The assessment of proprioception in contemporary clinical practice usually involves having the patients with eyes closed attempt to identify passively held test positions using verbal descriptions or limb matching responses. It is equally common for the examiner to estimate the accuracy of these responses without the aid of a measuring instrument. Since these uninstrumented assessments are unlikely to allow adequate identification or quantification of a patient's proprioceptive deficits, the aim of this study was to develop and validate an improved method for the clinical assessment of joint position sense. The two main types of assessment investigated were: 1. replication of joint positions using limb matching responses, during which the test and response positions were measured using computer-aided or manual digitisation of videotape images, and 2. joint position sense assessments where rating scales were used to define either the test or response positions. A series of experiments involving normal knee joints was initially undertaken to identify appropriate and inappropriate aspects of the current clinical joint position sense assessment procedures. Particular attention was given to: (1) active versus passive tests, (2) the use of different test positions, (3) the results from right and left knees, (4) the effects of preliminary practice and multiple test repetitions, (5) allowing observation of limb matching responses, (6) the effects of preceding muscle exercises, (7) non-weightbearing versus weightbearing tests, (8) age-related effects, and (9) scale-based versus video-based methods of measurement. Based on the results from these experiments it appeared that the optimum clinical assessment of joint position sense would most-likely involve: 1. non-weightbearing active position sense tests combined with active ipsilateral limb matching responses, and 2. measurement of test and responses positions by digitisation of videotape or digital photographic images. Clinical application of the proposed video-instrumented active tests with active ipsilateral limb matching responses was then investigated in the hemiplegic knee of recent stroke patients, and in the osteoarthritic knees of a second group of subjects. In the osteoarthritic subjects, a traditional subjective form of clinical assessment was also evaluated — where the subjects attempted to identify, then specify verbally, the direction (up or down) of small amplitude low velocity manually delivered passive flexion and extension movements. Following the clinical experiments, 14 (60.9%) of 23 hemiplegic knees and five (20.0%) of 25 osteoarthritic knees produced abnormal joint position sense assessment results. However, none of the osteoarthritic knees produced abnormal results following the subjective passive tests with verbal descriptive responses. It was concluded that: 1. video-based active assessment procedures are practical, accurate and sensitive with respect to all patients who have at least moderate levels of comprehension, compliance and voluntary motor control; 2. passive tests with passive ipsilateral matching responses should only be used where motor control is poor or absent, and patient compliance high; and 3. traditional subjective passive tests with verbal descriptive responses, whilst practical and convenient, are not sufficiently sensitive for routine clinical use. Full text under this address: http://thesis.lib.unimelb.edu.au/adt-root/uploads/approved/adt-VU2001.0012/public/
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