Background
Framework
Body functions | ||||||
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Sections of the review | Range of motion | Muscle strength | Proprioception | Joint torque coupling/synergies | Joint impedance | Walking function/Gait pattern |
ICF chapters | b710 | b730 | b260 | b760 | b735, b7500, b7650 | b770, d450 |
Mobility of joint functions | Muscle power functions | Proprioceptive functions | Control of voluntary movement functions | Muscle tone functions, Stretch motor reflex, Involuntary contractions of muscles | Gait pattern functions, walking |
Assessments validation – psychometric properties
Property | Definition | Measure |
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Reliability | Consistency of the results obtained on repeated administrations of the same test by the same person (intra-rater or test-retest) or by different people (inter-rater). | ICC: based on ANOVA statistics: between-subjects var/(between-subjects var + error), six different computational methods are possible; 0 ≤ ICC ≤ 1, unitless [212, 213]. Acceptance levels for ICC depends on the application. However, a general classification of reliability has been proposed [214]: 0.00 ≤ ICC ≤ 0.10 – virtually none; 0.11 ≤ ICC ≤ 0.40 – slight; 0.41 ≤ ICC ≤ 0.60 – fair; 0.61 ≤ ICC ≤ 0.80 – moderate; 0.81 ≤ ICC ≤ 1.0 – substantial.
\( SEM=SD\sqrt{1-ICC} \) (SD of the scores from all subjects). SEM has the same unit of the measured variable [18]. Bland-Altman plots: mean of two measures vs their difference. LOA = ±1.96∙SD [17] Cohen’s Kappa k: percent agreement among raters corrected for chance agreement [215]. |
Validity | Extent to which the instrument measures what it intends to measure. Concurrent validity: degree to which the measure correlates with a gold standard. Construct validity: ability of a test to measure the underlying concept of interest. | Correlation-based methods: Pearson (r) or Spearman (ρ) correlation coefficient, ICC [216]. For continuous measures of the same data type (e.g. two methods for measuring gait speed): Root Mean Square Error (RMSE) or Bland-Altman plots against gold standard. |
Responsiveness | Ability to accurately detect changes. Internal responsiveness: ability of a measure to change over a particular specified time frame. External responsiveness: extent to which changes in a measure over a specified time frame relate to corresponding changes in a gold standard [217] Minimal Detectable Change (MDC): minimal amount of change that is not likely to be due to random variation in measurement [218]. Minimal clinically important difference (MCID): smallest amount of change in an outcome that might be considered important by the patient or clinician [22]. Floor and ceiling effects: the extent to which scores cluster at the bottom or top, respectively, of the scale range. | Internal responsiveness: Cohen’s effect size: observed change in score divided by the SD of baseline score. Standardized response mean (SRM): observed change score divided by SD of change score in the group. External responsiveness: ROC curves: sensitivity vs specificity based on an external criterion [217] \( \mathrm{M}\mathrm{D}\mathrm{C} = \mathrm{S}\mathrm{E}\mathrm{M} \times 1.96 \times \sqrt{2} \) [18] MCID: anchor-based (compare a change score with external measure of clinically relevant change) or distribution-based methods (based on statistical characteristics of the sample) [218]. Floor and ceiling effects: percentage of the number of scores clustered at bottom/top. |
Overview of clinical assessments and robotic measures of lower limb functions
Measure | Instrument/test | Properties | Study | |||
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Validity | Inter-rater reliability | Intra-rater reliability | Responsiveness | |||
pROM | Universal goniometer | Knee angle : ICC ≥ 0.98 [219] | Ankle DF: 0.26 ≤ ICC ≤ 0.87 [32] Ankle PF: ICC = 0.74 [32] | Knee flex: 0.97 ≤ ICC ≥ 0.99 Knee ext: 0.91 ≤ ICC ≥ 0.98 Hip sagittal angle: 0.51 ≤ ICC ≥ 0.54, SEM = 4° [224] Ankle DF: 0.72 ≤ ICC ≥ 0.89 [34] | - | |
aROM | Universal goniometer | Knee flex: r ≥ 0.975 Knee ext: r ≥ 0.390 | Knee flex: ICC ≥ 0.977 Knee ext: ICC ≥ 0.893 | Knee flex: ICC = 0.997 Knee ext: ICC ≥ 0.972 | - | [29] |
End-feel | Manual examination | - | Hip flex: 0.21 ≤ k ≤ 0.41 Hip ext: k = − 0.13 Knee flex: − 0.01 ≤ k ≤ 0.31 Knee ext: 0.25 ≤ k ≤ 0.43 | Knee flex: k = 0.76 Knee ext: k = 1.00 | - | |
Muscle strength | MMT | Knee flex (vs isokinetic dynamometer): ρ = 0.74 Knee ext: r = 0.70 [11] | Lower extremities: 0.66 ≤ ICC ≤ 1 [226] MRC score: 0.62 ≤ ICC ≤ 0.88 [227] | Lower extremities: 0.77 ≤ ρ ≤ 0.99 [228] | External resp.: Sensitivity: 60.9 % to 70.3 % [77] | |
HHD | Knee ext: 0.43 ≤ r ≤ 0.99 Knee flex: 0.83 ≤ ICC ≤ 0.85 Ankle PF: r = 0.93 Ankle DF: r = 0.60 [79] | Knee flex: ICC = 0.95 Knee ext: ICC = 0.88 Ankle DF: ICC = 0.69 [78] | Hip: ICC = 0.82 (belt), ICC = 0.80 (therapist) [229] Knee flex: ICC = 0.97 Knee ext: ICC = 0.93 Ankle DF: ICC = 0.91 [78] | 95 % CI = 32.5 N (72 %) 95 % CI = 57.1 N (79 %) [229] | ||
Proprioception | Romberg test | - | - | - | - | |
Toe-test | - | - | - | - | ||
Joint impedance | MAS | vs ankle measurement device: r = 0.09 vs H-reflex: r = 0.47 vs Pendulum test: r = − 0.69 | 0.16 ≤ k ≤ 0.61 Ankle PF: r = 0.727 | 0.4 ≤ ICC ≤ 0.75 | - | [230] |
Pendulum test | vs MAS: − 0.63 ≤ ρ ≤ −0.89 | - | 0.651 ≤ ICC ≤ 0.844 | - | [153] | |
Walking function/Gait pattern | WISCI II | Construct validity: vs TUG: r = −0.76 vs 10MWT: r = −0.68 vs 6MWT: r = 0.60 | 0.98 ≤ ICC ≤ 1 | ICC = 1 | MDC: 1 level Effect size 2.05, moderate change – discrimination between 1 and 3 months post injury Effect size 0.73, small change – discrimination between 3 and 6 months post injury | [230] |
10MWT | vs TUG: ρ = 0.89 vs 6MWT: ρ = − 0.95 vs WISCI II: ρ = 0.795 |
r = 0.97 LOA = ± 7.0 s |
r = 0.98 LOA = ± 6.0 s | Effect size: 0.92 - discrimination between 1 and 3 months post injury Effect size: 0.47 - discrimination between 3 and 6 months post injury |
Measure | Instrument | Properties | Study and population tested | |||
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Validity | Inter-rater reliability | Intra-rater reliability | Responsiveness | |||
pROM | Lokomat | - | - | - | - | - |
Isokinetic dynamometer (Biodex System 3 Pro dynamometer - Biodex Medical Systems Inc., Shirley, NY, USA) | - | Ankle DF: ICC ≥ 0.938 SEM = 1.4° | Ankle DF: ICC ≥ 0.930 SEM = 0.8° | MDC = 2.2°-3.3° | [34], 15 stroke patients | |
Manual spasticity evaluator | - |
ρ = 0.95 | ICC = 0.86 | - | [45], 12 children with CP, 5 able-bodied (AB) adults | |
Anklebot | Mean absolute error over two planes ≤1° | - | - | - | [49], validation vs electrogoniometer using a mock-up foot | |
Ankle assessment device | - | - | Ankle DF: ICC = 0.846 Ankle PF: ICC = 0.958 | Ankle DF: MDC = 3.27° Ankle PF: MDC = 3.81° | [232], 9 AB subjects | |
aROM | - | - | - | - | - | No studies found |
Muscle strength | Isokinetic dynamometer (Biodex System 3) | - | - | Isometric peak torque control subjects: ICC ≥ 0.92; SEM ≤ 25.1 Nm Peak torque patients, contralesional limb ICC ≥ 0.86, SEM ≤ 23.9 Nm | - | [90], 17 subjects with stroke, 13 AB subjects |
Lokomat, isometric test | - | Hip: ICC ≥ 0.87, SEM ≤ 11.2 Nm; Knee: ICC ≥ 0.85, SEM ≤ 7.9 Nm. | Hip: ICC ≥ 0.79, SEM ≤ 10.5 Nm; Knee: ICC ≥ 0.84, SEM ≤ 8.2 Nm. | - | [10], 14 subjects with neurological movement disorders, 16 AB subjects | |
Ankle assessment device | - | - | Ankle DF: ICC = 0.949 Ankle PF: ICC = 0.858 | Ankle DF: MDC = 1.69 Nm Ankle PF: MDC = 1.68 Nm | [232], 9 AB subjects | |
Proprioception | Modified Biodex chair, TTDPM test | - | - | Knee frontal plane: ICC ≥ 0.40 | - | [104], 17 AB subjects |
Chair with knee actuator, TTDPM test | - | OA: ICC = 0.91, SEM = 2.13°, AB: ICC = 0.89, SEM = 0.43° | OA: ICC = 0.91, SEM = 2.26°, AB: ICC = 0.86, SEM = 0.39° | - | [113] 24 subjects with OA, 26 AB subjects | |
Lokomat, JPR test | vs clinical score: Hip: ρ = 0.507, Knee: ρ = 0.790 | - | SCI, Hip: ICC = 0.55, Knee: ICC = 0.882 AB, Hip: ICC = 0.493, Knee: ICC = 0.656 | - | [106], 23 SCI and 23 AB subjects | |
Lokomat, TTDPM test | vs manual kinesthesia assessment: left hip, r = −0.71; left knee, r = −0.86; right hip, r = −0.47; right knee, r = −0.57 | - | AB, hip: ICC = 0.88 left, ICC = 0.94 right; knee ICC = 0.90 left, ICC = 0.91 right. SCI, hip: ICC = 0.97 left, ICC = 0.96 right; knee: ICC = 0.95 left, ICC = 0.96 right | - | [114], 17 SCI and 17 AB subjects Manual kinesthesia assessment: 1 point for each correct movement detection | |
Abnormal joint synergies | - | - | - | - | - | No studies found |
Passive ankle stiffness | Manual spasticity evaluator | - | Ankle DF 4°: r = 0.81 | Ankle DF 4°: ICC = 0.82 | - | [45], 12 children with CP |
Ankle perturbator | Repeated testing of known static torque: ICC = 0.994 | ICC = 0.767-0.943 | - | - | [233], 10 AB subjects | |
Ankle assessment device | - | - | Ankle DF 20°: ICC = 0.863 Ankle DF 30°: ICC = 0.865 | Ankle DF 20°: MDC = 0.0686 Nm/° Ankle DF 30°: MDC = 0.1323 Nm/° | [232], 9 AB subjects | |
Active ankle stiffness | Ankle perturbator | - | - | r > 0.8 | - | [164], 11 AB subjects |
Ankle perturbator | - | Between-trial: ICC = 0.76–0.99 and between-day: ICC = 0.64–0.95 | - | - | [165], 38 children with CP and 35 AB subjects | |
Walking function/Gait pattern | Exosuit: strain sensors | Mean absolute error ≤ 8° | - | - | - | [61], 1 AB subject |
Soft ankle orthosis: strain sensors, IMUs | Mean error strain sensor: 0.255 ± 1.63° Mean error IMUs: 0.135 ± 2.85° | - | - | - | [204], 1 AB subject |