Comparison of MRI-based estimates of articular cartilage contact area in the tibiofemoral joint

Knee osteoarthritis (OA) detrimentally impacts the lives of millions of older Americans through pain and decreased functional ability. Unfortunately, the pathomechanics and associated deviations from joint homeostasis that OA patients experience are not well understood. Alterations in mechanical stress in the knee joint may play an essential role in OA; however, existing literature in this area is limited. The purpose of this study was to evaluate the ability of an existing magnetic resonance imaging (MRI)-based modeling method to estimate articular cartilage contact area in vivo. Imaging data of both knees were collected on a single subject with no history of knee pathology at three knee flexion angles. Intra-observer reliability and sensitivity studies were also performed to determine the role of operator-influenced elements of the data processing on the results. The method's articular cartilage contact area estimates were compared with existing contact area estimates in the literature. The method demonstrated an intra-observer reliability of 0.95 when assessed using Pearson's correlation coefficient and was found to be most sensitive to changes in the cartilage tracings on the peripheries of the compartment. The articular cartilage contact area estimates at full extension were similar to those reported in the literature. The relationships between tibiofemoral articular cartilage contact area and knee flexion were also qualitatively and quantitatively similar to those previously reported. The MRI-based knee modeling method was found to have high intra-observer reliability, sensitivity to peripheral articular cartilage tracings, and agreeability with previous investigations when using data from a single healthy adult. Future studies will implement this modeling method to investigate the role that mechanical stress may play in progression of knee OA through estimation of articular cartilage contact area.     

Comparison of kinematics in the healthy and ACL injured knee using MRI

Magnetic Resonance Imaging (MRI) was used to examine the characteristics of abnormal motion in the injured knee by mapping tibiofemoral contact. Eleven healthy subjects and 20 subjects with a unilateral ACL injury performed a leg-press against resistance. MRI scans of both knees at 15 degrees intervals from 0 degrees to 90 degrees of flexion were used to record the tibiofemoral contact pattern. The tibiofemoral contact pattern of the injured knees was more posterior on the tibial plateau than the healthy knees, particularly in the lateral compartment. The tibiofemoral contact pattern of the loaded knees did not differ from the unloaded knees. The difference in the tibiofemoral contact pattern in the ACL injured knee was associated with more severe knee symptoms, irrespective of the passive anterior laxity of the knee.     

Reliability of Visual Assessment of Non-Contrast CT,CT Angiography Source Images and CT Perfusion in Patients with Suspected Ischemic Stroke

Background and Purpose

Good reliability of methods to assess the extent of ischemia in acute stroke is important for implementation in clinical practice, especially between observers with varying experience. Our aim was to determine inter- and intra-observer reliability of the 1/3 middle cerebral artery (MCA) rule and the Alberta Stroke Program Early CT Score (ASPECTS) for different CT modalities in patients suspected of acute ischemic stroke.

Methods

We prospectively included 105 patients with acute neurological deficit due to suspected acute ischemic stroke within 9 hours after symptom onset. All patients underwent non-contrast CT, CT perfusion and CT angiography on admission. All images were evaluated twice for presence of ischemia, ischemia with >1/3 MCA involvement, and ASPECTS. Four observers evaluated twenty scans twice for intra-observer agreement. We used kappa statistics and intraclass correlation coefficient to calculate agreement.

Results

Inter-observer agreement for the 1/3 MCA rule and ASPECTS was fair to good for non-contrast CT, poor to good for CT angiography source images, but excellent for all CT perfusion maps (cerebral blood volume, mean transit time, and predicted penumbra and infarct maps). Intra-observer agreement for the 1/3 MCA rule and ASPECTS was poor to good for non-contrast CT, fair to moderate for CT angiography source images, and good to excellent for all CT perfusion maps.

Conclusion

Between observers with a different level of experience, agreement on the radiological diagnosis of cerebral ischemia is much better for CT perfusion than for non-contrast CT and CT angiography source images, and therefore CT perfusion is a very reliable addition to standard stroke imaging.     

Reproducibility of Frankfort Horizontal Plane on 3D Multi-Planar Reconstructed MR Images

Objective

The purpose of this study was to determine the accuracy and reliability of Frankfort horizontal plane identification using displays of multi-planar reconstructed MRI images, and propose it as a sufficiently stable and standardized reference plane for craniofacial structures.

Materials and Methods

MRI images of 43 subjects were obtained from the longitudinal population based cohort study SHIP-2 using a T1-weighted 3D sequence. Five examiners independently identified the three landmarks that form FH plane. Intra-examiner reproducibility and inter-examiner reliability, correlation coefficients (ICC), coefficient of variability and Bland-Altman plots were obtained for all landmarks coordinates to assess reproducibility. Intra-examiner reproducibility and inter-examiner reliability in terms of location and plane angulation were also assessed.

Results

Intra- and inter-examiner reliabilities for X, Y and Z coordinates of all three landmarks were excellent with ICC values ranging from 0.914 to 0.998. Differences among examiners were more in X and Z than in Y dimensions. The Bland–Altman analysis demonstrated excellent intra- as well as inter-examiner agreement between examiners in all coordinates for all landmarks. Intra-examiner reproducibility and inter-examiner reliability of the three landmarks in terms of distance showed mean differences between 1.3 to 2.9 mm, Mean differences in plane angulation were between 1.0° to 1.5° among examiners.

Conclusion

This study revealed excellent intra-examiner reproducibility and inter-examiner reliability of Frankfort Horizontal plane through 3D landmark identification in MRI. Sufficiently stable landmark-based reference plane could be used for different treatments and studies.     

Can generic knee joint models improve the measurement of osteoarthritic knee kinematics during squatting activity?

Knee joint kinematics derived from multi-body optimisation (MBO) still requires evaluation. The objective of this study was to corroborate model-derived kinematics of osteoarthritic knees obtained using four generic knee joint models used in musculoskeletal modelling – spherical, hinge, degree-of-freedom coupling curves and parallel mechanism – against reference knee kinematics measured by stereo-radiography. Root mean square errors ranged from 0.7° to 23.4° for knee rotations and from 0.6 to 9.0 mm for knee displacements. Model-derived knee kinematics computed from generic knee joint models was inaccurate. Future developments and experiments should improve the reliability of osteoarthritic knee models in MBO and musculoskeletal modelling.     

Quantitative detection of cartilage surfaces and ligament geometry of the wrist using an imaging cryomicrotome system

Biomechanical models may aid in improving diagnosis and treatment of wrist joint disorders. As input, geometrical information is required for model development. Previous studies acquired some elements of the average wrist joint geometry. However, there is a close geometric functional match between articulating surfaces and ligament geometry. Therefore, biomechanical models need to be fed with the geometric data of individual joints. This study is aimed at acquiring geometric data of cartilage surfaces and ligaments from individual wrist joints by using a cryomicrotome imaging system and the evaluation of inter- and intra-observer variability of the data.The 3D geometry of 30 cartilage surfaces and 15 ligaments in three cadaver wrists was manually detected and quantitatively reconstructed. The inter- and intra-observer variability of the cartilage surface detection was 0.14 and 0.19 mm, respectively. For the position of the radius attachment of the dorsal radiocarpal ligament (DRC), the observer variations were 0.12 and 0.65 mm, for intra-/inter-observer, respectively. For the DRC attachment on the triquetrum, the observer variations were 0.22 and 1.19 mm.Anatomic reconstruction from 3D cryomicrotome images offer a method to obtain unique geometry data of the entire wrist joint for modeling purposes.     

Landmarking the Brain for Geometric Morphometric Analysis: An Error Study

Neuroanatomic phenotypes are often assessed using volumetric analysis. Although powerful and versatile, this approach is limited in that it is unable to quantify changes in shape, to describe how regions are interrelated, or to determine whether changes in size are global or local. Statistical shape analysis using coordinate data from biologically relevant landmarks is the preferred method for testing these aspects of phenotype. To date, approximately fifty landmarks have been used to study brain shape. Of the studies that have used landmark-based statistical shape analysis of the brain, most have not published protocols for landmark identification or the results of reliability studies on these landmarks. The primary aims of this study were two-fold: (1) to collaboratively develop detailed data collection protocols for a set of brain landmarks, and (2) to complete an intra- and inter-observer validation study of the set of landmarks. Detailed protocols were developed for 29 cortical and subcortical landmarks using a sample of 10 boys aged 12 years old. Average intra-observer error for the final set of landmarks was 1.9 mm with a range of 0.72 mm–5.6 mm. Average inter-observer error was 1.1 mm with a range of 0.40 mm–3.4 mm. This study successfully establishes landmark protocols with a minimal level of error that can be used by other researchers in the assessment of neuroanatomic phenotypes.     

The glenohumeral joint rotation centre in vivo

Within the framework of the current call for standardization in upper extremity research, three methods to determine the glenohumeral joint rotation centre in vivo were tested. Therefore, subjects performed humeral movements, while a 3D electromagnetic tracking device registered the motion of the humerus with respect to the scapula. For the first method to estimate the glenohumeral joint rotation centre five scapular bony landmarks served as input to regression equations. The second method fitted a sphere through the humeral position data and the third method calculated the rotation centre determining an optimal helical axis. The experiment consisted of two parts, at first one subject was measured 10 times, subsequently one observer measured 10 subjects twice and another observer measured these subjects once. The first part of the experiment demonstrated that all methods are capable to reproduce the rotation centre within 4 mm, but the location of the centre differed significantly between methods (p<0.001). The second part, showed that inter- and intra-observer reliability was sufficiently for the sphere-fitting method and for the helical-axes method. The two observations of one observer differed significantly (p<0.008) using the regression method. The authors prefer the helical-axes method, it is a reliable and valid method which can be applied in movement registration of healthy subjects and patients with a shoulder endoprosthesis, it can be applied in hinge joints to determine a rotation axis instead of a rotation centre which is desirable in standardized upper extremity research, and calculation time is short.     

Evaluation of inter- and intra-observer variations in prostate gland delineation using CT-alone versus CT/TPUS

BackgroundThis study aims to explore the role of four-dimensional (4D) transperineal ultrasound (TPUS) in the contouring of prostate gland with planning computed tomography (CT) images, in the absence of magnetic resonance imaging (MRI).Materials and methodsFive radiation oncologists (ROs) performed two rounds of prostate gland contouring (single-blinded) on CT-alone and CT/TPUS datasets obtained from 10 patients who underwent TPUS-guided external beam radiotherapy. Parameters include prostate volume, DICE similarity coefficient (DSC) and centroid position. Wilcoxon signed-rank test assessed the significance of inter-modality differences, and the intraclass correlation coefficient (ICC ) reflected inter- and intra-observer reliability of parameters.ResultsInter-modality analysis revealed high agreement (based on DSC and centroid position) of prostate gland contours between CT-alone and CT/TPUS. Statistical significant difference was observed in the superior-inferior direction of the prostate centroid position (p = 0.011). All modalities yielded excellent inter-observer reliability of delineated prostate volume with ICC > 0.9, mean DSC > 0.8 and centroid position: CT-alone (ICC = 1.000) and CT/TPUS (ICC = 0.999) left-right (L/R); CT-alone (ICC = 0.999) and CT/TPUS (ICC = 0.998) anterior-posterior (A/P); CT-alone (ICC = 0.999) and CT/TPUS (ICC = 1.000) superior-inferior (S/I). Similarly, all modalities yielded excellent intra-observer reliability of delineated prostate volume, ICC > 0.9 and mean DSC > 0.8. Lastly, intra-observer reliability was excellent on both imaging modalities for the prostate centroid position, ICC > 0.9.ConclusionTPUS does not add significantly to the amount of anatomical information provided by CT images. However, TPUS can supplement planning CT to achieve a higher positional accuracy in the S/I direction if access to CT/MRI fusion is limited.     

A comparison of patellofemoral cartilage morphology and deformation in anterior cruciate ligament deficient versus uninjured knees

Anterior cruciate ligament (ACL) deficient patients have an increased rate of patellofemoral joint (PFJ) osteoarthritis (OA) as compared to the general population. Although the cause of post-injury OA is multi-factorial, alterations in joint biomechanics may predispose patients to cartilage degeneration. This study aimed to compare in vivo PFJ morphology and mechanics between ACL deficient and intact knees in subjects with unilateral ACL ruptures. Eight male subjects underwent baseline MRI scans of both knees. They then performed a series of 60 single-legged hops, followed by a post-exercise MRI scan. This process was repeated for the contralateral knee. The MR images were converted into three-dimensional surface models of cartilage and bone in order to assess cartilage thickness distributions and strain following exercise. Prior to exercise, patellar cartilage was significantly thicker in intact knees as compared to ACL deficient knees by 1.8%. In response to exercise, we observed average patellar cartilage strains of 5.4 ± 1.1% and 2.5 ± 1.4% in the ACL deficient and intact knees, respectively. Importantly, the magnitude of patellar cartilage strain in the ACL deficient knees was significantly higher than in the intact knees. However, while trochlear cartilage experienced a mean strain of 2.4 ± 1.6%, there was no difference in trochlear cartilage strain between the ACL deficient and uninjured knees. In summary, we found that ACL deficiency was associated with decreased patellar cartilage thickness and increased exercise-induced patellar cartilage strain when compared to the uninjured contralateral knees.     

Lower Body Symmetry and Running Performance in Elite Jamaican Track and Field Athletes

In a study of degree of lower body symmetry in 73 elite Jamaican track and field athletes we show that both their knees and ankles (but not their feet) are–on average–significantly more symmetrical than those of 116 similarly aged controls from the rural Jamaican countryside. Within the elite athletes, events ranged from the 100 to the 800 m, and knee and ankle asymmetry was lower for those running the 100 m dashes than those running the longer events with turns. Nevertheless, across all events those with more symmetrical knees and ankles (but not feet) had better results compared to international standards. Regression models considering lower body symmetry combined with gender, age and weight explain 27 to 28% of the variation in performance among athletes, with symmetry related to about 5% of this variation. Within 100 m sprinters, the results suggest that those with more symmetrical knees and ankles ran faster. Altogether, our work confirms earlier findings that knee and probably ankle symmetry are positively associated with sprinting performance, while extending these findings to elite athletes.     

The problem of assessing landmark error in geometric morphometrics: theory, methods, and modifications

Geometric morphometric methods rely on the accurate identification and quantification of landmarks on biological specimens. As in any empirical analysis, the assessment of inter- and intra-observer error is desirable. A review of methods currently being employed to assess measurement error in geometric morphometrics was conducted and three general approaches to the problem were identified. One such approach employs Generalized Procrustes Analysis to superimpose repeatedly digitized landmark configurations, thereby establishing whether repeat measures fall within an acceptable range of variation. The potential problem of this error assessment method (the "Pinocchio effect") is demonstrated and its effect on error studies discussed. An alternative approach involves employing Euclidean distances between the configuration centroid and repeat measures of a landmark to assess the relative repeatability of individual landmarks. This method is also potentially problematic as the inherent geometric properties of the specimen can result in misleading estimates of measurement error. A third approach involved the repeated digitization of landmarks with the specimen held in a constant orientation to assess individual landmark precision. This latter approach is an ideal method for assessing individual landmark precision, but is restrictive in that it does not allow for the incorporation of instrumentally defined or Type III landmarks. Hence, a revised method for assessing landmark error is proposed and described with the aid of worked empirical examples.     

Repeatability of Quantitative MRI Measurements in Normal Breast Tissue

PURPOSE: To evaluate the variability and repeatability of repeated magnetic resonance imaging (MRI) measurements in normal breast tissues between and within subjects. METHODS: Eighteen normal premenopausal subjects underwent two contrast-enhanced MRI scans within 72 hours or during the same menstrual phase in two consecutive months. A subset of nine women also completed diffusion-weighted imaging (DWI). Fibroglandular tissue (FGT) density and FGT enhancement were measured on the contrast-enhanced MRI. Apparent diffusion coefficient (ADC) values were computed from DWI. Between- and within-subject coefficients of variation (bCV and wCV, respectively) were assessed. Repeatability of all measurements was assessed by the coefficient of repeatability (CR) and Bland-Altman plots. RESULTS: The bCV of FGT density and FGT enhancement at visit 1 and visit 2 ranged from 47% to 63%. The wCV was 13% for FGT density, 22% for FGT enhancement, and 11% for ADC. The CRs of FGT density and FGT enhancement were 0.15 and 0.19, respectively, and for ADC, it was 6.1 x 10^-4 mm²/s. CONCLUSIONS: We present an estimate of the variability and repeatability of MR measurements in normal breasts. These estimates provide the basis for understanding the normal variation of healthy breast tissue in MRI and establishing thresholds for agreement between measurements.     

An MRI-based method to align the compressive loading axis for human cadaveric knees

There is a need to align the mechanical axis of the tibia with the axis of loading for studies involving tibiofemoral compression to interpret results and to ensure repeatability of loading within and among specimens. Therefore, the objectives of this study were (1) to develop a magnetic resonance imaging (MRI)-based alignment method for use with apparatuses applying tibiofemoral joint compression, (2) to demonstrate the usefulness of the method by aligning cadaveric knees in an apparatus that could apply tibiofemoral joint compression, and (3) to quantify the error associated with the alignment method. A four degree-of-freedom adjustable device was constructed to allow determination and alignment of the mechanical axis of the tibia of cadaveric knee joints with the axis of loading of an apparatus applying tibiofemoral joint compression. MRI was used to determine the locations of bony landmarks in three dimensions defining the mechanical axis of the tibia relative to an initial orientation of the four degree-of-freedom device. Adjustment values of the device were then computed and applied to the device to align the mechanical axis of the tibia with the axis of a compressive loading apparatus. To demonstrate the usefulness of the method, four cadaveric knees were aligned in the compressive loading apparatus. The vectors describing the mechanical axis of the tibia and the loading axis of the apparatus before and after adjustment of the four degree-of-freedom device were computed for each cadaveric knee. After adjustment of the four degree-of-freedom device, the mechanical axis of the tibia was collinear with the loading axis of the apparatus for each cadaveric knee. The errors in the adjustment values introduced by inaccuracies in the MR images were quantified using the Monte Carlo technique. The precisions in the translational and rotational adjustments were 1.20 mm and 0.90 deg respectively. The MR-based alignment method will allow consistent interpretation of results obtained during tibiofemoral compressive studies conducted using the apparatus described in this paper by providing a well-defined loading axis. The alignment method can also be adapted for use with other apparatuses applying tibiofemoral compression.     

MRI-based characterization of bone anatomy in the human knee for size matching of a medial meniscal implant

Allograft or synthetic menisci have been suggested as a means to restore contact pressures following meniscectomy. However, when the natural meniscus is severely damaged/absent, the necessary size cannot be determined according to the recipient size and there is a need to estimate it from magnetic resonance imaging (MRI) of the contralateral knee or the injured knee bones. The use of the contralateral-knee for size matching is problematic due to economic and practical reasons. Hence, there are significant advantages for a sizing algorithm based only on the candidate knee geometry. The aim of this study is to characterize midrange values and variability of knee dimensions and to develop a set of mathematical relations representing knee dimensions using a minimum of imaging-based bone measurements. Tibia, femur, and meniscus measurements were taken in 118 MRI scans and used to develop a representative parametric knee model in which all dimensions are expressed using tibia plateau width. The model was verified by comparing the predicted values to direct MRI measurements for 20 additional subjects by means of the Pearson correlation and Bland and Altman (1986, "Statistical Methods for Assessing Agreement Between Two Methods of Clinical Measurement," Lancet, 1, pp. 307-310) plot. Anatomical parameters in the male knee were significantly larger (～17%) compared with corresponding female measurements. However, most relations between tibia, femur, and meniscus measurements (43/56) were not significantly different between male and female populations (p ≥ 0.05), indicating that differences between male and female joints are generally related to scaling and not shape. Dimensions predicted by the knee model were in a good agreement with dimensions measured directly from the MRI (R(2)>0.96) and the Bland and Altman plot indicated that ～95% of data points were well within the ± 2 standard deviation lines of agreement. The model proposed in this study is advantageous in being able to describe typical knee proportions for a given tibial width and can be used to predict the dimensions of a candidate knee based on a single measurement. The anatomical/anthropometric data presented in the study can be utilized in a sizing algorithm for artificial meniscal implants or in the design of artificial meniscus prostheses.     

Validation of 3D spino-pelvic muscle reconstructions based on dedicated MRI sequences for fat-water quantification

ObjectivesTo evaluate a protocol, including MRI acquisition with dedicated sequences for fat-water quantification and semi-automatic segmentation, for 3D geometry measurement and fat infiltration of key muscles of the spino-pelvic complex.Materials and methodsMRI protocol: two axial acquisitions from the thoraco-lumbar region to the patella were obtained: one T1-weighted and one based on the Dixon method, permitted to evaluate the proportion of fat inside each muscle. Muscle reconstruction: with Muscl’X software, 3D reconstructions of 18 muscles or groups of muscles were obtained identifying their contours on a limited number of axial images 3D references were obtained only on T1 acquisitions identifying the contour of the muscles on all axial images. Evaluation: for two volunteers, three operators completed reconstructions three times across three sessions. Each reconstruction was projected on the reference to calculate the ‘point to surface’ error. Mean and maximal axial section, muscle volume, and muscle length calculated from the reconstructions were compared to reference values, and intra- and inter-operator variability for those parameters were evaluated.Results2xRMS ‘point to surface’ error was below 3 mm, on average. The agreement between the two methods was variable between muscles [–4.50; 8.00%] for the mean axial section, the length and the volume. Intra- and inter-operator variability were less than 5% and comparison of variability for the Fat and T1 reconstructions did not reveal any significant differences.DiscussionExcellent inter- and intra-operator reliability was demonstrated for 3D muscular reconstruction using the DPSO method and Dixon images that allowed generation of patient-specific musculoskeletal models.     

Normalization of the electromyography amplitude during a multiple-set resistance training protocol: Reliability and differences between approaches

The first aim was to investigate the impact of different electromyography (EMG) parameters as a reference to normalize the EMG amplitude of the superficial quadriceps femoris muscles across different sets of a knee extension exercise. The second aim is to examine the reliability between days of the EMG parameters used as a reference. Eleven young males attended the laboratory on 4 different days and performed one repetition maximum test, maximumvoluntary isometric contractions, and a resistance training protocol until failure. Surface EMG was placed over the rectus femoris, vastus lateralis, and vastus medialis muscles. Seven EMG parameters were calculated from the tasks and used to normalize EMG amplitude measured during the resistance training protocol. A repeated-measures two-way ANOVA was used (normalized EMG amplitude × set) to compare normalized EMG across sets, while an intraclass correlation coefficient, coefficient of variation, and Bland-Altman plots were used to calculate the intra-day reliability of the EMG parameters. The present investigation showed that normalized EMG amplitude of the superficial muscles of the quadriceps measured during a knee extension exercise is influenced by the EMG parameter and depends on the muscle. While rectus femoris and vastus lateralis normalized EMG amplitude presented one parameter among seven showing similar value to the other parameters, VM showed two. Lastly, all EMG parameters for all muscles presented an overall excellent reliability and agreement between days.     

Reproducibility of the cytologic diagnosis of human papillomavirus infection

As part of a larger epidemiologic investigation of the association between human papillomavirus (HPV) infection and cervical intraepithelial neoplasia, the reliability of the cytologic diagnosis of HPV infection was examined. A random sample of cervicovaginal specimens with cytologic changes characteristic of HPV infection were matched with a second set of slides, with regard to the date and severity of the smear and the age of the woman from whom the smear was obtained. The kappa statistic for interobserver agreement was 0.38 (p less than 0.0005), increasing to 0.68 (p less than 0.0005) when uncertain diagnoses were excluded. Intraobserver agreement ranged from kappa = 0.40 to 1.00. Although this agreement is within the range of reliability found for the diagnosis of other atypical cytologic changes, considerable variation is present. The effect of this variability on the validity of estimating the risk of cervical cancer associated with HPV infection may be considerable.     

Reliability of EMG power-spectrum and amplitude of the semitendinosus and biceps femoris muscles during ramp isometric contractions

Appropriate reliability is a necessary condition for the use of surface EMG for evaluation of hamstring muscle function in cases of knee joint pathologies or ligament injuries. The aim of the study was to investigate the test-retest reliability of power spectrum and amplitude of surface electromyographic (EMG) measurements of semitendinosus (ST) and biceps femoris (BF) during ramp isometric contractions. Eleven males performed maximum isometric contractions (MVC) of the knee flexors in two sessions, a week apart with simultaneous recording of surface EMG of the BF and ST. Intra class correlation (ICC) and standard error measurements (SEM) were applied to assess test-retest reliability of the averaged EMG (aEMG) and the median frequency (MF) over 10 levels of force, from 0% to 100% of the maximum. The ICC values ranged from 0.38 to 0.96 for the aEMG with SEM values reaching 11.37% of MVC. For the MF, the ICCs ranged from 0.44 to 0.98 (SEM range 4.49–18.19 Hz). In our set up, ramp contractions can be used to examine hamstring EMG patterns with acceptable reliability.