The patient is asked to bend forward and attempt to reach for the floor with their fingertips. The physical therapist then measures the distance between the patient’s right long finger and the floor using a standard measuring tape. Can a test get any simpler than that?
I must admit that I use the fingertip-to-floor (FTF) test as an outcome measure on the great majority of my patients presenting with lumbo-pelvic pain, for the simple reason that forward bending is one of the more painful and limited movements, especially in those with neural symptoms.
The FTF test has been shown to have excellent reliability without the use of standardized instructions and patient positioning (Gauvin et al 1990).
It must be stated that the FTF test has been criticized for not measuring isolated lumbar flexion ROM, with the argument that forward bending range is also based on pelvic, hip, thoracic spine, dural and shoulder mobility. This “limitation” may be considered to be the actual advantage of using the FTF test. In fact it is suggested that pure lumbar flexion active ROM measures should not be used as an outcome measure to monitor patient progress, as they have been shown to be weakly correlated to the patients’ level of disability (O’Sullivan et al 2000).
A study looked at both isolated lumbar and total lumbo-pelvic range and disability in a group of patients with chronic low back pain (LBP). They found that the total lumbo-pelvic range correlated more highly with disability scores and recovery than did true lumbar flexion (Rainville et al 1994). In fact, global trunk movement may be more predictive of self-reported disability than its sub-components of spine flexion (Waddell et al 1993).
A correlational study (Perret et al 2001) analyzed the validity of the FTF test using dynamic radiographs where patients with chronic LBP underwent the FTF test and also received radiographs in neutral and in full trunk flexion positions. They demonstrated that trunk flexion assessed by the FTF test and by radiologic measures had excellent correlation and both methods had excellent reliability.
Another longitudinal study (Ekedahl et al 2012) which involved patients with acute and subacute LBP with or without radicular symptoms, demonstrated that a change in the FTF test was significantly correlated to the 1-month and 1-year change in Roland Morris Disability Questionnaire. They also concluded that for patients with LBP the FTF had good validity and even better validity in those with radicular pain. The minimal detectable change for FTF test was shown to be 4.5cm.
FTF Test Clinical Application
The patient stands comfortably with the feet facing forward and is asked to bend forward. The instruction is, “Without bending your knees, attempt to touch the floor with your fingertips, go only as far as you can.” The distance between the patient’s right long finger and the floor is measured in centimetres. The test is performed 3 times where the best effort is measured and considered as the outcome.
The patient should be asked whether pain, stiffness or both limited the FTF test. If the FTF test is limited by pain, the location and pain score out of 10 should be should be documented. If the FTF test is 0cm or the patient is able to place their palms to the floor with no pain, a different outcome measure should be considered.
There are no “normative” values for the FTF test, as forward bending flexibility is highly variable even in the asymptomatic population. However most patients with LBP with or without neural symptoms present with FTF test measures of greater than 20cm.
For instance, a patient with LBP may measure 55cm on the FTF test, which increases his left-sided low back and leg pain to 7 out of 10. An ideal patient goal would be to have the FTF test measure 0cm with a pain score of 0 out of 10. However, it is important to ask the patient if they were ever able to touch the floor prior to the onset of their LBP. Although the ability to touch the floor may be an unrealistic goal for many individuals, resolving lumbar and lower extremity neural symptoms during the FTF test is a reasonable expectation, that should be regularly evaluated to monitor patient progress and treatment efficacy.
In conclusion, considering that the fingertip-to-floor test has excellent inter and intra-rater reliability, validity, and responsiveness, the use of this simple outcome measure in clinical practice is strongly recommended.
Ekedahl H, Jönsson B, Frobell RB. Fingertip-to-floor test and straight leg raising test: validity, responsiveness, and predictive value in patients with acute/subacute low back pain. Arch Phys Med Rehabil. 2012 Dec;93(12):2210-5.
Gauvin MG, Riddle DL, Rothstein JM. Reliability of clinical measurements of forward bending using the modified fingertip-to-floor method. Phys Ther. 1990 Jul;70(7):443-7.
Perret C, et al Validity, reliability, and responsiveness of the fingertip-to-floor test. Arch Phys Med Rehabil. 2001 Nov;82(11):1566-70.
Rainville J, Sobel JB, Hartigan C. Comparison of total lumbosacral flexion and true lumbar flexion measured by a dual inclinometer technique. Spine. 1994 Dec 1;19(23):2698-701.
Sullivan MS, Shoaf LD, Riddle DL. The relationship of lumbar flexion to disability in patients with low back pain. Phys Ther. 2000 Mar;80(3):240-50.
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