Acute systematic and variable postural adaptations induced by an orthopaedic shoe lift in control subjects

Scoliosis and Lower Limb Inequality: To Lift or Not to Lift, That Is the Question

In subjects with scoliotic alterations of the spine, asymmetrical lengths of the lower limbs are frequently observed, a condition commonly referred to as leg length inequality (LLI) or discrepancy (LLD). This asymmetry can induce pelvic misalignments, manifested by an asymmetric height of the iliac crests, and consequently an alteration of the spine's axis. Although correcting this discrepancy might appear to be a straightforward solution, further investigation may reveal other indications. The purpose of this article is to aid clinicians confronted with the decision of whether to compensate for an LLI in individuals with scoliosis, encompassing both adolescents and adults. It presents a literature review on the incidence of LLIs in the general population, distinguishing between structural LLI (sLLI) and functional LLI (fLLI) types of LLIs, and quantifying their magnitude with clinical and instrumental evaluation. Additionally, it links these two types of LLIs to the type of scoliosis (structural or functional). From a clinical perspective, it also examines the compensatory mechanisms employed by the pelvis in the presence of structural or functional LLIs in order to draw useful indications for therapeutic decisions. Moreover, it proposes an additional evaluation parameter in the coronal plane, namely the central sacral vertical line (CSVL), to aid in the decision-making process regarding LLI compensation. Although this parameter has been documented in the literature, it has been little associated with LLIs. The findings indicate that scoliotic discrepancies should be compensated (conservatively or surgically) only when the imbalance of the femoral heads is on the same side as the imbalance of the sacrum and the iliac crests; this corrective action should result in a reduction of the overhang in the coronal plane.

Leg Length Discrepancy and Nonspecific Low Back Pain: 3-D Stereophotogrammetric Quantitative Posture Evaluation Confirms Positive Effects of Customized Heel-Lift Orthotics

Background: The literature reports evidence of leg length discrepancy (LLD) associated with musculoskeletal disorders, alterations in spinopelvic alignment, and body posture, leading to low back pain and lumbar scoliosis. The most common conservative treatment for LLD is the use of internal or external shoe lifts although no treatment guidelines have been established.

Aim: The study aimed to contribute to low back pain–LLD relationship comprehension, highlighting the benefits of LLD correction in the nonspecific low back pain (NSLBP) population.

Methods: A cross-sectional observational study recruited a cohort of 80 NSLBP patients (48 females, 32 males) with LLD, age (μ = 35 ± 17.2). Entire body posture, including 3-D spine shape reconstruction, was measured using a nonionizing 3-D optoelectronic stereophotogrammetric approach. After the first 3-D posture evaluation, patients were provided with customized orthotics, including 100% LLD heel lift correction. No other therapeutic interventions were considered. Pain level was assessed using the numerical pain rating scale (NPRS). The gender, age-related, and time-dependent effects of LLD equalization treatment in NSLBP patients was investigated during 2 years of follow-up. The statistical analysis was performed at the global level using multivariate methods by Hotelling T² tests and intrasubject-level using t-test.

Results and Discussion: An initial average NPRS = 7.8 was determined. In the medium-term follow-up group (4 months), the NPRS dramatically decreased (NPRS = 1.1). The pain disappeared in the long-term (2 years) follow-up group (NPRS = 0). The study results highlight that LLD equalization treatment led to clear statistically significant improvements in all the postural parameters of the frontal plane, including the underfoot load asymmetry. No worsening has been detected. An adaptation period long enough is needed to obtain progressive pain relief improvements and structural posture changes. Younger NSLBP patients showed slightly better improvements than older ones. Minimal differences between healthy young adults’ and NSLBP patients’ postures were found either in natural erect standing posture or when LLD equalization is applied.

Conclusion: Heel-lift customized orthotics with 100% LLD correction are an effective short- and long-term treatment in patients with nonspecific LBP, inducing pain symptom recession and stimulating the improvement of postural parameters without contraindications.

Radiophobia Overreaction: College of Chiropractors of British Columbia Revoke Full X-Ray Rights Based on Flawed Study and Radiation Fear-Mongering

Fears over radiation have created irrational pressures to dissuade radiography use within chiropractic. Recently, the regulatory body for chiropractors practicing in British Columbia, Canada, the College of Chiropractors of British Columbia (CCBC), contracted Pierre Côté to review the clinical use of X-rays within the chiropractic profession. A "rapid review" was performed and published quickly and included only 9 papers, the most recent dating from 2005; they concluded, "Given the inherent risks of radiation, we recommend that chiropractors do not use radiographs for the routine and repeat evaluation of the structure and function of the spine." The CCBC then launched an immediate review of the use of X-rays by chiropractors in their jurisdiction. Member and public opinion were gathered but not presented to their members. On February 4, 2021, the College announced amendments to their Professional Conduct Handbook that revoked X-ray rights for routine/repeat assessment and management of patients with spine disorders. Here, we highlight current and historical evidence that substantiates that X-rays are not a public health threat. We also point out critical and insurmountable flaws in the single paper used to support irrational and unscientific policy that discriminates against chiropractors who practice certain forms of evidence-based X-ray-guided methods.

Pelvic Sagittal Torsion Caused by Induced Leg Length Discrepancy: Geometrical Illusion May Influence Measures Based on Superior-iliac Spines Positions

OBJECTIVE

To investigate whether a common measure of sagittal pelvic torsion based on the superior iliac spines behave similarly to predictions of a rigid (non-torsioned) plane, when leg length discrepancies (LLD) are induced.

METHOD

Twenty-four young asymptomatic participants were subjected to pelvic posture measurements that use the anterior-superior iliac spines (ASISs) and posterior-superior iliac spines (PSISs) as references, while standing on level ground and with a one-, two- and three-centimeter lifts under the left foot. A special caliper with digital inclinometers was used. The following angles were measured: angles of the right and left PSIS-to-ASIS lines; right-left relative angle (RLRA), as the angle between the right and left PSIS-to-ASIS lines, which is a traditional lateral-view measure intended to detect sagittal torsions; angle of the inter-ASISs line; angle of the inter-PSISs line; anterior-posterior relative angle (APRA), as the angle between the inter-ASISs and inter-PSISs lines. According to trigonometric predictions based on the geometry given by the lines linking the superior iliac spines (i.e. a trapezoid plane), a pure lateral tilt of the pelvis, without interinnominate sagittal motion, would change RLRA in a specific direction and would not change APRA.

RESULTS

Repeated-measures ANOVAs revealed that RLRA (p<0.001) and right and left PSIS-to-ASIS angles (p≤0.001) changed, and APRA did not change (p=0.33), as predicted.

CONCLUSIONS

At least part of the sagittal torsion detected by measures that assume the PSIS-to-ASIS angles as the sagittal angles of the innominates is due to pelvic geometry and not to the occurrence of actual torsion, when LLDs are induced.

Indications of sole lift and foot orthoses in the management of mild idiopathic scoliosis—a review

[Purpose] Leg length discrepancy is common among patients with scoliosis. Some studies reported reduced functional scoliosis curves with correction of leg length discrepancy. Others, however, have shown that induced leg length discrepancy has little effects on spinal deformities. Also, small number of studies assessed the use of foot orthoses in patients with faulty foot biomechanics and their impact on idiopathic scoliosis. In this context, a review of the literature is needed to determine the current evidence for the appropriate use of sole lift and foot orthoses in a context of scoliosis. [Methods] A literature review was performed. [Results] It appeared that sole lifts are indicated for functional lumbar scoliosis when the level of the sacrum is parallel to that of the hips. Sole lifts may not be indicated for patients with structural scoliosis, seemingly inducing a compensatory curve. Custom foot orthoses were found to reduce spinal curves in juvenile patients with mild idiopathic scoliosis and concomitant abnormal foot biomechanics. [Conclusion] Sole lift appeared to be indicated in the presence of certain types of functional scoliosis. Custom foot orthoses can be considered in the management of mild idiopathic scoliosis in juvenile patients. Evidence, however, is low and quality studies are needed to validate these findings.

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.

Shoe Lifts for Leg Length Discrepancy in Adults With Common Painful Musculoskeletal Conditions: A Systematic Review of the Literature

OBJECTIVE

To determine whether shoe lifts effectively treat leg length discrepancy (LLD)-associated morbidities in adults with common painful musculoskeletal conditions.

DATA SOURCES

Trip database, Cochrane Central Register of Controlled Trials database, PubMed database, Physiotherapy Evidence Database, and National Guideline Clearinghouse database. The search was performed in September 2017, was limited to English only, and had no time constraints.

STUDY SELECTION

Two reviewers independently determined study eligibility. Inclusion criteria were (1) participants ≥18 years old with musculoskeletal-related complaints and LLD; (2) a shoe lift intervention was used; and (3) the study reported on pain, function, range of motion, patient satisfaction, quality of life, or adverse events. Randomized controlled trials (RCTs) and controlled intervention, cohort, before-and-after, case series, and case report studies were included. Three-hundred and nineteen articles were screened, and 9 guidelines were reviewed.

DATA EXTRACTION

We extracted data pertaining to participant demographic characteristics, study setting, recruitment, randomization, method of LLD measurement, shoe lift characteristics, treatment duration, and outcome measures. We included 10 studies, including 1 RCT.

DATA SYNTHESIS

LLD was associated with low back pain, scoliosis, and osteoarthritis of the hip and knee. Description of LLD correction strategy was often inadequate. Study quality was very low or poor. In non-RCT studies reporting on the proportion of participants who improved with a shoe lift, 88%±3% of 349 participants treated had partial or complete pain relief (effect size range, 66.7%-100%). All 22 RCT participants receiving treatment experienced pain relief (mean pain reduction, 27±9mm on a 150-mm visual analog scale). Two of 9 guidelines recommended shoe lift use based on consensus and were of moderate-to-high quality.

CONCLUSIONS

There is low-quality evidence that shoe lifts reduce pain and improve function in patients with LLD and common painful musculoskeletal conditions. High-quality research evaluating a threshold LLD to correct and a strategy to do so is necessary. Developing an appropriate comparison group to test clinically relevant outcome measures would make a valuable contribution in this regard.

Normative 3D opto-electronic stereo-photogrammetric posture and spine morphology data in young healthy adult population

Design: Observational cross-sectional study. The current study aims to yield normative data: i.e., the physiological standard for 30 selected quantitative 3D parameters that accurately capture and describe a full-skeleton, upright-standing attitude. Specific and exclusive consideration was given to three distinct categories: postural, spine morphology and pelvic parameters. To capture such 3D parameters, the authors selected a non-ionising 3D opto-electronic stereo-photogrammetric approach. This required the identification and measurement of 27 body landmarks, each specifically tagged with a skin marker. As subjects for the measurement of these parameters, a cohort of 124 asymptomatic young adult volunteers was recruited. All parameters were identified and measured within this group. Postural and spine morphology data have been compared between genders. In this regard, only five statistically significant differences were found: pelvis width, pelvis torsion, the “lumbar” lordosis angle value, the lumbar curve length, and the T12-L5 anatomically-bound lumbar angle value. The “thoracic” kyphosis mean angle value was the same in both sexes and, even if, derived from skin markers placed on spinous processes it resulted in perfect agreement with the X-ray based literature. As regards lordosis, a direct comparison was more difficult because methods proposed in the literature differ as to the number and position of vertebrae under consideration, and their related angle values. However, when the L1 superior–L5 inferior end plate Cobb angle was considered, these results aligned strongly with the existing literature. Asymmetry was a standard postural-spinal feature for both sexes. Each subject presented some degree of leg length discrepancy (LLD) with μ = 9.37mm. This was associated with four factors: unbalanced posture and/or underfoot loads, spinal curvature in the frontal plane, and pelvis torsion. This led to the additional study of the effect of LLD equalisation influence on upright posture, relying on a sub-sample of 100 subjects (51 males, 49 females). As a result of the equalisation, about 82% of this sub-sample showed improvement in standing posture, mainly in the frontal plane; while in the sagittal plane less than 1/3 of the sub-sample showed evidence of change in spinal angles. A significant variation was found in relation to pelvis torsion: 46% of subjects showed improvement, 49% worsening. The method described in study presents several advantages: non-invasive aspect; relatively short time for a complete postural evaluation with many clinically useful 3D and 2D anatomical/biomechanical/clinical parameters; analysis of real neutral unconstrained upright standing posture.

Idiopathic scoliosis: Static analysis of the influence of shim use on postural angles

Abstract Introduction: Scoliosis is characterized as a three-dimensional deformity. In this scenario, the use of shims can promote correction of postural imbalances. Objective: To verify the static changes associated with unilateral manipulation of shims in idiopathic scoliosis. Methods: Two experimental groups composed of participants with scoliosis with double and single curves, and a control group of participants without scoliosis. 10 reflective markers were used, filmed for 15 seconds in the static position in three conditions (no shim; low shim of 1 cm, and high shim of 3 cm) on the right and left foot. The following postural angles were calculated: alpha 1, alpha 2, alpha 3, and alpha 4. Results: There were differences in the shim condition between the control group (CG) and experimental scoliosis with “S” (GES) for alpha 2 and 4 and Scoliosis “C” (GEC) for alpha 2. For shims under the right foot, there were differences between the control group and GES for alpha 4 and the GEC for alpha 1, 2 and 4, and between shims for the GES for alpha 3 and 4. Shims under the left foot were responsible for significant differences between the control group and the GES and GEC groups. Conclusion: These static postural changes indicate that scoliosis curves show adaptability and postural reorganization in response to manipulation with shims, and the greatest influence is seen in the lower segments, both in simple and double curves. According to the results it is concluded that residual scoliotic curvatures have flexibility that allows postural adjustment with shims.

Raster-stereographic evaluation of the effects of biomechanical foot orthoses in patients with scoliosis

[Purpose] Little is known about the effects of biomechanical foot orthoses in scoliosis, as determined by raster stereography. The objective of this study was to investigate the effect of individually manufactured biomechanical foot orthoses on scoliosis angle, trunk imbalance, and pelvic obliquity by comparing them with general insoles by using DIERS formetric 4 dimensional in patients with scoliosis. [Subjects and Methods] Twenty-six patients with scoliosis were recruited at Yeungnam University Hospital and allocated equally to one of two groups, the biomechanical foot orthoses group or the control group. Parameters, such as, trunk rotation, imbalance, and scoliosis angle, were obtained using a DIERS formetric 4D. [Results] Scoliosis angle, pelvic obliquity, and trunk imbalance were significantly different between the two groups and improved in the biomechanical foot orthoses group with time, but no significant improvement in any parameter was observed in the control group. [Conclusion] Biomechanical foot orthoses could be effective in patients with scoliosis, and DIERS formetric 4D provides a useful method for evaluating scoliosis parameters.

Influência de calços na orientação postural de indivíduos com escoliose idiopática

INTRODUÇÃO: A relação entre a orientação dos segmentos e os ajustes que podem ser desencadeados por calços e palmilhas em pacientes escolióticos durante a manutenção da posição ortostática é pouco conhecida. OBJETIVO: Verificar alterações estáticas e associadas com mudanças unilaterais de calços na orientação postural de indivíduos com escoliose idiopática. MATERIAIS E MÉTODOS: Grupo experimental com dez indivíduos com escoliose idiopática com curva dupla (menor 10°) e grupo controle com dez indivíduos sem escoliose (faixa etária de 13 a 24 anos). Participantes foram filmados na posição ortostática sem calço, com calço baixo (1 cm) e com calço alto (3 cm); estes foram colocados sob o pé direito e pé esquerdo dos indivíduos. Em cada condição, o participante manteve a posição estática durante 15 segundos e marcadores refletivos foram colocados em pontos anatômicos específicos. Foram calculados ângulos posturais: torácico alto; torácico médio; toracolombar e lombar e ângulos segmentares: ombro; escápula; pelve e joelho. RESULTADOS: Na condição sem calço, diferenças foram observadas entre grupos para os ângulos posturais toracolombar e lombar e para o ângulo segmentar do ombro. Com calço baixo e alto, sob o pé direito, diferença foi observada entre calços para os ângulos lombar, da pelve e do joelho. Com calço baixo e alto, sob o pé esquerdo, diferença foi observada entre grupos para o ângulo toracolombar e entre calços para os ângulos da pelve e do joelho. CONCLUSÕES: A utilização de calço promove reorientação nas regiões mais baixas da coluna e nos segmentos da pelve e do joelho. Estes resultados sugerem que nas escolioses duplas, manipulação da base de apoio modifica o alinhamento do tronco que pode provocar reorganização das estruturas e busca de um novo arranjo entre segmentos em indivíduos com escoliose idiopática.

Determination of the amount of leg length inequality that alters spinal posture in healthy subjects using rasterstereography

PURPOSE

Leg length inequalities (LLIs) can result in an increased energy consumption, abnormal gait or osteoarthritis of the hip. In a previous study we simulated different LLIs of up to 15 mm and evaluated their effects on the pelvic position and spinal posture. We found a correlation between LLIs and resulting changes of the pelvic position. Despite suggestions in the literature we were not able to detect significant changes of the spinal posture. Therefore, the purpose of this study was to determine the amount of LLI that would in fact alter the spinal posture.

METHODS

The subjects were placed on a simulation platform, whose height could be precisely controlled by the measuring device, to simulate different LLIs of up to 20 mm. For LLIs >20 mm, additional precision-cut wooden blocks were used under one foot. After an adaptation period the resulting changes of the pelvis and spine were measured with a rasterstereographic device.

RESULTS

We found a significant correlation between platform height changes and changes of the pelvic position. The frontal spinal parameters surface rotation and lateral deviation changed significantly when simulating differences greater than 20 mm. No changes of the sagittal spinal curvature were measured, however, a trend to decreasing kyphotic angles was noted.

CONCLUSIONS

Our study has shown for the first time that LLIs >20 mm will lead to significant changes in the spinal posture of healthy test subjects. However, these changes were only found in frontal (surface rotation and lateral flexion) spinal parameters, but not in sagittal parameters. Here for the kyphotic angle only a tendency to decreasing angles was noted. We have also found a significant correlation between different leg lengths and changes of the pelvic position. Further, females and males seem to react in the same way to LLIs.

The effect of simulating leg length inequality on spinal posture and pelvic position: a dynamic rasterstereographic analysis

INTRODUCTION

Leg length inequalities (LLI) are a common finding. Rasterstereography offers a non-invasive, contact-free and reliable method to detect the effects of LLIs on spinal posture and pelvic position.

MATERIALS AND METHODS

A total of 115 subjects were rasterstereographically examined during different artificially created leg length inequalities (5-15 mm) using a platform. The pelvic obliquity and torsion and the lateral and frontal deviation of the spine, as well as the surface rotation, were measured.

RESULTS

Changes in platform height led to an increase of the pelvic tilt and torsion. Only minor changes in the spinal posture were found by different simulated leg length inequalities.

CONCLUSIONS

Our study showed that there was a correlation between an artificial leg length inequality up to 15 mm and pelvic tilt or torsion, but only minor changes in the spinal posture were measured. Further studies should investigate the effects of greater leg length inequalities on spine and pelvis.

Functional scoliosis caused by leg length discrepancy

INTRODUCTION

Leg length discrepancy (LLD) causes pelvic obliquity in the frontal plane and lumbar scoliosis with convexity towards the shorter extremity. Leg length discrepancy is observed in 3-15% of the population. Unequalized lower limb length discrepancy leads to posture deformation, gait asymmetry, low back pain and discopathy.

MATERIAL AND METHODS

In the years 1998-2006, 369 children, aged 5 to 17 years (209 girls, 160 boys) with LLD-related functional scoliosis were treated. An external or internal shoe lift was applied.

RESULTS

Among 369 children the discrepancy of 0.5 cm was observed in 27, 1 cm in 329, 1.5 cm in 9 and 2 cm in 4 children. During the first follow-up examination, within 2 weeks, the adjustment of the spine to new static conditions was noted and correction of the curve in 316 examined children (83.7%). In 53 children (14.7%) the correction was observed later and was accompanied by slight low back pain. The time needed for real equalization of limbs was 3 to 24 months. The time needed for real equalization of the discrepancy was 11.3 months.

CONCLUSIONS

Leg length discrepancy equalization results in elimination of scoliosis. Leg length discrepancy < 2 cm is a static disorder; that is why measurements should be performed in a standing position using blocks of adequate thickness and the position of the posterior superior iliac spine should be estimated.

The relationship between pelvic torsion and anatomical leg length inequality: a review of the literature

OBJECTIVE

Although it is common to find assertions relating functional leg length inequality (LLI) to pelvic torsion and other states of subluxation, comments and/or data concerning anatomical LLI in this same context are uncommon. This review of the literature synthesizes the evidence on pelvic torsion in relation to anatomical LLI.

METHODS

The literature was searched using the PubMed; Manual, Alternative, and Natural Therapy Index System; Allied and Complementary Medicine Database; Cumulative Index to Nursing and Allied Health Literature; and Index to Chiropractic Literature databases for primary studies that related LLI, either artificially created or naturally occurring, to pelvic torsion. Extracted data included natural vs artificial LLI, method of creating or detecting LLI, subject selection, methodology for measuring pelvic torsion, and results.

RESULTS

Nine English-language studies were retrieved published 1936-2004. Seven determined the impact of artificial, transient LLI on pelvic torsion, whereas 2 studied the effect of naturally occurring LLI.

CONCLUSION

Across varying methodologies for measuring LLI and pelvic torsion, a consistent, dose-related pattern was identified in which the innominate rotates anteriorly on the side of a shorter leg and posteriorly on the side of the longer leg. This finding was contrary to the common assertion that the ilium rotates posteriorly on the side of a short leg and vice versa. Practitioners of manual medicine who derive vectors for intervention based on leg checking procedures should consider the possibility that the direction of pelvic torsion may be variable depending on whether the LLI is of anatomical or functional origin.

Three dimensional evaluation of posture in standing with the PosturePrint: an intra- and inter-examiner reliability study

Background

Few digitizers can measure the complexity of upright human postural displacements in six degrees of freedom of the head, rib cage, and pelvis.

Methods

In a University laboratory, three examiners performed delayed repeated postural measurements on forty subjects over two days. Three digital photographs (left lateral, AP, right lateral) of each of 40 volunteer participants were obtained, twice, by three examiners. Examiners placed 13 markers on the subjects before photography and chose 16 points on the photographic images. Using the PosturePrint^® internet computer system, head, rib cage, and pelvic postures were calculated as rotations (Rx, Ry, Rz) in degrees and translations (Tx, Tz) in millimeters. For reliability, two different types (liberal = ICC_3,1 & conservative = ICC_2,1) of inter- and intra-examiner correlation coefficients (ICC) were calculated. Standard error of measurements (SEM) and mean absolute differences within and between observers' measurements were also determined.

Results

All of the "liberal" ICCs were in the excellent range (> 0.84). For the more "conservative" type ICCs, four Inter-examiner ICCs were in the interval (0.5–0.6), 10 ICCs were in the interval (0.61–0.74), and the remainder were greater than 0.75. SEMs were 2.7° or less for all rotations and 5.9 mm or less for all translations. Mean absolute differences within examiners and between examiners were 3.5° or less for all rotations and 8.4 mm or less for all translations.

Conclusion

For the PosturePrint^® system, the combined inter-examiner and intra-examiner correlation coefficients were in the good (14/44) and excellent (30/44) ranges. SEMs and mean absolute differences within and between examiners' measurements were small. Thus, this posture digitizer is reliable for clinical use.

Postural sway at ground and bevel levels in subjects with spina bifida occulta

To assess whether the postural function is impaired by comparing the performances in upright standing at ground and bevel levels in adult subjects with spina bifida occulta (SBO). Eighty subjects with SBO (38 with minor type and 42 with major type) and 35 healthy control subjects participated in the study. All participants performed ten tests while standing upright on a platform at ground level (0 degrees, baseline) and on a beveled surface (with their feet in dorsiflexion and plantarflexion at 10 degrees and 20 degrees). Tests were done with their eyes open and closed. The postural sway was examined using a force platform (CATSYS, Danish) that records sway intensity and velocity. Sway intensity and sway velocity were universally associated with group, degree of bevel, open- or closed-eyes condition, and dorsiflexion or plantarflexion after adjusting for age and gender. With respect to sway intensity, the differences of minor or major SBO group were significantly decreased at different bevel degrees when compared with control groups, whereas the differences between minor and major SBO were significant differences at 10 degrees and 20 degrees. With respect to sway velocity, the differences of major SBO group were significantly decreased at different bevel degrees when compared with minor SBO and control groups, whereas the difference in minor SBO was only significant at 0 degrees when compared with control. Group differences (minor SBO vs. control, major SBO vs. control) showed a significant decrease in sway velocity when comparing at 10 degrees than at 0 degrees and at 20 degrees than at 0 degrees. In all subjects with SBO, the sway intensity/velocity values obtained with open eyes and with plantarflexion had lower values, when compared with values obtained with closed eyes and with dorsiflexion. This study supports the hypothesis that SBO impairs control of postural sway in both the resting upright and stressful postures. Our results imply that the larger the bone defect at the lumbosacral midline, the more the group differences in different stressful conditions. Both velocity and intensity were able to reflect the function of the postural sway from our results. This is the first report to add the bevel degree and foot position, as well as visual input as being the part of the study in investigating the postural sway.

Conservative Correction of Leg-Length Discrepancies of 10mm or Less for the Relief of Chronic Low Back Pain

OBJECTIVE

To study whether conservative correction in a leg-length discrepancy (LLD) of 10mm or less in patients with chronic low back pain (CLBP) can relieve pain.

DESIGN

Randomized, controlled intervention study, with a mean follow-up duration of 10 weeks.

SETTING

Physical therapy clinic of the national health services.

PARTICIPANTS

Thirty-three patients with CLBP were screened for an LLD of 10mm or less, which was measured with ultrasound. Patients were randomly divided into intervention and control groups.

INTERVENTION

In 22 patients, LLD was corrected by applying individually fitted shoe inserts. In 11 patients, LLD was not corrected.

MAIN OUTCOME MEASURES

Chronic pain intensity (visual analog scale) and disability score (Roland-Morris Disability Questionnaire).

RESULTS

Shoe inserts significantly reduced both pain intensity (P<.001) and disability (P<.05). A moderate positive correlation was found between LLD and the degree of pain relief after wearing shoe inserts (r=.47).

CONCLUSIONS

Shoe inserts appear to reduce CLBP and functional disability in patients with LLDs of 10mm or less. Shoe inserts are simple, noninvasive, and inexpensive therapeutic means that can be added to the treatment of CLBP.

Anatomic and functional leg-length inequality: a review and recommendation for clinical decision-making. Part I, anatomic leg-length inequality: prevalence, magnitude, effects and clinical significance

BACKGROUND

Leg-length inequality is most often divided into two groups: anatomic and functional. Part I of this review analyses data collected on anatomic leg-length inequality relative to prevalence, magnitude, effects and clinical significance. Part II examines the functional "short leg" including anatomic-functional relationships, and provides an outline for clinical decision-making.

METHODS

Online database--Medline, CINAHL and MANTIS--and library searches for the time frame of 1970-2005 were done using the term "leg-length inequality".

RESULTS AND DISCUSSION

Using data on leg-length inequality obtained by accurate and reliable x-ray methods, the prevalence of anatomic inequality was found to be 90%, the mean magnitude of anatomic inequality was 5.2 mm (SD 4.1). The evidence suggests that, for most people, anatomic leg-length inequality does not appear to be clinically significant until the magnitude reaches approximately 20 mm (approximately 3/4").

CONCLUSION

Anatomic leg-length inequality is near universal, but the average magnitude is small and not likely to be clinically significant.

A three-dimensional active shape model for the detection of anatomical landmarks on the back surface

In this study relations between anatomical landmarks on the dorsal surface of the human torso corresponding to underlying skeletal structures are established. By examining the statistics of the positions of the landmarks in a training set of subjects a point distribution model is derived. Rotations of the pelvis are simulated in order to show that the main mode shapes of variation are consistent with rotations of the pelvis relative to the trunk. The parameters of these mode shapes can therefore be used as independent measures of clinical parameters such as pelvic inclination, pelvic tilt, etc. The point distribution model is further applied to improve reliability and robustness for an automatic and objective detection of the anatomical landmarks on the back surface (active shape model). The results show that it is possible to replace radiographs by surface measurements in order to measure position and orientation of the pelvis, which is particularly valuable in the case of functional examinations that normally involve a large number of radiographs (e.g. to measure the position of the pelvis in a scoliosis).

Validity of compressive leg checking in measuring artificial leg-length inequality

OBJECTIVE

To determine the accuracy of instrumented prone compressive leg checking.

DESIGN

Repeated measures (n = 26) on single subjects (n = 3).

SETTING

Chiropractic college research clinic.

METHODS

A pair of surgical boots were modified to permit continuous measurement of leg-length inequality (LLI). Multiple prone leg-check observations of a blinded examiner on 3 subjects were tested against artificial LLI that was created by randomly inserting 0 to 6 1.6-mm shims in either boot. Accuracy was assessed both within observations (observed versus artificial LLI) and between observations (observed versus artificial changes in LLI). The intraclass correlation coefficient (ICC), Lin's concordance correlation coefficient (CCC), Bland-Altman limits of agreement, and linear regression statistics were obtained to determine the reliability and validity of compressive leg checking compared to a reference standard.

RESULTS

For each shim condition, test-retest reliability was excellent (ICC =.85 and CCC = 0.95). The 95% confidence interval for the limits of agreement for observed versus artificial change in LLI was -5.44 to 5.67. The observed and artificial LLI shared 87% of their variation within observations (n = 78) and 88% between observations (n = 75). The mean examiner error was 1.72 mm and 2.01 mm, respectively.

CONCLUSION

Compressive leg checking seems highly accurate, detecting artificial changes in leg length +/-1.87 mm, and thus possesses concurrent validity assessed against artificial LLI. Pre-leg-check and post-leg-check differences should exceed 3.74 mm to be confident a real change has occurred. It is unknown whether compressive leg checking is clinically relevant.

Effect of simulating leg length inequality on pelvic torsion and trunk mobility

Although techniques such as roentgenograms and magnetic resonance imaging can provide definitive information about leg length inequality, they are not easily implemented for screening purposes. Using relative heights of palpated iliac crests as criteria for determining degree of lateral pelvic tilt, we examined the immediate effect of simulating leg length inequality on pelvic torsion and trunk flexion. In seven healthy men and 22 healthy women, 18-28 years of age, a lift of at least 15 mm was placed under either foot to laterally tilt the pelvis 1.2 degrees or more. In eight subjects with pre-existing lateral pelvic tilts of 1.8 degrees or more, a lift was also used to eliminate the tilt. We examined how this tilting affected torsion between the innominates and mobility of the trunk. The innominate contralateral to the lift became more anteriorly rotated than the ipsilateral innominate and lateral flexion of the trunk increased toward the side of the lift. Both of these effects can be associated with clinical leg length inequality, so a lateral pelvic tilt on the order of 1.2 degrees, if encountered in the clinic, should signal the suitability of more extensive examination for possible lower limb asymmetry.