Dualer IQ TM The Smarter Inclinometer TM

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2 Dualer IQ TM The Smarter Inclinometer TM Published by JTECH Medical 470 Lawndale Dr., Ste G Salt Lake City, Utah Copyright 2005 JTECH Medical. All rights reserved. Part #

3 Table of Contents Dualer IQ Specifications i Register Your Dualer IQ Introduction to Dualer IQ Dualer IQ and Accessories Dualer IQ Operation Dualer IQ Orientation During Use Connecting Primary and Secondary Inclinometers.. 5 Turning Dualer IQ ON and Off The Dualer IQ Display Dualer IQ Control Buttons Clearing the Dualer IQ Memory How the Control Buttons Function Dynamic Testing Mode Static Testing Mode Reviewing Test Data Advancing Display to Perform Another Test Dualer IQ Accessories Dualer IQ Range of Motion Test Protocols Number of Repetitions Warmups About the Illustrations Cervical Spine Measurements Cervical Flexion/Extension Cervical Lateral Flexion Cervical Rotation Thoracic Spine Measurements Thoracic Neutral Posture (Minimum Kyphosis) Thoracic Flexion Thoracic Lateral Flexion Thoracic Rotation Lumbosacral Spine Measurements Lumbosacral Lordosis Lumbosacral Flexion/Extension Tightest Straight Leg Raise Lumbosacral Rotation Lumbosacral Lateral Flexion Additional Spine ROM Measurements Gross Combined Hip and Spinal Flex/Ext Gross Spinal Flexion/Extension Sacral Hip Flexion/Extension Scoliosis Measurements Extremity Protocols Upper Extremities Wrist Flexion/Extension Elbow Pronation/Supination Elbow Flexion/Extension Shoulder Internal/External Rotation Shoulder Flexion/Extension Shoulder Adduction/Abduction Lower Extremities Ankle Dorsiflexion/Plantar Flexion Knee Flexion/Extension Knee Extension Lag Hip Forward Flexion Hip Extension Hip Abduction/Adduction Hip Internal/External Rotation Dualer IQ Worksheets Spine ROM Worksheet Extremity ROM Worksheet Dualer IQ Care and Maintenance Dualer IQ Warranty

4 Dualer IQ Technical Specifications Display Sensors Operation Operation Modes Data Displayed Data Storage Data Capture Control Buttons Accuracy Repeatability Operating Temperature Storage Temperature Dimensions Weight Rail Attachment Housing Internally Powered EN Specifications Continuous Operation Class II equipment Liquid crystal Solid-state accelerometers Dual or single inclinometry Dynamic and Static measurement Dual inclinometry: Total ROM, Primary value, Secondary value, test number, repetition, mode symbol Single inclinometry: ROM, test number, repetition, mode symbol 19 tests, 6 repetitions each Dynamic automatic with change of direction, Static Start/Stop button Start/Stop, Scroll, Dynamic/Static +/- 1 degree +/- 1 degree degrees F, degrees C degrees F, -40 to 70 degrees C Primary: 3.6"L X 2.75" W X 1" D Secondary: 2.1"L X 2.75" W X 1" D Primary: Approx. 152g Secondary: Approx. 94g Magnetic Machined aluminum AAA alkaline battery BF insulated equipment IP20 Ingress rating Equipment not suitable for use in the presence of flammable anesthetics. i

5 Register Your Dualer IQ Please take a moment to register your Dualer IQ with JTECH Medical. This will ensure you easy access to JTECH's Customer Service and Technical Support and guarantee that you will be fully covered under your warranty. To register your Dualer IQ please do one of the following: Call customer service at or Copy the form below and fax or mail to JTECH Medical, attention Customer Service. Fax: Mail: JTECH Customer Service 470 Lawndale Dr., Ste G Salt Lake City, Utah Dualer IQ Registration Form Name: Company/Clinic Name: Street Address: City: State/Province: Zip/Postal Code: Phone Number: Fax Number: Date of Purchase: Purchased From: Serial Number: 1

6 Introduction to Dualer IQ The Dualer IQ was designed to make measuring spine and large extremity ranges of motion faster, easier and more accurate. The Dualer IQ allows you to measure spine ranges of motion using dual inclinometry, and to measure extremities using either single or dual inclinometry. The Dualer IQ includes many special features that truly make it a Smarter inclinometer. m Eliminates calculation, placement changes, and repeat procedures. m Provides Total Range of Motion, Upper Segment Extreme and Lower Segment Extreme for spine range of motion measurements (vital data for AMA-based impairment rating). m m m m m Records up to six repetitions per test and up to 19 tests. Features Dynamic and Static testing modes for the spine and extremities. In Dynamic mode, Dualer IQ automatically records movement end-points so testing is more convenient. Works as both dual and single inclinometer. Upgrades to JTech computerized Range of Motion system without modification. Dualer IQ and Accessories Please check your new Dualer IQ to make sure everything is present with your order. Three straps Primary Inclinometer Secondary Inclinometer Connecting Cable Protective Carrying Case (not shown) Two Alignment Rails The two alignment rails are located in a small slit in the foam padding. If any parts are missing from your order, please contact JTECH Customer Service at or

7 Dualer IQ Operation Dualer IQ Orientation During Use The Dualer IQ uses gravity (or the floor) as the reference point when measuring range of motion. Therefore, to ensure proper orientation and accurate measurement, the narrow side of the Primary and Secondary inclinometers must always be oriented as close to perpendicular to the floor as possible (shown below). They should never be tipped or rotated more than 40 degrees off perpendicular, as that will result in inaccurate readings. NOTE: The Secondary inclinometer functions the same as the Primary units shown below. Axis of Rotation The Dualer IQ Primary and Secondary inclinometers measure degrees of motion, up to 360 degrees, around the axis shown on the right. Incorrect Orientations Correct Vertical Orientations Incorrect Vertical Orientations Correct Horizontal Orientations (Narrow side perpendicular to floor) Floor Incorrect Horizontal Orientations (Narrow side is not perpendicular to floor) 3

8 Dualer IQ Orientation, Continued For dual inclinometry protocols, the side of Primary and Secondary inclinometers with the Dualer IQ label must both face the same direction, as shown below. If the labels do not face the same direction when testing, inaccurate readings can result. Correct Orientation (Logos face same way) Incorrect Orientation (Logos faces different directions) Orientation for Different Types of Tests Dualer IQ has an automatic Zero feature that makes placing the inclinometers and starting tests easier. When the inclinometers are positioned and you press the Start/Stop button (see Button Operation for more information), Dualer IQ automatically zeros. Any movement from the zero point is measured. This innovative feature allows you to position the inclinometers as shown below for different types of tests. Important Note: The Primary inclinometer should always be positioned superior to the Secondary inclinometer. For example, for cervical flexion/extension measurement, the Primary inclinometer should be positioned on the head since that is where the primary motion occurs. Basic Orientation Inclinometers positioned on patient to start test. Starting position for tests such as cervical flexion/extension. Starting orientation for measuring spine flexion and extension ranges of motion. Starting position for lateral bending tests and abduction/adduction tests. The following is an example of the flexibility automatic zeroing provides with the Dualer IQ. In these illustrations the Dualer IQ is being used to measure lateral bending. In both illustrations, automatic zeroing ensures that the start point for both lateral bending movements is 0, even though the Primary inclinometer on the right is rotated 90 degrees at the start. 4

9 Connecting Primary and Secondary Sensors The Primary and Secondary sensors are only connected when used for dual inclinometer measurements, such as spine ROM. Always make sure the Primary sensor is turned off when making the connection. 1. With the Primary sensor turned off, insert an end of the connecting cable into the phone jack (rs232) on top of the Primary sensor. Make sure the cable locks ( snaps ) in place. 2. Insert the other end of the connecting cable into the phone jack on the Secondary sensor, making sure it locks into place. Note: The Primary sensor functions as a stand-alone for single inclinometry procedures, while the Secondary unit only functions when attached to the Primary sensor. Primary Connection Secondary Connection Disconnecting Cables 1. Press the release pin on the cable connector. 2. Pull the cable end out of the Dualer IQ unit. Connected for Dual Inclinometry Cable Connector Release Pin Turning Dualer IQ On and Off The power toggle switch is located on top of the Primary sensor. This switch controls power to both units when the Secondary sensor is attached to the Primary. The symbols shown below, located on the front of the Primary sensor, indicate power ON and OFF positions. "ON" "OFF" Power Switch (shown in off position) Important Note: When test data is stored in the Dualer IQ memory, turning the power off does not erase that data from the memory. See Button Operation for information about clearing the memory. SLEEP MODE Dualer IQ conserves battery life with an automatic Sleep mode. When Dualer IQ is turned on but no activity is detected for five minutes, the unit goes into Sleep mode. All data recorded before entering Sleep mode is stored in memory for recall. To rouse from Sleep mode, move the Power Switch to OFF, wait a moment, then turn switch back to ON. Important Note: Even in Sleep mode, the Dualer IQ draws small amounts of power from the battery. Leaving the unit in Sleep mode for extended periods will eventually drain the battery. Therefore, when not in use, JTech recommends that you turn the Power Switch OFF to extend the battery life. Even when the battery goes dead, Dualer IQ will retain any data already stored in memory. 5

10 The Dualer IQ Display The Dualer IQ LCD provides you with both measurement data and operation information. When the Dualer IQ Primary sensor is turned on, the display will appear in one of the configurations shown below. Initial display with Secondary sensor attached. Initial display with Secondary sensor disconnected. Test number indicator Dynamic testing indicator (default testing mode) Test number indicator Dynamic testing indicator (default testing mode) Primary and Secondary measurements Total Range of Motion (Primary minus Secondary movement) Range of Motion (only movement of Primary sensor is displayed) Display Symbols The following list explains what the various symbols on the display represent: Test Number - This box shows the number of the test for which you are reviewing or collecting data. Dualer IQ stores data for up to 19 tests with up to six repetitions each. Dynamic Testing Mode - Primarily used for measuring range of motion in pairs (ie. flexion/extension). In this mode, a complete repetition is one flexion and one extension motion or vice versa. In Dynamic mode, Dualer IQ automatically records the furthest end point (greatest range of motion) for each movement. Static Testing Mode - Used for measuring a single motion. It is especially useful for kyphosis, ankylosis and extremity testing. In this mode, a repetition is either one flexion or one extension movement. In Static mode, endpoints are entered by pressing the Start/Stop button. Low Battery - When this symbol is displayed the battery is low and should be replaced. Degrees (angle) - Located next to ROM values to indicate measurements are in degrees. Total ROM (or differential angle) - This symbol is only displayed for dual inclinometry. The Total ROM value is the difference in angle between the Primary and Secondary inclinometers. It is produced by subtracting the Secondary movement value from the Primary movement value. Primary Inclinometer - Only displayed for dual inclinometry, the number to its right is the actual value measured by the Primary Inclinometer. Secondary Inclinometer - Only displayed for dual inclinometry, the number to its right is the actual value measured by the Secondary Inclinometer. Negative Movement - This symbol appears when motion of the Secondary Inclinometer is opposite that of the Primary Inclinometer. Repetitions - Shows repetitions performed for the test number displayed. In Dynamic mode, one half of the symbol represents the flexion and the other half the extension segment of the repetition. In Static mode, the symbol remains whole since only one motion direction is measured for each repetition. Up to six repetitions are available per test. 6

11 Dualer IQ Control Buttons All Dualer IQ functions are controlled by three buttons: one on the top, one on the left side and one on the right side. Each button is associated with a symbol on the face of the Primary sensor. Start/Stop Test n START/STOP - Starts and stops tests, and is used when clearing the memory. l SCROLL - Scrolls through collected data, advances to the next test, and is used when clearing memory. s DYNAMIC/STATIC - Switches between Dynamic and Static testing modes. Dynamic mode is used when the subject can move through ranges of motion. This makes testing of movements, such as flexion/extension faster and easier. Static mode collects data one measurement at a time. Scroll Dynamic/Static Modes Clearing the Dualer IQ Memory The Dualer IQ stores up to 19 tests with up to 6 repetitions each. You must clear the memory to erase data stored there. Note: The memory can be cleared regardless of whether or not the Secondary sensor is attached. 1. Make sure Primary sensor is turned on. 2. Simultaneously press and hold both the Start/Stop n and Scroll l buttons until CLr is displayed. 3. When cleared, the Dualer IQ resets to begin testing in Dynamic mode at test 1 repetition 1. How the Control Buttons Function Dynamic Testing Mode Using dual inclinometry in Dynamic testing mode is the preferred method for measuring most spine ranges of motion. Dynamic mode measures movement pairs, such as cervical flexion/extension or left and right cervical lateral flexion. Dynamic is the default testing mode, so the Dualer IQ automatically begins operation in Dynamic testing mode. Dynamic tests can be performed using dual or single inclinometry. For dual inclinometry, the display provides three measurements: movement of both sensors and Total Range of Motion. For single inclinometry, the display only shows the Primary sensor s movement. Dynamic Testing for dual or single inclinometry is essentially the same. Basic Operation for Dynamic Testing 1. For dual inclinometry tests, attach the Secondary sensor. Turn the Primary sensor on. 2. With the patient in neutral position, place the Dualer IQ on the patient according to the test protocol (see Test Protocols Section for more information). 3. Press the Start/Stop n button to automatically establish 0 and begin collecting test data. 4. Have the patient move in one direction, stop briefly at the farthest point, then move in the opposite direction to the furthest possible point. Continue doing the movements until the patient completes the requisite number of repetitions (up to six). To end the test, press the Start/Stop n button. NOTE: Dualer IQ automatically records the farthest point the patient is able to reach in each direction, so you do not need to press a button to capture the end range of motion data. 7

12 1. With inclinometers in place, press the Start/Stop n button to zero and begin collecting data. 2. Patient flexes forward to maximum range of motion. When test begins all values are set to 0 and half of the repetition symbol flashes. When patient stops and begins extension, Dualer IQ records the end-point and calculates Total Range of Motion. 3. Patient extends backward to maximum range of motion. As patient extends, right half of repetition symbol flashes. End points and Total ROM are recorded when patient begins flexion. 4. To end the test, have patient move back toward neutral and press the Start/Stop n button. Solid repetition symbols indicate completed repetitions. Static Testing Mode Static testing can be performed using either single or dual inclinometry protocols. Static testing means the patient s range of motion is measured in a static position. In Static mode, ROM is also only measured for a single joint movement, such as single inclinometry elbow flexion or dual inclinometry thoracic kyphosis. Dynamic is the default testing mode, so to perform static tests you must change into Static Testing mode. 1. With the Primary sensor on, press the Dynamic/Static s button to display the Static symbol. 2. Dualer IQ will remain in Static mode until changed back to Dynamic mode or until the Primary unit is turned off. Basic Static Single Inclinometry Testing NOTE: In Static testing mode the Dualer IQ does not automatically record the end-point value for range of motion. End point values are entered using the Start/Stop n button. 1. With the Secondary unit detached, turn the Primary sensor on. 2. Press the Dynamic/Static s button to change into Static mode. 3. Position the Primary sensor at the reference point according to the test protocols and press the Start/Stop n button to establish According to the protocol, either move the Primary sensor or have the patient move with the inclinometer to the second position and press the Start/Stop n button to record the ROM. 5. Repeat steps 3 and 4 for additional measurements or press the Scroll l button to advance to the next test. 8

13 This is an example of a static straight leg raise. 1. With Dualer IQ in Static mode and positioned on the patient, press Start/Stop n to establish 0. Static symbol When Start/Stop n is pressed the first time, the display is set at 0. Repetition symbol flashes. 2. Move patient to the end-point of the range of motion and press Start/Stop n to record range of motion. When Start/Stop n is pressed the second time, the ROM is recorded. NOTE: The display will continue to change, even though the ROM was recorded. Repetition symbol turns solid. 3. Repeat steps for more repetitions or press the Scroll l button to advance to the next test or to review test data. Basic Operation for Static Dual Inclinometry Testing Kyphosis and ankylosis measurements are just some of the special uses of Static dual inclinometry. In many of these tests, a flat surface, such as a table or wall, is used to establish the 0 point. 1. With the Secondary unit attached, turn the Primary sensor on. 2. Press the Dynamic/Static s button to display the Static symbol. 3. Place the inclinometers on a flat surface, such as a wall, or on the patient according to the test protocol and press the Start/Stop n button to establish According to the protocol, position the inclinometers on the patient or have the patient move to maximum ROM and press the Start/Stop n button to record the angle. 5. Repeat steps 3 and 4 for additional measurements or use the Scroll l button to advance to the next test or to review test data. In Static mode, place inclinometers on flat surface, such as a wall and press the Start/Stop n button to establish zero. Place the inclinometers on the patient and press the Start/Stop n button to record the angle. These illustrations are for measuring thoracic kyphosis with static dual inclinometry. 9

14 Reviewing Test Data After at least one test with one repetition is completed, you can use the Scroll n button to review data stored in the Dualer IQ memory. 1. To begin reviewing stored data, press the Scroll l button twice. (The first press advances to the next test, the second press displays test 1 repetition 1.) 2. Continue pressing the Scroll l button to advance through all completed tests and repetitions. Scrolling past the last stored repetition advances to the next available test. Pressing the button again goes back to test 1 rep 1. NOTE: You cannot back up or skip tests as you scroll through data. You can only advance through each test and repetition as they were performed. Advancing Display to Perform Another Test 1. Make sure that none of the repetition symbols is flashing. If one is flashing, you are still in Testing mode and cannot advance to the next test. (To exit Testing mode, press the Start/Stop n button.) 2. Press the Scroll l button once. The test number in the display s upper left-hand advances to the next test number. Values for the Primary and Secondary sensors are not displayed until you begin the next test by pressing the Start/Stop n button. 10

15 Dualer IQ Accessories Dualer IQ comes with several accessories that can be used to measure ranges of motion more accurately. Using Attachment Straps Velcro straps are provided for attaching Dualer IQ sensors to the body. Using the straps may increase examination time slightly more than holding sensors in place by hand, but the result is greater accuracy because the straps reduce slippage of sensors during joint movement. For spinal range of motion exams, some of the procedures do not require straps. Careful holding of the sensors to the body by hand is adequate to avoid slippage. The large strap that comes with the Dualer IQ is recommended for use on the head. This strap can be used with lateral flexion and rotational movement. The two shorter straps are used on the extremities. The straps are especially important when performing passive range of motion tests, as they free the clinician's hands to work with patient. Straps can also be used in special situations, such as swelling or large muscle mass, that may interfere with sensor placement. Note: When using straps with extremity procedures, be sure to zero the sensor after it is attached to the strap and when the subject is in neutral. Dualer IQ measures ROM from when the Start/Stop n button is pressed, and if neutral was not achieved, the final reading will be incorrect. If neutral cannot be reached, then alternate procedures for ankylosis should be used. Attaching straps to extremities and head To affix straps, select the proper strap size, place the non-fuzzy side of the strap against the skin, wrap around the body part stretching the material as you wrap, and affix with the Velcro end. Place Velcro on backside of sensor flat against the strap in the proper orientation. Wiggle the sensor against the strap to achieve better contact of the loop material of the strap against the hook material of the sensor. Using Alignment Rails Dualer IQ comes with two metal rails that are used to help align the inclinometers when testing. The feet, or bottom, of both the Primary and Secondary inclinometers are magnetized specifically for attaching the alignment rails. See Test Protocols section for application of the rails. Dualer IQ sensors have magnetic bottoms to hold alignment rails in place during testing. 11

16 Dualer IQ Range of Motion Test Protocols The following section describes protocols used to measure spine and extremity ranges of motion. Each protocol will tell you whether it is for dual or single inclinometry. Many of the protocols can be performed in Dynamic or Static testing mode. Illustrations are included to help you understand inclinometer placement for each protocol. Number of Repetitions Three repetitions are usually performed for spine range of motion measurements. When performing an AMA impairment rating three consecutive measurements must be within 5 degrees or 10 percent (whichever is greater) of the mean (average). If validity is not reached within six repetitions, the test is invalid for impairment rating. For more information see the Guides to the Evaluation of Permanent Impairment published by the American Medical Association. One repetition is usually performed for extremity measurements. However, when performing a straight leg raise for impairment rating, the 5 degree or 10 percent rule applies. Warm-ups When performing an impairment evaluation, the Guides 5th Edition recommends that warm-up range of motion movements be performed before the evaluation: two flexion/extension, two left and right rotation, two left and right lateral bending followed by one additional flexion/extension. Warmups do not need to be repeated before additional measurements on the same spinal region. About the Illustrations For clarity, illustrations omit examiner hand placement and the cord connecting the two sensors. Most of the illustrations are shown from the right side of the patient. The examiner should stand in a position that allows the sensors to be held firmly to the body through the entire movement. Cervical Spine Measurements Some of the cervical protocols include alternate methods for measuring range of motion with the Dualer IQ. Use the one most comfortable for you. Head Strap Some of the illustrations show the sensors used with a strap. Simply affix the sensors as shown. If straps are not used, place the sensors in the same locations, but use caution to ensure the sensors do not slip during movement. Cervical Flexion/Extension Dual inclinometry in Dynamic or Static modes With the subject seated and cervical spine in neutral, place the Secondary sensor in the sagittal plane at T1 and the Primary sensor in the sagittal plane on the calvarium. Make sure the sensors do not slip during flexion and extension. If slippage occurs the Primary sensor can be positioned above the ear using the strap. The subject can reach out and hold a solid object, such as a table, to prevent shoulder sway during the test. Have subject flex and extend cervical spine. Note: To avoid the patient bumping the Secondary unit in extension, move the Secondary unit slightly to the left or right before pressing the Start/Stop n button to begin the test. In neutral an imaginary line from the corner of the eye to the ear should be parallel to the floor. 12

17 Cervical Flexion/Extension Cont. Cervical flexion/extension with strap Ankylosis Single inclinometry in Static mode. If some movement is observed, have subject try to reach neutral. If movement to neutral is achieved, evaluate per previous Cervical Flexion/Extension protocol. Have patient attempt to reach neutral and hold maximum position. Place the Primary sensor at T1 and press the Start/Stop n button to establish 0. Move the sensor to the upper aspect of the cervical spine and press the Start/Stop n button to record the angle. With patient as close to neutral as possible, zero Primary at T1. T1 While patient maintains position, place the Primary at upper aspect of cervical spine and record the angle. Cervical Lateral Flexion Dual inclinometry in Dynamic or Static mode For best accuracy, draw a line at right angles to spine at T1. With subject in seated position and cervical spine in neutral, place the Secondary sensor in the coronal plane over T1 and place the Primary sensor over the calvarium. If slippage occurs with the Primary sensor, it can be attached at the back of the head with a strap. Have subject laterally flex right and left. Secondary sensor held at T1 and Primary sensor held on the calvarium. Cervical lateral flexion/extension with strap. Ankylosis Dual inclinometry in Static mode Draw a line over the T1 spinous process and attach alignment rails to both sensors. Place both sensors on a table and press the Start/Stop n button to establish 0. With subject seated and ankylosis minimized, place the Primary sensor in the coronal plane at the upper edge of the cervical spine perpendicular to the spine. Place the Secondary sensor at T1 with the base parallel to the skin mark. Measuring cervical lateral ankylosis using alignment rails on the Primary and Secondary sensors. 13

18 Cervical Rotation Single inclinometry in Dynamic or Static mode With the subject supine on a table and head in neutral rotation (nose pointing at the ceiling), place and hold the Primary sensor in the transverse plane securely on the forehead. If unable to hold the sensor securely, attach it to the top of the head over the calvarium using a strap. Note: When using the strap, attaching the rail to the sensor and aligning it with the back of the ears may improve accuracy. Make sure the inclinometer does not slip as the patient rolls head from side to side without lifting head from the table during the test. Cervical rotation with strap Alternate Cervical Rotation Dual inclinometry in Dynamic or Static mode Note: This procedure should not be used for impairment rating. Have subject standing or sitting, bent forward at the waist at least 45 degrees. With the cervical spine in neutral rotation, place the Primary sensor on the back of the head and the Secondary sensor over T1. Inclinometers are perpendicular to the floor when testing. Ankylosis Single inclinometry in Static Mode Attach the alignment rail to the Primary sensor, then place the sensor on a table and press the Start/Stop n button to establish 0. With the subject in a supine position with the head rotated as close to neutral as possible, place the Primary sensor over the calvarium and align the rail with the back of the ears, and record the angle. Position sensor over calvarium and align rails with back of the ears. 14

19 Thoracic Spine Measurements For thoracic measurements, the sensors are held at the ends of the region by the examiner. Stand to the side of the patient with your thumb and middle fingers on opposite sides of the sensor near the base, allowing easy access to the Start/Stop n button. Start tests when the subject is in neutral. Thoracic Neutral Posture (Minimum Kyphosis) Dual inclinometry in Static mode With subject either standing or sitting in a neutral military brace position, place the sensors on a wall and press the Start/Stop n button to establish 0. Place the Primary sensor at T1 and the Secondary sensor at T12 and record the angle. In static mode, place inclinometers on a wall, and press the Start/Stop n button to establish 0. Position inclinometers and press the Start/Stop n button to measure kyphosis. Thoracic Flexion Dual inclinometry in Static mode With subject standing or sitting in neutral military brace position, place the Primary sensor in the sagittal plane at T1 and the Secondary sensor at T12. Press the Start/Stop n button to establish 0. Have subject fully flex the thoracic spine (bending at the waist is permitted) and record the angle. Position inclinometers at T1 and T12. Press the Start/Stop n button to establish 0. Make sure narrow side of inclinometers is oriented parallel to the spine. Hip movement is automatically subtracted from Total ROM. Thoracic Lateral Flexion Dual inclinometry in Dynamic or Static mode Note: This measurement is not needed for AMA impairment ratings. For best accuracy, place a line at right angles to the spine at T1 and T12. With subject standing or seated with thoracic spine in neutral, place Primary sensor at T1 and the Secondary sensor at T12 in the coronal plane. Have subject bend laterally to the left and right. Primary at T1 and Secondary at T12 Right lateral flexion Left lateral flexion 15

20 Thoracic Lateral Flexion Cont. Ankylosis Dual inclinometry in Static mode Draw lines over the T1 and T12 spinal processes and attach alignment rails to both inclinometers. Place both sensors on a table and press the Start/Stop n button to establish 0. With subject minimizing the lateral flexion ankylosis, place the Primary sensor at T1 and the Secondary sensor T12 in the coronal plane with alignment rails positioned over the skin lines and record the angle. In Static mode, place inclinometers on a table and press the Start/Stop n button to establish 0. Place inclinometers at T1 and T12 in alignment with the skin marks you drew and record the angle. Thoracic Rotation Dual inclinometry in Dynamic or Static mode Place skin marks over the T1 and T12 spinal processes. With subject seated or standing, have the subject flex forward until the spine is horizontal with the floor. Place the Primary sensor at T1 and the Secondary sensor at T12 in the transverse plane. Make sure both sensors are perpendicular to the floor. Have subject rotate maximally left and right. Side view of inclinometer positioning Shown in standing positioning Neutral Position Right Rotation Left Rotation 16

21 Lumbosacral Spine Measurements For most lumbosacral measurements, the sensors are held at the ends of the region by the examiner. Stand to the side of the patient with your thumb and middle fingers on opposite sides of the sensor near the base, allowing easy access to the Start/Stop n button. Start tests when the subject is in neutral. Included in the Lumbosacral Section is the straight leg raise. This protocol is described in the AMA Guides to the Evaluation of Permanent Impairment as a validity check for lumbosacral flexion/extension. Lumbosacral Lordosis Dual inclinometry in Static mode Place both sensors on a wall and press the Start/Stop n button to establish 0. With subject standing in neutral, knees straight and weight equally on both feet, place at Primary sensor at T12 and the Secondary sensor over the sacral midpoint in the sagittal plane and record angle. Lumbosacral Flexion/Extension Dual inclinometry in Dynamic or Static modes Important Note: The Dualer IQ provides all the necessary data for complete lumbosacral flexion/extension impairment evaluation without additional inclinometer placements. When the Dualer IQ sensors are placed as described below, the display provides T12 ROM (Primary sensor), Sacral ROM (Secondary sensor) and Total ROM with each flexion/extension movement. Zero sensors on a wall T12 ROM Value T12 Sacral Midpoint Total ROM Value Sacral ROM Value Note: The AMA Guides requires three consecutive flexion and three consecutive extension repetitions to be within 5 degrees or 10 percent, which ever is greater, of the average for valid impairment rating. Validity does not necessarily mean they must be the same flexion/extension pair. For example, if the first three flexion movements are valid, but extension is not, continue the test until also reaching valid extension, up to six repetitions. You would then use the first three consecutive flexion values and the three consecutive extension values. Have subject stand with spine in neutral position, knees straight, weight equally on both feet and hands on hips. Place the Primary sensor at T12 and the Secondary sensor over the sacral midpoint in the sagittal plane. Have subject flex forward maximally, then extend maximally. Dualer IQ simultaneously measures and displays T12, sacral hip and total ROM values for lumbosacral flexion and extension. Primary at T12 Secondary center over sacral midpoint Extension Flexion 17

22 Tightest Straight Leg Raise - Accessory Validity Test Single inclinometry in Static mode Note: According to the Guides this validity test is only useful when sacral flexion plus sacral extension is less than 65 for women or 55 for men. For the straight leg raise test itself to be valid, three consecutive measurements must be with 5 degrees or 10 percent, whichever is greater, of the mean (average). If validity is not reached within six repetitions, the test is invalid for impairment rating. For the straight leg raise to establish the validity of lumbosacral flexion/extension, the difference between the tightest straight leg raise and sacral flexion plus extension must be less than or equal to 15. Tightest SLR - (sacral flexion + sacral extension) 15 = validity. With subject supine on a table and both knees extended, place the Primary sensor on the tibial crest of the leg and press the Start/Stop n button to establish 0. Keeping the knee straight, passively raise the right leg until the opposite hip begins to raise or the opposite knee begins to flex. Repeat the procedure for the opposite leg. For easier handling and stability, a strap can be used to attach the sensor to the leg. Of the three valid consecutive measurements for each leg, choose the maximum for each leg, then insert the smaller of the two maximums into the formula above. If tightest straight leg raise exceeds sacral flexion plus extension by more than 15, the lumbosacral flexion/extension test is invalid and should be repeated or the impairment disallowed. Primary positioned on tibial crest Passively raise the leg, keeping knee straight Sensor attached to leg with a strap Lumbosacral Rotation Dual inclinometry in Dynamic or Static mode Note: This measurement is not used for AMA impairment ratings. With subject seated or standing, bent at the waist until the spine is nearly horizontal with the floor, and spine in neutral rotation, place the Primary sensor at T12 and the Secondary sensor over the sacral midpoint. Have subject rotate maximally to the right and left. T12 Sacral Midpoint Side view of standing position Test can also be performed in a seated position. 18

23 Lumbosacral Rotation Cont. Ankylosis Dual inclinometry in Static mode Place both sensors on a table and press the Start/Stop n button to establish 0. With the subject either sitting or standing, flexed forward, and spine as close to horizontal and neutral rotation as possible, place the Primary sensor at T12 and Secondary over the sacral midpoint and record the angle. (See previous lumbosacral rotation illustrations for inclinometer placement.) Lumbosacral Lateral Flexion Dual inclinometry in Dynamic or Static mode For best accuracy, place a line at right angles to the spine at T12 and sacral midpoint. With subject standing in neutral with the knees straight, place the Primary sensor at T12 and the Secondary over sacral midpoint. Make sure bases of the sensors remain over the lines drawn on the skin throughout the movement. Note: If the sensors can be firmly held on the body without slippage, then alignment marks on the body and rails are not needed. T12 Sacral Midpoint Ankylosis Dual inclinometry in Static mode For best accuracy, place a line at right angles to the spine at the sacral midpoint and T12. Place both sensors on a table and press the Start/Stop n button to establish 0. With the subject minimizing the ankylosis, place the Primary sensor at T12 and the Secondary sensor over the sacral midpoint and press the Start/Stop n button to record the angle. Position the sensors and press the Start/Stop n button to record the angle. Place both sensors on a table and press the Start/Stop n button to establish 0. 19

24 Additional Spine ROM Measurements Gross Combined Hip and Spinal Flexion/Extension Dual inclinometry in Dynamic or Static mode Note: This measurement is not used for AMA impairment rating. Attach the Secondary sensor to the thigh with a strap and hold the Primary sensor at T1. With the subject standing upright in a neutral position, press the Start/Stop n button to establish 0. Have subject flex forward maximally, then extend maximally. Secondary attached to thigh. Primary at T1 Gross Spinal Flexion/Extension Dual inclinometry in Dynamic or Static modes Note: This measurement is not used for AMA impairment ratings. With the subject standing upright in a neutral position, place the Primary sensor at T1 and the Secondary sensor over the sacral midpoint. Have the subject flex maximally and extend maximally. Flexion Primary at T1. Extension Secondary over the sacral midpoint. Sacral Hip Flexion/Extension Dual inclinometry in Dynamic and Static modes Note: Dualer IQ automatically shows sacral hip motion when performing lumbosacral flexion/extension measurements. With the subject standing in neutral, attach the Secondary sensor to the thigh with a strap and hold the Primary sensor over the sacral midpoint. Have the subject flex maximally and extend maximally. Primary held over the sacral midpoint. Flexion Extension Secondary attached or held on the thigh. 20 Flexion Extension

25 Scoliosis Measurements Several methods can be used to determine the degree of scoliosis from x-ray. Two methods are described below. Ferguson's Method Single inclinometry in Static mode See Roentgen Diagnosis of Extremities and Spine: Attach a rail to the Primary sensor. Set the inclinometer to Static mode. 2. Place the x-ray film vertically in a view box. Mark the apical vertebrae of the curvature and the two points at the ends of the curve. 3. Span the middle and outer point defined above with the sensor and press the Start/Stop n button to establish Span the middle point and the other outer point and press the Start/Stop n button to record the angle. Position inclinometer over the upper vertebra and press the Start/Stop n button. Position inclinometer over the lower vertebra and press the Start/Stop n button to record the angle. Cobb's Method Single inclinometry in Static mode See Cobb: American Academy of Orthopedic Surgery, Attach a rail to the Primary sensor and set it to Static mode. 2. Place the x-ray film vertically in a view box. Determine an end vertebra of the curvature, place the sensor rail along the long axis of the segment, and press the Start/Stop n button to establish Determine the vertebra at the other end of the curve, place the sensor rail along the long axis of the segment, and press the Start/Stop n button to record the angle. Position inclinometer over the long axis of the vertebra at the top of the curve and press the Start/Stop n button. Position inclinometer over the vertebra at the lower end of the curve and press the Start/Stop n button to record the angle. 21

26 Extremity Protocols Dual and single inclinometer methods for measuring range of motion of each joint are illustrated. Choose the one most comfortable for you to use. Protocols for measuring ankylosed joints are also included. Simulated Goniometer Dualer IQ can be used to simulate a goniometer, both in dual and single inclinometry modes, when measuring extremity ranges of motion. While the individual angles of the Primary and Secondary units are displayed for dual inclinometry, only the Total Range of Motion value is typically required for extremity range of motion. The Dualer IQ is very accurate for measuring extremity ranges of motion because it effectively eliminates goniometer alignment errors and substantially increases inter- and intra-rater repeatability. Upper Extremities Wrist Flexion/Extension Dual inclinometry in Dynamic or Static mode Support the arm with the patient s wrist in neutral. Hold the Primary sensor on the dorsal aspect of the hand and the Secondary sensor on top of the forearm. Have subject flex and extend the wrist. Note: If either sensor does not parallel the longitudinal axis of the segment due to swelling, use static single inclinometry with alignment rails described below. Wrist Flexion Wrist Extension Single inclinometry in Static mode Note: If swelling is present, attach the alignment rail and align the Primary sensor along the axis of each segment instead of placing it on top of the forearm and hand. With the arm supported, have subject flex wrist maximally. Place the Primary sensor on the top of the forearm and press the Start/Stop n button to establish 0. While subject maintains wrist flexion, place the Primary sensor on the back of the hand and press the Start/Stop n button to record the angle. Have subject extend the wrist and repeat the above procedure. Start test with Primary on top of the forearm Wrist Flexion Wrist Extension Elbow Pronation/Supination Dual inclinometry in Dynamic or Static mode Note: For better accuracy attach the Secondary sensor to the upper arm with a strap. Have subject seated, elbow flexed to 90 degrees and the forearm in the neutral position. Strap or hold the Secondary sensor to the upper arm and place the Primary unit on the dorsal side of the wrist. Have subject pronate and supinate the elbow. Note the offset rotation of the Primary and Secondary sensors in the neutral position. The sensors can be placed this way because of Dualer IQ s automatic zero feature. Elbow at 90 degrees and wrist in neutral position. 22 Pronation Supination

27 Elbow Pronation/Supination Cont. Ankylosis Single inclinometry in Static mode Note: Use this procedure if the subject cannot reach neutral for elbow pronation or supination. Have the subject seated, elbow flexed at 90 degrees, and forearm as close to neutral as possible. Place the Primary sensor on a wall and press the Start/Stop n button to establish 0. Place the Primary sensor on the wrist and press the Start/Stop n button to record the angle. In Static mode, place the Primary sensor on a wall and press the Start/Stop n button to establish 0. With subject as close to neutral as possible, place the Primary sensor on the wrist and record the angle. Elbow Flexion/Extension Dual or Single inclinometry in Dynamic mode Note: For best accuracy, attach sensors with straps and support the upper arm on a flat table. For dual inclinometry, attach the Primary sensor to the forearm and the Secondary sensor to the upper arm. For single inclinometry, attach the Primary sensor to the forearm with a strap. Begin the test with the subject s shoulder flexed to 90 degrees and elbow at neutral. Have subject flex the elbow, then extend the elbow. Helpful Hint: If the sensors touch during dual inclinometry flexion, move one closer to the elbow and the other away from the elbow. Dual Inclinometry Elbow Flexion Single Inclinometry Elbow Flexion Single inclinometry in Static mode Note: Use this procedure for ankylosis measurement. Attach the alignment rail to the Primary sensor. Have subject s shoulder flexed to 90 degrees and elbow flexed maximally. Place the Primary sensor s alignment rail along the long axis of the upper arm and press the Start/Stop n button to establish 0. Without moving the upper arm, rotate the Primary sensor to the long axis of the forearm and press the Start/Stop n button to record the angle. 23

28 Shoulder Internal/External Rotation Single inclinometry in Dynamic or Static mode Attach the Primary sensor to the forearm with a strap. Have subject stand or sit with shoulder abducted to 90 degrees, elbow flexed to 90 degrees, and upper arm in neutral rotation. If torso sway is a problem, the Secondary sensor can be attached and positioned over the sternum. Have subject externally and internally rotate the shoulder. Note: This test can also be performed in a prone or supine position with the upper arm supported. Arm in Neutral Externally Rotated Internally Rotated Shoulder Flexion/Extension Single inclinometry in Dynamic or Static mode Attach the Primary sensor to the upper arm with a strap. Have subject stand with arm down and shoulder in neutral position. Have subject flex and extend the shoulder maximally. Note: For motion between the humerus and scapula, attach the Secondary sensor and hold it firmly against the scapula during motion. If torso sway affects the test, attach and hold the Secondary unit against the sternum. Secondary unit can be attached for scapular motion. To eliminate effects of sway, attach Secondary unit and place it on the sternum. shoulder in Neutral Shoulder Flexed Shoulder Extended Ankylosis Single inclinometry in Static mode Attach an alignment rail to the Primary sensor. Place the Primary sensor on a wall and press the Start/Stop n button to establish 0. Align the rail of the primary sensor along the axis of the upper arm and press the Start/Stop n button to record the angle. Note: If movement is possible, have subject flex or extend as far as possible and record the angles. 24

29 Shoulder Flexion/Extension Cont. Shoulder Extension Ankylosis Shoulder Flexion Ankylosis Establish 0 on a wall in this orientation for shoulder extension ankylosis. Establish 0 on a wall in this orientation for shoulder flexion ankylosis. Shoulder Adduction/Abduction Single inclinometry in Dynamic or Static modes Attach the Primary sensor to upper arm with a strap. Place subject in a standing position with arm down in neutral and hand supinated. Have subject adduct and abduct the shoulder maximally. Note: If torso sway affects the test, attach and hold the Secondary unit against the sternum. Secondary unit attached to compensate for sway during movement. Arm in Neutral Shoulder Adduction Shoulder Abduction Ankylosis Single inclinometry in Static mode Place an alignment rail on the Primary sensor and have subject stand with arm down as close to neutral as possible and hand supinated. Place the Primary sensor on a wall and press the Start/Stop n button to establish 0. Place the Primary sensor s rail along the axis of the upper arm and record the angle. Primary sensor aligned with upper arm. Establish 0 on a wall. 25

30 Lower Extremities Ankle Dorsiflexion/Plantar Flexion Single inclinometry in Static mode Place the subject on a horizontal surface with the foot in neutral position. Attach an alignment rail to the Primary sensor and place on the sole of the foot. Have subject dorsiflex and record the angle, then plantar flex and record the angle. Ankle in Neutral Dorsiflexion Plantar Flexion Single inclinometry in Static mode for impairment rating Verify that the wall used for zeroing the sensor is 90 degrees to the surface on which the patient is placed. Place the Primary sensor on the wall, press the Start/Stop n button to establish 0, then place it on the surface. Step 1. Place the subject supine on a horizontal surface with the tibia parallel to the surface and the ankle in neutral position. With an alignment rail attached, place the Primary sensor on the wall and press the Start/Stop n button to establish 0. Place the Primary sensor on the sole, and measure the dorsiflexion angle. Rezero the sensor on the wall and measure plantar flexion. Step 2 Flex the subject s knee to 45 degrees and align the sensor along the tibia and press the Start/Stop n button to establish 0. Dorsiflex the foot, place the Primary sensor on the sole, and record the angle. Repeat for plantar flexion. Subtract 90 degrees from the dorsiflexion value for the true dorsiflexion angle and subtract the plantar flexion value from 90 degrees for true plantar flexion. Step 3 Average the results of both sets of measurements and use to calculate the impairment. Establish 0 on a wall... then measure dorsiflexion. Establish 0 on a wall... then measure plantar flexion. With knee flexed at 45 degrees, align Primary sensor with tibia. Measure dorsiflexion and subtract 90 degrees. 26 Realign with tibia, measure plantar flexion and subtract the results from 90 degrees.

31 Knee Flexion/Extension Dual inclinometry in Dynamic mode Helpful Hint: If the sensors touch during flexion, move one closer to the knee and the other away from the knee. Attach one sensor to the lower leg and one to the thigh with straps. Have the subject lying on a horizontal surface with the knee neutral. Have the subject flex the knee maximally, then extend the knee. Single inclinometry in Static mode Attach a rail to the Primary sensor. With the subject supine on a horizontal surface and the knee flexed maximally, place the sensor's rail along the femur and press the Start/Stop n button to establish 0. Place the Primary sensor s rail along the tibia and press the Start/Stop n button to record the angle. If the subject cannot reach neutral, this value represents extension lag. Place the Primary sensor along the femur and press the Start/Stop n button to establish 0. Align the Primary sensor along the tibia and record the angle. Knee Extension Lag Dual inclinometry in Static mode Note: Use the procedure if subject cannot reach neutral knee position. Attach rails to the sensors and zero on a table. With the subject supine on a horizontal surface and the knee as close to neutral as possible, place one sensor's rail along the femur and the other along the tibia and record the angle. Establish 0 on a table. Subject supine on table, sensors on femur and tibia. Hip Forward Flexion Single inclinometry in Static mode Attach the Primary sensor to the thigh with a strap. With the subject supine on a table, place the hip to be evaluated in neutral position and extend the knee in neutral position. Have the subject flex the opposite hip and knee and hold them in position. Press the Start/Stop n button to establish 0, then have subject flex hip until the iliac spine begins to move and record the angle. Hip for evaluation in neutral, opposite hip flexed and held. Hip for evaluation is raised to maximum flexion and the angle is recorded. 27