Advances in Physiotherapy, 2011; 13: 128132

ORIGINAL ARTICLE

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Measuring chest expansion; A study comparing two

different instructions

MONIKA FAGEVIK OLSN1,2, HILDA LINDSTRAND2, JENNY LIND BROBERG2 &

ELISABETH WESTERDAHL3,4
1Department

of Physical Therapy, Sahlgrenska University Hospital, Sweden, 2Department of Occupational and Physical Therapy,
Sahlgrenska Academy, Gothenburg University, Sweden, 3Centre for Health Care Sciences, rebro County Council and School of
Health and Medical Sciences, rebro University, Sweden, 4Department of Medical Sciences, Clinical Physiology, Uppsala
University Hospital, Sweden

Abstract
The aim of this study was to examine and compare the effect of two alternative instructions when measuring chest expansion. In 100 healthy subjects, chest expansion was measured using a circumference tape. In 30 healthy subjects, chest expansion was measured by a Respiratory Movement Measuring Instrument (RMMI). Both measurements were made at the level
of the fourth rib and the xiphoid process. The two instructions evaluated were the traditional one: breathe in maximally
and breathe out maximally, which were compared with a new one breathe in maximally and make yourself as big as
possible and breathe out maximally and make yourself as small as possible. The addition of make yourself as big/small
as possible in the new instruction resulted in a significantly increased thoracic excusion, 1.4 cm in upper and 0.9 cm in
lower level of thorax, measured by tape, compared with the traditional instruction ( p 0.001). Measurements obtained using
the RMMI also showed a significant difference, 2.3 mm in upper and 4.1 mm in lower level of thorax, between the two
instructions in favour of the new instruction (p 0.05). The verbal instruction during measurement of chest expansion is of
importance when measured by tape and RMMI. To assess the maximal range of motion in the chest, the patient should be
instructed not only to breathe in/out maximally, but also instructed to make yourself as big/small as possible.
Key words: Instruction, measuring, range of motion, RMMI, thorax

Introduction
To measure and follow changes in pulmonary function, volumes and airflow measurements by spirometry are most frequently used. Measurement of
thoracic mobility and chest expansion could also be
important when exploring reasons for impaired pulmonary function, dyspnoea and decreased exercise
tolerance in patients with different kinds of pulmonary or rheumatic diseases, after thoracic surgery or
after trauma to the rib cage (13). To measure chest
expansion, different techniques are used.
In clinical practice, a simple and inexpensive technique for measurement is to use a tape measure. It is
often used by physiotherapists to diagnose and evaluate treatment, in different patient groups (13).
The technique was first used as diagnostic criteria for

rheumatic diseases (1,4), and has further been used

for evaluation of treatment for scoliosis (5). During
this manoeuvre, the circumference around the thorax
is measured at specific measuring points during maximal inspiration and maximal expiration (1,2,6). The
most commonly used levels, during thoracic excursion
measurement, are the xiphoid process and the third
to the fourth intercostal space/auxiliary level (13,7).
This method of measuring has been shown to be reliable in healthy volunteers (7,8) and in patients with
chronic obstructive pulmonary disease (3).
Sophisticated measurement instruments such as
inductive or opto-electronic plethysmography (9),
computed tomography or video systems for movement measuring (10) are other techniques available
to measure chest expansion. Breathing movements

Correspondence: Monika Fagevik Olsn, Department of Physical Therapy, Sahlgrenska University Hospital, SE 413 45 Gothenburg, Sweden. E-mail: monika.
fagevik-olsen@vgregion.se
(Received 3 May 2010 ; accepted 6 July 2011)
ISSN 1403-8196 print/ISSN 1651-1948 online 2011 Informa Healthcare
DOI: 10.3109/14038196.2011.604349

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Measuring chest expansion

can also be measured by a Respiratory Movement
Measuring Instrument (RMMI). This instrument
measures the changes in anteriorposterior breathing
movements, which has been described to correlate
with overall circumference mobility (1,11). The reliability of RMMI measurement in healthy subjects is
high (12).
Measuring chest expansion is frequently used in
the clinical settings. Different techniques of measurement have been described in the literature; however,
instructions, level of measurement sites and equipment vary. It is well known that diverse instructions
alter the results during spirometry (13). In clinical
practice, it has been observed that chest expansion
can be improved if the patient voluntarily activates
the muscles of the rib cage during measurement of
thoracic excursion. An additional instruction actively
to increase or decrease the volume of the thorax, over
and above the ordinary instruction to breathe in and
out maximally, could possibly optimize measurement
of chest expansion. The purpose of this study was
therefore to examine and compare changes in chest
expansion when adopting two different instructions.

Material and methods

The participants were recruited as a convenience
sample among friends, students and staff at the University of Gothenburg, Sahlgrenska University hospital, during spring 2009. The inclusion criteria were:
2065 years, body mass index within normal range
(1925 kg/m2), no neurological, orthopaedic, rheumatic or respiratory disease/injury causing impairment to the rib cage range of motion or pneumonia
during the last month. Measurements of chest expansion were performed using two different techniques
(tape measure and RMMI) and each technique was
evaluated using the two different verbal instructions.
The trial included two separate samples of participants. The first sample consisted of 100 subjects
(47 men and 53 women) with a mean age (SD) of
33 13.9 years. In this sample, a circumference tape
was used to measure thoracic excursion at two levels
around the chest.
The second sample consisted of another 30 subjects (15 men and 15 women) with a mean age of
38 11.1 years. Chest expansion evaluation was in
this group performed using the RMMI. Breathing
movements in the anteriorposterior diameter of the
thoracic and abdominal wall were assessed (11).
The procedures were conducted in accordance
with the ethical standards of the World Medical Association Declaration of Helsinki: Ethical Principles for
Medical Research Involving Human Subjects. The
participants gave their verbal consent to participate

129

after receiving verbal and written information about

the study.
Thoracic excursion measurement
The first study sample was assessed using a tape
(marked in mm) around the circumference of the
chest to give a measurement of chest expansion or
mobility (1,2,7). Thoracic excursion was measured
at two levels. Upper thoracic excursion was measured
at the level of the fourth costae at the mid-clavicular
line. Lower thoracic excursion was measured at the
level of the xiphoid process (1,2). The tests were performed with the volunteers standing with their hands
placed on their head (1). The participants were told
that the aim of the investigation was to evaluate two
different instructions on chest expansion and that
they should listen carefully and follow the instructions given. No further verbal instructions were given
during the test.
The traditional instruction for measuring thoracic excursion was breathe in maximally and
breathe out maximally (1). This instruction demonstrates thoracic excursion measurement and is
defined as thoracic excursion equals thoracic circumference at the end of forced inspiration minus
thoracic circumference at the end of forced expiration (7). The second, new instruction was Breathe
in maximally and make yourself as big as possible
and Breathe out maximally and make yourself as
small as possible.
The test procedure was standardized and the two
involved examiners trained the testing before study
start to avoid measurement errors and increase interrater reliability. The order of the levels (the fourth
costae and the xiphoid processus) was randomized
as well as the order of the two instructions by tossing
a dice. The tests were performed twice for each
instruction with the best value used in the analysis.
The result of the chest excursion measurement was
defined as the difference to the nearest 1 mm between
full expiration and inspiration.
Respiratory Movement Measuring Instrument
measurement
In the second sample, bilateral breathing movements
were measured with the RMMI (ReMo, Inc., Keldnaholt, Reykjavik, Iceland) (11). The RMMI was developed to detect changes in the anteriorposterior
diameter of the thoracic and abdominal wall during
quiet breathing and different breathing manoeuvres
(11). It consists of six laser distance sensors with an
accuracy of 0.0003 mm and a measuring frequency
of 21 Hz, an analogue to digital converter and a computer program for PC computer. Two rods are holding

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130

M. F. Olsn et al.

the sensors, three on each, to be positioned to measure

at defined points of the body. The rods are held by a
horizontal pole and are moveable sideways to account
for differences in chest width, and can be turned on
the rod from a vertical to horizontal position for measurements in supine, half-sitting, sitting or standing
positions. Four laser distance sensors were used in this
trial and the diodes were placed 15 cm over the measuring points (the fourth costae and the xiphoid processus). The subjects were seated in a chair with their
backs supported. The same two instructions, described
above, were given twice in a randomized order. The
best value on each side (right or left) was used in the
analysis. The procedure was standardized and performed by the same examiner.
Statistical analysis
Mean and standard deviation was calculated using
Excel 2003. The SPSS version 15.0 (SPSS Inc, Chicago, IL) was used for the statistical analysis. To analyse differences between the two instructions, a paired
t-test was used. Differences within the group is analysed by un-paired t-test as well as sub-groups for
women and men while lung function and breathing
movements are known to differ between gender
(11,14). To analyse carryover effects of the order of
the instructions un-paired t-test was used. Significance level was defined as p 0.05.

Results
Thoracic excursion
The results of the tape measure with each instruction,
for the whole group and separated into men and
women, are given in Table I. The addition of instructions to make yourself as big/small as possible
resulted in an increased thoracic excursion. There was
a significant difference of 0.91.4 cm between the two
evaluated instructions in the whole group at both thoracic levels (p 0.001). Significant differences for

men and women respectively were also seen (p 0.001).

In addition, there were also significant differences in
absolute values between men and women (p 0.05).
The included women had significantly smaller values
than the men. All participants chest expansions
assessed by thoracic excursion measurement after
traditional instruction (1) were all within normal
values (2).
Respiratory Movement Measuring Instrument
The results from each instruction measured by the
RMMI, for the whole group and separated into men
and women, are given in Table II. There was a
significant difference of 2.3 mm between the two
instructions at the level of the fourth costae (p 0.001)
and 4.1 mm at the level of the xiphoid process
(p 0.01). Also, when separated into two groups of
women and men, the differences were significant at
both levels (fourth costae p 0.01 and xiphoid process p 0.05 in both groups). There were no significant differences in absolute values between men and
women.
There was no carryover effect found when
analysing the order of the instructions measured by
tape or RMMI.

Discussion
The findings demonstrate that the new instruction
make yourself as big/small as possible in addition
to the traditional one breathe in/out maximally
resulted in significantly increased chest expansion.
There were significant differences in thoracic excursion results between the two instructions when measured by both tape and RMMI. These differences
were found in the whole group as well as in men and
women respectively. The instruction given seems to
be of importance in the results of the measurements.
Therefore, when measuring range of motion in the
thorax, the aim of the test must be clear. If the aim is
to measure respiratory movement between maximal

Table I. Results of the thoracic excursion measurement by tape for the two instructions at the level of costae 4 and processus xiphopideus.

Costae 4 (cm)

Processus xiphoideus (cm)

Group

Ordinary instruction

New instruction

p-value

Total
Women
Men
Total
Women
Men

5.5 1.5
5.2 1.6
5.8 1.3
6.5 2.0
5.9 1.8
7.1 2.0

6.9 2.5
6.1 2.1
7.8 2.7
7.4 2.3
6.8 1.9
8.1 2.5

0.001
0.001
0.001
0.001
0.001
0.001

Values given as mean SD. Total n 100, women n 53, men n 47. p-value 0.05;
and men.

p-value 0.01

differences between women

Measuring chest expansion

131

Table II. Results of the Respiratory Movement Measuring Instrument for the two instructions at the level of costae 4 and processus
xiphoideus.

Costae 4 (mm)

Processus xiphoideus (mm)

Group

Ordinary instruction

New instruction

p-value

Total
Women
Men
Total
Women
Men

15.4 5.2
15.4 5.9
15.4 4.6
10.3 5.7
8.3 5.9
12.2 5.0

17.7 5.3
19.1 6.1
18.2 4.2
14.4 8.6
12.3 6.7
16.4 10.0

0.001
0.01
0.01
0.01
0.05
0.05

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Values given as mean SD. Total n 30, women n 15, men n 15.

inspiration and maximal expiration, the instruction

by Moll & Wright (1), breathe in/out maximally, is
appropriate to use. However, if the aim is to measure
the maximal range of motion in the thorax, the new
instruction should be considered. This includes additional voluntarily activation of the rib cage muscles.
The new instruction is easy to use regardless of which
technique is used for the measuring. The subjects are
required to listen carefully to and follow the instructions in order to increase reliability.
In clinical practice, measurements of chest
expansion is used in patients with lung or rheumatic diseases, but also other groups of patients
who suffer from impaired range of motion in the
rib cage as after a thoracotomy are measured (15).
The differences in circumference between the
instructions were 0.91.4 cm in healthy subjects.
This is important and of clinical relevance when
evaluating lung and rib cage functions in several
diseases and conditions. It is still unclear, though,
whether different categories of patients show the
same differences as in this sample of healthy subjects and the topic needs therefore to be further
explored. The relation between chest expansion
and pulmonary function also needs to be further
explored while Malaguti et al. (3) has shown that
these do not correlate in patients with chronic
obstructive pulmonary disease (3).
In a previous trial, normal values of thorax excursion measured by tape have been presented (2). Normal values in younger (2049 years) men were 6.6
cm and in women 6.1 cm. This is in accordance with
the findings in this study, showing significant differences between men and women. Corresponding figures for older (5075 years) men and women were
6.1 and 4.7 cm, respectively (1).
Information about the tests in this trial was given
prior to measuring, with no further verbal instruction
given during the tests. There are previous trials,
which have presented different results when encouragement has been given during the tests (16). However, it is not known whether encouragement can
further improve the results of the new instruction

described in this study. It is therefore important to

investigate the effects of encouragement in a future
trial.
The evaluation between the two instructions was
made with two different pieces of equipment. The
advantage of measuring with a tape is that it is easily obtainable, easy to handle, cheap and can be
used wherever the patient is. On the other hand, the
test has its limitations. Different kinds of plethysmographs give a more sensitive measurement but
are rarely available in clinical practice. The other
method used was the RMMI, developed in Iceland
and used in some clinical trials (1719). It has been
shown to have a high reliability (12). It measures
the anteriorposterior changes, which are closely
connected to circumferential changes (1,11). The
results from the test cannot be compared directly
with the thoracic excursion test; lower values are to
be expected, since there is only registration of the
anteriorposterior movement of the rib cage and
not the circumference. The results also indicate that
the anteriorposterior movement is smaller at the
lower thoracic level of the xiphoid process than at
the upper level by the fourth costae (Table II). This
may be a reflexion that the upper thorax moves
more anteriorlyposteriorly than the lower part that
moves more laterally.
The difference between maximal inspiration and
expiration during the thoracic excursion test is created by the breathing muscles and restricted by the
lungs ability to expand and subside. During a maximal inspiration, the diaphragm presses the abdomen
downwards and the rib cage expands by lengthening
the thorax and lifting the lower ribs (2022). The
external intercostal muscles also move the ribs anteriorly and laterally, a motion that can be increased in
the upper thoracic region if the accessory muscles
are used. During a maximal expiration, the abdominal muscles press the abdominal content upwards to
decrease the lungs. The internal intercostals lower
and decrease the rib cage. Voluntary activation of the
whole rib cage during the instruction to make yourself as big/small as possible seems to reflect better

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M. F. Olsn et al.

the subjects total chest mobility capacity. These

results could possibly be useful for instructing deep
breathing exercises to patients with a restricted lung
capacity such as rheumatic patients, older people and
postoperative patients.

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Conclusions
The verbal instruction during measurement of chest
expansion is of importance when measuring by tape
and RMMI. To assess the maximal range of motion
in the chest, the patient should be instructed not only
to breathe in/out maximally, but also to make
yourself as big/small as possible.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for
the content and writing of the paper.

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