The influence of spasticity on goniometric range of motion measurement in children with cerebral palsy

The influence of spasticity on goniometric range of motion measurement in children with cerebral palsy | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The influence of spasticity on goniometric range of motion measurement in children with cerebral palsy Olof Lindén, Katarina Lauruschkus, Philippe Wagner, Gunnar Hägglund, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7542630/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 04 Mar, 2026 Read the published version in BMC Musculoskeletal Disorders → Version 1 posted 12 You are reading this latest preprint version Abstract Background Spasticity may introduce bias in passive range of motion (ROM) measurements in children with cerebral palsy. This study aimed to explore the impact of spasticity on the reliability and potential measurement bias of goniometric assessments of ankle dorsiflexion and knee extension in children with unilateral spastic cerebral palsy (USCP). Methods 32 children aged 6–17 years with USCP were recruited. ROM was assessed by two blinded investigators, using a two-axis goniometer. Spasticity was estimated using the Modified Ashworth Scale. Agreement between examiners was evaluated with Bland-Altman plots and paired t-tests. Inter-rater reliability was assessed using intraclass correlation coefficients (ICC). Results No statistically significant differences in examiner agreement of ROM were observed between the spastic and contralateral sides for ankle dorsiflexion (extended knee: mean difference 0.22°, 95% CI: − 2.53 to 2.09; flexed knee: 0.78°, 95% CI: − 3.57 to 2.01), knee extension (0.31°, 95% CI: − 1.63 to 1.01), or popliteal angle (0.50°, 95% CI: − 2.53 to 3.53). ICC indicated high inter-rater reliability. Conclusions These findings support the use of goniometry as a reliable tool for assessing joint mobility in clinical and research settings with results equally valid for measurements on a spastic and contralateral limb. Children Cerebral palsy Spasticity Goniometer Range of Motion Reliability Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Background The risk of joint contractures in the lower limbs is a significant concern in growing children with cerebral palsy (CP). Assessing joint mobility is essential for physicians and physiotherapists when evaluating and treating these children. Early identification of a decreasing passive range of motion (ROM) is crucial for enabling successful treatment and optimizing long-term outcomes ( 1 ). The development of contractures can sometimes progress slowly, requiring a measurement method that is both valid and reliable. The primary method for measuring joint ROM is the use of a manual goniometer, although techniques using smartphones or other electronic devices also have been demonstrated ( 2 – 4 ). Previous studies indicate that traditional goniometry is generally reliable for measuring both ankle and knee ROM in individuals with and without spastic muscles ( 5 – 10 ), even if some studies indicate that there is a considerable variability among children with spasticity ( 11 ). To our knowledge, no previous study has investigated children with unilateral spastic cerebral palsy (USCP) to evaluate the influence of spasticity on ROM measurement inter-examiner agreement. The aim of this study was to investigate the impact of spasticity on potential bias in goniometric ROM measurements of knee extension and ankle dorsiflexion in children with USCP. This was achieved by using each child as their own control, comparing measurements from the spastic limb to those of the contralateral limb. Materials and Methods In Sweden, almost all children with CP are connected to a local habilitation unit where regular assessments are conducted by the child’s physiotherapist through the Swedish Follow up Program for People with Cerebral Palsy (CPUP)( 12 ). Families of children aged 2–17 years with USCP were invited to participate in the study through a letter of invitation with information about the study. The information was given both to each child and their parents, including an easy-to-read child-appropriate version. After two weeks, a reminder was sent to all families who had not answered. Children with diagnoses other than USCP were excluded, as were those who had undergone lower extremity surgery within the past year or received botulinum toxin injections to the lower extremity within the last three months. USCP was diagnosed by a pediatric neurologist. The participants were assessed in a single session lasting approximately 30 minutes. ROM measurements of knee extension and ankle dorsiflexion were performed on both legs of each child by two investigators using a standard two-axis goniometer commonly used in clinical practice. The goniometer consists of two 20 cm arms joined by a pivot, with a graduated scale (Fig. 1 ). Standardized patient positioning and goniometer arm placement for measuring ROM in different joints were based on the guidelines from the CPUP manual ( https://cpup.se/wp-content/uploads/2023/01/FT-manual-2023.230116.pdf ) (Fig. 2 ). Popliteal angle was measured with the child positioned supine, with the hip of the measured leg flexed to 90°, while the contralateral leg was fixed in extended position. The pivot of the goniometer was placed laterally over the knee joint, with the fixed arm aligned along the femur and pointing toward the greater trochanter, and the moving arm held parallel to the anterior margin of the tibia, pointing toward the lateral malleolus. Knee extension was measured with the child in supine position and both knees extended. The pivot of the goniometer was placed laterally over the center of rotation of the knee joint. The fixed arm was aligned with the femur, pointing toward the greater trochanter, while the moving arm was held parallel to the anterior margin of the tibia, pointing toward the lateral malleolus. Any deficit in knee extension was recorded as a negative value. Ankle dorsiflexion was measured with the knee flexed and extended respectively, and the child in a supine position. The subtalar joint was stabilized by the examiner while intertarsal movement was inhibited by slightly inverting the forefoot. The fixed arm of the goniometer was aligned parallel to the anterior margin of the tibia, and the moving arm was positioned parallel to the lateral margin of the foot. A 90° ankle position was recorded as 0°, and dorsiflexion less than 0° was noted as a negative value. One investigator was a senior pediatric orthopedic surgeon, and the other was a senior pediatric physiotherapist. Data collected included age, sex, spastic side (right/left), and spasticity level according to the Modified Ashworth Scale (MAS) (Bohannon et al. 1987). The level of spasticity in plantar flexors, knee extensors and knee flexors on each side was determined by consensus between the two investigators. The investigators performed the ROM-measurements independently and were blinded to each other's results. Statistics Statistical power analysis indicated that a minimum of 32 children (64 legs) was required to detect a significant bias in ROM measurements. Bland-Altman plots were generated separately for the spastic and contralateral sides. The plots were used to assess the presence of systematic bias or proportional differences between the examiners' measurements. To compare potential bias in measurement variability between the spastic and contralateral sides, the differences between the two examiners' measurements were calculated for the spastic and the contralateral side, respectively. Subsequently, the difference between these differences (i.e., the discrepancy in examiner agreement between the spastic and contralateral sides) was computed for each participant. One-sample t-tests were performed, but the primary focus was on 95% confidence intervals of the mean differences; intervals including zero indicated no systematic bias. In addition, inter-rater reliability between the two examiners was assessed using the intraclass correlation coefficient (ICC), calculated separately for the spastic and contralateral sides. The examiners' measurements were treated as fixed effects and the participants as random effects. ICC values were interpreted according to Koo et al., with values below 0.5 indicating poor reliability, between 0.5 and 0.75 indicating moderate reliability, and above 0.75 indicating good to excellent reliability( 13 ). All statistical analyses were performed using SPSS Statistics, version 28.0. Results A total of 32 children with USCP participated in the study, including 17 boys and 15 girls. The mean age at assessment was 11.9 years (SD 3.9, range 6.0–18.3), with boys averaging 11.9 years (SD 3.4, range 6.7–17.2) and girls 12.0 years (SD 4.6, range 6.0–18.3). The spastic side was the right in 22 children and the left in 10 children. For some children mild spasticity was assessed in the contralateral side. However, spasticity was greater on the affected side, with the most pronounced spasticity observed in the plantar flexors (Table 1 ). Table 1 Level of spasticity (MAS) in respective muscle investigated. Muscle and side 0 1 1+ 2 3 4 Total (n) Gastrocsoleus spastic side 0 6 15 8 2 1 32 Gastrocsoleus contralateral side 18 13 1 0 0 0 32 Hamstrings spastic side 6 19 7 0 0 0 32 Hamstrings contralateral side 29 3 0 0 0 0 32 Rectus spastic side 28 4 0 0 0 0 32 Rectus contralateral side 32 0 0 0 0 0 32 MAS = Modified Ashworth scale. Ankle dorsiflexion was approximately 10° lower on the spastic side compared to the contralateral side, both with the knee extended and flexed. Knee extension and popliteal angles were about 5° lower on the spastic side. (Table 2 ) Table 2 Mean ROM ( ° ) for knee and ankle measurements Measurement Side Examiner 1 (mean (SD), range) Examiner 2 (mean (SD), range) Ankle Dorsiflexion extended knee Spastic 6.8 (7.4), -8-23 5.2 (7.9), -10-20 Ankle Dorsiflexion extended knee Contralateral 16.3 (6.9), 4–33 14.5 (7.6), 2–30 Ankle Dorsiflexion flexed knee Spastic 12.0 (8.9), -4-36 12.7 (8.8), -4-35 Ankle Dorsiflexion flexed knee Contralateral 24.0 (7.9), 10–42 24.0 (7.8), 10–40 Knee Extension Spastic 1.2 (6.8), -10-24 1.5 (6.1), -10-22 Knee Extension Contralateral 4.7 (6.7), -5-24 4.7 (6.2), -2-21 Popliteal Angle Spastic 143.2 (9.0), 125–165 147.4 (9.2), 122–170 Popliteal Angle Contralateral 146.6 (9.9), 119–168 151.2 (11.1), 118–175 ROM = Range of motion To explore potential side-related bias in inter-examiner agreement, the differences between the two examiners’ measurements were calculated separately for the spastic and contralateral sides. Subsequently, the difference between these differences was analyzed. Across all joint measures, no systematic side-related bias was observed, as the mean differences were close to zero and the confidence intervals included zero(Table 3 ). P-values are reported for completeness, but the interpretation primarily relies on the confidence intervals. Table 3 Mean difference in examiner agreement between spastic and contralateral limbs ROM measurement Mean Difference (degrees) SD 95% Confidence Interval p-value (Two-sided) Ankle dorsiflexion extended knee -0.22 6.40 -2.53, 2.09 0.848 Ankle dorsiflexion flexed knee -0.78 7.74 -3.57, 2.01 0.572 Knee extension -0.31 3.66 -1.63, 1.01 0.632 Popliteal angle 0.50 8.41 -2.53, 3.53 0.739 The agreement between Examiner 1 and Examiner 2 was evaluated using Bland-Altman plots. Across all measurements, the mean differences between examiners were generally small, indicating good agreement. The limits of agreement varied depending on the joint, limb side, and whether the knee was flexed or extended, with wider variation observed in some measures, particularly for popliteal angle and ankle dorsiflexion on the contralateral side. Detailed results for each measurement are presented in Figs. 3 – 6 . Inter-rater reliability assessed using single measures ICC, was generally good to excellent across the range of joint measurements. Agreement between examiners was strongest for knee extension and ankle dorsiflexion, particularly on the spastic side. Slightly lower levels of agreement were observed for measurements on the contralateral side, especially for ankle dorsiflexion with flexed knee and popliteal angle. The width of some confidence intervals, however, indicated limited statistical precision for these measures (Table 4 ). Table 4 Intraclass Correlation Coefficients (ICC) for knee and ankle ROM measurements ICC 95% CI Ankle dorsiflexion, extended knee (spastic side) 0.852 0.719–0.925 Ankle dorsiflexion, extended knee (contralateral side) 0.814 0.653–0.905 Ankle dorsiflexion, flexed knee (spastic side) 0.891 0.789–0.945 Ankle dorsiflexion, flexed knee (contralateral side) 0.653 0.399–0.814 Knee extension (spastic side) 0.911 0.827–0.956 Knee extension (contralateral side) 0.782 0.599–0.887 Popliteal angle (spastic side) 0.782 0.599–0.887 Popliteal angle (contralateral side) 0.688 0.451–0.835 Discussion The main finding in this study was that no systematic side-related bias was observed in the agreement between the examiners’ ROM measurements on the spastic and contralateral sides. This result suggests that the inter-examiner agreement for both the spastic and contralateral sides is comparable, despite potential differences in muscle tone between the two sides. The lack of systematic discrepancy of examiner agreement between the spastic and contralateral sides was consistent across all ROM measures. A distinctive feature of this study is the within-subject design, where each child’s contralateral limb served as a control. This approach reduces the risk of selection bias that may occur in studies comparing children with cerebral palsy to typically developing peers( 10 ), and allows for a more robust assessment of examiner agreement. The Bland–Altman analysis showed generally good agreement between the two examiners, with mean differences close to zero for most ROM measurements. However, the limits of agreement were somewhat wider on the contralateral side across several measures, indicating lower measurement consistency compared to the spastic side. This was most pronounced for ankle dorsiflexion with the knee flexed and for the popliteal angle, suggesting that end range was more difficult to standardize in the contralateral limb. Although the study was not specifically designed or powered to assess inter-rater reliability, the results in this cohort demonstrated good-to-excellent reliability for most joints, with slightly higher reliability observed for measurements on the spastic side compared to the contralateral side. The ICC values observed are comparable to those reported in similar studies evaluating joint angle reliability in children with cerebral palsy ( 10 , 13 , 14 ). Slightly lower reliability was observed for some measurements, such as ankle dorsiflexion with the knee flexed on the contralateral side. This could reflect greater variability in the contralateral limb due to less pronounced stiffness compared to the spastic side. Overall, these ICC findings support the validity of using goniometric measurements for assessing joint mobility, even in children with spasticity and CP. However, given that the study was not specifically powered for ICC analysis, these results should be interpreted with caution. The strength of this study is the inclusion of both the spastic and contralateral sides within the same individuals, which eliminates inter-individual variability and potential confounders such as age, overall motor function, and growth-related changes. This approach provides a more controlled comparison of joint angle differences and measurement reliability, making the results more robust than studies comparing children with cerebral palsy to typically developing peers. However, certain limitations must be acknowledged. The presence of mild spasticity in the contralateral limb questions the correct diagnosis of USCP in some of the children. These children might have a bilateral cerebral palsy with one more affected side. Given the relatively low levels of spasticity in the hamstrings and particularly in rectus femoris, it is not surprising that agreement in knee extension and popliteal angle measurements was high. To the best of our knowledge, no previous studies have compared ROM measurements between the spastic and contralateral sides within individuals with unilateral spastic cerebral palsy for the purpose of evaluating inter-examiner agreement. In the present study, no significant side-related bias was found, and the overall high inter-rater reliability across all measurements supports the use of goniometry as a robust and reliable method for assessing joint range of motion in this population. Declarations Ethics approval and consent to participate The study was approved by the Swedish Ethical Review Authority (Reg. no. 2023-00195-01). All methods were carried out in accordance with the Declaration of Helsinki. Written informed consent to participate was obtained from the parents/legal guardians of all participants. Age-appropriate assent was obtained from all children, and written informed consent was also obtained from participants aged 15–17 years. Consent for publication Not applicable; no individual person’s data (including images or identifying information) are presented. Competing interests The authors declare that they have no competing interests. Acknowledgement of AI use ChatGPT (OpenAI, version 4o) was used for assistance with language editing regarding translation, spelling and grammar. Funding This work was partly funded by Stiftelsen för bistånd åt rörelsehindrade i Skåne. Author Contribution OL conceived the study, collected data together with KL, and performed the statistical analyses and prepared all figures. All authors (OL, KL, PW, GH, HL) contributed to the study design, interpretation of results, and drafting and revising the manuscript. All authors reviewed the manuscript Acknowledgement The authors are grateful to the children and adolescents, and their families, who participated in this study. Data Availability The datasets analysed during the current study are available from the corresponding author on reasonable request. References Hagglund G, Andersson S, Duppe H, Lauge-Pedersen H, Nordmark E, Westbom L. Prevention of severe contractures might replace multilevel surgery in cerebral palsy: results of a population-based health care programme and new techniques to reduce spasticity. J Pediatr Orthop B. 2005;14(4):269–73. 10.1097/01202412-200507000-00007 . Ferriero G, Vercelli S, Sartorio F, Munoz Lasa S, Ilieva E, Brigatti E, et al. Reliability of a smartphone-based goniometer for knee joint goniometry. Int J Rehabil Res. 2013;36(2):146–51. 10.1097/MRR.0b013e32835b8269 . Herrero P, Carrera P, Garcia E, Gomez-Trullen EM, Olivan-Blazquez B. Reliability of goniometric measurements in children with cerebral palsy: a comparative analysis of universal goniometer and electronic inclinometer. A pilot study. BMC Musculoskelet Disord. 2011;12:155. 10.1186/1471-2474-12-155 . Hancock GE, Hepworth T, Wembridge K. Accuracy and reliability of knee goniometry methods. J Exp Orthop. 2018;5(1):46. 10.1186/s40634-018-0161-5 . Allington NJ, Leroy N, Doneux C. Ankle joint range of motion measurements in spastic cerebral palsy children: intraobserver and interobserver reliability and reproducibility of goniometry and visual estimation. J Pediatr Orthop B. 2002;11(3):236–9. 10.1097/00009957-200207000-00007 . Brosseau L, Balmer S, Tousignant M, O'Sullivan JP, Goudreault C, Goudreault M, et al. Intra- and intertester reliability and criterion validity of the parallelogram and universal goniometers for measuring maximum active knee flexion and extension of patients with knee restrictions. 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Gait Posture. 2000;12(2):114–21. 10.1016/s0966-6362(00)00068-0 . Alriksson-Schmidt AI, Arner M, Westbom L, Krumlinde-Sundholm L, Nordmark E, Rodby-Bousquet E, et al. A combined surveillance program and quality register improves management of childhood disability. Disabil Rehabil. 2017;39(8):830–6. 10.3109/09638288.2016.1161843 . Koo TK, Li MY. A Guideline of Selecting and Reporting Intraclass Correlation Coefficients for Reliability Research. J Chiropr Med. 2016;15(2):155–63. 10.1016/j.jcm.2016.02.012 . Kilgour G, McNair P, Stott NS. Intrarater reliability of lower limb sagittal range-of-motion measures in children with spastic diplegia. Dev Med Child Neurol. 2003;45(6):391–9. 10.1017/s0012162203000744 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 04 Mar, 2026 Read the published version in BMC Musculoskeletal Disorders → Version 1 posted Editorial decision: Revision requested 07 Nov, 2025 Reviews received at journal 27 Oct, 2025 Reviews received at journal 25 Oct, 2025 Reviewers agreed at journal 16 Oct, 2025 Reviewers agreed at journal 15 Oct, 2025 Reviews received at journal 12 Oct, 2025 Reviewers agreed at journal 08 Oct, 2025 Reviewers invited by journal 03 Oct, 2025 Editor invited by journal 09 Sep, 2025 Editor assigned by journal 08 Sep, 2025 Submission checks completed at journal 08 Sep, 2025 First submitted to journal 05 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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02:11:04","extension":"jpeg","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":1712450,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage5.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7542630/v1/7366871cb79b89b2ceefa75c.jpeg"},{"id":93728462,"identity":"42f32020-30bf-483f-abe1-e53658202624","added_by":"auto","created_at":"2025-10-17 02:11:08","extension":"jpeg","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":1851150,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage6.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7542630/v1/10b3770dfcd99705e9c51046.jpeg"},{"id":93728475,"identity":"597f8a8e-b575-412b-aa14-363b75701814","added_by":"auto","created_at":"2025-10-17 02:11:10","extension":"jpeg","order_by":11,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":1851150,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage7.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7542630/v1/403abcbe527242ffdd08cc98.jpeg"},{"id":93728496,"identity":"188533aa-9a73-487b-9a96-0ee1dfcdc33d","added_by":"auto","created_at":"2025-10-17 02:11:11","extension":"jpeg","order_by":12,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":1840014,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage8.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7542630/v1/d25164b8f3efbcdae9c87cdb.jpeg"},{"id":93728509,"identity":"f5869e66-e82f-4328-9f6a-2e0646110a2f","added_by":"auto","created_at":"2025-10-17 02:11:11","extension":"jpeg","order_by":13,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":1845578,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage9.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7542630/v1/563a621150cc296bea71d231.jpeg"},{"id":93728489,"identity":"59812325-fa1d-45e3-b59f-3def01be31a6","added_by":"auto","created_at":"2025-10-17 02:11:11","extension":"png","order_by":14,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":141716,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7542630/v1/2b15adc287d90f245d1d3fae.png"},{"id":93728485,"identity":"0d1a2ee1-c851-49b6-a17b-67a002c820e1","added_by":"auto","created_at":"2025-10-17 02:11:11","extension":"png","order_by":15,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":9318,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage10.png","url":"https://assets-eu.researchsquare.com/files/rs-7542630/v1/962e244160758067893f02f8.png"},{"id":93728499,"identity":"be46bf0c-bf2a-49d2-b874-7e73d743d941","added_by":"auto","created_at":"2025-10-17 02:11:11","extension":"png","order_by":16,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":978095,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7542630/v1/7971424c737dfc49eaa7c7e3.png"},{"id":93728478,"identity":"09c1cc4d-a41e-4a4b-ba6b-5bb40287efff","added_by":"auto","created_at":"2025-10-17 02:11:10","extension":"png","order_by":17,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":9368,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-7542630/v1/4bedb2e2f3c1a4372f84f281.png"},{"id":93728527,"identity":"9b466037-9b10-4479-9eba-9883002665fb","added_by":"auto","created_at":"2025-10-17 02:11:13","extension":"png","order_by":18,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":10332,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-7542630/v1/3cc6f3ccab5295bd1d11a0c7.png"},{"id":93728517,"identity":"f2a92980-19a9-4c42-a7ba-d0f7aeea2ac9","added_by":"auto","created_at":"2025-10-17 02:11:12","extension":"png","order_by":19,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":9984,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-7542630/v1/769f6c8e1ab911eed1a540b3.png"},{"id":93728534,"identity":"297f2db9-1cf9-45a1-9562-a59fd812962c","added_by":"auto","created_at":"2025-10-17 02:11:13","extension":"png","order_by":20,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":10062,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage6.png","url":"https://assets-eu.researchsquare.com/files/rs-7542630/v1/6a07039dd86429fae6e511ac.png"},{"id":93728464,"identity":"3100d63c-c93a-42d2-a5f6-f74e2c3526bf","added_by":"auto","created_at":"2025-10-17 02:11:08","extension":"png","order_by":21,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":8683,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage7.png","url":"https://assets-eu.researchsquare.com/files/rs-7542630/v1/630d909963d4981bf034a393.png"},{"id":93728365,"identity":"1b62cc5d-712b-4ed6-8420-b3c09747ec50","added_by":"auto","created_at":"2025-10-17 02:11:00","extension":"png","order_by":22,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":9134,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage8.png","url":"https://assets-eu.researchsquare.com/files/rs-7542630/v1/0a23a2c327dfb6cb85348967.png"},{"id":93728488,"identity":"cddbb60d-15b9-4233-9986-8b512f925fcf","added_by":"auto","created_at":"2025-10-17 02:11:11","extension":"png","order_by":23,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":9434,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage9.png","url":"https://assets-eu.researchsquare.com/files/rs-7542630/v1/2f8ab3387215639664ee682a.png"},{"id":93728411,"identity":"b20c529f-3b90-4b0b-b4df-996101505358","added_by":"auto","created_at":"2025-10-17 02:11:04","extension":"xml","order_by":24,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":70167,"visible":true,"origin":"","legend":"","description":"","filename":"88d4a2b2ae1f489faa3ed3a1e641dd3e1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7542630/v1/8cb326dbf6699e842ef63106.xml"},{"id":93728379,"identity":"b45b4cc6-fb65-4472-b48b-c38029eac347","added_by":"auto","created_at":"2025-10-17 02:11:02","extension":"html","order_by":25,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":79031,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7542630/v1/98b1bd134e47fab6a5d3ab5b.html"},{"id":93728466,"identity":"1c3c70e8-e195-4692-869e-9af36a9ccb57","added_by":"auto","created_at":"2025-10-17 02:11:09","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":43568,"visible":true,"origin":"","legend":"\u003cp\u003eStandard goniometer\u003c/p\u003e","description":"","filename":"1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7542630/v1/747d0555593fac4ac774e39b.jpeg"},{"id":93728432,"identity":"905e0b07-c657-4fa4-b63d-cc19a619786a","added_by":"auto","created_at":"2025-10-17 02:11:05","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":348549,"visible":true,"origin":"","legend":"\u003cp\u003eStandardized techniques were followed for measuring ROM, with the child in a supine position. The popliteal angle was measured with the knee flexed, and ankle dorsiflexion was evaluated with the subtalar joint stabilized with flexed and extended knee. (\u003ca href=\"https://cpup.se/wp-content/uploads/2023/01/FT-manual-2023.230116.pdf\"\u003ehttps://cpup.se/wp-content/uploads/2023/01/FT-manual-2023.230116.pdf\u003c/a\u003e)\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7542630/v1/e51c7ffda7fe6b474de1690a.png"},{"id":93728380,"identity":"bedd7d92-143c-488a-99fd-741c385bfdca","added_by":"auto","created_at":"2025-10-17 02:11:02","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":340750,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003ea. Bland-Altman plot showing the difference in ROM measurements between examiner 1 and examiner 2 (y-axis) against the mean ROM measurements (x-axis) for ankle dorsiflexion with the knee extended on the spastic side.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eb. Bland-Altman plot showing the difference in ROM measurements between examiner 1 and examiner 2 (y-axis) against the mean ROM measurements (x-axis) for ankle dorsiflexion with the knee extended on the contralateral side.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7542630/v1/2e786e33adb8d21476294a04.png"},{"id":93728425,"identity":"873e1e36-4548-492e-b3e4-da8887c35cd2","added_by":"auto","created_at":"2025-10-17 02:11:05","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":337153,"visible":true,"origin":"","legend":"\u003cp\u003ea. Bland-Altman plot showing the difference in ROM measurements between examiner 1 and examiner 2 (y-axis) against the mean ROM measurements (x-axis) for ankle dorsiflexion with the knee flexed on the spastic side.\u003c/p\u003e\n\u003cp\u003eb. Bland-Altman plot showing the difference in ROM measurements between examiner 1 and examiner 2 (y-axis) against the mean ROM measurements (x-axis) for ankle dorsiflexion with the knee flexed on the contralateral side.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-7542630/v1/7d3d599d879ef03b3ce1eeb0.png"},{"id":93728378,"identity":"9eb81c1d-5a9e-4ec0-a8c7-cbd012c1bfff","added_by":"auto","created_at":"2025-10-17 02:11:02","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":297446,"visible":true,"origin":"","legend":"\u003cp\u003ea. Bland-Altman plot showing the difference in ROM measurements between examiner 1 and examiner 2 (y-axis) against the mean ROM measurements (x-axis) for knee extension on the spastic side.\u003c/p\u003e\n\u003cp\u003eb. Bland-Altman plot showing the difference in ROM measurements between examiner 1 and examiner 2 (y-axis) against the mean ROM measurements (x-axis) for knee extension on the contralateral side.\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-7542630/v1/2fa040f30efe37e9da8814c9.png"},{"id":93728415,"identity":"36acffca-4c92-4161-b9d0-4ec09dc7e7ae","added_by":"auto","created_at":"2025-10-17 02:11:04","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":51004,"visible":true,"origin":"","legend":"\u003cp\u003ea. Bland-Altman plot showing the difference in ROM measurements between examiner 1 and examiner 2 (y-axis) against the mean ROM measurements (x-axis) for popliteal angle on the spastic side.\u003c/p\u003e\n\u003cp\u003eb. Bland-Altman plot showing the difference in ROM measurements between examiner 1 and examiner 2 (y-axis) against the mean ROM measurements (x-axis) for popliteal angle on the contralateral side.\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-7542630/v1/94dc9cb3663f381850f910ef.png"},{"id":104250698,"identity":"eeed5ba5-9f76-425a-9749-8e29757aa710","added_by":"auto","created_at":"2026-03-09 16:05:57","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2435839,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7542630/v1/cd68c7cb-73ea-4514-b307-2124028fa337.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The influence of spasticity on goniometric range of motion measurement in children with cerebral palsy","fulltext":[{"header":"Background","content":"\u003cp\u003eThe risk of joint contractures in the lower limbs is a significant concern in growing children with cerebral palsy (CP). Assessing joint mobility is essential for physicians and physiotherapists when evaluating and treating these children. Early identification of a decreasing passive range of motion (ROM) is crucial for enabling successful treatment and optimizing long-term outcomes (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). The development of contractures can sometimes progress slowly, requiring a measurement method that is both valid and reliable.\u003c/p\u003e\u003cp\u003eThe primary method for measuring joint ROM is the use of a manual goniometer, although techniques using smartphones or other electronic devices also have been demonstrated (\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Previous studies indicate that traditional goniometry is generally reliable for measuring both ankle and knee ROM in individuals with and without spastic muscles (\u003cspan additionalcitationids=\"CR6 CR7 CR8 CR9\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e), even if some studies indicate that there is a considerable variability among children with spasticity (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). To our knowledge, no previous study has investigated children with unilateral spastic cerebral palsy (USCP) to evaluate the influence of spasticity on ROM measurement inter-examiner agreement. The aim of this study was to investigate the impact of spasticity on potential bias in goniometric ROM measurements of knee extension and ankle dorsiflexion in children with USCP. This was achieved by using each child as their own control, comparing measurements from the spastic limb to those of the contralateral limb.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eIn Sweden, almost all children with CP are connected to a local habilitation unit where regular assessments are conducted by the child\u0026rsquo;s physiotherapist through the Swedish Follow up Program for People with Cerebral Palsy (CPUP)(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Families of children aged 2\u0026ndash;17 years with USCP were invited to participate in the study through a letter of invitation with information about the study. The information was given both to each child and their parents, including an easy-to-read child-appropriate version. After two weeks, a reminder was sent to all families who had not answered. Children with diagnoses other than USCP were excluded, as were those who had undergone lower extremity surgery within the past year or received botulinum toxin injections to the lower extremity within the last three months. USCP was diagnosed by a pediatric neurologist.\u003c/p\u003e\u003cp\u003eThe participants were assessed in a single session lasting approximately 30 minutes. ROM measurements of knee extension and ankle dorsiflexion were performed on both legs of each child by two investigators using a standard two-axis goniometer commonly used in clinical practice. The goniometer consists of two 20 cm arms joined by a pivot, with a graduated scale (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Standardized patient positioning and goniometer arm placement for measuring ROM in different joints were based on the guidelines from the CPUP manual (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://cpup.se/wp-content/uploads/2023/01/FT-manual-2023.230116.pdf\u003c/span\u003e\u003cspan address=\"https://cpup.se/wp-content/uploads/2023/01/FT-manual-2023.230116.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003ePopliteal angle was measured with the child positioned supine, with the hip of the measured leg flexed to 90\u0026deg;, while the contralateral leg was fixed in extended position. The pivot of the goniometer was placed laterally over the knee joint, with the fixed arm aligned along the femur and pointing toward the greater trochanter, and the moving arm held parallel to the anterior margin of the tibia, pointing toward the lateral malleolus.\u003c/p\u003e\u003cp\u003eKnee extension was measured with the child in supine position and both knees extended. The pivot of the goniometer was placed laterally over the center of rotation of the knee joint. The fixed arm was aligned with the femur, pointing toward the greater trochanter, while the moving arm was held parallel to the anterior margin of the tibia, pointing toward the lateral malleolus. Any deficit in knee extension was recorded as a negative value.\u003c/p\u003e\u003cp\u003eAnkle dorsiflexion was measured with the knee flexed and extended respectively, and the child in a supine position. The subtalar joint was stabilized by the examiner while intertarsal movement was inhibited by slightly inverting the forefoot. The fixed arm of the goniometer was aligned parallel to the anterior margin of the tibia, and the moving arm was positioned parallel to the lateral margin of the foot. A 90\u0026deg; ankle position was recorded as 0\u0026deg;, and dorsiflexion less than 0\u0026deg; was noted as a negative value.\u003c/p\u003e\u003cp\u003eOne investigator was a senior pediatric orthopedic surgeon, and the other was a senior pediatric physiotherapist. Data collected included age, sex, spastic side (right/left), and spasticity level according to the Modified Ashworth Scale (MAS) (Bohannon et al. 1987). The level of spasticity in plantar flexors, knee extensors and knee flexors on each side was determined by consensus between the two investigators. The investigators performed the ROM-measurements independently and were blinded to each other's results.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStatistics\u003c/h2\u003e\u003cp\u003eStatistical power analysis indicated that a minimum of 32 children (64 legs) was required to detect a significant bias in ROM measurements.\u003c/p\u003e\u003cp\u003eBland-Altman plots were generated separately for the spastic and contralateral sides. The plots were used to assess the presence of systematic bias or proportional differences between the examiners' measurements.\u003c/p\u003e\u003cp\u003eTo compare potential bias in measurement variability between the spastic and contralateral sides, the differences between the two examiners' measurements were calculated for the spastic and the contralateral side, respectively. Subsequently, the difference between these differences (i.e., the discrepancy in examiner agreement between the spastic and contralateral sides) was computed for each participant. One-sample t-tests were performed, but the primary focus was on 95% confidence intervals of the mean differences; intervals including zero indicated no systematic bias.\u003c/p\u003e\u003cp\u003eIn addition, inter-rater reliability between the two examiners was assessed using the intraclass correlation coefficient (ICC), calculated separately for the spastic and contralateral sides. The examiners' measurements were treated as fixed effects and the participants as random effects. ICC values were interpreted according to Koo et al., with values below 0.5 indicating poor reliability, between 0.5 and 0.75 indicating moderate reliability, and above 0.75 indicating good to excellent reliability(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAll statistical analyses were performed using SPSS Statistics, version 28.0.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 32 children with USCP participated in the study, including 17 boys and 15 girls. The mean age at assessment was 11.9 years (SD 3.9, range 6.0\u0026ndash;18.3), with boys averaging 11.9 years (SD 3.4, range 6.7\u0026ndash;17.2) and girls 12.0 years (SD 4.6, range 6.0\u0026ndash;18.3). The spastic side was the right in 22 children and the left in 10 children.\u003c/p\u003e\n\u003cp\u003eFor some children mild spasticity was assessed in the contralateral side. However, spasticity was greater on the affected side, with the most pronounced spasticity observed in the plantar flexors (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"char\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eLevel of spasticity (MAS) in respective muscle investigated.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMuscle and side\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e1+\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTotal (n)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eGastrocsoleus spastic side\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eGastrocsoleus contralateral side\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eHamstrings spastic side\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eHamstrings contralateral side\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eRectus spastic side\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eRectus contralateral side\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cem\u003eMAS\u0026thinsp;=\u0026thinsp;Modified Ashworth scale.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAnkle dorsiflexion was approximately 10\u0026deg; lower on the spastic side compared to the contralateral side, both with the knee extended and flexed. Knee extension and popliteal angles were about 5\u0026deg; lower on the spastic side. (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean ROM (\u003c/strong\u003e\u0026deg;\u003cstrong\u003e) for knee and ankle measurements\u003c/strong\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMeasurement\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSide\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eExaminer 1\u003c/p\u003e\n \u003cp\u003e(mean (SD), range)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eExaminer 2\u003c/p\u003e\n \u003cp\u003e(mean (SD), range)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAnkle Dorsiflexion extended knee\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSpastic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.8 (7.4), -8-23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.2 (7.9), -10-20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAnkle Dorsiflexion extended knee\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eContralateral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16.3 (6.9), 4\u0026ndash;33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14.5 (7.6), 2\u0026ndash;30\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAnkle Dorsiflexion flexed knee\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSpastic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12.0 (8.9), -4-36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12.7 (8.8), -4-35\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAnkle Dorsiflexion flexed knee\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eContralateral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24.0 (7.9), 10\u0026ndash;42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24.0 (7.8), 10\u0026ndash;40\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eKnee Extension\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSpastic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.2 (6.8), -10-24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.5 (6.1), -10-22\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eKnee Extension\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eContralateral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.7 (6.7), -5-24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.7 (6.2), -2-21\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePopliteal Angle\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSpastic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e143.2 (9.0), 125\u0026ndash;165\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e147.4 (9.2), 122\u0026ndash;170\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePopliteal Angle\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eContralateral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e146.6 (9.9), 119\u0026ndash;168\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e151.2 (11.1), 118\u0026ndash;175\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003ch3\u003eROM\u0026thinsp;=\u0026thinsp;Range of motion\u003c/h3\u003e\n\u003cp\u003eTo explore potential side-related bias in inter-examiner agreement, the differences between the two examiners\u0026rsquo; measurements were calculated separately for the spastic and contralateral sides. Subsequently, the difference between these differences was analyzed. Across all joint measures, no systematic side-related bias was observed, as the mean differences were close to zero and the confidence intervals included zero(Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e). P-values are reported for completeness, but the interpretation primarily relies on the confidence intervals.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean difference in examiner agreement between spastic and contralateral limbs\u003c/strong\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eROM measurement\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMean Difference (degrees)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSD\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e95% Confidence Interval\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ep-value (Two-sided)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAnkle dorsiflexion extended knee\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-0.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-2.53, 2.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.848\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAnkle dorsiflexion flexed knee\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-0.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-3.57, 2.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.572\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eKnee extension\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-0.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-1.63, 1.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.632\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePopliteal angle\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-2.53, 3.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.739\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eThe agreement between Examiner 1 and Examiner 2 was evaluated using Bland-Altman plots. Across all measurements, the mean differences between examiners were generally small, indicating good agreement. The limits of agreement varied depending on the joint, limb side, and whether the knee was flexed or extended, with wider variation observed in some measures, particularly for popliteal angle and ankle dorsiflexion on the contralateral side. Detailed results for each measurement are presented in Figs.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan class=\"InternalRef\"\u003e6\u003c/span\u003e.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eInter-rater reliability assessed using single measures ICC, was generally good to excellent across the range of joint measurements. Agreement between examiners was strongest for knee extension and ankle dorsiflexion, particularly on the spastic side. Slightly lower levels of agreement were observed for measurements on the contralateral side, especially for ankle dorsiflexion with flexed knee and popliteal angle. The width of some confidence intervals, however, indicated limited statistical precision for these measures (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003cdiv class=\"colspec\" align=\"char\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003ctable id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eIntraclass Correlation Coefficients (ICC) for knee and ankle ROM measurements\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eICC\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAnkle dorsiflexion, extended knee (spastic side)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.852\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.719\u0026ndash;0.925\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAnkle dorsiflexion, extended knee (contralateral side)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.814\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.653\u0026ndash;0.905\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAnkle dorsiflexion, flexed knee (spastic side)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.891\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.789\u0026ndash;0.945\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAnkle dorsiflexion, flexed knee (contralateral side)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.653\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.399\u0026ndash;0.814\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eKnee extension (spastic side)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.911\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.827\u0026ndash;0.956\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eKnee extension (contralateral side)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.782\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.599\u0026ndash;0.887\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePopliteal angle (spastic side)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.782\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.599\u0026ndash;0.887\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePopliteal angle (contralateral side)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.688\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.451\u0026ndash;0.835\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe main finding in this study was that no systematic side-related bias was observed in the agreement between the examiners\u0026rsquo; ROM measurements on the spastic and contralateral sides. This result suggests that the inter-examiner agreement for both the spastic and contralateral sides is comparable, despite potential differences in muscle tone between the two sides. The lack of systematic discrepancy of examiner agreement between the spastic and contralateral sides was consistent across all ROM measures. A distinctive feature of this study is the within-subject design, where each child\u0026rsquo;s contralateral limb served as a control. This approach reduces the risk of selection bias that may occur in studies comparing children with cerebral palsy to typically developing peers(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e), and allows for a more robust assessment of examiner agreement.\u003c/p\u003e\u003cp\u003eThe Bland\u0026ndash;Altman analysis showed generally good agreement between the two examiners, with mean differences close to zero for most ROM measurements. However, the limits of agreement were somewhat wider on the contralateral side across several measures, indicating lower measurement consistency compared to the spastic side. This was most pronounced for ankle dorsiflexion with the knee flexed and for the popliteal angle, suggesting that end range was more difficult to standardize in the contralateral limb.\u003c/p\u003e\u003cp\u003eAlthough the study was not specifically designed or powered to assess inter-rater reliability, the results in this cohort demonstrated good-to-excellent reliability for most joints, with slightly higher reliability observed for measurements on the spastic side compared to the contralateral side. The ICC values observed are comparable to those reported in similar studies evaluating joint angle reliability in children with cerebral palsy (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Slightly lower reliability was observed for some measurements, such as ankle dorsiflexion with the knee flexed on the contralateral side. This could reflect greater variability in the contralateral limb due to less pronounced stiffness compared to the spastic side. Overall, these ICC findings support the validity of using goniometric measurements for assessing joint mobility, even in children with spasticity and CP. However, given that the study was not specifically powered for ICC analysis, these results should be interpreted with caution.\u003c/p\u003e\u003cp\u003eThe strength of this study is the inclusion of both the spastic and contralateral sides within the same individuals, which eliminates inter-individual variability and potential confounders such as age, overall motor function, and growth-related changes. This approach provides a more controlled comparison of joint angle differences and measurement reliability, making the results more robust than studies comparing children with cerebral palsy to typically developing peers.\u003c/p\u003e\u003cp\u003eHowever, certain limitations must be acknowledged. The presence of mild spasticity in the contralateral limb questions the correct diagnosis of USCP in some of the children. These children might have a bilateral cerebral palsy with one more affected side. Given the relatively low levels of spasticity in the hamstrings and particularly in rectus femoris, it is not surprising that agreement in knee extension and popliteal angle measurements was high.\u003c/p\u003e\u003cp\u003eTo the best of our knowledge, no previous studies have compared ROM measurements between the spastic and contralateral sides within individuals with unilateral spastic cerebral palsy for the purpose of evaluating inter-examiner agreement. In the present study, no significant side-related bias was found, and the overall high inter-rater reliability across all measurements supports the use of goniometry as a robust and reliable method for assessing joint range of motion in this population.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e\u003cp\u003e The study was approved by the Swedish Ethical Review Authority (Reg. no. 2023-00195-01). All methods were carried out in accordance with the Declaration of Helsinki. Written informed consent to participate was obtained from the parents/legal guardians of all participants. Age-appropriate assent was obtained from all children, and written informed consent was also obtained from participants aged 15\u0026ndash;17 years.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003cp\u003eNot applicable; no individual person\u0026rsquo;s data (including images or identifying information) are presented.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eAcknowledgement of AI use\u003c/h2\u003e\u003cp\u003eChatGPT (OpenAI, version 4o) was used for assistance with language editing regarding translation, spelling and grammar.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eThis work was partly funded by Stiftelsen f\u0026ouml;r bist\u0026aring;nd \u0026aring;t r\u0026ouml;relsehindrade i Sk\u0026aring;ne.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eOL conceived the study, collected data together with KL, and performed the statistical analyses and prepared all figures. All authors (OL, KL, PW, GH, HL) contributed to the study design, interpretation of results, and drafting and revising the manuscript. All authors reviewed the manuscript\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors are grateful to the children and adolescents, and their families, who participated in this study.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHagglund G, Andersson S, Duppe H, Lauge-Pedersen H, Nordmark E, Westbom L. Prevention of severe contractures might replace multilevel surgery in cerebral palsy: results of a population-based health care programme and new techniques to reduce spasticity. 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Dev Med Child Neurol. 2003;45(6):391\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1017/s0012162203000744\u003c/span\u003e\u003cspan address=\"10.1017/s0012162203000744\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Children, Cerebral palsy, Spasticity, Goniometer, Range of Motion, Reliability","lastPublishedDoi":"10.21203/rs.3.rs-7542630/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7542630/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eSpasticity may introduce bias in passive range of motion (ROM) measurements in children with cerebral palsy. This study aimed to explore the impact of spasticity on the reliability and potential measurement bias of goniometric assessments of ankle dorsiflexion and knee extension in children with unilateral spastic cerebral palsy (USCP).\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003e32 children aged 6\u0026ndash;17 years with USCP were recruited. ROM was assessed by two blinded investigators, using a two-axis goniometer. Spasticity was estimated using the Modified Ashworth Scale. Agreement between examiners was evaluated with Bland-Altman plots and paired t-tests. Inter-rater reliability was assessed using intraclass correlation coefficients (ICC).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eNo statistically significant differences in examiner agreement of ROM were observed between the spastic and contralateral sides for ankle dorsiflexion (extended knee: mean difference 0.22\u0026deg;, 95% CI: \u0026minus;\u0026thinsp;2.53 to 2.09; flexed knee: 0.78\u0026deg;, 95% CI: \u0026minus;\u0026thinsp;3.57 to 2.01), knee extension (0.31\u0026deg;, 95% CI: \u0026minus;\u0026thinsp;1.63 to 1.01), or popliteal angle (0.50\u0026deg;, 95% CI: \u0026minus;\u0026thinsp;2.53 to 3.53). ICC indicated high inter-rater reliability.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eThese findings support the use of goniometry as a reliable tool for assessing joint mobility in clinical and research settings with results equally valid for measurements on a spastic and contralateral limb.\u003c/p\u003e","manuscriptTitle":"The influence of spasticity on goniometric range of motion measurement in children with cerebral palsy","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-17 02:10:44","doi":"10.21203/rs.3.rs-7542630/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-11-07T08:51:31+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-27T12:58:55+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-25T23:36:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"286344480425820434757884630916329761764","date":"2025-10-16T07:32:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"248644154697196374835629499160940123132","date":"2025-10-15T15:14:19+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-12T07:03:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"282174102328268290644595674515710348850","date":"2025-10-08T08:19:09+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-03T11:32:46+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-09-09T17:00:20+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-08T13:56:25+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-08T13:55:58+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Musculoskeletal Disorders","date":"2025-09-05T09:00:34+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"867bf7d6-f0a7-494f-93df-7b6037da8012","owner":[],"postedDate":"October 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-03-09T16:02:25+00:00","versionOfRecord":{"articleIdentity":"rs-7542630","link":"https://doi.org/10.1186/s12891-026-09659-3","journal":{"identity":"bmc-musculoskeletal-disorders","isVorOnly":false,"title":"BMC Musculoskeletal Disorders"},"publishedOn":"2026-03-04 15:57:24","publishedOnDateReadable":"March 4th, 2026"},"versionCreatedAt":"2025-10-17 02:10:44","video":"","vorDoi":"10.1186/s12891-026-09659-3","vorDoiUrl":"https://doi.org/10.1186/s12891-026-09659-3","workflowStages":[]},"version":"v1","identity":"rs-7542630","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7542630","identity":"rs-7542630","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}