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The objective of this study was to analyze the reliability of the intra and inter-evaluators measures, with universal goniometer and fleximeter. Overall, the results showed very strong ICC: 0. On inter-correlation instruments, there are strong coefficients on all measures 0.
In the studied movements, the evaluator experience did not influence the measurements and both the universal goniometer and the fleximeter showed high reliability.
Measurement of the joint range of motion ROM is an important component in the physiotherapeutic evaluation since it not only identifies joint limitations but it also allows following quantitatively the efficiency of therapeutic interventions during rehabilitation 1 - 3. It should be performed using reliable instruments, preferably noninvasive ones, which may be easily reproduced and should be based on scientific evidence 7.
Reliability of measures demonstrates its consistence obtained through an instrument or by an examiner in the same evaluation conditions. Intra-evaluator reliability is the consistence of measures performed in the same evaluation conditions in two different moments. On the other hand, the inter-evaluator reliability is associated with consistence of the measures performed by two or more different evaluators 8.
Among these instruments, both the universal goniometer UG 1 , 2 , 8 - 11 and the fleximeter electromagnetic goniometer 12 have showed reliability indices classified from "regular" to "excellent" depending on the joint and movement being analyzed. Although literature shows that variations between the second and seventh in the ROM are acceptable considering the tested joint 13 , and there has already been evidence of the reliability of UG and fleximeter alone 2 , 10 , studies in general restrict the number of instruments when two or more joints 11 , 14 are being compared.
Or they limit the number of movements to be analyzed when two or more instruments are being correlated 1 , 2 , 8 , 9 , 12 , Thus, this study aimed at analyzing the reliability of intra and inter-evaluators measures for elbow and knee flexion movements, ankle dorsiflexion and fist extension, which were performed with the UG and fleximeter.
In this study, the sample was chosen by convenience and 80 healthy subjects from both sexes were investigated 45 women and 35 men; They had no musculoskeletal alterations, pain or discomfort in the higher and lower limbs or any other disease or dysfunction that could compromise the elbow, fist, knee and ankle ROM.
In the UG, the part set apart to read the angles was covered with a poster paper in order to not influence the subsequent measures Figures 1A , 1C , 1E and 1G , while in the fleximeter, reading was always direct since the evaluator could not have an influence on the results.
The study included two evaluators: one deemed experienced three years of practice and another considered unexperienced only one month of practice , with low familiarization with the goniometer and fleximeter. Each measure was performed three times in the dominant limb, in only one session, by calculating their mean. Subjects were oriented to wear light clothes in order that the ROMs were not limited, and the evaluator demonstrated all movements before the maximum active ROM measuring.
One of the evaluators did measurement, while the second one performed its reading and recording in order to avoid induction of results. Measures of knee flexion Figure 1C and 1D and ankle dorsiflexion Figure 1E and 1F were performed in the prone position. In all measures done with the fleximeter, the same positions of goniometry were adopted. The fleximeter was positioned in the lateral face of the fist radius styloid process , of the ankle lateral malleolus , of the foot head of the fifth metatarsus and medial face of the hand fifth metacarpus to measure elbow and knee flexion, ankle dorsiflexion and fist extension respectively ICC tests between the three measures done with UG for each evaluator demonstrated that there was a very strong correlation 0.
With regard to comparisons between the three measures of ROMs performed using the fleximeter Table 2 , results also showed a very strong ICC 0. As to comparisons of inter-evaluators measures Table 3 , it was also seen a very strong ICC for elbow and knee flexion movements 0. In the physiotherapeutic practice, a measure cannot be deemed significant if it is not valid and reliable 3.
Therefore, reliability of the examiner and of the ROM evaluation instrument is very important to allow the consistence of measures during the clinical evolution and in scientific studies 3 , According to Bonagamba et al. When comparing data from the present study with literature, it was seen that the ICC indices generally were similar or even higher than in other studies 24 - 26 , both concerning evaluators and instruments, in most studied movements.
Under et al. Similarly to our results, Lustosa et al. Piriyaprasarth and Morris 29 , in a systematic revision article, stated that ROM measures are reliable using both the UG and the electromagnetic goniometer fleximeter , which is in agreement with the findings of this study.
On the other hand, Sacco et al. However, it is believed that these lower correlation levels, if compared to our study, happen because the researchers used a different methodology from the present study.
An investigation developed by Chaves et al. Nevertheless, although they have used the same instruments, they assessed different movements cervical spine that may justify the results, since some instruments present higher or lower ICC depending on the assessed movement. With regard to the measure of active ROM of ankle dorsiflexion, Venturini et al. When Konor et al. On the other hand, when Santos et al. Differently from the results of the present study, Van Trijffel et al.
They stated that it was harder to find bone marks accurately, making it more difficult to get the perfect alignment of the goniometer. However, some studies using UG showed high reliability for the knee flexion Currier et al.
Another study carried out by Carter et al. Like other authors 1 , 25 , 31 , 36 , the present study performed consecutive measures in only one session for all the movements. The first examiner did three consecutive measures, and the same procedure was repeated by the second examiner with the subject in the same position, for each studied movement. The fact that other studies 2 , 8 , 9 , 12 , 24 , 37 , 38 used intervals from two to seven days between the first and second measures, with the aim of eliminating effects of viscoelastic adaptation warming, extensibility, etc.
However, like other authors 1 , 25 , 31 , 36 , the present study performed consecutive measures, in only session, for all movements, which presented high reliability among them. Results from this study show that: evaluator's experience did not influence ROM measures of the joints studied; the instruments used UG and fleximeter generally present high reliability when performed in the same session of measurements; and use of fleximeter in the physiotherapeutic clinic may be expanded without damage to reliability of measures.
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Table 2 Values of the intraclass correlation coefficient ICC , intra-evaluators, of elbow and knee flexion fleximetry, fist dorsiflexion and extension. Table 3 Values of the intraclass correlation coefficient ICC , inter-evaluators, of elbow and knee flexion goniometry and fleximetry, fist dorsiflexion and extension.
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