1983 study on measuring spinal motion using goniometers

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1983; 63:1776-1781.PHYS THER.and Bruce RothschildG Kelley Fitzgerald, Kevin J Wynveen, Wendy RheaultValues for Lumbar Spinal Range of MotionObjective Assessment with Establishment of Normal

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Objective Assessment with Establishment of Normal Valuesfor Lumbar Spinal Range of MotionG. KELLEY FITZGERALD,KEVIN J. WYNVEEN,WENDY RHEAULT,and BRUCE ROTHSCHILD

The purpose of this article is to present an assessment method, in conjunctionwith age-related normal values, for lumbar spinal range of motion. Lumbarflexion, lumbar extension, and right and left lateral flexion were measured on172 subjects by a combination of goniometry and spinal distraction techniques.Normal values are given for six age groups; each group had a range of 10 years.The results demonstrate that a significant decrease in lumbar spinal range ofmotion is expected with increasing age. The interobserver reliability based on17 subjects was substantial for the four measurements taken; coefficientsranged from +.76 to +1.0. The information may prove useful to the clinician asan improved method for assessing the lumbar spine.Key Words: Aging, Lumbosacral region, Physical therapy, Reference values.

Measuring joint mobility accurately is important tothe physical therapist in assessing the lumbar spine.Knowledge of lumbar range of motion may aid indetermining levels of spinal pathology, guidelines fort reatment, and patient response to t rea tment .1 '2 Toperform an accurate assessment of the lumbar spine,objective clinical methods of measurement are necessary.3

Several methods are currently available for measuring spinal range of motion (eg, radiography, plumbline, distraction, and gon iometry ) .4 ,5 Although radiographic examination is accurate, it is expensive, re-quires exposure to harmful radiat ion, and is not al-ways accessible to the physical therapist. Plumb-lineand distraction methods have been used clinically forthe measurement of spinal range of motion in Eng

land .4 ,6 It is our opinion, however, that these m ethodsare somewhat t ime-consuming, and, furthermore,they are not commonly used in the United States.Goniometry is a relatively q uick and easy alternativemethod of measuring spinal mobility. It is readilyaccessible to the physical therapist and is commonlyused in the United States.Batch7 and Kapand j i8 have outlined objectivemethods of assessing lumbar spinal range of motion.Normal range has been presented by these cliniciansbut not verified by empirical studies or differentiatedby age.7 ,8 Other researchers have documented norm alvalues for lumbar range of motion; however, manydifferent assessment techniques besides goniometryhave been used. Clayson et al measured lumbar rangeof motion on 26 healthy subjects by using roentgenograms.9 Loebl used the inclinometer to measure alarger sample size of 176, but he measured onlylumbar flexion and extension.10 Other measurementtechniques in the literature include using the flexi-rule and the spondylometer.11,12 Troup and colleaguesalso measured lumbar flexion and extension and concluded that the assessment methods they used (in-cluding photo graph ic studies) were not well suited forthe clinic.13 Moll and Wright measured forward flexio n and lateral flexion by the distraction method andspinal extension by the plumb-line method.4 Theydocumented age-related changes based on data collected from 374 healthy subjects. To our knowledge,no such study has been done with the goniometricmethod. Therefore , a need exists to establish normalage-related values for lumbar range of motion by

Mr. Fitzgerald is Staff Physical Therapist , Sacred Heart Hospital ,1545 S Layton Blvd, Milwaukee, WI 53215.Mr. Wynveen is Staff Physical Therapist , Kaiser M edical C enter,4647 Zion Ave, San Diego, CA 92129.Mrs . Rheaul t is Assistant Professor of Physical Therapy, University of Health Sciences/The Chicago Medical School, 3333 GreenBa y Rd, N Chicago, IL 60064 (USA).Dr. Rothschild is Director of Medical Educat ion and Chief ofRheumatology, Menorah Medical Center, Kansas City, and Associate Professor, University of Missouri , Kansas City, MO 64110.At the t ime of this study, both Mr. Fitzgerald and Mr. Wynveenwere senior physical therapy students at the University of HealthSciences/The Chicago Medical School and Dr. Rothschild was As-sistant Professor of Medicine and Director of the Division of Rhe umatology at the University of Heal th Sciences /The Chicago M edica lSchool.Direct all correspondence to Mrs. Rheault .This article was submitted May 24, 1982; was with the authors forrevision 24weeks; andwas accepted June 24, 1983.

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RESEARCHusing techniques commonly chosen by the physicaltherapist.

Because the goniometer is the most comm only usedinstrument for measuring range of motion, the reliability of this method should be examined.14 Lowfound that measurement with a typical goniometer ismore reliable than estimating by eyesight.15 Helle-brand t an d associates reported good agreement in 780paired observations conducted by a single skilledobserver with the goniometer.16 They obtained identical readings 21 percent of the time; in 70 percent ofthe measurements, the second trial varied 3 degreesor less from that of the first; and in 95 percent, thevariation was 7 degrees or less. The foregoing studiesand the study by Boone and colleagues showed thatmeasurement reliability of the goniometer varies according to the joint being measured.17 Intraobservererror has been notably less than interobservererror.15-17 These studies, however, were conductedexclusively on the upper and lower extremities. Basedon a review of the literature, the reliability of thegoniometric method for assessing spinal range ofmotion has not been determined.

The purpose of this study was twofold: 1) to determine an objective clinical method for assessing lumbar spinal range of motion, establish normal valuesfor this method, and investigate interobserver reliability; and 2) to docum ent t he effect of increasing ageon the range of motion of the lumbar spine.

METHODS u b je c t s

Th e subjects consisted of 172 voluntee rs, 4 wom enand 168 men; all were patients at the Veterans Administration Hospital in North Chicago, Illinois. Because Moll and Wright have documented that spinalmob ility differs by only 7 to 10 percent be tween thesexes, we included women in this study. 4 The subjectsranged in age from 20 to 82 years, and for statisticalpurposes, they were categorized into six age groups,each w ith a class range of 10 years (T ab. 1 gives thenum ber of subjects in each age group). All data werecollected over a five-month period in the summer andfall of 1981 as part of an assessment of institutionalmanpower needs. All subjects had responded to aquestionnaire as part of the assessment and wereincluded in our study if back pain was not a currentcomplaint and if any previous back pain had lastedless than three months.

ProcedureWe observed anterior lumbar spinal flexion, right

and left lateral thoracolumbar spinal flexion, andspinal extension in this order. For each of the four

measurem ents, the subject performed three trials. Anterior flexion was measured by a distraction methoddeveloped by Shober.18 We chose this method becausewe had found it to be a good clinical assessmenttechnique. The American Academy of OrthopaedicSurgeons also suggests this method in its book ongoniometry.19 The other movements were measuredby the goniometer.The Shber method uses a plastic tape measure todetermine the amount of distraction (in centimeters)between two points on the lumbar spine during trunkflexion.18 According to the American Academy ofOrthopaedic Surgeons, the tape measure is perhapsthe most accurate clinical method of measuring thetrue motion of spinal flexion because it can conformto spinal curvatures.19 The subject was positionedstanding erect with feet approximately shoulder-width apart. The most superior aspects of the iliaccrests were located by palpation, and a small line was

applied with a marking pen over the correspondingspinal level. A second small line was placed 10 cmabove this first reference point. The observer stoodslightly posterior and lateral to the subject. The subject was then instructed to bend forward, as far aspossible, keeping the knees straight throughout theentire movement. When the subject had completedmaximal trunk flexion, determined by observers asan absence of further motion, the distance betweenthe two markings was measured and recorded, andthe subject was instructed to return to the uprightposition. Three trials were recorded for each subject.For each trial, the initial distance was subtrac ted fromthe final (maximal trunk flexion) distance.We used a goniometer to measure right and leftthoracolumbar spinal flexion and noted degrees ofmotion. While the subject was standing erect, thegoniometric axis was placed at approximately thelevel of the lumb osacral junctio n. Th e stationary armwas positioned in a line vertical to the floor, whilethe moving arm was aligned w ith the spinous processof C7. The American Academy of Orthopaedic Surgeons states that the relative position of the spinous

process of C7 to the pelvis is a method of measuringthoracic and lum bar lateral spinal bending.19 To makethe measurements, the observer sat directly behindthe subject so that the eyes of the observer wereapproximately at the level of the goniometer axis.The subject was instructed to stand erect with feetspread approximately shoulder-width apart (this position may stabilize the pelvis more effectively thanwith the feet together).20 Also, with the feet spread,the subject had a wider base of support, which aidedin maintaining balance while performing the movement. Instruction was given to bend directly to theside, as far as possible, and the observer recorded therange of motion in degrees. Measurements of threetrials to the right followed by three trials to the leftwere recorded for each subject.

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TABLE 1Means an d Standard Deviations in 10-Year Intervals for Lumbar Range of Motion

A ge(yr)2 0 - 2 93 0 - 3 94 0 - 4 95 0 - 5 96 0 - 6 97 0 - 7 9

3 .73 .93.13 .02 .42 .2

Shber(cm)s

0 . 7 21.000.811.100 . 740 . 69

CV19 . 52 5 . 626.136 . 73 0 . 83 1 . 4

na314 2164 32 69

Extension

4 1 . 24 0 . 031.12 7 . 417 . 416 . 6

()s

9 .68 .88 .98 .07 .58 .8

CV2 3 . 32 2 . 02 8 . 62 9 . 243.15 3 . 0

n314 4164 3271 0

R Lat Flexion

3 7 . 63 5 . 327.12 5 . 32 0 . 21 8 . 0

()s

5 .86 .56 .56 .24 .84 .7

CV1 5 . 41 8 . 42 4 . 02 4 . 52 3 . 826.1

n314 4164 42 71 0

L Lat Flexion

3 8 . 73 6 . 52 8 . 52 6 . 82 0 . 31 8 . 9

( )s

5 .76 .05 .26 .45 .36 .0

CV1 4 . 71 6 . 41 8 . 22 3 . 926.13 1 . 7

n314 41 64 42 71 0

TABLE 2Ninety-five Percent Confidence Intervals in 10-Year A ge G roups for Range of Values for Lumba r Range of Motion

Age (yr)2 0 - 2 93 0 - 3 94 0 - 4 95 0 - 5 96 0 - 6 97 0 - 7 9

Shber (cm)3 . 4 - 4 . 03 . 6 - 4 . 22 . 7 - 3 . 52 . 7 - 3 . 32 . 1 - 2 . 71.7-2.7

Extension ()3 7 . 7 - 4 4 . 73 7 . 3 - 4 2 . 72 6 . 4 - 3 5 . 82 4 . 9 - 2 9 . 91 4 . 4 - 2 0 . 41 0 . 3 - 2 2 . 9

R Lat Flexion ()3 5 . 5 - 3 9 . 73 3 . 3 - 3 7 . 32 3 . 6 - 3 0 . 62 3 . 4 - 2 7 . 21 8 . 3 - 2 2 . 11 4 . 7 - 2 1 . 3

L Lat Flexion ( )3 6 . 6 - 4 0 . 83 4 . 7 - 3 8 . 32 5 . 7 - 3 1 . 32 4 . 9 - 2 8 . 71 8 . 2 - 2 2 . 41 4 . 7 - 2 3 . 1

Spinal extension was also measured with a goniometer. The subject stood erect with feet approximately shoulder-width apart; the observer sat facingthe subject's side. The goniometric axis was placed atthe most superior aspect of the iliac crest, alignedwith the midaxillary line. The stationary arm waspositioned in a line perpendicular to the floor, whilethe mov ing arm was aligned with the midaxillary line.The subject was instructed to bend directly backwards, as far as possible, wh ile maintaining extensionof the knees. When the subject attained maximalspinal extension, determined by the observers as absence of further motion, the degrees of movementwere recorded.Analysis

The results were analyzed in 10-year age intervals,and the mean, standard deviation and coefficient ofvariation were calculated for each measurement. A95 percent confidence interval was determ ined for themeasurements by age group. Bar graphs were constructed to analyze variation in range of motion ofthe lumbar spine with age. An analysis of variance(A NO VA ) was used to test for significant differencesbetween age groups in the four lumbar range-of-motion measurements. Scheffe's multiple comparisons were used for post hoc analysis.

The interreliability data for this paper were collected by two independent observers on 17 physicaltherapy students from the University of Health Sci

ences/The Chicago Medical School who volunteeredas subjects. The two observers independen tly took thefour lumbar m easurements on each of the 17 subjects.Pearson reliability coefficients were calculated on thepaired results obtained by these observers.RESULTS

Interobserver reliability was as follows: ShberTest, r = 1.0; spinal extens ion, r = .88; right lateralspinal flexion, r = .76; and left lateral spinal flexion,r = .91. All coefficients were statistically significantat p < . 0 0 1 .

The means, standard deviations, and coefficients ofvariation (CVs) are given for each of the measurements according to age group (Tab. 1). The variationin range of motion of the lumbar spine with age isevident in Table 1. As reflected by the CVs, thevariability in normal range of motion generally increased for the older age groups.

The 95 percent confidence interval for each measurement represents the range of scores expected for95 percent of all subjects in the specific age group(Tab. 2). The confidence intervals provide the clinician with functional ranges of normal values forlumbar range of motion.

The AN OV A of the between-age-group differencesyielded significant F values for each of the four range-of-motion measurements (Tab. 3). The group meanvalues are graphically illustrated in the Figure, andthe results of the follow-up Scheffe comparisons of

a Different "n's" appear in some age groups because of the difficulty in measuring patients with various medicalconditions (eg, rash).

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RESEARCHpairs are presented in Table 4. T he o bvious trend wasa decrease in lumbar spine mobility with age. Theanalysis revealed a specific pattern for the threerange-of-motion measurements of spinal extensionand right and left lateral flexion. For these threemeasurements, none of the adjacent decade agegroups were significantly different from each otherexcept for the 30- to 39-year-old versus the 40- to 49-year-old and the 50- to 59-year-old versus the 60- to69-year-old age groups. T he pattern was a systematicdecrease in the measurements for 20-year intervals.For anterior flexion (Shber test), the pattern wasdifferent. Significant differences (p < .05) occurredbetween the 20- to 29-year-old group and the 60- to69-year-old and 70- to 79-year-old age groups. Significant differences (p < .05) between the 30- to 39-year-old and the three older age groups also werefound.DISCUSSION

Interobserver reliability based on 17 young adultswas found to be substantial for all four measurementsand verified the precision and objectivity of the assessment techniques. Because the interobserver reliability was based on 17 young adults, generalizingthese fndings to subjects ranging in age from 20 to 79years has limitations.Kapandji estimated the following average valuesacross all age groups for lumbar spinal range ofmotion: lumbar spinal extension, 35 degrees; anteriorflexion, 60 degrees; and lateral flexion, 40 degrees.8Batch assigned similar values to lumbar spinal mobility based on h is clinical observations: extension, 30degrees; anterior flexion, 70 degrees; and lateral flex

ion, 40 degrees.7 Neither Kapandji nor Batch made adistinction between the various age groups, and Batchdid not indicate how many patients he observed toestablish these values. R othschild has stated that normal values for the Shber test range from 3 to 5 cm .21Tables 1 and 2 show that our data for the younger

age groups are consistent with the values from otherstudies. As age increases, however, range of motiondecreases significantly, and Kapandji's and Batch'svalues are no longer consistent with the results of thepresent study. As pointed out earlier, the CVs indicatea greater variability in normal range for the older agegroups. This variability may be important to keep inmind when assessing older subjects.M oll and Wright documented a decrease in lumbarrange of motion with age.4 They used seven agegroups, each with a range of 10 years beginning with15 to 24 years of age. Because they used assessment

methods other than goniometry, comparing their results with ours is difficult. Because they did notcalculate the CVs, comparing the variability betweenage groups is also difficult. Their findings and the

Figure. Bar graphs of means for each m easurement byage group.

results of the present study, however, suggest thatrange of motion of the lumbar spine should be assessed in light of patient age.

An interesting pattern of the age-related change inspinal mobility was found by performing multiplecomparisons. The results suggest that lumbar extension and lateral flexion not only decrease with age,but that this decrease occurs in 20-year intervals.Although the statistical analysis did not yield thesame results, the graphs demonstrate a similar patternfor anterior flexion.

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TABLE 3Results of ANOVA of the Between-Age-Group D ifferences

VariableShber by age

Extension by age

R lat flexion by age

L lat flexion by age

SourceBetween groupsWithin groupsTOTALBetween groupsWithin groupsTOTALBetween groupsWithin groupsTOTALBetween groupsWithin groupsTOTAL

df51611 6 651 6 5

1 7 051 6 617151 6 6171

S S5 5 . 1 81 3 7 . 6 71 9 2 . 8 6

1 4 4 6 0 . 2 81 2 1 0 2 . 8 62 6 5 6 3 . 1 4

8 0 4 0 . 6 75 9 4 5 . 6 91 3 9 8 6 . 3 78 5 0 9 . 7 75 7 3 9 . 3 71 4 2 4 9 . 1 4

MS1 1 . 0 40 . 8 5

2 8 9 2 . 0 67 3 . 3 51 6 0 8 . 1 33 5 . 8 21 7 0 1 . 9 53 4 . 5 7

F1 2 . 9 0 a

3 9 . 4 3 a

4 4 . 9 0 a

4 9 . 2 3 a

TABLE 4Results of Scheffe Multiple Comparison Procedure Between Groups

Group20 to 29ShberExtensionR lat flexL lat flex30 to 39ShberExtensionR lat flexL lat flex40 to 49ShberExtensionR lat flexL lat flex50 to 59ShberExtensionR lat flexL lat flex60 to 69ShberExtensionR lat flex

L lat flex

30 to 39 40 to 49

aaa

aaa

50 to 60

aaaaaaa

60 to 69aaaaaaaa

aaa

aaa

70 to 79aaaaaaaa

aaa

aaa

Because our data were obtained from predominantly male subjects, a statement on gender differences in range of m otion of the lumbar spine cannotbe provided from this study. As mentioned earlier,Moll and Wright found that spinal mobility differedby only 7 to 10 percent between the sexes.4 Moreresearch in this area is needed.A limitation of this study concerns the sm all samplesizes in two of the groups, that is, n = 9 for the 70- to79-year-old group and n = 16 for the 40- to 49-year-old group.

CONCLUSIONWe have described an objective and reliablemethod for measuring lumbar spinal range of motionand established normal values according to age forthis method as indicated by a 95 percent confidenceinterval. The results of this study confirmed an age-related decrease in range of motion. We believe thatphysical therapists should make use of these norms inexamination and remember to assess patients' rangeof motion in light of their age.

a p < .001.

a Denotes pairs significantly different at .05 .

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1983; 63:1776-1781.PHYS THER.and Bruce RothschildG Kelley Fitzgerald, Kevin J Wynveen, Wendy RheaultValues for Lumbar Spinal Range of MotionObjective Assessment with Establishment of Normal

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1983 study on measuring spinal motion using goniometers

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