Instrumented strength assessment in typically developing children and children with a neural or neuromuscular disorder: A reliability, validity and responsiveness study

Ineke Verreydt, Ines Vandekerckhove, Elze Stoop, Nicky Peeters, Vanessa van Tittelboom, Patricia Van de Walle, Marleen Van den Hauwe, Nathalie Goemans, Liesbeth De Waele, Anja Van Campenhout, Britta Hanssen, Kaat Desloovere, Ineke Verreydt, Ines Vandekerckhove, Elze Stoop, Nicky Peeters, Vanessa van Tittelboom, Patricia Van de Walle, Marleen Van den Hauwe, Nathalie Goemans, Liesbeth De Waele, Anja Van Campenhout, Britta Hanssen, Kaat Desloovere

Abstract

The aim of this study was to determine the clinimetric properties, i.e., reliability, validity and responsiveness of an instrumented strength assessment in typically developing (TD) children and children with cerebral palsy (CP) and Duchenne muscular dystrophy (DMD). Force (N), torque (Nm) and normalized torque (Nm/kg) were defined for maximal voluntary isometric contractions (MVICs) of the lower limb muscles using a pre-established protocol. Intraclass correlation coefficient (ICC), standard error of measurement (SEM) and minimal detectable change (MDC) of TD children (n = 14), children with CP (n = 11) and DMD (n = 11) were used to evaluate intra-rater reliability for the three cohorts and the inter-rater intersession as well as inter-rater intrasession reliability for TD children. Construct validity was assessed by comparing MVICs in TD children (n = 28) to children with CP (n = 26) and to children with DMD (n = 30), using the Kruskal Wallis and post-hoc Mann-Whitney U tests. Responsiveness was investigated by assessing changes in MVICs following a strength intervention in CP (n = 26) and a 1 and 2 year follow-up study in DMD (n = 13 and n = 6, respectively), using the Wilcoxon Signed-Rank test. The overall intra-rater reliability, was classified as good to excellent for 65.1%, moderate for 27.0% and poor for 7.9% of the measures (47.6%, 76.2%, and 66.7% good-excellent; 28.6%, 23.8%, and 33.7% moderate; 23.8%, 0%, and 0% poor in TD, CP, and DMD, respectively), while ICC values for TD children were slightly lower for inter-rater intrasession reliability (38.1% good-excellent, 33.3% moderate and 26.6% poor) and for inter-rater intersession reliability (47.6% good-excellent, 23.8% moderate and 28.6% poor). Children with CP and DMD were significantly weaker than TD children (p < 0.001) and the majority of these strength differences exceeded the MDC. Children with CP significantly improved strength after training, with changes that exceeded the SEMs, whereas only limited strength decreases over time were observed in the DMD cohort. In conclusion, the investigated instrumented strength assessment was sufficiently reliable to confirm known-group validity for both cohorts and could detect the responsiveness of children with CP after a strength intervention. However, more research is necessary to determine the responsiveness of this assessment in children with DMD regarding their natural decline.

Keywords: Duchenne musclar dystrophy; cerebral palsy; clinimetric properties; instrumented strength assessment; muscle weakness; reliability; responsiveness; validity.

Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Copyright © 2022 Verreydt, Vandekerckhove, Stoop, Peeters, van Tittelboom, Van de Walle, Van den Hauwe, Goemans, De Waele, Van Campenhout, Hanssen and Desloovere.

Figures

FIGURE 1
FIGURE 1
Study design of all three parts of the study. Part one represents the reliability study (A), including (1) the intra-rater reliability, with data from session 1—assessor 1 and from session 2—assessor 1, (2) the inter-rater intrasession reliability, with data from session 1—assessor 1 and from session 1—assessor 2 and (3) the inter-rater intersession reliability, with data from session 1—assessor 2 and from session 2—assessor 1. Part two represents the validity study (B), based on the data of the children included in the reliability study complemented with data of additional participants. Part three represents the responsiveness study (C), based on (1) data of a strength training program in children with CP (* indicating that the hip joint was not assessed) and (2) data of the natural decline of the children with DMD. Abbreviations in alphabetic order: CP, cerebral palsy; DMD, Duchenne muscular dystrophy; TD, typically developing.
FIGURE 2
FIGURE 2
Custom-made chair used for assessment of maximal voluntary isometric contractions. The chair and handheld dynamometer are positioned to assess knee extension strength (A). Further, the whole measurement set-up is shown with the laptop placed in front of the child to give visual feedback. Close-up on the position of the handheld dynamometer for knee flexion strength (B). Close-up on the position of the handheld dynamometer for dorsiflexion strength (C).
FIGURE 3
FIGURE 3
Visual representation to compare the absolute SEM (white) and MDC (grey) values as retrieved from the reliability study for the children with CP and DMD with the absolute differences between the median values of TD children and the clinical cohorts (black) from the validity study. Panel A–C visualize the data for torque (A), normalized torque (B) and the force (C) in the children with CP. Panel D–F visualize the data for the torque (D), normalized torque (E) and the force (F) in the children with DMD. Abbreviations in alphabetical order: CP, cerebral palsy; DF, dorsiflexion; DMD, Duchenne muscular dystrophy; HA, hip abduction; HE, hip extension; HF, hip flexion; KE, knee extension; KF, knee flexion; MDC, minimal detectable change; N, Newton; Nm, Newton meter; Nm/kg, Newton meter per kilogram body weight; PF, plantar flexion; SEM, standard error of measurement; TD, typically developing.
FIGURE 4
FIGURE 4
Visual representation to compare the absolute SEM (white) and MDC (light grey) values as retrieved from the reliability study for the children with CP and DMD with the median of the absolute differences between the two assessments (black = CP and 1 year interval DMD; dark grey = 2 year interval DMD) from the responsiveness study. Panel A-C visualize the data for torque (A), normalized torque (B) and the force (C) in the children with CP. Panel D-F visualize the data for torque (D), normalized torque (E) and the force (F) in the children with DMD. Abbreviations in alphabetical order: CP, cerebral palsy; DF, dorsiflexion; DMD, Duchenne muscular dystrophy; HA, hip abduction; HE, hip extension; HF, hip flexion; KE, knee extension; KF, knee flexion; MDC, minimal detectable change; N, Newton; Nm, Newton meter; Nm/kg, Newton meter per kilogram body weight; PF, plantar flexion; SEM, standard error of measurement.

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