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Clinimetric properties of hip abduction strength measurements obtained using a handheld PDF

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Preview Clinimetric properties of hip abduction strength measurements obtained using a handheld

RESEARCHARTICLE Clinimetric properties of hip abduction strength measurements obtained using a handheld dynamometer in individuals with a lower extremity amputation RuudA.Leijendekkers1*,GerbenvanHinte1,AmyD.Sman1,J.BartStaal2,3,MariaW. G.Nijhuis-vanderSanden1,2,4,ThomasJ.Hoogeboom2 1 DepartmentofOrthopaedics,PhysicalTherapy,RadboudUniversityMedicalCentre,Nijmegen,the Netherlands,2 RadboudInstituteforHealthSciences,IQHealthcare,RadboudUniversityMedicalCentre, a1111111111 Nijmegen,theNetherlands,3 ResearchgroupMusculoskeletalRehabilitation,HANUniversityofApplied a1111111111 Sciences,Nijmegen,theNetherlands,4 DepartmentofRehabilitation,RadboudUniversityMedicalCentre, a1111111111 Nijmegen,theNetherlands a1111111111 *[email protected] a1111111111 Abstract OPENACCESS Introduction Citation:LeijendekkersRA,HinteGv,SmanAD, StaalJB,Nijhuis-vanderSandenMWG, Suitablehandhelddynamometer(HHD)-techniquestotesthipabductionstrengthinindivid- HoogeboomTJ(2017)Clinimetricpropertiesofhip ualswithalowerextremityamputation,irrespectiveoftheiramputationlevelareabsent. abductionstrengthmeasurementsobtainedusing TheaimofthisstudywastooptimiseaHHD-techniqueandtotestitsreproducibilityand ahandhelddynamometerinindividualswitha lowerextremityamputation.PLoSONE12(6): validity. e0179887.https://doi.org/10.1371/journal. pone.0179887 Methods Editor:HagenAndruszkow,Universitatsklinikum Thisstudyinvolvedthreephases,inwhichtwotechniqueswereevaluated.BothHHD-tech- Aachen,GERMANY niquesusedalever-armof22centimetre.HHD-technique1usedabreak-technique.After Received:February1,2017 obtainingwithin-sessiontest-retestreproducibility(phase1)weoptimisedtheHHD-tech- Accepted:June6,2017 niquebyaddingafixation-beltandusingamake-technique(HHD-technique2).Wetested thewithin-sessiontest-retestandinter-raterreproducibility(phase2)andthevalidity(phase Published:June22,2017 3)ofHHD-technique2usinganisokineticdynamometer.Newcohortsofparticipantswere Copyright:©2017Leijendekkersetal.Thisisan recruitedforeachphase. openaccessarticledistributedunderthetermsof theCreativeCommonsAttributionLicense,which permitsunrestricteduse,distribution,and Results reproductioninanymedium,providedtheoriginal Phase1:wetestedHHD-technique1in26participantswithalowerextremityamputation.It authorandsourcearecredited. wastest-retestreproducible(ICC3.1 :0.80–0.92,standarderrorofmeasurement DataAvailabilityStatement:Allrelevantdataare agreement (SEM):3.1–4.4Nmandsmallestdetectablechange(SDC):8.6–12.3Nm).Therewere withinthepaperanditsSupportingInformation files. questionsregardingthevalidityofthemeasurement,becausethemeanmuscletorqueof theresiduallimbandsoundlimbweresimilar,whichisuncommon.Phase2:reproducibility Funding:Theauthor(s)receivednospecific fundingforthiswork. ofHHD-technique2wastestedin44participantswithalowerextremityamputation.Itwas test-retestreproducible(ICC3.1 :0.96–0.97,SEM:3.9–4.7NmandSDC:10.9–12.9 Competinginterests:Theauthorshavedeclared agreement thatnocompetinginterestsexist. Nm)butnotinter-raterreproducibledespitehavinggoodreliability(ICC3.1 :0.92, agreement PLOSONE|https://doi.org/10.1371/journal.pone.0179887 June22,2017 1/19 Hipabductionstrengthmeasurementtechnique SEM:6.9–7.6NmandSDC:19.2–21.2Nm).Systematicbiasandbiasrelatedtothemagni- tudeofthemuscletorquewassuspected.Phase3:theconcurrentvaliditywasestablished in30healthyparticipants(r=0.84).Systematicbiasinmeasurementerrorwaspresent, includingaconsistentoverestimationofthemuscletorqueof28%usingtheHHD. Conclusion HHD-technique2isatest-retestreproducibleandvalidmeasuringtechniqueThetechnique maybefurtheroptimisedbytheuseofanexternaldevicetostabilisetheHHD. Introduction Lowerextremitymusclestrengthtrainingisanimportantelementofrehabilitationpro- grammesforindividualswithalowerextremityamputation[1–6].Theimportanceissup- portedbythefollowingfindings:1)strengthofthemusclesofthehipjointintheresiduallimb isdecreasedupto35%relativetohealthysubjectsandupto28%comparedtothesoundlimb [7,8];2)muscleatrophyoftheresiduallimbispresentupto73%comparedtothesoundlimb [9];3)decreasedandasymmetricmusclestrengthisassociatedwithlowergaitspeedandan asymmetricgaitpattern[10–13]4)decreasedstrengthofthemusclesofthehipjointisassoci- atedwithloweractivitylevels[7].Reliable,validandresponsivemeasurementinstrumentsare neededtomeasuremusclestrength.Thisisimportanttobeabletodeterminetheintensityof strengthtrainingandtoevaluatetheeffectivenessofarehabilitationprogramme. Inscientificresearchvariousinstrumentsareusedtoevaluatelowerextremitymuscle strengthinindividualswithalowerextremityamputation,suchasisokineticdynamometers [4,7,8,14],anOpticalTestingofIsometricMoments(OpTIMo)device[13],10-repetitionmax- imumtestsonresistancemachines[1]andhandhelddynamometers(HHD)[3,15].Fordaily clinicalpracticeameasurementhastobelowincost,non-time-consuming,portableandeasy touse,whichisonlythecaseforHHDmeasurements[16].Clinimetricpropertiesformuscle strengthmeasurementobtainedwithaHHDaremainlyestablishedinable-bodiedpersons, butarelackingforindividualswithalowerextremityamputation[16]. VariousmeasurementtechniquestoevaluatehipabductionstrengthusingaHHDare describedinthecurrentliterature[17–27].Noneofthesemeasurementtechniquesissuitable forindividualswithatransfemoralamputationbecauseofthepositioningoftheHHDinrela- tiontotheabsenceofakneeoranklejoint.Themainvariationsinexecutionarecharacterised by:1)theparticipants’position(side-lyingorsupineposition),2)thepositionoftheHHD (slightlyproximaltotheedgeofthelateralfemoralcondyleorthelateralmalleolus,respec- tively),3)theuseofadditionalfixation-belts,4)thetypeofresistancetechniqueused(‘break- technique’or‘make-technique’),5)theuseofadditionalportabledevicestostabilisetheHHD [17–27]. Theaimofthiscross-sectionalstudywastooptimiseahipabductionstrengthmeasurement techniqueforindividualswithalowerextremityamputation,irrespectiveoftheirlevelof amputation,andtotestitsreproducibilityandvalidity.TheoptimisationoftheHHDmeasure- menttechniqueinthisstudyinvolvedthreephases(Fig1),inwhichtwotechniqueswereeval- uated.InbothHHD-techniquesthemusclestrengthoftheparticipantwasassessedinsupine position,agravityneutralisedposition[22],topreventmeasurementbiasduetoweightdiffer- encesbetweentheresiduallimbandsoundlimb.Additionally,measurementvariationis reducedbytestinginasupinepositioncomparedtotestinginaside-lyingposition[24].A PLOSONE|https://doi.org/10.1371/journal.pone.0179887 June22,2017 2/19 Hipabductionstrengthmeasurementtechnique Fig1.Flowchartstudy. https://doi.org/10.1371/journal.pone.0179887.g001 newcohortofparticipantswasrecruitedforeachphaseofthestudy(Fig1).TheCOSMIN Checklistwasfollowedforthepreparationofthemanuscript[28]. Phase1:Test-retestreproducibilityofHHD-technique1 Methods Theaimofthisphasewastodeterminethewithin-sessiontest-retestreproducibilityofHHD- technique1;abreak-techniquewithouttheuseofanadditionalfixation-beltorportabledevice tostabilisetheHHD.Wechosenottouseanyadditionaltoolsinordertomakethetestas practicalaspossibleandtoimproveeasyimplementationindailyclinicalpractice. Participants. Allconsecutiveindividualswithin3months,withalowerextremityampu- tationwhofollowedarehabilitationprograminourcentreorhadaregularfollow-upwereeli- gibleforthestudy(Fig1).Awritteninformedconsentwasobtainedfromallparticipantsprior totheassessment.ThestudywasconductedaccordingtotheprinciplesoftheDeclarationof Helsinki(64thversion,19-10-2013).Theprotocolofthisphaseofthisstudy(registration PLOSONE|https://doi.org/10.1371/journal.pone.0179887 June22,2017 3/19 Hipabductionstrengthmeasurementtechnique number2012/547)wasapprovedbytheEthicsCommitteesoftheRadbouduniversitymedical centre.TheindividualdisplayedinFig2hasgivenwritteninformedconsent(asoutlinedin PLOSconsentform)topublishthisimage. Studyprocedure. Thetest-retestmusclestrengthassessmentwasperformedbyaphysio- therapystudent(RvE)followingtrainingfromanexperiencedphysiotherapist(RL).Apilot wasperformedwherethreeindividualsweretestedusingthemeasurementtechniqueto ensurestandardisationoftheprocedure.Both,thetestandretestassessmentwereperformed consecutivelyinonesessiononthesameday.Bothassessmentsstartedwithmusclestrength testingoftheleftlimbfollowedbytherightlimb.Theparticipantswereofferedsufficienttime (atleast1minute)torestbeforethemusclestrengthtestofeachlimbandbetweentheassess- ments.Themusclestrengthvaluewasnotvisiblefortheraterduringthetestasthescreenof theHHDwaspositioneddownwards(Fig2A),todecreasethechanceofmeasurementbias. Testingprocedure. Participantswerepositionedinsupinepositiononatreatmenttable, whichwascoveredwithanadditionalanti-slipmattopreventsliding(Fig2A).Thepartici- pantsheldtheirarmsbytheirchestandthelowerlimbswereinneutralposition(limbsshoul- der-widthapart).Theraterplacedamarkingontheskintoindicatethepointwheretheforce wouldbeapplied.Thismarkwasusedforboththetestandthere-test.Thepointwasmarked 20centimetre(cm)distalofthemostprominentaspectofthegreatertrochanter.Whenpartic- ipantshadashorterresiduallimb,thelever-armwasadjustedandnoted.Musclestrengthwas obtainedinNewton(N)usingthebreak-techniquewithaportableHHD(MicroFET2TM, HogganScientificLLC.,SaltLakeCity,Utah,UnitedStates)includinga4cmwidetransducer pad.Inthisprocedure,theraterappliedaresistancethatwassufficienttocounteracttheforce generatedbytheparticipant,afterwhichtheratergraduallyovercametheparticipants’force andstoppedthemomentthelimbgaveway.Thelever-armtothecentreofthepad(22cm) wasusedtocalculatethehipabductiontorquevalueinNewtonmetre(Nm). Followingawarming-upofonesubmaximalcontraction,allparticipantsperformedthree maximalcontractionsfor3to5secondswitha1-minuterestintervalforeachlimb[22,24]. Thehighestscoreofthethreemaximalcontractionswasusedforanalysis[24].Duringall strengthmeasurements,verbalencouragementwasgiven[22]. Statisticalanalysis. Participantcharacteristicsincludingsex,age,levelofamputationand thelengthoftheresiduallimbweredescribed[29].Theresiduallimblength(cm)wasmea- suredfromcrotchtothemostdistalendoftheresiduallimb.Thetorquevalues(Nm)werecal- culatedforboththeresiduallimbandthesoundlimb.Thedifferenceinmuscletorque(Nm) betweenthetestandtheretestwascalculated.Categoricaldatawerepresentedasexactnum- bersandpercentageswerecalculatedforthevariouslevels.Forthecontinuousdata,means andstandarddeviationswerecalculated. Reproducibility(test-retest)wasdividedinreliabilityandagreementparameters[30]. Reliabilitywastestedusingtheintraclasscorrelationcoefficient(ICC).ICC’swerecalculated usingatwo-waymixedeffectmodel(ICC3.1 ).with95%confidenceintervals(CI).The agreement InterpretationofICCvalueswasbasedonguidelinesofferedbyByrt[31]:0.01–0.20poorreli- ability,0.21–0.51slightreliability,0.41–0.60fairreliability,0.61–0.80goodreliability,0.81– 0.92verygoodreliability,and0.93–1.00excellentreliability.Standarderrorofmeasurement (SEM )andthesmallestdetectablechange(SDC )werecalculatedtoassess agreement agreement agreement.Bothareexpressedintheunitofthemeasurement(Nm).TheSEMwascalculated p p asSEM = σ2 = (σ2 +σ2 )[32].Thevarianceduetosystematicdifferences agreement error o residual betweentheobservers(σ2 )andtheresidualvariance(σ2 )wereobtainedfromthevar- o residual p companalysis[32].TheSEM wasusedtocalculatetheSDC =1.96(cid:3) n(cid:3) agreement agreement SEM[30].Inthisformula‘n’referstothenumberofmeasurements,whichistwoinourstudy [30].Additionally,theSEM%andSDC%werecalculatedasoutcomesindependentofthe PLOSONE|https://doi.org/10.1371/journal.pone.0179887 June22,2017 4/19 Hipabductionstrengthmeasurementtechnique Fig2.Assessmentset-up.A:Handhelddynamometer-technique1;B:Handhelddynamometer-technique2, indefaultsupineposition. https://doi.org/10.1371/journal.pone.0179887.g002 unitofmeasurement.TheSEM%andSDC%werecalculatedbydividingtheSEMandthe SDC,respectively,bytheaveragetorquevalueofthetestandtheretestandthenmultiplying PLOSONE|https://doi.org/10.1371/journal.pone.0179887 June22,2017 5/19 Hipabductionstrengthmeasurementtechnique Table1. Participantcharacteristics. Participantcharacteristics Phase1 Phase2 Phase3 HHD-technique1 HHD-technique2 Groupa Groupb n=26 n=44 n=30 n=7 Sex(male),n(%) 20 (77) 28 (64) 18 (60) 4 (57) Age(yrs),mean(SD) 51.7 (15.0) 53.9 (12.7) 33.1 (15.6) 22.0 (1.9) Amputationlevel -Transfemoralamputation,n(%) 18 (69) 35 (80) NA NA Lengthresiduallimb(cm),mean(SD) 21.4 (3.7) 21.1 (4.4) NA NA -Throughkneeamputation,n(%) 1 (4) 1 (2) NA NA -Transtibialamputation,n(%) 7 (27) 7 (16) NA NA -Footamputation,n(%) NA 1 (2) NA NA HHD:handhelddynamometer;Yrs:Years;cm:Centimetre;SD:Standarddeviation https://doi.org/10.1371/journal.pone.0179887.t001 by100[21,23].ABland-Altmanplotwasconstructedtodetermineiftherewasbiasinmea- surementerror[33,34].Thisplotshowstheraterdifferenceagainstthemeanmuscletorque. Theplotvisualisestherelationshipbetweenthemeasurementerrorandtheobservedvalue includingthepresenceofsystematicbiasandbiasrelatedtothemagnitudeofhipabduction strength[34].The95%limitsofagreement(95%LoA)wereshownintheplot(meandiffer- ence±1.96SDofthedifference).AllanalyseswereperformedusingIBMSPSSStatisticsv22 (SPSSInc.,Chicago,Illinois,UnitedStates).Inallcases,twosidedp-values<0.05wereconsid- eredtobestatisticallysignificant. Results Weincluded26participants(20men)withalowerextremityamputation(Table1).The meanageofthisgroupwas52years(range:24–80years).Wedidnothavetoadjustthede- faultlever-armof22cminanyoftheincludedparticipants(n=18)withatransfemoral amputation. Thetest-retestreproducibilityofHHD-technique1issummarisedinTable2.Wefound fairtoverygoodreliability(ICC3.1 :0.80,95%CI:0.58–0.91)fortheresiduallimband agreement verygoodtoexcellentreliability(ICC3.1 :0.92,95%CI:0.83–0.97)forthesoundlimb. agreement TheSEMwas5.4Nmand3.1NmandtheSDCwas15.1Nmand8.6Nmintheresiduallimb Table2. Phase1:Test-retestreproducibilityHHD-technique1. Testedlimb Test(Nm) Retest Difftest-retest 95%LoA ICC3.1 (95% SEM SEM% SDC SDC% agreement agreement (Nm) (Nm) (Nm) CI) agreement mean mean(SD) mean(SD) (Nm) (Nm) (SD) Residuallimb 57.5 60.8(12.9) -3.3(7.1) -17.2;10.6 0.80(0.58–0.91)* 5.4 7.4 15.1 25.5 (n=26) (11.0) Soundlimb 56.5 58.0(11.0) -1.4(4.2) -9.6;6.8 0.92(0.83–0.97)* 3.1 5.4 8.6 15.0 (n=26) (11.0) HHD:handhelddynamometer;Nm:Newtonmetre;SD:Standarddeviation;Diff:Difference;LoA:limitsofagreement;ICC:Intraclasscorrelationcoefficient; CI:Confidenceinterval;SEM:Standarderrorofmeasurement;SDC:Smallestdetectablechange %:Percentage *:p<0.001 https://doi.org/10.1371/journal.pone.0179887.t002 PLOSONE|https://doi.org/10.1371/journal.pone.0179887 June22,2017 6/19 Hipabductionstrengthmeasurementtechnique Fig3.Bland–Altmanplotsforwithin-raterdifferencesandtheirrelationtothemagnitudeofhip abductionstrengthmeasuredwithHHD-technique1.Nm:Newtonmetre;Thesolidlinerepresentsthe meandifference(systematicbias)andthedashedlinesillustratethe95%limitsofagreement(mean difference±1.96SDofthedifference). https://doi.org/10.1371/journal.pone.0179887.g003 andthesoundlimb,respectively.TheSEM%was9.1%and5.4%andtheSDC%was25.5% and15.0%intheresiduallimbandthesoundlimb,respectively.The95%LoAwas-17.2to 10.6Nmand-9.6to6.8Nmfortheresiduallimbandthesoundlimb,respectively(Table2 andFig3). Interpretationoftheresults. ThereproducibilityofHHD-technique1seemedgoodand nowithin-raterbiaswaspresent,buttheresultsquestionedtheinternalvalidityofthemea- surement.Themeanhipabductiontorqueoftheresiduallimbandsoundlimbwerealmost similar(Table2),whichdidnotcorrespondentwithourobservationsduringwalking.Further- more,theseresultswereunexpectedasnopreviousresearchreportedonthese[7,8].Inthe residuallimb,Ryseretal.[8]foundadeficitof28%inthehipabductormuscletorqueand Kowaletal.[7]foundadeficitof15%inthehipextensormuscletorquecomparedtothe soundlimb.Weidentifiedtwopossibleconfounderswhichcouldhaveinfluencedthevalidity: 1)inconsistentparticipants’fixationonthetablebecauseofdifferencesbetweenparticipants’ capacitytofixatethemselvesonthetablewitharesiduallimborasoundlimb,and2)therela- tivehighmusclestrengthvaluesduetotheuseoftheshort-lever-arm(22cm)andthebreak- technique[20].Highmusclestrengthvaluescanalsoinfluencetheparticipants’fixationonthe tableandmayhaveledtobiasedresultsbecausethestrengthoftheraterwillmorelikelyinflu- encetheoutcome[35].Becauseofthesefindingsandpossibleconfoundersweadjustedthe HHD-techniqueforthenextphase,resultinginHHD-technique2. Phase2:Test-retestandinter-raterreproducibilityofHHD- technique2 Methods Theaimofthisphaseofthestudywastodeterminethewithin-sessiontest-retestandinter- raterreproducibilityofHHD-technique2.WiththisHHD-techniquewestrivedtogather internallyvalidoutcomesbydecreasingthetorquevaluesandincreasingtheparticipants’fixa- tiononthetable(Fig2B).Therefore,wechangedtotheuseofamake-techniqueandtheuseof additionalfixation-belt.Apotentialadvantageofusingthemake-techniqueisthatitreduces theinfluenceofthestrengthoftheraterontheoutcomes,whereasabreak-techniqueproduces highertorquevalues[36,37]. PLOSONE|https://doi.org/10.1371/journal.pone.0179887 June22,2017 7/19 Hipabductionstrengthmeasurementtechnique Participants. Allconsecutiveindividualswithin30months,withalowerextremityampu- tationwhowereinvitedforapre-operativeassessmentforabone-anchoredprosthesis betweenMay2014andOctober2016wereeligibleforthispartofthestudy(Fig1)[38].Awrit- teninformedconsentwasobtainedfromallparticipantspriortotheassessment.Thestudy wasconductedaccordingtotheprinciplesoftheDeclarationofHelsinki(64thversion,19-10- 2013).Theprotocolofthisphaseofthisstudy(registrationnumber2014/196)wasapproved bytheEthicsCommitteesoftheRadbouduniversitymedicalcentre. Studyprocedure. First,thetest-retestassessmentswereperformedbythefirstauthor (RL).Second,anexperiencedcolleague(GvH)performedanadditionalassessmenttotestthe inter-raterreproducibility.Allassessmentswereperformedconsecutivelyinonesessionon thesameday.Allassessmentsstartedwithmusclestrengthtestingoftheleftlimbfollowedby therightlimb.Theparticipantswereofferedsufficienttime(atleast1minute)torestbefore themusclestrengthtestofeachlimbandbetweentheassessments.Themusclestrengthvalue wasnotvisiblefortheratersduringthetestasthescreenoftheHHDwaspositioneddown- wards(Fig2B),todecreasethechanceofmeasurementbias. Testingprocedure. ThetestingprocedureofHHD-technique2wassimilartoHHD-tech- nique1,withtheexceptionofthefollowing:1)amake-techniquewasusedand2)anaddi- tionalfixation-beltatthelevelofthepelvistofixatetheparticipantonthetablewasusedto preventsliding(Fig2B).ThiskindoffixationhaspreviouslybeendescribedbyPuaetal.[22]. Themake-techniqueinvolvedaresistance,appliedbytherater,thatwassufficienttocounter- acttheforcegeneratedbytheparticipant.Theparticipantwasinstructedtograduallyincrease theforceaimingatamaximalcontractionafter3to5seconds. Statisticalanalysis. Participantcharacteristicswerecalculatedandpresentedinthesame wayasdescribedinphase1ofthestudy.Thetorquevalues(Nm)ofboththeresiduallimband thesoundlimbwerecalculated.Thedifferenceinmuscletorque(Nm)withinthetest-retest andwithintheinter-raterassessmentwascalculated.ICC’swerecalculatedusingatwo-way mixedeffectsmodel(ICC3.1 )with95%CIforthetest-retestreliabilityandusinga agreement two-wayrandomeffectsmodel(ICC2.1 )fortheinter-raterreliability[32,34].The agreement sameparametersofagreementcalculateinphase1(SEM ,SDC ,SEM%and agreement agreement SDC%)werecalculatedinthisphase,forboththetest-retestandtheinter-raterreproducibil- ity.Thepresenceofbiasinmeasurementerrorwasassessedusingthe95%LoA.Allanalyses wereperformedusingIBMSPSSStatisticsv22(SPSSInc.,Chicago,Illinois,UnitedStates).In allcases,twosidedp-values<0.05wereconsideredtobestatisticallysignificant. Results Weincluded44participants(28men)withalowerextremityamputation(Table1).Themean ageofthisgroupwas54years(range:27–78years).In3outof35participantswithatransfe- moralamputationwehadtoadjustthedefaultlever-armfrom22cmto18cm. Thetest-retestreproducibilityofHHD-technique2issummarisedinTable3.Thetest- retestreliabilitywasexcellentforboththeresiduallimb(ICC3.1 :0.96,95%CI:0.93– agreement 0.98)andthesoundlimb(ICC3.1 :0.97,95%CI:0.94–0.99).TheSEMwas4.7Nmand agreement 3.9NmandtheSDCwas12.9Nmand10.9Nmintheresiduallimbandthesoundlimb, respectively.TheSEM%was8.3%and5.7%andtheSDC%was22.7%and16.0%intheresid- uallimbandthesoundlimb,respectively.The95%LoAwas-14.1to10.9Nmand-12.4to7.6 Nmfortheresiduallimbandthesoundlimb,respectively(Table3andFig4). Theinter-raterreproducibilityofHHD-technique2issummarisedinTable4.Theinter- raterreliabilitywasfairtoexcellentfortheresiduallimb(ICC2.1 :0.92,95%CI:0.59– agreement 0.97)andverygoodtoexcellentforthesoundlimb(ICC2.1 :0.92,95%CI:0.84–0.96). agreement PLOSONE|https://doi.org/10.1371/journal.pone.0179887 June22,2017 8/19 Hipabductionstrengthmeasurementtechnique Table3. Phase2:Test-retestreproducibilityHHD-technique2. Testedlimb Test(Nm) Retest Difftest-retest 95%LoA ICC3.1 (95% SEM SEM% SDC SDC% agreement agreement (Nm) (Nm) (Nm) CI) agreement mean mean(SD) mean(SD) (Nm) (Nm) (SD) Residuallimb 56.1 57.8(23.3) -1.6(6.4) -14.1;10.9 0.96(0.93–0.98)* 4.7 8.3 12.9 22.7 (n=44) (22.9) Soundlimb 67.0 69.4(24.6) -2.4(5.1) -12.4;7.6 0.97(0.94–0.99)* 3.9 5.7 10.9 16.0 (n=44) (24.5) HHD:handhelddynamometer;Nm:Newtonmetre;SD:Standarddeviation;Diff:Difference;LoA:limitsofagreement;ICC:Intraclasscorrelationcoefficient; CI:Confidenceinterval;SEM:Standarderrorofmeasurement;SDC:Smallestdetectablechange %:Percentage *:p<0.001 https://doi.org/10.1371/journal.pone.0179887.t003 TheSEMwas6.9Nmand7.6NmandtheSDCwas19.2Nmand21.2Nmintheresiduallimb andthesoundlimb,respectively.TheSEM%was11.6%and11.0%andtheSDC%was32.8% and30.8%intheresiduallimbandthesoundlimb,respectively.The95%LoAwas-20.9to7.3 Nmand-23.9to16.5Nmfortheresiduallimbandthesoundlimb,respectively(Table4and Fig4). Themeasurementsofbothrater1asrater2identifiedanasymmetryinmuscletorque betweenthetwolimbs.Themuscletorqueoftheresiduallimbwas11to16%lowerthanthe muscletorqueofthesoundlimb. Interpretationoftheresults. Thetest-retestreproducibilityofHHD-technique2was good.Thereliabilityhadincreased(ICC3.1 :0.96–0.97versusICC3.1 :0.80– agreement agreement 0.92)andtheSEMwassimilar(3.9–4.7Nmversus3.1–5.4Nm),comparedtoHHD-technique 1(Tables2and3).TheSDCoftheresiduallimbwasbetter(12.9Nmversus15.1Nm)andthe SDCofthesoundlimbwasslightlyworse(10.9Nmversus8.6Nm),relativetoHHD-tech- nique1.Nowithin-raterbiaswasfound,butthereweresuspicionsforsystematicbiasandbias relatedtothemagnitudeofthemuscletorquewithintheinter-ratertest,inparticularforthe testoftheresiduallimb.Onaverage,thevaluesofthesecondraterwerehigherthanthose fromthefirstrater.Thedifferencebetweenratersincreasedwhenthesubjectsexhibitedlarger hipabductionstrength(Fig4). Wefoundamuscletorquedeficitupto16%intheresiduallimbcomparedtothesound limb.Thisisinlinewithpreviousresearch,wheredeficitsof15to28%aredescribed[7,8]. BasedontheseresultsweweremoreconfidentthattheinternalvalidityofHHD-technique2 wassuperiortoHHD-technique1.TotesttheinternalvalidityofHHD-technique2,phase3 ofthisstudywasconducted. Phase3:ConcurrentvalidityofHHD-technique2 Methods TheaimofthisphasewastodeterminetheconcurrentvalidityofHHD-technique2usingan isokineticdynamometer.IntheHHDassessmentthedefaultparticipants’positionwasa supineposition,agravityneutralisedposition[22],topreventmeasurementbiasduetodiffer- entweightoftheresiduallimbandsoundlimb.Thedefaultpositionforparticipantsduring theisokineticdynamometerassessmentwasaside-lyingposition.Thiscouldnotbechanged, thereforethisphaseofthestudyinvolvedtwoparts(Fig1):1)assessmentoftheconcurrent validityofHHD-technique2insupinepositionand2)assessmentofthehipabduction PLOSONE|https://doi.org/10.1371/journal.pone.0179887 June22,2017 9/19 Hipabductionstrengthmeasurementtechnique Fig4.Bland–Altmanplotsforwithin-raterandbetween-raterdifferencesandtheirrelationtothe magnitudeofhipabductionstrengthmeasuredwithHHD-technique2.Nm:Newtonmetre;Thesolidline representsthemeandifference(systematicbias)andthedashedlinesillustratethe95%limitsofagreement (meandifference±1.96SDofthedifference). https://doi.org/10.1371/journal.pone.0179887.g004 strengthusingHHD-technique2inside-lyingposition.Theaimofthesecondpartwastorule outbiasresultingfromoftheparticipants’positiononthetable. Participants. ThisphaseofthestudywasconductedattheHANUniversityofApplied Sciences.AllphysiotherapystudentsoftheHANandtheirrelativeswereeligibleforthispart ofthestudy.Theywererecruitedwithinatimeperiodofthreemonthsusingposters,leaflets andsocialmedia.Allincludedparticipantswereassessedinsupineposition(groupa). Table4. Phase2:Inter-raterreproducibilityHHD-technique2. Testedlimb Tester Tester2 Difftest-retest 95%LoA ICC2.1 (95% SEM SEM% SDC SDC% agreement agreement (Nm) (Nm) (Nm) (Nm) CI) agreement mean(SD) mean(SD) mean(SD) (Nm) (Nm) Residuallimb 56.1(22.9) 62.9(26.1) -6.8(7.2) -20.9;7.3 0.92(0.59–0.97)* 6.9 11.6 19.2 32.3 (n=44) Soundlimb 67.0(24.5) 70.7(27.9) -3.7(10.3) -23.9;16.5 0.92(0.84–0.96)* 7.6 11.0 21.2 30.8 (n=44) HHD:handhelddynamometer;Nm:Newtonmetre;SD:Standarddeviation;Diff:Difference;LoA:limitsofagreement;ICC:Intraclasscorrelationcoefficient; CI:Confidenceinterval;SEM:Standarderrorofmeasurement;SDC:Smallestdetectablechange %:Percentage *:p<0.001 https://doi.org/10.1371/journal.pone.0179887.t004 PLOSONE|https://doi.org/10.1371/journal.pone.0179887 June22,2017 10/19

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First, the test-retest assessments were performed by the first author. (RL). [17] found a Pearson's correlation stepwise approach to optimise the HHD-technique where the findings of the first step were . 2017; 27(FEB): 137–41. https://doi.org/10.1016/j.math.2016.07.010 PMID: 27476066. 20.
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