A special thanks for my friends/partners working together throughout this paper: John Dominski, Sean Hickey, and Christopher Jones. Success is no accident.
The purpose of this post is to inform clinicians about best practice patterns for measuring spinal flexion/extension range of motion. As a group we began together with formulating a question and continued with a systematic literature search. Our question was based on the lack of a standardized way to measure lumbar range of motion in the clinic. Despite controversy, we believed this to be a valuable measure taken in the context of other functional measures and biopsychosocial variables. Taking body impairment measures follows the ICF model as well, which we believe to be an excellent guide to follow for an overall patient evaluation.
After coming to a brainstorming as a group, our postulated question was as follows:
“In persons with low back pain, which clinical tool has the highest intrarater and interrater reliability for accurately assessing lumbar spine range of motion: tape measure, inclinometer, or goniometer?”
To review the literature, a combination of search terms were used including:
|Search Terms||Database||Hits||Articles pulled|
|“Lumbar spinal range of motion AND Inter – rater reliability,”||PubMed||12||2 – (Kolber et al., 2013) and (Nitschke et al., 1999)|
|“Measuring lumbar spine range of motion,”||PubMed||25||1 – (Bedekar et al., 2014)|
|“Measuring Lumbar spine ROM AND interrater reliability,”||Google Scholar||4,170||1 – (Saur et al. 1996)|
|“Lumbar spine range of motion measurement systematic review,”||Google Scholar||28,400||2 – (Littlewood & May, 2007) and Tousignant et al., 2005)|
|“Lumbar spine ROM AND modified schober inclinometer”||PT Journal||12||1 – (Williams et al., 1993)|
|“Measuring lumbar spine ROM”||PT Journal||190||1 – (Burdett et al. 1986)|
The Google Scholar search with the search term of “Measuring lumbar spine ROM AND Inter-rater reliability” yielded 4,170 articles. With this large number of hits, refinement of our search for a lumbar spine pain CPG was required. We then performed a gray search of the articles used in the CPG measuring lumbar spine ROM. The group found that the CPG used one article that was also found in Google Scholar (1). Finally, we altered the search terms in Google Scholar to include “Lumbar spine range of motion systematic review” and received 28,400 hits. Within the first 20 sources listed, an acceptable systematic review was found (2).
The article search shows some evidence of convenience sampling. However, out of the searches that produced numerous articles related to the search term, very few of them addressed our question being asked. Moreover, a plethora of studies analyzed function in relation to range of motion without measuring reliability of those methods. Furthermore, when search terms specifically included lumbar spine range of motion, many of the articles found included the cervical range of motion or they did not dissociate lumbar range of motion from the pelvis. The inclusion criteria for articles selected was specifically focused on lumbar spine range of motion using standard measurement tools.
The intra and inter-rater reliabilities were ranked based on previously established categories (3) with high reliability from 0.90-0.99, good from 0.80-0.89, fair from 0.70-0.79, and poor 0.69 or less. This ranking system will be used to report outcomes for the remainder of the appraisal.
Modified-Modified Schober Test
Literature using Modified-Modified Schober Technique of measuring lumbar spine range of motion revealed low to moderate levels of evidence. These studies yielded poor to fair inter-rater reliability (2; 4; 5; 6) with the highest reported inter-rater reliabilities being 0.72 (4) and 0.76 (6). Meanwhile, the same articles demonstrated fair to high intra-rater reliability for flexion and extension measurements.
This test was originally designed for ankylosing spondylitis, but has been used altered for general range of motion since. Beginning with the Schober test, they have since re-named it twice.
Testing: Proper testing procedure is defined thoroughly by Tousignant et al. It begins with the examiner putting thumbs on the inferior margin of the subject’s PSIS. An ink mark is drawn along the midline of the lumbar spine horizontal to the PSIS (lower landmark). While the examiner holds the tape firmly against the subject’s skin, he marks a second line 15 cm above the original one (higher landmark). Then the subject is asked to do an active anterior flexion of the trunk. The new distance between the lower and higher landmarks is then measured. The subject returns to the neutral position. The difference in the initial distance between the skin markings in the neutral position and the new measurements made in the flexion position is used to indicate the amount of lumbar flexion. Measurements are recorded to the nearest mm
Literature using the double inclinometer (DI) showed heterogeneous results. Saur et al. 1996 found the inclinometer to be a reliable and valid measure compared to gold standard radiographs. However, the extension measurement needs refinement due to a low inter-rater and radiographic correlation coefficient (0.42). Bedekar et al. 2014, Littlewood et al. 2007, and Nitchshke et al. 1999 found limited evidence that the DI method is valid for measuring lumbar extension range. Bedekar et al. 2014 also stated that the despite its extension ROM limitations, DI may be a reliable tool for lateral flexion, forward bending, and pelvic inclination when measured by the same practitioner (good-fair intra-rater reliability). Williams et al. 2013 reported that mastery of the DI is key, and may be required to yield significant results. This group reported low ICC values (0.60 flexion, 0.48 extension). Finally, Kolber et al. 2013 examined two iPhone inclinometer applications and found good inter and intrarater reliability, concluding this may be an accurate and valid way of measurement.
The studies that examined the inter-rater reliability and intra-rater reliability of the standard goniometer included Nitschke et al. 1999 and Burdett et al. 1986. Evidence supporting the use of a standard goniometer while measuring inter and intra-rater reliability was seen to be fair to high (4; 7). The highest inter-rater and intra-rater reliability recorded was .84 and .92 during the lumbar flexion measurement (7). Both of these articles concluded that there were higher values for inter-rater and intra-rater reliability during lumbar flexion and extension (4; 7). However, Burdett et al. 1986, concluded that not one of the four instruments examined was superior to the other.
The LOE ranged from a low appraised psychometric study to 2a Systematic Review. This fits into the synthesis section of the “6S” hierarchy. Using the critical appraisal tool written by Bialocerkowski 2010, appraisal of each of the psychometric studies was performed based on a 1-8 Yes/No scale. The articles used ranged from 3/8 questions fulfilled to 7/8. Common issues included: lack of generalizability to the patient population in the CPPTC (narrow age range and asymptomatic), practitioners other than PT’s performing measurements, excessive time between measurements, and too homogeneous of a sample (low variability of measurements).
A table format of the results may be found below:
|Reliability Intra/Inter||Reason for Use/Don’t Use|
Littlewood et al. 2007, Tousignant et al. 2005, Williams et al. 1993
|Inter-rater reliabilities being 0.72 , 0.76, and 0.91
Intra-rater reliabilities was 0.97 while the lowest was 0.69
|Use: MMST produces quick and reliable measure of lumbar flexion and extension. Therapists reported MMST as “quicker and easier” to obtain. SEM 0.27cm with MMST (Tousignant et al. 2005).|
Burdett et al. 1986, Nitschke et al. 1999
|Intra-rater reliabilities between 0.82 and 0.92 Inter-rater reliabilities between 0.63 and 0.85.||Don’t Use: Poor inter and intra rater reliability noted in the 2nd and 4th editions of AMA Guides to measure low back ROM. (Nitschke et al. 1999). Note: Looking at reliabilities alone can be deceiving. SEM was 15 degrees (Nitschke et al. 1999)|
Bedekar et al. 2014, Kolber et al .2013, Littlewood et al. 2007, Nitschke et al. 1999, Saur et al. 1996, Williams et al. 1993
|Both Intra and inter-rater reliabilities ranged from 0.13-0.97.||Don’t Use: Poor intra and inter reliability 0.13|
To summarize in plain language, tape measure via Modified-Modified Schober Test provides the lowest degree of error, maximizes intra and inter rater reliability, and minimizes bias. Due to large SEM and poor-fair inter rater reliabilities, the goniometer was not recommended. The Double Inclinometer was also excluded due to poor intra and inter rater reliabilities along with excessive variability reported between studies.
Thank you for reading,
-Jared Burch, PT, DPT
- Saur, P. M., Ensink, F. B. M., Frese, K., Seeger, D., & Hildebrandt, J. (1996). Lumbar range of motion: reliability and validity of the inclinometer technique in the clinical measurement of trunk flexibility. Spine, 21(11), 1332-1338.
- Littlewood, C., & May, S. (2007). Measurement of range of movement in the lumbar spine—what methods are valid? A systematic review. Physiotherapy, 93(3), 201-211.
- Bedekar, N., Suryawanshi, M., Rairikar, S., Sancheti, P., & Shyam, A. (2014). Inter and intra-rater reliability of mobile device goniometer in measuring lumbar flexion range of motion. Journal of back and musculoskeletal rehabilitation, 27(2), 161-166.
- Burdett, R. G., Brown, K. E., & Fall, M. P. (1986). Reliability and validity of four instruments for measuring lumbar spine and pelvic positions. Physical therapy, 66(5), 677-684.
- Tousignant, M., Poulin, L., Marchand, S., Viau, A., & Place, C. (2005). The Modified–Modified Schober Test for range of motion assessment of lumbar flexion in patients with low back pain: A study of criterion validity, intra-and inter-rater reliability and minimum metrically detectable change. Disability and rehabilitation, 27(10), 553-559.
- Williams, R., Binkley, J., Bloch, R., Goldsmith, C. H., & Minuk, T. (1993). Reliability of the modified-modified Schöber and double inclinometer methods for measuring lumbar flexion and extension. Physical Therapy, 73, 26-26.
- Nitschke, J. E., Nattrass, C. L., Disler, P. B., Chou, M. J., & Ooi, K. T. (1999). Reliability of the American Medical Association Guides’ Model for Measuring Spinal Range of Motion: Its Implication for Whole‐Person Impairment Rating. Spine, 24(3), 262-268.
- Kolber, M. J., Pizzini, M., Robinson, A., Yanez, D., & Hanney, W. J. (2013). The reliability and concurrent validity of measurements used to quantify lumbar spine mobility: an analysis of an iphone® application and gravity based inclinometry. International journal of sports physical therapy, 8(2), 129