Objective: To verify the reproducibility of the Normal Flex set of tests as an instrument for evaluating the flexibility level of elderly women. Sample: Randomly composed of 50 active (n= 30) and inactive (n = 20) elderly women aged 67.15±4.21 years. Methods: Flexibility measurements of cervical spine rotation, shoulder horizontal extension, shoulder abduction, lumbar spine flexion and knees flexion were taken through analogical, digital and radiologic goniometry and by the Normal Flex protocol. Results: The intraclass coefficient of correlation (ICC) was used to verify the reliability within the same evaluators and between the evaluators. The statistical significance was p<0.05. Significant Pearson correlations showed validity for goniometry methods. The intra- and inter-rater reliability results for each joint in analogical goniometry and for Normal Flex varied from r = 0.90-0.99 (p<0.001), showing reproducible results. Conclusion: The reproducibility of Normal Flex as a method of evaluating flexibility of elderly women was confirmed.
The increase in the elderly population is a challenge to the 21st century [1], affecting structures of the society related to social [2], cultural and economical values [3] [4] [5] [6]. The inevitable population-aging process [7] has consequences in every facet of human life [8] : medical care, familial composition, and political aspect [9].
Concerning the biological changes that occur with the aging process [10] [11], the functional capacity is progressively lost [12] [13] [14]. This process is associated with morphological and functional changes in the muscle system leading to muscle-mass losses plus the reduction of muscle strength and movement velocity as well as the diminishing of flexibility levels [15] [16] [17]. As the joint motion ranges decrease due to enriched connective tissue and reduced muscle fibre elasticity, pathologies related to the osteomioarticular system occur [18] [19].
The physical incapacity can be observed as a result of lack of physical activity and the gait speed [20] [21] and it influences the daily living activities [22] that can profit from being physically active, even in the short term [23] [24], and gaining on flexibility [25].
The Normal Flex is a set of tests, in ordinal scale, designed to measure the flexibility level of an elderly. This set of tests aims to minimize the difficulties faced by health professionals when dealing with large groups of people, ofen in a short amount of time to perform the tests and with a low budget.
The purpose of this study was to verify the reproducibility of Normal Flex in elderly women flexibility evaluation.
The sample was composed of 50 elderly women (aged 67.15±4.21 years), 30 active and 20 inactive, all living in Rio de Janeiro city. At the end of the research, a sample loss of nine elderly women was observed: four by death and five by moving abroad.
The inclusion criteria were being a volunteer and over sixty, and the sample was selected by convenience. The exclusion criteria were dwelling in home facilities or having any disability that could compromise the performance of their daily activities.
This research was performed according to the Helsinki declaration [26] procedures and submitted to the Euro-American Net of Human Kinetics Ethical Committee - approved under the protocol # 007/2009.
Body weight was measured to the nearest 0.1 kg using a calibrated clinical scale, with each subject wearing a swimsuit. Height was determined barefoot to the nearest 0.5 cm, using a stadiometer, Filizola® (Brazil) and Body Mass Index (BMI) was calculated. Using a Lufkin (USA) metal anthropometric tape, abdomen circumference (AC), waist circumference (WC) and waist hips ratio (WHR) were obtained. All measures for each patient were taken by a single evaluator, in accordance with International Standards for Anthropometric Assessment [27].
The angular test of analogical goniometry utilised was the protocol of the Biometrics and Physiology of Effort Laboratory - LABIFIE [28] following the pattern index of normality with the Maturity Latin-American Development Group (GDLAM) protocol attributions for the elderly [29]. The flexibility level evaluation was performed via joint amplitude measures for the following movements: cervical spine rotation (CSR), horizontal extension of shoulder (HES), shoulder abduction (SA), and lumbar spine flexion (LSF) plus knees flexion (KF). The results were expressed in degrees using the Lafayette steel 360º goniometry instrument (USA).
The Normal Flex set of tests [30] was adapted to this research [31] resulting in a total of seven movements: Cervical Spine Rotation (CSR); Horizontal Extension of Shoulder (HES); Shoulder Abduction (SA); Lumbar Spine Flexion (LSF) – sitting and standing; Knees Flexion (KF). The measurement of joint amplitude of Normal Flex was performed through radiologic goniometry through 200000WH Salgado & Herman brand (Brazil), monthly calibrated by a specialised technique. The radiological goniometry was chosen because it is considered the gold standard of flexibility evaluation. An x-ray professional accompanied by the physical educator in charge photographed with x-ray the Normal Flex execution, and then compared with each joint movement evaluated by the analogical goniometry in order to properly verify the reproducibility of the studied set of tests.
The data were collected over four days by two different evaluators: one in the first two days and the other evaluator in other two days. Each tested elderly woman performed two attempts of execution of the Normal Flex, and the performance was therefore registered daily. Each evaluator took three trials of measures of each specific joint motion, and the best result of them was chosen.
Data were anaylyzed with SPSS 18.0 for Windows and are presented as mean and standard deviation. The Shapiro-Wilk test was performed to verify the sample’s homogeneity as well as the Spearman and Pearson correlation test in the between-variables association. The intraclass coefficient of correlation (ICC) was used to verify the reliability between the evaluators. The statistical significance was p<0.05.
Table 1 presents the anthropometrics characteristics: age, weight, height, body mass index (BMI), abdomen circumference (AC), waist circumference (WC) and waist hips ratio (WHR).
| Mean | Median | SD | Minimum | Maximum | SW | |
|---|---|---|---|---|---|---|
| Age (years) | 67.15 | 66.00 | 4.21 | 60.00 | 75.00 | 0.075 |
| Weight (kg) | 68.10 | 68.00 | 11.14 | 47.00 | 92.00 | 0.978 |
| Height (m) | 1.57 | 1.56 | 0.07 | 1.45 | 1.70 | 0.660 |
| BMI | 27.55 | 27.63 | 3.79 | 17.06 | 34.96 | 0.432 |
| AC (cm) | 98.75 | 97.50 | 11.34 | 79.00 | 123.00 | 0.152 |
| WC (cm) | 106.70 | 106.00 | 8.48 | 90.00 | 130.00 | 0.253 |
| WHR | 0.92 | 0.93 | 0.06 | 0.80 | 1.03 | 0.925 |
When the sample’s normality was analyzed through the Shapiro-Wilk test (table 1), it was observed that the p-value is superior to 0.05 in every variable, identifying a distribution close to a normal curve according to parameters of age, body mass and body fat percentage.
The results refer to values measured by both evaluators. Each one performed the measurement for two days in a row. These evaluations were performed at the same time with the same people and at the same joint area. Analysing the results obtained by both evaluators, they were compared to evaluate the joint movement amplitude. The descriptive data for the dependent variables are presented in table 2 together with the Shapiro-Wilk test result that was calculated to verify the variable homogeneity for the movements. The means and the standard deviations with the same evaluators and between the evaluators are very close to each other, which defines their consistence.
| Mean | Median | SD | Minimum | Maximum | p | |
|---|---|---|---|---|---|---|
| CSR - 1 A | 61.30 | 60.00 | 12.13 | 38.00 | 87.00 | 0.094 |
| CSR - 2 A | 61.35 | 61.50 | 14.23 | 35.00 | 93.00 | 0.068 |
| CSR - 1 B | 61.00 | 58.50 | 12.29 | 35.00 | 88.00 | 0.228 |
| CSR - 2 B | 63.35 | 61.50 | 12.85 | 37.00 | 90.00 | 0.370 |
| HES - 1 A | 64.25 | 66.00 | 13.87 | 42.00 | 89.00 | 0.446 |
| HES - 2 A | 65.55 | 60.00 | 13.83 | 45.00 | 99.00 | 0.224 |
| HES - 1 B | 65.30 | 63.00 | 13.99 | 45.00 | 103.00 | 0.060 |
| HES - 2 B | 66.10 | 64.50 | 13.27 | 48.00 | 102.00 | 0.088 |
| SA - 1 A | 122.65 | 114.00 | 23.75 | 97.00 | 178.00 | 0.010 |
| SA - 2 A | 125.20 | 117.50 | 22.22 | 99.00 | 176.00 | 0.018 |
| SA - 1 B | 126.00 | 117.50 | 21.44 | 98.00 | 169.00 | 0.008 |
| SA - 2 B | 126.00 | 119.00 | 23.12 | 94.00 | 172.00 | 0.041 |
| LSF - 1 A | 27.45 | 24.50 | 9.24 | 13.00 | 47.00 | 0.420 |
| LSF - 2 A | 27.95 | 27.00 | 8.10 | 17.00 | 47.00 | 0.221 |
| LSF - 1 B | 27.15 | 25.00 | 7.94 | 15.00 | 47.00 | 0.302 |
| LSF - 2 B | 27.55 | 25.50 | 8.78 | 16.00 | 48.00 | 0.138 |
| KF - 1 A | 28.60 | 28.00 | 12.88 | 11.00 | 51.00 | 0.238 |
| KF - 2 A | 28.65 | 24.50 | 13.82 | 10.00 | 48.00 | 0.012 |
| KF - 1 B | 28.65 | 24.50 | 13.82 | 10.00 | 48.00 | 0.012 |
| KF - 2 B | 30.15 | 27.00 | 14.61 | 11.00 | 52.00 | 0.020 |
3.3. Descriptive Data and Shapiro-Wilk of Radiological Goniometry
The evaluation of the flexibility through the goniometry performed with X - ray is presented in table 3.
| Mean | Median | SD | Minimum | Maximum | p | |
|---|---|---|---|---|---|---|
| CSR - 1 | 54.60 | 56.50 | 5.30 | 43.00 | 63.00 | 0.215 |
| CSR - 2 | 58.35 | 60.00 | 3.72 | 49.00 | 62.00 | 0.017 |
| CSR - 3 | 61.10 | 63.00 | 5.04 | 51.00 | 66.00 | 0.002 |
| HES - 1 | 61.15 | 61.00 | 15.08 | 42.00 | 98.00 | 0.172 |
| HES - 2 | 63.60 | 64.50 | 14.67 | 45.00 | 99.00 | 0.153 |
| HES - 3 | 65.95 | 67.00 | 14.66 | 47.00 | 101.00 | 0.187 |
| SA - 1 | 132.85 | 135.00 | 12.36 | 112.00 | 156.00 | 0.605 |
| SA - 2 | 132.95 | 127.00 | 18.81 | 104.00 | 169.00 | 0.447 |
| SA - 3 | 136.25 | 130.50 | 30.10 | 100.00 | 184.00 | 0.012 |
| LSF - 1 stand | 25.95 | 26.50 | 6.92 | 16.00 | 43.00 | 0.119 |
| LSF - 2 stand | 23.10 | 22.50 | 7.30 | 13.00 | 42.00 | 0.089 |
| LSF - 3 stand | 20.60 | 20.00 | 7.69 | 10.00 | 41.00 | 0.020 |
| LSF - 1 sitting | 30.20 | 28.00 | 7.82 | 19.00 | 48.00 | 0.006 |
| LSF - 2 sitting | 28.20 | 26.50 | 7.32 | 19.00 | 47.00 | 0.006 |
| LSF - 3 sitting | 26.70 | 23.50 | 7.93 | 17.00 | 48.00 | 0.010 |
| KF - 1 | 31.25 | 28.50 | 13.87 | 14.00 | 58.00 | 0.081 |
| KF - 2 | 28.00 | 26.50 | 13.57 | 12.00 | 56.00 | 0.080 |
| KF - 3 | 26.30 | 23.50 | 12.88 | 10.00 | 53.00 | 0.133 |
This study was performed with the 30 elderly women that composed Group 1 – the practitioners of physical activity. During the validation process the analogical goniometry was compared with the digital and with radiological goniometry. While attempting to analyze the relationship among these three ways of measuring, every joint was put together during the correlation analysis, rather than analysing each joint motion separately. For this purpose, data obtained by the second evaluator was used because these had the highest mean values for most variables. Pearson product-moment showed high and significant correlation (r=0.99; p<0.001) between analogical and digital goniometry. Moderate and significant correlations were found among the analogical and radiologic (r=0.63; p<0.01). The same values were found when correlating digital and radiologic goniometry. Therefore, evidence of concurrent validity was found for analogical, digital and radiologic goniometry.
| Values | CSR | % | SA | % | HES | % | LSF | % | KF | % | Total | % |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 4 | 27 | 90.0 | 4 | 13.3 | 13 | 43.3 | 16 | 53.3 | 27 | 90.0 | 87 | 58 |
| 3 | 3 | 10.0 | 24 | 80.0 | 11 | 36.7 | 11 | 36.7 | 2 | 6.7 | 51 | 34 |
| 2 | 0 | 0.0 | 2 | 6.7 | 6 | 20.0 | 3 | 10.0 | 1 | 3.3 | 12 | 8 |
| 1 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0 |
| Total | 30 | 100 | 30 | 100 | 30 | 100 | 30 | 100 | 30 | 100 | 150 | 100 |
One reason to explain this finding is the fact that the sample is composed of physically active elderly women, with 60% obtaining a score of 4 (maximum), since it is difficult to correlate both techniques when 92% of the sample obtained scores between 3 and 4.
The Normal Flex contains three tests to evaluate the LSF. It could be asked: why are there so many ways to measure approximately the same joint motion? Surely one of these tests would be sufficient to evaluate this? Therefore, it is important to determine if one of these tests could substitute the others. As such, Spearman correlation analysis was performed (table 5) and its significance for the three LSF movements evaluated through Normal Flex with data in an ordinal scale from 1 to 4.
| LSF stand1 | LSF stand 2 | |
|---|---|---|
| LSF stand 2 | 0.39 | - |
| LSF sitting | 0.44 | 0.33 |
The correlation observed was moderate and significant (p<0.05). The highest determination coefficient found showed that only 19% of data variability explains the other, which is not enough to confirm the existence of co-linearity between variables.
Each of the other tests - CSR, HES, SA, LSF and KF - tested only a single joint motion and was different from the others. Since they have different measurement goals, it would not be necessary to determine whether co-linearity exists between them.
The intraclass coefficient of correlation (ICC) was high and significant (r>0.90; p<0.001) during intra- and inter-rater reliability analysis for each joint in both analogical and digital goniometry. Analysis of Normal Flex showed that ICC varied from 0.90-0.99, with p<0.001.
The Pearson correlation results were higher than 0.90 and p<0.001, for both intra- and inter-raters. Based on these results, both the reliability of the study and the Normal Flex efficacy – significant for p <0.05 - can be confirmed.
The normality parameters are values obtained [32] through specific population samples, varying according to age and sex, in order to enable evaluation of the results obtained in the test as a function of distribution.
Intra-rater reliability is the consistency of measurements performed by a single rater under the same evaluation conditions at different moments [33], while inter-rater reliability refers to agreement among different evaluators for the analogical and the radiological goniometry measurements presented in tables 2 and 3.
In order to prove the validity of a test it must measure what it was designed for [34], showing reliability, stability and internal consistency. Proving the reliability and objectivity of a measure is therefore essential in order to guarantee data consistency, thereby enabling its use in scientific research. These consistent results represent reproducibility, i.e. the excellent degree of agreement for both reliability and objectivity [35]. The validity of a study should be analysed using two different perspectives: internal and external. Internal validity is related to controlling the intervening variable, without which it would be impossible to interpret the results and make any firm conclusion. This validity involves the control of variables for which the researcher can eliminate every hypothesis as explanations for the results obtained. The external variable refers to the generalisation of results for the population in general or for population groups when a sample is used. Yet even if the intervenient variables are controlled and the internal validity guaranteed, there is no certainty that the external validity will also be controlled. In order to achieve external validity or generalisability [36], i.e. whether the results can be reasonably applied to a definable group other than the population in the original study [37], the sampling process must be well conducted. In this study, there was a major concern in controlling all the variables that could interfere in the study results, so that the validation process could be developed properly.
The rapid increase in the elderly population worldwide raises concerns about their functional ability. Physical inactivity is considered a potential factor that aggravates aging problems [38]. The age-related reduction in flexibility – significantly affected by losses in muscle elasticity and joint mobility - is a factor in functional decline [18]. Evidence shows the beneficial effects of preserving physical and functional autonomy throughout aging [39] to protect the elderly population against developing physical disabilities and becoming clinically institutionalised [40]. Therefore, new studies and discussions will contribute to improving professional care for seniors [41]. Thus, the potential impact of this research is significant since it presents a set of tests capable of evaluating the flexibility of elderly women. Moreover, they are simple, feasible, efficient, and do not involve additional costs or equipment.
Considering the results obtained in relation to its applicability, reliability, consistency and validity, the Normal Flex set of tests exhibitedexcellent reproducibility capable of evaluating the flexibility of elderly women.
As aging progresses, flexibility decreases, influencing the autonomy and independence of individuals to perform activities of daily living. Within this framework, the Normal Flex set of tests was created and validated, evaluating joint flexibility in the spine and limbs of elderly individuals. The Normal Flex is non-dimensional, as it does not depend upon instruments, and consists of a set of movements that classify the flexibility level of cervical spine rotation, hip flexion, knee flexion and extension, in addition to shoulder flexion and abduction. This study determined the applicability, reliability, consistency, validity and reproducibility of the Normal Flex, providing sports medicine professionals with a remarkable instrument when dealing with the elderly.
It is suggested that future studies be performed with the Normal Flex for different age groups and in men.
The authors hereby declare that this research received no financial support and no relationship was involved that could pose conflicts of interest.
Dr. Carlos Soares Pernambuco from Universidade Estácio de Sá and Dr. Samaria Cader from University Federal do Estada do Rio de Janiero recommend the article for publication. The article is edited for English by Michael Germain from The Translation Enterprise MC TRADUÇÕES S/S LTDA.
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