Avon Curves Scale Manual
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Spasticity and contracture are major sources of disability in people with neurological impairments that have been evaluated using various instruments: the Modified Ashworth Scale, tendon reflex scale, pendulum test, mechanical perturbations, and passive joint range of motion (ROM). These measures generally are either convenient to use in clinics but not quantitative or they are quantitative but difficult to use conveniently in clinics. We have developed a manual spasticity evaluator (MSE) to evaluate spasticity/contracture quantitatively and conveniently, with ankle ROM and stiffness measured at a controlled low velocity and joint resistance and Tardieu catch angle measured at several higher velocities. We found that the Tardieu catch angle was linearly related to the velocity, indicating that increased resistance at higher velocities was felt at further stiffer positions and, thus, that the velocity dependence of spasticity may also be position-dependent. This finding indicates the need to control velocity in spasticity evaluation, which is achieved with the MSE. Quantitative measurements of spasticity, stiffness, and ROM can lead to more accurate characterizations of pathological conditions and outcome evaluations of interventions, potentially contributing to better healthcare services for patients with neurological disorders such as cerebral palsy, spinal cord injury, traumatic brain injury, and stroke. INTRODUCTION People with injuries such as stroke, cerebral palsy (CP), and traumatic brain injury (TBI) often experience residual physical impairments such as spastic hypertonia and muscle contracture –.
Spasticity is a major source of disability in these patients. Hypertonus and reflex hyperexcitability disrupt the remaining functional use of muscles, impede motion, and may cause severe pain. Prolonged spasticity may be accompanied by structural changes in muscle fibers and connective tissue, which may reduce joint range of motion (ROM) and lead to clinical contracture ,. Accurate and reliable evaluation of spasticity presents a constant challenge to the medical rehabilitation community. The Modified Ashworth Scale (MAS) is the most popular clinical measure of spasticity ; however, poor inter- and intrarater reliability of the MAS has been reported –.
The Tardieu scale is another clinical measure of spasticity that compares how spastic muscles “catch” at low, medium, and high velocities. The Tardieu scale has better reliability than the MAS when raters receive identical and intensive training , which implies that standardized training would improve reliability among raters who receive training from different trainers. In general, clinical scales are practical and convenient to use in clinics but less accurate than quantitative measurements. A handheld dynamometer or spring scale has been used to measure the force rotating the limb during spasticity testing in the clinic –. More sophisticated robotic devices have been used to obtain the torque-angle curve, from which joint ROM, (quasi-static) stiffness, and energy loss can be derived –.
The use of computer-controlled devices, however, adds procedures to existing assessment protocols, making the protocols more sophisticated, which may prevent clinicians from using them in clinical practice. This article presents a manual spasticity evaluator (MSE) that can be used conveniently by clinicians and that enables quantitative evaluation of spasticity and contracture at the ankle joint. The MSE was tested to measure ankle ROM at controlled low velocity, elastic stiffness, spasticity, and Tardieu catch angle at higher velocities. Manual spasticity evaluator used to measure spasticity at human ankle. With subject’s leg fixed to leg support, operator moves ankle at controlled velocity and terminal torque with real-time feedback. Ankle movement and joint torque measured by position sensor and torque sensor, respectively.
A custom data-acquisition program was developed to implement two functions: (1) measure, record, and display both the torque signal and the position signal and (2) produce real-time audio-visual feedback when a preset velocity and/or torque limit was reached. With the help of the real-time record of torque and position signals and audio-visual feedback, the examiner can characterize the pathological conditions more accurately by measuring the passive ROM at consistent peak torques, resistance torque at fixed positions, elastic stiffness, and catch angles and, in addition, have the capability to display and analyze the recorded data in different formats (e.g., angular position and torque signals as functions of time and torque-angle hysteresis loops). Human Subjects and Experimental Procedures Twelve children with CP aged 4 to 19 yr (12.0 ± 5.0 yr) who had ankle spasticity and five nondisabled children aged 12 to 14 yr (12.0 ± 1.4 yr) were recruited (all data presented as mean ± standard deviation unless otherwise noted). In addition, five nondisabled adults aged 21 to 31 yr (24.4 ± 3.7 yr) were recruited to determine the intra- and interrater reliability of the MSE system. The following procedure was performed to test passive ROM and spasticity. First, the subject’s foot was placed on the foot plate and the subject’s ankle joint was aligned with the rotation axis of the device by sliding the foot plate in anterior/posterior and proximal/distal directions. Then, the foot was fixed to the plate with Velcro straps.
The operator then manually moved the ankle joint from one extreme position to the other at a constant velocity. In this procedure, the laptop sampled and displayed the joint angular position and resistance torque (sampling rate: 1,000 Hz). When the desired terminal torque or target velocity was reached, the software alerted the operator with audio-visual displays. The operator repeated the passive motion tests at various velocities in both the dorsal and plantar directions. The position and torque data were recorded and then analyzed offline to calculate variables, including the Tardieu catch angle, for the quantitative assessment of the neuromuscular and biomechanical properties of the joints. Dancehall rock riddim 2004 zip. Screen display of data acquisition and test-control program. From top to bottom, plots show real-time ankle dorsiflexion angle, velocity, and joint torque, respectively.
Their target values and ranges can be seen as horizontal lines, and beeping sound is generated once target is within range. Simulated light-emitting diode buttons also indicate when target torque or velocity has been reached within certain range. Note that the target terminal torque and the target velocity shown by the broken lines in were used only to guide and inform the operator. To improve the quality of data obtained, the operator practiced before collecting actual data. Usually, the data collected were reliable and repeatable (as shown in ).
However, large artifacts could also be introduced if the subject moved his or her ankles during the testing (shown in the last plot in ). We therefore developed custom MATLAB (The MathWorks, Inc; Natick, Massachusetts) programs to help the operator visually screen and inspect the data immediately after a trial. With the help of those programs, the operator could include or exclude a specific trial according to the inspection.
Typical torque and position signals recorded using the manual spasticity evaluator. (a) x-axis represents ankle dorsiflexion angle. Solid, dashed, and dotted waveforms are torque, velocity, and Δtorque/Δtime shown as functions of joint angle, respectively. (b) Solid, dashed, dotted, and dot-dashed waveforms are torque, velocity, position, and Δtorque/Δtime shown as functions of time, respectively. The waveforms in imply that the Tardieu catch angle can be identified by three characteristics: (1) the time derivative of the torque (Δtorque/Δ t) increases to a peak value (position 1 in, time point 1 in ) and then decreases to a minimum value, (2) the position-torque curve moves backward shortly then moves forward (position 2 in, time point 2 in ), and (3) velocity decreases to a minimum and then increases (position 3 in, time point 3 in ). Three characteristics are associated with the catch phenomenon: (1) the examiner feels the sharp increase of the resistance torque (peak of the time derivative of the torque: position 1 in, time point 1 in ) when the catch phenomenon occurs. (2) The operator then responds to the sharp increase in torque by decreasing the velocity.
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If the velocity is decreased to negative, the position-torque curve moves backward (position 2 in, time point 2 in ). (3) As the operator decreases the velocity, the time derivative of the torque decreases. Then, the operator increases the velocity in the forward direction up to the extreme position. This causes the second increase in velocity after the minimum is reached (position 3 in, time point 3 in ). According to these observations, both time point 2 in the position-torque curve and time point 3 in the velocity-angle curve are caused by the sharp increase of the resistance torque (time derivative of the torque); the angle at which the time derivative of the torque reaches the maximum is considered the catch angle. Range of Motion and Stiffness Ankle ROM and elastic stiffness were measured at a controlled low velocity (about 30°/s).
For children with CP and limited ankle movement, the ROM (ROM1 in ) could be markedly smaller than that of nondisabled children (ROM2 in ). Across all the subjects, the total mean passive ROM for the CP and control groups was 93.4° ± 24.6° and 94.7° ± 24.0°, respectively. However, the difference was not statistically significant ( p = 0.9), which may be related to the small sample size and/or the wide age ranges of the participants in this study. Typical torque-angle curves (hysteresis loops) from child with CP (solid curve; CP.Stiff) and nondisabled (dashed curve; N.Stiff) subjects: x- and y-axes are dorsiflexion angle and passive resistance torque, respectively. CP = cerebral palsy, ROM = range of motion, ROM1 = ROM of children with CP and limited ankle movement, ROM2 = ROM for nondisabled children. The intra- and interrater reliability test showed that this measure has high reproducibility (ICC = 0.86, Pearson r = 0.95, p.
Free download hollywood movies tamil. DISCUSSION AND CONCLUSIONS Hypertonia is a major source of disability in patients with neurological disorders including CP, stroke, spinal cord injury (SCI), and TBI and is characterized by spasticity and/or contracture in the involved joints. The associated changes in the mechanical properties of muscles and tendons may reduce joint ROM and limb deformity. Accurate and reliable evaluation of spasticity is essential for diagnosis, treatment, and patient management (determining therapy and evaluating treatment outcomes). In this study, we developed a MSE and demonstrated its efficacy.
It is important to point out that the MSE is not designed exclusively for children. It can also be applied to characterize spasticity/contracture in adults with neurological disorders (e.g., SCI, TBI, and stroke). Children with CP have alterations in the biomechanical and reflex properties of the ankle. These changes have been assessed by such measures as the MAS, tendon reflex scale, pendulum test, mechanical perturbations, and passive joint ROM.
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Manual assessments through physical examination by experienced clinicians are intrinsically subjective and qualitative and may have poor intra- and interrater reliability. Sophisticated robotic devices can accurately measure the torque-angle curve, joint ROM, stiffness, and energy loss. However, they are usually not convenient to use in clinical settings.
Haptic robotic devices have been used to re-create the sensations clinicians would have felt during an in-person examination ; however, re-created haptic sensations are not identical to the actual feeling, which is important in clinical examinations. In this study, we designed an MSE that can be used to evaluate spasticity and stiffness quantitatively and conveniently.
The MSE provides clinicians with both transparent haptic feedback and quantitative measurements of the biomechanical and reflex properties of the ankle under controlled resistance torque and/or velocity. Using the MSE, we tested 12 children with CP and 5 nondisabled children. We measured the ankle ROM and stiffness at controlled low velocity, velocity-dependent resistance, and Tardieu catch angle at several different velocities in a clinical setting. The results show that the Tardieu angle, ROM, and stiffness in the spastic ankle can be determined quantitatively and conveniently. Compared with the control group, the CP group had higher joint stiffness, while no difference was noted in passive ROM between the two groups. We also found that the catch angle was linearly dependent on the movement velocity and thus should be determined at a well controlled velocity for consistent results. The linear relation between movement velocity and catch angle was also found in a related study on the upper limb.
We also tested five nondisabled adults to determine the intra- and interrater reliability of the MSE system. The results show that the MSE system has excellent reproducibility in passive ROM (ICC = 0.86, Pearson r = 0.95, p. Author Contributions: Acquisition of data: Q. Subject recruitment: D. Analysis and interpretation of data: Q. Drafting of manuscript: Q.
Critical revision of manuscript for important intellectual content: Q. Statistical analysis: Q. Obtained funding: L. Study supervision: L.
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Financial Disclosures: The authors have declared that no competing interests exist. Institutional Review: This study was approved by the institutional review board of Northwestern University. All subjects gave informed consent, and for children under 18 years old, parental consent was obtained. Participant Follow-Up: The authors do not plan to notify the study subjects of the publication of this article because of a lack of contact information.