Confiabilidad evaluaciones hombro

Hayes et al: Reliability of five methods for assessing shoulder range of motion

Reliability of five methods for assessing
shoulder range of motion
Kimberley Hayes, Judie R Walton, Zoltan L Szomor and George AC Murrell
University of New South Wales

In symptomatic subjects, the reliability of tests for shoulder joint range of motion has yet to be determined. For this reason,
inter-rater and intra-rater agreement trials were undertaken to ascertain the reliability of visual estimation, goniometry, still
photography, “stand and reach” and hand behind back reach for six different shoulder movements. Intra-class correlation
coefficients (Rho) were derived by using a random effects model. For flexion, abduction and external rotation fair to good
reliability was demonstrated for both trials using visual estimation (inter-rater Rho = 0.57-0.70; intra-rater Rho = 0.59-0.67),
goniometry (inter-rater Rho = 0.64-0.69; intra-rater Rho = 0.53–0.65) and still photography (inter-rater Rho = 0.62-0.73; intra-
rater Rho = 0.56–0.61). The tests had standard errors of measurement of between 14 and 25 degrees (inter-rater trial) and
11 and 23 degrees (intra-rater trial). [Hayes K, Walton JR, Szomor ZL and Murrell GAC (2001): Reliability of five methods
for assessing shoulder range of motion. Australian Journal of Physiotherapy 47: 289-294]

Key words: Clinical Protocols; Range of Motion, Articular; Reproducibility of Results; Shoulder

Introduction passive shoulder range of motion for six movements, in
patients with a spectrum of shoulder dysfunctions (rotator
Of all the joints, the shoulder has the greatest range of cuff repair, adhesive capsulitis and scapulothoracic fusion).
motion. The assessment of shoulder range of motion is
important in the diagnosis of disorders of the shoulder and Method
for the evaluation of the strategies that may alter shoulder
function. Subjects Two groups of subjects gave informed consent for
trials which investigated the inter-rater and intra-rater
There have been a number of tools designed to measure reliability of five joint range of motion assessment tests.
joint range of motion varying from simple visual All patients with shoulder pathology that warranted
estimation to high speed cinematography (Clapper and consultation with the participating orthopaedic surgeon
Wolf 1988, Fish and Wingate 1985, Hellebrandt et al 1949, between January 1996 and October 1998 were considered
Low 1976, Moore 1949, Moore 1949, Youdas et al 1994). for inclusion to these trials. From this patient list, subjects
Several of these have been trialled for measurement were randomly selected and contacted by telephone for the
reliability (Boone et al 1978, Clapper and Wolf 1988, Fish purpose of recruitment. This process was repeated until the
and Wingate 1985, Hellebrandt et al 1949, Low 1976, desired sample size had been obtained.
Mayerson and Milano 1984, Riddle et al 1987, Williams
and Callaghan 1990, Youdas et al 1994). However, notably Inter-rater reliability trial The inter-rater reliability trial
lacking is information specific to the shoulder joint, in consisted of eight volunteers, three males and five females,
symptomatic subjects, under conditions that reflect how ranging in age between 57 and 72 years (mean age = 66
measurements are taken in the clinical environment. Given years, SD = 5.7). All subjects had a current shoulder
that range of motion reliability varies from one patient complaint. Six patients had undergone rotator cuff repair
population to the next (Ashton et al 1978, Bartlett et al surgery within the past 24 months, one patient was 17
1985, Harris et al 1985), from one joint to the next (Boone months post scapulothoracic fusion, and one patient had
et al 1978, Clapper and Wolf 1988, Hellebrandt et al 1949, adhesive capsulitis.
Low 1976) and from one joint movement to the next
(Hellebrandt et al 1949, Riddle et al 1987), there is a clear Intra-rater reliability trial The intra-rater reliability trial
need to establish patient specific, joint specific and consisted of nine volunteers, five males and four females,
movement specific reliability indices for clinical practice. ranging in age between 29 and 74 years (mean age = 64
For this purpose, we determined the inter-rater and intra- years, SD = 14.7). One of these subjects had two
rater reliability, and the standard error of the measurement symptomatic shoulders. Of the 10 shoulders, eight were
for five easily applied methods for assessing active and symptomatic, being within 36 months of rotator cuff repair

Australian Journal of Physiotherapy 2001 Vol. 47 289


surgery. The remaining two shoulders were asymptomatic 3. Still photography, using a standard polaroid camera, for
at the time of testing. the active movements of flexion, abduction and external
rotation. Each rater labelled eight reference points on each
Raters subject prior to the commencement of photographic testing
using the following bony landmarks: T1 spinous process,
Inter-rater reliability trial Four raters, identified here as A T7 spinous process, postero-lateral acromion process of the
to D were used for the inter-rater reliability trial. Rater A scapula, lateral epicondyle of the humerus, a point 6cm
was an orthopaedic surgeon, Rater B was a sports physician inferior to the postero-lateral aspect of the acromion
trainee and Raters C and D were qualified physiotherapists. process of the scapula, end of rib 12, olecranon process of
All raters tested all eight subjects with the five range of the ulna, and ulna styloid process.
motion assessment tests. All raters were blinded to the
results of each other’s assessments. For flexion and abduction, the subject stood with feet
shoulder width apart. For external rotation, the subject was
Intra-rater reliability trial Only Rater A was used for the supine and the affected extremity was supported on the
intra-rater reliability trial. This rater tested all nine subjects treatment table (0 degrees glenohumeral joint abduction,
(including the one subject being tested bilaterally) on three 90 degrees elbow flexion, neutral supination/pronation
separate occasions within a 48 hour period, using the position). The subject moved the affected extremity (thumb
same five range of motion assessment tests. The pointing upwards) to the end of active range of shoulder
operating/treating surgeon was not involved in assessments flexion, abduction and external rotation. The rater took a
for the inter-rater or intra-rater reliability trials. polaroid photograph of each end of range position from a
Measurement tests perspective aligned with the axis of joint motion. Using a
plastic 15cm goniometer and the developed photograph,
The five tests used for measuring range of motion for both the rater manually calculated the resultant joint angle in
the inter-rater and intra-rater trials were: degrees. The flexion angle was formed by joining the
lateral epicondyle, the point 6cm below the postero-lateral
1. Visual estimation of passive range of motion (measured acromion process, and the end of rib 12. The abduction
in degrees) for the movements of flexion, abduction, angle was formed by the intersection of a line that ran
external rotation and hand behind back (measured to the through the lateral epicondyle and the postero-lateral
vertebral level). The subject was seated upright on the edge acromion process and another line that ran through T1 and
of a treatment table with feet supported on a footstool. The T7 spinous processes. The external rotation angle was
rater moved the affected extremity (thumb pointing formed by joining the ulna styloid process, the olecranon
upwards) to the end of passive range of shoulder flexion, process of the ulna, and a vertical line that passed through
abduction and external rotation (0 degrees glenohumeral the olecranon process of the ulna. Each rater removed the
joint abduction, 90 degrees elbow flexion, neutral labels prior to directing the patient to the next rater.
supination/pronation forearm position) and made a visual
estimation of each resultant angle. For maximum passive 4. Stand and reach test of maximum overhead reach
hand behind back position, the rater moved the affected (measured in centimetres), using a metric vertical wall
extremity upwards and towards the midline to the highest scale. The subject’s standing head height (measured in
vertebral level reached by the tip of the subject’s extended centimetres) was measured against a metric vertical wall
thumb. scale. The subject turned to face the wall and reached the
affected extremity to a maximum overhead position. The
2. Goniometry (measured in degrees), using a plastic, stand and reach value was recorded as the position of
41cm universal goniometer, for the active movements of maximum reach minus the patient’s standing head height.
flexion, abduction and external rotation. The subject was
positioned as for visual estimation tests. The subject moved 5. Tape measured distance of hand behind back reach in
the affected extremity (thumb pointing upwards) to the end centimetres. The subject was standing with feet shoulder
of active range of shoulder flexion, abduction and external width apart. With thumb extended, the subject reached the
rotation (0 degrees glenohumeral joint abduction, 90 affected extremity upwards and towards the midline to a
degrees elbow flexion, neutral supination/pronation maximum hand behind back position. The rater used a tape
forearm position). The flexion angle was formed by measure to record the distance in centimetres from the
aligning the goniometer with the lateral epicondyle of the thumb tip to T1 spinous process.
humerus, the middle of the glenoid fossa, and a vertical
line in the coronal plane. The abduction angle was formed Procedures For the inter-rater trial, all raters were briefed
by aligning the goniometer with the lateral epicondyle of on the study protocol and a five hour training session was
the humerus, the middle of the posterior glenohumeral conducted to ensure familiarisation and standardisation of
joint line, and a vertical line in the sagittal plane. The the five range of motion tests. The intra-rater trial was
external rotation angle was formed by aligning the conducted several weeks after the inter-rater trial and
goniometer with the ulna styloid process, the olecranon involved a different group of subjects. Both trials followed
process of the ulna, and a horizontal line in the transverse the procedures described.
plane. For each test, raters were asked to correct for compensatory

290 Australian Journal of Physiotherapy 2001 Vol. 47


Table 1. Inter-rater reliability and standard error of the measurement for five methods of assessing shoulder range of
motion.
Mean± SD, (range) ICC (Rho) 95% CI of ICC SEM 95% CI
Visual estimation
Flexion 142±34, (45 – 180)º 0.70 0.42 – 0.92 19º ±38º
Abduction 121±33, (45 – 180)º 0.66 0.37 – 0.90 19º ±38º
External rotation 47±21, (13 – 80)º 0.57 0.26 – 0.87 14º ±28º
Goniometry
Flexion 132±45, (0 – 170)º 0.69 0.40 – 0.91 25º ±50º
Abduction 118±39, (30 – 170)º 0.69 0.37 – 0.92 21º ±42º
External rotation 46±23, (-15 – 80)º 0.64 0.31 – 0.91 14º ±28º
Still photography
Flexion 120±45, (5 – 170)º 0.73 0.46 – 0.93 23º ±46º
Abduction 118±44, (15 – 160)º 0.73 0.45 – 0.93 23º ±46º
External rotation 50±25, (-10 – 90)º 0.62 0.32 – 0.89 15º ±30º
Stand and reach 43±7, (-64 – 54)cm 0.74 0.45 – 0.94 3cm ±6cm
Hand behind back T10±3, (T7 – S4) 0.26 -0.01 – 0.69 2 ±4
(vertebral level) (cm) 26±8, (16 – 48)cm 0.39 0.09 – 0.77 6cm ±12cm

Inter-rater reliability and standard error of the measurement for five methods of assessing shoulder range of motion. Each
test was performed on eight subjects by four raters. Intra-class correlation coefficients (Rho) were calculated using a two-
way mixed effect model. Mean, standard deviation and range of scores were calculated from the raw data. (SD = standard
deviation, ICC = intra-class correlation coefficient, CI = confidence interval, SEM = standard error of the measurement).

scapulothoracic or upper body movement and to ensure In addition, the standard error of the measurement (SEM)
that each movement occurred in the appropriate cardinal and 95% confidence intervals (±2 SEM) were calculated
plane (sagittal plane, coronal plane and transverse plane for for each range of motion test and expressed in units of the
flexion, abduction and external rotation, respectively). All measure. The standard error of the measurement was
measurements were taken at the pain limit to range of calculated according to the equation: SEM = SD x
motion. Each rater performed all five tests on a given √ (1 – ICC), where SD is the standard deviation and ICC is
subject before commencing assessment of the next subject. the Rho score (Portney and Watkins 1993).
This procedure was repeated until all eight subjects had
been measured by all four raters. Results
The order of the raters was randomised for each subject in
Intra-class correlation coefficient The intra-class
the inter-rater trial. The order of the subjects was
correlation coefficient (Rho score) is an index of reliability
randomised for the intra-rater trial. With the exception of
for measurements of the same material. Two types of
visual estimation, which was performed first, the order of
measurement reliability can be distinguished according to
the other four tests was random. This was done to prevent
whether each of several raters independently measures the
inadvertent biasing of the estimated angle with known
same material (inter-rater reliability), or whether one rater
cardinal data such as that provided by the goniometer.
makes two or more measurements of the same material
Statistical analysis (intra-rater reliability). An instrument with a Rho score of
1 will produce the same measurement each time it is used.
For the inter-rater and intra-rater reliability trials, two-way In contrast, an instrument with a Rho score of 0 will
random effect intra-class correlation coefficients (2,1) produce markedly different measurements. The confidence
(Rho), together with their confidence intervals, were interval of the intra-class correlation coefficient represents
calculated with SPSS statistical software (Yaffee 1998). In a range of possible Rho scores, on the basis of the sample
accordance with the suggestions of Fleiss (1986), a Rho data, for the population score (95% probability).
value of < 0.4 was deemed as representing poor reliability;
0.4-0.75 as fair to good reliability; and > 0.75 as excellent Inter-rater reliability trial The inter-rater intra-class
reliability. correlation coefficients (Rho) for each movement tested with
each of the range of motion tests are displayed in Table 1.



Table 2. Intra-rater reliability and standard error of the measurement for five methods of assessing shoulder range of
motion.

Mean± SD, (range) ICC (Rho) 95% CI of ICC SEM 95% CI
Visual estimation
Flexion 143±21, (100 – 170)º 0.59 0.28 – 0.85 13º ±26º
Abduction 135±33, (70 – 170)º 0.60 0.30 – 0.86 21º ±42º
Goniometry
Flexion 135±26, (77 – 165)º 0.53 0.21 – 0.82 17º ±34º
Abduction 129±35, (56 – 170)º 0.58 0.27 – 0.85 23º ±46º
Still photography
Flexion 128±28, (63 – 168)º 0.56 0.24 – 0.84 19º ±38º
Abduction 131±35, (57 – 170)º 0.61 0.31 – 0.86 22º ±44º
Stand and reach 39±19, (-22 – 59)cm 0.49 0.18 – 0.80 13cm ±26cm
Hand behind back
(vertebral level)(cm) T9±2, (T6 – S1) 0.14 -0.11 – 0.55 2 ±4
25±7, (15 – 39)cm 0.39 0.08 – 0.75 6cm ±12cm

Intra-rater reliability and standard error of the measurement for five methods of assessing shoulder range of motion. Each
test was performed on nine subjects, on three occasions by a single trained rater. Intra-class correlation coefficients (Rho)
were calculated using a two-way mixed effect model. Mean, standard deviation and range of scores were calculated from
the raw data. (SD = standard deviation, ICC = intra-class correlation coefficient, CI = confidence interval, SEM = standard
error of the measurement).

For the movements of flexion, abduction and external Standard error of the measurement The standard error of
rotation, agreement between the four raters was fair-good the measurement is a measure of discrepancy (error)
as assessed by visual estimation (Rho = 0.70, Rho = 0.66, between repeated scores. For the inter-rater trial, the
Rho = 0.57), goniometry (Rho = 0.69, Rho = 0.69, Rho = standard error of the measurement represents the extent of
0.64) and still photography (Rho = 0.73, Rho = 0.73, Rho error associated with different raters’ scores. For the intra-
= 0.62). Fair-good reliability was also demonstrated for the rater trial, the standard error of the measurement represents
stand and reach test (Rho = 0.74). For the movement of the extent of error associated with retesting. The
hand behind back, measured passively to the vertebral confidence interval of the measurement represents the
level, and as an active reach, agreement between the four smallest difference attributable to status change, as distinct
raters was poor (Rho = 0.26, Rho = 0.39). from measurement error (95% probability).
Intra-rater reliability trial The intra-rater intra-class Inter-rater reliability trial The standard error of the
correlation coefficients (Rho) for each movement tested measurement (SEM) together with the mean, standard
with each of the range of motion tests are displayed in deviation and range of scores for each movement tested
Table 2. with each of the range of motion tests, are displayed in
Table 1.
For the movements of flexion, abduction and external
rotation, agreement between the three ratings was fair-good For the movements of flexion, abduction and external
as assessed by visual estimation (Rho = 0.59, Rho = 0.60, rotation, the standard error of the measurement ranged from
Rho = 0.67), goniometry (Rho = 0.53, Rho = 0.58, Rho = 14-19 degrees for visual estimation, 14-25 degrees for
0.65) and still photography (Rho = 0.56, Rho = 0.61, Rho goniometry, and 15-23 degrees for still photography. For the
= 0.60). Fair-good intra-rater reliability was also stand and reach test, the standard error of the measurement
demonstrated for the stand and reach test (Rho = 0.49). For was three centimetres. For the movement of hand behind
the movement of hand behind back, measured passively to back, measured passively to the vertebral level, and as an
the vertebral level, and as an active reach, intra-rater active reach, the standard error of measurement was two
agreement was poor (Rho = 0.14, Rho = 0.39). vertebral levels, and six centimetres respectively.



Intra-rater reliability trial For the movements of flexion, ± 28-50 degrees; still photography = ± 30- 6 degrees) and
abduction and external rotation, the standard error of the the intra-rater trial (visual estimation = ± 22-42 degrees,
measurement ranged from 11-21 degrees for visual goniometry = ± 28-46 degrees; still photography =
estimation, 14-23 degrees for goniometry, and 13-22 ± 26-44 degrees). On the basis of this data, large
degrees for still photography. For the stand and reach test, differences in repeated scores are therefore prerequisite
the standard error of the measurement was 13 centimetres. when using these tests to assess actual change in clinical
For the movement of hand behind back, measured passively status.
to the vertebral level, and as an active reach, the standard
error of measurement was two vertebral levels, and six We evaluated the stand and reach test as it is a functional
centimetres, respectively. movement of practical importance. The results of this study
demonstrated fair to good reliability for the stand and reach
Discussion test (inter-rater Rho = 0.74; intra-rater Rho = 0.49).
Interestingly, this test was associated with a smaller
standard measurement error for the inter-rater trial (3cm)
The results of this study demonstrated fair-good reliability
than for the intra-rater trial (13cm).
for visual estimation, goniometry, still photography and the
stand and reach test for the movements of shoulder flexion, Poor reliability was demonstrated for both hand behind
abduction, external rotation and overhead reach in patients back tests for both the inter-rater trial (Rho = 0.26 for
with a variety of orthopaedic shoulder disorders (rotator passive hand behind back; Rho = 0.39 for active reach ) and
cuff repair, adhesive capsulitis and scapulothoracic fusion) the intra-rater trial (Rho = 0.14 for passive hand behind
when assessed by either an individual trained measurer or back; Rho = 0.39 for active reach). These findings may be
by a number of trained measurers. Hand behind back, a reflection of the complexity of the movement itself. To
whether tested passively or as an active reach, was found to effect the manoeuvre, contributions to range of motion are
be the least reliable movement of this study. required from the shoulder complex, elbow, forearm, wrist
and hand. Alternatively, the lower reliability associated
Williams and Callaghan (1990) have shown that in the
with this movement may reflect an attenuated range of
normal shoulder, visual estimation when employed by an
available scores. In the presence of certain shoulder joint
experienced clinician permits measurements that are as
pathologies, hand behind back range of motion is
reliable as those obtained with a mechanical goniometer.
frequently diminished (Murrell and Walton 2001). There
Using one asymptomatic subject, Low (1976) showed that
was a standard measurement error of two vertebral levels
examiners from various clinical backgrounds were more
for passive hand behind back and six centimetres for active
consistent in measuring full elbow flexion and full wrist
hand behind back reach for both the inter-rater and intra-
extension positions with a goniometer than by estimating
rater trials. Hand behind back range of motion is of
the same angles by eye. While there is some evidence to
functional importance and one that warrants further
suggest that the goniometer can be used reliably for
reliability testing.
measuring certain shoulder joint movements (Boone et al
1978), studies of the shoulder in symptomatic patients are The intention of this study was not to compare the
limited. In a comprehensive evaluation of passive shoulder reliability of active and passive range of motion tests for
range of motion in symptomatic subjects, Riddle (1987) the shoulder joint, in symptomatic subjects. Rather, this
reported variable results (Rho = 0.26-0.90 inter-rater; study established the reliability and measurement error of
Rho = 0.87-0.99 intra-rater). The results of this study five range of motion tests currently performed in clinical
showed comparable reliability for visual estimation and practice.
goniometry for both the inter-rater (visual estimation
Rho = 0.57–0.70; goniometry Rho = 0.64–0.69) and the Both the inter-rater and intra-rater trials were conducted
intra-rater (visual estimation Rho = 0.59–0.67; goniometry over a relatively short timeframe. The reliability of these
Rho = 0.53– 0.65) trials. methods for longer reassessment timeframes requires that
the raters do not change their technique. This study did not
Photographic procedures have been shown by Fish and establish the reliability of shoulder range of motion
Wingate (1985) to be more reliable than goniometry for assessments over time.
measurements of elbow joint position in an asymptomatic
subject. In the present study, all movements measured by Estimates of measurement reliability are applicable to the
still photography (active range of motion) demonstrated range of test scores and to the conditions of assessment.
fair-good reliability for both the inter-rater trial (flexion The mean values obtained for flexion, abduction and
Rho = 0.73, abduction Rho = 0.73, external rotation external rotation, for the inter-rater and intra-rater trials
Rho = 0.62) and the intra-rater trial (flexion Rho = 0.56, (Table 1, 2) show that most subjects obtained scores for
abduction Rho = 0.61, external rotation Rho = 0.60). In these movements in the upper ranges of motion. We did not
general, comparable reliability and measurement error was determine the reliability of these tests for scores measured
demonstrated for visual estimation, goniometry, and still primarily in the lower ranges of motion.
photography. Of note, large confidence intervals were
associated with these same tests for the inter-rater trial In summary, fair to good reliability was demonstrated for
(visual estimation = ± 28-38 degrees; goniometry = three shoulder movements assessed by visual estimation,



goniometry and still photography for both the inter-rater Fleiss JL (1986), cited in Delitto A and Strube MJ (1991):
and intra-rater trials. Standard measurement errors in the Reliability in the clinical setting. American Physical
range of 14–25 degrees for the inter-rater trial, and 11–23 Therapy Association Research Section Newsletter
degrees for the inter-rater trial for these three tests 24: 2-8.
highlighted considerable variation in the precision Harris SR, Smith LH and Krukowski L (1985): Goniometric
associated with range of motion testing of the shoulder reliability for a child with spastic quadriplegia. Journal of
joint in symptomatic subjects. Paediatric Orthopaedics 5: 348-351.
Hellebrandt FA, Duvall EN and Moore ML (1949): The
Acknowledgments The authors wish to thank the patients measurement of joint motion. Part 3. Physical Therapy
and clinicians (Larry Bryant, Kim Wade and Sophia Short) Review 29: 302-307.
who assisted in this study. We also thank Karen Ginn and Low JL (1976): The reliability of joint measurement.
acknowledge the support of St George Private Physiotherapy 62: 227-229.
Hospital/Health Care of Australia and the St George and
Sutherland Hospitals, South Eastern Sydney Area Health Mayerson NH and Milano RA (1984): Goniometric
measurement reliability in physical medicine. Archives of
Service. The results of this study were presented at the Fifth
Physical Medicine and Rehabilitation 65: 92-94.
IOC World Congress on Sport Sciences, held in Sydney in
1998. Moore ML (1949): The measurement of joint motion. Part 1.
Physical Therapy Review 29: 195-205.
Authors George Murrell, Department of Orthopaedic Moore ML (1949): The measurement of joint motion. Part 2.
Surgery, St George Hospital, Kogarah, New South Wales Physical Therapy Review 29: 256-264.
2217. E-mail: admin@ori.org.au (for correspondence). Murrell GAC and Walton J (2001): Diagnosis of rotator cuff
Kimberley Hayes, Judie Walton, Zoltan Szomor, tears. Lancet 357:769-770.
Department of Orthopaedic Surgery, St George Hospital,
Kogarah, New South Wales 2217. Portney LG and Watkins MP (1993): Foundations of Clinical
Research. Applications to Practice. Connecticut: Appleton
& Lange.
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