Reliability and Sensitivity of Ankle Proprioceptive Measures

by Nadini Deshpande

A thesis subrnitted to the School of Rehabilitntion Thenpy

in conformity with the requirements for the degree of Master of Science

Queen's üniversity

Kingston, Ontario. Canada August, 2 0 1

Copyright 8 Nadioi DeshpÛnde. 2001

Acqkithras and

Bibiiogaphic SeMces

..-

et

mbgraphiques

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motisatin,

Purpose: Deteriomtion in proprioception is common in neurological disordea. following joint a u m r in degenentive conditions of the joints and with aging. Loss of proprioception is &O a conaibuting fxtor in impakd balance and increased number of f d s in older adults. The pnmary purpose of this study was to assess the diabihty and sensitivity of five mkle proprhceptive measures. The ankle joint was selected due to its important mie in postural control. Methodology: Eight heaithy subjects were recruited in each of the three groups. Group I were young adults aged 20 to 39 yem. group II were middle-aged adults aged 40 to 59 yem and group Ut were older adults aged 60 yem and over. The proprioceptive rneasuns were: 1. threshold for perception of passive movement performrd 3t 0.25°/sec: 2. error in active reproduction of joint position 3t S0 doaiflexion. F0 plmtaflexi~nand 10" planMexion: 3. enor in ~pmductionof self-selected slow

velocity through the range of 30" doniflexion to

plantarflexion; 4. e m r in

reproduction of lONm toque of the adde dorsiflexor and planttimexor muscles: and 5. stitbilogram diffusion ywlysis of center of pressure excursion in an anteroposterior direction. Resdts: The tests of threshold for perception of passive rnovement and reproduction of position. movement velocïty as wetI as toque demonstrated excenent test-retest reliability (ICCs = 0-95.0.83.0.79 and 0.93. respectively). Three parameters of stabilogram difision malysis demonstrated good to excellent ~ h b i f i t y(ICCs = 0.64 to 0.91) whereas the remaining three parameters demonstrated poor to fair rehabihty (ICCs = 0.13 to 0.59). Mesures of threshold for perception of passive rnovement and

reproduction of position were found to be sensitive to detect the differences between the groups (p = 0.0093 and 0.023. respectively). None of the other measures couid

discriminate the three groups. Conclosion: The test of threshold for perception of passive movement was Found to be the most sensitive to age-reiated deterioration in proprioception of the mesures tested. None of the six stabilograrn difision mdysis p m e t e r s or the tests of velocity reproduction and torque reproduction could detect differences in performance mong the three subject groups. Further refinement of these measures is required to obiain more sensitive proprioceptive measures. A high level of self-reported rictivity level in older adults may have attenuated detenoration of these aspects of proprioception suggesting an important role of activity.

Acknowledgements My sincere thuiks to. Dr Elsie Culham for your expertise and for

i wondefil

beginning thût gave me

confidence.

Dr Pat Costigm for your trust. friendship and your invaluable contribution. Dr Brenda Brouwer for your encouragement and support. Dr Denise Comelly and Dr Andrew Leger for the unobstructed use of your lab facilities.

Dr Kathleen Norman for your vaLuable input and for making my advisory cornmittee meetings such an enjoyable leaning experience. Prof Diana Hopkins-Rosseel and Prof Liz Tata. I h d a great time working with you.

di the participants for your time and willingness md Ma. Ella Brisson for the love and c m 1 received from you.

hy. Akshay and Misha for your unconditionai support.

Table of contents CHAPTER 1:INTRODUCTION 1.1 Introduction 1 3 Objectives

CHAPTER 2: LITERATURE REVlEW 2.1 Proprioception Receptm 2.1.1 Joint ceceptors 2.1.2 Musculotendinous receptors 2 2 Cutaneous Receptors

2 3 Proprioception Measurement 73.1 Thr;shold for perception of passive movement 2.3.2 Reproduction of joint position 1.3.2.1 Active to active reproduction of joint position 2 3 - 2 2 Passive to pssive reproduction of joint position 2.3.2.3 P s s i v e ta active reproduction of joint position 2.32.4 Visud mdog technique 2.3.3 Balance mesurement 2.4 Deterioration in Proprioception 2.4.1 Aging 2-42 Peripherai neuropathy 1.4.3Articular injury 2.4.4 Fatigue

CHAPTER 3: METHODOLOGY 3.1 Research Design

3 2 Sample 3.2. L Subject groups 3 .L?Exclusion criteria 3.23 Subject recmitrnent 3.2.4 Sample size caicuiation 3 3 Data CoUettioa

3.3- 1 Instrumentation 3.3.2 Outcome mesures 3.3.2.1 Threshold for perception of passive movement 3.3.2.2 Active to active reproduction ofjoint position 3.3.3.3 Reproduction of movement velocity 3.3.3.4 Reproduction of torque 3.3.3.5 Bdmce assessrnent 3.3.3.6 Timed ten meter gait speed

3 5 Data Management and Data Anaiysis

3.4 Assumptions and Limitations

CHAPTER 4: RESULTS 4.1 Sample 4 2 Reliability Results 4.2.1 Proprioceptive mesures 4-22Bdance mesures

CHAPTER 5: DISCUSSION 5.1 Sample

5 2 Reliablity 5.2.1 Roprioceptive meosures

5.2.2 Bdance measures 5 3 Sensitivity

5.3.1 Proprioceptive measuns 3.3.2 Balance meslsures SA General Characteristics of the Protocof

5.5 Fmction and Pmprioception

5.6 Conclusion

REFERENCES

APPENDIX I (Mini Mental State Examination) APPENDIX II (Sarnple Size Caiculation) APPENDIX II1 (Advertisement) APPENDIX IV (Consent Form) APPENDIX V (Brief Clinical Examination) APPENDIX VI (Data Summvy Sheets) APPENDIX VI1 (Scatter Plots) VITA

Figure 1

Position of the subject for the test of threshold for perception of passive movement

Figure 2

Position of the subject for reproduction of the joint position md velocity tests

Figure 3

Position of the subject for ~pI'0ductionof toque test

Figure 4

Quiet standing eyes closed position of the subject on an AMTt force plate

Figure 5

Scatter plot of threshold €or perception of passive movement on &y 1 and &y 2

Figure 6

Scatter plot of short tenn difision coefficient values on &y L and day

-?

Figure 7

Threshold for perception of passive movement

Figure 8

Absolute error in reproduction of joint position

Figure 9

Absolute error in movement velocity reproduction

Figure 10

Absolute error in toque reproduction

Figure 1 1

Shon term diffusion coefFicients

Figure 12

Long term diffusion coefficients

Figure 13

Short rem scaling exponents

Figure 14

Long term scding exponents

Figure 15

Critical time Intervais

Figure 16

A

b

Table 1

Subject Characteristics. Mean and siandard deviation (in puentheses)

p. 48

Table 2

Interday reliability of proprioceptive memures

p. 51

Table 3

Interday reliability of stabilogram diffusion maiysis parameters

p- 54

1.lIntroduction

Muscular activity and joint movement. performed either consciously or subconsciously. is the product of multisite sensory input which is received and pmessed by the brain and spinal cord (Lephart et al.. 1998). Sensory information conveys details

about Iimb and body movement. Force, pressure, tension and movement in sprice needed for precision of motor control (Schmidt. 1999). This depends upon the integntive evduation of afferent information h m somatosensory. visual and vestibular systems (Dirner and Dichgnas. 1988; Lephart et al.. 1998). &ch of the ihret sensory systems is specialized to work within r certain domain of fquency and amplitude and therefore is not entirely redundmt in this respect (Nahner. 1981). The somatosensory system cepresents cutaneous sensation and proprioception (Maki and M c h y . 1996). Proprioception cm be defined as the perception or awareness

of the change in the muscle length, muscle tension in addition to perception of joint position and motion ( k p h u t et d.. 1998). The receptors for this input are m e c h r e c e p t ~ r sthat are lowted in joint capsule joint ügynents within the b o x menisci and musculotendinous unit (Lephan et al.. 1998). PRsent methods of proprioception quantification predominantly involve measurement of threshold br perception of passive movement and active or passive reproduction of a joint position. Threshold for perception of passive movement is an established test for measurement of proprioception (Roberts et ai., 1999; Taimela et al.,

1999; McChesney and Woollacott, 2000). The Limb is placed in a supporthg device. ïhe joint is passively moved and the subject is asked to indicate when they perceive the movement. The movement is done very slowly (=ZDAt where 3- is a Eneu displacement in anteroposterior (y) or mediolated (x) direction or a pl-

(r) displacement. The difhsion coefficient is an

average measure of the stochastic activity of CoP (Collins and De Luca. 1993). Two distinct regions are identitied in a stabilogram diffusion plot, namely short ierm and long term regions. These two regions are separated by a c n t i d point at which the dope of the plot decreases considerably. Therefore, the criticai point is estimttted at

the intenection point of the suoight Liner fimd to the short tem and the Long term

regions of the plot. This yields separate coefficients for a short term (Ds) and a long term (Dl) regions. Physiologicaiiy. the coordinates of the critical point represent the spatial (Y coordinate) and temporai ( X coordinate) characteristics at which the postud conml mrchanism changes from an open Iwp conml system to a closed loop conml system and utilizes the sensory information to manipulate the muscle activation for postural maintenance (Coilins et al., 1995; Riley et ai.. 1998). A similv plot is obtained h m the log values of mean squued displacement (Y

auis) against the time interval At (X a~is). Short term scaling exponent (Us) and long terni scaling exponent (Hl) are calculated from the following equation. 70% MVC) are underestimated (Jones and Hunter, 1982). The MVC values of the thRe age groups in this study were significmtiy different for doniflexors as weU as plantufiexon (~=û.O02and 0.004,respectively). This resuited in vuiability in test toque when cdculated in terms of percent of

MVC. The test torque of 10 Nm was 27%. 3 7 6

and 498 of the average dorsiflexor muscle MVC for young, middle-oged and older adults, respectively. Similuly, it w u 13%, 19-4% and 22% of the average planuitamexor muscle MVC for young, middle-aged and older adults, respectively. Aithough no specific evidence could be cited for the d

e muscle toque ceplication, it is possible that uiis

vdability differentidly &ected the abiibility to sequentiaiiy match the test torque. The Iower MVC vaiues (therefore, the higher test toque in ternis of MVC percentage) of the older adults may have resulted in better ability to mtch the test toque as compareci to the young adults. thereby counterbalancing the age reIated deteciontion to some extent.

However. the use of individuaüzed test toque. depending on the MVC value, was not possible due to limitations in the visual display gradation of the equipment. 5.3.2 Balance measures

None of the six pumeters of the stabilognm diffusion maiysis was able to differentiate the three age groups suggesting that these panmeten were not sensitive to detenontion of CoP excursion in an anteroposterior direction nlated to normai aging. Collins et d. (1995) reported significant differences (p4.05) between 25 young adults

and 12 heaithy older duits for short terni and long term scaling exponent and criticai mean square displacement suggesting a higher positive correlation (higher tendency of CoP to drift away From the equilibrium) and lower negative correlation (higher tendency of CoP to retum to its equilibnum position) for CoP excursion in an anteroposterior direction in older adults as compmd to young adults.

It is

possible that the differences

observed in the outcome of the two studies were due to various factors. in this study. the mem ages of the young and the older group were 30.5 and 69.7 yem respectively as

opposed to 22 and 75 years in the study by Collins et ai. ( 1995). Collins et d. ( 1995) have not reponed the activity level of their hedthy elderly population. The self reponed

aetivity of the oldef pptttation OF this study was h i e r rhan thet of the y w n g and the middle-aged population of this study. This may have ûttenuated the age-related deterioration in their neummuscular responses, thereby reducing the effect size. Visuai input w u obstmcted in t h s study to eliminate its contribution in maintenance of quiet standing posture. Eyes closed stance in quiet standing posture is known to increase within

subiect vviability (Brouwer et ai., 1998). thereby M e r making it difficult to detect between group differences. 5.4 General Characteristics of the Protocol A comprehensive protocol for assessrnent of the Yikle joint pmpioception was

developed in this study. Some of the important characteristics of the protocol were as tollows: 1. The iesting procedure was developed to assess al1 the aspects of propriocepiion

including the perception of passive movement. static and dyn;imic aspects of the joint movement and perception of muscle force. in addition. CoP excursion in the anteroposterior direction during eves closed quiet stance was dso mdyzed. These measures may represent functional aspects of the pmpnoception.

1. The instructions given to the subjects were uncomplicated and easy to follow. None of the subjects rrquired more han one pmctice trial to understand the

procedure for any of the tests. 3. The results of the reliability assessrnent demonsmted that no testing effect was

involved as there was no consistent pattern for improvement across the subjects during testhtg on seeotidoccasion.

4. Most of the testing procedures were cornpleted in a functional position (standing

position) relevant to the adde joint

Some of the ümitritionsof the promcolwere as fdhws: 1. A self-selected velocity was used for the test of reproduction of velocity for

various cernons. However, the subjects may have selected the velocity that was very cornfortable to ihem thereby nuskingkducing the enor in its reproduction. 3. The use of a constant test toque. due to equipment limitation. may have

differentidly aected the ability to ceproduce the toque.

3. A high self-reported activity level of the older adults could be a confounding factor in this study. Future studies of adde propcioception should use a design that will control this factor by classitjing the older dults depending on their activity level.

Genenlinbiiity of the test protocol: 1. A high level of cognition (MMSE score c 29/30) was used as the cut-off level for

older adults for inclusion in the study. The subjects with the lower level of cognition may not be able to follow the necessûry instructions. 2. The test procedures required complete cwpention h m the p h c i p a ~ g

subjects: r Limitation experienced during any form of sensory assessment. 3. A total of one and haif hours was required for the complete testing procedure. As

most of the teshg was completed in a standing position, the protocol was experienced as 'physicaily demmding' by many of the subjects. Sunilarly, some conditions. not directly involving the ;inkle joint. were exclusion cntena as they might have p~ciudedthe subjectî fmm standing for the q u i r d time.

Timed ten meter gait speed is a valid tool used to Pssess the hnctionai status of older adults (Potter et d.. 1995). No significant differences were observed between the young, middle-aged and the older duits for timed ten meter cornfoctable gait speed in this study. This suggests that the quantiiy of deficit observed in ankle proprioception of older adults. using threshold for perception of passive movement. did not influence the abiiity to perform less demanding tasks. In addition, the results of balance assessrnent demonstnted no significant differences between the young, rniddk-aged and the older adults For anteroposterior CoP excursion. if the ability to maintain a quiet standing posture is considered as

;in

indicator of neummuscular function. the findings funher

support this interpretation. However. the subjects in this study were not tested for more demanding functions like perturbation to quiet standing posture or timed maximum gait speed. Further investigation in different populations. such as older adults with a fear of fdling, rnay yield a threshold value of this deficit that may contribute to deterioration of even simple functional tsks.

5.6 Conclusion Threshoid For perception of passive movement was found to be the most sensitive and diable method to detect age related deteriontion of proprioception at the adde joint.

These findings suggest

h t

the test of threshold for perception of passive movement

might be a sensitive measure for detection of early impairment in posttd control. This test therefore. may &O ûssist in d e r e c ~ gsubtie impairmenfs for early diagnosis and for monitoring prognosis of a cikase pmess.

The ability to perceive a static position that is held actively is probably influenced by regular physicd activity. This indicates the usefulness of this test for assessing the efficacy of various exercise programs used for proprioception reaining. This study was unique in three aspects. First. an anernpt was made to quanti@ the dynamic aspect of proprioception and its deterioration due to normd aging. Similady. the ability to perceive muscle force as well as the deteriontion of this ability. due to normal

aging. was assessed. The measures used in this study could not detect the differences between the three age groups suggesting the necessity for further refinement of these mesures. Assessrnent of these sispects of propnoception m y be of hnctiond importance. due to their role in protecave responses particularly dunng physically demanding situations. Therefore. Further investigation of these measures will be important primvily for detecting impairment in at-risk populations such as elderly fdlers or those older adults who feu of Cdiing.

The third distinct aspect of the study w u the inclusion of a healthy middle-aged population. Numerous resemh smdies. directed towards age related aitentions in the sensory Cunctions. pnmanly include only young and older populations. This hos resulted in a paucity of data for rniddle-aged population on various measures of proprioception and bdmce. The small sample size (n=8) of the middle-aged population in this study may lead to difficulty in generalitztion of the Euidings, however. the results suggest that it is worthwhile to establish a normative data by conducting snidies on a larger scaie.

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Quilliam TA and Eüdley A: The ceceptoc cornmuni& in the bger t i p 1Physi~L 216(C):15P-l7P. 1971 Richardson JK and Ashton-Miller J A: Perip h e d neuropathy:an Often-overlwked cause of falls in elderly. Postgrad Med 99(6): 161-72. 19% Riley MA. Bdasubramanim R. Mitn S. Turvey MT: Visuai influences on COP dynimics in upright posture. Eco Psycho 10: 65-9 1. 1998 Roberts D. Friden T. Zatterstrom R, Lindstrand A, Moritz U: Proprioception in people with anterior cruciate ligament-deficient knees: comparison of symptornatic and asymptomatic patients. I Orthop Sports Phys Ther 29( 10): 587-94.1999 Rothwell J: Control of human voluntary movement. Chapman and Hd1, London. 1994 Rozzi SL. Lephart SM. Stemer R. Kuiigowski L: Balance training for pesons with Functionally unstable m e s . J ûrthop Sports Phys Ther 29(8):478-86. 1999 Saupe D: Algorithrns for mdom fractais. the science of fractd images. Springer. New York. 1988 Schmidt RA: Motor control and leming: A behavïonl emphasis. 3"Ledition. H u m Kinrtin. Champaign. K. 1999 Schultz RA. Miller DC. Kerr CS. Micheli L: Mechanonceptors in human cruciate ligaments. A histological study. J Bone Joint Surg Am 66(7): L073-6. 1984

Shock NW:Longitudinai snidy on aging in humans. in Hmdbook of biology of edition. Van Nostrand Renhold. New York, 1985 aging. Sirnoneau GG. Den SA. Ulbrecht JS. Becker MB, Cavanagh PR: Diabetic sensory neuropathy eflect on ankle joint movement perception. Arch Phys Med RehabiI 77(5): 43-60, 1996 S k i ~ eHB, r B m c k RL Cook SD: Age related decline in propnoception. C h Orthop 1û4: 208- I 1.19û4 Taimela S. Kankampaa M. Luoto S: The effect of lumbar fatigue on the abiiity to sense a change in lumbar position. A contmlled snidy. Spine 24( 13): 1377-7, 1999 Testerman C and Vander Griend R: Evaluation of ankie instability using the Biodex SEnbilty System. Fwt Ankle h t 20(5):317-21.1999

Thelen DG, Brockmiller C, Ashton-Miller JA, Schultz AB, Alexander NB: Thresholds for sensing foot dorsi-and plantarflexion during upright stance: effects of age and velocity. J Gerentol A Bi01 Sci Med Sci 53( 1): M33-8, 1998 van Deursen RW. Sanchez MM, Ulbcecht JS. Cavanagh PR: The role of muscle spindles in adde movement perception in human subjects with diabetic neuropathy. Exp Bmin Res 120(1): 1-8. L998 van Deursen RW and Simoneau GG:Foot and ankie sensory neuropathy. proprioception. and postural stabiiity. J Orthop Sports Phys Ther 29( 12): 7 18-26,

1999 Wall PD: The sensory m d motor role of impulses mveling in donai columns towds cerebrril cortex. Brain 93(3): 505-24. 1970 Wyke B: Articula neurology-a nview. Physiotherapy 58(3): 94-9.1972

Appendix t Mini Mental State Examination

Orientation What is the year. season. &te. &y ,month? Murimum score 5 Where are we : state, county. town, hospia flwr? Maximum score 5 Regkation Name 3 objects: 1 second to say each. Then ask the ciient dl 3 d e r you have soid them. Give one point for each correct ûNwer. Then repeat them until the client lems al1 t h e . Count triais and record. Mc~rimurnscore 3 Triais Attention and cdculation: serial 7's. t point for each correct. Stop dkr 5 answers. Altemative1y spell 'world' backw;uds Muximurn score 5 Recail: Ask for three objects repeated above. Give one point for each correct. M&murn score 3 Language: Name a pend and watch. 2 points R e p t the following: 'No ifs, and, or buts.' L point Follow a three-stage cornmuid: 'Tdce a papa in your right hand fold it in haif, and put it on the floor.' 3 points R e d and obey the following: 'Close your eyes.' 1 point Write a sentence. 1 point Copy design: Ipoint

Total score: -- / 30 Assess level of consciousness dong 3 continuum:

Mert

drowsy

stupor

coma

Appendix II Sample Siw Cdculation

using P Pearson-Hdey chut for degree of freedorn for numentor = a -1 = 2. degree of freedom for denorninator = a(n - I ) = 33 and 0 = 3.84 (Keppel. 199 1), power = 0.98

.

.

The sample sire was cdculated for power = 0.80 (0 = 1.9)

n-6

Considering approximtely 20%attrition rate.

APPENDIX III Advertisement

The frcqueney of falls incrases with qing Ieading t o numuwis disabling conditions and extensive hospitd stays. A gradua1 lost of sensations. for example the dccrcased abilify t o unse the position o f joints, is t h o q h t to contributr to balance impairment. Sensitive and dependable mcthods are netâed for assesstnenf in order t o deteet this impairnent and t o measurc the effectivanus of programi designcd t o improve sensoy function. You are invited t o participate in a rcseurch study designcd t o measurc: 1) the sensation of m u d e force and slow movement a t the ankle joint; 2) balance in quiet standing w i t h eyct closed: and 3) t o obsure if the mcthods of measurmuits u u d in this rtudy arc rcpmducible. "Healthy voluntecrs. between the ages o f 20 t o 90 years, are rquired t o participate in this study." All test proceduru will be completcd with the right foot. Thwe will be two t e s t sessions as per your cornenience within a two-week period. The fint session will take about two hours and the second session will take only one and a half hours. l h r e a n no a p p e n t r i s k hivolvcd in participuthg hr thk study, howeve~,you may ucpdcncc oome fatigue o f your Iq muscles which should disappear within a day. For more informarttion please tontact one of the invdgators listed btiow. Nandini beshpande, MSc candidate. School of Rehabilitcition Thempy, Quetn's University: 539 4422 Dr. ûenise Connelly. Phb, School of Rchabilitation Thcrapy. Queen's University: 533 6101

Appendix IV Consent Form

Project TitIe: Asessrnent of Reliabiiity and Semltivity of Proprioceptive Measures

Principal investigator. Nandini Deshpande. M Sc Candidate. School of Rehabilitation Therapy. Queen's University. Kingston. Tel. 6 l3-539-J422 Supervisor: Dr Elsie Culham, Associate hfessor, Physical Therapy Program. School of Rehabilitation Thenpy. Queen's University. Kingston. Tel. 6 13-533-679 Co-supervisor: Dr Denise Comelly, Assistant Professor. School of Rehabilitation Thenpy. Queen's University. Kingston. Tel. 6 13-533-6101 The frequency of fdls increases with aging leading to numerous disabling conditions and extensive hospital stays. Detenoration in sensory Function. for example the decreased ability to sense the position of joints. is thought to conmibute to bdance impairment. Sensitive objective methods are needed for rissessrnent of sensation in order to detect impairment and to mesure the effectiveness of intervections designed to improve sensory function. The purpose of this research study is to detennine the diabiiity and sensitivity of tests of joint position. muscle force and quiet standing bdance. You are eligible to participate in this study if you bave no medical problerns and are 20 yem of age or older. Procedure:

Testing will involve two visits to the Iabontory. The fiat visit will be approximûtely two hours whereas the second v i à t wiii be only one and half houn. Al1 the tests will be performed on the right f i t . You will be asked to complete a bnef test of your memory and communication ability if you are of age 70 y e m or older. 1. A medicd history will be taken and a brief clinicai examination of your ;uikle movement. ankle reflexes, ankle muscle strength and standing bdance will be conducted. 2. You will be sked to wdk a distance of ten meten at your normal cornfortable speedkeetirnes. 3. You wiU be asked to quietly stand with eyes closed for th* seconds on a plate h t will mesure the forces under your fwt. This test wiU be repeated ten times with a

rest period of one minute in between trials. 4. You will be asked to stand with one leg in the fwtplate attacheci to a motor. This footplate will move your ankle joint very slowly. You wiil not be able to see this movement as you wilf be blindfolded. You wiD concenate on the ankle and press a switch as soon as you perceive the dkction (up/down) ùi which your ankle joint is moving. 5. You wiiî be asked to rnove your fwt at a slow speed to a position selected by the investigator and then bring it back to the starhg position. Then you wiil try to position your fwt in the same position.

6- YQKwill be asked ID move youc anklejaint amslow cornfortable speed whüe the speed is measured. Then you will move your f w t a second time and rry to replicate the same speed. 7. The maximum force your adde muscles cm proâuce will be measured as you push ;iginst the footplate of the testing machine. You will then be asked to produce a force that is Iess thm 50% of your maximum capacity first with a visud feedback h m the computer monitor and then without this feedback. If you agree to participate. the tests will be repeated on the second occasion. as per your convenience within two weeks. This n-testing will help us to assess the reproducibility of these tests. However. cünicai examination ten meter wdking at normal speed and the mesurement OF the maximum force of the m e muscle will not be repeated. Risks: There is no apparent risk involved. however. you may expenence some fatigue of your leg muscles that should disappear within a &y or two. You will be given five minutes of rest between each of the tests to minimize this fatigue. Benefits: You will ~ c e i v eno direct benefit €rom pûnicipoting in this study. however. the results will provide information about the usefùlness of these tests in future studies investigating age or disease related changes injoint sensations. Confidentiality: Any infomatian obnincd in this snidy will be held in ~ R i c t confidence and will be avdable only to the investigators. Computer data fitiles will contain a code number nther than the patient name. When the information h m this study will be published in journais or presented in professionai meetings. your identification will be kept stnctly confidentid. Your participation in this study is voluntary and you cm withdraw at any time if you wish to. If you have my questions now or later. please feel Free to contact the investigators or rhe Directorof the Sdioot of R e M h t i m rtmrrpg.. Nandini Deshpmde: 6 13-539422 Dr. Denise Comelly. Co-supervisor: 6 13-533-610L Dr. San& Olney, Director, School of Rehabilitation Therapy, Queen's University: 613533-6 102

SUBJECT'S STATEMENT: I HAVE R W AND UNDERSTOOD TKE CONSENT FORM FOR THIS STUDY. t HAD AN ADEQUATE OPPORTUNITY TO DISCUSS THIS STUûY WITH THE WESTIGATORS AND HAD ALL MY QUESTIONS ANSWERED TO MY SATISFACTION. 1 AM VOLUNTARLY MAKING THE DECISION OF PARTICPATING [N THIS STUDY AND I HAVE THE RIGHT TO WITHDRAW FROM THE STUDY AT ANY TME. I WILL BE GiVEN A COPY OF THIS CONSENT FORM TO KEEP. BY SIGNING THIS CONSENT FORM I NDICATE THAT I AGREE TO PARTICIPATE [N THIS STUDY.

Signature of the Subject

Date

Signature of the Witness

Date

CONSENT FOR RETEST PARTICIPATION: I AGREE TO PARTICPATE ON THE SECOND OCCASION WCïHIN TWO WEEKS.

~&utureof the Subject

Date

WSTTGATOR'S STATEMENT:

IN MY JUDGEMENT THE SUBJECT IS VOLüNTARILY GNiNG INFORMED CONSENT AND POSSESSES THE LEGAL CAPACCTY TO DO SO.

Signa-

of the hvestigator

Date

Appendix V Brief Clinical Examination

. .

BriefChidName:

Code:

W d v ) Height:

Birth date:

Kg

cm Weight:

Address: Tel-no.

Medicd History Ankle joint pathology- degenerative / infective / aumatic (fncturesH none Periphed neuropûthy/ mini strokd Parkinson's diseasel Multiple sclerosid none yes 1 no

Dizziness-

Falls in p s t one yeu-

yes / no

yes / no

Diabetes-

Ankle sprain with present Functiond ins~bility-

yes / no

Lightheadrdness &ter getting up/ postural hypotension-

yes / no

Clinical Examination Right

I l

l

Range of motion ofankle

PF

1

I

1

Left

I l

DF

PF

1

i

I

Ankle retlex

t

I t

1

PF

Manuiil muscle testing of I

1 i

1

1 1

!

DF Ii EV I

I

/ INV 1 I

PF

/

DF

i

EV

1

[NV

I

Rornberg test

gaitspeed

1

Exetcise pattern:

11 I

I

1 I

i

Appendix VI Data Su-

Sheets

Threshold for perception of passive movement: THR Computer file nome:

Triai no.

1

Direction

l l

Thresholdin degrees

!

I

Trial 1

1

!

,

1

1

1 Correct identification (D) of direction

1

1 1

I

Trial 2 Trid 3 Trial 4 Trial 5 Triai 6

1

PF

1

Average displacement i

1

1

I

, ,

DF

II

, 1

l

/3

COMBINED AVERAGE 1

Comments:

1

1

Correct ID of direction Correct iD trial numbers

!

j

j

i

/3

l I

I

Computer file name: - - - - TOR

Test: Reproduction of Toque

Code:----

Nme:

Trial l= 1

MVC PF/DF

/ Trial ?=

1

Test Torque (N)

Average Ermr

/ Avg=

1 Trial 3= / 1

/

I

Reproduced Toque (N)

I

I

1

Difierence

!I mfference 1

!

'

1

Cornments:

Cornputer file name: - - - - Sm(1-x)

Test: Stabilogram Difision Andysis

as)

i Ml) t

I

i

Ws)

I

I

1

1

1

1

X

Cornments:

1

1

1

1

t

/

j

Criticai point

coordinates Time (T) 1 Est (D) I I

Cornputer file nune: - - - - VEL

Test: Reproduction of Velocity

1

Trial no

/

Average Velocity

Triai 1 test 1 Trial 2 repro. Trial 3 test / TRd il4 repro. i Triai 5 test 1 Triaî6re~ro. , T M 7 test Trid 8 remo. i Triai 9 test , Triai I O repro. : , Trid L 1 test : Trial 12 repro. Average error in DF direction =

Difference (emr)

'I

j

,

l 1

1

1

1

/

D k x b n of movement

1

I

I !

I

I I

1

j

!

I

l

1

1

f

I

1

1

I

I I

1

l

I

i

I

I

I

i

I

,

Ia

1 Average ermr in PF direction =

O

1 1

Average error = Cornments:

Cornputer file name: - - - - POS(T- or RA

Test: Reproduction of Position. Nme: ,

Triaino.

1

rrial L

code:---Approx.

Test

Position

Average

/

Reproduced 1 Average

i

j I

Error ! Estimation (Difference) 1 (overfunder) l

Appendix VI1 Scatter Plots

=

groupl group Il group Ill

A

Eiror in position reproduction on day 1

("1 Figure 1: Scatter plot of the error in reproduction of position on &y 1 and day 1 (n=ll). The regression line and 95% confidence bands are displayed.

= A

group l group Il group Ill

Error in velocity reproduction on day 1 ("I56c)

Figure 1:Scatter plot of the emr in reproduction of movement velocity on &y L and day 2 (n=13)-The tegression Line and 95%confidence bands are ciîsplayed.

A

Error in torque reproduction (Nm)

group 1 group Il group Ill

on day 1

Figure 3: Scatter plot of the error in reproduction of muscle torque on day 1 and &y 1 (n= 11).The regression line and 95%confidence bands are displayed.

A

groupl group Il group Ill

Long term diifhision ~06ffîcient-Dyîon day 1

Figure 4: Scaner plot of long term diffusion coefficient vaiues on &y L and &y 3 (n=12). The regresion h e and 95% confidence bands are displayed.

A

group! group Il group Ill

lCC(2,l b0.91 O.?

0.7

0.8

1.O

0.9

Short term sding exponent-Hw on dayl

Figure 5: Scatter plot of short term scding exponent values on day 1 and &y 2 (n= 12). The gr es si on iine and 95% confidence bands are displayed.

/

group 1 group il

Long term scaiing exponent-Hyt on day 1

Wgure 6: Scatter plot of long term scaling exponent values on day L and day 2 (n=12). The r e p s i o n üne and 95%coddence bands are displayed.

group i gtoup Il gtoup Il1

Critical time intervaldt on day 1 (sec)

Figure 7: Scatter plot of criticd tirne intervai on day 1 and &y2 (n=ll). The regression line and 95%confidence bands are displayed. Note:

n indicates overlapping o f data points

A

group l group Il group Ill

Critical m a n square displaœmnt-dy on day 1 (d)

Figure 8: Scatter plot of criticai mean square displacement on &y 1 and day? (n=17).The regression iÏne and 95% confidence bands are dûplayed