Tragus to Wall Test

Original Editor - Lauren Lopez

Top Contributors - Lauren Lopez, Kim Jackson, Lucinda hampton and Aminat Abolade  

Objective[edit | edit source]


To objectively measure the cervical mobility of an individual. 

A 2018 review of the Tragus to Wall Test (TWT) noted it is a simple, reliable and valid, clinical indicator of forward flexed posture[1]

Intended Population[edit | edit source]

For individuals with a flexed head and neck posture, particularly the elderly and those who have Parkinson's Disease or Ankylosing Spondylitis (Axial Spondyloarthritis) (AS). 

Method of Use[edit | edit source]

Shipe et al (2013) describe measuring the tragus to wall distance (TWD) as: “the horizontal distance between the tragus, the auricular cartilaginous flap anterior to the external auditory meatus, and a wall.”[2]

Haywood et al (2004) describe the following: “Horizontal distance between right tragus and wall, standing with heels and buttocks against the wall (to prevent pivoting), knees extended and chin is drawn in. Larger distance indicates worse spinal/upper cervical posture. Measured with a retractable steel tape measure.”[3] 

The TWD can be measured as cued or relaxed, i.e the clinician prompts the individual to assume as close to an anatomical posture as possible e.g “Stand tall.”, or the clinician measures the individual in their usual or presenting posture.  

The measurement can be done standing or sitting and it is worth documenting which position has been used. 

The TWD can be measured on both the individual’s right and left, and then an average can be calculated.   


Evidence[edit | edit source]

Reliability[edit | edit source]

In AS, test-retest correlations have been reported at between 0.93 and 0.95[5]. Inter-tester reliability has also been reported as “excellent” in individuals with Parkinson Disease[6].  

However, in individuals aged 18-34 without pathology, Shipe et al [2]observed variable inter-rater reliability results but found that intra-rater reliability was high. The authors subsequently recommended that in clinical practice, the TWT be repeated by the same person. 

Validity[edit | edit source]

In PD, the TWD has shown convergent validity with similar measures (occiput to wall status, C7 to wall distance, photographically derived trunk flexion angle, and inclinometric Thoracic Hyperkyphosis measure)[6]. It has also shown the ability to discriminate between groups (those who could touch occiput to wall when prompted to stand tall) and conditions (cued or relaxed)[6].

Responsiveness[edit | edit source]

Research reports limited evidence for the responsiveness of the TWT[1]. One study[3] reported small to moderate responsiveness to improvement but not deterioration in TWD.

Miscellaneous[edit | edit source]

Normative Data [edit | edit source]

The TWT is one measurement in a separate outcome measure, the Bath Ankylosing Spondylitis Metrology Index (BASMI)[7]. As part of a study to produce normative data for the BASMI[8], it was found that TWD did not deteriorate with age[7] . Results from the study showed the TWD was consistent across age groups and gender, which the authors noted was similar to a previous study of normative data using a seated TWT[9]. The authors concluded that TWD is instead disease-specific, in relation to AS. 

The TWD may be affected by body mass and weight loss or gain between measurements[10]

References[edit | edit source]

  1. 1.0 1.1 Bohannon RW, Tudini F, Constantine D. Tragus-to-wall: A systematic review of procedures, measurements obtained, and clinimetric properties. Journal of Back and Musculoskeletal Rehabilitation. 2019 Jan 1;32(1):179-89.
  2. 2.0 2.1 Shipe NK, Billek-Sawhney B, Canter TA, Meals DJ, Nestler JM, Stumpff JL. The intra-and inter-rater reliability of the tragus wall distance (TWD) measurement in non-pathological participants ages 18–34. Physiotherapy theory and practice. 2013 May 1;29(4):328-34.
  3. 3.0 3.1 Haywood KL, Garratt AM, Jordan K, Dziedzic K, Dawes PT. Spinal mobility in ankylosing spondylitis: reliability, validity and responsiveness. Rheumatology. 2004 Jun 1;43(6):750-7.
  4. BJC Health. Tragus to Wall test for Ankylosing Spondylitis. Available from: [last accessed 1/27/2023]
  5. Heuft-Dorenbosch L, Vosse D, Landewé R, Spoorenberg A, Dougados M, Mielants H, van der Tempel H, van der Linden S, van der Heijde D. Measurement of spinal mobility in ankylosing spondylitis: comparison of occiput-to-wall and tragus-to-wall distance. The journal of rheumatology. 2004 Sep 1;31(9):1779-84.
  6. 6.0 6.1 6.2 Nair P, Bohannon RW, Devaney L, Maloney C, Romano A. Reliability and validity of nonradiologic measures of forward flexed posture in Parkinson disease. Archives of Physical Medicine and Rehabilitation. 2017 Mar 1;98(3):508-16.
  7. 7.0 7.1 Chilton-Mitchell L, Martindale J, Hart A, Goodacre L. Normative values for the Bath Ankylosing Spondylitis Metrology Index in a UK population. Rheumatology. 2013 Nov 1;52(11):2086-90.
  8. Jenkinson TR, Mallorie PA, Whitelock HC, Kennedy LG, Garrett SL, Calin A. Defining spinal mobility in ankylosing spondylitis (AS). The Bath AS Metrology Index. The Journal of rheumatology. 1994 Sep 1;21(9):1694-8.
  9. Finsback C, Mannerkorpi K. Spinal and thoracic mobility-age-related reference values for healthy men and women. Nordisk fysioterapi. 2005;9(3):136.
  10. Ozaras N, Gulec MG, Celik HK, Demir SE, Guler M. Effect of body shape on tragus-to-wall distance in the normal population. Clinical rheumatology. 2014 Aug;33:1169-71.