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SPINAL POSTURAL ALIGNMENT VARIANCE ACCORDING TOSEX AND AGE IN 7- AND 8-YEAR-OLD CHILDREN

Patri

.`cia Jundi Penha,

a

Marina Baldini,b

and Si

.`lvia Maria Amado Joo, PhD

c

ABSTRACT

Purpose: Children's postural alignment undergoes many adjustments due to the changes in body proportions during the

stages of growth. The objective of this study was to quantitatively characterize and analyze spinal postural standards in

7- and 8-year-old children to verify which of the differences found were correlated to age and sex.

Methods: Two hundred thirty public school students (Amparo, So Paulo, Brazil) aged 7 to 8 years were divided into

groups according to postural alignment, which were further subdivided by sex and age, for comparison. Digital photos of

upright subjects were analyzed to evaluate posture. Lumbar and thoracic curvature, pelvic inclination, head posture, and

lateral spine deviation were measured using CorelDraw (Ottawa, Canada) software guidelines and bone landmarks.

Descriptive statistics and analysis of variance data analysis were utilized to verify differences among the groups. Thiswas a cross-sectional, descriptive study.

Results: Mean values for the variables analyzed were calculated. For lumbar lordosis, 7-year-old boys showed 38.49

15.32 in comparison to all other groups (42.29 7.13). For thoracic kyphosis, the 7-year-old children presented

28.07 7.73, and the 8-year-olds 30.32 7.73. Pelvic inclination presented a mean value of 15.82 5.46 and

single lateral spine deviation mean value of 3.48 2.12.

Conclusion: For the sample studied, differences based on sex and age were found for some of the body segments

analyzed. The values found in this study may contribute to improved physiotherapeutic treatment when associated with

other aspects of the clinical assessment and symptomatology. (J Manipulative Physiol Ther 2009;32:154-159)

Key Indexing Terms: Posture; Spine; Child

Posture is defined as the relative arrangement of body

parts.1

The ideal alignment in the vertical posture isrelated to the gravity line, which is a vertical line

passing through the body's center of gravity.2 When the

center of gravity of the segments deviate and change the

alignment, a number of postural abnormalities can occur, and

greater tension on the supportive structures may cause body

balance to be less efficient.1,3

Epidemiological data have shown a high prevalence of

spinal postural deviations in children and adolescents.4-6

Studies have shown that 11% to 51.2% of children of all

ages complain of back pain episodes and that their

occurrence increase with age.7,8 Lafond et al9 studied the

sagittal plane postural alignment of 1084 children, and their

results showed that, relative to a vertical reference, postural

alignment changes considerably between the ages of 4 and

12 years.

Variations in child posture are associated to the growth

stages, which change body proportions and cause balance

problems.10 Although deviations could be considered to be

within physiological norms at 1 musculoskeletal system

developmental phase, these same deviations may be

considered to be inappropriately generating an overload on

the body at a subsequent developmental phase.

Although reference standards can be found in the

literature for the ideal adult body alignment,1 these standards

are not appropriate for children. Using the adult standard for

body alignment would mischaracterize the greater mobility,

flexibility, and the temporary deviations in alignment that

occur in children during development1 as abnormalities.

According to Lafond et al,9 upright posture measurements of

children and adolescents might be a useful clinical tool to

identify musculoskeletal conditions at early stages during the

developmental process and aid prevention.

a Master Degree, Rehabilitation Sciences in the School ofMedicine, Department of Physical Therapy, Speech and Occupa-tional Therapy University of So Paulo, So Paulo, SP, Brazil.

b Physiotherapist, Physical Therapy Course of the School of

Medicine, Department of Physical Therapy, Speech and Occupa-tional Therapy, University of So Paulo, So Paulo, SP, Brazil.

c Physiotherapist, Department of Physical Therapy, Speech andOccupational Therapy, School of Medicine of the University of SoPaulo, So Paulo, SP, Brazil.

Submit requests for reprints to: Slvia Maria Amado Joo,Departamento de Fisioterapia, Fonoaudiologia e Terapia Ocupa-cional Universidade de So Paulo, R. Cipotnea 51 CidadeUniversitria, So Paulo 05360-000, SP, Brazil(e-mail: [email protected]).

Paper submitted January 21, 2008; in revised form August 1,2008; accepted September 9, 2008.

0161-4754/$36.00Copyright 2009 by National University of Health Sciences.doi:10.1016/j.jmpt.2008.12.009

154
mailto:[email protected]:[email protected]://dx.doi.org/10.1016/j.jmpt.2008.12.009http://dx.doi.org/10.1016/j.jmpt.2008.12.009mailto:[email protected]


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There is no standard approach to measuring posture.11

However, the use of photographs as a tool for postural

assessment has been defended by many researchers.3,12-15

Photographic observations of the ideal posture have been

ranked visually, and simple equipment such as tape

measures, penciled landmarks, and plumb lines have been

used.11 This technique has a quantitative character that

allows for the measurement of angles and distances among

bone references, joints, planes, and axes.13

In a previous study4 using photographic techniques, theauthors qualitatively assessed the posture of 132 girls

between 7 and 10 years of age, and the results showed

rates higher than 50% for pelvic anteversion and lumbar

hyperlordosis, among other postural alterations.4 Deviations

such as scoliosis and thoracic hyperkyphosis were prevalent

below 40% for the 7 and 8 year olds.4 Little description of

the quantitative analysis of spinal posture in children has

been found in the literature.9

Therefore, the objective of the present study was to

quantitatively characterize spinal posture to verify any

differences in the postural aspects analyzed and their

possible correlation to sex or age in 7- and 8-year-old publicschool students in the city of Amparo, So Paulo, Brazil.

METHODS

Setting

This cross-sectional, descriptive study was carried out in

public schools in the city of Amparo, So Paulo, Brazil, and

was classified as primary health care ranking.

Participants

The target population of this study was 7- and 8-year-old

male and female children, and thus, the study samplepopulation was composed of children of both sexes of the

targeted ages studying in public schools in the city of

Amparo, SP, Brazil. Sampling was stratified, and 6 public

primary schools were chosen, 1 from each urban neighbor-

hood (Centro, Jardim Santana, Popular, Jardim Silvestre, So

Dimas, and Rodovia).16

To calculate the smallest possible sample size, a 95%

confidence interval and a precision value of 5% were used.

First, the formula n = [(z

)2pq] /2 was applied to the data

for a result ofn = 384, and this result was then used in the

formula n = (Nn) / (N+ n), where N= 869 (total number of

children studying in the first and second grades of the public

schools), to obtain a result of 267. Ten percent was added to

this value to cover sample losses and resulted in a total of 294

children to be assessed.16 The sample loss (14%) was greater

than forecast because a great number of children were

excluded, as they did not belong to the age groups studied or

stopped attending the school before the conclusion of the

study. As a result, only 230 children 7 to 8 years of age were

included in the study (Table 1).

Additional exclusion criteria used were the presence of

neuromuscular, musculoskeletal, or heart-respiratory pathol-

ogies (ie, muscle dystrophy, history of fractures, rheumatic

pathologies, asthma); spinal lateral double curvature (11

children); and body mass index (BMI) above the 85th

percentile.17 Students, who participated in institutionally

organized sports or a physical exercise program in addition

to the regular physical education class for more than twice

per week and/or more than 3 hours per week18 were also

excluded because sport can influence posture by causingpermanent adaptations.19

After being given an explanation of the procedure, the

legal representative for the child signed an informed consent

form (Resolution 196/96). The University of So Paulo

ethics committee approved this study.

Procedure

The postural assessment was carried out by taking

photographs of the schoolchildren in the orthostatic position,

from the sagittal and frontal views. The children were

positioned on a wooden base (measurements: 19 cm inheight, 37 cm in width, and 44 cm in length), with their feet

at the same distance from the base midline. The subjects

were tested in the classroom, and efforts were made to

control the temperature, noise, and distractions.

A digital camera (Cyber-shot DSC-P41, 4.1 Mega pixels,

Sony) was rotated and locked at 90 to the horizontal plane to

focus on the subject's body longitudinally and positioned at a

standard distance of 2.40 m from the wooden base at a height

of 1 m. The wooden base was positioned immediately in

front of the simetrgrafo. The upper part of the wooden base

coincided with the bottom of the simetrgrafo. The

photographs were calibrated from the known dimensions

of the wooden base.The reference points cited by Kendall et al1 were used.

The following bone references of each schoolchild were

marked with adhesive dots: anterior superior and posterior

superior iliac spines; cervical (C5 and C7), thoracic3 (T1, T3,

T6, T9, and T12), lumbar3 (L3 and L5), and sacral (S2)

spinous processes; and the inferior angle of the scapula.

Some of these references were also marked with small balls

(diameter of 1 cm): anterior superior and posterior superior

iliac spines and the C7 spinous process.

In an attempt to minimize data collection errors, the

research assistant received comprehensive training to ensure

Table 1. Total number of children assessed according to age and

sex

7-year-olds (6 years

9 months to 7 years

8 months)

8-year-olds (7 years

9 months to 8 years

8 months) Total

Girls 66 64 130

Boys 49 51 100

Total 115 115 230

155Penha et alJournal of Manipulative and Physiological TherapeuticsSpinal Posture in ChildrenVolume 32, Number 2


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correct placement of the anatomical markers, positioning of

the subject, and camera placement.

The photograph file was first imported by CorelDraw,

where the size was increased to measure the angles under

study. Photos taken in the sagittal plane were used for the

measurements of lumbar lordosis, thoracic kyphosis, pelvic

inclination, and head position. For the first 3 measurements,

the child was also photographed with the elbow bent and 1

hand placed on the opposite shoulder level.20

Data Analysis

The angles measured between the bone references were

quantified in degrees and calculated using the CorelDraw v.

11.0 software guidelines help feature, based on the marked

bone references. The same researcher collected all of the data

and the measurements.

Lumbar lordosis. The angle between the upper thoracic

and gluteus region convexity curvature was measured, and

the vertex was the greatest lumbar concavity curvature.12

Th e a ngle used w as suppl em entary t o t he val ue

obtained.21,22 For this measurement, the photograph was

magnified 400 (Fig 1A).

Pelvic inclination. A horizontal line was drawn at the

height of the anterior superior iliac spine, and this was the

vertex of the angle formed between the horizontal line and a

second line drawn upward to the posterior superior iliac

spine.23 For this measurement, the photograph was magni-

fied 600 (Fig 1B).

Thoracic kyphosis. The angle between the upper cervical

and lumbar concavity curvature13,24 was measured, and the

vertex was the greatest thoracic convexity curvature.

However, for children with winged scapula, the lower

angle of the scapula was standardized as the vertex. This

measurement was made twice from the right and left views,

and the average used for the statistical calculation. The angleused was supplementary to the value obtained.21,22 For this

measurement, the photograph was magnified 400 (Fig 1C).

Head posture. The subject was photographed in the

sagittal plane, with the arms hanging down beside the body.

A horizontal line was drawn at C7, and a diagonal line was

drawn to the point where the horizontal line met the spine at

the external auditory meatus3 to calculate the angle between

these 2 lines. For this measurement, the photograph was

magnified 500.

Spinal lateral deviation. For this measurement, the

posterior frontal plane photograph was used (magnified

350) with the subject placed with his arms hanging down

alongside the body. The presence or absence of scoliosiswas assessed by a modification of the Watson and Mac

Donncha method.3 A horizontal line was drawn at the

height of the posterior upper iliac spine, and a vertical one

from the spinous processes.3 A line was then drawn from

the highest vertebra, aligned with the vertical line, parallel

to the horizontal line. The intersection between the lines is

the scoliotic angle vertex, formed between the vertical line

and the second line drawn following the first spinous

process to be deviated. This postural alteration was also

classified according to the location and convex side (right

or left) (Fig 1D).

Fig 1. Measurements of the angles studied. A, Lumbar lordosis(magnification 400); B, pelvic inclination (magnification 600);C, thoracic kyphosis (magnification 400); and D, lateral spinaldeviation (magnification 350).

Table 2. Mean and standard deviations for weight, height, and BMI

according to age and sex

Girls

(7-year-olds)

Girls

(8-year-olds)

Boys

(7-year-olds)

Boys

(8-year-olds)

Weight (kg) 23.54 3.35 26.07 3.62 23.80 3.08 26.62 3.45

Height (m) 1.23 0.06 1.29 0.05 1.24 0.05 1.28 0.05

BMI (kg/m2) 15.44 1.35 15.69 1.55 15.42 1.21 16.12 1.34

Table 3. Mean and standard deviation of the variables analyzed

Measurement Group Mean ()

Standard

deviation

Lumbar lordosis B7 a 38.49 15.32

G7, G8, and B8 a 42.29 7.13

Thoracic kyphosis 7-year-olds 28.07 7.73

8-year-olds 30.32 7.73

Head posture Girls 49.55 6.67

Boys 52.16 7.58

Pelvic inclination All children 15.82 5.46

Lateral spinal deviation All children 3.48 2.12

a B7, 7-year-old boys; G7, 7-year-old girls; G8, 8-year-old girls; and B8,

8-year-old boys.

156 Journal of Manipulative and Physiological TherapeuticsPenha et alFebruary 2009Spinal Posture in Children


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Financial Support

The study was financed by the Fundao de Amparo

Pesquisa do Estado de So Paulo and a student placement

grant.

Statistics

The data were analyzed using descriptive statistics such as

the mean, standard deviation, and percentage. The variables

analyzed showed normal distribution as verified by the

Anderson-Darling test. To detect any possible influence of

sex and age in each of the postural characteristics studied, an

analysis of variance model with 2 factors (sex and age) was

used. The significance level adopted was = 0.05. Microsoft

Excel 2002, Minitab V14, R V2.4.0 (Microsoft Inc,

Redmond, WA), and SAS v8 (Cary, NC) software were

used for the statistical calculations.

RESULTS

Table 2 shows the characteristics of the sample studied.

Only lumbar lordosis showed the influence of both factors

(P = .04). The Tukey-Kramer method was used to compare

the group averages, and it detected that only the group of

7-year-old boys was different from the other groups with

respect to the average lumbar lordosis. The effect of sex was

significant for head posture (P = .001 for both), whereas the

effect of age was significant for thoracic kyphosis (P= .002).

Neither pelvic inclination nor spinal pelvic deviation showed

any influence by either age or sex (PN .05). The results of the

analyses described above were also utilized to define the

confidence intervals for the means of each group (Table 3).

Of the 230 children studied, only 11.3% showed no lateral

spinal deviation. The most common side for this alteration

was to the left (53%), and the proportion of the deviation was

greater for boys (63%) than for girls (45%). Of the students

showing lateral spinal deviation, the most frequent location

for this alteration was thoracic (Fig 2). For children with

lateral spinal deviation to the left, most presented the

deviation in the thoracic (58%) or thoracolumbar (15%)

regions. However, for those showing the deviation to the

right, most presented it in the upper thoracic (49%), thoracic

(24%), or cervical (23%) regions.

DISCUSSION

This study reached its objectives of quantitatively

characterizing the lumbar lordosis, thoracic kyphosis, pelvic

inclination, head posture, and lateral spinal deviation of the

schoolchildren and of verifying possible differences between

the children due to sex and age with respect to the postural

aspects analyzed.

It is very difficult to compare the results of this study with

those found in the literature because other studies aboutpostural assessment in children have either analyzed the

standards and alterations in a qualitative way4,5 or used

different quantitative methodologies.11,21-22,25-38

With respect to lumbar lordosis, different values were

obtained in the present assessment for 7-year-old boys

(38.49 15.32) as compared to the other groups (42.29

7.13). Our results were similar to those of Chernukha et

al,28 who used different methodologies to measure the

lordosis curvature in radiographs of subjects from 1- to 30-

year-olds and found mean values of 40.13 8.84 (Cobb)

and 40.87 6.79 (TRALL) for the 6- to 10 year-old group.

In addition, these same authors28

and Kobayashi et al29

showed that most adults obtain the lumbar angle during the

first year of life after learning to maintain a standing posture,

and the peak then increased in the 11- to 15-year-old

subjects, due to structural changes caused by the puberty

growth spurt, with a tendency to decrease after the seventh

decade of life. Ferreira,23 using software for assessment of

posture for the measurements of the photographs, found

greater values for adults than were found in the present study

for children (47.70 15.44).

In the case of thoracic kyphosis, there was a difference

between the age groups, the 8-year-old children (30.32

7.73) were more kyphotic than the 7-year-olds (28.07

7.73). Mac-Thiong et al,30 using digitalized spine images,

obtained higher values (38.3 9.8) than obtained in the

present study, for children younger than 10. The same

occurred with adults assessed by photogrammetry, whose

average value for thoracic curvature was 55.39 7.36.25

Widhe25 obtained values closer to those obtained in the

present study using the Debrunner kyphometer, obtaining

30.1 8.7 for 5- to 6-year-old boys and 28.4 9.3 for

girls of the same age. According to Cil et al,26 thoracic

kyphosis increased until the age of 10, decreased between the

ages of 10 to 12 years, and then increased from 13 to 15 years

where the kyphosis approximated the amount of lumbar

Fig 2. Distribution of the children according to the location of thelateral spinal deviation and group.

157Penha et alJournal of Manipulative and Physiological TherapeuticsSpinal Posture in ChildrenVolume 32, Number 2


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lordosis. Using radiographs, Loder20 assessed teenagers with

spondylolisthesis and found no differences between sex and

age with respect to the measurements of thoracic kyphosis.

On the other hand Widhe,25 in his longitudinal study,

observed a decrease in thoracic kyphosis with age in fem ales.

This result was similar to that found by Hellsing et al.31 In

addition, Mellin and Poussa,32 using an inclinometer,

detected less thoracic kyphosis in girls than in boys. These

results, however, were different from those found by Fon

et al,33 who used the Cobb method and observed an increase

in thoracic curvature with age and no difference due to sex.

With respect to pelvic inclination, all the groups were

considered to be equal, and the mean value found was 15.82

5.46. Asher10 used the Wiles' inclinometer and measured the

pelvic inclination every 6 months, but the author failed to

describe which bone references were used. The values found

were from 30 to 40 and decreased with growth.10

Head posture differed significantly by sex. Girls showed

smaller angles (49.55 6.67) and greater forward headposition when compared to boys (52.16 7.58). Woodhull

et al34 and Barry-Greb35 found higher average values for the

head anterior position in men than in women, but there was

no significant difference. On the other hand, Harrison et al27

assessed subjects aged between 20 and 45 years using a

methodology similar to that used in the present study and

found significant differences in head position, the men

presenting more forward head position than the women, at

measured values of 49.3 7.

The value estimated for lateral spinal deviation in 88.7%

of the children studied was 3.48 2.12. The most common

side for this deviation was to the left (53%), and the mostcommon location among the 4 groups was thoracic. Loder20

also found the greatest incidence of scoliosis in the thoracic

region, but the most common side was to the right. However,

studies on scoliosis found in the literature measured the

lateral deviation from radiographs using the Cobb Method

and defined scoliosis as the tridimensional alteration of the

spineinvolving vertebral inclination and rotationwith

values greater than 10.20,36 This definition makes it difficult

to compare our results of the present study with those found

in the literature. In addition, because the values found in the

present study were small, they may be attributable to

possible errors in measurement, due to the location of the

anatomical landmarks and any measurements made with

CorelDraw software.

The qualitative postural assessment has been shown to be

less reliable and reproducible37 than photogrammetry, which

has shown good reliability, especially when the measure-

ments were assessed by the same examiner on different

occasions and by different examiners using the same

photograph.15 However, photogrammetry presents some

limitations such as the assessment of posture at a single

instant and plane. In their study, Harrison et al27 showed the

need to assess postural deviation at various points in time and

not from a single photographic registration due to the

anterior-posterior and lateral sway of the subject. McEvoy

and Grimmer11 stated that children had a higher center of

mass at about T12 as compared to L5-S1 in adults.

According to these authors,11 the combination of being

shorter and having a higher center of mass may result in

increased sway in children and greater difficulty in

maintaining static balance. However, the results of their

study did not agree with this hypothesis because there was no

significant difference among the 5 angles when measured

twice within 1 hour.11

The assessment of body segments on a single plane

compromises the analysis of 3-dimensional deviations that

also occur in the transverse plane, such as scoliosis. Some

studies38 have assessed the spine on the 3 planes, especially

to assess scoliosis. However, these same studies used

radiographsan expensive methodology and frequently

impracticable for health and ethical reasons.

CONCLUSIONS

This study reached its objectives of characterizing the

posture of 7- and 8-year-old children from photos and

suggesting quantitative reference values for lumbar lordosis,

thoracic kyphosis, pelvic inclination, head posture, and

lateral spinal deviation according to sex and age for the

population of children assessed. In the sample studied, the

behavior of some of the postural deviations varied according

to sex and age, whereas others were not influenced by either

of these 2 factors. Thus, future controlled longitudinal

studies are necessary to understand appropriate spinal

alignment and development in children.

REFERENCES

1. Kendall FP, McCreary EK, Provance PG. Msculos provas efunes. So Paulo (SP): Editora Manole; 1995.

2. Zatsiorsky VM, Duarte M. Instant equilibrium point and itsmigration in standing tasks: rambling and trembling compo-nents of the stabilogram. Mot Control 1999;3:28-38.

3. Watson AWS, Mac Donncha C. A reliable technique for theassessment of posture: assessment criteria for aspects of

posture. J Sports Med Phys Fitness 2000;40:260-70.

Practical Applications

Postural alterations may be found in children

Some of the variables analyzed differ according to

sex and age

In this study, the 8-year-old children are more

kyphotic than the 7-year-old ones

Girls showed greater head anteriorization than boys

No spinal standard for postural symmetry was

identified in the sample studied.

158 Journal of Manipulative and Physiological TherapeuticsPenha et alFebruary 2009Spinal Posture in Children


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