SPINE Volume 26, Number 1, pp 53– 60
©2001, Lippincott Williams & Wilkins, Inc.
Range of Motion and Lordosis of the Lumbar Spine
Reliability of Measurement and Normative Values
Joseph K.-F. Ng, MPhtySt,* Vaughan Kippers, PhD,† Carolyn A. Richardson, PhD,‡ and
Mohamad Parnianpour, PhD§
Study Design. Repeated measures for intratester reli-
ability were performed.
Objectives. To investigate the intratester reliability of a
new measurement technique that evaluates lumbar range
of motion in three planes using a pelvic restraint device,
and to examine the reliability of lumbar lordosis measure-
ment by inclinometer technique. Preliminary normative
data on lumbar range of motion and lumbar lordosis were
collected for comparison with the findings of previous
studies.
Summary of Background Data. Various noninvasive
measurement methods have been developed for record-
ing lumbar range of motion. However, pelvic movement
was not effectively restricted during the use of these mea-
surement techniques. The use of the pelvic restraint de-
vice to measure lumbar range of motion has not been
investigated previously. Very few studies have investi-
gated the reliability of quantifying lumbar lordosis by the
inclinometer technique.
Methods. Normative values were measured in 35
healthy men, and 12 of these subjects were included for
the reliability study. Pelvic motion was limited by the
pelvic restraint device during lumbar range of motion
measurement in standing. An inclinometer was used for
evaluation of lumbar flexion, extension, lateral flexion,
and lumbar lordosis, whereas a lumbar rotameter was
used to measure axial rotation.
Results. Good intratester reliability was shown in the
lumbar range of motion and lordosis measurement. Most
of the intraclass correlation coefficient and Pearson’s r
values (accompanied with nonsignificant paired t tests)
were greater than 0.9, and most of the intrasubject coef-
ficients of variation were less than 10%. The values of
lumbar range of motion in three planes and lumbar lor-
dosis found in the current study were comparable with
those from most of the previous studies on these mea-
surements in the normal population.
Conclusions. Inclinometer and lumbar rotameter mea-
surements with the use of a pelvic restraint device are
reliable for measuring lumbar spine range of motion. Use
of the inclinometer technique to record lumbar lordosis
also is a reliable measure. [Key words: impairment, inclino-
meter, lordosis, lumbar spine, range of motion, reliability]
Spine 2001;26:53– 60
From the *Departments of Physiotherapy and Anatomical Sciences,
University of Queensland, Australia, the †Department of Anatomical Sci-
ences, University of Queensland, Australia, the ‡Department of Physio-
therapy, University of Queensland, Australia, and §Department of Indus-
trial, Welding, and Systems Engineering, Ohio State University,
Columbus, Ohio.
Supported by the Dorothy Hopkins Award for Clinical Study.
Acknowledgment date: October 21, 1999.
First revision date: December 15, 1999.
Second revision date: January 31, 2000.
Acceptance date: March 31, 2000.
Device status category: 1.
Conflict of interest category: 15.
Joint range of motion (ROM) measurement is used com-
monly to document the impairment level. Because of the
complexity in movement of the spine, as compared with
movement of the peripheral joints, various measurement
strategies have been developed.39 The movement of ver-
tebrae can be measured more accurately through roent-
genographic studies, but the invasiveness and risk of ra-
diation preclude the use of the radiograph as a routine
measurement method in clinical practice. External mea-
surements of spinal ROM are now commonly used be-
cause they are easy to apply and noninvasive. It has been
demonstrated that external measurement may not reflect
the true intervertebral movement because of skin move-
ment error,43 but it can be taken as an index of back
movement.
One traditional external measurement method for
evaluating flexion of the lumbar spine is to measure the
distance from the fingertip to the floor. The contribution
of hip movement in the fingertip-to-floor test has not
been taken into account,15,44 thus making the test only a
gross measurement of the lumbar flexion. The modified
Schöber technique,22 which measures the change in dis-
tance between two skin markings over the lumbar spine,
also is prone to errors.33,45 This technique can measure
only lower lumbar levels and may not reflect the whole
lumbar spine.33 The more appropriate method for mea-
suring lumbar flexion is the inclinometer technique rec-
ommended by the American Medical Association.2 The
inclinometer technique can record regional movement of
the lumbar spine rather than the combined movement of
the spine and hip.6 This technique has been proved to
correlate well with measurements taken from a radio-
graph.1,26,34,47
The inclinometer technique also can be applied to the
measurement of lumbar spine extension.2 Although the
inclinometer technique was found to be valid and reli-
able, the procedure used for measuring extension had to
be refined.47 As reported in the literature, extension in
standing is uncomfortable, and the subject may find it
difficult to maintain balance.7,45 Strategies that could
help the subject to maintain the extension position
would be useful in refining the inclinometer measure-
ment technique.
Lateral flexion ROM has been found to be a good
indicator of the degree of low back pain32 and disabili-
ty.53 The common method of measurement is to record
the distance between the fingertip and the floor during
lateral flexion, but this estimates the flexibility of the
whole spine rather than only the lumbar spine. The re-
53
54 Spine • Volume 26 • Number 1 • 2001

gional lumbar spine movement in lateral flexion can be

measured by the inclinometer technique.2 In clinical ob-
servations, subjects commonly lift one foot, which is de-
scribed as heel lifting by Dillard et al,7 or bend the knees
during the lateral flexion movements. In this regard, sub-
jects usually are reminded to maintain their feet on the
floor3,34,53 and keep their knees straight3,19 during mea-
surement.
Axial rotation of the trunk commonly is measured by
goniometric methods that include movement of both
thoracic and lumbar spines.19,38 Several attempts have
been made to measure the regional lumbar axial rota-
tion. Using the inclinometer technique, Loebl21 mea-
sured the axial rotation of the lumbar spine by placing
the subject in a side-lying position with the hip and knee
flexed to a 90° angle and the shoulders rotated to the
prone position. Twomey and Taylor52 and Mellin29
measured the axial rotation of the lumbar levels with the
subject in a sitting position using a lumbar rotameter and
a compass, respectively. Keeley et al18 measured the axial
rotation using an inclinometer technique with the subject
standing with the trunk flexed in a 90° angle. A common
feature of all these measuring methods is that the trunk is
positioned in flexion so as to minimize pelvic movement.
At this writing, only a limited number of investiga-
tions have been made into noninvasive measurements of
lumbar axial rotation in erect standing. Sophisticated
equipment such as an electromagnetic device42 and the
computerized triaxial potentiometric system9 have been
used to measure lumbar axial rotation in standing. These
instruments may not be suitable for clinical use because
of the cost and difficulty in application. Inasmuch as
many patients may not be able to tolerate lumbar flexion
because of pain (especially in the acute stage), a simple
measuring device that can measure trunk axial rotation
in the standing position would be worthwhile. Figure 1. Subject standing in a metal frame with the pelvis stabi-
lized by a pelvic restraint device.
The aim of the present study was to examine the in-
tratester reliability of the measurement technique that
evaluates lumbar ROM (LROM) in three planes with the Experimental Procedure. All procedures, including the reli-
adoption of a pelvic restraint device. The inclinometer ability testing, were performed by one tester. A custom-built
pelvic restraint device was used in the current study (Figure 1).
technique has been used to measure lumbar lordosis for
A metal frame was built with four poles around a wooden base,
some time, but reports on its reliability are scarce. For on which the participant stood. The movement of the pelvis
this reason, reliability in measuring lumbar lordosis also was restrained by two bars, one placed in front and the other
was evaluated in the current study. In addition, prelimi- behind. The bar in front was placed just below the anterior
nary normative data on LROM and lumbar lordosis in superior iliac spine (ASIS), and the bar behind was placed be-
healthy subjects were collected so that comparison with low the posterior superior iliac spine (PSIS). The force of the
the findings of previous studies could be performed. fixation was adjusted without undue discomfort.
Surface bony landmarks were found with the participant in
the prone position, and L5 was located by palpating interven-
Methods
ing vertebrae from S2, which is at the level of PSIS, and by
Participants. For this study, 35 healthy men without any his- checking to make sure that the iliac crest was aligned at ap-
tory of back pain were recruited to participate. They had a proximately L4 –L5. In the same manner, T12 was found by
mean age of 29.9 ⫾ 7.3 years, a mean height of 1.7 ⫾ 0.1 m, palpating intervening vertebrae up from S2 and checked by
and a mean weight of 66.9 ⫾ 10.0 kg. Of the 35 participants, palpating intervening vertebrae downward from T7, which is
12 agreed to return at least 3 days after the first measurement to at the level of inferior angle of scapula. The T12–L1 and L5–S1
perform the repeat measurement for the reliability testing. This interspinous spaces were marked on the skin. The participant
study was approved by the Medical Research Ethics Commit- then was asked to do a warmup procedure, which involved
tee of The University of Queensland. All participants gave their trunk flexion, extension, lateral flexion, and axial rotation on
written consent to participate. both sides.
 Reliability of Lumbar ROM and Lordosis Measurement • Ng et al 55
Figure 2. Modified inclinometer apparatus for the measurement of lateral flexion range of motion (A and B).
Flexion and Extension. The inclinometer technique de-
scribed by Mayer et al26 was adopted for measuring the flexion
and extension ROM of the lumbar spine. The advantage of the
inclinometer technique is that both lumbar and pelvic move-
ment during flexion and extension are taken into consider-
ation. The angle of the tangent at a particular point with regard
to the vertical was recorded from the inclinometer. The sub-
traction of the measurement at L5–S1 (reflecting the pelvic
movement) from the measurement at T12–L1 (reflecting
both lumbar and pelvic movement) gives the regional lumbar
motion.
The participant stood inside the pelvic restraint device with
his feet about shoulder width apart. The pelvis was restrained
by the bars in front and behind. An inclinometer (BASELINE
Gravity Inclinometer, Fabrication Enterprises Inc., Irvington,
NY) with two-point contact at its base was used in the current
study. The participants was asked first to stand in his usual,
relaxed posture. The baseline inclinometer values were re-
corded at T12–L1 and L5–S1. Thereafter, the participant was
asked to bend forward and then backward to the end of his
active range with maximal effort. The readings at T12–L1 and
L5–S1 were measured in the maximum flexed and extended
positions.
Lateral Flexion. A modified inclinometer apparatus (Figure 2)
similar to that developed by Mellin28 was designed in the cur-
rent study to measure the lateral flexion of the lumbar spine.
The apparatus included a base with two-point contact and a
protractor on a joint. The inclinometer, positioned in the coro-
nal plane, was attached to the protractor. The hinged device
was to accommodate the posterior incline of T12–L1 so that
the inclinometer could be maintained in a vertical position. The
vertical position was maintained by checking the spirit level
attached at right angles to the inclinometer. The participant
then was placed in the pelvic restraint device, which controlled
the pelvic movement, as described in the preceding section. The
baseline measure of the inclinometer reading at T12–L1 was
recorded. The participant then was requested to do the side
bending of the trunk to both sides as far as possible without any
noticeable flexion– extension and axial rotation. The reading at
T12–L1 was recorded again from the inclinometer at the end
range of lateral flexion.
Axial Rotation. A lumbar rotameter devised by Twomey
and Taylor52 was used to measure regional lumbar axial rota-
tion in the current study. A belt was attached around the trunk
with the pointer at T12–L1. The protractor was placed under
the pointer, with the base of the protractor aligned parallel with
the coronal plane. As with the flexion– extension and lateral
flexion measurements described in preceding sections, the par-
ticipants were placed in the standing position with the pelvic
restraint device, which limited the pelvic rotation. With their arms
positioned across the chest, participants were asked to turn to the
right and to the left sides to the end of their active range using
maximal effort. The axial rotation ROM was read from the de-
flection of the pointer on the protractor. The participant was cor-
rected if there was observable flexion, extension, or lateral flexion
accompanied by axial rotation movement.
Lumbar Lordosis. Without the pelvic restraint device, the
participant was asked to stand in a relaxed posture with
the heels about shoulder width apart, hands hanging freely
by the side and eyes looking forward. The lumbar lordosis was
measured with inclinometer recordings at T12–L1 and L5–S1.
Statistical Analysis. To enable comparison with previous
studies, the intratester reliability for measurement of the
LROM and lordosis were examined using Pearson product–
moment correlation coefficients (Pearson’s r), paired t tests, and
a one-way analysis of variance (ANOVA). Intrasubject coeffi-
cient of variation (CVintra) and intraclass correlation coefficient
(ICC) were calculated from the ANOVA. The CVintra refers to
the root mean square error across trials as a percentage of the
mean of all observations.20 The ICC refers to the between vari-
ance divided by the total variance.49
The means and standard deviations of LROM in three
planes (flexion– extension, lateral flexion, and axial rotation)
and the lumbar lordosis were calculated. To compare the right
56 Spine • Volume 26 • Number 1 • 2001

Table 1. Various Reliability Measures for the Evaluation of Lumbar Range of Motion (LROM) and Lumbar Lordosis (n ⴝ 12)
ICC CVintra (%) Pearson’s r t*

Flexion 0.87 5.5 0.87 0.07†

Extension 0.92 14.2 0.92 ⫺0.79†
Sagittal plane (flexion and extension) 0.92 4.4 0.92 ⫺0.57†
Right lateral flexion 0.96 3.0 0.96 0.94†
Left lateral flexion 0.92 4.2 0.94 ⫺0.48†
Coronal plane (lateral flexion) 0.95 3.2 0.96 0.10†
Right axial rotation 0.96 5.5 0.96 0.22†
Left axial rotation 0.95 6.7 0.94 0.09†
Transverse plane (axial rotation) 0.96 5.2 0.96 0.17†
Lumbar lordosis 0.95 6.6 0.95 ⫺0.49†
* Paired t test, df ⫽ 11.
† P ⬎ 0.05.
ICC ⫽ intraclass correlation coefficient, CVintra ⫽ intrasubject coefficient of variation.

and left sides for lateral flexion and axial rotation, paired t tests 0.86, CV ⫽ 6.4% 28 ; CV ⫽ 13.4% 31 ; CV ⫽ 9.3–
were applied. 33.9%12; Pearson’s r ⫽ 0.797; ICC ⫽ 0.8919; ICC ⫽
Results 0.70 – 0.8646; Pearson’s r ⫽ 0.13– 0.8755) to good reli-
ability (Pearson’s r ⫽ 0.90 – 0.9618; Pearson’s r ⫽ 0.92,
The intratester reliability of the LROM in three planes CV ⫽ 5.1%8; Pearson’s r ⫽ 0.90, ICC ⫽ 0.90).36 The
and lumbar lordosis is shown in Table 1. Good reliability current study recorded a moderate to good reliability
was shown for all the measures, with most ICC and Pear- (Pearson’s r ⫽ 0.87, CVintra ⫽ 5.5%, ICC ⫽ 0.87), which
son’s r values (accompanied with nonsignificant paired t is comparable with that of previous studies.
tests) greater than 0.9 and most CVintra values less than Although the pelvic movement was limited by the re-
10%. The means and standard deviations for the incli- straint device in the current study, values of LROM flex-
nometer measurements of LROM in three planes and ion (52°) were found to be similar to corresponding val-
lordosis are presented in Table 2. No significant differ- ues in various previous studies, which ranged from 42° to
ences were demonstrated in axial rotation and lateral 65°.7,8,18,19,23,25,26,28,43,53 The pelvic restriction during
flexion between right and left sides. trunk flexion may be advantageous considering that
Discussion there is some correlation between flexibility of ham-
strings and lumbar flexion.27 Gajdosik et al11 demon-
Reliability of the proposed new measurement technique strated that hamstring tightness would affect both
for ROM and lordosis of the lumbar spine needed to be LROM and pelvic movement during trunk flexion. In
established before the technique could be adopted for this context, a method that could limit pelvic movement
clinical use. Intratester reliability was the focus of the during trunk flexion and thereby limit the influence of
current study. In addition, the quantified normative data hamstring flexibility may be warranted.
were compared with those from similar studies in the
literature for better evaluation of the proposed new mea- Extension
surement technique. The current study recorded a good intratester reliability
To demonstrate the validity of external measurement (Pearson’s r ⫽ 0.92, CVintra ⫽ 14.2%, ICC ⫽ 0.92) in the
methods in the current study, it would be best to com- extension ROM measurement. Mixed levels of intrat-
pare them with the roentgenographic measurements. ester reliability were demonstrated among previous stud-
However, few studies reported in the literature directly
compare external measurement with radiograph find- Table 2. Normative Values of Lumbar Range of Motion
ings, and their findings are not consistent. Both good (LROM) in Three Planes and Lumbar Lordosis (n ⴝ 35)
correlation1,26,34,47 and low correlation6,43 have been re-
ported. Furthermore, findings shown in radiograph stud- Mean (°) t*
ies measuring ROM and lordosis of the lumbar spine are
Flexion 52 ⫾ 9
variable.37,51 Because of these inconsistencies, compari- Extension 19 ⫾ 9
son of previously reported radiograph findings with the Sagittal plane (flexion and extension) 71 ⫾ 12
current data is beyond the scope of this article. Right lateral flexion 31 ⫾ 6 1.47†
Left lateral flexion 30 ⫾ 6
Flexion Coronal plane (lateral flexion) 60 ⫾ 11
Right axial rotation 32 ⫾ 9 ⫺1.74†
A number of previous studies7,8,12,18,19,28,31,36,43,46,55 Left axial rotation 33 ⫾ 9
have examined the intratester reliability of the inclinom- Transverse plane (axial rotation) 65 ⫾ 17
eter used to measure flexion of the lumbar spine. Various Lumbar lordosis 24 ⫾ 8
levels of reliability were found in these studies ranging * Paired t test, df ⫽ 34.
† P ⬎ 0.05.
from moderate reliability (CV ⫽ 16.4%43; Pearson’s r ⫽
 Reliability of Lumbar ROM and Lordosis Measurement • Ng et al 57
ies that evaluated lumbar extension using inclinometer
measurement. Most of the previous studies showed ei-
ther moderate intratester reliability (CV ⫽ 15.7%43;
ICC ⫽ 0.8219; Pearson’s r ⫽ 0.28 – 0.6655; Pearson’s r ⫽
0.71, ICC ⫽ 0.7036) or good intratester reliability (Pear-
son’s r ⫽ 0.90 – 0.9618; Pearson’s r ⫽ 0.93, CV ⫽ 3%28;
CV ⫽ 3.6 – 4.7%12; Pearson’s r ⫽ 0.94, CV ⫽ 18.1%).8
Poor reliability was demonstrated in two previous stud-
ies: Pearson’s r was found to be 0.27 in the study of
Dillard et al,7 and a CV of 50.7% was shown in the study
of Merritt et al.31
It is interesting to note that high ICC values are not
necessarily equal to low CV values, a fact that also has
been observed in previous studies.24,35 Therefore, cau-
tion should be exercised in the interpretation of the data
values. It has been suggested that CV is more a measure
of precision than of reliability.20 Because ICC measures
the degree of agreement in addition to the association
between the two variables, it may be regarded as a more
appropriate reliability test.20
The mean LROM in extension (19°) found in the cur-
rent study was similar to that found in other previous
studies, in which the extension range varied from 12° to
29°.7,8,18,19,23,25,26,28,43 Many reasons have been put
forward to explain why extension may be difficult to
measure. Extension is an awkward, uncomfortable posi-
tion,7,45,47 which makes it difficult for the subject to
maintain balance during extension.7,45 In addition, there
are also difficulties in measurement.10 For example, tis-
sue bunching at T12–L1 would affect the placement of
the inclinometer.7
There have been attempts to make the measure of
extension easier by stabilizing the pelvis or by helping the
subject to maintain balance during extension. Klein et
al19 asked subjects to stabilize the pelvis by placing their
hands over the posterior ilia. Newton and Waddell34 and
Waddell et al53 reported that the examiner helped to
maintain the subject’s balance by supporting the sub-
ject’s shoulder with one hand during the measurement.
Because it was a common finding that subjects could
easily bend the knees during trunk extension, they usu-
ally were reminded to keep their knees straight during
the extension movement.10,18,47 According to the obser-
vation of the current authors, the pelvic restraint device
in the current study helped to limit pelvic movement and
offered support for the participants. This may have
helped the participants to maintain their balance during
extension, also making it more difficult for them to bend
their knees during the measurement.
Lateral Flexion
Several previous studies7,8,28,36,45 have examined the re-
liability of measuring lateral flexion of the lumbar spine
using the inclinometer technique with no attempt to sta-
bilize the pelvis. Various levels of intratester reliability
were found in these studies, ranging from moderate reli-
ability (CV ⫽ 20 –25%45; Pearson’s r ⫽ 0.6 – 0.85, CV ⫽
8.6 –18.7%28; Pearson’s r ⫽ 0.667) to good reliability
(Pearson’s r ⫽ 0.93, CV ⫽ 7%8; Pearson’s r ⫽ 0.89 –
0.90, ICC ⫽ 0.89 – 0.90).36 Compared with previous
studies, the current study recorded a higher reliability
(Pearson’s r ⫽ 0.96, CVintra ⫽ 3.2%, ICC ⫽ 0.95). This
may result from the stabilization device adopted in the
current study.
Only a few studies in the literature have measured the
regional lateral flexion of lumbar spine. Mellin28 and
Mellin et al30 found that the range of total lateral flexion
on both sides ranged from 47° to 53°, which is different
from the mean degree of lateral flexion in the current
study (60°). This could be attributed to the difference in
the level at which the measurement was taken. In the
studies of Mellin28 and Mellin et al,30 the measurement
was taken on a line 20 cm above PSIS. In the current
study, measurements were made at T12–L1.
Varied results have been shown in previous studies
using T12–L1 as the reference point for measuring lat-
eral flexion of the lumbar spine. The range of total lateral
flexion on both sides from T12–L1 to L5–S1 was 49°,25
56°,8 58°,53 and approximately 71° to 77°.7 The results
of the current study were shown to lie within the range of
values from these four previous studies. There was no
attempt to stabilize the pelvis in any of the previous stud-
ies, whereas in the current study, the pelvis was stabilized
by the pelvic restraint device.
Although most of the participants in the current study
were right-hand dominant, no difference in ROM be-
tween right and left lateral flexion was found. A similar
range of lateral flexion between right and left sides also
was found in other studies.7,8 Dopf et al8 have shown
that hand dominance does not affect the ROM for lateral
flexion of the lumbar spine.
Axial Rotation
Three previous studies7,8,29 have evaluated the intrat-
ester reliability of measuring axial rotation ROM of the
lumbar spine. Mellin29 measured the lumbar axial rota-
tion range in sitting with a compass and found a moder-
ate intratester reliability (Pearson’s r ⫽ 0.7– 0.82). Dil-
lard et al7 measured the axial rotation range with a
compass in a standing position and found that the intrat-
ester reliability was poor (Pearson’s r ⫽ 0.47). Dopf et
al,8 using an inclinometer technique to measure trunk
axial rotation in stooping, recorded a nearly good reli-
ability (Pearson’s r ⫽ 0.89, CV ⫽ 15.6%). A better in-
tratester reliability (Pearson’s r ⫽ 0.96, CVintra ⫽ 5.2%,
ICC ⫽ 0.96) was demonstrated in the current study than
in those three previous studies. This may be attributed to
the stabilization device in the current study, which could
limit the pelvic movement sufficiently during axial rota-
tion in standing. In the study of Dillard et al,7 the pelvic
movement was controlled only by asking the subjects not
to move their pelvis. This poor pelvic stabilization strat-
egy may partly explain the unsatisfactory intratester re-
liability shown in the study of Dillard et al.7
A wide range of axial rotation ROM of the lumbar
spine measured by the noninvasive techniques have been
58 Spine • Volume 26 • Number 1 • 2001

Table 3. Summary of Previous Studies Measuring the Range of Motion (ROM) of Lumbar Spine in Axial Rotation
Measurement Axial Rotation
Researchers Technique Measurement Level Position ROM (°)

Loebl21 Inclinometer L1–L5 Side-lying with hip flexed 90° 25

Taylor and Twomey50 Lumbar rotameter L1–L5 Sitting 26–33
Keeley et al18 Inclinometer L1–L5 Stooping 21
29
Mellin Compass Approximately T10–L5 Sitting 73
Dillard et al7 Compass Approximately T10–L5 Standing 54–58
Boline et al5 Inclinometer L1–L5 Stooping 11
Dopf et al8 Inclinometer L1–L5 Stooping 13

found in previous studies (Table 3). These include mea- has been found in other studies.7,8,18,29 Dopf et al8 have
sures of 11°,5 13°,8 21°,18 25°,21 and 26° to 33°50 to an shown that hand dominance does not affect the ROM for
upper range of 73°.29 These large variations may be axial rotation of the lumbar spine.
caused by different positions of the spine during axial
Lumbar Lordosis
rotation ROM measurement, and also by the levels at
Good intratester reliability in lordosis measurement
which the measurements were taken. It can be seen from
(Pearson’s r ⫽ 0.95, CVintra ⫽ 6.6%, ICC ⫽ 0.95) was
Table 3 that the axial rotation ROM measured in stoop-
shown in the current study, which is comparable with
ing was less than that measured in sitting. Similar find-
that found in one previous study. Mellin28 also demon-
ings also were shown in a previous study41 that com-
strated good reliability (Pearson’s r ⫽ 0.94, CV ⫽ 7.7%)
pared axial rotation range in stooping with that in
in using an inclinometer to measure lumbar lordosis.
sitting. This has been attributed to the active contraction
Very few previous studies use an inclinometer to mea-
of the back muscles required to maintain the stooping
sure lumbar lordosis. Mellin28 and Waddell et al53 used
posture that also may restrict the axial rotation of the
the inclinometer and found that the lordosis was 23° and
spine.41
25°, respectively, in a mixed group of men and women,
It is difficult to compare the findings of the current
which was similar to the results (24°) in the current
study with those from the aforementioned studies re-
study. Because research findings on inclinometer use are
garding axial rotation range. In these studies, the lumbar
lacking in the literature, it is of interest to compare other
spine was placed in a flexed position (stooping and sit-
valid external measuring tools that have been used to
ting), whereas the current study used a neutral position
record lordosis in angular values with the inclinometer
(standing). It has been shown that the difference may be
used in the current study. Similar values of lordosis also
either a decrease8,13,14 or an increase16,41 in axial rota-
have been shown in these studies. Bergenudd et al,4 using
tion ROM with a flexed lumbar spine as compared with
a spinal pantograph, recorded a 28° angle for the lordo-
a neutral lumbar spine.
sis in healthy men. A Debrunner kyphometer was used
In measuring the axial rotation LROM in standing,
by Hultman et al,17 and it was found that the lordosis
expensive and sophisticated equipment such as an elec-
from T12 to L5–S1 was 27° in healthy male subjects.
tromagnetic device and the computerized triaxial poten-
Schenkman et al48 also adopted the Debrunner kyphom-
tiometric system was used, but significant skin move-
eter to measure lordosis and recorded a higher value of
ment was noted during axial rotation measurement.9,42
33°. This evaluation, however, was performed on a
To the best of the authors’ knowledge, there is only one
mixed group of men and women subjects and recorded
other study in the literature that used a simple clinical
results from T11–T12 to S1–S2.
device, a compass, to measure the axial rotation range in
standing. Dillard et al7 found that the axial rotation Limitations of Study
ROM from T10 to L5 was approximately 54° to 58° The inclinometer and rotameter measurement adopted
which is slightly different that found in the current study in the current study measured mainly the static end range
(65°). This can be attributed to the difference in stabili- of the lumbar spine, which the participant can actively
zation methods between the two studies. In Dillard et attain. Coupling movement40 of the spine during the
al’s7 study, the subjects, not having any external stabili- movement cannot be quantified, and movement changes
zation device, were instructed not to move the pelvis in a single segmental level54 of the spine cannot be re-
during the axial rotation measurement. This may not be corded. In addition, the reliability among different testers
sufficient stabilization for a subject with a stiff spine be- (intertester reliability) may need to be determined before
cause it may be difficult to perform a maximum range of this new measurement technique can be accepted for
axial rotation without moving the pelvis. clinical use.
As with the measurement of lateral flexion ROM,
Conclusions
there was no difference in ROM of axial rotation be-
tween right and left sides in the current study. Similar The current study described a new measurement method
axial rotation LROM between right and left sides also that used the pelvic restraint device in combination with
 Reliability of Lumbar ROM and Lordosis Measurement • Ng et al 59
an inclinometer or a lumbar rotameter to measure flex-
ion, extension, lateral flexion, and axial rotation of the
lumbar spine. The main advantage in using the pelvic
restraint device for LROM measurement is to limit pelvic
motion and other unnecessary movements. The intrat-
ester reliability of the new measurement method was
found to be good, and in some instances better than that
demonstrated in previous studies. The lordosis measure-
ment using an inclinometer technique also was reliable.
The values of ROM in three planes and the lordosis
found in the current study were comparable to most of
the previous findings. Considering the good reliability of
this new measurement method, further studies are war-
ranted to investigate its clinical application.
Key Points
● Good intratester reliability was shown for a new
measurement method that uses the pelvic restraint
device in combination with an inclinometer or a
lumbar rotameter to measure flexion, extension,
lateral flexion, and axial rotation of the lumbar
spine.
● The main advantage in using the pelvic restraint
device for spinal range of motion measurement is
limitation of pelvic motion and other unnecessary
movements.
● The lordosis measurement using an inclinometer
technique also was shown to be reliable.
● The values of lumbar range of motion in the
three planes and in lumbar lordosis found in the
current study were comparable to the values re-
ported in previous studies.
● Considering the good reliability of this new mea-
surement method, further studies are warranted to
investigate its clinical application.
References
1. Adams MA, Dolan P, Marx C, et al. An electronic inclinometer technique for
measuring lumbar curvature. Clin Biomech 1986;1:130 – 4.
2. American Medical Association. Guides to the Evaluation of Permanent Im-
pairment. 4th ed. Chicago: American Medical Association, 1993.
3. Battié MC, Bigos SJ, Sheehy A, et al. Spinal flexibility and individual factors
that influence it. Phys Ther 1987;67:653– 8.
4. Bergenudd H, Nilsson B, Udén A, et al. Bone mineral content, gender, body
posture, and build in relation to back pain in middle age. Spine 1989;14:577–9.
5. Boline PD, Keating JC Jr, Haas M, et al. Interexaminer reliability and dis-
criminant validity of inclinometric measurement of lumbar rotation in chronic
low back pain patients and subjects without low back pain. Spine 1992;17:
335– 8.
6. Burdett RG, Brown KE, Fall MP. Reliability and validity of four instruments
for measuring lumbar spine and pelvic positions. Phys Ther 1986;66:677– 84.
7. Dillard J, Trafimow J, Andersson GBJ, et al. Motion of the lumbar spine:
Reliability of two measurement techniques. Spine 1991;16:321– 4.
8. Dopf CA, Mandel SS, Geiger DF, et al. Analysis of spine motion variability
using a computerized goniometer compared to physical examination: A prospec-
tive clinical study. Spine 1994;19:586 –95.
9. Dvorák J, Vajda EG, Grob D, et al. Normal motion of the lumbar spine as
related to age and gender. Eur Spine J 1995;4:18 –23.
10. Ensink F-BM, Saur PMM, Frese K, et al. Lumbar range of motion: Influence
of time of day and individual factors on measurements. Spine 1996;21:1339 – 43.
11. Gajdosik RL, Albert CR, Mitman JJ. Influence of hamstring length on the
standing position and flexion range of motion of the pelvic angle, lumbar angle,
and thoracic angle. J Orthop Sports Phys Ther 1994;20:213–19.
12. Gill K, Krag MH, Johnson GB, et al. Repeatability of four clinical methods
for assessment of lumbar spinal motion. Spine 1988;13:50 –3.
13. Gregersen GG, Lucas DB. An in vivo study of the axial rotation of the human
thoracolumbar spine. J Bone Joint Surg [Am] 1967;49:247– 62.
14. Gunzburg R, Hutton W, Fraser R. Axial rotation of the lumbar spine and the
effect of flexion. An in vitro and in vivo biomechanical study. Spine 1991;16:
22– 8.
15. Helliwell P, Moll J, Wright V. Measurement of spinal movement and func-
tion. In: Jayson MIV, ed. The Lumbar Spine and Back Pain. 4th ed. Edinburgh:
Churchill Livingstone, 1992:173–205.
16. Hindle RJ, Pearcy MJ. Rotational mobility of the human back in forward
flexion. J Biomed Eng 1989;11:219 –23.
17. Hultman G, Saraste H, Ohlsen H. Anthropometry, spinal canal width, and
flexibility of the spine and hamstring muscles in 45- to 55-year-old men with and
without low back pain. J Spinal Disord 1992;5:245–53.
18. Keeley J, Mayer TG, Cox R, et al. Quantification of lumbar function: Part 5.
Reliability of range-of-motion measures in the sagittal plane and an in vivo torso
rotation measurement technique. Spine 1986;11:31–5.
19. Klein AB, Snyder-Mackler L, Roy SH, et al. Comparison of spinal mobility
and isometric trunk extensor forces with electromyographic spectral analysis in
identifying low back pain. Phys Ther 1991;71:445–54.
20. Knutson LM, Soderberg GL, Ballantyne BT, et al. A study of various nor-
malization procedures for within day electromyographic data. J Electromyogr
Kinesiol 1994;4:47–59.
21. Loebl WY. Regional rotation of the spine. Rheumatol Rehabil 1973;12:223.
22. Macrae IF, Wright V. Measurement of back movement. Ann Rheum Dis
1969;28:584 –9.
23. Mandell PJ, Weitz E, Bernstein JI, et al. Isokinetic trunk strength and lifting
strength measures: Differences and similarities between low-back-injured and
noninjured workers. Spine 1993;18:2491–501.
24. Mannion AF, Dolan P. Electromyographic median frequency changes during
isometric contraction of the back extensors to fatigue. Spine 1994;19:1223–9.
25. Mayer T, Gatchel RJ, Keeley J, et al. A male incumbent worker industrial
database: Part I. Lumbar spinal physical capacity. Spine 1994;19:755– 61.
26. Mayer TG, Tencer AF, Kristoferson S, et al. Use of noninvasive techniques
for quantification of spinal range of motion in normal subjects and chronic low
back dysfunction patients. Spine 1984;9:588 –95.
27. Mellin G. Correlations of hip mobility with degree of back pain and lumbar
spinal mobility in chronic low back pain patients. Spine 1988;13:668 –70.
28. Mellin G. Measurement of thoracolumbar posture and mobility with a
Myrin inclinometer. Spine 1986;11:759 – 62.
29. Mellin G. Method and instrument for noninvasive measurements of thora-
columbar rotation. Spine 1987;12:28 –31.
30. Mellin G, Kiiski R, Weckström A. Effects of subject position on measure-
ments of flexion, extension, and lateral flexion of the spine. Spine 1991;16:
1108 –10.
31. Merritt JL, McLean TJ, Erickson RP, et al. Measurement of trunk flexibility
in normal subjects: Reproducibility of three clinical methods. Mayo Clin Proc
1986;61:192–7.
32. Michel A, Kohlmann T, Raspe H. The association between clinical findings
on physical examination and self-reported severity in back pain: Results of a
population-based study. Spine 1997;22:296 –304.
33. Miller SA, Mayer T, Cox R, et al. Reliability problems associated with the
modified Schöber technique for true lumbar flexion measurement. Spine 1992;
17:345– 8.
34. Newton M, Waddell G. Reliability and validity of clinical measurement of
the lumbar spine in patients with chronic low back pain. Physiotherapy 1991;77:
796 – 800.
35. Ng JK-F, Richardson CA. Reliability of electromyographic power spectral
analysis of back muscle endurance in healthy subjects. Arch Phys Med Rehabil
1996;77:259 – 64.
36. Nitschke JE, Nattrass CL, Disler PB, et al. Reliability of the American Med-
ical Association guides’ model for measuring spinal range of motion: Its implica-
tion for whole-person impairment rating. Spine 1999;24:262– 8.
37. Nordin M, Frankel VH. Basic Biomechanics of the Musculoskeletal System.
2nd ed. Philadelphia: Lea & Febiger, 1989.
38. Norkin CC, White DJ. Measurement of Joint Motion: A Guide to Goniom-
etry. Philadelphia: FA Davis Company, 1985.
39. Pearcy M. Measurement of back and spinal mobility. Clin Biomech 1986;1:
44 –51.
40. Pearcy M, Portek I, Shepherd J. The effect of low back pain on lumbar spinal
movements measured by three-dimensional x-ray analysis. Spine 1985;10:
150 –3.
41. Pearcy MJ. Twisting mobility of the human back in flexed postures. Spine
1993;18:114 –19.
60 Spine • Volume 26 • Number 1 • 2001
42. Pearcy MJ, Hindle RJ. New method for the noninvasive three-dimensional
measurement of human back movement. Clin Biomech 1989;4:73–9.
43. Portek I, Pearcy MJ, Reader GP, et al. Correlation between radiographic and
clinical measurement of lumbar spine movement. Br J Rheumatol 1983;22:197–
205.
44. Rae PS, Waddell G, Venner RM. A simple technique for measuring lumbar
spinal flexion: Its use in orthopaedic practice. J R Coll Surg Edinb 1984;29:
281– 4.
45. Reynolds PMG. Measurement of spinal mobility: A comparison of three
methods. Rheumatol Rehabil 1975;14:180 –5.
46. Rondinelli R, Murphy J, Esler A, et al. Estimation of normal lumbar flexion
with surface inclinometry: A comparison of three methods. Am J Phys Med
Rehabil 1992;71:219 –24.
47. Saur PMM, Ensink F-BM, Frese K, et al. Lumbar range of motion: Reliability
and validity of the inclinometer technique in the clinical measurement of trunk
flexibility. Spine 1996;21:1332– 8.
48. Schenkman M, Shipp KM, Chandler J, et al. Relationships between mobility
of axial structures and physical performance. Phys Ther 1996;76:276 – 85.
49. Shrout PE, Fleiss JL. Intraclass correlations: Uses in assessing rater reliability.
Psychol Bull 1979;86:420 – 8.
50. Taylor J, Twomey L. Sagittal and horizontal plane movement of the human
lumbar vertebral column in cadavers and in the living. Rheumatol Rehabil 1980;
19:223–32.
51. Troyanovich SJ, Cailliet R, Janik TJ, et al. Radiographic mensuration char-
acteristics of the sagittal lumbar spine from a normal population with a method
to synthesize prior studies of lordosis. J Spinal Disord 1997;10:380 – 6.
52. Twomey L, Taylor J. A description of two new instruments for measuring the
ranges of sagittal and horizontal plane motions in the lumbar region. Aust J
Physiother 1979;25:201–3.
53. Waddell G, Somerville D, Henderson I, et al. Objective clinical evaluation of
physical impairment in chronic low back pain. Spine 1992;17:617–28.
54. Weitz EM. The lateral bending sign. Spine 1981;6:388 –97.
55. Williams R, Binkley J, Bloch R, et al. Reliability of the modified-modified
Schöber and double inclinometer methods for measuring lumbar flexion and
extension. Phys Ther 1993;73:26 –37.
Address reprint requests to
Joseph K.-F. Ng, MPhtySt
Department of Rehabilitation Sciences
The Hong Kong Polytechnic University
Hung Hom, Hong Kong
E-mail address: rsjoseph@polyu.edu.hk