[Development of indicators to promote measures for the prevention and rehabilitation of functional decline in older people]. / Développement d'indicateurs pour valoriser des actions de prévention et de réadaptation de la perte d'autonomie des personnes âgées.

BACKGROUND: In Europe and Asia, long-term care funding is disability-based. This introduces a perverse effect by inappropriately adding value to functional decline among beneficiaries. To support the efforts in prevention and rehabilitation made by personnel in long-term care services, indicators have to be developed to promote functional improvement of beneficiaries. As people receiving those services are already experiencing a functional decline process, it is essential to know the natural magnitude of functional decline in order to assess deviation from this expected decline. The objective of the study was to estimate the natural decrease of autonomy in beneficiaries of home care services and nursing homes. METHODS: Two databases were used: for home-dwelling people, 1235 subjects over 75 years old who participated in the PRISMA study; for institutions, 1330 residents over 65 years old of a nursing home in Sherbrooke (QC, Canada). These subjects were assessed several times over many years with the Functional Autonomy Measurement System (SMAF). Growth analyses were used to estimate the annual decrease in the SMAF score according to age, gender and the initial autonomy status. RESULTS: At home, only age was significantly associated with the slope of functional decline. The average annual decrease of subjects 75-84 years old was 2.4 points on the SMAF score (out of 87); for those aged over 85, the annual loss was 3.8 points. In institutions, gender and the initial autonomy profile were associated with the annual decrease. For men, the annual decrease varied between 0.7 for the most disabled subjects to 5.2 for the most autonomous. For women, those values varied from 0.2 to 6.6, respectively. CONCLUSION: A decrease in the SMAF score less than these expected values should be associated with a bonus to support personnel training, prevention activities, rehabilitation and activities aimed at supporting the autonomy of the beneficiaries. Such a strategy requires the implementation of a precise and reliable assessment instrument like the SMAF and also the availability of a longitudinal database where data for each beneficiary could be linked over time.

Home-care programmes for older adults with disabilities in Canada: how can we assess the adequacy of services provided compared with the needs of users?

The need for home care will probably continue to increase over the next decade as one response to innovative health practices designed to help people receive services at home instead of in institutions. However, there are no data for determining whether home-care programmes can meet user needs. The objectives of the present study were to describe the functional autonomy profile of the users of public home-care programmes in Québec, Canada, and to compare the level of adequacy between required and provided services in public home-care programmes for older adults with disabilities. This study was based on a cross-sectional design from September to December 2002. The population studied consisted of all users of public home-care services in one administrative region in the province of Québec over this 3-month period. Each user was assessed with the Functional Autonomy Measurement System (SMAF) and then classified into one of the 14 Iso-SMAF profiles. The total number of hours of care required was determined using the median number of hours of nursing care, personal care and support services associated with each profile. For the sake of comparison with the services required, the services provided were calculated from an administrative databank that included statistics of the time spent by health professionals on caring for home-care users. The ratio of hours of services provided to the number of hours of services required by home-care users highlights a discrepancy between the services provided and user needs. The results of this study show the feasibility of describing users of public home-care programmes and the adequacy of services provided in relation to user needs. Based on these results, public home-care programmes in the province of Québec appear to be under-funded.

Risk factors for completed suicide in schizophrenia and other chronic psychotic disorders: a case-control study.

OBJECTIVE: Despite an increased risk for suicide among individuals diagnosed with psychotic disorders, risk factors for completed suicide remain largely unexamined in this population. Using a case-control design, this study aimed to investigate clinical and behavioural risk factors for suicide completion in schizophrenia and other chronic psychotic disorders. METHOD: A total of 81 psychotic subjects were examined; of these, 45 died by suicide. Proxy-based interviews with, on average, 2 informants were conducted using the SCID I and II interviews and a series of personality trait assessments. RESULTS: Psychotic individuals at risk for suicide are most readily identified by the presence of depressive disorders NOS, moderate to severe psychotic symptoms and a family history of suicidal behaviour. They also exhibited fewer negative symptoms, had more comorbid diagnoses and, contrary to findings in other populations, we found that cluster A and C personality trait symptoms seem to have protective effects against suicide in schizophrenics and other chronic psychotic suicides. CONCLUSIONS: Our study suggests that behavioural mediators of suicide risk, such as impulsive-aggressive behaviours, do not play a role in schizophrenic and chronic psychotic suicide. This is contrary to findings in other diagnostic groups, thus implying heterogeneity in predisposing mechanisms involved in suicide.

In home telerehabilitation for older adults after discharge from an acute hospital or rehabilitation unit: A proof-of-concept study and costs estimation.

PURPOSE: The purpose of this study is to investigate rehabilitation through teletreatment as an alternative to a physical homecare visit to deliver services to individuals at home following discharge from an acute hospital or rehabilitation unit. METHOD: Four community-living elderly people were recruited for telerehabilitation services prior being discharged from an acute-care hospital and a geriatric rehabilitation unit. Once the patient returned home, an appointment was made for the assessing therapist to take the clinical measurements (T1) in a face-to-face session. Four clinical variables were used (functional autonomy, balance, locomotor performance in walking and lower-body strength). Telerehabilitation sessions with the participants were conducted with trained personnel in the individual's home. The system used to support telerehabilitation services for this proof of concept was built around network-attached remotely-controlled pan/tilt/zoom cameras with MJPEG compression, media displays and hands-free phones. Before the patient was discharged from the physiotherapy program, the same assessing therapist visited the subject again to take the T2 measurements in a face-to-face session. The satisfaction of the health-care professional was determined for each session with the homemade questionnaire. Costs related to telerehabilitation were compared to theoretically home visits. RESULTS: All four subjects improved on the four clinical variables. Mean costs for the telerehabilitation program, comprising 12 sessions over 4 weeks was $487. CONCLUSION: Telerehabilitation seems to be a practical alternative for dispensing rehabilitation services after patients are discharged from an acute hospital or rehabilitation unit.

The Modified-Modified Schober Test for range of motion assessment of lumbar flexion in patients with low back pain: a study of criterion validity, intra- and inter-rater reliability and minimum metrically detectable change.

PURPOSE: The objective was to estimate the psychometric properties of the Modified-Modified Schober Test (MMST). DESIGN: This study compared range of motion measurements of lumbar flexion in low back pain (LBP) patients using the MMST with measurements calculated on X-rays as the gold standard, and compared the measurements taken by two independent examiners. METHOD: This study was conducted at the main hospital in the Outaouais area, Quebéc, Canada. Thirty-one subjects with LBP from private and public clinics participated in the study. After a warm-up session, measurements with the MMST were taken in neutral position and an X-ray technician took an exposure in the same position. RESULTS: Pearson's correlation test (r) between measurements made with the MMST and the gold standard, intra-class correlation coefficient (ICC), minimum metrically detectable change (MMDC) and confidence interval (CI) were used to analyze the data. The MMST demonstrated moderate validity (r=0.67; 95%CI 0.44-0.84), excellent reliability (intra: ICC=0.95; 95%CI 0.89-0.97; inter: ICC=0.91; 95%CI 0.83-0.96) and a MMDC of 1 cm. CONCLUSIONS: In our sample of LBP patients, the MMST showed moderate validity but excellent reliability and MMDC.

Costs of a home-based rehabilitation program for older adults after lower limb orthopedic surgery: a pilot study.

Little is known about the cost of home-based rehabilitation programs in Quebec, Canada. The objective of this pilot project was to test a cost estimation methodology in the context of rehabilitation services delivered at home and to provide preliminary data on the costs for lower limb orthopedic surgery patients. This pilot study examined a short-term home care program for adults, aged 65 and over who returned home after lower limb surgery and required rehabilitation services. Efficacy was determined as the functional autonomy changes between admission and discharge from home rehabilitation program, as measured by the functional autonomy measurement system (SMAF). Costs of professionals, including direct and indirect time related to the intervention, were also determined in order to document cost-effectiveness of the program. Eighteen subjects were recruited. From those, 14 had complete data available for the analysis. The result shows that costs related to the combined natural improvement and the effect of the home-based rehabilitation program were CAN dollars 419 per unit of change of functional autonomy. The results of this pilot study confirm the feasibility of the cost estimation methodology for a home-based rehabilitation program.

Suicide and serotonin: study of variation at seven serotonin receptor genes in suicide completers.

Suicide is an important public health problem, accounting for a significant proportion of total mortality among young people, particularly males. There is growing and consistent evidence suggesting that genetic factors play an important role in the predisposition to suicide. Based on several lines of evidence supporting a reduced serotonergic neurotransmission in subjects who committed suicide, we investigated variation at genes that code for serotonin receptor 1B (5-HTR1B), 1Dalpha (5-HTR1Dalpha), 1E (5-HTR1E), 1F (5-HTR1F), 2C (5-HTR2C), 5A (5-HTR5A), and 6 (5-HTR6) in a total sample of 106 suicide completers and 120 normal controls. No differences were observed in allelic or genotypic distributions between groups for any of the loci investigated. Moreover, further analysis according to suicide method or psychopathology also failed to reveal differences between groups. Our results do not support a substantial role of these serotonergic receptors in suicide completion.

Development of a systematic observation protocol of physical exposure of the back: a preliminary study.

OBJECTIVE: At present there is no systematic observation protocol for the assessment of the multi-factorial aspects of physical exposure related to the back used within the constraints of occupational epidemiological research. In this context, a new preliminary systematic observation protocol is proposed to assess exposure to physical loading of the back using nine categories of physical risk factors: the SOPE back protocol. The objective of this study was to investigate whether the new protocol can correctly identify the level of exposure related to measured physical loading of the back. METHODS: The subjects of this closed cohort study were 451 manual workers at a natural gas distribution company. The assessment of exposure was made with the protocol using groups with different job titles. The workers were followed for a 2 yr period to establish the risk of a new occurrence of complete disability related to the back (NOCD back injury) in each job grouping. RESULTS: Based on the median of the total scores derived from the protocol, two levels of exposure were identified (high and low). CONCLUSION: Taking into account the limitations of this study, the protocol in development may be a good tool to establish two levels of exposure to physical loading of the back in large epidemiological studies of occupational low back pain. Further research is needed to replicate these results with larger samples and to test the reliability and predictive validity of the protocol.

Accuracy of student self-assessment ability compared to their own performance in a problem-based learning medical program: a correlation study.

OBJECTIVE: The purpose of this study was to evaluate the accuracy of self-assessment ability of students enrolled in a Problem-based Learning program. METHODS: Seventy students enrolled in their third year of a four-year program were invited to voluntarily participate in the study. Self-assessment questionnaire was used to measure the students' self-assessment ability on two different occasions: 1) prior to standardised oral examination in predicting their performance, and 2) following the examination estimating their performance. The accuracy of the self-assessment was investigated by the relation between self-assessment and performance of the students. RESULTS: Our study showed that self-assessment pre-examination was not accurate compared to performance at the oral examination (r ranging from 0.042 to 0.243). However, accuracy is slightly better when the student self-assesses his performance a posteriori, but the relation stays very low (r ranging from 0.257 to 0.334). CONCLUSION: According to our results, the students in the third year of a self-directed Problem-based Learning medical four year program demonstrated poor accuracy of the self-assessment when compared to their own performance.

Criterion validity study of lumbar goniometers BROM II and EDI-320 for range of motion of lumbar flexion of low back pain patients.

PURPOSE: The purpose was to estimate the criterion validity of the Back Range of Motion (BROM II) and Electronic Digital Inclinometer (EDI-320) devices. METHODS. This study compared the range of motion measurements of low back pain (LBP) patients taken with the BROM II and EDI-320 with measurements using the double inclinometer (DI) method as the gold standard. Forty subjects with LBP volunteered for the study. The subjects were asked to do three forward flexion movements. A measurement was taken with each of the three different devices for each movement. RESULTS: The BROM II demonstrated good linear relationship (Pearson r = 0.78; 95% CI: 0.78-0.94) and the EDI-320 very good linear relationship (Pearson r = 0.88; 95% CI: 0.62-0.89) with the gold standard, the DI. CONCLUSIONS: The Pearson correlation value indicates good validity of the EDI-320 in our sample of LBP patients. Although a good correlation was established for the BROM II, the significant difference of the mean ROM reported for this instrument compared to the gold standard data suggests that the BROM II actually measures ROM differently. Our results suggest that the EDI 320 is clinically useful in providing objective and valid data for outcome measures in a population with LBP. More research is needed on the BROM II before we can make final conclusion on its use in clinical settings as an outcome measure.

Intratester and intertester reliability of the Cybex electronic digital inclinometer (EDI-320) for measurement of active neck flexion and extension in healthy subjects.

This study examined the intratester and intertester reliability of the electronic digital goniometer EDI-320 for the measurement of active neck flexion and extension in healthy subjects. In the context of evidence-based practice, the EDI-320 instrument has the potential to improve patient assessment, provide a clearer picture of patient progress, and confirm the effectiveness of physiotherapy interventions. However, the psychometric properties of the EDI-320 have not yet been documented for cervical spine range of motion. Forty-four individuals with no known history of cervical disorder within the three months prior to the testing, voluntarily consented to participate in this study. Repeated measurements with the EDI-320 were taken by two trained testers (TH1 and TH2) and data were recorded by two separate observers. Subjects performed a standardized warm-up. Testers were required to repeat palpation of bony landmarks prior to each trial. Measurements were taken at the end-range of active cervical flexion and extension for each subject. Both testers measured each subject twice. The intraclass correlation coefficients (ICC) were derived from one-way ANOVA for intratester reliability and a two-way ANOVA for intertester reliability. Paired t -tests were then applied to verify for systematic error. Moderate intratester reliability was found for both testers for flexion (TH1: ICC=0.77; 95% CI: 0.62-0.87; TH2: ICC=0.77; 95% CI: 0.58-0.87). As for extension, high intratester reliability was found for TH1 (ICC=0.79; 95% CI: 0.65-0.88) and moderate for TH2: (ICC=0.83; 95% CI: 0.63-0.92). Intertester reliability results showed a moderate reliability for both flexion and extension (ICC=0.66; 95% CI: 0.24-0.84) on the first trial. On the second trial, reliability was moderate for flexion (ICC=0.73; 95% CI: 0.53-0.85) and high for extension (ICC=0.80; 95% CI: 0.64-0.89). The t -test analysis revealed the inclusion of systematic error by Tester 2 for intratester reliability. This error was also found for all but one of the intertester reliability calculations. This study has shown that the EDI-320 is a moderately reliable instrument for quantifying cervical flexion and extension range of motion. The presence of systematic error in the study highlights the importance of following standardized procedures and suggests that the EDI-320 could be more reliable than reported in this study. Further psychometric studies investigating the validity of the EDI and reliability with subjects affected by cervical pathology is warranted.

TPH and suicidal behavior: a study in suicide completers.

An association between the gene that codes for tryptophan hydroxylase (TPH)-the rate-limiting enzyme in the synthesis of serotonin-and suicidal behavior has been investigated with some detail in samples of living subjects who attempted suicide. In this study, we investigated TPH and suicide completion, the most severe form of suicidal behavior. A relatively large sample of suicide completers (n = 101) was genotyped at three TPH loci (two polymorphisms in the promoter region, A-6526G and G-5806T, and one in intron 7, A218C) and compared to psychiatrically normal living controls (n = 129). Although no significant differences were found between groups for genetic variation at single loci, haplotype analysis revealed that one haplotype (-6526G -5806T 218C) was significantly more frequent among suicide cases than in normal controls (chi(2) = 11.30, df = 2, P = 0.0008; OR = 2.0 CI: 1.30-3.6). Further analyses suggested that this haplotype is particularly more frequent among subjects who committed suicide using violent methods. Similar results were observed in recent haplotype analyses in suicide attempters, which found that the equivalent of haplotype -6526G -5806T 218C was more frequent in impulsive attempters (Rotondo et al, Mol Psychiatry 1999; 4: 360-368). Our results replicate in suicide completers previous data observed in suicide attempters. These and other results continue to point to the substantial role that the gene that codes for TPH may play in the neurobiology of suicidal behavior.

Intra- and intertester reliability and criterion validity of the parallelogram and universal goniometers for measuring maximum active knee flexion and extension of patients with knee restrictions.

OBJECTIVE: To examine the intra- and intertester reliability of the universal goniometer (UG) and parallelogram goniometer (PG), and to assess the criterion validity of the same instruments on subjects with knee restrictions. DESIGN: Reliability and validation study. SETTING: Radiology department at university hospital. PARTICIPANTS: Sixty subjects (34 men, 26 women; mean age, 52yr) with various knee restrictions. INTERVENTIONS: Sixteen goniometric measurements were collected per patient by 2 physical therapists. Subjects were evaluated in knee flexion and knee extension positions. To serve as a gold standard, radiographs were taken in both positions. MAIN OUTCOME MEASURES: Active knee flexion and knee extension on 2 goniometers, radiographs. Maximum active range of motion (AROM). RESULTS: The UG intratester reliability (intraclass correlation coefficients [ICCs]) was .997 in flexion and .972 to .985 in extension. The results were also high with the PG (ICC =.996,.953-.955) for flexion and extension, respectively. The intertester reliability was high for flexion (ICC =.977-.982) and for extension (ICC =.893-.926) when using the UG. For the PG, ICC results ranged from .959 to .970 for flexion and from .856 to .898 for extension. Criterion validity (r) varied from .975 to .987 for flexion and from .390 to .442 for extension with the UG, and from .976 to .985 for flexion and .423 to .514 for extension with the PG. CONCLUSION: Intra- and intertester reliability were high for both goniometers. The results for the criterion validity varied. Our study also revealed that it is preferable to use goniometry rather than visual estimations when measuring AROM. It is recommended that the same therapist take all the measurements when assessing AROM for UG and PG goniometric measurements on patients with knee restrictions.

Criterion validity of the cervical range of motion (CROM) goniometer for cervical flexion and extension.

STUDY DESIGN: This study used a validity protocol. OBJECTIVE: To estimate the criterion validity of the Cervical Range of Motion goniometer using a healthy population. SUMMARY OF BACKGROUND DATA: The results of the 1994 study by Mayo et al show that there are no validated tools currently available for clinically measuring the cervical range of motion. Numerous decisions regarding patient status and treatment are based wholly or in part on joint motion measurements. Because of current budgetary restrictions, clinicians are being asked to justify their interventions objectively, and to do so, they will need validated tools. METHODS: The population consisted of 31 healthy participants ranging in age from 18 to 45 years. None had experienced cervical problems in the previous 3 months or were pregnant. Data collection took place at the radiology department. After participants were positioned on a stool, the cervical range of motion goniometer frame was set on their head by the physiotherapist. With the participant in this neutral position, the physiotherapist took the first Cervical Range of Motion measurement. The radiograph technologist obtained the radiograph immediately afterward. This procedure was repeated with the participant in fully flexed and fully extended positions. RESULTS: A Pearson's r correlation test was used to evaluate the criterion validity of the Cervical Range of Motion goniometer versus the radiographic method. The two measurements proved to be highly correlated (flexion: r = 0.97, P < 0.001; extension: r = 0.98, P < 0.001). CONCLUSIONS: For this population of healthy participants, the Cervical Range of Motion goniometer was found to be valid for measurements of cervical flexion and extension. Further research is needed on the validity of this instrument for other cervical spine movements.

Occupational disability related to back pain: application of a theoretical model of work disability using prospective cohorts of manual workers.

BACKGROUND: A new model of work disability was developed based on the assumption that four different groups of workers are present at the beginning of a prospective epidemiologic study: one group of workers without back pain, and three groups of workers with back pain and a gradient of work disability. The goal of this research was to verify if these groups comprise workers at different levels of risk of occurrence of complete work disability related to back injury. METHODS: Prospective cohorts of manual workers (n=578) were followed for 1 year to document the risk of occurrence of complete disability related to back injury. RESULTS: The results showed that the workers who presented with back pain without work disability at the beginning of the study were at less risk compared to all the other workers in the cohort. Moreover, an effect modification was found between the workers who initially presented with back pain without work disability and a past history of compensation for back injury, adding credence to the non-similarity of these workers to the others. CONCLUSIONS: Based on these results, further studies should focus on improving the knowledge of the characteristics of these workers leading to a better understanding of how to prevent occupational low-back pain.

Development and evaluation of a complementation-dependent gene delivery system based on cucumber mosaic virus.

To engineer cucumber mosaic virus (CMV-Ix) into a gene vector, genome component RNA 3 of the virus was modified and split into two sub-components, RNA 3A and RNA 3B. In RNA 3A, the open reading frame of the movement protein (MP) was replaced by a reporter gene encoding the green fluorescent protein (GFP), to monitor virus replication and movement. In RNA 3B, the coat protein (CP) gene was eliminated and a multiple cloning site (MCS) was created for foreign gene insertion. Each sub-component alone is defective and relies on its companion sub-component to restore full RNA 3 function. The vector system was evaluated for its ability to deliver and express the bacterial beta-glucuronidase (GUS) gene and a modified bean yellow mosaic virus coat protein (BYMV-CP) gene in Nicotiana benthamiana plants. Results showed that the engineered virus was able to move from cell to cell in the inoculated leaf and enter the minor veins of the inoculated leaf. Foreign gene expression was detected in the inoculated leaves. However, intermolecular recombination between RNA 3A and 3B occurred frequently, preventing efficient systemic expression of the foreign gene(s). Modifications and further evaluations are being undertaken to improve the gene delivery system.

The Quebec Adolescent Refugee Project: psychopathology and family variables in a sample from 35 nations.

OBJECTIVE: This study presents the results of a psychiatric epidemiological survey using a sample of adolescents from refugee families. METHOD: The sample included 203 adolescents, aged 13 to 19 years, coming from 35 countries. Psychopathology was assessed with the Diagnostic Interview Schedule for Children Version 2.25 and general functioning with the Children's Global Assessment Scale (CGAS). RESULTS: The total rate of psychopathology excluding simple phobia was 21% compared with 11% in a province-wide survey of young adolescents. Overanxious disorder had a high prevalence of 13%. The rates of major depression and conduct disorders were also high, at 5% and 6%. The rate of 3% of attempted suicide was similar to the rate found in Montreal high schools. Girls had a higher rate of psychopathology than boys, with a gender ratio similar to the one found in the provincial survey. Father's long-term unemployment in the first year of settlement was associated with psychopathology for the whole sample, and family structure was associated with psychopathology for boys only. CONCLUSIONS: The high rate of psychopathology in this group confirmed results from other surveys with similar samples. On the other hand, the CGAS scores indicated that many of the adolescents with a diagnosis had good social adaptation.

Gender and suicide in India: a multiperspective approach.

The gap between male and female suicide rates in India is relatively small. However, society's views on female and male motives are quite different. In order to investigate the perceptions of male and female suicide, we interviewed a focus group of university professors as well as police inspectors, crime reporters, and hospital nurses in Bangalore. We also obtained four narratives of suicide. Women tended to be blamed for their own or their husband's suicide, although they were also viewed more often as victims of life adversities than men. A historical review illustrates that both men and women have been associated with culturally sanctioned suicides. One known form is sati, and we discuss the recent case of sati-murder of Roop Kanwar in 1987. The social sciences and the media also pay a lot of attention to the typical female suicides, symbolizing their role as martyrs of society, which seems to compensate for attribution of blame.

Viral Satellite RNAs for the Prevention of Cucumber Mosaic Virus (CMV) Disease in Field-Grown Pepper and Melon Plants.

A benign viral satellite RNA, in combination with a mild strain of cucumber mosaic virus (CMV-S), was used as a "vaccine" or "preinoculum" to demonstrate the feasibility of protecting pepper (Capsicum annuum cv. California Wonder) and melon (Cucurbita melo cv. Janus des Canaries) against two severe CMV strains, CMV-D and CMV-16, in the final 2 years of a 4-year pilot field and greenhouse experiment. In the field, healthy pepper and melon seedlings challenged with CMV-D and CMV-16 reduced yields by 33 to 60%; CMV-S caused only limited yield reduction in pepper and had no effect on the yield of melon. Different time intervals between preinoculation of pepper and melon seedlings with CMV-S and challenge inoculation with the severe CMV strains were tested. All plants challenged 3 weeks after vaccination showed nearly complete protection from subsequent infection by severe strains. The yield from preinoculated and challenged pepper plants was 80% that of untreated plants, while the yield from preinoculated and challenged melon plants was increased slightly over the untreated control plants. The use of this technology for biological control of plant viruses is discussed.

Intratester and intertester reliability and criterion validity of the parallelogram and universal goniometers for active knee flexion in healthy subjects.

BACKGROUND AND PURPOSE: A new parallelogram goniometer was designed by the Rehabilitation Centre of the Royal Ottawa Health Care Group in 1983. The advantage of using such a goniometer is that the clinician is not required to estimate the joint axis of rotation when taking a measurement. The parallelogram goniometer has obtained a good intratester and intertester reliability when measuring active range of motion of hip abduction on eight individuals with hip pathologies. However, the validity of the parallelogram goniometer has not been examined. The purposes of this study were to examine the intratester and intertester reliability and the criterion validity of the parallelogram and universal goniometers for active knee flexion on healthy individuals. SUBJECTS: Sixty healthy university students (44 females and 16 males; mean age of 20.6 yrs.) participated to this study. METHODS: Measurements with the universal and parallelogram goniometers were taken in two different positions, the smaller and larger angles of active knee flexion. All measurements were taken by two trained testers. A radiograph was taken in both positions to serve as the 'gold standard'. The sequence of the measurements and radiographs were randomly selected. The intra and intertester reliability of both goniometers were established by calculating the intraclass correlation coefficients (ICCs) using the repeated-measures ANOVA. The criterion validity was examined by calculating Pearson product-moment correlation coefficients (tau) between each goniometric and radiologic measurements. A 0.05 level of significance was chosen for each statistical test. RESULTS: Intratester reliability ranged from good to excellent for the small angles (ICC = 0.85 and 0.87) and the large angles (ICC = 0.91 and 0.96) when using the parallelogram goniometer. Intertester reliability was fair for the small angles of flexion (ICC = 0.43 to 0.52) and good to excellent for the large angles of flexion (ICC = 0.82 to 0.88). The parallelogram goniometer was found to have greater validity when measuring the large angles of knee flexion (r = 0.73 and 0.77) compared to the small angles of knee flexion (r = 0.33 and 0.41). Similar results of reliability and validity were obtained with the universal goniometer. CONCLUSION: The results of this study have clinical importance. The use of the parallelogram goniometer was found to be as reliable and valid as the universal goniometer when measuring active knee flexion. However, the parallelogram goniometer offered clinicians the advantages of obtaining precise angular measurements with fewer adjustments, and a faster application technique. Further studies on the parallelogram goniometer are necessary among individuals presenting with altered range of motion at different joints.