- Email: [email protected]
Passive Range of Movement of the Shoulder: A Standardized Method for Measurement and Assessment of Intrarater Reliability
PASSIVE RANGE OF MOVEMENT OF THE SHOULDER: A STANDARDIZED METHOD FOR MEASUREMENT AND ASSESSMENT OF INTRARATER RELIABILITY Justin Dougherty, BPhty(Hons), a Sarah Walmsley, PhD, b and Peter G. Osmotherly, PhD c
ABSTRACT Objective: The purpose of this study was to determine the intrarater reliability and reproducibility of a standardized procedure for measuring passive shoulder movement in asymptomatic individuals. Methods: A single assessor used a digital inclinometer and standardized protocol to measure the passive range of motion of 7 shoulder movements in 168 asymptomatic shoulders. Following a warm-up maneuver, 3 measurements were taken for each movement on 2 occasions. Both shoulders were measured using a standardized order of movement. Selection of measurement beginning with left or right shoulder was randomly determined. The entire process was repeated 7 days later to assess reproducibility. Intraclass correlation coefficients (ICCs) with 95% confidence intervals and standard errors of measurement (SEMs) were calculated to assess the intrarater reliability of the methods. Results: The intrarater reliability of our methods was substantial for total shoulder flexion (ICC = 0.82, SEM = 12.3°), whereas all other movements demonstrated moderate reliability (ICC range = 0.64-0.75) except external rotation in neutral abduction, for which reliability was classed as slight (ICC = 0.28, SEM = 31°). Moderate reliability was evident for all movements on follow-up at 7 days (ICC range = 0.60-0.77). Conclusions: These methods of measurement have moderate to substantial reliability for the majority of tested passive shoulder movements, with moderate reliability sustained after 1 week, in a large sample of asymptomatic individuals. (J Manipulative Physiol Ther 2015;38:218-224) Key Indexing Terms: Shoulder; Range of Motion; Articular; Reproducibility of Results
Clinically reliable measurement tools are integral to understanding and accurately measuring shoulder function in both clinical and research populations. 1,2 Clinicians and researchers commonly perform a variety of measurements at the shoulder region that guide the clinical decision-making process. 2–7 One such measurement is range of motion (ROM), a fundamental component of the musculoskeletal
a Graduate Physiotherapist, School of Health Sciences, The University of Newcastle, Callaghan, Australia. b Casual Academic, School of Health Sciences, The University of Newcastle, Callaghan, Australia. c Senior Lecturer in Physiotherapy, School of Health Sciences, The University of Newcastle, Callaghan, Australia. Submit requests for reprints to: Peter G. Osmotherly, PhD, School of Health Sciences, The University of Newcastle, Callaghan, NSW 2308, Australia. (e-mail: [email protected]). Paper submitted May 14, 2014; in revised form November 14, 2014; accepted November 28, 2014. 0161-4754 Copyright © 2015 by National University of Health Sciences. http://dx.doi.org/10.1016/j.jmpt.2014.11.006
examination. 4,8–10 Using reliable methods of measurement, researchers and clinicians can accurately distinguish real changes from normal variations in measurement, 5,11 thereby improving the precision of assessment and reassessment measures. Various tools have been proposed to measure shoulder ROM, with evidence suggesting the use of instruments to be more reliable than visual estimation. 1 Investigations have been conducted into the reliability of a variety of instruments to measure shoulder ROM, including goniometry, 3,6,7,11–14 still photography, 6 and tape measurement. 6,9 Inclinometry has also been suggested as an alternative form of measurement of shoulder range in several clinical studies. 2,4,5,8–10,15–24 Both mechanical and electronic inclinometers are relatively inexpensive, portable, and easy to use, providing a practical alternative to other forms of measurement of the shoulder. 25 Several studies have assessed both inter- and intrarater reliability of measurements using inclinometry of active shoulder ROM. 5,8,9,15–17,20 These have produced varied findings with intraclass correlation coefficients (ICCs) achieved ranging from 0.38 to 0.99 for various shoulder
Journal of Manipulative and Physiological Therapeutics Volume 38, Number 3
movements. Discrepancies in reliability estimates may be attributable to variations in movements assessed, lack of standardization of movement procedures, and the clinical status of the participant groups. Evidence for the reliability of measurements using inclinometry of passive shoulder movement has been characterized by examination of limited movement directions and methodological inconsistencies. 2,4,10,16–19 However, to date, no studies have used a standardized methodology and a previously determined sample size to determine the intrarater reliability of a digital inclinometer to measure a comprehensive set of passive shoulder ROM tests. The aim of this study was to determine the intrarater reliability of a standardized method of measuring passive shoulder movements using a digital inclinometer in an asymptomatic population.
METHODS Subjects Ninety asymptomatic adult participants, 54 women and 36 men, were recruited over a 2-month period from both staff and students of The University of Newcastle, Australia. Participants were eligible for inclusion if they were aged more than 18 years with pain-free shoulder movement and no history of shoulder pain in the preceding 12 months. Potential participants were excluded if they had current shoulder pain, a history of shoulder pathology within the preceding 12 months, or an inability to comprehend verbal instructions in the English language. Ethical approval for the study was granted by The University of Newcastle Human Research Ethics Committee (Approval H-2011-0106).
Study Design This study used a repeated-measurement study design. A single assessor, a final-year Physical Therapy honors student, who had received previous training in the use of the inclinometer and the standardized procedures performed all measurements. The training consisted of 3 days of specific instruction and practice under the supervision of 2 highly experienced (30 years each) musculoskeletal clinicians and researchers. Each shoulder movement was performed 3 times during measurement, the entire procedure occurring on 2 occasions at initial evaluation and on 1 occasion at follow-up 7 days later. The assessor was blinded to the results of the initial measurements during each follow-up assessment.
Shoulder ROM Measurement A standardized protocol for the measurement of passive shoulder movement using a digital inclinometer was performed based upon the method reported by Green et al 15
Dougherty et al Measurement of Shoulder Passive Movement
for assessing active shoulder movement. For movements performed in the sagittal and coronal planes, the participant was positioned seated firmly against the back of the chair to ensure trunk stabilization, with the head maintained in a neutral position. Total shoulder flexion and abduction were performed allowing movements of the entire shoulder complex. For each of the glenohumeral movements performed in sitting, an assistant provided manual downward pressure on the spine of the scapula to eliminate any contribution of scapula movement. Movements were assessed in the following order for all participants. Total Shoulder Flexion. The participant’s elbow was fully extended, with the thumb facing forwards to ensure neutral rotation. The inclinometer was placed on the anterior aspect of the arm, aligned parallel to the humerus. The participant was instructed not to arch back to avoid trunk extension. Leading with the thumb, the participant’s arm was taken through full passive range (Fig 1a). Total Shoulder Abduction. The participant’s elbow was fully extended, with the thumb facing laterally to ensure neutral rotation. The inclinometer was placed on the lateral aspect of the arm, aligned parallel to the humerus. The participant was instructed not to laterally flex their trunk. Leading with the thumb, the participant’s arm was taken through full passive range (Fig 1b). Glenohumeral Flexion. The participant’s scapula was stabilized by the assistant as previously described. The starting position, placement of the inclinometer, and movement direction were identical to the process described to measure total shoulder flexion (Fig 1c). Glenohumeral Abduction. The scapula was stabilized in the same manner as for glenohumeral flexion. The participant’s elbow was flexed to 90° for comfort to minimize placing tension on the axillary neural structures with scapula stabilization. Placement of the inclinometer was identical to total shoulder abduction. While ensuring 90° of elbow flexion, the participant’s arm was then taken through full glenohumeral abduction range (Fig 1d). The remaining movements were performed with the participant supine on a standard plinth. A towel was placed underneath the arm of the participant, with the thickness of toweling adjusted to ensure that the humerus was level with the plinth. This was determined by achieving a zero reading on the inclinometer when placed over the anterior aspect of the upper arm. The participant’s elbow was maintained at 90° of flexion throughout each movement. External Rotation in Neutral Abduction. The participant’s elbow was flexed to 90°, with the forearm positioned in neutral rotation. The arm was positioned in neutral abduction such that the humerus rested parallel to the body. The inclinometer was placed along the anterior aspect of the participant’s forearm. While maintaining 90° of elbow flexion, neutral rotation, and neutral abduction, the participant’s arm was taken through full external rotation range (Fig 2a).
219
220
Dougherty et al Measurement of Shoulder Passive Movement
Journal of Manipulative and Physiological Therapeutics March/April 2015
Fig. 1. Assessment of passive sagittal and coronal plane movements in sitting. a, Total shoulder flexion. b, Total shoulder abduction. c, Glenohumeral flexion. d, Glenohumeral abduction. (Color version of figure is available online.)
External Rotation in 90- of Abduction. The shoulder was abducted to 90°, with the participant’s arm positioned such that the plinth did not impede full ROM. The participant’s elbow was flexed to 90°, with the forearm maintained in neutral rotation throughout the movement. The inclinometer placement and movement direction were as previously described for external rotation in neutral abduction (Fig 2b). Internal Rotation in 90- of Abduction. The shoulder was abducted to 90°, with the participant’s arm positioned as described for external rotation in 90° of abduction. The inclinometer was placed along the posterior aspect of the participant’s forearm. While maintaining 90° of elbow flexion, neutral forearm rotation, and 90° of shoulder abduction, the participant’s arm was taken through full internal rotation range (Fig 2c). Downward pressure was applied over the anterior aspect of the acromion to prevent protraction occurring as previously described by Awan et al. 4 Procedures Participants provided demographic information including age, sex, shoulder dominance, and history of shoulder disorders. Selection of measurement beginning with the left
or right shoulder was randomly determined. The order of movement was standardized for all participants throughout the measurement process. A standard plinth, straight-backed chair, and Baseline digital inclinometer (Fabrication Enterprises Inc, White Plains, NY) were used for all measurements. The inclinometer was recalibrated prior to the measurement of each participant according to the manufacturer’s instructions. Prior to the measurement of each movement, warm-up movements were performed with the assessor taking the arm through the passive ROM 3 times. This was to limit any changes in tissue elasticity potentially resulting from repeated shoulder movement during testing 3 while also enabling the assessor to become familiar with the movement range of each participant. Full passive ROM was determined by a definitive end-feel. 26 The arm was returned to the starting position prior to commencement of each movement. As inconsistencies between starting positions have the potential to introduce measurement error, 16 careful attention was paid to minimize this by ensuring that the inclinometer started at zero prior to each measurement. On completion of the warm-up, 3 measurements were taken before proceeding to the next movement. The process
Journal of Manipulative and Physiological Therapeutics Volume 38, Number 3
Dougherty et al Measurement of Shoulder Passive Movement
Table 1. Characteristics of Study Sample Study subjects Sex Age (y), mean (SD) History of shoulder disorders Shoulder dominance
Total participants: 90 No. of shoulders measured: 168 Male: 36 Female: 54 23.5 (8.9) Yes: 14 No: 76 Right: 82 Left: 8
Data Analysis Data analysis was performed using SPSS version 19 (Sun Microsystems, Chicago, IL). Demographic information was analyzed using descriptive statistics. Intrarater reliability of the movements was determined using ICCs. Interpretation of ICCs was made using the criteria reported by Shrout 27. Standard error of measurement (SEM) was calculated for each passive movement under the method described by Harvill. 28 Sample size was determined using the formula proposed by Eliasziw et al 29 for estimating sample size for reliability studies. A minimum of 160 individual shoulders was determined to be necessary for this study.
RESULTS
Fig. 2. Assessment of passive rotational movements in supine position. a, External rotation in neutral abduction. b, External rotation in 90° of abduction. c, Internal rotation in 90° of abduction. (Color version of figure is available online.) continued until all 7 shoulder movements had been measured 3 times each. The entire process was then repeated on the contralateral shoulder, with movements repeated in the same order. Participants had to return for follow-up measurements 7 days later to determine the reproducibility of the measurement over time. Procedures and order of measurements were undertaken in the same manner as the initial measurements.
A total of 90 participants were included in the study, with measurements completed on a total 168 of shoulders. Characteristics of the study sample are given in Table 1. Intraclass correlation coefficients with 95% confidence intervals for both the initial and follow-up measurements are reported in Table 2, with the mean and standard deviation of each movement performed. Intrarater reliability was substantial for passive total shoulder flexion (ICC, 0.82). Intrarater reliability was moderate for the remaining movements of total shoulder abduction, glenohumeral flexion, glenohumeral abduction, external rotation in 90° of abduction, and internal rotation in 90° of abduction (ICC range, 0.64 -0.75). External rotation in neutral abduction was found to have the lowest reliability as a single measure (ICC, 0.28), indicating slight reliability. For follow-up measurements, all movements were found to have moderate reliability with ICCs ranging from 0.60 to 0.77, indicating that the results obtained demonstrated test-retest reliability over a 1-week period.
DISCUSSION This study has demonstrated that measurement of passive shoulder ROM using inclinometry is moderately to substantially reliable. Unlike previous studies examining passive shoulder movement, 2,16 the standardized methodology used in this study provides a method for assessing the
221
222
Dougherty et al Measurement of Shoulder Passive Movement
Journal of Manipulative and Physiological Therapeutics March/April 2015
Table 2. Intrarater and Test-Retest Reliability of Passive Shoulder Movements Measurement Day 1 Shoulder Movement
Measurement 7-day Follow-Up
Mean Angle (°) (SD) Mean Angle (°) (SD) Measurement 1 Measurement 2 ICC (95% CI)
Total shoulder flexion 173.04 (12.92) Total shoulder 178.09 (13.54) abduction Glenohumeral flexion 104.88 (10.41) Glenohumeral 71.31 (12.07) abduction ER in neutral abduction 67.70 (13.02) ER in 90° of abduction 96.67 (11.70) IR in 90° of abduction 74.45 (14.43)
Mean Angle SEM (°) (°) (SD)
ICC (95% CI)
SEM (°)
169.97 (29.40) 175.19 (30.49)
0.82 (0.74-0.88) 12.33 0.73 (0.61-0.82) 15.81
172.25 (29.47) 0.77 (0.65-0.85) 14.29 177.10 (30.58) 0.76 (0.65- 0.84) 14.98
101.23 (18.70) 69.12 (14.66)
0.75 (0.63-0.83) 0.75 (0.64-0.84)
9.37 7.27
104.23 (18.52) 0.77 (0.67-0.85) 65.80 (14.19) 0.60 (0.44-0.73)
8.80 8.98
0.28 (0.06-0.47) 30.90 0.66 (0.52-0.77) 10.95 0.64 (0.48-0.75) 10.87
67.48 (15.67) 0.71 (0.58-0.81) 98.10 (19.29) 0.61 (0.45-0.73) 74.25 (18.72) 0.68 (0.54-0.79)
8.41 12.09 10.56
69.95 (36.29) 96.01 (18.83) 69.31 (18.07)
CI, confidence interval; ER, external rotation; ICC, intraclass correlation coefficient; IR, internal rotation; SEM, standard error of measurement.
comprehensive suite of movements available at the shoulder complex for use by both researchers and clinicians. Loss of passive movement is pathognomic for several shoulder disorders including adhesive capsulitis and osteoarthrosis. Measurement of this range provides valuable information to determine severity of disease and prognosis for treatment. It also allows the clinician to assess treatment effects. Further, these movements are most likely to reproduce patient symptoms in the presence of pathology. 30,31 Reliable methods to measure these movements are therefore essential to identify any restriction and assist the clinical decision-making process. 2–10 The results of the current study provide clinicians and researchers with a moderate to substantially reliable method of measuring shoulder flexion and abduction. Measurement obtained using this standardized method has also demonstrated stability over time, arguably reinforcing the reliability of the measurements. Intrarater reliability estimates obtained from the present study follow estimates found in similar studies. 4,16,17 For instance, Tveita et al 16 assessed the reliability of measurement for passive glenohumeral flexion, abduction, external rotation, and internal rotation in 45° of abduction in the affected and unaffected shoulders of 32 participants with adhesive capsulitis. Methods used in that study were standardized and well described, producing ICCs ranging from 0.61 to 0.91, which demonstrate similar reliability values to those found in the current study. T’Jonck et al 17 assessed the reliability of measuring passive shoulder flexion, abduction, and internal and external rotation in 8 asymptomatic and 15 symptomatic participants. Their measurement techniques and standardization of movements were poorly described, making their findings difficult to reproduce and interpret. While reporting reliability coefficients ranging from 0.71 to 0.97, the data were analyzed using Pearson correlation coefficients rather than ICCs, resulting in an overestimation of the true effect size. Awan et al 4 assessed measurement of passive rotational shoulder movements in 56 asymptomatic high-school–aged participants with similar demographic characteristics to participants in the present study. Despite limited descriptions of their study methods
making reproducibility difficult, the reliability coefficients they obtained (ICC range, 0.64-0.71) followed those presented in this study. For measurements obtained on the initial assessment, intrarater reliability estimates for both total and glenohumeral flexion and abduction movements were higher than those obtained for internal and external rotation movements of the shoulder. This may indicate that movement in the sagittal and coronal planes is possibly more reliably measured than rotation, perhaps reflecting the biomechanical complexity of rotational shoulder movements. Interestingly, these findings contradict results of earlier studies. 16,17 However, reports from earlier studies used pathological populations, which would likely result in a greater variability in range of movement and pain provocation. Although the majority of movements in this study produced moderate to substantial levels of reliability, external rotation in neutral abduction was found to have poor reliability and a large SEM when assessed as a single measure. To our knowledge, this study is the first assessing the intrarater reliability of this passive movement. In the absence of any biological reason to explain why this movement would be substantially different to other assessed directions of movement, this poor reliability would most likely be due to a greater potential for trunk and elbow movement to contribute to the overall measurement resulting in more difficulty isolating the movement to a purely horizontal plane. This movement across planes may subsequently compound error in this measurement. Moderate reliability was maintained with repeat measurements performed 1 week later, suggesting that this method of measurement was stable over this period. When assessed after 1 week, glenohumeral abduction produced the lowest intrarater reliability. During this movement, the majority of participants reported discomfort near the axilla. This feature has not been reported in similar studies, 4,10,16–18 and we suggest that this was possibly due to tension placed upon neural structures during arm movement while the scapula remained stabilized. 32 Despite maintenance of elbow flexion during this measurement to minimize this effect,
Journal of Manipulative and Physiological Therapeutics Volume 38, Number 3
participants were still apprehensive making a purely passive movement problematic. The results follow the findings of the only previous study to examine the reproducibility of measurement of passive range of shoulder movement over a 1-week period. Tveita and colleagues 16 reported ICCs ranging from 0.61 to 0.91 in the measurement of 4 passive movement directions in the unaffected shoulders of a sample of 32 people with adhesive capsulitis. The ICCs reported in the current study ranged from 0.60 to 0.77. Besides the notably greater sample size used in our study, the results in the current study represent measurement of a more comprehensive range of directions of passive movement using a welldescribed standardized measurement protocol.
LIMITATIONS It has been suggested that measurements of passive movement are less consistent than active shoulder movements, with variations in force applied by the examiner being a possible explanation. 25 This may explain the lower reliability levels obtained in the present study when compared to studies assessing the intrarater reliability of active movements. 5,8,15–17 Assessment of the reliability of active and passive glenohumeral ROM has been reported previously. 2,10,15,16. Although the results of this study demonstrate moderate reliability for the measurement of passive glenohumeral movements, achieving consistent scapula stabilization may be difficult clinically. Downward pressure over the acromion to limit scapula movement is frequently used to assess reliability of glenohumeral movement 15,16; however, this necessitates using a second person to provide stabilization, potentially limiting the clinical utility of this approach. Despite this, results for both initial and follow-up measurements are comparable to those found in similar studies. 16 The consistency of downward pressure on the spine of the scapula applied during the examination cannot be quantified and remains a challenge for reliability of measuring passive glenohumeral movement. A further consideration, particularly in regard to comparison of measurements over time, is the need to monitor pelvic position in the sagittal plane. Test-retest reliability is dependent upon a standardized position from which to commence the motion. Although all measurements followed a standardized protocol in regard to positioning and measurement, it is possible that variation in pelvic rotation may have occurred in some participants. However, the estimates of reliability obtained suggest that the influence of any variation in pelvic starting position did not influence the results adversely in this study. Performing all of the described movements may be time consuming. However, in the clinical setting, it may not be necessary to complete the entire set of movements on each patient depending on the clinical presentation. It should be recognized that this study was conducted on a sample of asymptomatic young individuals. Further
Dougherty et al Measurement of Shoulder Passive Movement
studies assessing a broader participant population including people with shoulder disorders are required to improve the generalizability of these findings. Future examination of reliability of this approach to measurement of passive shoulder movement would benefit from the inclusion of a second examiner so that interrater reliability of the method may also be assessed, providing a more comprehensive suite of information for clinicians and researchers assessing patients with shoulder disorders in future clinical trials.
CONCLUSION This study has reported on the use of a standardized, reproducible method of measuring the ROM of 7 passive shoulder movements with a digital inclinometer. Using this method, moderate to substantial reliability for measurement of passive shoulder movement was demonstrated in a large sample of asymptomatic individuals for all movements with the exception of external rotation in neutral abduction. Moderate reliability was maintained over a 1-week interval for all movements, highlighting the stability of the measurement over time. This study may provide not only a clinically useful method of measurement for the shoulder but also a foundation for future research into the reliability and use of inclinometry in both symptomatic and asymptomatic populations.
FUNDING SOURCES AND POTENTIAL CONFLICTS OF INTEREST No funding sources or conflicts of interest were reported for this study.
CONTRIBUTORSHIP INFORMATION Concept development (provided idea for the research): P.O., S.W. Design (planned the methods to generate the results): J.D., P.O., S.W. Supervision (provided oversight, responsible for organization and implementation, writing of the manuscript): P.O. Data collection/processing (responsible for experiments, patient management, organization, or reporting data): P.O., J.D. Analysis/interpretation (responsible for statistical analysis, evaluation, and presentation of the results): P.O., J.D. Literature search (performed the literature search): J.D., S.W. Writing (responsible for writing a substantive part of the manuscript): P.O., S.W., J.D. Critical review (revised manuscript for intellectual content; this does not relate to spelling and grammar checking): P.O., S.W.
223
224
Dougherty et al Measurement of Shoulder Passive Movement
Practical Applications • This study investigated the reliability of a standardized method of assessing passive ROM of the shoulder using digital inclinometry in a sample of asymptomatic individuals. Intraclass correlation coefficient and SEM are presented for each of the 7 passive movements. • The method of measurement for 6 of the movements demonstrated moderate to substantial reliability on initial assessment. • However, reliability of external rotation measured in neutral abduction was slight. Moderate test-retest reliability existed for all measured movements when repeated 7 days later.
REFERENCES 1. van de Pol RJ, van Trijffel E, Lucas C. Inter-rater reliability for measurement of passive physiological range of motion of upper extremity joints is better if instruments are used: a systematic review. J Physiother 2010;56:7-17. 2. de Winter AF, Heemskerk MA, Terwee CB, et al. Interobserver reproducibility of measurements of range of motion in patients with shoulder pain using a digital inclinometer. BMC Musculoskelet Disord 2004;5. 3. Gajdosik RL, Bohannon RW. Clinical measurement of range of motion: review of goniometry emphasizing reliability and validity. Phys Ther 1987;67:1867-72. 4. Awan R, Smith J, Boon A. Measuring shoulder internal rotation range of motion: a comparison of 3 techniques. Arch Phys Med Rehabil 2002;83:1229-34. 5. Kolber MJ, Vega F, Widmayer K, Cheng M-SS. The reliability and minimal detectable change of shoulder mobility measurements using a digital inclinometer. Physiother Theory Pract 2011;27:176-84. 6. Hayes K, Walton JR, Szomor ZL, Murrell GAC. Reliability of five methods for assessing shoulder range of motion. Aust J Physiother 2001;47:289-94. 7. Pandya S, Florence JM, King WM, Robison JD, Oxman M, Province MA. Reliability of goniometric measurements in patients with Duchenne muscular dystrophy. Phys Ther 1985; 65:1339-42. 8. Kolber MJ, Saltzman SB, Beekhuizen KS, Cheng M-SS. Reliability and minimal detectable change of inclinometric shoulder mobility measurements. Physiother Theory Pract 2009;25:572-81. 9. Valentine RE, Lewis JS. Intraobserver reliability of 4 physiologic movements of the shoulder in subjects with and without symptoms. Arch Phys Med Rehabil 2006;87:1242-9. 10. Dwelly P, Tripp B, Odai M, McGinn P. Reliability of the clinical application of a mechanical inclinometer in measuring glenohumeral motion. Florida International University, 5th Annual South Florida College of Education Research Conference: Section on Allied Health Professions. Miami, FL; 2007. [Available from: http://education.fiu.edu/research_conference/docs/proceedings/ 2007_COERC_Proceedings.pdf]. 11. Low JL. The reliability of joint measurement. Physiotherapy 1976;62:227-9.
Journal of Manipulative and Physiological Therapeutics March/April 2015
12. Riddle DL, Rothstein JM, Lamb RL. Goniometric reliability in a clinical setting: shoulder measurements. Phys Ther 1987; 67:668-73. 13. Boone DC, Azen SP, Lin CM, Spence C, Baron C, Lee L. Reliability of goniometric measurements. Phys Ther 1978;58: 1355-60. 14. Tyler TF, Roy T, Nicholas SJ, Glein GW. Reliability and validity of a new method of measuring posterior shoulder tightness. J Orthop Sports Phys Ther 1999;29:262-74. 15. Green S, Buchbinder R, Forbes A, Bellamy N. A standardized protocol for measurement of range of movement of the shoulder using the Plurirneter-V inclinometer and assessment of its intrarater and interrater reliability. Arthritis Care Res 1998;11:43-52. 16. Tveita EK, Ekeberg OM, Juel NG, Bautz-Holter E. Range of shoulder motion in patients with adhesive capsulitis; intratester reproducibility is acceptable for group comparisons. BMC Musculoskelet Disord 2008;9. 17. T'Jonck L, Schacke S, Lysens R, Witvrouw E, Delvaux K, Peers K. Intertester and intratester reliability of the standard goniometer and the Cybex EDI 320 for active and passive shoulder range of motion in normals and patients. Proceedings of the First Conference of the International Shoulder Group; 1997 Aug 26-27; Delft University of Technology, the Netherlands. Maastricht: Shaker Publishing; 199841-7. 18. Andrews AW, Bohannon RW. Decreased shoulder range of motion on paretic side after stroke. Phys Ther 1989;69:768-72. 19. J-j Lin, Yang J-L. Reliability and validity of shoulder tightness measurement in patients with stiff shoulders. Man Ther 2006;11:146-52. 20. Johnson MP, McClure PW, Karduna AR. New method to assess scapular upward rotation in subjects with shoulder pathology. J Orthop Sports Phys Ther 2001;31:81-9. 21. Triffitt PD, Wildin C, Hajioff D. The reproducibility of measurement of shoulder movement. Acta Orthop Scand 1999;70:322-4. 22. Bower KD. The hydrogoniometer and assessment of glenohumeral joint motion. Aust J Physiother 1982;28:12-7. 23. Geertzen JH, Dijkstra PU, Steward RE, Groothoff JW, Ten Duis HJ, Eisma WH. Variation in measurements of range of motion: a study in reflex sympathetic dystrophy patients. Clin Rehabil 1998;12:254-64. 24. Barnett ND, Duncan RD, Johnson GR. The measurement of three dimensional scapulohumeral kinematics—a study of reliability. Clin Biomech (Bristol, Avon) 1999;14:287-90. 25. Lea RD, Gerhardt JJ. Current concepts review: range-ofmotion measurements. J Bone Joint Surg 1995;77:784-98. 26. Clarkson HM. Musculoskeletal assessment: joint range of motion and manual muscle strength. 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 2005. 27. Shrout PE. Measurement reliability and agreement in psychiatry. Stat Methods Med Res 1998;7:301-17. 28. Harvill LM. Standard error of measurement. An NCME instructional module. Educ Meas Issues Pract 1991;10:33-41. 29. Eliasziw M, Young SL, Woodbury MG, Fryday-Field K. Statistical methodology for the concurrent assessment of interrater and intrarater reliability: using goniometric measurements as an example. Phys Ther 1994;74:777-88. 30. Snyder SJ, Karzel RP, Del Pizzo W, Ferkel RD, Friedman MJ. SLAP lesions of the shoulder. Arthroscopy 1990;6:274-9. 31. Neer CS. Impingement lesions. Clin Orthop Relat Res 1983; 173:70-7. 32. Coppieters MWJ, Stappaerts KH, Everaerh DGM, Staes FFGM. A qualitative assessment of shoulder girdle elevation during the upper limb tension test 1. Man Ther 1999;4:33-8.
ABSTRACT Objective: The purpose of this study was to determine the intrarater reliability and reproducibility of a standardized procedure for measuring passive shoulder movement in asymptomatic individuals. Methods: A single assessor used a digital inclinometer and standardized protocol to measure the passive range of motion of 7 shoulder movements in 168 asymptomatic shoulders. Following a warm-up maneuver, 3 measurements were taken for each movement on 2 occasions. Both shoulders were measured using a standardized order of movement. Selection of measurement beginning with left or right shoulder was randomly determined. The entire process was repeated 7 days later to assess reproducibility. Intraclass correlation coefficients (ICCs) with 95% confidence intervals and standard errors of measurement (SEMs) were calculated to assess the intrarater reliability of the methods. Results: The intrarater reliability of our methods was substantial for total shoulder flexion (ICC = 0.82, SEM = 12.3°), whereas all other movements demonstrated moderate reliability (ICC range = 0.64-0.75) except external rotation in neutral abduction, for which reliability was classed as slight (ICC = 0.28, SEM = 31°). Moderate reliability was evident for all movements on follow-up at 7 days (ICC range = 0.60-0.77). Conclusions: These methods of measurement have moderate to substantial reliability for the majority of tested passive shoulder movements, with moderate reliability sustained after 1 week, in a large sample of asymptomatic individuals. (J Manipulative Physiol Ther 2015;38:218-224) Key Indexing Terms: Shoulder; Range of Motion; Articular; Reproducibility of Results
Clinically reliable measurement tools are integral to understanding and accurately measuring shoulder function in both clinical and research populations. 1,2 Clinicians and researchers commonly perform a variety of measurements at the shoulder region that guide the clinical decision-making process. 2–7 One such measurement is range of motion (ROM), a fundamental component of the musculoskeletal
a Graduate Physiotherapist, School of Health Sciences, The University of Newcastle, Callaghan, Australia. b Casual Academic, School of Health Sciences, The University of Newcastle, Callaghan, Australia. c Senior Lecturer in Physiotherapy, School of Health Sciences, The University of Newcastle, Callaghan, Australia. Submit requests for reprints to: Peter G. Osmotherly, PhD, School of Health Sciences, The University of Newcastle, Callaghan, NSW 2308, Australia. (e-mail: [email protected]). Paper submitted May 14, 2014; in revised form November 14, 2014; accepted November 28, 2014. 0161-4754 Copyright © 2015 by National University of Health Sciences. http://dx.doi.org/10.1016/j.jmpt.2014.11.006
examination. 4,8–10 Using reliable methods of measurement, researchers and clinicians can accurately distinguish real changes from normal variations in measurement, 5,11 thereby improving the precision of assessment and reassessment measures. Various tools have been proposed to measure shoulder ROM, with evidence suggesting the use of instruments to be more reliable than visual estimation. 1 Investigations have been conducted into the reliability of a variety of instruments to measure shoulder ROM, including goniometry, 3,6,7,11–14 still photography, 6 and tape measurement. 6,9 Inclinometry has also been suggested as an alternative form of measurement of shoulder range in several clinical studies. 2,4,5,8–10,15–24 Both mechanical and electronic inclinometers are relatively inexpensive, portable, and easy to use, providing a practical alternative to other forms of measurement of the shoulder. 25 Several studies have assessed both inter- and intrarater reliability of measurements using inclinometry of active shoulder ROM. 5,8,9,15–17,20 These have produced varied findings with intraclass correlation coefficients (ICCs) achieved ranging from 0.38 to 0.99 for various shoulder
Journal of Manipulative and Physiological Therapeutics Volume 38, Number 3
movements. Discrepancies in reliability estimates may be attributable to variations in movements assessed, lack of standardization of movement procedures, and the clinical status of the participant groups. Evidence for the reliability of measurements using inclinometry of passive shoulder movement has been characterized by examination of limited movement directions and methodological inconsistencies. 2,4,10,16–19 However, to date, no studies have used a standardized methodology and a previously determined sample size to determine the intrarater reliability of a digital inclinometer to measure a comprehensive set of passive shoulder ROM tests. The aim of this study was to determine the intrarater reliability of a standardized method of measuring passive shoulder movements using a digital inclinometer in an asymptomatic population.
METHODS Subjects Ninety asymptomatic adult participants, 54 women and 36 men, were recruited over a 2-month period from both staff and students of The University of Newcastle, Australia. Participants were eligible for inclusion if they were aged more than 18 years with pain-free shoulder movement and no history of shoulder pain in the preceding 12 months. Potential participants were excluded if they had current shoulder pain, a history of shoulder pathology within the preceding 12 months, or an inability to comprehend verbal instructions in the English language. Ethical approval for the study was granted by The University of Newcastle Human Research Ethics Committee (Approval H-2011-0106).
Study Design This study used a repeated-measurement study design. A single assessor, a final-year Physical Therapy honors student, who had received previous training in the use of the inclinometer and the standardized procedures performed all measurements. The training consisted of 3 days of specific instruction and practice under the supervision of 2 highly experienced (30 years each) musculoskeletal clinicians and researchers. Each shoulder movement was performed 3 times during measurement, the entire procedure occurring on 2 occasions at initial evaluation and on 1 occasion at follow-up 7 days later. The assessor was blinded to the results of the initial measurements during each follow-up assessment.
Shoulder ROM Measurement A standardized protocol for the measurement of passive shoulder movement using a digital inclinometer was performed based upon the method reported by Green et al 15
Dougherty et al Measurement of Shoulder Passive Movement
for assessing active shoulder movement. For movements performed in the sagittal and coronal planes, the participant was positioned seated firmly against the back of the chair to ensure trunk stabilization, with the head maintained in a neutral position. Total shoulder flexion and abduction were performed allowing movements of the entire shoulder complex. For each of the glenohumeral movements performed in sitting, an assistant provided manual downward pressure on the spine of the scapula to eliminate any contribution of scapula movement. Movements were assessed in the following order for all participants. Total Shoulder Flexion. The participant’s elbow was fully extended, with the thumb facing forwards to ensure neutral rotation. The inclinometer was placed on the anterior aspect of the arm, aligned parallel to the humerus. The participant was instructed not to arch back to avoid trunk extension. Leading with the thumb, the participant’s arm was taken through full passive range (Fig 1a). Total Shoulder Abduction. The participant’s elbow was fully extended, with the thumb facing laterally to ensure neutral rotation. The inclinometer was placed on the lateral aspect of the arm, aligned parallel to the humerus. The participant was instructed not to laterally flex their trunk. Leading with the thumb, the participant’s arm was taken through full passive range (Fig 1b). Glenohumeral Flexion. The participant’s scapula was stabilized by the assistant as previously described. The starting position, placement of the inclinometer, and movement direction were identical to the process described to measure total shoulder flexion (Fig 1c). Glenohumeral Abduction. The scapula was stabilized in the same manner as for glenohumeral flexion. The participant’s elbow was flexed to 90° for comfort to minimize placing tension on the axillary neural structures with scapula stabilization. Placement of the inclinometer was identical to total shoulder abduction. While ensuring 90° of elbow flexion, the participant’s arm was then taken through full glenohumeral abduction range (Fig 1d). The remaining movements were performed with the participant supine on a standard plinth. A towel was placed underneath the arm of the participant, with the thickness of toweling adjusted to ensure that the humerus was level with the plinth. This was determined by achieving a zero reading on the inclinometer when placed over the anterior aspect of the upper arm. The participant’s elbow was maintained at 90° of flexion throughout each movement. External Rotation in Neutral Abduction. The participant’s elbow was flexed to 90°, with the forearm positioned in neutral rotation. The arm was positioned in neutral abduction such that the humerus rested parallel to the body. The inclinometer was placed along the anterior aspect of the participant’s forearm. While maintaining 90° of elbow flexion, neutral rotation, and neutral abduction, the participant’s arm was taken through full external rotation range (Fig 2a).
219
220
Dougherty et al Measurement of Shoulder Passive Movement
Journal of Manipulative and Physiological Therapeutics March/April 2015
Fig. 1. Assessment of passive sagittal and coronal plane movements in sitting. a, Total shoulder flexion. b, Total shoulder abduction. c, Glenohumeral flexion. d, Glenohumeral abduction. (Color version of figure is available online.)
External Rotation in 90- of Abduction. The shoulder was abducted to 90°, with the participant’s arm positioned such that the plinth did not impede full ROM. The participant’s elbow was flexed to 90°, with the forearm maintained in neutral rotation throughout the movement. The inclinometer placement and movement direction were as previously described for external rotation in neutral abduction (Fig 2b). Internal Rotation in 90- of Abduction. The shoulder was abducted to 90°, with the participant’s arm positioned as described for external rotation in 90° of abduction. The inclinometer was placed along the posterior aspect of the participant’s forearm. While maintaining 90° of elbow flexion, neutral forearm rotation, and 90° of shoulder abduction, the participant’s arm was taken through full internal rotation range (Fig 2c). Downward pressure was applied over the anterior aspect of the acromion to prevent protraction occurring as previously described by Awan et al. 4 Procedures Participants provided demographic information including age, sex, shoulder dominance, and history of shoulder disorders. Selection of measurement beginning with the left
or right shoulder was randomly determined. The order of movement was standardized for all participants throughout the measurement process. A standard plinth, straight-backed chair, and Baseline digital inclinometer (Fabrication Enterprises Inc, White Plains, NY) were used for all measurements. The inclinometer was recalibrated prior to the measurement of each participant according to the manufacturer’s instructions. Prior to the measurement of each movement, warm-up movements were performed with the assessor taking the arm through the passive ROM 3 times. This was to limit any changes in tissue elasticity potentially resulting from repeated shoulder movement during testing 3 while also enabling the assessor to become familiar with the movement range of each participant. Full passive ROM was determined by a definitive end-feel. 26 The arm was returned to the starting position prior to commencement of each movement. As inconsistencies between starting positions have the potential to introduce measurement error, 16 careful attention was paid to minimize this by ensuring that the inclinometer started at zero prior to each measurement. On completion of the warm-up, 3 measurements were taken before proceeding to the next movement. The process
Journal of Manipulative and Physiological Therapeutics Volume 38, Number 3
Dougherty et al Measurement of Shoulder Passive Movement
Table 1. Characteristics of Study Sample Study subjects Sex Age (y), mean (SD) History of shoulder disorders Shoulder dominance
Total participants: 90 No. of shoulders measured: 168 Male: 36 Female: 54 23.5 (8.9) Yes: 14 No: 76 Right: 82 Left: 8
Data Analysis Data analysis was performed using SPSS version 19 (Sun Microsystems, Chicago, IL). Demographic information was analyzed using descriptive statistics. Intrarater reliability of the movements was determined using ICCs. Interpretation of ICCs was made using the criteria reported by Shrout 27. Standard error of measurement (SEM) was calculated for each passive movement under the method described by Harvill. 28 Sample size was determined using the formula proposed by Eliasziw et al 29 for estimating sample size for reliability studies. A minimum of 160 individual shoulders was determined to be necessary for this study.
RESULTS
Fig. 2. Assessment of passive rotational movements in supine position. a, External rotation in neutral abduction. b, External rotation in 90° of abduction. c, Internal rotation in 90° of abduction. (Color version of figure is available online.) continued until all 7 shoulder movements had been measured 3 times each. The entire process was then repeated on the contralateral shoulder, with movements repeated in the same order. Participants had to return for follow-up measurements 7 days later to determine the reproducibility of the measurement over time. Procedures and order of measurements were undertaken in the same manner as the initial measurements.
A total of 90 participants were included in the study, with measurements completed on a total 168 of shoulders. Characteristics of the study sample are given in Table 1. Intraclass correlation coefficients with 95% confidence intervals for both the initial and follow-up measurements are reported in Table 2, with the mean and standard deviation of each movement performed. Intrarater reliability was substantial for passive total shoulder flexion (ICC, 0.82). Intrarater reliability was moderate for the remaining movements of total shoulder abduction, glenohumeral flexion, glenohumeral abduction, external rotation in 90° of abduction, and internal rotation in 90° of abduction (ICC range, 0.64 -0.75). External rotation in neutral abduction was found to have the lowest reliability as a single measure (ICC, 0.28), indicating slight reliability. For follow-up measurements, all movements were found to have moderate reliability with ICCs ranging from 0.60 to 0.77, indicating that the results obtained demonstrated test-retest reliability over a 1-week period.
DISCUSSION This study has demonstrated that measurement of passive shoulder ROM using inclinometry is moderately to substantially reliable. Unlike previous studies examining passive shoulder movement, 2,16 the standardized methodology used in this study provides a method for assessing the
221
222
Dougherty et al Measurement of Shoulder Passive Movement
Journal of Manipulative and Physiological Therapeutics March/April 2015
Table 2. Intrarater and Test-Retest Reliability of Passive Shoulder Movements Measurement Day 1 Shoulder Movement
Measurement 7-day Follow-Up
Mean Angle (°) (SD) Mean Angle (°) (SD) Measurement 1 Measurement 2 ICC (95% CI)
Total shoulder flexion 173.04 (12.92) Total shoulder 178.09 (13.54) abduction Glenohumeral flexion 104.88 (10.41) Glenohumeral 71.31 (12.07) abduction ER in neutral abduction 67.70 (13.02) ER in 90° of abduction 96.67 (11.70) IR in 90° of abduction 74.45 (14.43)
Mean Angle SEM (°) (°) (SD)
ICC (95% CI)
SEM (°)
169.97 (29.40) 175.19 (30.49)
0.82 (0.74-0.88) 12.33 0.73 (0.61-0.82) 15.81
172.25 (29.47) 0.77 (0.65-0.85) 14.29 177.10 (30.58) 0.76 (0.65- 0.84) 14.98
101.23 (18.70) 69.12 (14.66)
0.75 (0.63-0.83) 0.75 (0.64-0.84)
9.37 7.27
104.23 (18.52) 0.77 (0.67-0.85) 65.80 (14.19) 0.60 (0.44-0.73)
8.80 8.98
0.28 (0.06-0.47) 30.90 0.66 (0.52-0.77) 10.95 0.64 (0.48-0.75) 10.87
67.48 (15.67) 0.71 (0.58-0.81) 98.10 (19.29) 0.61 (0.45-0.73) 74.25 (18.72) 0.68 (0.54-0.79)
8.41 12.09 10.56
69.95 (36.29) 96.01 (18.83) 69.31 (18.07)
CI, confidence interval; ER, external rotation; ICC, intraclass correlation coefficient; IR, internal rotation; SEM, standard error of measurement.
comprehensive suite of movements available at the shoulder complex for use by both researchers and clinicians. Loss of passive movement is pathognomic for several shoulder disorders including adhesive capsulitis and osteoarthrosis. Measurement of this range provides valuable information to determine severity of disease and prognosis for treatment. It also allows the clinician to assess treatment effects. Further, these movements are most likely to reproduce patient symptoms in the presence of pathology. 30,31 Reliable methods to measure these movements are therefore essential to identify any restriction and assist the clinical decision-making process. 2–10 The results of the current study provide clinicians and researchers with a moderate to substantially reliable method of measuring shoulder flexion and abduction. Measurement obtained using this standardized method has also demonstrated stability over time, arguably reinforcing the reliability of the measurements. Intrarater reliability estimates obtained from the present study follow estimates found in similar studies. 4,16,17 For instance, Tveita et al 16 assessed the reliability of measurement for passive glenohumeral flexion, abduction, external rotation, and internal rotation in 45° of abduction in the affected and unaffected shoulders of 32 participants with adhesive capsulitis. Methods used in that study were standardized and well described, producing ICCs ranging from 0.61 to 0.91, which demonstrate similar reliability values to those found in the current study. T’Jonck et al 17 assessed the reliability of measuring passive shoulder flexion, abduction, and internal and external rotation in 8 asymptomatic and 15 symptomatic participants. Their measurement techniques and standardization of movements were poorly described, making their findings difficult to reproduce and interpret. While reporting reliability coefficients ranging from 0.71 to 0.97, the data were analyzed using Pearson correlation coefficients rather than ICCs, resulting in an overestimation of the true effect size. Awan et al 4 assessed measurement of passive rotational shoulder movements in 56 asymptomatic high-school–aged participants with similar demographic characteristics to participants in the present study. Despite limited descriptions of their study methods
making reproducibility difficult, the reliability coefficients they obtained (ICC range, 0.64-0.71) followed those presented in this study. For measurements obtained on the initial assessment, intrarater reliability estimates for both total and glenohumeral flexion and abduction movements were higher than those obtained for internal and external rotation movements of the shoulder. This may indicate that movement in the sagittal and coronal planes is possibly more reliably measured than rotation, perhaps reflecting the biomechanical complexity of rotational shoulder movements. Interestingly, these findings contradict results of earlier studies. 16,17 However, reports from earlier studies used pathological populations, which would likely result in a greater variability in range of movement and pain provocation. Although the majority of movements in this study produced moderate to substantial levels of reliability, external rotation in neutral abduction was found to have poor reliability and a large SEM when assessed as a single measure. To our knowledge, this study is the first assessing the intrarater reliability of this passive movement. In the absence of any biological reason to explain why this movement would be substantially different to other assessed directions of movement, this poor reliability would most likely be due to a greater potential for trunk and elbow movement to contribute to the overall measurement resulting in more difficulty isolating the movement to a purely horizontal plane. This movement across planes may subsequently compound error in this measurement. Moderate reliability was maintained with repeat measurements performed 1 week later, suggesting that this method of measurement was stable over this period. When assessed after 1 week, glenohumeral abduction produced the lowest intrarater reliability. During this movement, the majority of participants reported discomfort near the axilla. This feature has not been reported in similar studies, 4,10,16–18 and we suggest that this was possibly due to tension placed upon neural structures during arm movement while the scapula remained stabilized. 32 Despite maintenance of elbow flexion during this measurement to minimize this effect,
Journal of Manipulative and Physiological Therapeutics Volume 38, Number 3
participants were still apprehensive making a purely passive movement problematic. The results follow the findings of the only previous study to examine the reproducibility of measurement of passive range of shoulder movement over a 1-week period. Tveita and colleagues 16 reported ICCs ranging from 0.61 to 0.91 in the measurement of 4 passive movement directions in the unaffected shoulders of a sample of 32 people with adhesive capsulitis. The ICCs reported in the current study ranged from 0.60 to 0.77. Besides the notably greater sample size used in our study, the results in the current study represent measurement of a more comprehensive range of directions of passive movement using a welldescribed standardized measurement protocol.
LIMITATIONS It has been suggested that measurements of passive movement are less consistent than active shoulder movements, with variations in force applied by the examiner being a possible explanation. 25 This may explain the lower reliability levels obtained in the present study when compared to studies assessing the intrarater reliability of active movements. 5,8,15–17 Assessment of the reliability of active and passive glenohumeral ROM has been reported previously. 2,10,15,16. Although the results of this study demonstrate moderate reliability for the measurement of passive glenohumeral movements, achieving consistent scapula stabilization may be difficult clinically. Downward pressure over the acromion to limit scapula movement is frequently used to assess reliability of glenohumeral movement 15,16; however, this necessitates using a second person to provide stabilization, potentially limiting the clinical utility of this approach. Despite this, results for both initial and follow-up measurements are comparable to those found in similar studies. 16 The consistency of downward pressure on the spine of the scapula applied during the examination cannot be quantified and remains a challenge for reliability of measuring passive glenohumeral movement. A further consideration, particularly in regard to comparison of measurements over time, is the need to monitor pelvic position in the sagittal plane. Test-retest reliability is dependent upon a standardized position from which to commence the motion. Although all measurements followed a standardized protocol in regard to positioning and measurement, it is possible that variation in pelvic rotation may have occurred in some participants. However, the estimates of reliability obtained suggest that the influence of any variation in pelvic starting position did not influence the results adversely in this study. Performing all of the described movements may be time consuming. However, in the clinical setting, it may not be necessary to complete the entire set of movements on each patient depending on the clinical presentation. It should be recognized that this study was conducted on a sample of asymptomatic young individuals. Further
Dougherty et al Measurement of Shoulder Passive Movement
studies assessing a broader participant population including people with shoulder disorders are required to improve the generalizability of these findings. Future examination of reliability of this approach to measurement of passive shoulder movement would benefit from the inclusion of a second examiner so that interrater reliability of the method may also be assessed, providing a more comprehensive suite of information for clinicians and researchers assessing patients with shoulder disorders in future clinical trials.
CONCLUSION This study has reported on the use of a standardized, reproducible method of measuring the ROM of 7 passive shoulder movements with a digital inclinometer. Using this method, moderate to substantial reliability for measurement of passive shoulder movement was demonstrated in a large sample of asymptomatic individuals for all movements with the exception of external rotation in neutral abduction. Moderate reliability was maintained over a 1-week interval for all movements, highlighting the stability of the measurement over time. This study may provide not only a clinically useful method of measurement for the shoulder but also a foundation for future research into the reliability and use of inclinometry in both symptomatic and asymptomatic populations.
FUNDING SOURCES AND POTENTIAL CONFLICTS OF INTEREST No funding sources or conflicts of interest were reported for this study.
CONTRIBUTORSHIP INFORMATION Concept development (provided idea for the research): P.O., S.W. Design (planned the methods to generate the results): J.D., P.O., S.W. Supervision (provided oversight, responsible for organization and implementation, writing of the manuscript): P.O. Data collection/processing (responsible for experiments, patient management, organization, or reporting data): P.O., J.D. Analysis/interpretation (responsible for statistical analysis, evaluation, and presentation of the results): P.O., J.D. Literature search (performed the literature search): J.D., S.W. Writing (responsible for writing a substantive part of the manuscript): P.O., S.W., J.D. Critical review (revised manuscript for intellectual content; this does not relate to spelling and grammar checking): P.O., S.W.
223
224
Dougherty et al Measurement of Shoulder Passive Movement
Practical Applications • This study investigated the reliability of a standardized method of assessing passive ROM of the shoulder using digital inclinometry in a sample of asymptomatic individuals. Intraclass correlation coefficient and SEM are presented for each of the 7 passive movements. • The method of measurement for 6 of the movements demonstrated moderate to substantial reliability on initial assessment. • However, reliability of external rotation measured in neutral abduction was slight. Moderate test-retest reliability existed for all measured movements when repeated 7 days later.
REFERENCES 1. van de Pol RJ, van Trijffel E, Lucas C. Inter-rater reliability for measurement of passive physiological range of motion of upper extremity joints is better if instruments are used: a systematic review. J Physiother 2010;56:7-17. 2. de Winter AF, Heemskerk MA, Terwee CB, et al. Interobserver reproducibility of measurements of range of motion in patients with shoulder pain using a digital inclinometer. BMC Musculoskelet Disord 2004;5. 3. Gajdosik RL, Bohannon RW. Clinical measurement of range of motion: review of goniometry emphasizing reliability and validity. Phys Ther 1987;67:1867-72. 4. Awan R, Smith J, Boon A. Measuring shoulder internal rotation range of motion: a comparison of 3 techniques. Arch Phys Med Rehabil 2002;83:1229-34. 5. Kolber MJ, Vega F, Widmayer K, Cheng M-SS. The reliability and minimal detectable change of shoulder mobility measurements using a digital inclinometer. Physiother Theory Pract 2011;27:176-84. 6. Hayes K, Walton JR, Szomor ZL, Murrell GAC. Reliability of five methods for assessing shoulder range of motion. Aust J Physiother 2001;47:289-94. 7. Pandya S, Florence JM, King WM, Robison JD, Oxman M, Province MA. Reliability of goniometric measurements in patients with Duchenne muscular dystrophy. Phys Ther 1985; 65:1339-42. 8. Kolber MJ, Saltzman SB, Beekhuizen KS, Cheng M-SS. Reliability and minimal detectable change of inclinometric shoulder mobility measurements. Physiother Theory Pract 2009;25:572-81. 9. Valentine RE, Lewis JS. Intraobserver reliability of 4 physiologic movements of the shoulder in subjects with and without symptoms. Arch Phys Med Rehabil 2006;87:1242-9. 10. Dwelly P, Tripp B, Odai M, McGinn P. Reliability of the clinical application of a mechanical inclinometer in measuring glenohumeral motion. Florida International University, 5th Annual South Florida College of Education Research Conference: Section on Allied Health Professions. Miami, FL; 2007. [Available from: http://education.fiu.edu/research_conference/docs/proceedings/ 2007_COERC_Proceedings.pdf]. 11. Low JL. The reliability of joint measurement. Physiotherapy 1976;62:227-9.
Journal of Manipulative and Physiological Therapeutics March/April 2015
12. Riddle DL, Rothstein JM, Lamb RL. Goniometric reliability in a clinical setting: shoulder measurements. Phys Ther 1987; 67:668-73. 13. Boone DC, Azen SP, Lin CM, Spence C, Baron C, Lee L. Reliability of goniometric measurements. Phys Ther 1978;58: 1355-60. 14. Tyler TF, Roy T, Nicholas SJ, Glein GW. Reliability and validity of a new method of measuring posterior shoulder tightness. J Orthop Sports Phys Ther 1999;29:262-74. 15. Green S, Buchbinder R, Forbes A, Bellamy N. A standardized protocol for measurement of range of movement of the shoulder using the Plurirneter-V inclinometer and assessment of its intrarater and interrater reliability. Arthritis Care Res 1998;11:43-52. 16. Tveita EK, Ekeberg OM, Juel NG, Bautz-Holter E. Range of shoulder motion in patients with adhesive capsulitis; intratester reproducibility is acceptable for group comparisons. BMC Musculoskelet Disord 2008;9. 17. T'Jonck L, Schacke S, Lysens R, Witvrouw E, Delvaux K, Peers K. Intertester and intratester reliability of the standard goniometer and the Cybex EDI 320 for active and passive shoulder range of motion in normals and patients. Proceedings of the First Conference of the International Shoulder Group; 1997 Aug 26-27; Delft University of Technology, the Netherlands. Maastricht: Shaker Publishing; 199841-7. 18. Andrews AW, Bohannon RW. Decreased shoulder range of motion on paretic side after stroke. Phys Ther 1989;69:768-72. 19. J-j Lin, Yang J-L. Reliability and validity of shoulder tightness measurement in patients with stiff shoulders. Man Ther 2006;11:146-52. 20. Johnson MP, McClure PW, Karduna AR. New method to assess scapular upward rotation in subjects with shoulder pathology. J Orthop Sports Phys Ther 2001;31:81-9. 21. Triffitt PD, Wildin C, Hajioff D. The reproducibility of measurement of shoulder movement. Acta Orthop Scand 1999;70:322-4. 22. Bower KD. The hydrogoniometer and assessment of glenohumeral joint motion. Aust J Physiother 1982;28:12-7. 23. Geertzen JH, Dijkstra PU, Steward RE, Groothoff JW, Ten Duis HJ, Eisma WH. Variation in measurements of range of motion: a study in reflex sympathetic dystrophy patients. Clin Rehabil 1998;12:254-64. 24. Barnett ND, Duncan RD, Johnson GR. The measurement of three dimensional scapulohumeral kinematics—a study of reliability. Clin Biomech (Bristol, Avon) 1999;14:287-90. 25. Lea RD, Gerhardt JJ. Current concepts review: range-ofmotion measurements. J Bone Joint Surg 1995;77:784-98. 26. Clarkson HM. Musculoskeletal assessment: joint range of motion and manual muscle strength. 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 2005. 27. Shrout PE. Measurement reliability and agreement in psychiatry. Stat Methods Med Res 1998;7:301-17. 28. Harvill LM. Standard error of measurement. An NCME instructional module. Educ Meas Issues Pract 1991;10:33-41. 29. Eliasziw M, Young SL, Woodbury MG, Fryday-Field K. Statistical methodology for the concurrent assessment of interrater and intrarater reliability: using goniometric measurements as an example. Phys Ther 1994;74:777-88. 30. Snyder SJ, Karzel RP, Del Pizzo W, Ferkel RD, Friedman MJ. SLAP lesions of the shoulder. Arthroscopy 1990;6:274-9. 31. Neer CS. Impingement lesions. Clin Orthop Relat Res 1983; 173:70-7. 32. Coppieters MWJ, Stappaerts KH, Everaerh DGM, Staes FFGM. A qualitative assessment of shoulder girdle elevation during the upper limb tension test 1. Man Ther 1999;4:33-8.