PubMed  Each subject was asked to complete a set of three lumbar flexion and extension movements prior to testing as a warm-up procedure. PubMed Google Scholar. Place the inclinometer on the top of the individual's head, making sure that the dial is adjusted to 0 degrees. Any one above the age of 18 was selected. To examine the intra and inter-rater reliability of lumbar flexion and extension measurements attained using three landmarking methods for dual inclinometry. Guides to the Evaluation of Permanent Impairment 4 th edition. Get the latest public health information from CDC: https://www.coronavirus.gov, Get the latest research information from NIH: https://www.nih.gov/coronavirus, Find NCBI SARS-CoV-2 literature, sequence, and clinical content: https://www.ncbi.nlm.nih.gov/sars-cov-2/. Flexion. It is important to stress that our study only included patients with normal lumbar spine anatomy and further inaccuracies in identification of the correct spinal level might be expected if there were sacralization or lumbarization of the lower spine (prevalence 8–15%) (Ford & Goodman, 1966; O'Driscoll et al. volume 16, Article number: 121 (2015) Landmarks? However, from a clinical standpoint, the PSIS to 15 cm cephalad method as used in the modified-modified Schobers test, is recommended, as it is the simplest to perform and aligns with routine clinical practice. Hence, studies on the relationship of spinal motion to function are needed to determine if this impairment should be considered important when evaluating impairment. Validity and reliability of using photography for measuring knee range of motion: a methodological study. The inclinometers are placed (centered) on the two palpation points and zeroed. None of the authors have any competing interests to declare. Instruct the individual to raise chin first and then move head backward as far as … KP and AK helped in the data collection. Measurements were recorded to the nearest degree. An analysis of new attenders in primary care. Distal Arm. PubMed  CAS  https://doi.org/10.1186/s12891-015-0578-2, DOI: https://doi.org/10.1186/s12891-015-0578-2. Analysis of spine motion variability using a computerized goniometer compared to physical examination. Hence, one strategy for improving reliability is to study the impact of different landmarking techniques. 1983;63(11):1776–81. JOINT MOTION TESTING POSITION STABILIZATION MEASUREMENTS LUMBAR • FLEXION •EXTENSION •LATERAL FLEXION STANDING PELVIS To prevent anterior tilting To prevent … To this end, we did not incorporate a complete hamstring stretching protocol which may have affected spinal motion and also we ensured that the stretches were performed within the limits of pain. Three different land marking methods (see below) were used to identify the start & end of the lumbar spine to be measured. Reliability of three lumbar sagittal motion measurement methods: surface inclinometers. The upper and lower spinal landmarks were marked by a horizontal line on a piece of adhesive tape. Moreover the criterion validity of dual inclinometer has been tested against the gold standard of radiographic measurements in previous studies [39, 40]. 1999;24(3):262–8. The poor results were mostly attributed to differences between the raters, reflected by the accuracy and consistency of manual palpation of bony landmarks, and the handling of the inclinometer heads along the subject’s spine [20]. Conclusion: single inclinometer in differentiating the various ROM components of the lumbar spine, pelvis, and hips during lumbar spine sagittal plane AROM. The inclinometer is centered over the mark at T 12 and zeroed. 2000;53(1):1–s29. Association between measures of spinal mobility and low back pain. Do MRI findings correlate with mobility tests? 60 (usually will be more than 60 people usually have a lot of rotation here) axis: goes through vertical axis on top of head. © 2020 The University of Scranton Scranton, Pennsylvania 18510 1-888-SCRANTON or (570) 941-7400 Scranton, Pennsylvania 18510 1-888-SCRANTON or (570) 941-7400 1995;75(9):786–92. Subjects were ten people without symptoms and 50 patients with low back pain. Position involves four factors: the patient, the joint, the goniometer, and yourself. Measurement: A - B = ROM Normal Range: 60°+ Lumbar Spine Extension Patient Position: Standing Inclinometer A: T12 (Sagittal) Inclinometer … CAS  Range of motion (ROM) amongst other variables has been identified to be an indicator of impairment due to back pain [4]. J Chiropractic Med. [15] At present, there is no conclusive evidence to advocate one method over another [16]. Thoraco-Lumbar Spine Forward Bending (Flexion) NOTE: There are several methods for measuring the range of motion of the lumbar and thoracic spines. To determine lower landmark, the subject’s PSISs were palpated and a line connecting both PSIS represents the level of S2. The patient should be comfortable. 2007;16(6):803–12. Epub 2017 Aug 10. 1994;19(5):586–95. Reliability problems associated with the modified Schober technique for true lumbar flexion measurement. (A)Starting position with the inclinometer was placed on the T 12 –L 1 spinal level. Subjects’ shirts were lifted up and clipped, in order to expose the lumbar spine. 2017 Oct-Dec;30(4):420-431. doi: 10.1016/j.jht.2017.06.010. Convenience sampling was used to obtain forty volunteer subjects. The adhesive marks were removed for each set and the order of rater was randomized. 2017 Jan 1;18(1):161-168. doi: 10.1093/pm/pnw136. (b) In flexed postures C=HZ-H,. Long DM, BenDebba M, Torgerson WS, Boyd RJ, Dawson EG, Hardy RW, et al. Article  Van A, J.A.M, der Korst V. Assessment of the flexibility of the LumbarÂ. The lumbar curvature C is calculated from the angles H, and BZ measured by the inclinometers. Procedures After we obtained consent and health history information, we used a piece of athletic tape to mark the point on the spine between T1 and T2 that served as a reference point for ROM measurements. 2001 Nov;6(4):235-41. doi: 10.1054/math.2001.0419. An ICC value can range between 0 and 1 with zero indicating no reliability and 1 indicating perfect reliability. Reliability was determined using intra-class correlation coefficients. Spine. Landmarks were palpated by the examiner. Three different landmarking methods were used: 1) straight palpation of PSIS and L1, 2) palpation of PSIS and the site of the nearest 5 cm interval point closest to L1 and 3) location of PSIS and 15 cm cephalad. Reliability of a noninvasive method for measuring the lumbar curve*. Three different landmarking methods were used: 1) straight palpation of PSIS and L1, 2) palpation of PSIS and the site of the nearest 5 cm interval point closest to L1 and 3) location of PSIS and 15 cm cephalad. Phys Ther. The aims of this study were two‐fold: (1) to assess if the spinal level found by identification of the intercristal line (ICL) by palpation of the bony landmarks agrees with the level identified through X‐ray imaging, and (2) to assess which spinal … Figure 5: Measurement of lumbar spine ROM using the gravity-based inclinometer. The study involved 30 healthy subjects (5 males, 25 females) aged 20 to 35 years. Background: According to guidelines set out by the American Medical Association (AMA) in its 4th and 5th edition, compensation entitlements for patients with low back pain were based in part, on the impairment of back movement [23, 24]. 2007;93(3):201–11. A fluid-filled bubble inclinometer (model Baseline Bubble; Fabrication Enterprises, Inc, White Plains, NY) was used to measure thoracic ROM during the lumbar-locked rotation test. Recording from an inclinometer attached … Proximal Arm. 1993. Please enable it to take advantage of the complete set of features! Furthermore, range of motion measurements often reflect physical impairment or functional mobility in which case external measures of the ROM are more directly applicable. (a) In erect standing C=-(H,+HzI. Symptomatic patients might not show impaired range of motion while symptomatic patients might present substantial impairment of lumbar movements. This study proposed a method to improve reliability of spinal motion measurements and there is value in adopting consistent methods to allow for greater comparability. Persistent back pain and sciatica in the United States: patient characteristics. Thirty individuals … In this … Rondinelli R, Murphy J, Esler A, Marciano T, Cholmakjian C. Estimation of normal lumbar flexion with surface inclinometry. J Orthop Sports Phys Ther. Lumbar Mobility and Performance-Based Function: An Investigation in Older Adults with and without Chronic Low Back Pain. doi: 10.1097/00007632-199403000-00015. Physical Ther Rev. Rater 2 was not present for the measurements taken by rater 1, ensuring blinding between raters. It recommended the use of multiple measures including the CDI and the MMS. Three different landmarking methods were used: 1) straight palpation of … 2003;8(1):45–50. Anatomical landmarks were identified with the patients in prone lying. Tracker M.E. Established specific spinal region landmarks for … Incorrectly positioning any of these items can result in an inaccurate measurement of joint motion. Thomas E, Silman AJ, Papageorgiou AC, Macfarlane GJ, Croft PR. Can Physiotherapists locate Lumbar spinal levels by palpation? 5th edition: Amer Medical Assn. Fleiss JL. 2. Man Ther. On each occasion the bony landmarks were palpated and the inclinometers attached as described above. Association between measures of spinal mobility and low back pain. Rondinelli RD, Genovese E, Brigham CR. Scand J Rheumatol. Position involves four factors: the patient, the joint, the goniometer, and yourself. 1986;8(4):180–4. The patient is instructed to stand erect. Eur Spine J. Tape was removed and landmarks were relocated by the same assessor (intra-rater) for an additional three trials; and this process was repeated by a second assessor (inter-rater). Two important aspects of subject preparation are: exposing the lower spine to improve landmarking and considering the flexibility of hamstrings which could reduce the movement in pelvis and consequently in the lumbar spine [37]. All three methods of land marking are reliable. 1992;17(3):345–8. Reliability within a set of three repetitions was very high (ICCs > 0.90); intra-rater reliability after relocating landmarks was high (ICCs > 0.80); reliability between therapists was moderate to high (0.60 > ICCs < 0.76).  |  Measurement of Lumbar Lordosis Lumbar lordosis was measured using a flexible curve as described by Hart and Rose (4). 1993;73(1):33–44. Repeat 2-3x to make sure the inclinometer did not move &/or some other error did not occur. Influence of the hamstring muscles on lumbar spine curvature in sitting. On the contrary, the current study has shown that with appropriate land marking techniques the reliability was fair to good. Subjects were also informed that participation in the study was completely voluntary, and they could withdraw at any time. Nitschke JE, Nattrass CL, Disler PB, Chou MJ, Ooi KT. This study demonstrates reliable methods of measuring lumbar ROM are available. Spinal motion is compound; therefore, it is important to use the dual-inclinometer technique when measuring spinal ROM during your OIC examinations. Faculty of Health Sciences, University of Western Ontario, London, Ontario, Canada, Joy C MacDermid, Vanitha Arumugam, Kimberly L Payne & Aubrey K So, Department of Surgery, University of Western Ontario, ON N6A 4L6, London, Ontario, Canada, Roth – MacFarlane Hand and Upper Limb Center, St. Joseph’s Healthcare London, London, Ontario, Canada, Joy C MacDermid, Vanitha Arumugam & Joshua I Vincent, School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada, You can also search for this author in In order to establish validity, further research, comparing spinal angles obtained from an inclinometer … 1998;23(3):343–7. Am J Phys Med Rehabil. We recommend the use of the PSIS to 15 cm cephalad method as used in the modified-modified Schobers test as it is the simplest to perform and aligns with current clinical practice. However, studies have shown that even highly experienced clinicians have low reliability in accurate ascertainment of spinal level, suggesting that measurement strategies based on palpation have inherent limitations [32]. 1987;67(3):364–9. Two assessors measured a series of lumbar flexion and extension movements using the J-Tech™ dual inclinometer. Article  MacDermid JCCK, Gandhi R. The reliability and validity of double inclinometer in measuring lumbar mobility. Pourahmadi MR, Taghipour M, Jannati E, Mohseni-Bandpei MA, Ebrahimi Takamjani I, Rajabzadeh F. PeerJ. 2007;12(1):56–62. The authors concluded that clinical use of such a method could demonstrate progress in rehabilitation and as- sist in determining the degree of impairment in pa- tients with low back pain. Spine. Recommended Testing Position. During each set, subjects performed a series of three alternating flexion and extension movements. Validity and reliability of palpation-digitization for non-invasive kinematic measurement - a systematic review. 2019 Mar 25;7(6):949-954. doi: 10.3889/oamjms.2019.117. An adhesive mark was placed on the T12-L1 and L5-S1 spinal interspaces. If you need to measure several motions, you should plan the sequence of measurements so you will minimally change the patient's position. An examination by Nitschke et al. Pain Med. The arch attachment was fixed to the inclinometer, and the rater held this portion of the inclinometer when zeroing the instrument and taking all measurements. To determine the center of the pedicle of each segment in the dorsal projection, a line was drawn bisecting the pedicle in its lateral and inferior view, following the bony contours onto the dorsal surface. Findings from previous reliability studies of the lumbar ROM measures suggest that palpation inaccuracies were the main source of error [3, 7, 8, 18, 19, 26, 27]. Three different land marking methods (see below) were used to identify the start & end of the lumbar spine to be measured. The two heads of the dual inclinometer were placed at the low marked levels along the spine; the MASTER head at the upper landmark and the SLAVE head placed at the lower landmark. (B) Maximum flexion was measured at the T 12 –L 1 spinal level. J Orthop Sports Phys Ther. An important and common source of error while measuring lumbar range of motion could be to do with the preparation of subjects. Previous studies have addressed the validity and reliability of the CDI [3, 7, 8, 17–19]. read directly off the inclinometer (Figure 2). While a number of factors including rater skill, equipment limitations, patient selection and pain status may affect reliability of results, certainly landmarking is one of the major issues that affects the reliability and validity of joint motion measurements. Cupon LN, Jahn WT. The first step is to identify the anatomical landmarks. Miller SA, Mayer T, Cox R, Gatchel RJ. All subjects were instructed to remove their shoes and to stand upright with feet shoulder-width apart, and both knees straight throughout the process. Forty subjects (26 male, 14 female), ranging in age from 19 to 71 (mean = 34.2, SD = 14.5) were recruited by convenience sampling to participate in the study. Currently, there is no clear evidence about the relevance of lumbar ROM in low back pain. inclinometer. Standing with cervical, thoracic, & lumbar spine in 0 0 of lateral flexion & rotation: Stabilize pelvis to prevent anterior tilting eCollection 2018. A limitation of this method is that it does not represent the same portion of the spine for people of different heights. The computer uses this point as the zero reference point. Tracker M.E. 2 Adhesive marks were removed and re-landmarked for each set of data. J-Tech Medical Industries, Utah, USA. doi: 10.1097/00002060-199208000-00004. Reliability and validity of an iPhone(®) application for the measurement of lumbar spine flexion and extension range of motion. Inter and intra rater reliability was calculated using intra class correlations (ICC) [33, 34]. Portney L, Watkins M. Foundation of Clinical Research: Applications to practice. Ideally tools and the associated procedures to use them are reliable, valid, cost-effective & easy-to-use [7]. The upper and lower spinal landmarks were marked by a horizontal line on a piece of adhesive tape.Footnote 2 Adhesive marks were removed and re-landmarked for each set of data. Measurement of Lumbar Lordosis Lumbar lordosis … Littlewood C, May S. Measurement of range of movement in the lumbar spine—what methods are valid? This would still provide an accurate measurement without the perfect alignment of the heads because the unit measures the angle between the intersecting planes created at the heads. Stokes IA, Abery JM. Spinal landmarks were repalpated for the second testing by rater 1 and again by rater 2. This study tested the reliability and validity of three methods of measuring lumbar spine mobility: inclinometer, kyphometer and fingers-to-floor. California Privacy Statement, The three landmarking techniques that were used. These original landmarks were modified to the spinal interspaces between T12-L1 and L5-S1 as an attempt to isolate the lumbar spine, and because it was thought that these landmarks are more easily … forehead through vertical axis. Upon landmarking, adhesive tape was used to mark landmarks and the inclinometer was placed on sites for three trials of flexion and extension. Landmarks were palpated by the examiner. Three different landmarking methods were used: 1) straight palpation of PSIS and L1, 2) palpation of PSIS and the site of the nearest 5 cm interval point closest to L1 and 3) location of PSIS and 15 cm cephalad. 2013 Feb;18(1):26-34. doi: 10.1016/j.math.2012.06.004. Two assessors measured a series of lumbar flexion and extension movements using the J-Tech™ dual inclinometer. Objective assessment with establishment of normal values for lumbar spinal range of motion. (A) Starting position with the inclinometer was placed on the T 12-L 1 spinal level. Reliability within a set of three repetitions was very high (ICCs > 0.90); intra-rater reliability after relocating landmarks was high (ICCs > 0.80); reliability between therapists was moderate to high (0.60 > ICCs < 0.76). National Center for Biotechnology Information, Unable to load your collection due to an error, Unable to load your delegates due to an error. A comparison of three methods. Quack C, Schenk P, Laeubli T, Spillmann S, Hodler J, Michel BA, et al. Spine. J Spinal Disord. An analysis of new attenders in primary care. Sources of error include the level of training of the therapist, how well the lumbar spine is exposed away from clothing, and the varying distances for individuals of the bony landmarks to the surface of the skin. Vanitha Arumugam. Sports Med. Physiotherapy. There are many different landmarking techniques currently used by clinicians to locate a specific spinal level. -, Rondinelli R, Murphy J, Esler A, Marciano T, Cholmakjian C. Estimation of normal lumbar flexion with surface inclinometry. NIH Cookies policy. 1998;23(3):343–7. Adjust the dial of the inclinometer so that it reads 0 degrees. Upon landmarking, adhesive tape was used to mark landmarks and the inclinometer was placed on sites for three trials of flexion and extension. Convenience sampling was used to obtain forty volunteer subjects. eCollection 2019 Mar 30. Phys Ther. Beattie P, Rothstein JM, Lamb RL. On the other hand, studies on palpation skills of clinicians in palpating and identifying spinal levels indicate great variability in terms of reproducibility and repeatability between clinicians [28–32]. JOINT MOTION TESTING POSITION STABILIZATION MEASUREMENTS LUMBAR • FLEXION •EXTENSION •LATERAL FLEXION STANDING PELVIS To prevent anterior tilting To prevent posterior tilting To prevent lateral tilting 6.7cm in males 5.8cm in females Average 6.3cm-6.9cm (Modified Schober test) 1.6cm (Modified Schober Test) 25 – 30 degree by AMA (double inclinometer) Measurement of Joint Motion: A Guide to Goniometry Measurement of Joint Motion: A Guide to Goniometry. doi: 10.1097/00007632-199802010-00011. The results of the current study indicate that regardless of the landmarking method utilized (methods 1, 2 or 3), dual inclinometry had good intra-rater reliability and fair to good inter-rater reliability for lumbar flexion and extension measurements. The measurement value of the lower spine is subtracted from the upper spine value. -, Thomas E, Silman AJ, Papageorgiou AC, Macfarlane GJ, Croft PR. Spine. Moreover, skin landmarks are inconsistently present, being completely absent in 26% of cases. To improve flexibility of the hamstrings we made our subjects perform some practice repetitions which can increase the flexibility of the hamstrings considerably through ‘warm-up’ [38]. The publishing cost of this manuscript is covered by Western libraries Open Access Fund. Madson, MS, PT ... single inclinometer in differentiating the various ROM components of the lumbar spine, pelvis, and ... between measurements and the bony landmarks … A prospective clinical study. Improvement can be made by moving either one of the measurements heads slightly lateral to prevent collision. Cite this article. The angle read was marked positive if an anterior tilt was present, negative for posterior tilt. 1990;12(1):24–9. From these angles, the lumbar … Quack and colleagues (2007) compared MRI findings to ROM tests of the lumbar spine and found no clear relationship between the changes observed on a MRI to the ROM tests of the lumbar spine [36]. Konieczka C, Gibson C, Russett L, Dlot L, MacDermid J, Watson L, Sadi J. J Hand Ther. These landmarks were marked with a pen to standardize the placement of the bubble inclinometers. This result is known as the “true angle”. One of the methods that has been used to measure joint mobility in research and clinical practice is computerized dual inclinometry (CDI). 2008. Spine. For exa… All three landmarking techniques have almost the same reliability. The Immediate Effect of Therapeutic Touch and Deep Touch Pressure on Range of Motion, Interoceptive Accuracy and Heart Rate Variability: A Randomized Controlled Trial With Moderation Analysis. PubMed  An adhesive mark was then placed at the 10 or 15 cm level above the S2 level located. Part of Upon landmarking, adhesive tape was used to mark landmarks and the inclinometer was placed on sites for three trials of Editor/Author Norkin, Cynthia C. and White, D. Joyce Publication Year: 2017 Publisher: … A measure of its validity. To determine the lower landmark, subject’s PSISs were palpated and a line connecting both PSIS represents the level of S2. Since, lack of such evidence resulted in ROM being excluded from the measures that are required to calculate impairment due to back pain [25]. Analysis of spine motion variability using a computerized goniometer compared to physical examination. JM, VA, and JV were responsible for manuscript thought, writing and editing. 2011. (C) Maximum extension was measured at the T 12 –L 1 spinal level. One set constituted three lumbar flexion movements and three lumbar extension movements that were alternating in nature. On the other hand in the current study we used an easy-to- identify landmark, PSIS which even a novice assessor can identify easily. A prospective clinical study. End. Enjoy the videos and music you love, upload original content, and share it all with friends, family, and the world on YouTube. mov arm: in midline of head or in line with nose. -. Instructions: Using a single mechanical inclinometer, place the middle of the base at/near T12. Google Scholar. Fourth lumbar vertebra L4 spinous is at the level of iliac crests. Mark at S2 and T1 for thoraco lumbar and S2 and T12 for lumbar Place inclinometers at landmarks - zero Have patient move Read angles on both devices Subtract sacral measurement from thoracic measurement AMA - lumbar ROM is 25 degrees 23 Back ROM - BROM Used for lumbar … What is the reliability of clinical measurement tests for humeral head position? The three methods used were the Pleurimeter V double inclinometer, the carpenter double inclinometer, and the computerized sensor single inclinometer. (D) Starting position with the inclinometer was placed on the S 1 –S 2 spinal level. Naylor JM, Ko V, Adie S, Gaskin C, Walker R, Harris IA, Mittal R. BMC Musculoskelet Disord. Motion. -, Nitschke JE, Nattrass CL, Disler PB, Chou MJ, Ooi KT. 1996;21(11):1332–8. Three different landmarking methods were used: 1) straight palpation of PSIS and L1, 2) palpation of PSIS and the site of the nearest 5 cm interval point closest to L1 and 3) location of PSIS and 15 cm cephalad. Start. Despite the mentioned sources of error, this study has shown dual inclinometry to be a reliable tool for measuring lumbar flexion and extension. Saur PM, Ensink FB, Frese K, Seeger D, Hildebrandt J. Lumbar range of motion: reliability and validity of the inclinometer technique in the clinical measurement of trunk flexibility. (B) Maximum flexion was measured at the T 12 –L 1 spinal level. All three methods of land marking are reliable. The technique of applying the dual inclinometer also has potential sources of error. st arm: straight ahead. [3] showed dual inclinometry had acceptable intra-rater reliability results (flexion ICC = 0.90, extension ICC = 0.71), but fair to poor inter-rater values (flexion ICC = 0.67, extension ICC = 0.35). A limitation of this current study is its inability to calculate values for absolute reliability which would have made the study even more clinically relevant. Phys Ther. [3] demonstrated poor inter and intra-rater reliability for measurements of thoracolumbar flexion, extension, lateral flexion and rotation using a J-Tech CDI with respect to reliability. NOTE: There are several methods for measuring the range of motion of the lumbar and thoracic spines. Adhia DB, Bussey MD, Ribeiro DC, Tumilty S, Milosavljevic S. Man Ther. NLM LUMBAR SPINE MEASUREMENT USING INCLINOMETERS Lumbar Spine Flexion Patient Position: Standing Inclinometer A: T12 (Sagittal) Inclinometer B: S1 (Sagittal) Movement: Patient bends forward as far as they can. Reliability of the attraction method for measuring lumbar spine backward bending. 2001;82(11):1566–70. Chen SP, Samo DG, Chen EH, Crampton AR, Conrad KM, Egan L, et al. Upon landmarking, adhesive tape was used to mark landmarks and the inclinometer … Investigators in the Nitschke et al. The examiner centered the slave and master inclinometer units over the adhesive marks and enters the neutral lumbar … 3 M™ Micropore™ Medical Tape, 3 M in Canada, London ON. 2003;89(2):74–81. Variance in the measurement of sagittal lumbar spine range of motion among examiners, subjects, and instruments. (A)Starting position with the inclinometer was placed on the T 12 –L 1 spinal level. Skin tends to distract even over completely immobile bony structures (eg, the sacrum), whereas, on average, only 3.5 of the 6 spinal segments (T12-S1) are included in the Schober technique for purported measurement of “lumbar … Arch Phys Med Rehabil. 12 For lumbar extension measurements, an excessive amount of lordosis artificially deflates the extension ROM measurement since the underlying vertebrae are already in a position of extension. Woods K, Bishop P, Jones E. Warm-up and stretching in the prevention of muscular injury. Instructions are also provided to facilitate reliable identification of relevant spinal landmarks such as the spinous processes of T1, T12, and S2.