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Effects of warming up on reliability of anthropometric techniques in ankylosing spondylitis.

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549
BRIEF REPORT
EFFECTS OF WARMING UP ON RELIABILITY OF
ANTHROPOMETRIC TECHNIQUES IN ANKYLOSING SPONDYLITIS
W. NEAL ROBERTS, MATTHEW H. LIANG, LORNA M. PALLOZZI, and LAWREN H. DALTROY
To determine the effect of warm-up on anthropometric measures, 10 patients with ankylosing spondylitis and 10 normal control subjects were measured over
a l-hour period by one therapist. A series of 4 measures-a modified Schober’s test, finger-to-floor with
the subject standing on a 23-em stool, chest expansion,
and cervical rotation using an arthrodial protractorwere repeated completely 4 times. Subjects exercised
between each series (except between the third and fourth
series). Intra-rater reliability was determined by comparing measurement 3 with measurement 4, and the
warm-up effect was determined by comparing measurement 1 with measurement 3. The Schober’s test and
chest expansion are stable measures and are not affected
by warm-up. However, the finger-to-floor and cervical
rotation exercises require warm-up to ensure stable
values for clinical or research followup of spondylitis.
Anthropometric techniques have long been
used to diagnose and monitor ankylosing spondylitis
(AS). The measurement of spinal motion was first
From the Departments of Medicine, Rheumatology and
Immunology, Brigham and Women’s Hospital, Harvard Medical
School, Robert B. Brigham Multipurpose Arthritis Center, Boston,
Massachusetts.
Supported by the World Rehabilitation Fund and NIH
grants AM-36308 and RR-05669.
W. Neal Roberts, MD: Instructor in Medicine, Harvard
Medical School, and Arthritis Foundation Fellow (current address:
Medical College of Virginia, Richmond); Matthew H. Liang, MD,
MPH: Associate Professor of Medicine, Harvard Medical School;
Lorna M Pallozzi, RPT; Lawren H. Daltroy, DrPH: Instructor,
Harvard Medical School and Harvard School of Public Health.
Address reprint requests to Matthew H. Liang, MD, MPH,
Robert B. Brigham Multipurpose Arthritis Center, 16B, Brigham
and Women’s Hospital, 75 Francis Street, Boston, MA 02115.
Submitted for publication February 14, 1986; accepted in
revised form October 13, 1987.
Arthritis and Rheumatism, Vol. 31, No. 4 (April 1988)
quantitated by Schober, by Moll and Wright, and by
Sturrock and coworkers (1-3). Numerous quantitative
methods have been proposed for assessing patients
with AS, including radiologic techniques ( 4 3 , measurement devices such as the spondylometer (6), the
goniometer (7), the inclinometer, and the cervical protractor @),other physical measurements such as chest
expansion (9), occiput-to-wall, intermalleolar straddle,
finger-to-floor, and neck rotation (lo), and various skin
distraction techniques (1,11,12). No one technique is
completely satisfactory, and the correlation of measurement techniques to one another ( 5 ) or to evaluation of
function in patient’s terms is arguable (13).
In one study of patients with rheumatoid arthritis or osteoarthritis, range of motion accounted for
about one-half the variation in function (14). Range of
motion incorporates many factors. For example, spinal range of motion decreases with age, shows wide
variation within each decade, varies by sex, and is
influenced by the presence of hip or knee disease (2).
Nevertheless, the majority of published measurements
incorporate, as a minimum, the Schober’s test, the
modified Schober’s test used by Moll and Wright, and
chest expansion. In evaluating measures for use in a
clinical trial, we studied the effect of warm-up on
measurement stability and reliability. Our findings are
relevant for the choice of measurements for clinical
trials and for clinical practice.
PATIENTS AND METHODS
Ten normal subjects and 10 AS patients from a
registry at our center were studied after informed
consent was obtained. The patients were evaluated by
one physician to determine disease and medical char-
BRIEF REPORTS
550
acteristics. Patients were entered into the study if their
rheumatologist believed that they had a spondylarthropathy and radiographs showed an abnormality in
at least one sacroiliac joint. Current radiographs were
not obtained. Existing radiographs were reviewed
independently in an unblinded manner by 2 rheumatologists not involved in care of the patients. Discrepancies between written evaluations by the clinical
radiologist, clinical rheumatologist, or either of the
study rheumatologists were resolved in favor of the
lower New York criteria grade (0-IV) (15). In 3
patients whose films were not available for review,
verbal or written reports of involved sacroiliac joints
were accepted as an indication of sacroiliitis. One
patient had bilateral grade IV sacroiliitis and 1 had
unilateral grade I changes; the remaining patient had
sacroiliac changes on both sides. Back pain was relieved by antiinflammatory medication in 9 patients
and by exercise in 7.
Clinical evaluation showed that only 1 patient
had advanced disease, with severe impairment of
spinal mobility and a high score on the Health Assessment Questionnaire (16). The Health Assessment
Questionnaire detected some functional impairment
for the group as a whole: 4 patients had a disability
index of 1 .O, 5 patients scored between 1.O and 1.5,
and 1 patient with longstanding AS had a disability
index of 2.65.
We selected 4 measures for their convenience
and because normative information was available.
Each physical measurement was taken 4 times independently, by one observer (LMP). Warming up or
stretching was done between measurements 1 and 2
and between measurements 2 and 3. In general, these
consisted of 3 repetitions of the motion necessary for
the measurement. Intra-rater reliability was studied
between measurements 3 and 4.The precise protocols
for each measure were as follows.
Smythe test (10-cm segment method). The 10-cm
segment method of the Smythe test requires that the
subject stand with feet at shoulder width. A tape is
used to mark the width of the stance. A line is drawn
between the posterosuperior iliac spines (PSIS). The
subject bends forward with knees straight, and 3
marks, at 10-cm intervals along the spine, are made in
a cephalad direction from the PSIS line. The subject
extends the spine in a prone position with arms
straight, allowing the abdomen to sag toward the
examining table. The 10-cm segments are then remeasured to give the resultant total measure. The Smythe
test has been used for 15 years in Canada and has been
described in a recent publication (12); its results are
highly correlated with results of the modified Schober's test used by Moll and Wright, the Schober's test
itself, and goniometric assessment. The 2 additional
evaluation items on the Smythe test are spinal extension and mobility of the lower thoracic and upper
lumbar regions.
Finger-to-floor. Distance between the fingers
and the floor was measured with the subject standing
on a 23-cm stool (with stance marked to keep it
constant), bent forward as far as possible with fingers
reaching toward the floor. If the subject reached
beyond his toes, the values were recorded as negative
numbers.
Chest expansion. Chest expansion was measured with the subject standing, hands on head and the
tape placed circumferentially over the xiphoid. The
subject inhaled maximally, then exhaled, and a value
was recorded; the subject then inhaled maximally and
a second value was recorded. Total change was recorded as the value at maximum inspiration minus the
value at maximum expiration.
Cervical rotation. Cervical rotation was measured with a protractor, with the subject seated (8).
The 0" center point of the protractor was placed over
the episternal notch and the 90" lines on the protractor
were aligned with the antra of the ears. The cervical
range of motion was recorded at the extremes of
cervical rotation in both directions, and the total
change was obtained by adding the measurements for
the left and right rotations.
Statistical analysis included paired-subject ttests to determine the significance of differences between the first and third measurements (the warm-up
Table 1. Characteristics of subjects
Men
Age range (mean)
Taking nonsteroidal
antihlammatory drugs
Radiographic involvement
Sacroiliac
Hip
Lumbar
Thoracic
Cervical
Current low back symptoms
History of inflammatory
low back pain
Ankylosing
spondylitis
patients
Normal subjects
(n
= 10)
~..
..,
(n = 10)
--,
9
9
6
31-54 (35)
0
10
-
2
-
20-47 (35)
1
0
1
9
9
\-
6
0
55 1
BRIEF REPORTS
effect) and simple correlation between the third and
fourth measurements to determine reproducibility.
The paired t-test was used for change scores, to allow
each subject to serve as his own control, taking into
account the wide variability between subjects on baseline measurements. Pearson’s product correlation was
chosen as the simplest representation of reproducibility, although this statistic is difficult to interpret when
between-subject variance is small.
RESULTS
The characteristics of the AS patients and controls are presented in Table 1. Figure 1 shows the
medians and ranges of the measures at each determination for patients and normal subjects.
Table 2 summarizes the observations and indications that the intra-rater reliability was high, and
shows the effect of warming up for each measurement
on normal controls and AS subjects. Patients with AS
all showed the same trend toward improvement with
warm-up, except in an instance in which a patient with
hamstring spasm during the finger-to-floor measurements regressed on the third measurement. As seen in
Table 2, the AS patients’ improvement after warm-up
was highly statistically significant (P < 0.002) for the
“r
OVERALL
Reliability and susceptibility to warm-up of 4
measurement techniques in ankylosing spondylitis (AS) patients
and normal subjects
Table 2.
Measurement,
patient group
Overall Smythe
AS
Normal
Lower (lumbar) Smythe
AS
Normal
Middle Smythe
AS
Normal
Upper Smythe
AS
Normal
Chest expansion
AS
Normal
Finger-to-floor
AS
Normal
Cervical rotation
AS
Normal
6-13
A 20-75
40-00
2 5 - 8 5
I
RANGES A - 1 3 - + 4
4-135
3
3s-80
30-85
3 5 - 0 5
0.08
0.15
0.98
0.47
0.28
-0.13
0.34
>0.5
0.90
0.83
0.28
0.30
0.03
0.22
0.82
0.44
0.43
0.90
0.02
0.01
0.95
0.86
0.15
0.25
0.98
0.97
- 4.70
-4.85
<0.002
<0.01
0.96
0.83
18.1
16.2
<0.002
<O.OOI
-------
0-t43
160[
2
3
4
-19-+2
-3-+395
-23-+25
-23-+45
-45-+365
-50-+36
CERVICAL ROTATION
4
MEASUREMENT
MEASUREMENT
RANGES
1 .oo
MEASUREMENT
55-135
5
2
0.72
\
MEASUREMENT
85-13
5-145
0.97
0.84
FINGER-TO-FLOOR
SMYTHE
19-13
55-140
3 5 - 0 5
40-105
RANGES A
110-160
25-145
120-165
3 5 - I50
120-175
3 5 - 160
110-170
41 160
-
Figure 1. For each of 4 anthropometric measures, median (not mean) values before
and after warm-up stretching
are displayed for 10 normal controls (A) and 10
ankylosing spondylitis patients (0).In each panel, the origin is non-zero for the
ordinate, and the ranges of the y values are listed below the x-axis.
(4)
P$
>0.5
0.4
sion, and finger-to-floor values are in cm, cervical rotation values
are in degrees..
$ Paired t-test.
oi
4-125
Warm-up
effectt
* Between measurements 3 and 4 (Pearson product correlation).
t Difference between measurements 1 and 3. Smythe, chest expan-
-lo
RANGESA
Intra-rater
reliability*
BRIEF REPORTS
552
finger-to-floor and cervical rotation measures. Low
between-subject variance was noted for normal subjects in the Smythe test and may explain the apparent
poor reproducibility of results in this group.
up selectively affects some measures is a subject for
future investigation.
DISCUSSION
REFERENCES
A variety of factors influence anthropometric
techniques, but the individual contribution of these
factors to measurement error has not been studied in
detail. That warm-up influences patient performance is
not surprising, but the published literature in this field
makes no mention of this factor, and our observation
that some measures are not affected seems somewhat
paradoxical. How does one explain our findings? Improved performance with repetition may be influenced
by the patient learning what is expected, or by the
examiner providing encouragement. We judge this
explanation to be unlikely, however, since our subjects neither had difficulty comprehending the task nor
were given any unusual encouragement. If improved
motivation or understanding had been a factor, we
would have expected it to have been operative for all
measures. Variation between measurements might
have been due to the timing of medication taken by AS
patients, but this cannot explain the similar results in
controls. A more probable explanation may be that the
techniques are measuring different joints or muscles,
some of which are inherently more susceptible to
warm-up than are others, o r that some movements,
such as chest expansion, are used constantly and thus,
are maximally warmed up at the start.
Parenthetically, we also observed that some
subjects with severe AS improved their performances
after the initial warm-up but then had decreased mobility, presumably due to spasm and pain. In addition,
cervical rotation takes as many as 6 repetitions before
maximum warm-up is achieved and measurements are
stabilized.
Warm-up improves performance for patients
and normal subjects in the measures of finger-to-floor
distance and cervical rotation, but not in the overall
Smythe test or chest expansion measures. Other measurement techniques may also be affected by warmup. Measurement error for finger-to-floor distance and
cervical rotation may be reduced by a warm-up protocol to achieve stability of performance. Why warm-
1. Schober P: Ledenwirbel saoule und kreuzachmerchen.
Munchener Medizinische Wochenschrift 84:336, 1937
2. Moll JMH, Wright V: Normal range of spinal mobility:
an objective clinical study. Ann Rheum Dis 30:381, 1971
3. Sturrock RD, WojtulewskiJA, Hart FD: Spondylometry
in a normal population and in ankylosing spondylitis.
Rheumatol Rehabil 12:135-142, 1973
4. Tanz SS: Motion of the lumbar spine: a roentgenological
study. AJR 69:399-412, 1953
5. Portek I, Pearcy MJ, Reader GP, Mowat AG: Correlation between radiographic and clinical measurement of
lumbar spine movement. Br J Rheumatol 22: 197-205,
1983
6. Dunham WF: Ankylosing spondylitis: measurement of
hip and spine movement. Br J Phys Med 12:126-129,
1949
7. Boone DC, Azen SP, Chun-Mei L, Spence C, Baron C,
Lee L: Reliability of goniometric measurements. Phys
Ther 11:1355-1360, 1978
8. Cheshire MW: New apparatus: a device for measuring
rotation of the neck. Arch Phys Med 38592, 1957
9. Moll JMH, Wright V: An objective clinical study of
chest expansion. Ann Rheum Dis 31:l-8, 1972
10. Defibaugh JJ: Measurement of head motion. Amer J
Phys Ther 44:157-162, 1964
11. Macrae IF, Wright V: Measurement of back movement.
Ann Rheum Dis 28584-589, 1969
12. Miller MH, Lee P, Smythe HA, Goldsmith CH: Measurement of spinal mobility in the sagittal plane: new
skin contraction technique compared with established
methods. J Rheumatol 11507-51 1, 1984
13. Badley EM, Wood PHN: The why and the wherefore of
measuring joint movement. Clin Rheum Dis 8533-544,
1982
14. Badley EM, Wagstaff S, Wood PHN: Measures of
functional ability (disability) in arthritis in relation to
impairment of range of joint movement. Ann Rheum Dis
43:563-564, 1984
15. Moll JMH, Wright V: New York criteria for ankylosing
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Acknowledgment. The helpful comments and assistance of Dr. Steven H. Stern, MD, are appreciated.
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