Reliability of Goniometric Measurements in Patients
with Duchenne Muscular Dystrophy
SHREE PANDYA,
JULAINE M. FLORENCE,
WENDY M. KING,
JENNY DIVELY ROBISON,
MINDY OXMAN,
and MICHAEL A. PROVINCE
Previous studies of reliability of goniometric measurements have produced varied
findings suggesting the need to document further the reliability of measuring
range of motion in different patient groups. The purpose of this study was to
determine the intratester and intertester reliability of goniometric measurements
of seven common upper and lower extremity joint limitations in children with
Duchenne muscular dystrophy. Five physical therapists participated in the study.
The procedure and order of measurements were standardized. Results showed
that intratester reliability for all measurements was high (ICC = .81 to .94), but
intertester reliability showed a wide variation (ICC = .25 to .91). The results of
this study indicate the need to use the same examiner for long-term follow-up
and for assessing results of specific treatment interventions.
Key Words: Clinical trials, Muscular dystrophy, Physical therapy.
Limitation of joint motion resulting from muscle contracture is a common finding in Duchenne muscular dystrophy
(DMD). Objective measurement of these limitations is necessary to document progression of the disease and to evaluate
the effectiveness of procedures such as stretching, splinting,
and surgery. Goniometry is the technique most commonly
used to make these measurements, but its reliability has not
been firmly established.
Previous studies of reliability of goniometric measurements
have produced varied findings. Hellebrandt et al studied the
reliability of measuring selected upper extremity motions and
found that the reliability was not the same for all motions.1
They suggested that this may be "due to the fact that the
technical difficulties inherent in the application of goniometry
may be significantly greater for certain movements than others." Boone et al reported similar findings from their study of
upper and lower extremity motions.2 Reliability was greater
Mrs. Pandya is Assistant Professor, Department of Neurology, University of
Rochester, Rochester, NY 14642 (USA).
Ms. Florence is Coordinator, Clinical Research, Irene Walter Johnson Rehabilitation Institute, and Research Assistant Professor, Department of Neurology, Washington University School of Medicine, St. Louis, MO 63110.
Mrs. King is Therapy Supervisor, Muscular Dystrophy Clinic, Department
of Neurology, Ohio State University, Columbus, OH 43210.
Mrs. Robison is Staff Physical Therapist and Chief Physical Therapist,
Muscular Dystrophy Clinic, Vanderbilt University Medical Center, Nashville,
TN 37212.
Ms. Oxman is an instructor in physical therapy at the University of Connecticut, Storrs, CT 06268.
Mr. Province is Statistician, Division of Biostatistics, Washington University
Medical School, St. Louis, MO 63110.
Other members of the Collaborative Investigation of Duchenne Dystrophy
Group are Jerry R. Mendell, MD, Ohio State University; Robert C. Griggs,
MD, and Richard Moxley, MD, University of Rochester; Gerald M. Fenichel,
MD, Vanderbilt University; Michael H. Brooke, MD, Kenneth K. Kaiser, BS,
Martha McCrate, BS, Philip Miller, AB, and Jack Schumate, MD, Washington
University; and Phillip Bach, PhD, CLMG Clinical Laboratory.
This article was submitted August 28, 1984; was with the authors for revision
six weeks; and was accepted March 21, 1985.
Volume 65/Number 9, September 1985
for the upper extremity motions (r = .86) than for the lower
extremity motions (r = .58), and they recommended further
investigation of the remaining lower extremity movements.
Baldwin and Cunningham, reporting on elbow measurements
in children with normal and restricted range of motion, found
a wide range of values among physical therapists and stated
that measurements were reliable only when taken by the same
therapist each time.3 Low was impressed by the intraobserver
consistency in his study of goniometric reliability of elbow
and wrist measurements and recommended that one person
should make all the measurements in a series.4 Ashton et al
studied the reliability of goniometric measurements of hip
motion in children with mild or moderate spastic diplegia.5
They concluded that the measurements could only be used to
assist clinical judgment and were not sufficiently reliable to
be used in research studies of cerebral palsy. In view of these
varied findings, the reliability of goniometric measurements
should be determined not only for each movement but also
for different patient groups. Therefore, the purpose of this
study was to determine the intratester and intertester reliability of goniometric measurements of seven common upper
and lower extremity joint limitations in patients with DMD.
METHOD
The data were collected as part of a multiclinic collaborative
study to document the natural history of DMD. Details of
the patient selection criteria, consent procedures, and the
protocol design have been published previously.6 Briefly, five
experienced physical therapists participated in the study. A
total of 150 children were examined between four clinics. The
patients' ages ranged from under 1 year to 20 years. They
presented a complete spectrum of physical ability from no
functional limitations to wheelchair confinement with corn1339
Shoulder Abduction
Fig. 1. Measurement of shoulder abduction limitation.
Hip Extension
Fig. 4. Measurement of hip extension limitation.
Elbow Extension
Knee Extension
Fig. 2. Measurement of elbow extension limitation.
Fig. 5. Measurement of knee extension limitation.
Wrist Extension
Fig. 3. Measurement of wrist extension limitation.
plete dependency in activities of daily living as a result of
severe muscle weakness and multiple contractures.
Passive range of motion measurements were made of bilateral shoulder abduction, elbow extension, wrist extension,
knee extension, ankle dorsiflexion, and hip extension in the
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supine position (Figs. 1-6), as recommended by the American
Academy of Orthopedic Surgeons.7 Contracture of the iliotibial bands (ITB) was measured as described by Siegel.8 We
placed the patient in the prone position and abducted the leg
to eliminate hip flexion contracture from the tensor fascia
lata. The knee was then flexed to 90 degrees and the leg
adducted while we maintained pressure on the sacrum. With
the patient's hip extended, we measured the angle of abduction with one arm of the goniometer on the posterior iliac
spines and the other arm extending down the midline of the
posterior aspect of the leg (Fig. 7). As illustrated in Figures 1
through 7, the measurements indicated the degrees of limitation from full range for each movement. The position, procedure, and order in which the measurements were made
were standardized. We made the measurements with a universal goniometer and read them to the nearest 5 degrees. At
no time during the study were results of previous evaluations
available to the therapists.
The data were collected in two parts. Each therapist examined the patient on admission to the study, at one week, and
at four weeks, so that the patient was measured three times
within a period of one month. These data were used to
determine the intratester reliability of measurement. Intertester reliability was calculated from measurements performed
PHYSICAL THERAPY
RESEARCH
Table
Intratester and Intertester Reliability
a
Ankle Dorsiflexion
Fig. 6.
Measurement of ankle dorsiflexion limitation.
Movements
Intratester ICCa
(n = 150)
Intertester ICC
(n = 21)
Shoulder abduction
Elbow extension
Wrist extension
Hip extension
Knee extension
Ankle dorsiflexion
ITB
.84
.94
.87
.85
.93
.90
.81
.67
.91
.83
.74
.58
.73
.25
ICC = Intraclass correlation coefficient.
intertester reliability of measurement of the three upper extremity limitations was better than that of the lower extremity
limitations.
DISCUSSION
Iliotibial Band
Fig. 7.
Measurement of iliotibial band contracture.
by all therapists on the same patients on the same day. Each
patient was examined individually by the therapists in separate booths with no opportunity for any therapist to observe
the other therapists' measurements. During the study, 21
patients were tested in three separate sessions in group meetings. We calculated intraclass correlation coefficients (ICC)
with a random effects analysis of variance model.
RESULTS
Intratester reliability was high for all measurements; ICC
ranged from .81 to .94 (Table). Intertester reliability showed
a wide variation; ICC ranged from .25 to .91 (Table). The
Volume 65/Number 9, September 1985
Our study confirmed previousfindingsthat the reliability
of measurements was not the same for all joints. The intratester reliability was better than the intertester reliability for all
the movements measured. The intertester reliability of measurements of the upper extremity movements was better than
that of the lower extremity movements. Similarfindingswere
reported by Boone et al.2 For the upper extremity movements,
shoulder abduction was less reliable than the movements at
the elbow and wrist. Hellebrandt et al observed the same
differences in their study of upper extremity measurements.1
The extremely poor intertester reliability of ITB contracture
measurement (ICC = .25) was surprising because the intratester reliability was good (ICC = .81). In seeking an explanation
for this, we reviewed the data again and found that the
intratester reliability of ITB measurements showed a definite
improvement over the study; the improvement from .68
during the first three months of the study to .83 during the
second three months and .96 during the third three months
suggests thefirstthree months had a training effect. A similar
trend was not seen for the other measurements. Most therapists do not routinely perform ITB measurements and, hence,
the repetition may have improved the skill and consistency.
In spite of this improvement in individual consistency, the
intertester reproducibility was still poor. We hypothesized
that the force exerted by the therapist during the passive
movement may be the variable that caused the goniometric
discrepancy because the position and procedure were standardized.
CONCLUSION
Goniometric measurements are an important part of the
examination of patients with DMD. We have documented
the reliability of goniometric measurements in patients with
DMD and have shown that the intratester reliability is high.
Intertester reliability was not as high and showed a wide range
for the movements tested. When goniometric measurements
are performed by the same examiner, they provide a good
objective measure to document progression of disease and
evaluate results of treatment to reduce tightness.
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REFERENCES
1. Hellebrandt FA, Duvall EN, Moore ML: The measurement of joint motion:
Part III—Reliability of goniometry. Phys Ther Rev 29:302-307, 1949
2. Boone DC, Azen SP, Lin CM, et al: Reliability of goniometric measurements. Phys Ther 58:1355-1360, 1978
3. Baldwin J, Cunningham K: Goniometry under attack: A clinical study
involving physiotherapists. Physiotherapy Canada 26:74-76, 1974
4. Low JL: The reliability of joint measurement. Physiotherapy 62:227-229,
1976
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5. Ashton BB, Pickles B, Roll JW: Reliability of goniometric measurements of
hip motion in spastic cerebral palsy. Dev Med Child Neurol 20:87-94, 1978
6. Brooke MH, Griggs RC, Mended JR, et al: Clinical trial in Duchenne
dystrophy, I. The design of the protocol. Muscle Nerve 4:186-197, 1981
7. Joint Motion: Method of Measuring and Recording. Chicago, IL, American
Academy of Orthopedic Surgeons, 1963
8. Siegel IM: The Clinical Management of Muscle Disease. London, England,
Heinemann Medical Books, 1977, p 96
PHYSICAL THERAPY