The Intra- and Inter-Rater Reliability of an Instrumented Spasticity Assessment in Children with Cerebral Palsy

Simon-Henri Schless, Kaat Desloovere, Erwin Aertbeliën, Guy Molenaers, Catherine Huenaerts, Lynn Bar-On, Simon-Henri Schless, Kaat Desloovere, Erwin Aertbeliën, Guy Molenaers, Catherine Huenaerts, Lynn Bar-On

Abstract

Aim: Despite the impact of spasticity, there is a lack of objective, clinically reliable and valid tools for its assessment. This study aims to evaluate the reliability of various performance- and spasticity-related parameters collected with a manually controlled instrumented spasticity assessment in four lower limb muscles in children with cerebral palsy (CP).

Method: The lateral gastrocnemius, medial hamstrings, rectus femoris and hip adductors of 12 children with spastic CP (12.8 years, ±4.13 years, bilateral/unilateral involvement n=7/5) were passively stretched in the sagittal plane at incremental velocities. Muscle activity, joint motion, and torque were synchronously recorded using electromyography, inertial sensors, and a force/torque load-cell. Reliability was assessed on three levels: (1) intra- and (2) inter-rater within session, and (3) intra-rater between session.

Results: Parameters were found to be reliable in all three analyses, with 90% containing intra-class correlation coefficients >0.6, and 70% of standard error of measurement values <20% of the mean values. The most reliable analysis was intra-rater within session, followed by intra-rater between session, and then inter-rater within session. The Adds evaluation had a slightly lower level of reliability than that of the other muscles.

Conclusions: Limited intrinsic/extrinsic errors were introduced by repeated stretch repetitions. The parameters were more reliable when the same rater, rather than different raters performed the evaluation. Standardisation and training should be further improved to reduce extrinsic error when different raters perform the measurement. Errors were also muscle specific, or related to the measurement set-up. They need to be accounted for, in particular when assessing pre-post interventions or longitudinal follow-up. The parameters of the instrumented spasticity assessment demonstrate a wide range of applications for both research and clinical environments in the quantification of spasticity.

Conflict of interest statement

Competing Interests: The authors have declared that no competing interests exist.

Figures

Fig 1
Fig 1
A. Measurement instrumentation. (1) three inertial measurement units (joint angle measurement); (2) a six degrees of freedom force/torque-sensor (torque measurement); (3) surface electromyography (muscle activation measurement); B. Measurement set-up for assessing the lateral gastrocnemius. (4) custom ankle orthosis; and (5) support frame. [25].
Fig 2. Measurement procedure for the four…
Fig 2. Measurement procedure for the four lower limb muscles.
LatGas, lateral gastrocnemius; MedHam, medial hamstrings; RecFem, rectus femoris; Adds, hip adductors. The red arrow indicates the direction of joint movement during stretch. Instrumentation: (1) three inertial measurement units (joint angle measurement); (2) surface electromyography (muscle activation measurement); and (3) a six degrees of freedom force/torque sensor attached to a shank or foot orthosis (torque measurement); (4) support frame. Modified from [30] with permission (S2 Fig).
Fig 3. Schematic illustrating the three aspects…
Fig 3. Schematic illustrating the three aspects of reliability evaluated within this study.
Inter-raterWS, inter-rater within sessions; Intra-raterWS, intra-rater within sessions; Intra-raterBS, intra-rater between session. The dotted lines indicate the involvement of each rater in their respective analysis.
Fig 4. The intra-class correlation coefficients (ICC)…
Fig 4. The intra-class correlation coefficients (ICC) and confidence intervals (CI) for intra-raterBS and inter-raterWS analyses.
LatGas, lateral gastrocnemius; MedHam, medial hamstrings; RecFem, rectus femoris; Adds, hip adductors; LV, Low Velocity; HV, High Velocity; HV-LV, Difference between HV and LV; VMAX, Maximum angular velocity; ROM, Range of Motion; MVIC, Maximum Voluntary Isometric Contraction; rms-EMG, root mean squared electromyography; AOC, Angle of Catch; ML, Muscle Length; MLV, Muscle Lengthening Velocity. The red vertical line indicates an ICC of 0.6, above which relative reliability is considered to be at least moderately high. A = an ICC that could not be calculated.

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