Accepted Manuscript

Title: A new iPhone® application for measuring active craniocervical range of

motion in patients with non-specific neck pain: a reliability and validity study

Author: Mohammad Reza Pourahmadi, Rasool Bagheri, Morteza Taghipour,

Ismail Ebrahimi Takamjani, Javad Sarrafzadeh, Mohammad Ali Mohseni-
Bandpei

PII: S1529-9430(17)30903-8
DOI: http://dx.doi.org/doi: 10.1016/j.spinee.2017.08.229
Reference: SPINEE 57458

To appear in: The Spine Journal

Received date: 20-4-2017

Revised date: 27-7-2017
Accepted date: 9-8-2017

Please cite this article as: Mohammad Reza Pourahmadi, Rasool Bagheri, Morteza Taghipour,
Ismail Ebrahimi Takamjani, Javad Sarrafzadeh, Mohammad Ali Mohseni-Bandpei, A new
iPhone® application for measuring active craniocervical range of motion in patients with non-
specific neck pain: a reliability and validity study, The Spine Journal (2017), http://dx.doi.org/doi:
10.1016/j.spinee.2017.08.229.

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 1 Title:

2 A new iPhone® application for measuring active

3 craniocervical range of motion in patients with non-
4 specific neck pain: a reliability and validity study
5

6 Running Head: iPhone® app for measuring active craniocervical ROM

7

8 List of Authors:
9 1- Mohammad Reza Pourahmadi, MSc, PT, Currently PhD Candidate in

10 Physiotherapy a

11 2- Rasool Bagheri, MSc, PT, Currently PhD Candidate in Physiotherapy a, b

12 3- Morteza Taghipour, MSc, PT, Currently PhD Candidate in Physiotherapy c

13 4- Ismail Ebrahimi Takamjani, PhD, PT, Dean, Professor a

14 5- Javad Sarrafzadeh, PhD, PT, Associate Professor a

15 6- Mohammad Ali Mohseni-Bandpei PhD, PT, Professor d, e

16

17 Institutions and Affiliations:

18 a
Department of Physiotherapy, School of Rehabilitation Sciences, Iran University of
19 Medical Sciences, Tehran, Iran
20 b
Neuromuscular Rehabilitation Research Center, Department of Physiotherapy,
21 Semnan University of Medical Sciences, Semnan, Iran
22 c
Student Research Committee, University of Social Welfare and Rehabilitation
23 Sciences, Tehran, Iran
24 d
Pediatric Neurorehabilitation Research Center, University of Social Welfare and
25 Rehabilitation Sciences, Tehran, Iran
26 e
University Institute of Physical Therapy, Faculty of Allied Health Sciences,
27 University of Lahore, Lahore, Pakistan

1
Page 1 of 26
 1

2  Corresponding Author:

3 Morteza Taghipour, Student Research Committee, University of Social Welfare and

4 Rehabilitation Sciences, Evin, Koodakyar Ave., Tehran, Iran. Postal Code:

5 1985713831. Tel: +98 21 22180039.

6 Email address: taghipour-morteza@hotmail.com (M. Taghipour)

8 Author Disclosures:
9 M.R.P.: Nothing to disclose. R.B.: Nothing to disclose. M.T.: Nothing to disclose. I.E.T.:
10 Nothing to disclose. J.S.: Nothing to disclose. M.A.M.B.: Nothing to disclose.
11

12 Abstract
13 BACKGROUND CONTEXT: Measurement of cervical spine range of motion (ROM) is
14 often considered to be an essential component of cervical spine physiotherapy assessment.

15 PURPOSE: To investigate the reliability and validity of an iPhone® app (Goniometer Pro©)
16 for measuring active craniocervical ROM (ACCROM) in patients with non-specific neck
17 pain.

18 STUDY DESIGN/SETTING: A cross-sectional study was conducted at the musculoskeletal

19 biomechanics laboratory located at Iran University of Medical Sciences.
20 PATIENT SAMPLE: Forty non-specific neck pain patients participated in this study.

21 OUTCOME MEASURES: ACCROM including flexion, extension, lateral flexion, and

22 rotation.

23 METHOD: Following the recruitment process, ACCROM was measured using a universal
24 goniometer and iPhone® 7 app. Two blinded examiners each utilized the universal
25 goniometer and iPhone® to measure ACCROM in the following sequences: flexion,
26 extension, lateral flexion, and rotation. The second (2 h later) and third (48 h later) sessions
27 were carried out in the same manner as the first session. Intraclass correlation coefficient
28 (ICC) models were used to determine the intra-rater and inter-rater reliability. The Pearson’s
29 correlation coefficients were used to establish concurrent validity of the iPhone® app.
30 Minimum detectable change at the 95% confidence level (MDC95) was also computed.

31 RESULTS: Good intra-rater and inter-rater reliability was demonstrated for the goniometer
32 with ICC values of ≥ 0.66 and ≥ 0.70 and the iPhone® app with ICC values of ≥ 0.62 and ≥
33 0.65, respectively. The MDC95 ranged from 2.21° to 12.50° for the intra-rater analysis and
34 from 3.40° to 12.61° for the inter-rater analysis. The concurrent validity between the two

2
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1 instruments was high, with r values of ≥ 0.63. The magnitude of the differences between the
2 UG and iPhone® app values (effect sizes) was small with Cohen’s d values of ≤ 0.17.

3 CONCLUSIONS: The iPhone® app possesses good reliability and high validity. It seems
4 that this app can be used for measuring ACCROM.
5

6 Keywords: arthrometry, articular; range of motion, articular; smartphone; neck; cervical

7 vertebrae.

3
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 1 Introduction

2 Measurement of cervical spine range of motion (ROM) is considered to be a useful parameter

3 to assess the level of function, establish a treatment plan, monitor the patient's progress, and
4 provide feedback on the effectiveness of therapeutic interventions [1]. The measurement is
5 usually conducted by using clinical instruments such as goniometer, measuring tape,
6 inclinometer, cervical ROM device, and etc [2].

7 The number of smartphone users has been increased worldwide during the last decade
8 and nowadays, smartphones are equipped with a set of cheap but powerful embedded sensors
9 that make the phone capable of detecting joint position and measuring joint ROM [3]. None
10 of the previously published papers have evaluated the validity of iPhone® applications (apps)
11 in neck pain patients [4, 5]. Therefore, this study aimed to examine the reliability and validity
12 of a new iPhone® app [Goniometer Pro© (G-pro©)] for measuring active craniocervical ROM
13 (ACCROM) in non-specific neck pain participants.

14

15 Methods

16 Study design

17 A cross-sectional study was conducted between November 2016 and March 2017 in Tehran,
18 Iran. The level of evidence of this investigation was level 2b. Approval for the study was
19 obtained from the Ethics Committee at Iran University of Medical Sciences (IUMS). In
20 writing the manuscript, we tried to follow the STROBE and GRRAS checklists items to
21 improve the quality of paper [6, 7].

22

23 Participants

24 The sample size of this study was calculated based on a pilot study (15 participants with non-
25 specific neck pain) using the 'sampicc' command in STATA statistical software [8]. The ICC
26 for inter-rater reliability for measuring flexion using the app was 0.68 (the lowest ICC of pilot
27 study). The null hypothesis was selected to be 0.40 [9], with the power set at 90%, type I
28 error fixed at 5%, and three repetitions were conducted for each measurement. The results
29 showed that a minimum of 33 patients with non-specific chronic neck pain was needed. To
30 allow for 20% attrition, this sample size was increased to 40 participants (20 male, 20

4
Page 4 of 26
 1 female). The population of the current investigation was a convenient sample, recruited by
2 purposive and snowball sampling. The inclusion and exclusion criteria of this study are listed
3 in Table 1. Before participation in this study, procedure of the investigation was explained
4 both verbally and using a written form. A written informed consent was obtained from all
5 volunteers and all procedures were performed according to the Declaration of Helsinki.
6 Participants’ baseline demographic characteristics are presented in Table 2.

8 PLEASE INSERT TABLES 1 & 2 ABOUT HERE

10 Examiners

11 All goniometric measurements were performed by two independent blinded examiners

12 (M.R.P. and M.T.) and ACCROM was read directly from the instruments by a third person
13 (R.B.). The examiners of the study were Ph.D. candidates in physiotherapy with a clinical
14 experience ranged from four to eight years. All the three examiners had experience in the use
15 of UG for measuring ROM. Moreover, M.R.P. and M.T. gathered experience in using the G-
16 pro© app for measuring ROM during a previous research project. R.B. had no experience
17 using the app.

18

19 Instrumentation

20 ACCROM of participants with non-specific neck pain was measured using a SAEHAN
21 plastic universal two-arm goniometer with 360° goniometer face, and 30 cm (11.81 inch)
22 movable arms (SAEHAN Corp., Dangjin-gun, South Korea). The UG used in the current
23 study was accurate to within 1° (Figure 1a, b). Furthermore, a jet black iPhone® model 7
24 (iPhone® is a trademark of Apple Inc., Cupertino, CA, USA) with the G-pro© app (version
25 2.7; downloaded for free from Apple’s App Store;
26 https://itunes.apple.com/us/app/goniometer-pro/id646925503?mt=8) was utilized to measure
27 ACCROM. The G-pro© is an app designed for smartphones and iPad/computer tablets. It
28 works like a digital gravity-based inclinometer and computes the angle between two adjacent
29 segments. The present app uses the iPhone’s built-in accelerometer sensor and a digital

5
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 1 display to show the measured angle (Figure 1c, d). The precision of the G-pro© app has been
2 reported between 0.2° and 0.3° [10].

4 PLEASE INSERT FIGURE 1 ABOUT HERE

6 Procedure

7 Following the recruitment process, demographic data including age, gender, stature, body
8 mass, and location of the symptoms were collected. For measuring active flexion, extension,
9 lateral flexion, and rotation using the UG, the participants were asked to sit upright on a chair
10 with a padded backrest supporting the thoracic spine with their feet flat on the floor and arms
11 positioned comfortably on the armrests beside them. To minimize the contribution of the
12 thoracic spine, the participant was securely strapped across the shoulders to the chair using an
13 inelastic belt. In order to standardize head posture, a visual target (white A5 paper with a
14 black circle drawn upon it) was adjusted to eye level in front of the participants. To measure
15 active craniocervical flexion and extension ROM, the center of the UG was placed over the
16 external auditory meatus. Then, the proximal arm (fixed arm) was positioned perpendicular to
17 the floor and the distal arm (moving arm) was placed over an imaginary line between the base
18 of the nostril and the external auditory meatus. One surface of the UG face was covered with
19 a white sheet of paper so that the figures could not be seen from the examiner side (Figure
20 1b). Following the goniometric placement, the physiotherapist asked the participants to
21 perform maximum craniocervical flexion. Verbal cues (feedbacks) were also provided by the
22 physiotherapist to encourage the participants to make their maximum effort in order to reach
23 the end of the available range. The same method of measurement was repeated for evaluating
24 craniocervical extension ROM. Active lateral flexion ROM was measured by placing the
25 center of the UG over the spinous process of C7, the proximal arm was perpendicular to the
26 floor and the distal arm was aligned with the occipital protuberance. Finally, in order to
27 measure active craniocervical left and right rotation ROM, the center of the UG was
28 positioned at the center of the head, the proximal arm was placed over the sagittal suture and
29 at the end of the movement, the distal arm was aligned with the nose [11]. All the measured
30 angles were documented by a third person (recorder: R.B.) (Figure 2). The movements were
31 measured in the following sequences: flexion, extension, left lateral flexion, right lateral
32 flexion, left rotation, and right rotation. Randomization in measurements was not used
6
Page 6 of 26
 1 because the purpose of the present study was to examine reproducibility, which requires a
2 consistent physiological status [12]. All the UG measurements were repeated by the second
3 physiotherapist (examiner B: M.T.).

4 ACCROM was also measured using the G-pro© app installed on the iPhone® 7. The
5 examiners activated the G-pro© app and pressed the ‘device axis’ button to adjust the axis
6 according to the test condition. For measuring flexion and extension, the testing position was
7 the same as that described for the UG measurements. The iPhone® was placed just beside the
8 external auditory meatus and one axis of the app was aligned with the imaginary line between
9 the base of the nostril and the external auditory meatus (Figure 2). Afterward, the examiners
10 asked the participants to move the craniocervical to the maximum available ROM. A piece of
11 white adhesive tape was placed over the iPhone® screen to cover the measured angles. When
12 the examiner was satisfied that measurement was complete, they tapped on the iPhone®
13 screen to record and store the angles. The recorder then documented the measured angles
14 from the device screen, before deleting them from the iPhone®. Active lateral flexion ROM
15 was measured in the sitting position (Figure 2). The center of the app was placed over the C7
16 spinous process and one axis of the app was aligned with the occipital protuberance. From
17 this position, the participants were requested to perform maximal right and left lateral flexion.
18 Finally, because of difficulty in using the app for measuring active craniocervical rotation in
19 sitting, this movement was evaluated in the supine position (Figure 2). However, the method
20 of placement for the iPhone® was the same as in the UG placement. the center of the app was
21 positioned at the center of the head and one axis was aligned with the nose. From this
22 position the participants were asked to perform maximum right and left rotation and the
23 angles were measured and documented. The sequence of ACCROM measurement using the
24 G-pro© app was the same as that listed for the UG and no randomization was done.

25 The procedure was repeated in the same manner after 2 and 48 h and no attrition was
26 occurred. All the measurements of ACCROM were conducted three times by the two blinded
27 examiners and the mean value of three repetitions from each measurement was used for
28 statistical analysis.

29

30 PLEASE INSERT FIGURE 2 ABOUT HERE

31

7
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 1 Statistical analysis

2 All statistical analyses were performed on a personal laptop using SPSS version 20.0 (SPSS
3 Inc., Chicago, IL, USA) and STATA version 13.0 (STATA Corp., College station, TX,
4 USA). Prior to the statistical analyses, several strategies were used for assessing normality
5 including the Kolmogorov–Smirnov (K–S) test, plotting histograms with kernel density and
6 normal probability density, mean and median similarity, as well as obtaining skewness and
7 kurtosis values. The results showed that the distribution of the values was normal.
8 Descriptive values are presented as mean angles and standard deviations (SD) calculated for
9 each series of measurements (Table 3). The reliability of all measurements was investigated
10 using the ICC model (3, k) for the intra-rater analysis and the ICC model (2, k) for the inter-
11 rater analysis. For the intra-rater reliability and concurrent validity, one examiner (examiner
12 A; M.R.P.) was the rater of interest.

13 The scale from Bland and Altman was utilized in the classification of the reliability data
14 (≤ 0.20 poor, 0.21–0.40 fair, 0.41–0.60 moderate, 0.61–0.80 good, and 0.81–1.00 excellent)
15 [9]. Standard error of measurement (SEM) was used to evaluate the precision of the

16 instruments and was computed as follows: pooled SD × 1 – ICC. In addition, minimum

17 detectable change at the 95% confidence level (MDC95) was calculated as 2 × 1.96 × SEM
18 [13]. Coefficient of variation (CV) was computed as the ratio of the SD to the mean
19 multiplied by 100 [14]. Furthermore, a 95% repeatability coefficient (Rc) was calculated as
2
20 1.96 × 2 (within-sub ect S ) [15].

21 In the present study, concurrent validity was assessed between the UG and iPhone® app
22 using the Pearson’s correlation coefficient (r) and Bland-Altman plots with 95% limits of
23 agreement (LOA) [16]. The values of the Pearson’s correlation coefficient were categorized
24 according to Hopkins’ extension of Cohen’s guidelines (0.00–0.09 nonexistent, 0.10–0.29
25 small, 0.30–0.49 medium, 0.50–0.69 large, 0.70–0.89 very large, 0.90-0.99 nearly perfect,
26 and 1.00 perfect) [17, 18]. In addition, Bland-Altman plots were created to determine the
27 magnitude and variability of the differences between the UG and G-pro© app for measuring
28 ACCROM. The 95% LOA were computed as mean difference ± 1.96 × SD [9]. Furthermore,
29 standardized mean difference was chosen as effect size measure, which is a simple way to
30 quantify the size of the difference between two groups. In this study, the effects sizes (with
31 95% confidence interval) were calculated using the 'esize twosample' command in the

8
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 1 STATA [17]. Finally, after statistically analyzing the variables, the results were rounded to
2 two decimal places. All probability values were set at the 0.05 level of significance.

4 Results

5 The mean and SD of all goniometric measurements (UG and iPhone® app) for both
6 examiners are reported in Table 3. Measurement data from the intra-rater (within-day and
7 between-day) and inter-rater (within-day) reliability analysis including the ICC with 95%
8 confidence interval (CI), SEM, 2 SEMs, MDC95, CV, Rc, and 95% LOA are presented in
9 Tables 4 and 5. Good to excellent intra-rater reliability was found with both the UG and
10 iPhone® app for measuring ACCROM ranging from 0.62–0.83 (Table 4). Moreover, the
11 results of the current study showed that the inter-rater reliability was good, ranging from
12 0.65–0.79 (Table 5). Concurrent validity analysis revealed large to very large correlations
13 (Pearson’s r) among the UG and iPhone® app with the r values reported in table 6. In
14 addition, relationships between the iPhone® app and UG measurements of maximum
15 ACCROM were displayed using the scatter plots (Figure 3).
16
17 PLEASE INSERT TABLES 3-6 ABOUT HERE

9
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 1 PLEASE INSERT FIGURE 3 ABOUT HERE

2 The 95% LOA (Bland-Altman plots; Figure 4) show that there are no differences
3 between the values measured by the 2 instruments as the zero point lies within the range of
4 differences between the UG and iPhone® values; however, individual differences may cause
5 variations in the measured angle by the iPhone® or UG. According to the results, in active
6 craniocervical flexion, differences (95% LOA) may range from the iPhone® being 11.1°
7 greater to 11.3° less than the UG. Differences between the UG and iPhone® for other
8 measurements are depicted by the Bland-Altman plots in Figure 4. Histograms are also
9 plotted to display the distribution of measurement (observational) error (Figure 4). The effect
10 sizes indicate that there are very small differences (Cohen’s d ≤ 0.17) in mean values of UG
11 and iPhone® measurements (Table 7).

12
13 PLEASE INSERT FIGURE 4 ABOUT HERE

14 PLEASE INSERT TABLE 7 ABOUT HERE

15

16 Discussion

17 Measurement of cervical spine ROM with valid and reliable instruments can help clinicians
18 provide more accurate clinical assessment in individuals with cervical spine injuries. A UG is
19 an instrument which can be used for measuring cervical ROM [11, 19]. The reliability of the
20 UG in the current study is consistent with previous studies which have reported good overall
21 ICC values [19, 20]. Youdas et al. determined the reliability of a UG for the measurement of
22 ACCROM in patients with neck disorders and reported the ICC values ranged from 0.78 to
23 0.90 for the intra-rater reliability and 0.54 to 0.79 for the inter-rater reliability [19]. In
24 addition, Tucci et al. likewise indicated poor inter-rater reliability for neck flexion in healthy
25 participants [20]. However, Chaves et al. reported moderate intra-rater reliability and poor to
26 moderate inter-rater reliability for goniometry in healthy children. In this study, the ICC
27 values for the intra-rater reliability of measuring ACCROM using a UG were between 0.68-
28 0.83, and for the inter-rater reliability, the ICC values ranged from 0.70 to 0.75. Good
29 reliability is likely due to accurate and firm placement of the UG and controlling its slippage
30 on participants’ skin during movement, three repetitions of each measurement, the simplicity
31 of the instrument being used, and increased familiarity of participants with the testing

10
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 1 procedures. The reliability of the iPhone® app was good, with the ICC ranging from 0.62 to
2 0.79. All above-mentioned reasons could also be an explanation for high reliability in
3 ACCROM using the iPhone®. Due to the lack of research in using smartphone for measuring
4 ACCROM, a comparison between the reliability results of our study and previous research
5 cannot be made.

6 The mean descriptive measurement values of the two instruments were similar and there
7 was no statistically difference between the UG and app mean values. Chaves et al. (2008)
8 measured ACCROM using a UG and fleximeter in 106 children [11]. The mean values of
9 ACCROM measured using the UG were higher in comparison with our study results. Two
10 main reasons may explain these differences: first, the participants of Chaves et al. study [11]
11 were asymptomatic children, whereas the participants of our investigation were adult patients
12 with non-specific neck pain; and second, the method of ACCROM measurement was
13 different in both studies. The mean ACCROM values of non-specific neck pain participants
14 were lower than normal cervical spine ROM [19, 21]. All participants had pain intensity rated
15 as mild to moderate at rest on the VAS; therefore, pain could be the reason behind the
16 decreased ACCROM in the participants of this study.

17 The CV which is a measure of dispersion (variability) was used to estimate the precision
18 of experiments [22]. The results showed that the CV values of the UG and iPhone® app were
19 almost similar. Therefore, it means that both instruments exhibit nearly the same level of
20 precision. The similarity in the measurement methods (except in rotation) and the experience
21 of the examiners who performed all the ACCROM measurements could be the potential
22 reasons responsible for the same level of precision between the UG and iPhone® app. There is
23 evidence that the experience can improve the precision of performing tasks [23]. The Rc is a
24 reliability measure that represents the maximum difference likely to occur between repeated
25 measurements of the same variable (ACCROM) with a probability of 95% [16]. In general,
26 smaller Rc(s) were found for measuring ACCROM using the iPhone® app, indicating slightly
27 better reproducibility. However, differences between the Rc(s) of the two instruments were
28 not statistically significant and the ICC analysis revealed good reliability of both instruments.
29 In addition, the concurrent validity was assessed using the Bland-Altman plots and the results
30 indicated that there were no differences between the values of the two instruments. The
31 findings also indicated that the effect size measures were small (< 0.20). Therefore, the
32 magnitude of clinical differences between the UG and iPhone® app values was small.

11
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 1 One advantage of using the iPhone® app over the UG is that the app is available anytime
2 and can be downloaded for free from Apple's App Store. Moreover, the trial version of this
3 app is also available for free for Android smartphones on Google Play. However, it is
4 important to consider limitations related to smartphone use. Clinicians may be reluctant to
5 use their personal smartphones for assessment due to the direct contact between the
6 smartphone and the patient's skin [12, 24, 25]. Smartphones sometimes hang unexpectedly
7 and would therefore, interfere with the measurement [26]. Attention to smartphone's battery's
8 charge level is another important factor. Insufficient battery charge level results in turning off
9 the smartphone and the collected data may be lost [26].

10

11 Study limitations and future research recommendation

12 The main limitation is that only ACCROM was assessed. In each of the three sessions,
13 ACCROM was measured three times by the two blinded examiners, hence, we thought that
14 the measurement of passive CCROM (PCCROM) in addition to ACCROM could cause
15 microtrauma to the participants. Further studies can investigate the reliability and validity of
16 the G-pro® app for measuring PCCROM.

17

18 Conclusions

19 This investigation demonstrated that the G-pro© app possesses good to excellent reliability
20 and concurrent validity with a UG for measuring ACCROM. According to the results of this
21 study, it seems that the app can be used for ACCROM evaluation.

22

23 Acknowledgments

24 The authors would like to thank Ms. Roya Shekarabi for her assistance in preparing the
25 graphs.

26

27 Sources of support

28 Own source.

29
12
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1 Competing interests

2 Nil.

13
Page 13 of 26
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of a new iPhone goniometric application for measuring active wrist range of motion: a cross-sectional
study in asymptomatic subjects. Journal of Anatomy. 2017;230(3):484-95.

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Fig 1. A) Testing UG. B) One surface of the UG face was blinded to the examiners and the
numerical side was visible to the recorder. C) iPhone® model 5 with screen showing the G-
pro© app. B) Definition of each item on the app (from
https://itunes.apple.com/us/app/goniometer-pro/id646925503?mt=8).

Fig 2. Starting positions for measuring ACCROM using the UG and the iPhone® app: A and
D) Starting position for measuring flexion and extension, B and E) Starting position for
measuring lateral flexion, and C and F) Starting position for measuring rotation.

Fig 3. Scatter plots showing the relationships between the iPhone® app and UG
measurements of maximum active craniocervical (A) flexion, B) extension, (C) left lateral
flexion, (D) right lateral flexion, (E) left rotation, and (F) right rotation.

Fig 4. Bland–Altman plots (left column) representing mean differences and 95% LOA
between the UG and iPhone® measurements of maximum active craniocervical (A) flexion,
B) extension, (C) left lateral flexion, (D) right lateral flexion, (E) left rotation, and (F) right
rotation (degrees). Histograms (right column) are also included to represent the distribution
of measurement error.

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Table 1. Inclusion and exclusion criteria of the study
Inclusion criteria Exclusion criteria
1- Adults from 18-40 years age of both genders 1. Pregnancy
2- Non-traumatic neck pain 2. Inflammatory arthritis which affect the cervical
3- Moderate pain intensity of 3-6 at rest on a spine (eg, rheumatoid arthritis, ankylosing
10-cm visual analog scale (VAS) spondylitis)
4- No history of cervical surgery and fracture 3. Nervous system disorders which affect the
5- Ability to provide written informed consent cervical spine (eg, polio, Parkinson disease,
stroke, and multiple sclerosis)
4. Signs of nerve-root compression (eg,
paraesthesia and numbness in the upper
extremity)

Table 2. Baseline demographic characteristics of participants with non-specific neck pain*

VAS
b
Stature Body BMI
a
Participants Gender n Age (y) 2 score at
(cm) mass (kg) (kg/m )
rest
20 31.05 173.25 71.8 23.91 3.55
Male
(50%) (6.20) (6.66) (8.02) (2.14) (0.95)
Non-specific neck 20 31.20 169.17 66.78 23.33 3.87
Female
pain (50%) (6.63) (6.44) (7.64) (2.36) (1.14)
40 31.12 171.21 69.28 23.61 3.71
Total
(100%) (6.38) (6.83) (8.18) (2.26) (1.06)
* Values as mean units (± standard deviation).
BMI: Body mass index
a

VAS: Visual analog scale

b

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Table 3. Descriptive statistics for the UG and iPhone® app values
Examiner

A B
Late Late Late Late
ral ral Rotat Rotat ral ral Rotat Rotat
Instru Flex Exten Flex Exten
flexi flexi ion ion flexi flexi ion ion
ment ion sion ion sion
on on (Lt) (Rt) on on (Lt) (Rt)
(Lt) (Rt) (Lt) (Rt)

41.3 37.6 36.4 71.28 72.45 40.0 37.4 36.9 69.76 69.81
Mean 8◦ 31.71◦ 0◦ 9◦ ◦ ◦
7◦ 32.41◦ 9◦ 4◦ ◦ ◦
UG ◦ ◦
(SDa) (5.34 (4.51◦) (1.8 (3.0 (9.03 (7.89 (5.05 (4.08◦) (2.4 (3.0 (8.16 ◦
(8.87◦
◦
) 6◦) 9◦) ) ) ◦
) 5◦) 1◦) ) )

41.2 37.2 37.0 71.75 71.84 39.5 37.5 37.3 70.36 70.43
iPhon Mean 7◦ 30.95◦ 8◦ 1◦ ◦ ◦
7◦ 31.57◦ 7◦ 5◦ ◦ ◦
®
e app (SDa) (4.77 (4.73◦) (2.2 (3.0 (7.33◦ (8.31◦ (4.48 (4.88◦) (2.5 (2.8 (5.94◦ (6.87◦
◦
) 6◦) 4◦) ) ) ◦
) 2◦) 5◦) ) )

Level
of
0.93 0.10 0.22 0.11 0.27 0.50 0.43 0.60 0.78 0.14 0.82 0.50
signific
antly

SD: Standard deviation

a

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Table 4. Intra-rater reliability of the UG and iPhone® app
®
UG iPhone app
ROM measurement Intra-rater reliability Within-day (2 h) Between-day (48 h) Within-day (2 h) Between-day (48 h)
Flexion ICC (95% CI ) 0.78 (0.58 , 0.88) 0.69 (0.42 , 0.84) 0.76 (0.54 , 0.87) 0.69 (0.42 , 0.83)
a b

◦ ◦ ◦ ◦
SEM 3.29 4.29 2.49 3.11
c

◦ ◦ ◦ ◦
2 SEMs 6.58 8.58 4.98 6.22
d

◦ ◦ ◦ ◦
MDC95 9.12 11.89 6.90 8.62
e

CV (%) 15.13 18.58 12.51 13.81

f
◦ ◦ ◦ ◦
Rc 19.46 21.39 14.15 15.55
g
◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦
95% LOA -9.90 , 13.57 -14.70 , 15.36 -7.95 , 9.99 -9.56 , 12.12
h

Extension ICC (95% CI ) 0.74 (0.52 , 0.86) 0.68 (0.42 , 0.83) 0.76 (0.54 , 0.87) 0.71 (0.45 , 0.84)
a b

◦ ◦ ◦ ◦
SEM 2.35 2.77 2.40 2.57
c

◦ ◦ ◦ ◦
2 SEMs 4.70 5.54 4.80 5.14
d

◦ ◦ ◦ ◦
MDC95 6.51 7.68 6.65 7.12
e

CV (%) 16.15 13.53 16.02 15.31

f
◦ ◦ ◦ ◦
Rc 13.89 12.07 13.62 13.28
g
◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦
95% LOA -7.68 , 10.21 -9.63 , 7.04 -7.93 , 9.41 -9.42 , 8.84
h

Lateral flexion (Lt) ICC (95% CI ) 0.74 (0.50 , 0.86) 0.70 (0.44 , 0.84) 0.76 (0.54 , 0.87) 0.69 (0.42 , 0.84)
a b

◦ ◦ ◦ ◦
SEM 0.80 1.31 1.03 1.23
c

◦ ◦ ◦ ◦
2 SEMs 1.60 2.62 2.06 2.46
d

◦ ◦ ◦ ◦
MDC95 2.21 3.63 2.85 3.40
e

CV (%) 4.20 6.46 5.66 5.90

f

◦ ◦ ◦ ◦
Rc 4.38 6.79 5.89 6.15
g

◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦
95% LOA -3.31 , 2.19 -5.01 , 4.36 -4.04 , 3.49 -4.28 , 4.38
h

Lateral flexion (Rt) ICC (95% CI ) 0.71 (0.46 , 0.84) 0.66 (0.38 , 0.82) 0.78 (0.58 , 0.88) 0.69 (0.43 , 0.84)
a b

◦ ◦ ◦ ◦
SEM 1.54 1.76 1.42 1.46
c

◦ ◦ ◦ ◦
2 SEMs 3.08 3.52 2.84 2.92
d

◦ ◦ ◦ ◦
MDC95 4.26 4.87 3.93 4.04
e

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 CV (%) 7.94 8.39 8.14 7.08
f

◦ ◦ ◦ ◦
Rc 7.94 8.38 8.40 7.30
g

◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦
95% LOA -4.71 , 6.06 -5.30 , 6.74 -5.05 , 5.31 -4.66 , 5.52
h

Rotation (Lt) ICC (95% CI ) 0.75 (0.53 , 0.87) 0.71 (0.46 , 0.85) 0.70 (0.43 , 0.84) 0.62 (0.30 , 0.79)
a b

◦ ◦ ◦ ◦
SEM 4.34 4.27 3.54 4.51
c

◦ ◦ ◦ ◦
2 SEMs 8.68 8.54 7.08 9.02
d

◦ ◦ ◦ ◦
MDC95 12.02 11.83 9.81 12.50
e

CV (%) 12.22 11.04 9.23 10.41

f

◦ ◦ ◦ ◦
Rc 24.08 22.02 17.95 11.74
g

◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦
95% LOA -14.51 , 16.55 -15.67 , 14.48 -9.35 , 14.39 -12.61 , 17.53
h

Rotation (Rt) ICC (95% CI ) 0.83 (0.68 , 0.91) 0.73 (0.50, 0.86) 0.78 (0.59 , 0.88) 0.70 (0.44 , 0.84)
a b

◦ ◦ ◦ ◦
SEM 3.54 4.40 3.57 4.50
c

◦ ◦ ◦ ◦
2 SEMs 7.08 8.80 7.14 9.00
d

◦ ◦ ◦ ◦
MDC95 9.81 12.19 9.89 12.47
e

CV (%) 11.75 11.81 10.76 11.38

f

◦ ◦ ◦ ◦
Rc 23.79 23.49 21.17 22.80
g

◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦
95% LOA -13.14 , 13.03 -13.74 , 17.08 -10.88 , 14.40 -15.68 , 15.93
h

ICC: Intraclass correlation coefficient

a

CI: Confidence interval

b

SEM: Standard error of measurement

c

2 SEMs: Two standard errors of measurement

d

MDC95: Minimum detectable change at the 95% confidence level

e

CV: Coefficient of variation

f

Rc: Repeatability coefficient

g

95% LOA: 95% Limits of agreement

h

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Table 5. Inter-rater reliability of the UG and iPhone® app
UG iPhone® app
Lateral Lateral Lateral Lateral
Inter-rater Rotation Rotation Rotation Rotation
Flexion Extension flexion flexion Flexion Extension flexion flexion
reliability (Lt) (Rt) (Lt) (Rt)
(Lt) (Rt) (Lt) (Rt)
0.70 0.73 0.71 0.73 0.75 0.65 0.67 0.71 0.76 0.76 0.79
ICC (95%
a
0.72 (0.48
(0.44 , (0.49 , (0.45 , (0.50 , (0.53 , (0.35 , (0.38 , (0.39 , (0.56 , (0.55 , (0.61 ,
CI ) , 0.85)
b
0.85) 0.86) 0.84) 0.86) 0.87) 0.81) 0.82) 0.85) 0.87) 0.87) 0.89)
◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦
SEM 3.35 2.58 1.23 1.60 4.55 4.19 2.78 2.75 2.12 1.48 3.30 3.49
c

◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦
2 SEMs 6.70 5.16 2.46 3.20 9.10 8.38 5.56 5.50 4.24 2.96 6.60 6.98
c

◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦
MDC95 9.28 7.15 3.40 4.43 12.61 11.61 7.70 7.62 5.87 4.10 9.14 9.67
e

CV (%) 15.33 15.52 5.25 8.28 12.12 11.86 11.67 15.32 6.36 7.91 9.50 12.14
f

◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦
Rc 16.99 17.87 5.49 8.46 23.86 23.26 13.08 13.33 6.63 8.18 18.72 21.17
g

◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦
95% LOA -9.18 , -9.56 , -3.89 , -6.60 , -14.85 , -11.77 , -8.04 , -10.21 , -4.08 , -5.57 , -9.50 , -11.55 ,
h
◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦
13.47 8.83 4.10 5.71 17.12 17.06 10.89 8.97 3.50 4.88 13.37 13.73
ICC: Intraclass correlation coefficient
a

CI: Confidence interval

b

SEM: Standard error of measurement

c

2 SEMs: Two standard errors of measurement

d

MDC95: Minimum detectable change at the 95% confidence level

e

CV: Coefficient of variation

f

Rc: Repeatability coefficient

g

95% LOA: 95% Limits of agreement

h

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Table 6. Correlations between the UG and iPhone® app values
ROM measurements Pearson’s correlation coefficient (r)
Flexion 0.63
Extension 0.81
Lateral flexion (Lt) 0.72
Lateral flexion (Rt) 0.79
Rotation (Lt) 0.77
Rotation (Rt) 0.75

Table 7. The clinical importance of the differences in ACCROM values between the UG and
iPhone® app
ROM measurements Effect Size (Cohen’s d) 95% CIa
Flexion 0.02 -0.42 , 0.45
Extension 0.16 -0.27 , 0.60
Lateral flexion (Lt) 0.17 -0.27 , 0.61
Lateral flexion (Rt) -0.17 -0.61 , 0.27
Rotation (Lt) -0.12 -0.56 , 0.31
Rotation (Rt) 0.07 -0.36 , 0.51
CI: Confidence interval
a

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Figure 1.tif

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Figure 2.tif

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Figure 3.tif

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Figure 4.tif
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