Elsevier

Manual Therapy

Volume 18, Issue 1, February 2013, Pages 26-34
Manual Therapy

Systematic review
Validity and reliability of palpation-digitization for non-invasive kinematic measurement – A systematic review

https://doi.org/10.1016/j.math.2012.06.004Get rights and content

Abstract

Joint kinematic assessment using an electromagnetic tracking device (EMTD) requires palpation-digitization (PD) of bony landmarks to define the anatomical axes. Errors in PD of bony landmarks can perturb the anatomical axes and affect the validity and reliability of kinematic measurements. The validity and reliability of PD for kinematic measurement needs to be explored before recommending its wider use. A systematic search of 15 electronic databases located studies assessing validity and/or reliability of PD for joint kinematic assessment. Two independent reviewers used the QUADAS and QAREL tools to assess quality of validity and reliability studies respectively. The results were synthesized qualitatively using a level of evidence approach. Eight studies satisfied the final eligibility criteria and were included in the review. The validity, intra-rater reliability and inter-rater reliability were assessed in three, seven and one study respectively. The overall level of evidence for validity of PD technique was strong with high correlation (≥0.80) reported by three high (≥60%) quality studies. The overall level of evidence for intra-rater reliability was also strong with very high ICC (≥0.90) and satisfactory SEM (SEM% ≤ 10%) reported by four high quality studies. However the level of evidence for inter-rater reliability was limited and needs to be addressed by future research.

Introduction

Evaluation of joint kinematics is essential to musculoskeletal assessment, helping clinicians determine baseline data, monitor progress and guide appropriate implementation of treatment strategies (Smith, 1982). While clinicians often use simple non-invasive devices such as goniometers or inclinometers to measure joint kinematics, these can only assess two-dimensional motion and have reduced accuracy in measuring motion outside the sagittal plane (Ordway et al., 1997; Nussbaumer et al., 2010). Thus, it would be advantageous to have a simple non-invasive device that allows accurate and reliable measurement of three-dimensional (3D) joint motion (An et al., 1988). Recently, electromagnetic tracking devices (EMTD) have become a popular tool for non-invasive clinical evaluation of 3D joint motion particularly in complex joints such as spine (Assink et al., 2008; Heneghan et al., 2009). The use of EMTD for joint kinematic assessment can be considered an important advancement that can have both research and clinical utility providing an ability to determine multiplanar joint kinematics and guiding appropriate implementation of treatment strategies (An et al., 1988; Bussey et al., 2004).

An EMTD uses a low frequency electromagnetic field generated by a transmitter to detect 3D position and orientation of sensors fixed to body segments (Pomianowski, 2001). The arbitrary axis of the system may be converted to a meaningful anatomical joint axis using palpation-digitization (PD) of anatomical bony landmarks (Pennock and Clark, 1990; Wu et al., 2005). The PD technique involves the tester palpating the most prominent part of a bony landmark followed by physically collecting the 3D co-ordinates of the bony landmark using an electromagnetic digitizing stylus (sensor embedded in a pen) (Bussey et al., 2004). The 3D co-ordinates of sensors and digitized bony landmarks relative to the source are obtained from electronic software connected to the EMTD system; and the relative 3D movement between distal and proximal body segments is then determined using these co-ordinates. The PD technique of EMTD has been used in both the clinical and research environment; however it can be affected by several sources of error.

Errors during a PD technique can arise from tester, subject, and procedure-related variability (Smidt et al., 1992). As bony landmarks are irregular structures (de Groot, 1997; Croce et al., 2005), the accurate and consistent palpation of bony landmarks is a primary concern while using this technique (Seffinger et al., 2004; Stochkendahl et al., 2006). Further, with some bony landmarks being more superficial than others the ability to accurately palpate may differ with anatomical location (Harlick et al., 2007). Inaccuracies in palpation of bony landmarks may result in digitization errors leading to misalignment of the anatomical axis system about which the movements are assumed to occur (e.g., the flexion-extension axis of a joint coordinate system should be aligned in the medio-lateral direction) (Piazza and Cavanagh, 2000). Errors in PD of bony landmarks can affect the validity and reliability of kinematic measurements leading to misinterpretation of results (de Groot, 1997; Meskers et al., 1998; France and Nester, 2001; Croce et al., 2005; Morton et al., 2007; Langenderfer et al., 2009; Moriguchi et al., 2009). Thus, the level of evidence for validity and reliability of PD techniques for joint kinematic measurements is essential for EMTD to produce clinically meaningful results, and needs to be established before recommending its wider use. Therefore, the purpose of this research is to systematically review the literature concerning the validity and reliability of PD technique of bony landmark identification for joints kinematic assessment using EMTD.

Section snippets

Search strategy

A systematic search strategy was conducted to locate studies assessing validity and/or reliability of PD for joint kinematic measurements using EMTD, in any sampled population. Three relevant subject areas; namely 1) EMTD, 2) validity and/or reliability, and 3) kinematic measurements; along with their related terms were used to perform the systematic search (Table 1). The databases were searched using combinations of keywords and specific subject headings. The Boolean operators “OR” and “AND”

Literature search

Fig. 1 displays the flow diagram, based on PRISMA guidelines (Liberati et al., 2009), of the flow of articles through the review process as approved by two reviewers. Of 2219 articles, only eight articles were identified as assessing validity (Sprigle et al., 2002), reliability (Culham and Peat, 1993; Gould, 2003; Ludewig et al., 2004; Laprade and Lee, 2005; Singh et al., 2010) or validity + reliability (Kulkarni-Lambore and Peat, 2000; Bussey et al., 2004).

Validity studies

The two reviewers initially disagreed

Summary of results

The results of this systematic review demonstrate overall strong evidence for high levels of validity of PD technique for assessment of pelvic, hip and metacarpo-phalangeal joint kinematics using EMTD. The mean difference between the reference standard and the index test was least for innominate ROM assessment (0.34° ± 0.52°) and highest for pelvic tilt assessment (8.00° ± 7.80°). These discrepancies can be partly attributed to the use of Polhemus™ EMTD, with higher static accuracy (0.76 mm),

Conclusions and future recommendations

The results of this systematic review demonstrate overall strong level of evidence for the validity and intra-rater reliability of PD of bony landmarks for joint kinematics assessment. A high level of validity and very high level of relative intra-rater reliability were demonstrated for most joint segments evaluated. The results of absolute intra-rater reliability statistics (SEM%) also demonstrated satisfactory results; however the sensitivity of these measurement errors on the outcome

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