Impact of Lateral Elbow Pain on Pronation and Supination Torques and Influence of Forearm Rotation Angle

Abstract

Importance: Lateral elbow pain (LEP) is associated with damage to the accessory rotator muscles of the forearm, but there is little evidence of the effect of LEP on pronosupination torques and its influencing factors.

Objective: To analyze the differences in forearm pronosupination torques between affected and sound limbs in patients with LEP and to investigate the influence of sex, age, dominance, and forearm position.

Design: A cross-sectional study, using a stepwise selection algorithm for analysis of variance, to assess torque variations on the basis of the considered factors.

Setting: Biomechanical analysis laboratory in a university research institute.

Participants: A convenience sample of 36 people with LEP, predominantly middle-aged, with a majority presenting with dominant upper limb involvement.

Outcomes and Measures: Torque measurements for pronation and supination in multiple forearm positions.

Results: Participants had significant deficits in pronosupination torques in affected limbs compared with sound limbs, particularly in extreme positions. The largest differences were observed in the supination direction with 60° of forearm pronation and the pronation direction with 60° of forearm supination. Sex and dominance significantly influenced torque production, but age did not.

Conclusions and Relevance: The greatest values and differences in torque between sound and affected limbs occurred for extreme rotations of the forearm opposite to the direction of the movement, with significant amplifications on torque reduction for the affected side, nondominant limb, and female patients. Those results can be used to define assessment methods and to design training and evaluation methods that address relevant strength deficits of patients affected by LEP.

Plain-Language Summary: Understanding the torque profiles of pronation and supination in lateral elbow pain can provide insights into functional impairments and guide occupational therapy rehabilitation strategies as well as progressive reincorporation into certain activities of daily living and work-related manual tasks. Our findings highlight the importance of assessing forearm movement in rehabilitation settings and emphasize the need for targeted interventions that focus on pronosupination function in patients with lateral elbow pain.

The study findings highlight the importance of assessing forearm movement in rehabilitation settings and emphasize the need for targeted occupational therapy interventions.

Lateral elbow pain (LEP), or lateral epicondylopathy—also referred to as lateral epicondylitis, tennis elbow, or lateral epicondylalgia—is a pathological condition that affects about 2% of the working-age population, especially those age 40 yr and older (Kim et al., 2019). It has been associated with activities with high manual demand, with up to 10.5% prevalence among this type of worker (Lenoir et al., 2019).

Its diagnosis is mainly based on physical examination, attending to nonpathognomonic signs and symptoms and specific provocative maneuvers such as Cozen, Mills, or Maudsley, which usually involve resisted extension of wrist and fingers and, in some cases, resisted supination (Di Filippo et al., 2022; Inagaki, 2013). Sometimes it is necessary to perform imaging tests such as ultrasound or magnetic resonance, and accessory techniques such as electroneurography, that help confirm the diagnosis and rule out other entities with similar symptoms, such as radial tunnel syndrome (Lenoir et al., 2019).

Despite some recent debate pointing toward other causes, such as a primary nervous system disorder (Bordachar, 2019), the most widespread opinion points to degenerative changes in the extensor carpi radialis brevis tendon (ECRB) that are due to repetitive microtrauma as primarily responsible for the pathology (Ma & Wang, 2020). For this reason, most authors who try to characterize its functional impact either study the electromyographic activity of the ECRB or measure grip, wrist extension, and finger extension strength, actions with different levels of ECRB involvement (Akınoğlu et al., 2024; Bhargava et al., 2010; Chen et al., 2023; Dorf et al., 2007; Hill et al., 2023; Ikeda et al., 2024; Unyó et al., 2013). Although some authors point toward the possible involvement of the supinator brevis in the development of the pathology (Erak et al., 2004), and although the ECRB and other muscles have been identified as accessory rotators of the forearm (Mukhopadhyay et al., 2007; O’Sullivan & Gallwey, 2005), there is little information on the effect of LEP on forearm pronosupination torques (Croisier et al., 2007; Pienimäki et al., 1997, 2002). Besides, the authors who study this do not address the effect of specific rotation positions of the forearm on torques in LEP, as has been done for other pathologies (Ploegmakers et al., 2015; Schmidt et al., 2014).

In this context, the present study evaluates how LEP affects pronation and supination torques in different positions of the forearm and analyzes the influence of sex, dominance, and age over torques in this population.

Method

We used a load-weighing sensor attached to a cylindric T-bar grip handle for this study. The development of this device and its reliability study are presented in a previous work (Ligero et al., 2023), where the device features and the measurement protocol are described. The device measures the torque (in Newton-meters; Nm) exerted in the pronation and supination directions, in five different forearm positions equivalent to different rotation angles: 60° of supination (60SUP), 30° of supination (30SUP), 0° of pronosupination (NEU), 30° of pronation (30PRO), and 60° of pronation (60PRO). This provides 10 measures per limb and 20 per subject.

For this work, we evaluated a convenience sample of 36 men and women with LEP, ages 18 to 65 yr. Given that an LEP diagnosis is eminently based on clinical findings (Ma & Wang, 2020; Shiri & Viikari-Juntura, 2011), LEP inclusion criteria were based on the existence of LEP persisting for at least 2 wk, hindering daily activities. Diagnosis required the presence of at least one positive specific maneuver (Mill’s Test or Cozen test) to rule out other pathologies. Upper limb deformities or conditions beyond LEP were excluded. An experienced physiotherapist and a physician always checked for the fulfillment of recruitment criteria. Participants were classified into four age groups—A0 (18–29 yr), A1 (30–39 yr), A2 (40–49 yr), and A3 (50–65 yr)—and upper limbs were classified as affected or sound. The course of LEP was considered acute if it lasted for less than 6 mo and was considered chronic if it lasted from 6 mo on.

We used a repeated-measures ANOVA to analyze the influence of forearm posture on measured torques, considering whether the upper limb was affected or sound, as well as the other factors of potential influence. A mixed linear model was defined, with sex, age group, dominance, upper limb group (sound or affected), course (acute or chronic), direction of movement (pronation or supination), and forearm position as fixed factors, and the subject as a random effect. As in our previous study (Ligero et al., 2023), the relevant interactions between fixed factors were selected using a stepwise algorithm (Venables & Ripley, 2002) and analyzed with a simple effects test (Schabenberger et al., 2000).

We defined statistically significant differences considering a Type I error of α = .05 (p < .05). We conducted all analyses using the R package (Version 4.3.1) for statistical computing (R Core Team, 2022). The dataset and code used in the analysis are given in a CSV file and a notebook Appendixes A.1 and A.2 in the Supplemental Material, available online with this article at https://research.aota.org/ajot.

The study was approved by the Ethics Committee in Human Research of Universitat Politècnica de València (P14_09_04_19). All subjects agreed to participate after being informed of the purposes and methodology of the research and signed an informed consent. All of them were informed that they could withdraw from the study at their discretion.

Results

There were 36 participants with LEP in our study (Table 1). Two subjects had bilateral involvement, which made a total of 34 sound and 38 affected upper limbs. Of these 38 affected limbs, 27 corresponded to the dominant side. Regarding dominance, all participants were right-handed, except for 3. The course was acute for 24 subjects and chronic for 12.

Table 1.

Sample Characteristics Regarding Sex and Age

Gender	Age Group				Total
Gender	A0	A1	A2	A3	Total
Male	0	4	7	5	16
Female	1	2	15	2	20
Total	1	6	22	7	36

Note. A0 = 18–29 yr; A1 = 30–39 yr; A2 = 40–49 yr; and A3 = 50–65 yr.

Table 2 shows the main factors and interactions that the stepwise selection algorithm left as influential factors of the statistical model, together with the results of the ANOVAs.

Table 2.

Analysis of Variance (Type 2 Sum of Squares) Results

Variable	F	df	p
UL group	89.910	1	<.001
Sex	44.721	1	<.001
Direction of movement	59.979	1	<.001
Forearm position	151.221	4	<.001
Course	3.369	1	.075
Dominance	9.839	1	.002
Interactions between variables
UL Group × Sex	5.499	1	.019
UL Group × Direction of Movement	3.205	1	.074
UL Group × Forearm Position	3.917	4	.004
UL Group × Course	3.499	1	.062
Direction of Movement × Forearm Position	9.849	4	<.001

Note. Values in bold are statistically significant. df = degrees of freedom; UL Group = upper limb group.

The greatest difference in torques was marked by sex, with an expected mean torque of 6.41 Nm in men, compared with 2.86 Nm in women, followed by the difference between affected (4.56 Nm) and sound (5.72 Nm) limbs and between dominant and nondominant limbs (5.31 Nm and 4.97 Nm, respectively). Regarding the direction of movement (pronation and supination), the torque is equivalent between pronation and supination in the first posture (60SUP and 60PRO, respectively) and decreases as the forearm rotates on both the affected and sound sides, with this decrease being more marked in the direction of pronation (Figure 1). This makes the overall difference between affected and sound sides greater in supination than in pronation torques (−0.98 Nm and −1.33 Nm, respectively; SE = −0.16; shown later in Table 4). As for position, the greatest supination torque was achieved at 60PRO, and the greatest pronation torque was achieved at 60SUP, for either affected or sound upper limbs (Table 3).

Figure 1.

Torques in pronation and supination directions, considering affected and sound upper limb groups.

Table 3.

Adjusted Mean for Each Given Torque Considering Direction and Position, Considering the Whole Sample

Direction and Forearm Position	M _Adj. ^a
Pro
60SUP	6.504
30SUP	6.185
NEU	4.869
30PRO	3.517
60PRO	2.713
Sup
60PRO	6.546
30PRO	6.250
NEU	5.832
30SUP	5.080
60SUP	3.881

Note. 30PRO = 30° of pronation; 30SUP = 30° of supination; 60PRO = 60° of pronation; 60SUP = 60° of supination; M _Adj. = adjusted mean; NEU = 0° of pronosupination; Pro = pronation; Sup = supination.

^a SE = 0.248.

The differences between affected and sound limbs varied across factors such as sex and course of the pathology (Figure 2). The interactions identified by the ANOVA translate into a significantly greater difference in torque of affected against sound limbs in male compared with female subjects, and in the initial postures compared with the final ones (considering as initial posture −60, which equals 60PRO for supination and 60SUP for pronation). Related to the interaction between forearm position and direction of torque turns, the greatest difference between affected and sound limbs can be observed in Sup_60PRO, followed by Sup_30PRO, Pro_60SUP, and Pro_30SUP, with statistically significant differences in all cases (p < .00; Table 4) except Pro_60PRO (p = .086). Finally, although differences tend to be greater between affected and sound upper limbs for supination compared with pronation direction and in patients with a chronic course of LEP compared with healthy subjects, neither of these interactions were significant in the ANOVA.

Figure 2.

Distributions of pronation and supination torques at each position of the forearm for sound and affected limbs, considering female and male populations and acute or chronic LEP course.

Table 4.

Interaction Analysis Between the Upper Limb Group and Principal Effects

Variable	Mean Difference	SE	p
Female	−0.921	0.155	<.001
Male	−1.393	0.162	<.001
Acute LEP course	−0.951	0.127	<.001
Chronic LEP course	−1.362	0.195	<.001
Pro	−0.983	0.156	<.001
Sup	−1.330	0.156	<.001
−60°	−1.628	0.229	<.001
−30°	−1.525	0.229	<.001
0°	−1.139	0.229	<.001
30°	−0.891	0.229	<.001
60°	−0.602	0.229	.009
Pro_60SUP	−1.454	0.249	<.001
Pro_30SUP	−1.351	0.249	<.001
Pro_NEU	−0.965	0.249	<.001
Pro_30PRO	−0.716	0.249	<.001
Pro_60PRO	−0.427	0.249	.086
Sup_60PRO	−1.802	0.249	<.001
Sup_30PRO	−1.699	0.249	<.001
Sup_NEU	−1.312	0.249	<.001
Sup_30SUP	−1.064	0.249	<.001
Sup_60SUP	−0.775	0.249	<.001

Note. The mean difference reflects the comparison of torque (Nm) between affected and sound limbs. For all values, the p-value tests a χ²(1). Bold face indicates statistically significant p values. 30PRO = 30° of pronation; 30SUP = 30° of supination; 60PRO = 60° of pronation; 60SUP = 60° of supination; df = degrees of freedom; LEP = lateral elbow pain; NEU = 0° of pronosupination; Pro = pronation; SE = standard error; Sup = supination.

Discussion

The use of instrumental techniques is widely established in upper limb pathologies as a way of objectifying functional impairment, as opposed to the subjectivity inherent in other types of instruments, such as perceived disability questionnaires. Some authors point to the absence of a clear correlation between the two methodologies, which, in some cases, is interpreted as a possible limitation of assessment technologies (Jester et al., 2005; Karnezis & Fragkiadakis, 2002). Nevertheless, both methodologies assess different and complementary aspects of disability, which could explain this lack of correlation.

As a reflection of the usefulness of functional assessment technologies, the use of grip strength analysis (Akınoğlu et al., 2024; Bobos et al., 2020; Liu et al., 2022), including grip in different elbow positions (Dorf et al., 2007; Kwasniewski, 2008) and pain-free grip strength tests (Di Filippo et al., 2022; Eapen et al., 2023; Hill et al., 2023) or the strength profile of wrist flexor and extensor muscles (Ikeda et al., 2024; Rojas et al., 2007), is common among LEP studies. However, there are very few examples of strength profile evaluation for forearm supination, and especially for pronation, in this pathology. This is striking, given the importance of this arc of movement in many daily activities. Wrist flexor and extensor muscles can act as accessory rotators through their action on the carpal bones (Soubeyrand et al., 2017) and there is a moment-arm contribution of wrist extensors in tasks that involve forearm twisting, especially when accompanied by grasping (O’Sullivan & Gallwey, 2002; Stegink-Jansen et al., 2021). In fact, these authors have found that wrist extensors are active during forearm rotation with gripping, which supports the inclusion of forearm rotation assessment in LEP. The few authors who assess the isokinetic profiles of supination and pronation strength in subjects with LEP find, in all cases, differences in these forces compared with normative values (Croisier et al., 2007; Pienimäki et al., 1997, 2002). Our study goes a step further and aims to analyze not only whether there are deficits in pronation and supination torques in patients with LEP but also how torques are affected by the position of rotation of the forearm, as well as the influence of relevant factors such as age, sex, and dominance. This has been done previously for other pathologies such as biceps tendon rupture (Schmidt et al., 2014) or fractures of the distal end of the radius (Ploegmakers et al., 2015).

To achieve our goal, we studied a sample of 36 subjects with LEP, comparable to or larger than the studies mentioned above. Because of convenience sampling, we obtained a sample with more female (20 female, 16 male) subjects, a greater representation of the middle-aged group, and a majority of affected upper limbs that were dominant. This distribution is closely related to the actual epidemiology of the disease— and is, therefore, representative of the real population—which is most common between the ages of 40 and 60 (Shiri & Viikari-Juntura, 2011), with a peak incidence at 40 to 49 yr old (Konarski & Poboży, 2023). In turn, some authors have found a higher prevalence in female subjects and on the dominant side (Chen et al., 2024; Park et al., 2021). In addition, the number of patients with an acute course of LEP doubled that of patients with a chronic course of LEP in our sample, probably because the response to conservative treatments is usually positive in the first 6 mo (Haahr & Andersen, 2003).

We found that dominance and sex significantly affect pronosupination torques, but age did not. This matches the results from our previous analysis (Ligero et al., 2023), carried out with healthy subjects, and coincides with the results from previous studies (Gallagher et al., 1997; Kerschbaum et al., 2017).

As expected, the upper limb group (affected or sound) was an influencing factor. We have not found any previous studies evaluating pronation and supination torques in patients with LEP in different positions with which to compare our results. However, authors such as Akınoğlu et al. (2024) have also found a global deficit in the torques of the affected side, compared with the unaffected side for lateral epicondylitis, which includes muscle groups directly involved in the pathology (in this case, wrist extensors) and their antagonists (wrist flexors). The global deficit of pronosupination torques on the affected limbs, compared with the healthy ones found in our study, may be due to several factors. The ECRB, which is the main muscle affected in LEP, acts mainly as an extensor of the carpus but has a secondary supination action (Erak et al., 2004) and participates as an accessory rotator of the forearm through traction over the carpus (Soubeyrand et al., 2017). Accordingly, this muscle has been shown to remain active during pronation and supination torques (Stegink-Jansen et al., 2021). In the study by Mukhopadhyay et al. (2007), 36 healthy subjects performed different levels of pronation torques at different elbow angles and forearm rotations (60% prone, 60% supine, and neutral), finding electromyographic activity of the ECRB in all positions and being significantly greater in 60% pronation. In turn, O’Sullivan & Gallwey (2002) measured pronosupination torques of 24 healthy subjects at 75% prone, 75% supine, and neutral forearm rotation angles. They observed high ECRB activity in all postures and found that the activity correlated with forearm rotation (greater at 75% prone) for pronation torques, but not for supination torques. The authors associated this finding with a stabilizing action of the ECRB on wrist flexors concerning the gripping of the device, which would be greater in the pronation position (Mogk & Keir, 2003), whereas in supination, it would act mainly as an indirect supinator through carpal extension. It should be noted that, as in our study, these authors opted for a T-Bar handle device, which implies gripping and, thus, a certain level of moment-arm contribution of wrist extensor muscles.

Compared with the use of a device that does not involve any action of the wrist, a T-Bar handle is more functional and, thus, better resembles tasks of daily life or work without being as disadvantageous as the use of other types of handles such as doorknobs or screwdriver handles (Timm et al., 1993). In addition, studying the performance in tasks that involve grip force in combination with forearm rotation postures is of special interest, because they have been identified as risk factors for the development of LEP (Stegink-Jansen et al., 2021).

Another possible cause of pronation and supination torque deficits in LEP is the potential involvement of other muscle groups or structures. These include ligamentous, capsular, or nerve structures, or muscles such as the extensor digitorum communis (EDC) and, especially, the supinator (Stegink-Jansen et al., 2021; Kim et al., 2019), whose involvement could be related to the results of our study. Erak et al. (2004) performed a cadaveric biomechanical analysis of the contribution to the tensile force of the muscles originating from the lateral epicondyle. They found that, although the greatest forces occurred in the ECRB and EDC, there was a moderate increase in tensile force when suspending a weight of 1 kg from the proximal portion of the supinator’s superficial head, which supports the participation of this muscle in the etiology of LEP.

In addition to these possible causes of the pronosupination torque deficit found in our study, we must consider the effects of pain and disuse on the agonist–antagonist muscle function (Pienimäki et al., 2002) and the existence of deficits in neuromuscular control in LEP (Chen et al., 2023), which would cause a generalized loss of strength in the affected limb, even in proximal muscle groups (Alizadehkhaiyat et al., 2007).

Forearm posture influenced the torque exerted, with Sup_60PRO and Pro_60SUP showing significantly greater torque values and torque decreasing as posture approached the direction of movement. This was similar to our previous analysis (Ligero et al., 2023) and means that the pattern of influence of forearm posture is maintained in the affected limbs. The causes were explained in the said study, and they coincide with the results of authors (e.g., Gordon et al., 2004; Matsuoka et al., 2006; O’Sullivan & Gallwey, 2002), with larger lever arms in postures contrary to torque direction and in a maneuver that involves grasping, which adds an action of carpal flexors and extensors especially marked in extreme postures (Haugstvedt et al., 2001). This finding is in line with those of (Schmidt et al., 2014), who studied supination torque in distal bicep rupture and healthy subjects, with an equivalent pattern in both populations; in this case, a greater supination torque in the opposite position (60° of forearm pronation). We also observed an effect of direction (pronation or supination) on torque, with higher mean supination due to a greater decrease in pronation torques in disadvantageous positions (the ones equal to the direction of movement). Because, in our study, pronation and supination torques have been equivalent in the most advantageous positions, we believe that our protocol may induce a greater mechanical disadvantage for pronator and accessory muscles in extreme positions for pronation torque (mostly for Pro_30PRO and Pro_60PRO), rather than our results being related to a hypothetical difference in the power of the supinator musculature (mainly biceps and supinator) versus pronators. These findings guide clinicians to take these mechanical disadvantages into account when assessing deficits, especially in pronation, and to consider a progressive and controlled recovery and return to gestures in this type of disadvantageous postures, which may require more time for readaptation.

The interactions between variables found in the ANOVA indicate a greater difference between sound and affected limbs under the influence of factors that promote greater torque generation. That is, there is a bigger difference and, therefore, a greater deficit on the affected side compared with the sound side, in male subjects and in the most advantageous positions (contrary to movement direction), which would, therefore, be more sensitive in finding differences. We observed a greater difference between affected and sound limbs in patients with a chronic LEP course compared with patients with an acute course, with greater magnitude of torques applied on their sound side for those with a chronic course. This aligns with clinical theories that point toward a neurophysiological mechanism of contralateral strength training effect on the untreated side (Carroll et al., 2006), and compensation strategies where patients with a chronic course avoid using the affected limb because of pain or fear and increase the use of the sound side, causing muscle adaptations and strength gains. However, that interaction effect between the upper limb group and LEP course was not found to be significant in the ANOVA. Thus, we believe that a greater sample, with a higher representation of both the chronic- and acute-course groups, could have yielded significant results in this comparison for the ANOVA.

Finally, because of its importance and clinical relevance, we must highlight the interaction between direction and posture, which has allowed us to observe which tests are more sensitive in assessing LEP to find differences between sound and affected sides. Although the magnitudes were always lower on the affected side, the greatest differences were found in Sup_60Pro, a test in which the torques generated were higher overall, followed by Sup_30Pro, Pro_60SUP, and Pro_30SUP. On the other hand, the only nonsignificant difference, although with also lower results on the affected side, was found in Pro_60PRO, a test in which the overall magnitude of torque was lower. The fact that there is more difference in postures that are opposed to movement direction coincides again with greater torques achieved on those, and it is associated with a predominant action of the accessory rotators in these postures, which include ECRB but also other muscles, such as the extensor and flexor carpi ulnaris (Haugstvedt et al., 2001). In the case of Sup_60Pro, it coincides with high stress on the ECRB tendon because of greater passive stretch in the context of elongation and greater active force production in this posture (Stegink-Jansen et al., 2021).

Last, some methodological considerations must be made:

▪ We have based our recruitment criteria on verifying clinical findings and positive manual tests, which we find methodologically correct on the basis of the available evidence. However, it is impossible to ignore the possible concurrence of other diagnoses that are difficult to differentiate, such as radial tunnel syndrome (which can only be ruled out with complementary tests).

▪ The sample’s representativeness has been subject to the inherent limitations of convenience sampling, with characteristics in terms of sex, age, or dominance related to the actual epidemiology of LEP. In our sample, the A0 group of subjects with LEP is misrepresented, and most subjects with LEP are in the A2 group (40–49 years old), with most participants being right-handed and a majority having an acute course of LEP that mainly affected the dominant side. This circumstance may have somehow affected the study of the influence of these factors.

Implications for Occupational Therapy Practice

The findings of this study have the following implications for occupational therapy practice:

▪ The assessment of pronosupination torque deficits associated with LEP is most sensitive in the posture labeled as Sup_60PRO, followed by Sup_30PRO, Pro_60SUP, and Pro_30SUP.

▪ Training and evaluation of the recovery of pronosupination torques in those extreme rotation positions should be emphasized in the interventions addressed to gain strength, before gradually reintroducing manual tasks that involve this type of effort.

▪ During LEP recovery, the readaptation of tasks that need to apply pronosupination torques should facilitate neutral rotation positions in which fewer deficits are likely to happen.

▪ Attention should be paid to possible events such as compensatory overuse of the healthy side, including bilateral upper extremity rehabilitation to address this issue.

▪ It is necessary to take into account the influence of intrinsic factors such as dominance or sex over torques when establishing the real strength deficit and setting objectives in recovery, always trying to reach levels as close as possible to the person’s baseline state and to what is expected considering those factors.

Conclusion

This study quantified the effect of LEP on pronation and supination torques and the crossed influence of sex and limb dominance, and it has identified the forearm positions in which the greatest torques are observed and the greatest differences between sound and affected limbs can be found. Those results can be used to define sensitive assessment methods that address relevant strength deficits and enable the design of tailored therapeutic approaches for patients affected by LEP.

Supplemental Material

Supplemental Information

Supplementary material for Impact of Lateral Elbow Pain on Pronation and Supination Torques and Influence of Forearm Rotation Angle

Supplementary material, sj-pdf-1-aot-10.5014_ajot.2025.051118.pdf for Impact of Lateral Elbow Pain on Pronation and Supination Torques and Influence of Forearm Rotation Angle by Cristina Herrera-Ligero, Daniel Sánchez-Zuriaga, Úrsula Martínez-Iranzo and Helios De Rosario in The American Journal of Occupational Therapy

Footnotes

Acknowledgments

We thank Umivale Activa (Mutual Collaborator with Social Security No. 33) and especially Dr. María Teresa Hervás, head of the Functional Assessment Laboratory of the Umivale Activa Quart de Poblet Clinic, for her collaboration, without which the study described in this article would not have been possible.

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