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by
Doctoral Committee:
Associate Professor Melissa Gross, Co-chair
Research Scientist James Ashton-Miller, Co-chair
Professor Dee Edington
Associate Professor Bernard Martin
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Copyright 2002 by
Moga, Paul John
All rights reserved.
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UMI
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2002
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DEDICATION
ii
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ACKNOWLEDGMENTS
I would like thank the members o f my dissertation committee for their invaluable
assistance. One of my co-chairs, Dr. Melissa Gross, Associate Professor of Movement
Science, Division o f Kinesiology, exhibited exceptional tolerance in reviewing my early
drafts. I also owe a debt o f gratitude to my other co-chair, Dr. James Ashton-Miller,
Research Scientist, Department o f Mechanical Engineering and Applied Mechanics,
College of Engineering, for his guidance and many suggestions.
Both Dr. Ashton-Miller and Edward Wojtys, M.D., Division o f Orthopaedic
Surgery, University o f Michigan Medical School, were the original projects co
investigators, which was sponsored in part by a grant from the Orthopaedic Research and
Education Foundation. I thank them both for supporting me as a graduate assistant for
two years and the giving me the opportunity to do the secondary analyses on their data
that make up the bulk o f this dissertation.
Professor Dee Edington, Director o f the Center for Health Behavior Research and
former Director o f the Division o f Kinesiology, had always shown me opportunities during
my enrollment at the University. Dr. Bernard Martin, Associate Professor o f Industrial
and Operational Engineering, College o f Engineering, continuously gave me
encouragement to complete the project.
My thanks to Dr. Donita Bylski-Austrow, University o f Cincinnati, for sharing her
iii
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findings on her porcine spine loading. Thanks also are extended to R.N. Hensinger, M.D.,
Professor o f Orthopaedics, University o f Michigan Medical School, for his Scheuermanns
Kyphosis slides.
I also thank my European contacts who helped with my research: Dr. T.E.
Kennedy, Chief o f International Affairs, and Connie Olsen of the Danish Medical
Association (Copenhagen); Eivind Thorling, Curator of Medical History at the Steno
Museum (Arhus), and Joem Street-Jensen o f the State and University Library (Arhus) for
their help with biographical sketches o f the Danish physicians H.W. Scheuermann, M.D.,
K. V. Wassman, M.D., and K.H. Sorensen, M.D. Thanks also to Tina Craig o f the Royal
College o f Surgeons (London) for the biographical sketch on C. Lambrinudi, M.D.
I would like to acknowledge the kind assistance o f K.P. Singer, Ph.D. (University
o f Western Australia), Julie Lawley (W.B. Saunders), Ametta Queen (Lippincott,
Williams & Wilkins), Sherman Kupfer, M.D. (Editor-in-Chief, Mt. Sinai Journal of
Medicine), Mady Tissenbaum (Managing Editor, JBJS, Inc.), Ann Curtin (BMJ Publishing
Group, London), Caroline Caulton and Nadine Barton (Lancet Publishing Group,
London), Stephen Bishop (JBJS London), J. Kirby Robinson (Cardin Jennings), and
Jeremy J. Kaye, M.D. (International Skeletal Society) in granting permission to use
copyrighted images.
On a personal note, thanks to my draftsman dad for his work on the images. Our folks
Traian, Anna, Gill, and Joyce helped in countless ways during this quest. Thanks also to
their siblings as well as our own (and their respective families) for listening throughout the
iv
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years. A great big thank-you to my wife Kris, Annie, Joey, and Timmy for their
boundless patience and support. Finally, an acknowledgment to those who came before
us, paving the way and teaching us perseverance, amongst other things: Pavel, Raveica,
Ionita, and Cristina.
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TABLE OF CONTENTS
DEDICATION
ii
ACKNOWLEDGMENTS
iii
LIST OF FIGURES
xii
LIST OF TABLES
xv
LIST OF APPENDICES
xxi
CHAPTER
I.
INTRODUCTION
10
13
13
14
Vertebral Development
16
19
22
vi
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O.
m.
24
Background
25
26
28
34
34
36
Discussion
38
Conclusions
39
41
Introduction
41
42
Background
43
44
46
Test Protocol
47
Data Reduction
52
vii
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IV.
V.
54
Results
54
Discussion
62
Limitations
64
Conclusions
65
66
Introduction
66
Background
68
70
71
73
Results
74
74
77
80
Discussion
83
Limitations
87
Conclusions
90
92
viii
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Introduction
92
Background
93
94
Hamstring Function
96
98
100
102
Data Analysis
104
Results
104
Discussion
VI.
108
Limitations
109
Conclusions
110
112
Introduction
112
Background
114
116
Prevalence
118
119
120
121
be
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VH.
Results
121
Discussion
126
Limitations
128
Conclusions
128
130
Background
131
133
13 3
Results
134
Discussion
142
Limitations
145
Conclusions
146
147
Background
148
150
Data Analysis
151
Results
151
151
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IX.
X.
157
Discussion
164
Limitations
165
Conclusions
166
GENERAL DISCUSSION
168
168
169
170
Anthropometric Characteristics
172
172
176
Significance
178
Limitations
179
185
CONCLUSION
189
APPENDICES
192
REFERENCES
247
xi
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LIST OF FIGURES
Figure
1.1. Holger Werfel Scheuermann, M.D.
11
1.6
16
2.1
29
2.2
30
2.3
31
2.4
32
2.5
32
33
34
3.1.
Test Apparatus
49
3.2.
51
3.3.
57
59
59
60
61
xii
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102
103
117
138
142
153
157
8.3. Leg Length/Spine Length Ratio vs. Reach Distance for 11 year-olds
158
158
159
G .l. Straight Leg Raising Test (adapted from Bohannon, et al, 1985)
204
207
209
211
G.5. Modified Sit and Reach Test (from Hoeger and Hopkins, 1992)
212
213
G.7. Hip Flexion Angle (adapted from Stokes and Abery, 1980)
215
xiii
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218
219
224
228
230
230
237
xiv
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LIST OF TABLES
Table
1.1 Ranges o f Thoracic Kyphosis Angles from Various Studies Using
Radiographic and Non-radiographic Methods
3.1 Differences o f Mean Age, Height, Weight, and Thoracic Angle (T)
between Unmatched Controls and Athlete Groups
55
3.2. Subject Number and Gender Composition for Three Separate Subject
Groups: Active Athletes, Inactive Controls, and a Athlete/Control
Group Matched for Age, Height, and Weight
55
3.3. Differences o f Mean Age, Height, Weight, and Thoracic Angle (T)
between Matched Controls and Athletes
56
3.4.
3.5.
57
60
3.6.
61
4 .1.
71
4.2.
74
75
4.3.
4.4. Mean Age, Height, and Weight by Sport (Male and Female
Athletes)
75
76
76
4.7. Mean Body Mass Index (BMI) by Sport for Female Athletes
over Age 14 years
77
xv
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4.8. Mean Annual Training Time (Time) and Thoracic Kyphosis Angle
(T) by Sport
78
4.9. Mean Thoracic Kyphosis Angle and Annual Training Time for
l4-to-l8 year-old Female Volleyball Players and Swimmers
78
4.10. Mean Annual Training Time-to-Body Mass Index for Male Athletes 79
4.11. Mean Annual Training Time and Thoracic Kyphosis Angle for
Wrestlers grouped as Normokyphotic and Hyperkyphotic
80
4.12. Mean Ages o f each Age Group for Males and Females
81
81
4.14. The Ratio o f Thoracic Kyphosis Angle per Annual Training Hour
Controlled (Normalized) by Age for Female and Male Athletes
83
83
4.16. Mean Annual Training Time for each Age Group, with Standard
Deviation (s.d.) expressed as a Percentage o f the Mean
89
5.1. Spine Angle, Reach Distance, and Range of Motion for HamstringNormal and Hamstring-Short Subjects
105
107
107
122
123
xvi
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125
126
7.1. Mean Age and Reach Distance for Controls and Athletes, with
Reach Distance Normalized by Age
134
7.2. Mean Age, Annual Training Time, Period, and the Training Variables
Normalized for Age for Athletes grouped as Hamstring-Normal or
Hamstring-Short
135
7.3. Mean Age, Period, and Annual Training Time (Time) for Athletes
grouped by Hamstring Shortness Category
135
136
137
7.6. Mean Annual Training Times for Female and Male Athletes
grouped by Age Group and Hamstring Shortness Category
137
7.7.
139
7.8. Mean Age and Period for Male Athletes grouped by Hamstring
Shortness Category
139
7.9.
140
140
141
151
152
xvu
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I S3
8.4. Mean Thoracic Angles and Thoracic Spine Lengths for Subjects
grouped according to Thoracic Angle Magnitude from both
Large and Small Study Samples
154
8.5.
155
8.6. Mean Spine Length Normalized for Height for both Females and
Males by Sport and Age Group
156
8.7. Mean Spine Length Normalized for Height for both Normokyphotic
and Hyperkyphotic Females and Males by Age Group
156
8.8. Linear Regression Equation for All Subjects (Reach Distance)
159
160
160
161
8.12. Mean Age for Males and Females by Hamstring Shortness Category 161
8.13. Mean Leg Length-to-Spine Length Ratio for Subjects grouped by
Hamstring Shortness Category (Males younger than 14 years)
162
163
8.15. Mean Leg Length-to-Spine Length Ratio for each Gender by Age
Group and Hamstring Shortness Category
163
9.1. Mean Annual Training Times by Age Group for Female and Male
Athletes grouped by Kyphosis Category, Hamstring Shortness
Status, and Sport
174
9.2. Annual Training Time Group Means for Male Athletes grouped by
Kyphosis Category and Hamstring Shortness Status and according
to Age, Age Group, and Sport
175
xviii
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176
182
G. I .
202
203
G.3.
205
G.4.
207
G.2.
216
217
219
220
229
229
231
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232
232
240
240
242
I.1. Mean Annual Training Times by Age in Years for Female and Male
Athletes grouped by Kyphosis Category and Hamstring
Shortness Status
246
1.2.
Mean Annual Training Times by Age Group for Female and Male
Athletes grouped by Kyphosis Category and Hamstring
Shortness Status
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246
LIST OF APPENDICES
Appendix
A. Reported Prevalence o f Scheuermann's Juvenile Kyphosis
193
194
195
D. Vertebral Development
196
E. Subject Questionnaire
198
199
202
222
246
xxi
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CHAPTER I
INTRODUCTION
Thoracic hyperkyphosis is a significant spine problem. It is associated with a
distinct cosmetic deformity, a restriction o f normal trunk motion, and a reduction of
physical function (Ryan and Fried, 1997). At least one form, Scheuermanns Disease, has
a reported prevalence o f 0.4% to 8.3% (Sorensen, 1964) and above, depending upon
diagnostic methods used (radiographic or clinicalBradford, 1995) and subject sample
(Appendix A). The more permanent, non-postural type o f hyperkyphosis may also be
associated with adult onset back pain, particularly if the deformity is at the thoracolumbar
area. In rare instances, those with severe hyperkyphosis may have spinal cord
compression and nerve root impingement, or, in extreme cases, may suffer from
ventilatory and circulatory embarrassment (Sorensen, 1964).
Because o f the significance o f the sequellae associated with the deformity, it is
preferable to prevent thoracic hyperkyphosis, rather than be obliged to treat it after the
fact. It is the goal o f the studies described in this dissertation to identify certain
relationships that may be integrated into the design o f training or rehabilitation programs
that are aimed at preventing the development of non-postural, thoracic hyperkyphosis.
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Table 1.1. Ranges of Thoracic Kyphosis Angle from Various Studies using Radiographic and Non-radiographic Methods
[After Table 1, "Radiographic assessment o f thoracic kyphosis with reference to population, measurement and recorded values on page 22 in Singer KP,
Jones TJ, Breidahl PD, A comparison o f radiographic and computer-assisted measurements o f thoracic and thoracolumbar sagittal curvature.
Skeletal Radiology 19:21-26,1990; copyright holder: International Skeletal Society; n.a. = not available; p = pantograph; x = x-rqy]
Mathod
Author
Sample
Radioaraohic
Bosaker (1958)
Cowan (1965)
121 children
139 males
167femalee
163 males
133fematas
159 mates
157 females
104 "normals''
114 safeties
18 patients
(kyphotic deformity)
75 males
62 females
251 males
419 females
Fonatal. (I960)
Propst-Proctor and Black (1963)
Axelgaard, at al. (1963)
Stagnara, et al. (1962)
Voutsinas and Mac Ewan (1966)
Non-ndiooraohic
121 children
Winer (1961)
15scoiiotics
40 controls
16 Scheuermann's
560 males
540 females
56 (intra-observer
reliability sample)
Kyphosis Angle
mean(a.d.)(deg.)
Age
(years)
n.a.
60 to 69
60 to 69
70 to 79
70 to 79
2to77
2 to 77
2 to 19
2 to 19
n.a.
43
50
49
56
25.1 (8.2) for 2810-19 y.o.
26 (7.4) for 2210-19 y.o.
27
28
57(10)
20 to 29
20 to 29
5to9
10 to 14
15 to 20
37
37
36.7(6.9)
37.5(8.0)
38.5(8.1)
Range
(deg.)
(2542]
Measurement Criteria
(5-66]
(7-56]
[21-33]
[16-36]
[42-73]
[7-37]
[7-37]
T4 to "intermediate
vertebral bod/*
T2stoT12
(if T2 not visible, -> T3)
n.a.
T2-3toT11-12
T3toT12(shOMi)
[20-50]
teenagers
pantographs
angle in 286 radiographs. They reported thoracic angle ranges o f 32 to 44 Cobb for
males 10-19 years o f age (n = 10; mean = 33.8 5.2 ) and 18 to 40 for females o f the
same age group (n = 3; mean = 31.0 11.5). The males had a mean thoracic angle o f
33.8 ( 5.2), while the females mean was 31.0 ( 11.5). The results of Singer, et al.
(1990) were similar to those reported by Fon, et al. (1980) for male and female subjects of
the same age group. In Fons study, male subjects (n = 28) had a mean thoracic angle o f
25.1 ( 8.2), with a range o f 8 to 39. Females (n = 22) had a mean angle value o f
26.0 ( 7.4) and a range 11 to 41.
In some instances, non-radiographic methods were used by authors as Willner
(1981) and Nissinen (1995). Both used the surface device known as a pantograph, whose
measurements underestimated those o f radiographic methods from less than 2 (Willner,
1981, Table 1.1) to about 5.5 (Nissinen, 1995). Even with the difference in methods,
over two-thirds of Nissinens sample o f 1060 children had thoracic angles within the
radiographic 20 to 40 range.
Hyperkyphosis may be grouped into two general categories: postural, which is the
result o f poor posture and is more readily correctable, and non-postural. The latter tends
to be fixed and is the result o f the inadequacy o f one or more o f the spines support
mechanisms (Winter and Hall, 1978). These support mechanisms include the vertebral
body, intervertebral disc, as well as the muscular and ligamentous soft tissues.
Non-postural hyperkyphosis may be further subdivided into three subtypes:
congenital, pathologic, and acquired (Appendix C). Congenital hyperkyphosis is caused
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from his landmark, radiographic study of patients who demonstrated a unique type o f
thoracic hyperkyphosis. In his paper, Dr. Scheuermann identified unique,
roentgenographic findings that have become the prerequisite characteristics of the disease
process that bears his name: osseous wedging o f the anterior aspects o f the thoracic
vertebrae in otherwise healthy adolescents whose spines were still developing (Figure 1.2).
Sorensen (1964) suggested that the magnitude o f the wedging should be at least 5 by the
Cobb method (described below) and should be present in at least three, adjacent vertebrae
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The amount o f vertebral wedging, as well as the overall angle o f the thoracic spine
segment, is generally determined using the Cobb method (Cobb, 1948). The method is
illustrated in Figure 1.4, showing the angle o f interest as the angle between two
intersecting tangents to vertebral endplates at either extreme o f the spine segment.
Scheuermann made additional observations that further characterized thoracic
hyperkyphosis. He wrote that the disease was noted especially in youngsters who were
8
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involved in strenuous, agricultural work, and credits Schanz (1907, 1911) for first having
called attention to the occupational, or apprentice's, deformation (Scheuermann, 1934).
The relation between work and hyperkyphosis was also observed by Wassman (1951),
who noted that Scheuermanns Disease was more prevalent not in urban dwellers, but
rather in the lads from the country (a phrase likely from a lecture delivered on
September 6,1946, at the Dansk Selskab for Gigtforskning).
Since Scheuermanns observations were first published, an anecdotal association
has also been made between thoracic hyperkyphosis and repetitive work in the form o f
sports activities. Authors as Hafner and Surrey (1952), Micheli (1979), Endler, et al.
(1980), Falter, et al. (1981), Wilson, et al. (1982), and Sward (1992) all reported an
association between hyperkyphosis and sports activities, which included gymnastics,
9
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rowing, and swimmingsports that involve repetitive and extreme flexion o f the torso.
However, experimental evidence to support the observations that repetitive work was a
likely cause o f Scheuermanns Disease was still lacking.
10
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thoracolumbar Scheuermanns (Keim and Hensinger, 1985). Schmorls nodes were first
described by Dr. George Schmorl (1930) as the radiographic representation o f an
extravasation o f the intervertebral discs nucleus pulposus material into the bony
spongiosum o f the vertebral body (Figure 1.5). This herniation, which is said to be
11
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may also demonstrate the typical radiographic findings. Dorsolumbar kyphosis (Wiles,
1949) has been identified at the thoracolumbar junction (Hafiier and Surrey, 1952).
Sorensen (1964) identified 23% o f Scheuermanns Juvenile Kyphosis cases in his subjects
as being at the regions o f T l l-L l or T12-L2. In contrast to the thoracic form, which is
initially pain-free, at least 78% o f those having Scheuermanns Disease at the
thoracolumbar region have marked pain (Sorensen, 1964). Lumbar Scheuermanns has
also been documented (e.g. Lindemann, 1933; Edgren and Vainio, 1957). In these cases,
end-plate deformity and disc space narrowing is seen more than the typical, anterior
vertebral wedging (Sorensen, 1964), and degenerative disc disease is a common sequella
(Paajenen, et al., 1989).
Several gross anatomic findings have been identified in cases o f Scheuermanns
Juvenile Kyphosis. These include contracted, thickened anterior vertebral longitudinal
ligaments (Bradford and Hensinger, 1985) and an atypical insertion o f the annulus fibrosus
o f the intervertebral disc. Anchoring o f annular fibers into sites such as the apophyseal
ring, for example, may produce a vertebral segment that is less resistant to mechanical
stresses (Ippolito, et al., 1985). In addition, thickening and subsequent bowstringing o f
the anterior longitudinal ligament would tend to augment anterior compression o f the
involved vertebral segment. This notion is supported by the work o f Bimbaum, et al.
(2001), who were able to demonstrate a correction of kyphotic deformity by surgically
transecting the anterior longitudinal ligament in cadavers.
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stabilizing mechanisms, which include the vertebral bodies, intervertebral discs, and, less
importantly, the ligamentous, intervertebral joint capsules (less developed in the thoracic
spineWhite, et al., 1977) may lead to a larger flexion moment and subsequent greater
compression load to the mid-thoracic spine (Skogland and Ashton-Miller, 1980), with the
development o f hyperkyphosis as a possible result.
14
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approximately the same thoracic region that is affected by the classic, thoracic type o f
Scheuermanns Disease (Sorensen, 1964). It is likely that vertebrae having narrow
endplates would be more susceptible to the effects o f repetitive loading, which include a
loading-related reduction in the local blood supply plays a role in vertebral wedging
suggested by authors as Mau (1927), Ferguson (1949), and Roaf (1960).
When viewed from the lateral aspect, the thoracic vertebrae display yet another
unique, morphologic characteristic. There is an anterior wedging of the individual
thoracic vertebral bodies o f approximately 3.8 (Panjabi, et al., 1991), slightly less than the
5 minimum required for a diagnosis of Scheuermanns Disease. Goh, et al. (1999)
quantified vertebral wedging as an anterior-to-posterior vertebral height ratio. They found
the ratio was highly predictive o f thoracic curvature, which supports the idea that
physiologic wedging contributes to the normal, thoracic kyphotic curve. These factors
may predispose the thoracic spine to the development o f hyperkyphosis and
All o f these morphologic features can enhance the risk o f compressive injury to the
thoracic vertebral ventra (e.g. Kasra and Grynpas, 1997). They can do so not only by
affecting developing bone at the endplates, but by contributing to a non-uniformity o f
compressive strain distribution within thoracic vertebral trabecular bone as well. Bay, et al.
(1997) identified a load-dependence o f the intraosseous, strain distribution pattern o f
trabecular bone. They found that, when vertebrae were subjected to loads o f 60% o f
ultimate bony failure, most compressive strain was located in the anterior aspect o f the
vertebral body. If such a strain occurred in immature bone, it is likely that the structure
15
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would be at risk for the poor development and enhanced wedge deformity, as discussed
below.
Vertebral Development
The third factor that is important in the pathogenesis o f juvenile hyperkyphosis is
vertebral development. The sequence o f ossification begins at birth, when the vertebral
body centrum and an unfused pair of vertebral arches are ossified (e.g. Gray, 1974;
Appendix D) (Figure 1.6). The process extends gradually from each vertebral centrum,
AT
BIRTH
V E R T E B R A L 8O 0 Y
AND NEURAL ARCH
2Y R S . O F AGE
LAMINAE FUSE POSTERIORLY
( STARTS I N LLM8AR AREA AND
ASCENDS 8U T SACRUM IS LASTJ
CT TO lO YRS )
BY 6 - 7 YRS. OLD
neural
arch
u n i t e s w it h
V E R T E B R A L B O O Y ( EA RLIEST
IN N E C K .L A S TIN SACRUM ;
SECONOARY C E N T E R S O F O S S .F IC A T O N
A PPEA R
AT PU B ER TY AND FU SE A T
25 Y E A R S O F A O *
16
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with bony tissue replacing chondral (cartilaginous) tissue until, in adolescence, two
cartilaginous plates at both superior and inferior vertebral margins remain. These plates
represent the longitudinal growth physes for endochondral ossification and are zones that
display a particularly active cell turnover during the growth spurt (Taylor, 1975; Meschan
and Farrer-Meschan, 1985; Ogden, et al., 1994).
The growth areas that contribute to the development o f the anterior, load-bearing
rims o f the vertebrae are the ring apophyses. These C-shaped regions are located at
the anterolateral margins of the superior and inferior surfaces o f the vertebrae. They begin
to appear at about age 6 and start to ossify at age 13 years (Bick and Copel, 1951). The
ossification process is generally not complete radiographicaUy until the late teens, with
histologic fusion o f the ring apophysis with the vertebral body occurring by the early to
mid-twenties (e.g. Matsumoto, 1988). Incomplete dorsally and not a contributor to
longitudinal growth (Bick and Copel, 1951), these structures act both to anchor the
intervertebral disc to the vertebral body (Ippolito, et al., 1985; Outland and Sneddon,
1955) and to eventually provide the osseous collars o f the superior and inferior aspects
o f the vertebrae. With such important functions, it is possible to imagine that poor
ossification might lead to vertebral structural deficit and wedge deformities.
The rapid growth spurt during adolescence is likely a key factor in the
susceptibility o f the immature spine to repetitive loading, as suggested by Mau (1929) and
Ferguson (1949). Tanner (1962, 1973) wrote that, in females, the adolescent growth
spurt occurs from ages 9.5 to 14.5 years, with a maximum growth velocity (peak height
velocity) at a mean age o f 12 years. The end o f the growth spurt in females occurs at
17
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menarche, whose onset is said to correlate with body composition (e.g. Frisch and
Revelle, 1971; Crawford and Osier, 1975; Zacharias and Rand, 1983). In males, the
growth spurt occurs later, from about ages 10.5 to 16 years, and reaches a peak height
velocity at about 14 years o f age.
During the growth spurts, there is an increase o f total body height, which is based
upon growth o f the head, spine, pelvis, and lower extremities. The length o f each o f these
segments increases at different rates (Anderson, et al., 1978). The lower extremities grow
fastest while growth o f the head is slowest, with the spine growth rate between the two
(Lonstein, in Moe, 1978). DiMeglio and Bonnel (1990) measured spinal growth rates for
three age groups: birth to age 5 years, greater than 5 years to age 10 years, and greater
than 10 years to 16 years. They observed that, between the first thoracic vertebra (Tl)
and the first sacral segment (SI), the thoracic region accounts for 63% o f the spines
growth, with longitudinal growth increasing at a rate of 1.2 centimeters per year between
the ages of 10 and 16 years. The lumbar spine elongates at a rate o f 0.6 centimeters per
year over the same time interval, a rate one-half that of the thorax. The comparatively
rapid thoracic growth rate during this time period with the associated rapid turnover of
developing cellular structures may enhance the regions relative susceptibility to the effects
o f increased spine loading. In fact, Willner and Johnson (1983) demonstrated a positive
correlation between growth velocity and the range o f thoracic kyphosis, a trend that was
not demonstrated for lumbar lordosis.
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hours. Because o f this association, it was assumed that there would also be a significant
relation between thoracic angle and one or both o f these component variables. Thus, in
this study, the extrinsic loading o f athletic training was modeled by annual training hours
and a comparison o f mean, thoracic kyphosis angles was made between inactive controls
and active athletes. In addition, it was felt that the actual training time in hours would be
clearer to coaches and those who designed training programs.
Chapter IV summarizes the next step in the secondary analysisthe confirmation
o f what was suggested in the previous chapter regarding the relation between thoracic
kyphosis and training. This was performed by comparing thoracic angles and annual
training times within the athlete group. Chapter IV also presents an attempt to quantify
the relation between thoracic kyphosis and athletic training in an effort to determine how
much training might be too much. This was done by calculating both the amounts o f
training per sport and age group for normokyphotics and hyperkyphotics, and the ratio of
the number o f annual training hours to thoracic kyphosis angle.
The next three chapters address the second primary questionIs there
experimental evidence to confirm a relation between thoracic hyperkyphosis and intrinsic
loading in the form o f hamstring shortness? Chapters V and VI report the results o f
studies that use data generated from the same subject sample and methods as the two
previous chapters (the large sample study), as well as data obtained from a second,
smaller subject sample using a different method. Chapter V describes the qualitative
relation between hamstring shortness, which is determined using the Finger-to-Floor
Reach method (Appendix G), pelvic tilt, and lumbar lordosis. Chapter VI examines the
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relationship between hamstring shortness and thoracic kyphosis, presenting evidence that
supports the idea o f hyperkyphosis as an adaptive mechanism. Chapter VII examines the
relation between hamstring shortness and athletic training. In a manner similar to the
number o f training hours associated with thoracic hyperkyphosis, as presented in Chapter
IV, this chapter includes the amounts o f annual training times associated with hamstring
shortness. This information may be helpful in the design o f confirmatory, prospective
studies aimed at supplying quantitative information regarding training times and
anthropometric norms.
Chapter VQI addresses the third primary questionIs there experimental evidence
demonstrating a relation between anthropometry and hyperkyphosis? Data obtained from
both subject samples using the two different methods are used to identify a relation
between these two variables. Chapter IX, the General Discussion, integrates the main
findings o f the studies and how they support the traditional models o f thoracic
hyperkyphosis. In addition, the strengths and weaknesses o f the studies are presented.
Finally, Chapter X presents the conclusions.
The Appendices include miscellaneous information, such as the Subject
Questionnaire, a summary o f the image processing protocol, and summaries o f hamstring
shortness and spine curvature measurement methods. It also includes a technical paper
that describes the development o f a unique platform marker for use in determining spine
anglesa preliminary project essential to the optoelectronic method used to estimate the
spine angles. The first part of this paper describes the quantification o f skin surface
distraction at select landmark points over the midline of the spine during sagittal plane
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flexion from upright to frilly flexed postures. The second part o f this paper describes the
design o f the marker, while the third part describes the validation o f the platform marker.
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thinking and planning, the primary hypotheses, and the study design for the original
project. With the bulk o f the data gathered, my tasks included assisting in the remaining
data collection from inactive controls, and in the data processing and analysis. Scott
Booth, a graduate student, was instrumental in the latter part, having written the necessary
specialized, data processing programs (Appendix F).
I was able to play more o f a role in the much smaller hamstring shortness study,
helping to select the equipment, to develop and test a unique spine marker (with technical
advice from Dave Warwick, Mechanical Engineering and Applied Mechanics
Biomechanics Research Lab, University o f Michigan), and to establish a protocol. I was
also able to help recruit and test subjects, and to process and analyze the data.
Many o f the ideas for the secondary analyses stemmed from our weekly group
meetings. I would especially like to credit Dr. Ashton-Miller, the co-chair o f my
dissertation committee, for his many observations and informal suggestions, including his
ideas regarding the development o f our unique spine marker (Appendix H). His query as
to the possibility o f thoracic hyperkyphosis as a compensatory mechanism formed the
basis for the analysis reviewed in Chapter VI. His earlier work on the relation between
scoliosis and anthropometry was the inspiration for the study reviewed in Chapter VIII.
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CHAPTER H
ON THE RELATION BETWEEN THORACIC HYPERKYPHOSIS
AND SPINE MECHANICAL LOADING: THE ANIMAL MODELS
Introduction
In the early 1920s, H.W. Scheuermann made three important points regarding a
unique type o f thoracic hyperkyphosis that would eventually bear his name. First, he used
roentgenographic imaging to describe the vertebral wedging responsible for the abnormal
increase in the sagittal plane curvature o f the thoracic spine. Second, he observed that the
wedging and the deformity that it caused seemed to be more prevalent in adolescent
agricultural workers. Third, he postulated that the pathognomonic wedging was the result
o f epiphyseal plate abnormalities.
If Scheuermanns ideas are valid, then two things should follow. The increased
prevalence o f the disease among adolescent laborers whose spines are still developing
implies a link between spine deformity and heavy or repetitive loading. If there is a link,
then it should be possible to experimentally produce hyperkyphotic deformity by externally
loading vertebrae. Second, if the epiphyseal plate is involved in the development of
vertebral wedging, then tissue from experimentally wedged vertebrae should have
histologic characteristics that are similar to tissue samples from Scheuermanns Disease
patients. This paper provides evidence to support both o f these notions.
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Background
For almost a century, repetitive loading has been implicated as a cause o f acquired,
non-postural, thoracic hyperkyphosis. Scheuermann credited Schanz (1907) as being the
first to use the label apprentice in connection with deformity o f the spine
(Lehrlingekyphose or Lehrlingescoliose, as reported by Sorensen, 1964). In his now
classic publication o f 1920, Scheuermann echoed Schanz sentiment by observing that
most o f the young subjects in his study who had the typical findings o f Kyphosis Dorsalis
Juvenilis (Juvenile Thoracic Kyphosis) were also farm workers. He wrote that the
etiology o f adolescent, thoracic hyperkyphosis was the involvement o f strenuous physical
work during the period o f increasing growth spurt during puberty (Scheuermann, as
translated by EM Bettmann, 1977).
Not only did Scheuermann report the typical radiographic wedging now commonly
identified with this disease, but he also noted that there was radiographic evidence of
changes in epiphyseal plate architecture. In his original paper, he acknowledged the
presence o f irregular epiphyses of the vertebral bodies at the involved spine segments.
These triangular shadows were at the anterior vertebral borders, and were structures
which he would later (1934) describe as annular epiphyses (ring apophyses). He stated
that these structures, plus the columnar layer of cartilage at the zone o f growth, were
affected by the disease. Insufficient growth o f these structures was thought to occur,
which resulted in wedging o f the anterior vertebral bodies.
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o f unloaded controls. Aronsson, Stokes, et al. (1999) found the same vertebral growth
differential using calf tails loaded asymmetrically loaded with a 30-50N load for a period
o f 6 months. The longitudinal growth rate o f compressed vertebrae was 68 42% that of
adjacent controls, while the growth rate o f distracted vertebrae was 123 78% that o f
controls. These patterns o f growth modulation supported the Hueter-Volkmann Law,
which is a clinical tenet stating that bone growth is retarded by compression and is
accelerated by tension.
Mente, Stokes, et al. (1997) went on to confirm that vertebral wedging resulted
from asymmetric loading. The rat tail model was again used, with tails loaded in
compression with a force o f 34-58% body weight for 6 weeks. Within a few days o f
loading, tail wedging was noted. Ninety-six percent o f this early wedging was shown to
take place at the intervertebral disc, likely due in part to a hydrostatic water shift within
the disc. By the sixth week after loading, the disc-deformation contribution to wedging
dropped to about 57%, while 43% of wedging was now due to asymmetrical physis
growth o f the vertebrae. The longitudinal growth rate o f the compressed vertebrae was
suppressed, averaging 61.3% 10.2% the growth rate o f unloaded controls. By using
calcein, a fluorochrome that labels ossifying bone, Mente, et al. were able to quantify the
difference in growth between the convex and concave sides o f the bent rat tails, which
averaged 2.7 1.5 tim/day. These findings indicated that unequal growth rates resulted in
vertebral wedge deformities.
Mente, et al. (1999) again used the rat tail model to investigate the reversibility of
loading-related, vertebral wedging. External fixators were used to produce an angular
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deformity o f 30 in rat tails, with a compressive force o f 60% body weight. After 4 weeks,
the fixators were removed, having produced an average vertebral wedge deformity o f 10
4.4. A group o f rats then underwent load reversal, with one week o f distraction loading
and four weeks o f angular deformity and compression on the opposite aspect o f the tail.
The load removal-only group demonstrated a slight but significant improvement o f
wedging (to 7.3 3.9). The load removal-plus-opposite-side-reloading group
demonstrated a pronounced wedge improvement, with a decrease to an average o f 0.1
1.4. These findings provide important implications for the treatment of human spine
curve abnormality, suggesting that removal of load and modification of posture from
compression to distraction might modify the curve.
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appearance than those o f rats whose tails were subjected to loading. The control rat tails
(Figure 2.1) demonstrated a parallel, columnar arrangement o f deep zone chondrocytes,
the cells that maintain healthy cartilage. These cells are normally oriented perpendicular to
the tidemark delineation between cartilage and subchondral bone (Nordin and Frankel,
1981). In contrast, caudal tissue specimens from experimental group subjects (Figure 2.2)
displayed disrupted and uneven deep zone chondrocyte columns. These findings suggest
that abnormal loading disrupts the physiologic arrangement o f chondrocytes in vertebral
cartilage endplates.
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The work of Revel, et al. (1992) does more than suggest a relation between
external loading and changes in vertebral ultrastructure. Revels micrographs are
strikingly similar to those from human spines. Like Revels unloaded rat tail specimen, the
normal, human vertebral epiphysis demonstrates a parallel, columnar arrangement o f
deep layer chondrocytes (Figure 2.3). Revels loaded rat tail specimen demonstrates the
same types o f changes found in the growth plates o f Scheuermanns Disease patients.
Like the rat tail specimens, micrographs of both the post mortem specimen o f Ippolito and
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Ponseti (1981)(Figure 2.4) and the cadeveric specimens o f Scoles, et al. (l991)(Figure
2.5) display disorganized cartilage columns and chondrocytes that are arranged in clumps
or clusters.
Similar loading-related alterations in chondrocyte organization has been observed
by others. Bylski-Austrow, et al. (2000) used a porcine spine model to demonstrate how
surgical intervention might modify spine growth. First, staples were surgically fixed at the
anterior aspects of the mid-thoracic vertebrae o f domestic pigs. These staples spanned the
intervertebral disc and two adjacent growth plates o f at least three contiguous motion
3t
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(Permission granted by the copyright holder: The Journal o f Bone and Joint Surgery, Inc.: image is
Figure 2 page 176from: Ippolito E, Ponseti IV. Juvenile kyphosis, histological and histochemical studies.
JBJS(Am), 63-A(2):175-182, Feb 1981.)
(Permission granted by the copyright holder: Lippencott, Williams & Wilkins; image is Figure 4B, page
512 from Scoles PV, Latimer BM, DiGiovanni BF, Vargo E, Bauza S, Jellema LM. Vertebral alterations
in Scheuermann's kyphosis. Spine, 16(5):509-515, 1991.)
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segments (six vertebrae). The staples were left in place for six to nine weeks, after which
the spines were for histologic analysis.
The group made two observations. First, the surgical stapling o f the anterior
aspect of the spine resulted in a 20-25 to 35-40 increase in the thoracic spine curvature.
This finding illustrates the Hueter-Volkman Law, as the fixed anterior aspect could be
thought of as being held in relative compression, while the posterior aspect of the spine
was left free to grow. The second observation was made by comparing growth plate
micrographs from the unstapled aspect of the porcine vertebrae (Figure 2.6) to those o f
the stapled, or loaded sides (Figure 2.7). Chondrocytes from growth plate cartilage o f
the unstapled aspects were linearly arranged in parallel columns, similar in appearance to
Figure 2.6. Porcine spinal growth plate structure on the unstapled side.
Chondrocytes o f the deep layer (lower aspect o f the stripe in the middle o f the image)
are linearly arranged and are in parallel columns.
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Figure 2.7. Porcine spinal growth plate structure on the stapled side.
Chondrocytes are poorly organized, losing the parallel column orientation.
(Permission fo r use o f these images granted by the copyright holder: images are from Crawford AH.
Endoscopic Mechanical Spinal Hemiepiphysiodesis Modifies Spine Growth. Abstract presented at the
2000IMAST meeting as cited in Orthopedics forum : Copyright 2000Carden Jennings Publishing Co.,
Ltd., Charlottesville, VA.)
those o f unloaded rat tail (Figure 2.1) and normal human spines (Figure 2.3). In contrast,
chondrocytes from growth plate cartilage o f the stapled aspects, the side under relative
compression loading, were poorly organized, similar in appearance to those from loaded
rat tails (Figure 2.2) and humans having Scheuermanns Disease (Figures 2.4 and 2.5).
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cartilage (Bright, et al., 1974). This notion is supported by the work o f Pazzaglia, et al.
(1997). In their study, forty-eight Sprague-Dawley rats were divided into two groups
young rats and adult rats. The experimental group had their tails bound in a loop for 3060 days. Subsequent, histologic analysis o f the tail vertebrae revealed significant
differences in the appearance o f both growth plates and osseous trabeculae between the
young and adult rats. Unlike the tails o f old rats, the compressed aspects o f the young rat
tails demonstrated fragmented and irregular growth plates, along with shortening and
thickening o f the epiphyseal and metaphyseal trabeculae. In addition, the distracted
aspects of the young rat tails under tension demonstrated transverse fractures o f the
hypertrophic chondrocyte layers. These findings supported the idea that the loading
response of cartilage is age-dependent.
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addition to enhancing collagen synthesis, TGF-B has also been shown to stimulate both
stem cell differentiation into chondrocytes and dedifferentiated chondrocyte reexpression
o f normal function (Qiao, et al., 1998). A strain-sensitive subtype o f the growth factor,
TGF-fil, has been shown to stimulate periosteal mesenchymal precursors to proliferate
and differentiate in the growth plate (Joyce, et al., 1990) and to regulate expression of
osteopontin messenger ribonucleic acid (mRNA) expression, itself important in bone
mechanotransduction.
Excessive loading is linked to an alteration of both gross cartilage appearance and
cartilage physiology. These abnormal tissues have a relative paucity o f chondrocytes,
which are arranged in a disorganized fashion. Fewer chondrocytes produce less collagen
fibrils and proteoglycans, components that help to determine the tissue's biomechanical
behavior (Nordin and Frankel, 1989). It is likely that abnormal epiphyseal cartilage
ossifies in an abnormal manner, leading to the vertebral wedge deformities seen in
Scheuermanns Disease.
Discussion
At least one question foliowsgiven the predisposition of the thoracic spine to
hyperkyphosis described here, why dont all repetitively loaded, immature spines develop
Scheuermanns Disease? The probable answer is that a combination o f factors is likely
necessary. These factors might include a familial tendency towards the disease (e.g.
Sorensen, 1964). They may include age, gender, the amount o f training, and factors such
as hamstring tightness and anthropometry.
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Conclusions
Several different studies have investigated the effect o f asymmetric loading on
vertebral growth and structure. Whether rat, bovine, or porcine models are used, all have
shown that asymmetric growth is the result, with retarded vertebral growth resulting from
compression loading. The histologic samples from these compressed tissues all have a
striking resemblance to specimens from Scheuermanns Disease patients. The similarities
between experimentally loaded tissue and pathologic human tissue support Scheuermanns
observation o f abnormal epiphyseal plate behavior in thoracic hyperkyphosis.
If the gross and histologic findings o f the animal model experiments are
extrapolated to the human thoracic spine and asymmetric, bending, compressive loading is
modeled as the intense, repetitive sagittal plane flexion o f farm work or athletic training, it
is feasible that a hypothetical vicious cycle o f hyperkyphosis can result. The cycle is one
in which increased thoracic flexion augments compressive loading o f the anterior aspects
o f the vertebrae, leading to asymmetric growth and wedging, which allows more flexion,
an increased flexion moment, more loading, then more wedging, and so on. If one takes
into account the reports o f age-related susceptibility o f vertebral tissues to the effects o f
loading, it is easy to see that early pioneers as Schanz and Scheuermann were likely
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CHAPTER HI
A CROSS-SECTIONAL STUDY ON THE RELATION BETWEEN
THORACIC KYPHOSIS AND REPETITIVE LOADING IN THE FORM
OF ATHLETIC TRAINING IN 1,822 8-TO-18 YEAR-OLDS
Introduction
Is thoracic kyphosis related to repetitive loading, as suggested by H.W.
Scheuermann and others? As described thus far in this dissertation, two lines o f evidence
support this observation. First, the in vivo application o f abnormal amounts o f external
loading onto mammalian vertebrae caused gross spine curve deformity and the typical
vertebral wedging similar to that identified by Scheuermann. Second, the same type o f
experimental loading produced ultrastructural changes that were remarkably similar to
those present in the vertebral tissues o f Scheuermanns Disease patients.
Until recently, evidence that confirms a link between thoracic kyphosis and
repetitive, external loading in the form o f physical activity has been lacking. This chapter
reviews the findings o f a secondary analysis o f data from the cross-sectional study of
Wojtys, et al. (2000), one of the first studies to demonstrate a statistical link between
thoracic kyphosis and athletic training, which includes the repetitive use o f sport-specific
conditioning, and strengthening techniques. The analysis described herein is intended to
support the original study by testing the hypothesis that thoracic kyphosis is associated
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with the amount o f physical activity in the form o f athletic training, as modeled by the
number o f annual participation hours reported by the subjects.
^controls
^athlete group
It was expected that there would be a difference in the magnitude o f the mean thoracic
kyphosis angle between athletes and controls. If repetitive loading were a factor, then
athletes should have a larger mean kyphosis angle.
Several secondary hypotheses were subsequently tested in a post-hoc fashion.
These were aimed at identifying age, gender, and anthropometric differences between the
Control and Athlete groups. They were also aimed at identifying age, gender, and
age*gender interaction effects on both thoracic kyphosis angle and annual training time.
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It was anticipated that there would be differences o f annual training time by age in
athletes, such that the amount o f training increased with age. It was also anticipated that
there might be gender-related difference in both training and thoracic kyphosis angle.
Background
The notion that hyperkyphosis is related to increased loading is decades old. As
mentioned earlier, Scheuermann (1920) observed that most o f his subjects who
demonstrated the unique radiographic findings o f Juvenile Kyphosis were adolescents
engaged in repetitive agricultural work. Scheuermanns idea o f the work-relatedness was
based primarily on surveys o f the occupations o f the adolescent, hyperkyphotic subjects,
particularly those of males. In two studies, his reported percentages o f those
hyperkyphotic subjects engaged in heavy agricultural work were 46% (1934) and 61%
(1920).
Others also felt that work was somehow associated with thoracic kyphosis,
including Dr. K.V. Wassman (1951), who characterized this same type o f hyperkyphosis
as an occupational disorder. He observed that, in a sample o f 24 cases in which
occupational trauma occurred proximate to development o f hyperkyphosis, 23 were
involved in hard physical labor. He noted that the disease was eight times more prevalent
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in the country than in the city, based on his study that compared the prevalence o f the
disease in urban and rural military conscripts. Of the 750 lads from the country in
Wassmans study, 3.2% exhibited the findings o f Scheuermanns Disease, whereas only
0.4% o f the sample o f 1500 urban conscripts had thoracic hyperkyphosis.
Athletic activities have also been named as a source of repetitive loading
associated with the development o f thoracic hyperkyphosis (e.g. Aggrawal, et al., 1979).
Competitive athletes have been anecdotally observed to have an apparent higher rate o f
hyperkyphosis than youngsters who did not engage in rigorous sport activity (Hensinger,
as cited in Wojtys, et al., 2000). Blazek, et al. (1986) reported an incidence o f
Scheuermanns Kyphosis that was four times greater in 81 top sportsmen than in non
sportsmen o f the same 18-25 year old age group (40.5% versus 9.6%). These
observations, plus those of a link between sport and back complaints in general (Kujala,
1992; Balague, 1988; Micheli, 1979) have likely contributed to the decision to discourage
competitive weightlifting and the use o f maximal weights in prepubescents (Bar-Or,
1989), and for the American Academy of Pediatrics to issue a warning regarding the
possibility of sport-related, epiphyseal damage in preadolescents (AAOP, 1992).
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consisted o f 2270 volunteer 8-to-18 year-olds. The 407 female and 1863 male subjects
had a mean age o f 14.6 ( 2.1) years, mean height of 1.69 ( 0.13) meters (range: 1.23 to
1.96 meters), and a mean weight o f 62.82 ( 18.38) kilograms (range: 20.45 to 133.18
kilograms). Most o f the subjects were from the University of Michigans annual summer
sports clinics, while 182 were tested at local public schools during the academic year. All
enrollees at each testing site were invited to participate, and those who chose to were
required to obtain written parental permission in order to act as subjects in this Human
Use Committee-approved project.
Each subject was required to complete a questionnaire, the test/retest reliability of
which was determined using kappa statistics. The information obtained from these
questionnaires (Appendix E) included sports participation data. From these raw data,
three parameters were used to quantify the amount o f training for each participant:
Annual Training Time (the number o f reported training hours per year), Period (the
number o f years of participation), and the product o f these two variablesCumulative
Training Time. The calculation o f Annual Training Time may be illustrated by the young
athlete who reports training two and a half hours per day for a five day training week
during a season which lasts an average o f 3 months at the high school level. That
students annual training time would be 2.5 hours/day x 5 days/week x 12 weeks/season,
or 150 hours/season. Training time was expressed as hours/year if the subject participated
in only one primary sport, which included football, gymnastics, ice hockey, track,
swimming, volleyball, or wrestling. Active athletes were defined as those who trained for
at least one primary sport on four or more days per week for at least four months per year.
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Those individuals having an Annual Training Time o f zero hours were classified as
Inactive Controls.
In addition to the subjective questionnaire information, objective anthropometric
data were collected for each participant. These included measurements as height, weight,
arm and leg lengths, shoulder and abdominal breadths and depths, and the greater
trochanter-to-floor height (GTF). Hamstring shortness was determined using a Finger-toFloor Reach Test (Appendix G). Subjects standing with feet separated at shoulder width
and with knees straight were asked to touch the floor. Those able to touch the floor were
classified as hamstring-normal, while those unable to touch the floor were hamstringshort. Specific spine segment lengths were also measured, including the distances
between the first sacral segment (SI) and each o f several landmarks: the greater
trochanterion (GT), third lumbar vertebra (L3), the tenth thoracic vertebra (TIO), and the
first thoracic vertebra (T l). The four bony landmarks at the spine midline (T l, TIO, L3,
SI) were selected as the locations for surface markers that would be used in the
photographic determination o f sagittal plane spine curvature.
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in which each participant was fixed in standardized test positions and orientations. As
described in Wojtys, et al. (2000), the platform supported both light emitting diodes
(LEDs) and a rotating pivot point. The fixed LED arrays were used in the calibration
procedure and for subject position reference. The pivot points provided a rotational axis
for either calibration board or subjects. The apparatus permitted fixation of the subjects
pelvis and permitted trunk rotation in flexion at the hips while eliminating body sway from
either knee or ankle motion.
Test Protocol
Bright tape markers large enough to be detected on photographs (S/8 inch by 1
and 1/4 inch) were affixed to the skin surface at the midline o f the bared backs o f each
subject. These markers were placed at palpated landmarks representing the first and tenth
thoracic vertebrae (Tl & TIO), the third lumbar vertebra (L3), and the first sacral segment
(SI). Each subject was instructed to position themself in postures ranging from upright
(vertical) to fully flexed (horizontal), with intermediate positions intended to place the
spine landmarks T l, TIO, and L3 in a horizontal plane. The desired subject orientation
was obtained by instructing each person to stand in one of several test postures. For
Position 1, the subject stood in a relaxed, upright position with head held erect, arms at
the sides, and hands clasped. In Position 2, subjects were instructed to roll the shoulders
forward and cross the arms across the chest. Subjects slouched their shoulders and flexed
head and neck in Position 3, rounded the upper back in Position 4, and tried to touch their
toes in Position S. A fluorescent light and a pair o f red and green filters were built into the
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platform floor. Oriented along the floors long axis, the light provided a means o f
maintaining true sagittal orientation during torso flexion. The fluorescent tube and
colored filters were arranged so that when light escaped through a narrow slit in the
platform floor, the subject would see a white color if he was flexing in the desired sagittal
plane, red if he veered to the right o f that plane, or green if he veered off to the left.
Photographs were then taken o f each subject in each posture, providing the raw
spine angle data. The photographic equipment consisted of one pair o f motor-driven,
35mm single lens reflex cameras and one pair o f projectors. These were positioned
around the platform as depicted in Figure 3.1. Paired as one camera (C) and one projector
(P), each was supported by individual stands at either end o f the apparatus. The first pair,
Cl /PI, was positioned behind the subjects as they stood on the apparatus. This pair was
used to record the sagittal curvature o f each subjects back at the midline from the first
thoracic vertebral surface landmark (T l) to the first sacral segment surface landmark
(SI) for the upright, standing posture and three increments o f partial flexion. The second
camera/projector pair (C2/P2) was positioned at the opposite end and was used to record
the spine curvature (TI to SI) in a standardized, fully-flexed position.
The light projectors served two functions in data collection. First, they illuminated
the otherwise darkened test room. Second, they projected a grid slide image onto
whatever was positioned on the platformeither calibration board or subject. The grid
slide was a photographic slide marked with parallel lines o f known spacing and geometry.
It was sandwiched between the projectors light source and lens, so that light passing
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1192 mm
1369 mm
C2
Cl
O
60S nun
j 850
Platform
-+
m i
P2
vii
DEVICE
Camera 1 (Cl)
Projector 1 (PI)
HEIGHT
2460 nun
2140 mm
"*j*------------ ^
1695 mm
ANCLE
37.0
21.4
940 mm
DEVICE
Camera 2 (C2)
Projector 2 (P2)
HEIGHT
2170 mm
2370 mm
PI
ANGLE
36-3
42.9
SUBJECT stands between the stanchions with left side to L and right side to R, looking down the long axis of the platform.
HEIGHT is measured from the floor to the intersection of lens axis and either camera film plane or projector grid-slide plane.
ANGLE is measured from the horizontal to the lens optical axis.
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
through it would cast a grid shadow on the target surface. The grid had a darkened line in
its center which served to accent the midline o f the spine and provide a clean, non-contact
reference for the locations o f the coordinates o f the spine contour landmark points (Figure
3.2).
A calibration procedure was performed at the beginning o f each test day. First, a
calibration structure imprinted with a rectangular pattern o f nine, equally spaced, fixed
dimension points was placed between the stanchion pivots. The calibration board, a flat
reference plane, was positioned vertically when the subjects would be photographed in the
upright and partially flexed subject positions (Positions I through 4). Projector PI and
Camera C l were used to project the grid and record the images while subjects were in the
upright postures. Their optical axes were focused at the center point o f the calibration
board during the calibration procedure. For imaging o f the subjects in the fully flexed
position (Position 5), the calibration board was oriented horizontally. For this posture,
Camera C2 and Projector P2 were used. Both C2 and P2 were also initially focused at the
center point o f the board during calibration.
Once the cameras and projectors were aligned, the system was ready for
calibration. First, the grid slide image was first projected onto the calibration board.
Measurements were made o f the distances between the nine calibration board reference
points, as well as between each point and the central point (origin) o f the nine-point
rectangle. The central point, O, was the target point for the optical focusing process
and was the intersection o f the projected central light ray with the plane. The distances
between the nine calibration points and the four, fixed LEDs arranged as paired arrays on
50
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Figure 3.2. Grid Pattern Projected onto Calibration Board, Subjects Back
(LEDs as white dots located on either side of board or subject; rectangular tape pieces
may be seen along the subjects midline at T l, TIO, L3, and SI
51
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the stanchion were also measured. These dimensions were entered into a digital file for
eventual use in data processing. Next, calibration photographs were made o f the
calibration board in both vertical and horizontal positions by Camera/Projector pair 1 and
pair 2. The same dimensions that were hand-measured would now be taken from the
photographs using a program custom written for the purpose o f semi-automated data
processing. Thus, the calibration board was used both to provide a scale and to locate
each subject relative to the apparatus. This was accomplished by comparing the
calibration points to the LED locations and then by comparing the subjects spine data to
the LED locations.
With the calibration process was complete, the flat reference board could be
removed and subject photos taken. Each subject would have a complete data set o f five
35mm color slides representing each o f the five test positions: fully upright, three
increments of forward-flexion, and folly flexed. Testing o f each subject required
approximately ten minutes. Two minutes were used for the interview and questionnaire
and two to three minutes were needed for anthropometry. Skin marker application took
approximately two minutes, while subject positioning and photography required the
remaining two to three minutes.
Data Reduction
The analog photographic images for the folly upright posture (Position I) were
then converted to digital bitmap files o f approximately 150 kbytes each using a Nikon
CoolScan slide scanner (Nikon Corporation, Toyko, Japan). The bitmap files were then
52
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53
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1 were lost during the development process because the exposures were located too close
to the beginning o f the film roll.
Results
The primary null hypothesis was tested first. The analysis revealed a significant
difference (p=0.013) between the mean thoracic kyphosis angles o f the inactive controls
and those o f active athletes (Table 3.1), with the mean angle o f the athletes being about
24% larger than that of controls. The 75 controls had, by definition, an Annual Training
Time equal to zero, while the 2195 athletes had a mean training time 260.3 ( 190.9)
hours. However, the gender composition o f the two groups was different, as the athlete
group had a significantly greater number o f males than did the control group (p=0.000;
54
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Table 3.2). The inactive controls were also significantly younger, with a mean age about
16% less than that o f the athlete group. The controls were also about 8% lighter and
21% shorter than athlete subjects, reflecting the direct relation between age and the
anthropometric variables o f height and weight. The differences between subject groups
led to the rejection o f the first o f the Secondary Null Hypotheses, H02 , which was that
there were no significant differences of age, gender, or anthropometry differences between
controls and athletes.
Table 3.1. Differences of Mean Age, Height, Weight, and Thoracic Angle (T)
between Unmatched Control and Athlete Groups
G roup
Controls
Athletes
p-values
Table 3.2. Subject Number and Gender Composition for Three Separate
Subject Groups: Active Athletes, Inactive Controls, and a Athlete/Control
Group Matched for Age, Height, and Weight
G en der
Male
Female
Totals
A thletes
1796
374
2170
%
82.76
17.24
100
C o n trols
56
33
89
%
62.92
37.08
100
36
16
52
%
69.23
30.77
100
Regression modeling (Table 3.4) suggested that the variables age, gender, and
anthropometry were all predictors o f thoracic angle. To control for the mean differences
o f age, height, and weight between the two groups, a sample o f active athletes was
matched to a sample o f inactive subjects according to these three variables. As was the
case hi the larger sample, t-tests again demonstrated a significant difference o f mean
55
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thoracic kyphosis angle between the Control and Athlete groups (p=0.000, n=52; Table
3.3). Because the athlete groups for both sample sets had a significantly larger mean
Afle (y rs.)
13.77 (+1-2.67)
13.77 (+1-2.67)
n .s.
H eight (m.)
1.66 (+/-0.14)
1.66 (+/-0.14)
n .s.
W eight (kg.)
58.06 (+/-14.55)
58.74 (+/-17.19)
n .s.
T (deg.)
28.93 (+/-21.54)
44.02 (+/-15.02)
0.000
thoracic kyphosis angle than controls, the decision was made to reject the Primary Null
Hypothesis, Hoi, which was that the mean thoracic angle o f controls was equal to that of
athletes.
The significant difference o f the mean Thoracic Kyphosis Angle between Controls
and Athletes when matched by age, gender, height, and weight, implied a direct relation
between this dependent variable and Annual Training Time. This was confirmed by Linear
Regression (Table 3.4).
The analysis confirmed the findings o f the t-tests by showing that Annual Training
Time (Time) was a significant (p=0.004) predictor o f Thoracic Angle (T). A scatterplot
o f these two variables demonstrates the direct relation (Figure 3.3). The use o f LOWESS
(LOcally JFEighted Sbatterplot Smoothing) for smoothing demonstrates the non-linearity
o f the relation as indicated by the low r2. Other significant predictors o f T included Age,
Sex, and the interaction o f Age and Sex. O f all the anthropometric variables, including
height and weight, only Torso Depth at L3 (LDP) and Spine Length (STl) were
56
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significant predictors. The relation between anthropometry and angle will be discussed in
Chapter V m .
P (2 TAIL)
0.000
0.003
0.001
0.000
0.000
0.004
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After gender and age were identified as significant predictors of thoracic angle, ttests were used to further test the Secondary Null Hypotheses. First, a significant gender
difference o f mean thoracic angle (p=0.007) was identified, with the mean angle of males
(38.43 14.98) being about 7% larger than that o f females (35.84 17.65). Male
athletes, who made up the majority of the subject sample, were significantly older
(p=0.000) than female athletes [14.86 ( 1.94) years versus 13.83 (2.08) years]. Unlike
their male counterparts, female athletes demonstrated a significant relation between Age
and Thoracic angle, such that older females tended to have larger angles than younger
females (p=0.006). However, when thoracic angle was normalized for age, there was no
significant difference o f T between genders and H03 , stating that there were no age- or
gender-related differences in thoracic kyphosis angle, was accepted.
The interaction between the variables Age and Sex was also a significant predictor
o f thoracic angle. The relation o f these two variables to T is illustrated below. Figure 3.4
shows that in male athletes, mean thoracic angle remained relatively unchanged with
increasing age. Figures 3.5 and 3.6 illustrate that this was not the case with controls or
female athletes, whose mean thoracic angle decreased with age in the l4-to-l8 years o f
age. The 168 female !4-to-l8 year old athletes had a significantly smaller (p=0.000) mean
thoracic angle, T, o f 32.07 ( 17.02), while the 1271 male 14-to-18 year old athletes had
a mean T o f 38.45 ( 15.39). Because o f this difference, the decision was made to reject
Ho4 that there were no interaction effects o f age and gender on thoracic kyphosis angle.
58
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Figure 3.4. Mean Thoracic Kyphosis Angle by Age for Male Athletes
Note that there are no differences in mean thoracic angle between male athletes younger
than 14 years and those 14 years or older.
5=
:
-
...
..
. ..
-c e
-6
--
.i
rri
Figure 3.5. Mean Thoracic Kyphosis Angle by Age for Female Athletes
Thoracic Angle (T) is in degrees, Age is in years. In contrast to Male Athletes,
mean T values decrease with age for the L4-to-l8 year-olds.
59
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The next o f the secondary null hypotheses examined the relation between age,
gender, and the interaction o f the two (Age*Sex) with Annual Training Time. Again, a
general linear model was used to identify significant predictors o f Training Time, which
included Sex, Age*Sex, and Height (Sex: p=0.000, Age*Sex: p=0.000; Table 3.5).
Female athletes reported a significantly larger (p = 0.000) mean annual training time [320
( 246) hours] than their male counterparts [259 ( 179) hours], a finding that was true
Table 3.5. Stepwise (Backward) Linear Regression Equation for Active Athletes
[p=0.000 (ANOVA), r:=0.047; N=2150, with 45 cases deleted due to missing data]
rim*
where
P (2 TAIL)
0.000
0.000
60
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even after normalizing Time by Age. While Training Time increased in age in both
subjects o f both genders, the relation between the two variables was significant in male
athletes, such that older males tended to train more than younger males (p=0.000; Table
3.6 and Figure 3.7). This gender-related difference illustrates the Age*Sex interaction
effect on Time. These findings led to the decision to reject secondary null
Table 3.6. Mean Annual Training Times by Age Group for Athletes
While the Training Times of Females are larger than those of Males in every age group,
there are increases o f mean training times between male age groups.
A ge G roup M ean
Fem ales
8-10 yrs.
11-13 yrs.
14-18 yrs.
M ales
8-10 yrs.
11-13 yrs.
14-18 yrs.
Time (h is.)
s.d.
296
317
321
213
246
246
9.7
12.4
15.1
0.5
0.7
1.0
30
121
167
131
211
267
140
195
173
9.5
12.3
15.7
0.7
0.6
1.1
72
285
1401
2
i
I__L
'
Figure 3.7. Annual Training Time versus Age for Male Athletes
Note the direct increase o f annual training time with age (p = 0.000; r2 = 0.049).
61
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hypotheses H os and H 06, which stated that there were no age- or gender-related differences
in training time and there were no age*gender interaction effects on training time.
Discussion
Prior to this analysis, only one study, Wojtys, et al. (2000), demonstrated a direct
relation between thoracic kyphosis and repetitive loading in the form of athletic training.
In that study, training was calculated as Cumulative Training Timethe product o f selfreported Annual Training Time (in hours) and self-reported Period, the number o f years o f
sport participation. In this chapter, athletic training was represented by Annual Training
Time (in hours) alone. That variable was chosen as it was thought to be a simpler
representation of the amount o f training, and was a variable more easily conceptualized
when making training recommendations to coaches. Regression analysis supported this
decision, as annual training time was more often a significant predictor o f thoracic angle
than period.
The findings described in this chapter support those o f Wojtys, et al. (2000).
However, they are different in that many years o f sports participation are not required to
be associated with larger thoracic kyphosis angles. Rather, the training undertaken in only
a year has been shown to have a direct relation. Perhaps, future analysis to estimate the
interaction o f period could be achieved by looking at the relation between thoracic angle
and athletic training hours with subjects grouped into the number o f years o f sport
participation.
The large data set o f Wojtys, Ashton-Miller, et al. (2000) was the source for this
secondary analysis. These authors reported a mean thoracic angle o f 38.5 ( 13.6). For
62
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these values, the range o f thoracic kyphosis angles within one standard deviation was
about 25 to 52. Subtracting the 7, systematic overestimation o f radiographic angles
reported from the validation portion of the Wojtys, et al. (2000) study gives a
roentgenographic equivalent range o f 18 to 45. This agrees well with the 15 to 45
normal kyphosis range suggested as normal by Winter and Hall (1978) and closely
approximates the 20 to 45 range suggested by Bradford (in Moes text, 1995) and by
Nissenen (1995).
Eleven percent o f our inactive control subjects and seventeen percent o f our active
athletes had thoracic kyphosis angles beyond one standard deviation from the mean (52,
as determined using the photogrammetric/surface method). These values approximate
prevalences reported for Juvenile Kyphosis by Blazek, et al. (1986) [9.6% in inactive
controls (ages 18-25 years)] and by Nitzsche and Hildenbrand (1990) for active males
(15.3%). About 4% o f subjects had kyphosis angles greater than two standard deviations
from the mean (greater than 65). This figure agrees well with what has been reported by
Ascani, et al. (1977) and is within the range o f the prevalence reported by Sorensen
(1964) and Tertti (1990) for subjects o f similar ages (Appendix A).
The subjects o f our study were not subjected to radiographic analysis. Therefore,
we could not presume that our hyperkyphotic subjects had Scheuermanns Disease.
Nonetheless, the prevalence of hyperkyphosis in our subject sample compared favorably
with the prevalence o f Scheuermanns Disease as reported by others. O f our sample o f
307 female athletes, 16% had thoracic kyphosis angles greater than 52, while 17% o f a
63
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sample o f 1581 male athletes had angles greater than 52. In our non-athlete control
sample, 11% had thoracic kyphosis angles greater than 52.
Limitations
The methods used to obtain the spine angle and training time data were those
described by Wojtys, et al. (2000). The limitations o f those methods are described in that
publication and in greater detail in Chapter IX. One of the most notable limitations is the
use o f surface, photogrammetric methods for spine angle estimations. Our method was
shown to systematically overestimate radiographic angles by about 7. However, after
accounting for this error, our subject sample thoracic angle mean and standard deviation
support the normal range for thoracic kyphosis angle described by Bradford (1981) and
others.
The use o f childrens self-reporting has its own limitations (e.g. Anderssen, et al.,
1995). Our test/retest validation of our survey instrument demonstrated repeatability o f
the subjects responses, although with this method we had no way o f knowing the
accuracy o f their participation time estimates. In addition, the convenience sample o f
volunteers was not a random sample. Because summer sports camps were the sources o f
many o f the subjects, socio-economic limitations excluded those who could not afford to
participate. Thus, the results o f these analyses could not be generalized to the entire
population.
64
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Conclusions
The results o f this secondary analysis o f data from a cross-sectional study implied a
direct relationship between thoracic kyphosis and annual athletic training hours. While the
cross-sectional design o f the study prohibited the establishment o f cause and effect, the
results showed that, in an 8-to-l8 year old, public school student, volunteer sample, the
mean thoracic kyphosis angle o f active athletes was significantly larger than that of
inactive controls. This finding remained true when controlling for age, gender, and
anthropometric differences (height and weight) between subject groups. Regression
analysis confirmed that Annual Training Time was a significant, direct predictor of
Thoracic Angle in athletes, indicating that those who trained more tended to have larger
thoracic angles.
These results lend support to the anecdotal clinical observations that the
development o f thoracic hyperkyphosis is related to work in adolescent individuals whose
immature spines are likely more susceptible to loading. The implication is o f these
findings is important, for modification o f activity could result in the prevention and
possibly the improvement o f hyperkyphotic deformity. In the next chapter, the relation
between thoracic angle and training time is further investigated within active athletes, and
an effort is made to quantify the actual amounts of training time associated with thoracic
kyphosis by sport.
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CHAPTER IV
A CROSS-SECTIONAL STUDY OF THORACIC HYPERKYPHOSIS
AND ATHLETIC TRAINING HOURS FOR SIX SELECTED SPORTS
IN 8-TO-I8 YEAR OLDS
Introduction
The preceding chapters have presented evidence to support the notion that
repetitive loading is associated with thoracic hyperkyphosis in adolescents whose
immature spines are still developing. This evidence includes animal model experiments
that have produced both gross and microscopic changes typical o f those seen in
Scheuermanns Disease, a type o f acquired thoracic hyperkyphosis. The evidence also
includes the results of a secondary analysis of the data from a cross-sectional study by
Wojtys, et al. (2000) that demonstrate a direct relation between thoracic hyperkyphosis
and repetitive loading in the form o f athletic training. In that study, active athletes had
larger thoracic kyphosis angles than inactive controls. In addition, those active athletes
who logged more training hours tended to have larger kyphosis angles.
In this chapter, we will continue to look at the association between thoracic
kyphosis and athletic training. We will do so by analyzing the data from the Wojtys, et al.
(2000) study with active athletes grouped according to their primary sports activity.
Because o f the uniqueness o f sports activities, we anticipate that there will be differences
in the amounts o f reported training between sports. I f there is an association between
66
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thoracic kyphosis and the amount o f repetitive, physical activity, then participants of
sports requiring more training should have larger kyphosis angles. Within sports, those
who train more should similarly have larger angles. Expressed as the Primary Null
Hypotheses:
between sports
H 0 2 : There are no differences of mean annual training time
between normokyphotic and hyperkyphotic athletes within sports
In Chapter HI, regression analysis showed that in addition to annual training hours,
both age and gender were significant predictors o f thoracic kyphosis angle (Table 3.5).
Thus, additional comparisons were made between sports in order to identify differences o f
age, gender, and anthropometry by addressing the Secondary Null Hypothesis:
It was expected that there would be differences o f age and gender between sports,
as well as differences o f height and weight.
The remainder o f this analysis was aimed at estimating how much training is too
much? This was done in two ways. First, the amount o f training associated with
thoracic hyperkyphosis was quantified by first calculating the number o f annual training
hours by sport for each o f three age groups for both normokyphotic and hyperkyphotic
subjects. Next, the sports in which the relationship between kyphosis and training was the
67
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strongest were identified. This was done by determining the mean thoracic angle per
annual training hour by sport.
Background
Certain types o f exercise have been shown to enhance the mechanical competence
o f the skeleton in prepubertal and peripubertal athletes (Daly, et al., 1999) by mechanisms
that include an increase o f bone mineral density (Bass, et al., 1998). In fact, the growth of
the intervertebral disc and vertebrae have been shown to be dependent upon activity
(Taylor, 1975).
In contrast, excessive sports activity has long been thought to have a negative
effect on the spine (e.g. Hafiier and Surrey; 1952). Based on what has been discussed in
Chapters I and n , it is not surprising that the repetitive microtrauma (Dalton, 1992), the
rapid or forceful movements (Sward, et al., 1990-A), or the increased compressive
loads on the vertebral end plates (Wilson and Lindseth, 1982) from sports such as
gymnastics, wrestling, volleyball (Stiletto, et al., 1996) could adversely affect normal spine
development.
Athletic training has been identified with several types o f back problems. Harreby,
et al. (2001), studying 1,389 eighth and ninth grade students, identified a positive
correlation between competitive sports and recurrent or continuous back pain. Tanchev,
et al. (2 0 0 0 ) identified an incidence o f one type o f spine deformity, scoliosis, that, in active
individuals, was over ten times the incidence in inactive controls (12% versus 1%). The
Tanchev group observed that repeated, asymmetric stress on the spine was a typical
68
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element of the active groups training program. Another type o f spine abnormality,
spondylolysis, was observed by Hellstrom, et al. (1990) to occur in male athletes at a rate
two to three times that o f non-athletes. Hellstroms group also observed that radiographic
spine lesions such as anterior Schmorls nodes and reduced disc height were displayed by
57% o f a sample o f 30 wrestlers and by 43% o f a sample o f 52 gymnasts, roughly 3 to 4
times that of the 13% prevalence in a group of 30 non-athlete controls.
Other spine problems have also been found to be more prevalent in wrestlers and
gymnasts. When compared to soccer and tennis players, wrestlers reported 69% more
back pain, while gymnasts reported 85% more (Sward, et al., 1990-C). In a study by
Goldstein, et al. (1991), 63% o f elite gymnasts were found to exhibit spine lesions, which
were found to be associated with both age and training. Such sport-related spine lesions
include osteochondrotic lesions (Lohrer, 1998), apophyseal excavation (Sward, et al.,
1993), and intervertebral disc abnormalities (Tertti, et al., 1990), all o f which are similar to
what have been observed in Scheuermanns Disease.
As mentioned in Chapter m , several authors have related the thoracic
hyperkyphosis o f Scheuermanns Disease to sports activities (e.g. Hafiier and Surrey;
1952; Micheli, 1979; Sward, 1992). Blazek, et al. (1986) observed that 40% o f top
sportsmen participating in sports that included gymnastics and volleyball displayed
radiographic findings o f Juvenile Kyphosis~fbur times the prevalence in non-athletes.
Tertti et al. (1990) noted that 43% o f gymnasts with abnormal discs also had
Scheuermanns Disease. Sward (1992) noted that the thoracolumbar form o f
Scheuermanns was much more common in athletes than non-athletes. Falter and Hellerer
69
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(Table 4.1). Grids were optically projected onto both a calibration board and onto all
subjects (Chapter in, Figure 3.2). For each participant, four, predetermined landmark
points and a number o f additional points were selected and digitized along the length o f
the highlighted, spine midline. This information was then combined with calibration data
and processed using computer programs to eventually yield subject thoracic angle data.
The thoracic angles were compared between subjects divided according to sport. Sport,
age, and training data were obtained using self-reporting questionnaires, while
anthropometric measurements were taken at the time o f testing.
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The next phase o f accuracy testing involved the comparison o f the results of
manual digitization with those o f computer-based data processing. In the early, pilot
stages o f this study, the spine angles were determined using manual digitization. The
projected images o f approximately 247 subjects were calculated from data points that had
been hand-digitized. Subject slides were projected onto a SAC digitization platform
having a resolution o f 1 : 2 0 0 0 and at least
100
midline from T 1 to SI. However, this method was both time- and labor-intensive, and it
was determined that a computer-based data handling system would facilitate the process.
As described earlier, the use o f the digital system began with the analog-to-digital
conversion of the photographic images. After testing various combinations o f cropped
and uncropped preparations o f the calibration and subject slides, it was determined that
uncropped calibration slides and cropped subject image slides provided the combination of
new-method angle values most consistent with those obtained using hand-digitization.
This combination had the highest correlation coefficient (r = 0.87), with t-test showing no
significant differences between angles measured using manual and digital methods.
Once an automated protocol was selected, the repeatability o f the spine angle
results was tested. Repeated measurements were made o f 10 subject slides to determine
the error due to operator digitization and software angle calculations. Each o f the ten
slides were digitized using computerized techniques. The spine angles for the ten slides
were calculated on three separate occasions, with a test-retest error o f approximately 3.
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there was a high correlation between the two (r2 = 0.85). When the mean angles
generated by each method and expressed in degrees were compared, the thoracic angle
mean difference was 1.88, while that o f lumbar angles was 2.47. Despite their close
similarity, the landmark tangent method angles were selected for analysis because their
variances were about one-half o f those angles generated from spine inflection point
tangents.
Results
n
286
1529
Age (yrs.)
m ean s.d .
2.0
13.6
14.9
1.7
0.000
Heightt(m .)
m ean s.d.
0.1
1.6
1.7
0.1
0.000
W eight (kg.)
m ean s.d.
52.0
11.3
66.3
18.1
0.000
In order to test the secondary null hypotheses and to control for gender-related
differences o f age, anthropometry, and training time, subjects were grouped according to
74
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their primary sports. First, the number o f males and females were tallied for each sport to
identify any gender composition differences. As noted in Table 4.3, the distribution of
subjects according to sport was gender-related in most instances. Several sports were
found to be comprised exclusively o f either male or female subjects, while others were
dominated by one gender. Female-dominated sports included volleyball and gymnastics,
whereas male-specific sports were wrestling, football, and ice hockey.
Table 4.4. Mean Age, Height and Weight by Sport (Male and Female Athletes)
As expected, Height and Weight increase along with increasing Age
0.07
54.7
7.91
2.0
1.6
0.09
51.3
9.32
2.4
1.5
0.11
44.7
9.92
13.4
2.1
1.6
0.1
55.1
153
15.0
1.5
1.7
0.1
62.9
16.0
16.1
1.1
1.8
0.1
83.7
14.6
13.9
2.2
1.7
0.1
57.9
13.5
3
n
c
1.5
Males
hockey
n = 187
wrestling
n = 942
football
n = 389
swimming
n-175
75
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Table 4.5. Differences (p-values) of Mean Age, Height, and Weight between Sports
Older subjects were also taller and heavier, (n.s. = not significant)
A ge (yrs.)
0.000
0.001
0.003
0.007
0.045
0.000
0.024
0.000
0.017
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.017
0.000
0.000
n.s.
0.000
0.000
0.004
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
n.s.
0.000
0.000
using ANOVA and t-tests. As anticipated, older subjects tended to be taller and heavier.
The statistical significance o f these differences led to the decision to reject H03 , which
stated that there were no age, gender, or anthropometry differences between sports.
In some instances, the between-sport differences o f mean height and weight
persisted, even when controlling for gender and age (Table 4.6). Data from female
I
I
G roup
S p o rt
age 12 yrs.
Swimming
Gymnastics
31
p-value Il
M ales
Football
age 14 yrs.
Hockey
p-value
Wrestling
Swimming
p-value
Height.<m.)
m ean s.d.
W eight (kg.) |
m ean a.d.
1.58
1.52
0.06
0.10
46.29
41.59
0.050
523
7.75
1.76
1.68
0.001
146 1.67
24 1.73
0.08
0.09
76.78
57.52
0.000
14.09
10.07
28
29
0.08
0.07
76
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athletes age
12
years and male athletes age 14 years were used to illustrate a significant
difference in mean height between certain sports. This finding was interpreted as implying
that certain sports may be associated with specific somatotypese.g. the husky football
player and the lithe gymnast. It is reflected by the comparison of Body Mass Index (BMI-kg./m2) between sports. This variable combines both height and weight values to give an
approximation o f body habitus. As noted in Table 4.7, gymnasts have a smaller, mean
BMI than volleyball players or swimmers.
S p o rt
Volleyball
Swimming
Gymnastics
n
25
69
9
BMI
34.1
33.9
32.2
s.d.
3.2
3.3
2.1
Differences o f Training Time and Thoracic Angle between Sports and within Sports
Both training time and thoracic angle were calculated for each sport grouped by
gender predominance (Table 4.8). As expected, training time differed significantly
between sports for both genders. For females, the level o f significance was p = 0.000
(ANOVA; r2 = 0.483). For males, comparison o f mean training hours between sports also
showed significance, such as between wrestlers and swimmers (t-test; p = 0 .0 0 0 ) and
between football and ice hockey players (p = 0 .0 0 0 ).
In general, greater amounts o f training time was associated with larger thoracic
angles. This remained true even after controlling for age, as for a sample o f 14-to-l8 year
old female athletes (n = 134; Table 4.9). In these subjects, annual training time was found
77
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T (deg.)
s.d.
27
15
41
16
42
15
3
II
198
166
37
13
230
136
39
13
284
163
41
17
417
295
38
14
S p o rt
Volleyball
Swimming
Gymnastics
n
32
91
11
78
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For males, swimmers had the largest reported training time but did not have the
largest thoracic angle. Since age and anthropometry were shown to differ between sports,
and anthropometric variables have been identified as significant predictors of thoracic
angle (Chapter EQ), then perhaps male swimmers exhibited a unique, anthropometric
feature. The ratio of Annual Training Time-to-Body Mass Index was developed and
determined for male sports (Table 4.10). The value for swimmers was nearly twice that o f
wrestlers, football players, and ice hockey players (p = 0.000). A similar relation was not
seen in female swimmers.
Table 4.10. Mean Annual Training Time-to-Body Mass Index for Male Athletes
Swimmers have a mean ratio value nearly twice that of wrestlers, football players, and hockey players.
S p o rt
Wrestling
Swimming
Football
Ice Hockey
m ean
6.30
12.34
6.21
6.27
n
932
173
389
182
s.d .
3.65
8.49
3.72
5.68
Thus far, between-sport evidence for an association between training and thoracic
angle has been found. But did the association hold true within sports? To answer that
question, the next of the primary null hypotheses was tested. Mean annual training hours
were calculated for athletes having kyphosis angles between 25 and 52 photogrammetric
method (normokyphotic) and those having angles over 52 (hyperkyphotic) (see Chapter
III). Our subject sample o f 754 wrestlers exemplified the general trend, such that, with no
difference of age, height, or weight between kyphosis groups, training time was
significantly larger in the hyperkyphotic subjects (Table 4.11). This finding led to the
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rejection o f H0 2 , which stated that there were no differences o f mean annual training time
between normokyphotic and hyperkyphotic athletes.
Table 4.11. Mean Annual Training Time and Thoracic Kyphosis Angle for
Wrestlers grouped as Normokyphotic and Hyperkyphotic.
The hyperkyphotic wrestlers, having a significantly larger thoracic angle than normokyphotics,
also have a significantly larger mean annual training time.
G roup
Normokyphotic
Hyperkyphotic
p-value
n
624
133
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Table 4.12. Mean Ages of each Age Group for Males and Females
Age
G roup
8 to 10
11 to 13
14 to 18
n
41
137
224
FEMALES
m ean yrs.
9.51
12.29
15.37
xd.
0.67
0.75
1.15
n
92
301
1429
xd.
m ean yrs.
9.37
12.31
15.65
0.72
0.79
1.08
growth spurt mean age of females, at about age 12 years (Lonstein, 1978), would fall in
the middle school category, while that o f males (at approximately age 14) would lie within
the high school grades. With subjects thus divided, the mean annual training times were
determined for each sport for both normokyphotic and hyperkyphotic subjects (Table
4.13).
Table 4.13. Mean Annual Training Times for Athletes grouped by
Gender, Sport, Age Group, and Thoracic Kyphosis Category
(Age Group: 1 = 8-l0yrs., 2 = 11-13 yrs., 3 = 14-18 yrs.; s.d. = standard deviation)
In general, hyperkyphotics reported training more than normokyphotics.
Sport
Females
sw im m in g
g ym n a stics
vo lleyb a ll
Noimoky ihotic
mean hrs. xd.
Age
Group
1
2
3
1
2
3
2
3
25
86
104
5
17
11
18
35
319
340
364
228
352
518
125
160
235
217
227
124
324
397
78
80
2
3
1
2
3
1
2
3
1
2
3
5
376
17
71
88
14
57
100
6
137
796
225
292
186
169
216
276
398
481
127
164
242
173
161
159
182
148
285
260
299
57
102
136
Hyperkyphotic
mean hrs. x d .
483
404
360
220
816
576
90
145
221
163
262
480
248
322
232
781
508
144
191
275
151
204
42
Males
fo o tb all
ic e h o c k e y
sw im m in g
w restlin g
254
281
121
500
305
.
80
150
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'rcracic
i*
hr
Table 4.14 shows the mean Angle/Time quotients with subjects grouped by gender
and sport, while Table 4 .IS shows the quotients for subjects further divided according to
age group. For males, ice hockey players had the largest ratio values, followed by
wrestling. There were significant differences o f the ratio means between wrestling and
swimming (p = 0.001) and between ice hockey and football (p = 0.000). For females,
gymnasts had the largest ratio values, followed by volleyball players, although betweensport differences were not significant.
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Table 4.14. The Ratio of Thoracic Kyphosis Angle per Annual Training Hour
Controlled (Normalized) by Age for Female and Male Athletes
Those with the largest ratio are also the youngest for both females or males.
(s.d. = standard deviation)
S p o rt
Fem ale
Volleyball
Swimming
Gymnastics
MaLe
Ice Hockey
Swimming
Wrestling
Football
Ratio
(deg./hr./yr.)
s.d.
51
217
33
0.016
0.015
0.023
0.017
0.025
0.057
187
175
954
389
0.027
0.012
0.016
0.012
0.026
0.016
0.017
0.010
S port
sw im m in g
g y m n a stic s
vo lleyb a ll
8 to 10 yr. o ld s
s.d .
0.019
0.027
0.014
0.014
|
n
23
5
11 to 13 yr. o ld s
s.d . I n
14 to 1t1yr. o lds |
deg/hr/yr s.d.
n
0.019
0.037
0.026
0.037
0.087
0.024
77
12
15
0.011
0.007
0.012
0.011
0.005
0.009
91
11
32
0.017
0.031
0.015
0.028
0.007
0.027
0.020
0.028
5
70
43
128
0.012
0.020
0.008
0.014
0.010
0.020
0.007
0.013
338
87
92
727
Malee
fo o tb a ll
h ockey
sw im m in g
w restlin g
0.045
0.037
0.031
0.042
0.030
0.140
15
10
5
Discussion
The results o f this secondary analysis complement what has already been discussed
in Chapter HI. The significant difference of mean thoracic kyphosis angle that was
identified between inactive controls and active athletes implied a direct relation between
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thoracic angle and physical activity (in this case, athletic training and participation). That
conclusion was drawn because the active subjects had the larger mean thoracic angle.
In this chapter, similar findings were made using active athletes alone as the subject
sample. Simply put, those who trained more tended to have larger kyphosis angles. This
observation was well illustrated both between sports (e.g. female swimmers and gymnasts,
Table 4.7) and within sports (e.g., wrestlers, Table 4.11). These findings corroborate
those o f Wojtys, et al. (2000), one o f the few studies to show a statistically significant
relation between thoracic kyphosis and physical activity. They also support the ideas of
earlier authors who associated thoracic curvature with some type of work (e.g. Schanz,
1907; Scheuermann, 1920; Wassman, 1951; Hafiier and Surrey, 1952).
Athletes o f both genders displayed a similar pattemthose who reported more
practice hours also had larger mean kyphosis angles. For instance, even though they were
the youngest, female gymnasts reported the most annual training hours and had the largest
mean thoracic kyphosis angles, followed next by swimmers and then by volleyball players.
Older male athletes logged more training hours and had larger mean kyphosis angles than
did younger athletes. Hockey players, those with the least reported hours were the
youngest and had the smallest mean thoracic kyphosis angle (Table 4.8). Wrestlers,
followed finally by football players, were older, logged more hours, and had larger mean
thoracic angles.
Male swimmers were an exception to this observation. This group had the largest
reported, mean annual training time (Table 4.8). I f thoracic angle is directly related to
training, then male swimmers should have had the largest, mean thoracic angle. It is likely
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that this discrepancy was due to an interaction o f other variables, including age and
anthropometry, as the swimmers had a mean weight that was lighter than that of both
football players and wrestlers. To further investigate this exception, the variable Body
Mass Index, based on the anthropometric variables Height and Weight, was used as a
representation o f relative subject size. It was combined with training time to form a ratio
whose value for swimmers was about twice that o f the wrestlers, football players, and
hockey players. The comparison indicated that the male swimmers had the smallest body
size relative to the amount o f time spent in training. While it is speculation, and causeand-effect conclusions cannot be made, perhaps this anthropometric feature protected"
their spines from hyperkyphosis.
Our BMI comparisons between sports in females agrees favorably with the
findings o f Peltenberg, et al. (1984). The group compared indices o f maturation, body
composition, and growth of 1,064 female gymnasts, swimmers, and controls ages 8-to-14
years. They found that gymnasts were smaller than girls in the other groups, a difference
that was even more pronounced" after 10 years o f age. It is possible that findings such as
these indicate the likelihood that successful performance in each sport favors certain
anthropometric characteristics, that training for the sport enhances these characteristics,
and that self-selection for physical activity (e.g. Janz, et al., 1992) may be based, in part,
on sport-specific characteristics. The relation between anthropometry and thoracic angle
will be explored further in Chapter Vm .
Division o f the athlete subjects into two kyphosis categories formed the basis for
the next portion o f this study: the identification o f specific training times. As expected,
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the mean training times o f the hyperkyphotic subjects were generally larger than those o f
the normokyphotic subjects (Table 4.13). These findings further help to confirm the
observations made in Chapter III about thoracic angle and training.
Next, the variable Thoracic Kyphosis Angle/Annual Training Time was developed
in an attempt to identify the sports in which the relation between thoracic angle and
training was stronger. As indicated in Table 4.14, for females, the largest quotient value
was seen in gymnasts, followed by volleyball players and swimmers. For males, ice
hockey players had the largest thoracic kyphosis angle per annual training time values,
followed by wrestlers and then by swimmers and football players. If our study design
permitted cause-and-effect conclusions, these results imply that for females, training for
gymnastics and for older adolescents, volleyball, may be more strongly associated with
thoracic hyperkyphosis. A similar relation may be noted for males training for ice hockey
and wrestling. Such notions are not unreasonable, given the repeated extremes of flexion
postures associated with these sports and the relation between hyperkyphosis and
repetitive loading.
Whereas the mean and median o f our variable Thoracic Angle were fairly close
(mean o f 37.9 degrees and median o f 38.4 degrees), the formed quotient Angle/Time
quotient had a heavy-tailed distribution. As such, Angle/Time values were not normally
distributed, but rather skewed slightly to the right (Figure 4.1). In that distribution, the
mean, median, and mode are no longer the same, as in the case o f normal distributions
(e.g. Mendenhall and Reinmuth, 1982). Rather, the mode is at the highest point on the
graph (point o f greatest frequency), the median (the middle value when data are ordered
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by magnitude) is the next closest parameter from the mode, and the mean (arithmetic
average) now lies farthest from the mode, along the skewed tail. Thus, the standard
deviation distributions are no longer symmetrical (normally distributed), negatively
affecting statistical inference.
Others have identified the same sports as being associated with spine pathology.
An increased prevalence o f back problems has been observed in gymnastics, wrestling
(e.g. Goldstein, et al., 1991; Sward, et al., 1990-C) and volleyball (e.g. Stiletto, et al.,
1996; Blazek, et al., 1986). Our findings regarding also agree with those o f others
regarding hockey, a sport whose repetitive, maximum spine ranges o f motion have been
anecdotally reputed to be bad for posture (Watson, 1983) and have been associated with
back pain (Kujala, et al., 1997). Field hockey, a sport that also requires repeated, flexed
spine postures, has been also associated with "physiologic strain and excess spinal
loading (Reilly and Seaton, 1990).
Limitations
Many o f the limitations o f the photogrammelric method employed for the original
data collection have been addressed in Wojtys, et al. (2000) and in Chapter IX. There are
at least two primary limitations. The first is a concern over the use o f surface methods as
an indicator o f radiographic angles. Our value o f r2 = 0.985 for the relationship between
photographic and radiographic techniques agreed well with a similar between-method,
correlation coefficient o f 0.91 reported by Troup, et al. (1968).
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Significant memory decay in children has been identified over as little o f seven
days. Wallace, et al. (1985) found that children could remember only 46% o f the mode
o f activity, while Baranowski, et al. (1984) could remember only 55 to 65% o f their
activities. Wallaces group found that their subjects (n = 11) underestimated their
activities, reporting only about 75% o f the observed amount o f activity.
At least two factors, age and time span o f the recall, have been related to validity
(or does the instrument measure what we think its supposed to be measuring
Baranowski, 1988). Sallis, et al. (1996) have indicated that pre-adolescents will have
trouble with recalling physical activity, and that younger children are more sensitive to the
period recall. Age-related, reporting accuracy is reflected in Table 4.16, which lists the
mean reported, annual training time and standard deviation by age group. With standard
deviation expressed as a percentage o f the mean, the value for the older age groups is less
than that of the young children.
Table 4.16. Mean Annual Training Time for each Age Group, with
Standard Deviation (s.d.) expressed as a Percentage of the Mean
8 to 10
11 to 13
14 to 18
n
110
420
1621
m ean i a.d.
169.31
177.68
237.55
215.35
272.16
181.13
p ercen t
104.95
90.66
66.55
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analysis was made for subjects o f all age groups for both genders, not just the older
individuals who perhaps report more accurately. In our case, the addition o f the possibly
underestimated 25% to our reported annual training hours did not strengthen the already
weak r2 o f 0.005, nor did it change the p - 0.003 between thoracic angle and training time.
This studys design was not the prospective, experimental design necessary to
imply causality. Because of this, only associations between the variables could be
demonstrated. However, if athletic training were a causative factor in the development o f
hyperkyphosis, then modification o f the amount o f training might help to prevent spine
curve abnormalities. If such a relationship were valid, then training time information
provided here could be incorporated into training program designs for just that purpose.
In Chapters II, HI, and IV, a relation between thoracic hyperkyphosis and
repetitive loading was been identified. The next section o f this dissertation will be aimed
at investigating the association between thoracic kyphosis and another variable, hamstring
shortness, long thought to be a cause o f at least one type o f hyperkyphosis
Scheuermanns Disease (Lambrinudi, 1934). In order to identify such a relationship, the
link between hamstring shortness and pelvic tilt will first be addressed.
Conclusions
Three points were made based upon the results o f this study. While the design o f
the study prohibited the establishment o f cause and effect, the results showed that, in an 8 to-18 year old, public school student, volunteer sample, those who trained more tended to
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have larger thoracic angles. Not only was this true between inactive controls and active
athletes (Chapter III), but it was true between sports and within sports.
The second and third points was an approximation o f amounts o f time associated
with hyperkyphosis. This was done by calculating the number o f annual training hours and
the Thoracic Kyphosis Angle per Annual Training Time ratio for each sport by age group
and by kyphosis status. In virtually every age group, normokyphotic athletes had smaller
mean training times than did hyperkyphotic athletes. Female gymnasts, followed by
volleyball players, had the largest number o f degrees per hour o f training values. For male
athletes, those having the largest Kyphosis Angle per Training Time were ice hockey
players, followed by wrestlers.
Our findings are important pieces o f information that may be o f assistance in the
design of athletic training programs. Although the values listed are specific to our subject
sample, coaches and support staff might be able use them as rough guidelines, making sure
to keep the number o f annual training hours under the values listed for hyperkyphotics.
Particular care should be taken in designing programs for those sports in which the
Thoracic Angle/Training Time ratios are the largest, with the understanding that training
times are safer when selected closer to normokyphotic mean values. Prudent monitoring
o f annual training time may help in the prevention o f acquired and load-related spine
deformities in adolescents, as well as the prevention their sequellae, which include reduced
function and back pain.
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CHAPTER V
A CROSS-SECTIONAL STUDY OF HAMSTRING SHORTNESS AND ITS
RELATION TO PELVIC TILT AND LUMBAR LORDOSIS IN A SMALL
SAMPLE OF CHILDREN AND ADULTS
Introduction
What other factors are associated with thoracic kyphosis? In Chapter II, we had
seen that vertebral abnormality similar to what is found in the hyperkyphosis of
Scheuermanns Disease can be induced experimentally by external loading. In Chapters
III and IV, we had seen that thoracic hyperkyphosis in adolescents is related to repetitive
loading in the form o f athletic training, such that hyperkyphotic individuals tend to be
those who train more, thereby submitting their immature spines to repetitive loading. Is
hamstring shortness also related to thoracic hyperkyphosis, as suggested by Lambrinudi
(1934)?
To understand the relation between the hamstring shortness and the thoracic spine,
one must first understand how it relates to the pelvic tilt and lumbar lordosis. This chapter
describes the results o f a study intended to define that relationship. It does so by
addressing several questions concerning popularly held notions. First, is hamstring
tightness, more accurately defined as hamstring shortness, associated with a posterior
pelvic tilt, as is commonly described in the literature? If it is, then hamstring-short
subjects should have a greater pelvifemoral angle than hamstring-normal subjects.
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Second, is posterior pelvic tilting associated with flattening o f the lumbar spine, as is also
commonly described? If it is, then the lumbar lovdosis angles of hamstring-short subjects
should be smaller than those of hamstring-normals. Third, is it possible that hamstring
shortness limits the sagittal plane, flexion range o f motion o f the torso? If so, then there
should be significant differences of individual, segmental spine ranges o f motion between
hamstring-normal and hamstring-short individuals. These questions may be expressed as
Null Hypotheses:
Null Hypotheses
Hoi: There is no difference of pelvic tilt, as defined by the pelvifemoral angle,
between hamstring-normal and hamstring-short subjects.
H 0 2 : There is no difference of the lumbar lordosis angle between hamstring-normal
and hamstring-short subjects.
H 0 3 : There is no difference of sagittal plane, trunk range of motion between
hamstring-normal and hamstring-short subjects.
where
Background
Like thoracic kyphosis, hamstring tightness is an important problem. Defined here
as hamstring shortness, an actual reduction in the normal length o f the musculo-tendinous
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unit (GajdosDc, 1991; Hoffinger, et al., 1993), it has been linked to several types o f spine
pathology. These include Scheuermanns Juvenile Kyphosis (e.g. Lambrinudi, 1934), back
pain (Fisk, 1979; Stephen, 1983), paravertebral muscle spasm, lumbar degenerative disc
disease, disc herniation, spondylolysis, spondylolithesis (Hoppenfeld, 1976; Takata and
Takahashi, 1994), and nerve root compression (Stokes and Abery, 1980). Hamstring
shortness has also been associated with sciatica (Takata and Takahashi, 1994), as well as
sacroiliac strain and dysfunction (Kendall and Boynton, 19S2; Cibulka, et al., 1986).
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perimysium and endomysium, a greater proportion o f collagen (Williams, et al., 1988), and
a rearrangement o f collagen fibers to a more acute orientation relative to the muscle fiber
axes (Williams and Goldspink, 1984).
Regardless o f the etiology, muscle shortness exhibits several functional
characteristics. These include a reduced cross-sectional area (Booth and Criswell, 1997),
less contractile force, and, subsequently, less torque (Rassier, et al., 1999; Jonhagen, et al.,
1994). Tight hamstrings are stiffer (Williams and Goldspink, 1984), and have a lower
stretch tolerance (Magnusson, et al., 1997). These factors likely contribute to an increase
o f the passive tension and a left shift o f the length-tension curve (Brown, et al., 1999).
Hamstring Function
The hamstring muscles perform several roles. First, these biarticular muscles are
important in trunk kinematics and gait. They serve as both knee flexors and hip extensors,
depending upon the load bearing status o f the limb. Hamstring shortness interferes with
this normal function by causing changes such as diminished hip range o f motion (e.g.
Halbertsma and Goeken, 1994). Not only are these factors associated with joint
dysfunction (Ekstrand and Gilquist, 1982; Starring, 1988), but they are also associated
with lower extremity muscle injuries, which include hamstring strain (Worrell et al., 1991;
Sullivan et al., 1992; Jonhagen et al., 1994).
The hamstrings also perform another important rolethat o f primary postural
muscles. In the upright posture, this muscle group influences the position o f the pelvis
(Carlsoo, 1961; Cibulka, et al., 1986), such that hamstring contraction acts to extend the
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hip and posteriorly tilt the pelvis. Pathologic shortening o f the hamstrings interferes with
this role by restricting the pelvis in this tilted position (DeLuca, et al., 1998).
Pelvic tilt, in turn, has been shown to affect the spine. First, it affects sacral
position, largely because the complex and tight articulations between the two structures
(Gerlach and Lierse, 1992) permit only a small amount o f movement at the sacroiliac
joints (Miller, et al., 1987). The sacrum is tightly articulated with the lumbar spine and its
position is an important determinant o f lumbar lordosis (Amonoo-Kuofi, 1992). Thus,
pelvic tilt influences the lumbar spine (Beal, 1982; Grieve, 1982; Legaye, et al., 1998).
The relation is such that lumbar curve flattening results from posterior pelvic tilting,
especially in sagittal plane flexion (Day, et al., 1984; Yasukouchi and Isayama, 199S;
Levine and Whittle, 1996; Delisle, et al., 1997; Korovessis, et al., 1998). It is through the
sacropelvic mechanism that lumbar curve flattening has been identified in cases o f
hamstring shortness (McCarthy and Betz, 2000).
Hamstring shortness has been shown to affect not only torso posture, but sagittal
plane torso flexion as well (Winter, et al., 1997). Full torso flexion requires normal ranges
o f motion o f hip, pelvis, and spine (Anderson and Hall, 1995). If any o f these component
ranges are restricted by hamstring shortness (Stokes and Abery, 1980; Gleim et al., 1990;
Gajdosik et al., 1992), then two things can result. First, forward reach distance is
reduced, especially when standing with the knees extended (Daniels and Worthingham,
1980). Second, there is an increase in spine musculo-ligamentous stress (Fisk and
Baigent, 1981; Fisk et a l, 1984), which predisposes the soft tissues o f the back to injury
(Stokes and Abery, 1980; Gajdosik et al., 1992).
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that were attached to the chemically cleansed skin surface by means o f adhesive electrode
patches. The wire loops had pieces soldered to them which were perpendicular to the
surface o f the skin (Appendix H, Figure H.7). Reflective tape patches were attached to
both ends o f vertical stanchionsone placed proximal and one placed distal to the skin.
The infrared light source o f the camera system optically activated the tape markers, whose
reflection was sensed by the camera.
Once the markers were in place, subjects were then tested according to the
following protocol. The subjects stood in front o f the camera, which was oriented at a
right angle to the each persons antero-posterior plane. The camera was positioned to
include in its field o f view the entire right side of each subject, as well as a reference post
upon which reflective tape was placed at a height o f SO cm. (Figure 5.1). The subjects,
standing upright with feet set shoulder-width apart, toed a line that was positioned on
the floor. Each participant was then asked to bend forward at the waist with knees held
straight and attempt to touch the floor. Once they reached the end o f their flexion range
o f motion, they would return to the upright position-all within a ten second time span.
The protocol was repeated for each subject, with image acquisition taking place during
both flexion attempts.
Each subject was positioned in a manner that would optimize video recording.
Participants, dressed in gym trunks taped at the hip, were asked to clasp their hands in
front o f their waists while flexing forward. This modification o f the method described by
Polley and Hunder (1978) permitted visualization o f the trochanteria, ASIS, PSIS, and SI
landmarks at all times and in both upright and flexed postures.
101
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CAMERA
COMPUTER
VIDEO PROCESSOR?
MONITOR
SUBJECT
REFERENCE POST
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stanchions and landmark tape pieces were first reduced to centroid coordinates (X,Y)
using the MacReflex system. The spine marker and pelvifemoral landmark points were
then paired, as illustrated in Figure S.2. The centroid positional data from the reflected
point pairs provided the basis for the automated creation o f paired lines, whose
intersections were measured by the WingZ* software as the spine segment angle o f
interest (expressed in degrees). The segments used in this study included the Thoracic
(T1-T10), Thoracolumbar (T10-L3), Lumbosacral (L3-SI), and Pelvifemoral angles (PF).
TITIO
T10L3
L3SI
PELVIFEMORAL
The Pelvifemoral angle defined the pelvis position relative to the femoral shank,
and quantified pelvic tilt. It was the angle between two lines: one that was defined by a
pair o f points on the Anterior-Superior and the Posterior-Superior Iliac Spine
(ASIS/PSIS), and one formed by a pair o f points on the greater trochanterion to lateral
femoral condyle o f the thigh (after the Hip Flexion Angle method o f Stokes and Abery,
1980).
103
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Three values were reported for each spine segment. Angles were determined with
subjects in the upright posture, the initial position and in the flexed posture, or final
position. The differences between initial and final position values were then calculated,
and reported as the range.
Data Analysis
Data were analyzed in the same manner as in the previous studies. Commercially
available, PC-based statistical software packages (Systat, SAS) were used. With the
level o f significance (a) set at 0.05, t-tests and one-way Analysis o f Variance (ANOVA)
were used to determine significant mean differences and relationships. Stepwise, linear
regression was used to identify significant predictor variables.
Results
Subjects from the small sample, optoelectronic study were grouped as hamstringnormal and hamstring-short. T-tests revealed that there were no significant differences of
mean age, gender, height, weight, and the anthropometric variables. T-tests were also
used to compare mean angle values between the two hamstring groups (Table 5.1). There
were significant differences o f the Pelvifemoral angle (PF) in both the upright and flexed
postures. This finding led to the decision to reject the first null hypothesis, Hot, which
stated that there was no difference in pelvifemoral angle between hamstring shortness
groups.
The second null hypothesis, that there was no between-group difference o f lumbar
lordosis angle, was then tested. The flexed posture, mean lumbosacral angle (L3-S1) o f
104
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S pine
S egm ent
T1T10
1
II
T10L3
II
II
L3S1
II
ll
PF
ll
II
FB
ROM
ROMHTM
Angle
Initial
Final
Range
Initial
Final
Range
Initial
Final
Range
Initial
Final
Range
*
Ham string-Norm al
m ean (deg.)
s.d.
39.80
8.91
13.87
13.99
25.93
12.61
-10.73
8.78
16.07
15.79
32.40
11.06
25.60
9.66
[-10.53]
8.62
36.13
8.63
73.60
6.71
7.79
7.33
66.27
11.52
0.00
0.00
160.73
21.46
96.26
14.55
Hamstring -Short
m ean (deg.)
s.d.
41.50
13.21
26.00
12.77
15.50
7.09
-9.94
8.67
8.63
25.31
35.25
10.52
27.37
7.70
M .19]
8.12
31.56
9.76
79.25
7.61
24.12
17.42
55.13
17.23
127.38
54.07
137.44
18.37
83.67
11.11
p-value
n.s.
0.018
0.01
n.s.
0.058
n.s.
n.s.
0.044
n.s.
0.036
0.002
0.043
0.000
0.003
0.012
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Group
11 y.o. athletes
14-to-18y.o. hockey players
H amstring-Normal
s.d.
m ean (deg.)
14
48
11
40
n
26
60
H am string-S hort
n
m ean (deg.) s.d.
15
39
12
27
34
13
P
0.045
0.047
The third null hypothesis was addressed by comparing the mean torso flexion
ranges o f motion between the two hamstring shortness groups. As mentioned previously,
the flexion range o f motion (ROM) was defined as the sum o f the component spine
segment ranges, or ROM = T 1 - T 1 0 r a n g e
+ T 1 0 - L 3 RAn g e + L 3 - S 1 r a n g e
+ P F range- There
was a significant difference (p=0.003) o f the mean torso flexion range o f motion between
hamstring-normal and hamstring-short subjects, with hamstring-normal subjects having a
mean sagittal flexion range o f 160.73 ( 21.46) and hamstring-short subjects having a
smaller mean flexion range o f 137.44 ( 18.37) (Table 5.1). The between-group
difference persisted even after normalizing for height (ROMHTM). These findings led to
the rejection of H03, which stated that there was no difference o f sagittal plane, trunk
range o f motion between hamstring-normal and hamstring-short subjects.
Linear regression was used next to assess the relative contributions of the various
component spine segment angle ranges to the flexion range o f motion (Table 5.3). The
predictive model was developed with an effort to keep tolerance as high as possible, while
striving to obtain the lowest possible analysis o f variance significance. Despite this, the
small subject sample restricted the number o f variables that could used in the regression
models. One model was based upon a variable for each ten subjects, the other was based
106
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on the square root o f the sample size. The best models are shown below (Tables 5.3 and
5.4). Although males were older and significantly taller and heavier, Age, Sex, Age*Sex,
and the anthropometric variables were not predictors o f either reach distance or range o f
motion. Body Mass Index was, in addition to Pelvifemoral Angle in the upright position,
a significant predictor o f Reach Distance (Table 5.4).
Significant Prmdictors
VARIABLE
TTI
TTF
PFF
where
ROM
K
TTI
TTF
PFF
P (2 TAIL)
0.000
0.000
0.000
P (2 T AI L)
0.005
0.011
(deg.)
107
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Discussion
What has been observed in the literature regarding the relation between hamstring
shortness, pelvic tilt, and the lumbar spine was supported by our results. First, all three o f
our pelvifemoral angles from the small study were significantly different between the
hamstring shortness groups, which were matched for age and gender (Table S.l). These
angles were the initial (upright posture), the fin a l (flexed posture), and the range (the
difference between upright and final values). The mean upright, pelvifemoral angle o f the
hamstring-tight group was approximately 7% greater than that o f the normal group. The
mean pelvifemoral angle in full flexion was almost three times greater in the hamstringtight group. Finally, the mean pelvifemoral angle range was about 17% larger in the
hamstring-normal group. The larger mean initial and final angles in hamstring-short
subjects were interpreted as representing a posterior pelvic tilt in hamstring-short subjects.
The significantly lower pelvifemoral range that was about 10 less in hamstring-short
subjects was thought to indicate a restriction o f sagittal plane flexion.
Our pelvic tilt findings agree with those o f others, including Fisk and Baigent
(1981), and Yasukouchi and Isayama (1995). In fact, our mean standing pelvic angle
values (Table 5.1) were within the angle range reported by Gajdosik, et al. (1994), who
used a similar method. Their 30 subjects had a similar mean age o f 23 (4.1) years, a
mean height o f 178.6 ( 7.2) cm, and a mean weight o f 77.5 ( 10.7) kg.. Their upright
pelvic tilt angle ranges were 75.5 to 90.8 for hamstring-short subjects and 71.5 to 90.5
for hamstring-normal subjects. In addition, our flexion ranges o f motion values were also
108
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Limitations
Many o f the limitations of the small sample study were similar to those reported
for the large sample study. The original design o f a cross-sectional study prohibited the
drawing o f cause-and-effect conclusions, which would require a randomized, clinical trial.
109
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Our small sample size prohibited the development of multi-variable predictive regression
models. In addition, the sample was a convenience sample, rather than a truly random
one. The subjects were o f a particular socio-economic and ethnic pool, which would pre
empt extrapolation of the results to the general population.
Like the large sample study, the use of surface, optical methods to estimate
radiographic angles is a concern. In our validation study (Appendix H), surface marker
placement error was greatest at SI, and was likely due in part to the overlying soft tissue
thickness at the lumbosacral region (e.g. Bryant, et al., 1989; Refshauge, et al., 1994). It
is likely that placement error accounted for the significant underestimation o f the L3-S1
angle seen in this method, similar to what has been reported by others (e.g. Chemukha, et
al., 1998; Leroux, et al., 2000). Despite this systematic error, relative flattening o f the
lumbar spine angle was seen in two different subject samples using two different optical
methods.
Conclusions
Several important findings were made in this study. The first was that, for the
subjects of our study, hamstring shortness was 25-33% less prevalent in females, which
suggested that females were more flexible than males. Hamstring shortness was also over
50% less prevalent in athletes, which indicated that a baseline amount o f physical activity
is important for flexibility.
The next several findings pertained to the relation between tightness and the spine.
Our hamstring-short subjects demonstrated posterior pelvic tilting. They had smaller
angles o f lumbar lordosis, as determined by non-invasive, optical methods o f metrology,
110
indicating flattening o f the lumbar spine. Finally, hamstring-short subjects had smaller
sagittal flexion ranges o f motion, largely due to smaller thoracic, lumbosacral, and
pelvifemoral ranges. These findings agreed with popularly held notions regarding
hamstring shortness and the spine.
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CHAPTER VI
ON THE RELATION BETWEEN HAMSTRING SHORTNESS
AND THORACIC KYPHOSIS IN SMALL AND LARGE,
CROSS-SECTIONAL SAMPLES OF CHILDREN AND ADULTS
Introduction
Is there a link between thoracic kyphosis and hamstring shortness, as suggested by
early authors as Lambrinudi? This chapter presents the results o f a study in the form of a
post-hoc analysis intended to define the relation between these two variables. The analysis
was done using data originally collected for the study o f Wojtys, et al. (2000), a study that
was designed to identify the relation between thoracic kyphosis and athletic training. The
corroboration o f a relation between thoracic kyphosis and hamstring shortness is
important for at least two reasons. First, if a direct relationship does exist, then it could be
possible to prevent the development o f hyperkyphosis, an increase o f the thoracic kyphosis
angle beyond the normal range, by preventing hamstring shortness and maintaining
flexibility. Second, it may likewise be possible to treat existing hyperkyphosis by
correcting hamstring shortness.
In the last chapter, three observations were made regarding hamstring shortness
and the spine. The first was that hamstring shortness was associated with a posterior
tilting o f the pelvis. The second was that hamstring shortness was also associated with a
relative flattening of the lumbar lordotic curve. The third was that sagittal plane flexion o f
the torso was restricted in hamstring shortness. All three o f these observations agree with
112
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the findings o f others (e.g. Fisk and Baigent, 1981; Day, et al., 1984; Gajdosik, et al.,
1994; Winter, et al., 1997; McCarthy and Betz, 2000).
In order to define the relation between hamstring shortness and the thoracic curve,
an apparent contradiction must be resolved. The first part o f this contradiction is that
spine curves have been said to balance one another (e.g. Stagnara, et al., 1982). If that
were true, then the flattening o f the lumbar curve associated with hamstring shortness
should be accompanied by a flattening o f the thoracic curve. Thus, the mean thoracic
kyphosis angle o f hamstring-short subjects should be smaller than that o f hamstringnormal subjects. The second part o f the contradiction is based on the anecdotal
association o f hamstring shortness with the acquired hyperkyphosis o f Scheuermanns
Disease. Here, hamstring shortness has been implicated as a cause of hyperkyphosis
(Lambrinudi, 1934). In this instance, the mean thoracic angle o f hamstring-short subjects
should be larger than that of hamstring-normal subjects.
One theory may explain this apparent contradiction. It may be possible that both
observations are true, and that some hamstring-short subjects might exhibit thoracic curve
flattening while others might exhibit hyperkyphosis. If, as suggested by Ashton-Miller
(personal communication, 1995), an increase in the normal thoracic kyphosis angle is an
adaptive mechanism to enhance the otherwise restricted sagittal plane flexion o f hamstring
shortness, it is likely that this adaptation occurs over time. If so, then older hamstringshort subjects, those who have been hamstring-short longer, could tend towards
hyperkyphosis and display a direct relation between tightness and thoracic angle. In
contrast, younger subjects, those whose spines have not yet had time to adapt to
113
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hamstring shortness, would simply have a flatter thoracic spine, one that balances the
relative flattening o f the lumbar curve seen in tight hamstring mediated, posterior pelvic
tilting. These subjects would display an inverse relation between hamstring shortness and
thoracic angle.
If this theory regarding a temporal component to the relation between
hyperkyphosis and hamstring shortness were true, then several things should follow. First,
there should be a significant, mean difference o f thoracic kyphosis angle between
hamstring-normal subjects and hamstring-short subjects. Second, if the relation between
tightness and kyphosis angle is direct, there should be differences o f mean kyphosis angle
between moderately tight and severely tight subjects. Lastly, if hyperkyphosis is an
adaptive mechanism, then at least some o f the severely tight subjects should be
significantly older than moderately tight subjects. Expressed as null hypotheses:
Null Hypotheses
H oi: There is no difference of the angles o f thoracic kyphosis or lumbar
lordosis between hamstring-normal and hamstring-short subjects.
H 0 2 : There is no difference of thoracic kyphosis angle between those who are
moderately hamstring-short and those who are severely hamstring-short.
H 0 3 : There is no difference o f age between those who are moderately hamstring
tight and those who are severely hamstring-short.
Background
Both the thoracic and lumbar regions o f the spine have been said to balance one
another, particularly in the upright posture (Stagnara, et al., 1982; Willner and Johnson,
1983; Bridger, et al., 1989). Voutsinas and MacEwen (1986), in their study o f 670
114
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in Scheuermanns Disease, which ranges from about half (50%Butler, 1955; 67%-MacGowan, 1944) to virtually all (Apley, 1977; Salter, 1970; Sorensen, 1964), it is not
difficult to imagine that hyperkyphosis could be an adaptive mechanism.
Other studies have also confirmed an association between spine flexion range o f
motion and hamstring shortness. In their photogrammetric method study (n = 30),
Gajdosik, et al. (1994) identified a decrease in both pelvic and lumbar ranges in short
hamstring subjects. They also found that the mean flexed position, thoracic kyphosis
angle of hamstring-short subjects was larger than the mean kyphosis angle of hamstringnormal subjects [39.7 ( 9.0) versus 34.4 ( 7.8)].
Two important relationships have been demonstrated in the literature. First,
hamstring-short subjects have reduced sagittal plane flexion ranges o f pelvic and lumbar
spine motion. Second, groups o f hamstring-short subjects have larger kyphosis angles
than hamstring-normal subjects. If hamstring shortness causes increased stress and
strain on the thoracic spine (Lambrinudi, 1934, as quoted by Fisk and Baigent, 1981), if
spine wedging can occur from compression (Chapters I and II), and if motion restriction at
one spine level leads to increased motion at another (Nordin and Frankel, 1989), the
subsequent development o f thoracic hyperkyphosis as an adaptive response to loading and
to the otherwise reduced reach distance o f hamstring shortness seems plausible.
116
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MajkCma
D iagram
117
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In 1934, Dr. Lambrinudi published his paper outlining a possible causal relation between
these two variables, and illustrated his ideas with a stick figure drawing (Figure 6.2). In
this drawing, Lambrinudis two normal figures (A and B) are depicted as being able to
reach the floor in sagittal plane flexion. Not only did these subjects have a smooth
curvature of the spine, but they had normal pelvic motion as well. The short hamstrings
subjects (Figures C and D) did not exhibit these characteristics. They were not able to
reach the floor in sagittal flexion and their pelvic motion was restricted. Figure D also
depicts an increased kyphosis o f the thoracolumbar spineperhaps an adaptation to
enhance the otherwise restricted forward reach distance.
Prevalence
The prevalence o f hamstring shortness in the large study subject sample was
comparable to that reported by others. The overall prevalence o f 14.3% was quite close
to the 16% figure reported by Kuntzleman, et al. (1993). Like Kuntzlemans sample, most
o f our subjects were not screened radiographically for Scheuermanns Disease. O f a
sample of five documented Scheuermanns Disease patients whose data were used in
method validation, 66% had hamstring tightness, a figure that agrees with the 67%
prevalence reported by MacGowan (1944).
The prevalence o f hamstring shortness for each gender only approximated what
had been previously reported. In their study o f Scheuermanns patients, Fisk and Baigent
(1981) found that 24% o f male and 15% o f female hyperkyphotic subjects were
hamstring-short. In our study, 15.4% o f male hyperkyphotic subjects and 13.7% of
118
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female hyperkyphotic subjects had hamstring shortness. In our study, the prevalence of
hamstring tightness in hyperkyphotics was greater than that o f normokyphotics (about 5%
in females and about 1% in males).
Dividing our subjects according to sport participation confirmed that there was a
gender difference o f hamstring shortness prevalence. O f our inactive controls, 29% o f
females and 41% of males were hamstring-short. Of our active athletes, 9.6% o f females
and 14.6% o f males were hamstring-short. If hamstring shortness reflects flexibility, then
these figures indicate that our female subjects were more flexible than males. In addition,
the fact that hamstring shortness was more than twice as prevalent in inactive controls
than it was in our active athletes subjects implied some benefit in flexibility from training.
The relation between hamstring shortness and athletic training will be explored in Chapter
VII.
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It was designed to define the relation between spine angle (optoelectronically determined)
and hamstring shortness (Chapter V). Questionnaire information was obtained from all
subjects (Appendix E) and anthropometric measurements were taken on these same
subjects. In both studies, hamstring shortness was ascertained by using the Finger-toFloor Forward Reach Test. Each subject was asked to bend forward in the sagittal plane
from an upright position, with knees extended, in an attempt to touch the floor. Those
who were unable to touch the floor with their fingertips were classified as hamstring-short,
and the distances from their fingertips to the floor were measured. Those able to touch
the floor with their fingertips were classified as hamstring-normal.
120
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Results
First, the relation o f thoracic kyphosis angle to hamstring shortness was examined.
Subjects were grouped as being hamstring-normal, or those able to touch the floor in
sagittal plane flexion, and hamstring-short, or those unable to touch the floor. T-tests
revealed no statistically significant differences of age, height, or weight between these two
groups. However, hamstring-normals tended to have larger thoracic kyphosis and lumbar
lordosis angles than hamstring-short subjects (Table 6.1). Because o f this trend and the
finding of significance in subgroups such as the 15 year old, male ice hockey players, the
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decision was made to reject Hoi, which stated that there were no differences o f thoracic or
lumbar angles between hamstring shortness groups.
Table 6.1. Mean Thoracic and Lumbar Angles for Hamstring-Normal and
Hamstring-Short Subjects
G roup
Large Sam ple
Ice Hockey
Angle
Thoracic
Lumbar
14-18 y/o hockey Thoracic
Thoracic
15 y/o hockey
Lumbar
Sm all Sam ple
under 18 years Thoracic
Lumbar
Hamatring-Normal
n
m ean (deg.) s.d.
Hamatrinta-Short
m ean (deg.) s.d.
n
38
46
40
43
49
13
14
11
8
13
124
124
60
18
18
35
41
34
30
37
12
15
13
11
16
61
61
27
12
12
0.063
0.065
0.047
0.003
0.053
44
11
9
11
8
8
37
9
16
11
8
8
n.s.
n.s.
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Two additional lines o f evidence helped to support the notion o f thoracic and
lumbar curve balancing. One was that normokyphotic subjects, those having thoracic
angles within a range o f 25 to 52 by the photogrammetric method (Chapters i n and IV),
had a significantly smaller (t-test, p = 0.000), mean lordosis angle than hyperkyphotic
subjects (those with thoracic angles greater than 52) (Table 6.2). The other line of
Table 6.2. Mean Thoracic and Lumbar Angles for Subjects
grouped as Normokyphotic or Hyperkyphotic
G roup
Normokyphotic
Hyperkyphotic
n
1094
294
p-value
T horacic Angle
m ean (deg.)
s.d.
38.9
7.4
60.6
7.3
0.000
evidence is illustrated in Figures 6.3 and 6.4graphs of both thoracic and lumbar angles
versus reach distance. In Figure 6.3, as reach distance increased (subjects become
tighter), both thoracic and lumbar spine angles initially decreased in a roughly parallel
manner. This finding was interpreted as a relative straightening of the spine. However, at
reach distances o f about 95 to 155 mm., the parallel change in the spine angles ceased.
With increasing hamstring shortness, the thoracic angle was now seen to increase. As
similar pattern was also displayed by small study subjects. Like Figure 6.3, Figure 6.4
illustrates a parallel decrease o f both thoracic and lumbar angles for reach distances o f less
than about 130 mm. At about 165 mm. or so, the thoracic angle again began to increase
directly with reach distance.
Hamstring-short subjects were then divided according to the approximate reach
distance ranges in which the slope o f the thoracic angle quadratic smoothing lines changed
123
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Figure 6.3. Thoracic Kyphosis Angle (Lower Line) and Lum bar Lordosis Angle
(Upper Line) versus Reach DistanceLarge Sample, 8-to-10 year-olds
The two spine angles tend to decrease in a parallel fashion for less tight subjects (reach distances less
than about ISO mm.) indicating a spine curve balance. Beyond about ISO mm., thoracic angle
tends to increase, which supports the idea of a compensatory mechanism (p = 0.000; n = 65;
for thoracic curve: r2 = 0.014; for lumbar curve: r = 0.068).
in Figures 6.3 and 6.4. Those with a reach distance of 95 mm. to 159 mm. were classified
as moderately tight and those with a reach distance of 160 mm. and above were classified
as severely tight. Comparison o f the mean thoracic angles and ages between these two
groups showed important differences. Data from hamstring-short wrestlers were used to
illustrate these differences. Not only did severely tight subjects have a significantly larger
mean thoracic angle than moderately tight subjects, but they were also older (Table 6.3).
These findings led to the decision to reject H02 and H03 , which stated that there were no
differences o f thoracic kyphosis or age between moderately hamstring-short and severely
hamstring short subjects.
124
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ntikijcrt
>mm
Figure 6.4. Lumbar Lordosis Angle (Lower Line) and Thoracic Kyphosis Angle
(Upper Line) versus Reach DistanceSmall Sample
Both lines decrease with increasing reach distance to about a reach distance of 160 mm.,
illustrating spine curve balancing. Similar to what is illustrated for the Large Sample (Figure 6.3),
as the degree of hamstring shortness increases beyond 160 mm., the thoracic angle increases, again
illustrating a possible compensatory relation. The graph is slightly different in appearance, due to
the difference in optical methods (Chapters III, IV, and V) [n = 16; for thoracic curve: p = 0.048;
r = 0.269; for lumbar curve: p = n.s.; r = 0.004).
P
0.045
0.046
In order to lend support to the rejection o f H03 , the mean ages o f hamstring-normal
and hamstring-short subjects were compared between kyphosis categories (Table 6.4).
Hyperkyphotic, hamstring-short subjects were found to be older, with no significant
differences o f height and weight between the two kyphosis groups. For large sample,
hamstring-short subjects, this difference was statistically significant. In contrast, large
125
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G roup
HSS
HSN
Study
Small
Large
Large
N orm okyphotic
m ean
s.d.
20.8 yrs.
11.5yrs.
14.1 yrs.
Z 1 yrs.
14.8 yrs.
1.9 yrs.
n
12
167
856
H yperkyphotic
m ean
s.d.
37.8 yrs.
24.8 yrs.
14.9 yrs.
1.7 yrs.
14.9 yrs.
1.8 yrs.
n
4
47
248
P
n.s.
0.009
n.s.
Discussion
Three findings supported the idea o f other authors (e.g. Stagnara, et al., 1982) that
spine curves tended to balance one another. In Chapter V, hamstring-short subjects were
shown to have both posterior pelvic tilting and relatively smaller lumbar lordosis angle (a
flattening of the lumbar spine). In this chapter, hamstring-short subjects were also
shown to have significantly smaller thoracic kyphosis angles. This finding agreed with
Lambrinudis observation (1934) that both lower thoracic and lumbar regions were less
convex in hamstring short individuals. Lambrinudis theory was also supported by a
second finding, illustrated by graphs o f spine angle versus reach distance for hamstringshort subjects. Both thoracic and lumbar curve values tended to decrease in a roughly
parallel fashion with increasing reach distance (tightness), at least for distances less than
about 100 mm.
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The third finding that supported spine curve balancing was the high correlation
between thoracic and lumbar spine angles in hamstring-short subjects. Strong correlations
between these angles have been reported by groups as Voutsinas and MacEwen (1986)
and Korovessis, et al. (1998). In fact, the correlation coefficient o f 0.730 in our
hamstring-short subjects was comparable to the findings o f Hetlsing, et al. (1987), who
reported correlation coefficients o f up to 0.690.
Two lines o f evidence helped to give credence to the idea that an increased
kyphosis angle might be a compensatory change, as suggested in the Introduction. If this
notion was valid, then some hamstring-short subjects would not demonstrate spine curve
balancing, a parallel decrease o f angle values with increasing reach distance, but rather an
increase in the thoracic kyphosis angle. Graphs o f spine angle versus reach distance for
both large and small sample subjects (Figures 6.3 and 6.4) showed an initial, parallel
relation o f reach distance to both thoracic and lumbar angles. However, beyond reach
distances o f about 110 mm. to about 160 mm., thoracic angle increased with reach
distance (increased with the severity of hamstring shortness). This relation between
thoracic kyphosis angle and reach distance would give a sagittal plane, range o f motion
advantage to those hamstring-short subjects having larger angles.
The second line o f evidence that supported a theory o f compensatory, thoracic
curve adaptation was a difference o f age between subject groups. In both large and small
sample studies, using spine angle data acquired using two different, optical methods, the
hamstring-short, hyperkyphotic group tended to be older than the hamstring-short,
normokyphotic group.
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Limitations
The limitations of the optical methods used to collect the spine angle data as well
as the use of convenience subject samples are discussed in detail elsewhere (e.g. Chapters
III, IV, and IX). For this analysis, perhaps the most important limitation is one o f study
design. In contrast to a randomized, clinical trial, the cross-sectional design does not
permit cause-and-effect conclusions. Because o f this, while the results might imply certain
things, any conclusions regarding spine curve balancing the development o f thoracic
hyperkyphosis as active, adaptive processes are purely speculative.
Conclusions
This secondary analysis produced several important findings. First, there was a
significant difference of thoracic and lumbar angles between hamstring-normal and
hamstring-short subjects, with the latter having smaller mean angle values. The smaller
mean thoracic and lumbar angle values indicated flattening of the spine. Second,
subjects with severe hamstring shortness, or those having reach distances beyond about
160 mm., tended to have larger thoracic angles than those able to reach closer to the
ground. In addition, these severely tight subjects also tended to be older. While causeand-effect conclusions cannot be drawn, these results imply that, at least initially, the spine
curve tends to straighten in hamstring shortness, with the thoracic curve balancing the
relatively flattened lumbar curve seen in hamstring-short subjects, the posterior pelvic
tilting associated with hamstring shortness. Since severely tight subjects have not only
larger kyphosis angles, but are older, the implication is that hyperkyphosis may be an
128
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adaptive response to hamstring shortness, one that develops over time as a compensatory
change to offset the otherwise restricted, sagittal plane flexion of hamstring shortness.
129
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CHAPTER VU
ON THE RELATIONSHIP BETWEEN HAMSTRING SHORTNESS AND
ATHLETIC TRAINING IN 8-TO-I8 YEAR-OLDS
Introduction
Is there a relation between hamstring shortness and physical activity? As
mentioned in Chapter V, the prevalence o f hamstring shortness in active athletes was
found to be less than one-half that o f inactive controls, those subjects who reported zero
annual training hours. The marked difference in the prevalence o f hamstring shortness
between inactive and active subjects suggests that hamstring muscle tightness may be
related to the level of physical activity.
If hamstring muscle tightness were related to physical activity, then at least two
relationships should hold true. First, there should be significant differences in the Fingerto-Floor Reach Distances (our indicator o f hamstring shortness) between active and
inactive individuals. Similarly, among active individuals, there should be significant
differences o f physical activity training times between subjects grouped as hamstringnormal or hamstring-tight. In this secondary analysis o f the data from a cross-sectional
study by Wojtys, et al. (2000), two variables were used to model physical activitythe
number o f Annual Training Hours (Time) and the number o f years o f sports participation
(Period), Written as null hypotheses:
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This study was also aimed at answering an additional question. Was there a
difference o f reach distance between males and females, as is suggested by the gender
difference in hamstring shortness prevalence cited in Chapter V? Two secondary null
hypotheses were posed to answer this question:
Secondary Null Hypotheses
H 0 3 : There is no difference of Reach Distance between males and females.
H 0 4 : There is no difference of the amounts of training normalizedfor age between male
and female athletes.
It was expected that hamstring shortness was indeed related to physical activity,
such that those who trained more would have smaller reach distances. It was also
expected that females and older individuals, those who had participated in sports for
longer periods o f time, would be less tight.
Background
Why should hamstring shortness be avoided? In Chapters V and VI, hamstring
shortness was described as being associated with several problems, which included
hyperkyphosis (e.g. Lambrinudi, 1934), low back pain (Stephen, 1983), a reduction in
torso motion (Gajdosik, et al., 1994), and lower extremity injuries (Burkett, 1971;
Jonhagen, et al., 1994; Krivickas and Feinberg, 1996), especially muscle strains (Garrett,
et al., 1984). In addition, muscle inactivity has been cited as a general cause o f muscle
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shortness (e.g. Jozwiak, et al., 1997). To reduce the incidence o f these problems,
clinicians and coaches have relied on stretching programs to enhance muscle flexibility and
to reduce muscle tightness (Starring, et al., 1988; Sullivan, et al., 1992; Bandy and Irion,
1994).
The use of stretching to enhance muscle flexibility is important for several reasons.
Hamstring stretching has been shown to lengthen the hamstring muscles (Gajdosik, 1991),
to enhance both joint range o f motion (Magnusson, 1998) and torso flexion in the sagittal
plane (Li, et al., 1996), and to improve hamstring torque, especially at the end range-ofmotion (Wiemann and Hahn, 1997). These types of functional improvements likely
accounted for the reduced incidence o f lower extremity injuries seen in military trainees,
who had more flexible hamstrings (Hartig and Henderson, 1999).
Muscle stretching has also been shown to have several, positive tissue
ultrastructural effects. These include prevention of serial sarcomere loss (Williams, 1990)
and improvement o f serial elastic component compliance (Almeida-Silveira, et al., 1994).
Increases in the volume density o f non-contractile tissue, muscle fiber cross-sectional area,
and total number of fibers have also been demonstrated, at least in avian muscle (Alway, et
al., 1989). Passive stretching has been shown to increase the levels o f muscle regulatory
factors (Zador, et al., 1999) and glucose transport in muscle (Ihlemann, et al., 1999). It is
likely that hamstrings use in athletic training acts to stretch the muscle tissues and thus
provide these positive effects.
132
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133
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Time greater than zero). Linear regression analysis was used to assess predictor variables
for Finger-to-Floor Reach Distance (FB).
Results
Subjects were first divided into two groups according to physical activity-inactive
controls and active athletes. A comparison of their finger-to-floor reach distances showed
that inactive controls had a mean reach distance over twice that o f active athletes (Table
7.1). Because they were also significantly younger, reach distance was normalized for
age. These normalized means were still significantly different (p = 0.001), a finding that
led to the decision to reject the first null hypothesis, Hoi, which stated that there is no
difference o f Reach Distance between controls and athletes.
Table 7.1. Mean Age and Reach Distance for Controls and Athletes,
with Reach Distance Normalized by Age
C ontrols
m ean
s.d.
Variable
3.15 yrs.
Age
12.46 yrs.
69 mm.
44 mm.
Reach Distance
Normalized Reach 3.72 mm./yr. 6.17 mm./yr.
n
88
83
82
m ean
14.68 yrs.
20 mm.
1.42 mm./yr.
A thletes
s.d.
2.01 yrs.
55 mm.
3.86 mm./yr.
n
2128
1757
1717
P
0.000
0.003
0.001
To test the second primary null hypothesis, active athletes were grouped according
to hamstring shortness categorythose able to touch the floor in sagittal plane flexion
were Hamstring-normal and those unable to do so were Hamstring-short. Next, the
means of the training variables Annual Training Time and Period were calculated for each
hamstring group. Because o f the significant difference in Age between groups, both o f the
training variables were again normalized for age (Table 7.2). All o f the training variable
134
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means were larger for the hamstring-normal group, which led to the decision to reject H0 2 ,
which stated that there was no difference in training time between hamstring-normal and
hamstring-short athletes.
Table 7.2. Mean Age, Annual Training Time, Period, and the Training Variables
Normalized for Age for Athletes grouped as Hamstring-Normal or Hamstring-Short
(* = values for 14-18 year old wrestlers; s.d. = standard deviation)
Variable
Age
Per
Normalized Period*
Time
Normalized Time
Hamstring-Normal
m ean
s.d.
1.99 yrs.
14.80 yrs.
4.78 yrs.
2.65 yrs.
0.266
0.161
288 hrs.
206 hrs.
14 hrJyr.
20 hr./yr.
n
1440
1446
520
1470
1440
H am string-Short
m ean
s.d.
14.13 yrs.
2.19 yrs.
4.44 yrs.
2.65 yrs.
0.216
0.152
251 hrs.
173 hrs.
18 hrVyr.
12 hrJyr.
n
294
304
72
305
294
P
0.000
0.043
0.011
0.001
0.017
The relation o f age to hamstring shortness groups was better illustrated when
subjects were divided into three hamstring categories. The hamstring-loose category,
those who were able to touch the floor with flattened palms, were found to be significantly
older and to log significantly more training. Mean age and training times were less in the
hamstring-normals and hamstring-shorts, respectively (Table 7.3). These findings
indicated that hamstring shortness decreased with increased amounts o f training, such that
hamstring-loose subjects logged the most training.
Table 7.3. Mean Age, Period, and Annual Training Time (Time) for Athletes
grouped by Hamstring Shortness Category
( * = between hamstring-normals and hamstring-short groups)
Variable
Age (yrs.)
Period (yrs.)
Time (hrs./yr.)
n
Hamstring-Loose
mean
s.d.
15.17
1.68
2.6
5.0
337
228
352
Hamstrinjg-Normal
mean
s.d.
2.01
14.68
4.7
2.7
272
195
1118
Hamstring-Short
mean
s.d.
2.19
14.13
2.7
4.4
173
251
305
135
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P
0.000
0.010
0.001*
The secondary null hypotheses were tested with subjects grouped by gender and by
comparing the means o f several variables between these groups (Table 7.4). Although
females were significantly younger, they logged significantly more training hours and had
smaller mean reach distances. These differences remained even after normalizing for age.
These findings led to the rejection o f both H03 and H04 , which stated that there were no
differences o f reach distance or normalized training time between genders.
Table 7.4. Mean Age, Annual Training Time, Reach Distance by Gender,
with both Time and Reach Distance Normalized by Age
Fem ales
Variable
m ean
Age
14 yrs.
Time
284 hrs.
Reach Distance
13 mm.
Normalized Time 20.83 hrs./yr.
Normalized Reach
1 mm./yr.
s.d.
2 yrs.
240 hrs.
40 mm.
17.76 hrs./yr.
3 mm./yr.
Males
n
402
407
304
402
300
mean
15 yrs.
245 hrs.
23 mm.
16 hrs./yr.
2 mm./yr.
s.d.
2 yrs.
181 hrs.
1822
1862
1540
1822
1502
58 mm.
12 hrs./yr.
4 mm./yr.
P
0.000
0.002
0.000
0.000
0.003
To illustrate the relation between training and hamstring shortness, mean annual
training time was determined for both hamstring-normal and hamstring-short subjects.
Training times were tabulated both by age in years (Table 7.5) and with subjects divided
according to three age groups (Table 7.6), as described in Chapter IV. For most ages,
hamstring-short subjects had smaller, mean training times than hamstring-normals.
However, 18 year old males and 14-18 year old females males were an exception to this.
Figure 7.1 is a graph Reach Distance versus Training Time for the older group o f female
athletes. An negative relation between the two variables is maintained until about 400
136
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hours, after which the relation becomes positive and those with greater amounts o f
training also have larger reach distances (are more tight). While it is purely speculation,
perhaps too much training is also related to hamstring shortness.
Male
Table 7.6. Mean Annual Training Times for Female and Male Athletes
by Age Group and Hamstring Shortness Category
Gender
Female
Male
Hamstring-Short
Hamstring-Normal
Age Group mean hrsJyr. Stf. mean hrsJyr. s.d.
340
207
66
8
8 to 10 yrs.
297
191
262
386
11 to 13 yrs.
200
414
270
429*
14 to 18 yrs.
117
180
182
208
8 to 10 yrs.
156
232
211
243
11 to 13 yrs.
176
184
274
279
14 to 18 yrs.
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ZCO
4 CO
00.0
O'00
138
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P (2 TAIL)
0.024
0.001
0.049
0.017
0.041
0.001
0.000
where
FB = Finger-to-Floor Reach Distance (ram.)
K = Constant
Age = Age (yrs.)
Sex =* Gender (Female: 1, Male: 2)
GTF = Greater Trochanterion-to-Floor Distance (m.)
Per = Period (number of years in primary sport)
WTKG = Weight (kg.)
SWTH = Torso width at the SI level (m.)
LDP Torso depth at the L3 level (m.)
HTM Height (m.) ( n . s . , p - 0 . 1 1 8 )
C ategory
Hamstring-Loose
Hamstring-Normal
Hamstring-Short
n
226
757
178
Age (years)
m ean
s.d.
15.98
0.92
15.64
1.09
15.44
1.11
P eriod (years)
m ean
s.d.
2.54
4.88
2.76
4.79
4.57
2.79
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Table 7.9 . Mean Age and Period for Athletes grouped by Age Category
As noted previously, older subjects report a larger Period (p = 0.000; r = 0.058; n = 2142)
r
8-to-10
11-to-13
14-to-18
f 1
n
109
418
1615
Age (years)
m ean
s.d.
9.53
0.62
0.76
12.33
15.61
1.08
P eriod (years)
s.d.
m ean
3.24
1.87
4.45
2.38
4.75
2.73
(Table 7.9). In addition, there were gender differences related to Period, in that, for each
year o f age, females reported training for longer periods o f time than males, a difference
that is significant in 16 year-olds (p = 0.007; Table 7.10).
Table 7.10. Mean Period by Gender for 16 Year-Old Athletes
G ender
F em a les
M a les
m ean (yrs.)
6.1
4.8
s.d .
3.0
2.6
To control for the difference o f age and gender differences and to illustrate the
difference in Period between hamstring categories, data from male subjects, ages 8-to-10,
were selected for analysis. In this group, there was no difference in mean age between the
hamstring-normal and hamstring-short subjects. Nor were there differences in height,
weight, or the torso anthropometry variables. However, mean Period was still
significantly smaller (t-test, p = 0.049) in the hamstring-short group [2.81 years ( 2.27
years); n = 13] than it was for hamstring-normals [4.47 years ( 2.04 years); n = 17].
140
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In keeping with our goal o f identifying the relationship between our dependent
variables and independent variables such as age, sex, and somatotype, several
anthropometric variables were included in the regression modeling. Four of these
variables were found to be significant predictors o f reach distance. Older subjects were
found to have larger mean values o f the anthropometric variables (Table 7.11), which was
interpreted as reflecting age-related growth. Three o f the four variables were interrelated,
with both Torso Width at SI (SWTH) and Torso Depth at L3 (LDP) having strong
Pearson correlations with Weight (r equal to 0.839 and 0.788, respectively). This direct
relation suggested that the torso variables were more indicators of weight, rather than o f
reach distance.
The fourth, significant, anthropometric predictor variable was Trochanterion
Height (GTF). As depicted in Figure 7.2, the relation between this variable and reach
Variablo
Age
FB
GTF
SW TH
LDP
TIME
PER
8-to-10 year-olds
(n=53)
m ean
s.d.
9.67
0.52
45.97
60.39
0.737
0.050
0.022
0.346
0.018
0.166
130.58
140.31
3.64
1.89
11-to-13 y ear-o ld s
(n=275)
m ean
s.d .
0.77
12.36
27.08
56.75
0.060
0.829
0.034
0.382
0.171
0.023
211.3
195.28
4.37
2.28
14-to-18 year-olda
(n-1369)
m ean
s.d.
15.65
1.06
54.44
17.98
0.913
0.059
0.444
0.039
0.193
0.029
267.31
172.99
4.72
2.72
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distance was direct, such that subjects with leg length values o f about 0 . 8 m. tended to be
have larger reach distances. This link between hamstring shortness and anthropometry
will be explored in more detail in Chapter VIIL
'i
-1 a
-I
C'l'
r i r 'c n / i n t o r w n
m ,
Discussion
Up to now, data linking hamstring shortness with specific amounts o f physical
activity have been lacking. We have identified a negative relation between the two
variables, such that those who train more have less hamstring shortness and are able to
reach closer to the ground. If one could assume that physical activity in the form of
athletic training acts to provide a form o f cyclic, hamstring stretching, then these findings
agree with what has been suggested in the literature, namely that hamstring muscle
stretching increases the muscle length and therefore, increases joint range o f motion (e.g.
Starring, et al., 1988; Bandy and Irion, 1994; Magnusson, et al. 1998).
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There are several theories as to why stretching increases muscle length. These
include change o f muscle stretch tolerance (Halbertsma and Goeken, 1994) and a
reduction o f series elastic stiflhess (McNair and Stanley, 1996). Ultrastructurally, muscle
tissue subjected to stretch has been reported to exhibit increased protein synthesis
(Goldspink, 1977), fiber phenotype adaptation, and IGF-I gene expression increase (Yang,
et al., 1997).
For most subjects, increased training was related to decreased reach distance
(decreased hamstring shortness). However, in older, female, hamstring-short subjects, the
opposite was found to occur. Those who trained more than 440 hours per year tended to
have larger reach distance, signifying tighter hamstrings. For the same small group (n =
26), the same finding was true o f Period, a significant predictor o f reach distance. Those
who reported participation for more than about 4.5 years tended to have larger reach
distances. These findings suggested that, in some individuals, too much training may be
deleterious to muscle flexibility. It is possible that high amounts o f training could have
been responsible for the relative hamstring shortness observed in the study o f Wang, et al.
(1993). In their study o f 40 subjects having a mean age o f 25.6 ( 5.5) years, long
distance runners were found to have tighter hamstrings than inactive controls, the
converse o f what might have been expected.
Since training was shown to be a predictor o f hamstring shortness as defined by
reach distance, it was not surprising that both Age and Sex were identified as predictor
variables, as females and older individuals log more training hours (Chapter IV). For
example, our 14-to-l8 year old males had a reach distance o f less than half that o f the 8 143
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to-10 year olds, and logged about twice the number o f training hours (Table 7.8). If one
were able to assume a cause-and-effect relation between the two variables, this was equal
to about a 4 mm. per-year-of-age reduction o f finger-to-floor distance between the two
groups.
Our identification o f a relation between gender and hamstring shortness also agrees
with what has been suggested in the literature. First, females had significantly smaller
reach distances than males, even when normalizing for height, controlling for training, and
with no significant age difference between select subject groups. Second, the prevalence
o f hamstring looseness was greater in females, with over twice the percentage o f
hamstring-loose subjects as compared to males (35.2% versus 16.2%). Third, the
prevalence o f hamstring shortness was much less in female athletes, such that, o f the
hamstring-short subjects, only 11% were female, while 89% were male. The increased
normalized reach distances and difference o f prevalences implies a gender-difiference o f
hamstring muscle flexibility, similar to that reported by Wang, et al. (1993) and Kuo, et al.
(1997).
There was also a relationship between age, reach distance, and the amount o f
training. Hamstring-loose, female and male athlete subjects were about 7% older, had
about a 14% larger training period, and had about 35% more annual training time than
hamstring-short subjects. In an attempt to quantify these differences, a rough estimate o f
reach distance per amount of training was made by dividing the mean difference o f reach
distance between hamstring shortness groups by the mean difference o f both annual
training time and training period between hamstring shortness groups. If a cause-and144
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effect conclusion were possible, the resulting quotients would imply that reach distance
decreased by about 0.21 mm. per annual training hour and by about 2.77 mm. per year of
training. Such an implication would lend credence to the findings of others who have
suggested that muscle inactivity from the lack o f exercise is a cause o f hamstring shortness
(Fisk and Baigent, 1984; Starring, et al., 1988; Jozwiak, et al., 1997).
In addition to Age, several anthropometric parameters, including Greater
Trochanterion-to-Floor Leg Length (GTF), were predictors o f Reach Distance (Table
7.7). Not surprisingly, the GTF increased with age, as did the other anthropometric
predictors (Table 7.8). It is likely that a unique ratio incorporating this anthropometric
variable exists that would lend support to an explanation o f hamstring shortness in terms
o f a differential growth rates between long bone and soft tissue. The relation between
anthropometry and hamstring shortness will be discussed at length in the next chapter.
Limitations
Some o f the limitations of this study have been discussed in Chapters III, IV, V,
and IX. First, the subjects from both large and small studies were convenience samples
from relatively narrow ethnic and socio-economic pools. As such, one cannot assume
randomness, nor can one extrapolate the results to the general population. Second, some
have reported concern regarding the accuracy o f childrens self-reporting as a data source
(e.g. Anderssen, et al., 1995). However, the test-retest validity of the questionnaire
instrument (Chapter HI) and the consistency o f the athletic training time/hamstring
shortness relationship for our three age groups and for each gender lessens this concern.
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Conclusions
While our study design did not allow cause-and-effect conclusions, the statistically
significant, indirect relation between reach distance and the amount of athletic training
implied that hamstring shortness is improved with physical activity. Females and older,
more trained subjects in this study were able to reach closer to the floor than males and
younger, less trained subjects. These observations were made in spite o f the direct
relation o f hamstring shortness to several anthropometric variablesvariables which
themselves increase linearly with age. The relation o f hamstring shortness to training is
clinically important, as exercise programs can be designed to assure hamstring-safe
amounts o f training.
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CHAPTER VIII
ON THE RELATION BETWEEN THORACIC KYPHOSIS, HAMSTRING
SHORTNESS, AND ANTHROPOMETRY IN SMALL AND LARGE,
CROSS-SECTIONAL SAMPLES OF CHILDREN AND ADULTS
Introduction
Do individuals with thoracic hyperkyphosis or hamstring shortness exhibit unique
anthropometric characteristics? In two previous chapters, linear regression analysis used
in post-hoc analyses identified at least two significant, anthropometric predictors o f the
dependent variables Thoracic Kyphosis Angle (Chapter III) and Finger-to-Floor Reach
Distance (Chapter VII). These predictors included Spine Length from the First Sacral
Segment to the First Thoracic Vertebra (ST1, Table 3.4), which was a predictor o f
Thoracic Angle (p = 0.000), and the Greater Trochanterion-to-Floor Height, which was a
predictor o f Reach Distance (p = 0.049), our determinant of hamstring shortness.
It was theorized that these predictor variables could be the basis for the
development o f two unique, anthropometric indicators. This chapter describes the results
o f a study aimed at defining the relation between thoracic kyphosis, hamstring shortness,
and anthropometry. The study was done as a post-hoc analysis using data originally
collected to answer other questions (Wojtys, et al., 2000). This chapter also describes the
development o f anthropometric indicators, which are intended for use as screening tools
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to help identify those individuals at risk for either the development o f acquired
hyperkyphosis or for lower extremity injuries stemming from hamstring muscle tightness.
Background
For several years, stature has been associated with spine curve abnormalities. For
example, taller males have been said to be more prone to the development o f the thoracic
hyperkyphosis o f Scheuermanns Disease (Fisk, et al., 1984). Girls with another type of
spine deformity, idiopathic scoliosis, have also been found to be significantly taller than
those having normal spines (Willner, 1975; Nordwall and Willner, 1977, Normelli, et al.,
1985).
Some authors have related anthropometric factors in females to the menarche and
growth spurt. Females who tended to be taller than average were observed to be so
two years before the pubertal growth spurt and to display an early pubertal maturation
(Hagglund, et al., 1992). Skogland and Miller (1981) suggested that the pubertal growth
spurt o f the spine started earlier and lasted longer in scoliotic subjects, and indicated that
scoliotic children are likely to have longer thoracic spines. In their radiographic study of
274 children ages 6.5 to 18.5 years old, they found that scoliotics had significantly taller
T 6 vertebrae. Skogland, et al. (1985) went on to report that the incidences o f both
scoliosis and Scheuermanns Disease in tall stature females were much higher...than
normal. In their sample o f 62,9-18 year old girls, 21% had scoliosis, 29% had thoracic
hyper-kyphosis, and 18% had findings o f Scheuermanns Disease.
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Fewer studies have looked at the relation between anthropometry and hamstring
shortness. Two ideas from these sparse studies formed the basis for the development o f
our unique, indicator variable. The first was the notion that unequal growth rates o f long
bone and the musculoskeletal unit cause passive muscle tension and, as a result, muscle
tightness (Burkett, 1970; Ekstrand and Gillquist, 1983; Jozwiak, et al., 1997). The second
idea involved an observation o f a disparate growth rate between the leg and the spine.
The leg has been shown to lengthen at a constant rate until the growth spurt peaks in both
males and females, after which the lengthening rate declines (Terver, et al., 1980). The
trunk peak growth rate lags behind that o f the legs, which allows for a continued increase
in stature after the legs have stopped elongating (Anderson, et al., 1978). Upadhyay, et al.
(1991) used a similar measure, the leg-to-spine ratio, in their study o f scoliotic girls, ages
8-to-21 years. They found that those subjects whose angles were severe enough to
require fusion had a significantly larger leg-to-spine ratio than normals.
By combining what has been reported in the literature with the findings reported in
the preceding chapters regarding anthropometric predictors, two indicators were
developed. The first indicator, the Spine Length-to-Height ratio, was intended to be a
predictor o f thoracic kyphosis angle. The second indicator, the Leg Length-to-Spine
Length ratio, was theorized to be a predictor o f reach distance, and thus, an indicator o f
hamstring shortness. To test the applicability o f these variables as indicators, the
following Primary Null Hypotheses were advanced:
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It was anticipated that those with larger thoracic angles would have longer
thoracic spines relative to overall height, and that hamstring-short subjects would have
longer leg lengths relative to their spine length.
Secondary hypotheses were advanced to look at the differences o f age and body
habitus between groups. These were:
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kyphosis, lumbar lordosis, and pelvic tilt (Chapters V and VI). Again, anthropometric
measurements were taken on all subjects, and each subject was evaluated for hamstring
shortness. Spine length was measured from palpated landmark to palpated landmark,
along the surface o f the skin with subjects in the upright position.
Data Analysis
The same statistical methods used in the previous studies were employed here.
ANOVA and t-tests were used to compare means between various groups, while linear
regression was used to identify predictors o f our dependent variables thoracic angle and
reach distance.
Results
n
m ean y i* .
1224
14.64
327
14.89
s.d.
1.92
1.86
m ean m.
1.69
1.71
s.d.
0.12
0.11
m ean kg.
63.10
64.33
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s.d.
18.24
16.38
Variable
T1 to S1 Length (mm.)
T1 to T10 Length (mm.)
N orm okyphotic
m ean
s.d.
446
44
250
30
H yperkyphotic
m ean
s.d .
461
42
260
30
p-value
0.004
0.002
weight between groups, both spine lengths were larger in hyperkyphotic subjects. The
difference of thoracic spine length was more significant (p = 0.002) than that of the entire
spine (p = 0.004). Of the two, the thoracic region was the spine region more typically
associated with the classic forms of hyperkyphoses such as Scheuermanns Disease. For
those reasons, the analysis was continued using the TI-T10 length as the basis for a new
predictor variable.
In Chapter m , regression analysis identified Height as a significant predictor o f
thoracic angle (Table 3.4). Because Height was significantly different between genders (p
= 0.000; Table 8.3) and between age groups (p = 0.000; r2 = 0.627; Table 8.3), it was
decided that the TI-T10 Length should be normalized for Height to help control age- and
152
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gender-related differences o f stature. The density plot for normalized thoracic spine
length is displayed below (Figure 8.1). Note the relative closeness of the mean and
median values, indicating a normal distribution.
Table 8.3. Mean Height for Subjects divided according to Age Group and Gender
Mean height (m.) increased with age, and was greater in males (who were also older).
G roup
8-to-10 year olds
11-to-13year olds
14-to-18 year olds
Fem ales
Males
n
132
432
1641
403
1846
mean m.
s.d.
1.42
1.58
1.74
1.61
1.70
0.08
0.10
0.09
0.11
0.13
7: L
(]r\
7rcraC'-C iC'f'e L.
To test the first null hypothesis, the new spine length variable was compared
between normokyphotic and hyperkyphotic subjects from both the large sample study
(Chapters HI and IV) and the small sample study (Chapters V and VI). Table 8.4 shows
that the hyperkyphotic subjects o f both samples have significantly larger normalized,
thoracic spine lengths than the normokyphotic subjects, despite the differences o f optical
153
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method used in the studies. There were no significant differences o f age, height, or weight
between the kyphosis categories o f either sample. Because o f these differences, the
decision was made to reject Hoi, which stated that there was no difference in Spine
Length-to-Height between kyphosis groups.
Linear regression was used next to confirm whether the normalized, spine length
variable was a significant predictor o f thoracic angle. In Chapter m , regression analysis
showed that the variable Spine Length alone (S T llength from SI to LI) was a
significant predictor of thoracic angle, as were both Age and Sex (Table 3.4). The new
regression model (Table 8.S) did indeed show that normalized Thoracic Spine Length was
a significant predictor (p = 0.000), along with Sex, LDP (an indicator of weight), and
Table 8.4. Mean Thoracic Angles and Thoracic Spine Lengths for Subjects grouped
according to Thoracic Angle Magnitude from both Large and Small Study Samples
s.d. = standard deviation. Normalized Length is the T1-T10 Length normalized for Height
Note that those with greater kyphosis angles from both subject samples have longer mean
thoracic spine lengths.
Sam ple
Large
Small
Variable
Thoracic Angie (deg.)
Normalized Length mm.)
n
Thoracic Angle (deg.)
T-spine Length (mm.)
Normalized Length (mm.)
1
n
Normok)^photic
m ean
s.d.
12
38
146
13
1726
37
9
218
35
14
131
26
-
H yperkyphotic
a.d.
m ean
72
6
14
151
73
57
6
17
250
146
6
5
.
p-value
0.000
0.004
0.000
0.010
0.002
*
Annual Training Time (as discussed in Chapters III and IV). The new model resulted in a
reduction in the number o f predictor variables, as Age and the Age*Sex interaction were
no longer significant. There was an increase in r-squared value (albeit small, from 0.049
to 0.051), although this did little to enhance the already weak linearity o f the equation.
154
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Table 8.S. Linear Regression Equation for Active Athletes (Thoracic Angle)
[General Linear Model, Stepwise/Backward Regression; N=1828, with
367 cases deleted due to missing data; p=0.000 (ANOVA); r^O.051]
T = 1 5 . 2 2 1 (K) - 0 . 3 0 8 ( A g a )+ 4 . 0 5 5 (Sm x)- 0 . 0 5 7 (LDP)
+ 0. 0 0 6 (Tixam) + 1 9 8 .1 7 0 (TBTH)
Significant Predictors
VARIABLE
Sex
LDP
Time
THTM
where
P ( 2 TAIL)
0.000
0.000
0.002
0.000
155
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S p o rt
FEMALE
Swimming
8 to 10 yrs.
11 to 13 yrs.
14 to 18 yrs.
G ym nastics
8 to 10 yrs.
11 to 13 yrs.
14 to 18 yrs.
Volleyball
11 to 13 yrs.
MALE
Hockey
8 to 10 yrs.
11 to 13 yrs.
14 to 18 yrs.
Swimming
8 to 10 yrs.
11 to 13 yrs.
14 to 18 yrs.
W restling
8 to 10 yrs.
11 to 13 yrs.
14 to 18 yrs.
Norm okyphotic
m ean
s.d.
H yperkyphotic
m ean
s.d .
0.148
0.147
0.149
0.013
0.012
0.013
0.156
0.148
0.155
0.024
0.009
0.017
0.148
0.143
0.147
0.016
0.010
0.011
0.156
0.134*
0.148
.
0.002
0.146
0.017
0.130*
0.004
0.144
0.138
0.142
0.009
0.017
0.013
0.140*
0.135
0.147
0.009
0.010
0.136
0.141
0.147
0.015
0.021
0.012
0.141
0.150
0.148
0.010
0.021
0.010
0.141
0.143
0.147
0.012
0.012
0.013
0.149
0.145
0.149
0.019
0.012
Table 8.7. Mean Spine Length Normalized for Height for both
Normokyphotic and Hyperkyphotic Females and Males by Age Group
s.d. = standard deviation; normo- = normokyphotic; hyper- = hyperkyphotic. In most cases,
hyperkyphotics have larger mean values than normokyphotics.
m ean
8 to 10 yrs.
normohyper11 to 13 yrs.
normohyper14 to 18 yrs.
normohyper-
F em ales
s.d .
m ean
M ales
s.d .
0.148
0.156
0.013
0.02
21
4
0.142
0.142
0.011
0.008
21
5
0.146
0.145
0.012
0.01
60
24
0.141
0.143
0.015
0.017
176
29
0.148
0.155
0.015
0.016
89
21
0.147
0.149
0.013
0.012
793
222
156
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*rcrr. m
The second point were the observations o f Terver, et al. (1980) and Anderson, et
al. (1978), who identified a difference in the relative growth rates o f the torso and
extremities. Because the peak growth rate o f the trunk was shown to lag behind that of
the leg, the variable Leg Length-to-Spine Length ratio (GTF/ST1 or GS), which
combined leg length and spine length, was set up with Leg Length in the numerator and
157
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Spine Length (not a significant predictor o f Reach Distance) in the denominator. Like
GTF and Reach Distance, the relation between GS and Reach Distance was direct (e.g.
Figure 8.3). Figure 8.4 shows the variable values plotted by age for all subjects, while
Figure 8.5 is the density plot o f the Leg Length/Spine Length variable. Note the close
proximity o f the mean and median, which indicates minimal skewness.
--s-ratf
Figure 8.3. Leg Length/Spine Length Ratio vs. Reach Distance for 11 year-olds
Tighter subjects tend to have larger ratio values (n = 75; p = 0.014; r = 0.677).
Figure 8.4. Mean Leg Length-to-Spine Length Ratio by Age (All Subjects)
Note that the values peak in the peripubertal period, from ages 10 to 14.
158
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Regression analysis confirmed that the new variable was a significant predictor
(Table 8 .8 ). In addition to the GS ratio, Sex, Age*Sex, and the training time variable,
Table 8.8. Linear Regression Equation for All Subjects (Reach Distance)
[General Linear Model, Stepwise Regression; N=1760, with
511 cases deleted due to missing data; p=0.000 (ANOVA); r2=0.030]
FB = - 1 0 3 . 0 0 2 (K )+ 4 1 . 5 6 2 (Smx)+ 2 6 . 1 1 9 (HTH) - 2 . 2 0 5 (Agm*Sx)
- 0 . 9 9 0 (PER)+ 2 7 . 5 6 2 (GTFST1)+ 0 . 0 9 8 (T 10-L 3)
Significant Prmdictora
VARIABLE
Sex
Age*Sex
GTFST1
Per
where
P (2 TAIL)
0.000
0.000
0.002
0.032
159
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Period, were also predictors. Comparisons o f mean reach distance by gender (Table 8.9)
revealed that males had a larger reach distance, signifying that their hamstrings were
shorter. Males were also older, heavier, and taller. The low r2 (0.030) o f the equation
was interpreted as indicating the weak linearity o f the model.
Table 8.9. Mean Age, Height, Weight, and Reach Distance by Gender
G ender
Female
Male
p -v a lu e
Weighl
R sach D istance
Age
H eight
n
m ean yre. s .d . m ean m. s .d . m ean kg. s .d . m ean mm.
s .d .
2.23
51.88
12.76
58.32
402
13.72
1.61
11. s s
0.11
1.7
65.18
22.92
1822
18.73
40.41
14.78
Z 03
0.13
0 .0 0 0
0 .0 0 0
0 .0 0 0
0 .0 0 0
To test the secondary null hypothesis H0 4 , means of the same variables were
compared between hamstring shortness categories. Table 8.10 shows that age, height, and
weight were also significantly different between categories, with hamstring-short subjects
being younger, shorter, and lighter. This finding led to the rejection of H 0 4 , which stated
that there was no difference o f age, height, or weight between hamstring groups.
The younger, hamstring-short subjects had participated in their primary sports for fewer
years than the older, hamstring-normal subjects (Table 8.11). They also had larger mean
Leg Length-to-Spine Length ratios.
160
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The effect o f the last predictor variable, Age* Sex interaction, is illustrated in Table
8
.12. Both males and females demonstrated a difference o f age between hamstring
shortness categories, such that hamstring-short subjects were younger than hamstringnormals. However, this difference was significant (p = 0.000) only in males.
Table 8.11. Mean Period and Leg Length-to-Spine Length Ratio (GTFST1)
by Hamstring Shortness Category
Hamstring-Normal
Hamstring-Short
p-va/ue
n
1510
330
Period
m ean y rs.
s.d .
4.65
2.73
4.09
2.79
0.001
GTFST1
m ean
s.d .
1.98
0.15
2.03
0.17
0.000
Table 8.12. Mean Age for Males and Females by Hamstring Shortness Category
Hamstring-Normal
Hamstring-Short
p-va/ue
n
1198
259
M ales
m ean y rs.
s.d .
1.84
15.03
14.21
2.18
0.000
n
182
23
F em ales
m ean y rs.
s.d .
13.23
2.13
13.09
1.62
n.s.
To test the second, primary null hypothesis H02 , mean Leg Length-to-Spine Length
ratio was compared between subjects grouped into hamstring shortness categories.
Hamstring-normal subjects, those able to touch the floor in sagittal plane flexion, had a
significantly smaller mean GS ratio than hamstring-short subjects, those who were unable
to touch the floor (p = 0.000; Table 8.11).
The hamstring-normals were also significantly older, heavier, and taller than
hamstring-short subjects. Since there was a direct relation between age and
anthropometry, it was necessary to control for this variable. Division o f subjects by age
161
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(e.g., less than 15 years-old) or by gender and age (e.g. males younger than 13 years-old)
controlled for between-hamstring group differences o f the age, height, weight, GTF, ST1,
and BMI. After controlling for these variables, there were still significant differences o f
the GS ratio between hamstring-shortness groups (Table 8.13). These findings led to the
Table 8.13. Mean Leg Length-to-Spine Length Ratio for Subjects grouped
by Hamstring Shortness Category (Males younger than 14 years)
(s.d. = standard deviation)
Group
All < 15 years
Males < 13 yrs.
Males 14 yrs.
H am string-N orm al
m ean
s.d.
n
2.024
0.148
560
0.148
2.031
140
0.154
145
2.015
H am string-S hort
m ean
n
s.d.
0.169
177
2.078
0.17
67
2.092
0.168
2.105
43
p-value
0.000
0.013
0.003
decision to reject H0 2 , which stated that there was no Leg Length-to-Spine Length
difference between hamstring groups.
Mean Leg Length-to-Spine Length values were then determined for subjects
divided by hamstring-shortness status, sport, and age group, as well as by gender and age
group (Tables 8.14 and 8.15). As predicted, hamstring-short subjects had larger mean
Leg Length/Spine Length ratios. Again, while these values are specific to our subject
sample, they provide rough estimates that may be used by those involved in designing
training programs and in screening potential participants.
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S p o rt
FEMALE
Swim m ing
8 to 10 yrs.
11 to 13 yrs.
14 to 18 yrs.
H am stringI Normal
m ean
s.d .
8 to 10 yrs.
11 to 13 yrs.
14 to 18 yrs.
MALE
F ootball
8 to 10 yrs.
11 to 13 yrs.
14 to 18 yrs.
Hockey
8 to 10 yrs.
11 to 13 yrs.
14 to 18 yrs.
Swim m ing
8 to 10 yrs.
11 to 13 yrs.
14 to 18 yrs.
W restling
8 to 10 yrs.
11 to 13 yrs.
14 to 18 yrs.
H am string S ho rt
m ean
s.d .
0.014
2.030
2.007
1.968
0.178
0.154
0.121
2.180
2.014
2.117
2.011
0.175
0.110
0.088
.
.
2.193
1.996
0.202
0.148
2.210
2.084
2.001
0.166
0.137
0.163
2.154
2.060
0.168
0.129
2.018
2.025
1.965
0.157
0.122
0.174
2.048
2.083
2.008
0.033
0.226
0.138
2.010
2.037
1.952
0.107
0.136
2.052
1.992
0.100
0.166
Table 8.15. Mean Leg Length-to-Spine Length Ratio for each Gender
by Age Group and Hamstring Shortness Category
(s.d. = standard deviation)
A ge G roup C ategory
Normal
8 to 10 yrs.
Short
11 to 13 yrs. Normal
Short
14 to 18 yrs. Normal
Short
F em ales
m ean s.d.
2.027 0.174
2.180 0.014
2.028 0.153
2.027 0.16
1.968 0.123
1.953 0.13
n
25
2
77
18
88
16
m ean
2.050
2.053
2.044
2.083
1.971
2.008
M ales
s.d.
0.173
0.165
0.128
0.164
0.147
0.17
163
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n
32
18
177
60
970
177
Discussion
Up until now, there was relative little in the literature addressing a link between
anthropometry and thoracic kyphosis. One o f the few studies addressing the
anthropometric components o f spine curve abnormalities was by Skogland and AshtonMiller (1981). They had noted that scoliotics tended to have longer spines than nonscoliotic subjects. In our subjects, those having larger thoracic angles also tended to have
longer total spine lengths as well as significantly longer Tl-to-TIO spine segment lengths
(p = 0.000; Table 8.2). This same significant difference was true even after normalization
by height and with no statistically significant differences o f age, height, weight, or body
mass index between normokyphotic and hyperkyphotic individuals (Table 8.4).
Likewise, there has been little work done looking at the relation between
anthropometry and hamstring shortness. Our hamstring-short subjects had larger Leg
Length-to-Spine Length ratios than hamstring-normals. As discussed in Chapter VII, the
hamstring-short subjects tended to be younger and trained less. However, several groups
displayed significant differences o f this unique variable between hamstring categories, with
no significant, between-category differences o f age or training.
Figure 8.1 shows the mean Leg-Length/Spine Length ratio values for our samples
male subjects by year o f age. Note that these values were highest during the peripubertal period from ages 10 to 14 years and tapered off after the growth spurt. This
indicated that younger subjects had larger leg lengths relative to their spine lengths than
older subjects, whose spine lengths tended to be larger relative to their leg lengths. While
the study design prohibits cause-and-effect conclusions, one implication is that, in younger
164
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individuals, the rate of elongation of the lower extremities is greater than that o f the spine.
These findings are consistent with the observations o f both Tervers and Andersons
groups.
In contrast to our quotient described in Chapter IV, the distributions o f the two
quotients whose development was described here were not skewed, but rather normally
distributed. The means and medians o f the new quotients (Figures 8.1 and 8.5) were
closer than that o f at least one o f their two respective component variables (e.g. Height,
with a mean o f 1.686 m. and a median of 1.702 m., or Leg Length, with a mean of 0.884
m. and a median o f0.890 m.). The normal distribution implies the potential for
generalization to a population.
Limitations
The limitations o f optical methods that were used to generate the thoracic angle
data, of the self-reporting questionnaire used to generate training time data, and of the
subject selection employed in the original studies have been discussed elsewhere (e.g.
Chapters HI, V, and IX). This secondary analysis of cross-sectional data from a
convenience sample cannot be used to establish cause-and-efiect conclusions. Even if it
did, our sample from a specific socio-economic group would prohibit extrapolation o f the
results to the general population.
In light o f the inherent limitations, several tables were constructed to illustrate
certain trends. Table 8.6 and 8.7 were meant to show differences in thoracic spine length
between several groups o f subjects divided as normokyphotic and hyperkyphotic. Tables
165
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8.14 and 8.15 were meant to show differences o f the Leg Length-to-Spine Length variable
between subjects divided as hamstring-normal and hamstring-short. While the values
contained in these tables are specific to our subject sample, were cause-and-effect
established, the values listed in these tables might be used as rough guidelines by clinicians
and coaches in screening sports participants. Those who might be at risk for the
development of hyperkyphosis or hamstring shortness-related injury could be identified,
and special care could be used in designing their training programs and monitoring their
progress.
While it is difficult to say, it is possible that our between-landmark, surface
measurement o f spine length may have underestimated the actual length. This may have
due to error in marker placement or to the thickness o f the soft tissues over the lumbar
region (e.g. Willner, 1981; Bryant, et al., 1989). If so, then a systematic error would
overestimate the size o f the Leg Length/Spine Length, perhaps resulting in an
overestimation o f group differences.
Conclusions
Two findings were noted in this study. The first was that those 8-to-18 year old
hyperkyphotic subjects, those with thoracic angles greater than 52 (photogrammetric
method) tended to have significantly longer thoracic spines normalized by height than
normokyphotics (those with kyphosis angles between 25 and 52) . The second was that
hamstring-short subjects tended to have longer leg lengths normalized by spine length than
hamstring-normal subjects. While cause-and-efiect conclusions could not be made
166
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because o f study design, these results imply that those with proportionally longer thoracic
spines are predisposed to the development o f acquired hyperkyphosis, and those with
proportionally longer legs may by prone to hamstring shortness, which, in turn, may be
directly related to the development o f thoracic hyperkyphosis.
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CHAPTER IX
GENERAL DISCUSSION
In his classic paper o f 1920, Dr. Holger W. Scheuermann theorized that farm
work, a form o f repetitive physical activity, and cartilage abnormalities were likely causes
o f the hyperkyphosis that would eventually be named after him. Later, Constantine
Lambrinudi (1934) suggested that hamstring shortness was a possible cause o f the nonpostural, acquired thoracic hyperkyphosis described by Scheuermann. The purpose o f this
dissertation was to determine the relation between thoracic hyperkyphosis and physical
activity (repetitive loading in the form o f athletic training), hamstring shortness, and
anthropometry. Although our subjects were not diagnosed as having Scheuermanns
Disease, or Juvenile Thoracic Kyphosis, our findings support the notions o f these two
authors.
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1985), or were prevalence studies (Sorensen, 1964; Wassman, 1951). In contrast to the
work of others, the work o f Wojtys, et al. (2000) and the present study found a
statistically significant, direct relation between the angle o f thoracic kyphosis and the
hours of athletic training. The relation was such that individuals who reported more
athletic training hours tended to have larger thoracic spine angles (Chapter m ). While the
cross-sectional, study design prohibited the identification o f causal relationships, these
results suggested that repetitive, physical work may indeed be linked to the development
o f hyperkyphosis in the susceptible spines o f adolescents. This finding is important
because it might be possible to reduce the risk o f thoracic hyperkyphosis by modifying the
amount o f annual athletic training.
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170
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others (e.g. Halbertsma and Goeken, 1994), a restriction o f sagittal plane flexion range o f
motion was also noted in our subjects, both for the pelvic and total ranges. In addition,
the lumbar lordosis angles were smaller, a finding interpreted as being a relative
flattening o f the lumbar spine. Similar observations have also been reported elsewhere
(e.g. Beal, 1982; Day, et al., 1984; McCarthy and Betz, 2000).
Smaller, mean thoracic kyphosis angles were also identified in our hamstring-short
subjects. Interpreted as a relative flattening o f the thoracic spine, this finding corroborated
the notion o f others that spine curves tend to balance one another (e.g. Stagnara, et al.,
1982; Willner and Johnson, 1983; Voutsinas and MacEwen, 1986; Bridger, et al., 1989;
Korovessis, et al., 1998). This spine balance was noted particularly in younger
hamstring-short subjects with reach distances less than about 95 mm. Subjects with more
severely hamstring shortness, having reach distances above about 160 mm., tended to be
hyperkyphotic and older. While cause-and-effect results cannot be assumed, due to
research design, one implication o f these findings is that perhaps a larger thoracic kyphosis
angle may be an adaptive response to enhance the otherwise restricted reach distance
found in hamstring-short subjects. This idea agrees with the general concept o f Farcy and
Schwab (1997), who concluded that restricted motion in one area tends to lead to
increased motion in another.
Data from our hyperkyphotic subjects did not support Lambrinudis idea that
hamstring shortness is the sole etiology o f hyperkyphosis. The main reason is that not all
hyperkyphotics were hamstring-short. Seventeen percent o f our 889 hyperkyphotics were
hamstring-short, although diagnoses o f Scheuermanns Disease could not be inferred for
171
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Anthropometric Characteristics
One unique finding o f our studies is similar to what has been observed by Skogland
and Miller (1981) in their study o f scoliotic subjects. Our hyperkyphotic subjects tended
to have proportionally longer thoracic spines (Chapter V O ). It is possible that this
characteristic predisposes the anterior aspects o f thoracic vertebrae to an increased flexion
moment (Chapter I), which, with repeated loading, may result in wedge deformity.
The hamstring-short subjects o f our studies also displayed unique, anthropometric
characteristics. They tended to have proportionally longer legs, relative to their height or
spine lengths (Chapter V O ). Likely the result o f the growth rate differential between legs
and torso, it is possible that the lengthening bone actually puts a passive stretch on the
hamstring muscles, thereby causing relative tightness.
172
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This was followed by volleyball, with a mean angle/hour value 30% less than that of
gymnasts. For males, participants in ice hockey had the largest mean angle/hour value,
followed by wrestlers, whose mean was 41% less. Participants o f these same sports were
also identified as having increased thoracic kyphosis angles by several other groups,
including Kujala, et al. (1997), Stiletto, et al. (1996), Goldstein, et al. (1991), and Reilly
and Seaton (1990).
Just how much training is associated with larger thoracic kyphosis angles, or with
hamstring shortness? Because the immature spine is likely particularly vulnerable to
excessive loading (e.g. Mau, 1929; Ferguson, 1949), partially because the immature
cartilage and bone are undergoing relatively rapid development, it was deemed important
to attempt to quantify the amounts of training seen in hyperkyphotic subjects and in
hamstring-short individuals. Unfortunately, cause-and-efiect cannot be presumed in our
studies. Thus, our training times tabulated here, which arc specific to our subject sample,
should not be used clinically for a basis for the establishment o f training programs, but
rather to give academic insight as to the relative times between groups of subjects.
Mean annual training times were tabulated for athlete subjects grouped in several
ways. First, subjects were divided according to gender. Next, they were divided into four
groups: normokyphotic (those with thoracic kyphosis angles between 25 and 52
photogrammetric method), hyperkyphotic (those with kyphosis angles greater than 52),
hamstring-normal, and hamstring-short. Following that, the subjects were divided
according ageeither by age in years or into one o f three age groups. The mean training
hour data for subjects divided by gender and age are displayed in Appendix I (Tables 1.1
173
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and 1.2). Annual training time means for subjects also divided according to primary sport
are displayed below (Table 9.1).
Table 9.1. Mean Annual Training Times by Age Group for Female and Male
Athletes grouped by Kyphosis Category, Hamstring Shortness Status, and Sport
Age Group: 1 = 8-10 years, 2 = 11-13 years, 3 = 14-18 years; s.d. = standard deviation
Sport
Female
Swimming
Gymnastics
Volieyball
Male
Football
Ice Hockey
Swimming
Wrestling
Age
Nomnlkyphotic
Group m ean
s.d.
1
2
3
1
2
3
2
3
319
340
364
228
352
518
125
160
235
217
227
124
3 24
66
309
457*
39 7
78
60
2
3
1
2
3
1
2
3
1
2
3
225
292
186
169
216
276
398
481
127
164
242
173
161
159
182
148
285
260
299
57
102
136
8
193
220
148
285
170
212*
203
219
322
440
152
154
240
368
372
389
226
445
607
218
212
226
107
416
450
6
170
102
152
143
175
214
249
57
90
122
243
290
203
166*
224
318
475
514
54*
183
261 I
Hyparity photic
mean
s.d.
483
404
360
220
816
576
90
145
221
163
204
.
42
209
163
195
188
176
229
305
326
105
148
262
480
248
322
232
781
508
144
191
275
151
254
281
121
500
305
.
80
150
Despite the method used for grouping subjects, a pattern emerged, which is
illustrated using the group means for males (Table 9.2). Normokyphotic subjects tended
to log the smallest number of annual training hours. These were followed by hamstringshort subjects and hamstring-normal subjects. As indicated previously, hyperkyphotic
subjects logged the greatest amounts o f training hours. In some cases, this pattern was
not followed. These tended to be instances in which the mean training times were
calculated from smaller subject samples.
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Table 9.2. Annual Training Time Group Means for Male Athletes grouped
by Kyphosis Category and Hamstring Shortness Status and according to Age,
Age Group, and Sport
Times are in hours; s.d. = standard deviation
G rouped by;
Profiles o f typical female and male individuals are displayed below (Tables 9.3 and
9.4). These tables were prepared by determining the mean variable values for each o f the
categories o f kyphosis and hamstring shortness. As indicated previously, the hamstringshort subject is younger, is longer-legged, and trains less than the hamstring-normal
subject. The hyperkyphotic male is older, has a longer thoracic spine, and trains more
than the normokyphotic male.
Table 9.3. Profile of Typical Female Subjects who are either Hamstring-Normal
(HSN), Hamstring-Short (HSS), Normokyphotic (NK), or Hyperkyphotic (HK)
Age
hit
Wt
BMI
GTF
ST1
GTFST1
T1-T10
THTM
Time
Per
Reach
T
I
HSN
13.6
1.6
50.86
31.50
0.849
0.425
2.007
0.235
0.147
335.5
4.66
0.0
38.2
HSS
13.1
1.62
51.32
31.6
0.860
0.432
1.999
0.242
0.149
332.8
4.94
99.7
40.8
NK
13.4
1.61
51.44
31.8
0.851
0.421
2.032
0.237
0.147
323.1
4.8
9.6
39.2
HK
13.3
1.62
50.90
31.3
0.846
0.430
1.972
0.242
0.150
395.4
5.24
15.6
61.7
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Table 9.4. Profile of Typical Male Subjects who are either Hamstring-Normal
(HSN), Hamstring-Short (HSS), Normokyphotic (NK), or Hyperkyphotic (HK)
Age
Ht
Wt
BMI
GTF
ST1
GTFST1
T1-T10
THTM
Time
Per
Reach
T
HSN
15.0
1.71
67.0
38.7
0.90
0.46
1.984
0.252
0.147
267.3
4.6
0.0
39.8
HSS
14.4
1.69
62.7
36.6
0.90
0.44
2.030
0.245
0.145
253.4
4.5
119.8
40.1
NK
14.8
1.70
65.1
37.8
0.89
0.45
1.998
0.248
0.146
254.8
4.4
21.0
38.9
HK
15.2
1.73
67.0
38.4
0.91
0.46
1.980
0.256
0.148
281.3
4.9
21.2
60.3
o f traction on the skin caused by the dependence o f osseous and soft tissue [upper
extremities, scapulae, and breast tissue (Fouquet, et al., 1991)] in forward flexion. The
superoinferior skin distraction, expressed in terms o f strain, increased consistently from
cephalad to caudad along the spine, with the greatest mean distraction over the PSIS and
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strong correlations between angles generated from marker-based lines and lines drawn
based on radiographic landmarks, at least for the thoracic spine and thoracolumbar spines.
Placement o f the surface marker over landmarks at mid-lumbar and below resulted in
angles that were poorly correlated with those generated from x-rays, an observation made
by other authors (e.g. Refshauge, et al., 1994). This was thought to be due primarily to
the thickening o f the soft-tissues superficial to the vertebral column at the lumbar and
lumbosacral regions.
Significance
Why is it important to investigate the relation between spine curvature and loading
or between spine curvature and hamstring shortness? Many types of back pathologies are
common to both thoracic hyperkyphosis and hamstring shortness. Both hyperkyphosis
and hamstring shortness have been associated with changes o f normal kinematics and
spine load bearing, factors which have been shown to result in injury. Because o f the
epidemiologic and financial significance o f back injury, it would be beneficial to prevent
both hyperkyphosis and hamstring shortness.
How can the information discussed in this dissertation be o f benefit? The
limitations o f our study design do not enable us to show a causal relation. Only a
prospective, randomized clinical trial could corroborate what has been suggested in this
dissertation. Were that the case, we could give in to the temptation to state that our
training time table values (Table 9.1) could be used as approximate guidelines in the
design o f training programs, so that annual training hour minima for the prevention o f
hamstring shortness and training hour maxima for the prevention o f hyperkyphosis may be
178
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estimated. Astute coaching staff could use the training time information to help determine
how much training is appropriate to the sport, age group, and gender of their athletes. We
could likewise be tempted say that the anthropometric predictor variable values presented
in Chapter V m could be used in pre-participation screening exams as a predictor of who
might be at risk for the development of thoracic hyperkyphosis or hamstring shortness
related injury. Early identification would thus facilitate enable timely clinical intervention.
Besides adolescents, who else might benefit from the information provided by
these studies? Rehabilitation practitioners, physiatrists, manual medicine practitioners,
orthopaedists, athletic trainers, physical therapists, and others involved in the diagnosis
and treatment o f low-back pathology, as well as those associated with worksite wellness
and the burgeoning health and fitness industry, could benefit by the application of these
testing methods to permit early identification of those at risk. The health care professional
can assist in the training program design process, advising young athletes as to the amount
of training that is appropriate for healthy spine development. They can help to develop
preventative programs that might include stretching and strengthening protocols aimed at
normalizing posture and improving torso and pelvic mechanics. They could also include
the routine monitoring o f the patients progress. Our optical methods are well suited for
this, as they are relatively simple to use, inexpensive, and are non-invasive.
Limitations
Several limitations, or threats to internal validity, were inherent to these studies. In
general, limitations may be divided into several types or families (Wiersma, 1994).
179
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180
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Surface markers at the lumbar area are less reliable for other reasons, which
include soft tissue thickness (Bryant, et al., 1989; Willner, 1981). The thickness o f the
superficial tissues, especially at the lumbosacral area, can affect marker position relative to
the bony reference point. This is reflected by our finding o f a surface marker positioning
error at SI that was twice that o f the positioning error at T1 (Appendix H, Table H.7).
Because o f the potential for inaccuracy in measuring the lower spine (L3-S1) angles,
special care must be taken when placing surface markers at this region.
Testing limitations also posed a potential threat to internal validity. Our testing
protocols and apparatus were standardized, and there were no post-treatment evaluations.
However, testing was carried out at several different locations over the span of six years
by different testing crews. To minimize interoperator differences in technique, we tried to
have a veteran team member take our measurements (or at least, instruct as to
methodology).
Because there was no post-treatment evaluation, limitations such as maturation or
subject loss were not as important. Likewise, the selection-maturation interaction was
likely not as important as differential selection (discussed below). History, on the other
hand, may have been important. Over the course o f the data collection, it was likely that
testing may have been administered at different seasons and at different times o f the day.
Postural reactions to cold weather and diurnal adaptations may have affected thoracic
kyphosis values (e.g. Adams, et al., 1990; Broberg, 1993; Keller and Nathan, 1999).
Even though most sports and age groups demonstrated statistical differences in
training times and thoracic angles, large variance in the thoracic kyphosis angles was
181
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responsible for lack o f statistical significance for all sports and age groups. While the
testing methods used in the study agreed well with radiographic standards and between
themselves, there was still variance in the kyphosis angle means. For example, the
thoracic angle variance for the female subjects (n = 407, mean o f 36, 18) was 316,
while for male subjects (n = 1862; mean of 38, 15) was 228. Nissenen (1995)
identified large variance as physiologic.
Another inherent limitation was the question of the reliability of childrens selfreporting, since questionnaires were the sole source for training information. There were
large variances of annual training times reported by our subjects (Table 9.5). In part,
these large values likely reflect the different training regimens o f the various sports, as the
variance o f training times reported by wrestlers, for instance, is considerably less than
those of the subject sample as a whole.
Table 9.5. Annual Training Time Means, Standard Deviations, and Variance
for All Subjects and Wrestlers divided according to Age Group
1
j
1
1
n
8 to 10
11 to 13
14 to 18
133
438
1654
A ll S u b j e c t s
m ean
h rs.
140
228
267
\W
s.d .
v a ria n c e
174
216
183
30201
128
46695
133
164
33603
791
241
m ean
h rs.
re s tle rs
s.d .
v a ria n c e
46
97
136
2080
9328
48539
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Instead o f using interviews, we had validated our instrument by having subjects repeat
their written responses in a test/retest fashion.
There were several other factors that could bias the outcome o f these studies. One
such factor is obesity. Generally associated with a protruding abdomen, obesity has been
associated with an increase in the lordotic angle (e.g. Ridola, et al., 1994). It is likely that
the mechanism is one o f mechanical traction by the abdominal musculature and
interconnected soft tissues on the anterior aspect o f the lumbar spine. Since there is an
association between the lumbar lordosis angle and the thoracic kyphosis angle (Chapter
VT), it is possible that obesity is also related to thoracic hyperkyphosis. While not an
exclusionary characteristic in data selection, there were no morbidly obese subjects in our
pool. Furthermore, in most cases in our analyses, there were no significant differences o f
height or weight were noted.
The differential selection o f subjects was another threat to internal validity. Two
other interrelated factors that may bias the results are socioeconomic status and nutrition.
Malnutrition has been associated with thoracic hyperkyphosis (Kemp, et al., 1948), as has
vitamin deficiency (Simon, 1942; Ellender and Gazelakis, 1996; Appendix C). Most o f the
participants o f the summer sports camp were volunteers from the area's public schools.
The socioeconomic make-up was largely upper middle class, with most students reared in
an environment o f good nutrition and health care. Thus, in our sample, the likelihood o f
hyperkyphosis from nutritional causes was minimized.
Because o f the socioeconomic stratum represented by our convenience sample,
certain ethnic or racial groups may not have been represented. Such groups may have a
183
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and thoracic kyphosis or between hamstring shortness and thoracic kyphosis. Future
studies should prospective, controlled protocols, in which training regimens could be
designed, standardized, documented, and applied, and in which outcomes could be closely
observed. The results would have been more predictive, and interventions such as passive
hamstring stretching might or spine manipulation could have been made to enhance the
scope of the studies.
Finally, our the original method used to determine hamstring shortness did not
quantify the reach distance o f hamstring loose subjects. The use o f a raised platform
would have permitted this measurement. As a result, between-group significance would
have been enhanced and much more predictive information would have been obtained by
quantifying the reach distances o f those subjects, rather than assigning a qualitative value
to the variable.
Suggestions for Future Study
To offset our inherent design weaknesses of the study design, a prospective,
controlled study is needed in which quantifiable loading can be applied and outcomes can
be measured directly. A primate model whose results could be generalized to humans
should be used. In this study, repetitive tasks such as repetitive flexing, rowing,
pulling/dragging, or lifting could be used to load the spine. Indwelling intradiscal or
intravertebral load cells may be used to directly measure spine loading. Indirect
measurement may be done by using EMG to quantify paravertebral muscle contraction
force. Either x-ray or optical methods may be used to quantify spine angle, with the
anticipation that large amounts o f loading will cause greater hyperkyphosis, and small
185
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amounts will cause less. This type o f evaluation would confirm a causal relation between
the thoracic kyphosis angle and repetitive loading and support our observations.
The primate model may also be used to examine the relation between thoracic
kyphosis and hamstring shortness. Hamstring muscle length may be adjusted surgically to
test whether shortening causes an increase in thoracic spine angle or whether lengthening
causes a decrease. Human, clinical interventional studies may also be conducted to test
whether conservative treatment o f hamstring shortness results in spine angle reduction.
Longitudinal follow-up o f the large sample studys current subjects could be done
next. Evaluation of progress o f the thoracic angle relative to the amounts o f training
would be an important next step. Hyperkyphotics who train more than the amounts listed
for normokyphotics can have their training hours reduced, with the anticipation that their
kyphosis angles might reduce [using the animal model, Mente, et al. (1999) found that
curve deformities may be reversible].
Longitudinal studies may also be used to quantify the effectiveness of
hyperkyphosis treatment programs. For example, in non-surgical cases o f Scheuermanns
Juvenile Kyphosis, those having thoracic kyphosis angles ranging from about S0 to 65
(Sorensen, 1964; Bradford and Hensinger, 1985), spine-extension exercises are used with
or without bracing. Our training time guidelines may similarly be evaluated. The
prevalence of both hyperkyphosis and hamstring shortness could be compared between
those who adhere to our general recommendations and those who do not.
Predictive models may be developed from the dynamic evaluation o f the changes
in spine angles. It is likely that both the spine and pelvis motion o f the hamstring-normal
186
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and hamstring-short groups move differently as subjects bend from the upright to frilly
flexed postures. The use o f time-course data from this type o f study could define the
influence o f hamstring shortness on spine angle rates-of-change.
Additional studies may help to verify the histologic etiology o f hyperkyphosis and
hamstring shortness. One study could involve the use o f hamstring muscle biopsies
obtained from both hamstring-normal and hamstring-short individuals. These samples
would be used to examine sarcomere ultrastructure and fibrous connective tissue content
and would be compared to confirm the ultrastructural characteristics o f short hamstring
muscles. Another study could use Magnetic Resonance Imaging (MRI) to confirm
whether the anterior longitudinal spine ligament is one of the possible causes o f
hyperkyphosis. It has been anecdotally noted that thickening and bowstringing o f this
ligament is a gross anatomical finding o f Scheuermanns Disease (Bradford, 1985). If
spine ligament thickening is present in most cases o f documented Scheuermanns Juvenile
Kyphosis, the non-roentgenographic, MRI method may be used to predict who might be
at risk for the development o f hyperkyphosis.
The current testing protocols may be improved in several ways. Statistical
significance would be enhanced if it were possible to reduce the variance o f the outcome
variable, thoracic kyphosis angle. Perhaps this may be achieved by using additional
methods o f thoracic angle measurement (as goniometry), or by dividing the subjects into
more limited age and anthropometry groups. Significance may also be enhanced by
subdividing hyperkyphotic subjects into two thoracic curve categorieseither postural or
permanent, because it is likely that the relation between spine curve and hamstring
187
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shortness is different between the two groups. Additional methods o f evaluation using
tests as the Prone Extension Test (Appendix G) may help to differentiate whether subjects
have a permanent or temporary (postural) hyperkyphosisone that disappears with
extension and changes with sagittal plane flexion.
The hamstring shortness protocols used in these studies may be improved by using
certain technical improvements. These include the use o f an elevated platform to more
accurately quantify the finger-to-floor reach distance. The reach distance o f hamstringloose subjects, those able to touch the floor with fingertips or even palms, would be more
accurately determined if these subjects stood on a surface that extended above the floor.
This would enhance the data base and permit more inferences to be drawn from the
hamstring shortness/spine angle relation.
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CHAPTER X
CONCLUSION
Comparison between micrographs o f immature vertebral endplates from animals
whose vertebrae were deformed in vivo by the application o f asymmetric, compressive
loading and micrographs o f Scheuermanns Disease patients demonstrate similar patterns
o f chondrocyte column disruption (Chapter II). This observation implies a causal link
between asymmetric, compressive spine loading and vertebral deformity in skeletallyimmature humans.
When the relation between thoracic kyphosis and spine loading (modeled by the
amount o f time 8-to-18 year-old students spent in athletic training) was examined in a
cross-sectional study (Chapters HI and IV), the following conclusions were reached:
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Next, the relation between thoracic kyphosis and hamstring shortness was
examined (Chapters V, VI, and VII) and the following conclusions were drawn:
190
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Finally, the relation between thoracic kyphosis and anthropometry was examined
(Chapter VHI) and the following conclusions drawn:
In sum, these results are consistent with the hypothesis that thoracic hyperkyphosis
is the result o f repetitive loading of the spine. Likewise, the observations relating to
hamstring shortness, pelvic tilt, lumbar lordosis, and thoracic kyphosis corroborate the
findings o f Lambrinudi (1934).
191
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APPENDICES
192
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20-30% (frequency)
68% (oarsmen)
30.3% (females)
56.3% (males)
38%
12%
9%
Nissinen (1995)
12% (females)
15.3% (males)
Sorensen (1964)
38%
193
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Scheuermann (1920):
Mau (1929)
Schmorl (1930)
Hellstadius (1947)
Ferguson (1949)
Butler (1955)
from
R oaf(1960)
Stephen (1983)
194
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NON-POSTURAL (fixed)
I. CO N G EN ITAL (absence o f vertebral bodies; anterior failure o f segmentation)
U. PATH O LO G IC
A. Paralytic
B. Myelomeningocele
C. Inflammatory (e.g. tuberculosis spondylitis)
D. Post-irradiation and destructive lesions
E. Metabolic (e.g. rickets, osteogenesis imperfecta, idiopathic juvenile osteoporosis)
F. Developmental [e.g. bone dyplasias: achondroplasia, pseudoachondroplasia;
diastrophic and metatrophic dwarfism; spondyloepiphyseal dysplasia congenita and tarda
M uhlbach, et al. (1970); Gardemin and Herbst (1966)]
J. Nutritional [e.g. fluoride (Bradford and Hensinger, 1985), malnutrition (Kemp, et al.,
1948), rickets, or vitamin deficiency, especially that o f vitamin A (Simon, 1942), vitamin
C (Ellender and Gazelakis, 1996]
III. A C Q U IRED
A. Scheuermann's (vertebral wedging, end-plate irregularity, disc narrowing)
B. Post-traumatic (e.g. serial compression fractures, fracture/dislocations)
C. Post-surgical (e.g. Post-laminectomy)
195
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Appendix D (cond)
C. By month 4, the posterior aspect has fused, with processes growing from these
arch components.
1. Mesodermal tissue bar or hypochordal brace remains in C 1 to form arch
and dens o f C2.
2. Vestigial notochord evolves into nucleus puiposus.
197
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SPORT CAMP:
Bl&THDATE:.
R/L HAND:_
SEX:
HEIGHT
WEIGHT:.
CT-FLOOR
SHOULDER WIDTH: _
GT-S1:
SHOULDER DEPTH:.
S l-T l:.
U WIDTH:.
Sl-TIO:.
U DEPTH:.
S1-L3:
SUDE *
TEST DATE:_
NAME:
ASM LEHCTH:
TESTED BY US LAST SUMMER? V / H
r o f a school caaa?
a club eaaa?
ochor?
ooc of aaaaon
Y/ H
Y/ H
198
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UV2XY reads the position o f the d2 (top-left) LED from the digitized subject image file and from the CALFILE flic
generated by VERAI from the digitized calibration image file. It uses the difference in the LED's position in these
files to shift the coordinate system for the subject image. It ignores the position of the remaining 3 LEDs, under the
assumption that all o f the subject files corresponding to a particular calibration file will be digitized at the same
magnification and rotationa plausible assumption.
This means that if we merely make our scanning/digitizing system (i.e. KPROC and KPOST) generate an output file
whose format is identical to the flies generated by the old digitizer, we cannot get meaningful data from images that
lack a d2 (top-left) LED. On the other hand, if we keep track of the location o f all 4 LEDs in the calibration image
(by having KCAL write an extra file) and use this information in the KPOST program, we can accomplish the
following objectives:
Verification o f consistent image scaling or correction for inconsistent scaling (by measuring the distance
between two o f the LEDs on the calibration image and on the subject image)
Correction for rotation of the image by measuring the angle between the u (or v) axis and a line connecting
two o f the LEDs (may not be important).
Reconstruction o f the position o f the d2 (top-left) LED if it is missing from the subject image. If we have
two other LEDs in the subject image, and all four LEDs in the calibration image, we can correct for both
shifting and scaling factors and figure out where the d2 LED would have been in the subject image.
Move a calibration file (e.g. 6II0CLI V.BMP) and its associated subject files (e.g. 6llxxxVl.BM P) to a directory
for batch processing:
(in a DOS window, starting from the directory containing the image files)
MD 611BATCR
MOVE 6 1 10C L lV .b m p 611BATCH
MOVE 6 1 1 ? ? ? V 1 .b m p 611BATCH
CD 611BATCH
DIR * .BMP / - P > BATCH.DIR
199
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Notes:
a. May use copy command to avoid losing original data that may otherwise occur with program testing.
b. Can evoke f:\salvage to undelete any files.
c. May also copy fi\* batch and f:\programs to f:\tmp
d. At this point, must copy programsW* to the batchfile, in order for KBATCH command to work.
2.
KBATCH
when prompted for the batch directory file, enter BATCH. DIR
when prompted for the desired action, choose KPROC (image processing and feature extraction)
Notes:
a. May cd fA*batch
b. May run KPRO <filename> for a step-wise display o f the various outputs o f the program, thus being able to
visualize the data file without horizontal lines, vertical lines, and spurious pixels, as well as seeing it in its final form
(and being able to print).
c. Could use a pause during this sequence, enabling the printing o f each step.
KPROC
3.
Input: *.bmp
O utput: *.mat, with same names, containing features extracted from the images.
when prompted for the calibration file, enter it (e.g. 6110C L1V )
Notes:
a. Old calfiles have been saved by typing copy calfile veal*.*'.
b. In KCAL, you use the mouse to select the LEDs and the 9 reference positions A-l.
KCAL
4.
Notes:
a. Enter calibration filename
b. May KPOST <filename>
c. Could use Manual Mode for selecting LEDs which the program has missed
d. Could use an Escape command, to abort and restart (or backup).
e. In KPOST, you use the mouse to do the following:
add or remove segments or pixels from the spine midline
-interpolate points missing from the spine midline
-select landmarks
-select LEDs
200
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KPOST
Input: *.kps from calibration files and, from subject files, *.mai (created by KPROC)
Output: *uv, with same names as *.mat's (for UV2XY).
5. Run VERAI on the file generated by KCAL. (Note: VERAI also needs a file called CALPTS.)
(in a DOS window)
VERAI < 6 1 1 0 C L 1 V .v e r
VERAI
6.
Notes:
a. It is likely that KBATCH can be made to also run VERAI and UV2XY (and any other DOS programs needed
finish the processing) so that we wont need to write additional batch files for this purpose.
b. Old version called by *uv2xy *.0lp > *.lp
UV2XY
Input: CALFILE and data digitized from subject slides (*.uv from KPOST)
Output: A series of files ending in .xy which will be used for the remaining programs.
7. Run POLY.EXE (a quadratic polynomial smoothing program for UV2XY output)
(in old manual version:)
POLY < * .lp > $*.lp
POLY
8.
Run ANGLE.EXE (calculates kyphosis and lordosis angles, formatting them as:)
Output: #*.*
201
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test
LBP
No LBP
56 (10)
65 (15)
63(21)
61(6)
77(7)
79(7)
According to the methods critics, the confounding problem is pelvic rotation. Such motion
should be controlled, as, according to Bohannon, et al. (1985), it may contaminate the results of the test
by exaggerating hip motion by as much as 11 (Pitkin and Pheasant, 1936) when compared to methods as
the over the Popliteal Angle Test. The most common means to secure the pelvis is to use straps, a method
evaluated by Gajdosik, et al. (1993). First, with subjects supine, pelves and opposite thighs were
stabilized, and SLR performed. Next, again with subjects supine, their low backs were actively flattened
and opposite thighs slightly flexed, being on pillows, which induced a 10 pelvic tilt. Although others
have suggested that short hip flexors (ascertained by the Thomas test) would limit posterior pelvis
202
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rotation, hamstring tightness using the Straight Leg Raise Test with both approaches to pelvis control
yielded essentially the same results. Other pelvis motion control methods include having the subject
actively extend the knee during the leg lift. This, according to Bohannon (1982), would essentially
eliminate pelvis, sacroiliac joint and low back motion, as subjects dont force their legs past the point of
initial mild resistance.
In addition to controlling the pelvis, Gajdosik, et al. (1985). suggest monitoring the position of
both foot and ankle during the test. When the SLR test is used to assess hamstring muscle tightness
(referred to as a passive muscle stretch test by Halbertsma and Goeken, 1994), the ankle should be
relaxed in plantarflexion. For the purpose o f diagnosing sciatica and nerve root irritation, the ankle
should be held in dorsiflexion. This augments tension on the nerve roots and is Lasegues test for
neurogenic pathology ( Halbertsma and Goeken, 1994). In the SLR test, dorsiflexion of the foot limited
the SLR range by about 7, presumably from soft tissue tension across leg. O f course, as with most of
the tests for hamstring tightness, the SLR should be used judiciously with subjects having a history of
neurologic completes or disorders of the thigh, pelvis, lumbar spine, hip, and sacroiliac joints (Bohannon,
et al., 1985).
There is some disagreement whether a pre-test warm-up, or prestretch, should by used prior to
applying the SLR test. Some, as Halbertsma and Goeken (1994), feel that there should be no pre
stretching, and that the initial test should be used. In theory, this disallows a training effect and prevents
lengthening of the connective tissue elastic components. Others, as Gajdosik, et al. (1994), believing that
the stretched tissue permits a more realistic evaluation, and allow several warm-ups, using the 6th stretch
and the test and the 7th as a retest.
The accuracy of the method differs amongst authors. Gleim, et al. (1991) advised that the use of
goniometry to determine the SLR angle carries a +/-100 error. Others, as deVries and Housch (1994),
have suggested a coefficient of more than 0.90 when using more advanced goniometers as the Leighton
flexometer. Kendall and Kendall (1949) suggested that there could be apparent hamstring tightness
when, in actuality, the hip flexors were short, especially on the side of the thigh that is pushed to table. In
these instances, the lumbar spine is hyperextended and the pelvis tilted anteriorly, so that when the
measured side appeared artificially tightin actuality, it was lengthened or stretched. Similar
findings can result from lower erector spinae tightness and hip flexor tightness, where the apparent
range of hip flexion is augmented by tilting the pelvis more posteriorly after maximum hip flexion is
achieved (at 80XTable G.2).
Table G.2. Range of Motion Parameters for the Three Hamstring Length Categories by Author
and Method (SLR and Hip Flexion Angles; after Gajdosik, et al., 1994)
short
medium
long
SLRtdeq.)
Gajdosik, et al.
Stokes and Abery
Hip Flexion(deq.)
Gajdosik, et al.
(1994)
(1980)
(1994)
<65
65-85
>85
<40
40-70
>70
59.0
68.7
76.7
To correct for these technical problems, the supported thigh could be allowed
to flex enough to permit flattening of the lumbar spine on the table's surface.
203
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Figure G .l. Straight Leg Raising Test (adapted from Bohannon, et al., 1985)
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Gajdosik, et al.
(1994)
SLR <65
SLR = to or 65 to 85
SLR >85
Short:
Medium:
Long:
Gleim, et al.
(1990)
tight = < 6 0
normal = 6 0 -9 0
loose = >90
56 +/- 10 (LBP)
Jonhagen, et al.
(1994)
74.1 (uninjured R)
67.2 (injured R)
Normal approx. 80
Wang, et al.
(1993)
KEY:
M = Male
F = Female
LBP = Low Back Pain
d = dominant
R = Runners
nd = non-dominant
NR = Non-Runners
205
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206
with permission of the copyright owner. Further reproduction prohibited without permission.
< 30
> 30 (Bandy and Irion, 1994)
> 40 (Delp, et al., 1996)
207
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208
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Table G.5. Category Definitions: Standing Reach Test (after Gleim, et al., 1990)
Normal
Loose
T ight
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210
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I. Traditional
A. Subject seated on floor, legs extended and spread approximately 1012 apart
1. Scale (standard yardstick) placed in midline on box between
legs at fixed distance (may be performed with or without box)
2. With box, starting point requires placement o f feet against box,
relative to 12 inch point (zero point)
B. Subject flexes trunk, reaching forward, holding final position for 2
seconds, and touches scale with fingertips
C. Reading taken along scale, which is zeroed at heel line
1. Criterion score as 12 inches, +/- distance reached (Hoeger and
Hopkins, 1992)
Fixed
Measurement Scale
Figure G.4. Sit and Reach Test (Subject begins in upright position)
(adapted from Hoeger and Hopkins, 1992)
211
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II. Modified
A. Subject positioned with head, back, and hips against wall, with feet
12-18 apart, against box (30.S cm high), upon which is sliding
measurement scale with 0-70 cm range. The box elevates the scale
between the subjects legs.
B. Initial reach: upper body against wall, hands in front with palms
touching, then hand over hand reach over scale, with scapulae abducting
C. Scale moved to zero at fingertips (finger-to-box distance)
establishes zero based upon proportional differences in limb lengths
D. Subject flexes trunk, with final reading as forward-bending reach and
final finger position along scale marked
1. Difference between two values gives reach
E. Negates bias of disproportionate arm and leg length (Hoeger and
Hopkins, 1992).
Sliding
Measurement Scale
Figure G.5. Modified Sit and Reach Test (from Hoeger and Hopkins, 1992)
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Hip Flexion
Perhaps this test could be classified as a variation o f the Standing-Flexion method, as it involves
trunk flexion in the sagittal plane, utilizing its gravity-related benefits. Rather than measuring the
distance from the fingertips to the floor, the angle of hip flexion is determined. The definition of hip
flexion angle varies among authors, as it is measured by several approaches. In the broad sense, it is the
pelvifemoral anglethe angle between the long axis o f the femur and the pelvis. The femur is readily
labeled by skin markers positioned at proximal (trochanterion) and distal (lateral femoral condyle)
anatomic landmarks. The demarcation o f the pelvis is less standardized. Clayson, et al., in their
radiographic study of 1962, used the method of Mundale and associates (1956) and compared the femoral
line to the longitudinal axis of the pelvis. This is delineated by a perpendicular from the innominate
transverse axis (a line between the ASIS and the posterior-superior iliac spine, PSIS) running through the
acetabulum (Figure G.6). The ASIS and PSIS line has since been used by itself to represent the pelvis to
track pelvic position and tilt (Bohannon, et al., 1985; Gajdosik, et al., 1994).
ASIS/PSIS LINE
P E L V I F E M O R A L L IN E
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reproducibility o f+/- 2, and revealed that, in an unselected group of 35 adults, 10% had loose hamstrings
and 10% had tight hams, as defined by standards noted below (Table G.6).
Gajdosik, et al. (1994) used an SLR test to screen and select subjects with tight hamstrings for
inclusion in a hip flexion angle experiment. Using a ASIS/PSIS line to track pelvis motion, surface
markers were placed along the femoral shank, while platform perpendiculars were positioned at T 12/Ll
and C7/T1. Thoracic, lumbar and pelvis angles were then defined according to surface landmarks and
marker positions (method similar to Figure G.7). The lumbar angle was defined relative to pelvis and the
sacrum not considered, largely because of the small 1 to 2 motion found at the sacroiliac joint. Their
results included the identification of a significant difference in the toe-touching range of motion between
the short and medium hamstring groups and the short and long hams groups. They also noted a
significant difference in thoracic angle and all flexion range of motion measurements between short and
long hamstrings groups.
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Table G.6. Typical Ranges - Hip Flexion Angle (after Stokes and Abery, 1980)
Loose =
Normal
Tight =
>70
= 40-70
<40'
Figure G.7. Hip Flexion Angle (adapted from Stokes and Abery, 1980)
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Conclusions
It is difficult to declare which method for measuring hamstring muscle tightness is the best and
which is inadequate. All have been shown to have high coefficients of reliability (Table A3.4.7). Perhaps
the best test depends upon its application and subject group. For example, youngsters who might be afraid
of standing on a box and bending forward as in a Finger-to-Floor Test might be better suited for a
Modified Sit and Reach Test. Investigators looking for a simpler method might select a Straight Leg
Raising Test over those which require the extensive use of skin markers and photographic methods. In
contrast, flexion-contractured subjects may require the application of the Passive Popliteal Angle Test,
rather than an active test as the Sitting or Standing Reach.
Table G.7. Comparison of the Reliability Coefficients of the Various Methods
Author
Test
Coefficient
AKE
0.99
PKE
0.98
Sit-and-Reach (SAR)
0.98
Modified SAR
0.94
Standing-Reach
0.97
(Fleishman, 1964)
Hip Flexion
0.93-0.98
Kuntzleman, et al. (1993), referred to two tests as gold-standard teststhe Leighton Flexometer
and SLR/Goniometer (AAOS, 1966). The group stated that the former is most helpful to determine hip
and lower back flexibility. It is performed during the Kraus-Weber Standing-FIexion Test, using a
Leighton pendulum goniometer applied with straps to the chest under the axillae, while the subject rests
his hands on his head. Following that, the arms are lifted above the head and the instrument is zeroed.
Finally, the subject bends forward and maintains a maximum flexion position for three seconds, at which
point, both fingertip distance and Flexometer readings are taken (Broer and Galles, 1958).
Including operator involvement and goniometric measurement, the passive tests, as PKE and
SLR, require extensive hands-on involvement, as well as a treatment table. The AKE and Sit-andReach Test require a table and floor space, respectively, as well as subject effort. In and o f itself, the
Standing-Reach Test needs no operator contact and only minimal eflort, as gravity assists the subject.
The Hip Flexion Angle version o f this test needs hands-on contact only for marker application, but
requires perhaps the most equipment and processing. However, this last method yields the most
information about trunk, pelvis, and pelvifemoral motion.
It is probable that those who combine tests as Gleim, et al. (1990), who used both SLR and
Standing-FIexion in a screening battery, or Gajdosik, et al. (1994), utilizing both SLR and Hip Flexion
Angle, may get optimal results. Combining Standing-Reach and Hip Flexion Angle might yield a means
for quantifying the former in terms o f the latter. If appropriate markers are applied, additional data about
pelvisacral movement can be taken, increasing the base o f information.
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Appendix G (cond.)
Spine Curvature Methods
Introduction
As is the case with hamstring tightness, there are several approaches to quantifying spinal
curvature and range of motion. Like many measurement methods, the one selected depends upon the
application and available resources. The more popular techniques, some which have been used
interchangeably with hamstring assessment, will be summarized in this chapter.
General Considerations
Chaffin and Andersson (1991) reviewed several methods for acquiring joint range of motion
information, compiling several 'universal considerations for selecting an appropriate technique. In
developing their list, they had compared several methods, including goniometers, flexometers, and spatial
imaging. The general points essential in the selection of the measurement approach are reviewed below
(Table G.8). One important consideration not listed below is the system resolution.
Table G.8. General Measuring System Considerations (after Chaffin and Andersson, 1991)
1.
2.
3.
4.
5.
6.
Radiographic
Perhaps the gold standard for measuring spinal curvature has been by the use of
roentgenographic methods, primarily those of Cobb (1948) or Ferguson (1949). The former measures the
angle between two tangents to the vertebral endpiates at either end o f the spine segment of interest,
whereas the method o f Ferguson measures the angle between lines drawn at the centroids of three
vertebral bodies: two at the curves extremes and one at the curves apex.
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The Schdber test compares the distance between two points on the skin surface over the low back
in two postures: standing and flexed in the sagittal plane. The initial point is at the SI landmark, defined
as being in the midline at the level of the sacroiliac dimples. Points are marked on the skin 10 cm
cephalad and 5 cm caudad to S I. The interpoint distance is then measured and IS subtracted for the final
value. Macrae and Wright (1969) described a variation of this test, which included the vertical
measurement to a surface landmark point over C7. Subjects perform a seated flexion test, with the
distances between points measured in the same manner as in the Schdber test, but with the additional
measurement of the distance from the most caudad point to the cervical spine point.
Finally, Loebls pendulum goniometer (inclinometer) is a single goniometric method (Figure
G.8). The technique traditionally uses the T12 spinous process as the landmark, with the subject first in
an erect, then flexed seated position.
Luttgens, et al. (1992) suggested that one of the limitations o f the goniometric methods lies in the
instruments positioning. Accuracy suffers if the instrument is not placed properly over the joint axis o f
rotation, or if bony landmarks are poorly defined (as in the case o f excessive soft tissue). They suggested
that pendulum goniometers, including the Leighton (Leighton, 1955) or Elgon (Adrian, 1968)
instruments, might improve upon this weakness. Gleim, et al. (1991) felt that there was generally a +/10 error with goniometric measurements. Agreeing with Dopf, et al. (1994), they preferred
the modified Schdber test for trunk flexion determination, claiming that Loebl test required more time,
training, and calculations than either of the former two methods. Troup, et al. (1968), commented that
use of Loebls method could better overcome the pelvis movement that contaminates and overestimate true
torso motion. However, even these methods were subject to such error because they, too, encompassed
sacroiliac rotation. More contemporary groups, as Gajdosik, et al. (1994), include sacroiliac motion as
part o f the lumbar spine range, because the motion is so slight and otherwise difficult to control for.
Ohlen, et al. (1989) compared the techniques of Loebls inclinometer to Debrunners
kyphometer. Although more expensive than a goniometer, the measurement time proved to be less
(readings in I minute, as compared to 5 minutes using Loebls inclinometer) and exhibited good
repeatability (Dopf et al., 1994). In addition, determining sagittal mobility was reported to be easier than
with a pantograph (Willner, 1983) and gave good correlations with the Myrin goniometer (Figure G.9).
218
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D isadvanCages:
1.
2.
3.
4.
219
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Dopf, et al. (1994) critiqued most of the standard methods and experimentally compared a
commercialiy-produce computerized electrogoniometer with both Schdber and the more complex double
inclinometer methods. For the latter, the angle of interest is the difference of angle readings from two
goniometers placed at different locations along the spine. In addition to quantifying flexion, the authors
suggested that both the inclinometer and electrogoniometer could be used for measuring extension, lateral
flexion, as well as rotation. The good correlation between goniometry, especially, double inclinometer
techniques, and radiographs have led clinical groups as the American Academy of Orthopedic Surgeons
and American Medical Association to recommend their use in spine function evaluation.
3.
4.
5.
Photogram m etric
1.
2.
3.
4.
5.
Disadvantages:
1.
2.
3.
4.
Videographic
( t e l e v i s i o n and o p to e le c tr o n ic )
220
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Applications o f these techniques include the comparison of the angles between lines extended
from skin-mounted platform markers placed along the spine in the standing position (Flint, 1963; Troup,
et al., 1968). When ascertaining spine motion or curvature, these markers are frequently positioned at the
ends o f each thoracic and lumbar regions. Such locations include T l, T 11/12, the commonest site o f the
thoracolumbar mortice joint or upper functional limit of the lumbar region (Davis, 19SS), LI, and S2.
Dopf, et al. (1994), in reviewing the use of photogrammetric methods, felt that there was marker
placement variability. In contrast, Drerup and Hierholzer (198S) cited a coefficient of reliability o f 0.87
using the moire fringe technique, at least in the thoracic region.
Summary
Examination methods to quantify trunk motion include the popular Schdber, Debrunner, and
double inclinometer techniques, as well as more sophisticated optoelectronic methods. O f the first three,
the double inclinometer appears to have the most applicability in the clinical environment, where a
reliable estimate in required in a fairly rapid and cost-effective manner. The automated methods,
although requiring additional training and greater financial investment, can provide both static and
dynamic data in a non-contact, non-roentgenographic manner. Data processing for these techniques may
be automated considerably because of their direct computer interface. The lack of operator intervention in
taking the actual measurements obviates one important source o f error, thus enhancing the methods
attractiveness. Perhaps the best technique is a combination o f methods, using a simple screening
approach and reserving more expensive applications for more exacting measurement.
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Appendix H
THE DEVELOPMENT OF A PLATFORM MARKER
FOR USE IN DETERMINING SPINE ANGLES
Introduction
What is necessary to determine spine angles in a non-radiographic, non-contact
fashion? Two different methods o f optic metrology have been used in the studies
described in the preceding chapters. Both methods required the use o f surface markers
that were affixed to the skin over the midline o f subjects spine. The photogrammetric
method o f Wojtys, et al. (2000) utilized flat, adhesive markers placed on the skins
surface. These markers were appropriate for this method, because the cameras
photographic axis was perpendicular to the plane of the subjects backs, positioning that
was somewhat dependent upon the test platform (Chapter m ). In contrast, the
optoelectronic method described in Chapter V required that the cameras photographic
axis to be parallel to the plane o f our subjects back. This arrangement necessitated the
use o f three-dimensional, spine surface markers.
Pilot studies revealed that commercially available platform markers had two basic
design problems. First, the markers base had a tendency to dislodge when the skin was
distracted during torso movement. In addition, the protrusion of vertebral spinous
processes during torso flexion changed the orientation o f the markers vertical arm relative
to the skins surface. This positional change caused a loss o f marker perpendicularity
relative to the underlying vertebral bodies, which resulted in inaccurate spine angle
measurements.
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Background
There are primarily two approaches used to determine spine segment angles:
contact and non-contact. The contact approach requires the application o f goniometric
measuring devices directly to the skin over palpated landmarks. Some o f the more
popular contact methods and goniometric devices are reviewed in Appendix G.
The non-contact approach may be subdivided into two basic categories:
radiographic and non-radiographic. The radiographic (or roentgenographic) approach
utilizes x-ray exposure o f the subject to identify certain vertebral landmarks. The angles
between the these landmarks are then generally determined by using either the Cobb or,
less commonly, the Ferguson method. Both methods measure the angle between two lines
that demarcate the spine segment o f interest. In the Cobb technique (1948) (Figure 1.3,
page 6), the most cephalad vertebra of the spine segment of interest is demarcated by a
line tangent to its superior endplate. The most caudad vertebra o f the same spine segment
is similarly marked, only by a tangent to its inferior endplate. The angle between the two
tangents at their intersection represents the spine segment angle.
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Fergusons method (1949) also determines a spine segment angle by measuring the
angle between two intersecting lines. In this case, centroids o f three vertebral bodies are
used as landmark points, rather than two vertebral endplates. The vertebral bodies that
are selected are at either end (cephalad and caudad) and at the apex o f the spine segment
o f interest (Figure H .l). Centroids are then determined for these vertebrae, and two lines
are drawn, one from the cephalad vertebra to the apical vertebra and one from the caudad
vertebra to the apical vertebra. As in the Cobb method, the angle between the intersection
o f two lines represents the spine segment angle.
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modification o f the Ferguson method was used in our photogrammetric method (Chapter
III) to measure the angles o f intersection between lines tangent to the skins surface that
originated at surface landmarks at either end o f the spine segment o f interest. A
modification o f the Cobb technique was utilized in our optoelectronic method (Chapter V)
to measure the angles o f intersection between lines that originated from perpendiculars to
the skin surface at either end o f the spine segment o f interest. In both instances, the angle
between two intersecting lines gave the spine segment angle.
Do skin surface markers accurately reflect the position of bony landmarks? The
use of these types o f markers for kinematic studies has been a concern because o f the
potential for inaccuracy in representing both skeletal position and motion. Authors as
Thurston and Harris (1983) or Stokes (1977) have shown that the error between skin
mounted targets and true skeletal motion ranges from 8 to 10%. Troup, et al. (1968)
obtained correlation coefficients o f 0.91 between surface marker and x-ray spine angles
for erect and fully flexed postures for 14 observations, with no significant differences
between the methods by Students t-test at the p< 0.001 level. Using platform markers
perpendicular to the spine at the midline, they nonetheless made the observations that
displacements o f the skin in the long axis o f the spine ... proved to be considerable, and
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that movement o f the skin was a particular source o f errors, especially in the lumbar
region.
Surface markers at the lumbar area are less reliable for other reasons, which
include soft tissue thickness (Willner, 1981; Bryant, et al., 1989). Special care must be
taken when placing surface markers at this region, as the thickness of the superficial
tissues can affect marker position relative to the bony reference point. O f course, such a
feature is less important if radiographic methods are used to identify spine landmarks.
Part One:
The Distraction of the Skin at Select Landmark Points over the Spine Midline
during Sagittal Plane Flexion from Upright to Fully Flexed Postures
The accuracy o f spine angle measurements that are based on skin surface markers
depends on the markers ability to withstand skin distraction. Quantification o f such
movement is therefore essential to surface marker design. Because such information is
lacking in the literature, a small, experimental study was performed to answer two
questions: first, how much does the skin distract over the midline o f the spine at select
landmarks and second, are there significant differences in the amount o f distraction
between landmarks? The answers to these questions provided information that would be
incorporated into the design of a unique surface marker for use in our optoelectronic study
(Chapter V). In that study, optoelectronic methods would be used to determine the spine
angles for hamstring normal (those able to touch the ground in sagittal plane flexion) and
hamstring tight (those unable to touch the ground in sagittal plane flexion) subjects
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positioned in both upright and fully flexed postures. In keeping with the hamstring
category comparison, one primary null hypotheses was advanced:
It was expected that hamstring tight subjects would have less skin distraction than
hamstring normals, reflecting a reduced flexion range o f motion.
The secondary null hypothesis was similar to those o f previous chapters:
Methods
Twenty-one volunteers (nine male and twelve female) served as the subject
population for this Human Use Committee-approved study. Our subjects had no gross
kyphoscolioses, had a mean age o f 26.9 ( 10.5) years, a mean height o f 1.73 ( 0.09)
meters, and a mean weight o f 67.68 ( 9.71) kilograms. Approximately one-half exhibited
hamstring tightness (shortness) and were unable to touch the floor with their fingertips in
full sagittal plane flexion (Finger-to-Floor Reach Test, Appendix G).
Skin distraction was measured at five landmark points on the bared backs o f each
subject. These points were the first and the tenth thoracic vertebrae (T l, T10), the third
lumbar vertebra (L3), the first sacral segment (SI), and the posterior-superior iliac spine
(PSIS). The skin over these landmark points was then marked using non-toxic, watersoluble ink. A pattern o f four dots, one at each comer o f a balsa wood template (Figure
227
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H.2), was placed at each landmark point. The template consisted o f two, rectangular
pieces of wood fastened together at right angles.
Distraction o f the skin over the each landmark site was then determined. Initial
measurements were taken between superoinferior and mediolateral pairs of template
points at all five landmarks with the subjects in the upright posture. Each participant was
then asked to fully flex in the sagittal plane (bend forward) and the measurements between
the same pairs o f template points were repeated. The differences between the initial and
final measurements at all landmark points for each subject were then calculated and
expressed as percent strain, with mean strains calculated for both hamstring normal and
hamstring tight groups. Repetition o f the measurements produced an error which, with
the exception of two outliers, ranged from an underestimation o f 1.5 mm. to an
overestimation o f the initial value by 1.5 mm., with a mean underestimation o f 0.07 mm.
This measurement error, similar to that found by van Weeren and Bameveld (1986), was
propagated as a maximum strain error o f approximately 1.7%.
228
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Superoinferior
Landmark m ean (mm.) s.d.
T1
-3.7
13.1
T10
10.7
10.2
7.1
L3
41.7
S1
49.7
9.7
PSIS
53.9
11.8
M ediolaterai
m ean (mm.)
s.d.
0.0
6.1
10.2
20.5
6.1
6.5
6.3
1.6
4.9
0.1
The mean percent strain differences between adjacent landmarks were then
calculated (Table H.2). The greatest change in superoinferior strain occurred between the
T10 and L3 levels, more than twice that of the T1-T10 difference. The greatest difference
in mediolaterai strain was between T1 and T10, almost twice that o f T10-L3. These
findings were exhibited by both gender groups (Figures H.3 and H.4).
Superoinferior
14.4
31
8
4.2
Mediolaterai
20.5
-14.4
-4.5
-1.5
229
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601
11 MALES
a
fe m a le s
-20 J
-------------------------------------------------------------------------------------------------------T10
L3
si
psis
Landmarks
9
a
MALES
FEMALES
-10 J --------------------------------------------------------------------------------------------------------------------------
XI
T10
L3
SI
PSIS
Landmarks
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T-tests were then used to compare the means of the skin distraction percent strains
at the various landmarks between hamstring normal and hamstring tight subjects. There
were no significant differences o f percent strains between the two groups at the a=0.05
significance level. However, after dividing the subjects according to gender, t-tests
revealed a significant difference o f superoinferior percent strain at the L3 landmark
between hamstring groups for males (p=0.049) and a difference that approached
significance (p=0.080) o f the mediolaterai percent strain at the L3 landmark between
hamstring groups for females (Table H.3). Interestingly, this landmark had a moderately
strong, inverse correlation (r = -0.720) between mediolaterai percent strain and reach
distance in hamstring tight subjects. These findings led to the acceptance of the first null
hypothesis.
Females
mediolaterai
n
Males
superoinferior
n
p-value
7.62
7
5.42
2.49
5
2.51
0.080
46.33
3
4.61
35.12
3
5.18
0.049
The data were then examined for significant differences of skin distraction by age
and between genders. Subjects were divided into two ages groupunder 30 years old and
over 30 years old (Table H.4). Contrary to what was expected, there were no significant
differences o f percent strains between age groups. Neither were there significant
231
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differences o f percent strains between genders, even though males were significantly taller
and heavier than females (Table H.5). These findings led to the acceptance o f the second
null hypothesis.
< 30 yrs.
> 30 yrs.
s.d.
2.82
19.92
m ean yrs.
23.72
46.00
n
18
3
Table H.S. Mean Weight and Height for Females and Males
(s.d. = standard deviation) Males were significantly larger than females.
females
males
p-value
W eight (kg.)
m ean
s.d.
4.70
61.51
75.91
8.50
0.000
H eight (m.)
m ean
s.d.
1.67
0.06
1.81
0.06
0.000
n
12
9
232
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forward flexion. Tissue dependence was likely also the explanation o f the large difference
in mediolaterai strain between T1 and T10.
How did the differences o f percent strain from landmark to landmark compare?
There was a pronounced difference in mean superoinferior strain between the TIO and L3
landmarks. This likely reflected the greater flexion range o f motion that the lumbar spine
has as compared to the thoracic spine, which is relatively fixed due to the ribs. The greater
flexion range o f motion may also be the explanation o f the moderately strong inverse
correlation between reach distance and mediolaterai distraction at L3 in hamstring tight
subjects.
Conclusions: Skin Distraction
At least two important points were made in this small study. The first point was
the quantification o f the superoinferior and mediolaterai skin distraction at several
landmarks along the human spine, something that is lacking in the literature. The
superoinferior percent strain increased and mediolaterai percent strain decreased from
thoracic to sacral regions, reflecting the relative increase in spine segment motion from
thoracic to lumbar region.
The second point is that hamstring normal subjects able to touch the floor in a
Finger-to-Floor Reach Test had significantly larger superoinferior and mediolaterai skin
distraction than hamstring tight individuals, those unable to touch the floor in sagittal
plane flexion. While it is not possible to prove it in this study, this finding suggests that
hamstring tightness affects lumbar motion during flexion.
233
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Part Two:
The Design of the Unique Platform Marker
Introduction
What kind o f design specifications are required of the new platform marker? The
ideal platform marker for skin surface must adapt to skin motion and maintain a
perpendicular orientation to the skins surface independent o f the subjects degree o f
flexion. This orientation was required in order to use the Cobb method to measure the
angles between lines denoting spine segment endpoints.
From an earlier pilot study, it was apparent that markers modeled after what was
commercially available, a flat base with a vertical arm, would not accurately reflect the
position of the vertebrae in dynamic situations. As stated above, the vertical arm would
have to maintain a perpendicular orientation to the skins surface. The frame that
supported the vertical arm would require both the strength and flexibility to withstand the
skin surface motion that accompanied postural change. These surface motions included
skin distraction o f up to about 54% strain in the superoinferior direction and up to about
21% in the mediolaterai direction. They also included changes in surface topography from
projecting spinous processes and prominent paravertebral musculature.
234
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two camera lenses in stereo, would detect light that originated from the IREDs and was
reflected at the target by means o f an optical material, in this case, reflective tape. The
diodes were arranged in arrays surrounding each o f the sensor lenses. Once detected, the
geometric area o f the reflected light signals would be reduced to centroid points and
translated to two-dimensional, point coordinate data using the MacReflex software.
Surface platform markers were designed to act as the carriers o f the
retroreflective, adhesive tape. The markers vertical arms would serve as a frame upon
which two pieces o f the retroreflective tape could be affixed. These pieces of tape, one
placed proximal and one distal to the skin surface, would serve as the basis for spine angle
determination. When optically illuminated and recorded, the two points marked by the
separate tape pieces would be used to establish lines perpendicular to the skins surface.
With one surface marker positioned at either end o f the spine segment o f interest, the
intersection angle o f the two projected lines could then be determined using a method
similar to the Cobb technique (Chapter 1).
The materials selected for the fabrication o f the marker needed to be both rigid and
flexible. Rigidity was required so that the optical marker portion would not loose its
orientation normal to the subjects skin surfaces. Flexibility was necessary in order to
provide clearances for the skin distraction, protruding vertebral processes, and contracting
paravertebral muscles that would accompany changes in subject posture. Nineteen gauge,
beryllium bronze wire was found to be both flexible and rigid, which provided a tolerance
to the experimentally determined skin strains without permanent deformation. A
prototypical design o f a pair o f soldered, A shaped arches having four pivoting balsa
235
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feet did not meet the distraction criteria and was difficult to affix to the skin. In the final,
improved design, the number o f mounting feet was reduced from four to two, thereby
limiting skin contact area and simplifying application. The construction material o f the
feet was changed from balsa to 0.006 brass shimstock, which also provided the required
rigidity and flexibility. Each shimstock mounting foot was formed as an arch and was
oriented perpendicular to the long axis of the marker. This design o f the shimstock bases
permitted accommodation o f the protruding anatomical structures as well as for the
mediolaterai distraction o f the skin.
The skin surface platform markers were then constructed. The beryllium bronze
wire was shaped as a distensible loop, thereby forming a frame whose rigidity in the
longitudinal orientation was adjusted simply by enlarging the loop size (Figure H.5). A
wire stanchion, constructed o f the same material, was then soldered at the apex o f the
frame loop, perpendicular to it. One piece of retroreflective tape was positioned at either
end o f the stanchion, which would be oriented as a vertical to the skin surface. The two
pieces of tape provided the optical point sources which provided the raw data.
The shimstock feet were then affixed to either end o f the wire loop. The thin,
contoured feet were soldered to sections o f 19 gauge hypodermic needle, which acted as
ferrules. Assembled in this fashion, the shimstock feet would pivot on the bearings. When
the marker was affixed to the skin surface using double-side electrode adhesive tape in a
pre-loaded fashion (pre-bent in compression), the loop could expand and contract
according to the amount o f skin distraction, without disrupting the perpendicular
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orientation o f the markers stanchion relative to the skin surface and to the underlying
vertebra.
Part Three:
Validation of the Unique Platform Marker
Introduction
The third part o f this chapter focuses on the validation o f the marker by answering
three questions: Do the marker perpendiculars remain normal to the skin surface during
distraction? Can the markers be positioned accurately over the spine landmarks whose
position they are to represent? Are the vertebral segment angles generated by these
surface markers equal to those obtained radiographically?
237
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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
239
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The distance between stanchion lines and endplate lines was expressed in terms of
vertebral body height, rather than in millimeters. This was done for two reasons: first, to
control for any age, gender, and stature-related differences in vertebral height and second,
to control for the different vertebral proportions characteristic o f each spine region.
Table H.6 shows that the majority of placement errors were small, ranging from no error
(0) to a difference o f one vertebral body height between surface stanchion line and the
intended, landmark vertebra endplate line (I)- Table H.7 shows the marker placement
error for each landmark vertebra, expressed as an average o f the distances in terms of
fractions o f vertebral body height.
% o f m e a a u rm e n ts
35
0 .5
35
20
1 .5
2 .5
5
100
Table H.7. Mean Distance between Surface Marker Perpendicular Line and
Endplate Tangent for each Landmark Vertebra, expressed as
Fractions of Vertebral Body Height
1
m ean
T1
T10
L3
S1
0 .7
0 .3
0 .2
1 .4
s.d.
0.45
0.27
0.27
1.29
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Discussion
Surface Marker Placement
The vast majority (90%) o f the surface markers were positioned within one
vertebral body height of their intended radiographic targets (35% directly at their targets,
35% within half a vertebral body away, and 20% one vertebral body away). Placement
errors greater than two vertebral body heights away from their mark all occurred at the SI
level. This difference was likely the result of two factors: the thickness of the soft tissue
at that level o f the sacrum and the inclination of the sacral base away from the skin surface
at that point. Surprisingly, the most reliable marker placement was at the level o f L3, with
an average surface marker perpendicular-to-endplate distance o f 0.2 vertebral body
heights (Table H.7). The mean distance values then increased from T10, followed by T l,
and then, SI. The placement error at T l was due not so much to palpatory difficulty (as
this is perhaps the easiest surface landmark to palpate), but in identifying radiographic
endplate landmarks at that level. On x-ray, the first thoracic vertebrae are frequently
washed-out, or obscured, due to the thickness and relative opacity o f the soft and
osseous tissues o f the shoulder girdle.
Comparison of the Spine Segment Angles based on Surface Markers and X-rays
Methods
In the third portion of the Validation Study, we compared the spine segment
angles generated using skin surface markers to those obtained from radiographs. Lateral
radiographs from our five volunteers were again used. The three females and two males
241
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had a mean age o f 19.3 ( 8.5) years, a mean height o f 1.68 ( 0.07) meters, and a mean
weight o f 57.59 ( 5.25) kilograms. This time, the positions o f the surface marker
stanchion lines were not compared to the positions o f the vertebral body endplate lines.
Rather, the four markers used in Section 2 (T l, T10, L3, and S I) were paired into groups
denoting three spine segments: T1-T10, T10-L3, and L3-S1.
Because the surface markers were radio-opaque, each subjects lateral view x-ray
could provide both surface marker-based and vertebral marker-based spine segment angle
data. Thus, the angle between the vertical stanchion lines from the surface markers over
T l and T10 would be the surface marker method data for the T1-T10 spine segment. The
angle between the superior endplate o f the Tl vertebral body and the inferior endplate o f
the T10 vertebral body would be the radiographic method data for the same segment.
These angles were determined using the Cobb technique, described in Chapters I.
T1T10
T10L3
L3S1
49
11
53
M ark e r
s.d.
10
7
8
m ean deg.
s .d
44
15
42
7
14
p -v a lu e
n .s .
n .s .
0 .0 0 2
242
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There was, however, a significant difference between x-ray and platform marker
angles for the L3-S1 spine segment (p=0.002). Like Leroux, et al. (2000), who studied
the difference o f thoracic angles generated by radiographic and stereovideographic
methods in 124 subjects, our results showed that there was a greater between-method
difference o f angle values for the lumbar region that for the thoracic region. While our
surface method underestimated the radiographic method angle, as did the surface tangent
method o f Chemukha, et al. (1998), it did so more dramatically, in that our x-ray based
angle mean was about two and one-half times that o f the surface marker method mean.
With the highest marker placement error at SI, it is likely that the more pronounced
lumbosacral angle o f L5-SI was not incorporated in surface measurements. As stated
earlier, it is likely that soft tissue thickness is a factor, similar to what was reported by
Bryant, et al. (1989) or Refshauge, et al. (1994), who compared surface contour to
radiographic measurements o f the upper spine.
Our findings contradict the observations o f Portek, et al. (1983), who wrote that
surface markers used in the lumbar region tend to overestimate angles. They are also do
not agree with the findings o f Vanneuville, et al. (1994), who had reported that the
overestimation o f spine angles by surface markers was greatest at the L3-S1 segment and
decreased towards the thoracolumbar region, the approximate area where surface markerbased angles began to underestimate radiographic angles.
243
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anthropometrically-based correction factors for skin thickness and sacral orientation can
be developed from a larger sample.
245
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Table 1.1. Mean Annual Training Times by Age in Years for Female and Male
Athletes grouped by Kyphosis Category and Hamstring Shortness Status
Age in years; times are in hours; s.d. = standard deviation; * = small n
N o rm o k y p h o tlc
A ge
m ean
a.d.
H a m s trin g S h o rt
m ean
s.d.
H y p e rk y p h o tic
H a m s trin g -N o rm a l i
m ean
m ean
& d.
s.d.
Female
9
219
94
10
343
253
66
11
360
117
274
229
205
202
222
417
358
12
342
13
282
14
280
15
289
16
401
17
494
208
332
(4 5 1 )*
(4 6 5 )*
326
8
3
172
214
174
270
122
208
58
220
414
483
(6 7 2 )*
364
220
147
251
411
303
405
(4 1 3 )*
241
184
328
371
347
406
(3 2 0 )*
512
584
388
367
445
(3 8 1 )*
145
576
248
282
165
169
168
209
Male
9
155
10
(1 9 3 )*
11
197
12
191
13
233
14
226
15
260
16
274
17
313
18
314
145
191
175
183
197
165
168
167
188
179
174
186
189
198
232
( 2 5 1 )*
270
270
305
( 4 1 0 )*
137
117
147
184
145
191
149
167
201
288
219
240
227
232
251
(2 5 1 )*
272
288
316
(3 0 8 )*
207
215
218
243
218
196
185
177
178
143
300
240
260
323
275
288
273
282
290
244
255
110
353
398
221
264
140
167
173
103
Table 1.2. Mean Annual Training Times by Age Group for Female and Male
Athletes grouped by Kyphosis Category and Hamstring Shortness Status
Age Group: I = 8-10 years, 2 = 11-13 years, 3 = 14-18 years; s.d. = standard deviation; * = small n
A ge
G ro u p
N o rm o lg / p h o t i c
m ean
H a m s trl n g - S h o r t
s.d.
m ean
219
228
245
297
s.d.
H a m s trin g -N o rm a l
m ean
s.d.
Female
1
302
314
330
66
(4 2 9 )*
8
191
200
340
386
414
H yp e rk y rp h o tic
! m ean
s.d.
207
262
270
417
180
232
184
264
153
287
295
281
174
412
372
177
256
162
Male
1
183
214
269
179
189
173
182
211
274
117
156
176
208
243
279
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247
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