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 ...

Watch this Scientific Journal Video about A Standardized Method for Measurement of Elbow Kinesthesia at JoVE.com

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 ...

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