Validity and reliability of photographic measures to evaluate waistline asymmetry in idiopathic scoliosis

Responsiveness of trunk asymmetry measurements in clinical photographs after adolescent idiopathic scoliosis surgery

PURPOSE

To evaluate the correlation between changes in body image perception and trunk asymmetry measured in clinical photographs after adolescent idiopathic scoliosis (AIS) surgical treatment.

MATERIALS AND METHODS

This is a prospective study of patients operated on for AIS with Lenke curves 1 and 2. Preoperatively and one year after surgery, patients underwent full-spine X-rays and digital photographs. They also completed the SRS-22R and Trunk Appearance Perception Scale (TAPS) questionnaires. On X-rays, the coronal Cobb angle was measured. In back torso photographs, the shoulder (SHA), axillary (AHA), and waist (WHA) height angles, waist fold angle (WA-r and WA-I), and the right/left ratio of hemitrunks (ArT) were measured. The pre- and post-surgery mean differences for all variables were calculated. The correlation between the improvement in the photographic variables and the questionnaire scores was also analyzed.

RESULTS

52 patients (82.7% female; mean age 15.6 years, mean preoperative Cobb 65.8°) were included. Significant differences were found between pre and postoperative mean scores in all variables. No correlation was found between the change in trunk asymmetry photographic parameters and the change in SRS-22/ TAPS imaging scale scores.

CONCLUSIONS

Surgery for idiopathic scoliosis significantly improves radiological deformity, trunk asymmetry, perception of trunk deformity, and body image. Photographic measures show significant responsiveness after surgery. The effect size of the change in photographic parameters was similar to that observed in the SRS-22 questionnaire and less than the radiological. However, no relationship was found between the changes observed in patient reported, radiological and photographic measures.

Assessing the Diagnostic Validity of Torsobarography in Scoliosis

Adolescent idiopathic scoliosis (AIS) is treated with various forms of conservative care or surgery, depending on the degree of severity. When AIS is detected early, it can be monitored and initially treated with reduced invasiveness to prevent further progression. AIS manifests itself through deformations of the trunk, which are mostly identified as asymmetries in manual clinical examination. Torsobarography is a new pressure-based surface topographic system for posture analysis and evaluates such associated morphologic asymmetries. The aim of this study is to investigate the diagnostic validity of torsobarography by examining correlation of extracted torsobarographic indices with the Cobb angle and its ability to differentiate between different severities of scoliosis: no scoliosis, mild scoliosis, and moderate scoliosis. A total of 87 subjects (51 females and 36 males) were examined with torsobarography. Six torsobarographic indices were calculated for all subjects: torsobarography angle (TBA), sagittal imbalance index (SII), torso asymmetry index (TAI), shoulder asymmetry angle (SAA), waist asymmetry angle (WAA), and pelvis asymmetry Angle (PAA). These indices were correlated with the Cobb angle, and the differences between severities were statistically analyzed. Three out of six indices (TBA, TAI, and WAA) were able to significantly distinguish between mild and moderate scoliosis. Additionally, those indices showed moderate correlation (ρ = 0.37-0.50) with the Cobb angle measurements. The WAA was the only statistically significant index capable of differentiating between no scoliosis and moderate scoliosis. This study is the first to demonstrate that torsobarography can distinguish between different severities of scoliosis and thus identify a scoliotic deformity that requires bracing over monitoring.

Clinical Significance of Pose Estimation Methods Compared with Radiographic Parameters in Adolescent Patients with Idiopathic Scoliosis

Introduction

Human pose estimation, a computer vision technique that identifies body parts and constructs human body representations from images and videos, has recently demonstrated high performance through deep learning. However, its potential application in clinical photography remains underexplored. This study aimed to establish photographic parameters for patients with adolescent idiopathic scoliosis (AIS) using pose estimation and to determine correlations between these photographic parameters and corresponding radiographic measures.

Methods

We conducted a study involving 42 patients with AIS who had undergone spinal correction surgery and conservative treatment. Preoperative photographs were captured using an iPhone 13 Pro mounted on a tripod positioned at the head of an X-ray tube. From the outputs of pose estimation, we derived five photographic parameters and subsequently conducted a statistical analysis to assess their correlations with relevant conventional radiographic parameters.

Results

In the sagittal plane, we identified significant correlations between photographic and radiographic parameters measuring trunk tilt angles. In the coronal plane, significant correlations were found between photographic parameters measuring shoulder height and trunk tilt and corresponding radiographic measurements.

Conclusions

The results suggest that pose estimation, achievable with common mobile devices, offers potential for AIS screening, early detection, and continuous posture monitoring, effectively mitigating the need for X-ray radiation exposure. Level of Evidence: 3.

Evaluation of the changes in waistline asymmetry using digital photography in adolescents with idiopathic thoracolumbar/lumbar scoliosis after corrective surgery

PURPOSE

Waist line asymmetry is a major cosmetic concern in patients with adolescent idiopathic scoliosis (AIS). The primary surgical goal in patients with AIS is to correct spinal deformities and prevent further progression while maintaining global alignment. Additionally, an important objective of surgical treatment is to address physical appearance by reducing asymmetry. This study aimed to evaluate changes in waistline asymmetry using digital photographs in adolescents with thoracolumbar/lumbar (TL/L) scoliosis who underwent corrective surgery.

METHODS

We retrospectively analyzed the data of patients with Lenke types 5C and 6C AIS who underwent posterior fusion surgery with at least 2 years of follow-up. Waist line asymmetry was assessed using digital photography. The waist angle ratio (WAR), waist height angle (WHA), and waistline depth ratio (WLDR) were measured pre- and postoperatively. Radiographic parameters and the revised 22-item Scoliosis Research Society Questionnaire (SRS-22r) were also evaluated.

RESULTS

Forty-two patients (40 females and 2 males; 34 with type 5C and 8 with type 6C) were included in the study. The WAR, WHA, and WLDR significantly improved after surgery (0.873 → 0.977, - 2.0° → 1.4°, and 0.321 → 0.899, respectively). Every waistline parameter moderately correlated with the apical vertebral translation of the TL/L curve (WAR: r =  - 0.398, WHA: r =  - 0.442, and WLDR: r =  - 0.692), whereas no correlations were observed with the TL/L curve magnitude. No correlations were observed between the photographic parameters and SRS-22r scores.

CONCLUSION

Lateral displacement of the apical vertebra on the TL/L curve correlated with waistline asymmetry. Preoperative waistline asymmetry improved with scoliosis correction.

LEVEL OF EVIDENCE

Level 4.

Reliability of a New Digital Tool for Photographic Analysis in Quantifying Body Asymmetry in Scoliosis

Background: Advancements in non-ionizing methods for quantifying spinal deformities are crucial for assessing and monitoring scoliosis. In this study, we analyzed the observer variability of a newly developed digital tool for quantifying body asymmetry from clinical photographs. Methods: Prospective observational multicenter study. Initially, a digital tool was developed using image analysis software, calculating quantitative measures of body asymmetry. This tool was integrated into an online platform that exports data to a database. The tool calculated 10 parameters, including angles (shoulder height, axilla height, waist height, right and left waistline angles, and their difference) and surfaces of the left and right hemitrunks (shoulders, waists, pelvises, and total). Subsequently, an online training course on the tool was conducted for twelve observers not involved in its development (six research coordinators and six spine surgeons). Finally, 15 standardized back photographs of adolescent idiopathic scoliosis patients were selected from a multicenter image bank, representing various clinical scenarios (different age, gender, curve type, BMI, and pre- and postoperative images). The 12 observers measured the photographs at two different times with a three-week interval. For the second round, the images were randomly mixed. Inter- and intra-observer variabilities of the measurements were analyzed using intraclass correlation coefficients (ICCs), and reliability was measured by the standard error of measurement (SEM). Group comparisons were made using Student's t-test. Results: The mean inter-observer ICC for the ten measurements was 0.981, the mean intra-observer ICC was 0.937, and SEM was 0.3-1.3°. The parameter with the strongest inter- and intra-observer validity was the difference in waistline angles 0.994 and 0.974, respectively, while the highest variability was found with the waist height angle 0.963 and 0.845, respectively. No test-retest differences (p > 0.05) were observed between researchers (0.948 ± 0.04) and surgeons (0.925 ± 0.05). Conclusion: We developed a new digital tool integrated into an online platform demonstrating excellent reliability and inter- and intra-observer variabilities for quantifying body asymmetry in scoliosis patients from a simple clinical photograph. The method could be used for assessing and monitoring scoliosis and body asymmetry without radiation.

The intra- and inter-rater reliability of measuring trunk coronal asymmetry by adjusting positioning variability: A prospective study

BACKGROUND

Chronic low back pain (LBP) can lead to muscle spasms, limited range of motion, and abnormal posture, resulting in trunk muscle asymmetry.

OBJECTIVE

This study aimed to assess the intra- and inter-rater reliability of a quantitative measurement of trunk coronal asymmetry in patients with chronic LBP, minimizing unnecessary gravity and friction force using a manual table in the prone position.

METHODS

This prospective study was conducted at a single center, targeting patients with chronic LBP to measure trunk coronal asymmetry on a manual table in the prone position. The intra-class correlation coefficient (ICC) was calculated using one-way random-effects and two-way mixed-effects models.

RESULTS

Fifty-eight patients who had LBP for more than three months were enrolled from May 1, 2021, to December 31, 2021. The intra- and inter-rater reliabilities of the two examiners' measurements were 0.872 and 0.899, and 0.852, respectively. Based on pain severity, the participants were classified into mild and severe groups, with ICCs of 0.823 and 0.889, and 0.936 and 0.918, respectively.

CONCLUSION

Measurement of trunk coronal asymmetry in the prone position using a manual table demonstrates high intra- and inter-rater reliability. In addition, the reliability increases with greater pain severity.

A Brief Overview of Neutrophils in Neurological Diseases

Neutrophils are the most abundant leukocyte in circulation and are the first line of defense after an infection or injury. Neutrophils have a broad spectrum of functions, including phagocytosis of microorganisms, the release of pro-inflammatory cytokines and chemokines, oxidative burst, and the formation of neutrophil extracellular traps. Traditionally, neutrophils were thought to be most important for acute inflammatory responses, with a short half-life and a more static response to infections and injury. However, this view has changed in recent years showing neutrophil heterogeneity and dynamics, indicating a much more regulated and flexible response. Here we will discuss the role of neutrophils in aging and neurological disorders; specifically, we focus on recent data indicating the impact of neutrophils in chronic inflammatory processes and their contribution to neurological diseases. Lastly, we aim to conclude that reactive neutrophils directly contribute to increased vascular inflammation and age-related diseases.

The effect of watching shoulder ROM changes on functional outcome and quality of life following arthroscopic rotator cuff repair

PurposeThis study aimed to evaluate the effectiveness of watching video records of their shoulder motion changes on functional outcomes and quality of life after arthroscopic rotator cuff repair (ARCR). Methods The patients were divided into two groups. In Group 1, video records of pre- and postoperative shoulder motions were recorded and showed. In Group 2, no video was showed to the patients. In Group 1, the first postoperative evaluation was done before video watching, and the second evaluation was done just after watching video records. In Group 2, the first and second postoperative measurements were performed with 10-20 days interval. The Constant Murley score (CS), the American Shoulder and Elbow Surgeons score (ASES), the Short-Form 36 (SF-36) score, and active shoulder range of motion (ROM) values were used as an outcome tool. Results A total of 196 patients (Group 1; 76 patients and Group 2; 120 patients) with a mean age of 62.06 ± 7.17 years were included. There was a significant improvement in postoperative scores of SF-36 subscales (except emotional well-being and energy/fatigue), ASES, CM scores, and joint ROM values when compared to preoperative values for both groups (p < .001). The first postoperative outcomes were similar between groups (p > .05). In the second postoperative evaluation, emotional role functioning, energy/fatigue, emotional well-being, health change subscales of SF-36, and ASES scores were significantly higher in Group 1 compared with Group 2 (p < .05). Conclusion When patients watch the pre- and postoperative video records of their shoulder ROM after ARCR, patients' satisfaction and well-being perception increase in the short-term despite unchanged shoulder ROM.

Evaluation of Self-Perceived Body Image in Adolescents with Mild Idiopathic Scoliosis

Adolescent idiopathic scoliosis (AIS) is the most prevalent types of scoliosis, affecting up to 3% of children around the world. The progression of AIS can cause alteration in psychological components such as self-perceived body image and self-identity, which negatively affect the teenager quality of life (QoL). The mainly aim of this cross-sectional study is to investigate how mild AIS impacts self-perceived body image in young people. Fifteen participants (mean age = 14.47 ± 2.825) of both sexes (male = 5; female = 10) with a curve magnitude from 10° up to 25° completed the Scoliosis Research Society Patient Questionnaire (SRS-22), the Trunk Appearance Perception Scale (TAPS) and were subject to spinal analysis and photogrammetry. Results display statistical differences between self-perceived body image and other SRS-22 domains (Hotelling t2= 70.29; F(3,12) = 20.08; p < 0.001). Additionally, the regression model, which better explained the self-perceived variability, was fit by function/activity, pain, and mental health domains (F(4,10) = 4.39; p = 0.029; R2 = 0.545). Although AIS was not severe, it negatively affected participants self-perceived body image. More attention in AIS qualify of life is needed, and early treatments could be necessary to prevent psychological impairments self-perception related.

Test-retest reliability of posture measurements in adolescents with idiopathic scoliosis

BACKGROUND CONTEXT

Posture changes are a major consequence of idiopathic scoliosis (IS). Posture changes can lead to psychosocial and physical impairments in adolescents with IS. Therefore, it is important to assess posture, but the test-retest reliability of posture measurements still remains unknown in this population.

PURPOSE

The primary objective of the present study was to determine the test-retest reliability of 25 head and trunk posture indices using the Clinical Photographic Postural Assessment Tool (CPPAT) in adolescents with IS. The secondary objective was to determine the standard error of measurement and the minimal detectable change.

STUDY DESIGN/SETTING

This is a prospective test-retest reliability study carried out at two tertiary university hospital centers.

PATIENTS SAMPLE

Forty-one adolescents with IS, aged 10-16 years old with curves 10°-45° and treated by medical intervention, were recruited.

METHODS

Two posture assessments were done using the CPPAT 5-10 days apart following a standardized procedure. Photographs were analyzed with the CPPAT software by digitizing reference landmarks placed on the participant by a physiotherapist evaluator. Generalizability theory was used to obtain a coefficient of dependability, standard error of measurement, and the minimal detectable change at 90% confidence interval.

RESULTS

Fourteen of 25 posture indices had a good reliability (ϕ≥0.78), 10 had moderate reliability (ϕ=0.55-0.74), and 1 had poor reliability (ϕ=0.45). The most reliable posture indices were waist angle asymmetry (ϕ=0.93), right waist angle (ϕ=0.91), and frontal trunk list (ϕ=0.92). Right sagittal trunk list was the least reliable posture index (ϕ=0.45). The MDC₉₀ values ranged from 2.6 to 10.3° for angular measurements and from 8.4 to 35.1 mm for linear measurements.

CONCLUSIONS

The present study demonstrates that most posture indices, especially the trunk posture indices, are reproducible in time among adolescents with IS and provides reference values. Clinicians and researchers can use these reference values to assess change in posture over time attributable to treatment effectiveness.

Workflow Challenges of Enterprise Imaging: HIMSS-SIIM Collaborative White Paper

With the advent of digital cameras, there has been an explosion in the number of medical specialties using images to diagnose or document disease and guide interventions. In many specialties, these images are not added to the patient's electronic medical record and are not distributed so that other providers caring for the patient can view them. As hospitals begin to develop enterprise imaging strategies, they have found that there are multiple challenges preventing the implementation of systems to manage image capture, image upload, and image management. This HIMSS-SIIM white paper will describe the key workflow challenges related to enterprise imaging and offer suggestions for potential solutions to these challenges.

Two-dimensional digital photography for child body posture evaluation: standardized technique, reliable parameters and normative data for age 7-10 years

BACKGROUND

Digital photogrammetry provides measurements of body angles or distances which allow for quantitative posture assessment with or without the use of external markers. It is becoming an increasingly popular tool for the assessment of the musculoskeletal system. The aim of this paper is to present a structured method for the analysis of posture and its changes using a standardized digital photography technique.

MATERIAL AND METHODS

The purpose of the study was twofold. The first one comprised 91 children (44 girls and 47 boys) aged 7-10 (8.2 ± 1.0), i.e., students of primary school, and its aim was to develop the photographic method, choose the quantitative parameters, and determine the intraobserver reliability (repeatability) along with the interobserver reliability (reproducibility) measurements in sagittal plane using digital photography, as well as to compare the Rippstein plurimeter and digital photography measurements. The second one involved 7782 children (3804 girls, 3978 boys) aged 7-10 (8.4 ± 0.5), who underwent digital photography postural screening. The methods consisted in measuring and calculating selected parameters, establishing the normal ranges of photographic parameters, presenting percentile charts, as well as noticing common pitfalls and possible sources of errors in digital photography.

RESULTS

A standardized procedure for the photographic evaluation of child body posture was presented. The photographic measurements revealed very good intra- and inter-rater reliability regarding the five sagittal parameters and good reliability performed against Rippstein plurimeter measurements. The parameters displayed insignificant variability over time. Normative data were calculated based on photographic assessment, while the percentile charts were provided to serve as reference values. The technical errors observed during photogrammetry are carefully discussed in this article.

CONCLUSIONS

Technical developments are allowed for the regular use of digital photogrammetry in body posture assessment. Specific child positioning (described above) enables us to avoid incidentally modified posture. Image registration is simple, quick, harmless, and cost-effective. The semi-automatic image analysis, together with the normal values and percentile charts, makes the technique reliable in terms of child's posture documentation and corrective therapy effects' monitoring.

Do the SRS-22 self-image and mental health domain scores reflect the degree of asymmetry of the back in adolescent idiopathic scoliosis?

Background

Patient-reported outcomes are becoming increasingly recognised in the management of patients with adolescent idiopathic scoliosis (AIS). Integrated Shape Imaging System 2 (ISIS2) surface topography is a validated tool to assess AIS. Previous studies have failed to demonstrate strong correlations between AIS and patient-reported outcomes highlighting the need for additional objective surface parameters to define the deformities associated with AIS. The aim of this study was to examine whether the Scoliosis Research Society-22 (SRS-22) outcome questionnaire reflects the degree of measurable external asymmetry of the back in AIS and thus is a measure of patient outcome for external appearance.

Methods

A total of 102 pre-operative AIS patients were identified retrospectively. Objective parameters were measured using ISIS2 surface topography. The associations between these parameters and the self-image and mental health domains of the SRS-22 questionnaire were investigated using correlation coefficients.

Results

All correlations between the parameters of asymmetry and SRS-22 self-image score were of weak strength. Similarly, all correlations between the parameters of asymmetry and SRS-22 mental health score were of weak strength.

Conclusion

The SRS-22 mental health and self-image domains correlate poorly with external measures of deformity. This demonstrates that the assessment of mental health and self-image by the SRS-22 has little to do with external torso shape. Whilst the SRS-22 assesses the patient as a whole, it provides little information about objective measures of deformity over which a surgeon has control.

The effects of scoliosis and subsequent surgery on the shape of the torso

Background

Adolescent idiopathic scoliosis (AIS) causes asymmetry of the torso, and this is often the primary concern of patients. Surgery aims to minimise the visual asymmetry. It is not clear how scoliosis makes the torso asymmetric or how scoliosis surgery changes that asymmetry when compared to the distribution of asymmetries seen in a non-scoliotic group of normal controls.

Methods

Surface topography images were captured for a group with AIS both pre-operatively and post-operatively. Identifiable points were compared between the images to identify the effects of AIS on the shape of the torso by looking at the relative heights and distances from the midline of the shoulders, axillae and waist in a two-dimensional coronal view. This was then compared to a previously reported group of normal non-scoliotic children to analyse whether surgery recreated normality.

Results

There were 172 pairs of images with 164 females and 8 males, mean age at pre-operative scan of 13.7 years. The normal group was 642 images (237 females and 405 males) from 116 males and 79 females, mean age of 12.5 years.

The curve patterns seen in the scoliotic group matched the patterns of a main thoracic curve (n = 146) and main thoracolumbar curve (n = 26). The asymmetries seen in both shoulders, axillae and waist were different between the two different types of curve. Across both groups, the shoulder asymmetry was less than that of the corresponding axillae.

There was a statistically significant reduction in all asymmetries following surgery in the main thoracic group (p < 0.001). This was not seen in the main thoracolumbar group, thought to be due to the small sample size. In the main thoracic group, there were statistically significant differences in the asymmetries between the post-operative and normal groups in the shoulders and axillae (p < 0.001) but not the waist.

Conclusions

This paper demonstrates quantitatively the range of asymmetries seen in the AIS torso and the degree to which surgery alters them. Surgery does not recreate normality but does cause a statistically significant change in torso shape towards that seen in a non-scoliotic group.

What is the variability in shoulder, axillae and waist position in a group of adolescents?

The clinical assessment of scoliosis is based on the recognition of asymmetry. It is not clear what the degree of asymmetry is in a population without scoliosis, which could make the differentiation between abnormal and normal uncertain. This study defines the range of normality in certain parameters of torso shape that are also associated with the clinical assessment of scoliosis. This was done by analysing the surface topography of a group of 195 children serially measured over a 5-year period. The analysis considered both the spinal curvature and the relative position of shoulders, axillae and waist on each side. The bivariate relationships were examined using 95% confidence interval data ellipses. Our results showed that a degree of spinal curvature was seen, either as a main thoracic or main thoracolumbar curve. The distribution of the data about a mean point is illustrated by 95% confidence interval (CI) data ellipses with shoulder, axilla and waist data plotted against spinal curvature. The mean values were close to zero (exact symmetry) for all of the measured parameters, with the ellipses showing little differences in the distributions. We conclude that mild asymmetry of the measured torso parameters is normal. These results define what is normal and beyond what point asymmetry becomes abnormal. This information is of use for those managing and counselling patients with scoliosis both before and after surgery.