A study to compare two goniometric methods for measuring active pronation and supination range of motion

Abstract

Introduction

Movement of the forearm allows positioning the hand during several functional activities of daily living. Assessing range of motion of supination and pronation is essential for clinical identification of functional limitations, although many methods can be used. Confounding values can be found due to different techniques used by therapists. The purpose of this study was to compare two standard goniometric methods for measuring active range of motion of forearm pronation and supination, aiming to define its reliability and ease of use.

Methods

The study included 33 individuals, 13 injured and 20 non-injured volunteers. We analyzed two standard goniometric methods for measuring pronation and supination. For the first method, the volunteers had to hold a pencil as a guide for the movable arm of the goniometer and for the second method the movable arm was in contact with the distal dorsal surface of the wrist near the ulna head, and the hand was free. Two trained examiners performed the evaluations. Intraclass correlation coefficient and limits of agreement of Bland and Altman were used to analyze the data.

Results

Intraclass correlation coefficient values were excellent for both groups and movements at inter-rater and inter-methods comparison. Bland and Altman plots showed that, although excellent reliability, some data dispersion was present.

Conclusion

These data suggest that both methods could be used in clinical practice with excellent reliability. The goniometric method with the movable arm placed in contact with the distal dorsal surface of the wrist near the ulna head might be easier to perform and useful in cases where finger prehension is absent or weak, which would prevent the use of a pencil as reference.

Keywords

Reliability goniometry forearm pronation supination

Introduction

The forearm complex promotes the rotation of the hand in space, allowing redistribution of forces during supination and pronation, with meaningful functional importance in tasks such as eating, typing and picking up objects.^1–3

Range of motion (ROM) of supination and pronation can be altered by musculoskeletal biomechanics imbalance, inflammation or trauma^2,3 and can be associated with a loss of motion related to joint stiffness.^4,5

Goniometric measurement is the most objective and reliable method for ROM assessment used by therapists as part of a comprehensive evaluation of the joint and surrounding soft tissues.^6–9 Based on these measurements, therapists can indicate the most appropriate therapeutic intervention, and also document the outcomes during the rehabilitation process.^10,11

Gajdosik and Pohannon,¹² reported the importance of reliable methods for evaluating pronation and supination ROM aiming to identify clinical and functional limitations. McAuliffe¹³ reported excellent correlation between inter- and intra-examiner goniometric evaluation of flexion–extension and pronation–supination, highlighting ROM variations according to age, sex, occupation or activity patterns, joint structures, dominance and type of movement. Armstrong et al.¹⁴ conducted a study to establish a reliable technique that could be used by both experienced and inexperienced evaluators to ensure consistency between therapists. They concluded that repeated error measurement is least when the measurements are made by the same tester and most when different instruments are used.

Positioning the goniometer is a critical factor when assessing ROM as the position of the goniometer affects the tension in the soft tissue structures.¹⁵ When successive measurements are taken, it is important that this amount of tension is consistent between measurements to ensure that the measure is reliable. Pratt and Burr⁹ confirmed that standardized protocols could positively influence the precision of the data collection and ensure reliability.

The examiner should use palpable and exposed bony anatomical landmarks to more accurately visualize the joint segment. In general, the stationary arm is often aligned parallel to the longitudinal axis of the proximal segment and the moving arm of the goniometer must be aligned with the distal segment of the joint being evaluated. The fulcrum of the goniometer may be parallel over the approximate location of the axis of the motion, with emphasis on the alignment of the arms of the goniometer and the examiner at eye level with the goniometer to avoid parallax.¹⁵

Many studies have examined the elbow and forearm ROM measurements with a universal goniometer and found good to excellent reliability.¹⁵ However, the forearm rotation can cause some difficultly with positioning the goniometer and currently two standard techniques are being frequently used in clinical practice to assess ROM, with differences related to alignment of goniometry arms that could prompt some issue over the accuracy of the reading. Therefore, the objective of this study was to evaluate the inter-rater reliability of two standard goniometric methods and analyze their ease of use.

Methods

Following approval by the local research ethics committee, a convenience sample of 13 patients and 20 healthy volunteers with age ranging between 18 and 70 years old were approached and consented to participate in the study. The patients underwent rehabilitation at a tertiary clinical hospital, from January to October 2007 and had previous trauma associated or isolated in the region of the elbow such as soft tissue injury, fracture of the distal humerus and/or proximal radius and/or ulna or dislocation of the elbow joint. All individuals received previous orthopedic treatment, (conservative or surgical) and were able to actively rotate their forearm. We excluded patients with neurological diseases, rheumatic diseases and pain that could prevent active pronation and supination.

Instrumentation

An acrylic universal goniometer CARCI™ was used to assess ROM. This goniometer had a wide fulcrum, which was subdivided into 360°, 2° spaces, and was composed of two long arms of 17 cm each. To provide a reference for measuring the movements of pronation and supination using one of the two standard approaches, a 15 cm length pencil was used as reference.

Procedure

Initially, the volunteer received information about the objectives of the study to become familiar with the procedure, posture and the movements that would be required during the two goniometric methods testing.

The first goniometric method used was the Hand-held Pencil Gilewich described by Clarkson and Gilewich,¹⁶ in which a pencil is used as a reference for alignment of the movable arm to read the movement of pronation and supination (Figure 1). Individuals were positioned sitting with knees bent and aligned to 90°, the elbow flexed at 90° keeping the arm close to the body and forearm in a neutral position between pronation and supination. The goniometer was placed parallel to the dorsal surface of the metacarpals with the axis positioned at the midpoint of the middle finger metacarpophalangeal joint. The fixed arm was placed parallel to the longitudinal axis of the humerus and perpendicular to the floor. The movable arm of the goniometer was aligned parallel to the longitudinal axis of a pencil in the hand with fingers flexed in a full fist, and followed the movement of pronation and supination.

Figure 1.

Hand-held and pencil method described by Clarkson and Gilewich¹⁶ using a pencil as a guide for the movable arm of the goniometer CARCI™, with the stationary arm parallel to the humerus, perpendicular to the floor.

Another goniometric method used was proposed by Norkin and White.¹⁵ The same procedures were performed with respect to patient positioning; the only difference was the goniometer alignment. The fulcrum was perpendicular to the distal forearm with the fixed arm of the goniometer parallel to the longitudinal axis of the humerus and perpendicular to the floor and the movable arm placed at the level of the ulnar styloid process, on the dorsal surface of the wrist to asses pronation and on the anterior surface of the wrist, to assess supination (Figure 2).^{8,14,15,17–19}

Figure 2.

Method described by Norkin and White¹⁵ using the fulcrum of the goniometer CARCI™ close to wrist joint. The stationary arm was parallel to the humerus and perpendicular to the floor, and the movable arm was in contact with the dorsal surface of the wrist, near the styloid process.

All pronation and supination movements were measured three consecutive times,¹⁰ with a 30-second interval between each measurement, by two trained physiotherapists following the same procedures, in a randomized order. Each examiner had no access to their previous records of ROM for each volunteer/patient.

Analysis

Analysis was carried out by means of descriptive statistics calculated for the mean and standard deviation of trials and methods in degrees. Reliability statistics were performed using SAS™ 9.0 PROC MEANS (SAS Institute Inc., Cary, USA) to generate mean square values from one-way repeated measures analysis of variance. These were used to calculate an intraclass correlation coefficient (ICC; 2,1 agreement) to assess inter-methods and inter-rater reliability. Reliability was considered to be excellent with an ICC greater than 0.75, fair to good from 0.40 to 0.75 and poor less than 0.40.^20,21 In addition, limits of agreement (LOA) or Bland and Altman analysis was used to evaluate the LOA between the methods and raters, through two standard deviations with 95% confidence interval using MedCalc™.^22–25 Sample size calculation was defined using the software GraphPad StatMate 2.

Results

The ICC between the methods was excellent for both groups and movements (Table 1) as in the inter-rater comparison (Table 2). Bland and Altman plots (Figures 3 and 4) showed that, although excellent reliability, some data dispersion was present in pronation, with outliers in rater 1 for pronation and supination in both methods.

Figure 3.

Bland and Altman plots comparing raters and methods for pronation (R1, R2: raters/M1, M2: methods).

Figure 4.

Bland and Altman plot comparing raters and methods for supination (R1, R2: raters/M1, M2: methods).

Table 1.

Concordance between methods using ICC.

Group	Methods	Movement	Mean (°)	SD	ICC	95% CI
Injured	HHP	Pronation	50.31	16.90	0.96	(0.92–0.99)
n = 13	NW	Pronation	50.18	16.74
HHP	Supination	62.64	27.16	0.97	(0.95–0.99)
NW	Supination	61.12	26.02
Non-injured	HHP	Pronation	77.23	10.36	0.83	(0.73–0.92)
n = 20	NW	Pronation	77.83	8.70
HHP	Supination	93.13	11.88	0.93	(0.88–0.97)
NW	Supination	92.03	10.33

ICC: intraclass correlation coefficient; HHP: hand-held with pencil described by Clarkson and Gilewich¹⁶; NW: method described by Norkin and White¹⁵; SD: standard deviation; CI: confidence interval.

Table 2.

Concordance between examiners using ICC.

Group	Methods	Movement	Examiner	Mean	DP	ICC	95% CI
Injured	HHP	Pronation	1	49.59	16.33	0.93	(0.92–0.99)
n = 13	HHP	2	51.03	17.76
HHP	Supination	1	60.51	29.04	0.97	(0.94–0.99)
HHP	2	64.77	25.35
NW	Pronation	1	48.36	15.81	0.94	(0.89–0.99)
NW	2	52.00	17.65
NW	Supination	1	59.13	26.90	0.97	(0.95–1.00)
NW	2	63.10	25.29
Non-injured	HHP	Pronation	1	78.73	9.29	0.76	(0.62–0.89)
n = 20	HHP	2	75.82	11.21
HHP	Supination	1	96.67	13.27	0.92	(0.87–0.97)
HHP	2	93.60	10.40
NW	Pronation	1	78.32	8.98	0.92	(0.87–0.97)
NW	2	77.35	8.46
NW	Supination	1	92.42	10.95	0.95	(0.92–0.98)
NW	2	91.63	9.75

Discussion

Our results showed that inter-methods and inter-rater reliability were excellent for both pronation and supination. Karagiannopoulos et al.²⁶ compared two instruments for measuring different pronation and supination ROM and found a reliability index equal to or greater in affected individuals compared to non-injured, similar to our sample.

The excellent reliability found in this study suggests that the two methods might be used interchangeably for ROM rotation measurement, although, some data dispersion was found in the Bland and Altman plots related to pronation and some outliers in pronation and supination for rater 1, in both methods. These plots are extensively used to evaluate the agreement among two different instruments or two measurements techniques, to investigate the existence of any systematic difference between the measurements and to identify possible outliers.^22–25 Our findings could be related to some discrepancies between the measurements. The mean active range of motion (AROM) were smaller for our injured group. These patients were still in rehabilitation and had some dysfunction related to joint stiffness and/or muscle weakness or even some pain, compared to no-injured group. It could be explained by patients’ possible compensation not detected in the measurements, or even lack of procedure understanding. In one patient, the measurements made by rater 1 were almost 50% higher than rater 2 with the method that used a pencil as reference. The existence of this proportional bias could indicate that the methods do not agree equally through the range of measurements.

The limitations of our study could be related to the raters, because even with previous training, they had different clinical experience in AROM assessment. In addition, related to the patients, who were in different rehabilitation phases, who had some inability to move, either by pain or muscle shortening, which could bring some movements’ incoordination in successive measurements, even with a rest interval between them.

Therapists in clinical practice must decide which goniometric method better fits each patient. Depending on the dysfunction, one or other can be the choice. This must be based on literature evidence but also on experience. Colaris et al.⁸ found excellent reliability with ICC ranging from 0.75 to 0.94, between visual estimation and conventional goniometry and suggested the visual estimation as a second choice in an uncooperative child. Our ICC was also excellent (0.76–0.97), comparing the two alignment methods of using the goniometer arms for forearm rotation assessment. The method based on the reference of the pencil to align the movable arm could be a choice, however is dependent on active finger flexion. Being aware of careful goniometric standardization would prevent some compensation during the full fist, which could lead to a failure of the movable arm reference. In cases where patients have weak or absence grip, therapists would require the Norkin and White¹⁵ method in which the movable arm is dorsal or volar, without need of any further support to goniometric alignment, and the hand is free.²⁷ This condition could make this method easier and more accurate for AROM forearm assessment.

Conclusion

In the sample studied, the data suggest that the two methods could be used in clinical practice, with excellent intra-examiner and inter-methods reliability. The method with the goniometer arms placed on the edge of the distal forearm might be easier to use and indicated in patients who have no active grip that prevent them to use the pencil as a reference.

Footnotes

Acknowledgments

The authors wish to thank the patients who kindly participated in this study. Thanks are also extended to the therapist Diego de Freitas Espinoza who participated in the data collection and Dr Emily Lalone who kindly did the revision of the English version.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Conflict of interest

None declared.

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