Hand reach star excursion balance test as a measure of joint mobility

Abstract

Joint range of motion (ROM) is commonly measured using goniometry with accepted reference values such as American Academy of Orthopedic Surgeons (AAOS) (Greene & Heckman, 1994). The procedures of obtaining these measures are based on unidirectional and uniplanar passive testing of isolated joint motions in supine, prone or seated positions.
The relationship of such ROM measures to performance have been found to be variable (Craib et al., 1996; Menz, Morris, & Lord, 2006). Utilizing tests of the full kinematic chain from an upright standing position that involve the concurrent use of multiple joints, directions and planes of motion might be one solution to the shortcomings of the traditional ROM testing procedures. Full kinematic chain tests have the advantage of greater specificity to most human movements such as athletic performance.

The Star Excursion Balance Test (SEBT) is a widely accepted test of dynamic postural control and balance (Gribble, Hertel, & Plisky, 2012) that challenges coordination, mobility, and strength (Hubbard, Kramer, Denegar, & Hertel, 2007). However it does not challenge all joint movements at and above the hip (Delahunt et al., 2013), but it offers a platform from which a whole-body mobility and balance test can be created. In the current study we propose a Hand Reach Star Excursion Balance Test (HSEBT), which combines a systematic use of unilateral and bilateral hand reaches, thus also challenging mobility in hip and upper body joints.

The purposes of this study were to (1) provide joint movement reference data for HSEBT; and (2) compare the 22 elicited joint movements of the ankle, knee, hip and spine elicited by HSEBT to ROM reference values and joint movements elicited by SEBT.

Full text

Hand reach star excursion balance test as a measure of joint mobility
Eriksrud, O.1, Cabri, J.1 and Federolf, P.2
1Department of Physical Performance, Norwegian School of Sport Sciences, Oslo, Norway
2Faculty of Psychology and Sport Science, University of Innsbruck, Innsbruck, Austria
{ola.eriksrud, jan.cabri}@nih.no, peter.federolf@uibk.ac.at
1 OBJECTIVES
Joint range of motion (ROM) is commonly
measured using goniometry with accepted reference
values such as American Academy of Orthopedic
Surgeons (AAOS) (Greene & Heckman, 1994). The
procedures of obtaining these measures are based on
unidirectional and uniplanar passive testing of
isolated joint motions in supine, prone or seated
positions.
The relationship of such ROM measures to
performance have been found to be variable (Craib
et al., 1996; Menz, Morris, & Lord, 2006). Utilizing
tests of the full kinematic chain from an upright
standing position that involve the concurrent use of
multiple joints, directions and planes of motion
might be one solution to the shortcomings of the
traditional ROM testing procedures. Full kinematic
chain tests have the advantage of greater specificity
to most human movements such as athletic
performance.
The Star Excursion Balance Test (SEBT) is a
widely accepted test of dynamic postural control and
balance (Gribble, Hertel, & Plisky, 2012) that
challenges coordination, mobility, and strength
(Hubbard, Kramer, Denegar, & Hertel, 2007).
However it does not challenge all joint movements
at and above the hip (Delahunt et al., 2013), but it
offers a platform from which a whole-body mobility
and balance test can be created. In the current study
we propose a Hand Reach Star Excursion Balance
Test (HSEBT), which combines a systematic use of
unilateral and bilateral hand reaches, thus also
challenging mobility in hip and upper body joints.
The purposes of this study were to (1) provide
joint movement reference data for HSEBT; and (2)
compare the 22 elicited joint movements of the
ankle, knee, hip and spine elicited by HSEBT to
ROM reference values and joint movements elicited
by SEBT.
2 METHODS
Twenty-eight healthy male subjects without
musculoskeletal dysfunction in the past 6 months
volunteered for the study. HSEBT was performed on
a testing grid that featured nine concentric circles at
10 cm intervals with eight vectors projecting from
the centre of the mat at 45° intervals and marked at
one centimetre intervals. The vectors were used as
reference for the horizontal reach tests (HR) and
named as follows: 1) Anterior (A0). 2) Left 45°
(L45). 3) Right 45° (R45). 4) Left 90° (L90). 5)
Right 90° (R90). 6) Left 135° (L135). 7) Right 135°
(R135) and 8) Posterior (P180). All HR are
measured in centimetres (cm). The rotational reaches
(RR) were measured in degrees (°) using the outer
concentric circle with degrees identified at 5°
intervals. When performing overhead or rotational
reaches a plumbline was used to project reach
distance to the mat. All subjects performed 20 hand
reaches, 10 on each leg, in the same order without
warming up.
Movements of the participants were captured
using 58 reflective markers and fifteen Oqus
cameras (ProReflex®, Qualisys Inc., Gothenburg,
Sweden) recording at 480 Hz to create the foot, leg,
thigh, pelvis, thorax and upper arm segment. Data
analysis was performed using Visual 3D® (C-
Motion Inc., Rockwille MD, USA).
Three-dimensional joint movements of the foot,
knee, hip and trunk (θ=ϕmax-ϕstart) triggered by
different hand reach tests were calculated from
starting (ϕstart = meanframes 5-100) and maximum reach
position (ϕmax) of the fifth metacarpal marker of the
reaching hand(s). The maximum reach position was
defined to reflect the maximum HR and RR scores.

Descriptive statistics were then calculated for all
joint movements and hand reach performance.
3 RESULTS
Twenty-eight healthy male subjects (age 23.8 ±
2.2 years; height 181 ± 6.0 cm; weight = 78.3 ± 9.2
kg) completed all 20 tests. The HSEBT test that
elicited the greatest joint movement, plane and
direction, of the ankle, knee, hip and spine is
identified in Table 1. HSEBT elicited eleven out of
twenty-two joint movements within or greater than
goniometric ROM reference values.
4 DISCUSSION
Dorsiflexion (29.2±6.0°) is greater than ROM
reference values. However, more appropriate
comparisons can be made to the weight bearing
modified lunge test (38,2°) (Menz et al., 2003). Foot
eversion (18.1±3.2°) is within ROM reference
values and similar to the test found to elicit
maximum ankle eversion in the SEBT (16.4±1.9°)
(Doherty et al., 2015). Inversion (7.8±4.4°) is not
within range of ROM reference values, however,
similar to what has been found for SEBT (7.1±1.9°)
(Kang et al., 2015). To the authors’ knowledge no
goniometric ROM for abduction and adduction exist,
however the joint movements obtained is similar to
stance phase of running (Freedman Silvernail,
Boyer, Rohr, Bruggemann, & Hamill, 2015).
Maximum knee flexion (94.3±22.4°) is below
ROM reference values, but greater than in the SEBT
(66.3°-68.9°) (Doherty et al., 2015; Kang et al.,
2015). Knee internal rotation is within the range
while external rotation is greater, (7.8°-26.6°) and
(5.3±14.7°) respectively, when compared to SEBT
(Doherty et al., 2015; Kang et al., 2015). The frontal
plane arch (23°) obtained in this study is greater than
the ROM reference values (Table 1), but similar to a
functional task such as a jump-stop unanticipated cut
(27°) (Ford, Myer, Toms, & Hewett, 2005)
Table 1: HSEBT joint movement comparison to selected ROM reference values.
Joint
Plane
Motion
Test
Result (
°)
ROM reference values (°)
Foot
Sag
DF
R45
29.2±6.02
11-27 (Lindsjo, Danckwardt-Lilliestrom, & Sahlstedt,
1985; Mudge et al., 2013)
Sag
PF
LROT
0.4±4.6
36-56 (Boone & Azen, 1979; Lindsjo et al., 1985)
Front
Ev
R90
18.1±3.22
13-34 Schwarz, 2011 #1564;Macedo, 2009 #1567}
Front
Inv
L90
7.8±4.4
21-43 (Macedo & Magee, 2009; Schwarz, Kovaleski,
Heitman, Gurchiek, & Gubler-Hanna, 2011)
Trans
Abd
RROT
14.2±3.5
NR
Trans
Add
LROT
16.9±5.1
NR
Knee
Sag
Flex
A0
94.3±22.4
132-149 (Macedo & Magee, 2009; Roach & Miles,
1991)
Sag
Ext
RROT
7.9±12.8
-2 -4 (Boone & Azen, 1979; Mudge et al., 2013)
Front
Abd
LROT
5.5±2.42
frontal plane movement arch of 13° at 20° of knee
flexion (Levangie & Norkin, 2011).
Front
Add
R45
18.2±6.92
Trans
IR
LROT
15.7±3.72
15 (Almquist et al., 2002)
Trans
ER
RROT
24.4±5.22
20 (Almquist et al., 2002)
Hip
Sag
Flex
R45
109.0±8.2
113-133 (Macedo & Magee, 2009; Sankar, Laird, &
Baldwin, 2012)
Sag
Ext
L135
30.5±6.92
3-19 (Moreside & McGill, 2011; Roach & Miles, 1991)
Front
Abd
L90
18.2±7.4
34-60 (Macedo & Magee, 2009; Sankar et al., 2012)
Front
Add
R90
28.3±5.32
14-31 (Roaas & Andersson, 1982; Sankar et al., 2012)
Trans
IR
LROT
27.2±5.32
27-58 (Moreside & McGill, 2011; Mudge et al., 2013)
Trans
ER
RROT
32.2 ±5.42
32-48
(Mudge et al., 2013; Roach & Miles, 1991)
Trunk
Sag
Flex
A0
58.1±9.0
Lumbar: 40-60 Thoracic: 20-45 (Magee, 2006)
Sag
Ext
P180
35.1±7.8
Lumbar: 20-35 Thoracic: 25-40 (Magee, 2006)
Front
Lat Flex
L90/R90
38.1±6.71, 2
Lumbar: 15-20 Thoracic: 20-40 (Magee, 2006)
Trans
Rot
LROT/RROT
33.1±4.31
Lumbar: Rot: 3-18 Thoracic: 35-50 (Magee, 2006)
1= kinematic average of two tests
2= within or greater than range of ROM reference values
Abbreviations: NR=None Reported; L=Left; R=Right; B=Bilateral; DF=Dorsiflexion; PF=Plantarflexion; Ev=Eversion;
Inv=Inversion; Abd=Abduction; Add=Adduction; Flex=Flexion; Ext=Extension; IR=Internal Rotation; ER=External
Rotation; Lat Flexion= Lateral flexion; Rot=Rotation

HSEBT is eliciting more hip flexion than the
SEBT (72.0°-77.0°) (Doherty et al., 2015; Kang et
al., 2015). Hip extension is greater than ROM
reference values, but closer to what have been
observed in activities thought to require hip
extension such as sprint running (22°) (Kivi, Maraj,
& Gervais, 2002) and football kick (25°) (Smith &
Gilleard, 2015). In comparison, SEBT does not
challenge hip extension. Both hip internal and
external rotation are at the lower end of ROM
reference values. The rotational values are greater
than the internal (4.3°-8.0°) and external rotation
(5.2°-23.5°) values reported for the SEBT (Doherty
et al., 2015; Kang et al., 2015; Robinson & Gribble,
2008). Hip adduction is within ROM reference
values and greater than what has been found with the
SEBT (15°) (Doherty et al., 2015). Hip abduction is
less than ROM reference values, but similar to
SEBT (15°) (Robinson & Gribble, 2008).
Spine movements elicited by the HSEBT are
representative of both lumbar and thoracic spine
movement. The HSEBT is able to elicit flexion and
lateral flexion within, and extension, and rotation
just outside range of ROM reference values (Magee,
2006). SEBT do not elicit spine movements within
ROM reference values. However, selected
movements do predict reach distance (Kang et al.,
2015), which might indicate their importance in
balance and postural adjustments.
HSEBT elicits unique combinations of
movements in ankle joint complex, knee, hip and
spine. Observed joint movements, nine of twenty-
two possible, were within the ranges of goniometric
ROM reference values, while two (ankle
dorsiflexion and hip extension) where greater. In
comparison to the SEBT, the HSEBT elicits similar
or lower values for the ankle, but greater values for
the knee, hip and spine. In addition, hip extension
and spine movements are elicited by the HSEBT and
not SEBT. HSEBT offers a new and promising
approach to functional mobility testing that
integrates the full kinematic chain.
REFERENCES
Almquist, P. O., Arnbjornsson, A., Zatterstrom, R.,
Ryd, L., Ekdahl, C., & Friden, T. (2002).
Evaluation of an external device measuring
knee joint rotation: an in vivo study with
simultaneous Roentgen stereometric
analysis. Journal of orthopaedic research :
official publication of the Orthopaedic
Research Society, 20(3), 427-432.
doi:10.1016/S0736-0266(01)00148-6
Boone, D. C., & Azen, S. P. (1979). Normal range
of motion of joints in male subjects. J.Bone
Joint Surg.Am., 61(5), 756-759. Retrieved
from PM:457719
Craib, M. W., Mitchell, V. A., Fields, K. B., Cooper,
T. R., Hopewell, R., & Morgan, D. W.
(1996). The association between flexibility
and running economy in sub-elite male
distance runners. Med.Sci.Sports Exerc.,
28(6), 737-743. Retrieved from
PM:8784761
Delahunt, E., Chawke, M., Kelleher, J., Murphy, K.,
Prendiville, A., Sweeny, L., & Patterson,
M. (2013). Lower limb kinematics and
dynamic postural stability in anterior
cruciate ligament-reconstructed female
athletes. Journal of athletic training, 48(2),
172-185. doi:10.4085/1062-6050-48.2.05
Doherty, C., Bleakley, C. M., Hertel, J., Caulfield,
B., Ryan, J., & Delahunt, E. (2015).
Laboratory Measures of Postural Control
During the Star Excursion Balance Test
After Acute First-Time Lateral Ankle
Sprain. Journal of athletic training, 50(6),
651-664. doi:10.4085/1062-6050-50.1.09
Ford, K. R., Myer, G. D., Toms, H. E., & Hewett, T.
E. (2005). Gender differences in the
kinematics of unanticipated cutting in
young athletes. Med Sci Sports Exerc,
37(1), 124-129. Retrieved from
http://www.ncbi.nlm.nih.gov/pubmed/1563
2678
Freedman Silvernail, J., Boyer, K., Rohr, E.,
Bruggemann, G. P., & Hamill, J. (2015).
Running Mechanics and Variability with
Aging. Med Sci Sports Exerc.
doi:10.1249/MSS.0000000000000633
Greene, W., & Heckman, J. D. (1994). The clinical
measurement of joint motion. Rosemont,
IL: American Academy of Orthopedic
Surgeons.
Gribble, P. A., Hertel, J., & Plisky, P. (2012). Using
the Star Excursion Balance Test to assess
dynamic postural-control deficits and
outcomes in lower extremity injury: a
literature and systematic review. Journal of
athletic training, 47(3), 339-357.
doi:10.4085/1062-6050-47.3.08
Hubbard, T. J., Kramer, L. C., Denegar, C. R., &
Hertel, J. (2007). Contributing factors to

chronic ankle instability. Foot Ankle Int,
28(3), 343-354.
doi:10.3113/FAI.2007.0343
Kang, M. H., Kim, G. M., Kwon, O. Y., Weon, J.
H., Oh, J. S., & An, D. H. (2015).
Relationship Between the Kinematics of the
Trunk and Lower Extremity and
Performance on the Y-Balance Test. PM &
R : the journal of injury, function, and
rehabilitation.
doi:10.1016/j.pmrj.2015.05.004
Kivi, D. M., Maraj, B. K., & Gervais, P. (2002). A
kinematic analysis of high-speed treadmill
sprinting over a range of velocities. Med
Sci Sports Exerc, 34(4), 662-666.
Retrieved from
http://www.ncbi.nlm.nih.gov/pubmed/1193
2576
Levangie, P. K., & Norkin, C. C. (2011). Joint
Structure and function a comprehensive
analysis, 5th Ed. Philadelphia, PA: F. A.
Davis Company.
Lindsjo, U., Danckwardt-Lilliestrom, G., &
Sahlstedt, B. (1985). Measurement of the
motion range in the loaded ankle. Clinical
orthopaedics and related research(199),
68-71. Retrieved from
http://www.ncbi.nlm.nih.gov/pubmed/4042
498
Macedo, L. G., & Magee, D. J. (2009). Effects of
age on passive range of motion of selected
peripheral joints in healthy adult females.
Physiother Theory Pract, 25(2), 145-164.
doi:10.1080/09593980802686870
Magee, D. J. (2006). Orthopedic physical
assessment, 4th Ed: Saunder, Philadelphia,
PA. (Reprinted from: NOT IN FILE).
Menz, H. B., Morris, M. E., & Lord, S. R. (2006).
Foot and ankle risk factors for falls in older
people: a prospective study. J Gerontol A
Biol Sci Med Sci, 61(8), 866-870.
Retrieved from
http://www.ncbi.nlm.nih.gov/pubmed/1691
2106
Menz, H. B., Tiedemann, A., Kwan, M. M., Latt, M.
D., Sherrington, C., & Lord, S. R. (2003).
Reliability of clinical tests of foot and ankle
characteristics in older people. J Am
Podiatr Med Assoc, 93(5), 380-387.
Retrieved from
http://www.ncbi.nlm.nih.gov/pubmed/1313
0085
Moreside, J. M., & McGill, S. M. (2011).
Quantifying normal 3D hip ROM in
healthy young adult males with clinical and
laboratory tools: hip mobility restrictions
appear to be plane-specific. Clinical
biomechanics, 26(8), 824-829.
doi:10.1016/j.clinbiomech.2011.03.015
Mudge, A. J., Bau, K. V., Purcell, L. N., Wu, J. C.,
Axt, M., J., Selber, P., & Burns, J. (2013).
Normative reference values of lower limb
joint range, bone torsion, and alignment in
children aged 4-16 years. J Pediatr Orthop,
23, 15-25.
Roaas, A., & Andersson, G. B. (1982). Normal
range of motion of the hip, knee and ankle
joints in male subjects, 30-40 years of age.
Acta Orthop Scand, 53(2), 205-208.
Retrieved from
http://www.ncbi.nlm.nih.gov/pubmed/7136
564
Roach, K. E., & Miles, T. P. (1991). Normal hip and
knee active range of motion: the
relationship to age. Phys.Ther., 71(9), 656-
665. Retrieved from PM:1881956
Robinson, R., & Gribble, P. (2008). Kinematic
predictors of performance on the Star
Excursion Balance Test. Journal of sport
rehabilitation, 17(4), 347-357. Retrieved
from
http://www.ncbi.nlm.nih.gov/pubmed/1916
0909
Sankar, W. N., Laird, C. T., & Baldwin, K. D.
(2012). Hip range of motion in children:
what is the norm? J Pediatr Orthop, 32(4),
399-405.
doi:10.1097/BPO.0b013e3182519683
Schwarz, N. A., Kovaleski, J. E., Heitman, R. J.,
Gurchiek, L. R., & Gubler-Hanna, C.
(2011). Arthrometric measurement of
ankle-complex motion: normative values.
Journal of athletic training, 46(2), 126-132.
doi:10.4085/1062-6050-46.2.126
Smith, T., & Gilleard, W. (2015). Three-dimensional
analysis of a lofted instep kick by male and
female footballers. Eur J Sport Sci, 1-8.
doi:10.1080/17461391.2014.992477