See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/256545484

Agreement between visual and goniometric assessments of adductor and

popliteal angles in infants

Article  in  Journal of Pediatric Neurosciences · September 2013

CITATIONS READS

0 60

5 authors, including:

Thejus Jayakrishnan Suvasini Sharma

Cleveland Clinic Lady Hardinge Medical College
181 PUBLICATIONS   809 CITATIONS    207 PUBLICATIONS   1,594 CITATIONS   

SEE PROFILE SEE PROFILE

Sheffali Gulati Sanjay Wadhwa

All India Institute of Medical Sciences All India Institute of Medical Sciences
286 PUBLICATIONS   2,733 CITATIONS    34 PUBLICATIONS   433 CITATIONS   

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

To study the prevalence of cardiac channelopathies in children aged 5-18 years undergoing treatment for epilepsy View project

Save the Hip Project: The Indian Hip Surveillance Guidelines for Children with Cerebral Palsy. 2020-2021 View project

All content following this page was uploaded by Thejus Jayakrishnan on 03 June 2014.

The user has requested enhancement of the downloaded file.

[Downloaded free from http://www.pediatricneurosciences.com on Saturday, September 07, 2013, IP: 117.204.90.126]  ||  Click here to download free Android applica
for this journal

Original Article

Agreement between visual and goniometric

assessments of adductor and popliteal angles
in infants
Thejus T. Jayakrishnan, Suvasini Sharma, Sheffali Gulati, R. M. Pandey1, Sanjay Wadhwa2,
Vinod K. Paul
Departments of Pediatrics, 1Biostatistics, and 2Physical Medicine and Rehabilitation, All India Institute of Medical Sciences,
New Delhi, India

Address for correspondence: Dr. Sheffali Gulati, Child Neurology Division, Department of Pediatrics, All India Institute of Medical
Sciences, New Delhi ‑ 110 029, India. E‑mail: sheffaligulati@gmail.com

ABSTRACT
Context: Amiel‑Tison method is a commonly used technique for assessing tone and neurological status
of infants. There is a paucity of data on the reliability of visual assessment of angles, a component of this
method. Subjects and Methods: We compared the visual and the goniometric assessment of adductor and
popliteal angles in infants with hypertonia and neurologically normal controls. A total of 16 infants with
hypertonia and 15 normal infants underwent blinded assessment of the adductor and popliteal angles.
Statistical Analysis: The mean and standard deviation for the difference between visual and goniometric
measurements were calculated for popliteal and adductor angles. Results: The mean differences between visual
and goniometric measurements for the popliteal angle were 4.94 (SD3.40) and 8.73 (SD6.10) degrees for the
cases and controls respectively. Similarly, the values for adductor angle measurements were 8.94 (SD8.23) and
14.47 (SD8.47) degrees respectively. Conclusion: The deviation of visual assessment from goniometric measurement
was found to be less for popliteal angle measurement as compared to adductor angle measurements. It was
note‑worthy that the difference was less for the measurements of children with spasticity.

Key words: Amiel‑Tison method, goniometer, hypertonia, spasticity

Introduction One of the commonly used methods for assessing neuromotor

Hypertonia is a sign of upper motor neuron dysfunction
marked by an abnormal increase in passive muscle tone and
a reduced ability of the muscle to stretch. Spasticity and
dystonia are the most common types of hypertonia. Spasticity
is defined as a velocity dependent increase in resistance to
passive stretching. Dystonia refers to involuntary movements
and prolonged muscle contraction, resulting in twisting body
motions, tremor, and abnormal posture.
Access this article online
Quick Response Code:
Website:
www.pediatricneurosciences.com
DOI:
10.4103/1817-1745.117834
status including tone in infants and young children is the
Amiel‑Tison method. This method was developed to detect
transient as well as permanent abnormalities in an infant’s
neuromotor development. Its main focus is to examine active
and passive muscle tone. It detects transient neuromotor
problems in the 1st year of life that maybe associated with
significant behavioral, neurological, and intellectual deficits
when the children reach school age.[1]
In the Amiel‑Tison method, spasticity is assessed by visual
assessment of different angles – popliteal angle, adductor
angle, and dorsiflexion angle of foot etc., The angle
measurement is important as it helps in the quantification of
hypertonia. These measures are useful for a rough objective
estimate of the range of motion, which can be compared
to the age‑related norms, and for follow‑up in the same
patient. There is a paucity of data on the reliability of the
visual assessment as compared to the goniometric assessment
2013 / May-Aug / Volume 8 / Journal of Pediatric Neurosciences / 93
[Downloaded free from http://www.pediatricneurosciences.com on Saturday, September 07, 2013, IP: 117.204.90.126]  ||  Click here to download free Android applica
for this journal
Jayakrishnan, et al.: Agreement between visual and goniometric measurements for spasticity assessment in infants
of these angles. Hence, this study was planned to compare
the visual and goniometric assessments of the adductor and
popliteal angles in infants with hypertonia and neurologically
normal controls.
Subjects and Methods
Participants
The study was conducted as a prospective study at the
Out‑patient Pediatric Department of a tertiary care hospital
between September and November 2009. The study was
approved by the Institute’s Research Ethical Committee.
A total of 16 infants with hypertonia and 15 neurologically
normal children aged 3‑24 months were enrolled consecutively.
All the enrolled children underwent a detailed neurological
examination by a Pediatric Neurologist. None of the children
had any history of lower limb surgery in the previous 12 months.
Prior written informed consent was taken from the parents.
Measurement
Assessment of angles
The examination was conducted when the infant was quiet
and alert. Two Pediatric Neurology residents with experience
in measuring angles in infants were made the raters. The
readings were recorded by a recorder (who was the principal
investigator).
For the popliteal angle assessment, the thighs were flexed
at the hip along both sides of the abdomen and brought
perpendicular to the horizontal. While holding the infant in
this position the examiner extended the lower leg as far as
possible from the thigh. The popliteal angle, which is formed
between the calf and the thigh, was estimated on the right
side. The axial hinge of the goniometer was placed on the
lateral epicondyle of the right femur and the reading was
recorded after extending the arms parallel to the calf and
thigh.
The adductor angle was measured with the infant lying
supine. The legs were extended and gently pulled as far
apart as possible. The angle formed by the lower limbs at the
symphysis pubis was visually assessed as the adductor angle.
For goniometric measurement, the axial hinge was placed on
the pubic symphisis and the arms extended parallel to the legs.
Blinding
Goniometer was covered on one side by the principal
investigator and used with the blinded side toward the
observer. Thus, the observers were blinded for their own
goniometric measurements. The measurements were
taken consecutively by two observers and they were not
informed about the measurements of their colleague until
the completion of all the assessments [Figure 1].
94 / Journal of Pediatric Neurosciences / Volume 8 / May-Aug / 2013
a b
Figure 1: Assessment of angles with covered goniometer for blinding during
measurements. (a) Popliteal angle and (b) adductor angle
Statistical analyses
Data were analyzed using the SPSS 16.0. Differences between
the visual and goniometric measurements were calculated for
each subject after taking an average of the measurements by
two observers. The means and standard deviation (SD) of
these differences were also determined.
Results
There were 16 children in the hypertonia group and
15 neurologically normal children. The mean age
of hypertonia group (13.1 ± 5.6 months) and control
group (13.8 ± 6.8 months) were comparable.
Averages of the measurements made by the two observers
were calculated for each angle and the difference of
visual and goniometric measurements determined. The
mean differences (SD) between visual and goniometric
measurements for the popliteal angle were 4.94 (3.40) and
8.73 (6.10) degrees for the cases and controls respectively.
For adductor angle measurements, they were 8.94 (8.23) and
14.47 (8.47) degrees respectively [Table 1].
Discussion
The measurement of popliteal and adductor angles is
important as it helps in the assessment of hypertonia and
following up outcome after therapy. [1] Lack of reliability
may lead to erroneous interpretation with consequences on
management and follow‑up. The visual method of assessment
is subjective. The goniometric method, though objective is
less convenient in a busy hospital setting. The reliability of
different methods for assessing hypertonia therefore needs to
be studied. The popliteal angle measurement, a component
of Amiel‑Tison’s neurological assessment of newborn, is the
most widely used clinical measure to evaluate spasticity.[2,3]
While many studies have ascertained the reliability of
Amiel‑Tison’s method, reliability of visual estimation of angles
[Downloaded free from http://www.pediatricneurosciences.com on Saturday, September 07, 2013, IP: 117.204.90.126]  ||  Click here to download free Android applica
for this journal
Jayakrishnan, et al.: Agreement between visual and goniometric measurements for spasticity assessment in infants
Table 1: Details (mean, SD) of goniometric and visual measurements of popliteal and adductor angles in those
with spasticity and those who were neurologically normal
Groups
Popliteal angle
Visual Goniometer Mean of Mean of
mean (SD) mean (SD) difference (SD) difference±1.96 SD mean (SD) mean (SD) difference (SD) difference±1.96 SD
Children with spasticity 95.13 95.75 4.94
(group 1) n=16 (18.17) (17.88) (3.40)
Normal children 135.07 129.67 8.73
(group 2) n=15 (23.82) (20.25) (6.10)
SD: Standard deviation, LOA: Limits of agreement, ICC: Intra class correlation coefficient, CI: Confidence interval. *Measurements in degrees
have itself been very variable. Paro‑Panjan et al. compared
the Amiel‑Tison neurological assessment with Prechtl’s
qualitative assessment of general movements in a group of
45 pre‑term infants. Measurements were done at birth and
at a corrected age of 3 months and predictive power were
analyzed by comparing it with the outcome at 12‑15 months.
The sensitivity of both techniques was found to be good but
the agreement of the neurologic and developmental outcome
was better with the Amiel‑Tison assessment.[4] Deschênes
et al. demonstrated fair to excellent reliability among most of
the items tested in this method using a sample of 35 infants.[5]
There have been a few studies on the comparison of visual
and goniometric assessment of angles in older children.
Allington et al. did a comparison 46 ankle measurements
and showed a high reliability for intra‑ and inter observer
measurements (r > 0.75), between the visual estimation
and goniometry (correlation co‑efficient, r > 0.967). These
finding suggested that visual estimation and goniometry
ankle range‑of‑motion measurements were reliable and
reproducible in spastic cerebral palsy children.[6]
On the other hand, considerable inconsistency was found to
exist when two or more physical therapists made repeated
goniometric and visual measurements of the ankle joint
motion on the same subject.[7] Based on the examination of
intra tester and inter tester reliability for goniometric and
visual estimation of the ankle joint active range of motion,
Youdas et al. recommended that a physical therapist should
use a goniometer when making repeated measurements of
the ankle joint. The main concern was a physical therapist
making erroneous conclusion about change in the range of
motion due to treatment when the change could be attributed
to a lack of inter tester reliability.[7]
Interestingly, a study by Berge et al. showed low reliability
of both visual and goniometric measurements based on
intra‑class correlation coefficients for intra observer and inter
observer measurements. The reliability was worse for children
with spasticity as compared to normal children. The study
included popliteal angle measurements of 15 Cerebral Palsy
patients and 15 normal children by three different observers.
Measurements were carried out both visually and with a
goniometer. The intra‑class correlations for inter observer
reliability of visual estimates and goniometric measurements
were low for both groups.[8]
Measurements*
Adductor angle
Visual Goniometer Mean of Mean of
−1.71‑11.59 93.5 93.62 8.94 −7.19‑25.07
(24.03) (15.09) (8.23)
−3.23‑20.69 139.2 127.53 14.47 −2.66‑31.6
(24.75) (17.72) (8.74)
The above mentioned studies have used either kappa
coefficient or intra‑class correlation coefficient to measure
agreement. It has been argued that intra‑class correlation
coefficient may not be a good tool for assessing agreement as
the correlation could exist even in the absence of agreement.[9]
In the present study, we determined the mean of the difference
between visual and goniometric measurements to compare
between different groups. The deviation of visual assessment
from goniometric measurement was less for popliteal angle
measurements as compared to adductor angle measurements.
It was also noteworthy that the differences were lesser for
spastic children.
Neurologists often assess spasticity by judging tone, rather
than the angulation. However, numerically quantifiable
measurements are important to therapists to monitor therapy.
The results of this study support use of visual assessment of tone
in children with neuromotor problems. The variation observed
between the visual and goniometric assessments (4°‑15°)
may be acceptable. Moreover, the assessment of tone is not
one point estimate but done over a period of time to monitor
therapy. So, the difference in visual and goniometer assessment
of tone may make no clinical difference if visual assessment
is done carefully.
References
1. McCarraher‑Wetzel AP, Wetzel RC. A review of the Amiel‑Tison
neurologic evaluation of the newborn and infant. Am J Occup Ther
1984;38:585‑93.
2. Katz K, Rosenthal A, Yosipovitch Z. Normal ranges of popliteal angle
in children. J Pediatr Orthop 1992;12:229‑31.
3. Bleck EE. Orthopaedic Management in Cerebral Palsy. Philadelphia: 
J. B. Lippincott; 1987.
4. Paro‑Panjan D, Sustersic B, Neubauer D. Comparison of two methods
of neurologic assessment in infants. Pediatr Neurol 2005;33:317‑24.
5. Deschênes G, Gosselin J, Couture M, Lachance C. Interobserver
reliability of the Amiel‑Tison neurological assessment at term. Pediatr
Neurol 2004;30:190‑4.
6. Allington NJ, Leroy N, Doneux C. Ankle joint range of motion
measurements in spastic cerebral palsy children: Intraobserver and
interobserver reliability and reproducibility of goniometry and visual
estimation. J Pediatr Orthop B 2002;11:236‑9.
7. Youdas JW, Bogard CL, Suman VJ. Reliability of goniometric
measurements and visual estimates of ankle joint active range
of motion obtained in a clinical setting. Arch Phys Med Rehabil
1993;74:1113‑8.
2013 / May-Aug / Volume 8 / Journal of Pediatric Neurosciences / 95
[Downloaded free from http://www.pediatricneurosciences.com on Saturday, September 07, 2013, IP: 117.204.90.126]  ||  Click here to download free Android applica
for this journal

Jayakrishnan, et al.: Agreement between visual and goniometric measurements for spasticity assessment in infants

8. Ten Berge SR, Halbertsma JP, Maathuis PG, Verheij NP, Dijkstra PU,

Cite this article as: Jayakrishnan TT, Sharma S, Gulati S, Pandey RM,
Maathuis KG. Reliability of popliteal angle measurement: A study
Wadhwa S, Paul VK. Agreement between visual and goniometric assessments
in cerebral palsy patients and healthy controls. J Pediatr Orthop of adductor and popliteal angles in infants. J Pediatr Neurosci 2013;8:93-6.
2007;27:648‑52.
Source of Support: TJ received a “Short Term Studentship”
9. Bland JM, Altman DG. Statistical methods for assessing
(STS) research grant from the Indian Council of Medical Research
agreement between two methods of clinical measurement. Lancet
(ICMR) for the study. Conflict of Interest: None declared.
1986;1:307‑10.

Author Help: Reference checking facility

The manuscript system (www.journalonweb.com) allows the authors to check and verify the accuracy and style of references. The tool checks
the references with PubMed as per a predefined style. Authors are encouraged to use this facility, before submitting articles to the journal.
• The style as well as bibliographic elements should be 100% accurate, to help get the references verified from the system. Even a
single spelling error or addition of issue number/month of publication will lead to an error when verifying the reference.
• Example of a correct style
Sheahan P, O’leary G, Lee G, Fitzgibbon J. Cystic cervical metastases: Incidence and diagnosis using fine needle aspiration biopsy.
Otolaryngol Head Neck Surg 2002;127:294-8.
• Only the references from journals indexed in PubMed will be checked.
• Enter each reference in new line, without a serial number.
• Add up to a maximum of 15 references at a time.
• If the reference is correct for its bibliographic elements and punctuations, it will be shown as CORRECT and a link to the correct
article in PubMed will be given.
• If any of the bibliographic elements are missing, incorrect or extra (such as issue number), it will be shown as INCORRECT and link to
possible articles in PubMed will be given.

96 / Journal of Pediatric Neurosciences / Volume 8 / May-Aug / 2013

View publication stats