Journal of Orthopaedic & Sports Physical Therapy

Official Publication of the Orthopaedic and Sports Physical Therapy Sections of the American Physical Therapy Association
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Christos Karagiannopoulos, MPT, MEd, ATC 1 Michael Sitler, EdD, ATC 2 Shipping/Billing Information 3 Susan Michlovitz, PT, PhD, CHT

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Reliability of 2 Functional Goniometric Methods for Measuring Forearm Pronation And Supination Active Range of Motion
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Name _______________________________________________________________________________________________ Address _____________________________________________________________________________________________ Address Design: Test-retest reliability study. Study _____________________________________________________________________________________________ important for clinical identificaObjectives: To determine intra- and intertester reliability of the hand-held pencil (HHP) and the tion City _______________________________State/Province __________________Zip/Postal of impairments, functional Code _____________________ plumbline goniometer (PLG) methods for measuring active forearm pronation and supination limitations, and monitoring effimotions in individuals with and without injuries. cacy of interventions during the Phone _____________________________Fax____________________________Email _____________________________ Background: The distal forearm method has been considered the gold standard for measuring rehabilitation process.6 forearm pronation receive JOSPT email updates and renewal notices? Would you like to and supination motion. The HHP and PLG, however, are 2 more functional I No I Yes The distal forearm method is methods for measuring forearm motions, though limited information on the psychometric the most common measurement properties of these tests is currently available. Methods and Measures: Intra- and intertester reliability of the HHP and PLG methods were technique used and is considered Payment Information convenience (20 injured and 20 noninjured). Two testers performed 3 the gold standard for measuring determined in 40 subjects of repeated measurements for each motion and method on all subjects. Intraclass correlation pronation and supination AROM.5 I coefficients (ICC for intratester reliability, ICC for intertester reliability) and standard error of Check enclosed (made payable to the JOSPT). 3,1 2,3 This method consists of aligning a measurements (SEMs) were determined. I Credit Card (circle one) MasterCardpronation and supination using the HHP and PLG goniometers stationary arm paralVISA American Express Results: The ICCs for the measurements of lel to the humerus anterior methods were high (range, 0.86-0.98) for individuals with and without injuries, with the reliability midline while the moving arm is Card Number ___________________________________Expiration for the _________________________________________ for the PLG method being equal or slightly greater than the HHP method Date majority of placed on the volar or dorsal distal pronation and supination measurements. Intratester ICCs were higher (SEMs were conversely 14 A limitation of the Signature ______________________________________Date __________________________________________________ lower) than intertester ICCs for nearly all measurements. The ICC values were generally the same forearm. distal forearm method is that it or higher for individuals with injuries compared to individuals without injuries. Conclusions: The HHP and PLG are highly reliable methods for measuring functional forearm requires measuring pronation and pronation and supination. Because plumbline To order are not commercially available and the supination AROM in a nonfuncgoniometers call, fax, email or mail to: instrumentation for the HHP method is readily accessible, clinicians should consider the latter as tional manner,5 as it does not 1111 North forearm Street, and supination. J Orthop Sports simulate their method of choice for measuring functional Fairfax pronationSuite 100, Alexandria, VA 22314-1436 many manual activities of Phys Ther 2003;33:523-531. Phone 877-766-3450 Fax 703-836-2210 Email: subscriptions@jospt.org daily living that combine forearm rotation and hand use. Current Key Words: goniometry, radioulnar joints, upper extremity Thank you for subscribing! clinical standards stress the use of functional methods for measuring he amount of active range of motion (AROM) for forearm and restoring physical capacity. Aspronation and supination can be altered by disruption of sessment of functional pronation the radioulnar and radiocarpal joints biomechanics result- (eg, pronation combined with ing from trauma and inflammatory processes.8 Reliable gripping) and supination AROM methods for assessing pronation and supination AROM are should include methods that measure concurrent radioulnar joint ro1 Senior Physical Therapist, Temple University Physical Therapy, Temple University Hospital, Philadel- tation (proximal and distal) and phia, PA. accessory wrist motion4,10 at the 2 Chair, Department of Kinesiology, Temple University, College of Education, Philadelphia, PA. 5 3 Professor, School of Physical Therapy, Temple University, College of Health Professions, Philadelphia, radiocarpal and midcarpal joints. The hand-held pencil (HHP) PA. Work for this study was done in partial fulfillment of the requirements for the degree Master of Education. and plumbline goniometer (PLG) The research protocol was approved by the Institutional Review Board of Temple University. Send correspondence to Christos Karagiannopoulos, Temple University Hospital, Outpatient Building, 5th are the only 2 reported assessment methods that present the potential Floor, 3401 North Broad Street, Philadelphia, PA 19140. E-mail: karagianopou@netcarrier.com

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for measuring functional pronation and supination. The HHP method, which was first described by McRae13 and later modified by Clarkson and Gilewich,3 consists of measuring pronation and supination with the goniometer aligned with a pencil held in the hand of the person being measured. The PLG method, which was first described by Flowers et al,5 consists of measuring pronation and supination with a plumb line attached to a hand-held single-arm goniometer. Limited psychometric testing has been conducted on the 3 aforementioned methods of measuring active and passive range of motion of the forearm in pronation and supination. Intra- and intertester reliability for measurements using the distal forearm method in subjects with injuries range from 0.79 to 0.98.1,5 Neither intra- nor intertester reliability has been reported for the HHP method. Intratester reliability for the measurement of passive pronation and supination range of motion has been reported (ICC = 0.87 and 0.95) for the PLG method but for subjects with injuries only.5 The purpose of this study was to determine the intra- and intertester reliability of the HHP and PLG methods for measuring active forearm pronation and supination in individuals with and without injuries. The outcome of this study is intended to improve clinical examination technique by determining the reliability of 2 functional methods for assessing forearm motion.

METHODS Research Design

Two testers performed 3 measurements of pronation and supination with both methods within a single testing session. The independent variables were measurement method (HHP and PLG), tester (1 and 2), motion (pronation and supination), and group (injured and noninjured). The dependent variable was AROM.

Subjects
Two independent groups of subjects participated in the study. The first group consisted of a sample of convenience of 20 subjects with recent injuries (10 males, 10 females) who were on average ( SD) 51 14.5 years of age (range, 31-80 years). This group was used to determine the intra- and intertester reliability of the HHP and PLG methods in a population with injuries. The subjects in this group were patients at Temple University Department of Orthopaedic Surgery and Sports Medicine at Northeastern Hospital and were seen within 1 to 10 weeks following forearm immobilization due to hand, wrist, forearm, or elbow trauma (Table 1). Exclusion criteria were: neurological pathologies resulting in paralysis or paresis of the arm; pain or deformity secondary to rheumatoid disease; hand, wrist, forearm, or elbow musculoskeletal injuries not treated via immobilization; and inability to touch the distal palmar crease with the tips of the second through the fifth digits

TABLE 1. Diagnoses and demographics of subjects with injuries. Subject Number 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Abbreviations: M, male; F, female; L, left; R, right. Sex F M M M F M F M F F M M M F M F M F F F Age (y) 49 36 39 33 56 44 38 71 80 37 31 57 38 65 60 50 54 59 77 46 Diagnosis R elbow epicondylectomy L distal humerus fracture R radial head fracture L proximal ulnar fracture L radial head fracture R lateral epicondyle release L distal radius fracture L scapholunate ligament repair R distal radius fracture L radial head fracture R scaphoid fracture R distal radius fracture R distal radius fracture L metacarpal fracture L scaphoid fracture R lateral epicondyle fracture L distal radius fracture L metacarpal fracture L distal radius fracture L distal radius fracture

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when making a full fist. The full-fist criterion was required for testing for both measurement methods. The second group consisted of a sample of convenience of 20 subjects without injuries (8 males, 12 females), who were on average ( SD) 41 13 years of age (range, 20-74 years). This group was used to determine the intra- and intertester reliability of the HHP and PLG methods in a population without injuries. All subjects were employees or patients at the aforementioned medical facility. The exclusion criteria were limited to the neurological pathologies, rheumatoid disease complications, and upperextremity musculoskeletal injuries as identified for the subjects with injuries. The study was approved by the Temple University Institutional Review Board. Subjects read and signed an informed consent prior to participating in the study.

Instrumentation
Data Recording Forms A demographic data form was used to collect subject age, sex, hand dominance, and presence of inclusion and exclusion criteria information. Hand dominance was determined via the modified Edinburgh Handedness Inventory,2 a 5-item questionnaire based on writing, throwing, drawing, scissor use, and toothbrush use. Dominance was defined as the hand with the highest number of positive responses. A separate form was used to record the pronation and supination AROM values measured for the HHP and PLG methods. Data were recorded for each subject and each tester on a separate form to minimize tester bias. Hand-Held Universal Goniometer A plastic goniometer (AliMed, Dedham, MA) with a central 360 scale in

FIGURE 1. Plumbline goniometer.

5 increments, and two 14.5-cm-long arms were used for the HHP method. One side of the goniometers central scale was covered with white adhesive paper to minimize tester bias during each measurement. The same goniometer was used for all HHP measurements for both testers. A 5 increment goniometer was selected due to its common use in the clinical setting and the fact that measurement fluctuation of up to 5 is usually expected and attributed to instrument error.12 Plumbline Goniometer A 14.5-cm-long single-arm plastic goniometer with a plumbline attached to the center of its 360 central scale5 was used for the PLG method (Figure 1). The central scale of the plumbline goniometer had identical degree increments as the central scale of the HHP goniometer. The string of the plumbline was free to move about its axis of rotation at the center of the goniometers central scale. A 2.54-cm-diameter tubular handle was attached at the goniometers midpoint at a 90 angle. This angle allowed the plumbline goniometer to be positioned horizontally over the radial aspect of the hand while the subject held the tubular handle. The same plumbline goniometer was used for all PLG measurements for both testers. HHP Goniometric Measurement Method Pronation and supination AROM using the HHP method were measured via a standardized testing protocol as described by Clarkson and Gilewich.3 Measurements were conducted with each subject seated in an armless chair in a comfortable erect position with hips and knees flexed to 90, feet flat on the floor, ipsilateral arm fully adducted to the side, and elbow flexed to 90. The forearm was unsupported and placed in a neutral position (ie, forearm horizontal to the floor, palmar aspect of the hand facing medially with the thumb directed upwards) (Figure 2). For this method, each subject held a 15-cm-long pencil in a tight full fist. The pencil extended from the radial aspect of the subjects hand. The goniometer was positioned as follows: axis aligned with the head of the third metacarpal, stationary arm perpendicular to the floor, and movement arm parallel to the pencil (Figure 2). The goniometers central scale was positioned with its covered side facing the tester. When the patient reached maximum active pronation or supination, the tester aligned the goniometers movement arm parallel to the pencil while the axis and stationary arms remained at their initial positions (Figure 3). Then, the tester turned the goniometer and read the exposed side of its central scale. All pronation and supination AROM measurements were taken with reference to the neutral, or 0, position. Measurements were rounded to the closest 5 increment (eg, 5, 10, 15).11 The goniometer was repositioned to 0 prior to each measurement. Goniometric measurements were repeated 3 times each for pronation and supination.
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Procedures
After completion of the demographic data form, subjects were stratified into 1 of 2 groups (noninjured or injured). Order of testing for measurement method (HHP and PLG) and motion (supination and pronation) were randomized by coin flip within each group for each subject. All subjects were measured by 2 testers, and the order of testing for the testers was also randomized. The testers were 2 male physical therapists with 2 and 4 years of professional experience and no prior clinical exposure to the HHP and PLG methods. Testers were formally trained on each method and practiced each method on 10 subjects without injuries prior to the study. For the subjects with injuries, measurements were taken on the injured arm. For subjects without injuries, measurements were taken on the dominant arm. Subjects were positioned as aforementioned and asked to turn their palms towards the floor as far as possible prior to each pronation measurement, and turn their palms towards the ceiling as far as possible prior to each supination measurement. Testers used the same instrument for each method to complete all measurements. Each tester read and recorded his own goniometric measurements in separate recording forms. Privacy of each testers recording form was ensured during measurements to prevent tester bias. Three repeat measures were completed on each

FIGURE 2. Neutral forearm position for the hand-held pencil method.

PLG Goniometric Measurement Method Pronation and supination AROM using the PLG method were measured via a standardized testing protocol as described by Flowers et al.5 Measurements were conducted with each subject seated in the same position as for the HHP method. Each subject held the plumbline goniometer by its tubular handle in a tight full fist (Figure 4). The tester rotated the goniometer handle in the subjects hand to a horizontal position, allowing the plumbline to make full contact with the goniometers central scale. All pronation and supination AROM measurements were taken with reference to the neutral, or 0, position (Figure 4). The plumbline was placed medial to the hand for the measurement of pronation and lateral to the hand for supination. A measurement was taken when the subject reached maximum active pronation or supination with the plumbline lying flush on the surface of the goniometers central scale without oscillating (Figure 5). The tester manually stopped any oscillatory movements of the plumbline prior to reading the value. Goniometric measurements were repeated 3 times each for pronation and supination.
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FIGURE 3. Measurement of active range of motion in supination with the hand-held pencil method.

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TABLE 2. Descriptive statistics for measurement of active range of motion (in degrees) of the forearm with the hand-held pencil and plumbline goniometer techniques. Values are based on the average of trial 2 and 3 made by each tester. HHP Motion Pronation Tester 1 2 Supination 1 2 Group IG NIG IG NIG IG NIG IG NIG Mean SD 76 12 79 10 78 10 79 8 81 16 103 10 80 14 101 11 Range 48-100 55- 95 55- 98 60- 90 50-110 90-128 55-108 88-125 Mean SD 76 15 78 11 75 11 78 9 82 16 104 12 80 14 101 11 PLG Range 43-100 53-100 48- 95 55- 90 50-115 90-130 55-115 88-125

Abbreviations: HHP, hand-held pencil; PLG, plumbline goniometer; IG, injured group (n = 20); NIG, noninjured group (n = 20).

subject by both testers within the same test session. The testers visually inspected the subjects body positions prior to and during each trial to ensure proper body and arm alignment. The same type of chair was utilized for all measurements.

Data Analysis
Intraclass correlation coefficients (ICC) and standard error of measurements (SEM) were used to determine the intra- and intertester reliability of the HHP and PLG methods. ICC3,1 was used to calculate the intratester reliability for each tester, and ICC2,3 was used to calculate the intertester reliability.16 ICC calculations were based on the 20 subjects for each reliability measure. From the 3 trials for each motion, the second and third trials of both testers were used to calculate the intratester reliability for each method. The mean value from the 3 trials of each tester was used in the intertester reliability analysis for each method. The Statistical Package for Social Sciences for Windows 10.1 (SPSS, Inc., Chicago, IL) was used to analyze the data. ICC values were interpreted as follows: equal to or greater than 0.75 were classified as high, 0.40 to 0.75 were classified as moderate, and below 0.40 were classified as poor.1,9,16

the lowest ICC value (highest SEM value). The PLG had the same or lower SEM values than the HHP within testers but higher between testers. Intratester ICCs were higher (SEMs were conversely lower) than intertester ICCs (SEMs were conversely higher) for both goniometric measurement methods except HHP pronation measurement for tester 2.

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RESULTS
Descriptive statistics for pronation and supination AROM using the HHP and PLG methods for each tester are reported in Table 2. These values are based on the average of trial 2 and 3 made by each tester.

Subjects With Injuries

The intra- and intertester ICC and SEM values for pronation and supination AROM for the HHP and PLG methods for the subjects with injuries are reported in Tables 3 and 4, respectively. ICC values for the 2 methods ranged from 0.92 to 0.98. SEM values ranged from 1.4 to 3.6. The PLG method had the same or higher ICC values than the HHP method except for intertester pronation, which had

FIGURE 4. Neutral forearm position for the plumbline method.

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values ranged from 1.4 to 3.9. No consistent pattern of differences existed in the ICC and SEM values of the PLG and HHP methods for intra- and intertester measurements. The highest SEM value existed in the HHP intertester supination measurement. Intratester ICCs were higher (SEMs were conversely lower) than intertester ICCs (SEMs were conversely higher) for both goniometric measurement methods except for the HHP pronation and PLG supination measurements for tester 2.

Comparison Between Subjects With and Without Injuries

Intra- and intertester ICC values were the same or higher for the individuals with injuries compared to individuals without injuries, except for HHP pronation for tester 1. The same was not true for SEM values, which did not display a consistent relationship between the 2 groups.

DISCUSSION
The forearm and wrist constitute a multi-joint system which primary function is to position the hand in space during pronation and supination. A variety of assessment instruments to measure forearm pronation and supination have been used in the clinical setting.4,7,13,15 The HHP3 and PLG5 methods allow for functional measurement of forearm pronation and supination AROM but have not been thoroughly assessed for psychometric properties. Establishing psychometric properties of these methods for individuals with and without injuries provides important information useful for clinical practice and future research. There is no previous reliability study that has presented such a comparison in measuring active range of motion for pronation and supination. For individuals with and without injuries alike, the HHP and PLG methods produced high16 pronation and supination intra- and intertester ICC values (range, 0.86-0.98). A comparison of the 2 methods revealed that the PLG had the same or slightly higher ICC values than the HHP method for all measurements except for intertester pronation

FIGURE 5. Measurement of active range of motion in pronation for the plumbline method.

Subjects Without Injuries

The intra- and intertester ICC and SEM values for pronation and supination AROM for the HHP and PLG methods for the subjects without injuries are reported in Tables 3 and 4, respectively. ICC values for the 2 methods ranged from 0.86 to 0.98. SEM

TABLE 3. Intratester pronation and supination intraclass correlation coefficients and standard error of measurements (in degrees) of each tester for subjects with and without injuries. Pronation Tester 1 Group Injured Noninjured Method HHP PLG HHP PLG ICC 0.97 0.98 0.98 0.97 SEM 2.0 1.8 1.4 2.0 ICC 0.95 0.96 0.86 0.95 Tester 2 SEM 2.2 2.1 2.8 1.8 ICC 0.98 0.98 0.96 0.98 Tester 1 SEM 2.1 2.1 2.1 1.5 ICC 0.98 0.98 0.96 0.94 Supination Tester 2 SEM 1.9 1.4 2.2 2.6

Abbreviations: ICC, intraclass correlation coefficients; SEM, standard error of measurements; HHP, hand-held pencil; PLG, plumbline goniometer.

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TABLE 4. Intertester pronation and supination intraclass correlation coefficients and standard error of measurements (in degrees) for subjects with and without injuries. Pronation Group Injured Noninjured Method HHP PLG HHP PLG ICC 0.95 0.92 0.92 0.91 SEM 2.4 3.6 2.4 3.0 ICC 0.96 0.96 0.94 0.96 Supination SEM 2.9 3.0 3.9 2.2

Abbreviations: HHP, hand-held pencil; PLG, plumbline goniometer; ICC, intraclass correlation coefficients; SEM, standard error of measurements.

in both groups, and for intratester pronation (tester 1) and intratester supination (tester 2) in subjects without injuries. The slightly higher PLG ICCs could be attributed to instrument and methodology differences between the 2 methods. The HHP required tester identification of bony landmarks and goniometer alignment, whereas the PLG method did not. The PLG method consisted of rotation of the hand-held instrument by the subject and tester assessment of joint motion via the constant gravitational force line of the plumbline. Because the gravitational force line is always perpendicular to the ground, the PLG method negated the testers dual responsibility of aligning and reading the goniometer during a measurement. It would be expected that the aforementioned instrumentation differences would lead to higher ICC values for all conditions. Therefore, the reason for the same or higher intra- and intertester ICC values with the HHP method for forearm pronation and supination in both groups is not clear. In general, the higher the ICC value the lower the SEM value. Such an inverse relationship between ICC and SEM values is expected, as measurements of greater reliability are associated with lower experimental error. This inverse relationship between ICC and SEM values was consistently seen among all subjects except for intra- and intertester supination measurements for the subjects with injuries. Such findings may be attributed to the greater range of motion variability among the subjects with injuries, as indicated by the larger standard deviation values. Intratester ICCs were higher (SEMs were conversely lower) than intertester ICCs (SEMs were conversely higher) for both measurement methods among all subjects, except for the intratester HHP pronation and PLG supination measurements (tester 2) for subjects without injuries. No study to date has reported on the differences between intra- and intertester reliabilities for assessing functional pronation and supination AROM. Armstrong et al1 reported higher intra- than intertester reliability for active pronation and supination AROM measurements using the distal forearm method. Horger9 also reported higher intra- than intertester reliability for measurements of range of motion for active wrist flexion, extension, and radial and ulnar deviations

when using a universal goniometer. These findings were anticipated because a lower error of measurement is typically associated with repeated measurements conducted by a single rather than multiple testers.6 The ICC values obtained on the measurements made on the subjects with injuries were the same or higher than the ICC values obtained on the subjects without injuries, except for the measurement of HHP pronation for tester 1. This result was not anticipated as greater measurement variability and error was expected in subjects with injuries. Rothstein et al17 reported high ICC values (range, 0.90-0.96) for elbow flexion and extension AROM in subjects with injuries, but did not include subjects without injuries in their study. No study to date has determined reliability differences between subjects with and without injuries for any upper- or lower-extremity goniometric assessment. Because ROM measurement reliability depends on factors such as patient population and type of injury,6 comparisons between noninjured and injured populations should be joint or injury specific prior to making generalizations for clinical practice. In contrast to the ICC findings, the SEM values followed an inconsistent relationship between subjects with and without injuries. SEM values for subjects with injuries were higher than for the subjects without injuries for all PLG measurements, except for the measurement of pronation for tester 1 and supination for tester 2. SEM values for subjects without injuries were the same or higher than for the subjects with injuries for all HHP measurements, except for measurements of pronation for tester 1. This result was not anticipated because measurement error would be more difficult to control for subjects with injuries than for subjects without injuries. Accordingly, greater measurement error was expected among the subjects with injuries regardless of measurement method. In our study, potential sources of experimental error included lack of standardization for pain and assessment time postimmobilization, lack of control of subjects clothing, using a goniometer with 5 scale increment, which was not calibrated prior to measurements. Typically, AROM measurements with a 1 scale increment goniometer eliminate the need for estima529

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tion of readings over a 5 interval and are expected to have lower SEM values than measurements with a 5 scale increment goniometer. Interestingly, our studys forearm AROM measurements obtained with a 5 scale increment goniometer resulted in lower SEM values (range, 1.4-3.0) than the SEM values reported by Horgen9 (range, 2.5-7.0) for wrist AROM measurements obtained via a 1 scale increment goniometer in subjects with injuries. Although we believe that masking the HHP method goniometer and recording AROM values in separate forms for each tester during measurements provided adequate blinding in this study, a doubleblind study design would have offered lower threat to intratester reliability. Not covering the dial of the plumbline goniometer was not considered a threat to intratester reliability of the PLG method in this study because AROM was controlled by the subject and measurement simply consisted of only reading without aligning the goniometer by the tester. In addition, subjects were not allowed to look at the goniometer and verbal instructions to each subject were standardized to avoid coaching the subject to the previous angle during PLG measurements. The quality of this studys intertester reliability values was protected by having testers blinded to each others results by using separate recording forms and ensuring the privacy of these forms during measurements. A final limitation of this study was the lack of significant AROM restriction found among the individuals with injuries. Such a limitation may have decreased the anticipated higher measurement variability and experimental error among subjects with injuries. In the current study, pronation values (mean SD) obtained with the HHP and PLG methods for subjects without injuries were 79 8 and 78 9, respectively. Glanville and Kreezer7 and Darcus and Salter4 reported functional pronation values of 91 26 and 63 10, respectively, for subjects without injuries. The values for forearm supination obtained with the HHP and PLG methods in the current study were 103 10 and 104 12, respectively. These values were similar to those reported by both Glanville and Kreezer7 (99 11) and Darcus and Salter4 (102 11) for subjects without injuries. Variability in functional pronation AROM among these studies is attributed to differences in instrumentation (eg, handle size, grip force), age, and subject sampling (eg, random, subjects of convenience, sex). Current clinical standards require the use of functional methods for measuring and restoring patients physical capacities. In an attempt to improve the clinical examination technique of functional forearm motion, this studys outcome supports the clinical use of both the HHP and PLG methods. Although both methods seem to be reliable, at present, the HHP method is a more accessible and cost-effective instru530

mentation for todays clinical settings. A future multicenter reliability study that compares todays gold standard distal forearm method to either the HHP or PLG method on a larger sample of subjects with injuries using multiple measurement sessions may offer a greater external validity of results and finally answer, once and for all, the question of which method (nonfunctional versus functional) is the most reliable for measuring forearm pronation and supination.

CONCLUSIONS
Results of this study demonstrated that the HHP and PLG methods have both high intra- and intertester reliability for measuring forearm pronation and supination AROM in subjects with and without injuries. The slightly higher reliability of the PLG method is offset by the simplicity and availability of the instrumentation needed for the HHP method. Because plumbline goniometers are not commercially available and the instrumentation for the HHP is readily accessible in the clinical setting, the latter should be considered the method of choice by clinicians for measuring functional forearm pronation and supination.

ACKNOWLEDGMENTS
Thanks to Matthew Spiegler, MPT, who so diligently offered his substantial participation in the data collection process of this study.

REFERENCES
1. Armstrong AD, MacDermid JC, Chinchalkar S, Stevens RS, King GJ. Reliability of range-of-motion measurement in the elbow and forearm. J Shoulder Elbow Surg. 1998;7:573-580. 2. Bryden MP. Measuring handedness with questionnaires. Neuropsychologia. 1977;15:617-624. 3. Clarkson HM, Gilewich GB. Musculoskeletal Assessment: Joint Range of Motion and Manual Muscle Strength. Baltimore, MD: Williams and Wilkins; 1989. 4. Darcus HD, Salter N. The amplitude of pronation and supination with the elbow flexed to a right angle. J Anat. 1953;87:169-184. 5. Flowers KR, Stephens-Chisar J, LaStayo P, Galante BL. Intrarater reliability of a new method and instrumentation for measuring passive supination and pronation: a preliminary study. J Hand Ther. 2001;14:30-35. 6. Gajdosik RL, Bohannon RW. Clinical measurement of range of motion. Review of goniometry emphasizing reliability and validity. Phys Ther. 1987;67:1867-1872. 7. Glanville AD, Kreezer G. The maximum amplitude and velocity of joint movements in normal male human adults. Hum Biol. 1937;9:197-211. 8. Graham TJ, Fischer TJ, Hotchkiss RN, Kleinman WB. Disorders of the forearm axis. Hand Clin. 1998;14:305316. 9. Horger MM. The reliability of goniometric measurements of active and passive wrist motions. Am J Occup Ther. 1990;44:342-348.

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10. Linscheid RL. Kinematic considerations of the wrist. Clin Orthop. 1986;27-39. 11. Low JL. The reliability of joint measurement. Physiotherapy. 1976;62:227-229. 12. Mayerson NH, Milano RA. Goniometric measurement reliability in physical medicine. Arch Phys Med Rehabil. 1984;65:92-94. 13. McRae R. Clinical Orthopaedic Examination. Edinburgh, UK: Churchill and Livingstone; 1981. 14. Norkin CC, White DJ. Measurement of Joint Motion: A Guide to Goniometry. Philadelphia, PA: FA Davis; 1985.

15. Patrick J. A study of supination and pronation with especial reference of the treatment of forearm fractures. J Bone Joint Surg Am. 1946;28:737-748. 16. Portney LG, Watkins MP. Foundations of Clinical Research: Applications to Practice. Norwalk, CT: Appleton and Lange; 1993. 17. Rothstein JM, Miller PJ, Roettger RF. Goniometric reliability in a clinical setting. Elbow and knee measurements. Phys Ther. 1983;63:1611-1615.

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