Aviva L. Wolff

Accuracy and Reliability of Three Different Techniques for Manual Goniometry for Wrist Motion: A Cadaveric Study

PURPOSE Despite the ubiquitous use of manual goniometry in measuring objective outcomes of hand surgery and therapy, there are limited data concerning its accuracy or repeatability for wrist motion. The purpose of this study was to evaluate the accuracy and reliability (both inter- and intra-rater) in measuring wrist flexion and extension using 3 manual goniometric alignment techniques (ulnar, radial, and dorsal-volar) in cadaveric upper extremities, using fluoroscopic verification of posture as a gold standard. In addition, we sought to assess the accuracy and reliability of the dorsal-volar technique for measurement of radioulnar deviation. METHODS External fixators were applied to 10 cadaveric wrists with intramedullary cannulated rods in the radius and third metacarpal for gold-standard fluoroscopic verification of posture. Manual goniometric measurements with each technique were captured by 2 raters (a hand surgeon and a hand therapist) for reliability measurements and by a single rater for accuracy. Wrists were positioned at angles of maximum flexion, extension, and radial and ulnar deviation for reliability testing and at preselected angles across the range of motion for accuracy testing. At each position, wrist angle was measured with a 1 degrees increment goniometer, and fluoroscopic angles were measured digitally. Intraclass correlation coefficients and root mean square values were calculated for all combinations, and analysis of variance was used to test differences between techniques. RESULTS No technique was statistically less accurate than any other (6 degrees to 7 degrees ). Each method was found to have high intra-rater reliability. For measurement of wrist flexion and extension, the dorsal-volar technique demonstrated the greatest inter-rater reliability, as compared to ulnar and radial, respectively. CONCLUSIONS Although each measurement technique demonstrated a similar degree of accuracy and intra-rater reliability, the dorsal-volar technique demonstrates the greatest level of inter-rater reliability for measurement of wrist flexion and extension. This information is important clinically, as measurements are regularly exchanged between hand surgeons and therapists as a basis for decisions regarding patient care.

Wrist kinematic coupling and performance during functional tasks: effects of constrained motion.

PURPOSE To quantify the coupled motion of the wrist during selected functional tasks and to determine the effects of constraining this coupled motion using a radial-ulnar deviation blocking splint on performance of these tasks. METHODS Ten healthy, right-handed men performed 15 trials during selected functional tasks with and without a splint, blocking radial and ulnar deviation. The following tasks were performed: dart throwing, hammering, basketball free-throw, overhand baseball and football throwing, clubbing, and pouring. Kinematic coupling parameters (coupling, kinematic path length, flexion-extension range of motion, radial-ulnar deviation range of motion, flexion-extension offset, and radial-ulnar deviation offset) and performance were determined for each functional task. A generalized estimation equation model was used to determine whether each kinematic coupling parameter was significantly different across tasks. A repeated-measures generalized estimation equation model was used to test for differences in performance and kinematic coupling parameters between the free and splinted conditions. RESULTS Wrist motion exhibited linear coupling between flexion-extension and radial-ulnar deviation, demonstrated by R(2) values from 0.70 to 0.99. Average wrist coupling and kinematic path lengths were significantly different among tasks. Coupling means and kinematic path lengths were different between free and splinted conditions across all tasks other than pouring. Performance was different between wrist conditions for dart throwing, hammering, basketball shooting, and pouring. CONCLUSIONS Wrist kinematic coupling parameters are task specific in healthy individuals. Functional performance is decreased when wrist coupling is constrained by an external splint. CLINICAL RELEVANCE Surgical procedures that restrict wrist coupling may have a detrimental effect on functional performance as defined in the study. Patients may benefit from surgical reconstructive procedures and wrist rehabilitation protocols designed to restore kinematic coupling.

Functional kinematics of the wrist

The purpose of this article is to review past and present concepts concerning functional kinematics of the healthy and injured wrist. To provide a context for students of the wrist, we describe the progression of techniques for measuring carpal kinematics over the past century and discuss how this has influenced today’s understanding of functional kinematics. Next, we provide an overview of recent developments and highlight the clinical relevance of these findings. We use these findings and recent evidence that supports the importance of coupled motion in early rehabilitation of radiocarpal injuries to develop the argument that coupled motion during functional activities is a clinically relevant outcome; therefore, clinicians should develop a framework for its dynamic assessment. This should enable a tailored and individualized approach to the treatment of carpal injuries.

Surgical Treatments for Scapholunate Advanced Collapse Wrist: Kinematics and Functional Performance

PURPOSE The purpose of this investigation was to compare kinematic motion and functional performance during 2 tasks in patients following 4-corner fusion (4CF) or proximal row carpectomy (PRC) and to compare these data with those from healthy asymptomatic individuals. METHODS Twenty men (10 4CFs and 10 PRCs, ages, 43-82 y) were recruited for 3-dimensional wrist motion analysis testing. Kinematic coupling (the ratio of wrist flexion/extension to radial-ulnar deviation), kinematic path length (a measure of total angle distance), clinical measures, and performance measures were collected during 2 tasks: dart throwing and hammering. For each outcome, between-group comparisons employed a 1-way analysis of variance with post hoc analysis using the Fisher least significant difference test. RESULTS All clinical measures (flexion-extension, radial-ulnar deviation, and grip strength) were decreased for 4CF and PRC patients compared with healthy subjects. Coupling, kinematic path length, and performance were all significantly reduced in 4CF and PRC patients compared with healthy subjects during both tasks. Reduced coupling and a shorter kinematic path length are indicative of less global and combined wrist motion. There were no differences identified in coupling patterns or performance between the surgical groups for the dart-throwing task. However, in hammering, the kinematic path length and performance (time and total strikes) were worse in 4CF than in PRC. CONCLUSIONS Differences in wrist kinematics and performance were identified between the groups. PRC subjects performed better on kinematic and performance variables. As expected, both groups demonstrated decreased wrist kinematic motion and functional performance compared with individuals with normal wrists. These results require confirmation and while they cannot be used to determine the benefits of one procedure over the other, they are an important step in quantifying differences in motion and function between procedures. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic II.

Development of an anatomical wrist joint coordinate system to quantify motion during functional tasks

The purpose of this study was to develop a three-dimensional (3D) motion analysis based anatomical wrist joint coordinate system for measurement of in-vivo wrist kinematics. The convergent validity and reliability of the 3D motion analysis implementation was quantified and compared with manual and electrogoniometry techniques on 10 cadaveric specimens. Fluoroscopic measurements were used as the reference. The 3D motion analysis measurements (mean absolute difference [MAD] = 3.6°) were significantly less different (P < .005) than manual goniometry (MAD = 5.7°) but not (P = .066, power = 0.45) electrogoniometry (MAD = 5.0°) compared with fluoroscopy. The intraclass correlation coefficient (ICC[2,1]) was highest for 3D motion analysis compared with manual and electrogoniometry, suggesting better reliability for this technique. To demonstrate the utility of this new wrist joint coordinate system, normative data from 10 healthy subjects was obtained while throwing a dart.

The effect of simulated elbow contracture on temporal and distance gait parameters

BACKGROUND Elbow contractures can be functionally debilitating. Extensive research has been published on treatments to restore elbow motion, but few have discussed clinical implications beyond the affected extremity. Reciprocal arm swing in normal gait has been shown to increase stability and reduce energy expenditure. The importance of arm swing has been clinically demonstrated in patients with cerebral palsy, stroke and Parkinsons disease. We hypothesized that elbow contractures would result in an abnormal spatio-temporal gait parameters. METHODS Forty volunteer subjects walked on the Gaitmat II which provided real-time analysis of temporal and distance gait parameters. Five conditions were tested: no brace (control 1), elbow brace unlocked (control 2) and brace locked in 30°, 90° or 120° flexion (simulating fixed elbow contractures). Condition order was randomized for each subject. Each condition consisted of five walking trials. RESULTS All three fixed elbow conditions (120°, 90° and 30°) demonstrated significantly decreased gait velocity (1.37, 1.39 and 1.39m/s) and stride length (1.45, 1.46 and 1.46m) compared to the control condition (1.42m/s and 1.48m, respectively). Single limb stance and double support times were decreased and increased, respectively, compared to control. There was no significant difference in cadence or limb asymmetry in the three fixed elbow conditions. CONCLUSIONS Despite well-established functional limitations in elbow contracture patients and importance of arm swing in normal gait, the impact of elbow contractures on gait is unknown. This study demonstrates that simulated elbow contracture results in significant differences in spatio-temporal gait parameters suggesting that elbow contractures have a broader functional impact beyond the affected extremity. LEVEL OF EVIDENCE II.

Rehabilitation for scapholunate injury: Application of scientific and clinical evidence to practice

In this article, the development of a rehabilitation approach is describe using scapholunate injury as a model. We demonstrate how scientific and clinical evidence is applied to a treatment paradigm and modified based on emerging evidence. Role of the scapholunate interosseous ligament within the pathomechanics of the carpus, along with the progression of pathology, and specific rehabilitation algorithms tailored to the stage of injury. We review the recent and current evidence on the kinematics of wrist motion during functional activity, role of the muscles in providing dynamic stability of the carpus, and basic science of proprioception. Key relevant findings in each of these inter-related areas are highlighted to demonstrate how together they form the basis for current wrist rehabilitation. Finally, we make recommendations for future research to further test the efficacy of these approaches in improving functional outcomes.

Anatomical and biomechanical framework for shoulder arthroplasty rehabilitation

ABSTRACT This article provides an anatomical and biomechanical framework for the postoperative management and progression of treatment for shoulder arthroplasty. The clinical relevance of normal shoulder anatomy, biomechanics, and pathomechanics related to this surgery is emphasized to provide the reader with an understanding of the rationale for treatment. We review the rehabilitation implications of surgical indications and technique for both traditional total shoulder arthroplasty and reverse total shoulder arthroplasty procedures with an emphasis on biomechanical considerations. Relevant factors that affect rehabilitation outcomes are discussed along with supporting evidence from the literature. Principles to guide and progress treatment are highlighted with a discussion on return to sports with the ultimate objective of providing a comprehensive approach for successful rehabilitation.

AN EXTENSION TO THE ISB WRIST JOINT COORDINATE SYSTEM: AN IN VITRO ACCURACY STUDY

INTRODUCTION Investigators have used a variety of marker sets and methods to describe upper extremity kinematics. However, without a standard set of anatomical and joint coordinate system definitions for 3-D motion analysis (3DMA), data sets cannot be compared between investigators. In an effort to summarize the descriptions of upper extremity motion, Wu and colleagues [1] published a set of joint coordinate system recommendations. This proposed kinematic solution is an extension from that standard. The purpose of this investigation is to develop an anatomically based wrist joint coordinate system (WJCS) and appropriate tracking frames. To test this new WJCS a comparison between the 3-D motion analysis (3DMA) implementation, manual goniometry (MG), and electro-goniometry (EG) was performed. We hypothesize that 3DMA would provide increased accuracy over the other methods.

Clinical relevance commentary in response to: Force transmission through the wrist during performance of push-ups on a hyperextended and a neutral wrist

Patients recovering from wrist injury commonly express the desire to return to activities that require loading the wrist in extension, such as push-ups, planks, and various yoga and pilates positions.1-3 These activities are fundamental to many fitness programs and have become a goal for many people undergoing rehabilitation. Furthermore, dorsal wrist pain with extended loading during these activities is a common complaint among individuals seeking treatment and has been found to be linked to an increased prevalence of pathology on magnetic resonance imaging.1 In extreme situations, weight-bearing on the wrist due to excessive push-ups or intensive gymnastics can lead to stress fractures in the ulna and other acute wrist injuries.4,5 The authors address these issues in a biomechanical study designed to determine the effect of wrist position on force transmission across the wrist joint during wrist weight-bearing activity. Using standard motion capture methods, they studied force transmission across the wrist during a typical push-up with the wrist extended and a modified push-up with the fist closed and wrist in neutral. The specific question addressed in this study is as follows: Are there differences in force transmission across the wrist joint between push-ups performed in the standard wrist extended position compared with a modified wrist neutral position?