Does the Duncan-Ely test predict abnormal activity of the rectus femoris in stroke survivors with a stiff knee gait?
DOI:
https://doi.org/10.2340/jrm.v53.637Keywords:
stroke, stiff knee gait, rectus femoris, spasticity, Duncan-Ely test, diagnosticAbstract
Objective: To determine the diagnostic value of the Duncan-Ely test in predicting abnormal rectus femoris activity during gait in stroke survivors walking with a stiff knee gait.
Design: Cross-sectional diagnostic study.
Subjects: A total of 95 patients with chronic stroke.
Methods: During physical examination, the Duncan-Ely test was performed and scored. Surface electromyography of the rectus femoris was then recorded during dynamic gait. To determine the diagnostic value, the results of the Duncan-Ely test and surface electromyography recordings (gold standard) were compared.
Results: The Duncan-Ely test had a sensitivity of 73%, a specificity of 29%, a positive predictive value of 60%, and a negative predictive value of 42%. The area under the curve was 0.488 ([AQ1] CI 0.355–0.621, p = 0.862), showing that the Duncan-Ely test is not better than random guessing.
Conclusion: The Duncan-Ely test has no predictive value for determining abnormal activity of the rectus femoris during gait. Using this test can lead to incorrect identification of abnormal rectus femoris activity, which might hamper the selection of optimal treatment options. We recommend stopping use of the Duncan-Ely test to predict rectus femoris overactivity during swing, and instead use surface electromyography.
Downloads
References
Riley PO, Kerrigan DC. Torque action of two-joint muscles in the swing period of stiff-legged gait: a forward dynamic model analysis. J Biomech 1998; 31: 835-840.
https://doi.org/10.1016/S0021-9290(98)00107-9
Piazza SJ, Delp SL. The influence of muscles on knee flexion during the swing phase of gait. J Biomech 1996; 29: 723-733.
https://doi.org/10.1016/0021-9290(95)00144-1
Goldberg SR, Anderson FC, Pandy MG, Delp SL. Muscles that influence knee flexion velocity in double support: implications for stiff-knee gait. J Biomech 2004; 37: 1189-1196.
https://doi.org/10.1016/j.jbiomech.2003.12.005
Perry J. Gait analysis: normal and pathological function. Thorofare, NJ: Slack, 1992.
https://doi.org/10.1097/01241398-199211000-00023
Tenniglo MJB, Buurke JH, Prinsen EC, Kottink AIR, Nene AV, Rietman JS. Influence of functional electrical stimulation of the hamstrings on knee kinematics in stroke survivors walking with stiff knee gait. J Rehabil Med 2018; 50: 719-724.
https://doi.org/10.2340/16501977-2367
Stoquart GG, Detrembleur C, Palumbo S, Deltombe T, Lejeune TM. Effect of botulinum toxin injection in the rectus femoris on stiff-knee gait in people with stroke: a prospective observational study. Arch Phys Med Rehab 2008; 89: 56-61.
https://doi.org/10.1016/j.apmr.2007.08.131
Tenniglo MJ, Nederhand MJ, Prinsen EC, Nene AV, Rietman JS, Buurke JH. Effect of chemodenervation of the rectus femoris muscle in adults with a stiff knee gait due to spastic paresis: a systematic review with a meta-analysis in patients with stroke. Arch Phys Med Rehab 2014; 95: 576-587.
https://doi.org/10.1016/j.apmr.2013.11.008
Perry J. Distal rectus femoris transfer. Develop Med Child Neurol 1987; 29: 153-158.
https://doi.org/10.1111/j.1469-8749.1987.tb02130.x
Gage JR, Perry J, Hicks RR, Koop S, Werntz JR. Rectus femoris transfer to improve knee function of children with cerebral palsy. Develop Med Child Neurol 1987; 29: 159-166.
https://doi.org/10.1111/j.1469-8749.1987.tb02131.x
Millodot M. Dictionary of Optometry and Visual Science, 7th ed, Edinburgh; New York, Butterworth-Heinemann Elsevier. 2009
Drefus LC, Clarke S, Resnik K, Koltsov J, Dodwell ER, Scher DM. The Root-Ely modified test of rectus femoris spasticity has reliability in individuals with cerebral palsy. HSS J 2018; 14: 143-147.
https://doi.org/10.1007/s11420-018-9609-5
Marks MC, Alexander J, Sutherland DH, Chambers HG. Clinical utility of the Duncan-Ely test for rectus femoris dysfunction during the swing phase of gait. Develop Med Child Neurol 2003; 45: 763-768.
https://doi.org/10.1111/j.1469-8749.2003.tb00886.x
Bleck EE. Orthopaedic management in cerebral palsy. Clinics in developmental medicine Vol No 99/100. London: Mac Keith Press, 1987.
Sutherland DH, Davids JR. Common gait abnormalities of the knee in cerebral palsy. Clin Orthop Relat Res 1993; 288: 139-147.
https://doi.org/10.1097/00003086-199303000-00018
Fleuren JF, Voerman GE, Erren-Wolters CV, Snoek GJ, Rietman JS, Hermens HJ, et al. Stop using the Ashworth Scale for the assessment of spasticity. J Neurol Neurosurg Psychiatry 2010; 81: 46-52.
https://doi.org/10.1136/jnnp.2009.177071
Hermens HJ, Freriks B, Merletti R, et al. European Recommendations for Surface ElectroMyoGraphy. Enschede: Roessingh Research and Development, 1999.
Byrne CA, Lyons GM, Donnelly AE, O'Keeffe DT, Hermens H, Nene A. Rectus femoris surface myoelectric signal cross-talk during static contractions. J Electromyogr Kinesiol 2005; 15: 564-575.
https://doi.org/10.1016/j.jelekin.2005.03.002
Perry J, Hoffer MM, Antonelli D, Plut J, Lewis G, Greenberg R. Electromyography before and after surgery for hip deformity in children with cerebral palsy. A comparison of clinical and electromyographic findings. J Bone Joint Surg Am 1976; 58: 201-208.
https://doi.org/10.2106/00004623-197658020-00007
Tok F, Balaban B, Yasar E, Alaca R, Tan AK. The effects of onabotulinum toxin A injection into rectus femoris muscle in hemiplegie stroke patients with stiff-knee gait. Am J Phys Med Rehabil 2012; 91: 321-326.
https://doi.org/10.1097/PHM.0b013e3182465feb
Chantraine F, Detrembleur C, Lejeune TM. Effect of the rectus femoris motor branch block on post-stroke stiff-legged gait. Acta Neurol Belg 2005; 105: 171-177.
Ellington MD, Scott AC, Linton J, Sullivan E, Barnes D. Rectus femoris transfer versus rectus intramuscular lengthening for the treatment of stiff knee gait in children with cerebral palsy. J Pediatr Orthop 2018; 38: e213-e218.
https://doi.org/10.1097/BPO.0000000000001138
Gross R, Robertson J, Leboeuf F, Hamel O, Brochard S, Perrouin-Verbe B. Neurotomy of the rectus femoris nerve: short-term effectiveness for spastic stiff knee gait: clinical assessment and quantitative gait analysis. Gait Posture 2017; 52: 251-257.
https://doi.org/10.1016/j.gaitpost.2016.11.032
Lee SY, Sung KH, Chung CY, Lee KM, Kwon SS, Kim TG, et al. Reliability and validity of the Duncan-Ely test for assessing rectus femoris spasticity in patients with cerebral palsy. Dev Med Child Neurol 2015; 57: 963-968.
https://doi.org/10.1111/dmcn.12761
Banky M, Ryan HK, Clark R, Olver J, Williams G. Do clinical tests of spasticity accurately reflect muscle function during walking: a systematic review. Brain Inj 2017; 31: 440-455.
https://doi.org/10.1080/02699052.2016.1271455
Ada L, Vattanasilp W, O'Dwyer NJ, Crosbie J. Does spasticity contribute to walking dysfunction after stroke? J Neurol Neurosurg Psychiatry 1998; 64: 628-635.
https://doi.org/10.1136/jnnp.64.5.628
Graham HK. Pendulum test in cerebral palsy. Lancet 2000; 355: 2184.
https://doi.org/10.1016/S0140-6736(00)02399-0
Brashear A, Elovic E. Spasticity: diagnosis and management. Demos Medical, New York: Springer Publishing Co.; 2011.
Dietz V, Sinkjaer T. Spastic movement disorder: impaired reflex function and altered muscle mechanics. Lancet Neurol 2007; 6: 725-733.
https://doi.org/10.1016/S1474-4422(07)70193-X
Yelnik A, Albert T, Bonan I, Laffont I. A clinical guide to assess the role of lower limb extensor overactivity in hemiplegic gait disorders. Stroke 1999; 30: 580-585.
https://doi.org/10.1161/01.STR.30.3.580
Perry J, Waters RL, Perrin T. Electromyographic analysis of equinovarus following stroke. Clin Orthop Relat Res 1978; 131: 47-53.
https://doi.org/10.1097/00003086-197803000-00007
Fleuren JF, Nederhand MJ, Hermens HJ. Influence of posture and muscle length on stretch reflex activity in poststroke patients with spasticity. Arch Phys Med Rehabil 2006; 87: 981-988.
https://doi.org/10.1016/j.apmr.2006.03.018
Kakebeeke TH, Lechner H, Baumberger M, Denoth J, Michel D, Knecht H. The importance of posture on the isokinetic assessment of spasticity. Spinal Cord 2002; 40: 236-243.
https://doi.org/10.1038/sj.sc.3101282
Vodovnik L, Bowman BR, Bajd T. Dynamics of spastic knee joint. Med Biol Eng Comput 1984; 22: 63-69.
https://doi.org/10.1007/BF02443747
Lamontagne A, Malouin F, Richards CL. Locomotor-specific measure of spasticity of plantarflexor muscles after stroke. Arch Phys Med Rehabil 2001; 82: 1696-1704.
https://doi.org/10.1053/apmr.2001.26810
Nonnekes J, Benda N, van Duijnhoven H, et al. Management of gait impairments in chronic unilateral upper motor neuron lesions: a review. JAMA Neurol 2018; 75: 751-758.
https://doi.org/10.1001/jamaneurol.2017.5041
Kay RM, Rethlefsen SA, Kelly JP, Wren TA. Predictive value of the Duncan-Ely test in distal rectus femoris transfer. J Pediatr Orthop 2004; 24: 59-62.
https://doi.org/10.1097/01241398-200401000-00011
Muthusamy K, Seidl AJ, Friesen RM, Carollo JJ, Pan Z, Chang FM. Rectus femoris transfer in children with cerebral palsy: evaluation of transfer site and preoperative indicators. J Pediatr Orthop 2008; 28: 674-678.
https://doi.org/10.1097/BPO.0b013e3181804c04
Hemo Y, Aiona MD, Pierce RA, Dorociak R, Sussman MD. Comparison of rectus femoris transposition with traditional transfer for treatment of stiff knee gait in patients with cerebral palsy. J Child Orthop 2007; 1: 37-41.
https://doi.org/10.1007/s11832-006-0002-4
Lofterod B, Terjesen T. Results of treatment when orthopaedic surgeons follow gait-analysis recommendations in children with CP. Dev Med Child Neurol 2008; 50: 503-509.
Published
How to Cite
License
Copyright (c) 2021 Martin J. B. Tenniglo, Marc J. Nederhand, Judith F. Fleuren, Johan S. Rietman, Jaap H. Buurke, Erik C. Prinsen
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
All digitalized JRM contents is available freely online. The Foundation for Rehabilitation Medicine owns the copyright for all material published until volume 40 (2008), as from volume 41 (2009) authors retain copyright to their work and as from volume 49 (2017) the journal has been published Open Access, under CC-BY-NC licences (unless otherwise specified). The CC-BY-NC licenses allow third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material for non-commercial purposes, provided proper attribution to the original work.
From 2024, articles are published under the CC-BY licence. This license permits sharing, adapting, and using the material for any purpose, including commercial use, with the condition of providing full attribution to the original publication.
