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Abstract

BACKGROUND:

Reduced mobility of upper and lower limbs has been associated with injuries in athletes. The Combined Elevation Test (CET) and the Weight-Bearing Dorsiflexion Lunge Test (WBDLT) are frequently used in clinical and research settings in face-to-face evaluations. However, some situations require physical distancing, and it is unknown whether those tests via telehealth are reliable.

OBJECTIVE:

To evaluate the intra-rater reliability, the Standard Error of Measurement (SEM), and the Minimum Detectable Change (MDC) for considering a real change on the CET and WBDLT were calculated for healthy athletes via telehealth.

METHODS:

67 athletes (25 years, 73 kg, and 1.75 m on average) participated in this study. 37 athletes performed the CET and 50 performed the WBDLT (20 performed both tests). Reliability was assessed through two online evaluations (7 to 15-days apart).

RESULTS:

ICC ${}_{3,3}$ ranged from 0.88–0.97 for the CET and from 0.95–0.98 for the WBDLT. For both tests, SEM values were low ( $<$ 8.9%) and the MDC ${}_{90}$ was approximately 4 cm and 2 cm for the CET and WBDLT, respectively.

CONCLUSIONS:

Telehealth-based findings relating to CET and WBDLT are reliable in healthy adult athletes and can be used to screen this population when face-to-face evaluations are not feasible.

Keywords

Reproducibility range of motion physical therapy modalities telehealth

1. Background

Mobility tests are frequently used to assess athletic and non-athletic populations, either in healthy individuals as part of injury prevention programs, or in those undergoing post-injury rehabilitation to assess changes after a treatment and the likelihood of return to sports practice [1, 2, 3].

The Combined Elevation Test (CET) is a mobility test that assesses the active range of motion of the trunk and shoulders, including thoracic extension and elevation of the arms against gravity [3, 4, 5]. The CET was developed to assess swimmers, but it has been also used to assess different athletic or non-athletic populations due to the association between shoulder pain and reduced mobility of the thoracic spine and glenohumeral joint [2, 3, 6].

The Weight-Bearing Dorsiflexion Lunge Test (WBDLT) assesses the ankle weight-bearing dorsiflexion range of motion [7, 8]. It is widely used to access athletes of several sports modalities, such as cutting/pivoting sports [2, 9, 10, 11, 12, 13, 14], cricket [15], volleyball [16], running [17], judo [18], and artistic gymnastic [19]. The reduced ankle dorsiflexion range of motion has been associated with several lower limb injuries [9, 11, 15, 20, 21], so the WBDLT is considered a key component of periodic health evaluation using screening tests and is frequently used as outcome measure of clinical trials [7, 20, 21, 22].

The CET and the WBDLT are easily assembled and performed using inexpensive materials often used in face-to-face evaluations. Furthermore, those tests do not need a specific clinical environment and they can be applied in situations when face-to-face evaluations are disrupted or discontinued.

Recently, the COVID-19 pandemic required social distancing and showed that the assessment and periodical health evaluations of athletes may be a challenging situation. In this context, there was a need for alternative ways of continuing evaluating athletes for prevention or for rehabilitation of musculoskeletal injuries. So, the assessment via telehealth emerged to replace face-to-face assessments when they were not secured. Besides the pandemic context, telehealth has the advantage of assuring the screening and clinical follow up with no need for clinic time and space, diminishing the costs for the clinician and also reducing time and money spent on the transportation of the patient to the clinic [23, 24].

Some psychometric properties of the CET and the WBDLT have been investigated previously using a face-to-face assessment [2, 3, 6, 7, 16, 20, 25]. However, the circumstances that the measurements are taken might influence the psychometric properties of an instrument. With regard to telehealth assessments, data referring to reliability, measurement error, and minimum detectable change have not yet been presented. Therefore, the aim of this study was to evaluate the intra-rater reliability, error measurement and minimum detectable change of these two mobility tests performed via telehealth assessments with healthy athletes.

2. Methods

2.1 Subjects

Sixty-seven asymptomatic athletes (86.5% amateurs; 25 years, 73 kg and 1.75 m in average) were recruited through online advertisements posted in social media between January and July of 2021. Athlete’s demographic characteristics and level of training/competition are shown in Table 1, according to the test performed. 37 athletes (19 males) performed the CET and 50 athletes (24 males) performed the WBDLT. In total, 20 athletes performed both tests, so their demographic characteristics were duplicated for each test.

Table 1
Characteristics of the athletes that performed the combined elevation test and the weight-bearing dorsiflexion lunge test

	Combined elevation test			Weight-bearing dorsiflexion lunge test
	All athletes ( $n=$ 37)	Males ( $n=$ 19)	Females ( $n=$ 18)	All athletes ( $n=$ 50)	Males ( $n=$ 24)	Females ( $n=$ 26)
Demographic characteristics
Age (years)	24.51 $\pm$ 5.97	25.84 $\pm$ 6.44	23.11 $\pm$ 5.25	24.98 $\pm$ 5.64	25.79 $\pm$ 5.97	24.23 $\pm$ 5.32
Body mass (kg)	75.85 $\pm$ 12.32	83.55 $\pm$ 9.76	67.73 $\pm$ 9.20	70.71 $\pm$ 12.27	78.66 $\pm$ 10.69	63.38 $\pm$ 8.57
Stature (m)	1.79 $\pm$ 0.09	1.78 $\pm$ 0.06	1.66 $\pm$ 0.08	1.71 $\pm$ 0.08	1.77 $\pm$ 0.04	1.66 $\pm$ 0.06
Body Mass Index (kg/m ${}^{2}$ )	25.2 $\pm$ 3.24	26.0 $\pm$ 2.95	24.2 $\pm$ 3.37	23.9 $\pm$ 2.95	25.01 $\pm$ 3.16	22.9 $\pm$ 2.40
Experience (years)	9.35 $\pm$ 5.66	8.84 $\pm$ 5.38	9.88 $\pm$ 6.04	8.85 $\pm$ 5.00	8.30 $\pm$ 5.91	9.36 $\pm$ 4.04
Level of practice
Amateurs	32 (86.5%)	18 (94.7%)	14 (77.8%)	44 (88%)	21 (87.5%)	21 (87.5%)
Professionals	5 (13.5%)	1 (5.3%)	4 (22.2%)	6 (12%)	3 (12.5%)	3 (11.5%)
Highest level of competition
State	17 (45.9%)	6 (31.6%)	11 (61.1%)	22 (44%)	9 (37.5%)	13 (50%)
National	9 (24.3%)	7 (36.8%)	2 (11.1%)	10 (20%)	6 (25%)	4 (15.4%)
International	5 (13.5%)	2 (10.5%)	3 (16.7%)	7 (14%)	2 (8.3%)	5 (19.2%)
Regional	5 (13.5%)	4 (21.1%)	1 (5.6%)	7 (14%)	4 (16.7%)	3 (11.5%)
Local	1 (2.7%)	0 (0%)	1 (5.6%)	4 (8%)	3 (12.5%)	1 (3.8%)

kg: kilogram; m: meters. Values expressed in Mean $\pm$ Standard Deviation.

Athletes were included if they: 1) presented at least two years of experience in any sports modality; 2) were classified as “physically active” according to the Brazilian Portuguese version of the International Physical Activity Questionnaire – Short Form [26, 27]; 3) were enrolled in a sports club or team; 4) participated in sports competitions in the last two years and 5) did not present history of surgery or bone fracture in the previous twelve months or joint dislocations. Athletes who missed an evaluation or reported pain/injury during the study period were excluded.

A questionnaire was sent via Google ${}^{\@setsize{\scriptsize}{8pt}{\viipt}{\@viipt}{\textregistered}}$ Forms (© Google LLC, CA, USA) prior to the assessments to track the stability of pain, well-being and recovery on the days before each assessment. The presence and intensity of any pain was determined using the Numerical Pain Rating Scale [28]. Aspects of well-being were assessed by considering fatigue, sleep, muscle soreness, stress and mood [29] and the overall recovery was measured using the Total Quality Recovery scale [30], with a score from 6 (not recovered) to 20 (fully recovered).

2.2 Procedures

This study was approved by the Human Research Ethics Committee of the Federal University of São Carlos (No. 4.365.562), São Carlos, SP, Brazil. All athletes received explanations about the study and those who agreed to participate signed an online informed consent via Google ${}^{\@setsize{\scriptsize}{8pt}{\viipt}{\@viipt}{\textregistered}}$ Forms. The present study is in accordance to the declaration of Helsinki [31] for experiments involving humans and was designed and reported according to the COnsensus-based Standards for the selection of health status Measurement INstruments [32] and the Guidelines for Reporting Reliability and Agreement Studies [33], respectively.

The athletes interested in participating in this study answered an online form (via Google ${}^{\@setsize{\scriptsize}{8pt}{\viipt}{\@viipt}{\textregistered}}$ Forms) with their contact information. Afterwards, the researcher contacted the participants and provided detailed information about the study. If the athlete agreed to participate, the online consent form was sent and they should read and sign it. Athletes were then assessed for eligibility through another online form containing questions based on the study’s inclusion criteria.

Three independent raters (GVG, HRFF, and MTMJ) contacted, screened, and conducted the standardized online evaluations with the athletes, supervised by three experienced physiotherapists (DHK, GMB, and LBC). All raters participated in a standardized training before the beginning of the study, and the whole procedure of recruiting, contacting, checking for eligibility, and both online evaluations of each athlete was made by the same rater. Inter-rater reliability was not assessed in this study L134-6.

Each athlete participated in two 20-min real-time evaluations via Google ${}^{\@setsize{\scriptsize}{8pt}{\viipt}{\@viipt}{\textregistered}}$ Meet (© Google LLC, CA, USA) conducted by the same rater and separated by an interval of 7 to 15 days. Prior to the first evaluation, all athletes received a detailed material with instructions for the setting up and performing of the tests. Furthermore, the athletes were instructed to perform both evaluations in the same place (in their houses, preferably) and period of the day to ensure similar conditions.

In both assessment sessions and before the mobility tests, all athletes performed a warm-up consisting of aerobic exercises (skipping and jumping jacks) for 3-min with moderate intensity, according to the Modified 1–10 Rating of Perceived Exertion Scale [34]. Then, the athletes performed the CET or WBDLT, according to their sport modality. The athletes of overhead, water, combat, and racket sports performed the CET. The athletes of modalities that involve jumping, running, combating, and change of direction abilities performed the WBDLT. When the sport modality involved movements in both upper and lower body, the athlete was invited to perform both tests.

2.3 Combined elevation test (CET)

The CET assesses the combined active range of motion of the thoracic extension and arm elevation against gravity [3, 4, 5]. Prior to the assessment session, the athletes received instruction to build a simple device using paper and masking tape. The athlete folded the paper and attached it to a masking tape that was vertically placed on the wall. The folded paper was supposed to slide up on the vertical tape while the athlete performed the test, enabling the athletes to measure the test’s outcome (Fig. 1).

Figure 1.

Device made for assessing the combined elevation test.

Figure 2.

Starting position for the combined elevation test assessment.

The laptop/smartphone camera was positioned laterally, providing the rater a view of the device and the athlete’s torso. Then, they were instructed to lie prone on the floor, with the forehead in contact with the floor, upper limbs positioned above the head (approximately 180 degrees of shoulder flexion), elbows fully extended and fingers intertwined with the thumbs pointing to the ceiling (Fig. 2) [1, 3]. During the test, the athletes deeply breathed in and raised their upper limbs off the floor, reaching the maximum height they could while sliding up the folded paper with their intertwined fingers [1, 3]. The forehead and torso should remain in contact with the floor during the test (Fig. 3). If the forehead lost contact with the floor or the device did not work properly, a new trial was performed. No words of encouragement were given during the test [1, 3].

Figure 3.

Final position for the combined elevation test assessment.

In both sessions, a familiarization trial was allowed before the athlete performed three maximum efforts, with 20-s rest period between them. The perpendicular distance between the inferior border of the folded paper and the floor was measured (in cm) and the mean value of the three trials was considered for the analysis.

2.4 Weight-bearing dorsiflexion lunge test (WBDLT)

The WBDLT was used to assess the range of motion of the ankle during weight-bearing dorsiflexion [7, 8]. To determine the order of assessment, dominant and non-dominant limbs were randomized in the first assessment session and the order was repeated in the second assessment session. To guide the alignment of the lower limb during the test (foot, leg, and hips), the athletes were instructed to place a 40 cm length masking tape line on the floor. Then, they placed a 70 cm length vertical tape on the wall, aligned with the tape on the floor (Fig. 4).

Figure 4.

Set-up for the weight-bearing dorsiflexion lunge test assessment.

The athlete assumed the lunge position while facing the wall, with the foot to be assessed in front. The second toe and the heel of the foot to be assessed should be aligned with the tape on the floor, while the contralateral limb could be freely positioned. To maintain balance, the hands should be placed on the wall [7, 8].

The laptop/smartphone’s camera was positioned close to the wall and laterally to the assessed ankle, providing the rater a view of the athlete’s lower limb during the test. Then, the athlete was instructed to lunge forward and touch the patella against the masking tape placed on the wall, while keeping the knee in line with the second toe and the heel on the ground. The test aimed to obtain the maximum distance between the tip of the second toe and the wall, keeping the heel on the floor (i.e. maximum dorsiflexion angle) (Fig. 5) [7, 8].

Figure 5.

The Weight-bearing dorsiflexion lunge test assessment.

Table 2

Sports modalities of the athletes that performed the combined elevation test

Sports modalities	All athletes ( $n=$ 37)	Male ( $n=$ 19)	Female ( $n=$ 18)
Handball/Beach Handball	18 (48.6%)	4 (21.1%)	14 (77.8%)
Rugby	5 (13.5%)	3 (15.8%)	2 (11.1%)
Water Sports	5 (13.5%)	3 (15.8%)	2 (11.1%)
Combat Sports	3 (8.1%)	3 (15.8%)	0 (0%)
Racket Sports	3 (8.1%)	3 (15.8%)	0 (0%)
Volleyball/Beach Volleyball	2 (5.4%)	2 (10.5%)	0 (0%)
Basketball	1 (2.7%)	1 (5.3%)	0 (0%)

Table 3

Sports modalities of the athletes that performed the weight-bearing dorsiflexion lunge test

Sports modalities	All athletes ( $n=$ 50)	Male ( $n=$ 24)	Female ( $n=$ 26)
Handball/Beach Handball	18 (36%)	3 (12.5%)	15 (57.7%)
Rugby	7 (14%)	6 (25%)	1 (3.8%)
Athletics	5 (10%)	4 (16.7%)	1 (3.8%)
Combat Sports	4 (8%)	1 (4.2%)	3 (11.5%)
Running	4 (8%)	2 (8.3%)	2 (7.7%)
Racket Sports	3 (6%)	3 (12.5%)	0 (0%)
Futsal/Soccer	3 (6%)	0 (0%)	3 (11.5%)
Basketball	2 (4%)	2 (8.3%)	0 (0%)
Volleyball/Beach Volleyball	2 (4%)	2 (8.3%)	0 (0%)
Water Sports	1 (2%)	0 (0%)	1 (3.8%)
Cycling	1 (2%)	1 (4.2%)	0 (0%)

Each lower limb was alternately tested twice, with no rest between trials. No familiarization trial was necessary and the number of lunge attempts for reaching the maximum dorsiflexion angle was not restricted. The athlete was instructed to measure the distance between the tip of the second toe and the wall (in cm) when the maximum distance was reached keeping the heel on the floor. The mean value of the two trials of the dominant and non-dominant limbs was considered for the analysis.

2.5 Data analysis

Descriptive data was presented as mean and Standard Deviation (SD). Data normality was verified by Kolmogorov-Smirnov’s test. The intra-rater reliability was measured with the Intraclass Correlation Coefficient (ICC) and with a 95% Confidence Interval (95%CI). The intra-rater reliability was analyzed with an ICC ${}_{(3,3)}$ for the CET and an ICC ${}_{(3,2)}$ for the WBDLT. The ICC were classified as poor when below 0.50, moderate from 0.50 to 0.75, good from 0.75 to 0.90, and excellent when greater than 0.90 [35].

The IBM ${}^{\@setsize{\scriptsize}{8pt}{\viipt}{\@viipt}{\textregistered}}$ SPSS ${}^{\@setsize{\scriptsize}{8pt}{\viipt}{\@viipt}{\textregistered}}$ Statistics 22.0 (© IBM Corp., NY, USA) for Microsoft ${}^{\@setsize{\scriptsize}{8pt}{\viipt}{\@viipt}{\textregistered}}$ Windows ${}^{\@setsize{\scriptsize}{8pt}{\viipt}{\@viipt}{\textregistered}}$ 10 (© Microsoft, WA, USA) was used for data analysis. Standard Error of Measurement (SEM) and Minimum Detectable Change at the 90% confidence interval (MDC ${}_{90}$ ) were calculated using Microsoft ${}^{\@setsize{\scriptsize}{8pt}{\viipt}{\@viipt}{\textregistered}}$ Excel ${}^{\@setsize{\scriptsize}{8pt}{\viipt}{\@viipt}{\textregistered}}$ 2016 (© Microsoft, WA, USA), by the following formulas: SEM $=$ SD ${}_{\textit{pooled}}x\surd$ (1 – ICC) and MDC ${}_{90}$ $=$ SEM $x$ 1.65 $x$ $\surd$ 2. The SEM represents a random measurement error, while the MDC ${}_{90}$ is responsible for defining the minimum change that must be achieved for considering the occurrence of a real change in the outcome, beyond of random measurement error. Both values are described in the same unit as the measurement itself [35].

3. Results

The predominant modalities of the athletes that performed the CET were handball/beach handball (48.6%), rugby (13.5%), and water sports (13.5%) (Table 2). For those who performed the WBDLT, handball/beach handball (36%), rugby (14%), and athletics (10%) were the most common modalities (Table 3).

Table 4
Results of the intra-rater reliability for the total sample

	Evaluation	Mean $\pm$ SD	ICC (95%CI)	SEM	MDC ${}_{9}$
All athletes
CET (cm)	1 ${}^{\text{st}}$	40.00 $\pm$ 7.65	0.94 (0.88–0.97)	1.86	4.34
( $n=$ 37)	2 ${}^{\text{nd}}$	38.80 $\pm$ 7.55
WBDLT (cm)
Dominant	1 ${}^{\text{st}}$	9.64 $\pm$ 4.14	0.97 (0.95–0.98)	0.71	1.66
( $n=$ 50)	2 ${}^{\text{nd}}$	9.74 $\pm$ 4.11
Non-dominant	1 ${}^{\text{st}}$	9.62 $\pm$ 4.17	0.97 (0.95–0.98)	0.69	1.61
( $n=$ 50)	2 ${}^{\text{nd}}$	9.70 $\pm$ 3.83
Male athletes
CET (cm)	1 ${}^{\text{st}}$	40.14 $\pm$ 8.85	0.97 (0.90–0.99)	1.56	3.64
( $n=$ 19)	2 ${}^{\text{nd}}$	38.04 $\pm$ 9.32
WBDLT (cm)
Dominant	1 ${}^{\text{st}}$	8.93 $\pm$ 3.73	0.97 (0.94–0.99)	0.67	1.56
( $n=$ 24)	2 ${}^{\text{nd}}$	8.97 $\pm$ 4.08
Non-dominant	1 ${}^{\text{st}}$	9.23 $\pm$ 3.92	0.95 (0.88–0.97)	0.82	1.91
( $n=$ 24)	2 ${}^{\text{nd}}$	9.19 $\pm$ 3.47
Female athletes
CET (cm)	1 ${}^{\text{st}}$	39.85 $\pm$ 6.40	0.88 (0.70–0.95)	2.00	4.67
( $n=$ 18)	2 ${}^{\text{nd}}$	39.60 $\pm$ 5.23
WBDLT (cm)
Dominant	1 ${}^{\text{st}}$	10.30 $\pm$ 4.45	0.97 (0.94–0.98)	0.73	1.70
( $n=$ 26)	2 ${}^{\text{nd}}$	10.46 $\pm$ 4.09
Non-dominant	1 ${}^{\text{st}}$	9.98 $\pm$ 4.44	0.98 (0.96–0.99)	0.60	1.40
( $n=$ 26)	2 ${}^{\text{nd}}$	10.16 $\pm$ 4.15

SD: Standard Deviation; ICC: Intraclass Correlation Coefficient; 95%CI: 95% Confidence Interval; SEM: Standard Error of Measurement; MDC ${}_{9}$ : Minimal Detectable Change at the 90% Confidence Level; cm: centimeters; CET: Combined Elevation Test; WBDLT: Weight-Bearing Dorsiflexion Lunge Test.

Values of mean, SD, ICC, SEM, and MDC ${}_{90}$ for both tests are presented in Table 4. The CET showed excellent intra-rater reliability (ICC $=$ 0.94), SEM of 1.86 cm, and MDC ${}_{90}$ of 4.34 cm. The WBDLT presented excellent intra-rater reliability (ICC $=$ 0.97 for both dominant and non-dominant lower limbs), with SEM of 0.71 cm and 0.69 cm and the MDC ${}_{90}$ of 1.66 cm and 1.61 cm for the dominant and non-dominant lower limbs, respectively.

Table 4 shows the data analysis by sex. For the CET, men presented excellent intra-rater reliability (ICC $=$ 0.97), SEM of 1.56 cm, and MDC ${}_{90}$ of 3.64 cm; women presented good intra-rater reliability (ICC $=$ 0.88), SEM of 2.00 cm, and MDC ${}_{90}$ of 4.67 cm. Men and women presented excellent intra-rater reliability for the WBDLT in both dominant and non-dominant sides (ICC between 0.95 and 0.98); the SEM ranged from 0.60 to 0.82 cm and the MDC ${}_{90}$ ranged from 1.40 to 1.91 cm.

4. Discussion

The aim of this study was to evaluate the intra-rater reliability of two mobility tests (WBDLT and CET) applied in healthy athletes via telehealth assessment. Our findings indicated good-excellent intra-rater reliability for the CET and the WBDLT considering the total sample. In addition, SEM and MDC ${}_{90}$ values were provided for both tests, which may be useful for clinical practice and for future research with the same population.

4.1 CET

The CET measures active trunk and shoulder mobility and has been widely applied to athletes of different ages, sports modalities, and levels of competition [2, 5, 36]. Previous studies showed excellent intra-rater reliability for the CET applied face-to-face in healthy adolescents [3], young cricket athletes [6], and elite soccer athletes [2]. The results of this study indicated that CET applied via telehealth presents similar reliability to face-to-face assessments.

The SEM and MDC of the present study were also similar to previous face-to-face studies. The CET via telehealth showed approximately 7% of error, which is low and equivalent to the error observed in face-to-face evaluations with healthy adolescents [3] and cricket athletes [6]. In this study, the CET presented a MDC ${}_{90}$ of 4.34 cm, suggesting that a change on the CET applied via telehealth score can be considered relevant when it is greater than 11%. To the authors’ knowledge, this is the first study to provide MDC ${}_{90}$ values for the CET, which may assist the clinicians and researchers to interpret whether changes over time represent a real change.

4.2 WBDLT

In accordance with the results obtained in this study, several studies also presented excellent intra-rater reliability for the WBDLT for young and healthy cricket athletes [6], elite soccer players [2], volleyball athletes [16], and adults with and without a history of ankle injuries/disorders [7, 20, 25]. Similarly, these studies also used the toe-to-wall distance as the test’s measure, once it is easier to assess and has equivalent reliability to the assessment in degrees [7].

In the present study, the WBDLT presented a mean SEM of 7%, which was similar to other studies that showed SEM values ranging from 4 to 6% [7, 25] in healthy adults and 5% in healthy females volleyball athletes [16]. Furthermore, a study assessing subjects with ankle dysfunctions observed a SEM of 4% [20]. Apparently, the WBDLT applied via telehealth presents higher SEM values compared to face-to-face assessments, but still, they can be considered small.

Furthermore, this study’s results showed that smaller changes than 2 cm should not be considered relevant for the WBDLT applied via telehealth. This finding is in accordance with previous studies that assessed subjects with and without ankle disorders history using face-to-face modalities of assessment and showed MDC ${}_{90}$ values between 0.93 and 1.40 cm [20, 25].

4.3 Clinical implications

Carrying out physical evaluations through real-time video calls has become a common alternative when social distancing between athletes and clinicians is necessary or preferable. Considering this context, this study showed that applying two mobility tests through real-time video calls and using low-cost materials that are easily available is reliable and can be used for screening athletes beyond the clinical environment. Nevertheless, we faced some specific challenges related to telehealth assessments, such as poor internet connection and losses in the video/audio quality due to problems with the camera, poor light, noise, and/or limitations of electronic equipment. However, these problems did not negatively impact the reliability of the tests.

4.4 Limitations of the study

The sample of the present study is composed of healthy athletes of 18–40 years old and, so the results should not be generalized for other populations such as injured adults, children or teenagers, or the non-athletic population. The sample was also heterogeneous in terms of sports and competition levels. Finally, the present results should not be generalized to inter-rater assessments.

4.5 Suggestions for future studies

Further studies should assess reference values, inter-rater reliability, validity, and responsiveness of the WBDLT and CET applied via telehealth. Although WBDLT and CET showed satisfactory reliability, it is unknown whether the telehealth assessments would present similar results in comparison to the same tests assessed face-to-face. Also, future studies should investigate the reliability, SEM, and MDC according to the sports modalities and competition, age, and presence of injuries.

5. Conclusion

The findings of this study showed that both CET and WBDLT via telehealth are reliable in healthy adult athletes and can be used to screen this population when face-to-face evaluations are not feasible. Assessing a patient via telehealth diminishes the costs for the clinician and also reduces time and money spent on the patient’s transportation. Knowing the reliability, SEM, and MDC values of these outcome measures makes them more trustworthy.

Author contributions

CONCEPTION: Letícia B Calixtre, Danilo H Kamonseki and Germanna M Barbosa.

PERFORMANCE OF WORK: Hilmaynne RF Fialho, Gustavo V Gonçalves, Maycon TM Jales, Letícia B Calixtre, Danilo H Kamonseki and Germanna M Barbosa.

INTERPRETATION OR ANALYSIS OF DATA: Hilmaynne RF Fialho and Letícia B Calixtre.

PREPARATION OF THE MANUSCRIPT: Hilmaynne RF Fialho and Letícia B Calixtre.

REVISION FOR IMPORTANT INTELLECTUAL CONTENT: Danilo H Kamonseki and Germanna M Barbosa.

SUPERVISION: Letícia B Calixtre, Danilo H Kamonseki and Germanna M Barbosa.

Ethical considerations

The present study was approved by the Human Research Ethics Committee of the Federal University of São Carlos (No. 4.365.562), São Carlos, SP, Brazil. All athletes received explanations about the study and those who agreed to participate signed an online informed consent. The present study is in accordance to the declaration of Helsinki for experiments involving humans.

Funding

The authors report no funding.

Footnotes

Acknowledgments

The authors would like to acknowledge the athletes who volunteered to participate in this study.

Conflict of interest

The authors have no conflicts of interest to report.

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Intra-rater reliability of the combined elevation test and the weight-bearing dorsiflexion lunge test using telehealth in healthy athletes

Abstract

BACKGROUND:

OBJECTIVE:

METHODS:

RESULTS:

CONCLUSIONS:

Keywords

1. Background

2. Methods

2.1 Subjects

Table 1 Characteristics of the athletes that performed the combined elevation test and the weight-bearing dorsiflexion lunge test

2.3 Combined elevation test (CET)

3. Results

Table 4 Results of the intra-rater reliability for the total sample

4.1 CET

4.2 WBDLT

4.3 Clinical implications

4.4 Limitations of the study

4.5 Suggestions for future studies

5. Conclusion

Author contributions

Ethical considerations

Funding

Footnotes

Acknowledgments

Conflict of interest

References

Table 1
Characteristics of the athletes that performed the combined elevation test and the weight-bearing dorsiflexion lunge test

Table 4
Results of the intra-rater reliability for the total sample