Original ResearchInter-rater reliability and validity of angle measurements using smartphone applications for weight-bearing ankle dorsiflexion range of motion measurements
Introduction
Ankle dorsiflexion range of motion measurements have been utilised to determine the effects of rehabilitation (Cadenhead, McEwen, & Thompson, 2002) and to prevent injury induced by physical activity (DiGiovanni et al., 2002; Riddle, Pulisic, Pidcoe, & Johnson, 2003). However, ankle dorsiflexion range of motion measurements during non-weight-bearing was reported to have no correlation with clinical and radiological data (Backer & Kofoed, 1989). Additionally, it was reported that ankle dorsiflexion range of motion in the weight-bearing and non-weight-bearing measurements are significantly different (Rabin & Kozol, 2012). Rabin and Kozol (2012) noted that because the non-weight-bearing measurement does not stress the ankle to full excursion, measurements may not be sensitive enough. Therefore, ankle dorsiflexion range of motion measurements in non-weight-bearing using goniometers have decreased validity. In addition, two literature reviews on reliability of ankle dorsiflexion goniometric measurement (Martin & McPoil, 2005; Van Trijffel, van de Pol, Oostendorp, & Lucas, 2010) reported different results showing acceptable or unacceptable interrater reliability. There were two selected studies concerning these views. Van Gheluwe, Kirby, Roosen, and Phillips (2002) reported an intra-class correlation coefficient (ICC) of 0.26 and Elveru, Rothstein, and Lamb (1988) reported an ICC1,1 of 0.50, which exhibited unacceptable reliability. Therefore, the validity and reliability of ankle dorsiflexion range of motion measurements during non-weight-bearing using goniometers have not been established due to technical problems (Backer & Kofoed, 1989; Martin & McPoil, 2005; Rome, 1996).
Measurements performed in the weight-bearing position using goniometers, inclinometers, and tape measures as measuring devices have been reported as highly reliable (Bennell et al., 1998; Konor, Morton, Eckerson, & Grindstaff, 2012; Krause, Cloud, Forster, Schrank, & Hollman, 2011; Rabin & Kozol, 2012). However, these measuring devices are associated with several problems. For example, the goniometer is affected by the operating technique (Rome, 1996), and the inclinometer and tape measure are dependent on the alignment of the subject and can be affected by heel contact conditions, lower leg bone shape, and lower leg length (Bennell et al., 1998).
Recently, the reliability of measurements using photographs and smartphone applications (Ferriero et al., 2011, 2013; Walter, Kosy, & Cove, 2013) for various body parts has been studied, and high reliability has been reported. However, measurement validity was examined by using digital images and applications for the range of motion of the knee joint, the range of motion of the elbow joint, and the hallux valgus angle, and high validity was reported in comparison with radiographic measurements. In addition, the validity of application measurements using a protractor has been reported (Awatani, Enoki, & Morikita, 2017). Ege, Kose, Koca, Demiralp, and Basbozkurt (2013) did not directly photograph the subject during their validity study; instead, they obtained radiographic images on a personal computer screen and performed measurements with an application. However, the reliability and validity of ankle dorsiflexion range of motion measurements in the weight-bearing position using an application have not been clarified.
Measurement methods with high reliability and validity will help improve the quality of clinical research because the effectiveness of rehabilitation will be able to be correctly judged. Therefore, the purpose of this study was to use an application to examine the inter-rater reliability, validity, and measurement errors of the ankle dorsiflexion range of motion in the weight-bearing position.
Section snippets
Participants
Eighteen healthy volunteers (9 men, 9 women; mean ± standard deviation [SD]: age, 25.3 ± 2.8 years; height, 167.4 ± 8.9 cm; and body weight, 63.1 ± 11.8 kg) participated in the study. Participants did not have lower extremity injuries within the past 6 months and did not have diseases or symptoms that impeded measurements. This study was approved by the Research Ethics Committee of Osaka University of Health and Sport Sciences (approval no. 13-2). The participants were well informed, orally and
Results
Using APPmarkerless, the ICC2,1 was 0.945 (almost perfect), and the SEM (SEM%) was 1.6° (5.5%) (Table 1); this was also a small error. Using APPmarker, the ICC2,1 was 0.995 (almost perfect), and the SEM (SEM%) was 0.5° (1.9%) (Table 1); this was also a small error.
Regarding the correlation coefficient between radiographic measurements and APPmarkerless, three examiners showed very high correlation (r > 0.9) and almost perfect ICCs (ICC2,1 = 0.892–0.944) (Table 2). Regarding the correlation
Discussion
Radiographic measurements with 250-cm distances between the X-ray generator and the subject were reported to have high validity, inter-rater reliability, and minor errors in the present study (Awatani et al., 2017). Additionally, placing approximately 2 m of distance between the smartphone and the subject was recommended for application measurements (Awatani et al., 2017). However, comparative studies of ankle dorsiflexion range of motion measurements using an application and radiographs are
Conclusion
In this study, the inter-rater reliability, validity, and measurement error of application measurements were examined. The results of this study proved the validity of APPmarkerless. In other words, the application measurements under appropriate conditions are precise and accurate for weight-bearing ankle dorsiflexion range of motion measurements. Additionally, if examiners have the knowledge of the anatomy, then only small measurement errors may occur with APPmarkerless; therefore, an examiner
Conflicts of interest
Not applicable.
Funding
Not applicable.
Acknowledgments
We thank Editage (www.editage.jp) for English language editing.
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