Comparison of the Validity and Reliability of Three Different Methods Used for Wrist Proprioception Measurement
Conditions: Position Sense Disorders, Wrist
Sponsor: Gazi University

COMPARISON OF THE VALIDITY AND RELIABILITY OF THREE 
DIFFERENT METHODS USED FOR WRIST PROPRIOCEPTION 
MEASUREMENT 
The most recently revised date: 06.25.2018 
The Human Subjects Protection Review Board 
approbation date: 06.25.2018 

STUDY PROTOCOL 
Participants 
 The prior sample size calculation section of G*Power 3.1.9.2 software revealed that the 
inclusion of 32 healthy participants (64 wrists) was necessary for achieving 95% power 
individuals who suffered an injury or underwent a surgical procedure in the last six 
months that could affect hand functions or senses were excluded from the study. 
Additionally, individuals with a history of neuromuscular disease, traumatic nerve injury, 
congenital anomalies, or skin infections were excluded. An informed consent form was 
obtained from all participants. An independent ethics committee approved the study 
(approval number:24074710--028). 
Instrumentation 
The Cybex isokinetic dynamometer [Cybex NORM®, Humac, CA, USA] was used as a 
reference standard to test the validity of the universal goniometer, inclinometer [Acumar, 
Lafayette Instrument Co., Lafayette, USA], and JPSG. The isokinetic dynamometer is a 
well-known instrument for measuring passive and active joint position sense (AJPS) and 
provides a target angle result without rater bias (Relph &  Herrington, 2015). The Cybex 
isokinetic dynamometer has a good reliability in evaluating wrist AJPS (Seven et al., 
2019).  
Procedures 
The evaluation of proprioception using the isokinetic dynamometer was performed with 
the participants in sitting. The shoulder was positioned in the midline, the elbow was 
flexed about 90°, and the wrist was positioned in supination (Brown, 2000). During the 
evaluation, the forearm was fixed with a strap to prevent the forearm from moving and 
changing the angle of the wrist. The rotation axis of the dynamometer was aligned with 
the diagonal axis of the distal tubercule of radius and the head of ulna (Figure 1). The 

wrist was placed in a 0° position. In this starting position, the range of motion was set as 
40° flexion and 40°extension (Ellenbecker et al., 2006). The device was calibrated before 
the evaluation of each participant.  
 
The goniometric (1° scale increments) measurement was performed with the elbow 
positioned at 90° flexion and resting on the table, the forearm was in mid-pronation, and 
the fingers were relaxed (Hagert, 2010; Karagiannopoulos et al., 2016; Pilbeam &  Hood-
Moore, 2018). The movement axis of the mid-carpal and radiocarpal joints is defined as 
the pivot point of the goniometer to ensure a compatible measurement of wrist movement. 
The stable arm of the goniometer was placed parallel to the radius, and the mobile arm 
was followed the third metacarpal bone (Figure 2) (Pilbeam &  Hood-Moore, 2018). 

The JPSG consists of two wooden boards fixed at an angle of 90°. The plate perpendicular 
to the ground has an opening that the wrist can go through. 0 to 180° angle values with 1° 
increment were drawn on the plate that parallels the floor (Erdem, 2013). For the 
evaluation, the participant was asked to sit in front of the table with the trunk upright and 
the shoulder in the neutral position. The patient's forearm passed through the opening in 
the JPSG, and the wrist joint was adjusted to match the axis of movement (Figure 3). The 
forearm was positioned in mid-pronation, the wrist was positioned at 0° flexion/extension, 
and the forearm was in the neutral position. Participants were asked not to contact the 
plates during the measurements. 

 
Another tool used to evaluate wrist AJPS was the digital dual inclinometer. The limb 
position used during the inclinometer evaluations was the same as the position for the 
goniometer. One of the inclinometer sensors was placed on the 3rd metacarpal bone on the 
dorsal side of the hand. The other sensor was placed on the dorsal side of the forearm, 
perpendicular to the flexion/extension movement axis (Figure 4).  
 
AJPS was measured to evaluate wrist proprioception. An eyepatch was used during all 
tests to prevent visual stimuli, and the evaluations were performed in a quiet room. The 

30° extension, which is the functional position of the wrist, was selected as the target 
angle for AJPS assessment (Neumann, 2002; Seven et al., 2019). After the test was 
explained to the participants, they were asked to actively bring the wrist from the neutral 
(0° flexion/extension) to 30° extension (a barrier was placed at 30° line) and wait for 5 
seconds at this position. The participants were then asked to return to the starting position 
(a block was also placed at 0°). The participants were then asked to find the target angle. 
This trial was repeated three times. The amount of error between the target and achieved 
angles were recorded as the absolute angular error. The relative error amount was 
calculated using the arithmetic mean of these three absolute angular errors (Suner-Keklik 
et al., 2017). The same measurements were repeated for the other limb. The same rater 
performed all measurements. 
All evaluations were repeated at the same hour of the day, seven days after the first 
measurement by the same rater to examine the test-retest reliability of the methods 
(Holmbäck et al., 1999). To avoid the learning effect(Feiring et al., 1990), the order which 
extremities were assessed (right/left) was determined using a web-based “Random 
Sequence 
Generator 
Application” 
(https://www.random.org/sequences/).The 
same 
randomization method was used to determine the order of the evaluation methods. The 
sequence used for each participant on the first evaluation was repeated on the second 
evaluation. A five-minute rest period was given between each measurement to eliminate 
the effect of muscle fatigue. As AJPS was demonstrated to significantly reduce during the 
menstruation period, the evaluation days of the female participants were arranged not to 
coincide with the week of menstruation (Aydoğ et al., 2005). 

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