Tragus to Wall Test
- Fysiobasen
- Sep 14
- 3 min read
The Tragus to Wall Test (TWT) is a simple, reliable, and valid clinical tool for assessing forward head posture and cervical mobility. It is widely applied in conditions such as Parkinson’s disease and Ankylosing Spondylitis (AxSpA), where postural changes and spinal stiffness are common¹.
Target Population
TWT is particularly useful for:
Older adults with age-related postural changes
Patients with Parkinson’s disease
Patients with Ankylosing Spondylitis
Individuals with general forward head posture
Test Procedure
Positioning:
Patient stands with heels and buttocks against the wall, knees straight.
Chin is gently tucked to standardize neck position.
Measurement is taken horizontally from the tragus (ear cartilage) to the wall.
Variants:
Cued: Patient is instructed to “stand as tall and upright as possible.”
Relaxed: Patient assumes natural, habitual posture.
Measurements can be taken bilaterally, and the mean can be used for analysis²³.
Evidence
Reliability:
Ankylosing Spondylitis: ICC 0.93–0.95 (excellent)⁵
Parkinson’s disease: Excellent inter-rater reliability⁶
Healthy adults (18–34): Variable inter-rater but high intra-rater reliability²
Validity:
Shows convergent validity with Occiput-to-Wall Test, C7-to-Wall Distance, thoracic kyphosis angles, and photographic posture assessments⁶.
Discriminates between cued vs. relaxed posture and between patient groups.
Responsiveness:
Limited evidence; small to moderate responsiveness in detecting improvement³.
Normative Data:
Not significantly affected by age or sex⁷.
Body shape and BMI can influence results¹⁰.
Clinical Integration:
TWT is a component of the Bath Ankylosing Spondylitis Metrology Index (BASMI)⁷.
Clinical Significance
The Tragus to Wall Test is a fast and practical tool for quantifying cervical mobility and forward head posture. While disease-specific (especially in AxSpA), it should be used alongside other mobility and posture assessments for a complete evaluation. Its simplicity and strong clinimetric properties make it valuable in both neurological and rheumatological practice.
Sources:
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.
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.
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.
Gjennomgått - trukket
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.
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.
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.
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.
Finsback C, Mannerkorpi K. Spinal and thoracic mobility-age-related reference values for healthy men and women. Nordisk fysioterapi. 2005;9(3):136.
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.
