Interobserver reproducibility of the visual estimation of range of motion of the shoulder

OBJECTIVES: To assess interobserver reproducibility (agreement and reliability) of visually estimated shoulder range of motion (ROM) and to study the influence of clinical characteristics on the reproducibility. DESIGN: Test-retest analyses. SETTING: Various health care settings in the Netherlands. PARTICIPANTS: Consecutive patients with shoulder complaints (N = 201) referred by 20 general practitioners, 2 orthopedic physicians, and 20 rheumatologists. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Independent visual estimation by 2 physiotherapists of the ROM. Agreement was calculated as the mean difference in visual estimation between examiners +/-1.96 x standard deviations of this mean difference. The intraclass correlation coefficient (ICC) was calculated as a measure of reliability, based on a 2-way random effects analysis of variance. RESULTS: The lowest level of agreement was for visual estimation of active and passive elevation (limits of agreement, -43.4 to 39.8 and -46.7 to 41.5, respectively, for the difference between the affected and contralateral sides), for which the level of agreement was most clearly associated with pain severity and disability. The ability to differentiate between subjects was acceptable for all movements for the difference between the affected and contralateral sides (ICCs, > .70) except for horizontal adduction (ICC = .49). CONCLUSIONS: Interobserver agreement was low for the assessment of active and passive elevation, especially for patients with a high pain severity and disability. Except for horizontal adduction, visual estimation seems suitable for distinguishing differences between affected and contralateral ROM between subjects.     

Intra- and inter-rater reliability of a modified measure of hand behind back range of motion

The aim of this reliability study was to identify the clinimetric properties, specifically intra- and inter-rater reliability, for measuring the functionally and clinically important hand behind back (combined shoulder internal rotation/adduction and elbow flexion) range of motion using a modified technique. Sixty asymptomatic participants (20 male, 40 female) aged 45.4 ± 11.7 years (mean ± SD). Hand behind back was measured as the distance from the mid-line between the posterior superior iliac spines (PSIS) to the tip of the thumb and recorded in centimetres above the PSIS (a positive measure) or below the PSIS (a negative measure). The intra- and inter-rater reliability for the measurement were excellent, with ICC (2,1) of 0.95 for intra-rater and ICC (2,2) of 0.96 for inter-rater reliability. The standard error of the measurement (SEM) and smallest real difference (SRD) values showed acceptable levels of measurement error, SEM 4.3 mm and SRD 12.8 mm for intra-rater reliability and SEM 2.6 mm and SRD 7.7 mm for inter-rater reliability. The assessment of hand-behind-back motion from a point equidistant between the PSISs to the tip of the thumb is more reliable than traditional methods and a useful clinical tool.     

Triceps denervation as a predictor of elbow flexion contractures in C5 and C6 tetraplegia

OBJECTIVE: To determine whether the existence of elbow flexion contractures in persons with C5 or C6 tetraplegia is related to a lack of residual voluntary triceps function and triceps denervation (ie, lower motoneuron damage). DESIGN: A retrospective study of impairment data from 74 arms to identify the incidence of elbow flexion contractures and the contributing factors toward this deformity. SETTING: Five spinal cord injury (SCI) rehabilitation centers in the United States, 1 in England, and 1 in Australia. PARTICIPANTS: Forty-three subjects with motor complete C5 or C6 traumatic SCI. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Active and passive elbow extension, triceps voluntary muscle strength, and triceps response to electric stimulation. RESULTS: Subjects with weak voluntary triceps had significantly fewer and less severe elbow flexion contractures than those with paralyzed triceps ( P =.024). Subjects with completely denervated triceps (ie, no response to electric stimulation) had significantly more elbow flexion contractures than subjects with even a weak response to electric stimulation ( P =.003). Overall, 51% of the arms could not be passively extended to zero. Forty-six percent of the arms classified as C5 lacked full passive elbow extension, compared with 63% of the arms classified as C6 ( P =.302). CONCLUSIONS: A relationship has been found between elbow flexion contractures and lack of residual voluntary triceps and triceps denervation in subjects with C5 or C6 tetraplegia. There should be a greater awareness of the elbow flexion contractures that may develop as a result of this relationship. A better understanding of this deformity and its characteristics can lead to more effective clinical treatment and prevention strategies.     

Effect of passive stretch on reproducibility of hip range of motion measurements

OBJECTIVE: To examine the intra- and intertester and intra- and interday reliability of hip passive range of motion (PROM) measurements and the effect of passive stretch on the reproducibility of PROM measurements. DESIGN: Reliability study. SETTING: Rehabilitation clinic at university hospital. PARTICIPANTS: Twenty volunteers (12 women, 8 men; age range, 18-45 y). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Two physical therapists made 2 PROM measurements on the first day and repeated them once after 2 days. The PROM in hip flexion, extension, and inner rotation and knee flexion were determined. The measurements of the hip flexion and inner rotation involved either 1 or 8 short-term passive stretches. The reproducibility was expressed as the intraclass correlation coefficient (ICC) and the coefficient of variation (CV) (in percent). RESULTS: The passive stretch increased significantly ( P <.05 to P <.001) the PROM of the hip joint. The reproducibility of the PROM measurement did not increase after repetitive passive stretch. The intra- and interday intra- and intertester ICC and CV of the PROM of the hip flexion and hip inner rotation ranged from .655 to .988 and 2.1% to 12.6%, respectively. The intra- and intertester intra- and interday ICC of the PROM of the hip extension ranged from .740 to .961, and the CV ranged from -85.5% to 242.6%. The intra- and intertester intra- and interday ICC of the PROM of the knee flexion ranged from .497 to .913, and the CV ranged from 2.5% to 9.9%. CONCLUSIONS: Repetitive stretching increased significantly the PROM in hip flexion and inner rotation, but the reproducibility of the PROM measurement did not improve. The hip flexion and the hip inner rotation PROM measurements had moderate to very high intra- and interday intra- and intertester reliabilities. The reliability of the PROM in hip extension and knee flexion was poor.     

Inter- and intrarater reliability of a back range of motion instrument

OBJECTIVE: To examine the interrater and intrarater reliability of a back range of motion (BROM) instrument when measuring lumbar spine active planar motions and pelvic inclination. DESIGN: Single-group repeated measures for inter- and intrarater reliability. SETTING: Academic institution. PARTICIPANTS: Ninety-one participants (61 women, 30 men; mean age, 28 y) without a current complaint of low back pain volunteered. INTERVENTION: Two examiners measured pelvic inclination and all lumbar motions by using the BROM device. Subjects alternated between examiners for 4 complete trials; examiners remained blinded to the measurements. MAIN OUTCOME MEASURES: Intraclass correlation coefficients (ICCs) were used to determine intrarater and interrater reliability. Regression analysis was performed to determine the role palpation played in sagittal plane measurement error. RESULTS: Intrarater reliability for side bending was good (ICC range, .85-.83), lumbar forward flexion and pelvic inclination was good to fair (ICC range, .84-.79), and extension and rotation was fair to poor (ICC range, .76-.58). Interrater reliability was fair to poor for all lumbar motions and for pelvic inclination (ICC range, .79-.55). Less than 2% of the variation in sagittal plane measurements was explained by consistency of palpation for device placement. CONCLUSIONS: The BROM provides a reliable means of measuring lumbar forward flexion, side bending, and pelvic inclination when performed by the same examiner in asymptomatic subjects.     

Reliability of the assessment of lumbar range of motion and maximal isometric strength

OBJECTIVE: To examine the interobserver reliability and intrasubject variability of the assessment of lumbar range of motion (ROM) and maximal isometric strength in asymptomatic subjects by using commercially available equipment. DESIGN: A cross-sectional repeated-measures design. SETTING: Ambulatory care in a university hospital. PARTICIPANTS: Convenience sample of 61 asymptomatic healthy subjects aged 20 to 55 years. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Six movements of the lumbar spine were assessed with commercially available equipment. Both the ROM and the maximal isometric strength for flexion, extension, lateroflexion, and rotation of the lumbar spine were assessed by 2 investigators who were blinded to the outcome of the assessment performed by their colleague. RESULTS: The intraclass correlation coefficient (ICC) was above .95 for all the strength measurements. For the assessment of the ROM of the lumbar spine, the ICC varied between .77 and .94. There was a significant intrasubject variability for 8 of 12 measurements. CONCLUSIONS: The interobserver reliability is excellent for the measurement of the maximal isometric strength and good for the assessment of the ROM of the lumbar spine. There is a significant intrasubject variability, which requires the use of the mean or the best value of different trials.     

Effect of heat in increasing the range of knee motion after the development of a joint contracture: an experiment with an animal model

OBJECTIVE: To compare the effects of 2 different heat modalities, infrared and ultrasonic therapy, on a knee flexion contracture. DESIGN: In vivo, experimental, controlled study involving a rat knee joint contracture model that was immobilized using a ligature in flexion for 40 days. SETTING: Collegiate research laboratory. ANIMALS: Ninety-three adult male Wistar rats. INTERVENTIONS: After remobilization, rats were assigned to 3 treatment groups: stretching only (S), stretching with infrared therapy (S+IR), and stretching with ultrasonic therapy (S+US). Six treatment sessions were given in 2 weeks. MAIN OUTCOME MEASURES: The angle of maximum knee extension, wet-weight of triceps surae muscles, phase lag, and dynamic stiffness as mechanical responses were measured, and histologic study was conducted. RESULTS: Compared with the S group, both the S+IR and S+US groups exhibited a significant increase in range of motion (ROM) (P=.021, P=.008, respectively) and a tendency to decrease the phase lag, but there was no significant difference between the 2 heat-combined groups. There were no differences in the weights of the triceps surae muscles and in dynamic stiffness among the groups. CONCLUSIONS: Six treatment sessions of stretching with infrared or ultrasound were more effective than stretching without heat at increasing the ROM and decreasing the phase lag of a moderately severe joint contracture. The clinical implementation of heat is advocated to regain a normal ROM and mechanical property when experiencing a joint contracture.     

Assessing physical function in adult acquired major upper-limb amputees by combining the Disabilities of the Arm, Shoulder and Hand (DASH) Outcome Questionnaire and clinical examination

Østlie K, Franklin RJ, Skjeldal OH, Skrondal A, Magnus P. Assessing physical function in adult acquired major upper-limb amputees by combining the Disabilities of the Arm, Shoulder and Hand (DASH) Outcome Questionnaire and clinical examination.

Objectives

To describe physical function in adult acquired major upper-limb amputees (ULAs) by combining self-assessed arm function and physical measures obtained by clinical examinations; to estimate associations between background factors and self-assessed arm function in ULAs; and to assess whether clinical examination findings may be used to detect reduced arm function in unilateral ULAs.

Design

Survey: postal questionnaires and clinical examinations.

Setting

Norwegian ULA population. Clinical examinations performed at 3 clinics.

Participants

Questionnaires: population-based sample (n=224; 57.4% response rate). Clinical examinations: combined referred sample and convenience sample of questionnaire responders (n=70; 83.3% of those invited). Survey inclusion criteria: adult acquired major upper-limb amputation, resident in Norway, mastering of spoken and written Norwegian.

Interventions

Not applicable.

Main Outcome Measures

The Disabilities of the Arm, Shoulder and Hand (DASH) Outcome Questionnaire, and clinical examination of joint motion and muscle strength with and without prostheses.

Results

Mean DASH score was 22.7 (95% confidence interval [CI], 20.3–25.0); in bilateral amputees, 35.7 (95% CI, 23.0–48.4); and in unilateral amputees, 22.1 (95% CI, 19.8–24.5). A lower unilateral DASH score (better function) was associated with paid employment (vs not in paid employment: adjusted regression coefficient [aB]=−5.40, P=.033; vs students: aB=−13.88, P=.022), increasing postamputation time (aB=−.27, P=.001), and Norwegian ethnicity (aB=−14.45, P<.001). At clinical examination, we found a high frequency of impaired neck mobility and varying frequencies of impaired joint motion and strength at the shoulder, elbow, and forearm level. Prosthesis wear was associated with impaired joint motion in all upper-limb joints (P<.006) and with reduced shoulder abduction strength (P=.002). Impaired without-prosthesis joint motion in shoulder flexion (ipsilateral: aB=12.19, P=.001) and shoulder abduction (ipsilateral: aB=12.01, P=.005; contralateral: aB=28.82, P=.004) was associated with increased DASH scores.

Conclusions

Upper-limb loss clearly affects physical function. DASH score limitation profiles may be useful in individual clinical assessments. Targeted clinical examination may indicate patients with extra rehabilitational needs. Such examinations may be of special importance in relation to prosthesis function.     

Thirty minutes of positioning reduces the development of shoulder external rotation contracture after stroke: a randomized controlled trial

OBJECTIVE: To determine the efficacy of positioning the affected shoulder in flexion and external rotation to prevent contracture shortly after stroke. DESIGN: Prospective, parallel-group, randomized controlled trial. SETTING: Four metropolitan mixed rehabilitation units. PARTICIPANTS: A volunteer sample of 36 subjects (minus 5 dropouts), whose mean age was 68 years and had had their first stroke within the past 20 days. INTERVENTIONS: The experimental group received two 30-minute sessions a day, 5 days a week, for 4 weeks, during which the affected upper limb was placed in maximum comfortable external rotation and 90 degrees of flexion. Both the experimental and control groups received up to 10 minutes of shoulder exercises and standard upper-limb care. MAIN OUTCOME MEASURES: Contracture was measured as the maximum passive shoulder external rotation and flexion of the affected side as compared with the intact side. Measures were taken at 2 and 6 weeks after stroke by an assessor blinded to group allocation. RESULTS: The 30-minute program of positioning the shoulder in maximum external rotation significantly reduced the development of contractures in the experimental group, compared with the control group ( P =.03). The 30-minute program of positioning the shoulder in 90 degrees of flexion did not prevent contractures in the experimental group as compared with the control group ( P =.88). CONCLUSIONS: At least 30 minutes a day of positioning the affected shoulder in external rotation should be started as soon as possible for stroke patients who have little activity in the upper arm.     

Impact of a pushrim-activated power-assisted wheelchair on the metabolic demands, stroke frequency, and range of motion among subjects with tetraplegia

OBJECTIVES: To determine differences in metabolic demands, stroke frequency, and upper-extremity joint range of motion (ROM) during pushrim-activated power-assisted wheelchair (PAPAW) propulsion and traditional manual wheelchair propulsion among subjects with tetraplegia. DESIGN: Repeated measures. SETTING: A biomechanics laboratory within a Veterans Affairs medical center. PARTICIPANTS: Fifteen full-time manual wheelchair users who had sustained cervical-level spinal cord injuries. INTERVENTIONS: Participants propelled both their own manual wheelchairs and a PAPAW through 3 different resistances (slight, 10W; moderate, 12W; high, 14W) on a wheelchair dynamometer. Each propulsion trial was 3 minutes long. MAIN OUTCOME MEASURES: Primary variables that were compared between the 2 wheelchairs were participants mean steady-state oxygen consumption, ventilation, heart rate, mean stroke frequency, and maximum upper-extremity joint ROM. RESULTS: When using the PAPAW, participants showed a significant ( P <.05) decrease in mean oxygen consumption and ventilation throughout all trials. Mean heart rate was significantly lower when using the PAPAW for the high resistance trial. Stroke frequency was significantly lower when using the PAPAW for the slight and moderate resistances. Overall joint ROM was significantly lower when using the PAPAW. CONCLUSIONS: For subjects with tetraplegia, PAPAWs reduce the energy demands, stroke frequency, and overall joint ROM when compared with traditional manual wheelchair propulsion.     

Poststroke shoulder pain: its relationship to motor impairment, activity limitation, and quality of life

OBJECTIVE: To assess the relationship between poststroke shoulder pain, upper-limb motor impairment, activity limitation, and pain-related quality of life (QOL). DESIGN: Cross-sectional, secondary analysis of baseline data from a multisite clinical trial. SETTING: Outpatient rehabilitation clinics of 7 academic medical centers. PARTICIPANTS: Volunteer sample of 61 chronic stroke survivors with poststroke shoulder pain and glenohumeral subluxation. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: We measured poststroke shoulder pain with the Brief Pain Inventory question 12 (BPI 12), a self-reported 11-point numeric rating scale (NRS) that assesses "worst pain" in the last 7 days. Motor impairment was measured with the Fugl-Meyer Assessment (FMA). Activity limitation was measured with the Arm Motor Ability Test (AMAT) and the FIM instrument. Pain-related QOL was measured with BPI question 23, a self-reported 11-point NRS that assesses pain interference with general activity, mood, walking ability, normal work, interpersonal relationships, sleep, and enjoyment of life. RESULTS: Stepwise regression analyses indicated that poststroke shoulder pain is associated with the BPI 23, but not with the FMA, FIM, or AMAT scores. CONCLUSIONS: Poststroke shoulder pain is associated with reduced QOL, but not with motor impairment or activity limitation.     

正常老年人关节活动范围的研究

目的确定各年龄组正常老年人的主要关节活动范围(ROM)的正常值,各组内ROM的性别间差异,ROM随增龄而下降的情况,及这种下降是否影响日常生活活动(ADL).方法50～89岁4个年龄组共200人,男女各100人,测量肩、肘、前臂、腕、髋、膝、踝等关节的共24个ROM.计算各组ROM的95%正常值范围,按双侧估计95%正常值,-x±1.96s;对组内性别间ROM差异按α=0.05进行成组设计的两样本均数比较的t检验;对老年前期组与老年组ROM差异按α=0.05进行两大样本均数比较的u检验.结果50～59岁、60～69岁、70～79岁、80～89岁4组ROM的正常值均随年龄的增加而进行性下降趋势;组内ROM的性别间差异多无显著性意义.结论老年人各组ROM均随年龄的增加有不同程度的下降,但明显大于基本ADL所需的数值.     

Validity of an Alternate Hand Behind Back Shoulder Range of Motion Measurement in Patients With Shoulder Pain and Movement Dysfunction

Objectives

The purpose of this study was to determine the criterion-related validity of a novel method of measuring hand behind back (HBB) shoulder range of motion (ROM) for evaluating pain and disability in people with shoulder pain and movement impairment.

Intraobserver reliability of 4 physiologic movements of the shoulder in subjects with and without symptoms

OBJECTIVE: To assess intraobserver reliability of 4 physiologic movements of the shoulder. DESIGN: Test-retest analyses. Blinded data entry. SETTING: Outpatient department in National Health Service teaching hospital. PARTICIPANTS: Forty-five asymptomatic volunteers and 45 subjects with shoulder symptoms. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Intraclass correlation coefficients (ICC), 95% confidence intervals, and standard error (SE) of measurements for bilateral measurements of shoulder flexion and abduction (gravity dependent inclinometer), shoulder external rotation (tape measure), and shoulder internal rotation (visual estimation). RESULTS: For subjects without symptoms, single measure ICC results ranged from .85 to .96; SE of measurement results for the angular movements ranged from 2.1 degrees to 2.8 degrees and for the linear measurements 1.1 to 1.6 cm. For subjects with symptoms, single measure ICC results ranged from .82 to .98; SE of measurement results for the angular movements ranged from 1.5 degrees to 13.3 degrees and for the linear measurements 1.3 to 1.6 cm. CONCLUSIONS: With the exception of painful shoulder flexion in the group of subjects with symptoms, the single-measure ICC results were very good to excellent and the highest SE of measurement values were 5.3 degrees for the angular measurements and 1.6 cm for the linear measurements. For clinicians involved in the management of subjects with shoulder symptoms, the SE of measurement results provide guidance as to the error associated with the individual measurements. Using the SE of measurement results, a clinician may determine if a clinically important change, be it negative or positive, has occurred as a result of any intervention offered.     

Validity of the Fingertip-To-Floor Test and Straight Leg Raising Test in Patients With Acute and Subacute Low Back Pain: A Comparison by Sex and Radicular Pain

Ekedahl KH, Jönsson B, Frobell RB. Validity of the fingertip-to-floor test and straight leg raising test in patients with acute and subacute low back pain: a comparison by sex and radicular pain.

Objective

To use self-reported disability (Roland-Morris Disability Questionnaire [RMDQ]) to assess the criterion validity of straight leg raising (SLR) test and flexion range of motion (ROM) (fingertip-to-floor test) before and after stratification by sex and presence/absence of radicular pain.

Design

Cross-sectional study.

Setting

Outpatient physical therapy clinic.

Participants

Subjects with acute/subacute low back pain with (n=40) and without (n=35) radicular pain.

Interventions

Not applicable.

Main Outcome Measures

We examined the relationship between RMDQ (reference variable) and SLR test and fingertip-to-floor test. The sample was stratified by presence/absence of radicular pain (categorized by the dichotomous slump test).

Results

In the entire sample, fair correlations were found between both physical impairment tests (ie, SLR test and flexion ROM) and self-reported disability (.27<r>.44). After stratification by sex, the correlation between RMDQ and flexion ROM and between RMDQ and nonside-specific SLR test increased in women but decreased in men. In those with radicular pain, good correlations were found between RMDQ and flexion ROM (r=.68 for men and r=.70 for women), and moderate correlation was found between the RMDQ and SLR tests of the affected side in women (r=.60), but only fair correlation was found between the RMDQ and SLR tests of the affected side in men (r=.28).

Conclusions

After stratification by sex and presence/absence of radicular pain, the present study supports a good validity of the fingertip-to-floor test for both men and women with radicular pain. The SLR test, however, was of less value as an indicator of self-reported disability after stratification, especially for men.     

A new shoulder range of motion screening measurement: its reliability and application in the assessment of the prevalence of shoulder contractures in patients with impaired consciousness caused by severe brain damage

OBJECTIVES: To determine the reliability of a new shoulder joint range of motion (ROM) measurement for unconscious patients and to assess the prevalence of shoulder joint contractures in such patients. DESIGN: Prospective cohort survey. SETTING: An early rehabilitation center for adult persons with neurologic disorders. PARTICIPANTS: Fifty patients with impaired consciousness caused by severe cerebral damage of various etiologies. In addition, reference values were measured in 60 healthy adults. INTERVENTION: Shoulder ROM was assessed by measuring the distance between the olecranon and underlay while the patient lay supine on a solid surface and the patient's hands were passively positioned behind the neck. Distances between the olecranon and underlay were measured, first, manually by the rater and, second, for control, digitally by a blinded person from a digital photo taken while a constant force was applied to the elbow. MAIN OUTCOME MEASURES: Prevalence of contractures defined as increased distance between the olecranon and underlay or impossibility of positioning the hands passively behind the neck, and intra- and interrater-reliability of the 2 shoulder ROM measurements with the interclass correlation coefficient (ICC). RESULTS: Measurement of shoulder ROM showed high intra-(ICC range, .78-.91) and interrater reliability (ICC range, .77-.90) for manual measurement, high intra- (ICC range, .91-.95) and interrater reliability (ICC range, .90-.94) for the digital analysis, and a high ICC for both methods (ICC=.87). The prevalence of shoulder contractures was 56% in the patients and 50% of all shoulder joints. CONCLUSIONS: The described method provided a reliable measurement for reduced shoulder ROM and appears to be a useful screening method to show the prevalence of shoulder joint contracture in these patients.     

Muscle strength and flexibility characteristics of people displaying excessive medial knee displacement

Bell DR, Padua DA, Clark MA. Muscle strength and flexibility characteristics of people displaying excessive medial knee displacement.

Objective

To determine differences in strength and range of motion (ROM) between participants who exhibit medial knee displacement (MKD) during a squat that is corrected by a heel lift and those who do not.

Design

Case control.

Setting

Sports medicine research laboratory.

Participants

Thirty-seven healthy subjects (control, 19; MKD, 18) with no lower-extremity injury in the past 6 months volunteered to participate.

Interventions

Not applicable.

Main Outcome Measures

Peak force was measured in newtons using a hand-held dynamometer and passive ROM was measured in degrees with a goniometer. Separate multivariate analyses of variance were used to determine differences in strength and ROM between groups. Post hoc testing was used to elucidate differences between groups.

Results

The MKD group had the following: greater hip external rotation strength (P=.03), increased hip extension strength (P=.01), less plantarflexion strength (P=.007), and increased hip external rotation ROM (P=.008).

Conclusions

The MKD group exhibited tight and weak ankle musculature. Interventions focusing on improving strength and ROM of the ankle may improve kinematics during a squat.     

The effect of heat on tissue extensibility: a comparison of deep and superficial heating

OBJECTIVE: To compare the effects of deep heating (shortwave diathermy [SWD]) and superficial heating (hydrocollator packs) on tissue extensibility. DESIGN: A double-blind, repeated-measures study. Possible effects of sex and intervention order were controlled. SETTING: A clinical laboratory. PARTICIPANTS: Twenty-four subjects with no neurologic or musculoskeletal pathologies affecting their lower limbs. INTERVENTIONS: Three intervention conditions: deep heating (SWD), superficial heating (hot packs), and no heating were applied in preallocated order to each subject at least 36 hours apart. MAIN OUTCOME MEASURES: Ankle dorsiflexion in weight bearing was measured by using an inclinometer to ascertain changes in the extensibility of the calf muscles and associated soft tissues. RESULTS: Deep heating increased the range of ankle dorsiflexion by 1.8 degrees +/-1.9 degrees . The change in ankle dorsiflexion after superficial and no heating was 0.7 degrees +/-1.5 degrees and -0.1 degrees +/-1.0 degrees , respectively. CONCLUSIONS: Deep heating, in the absence of stretching, increases tissue extensibility more than superficial heating or no heating. Superficial heating is more effective than no heating, but the difference was not statistically significant.