title: Interrater and Intrarater Reliability in the Measurement of Kyphosis in Postmenopausal Women With Osteoporosis Prediction of thoracic kyphosis using the Debrunner kyphometer. Clinical measurement of the thoracic kyphosis. A study of the intra-rater reliability in subjects with and without shoulder pain A new skin-surface device for measuring the curvature and global and segmental ranges of motion of the spine: reliability of measurements and comparison with data reviewed from the literature Radiographic measures of thoracic kyphosis in osteoporosis: Cobb and vertebral centroid angles Development and validation of a discriminative quality of life questionnaire for osteoporosis (the OPTQoL). Measurement of Spinal Sagittal Configuration and Mobility with Debrunner's Kyphometer Reproducibility and repeatability: errors of three groups of physiotherapists in locating spinal levels by palpation. Reliability of photogrammetry in the evaluation of the postural aspects of individuals with structural scoliosis.
abstract: Study Design . A reliability study was performed using repeated r and om measurements involving three observers , 26 subjects and three instruments . Objectives . To determine the most reliable , cost‐effective , noninvasive , and clinical ly feasible method of measuring spinal kyphosis .  Summary of Background Data . The most clinical ly useful , noninvasive and reliable method of measuring postural deformity in spinal osteoporosis ( kyphosis ) remains unqualified . Despite traditional use of costly , invasive roentgenographs for the evaluation of spinal kyphosis , the reliability of this method remains question able . Methods . Twenty‐six postmenopausal women with known bone mineral density and a diagnosis of osteoporosis were recruited from the Osteoporosis Program at Women 's College Hospital , Toronto , Canada . Noninvasive measurements of thoracic kyphosis were obtained by three trained examiners using the DeBrunner 's kyphometer and the flexicurve ruler . The intrarater and interrater reliability of and between each method was compared , using roentgenographic films obtained in the sagittal plane . Spinal posture was classified according to the method of Itoi ( 1990 ) . Statistical computations were performed using SAS statistical software . Results . Consistent measurements were obtained with the  DeBrunner 's kyphometer  and the flexicurve ruler by each observer , according to the results of critical two‐way analysis of variance ( Intraclass Correlation Coefficient 2,1 ) . Measurements in two subgroups , healthy backs ( n = 11 ) and rounded backs ( n= 13 ) , showed consistent use of each noninvasive instrument with some examiner preference for specific tools . There was marginally better intrarater and interrater reliability using the DeBrunner 's kyphometer compared with that obtained with the flexicurve ruler . Two‐way analysis of variance ( Intraclass Correlation Coefficient 2,1 ) of collapsed data showed no significant difference in the reliability of the kyphometer , flexicurve ruler , or roentgenographs in the measurement of thoracic kyphosis . Conclusions . The flexicurve ruler and DeBrunner 's kyphometer had the closest agreement in the measurement of spinal kyphosis . The kyphometer demonstrated the least variation in intrarater and interrater reliability when compared with the flexicurve ruler and roentgenographs . The flexicurve ruler permits qualitative assessment of posture , however , and is the most costeffective instrument . The results of this study challenge the traditional belief that roentgenographic analysis is the best method for evaluating spinal kyphosis . The DeBrunner 's kyphometer and flexible ruler may represent viable , cost‐effective and noninvasive alternatives to roentgenographic evaluation of spinal kyphosis The Debrunner kyphometer is an accepted tool for detecting and evaluating  thoracic kyphosis .  This prospect i ve study was conducted to create a mathematical formula that provides , with high approximation , the roentgenographic angle of thoracic kyphosis ( T4-T12 ) using only the kyphometer . Several clinical ( kyphometer value , age , and sex ) and radiographic ( Cobb angle [ T4-T12 ] ) parameters from 90 consecutively screened adolescents ( 44 male and 46 female ) were correlated using simple and multiple linear regression analyses . The reliability of measurement using the Debrunner kyphometer was high . The kyphometer value was strongly correlated with the roentgenographically measured thoracic Cobb angle ( simple linear regression analysis ; probability range , 0.0026 to 0.0002 ) . There was no correlation between age or sex and thoracic kyphosis . The predicted kyphosis angle using the kyphometer and the mathematic formula was 44.66 degrees + /- 2.68 degrees , ( range 27 to 62 degrees ) , and the real roentgenographic kyphosis angle was 47.5 degrees + /- 3.53 degrees , ( range , 24 to 70 degrees ) . The kyphometer and formula were more reliable and accurate when kyphosis less than 50 degrees was measured . In this study , the authors constructed a mathematical formula that accurately provides the roentgenographic T4-T12 kyphosis angle in adolescents using only the Debrunner kyphometer with a deviation of less than 3 degrees . The authors recommend that all physicians engaged in kyphosis screening programs use the kyphometer combined with the recently constructed simple mathematic formula . This method will reduce the cost of school screening programs , overdiagnoses , and unnecessary exposure of adolescents to irradiation Background Clinical sagittal plane assessment of the thoracic kyphosis angle is considered an essential component of the postural examination of patients presenting with upper body pain syndromes . Cervical headaches and conditions involving the shoulder , such as subacromial pain syndrome , have all been associated with an increase in the thoracic kyphosis . Concomitantly a decrease in the thoracic kyphosis as a result of a stretching and strengthening rehabilitation programme is believed to be associated with a reduction in symptoms and pain and improvement in function . Clinicians generally measure the sagittal plane kyphosis angle visually . There is no certainty that this method is reliable or is capable of measuring angular changes over time or in response to intervention . As such a simple and reliable clinical method of measuring the thoracic kyphosis would enable clinicians to record this information . The aim of this investigation was to determine the intra-tester reliability of measuring the thoracic kyphosis angle using a clinical method Methods Measurements were made in 45 subjects with and 45 subjects without upper body symptoms . Measurements were made with the subjects in relaxed st and ing . Two gravity dependent inclinometers were used to measure the kyphosis . The first was placed over the region of the 1st and 2nd thoracic spinous processes . The other , over the region of the 12th thoracic and 1st lumbar spinous processes . The angle produced by each inclinometer was measured 3 times in succession . Each set of 3 measurements was made on two occasions ( separated by a minimum of 30 minutes and additional data collection involving 46 further measurements of posture and movement on the same and an additional subject before the thoracic kyphosis measurements were re-measured ) by one rater . The reliability of the measurements was analyzed using 2-way ANOVA intraclass correlation coefficients ( ICC ) , 95 % confidence intervals ( CI ) and st and ard error of measurement ( SEM ) for precision , for a single measurement [ ICC(single ) ] and the average of 3 measures [ ICC(average ) ] . The assessor remained ' blinded ' to data input and the measurements were staggered to reduce examiner bias . Results The measurement of the thoracic kyphosis as used in this investigation was found to have excellent intra-rater reliability for both subjects with and without symptoms . The ICC(single ) results for the subjects without symptoms were , .95 ; ( 95 % CI .91-.97 ) . The corresponding ICC(average ) results were ; .97 ; ( 95 % CI .95-.99 ) . The results for the subjects with symptoms were ; 93 ; ( 95 % CI .88-.96 ) , for ICC(single ) and for ICC(average ) ; .97 ; ( 95 % CI .94-.98 ) . The SEM results for subjects without and with symptoms were 1.0 ° and 1.7 ° , respectively . Conclusions The findings of this immediate test-retest reliability study suggest that the clinical measurement of the thoracic kyphosis using gravity dependent inclinometers demonstrates excellent intra-rater reliability . Additional research is required to determine the inter-rater reliability of this method .Trial registration National Research Register : There is an increasing awareness of the risks and dangers of exposure to radiation associated with repeated radiographic assessment of spinal curvature and spinal movements . As such , attempts are continuously being made to develop skin-surface devices for use in examining the progression and response to treatment of various spinal disorders . However , the reliability and validity of measurements recorded with such devices must be established before they can be recommended for use in the research or clinical environment . The aim of this study was to examine the reliability of measurements using a newly developed skin-surface device , the Spinal Mouse .  Twenty healthy volunteers ( mean age 41±12 years , nine males , 11 females ) took part . On 2 separate days , spinal curvature was measured with the Spinal Mouse during st and ing , full flexion , and full extension ( each three times by each of two examiners ) . Paired t-tests , intraclass correlation coefficients ( ICC ) , and st and ard errors of measurement ( SEM ) with 95 % confidence intervals were used to characterise between-day and interexaminer reliability for : st and ing sacral angle , lumbar lordosis , thoracic kyphosis , and ranges of motion ( flexion , extension ) of the thoracic spine , lumbar spine , hips , and trunk . The between-day reliability for segmental ranges of flexion was also determined for each motion segment from T1 - 2 to L5-S1 . The majority of parameters measured for the ‘ global regions ’ ( thoracic , lumbar , or hips ) showed good between-day reliability . Depending on the parameter of interest , between-day ICCs ranged from 0.67 to 0.92 for examiner 1 ( average 0.82 ) and 0.57 to 0.95 for examiner 2 ( average 0.83 ) ; for 70 % of the parameters measured , the ICCs were greater than 0.8 and generally highest for the lumbar spine and whole trunk measures . For lumbar spine range of flexion , the SEM was approximately 3 ° . The ICCs were also good for the interexaminer comparisons , ranging from 0.62 to 0.93 on day 1 ( average 0.81 ) and 0.70 to 0.94 on day 2 ( average 0.86 ) , although small systematic differences were sometimes observed in their mean values . The latter were still evident even if both examiners used the same skin markings . For segmental ranges of flexion , the ICCs varied between vertebral levels but overall were lower than for the global measures ( average for all levels in all analyses , ICC 0.6 ) . For each examiner , the average between-day SEM over all vertebral levels was approximately 2 ° . For ‘ global ’ regions of the spine , the Spinal Mouse delivered consistently reliable values for st and ing curvatures and ranges of motion which compared well with those reported in the literature . This suggests that the device can be reliably implemented for in vivo studies of the sagittal profile and range of motion of the spine . As might be expected for the smaller angles being measured , the segmental ranges of flexion showed lower reliability . Their usefulness with regard to the interpretation of individual results and the detection of ‘ real change ’ on an individual basis thus remains question able . Nonetheless , the group mean values showed few between-day differences , suggesting that the device may still be of use in providing clinical ly interesting data on segmental motion when examining groups of individuals with a given spinal pathology or undergoing some type of intervention ObjectiveS everal measures can quantify thoracic kyphosis from radiographs , yet their suitability for people with osteoporosis remains uncertain . The aim of this study was to examine the validity and reliability of the vertebral centroid and Cobb angles  in people with osteoporosis . Design and patients  Lateral radiographs of the thoracic spine  were captured in 31 elderly women with osteoporosis .  Thoracic kyphosis was measured globally ( T1–T12 ) and regionally ( T4–T9 ) using Cobb and vertebral centroid angles . Multisegmental curvature was also measured by fitting polynomial functions to the thoracic curvature profile . Canonical and Pearson correlations were used to examine correspondence ; agreement between measures was examined with linear regression . Results Moderate to high intra- and inter-rater reliability was achieved ( SEM = 0.9–4.0 ° ) . Concurrent validity of the simple measures was established against multisegmental curvature ( r = 0.88–0.98 ) . Strong association was observed between the Cobb and centroid angles globally ( r = 0.84 ) and regionally ( r = 0.83 ) . Correspondence between measures was moderate for the Cobb method r = 0.72 ) , yet stronger for the centroid method ( r = 0.80 ) . The Cobb angle was 20 % greater for regional measures due to the influence of endplate tilt . Conclusions Regional Cobb and centroid angles are valid and reliable measures of thoracic kyphosis in people with osteoporosis . However , the Cobb angle is biased by endplate tilt , suggesting that the centroid angle is more appropriate for this population We report the development and validation of an osteoporosis-targeted quality of life question naire to measure the impact of the disease in the general population . From multiple focus groups with women with osteoporosis , healthy women at risk for osteoporosis , spouses and relatives of women with osteoporosis , and health care providers , we identified over 300 potential items related to the disease . A lengthy question naire incorporated these items and was administered to a second large study cohort of 222 women with clinical osteoporosis ( history of fracture , significant height loss , and /or kyphosis ) ; 101 women with known low bone mineral density levels that would categorize them as osteoporotic but who had not yet shown obvious physical manifestations of the disease ; and 142 women with other conditions ( such as arthritis , cancer , depression ) expected to also have an impact on quality of life . Final items from among the original 300 were chosen for their demonstrated relationship with osteoporosis as measured by clinical manifestations and low bone density and with quality of life measured by a st and ard generic question naire , the SF-36 . The final question naire contains 26 scored items in three domains-physical activity , adaptations , and fears- and six nonscored questions relating to osteoporotic changes and diagnosis . This instrument is unique among osteoporosis-targeted question naires in that it attempts to measure the total impact of the disease on quality of life within a population at a single point in time A considerable number of instruments have been described for noninvasive measurements of the sagittal configuration and mobility of the thoracolumbar spine . With Debrunner 's kyphometer , it is possible to obtain this information in approximately 1 minute in a clinical setting . A minor modification of the kyphometer to increase its range of measurement of lumbar extension is described . Repeatability of measurements with the instrument was studied on 31 healthy individuals in a r and omized cross-over model . In another study , ten individuals were examined ten times each by the same investigator within 3 weeks . These studies showed good reproducibility for measurements with the  kyphometer .  The importance of st and ardized instructions for measurement procedures is emphasized . The statistical approach to repeatability of measurements is discussed Location of spinal levels by palpation is an essential part of physiotherapy assessment and treatment of spinal musculoskeletal conditions . This study aim ed to ( i ) investigate the reproducibility and repeatability of three groups of physiotherapists in locating three r and omly selected spinal levels by palpation , ( ii ) explore whether these groups were palpating similar points at each level , and ( iii ) investigate whether there were differences in palpation across the spinal levels tested . Reproducibility was estimated using a convenience sample of 30 physiotherapists : 13 undergraduate students , 10 clinicians , and seven manual therapists ( MTs ) . Repeatability was investigated using six physiotherapists ( two students , two clinicians and two MTs ) . Each therapist palpated the spinous processes ( C5 , T6 , L5 ) once for reproducibility , and 10 times for repeatability , on each asymptomatic model . The skin overlying the spinal levels was marked with an invisible pen . Using an ultra-violet light , marks were transcribed onto transparent plastic strips for analysis , and the distances were measured with an electronic caliper . Repeated measures analyses of variance ( ANOVA ) indicated poor reproducibility across therapists at all spinal levels ( F=18.43 , P=0.001 ) , but good repeatability within therapists ( F=2.09 , P=0.161 ) . Students produced different mean locations of their palpatory marks from the other two groups in two spinal levels . Clinicians and MTs were more reproducible than students , and located similar levels . Palpation of L5 spinous process presented the most difficulty , for all groups . Further research is needed to compare different methods of palpation and explore whether reproducibility can be improved PURPOSE The purpose of this study was to investigate the reliability of photogrammetry in the measurement of the postural deviations in individuals with idiopathic scoliosis . METHODS Twenty participants with scoliosis ( 17 women and three men ) , with a mean age of 23.1 ± 9 yrs , were photographed from the posterior and lateral views . The postural aspects were measured with CorelDRAW software . RESULTS High inter-rater and test-retest reliability indices were found . It was observed that with more severity of scoliosis , greater were the variations between the thoracic kyphosis and lumbar lordosis measures obtained by the same examiner from the left lateral view photographs . A greater body mass index ( BMI ) was associated with greater variability of the trunk rotation measures obtained by two independent examiners from the right , lateral view ( r = 0.656 ; p = 0.002 ) . The severity of scoliosis was also associated with greater inter-rater variability measures of trunk rotation obtained from the left , lateral view ( r = 0.483 ; p = 0.036 ) . CONCLUSIONS Photogrammetry demonstrated to be a reliable method for the measurement of postural deviations from the posterior and lateral views of individuals with idiopathic scoliosis and could be complementarily employed for the assessment procedures , which could reduce the number of X-rays used for the follow-up assessment s of these individuals
target: The strongest levels of evidence for reliability exists in support of the Debrunner kyphometer , Spinal Mouse and Flexicurve index , and for validity supports the arcometer and Flexicurve index .
background: BACKGROUND A wide array of instruments are available for non-invasive thoracic kyphosis measurement .
  Guidelines for selecting outcome measures for use in clinical and research practice recommend that properties such as validity and reliability are considered .
  This systematic review reports on the reliability and validity of non-invasive methods for measuring  thoracic kyphosis .