Authors:

Sophie Louise Vohralik, BAppSc

(Physiotherapy)(Hons) Measurement
Annika Rose Bowen, BAppSc
(Physiotherapy)(Hons)
Joshua Burns, BAppSc
(Podiatry)(Hons), PhD
Claire Elizabeth Hiller, BAppSc
(Physiotherapy), MAppSc, PhD
BRIEF REPORT
Elizabeth Jean Nightingale, BAppSc
(Physiotherapy), MBiomedE, PhD

Affiliations:
From the Arthritis and Musculoskeletal
Research Group, Faculty of Health
Sciences, The University of Sydney,
Cumberland Campus, Lidcombe (SLV,
ARB, JB, CEH, EJN); and Paediatric
Gait Analysis Service of New South
Wales, The Children’s Hospital at
Westmead, Westmead, Australia (JB).
Correspondence:
All correspondence and requests for
reprints should be addressed to:
Elizabeth Jean Nightingale,
BAppSc(Physiotherapy), MBiomedE,
PhD, Faculty of Health Sciences,
University of Sydney, 75 East St,
Lidcombe, New South Wales 2141,
Australia.
Disclosures:
Sophie Louise Vohralik,
BAppSc(Physiotherapy)(Hons), and
Annika Rose Bowen,
BAppSc(Physiotherapy)(Hons), are
joint first authors.
Financial disclosure statements have
been obtained, and no conflicts of
interest have been reported by the
authors or by any individuals in control
of the content of this article.
0894-9115/15/9404-0325
American Journal of Physical
Medicine & Rehabilitation
Copyright * 2014 Wolters Kluwer
Health, Inc. All rights reserved.
DOI: 10.1097/PHM.0000000000000221
Reliability and Validity of a
Smartphone App to Measure
Joint Range
ABSTRACT
Vohralik SL, Bowen AR, Burns J, Hiller CE, Nightingale EJ: Reliability and validity
of a smartphone app to measure joint range. Am J Phys Med Rehabil
2015;94:325Y330.
In clinical and research settings, objective range of motion measurement is an es-
sential component of lower limb assessment and treatment evaluation. One reliable
tool is the digital inclinometer; however, availability and cost preclude its widespread
use. Smartphone apps are now widely available, allowing smartphones to be used
as an inclinometer. Reliability and validity studies of new technologies are scarce.
Intrarater and interrater reliability of the iHandy Level app installed on a smartphone
and an inclinometer were assessed in 20 participants for ankle dorsiflexion using
a weight-bearing lunge test. Criterion validity was assessed between a Fastrak and
the app, and construct validity was assessed between the inclinometer and the app.
Intraclass correlation coefficients2,1 demonstrated excellent intrarater and interrater
reliability (intraclass correlation coefficient, 0.97 and 0.76, respectively). Tests of
validity demonstrated excellent correlation between all three methods (r 2 9 0.99).
The smartphone app is both reliable and valid, provides a low-cost method of mea-
suring range of motion, and can be easily incorporated into clinical practice.
Key Words: Range of Motion, Ankle Joint, Measurement Accuracy, Biomedical
Technology, Cellular Phone
BACKGROUND
Accurate measurement of joint range of motion is often required in bio-
mechanical research and clinical practice. One of the most reliable tools to
measure joint range is the digital inclinometer1,2; however, accessibility and cost
often preclude its use. Several methods have been reported in the literature
for measuring joint range, such as video-based three-dimensional kinematics,3
Fastrak,4,5 goniometers,2,3,6Y8 and digital inclinometers.2,3,7,9
Considering just ankle dorsiflexion range, only the reliability of digital in-
clinometer measurements has been considered to date.1Y3,7,9 The validity of digital
inclinometer measurements is really considered only in cervical spine and shoulder
measurement, in which the large range of motion across multiple planes can alter
the values obtained considerably.10,11 With the advent of the smartphone, there are
now many free applications (apps) available (e.g., the TiltMeter, Clinometer, and

www.ajpmr.com A Smartphone App to Measure Joint Range 325

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

 Inclinometer) allowing the smartphone to be used as
an inclinometer. An inclinometer is popular because
it is easy to use and requires just one standardized
point for testing compared with a goniometer or
more complex biomechanical instruments such as
the Fastrak. The inclinometer (approximately $620),
despite its relative cost savings compared with bio-
mechanical instruments (9$5000), is often still
regarded as too expensive for the clinical setting.
Therefore, cost or impracticalities preclude many of
these devices being used routinely. The aim of this
study was to evaluate the reliability and validity of
a free smartphone inclinometer app, the iHandy
Level, for ankle dorsiflexion, using a weight-bearing
lunge test.
METHODS
Reliability
With the use of a sample of convenience, ankle
dorsiflexion range of motion was assessed in 20 healthy
participants (7 men and 13 women), aged 21Y28 yrs
(mean [SD], 22.4 [2] yrs), with a mean (SD) height of
172.5 (8.9) and a mean (SD) weight of 67.2 (12.9).
The participants were active university students with
no history of lower limb injury in the past year. The
study was approved by The University of Sydney,
Human Research Ethics committee, and the partici-
pants gave their written consent before participation.
Ankle dorsiflexion range was measured using a
digital, medically rated inclinometer (Baseline; Fabri-
cation Enterprises Incorporated, New York; Fig. 1A)
FIGURE 1 Measurement devices used: baseline inclinometer (A) and iPhone with iHandy Level app (B).
326 Vohralik et al. Am. J. Phys. Med. Rehabil. & Vol. 94, No. 4, April 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
and the iHandy Level app on an iPhone (iPhone;
Apple, Cupertino, CA; Fig. 1B). The participants were
assessed independently by two raters on one occa-
sion. The raters were physiotherapy honor students
in their final year of study. One student performed
the measures, whereas the other recorded the mea-
sures to maintain blinding. Both students assessed
the participant initially for interrater reliability, with
reassessment occurring after a rest period of 5 mins
for intrarater reliability.
Before testing, each participant actively performed
three 30-sec calf stretches on their right leg to warm
up. The test procedure was explained and demon-
strated to each participant. On the basis of
the published lunge test method, testing involved
each assessor marking a point 15 cm distal to the
tibial tuberosity on the anterior border of the tibia
with a felt-tipped pen.1 Between each test, the mark was
removed with an alcohol wipe. This was the place-
ment point for each device, and the order of the devices
was randomized. To standardize device placement,
the BHome[ button on the short side of the iPhone
and BB[ from the word baseline for the inclinometer
were aligned with the mark on the tibia. To ensure
the same foot placement for testing, the distance of
the great toe from the wall was measured, recorded,
and reused for each test (Figs. 1A, B).
The participants’ right foot was positioned per-
pendicular to a wall, using their hands in front of
them for balance.1 A tape measure was placed on the
floor to ensure that the second toe and the center
of their heel were aligned perpendicular to the wall,
 TABLE 1 Intrarater reliability
Difference Between
Mean Angles, Degrees SEM
Inclinometer 0.07 1.25
Smartphone app 0.20 1.35
and the participants were instructed to lunge for-
ward, bringing their knee in contact with a vertical
tape on the wall. For the first test, the participants
were encouraged to keep moving their foot away from
the wall to obtain the largest angle possible, while
keeping their heel on the ground. For each device,
three measurements were obtained to calculate a
mean angle.
Validity
Criterion validity was tested using 20 pieces of
timber with angles ranging between 0 and 58 degrees.
This was done to control the number of variables that
could potentially contribute to differences in angu-
lar readings that may be affected by soft tissue vis-
cosity.12 One Fastrak sensor was used, and angular
data were collected by custom-made LabVIEW soft-
ware. The Fastrak data were used as the criterion
standard measure.13,14 Angles were measured using
a 3Space Fastrak (Polhemius, Inc, Vermont), the app,
and the digital inclinometer, in that order.
Each piece of timber had a dot in the middle of
the bottom edge and was marked with the angle in
which it was cut. The angle measure was covered by
a piece of paper, and the assessor measuring the angle
remained blinded to the angles of the pieces of timber.
Each device was lined up with the dot on the timber
to obtain a measure. Three measurements were
obtained with each device for all 20 pieces of timber, and
a mean measure was then calculated for each device.
FIGURE 2 Bland-Altman plots of intrarater reliability with mean (solid line) and 2 SDs (dashed lines) marked.
A, Inclinometer; B, iPhone.
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95% CI 95% CI
ICC2,1 (Lower Bound) (Upper Bound)
0.98 0.95 0.99
0.97 0.92 0.99
Statistics
SPSS (IBM SPSS Statistics for Windows, version
21.0; IBM Corp, Armonk, NY) was used to calculate
intraclass correlation coefficients (ICCs2,1) and 95%
confidence intervals (CIs) to determine intrarater and
interrater reliability. ICCs were interpreted according
to Fleiss,15 whereby coefficients of less than 0.4
were considered poor, coefficients between 0.4 and
0.75 were fair/good, and coefficients greater than
0.75 were excellent. Standard error of the measure
and Bland-Altman plots were also produced. Pearson
product-moment correlation coefficients were cal-
culated to assess the criterion validity between the
smartphone app and the Fastrak (criterion standard)
as well as the construct validity between the iPhone
app and the digital inclinometer.
RESULTS
Reliability
Intrarater Reliability
The ICCs and 95% CIs for the inclinometer and
the smartphone app were both in the excellent
range (0.98; CI, 0.95Y0.99, and 0.97; CI, 0.92Y0.99,
respectively), with narrow CIs. There was only a
0.07-degree and 0.2-degree difference between ses-
sions for the inclinometer and the app, respectively
(Table 1). Standard error of the measure (Table 1)
and Bland-Altman plots (Fig. 2) demonstrate that
the inclinometer measures were closer together,
A Smartphone App to Measure Joint Range 327
 TABLE 2 Interrater reliability
Difference Between
Mean Angles, Degrees SEM
Inclinometer 2.00 2.05
Smartphone app 3.40 2.68
with the mean differences smaller than those of
the smartphone app, although the differences are
not significant.
Interrater Reliability
The ICCs for the inclinometer and the smartphone
app were both in the excellent range (0.90; CI,
0.43Y0.97, and 0.76; CI, 0.005Y0.932, respectively),
although CIs were wider (Table 2). There was a
2-degree difference between assessors with the in-
clinometer and a 3.4-degree difference with the
smartphone app. Standard error of the measure
(Table 2) and Bland-Altman plots (Fig. 3) demon-
strate the same trend as the intrarater reliability,
with larger differences as is typical in clinical mea-
sures, whereby intrarater reliability is better than
interrater reliability.
Validity
The iHandy Level was highly correlated with
both the Fastrak (r 2 = 0.99, P G 0.01) and the digital
inclinometer (r2 = 1.0, P G 0.01). The smartphone
predicted 99.9% of the variation of the inclino-
meter and 99.8% of the variation of the Fastrak when
measuring static angles (Fig. 4).
DISCUSSION
The iHandy Level app is a reliable and valid
measure of ankle dorsiflexion range of motion. The
FIGURE 3 Bland-Altman plots of interrater reliability with mean (solid line) and 2 SDs (dashed lines) marked.
A, Inclinometer; B, iPhone.
328 Vohralik et al. Am. J. Phys. Med. Rehabil. & Vol. 94, No. 4, April 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
95% CI 95% CI
ICC2,1 (Lower Bound) (Upper Bound)
0.90 0.43 0.97
0.76 0.01 0.93
results of this study concur with the high reliability
of the TiltMeter app,16 the only other app validated
for the ankle to date.17 The iHandy Level is designed
to use the inbuilt accelerometers of the smart-
phone, and since this study was conducted, it
has been validated for measuring spine mobility,
although its development was initially for use in
carpentry.18 The TiltMeter app in comparison is a
magnetometer-based app and, although reliable in
measuring ankle dorsiflexion, is limited to measures
in the horizontal plane.
The use of apps in joint measurement is a
growing area as demonstrated by the first system-
atic review in this area that collected 17 articles
from 2011 onward.17 Many of the available apps use
the inbuilt accelerometers of the smartphone, but
magnetometers and photographic systems are also
used. The apps make an attractive alternative to
other clinical methods because of their cheapness
and availability across a range of smartphones and,
in comparison with goniometry, their ease and speed
of use. Hygiene issues are similar to those encoun-
tered using an inclinometer, and smartphones with
smoother exteriors that may be wiped down with
alcohol wipes do have advantages for this aspect in
clinical practice and research use.
Both intrarater and interrater reliabilities of
this study were excellent, with greater intrarater re-
liability, as is typical of clinical measures. Lower
interrater reliability might be explained by the size
FIGURE 4 Bland-Altman plots of validity with mean (solid line) and 2 SDs (dashed lines) marked. A, iPhone vs.
Fastrak; B, inclinometer vs. Fastrak.
difference between the inclinometer compared with
the smartphone app. The smartphone has a narrower
base, making it more difficult to place consistently
on the patient across multiple planes, possibly in-
troducing more error in the measurements. In this
study, the short side of the smartphone was used,
making it less stable, and, in the future, the authors
recommend that the long side be used to try and
minimize placement variation between raters.
High levels of construct and criterion validity
have been demonstrated, with r 2 values of 0.99 and
1.0 for the Fastrak and the inclinometer, respectively.
Comparison of the smartphone app with the Fastrak
as the criterion standard angular measurement tool
was almost perfect. Further research should deter-
mine whether these high levels of validity transfer
directly to the measurement of all joint angles.
Blinding of assessors was one of the study
strengths but did cause difficulties not usually en-
countered in clinical practice. To achieve blinding
in the reliability study, the devices were faced away
from the assessor. Maintaining the device position
without clearly visualizing the display was difficult.
Future studies could mark a spot on the back of each
device to ensure that the correct position was main-
tained and use the long edge of the smartphone to
maximize accurate placement.
Possible limitations of this study include a sam-
ple of convenience for reliability testing. The partici-
pants were predominantly young and healthy, with
little limitation to ankle dorsiflexion. Therefore, these
results may not generalize across a wider population
with greater range of motion. Validation with human
participants would also confirm the generalizability
of the iHandy Level app.
In conclusion, a smartphone with the iHandy
app can be used in clinical practice and research as
an easy and convenient alternative to an inclinom-
eter. A smartphone with the iHandy Level app can
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Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
measure ankle dorsiflexion with high reliability as
well as construct and criterion validity.
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