NUMBER 6 1964 Use of Noninvasive Techniques for Quantification of Spinal Range-of-Motion in Normal Subjects and Chronic Low-Back Dysfunction Patients TOM G. MAYER, MD," ALLAN F. TENCER, PhD," SANDRA KRISTOFERSON, MS, PT,t and VERT MOONEY, MD* Quantitative messures of physical function (range of motion, sirongth, stability) are crtlcal to musculoskeletal care of the extremeties, yet such objective measuresin the re currently unavailable. In this paper, the authors ‘imple, single inclinometer modification of the method of Loebl,252! which offers the opportunity to separate the components of the compound motion of hip and spine. Analysis of the motion in normal and chronle low-back pain patients allows differentiation of the ‘groups, demonstration of progress in rehabllltatio grams, determination of impairment, and provides tests of patient compliance and level of motivation. [Key words: Inclinometer, gross range of motion, true lumbar motion} public health problems facing industrialized societies today. In the United States alone, the cost of low-back pain is estimated to be as much as $14 billion, including medical costs and compensation claims, with an additional $2.5 billion in lost ‘wages, since low-back pain usually occurs in individuals during their most productive years.” The ability to determine objectively the extent and severity of physical impairment due to low-back dysfunction would appear to be of importance, yet measurement techniques for assessing musculoskeletal function in the spine are inadequate,” imprecise, and commonly not employed, Range of motion measurements are of major importance in assessing the function of peripheral joints, such as the knee. Musculoskeletal specialists employ goniometers regularly to assess progress in reconditioning, to evaluate the ability to return to work or sports, and to determine the need for surgery. Because the three-joint complex (dis, facets) of the intersegmental spinal articulatio inaccessible to simple inspection, relatively little effort has been ‘made to assess motion in making judgements concerning lumbar spine function, and, thus, little is known of the relationship of ‘motion to function. Difficulties arise because bending of the lumbar spine is a complex movement combining lumbar inter- segmental motion and hip motion. It is well known that an individual with a completely fused spine can bend forward to ouch his or her toes in the presence of good hip motion alone, L ‘ow.BACK PAIN generally is thought to be one of the major From the *Universiy of Texas Health Science Canter at Dallas andthe ‘Pain and Rehabilitation Intute of Dali, Dallas, Texas, ‘Submited for publeation December 31, 1983 ‘The authors acknowledge the sesstanceof Lee Benet, MD, and Brace Blome, MD, for radiographic rings. The authors also would like 10 thank hs, Sunde P, Vaughan and Ms, Karen Works for preparation of the manuscript Spinal range of motion can be assessed using planar x-rays, particularly in flexion/extension!*™ 16821274 2.7483056 gn has been correlated with severe dise degeneration."""™* Biplanar x-rays provide information on out-of-plane motion." How- ever, the use of radiographic methods for long-term, rehabilita- tive evaluation is unjustifiable in terms of cost and patient risk, In order to provide simple, semiobjective measures of motion, devices such as standard goniometers have been ap- plied."***"°" However, it clearly is not possible to estimate angles of movement without more objective devices, Protractor methods" an #9535) which measure the absolute orientation of line ina vertical plane (the line formed by two vertebral reference points), have provided more objective measures of spinal inclination but are not in common use Objective, thoracolumbar extension measurements using a plumb line have been shown" to correlate reasonably well with radiographic measurements of the same movements (r= + 0.79, P-<0.001), as have lateral bending movements.” Very few rotation studies ofthe spine, using clinically applicable methods have been published. ‘The objectives of this study are to report on the clinical use of| two simple inciinometer techniques for measurement of spinal range of motion. The accuracy of the method, compared with flexion/extension x-rays was studied, the distinction between Jumbar spinal and pelvie motion was determined, and the method ‘was applied to follow the progress of a group of chronic patients ‘undergoing intensive range-of-motion training, MATERIALS AND METHODS Range-of-Motion Measurement, Two inclinometer technique: In this technique, generally attributed to Loebl™ and Troup,” inclinometers (Figure 1) are used to measure the sagittal and coronal movement of the spine, An inclinometer consists of a circular, Nuid-filed dise with a weighted needle indicator, whict ‘maintained in the vertical direction, The disc is graduated in 0.5° intervals over the 360° range and is affixed either toa straight edge base, Figure 1A (Prolevel, Pro Products Co.; Rockford, IL}, two point contact base (Med Design; London, England), ora plastic {goniometer (Pleurimeter; La Conversion, Switzerland), The latter {wo more expensive incinometers have seales that may be rotated relative to the base to permit zeroing of the device. AAs shown in Figure 2A, one inclinometer is placed over the sacrum with the patient in the erect position. A two-point contact ‘oniometer is favored because it best maintains contact over the convex dorsal aspect of the sacrum, The second goniometer spans the TI2-LI spinous processes, once they have been identified, As in other measurement techniques relying on anatomic markers, theFig 1. A, let, Easily obiained streighl-edged inctinometer for use in single- or double-inclinometer measurement methods. 8, right, Spe- clalized inclinometer with two-point body contact area and rotating ‘ase, ideal for sacral measurement, accuracy of the readings is decreased in markedly overweight subjects, since the landmarks become more difficult to identity Angular readings are taken holding the inclinometers in place with the patient in a neutral standing position (Figure 2A). The patient then is instructed to flex forward maximally while the readings of the two inclinometers are taken in the forward flexed position (Figure 2B). The upper inclinometer reading represents the gross motion, while the sacral inlinometer measures the pelvic oF hip motion, The subject then extends maximally, and the gross extension and pelvicextension are recorded similarly. Truelumbar motion then is obtained from the simple subtraction of the pelvic ‘motion from the gross motion expressed in angular degrees of flexion or extension. As shown in Figure 2 the technique can be employed easily by a single examiner. ‘Single inclinometer technique: An alternative, less expensive method employs a single, straight-edge inclinometer. In this method of measurement (Figure 3A), the examiner's hands span the anterior and posterior paris of the iliac crest to allow ‘measurement of pelvic mobility, Using the thumb and index finger of each hand to span these prominences bilaterally, the fingers are positioned so the plane they form is parallel to the floor. As as- sistant then holds a single inclinometer spanning T12-LI in the erect position and holds it there as the patient flexes forward (Figure 3B), The gross motion is read directly after which the straight edge ofthe inclinometer is placed across the plane between. the thumb and finger and the pelvic motion is measured (Figure 30). The identical two readings are taken with the patient in the extended position, Subjects, Both normal subjects and patient groups were studied. Normal subjects were selected from a group of well- ‘motivated volunteers who had no history of a low-back pain episode within the past 5 years or any previous episode involving more than 5 days of lost work-time. No concurrent disease of any ‘consequence was present, The mean age of the 13 subjects was 31 ‘years, with a renge of 19 o SI years of age. There were seven male and six female subjects. All held predominantly sedentary jobs and performed only recreational athletics. ‘The patient group was comprised of 38 patients with chronic dysfunction, being treated in a comprehensive, intra- disciplinary, pain management program because they had been refractory to other forms of low-back treatment, The 38 patients ranged in age from 20 to $9 years, with a mean of 34 years of age. ‘There were 25 male and 13 female patients. Seven patients had undergone diskectomy, six at one leveland oneat two levels. Three patients had undergone surgical fusion, oneat onelevel, oneat two levels, and one at three levels. Fifteen patients had been disabled from 5-12 months, while 23 patients had been out of work from ‘more than | year, This group was subdivided into an inital group SPINAL RANGE-OF-MOTION’* MAYER ET AL Fig 2A, Double-inctinometer measurement technique showing positon or measurements in erect postion. Theupperinctinometeris held tangent to spine al 712-L1, while sacralincinometerisrotatedto "zero" positon Fig 2. B, In flexion, readings are taken at upper and lower gonio- meters. Gross motion flexion reading erect reading on upper Inelinometer, Pelvic motion = flexion reading ~ erect reacing on lower inclinometer. True lumbar motion = gross motion = pelvic motion, Patient is encouraged to continue flexing unl pelvic motion is within 20% ol straight log raising (SLA) measurement "lightest" hamstring, of 12.whose flexion extension radiographic motion measurements were compared with the inclinometer measurements, and a second group of 26 who were evaluated before and after a 3-week exercise program. For range of motion measurements, data from the complete group was used, Studies Performed. ‘The present study involves three distinct parts, First, a comparison of radiologic and noninvasive motion measurement techniques in low-back dysfunction was made to590 SPINE ¢ VOLUME 9 « NUMBER 6 « 1984 Fig 3. A, Single-incinomster technique: erect measurement. Ex ‘amine?’ thumb and index fingers span pelvis making plane paralolto oor. Fig 3. B, Flexion measurements: assistant inal measures Inol- nation at T12-L1 and subtracts inclination in erect positon fo obtain 91085 motion determine the accuracy of the noninvasive technique, Normal studies then were performed to compare the two noninvasive methods and determine the relationship of normal pelvic to lumbar spine motion. Finally, studies were performed on chronic, low-back pain patients to determine the relation of lumbar spine ‘motion to straight leg raising and to document changes in motion, due to intensive exercise, Normal subjects: Thirteen normal subjects underwent study of gross and true lumbar spine motion using the two inclinometer technique described previously, followed by striaght leg raising. tests withthe end point measured when the knee could no longer be ‘maintained straight or the pelvis began to flex, The contralateral Jeg was left in full extension to assist the limitation of pelvic Fig 8. ©, Flexion measurement: essistant places inclinometer on examiner's thumb/index finger, oblaining direct reading of pelvic, ‘mation. ‘motion, A comparison was made in the thirteen normal subjects between range of motion measurements using the two inclinometer and the inclinometer goniometer technique. To determine the magnitudes of pelvic and lumbar motion during the range of flexion, normal subjects flexed slowly forward from the erect position. Their progress was halted after traveling 15°, 30°, 45°, 60°, 90°, and, if achievable, 120° of gross motion. “The amount of pelvic flexion accompanying the gross motion was recorded, and the true motion then was calculated to assess Whether pelvic or lumbar motion was consistently more prominent in any phase of motion. tients: ‘Twelve male and female subjects with chronic lumbar spine pain participating in a spine rehabilitation program had routine flexion extension x-rays made in the standing position. At the time of radiologic examination, noninvasive measurements of lumbar spine motion using the two inelinometer technique were taken, Gross and peivic motion was determined at full lexion and, with the patient holding the position, the flexion x-ray was performed, Similarly, the patient extended fully and while holding the identical position from which inclinometer measurements were taken, the extension x-ray was made. Straight leg raising tests were performed immediately afterward, while the lumbar range of ‘motion was measured from the x-rays by a radiologist blinded to the inclinometer measurements, Using the flexion and extension xerays, the radiologist drew lines parallel to the superior surface of SI and the inferior surface of T12, dropped perpendicular lines, and measured the angle of inclination at the intersection and ‘whether the apex pointed posteriorly or anteriorly. Subtraction of results from the full flexion film and the film taken at the neutral Position the radiologic true lumbar motion result ‘The results of measurements of range of motion ina further 26, patients were combined with those of the previous 12 to provide data on gross, true, and pelvic motion to be compared with data from the normal group. The second group of 26 patients ‘underwent inclinometer measurements of umbar spine motion and straight leg raising at the time of entry into a pain rehabi tion program. All the patients had been screened prior to entering. the program and averaged 12 months since injury. Most patients hhad been through tral outpatient physical therapy, and all had at Teast some exposure to a flexion mobility program (Williams exercises) prior to entering the program, Patients then participated ina 3-week rehabilitation program featuring physical recondition- ing, which focused on increasing mobility with supervised exercises three times daily, behavior modification, and occupationaltherapy. At the conclusion of the 3-week period, just prior to discharge, range of motion measurements using the two-inelino- meter technique were taken once again by the same observer for comparison with the initial measurements, RESULTS. Studles of Range of Motion in Normal Subjects Results of the range of motion measurements for nornial subjects are shown in Figure 4 Gross range of motion (the compound motion from T12-S1 and hip motion) was 167° (SD, 224°), Mean flexion measured 122° (SD, 15.6°), and extension measured 45° (SD, 14.6°). The arbitrary starting point for flexion and extension range was the subjec’s fully erect position, where the inclination at T12-L1 was usually from 10-20° in extension, ‘otal true lumbar motion averaged 82° (SD, 18.1°). The lexion component had a mean of 55° (SD, 9.2°), while the mean extension was 27° (SD, 12.8). Pelvic or hip motion, measured directly from the inclinometer on the sacrum, showed @ mean total range of 84°, Mean pelvic flexion was 66° (SD, 14.3°), as contrasted with a mean straight leg raise of 82° (SD, 19.9), which ‘was not statistically significant at a 9895 confidence level, The pelvic extension range had a mean of 18°, Comparison of Inclinometer Techniques Pelvic motion in six of the 13 normal subjects was compared using the sacral inclinometer versus measurement of the angle traversed by the examiners hands on the subject's pelvis. For the double-inclinometer technique, the mean pelvic flexion measured 63° (SD, 14.8). For the single inclinometer method with ex- miner's hands spanning the iliac erest, the mean range was 63° (SD, 15.1°). There was clearly no difference in the results between the two techniques. RANGE OF MOTION (ec) RANGE OF MOTION 189} NORMAL, MEAN AGE, 3t Net 159} ls 12 : | 20 | TOTAL FLEKEXT TOTAL EXTENT — FLEXT Gross TRUE PELVIC.=— SLR Fig 4, Range of mation resulls for 18 normal subjects with amean age {91 81 years. (Legend: gross-olal motion, true-lumbar spine motion, SLA—8tcaigh lg raising) SPINAL RANGE-OF-MOTION # MAYER €T AL Differential Mobility of Pelvis and Lumbar Spine through the Flexion Arc, in Normal Subjects ‘Seven of the normal subjects underwent measurement of true ‘lumbar, and pelvie motion as the gross or compound motion at T12 was progressed incrementally in 15~30° segments from fully erect to fully flexed position. Results are shown in Figure 5, Since ‘ot all subjects could reach 120° of flexion, the last data point at 120° of gross motion is based on results from four subjects, The results show an almost linear increase in both pelvic and lumbar motion with progressive gross exion, although at different rates, ‘The slope of the lumbar motion line is 0.63° of lumbar motion per degree of gross flexion, while the slope for the peivie motion line is 0.37° per degree of gross motion, Thus, the ratio of lumbar Alexion to pelvic lexion is 0.63/0.37 or 1.72 up to 90° of gross flexion, Between 90° and 120°, the ratio becomes 0,17 as the Jumbar spine flexes only 4,3°, while the pelvis rotates 25.7. ‘Comparison of X-1 ¥y and Inclinometer Measurements ‘Twelve patients had measurements of total lumbar motion ‘measured by inclinometer and radiographic techniques as de- scribed previously. As shown in Figure 6, ineinometer measure- ‘ments at the time of radiographicflexion extension films showed a ‘mean lumbar motion of 60.5° (SD, 16.7°). The motion measured fn flexion extension x-rays showed a mean range of motion of '58.5°. The statistical analysis showed no significance between the two measurement techniques (P= 0.0). Studies on Low-Back Pain Patients Figure 7 shows the results of range of motion studies on the 38 low-back patients. Mean gross motion was 84°, witha mean of 65° of flexion (SD, 24°) and 19° of extension (SD, 13°). Total, true, lumbar motion was 37° (SD, 21.6°), with a mean of 28 of flexion (SD, 14.1°) and 9° of extension (SD, 9.5°), The mean pelvic flexion was 42.2° (SD, 185°) as measured by the inclinometer technique, while straight leg raising measured 56° (SD, 15°). This, difference in means was statistically significant (P < 0.01). The ratio of pelvic lexion to straight leg raising was 0.75 Effect of ROM Exercises in Patients Figure 8 shows the change in range of motionin this group of 26 patients over the 3week period of time. Total gross motion had increased to 130° (SD, 27.5°), an increase of $59, True lumbar range increased to 65° (SD, 19.8°) from 37°, an increase of 72%, ‘hile total pelvic motion inereased to 65°, an increase of 39%, DISCUSSION In the approach to the knee joint, the orthopaedic surgeon uses {quantitative measurements of physicel function in addition to historical and radiographic findings to make diagnoses and mark progress in rehabilitation towards normal function. Nowhere is this more in evidence than in the sports medicine approach to ligament tears tothe knee. Beceuse of the difficulty of obtaining accurate, physical measurements (motion, stability, strength, and endurance), minimal attention is paid to physical findings in the lumbar spine. Several techniques have been described for measurement of lumbar spine motion,**%*°©" appearing mainly in the rheumatology and physical medicine literature, but none have ‘become popular among physicians treating low-back pain, Thisis ‘best illustrated by the technique for spinal motion measurement still advocated by the American Academy of Orthopedic sor592 SPINE ¢ VOLUME 9 + NUMBER 6 © 1954 70. ROM,deg 50 40. 30: 20: 10% Ey 60 90 GROSS FLEXION, deg Fig 5. Polvic and lumbar spine motion with increasing gross mation 7010 Surgeons" which combines lumbar and thoracic measurements and makes no provisions for diferentiating the spinal and hip components of compound sagital motion. Unfortunately, since range of motion is considered the only “objective” finding in Aisabilty determination according to the widely used AMA sidelines, the use ofthe Academy spinal motion technique,” by not separating hip and spine motion, givesinadequateinformation for objective determination of hip and spine motion. In the present study, we have looked atthe usefulness of two ilar techniques for measurement of spinal mobility avalable to the clinician. The double incinometer technique?™ has been compared with our single inclinometer technique, and both appear to be equally satisfactory. Both techniques can be used by the physician or an assistant in an office setting with no more time expended than it takes to obtain a blood presure reading. Thus, serial examinations and rapid development of expertise with the system are achieved easily, While a specialized inlinomete it de- sirable, the measurements can be taken with an inexpensive in- clinometer available in any hardware store, The landmarks chosen are extremely important—T12-Ll, at the end ofthe rbbed spine, makes a convenient, upper measurement limit, One couldas easily choose a tower interspace, such as L2~3, thereby gaining more information about the part ofthe lumbar spine most frequently associated with degenerative change. Besides giving a true measurement of lumbar spine motion, the technique also helps the clinician to document the consistency of the patient’ level of effort. Standing pelvic flexion with the knees extended is restrained ultimately by hamsting tightness on the most limited side, Posterior hip capsules are generally more TRUE LUMBAR FLEX-EXTENSION 2-81 (DEG) sD Nei2 INGLINOMETER X-RAY Fig 6. A comparison of lumbar lexion range as measured by the two inelinometer technique, let, and radiographs, righ, fr 12 low-back pain patents (SD = standard deviation) extensible than hamstrings since more hip flexion is generally ‘obtained with the knee bent than with the knee straight, Therefore, straight leg raising is an excellent check for the degree of ‘compliance by the patient, In a cooperative individual, standing pelvie flexion is shown commonly to be 2095 ess than the straight leg raise on the patients “tightest” side. Infact, careful observation "usualy shows that in patients with asymmetric straight leg raising, foreward flexion proceeds to the point where the most limited hamstring is stretched, after which the patient attempts to flex further by veering off to the contralateral side, I'the straight leg raising measure is known before the inclinometer measurement is, performed, patients can often be encouraged to produce additional effort to increasing forward flexion. ‘The causes for inconsistency between pelvic mobility and straight leg raising tests may be multiple Pain or fear of producing pain is perhaps the most frequent cause ina low-back pain patient population since flexion increases load on lumbar dises, Better motion testing often can be achieved in these patients by asking them to support themselves with arms on thighs, while they lex forward to permit the best possible physical measurement. In our Present study, normal subjects showed 16° greater straight leg raising (82°) than pelvic flexion (66°) on average (249%), while in the initial patient measurements straight leg raising (56°) and 14° ‘more than the pelvic flexion (42°) (339%). Symptom magnifiers ‘may be expected to show wider discrepancies than patients limited only by pain,iow eo, eae ie ee an 7 Rang-taton inet eis ton 28 cr Soa agen pn aon Wo tat CRF gee felon SHA ala hog og waa ‘There are at least two reasons why pelvic motion can be ‘expected to be less than straight leg raising measures even in well motivated subjects, The first is that the standing bend places a large, eccentric load on the hamstring; the contracting muscle is not likely to be as extensible as the hamstrings stretched in the supine position, Second, the mest oommonly performed technique of straight leg raising in the supine positon wit the contralateral Jeg extended, has two sources of error. Sight knee-exion permits sreater straight leg raising, and laxity of the anterior hip capsule permits hyperextension of the contralateral hip with accompany ing pelvic flexion at terminal, straight leg caising, The following precautions can eliminate these difficulties (but were not taken in this study) and decrease expected variance between pelvic flexion and straight leg raise: (1) the knee should not be permitted to flex; (2) the contralateral thigh should be hyperextended off the edge of the table to “lock” the pelvis; or (3) the pelvis should be palpated (or marked with tape), while performing the straight leg raise, discontinuing the lit as soon as pelvic motion is detected. Great discrepancies between pelvic mobility and supine leg raising should elert the clinician to the possibilty of suboptimal motivation. A further check on the consistency of the examination is provided by comparison of relative lumbar and pelvic measure- ment throughout the range of motion. In the normal subject (Figure 4), lumbar motion is 63% of gross motion (63:37 lumbar:pelvie ratio) through the initial 90° of flexion, Once ‘maximum, true, lumbar motion is achieved, terminal flexion occurs almost exclusively through pelvic motion, ultimately depending on the degree of hamstring tightness, It has been our experience that this, consistent relationship between spinal and pelvic mobility is reproducible, though it may change with added "upper body load.” In our patient population, however, inital, true, lumbar spine Mexion averaged only 43% of gross flexion. Yet, bythe end of the intensive group stretching program, mean, tue, lumbar mobility had increased to 719 of gross flexion. ‘Thus, it appears that patients who truly are limited by the facet joint stiffness and lumbar myofacal tightness wil show a significant reduction inthe true lumbar/pelvic mobility ratio. Conversely, individuals with SPINAL RANGE-OF-MOTION # MAYER ET AL pain or poor motivation, but no organic change, will likely ‘demonstrate a decrease in their pelvic Nexion/straight leg raising. ratio below 809%, but no significant change in the true lumbar mobility/pelvic mobility ratio below $0-60%, Treatment strategies should be geared more to intensive stretching forthe “ff” group, and emotional support for the “suboptimal effort” group. ‘The very rapid improvement in motion in a chronic pain population is dramatic proof that a highly repetitious, nonbalistic mobility program effectively can alter one component of chronic, lumbar spine dysfunction, We note that most of our patients ‘maintain their backs in a relatively rigid vertical position, even ‘when not wearing the still common lumbar corset, Exercises were performed slowly in flexion and extension and directed at mobility ‘of the lumbar spine, hips, and hamstrings and were performed 6-8 times for a total of 2 hours per day, interspersed with bicycling and walking. Larger gains were made in lumbar spine mobility (719%) than in pelvic (hamstrings) mobility (399). Though we cannot identify the source of the joint immobility, it is our clinical impression that older patients with advanced facet and dise degenerative change make slower and more limited gains than younger, less involved individuals, We may speculate that older individuals with substantial facet arthritis develop capsular and ligament contractures with refractory limitation of motion. Finally, we should note the accuracy of the method in com- parison to spine flexion/extension radiographs, Except in the relatively obese individual, where loss of bony landmarks makes TRUE LUMBAR ROM, TI2-SI, (Dee) 80} N=26 79} 69} 50} 40} 30} 20} 10} INITIAL ‘3 WEEKS Fig 8, Change in lumbar spine range of motionin26 chroniclow-back pain patients 3 weeks alter starting @ comprehensive reconcitoning program, 593SPINE * VOLUME 9 # NUMBER 6 ¢ 1984 both single- and double-nclinometer techniques less accurate, the ‘methods can be expected to give measurements within 10% of those achieved with radiography. Because of relatively large radiation exposure with flexion/extension films, itis desirable to repeat these studies as infrequently as possible, When these films fare used to assist in the evaluation of segmental instability for possible surgical fusion, the patient is most symptomatic, and, ‘therefore, most immobile. Thus, another potential use for quanti- tative spinal mobility measurement is to document adequate, spinal mobility before flexion/extension films are taken. In this ay, a false-positive finding of segmental instability can be avoided by preventing concentration of excessive load from a rigid lumbar spine to a single poorly defended motion segment, CONCLUSIONS ‘The following conclusions can be summarized from this study: (1) The two noninvasive inclinometer techniques described here show no significant differences from results of radiographic range fof motion measurements. (2) In normal subjects, Lumbar motion account for 63% of gross flexion with 3796due to pelvie motion in the range up to about 90° of flexion, The straight leg raising test results, although larger than pelvic motion measurements (24%), ‘were not different statistically. (3) Low-back pain subjects exhibit, lower, gross motion than normal subjects (54%), withthe ratio of lumbar flexion to gross flexion decreased (63% to 43%). The straight leg raise measured 33% more than the pelvic motion, probably because ofthe desire ofthe patient to limit spinal load. (4) ‘Range-of-motion exercising significantly can inerease functional pain-free range both in lumbar (7194) and pelvie motion (39%) over a Beek period. (5) Inclinometer measurement of range-of- motion is a simple, effective quantitative technique for assessing disability and measuring progress in rehal REFERENCES 1, Albrook D: Moverens of the lumbar spinal clums, J Bone Joint Surg 39B:339-245, 1957 2 American Academy of Orthopedic Surgeons: Joint Motion: Method of Measuring and Recording. Edinburgh, Livingston, 1966, p50 3. American Medical Assocation Guides to the Evaluation of Permanent Impairment. AMA Chicago, 1971 4 Anderson JA: The thoraco-lumbar spine. Clin Rhewm Dis 8631-65, 1982 5, Anderson JA, Sweetman BJ: A combined flexirule/hydrogoniometer for measurement of lumbar spine and is sagittal movement, Rheum and Rehab 14:173, 1975 6 Asmussen E, Hecboll-Micsen K: Posture, mobility and strength ofthe back in boys, 7 to 16 yeas old. Acta Orthop Scand 28174, 1959 17, Bistcom 0: Need degenerative changes in the spinal column entail, back pain. Ann Chir Gynecol Fenn 4329-44, 1984 {& Bistrom O: Congenital anomalies of the lumbar spine of persons with painless backs. Ann Chie Gynecol Fenn 43:102-115, 1954 9, Brown RH, Burstein AH, Nash CL, Schock CC: Spinal analysis ting three dimensional radiographic technique. J Biomech 355-365, ww 10, Cave EF, Roberts SM: A method for measuring and recording joint function. J Bare Joint Surg 18455, 1936 1H, Committe for Study of Joint Motion: Method of Measuring and Recording, Chicago, American Academy of Orthopedic Surgeons, 1965 12, Bvans DP, Burke MS, Lloyd K, Roberts E, GM: Lumbar spinal ‘manipulation on tri: 1, einical assessment, Rheum and Rehab 17 46-53, 1978 1b, Farfan HE: Mechanical Disorders ofthe Low Back, Lea & Febiger, Philadelphia, 1973, 14, Farrell JP, Towmey LT: Acute low back pain: Comparison of two ‘consecutive treatment approgches. Med J Austral 2:20, 1982 15, Fitzgerald G, Wyaven K, Result W, Rothchild B: Objective asses ‘ment with establishment of normal values for lumbar spinal range of motion. Phys Ther 6%:1776-1781, 1983, 16 Galante JO: Tensile properties of human lumbar annulus fibrosis ‘Acta Orthop Seand (Supp!) 100, 1967 17, Greene J, Armstrong WE: Radiograph measurement of the lumbo- sacral angle. Arch Phys Med Rehab 48:240-263 1967 18 Horal J; The linial appearance of low back pain disorders in the ety of Gotheburg, Sweden. Acta Orthop Seand (Suppl) 118, 1969 19, Hult L: Cervieal, dorsal, and lumbar spinal syndromes. Acta Orthop Scand (Suppl) 17, 1954 20, Hussar AE, Guller EJ: Correlation of pain and the roentgenographic findings of sponsyoss of the cervical and lumbar spine. Am J Med Sei 232:518-527, 1986 21, Jonck LM, Van Niekerk J: A roentgenologial study ofthe motion of the lumbar spine ofthe wbantu, So Aie J Lab and Clin Med 7:67, 1961 22. Kelsey JL: An epidemiologial study of acute herniated lumber limervertebral dies. Rheumatol Rehabil 14:144-159, 1975 23, Lawrence JS: Dise degeneration. Is frequency and relationship 10 symptoms. Ana Rheum Dis 2121-137, 1969 24. Lindahl O: Determination of Sagital mobility ofthe lambar spine. ‘Acta Orthop Scand 37:241-284, 1966 25, Loeb! WY: Measurements of spinal posture and rangeinspinsl move- ‘ments. Ann Phys Med 9:103, 1967 26, Locbl WY: Regional rotation ofthe spine. Rheum and Rehab 12:223, 1913 27, Magora A, Schwartz A: Relation between the low back pain syndrome and xray findings, 1. Degenerative osteoarthritis. Scand J Rehabil Med 115-128, 1976 28, Markolf KL: Determination of the thoracolumbar intervertebral joins in reponse to external loads: A biomechanical study using Autopsy material, J Bone Joint Surg S4A:SII-833, 1972 28. Mayer T: Rehabilitation ofthe patient with spinal pain. Onhop Clin North Am 14:623-639, 1983 ‘3M. MeCray IF, Weight V: Measurement of back movement, Ann Rheum Dis 28:58, 1969 31, Moll J, Wright V: Measurement of Spinal Movement inthe Lumbar Spine and the Back Pain, Eated by M Jayson. New York, Grune & Stratton, 1975, pp 93-112 32, Moll JM, Wright V: Normal range of spinal mobility: An objective lineal study, Ann Rheum Di 30381, 1971 33, Moll JMH, Lujanage SP, Wright V: An Objective Clinial method to measure spinal extension, Rheum Phys Med 1:283, 1972 34. Nachemson A: The load on lumbar dsc in diffrent positions of the ‘body. Clin Orthop 45:107-122, 1966 36. Norien PL, Brown T: The immobilizing etficeney of back braces ‘Ther effect on the posture and motion of the lumbosacral spine. J Bone Joint Surg 39A:111-138, 1957 36, Panjabi MM: Experimental determination of spinal motion segment behavior. Orthop Clin Am 8:170-180, 1977 237, Perry J: The use of external suppor inthe treatment low beck pan, Ani Limbs 1449-57, 1970 138, Pope M, Rosen J, Wilder D, Frymoyet JW: Relation between bio- ‘mechanical and psychological actors in patients with low back pain. Spine 5173-199, 1980 538. Rab GT, Chto EY: Three Dimensional Roentgenographie Analysis ofthe Lumbar Spine. Twenty-seventh annual ACEMB, 1974 40. Reynolds PMG: Measurement of spinel mobility: A comparison of, thee methods. Rheum and Rehab 14:180-185, 975 41, Rowe ML: Preliminary statistical study of low back pain. J Occup Med 5336-34, 1963, 42, Russtk AS: Biomechanical and psychological basis for ambulatory treatment of low back pain. Orthop Rev 5:21-3, 1976 48, Schober P: Lendenwirbelaule und krewzsehemerzen, Munch Med Wocke 84:336, 1937 44, Splthoff CA: Lumbosacral junction, Reetgenographie comparison ofpatents with and without backaches, JAMA 152:1610-1613, 1953 45, Stubbs BA: Back problems in work end leisure. Physiother 68: 174-176, 1983 46, Stokes IAF, Medlicott RA, Wilder DG: Measurement of movement in paingulimervertebral joints. Med Biol Eng 18:€94-700, 1980 47, Tana 8S: Motion ofthe lumbar spine. A roentgenologe study. Am J Roentgenol Rad Ther Nuel Med 69:399-412, 1953 48, Taylor J, Twomey LT: Sagittal and horizontal plane movement ofthe human lumbar vertebral column in cadavers and in the living. Rheum ‘Ato! Rehab 19:223-232, 1980 49, Tichauer ER, Miler M, Nathan IM: Lordesimetery: Anew teehnigue for the measurement of postural response to materials handing. Am Ind Hyg Assn J 344-12, 1973, 50, Torgerton BR, Dotter WE: Comparative roentgenographie study of the asymptomatic and symptomatic lumbar spine. J Bone Joint Surg S8A:850-853, 1976 51, Troup JD, Hood C, Chaprean AE: Measurements of sagittal mobility ‘of the lumbar spine and hips. Ann Phys Med 9:38, 1968: 52 Twomey LT, Taylor JR: A description of two new instruments for SPINAL RANGE-OF-MOTION MAYER ET AL. measuring the ranges of sgital and horizontal plane motion in the lumbar region. Aust J Physiother 25:257-263, 1979 58. Twomey LT, Taylor JR: Sagital movement of the human lumbar veriebral column: A quantitative study of the role of the posterior vertebral elements. Arch Phys Med Rehab 64:322-325, 1983 SA, Wikeri M, Nummi J, Rihimaki H, Wiekstrom G: Radiologially detectable lumbar dise degeneration in reinforcement workers, Scand J Work Environ Health (Supp) s(1)47-58, 1978 Address reprint requests 10 ‘Tom G. Mayer, MD University of Texas Health Science Center at Dallas Orthopedic Surgery 5323 Harry Hines Blvd. Dallas, TX 75235 ‘Accepied for publication February 9, 1984 595