Sagittal Standing Posture and its Association with Spinal Pain: A School-based Epidemiological Study of 1196 Flemish Adolescents Before Age at Peak Height Velocity
SOURCE: Spine (Phila Pa 1976). 2012 (Sep 1); 37 (19): 1657-1666
Mieke Dolphens; Barbara Cagnie; Pascal Coorevits; Guy Vanderstraeten; Greet Cardon; Roseline D’hooge; Lieven Danneels
Department of Rehabilitation Sciences and Physiotherapy,
Faculty of Medicine and Health Sciences,
Ghent University, Artevelde University College, Ghent, Belgium.
STUDY DESIGN: Cross-sectional baseline data set on the sagittal standing posture of 1196 adolescents.
OBJECTIVE: To describe and quantify common variations in the sagittal standing alignment in boys and girls who are in the same phase of growth and to explore the association between habitual standing posture and measures for spinal pain.
SUMMARY OF BACKGROUND DATA: Data on postural characteristics and spinal pain measures in adolescence are sparse, especially when somatic and biological maturity status is to be considered. Our understanding of the relationship between standing posture in the sagittal plane and spinal pain is also deficient.
METHODS: A total of 639 boys (age [mean ± SD], 12.6 ± 0.54 yr) and 557 girls (10.6 ± 0.47 yr), with predicted years from peak height velocity (PHV) being 1.2 ± 0.71 and 1.2 ± 0.59 pre-PHV, respectively, were studied. Postural examination included the assessment of global alignment and local spinopelvic characteristics, using post hoc analyses of digital images and direct body measurements (palpation, digital inclinometry, and wheeled accelerometry). Spinal pain experience was assessed by questionnaire.
RESULTS: A wide interindividual variation in sagittal posture characteristics was observed. Logistic regression analyses yielded global alignment parameters to be associated with low back pain (lifetime prevalence), neck pain (lifetime prevalence, 1–mo prevalence, and doctor visit), and thoracic spine pain (doctor visit) outcome measures. None of the included local spinopelvic parameters could be identified as an associated factor with measures of spinal pain.
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CONCLUSION: The orientation of gross body segments with respect to the gravity line seems superior to local spinopelvic features in terms of clinical importance, at least in the current pre-PHV cohort. Opportunities may exist for postural subgrouping strategies to begin with global alignment parameters in order to gain further insight into the relationship between sagittal alignment and the relative risk of developing spinal pain/seeking medical consultation for this pain.
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There is a belief among clinicians that “nonneutral” postures when compared with “neutral” or “ideal” postures involve different patterns of mechanical loading and motor control, resulting in a mechanism with tissue strain and pain. Consequently, postural retraining has traditionally been an integral part of physiotherapeutic intervention in the prevention and treatment of spinal pain disorders. Evidence from epidemiological studies, however, does not support an association between sagittal spinal curves and spinal pain. [1, 2] It is also well established that the physiological upright standing posture can be reached in a different way for each person with a unique and individual pattern of spinopelvic balance and sagittal alignment. [3, 4] Accordingly, previous publications have documented a high degree of variability in the sagittal standing alignment of the human spine and pelvis in healthy adolescents, [5–7] adults, [3, 5 ,8 ,9] middle-aged and older subjects, 10 and populations experiencing spinal pain. [11–13] Characteristic changes in sagittal alignment have also been identified throughout the entire time of ontogenesis. [5, 14–18]
Two separate yet intermingled control mechanisms are involved in building up standing posture: one relating to the control of the center of mass projection with respect to the feet, and another relating to the orientation of body segments with respect to the vertical.  The center of gravity projection or the gravity line has been shown to be located within a narrow perimeter in relation to the feet in standing subjects. [18, 20] On the contrary, when regarding the geometry of the body, one viewpoint in the literature is that posture is based on the superimposed segments (head, trunk, and legs), each of which is linked to the next, preserving the specific orientation of each segment with respect to the external world and/or adjacent segment.  Only a relatively few studies regarding posture or its clinical relevance have addressed the orientation of gross body segments in space by implementing a type of a sagittal plumb line assessment, [16, 21–27] whereas a multitude of studies have focused on regional or segmental spinopelvic features. [10, 11, 14, 28–30] It should be noted that most of the studies that have considered global alignment were radiological examinations, implying that an accurate representation of the relaxed standing posture might be challenged.  Furthermore, anatomically remote factors, such as the alignment of the lower limb segment, have been largely overlooked despite their potential signifi cance in closed kinematic chain activities such as standing.