Reliability of Passive Wrist Flexion and Extension ......tester's measurements was 2 to 3 minutes. Each subject's passive wrist flexion and extension was therefore mea- sured three

Research Report

Reliability of Passive Wrist Flexion and Extension Goniometric Measurements: A Multicenter Study

Key Words: Goniomety; Tests and measurements, range of motion; Upper extremity; Wrist.

Background and Purpose. The purpose of this study was twofold. (1) to determine whether passive wrist flmon and ex tmon goniomemc measurements using ulnur algnment, radial alignment, and volarldorsal alignment were similar or dissimilar and (2) to examine which of these three techniques had the greatest in-

Wrist injuries frequently cause sec- wrist. The goniometer is used to mea- ondary limitation of motion at the sure wrist active range of motion

Paul C LaSteyo Donna L Wheeler

PC LaStayo, PT, CHT, is Instructor, Department of Physical Therapy, College of Health Related Pro- fessions, University of Florida, JHMHC Box 100154, Gainesville, FL 32610 (USA). Address all corre- spondence to Mr LaStayo.

tratester land intertester reliability. Sut#ects. One hundred forty patients (141 wrist) were measured. The testers were 32 therapists@m eight d~fferent handlupper- extremity clinical sites around the United States. Metbods. Randomly paired testers measured passive wrist flmon and extmbon The intraclass correlation coeficient (ICC) was used as an estimate of agreement for both intratherapist (model 3,1) and intertherapist (model 2,I) reliability. Results. Six of the eight clinics showed sign$- cant dzrerences among the various goniomenic techniques. Flexion intratherapist mean ICCs for the radial, ulnar, and dorsal alignment techniques were .86, .87, and .92, respectively. &tension intratherapist mean ICCs were .80, .80, and .84 for the three techniques. Intertherapistflexion mean ICCs were 88, 39, and .93 for the radial, ulnar, and volar alignment techniques, respectively. Extension intertherapist mean ICCs were .80, .80, and .84 for the three techniques. The standard error of measurement was also used to quantzh reliability, with the volarldorsal alignment technique consistently producing less error than the ulnar and radial alignment techntques. The generalizability theo y statistical model was utilized to ident@y the sources of emr . The patient conm'buted to variance the most, although inherent error within the study, diagnostic catego y, therapeutic approach, and goniomem'c technique also contributed Conclusion and DLscussim. The overall results indicated there were dt@erences among the three goniometric techniques. The velar/ dorsal alignment technique is the goniometric technique of choice, as it consistently had the greatest reliability. [LaStayo PC, Wheeler DL. Reliability of passive wrist flexion and t'xtm'on goniometric measurements: a multicenter study. Phys Ther. 1994; 74:162-I 761

DL Wheeler, PhD, is Research Assistant, Department of Onhopaedics, University of Florida

This study was approved by [he Research Committee in [he Department of Orthopaedics at the University of' Florida.

(AROM) and passive range of motion (PROM) for documentation purposes and to assist in making clinical decisions. Many of these clinical decisions are based on how much wrist range of motion (ROM) a patient needs for his or her activities of daily living (ADL) and return-to-work require- ments. When wrist PROM is limited, therapists utilize a wide range of passive treatments to address this

This article was submitted Seplernber 22, 1992, and was accepted August 18, 1993

Physical Therapy /Volume 74, Number 2Februa1-y 1994

restriction. These treatments include, but are not limited to, PROM stretch- es,' joint mobili~ation,~ dynamic splinting,3 static progressive ~pl int ing,~ and serial casting.' To assess the effec- tiveness of these passive treatments, a passive measure, such as goniometry, must be used. Does a change in a goniometric reading, however, indi- cate an actual change in a patient's passive joint motion, o r is the measurement device unreliable or invalid? Only with a reliable and valid ROM measuring instrument will a therapist know whether a passive treatment is efficaci~us.~

Multiple goniometric techniques are used for measuring ROM of wrist flexion and extension. These techniques differ in respect to placement of the goniometric arms. For example, the American Medical Associa- tion7 and the American Society of Hand Therapistsn suggest volar and dorsal approaches to the measurement of extension and flexion, respectively, whereas ulna@-" and radial10J2 goniometric alignments are also suggested in the literature. Con- sequently, with therapists using different ROM measuring techniques, critical comparisons of treatments that affect ROM are impossible, as it is unknown how measurement results vary from one goniometric technique to another.

Although functional goals are para- mount, goniometric results certainly influence treatment decisions. For instance, a goniometric measurement taken on the ulnar side of the wrist may satisfy a ROM goal for ADL, but a radial or volar/dorsal measurement may not meet that ROM criterion. The clinician who uses the ulnar goniometric approach may discontinue attempts to gain more motion, whereas the clinician who uses the other measuring techniques may continue to try and regain motion. This potential difference in goniometric results may have significant clinical implications, particularly in determin- ing functional ROM after palliative/ stabilizing procedures such as partial wrist fusions,l3 total wrist arthroplas-

ties,l4 and ligament reconstructive procedures at the wrist.15

The reliability of goniometric measurements of joint motion has been assessed under many conditions for various joints.1622 Most researchers have either attempted to control vari- ables that are not typically controlled in a clinical setting or used subjects without any pathology. Their results, therefore, have limited application to the clinician. Rothstein et a123 have provided a protocol for the study of intrarater and interrater reliability of goniometric measurements under clinical conditions.

Two studies of wrist goniometric reliability have been perf0rmed,~4>~5 with only one study having been done under clinical conditions.24 In both studies, reliability of measurements obtained with the ulnar and radial measuring techniques was assessed. The results of these studies were conflicting, as greater reliability was seen with an ulnar technique in one study and with the radial technique in the other study. Horger24 found high intratester and intertester reliability, especially when an ulnar technique was used. The most reliable measurements in that study were obtained by a variation of the previously described ulnar technique,"-" which used the third metacarpal for goniometric alignment rather than the more traditionally used mobile fifth metacarpal. Duffin and Zoeller25 found greater reliability with the radial rather than the traditional ulnar technique.

Heretofore, there has been no comparison of all three goniometric techniques in terms of measurement results and reliability. It was impera- tive that all measuring techniques be assessed to determine which goniometric technique had the greatest reliability. Therefore, this study was designed to ensure that all techniques were evaluated within a clinical environment. The purpose of this study was twofold: (1) to determine whether passive wrist flexion and extension goniometric measurements obtained using radial alignment, ulnar

alignment, and volar/dorsal alignment were similar o r dissimilar and (2) to examine which of these three PROM wrist flexion and extension goniometric techniques had the greatest intratester and intertester reliability.

Method

One hundred forty patients (141 wrists) from eight handlupper- extremity clinics around the United States (Appendix) participated in this multicenter study. Patients were included in the study if they were re- ferred to one of the eight clinics and if wrist PROM would normally have been included in their assessment. All subjects read and signed an informed consent statement before admission to the study. Subject data collection included each patient's age, sex, and diagnosis. Whether the subject was treated prior to o r immediately after wrist PROM was measured was also noted. Although each clinic was required to collect data on 25 subjects, five of the eight clinics collected data on 21 o r fewer subjects (Tab. 1). The data on one subject could not be deciphered from the recording form and were discarded. The average number of subjects per clinic was 17.5 (range=7-25). The average age of the subjects was 41.5 years (range=G81). An average of 65% (range=48%-85%) of the subjects were male, and an average of 35% (range= 15%-50%) were female (Tab. 1). All data collection was done in one clinic session.

Testers

Goniometric measurements were obtained by 32 therapists from eight different handlupper-extremity clinics (4 therapists per clinic). For inclusion in the study, each clinic was required to have 4 therapists present at one time to allow randomization of testers. In four clinics, 1 of the measuring therapists left the study. The randomization of therapists precluded the inclusion of new therapists into the study; therefore, data collection was terminated prematurely. Data

Physical Therapy/Volume 74, Number 2February 1994

Table 1. Subject Characteristics by Clinic

Age (Y) Treatment (%) Dlagnoatlc Category (%)b (Pretreatment1

Clinicm No. of Subjects Male/Female (%) SD Range Posttreatment) I II Ill IV

Osee Apper~dix for listing of clinics.

'~iagnostic categories: I=postsurgical, II=postfracture, III=general onhopedics, IV=neurological.

collectiorl was discontinued either when a clinic recorded data on 25 wrists or 1 of the testers left the study. The 32 testers had an average of 10 years' experience (range = 1.5-20 years). The testers were 25 occupational the:rapists, 6 physical therapists, and 1 combined occupational/physical therapist. Of the 32 testing therapists working in hand clinics, 17 were certified hand therapists (Tab. 2).

lnstrumentatlon

Each participating clinic was issued two plasti.~, 15.2-cm (6-in) goniometers to use for all measurements.' Each goniometer's accuracy was assessed by measuring 10 randomly chosen, computer-generated angles between 0 and 180 degrees. All goniometric measurement angles were in agreement with the computer- generated angles.

One side of the goniometers' numerical scale was covered with moleskin to blind the measurer from reading the scale. This precaution prevented the tester from viewing the measurement results, but allowed a recorder to view the reverse side of the goniometer and record the results (Fig. 1).

Procedure

This study used a modified version of a goniometric measurement method originally described by Rothstein et al.23 At each clinic, measurements of subjects were performed by randomly paired sets of testers.

A patient was identified as a potential subject by one of the testing therapists. The therapist then obtained consent from the patient, collected subject data, and decided whether goniometric measurements were going to be performed prior to or after that day's therapeutic session. That therapist was also the first testing therapist. Prior to taking any goniometric measurements, the first testing therapist randomly chose the second tester, thus establishing the measuring pair. This entire procedure was repeated for every subject at every clinic.

The first tester then measured the subject's passive wrist extension and flexion in the following order: (1) radial goniometric technique, (2) ulnar goniometric technique, and (3) volar/dorsal goniometric technique (Figs. 2-5). Operational definitions were provided so that each of the

testers could use them as guidelines (Tab. 3). A recorder, trained in reading the goniometer, at each clinic read and documented each goniometric measurement while ensuring that the tester did not see the result. After measuring the subjects in the defined order, the first tester remeasured the same subject in the same order after a 30- to 60-second interval. The second tester of the measuring pair then repeated all of the measurements twice while the recorder documented the results. The elapsed time between the first tester's and the second tester's measurements was 2 to 3 minutes.

Each subject's passive wrist flexion and extension was therefore measured three different ways a total of four times (two times per tester) by two different testers. No therapeutic activity was performed between any of the measurements. None of the testers had access to the measurement results, nor were they permitted to watch any of the other testers measure subjects. All eight clinics were instructed to collect data on 25 different subjects; however, the final number of subjects per clinic varied (Tab. 1). On completion of data collection, all results were returned to us for analysis.

*North Coast Medical Inc, 187 Stauffer Blvd, San Jose, CA 95125-1042

Physical Therapy/Volume 74, Number 2Pebruary 1994

- -

Table 2. Tester Characteristics by Clinic

ANOVA; however, it partitions the variance into differences between subjects, errors, and raters. This parti-

Experience (y)

Cllnlcg Profeclrlonb (%I X SD Range

A PT

OT

CHT

B PT

OT

CHT

C PT

OT

CHT

D PT

OT

CHT

E PT

OT

CHT

F PT

OT

CHT

G PT

OT

CHT

H PT

OT

CHT

'See Appendix for listing of clinics.

h ~ ~ = p h y s i c a l therapy, OT=occupational therapy, CHT=cenified hand therapist

Data Analysis

In an attempt to determine whether the radial, ulnar, and volar/dorsal goniometric techniques produced similar or dissimilar results on the same subject, an analysis of variance (ANOVA) was used. The ANOVA allowed a comparison of the mean goniometric results of the three techniques by clinic. If significance was noted (P= .05), a Tukey Honestly Significant Difference Multiple- Comparison Test was performed to determine which techniques were different from one another. This test is one of the more conservative multiple-comparison designs and has stringent statistical criteria that must be met before deeming variance as

significantly different.z6 The results of this test may help the clinician decide whether these three different techniques could be used interchangeably.

The intraclass correlation coefficient which is based on an ANOVA,

was used to provide an estimate of agreement both within raters (model 3,l) and between raters (model 2,l). In the 3,l model, the tested raters are the only raters of interest, thus making it an appropriate model for assessment of within-tester reliability.27 Shrout and Fleiss2' support this view, as they do not feel it is reasonable to generalize one rater's score to a larger population using the 3, l model. The 2,l model also uses an

tioning permits generalization of results beyond the raters in this study. The use of model 2,l is suggested when assessing between-rater reliabil- ityS2Vor the determination of intertester reliability, the mean of each therapist's two trials was used. The ICC reliability index has been com- monly utilized as the primary determinant of reliability in previous wrist goniometry studies.24.25

The amount of measurement error, or the standard error of measurement (SEM), was also used to quantify reliability.29 The SEM may be the most desired index of reliability, as it pro- vides a number that represents the way a single score will vary if a test is administered more than once. The SEM's clinical revelance is enhanced by the fact that it is expressed in the metric unit of the mea~urernent.~9

A generalizability statistical model,30 an extension of the intraclass reliability model, was used to identify the percent contribution of numerous components to error variation. Sources of error analyzed included goniometric technique, therapist, diagnostic category, treatment, patient, and miscellaneous error. All of these statistical calculations were organized and processed on the Statistical Analy- sis System computer pr0gram.3~ De- scriptive statistics, measures of central tendency (mean, standard deviation, and range), were used to represent all of the clinics with a statistical value.s2

Results

There was a wide range of passive wrist flexion and extension among the subjects. Overall, the subjects' goniometric measurements varied from 5 to 95 degrees in both flexion and extension.

The ANOVA and the Tukey Honestly Significant Difference Multiple- Comparison Test revealed significant differences (P= .05) among the mean goniometric results of the specified

72 / 165 Physical Therapy /Volume 74, Number 2February 1994

time for intratherapist flexion and intertherapist flexion, respectively. For

Flgure 1. Testing goniometers: One side blinded to the tester; the numerical side visible to the recorder.

techniques for flexion in six of the eight clinics and for extension in three of the eight clinics (Tab. 4).

The ICC results for intratherapist and intertherapist flexion and extension for each clinic are displayed in Fig- ures 6 through 9. The descriptive statistics pertaining to the ICC for all

clinics combined are presented in Table 5.

For the ICC results exceeding .90, the flexion measurements of all techniques were always better than the extension measurements. The dorsal goniometric technique exceeded the .90 ICC mark 75% and 100% of the

Flgure 2. Radial goniometric alignment forjlexion and extension.


both intratherapist and intertherapist extension, the volar technique exceeded the .90 ICC mark 38% of the time. The ulnar goniometric technique exceeded the .90 ICC mark 38% and 50% for intratherapist and intertherapist flexion, respectively, whereas it never exceeded .90 for either intratherapist or intertherapist extension. For measurements taken on the radial side, the .90 ICC mark was exceeded 25% of the time for intratherapist flexion and 50% of the time for intertherapist flexion. Both intratherapist and intertherapist extension radial measurements never exceeded the .90 ICC mark.

The SEM results for intratherapist and intertherapist flexion and extension for each goniometric technique are presented in Table 6. For intratherapist flexion and extension, the SEM of the volar/dorsal technique was lowest 100% and 75% of the time, respectively, as compared with the SEMs of the other techniques. For both intertherapist flexion and extension, the SEM for the volar/dorsal technique was the lowest 80% of the time.

The greatest effect on variance among all measurements, as analyzed via the generalizability model, was accounted for by the patient 65% (range= 38%-80%) of the time and then by inherent error within the study (ie, study design, recorder error, and so forth) 16% (range=12%-25%) of the time (Fig. 10).

The diagnostic category had an effect on reliability an average of 9% (range=0%-49%) of the time (Fig. 11). The most frequently encountered diagnosis was postsurgical 72% of the time. This postsurgical category included subjects who undement procedures such as carpal tunnel release, open reduction and internal fixation of the carpus or radius/ulna, limited carpal fusions, and tendon transfers. The postfracture diagnostic group was encountered 16% of the time and included radiusiulna fractures, carpal fractures, and metacarpal fractures that were not openly reduced or

166/73

goniometric measurement on reliability was averaged at 6% (range= 0%-30%) (Fig. 11). An average of 35% -4 of the subjects were treated before

Flgure 3. Ulnar goniometric alignment forpexion and extension.

internally fixated. General orthopedics was seen 8% of the time and con- sisted of distal radiushlna, carpal, and soft tissue strains, sprains, and tears. Burns were also included in this category. The neurological category was encountered least often at 4% of the

time and included peripheral nerve entrapments, central nervous system disorders, and iatrogenic neuroprax- ias (Tab. 1).

The effect of whether treatment was administered prior to or after the

being measured, and 65% were measured after treatment (Tab. l). The actual goniometric technique effect on

I reliability was 3% (range= 1%-5.5%), and the therapist effect-was 2% (range=0%-6.5%) (Fig. 12).

Overall, many factors can effect wrist goniometric measurements. With this in mind, the results of the three goniometric techniques were significantly different on many occasions. In terms of reliability, the results of the ICC and the SEM show the volar/dorsal technique to be the most reliable of the three different techniques.

Despite the fact that all three goniometric techniques are utilized for measuring wrist PROM, they produced significantly different results when compared in this study. From the results of the ANOVA and the subsequent Tukey Multiple- Comparison Test, it is apparent that many instances the results of the three techniques were significantly different. his finding hasclinical ' implications, as one therapist may be making clinical decisions based on - one technique, whereas another therapist may be making treatment decisions based on a different goniometric technique. Although these results address one of the purposes of the study, they do not address the question of which is the most reliable technique. For this purpose, the ICC was used as a statistical index of reliability. When inherent variability is high, as it was in this study with wrist PROM measurements ranging from 5 to 95 degrees, one can have great confidence in the ICC as strong index of reliability.2" Additionally, using the SEM as an index of reliability allows the reader to determine whether the amount of measurement error is clinically significant.

Reliability denotes the stability of a measure and whether one tester, or

Figure 4. velar goniometric alignment for extension. two testers, can obtain similar mea-

74/167 Physical Therapy/Volume 74, Number 2Pebruary 1994

Figure 5. Dorsal goniometric alignment forpexion.

surements of the same variable on separate occasions. Most researchers and clinicians establish their own definitions of what is "acceptable reliability." One must consider the nature of the measurement and whether measurement stability is necessary for a clinical decision to be made. For instance, clinicians might tolerate lower reliabilities when the measuring technique is only one of many different ways to measure an

attribute. Higher reliabilities may be required, however, when one measurement alone dictates how a clinician will approach the treatment plan. High ROM measurement reliability at the wrist is particularly useful, as changes in ROM may determine the success or failure of a treatment. Fur- ther standards for tests and measurements related to reliability have been previously established.33 -

Table 3. Operational Definitionsfor Wrist Goniometry

Alignment Technique Definition

Radial Stationary arm placement will parallel the longitudinal midline of the radial forearm

Movable arm will parallel the longitudinal axis of the second metacarpal

Ulnar Stationary arm will parallel the longitudinal midline of the ulna toward the olecranon

Movable arm will parallel the longitudinal axis of the third metacarpal

Volar (Extension only) stationary arm will lie along the volar surface of the forearm


Dorsal (Flexion only) stationary arm will lie along the dorsal surface of the forearm


Of the three goniometric techniques, the volar/dorsal technique was the most reliable, with consistently higher ICC and lower SEM results than the radial and ulnar techniques both within and between testers. This finding differs from those of previous reliability studies. In those studies, the volar/dorsal technique was not assessed and consequently could not be compared with the radial and ulnar techniques. We felt a critical analysis of all three techniques was warranted, especially as the volar/dorsal technique is recommended by the Ameri- can Medical Association7 and the American Society for Hand Therapists.8

Additionally, it appears that anyone who is measuring wrist ROM should know which goniometric technique has the greatest reliabilty, because the result can have profound implications for the patient. The goniometric result may determine what type of further treatment is warranted. It may deem a surgical result as successful or unsuccessful.

Additionally, it may play a major role in a patient's partial or permanent impairment rating. When a wrist PROM measurement will be used as a primary determinant in making a clinical decision, or will be an independant variable in a research study, the volar/dorsal approach may be the goniometric technique of choice. The voladdor- sal technique consistently was above the .90 ICC level as compared with the other techniques. In addition, the volar/dorsal technique consistently had the highest ICC value and the lowest SEM both within and between testers. If, however, a gross anatomical volar or dorsal abnor- mality prevents accurate goniometric alignment, the radial or ulnar technique would suffice. There should be no alternating of measurement techniques on the same patient.

Unlike other reliability studies, this study revealed a trend toward intertester ICC and SEM results being slightly better than intratester results. Clinically, the differences

Physical Therapy/Volume 74, Number 2February 1994

Table 4. Comparison of Mean Goniometric Result? by Clinic

Flexlon (") Extenrlon (")

Cllnlcb Radlal Ulnar Dorral Radial Ulnar Volar

"Standard deviation shown in parentheses. Asterisks (*,**) denote significant difference (P1.05, df=2; analysis of variance followed by a Tukey Honestly Significant Difference Multiple-comparison Test) between similarly labeled techniques.

h ~ e e Appendix for listing of clinics.

noted may be insignificant; however, that repeated measurements made more conservatively than measure- it does question traditional wisdom by different therapists be interpreted ments made by the same therapist.

The percent effect of various factors on the reliability of wrist goniometric measurements was analyzed by the generalizability theory. Classical reliability theory partitions a score or measurement into a true component and an error component, with any deviation from the true score being deemed external random error. The generalizability theory forces one to interpret reliability in a multidimen- sional fashion. The underlying prem- ise is that not all variations from trial to trial should be attributed to random error. Instead, the generalizability theory is used to identify other factors that might influence test scores. With the identification of other relevent effects on test scores, the therapist should be able to explain, predict, and control for these factors and thus leave less variance unexplained as simply "error."28 The generalizability statistical analysis allowed

Flgure 6. Intrutherapist intraclass correlation coeficient (ICC) results for flexion by clinic (see Appendix for listing of clinics).

76 / 169 Physical Therapy/Volume 74, Number 2Pebruary 1994

Figure 7. Intrutherapist intracIass correlation coeficient (ICC) results for extension by clinic (see Appendix for listing of clinics).

quantification of which factors con- In our study, the patients' wrist mo- tributed to variance and ultimately to tion provided the greatest amount of reliability. variance. This finding was not unex-

pected, as some subjects had near-

Flgure 8. Intertherapist intraclass correlation coeficient (ICC) results for flexion by clinic (setb Appendix for listing of clinics).

normal PROM, whereas others had severely limited motion at the wrist. Unexplained error had the second greatest effect on reliability and may have included testing conditions, such as time of day, or positioning of the subject, among other factors. Deficien- cies in the study design can also be categorized under "unexplained error." The effect of diagnostic category and treatment can certainly influence variance among measurements. Scar- ring, bony o r soft tissue deformities, o r pain may cause imprecise goniometric placement. Inconsistent external force application, which is required for PROM measurements, may also affect the results. The effect of the actual goniometric technique and the effect of the therapist on variance is small but not inconsequential, and should be considered when measuring wrist ROM.

Other potential sources of error dur- ing goniometric measurements may have been poor visualization of bony landmarks. Perhaps when edema or an aberrant bony prominence was encountered, the testers attempted to be more precise in placement of the goniometer's arms, hence the greater reliabilty of the volar/dorsal technique. These anatomical obstructions, however, may cause the therapist to question what is actually measuring, or the validity of the measurement. Horger2* noted external force application most often as a potential source of error in wrist flexion and extension PROM measurements. In our study, however, the potential for more consistent external force application for a PROM measurement dur- ing the volar/dorsal method may have been one of the reasons it had greater reliabilty. In the volar/dorsal technique, the distal arm of the goniometer is placed where a passive external force is applied to the wrist, thus allowing greater repeatability of the passive force application. Other potential sources of error may include inconsistent positioning of the patient for the measurement or pain while moving the wrist passively. All potential sources of error may have been more profound in measuring extension rather than flexion. as flex-

Physical Therapy /Volume 74, Number 2February 1994

Figure 9 . Intertherapist intraclass correlation coefficient (ICC) results for extension by clinic (see Appendix for listing of clinics).

ion measurement reliability was greater. All of these potential sources of error have previously been reported in the literature.2124'34'35

In this study, an effort was made to sample a broad range of patients and therapists in an attempt to allow generalization of results beyond this

study. The design of the study ensured the assessment of all three goniometric techniques. In Horger's study,24 the therapists were allowed to choose whichever technique they preferred. In Horger's study, all specialized therapists (those who practice at hand clinics) chose the ulnar technique, whereas all nonspecialized

therapists (those who do not practice at hand clinics) chose the radial technique. The results of Horger's study, therefore, may be an assessment of specialty versus nonspecialty therapists rather than an assessment of goniometric techniques. The study by Duffin and Zoeller25 used nondisabled subjects and was limited to only one rater, who measured wrist flexion and extension radially and ulnarly. In our study, a broad range of clinical experience among the therapists, including certified hand therapists who practice in a hand/upper-extremity environment, ensured heterogeneity. Multiple clinics across the United States were used to allow for regional differences. Finally, the randomization and "blinding" of the tester minimized bias within the study.

Although this was a multicenter study, we believe separate analysis of each clinic was required because randomization of testing pairs occurred within clinics but not between clinics. Testing pairs had an opportunity to measure subjects only within their own clinic. Therefore, the ANOVA, Tukey Multiple-Comparison Tests, ICC, SEM, and generalizability statistics were utilized for each individual clinic. The descriptive statistics (mean, standard deviation, and range) were calculations of general trends across all clinics.

T a b l e 5 . Results of Descriptive Statistics Across All Clinics

Intratherapist (ICCa[3,1])

Radial

Ulnar

Dorsal

Volar

Intertherapist (ICC[2,

Radial

Ulnar

Dorsal

Volar

1])

Flexion

X

.86

.87

.92

.88

.89

.93

SD

.058

.053

.026

.054

.045

.019

Range

J5-.92

.79-.93

.88-.96

.77-.92

.82-.94

.90-.95

Extension

X

.80

.80

.84

.80

.80

.84

SD

.061

.077

.097

.091

.093

.097

Range

.68-.86

.66-.88

.66-.94

.69-.87

.61-.88

.66-.95

"ICC=intraclass correlation coefficient.

This study assessed only PROM for wrist flexion and extension. Active-range-of-motion goniometric reliability should be assessed in future studies. Although the literature suggests that AROM measurements are more reliable than PROM measurements,24,36 passive motion measurements are thought to be more valid indicators of changes in periarticular connective tissue.6 Additionally, a PROM measurement appears to be the most appropriate measurement for assessing widely used passive treatments.6 The design of this study prohibited the therapists from choosing a goniometric technique to use. By requiring each measurer to use all of the techniques, the study design ensured assessment of all three goniometric methods. In addition, the

78/171 Physical Therapy/Volume 74, Number 2/February 1994

Table 6. Intratherapistllntertherapist Standard Error of Measurement (in Degrees) for All Clinics and Goniometric Techniques

lntratheraplst lntertheraplst

Flexlon Extension Flexlon Extension

Cllnlca Radlal Ulnar Dorsal Radlal Ulnar Volar Radlal Ulnar Dorsal Radlal Ulnar Volar

"See Appendix for listing of clinics

study design allows generalization of the results beyond the testers in this study. The operational definitions were co~npiled from textbooks that are used. to teach goniometry in physical therapy and occupational therapy curricula. The use of a recorder to read the goniometer did not repro- duce the true clinical environment,

but minimized bias. Finally, the use of multiple centers resulted in an un- equal number of subjects from each clinic and the inability of each measuring pair to have an equal opportunity to measure all subjects. This limitation restricted the use of the ICC statistical analysis to each clinic inde-

Flgure 10. Sources of error (in percentages): contribution of patient and miscellaneous error (see Appendix for listing of clinics).

pendently rather than to all clinics as a whole.

Future studies should assess wrist AROM measurement reliability and validity. Additionally, studies that try to further analyze some of the identified sources of wrist mesurement error may help provide more specific guidelines for measurement. For example, different measuring techniques for specific diagnostic categories may be useful. Controlling external force application for PROM at the wrist may improve reliability further.

The radial, ulnar, and volar/dorsal goniometric techniques should not be used interchangeably, as their results frequently will be inconsistent. There- fore, when given the choice, the volar/dorsal goniometric technique should be used, as it appeared to be the most reliable method both within and between testers for measurements of passive wrist flexion and extension. The clinician should be cautious, however, when interpreting these data, as goniometric reliability for wrist passive flexion and extension measurements were population-specific.

Physical Therapy /Volume 74, Number 2iFebruary 1994

Appendix. Clinics Participating in Multicenter Study

A-Curtis Hand Center, Union Memorial Hospital, Baltimore, MD

0-University of Florida, Department of Orthopaedics, Gainesville, FL

C-Hand Rehabilitation Center of Gainesville Inc, Gainesville. FL

D-Loyola University Medical Center, Department of Occupational Therapy, Maywood, IL

E-Hand Rehabilitation Association of San Antonio Inc, San Antonio, TX

F-Hand Surgery Associates PC, Denver, CO

G--University of Pennsylvania, Medical Center Penn Hand Specialists, Philadelphia, PA

H-Michigan Hand Rehabilitation Center Inc, Warren, MI

Figure 1 1. Sources of error (in percentages): contribution of diagnostic categoly and treatment (see Appendix for listing of clinics).

References

Acknowledgment

We thank all of the clinics involved in this study. Without their participation,

this have 1 McEntee PM, Therapistss management of the been possible. stiff hand. In: Hunter JM, Schneider LH, Mackin

EJ, Callahan AD, eds. Rehabilitation of the Hand: Surgely and Therapy. 3rd ed. St Louis, Mo: CV Mosby Co; 1990:328-341. 2 Mennell JM. Joint Pain: Diagnosis and Treatment Using Manipulative Techniques. Boston, Mass: Little, Brown and Company Inc; 1964:4447.

Figure 12. Sources of error (in percentages): contribution of goniometric technique and therapist (see Appendix for listing of clinics).

3 Colditz JC. Dynamic splinting of the stiff hand. In: Hunter JM, Schneider LH, Mackin EJ, Callahan AD, eds. Rehabilitation of the Hand: Surgely and Therapy. 3rd ed. St Louis, Mo: CV Mosby Co; 1990:342-352. 4 Schultz-Johnson K. Splinting: a problem- solving approach. In: Stanley B, Tribuzi S, eds. Concepts in Hand Rehabilitation. Philadelphia, Pa: FA Davis Co; 1992:238-271. 5 Bell-Krotoski JA. Plaster cylinder casting for contractures of the interphalangeal joints. In: Hunter JM, Schneider LH, Mackin EJ, Callahan AD, eds. Rehabilitation of the Hand: Surgely and Therapy. 3rd ed. St Louis, Mo: CV Mosby CO; 1990:1128-1133. 6 Flowers KR, Michlovitz SL. Assessment and management of loss of motion in onhopaedic dysfunction. In: Postgraduate Advances in Physical Therapy. Alexandria, Va: American Physical Therapy Association; 1988: 1-1 1. 7 Guides to the Evaluation of Permanent Im- painnent. 2nd ed. Chicago, Ill: American Medi- cal Association; 1984. 8 Fess EE, Moran CA. Clinical Assessment Rec- ommendations. Garner, NC: American Society of Hand Therapists; 1981. 9 Esch D, Lepley M. Evaluation of Joint Mo- tion: Methods of Measurement and Recording. Minneapolis, Minn: University of Minnesota Press; 1973.

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10 Moore ML. Clinical assessment of joint motion. In: Basmajian JV, ed. Therapeutic Exercise. 4th ed. Baltimore, Md: Williams & Wilkins; 1984:194-224. 11 Norkin CC, White DJ. Measurement of

Joint Motion: A Guide to Goniomety. Philadel- phia, Pa: F,4 Davis Co; 1985. 12 Scott N, Trombly CA. Evaluation. In: Trom- bly CA, ed Occupational Therapy for Physical Dysfunction. 2nd ed. Baltimore, Md: Williams & Wilkins; 1983:126229. 13 Watsor~ HK, Hempton RF. Limited wrist arthr0desis.J Hand Surg [Am] 1980;15:320- 327. 14 Cooney WP, Beckenbaugh RD, Linscheid RL. Total wrist arthroplasty. CIin Orthop. 1983; 187:121-128. 15 Palmer AK, Dobyns JH, Linscheid RL.. Man- agement of post-traumatic instability of the wrist secondary to ligament rupture. J Hand Surg /Am]. 1978;3:507-532. 16 Cobe HM. The range of aaive motion at the wrist of white adults.]Bone Joint Surg. 1928;26:763-774. 17 Hewitt D. The range of active motion at the wrist of woman./ Bone Joint Surg. 1928; 26:775-787. 18 Hellebrandt FA, Duvall EN, Moore ML. The measurement of joint motion, part 3: reliability of goniometry. Phys Ther Rev. 1949;29:302-307.

19 Hamilton GF, Lachenbruch PA. Reliability of goniometers in assessing finger joint angle. Phys Ther. 1969;49:465469. 20 Low JL. The reliability of ioint measurement. Physiotherapy. 1976;62:227-229, 21 Fish DR, Wingate L. Sources of goniometric error at the elbow. Phys Ther. 1985;65:1666 1670. 22 Solgaard S, Carlsen A, Kramhoft M, Peter- sen VS. Reproducibility of goniometry of the wrist. ScandJ Rehabil Med. 1986;18:5-7. 23 Rothstein JM, Miller PJ, Roetger RF. Gonio- metric reliability in a clinical setting: elbow and knee measurements. Phys Ther. 1983;63: 1611-1615. 24 Horger MM. The reliability of goniometric measurements of active and passive wrist mo- tions. A m ] Occup Tho . 1990;44:342-348, 25 Dufin L, Zoeller R. Reliability and comparison of two goniometric methods for the wrist. Presented at the 66th Annual Conference of the American Physical Therapy Association; June 23-27, 1991; Boston, MA. 26 Marks RG. Analyzing Research Data: The Basis of Biomedical Research Methodology. London, England: Lifetime Learning; 1982. 27 Shrout PE, Fleiss JL. Intraclass correlations: uses in assessing rater reliability. Psycho1 Bull. 1979;86:420428, 28 Portney LG, Watkins MP. Foundations of Clinical Research: Applications to Practice. East

Invited Commentary

Norwalk, Conn: Appleton & Lange; 1995505- 528. 29 Rothstein JM. Measurement and clinical practice: theory and application. In: Rothstein JM, ed. Measurement in Physical Therapy. New York, NY: Churchill Livingstone Inc; 1985:146. 30 Cronbach LC. The Dependability of Behav- ioral Measurements: T h e o y of Generalization

for Scores a n d ProJIes. New York, NY: John Wiley & Sons Inc; 1972. 31 SASSTAT 6.03. Cary, NC: SAS Institute Inc; 1988. 32 Morehouse CA, Stull GA. Statistical Princi- pals a n d Procedures With Applications for Pbvsical Education. Philadelphia, Pa: Lea & Febiger; 1975. 33 Task Force on Standards for Measurement in Physical Therapy. Standards for tests and measurements in physical therapy practice P h y ~ Thm 1991;71:589-622. 34 Moore ML. The measurement of joint motion, pan 1: introductory review of the literature. Phys Ther Rev. 1949;29:195-205. 35 Hamilton GF, Lachenbruch PA. Reliability of goniometers in assessing finger joint angle. Pbvs Ther 1969;49:465469. 36 Gaidosik RL., Bohannon RW. Clinical measurement of range of motion: review of goniometry emphasizing reliability and validity. P h y ~ Thet. 1987;67:1867-1872.

The authors' work on reliability of passive-range-of-motion (PROM) goniometry of wrist flexion and extension is in the spirit of Peacock's observa- tion that "the greatest advance in hand therapy in the last few decades and certainly one of the greatest con- tributions to care of patients has been the introduction of the science of measurement . . . it is the only way we can know accurately what is being accomplished."l The need for accuracy in measurement is critical to clinical decision making, especially when it comes to PROM readings in relation to evaluating the appropriate- ness of stress delivery to the stiff joint.2 If changes in goniometric find- ings from visit to visit are to trigger an increase or a decrease in the stress dosage, we must have confidence in the accuracy of the reading. There- fore, reliability is neither a casual nor an esoteric issue.

The authors are quite correct to warn against the mixing of techniques in the test-retest process of day-to-day re-evaluation. However, can we be certain from this report that the volar- dorsal technique, which consistently scored higher on the intraclass correlation coefficient (ICC) values, is the preferred clinical test?

Two major concerns occur to me involving the ulnar technique, which appeared less reliable than the volar- dorsal technique. The operational instructions provided for the testers called for placing the mobile arm of the goniometer parallel to the third metacarpal, rather than the fifth metacarpal. Visualizing the long axis of the third metacarpal can be proble- matic. Alignment with the readily visible fifth metacarpal might be more accurate, perhaps resulting in better reliability. However, use of the fifth metacarpal introduces an additional

source of error that must be controlled when performing the technique. Because as much as 20 degrees of flexion has been observed at the fifth carpometacarpal (CMC) joint? care must be taken not to direct the passive force through the mobile fifth metacarpal. Rather, the force should be applied through the third metacarpal. In the study's operational instructions, there was no direct mention of this factor, and some testers therefore may have applied force through the mobile fifth metacarpal.

Testing ulnarly carries a further potential error, not in measurement, but in the interpretation of the finding as pertains to the potential 20 degrees of CMC motion. For example, if one's goal for wrist flexion is 40 degrees, which the Mayo Clinic has reported as the wrist's functional range of flexion? but 20 degrees is actually attrib- utable to the CMC joint, then a 40-


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Reliability of Passive Wrist Flexion and Extension ......tester's measurements was 2 to 3 minutes. Each subject's passive wrist flexion and extension was therefore mea- sured three