<%server.execute "isdev.asp"%> Agreement between visual and goniometric assessments of adductor and popliteal angles in infants Jayakrishnan TT, Sharma S, Gulati S, Pandey R M, Wadhwa S, Paul VK - J Pediatr Neurosci
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ORIGINAL ARTICLE
Year : 2013  |  Volume : 8  |  Issue : 2  |  Page : 93-96
 

Agreement between visual and goniometric assessments of adductor and popliteal angles in infants


1 Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
2 Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
3 Department of Physical Medicine and Rehabilitation, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication7-Sep-2013

Correspondence Address:
Sheffali Gulati
Child Neurology Division, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi 110 029
India
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Source of Support: TJ received a “Short Term Studentship” (STS) research grant from the Indian Council of Medical Research (ICMR) for the study., Conflict of Interest: None


DOI: 10.4103/1817-1745.117834

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   Abstract 

Context: Amiel-Tison method is a commonly used technique for assessing tone and neurological status of infants. There is a paucity of data on the reliability of visual assessment of angles, a component of this method. Subjects and Methods: We compared the visual and the goniometric assessment of adductor and popliteal angles in infants with hypertonia and neurologically normal controls. A total of 16 infants with hypertonia and 15 normal infants underwent blinded assessment of the adductor and popliteal angles. Statistical Analysis: The mean and standard deviation for the difference between visual and goniometric measurements were calculated for popliteal and adductor angles. Results: The mean differences between visual and goniometric measurements for the popliteal angle were 4.94 (SD3.40) and 8.73 (SD6.10) degrees for the cases and controls respectively. Similarly, the values for adductor angle measurements were 8.94 (SD8.23) and 14.47 (SD8.47) degrees respectively. Conclusion: The deviation of visual assessment from goniometric measurement was found to be less for popliteal angle measurement as compared to adductor angle measurements. It was note-worthy that the difference was less for the measurements of children with spasticity.


Keywords: Amiel-Tison method, goniometer, hypertonia, spasticity


How to cite this article:
Jayakrishnan TT, Sharma S, Gulati S, Pandey R M, Wadhwa S, Paul VK. Agreement between visual and goniometric assessments of adductor and popliteal angles in infants . J Pediatr Neurosci 2013;8:93-6

How to cite this URL:
Jayakrishnan TT, Sharma S, Gulati S, Pandey R M, Wadhwa S, Paul VK. Agreement between visual and goniometric assessments of adductor and popliteal angles in infants . J Pediatr Neurosci [serial online] 2013 [cited 2019 Apr 18];8:93-6. Available from: http://www.pediatricneurosciences.com/text.asp?2013/8/2/93/117834



   Introduction Top


Hypertonia is a sign of upper motor neuron dysfunction marked by an abnormal increase in passive muscle tone and a reduced ability of the muscle to stretch. Spasticity and dystonia are the most common types of hypertonia. Spasticity is defined as a velocity dependent increase in resistance to passive stretching. Dystonia refers to involuntary movements and prolonged muscle contraction, resulting in twisting body motions, tremor, and abnormal posture.

One of the commonly used methods for assessing neuromotor status including tone in infants and young children is the Amiel-Tison method. This method was developed to detect transient as well as permanent abnormalities in an infant's neuromotor development. Its main focus is to examine active and passive muscle tone. It detects transient neuromotor problems in the 1 st year of life that maybe associated with significant behavioral, neurological, and intellectual deficits when the children reach school age. [1]

In the Amiel-Tison method, spasticity is assessed by visual assessment of different angles - popliteal angle, adductor angle, and dorsiflexion angle of foot etc., The angle measurement is important as it helps in the quantification of hypertonia. These measures are useful for a rough objective estimate of the range of motion, which can be compared to the age-related norms, and for follow-up in the same patient. There is a paucity of data on the reliability of the visual assessment as compared to the goniometric assessment of these angles. Hence, this study was planned to compare the visual and goniometric assessments of the adductor and popliteal angles in infants with hypertonia and neurologically normal controls.


   Subjects and Methods Top


Participants

The study was conducted as a prospective study at the Out-patient Pediatric Department of a tertiary care hospital between September and November 2009. The study was approved by the Institute's Research Ethical Committee. A total of 16 infants with hypertonia and 15 neurologically normal children aged 3-24 months were enrolled consecutively. All the enrolled children underwent a detailed neurological examination by a Pediatric Neurologist. None of the children had any history of lower limb surgery in the previous 12 months. Prior written informed consent was taken from the parents.

Measurement

Assessment of angles

The examination was conducted when the infant was quiet and alert. Two Pediatric Neurology residents with experience in measuring angles in infants were made the raters. The readings were recorded by a recorder (who was the principal investigator).

For the popliteal angle assessment, the thighs were flexed at the hip along both sides of the abdomen and brought perpendicular to the horizontal. While holding the infant in this position the examiner extended the lower leg as far as possible from the thigh. The popliteal angle, which is formed between the calf and the thigh, was estimated on the right side. The axial hinge of the goniometer was placed on the lateral epicondyle of the right femur and the reading was recorded after extending the arms parallel to the calf and thigh.

The adductor angle was measured with the infant lying supine. The legs were extended and gently pulled as far apart as possible. The angle formed by the lower limbs at the symphysis pubis was visually assessed as the adductor angle. For goniometric measurement, the axial hinge was placed on the pubic symphisis and the arms extended parallel to the legs.

Blinding

Goniometer was covered on one side by the principal investigator and used with the blinded side toward the observer. Thus, the observers were blinded for their own goniometric measurements. The measurements were taken consecutively by two observers and they were not informed about the measurements of their colleague until the completion of all the assessments [Figure 1].
Figure 1: Assessment of angles with covered goniometer for blinding during measurements. (a) Popliteal angle and (b) adductor angle

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Statistical analyses

Data were analyzed using the SPSS 16.0. Differences between the visual and goniometric measurements were calculated for each subject after taking an average of the measurements by two observers. The means and standard deviation (SD) of these differences were also determined.


   Results Top


There were 16 children in the hypertonia group and 15 neurologically normal children. The mean age of hypertonia group (13.1 ± 5.6 months) and control group (13.8 ± 6.8 months) were comparable.

Averages of the measurements made by the two observers were calculated for each angle and the difference of visual and goniometric measurements determined. The mean differences (SD) between visual and goniometric measurements for the popliteal angle were 4.94 (3.40) and 8.73 (6.10) degrees for the cases and controls respectively. For adductor angle measurements, they were 8.94 (8.23) and 14.47 (8.47) degrees respectively [Table 1].
Table 1: Details (mean, SD) of goniometric and visual measurements of popliteal and adductor angles in those with spasticity and those who were neurologically normal


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   Discussion Top


The measurement of popliteal and adductor angles is important as it helps in the assessment of hypertonia and following up outcome after therapy. [1] Lack of reliability may lead to erroneous interpretation with consequences on management and follow-up. The visual method of assessment is subjective. The goniometric method, though objective is less convenient in a busy hospital setting. The reliability of different methods for assessing hypertonia therefore needs to be studied. The popliteal angle measurement, a component of Amiel-Tison's neurological assessment of newborn, is the most widely used clinical measure to evaluate spasticity. [2],[3]

While many studies have ascertained the reliability of Amiel-Tison's method, reliability of visual estimation of angles have itself been very variable. Paro-Panjan et al. compared the Amiel-Tison neurological assessment with Prechtl's qualitative assessment of general movements in a group of 45 pre-term infants. Measurements were done at birth and at a corrected age of 3 months and predictive power were analyzed by comparing it with the outcome at 12-15 months. The sensitivity of both techniques was found to be good but the agreement of the neurologic and developmental outcome was better with the Amiel-Tison assessment. [4] Deschκnes et al. demonstrated fair to excellent reliability among most of the items tested in this method using a sample of 35 infants. [5]

There have been a few studies on the comparison of visual and goniometric assessment of angles in older children. Allington et al. did a comparison 46 ankle measurements and showed a high reliability for intra- and inter observer measurements (r > 0.75), between the visual estimation and goniometry (correlation co-efficient, r > 0.967). These finding suggested that visual estimation and goniometry ankle range-of-motion measurements were reliable and reproducible in spastic cerebral palsy children. [6]

On the other hand, considerable inconsistency was found to exist when two or more physical therapists made repeated goniometric and visual measurements of the ankle joint motion on the same subject. [7] Based on the examination of intra tester and inter tester reliability for goniometric and visual estimation of the ankle joint active range of motion, Youdas et al. recommended that a physical therapist should use a goniometer when making repeated measurements of the ankle joint. The main concern was a physical therapist making erroneous conclusion about change in the range of motion due to treatment when the change could be attributed to a lack of inter tester reliability. [7]

Interestingly, a study by Berge et al. showed low reliability of both visual and goniometric measurements based on intra-class correlation coefficients for intra observer and inter observer measurements. The reliability was worse for children with spasticity as compared to normal children. The study included popliteal angle measurements of 15 Cerebral Palsy patients and 15 normal children by three different observers. Measurements were carried out both visually and with a goniometer. The intra-class correlations for inter observer reliability of visual estimates and goniometric measurements were low for both groups. [8]

The above mentioned studies have used either kappa coefficient or intra-class correlation coefficient to measure agreement. It has been argued that intra-class correlation coefficient may not be a good tool for assessing agreement as the correlation could exist even in the absence of agreement. [9] In the present study, we determined the mean of the difference between visual and goniometric measurements to compare between different groups. The deviation of visual assessment from goniometric measurement was less for popliteal angle measurements as compared to adductor angle measurements. It was also noteworthy that the differences were lesser for spastic children.

Neurologists often assess spasticity by judging tone, rather than the angulation. However, numerically quantifiable measurements are important to therapists to monitor therapy. The results of this study support use of visual assessment of tone in children with neuromotor problems. The variation observed between the visual and goniometric assessments (4°-15°) may be acceptable. Moreover, the assessment of tone is not one point estimate but done over a period of time to monitor therapy. So, the difference in visual and goniometer assessment of tone may make no clinical difference if visual assessment is done carefully.

 
   References Top

1.McCarraher-Wetzel AP, Wetzel RC. A review of the Amiel-Tison neurologic evaluation of the newborn and infant. Am J Occup Ther 1984;38:585-93.  Back to cited text no. 1
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2.Katz K, Rosenthal A, Yosipovitch Z. Normal ranges of popliteal angle in children. J Pediatr Orthop 1992;12:229-31.  Back to cited text no. 2
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3.Bleck EE. Orthopaedic Management in Cerebral Palsy. Philadelphia: J. B. Lippincott; 1987.  Back to cited text no. 3
    
4.Paro-Panjan D, Sustersic B, Neubauer D. Comparison of two methods of neurologic assessment in infants. Pediatr Neurol 2005;33:317-24.  Back to cited text no. 4
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5.Deschênes G, Gosselin J, Couture M, Lachance C. Interobserver reliability of the Amiel-Tison neurological assessment at term. Pediatr Neurol 2004;30:190-4.  Back to cited text no. 5
    
6.Allington NJ, Leroy N, Doneux C. Ankle joint range of motion measurements in spastic cerebral palsy children: Intraobserver and interobserver reliability and reproducibility of goniometry and visual estimation. J Pediatr Orthop B 2002;11:236-9.  Back to cited text no. 6
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7.Youdas JW, Bogard CL, Suman VJ. Reliability of goniometric measurements and visual estimates of ankle joint active range of motion obtained in a clinical setting. Arch Phys Med Rehabil 1993;74:1113-8.  Back to cited text no. 7
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8.Ten Berge SR, Halbertsma JP, Maathuis PG, Verheij NP, Dijkstra PU, Maathuis KG. Reliability of popliteal angle measurement: A study in cerebral palsy patients and healthy controls. J Pediatr Orthop 2007;27:648-52.  Back to cited text no. 8
[PUBMED]    
9.Bland JM, Altman DG. Statistical methods for assessing agreement between two methods of clinical measurement. Lancet 1986;1:307-10.  Back to cited text no. 9
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    Abstract
   Introduction
   Subjects and Methods
   Results
   Discussion
    References
    Article Figures
    Article Tables

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