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Interrater reliability of flexicurve postural

measures among novice users

Article in Journal of Back and Musculoskeletal Rehabilitation · April 2004

DOI: 10.3233/BMR-2004-17107

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Martha Rammel Hinman

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Journal of Back and Musculoskeletal Rehabilitation 17 (2003/2004) 33–36 33
IOS Press

Interrater reliability of flexicurve postural

measures among novice users
Martha R. Hinman∗
The University of Texas Medical Branch, Galveston, TX, USA

Abstract. The purpose of this study was to establish the interrater reliability of the flexicurve when used by novice testers
to measure thoracic kyphosis and lumbar lordosis in a community-based population. Three graduate students independently
measured 51 healthy women (aged 21 to 88 years). The flexicurve was molded to the contour of the spine and traced onto a plain
piece of paper to calculate the Index of Kyphosis (IK) and Index of Lordosis (IL). Subjects were measured while standing in their
usual relaxed posture and again in their maximally erect posture. Intraclass correlation coefficients (ICCs) were calculated to
determine the reliability among the three testers. IK measures were more reliable than IL measures with ICCs of 0.94 and 0.93
for the relaxed and erect postures, respectively. ICCs for the IL were 0.60 when relaxed and 0.73 when maximally erect. Greater
variability in the lumbar measures may be attributed to difficulty in conforming the flexicurve to the smaller, concave curvature
of the lumbar spine and interference from some subject’s clothing. Nevertheless, these findings indicate good reliability for
flexicurve measures of thoracic kyphosis and support the use of this measurement when documenting clinical changes in posture
or identifying postural abnormalities in community-based screenings.

Keywords: Posture, spine, postural assessment, kyphosis, lordosis

1. Introduction 8,10]. However, measurement protocols for the flexi-

The flexicurve, or flexible ruler, is a simple instru-
ment that can be used to measure both thoracic and
lumbar postural curves in the sagittal plane. It is a
61-cm long, flexible piece of lead covered in durable
plastic that can be molded to the contour of the spine.
The flexicurve provides a quick, inexpensive, and non-
invasive way to assess posture in clinical or community-
based settings. Several investigators have established
the validity of flexicurve postural measures by corre-
lating them with spinal radiographs and other instru-
ments such as goniometers, kyphometers, and incli-
nometers [1,5,8,10,11]. Flexicurve measures have also
been used to identify age-related postural changes, low
bone mass, impaired fitness, and low back pain [3,4,
∗ Address for correspondence: Martha R. Hinman, EdD, PT, As-
sociate Professor, Department of Physical Therapy, Rt. 1144, The
University of Texas Medical Branch, 301 University Blvd., Galve-
ston, TX 77555-1144, USA. Tel.: +1 409 772 9493; Fax: +1 409
747 1613; E-mail: mhinman@utmb.edu.
curve vary and little is known about the reliability of
this postural measure among novice users.
Previous studies have demonstrated higher intrarater
(i.e., test-retest) reliability for flexicurve measurements
than interrater reliability. Lovell et al. [6] reported intr-
aclass correlation coefficients (ICCs) of reliability both
within and between two physical therapists who used
the flexicurve to measure lumbar lordosis in 40 subjects
with and without low back pain. Intrarater ICCs ranged
from 0.73 to 0.94, but interrater reliability was much
lower, ranging from 0.41 to 0.54. Burton [1] stud-
ied flexicurve measures of the sagittal lumbar mobility
(i.e., in maximum flexion and extension) within and
between trained testers. A mean discrepancy of 8.75%
was observed for measurements repeated by the same
tester, whereas a 15% discrepancy was found between
measures performed by different testers. Tillotson et
al. [11] compared short-term and long-term intrarater
reliability for several lumbar mobility measures taken
5–30 minutes apart versus 2–4 days apart by one trained
tester. Reliability coefficients (r) for short-term were

ISSN 1053-8127/03/04/$17.00  2003/2004 – IOS Press and the authors. All rights reserved
34 M.R. Hinman / Interrater reliability of flexicurve postural measures among novice users

very high (0.95–0.97); a comparable reliability was

found for measurements taken over the longer interval
(0.82–0.98). Hart et al. [5] reported similar findings for
flexicurve measures of lumbar lordosis performed by a
single tester (ICC = 0.97).
Fewer studies have examined the reliability of flexi-
curve measures of the thoracic spine. Lundon et al. [7]
compared intra- and interrater reliability of 3 measures
of kyphosis (flexicurve, kyphometer, and roentgeno-
graph) performed by 3 trained testers on a group of
26 postmenopausal women. Intrarater reliability was
similar across the three methods with ICCs ranging
from 0.89–0.99 (kyphometer) 0.89–0.97, (flexicurve),
and 0.81–0.99 (x-ray). Interrater reliability was highest
for radiographic assessment (ICC = 0.92) but slightly
lower for kyphometer and flexicurve measures with
ICCs of 0.88 and 0.87, respectively. In another study
involving 10 older men, Caine et al. [2] reported in-
trarater reliability coefficients (r) of three measures of
kyphosis performed by a single trained tester. The
highest reliability (0.93) was reported for the kyphotic
index which is a ratio of curve width to height (i.e.,
length). Lower reliabilities were found for measures
of maximum and mean curvature (r = 0.60 and 0.75,
respectively).
An increasing awareness of osteoporosis has
prompted more widespread use of the flexicurve to
screen individuals for postural changes, particularly
Fig. 1. Flexicurve measurements and calculations for the Index of
kyphosis, that may be associated with that condition [3,
Kyphosis (IK) and Index of Lordosis (IL): IK = TW / TL X 100; IL
4,8]. However, little is known about the reliability of = LW / LL X 100.
this measure when used during mass screenings by in-
dividuals who have had little prior training in its use. 2.2. Data collection procedures
Thus, this study was designed to explore the interrater
reliability of flexicurve measures of thoracic and lum- Three graduate students who had no prior experi-
bar curvature when performed by 3 novice testers on a ence using the flexicurve measured each subject. To
sample of healthy women living in the community. guard against the possibility of a learning effect, the
testers participated in five practice sessions to learn
the measurement technique prior to data collection. A
2. Methods
61-cm surveyor’s flexicurve (Alvin; Hartford, CT) was
2.1. Sample used to measure each subject in two different positions.
The first measurement was performed with the sub-
An age-stratified sample of 25 pre- and 26 post- ject standing in her usual relaxed posture, and the sec-
menopausal women was recruited from students and ond was taken while she stood in her maximum erect
staff at a large academic health science center and local posture. Subjects were asked to loosen the clothing
community in southeast Texas. Premenopausal sub- around their waist so the tester could accurately palpate
jects were between the ages of 21 and 51 years (mean bony landmarks and position the flexicurve. In order to
= 29.2), and postmenopausal subjects ranged from 66 simulate the conditions used during community-based
to 88 years (mean = 72.3). Subjects were excluded if postural screens, subjects were not asked to completely
they were pregnant, had any known spinal pathology, remove all of their clothing.
or were unable to follow verbal directions due to cog- The flexicurve measurement protocol was based on
nitive deficits or language barriers. The university’s the one described by Milne [8] (Fig. 1). First, the tester
Institutional Review Board approved this study. palpated and marked the spinous process of the seventh
 M.R. Hinman / Interrater reliability of flexicurve postural measures among novice users
cervical vertebra (C-7) and the superior aspect of the
sacrum (S-1). The flexicurve was then placed over the
spinous processes of the thoracic and lumbar spine and
shaped to fit the contours of these spinal curves. The
instrument was carefully removed and traced onto a
piece of plain white paper. A vertical line was drawn to
connect the C-7 and S-1 landmarks. The point where
this line intersected the traced curve marked the tran-
sition between the thoracic and lumbar curves. The
maximum width and the total length of each curve were
measured in centimeters. An Index of Kyphosis (IK)
and Index of Lordosis (IL) were calculated from the
width and length measures of the thoracic and lumbar
portions of the spine using the following formulae:
IK = thoracic width / thoracic length X 100
IL = lumbar width / lumbar length X 100
Higher indices indicated greater degrees of kypho-
sis/lordosis and vice versa.
2.3. Data analysis
Using an analysis of variance (ANOVA) model, an
intraclass correlation coefficient (ICC 2,1 ) was calcu-
lated to determine the degree of interrater reliability
for the IK and IL measurements taken in each position
by the three testers. Data were analyzed using SPSS
statistical software.
3. Results
The mean IK for the sample was 11.1 ± 3.3 in the
relaxed position and 9.2 ± 3.7 in the erect position.
The mean IL was 7.8 ± 2.5 in the relaxed position and
8.0 ± 2.4 in the erect position. Interrater reliability co-
efficients (ICCs) for the IK and IL and their confidence
intervals are listed in Table 1 for both the relaxed and
erect postures. The reliability was generally higher for
measures of kyphosis than measures of lordosis. The
IL measure was more reliable when subjects were mea-
sured in their maximum erect posture; however, the re-
liability of the IK was comparable in both the erect and
relaxed postural positions.
35
Table 1
Interrater reliability coefficients for flexicurve measures in two pos-
tural positions (n = 3 testers, 51 subjects)
Flexicurve measure ICC 95% CI
Index of Kyphosis – Relaxed 0.94 0.90–0.96
Index of Kyphosis – Erect 0.93 0.89–0.96
Index of Lordosis – Relaxed 0.60 0.45–0.73
Index of Lordosis – Erect 0.73 0.61–0.82
4. Discussion
These findings suggest that the interrater reliability
of flexicurve measures of kyphosis (IK) is comparable
to the test-retest reliability reported by previous inves-
tigators and slightly better than the interrater reliability
reported by Lundon et al. [7] However, in Lundon’s
study the angle of kyphosis was calculated using the
Cobb technique which is the method used to measure
spinal curves on radiographs. The interrater reliabil-
ity for flexicurve measures of lordosis (IL) was lower
than the reliability of the IK measures, but consider-
ably higher than that reported previously by investi-
gators who examined lumbar postures and movements
using more complicated methods to calculate the angle
of lordosis (i.e., drawing tangents to the curves) [1,6].
Thus, the IK and IL are not only simpler calculations
but also appear to be more reliable than other flexicurve
measurement protocols.
Several factors may have contributed to the lower
reliability associated with the IL measures in this study.
Bulky clothing around the subject’s waist sometimes
made it difficulty to accurately palpate the sacrum and
mold the flexicurve to the concavity of the lumbar spine.
The flexicurve conformed more easily to the thoracic
spine because of its convex shape and added length.
Other potential sources of variation in the measure-
ments may have been attributed to variations in the
verbal cues that testers gave to subjects as well as the
amount of pressure testers applied when conforming
the flexicurve to the spine. In addition, actual changes
in the relaxed posture of subjects may have occurred as
they became fatigued from undergoing repeated mea-
surements.
Overall, the results of this study indicate that flexi-
curve postural measures of the thoracic spine (IK) are
highly reproducible among novice testers when per-
forming a postural screening on healthy women. How-
ever, lumbar postural measures (IL) are only moder-
ately reliable. According to Portney and Watkins [9]
coefficients above 0.75 generally indicate good reli-
ability, but reliabilities of 0.90 or higher are recom-
mended for diagnostic tests. Although flexicurve pos-
36 M.R. Hinman / Interrater reliability of flexicurve postural measures among novice users
tural measures are most often used to document clin-
ical progress in response to a therapeutic intervention
rather than to diagnosis a condition, some investiga-
tors have suggested the usefulness of these measures in
screening individuals for underlying pathologies such
as osteoporosis, detecting individuals with low fitness
levels, and predicting survival time for older adults [3,
4,8]. However, further studies are needed to establish
the diagnostic value of flexicurve measures for other
conditions and patient populations.
Acknowledgements
The author would like to thank Marcy Mains, Tina
Schulte, and Heather Spiller for participating in the
data collection for this study, and the Marilyn Brodwick
in the Sealy Center on Aging for her assistance with
subject recruitment.
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