ORIGINAL ARTICLE
Normal Functional Range of Motion of the Cervical Spine
During 15 Activities of Daily Living
Jesse E. Bible, BS, Debdut Biswas, BA, Christopher P. Miller, BA, Peter G. Whang, MD,
and Jonathan N. Grauer, MD
Study Design: Prospective clinical study.
Objective: The purpose of this investigation was to quantify
normal cervical range of motion (ROM) and compare these
results to those used to perform 15 simulated activities of daily
living (ADLs) in asymptomatic subjects.
Summary of Background Data: Previous studies looking at
cervical ROM during ADLs have been limited and used
measuring devices that do not record continuous motion. The
purpose of this investigation was to quantify normal cervical
ROM and compare these results with those used to perform 15
simulated ADLs in asymptomatic subjects.
Methods: A noninvasive electrogoniometer and torsiometer were
used to measure the ROM of the cervical spine. The accuracy
and reliability of the devices were confirmed by comparing the
ROM values acquired from dynamic flexion/extension and
lateral bending radiographs to those provided by the device,
which was activated while the radiographs were obtained.
Intraobserver reliability was established by calculating the
intraclass correlation coefficient for repeated measurements on
the same subjects by 1 investigator on consecutive days. These
tools were employed in a clinical laboratory setting to evaluate
the full active ROM of the cervical spines (ie, flexion/extension,
lateral bending, and axial rotation) of 60 asymptomatic subjects
(30 females and 30 males; age, 20 to 75 y) as well as to assess the
functional ROM required to complete 15 simulated ADLs.
Results: When compared with radiographic measurements, the
electrogoniometer was found to be accurate within 2.3 ± 2.2
degrees (mean ± SD) and the intraobserver reliabilities for
measuring the full active and functional ROM were both
excellent (intraclass correlation coefficient of 0.96 and 0.92,
respectively). The absolute ROM and percentage of full active
cervical spinal ROM used during the 15 ADLs was 13 to 32
degrees and 15% to 32% (median, 20 degrees/19%) for flexion/
extension, 9 to 21 degrees and 11% to 27% (14 degrees/18%)
for lateral bending, and 13 to 57 degrees and 12% to 92% (18
degrees/19%) for rotation. Backing up a car required the most
ROM of all the ADLs, involving 32% of sagittal, 26% of lateral,
Received for publication September 2, 2008; accepted December 8, 2008.
From the Department of Orthopaedics and Rehabilitation, Yale
University School of Medicine, New Haven, CT.
Reprints: Jonathan N. Grauer, MD, Department of Orthopaedics and
Rehabilitation, Yale University School of Medicine, PO Box 208071,
New Haven, CT 06520-8071 (e-mail: jonathan.grauer@yale.edu).
Copyright r 2010 by Lippincott Williams & Wilkins
J Spinal Disord Tech  Volume 23, Number 1, February 2010
and 92% of rotational motion. In general, personal hygiene
ADLs such as washing hands and hair, shaving, and applying
make-up entailed a significantly greater ROM relative to
locomotive ADLs including walking and traveling up and down
a set of stairs (P<0.0001); in addition, compared with climbing
up these steps, significantly more sagittal and rotational motion
was used when descending stairs (P = 0.003 and P = 0.016,
respectively). When picking up an object from the ground, a
squatting technique required a lower percentage of lateral and
rotational ROM than bending at the waist (P = 0.002 and
P<0.0001).
Conclusions: By quantifying the amounts of cervical motion
required to execute a series of simulated ADLs, this study
indicates that most individuals use a relatively small percentage
of their full active ROM when performing such activities. These
findings provide baseline data which may allow clinicians to
accurately assess preoperative impairment and postsurgical
outcomes.
Key Words: cervical, spine, range of motion, activities of daily
living
(J Spinal Disord Tech 2010;23:15–21)
A n adequate range of motion (ROM) of the cervical
spine is necessary for various activities of daily living
(ADLs). There are several different factors associated
with decreased cervical ROM such as spondylosis, which
in some cases may limit a patient’s ability to perform
these ADLs. Another example is cervical fusion surgery,
which is generally effective in addressing a number of
spinal conditions but may give rise to focal restriction of
ROM and precipitate compensatory changes at adjacent
levels1–6; in an effort to maintain physiologic motion, a
number of novel approaches (eg, disk arthroplasty) have
been introduced as potential alternatives to conventional
arthrodesis techniques.3,7–10
Unfortunately, the global ROM of the cervical
spine has not been well characterized at this time. Most of
the preexisting studies have simply evaluated the extremes
of motion exhibited by subjects which represents the full
active ROM.11–17 Although the amount of movement
required for ADLs is believed to be significantly less than
the full active motion, there is currently a paucity of
normative data regarding the functional ROM of the
cervical spine. Bennett et al18 reported the ROM of the
www.jspinaldisorders.com | 15
Bible et al
cervical spine during several ADLs including the opening
of a door, writing at a table, and holding a telephone.
However, these calculations were derived from a small
cohort of college students who wore multiple inclinometer
gauges on their heads during these experiments. The
manual design of this device required that the subject stop
their specific movement in order for the device’s gauges
to be read by an observer, only allowing the device to be
recorded when the subject’s neck was stationary at the
end point of the activity and could not be continually
recorded during dynamic movements. To our knowledge,
this remains the only study that has evaluated functional
cervical ROM during ADLs.
Flexible electrogoniometers are designed to provide
instantaneous ROM measurements and these devices
have been shown to be an effective and accurate method
for assessing the motion of numerous joints.19–27 Electro-
goniometry is also known to correlate well with spinal
radiographs.25 These measuring devices allow for the data
to be continually recorded, permitting a more realistic
evaluation of dynamic motion in joints. The purpose of
this prospective investigation was to use flexible electro-
goniometers to quantify cervical spinal ROM in asymp-
tomatic patients as they performed a series of simulated
ADLs and compare these results with their full active
ROM.
MATERIALS AND METHODS
Electrogoniometer and Torsiometer
Measuring System
The electrogoniometer and torsiometer measuring
system used in this study (SG150 and Q150, Biometrics
Ltd, Gwent, UK) consists of a thin, flexible, strain-
gauged strip (also known as a shin) with 2 lightweight
plastic plates attached to each end. In the electrogonio-
meter, the transducer measures angles in 2 planes of
movement: flexion-extension and lateral bending. In the
torsiometer, the transducer measures axial rotation in
both left and right directions (Fig. 1A).
The proximal endplate of each device has a
telescopic arrangement, which permits the relative dis-
tance between the 2 endplates to change during joint
movement, preventing an overstretching or buckling of
the measuring element. However, during flexion and
extension of the cervical spine, linear displacements
occurring between the spinous processes of the upper
and lower vertebrae would exceed this distance. To
overcome this limitation, lightweight aluminum carriages
(5 inch) were constructed to house the distal endplate
for both devices. Additionally, each distal endplate was
expanded in length using a lightweight aluminum cover-
ing. Each carriage allowed the endplate to move freely
along its length, resulting in an increase in the linear
excursion of both devices, but prevented movement in
other planes (Fig. 1B). This strategy has already been
evaluated in a previous study where these types of
modifications were shown to successfully maintain the
16 | www.jspinaldisorders.com
J Spinal Disord Tech  Volume 23, Number 1, February 2010
FIGURE 1. A, Electrogoniometer and torsiometer with its
associated aluminum carriages, head-piece, and chest harness.
B, Two lightweight aluminum carriages, which comprise the
housing of the distal endplates for both devices. C, Measuring
system after being placed on a subject.
accuracy of the flexible goniometer for measuring lumbar
ROM.28
The proximal endplates were attached to the occiput
of the skull by an elastic head-band whereas the distal
portions of each device were secured to the midline of the
upper thoracic region directly over the spinous processes
of T1-T4 by applying a chest harness (Fig. 1C). The
goniometer and torsiometer were both connected to a
hand-held display unit (DataLog, Biometrics Ltd, Gwent,
UK), which generated real-time data that was continu-
ously recorded for subsequent analysis.
To validate the accuracy and reliability of the
electrogoniometer used, ROM measured by the electro-
goniometer was compared with that of a manual
goniometer. This calibration process was repeated after
every 10 subjects and found to be consistently accurate. A
series of cervical spine x-rays (anteroposterior, right and
left lateral bending, neutral lateral, flexion, and extension
views) were also obtained while these appliances were
affixed to a subject so that the electrogoniometer
measurements could be compared with those provided
by the measuring tools of the digital radiography system.
ROM in Asymptomatic Subjects
Investigational Review Board approval was ob-
tained before the initiation of this investigation. The
study population consisted of 60 asymptomatic indivi-
duals evenly distributed among 4 age groups (20 to 29, 30
to 39, 40 to 49, and >50 years old), none of whom
reported any current axial spinal discomfort or a history
of any previous spinal surgeries. After the goniometer and
torsiometer system was applied as described above, the
display unit was zeroed with the subject in a neutral
r 2010 Lippincott Williams & Wilkins
J Spinal Disord Tech  Volume 23, Number 1, February 2010
position. The full active ROM was quantified by asking
the subject to achieve maximum flexion, extension, lateral
bending (left and right), and axial rotation (left and
right). These individuals were subsequently asked to
perform the same series of 15 simulated ADLs in a
standardized clinical laboratory space to determine the
functional ROM required for these endeavors (Table 1).
This list of ADLs was derived from extensively referenced
physical and occupational therapy literature which
indicated the impact that spinal disorders may have on
these activities.29–31 To ensure each activity was as natural
as possible, minimal restrictions were placed on how each
activity was performed. Each subject was prompted by
the same investigator, whereas a second investigator
applied the measuring device and held the display unit.
The maximum ROM used in each of the 6 directions was
recorded throughout the entire duration of an ADL, from
the initiation up to its completion.
All seated ADLs were performed using an 18-inch
stool. When asked to back up a car, subjects were asked
to look over their right shoulders until they could read a
sign 150 degrees behind them; in this situation, only the
right-sided values for functional rotation were considered.
For putting on a sock and tying shoelaces, individuals
lifted up their right lower extremities to a height so that
they could reach their right foot before returning to an
erect sitting position. Hand washing was performed in
a sink located 36 inches from the ground and 16 inches
deep. Next, each subject was asked to simulate washing
their hair as if in the shower. Similarly, males were given a
bladeless plastic razor and wall mirror to simulate shaving
their face and females used the mirror to apply make-up.
A 2 lb circular weight placed midline 8 inches in front of
the subject was picked up from the floor both from a
squatting position and by bending their lower backs while
keeping their legs straight. After walking down a hallway
while looking straight ahead, individuals climbed and
descended several stairs that were 6 inches in height and
10 inches deep.
TABLE 1. Fifteen Activities of Daily Living in Which Cervical
Range of Motion Was Assessed
Order of the 15 ADLs
1. Standing to sitting position
2. Backing up car
3. Reading a magazine in lap
4. Cutting food with knife and fork and bringing food to mouth
5. Putting on socks
6. Tying shoelaces
7. Rising from sitting position
8. Washing hands in standing position
9. Washing hair in shower
10. Shaving facial hair (males)/applying make-up (females)
11. Picking up object from floor using squatting technique
12. Picking up object from floor using bending technique
13. Walking
14. Walking up stairs
15. Walking down stairs
ADL indicates activities of daily living.
r 2010 Lippincott Williams & Wilkins
Normal Functional ROM of the Cervical Spine
Data Analysis
Cervical ROM data were continuously recorded on
the display unit during all the ADLs. The average full
active ROM was calculated for all 60 subjects in flexion,
extension, lateral bending, and axial rotation. The
average functional ROM was also determined for each
of the 15 ADLs and expressed as a percentage of the full
active ROM.
The output data were analyzed using DataLog 6
software (Biometrics Ltd, Gwent, UK) and compiled into
SPSS 16.0 (SPSS Inc, Chicago, IL). The full active and
functional ROMs of 5 subjects were reassessed on 3
consecutive days at the same time of day to characterize
the intraobserver reliabilities. Intraclass correlation co-
efficients (ICCs) were calculated for both the full active
and functional ROM values using 2-way random effects
analysis of variance in conjunction with the consistency
definition. The ROM employed for the various ADLs
were compared with paired t tests. Any associations
between ROM and patient factors such as age, sex, and
body mass index (BMI) were identified by performing
multivariate linear regression. Regression analysis was
performed for each of the 3 motion planes for active
ROM and functional ROM for each ADL. All 3 patient
factors (age, sex, and BMI) were included in the final
regression model. Statistical significance was established
at a 2-sided á level of 0.05 (P<0.05).
RESULTS
Radiographic Validation
The accuracy of the electrogoniometer was quanti-
fied by comparing the ROM measured on dynamic
flexion/extension and lateral bending radiographs with
the values registered by the device which was worn while
these studies were obtained. According to this assessment,
the electrogoniometer was found to be accurate within
2.3 ± 2.2 degrees (mean ± standard deviation).
Intraobserver Reliability
The a priori analysis revealed excellent intra-
observer reliabilities for both full active [ICC, 0.96; 95%
confidence interval (CI), 0.93-0.98) and functional ROM
(ICC, 0.92; 95% CI, 0.91-0.93). The results demonstrate
that these subjects exhibited similar amounts of cervical
motion on consecutive days.
Full Active ROM
Of the 60 asymptomatic individuals who were
included in this series, there were 30 males and 30 females
with an average age of 40.2 years (range, 20 to 75 years)
and an average BMI of 25.3 (range, 19.8 to 34.4). The
mean full active ROM for flexion and extension was 63.4
degrees (95% CI, 61.2-65.6 degrees) and 38.7 degrees
(95% CI, 35.5-41.9 degrees), respectively; 38.9 degrees
(95% CI, 36.6-41.2 degrees) and 37.4 degrees (95% CI,
34.9-39.8 degrees) for left and right lateral bending,
respectively; and 55.8 degrees (95% CI, 53.1-58.4 degrees)
www.jspinaldisorders.com | 17
Bible et al J Spinal Disord Tech  Volume 23, Number 1, February 2010

and 53.2 degrees (95% CI, 50.2-56.1 degrees) for left and associated with these activities was 15% to 32% (median,
right axial rotation, respectively. 19%) of flexion/extension, 11% to 27% (18%) of lateral
bending, and 12% to 92% (19%) of total rotational
Functional ROM motion. The percentage for each specific activity is listed
The functional ROM used across all 15 ADLs tested in Table 2.
in this investigation included 13 to 32 degrees (median, 20 Backing up a car necessitated the most ROM of all
degrees) in the sagittal plane, 9 to 21 degrees (14 degrees) the simulated ADLs, which involved 32 degrees/32% of
of lateral bending, and 13 to 57 degrees (18 degrees) of flexion/extension, 20 degrees/26% of lateral bending, and
rotation; the absolute ROM values for these ADLs are 57 degrees/92% of rotation to the right. Of the 2 methods
shown in Figure 2. The percentages of full active ROM for picking up an object from the ground, squatting

A Cervical Flexion / Extension

Average Maxim um Flexion

60

40
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C Cervical Rotation
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FIGURE 2. The average amount of motion used for each ADL with the average maximum ROM values for cervical (A) flexion/
extension, (B) lateral bending, and (C) rotation. Error bars = 95% confidence intervals. ADL indicates activities of daily living;
ROM, range of motion.

18 | www.jspinaldisorders.com r 2010 Lippincott Williams & Wilkins

J Spinal Disord Tech  Volume 23, Number 1, February 2010 Normal Functional ROM of the Cervical Spine

TABLE 2. Percentage of Total Active ROM Used for Each Activity of Daily Living
Average Percentage of Full Active ROM
Activity of Daily Living Flexion/Extension (%) Lateral Bending (%) Axial Rotation (%)
Stand to sit 20 14 14
Backing car 32 26 92*
Reading 16 12 16
Feeding 15 15 14
Socks 19 19 21
Tying shoelaces 18 18 17
Sit to stand 18 10 15
Washing hands 19 20 29
Washing hair 27 23 25
Shaving 23 25 34
Make-up 22 24 33
Squatting 29 22 24
Bending 30 27 32
Walking 13 11 13
Up stairs 16 13 12
Down stairs 21 13 15
*Only right full active ROM used in rotational percentage for backing up a car.
ROM indicates range of motion.

required significantly less lateral bending and rotation
than bending at the waist (17 vs. 21 degrees, P = 0.002; 17
vs. 35 degrees, P<0.0001) but there were no significant
differences observed in sagittal plane motion (30 vs. 31
degrees, P = 0.486). Descending stairs entailed signifi-
cantly more flexion/extension and rotation relative to
climbing up the staircase (P = 0.003 and P = 0.016).
Finally, transitioning from standing to sitting required
significantly more lateral bending than transitioning from
a sitting to standing position (P = 0.001). Compared with
the 3 locomotive movements (ie, walking, transversing up
and down stairs), significantly greater motion was
recorded in all 3 planes with personal hygiene ADLs (ie,
washing hands and hair, shaving, and applying make-up)
(P<0.0001).
Multivariate Analyses
Age was determined to be a highly significant
predictor of decreased active ROM in each of the 3
motion planes (sagittal, P = 0.020; lateral, P<0.0001;
rotational, P = 0.012), which is consistent with previous
reports about active ROM.12,32 Other than a significant
decrease in rotation noted in male subjects (P = 0.009),
sex and BMI did not correlate with decreased active
ROM. There were also no apparent associations between
any of these variables and functional ROM as well
(P<0.05).
DISCUSSION
A number of studies have already characterized the
peripheral joint motion that occurs during various
ADLs.23,27,33–41 Similarly, active cervical ROM has also
been discussed extensively in the literature but there
continues to be a paucity of data regarding the motion
that is necessary to perform certain activities. Thus,
the purpose of this investigation was to measure the
functional ROM exhibited by a diverse cohort of
asymptomatic subjects as they completed 15 common
ADLs.
Although the mean full active flexion/extension and
lateral bending observed in this study were within 1
standard deviation of those published in previous reports
of normal cervical ROM,13,15,42,43 the amount of axial
rotation was considerably less [109 degrees (12-degree
SD) vs. 141 degrees (12-degree SD) and 144 degrees
(20-degree SD)].13,15 It is possible that this finding may
be accounted for in part by the higher average age of the
subjects in this population relative to these other series
(40 y vs. approximately 25 y).
Of all the ADLs that were tested, the greatest
sagittal motion was used when backing up a car and
picking up an object from the ground, either by bending
at the waist or squatting at the knees, necessitated only
one-third of the total sagittal plane motion. However,
bending required more lateral and rotational movement
compared with squatting. The squatting technique has
been widely advocated in an effort to minimize the
stresses applied to the lumbar facet joints, paraspinal
musculature, and other spinal structures. As bending at
the waist appears to entail greater cervical motion than
squatting, the latter method may serve to maintain
physiologic alignment of the spinal column and reduce
the deleterious forces generated when picking up objects
from the floor.
Backing up a car required the most rotational
motion in the cervical spine, as over 90% of full active
ROM was used by the subjects. These results are not
surprising, as drivers usually use ocular and cervical
rotational motion before initiating lumbar or pelvic
motion when looking over their shoulder. Of the other
remaining ADLs, personal hygiene activities, such as
shaving and applying make-up, required the greatest
amounts of rotation using a third of total rotational
motion.

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Bible et al
In general, these subjects employed significantly
greater ROM for personal hygiene activities than for
locomotive ADLs and transfers such as walking and
sitting down in a chair. These findings suggest that
clinicians may be able to more accurately gauge a
patient’s level of disability by specifically inquiring about
any difficulties or limitations encountered during his or
her daily routine. Furthermore, it may be preferable
to assess functional status by asking these individuals to
perform several simulations rather than by simply
observing them walk and sit in the examination room.
Bennett et al,18 previously quantified cervical ROM
during 4 of the ADLs that were also included in our
analysis (ie, tying shoes, backing up a car, rising from a
chair, and washing hair). Although their results are
largely analogous to those of the present investigation,
there are several discrepancies between these studies. For
instance, the subjects in this series demonstrated increased
flexion/extension when backing up a car (32 vs. 5
degrees); alternatively, when washing their hair they
required less sagittal motion (28 vs. 43 degrees) but used
more axial rotation (27 vs. 12 degrees). These incon-
sistencies may be attributed to certain differences in
technique because Bennett et al only recorded the position
of the cervical spine at the conclusion of the ADL rather
than collecting ROM data continuously over the course
of the entire activity. Furthermore, these authors only
evaluated a rather uniform cohort of college students
whereas our measurements were derived from subjects
across several different age groups.
On the basis of the electrogoniometer readings
of cervical motion recorded during these simulations,
asymptomatic patients seem to use an average of 21% of
flexion/extension, 18% of lateral bending, and 25% of
rotation while performing a variety of ADLs, which
suggests that only a small percentage of full, active ROM
is required to complete most of these activities. These
baseline values may be important to consider when
comparing different surgical treatments for spinal pathol-
ogy. As an example, multiple reports have documented
significant decreases in cervical ROM after arthrodesis
procedures, which have been widely cited as the rationale
for motion-sparing implants such as artificial disk
replacement.1–6 Despite the reductions in segmental
ROM associated with cervical spine fusions, the findings
of the current investigation indicate that these interven-
tions are less likely to compromise a patient’s ability to
complete a majority of ADLs and may therefore be
expected to give rise to acceptable postoperative func-
tional outcomes in the majority of cases.44–48
It must be acknowledged that this study is not
without certain limitations. First of all, it is conceivable
that a sampling error may have occurred such that these
subjects may not be representative of all individuals in the
general population. Similarly, the 15 ADLs included in
this series may not necessarily reflect all of the motion
that is required of the cervical spine during the course of a
single day; however, this list of activities was compiled by
referencing the physical and occupational therapy litera-
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J Spinal Disord Tech  Volume 23, Number 1, February 2010
ture to ensure that appropriate simulations were in-
cluded.29–31 Nevertheless, we do not believe that these
relatively minor issues detract from the overall validity of
these results.
In summary, this investigation quantifies the
amounts of cervical spine motion used by asymptomatic
subjects as they complete a number of simulated ADLs.
According to a specialized electrogoniometer, which was
shown to exhibit excellent accuracy and reliability for
these measurements, it is clear that most individuals only
employ a small percentage of their full active ROM when
performing these activities. This information provides
normative data, which may be valuable for assessing any
clinical impairment that may arise secondary to spinal
pathology and comparing the functional outcomes of
various nonoperative and surgical treatments for these
conditions.
REFERENCES
1. Prybis BG, Tortolani PJ, Hu N, et al. A comparative biomechanical
analysis of spinal instability and instrumentation of the cervicothor-
acic junction: an in vitro human cadaveric model. J Spinal Disord
Tech. 2007;20:233–238.
2. Rao RD, Currier BL, Albert TJ, et al. Degenerative cervical
spondylosis: clinical syndromes, pathogenesis, and management.
J Bone Joint Surg Am. 2007;89:1360–1378.
3. Sasso RC, Smucker JD, Hacker RJ, et al. Artificial disc versus
fusion: a prospective, randomized study with 2-year follow-up on 99
patients. Spine. 2007;32:2933–2940; discussion 2941-2942.
4. Takeuchi K, Yokoyama T, Ono A, et al. Limitation of activities of
daily living accompanying reduced neck mobility after laminoplasty
preserving or reattaching the semispinalis cervicis into axis. Eur
Spine J. 2008;17:415–420.
5. Takeuchi K, Yokoyama T, Ono A, et al. Limitations of activities of
daily living accompanying reduced neck mobility after cervical
laminoplasty. Arch Orthop Trauma Surg. 2007;127:475–480.
6. Wada E, Suzuki S, Kanazawa A, et al. Subtotal corpectomy versus
laminoplasty for multilevel cervical spondylotic myelopathy: a long-
term follow-up study over 10 years. Spine. 2001;26:1443–1447;
discussion 1448.
7. Auerbach JD, Wills BP, McIntosh TC, et al. Evaluation of spinal
kinematics following lumbar total disc replacement and circumfer-
ential fusion using in vivo fluoroscopy. Spine. 2007;32:527–536.
8. Orr RD, Postak PD, Rosca M, et al. The current state of cervical
and lumbar spinal disc arthroplasty. J Bone Joint Surg Am. 2007;
89(suppl 3):70–75.
9. Sasso RC, Best NM. Cervical kinematics after fusion and bryan disc
arthroplasty. J Spinal Disord Tech. 2008;21:19–22.
10. Yang S, Wu X, Hu Y, et al. Early and intermediate follow-up results
after treatment of degenerative disc disease with the Bryan cervical
disc prosthesis: single- and multiple-level. Spine. 2008;33:E371–E377.
11. Dopf CA, Mandel SS, Geiger DF, et al. Analysis of spine motion
variability using a computerized goniometer compared to physical
examination. A prospective clinical study. Spine. 1994;19:586–595.
12. Dvorak J, Antinnes JA, Panjabi M, et al. Age and gender related
normal motion of the cervical spine. Spine. 1992;17(10 suppl):
S393–S398.
13. Feipel V, Rondelet B, Le Pallec J, et al. Normal global motion of the
cervical spine: an electrogoniometric study. Clin Biomech (Bristol,
Avon). 1999;14:462–470.
14. Ferrario VF, Sforza C, Serrao G, et al. Active range of motion of the
head and cervical spine: a three-dimensional investigation in healthy
young adults. J Orthop Res. 2002;20:122–129.
15. Lantz CA, Klein G, Chen J, et al. A reassessment of normal cervical
range of motion. Spine. 2003;28:1249–1257.
r 2010 Lippincott Williams & Wilkins
J Spinal Disord Tech  Volume 23, Number 1, February 2010
16. Mayer T, Brady S, Bovasso E, et al. Noninvasive measurement
of cervical tri-planar motion in normal subjects. Spine. 1993;18:
2191–2195.
17. Youdas JW, Carey JR, Garrett TR. Reliability of measurements of
cervical spine range of motion–comparison of three methods. Phys
Ther. 1991;71:98–104; discussion 105–106.
18. Bennett SE, Schenk RJ, Simmons ED. Active range of motion
utilized in the cervical spine to perform daily functional tasks.
J Spinal Disord Tech. 2002;15:307–311.
19. Myles CM, Rowe PJ, Nutton RW, et al. The effect of patella
resurfacing in total knee arthroplasty on functional range of
movement measured by flexible electrogoniometry. Clin Biomech.
2006;21:733–739.
20. Myles CM, Rowe PJ, Walker CR, et al. Knee joint functional range
of movement prior to and following total knee arthroplasty
measured using flexible electrogoniometry. Gait Posture. 2002;16:
46–54.
21. Rowe PJ, Myles CM, Hillmann SJ, et al. Validation of flexible
electrogoniometry as a measure of joint kinematics. Physiotherapy.
2001;87:479–488.
22. Rowe PJ, Myles CM, Nutton R. The effect of total knee
arthroplasty on joint movement during functional activities and
joint range of motion with particular regard to higher flexion users.
J Orthop Surg. 2005;13:131–138.
23. Rowe PJ, Myles CM, Walker C, et al. Knee joint kinematics in gait
and other functional activities measured using flexible electrogonio-
metry: how much knee motion is sufficient for normal daily life?
Gait Posture. 2000;12:143–155.
24. Rowe PJ NA, Kelly IG. Flexible goniometer computer system for
the assessment of hip function. Clin Biomech. 1989;4:68–72.
25. Thoumie P, Drape JL, Aymard C, et al. Effects of a lumbar support
on spine posture and motion assessed by electrogoniometer
and continuous recording. Clin Biomech (Bristol, Avon). 1998;13:
18–26.
26. van der Linden ML, Rowe PJ, Myles CM, et al. Knee kinematics in
functional activities seven years after total knee arthroplasty. Clin
Biomech. 2007;22:537–542.
27. Walker CR, Myles C, Nutton R, et al. Movement of the knee in
osteoarthritis. The use of electrogoniometry to assess function.
J Bone Joint Surg Br. 2001;83:195–198.
28. Boocock MG, Jackson JA, Burton AK, et al. Continuous
measurement of lumbar posture using flexible electrogoniometers.
Ergonomics. 1994;37:175–185.
29. Occupational Therapy Practice Framework: domain and process.
Am J Occup Ther. 2002;56:609–639.
30. Cook CE, Richardson JK, Pietrobon R, et al. Validation of the
NHANES ADL scale in a sample of patients with report of cervical
pain: factor analysis, item response theory analysis, and line item
validity. Disabil Rehabil. 2006;28:929–935.
r 2010 Lippincott Williams & Wilkins
Normal Functional ROM of the Cervical Spine
31. Nelson DL. Critiquing the logic of the domain section of the
Occupational therapy practice framework: domain and process.
Am J Occup Ther. 2006;60:511–523.
32. Simpson AK, Biswas D, Emerson JW, et al. Quantifying the effects
of age, gender, degeneration, and adjacent level degeneration on
cervical spine range of motion using multivariate analyses. Spine.
2008;33:183–186.
33. Hemmerich A, Brown H, Smith S, et al. Hip, knee, and ankle
kinematics of high range of motion activities of daily living.
J Orthop Res. 2006;24:770–781.
34. Protopapadaki A, Drechsler WI, Cramp MC, et al. Hip, knee, ankle
kinematics and kinetics during stair ascent and descent in healthy
young individuals. Clin Biomech (Bristol, Avon). 2007;22:203–210.
35. Nadeau S, McFadyen BJ, Malouin F. Frontal and sagittal plane
analyses of the stair climbing task in healthy adults aged over 40
years: what are the challenges compared to level walking? Clin
Biomech (Bristol, Avon). 2003;18:950–959.
36. Kowalk DL, Duncan JA, Vaughan CL. Abduction-adduction
moments at the knee during stair ascent and descent. J Biomech.
1996;29:383–388.
37. Yu B, Stuart MJ, Kienbacher T, et al. Valgus-varus motion of the
knee in normal level walking and stair climbing. Clin Biomech
(Bristol, Avon). 1997;12:286–293.
38. Costigan PA, Deluzio KJ, Wyss UP. Knee and hip kinetics during
normal stair climbing. Gait Posture. 2002;16:31–37.
39. Morrey BF, Askew LJ, Chao EY. A biomechanical study of normal
functional elbow motion. J Bone Joint Surg Am. 1981;63:872–877.
40. Ryu JY, Cooney WP III, Askew LJ, et al. Functional ranges of
motion of the wrist joint. J Hand Surg (Am). 1991;16:409–419.
41. Vasen AP, Lacey SH, Keith MW, et al. Functional range of motion
of the elbow. J Hand Surg (Am). 1995;20:288–292.
42. Mannion AF, Klein GN, Dvorak J, et al. Range of global motion of
the cervical spine: intraindividual reliability and the influence of
measurement device. Eur Spine J. 2000;9:379–385.
43. Tousignant M, de Bellefeuille L, O’Donoughue S, et al. Criterion
validity of the cervical range of motion (CROM) goniometer for
cervical flexion and extension. Spine. 2000;25:324–330.
44. Boakye M, Patil CG, Santarelli J, et al. Cervical spondylotic
myelopathy: complications and outcomes after spinal fusion.
Neurosurgery. 2008;62:455–461; discussion 461–452.
45. Huckell CB. Clinical outcomes after cervical spine fusion. Orthop
Clin North Am. 1998;29:787–799.
46. Lad SP, Patil CG, Berta S, et al. National trends in spinal fusion for
cervical spondylotic myelopathy. Surg Neurol. 2009;71:66–69.
47. Malloy KM, Hilibrand AS. Autograft versus allograft in degen-
erative cervical disease. Clin Orthop Relat Res. 2002;394:27–38.
48. Samartzis D, Shen FH, Matthews DK, et al. Comparison of
allograft to autograft in multilevel anterior cervical discectomy and
fusion with rigid plate fixation. Spine J. 2003;3:451–459.
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