Advances in Physiotherapy.

2005; 7: 84
/91

ORIGINAL ARTICLE

Intra-rater reliability in measuring range of motion in infants with

congenital muscular torticollis

EVA PERBECK KLACKENBERG1, BRITT ELFVING2, YVONNE HAGLUND-ÅKERLIND3

& EVA BROGREN CARLBERG4
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1
Physical Therapy, Astrid Lindgren Children’s Hospital, Karolinska University Hospital, 2Neurotec Department, Division of
Physiotherapy, Karolinska Institute, 3Department of Pediatric Orthopedics, Astrid Lindgren Children’s Hospital, Karolinska
University Hospital, 4Neuropediatric Research Unit, Dept. of Woman and Child Health, Karolinska Institute, Stockholm,
Sweden

Abstract
The aim of this study was to test the intra-rater reliability of measures in rotation and lateral flexion of the head in infants
with congenital muscular torticollis (CMT). Twenty-three infants with CMT, aged 1
/5 months, were classified into two
groups. Group I was measured twice without time interval and Group II was measured with an interval of 1 h. All infants
For personal use only.

were examined supine. A goniometer was used to measure rotation and a protractor for lateral flexion. Photos were taken
simultaneously with the readings of range of motion. Repeated-measures analysis of variance (ANOVA) was used to
determine any significant differences between test and retest. The intraclass correlation coefficient and the standard error of
measurement were calculated to determine intra-rater reliability. Results show high intra-rater reliability regardless of time
intervals between the two measures, measured movement directions and differences in the end-feel of the sternocleido-
mastoideus muscle. Least agreement was found when comparing measures on infants and on photos taken simultaneously.
The high intra-rater reliability found in this study indicates that evaluation of treatment effects over time can be made with
adequate reliability when the measures are performed by an experienced physiotherapist. The methods used could form a
good basis for performing a larger inter-rater reliability study.

Key words: Agreement, lateral flexion, movement directions, repeatability, rotation

Introduction recedes after a few months. However, in some

Congenital muscular torticollis (CMT) is caused by
a shortening of the sternocleidomastoid muscle
(SCM) in infants, inducing a lateral flexion of the
head to the ipsilateral and a turning of the head to
the contralateral side (Figure 1). The reported
prevalence has ranged from 0.3% to 2.0% (1). The
shortening of the SCM can either depend on a
contracture in the muscle or an exaggerated con-
traction of the muscle (2,3). The latter is often
referred to as ‘‘postural torticollis’’ (1
/3). In some
literature lately this condition has also been called
positional torticollis (4,5). When the infant has a
contracture it is sometimes generated by a benign
sternomastoid tumour, often recognized when the
infant is 1
/4 weeks old (6,7). The tumour always
infants (10
/20%) the muscle may become fibrotic
leading to a manifest contracture (8,9). Currently
intrauterine or perinatal compartment syndrome, as
a result of the infant being confined for space in a
disadvantageous position in the womb, is considered
the cause (10). Experiments on animals indicate that
venous occlusion can result in fibrotic tissue (2,3).
The infants are frequently referred to a phy-
siotherapist, often between 1 and 3 months of age.
The physiotherapist instructs the parents how to
stretch the short SCM muscle and how to gain better
strength through active movements of the head using
the non-affected, often weak, SCM muscle (5). The
parents are also instructed to support symmetrical
head and trunk movements of the child. Apart from

Correspondence: Eva Perbeck Klackenberg, Physical Therapy, Astrid Lindgren Children’s Hospital, Karolinska University Hospital, 171 76 Stockholm,
Sweden. E-mail: eva.perbeck-klackenberg@karolinska.se

(Received 7 October 2004; accepted 3 January 2005)

ISSN 1403-8196 print/ISSN 1651-1948 online # 2005 Taylor & Francis Group Ltd
DOI: 10.1080/14038190510010331

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Figure 1. Boy with a left-sided congenital muscular torticollis.
inducing an asymmetrical position of the head in the
upright position, an uncorrected CMT can also lead
to positional plagiocephaly (11). Positional plagio-
cephaly denotes that the infant’s head and skull has
become asymmetrical, because the infant has been
obliquely positioned in supine.
For personal use only.
The range of motion (ROM) and the strength in
the non-affected SCM muscle are continuously
followed throughout the treatment period. When
the contracture is persistent, the infant is referred to
surgical lengthening of the SCM muscle, which
nowadays in Stockholm is preceded by at least
6 months of training.
It is crucial to follow the change in ROM when
evaluating treatment effects and for knowing when to
refer to surgery (1,2,12
/14). Also after surgery,
during the intense treatment that follows, it is of
importance to follow the regain of ROM to avoid
recurrence. Therefore the reliability of the measures
is of importance.
In adults, passive ROM in the neck is commonly
measured in sitting position (15
/17). The degree of
reliability in measures performed in sitting is influ-
enced by the kind of device used for measuring. Poor
to moderate reliability was obtained when assessing
passive rotation and lateral flexion using a strap-on
goniometer [intraclass correlation coefficient (ICC
1.1) values ranging from 0.38 to 0.64] (16), whereas
good inter- and intra-rater reliability was reached
when the measures were performed with an electro-
goniometer (ICC values ranging from 0.90 to 0.98)
(17).
The sitting position is, however, not suitable for
measuring infants with CMT, since they have not
yet gained complete control of the head in the
upright position. The supine position is therefore
probably the most suitable position to measure
Reliability of ROM in infants with CMT 85
passive ROM on infants with CMT. To our knowl-
edge, no previous studies have evaluated the
reliability of goniometric measures on infants in
this position.
At the time of the study in Astrid Lindgren
Children’s Hospital in Stockholm, most measures
on infants with CMT were performed by one
specialized physiotherapist (EPK). This PT was
also mainly responsible for treatment and follow-up
of the infants with a serious form of CMT. There-
fore, the primary focus of this study was to evaluate
intra-rater reliability. Such a pilot study could also
provide a good basis for a study on inter-rater
reliability by shedding light on various sources of
measurement variability. The aim of this study was
to test the intra-rater reliability of measures in
rotation and lateral flexion of the head performed
in supine on infants with CMT. The following
questions were asked: Is the reliability influenced
by: (i) the time interval between the measures;
(ii) the measured directions of ROM; (iii) the end-
feel of the muscle? The first question is related to the
feasibility of performing an inter-rater reliability
study. A short time interval between measures is
more practical, but a stretch of the muscle could
influence the ROM, giving rise to a systematic
measurement error. The second question deals
with whether the reliability could be influenced by
the different procedures used when measuring lateral
flexion vs. rotation. The third question is based on a
hypothesis that the end-feel of a contract muscle
could influence the reliability, giving rise to larger
variation when measuring the movement directions
of a contract SCM muscle than those of a non-
affected muscle. Furthermore, we were interested in
determining the agreement between measures made
directly on the infants and measures made on photos
taken simultaneously with the readings, i.e. we
were interested in comparing the measurements
made by a trained physiotherapist with an objective
way of measuring ROM, i.e. a photo. (iv) Could a
photo taken in a standardized way provide an
objective measure and, if so, how do the measures
of the physiotherapist deviate from these ‘‘true’’
values?
Material and method
Subjects
Twenty-three infants aged 1
/5 months were referred
consecutively to a physiotherapist (EPK) from a
paediatrician or an orthopaedic surgeon for assess-
ment and treatment of CMT. All parents gave
informed consent and the study was approved by
the Medical Ethical Committee of the Karolinska
 86 E. Perbeck Klackenberg et al.

Hospital, Stockholm. Ten infants had a shortening

of the left SCM muscle and 13 had a shortening of
the SCM muscle on the right side of the neck. The
infants were randomly assigned into two groups
(Table I). The children in Group I (n /11) were
tested first. The median age of the children in this
group was 3 months (range 2
/5 months). Group II
contained 12 infants with a median age of 2 months
(range 1
/5 months). The measurements in Group II
were performed with an interval of approximately
1 h, whereas the measurements in Group I were
made adjacently.

Method
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A standard goniometer with one stationary arm and

one movable arm (MEDEMA) was used for mea-
suring rotations. For measuring lateral flexion, a
measurement device, a protractor (Figure 2) fabri- Figure 2. The protractor used to measure lateral flexion.
cated from a hard, square cushion (75 /60 /9 cm)
was used. ROM of 608, depending on the thickness of the
infant’s cheek.
Initially the non-affected side was measured in
Procedure
rotation to avoid irritating the infant. Furthermore,
All measures were performed supine, the head in the movements were performed slowly to prevent the
For personal use only.

midline and the head and body aligned along a
sagittal axis marked with tape onto the support
surface. Furthermore, a line was taped at 908 to
this line across the support surface, parallel to which
the shoulders of the child were placed. One person
(often the parent) fixated the shoulders of the infant
to the support surface while the first author (EPK)
performed the measures. When rotations were mea-
sured, the goniometer was placed above the infant’s
head with the movable arm of the goniometer in line
with the nose of the infant, after which the head was
rotated (Figure 3). ROM in rotation was considered
complete when the infant’s cheek attained the
support surface, generally about 708 or 808 depend-
ing on the thickness of the infant’s cheek. During
lateral flexion, the infant’s head was placed on the
protractor, the position corresponding to zero on the
protractor scale (Figure 4). Lateral flexion was
considered complete when the ear of the infant
reached the shoulder, generally corresponding to a
Table I. Infants included in the study. In Group I two measures
were performed adjacently and in Group II the second measure
was performed after 1 h.
Group I, Group II,
n/11 n/12
Age (months) (median, range) 3 (2
/5) 2 (1
/5)
Right-sided CMT (n ) 5 8
Left-sided CMT (n ) 6 4
child from getting tense and/or actively applying
force against the stretch induced by the physiothera-
pist. When full ROM was reached, the child
exhibited a tendency to lift the shoulder. Under
these circumstances, the physiotherapist stopped the
stretching. After the rotations, lateral flexion was
measured, this time starting with the affected side,
again initially using a movement direction that did
not irritate the infant. Thus four measures were
taken initially, followed adjacently or after approxi-
mately 1 h by four comparable measures. If an exact
value could not be noted, which could happen if the
child was moving the head, two values were noted,
i.e. 55/608. In the statistical analysis, the mean of
these two values was used.
Simultaneously with all measures, the ROM was
registered with a camera (Kodak DC240/DC280
Zoom Digital). The photos were taken by a third
person when ROM was at its maximum (at the
point where the physiotherapist made a reading).
Two markers were placed on the head, one on os
frontale in line with the nose and the other on the tip
of the nose. The camera was placed on a stand
85 cm above the protractor. When measuring rota-
tions, the camera was placed at the short side of
the bench, 50 cm from the taped line. The lowest
part of the camera objective was placed 4 cm above
this surface. The pictures were edited, deleting
the goniometer and the protractor. Thereafter the
angles were measured with a goniometer on the
photos.

Figure 3. Rotation measured with goniometer placed above the infant’s head.
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In Group II (n /12), all intended measures were
obtained (48 paired measures). In Group I (n /11),
only 33 paired measures of 44 planned were
achieved, since the close administration of measure-
ments irritated the infants.
Statistic analysis
Reliability will be expressed as systematic bias, ICC
1.1 and random measurement error (18,19). The
For personal use only.
systematic bias refers to the mean difference between
measure 1 and 2. The ICC is a ratio of variances.
Briefly, a high ICC indicates that the within-subject
variance is smaller than the between subject
variance. Therefore, as a complement to the ICC,
for clinical purposes, it is recommended to use
the random measurement error, e.g. the standard
error of measurement (Sw ), which is unaffected
by the range of the measured values of the subjects
(18).
To inspect data, the individual differences between
measure 1 and 2 (diffwithin ) and the individual means
of the two measures were plotted according to Bland
& Altman (20). No relations between the diffwithin
and the size of the values were found (i.e. data were
homoscedastic) and conventional parametric statis-
tics could be used (18).
Figure 4. Lateral flexion measured with the infant placed on a protractor.
Reliability of ROM in infants with CMT 87
Repeated-measures analysis of variance (ANOVA)
was used to determine any significant mean differ-
ences, i.e. systematic bias, between measure 1 and 2;
p B/0.05 was considered a significant difference.
The ICC 1.1 was calculated, using the between-
and within-subject mean squares from the ANOVA,
to determine intra-rater reliability (19). In this
study, ICC values of 0.90
/0.99 indicate high relia-
bility, 0.80
/0.89, good reliability, 0.70
/ 0.79
fair reliability, and 0.69 and below, poor reliability
(21).
The standard error of measurement (Sw ) was
calculated as the square root of the within-subject
variance from the ANOVA (20). Furthermore, the
standard deviation of the differences (Sdiff ), was
calculated using the formula: Sdiff /â2 /Sw to
determine the reproducibility of the method
(20,22,23). The repeatability, as expressed by the
difference between two measurements for the same
subject, is expected with 95% probability to be
within 1.96 /Sdiff (20,22,23). Since the interest in
this article is to describe the repeatability for future
clinical use in treatment outcome, 1.96 /Sdiff will be
presented in the results as a measure of random
error. All calculations were made using Microsoft
Excel.
 88 E. Perbeck Klackenberg et al.

Results Repeatability for the affected movement directions

Group I (measures adjacently taken) and Group II (1 h
between measures)
In measures performed in close connection to each
other (Group I) the repeatability (1.96 /Sdiff ) varied
between 28 and 58 depending on the movement
direction. A longer time interval between measures
(Group II) affected the repeatability only slightly: 4
/
68 (Table II). The ICC was high (0.97
/0.99) in
Group I and fair to high (0.77
/0.95) in Group II
(Table II). Although the ICC values varied slightly,
the clinically important repeatability expressed in
degrees (1.96 /Sdiff ) could be considered very small,
i.e. 2
/68. Pooled data of Group I and II are found in
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was 5
/68 and for the unaffected directions 3
/58
(Table II). No significant systematic bias between
measure 1 and 2 was found. The ICC values were
higher when measuring the affected movement
directions. For children with right-sided CMT, the
rotation to the right and the lateral flexion to the left
showed ICC values between 0.82 and 0.95, whereas
the reliability when measuring the non-affected
rotation and lateral flexion was noticeably lower at
0.58
/0.65. In children with left-sided CMT, the
same tendency was found (Table III). Movement
directions with a good repeatability, i.e. a low 1.96 /
Sdiff, , were connected to a low ICC (Table III). This
seems to be due to an occasional small between-

Table II. subjects variability demonstrated by the comparably

Movement directions
/ rotation vs. lateral flexion
For measures of rotation, the repeatability was
slightly better for Group I (2
/38) than for Group
II (5
/68). For measures of lateral flexion, the
repeatability varied between 48 and 68, similarly for
Group I and II. Although a significant systematic
bias (p B/0.035) was found for rotation left in Group
For personal use only.
smaller standard deviations.
Agreement infant
/photo
The reliability between the measures made on the
infant and those performed on photos taken simul-
taneously with the readings was somewhat lower
than the reliability for the test
/retest. Repeatability
was 6
/108 and ICC was fair to good (0.74
/0.90)

I, the mean difference was only 18. The lower ICC
for rotation in Group II could partly be due to a
smaller between subject variance, as can be seen
on the smaller standard deviations in Table II
(SD 3.1
/4.6).
(Table IV). A significant systematic bias was found
when measuring lateral flexion in both directions.
The readings taken from the photos were lower by
2
/38 degrees (p B/0.001), than those performed on
the infant.

Right-sided and left-sided CMT
/ difference in end-feel Discussion

Data from Groups I and II were pooled to calculate The study showed, in principle, high intra-rater
the reliability for right-sided and left-sided CMT. reliability regardless of the time intervals between
Table II. Reliability of measures performed adjacently (Group I) and measures performed with a time interval of 1 h (Group II).

Movement Measure 1, Measure 2, 1.96/Sdiff ,

direction n mean (SD), degrees mean (SD), degrees ICC degrees p -value

Group I
RR 7 65.7 (5.3) 65.4 (6.2) 0.99 1.9 0.356
RL 9 65.3 (8.2) 66.4 (8.8) 0.98 3.3 0.035
LFR 9 53.1 (10.1) 53.1 (10.2) 0.97 4.6 1.0
LFL 8 49.1 (10.8) 48.1 (12.6) 0.98 4.6 0.285
Group II
RR 12 65.8 (4.6) 65.0 (4.5) 0.77 6,0 0.368
RL 12 67.7 (4.2) 68.3 (3.1) 0.79 4.7 0.389
LFR 12 53.3 (8.9) 53.4 (8.1) 0.95 5.5 0.809
LFL 12 50.2 (6.1) 49.6 (6.1) 0.94 4.2 0.339
Groups I/II
RR 19 65.8 (4.7) 65.1 (5.0) 0.87 4.9 0.262
RL 21 66.7 (6.2) 67.5 (6.1) 0.94 4.1 0.069
LFR 21 53.2 (9.2) 53.3 (8.8) 0.96 5.1 0.841
LFL 20 50.1 (8.0) 49.5 (8.9) 0.97 4.4 0.137

Movement directions are: RR, rotation to the right; RL, rotation to the left; LFR, lateral flexion to the right; LFL, lateral flexion to the left; n
indicates number of paired measures. Reliability is expressed as intraclass correlation coefficient (ICC 1.1). Repeatability is expressed as
1.96/Sdiff . p -values from repeated-measures analysis of variance (ANOVA) show the significance between measures 1 and 2.
 Reliability of ROM in infants with CMT 89
Table III. Reliability of measures performed on infants with CMT in the right and left side SCM-muscle.

Movement Measure 1, Measure 2, 1.96/Sdiff ,

direction n mean (SD), degrees mean (SD), degrees ICC degrees p -value

Right-sided CMT
RR 10 63.0 (4.7) 62.5 (5.4) 0.82 5.8 0.619
RL 11 69.5 (1.9) 69.8 (0.8) 0.58 2.6 0.588
LFR 12 58.5 (2.9) 57.9 (3.4) 0.65 5.1 0.429
LFL 13 46.0 (7.2) 44.8 (8.3) 0.95 4.7 0.082
Left-sided CMT
RR 9 68.9 (2.2) 68.1 (2.4) 0.68 3.7 0.195
RL 10 63.5 (7.7) 65.0 (8.2) 0.94 5.4 0.081
LFR 9 46.1 (10.0) 47.2 (10.3) 0.97 5.2 0.225
LFL 7 56.8 (3.5) 56.8 (2.8) 0.82 3.7 1.0

Movement directions are: RR, rotation to the right; RL, rotation to the left; LFR, lateral flexion to the right; LFL, lateral flexion to the left; n
indicates number of paired measures. Reliability is expressed as intraclass correlation coefficient (ICC 1.1). Repeatability is expressed as
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1.96/Sdiff . p -values from repeated-measures analysis of variance (ANOVA) show the significance between measures 1 and 2. The number
of measures in bold indicate the affected movement directions.

the two measures, the measured movement direc-
tions and differences in the end-feel of the muscle.
Least agreement was found when comparing mea-
sures on infants and on photos taken simultaneously.
To follow the passive ROM in infants with CMT is
of great importance when evaluating treatment
effects and for knowing when to refer to surgery.
For personal use only.
muscle during initial measurements would induce an
elongation of the muscle and thus differences in
ROM, which persisted when the measures were
performed a second time. This would thus create a
systematic error with a higher value during the
second reading. This was, however, not the case.
Instead, the variation between measures performed

The high intra-rater reliability found in this pilot
study indicates that evaluation of treatment effects
and referral to orthopaedic surgery can be made
with adequate reliability when the measures are
performed by the physiotherapist in this study
(EPK). The methods used could form a good
basis for performing a larger inter-rater reliability
study.
The time that elapsed between the measures
influenced the reliability only slightly with somewhat
better reliability when measures were made in close
connection to each other. One possible explanation
might be that the investigator partly remembered
the values from the first reading. On the other hand,
it could be hypothesized that the stretch of the
after 1 h was to some extent larger. An inter-rater
reliability study could thus be based on adjacently
performed measures, although care should be taken
to avoid irritating the infants.
Repeatability (1.96 /Sdiff ) was larger, although
ICC was higher when the ROM in the affected
movement directions was measured compared to
the non-affected directions. The finding is in line
with our hypothesis that the different end-feel of
the affected muscle would cause more within-subject
variability. The 1.96 /Sdiff did not, however, exceed
68, indicating clinically satisfactory repeatability.
The lower ICC when measuring the non-affected
side was probably due to a smaller between-subjects
variance. Very homogeneous groups can give rise to

Table IV. Reliability of measures performed on infants with CMT comparing goniometer readings on infants and on photos.

Movement Infant mean Photo mean 1.96/Sdiff

direction n (SD) degrees (SD) degrees ICC degrees p -value

RR Group I 18 65.4 (5.1) 64.1 (5.8) 0.80 6.7 0.093

RR Group II 16 64.8 (5.4) 64.3 (5.4) 0.74 7.7 0.561
RL Group I 19 67.0 (6.3) 67.2 (6.7) 0.90 5.6 0.787
RL Group II 18 67.1 (6.5) 67.2 (6.6) 0.86 6.7 0.921
LFR Group I 23 52.7 (8.9) 50.0 (8.9) 0.88 8.6 B/0.001
LFR Group II 21 53.3 (8.8) 50.0 (7.9) 0.84 9.5 B/0.001
LFL Group I 20 50.3 (8.3) 48.4 (8.8) 0.87 8.5 0.055
LFL Group II 20 51.0 (6.1) 49.2 (6.2) 0.79 7.9 0.042

Movement directions are: RR, rotation to the right; RL, rotation to the left; LFR, lateral flexion to the right; LFL, lateral flexion to the left. n
indicates number of paired measures. Reliability is expressed as intraclass correlation coefficient (ICC 1.1). Agreement infant/photo is
expressed as 1.96/Sdiff . p -values from repeated-measures ANOVA show the significance between measures on infant and photo.
 90 E. Perbeck Klackenberg et al.
a low ICC, even if the measures have a high
precision. The homogeneity was created by the
infants often reaching the ROM end-point on the
non-affected side, i.e. in lateral flexion to the infant’s
shoulder and in rotation stopping at the support
surface. This indicates the relativity of ICC as a
measure of reliability.
For both groups and for all movement directions,
the repeatability was about 58, i.e. a clinically
significant change should exceed this value. Repeat-
ability is not frequently reported in reliability studies
with children. Engelbert et al. (24) reported a
repeatability of 9.28 for healthy children. However,
this value is an average of intra- and inter-rater
reliability and of measures of all extremity joints in
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the study group, and therefore not directly compar-
able with our study, which deals only with intra-rater
reliability and neck movements.
The intention when taking photos simultaneously
with the physiotherapist’s reading was to obtain a
gold standard. The photos did not, however, present
such a possibility. Various reasons for this could be
suggested. A lack of synchronization between the
physiotherapist making the readings and the person
taking the photo, and a delay between the manual
For personal use only.
triggering of the camera and the activation of the
camera, could have created the time differences. A
source of error might also be present when measur-
ing on the photos.
Conclusion
The intra-rater reliability when measuring ROM in
infants with CMT proved to be satisfactory for
following treatment effects over time. The method
used could form a good basis for performing a study
on inter-rater reliability. The measures could then
be made in close connection to each other. Such a
study might, in addition, be accompanied by an
evaluation of ROM with a system for three-dimen-
sional movement analysis to obtain a gold standard.
A comparison between clinical measures and three-
dimensional measurements could reveal sources of
variability.
Acknowledgements
The first author (EPK) would like to thank the
Norrbacka Eugenia Foundation for the financial
support.
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