Manual Therapy 17 (2012) 298e304

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Manual Therapy
journal homepage: www.elsevier.com/math

Original article

Within-day reliability of shoulder range of motion measurement with

a smartphone
Seung Han Shin a, Du Hyun Ro a, O-Sung Lee a, Joo Han Oh a, b, Sae Hoon Kim a, *
a
Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 110-744, Republic of Korea
b
Seoul National University Bundang Hospital, 166 Gumi-ro, Bundang-gu, Seongnam-si, Gyeonggi-do 463-707, Republic of Korea

a r t i c l e i n f o a b s t r a c t

Article history: Measuring range of motion (ROM) is the first step of a physical examination and functional evaluation of
Received 7 September 2011 the shoulder joint. Digital inclinometers are available on the market; however, they are expensive, and
Received in revised form hence will not come into wide use. In this study, we present a new method for the shoulder ROM
9 January 2012
measurement using the inclinometer application on a smartphone. We hypothesized that the method
Accepted 16 February 2012
would demonstrate acceptable reliability and reproducibility. Three observers performed goniometric
and smartphone inclinometric measurements of various shoulder movements, including both active and
Keywords:
passive ROM for forward flexion, abduction, external rotation while the arms are at the sides, external
Range of motion
Clinometers
rotation at 90
abduction, and internal rotation at 90
abduction. Measurements were performed in the
Smartphone affected shoulders of 41 patients. All measurements were taken twice to assess the intra-observer
Shoulder reliability. Inter- and intra-observer reliabilities were evaluated using the intraclass correlation coeffi-
cient (ICC). Reliability between two measurements was also assessed in terms of the ICC. Both the
goniometric and inclinometric measurements showed satisfactory inter-observer reliability except for
internal rotation at 90
abduction for which the ICC value was <0.7 (range, 0.63e0.68). Intra-observer
reliability was excellent with an ICC value > 0.9, except for some movements. Within-day inclino-
metric measurements with a smartphone showed acceptable reliability compared to the classical
goniometric measurements of movements and the correlation between the two measurements was
fairly high. Considering convenience and cost-effectiveness, this new method could be widely used for
measuring the shoulder ROM, although the between-day reliability needs to be established first.
Ó 2012 Elsevier Ltd. All rights reserved.

1. Introduction similar to that of classical goniometric measurements. Nonetheless,

An accurate assessment of shoulder range of motion (ROM) is an
integral part of both the physical and functional evaluation. The
shoulder has the widest ROM along the multiplanar axis among all
joints in the human body. Therefore, the reliability of shoulder ROM
measurement has always been an issue. Classically, ROM of the
shoulder is measured with a goniometer and the reliability of the
ROM measurement varies, with intraclass correlation coefficients
(ICCs) ranging from 0.26 to 0.95 (Riddle et al., 1987; Hayes et al.,
2001; Mullaney et al., 2010). Measuring the ROM with an incli-
nometer has been suggested to overcome the disadvantages of
measuring the ROM with a goniometer (Green et al., 1998; Hoving
et al., 2002; de Winter et al., 2004; Valentine & Lewis, 2006; Tveita
et al., 2008; Cadogan et al., 2011; Kolber et al., 2011). The reliability
of inclinometric measurements has been reported to be superior or
* Corresponding author. Tel.: þ82 (0)2 2072 3930; fax: þ82 (0)2 764 2718.
E-mail address: drjacobkim@gmail.com (S.H. Kim).
its feature of handiness has been emphasized. Although an incli-
nometer has some advantages over a goniometer, the main disad-
vantage of using an inclinometer is that we have to be equipped
with special devices. Inclinometers are either digital or gravity-
based analog devices and vary in cost. Digital inclinometers are
preferred over gravity-based inclinometers; however, they are
considerably more expensive than gravity-based inclinometers and
conventional goniometers (de Winter et al., 2004; Mullaney et al.,
2010; Kolber et al., 2011).
Many tasks can be accomplished with smartphones. The
number of smartphone users in the author’s country is over ten
million (approximately 60% of cellular phone users) at present and
is growing rapidly. Due to the growth of the smartphone market,
there are an enormous number of applications in use. Recently,
smartphones have been equipped with a gyro-sensor system that
enables to perform various inclinometric functions. We used the
Galaxy S smartphone (Samsung Electronics, Suwon-si, Gyeonggi-
do, Korea) with a clinometer application, clinometer-level and

1356-689X/$ e see front matter Ó 2012 Elsevier Ltd. All rights reserved.
doi:10.1016/j.math.2012.02.010
 S.H. Shin et al. / Manual Therapy 17 (2012) 298e304 299

slope finder (Plaincode Software Solutions, Stephanskirchen,

Germany) to examine the shoulder ROM and to evaluate the reli-
ability of this smartphone application.
Thus, the aim of this study was to compare intra- and inter-
observer reliability of measurements between a goniometer and
the inclinometer application on a smartphone for various shoulder
movements. Our hypothesis was that shoulder ROM measurement
with a smartphone would provide similar reliability as that of
classical measurements using a double-arm goniometer.

2. Methods

2.1. Subjects

Forty-one new patients with unilateral symptomatic shoulders

participated in the study. There were 20 males and 21 females,
whose ages ranged from 19 to 79 years (mean age, 52.7  17.5
years). Patients who had suffered from an acute traumatic event or
who had severe stiffness and could not reach an abduction of 90

were excluded from the study. The clinical diagnosis in 19 patients
was impingement syndrome, in 16 patients was a rotator cuff tear,
in two patients was post-traumatic stiffness, in two patients was
a superior labral anterior to posterior lesion, in one patient was stiff
shoulder, and in one patient was anterior shoulder instability.
Dominant side involvement was observed in 22 shoulders.

2.2. Observers

To evaluate inter- and intra-observer reliability of the gonio-

metric and smartphone inclinometric measurements, two ortho-
pedic resident doctors (first and third grade, observer A and B) and
one orthopedic surgeon who was fellowship-trained in shoulder
surgery (observer C) measured various shoulder movements,
including both active and passive ROM for forward flexion (FF),
abduction (ABD), external rotation while the arms are at the sides
(ERS), external rotation at 90
abduction (ER90), and internal
rotation at 90
abduction (IR90). Each measurement was taken Fig. 1. (A) Standard double-armed goiniometer (B) smartphone with inclinometer
application [Clinometer-level and slope finder (Plaincode Software Solutions, Ste-
twice. All patients underwent measurements once by observers A phanskirchen, Germany)] has been run (left) and applied to the patient using an
to C and then had an approximately 30-min rest interval. After the armband (right).
interval, the second evaluation was performed by observers A to C
one at a time. Observers were located in a separate room and were for the inclinometric measurement, with the vertical line set to
not aware of the other observer’s results. After the first session, the zero. For the FF and abduction movement, both the arms were
recorded sheets were collected; therefore, observers could not refer raised together to prevent the torso from bending toward the other
to their first evaluation. During each session, the goniometric side. Passive ROM was measured with the observer gently pressing
measurement was performed before reading the inclinometric the patient’s arm at the elbow level (Figs. 2 and 3).
measurement value to eliminate any preconceptions. Prior to the
study, several meetings were held to standardize performance
measurements and to make sure that the observers assessed the
patients in the same way.

2.3. Procedures

The goniometer used in the study was a double-arm goniom-

eter, with 360
marked in 1
increments, and each arm was 18 cm
long (Fig. 1A). For the inclinometric measurements, the smartphone
was fixed at the ventral side of the patient’s forearm at the wrist
level with a DualFit Armband (Belkin, Playa Vista, CA; Fig. 1B).
The patient was asked to stand with his/her back and buttocks
touching the wall to prevent trunk motion for the FF and abduction
ROM measurements. While keeping the elbows straight, the
patient was asked to raise his/her arm in the sagittal plane for the
active FF measurement and in the coronal plane for abduction.
Once the patient had reached the maximal level, the goniometer
was placed over the patient’s upper arm. References were a vertical
line and the arm axis. Then the observer read the displayed figures Fig. 2. Measurement of forward flexion: smartphone (left) and goniometer (right).
300 S.H. Shin et al. / Manual Therapy 17 (2012) 298e304
Fig. 3. Measurement of abduction: smartphone (left) and goniometer (right).
For the ERS, ER90, and IR90 measurements, the patient was
asked to lie down in the supine position on a table. For the ERS
measurement, the arm was externally rotated while maintaining
the upper arm in contact with the torso, with the elbow flexed at
90
. After the maximal level was reached, the goniometer was
placed on the forearm axis and an imaginary vertical axis, and the
measurement was taken. To evaluate the ER90 and IR90, the arm
was abducted 90
with support of the table, and the elbow was
flexed 90
. Once the arms were positioned, the patient was asked to
externally and internally rotate his or her arm, taking caution to
minimize the scapular motion by keeping the shoulder and back
touching the table. The goniometric value was measured from the
amount of forearm rotation from an imaginary vertical reference
axis. Again, a passive ROM measurement was performed after
providing gentle pressure to the patient’s forearm at the wrist level.
Inclinometric measurements were obtained by reading the values
on the screen after the same conditions were reached (Figs. 4e6).
2.4. Statistical analysis
Statistical analyses were performed using the SPSS software
package version 18.0 (SPSS Inc., Chicago, IL, USA). Inter-observer
reliability was evaluated by the ICC (2, 1), a two-way random
effects model (observers and subjects are treated as random effects)
with a single measure and absolute agreement for each movement.
Intra-observer reliability for each observer was assessed in terms of
the ICC (3, 1), a two-way fixed effects model (observers are treated
as fixed and subjects are treated as random effects) with a single
measure and absolute agreement for each movement. In addition,
the reliability of the goniometric and inclinometric measurements
were analyzed by the ICC (3, 1), a two-way fixed effects model with
a single measure and absolute agreement for each movement and
each observer. The ICC value can range from 0 to 1; values close to 1
Fig. 4. Measurement of external rotation while the arms are at the sides: smartphone
(left) and goniometer (right).
Fig. 5. Measurement of external rotation at 90
abduction: smartphone (left) and
goniometer (right).
indicate high reliability. An ICC value of at least 0.70e0.75 is
considered satisfactory for group comparisons, and an ICC value of
0.90e0.95 is considered satisfactory for individual comparisons
(Burdock & Hardesty, 1963; Scientific Advisory Committee of the
Medical Outcome Trust, 2002; de Winter et al., 2004; Kolber et al.,
2011). The measurement error was evaluated by the standard
error of measurement (SEM) for intra- and inter-observer reliability
pffiffiffiffiffiffiffiffiffiffiffi
using the formula: SEM ¼ SD  1  r where SD is the standard
deviation of observed test scores and r is the reliability coefficient
for that data (Portney & Watkins, 1993; Kolber et al., 2011). Also, the
minimal detectable change (MDC) at the 90% confidence level was
employed to analyze clinically meaningful degree of difference pffiffiffi
using SEM, and was defined as MDC90 ¼ 1:65  SEM  2
(Portney & Watkins, 1993; Kolber et al., 2011). In studies comparing
the reliability of two different instruments, the ICCs can be
misleading for making the interpretations. Therefore, an analysis
using Bland and Altman’s 95% limits of agreement (LOA) was also
performed to compare the absolute reliability between the two
measurements (Bland & Altman, 1986; Atkinson & Nevill, 1998;
Mullaney et al., 2010). The correlation between smartphone incli-
nometric and goniometric measurements were analyzed addi-
tionally using Pearson’s correlation coefficient (PCC).
3. Results
3.1. Intra-observer and inter-observer reliability
In the ICC analysis, both goniometric and inclinometric
measurements showed satisfactory inter-observer reliability,
except for the IR90 values, for which the ICC value was <0.7 (range,
0.63e0.68, Table 1). Intra-observer reliability was excellent with an
ICC value > 0.9 except for the goniometric measurement of active
ROM for FF by observer A, the smartphone inclinometric
measurement of active ROM for IR90 by observer B, and the
goniometric measurement for passive ROM for IR90 by observer C
(Table 2). However, the ICC values for these exceptions were still
acceptable (range, 0.79e0.89).
The SEM and MDC90 values for the inter-observer reliability are
shown in Table 3, and the SEM and MDC90 values for the intra-
observer reliability of observer A are shown in Table 4. The values
were much greater in the inter-observer reliability analysis than in
Fig. 6. Measurement of internal rotation at 90
abduction: smartphone (left) and
goniometer (right).
 S.H. Shin et al. / Manual Therapy 17 (2012) 298e304 301

Table 1 Table 3
Inter-observer reliability for both the smartphone inclinometric and goniometric SEM and MDC90 for the inter-observer reliability (first and second sessions).
measurements (first and second sessions).
Modality Movement First session Second session
Modality Movement First session Second session
SEM
MDC90
SEM
MDC90

ICC 95% CI ICC 95% CI Smartphone FF a 9.99 23 9.56 22
Smartphone FF a 0.83 0.73e0.90 0.84 0.74e0.90 inclinometer FF p 10.32 24 10.09 24
inclinometer FF p 0.73 0.59e0.83 0.74 0.61e0.84 ABD a 13.84 32 13.21 31
ABD a 0.78 0.66e0.87 0.79 0.68e0.87 ABD p 14.15 33 13.83 32
ABD p 0.70 0.56e0.81 0.72 0.58e0.83 ERS a 9.39 22 9.67 23
ERS a 0.77 0.64e0.86 0.76 0.63e0.86 ERS p 9.56 22 9.48 22
ERS p 0.78 0.66e0.87 0.78 0.66e0.87 ER90 a 7.80 18 7.76 18
ER90 a 0.87 0.79e0.92 0.87 0.80e0.93 ER90 p 7.34 17 7.15 17
ER90 p 0.89 0.82e0.93 0.90 0.83e0.94 IR90 a 10.29 24 10.62 25
IR90 a 0.67 0.51e0.79 0.66 0.49e0.79 IR90 p 11.54 27 10.50 25
IR90 p 0.63 0.47e0.77 0.68 0.50e0.81
Goniometer FF a 12.03 28 8.80 21
Goniometer FF a 0.77 0.64e0.86 0.86 0.77e0.92 FF p 7.53 18 6.30 15
FF p 0.84 0.75e0.91 0.89 0.82e0.93 ABD a 11.85 28 10.01 23
ABD a 0.85 0.76e0.91 0.89 0.82e0.94 ABD p 12.77 30 11.14 26
ABD p 0.78 0.65e0.87 0.83 0.72e0.90 ERS a 8.35 19 8.32 19
ERS a 0.81 0.70e0.89 0.80 0.69e0.88 ERS p 8.98 21 8.62 20
ERS p 0.79 0.67e0.88 0.80 0.68e0.88 ER90 a 6.33 15 7.49 17
ER90 a 0.91 0.85e0.95 0.87 0.77e0.93 ER90 p 6.83 16 7.71 18
ER90 p 0.90 0.84e0.94 0.88 0.79e0.93 IR90 a 10.94 26 11.35 26
IR90 a 0.67 0.43e0.82 0.67 0.33e0.83 IR90 p 11.70 27 11.43 27
IR90 p 0.64 0.41e0.79 0.68 0.31e0.85
SEM, standard error of measurement; MDC90, minimal detectable change at the 90%
ICC, intraclass correlation coefficient; CI, confidence interval; FF, forward flexion; ABD, confidence level; FF, forward flexion; ABD, abduction; ERS, external rotation while
abduction; ERS, external rotation while the arms are at the sides; ER90, external the arms are at the sides; ER90, external rotation at 90
abduction; IR90, internal
rotation at 90
abduction; IR90, internal rotation at 90
abduction; a, active; p, passive. rotation at 90
abduction; a, active; p, passive.

intra-observer reliability analysis. In the intra-observer reliability
analysis of observer A, the values for smartphone inclinometric
measurement were better (smaller) than those for goniometric
measurement, suggesting that the measurement error was smaller
with the use of the smartphone inclinometer. However, the values
for active ROM for FF were much greater than those for other
movements, in both the smartphone inclinometric and goniometric
measurements.
measurements for most of the shoulder movements in all the
observers (Table 5). The Bland and Altman’s 95% LOA ranged from
10
to 40
, showing greater values for the FF and ABD measurements
of observer A (Table 6). The PCC analysis showed strong positive
correlation between the two methods of measurement, with coef-
ficient values ranging from 0.79 to 0.97 for each movement (Table 6).
4. Discussion

3.2. Agreement between smartphone inclinometric and goniometric
measurements
In the ICC analysis, the inclinometric measurements
showed acceptable reliability when compared to the goniometric
In this study, we presented a new method for measuring the
shoulder ROM using the inclinometer application on a smartphone.
As seen in the results, the reliability the measurements obtained
using this new method was similar to the classical double-armed
goniometric measurements and was even better with respect to

Table 2
Intra-observer reliability for the smartphone inclinometric and goniometric measurements.

Modality Movement Observer A Observer B Observer C

ICC 95% CI ICC 95% CI ICC 95% CI

Smartphone inclinometer FF a 0.99 0.99e1.00 0.97 0.95e0.99 0.97 0.95e0.99
FF p 0.99 0.98e0.99 0.96 0.92e0.98 0.97 0.95e0.99
ABD a 0.96 0.93e0.98 0.99 0.98e0.99 0.97 0.95e0.98
ABD p 0.97 0.95e0.99 0.99 0.98e1.00 0.97 0.93e0.98
ERS a 0.97 0.95e0.98 0.97 0.93e0.98 0.95 0.89e0.97
ERS p 0.98 0.96e0.99 0.97 0.95e0.98 0.97 0.94e0.98
ER90 a 0.98 0.95e0.99 0.97 0.95e0.98 0.96 0.92e0.98
ER90 p 0.98 0.97e0.99 0.98 0.95e0.99 0.98 0.96e0.99
IR90 a 0.99 0.98e0.99 0.79 0.64e0.88 0.97 0.94e0.98
IR90 p 0.97 0.95e0.98 0.93 0.85e0.97 0.90 0.82e0.95

Goniometer FF a 0.80 0.65e0.89 0.92 0.83e0.96 0.96 0.92e0.98

FF p 0.99 0.98e0.99 0.95 0.88e0.98 0.97 0.95e0.99
ABD a 0.99 0.99e1.00 0.98 0.96e0.99 0.94 0.88e0.97
ABD p 0.99 0.99e1.00 0.98 0.96e0.99 0.95 0.92e0.98
ERS a 0.98 0.96e0.99 0.96 0.93e0.98 0.96 0.92e0.98
ERS p 0.99 0.95e1.00 0.93 0.88e0.96 0.95 0.91e0.97
ER90 a 0.99 0.97e0.99 0.97 0.94e0.99 0.96 0.93e0.98
ER90 p 0.97 0.95e0.98 0.97 0.92e0.99 0.97 0.94e0.98
IR90 a 0.98 0.96e0.99 0.94 0.87e0.97 0.96 0.92e0.98
IR90 p 0.97 0.94e0.98 0.96 0.92e0.98 0.89 0.80e0.94

ICC, intraclass correlation coefficient; CI, confidence interval; FF, forward flexion; ABD, abduction; ERS, external rotation while the arms are at the sides; ER90, external rotation
at 90
abduction; IR90, internal rotation at 90
abduction; a, active; p, passive.
302 S.H. Shin et al. / Manual Therapy 17 (2012) 298e304

Table 4 Table 6
SEM and MDC90 for the intra-observer reliability of observer A. Bland and Altman’s 95% LOA and PCC between smartphone inclinometric and
goniometric measurements.
Movement Smartphone Goniometer
Movement Observer A Observer B Observer C
SEM
MDC90
SEM
MDC90

FF a 2.69 12 6.28 27 LOA PCC LOA PCC LOA PCC
FF p 2.30 2 5.36 4 FF a 29 0.84 15 0.95 18 0.93
ABD a 6.30 3 14.70 7 FF p 28 0.79 14 0.92 18 0.91
ABD p 4.51 3 10.52 6 ABD a 30 0.88 14 0.97 24 0.92
ERS a 3.26 3 7.61 6 ABD p 40 0.80 13 0.97 23 0.92
ERS p 2.79 2 6.51 4 ERS a 17 0.90 12 0.96 15 0.93
ER90 a 3.01 2 7.01 5 ERS p 18 0.89 16 0.91 17 0.91
ER90 p 3.04 3 7.09 8 ER90 a 14 0.95 13 0.95 10 0.97
IR90 a 1.86 3 4.33 6 ER90 p 13 0.96 14 0.95 11 0.97
IR90 p 3.18 3 7.42 7 IR90 a 14 0.93 15 0.90 14 0.93
IR90 p 14 0.92 11 0.95 22 0.84
SEM, standard error of measurement; MDC90, minimal detectable change at the 90%
confidence level; FF, forward flexion; ABD, abduction; ERS, external rotation while LOA, limits of agreement; PCC, Pearson’s correlation coefficient; FF, forward flexion;
the arms are at the sides; ER90, external rotation at 90
abduction; IR90, internal ABD, abduction; ERS, external rotation while the arms are at the sides; ER90,
rotation at 90
abduction; a, active; p, passive. external rotation at 90
abduction; IR90, internal rotation at 90
abduction; a, active;
p, passive.

the smaller measurement error. When compared to the previous being informed about the protocol. This also led to a greater SEM
studies on inclinometric measurements of shoulder ROM, the and MDC90 for active FF measured by observer A than those for
results of our study showed a slightly superior or similar reliability other movements (Table 4). The reason for lower inter-observer
based on the ICC analysis (Table 7) (Hoving et al., 2002; de Winter reliability and wider confidence intervals for intra-observer vari-
et al., 2004; Tveita et al., 2008; Mullaney et al., 2010; Cadogan et al., ability of IR90 measurement may be due to the varying amount of
2011; Kolber et al., 2011). scapular motion control, which is not restricted physiologically or
Previous reliability results vary based on the direction of due to the examination table as is the case when ER90 is measured.
movement (Riddle et al., 1987; Hoving et al., 2002; de Winter et al., Although we had consensus regarding controlling scapular motion
2004; Tveita et al., 2008; Mullaney et al., 2010; Cadogan et al., 2011; and the measurements were performed in the supine position, it is
Kolber et al., 2011). Despite the overall acceptable reliability, our difficult to completely eliminate inter-observer and even intra-
study also demonstrated variable reliabilities for some movements: observer variability.
the ICC values for inter-observer reliability of the IR measurement The PCC analysis showed strong positive correlation between
were lower and had wider confidence intervals (Table 1); the ICC the two methods of measurement including FF, ABD, and IR
values for intra-observer reliability of the FF and IR measurements measurements. This suggests that the two methods are consistent
of some observers were lower and had wider confidence intervals with each other despite the difference in the absolute values of
(Table 2). While comparing smartphone inclinometric and gonio- measurements, and therefore the new smartphone inclinometric
metric measurements, the ICC values for FF had wider confidence measurements can be as useful as the classical goniometric
intervals than those for other movements (Table 5); the Bland and measurements if the method is used consistently.
Altman’s 95% LOAs for FF and ABD measured by observer A were The result of SEM and MDC90 analyses for inter-observer reli-
greater than that measured by the other observers (Table 6). ability of both smartphone inclinometric and goniometric
The lower reliability and wider confidence intervals of the FF measurements was not as good as the result of ICC analysis,
and ABD measurements could be attributed to the variability of the showing greater values (range, 6.30
e14.15
for SEM; 15
e33
for
normal carrying angle of the elbow and the degree of uncontrolled MDC90) (Table 3) compared to those reported by Kolber et al.
elbow flexion during the measurement. The smartphone was fixed (range, 1.64
e4.27
for SEM; 4
e9
for MDC90) (Kolber et al., 2011).
to the patient’s forearm, while the reference for goniometric This also means that the absolute values for each ROM measured by
measurement of FF and ABD was the patient’s upper arm. There- the three observers generally varied more in our study than in
fore, there can be variable differences depending on the elbow previous studies, despite consensus on the measurement protocol.
angle, especially in old aged patients who tend to flex their elbow in However, SEM and MDC90 values for intra-observer reliability of
order to elevate the arm higher while measuring FF or ABD despite smartphone inclinometric measurements of observer A were much
better (range, 1.86
e6.30
for SEM; 2
e12
for MDC) (Table 4) than
those for inter-observer reliability of smartphone inclinometric
Table 5
ICCs between smartphone inclinometric and goniometric measurements. measurements, suggesting that consistent measurements could be
achieved using the smartphone inclinometer, if the measurements
Movement Observer A Observer B Observer C
were performed consistently by one observer or if a more strictly
ICC 95% CI ICC 95% CI ICC 95% CI standardized measurement protocol was used.
FF a 0.80 0.56e0.90 0.90 0.42e0.97 0.89 0.72e0.95 Once the reliability of a method for specific physical examina-
FF p 0.72 0.42e0.86 0.87 0.53e0.95 0.87 0.66e0.94 tion is proven, ease of use and cost-effectiveness could be the next
ABD a 0.88 0.79e0.94 0.97 0.94e0.98 0.91 0.94e0.95
ABD p 0.80 0.65e0.89 0.97 0.95e0.98 0.88 0.72e0.95
issue. Previous authors have already emphasized on the ease of
ERS a 0.89 0.81e0.94 0.93 0.77e0.97 0.92 0.86e0.96 measuring ROM with an inclinometer (de Winter et al., 2004;
ERS p 0.89 0.81e0.94 0.90 0.82e0.95 0.90 0.79e0.95 Cadogan et al., 2011; Kolber et al., 2011). Realignment of the
ER90 a 0.94 0.89e0.97 0.95 0.91e0.97 0.97 0.94e0.98 device during an inclinometric measurement is usually not
ER90 p 0.94 0.88e0.97 0.95 0.91e0.98 0.97 0.94e0.98
required, so it can be held with one hand, leaving the examiner’s
IR90 a 0.93 0.86e0.96 0.87 0.66e0.94 0.93 0.86e0.96
IR90 p 0.91 0.81e0.95 0.93 0.71e0.97 0.84 0.72e0.91 other hand free to stabilize the device. Moreover, if the inclinom-
eter is attached to the patient’s arm, as was the case in our study,
ICC, intraclass correlation coefficient; CI, confidence interval; FF, forward flexion;
ABD, abduction; ERS, external rotation while the arms are at the sides; ER90,
both the examiner’s hands are free. Therefore, the axis of the
external rotation at 90
abduction; IR90, internal rotation at 90
abduction; a, active; patient’s arm can be fixed with one hand, and the other hand can
p, passive. provide pressure to the arm while measuring the passive ROM. In
 S.H. Shin et al. / Manual Therapy 17 (2012) 298e304
Table 7
Reliabilities and characteristics of previous studies on inclinometric measurements of the shoulder ROM.
Authors Publication Methods Cases
year
Cadogan et al. 2011 Inclinometer 40 Patients
Kolber et al. 2011 Inclinometer 30 Volunteers
Mullaney et al. 2010 Inclinometer and 20 Patients
goniometer
Tveita et al. 2008 Inclinometer 32 Patients
de Winter et al. 2004 Inclinometer 155 Patients
Hoving et al. 2002 Inclinometer 6 Volunteers
a
Note that the data are of inclinometric measurements.
our study, all three observers mentioned this convenience of using
an inclinometer. Additionally, we expect that the reading error
could be minimized further, because we used the figures displayed
on the monitor, rather than the gradations on the goniometer.
Moreover, we did not have to set an imaginary vertical line, which
usually is required while performing a goniometric measurement,
so the error can be further minimized. However, commercial
inclinometers have many disadvantages and the clinics must be
equipped with expensive devices. In contrast, when the smart-
phone is used as an inclinometer, there is no need to purchase
a special device. Besides, the application that we used in this study
was free of cost (Android market for smartphones). There are many
inclinometer programs for smartphones on the market and we
think other applications would provide similar convenience
compared to the one that we used. In addition, we usually do not
need any additional room for a smartphone in our clinic. In this
study, we simply attached the smartphone to the patient’s forearm
using a commercial armband designed for smartphones, which
allowed both the examiner’s hands to be free; however, a patient
can also attach a smartphone to him/her self at home, so that there
is no need to visit a particular place where the measuring device
exists, as was the case in the previous studies (Mullaney et al., 2010;
Cadogan et al., 2011; Kolber et al., 2011).
The observers who participated in this study had varying levels
of experience; from a novice orthopedic resident to a fellowship-
trained shoulder surgeon. We speculated that the intra-observer
reliability would be inferior in the less experienced doctors;
however, this was not the case. We think that standardization and
education regarding the measurement method in several prelimi-
nary meetings minimized this problem.
In our study, only symptomatic patients with the affected side
were included for evaluation. We believe that this represents the
actual clinical situation rather than including volunteers (Hoving
et al., 2002; Kolber et al., 2011). Some previous studies included
ROM of the unaffected side in symptomatic patients for the analysis
and calculation of reliability (de Winter et al., 2004; Tveita et al.,
2008; Mullaney et al., 2010). One study showed similar reliability
between both (Tveita et al., 2008); however, two other studies
showed inferior reliability in the unaffected side (de Winter et al.,
2004; Mullaney et al., 2010).
Due to multiplanar motion of the shoulder, researchers usually
choose either a passive or active ROM for a reliability analysis
(Riddle et al., 1987; Hoving et al., 2002; de Winter et al., 2004;
Mullaney et al., 2010; Kolber et al., 2011). However, some studies
have analyzed both the ranges of motions and showed similar
reliabilities (Tveita et al., 2008; Cadogan et al., 2011). Our study
measured both the ranges of motions and showed similar results as
those in previous studies.
Another great advantage of measuring the ROM with the smart-
phone application is that the patient can monitor his/her ROM
without having to buy an expensive device. Home-based physical
therapy is important during the postoperative course of rehabilitation
or the treatment course for a stiff shoulder. Immediate self-feedback
303
No. of raters Range of motion Inter-observer Intra-observer reliability
included reliability
2 Active and passive 0.45e0.95 0.85e0.99 (within-day)
2 Active 0.58e0.95 0.83e0.94 (within-day)
2 Active 0.31e0.93a 0.91e0.99a (within-day)
1 Active and passive 0.72e0.93 (between-day)
2 Passive 0.28e0.90
6 Active 0.11e0.80 0.32e0.91 (within-day)
is possible and this can motivate the patients for an enthusiastic self
rehabilitation. Therefore, we are planning to evaluate the effective-
ness of home monitoring of shoulder ROM in our next study.
There are limitations to this study. Although we measured
shoulder movements in various directions, we could not measure
the internal rotation at the back of the shoulder or cross body
adduction. These movements can be measured at the level of the
spinous process using a tape. Therefore, this limitation is true for
our study and all other studies with inclinometric measurements.
The other limitation is that we claimed that the smartphone could
relieve the financial burden of buying an inclinometer; however, it
is assumed that the doctor has a smartphone, particularly the one
with a gyro-sensor system. We confirmed that some other smart-
phones are equipped with gyro-sensors and have an inclinometer
application as well (e.g., iPhone 3G and 4G [Apple Computer Inc.,
Cupertino, CA, USA] and Optimus 2X [LG Electronics, Seoul, Korea]),
although the applications for some smartphones need to be
purchased (e.g., $ 0.99 for the iPhone) However, as far as we know,
not all smartphones can be used as an inclinometer because of the
lack of a gyro-sensor system. Yet another limitation is the lack of
between-day reliability data. It is well known that studies in which
repeated tests are performed at short time intervals, as was the case
in the present study, may yield very different results than those in
the studies in which repeated tests are performed at longer time
intervals (i.e., days or weeks) (Gajdosik & Bohannon, 1987).
However, there is a substantial difficulty in following up the
patients for the ROM measurement within a short time interval
such as days, which is not absolutely necessary for the management
of the patients’ problems. Meanwhile, if the follow-up interval is
longer such as weeks or months, the ROM may vary to a greater
extent according to the patients’ clinical course, than according to
the observational error. This generally limits the use of a measuring
device for comparing the effects of rehabilitation over time. For this
reason, a further study should be performed to investigate whether
the between-day reliability of the smartphone is acceptable, before
its clinical use for documenting the change in the ROM over time.
5. Conclusions
The shoulder ROM measurements with a smartphone application
were comparably reliable to the conventional goniometric measure-
ments, although the between-day reliability remains to be established.
Considering their convenience and cost-effectiveness, smartphones
could be used widely in clinics. Another advantage of a smartphone is
that the patient can monitor their ROM during home-based physical
therapy for conservative or postoperative management.
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