Tássia Silveira Furlanetto

Validity and Reproducibility of the Measurements Obtained Using the Flexicurve Instrument to Evaluate the Angles of Thoracic and Lumbar Curvatures of the Spine in the Sagittal Plane

Objective. to verify the validity and reproducibility of using the flexicurve to measure the angles of the thoracic and lumbar curvatures. Method. 47 subjects were evaluated by: (1) palpation and marking of the spinous processes using lead markers, (2) using X-rays in the sagittal plane to measure the Cobb angles, (3) molding the flexicurve to the spine, and (4) drawing the contour of the flexicurve onto graph paper. The angle of curvature was determined with the flexicurve based on a 3rd order polynomial. Results. No differences were found between the Cobb angles and the angles obtained using the flexicurve in thoracic and lumbar curvatures (P > 0.05). Correlations were strong and significant for the thoracic (r = 0.72, P < 0.01) and lumbar (r = 0.60, P < 0.01) curvatures. Excellent and significant correlations were found for both the intraevaluator and interevaluator measurements. Conclusion. The results show that there is no significant difference between the values obtained using the flexicurve and those obtained using the X-ray procedure and that there is a strong correlation between the two methods. This, together with the excellent level of inter- and intraevaluator reproducibility justifies its recommendation for use in clinical practice.

Validation, repeatability and reproducibility of a noninvasive instrument for measuring thoracic and lumbar curvature of the spine in the sagittal plane.

BACKGROUND The need for early identification of postural abnormalities without exposing patients to constant radiation has stimulated the development of instruments aiming to measure the spinal curvatures. OBJECTIVE To verify the validity, repeatability and reproducibility of angular measures of sagittal curvatures of the spine obtained using an adapted arcometer, by comparing them with Cobb angles of the respective curvatures obtained by using X-rays. METHODS 52 participants were submitted to two procedures designed to evaluate the thoracic and lumbar curvatures: (1) X-ray examination from which the Cobb angles (CA) of both curvatures were obtained, and (2) measuring the angles with the arcometer (AA). Two evaluators collected the data using the arcometer, with the rods placed at T1, T12, L1 and L5 spinous processes levels in a way as to permit linear measurements which, with aid of trigonometry, supplied the AA. RESULTS There was a very strong and significant correlation between AA and CA (r=0.94; p<0.01), with no-significant difference (p=0.32), for the thoracic curvature. There was a strong and significant correlation for the lumbar curvature (r=0.71; p<0.01) between AA and CA, with no-significant difference (p=0.30). There is a very strong correlation between intra-evaluator and inter-evaluator AA. CONCLUSION It was possible to quantify reliably the thoracic and lumbar curvatures with the arcometer and it can thus be considered valid and reliable and for use in evaluating spinal curvatures in the sagittal plane.

Validating a postural evaluation method developed using a Digital Image-based Postural Assessment (DIPA) software

OBJECTIVE To investigate (1) the accuracy of the palpatory method to identify anatomical points by comparison with the X-ray exams, (2) the validity of classifying spinal posture in the frontal plane using Digital Image-Based Postural Assessment (DIPA) software by comparison with the X-ray exams and (3) the intra and inter-evaluator reproducibility of the DIPA software. MATERIALS AND METHODS The postural assessment and X-ray examination of the spine, both in the frontal plane and standing position, were performed consecutively in 24 subjects. The postural assessment protocol consisted of: (1) palpation and the use of reflective markers containing lead to mark the spinous processes (SP) of the C7, T2, T4, T6, T8, T10, T12, L2, L4 and S2 vertebrae and; (2) acquisition of photographic records. First, the X-ray examinations were used to check the correlation between the palpated and marked SP and the true location of the SP of the vertebra in question, by assessing the distance between them. The spinal posture was classified based on the calculation of the scoliosis arrows in the DIPA (DIPA-SA). The X-ray examinations provided the scoliosis arrows (X-SA), the Cobb angles and the classification of spinal posture based on the Cobb angle. The results from the DIPA protocol were compared to those from the X-ray examination-based protocol. The statistical tests used were: (1) Kruskal-Wallis--differences in terms of the numerical distance between the markers and the anatomical landmarks, (2) Pearsons Correlation--DIPA-SA and Cobb angles, (3) Pearsons Correlation--X-SA and DIPA-SA; (4) Bland and Altmans graphic representation--X-SA and DIPA-SA, (5) Spearmans Correlation--classification of spinal posture obtained using the X-ray and DIPA protocols, (6) the intraclass correlation test (ICC) for the relationship between the DIPA-SA made by each evaluator (inter-evaluator), and (7) independent t-test to compare the data from the two evaluation days (intra-evaluator), α=0.05. RESULTS There were no significant differences between the location of the anatomical points located using palpation and identified with reflective markers and the respective location of the SP as identified using X-ray exams (χ²=9.366, p=0.404). Significant correlations were found between the DIPA-SA and the Cobb angles in the dorsal (r=0.75, p<0.001) and lumbar (r=0.76, p=0.007) regions; between the DIPA-SA and the X-SA in the dorsal (r=0.79, p<0.001) and lumbar (r=0.92, p<0.001) regions and; between the classifications of posture obtained with the DIPA and X-ray protocols (r=0.804, p<0.001). Bland and Altmans representation showed agreement between DIPA-SA and X-SA for both curvatures. Significant correlations were found for the intra-evaluator test in the thoracic (r=0.99, p<0.001) and lumbar (r=0.98, p<0.001) regions; for the inter-evaluator test in the thoracic (r=0.99, p<0.001) and lumbar (r=0.88, p<0.001) regions. CONCLUSION The results suggest that the DIPA protocol constitutes a valid simple, practical and low-cost non-invasive tool for the evaluation of the spine in the frontal plane which can be used to obtain reproducible measurements (inter and intra-evaluators).

Photogrammetry as a tool for the postural evaluation of the spine: A systematic review.

AIM To evaluate the use of photogrammetry and identify the mathematical procedures applied when evaluating spinal posture. METHODS A systematic search using keywords was conducted in the PubMed, EMBASE, Scopus, Science and Medicine(®) databases. The following inclusion criteria adopted were: (1) the use of photogrammetry as a method to evaluate spinal posture; (2) evaluations of spinal curvature in the sagittal and/or frontal plane; (3) studies published within the last three decades; and (4) written entirely in English. The exclusion criteria were: (1) studies which objective involved the verification of some aspect of validation of instruments; (2) studies published as abstracts and those published in scientific events; and (3) studies using evaluation of the anteriorization of the head to determine the angular positioning of the cervical spine. The articles in this review were included and evaluated for their methodological quality, based on the Downs and Black scale, by two independent reviewers. RESULTS Initially, 1758 articles were found, 76 of which were included upon reading the full texts and 29 were included in accordance with the predetermined criteria. In addition, after analyzing the references in those articles, a further six articles were selected, so that 35 articles were included in this review. This systematic review revealed that the photogrammetry has been using in observational studies. Furthermore, it was also found that, although the data collection methodologies are similar across the studies, in relation to aspects of data analysis, the methodologies are very different, especially regarding the mathematical routines employed to support different postural evaluation software. CONCLUSION With photogrammetry, the aim of the assessment, whether it is for clinical, research or collective health purposes, must be considered when choosing which protocol to use to evaluate spinal posture.

PROPRIOCEPTION, BODY BALANCE AND FUNCTIONALITY IN INDIVIDUALS WITH ACL RECONSTRUCTION

Objective : To evaluate and compare proprioception, body balance and knee functionality of individuals with or without unilateral anterior cruciate ligament (ACL) reconstruction. Methods : Forty individuals were divided in two groups: Experimental group, 20 individuals with ACL reconstruction at six months postoperative, and control group, 20 individuals with no history of lower limb pathologies. In the experimental group, we assessed lower limbs with reconstructed ACL and contralateral limb; in the control group the dominant and the non-dominant lower limbs were assessed. All subjects were submitted to joint position sense test to evaluate proprioception, postural control measure in single-limb, and step up and down (SUD) test for functional assessment. Results : There were no deficits in proprioception and postural control. In the SUD test, a 5% decrease in lift up force was found in reconstructed ACL lower limbs, however, a statistically not significant difference. The impact and step down force during the course of test were 30% greater in anatomic ACL than in control lower limbs. Conclusion : The individuals with ACL reconstruction at six months postoperative did not show changes in proprioception and postural control, but showed motor control changes, influencing knee functionality. Level of Evidence IV, Prognostic Studies.

Monitoring the prevalence of postural changes in schoolchildren

[Purpose] The aim of this study was to identify whether postural changes are prevalent with advancing age using a photogrammetric method performing one-year follow-up study. [Subjects and Methods] Thirty-eight schoolchildren were evaluated in 2011 and 2012 in this cohort study. The subjects underwent a postural evaluation, which involved palpation of reference anatomic points, placement of reflexive markers over the anatomic points, image acquisition, and point digitalization using the Digital Image-based Postural Assessment evaluation software. For data analysis, descriptive statistics and inferential statistics were analyzed by McNemar’s test. [Results] The results showed a significant increase in postural change prevalence for the lumbar spine in the sagittal plane (from 42.2% to 81.6%) and the knees in the frontal plane (from 39.5% to 63.2%) and a significant decrease in the prevalence of scoliosis (from 68.5% to 42.2%). [Conclusion] The findings indicate an increase in the prevalence of postural changes in schoolchildren from Teutônia, RS, Brazil, in 2012 compared with 2011. The development of longitudinal investigations for long-term monitoring of the evolution of posture and of schoolchildren habits’s representing a viable alternative to subsidize health actions.

Pontos marcados na superfície da pele representam os processos espinhosos quando a postura é modificada

The objective was to radiographically verify if the position of skin markers, identified by palpation in orthostasis posture, changes when the subject position shifts to lying posture. Ten subjects underwent two X-ray tests, first, in orthostasis and right lying posture. Ten subjects were palpated and marked with skin markers in the orthostasis posture, in the spinous process of the vertebrae C7, T2, T4, T6, T8, T10, T12, L2, L4 and S2 . After palpation, subjects underwent X-ray exams in orthostasis and lying postures to verify if the surface marker matched the spinous process shown on X-ray. A two-way ANOVA indicated significant differences for the displacement of the skin markers, for the C7, T2, T4, T6, T8, T10, L2 and S2 spinous processes (p<0.001). The T12 and L4 spinous processes did not indicate significant differences. The skin markers locations were not consistent with the spinous processes identified in X-rays for both positions. The skin movement may have displaced the skin markers when the subject changed from orthostasis to lying posture.

Evaluation of the precision and accuracy of the DIPA software postural assessment protocol

Abstract To evaluate the repeatability and intra- and inter-rater reproducibility of the DIPA protocol for postural evaluation of the frontal and sagittal planes; and to evaluate the validity of the results of evaluating the spine in the sagittal plane using the DIPA software. To evaluate the intra- and inter-rater reproducibility and repeatability (n = 16), the DIPA protocol was conducted on the individuals by three raters, by the same rater on different two occasions and by same rater twice immediately, respectively. To evaluate validity, 54 individuals underwent X-ray evaluation of the spine in the sagittal plane and the DIPA protocol. The Intraclass Correlation Coefficient, the Standard Error of Measurement (SEM) and the Minimum Detectable Change (MDC) were used to evaluate the repeatability and reproducibility; and the Pearson’s correlation test, the independent t test and the Morgan–Pitman’s test were used to evaluate the validity. The knee angle, sagittal and scoliotic arrows presented acceptable levels of correlation, with low SEM and MDC values. When compared to X-ray examination, the results of the DIPA software were excellent, with no significant difference, random error and similar variance between measurements. The DIPA protocol is accurate and precise, and can be used by the same or different raters.

Development and Validation of Prediction Equations for Spinal Curve Angles Based on Skin Surface Measurements

Objective The purpose of this study was to develop, assess the reliability of, and validate prediction equations that estimate the sagittal curves of the spine from the skin surface. Methods Forty digital panoramic radiographs were used to develop the prediction equation, and 59 radiographs were used to assess reliability and validate the equations. For evaluation of the thoracic and lumbar curves, anatomical reference points were marked on the vertebral body, spinous process, and skin surface at the C6, C7, T2, T4, T6, T8, T10, T12, L2, L4, and S2 vertebrae. Three third‐degree polynomials were obtained, estimated with the least squares method: inner curves from the centroid of the vertebral bodies and from the apex of the spinous processes and external curve from the skin surface. The magnitude of the curves of each region was estimated based on the angle between tangent lines at several vertebral levels. Prediction equations were obtained (simple linear regression) for the vertebral levels that had the best correlation between the inner and surface curves. The validation of the prediction equations was confirmed using Pearson’s correlation (r), Student t test, and root mean square error. The reliability of the method was confirmed using the intraclass correlation coefficient, standard error of measurement, and minimal detectable change (&agr; = 0.05). Results The best correlations were obtained between the T4‐T12 (thoracic) and T10‐S2 (lumbar) levels (r > 0.85). For the intrarater and interrater reliability, the correlation was higher than 0.965 and higher than 0.896, respectively. There was a significant and strong correlation between estimated and actual values for the thoracic and lumbar curves, which was confirmed by the t‐test results and by the root mean square error inferior to 1°. Conclusion Prediction equations can precisely and accurately estimate the angles of the internal sagittal curves of the spine from the skin surface.

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.