van de Pol et al: Reliability of measurement of passive joint movements

Inter-rater reliability for measurement of passive

physiological range of motion of upper extremity joints
is better if instruments are used: a systematic review
Rachel J van de Pol1, Emiel van Trijffel2 and Cees Lucas2
1
Private Practice Physiotherapy, The Hague, 2University of Amsterdam, Academic Medical Centre, Amsterdam
The Netherlands

Question: What is the inter-rater reliability for measurements of passive physiological or accessory movements in upper
extremity joints? Design: Systematic review of studies of inter-rater reliability. Participants: Individuals with and without upper
extremity disorders. Outcome measures: Range of motion and end-feel using methods feasible in clinical practice. Results:
Twenty-one studies were included of which 11 demonstrated acceptable inter-rater reliability. Two studies satisfied all criteria
for internal validity while reporting almost perfect reliability. Overall, the methodological quality of studies was poor. ICC
ranged from 0.26 (95% CI –0.01 to 0.69) for measuring the physiological range of shoulder internal rotation using vision to 0.99
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physiological range of motion using instruments were more reliable than using vision. Measurements of physiological range
of motion were also more reliable than measurements of end-feel or of accessory range of motion. Conclusions: Inter-rater
reliability for the measurement of passive movements of upper extremity joints varies with the method of measurement. In
order to make reliable decisions about joint restrictions in clinical practice, we recommend that clinicians measure passive
physiological range of motion using goniometers or inclinometers. <WBO
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reliability for measurement of passive physiological range of motion of upper extremity joints is better if instruments
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XPSET: Upper extremity; Reliability; Physical examination; Range of motion

Introduction
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Journal of Physiotherapy 2010 Vol. 56 – © Australian Physiotherapy Association 2010
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Method
Identification and selection of studies
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. Inclusion criteria
Design
š Repeated measures between raters
Participants
š Symptomatic and asymptomatic individuals
Measurement procedure
š Performed passive (ie, manual) physiological or
accessory movements in any of the joints of the
shoulder, elbow, or wrist-hand-fingers
š Reported range of motion or end-feel
š Used methods feasible in clinical practice
(considering instruments, costs, amount of training
required)
Outcomes
š Estimates of inter-rater reliability
Assessment of characteristics of the studies
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8 Journal of Physiotherapy 2010 Vol. 56 – © Australian Physiotherapy Association 2010
#PY
. Criteria for assessing methodological quality
1. Was a representative sample of participants used?
2. Was a representative sample of raters used?
3. Is replication of the measurement procedure
possible?
4. Was clinical information from participants available to
raters and comparable to clinical practice?
5. Were participants’ characteristics stable during the
study?
6. Were raters’ characteristics stable during the study?
7. Were raters blinded to each other’s results?
8. Can non-random loss to follow-up be ruled out?
9. Was an estimate of intra-rater reliability validly
determined and was it above 0.80?
10. Were appropriate measures (Kappa, ICC) used for
calculating reliability?
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Results
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Description of studies
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 van de Pol et al: Reliability of measurement of passive joint movements

Inter-rater reliability by joint

Titles and abstracts screened (n = 455)
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š EMBASE (n = 34)
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double citations (n = 429)
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Papers included in review (n = 21) gVc\ZY [gdb %#'+ .* 8> ·%#&+ id %#+- ^c [jaa h]djaYZg
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Journal of Physiotherapy 2010 Vol. 56 – © Australian Physiotherapy Association 2010 9

 Research
5BCMF
 Summary of included studies (n = 21).
10

Study Participants Raters Joints Position Movement Method Outcome Reliability

Movement performed reported statistic
direction
Awan et al n = 56 n=4 Shoulder Supine Physiological Digital ROM ICC
(2002) Age = range 13–18 yr Profession = 2 physiatrists, š?H Sh 90° Abd inclinometer
Condition = normal 1 PT, 1 resident doctor š;H Vision
Training = Y
Bovens et al n = 148 n=3 Wrist-hand- Palms together Physiological Vision ROM R
(1990) Age = mean 48 yr (SD 7) Profession = physician fingers Hands together
Condition = normal Training = Y šMh_ij<
šMh_ij;
Chesworth et al n = 34 n=2 Shoulder Supine Physiological Vision ROM ICC (2,1)
(1998) Age = mean 55 yr (SD 18.5) Fhe\[ii_ed3FJ%CJ š;H Sh 20° Abd Manual End-feel
Condition = shoulder Training = N Elbow 90° F
pathology, post-surgery
De Kraker et al n = 25 n=2 Wrist-hand- Seated Physiological Pollexograph ROM ICC
(2009) Age = mean 30 yr (SD 7) Profession = 1 HT, fingers Elbow 90° F Goniometer
1 trainee plastic and šJ^kcX7XZ
Journal of Physiotherapy 2010 Vol. 56 – © Australian Physiotherapy Association 2010

Condition = normal Wrist neutral

reconstructive surgery
Training = N
De Winter et al n = 155 n=2 Shoulder Seated Physiological Digital ROM ICC
(2004) Age = mean 47 yr (SD 12.6) Profession = PT š7XZ Supine inclinometer
Condition = shoulder path Training = Y š;H
Glasgow et al n = 10 n=2 Hand-wrist- Unknown Physiological Goniometer ROM ICC (2,1)
(2003) Age = mean 39.7 yr (SD 13.5) Profession = unknown fingers
Condition = traumatic hand Training = N š?F<
injuries š?F;
šC9F<
šC9F;
šJ^kcX<
šJ^kcX;
Hayes et al n=8 n=4 Shoulder Seated Physiological Vision ROM ICC (2,1)
(2001) Age = mean 66 yr (SD 5.7) Profession = 2 PT, š<
Condition = shoulder 1 orthopaedic surgeon, š7XZ
pathology, post-surgery 1 sports physician
š;H
Training = Y
š?H
Journal of Physiotherapy 2010 Vol. 56 – © Australian Physiotherapy Association 2010

>Wo[i n = 18 n=2 Shoulder Standing (with Physiological Manual End-feel Kappa

Petersen Age = mean 34.3 yr (SD 12.9) Profession = PT š7XZ and without
(2001) scapular
Condition = shoulder pain Training = Y š;H stabilisation)
š?H
š>eh7ZZ
š<kbb7XZ
Heemskerk n = 12 n=2 Shoulder Seated Physiological Digital ROM ICC
et al Age = mean 36 yr (range Profession = PT š7XZ Supine inclinometer
(1997) 25–49) Training = N š;H
Condition = normal
Horger n = 48 n = 26 Wrist Unknown Physiological Goniometer ROM ICC (1,1)
(1990) Age = mean 38.8 yr (range Profession = 11 OT, 2 PT, š;
18–71) 6 HT, 7 non-specialised š<
Condition = wrist injuries raters
š7XZ
Training = N
š7ZZ
BWIjWoe n = 140 n = 32 Wrist Unknown Physiological Goniometer ROM ICC (2,1)
Wheeler Age = mean 41.5 yr (range Profession = 25 OT, 6 PT, š;

van de Pol et al: Reliability of measurement of passive joint movements

(1994) 6–81) 'EJ%FJ'-e\m^_Y^>J š<
Condition = wrist pathology Training = N
B_dOWd] n = 16 n=2 Shoulder Supine Physiological Inclinometer ROM ICC (3,1)
(2006) Age = mean 54.5 yr (SD 9.2) Profession = PT š>eh< Sh 90° F
Condition = shoulder stiffness Training = N š>eh; Sh 0° adduction
Scapula
stabilised
MacDermid n = 34 n=2 Shoulder Supine Physiological Goniometer ROM ICC
et al Age = mean 55 yr (SD 18) Fhe\[ii_ed3FJ%CJ š;H Sh 20° to 30°
(1999) Abd
Condition = shoulder Training = N
pathology, post-surgery Elbow 90° F
Nomden et al n = 91 n=2 Shoulder Seated Physiological Vision ROM ICC (1,1)
(2009) Age = mean 48.5 yr (SD 11.8) Fhe\[ii_ed3'FJ"'FJ% š7XZ Abd: Sh 0° Abd
Condition = shoulder MT š;H Sh ER
pathology Training = N Thumb up
ER: Sh 0° F
Elbow 90° F
FWjbWFWh_i n = 20 n=2 Elbow Standing Physiological Goniometer ROM Kappa
(1993) Age = ? Profession = PT š; Sh 20° Abd Manual End-feel
Condition = normal, elbow Training = Y š< Elbow 20° F
pathology
11
 Research
12

Study Participants Raters Joints Position Movement Method Outcome Reliability

Movement performed reported statistic
direction
Riddle et al n = 50 n = 16 Shoulder Supine Physiological Goniometer ROM ICC (1,1)
(1987) Age = mean 48.6 yr (SD 14.4) Profession = PT š< Prone
Condition = shoulder Training = N š; Seated
pathology š7XZ Side lying
š>eh7XZ Standing
š>eh7ZZ
š;H
š?H
Rothstein et al n = 12 n = 12 Elbow Unknown Physiological Goniometer ROM ICC
(1983) Age = ? Profession = PT š;
Condition = elbow pathology Training = N š<
Staes et al n = 30, 15 n=2 Wrist Resting position Accessory Vision ROM Weighted
(2009) Age = mean 21.3 yr (SD 1.6), Profession = PT š>WcWj[ End-feel Kappa
mean 38.3 yr (SD 11) Training = Y šBkdWj[
Condition = normal, wrist šIYWf^e_Z
pathology
Journal of Physiotherapy 2010 Vol. 56 – © Australian Physiotherapy Association 2010

šJhWf[pe_Z
against
Capitate
Terwee et al n = 201 n=2 Shoulder Seated Physiological Vision ROM ICC (2,1)
(2005) Age = mean 48 yr (SD 12) Profession = PT š;B; Sh 0° F
Condition = shoulder Training = Y š7XZ Elbow 90°F
pathology š;H
š>eh7ZZ
Tyler et al n = 28 n=2 Shoulder Side lying Physiological Measuring ROM ICC (3,k)
(1999) Age = mean 30 yr (SD 8.9) Profession = PT š>eh< Sh 90° Abd tape
Condition = normal Training = N Scapula
stabilised
LWd:k_`d n = 18 n=6 Shoulder Supine Accessory Vision ROM ICC (2,1)
Jensen Age = mean 36.6 yr (SD 10) Profession = PT š?d\]b_Z[
(2001)
Condition = shoulder Training = N
pathology, normal
Abd = abduction, Add = adduction, ELE = elevation, ER = external rotation, E = extension, F = flexion, HT = hand therapist, Hor = horizontal, INF GL = inferior glide, IP = interphalangeal, IR = internal
rotation, MCP = metacarpophalangeal, MED = medial, MT = manual therapist, N = No, OT = occupational therapist, PT = physiotherapist, ROM = range of motion, Sh = shoulder, Y = Yes
 van de Pol et al: Reliability of measurement of passive joint movements

5BCMF
. Methodological quality of included studies by joint.

Study External validity Internal validity Statistical methods

1 2 3 4 5 6 7 8 9 10
Shoulder
Awan et al (2002) N U Y N Y U Y Y N U
Chesworth et al (1998) Y N Y Y N U Y Y N Y
De Winter et al (2004) Y U Y U Y Y U N N U
Hayes et al (2001) Y U Y U N U Y Y N Y
 >Wo[iF[j[hi[d(&&' N Y Y Y U U Y Y N U
Heemskerk et al (1997) N U N N U N Y Y N U
 B_dOWd](&&, Y U Y U U U Y Y N Y
MacDermid et al (1999) Y Y Y Y U U Y Y N U
Nomden et al (2009) Y Y Y U Y Y Y Y U Y
Riddle et al (1987) Y Y U N U U Y Y N Y
Terwee et al (2005) Y Y Y N Y U Y Y U Y
Tyler et al (1999) N U Y N Y U U Y Y Y
 LWd:k_`d@[di[d(&&' N Y Y N Y U Y Y N N
Elbow
 FWjbWFWh_i'//) N U Y U Y U U Y U Y
Rothstein et al (1983) U Y U N U U Y Y N U
Wrist-hand-fingers
Bovens et al (1990) N U Y U Y Y U Y U U
De Kraker et al (2009) N U Y U U N Y Y N U
Glasgow et al (2003) Y U Y N Y Y Y N Y Y
Horger (1990) Y Y N U U U Y Y N Y
 BWIjWoeM^[[b[h'//* Y Y Y N U U Y Y N Y
Staes et al (2009) N U Y N U Y Y N N U
U = unknown because insufficient information provided

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Journal of Physiotherapy 2010 Vol. 56 – © Australian Physiotherapy Association 2010 13

Research

Table 3. Inter-rater reliability (95% CI) for measurement of passive physiological range of motion by method of measurement,
joint and movement direction.

Method of measurement Study Inter-rater reliability

Inclinometer
Shoulder
External rotation Awan et al (2002) ICC 0.41, 0.51
De Winter et al (2004) ICC 0.90
Heemskerk et al (1997) ICC 0.81 to 0.87
Internal rotation Awan et al (2002) ICC 0.50 to 0.66
Abduction De Winter et al (2004) ICC 0.83
Heemskerk et al (1997) ICC 0.27 to 0.84
Horizontal flexion B_dOWd](&&, ICC 0.82 (0.54 to 0.94)
Horizontal extension B_dOWd](&&, ICC 0.89 (0.69 to 0.96)
Goniometer
Shoulder
External rotation MacDermid et al (1999) ICC 0.85 (0.73 to 0.91), 0.86 (0.72 to 0.92)
Riddle et al (1987) ICC 0.88, 0.90
Internal rotation Riddle et al (1987) ICC 0.43, 0.55
Abduction Riddle et al (1987) ICC 0.84, 0.87
Horizontal abduction Riddle et al (1987) ICC 0.28, 0.30
Horizontal adduction Riddle et al (1987) ICC 0.35, 0.41
Flexion Riddle et al (1987) ICC 0.87, 0.89
Extension Riddle et al (1987) ICC 0.26, 0.27
Elbow
Flexion Rothstein et al (1983) ICC 0.85 to 0.97
Extension Rothstein et al (1983) ICC 0.92 to 0.95
Wrist-hand-fingers
Wrist Flexion Horger (1990) ICC 0.86 (0.78 lower limit)
BWIjWoeM^[[b[h'//* ICC 0.88 to 0.93
Wrist Extension Horger (1990) ICC 0.84 (0.75 lower limit)
BWIjWoeM^[[b[h'//* ICC 0.80 to 0.84
Wrist Abduction Horger (1990) ICC 0.66 (0.51 lower limit)
Wrist Adduction Horger (1990) ICC 0.83 (0.74 lower limit)
Thumb abduction De Kraker et al (2009) ICC 0.37 (–0.42 to 0.79)
  <_d][h%j^kcXÆ[n_edWdZ[nj[di_ed Glasgow et al (2003) ICC 0.99 (0.98 to 1.0)
Vision
Shoulder
External rotation Chesworth et al (1998) ICC 0.83 (0.70 to 0.90), 0.90 (0.83 to 0.95)
Hayes et al (2001) ICC 0.57 (0.26 to 0.87)
Nomden et al (2009) ICC 0.70
Terwee et al (2005) ICC 0.73 (0.22 to 0.88)
Internal rotation Awan et al (2002) ICC 0.51, 0.65
Hayes et al (2001) ICC 0.26 (-0.01 to 0.69)
Abduction Hayes et al (2001) ICC 0.66 (0.37 to 0.90)
Nomden et al (2009) ICC 0.96
Terwee et al (2005) ICC 0.67 (0.35 to 0.81)
Horizontal adduction Terwee et al (2005) ICC 0.36 (0.22 to 0.48)
Flexion Hayes et al (2001) ICC 0.70 (0.42 to 0.92)
Elevation Terwee et al (2005) ICC 0.87 (0.83 to 0.90)
Wrist-hand-fingers
Wrist flexion Bovens et al (1990) r 0.59
Wrist extension Bovens et al (1990) r 0.09
Tape measure
Shoulder
External rotation Tyler et al (1999) ICC 0.80
Pollexograph
Wrist-hand-fingers
Thumb abduction De Kraker et al (2009) ICC 0.59 (0.42 to 0.89)

14 Journal of Physiotherapy 2010 Vol. 56 – © Australian Physiotherapy Association 2010

 van de Pol et al: Reliability of measurement of passive joint movements

5BCMF
. Inter-rater reliability (95% CI) for measurement of bZi]dYdad\^XVaÅVlh!Y^gZXi^dcd[g^h`d[W^Vh^hY^[ÄXjaiid

passive accessory range of motion by joint and movement
direction.
Accessory motion Study Inter-rater
reliability
Shoulder
Inferior glide LWd:k_`d ICC 0.52
Jensen (2001)
Wrist-hand-fingers
Wrist capitate Staes et al Kw 0.29 to 0.42,
(2009) 0.33 to 0.87
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Table 5. Inter-rater reliability (95% CI) for measurement of physiological end-feel by joint and movement direction.

End-feel Study Inter-rater reliability

Shoulder
External rotation Chesworth et al (1998) ICC 0.34 (0.05 to 0.57) to 0.91 (0.84 to 0.95)
>Wo[iF[j[hi[d(&&' K 0.47 (0.08 to 0.87)
Internal rotation >Wo[iF[j[hi[d(&&' K 0.41 (0.03 to 0.80)
Abduction >Wo[iF[j[hi[d(&&' K 0.70 (0.31 to 1.0)
Horizontal adduction >Wo[iF[j[hi[d(&&' K 0.40 (0.01 to 0.79)
Full abduction >Wo[iF[j[hi[d(&&' K 0.26 (–0.16 to 0.68)
Elbow
Flexion FWjbWFWh_i'//) K 0.40
Extension FWjbWFWh_i'//) K 0.73

Journal of Physiotherapy 2010 Vol. 56 – © Australian Physiotherapy Association 2010 15

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16 Journal of Physiotherapy 2010 Vol. 56 – © Australian Physiotherapy Association 2010
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