__Measurement_of_Joint_Motion__A_Guide_to_Goniometry_3rd_Edition

The Cervical Spine • Structure and Function arriculares with ::t facer on the internal surface of the arias , (CI). The two lateral joints are composed of the right and Atlanto-occipital and Atlantoaxial Joints left superior facets of the axis (C2) that articulate with ~' Anatomy the right and left slightly convex inferior faccts on the atlas (CI) (Fig. 11-2). ! The atlanto-occipital joint is composed of the righr and left slightly coocave superiot facets of the atlas (CI) thar The arlanro·occipiral and arlanroaxial joims are rein- arriculate . with the tight and left convex occipital condyles of the skull (Fig. II-I). forced by rhe posrerior and anterior arlantoaxial liga- The atlantoaxial joint is composed of three separare meors, rhe rransverse hand of the cruciatc ligamenr, the articulations: the median atlanroaxial and two lareral alar ligaments, and the tectorial membrane. joints. The median arlamoaxial joint consisrs of an ante· riot facet on the dens (the odontoid process of C2l that Osteokinematics Occipital c~)ndyle The atlanto-occipital joint is a plane synovia' joint thar permits f1cxion·cxrension, some axial rorarion, and latcral flexion. Flexion-extension takes place in the sagit- tal plane around a medial-lateral axis. Axial rotation takes place in the transverse plane around a ve;tical axis - - / ' - Occipital Superior band Transverse ctuciale band ligament bone cruciale ligament Superior arlicular 'X,,-=:::-- facet __~?>,=- \"\";>-~--- Spinous process ~'-I- Lateral aUantoaxial joint Superior allanlal Atlas articular proces.s (C1) Inferior arlicular lacet Transverse process Median atlantoaxial FIGURE 11-1 A larcral view of a porrion of rhe atlanw-occip- joint ital joint shows rhe superior atlam'al articular process of the atlas (el) and the corresponding occipital condyle. The joint Axis Inferior band space has been widened to show the articular processes. (C2) cruciale ligament FIGURE 11-2 A posterior vicw of the arlanwaxial joim and r~c superior, inferior, and transverse bands of the cruciatc ligamcllt.. 295

296 PART IV TESTING OF THE SPJNE AND TEMPOROMANDIBULAR JOINT and lateral flexion takes place in the frontal plane around (dlll\\'l'X :-urf.1Ct'~ l1Ioving on (Ol\\C;lVC surlau's). the oee(\" an anterior-posterior axis. Flexion is limited by osseous Hal t'()IldylL''t glide in lilt' dirt'ction oppositc to rhc mov contact of the anterior ring of the foramen magnum with IIlclH of dlC top of rhl' hL'ad. In t'lcxioil, tht' condyles glid the dens and by tension in the ceccarial membrane. posteriurly on thl\" :ulas ,lftiul1ar ~urf:1ct'l:;. In extension Extension is limited by the anterior atlantoaxial ligament. the <.H:cipir:d c()!Idylc~ glide a!ltcrior!y on the arla,';- Combined flexion-extension is reported to be berween 20 whereas the lu...k ot the IlL';ll.J nHtn.:s posteriorly, degrees 1 and 30 degrees2 and is usually described as the amount of motion thar occurs during nodding of the At Ih,,· lateral arlantoaxlal !OllttS rhe inferio head. However, according ro Cailliet,' the range of motion (ROM) in flexion is 10 degrees and the range in I.ygapophyscal artii:ubr lan:rs of tilt arias art' convex a\"n' extension is 30 degrees. Maximum rotarion at the atlanto-occipital joint is between approximately 2.5 :1 rricub [{: wirh rhe Sll pt.:rit ,r C(lnCl \\'l· ;1 f[ icub r facets of th percent and 5 percent of the total cervical spine rota- tion\"·5 Lateral flexion is approximately 10 degrees.' th;lxis. r\\r tht.' lIli.'dian joint the albs forms ;1 ring with The two lateral atlantoaxial joints are plane synovial tr;Hls\\\"crSl' lil;,HllCIH {hand} of rht' cru('i:Ht.: li~amcnt, ail joints that allow flexion-extension, lateral flexion, this ring rOLlte::- arolllH.l IIll' dens (odontoid process) and rotation. The median atlantoaxial joint is a which serves as .1 pi VOl tor rotation. Tht, dens articulate synovial trochoid (pivot) joint that permits rotarian. with:1 slllall faCet ill th,,' <:clltral area of the anterior arc Approximarely 55 percent of the total cervical range of of rhe arias, rotation occurs at the atlantoaxial joint. Rotation at the median atlantoaxial joint is limired by the two alar liga- Capsular Pattern ments. About 45 degrees of rotation to the right and left sides are available. The motions permitted at the three TIlt: \"\";lpsubr pa[{arl for the arlanro-o(\":lpir:ll joint is an\"' atlantoaxial articulations are flexion-extension, lareeal cqu;d rc!';[ri('tiOIl of L'Xll'llsiOIl ;1I1d lateral flexion/ flexion, and roratlon. i{oLHioll ,md flexion arc nor aHcch:d. J Arthokinematics Intervertebral and Zygapophyseal Joints At the atlanta-occipital JOint, the inferior convex Anatomy condyles of the occiput articulate with the two superior concave zygapophyseal articular facets of the lateral Tht,' intervertehral jCllnb :Ul' ,,:oll1posed of dK> superior bodies of the atlas. When the head moves on the atlas and inferlo[ surfaces of the \\'crrchral hodi('s and rhe adja~ (('Il( ilH('rvcrtcbrai discs (Fig. 11-3). The joilHs are rein-\" Zygapophyseal forced 3IHaiorly hy the ,1tHt,'rior longitudinal Iigament,::- joints whkh 11m irs extension. anJ postaiorly by rhe posterior\" longitudinal ligament. ligamt'lHlllTl 1l11..:h'lt'. and ligamen- Intervertebral tum fbvurn. which help ro limit flexion. joints Tht.' zygapophyseal joints arc formcd hy the righr and Vertebral Idt supcrltJr ;lrt;('ubr facl'rs (processes) of Oilt.' vertebra body and the right and Idt interior arriLular facNs of an adja-\"~ cent superior vertehra (Fig. I 1-4), Each juint has its own Intervertebral clpsuk and capsular Ij~;HnCllt~. which ;,lre lax and permit disc a r('/ati\\\"('ly hugl' RO\\1. The liga1llentum fbnlOl helps to reinforce the joinr capsules. FIGURE 11-3 A lateral view of the cervical spine shows the intervertebral and zygapoph)'seal joints from C3 to C7. Osteokinematics f\\ccording to \\'ihite and Punjahi.\" Olll' \\,atebr;l call move in rdatioll [0 an adjact'IH vertebra in six dift(:rellt direc- rions (thr('(' tr:lnsLltiollS and thrt,·c rorations) ,dong and around threc :JX(,~. The: compound (·fft':crs of sliding and tilring iH a series of vertt:·brae produce a large ROM for the column ~lS a whole, in....lllding flexion-cxtension, Iata:ll flexion. and roration. SOIllC motions ill the verte~ bral ....olumn are coupled with otht:r motiolls; rhis coupling \\'aril's from region to region, :\\ coupled mocion is one ill which one motion ,lround one axis is ulilsis- tently associated wiIh another lllmion or mOtions around a dift'erL'nr axis or axes, For eX;1Il1pk. left lareral flexion from C2 ro C5 is accompanil'd by rmarion ro the left (spinous processes mo\\'(.' {() the right) and forward flex- iOIl. In thl' cervical re~ion from C2 to C7. flexion and exrl'llsioll arc the only motions that ;trl' not cOllpled,\" L

CHAPTER 11 THE CERVICAL SPINE 297 Uncinate processes of the intervertebral disc acrs as a pivot for the tilting and I sliding motions of the vertebrae. Flexion is a result of Zygapophyseal anterior sliding and tilting of a superior verrebra on the I interposed disc of an adjacent inferior vereebra, joint Extension is rhe result of posterior sliding and tilting. fIGURE 11-4 An amerior view of the righr and lefr The zygapophyseal joints permir small amoums of sliding of the righr and left inferior facets on the right and _~ ~gapophyseal joints between tWO cervical venebrae. The vene· left superior facets of an adjacem inferiot vertebta. In flexion, the inferior facets of the superior vcrrebrae slide \"'brae have been separated to provide a clear view of the inferior ameriorly and superiorly on rhe superior facers of the inferior vertebrae. In extension, the inferior facets of the ~anicular facets of the superior vertebra and the superior articu- superior vertebrae slide posteriorly and inferiorly on the 'Iar,facets of the adjacent inferior vertebra. superior facers of rhe inferior vertebrae. In lateral flexion and rotation, one inferior facet of the superior vertebra \"\"', slides inferiorly and posreriorly on the superior facet of the infetior vertebra on the side to which the spine is VThe intervertebral joints arc cartilaginous joints of the laterally flexed. The opposite inferior facet of rhe supe- rior vertebra slides superiorly and anteriorly on the supe- :,,;'ymphysis rype. The zygapophyseal joints are synovial rior facet of the adjacent inferior vertebra. plane joints. In the cervical region, the facets ate oriented Capsular Pattern at 45 degrees to the transverse plane. The inferior facets The capsular partern for C2 to C7 is recognizable by pain (of the supetior vertebrae face anteriorly and inferiorly. and equal limitation of all motions except flexion, which , e superior facets of the inferior vertebrae face posteri- is usually minimally restricted. The capsular pattern for Q~ly and superiorly. The orientation of the articular unilateral facet involvement is a greater restriction of Jacets, which varies from region to region, determines the movement in Iareral flexion to rhe opposite side and in qirection of rhe tilting and sliding of the vertebta, rotarion to the same side. For example, if the right anic- \",hereas the size of the disc determines the amount of ular facet joint capsule is involved, lateral flexion to rhe 1J)0tion. In addition, passive tension in a number of soft left and rotation to the righr are rhe motions most .issues and bony contacts controls and limits motions of restricted. 7 ,the vertebral column. In general, although regional vari- :'tions exist, the soft tissues that control and limit • Research Findings extremes of motion in forward flexion include the 's,upraspinous and interspinous ligaments, zygapophyseal Effects of Age, Gender, and Other Factors joint capsules, ligamentum flavum, posterior longitudinal ligament, posterior fibers of the. annulus librosus of the Measurement of the cervical spine ROM is complicated intervertebral disc, and back extensors, by the region's multiple joim structure, lack of well defined landmarks, lack of an accurate and workable 'i,:; Extension is limited by bony contact 01 the spinous definition of the neuttal position, and the lack of a stan- dardized method of stabilization to isolate cervical \"processes and by passive tension in the zygapophyseal motion from thoracic spine motion. The search for ,joint capsules, anterior fibers of the annulus fibrosus, instruments and methods that are capable of providing \"Interior longitudinal ligament, and anterior trunk accurate and affordable measuremems of the cervical wuscles. Latetal flexion is limited by the intertransverse spine ROM is ongoing, and the following sections \"ligaments, by passive tension in rhe annulus fibrosus on provide a sampling of scudies that have investigated the side opposite the motion on the convexiry of the cervical ROM. Tables 11-1 and 11-2 provide cervical \"-curve, and by rhe uncinate processes. Rotarion is limited spine ROM values from various SOurces and with use of a variery of methods. by fibers 01 rhe annulus librosus. Age VArthrokinematics A large number of researchers have investigated the The intervertebral joints permir a small amoum of sliding effects of age on cervical ROM, '4-25 but differences ':and tilring of one vertebra on another. In all of the between the populations tested and the wide variety of instruments and procedures employed in these scudies motions at the imervertebral joints, the nucleus pulposus make it difficult to compare results. Generally, [esearchers agtee that a tendency exists for cervical ROM

298 PART IV TESTING OF THE SPINE AND TEL11'(j?()~\"i;\\;'>itl;Hi;L;,f( l(ji;-~ Mean og~ ';:'21.5 y~ ;,.:: _:...:...--..,..,_,,=..:.,_20 i '_\"\"'\",..:.'_\"_\"'_'_-\".;,:.,...:.,-,: , Mean (SO) ; Flexion 'f: S1 (9) f, E~ten~ion ' ' ' ' 70 (9) . Right lateral flexion left lateral flexion 4,) (8) Right rotation' ~ Left rotation 71 (5) CROM = Cervical Range of Motion device; ROM -::::= range of motion; (SD) :'!'Hl(l;lfG d(·'.':;-d:ol' . • Values for active ROM were obtained with usc of the CA·6000 spine mouon ':!'.IJy/U , Values obtained using an inclinomeler. ; Values obtained using the CROM device. SValues for active ROM obtained using a univers,ll goniometer. to decrease with increasing age. The only exception is ,·\\I\"[(.\"..l hl.-t\", ,'l'l, I:', ,lv-.. 11l~j tV1!Llk .... :\\ l\\wh!pk rC1:lfcssioo axial rorarion (occurring primarily at rhe atlamoaxial .1l~.lk...i\" .. l\\('\\\\'i..d rh.1! .\\~;l· .done l·\\:pLI!I\\...~l ,1 \"igllificanr[ joim), which h~lS been shown either to stay the same or to increase with age to compensate for an <lgc-rclated ~n!!\\H!!l! oi :itl' Lln,!!!I!!l, bur u.·t:n: ...... illll !lIlI.:\" for males~ decrease in rotation in rhe lower cervical spine. Ii.:!:) Age may nor aCCOUrl( for a large amount of the variance in .lthl fl'lll.lk ... \\\\·l'rl' ... ~L:l1!!i\\,·,l!l!h dlir,Tl'!E ROM: but age appears ro have a stronger effect than gender. O'Driscoll and Tomenson 1·1 srudicd cervical T!hl.- I l-'~ \"ho\\,', rill' l\"ikLh (It :l::'l' lin ;,:cfncll spine ROM across age groups. These investigators used a spirir inclinometer (a hydrogoniomcter that works on i.l pendu- !ZO.\\1. V.dw,:.; pn':'l'll!l'd ill 'L~bk 11-) \\\\'l'l'l' obtained; lum principle) for rheir measurements. They measured 79 females and 80 males ranging in age from 0 to 79 years. i1'< ill) ) -) - h,·-! td1\\ ,'j dUnfnT., t I-I Il'll1.I1I'''' ;lIld 166? RONt dccrensed with increasing age, and differences In;dt.:·.;', Thl\" \"uhin:h \\\\'l';\"l' 1l1;:J;\"UfU! u .. lI1.:-: lIll' ~('rvical TABlE:11-2 Cervical Spine Range of Motion \" , , Measured with a Tape Measure: Mean Values ' Llllg<,: of 11\\1'£;:111 tCR().\\l; dnKl\": dh·rl..'forl'. rhe values\"'; in Centimeter~ prc:'l'ruu! ill rhl\"\"' uhk-, .,h,luld hl' u\"l,\\l for rdl'rence UI1/.:' l { l' ,\\.I:1l1 li(TS .11\"\\' t! ...i n;..: ;\\ CR( ).\\ I d(·'·1\\,.\"l' lor [heir\" lll:...l'!lni!~: J!h!!'\"Will\"lH. Ilo\\\\'n'n, llll' i.lhll'\" ,1 fl' tlsdul in' [h,ll lh:.·~· ....!HI\\\\· !Ill' \"it'n.-r... of ,lgl' nn ',::\"I'\\\"Ii..';1I ROM~',;:.' ldr.dly, th,: l',\\;!l1i111',T ,,,hould lhl' IlOt\"lll,,,, 1'1ut ;11\"(' appro- .. pri.Ul' til ih\" !lll'dllld 01 1l11',bur(.·i!:l·m .111d Ihl\" ;lgC and ,,'. ~~l'lldt\"l' p;' lilt' il1di\\'Hhu!:-. ht:lll~ l·\\.l111i!ll'd. In T,lhlc 11-3/~.:. ~hl' !11l'.liJ \\'.'dUl' {«1\" ,h:tin' :Il'~'k ~k\\IOI1 III d1l' [\\'.'(J nldcstU; .L:rPI1I\" or lJ).:!t- ,lpd kilLIk., .1rl· Ie....... dun d1l' tlll.',lfl \\'~llucs ,ihl.linnl III ihr ~·()llll.~~l·\"'! ~ftillp. h;..:hr~·, £0 ninl'[~·~yt:ar· old '\\uhji..'i:t' .. \"lll1\\\\' ,ilkHIl ~.O ~!c:~!\\·l'., k,-\" !!loti(JIl rhall 11 Flexion, (US) , ,S (L60) 4,3 (2,0) H. ! ':j ~·l·.H tlld ... uhil\"l't-.. 20,S (236) lS,5 (2,0) Extension (1,56) 11,5 (2,10) 12,9 (2A) 1\\,ll.h,:hl,\\ .lild B(Jh,lll11nll\"~ fou!1d dl.lI !hl' llll'JI1 \"alues (l,92) 11,1 (2,07) l2,S (25) for I:l!l'r.l! t!c\\\\O!l 11~ '-tlhll\"'!S \"'(lungei\" rh;l!\\ .W VCilrs of Right lateral flexion 101 (L87) 12,6 (2,52) 11 ,0 (25) 11,6 (l13) 13,2 (237) 11,0 (25) .lgl' n: ..:n'dnl -i2 dq~rl'l''', ,\\·h:.T~·.'''' ll;l';lll '·;l!ue.. ti;r lareral Left lateral flexion 11,2 (L8S) Right Rotation t\"k\\\"itll! ill .,llhj\\·Ch ohkr dUll -I) \\:.\"\\1'\" (If .I~l· Wl'ri..' less left Rotation dUll 2S d(:~I\"t'l·\". :\\il\"\"ol1, Ibn,\"~\"~'!\\' .11HI c:fll'i\"tl'lbCIl,IS CI -:-:: Confidence interval; r =:: Pearson product moment correlation III ,l ... rlld~· :)f l)(l IW:llthy Illl'll ;1Il~! \\\\'Ollll'n ,lgnl 20 (0 60 coefficient; (SD) :::= standard deviiltion. \\'1..',11'\". ,:·01h:llidt.:·d th,lI the dl\"i.:rcl\"l· 11\\ ':l'n'i~,:;d passive ·99 percent confidence interval of measurement error ranged from 1.4 cm to 2.55 cm for tester 1 (experienced). (I ranged from 1.91 !~O\\I wirh :!1lTl,;,-.;rn~'. ,lgl' ()ul,l hl' l'\\pLl!1Jl'd hy using J em to 3,30 cm for tester 2 (inexperienced). ...i!llpk linc.lf rcgrl'~... ioll of RO.\\ I a:-. ;1 IlllH.\"tj(l1\\ of age. t r values ranged from 0,26 to 0.88 for intra tester reliability and from ( hl'n .lr1d ~·()!le.lpll·\"\"'~ ~ ill .1 dl'l.lik·\\! r(.,,·il'\\\\' (If !Ill· lircra- 0,30 to 0.92 for intertester reliability. llift' fl'~-'~ll'lhi1~~ the d(n_ t\" llf .I~ill\\.' (It\\ ..:t·ni\\.:,d ~pinc IU)',\\\\RO.\\!. '~(llkh'l~kd th.li Jl.'!in' dn:re.lsnl hy 4 dq:rl'l\" !,IT dC(';\\i,k, Thi:-. finding !\" \"lTy I..\"lo:-c W {hI,: 5- \\lcgn'''' dl'l'l·l·;l-.l· {oulld !W )\"t\\u,b:-- ~ll1d ;b\\(l(i.lIl\"'. !i, 'Ot!h:r ill':t·:.lig;l!(lr\" h:~n.' fplIlld \",Ollie l'\\·id:.'Ili.x r!ur the

CHAPTER 11 THE CERVICAL SPINE 299 TABLE 11-3 Effects of Age on Active Cervical Flexion Range of Motion in Males and Females , Aged 11 to 89 Years: Mean Values in Degrees' ~f,Wh~I~!~·.~~ll1l;~1~)J[~~1~~1~jJJl~!f~:iA~~i~i~~)~;\";j~ .i;~~JG2~iJ_?).1J'.i~il~I;~:~;!??J~~Jii~ Standard deviation. 'Arl,nt,ed from Youdas, jW, et a1 16: Reprinted from Physical Therapy with the permission of the American Physical Therapy Association. !~'A.a\"\"\"m\"nts were obtained with use of a Cervical Range of Motion (CROM) device. effecrs of age o~ ROM may be morion specific and age and colleagues!' found that the greatest decrease in flex- specific; however, the evidence appears [0 be somewhat ion-exrension ROM in 60 healrhy men and women (aged M,,,,,~\",>,,,i\"1 Tro{{ and colleagues21 found a Significant 20 to 59 years) occurred berween rhe 20-year-old group and rhe 30-year-old group. in the means of all motions (flexion-extension) Gender latcral flexion, and axial rotation) with increasing age, but they determined that most coupled motions were nor Many of the same researchers who looked at the effects affecred by age. Pearson and Walmsley\" and Walmsley, of age on cervical ROM also studied rhe effecrs of gender, Kimber, and Culham20 were rhe only aurhors to include bur the results of these studies appear to be more incon- the cervical spine motions of retraction and protraction sisrcnc than the results of the age srudies. In some srudies, in rheir studies. Pearson and Walmsley's found rhar rhe the trend for women to have a greater ROM than men was apparent, alrhough differences were small and gener- older age groups had less ROM in retraerion, bur thar ally not significant. Also, in some instances, the effects of they showed no age difference in the neutral resting posi~ gender appeared to be morion specific and age specific in rion. In contrast to Pearson and Walmsley's IS findings, that some motions at some ages were affected more (han Walmsley, Kimber, and Culham!O found age-related orhers. decreases in both protraction and retraction. Lantz, Castro25 was one of the authors who found significant gender differences in cervical ROM, bur these authors Chen, and Buch,s in a' srudy of 52 marched males and nored rhat rhe differences occutred primarily in the females, found a significant age effect, with subjecrs in motions of lateral flexion and flexion-extcnsion in the rhird decade having grearer ROM in rorarion and subjects berween the ages of 70 and 79 years (Tables flexion-exrension rhan subjecrs in rhe fourth decade. 11-4, 11-5, and 11-6). Women older than 70 years of Dvorak and associates I? determined that the mOSt agc wcre on the average more mobile in flexion- extension than men of the same agc. Nilsson, Harrvigsen, dramatic decrease in ROM in 150 healrhy men and women (aged 20 to 60 years and older) occurred between rhe 30-year·old group and rhe 40-year-old group. In contrast to the findings of Dvorak and associares,17 Trott TABLE 11-4 Effects of Age and Gender on Cervical lateral Flexion Range of Motion in Males and Females Aged 20 to 80 Years and Older: Mean Values in Degrees' I ~!~ff~', (SO) = Standard deviation. ~ The values in this table represent the combined total of right and left lateral flexion range of motion. f Nilsson et al.. used the Cervical Range of Motion (CROM) device to measure passive range of motion. t Dvorak et al. used the CA 6000 spinal motion analyzer to measure passive range of motion. § Castro et a1. used an ultasound-based coordinate measuring system, the eMS 50, to measure active range of motion.

300 PART !V r E 5 T 1NC.O ~ THE sri N E ;\\ N D T f 1....' r 0 H 0 t,-I ;\\ N D I ;; U L ,\\ RIO 1NT 20-29 yrs 129 (6) 153(20) 149(18) 128(12) 149 (12) 152 (15) 30-39 yrs 120 (8) 141(11) 135 (26) 120 (12) 1.\\6 (lJ) 141 (132) 40-49 yrs 11 0 (6) 131 (19) 129(21) 114 (10) 140(13) 125 (13) 50-59 yr:s. 11 1 (8) 136(16) 116(14) 117(19) 127(15) 124 (24) 60-69 yrs 116 (19) 110(16) I3l (8) 11 7 (15) 70-79 yrs 102 (13) 121 (21 ) 80+ yrs 98 (11) (SD) '0' St,lIldard devi,1[ion . • fhe villtle~ in this t,~b!e represent thc- cOl11binNI total of trexion iHld (':<:t('lls;on rilflqc· oj rnotlOIi. r NiJ..,:wn el ill. used the (crvtCdl Rim~y> of MOllOI' dc-vice (CROM) to rn~\"'~lIr(' pds\\ivC r,m<!,' 01 Illotion : Dvorak et (ll. used t1a.. CA-6000 spinal motion <u\\alYLN to m(',hurc paS\\M.' ROM >, Clsiro et ill. used <Hl ul!<l\\ouncl-hascd coordinJtf: 1ll(',]surin9 S)'S[C'Ill, tho:' eMS ,)0, to m<:'t\\U((' M.tlve (,1119(' of mution . ;\\Ild <:hris;:ellsl.:Il I\" found ~l diffcrt'llI..:e bCrWl'l'Jl gl'lldcrs III .lgC group. I 1()\\\\'l'\\'n, widllil t':\\(!l uf d1l' nther .lgC groups [;m:r;l] t!t.'XiOll R( )\\-1. 'Tilt difkrUlC('~ were \"i!-!.nit'Ii.::llH, In to 29 ~'(',Ir:'. 60 ro (l9 yl·;U· ... 70 ro -::I~) ::~:.lr... Jnd SO to hut, III this scudy. m::lle~ WCrl' more mohile dUll t\"l'lIuks ~9 yl~,lr~. no lhlln\"Ih.·l'''' III In\\·i ..·,ll RC).\\\\ WLTe found (T:lblc 11-4). Lantz. Chell. alld Blh.:h~ swdinl .1 WLl] of het wccn gl'\"n~lcr... 56 Ih:<llthy 11\\1.:n :llld women ~\\gt:d 10 ('0 31) Yl:,lr~. 'The 'luthors found I1U <.lift·LTl'llee betwl'tl1 gClldLT~ in Wt;t! Tlbll':' J 1-7 ,lilt.! I I-S i.:t\\l\\Uill illt'OI\"!lUrlOll (rom a comhined Idt and righr btl.'Ld t1t.::>o.:ioll. bur WOtllell Iud ~rlld~' h~' YOllt.!.i<., and ,h\"'(Jl-'I,Itl\"~;h :-howillg llLlt fCfI)ales in gn::arl'r r:lIlgcs or\" ;h.:ri\\\"(: ~1I\\(.J p:lssivl' :D': i:l I [\"O{;lEiOIl ant.! flexion-extl'nsion than lHl'll of rhe- S;lIlH.: :lge, \\XiOI1l l'll Iud ;t!IIHJ\",r .111 'l)!.l· grilUp'\" :lppl',lr ttl h.I\\\"(..' grc;ltn 11H,:,lll \\;t\\ues ;tn a\\\"c:r:tgc of 12.7 degn.:es more activ(' fll':-.:io!l-I.::-.:tl'lIS;OI\\ f'l[\" ;\\L'{i\\T (l·l\",.. il-'al llHIlitJl1 rllall lllal('~. 1'(Hld:i~ ,lilt.! asso- ~llld ,111 avcrage of 6,50 degrees mon: ;l('ti\\\"l' ,l:\\i,d ror:HioJ) ('i,Ul':-';/< found .1 :-.igniti;':'ll1t gt'l1dn dfl';,:r ill .111 motions than Illcn of the salllC :l!!-C. \\\\lOfllCIl :1150 h:hl grl';\\{l'f passivl' RO,\\l in ~111 ct.:n·icli motions. D\\'or:lk :1Ihl as:-ol..'!- ex(cpr tl::'\\lon .lild ,k-tCl\"1Jlillt'd dl.lf malt':' .tnL! females ..HCS!- found that wOlllcn h('[wcl..'n 40 :lnd 49 years of 'lgC Jo\"c ;1 hour :) d(\"~rl\"l's ot' ;l(tl\\'(' cxtlTlSioll .111d .) degrl'L'S of .I(ti\\·l..' I:HLT.d flc:-.;ipll ;ll1d r(J{;lti<lll with c;Kh 10-yea! had grC;l{tr RO\\'I in all motions {hall llH,'1l in {he :UlTll' 11lcrl'.1\"c in ,I~l..'. If rhl..' lllt',lSllrC1llL'!lt\" thlUg till' CR01V[ dn'iCt' ,lIT \\':llid, (llll' (;;111 (':\\pn,:t to find appro:\\illl:ltcly 15 dq!,rn·... to 20 dq!,l\"t'l':-' it·...... ,\\('tl\\'C' llL'l,:h: l·.\\[t'l1sio[1 in a 20-29 yrs 174 (13) 184(12) 161 (16) 174 (13) 182 (10) 160 (14) 30-39 yrs 166(12) 175(10) 156 (32) 167 (13) 186 (10) 150(15) 4Q--49 yrs 161 (21) 157 (20) 141 (15) 170(10) 169 (14) 142 (15) 50-59 yrs 158(10) 166 (14) 145 (11) 163 (12) 152 (16) 139 (19) 60-69 yrs 146 (13) 136(18) 154 (15) 126(14) 70-79 yrs 121 (14) 135 (16) 80+ yrs 113 (21) (SD) _. Standard clevi<ltion . • The v,)lues in lhis table represent tht' combined lot,)l of righl <lnd left rot,Hion raoge oi lIlotion, , Nilsson et <11 used the Ccrvictll R'lllgC' oi Motion devicC' (CROM) to lllC',lS11re p.l:.s.iv(' rilnge of 1ll0llOl\\, t Dvor<lk £'l .11 lIsecilhe CA 6000 spinilll1lotion ,lllillylN to 1ll(\\1511re pilssi'l(, ROM. ~ Castro et ill used .111 (dtilsound·bilsed coordinille nWClsl.J{ing syst':ll1. the Ck\\S 50. [0 measure ilctive fi1ll9C' of lllotion.

CHAPTER 11 THE CERVICAL SPINE 301 .~ \\ ; -~ lSD) = Standard deviation. ~dapted from Youdas, IW, et a1 16; Reprinted from Physical Therapy with the permission of the American Physical Therapy Association. 'eMeasurements were obtained using the Cervical Range of Motion device (CROM). 'health)' 60-)'ear-old individual compared with a health)' (half-c)'c1e motions) compared with those statting at the f20-)'ear-old individual of the same gendcr. end of one ROM and conrinuing to the end of another ROM (full-c)'c1e motions). Studies that have attempted to In contrast to the preceding studies, the following bettet define rhe neurral position have used either radi- . investigators concluded that gender had no effect on ographs26•27 or motion analysis systems.18•29 In the radi- ,'cervical RONI. Feipel and coworkcrs,24 in a study involv- ographic study conducted by Ordway and associates,26 the authors determined that when the cervical spine is in ing 250 subjects between the ages of 17 and 70 )'ears, the neutral position, the upper segments arc in flexion concluded that gender had no effect on cervical ROM. and the lower segmenrs have ptogressivel), less flexion; Walmsle)\" Kimber, and Culham20 found no differences in tberefore, at C6 to C7, the spine is in a considerable axial rotation that were attributable [0 gender. Trott and amount of extension. !vliller, Polissar) and Haas,27 in the colleagues,21 in a srudy of 120 men and women between other radiographic study, found that the cervical spine is 20 and 59 )'ears of age, also found that gender did not in the neutral position when the hard palate is in the hoti- zontal plane. Although these findings are of considerable iii have a significant effect either on coupled motions or on interest, they provide Ilnle help to the average clinician) who does not have access to radiographs for patient posi- ROM. However, age-telated effects wete different tioning. «:i; between males and females. Ordway and associarcs26 Two studies thar arc more c1inicall)' relevant used rhe -~r found a nonsignificant gender effect, and Pellachia and CA-6000 Spine Anal)'zer.,\"·2' This motion anal)'sis s),stem is capable of giving the location of neutral 0 posi- ;; Bohannon,22 in a stud)' of 135 subjects aged 15 to 95 tion as coordinates in three dimensions corresponding to the three planes of motion. Christensen and Nilsson28 ?J: years with a history of neck pain, concluded (har neither found that the abilir)' of 38 healthy subjects to reproduce '< neck pain nor gender had an)' effect on ROM. Testing Position The lack of a well-defined neutral cervical spine position is thought to be responsible for the lower reliabiliry of cervical spine motions srarring in the neutral position TABLE 11-8 Effects of Age and Gender on Active Cervical Spine Motion in Males and Females Aged SO to 89 Years: Mean Values in Degrees' (SD) ; Standurd deviation. Adapted from Youdas, IW, et a1 16: Reprinted from Physical Therapy with the permission of the American Physical Therapy Association. *Measurements were obtained using the Cervical Range of Motion device (CROM).

r 302 PART IV T EST I N G 0 F THE S PIN E AND T E Iv! P 0 R 0 ~·.1;, 1\\; D I 3 v t. A R j 0 i N r I the neutral spine posICIon with eyes and mouth closed Obviously, ...::dCld:nillll ot' POD i... not ne(L\"~s;lry if the was very good. The mean difference from neutral 0 in progress of nnly one ... uhjcu i~ ml::I~url·(1. three motion planes was 2.7 degrees in the sagittal plane, 1.0 degree in rhe horizontal plane, and 0.6.1 degrees in Functional Range of Motion the fronral plane. Possibly, patients may be able to find the neutral position on their ownt bur the subjects in this tvtmion (If the c('fvic;\\] Spillt· i:-. Ill·(Cs:-.Jry lor lllOst activi- study were healthy individuals, and the abiliry of patienrs ries of tinily living ;h \\'.\"(\"11 :1\\ IIltl\\f l'i..·;.:rcJtiollal and occu- to reproduce the neutral position is unknown. Solinger, r'~Hi(lll;ll a...:tivitil· .... !{cbri\\'ck. ...1ll;\\11 ;\\11l0unr .. of flexion, Chen, and Lamz29 attempted ro standardize a neurral . ,t:xlcnsioll, and roratioll an: fl·qul.rcd lor l':nillg, reading head position when measuring cervical motion in 20 \\vririllg, ;lnd llsing ;1 COllll'utl.:r, Drinking I\"equln.:s more subjects. For flexion and extension, the authors described ccrvicJI l·Xtt:ll:-.ioll !{().\\f dl;1l1 l\"ttirl).!\" :lIH.I ~t,!r·g<lzing Or a neutral position as onc in which the corner of the eye simply looking \"I' :11 (he (eiling j'\\\"'quires a (1111 ROi\\i in was aligned with the upper angle of the car, at the point c.\\rt.:llsioll i.!\"\"ig. 11·---5l. Using:1 tl'll'I)honl' l'l'quircs lateral where it meets rhe scalp. For !atcral flexion, neutral was flexion as \\\\TI: ;1,\\ rOLlrion. Ci1lbidn,tbly 1110r\\,.· motion is defined as the poinr ar which the axis of the head was n:quirl'd for h.uhing ,Iud y.r(l(illlill~, Spon:-. ;l\\':livirit:s such perceived to be verticllly aligned. Compared with data :lS sn\\'il1g ;1 (ennis h;lil. l';n-.:hillg or h,ltting ;1 h:ls<.:balI, collected using a less stringenr head positioning, Solinger, cUlo\\,.·ing, :lIlt! k.!~·Jkill~ 1Il,1~' rl.·l..jlllr\\,.' ;1 full RO.\\l in all Chen, and LalHz2') demonsrrated that by standardizing head position they obtaincd increases in reliability of 3 percem to 15 percent for rotation and lateral flexion but showed a decrease in reliabiliry of up to 14 percent for flexion-extension. In a study using (the 3-Space Isotrak System) Pearson and Walmsley'\" found a significanr difference in the neutral resting position (it became more retracted) after repeated neck retractions performed by 30 healthy subjects. Another potential positional problem that resters need to be aware of has been identified by Lantz, Chen, and Buch.l'i These iluthors found that ROM measurements of the cervical spine taken in the seated position were consistendy about 2.6 degrees greatcr than measurements taken in {he standing position in all planes of morion. Greater differences occurred between scared and standing positions when flexion <md extension were measured as half-cycle motions staning in the neutral 0 position as opposed to measurement of full-cycle motions. Body Size \\ Castro25 found that obese patients were not as mobile as \\, nonobese patients. Mean values for motions in all planes decreased with increasing body weight. Chibnall, FIGURE t l-S OIH' llcnl:- ;11 1e;\\:-.( ·10 (0 W lb~rl'(\"\" (It (l'n'iral Duckro, and Baumer,'o in a study of 42 male and female subjects, found that body size reflected by distances (·.'\\!l·llsion l';l\\)~l' of 1l10llPlI !IU );\\ I) til look lip .;, till..' ..:eilill~.1 If berween specific anatomic landmarks (e.g., between the Cl'n·jl.:;l! eX{l'll:-';O!1 RO.\\1 l~ 11l11lll·~1. llw I'n\";l1l1 IllI!',! l'xfl'ml rhe chin and the acromial process) influenced ROM meas- cflIire SpllR' ill ,Ill l'!'hlfl to l'Lh.:c dIe he.1L! III .1 pO':'olliuo \\dlt.:rl'by urcmems taken wirh a rape measure. Any variation in body size among subjects resulred in an undcrestimation [be e}'l'S (all louk up ;H rhe l:dll1l;' of ROM for subjects with large distances between land- marks and an overestimation of ROM for subjects with small distances bctween landmarks. The authors concluded that the use of proportion of distance (POD) should be used when comparing testing results among subjects. The usc of POD (calculated by dividing the distance between the at-reSt value and the end-of-range value by the at-rest value) helps to eliminate the effect of body size on ROM values obtained with a tape measure.

CHAPTER 11 THE CERVICAL SPINE 303 FIGURE 11-6 One needs a minimum of 60 to 70 degrees of cervical roration to look oyer the shoulder. l If cervical rotation range of motion is limited, the person has to rotate the entire trunk to position the head to check for oncoming traffic. Curh]l compared cervical rotation ROM in a to obtain a true validation of cervical ROM measure- of 40 swimmers with that in 40 nonathletic vol un- ments because radiographic measurement has not been The swimmers aged 14 to 17 years had a mean subjected to reliability and validity studies. Therefore, no rotation RO!vI that was 9 degrees greater than the valid gold standard exists. The only options available for of those aged 14 to 17 years in the control group. investigators at the present time are to conduct concur- OCCuioati0l1al activities such as house painting or wallpa- rent validity studies to obtain agreemcnt betwcen instru- require a full range of cervical extension and, ments and procedures. Some of the studies that have been p0'5Sii,ly, a full range of flexion. A full ROM in cervical conducted to assess reliability or validity (or both) of the Wl:a[l.on is essential for safe driving of cars or trucks (Fig. vartOUS IIlstruments and methods arc reviewed in the following section. Reliability and Validity Universal Goniometer and Gravity Goniometer .Many different methods and instruments have been Tucci and coworkersJ2 compared the intratester and employed to assess motion of rhe head and neck. Similar inrerrester reliability of cervical spine motions measured to other areas of the body, inrratesrer reliability generally with both a universal goniometer and a gravity goniome- is better than intertcstcr reliability, no matter what instru- ter. Intradass correlation coefficients (ICCs) for ment is used. Also, some motions seems to be more reli- intcrtester reliability ranged from -0.08 for flexion [() ably measured than others. For example, the total 0.82 for extension, for measurements taken with the (combined) ranges of flexion-extension and right-left universal goniometer by two experienced testers on 10 lateral flexion appear to be more reliably measured than volunteer subjects. ICCs for intertcster reliability ranged single motions such as flexion or extension measured from 0.80 for right rotation to 0.91 for left rotation, for from the neutral position. This finding may be owed to measurements taken with the gravity goniometer by one the variability of the neutral position and the lack of a experienced and one novice tester on 11 different volun- Standardized method that an examiner can use for plac- teers. The authors concluded that the gravity goniometer ing a subject in the neutral position. that they had developed had good intertester reliability and was an accurate and reliable instrument. According to Chen and colleagues,23 it is not possible

;, TESTING OF THE SPINE AND TEMPOROMANDIBULAR JOINT 304 \"i?{~~~~fttrr~~?l~~#~~~·- Author _J<){;,~~- 1\". Tes!er (upuano- 2 20 Flexion Pucci Cl al lO (4 males, Tester 1 0.63 16 females) TeSler 2 0.91 I Extension 0.90 Tester 1 0.82 Tester 2 Right lateral flexion TeSler 1 0.79 0.84 Tester 2 0.89 Right rotation Tester 1 0.85 0.84 Tester 2 0.62 Youdas et alIt> 5 6 (Intra tester) 27.2 yrs Healthy Flexion 0.88 0.83 20 (Inlertester) 33.0 yrs utemian 0.94 0.90 ~ Right lateral flexion 0.88 0.87 ~ Right fOlcHion 0.82 0.82 Garrett et .:lr u 7 Forward heild 0.93 0.83 40 59.1 yrs posture Nilsson· ~.; 2 14 20-15 yrs HClllthy Flexion 0.76 0.71 (1 experi- Extension 0.85 0.47 \"i enced; 1 no Right lateral flexion 0.61 0.58 experience) ~ Nilsson et ,11- lS 2 35 20-28 yrs Healthy Right [olution 0.75 0.66 Flexion 0.65 0.70 Extension 0.54 0.55 Right lateral flexion 0.64 0.70 Right rotation 0.41 0.41 Flexion--extemion 0.60 0.61 Right-left latefill 0.69 0.71 flexion Right-left rotation 0.88 0.88 Rheault et al lri 22 37.4 yrs Hx 01 Flexion 0.76 cervical Extension 0.98 spine Right lateral flexion 0.87 pathology Right rotation 0.81 Olson et al)} 4 12 34 yrs Neck pain Flex.ion 0.88 0.58 Extemioll 0.99 0.97 Right lateral flexion 0.98 0.96 Right rotation 0.99 0.96 YOlldas et alII 11 20 55,9 yrs Orthopedic Flexion 0.95 0.86 disorders Extension 0.90 0.86 20 60,7 yrs Right lateral flexion 0.92 0.88 20 60.8 yrs Left lateral f1ex.ion 0.93 0.92 ICC c-c Intr,lclass correlation coetficienl, r .-c Peilrson product moment correlation coefficient; SEM 0\":\". stilndMd error of measurement. * Nilsson meusured passive' RQr-..·1. t 95 percent Cl for single subject measurClllent (mean 01 .s measurements). : Represents inters~lbjcct SErv!o Universal Goniometer, Visual Estimation, and the iIHcrtCS[(T f'l'liJbilit'}· varied aJ1l0ng the morions rested, CROM Device bur. gc.:I1t:r:lII y, inrratcsrc.:r reliabilir:' using either the \"(oll(bs. Carey, ~Hld G:trn:tt II usnl rht.: followill b rhfl't' univers:tl goniO!lleTeT OT rhL: CRO~vl device \\\\TTL' good methods to detefmine ;Ktive t.:t.Tvica! ROM: visual l'st'i- (ICes greater rfl;lll (UH)). ICes for illtcrrcsrcr reliability Illilrion, a univcrsal goniolllcter, alld rhe tTrvical ROM of borh rhe lInivt:fsal goniOlllt'h:r and visual ('srimares I dc.:\\';cc. Prior to [csting. the rhn:lpists hile! I hour of illsrfUdi(lll :lnd rracri(:(' lIsing s£andardizt:tIIllt::1SUfCIllC.'llf Wt,:fl' less rh:m O.SO, Inrcrrt'stl'r ICes lor visual t:srimJrion wt.'n,,' lower rhan rhosl.: of dH.· lInin'rs;ll gOlliolllcrer for procedures tor cach Illstrument. IIltLw,:S[Cr and all lllotion:- cx(\"cp[' rotatioll, (mCftCsrcf reliability for

CHAPTER 11 THE CERVICAL SPINE 305 1 the CRaM device was good. ICCs were poor to fair for system with 6 degrees of freedom) and with radiographic 1 interdcvice comparisons among the three methods measurements. The aurhors determined that flexion- (visual estimation, universal goniometer, and CR01v1 extension could be measured reliably by all three meth- ':i device) for all cervical motions. The authors concluded ods but that there was no measurement consistency lhat, because of poor interdevice reliability, the three between rhe methods. However, the CRaM device's methods should not be used interchangeably. The fact advantages over thc 3-D Spacc System were lower cost '. that intertester reliability was higher with the CRaM and ease of usc. \"'device than with the universal goniometer suggesrs that use of the CRaM device for measuring cervical ROM is Tousignant,J9 using radiographs to determine crite- <,preferable to use of either the universal goniometer or rion validity of the CRaM device, found thar the meas- ~isual estimation when different therapists take meaSute- urements of flexion and extension in 31 healthy ments on a particular patient. participants aged 18 co 25 years were highly correlated. .' CROM Device One drawback of this study was the ract thar the neutral Capuano-Pucci and coworkers lO srudicd intratcsrcr and position was not defined. intertester reliability using the CRaM device and concluded that the instrument had acceptable reliability. CA-6000 Spine Motion Analyzer Intertester reliability was slightly higher than intratester reliability, a finding attributed to the fact that the time The CA-6000 Spine Motion Analyzer, which consists of interval between testers was only minutes, whereas the 6 potentiometers linked by a series of hinged rods, is a time interval between the first and the second lrials by very expensive piece of equipment used primarily for one tester was 2 days. See Table 11-9 for more detailed research purposes. Christensen and Nilsson4o found information about this study and other studies in this good intratcstcr and interrester reliability for measure- ments of active cervical ROM in 40 individuals tested by section. 2 examiners. Intratester reliability was also good for passive ROM, but intertester reliability was good only Youdas and associarcs 16 determined the intrarcsrer for passive ROM of combined motions. Lantz, Chen, reliability of cervical ROM measurements during and BuchS determined the validity of the CA-6000 Spine repeated testing on six healthy subjects. The testers Motion Analyzer conCurrent with the dual inelinometer followed a written protocol and were given a 30-minute by demonstrating almost identical mean values for f1ex- training session using lhe CRaM device prior to ion/exrension and lateral flexion. Full-cycle ROM had testing. Intenester reliability was determined based on less variability than ROM measured from neutml and measurements of 20 healthy volunteers (11 females and axial rotation, and lateral Aexioo measuremcms had 9 males) between 22 and 50 years of age. Each subject's gremer reliability than flexion-extension measurements. active ROM in six cervical motions was measured Intertester and intratester reliability was high for toral independently by three testers wirhin moments of each active motion, and reliability values were consistcntly other. higher for active motion than for passive motion. Solinger, Chen, and Lamz,!· in a study of cervical ROM Nilsson34 found that intratester reliability for passive in 20 healthy men and women volunteers aged 20 to 40 ROM with use of the CRaM device was moderately reli- years, also found that reliability values were consistently able, but intertester reliability was less than acceptable. lower for measurements beginning in the neutral posi- In a follow-up study, Nilsson, Christensen, and tion compared with those taken at full-cycle ROM. The Hartvigsen3S found that both intratester and intertester range of intertester and intratester reliability values reliability was unacceptable if motions were started in (ICCs) for full-cycle motions of left and right rotation the neutral position. Measurement of total ROM and lefr and right lateral flexion were 0.93 to 0.97 (combining the motions of flexion and exrension by compared with the single motions starring in the nemeal measuting from a position of full flexion to a position of position whose range was 0.83 to 0.95. Flexion from the full extension) improved intratester reliabiliry to an neutral position was the least reliable measurement, even acceptable level. Rheault and colleagues\" found small when taken by a single examiner. mean differences ranging from 0.5 degrees to 3.6 degrees between two testers who measured extension with the Pendulum Goniometer CRaM device. See Table 11-9. Defibaugh41 used a pendulum goniometer with an CROM Device, 3-D-Space System and atr3ched mouthpiece (0 measure cervical motion. The 30 male subjects in this srudy ranged in age from 20 to 40 Radiographs years. The author found coefficients of 0.90 to 0.71 for intratcstcr reliability and coefficients of correlations of Ordway and associates'\" compared measurements of 20 0.94 to 0.66 for intenester reliability. Unlike the major- volunteers' combined flexion~extension taken with a ity of other researchers, the author found thar inrertester CRaM device with those taken with the 3-D-Space reliability was higher than intratester reliability for some System (an internally referenced computed tracking

306 PART IV TESTING OF THE SPINE AND T[r,lI'OH()rv1i\\NOlf:ULAH JOIN-r motions. However, I to 7 days elapsed between the first h:JPP;l rc!l;lhility ... odficicnt for 111tr;ltcstn ;lgnTllH:nr in and the second measurements taken by the same tester, whereas only 2 hours elapsed between one tester's meas- l:;lll:g0rlCS of normal IllJlltnl, or rn:lrkedlj' limited IZOjvl, urements and those taken by another tester. The higher intenester reliability was attributed to the short lapse of r;lngcd from O,SO to O.S(l, time between measurements. III the study hy l'oud:ls, eire>\" :lfHJ (;arrctr, i I rhe Herrmann42 took radiographic measurements of \"llhjc... rs WLTe hO orthopedic pJtiellh rangillg ill ;lgt: from passive ROM of neck flexion-extension in 16 individuals 21 to :-;4 Yl'<HS. IIHcrt'e\"tcr rchahility for visu:J1 estimarcs aged 2 to 68 years. The radiographic measurements were compared wirh those obtained by means of a pendulum nex: : ;:of hoth :Ietivc fleXIon ;]!](J extt:nSlOIl was poor goniometer. ICes of 0.98 indicated a good agreement between the two methods. 0.42). Intcr[csrcr rcli;lhiliry for visllalesrirn;lt'l's of acrive fleck btcr~d fkxioll 1\\0:\\1 was fair. The ICC for left Gravity Goniometer and Tape Measure LucLlI flexion \\V;1S O.h,); for right Lncr;1i flexion it was (l.70. The illtLTtcstcr reliahility· for viSll;tl c\"timates of Balogun and coworkers,13 in a study that employed three !\"Or;ltioll W;ls poor tor lefr roution (ICC 0.(9) and testers and 21 healthy subjects, compared the reliability good (or righr ror:nioll lICC (1.:-;2l. of measurements obtained with a Myrin Gravity- Reference Goniometer (Inclinometer) (OB Rehab AB, Flexible Ruler Soina, Sweden) with measurements taken by a tape meas- ure. [ntratester reliability coefficients for both the incli- Rhc:lldt ~llH.I colleaguc,,;;' foulld th:n illtcnesrcr reliability nometer and the tape measure were moderately high for with J fleXible ruler \\V~lS good (r O.SOI for obr;lining all motions except flexion. Intertester reliability was measure!IJcnts of the Ilelltr~ll cervicli spine positioJl and slightly higher for the tape measure method than for the high (r (l. l)OJ for obtaining !T1L\\l\"tlri.'llll'!HS of cervical Myrin goniametric method. However, intertester reliabil- spinc fln.:ioll .. \\!casUrCrTlt:llb \\\\Tl\"l' LIken on 20 healthy ity of flexion measurements was poor for both methods. suhjeus ( 14 women and 6 l1lenj. See Table 11-2 for additional information. Summary In a reliability study of the tape measure method, by Hsieh and Yeung,12 an experienced tester (tester I) and L;lCh ot the rC'chniquc\" for Illl';1Suf\"illg Cl:rviGll R01\\1 an inexperienced tester (tester 2) measured active cervical discussed ill thi\" l:luptcr h~IS u.-ruill ;l\\.IV;lIl(;lgl'S and motion. Tester 1 measured 17 subjects and tester 2 meas- dis;H.lv;lntages, ['hi., ullivns~d goniometer. upe melsurc, ured a different group of 17 subjects. Intratester reliabil- alld tkxihlc ruler ~1I\"l' the k';1St Illl:xpen\"lve :lnd e~lsicst to ity coefficients (Pearson's r) ranged from 0.80 to 0.95 for ohr:lin. trallSport', Jlld usc. Rl.'!i;lbiliry tends to be morion tester I and 0.78 to 0.91 for tester 2. See Table 11-2 for speL'ifiL\" :llld. gCllcr:I1ly, inrLHestcr reli;lhility is bener measurement error. t!l;lll ilHerrcstn rcliabilir;.·. Thl.'n.:foI'C, if thcsc lllcdlOds are llsed to dcrerllllllc ;l p;ltielH\\ progrcs\". 1l11';lSurements Visual Estimation should he Uh:1'11 by ;l single rhn;lpisr. The reliability of visual estimates has been studied by III L'ol1\"ider:nioll of the cost' ;111<..1 aVJiLlbilitj' of the vari- Viikari-juntura43 in a neurological patient population ous instrtllllelHS for 1l1(';l\"Ul'illg cerviGtl RO;\\'1, and and by Youdas, Carey, and Garrett ll in an orthopedic patient population. In the study by Viikari-juntura:.1 the IwclLlse of the fad rh;lt' the ilHLllesrer reli:lhiliry of the subjects were 52 male and female neurological patients ranging in age from 13 to 66 years, who had been Llllivns;d gonlometcr Jnd tape lllC~lSllrl' ,1ppe,lrS compa- referred for cervical myelography. Intenester reliability Llble \\\\·ith tlUt of IllCaSllrClllems takcn wirh other instru- between two testers of visual estimates of cervical ROM ml.'ms. we dC'l'ided to l\"l'Uill rhe univcrs:tl goniometcr and was determined by the authors to be fair. The weighted t<l(lC me;lSllrc flledHH.ls ill this cditiol!. bur \\\\'l.' ;u..!ded the double inc!inoillcrn :md the CRO.\\I devIL·e. If the tape IlleJSllrC IS helng lIsed to COlllp:lre IZU\\\\ ;lll1011g subjects, ...;l!cuLHlOIl of P()1) should help 10 ehlllin:ltc the cHecrs of differcnt hudy' sizes on IllC:1StlITll1elHs.'(I

CHAPTER 11 THE CERVICAL SPINE 307 Range of Motion Testing Procedures: Cervical Spine ,, 1

308 r'A R' I V TESTING or fHf. SPINE AND T(MPOROMANDIBULf\\H J(JIN! HGURF. II-~) Surface an;ltofTlY lIsed to mC;lSUfC ccrvic::11 motion with;] rape Jnl';]surc: tip of the \"hill, S[Cf!l:lI Jlotch, and acromion proC(;!'$. The l1l:lsloid \\...·hich is uSl,d to measure bIeral flexion, included in Figure \"I 1-8. , Tip of nose Sternal F!t;URE 11·10 Bony all~tomicall~md~ notch marks for measuring cervical rangt: of motion with :l l:lpt.: rnc.:1surc. Tip 01 chin Acromion process r

CHAPTER 11 THE CERVICAL SPINE 309 FIGURE 1]-]] A posterior view of the subject's head and cervical spine shows the surface anatomy landmarks lIsed for measuring lateral flexion with a goniometer and flexion and extension with dual inclinometers. I Occipital I bone Ir ;' FIGURE I ]-12 Bony anatomical landmarks used ro align Spine of scapula the goniometert ,' inclinometers) and cervical range of niotion device.'All of these instruments use the spinous .. process of the seventh cervical vertebra as a landmark for the measurement of at least one cervical motion. /~

·-uJ:' 310 PART IV TESTING OF THE SPINE AND Tf.MP()RO~\\tlANDIBULAR IOIN-' Z FLEXION Testing Motion ;;: Motion occurs in rhe sagittal plane around a medial- Put nlll' h:llld Oil tht,: h;l(k of the suhjn.:t\\ hL';ld and, with lareral axis. The mean cervical flexion ROM measured lilt' O[!ltr hand, hold thL' subject\\, chill. Pll~h gemly but VI with a universal goniometer is 40 degrees (SD = 12) flrlnl \\\" Oil [hl\" hack of rhl.: ~1I hjcci ':-. IW:HI I {I l11on.' t hl..\" head degrees. II See Table 11-1. :llHcr·jork. Pull the slIhjt:u's (hin ill toward the chest (0 -' move th~ ~lIhieC{ through fkxiol1 I{O\\,t (Fig. 11-13). The Testing Position ~ Place rhe subject in the sitting position, with rhe thoracic L:'nd of tht: RO;\\f occurs wht'll n::sisra rKL' ro further and lumbar spine well supported by the back of a chair. llHltlUll is fclt JTH.l furrhtr attempts ;H flt;.;i()ll cause U Position the cervical spine in 0 degrees of roration and (orward flexioJl of the Hunk. lateral flexion. A tongue depressor can be held berween > the teeth for reference. Normal End-feel '\"u.I Stabilization Tht· normal ('tid-floc! i~ finll owing [() stn.:t\\.:hing of the Srabilize rhe shoulder girdle either by a strap or by the P()sll,:ri()r ligamenls {supraSpilHlllS, inlr;1~piIHH1!\\. ligamen- U examiner's arm to prevent flexion of the thoracic and lumbar spine. tum flanlln. and li~al1}(:ll[lllll 1I11Ch;1l:}, posterior fibers of Vi tht: annulus fihros~l'\" ill tht ilt(I..'f\\'(\"rrebr~\\1 disks. and the u.I zy~ap(lphys(.'al joint ClpSU!cS; ;1I1J he-caw.!\".\" of impaction '\":;) of till: suhrnarH.lihuLlr [issues against tht..' throat and p:n'si\\'1..' tl..'rlSiOll ill rhl..' loJlowillg lll11sdl..'s: iliocostalis o tj. og: \"z'. i= VI u.I I- oZ S ~ ou.. u.I 'Z\" I I I ~I1 I ./, j F IFIGURE 11-13 The subject at [he end of cervical flexion range FIGURE 11-14 In rhl..' 0 starling posirion lor llll..';lsuring ccr\\'l- \" (.\";11 f1l'xion r;tn~(' of motion. tht: g.onioml'((·r rt·;lds 9(1 dl'grces. Iof Illmiol1. This rculinl; should bl' tr;lnsl'0sl'd and n.:t:orck\"d :1$ 0 degrees. d\" I $I I Ii I

CHAPTER 11 THE CERVICAL SPINE 311 \".~ cerVICls, longissimus CapitiS, longissim'us cervicis, Alternative Measurement Method for Flexion: Tape obliquus capitis superior, rcctus capitis posterior major, Measure rectus capitis posterior minor, semispinalis capitis, semi- spinalis cervicis, splenius cervicis, splenius capitis, The mean cervical flexion ROM obtained with a tape spinalis capitis, spinalis ccrvicis, and upper trapezius. measure ranges from 1.0 to 4.3 Col \\2.\\3 (see Table 11-2). Measure rhe distance between the tip of the chin and the Goniometer Alignment lower edge of the sternal notch at the end of the ROM. Make sure that the subject's mourh remains closed (Fig. See Figures 11-14 and 11-15. 11-16). 1. Center the fulcrum of the goniometer over the external auditory meatus. 2. Align the proximal arm so thar it is eirher perpen- dicular or parallel to the ground. 3. Align the distal arm with the base of the narcs. If a tongue depressor is used, align the arm of the goniometer parallel to the longitudinal axis of rhe tongue depressor. FIGURE 11-15 The goniometer reads 130 degrees at the end FIGURE 11-16 In the alternative method for measuring cervi- of the tange of mot;on (ROM), but the ROM should be cal flexion. the examiner uses a tape measure £0 determine the recorded as 0 to 40 degrees because the goniometer reads 90 distance from the tip of the chin £0 rhe sternal notch. degrees in the 0 st:l.rcing position, The tongue depressor that the subject is holding between her teeth may be used as an alterna- tive landmark for rhe alignment of the distal goniometer arm.

PART IV T EST I N G 0 F THE S PIN E AND T ( ~~l PO ROM AND I B U L;\\ R : 0 I N I Alternative Measurement Method for Flexion: ;\\! the l\"11<..1 lit Ihl.: l!lo{lCHl. reId and rn:ord tht infor~ Double Inclinometers In.U!OIl Clll rllt' dl;!1, of to,lell iIlLliIIOl!It.:tl..'r. The 1{(L\\l is (he Both inclinometers must be zeroed after they are pOSI- dltr'LTl\"IlL\"l\" hl'(wl'I:n ii'll: reHling ... of rhL' !WO ill~[rlllllL'nrs. tioned on the subject and ptiot to the beginning of the measurement. To zero the inclinometer, adjust the rotat- Alternative Measurement Method lor Flexion: ing dial so the bubble or pointer is ar 0 on the scale. CROM Device Inclinometer Alignment \"I'he lHL';lll flexion !{().\\! ()r the (:R()l\\\\ <!C.:ViCl· ranges frollJ 64 degre(·.. in ~\\lhien~ aged I 1 {() 19 ycar~ to 40 1. Place onc inclinometer directly over the spinous di.:grccs in subjecrs :lgcd XO [0 X9 yC;lr:-.. 1f' Rein to Tables process of the C-7 vertebra, making sure that the 11-1 ~Ind 11-3 for :'Ilklitioll;ll ill(orlll;ll'ioll, inclinometer is adjusted to O. hnnikuil.(: yourself with the (;],0:\\1 I.!tViL'l' pnor to 2. Place the second inclinometet fitmly on the poste- heginning [he IIH.:a':>LlrtIlH:JH -rhe <:1\\0\\1 dcvin l..:ollsists rior aspect of the head, making sure thar the incli- o( ~l h(:~ldpin:\":e thar \"'lIppons two gravity illl..:lillOlllttcrs nometer is adjusted to 0 (Fig. 11-17). and ;1 ....ompas.s irlClil~onl(.:n:r. The gr~I\\'i{y iru.:linomercrs ~ln.: lIsed ro nle:hllft flt-xi!)!l, ex{en ....ion, and lalt:ral f1ex- Testing MOlion iOll. The ....omp:bs goniometer is used {O measure rota- Instruct the subject to bting the head forward into flex- riOlI. :\\ Ilcd:pil'C<..' ('(Inclining two strollg rnagrH:tS is worn ion while keeping the trunk straight. (Fig. 11-18). (Note (0 c!l~llrc rhl' ;lu:ur:ll.\"y of the compass in<.:li!1onlcru. that aClive ROM is being measured. FIGURE 11-17 Indinom~teralignment in rhe starring position '-, for measuring cervical flexion range of motion. J i f :4t ,J',;j. FIGURE 11-18 Inl.:lillol'nct.cr \"lrglllllC!H at till: \"lld of cervical flexion range of mution.

CHAPTER 11 TH~ CERVICAL SPINE 313 ~, The CROM device should fir comforrably over rhe nose and rhe band fits snugly across the back of the subjecr's head (Fig. 11-19). ,\\., bridge of rhe subjecr's nose, A Velcro srrap rhar goes 2. Position the subject's head so that the inclinometer '. around rhe back of rhe head can be adjusred to make a on rhe side of rhe head reads O. ,i;/(;';;',:\"snug fit. One size instrument fits all, and it is relatively Testing Motion ;;::,:>:>',,:~asy for an examiner to fit the device to a subject Push gently bur firmly on rhe back of the subjecr's head ro move it anteriorly and inferiorly through flexion ROM FiS;,CROM Device Alignmenr44 (Fig. 11-20). Ar rhe end of the marion, read the dial Oil the inclinomerer on rhe sidc of the head. ';'r< L Place rhe CROM device carefully on the subject's head so rhac rhe nosepiece is on the bridge of rhe ,;,FIGURE 11-19 The CROM posirioned 00 the subject's head in FIGURE 11-20 The examiner is shown stabilizing the trunk ~ «/,,:,~the starting position for measuring cervical flexion range of with one hand and maintaining the end of the flexion range of ;. \"';;,!?morion. The dial on rhe gravity inclinometer loclltcd on the side motion with her other hand. of the subjects head is at 0 degrees. ; ·'f

Ij//::i-'-~ w 314 PART IV T EST I N G 0 F THE 5 PIN E AND T E ~,1 P () H 0 1'/1 ;\\ N D I B U 1 A H I 0 I ,'-i i I,Z c;: I<J) .... Iu<: EXTENSION ~lIPP{)rt troln rhe h;\\ck of the ,:hJir. :\\ ~r[\";lp placL'd arOund I0w:: lateral axis. Mean cervical extension ROM measured ;; Motion occurs in the sagittal plane around a medial- thL' clll'''[ ;ll1ll rhe h;l\\.:k of [he c!Lllr ,l!,,() !1UY he used. IU with a universal goniometer is 50 degrees (SD = 14 Testing Motion 0::Vwi degrees).!! Refer to Table 11-1 for additional informa- t\\n OIH,: IL11H.I <Hl the h;lCk of the \"lIhjc'I.\",t\\ he;ld and, with I::l tion. the othel\" h;l11d, hold rhe :-.uhjed\\ L'hin, Pu:.h gemly but firlllly Up\\\\';lrd ,11ld po\"rcrior!;.' oJl the ..-hin t(l move the Iw0 , Testing Position he:ld thWllgh till\" RO.\\l in V.\\[C'lhioll \\hg. 11-21), The e!ld of the !Z().\\\\ OL\",:lIr\" \\\\\"!lcn re:.i..,[;lrlee to further U !l1otiO!1 i.., fl'h ,1ml further .1l[Vlllpr.., ;H eXrClbl()!1 calise I0 Place the subject in the sitting position, with the tboracic VX[CI1..,!O!l PI' the trllnk, IQ., and lumbar spine well supported by the back of a chair.0:: (.;) t, Position the cervical spine in 0 degrees of rotation and zf= i,:. rIShateracrtbea,e.I/,t.fhzleafXoti,.roonrne· fAerernacneg.ue depressor can be held between Normal End-feel <J) The' !lorl11Jlc'l1d\"fn,1 1\" finn O\\\\'il1g to [he pa\"si\\'e tt:nsion iw I- dl'\\'l.'loped h!\" stl\"l·tchin,L'; of the ,11Hl'l\"iol\" ]o!\\girudinalliga_ lllcllt, ;lllrcriur fihl'r.., or the ;lllllUlus fihro:-.lIs, zyg;lpophy~ § IZ :'l'al IOI1lt c,lp:.ulc:-., .111d thl' following muscles: :\"\\rer!loclcidolT1;l:.t(lld, !O!lgu\" c;lpili\", IO!1gu:\"\\ colli, rcctus 0 Stabilize the shoulder girdle ra prevent extension of the L';lpiti:-. ;\\IHLTiol\", Jnd \"eJlcllllS :1JHcriol\", Fxtrl'lllcs of Cxten- I thoracic and lumbar spine. Usually, the stabilization is I:; ! achieved through the cooperation of the patient and ..... 0 w z(.;) I<: !, 0:: FIGURE 11-21 The end of the cervical extension range of FlCURE 11-22 III thl' I) :.t.Hling pmitioll (or Illl\\huring ccrvi~ motion. The examiner prevents both cervical rotation and ,-\";lll'x(l'llsion range of Inotion till' gOl1iOllwtL'r rl'.ld:-. '10 dt:grces. lateral flexion by holding the subject's chin with one hand and Thi\" n:;Hlillg ,,!lould he rL\\llsposnl ,111\\1 H',-\"orded ;h () degrees. the back of rhe subject's head with her other hand. The back of \"'I the ch,air (not visible) helps to prevent thoracic and lumbar extension. , j ...._L ---------------------_

CHAPTER 11 THE CERVICAL SPINE 315 be limited by contact between the spinous Alternative Measurement Method for Extension: Tape Measure ~niometer Alignment The mean cervical extension ROM measured with a tape 'e figutes 11-22 and 11-23. measure ranges from 18.5 to 22.4 cm. l2.D Sec Table 1. Center the fulcrum of the goniometer over the 11-2 for additional information. external auditory meatus. Align the proximal arm so that it is either perpen- A tape measure can be lIsed to measure the distance dicular or parallel to the ground. between the tip of the chin and the sternal notch (Fig. Align the distal arm with the base of the nares. If a 11-24). The distance between the two points of reference tongue depressor is used, align the arm of the is recorded in centimeters at the end of the ROM. Be sure goniometer parallel to the longitudinal axis of the that the subject's mouth remains closed during the meas- tongue depressor. urement. AGURE 11-23 At the end of cervical extension, the examiner FIGURE 11-24 In the alternative method for measuring cervi- maintains the perpendicular alignmem of the proximal cal extension, one end of the tape measure is placed on the rip goniometer arm with one hand. With her other hand, she aligns of rhe subjecr's chin; rhe other end is placed at the subject's ster- the distal arm with the base of the nares. The tongue depressor nal notch. bct\\vcen the subject's teeth also can be used to align the distal arm.

316 PART IV TESTING OF THE SPINE AND T(MPOi~O\\rl..\\:\\li):BUlAR IOINT Alternative Measurement Method for Extension: Testing Motion Double Inclinometers !1l'tI\"U',:, !ht' -;llhin.:t 10 tllO\\-t' dh,llV.ld lIHO l'XICll ... ioll while Inclinometer Alignment kn:plll~: rill' trllnk -.tr.Il~',hr ih,l,:. 11-26:. i:\"l)r,: r1Ut :lCtive 1. Place one inclinometer directly over the spine of the J«).\\ 1 i... \\lviii,,'. l'IH::i<\"lI:\"l,·dJ ..\\1 lill.' vild ()! thl\" 111ulinn, read scapula. Adjust the dial of the inclinometer so that :111-1 t'l'c'()rd thl' illt'(lrll1:l!!Oll IHI till' di:l!<., of l':h.:h i!lcli~ it reads O. (If the inclinometer is placed over rhe i'(lIIH:tt·r. \"['hl' R()\\ll\" rllt' dit'kn:rh:t,IH:tWLTll rht, rl:tldings sevcmh cervical vertebra it may impact the other 01 i11l.: i\\\\\"l> ill\"lnlllll'nh. inclinometer in full extension.) Alternative Meowrement Method for Extension: 2. Place rhe second inclinomeler firmly on Ihe posle- CROM Device rior aspect of the head, making Slire that the incli- nomeler reads 0 (Fig. 11-25). Thl' 1I11';11l (,.-en·It·,li RO.\\I III c,\\(l'n\"i(lll llll'.l\"llred wirh rhe Ci{()\\1 range,,- from S() lkgrccs in l1l,d!..',,- .Ignl II to 19 ;!- FIGURE 11-25 Inclinometer alignment in the starting position CII\"FleUR!' 11-26 I\"di,,,,,\"et\", .di~\"\"\"·1H at the \"i for measuring cervical extension ROM. The examiner has zeroed both inclinometers prior to beginning the motion. t::>.:tt:n:.ttlll r,mgt: ot motion. )'1''.'' I '>1 I j

CHAPTER' , THE CERVICAL SPINE 317 years and ro 49 degrees in males aged 80 to 89 years.'\" 2. Position the subject's head so thar the gravity incli- Refer ro Tables 11-1, 11-7, and 11-8 for additional nometer on the side of the head rcads O. information. Testing Motion CROM Device Alignment''' Guide d1C subject's head posteriorly and interiorly 1. Place the CROM device carefully on the suhject's through extension ROM (Fig. 11-28). At the end of the head so thar the nosepiece is on the bridge of the motion rcad the dial on the inclinometer on the side of nose and the band fits snugly across the back of the the head. subject's head (Fig. 11-27). I f FIGURE 11-27 The subject is positioned in the starting posi- tion with the CROiv'1 device in place. The gravity inclinomccer located at the side of the subject's head is at 0 prior to begin- ning the motion. FIGURE 11-28 At the end of cervical extension range of motion (ROM), the examiner is stabilizing the trunk with one hand and maintaining rhe end of the ROM with her other hand on top of the subject's head. Note rhar this subject's passive ROM in extension is mllch greater than his active ROM in extension as shown ill Fig. 11-26.

318 PART IV TESTING Of THE SPINE AND TEMPOROMANDIBULAR JOINT LATERAL FLEXION or exn:nd during rhe motion (rig. 11-29). The l'nd of the motion occurs whl'n resistance to motion i\" felt and Motion occurs in the frontal plane around an anrerior- attempts [() produce addiriOll,l! motio!l cause lateral posterior axis. The mean cervical lateral flexion ROM to trunk flexioll. one side, measured with a universal goniometer, is 22 degrees (SO = 7 to 8 degrees). Refer to Table 11-1 for Normal End-feel additional information. The normal end-fcel is firm o\\ving to the p,lssivc tension Testing Position developed in tht: ifHt:rrr;\\f1SVLTSC Jigarncnts, the lateral annulus fibroslls fibns, and the follo\\\\'jng conrralareral Place the subject sitting, with the thoracic and lumbar musclt::s: longus capitis, longus colli, scalenus anterior, spine well supporred by the back of a chair. Position the and stcrt!oclcidolll'lSt(lId. cervical spine in 0 degrees of flexion, extension, and rota- tion. Goniometer Alignment Stabilization See Figures I 1-30 and I 1-3 I. Stabilize the shoulder girdle to prevent lateral flexion of the thoracic and lumbar spine. 1. Center thl' fulcrum of thl' gOllioiTll'ter over the spin- Testing Motion ous process of th(~ <:7 verrl'hra. Grasp the subject's head at the top and side (opposite to 2. Align the proximal ;1rm with the spinoLls on:>c('\",>, the direcrion of rhe morion). Pull the head toward the shoulder. Do not allow the head to rotate, forward flex, of the thoracic verrebrae so that the arm is \"\"mo'n. dicubr to the ground. 3. Align the distal arm with thc dorsal midline of head, Llsing the occipital protuberancc for cncc. FIGURE 11-29 ThL' L'nd of thL' c<.-'rvic;ll latcral rangc of motion, \"fl1e cxaminer's hand holds thL' subject's Ieft'shoulder to preVL'nt Lueral flexion 01 the thoracic and lumbar spine. The examiner's other hand m~lin[;lins cervi- cal lateral flexion by pulling the subie(['s head laterally.

CHAPTER 11 THE CERVICAL SPINE 319 FIGURE 11-30 In the starring position for mCilsuring cervical lateral flexion range of motion> the proximal goniometer arm is perpendicular ro the floor. FIGURE 11-31 At the end of the kucral flc:<ion range of !notion. the examiner mainrains alignmenc of the proximal goniometer afm with one hand. In prnctice. the examiner would have onc hand on the subject's head to maintain lateral flexion; the exam- iner is using only one hand so [hat the goniometer alignmcnc is visible.

! IJ.I 1 - 3 2 - 0 - - - - - - - - - - - - - - - - - - - - - - - - - - - - Z§ PART IV TESTING Of THE SPINE AND TEMPOROMANDIBULAR JOINT &Q: I <Jl <...tl I, >Uc.:: tiIg IJ.I , ~~II e05n11 (~,;)~I ~! I- W ~I<Jl \" oI io~= ~~ \"',ou.;; ~ II IJ.I ~ \\, (,;) Ii I<Zt \"' e>: I I FIGURE 11-32 In tilt: altcrnativt.' method for measuring cervical lateral flexion, the subject holds a I tongue depressor between her teeth (in this photograph the tongue depressor is almost completely hidden I by the goniometer <1fl11). The proximal arm is perpendicular to the floor. \";~ il a I,l I I ;m I~ I I II i*~ Ii I ~ I, ~ f1 1iI IIi FIGURE 11~33 At the end of lateral flexion, the l'xamint:r maintains alignment of the distal goniometer arm with OIlC hand while holding d1(' fulcrum of the instrumenr with her other hane!. Ii U 5 11

CHAPTER' , THE CERVICAL SPINE 321 t~rnative Goniometer Alignment Alternative Measurement Method for Lateral Flexion: Tape Measure ace a tongue depressor between the upper and the wer tee,h of both sides of ,he subject's mou,h. The mean cervical la'eral flexion ROM measured with a Yf:. Cenrer ,he fulcrum of the goniometer near one end '0tape measure ranges from 10.7 to 12.9 cm. Refer Table of ,he tongue depressor (Fig. 11-32). 11-2 for addi'ional information. Align the proximal arm so that it is either perpen~ dicular or parallel to ,he ground. A tape measure can be used to measure the distance Align ,he disral arm wirh ,he longirudinal axis of between the mastoid process and ,he lateral tip of rhe the tongue depressor (Fig. 11-33). acromial process (Fig. 11-34). The examiner measures ,he distance berween ,he subject's masroid process and ,he acromial process, a' the end of ,he ROM. FIGURE 11-34 The subject is shown at the cnd of ccrvicallarcral flexion range of morion. ,I

PART IV TE 5 TIN G 0 f THE 5 PIN E AND T f 'e! H)if C>',' U i b [I l ,\\;~ i U ! r,lf Alternative Measurement Method for Lateral TC'tlllg \"lotlon Flexion: Double Inclinometers !n:-'[l\"lI<.:r [he \"\\Ih)l:;l...'t to 111m't' [he he;ld Ill[O Lltel\";:! flexion Inclinometer Alignment \\\\'hJ!l' kceplng the trunk srr;lighr ihg. [!--,)hi. (NOte that :h:tl\\T !ZO.\\\\ L-> hcillg 111C;\\ .... urnl.) The RO\\l is the difftr- 1. Position one inclinometer directly over the spinolls process of the seventh cervical vertebra. Adjust the e!1I...'C hC[WtTIl [he two ilhlTUlllt'!H'i, rotating dial so that the bubble is at 0 on the scale. Alternative Measurement Method for Lateral 2. Place the second inclinometer firmly on the [Op of Flexion: CROM Device the suhject's head and adjust the dial so that it reads 0 (Fig. 11-35). The lllc;lJ1 RO\\l !;HcLII tl:xio!1 llSll'Ig [he cervical ROM dC\\'i...:c r;1I1gc;, fro!ll ;\\ IIlC;lll of ·lS degrces ill suhlects aged \\\\ , FIGURE 11-35 In the smrting position for measuring cervical FIGURE 11-.% [lh.-linoll1c[t'l\" :dig!l1l1l'nt ;\\{ rhe end (If lateral 2 lateral flexion range of motion, one inclinometer is positioned ikxiol1 L1Jl~c o( Il)Olioll. At till' end 01 thc motion. the cxaminer at the level of the spinolls process of the seventh cervical verte\" bra. A piece of tape has been placed at that level to help align I\"c;\\i.ls ;llld 'fh:ords the in!orlll:Hioll Oil the tli;l!.... of l'~lCh incli- the inclinometer. The examiner has zeroed both inclinometers prior to beginning rhe motion. flOll1L'tcL I\"k' Llnge of motioll i.. rhl.' diHt'l\"l'llLl' hc[\\\\'(:cn the rC;ldlllgs of tht\" two insrrtllllC1HS.

CHAPTER 11 THE CERVICAL SPINE 323 to 19 years ro 23 degrees in subjects aged 80 to 89 2. Position the subject in the testing position so that ,6 See Tables 11-1, 11-7, and 11-8 for additional the gravity inclinometer on the from of the CROM device reads 0 degree (Fig. 11-37). '.Kv,n Device Alignmcnt44 Testing Motion Place the CROM device on the subject's head so that the nosepiece is on the bridge of the nose and Guide the subject's head lateral. At the end of the motion, the band fits snugly across the back of the subject's read the dial located in front of the forehead. head. FIGURE 11-37 The subject is placed in the starting position FIGURE 11-38 At ,he end of lateral flexion range of motion (ROM), the examiner is stabilizing the subject's shoulder with for measuring cervical lateral flexion range of motion so that the inclinometer located in front of the subject's forehead is one hand and maintaining rhe end of the ROM with her other zeroed before starting the motion. hand on the subject's head.

324 PART IV TESTING OF THE SPINE AND TFr--1POi<O\\,,1;\\r'-JDibULAH JOINT ROTATION Normal End-feel Motion occurs in the transverse plane around a vertical The llorrJu! l'I1d~fCl'1 is firlll owing t{) srrl'rl-hillg of the axis. The mean cervical ROM in rotarion with usc of a ,ILll\" lig;lJI1Cllf, rllt' rilwrs oj the l;,'g;lpophyscal joint universal goniometer is 49 degrees to the left (SD = 9 degrees) and 51 degrees to the right (SD = 11 degrees).\" Clp\"ldcs, ;1I1d thl- tollm\\'ing ({)ll(rJLUl'r-;lJ muscles: longus See Table 11-1. Magee 'reports that the range of motion (;lpiri\\, longlL\\ l.:olli, ;l11d SCJ!cllUS ;lIHl'rior. P;lssive tension in rotation is between 70 and 90 degrees but cautions III the ip'>iLHcral 'i[(Tlloclcidof]usroid lllay lirnit extremes rhar cervical roration past 50 degrees may lead to kinking of the contralateral vertebral artery. The ipsilateral artery of roLlli(l!1. may kink at 45 degrees of rotation.' Goniometer Alignment Testing Position Scc Figures I 1--40 and 1 1-41. Place the subject sitting, with the thoracic and lumbar spine well supported by the back of the chair. Position the I. CClHer rhe fulcrulll of the gO!liolllctn over the cervical spine in 0 degrees of flexion, extension, and lateral flexion. The subject may hold a tongue depressor ,--'clHcr of thc CfJlli;l1 ;1SPCC{ of rhl' he;ld. between the front teeth for reference. 2. Align rhe proxirn:ll ;lrrn paralIc] to all im:lginary Stabilization line hc[\\vcen [he [wo acrollli;I1 processes. .1. Align the distal ,lrrn with rhe tip of rhe nose. If a Stabilize the shoulder girdle to prevent rotation of the thoracic and lumbar spine. tongue depressor is used, align rhe arm of the goniometcr p:lrallcl 10 the IOllgirudinal axis of the Testing Motion tongue depressor. Grasp the subjecr's chin and rotate the head by moving the head toward the shoulder as shown in Figure 11-39. The end of the ROM occurs when resistance to move- ment is felt and further movement causes rotation of the trunk. FIG lJR f·: 11-39 The end of rhl' \".-nvic;ll ro(;uio!1 range of motion. OIlC of rhe eX;l111illcr's hands Ill:liflLlillS rotation and prcvcnt'i CefviCll flcxion ;ll1d l'xll:flsioll. \"fill' l'X:ll11iJll'f's other !l:llld is pl<l(('d Oil rhe subject's lett shoulder [0 prl'vcnt rotation 01 [he [h()r:lCi~: ;ll1d 11I1llh;H 'ipine.

CHAPTER 11 THE CERVICAL SPINE 325 FIGURE 11-40 To align the goniometer at the starring position for measuring cervical rotation range of motion, the examiner stands in back of the subject, who is seated in a low chair. FIGURE 11-41 At the end of the range of right cervical rotation, one of the the examiner's hands main- tains alignment of the distal goniometer arm with the rip of the subject's nose and with the tip of the [Dogue depressor. The examiner's other hand keeps the proximal arm aligned parallel to the imaginary line between the acromial processes.

326 PART IV TESTING OF THE SPINE AND TEMPOROMANDIBULAR JOINT Alternative Measurement Methad far Rotation: Tape Measure The mean cervical rotation ROM to the left measured with a tape measure ranges from 11.0 to 13.2 centime- [ersll,D. l'A.easure the dismnce between the rip of the chin and the acromial process at the end of the motion (Fig. 11-42). FIGURE 11-42 At the end of the right cervical range of morion, rhe examiner is using a rape measure to determine the distance between the rip of rite subject's chin and her right acromial process. Alternative Measurement Method for Rotation: Inclinometer Testing Position Place the subject supine with the head in neutral rotation, lateral flexion, flexion, and extension. Inclinometer Alignment 1. Place the inclinometer in the middle of the subject'S forehead, and zero the inclinometer (Fig. 11-43). 2. Hold the inclinometer firmly while the subject'S head moves through rotation ROM (Fig. 11-441· Testing Motion Instruct the subject to roll the head into rotation. The ROM can be read on the inclinometer at the end of [he ROM.

CHAPTER 11 THE CERVICAL SPINE 327 :; ., I S 1 1 ~ ..•... ]'1 FIGURE 11-43 Inclinometer alignmenr in the starring position for measuring cervical rotation range of motion. Only one inclinometer is used for this l11e~lsurernenr. FIGURE 11-44 Inclinometer alignment ar the end of cervical romrion range of motion (ROM). The Iwmber of degrees on the dial of the inclinometer equals the: ROM in rotation.

328 PART IV TESTING Of THE SPINE AND TEMPOROMANDIBULAR JOINl Alternative Measurement Method for Rotation: he'Hl. The arro\\\\' on the magnetit..' yoke should be CROM Device poill[ing north (rig. 11-45). The mean cervical ROM in roration with use of the To ensure rh;l[ rhl' CO!T1P~lSS inclinollletcr is level, CROM varies from 75 degrees in subjects aged 11 to 19 years to 46 degrees in subjects aged 80 years.· 6 Refer to adju\\t thl' position of the SUhjcd\\ ht:;ld s{) that Tables 11-1 and 11-7 and 11-8 for additional informa- hoth gr;lvity inclinoll\\eters read () (rig, 11--46). tion regarding rotation ROM using the CROM device. LAtter leveling the t..'Orllpass int..'lill{)I1lCft:r, turn the CROM Device Alignment44 r(l(;l[IOJ] Illcter on the L\"OlllP;lS:-' illl\"li!l{)!T1cter until 1. Place the CROM device on the subject's head so the pointer is at o. that the nosepiece is on the bridge of the nose and the band fits snugly across the back of the subject's Testing j\\t1otiot1 Cuidc the \\llhjecrs head IIlfO rotation ;llld rC;hl the incli- lIolllt:tcr at the \"lid of the RON!. I I I I I'I· FIGURE 11-46 .\\t rill' end of right ro[;nion Ll1lgC (If Illotion I (RO\\l,l, rill' examiner i\" s[,lhilizil1g [he subject's shoulder with one h;wd ,111d l11;linr~lil1il1g (he cfld of ro[,uion RO,\\1 with the I o(hcr h:lnd. The n;;llllinLT will rl'.ld [he di,d of rll,' indinolllctt:r I on rhe lOp of the U{O\\l dl'\\'icl'. RULHioll ]{O\\\\ will be the I 11umh,'!\" of degrees Oil rill' di.ll ;l[ rhe ,'nd ot lhe I(O\\\\. I I FIGURE 11-45 The compass inclinometer on tbe top of the I CROM device has been leveled so that the examiner is able to ¥! zero it prior to the beginning of the motion. M @ I ~ ,nn \"

CHAPTER 11 THE CERVICAL SPINE 329 REFERENCES 24. Feipcl, V, et al: Norm::ll glob:.1 motion of the cerviC:l1 spine: An electrogoniomcttic srudy. elin Biomech (Brisrol, Avon) 14:462, 1. Magee, DJ: Orthopedic Physicnl Assessment, cd 4. WB Saunders, 1999. Philadelphia, Elsevier Science USA, 2002. 25. Castro, WHM: Noninvasive three·dimension:l1 ::lnalysis of cervi* ~_~inc mmion in normal subjects in rclation to age :lnd sex. 2. God, VK: Momcnt-rOtarion relationships of the ligamentous / Spme 25:445, 2000. occipico-adamo.axial complex. J Biomcch 8:673, 1988. -~ 26. Ordw3y, NR, Ct :II: Cervical flexion, extension, protrusion ::lnd Caillic. R: Soft Tissue Pain and Dis3bility,. cd 3. FA Davis. retraction. A r3diographic segmental analysis. Spine 24:240, Philadelphia, 1991. 1999. mqE.c1Crisco,JJ. Panjabi, MM, and Dvorak.J: A 27. Miller, jS, Polissar, NL, :uld Ha::ls, M: A radiogr:lphic comparison oLthc abr liga- of neutral cervical pOsturc with cervical flexion and extension ments of rhe upper cervical spine in axi:tl rotation. J Biomcch ranges of motion.] Manipulative Physiol Ther 19:296, 1996. 24,607, 1991. 28. Christiansen, HW, :lnd Nilsson, N: The ability w reproduce the Dumas, JL. C[ 31: Rotation of the cervical spinal column. A neutral zero position of the head. J Manipulative Physiol Ther computed tomogr:lphy in vivo study. Stlrg Radiol Anar 15:33, 22,26, 1999. 1993. 29. Solinger, AB, Chen, J, and Lnnr7., CA: Standardized initial head White, AA, and Punj.:lbi, MM: Clinical Biomechanics of the Spine, position in cervical f::lnge-oE-motion asscssmelH: Reliability ::lnd ed 2. JB Lippinco\", Philadelphia, 1990. error analysis. J Manipularive Physiol 23:20, 2000. Herding, D, ;111d Kessler, RM: Management of Common 30. Chibnall, JT, Duckro, PN, and B:lumer, K. The influence of body size on linC.::lr measurements used to reflect cervical range of Musculoskeletal Disorders, cd 3. JB lippincon, Philadclphin, motion. Phys Ther 74: 1134, 1994. 1996 31. Gurh, EH: A comp::lrison of cervic::ll rotation in :lge-matched 8. LanrJ.. CA, Chen, J, and Buch, D: Clinical validity and smbility of adolescent comperitive swimmers ::lnd he::llthy males. J Orthap active nod passive cervical range of motion with regard to total SportS Phys Ther 21:21,1995. and unilateral uniplanar motion. Spine II: 1082, 1999. 32. Tucci, SM, et al: Ccrvic:tl motion .::l5.SCssmcnt: A new, simple and 9. American Medical Association: Guides to the Evaluation of :lccu(:J[e method. Arch Phys Mcd Rehabil 67:225, 1986. Permanent Impairment, cd 3. AMA, Chic:l.go, 1988. 33. Garrett, TR, Youd::ls, JW, and Madson, TJ: Reliability of measur- ing the forward head posrure in p3rie1l1s (abstract). Phys Ther 10. Capll:l.no-Pucci, 0, et al: Intratesrcr and imcncster rcliabiliry of 71,S54, 1991. [he cervical range of motion device. Arch Phys Med Rehabil 34. Nilsson N: Measuring p;lssivc cervical motion: A study <If relia- 72,138,1991. hiliry. J Manipul:ltive Physiol Ther 18:293, 1995 Youdas, JW, Carey, JR, and Garrcrr, TR: Reliabiliry of measure- 35. Nilsson N, Christensen, HW, and Hartvigsen, J: The imerexam- ments of cervical spine r:mge of motion: Comparison of three iner reliability of measuring passivt.\" cervical range of motion. J methods. Ph)'s Ther 71 :2, 1991. Manipulative Physial Ther 19:302, 1996. Hsieh, C-Y, and Yeung, BW: Active neck mOtion measurements 36. Rheault, W, et al: Intcnester rdiability of the flexible ruler far the wirh a rape measure. J Orthop SPOrtS Phys Titer 8:88, 1986. cervical spine. J Orthop SPOrtS Phys Ther J:1n:254, 1989. Balogun, JA, er al: lmcr* and intra rester reliability of measuring 37. Olson, Sl, er al: Tender point sensitivity, range of mo[ion, ::lnd neck motions with tape measure and Myrin gravity-rderence perceived disability in SUbjl'C[S wilh neck p::lin. J Orrhop Sports goniometer. J Orthop Sporrs Phys Ther Jan:248, 1989. Phys Ther 30: 13, 2000. O'Driscoll, Sl, :lIld Tomcnson, J: The cervical spine. Clin Rheum 38. Ordw::ly, NR, er al: Cervic:lI sagitt.::ll r.::lnge of motion. t\\n;llysis Dis 8:617,1982. using three methods: Cervical r'lnge-of·motion device. 3. Sp::lce 15. Keske, J, Johnson, G, and Ellinghnm, C: A reliability study of and radiogrnphy. Spine 22:501,1997. cervical r:lnge of motion of young and elderly subjccts using an 39. Tousignant, MA: Criterion validity of che cervic:l1 range of motion cJecrrom:agnetic r:tnge of motion sysrem (EN ROM) (3bsrrncr). (CROM) goniomc[er for cervic::ll flexion and extension. Spine Phys Ther 71:594. 1991. 25,324,2000. 16. Youdas: JW, et al: Norm::ll range of morion of the cervic::l1 spine: 40. Chrisrensen, HW, and Nilsson, N: The reliability of measuring acrive :lnd p3ssive c~fvic:l1 range of mocion: An obse(\\'cr blinded An initial goniomctric srudy. Phys Ther 72:770, 1992. and randomiz.ed repeated measures design. J M:tllipulative Physiol 17. Dvor::lk, J, er al: Age ::lnd gender related normal morion of the The< 2U41, 1998. cervic::l1 spine. Spine 17:S-393, 1992. 41. Ddib:lUgh, JJ: MC:.lsurclTlcnr of head motion. Pan II: An cxperi- 18. Pearson, ND, and Walmsley, RP: Trial into the effects oE repeated ment:ll snldy of head motion in adulr males. Phys Ther 44:163, neck retracrions in norm:ll subjccrs. Spint.\" 20: 1245, 1995. 1964. 19_ Nilsson. N, Harrvigsen, J. ::lnd Chrisrensen, HW: Normal ranges of p:lssive cervical mO[ion for women :l.nd men 20-60 years old. J 42. Herrmann, DB: Validity study of head and neck flexion-extension Manipulative Physiol Ther 19:306, 1996. motion comparing measurements of a pendulum goniometer :md Walmsley, RP, Kimber, P, :lnd Culham, E: The effect of initial head roelHgel1ograms. J Orrhop Sports Phys Ther 11 :414, 1990. 43. Viikari-Juntura, E: Interexaminer reliability of observations in position on active cervical axial rO[:lrion range of marion in rwo physical examinarion of the neck. Phys Ther 67:1526,1987. ;J,ge populations. Spine 21:24335, 1996 44. CROM Procedure M:l.llU:ll: Procedure for Me:lsuring Neck Trott, PH, et al: Three dimensional analysis of active cervical Motion wilh the CROM. Performance AU::linment Assoc., St motion: The cffect of age :lnd gender. Clin Biomech 11:201, 1996. Paul. Pellachia, Gl, ,1I\\d Bon,lOnon, RW: Active lateral neck flexion range of motion me::lsurcmcnts obtained with a modified goniometer: Rcli;'lbiliry and estimates of normal. J Manipulati\\'c Physiol Ther 21:443,1998. 23. Chen, J, er 31: Met:l.-analysis of normative cervical motion_ Spine 24,1571, 1999. ::

...'. The Thoracic and ~umbar Spine , • Structure and Function superior aspect of rhe adjacent inferior vertebral body. Some of rhe costovertebral facets also articulate with the 'Thoracic Spine imerposed imervertebral disc, whereas the 1st, 11th, and 12rh ribs articulate with only one vertebra. A thin, 'i-'; fibrous capsule, which is strengthened by radiare liga- ments and rhe posterior longitudinal ligament, surrounds (Anatomy the cosroverrebral joints. An iotra-articular ligament lies within the capsule and holds the head of the rib to the 'The 12 vertebrae of the thoracic spine form a curve that annulus pulposus. 'is,convex posteriorly (Fig. 12-IA). These vertebrae have The costotransverse joints arc the articulations ~\"number of unique features. Spinous processes slope berween the costal tubercles of rhe 1st ro the 10rh ribs .'Inferiorly from TI to TIO and overlap from TS to T8. and the costal facers on the transverse processes of the 1st to rhe 10th thoracic vertebrae. The costal rubercles of The spinous processes of TIl and T12 take on the hori- the 1st ro rhe 7th ribs are slightly convex, and the costal :'~_'?ntal orientation of the spinous processes in lumbar facets on the corresponding transverse processes are .'yertebrae. The transverse processes from the Tl to the slightly concave (see Fig. 12-1 B). The articular surfaces of the costal and vertebral facets are quite flat from \"'110 arca are large, with thickened ends that support about T7 ro TI0. The costotransverse joint capsules are strengthened by the medial, lareral, and superior costO- ~aired cosral facets for articulation with the ribs. The transverse ligaments. Y~ertebral bodies from T2 to T9 have paired demifacets :rl(~~perior and inferior costovertebral facets) on the Osteakinematics ',·p.osterolateral corners. The interverrebral and The zygapophyseal articular facets lie in the frontal plane ,-fj-gapophyseal joints in rhe thoracic region have essen- from Tl to T6 and therefore limir flexion and extension ·ti~lly the same structure as described for the cervical in this region. The articular facets in the lower thoracic ,legion, except that the superior articular zygapophyseal region are oriented more in the sagittal plane and thus permit somewhat more flexion and extension. The ribs \"'Iacets face posteriorly, slightly laterally, and cranially. and COStal joints restrict lateral flexion in rhe upper and ~'i:'The superior articular facet surfaces are slightly convex, middle thoracic region, bur in the lower thoracic '<1~hereas the inferior articular facet surfaces are slightly segments, lateral flexion and rotation are relatively free ~, ~j~~,~caYc. The inferior articular facets face anteriorly and because these segments are nor Iimired by the ribs. In general, the thoracic region is less flexible than the cervi- slIghtly medially and caudally. In addition, the joint ~psules are tighter than those in the cervical region. 331 \"The costovertebral joints arc formed by slightly :;, ~vex costal superior and inferior demifaccrs (coscovcr- 'bral facets) on the head of a rib and corresponding emifacets on the vertebral bodies of a superior and an --Ierior vertebra (Fig. 12-IB). From T2 to T8, the 'stovertebral facets articulate with concave demifacets ated on the inferior body of one vertebra and on the

332 PART IV TESTING OF THE SPINE AND TEMPOROMANDIBULAR IOINT Transverse process IIp\\\\'ard~ {Hl the slIpt:ri<Jr :uti<..\"ubr b\\,.\"\\,.,[s of the adjacent inferior \\'errehra\" In extellsioll, tht: OpP()~jtc motions r;i;:::::>--- $pinOlls process ()((llr: till' ~lIpl'ri(lr \\·t:rrt.:hr;l [ilt~ ;1I111 rranslares pOsteri_ orly :llld Ihl\" inft:riol' arricubr fat:e.:ts glide downward on \",.I,i~~~~ Costallacels lilt: slIpt:rior anicllbr fal\"l~{S of tht: adjac\"\"IH inferior venc. Zygapophyseal joints hra. In LHeral f1e:\\illll to rhe right, the.: righ( ink-rior articu~ Superior and :::;\"f~~~\\ lar f'1l.:e!:-> of rhe :,>upt:rior vertebra glide dowll\\vard on the inferior costovertebral right superior articular (:\\((\"[s of the ink'rior vtrt'ehra, On facets rh,: conrrala[l'f;J! sidl.', the left inferior ;\\rriL:lIlar facets of rhe superior ver[chl\"\\ glide upw:1rd on the k:ft superior Vertebral body --\"f,:J~!'>.' articubl' fac('rs of the adj;lu:lH inh:rior vCf[t:hra, A Vertebral body III <1:\\i;11 rm;ltioll. tht,: ~llperior n:rtchra rotiltcs on the Costovertebral joint infaior vt:ncbra, :lnd the,: inil'fior aniCllbr slIrbccs of the Rib Costotransverse supl:rior vCf[t.:hra iHlP:h:t on rhe.: slIpt.:rior anicular ligament-_J \",llrfaccs of rhe adi~h':t.:fl( illfL'riur ve.:f(e.:hra, h)r example, in rot:Hioll to thl' ldr. rhc righr inferior arriddar facet Joinl capsule Superior articular processes (facets) illlP:1US on th\",· right \\uplTior :\\rril..'ular fal't.:t of the adja- l\",,'IH inferior HTtehr:\\. Roration and gliding morions Lateral costotransverse Spinous process ligament Oi..'cur h..·twecll rht.' rihs and rhe verrehral bodies .n the B or(O;\"WVlTtehr;11 j\"illb. A slighr .HnpUIH rotarion is FIGURE 12-1 (A) A hueral view of the thoracic spine shows p()s~ihle herw('l'1I dH' it/ill[ ~t1rbcl.'s CIt\" rh .., rihs ~lnd the the costal facets on the cnlar~ed ends of the transverse processes from Tl to T10 and the costovertebral facets on rhe lateral rr:ll1.\"\\·crSi.: prO\\,.·l· .. \"'i..· ... ,n tht.' tlppLT \\,.·o~r{)tr:llb\\·(,'rs(' ioinrs, edges of the superior and inferior aspects of the vertebral ~\\lld !\\lore rotalio!1 is :lllownl ill the gliding rh~1t occurs at bodies. The zygapophyscal joints are shown bct\\'Veen the infe- rhl' lower jOlllls lT7 to T I 01\" 'fhl' IllO\\\"CI1It.'Ilt's;\\t rhl' cO$ral rior articular facets of the superior vertebrae and the superior joims ;lrl' prilll~1rily fClr \\\"l'llt'iLltioll of rhl' lungs but' also articular facets of the adjacent inferior vertebra. (B) A superior .lllo\\\\' SPIJle tl::\\ihilit)' ot' dll' thoraei\\\"\" rt.:giOll. view of a thoracic vertebra shows the articulations between the vertebra and the ribs: the left and right costovertebral joints, the Capsular Pattern costotransverse joints bct\\veen the costal facets on the left and right transverse processes, and the costal tubercles on the corre- Tlk clpsubr patrnll for rh ..· rhor:Ki\",\" ~pin ..· is a greater sponding ribs, lilllirariofl of l.-·xtl'nsioll. L1tcr~d f1e:\\ion, ;1111.1 ror;1ciun rhan of forward fk:'\\ioll, cal spine because of the limitations on movement I,\";, imposed by the overlapping spinous processes, the tighter Lumbar Spine joint capsules, and the rib cage, Anatomy Arthrokinematics Thl: bodies of rill' t\"ivl' lumhar HTtl'hrac ;11'<.' llInl'e.: massive In flexion, the body of the superior vertebra tilts anteri- rh:lll those in till' othl'l' region~ ot\" till' spinl'. Spinous orly, translates anteriorly and rotates slightly on the adja- pron'sscs arc hroad ;Jlld thick :llld l':\\{{'nd Iwril.onrally cent inferior vertebra. At the zygapophyseal joints, the (Fig. [2-l,r\\). Sllrt':H.:l'S of the superior :lI'ricuLlr facers at inferior articular facets of the superior vertebra slide till' zyg,lpophyseal ipims ;11\"e C0I11..':1\\'l.' and t\":lCl.' medially :lud posteriorly, Inf\"rio!' :lrrlcllbr Lll'Cr slIrf:Kl's are ,,:OllVl'X ;Hld t\";l\\:c btcf':dly :llld ;llltl'riorly\" 'fhl' fifth lumbar vl'ffl'hr:l diff('l\"~ from (hl' orher four v('rtchra ..· III having a wnlg,c-shapL'd hody, wirh (he aIHnior height grC:Hcr [han rhe.: pos(('fior heighr. The illtnior ~lrliCllbr f:l(CrS of rhe fifth \\'trlcbra an,' widdy spal·...d for :lrtit.:u!atioll with the S:lcrUIl1, .Ioim capsules ;1(e srr(lng alld li~;lll1t.·IHS of rh ... region :Irt.· t.·sse.:llli;llly rht.' S:lllll' as rhose tor rh\" thoracic region, exc('pr for tht.· additioll of the iliollll11h:11' :lnd (hora- i.:olull1har fa.sci~1. Tht.· supraspinous lig~lI11t.·IH is \\\\\"...11 dcvcl- opt.·d only in rhe lIppt.·r lumhar spine, Tht.· inrerspinous lig;llllenrs COllllect onL' spinolls process to ,lllorher, The iliollll1lhJr ligal111.'1l! hl'lps to srabili!.(' rlw Itl11lhlls:lcral joint :llld pn:\\'etl! anterior displaccflll.'lH. Till' illtcrtr<,lnS-

CHAPTER 12 THE THORACiC AND LUMBAR SPINE 333 t===I~~T---Spinous process combined flexion and extension, the greatest mobility takes place between L4 and L5. The greatest amount of Body _ _-\\- ...-:~?-,_::::::..Transverse process flexion takes place at the lumbosacral joint, L5-Sl. Lateral flexion and rotation are greatest in the upper __~ lumbar region, and little or no latetal flexion is present at the lumbosacral joint because of the orientation of the Disc facets. L5 Arthrokinematics +-__ Sacrum According to Bogduk,' flexion at the intervertebral joints consistently involves a combination of 8 to 13 degtees of A anterior rotation (tilting), 1 to 3 mm of anterior transla- tion (sliding), and some axial rotation. The superior Anterior longitudinal M1~=~~\"\"l\":':::>---..lnlelrigSaPmjennotus vertebral body rotates, tilts, and translates (slides) anteri- orly on the adjacent inferior vertebral body. During flex- ligament - - - - j L - 1 ~,fJ... ...:SupraSPinous ion at the zygapophyseal joints, the inferior articular facets of the superior vertebra slide upward on the supe- ligament rior articular facets of the adjacent inferior vertebra. In extension, the opposite motions occur: The vertebral B body of the superior vertebra tilts and slides posteriorly on the adjacent inferior vertebra, and the inferior articu- FIGURE 12-2 (A) A lateral view of the lumbar spine shows the lar facets of the superior vertebra slide downward on the broad, thick. horizontally oriented spinous processes and large superior articular facets of the adjacent inferior vertebra. vertebral bodies. (B) A lateral view of the lumbar spine shows In lateral flexion, the superior verrebra tilts and translates the anterior longitudinal, supraspinous, and interspinous Iiga M laterally on the adjacent vertebra below. ments. In lateral flexion to the right, the right inferior articu- verse ligament is well developed in the lumbar area, and lar facets of the superior vertebra slide downward on the the anterior longitudinal ligament is strongest in this area right superior facets of the adjacent inferior verrebra. The (see Fig. 12-2B). The posterior longitudinal ligament is left inferior articular facets of the superior verrebra slide not well developed in the lumbar area. upward on the left superior facets of the adjacent inferior vertebra. In axial rocation, the superior vertebra rotates Osteokinematics on the inferior vertebra, and the inferior articular The zygapophyseal articular facets of L1 to L4 lie prima- surfaces of [he superior vertebra impact on the superior rily in the sagittal plane, which favors flexion and exten- arricular facet surfaces of the adjacent inferior verrebra. sion and limits lateral flexion and rotation. Flexion of the In rotation to the left, the right inferior arricular facet lumbar spine is more limited than extension. During impacts on the right superior facet of the adjacent infe- rior vertebra. Capsular Pattern The capsular pattern for the lumbar spine is a marked and equal restriction of lateral flexion followed by restriction of flexion and extension.2 • Research Findings Table 12-1 shows thoracolumbar spine range of motion (ROM) values from the American Academy of Orthopaedic Surgeons (AAOS)3 and lumbar spine ROM values from the American Medical Association (AMA).' Effects of Age, Gender, and Other Factors Age A wide range of instruments and methods have been used to determine the range of thoracic; thoracolumbar, and

334 PART IV TESTING OF THE SPINE AND TEMI'OROMANDIBlILi\\R IOINT TABLE 12-1 Thoracic and lumbar Spine SWl..'l·tlll,If\\'·' clllploy<..·d .\\ d1..,\\·j({: th.ll ~(Ililhilh:d .\\ Ilt.:xihlc ( Motion: Values in Inches and Degrees from A Selected Sources orrllll..' .lIlt!.1 hydrogol1ioI11L'It:r to IllL';\\SlIrl\" thl' RO.\\\\ 432 . ..,~, \"'/;- working lIlt'll ;Ignl 20 If) :)~ ~T;lr.... III\"'Tl';l~iJlg agl: was .1'o~1Il\"i;\\lnl wirh;1 !tl\\vL'r 1()(;1! 11IIIlh;l!\" spillc R()\\l (flexion jfl~xi~, alld l'X[l\"lI:..ioll)_ From;l (ot:ll ot\" 7-1 l11el1 who Iud k'~~ [han Extensio 50 degfei.:' cOlllhined fk:-':lon-cxlcflSIOll. 12 Wl'fe in [he l...\"lfq',ory oi )\"()-ye,lr-(lld to '9-year-old sHhicus, i!·L~.~Ri~i;~gr1Hati\\l~~~iX(~9erri;~~<,s1.~\\ei\"(i')99~nr0ij;,;, I...'(lfnp,lrnl with') ill rhl' group o( 20--yL';lr·old to 29-ycar- AAOS = American Association of Orthopaedic Surgeons; AMA = American Medical Association. old suhjects, Of thL' 1(ll II'll'!l who Iud more tlLlfl 60 dq~rL'es [(luI RO:\\l, 22 wert: ill the'O-yc;lr'old to 59- • Values represent thofacolumbar motion. Flexion measurement in Yl';ll'~(lld ;.;roup ;1I1d (,() \\\\'l're ill [11(· 20-yt:;l!\"'ljJd to 29·ycar- inches was obtained with a tape measure with use of the spinous processes of C7 and $1 as reference points. The remaining (lId (;Hcgory. motions were measured with a universal goniometer and are in One of (he follo\\\\'ill~ lWo \"ludiL's illVl'srig;unl \"itgmcn- degrees. !ill mobility, whtre;l:\" rht: otll1.:r inn-slig;llnlltllllh;lr spine t lumbosacral motion was measured from midsacrum to T12 with use of a two-inclinometer method (values in degrees). llloriOll in all plancs. Sl.'glllcllul ;l'HI ll1ocioo-specific (ha 1l~I.:S \\\\·t.Tt: fotllHI wit h i Ih,:rchi llg .q.!S, (; l-;l(o\\,crskv lumbar motion. Therefore, comparisons berween studies are difficult. As is ttue fOt othet regions of the body, and ~ls:-oci:Hesl\" found ;J :..igllifil.....llH· dif'lefl:l1ct.· hL'[Wt'C~ conflicting evidence exists regarding the effects of age on ROM. However, most studies indicate that age-related young ;'Ilul old in ;1 group of 40 suhjL:\\,. rs ;lgL'd J l) ro 64 changes in the ROM occur and that these changes may ye;H:-. Older \"llhj:\"l:b Iud deI...Tcl~l·d scgllll'l1UI /Hohilir)' in affeCt certain motions more than others at the same joint thl' IO\\\\'I.:f Illlllh;H \"\"pllll' I.:olllpafni \\\\'Irh ynllll~n subjc<..'rs. or region. 5- 11 \"(~I CUlllPCI\\S,ltc fOf ~hc tb... re;lsc ill llIohiliry, tht older ~llhil.·l\".·ts illl:rC;bcd rill...· dllllrihution of dll...' pl.:h i:-. [(l fkxioll In one of the earlier studies, Loebls used an incli- J!H.l L'xtl·IlSio!l. :\\L... Crl\".·g(ll'• .\\'h:C;lrthy, ,lnd l'lughcs ll nomctcr to measure active ROM of the thoracic and lumbar spine of 126 males and females berween 15 and [oulld th;\\( ;lIt!lough ;Igl' Iud J Sig1l1fi',:;I1\\[ dt\"t.·Cl on aU 84 years of age. He found age-related effects for borh males and females and concluded that bath genders planl's nt' mOfino, rhe dfl'l\".·r \\';Hled for C;Il:h m(ltion, and should expect a loss of about 8 degrees of spinal ROM per decade with increases in age. In a morc recent study, ;lgt.: :ll...·(OllrHcd for olll!' ;1 Sl1ull portio\\1 of dH.' variability Sullivan, Dickinson and Troup· used double inclinome- ters to measure sagittal plane lumbar morion in 1126 seell ill rhe 203 1l0nlwJ suhjeus sludiL'tL .\\'I:lxilllum healthy male and female subjects. These authors found that when gender was controlled, flexion, extension, and eXH.'llsioll W;h rhe 1l1O!o.[ ;It\"IL'unllllotioll, wirh ::.igniticanr total ROM decreased with increasing age. The authors d\\,.·;,:rt.·;bl'S ht.:[WeCll \\,.·;1(h i.kC;ldL·. 1.~1t('r;11 f1CXilHl ...k·<.:rcased suggested that the ROM thresholds that determine impairment ratings should take age into consideration. ~lIrl'r ;lgL' --to alld I..';ll.:h dl.:cade rhcrcJlref. Fkxion Different measurement methods were used in each of dCi.Tl';\\snl iniri;llly ;\\!rcr ;lgc 30 YClr:-. hut suy(.'d rht.' same the following three srudies to assess the effects of age on ulllil ;Ill ,Idditiolla! dCGL..1Sl· ;\\hn ,lgl' 50 YGlr~. :'-:0 simi- lumbar sagittal plane ROM. In each instance, the inves- 1.11' dl:t'rl',lsl\" or tl\"{.·lHI!o. Wl're found in ;lxi.t1 rotation. tigators found decreases in ROM with increases in age. Macrae and Wright,' using a modification of the Thl' rt.·sll!ts of ~l 'lmly hy Fiti'.glT;dd ;lnd ;lss<Kiates. 12 Schober technique to measure forward flexion in 195 ;lJ't' pH'sL'llted in Tahlt· 12-2. The ;llHhors ill\\·t.'stigarcd women and 147 men (18 to 71 years of age), found that cft\"l'crs (II ;lgC on rhoral...·olllll1h;u RO\\L .-\\ rl'\\'icw of rhe active flexion ROM dec teased with age. Moll and \\'alllt.·s in TJhlc 12-2 shows th,1( rhe oldc~r group had Wright' used skin markings and a plumb line to measure cOrlsidcClhly lcss motion rhan [he youngL'sr group ~n all the range of lumbar extension in a srudy involving 237 !llotiolls exccpt for fk'xioll,Thc cort\"fil:icllrs of variation subjects (119 men and 118 women) aged 20 to 90 years. These authors found a wide variation in normal values indicHt:d t'lUt ;l greater' ;\\!1l(lunt of \\'Jri:lhiJity L'xistcd in but detected a gtadual dectease in lumbar extension in tht: RO:vl in the oldcsr groups. subjects between 35 and 90 years of age. Anderson and Gender Im'L'srig;Hions of rhl' e.:t\"fL·\\,,·IS of gl'odlT on lumhar spine RO~t indicare th;H rht.:y 1l\\,ly he.: mmion spc.:cit\"ic and possihly ;l~(, spccific. hm ((Jll!ro\\'l'fsy still l·~is.cs ;lhout which motions arc alkctL'd, ;lfl<.1 some ;\\ll[hors rt'port that ~l'l1(kr Ius no cffcl...·rs. The her dur imTstig:Hors used ditfefl'llr instrUIlll'llts alld l1\\Crh<lds llUkcs (ornparisons llL'twccn srudil'S difficulr. For l'~;lIl1plc, lhc rl-sl::ll'ch (ired ill rhe following p;lr;lgr;lph W;IS 1...·~lrrinl Oll[ hy ll1c~lllS of C;ll'l.\" nh:;lSUfc.:S. indiuOlllCfL'fS. and !,Iunlh lines, M:lcrac ;Uld \\\\/righr- found rlU[ fl'nl;llcs h:1(1 signifi- t~:lnrlv 1ess forward flexion rlun lll~lIl'S ;lC!\"OSS :d! age grnUI)s. Sullivan, Dickinsoll, :lnd 'l'roupi> fOllnd that when ;\\gL: was controlled, nH.'all flexion RO\\I W;IS grcater in

CHAPTER 12 THE THORACIC AND LUMBAR SPINE 335 TABLE 12-2 Effects of Age on Lumbar and Thoracolumbar Spine Motion: Mean Values in Degrees = Standard deviation. Adapted from Fitzgerald, GK, et al: Objective assessment with establishment of normal values for lumbar spine range of motion. Phys Ther 63:1776, 1983. With the permission of the American Physical Therapy Association . • Flexion measurements were obtained with use of the Schober method and are reported in centimeters. All other measurements were obtained with use of a universal goniometer and are (eported in degrees. Subjects were 172 volunteer patients without current back pain. males) bur mean extension ROM and total ROM were studies reported no significant effects for gender on I significantly greater in females. Subjects in the study were lumbar spine ROM. Loebl5 found no significant gender 1126 healthy male and female volunteers aged 15 to 65 differences between the 126 males and females aged 15 to , years. The authors noted that although female total 84 years of age for measurements of lumbar flexion and ROM was significantly greater than male total ROM, the extension. Bookstein and associates 13 used a tape meas- .I.. difference of 1.5 degrees was not clinically relevant. Age ure to measure the lumbar extension ROM in 75 e1emen- taty school children aged 6 to 11 years. The authots I,• and gender combined accounted for only 14 percent of found no differences for age or gender, but they found a variance in flexion, 25 percent in extension and 20 significant difference for age-gender interaction in the 6- year-old gtoup. Girls aged 6 years had a mean range of percent of the variance in total ROM. Measurements of extension of 4.1 em in cOntrast to the 6-year-old boys, who had a mean range of extension of 2.1 cm. lumbar spine motion were taken with an inclinometer. Flexion was measured in the sitting position and exten- Occupation and Lifestyle sion in the prone position (Table 12-3). Moll and Wright'sS findings recarding lumbar spine extension arc Researchers have investigated the following factors directly opposite to the findings of Sullivan, Dickinson, among others in relation to their effects on lumbar ROM: and Troup6 in that Moll and Wright8 determined that occuparion, lifestyle,,,,H-16 time of day, 17 and disabil- male mobility in extension significantly exceeded female ity.6.18-22 Similar to the findings related to age and mobility by 7 percent. Differences in findings between studies may have resulted from the fact that Moll and gender, the results have been controversial. Wright did not control for age. These authors used skin Sughara and colleagues,14 using a device called a spin- markings and a plumb line to measure the range of ',. lumbar extension in a study involving 237 subjects (119 ometer, studied age-related and occupation-related :;,X·males and 118 females) aged 15 to 90 years, who were changes in thoracolumbar active ROM in 1071 men and J,;(clinically and radiologically normal relatives of patients 1243 women aged 20 to 60 years. The subjects were ':\\vith psoriatic arthritis (Tables 12-4 and 12-5). selected from three occupational groups: fishermen, farmers, and industrial w()rkers. Although both flexion ,',,~ , In contrast to the preceding authors, the following two TABLE 12-3 Effects of Age and Gender on Lumbar Motion in Individuals 15-65 years: Mean Values in Degrees'

j;>'.' 336 PART IV TESTING OF THE SPINE AND TEMPOROMANDIBULAR JOIN r TABLE 12-4 Effects of Age and Gender on Lumbar and Thoracolumbar Motion in Individuals Age 15-44 years: Mean Values in Centimeters (0.B2) 6.69 (1.09) 6.88 (0.88) 6.29 (1.04) (1.41 ) 4.76 (1.53) 3.73 (1.47) 3.09 (1.31) (1.06) 6.32 (1.93) 4.B3 (1.34) 5.30 (1.61) (1.07) 6. I 3 (1.42) 4.83 (0.99) 5.48 (1.30)::: Adapted from Moll, JMH, and Wright, V: Normal range of spinal mobility: An objf:ClivC' clinical ~llidy. ,\\nn Rheum Dis 30: 381, 1971. The authors used skin markings and a plumb line on the thorax for latera! flexion, (SD) = Standard deviation. -lumbar motion 'Thoracolumbar motion and extension were found to decrease with increasing exisr hl'rwccl1 :-I..'hool hus USc alld ph~'si\"'::ll performance age, decreases in the cxtension ROM were greatcr than \\\\,:lS ..:onfirllll'd. 'rhe disCII'K(' IL1\\'<:!l'd h)' thl' SdlOOI bus decreases in flexion. Decreases in active extension ROM was in\\·lT~t1~· .l~~o,.:iatt.:d with h.lI11Srrill!!. tl:xihility and were less in the group of fishermen and their wives than othn hip IlHI[ions hur nor wirh low-h:h.:k t'lt.:xion. in the fatmets and industrial wOtker groups and their \\V~llkin~ Of hlc)'l.'ling w leislIrt: ;h:ti\\·iril.':\" \\\\'as positively wives. The authors concluded that because the fisher- ,\\Sso..:i;lr(·d wirh low-h'1L.'k Qrel1).!.th. Il)W·h:\\L.'k extension men's wives, like the fishermen, had more extension than other groups, variables other than the physical demands 1\\0\\1 alld hip t'k'\\io!l :llH.l extension. of fishing were affecting the maintenance of extension Freidrieh and l.'olltagu(,·s I\" conducted a l\"olllprdlCI1sive ROM in the fisherman group. or(,'xaillinatioll :-opiual pOSfun: during s[()op(,'d walking in Sjolie l • compared low-back strength and low-back 22 Ill:lk Sl'wer workers :\\gl'J 2.4 ro 49 ~·L~;HS. \\\\lorking in and hip mobility between a group of 38 adolescents ;l swoped pOSllIrL' has hL'1'11 iucIHifieJ a~ one of rhe risk living in a community without access to pedestrian roads LlCwrs associ:HL'\\.1 with spinal disorckrs, Fi\\'C posture and a group of 50 adolescents with excellent access to k'\\'c]s \":OrtTsponding to ~,I[;llldardized Sl'\\\\\"t::r heights rang- pedestrian roads. Low-back mobility was measured by illg from !50 TO 105 ('Ill were L1Pl.'d by ~1 video-based means of the modified Schober technique. The results morion ,lllalysis SYSlL'lll. ThL' n:slIlrs showed that the showed that adolescents living in rural areas without easy llllllb.ll' spille ;lhruprly dl:lngcd (rolll the usual lordotic access to pedestrian roads had less low-back extension posirion in normal uprighr \\\\';llking 10 J k~'ph()[ic posi~ and hamstring flexibility than their counterparts in urban lion in mild. 150-011 headroom restriction. As ceiling areas. The hypothesis that negative associations would height' deLTC;Jscd, the flL'ck progn:ssivcly assumed :1 more eXt'clllkd lordotic positioll, rhe (horae] ... spine extended TABLE 12-5 Effects of Age and Gender on Lumbar and Thoracolumbar Motion in Individuals Aged 45-74 years: Meal) Values in Centimeters .\" ~n~,*!Rn>it -~B;;~::@J;<f~;1I~~?;1;~/q<~;~79)0~~~0X:81Y€:cf~f>(1~~?)\", 0~tensi? , :i:~f. 3,8.ll'y(1.l9j·,i,:: 3,g·;p.36);!:,. ).!:!.;;'~!9hSI.i~\"'\"flexio~.;:,;-•. 9»,(1.3_5)}U~; ,B7i(1.54) 'A:14leWI\"le\"J fljfxiontf·(.!\"'~:55'.30.9~r. 5.05 (1;54)'·:·. ·\":4.94 Adapted from Moll, JMH, and Wright, V: Normal range of spinal mobility: An objective cHnicdl ~tudy. l\\nn Rheum Dis 30:381, 1971. The authors used skin markings and a plumb line on the thorax for lateral flexion. (SD) = Standard deviation. -lumbar Motion trhoracolumbar Motion

CHAPTER 12 THE THORACIC AND LUMBAR SPINE 337 dnd flattened, becoming less kyphotic, and the lumbar values obtained with three different instruments in 44 \"'spine became more kyphotic. As expected, the older patients with chronic low-back pain whose mean age was 38 years. Measurements obtained with the SPINETRAK workers showed decreased segmental mobility in the (Motion Analysis Corp., Santa Rosa, Cal.) werc signifi- lumbar spine and an increase in cervical lordosis with cantly correlated (r = .62) with ROM determined by decreasing ceiling height. liquid inclinometers, bur only mildly correlated with the McdX (lumbar extension resting and exercise machine) Disability ROM measurements. T-test results showed that measure- ments taken with the SPINETRAK were significantly - Sullivan, Dickinson, and Troup6 used dual inclinometers lower than those taken with either the liquid inclinome- to measure lumbar spine sagittal motion in 1126 healthy ter or the MedX. The SPINETRAK measurements also ~t::~~individuals.The authors found a large variation in meas- were about 12 to 16 degrees lower than the values set by \"~u;cmcncs and suggested that detection of ROM impair- the AMA guide for determining disability. j'ments might be difficult because 95 percent confidence \". intervals yielded up to a 36-degree spread in normal Functional Range of Motion ROM values. Sullivan, Shoaf, and Riddle'S examined the relationship between impairment of active lumbar flexion Hsieh and Pringle\" used a CA-6000 Spinal Motion ROM and disability. The authors used normative data to Analyzer (Orthopedic Systems, Inc., Hayward, CaL) to determine when an impairmcm in flexion RONI was measure the amount of lumbar motion required for present, and used the judgement of physical therapists to selected activities of daily living performed by 48 healthy determine whether flexion ROM impairment was rele- subjects with a mean age of 26.5 years. Activities vant to rhe patient's disability. Low correlations between included stand to sit, sir to stand) purring on socks, and lumbar ROM and disability were found, and the authots picking up an object from the floor. The individual's peak flexion angles for the activities were normalized to the that active lumbar ROM measurements subject's own peak flexion angle in crecr standing. Srand should not be used as treatment goals. to sit and sit to stand (Fig. 12-3) required approximately 56 percem to 66 percem of lumbar flexion. The mean Lundberg and Gerdle!'! investigated spinal and periph. eral joint mobiliry and spinal posture in 607 female FIGURE 12-3 Sit to stand requires an average of 35 degrees employees (mean age = 40.5 years) working at least 50 lumbar flexion.!] percent patt time as homecare personnel. Lumbar sagit· tal hypo mobility alone was associated with higher disability, and a combination of positive pain prnvoca- tion tests and lumbar sagittal hypomobility was associ- ated with particularly high disability levels. Peripheral joint mobility, spinal sagittal posture, and thoracic sagit- tal mobility showed low correlations with disability. Kujala and coworkers20 conducted a 3-year longitudi- nal srudy of lumbar mobility and occurrence of low-back pain in 98 adolescents. The subjects included 33 nonath- letes (.16 males and 17 females), 34 male athletes, and 31 female athleres. Participation in spons and low maximal lumbar flexion predicted low-back pain during the follow-up in males bur accounted for only 16 percent of the variance between groups with and without low-back pain. A decreased ROM in the lower lumbar segments, low maximal ROM in extension and high body weight were predictive of low-back pain in females and accounted for 31 percent of the variability between groups. Natrass and associates!! used a long-arm goniometer and dual inclinometers to measure low-back ROM in 34 patients with chronic low-back pain. ROM for all subjects was compared with their ratings on commonly used impairment and disability indexes. The investigators fOund no relationship between the ROM measurements and the impairment ratings as determined by the tests. The authors concluded that the instruments and methods of measurement had poor validity. Shirley and colleagues\" compared lumbar ROM

338 PART IV T EST I N G 0 F THE S PIN E AND T F 1'vl P 0 R 0 ~vl r\\ N D I B U L f\\ H J 0 ) r--J Inclinometer Lochl' ILlS slated that the only rchahk. technique for Ilh:;lsuring Illlllh;\\r ..,pine Il1otion is Lldiography. llo\\\\'cvcr, r:Hliogr:lph:\" is n,:pcll,>ivc ,)ilL! po,>cs ;\\ hl';drh risk to the suhject; 1l1Orl'0\\'{.T, thl' \\·alidiry of radiogr;lphi,: assl:ssment of !\\().\\1 is unreported. Therdore, fcscarc!1lTs h~lvc llsed !lUlly diffclTIlt instruments ;llld Illcthods ill a search for rcli,lblc Jlld valid flleasurcs of IUlllhar spine motion. LOt\"bl ~ used anj!lel iIlOIlk'ter to Illea Sll rc flex ion and ext'ensioll ill nine suhjects, I Ie foulld rlUt ill five repeated ;lui\\'L\" llle,burelllellb, rhe !\\();\\l varinl hy S degrees in the Illost C01lsistt'nt suhjcu 'lllt.! h:' 2,) degrccs in the most inco1lsistent sllbjccr. Variahilit':, deCl'cJsnl when mcasure- Illents Wl'l\"C rah:cn on all hour!\\- hasis r~lther [han on a daily basis, Pat'el ..~'l who used' the double-ll1clillometer Ilh.'dlOd to !l1easure lumh;u flexion 011 25 subjects aged 21 to ,) - :\\.',\\rs. found inrr:ltt'srer rcli,lhility to he high (r O,l) I) hut illtnresrcr rcli,lhility to he' ollly ITHH.!t:ratc (r {J.6~ I. FIGURE 12-4 Putting on socks requires an average of 56 degrees of lumbar flcxion.23 was 34.6 degrees (SO = 14 degrees) for sit to stand. The mean was 41.8 degrees (SO = 14.2 degrees) for stand to sit. Putting on socks (Fig. 12-4) required 90 percent of lumbar flexion (mean = 56.4 degrees and the SO = 15), and picking up an object from the floor (Fig. 12-5) required 95 percent of lumbar flexion (mean = 60.4 degrees). In view of these findings, one can understand how limitations in lumbar ROM may affect an individ- ual's ability to independently carry out dressing and other activities of daily living. Reliability and Validity FIGURE 12-S Pi...:killg tip ,111 objc...:t from tht' (Ioor requires an ,ll,'l'r,lgc of (,() degrees of lumhar flexion,':' \\ The following section on reliability and validity has been divided according to the instruments and methods used to obtain the measurements. Some overlap occurs between the sections because several investigators have compared different methods and instruments within one srudy.

CHAPTER 12 THE THORACIC AND LUMBAR SPINE 339 'i4t'f?ii\";-lTmhpaeiTmAelMlfA~ Guides to the Evaluation of Permanent agraphic ROM measurements with inclinometer ROM stares that \"'measurement techniques using measurements demonstrated an almost linear correlation 0i3j\"inclinomcrcrs are necessary (0 obmin reliable spinal for flexion (r = 0.98) and rorallumbar flexion/exrension ROM (r = 0.97, bur extension did nor correlate as well f#J~ J1lobility measurements. n However, in a study by (r = 0.75). Intertester reliability of the inclinometry rech- '.§~t:Williams and coworkers25 that compared the measure- nique for roral ROM in a subgroup of 48 patients was [;:J\"~men[s of the inclinometer with those of the tape measure, high ( r= 0.94), and flexion was good (r=0.88), bur extension was poor (r = 0.42). The aurhors concluded --b'/the authors found that the double-inclinometer technique that the Pleurimerer V was a reliable and valid merhod for measuring lumbar ROM and that with use of rhis ;;-had questionable relIabllIry (Table 12-6). instrument it was possible to differentiate lumbar spine ~ Mayer and associates26 compared repeated measure- movements from hip movements. z~;ri.ents of lumbar ROM of 18 healrhy subjecrs raken by 14 :~~~'differcnt examiners using three different instruments: a In contrast ro the findings of Saur and colleagues,\" a ~f~r.fluid-filled inclinometer, the kyphomerer, and rhe electri- number of aurhors!S-J' have reported poor criterion cal inclinometer. The three instruments were found [Q be validity and poor intcrrester and intratcster reliability with use of inclinometers. Sarno and coworkers28 ),::equally reliable, bur significant differences were found compared radiographic measurements of lumbar ROM in 30 subjects with measurements raken with the follow- :~~iL between examiners. Poor inrcrcesrcr reliability was the ing rhree insrruments: a Pleurimeter V (double incli- ':jW,.!J1osr significant source of variance. The authors idcnti· nometer), a carpenter's double inclinometer. and a compured single-sensor inclinometer. All ICCs between -ir·%ed sources of error as being caused by differences in radiographs and for each merhod were below 0.90 and therefore judged by the aurhors ro have poor crirerion tlfbf;g}nsrrument placement among examiners and inability to validity. Chen and associates:!9 investigated inrerrester gp' 'locate the necessary landmarks. and intrarester reliability using rhree health professionals 'x.:.~;';j ;:~; Saur and colleagues!7 used Pleurimeter V inclinome- ters to measure lumbar ROM in 54 patients with chronic ii/Jaw-back pain who were between 18 and 60 years of age. Measurements were taken with and without radiographic serificatinn of the T12 and S1 landmarks used for posi- tioning the inclinometers. Also, correlation of radi- TABLE 12-6 Intratester and Intertester Reliability for Thoracolumbar and Lumbar ROM . BROM 11= Back Range of Motion Device; OSI CA 6000 = Spine Motion Analyzer; MMS= Modified Modified Schober • Lumbar ROM + Thoracolumbar ROM

340 PART IV TESTING OF THE SPINE AND TEt\\l\\rORO~·1AN[)!BUl;\\R JOINT [0 measure lumbar ROivt with rhe same instruments used Stllll:1I1'; dl'(l'l\"lllilled (h;H rot,nill\" hut I\\(I[ f1e\"io!l could t in rhe srudy by Sarno and co\\Vorkers2S Inrcrtesrcr rdia- hl' celiably Illeasuced bn: T;lhk 12-()). (JotelHi;i1 ~(lur«'S C biliry was poor, wirh all ICCs bclow 0.75, and with a 01 aroc idl'llrifil'll hy :VLtdSllll. YOlld:b. ;lnd Slll1lan·H single exception, intrarcsrcr reliability was below 0.90. illdlltlnl \"Iipp;lgl' of till' dl'\\'il':c O\\'eC (he -';lI..Tlllll during ( The authors determined that rhe largest source of meas- tkxion ;lI1d l'xH:nsioll ;lIld \\':lri;nilllll> in £Ill.: idelHificarion urement error was 3rrriburable (Q rhe examiners and (If blldnurk..; fro III (lIll' Illl';I\\UCl'llll'llr to :Illorher. C associated factors :tnd concluded that these three surface :1 merhods had only limired clinical usefulness. Tope Measure Methods I Mayer and colleaguesJO used a Cybex EDI-320 .\\1;h:C:1l' :llld \\'('cight,-' rl'STl,d rhl' \\';'di<liry CIt\" h(lrh rhe orig- (Lumcx, Ron Konkoma, NY), a computed inclinometer d with a single sensor, to measure lumbar ROM in 38 illal t\\vO-lll;ICk Schohl'r rl'clllliqul' :\\nd;l thcl'l'-mark Illodi- healthy individuals. Total sagittal ROM was the mosr (i~ari(jll of thl' Schohel\" (l'chlliqllL' (Illudi(inl Schober). 1 accurate measurement and extension was the Icast accu- The ;lllt!loCS found :1 lilll.:ac r('bri()ll~hir hl'l\"Wl't'll mcas- ratc. Errors in loc;:uing T12 and 51, improper instruction un:lllelll\", 01 lumhac flexion ohtainl'd hy thl'~l' Illtrhods s of patients, lack of firm placement of rhe inclinometer, ,111(1 IllI.:;lSUrl'IlH:nts r,lkell cadiogr:lphi.::1l1y. Thl' correla- f device error, and human variability conrriburcd to a lack rion coct\"fi..:il'nr was 1I.9{) hC[WCl'!l r1h: Sl·hohl'c [l'chnique f of mcasuremenr accuracy_ Clinical utility of lumbar sagit- H ral plane ROM measuremenr appeared to be highly sensi- alld r;ldiogcaphs (x-rays) \\\\'irll .1 sCl1h.lacd nroc of 6.2 fl tive to the training of the test administrator in aspects of dq.:,rl'l'-\" The c(lcrebriclil CCldfi\\\",jt:llf \\\\'a~ (),9- hl'r\\\\'('C'1I the d the process such as locating bony landmarks and main- Ifll.ldifinl Schoher 1llt'<lSUCt'Ill\\,,'llf ;lnd {hl' c;ldi()~raphic P taining inclinometer placement without rocking on the IIlc\\:-.un... mt'IH.... wirh ,1 ~L11ld,lrd ncur (If ,;'!.5 degrees. sacrum. The authors determined that device error was Clinical it..!cnriticHio!l of rhl.: 11ll1lhos:ll'J':11 jUllcrion was S negligible relative to the error associated with the test HOt' e:ISY. Jill! f:lulr~' pLlC<\"llil'IH of skill 1l\\:lrb seriollsly process itself and that practice was the most signific,lnt lI11pJircd rhe :lCCllr~h'::' o( rhl' 1l!11l10~lifjl'd Sclwhcr rech- [( factor in eliminating the largest source of error when niqul', Placelllent o( rn;Hks 2. ern roo low It,d ('(l ;11l over- inexperienced examiners were used. l'st'irn;Hl' o( 14 degrees, :vLlrks pLh:l·d 1 ern roo high led eg to ;lll tlndcrcSrlllUle of IS (!l:grc(:s, III the modified Nitschke and colleaguesJI compared the following Selwhl.:r [(·chniquc. rhl' sallH' errors tn pbcelllcnt led to II measurement methods in a study involving 34 male and female subjects with chronic low-back pain and twO O\\'l'I\"esrillLHcs ;ll1d undcccsrim:Hi,:S of 5\" :1I1d 3 degrees, e, examiners: dual inclinometers for lumbar spine ROM (flexion, extension, 'llld lateral flexion) and a plastic long rt'spccrive!y, sc arm goniometer for rhoracolumbar ROM (flexion, exren- cl1 sion, lateral flexion, and rotation). Reynolds'\" eornp;lrL'd inrr:u('srcr :tnd inrer[l'srl.'c relia- fic hility wirh lISC o( :1 SpOlH.lyloJll('rLT. :1 plumb line and skin lntenester reliability was POOf fOf all mcasurements disrr'lcrioll. ,wd an indinnnH:rl'l\", SubjeCTS \\\\'cre 30 volun- CC except for flexion taken with the long arm goniomcter tl'l'CS \\\\'idl ~I illean age 01 .;S, I yl';HS. IIHI.'rrL·SH:r error was \\\\'1 \\\"'.lklll:m,:d h~' 1.:0I11P:1Cill~ rhl' CL'sull!'. of t\\\\'o tL'sters wking (Table 12-6). The dual inclinomerer merhod had no 10 repealed llle:1SUCl'IlKllrS of Illlllh;lr fk';..:i<.H1. l:xtL'nsiol1, co :111<1 I:Hl.'cal tl:.·xion Oil 30 \\'olulHl'l\"fs wirh .1 l11e:1I1 age of .1, systematic errOf, bur there was a large random error for 3X.1 YL';:HS. Hi~hly signific:l1H pusiri\\'I.: ..:ocrdariuns were all measurements. The amhors concluded rhat the st(ln- tl.lllild b('l\\\\'l.'Cn fkxioll-eXCt'llsillll RO,\\! Illt'aSurcd wirh Pc clard error of measurement might be a better indicator of rhl' ilh,:lifHl/lll'rer ;\\£lL! rh;1t l1lt.\":lsllrl·d wirh rhe spondy- ca reliability than the ICC. l(lllll'fcr. 1.1Illlhac fll.:xi(lll 1llt,:aSUCl'Il1Cl\\ts L'(Irrdatec! well ex with skill disrr:u:rion :tlld rhl' ilh:lillonH:rLT, The incli- Back Range of Motion Device nOml'[l:1' h;\\t.! JCl\"l..'prahlc irHntl'srl'r n:liahiliry, hur rhe skin disrr:lction Illerhod Iud :h,:cl'prahk inrlTtl'StL:f celiability The back range of motion (BROM) II device only foc exrcnsioll, Thl.: highl'sf illtc:ltt'srn n.:liahiliry \\\",as (Performance Attainment Associates, Roseville, Minn.) (oulld foc indinolllcrn IllCasurelll('l\\( 01 brn;ll flexion [0 has been used to measure lumbar spine marion. It is rela- rhe ci.. hr tively expensive (see Appendix B), and we are not convinced that its measurements are bettcr than less \\-lillt'; and (ollcaglll's·'5 (Olllp:1t'l'd rht' following four cxpcnsive measurement methods. Two groups of methods foc lllc,lslIring, rhor:1colulllh;lr Ilwhilitv: rhe researchers investigaring the reliabiliry of the BROM II t\"ingl\"ftip-rn-lloor mech(:d. rhe modifil'd Schober' rcch- device agreed that rhe instrumenr had high reliabiliry for niqul', rhe OB ,\\tyrin ~LlVi(y gOllionl('t('l' (LIe Rehab, measuring lumbar lateral flexion and low reliabiliry for S\\I.·l'<.kll), ;1Ilt! ;l :-:.kin comcKriol1 IO-c!H-sct:,IllCIH merhod mc~suring extension, However, the rwo groups differed with ;1 tapl' lll<.';lsur('. J.'Oll!\" r('steTs IIsing all'\" fOllr merhods regarding rhe reliabiliry of rhe BROM II device for meas- llle,lSuced fouc suhjects (ont: !lc;llthy suhjet.:r ;:llld three uring flexion and roration. Rreurn, \\'7iberg, and Bol[On32 p;HicIHS \\vith anky-losing spondyliris). IIHcrt'l'ster error concluded rhat the BROM II device could measure flex- W:1S nor found 10 be a signific;uH $Oill\"':L' of v:HiJrioll. The ion and roration reliably, whereas !vladson, Youdas, and IO-elll-scgmCnt mcthod was found to be rhe mosr sensi~ rive in dC!CClillg:1 l(l~~ of spiJl;llllJ()biliT~'in the upper and

CHAPTER 12 THE THORACIC AND LUMBAR SPINE 341 lO-cm segments. The fingertip-to-f1oor method went training in the use of standardized procedures for ':' the next sensitive, followed by the 10-cm-segment each method prior to testing. According to the testers, the iCdlfiHlue for the lower 10-cm segment, and the modified Nl1vlS was easier and quicker to usc than the double-incli- !>chob'er technique. The least sensitive was the OB Myrin nometer method. The only disadvantage to llsing rhe iBrliOIneltric measurement. The testers rated the fingertip~ MMS method is that norms have not been established for '''.I'lnt)r method as the most convenient, followed by the all age groups. inodltlleu Schober technique, the lO-cm-segment method, Flexible Ruler OB Myrin goniometric technique. and colleagues36 compared the modified The flexible ruler has been investigated as a possible instrument for measuring lumbar spine ROM as well as method and two other clinical methods with fixed posrures:HJ.-44 1vleasuremenrs taken with the ruler other and with radiographs. These authors found must be calculated, and Youdas, Suman, and Garrett41 determined that two commonly used methods for calcu- correlation either among the measurements lating measurements can be used interchangeably. ICCs obltair1ed by two testers using three clinical techniques to for each motion and calculation method in this srudy were in the good (0.80 to 0.90) to high (0.90 to 0.99) me\"sure lumbar flexion in 11 subjects or among the three range. Lindahl40 described the flexible ruler as providing a \"fairly accurate\" method of measuring nexioo and rechniques and radiographs. A Pearson's reliabil- extension compared with the fingertip-to-f1oor method. co\"ffi,cielot of 0.43 was found between the modified Lovell, Rothstein, and Personius,44 in a study involving Schobr,r technique and the radiographic measurement. 80 subjects, found thar the intratester reliabiliry for meas- intertester error for the modified Schober method for uring lumbar lordosis ranged from 0.73 to 0.94. However, intertester reliability was poor. Bryan and flexion showed significant differences between colleagues43 measured lumbar lordosis in 45 subjects and according to paired t-tests. However, intcrtester found a poor correlation between measurements taken was calculated between 10 measurements on 10 with the flexible ruler and radiographs. Based upon a diflren'nt days, and rhe authors attributed the error to lack of norms and the fact that the flexible ruler has been OltllCUIlW'5 in reestablishing a neutral starting position used only for measuring flexion and extension, we the mobiliry of the skin over the landmarks. decided not to include this instrument in the procedures and cnworkers37 compared the reliability of four section of the book. l11ethc)ds of measurement including fingertip-to-f1oor 91S1:ance, the modified Schober technique, the two-incli- Functional Axial Rotation Device method, and a photometric technique. The Schenkman and coworkers45 developed a device and a s~b,jects of the study were 10 volunteers (five men and measurement technique for quantifying axial rotation of the spine. The functional axial rotation (FAR) device women), aged 24 to 34 years. Repeatability of the consists of a 1-m-diameter circular hoop that is ,tlnt;erltlp··to·llc)or method was poor (CV = 14.1 percent). suspended by tripods at the eye level of a seated subject. It is designed to measure functional movements of the of the inclinometer for the measurement of neck and trunk such as those that occur when one rotates was also poor (CV = 33.9 percent). However, the body to look at children in the back seat of a car. modified Schober technique yielded a CV of 0.9 Axial motion is quantified by the distance that the head for full flexion and a CV of 2.8 percent for exten- is moved in relation to the pelvis. In a study of 17 subjects aged 20 to 74 years, test retest reliability was Fitzgerald and associates 12 used the Schober technique high (ICC greater than 0.90) and intertester reliability measure forward lumbar flexion and the universal was also high (ICC = 0.97). In a subsequent study by gor,iOlneter to measure thoracolumbar lateral flexion and Schenkman and assoeiates46 involving 15 patients with Parkinson's disease, ranging from 64 to 84 years of age, Intertester reliability was calculated from the ICC for test retest reliability was 0.89. ll1e\"surernelots taken by two testers on 17 physical ther- Motion Analysis Systems student volunteers. Pearson reliability coefficients calculated on paired results of the two testers (see A number of researchers have investigated the reliability 12-6). of motion analysis systems including, among others, the Williams and coworkers25 measured flexion and CA·6000 Spine Motion Analyzer,\"·12.47 the SPINE- TRAK;'8 and the FASTRAK (Polhemus, Colchester, on 15 patient volunteers (eight females and Vt.).49 Two research groups found that intratester relia- males) with a mean age of 35.7 years who had bility for measuring lumbar flexion was very high with low-back pain. The authors compared the modi- t1edl-n'lodifi,:d Schober technique (MMS);\" which is also to as the simplified skin distraction method,39 the double-inclinometer method. Intratester Pearson Sorrelation coefficients for the MMS were 0.89 for tester 0.78 for tester 2, and 0.83 for tester 3. Intertester correlation coefficients between the three physi- therapist testers were 0.72 for flexion and 0.77 for 'hU:llSlon with use of the MMS. The therapists under-

342 PART IV TESTING Of THE SPINE AND TEMPOROMANDIBULAR JOINT use of the CA_6000. 1I •23 In one of the studies, both healthy men. Segmental forward flexion showed large intratester and intertesrcr reliability ranged from good to intersubjecr variation. high for lumbar forward flexion and extension, bur intratester and inrertcsrcr reliability were poor for rota- Summary tion.\" In a study using the SPINETRAK,48 ICCs were 0.89 or gteater for intratester reliability. ICCs for The sampling of studies reviewed in this chapter reflects intertester teliability ranged from 0.77 for thoracolumbar the amount of effort that has been directed toward find- flexion to 0.95 fot thoracolumbopelvic flexion. Steffan ing a reliable and valid method for measuring spinal and colleagues49 used the FASTRAK system to measure motion. Each method reviewed has advantages and segmental motion in forward lumbar flexion by tracking disadvantages, and clinicians should first select a method sensors attached to Kitschner wires that had been that appears to be appropriate for their particular clinical inserted into the spinous processes of L3 and L4 in 16 situation and then determine its reliability.

CHAPTER 12 THE THORACIC AND LUMBAR SPINE 343 Range of Motion Testing Procedures ods. The inclinometer merhod has been included in rhis edition because examiners may find these instruments The testing procedures that arc presented in the next being used in the clinical setting. We hope that by the section include the universal goniometer, the tape meas- time the next edition of this textbook is being prepared, ure method, the modified Schober technique as described more norms will have been published for the simplified by Mactae and Wright,? the MMS technique or simpli- skin distraction method and that additional evidence fied skin distraction method, and the double-inclinome- regarding the reliability and validity of methods of meas- ter method. The first four methods were selected because uring spinal ROM will be available. they were inexpensive, were relatively easy to usc, and had reliabiliry and validity comparable with other meth- 'lURE' 12·6 Surface ana amY'An mar ~he' thoracic, FIGURE, 12-7 Bony anatomical landmarks for tape meas- and inclinometer alignin'e,nt:: for<'meas ur~:'411d,:jndi.n,,()~~tc:r aHgnme,n~, fo~, measuring thoracic and lumbar spine motion~tIllie'dots\"a~e located:over,:spinpils lumbar,'spine motion.' ' sses of C7, Tl, TI2, Lt, LS, and 52 as well as over the hr and left posterior superior iliac spines (PSIS).

w PART IV TESTING OF THE SPINE AND TEMPOROMANDIBULAR JOINT Z 344 Cl. .. • enccd by the subject and rhe examiner feels the pelvIs V\"l start to tip anteriorly. •• • Normal End-feel !vlotion occurs In the sagirral plane around a mcdial- lateral axis. Testing Position The normal end-feel is firm owing to the stretching of the posterior longitudinal ligament (in the thoracic regionl, Place the subject standing, with the cervical, thoracic, the ligamentum flavum, the supraspinolls and inter- aand lumbar spine in degrees of Lucral flexion and r()[a~ spinaliS ligaments, and the posterior fibers of rhe annulus tion. pulposus of the intervertebral discs and the zygapophy- Stabilization seal joint capsules. Passive tension in the thoracolumbar fascia and the following muscles may contribute to the Stabilizc the pelvis to prevent antcrior tilting. end-feel: spinalis thoracis, semispinalis thoracis, ilio- Testing Motion costalis lumbofUI11 and iliocostalis rharaeis, interspinales, inrcrtransvcrsarii, longissimus thoracis, and multifidus. Direcr the subject to bend forward gradually while keep- The oriemarion of the zygapophyscal facers from Tl to ing the arms relaxed (Fig. 12-8). The end of the motion T6 restrict flexion in the upper thoracic spine. occurs when resistance to additional flexion is expcri- FIGURE 12-8 The subject is shown at the end of combined thoracic and lumbar flexion range of motion. The examiner is shown stabilizing the subject's pelvis to prevent anterior pelvic tilting.

CHAPTER 12 THE THORACIC ANO LUMBAR SPINE 345 ;. Measurement Method for Thoracic and Lumbar Alternative Measurement Method for Thoracic and '-'. Flexion: Tape Measure Lumbar Flexion: Fingertip-to-Floor Four inches is considered to be an average mcasurcmem In this method the subject is asked to bend forward as far healthy adults.' as possible in an attempt to touch the floor with the fingers while keeping knees extended. No stabillzarion is Use a skin-marking pencil to mark the spinous provided by the examiner. processes of C7 and Sl. 2. Align the tape measure between the twO processes At the end of flexion ROM, measure the distance and note the distance (Fig. 12-9). between rhe rip of the subject'S middle finger and the 3. Hold the tape measure in place as rhe subject floor. This tesr combines spinal flexion and hip flexion, performs flexion ROM. (Allow the tape measure to making it impossible to isolate and measure either unwind and accommodate the marion.) motion. Therefore, this test is nOt recommended for 4. Record the distance at the end of the ROM (Fig. 12-10). The difference between the first and the measuring thoracic and lumbar flexion, but it can be used second measurements indicates the amount of to assess general body flexibility.so\"52 thoracic and lumbar flexion that is present. FIGURE 12-9 Tape measure aliglllm:nt in the starring position FIGURE 12-10 1:1pe mcnsure alignmcnt ar rhe end of thoracic for measuring rhor<lcic and lumbar flexion range of motion. and lumbar tlcxion range of motion. The metal rapc measure C~lSC (not visible in rhe photo) is in the examiner's right hand.