Introduction
Methods
Study selection
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The paper had to be written in English or Dutch;
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Studies had to pertain to the cervical or upper thoracic spine;
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Studies had to investigate the reproducibility, validity or responsiveness of instruments or tests for measuring ACROM;
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The instrument or test used had to be described clearly, enabling eventual replication of the test,
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And the instrument or test had to be portable, affordable (maximum 1,000 Euros) and easy to use (time to test maximum 5 min) by healthcare professionals in daily practice.
Data abstraction and quality assessment
Clinimetric property | Definition | Criteria |
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Reproducibility | Degree to which repeated measurements in stable persons provide similar answers | K: nominal/ordinal data ICC: ordinal/parametric data + Adequate design, method, intraobserver ICC > 0.85 or K > 0.41 interobserver ICC > 0.70 or K > 0.41 ± Adequate design, method, intraobserver ICC < 0.85 or K < 0.40 interobserver ICC < 0.70 or K < 0.40 ? Doubtful method used o No information found Limits of agreement, SEM or SDC are presented + Adequate design method and result ? Doubtful method used − No information found |
Reliability | The extent to which patients can be distinguished from each other, despite measurement error | |
Agreement | The ability to achieve the same value with repeated measurements | |
Construct validity | The extent to which a test identifies the concept or trait of which is being measured | Pearson R or Spearman Rho + Adequate design, method, r > 0.65 ? Doubtful method used − Inadequate construct validity o No information found |
Responsiveness | Ability of an instrument to detect important change over time in the concept being measured | Hypotheses were formulated and results are in agreement + Adequate design method and result ? Doubtful method used − Inadequate responsiveness o No information found |
Interpretability | The degree to which one can assign qualitative meaning to quantitative scores | Authors provided information on the interpretation of scores, MIC defined Mean and SD scores before and after treatment |
Description of the instruments for the assessment of ACROM
Reproducibility
Validity
Responsiveness
Interpretability
Overall quality
Results
Selection of the studies
Author and tool | Purpose | Patient | Examiner | Procedure/protocol | Results |
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Agarwal [1] Spin-T goniometer | Intraobserver Reliability | Thirty healthy subjects | ? | Patient seated near front wall for reference subject seated fl/ext/lfl/rot Warming-up? All movement measured three times test-retest interval no, blinding ex-pt? | ICC intra > 0.96 |
Agarwal [2] Spin-T goniometer | Validity | Four healthy subjects and foam head model | ? | Reference test Motion star recording simultaneously foam head model and four men. Readings fl/ext/lfl/rot | Coefficient determination (R
2) higher than 0.99 |
Alantara [3] Liquid inclinometer Gravitation inclinometer | Intra and interobserver Reliability | Twenty-four healthy subjects | two physical therapists | Warming-up? Intraobserver one-year interval Interobserver one week interval Blinding ex-pt? | Reliability factor Intra Fl/EXT 0.68 LFL 0.61 ROT 0.37 systematic difference (P) Fl/EXT 0.58 LFL 0.38 ROT 0.00 Inter FL/EXT 0.69 LFL 0.79 ROT 0.86 systematic difference (P)Fl/EXT 0.42 LFL 0.31 ROT 0.24 |
Balogun [8] Myrin goniometer | Intra and interobserver Reliability | Twenty-one healthy subjects | Three physical therapist | Subject seated Myrin location: Fl-ext above earlobe LFL forehead ROT vertex Warming-up: ? Number of measurements? test-retest interval 4 days blinding ex-pt? | Pearson r Gonio Fl 0.31–0.34 EXT 0.71–0.86 ROT R 0.49–0.67 ROT L 0.53–0.56 LFL R 0.0.49–0.78 LFL L 0.61–0.67 |
Bush [15] inclinometer | Reliability Validity | Three healthy subjects | Thirty-four physical therapists | Patient seated FL/EXT/LFL. Patient supine ROT three methods used reliability single method double method, stabilization method Validation RX flexion/extension/lfl CT scan rotation test-retest interval?, blinding ex-pt? | ICC inter Single 0.91–0.93 Double 0.89–0.93 Stab 0.89–0.94 VAL Criteria within ±5° RX FL: single/double EXT: single/stab LFL/ROT not valid |
Capuano-Pucci [16] CROM | Intra and interobserver Reliability | Twenty healthy subjects | ? | Subject seated fl/ext/lfl/rot Warming-up three repetitions half cycle ROM test-retest interval 2 days, blinding ex-pt? | Pearson S Intra tester one 0.63–0.90 tester two 0.62–0.91 Inter session one 0.80–0.87 session two 0.74–0.85 |
Cleland [20] Inclinometer Universal goniometer | Intra and interobserver Reliability Agreement | Twenty-two patients mechanical neck pain | Four physical therapists | Inclinometer patient seated FL/EXT/LFL UG Rotation Patient seated Test-retest interval one directly after the other, blinding examiner-patient? | Inclino ICC inter FL 0.75 (0.50–0.89) EXT 0.74 (0.48–0.88) LFL R 0.66 (0.33–0.84) LFL L 0.69 (0.40–0.86) SEM FL 6.8°, EXT 4.7°, LFL R 3.6°, LFL L 7° MDC FL 18.8°, EXT 13.0°, LFL R 10.0°, LFL L 19° LoA FL 0.76 ± 16.6, EXT 1.6 ± 11.7, LFL R-0.5 ± 9.5, LFL L 2.2 ± 18.3 UG ICC inter ROT R 0.77(0.52–0.90) ROT L 0.57(0.14–0.81) SEM ROT R 5°, ROT L 5.5° MDC ROT R 13.9° ROT L 13.9° LoA ROT R –0.3 ± 15.9 ROT L −1.5 ± 6.4 |
Haynes [32] Spin-T goniometer | Intra and interobserver Reliability Agreement | Twenty-three healthy subjects | Chiropractor & physical therapist | Patient seated corner of room for reference subject seated FL/EXT/LFL/ROT warming-up: two all movement measured: two times Test-retest interval one directly after the other, blinding ex-pt yes | ICC Intra I/II Fl 0.91/0.95 Ext 0.96/0.1 LFL R 0.87/0.98 LFL L 0.87/0.98 ROT R 0.94/0.96 ROT L 0.97/0.97 Inter Fl 0.85 (0.68–0.93) Ext 0.91 (0.80–0.96) LFL R 0.75 (0.50–0.89) LFL L 0.82 (0.62–0.92) Rot R 0.96 (0.91–0.98) Rot L 0.96 (0.89–0.98) SEM Fl 2.7° EXT 4.1° LFL L 3.9° LFL R 4.3° ROT L 2.7° ROT R 2.6° |
Hole [33] CROM Inclinometer | Intra and interobserver Reliability Validity | Thirty healthy subjects | Final year chiropractic student | Subject seated FL/EXT/LFL/ROT, inclinometer pt supine for rotation Warming up? 2 measurements each movement, half cycle ROM Test-retest interval?, blinding ex-pt yes | CROM ICC Intra Fl/EXT 0.96 LFL R 0.96 LFL L 0.96 ROT R 0.92 ROT L 0.92 Inter Fl/EXT 0.88 LFL R 0.82 LFL L 0.86 ROT R 0.94 ROT L 0.90 Inclino ICC Intra Fl/Ext 0.94 LFL R 0.94 LFL L 0.88 ROT R 0.93 ROT L 0.84 Inter Fl/Ext 0.84 LFL R 0.82 LFL L 0.81 ROT R 0.76 ROT L 0.86 Validity ICC FL/EXT 0.80, LFL R 0.80, LFL L 0.78, ROT R −0.23 ROT L −0.12 |
Hoving [35] EDI-320 | Intra and interobserver Reliability Agreement | Thirty-two patients median 13.5 weeks a-specific neck pain | Two physical therapists | Patient seated FL/EXT/LFL patient supine ROT full cycle ROM Warming-up 2× Test-retest interval one directly after the other, blinding ex-pt yes | ICC intra rater 1/rater 2 (95%CI) Fl/Ext 0.96 (0.93–0.98)/0.97 (0.86–0.97) LFL 0.93(0.86–0.97)/0.93 (0.86–0.96) Rot 0.91 (0.91–0.98)/0.96 (0.92/0.98) Inter (95%CI) Fl/Ext 0.95 (0.90–0.98) LFL 0.89 (0.77–0.94) Rot 0.95 (0.90–0.98) LoA intra F/E -2.5±11.1° LFL −0.1 ± 10.4° ROT −5.9 ± 13.5° LoA inter F/E 3.3 ± 17°, LFL 0.5 ± 17°, ROT −1.3 ± 24.6° SDD F/E (11.1°) rot (13.5°) equal to predefined criteria LFL (10.4°) predefined (7.2°) |
Jenkinson [37] inclinometer | Intra and interobserver Reliability | Forty subjects with Ankylosing spondylitis | Three physical therapists | PT seated FL/EXT pt supine ROT Warming-up? Test-retest interval measured on consecutive days, blinding ex-pt? | Pearson r intra 0.99 P < 0.001 inter 0.98 P < 0.001 |
Kadir [41] Goniometer head-gear based | Intra and interobserver Reliability | Thirty subjects both healthy subjects and subjects with neck pain | ? | Patient seated Warming-up? Full cycle ROM measured Test-retest interval one directly after the other, blinding ex-pt? | Intra 95% CI of differences, experienced observer fl/ext ± 13.5°, lfl ± 9.4°, rot ± 7.6°, inexperienced observer fl/ext ± 15°, lfl ± 11.4°, rot ± 10.4° Interobserver >90% total variation because of variation between volunteers (2-way ANOVA). Variation between observers accounted for 1.6% or less of variation, only rotation was significantly different between observers (P < 0.5), range of differences fl/ext 2°–21°, lfl 2°–18°, rot 5°–44° |
Klaber-Moffett [51] Inclinometer | Intra and interobserver Reliability | Twelve healthy females for intraobserver 14 healthy females for interobserver | ? | Patient seated FL/EXT/LFL/ROT Warming-up? Test-retest interval 3× within 1 h, blinding ex-pt? | Intra: repeated measures anova: no sign difference between 3 measurements; 9 of 216 differences >10°, individual measurements rarely fluctuate by more than 15°; 95% prediction interval for difference between observation: fl ± 3.2°, ext ± 13.6°, rot r ± 9.4°, rot l ± 13.2°, lfl r ± 7.2°, lfl l ± 10.7° Inter: paired student t-test no significant difference between observers; 95% prediction interval for difference between observation: fl ± 15.1°, ext ± 19.8°, rot r ± 11.3°, rot l ± 11.6°, lfl r ± 8.9°, lfl l ± 7.8° |
Maksymowich [48] Goniometer | Intra and interobserver Reliability Agreement Validity Responsiveness | Patients with ankylosing spondylitis 44 reliability, 33 responsiveness | Clinician nurse, rheumatologist, trained medical student | pt seated rotation goniometer centre of the head, one arm moved over the plane of the nose as the pt rotates. Score 0: >70,1: 20–70 ,2: <20. Test-retest interval? blinding ex-pt? | ICC Intra 0.98 & 0.97 Inter 0.95 LoA −10.1 to 12.0 Spearman Rho gonio Age −0.41 (<0.001) disease duration −0.42 (<0.001) BASDAI −0.27 (0.001) Responsiveness ES 0.34 SRM 0.86 P < 0.001 |
O’ Driscoll [53] Spirit inclinometer (hydrogoniometer) | Intraobserver Reliability | Ten subjects intraobserver study Ten subjects interobserver study | Metrologists and clinician with several years experience | pt seated FL/EXT/LFL pt supine ROT Warming-up? Intraobserver one-month interval, blinding ex-pt? | Intraobserver SD of differences Fl ± ext 4.1°, lfl 4.7°, rot 3.7° Mean difference± standard error fl/ext 1.9 ± 3.1° lfl 1.5 ± 3.2° rot 1.9 ± 3.8° |
Olson [54] CROM | Intra and interobserver Reliability Agreement | Twelve healthy subjects | ? | Subject seated FL/EXT/LFL/ROT Warming-up 5 times, 2 measurements each movement, half cycle ROM Test-retest interval? blinding ex-pt? | ICC Intra Fl 0.88 EXT 0.99 LFL R 0.98 LFL L 0.98 ROT R 0.99 ROT L 0.97 Inter Fl 0.58 Ext 0.97 LFL R 0.96 LFL L 0.94 ROT R 0.96 ROT L 0.98 SEM Fl 4° EXT 3° LFL L 2° LFL R 2° ROT L 3° ROT R 2° |
Ordway [55] CROM | Validity | Twenty healthy subjects | ? | Reference test Radiographic/computerised tracking system 3 space Patient seated, flexion extension Warming-up three times, number measurement? measurements simultaneously, blinding ex-pt? | Test Newman Keuls post hoc test, no difference CROM-RX, CROM-3 space significant difference (P < 0.05) |
Pellechia [56] Plastic goniometer with paperclip placed through axis of rotation | Intra and interobserver Reliability | Hundred healthy subjects, intratester, 35 healthy subjects intertester | Two physical therapists, 13 and 2 years experience | Subject seated cervical lateral flexion Warming-up? 2 repetitions for each measurement, Test-retest interval?, blinding ex-pt? | ICC intraobserver LFL L 0.91 LFL R 0.94 ICC interobserver LFL L 0.65 LFLF R 0.86 |
Piva [59] inclinometer | Interobserver Reliability, Agreement Validity | Thirty neck pain patients | Manual therapists | Patient seated, extension/flexion/lfl Patient supine rotation Warming-up? Test-retest interval one directly after the other, blinding ex-pt? Validity correlation AROM-NDI | ICC Inter (95%CI) Fl 0.78 (0.59–0.89) EXT 0.86 (0.73–0.93) LFL R 0.87 (0.75–0.94) LFL L 0.85 (0.70–0.92) ROT R 0.86 (0.74–0.93) ROT L 0.91 (0.82–0.96) SEM; Fl 5.8° EXT 5.6° LFL L 4.2° LFL R 3.7° ROT L 4.1° ROT R 4.8° MDC; Fl 16° EXT 16° LFL L 12° LFL R 10° ROT L 11° ROT R 13° Pearson r AROM FL/EXT r 0.43, ROT r 0.40 |
Rheault [61] CROM | Interobserver Reliability | Twenty-two subjects with cervical sprain/spondylosis/degenerative disc/herniated disc/undiagnosed neck pain | ? | Subject seated FL/EXT/LFL/ROT Warming-up ? 2 measurements each movement, half cycle ROM Test-retest interval ?, blinding ex-pt? | ICC Inter Fl 0.76 EXT 0.98 LFL R 0.87 LFL L 0.86 ROT R 0.81 ROT L 0.82 |
Tousignant [69] CROM | Validity | Thirty-one healthy subjects | Three physical therapists | Reference test Radiographic Flexion/extension, warming-up yes, simultaneous measurements, blinding ex-pt? | Pearson r Flexion 0.97 Extension 0.98 |
Tousignant [68] EDI 320 | Intra and interobserver Reliability | Forty-four healthy subjects | Two testers 2 recorders 4 year physical therapy students | Patient seated FL/EXT half cycle ROM test-retest interval one directly after the other, blinding ex-pt ? | ICC intra 0.77–0.83 inter 0.66–0.80 |
Tousignant [70] CROM | Validity | Twenty-four subjects, minimum 18 years old, who received physiotherapy past 3 months for neck pain | Three physical therapists | Reference test Radiographic Lateral flexion left/right measurements simultaneously, blinding ex-pt? | Pearson r LFL L 0.82 (95% CI 0.62–0.92) LFL R 0.84 (95% CI 0.66–0.93) |
Tousignant [71] CROM | Validity | Forty-five healthy subjects | Research assistant with rehabilitation background | Reference test Optotrack Rot/lfl/ fl/ex Warming-up: 1 measurement 1 number of measurements simultaneously, blinding ex-pt? | Pearson r FL 0.98 (95% CI 0.97–0.99) EXT 0.99 (95% CI 0.98–0.99) LFL R 0.91 (95% CI 0.85–0.95) LFL L 0.89 (95% CI 0.82–0.93) ROT R 0.89 (95%CI 0,81–0.94) ROT L 0.94 (95% CI 0.90–0.97) |
Tucci [73] Universal goniometer gravity goniometer with head adapter | Interobserver Reliability | Ten healthy subjects | ? | pt seated FL/EXT/LFL pt supine ROT Warming-up several trails test-retest interval within one hour, blinding ex-pt? | ICC Inter, UG 2 experienced examiners Fl −0.08 (NS) Ext 0.82 (P < 0.05) ROT r 0.52 (p<0.05) ROT L 0.604 (P < 0.05) LFL r 0.21 (NS) LFL L 0.33(NS) Interobserver, gravity goniometer and head adapter, 1 experienced and 1 novice examiner Fl 0.84 (P < 0.01) Ext 0.86 (P < 0.01) ROT R 0.80 (P < 0.01) ROT L 0.91 (P < 0.01) LFL R 0.87 (P < 0.01) LFL L 0.82 (P < 0.01) |
Viitanen [78] Myrin goniometer | Reliability | Fifty-two male patients with ankylosing spondylitis | Physiotherapists | fl/ext/lfl/rot Warming-up no, number measurements 2 test-retest interval on successive days, blinding ex-pt? | ICC ranged 0.89–0.98, no other details |
Youdas [84] CROM | Intra and interobserver Reliability | Sixty subjects orthopaedic disorders, mainly cervical muscle pain | Eleven physical therapists | Subject seated fl/ext/lfl/rot Warming up three repetitions two measurements each movement, half cycle ROM Test-retest interval one directly after the other, blinding ex-pt? | ICC Intra Fl 0.95 EXT 0.90 LFL R 0.92 LFL L 0.84 ROT R 0.93 ROT L 0.90 Inter Fl 0.86 EXT 0.86 LFL R 0.88 LFL L 0.73 ROT R 0.92 ROT L 0.82 |
Youdas [85] CROM | Intra and interobserver Reliability | Healthy subjects intraobserver reliability 6 subjects, interobserver reliability 20 subjects | 5 physical therapists, faculty members school for physical therapy | Subject seated FL/EXT/LFL/ROT Warming up three repetitions 2 measurements each movement until AROM stopped by muscle tightness/pain/substitution movement half cycle ROM Test-retest interval one directly after the other, blinding ex-pt? | ICC (range) Intra Fl 0.23–0.88 EXT 0.89–0.96 LFL R 0.81–0.95 LFL L 0.67–0.90 ROT R 0.58–0.99 ROT L 0.81–0.95 Inter Fl 0.83 EXT 0.90 LFL R 0.87 LFL L 0.89 ROT R 0.82 ROT L 0.66 |
Wainner [80] inclinometer | Interobserver Reliability Agreement | Eighty-two subjects, 18 cervico radiculopathy, 28 carpal tunnel syndrome, 36 healthy subjects | Two physical therapists | Warming-up two repetitions. Patient seated FL/EXT/LFL Test-retest interval one directly after the other, blinding ex-pt yes | ICC Inter (95%CI) Fl 0.79(0.65–0.88) EXT 0.84 (0.70–0.95) LFL R 0.68 (0.62–0.87)LF L L 0.63 (0.40–0.78) SEM FL 4.6° EXT 4.8° LFL L 5.3° LFL R 5.4° |
Zachman [86] Goniometer Rangiometer | Interobserver Reliability and Validity | Twenty-four healthy subjects | Two chiropractors | Subject seated FL/EXT/LFL/ROT Warming-up three repetitions Test-retest interval? Blinding ex-pt? | Pearson r inter rangiometer Fl 0.64 EXT 0.89 ROT R 0.62 ROT L 0.69 LFL R 0.84 LFL L 0.79 Goniometer Fl 0.54 EXT 0.85 ROT R 0.52 ROT L 0.47 LFL R 0.43 LFL L 0.61 Concurrent validity: r 0.31–0.83 |
Author and tool | Purpose | Patient | Examiner | Procedure/protocol | Results |
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Hoppenbrouwers [34] Visual estimation | Interobserver Reliability | Sixty-nine subjects, healthy and non-specific neck pain | Twenty-four-year physiotherapy students | Active ROM, as described by Dos Winkel, warming up one repetition, 1 measurement classification restricted or not test-retest interval? blinding ex-pt yes | K inter Fl 0.57 Ext 0.88 ROT (l/r) 0.49 (L: 0.43/R: 0.54) LFL (l/r) 0.35 (L: 0.33/R: 0.36) All movements Together 0.52 |
Viikari-Juntura [77] Visual estimation | Interobserver Reliability | Fifty-two patients neck and radicular pain | Physician in physical medicine and rehabilitation and physical therapist | Warming-up active ROM Fl/ext normal >45° limited 30–45° markedly limited <30° ROT normal >80° limited 60–80° markedly limited <60° LFL normal >30° limited 20°–30° markedly limited <20° test-retest interval 1 h, blinding ex-pt yes | Kw inter Fl 0.43 Ext 0.56 ROT R 0.56 ROT L 0.40 LFL R 0.51 LFL L 0.41 |
Author plus tool | Purpose | Patient | Examiner | Procedure/protocol | Results |
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Balogun [8] Tape | Intra and Interobserver Reliability | Twenty-one healthy subjects | Three physical therapist | Subject seated FL/EXT/LFL/ROT Protocol tape as in Hsieh test-retest interval 4 days blinding ex-pt? | Intra Pearson r FL 0.26–0.49 EXT 0.72–0.88 ROT R 0.59–0.86 ROT L 0.58–0.83 LFL R 0.53–0.86 LFL L 0.65–0.77 Inter Pearson r FL 0.30–0.80 EXT 0.86–0.92 ROT R 0.74–0.87 ROT L 0.68–0.85 LFL R 0.51–0.79 LFL L 0.47–0.82 |
Hsieh [36] Tape | Intraobserver Reliability and Agreement | Thirty-four healthy subjects | Physical therapist and physical therapist assistant | Subject seated warming-up? Two repetitions Fl-EXT distance sternal notch-chin ROT distance acromion process-chin LFL distance acromion process-lowest point ear lobe Test-retest interval one direct after each other, blinding ex-pt no | Intra Pearson r FL 0.95 0.86 Ext 0.94 0.79 ROT R 0.88 0.78 ROT L 0.80 0.81 LFL R 0.88 0.91 LFL L 0.87 0.86 SEM (tester1 & 2) Fl 1.4 & 1.91 EXT 1.18 & 3.30 ROT R 1.97 & 2.95ROT L 2.55 & 2.75 LFL R 1.77 & 2.25 LFL L 2.05 2.69 |
Maksymowich [48] Tape | Intra and Interobserver Reliability, agreement, validity, responsiveness | Patients with ankylosing spondylitis 44 for reliability, 33 for responsiveness | Clinician nurse, rheumatologist, trained medical student | Pen mark on suprasternal notch, pt rotate head, distance pen mark and tragus of the ear is recorded. goniometer centre of the head, one arm moved over the plane of the nose as the pt rotates. Score 0,1,2: rotation>70, 20–70, <20. Test-retest interval? blinding ex-pt? | ICC Intra tape 0.80 & 0.89 Inter tape 0.82 LoA tape −1.13 to 1.48 Spearman Rho tape Age −0.18 (0.004) Disease duration −0.28(<0.001) BASDAI 0.04 (NS) Responsiveness ES 0.15 SRM 0.26 P 0.14 |
Viitanen [78] Tape | Reliability | Fifty-two male patients with ankylosing spondylitis | Physiotherapists | Warming-up no LFL distance ear lobe-tuberculum coronoideus claviculae ROT distance chin top- tuberculum coronoideus claviculae test-retest interval on successive days, blinding ex-pt? | ICC ranged 0.89–0.98, no other details |
Goniometers/inclinometers
Visual estimation
Tape measurement
Overall quality
Reliability | Agreement | Validity | Responsiveness | Interpretability | |
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CROM (ten studies) | + | ? | + | O | O |
Universal goniometer (five studies) | ? | ? | ? | ? | O |
Visual estimation (two studies) | − | O | O | O | O |
Tape measure (four studies) | ? | ? | ? | ? | O |
Single inclinometer (four studies) | + | + | ? | O | O |
EDI-320 (two studies) | + | + | O | + | O |