Quantification of upper limb position sense using an exoskeleton and a virtual reality display

Proprioceptive sense plays a significant role in the generation and correction of skilled movements and, consequently, in most activities of daily living. We developed a new proprioception assessment protocol that enables the quantification of elbow position sense without using the opposite arm, involving active movement of the evaluated limb or relying on working memory. The aims of this descriptive study were to validate this assessment protocol by quantifying the elbow position sense of healthy adults, before using it in individuals who sustained a stroke, and to investigate its test-retest reliability.

Elbow joint position sense was quantified using a robotic device and a virtual reality system. Two assessments were performed, by the same evaluator, with a one-week interval. While the participant's arms and hands were occluded from vision, the exoskeleton passively moved the dominant arm from an initial to a target position. Then, a virtual arm representation was projected on a screen placed over the participant's arm. This virtual representation and the real arm were not perfectly superimposed, however. Participants had to indicate verbally the relative position of their arm (more flexed or more extended; two-alternative forced choice paradigm) compared to the virtual representation. Each participant completed a total of 136 trials, distributed in three phases. The angular differences between the participant's arm and the virtual representation ranged from 1° to 27° and changed pseudo-randomly across trials. No feedback about results was provided to the participants during the task. A discrimination threshold was statistically extracted from a sigmoid curve fit representing the relationship between the angular difference and the percentage of successful trials. Test-retest reliability was evaluated with 3 different complementary approaches, i.e. a Bland-Altman analysis, an intraclass correlation coefficient (ICC) and a standard error of measurement (SEm).

Thirty participants (24.6 years old; 17 males, 25 right-handed) completed both assessments. The mean discrimination thresholds were 7.0 ± 2.4 (mean ± standard deviation) and 5.9 ± 2.1 degrees for the first and the second assessment session, respectively. This small difference between assessments was significant (- 1.1 ± 2.2 degrees), however. The assessment protocol was characterized by a fair to good test-retest reliability (ICC = 0.47).

This study demonstrated the potential of this assessment protocol to objectively quantify elbow position sense in healthy individuals. Futures studies will validate this protocol in older adults and in individuals who sustained a stroke.