Reliability and validity of non-radiographic methods of thoracic kyphosis measurement: a systematic review

Intra- and inter-rater reliability of thoracic spine mobility and posture assessments in subjects with thoracic spine pain

Background

The thoracic spine (TS) has been neglected in the study of the spine despite its essential role in the stability and posture of the entire spinal complex. Therefore, there is an inevitable need to investigate the reproducibility of different thoracic spinal posture measures used in subjects with TS pain.

Methods

Thirty-two subjects (16 females and 16 males, mean age 39 years) were evaluated by two physiotherapists on the same day to gauge inter-rater reliability and on two consecutive days to gauge intra-rater reliability. TS posture was assessed by observation, and thoracic spine mobility was measured by manual assessment of segmental flexion and extension mobility in a seated position. Additionally, posterior-to-anterior accessory mobility in a prone position was assessed manually. Moreover, cervicothoracic flexion in a seated position, thoracic posture, and thoracic flexion and extension mobility in a standing position were assessed with a tape measure, and flexion and extension mobility in a seated position and TS posture in seated and standing positions were measured with an inclinometer. The intraclass correlation coefficient (ICC), standard error of measurement (SEM), mean difference (MD), Bland-Altman (B&A) plot features and coefficient of repeatability (CR) were calculated.

Results

The mean and standard deviation (SD) of the duration of TS pain was 22 (SD 45) months, with the intensity of pain being rated at 27 (SD 21) mm on a visual analogue scale (VAS). Intra-rater reliability was very strong (ICC ≥ 0.80) for the evaluation of seated and standing upper TS posture, standing whole TS posture and seated lower TS posture with an inclinometer. Moreover, TS posture evaluation with a measuring tape, posture inspection in a seated position, and manual assessment of segmental extension were found to have very strong intra-rater reliability. Inter-rater reliability was very strong for inclinometer measurements of standing and seated upper TS posture as well as standing whole TS posture.

Conclusion

Intra-rater reliability was higher than inter-rater reliability in most of the evaluated measurements. Overall, posture measurements with an inclinometer were more reliable than mobility measurements with the same instrument. The manual assessments can be used reliably when same evaluator performs the examination.

Trial registration

Clinical Trials, NCT01884818. Registered 24 June 2013, https://clinicaltrials.gov/ct2/show/NCT01884818?cond=thoracic+spine&cntry=FI&rank=1

Mobile Applications for Assessing Human Posture: A Systematic Literature Review

Smartphones are increasingly incorporated with features such as sensors and high resolution cameras that empower their capabilities, enabling their use for varied activities including human posture assessments. Previous reviews have discussed methods used in postural assessment but none of them focused exclusively on mobile applications. This paper systematically reviews mobile applications proposed for analyzing human posture based on alignment of the body in the sagittal and coronal plane. The main digital libraries were searched, 26 articles published between 2010 and 2020 were selected, and 13 mobile applications were identified, classified and discussed. Results showed that the use of mobile applications to assist with posture assessment have been demonstrated to be reliable, and this can contribute to clinical practice of health professionals, especially the assessment and reassessment phases of treatments, despite some variations when compared to traditional methods. Moreover, in the case of image-based applications, we highlight the advantage that measurements can be taken with the assessor at a certain distance with respect to the patient’s position, which is an important function for assessments performed in pandemic times such as the outbreak of COVID-19.

Concurrent Validity of Digital Image-based Postural Assessment as a Method for Measuring Thoracic Kyphosis: A Cross-Sectional Study of Healthy Adults

OBJECTIVE

To analyze the concurrent validity of the Digital Image-based Postural Assessment (DIPA) method for identifying the magnitude and classification of thoracic kyphosis in adults.

METHODOLOGY

On the same day and in the same place, thoracic kyphosis was assessed in 68 adults using 2 methods: the DIPA software protocol and radiography. The DIPA software provided angular values of thoracic kyphosis based on trigonometric relations, while with the radiograph, the curvature was calculated using the Cobb method. The following tests were applied in the statistical analysis: Pearson's correlation, Bland-Altman's graphic representation, root mean square error, and receiver operating characteristic (ROC) curve; α = 0.05. The reference angular values for the standard thoracic posture used in DIPA were determined with the ROC curve based on the Cobb angles.

RESULTS

The correlation between the angles obtained for thoracic kyphosis using the DIPA and Cobb methods was found to be high (r = 0.813, P < .001), and the accuracy was ±4°. According to Bland-Altman's representation, the magnitudes provided by the DIPA software were in agreement with those of the Cobb method. In reference values for determining the standard posture of the thoracic spine, the ROC curve indicated good accuracy in diagnosing a decrease in thoracic kyphosis (with a value of 33.9°) and excellent accuracy in diagnosing thoracic hyperkyphosis (with a value 39.9°) when using DIPA.

CONCLUSION

The DIPA postural assessment method is valid in the sagittal plane for identifying the magnitude of thoracic kyphosis in adults. Furthermore, it is accurate in diagnosing alterations in thoracic kyphosis.

Reliability and validity of lateral curvature assessments using clinical ultrasound for the patients with scoliosis: a systematic review

PURPOSE

Clinical ultrasound is radiation-free, low cost and user friendly, which makes it probable in assessment of scoliosis. Numerous studies have been conducted about the feasibility of using clinical ultrasound to assess scoliosis; thus, an inclusive review of the literature would be beneficial for researchers, clinicians and patients. This study aimed to systematically review the reliability and validity of coronal curvature assessments obtained from different clinical ultrasound imaging methods.

METHODS

A comprehensive search of 6 databases and Google Scholar search engine was performed for retrieving articles assessing reliability and/or validity of spinal curvature measurements obtained from clinical ultrasound. Two reviewers assessed the methodological quality of selected articles independently using criteria appraisal instrument. The results were analysed and synthesized qualitatively using level of evidence method.

RESULTS

Fourteen articles were included. Thirteen articles investigated both the reliability and validity, of which nine were of high quality; and one article evaluated only the reliability and was of high quality. Totally five ultrasound methods were evaluated. Very high reliability (intra-class correlation coefficient = 0.80-1.00) but limited levels of evidence were found for the majority of the studied ultrasound methods. Almost all the methods showed good to excellent validity (correlation coefficient = 0.76-1.00) but limited to moderate levels of evidence.

CONCLUSION

A high level of evidence was found in support of the reliability and validity of the COL (centre of lamina) ultrasound method. Further reliability and validity studies should be conducted to strengthen the level of evidence for those ultrasound methods with moderate, limited or conflicting level of evidence. These slides can be retrieved under Electronic Supplementary Material.

Which is the best-suited landmark to assess the thoracic orientation?

Several skin surface-based techniques exist to non-invasively determine the spinal kinematics. However, the accuracy of these techniques is limited by soft-tissue artefacts. Furthermore, structures like the thorax are frequently assumed to be rigid but display considerable mobility within itself. This study aimed to quantify the accuracy at different thoracic landmarks for measuring mobility in healthy individuals during different activities to provide a recommendation for the best suited measurement location. The locations of 29 landmarks were continuously captured on 19 individuals (age: 25-59 years) during sitting, standing, walking, jumping, intra-thoracic motions, and different breathing depths using reflective markers. Marker triplets were used at every landmark to calculate their orientations by first backtracking the rigid-body motion (RBM) of the thorax in general, and subsequently calculating the RBM of each rigid marker triplet. Of the latter, the maximum axis angle for each exercise was statistically evaluated. Landmarks at the middle of the clavicles displayed the largest overall errors (approximately 90° during worst case scenario). However, the variability of errors among the investigated exercises was large. Landmarks at the cranial sternal region (particularly at the "Louis angle") and at the T3 spinous process showed the smallest errors for all subjects and tasks (e.g., <5° and <11°, respectively, during normal breathing). When only one sensor is to be used, it is recommended to use the cranial sternal region to assess the thoracic orientation. Study results highly sensitive to thoracic orientation should be considered with care or performed using more appropriate methods.

The effectiveness of a comprehensive corrective exercises program and subsequent detraining on alignment, muscle activation, and movement pattern in men with upper crossed syndrome: protocol for a parallel-group randomized controlled trial

Background

Upper crossed syndrome (UCS) refers to specific altered muscle activation and changed movement patterns along with some postural deviations in the upper quarter of the body. This syndrome might contribute to the dysfunction of the cervicothoracic and glenohumeral joints.

Objectives

The present study will aim to investigate the effectiveness of a comprehensive corrective exercises program (CCEP) and subsequent detraining on alignment, muscle activation and movement pattern in men with UCS.

Methods/design

This is a parallel-group randomized controlled trial. Participants will be 22 men aged 18 to 28 years who are suffering from UCS. Participants in the intervention group will conduct CCEP (three times a week for 8 weeks), followed by 4 weeks of detraining. The control group will do their daily activities. Participants will be randomized (1:1) into the intervention or the control group. The primary outcome will be upper trapezius activations. Secondary outcomes consist of electromyography of middle and lower trapezius and serratus anterior muscles, scapular dyskinesis test, forward head and shoulder angles, thoracic kyphosis angle, and neck flexion pattern test.

Discussion

We propose to evaluate the effectiveness of a randomized controlled trial of a CCEP in men with UCS on their alignment, selected muscle activations, and relevant movement patterns. Results from our trial may provide new insights into the effects of exercise not only on the alignment but also on muscle activation and movement patterns that are important outcomes for people with postural malalignments and, if successful, could assist therapists in evidence-based clinical decision-making.

Trial registration

Iranian Registry of Clinical Trials, IRCT20181004041232N1. Registered on 26 October 2018.

Psychometric Properties of the iHandy Level Smartphone Application for Measuring Lumbar Spine Range of Motion and Lordosis: A Systematic Review of the Literature

CONTEXT

Advent of smartphones has brought a wide range of clinical measurement applications (apps) within the reach of most clinicians. The vast majority of smartphones have numerous built-in sensors such as magnetometers, accelerometers, and gyroscopes that make the phone capable of measuring joint range of motion (ROM) and detecting joint positions. The iHandy Level app is a free app which has a visual display alike with the digital inclinometer in regard to numeric size.

OBJECTIVE

The purpose of this systematic review was to evaluate available evidence in the literature to assess the psychometric properties (ie, reliability and validity) of the iHandy Level app in measuring lumbar spine ROM and lordosis.

METHODS

PubMed/MEDLINE, Scopus, Ovid, Google Scholar, and ScienceDirect were searched from inception to September 2018 for single-group repeated-measures studies reporting outcomes of lumbar spine ROM or lordosis in adult individuals without symptoms of low back pain (LBP) or patients with LBP. The quality of each included study was assessed using the Quality Appraisal of Reliability Studies checklist.

RESULTS

A total of 4 studies with 273 participants were included. Two studies focused on measuring active lumbar spine ROM, and 2 studies evaluated lumbar spine lordosis. Three studies included asymptomatic subjects, and one study recruited patients with LBP. The results showed that the iHandy Level app has sufficient psychometric properties for measuring standing thoraco-lumbo-sacral flexion, extension, lateral flexion, isolated lumbar spine flexion ROM, and lumbar spine lordosis in asymptomatic subjects. One study reported poor concurrent validity with a bubble inclinometer (r = .19-.53), poor intrarater reliability (intraclass correlation coefficient = .19-.39), and poor to good interrater reliability (intraclass correlation coefficient = .24-.72) for the measurement of active lumbar spine ROM using the iHandy Level app in patients with LBP.

CONCLUSIONS

This review provided a valuable summary of the research to date examining the psychometric properties of the iHandy Level app for measuring lumbar spine ROM and lordosis.

Clinical phenotypes based on clinical prognostic factors in patients with secondary hip osteoarthritis: preliminary findings from a prospective cohort study

OBJECTIVES

Recently, several clinical prognostic factors for hip osteoarthritis (OA) progression such as spinal malalignment, reduced spinal mobility, and excessive daily cumulative hip loading have been identified. This study aimed to identify clinical phenotypes based on clinical prognostic factors in patients with secondary hip OA using data from prospective cohort studies and to define the clinical features of each phenotype.

METHODS

Fifty patients participated. Two-step cluster analysis was performed to identify the phenotypes using the following potential prognostic factors for hip OA progression: spinal inclination in standing, thoracolumbar spine mobility, daily cumulative hip moment, and minimum joint space width (JSW) at baseline. Comprehensive basic and clinical features (age, body mass index, hip pain, Harris hip score, JSW, radiographic hip morphology, hip impairments, spinal alignment and mobility, and gait-related variables) and ratio of progressors in 12 months were compared among the phenotypes using bootstrap method (unadjusted and adjusted for age).

RESULTS

Three phenotypes were identified and each phenotype was characterized as follows (P < 0.05): phenotype 1 (30%)-relatively young age and higher daily cumulative hip loading; phenotype 2 (42.0%)-relatively older age, reduced JSW, and less spinal mobility; and phenotype 3 (28.0%)-changed thoracic spine alignment and less spinal (especially in the thoracic spine) mobility. The ratio of progressors among the phenotypes was not statistically significantly different. These characteristics remained after adjustment for age.

CONCLUSION

Three phenotypes with similar progression risk were identified. This finding will help in designing treatment tailored to each phenotype for hip OA progression prevention.Key Points• Three phenotypes with similar progression risk were identified based on clinical prognostic factors.• Phenotype 1 was characterized by young age and higher daily cumulative hip loading.• Phenotype 2 was relatively old age and had reduced JSW and less spinal mobility.• Phenotype 3 had changed thoracic spine alignment and less thoracic spine mobility.

Spinal sagittal alignment, spinal shrinkage and back pain changes in office workers during a workday

Purpose. Prolonged sitting is a risk factor for the appearance of lower back pain during work. The aim of this study was to observe changes in spinal sagittal alignment, height and the perception of back pain in office workers during a workday. Materials and methods. Forty-one office workers (20 women) were enrolled into a cross-sectional study. Height, sitting height and degrees of thoracic kyphosis and lumbar lordosis as well as perceived neck pain, lower back pain and upper back pain were determined, before and after an 8-h workday. Results. At the end of the day, workers had a significant decrease (p = 0.000) in height and sitting height, and upper back pain increased significantly (p = 0.023). In men, spinal shrinkage correlated with neck pain (r = 0.410, p = 0.027), and lumbar lordosis degrees in women correlated negatively with upper back pain at the end of the day (r = -0.440, p = 0.012). Conclusions. Spinal shrinkage equally affects men and women who perform the same work. There are no changes in spinal sagittal alignment throughout the workday in office workers. Office workers show significantly increased pain in the upper back at the end of the day.

Effect of Global Postural Reeducation Exercise on Pain and Hip Muscle Flexibility in Patients with Chronic Low Back Pain and Movement Control Dysfunction

Introduction: Patients with non-specific low back pain (NSLBP) and movement control dysfunction demonstrate alternation in hip muscles flexibility and spinal movement patterns. Therapeutic modalities that augment hip muscles flexibility could help these patients. The aim of this study was to investigate the effect of global postural reeducation (GPR) on pain and hip muscle flexibility in patients with NSLBP and movement control dysfunction. Materials and Methods: A total of 27 men with a mean age of 31.21±2.5147 years, height of 166.44±6.11 cm, and weight of 64.21±5.25 kg participated in this study. The visual analogue scale (VAS) was used to evaluate pain. The flexibility of hip muscles (rectus femoris, tensor fasciae latae, external rotators and hamstring) was measured using universal goniometer. All data were assessed at baseline and after the intervention. The Shapiro-Wilk test and paired t test were used for statistical analysis at significance level of P=0.05. Results: Our results revealed a decline in pain (P<0.004) and an increase in the flexibility of the hamstring muscles in the right (P<0.003) and left (P<0.003) legs. There were no statistically significant differences in the flexibility of rectus femoris muscle, external rotators, and tensor fasciae latae. Conclusion: The results suggest that GPR had a significant effect on the level of pain. Further, it affected the flexibility of hamstring muscles in legs. Using GPR is recommended for pain relief and improving the flexibility of hamstring muscles in patients with NSLBP.

Risk factors of low back pain and the relationship with sagittal vertebral alignment in Tanzania

Background

LBP is a common and serious problem affecting vast populations of the world. However, only few studies on LBP in sub-Saharan Africa have been conducted. Studies report that LBP and pelvic angle are interrelated, and African residents have a high pelvic tilt. The strategy to prevent LBP should focus on activities that promote holistic health. For that purpose, it is important to grasp the state of LBP and how it affects people’s lifestyle in Tanzania to clarify the direction of implementation of physiotherapy treatment and reduce the incidences of LBP among adults. This study aimed to investigate the prevalence and presentation of low back pain (LBP) and the relationship between anthropometric measurements and LBP among people in Moshi city, Kilimanjaro region Tanzania.

Methods

Following signing consent forms, participants were given questionnaires regarding LBP and then grouped accordingly into either asymptomatic or symptomatic cohorts. Anthropometric measurements of participants’ height, weight, curvature of the spine, and pelvic angle were obtained.

Results

A Mann-Whitney U test analysis showed a significant difference in pelvic angle, body mass index (BMI), and thoracic kyphosis angle between the asymptomatic group and the symptomatic group. No significant differences in lumbar lordosis angle or abdominal muscle strength were found between the two groups.

Conclusions

A person with symptomatic LBP in Tanzania has a large anteversion of the pelvic tilt and a thoracic kyphotic posture. This study shows a relationship between sagittal spinal alignment and LBP in Tanzania, which could allow for prospective identification of subjects prone to developing LBP in the future.

Spinal shrinkage, sagittal alignment and back discomfort changes in manufacturing company workers during a working day

Prolonged standing and lifting heavy loads are risk factors for the appearance of low back pain in work. The aim of this study was to observe changes in the height, spinal sagittal alignment, and the lumbar and dorsal discomfort perception in assembly line workers. Cross-sectional study, 40 assembly line workers (6 females). Height, sitting height, grades of thoracic kyphosis and lumbar lordosis and perceived spine discomfort, before and after the working day, were determined. Thoracic and lumbar sagittal alignment was compared between discomfort developers and no developers. There was a significant decrease in the height and sitting height of the workers at the end of the day. Thoracic and lumbar curvature increased significantly, as did the perceived lumbar discomfort. Workers on the assembly line, in a prolonged standing work, suffer an increase in lumbar discomfort, and changes in height and thoracic and lumbar curvatures. Practitioner summary: Spinal shrinkage, sagittal alignment and back discomfort (upper and lower back), were analysed in assembly line workers in prolonged standing during a workday. Assembly line workers suffer a decrease in height, an increase in their thoracic and lumbar curvature, and in lumbar discomfort throughout their workday.

A comparison of sagittal spine deformities among elementary school students using spinal mouse device

BACKGROUND

Sagittal spine curvature deformities are common among elementary school students due to long malposition and lack of physical activity.

OBJECTIVES

This study aims to compare sagittal spine deformities among first graders (young and elder school students) in elementary schools.

METHODS

The sagittal spinal curvatures of 45 young school students aged 5-7 years and 50 elder school students aged 9-11 years were examined by using spinal mouse device.

RESULTS

Independent sample t-test shows statistically significant differences in sagittal spinal deformities with increased thoracic kyphosis and spinal flexion in young children than elder children (P = .000, t = 10.72). However, young children show lesser lordosis than elder children (P = .001, t = -4.47). In addition, the young children established a higher significant coefficient of compensation (CC) than elder children (P = .000 t = 12.58).

CONCLUSION

The results suggest that the forward flexion of the trunk is more common among young children than elder children. This may be attributed to differences in postural awareness and way of sitting among students of elementary school. So, it is recommended to encourage the proper postures among students of first graders especially young children.

Thoracic kyphosis assessment in postmenopausal women: an examination of the Flexicurve method in comparison to radiological methods

The Flexicurve ruler is an alternative method to radiographs for measuring thoracic kyphosis (curvature), but it is not certain that it is comparable. This study shows that Flexicurve can estimate radiographic vertebral centroid angles with less error than Cobb angles but that its accuracy would be inadequate for most clinical purposes.

INTRODUCTION

The Flexicurve ruler provides a non-radiological method of measuring thoracic kyphosis (TK) that has moderately strong correlations with the gold-standard radiographic Cobb angle method, while consistently underestimating the TK angle. Cobb angles can include measurement errors that may contribute to poor agreement, particularly in older populations. The vertebral centroid angle could be a better radiographic reference method for the validation of Flexicurve. Using two separate radiographic measurements of TK, we examined the validity of Flexicurve. We aimed to ascertain the level of agreement between measures and to empirically explore reasons for between-method differences.

METHODS

TK angles determined using Flexicurve and radiographic Cobb and vertebral centroid methods were compared using data from 117 healthy postmenopausal women (mean (SD) age 61.4 (7.0) years). Bland and Altman plots were used to assess differences between methods. Age, bone mineral density and body mass index were examined as characteristics that might explain any differences.

RESULTS

Flexicurve angles were scaled prior to analysis. There was no statistically significant difference between angles produced by Flexicurve and vertebral centroid methods (MD - 2.16°, 95%CI - 4.35° to 0.03°) although differences increased proportionally with TK angles. Flexicurve angles were significantly smaller than radiographic Cobb angles and depending on the scaling method used, systematic error ranged between - 2.48° and - 5.19°. Age accounts for some of the differences observed (R² < 0.08, p < 0.005).

CONCLUSIONS

TK measured using the Flexicurve shows better agreement with the radiographic vertebral centroid method, but inaccuracy of the Flexicurve increases with increasing angle of kyphosis.

Validity and reliability of speed tests used in soccer: A systematic review

Introduction

Speed is an important prerequisite in soccer. Therefore, a large number of tests have been developed aiming to investigate several speed skills relevant to soccer. This systematic review aimed to examine the validity and reliability of speed tests used in adult soccer players.

Methods

A systematic search was performed according to the PRISMA guidelines. Studies were included if they investigated speed tests in adult soccer players and reported validity (construct and criterion) or reliability (intraday and interday) data. The tests were categorized into linear-sprint, repeated-sprint, change-of-direction sprint, agility, and tests incorporating combinations of these skills.

Results

In total, 90 studies covering 167 tests were included. Linear-sprint (n = 67) and change-of-direction sprint (n = 60) were studied most often, followed by combinations of the aforementioned (n = 21) and repeated-sprint tests (n = 15). Agility tests were examined fewest (n = 4). Mainly based on construct validity studies, acceptable validity was reported for the majority of the tests in all categories, except for agility tests, where no validity study was identified. Regarding intraday and interday reliability, ICCs>0.75 and CVs<3.0% were evident for most of the tests in all categories. These results applied for total and average times. In contrast, measures representing fatigue such as percent decrement scores indicated inconsistent validity findings. Regarding reliability, ICCs were 0.11–0.49 and CVs were 16.8–51.0%.

Conclusion

Except for agility tests, several tests for all categories with acceptable levels of validity and high levels of reliability for adult soccer players are available. Caution should be given when interpreting fatigue measures, e.g., percent decrement scores. Given the lack of accepted gold-standard tests for each category, researchers and practitioners may base their test selection on the broad database provided in this systematic review. Future research should pay attention to the criterion validity examining the relationship between test results and match parameters as well as to the development and evaluation of soccer-specific agility tests.

Impact of wearable physical activity monitoring devices with exercise prescription or advice in the maintenance phase of cardiac rehabilitation: systematic review and meta-analysis

BACKGROUND

Physical activity (PA) is a component of cardiac rehabilitation (CR). However, life-long engagement in PA is required to maintain benefits gained. Wearable PA monitoring devices (WPAM) are thought to increase PA. There appear to be no reviews which investigate the effect of WPAM in cardiac populations. We firstly aimed to systematically review randomised controlled trials within the cardiac population that investigated the effect WPAM had through the maintenance phase of CR. We specifically examined the effect on cardiorespiratory fitness (CRF), amount and intensity of daily PA, and sedentary time. Secondly, we aimed to collate outcome measures reported, reasons for drop out, adverse events, and psychological impact from utilising a WPAM.

METHODS

A systematic search (up to January 2019) of relevant databases was completed, followed by a narrative synthesis, meta-analysis and qualitative analysis.

RESULTS

Nine studies involving 1,352 participants were included. CRF was improved to a greater extent in participants using WPAM with exercise prescription or advice compared with controls (MD 1.65 mL/kg/min;95% confidence interval [CI; 0.64-2.66]; p = 0.001; I2 = 0%). There was no significant between group difference in six-minute walk test distance. In 70% of studies, step count was greater in participants using a WPAM with exercise prescription or advice, however the overall effect was not significant (SMD 0.45;95% [CI; - 0.17-1.07] p = 0.15; I2 = 81%). A sensitivity analysis resulted in significantly greater step counts in participants using a WPAM with exercise prescription or advice and reduced the heterogeneity from 81 to 0% (SMD 0.78;95% [CI;0.54-1.02]; p < 0.001; I2 = 0%). Three out of four studies reporting on intensity, found significantly increased time spent in moderate and moderate-vigorous intensity PA. No difference between groups was found for sedentary time. Three of six studies reported improved psychological benefits.No cardiac adverse events related to physical activity were reported and 62% of non-cardiac adverse events were primarily musculoskeletal injuries. Reasons for dropping out included medical conditions, lack of motivation, loss of interest, and technical difficulties.

CONCLUSIONS

Our meta-analysis showed WPAM with exercise prescription or advice are superior to no device in improving CRF in the maintenance phase of CR and no cardiac adverse events were reported with WPAM use. Our qualitative analysis showed evidence in favour of WPAM with exercise prescription or advice for both CRF and step count. WPAM with exercise prescription or advice did not change sedentary time. Psychological health and exercise intensity may potentially be enhanced by WPAM with exercise prescription or advice, however further research would strengthen this conclusion.

TRIAL REGISTRATION

PROSPERO Registration Number: CRD42019106591.

Back Muscle Function in Older Women With Age-Related Hyperkyphosis: A Comparative Study

OBJECTIVE

The purpose of this study was to compare static maximal back extensor muscle force, endurance, and characteristics of flexion relaxation phenomenon (FRP) in older women with and without age-related hyperkyphosis.

METHODS

Maximum back extensor force and endurance measured in a sitting position with a designed load cell setup; appearance, onset, and offset angles of FRP; and extension relaxation ratio (ERR) during a dynamic flexion-extension task were compared between 24 older women with hyperkyphosis (thoracic kyphosis angle ≥50°), mean age 65 ± 4.4 years, and 24 older women without hyperkyphosis (thoracic kyphosis angle ≪50°), mean age 63 ± 4.3 years. Variables of force, endurance, angles of FRP, and ERR were analyzed using an independent sample t test. A χ² test was used to identify differences between groups in FRP appearance.

RESULTS

Static back extensor force and endurance were significantly lower among those with versus those without hyperkyphosis (P ≪ .001). Although the 2 groups did not differ in FRP appearance and ERR in the superficial erector spinal muscles (P ≫ .05), FRP in the hyperkyphosis group started sooner and ended later than in the group without hyperkyphosis (P ≪ .05).

CONCLUSION

Our study indicates that women with age-related hyperkyphosis had decreased static maximal force and endurance of the back extensor muscles and prolonged myoelectrical silence of the superficial erector spinal muscles. Reduced endurance of the superficial erector spinal muscles may trigger early onset of FRP and prolonged relaxation of these muscles.

Green exercise and mg-ca-SO4 thermal balneotherapy for the treatment of non-specific chronic low back pain: a randomized controlled clinical trial

BACKGROUND

Non-specific chronic low back pain (nscLBP) has a high socio-economic relevance due to its high incidence, prevalence and associated costs. Therefore, it is essential to evaluate effective therapeutic strategies. This study examines the effects of moderate mountain exercise and spa therapy on orthopedic and psychophysiological parameters. Based on a three-armed randomized controlled trial, guided mountain hiking tours and balneotherapy in thermal water were compared to a control group.

METHODS

Eighty patients with diagnosed nscLBP were separated into three groups: The two intervention groups GE (green exercise) and GEBT (green exercise and balneotherapy) undertook daily mountain hiking tours, whereas the GEBT group got an additional treatment with baths in Mg-Ca-SO₄ thermal water. The third group (CO) received no intervention. GE and GEBT group were treated for 6 days; all groups were followed up for 120 days.

RESULTS

Compared to GE and CO group, the GEBT treatment showed significant improvements of pain, some orthopedic parameters, health-related quality of life and mental well-being in patients with nscLBP.

CONCLUSIONS

The results of this study confirmed a benefit of mountain hiking combined with Mg-Ca-SO₄ spa therapy as a multimodal treatment of patients with nscLBP. Further studies should focus on long-term-effects of this therapeutic approach.

TRIAL REGISTRATION

ISRCTN, ISRCTN99926592 . Registered 06. July 2018 - Retrospectively registered.

Reliability and validity of clinically accessible smartphone applications to measure joint range of motion: A systematic review

Measuring joint range of motion is an important skill for many allied health professionals. While the Universal Goniometer is the most commonly utilised clinical tool for measuring joint range of motion, the evolution of smartphone technology and applications (apps) provides the clinician with more measurement options. However, the reliability and validity of these smartphones and apps is still somewhat uncertain. The aim of this study was to systematically review the literature regarding the intra- and inter-rater reliability and validity of smartphones and apps to measure joint range of motion. Eligible studies were published in English peer-reviewed journals with full text available, involving the assessment of reliability and/or validity of a non-videographic smartphone app to measure joint range of motion in participants >18 years old. An electronic search using PubMed, Medline via Ovid, EMBASE, CINAHL, and SPORTSDiscus was performed. The risk of bias was assessed using a standardised appraisal tool. Twenty-three of the eligible 25 studies exceeded the minimum 60% score to be classified as a low risk of bias, although 3 of the 13 criteria were not achieved in >50% of the studies. Most of the studies demonstrated adequate intra-rater or inter-rater reliability and/or validity for >50% of the range of motion tests across all joints assessed. However, this level of evidence appeared weaker for absolute (e.g. mean difference ± limit of agreement, minimal detectable change) than relative (e.g. intraclass correlation, correlation) measures; and for spinal rotation than spinal extension, flexion and lateral flexion. Our results provide clinicians with sufficient evidence to support the use of smartphones and apps in place of goniometers to measure joint motion. Future research should address some methodological limitations of the literature, especially including the inclusion of absolute and not just relative reliability and validity statistics.

Gait- and Posture-Related Factors Associated With Changes in Hip Pain and Physical Function in Patients With Secondary Hip Osteoarthritis: A Prospective Cohort Study

OBJECTIVE

To identify gait- and posture-related factors associated with changes in hip pain and physical function in patients with hip osteoarthritis (OA).

DESIGN

Prospective cohort study.

SETTING

Clinical biomechanics laboratory of a university.

PARTICIPANTS

Consecutive sampling of female patients with mild-to-moderate secondary hip OA (N=30).

MAIN OUTCOME MEASURES

Hip pain (visual analog scale) and physical function (physical component summary of the Medical Outcomes Study 36-Item Short-Form Health Survey) were measured at baseline and 12 months later. With changes in hip pain and physical function as dependent variables, linear regression analyses were performed with gait- and posture-related factors as independent variables with and without adjustment for age, joint space width, and hip pain or physical function at baseline. Posture-related factors included angles of thoracic kyphosis, lumbar lordosis, sacral inclination, spinal inclination, and spinal mobility. Gait-related factors were walking speed, steps per day, joint angles, external hip joint moment impulses, and daily cumulative hip moments.

RESULTS

Multiple linear regression analyses showed that limited hip extension (adjusted standardized B coefficient [95% confidence interval]: -0.52 [-0.88 to -0.17]) and limited external rotation angles (-0.51 [-0.85 to -0.18]) during walking were associated with the worsening of hip pain. An increased thoracic kyphosis (-0.54 [-0.99 to -0.09]), less sacral anterior tilt (0.40 [0.01-0.79]), reduced thoracic spine mobility (0.59 [0.23-0.94]), less steps per day (0.53 [0.13-0.92]), and a slower walking speed (0.45 [0.04-0.86]) were associated with deterioration in physical function.

CONCLUSIONS

Gait- and posture-related factors should be considered when assessing risk and designing preventive interventions for the clinical progression of secondary hip OA.

Effects of exercise programs on kyphosis and lordosis angle: A systematic review and meta-analysis

Many authors are interested in the effects that a specific exercise program could have on sagittal spinal curvatures. The purpose of this study was to determine the effects of different exercise programs on thoracic kyphosis and lumbar lordotic angle. This meta-analysis adhered to the PRISMA guideline and it was registered at PROSPERO. Five electronic databases (Pub Med, Cochrane, WOS, PEDro and EBSCO) were searched up to 31 July 2018. Eligible studies were randomized controlled trials that applied an exercise intervention and measured a kyphosis and/or lordotic angle. Study quality was performance by PEDro score. Risk of bias was assessed using the SIGN 50 checklist for randomized controlled trials. External validity was assessed using the EVAT. Ten randomized controlled trials were included for systematic review and meta-analysis. Meta-analysis with a random effect model was performed to infer the pooled estimated standardized mean difference. All studies were RCTs and they involved a total of 284 cases and 255 controls. Seven studies measured kyphosis angle. A large significant effect of the exercise on kyphosis was identified (SMD = -1.400 (95% CI-2.150 a -0.660), p = 0.000). Four studies assessed lordotic angle and moderate but not significant improvement was shown (SMD = -0.530 (95% CI-1.760 a -0.700), p = 0.401). The results suggest that exercise programs may have a positive effect on thoracic kyphosis angle, but no clear effect on lordotic angle. This systematic review suggests that strengthening rather than stretching could be more relevant for kyphosis and both qualities are important for lordosis. It is necessary to conduct more randomized controlled trials to assess the effects of strengthening and/or stretching program on kyphosis and lordotic angle and to establish the type of the exercise that is better for maintaining the sagittal disposition within normal ranges.

Prevalence of Musculoskeletal Disorders Symptoms Among Czech Dental Students. Part 2: The Predictive Value of Digital Assessment

This article is the second part of an evaluation of musculoskeletal disorders (MSDs) prevalence among dental students. As the majority of complaints are in the back region, there is an endeavor to analyze objectively the disorders in this region. One of the non-invasive and non-radiation methods is the spinal curve mapping using the Spinal Mouse® device (Idiag AG, Fehraltorf, Switzerland). The aim of this study was to determine a correlation between subjectively described complaints and the results of an objective examination of the spine using the Spinal Mouse® device. Information about the participants is given in the first part of the article. All the participants were examined with the Spinal Mouse® device in several body positions. Further, the Matthiass test was performed to evaluate neuromuscular stabilization of the axial skeleton in static conditions. Musculoskeletal pain occurred more often in students who had a higher range of motion (ROM) and had worse static stabilization of spine. Other assessed factors or measured parameters did not have any influence on musculoskeletal pain. Some of the parameters measured with the Spinal Mouse® device showed a correlation with the prevalence of musculoskeletal.

Assessment of Spinal Curvatures in Children With Upper Trunk Obstetrical Brachial Plexus Palsy

PURPOSE

Effects of upper trunk obstetrical brachial plexus palsy (OBPP) on the spinal curvature and relationship between the curvature degrees and upper limb movements have not been reported.

METHODS

Spinal Mouse was used to assess spinal curvature characteristics in the sagittal and frontal planes. Upper limb movements were assessed with using the Active Movement Scale in only study group.

RESULTS

The degree of frontal plane curvatures was higher in the study group. In the OBPP group, 11 of 25 (44%) children had thoracal C-shaped scoliosis. Nine of these children had contralateral side scoliosis. Shoulder external rotation was inversely correlated with scoliosis angle. Moreover, shoulder external rotation and elbow flexion were lower in children with scoliosis in the OBPP group.

CONCLUSIONS

Upper trunk OBPP may affect frontal plane alignment. Especially insufficient shoulder external rotation scores may lead to constitute thoracal scoliosis as a result of trunk compensation.

Association between visual classification of kyphosis and future ADL decline in community-dwelling elderly people: the Kurabuchi study

This cohort study conducted in Japan showed that severe age-related kyphosis was visually detected. The visual assessment of kyphosis was associated with declines in ADL, suggesting that we can easily identify people at high risk to develop future ADL reduction in the community setting.

PURPOSE

Age-related kyphosis is related with declines in activities of daily living (ADL). Its conventional diagnosis has been made by orthopedic surgeons and trained examiners using specialized equipment such as X-rays. We investigated whether visual classification of kyphosis by laypersons accurately predicted future ADL decline.

METHODS

This study was part of the Kurabuchi Study, a cohort study of community-dwelling elderly Japanese. Between 2009 and 2010, three layperson raters used reference illustrations to classify 532 participants without ADL decline at study baseline into four categories. Other examiners used conventional methods to assess kyphosis in the same participants: curve ruler, Spinal Mouse, and the block method. ADL decline was defined as the development of dependence according to the Katz Index, admission to a nursing home, or certification of long-term care need.

RESULTS

Thirty-five of the participants (6.6%) were classified with the most severe degree of kyphosis at baseline by visual assessment. Interrater agreement was high (Kappa = 0.73) for the most severe group. During 4.5 years of follow-up, 106 participants (19.9%) showed ADL decline. On the basis of visual assessment, the adjusted risk ratio for ADL decline among the participants with the most severe kyphosis was 2.6 (95% CI: 1.4-4.6). Assessments of kyphosis made with the Spinal Mouse also accurately predicted ADL decline.

CONCLUSIONS

Visual assessment of kyphosis predicted future declines in ADL in this study. Since our method requires no special tools or training, it may be useful for identifying those at high risk of ADL decline.

Reliability and validity of non-radiological measures of thoracic kyphosis in chronic obstructive pulmonary disease

Background/Aims:

Thoracic kyphosis in people with chronic obstructive pulmonary disease can be measured from digital photogrammetry or three-dimensional motion capture. This study aimed to determine the reliability, validity and agreement for non-radiological measures of thoracic kyphosis in chronic obstructive pulmonary disease.

Methods:

A total of 19 participants with chronic obstructive pulmonary disease were included. Cobb angles from chest radiographs and spinous process landmarks using photogrammetry and three-dimensional motion capture were evaluated.

Findings:

The mean kyphosis (± standard deviation) was 48.8 ± 10.9 degrees by radiograph; 49.6 ± 12.9 degrees by three-dimensional motion capture and 52.2 ± 11.1 degrees by photogrammetry. Radiographic Cobb angle and photogrammetry measurements demonstrated excellent intra- and inter-rater reliability. Correlation between non-radiological kyphosis measurements and chest radiographs was strong (Pearson's r2 >0.75 for both). Limits of agreement between radiographs and 3D motion capture were –9 degrees to 7 degrees, and –12 to 8 degrees between radiographs and photogrammetry.

Conclusions:

Non-radiological measures of thoracic kyphosis are reliable and valid in chronic obstructive pulmonary disease.

Current evidence for spinal X-ray use in the chiropractic profession: a narrative review

The use of routine spinal X-rays within chiropractic has a contentious history. Elements of the profession advocate for the need for routine spinal X-rays to improve patient management, whereas other chiropractors advocate using spinal X-rays only when endorsed by current imaging guidelines. This review aims to summarise the current evidence for the use of spinal X-ray in chiropractic practice, with consideration of the related risks and benefits. Current evidence supports the use of spinal X-rays only in the diagnosis of trauma and spondyloarthropathy, and in the assessment of progressive spinal structural deformities such as adolescent idiopathic scoliosis. MRI is indicated to diagnose serious pathology such as cancer or infection, and to assess the need for surgical management in radiculopathy and spinal stenosis. Strong evidence demonstrates risks of imaging such as excessive radiation exposure, overdiagnosis, subsequent low-value investigation and treatment procedures, and increased costs. In most cases the potential benefits from routine imaging, including spinal X-rays, do not outweigh the potential harms. The use of spinal X-rays should not be routinely performed in chiropractic practice, and should be guided by clinical guidelines and clinician judgement.

The reliability and validity of goniometric elbow measurements in adults: A systematic review of the literature

BACKGROUND

The universal goniometer is a simple measuring tool. With this review we aimed to investigate the reliability and validity of the universal goniometer in measurements of the adults' elbow.

METHODS

Preferred Reporting Items for Systematic reviews and Meta-Analysis guidelines were followed and our study protocol was published online at PROSPERO. A literature search was conducted on relevant studies. Methodological quality was assessed using the Quality Appraisal of Diagnostic Reliability (QAREL) scoring system.

RESULTS

Out of 697 studies yielded from our literature search, 12 were included. Six studies were rated as high quality. The intrarater reliability intraclass correlation coefficient ranged from 0.45 to 0.99, the interrater reliability ranged from intraclass correlation coefficient 0.53-0.97. One study providing instructions on goniometric alignment did not find a difference in expert versus non-expert examiners. Another study in which examiners were not instructed found a higher interrater reliability in expert examiners. One study investigating the validity of the goniometer in elbow measurements found a maximum standard error of the mean of 11.5° for total range of motion.

DISCUSSION

Overall, the studies showed high intra- and interrater reliability of the universal goniometer. The reliability of the universal goniometer in non-expert examiners can be increased by clear instructions on goniometric alignment.

Dual energy X-ray absorptiometry positioning protocols in assessing body composition: A systematic review of the literature

OBJECTIVES

To systematically identify and assess methods and protocols used to reduce technical and biological errors in published studies that have investigated reliability of dual energy X-ray absorptiometry (DXA) for assessing body composition.

DESIGN

Systematic review.

METHODS

Systematic searches of five databases were used to identify studies of DXA reliability. Two independent reviewers used a modified critical appraisal tool to assess their methodological quality. Data was extracted and synthesised using a level of evidence approach. Further analysis was then undertaken of methods used to decrease DXA errors (technical and biological) and so enhance DXA reliability.

RESULTS

Twelve studies met eligibility criteria. Four of the articles were deemed high quality. Quality articles considered biological and technical errors when preparing participants for DXA scanning. The Nana positioning protocol was assessed to have a strong level of evidence. The studies providing this evidence indicated very high test-retest reliability (ICC 0.90-1.00 or less than 1% change in mean) of the Nana positioning protocol. The National Health and Nutrition Examination Survey (NHANES) positioning protocol was deemed to have a moderate level of evidence due to lack of high quality studies. However, the available studies found the NHANES positioning protocol had very high test-retest reliability. Evidence is limited and reported reliability has varied in papers where no specific positioning protocol was used or reported.

CONCLUSIONS

Due to the strong level of evidence of excellent test-retest reliability that supports use of the Nana positioning protocol, it is recommended as the first choice for clinicians when using DXA to assess body composition.

Classification of Tendon Matrix Change Using Ultrasound Imaging: A Systematic Review and Meta-analysis

Ultrasound imaging (US) is an accurate and reliable method used to diagnose tendinopathy. This systematic review was aimed at identifying common criteria and parameters used to diagnose tendinopathy, the methodological quality of studies and the predictive value of US. Nineteen studies met the inclusion criteria, with the Achilles, quadriceps and patella tendons being investigated. Overall, there was significant heterogeneity between the criteria used to diagnose tendinopathy utilising US. The methodological quality of included studies was "good." Additionally, meta-analysis revealed that US-identified abnormalities were predictive of future symptoms, and classification of tendinopathy using three US defined parameters indicated a higher relative risk of developing clinical tendinopathy compared with the use of two US-defined parameters. Further research into the development of a standardised US criterion that incorporates both clinical and US findings is required to allow for greater consistency in the diagnosis of tendinopathy.

Camptocormia: Etiology, diagnosis, and treatment response

Background

We sought to determine the etiologies, diagnostic testing, and management of a retrospective cohort of patients with camptocormia evaluated at a single center.

Methods

We reviewed medical records of all adult patients evaluated at Mayo Clinic Rochester with a diagnosis of camptocormia from 2000 to 2014. Demographic and clinical data were abstracted and analyzed.

Results

There were 276 patients (58.0% male), with mean age at presentation of 68.6 (±12.7) years. An etiology was identified in 98.2%. The most common etiologies were idiopathic Parkinson disease (22.5%), idiopathic axial myopathy (14.1%), and degenerative joint disease without fixed deformity (13.0%). We also identified several rare causes of camptocormia. Investigations included spine imaging, needle and surface EMG, and muscle biopsy. Most patients received physical therapy and orthotic support with limited benefit. Limited improvement of camptocormia was seen where a treatable etiology was identified.

Conclusions

An etiology can be identified in almost all cases of camptocormia. Most cases are due to 3 common disorders: Parkinson disease, axial myopathy, and degenerative joint disease. A diagnostic and treatment algorithm is proposed.

Is the inclinometer a valid measure of thoracic kyphosis? A cross-sectional study

BACKGROUND

Radiographs are used to monitor thoracic kyphosis in individuals with certain pathologies (e.g. osteoporosis), exposing patients to potentially harmful radiation. Thus, other measures for monitoring the progression of thoracic kyphosis are desirable. The gravity-dependent inclinometer has been shown to be reliable but its validity as a measure of thoracic kyphosis has not been investigated.

OBJECTIVES

To determine the validity of the gravity-dependent (analogue) inclinometer for measuring thoracic kyphosis.

DESIGN

Cross-sectional study.

METHOD

Participants (n=78) were recruited as part of a larger study of shoulder impingement syndrome. Healthy participants (n=39) were age and gender matched to the shoulder impingement syndrome group (n=39). Measurements of thoracic kyphosis using a gravity-dependent inclinometer were compared with modified Cobb angle results obtained from a sagittal view of lateral radiographs. A Bland-Altman plot assessed agreement. The Pearson correlation coefficient and linear regression was used to determine the association between modified Cobb angles and inclinometer measurements.

RESULTS

The Bland-Altman plot demonstrated good agreement. The Pearson correlation coefficient, r=0.62 (p<0.001), and linear regression model established a strong association between the thoracic kyphosis angle from the inclinometer readings and the modified Cobb angle measured from the radiographs (β=0.47, 95% CI 0.29, 0.65, p<0.001, R²=0.52, n=78). Age as a confounder was included in the model (β=0.35, 95% CI 0.19, 0.51, p<0.001).

CONCLUSIONS

The gravity-dependent (analogue) inclinometer produces angles that are comparable to the modified Cobb angle obtained from radiographs, establishing its criterion validity as a safe clinical tool for measuring thoracic kyphosis.

Thoracic dysfunction in whiplash associated disorders: A systematic review

BACKGROUND

Research investigating Whiplash Associated Disorder (WAD) has largely focused on the cervical spine yet symptoms can be widespread. Thoracic spine pain prevalence is reported ~66%; perhaps unsurprising given the forceful stretch/eccentric loading of posterior structures of the spine, and the thoracic spine's contribution to neck mobility/function. Approximately 50% WAD patients develop chronic pain and disability resulting in high levels of societal and healthcare costs. It is time to look beyond the cervical spine to fully understand anatomical dysfunction in WAD and provide new directions for clinical practice and research.

PURPOSE

To evaluate the scope and nature of dysfunction in the thoracic region in patients with WAD.

METHODS

A systematic review and data synthesis was conducted according to a pre-defined, registered (PROSPERO, CRD42015026983) and published protocol. All forms of observational study were included. A sensitive topic-based search strategy was designed from inception to 1/06/16. Databases, grey literature and registers were searched using a study population terms and key words derived from scoping search. Two reviewers independently searched information sources, assessed studies for inclusion, extracted data and assessed risk of bias. A third reviewer checked for consistency and clarity. Extracted data included summary data: sample size and characteristics, outcomes, and timescales to reflect disorder state. Risk of bias was assessed using the Newcastle-Ottawa Scale. Data were tabulated to allow enabling a semi-qualitative comparison and grouped by outcome across studies. Strength of the overall body of evidence was assessed using a modified GRADE.

RESULTS

Thirty eight studies (n>50,000) which were conducted across a range of countries were included. Few authors responded to requests for further data (5 of 9 contacted). Results were reported in the context of overall quality and were presented for measures of pain or dysfunction and presented, where possible, according to WAD severity and time point post injury. Key findings include: 1) high prevalence of thoracic pain (>60%); higher for those with more severe presentations and in the acute stage, 2) low prevalence of chest pain (<22%), 3) evidence of thoracic outlet syndrome, with some association to and involvement of the brachial plexus, 4) muscle dysfunction in the form of heightened activity of the sternocleidomastoid or delayed onset of action of the serratus anterior, 5) high prevalence of myofascial pain and trigger points in the scalene muscles, sternocleidomastoid and mid/lower fibres of trapezius muscle (48-65%), and 6) inconclusive evidence of altered thoracic posture or mobility.

CONCLUSIONS

Considerable evidence supports thoracic pain and dysfunction in patients with WAD, involving primarily nerves and muscles. Notwithstanding the low/very low level of evidence from this review, our findings do support a more extensive clinical evaluation of patients presenting with WAD. Additional high quality research is required to further characterise dysfunction across other structures in the thoracic region, including but not limited to the thoracic spine (mobility and posture) and thoracic muscles (stiffness, activation patterns). In turn this may inform the design of clinical trials targeting such dysfunction.

Sagittal alignment and mobility of the thoracolumbar spine are associated with radiographic progression of secondary hip osteoarthritis

OBJECTIVE

To identify predictors of radiographic progression of hip osteoarthritis (OA) over 12 months among functional hip impairments and spinal alignment and mobility.

DESIGN

Fifty female patients with secondary hip OA, excluding those with end-stage hip OA, participated in this prospective cohort study. Joint space width (JSW) of the hip was measured at baseline and 12 months later. With radiographic progression of hip OA over 12 months (>0.5 mm in JSW) as dependent variable, logistic regression analyses were performed to identify predictors for hip OA progression among functional impairments of the hip and spine with and without adjustment for age, body mass index (BMI), and minimum JSW at baseline. The independent variables were hip pain, Harris hip score (HHS), hip morphological parameters, hip passive range of motion (ROM) and muscle strength, and alignment and mobility of the thoracolumbar spine at baseline.

RESULTS

Twenty-one (42.0%) patients demonstrated radiographic progression of hip OA. Multivariable logistic regression analysis showed that larger anterior inclination of the spine in standing position (adjusted OR [95% CI], 1.37 [1.04-1.80]; P = 0.028) and less thoracolumbar spine mobility (adjusted OR [95% CI], 0.96 [0.92-0.99]; P = 0.037) at baseline were statistically significantly associated with radiographic progression of hip OA, even after adjustment for age, BMI, and minimum JSW.

CONCLUSIONS

The findings suggest that spinal alignment and mobility should be considered when assessing risk and designing preventive intervention for radiographic progression of secondary hip OA.

Concordance and Reliability of Photogrammetric Protocols for Measuring the Cervical Lordosis Angle: A Systematic Review of the Literature

OBJECTIVE

The aim of this study was to examine and interpret the concordance, accuracy, and reliability of photogrammetric protocols available in the literature for evaluating cervical lordosis in an adult population aged 18 to 59 years.

METHODS

A systematic search of 6 electronic databases (MEDLINE via PubMed, LILACS, CINAHL, Scopus, ScienceDirect, and Web of Science) located studies that assessed the reliability and/or concordance and/or accuracy of photogrammetric protocols for evaluating cervical lordosis, compared with radiography. Articles published through April 2016 were selected. Two independent reviewers used a critical appraisal tool (QUADAS and QAREL) to assess the quality of the selected studies.

RESULTS

Two studies were included in the review and had high levels of reliability (intraclass correlation coefficient: 0.974-0.98). Only 1 study assessed the concordance between the methods, which was calculated using Pearson's correlation coefficient. To date, the accuracy of photogrammetry has not been investigated thoroughly.

CONCLUSION

We encountered no study in the literature that investigated the accuracy of photogrammetry in diagnosing hyperlordosis of cervical spine. However, both current studies report high levels of intra- and interrater reliability. To increase the level of evidence of photogrammetry in the evaluation of cervical lordosis, it is necessary to conduct further studies using a larger sample to increase the external validity of the findings.

The effectiveness of combining inspiratory muscle training with manual therapy and a therapeutic exercise program on maximum inspiratory pressure in adults with asthma: a randomized clinical trial

OBJECTIVE

The objective of this study was to evaluate whether the addition of manual therapy and therapeutic exercise protocol to inspiratory muscle training was more effective in improving maximum inspiratory pressure than inspiratory muscle training in isolation.

DESIGN

This is a single-blinded, randomized controlled trial.

SUBJECTS

In total, 43 patients with asthma were included in this study.

INTERVENTIONS

The patients were allocated into one of the two groups: (1) inspiratory muscle training ( n = 21; 20-minute session) or (2) inspiratory muscle training (20-minute session) combined with a program of manual therapy (15-minute session) and therapeutic exercise (15-minute session; n = 22). All participants received 12 sessions, two days/week, for six weeks and performed the domiciliary exercises protocol.

MAIN MEASURES

The main measures such as maximum inspiratory pressure, spirometric measures, forward head posture, and thoracic kyphosis were recorded at baseline and after the treatment.

RESULTS

For the per-protocol analysis, between-group differences at post-intervention were observed in maximum inspiratory pressure (19.77 cmH₂O (11.49-28.04), P < .05; F = 22.436; P < .001; η²_p = 0.371) and forward head posture (-1.25 cm (-2.32 to -0.19), P < .05; F = 5.662; P = .022; η²_p = 0.13). The intention-to-treat analysis showed the same pattern of findings.

CONCLUSION

The inspiratory muscle training combined with a manual therapy and therapeutic exercise program is more effective than its application in isolation for producing short-term maximum inspiratory pressure and forward head posture improvements in patients with asthma.

Assessing the Reliability of Ultrasound Imaging to Examine Peripheral Nerve Excursion: A Systematic Literature Review

Ultrasound imaging (USI) is gaining popularity as a tool for assessing nerve excursion and is becoming an important tool for the assessment and management of entrapment neuropathies. This systematic review aimed to identify current methods and report on the reliability of using USI to examine nerve excursion and identify the level of evidence supporting the reliability of this technique. A systematic search of five electronic databases identified studies assessing the reliability of using USI to examine nerve excursion. Two independent reviewers critically appraised and assessed the methodological quality of the identified articles. Eighteen studies met the eligibility criteria. The majority of studies were of "moderate" or "high" methodological quality. The overall analysis indicated a "strong" level of evidence of moderate to high reliability of using USI to assess nerve excursion. Further reliability studies with consistency of reporting are required to further strengthen the level of evidence.

Relationship between spinal morphology and function and adolescent non-specific back pain: A cross-sectional study

CONTEXT

Non-specific back pain has become a public health problem affecting adolescent health.

OBJECTIVE

To examine the relationships between abnormalities in spinal morphology and non-specific back pain among adolescents.

DESIGN

Cross-sectional study.

SETTING

Junior and senior high schools.

PATIENTS

Participants were screened using a questionnaire regarding back pain. Students in the pain group (n= 273, 121 boys and 152 girls) reported experiencing upper and/or lower back pain within the previous month, and those who did not report pain were assigned to the group without pain (n= 127, 63 boys and 64 girls). Participants who had experienced acute upper and/or lower back injuries within the previous month or received a definitive diagnose of disease were excluded.

METHODS

The SpinalMouse® was used to measure the thoracic kyphosis angle (TKA), lumbar lordosis angle (LLA), sacrum/hip angle (SA), and incline angle (INA) in both the standing position and sitting position. The SpinalMouse® also was used to measure the sacral, thoracic, and lumbar range of motion (ROM) in the fully flexed position and fully extended position in the sagittal plane. The thoracic and lumbar ROM in left/right lateral flexion was recorded. The Matthiass test was used to assess changes in the measured angles upon loading.

RESULTS

Among junior high school students, 47.0% of boys and 53% of girls had an abnormal TKA. Among senior high school students, 52.6% of boys and 46.99% of girls had an abnormal TKA. The incidence of LLA abnormality was significantly higher among junior high boys than girls (p< 0.05), as was the incidence of hypolordosis (p< 0.05). Significantly fewer senior high boys than girls had a normal LLA value (p< 0.05). An excessive TKA (p< 0.05, odds ratio = 1.236) and limited lumbar ROM (p< 0.01, odds ratio = 0.975) were correlated with back pain in adolescents.

CONCLUSIONS

The incidences of TKA and LLA abnormality are high among Chinese adolescents, and an excessive TKA and insufficient total lumbar ROM may be risk factors for non-specific back pain in adolescents.

Accuracy of a Radiological Evaluation Method for Thoracic and Lumbar Spinal Curvatures Using Spinous Processes

OBJECTIVE

The purpose of this study was to assess a radiographic method for spinal curvature evaluation in children, based on spinous processes, and identify its normality limits.

METHODS

The sample consisted of 90 radiographic examinations of the spines of children in the sagittal plane. Thoracic and lumbar curvatures were evaluated using angular (apex angle [AA]) and linear (sagittal arrow [SA]) measurements based on the spinous processes. The same curvatures were also evaluated using the Cobb angle (CA) method, which is considered the gold standard. For concurrent validity (AA vs CA), Pearson's product-moment correlation coefficient, root-mean-square error, Pitman- Morgan test, and Bland-Altman analysis were used. For reproducibility (AA, SA, and CA), the intraclass correlation coefficient, standard error of measurement, and minimal detectable change measurements were used.

RESULTS

A significant correlation was found between CA and AA measurements, as was a low root-mean-square error. The mean difference between the measurements was 0° for thoracic and lumbar curvatures, and the mean standard deviations of the differences were ±5.9° and 6.9°, respectively. The intraclass correlation coefficients of AA and SA were similar to or higher than the gold standard (CA). The standard error of measurement and minimal detectable change of the AA were always lower than the CA.

CONCLUSION

This study determined the concurrent validity, as well as intra- and interrater reproducibility, of the radiographic measurements of kyphosis and lordosis in children.

The Reliability of Standing Sagittal Measurements of Spinal Curvature and Range of Motion in Older Women With and Without Hyperkyphosis Using a Skin-Surface Device

OBJECTIVE

The purpose of this study was to investigate the intrarater reliability of a skin-surface instrument (Spinal Mouse, Idiag, Voletswil, Switzerland) in measuring standing sagittal curvature and global mobility of the spine in older women with and without hyperkyphosis.

METHODS

Measurements were made in 19 women with hyperkyphosis (thoracic kyphosis angle ≥50°), mean age 67 ± 5 years, and 14 women without hyperkyphosis (thoracic kyphosis angle <50°), mean age 63 ± 6 years. Sagittal thoracic and lumbar curvature and mobility of the spine were assessed with the Spinal Mouse during neutral standing, full spinal flexion, and full spinal extension. Tests were performed by the same examiner on 2 days with a 72-hour interval. The intrarater reliability of the measurements was analyzed using the intraclass correlation coefficient, standard error of measurement and minimal detectable change.

RESULTS

Intraclass correlation coefficients ranged from 0.89 to 0.99 in both groups. The standard errors of measurement ranged from 1.02° to 2.06° in the hyperkyphosis group and from 1.15° to 2.22° in the normal group. The minimal detectable change ranged from 2.85° to 5.73° in the hyperkyphosis group and from 3.20° to 6.17° in the normal group.

CONCLUSIONS

Our results indicated that the Spinal Mouse has excellent intrarater reliability for the measurement of sagittal thoracic and lumbar curvature and mobility of the spine in older women.

Test-retest reliability and validity of a motion capture (MOCAP) system for measuring thoracic and lumbar spinal curvatures and sacral inclination in the sagittal plane

OBJECTIVE

To evaluate the test-retest reliability and validity of the MOCAP system for measuring spinal sagittal thoracic and lumbar curvatures and sacral inclination in a standing posture.

METHODS

Twenty-five male adults were evaluated on lateral standing radiographs. The thoracic and lumbar curvatures were calculated by Harrison's posterior tangent method. The sacral inclination was defined as the angle between the tangent line of the sacral and vertical plane. In addition, MOCAP was used to calculate the spinal curvatures and sacral inclination.

RESULTS

The thoracic and lumbar spine and sacral inclination demonstrated excellent reliability, with mean ICCs levels greater than 0.980 and low CVs (mean: 2.15%). Systematic biases were not significant and were very near 0, and the mean standard errors were 0.257∘. ANOVA of the radiographic and MOCAP measures did not report any statistically significant differences in the comparisons. The systematic biases and mean random errors were lower than 1∘, with CVs lower than 5% and mean ICCs higher than 0.90 between sessions.

CONCLUSION

The MOCAP system delivered consistently reliable and valid results for standing curvatures compared with a radiographic technique. This system could be used with confidence in research and clinical environments for sagittal spinal curvature measurements.

Non-radiographic methods of measuring global sagittal balance: a systematic review

Background

Global sagittal balance, describing the vertical alignment of the spine, is an important factor in the non-operative and operative management of back pain. However, the typical gold standard method of assessment, radiography, requires exposure to radiation and increased cost, making it unsuitable for repeated use. Non-radiologic methods of assessment are available, but their reliability and validity in the current literature have not been systematically assessed. Therefore, the aim of this systematic review was to synthesise and evaluate the reliability and validity of non-radiographic methods of assessing global sagittal balance.

Methods

Five electronic databases were searched and methodology evaluated by two independent reviewers using the13-item, reliability and validity, Brink and Louw critical appraisal tool.

Results

Fourteen articles describing six methodologies were identified from 3940 records. The six non-radiographic methodologies were biophotogrammetry, plumbline, surface topography, infra-red motion analysis, spinal mouse and ultrasound. Construct validity was evaluated for surface topography (R = 0.49 and R = 0.68, p < 0.001), infra-red motion-analysis (ICC = 0.81) and plumbline testing (ICC = 0.83). Reliability ranged from moderate (ICC = 0.67) for spinal mouse to very high for surface topography (Cronbach α = 0.985). Measures of agreement ranged from 0.9 mm (plumbline) to 22.94 mm (infra-red motion-analysis). Variability in study populations, reporting parameters and statistics prevented a meta-analysis.

Conclusions

The reliability and validity of the non-radiographic methods of measuring global sagittal balance was reported within 14 identified articles. Based on this limited evidence, non-radiographic methods appear to have moderate to very high reliability and limited to three methodologies, moderate to high validity. The overall quality and methodological approaches of the included articles were highly variable. Further research should focus on the validity of non-radiographic methods with a greater adherence to reporting actual and clinically relevant measures of agreement.

Intrarater and Inter-rater Reliability of Active Cervical Range of Motion in Patients With Nonspecific Neck Pain Measured With Technological and Common Use Devices: A Systematic Review With Meta-regression

OBJECTIVES

The purpose of this systematic review was to compare intrarater and inter-rater reliability of active cervical range of motion (ACROM) measures obtained with technological devices to those assessed with low-cost devices in patients with nonspecific neck pain. As a secondary outcome, we investigated if ACROM reliability is influenced by the plane of the assessed movement.

METHODS

Medline, Scopus, Embase, the Cochrane Library, CINHAL, PEDro, and gray literature were searched until August 2016. Inclusion criteria were reliability design, population of adults with nonspecific neck pain, examiners of any level of experience, measures repeated at least twice, and statistical indexes on reliability. A device was considered inexpensive if it cost less than €500. The risk of bias of included studies was assessed by Quality Appraisal of Reliability Studies.

RESULTS

The search yielded 35 151 records. Nine studies met all eligibility criteria. Their Quality Appraisal of Reliability Studies mean score was 3.7 of 11. No significant effect of the type of device (inexpensive vs expensive) on intraclass correlation coefficient (ICC) was identified for intrarater (ICC = 0.93 vs 0.91; P > .99) and inter-rater reliability (ICC = 0.80 vs 0.87; P > .99). The plane of movement did not affect inter-rater reliability (P = .11). Significant influences were identified with intrarater reliability (P = .0001) of inexpensive devices, where intrarater reliability decreased (P = .01) in side bending, compared with flexion-extension.

CONCLUSIONS

The use of expensive devices to measure ACROM in adults with nonspecific neck pain does not seem to improve the reliability of the assessment. Side bending had a lower level of intrarater reliability.

Inclinometric measurement of kyphotic curvature: Description and clinimetric properties

BACKGROUND

Hyperkyphosis is associated with physical impairments, activity limitations, and reduced quality of life. Therefore, a simple, reliable, responsive, and valid clinical measure of dorsal kyphosis would be valuable to clinicians.

OBJECTIVE

To describe a novel procedure for measuring kyphotic curvature-the inclinometric kyphosis measure (IKM)-and provide an estimation of reliability, responsiveness, and validity.

METHODS

During 2 sessions spaced days apart, we used a bubble inclinometer to measure dorsal kyphosis in 68 patients receiving outpatient physical therapy. We also documented occiput-to-wall status and tragus-to-wall distance.

RESULTS

Intra-rater reliability of the IKM was supported by intra-class correlation coefficients (ICC_3,1) of 0.94 and 0.91 for relaxed and cued conditions, respectively. Responsiveness, as indicated by minimal detectable change, was 8.0 and 10.0 degrees under relaxed and cued conditions, respectively. Validity was supported by significant correlations between the IKM and tragus-to-wall and by differences in the IKM between: 1) relaxed and cued conditions; 2) patients who could and could not touch occiput to the wall; and 3) patients who were older versus younger than 50 years of age.

CONCLUSIONS

The IKM is a simple, reliable, responsive, and valid method for assessing posture in patients with musculoskeletal conditions.

Age-related hyperkyphosis: update of its potential causes and clinical impacts-narrative review

The present study aims to qualitatively review the contributing factors and health implications of age-related hyperkyphosis. We conducted a narrative review of observational and cohort studies describing the risk factors and epidemiology of hyperkyphosis from 1955 to 2016 using the following key words: kyphosis, hyperkyphosis, posture, age-related hyperkyphosis, kyphotic posture, aetiology and causes. This review included 77 studies. Approximately 60-70 % of the most severe hyperkyphosis cases have no evidence of underlying vertebral compression fractures. Other proposed factors contributing to hyperkyphosis are degenerative disc disease, weakness of back extensor muscles and genetic predisposition. Strength and endurance of back extensor muscles are very important for maintaining normal postural alignment. Recent evidence suggests that age-related hyperkyphosis is not equivalent to spinal osteoporosis. Due to the negative impact of hyperkyphosis on physical function, quality of life and mortality rates, physicians should focus not only on osteoporosis, but also on age-related postural changes. More research about the relationship between spinal morphology and modifiable factors, especially the structural and functional parameters of trunk muscles, could further illuminate our understanding and treatment options for hyperkyphosis.

Clinimetric properties of lower limb neurological impairment tests for children and young people with a neurological condition: A systematic review

Background

Clinicians and researchers require sound neurological tests to measure changes in neurological impairments necessary for clinical decision-making. Little evidence-based guidance exists for selecting and interpreting an appropriate, paediatric-specific lower limb neurological test aimed at the impairment level.

Objective

To determine the clinimetric evidence underpinning neurological impairment tests currently used in paediatric rehabilitation to evaluate muscle strength, tactile sensitivity, and deep tendon reflexes of the lower limb in children and young people with a neurological condition.

Methods

Thirteen databases were systematically searched in two phases, from the date of database inception to 16 February 2017. Lower limb neurological impairment tests were first identified which evaluated muscle strength, tactile sensitivity or deep tendon reflexes in children or young people under 18 years of age with a neurological condition. Papers containing clinimetric evidence of these tests were then identified. The methodological quality of each paper was critically appraised using standardised tools and clinimetric evidence synthesised for each test.

Results

Thirteen papers were identified, which provided clinimetric evidence on six neurological tests. Muscle strength tests had the greatest volume of clinimetric evidence, however this evidence focused on reliability. Studies were variable in quality with inconsistent results. Clinimetric evidence for tactile sensitivity impairment tests was conflicting and difficult to extrapolate. No clinimetric evidence was found for impairment tests of deep tendon reflexes.

Conclusions

Limited high-quality clinimetric evidence exists for lower limb neurological impairment tests in children and young people with a neurological condition. Results of currently used neurological tests, therefore, should be interpreted with caution. Robust clinimetric evidence on these tests is required for clinicians and researchers to effectively select and evaluate rehabilitation interventions.