Objective Assessment with Establishment of Normal Values for Lumbar Spinal Range of Motion G Kelley Fitzgerald, Kevin J Wynveen,

Wendy Rheault and Bruce Rothschild PHYS THER. 1983; 63:1776-1781.

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Objective Assessment with Establishment of Normal Values for Lumbar Spinal Range of Motion
G. KELLEY FITZGERALD, KEVIN J. WYNVEEN, WENDY RHEAULT, and BRUCE ROTHSCHILD

The purpose of this article is to present an assessment method, in conjunction with age-related normal values, for lumbar spinal range of motion. Lumbar flexion, lumbar extension, and right and left lateral flexion were measured on 172 subjects by a combination of goniometry and spinal distraction techniques. Normal values are given for six age groups; each group had a range of 10 years. The results demonstrate that a significant decrease in lumbar spinal range of motion is expected with increasing age. The interobserver reliability based on 17 subjects was substantial for the four measurements taken; coefficients ranged from +.76 to +1.0. The information may prove useful to the clinician as an improved method for assessing the lumbar spine. Key Words: Aging, Lumbosacral region, Physical therapy, Reference values.

Measuring joint mobility accurately is important to the physical therapist in assessing the lumbar spine. Knowledge of lumbar range of motion may aid in determining levels of spinal pathology, guidelines for treatment, and patient response to treatment. 1 ' 2 To perform an accurate assessment of the lumbar spine, objective clinical methods of measurement are necessary.3 Several methods are currently available for measuring spinal range of motion (eg, radiography, plumb line, distraction, and goniometry). 4,5 Although radiographic examination is accurate, it is expensive, requires exposure to harmful radiation, and is not always accessible to the physical therapist. Plumb-line and distraction methods have been used clinically for the measurement of spinal range of motion in Eng-

Mr. Fitzgerald is Staff Physical Therapist, Sacred Heart Hospital, 1545 S Layton Blvd, Milwaukee, WI 53215. Mr. Wynveen is Staff Physical Therapist, Kaiser Medical Center, 4647 Zion Ave, San Diego, CA 92129. Mrs. Rheault is Assistant Professor of Physical Therapy, University of Health Sciences/The Chicago Medical School, 3333 Green Bay Rd, N Chicago, IL 60064 (USA). Dr. Rothschild is Director of Medical Education and Chief of Rheumatology, Menorah Medical Center, Kansas City, and Associate Professor, University of Missouri, Kansas City, MO 64110. At the time of this study, both Mr. Fitzgerald and Mr. Wynveen were senior physical therapy students at the University of Health Sciences/The Chicago Medical School and Dr. Rothschild was Assistant Professor of Medicine and Director of the Division of Rheumatology at the University of Health Sciences/The Chicago Medical School. Direct all correspondence to Mrs. Rheault. This article was submitted May 24, 1982; was with the authors for revision 24 weeks; and was accepted June 24, 1983.

land. 4,6 It is our opinion, however, that these methods are somewhat time-consuming, and, furthermore, they are not commonly used in the United States. Goniometry is a relatively quick and easy alternative method of measuring spinal mobility. It is readily accessible to the physical therapist and is commonly used in the United States. Batch7 and Kapandji 8 have outlined objective methods of assessing lumbar spinal range of motion. Normal range has been presented by these clinicians but not verified by empirical studies or differentiated by age. 7,8 Other researchers have documented normal values for lumbar range of motion; however, many different assessment techniques besides goniometry have been used. Clayson et al measured lumbar range of motion on 26 healthy subjects by using roentgenograms.9 Loebl used the inclinometer to measure a larger sample size of 176, but he measured only lumbar flexion and extension.10 Other measurement techniques in the literature include using the flexirule and the spondylometer.11,12 Troup and colleagues also measured lumbar flexion and extension and concluded that the assessment methods they used (including photographic studies) were not well suited for the clinic.13 Moll and Wright measured forward flexion and lateral flexion by the distraction method and spinal extension by the plumb-line method.4 They documented age-related changes based on data collected from 374 healthy subjects. To our knowledge, no such study has been done with the goniometric method. Therefore, a need exists to establish normal age-related values for lumbar range of motion by PHYSICAL THERAPY

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RESEARCH using techniques commonly chosen by the physical therapist. Because the goniometer is the most commonly used instrument for measuring range of motion, the reliability of this method should be examined.14 Low found that measurement with a typical goniometer is more reliable than estimating by eyesight.15 Hellebrandt and associates reported good agreement in 780 paired observations conducted by a single skilled observer with the goniometer.16 They obtained identical readings 21 percent of the time; in 70 percent of the measurements, the second trial varied 3 degrees or less from that of the first; and in 95 percent, the variation was 7 degrees or less. The foregoing studies and the study by Boone and colleagues showed that measurement reliability of the goniometer varies according to the joint being measured.17 Intraobserver error has been notably less than interobserver error.15-17 These studies, however, were conducted exclusively on the upper and lower extremities. Based on a review of the literature, the reliability of the goniometric method for assessing spinal range of motion has not been determined. The purpose of this study was twofold: 1) to determine an objective clinical method for assessing lumbar spinal range of motion, establish normal values for this method, and investigate interobserver reliability; and 2) to document the effect of increasing age on the range of motion of the lumbar spine. METHOD Subjects The subjects consisted of 172 volunteers, 4 women and 168 men; all were patients at the Veterans Administration Hospital in North Chicago, Illinois. Because Moll and Wright have documented that spinal mobility differs by only 7 to 10 percent between the sexes, we included women in this study.4 The subjects ranged in age from 20 to 82 years, and for statistical purposes, they were categorized into six age groups, each with a class range of 10 years (Tab. 1 gives the number of subjects in each age group). All data were collected over a five-month period in the summer and fall of 1981 as part of an assessment of institutional manpower needs. All subjects had responded to a questionnaire as part of the assessment and were included in our study if back pain was not a current complaint and if any previous back pain had lasted less than three months. Procedure We observed anterior lumbar spinal flexion, right and left lateral thoracolumbar spinal flexion, and spinal extension in this order. For each of the four Volume 63 / Number 11, November 1983 measurements, the subject performed three trials. Anterior flexion was measured by a distraction method developed by Shober.18 We chose this method because we had found it to be a good clinical assessment technique. The American Academy of Orthopaedic Surgeons also suggests this method in its book on goniometry.19 The other movements were measured by the goniometer. The Shber method uses a plastic tape measure to determine the amount of distraction (in centimeters) between two points on the lumbar spine during trunk flexion.18 According to the American Academy of Orthopaedic Surgeons, the tape measure is perhaps the most accurate clinical method of measuring the true motion of spinal flexion because it can conform to spinal curvatures.19 The subject was positioned standing erect with feet approximately shoulderwidth apart. The most superior aspects of the iliac crests were located by palpation, and a small line was applied with a marking pen over the corresponding spinal level. A second small line was placed 10 cm above this first reference point. The observer stood slightly posterior and lateral to the subject. The subject was then instructed to bend forward, as far as possible, keeping the knees straight throughout the entire movement. When the subject had completed maximal trunk flexion, determined by observers as an absence of further motion, the distance between the two markings was measured and recorded, and the subject was instructed to return to the upright position. Three trials were recorded for each subject. For each trial, the initial distance was subtracted from the final (maximal trunk flexion) distance. We used a goniometer to measure right and left thoracolumbar spinal flexion and noted degrees of motion. While the subject was standing erect, the goniometric axis was placed at approximately the level of the lumbosacral junction. The stationary arm was positioned in a line vertical to the floor, while the moving arm was aligned with the spinous process of C7. The American Academy of Orthopaedic Surgeons states that the relative position of the spinous process of C7 to the pelvis is a method of measuring thoracic and lumbar lateral spinal bending.19 To make the measurements, the observer sat directly behind the subject so that the eyes of the observer were approximately at the level of the goniometer axis. The subject was instructed to stand erect with feet spread approximately shoulder-width apart (this position may stabilize the pelvis more effectively than with the feet together).20 Also, with the feet spread, the subject had a wider base of support, which aided in maintaining balance while performing the movement. Instruction was given to bend directly to the side, as far as possible, and the observer recorded the range of motion in degrees. Measurements of three trials to the right followed by three trials to the left were recorded for each subject.

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TABLE 1 Means and Standard Deviations in 10-Year Intervals for Lumbar Range of Motion Age (yr) 20-29 30-39 40-49 50-59 60-69 70-79 3.7 3.9 3.1 3.0 2.4 2.2 Shber (cm) s 0.72 1.00 0.81 1.10 0.74 0.69 CV 19.5 25.6 26.1 36.7 30.8 31.4 na 31 42 16 43 26 9 41.2 40.0 31.1 27.4 17.4 16.6 Extension R Lat Flexion

()
s 9.6 8.8 8.9 8.0 7.5 8.8 CV 23.3 22.0 28.6 29.2 43.1 53.0 n 31 44 16 43 27 10 37.6 35.3 27.1 25.3 20.2 18.0 s

()
CV 15.4 18.4 24.0 24.5 23.8 26.1 n 31 44 16 44 27 10 38.7 36.5 28.5 26.8 20.3 18.9

L Lat Flexion () s 5.7 6.0 5.2 6.4 5.3 6.0 CV 14.7 16.4 18.2 23.9 26.1 31.7 n 31 44 16 44 27 10

5.8 6.5 6.5 6.2 4.8 4.7

a Different "n's" appear in some age groups because of the difficulty in measuring patients with various medical conditions (eg, rash).

TABLE 2 Ninety-five Percent Confidence Intervals in 10-Year Age Groups for Range of Values for Lumbar Range of Motion Age (yr) 20-29 30-39 40-49 50-59 60-69 70-79 Shber (cm) 3.4-4.0 3.6-4.2 2.7-3.5 2.7-3.3 2.1-2.7 1.7-2.7 Extension () 37.7-44.7 37.3-42.7 26.4-35.8 24.9-29.9 14.4-20.4 10.3-22.9 R Lat Flexion () 35.5-39.7 33.3-37.3 23.6-30.6 23.4-27.2 18.3-22.1 14.7-21.3 L Lat Flexion () 36.6-40.8 34.7-38.3 25.7-31.3 24.9-28.7 18.2-22.4 14.7-23.1

Spinal extension was also measured with a goniometer. The subject stood erect with feet approximately shoulder-width apart; the observer sat facing the subject's side. The goniometric axis was placed at the most superior aspect of the iliac crest, aligned with the midaxillary line. The stationary arm was positioned in a line perpendicular to the floor, while the moving arm was aligned with the midaxillary line. The subject was instructed to bend directly backwards, as far as possible, while maintaining extension of the knees. When the subject attained maximal spinal extension, determined by the observers as absence of further motion, the degrees of movement were recorded.

ences/The Chicago Medical School who volunteered as subjects. The two observers independently took the four lumbar measurements on each of the 17 subjects. Pearson reliability coefficients were calculated on the paired results obtained by these observers.

RESULTS
Interobserver reliability was as follows: Shber Test, r = 1.0; spinal extension, r = .88; right lateral spinal flexion, r = .76; and left lateral spinal flexion, r = .91. All coefficients were statistically significant at p <.001. The means, standard deviations, and coefficients of variation (CVs) are given for each of the measurements according to age group (Tab. 1). The variation in range of motion of the lumbar spine with age is evident in Table 1. As reflected by the CVs, the variability in normal range of motion generally increased for the older age groups. The 95 percent confidence interval for each measurement represents the range of scores expected for 95 percent of all subjects in the specific age group (Tab. 2). The confidence intervals provide the clinician with functional ranges of normal values for lumbar range of motion. The ANOVA of the between-age-group differences yielded significant F values for each of the four rangeof-motion measurements (Tab. 3). The group mean values are graphically illustrated in the Figure, and the results of the follow-up Scheffe comparisons of

Analysis
The results were analyzed in 10-year age intervals, and the mean, standard deviation and coefficient of variation were calculated for each measurement. A 95 percent confidence interval was determined for the measurements by age group. Bar graphs were constructed to analyze variation in range of motion of the lumbar spine with age. An analysis of variance (ANOVA) was used to test for significant differences between age groups in the four lumbar range-ofmotion measurements. Scheffe's multiple comparisons were used for post hoc analysis. The interreliability data for this paper were collected by two independent observers on 17 physical therapy students from the University of Health Sci-

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RESEARCH pairs are presented in Table 4. The obvious trend was a decrease in lumbar spine mobility with age. The analysis revealed a specific pattern for the three range-of-motion measurements of spinal extension and right and left lateral flexion. For these three measurements, none of the adjacent decade age groups were significantly different from each other except for the 30- to 39-year-old versus the 40- to 49year-old and the 50- to 59-year-old versus the 60- to 69-year-old age groups. The pattern was a systematic decrease in the measurements for 20-year intervals. For anterior flexion (Shber test), the pattern was different. Significant differences (p < .05) occurred between the 20- to 29-year-old group and the 60- to 69-year-old and 70- to 79-year-old age groups. Significant differences (p < .05) between the 30- to 39year-old and the three older age groups also were found. DISCUSSION Interobserver reliability based on 17 young adults was found to be substantial for all four measurements and verified the precision and objectivity of the assessment techniques. Because the interobserver reliability was based on 17 young adults, generalizing these fndings to subjects ranging in age from 20 to 79 years has limitations. Kapandji estimated the following average values across all age groups for lumbar spinal range of motion: lumbar spinal extension, 35 degrees; anterior flexion, 60 degrees; and lateral flexion, 40 degrees.8 Batch assigned similar values to lumbar spinal mobility based on his clinical observations: extension, 30 degrees; anterior flexion, 70 degrees; and lateral flexion, 40 degrees.7 Neither Kapandji nor Batch made a distinction between the various age groups, and Batch did not indicate how many patients he observed to establish these values. Rothschild has stated that normal values for the Shber test range from 3 to 5 cm.21 Tables 1 and 2 show that our data for the younger age groups are consistent with the values from other studies. As age increases, however, range of motion decreases significantly, and Kapandji's and Batch's values are no longer consistent with the results of the present study. As pointed out earlier, the CVs indicate a greater variability in normal range for the older age groups. This variability may be important to keep in mind when assessing older subjects. Moll and Wright documented a decrease in lumbar range of motion with age.4 They used seven age groups, each with a range of 10 years beginning with 15 to 24 years of age. Because they used assessment methods other than goniometry, comparing their results with ours is difficult. Because they did not calculate the CVs, comparing the variability between age groups is also difficult. Their findings and the Volume 63 / Number 11, November 1983

Figure. Bar graphs of means for each measurement by age group.

results of the present study, however, suggest that range of motion of the lumbar spine should be assessed in light of patient age. An interesting pattern of the age-related change in spinal mobility was found by performing multiple comparisons. The results suggest that lumbar extension and lateral flexion not only decrease with age, but that this decrease occurs in 20-year intervals. Although the statistical analysis did not yield the same results, the graphs demonstrate a similar pattern for anterior flexion. 1779

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TABLE 3 Results of ANOVA of the Between-Age-Group Differences

Variable Shber by age Source Between groups Within groups TOTAL Between groups Within groups TOTAL Between groups Within groups TOTAL Between groups Within groups TOTAL df 5 161 166 5 165 170 5 166 171 5 166 171 SS 55.18 137.67 192.86 14460.28 12102.86 26563.14 8040.67 5945.69 13986.37 8509.77 5739.37 14249.14 MS 11.04 0.85 2892.06 73.35 1608.13 35.82 1701.95 34.57 F 12.90 a

Extension by age

39.43 a

R lat flexion by age

44.90 a

L lat flexion by age

49.23 a

p < .001. TABLE 4 Results of Scheffe Multiple Comparison Procedure Between Groups
Group 20 to 29 Shber Extension R lat flex L lat flex 30 to 39 Shber Extension R lat flex L lat flex 40 to 49 Shber Extension R lat flex L lat flex 50 to 59 Shber Extension R lat flex L lat flex 60 to 69 Shber Extension R lat flex L lat flex 30 to 39 4 0 to 49 50 to 60 60 to 69 a a a a a a a a 70 to 79 a a a a a a a a

a a a

a a a a a a a

a a a

a a a

a a a

a a a

a a a

Denotes pairs significantly different at .05.

Because our data were obtained from predominantly male subjects, a statement on gender differences in range of motion of the lumbar spine cannot be provided from this study. As mentioned earlier, Moll and Wright found that spinal mobility differed by only 7 to 10 percent between the sexes.4 More research in this area is needed. A limitation of this study concerns the small sample sizes in two of the groups, that is, n = 9 for the 70- to 79-year-old group and n = 16 for the 40- to 49-yearold group. 1780

CONCLUSION We have described an objective and reliable method for measuring lumbar spinal range of motion and established normal values according to age for this method as indicated by a 95 percent confidence interval. The results of this study confirmed an agerelated decrease in range of motion. We believe that physical therapists should make use of these norms in examination and remember to assess patients' range of motion in light of their age. PHYSICAL THERAPY

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RESEARCH REFERENCES
1. Moll JMH, Liyanage SP, Wright V: An objective clinical method to measure spinal extension. Rheumatology and Physical Medicine 11:293-312, 1972 2. Moskowitz RW: Clinical Rheumatology: A Problem Oriented Approach. Philadelphia, PA, Lea & Febiger, 1975, pp 7-21 3. Bilka PJ: Physical examination of the arthritic patient. Bull Rheum Dis 20:7, 1970 4. Moll JMH, Wright V: Measurement of Spinal Movement. In Malcom Jason: The Lumbar Spine and Back Pain. New York, NY, Grune & Stratton Inc, 1976, p 93 5. Woesner ME, Mitts MG: The evaluation of cervical spine motion below C2: A comparison of cineroentgenographic and conventional roentgenographic methods. American Journal of Roentgenology, Radium Therapy & Nuclear Medicine 115:148-154, 1972 6. Archer IA, Moll JMH, Wright V: Chest and spinal mobility in physiotherapists: An objective clinical study. Physiotherapy 60:37-39, 1974 7. Batch JW: Measurements and recording of joint function. US Armed Forces Medical Journal 6:359-382, 1955 8. Kapandji IA: The Physiology of the Joints, ed 2. New York, NY, Churchill Livingstone Inc, 1974, vol 3, pp 1 1 4 - 1 1 8 9. Clayson SJ, Newman IM, Debevec DF, et al: Evaluation of mobility of hip and lumbar vertebrae of normal young women. Arch Phys Med Rehabil 4 3 : 1 - 8 , 1962 10. Loebl WY: Measurement of spinal posture and range of spinal movement. Annals of Physical Medicine 9:103-110, 1967 11. Anderson JAD, Sweetman BJ: A combined flexi-rule/hydrogoniometer for measurement of lumbar spine and its sagittal movement. Rheumatol Rehabil 14:173-179, 1975 12. Sturrock RD, Wojtulewski JA, Hart FD: Spondylometry in a normal population and in ankylosing spondylitis. Rheumatol Rehabil 12:135-142, 1973 13. Troup JDG, Hood CA, Chapman AE: Measurements of the sagittal mobility of the lumbar spine and hips. Annals of Physical Medicine 9:308-321, 1968 14. Peat M, Campbell G: Measurement systems in physical therapy. Physiotherapy Canada 31:132-136, 1979 15. Low J: The reliability of joint measurement. Physiotherapy Canada 62:227-229, 1976 16. Hellebrandt FA, Duvall EN, Moore ML: The Measurement of Joint Motion: Part III, Reliablity of goniometry. The Physical Therapy Review 29:302-307, 1949 17. Boone DC, Azen SP, Lin C, et al: Reliability of goniometric measurements. Phys Ther 58:1355-1360, 1978 18. Shober P: The lumbar vertebral column and backache. Muenchener Medizinische Wochenschrift 84:336, 1937 19. American Academy of Orthopaedic Surgeons: Joint Motion, Method of Measuring and Recording. Chicago, IL, 1965, pp 48-51 20. Polley H, Hunder G: Rheumatologic Interviewing and Physical Examination of the Joints. Philadelphia, PA, WB Saunders Co, 1978, p 168 2 1 . Rothschild BM: Rheumatology: A Primary Care Approach. Brooklyn, NY, Yorke Medical Books, 1982, p 23

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Objective Assessment with Establishment of Normal Values for Lumbar Spinal Range of Motion G Kelley Fitzgerald, Kevin J Wynveen, Wendy Rheault and Bruce Rothschild PHYS THER. 1983; 63:1776-1781.

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