Intra-and Inter-rater Reliability Research Articles

OP32 – 2680: Validity, reliability and correlations with clinical assessments of the German version of the “Selective Control Assessment of the Lower Extremity” (SCALE) in children with cerebral palsy

Objectives As a loss of selective voluntary movement control (SVMC) can hamper mobility in children with cerebral palsy (CP), assessing SVMC has gained increasing clinical interest. To improve assessment of SVMC the following three objectives were chosen: 1) translation of the “Selective Control Assessment of the Lower Extremity” (SCALE) into German, 2) evaluation of the SCALE's reliability and validity, 3) testing clinical driven hypotheses concerning correlations between the SCALE and other commonly used assessments. Methods Thirty-nine children (21 males) with spastic CP, mean age 12y 6mo [SD 3y 7mo], Gross Motor Function Classification System (GMFCS) levels I to IV participated. Discriminant validity: Differences in SCALE scores were determined between leg joints, more and less affected leg and GMFCS levels. For concurrent validity assessment, SCALE results were correlated with item III and IV of the Fugl-Meyer Assessment (FMA). To determine reliability, SCALE was applied once and recorded on video. Correlations were computed between SCALE and the Manual-Muscle-Test, Modified Ashworth Scale, Trunk Control Measurement Scale and the Timed-up and Go Test respectively. Results Discriminant validity: SCALE scores differed between most leg joints and between the less and more affected leg. Total SCALE scores differed significantly between GMFCS levels I and II. Concurrent validity of SCALE with FMA items was excellent. Intraclass correlation coefficients for intra-and inter-rater reliability were above 0.9; with the minimally detectable change below 2 points. Spearman correlations between the SCALE and the other assessments were significant (ρ=0.49–0.88; p Conclusion The SCALE appears to be a valid and reliable tool to assess SVMC of the legs in children with spastic CP. The correlations with the other tests indicate that the SCALE could valuably complement to routine clinical examination to improve our understanding of motor problems in children with CP.

Reliability of coronal curvature measurements on 3D ultrasound images for AIS

Methods Forty participants (35F, 5M; mean age 14.0±2.0 years) who (1) were diagnosed with AIS, (2) had no prior spine surgical treatment, (3) had radiographs on the study day that were not in-brace, and (4) had the major Cobb angle less than 45°, were recruited consecutively from the local scoliosis clinics. All US images and radiographs were acquired in standing positions within an hour of each other. Three raters, who were blinded to the clinical information, measured the Cobb angles from the US and x-ray images at least 3 days apart. The raters repeated these measurements at least 1 week apart to minimize memory bias. The mean absolute deviation (MAD) and the standard deviation (SD) between the two measurements methods were used to estimate the reliability of the US measurement. The intraand interrater reliabilities were assessed by calculating the interclass correlation coefficients and standard errors of measurement (SEM).

Modified Gait Abnormality Rating Scale in Patients with Conversion Disorder: A Reliability and Responsiveness Study

Objective: Patients with conversion disorder have neurologic symptoms such as gait disturbances that are not attributed to an underlying organic cause. The modified gait abnormality rating scale (GARS-M) may be useful for quantifying gait abnormalities in these individuals. The purpose of this study was to examine the reliability and responsiveness of the GARS-M to quantify gait abnormalities in individuals with conversion disorder. Design: The study used a single-group pretest-posttest design. Preand postintervention videos were obtained during 10-m walks. Four examiners independently evaluated gait performance according to the GARS-M criteria. One examiner re-evaluated the videos approximately two months later. Setting: This study was conducted within an outpatient therapy clinic at a large, academic tertiary referral center. Participants: Data from 27 consecutive patients with conversion disorder who completed Mayo Clinic’s multidisciplinary Behavioral Shaping Therapy program were included in the study. Interventions: N/A. Main Outcome Measure(s): Interand intra-rater reliability of scores obtained with the GARS-M were estimated with intraclass correlation coefficients (ICCs). Responsiveness was estimated with the minimum detectable change (MDC). Results: GARS-M scores were quantified with good-to-excellent inter(ICCZ0.878) and intra-rater reliability (ICCZ0.989). The MDC was 2 points; 85% of the patients had improvements in GARS-M scores that exceeded the MDC. Furthermore, GARS-M scores and walking speed measurements were moderately correlated (rZ-0.582, pZ0.004), indicating that the GARS-M has acceptable criterion-related validity. Conclusions: Our findings provide evidence that the GARS-M is scored reliably in patients with conversion disorder. Additionally, it is a responsive andvalid instrument toquantify changes ingait abnormalities in these patients.

P103: Using Multidimensional Prognostic Index (MPI) based on Healthcare System Database in subjects admitted to Nursing Homes: results of the EU-funded MPI_AGE project

Methods: Geriatric patients (60–96 years old) treated stationarily, in a day hospital or in ambulatory rehabilitation participated in the study. For the validity occupational therapists/ergotherapists assigned 205 patients to five ICF-oriented severity levels of fine motor disorders on the basis of a self-assessment questionnaire and standardized functional tests. Blinded physiotherapists applied thereafter the 20-C-T. The reliability was tested on 189 patients. Results: 26.6% of the patients suffered from disturbances of fine motor skills relevant to everyday life, only 39.9% were without any abnormalities. In both currencies the results of the 20-C-T correlated with the clinical severity. With regard to sensitivity and specificity different thresholds can be chosen depending on the intention to use the test. Patients who managed to transport 20 coins within 30 seconds had rarely, those who needed more than 50 seconds very likely a disorder of fine motor function. The intraand interrater reliability was good (ICC >0.9). Conclusions: The 20-C-T is suitable as a tool for screening and basic assessment of fine motor function. It can help to detect treatment need before patients suffer a loss of independence in the activities of daily living.

Reliability of the spine adverse events severity system (SAVES) for individuals with traumatic spinal cord injury.

Test-retest analysis. To determine the intra- and inter-rater reliability of the Spine Adverse Events Severity System for Spinal Cord Injury (SAVES-SCI) in patients with traumatic SCI. Quaternary care spine program in Vancouver, Canada. Ten hypothetical patient cases were developed. The cases were completed by 10 raters (seven physicians, one nurse, one physiotherapist and one researcher) who were asked to identify and grade the severity of adverse events using SAVES-SCI twice with 1-week interval. Intra- and inter-rater reliability were calculated using kappa statistics and intraclass correlation coefficients (ICC). Intra-rater reliability for both identifying and grading AEs were high with all AEs (kappa greater than 0.6) except for bone implant, diathermy burn, massive blood loss, myocardial infarction, neurological deterioration, pressure ulcer, return to operating room and tracheostomy requirement. The inter-rater reliability measured with ICC were all above 0.6 for identifying and grading intraoperative, pre and postoperative AEs and consequences of SCI. The SAVES-SCI demonstrated acceptable intra-and inter-rater reliability for a majority of the AEs. Further clarification and definition of some of the AEs as well as provision of sample training cases for clinicians would assist in reducing measurement errors. The SAVES-SCI is a useful tool to assess and capture AEs in patients with acute traumatic SCI.

Reliability of sonographic measurement of thickness and echogenicity of the plantar fascia

Objective To evaluate the intra-and inter-rater reliability in ultrasonographic measurement of thickness and echogenicity of the plantar fascia.Methods Enrolled in this study were 22 patients (42 feet) who had been diagnosed with plantar aponeurositis from January 2012 to January 2013 and 28 normal volunteers (56 feet).Ultrasonography was performed to measure the thickness and echogenicity of the plantar fascia in both longitudinal and transverse planes.The mean gray level in the region of interest was quantified using Histgram software.Two sonographers independently conducted the measurements in a double-blind manner.Volunteers were assessed twice in an interval of one week by the same sonographer to evaluate intrarater reliability.Results The intraclass correlation coefficients (ICC) for intra-and interrater measurements of plantar fascia thickness ranged from 0.82 to 0.95 in longitudinal and transverse planes in the control group; the ICC of the plantar fascia thickness were 0.80 and 0.56 in the study group in the longitudinal and transverse planes; the ICC for the average gray level by Histgram measurement were 0.74 and 0.53 in the study group in longitudinal and transverse planes; the Kappa values for evaluation of presence and absence of low echogenicity were 0.34 and 0.35 in the study group in the transverse and longitudinal planes.Conclusion Ultrasonography can be used as an effective diagnostic tool for the plantar fascia,because it is reliable in evaluation of its thickness and the mean gray-level of echogenicity. Key words: Ultrasonography; Heel pain; Diagnosis; Reliability; Plantar fascia

O28: Comparison of the language lateralizations suggested by magnetoencephalography and navigated transcranial magnetic stimulation in healthy subjects using a picture naming task

O28: Comparison of the language lateralizations suggested by magnetoencephalography and navigated transcranial magnetic stimulation in healthy subjects using a picture naming task

Su1256 Inter-and Intrarater Reliability of the Chicago Classification in Pediatric High-Resolution Esophageal Manometry Recordings

Su1256 Inter-and Intrarater Reliability of the Chicago Classification in Pediatric High-Resolution Esophageal Manometry Recordings

Reliability and Validity of the Arabic Dynamic Gait Index in People Poststroke

Background and Objective: The Dynamic Gait Index (DGI) is a valid and reliable measure of gait, balance, and fall risk. The purpose of this study was to translate the DGI into Arabic and evaluate the reliability and validity of the Arabic version of the DGI (A-DGI) in patients with stroke. Methods: The DGI was translated into Arabic according to the World Health Organization forward/backward translation protocol for translating assessment tools. It was then administered to a convenience sample of patients with stroke. The inter-and intrarater reliability as well as convergent and discriminant validity of the A-DGI were examined. Results: Fifty-one patients with stroke (mean [SD] age, 64 [12] years; 33 male) were enrolled in the study. The A-DGI score reflected high agreement for both interrater (intraclass correlation coefficient [ICC]3,1 = .98; 95% confidence interval [CI], .97-.99) and intrarater (ICC1,1 = .97; 95% CI, .95-.98) reliability and correlated moderately but significantly with the Glasgow Coma Scale (rho = .39, P = .01), Beck Depression Inventory (rho = -.50, P < .01), and Stroke Impact Scale-16 version 3.0 domains. The A-DGI discriminated between subjects who were at risk of fall and those who were not (U = .00, P < .01), younger and older adults (U = 195, P = .03), side of hemiplegia (U = 218, P = .04), and mild and moderate (U = 105.5, P = .02) as well as mild and severe stroke severity (U = 30, P < .01). Conclusions: The A-DGI reflected high reliability and validity in the stroke population. The availability of a reliable and valid A-DGI facilitates its use among therapists from Arabic origins, which will enrich the rehabilitation process in their clinical practice.

In the April 2014 issue of Medical Express

Having got off to a good start with our February issue, we are now happy to announce our second, MedicalExpress, April, 2014. For our first issue, February, 2014, we now have the data showing that the average interval between submission and first action was 10 days (range 4 – 24 days). Between acceptance and publication the average interval was 50 days (range: 40 – 54 days); this is longer than established in our project, mainly because of set-up problems incumbent upon a new periodical. With this second issue we are keeping the average interval to first action at 10 days post submission. However, for this issue, we definitely expect to shorten the acceptance to publication interval to circa 35 – 40 days. This issue appears with two reviews and five original Research papers. Our reviews come from the University of Pisa, Italy and from the Southern Medical University, Guangzhou, China. They cover two interesting themes. Gian Maria Pacifici reviews the use of Ibuprofen for the closure of a persistent ductus arteriosus in premature babies and meta-analyzes the two possible routes of administration, intravenous vs. oral. He clearly shows that the more recently introduced oral route produces better results, less kidney damage and should be looked upon as presenting the best risk/benefit ratio. Huang Quiaobing et al review the relevant theme of microvascular permeability in burnt patients, covering mainly the period of the last 10 years. The most relevant aspects of this review are the systematic presentation of science originating from China and of papers relating to inter-cell signaling. Three original research articles originate from Sao Paulo University, all of them involving the Medical College. In a project undertaken jointly between the Institute of Orthopedics and Traumatology of the Medical College and Escola de Artes, Ciencias e Humanidades, University of Sao Paulo da Silva Santos et al analyzed the acceleration, velocity and direction of movement in paraplegic wheelchair basketball players and conclude that wheelchair basketball athletes moved their body faster in the left/right direction. This result suggests that postural control is direction-dependent for the wheelchair-bound individual. In another paper from the same institution, a joint project between the Division of Psychology and the Department of Obstetrics and Gynecology, Juhas et al perform an extensive review of major depression in obstetrics patients, comparing out-patients vs. hospitalized patients and draws attention to the fact that ward patients may be less well evaluated for risk. Their results indicate a definite need for periodical evaluation of depressive symptomatology in ward patients in order to provide adequate treatment for this population. In a another joint project, this time from the Institute of Psychiatry, Federal University of Rio de Janeiro and the Federal Fluminense University, King et al analyze the different responses of patients with panic disorder and agoraphobia vs. healthy controls to an emotionally charged story and find that their respective memories retain quite different aspects of what they see and hear. Ribeiro et al, from the Midwestern State University, Parana, Brazil, describe a novel property of aqueous extracts of Uvarana (Cordyline dracaenoides Kunth). Uvarana has been used from time immemorial namely its capacity to raise the pain threshold to a noxious thermal stimulus. In yeat another joint project, Alonso et al from the Departments of Orthopedics, Federal University of Sao Paulo and Sao Paulo University Medical College, compare interand intra-rater reliability on the assessment of shoulder rotation using goniometry and biophotogrammetry. They found that both procedures are reliable and reproducible, but have shown biophotogrammetry to be more reliable. EDITORIAL

Fulfilment of patients’ and surgeons’ expectations in total hip arthroplasty

nication modes), and (3) strategies used for improving communication. It should be simple and easy to use. A questionnaire was created, the central part of which (2) comprised 15 questions to be presented to the patient’s carers or relatives. Quality criteria were analyzed in the environment of 40 in-patients admitted to an awakening unit. Results.– The questionnaire was presented to caregivers. The intraand interrater reliability was good, with intra-class correlation coefficients for the main parts of the test and the total score 0.90 and Cohen Kappa coefficients for each item 0.50. The reproducibility of questions about communication strategies was good. Internal consistency was excellent (Cronbach acoefficient = 0.89) for the 15 questions. Convergent validity was good with theWHIM and themodified Rankin scale. Therewas no relationship of the scale with the age, gender and education level. On two assessments performed with a mean time interval of 37 days, the scale showed sensitivity to change (effect size = 0.82). The time required for presenting the 2nd part of the test ranged from 5 to 8 minutes. Discussion.– This scale measures three key domains, participation, themes and modes of communication and participates in the implementation of facilitating means of this communication. She has fair metrological properties and is a practical tool for everyday practice.

The effect of radiographic vertebral body and intervertebral disc wedging on curve progression in idiopathic scoliosis

Methods Baseline and 30-year follow-up x-rays from 56 AIS patients were evaluated. Wedging measurements included apical vertebral body height ratios (VBHR), apical vertebral body angles (VBA) and apical intervertebral disc wedging angles (IVDA). Intraand inter-rater reliability was estimated using 2 readers and a subset of 20 curves. Multivariate regression estimated the contribution of wedging to prediction of curve progression.

Reliability of a uni-compartmental scale for the radiographic evaluation of knee arthritis: data from the multicenter osteoarthritis study

Reliability of a uni-compartmental scale for the radiographic evaluation of knee arthritis: data from the multicenter osteoarthritis study

Clinical assessment of ankle plantarflexor spasticity in adult patients after stroke: Inter-and intra-rater reliability of the Modified Tardieu Scale

Primary objective: To evaluate the reliability of the Modified Tardieu Scale (MTS) in the measurement of ankle plantarflexor spasticity in patients after stroke.Research design: Inter- and intra-rater reliability study.Interventions: Not applicable.Methods and procedures: Adult patients after stroke participated. Patients were tested by two raters for inter-rater reliability. Patients were re-tested by one rater at least 1 week later for intra-rater reliability. The plantarflexors on the hemiparetic side were tested.Main outcomes and results: The ICCs of inter and intra-rater reliability across all components of MTS were moderate and moderately high (range 0.40–0.71). Inter- and intra-rater reliability for the dynamic component of spasticity (R2–R1) were moderate (ICC = 0.57 and 0.40, respectively). The difference between the two raters for R2 was statistically significant (p = 0.001).Conclusions: The reliability of the Modified Tardieu Scale in the measurement of ankle plantarflexor spasticity in adult patients after stroke was insufficient for routine use in clinical settings and research.

A Semi-Automated Method for Measuring White Matter Hyperintensity Volume

YongSoo Shim, M.D.*, Bora Yoon, M.D.†, Yun Jeong Hong, M.D.‡, A-Hyun Cho, M.D.*, Dong-Won Yang, M.D.* Department of Neurology*, The Catholic University of Korea, Seoul; Department of Neurology†, Konyang University College of Medicine, Daejeon; ‡Hyoja Geriatric Hospital, Yongin, Korea Background: White matter hyperintensities (WMHs) on magnetic resonance imaging (MRI) have been considered as a reliable biomarker of small vessel damages. To evaluate the severity of WMHs, it is vital to develop reliable methods to measure the volume of WMHs. We applied open source software to measure WMH volume in the semi-automated way, and tested the reliability and validity by comparing with the commonly used qualitative rating scale. Methods: Twenty five subjects with variable WMHs were recruited. ANALYZE 10.0 was used for the image processing and volumetric measurement of WMHs. The inhomogeneity and artifacts of signal were corrected with Insight Segmentation and Registration Toolkit in ANALYZE. For the gold standard of the WMH volumetric measurement, threshold method was applied with consensus of manual editing on each slice of the MRI images by two raters. Histogram of the all slices of the Fluid Attenuated Inversion Recovery (FLAIR) MRI was generated to calculate the optimal voxel intensity of threshold, and the lowest voxel threshold was decided as the mean+1.4 SD. The volumes of WMHs were generated by multiplying the area and the thickness of each slice. Interand intrarater reliability of the semi-automated volumetric and Scheltens’methods, and the association between the individual methods were analyzed. Results: The semi-automated WMH volume at the threshold of 1.4 SD as well as the gold standard volume was well correlated with the Scheltens’ visual scale (r= 0.75, p< 0.001). The semi-automated volumetry showed the excellent intra-rater (ICC= 0.9929; 95% CI, 0.98400.9968) and inter-rater reliability (ICC= 0.9830; 95% CI, 0.9620-0.9925), superior to the Scheltens’ visual rating scale. Conclusions: The semi-automated volume measurement of the WMHs with Analyze was a valid and a reliable method to quantify subcortical white matter damages of various etiologies. Received: November 15, 2012 Revision received: March 29, 2013 Accepted: March 29, 2013

Association between Cerebral Performance Category, Modified Rankin Scale, and discharge disposition after cardiac arrest

Background Cerebral Performance Category (CPC), Modified Rankin Scale (mRS) and discharge disposition are commonly used to determine outcomes following cardiac arrest. This study tested the association between these outcome measures. Methods Retrospective chart review of subjects who survived to hospital discharge between 1/1/2006 and 12/31/2009 was conducted. Charts were reviewed for outcomes (CPC, mRS, and discharge disposition). Discharge disposition was classified in 6 categories: home with no services, home with home healthcare, acute rehabilitation facility, skilled nursing facility, long term acute care facility, and hospice. Intra-and inter-rater reliabilities were calculated for outcome measures. Rates of “good outcome” (defined as a CPC of 1–2, mRS of 0–3, or discharge disposition to home or acute rehabilitation facility) were also determined. Kendall's tau correlation coefficients explored relationships among measures. Results A total of 211 charts were reviewed. Mean age was 60 years (SD 16), the majority (75%) were white males, in- and out-of hospital cardiac arrests were equally prevalent, and ventricular dysrhythmia was most common ( N = 109, 52%). Half of the subjects were comatose following resuscitation and 75 (35%) received therapeutic hypothermia. Inter-rater percentage agreement for CPC and mRS abstraction was 95.24% (kappa 0.89, p < 0.001) and 95.24% (kappa 0.90, p < 0.001) respectively. “Good outcomes” were found in 44 subjects (20%) using the CPC definition, 47 subjects (22%) using the mRS definition, and 129 subjects (61%) subjects using discharge disposition definition. There was fair relationship between the CPC and mRS (tau 0.43) and poor relationships between CPC and discharge disposition (tau 0.23) and between mRS and discharge disposition (tau 0.25). Conclusions Determination of the CPC, mRS and discharge disposition at hospital discharge is reliable from chart review. These instruments provide widely differing estimates of “good outcome”. Agreement between these measures ranges from poor to fair. A more nuanced outcome measure designed for the post-cardiac arrest population is needed.

Validación de herramienta informática para el cálculo de linfedema en pacientes con afectación unilateral de extremidad superior

Background Lymphedema following breast cancer surgery is a serious sequel that affects the quality of life of breast cancer patients. There are several methods to evaluate lymphedema. We have aimed to present and validate a computer tool that calculates the lymphedema volume based on perimeter measurements and to show the results of its reliability analysis. This tool design was developed without a randomized clinical trial with a control group. Material and methods A total of 29 patients were randomly selected from the Rehabilitation consultations of two centers in Madrid suffering unilateral lymphedema after mastectomy. Two rehabilitation doctors measured the arm perimeters of each patient using anatomic structures and with the frustum formula, using an Excel macro. Mean volume, standard deviation (SD) and variation coefficient (VC) were obtained for each measurement. Intra-and inter-rater reliability were calculated by estimation of the intra-class correlation coefficient (ICC) and its confidence interval (CI). Results Mean volume of affected arm was 3155.82 mL (877 SD) and for the healthy arm 2748.76 mL (667.1 SD). There were no significant differences in the SD and CV dispersion. Intra-rater ICC for the affected arm was 0.991 and 0.979, and for healthy arm 0.967 and 0.961 for each observer. Inter-rater ICC for the affected arm was 0.952 and for the healthy arm 0.976. Conclusions The «lymphedema calculator» is a reliable, reproducible, easy to use and low cost computer tool that helps the clinician to evaluate lymphedema volume as well as to objectify its distribution.

Sixty second screening identifies persons at risk for diabetic foot ulcers

aim: To develop and apply a low-tech screening tool for risk status of developing diabetic foot ulcers in a resource-poor setting. Methods: The 60 second screening tool identifies high risk status on the basis of history, examination of the foot for lesions or deformity, monofilament loss of protective sensation, joint stiffness and the absence of a pedal pulse. The tool was applied in a weekly medical diabetic clinic at Georgetown Public Hospital Corporation, (Guyana’s only referral and teaching hospital). The clinic has a population base of more than 2000 patients. High risk status was defined as a single positive score on the tool. Identified high risk patients were referred to the Diabetic Foot Centre for further assessment to prevent foot ulcers through patient education and the supply of appropriate footwear and orthotics. results: Audit of initial screened 1000 patients: 70% of screened population is female; 40% of total screened population is at high risk; 13% had previous ulcers; 5% previous amputation; 8.5% an absent foot pulse; 7.7% an active ulcer. The tool profiles the frequencies of risk factors in the population. Interand intra-rater reliability of the tool will be presented. High risk patients referred to DFC form a cohort to determine the effects of patient education, follow-up concerning foot care and the wearing of appropriate footwear on ulcer prevention. Discussion/conclusions: Screening of people with diabetes for high risk status is an essential component of comprehensive diabetes care. It focuses preventive practices and reduces workload for the treatment of foot ulcers and their complications. It also identifies unrecognized ulcers at an early stage. Screening and patient education to change behaviors are the keys to preventing diabetic foot ulcers. The 60 second tool has been adopted by the Ministry of Health in Guyana.

P039 Three-dimensional evaluation of knee function in anterior cruciate ligament-deficient and reconstructed knee

s of the 17th Annual Meeting of ESMAC, Poster Presentations / Gait & Posture 28S (2008) S49–S118 S73 pelvis and trunk were assessed at eight instances during the gait cycle, representing initial contact, loading response, mid stance, terminal stance, preswing, initial swing, mid swing and terminal swing. To determine intraand interrater reliability, the Intraclass Correlation Coefficient (ICC), the Standard Error of Measurements (SEM) and the Smallest Detectable Difference (SDD) were calculated for each joint and for each phase of the gait cycle. Results: Intrarater reliability was good for the tibia, ankle, knee and pelvis and moderate to good for the trunk. Interrater reliability was good for the tibia, ankle and knee, moderate to good for the hip and pelvis and moderate for the trunk. All angles could be measured with errors (SEM/SDD) ranging from 0.7−6.8 degrees/1.8−18.8 degrees (see table 1).

RELIABILITY OF A MODIFIED RULER USED TO ASSESS FIRST RAY MOBILITY

INTRODUCTION Excessive or insufficient mobility of the first ray is a functional impairment that is widely associated with plantar foot pain or abnormal gait. A qualitative method was usually used to describe limitation of the first ray clinically. Glasoe et al. examined first ray mobility test using a ruler method and demonstrated a poor intraand inter-rater reliability. In this study, a modified ruler method was introduced to overcome the problem of foot fixation during first ray measures. The purposes of this study were to design a simple, inexpensive ruler to quantify first ray mobility and to assess its inter-rater and intra-rater reliability.