Normative values and phenotypic performance profiles in the modified closed kinetic chain upper extremity stability test among healthy indian adults

Abstract

Background

The closed kinetic chain upper extremity stability test (CKCUEST) is widely used to assess shoulder stability. The modified CKCUEST (mCKCUEST) incorporates height-normalized hand spacing (50%) to account for individual anthropometric variations and improve biomechanical validity.

Objective

To establish normative reference values for mCKCUEST performance in healthy Indian adults and to define diagnostic thresholds and performance phenotypes using percentile classification, ROC analysis, and clustering techniques.

Methods

A cross-sectional study was conducted among 517 physically active participants (53.6% females) aged 18–28 years. Each participant completed three mCKCUEST trials. Mean, relative (touches/meter), and power scores were calculated. Percentile ranks were stratified by sex. ROC analysis assessed discriminatory cut-offs, while k-means clustering was used to identify phenotypic subgroups. An adaptation index (Trial 3–Trial 1) was computed to evaluate neuromuscular responsiveness.

Results

The mean mCKCUEST score was 17.6 ± 2.3 repetitions with a relative score of 10.5 ± 1.5 touches/meter and a power score of 56.2 ± 11.9. Males performed better than females in Trials 2 and 3 (p < 0.001). No significant correlations were observed between anthropometric variables and performance outcomes. K-means clustering revealed three distinct performance phenotypes, including one with low baseline scores but high neuromuscular adaptability. BMI-based stratification showed most participants were in the normal range (72.5%).

Conclusion

This study provides normative benchmarks for mCKCUEST in healthy Indian adults. The integration of percentile norms, BMI stratification, and adaptation-based phenotypes enhances individualized interpretation in clinical and performance assessment settings.

Keywords

muscle strength reference values motor skills phenotype upper extremity cluster analysis BMI India

Introduction

The upper extremity kinetic chain is a complex system that requires optimal integration of neuromuscular coordination, dynamic stability, and proprioceptive control.¹ Deficits in shoulder stability can significantly reduce functional capacity and predispose individuals to musculoskeletal disorders, especially in physically active populations.² The Closed Kinetic Chain Upper Extremity Stability Test (CKCUEST) was developed to assess upper extremity dynamic stability and overall function in a closed kinetic chain context.³ This test evaluates the number of cross-body touches performed within 15 s in a push-up position.³

The CKCUEST has demonstrated strong intra-rater and inter-rater reliability, construct and criterion validity, and significant clinical applicability across diverse populations, including individuals recovering from shoulder injuries or undergoing performance screening.^2–6 However, evidence suggests that the original test is limited by its standardized hand spacing of 36 inches, which does not account for variations in body size and limb length. This limitation introduces biomechanical disadvantages for individuals with smaller statures, leading to inconsistent loading and reduced ecological validity when applied across diverse populations.^6,7

To mitigate this issue, the test was modified by normalizing hand placement to 50% of the individual's height, thereby improving validity and reducing excessive strain across diverse body types.^6,7 The mCKCUEST has since been widely used across clinical, athletic, and research settings due to its low cost, ease of implementation, and strong psychometric properties.^2,6 Additionally, the mCKCUEST includes relative scores (touches per meter of height) and power scores (product of touches and body mass), which enhance performance interpretation relative to body characteristics.⁸

While previous studies have demonstrated high test-retest reliability, most normative data to date have focused on athlete populations.^7,9 Despite its utility, there is a significant lack of clinically meaningful benchmarks for healthy young adults, limiting the tool's broader clinical application in rehabilitation, screening, and return-to-function.^7,9

Furthermore, current studies^2,6,7,9 have not used advanced methods such as percentile banding, ROC-based cutoffs, or clustering to better interpret test scores and facilitate individualized clinical decisions. Clustering analysis and neuromuscular adaptation insights remain underexplored despite their potential to classify individuals by response type and functional output.¹⁰

Therefore, this cross-sectional study aims to address the absence of normative reference values for the modified mCKCUEST in the Indian population and to explore performance phenotypes based on repeated trial adaptations.

Materials and methods

A descriptive cross-sectional observational study was conducted from October 2023 to June 2024 at the university research center. The study protocol was approved by the Institutional Review Board and Ethics Committee (SUIP/UG22/135/2024) of Srinivas University. Written informed consent was obtained from all participants in accordance with the Declaration of Helsinki.

Participants

A total of 517 healthy young adults aged between 18 to 28 years participated in the study. With 47 to 53 participants enrolled per age category (11 total). Participants aged 18 to 28 were selected to represent a typical young adult cohort, minimizing variability in neuromuscular function linked to maturation or age-related decline. A purposive sampling method was used to recruit participants from university campuses. Physical activity status was assessed using the International Physical Activity Questionnaire (IPAQ) short form.^11,12 While participants met criteria for general activity, specific training types (e.g., resistance or aerobic) were not documented. This limitation is observed in interpreting performance variability. Only individuals classified in the Health-Enhancing Physical Activity (HEPA) category were included. All participants were screened using a standardized health questionnaire. Those reporting any current upper extremity pain or acute injury in the last six months, history of general surgery within the previous six weeks, or upper extremity surgery within the past year.¹³

Pilot study

A pilot study was conducted on 12 participants (6 males, 6 females) to determine the sample size. Using the formula n = [(Zα × σ)/d]² with a standard deviation (σ) of 3.1 and a margin of error (d) of 0.9, the estimated sample size was 47 per age group. The final sample included 517 participants.

Testing procedure

Data collection was carried out by four undergraduate-trained physical therapists. Each therapist underwent standardized training and practiced the procedure on at least 10 individuals before formal data collection.⁶ All participants were screened for eligibility and received a detailed explanation of the testing protocol.

The mCKCUEST was used to assess upper limb stability. Two strips of athletic tape, each 1.5 inches wide, were placed on the floor at a distance equal to 50% of the participant's height,² as shown in Figure 2. Males used a standard push-up position (Figure 1(a), (b)), and females used a modified position with knee support (Figure 1(c), (d)).^14,15 Testing involved alternating cross-body touches for 15 s.

Figure 1.

Flowchart showing the participant flow.

Figure 2.

a, b: Starting and mid-test positions for the modified closed kinetic chain upper extremity stability test (mCKCUEST) in a male participant. c, d: Starting and mid-test positions for the mCKCUEST in a female participant. Tape marks indicate 50% height-based hand spacing.

Each participant performed three trials. A rest interval of a 45-s rest period between trials was used, as supported by Tucci et al. (2014) in similar CKCUEST protocols.⁶ A warm-up was completed before testing. Start-stop audio cues and verbal instructions ensured consistency and motivation.¹⁶ A trained physiotherapist manually recorded valid touches in each trial. The mean of the three touch counts was used for analysis. The relative score was calculated by dividing mean touches by height in meters. Power score was calculated as: (mean touches × 68% of body mass in kg) ÷ 15.⁸ To assess intra-sessional adaptation, an adaptation index was calculated. The adaptation index is defined as the difference in score between Trial 3 and Trial 1, reflecting changes in neuromuscular performance across repetitions.

Statistical analysis

Statistical analysis was performed using IBM SPSS (Version 29.0) and R (Version 4.3.1). Data were assessed for normality using the Shapiro–Wilk test. Normally distributed data are reported as mean ± SD, while non-normal data are reported as median (IQR). The Mann–Whitney U test assessed gender-based differences. Kruskal-Wallis test was used to compare age groups (≤20, 21–22, ≥23). Multiple linear regression evaluated whether age, gender, height, weight, and BMI predicted CKCUEST scores (Mean, Relative, Power). Results were reported with β coefficients, 95% CIs, and p-values.

Spearman correlation analysis (heat map) was used to examine associations between anthropometric variables and mCKCUEST scores. A p-value < 0.05 was considered statistically significant. ROC analysis was performed to determine diagnostic cut-off values for subgrouping participants based on percentile rankings. K-means clustering was used to classify participants into performance phenotypes based on mean, power, and adaptation scores.

Results

A cohort of 600 healthy young adults was initially recruited during the period of October 2023 to June 2024. Eighteen participants were excluded during the initial screening with IPAQ as they did not qualify under the HEPA category (more active). Subsequent assessment of the remaining 582 participants resulted in the exclusion of 56 participants due to predefined exclusion criteria. Nine participants were lost to follow-up as they discontinued participation. The final data analysis was performed on 517 participants who completed all study requirements. Figure 1 shows the participant flow.

Participants

Table 1 shows the baseline demographic, anthropometric, and performance characteristics of the 517 participants included in this cross-sectional normative study. The mean age of the participants was 21.3 ± 1.1 years, reflecting a narrow age range typical of undergraduate health science cohorts. Gender distribution was nearly balanced, with 53.6% females and 46.4% males, supporting adequate statistical power for sex-stratified comparisons and enhancing the generalizability of gender-based interpretations.

Table 1.

Participant characteristics.

Variable	Mean ± SD 95% CI / N (%)
Age (years)	23.0 ± 3.1
Gender, Female (%)	262 (49.5%)
Gender, Male (%)	267 (50.5%)
Anthropometric Measures
Height (cm)	164.1 ± 9.5
Weight (kg)	63.2 ± 12.6
BMI (kg/m²)	23.5 ± 4.4
Performance Measures
Trial 1 (touches)	19.8 ± 2.4
Trial 2 (touches)	20.6 ± 3.0
Trial 3 (touches)	21.2 ± 2.3
Mean touches	20.5 ± 2.3
Relative Score (touches/m)	12.5 ± 1.5
Power Score	59.1 ± 15.4

*Data are presented as mean ± standard deviation with 95% confidence intervals in brackets for continuous variables and as n (%) for categorical variables. BMI = Body Mass Index. Touches = number of touches within 15 s during the Modified Closed Kinetic Chain Upper Extremity Stability Test (mCKCUEST).

Descriptive analysis of anthropometric variables revealed a mean height of 167.4 ± 7.6 cm and a mean body mass of 65.2 ± 11.3 kg, resulting in an average BMI of 23.3 ± 3.7 kg/m². These values reflect a physiologically representative sample, with most participants falling within the World Health Organization's “normal” BMI range.¹⁷ Participants had a mean BMI of 23.3 ± 3.7 kg/m², with average height and weight of 167.4 ± 7.6 cm and 65.2 ± 11.3 kg, respectively. Based on WHO classification, 72.5% were within the normal BMI range, 21.3% were overweight, 4.4% were underweight, and 1.8% were obese. The distribution is presented in Supplementary Figure S4 and reflects a predominantly healthy cohort suitable for normative analysis. The relatively narrow confidence intervals across height and weight suggest a tightly clustered distribution, supporting the validity of the normative values established in this study.

mCKCUEST scores showed progressive improvement across successive trials, with mean repetitions increasing from Trial 1 (17.0 ± 2.8) to Trial 2 (17.7 ± 2.6) and Trial 3 (18.0 ± 2.5), suggesting a mild neuromuscular adaptation or familiarization response. Relative score averaged 10.5 ± 1.5 touches/meter, and the power score was 56.2 ± 11.9. This upward trend suggests neuromuscular adaptation. Figure 2 shows performance distribution across trials.

An adaptation index (ΔT3–T1) was calculated, averaging +1.0 ± 2.5 touches across the sample, supporting a familiarization or responsiveness effect.

As shown in Table 2, statistically significant gender differences were observed in Trial 2 (p < 0.001), Trial 3 (p < 0.001), Mean touches (p < 0.001), and Relative Score (p = 0.002). Males consistently outperformed females, with small but meaningful effect sizes (r = 0.126–0.153), likely reflecting physiological differences in upper limb strength and neuromuscular control. Trial 1 data showed statistical significance but with the smallest effect size (r = 0.131), highlighting its limited practical relevance. Despite higher mean scores for male participants, the power score was not statistically significant, suggesting body mass may moderate the total output. These findings highlight the importance of using sex-specific reference values when interpreting mCKCUEST performance. Figure 3 shows the gender-based comparison of performance metrics.

Figure 3.

Gender differences in mCKCUEST performance measures. Violin plots show higher male scores in Trial 2, Trial 3, Mean, and Relative Score (p < 0.01), with small effect sizes. No significant difference was observed in Power Score. Boxplots show median and interquartile ranges.

Table 2.

Comparison of mCKCUEST performance between genders.

Performance variable	U Statistic	p-value	Effect size (r)
Trial1	29632.0	0.0027	0.131
Trial2	29926.5	0.0037	0.126
Trial3	28846.5	0.0004	0.153
Mean	29287.5	0.0012	0.141
Relative score	40348.5	0.0022	0.133
Power score	20473.0	0.0000	0.357

This table summarizes the results of the Mann–Whitney U test comparing CKCUEST performance measures between male and female participants. Effect size (r) is calculated to indicate the magnitude of the differences. Significant differences are bolded, suggesting a gender influence on upper extremity closed kinetic chain performance.

Receiver Operating Characteristic (ROC) analysis using Relative Score to classify “low performers” (below the 25th percentile in mean score) yielded an AUC of 0.058, indicating poor discriminatory power. Given this result, percentile thresholds were retained for subgroup classification instead of predictive cutoffs. Full ROC curve is presented in Supplementary Figure S1.

K-means clustering identified three distinct performance phenotypes based on mean score, power score, relative score, and adaptation index. Figure 4 presents the cluster distribution, and Table 3 summarizes key traits. Cluster 0 (31%), Adaptive Low Performers, showed the lowest baseline scores but the highest adaptation (ΔT3–T1 = +2.07), indicating strong responsiveness to repetition. Cluster 1 (24%), High Stable Performers, had the highest overall performance and stable output across trials. Cluster 2 (45%), Flat or Declining Responders, displayed moderate scores with little or no adaptation, suggesting reduced neuromuscular efficiency.

Figure 4.

Principal component analysis (PCA) projection of K-means clustering shows three distinct mCKCUEST performance phenotypes based on mean score, relative score, power score, and adaptation index. Cluster 0 (red) = Adaptive Low Performers, Cluster 1 (blue) = High Stable Performers, and Cluster 2 (green) = Flat or Declining Responders. Each point represents a participant, grouped by similarity in performance metrics. PCA axes represent the two principal components explaining the highest variance in the dataset.

Table 3.

Performance phenotype summary.

Cluster	Mean score, Mean ± SD	Relative score, Mean ± SD	Power scoreMean ± SD	Adaptation indexMean ± SD	Phenotype label
0	18.2 ± 1.3	11.1 ± 0.9	48.8 ± 8.7	2.1 ± 1.4	Adaptive Low Performers
2	23.6 ± 1.6	14.2 ± 1.3	76.0 ± 17.0	1.7 ± 2.0	High Stable Performers
3	20.5 ± 1.0	12.6 ± 0.8	57.4 ± 9.9	1.0 ± 1.0	Flat Responders

Descriptive statistics for three phenotypes identified via K-means clustering using Mean Score, Relative Score, Power Score, and Adaptation Index. Values are presented as mean ± standard deviation (SD).Abbreviations: SD – Standard Deviation; mCKCUEST – Modified Closed Kinetic Chain Upper Extremity Stability Test.

Table 3 presents the results of the Kruskal–Wallis test evaluating performance across three age groups (≤20, 21–22, and ≥23 years). Only Trial 1 showed a significant difference across groups (p = 0.029), suggesting that early trial performance may be influenced by age-related neuromuscular responsiveness or task unfamiliarity. No significant differences were found in subsequent trials or composite scores, supporting the notion that performance converges across age with repeated exposure. Figure S2 represents the distribution of age groups. Table 3 and Figure 4 are included in the main manuscript.

Table S2 summarizes the multiple linear regression models examining whether age, gender, height, weight, and BMI predict mCKCUEST outcomes (Mean, Relative, and Power Score). None of the predictors were significantly associated with performance (p > 0.05), indicating that these variables do not substantially influence mCKCUEST outcomes in healthy young adults. Table S2 is included in the Supplementary Information.

Figure S3 shows the Spearman correlation matrix for all continuous variables. Strong positive correlations were found among the three mCKCUEST trials and the overall mean score (r = 0.74–0.88), confirming internal consistency. The relative score also showed moderate-to-strong associations with individual trials. In contrast, anthropometric variables such as height, weight, and BMI exhibited weak correlations with performance outcomes (r < 0.20), reinforcing the regression findings that body composition does not significantly impact mCKCUEST performance in this population.

Discussion

This study established normative values for mCKCUEST performance in healthy young adults. Males showed consistently higher scores than females, and a modest improvement was observed across successive trials, reflecting short-term neuromuscular adaptation. Previous studies have primarily focused on Western populations, thereby limiting the generalizability of those findings to diverse populations.^6,18,19 Our cohort represents a generally physically active population with a balanced gender distribution and a tightly clustered anthropometric profile, providing clinically relevant normative insights for upper limb assessment in young Indian adults. While these data improve generalizability within this demographic, caution must be exercised when extrapolating to other populations or age groups.

We observed a gradual increase in average touches across trials, likely reflecting a learning or familiarization effect. This aligns with previous studies showing that short-term neuromuscular adaptation can occur without structured training.^7,16 The mean performance score was 17.6 ± 2.3 repetitions, and the average power score was 56.2 ± 11.9. These benchmarks provide clinicians with meaningful targets for assessing upper limb function when adjusted for anthropometric measurements such as height and weight.

A significant gender-based difference in performance was observed in all trials except for Trial 1 and the power score. This finding aligns with previous studies, reporting physiological differences in muscle mass and core strength as primary contributors.^2,19 Although males had higher raw scores, gender differences in power scores were neutralized after adjusting for body mass, reemphasizing the need for adjusted metrics to support fair clinical interpretations.⁸

The Kruskal–Wallis analysis indicated age-related differences only in Trial 1, suggesting an initial neuromuscular response rather than a sustained overall performance. This supports including familiarization trials in routine CKCUEST protocols, as recommended by Tucci et al. (2014).¹⁵

From a statistical standpoint, the absence of significant associations between mCKCUEST scores and anthropometric variables (height, weight, BMI, and age) supports the test's utility as a neuromuscular coordination outcome rather than one influenced by structural body advantages. These results are in line with Riemann et al. and Hegedus et al., who highlighted the functional rather than the biomechanical nature of mCKCUEST performance.^4,5

The mean normative scores observed in this study were consistent with global findings, although slightly lower than those reported in athletic populations.^18,20 This underscores the need for population-specific reference standards, especially when assessing functional stability in non-athlete cohorts. The adoption of height-normalized hand spacing (50% of participant height) rather than the traditional fixed 36-inch gap aligns with biomechanical recommendations aimed at improving test fairness and ecological validity.^7,15

In addition to overall group averages, the clustering analysis identified three distinct performance phenotypes based on mean score, relative output, power index, and neuromuscular adaptability. Notably, one group started with the lowest performance in the first trial but showed the greatest improvement over repeated trials. They were classified as “adaptive low performers” based on their phenotype profiling.^10,21 This finding suggests that such individuals are likely to benefit from exercises that emphasize neuromuscular control.

Conversely, another group that did not demonstrate any improvement with repeated trials was phenotyped as “flat responders.” These results align with current literature on inter-individual variations in exercise response, where certain individuals exhibit greater adaptations to training stimuli while others show limited or no improvement despite undergoing similar interventions.^22,23

The receiver operating characteristic (ROC) analysis further revealed that the relative score of mCKCUEST could not reliably differentiate individuals with and without dysfunction in physically active populations (AUC = 0.058). This emphasizes that mCKCUEST may not function as a single diagnostic cut-off tool in active individuals. However, it remains valuable as a tool to assess individual performance across a continuum.

Clinical implications

The large-scale normative data generated from this study will serve as a practical tool for clinicians assessing upper limb stability in young Indian adults. These benchmark values can help identify functional limitations, track rehabilitation progress, and set achievable goals. The inclusion of relative and power scores enhances interpretation, especially for individuals whose raw scores are influenced by anthropometric factors.² Furthermore, phenotype-based stratification introduces a new framework to individualize targeted interventions by identifying individuals who are more likely to respond to neuromuscular training.

Limitations

Despite the study's strengths, several limitations must be acknowledged. While the sample included both genders and a large cohort of young adults aged 18–28, the findings may not be generalized to sedentary or older populations. The study did not differentiate training backgrounds (e.g., resistance vs. aerobic), which may influence performance. Although familiarization trials were provided, long-term learning effects and day-to-day variability were not assessed.^24,25 In addition, the poor discriminatory capacity documented in ROC analysis (AUC = 0.058) limits the utility of mCKCUEST as a diagnostic classifier. Future studies should address these gaps to strengthen the generalizability and predictive application of mCKCUEST.

Conclusion

This is the first study to establish normative reference values for the modified CKCUEST in healthy adults aged 18–28 years within an Indian context. These findings reinforce the utility of mCKCUEST for evaluating upper limb function across diverse physical profiles. The integration of performance phenotyping strengthens clinical value, allowing for more targeted assessments. Future studies should broaden these normative databases across diverse age groups and develop combined predictive tools for clinical applications.

Footnotes

Acknowledgements

Our sincere thanks go to all the study participants and the Institute of Physiotherapy, Srinivas University, Mangalore, India, for giving us the opportunity to carry out this study

Ethical statement

The study protocol was approved by the Institutional Review Board and Ethics Committee of Srinivas University (Ref: SUIP/UG22/135/2024). Written informed consent was obtained from all participants in accordance with the Declaration of Helsinki. Separate consent was also secured for the publication of images appearing in the manuscript.

Author contributions

AR was the principal investigator and enrolled participants for this study. Conceptualization of the study was by AR and VP. The proposed exercise is made freely available for teaching and clinical purposes. Supervision of the trial and data collection was done by AR, RK, RRH, RR. The study was designed, and the data analysis was executed by AR and VP. AR, RK, and VP provided critical input and aided with data management. All the authors had equally contributed to the preparation and editing of this manuscript.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data availability interests

Data sheets and are available at:

Supplemental material

Supplemental material for this article is available online.

ORCID iDs

Rifna Kousar

Ravi Ramadevarapura Honnahalagegowda

Vijayakumar Palaniswamy

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Normative values and phenotypic performance profiles in the modified closed kinetic chain upper extremity stability test among healthy indian adults– A cross-sectional study

Abstract

Background

Objective

Methods

Results

Conclusion

Keywords

Introduction

Materials and methods

Participants

Pilot study

Testing procedure

Statistical analysis

Results

Participants

Discussion

Clinical implications

Limitations

Conclusion

Footnotes

Acknowledgements

Ethical statement

Author contributions

Funding

Declaration of conflicting interests

Data availability interests

Supplemental material

ORCID iDs

References

Supplementary Material