occlusion headphones</td>
			<td>Coby</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Isopropyl alcohol</td>
			<td>Mountain Falls</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Paper tape</td>
			<td>3M</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Ruler with inch markings</td>
			<td>Westcott</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Standard height chair</td>
			<td>KI</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>String</td>
			<td>Quality Park</td>
			<td></td>
			<td>Approximately 15 inches of string needed. String used for standardization of electrogoniometer placement.</td>
		</tr>
		<tr>
			<td>Trigno Goniometer Adapter</td>
			<td>Delsys</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Trigno Wireless Electromyography Sensors</td>
			<td>Delsys</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Washable marker</td>
			<td>Crayola</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Washcloth</td>
			<td>Aramark</td>
			<td></td>
			<td>Used in combination with isopropyl alcohol for cleaning participant&#39;s skin prior to EMG sensor placement.</td>
		</tr>
	</tbody>
</table>

a standardized method for measurement of elbow kinesthesia

Proprioception is an important component of controlled movement. The threshold to detection of passive movement (TDPM) is a commonly used method for quantifying the proprioceptive submodality of kinesthesia in research settings. The TDPM paradigm has been found to be valid and reliable; however, the equipment and methods used for TDPM vary between studies. In particular, the research laboratory apparatuses for producing passive movement of an extremity are often custom designed by individual laboratories or inaccessible due to high cost. There is a need for a standardized, valid, and reliable method for measuring TDPM using readily available equipment. The purpose of this protocol is to provide a standardized method for measurement of TDPM at the elbow that is economical, easy to administer, and that produces quantitative results for measurement purposes in research-based settings. This method was tested on 20 healthy adults without neurological impairment, and eight adults with chronic stroke. The results obtained suggest this method is a reliable way to quantify elbow TDPM in healthy adults, and provides initial support for validity. Researchers seeking a balance between equipment affordability and measurement precision are most likely to find this protocol of benefit.

Participants: 
Using the protocol presented here, elbow TDPM was measured in an academic research laboratory for two different groups of individuals: 20 healthy adults, and eight adults with chronic stroke. Participants for both groups were recruited from the community using fliers, emails, and word-of-mouth. The healthy adults (14 females, six males; mean age (SD) = 28 (7.9) years; 19 right- and one left-handed) were tested to generate representative results for an unimpaired population. Inclusion ...

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A Standardized Method for Measurement of Elbow Kinesthesia

Here, we present a standardized method for measurement of elbow passive kinesthesia using the threshold to detection of passive movement (TDPM) that is appropriate for a research setting.

Proprioception is an important component of controlled movement. The threshold to detection of passive movement (TDPM) is a commonly used method for ...

Our laboratory found the need for an inexpensive quantitative measure of upper limb kinesthetic sense. So we refined and standardized a protocol for the threshold to detection of passive movement of the elbow. To keep the method feasible, we used a continuous passive motion machine and commonly available laboratory instruments.Here we present a detailed protocol that yielded valid and reliable results using this method. We suggest the method may also be adopted for other joints in the future. Enjoy the paper.This protocol requires fabrication of a visual screen. See written protocol for instructions. Begin equipment preparations by calibrating the electric goniometer and EMG sensors according to the manufacturer's instructions.Turn on the continuous passive motion machine and activate Extension Flexion mode. Program the CPM machine to move through 90 to 130 degrees of elbow extension at a speed of 0.23 degrees per second. Seat the participant in a standard-height chair, ensuring that they are sitting with a straight back and feet flat on the floor.Verbally prepare the participant for EMG sensor and electro goniometer placement using the standardized script. Next, attach the biceps brachii and triceps brachii EMG sensors. Manually resist elbow flection to locate the biceps brachii muscle belly and mark the central point of the muscle belly with a small dot of washable marker to denote location for EMG sensor placement.Manually resist elbow extension to locate the central point of the bulk of the muscle belly of the lateral head of the triceps, and denote this location for EMG sensor placement. Prepare the skin by removing dead skin cells, followed by scrubbing with an alcohol swab. Then attach the EMG sensors.Repeat the process for placement of the triceps brachii EMG sensor. Standardized placement of the electro goniometer begins by identifying landmarks. Determine the midpoint of the dorsal aspect of the wrist, and mark with washable marker.Palpate the most prominent aspect of the lateral epicondyle and mark with washable marker. Palpate the greater tubercle of the humerus and mark with washable marker. The location of the greater tubercle can be verified by passively moving the testing arm through internal and external rotation.Attach one end of the string to the lateral epicondyle mark using paper tape. Pull the string taut, connecting it to the dorsal wrist midpoint mark. Trace a line along the proximal forearm, in line with the string, using washable marker.Move the free end of the string to the greater tubercle mark and pull string taut. Trace a line along the distal humerus and line with the string using washable marker. Then remove the string.Measure one and a half inches from the lateral epicondyle mark along the proximal forearm line and mark this location with a small dot of washable marker. This is the location for placement of the distal paddle of the electric goniometer. Measure one and a half inches from the lateral epicondyle mark along the distal humerus line and mark the location with a small dot of washable marker.This is the location for the placement of the proximal paddle of the electric goniometer. Secure the remaining components of the electric goniometer to the skin using paper tape. Position the participant's upper extremity in the CPM machine.Adjust the height and orientation of the CPM machine to achieve a position of 90 degrees sagittal plane shoulder flection, 90 degrees elbow flection, and a neutral forearm. The participant's lateral epicondyle should be aligned with the rotational axis of the CPM machine. Adjust the CPM hand support to fit comfortably with the palm of the participant's hand, and secure the participant's forearm to the CPM via the wrist strap.Inform the participant of the testing procedure using the standardized verbal information. Hand participant the switch and test switch. Inform participant of additional aspects of the testing procedure.Diminish auditory input by placing noise-canceling headphones on the participant. Occlude visual input of the CPM machine and test arm, using the visual screen. Loudly state.Begin.And wait the corresponding amount of time per trial before initiating movement of the CPM. Monitor EMG sensor feedback readings to ensure the participant does not attempt to use active movement to assist in movement detection. Between each trial, remove the participant's test arm from the CPM machine and passively move the elbow through full extension, then back to 90 degrees for placement in the CPM machine.Complete eight trials, including two catch trials where the participant's arm is not moved. If during a catch trial, the participant reports they can't feel the CPM move or depresses the trigger switch, use the standardized script. To determine a participant's TDPM value for each trial, use the electric goniometer tracing to identify the angle measurement for the point at which the CPM machine movement started, and for the point at which the participant indicated movement was felt.The difference in degrees between these two points determines the TDPM value for that trial. To determine a participant's overall TDPM score, remove the smallest and largest TDPM values from the six non-catch trials, then average the remaining four trial scores. Using the standardized method for measurement of the threshold to detection of passive movement at the elbow, 20 healthy adults with no known upper limb pathology were tested.Additionally, the non-affected upper extremity in eight adults with chronic stroke was tested. Exploratory results demonstrating the TDPM in the healthy adult versus chronic stroke population are shown here. The average TDPM for healthy participants was 1.19 degrees.The average TDPM for individuals post-stroke was 8.24 degrees. Using a two-tailed T test, this difference between groups was found to be significant, suggesting the discriminative capabilities of this TDPM protocol. In the healthy control participants, a retest was completed one week after the initial measurement.Spearman correlation and inter-class correlation coefficients were calculated to evaluate test/retest reliability, with the value suggesting moderate to good reliability of the measure among the healthy control participants. Construct validity of this elbow TDPM method was examined by evaluating the Spearman correlation between elbow TDPM and error and targeted reaching, as measured by the tablet version of the brief kinesthesia test. A moderate relationship was found between these two measures of kinesthesia.This protocol outlines a method for measurement of threshold to detection of passive movement at the elbow that can produce precise, reliable results. It is unique in that it uses equipment that is commonly found in rehabilitation and sensory motor laboratories. The field of sensory motor research is in need of tools that can quantify sensory motor impairment as well as the impact of interventions.It is our hope that this practical method is found useful by those seeking to advance sensory motor research.

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