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Physical & Occupational Therapy in Pediatrics, 33(3):313326, 2013


C 2013 by Informa Healthcare USA, Inc.
Available online at http://informahealthcare.com/potp
DOI: 10.3109/01942638.2012.747582

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Differences in Standing and Sitting Postures of


Youth with Idiopathic Scoliosis from Quantitative
Analysis of Digital Photographs
Carole Fortin1,2 , Debbie Ehrmann Feldman3,4 , Farida Cheriet1,5 ,
& Hubert Labelle1,2
1

Centre de recherche, CHU Sainte-Justine, Montreal, Quebec, Canada, 2 Faculte de

medecine, Universite de Montreal, Montreal, Quebec, Canada, 3 Ecole


de readaptation,
4
Universite de Montreal, Montreal, Quebec, Canada, Institut de Recherche en Sante

Polytechnique
Publique de lUniversite de Montreal, Montreal, Quebec, Canada, 5 Ecole
de Montreal, Montreal, Quebec, Canada

ABSTRACT. The objective of this study was to explore whether differences in standing
and sitting postures of youth with idiopathic scoliosis could be detected from quantitative analysis of digital photographs. Standing and sitting postures of 50 participants
aged 1020-years-old with idiopathic scoliosis (Cobb angle: 15 to 60 ) were assessed
from digital photographs using a posture evaluation software program. Based on the
XY coordinates of markers, 13 angular and linear posture indices were calculated in
both positions. Paired t-tests were used to compare values of standing and sitting posture indices. Significant differences between standing and sitting positions (p < 0.05)
were found for head protraction, shoulder elevation, scapula asymmetry, trunk list, scoliosis angle, waist angles, and frontal and sagittal plane pelvic tilt. Quantitative analysis
of digital photographs is a clinically feasible method to measure standing and sitting
postures among youth with scoliosis and to assist in decisions on therapeutic interventions.
KEYWORDS.

Idiopathic scoliosis, measurement, sitting posture, standing posture

Muscle balance (e.g., symmetry of length and strength between paired anterior and
posterior muscles of the trunk and extremities) is an aim of physical therapy intervention for youth with idiopathic scoliosis (IS). Posture is usually assessed in the
standing position. However, children and adolescents spend many hours a day in
the sitting position at school or during leisure activities. Because assuming positions for long time periods may influence scoliosis progression, a recommendation
is to assess posture in both standing and sitting positions (Gram & Hasan, 1999;
Address correspondence to: Carole Fortin, P.T., Ph.D., Laboratoire LAVIANI, Centre de recherche,

CHU Sainte-Justine 3175, Cote-Sainte-Catherine,


Montreal, Quebec, Canada, H3T 1C5 (E-mail: carole.fortin@umontreal.ca).
(Received 26 February 2011; accepted 31 October 2012)

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Fortin et al.

Souchard & Ollier, 2002). Moreover, abnormal posture patterns, such as hypo or
hyper sagittal vertebral curves, pelvic tilt, scoliosis, or trunk list, could be caused by
short anterior or posterior muscles that might influence trunk kinematics and muscle activity differently in standing and sitting positions (Al-Eisa, Egan, Deluzio, &
Wassersug, 2006; Gram & Hasan, 1999; Link, Nicholson, Shaddeau, Birch, & Gossman, 1993; OSullivan et al., 2002; Souchard, 2003; Winter & Pinto, 1986). For example, in youth with thoraco-lumbar or lumbar scoliosis in standing lateral pelvic
tilt in the frontal plane is frequently attributed to lower limb discrepancy. However,
according to Winter and Pinto (1986), pelvic obliquity may also be caused by hip
contractures, the scoliosis itself, or both. Assessing differences between standing
and sitting postures may help determine whether lateral pelvic tilt in the frontal
plane is associated with scoliosis or lower limb asymmetries or discrepancy and be
useful in terms of treatment planning.
In order to assess differences in posture asymmetries between standing and sitting positions, Souchard (2003; Souchard & Ollier, 2002) has proposed a posture
evaluation and treatment approach called Global Postural Re-education (GPR).
Evaluation is divided into three components: general photography, examination
of retractions, and re-equilibration. General photography corresponds to the persons morphology type. Anterior morphology type is described as having shoulders
rolled forward, an exaggeration of sagittal vertebral curves, and valgus of the lower
limbs. Posterior morphology type typically presents as elevated shoulders, decrease
in sagittal vertebral curves, and varus of the lower limbs. A mixed morphology type
presents anterior and posterior characteristics. Examination of retractions is the visual evaluation of posture to corroborate anterior or posterior characteristic and
thus anterior or posterior muscular chain contribution (Fortin, Feldman, Tanaka,
Houde, & Labelle, 2012b). Re-equilibration serves to determine if scoliosis appears
to worsen in standing (anterior muscular chain) or in long sitting (posterior muscular chain) and to assess the reducibility of the posture alterations and of the scoliosis curves in standing and sitting positions using a qualitative rating scale (+, minor compensation; ++, moderate to severe compensation; and +++, impossible to
correct and/or pain). Results are interpreted as follows: less reducibility in standing
indicates anterior muscular chain stiffness whereas less reducibility in long sitting
position indicates posterior muscular chain stiffness. The evaluation is intended to
guide clinicians in the selection of stretching postures and sensory integration exercises in the standing and/or sitting positions (Bonetti et al., 2010; Fernandez-de-laPenas, Alonso-Blanco, Morales-Cabesas, & Miangolarra-Page, 2005; Moreno et al.,
2007; Souchard, 2003).
Several authors consider that muscles are organized into muscular chains and
that compensation in body posture occurs when a muscle in the muscular chain is
retracted creating modification in a subsequent segment alignment (Bonetti et al.,
2010; Fernandez-de-la-Penas et al., 2005; Miramand, 1991; Souchard, 2003). According to Souchard (2003), the standing position puts tension onto anterior muscles whereas the long sitting position puts tension onto posterior muscles. Link
et al. (1993) showed that persons with short hip flexor muscles (anterior muscles)
had greater lumbar lordosis in the standing position than persons with longer hip
flexors. In the long sitting position, the hamstring muscles are stretched and because of their insertion on the ischial tuberosity, they tend to pull the pelvis into a

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posterior tilt. Several types of sit-and-reach tests (conventional, back saver, and
chair) are used to assess the flexibility of posterior muscles (Baltaci, Un, Tunay,
Besler, & Gerceker, 2003; Lopez-Minarro, de Baranda Andujar, & RodrguezGarcia, 2009; Rodriguez, Santonja, Lopez-Minarro, de Baranda, & Juste, 2008).
However, these tests are not designed to assess posture compensations throughout
the body. To do so would necessitate direct measurements of several body segments.
Moreover, the validity of these tests has been questioned because anthropometric factors might confound assessment of flexibility of hamstring and back muscles
(Baltaci et al., 2003; Jackson & Baker, 1986).
Evaluation and selection of appropriate posture re-education in standing and/or
sitting positions are often based on subjective impressions that are not quantified
by reliable and valid clinical measures. Our team has developed a software program for quantitative analysis of posture from digital photographs in youth with
IS (Fortin, Feldman, Cheriet, & Labelle, 2010; Fortin et al., 2012a). This posture
evaluation software program may be useful to assist the clinician in determining which positions (standing versus sitting) and muscles (anterior or posterior)
should be targeted for treatment (as proposed in GPR) and may also serve to document the effectiveness of stretching exercises used in physical therapy to improve
posture. The ability of this posture evaluation software program to quantify differences between standing and sitting posture indices, however, has not yet been
established.
The objectives of this study were to explore whether: (1) differences in standing
and sitting postures could be detected in youth with idiopathic scoliosis from quantitative analysis of digital photographs of trunk posture using a computer software
program developed by our team, and (2) to compare differences between thoracic
and thoraco-lumbar or lumbar scoliosis.

METHODS
Participants
Fifty participants were selected from our previous study on reliability and validity of this posture evaluation software program (Fortin et al., 2010, 2012a). They
were recruited from the scoliosis clinic at Sainte-Justine University Hospital Center. Youth were selected if they had idiopathic scoliosis diagnosis with a primary
single curve (thoracic and thoraco-lumbar or lumbar scoliosis). Other inclusion criteria were: ages 1020-years-old, Cobb angle between 15 and 60 , and pain-free
at the time of evaluation. We excluded participants who had a double curve, a leg
length discrepancy greater than 1.5 cm, as well as those who had had spine surgery.
Among the 50 participants, 43 (86%) were girls. Mean age was 15.4 (2.6) years
and average weight and height were 51.8 (8.5) kg and 161.6 (10.2) cm, respectively.
Twenty-nine participants had a primary right thoracic scoliosis mean angle of 36
(12 ), 14 had a thoraco-lumbar scoliosis mean angle of 27 (8 ), and seven a lumbar scoliosis mean angle of 29 (10 ). Twenty-six participants had a compensatory
curve. The study was approved by the ethics committee of Sainte-Justine University Hospital Center and all participants and their parents signed informed consent
forms.

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Fortin et al.

FIGURE 1. Graphical interface with a reduced set of markers of the posture evaluation
software program at the left and two numerical photographs of a participant in standing
and long sitting position at the right. The green circles can be individually displaced by the
operator for the calculation of 2D posture indices. The six figures represent the scapula
asymmetry (6), the scoliosis angle (10), the right and left waist angles (7, 8), the trunk list
distance (9), and the lateral pelvic tilt in the frontal plane (11).

Instrumentation and Procedures


Participants were assessed by a physical therapist at our laboratory. A quantitative posture evaluation software program developed in our laboratory by our
multidisciplinary team (physical therapists, engineers, and orthopedic surgeon)
was used to calculate posture indices of the head and trunk (see Fortin et al.,
2012a, for more details). The software has a user-friendly graphical interface and
it allows calculation of posture indices from a set of markers selected interactively
on the digital photographs (Figure 1). These markers (5 mm in diameter) were
placed on each participants tragus, spinous processes (C2, C4, and C7 to S1),
coracoid process, inferior angle of scapulae, anterior superior iliac spine (ASIS),
and posterior superior iliac spine (PSIS). To facilitate measurement of sagittal
posture indices, hemispheric 10 mm reflective markers were added onto C4, C7,
ASIS, and PSIS. Other anatomical reference points such as eyes, tips of the ears,
upper end, lower end, and center of waist also served for angle calculations.
Measures obtained using the posture evaluation software program have good
psychometric properties for assessing standing posture in youth with IS (testretest
and inter-rater reliability for marker placement as well as concurrent validity with
radiographs and a 3D surface topography system; Fortin et al., 2010, 2012a).

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Digital photographs were taken with two Panasonic Lumix cameras (DMCFX01, 6.3 mega pixels) fixed on the bars of the 3D system (used for the validity
study) and adjusted vertically in order to be able to capture the full height of all
participants. The cameras were placed at a distance of 159 cm for anterior and right
lateral views and 173 cm for posterior and left lateral views at a height of 87.5 cm.
This set up of the cameras was imposed by the simultaneous use of a 3D system
in a concomitant study. Vertical and horizontal level adjustments of the cameras
were done with a carpenter level. Instructions given to all participants concerning
positioning for data collection were standardized. To limit the variability associated with participants standing positions, two reference frames for feet placement
(triangles of 30 ) were drawn on the floor for frontal and sagittal standing views
(Watson & Mac Donncha, 2000). Participants were asked to look straight ahead
and stand in a normally comfortable position (McEvoy & Grimmer, 2005; Watson
& Mac Donncha, 2000).
For sitting position acquisitions, a table (75.5 cm in height and 137.5 cm long)
was placed at the same distance from the two cameras. Participants were sitting in
long sitting an erect position with legs as straight as possible on the table and
were asked to look straight ahead. Before each set of acquisitions in the long sitting
position, palpation was done again and markers were repositioned when necessary
on the anatomical landmarks. The long sitting position with extended knees was
chosen firstly, because it has already been used in studies evaluating back and lower
limb posterior muscle flexibility and, secondly, to better see the repercussion of
lower limb posterior muscle stiffness on the spine (Baltaci et al., 2003; Rodriguez
et al., 2008).
Data acquisitions were first taken in the standing position in anterior and posterior views. The participant was then asked to turn and was repositioned for the
sagittal views (right and left) acquisitions. Subsequently, after the table placement
(with references on the floor for the frontal and sagittal views), the same procedure
was done in the sitting position for anterior and posterior views. Finally, the table
was turned and the participant was positioned for the sagittal set of acquisitions
(right and left views).
Quantitative posture indices from digital photographs were calculated with the
custom software program allowing the operator to select a specific marker from the
graphical interface and to put it directly on the corresponding anatomical landmark
on the photograph. Different sets of markers are available according to each view
(anterior, posterior, or lateral). Following the selection of the markers associated
with the calculation of an angle, its value is automatically displayed (Figure 1). For
angle calculation on photographs, the origin of the horizontal and vertical axes
is located at the left bottom corner of the image. For calibration, a cube of 15 cm
was used. The Appendix describes the methods for angle and distance calculation.
All postural photos were digitalized by the same trained operator in standing and
sitting positions. To obtain a better estimate of the participants true score, the
mean of two trials per each position and view was used for data analysis (Crocker
& Algina, 1986).
Data Analysis
We used descriptive statistics [mean, standard deviation (SD), range] to characterize participants with scoliosis and the magnitude of posture indices from the clinical

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posture assessment tool in standing and sitting positions. We compared the average
values of each posture index in the standing and sitting positions using paired ttests. Certain indices could have positive or negative values: for example, shoulder
elevation could be positive if the left shoulder was higher or negative if the left
shoulder was lower. To compare mean values between participants and positions,
we transformed the values to the same reference sign.
We used independent t-tests to compare the magnitude of the head, shoulder,
scapula, trunk list, and lateral pelvic tilt in the frontal plane posture indices according to the type of scoliosis (thoracic scoliosis and thoraco-lumbar or lumbar
scoliosis) in both positions (within-posture comparison). We did not include right
and left waist angles and sagittal pelvic tilt since these indices are dependent on
the side of the scoliosis and the number of participants was not sufficient to subdivide the scoliosis types into right and left. Paired t-tests were used to determine
differences between positions among these two scoliosis categories for each posture index (between-posture comparison) except for the index cervical lordosis.
Between-position comparison was not performed on this index because no significant difference was found when all participants were analyzed together and number
of measurable values was small for this index (n = 31). For this analysis, participants were categorized according to their primary curve; three participants were
excluded for the following reasons: X-rays could not be retrieved, X-rays were too
old, and lack of clarity regarding the primary scoliosis. All calculations were done
using SPSS statistical analysis software (version 17.0 for Windows).
RESULTS
Differences Between Standing and Sitting Positions
We found differences between standing and sitting positions for 10 out of 13 posture
indices when the data from all 50 participants were analyzed together (Table 1).
At the head and neck body segment, only the head protraction index showed a
statistically significant difference between the standing and sitting postures. The
angle of head protraction was increased in the sitting position. Shoulder elevation
and scapula asymmetry were both significantly lower in the sitting position than in
standing. At the back level, left and right waist angles, trunk list, and scoliosis angle
were significantly different in the two positions. For the pelvis, the lateral pelvic tilt
in the frontal plane was significantly lower in the sitting position and left and right
sagittal pelvic tilts were tilted significantly more posteriorly in the sitting position.
Differences According to the Type of Scoliosis
Independent t-tests performed on posture indices revealed statistically significant
differences according to the type of scoliosis only for trunk list (p = 0.02) and lateral
pelvic tilt in the frontal plane (p = 0.01) in the standing position (within-posture
comparison; Figure 2, A and B, number (1)). Participants with thoraco-lumbar or
lumbar scoliosis had greater trunk list and lateral pelvic tilt in the frontal plane than
participants with thoracic scoliosis.
Participants with thoracic scoliosis demonstrated significant differences between
standing and sitting positions for six out of 12 indices whereas participants with
thoraco-lumbar or lumbar scoliosis demonstrated significant differences between

Differences in Standing and Sitting Postures

319

TABLE 1. Differences in Posture Indices in the Standing and Sitting Positions of Children
and Youth with Idiopathic Scoliosis

Posture indices
Frontal eyes obliquity ( )
Head lateral bending ( )

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Head protraction ( )
Cervical lordosis ( )
Shoulder elevation ( )
Scapula asymmetry ( )
Trunk list (mm)
Waist angle (L) ( )
Waist angle (R) ( )
Scoliosis angle ( )
Lateral pelvic tilt in frontal plane
( )
Sagittal pelvic tilt (L) ( )
Sagittal pelvic tilt (R) ( )

Standing

Sitting

Difference

Mean (SD)
[Range]

Mean (SD)
[Range]

Mean (SD)
[CI 95%]

2.3 (1.8)
[0.1, 8.2]
2.2 (1.7)
[0.03, 7.2]
127.83 (4.17)
[119.50, 138.96]
162.75 (6.35)
[155.28, 184.26]
3.5 (2.2)
[8.8, 0.3]
7.2 (5.4)
[20.0, 0.2]
16.7 (12.9)
[62.0, 1.1]
154.3 (10.2)
[132.9, 177.0]
155.1 (9.0)
[131.5, 173.1]
163.6 (9.1)
[187.4, 144.7]
2.9 (2.5)
[10.6, 0.1]
11.1 (4.8)
[1.0, 20.3]
10.9 (5.5)
[1.3, 24.2]

2.0 (2.4)
[4.6, 7.9]
2.0 (2.5)
[5.7, 6.6]
129.48 (5.12)
[121.70, 140.72]
161.84 (7.05)
[146.69, 174.01]
2.5 (2.0)
[7.4, 1.1]
6.0 (5)
[17.4, 5.5]
12.9 (13.7)
[40.0, 17.0]
156.8 (8.9)
[138.8, 174.7]
159.1 (8.6)
[137.3, 173.8]
164.9 (9.0)
[180.0, 143.1]
1.9 (2.9)
[11.7, 3.1]
27.2 (7.2)
[45.4, 11.8]
29.2 (7.8)
[46.0, 11.6]

0.3 (1.7)
[0.2, 0.7]
0.3 (1.8)
[0.28, 0.8]
1.66 (3.31)
[3.02, 0.29]
1.24 (6.59)
[1.22, 3.70]
1.1 (1.8)
[1.6, 0.6]
1.2 (2.7)
[2.0, 0.4]
3.8 (12.3)
[7.3, 0.3]
2.6 (5.8)
[4.2, 0.9]
3.9 (6.6)
[5.8, 2.1]
1.2 (4.2)
[0.0, 2.5]
1.0 (2.8)
[1.8, 0.2]
38.2 (6.4)
[36.1, 40.3]
40.1 (6.9)
[37.8, 42.4]

p-Value
(paired t-test)
0.27
0.36
0.02
0.31
0.000
0.003
0.03
0.003
0.000
0.046
0.01
0.000
0.000

Statistically significant p < 0.05.


Note: L = left; R = right; positive sign in differences indicate a larger mean in the standing position; negative sign in
differences indicate a lower mean in the standing position.

positions in eight out of 12 indices (Table 2). Significant differences between the
standing and sitting positions were found for shoulder elevation, waist angles (left
and right), and the left and right sagittal pelvic tilts indices in both types of scoliosis. A difference in head protraction index was found in participants with thoracic
scoliosis whereas differences in scapula asymmetry, trunk list, and lateral pelvic tilt
in the frontal plane were found in participants with thoraco-lumbar or lumbar scoliosis (Table 2). No significant difference was found for the index scoliosis angle in
both groups of scoliosis. The indices for trunk list and lateral pelvic tilt in frontal
plane for participants grouped by type of scoliosis are described in Figure 2 (A and
B). For these two posture indices, no significant between-position differences were
found for participants with thoracic scoliosis (Figure 2, A and B, number (2)).

DISCUSSION
Differences between standing and sitting positions were detected for 10 out of
13 posture indices when all participants were analyzed together, and, in addition,

320

2.0 (1.5)
1.9 (1.2)
128.5 (4.3)
3.4 (2.0)
8.0 (5.7)
12.5 (8.3)
152.1 (9.3)
156.6 (6.9)
157.9 (6.5)
2.0 (2.1)
12.6 (4.0)
13.8 (5.1)

Stand
1.7 (2.2)
1.5 (2.2)
131.1 (5.3)
2.3 (2.4)
7.0 (5.5)
11.1 (13.9)
154.5 (8.7)
160.6 (7.1)
159.2 (6.6)
1.9 (3.1)
24.9 (7.8)
26.3 (9.0)

Sit
0.3 (1.8)
0.4 (1.8)
2.5 (3.4)
0.9 (1.7)
1.0 (3.1)
1.4 (12.6)
2.4 (5.7)
3.9 (5.5)
1.3 (4.4)
0.1 (2.5)
37.5 (7.2)
40.1 (7.6)

Diff
0.40
0.23
0.01
0.008
0.11
0.58
0.04
0.001
0.06
0.88
0.000
0.000

p
2.5 (1.8)
2.6 (1.9)
126.6 (3.9)
3.9 (2.4)
6.7 (5.2)
22.2 (16.3)
158.0 (11.8)
152.4 (11.4)
170.7 (6.5)
3.9 (3.1)
10.0 (4.7)
8.0 (4.1)

Stand

2.1 (2.5)
2.5 (2.6)
126.7 (3.5)
2.4 (1.7)
4.9 (4.4)
14.7 (14.2)
161.3 (7.8)
157.1 (10.4)
171.9 (6.3)
1.9 (3.0)
30.0 (6.0)
32.9 (8.0)

Sit

0.3 (1.7)
0.1 (1.8)
0.1 (2.5)
1.5 (2.0)
1.8 (2.1)
7.5 (12.1)
3.3 (6.1)
4.6 (7.6)
1.1 (5.0)
2.0 (2.9)
40.0 (4.9)
40.9 (6.0)

Diff

Thoraco-lumbar or lumbar scoliosis: mean(SD)

Number of participants was 16 for thoracic scoliosis and 9 for thoraco-lumbar or lumbar scoliosis; statistically significant p < 0.05.
Note: L = left; R = right; positive sign in differences indicate a larger mean in the standing position; negative sign in differences indicate a lower mean in the standing position.

Frontal eyes obliquity ( )


Head lateral bending ( )
Head protraction ( )
Shoulder elevation ( )
Scapula asymmetry ( )
Trunk list (mm)
Waist angle (L) ( )
Waist angle (R) ( )
Scoliosis angle ( )
Lateral pelvic tilt in frontal plane ( )
Sagittal pelvic tilt (L) ( )
Sagittal pelvic tilt (R) ( )

Posture indices

Thoracic scoliosis: mean (SD)

0.38
0.87
0.87
0.004
0.001
0.01
0.03
0.01
0.31
0.006
0.000
0.000

TABLE 2. Differences (Diff) in Posture Indices in Standing (Stand) and Sitting (Sit) Positions of Children and Youth Grouped by Type of Scoliosis

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FIGURE 2. Mean (SD) for (A) trunk list and (B) lateral pelvic tilt in the frontal plane in
standing and sitting positions for all participants, participants with thoracic scoliosis, and
participants with thoraco-lumbar or lumbar scoliosis. 1 represents the difference in the
standing position (within posture comparison) and 2 represents the difference between the
standing and sitting positions (between-posture comparison).

differences were found between children and youth with thoracic scoliosis and
children and youth with either thoraco-lumbar or lumbar scoliosis. Our results are
similar to those of Nault et al. (2002) regarding the magnitude of head, shoulder,
and pelvis posture asymmetries in the standing position. In agreement with Gram
and Hasans (1999) results, we found larger values in the standing position for
trunk list for youth with thoraco-lumbar or lumbar scoliosis type. Thoraco-lumbar
and lumbar scoliosis are more associated with pelvic and lower limb asymmetries
that can increase the trunk list in the standing position (Giakas, Baltzopoulos, Dangerfield, Dorgan, & Dalmira, 1996; Guillaumat, Lebard, Khouri, & Tassin, 1991).
Except for head position and waist angles, the mean values of posture indices
were lower in the sitting position indicating less asymmetry. In the sitting position,
the base of support is greater and the impact of lower limb discrepancy is eliminated creating more stability and less compensation, especially in thoraco-lumbar
and lumbar scoliosis (Bennett, Abel, & Granata, 2004). The position of the head
in the frontal plane (frontal eyes obliquity and head lateral bending) was stable
across positions and types of scoliosis, in agreement with previous report (Nault
et al., 2002). However, in the sagittal plane, head protraction was increased in sitting and was associated with thoracic scoliosis. Thoracic scoliosis is often characterized by a decrease in thoracic kyphosis that has been attributed to retraction of
spinal muscles (Miramand, 1991; Souchard & Ollier, 2002). The long sitting position
places tension on the posterior muscles (Baltaci et al., 2003; Rodriguez et al., 2008;
Souchard & Ollier, 2002). It is possible that for the youth in our sample with thoracic scoliosis, their posterior muscles were stiffer than their anterior muscles and,
thus, they compensated by bending their head to maintain balance. This hypothesis
should be examined with a larger sample size.
Gram and Hasan (1999) previously assessed the effect of standing and sitting postures on spinal curves in youth with IS. Using a 3D posture analysis system, they

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reported significant differences between standing and sitting postures for their 3D
scoliosis angle (named 3D apex angle) but not for the trunk list (lateral lean) and
the 2D scoliosis angle (named frontal apex angle) when all curve types were analyzed together. This discrepancy with our findings may be attributable to our larger
sample size (n = 19 in Gram & Hasan study) or to the different sitting position
used in our study. However, when our participants were divided into two scoliosis
groups, our results were similar to those of Gram and Hasan (1999). According to
our results and those reported by Gram and Hasan (1999), it is possible that position (standing versus sitting) does not affect the scoliosis angles in the same manner. Youth may compensate differently according to factors such as muscle activity,
muscle stiffness, and magnitude of the curve (scoliosis). Gram and Hasan (1999)
reported an increase in muscle activity of all posterior back muscles in the erect
sitting position that may contribute to stabilize the spine and decrease the scoliosis
angle (3D) in sitting because of the rotation of the spine. In our study, participants
demonstrated an increased posterior pelvic tilt in the long sitting position compared
with standing that could be linked to posterior muscle stiffness (Baltaci et al., 2003;
Rodriguez et al., 2008). Tension on posterior muscles may also have concurred to increase the rotation of the spine and decrease the scoliosis angle (frontal component
of the scoliosis) in the sitting position (Miramand, 1991; Souchard & Ollier, 2002).
Clinical Implications
The posture evaluation software program used to measure digital photographs detected differences between standing and sitting positions for several posture indices
among youth with IS. This posture assessment method may contribute to improvement in management of youth with IS by analysis of differences in posture between
positions, assessment of sitting posture for ergonomic purposes, and by quantifying
the impact of posterior muscle flexibility (of the back and lower limbs) on sitting
posture indices using means of angles and distances calculations. The development
of other posture indices in the sitting position such as thoracic kyphosis, lumbar
lordosis, sagittal trunk list, and hip, knee, and ankle joint angles are recommended
for a complete analysis of posterior muscle stiffness on posture.
The significant difference between standing and sitting positions for the lateral
pelvic tilt in frontal plane index indicates that this posture evaluation software program may also serve as a screening tool to establish if pelvic obliquity is attributable
to lower limb discrepancy or asymmetries (the lateral pelvic tilt in the frontal plane
decreases in the sitting position) or spine deformity (lateral pelvic tilt in the frontal
plane is similar in both standing and sitting positions; Souchard & Ollier, 2002;
Winter & Pinto, 1986). This differential evaluation may guide the clinician in determining the degree (or amount) of lower limb correction needed to level the pelvis
and its influence on other body segments in the standing position. This application
potentially might reduce the frequency of lower limb scannography.
Quantitative analysis from digital photographs can also provide measurements
of standing and sitting heights (to determine growth localization and velocity) that
is recommended in the follow-up of children and youth with different types of scol
iosis (Charles, Daures, de Rosa, & Dimeglio,
2006; Guillaumat et al., 1991). Growth
spurt, growth velocity, and growth localization (lower limbs versus trunk segment)
are important risk factors for scoliosis progression (Charles et al., 2006; Cheung

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et al., 2004). The good testretest and inter-rater reliability found for marker placement in our previous study (reliability coefficients between 0.90 and 0.996; Fortin
et al., 2012a) combined with the results of this study support this clinical utility.
Photograph acquisitions and calculation of posture indices (angles and distances)
are fast and non-radiating (as opposed to x-rays), accessible in a clinical setting, and
can be used in repeated measurements of standing and sitting postures in youth with
different types of scoliosis. Our previous studies showed that photographs provide
reliable testretest measurement of posture indices (standard error of measurement
[SEM] between 0.5 and 3 for angles and 3 mm for trunk list; Fortin et al., 2012a)
and are valid indicators of 3D and radiograph measurements (Pearson correlation
coefficients [r] > 0.75, p < 0.01) except for the thoraco-lumbar or lumbar scoliosis
angle (r = 0.56 with 3D system and 0.33 with x-ray, p < 0.05; Fortin et al., 2010). Although our reliability and validity studies were done in the standing position, similar
results were also obtained by other groups in the sitting position supporting the clinical relevance of quantitative posture assessment from digital photographs in both
positions (Perry, Smith, Straker, Coleman, & OSullivan, 2008; van Niekerk, Louw,
Vaughan, Grimmer-Somers, & Schreve, 2008). Research is recommended to exam
sensitivity to change over time and the relationship between muscle stiffness and
head and trunk postures to further evaluate the validity of this posture evaluation
software program. Following further validation of our posture assessment method
(responsiveness), this software program should be available for distribution.
Limitations
The main limitations of this study are related to the small number of participants in
each scoliosis group and the fixed width of the table that may have modified the position of the upper extremities especially for smaller participants. We did not collect
data on hamstring tightness. These data would have served to interpret differences
reported for sagittal pelvic tilt between standing and long sitting position.
CONCLUSION
This study demonstrated that among youth with IS, it is possible to detect differences in posture indices between standing and sitting positions from quantitative
analysis of digital photographs using a posture evaluation software program. The
differences found in posture indices were associated with the type of scoliosis. This
new software program may contribute to improve clinical practice by facilitating
the analysis of posture in different positions. As such, it can help guide the clinician
in the selection of appropriate stretching postures and sensory integration exercises
in the standing and/or sitting positions for adolescents with IS. However, further research with larger numbers of participants with different types of scoliosis and with
other health conditions (such as back pain, osteoarthritis, or neurological impairments) are needed to demonstrate if posture indices calculated using this posture
evaluation software program is responsive to change over time.
ACKNOWLEDGMENTS
The authors acknowledge Ionut Alexandrescu, Christian Bellefleur, Philippe De Fabiana Dias Antunes, and Philippe Labelle for their technical assistance;
banne,

324

Fortin et al.

erique

Fred
Gauthier for data collection; Erin Grunstein for the recruitment of participants with IS; and all participants.

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Declaration of interest: The authors report no conflicts of interest. The authors


alone are responsible for the content and writing of this article.
This project was supported by the Discovery Advancement Program of the Canadian Arthritis Network. C. Fortin was supported by a PhD scholarship from the
FRSQ, MENTOR, a strategic CIHR training program/REPAR and research center
of Sainte-Justine University Hospital Center. Debbie Ehrmann Feldman is funded
by the FRSQ.
ABOUT THE AUTHORS
Carole Fortin, PT, PhD, is researcher-professor associated with CHU Sainte

Justine, Centre de recherche and Ecole


de readaptation
of Universite de Montreal,
Quebec, Canada. Her fields of interest include: posture, scoliosis and rehabilitation;
publications on gait analysis and posture assessment; position. Debbie Ehrmann

Feldman, PT, PhD, is titular professor and researcher at Ecole


de readaptation
and at Institut de Recherche en Sante Publique de
of Universite de Montreal
Quebec, Canada. Her fields of interest include: health
lUniversite de Montreal,
services, rhumatology and epidemiology in rehabilitation, publications on rehabilitation services for children with physical disabilities and arthritis. Farida Cheriet,

and researcher at
PhD, is titular professor at Ecole
polytechnique de Montreal
CHU Sainte-Justine, Centre de recherche, Montreal, Quebec, Canada. Her fields of
interest include: medical imaging, 3-D surface reconstruction, 3-D movement estimation; publications on scoliosis curve type classification, on the Analysis of Trunk
Surface Topography and on medical imaging techniques. Hubert Labelle, MD, is
an orthopedic surgeon and researcher at CHU Sainte-Justine, Montreal, Quebec,
Canada. His fields of interest include: scoliosis, spondylolisthesis and spine surgery;
publication on scoliosis and spondylolisthesis classification, scoliosis surgery and
3D reconstruction of the spine.
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APPENDIX
Posture indices of the tool and methods of angle and distance calculation
Body
segment
Head and
neck

Posture indices
1. Frontal eyes obliquity
2. Head lateral bending

3. Head protraction
4. Cervical lordosis
Shoulder and
scapula

5. Shoulder elevation

6. Scapula asymmetry
Trunk

7. Waist angle R
8. Waist angle L
9. Trunk list
10. Scoliosis angle

Pelvis

11. Lateral pelvic tilt in


the frontal plane
12. Sagittal pelvic tilt R
13. Sagittal pelvic tilt L

Body angle calculation


The angle formed by a line drawn between the left and right
eye, and the angle of this line to the horizontal.
The angle formed by a line drawn between the inferior tip of
the left and right ear, and the angle of this line to the
horizontal.
The angle formed by a line drawn between the tragus of the
ear and C7 and a horizontal line through C7.
The angle formed by lines drawn through C2 and C4, and
through C4 and C7.
The angle formed by a line drawn between the left and right
coracoid process markers, and the angle of this line to the
horizontal.
The angle formed by a line drawn from the left and right
inferior angle of scapula and the horizontal.
The angle formed by lines drawn through the upper end of
waist to the center of waist and the center of waist through
the lower end of waist.
Distance between a line drawn from C7 and S1.
The angle formed by lines drawn through the upper-end
vertebra of the curve to the apex of the thoracic,
thoraco-lumbar, or lumbar scoliosis and the apex through
the lower-end vertebra of the curve.
The angle formed by the horizontal and by the line joining the
two PSIS.
The angle formed by the horizontal and by the line joining the
PSIS and ASIS.