Portable fixed dynamometry: towards remote muscle strength measurements in patients with motor neuron disease

Jaap N E Bakers, Leonard H van den Berg, Toju G Ajeks, Maxine J Holleman, Jill Verhoeven, Anita Beelen, Johanna M A Visser-Meily, Ruben P A van Eijk, Jaap N E Bakers, Leonard H van den Berg, Toju G Ajeks, Maxine J Holleman, Jill Verhoeven, Anita Beelen, Johanna M A Visser-Meily, Ruben P A van Eijk

Abstract

Background: We aimed to determine (1) the test-retest reliability of a newly developed portable fixed dynamometer (PFD) as compared to the hand-held dynamometer (HHD) in patients with motor neuron disease (MND) and (2) the PFD's ability to reduce possible examiner-induced ceiling effects.

Methods: Test-retest reliability of isometric muscle strength of the quadriceps was measured in patients with MND and non-neurological controls using the HHD and PFD. Reliability was estimated by the intraclass correlation coefficient (ICC) and standard error of measurement (SEM) using linear mixed effects models, and the Bland-Altman method of agreement.

Results: In total, 45 patients with MND and 43 healthy controls were enrolled in this study. The ICC of the PFD was excellent and similar in both patients and controls (ICC Patients 99.5% vs. ICC Controls 98.6%) with a SEM of 6.2%. A strong examiner-induced ceiling effect in HHD was found when the participant's strength exceeded that of examiner. Employing the PFD increased the range of muscle strength measurements across individuals nearly twofold from 414 to 783 N.

Conclusions: Portable fixed dynamometry may significantly reduce examiner-induced ceiling effects, optimize the standardization of muscle strength testing, and maximize reliability. Ultimately, PFD may improve the delivery of care due to its potential for unsupervised, home-based assessments and reduce the burden to the patient of participating in clinical trials for MND or other neuromuscular diseases.

Keywords: Fixed dynamometry; Motor neuron disease; Muscle strength; Reliability study; Remote monitoring.

Conflict of interest statement

The authors declare that they have no conflict of interest.

Figures

Fig. 1
Fig. 1
Overview of study procedures
Fig. 2
Fig. 2
Prototype of the Portable Fixed Dynamometer. A rigid framework with two holders for the MicroFET dynamometers (*) was created to remove the need for an examiner when evaluating quadriceps strength. With the vertical arm (a), the height was adjusted to prevent the feet from touching the ground. The diagonal arm (b) enabled adjustment of the dynamometer pad to 1 centimeter proximal to the midline between the malleoli
Fig. 3
Fig. 3
Bland–Altman plots for test–retest reliability. Bland–Altman plots of the HHD (a–b) and PFD (c–d) for non-neurological controls and patients with MND, respectively. Due to the heteroscedastic nature of the data, we applied a 10log-transformation. MD mean difference between trials 1 and 2, ICC intraclass correlation coefficient, SEM standard error of measurement, expressed as percentage of the mean on the original scale (Newton) [35]
Fig. 4
Fig. 4
Association between hand-held and portable fixed dynamometry. a Association between HHD and PFD measurements. The dotted line represents a correlation of 1 (i.e., HHD measurement = PFD measurement and vice-versa). The black solid line represents the observed association, estimated using a linear mixed effects model. The dots with crosses are data points classified as unable-to-break. b Muscle strength based on hand-held dynamometry data was categorized and per sub-group we determined the proportion unable-to-break A clear pattern emerges with the assessor no longer being able to measure the full muscle strength from 300 N upwards (i.e., a proportion of unable-to-break of 1)
Fig. 5
Fig. 5
Relationship between functional loss and muscle strength measurements. Boxplot of the HHD and PFD measurements in 45 patients with MND and 43 non-neurological controls (blue). Functional loss in MND patients was categorized using self-reported function scores of the ALS functional rating scale item 8 (walking); the score range was 0 to 4, where 0 indicates no leg muscle function (not included) and 4 indicates normal walking function

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