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 each 30 inch (76.2 cm) piece, and a 90&#176; PVC elbow on the other end. Insert 8 inch (20.3 cm) pieces into the remaining open ends of both elbows. Connect open ends of the two 8 inch (20.3 cm) pieces with the&#160;PVC tee to create a screen base.</li>
	<li>Insert the&#160;44 inch (111.8 cm) PVC piece into the&#160;vertical portion of the PVC tee&#160;to create a vertical support for screen. Place the&#160;45&#176; PVC elbow on the open end of the 44 inch (111.8 cm) piece. Insert the&#160;32 inch (81.3 cm) piece into the open end of the 45&#176; PVC elbow to create a screen fabric holder. Place an end cap on the open end of the 32 inch (81.3 cm) piece.</li>
	<li>Place dishtowels on top of one another to ensure fabric opacity. Secure to the 32 inch (81.3 cm) piece with athletic tape. The fully assembled screen can be seen in Figure 1.</li>
</ol>
2. Preparation of the testing equipment
<ol>
	<li>Calibrate electrogoniometer and electromyography (EMG) sensors according to the manufacturers&#8217; instructions.</li>
	<li>Turn on the continuous passive motion (CPM) machine and activate Extension/Flexion mode. Program the CPM machine to move through 90&#176; to 130&#176; of elbow extension at a speed of 0.23&#176;/s.</li>
</ol>
3. Preparation of the participant for TDPM testing
<ol>
	<li>Seat the participant in a standard height chair (18 inch/45.7&#160;cm), ensuring sitting with a straight back and feet flat on floor.</li>
	<li>Verbally prepare the participant for the EMG sensor and the electrogoniometer placement using a standardized script: &#8220;To begin, I am going to prepare your skin to attach sensors. They will help record movement and ensure your muscles are relaxed during the test. I&#8217;m going to mark landmarks on your arm and start attaching the sensors, so you can just relax in the position I place you in.&#8221;</li>
	<li>Attach the biceps brachii and the triceps brachii EMG sensors.
	<ol>
		<li>Manually resist elbow flexion 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 the location for the EMG sensor placement. Prepare the skin by removing the dead skin cells followed by scrubbing with an alcohol swab, and then attach the EMG sensor.</li>
		<li>Manually resist elbow extension to locate the muscle belly of the lateral head of the triceps brachii and mark the central point in the bulk of the muscle belly with a small dot of washable marker to denote the location for the EMG sensor placement. Prepare the skin by removing dead skin cells followed by scrubbing with an alcohol swab, and then attach the EMG sensor.</li>
		<li>Test the EMG function by evoking an isometric biceps brachii contraction, followed by an isometric triceps brachii contraction, and observing for EMG activation.</li>
	</ol>
	</li>
	<li>Attach the electrogoniometer to the participant.
	<ol>
		<li>Determine the midpoint of the dorsal aspect of the wrist and mark with a washable marker.</li>
		<li>Palpate the most prominent aspect of the lateral epicondyle and mark with a washable marker.</li>
		<li>Palpate the greater tubercle of the humerus and mark with a washable marker. Verify the greater tubercle location by passively moving the testing arm through internal and external rotation of the humerus as needed.</li>
		<li>Attach one end of the string to the lateral epicondyle mark using paper tape. Pull the string taut, connecting it with the dorsal wrist midpoint mark.</li>
		<li>Trace a line along the proximal forearm in line with the string using a washable marker.</li>
		<li>Move the free end of the string to the greater tubercle mark and pull the string taut.</li>
		<li>Trace a line along the distal humerus in line with the string using a washable marker, and then remove the string.</li>
		<li>Place the distal paddle of the electrogoniometer along the path of the traced line, 1.5 inches (3.8 cm) distally from the lateral epicondyle mark.</li>
		<li>Place the proximal paddle of electrogoniometer along the path of the traced line, 1.5 inches (3.8 cm) proximally from the lateral epicondyle mark. Secure the remaining components of the electrogoniometer to the skin using paper tape.</li>
	</ol>
	</li>
	<li>Position the participant&#8217;s upper extremity comfortably in the CPM machine.
	<ol>
		<li>Adjust the height and orientation of the CPM machine to achieve a position of 90&#176; sagittal plane shoulder flexion, 90&#176; elbow flexion, and a neutral forearm. Align the participant&#8217;s lateral epicondyle with the rotational axis of the CPM machine.</li>
		<li>Adjust the CPM machine hand support to fit comfortably with the palm of the participant&#8217;s hand and secure the forearm via a wrist strap. Figure 1 shows the final participant setup for TDPM testing.</li>
	</ol>
	</li>
</ol>
4. Administration of the TDPM test
<ol>
	<li>Inform the participant of the testing procedure with the following standardized verbal information: &#8220;During this test, the machine is going to move very slowly to either straighten or bend your elbow. We will say &#8220;begin&#8221; at the start of each trial, there will be eight trials. When I say begin, the machine may or may not move your arm. Please press the button as soon as you feel your arm move, but only when you feel movement. If you don&#8217;t feel movement, we will stop the trial after a period of time; try to pay attention until we stop the trial. This is the button you&#8217;ll be using. Please press the button right now to test it.&#8221;</li>
	<li>Hand the participant the electrogoniometer event marking trigger switch and test the switch.</li>
	<li>Inform the participant of additional aspects of the procedure: &#8220;In between each trial, whether your arm moved or not, we will take your arm out of the machine and straighten it, and then place it back in the machine. Please remain relaxed. Do you have any questions about the test? We will be using this curtain to block your vision during this test and place this hearing protection over your ears to minimize any sounds you might hear during the testing.&#8221;</li>
	<li>Occlude visual input by blocking the view of the arm being tested and the CPM machine using a visual screen. Drape screen material at the participant&#8217;s shoulder to avoid sensory input during arm movement. Diminish auditory input by placing noise-cancelling headphones on the participant (see Figure 1).</li>
	<li>Loudly state &#8220;begin,&#8221; and wait the corresponding amount of time per trial before initiating movement of the CPM machine to decrease participant guessing when movement will begin19. Standardized delay times are shown in Table 1.</li>
</ol>
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Trial Number</td>
			<td>1</td>
			<td>2</td>
			<td>3</td>
			<td>4</td>
			<td>5</td>
			<td>6</td>
			<td>7</td>
			<td>8</td>
		</tr>
		<tr>
			<td>Delay (s)</td>
			<td>1</td>
			<td>Catch</td>
			<td>3</td>
			<td>1</td>
			<td>2</td>
			<td>Catch</td>
			<td>3</td>
			<td>1</td>
		</tr>
	</tbody>
</table>
Table 1: Standardized time delays and catch trial locations. Varied trial start time delays are included to prevent participant attempts to guess when movement will begin. Catch trials are included to test whether or not participant is actually detecting movement19,31.
<ol start="6">
	<li>Observe for activation of biceps brachii and triceps brachii muscles by monitoring EMG sensor feedback readings to ensure that the participant does not attempt to use active movement to assist in movement detection.
	<ol>
		<li>If muscle activation is noted, stop the trial and use the following standardized script: &#8220;Your muscles are activating. Please try to keep your arm relaxed during the test.&#8221; This trial should be noted for exclusion from data analysis, with the researcher proceeding with resetting the participant and CPM to start the next trial (protocol step 4.7).</li>
	</ol>
	</li>
	<li>Between each trial, remove the participant&#8217;s testing arm from the CPM machine and return the CPM machine to a 90&#176; start position. Passively move the participant&#8217;s elbow through full extension and then back to 90&#176; flexion to standardize the muscle spindle movement history27,28. Place the arm back in the CPM machine for the next trial.</li>
	<li>Complete eight trials, including two &#8220;catch&#8221; trials where the participant&#8217;s arm is not moved19. Terminate each trial (catch and non-catch) when the participant depresses the trigger switch, or after 15 seconds if the trigger switch is not depressed.</li>
	<li>If during a catch trial a participant verbally reports they cannot feel movement, or depresses the trigger switch, use the following standardized response: &#8220;Your arm did not actually move during that trial. I know it&#8217;s hard to feel, the machine moves very slowly; try to concentrate and push the button as soon as you feel your arm move or that your arm position has changed.&#8221;</li>
</ol>
5. Calculation of participant&#8217;s TDPM score
<ol>
	<li>Using the electrogoniometer tracing, identify the electrogoniometer angle measurement for the point at which the CPM machine movement started, and for the point at which the participant depressed the trigger switch indicating movement was felt. See Figure 2 for a representative example.</li>
</ol>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/61391/61391fig02.jpg" /> 
Figure 2: Example electrogoniometer tracing with detection point.&#160;The electrogoniometer line tracing (green line), start point of the continuous passive motion (CPM) machine movement, and the point at which participant indicated movement was detected (first blue peak) are shown. The difference between electrogoniometer readings at the start of the trial (pink circle) and at detection point (orange circle) determines the TDPM value for that trial. <a href="https://www.jove.com/files/ftp_upload/61391/61391fig02large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<ol start="2">
	<li>Subtract the starting angle from the final angle, thus identifying the number of degrees the CPM moved; this is the participant&#8217;s elbow TDPM value for that trial.</li>
	<li>To determine participant&#8217;s overall TDPM score, remove the smallest and largest TDPM values from the six non-catch trials, and then average the remaining four trial scores29.</li>
</ol>

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W., Sharma, L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Effect+of+age+and+osteoarthritis+on+knee+proprioception.">Effect of age and osteoarthritis on knee proprioception.</a> Arthritis &amp; Rheumatism. 40 (12), 2260-2265 (1997).</li><li>Dunn, W., 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=Measuring+change+in+somatosensation+across+the+lifespan.">Measuring change in somatosensation across the lifespan.</a> American Journal of Occupational Therapy. 69 (3), (2015).</li><li>Alghadir, A., Zafar, H., Iqbal, Z., Al-Eisa, E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Effect+of+sitting+postures+and+shoulder+position+on+the+cervicocephalic+kinesthesia+in+healthy+young+males.">Effect of sitting postures and shoulder position on the cervicocephalic kinesthesia in healthy young males.</a> Somatosensory &amp; Motor Research. 33 (2), 93-98 (2016).</li></ol>

The authors declare they have no competing financial interests.

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>3/4 inch diameter PVC tee (x1)</td><td>Charlotte Pipe</td><td></td><td></td></tr><tr><td>45&amp;deg; PVC elbow (x1)</td><td>Charlotte Pipe</td><td></td><td></td></tr><tr><td>90&amp;deg; 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&#039;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&#039;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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7.0K Views.  The College of St. Scholastica. 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.

Video: A Standardized Method for Measurement of Elbow Kinesthesia

A Novel Method for Assessing Proximal and Distal Forelimb Function in the Rat: the Irvine, Beatties and Bresnahan (IBB) Forelimb Scale

Several experimental models of cervical spinal cord injury (SCI) have been developed recently to assess the consequences of damage to this level of the spinal cord (Pearse et al., 2005, Gensel et al., 2006, Anderson et al., 2009), as the majority of human SCI occur here (Young, 2010; www.sci-info-pages.com). Behavioral deficits include loss of forelimb function due to damage to the white matter affecting both descending motor and ascending sensory systems, and to the gray matter containing the segmental circuitry for processing sensory input and motor output for the forelimb. Additionally, a key priority for human patients with cervical SCI is restoration of hand/arm function (Anderson, 2004). Thus, outcome measures that assess both proximal and distal forelimb function are needed. Although there are several behavioral assays that are sensitive to different aspects of forelimb recovery in experimental models of cervical SCI (Girgis et al., 2007, Gensel et al., 2006, Ballerman et al., 2001, Metz and Whishaw, 2000, Bertelli and Mira, 1993, Montoya et al., 1991, Whishaw and Pellis, 1990), few techniques provide detailed information on the recovery of fine motor control and digit movement.
The current measurement technique, the Irvine, Beatties and Bresnahan forelimb scale (IBB), can detect recovery of both proximal and distal forelimb function including digit movements during a naturally occurring behavior that does not require extensive training or deprivation to enhance motivation. The IBB was generated by observing recovery after a unilateral C6 SCI, and involves video recording of animals eating two differently shaped cereals (spherical and doughnut) of a consistent size. These videos were then used to assess features of forelimb use, such as joint position, object support, digit movement and grasping technique.
The IBB, like other forelimb behavioral tasks, shows a consistent pattern of recovery that is sensitive to injury severity. Furthermore, the IBB scale could be used to assess recovery following other types of injury that impact normal forelimb function.

A Novel Method for Assessing Proximal and Distal Forelimb Function in the Rat: the Irvine, Beatties and Bresnahan IBB Forelimb Scale

Here we will describe a rodent behavioral assay that can detect recovery of both proximal and distal forelimb function including digit movements during a naturally occurring behavior that does not require extensive training or deprivation to enhance motivation.

Several experimental models of cervical spinal cord injury (SCI) have been developed recently to assess the consequences of damage to this level of the ...

Neuroscience

A Simple Non-invasive Method for Temporary Knockdown of Upper Limb Proprioception

Proprioception may be the least well measured of all contributors to the neural control of movement. New precise, reliable measures of proprioception are needed for clinical diagnosis of impairment, and to measure outcomes of proprioceptive training. The purpose of this simple, non-invasive method is to temporarily knockdown upper limb proprioception in healthy adults, to an extent that would be useful in the development and testing of upper limb proprioception measures. Knockdown models have two main advantages over studying humans with impaired proprioception: participant availability and the ability to control the extent of impairment across participants. Current published methods of temporary proprioception knockdown of the upper limb, such as ischemic nerve blocks and cryotherapy, are invasive, impractical, or uncomfortable for the participant. Here, vibration over the ulnar groove was used to reduce upper limb proprioception. High frequency vibration may reduce proprioceptive acuity by inhibiting pacinian corpuscle-induced input. The effect of vibration used in this protocol was confirmed using two quantitative measures. This method was simple to administer, comfortable for participants, and practical.

The goal of this protocol is to demonstrate a practical method to temporarily interfere with proprioception in the upper limb of healthy humans.

Proprioception may be the least well measured of all contributors to the neural control of movement. New precise, reliable measures of proprioception are ...

Measurement of Dynamic Scapular Kinematics Using an Acromion Marker Cluster to Minimize Skin Movement Artifact

The measurement of dynamic scapular kinematics is complex due to the sliding nature of the scapula beneath the skin surface. The aim of the study was to clearly describe the acromion marker cluster (AMC) method of determining scapular kinematics when using a passive marker motion capture system, with consideration for the sources of error which could affect the validity and reliability of measurements. The AMC method involves placing a cluster of markers over the posterior acromion, and through calibration of anatomical landmarks with respect to the marker cluster it is possible to obtain valid measurements of scapular kinematics. The reliability of the method was examined between two days in a group of 15 healthy individuals (aged 19-38 years, eight males) as they performed arm elevation, to 120&#176;, and lowering in the frontal, scapular and sagittal planes. Results showed that between-day reliability was good for upward scapular rotation (Coefficient of Multiple Correlation; CMC = 0.92) and posterior tilt (CMC = 0.70) but fair for internal rotation (CMC = 0.53) during the arm elevation phase. The waveform error was lower for upward rotation (2.7&#176; to 4.4&#176;) and posterior tilt (1.3&#176; to 2.8&#176;), compared to internal rotation (5.4&#176; to 7.3&#176;). The reliability during the lowering phase was comparable to results observed during the elevation phase. If the protocol outlined in this study is adhered to, the AMC provides a reliable measurement of upward rotation and posterior tilt during the elevation and lowering phases of arm movement.

This report presents details of how to adopt the acromion marker cluster method of obtaining scapular kinematics when using a passive marker motion capture device. As has been described in the literature, this method provides a robust, non-invasive, three-dimensional, dynamic and valid measurement of scapular kinematics, minimizing skin movement artifact.

The measurement of dynamic scapular kinematics is complex due to the sliding nature of the scapula beneath the skin surface. The aim of the study was to ...

Medicine

Integrating VR and Biosensors for Quantitative Motion-Muscle Activity Assessment

Setup for the Quantitative Assessment of Motion and Muscle Activity During a Virtual Modified Box and Block Test

The ability to move allows us to interact with the world. When this ability is impaired, it can significantly reduce one's quality of life and independence and may lead to complications. The importance of remote patient evaluation and rehabilitation has recently grown due to limited access to in-person services. For example, the COVID-19 pandemic unexpectedly resulted in strict regulations, reducing access to non-emergent healthcare services. Additionally, remote care offers an opportunity to address healthcare disparities in rural, underserved, and low-income areas where access to services remains limited. 
Improving accessibility through remote care options would limit the number of hospital or specialist visits and render routine care more affordable. Finally, the use of readily available commercial consumer electronics for at-home care can enhance patient outcomes due to improved quantitative observation of symptoms, treatment efficacy, and therapy dosage. While remote care is a promising means to address these issues, there is a crucial need to quantitatively characterize motor impairment for such applications. The following protocol seeks to address this knowledge gap to enable clinicians and researchers to obtain high-resolution data on complex movement and underlying muscle activity. The ultimate goal is to develop a protocol for remote administration of functional clinical tests. 
Here, participants were instructed to perform a medically-inspired Box and Block task (BBT), which is frequently used to assess hand function. This task requires subjects to transport standardized cubes between two compartments separated by a barrier. We implemented a modified BBT in virtual reality to demonstrate the potential of developing remote assessment protocols. Muscle activation was captured for each subject using surface electromyography. This protocol allowed for the acquisition of high-quality data to better characterize movement impairment in a detailed and quantitative manner. Ultimately, these data have the potential to be used to develop protocols for virtual rehabilitation and remote patient monitoring.

Author Spotlight: Enhancing Remote Rehabilitation with Virtual Reality and Electromyography

The protocol described here aims to enhance the quantitative evaluation of upper limb deficits, with the goal of developing additional technology for remote assessment both in the clinic and at home. Virtual reality and biosensor technologies are combined with standard clinical techniques to provide insights into the functioning of the neuromuscular system.

The ability to move allows us to interact with the world. When this ability is impaired, it can significantly reduce one's quality of life and ...

Engineering

Isokinetic Robotic Device to Improve Test-Retest and Inter-Rater Reliability for Stretch Reflex Measurements in Stroke Patients with Spasticity

Measuring spasticity is important in treatment planning and determining efficacy after treatment. However, the current tool used in clinical settings has been shown to be limited in inter-rater reliability. One factor in this poor inter-rater reliability is the variability of passive motion while measuring the angle of catch (AoC) measurements. Therefore, an isokinetic device has been proposed to standardize the manual joint motion; however, the benefits of isokinetic motion for AoC measurements has not been tested in a standardized manner. This protocol investigates whether isokinetic motion itself can improve inter-rater reliability for AoC measurements. For this purpose, a robotic isokinetic device was developed that is combined with surface electromyography (EMG). Two conditions, manual and isokinetic motions, are compared with the standardized method to measure the angle and subjective feeling of catch. It is shown that in 17 stroke patients with mild elbow flexor spasticity, isokinetic motion improved the intraclass correlation coefficient (ICC) for inter-rater reliability of AoC measurements to 0.890 [95% confidence interval (CI): 0.685&#8211;0.961] by the EMG criteria, and 0.931 (95% CI: 0.791&#8211;0.978) by the torque criteria, from 0.788 (95% CI: 0.493&#8211;0.920) by manual motion. In conclusion, isokinetic motion itself can improve inter-rater reliability of AoC measurements in stroke patients with mild spasticity. Given that this system may provide greater standardized angle measurements and catch of feeling, it may be a good option for the evaluation of spasticity in a clinical setting.

Using a robotic isokinetic device with electromyography (EMG) measurements, this protocol illustrates that isokinetic motion itself can improve inter-rater reliability for the angle of catch measurements in stroke patients with mild elbow flexor spasticity.

Measuring spasticity is important in treatment planning and determining efficacy after treatment. However, the current tool used in clinical settings has ...

Bioengineering

Biplanar Videoradiography to Study the Wrist and Distal Radioulnar Joints

Accurate measurement of skeletal kinematics in vivo is essential for understanding normal joint function, the influence of pathology, disease progression, and the effects of treatments. Measurement systems that use skin surface markers to infer skeletal motion have provided important insight into normal and pathological kinematics, however, accurate arthrokinematics cannot be attained using these systems, especially during dynamic activities. In the past two decades, biplanar videoradiography (BVR) systems have enabled many researchers to directly study the skeletal kinematics of the joints during activities of daily living. To implement BVR systems for the distal upper extremity, videoradiographs of the distal radius and the hand are acquired from two calibrated X-ray sources while a subject performs a designated task. Three-dimensional (3D) rigid-body positions are computed from the videoradiographs via a best-fit registrations of 3D model projections onto&#160;to each BVR view. The 3D models are density-based image volumes of the specific bone derived from independently acquired computed-tomography data. Utilizing graphics processor units and high-performance computing systems, this model-based tracking approach is shown to be fast and accurate in evaluating the wrist and distal radioulnar joint biomechanics. In this study, we first summarized the previous studies that have established the submillimeter and subdegree agreement of BVR with an in vitro&#160;optical motion capture system in evaluating the wrist and distal radioulnar joint kinematics. Furthermore, we used BVR to compute the center of rotation behavior of the wrist joint, to evaluate the articulation pattern of the components of the implant upon one another, and to assess the dynamic change of ulnar variance during pronosupination of the forearm. In the future, carpal bones may be captured in greater detail with the addition of flat panel X-ray detectors, more X-ray sources (i.e., multiplanar videoradiography), or advanced computer vision algorithms.

Biplanar videoradiography (BVR) is an advanced imaging technique for understanding the three-dimensional movement of skeletal bones and implants. Combining density-based image volumes and videoradiographs of the distal upper extremity, BVR is used to study the in vivo motion of the wrist and distal radioulnar joint, as well as joint arthroplasties.

Accurate measurement of skeletal kinematics in vivo is essential for understanding normal joint function, the influence of pathology, disease progression, ...

Measuring 3D In-vivo Shoulder Kinematics using Biplanar Videoradiography

The shoulder is one of the human body's most complex joint systems, with motion occurring through the coordinated actions of four individual joints, multiple ligaments, and approximately 20 muscles. Unfortunately, shoulder pathologies (e.g., rotator cuff tears, joint dislocations, arthritis) are common, resulting in substantial pain, disability, and decreased quality of life. The specific etiology for many of these pathologic conditions is not fully understood, but it is generally accepted that shoulder pathology is often associated with altered joint motion. Unfortunately, measuring shoulder motion with the necessary level of accuracy to investigate motion-based hypotheses is not trivial. However, radiographic-based motion measurement techniques have provided the advancement necessary to investigate motion-based hypotheses and provide a mechanistic understanding of shoulder function. Thus, the purpose of this article is to describe the approaches for measuring shoulder motion using a custom biplanar videoradiography system. The specific objectives of this article are to describe the protocols to acquire biplanar videoradiographic images of the shoulder complex, acquire CT scans, develop 3D bone models, locate anatomical landmarks, track the position and orientation of the humerus, scapula, and torso from the biplanar radiographic images, and calculate the kinematic outcome measures. In addition, the article will describe special considerations unique to the shoulder when measuring joint kinematics using this approach.

Biplane videoradiography can quantify shoulder kinematics with a high degree of accuracy. The protocol described herein was specifically designed to track the scapula, humerus, and the ribs during planar humeral elevation, and outlines the procedures for data collection, processing, and analysis. Unique considerations for data collection are also described.

The shoulder is one of the human body's most complex joint systems, with motion occurring through the coordinated actions of four individual joints, ...

Screening of Axonal Degeneration in Carpal Tunnel Syndrome Using Ultrasonography and Nerve Conduction Studies

Axonal degeneration, indicative of surgical decompression, may coexist in carpal tunnel syndrome (CTS) as the disease progresses. However, the current diagnostic and severity gradation system cannot clearly indicate its coexistence, resulting in&#160;confusion of appropriate treatment prescription. There are also constraints in conventional methods for&#160;differentiation as well. This study aims at introducing an innovative, efficient, and quick screening protocol to differentiate axonal degeneration associated with CTS, using ultrasound and nerve conduction studies (NCS). It starts by using NCS to perform orthodromic stimulation at the wrist, to obtain the sensory conduction of the median and the ulnar nerves respectively. Meanwhile, the motor conduction&#160;of the median nerve is collected by stimulating the palm, wrist, and elbow, followed by the stimulation of the ulnar nerve at the wrist,&#160;below and above the elbow. Then, an ultrasound assessment is performed, using a linear array transducer, with cross-sectional area (CSA) and perimeter (P) at the wrist and at the one-third distal forearm calipered. Ratios (R-CSA, R-P) and changes from wrist to one-third distal forearm (&#916;CSA and &#916;P) are calculated according to a standard format. Potential axonal degeneration coexisting in CTS will be screened according to the criteria of NCS and cut-off values of ultrasound measurements established in a previous study. In terms of its noninvasiveness, low cost, convenience, and efficiency, it is easy to apply ultrasound complimentarily in clinical practice to prescreen patients with potential coexisting axonal degeneration. Nevertheless, the ultrasonographic imaging cannot directly reflect axonal degeneration. It still relies on conventional but invasive methods&#160;such as electromyography (EMG) and biopsy&#160;for confirmation if needed.

Here we present a protocol using nerve conduction studies and ultrasound to screen potential axonal degeneration associated with carpal tunnel syndrome. The criteria for differentiation are established. Compared to conventional approaches, this method is noninvasive, convenient, and efficient, with an overall satisfactory accuracy, sensitivity, and specificity.

Axonal degeneration, indicative of surgical decompression, may coexist in carpal tunnel syndrome (CTS) as the disease progresses. However, the current ...

Neuromuscular Ultrasound of the Median Nerve at the Carpal Tunnel

The use of neuromuscular ultrasound greatly enhances the evaluation of carpal tunnel syndrome as an adjunct diagnostic tool as it provides dynamic and structural information about the median nerve and its surrounding anatomy.&#8239;Neuromuscular ultrasound aids in diagnostic accuracy (when used with electrodiagnostic testing) and offers etiologic information as a non-invasive, painless, cost-effective, and radiation-free imaging technology that can be easily carried out at the bedside for immediate interpretation. Neuromuscular ultrasound has the limitation of subjectivity, and the need for training and experience will affect the interpretation of results. This article describes a basic practical guide to visualizing the median nerve using neuromuscular ultrasound in a step-by-step manner to aid in the evaluation of carpal tunnel syndrome. Even though the use of ultrasound in the assessment of median nerve entrapment has been long established, there has been no recognized standard protocol. The present protocol aims to provide clear and concise instructions to describe a standard technique to visualize the median nerve through diagnostic ultrasound.

The present protocol describes a technique for the standardization of median nerve ultrasound in cases of suspected carpal tunnel syndrome.

The use of neuromuscular ultrasound greatly enhances the evaluation of carpal tunnel syndrome as an adjunct diagnostic tool as it provides dynamic and ...

Ultrasound Scanning Protocol in the Assessment of Ulnar Neuropathy at the Elbow

Ulnar neuropathy at the elbow is commonly encountered in clinical practice and is the second most common entrapment neuropathy. Left untreated, ulnar neuropathy at the elbow can result in significant disability due to loss of dexterity and grip strength secondary to the weakness of intrinsic hand muscles. Precisely localizing a lesion in ulnar neuropathy can be challenging with electrodiagnostic testing alone. Ultrasound is a relatively quick and useful adjunctive diagnostic modality in overcoming this limitation, as an increase in the cross-sectional area (CSA) of the nerve is a common and validated finding in ulnar neuropathies at the elbow. Sonographic assessment of the nerve's echotexture and vascularity can provide additional diagnostic clues. Ultrasound also offers the unique benefit of detecting ulnar nerve subluxation or dislocation out of the retroepicondylar groove during dynamic assessment, although the clinical significance of this is controversial. Finally, ultrasound can also identify structural abnormalities leading to nerve compressions, such as the presence of bony abnormalities, scar tissue, and space-occupying lesions. These findings may influence management strategies and surgical planning. This protocol aims to illustrate the technique of static and dynamic sonographic imaging of the ulnar nerve around the elbow as a complement to electrodiagnostic testing in the assessment of ulnar neuropathy at the elbow.

This is a standardized protocol for evaluating the ulnar nerve at the elbow using ultrasound.

Ulnar neuropathy at the elbow is commonly encountered in clinical practice and is the second most common entrapment neuropathy. Left untreated, ulnar ...