Parameters characterizing the posture of preterm children in standing and sitting position

Abstract

BACKGROUND:

Systematic observations of fetal posture show that, although for most of the time the fetus does not have a preferred posture, it has a certain repertoire of repeated active postures. The observed postures cannot be considered random configurations of head and limb position: the fetus and the young infant have an active, but variable posture that is relatively unrelated to the orientation of the force of gravity.

MATERIALS AND METHOD:

RESULTS:

Significant statistical differences in GAMMA ( $p<$ 0.001) and KLL ( $p=$ 0.020) parameters in preterm children and in control group were noted. Both parameters presented higher value in the control group.

CONCLUSIONS:

The posture of preterm children is characterized by a smaller angle of upper thoracic curvature and smaller angle of lumbar lordosis. The posture of preterm children in sitting position is characterized by a smaller angle of thoracic kyphosis. Preterm birth disturbs the development of proper antigravitational mechanism and causes possible posture dysfunctions at the age of 6.

Keywords

Body posture spine photogrammetric method preterm infant

1. Background

Uterine cavity is the perfect place to guarantee proper development of the fetus while shortening of this time results in occurrence of developmental differences between preterm and full-term children [1].

The most characteristic feature of a preterm infant in general is lower muscle tension. The earlier the birth, the bigger the flaccidity. Free flexed positioning, so typical for full-term infants, turns out to be very difficult to obtain by preterm ones due to both lower muscle tension and gravitation [2].

Table 1
Anthropometric parameters in the research group

Variables	Preterm children			Control group			Z	$p$
	( $n=$ 50)			( $n=$ 51)
	$\bar{x}$	Me	SD	$\bar{x}$	Me	SD
Body height	116.52	115.50	8.02	118.98	118.00	7.91	$-$ 1.82	0.069
Body weight	21.11	19.90	4.78	23.12	21.90	4.74	$-$ 2.57	0.010
BMI	15.40	15.11	2.05	16.20	15.80	1.94	$-$ 2.35	0.019

Usually in the first weeks of life, premature babies are lying on their backs with erected extremities and they tend to abduct them. Gravitation, physiological flaccidity and adverse positioning cause the preservation of hyperextension of neck and back muscles in premature infants. Especially among children with extended controlled ventilation, increased neck muscle tension, retraction of upper extremities and shoulder joints, lower pelvis mobility, elevation of scapula and backward curvature of trunk are being observed [3, 4, 5].

Neonatal posture requires a number of active postural control mechanisms – that is, neuromotor functions – which allow a living organism to control its body posture at rest, during displacement and during active movements [6]. Postural control is intimately linked with motor control: dynamic motor actions cannot be performed without prior stabilization of body posture [7]. This applies to both voluntary and involuntary movements [8].

The postural dysfunctions in preterm infants have been assessed repeatedly, however available literature does not provide the data concerning the influence of those dysfunctions on the body posture [8, 10, 11, 12].

One of the important factors determining the quality of body posture is the spinal curvature in the sagittal plane [13, 14]. Slight lumbar lordosis and thoracic kyphosis are typical features of perfect standing position [14]. The optimal sitting position, however, is still being discussed [15, 16]. Some authors maintain that spinal curves during sitting should be similar to those in perfect standing position [14, 16].

The aim of the paper was to estimate the parameters characterizing the standing and sitting body posture in prematurely born children.

2. Materials and method

2.1 Participants

The study included 101 children, aged 6–7, including 50 preterm children, 48 boys and 53 girls (research group) and 51 full-term children; 22 boys and 53 girls (control group). The basic anthropometric data is shown in Table 1. The criteria of qualification to the research group included: consent of both guardians and children to participate in the research, birth before the 32 weeks gestational age, lack of neurological and orthopedic diseases influencing the posture. The qualification to the control group required: consent of both parents and children to participate in the study, lack of neurological and orthopedic diseases influencing the posture, birth after 36 and before 42 weeks gestational age. The research was conducted in southeast Poland at the Center for Innovative Research in Medical and Natural Sciences, Medical Faculty of University of Rzeszow. The research was approved by the local bioethics committee.

Table 2
Body posture – standing position

Variables	Preterm children			Control group			$t$ /Z	$p$
	( $n=$ 50)			( $n=$ 51)
	$\bar{x}$	Me	SD	$\bar{x}$	Me	SD
ALFA	7.09	6.95	5.07	9.36	5.70	12.20	$-$ 0.27	0.788
BETA	5.65	4.75	3.77	4.51	4.50	2.61	1.77	0.079
GAMMA	12.12	12.10	3.87	15.10	14.30	4.82	12.11	$<$ 0.001
KPT	3.47	3.40	2.27	4.62	4.00	4.98	$-$ 1.58	0.114
KKP	162.71	162.90	5.78	161.73	161.90	4.87	0.92	0.359
KLL	169.56	169.30	6.82	176.57	172.40	17.03	$-$ 2.33	0.020
KNM	2.50	2.20	2.02	2.84	2.80	2.26	$-$ 0.71	0.480
KSM	2.75	1.70	2.36	3.46	2.60	2.55	$-$ 1.62	0.105
GKP	8.91	6.00	6.68	9.65	7.70	7.31	$-$ 0.45	0.648
GLL	5.45	5.20	4.27	5.35	3.40	4.32	0.31	0.756

$n$ : number of observations; arithmetic average; ME: median; SD: standard deviation; $t$ -test result; $t$ : student for independent variable; Z: Mann-Whitney U test results; $p$ : probability level. ALPHA ( ${}^{\circ}$ ) – lumbosacral region angle; BETA ( ${}^{\circ}$ ) – thoracolumbar region angle; GAMMA ( ${}^{\circ}$ ) – upper thoracic region angle; KPT – trunk tilt angle; KKP ( ${}^{\circ}$ ) – thoracic kyphosis angle; KLL ( ${}^{\circ}$ ) – lumbar lordosis angle; KNM (mm) – pelvic tilt; KSM (mm) – pelvic torsion; GKP (mm) – thoracic kyphosis depth; GLL (mm) – lumbar lordosis depth.

2.2 Methods and procedures

All measurements were done on the same day, beginning with anthropometric ones. The height was measured with 0.1 cm precision with the use of Seca 213 stadiometer. Body weight was measured with 0.1 kg precision on OMRON BF 500 electronic scale. The measurements were done in standard conditions, children were barefoot, wore underwear, and were in erect position without bent knees. The anthropometric parameters of both groups are presented in Table 1.

The photogrammetric method with moire effect on Mora 4G CQ Elektronik [17] was used to examine the body posture. It is a noninvasive method and presents high compliance with radiology examination [18, 19, 20], and it is therefore frequently used as a substitute of radiology in posture examination. Prior to the examination the following anthropometric points on the patient’s skin were marked: spinous processes from C7 to S1, right and left posterior superior iliac spine, point between thoracic and lumbar spine and right and left inferior angle of scapula. The examination was conducted by a physiotherapist with 10 years of experience in equipment operation and 15 years of practice in body posture examination. The patient was standing in proximity of 260 cm from the camera in a habitual position with upper extremities by sides and lower ones with hip and knee joints in erect position. When the patient kept adjusting the posture, the measurements were repeated to capture functional dysfunctions.

The following parameters were analyzed and are presented in Fig. 1 and Table 1: ALPHA ( ${}^{\circ}$ ) – lumbosacral region angle; BETA ( ${}^{\circ}$ ) – thoracolumbar region angle; GAMMA ( ${}^{\circ}$ ) – upper thoracic region angle; KKP ( ${}^{\circ}$ ) – thoracic kyphosis angle; KLL ( ${}^{\circ}$ ) – lumbar lordosis angle; GLL (mm) – lumbar lordosis depth; GKP (mm) – thoracic kyphosis depth; KSM – pelvic tilt; KPT – trunk tilt angle.

Figure 1.

Postural parameters in the sagittal plane [9]. $\alpha$ ALPHA ( ${}^{\circ}$ ) – lumbosacral region angle, $\beta$ BETA ( ${}^{\circ}$ ) – thoracolumbar region angle; $\gamma$ GAMMA ( ${}^{\circ}$ ) – upper thoracic region angle; KKP ( ${}^{\circ}$ ) – thoracic kyphosis angle; KLL ( ${}^{\circ}$ ) – lumbar lordosis angle; KNM (mm) – pelvic tilt; KSM (mm) – pelvic torsion; GKP (mm) – thoracic kyphosis depth; GLL (mm) – lumbar lordosis depth; KP – thoracic kyphosis; LL – lumbar lordosis; PL – intervertebral space TH/L.

2.3 Statistical analysis

Statistical analyses of the collected materials were performed using Statistica 10.0 from StatSoft. Both parametric and nonparametric tests were applied in the analysis of the variables. The choice of the parametric test depended on the fulfillment of its basic assumptions, i.e. conformity of the distributions of the examined variables with normal distribution, which was verified with the Shapiro-Wilk W-test. Descriptive statistics, calculated for all numerical variables, included: mean, median and standard deviation. Assessment of differences in the average value of a numerical characteristic in the two populations was performed with the Student’s $t$ -test for independent variables, or, alternatively, with the nonparametric Mann-Whitney U test. Analysis of qualitative data was carried out using Pearson’s chi-squared test. Statistical significance was assumed at $p<$ 0.05.

Table 3
Body posture – standing position – girls

Variables	Preterm girls			Control girls			$t$ /Z	$p$
	( $n=$ 25)			( $n=$ 29)
	$\bar{x}$	Me	SD	$\bar{x}$	Me	SD
ALFA	8.58	7.80	5.21	8.76	5.70	7.25	0.54	0.591
BETA	6.90	6.00	4.07	4.40	4.20	2.09	2.89	0.005
GAMMA	12.24	12.20	4.72	15.31	14.30	4.89	$-$ 2.34	0.023
KPT	3.22	2.80	2.73	4.18	4.40	2.02	$-$ 2.02	0.043
KKP	161.62	162.20	7.18	161.47	161.90	4.88	0.08	0.931
KLL	168.60	167.00	7.69	174.01	170.90	13.26	$-$ 1.60	0.109
KNM	2.37	1.70	2.09	3.02	2.80	2.25	$-$ 1.01	0.311
KSM	2.52	1.70	2.27	3.33	2.60	2.69	$-$ 1.21	0.227
GKP	10.97	7.70	7.42	9.10	7.70	6.57	$-$ 0.91	0.357
GLL	6.08	6.00	4.49	5.27	3.40	4.03	$-$ 0.66	0.504

Table 4

Body posture – standing position – boys

Variables	Preterm boys			Control boys			$t$ /Z	$p$
	( $n=$ 25)			( $n=$ 22)
	$\bar{x}$	Me	SD	$\bar{x}$	Me	SD
ALFA	5.60	4.50	4.55	10.15	5.65	16.83	$-$ 0.91	0.365
BETA	4.39	4.00	3.02	4.64	4.60	3.22	$-$ 0.27	0.785
GAMMA	12.00	12.00	2.87	14.81	14.25	4.83	11.99	0.017
KPT	3.72	3.90	1.72	5.19	3.60	7.28	$-$ 0.05	0.957
KKP	163.80	163.80	3.77	162.06	161.70	4.96	1.35	0.181
KLL	170.52	170.20	5.83	179.94	175.95	20.86	$-$ 2.10	0.036
KNM	2.64	2.20	1.98	2.59	1.95	2.31	0.31	0.756
KSM	2.97	2.60	2.48	3.63	3.40	2.40	$-$ 1.20	0.229
GKP	6.84	5.20	5.21	10.39	7.70	8.28	$-$ 1.40	0.159
GLL	4.82	5.20	4.02	5.44	3.85	4.76	$-$ 0.02	0.982

$n$ : number of observations; arithmetic average; ME: median; SD: standard deviation; $t$ -test result; $t$ : student for independent variable; Z: Mann-Whitney U test results; $p$ : probability level; ALPHA ( ${}^{\circ}$ ) – lumbosacral region angle; BETA ( ${}^{\circ}$ ) – thoracolumbar region angle; GAMMA ( ${}^{\circ}$ ) – upper thoracic region angle; KPT – trunk tilt angle; KKP ( ${}^{\circ}$ ) – thoracic kyphosis angle; KLL ( ${}^{\circ}$ ) – lumbar lordosis angle; KNM (mm) – pelvic tilt; KSM (mm) – pelvic torsion; GKP (mm) – thoracic kyphosis depth; GLL (mm) – lumbar lordosis depth.

Table 5

Body posture – sitting position

Variables	Preterm children			Control group			$t$ /Z	$p$
	( $n=$ 42)			( $n=$ 51)
	$\bar{x}$	Me	SD	$\bar{x}$	Me	SD
ALFA	17.42	17.30	8.33	19.15	19.40	8.27	$-$ 1.00	0.320
BETA	5.39	5.55	2.67	4.67	4.50	3.18	1.53	0.125
GAMMA	23.33	24.40	6.10	24.90	24.50	6.07	$-$ 1.24	0.220
KPT	6.95	6.95	2.43	6.82	6.60	2.41	0.26	0.793
KKP	161.67	161.85	6.50	158.71	159.10	6.73	2.15	0.034
KLL	201.73	202.25	9.19	202.76	201.90	8.26	$-$ 0.29	0.775
KNM	2.79	2.20	2.44	3.79	3.30	3.31	$-$ 1.37	0.172
KSM	3.02	2.60	2.57	4.40	3.40	4.73	$-$ 1.47	0.141
GKP	20.52	20.60	8.96	21.56	21.50	9.83	$-$ 0.53	0.597
GLL	6.40	4.30	5.00	9.10	7.70	7.68	$-$ 1.71	0.087

$n$ : number of observations; arithmetic average; ME: median; SD: standard deviation; $t$ -test result; $t$ : student for independent variable; Z: Mann-Whitney U test results; $p$ : probability level; ALPHA ( ${}^{\circ}$ ) – lumbosacral region angle; BETA ( ${}^{\circ}$ ) – thoracolumbar region angle; GAMMA ( ${}^{\circ}$ ) – upper thoracic region angle; KPT – trunk tilt angle; KKP ( ${}^{\circ}$ ) – thoracic kyphosis angle; KLL ( ${}^{\circ}$ ) – lumbar lordosis angle; KNM (mm) – pelvic tilt; KSM (mm) – pelvic torsion; GKP (mm) – thoracic kyphosis depth; GLL (mm) – lumbar lordosis depth.

Table 6

Body posture – sitting position – girls

Variables	Preterm girls			Control girls			$t$ /Z	$p$
	( $n=$ 22)			( $n=$ 29)
	$\bar{x}$	Me	SD	$\bar{x}$	Me	SD
ALFA	14.13	14.45	7.13	17.76	16.90	7.13	$-$ 1.80	0.078
BETA	5.53	5.90	2.75	3.96	3.20	2.86	1.98	0.053
GAMMA	21.94	22.00	6.78	23.67	23.70	5.93	$-$ 0.97	0.337
KPT	6.98	7.15	2.59	6.57	6.60	2.27	0.61	0.548
KKP	163.21	162.80	7.07	160.02	162.10	5.73	1.34	0.180
KLL	197.95	200.25	9.25	201.45	201.20	7.92	$-$ 1.04	0.300
KNM	2.71	2.20	2.26	3.79	3.30	3.10	$-$ 1.12	0.261
KSM	2.86	2.60	2.26	3.41	3.40	2.84	$-$ 0.56	0.577
GKP	18.94	18.90	8.60	19.26	18.00	9.84	0.11	0.905
GLL	5.11	3.85	3.62	7.20	6.00	5.39	$-$ 1.22	0.221

$n$ : number of observations; arithmetic average; ME: median; SD: standard deviation; $t$ -test result; $t$ : student for independent variable; Z: Mann-Whitney U test results; $p$ : probability level; ALPHA ( ${}^{\circ}$ ) – lumbosacral region angle; BETA ( ${}^{\circ}$ ) – thoracolumbar region angle; GAMMA ( ${}^{\circ}$ ) – upper thoracic region angle; KPT – trunk tilt angle; KKP ( ${}^{\circ}$ ) – thoracic kyphosis angle; KLL ( ${}^{\circ}$ ) – lumbar lordosis angle; KNM (mm) – pelvic tilt; KSM (mm) – pelvic torsion; GKP (mm) – thoracic kyphosis depth; GLL (mm) – lumbar lordosis depth.

Table 7

Body posture – sitting position – boys

Variables	Preterm boys			Control boys			$t$ /Z	$p$
	( $n=$ 20)			( $n=$ 22)
	$\bar{x}$	Me	SD	$\bar{x}$	Me	SD
ALFA	21.04	22.55	8.20	20.99	23.40	9.42	0.02	0.984
BETA	5.24	5.20	2.63	5.61	5.10	3.39	$-$ 0.40	0.694
GAMMA	24.86	25.40	4.97	26.52	27.30	6.01	$-$ 0.97	0.339
KPT	6.92	6.85	2.31	7.15	6.95	2.60	$-$ 0.30	0.765
KKP	159.98	158.35	5.51	156.98	155.75	7.66	1.44	0.157
KLL	205.89	206.35	7.27	204.48	207.10	8.57	0.57	0.570
KNM	2.88	1.95	2.69	3.80	2.75	3.64	$-$ 0.76	0.446
KSM	3.19	2.15	2.91	5.71	3.85	6.28	$-$ 1.68	0.092
GKP	22.25	21.45	9.26	24.60	25.35	9.15	$-$ 1.27	0.202
GLL	7.82	7.70	5.96	11.60	11.20	9.50	$-$ 1.21	0.225

$n$ : number of observations; arithmetic average; ME: median; SD: standard deviation; $t$ -test result; $t$ : student for independent variable; Z: Mann-Whitney U test results; $p$ : probability level; ALPHA ( ${}^{\circ}$ ) – lumbosacral region angle; BETA ( ${}^{\circ}$ ) – thoracolumbar region angle; GAMMA ( ${}^{\circ}$ ) – upper thoracic region angle; KPT – trunk tilt angle; KKP ( ${}^{\circ}$ ) – thoracic kyphosis angle; KLL ( ${}^{\circ}$ ) – lumbar lordosis angle; KNM (mm) – pelvic tilt; KSM (mm) – pelvic torsion; GKP (mm) – thoracic kyphosis depth; GLL (mm) – lumbar lordosis depth.

3. Results

Significant statistical differences in GAMMA ( $p<$ 0.001) and KLL ( $p=$ 0.020) parameters in preterm children and in the control group were noted (Table 2). Both parameters presented higher values in the control group.

Significant statistical differences in BETA ( $p=$ 0.005), Gamma ( $p=$ 0.023) and KPT ( $p=$ 0.043) parameters among girls in both preterm and the control group were noted (Table 3). GAMMA and KPT parameters showed higher values in the control group while BETA parameter was higher in preterm children group.

Statistically significant differences in GAMMA ( $p=$ 0.017) and KLL ( $p=$ 0.036) parameters among boys in both preterm and the control group were noted (Table 4). Both parameters showed higher values among the boys in the control group.

Significant statistical differences in KKP parameter ( $p=$ 0.034) were noted in both groups (Table 5). Higher values of this parameter were observed in the preterm group.

No significant statistical differences in parameters characterizing body posture in the sitting position among girls in both preterm and control groups were observed (Table 6).

No significant statistical differences in parameters characterizing body posture in the sitting position among boys in both preterm and control groups were observed (Table 7).

4. Discussion

The results of the research showed significantly a smaller upper thoracic spine angle and lumbar lordosis angle in preterm children. Due to a smaller angle of lumbar lordosis, the body posture of preterm children showed deeper lumbar lordosis but those discrepancies represent no statistic significance. Similar parameter discrepancies occur in the sitting position, but those are also of no statistic significance. The angle of thoracic kyphosis, however, is considered the main difference between the two groups in the sitting position. The angle is bigger in the preterm group and these children therefore develop shallower thoracic kyphosis than full-term children.

The results of research showed that the posture of preterm children is characterized by distinctly marked lumbar lordosis, distinctly shallower upper thoracic kyphosis, lower thoracic curvature as well as pelvis posteriorly tilted. In Staffel typology this is described as a flat back. Those symptoms can be triggered by a distinctively different development pattern in extension and lower postural muscle tension, which, in turns, leads to anti-gravitational mechanism dysfunctions of spastoidal character. The posture of preterm children is actively balanced, which manifests itself by early readiness to stand with the tendency to tiptoe, anteversion of pelvis and increased tension of paraspinal muscles. Small activity of the trunk is noted in positioning and balancing reactions accompanied by clear influence of active peripheral compensation. These are derived from significantly worse postural and balance control due to low, basic muscle tension [21, 22, 23].

The available literature does not contain the insights concerning the parameters characterizing the posture of preterm children. So far, researchers have focused only on the evaluation of postural control or posture itself [24, 25].

The results of the current research indicate the differences concerning the infants.

According to the authors, the number of atypical qualitative posture and movement findings demonstrated by the preterm infants was significantly greater than the one observed in the full-term group for infants ranging in age from birth to 9 months but not for those from 10 to 12 months of age. The predominant difference between the two samples was the presence of neck hyperextension and arching of the trunk which occurred significantly more frequent in the preterm infants [26].

Some of the preterm infants, at the age of three months, still remained at level 2 in supine position due to a less developed flexion, in comparison to the one observed in full-term infants. There is no consensus in explaining the more extended position of preterm infants in supine. Several authors suggest that it occurs because a global muscle tone is lower than normal [27, 28]; others suggest that it is caused by an increased muscle power of the trunk extensors [29, 30]; and one suggests that it is caused by a lack of tactile and proprioceptive stimulation as a result of the limited intra-uterine space at the end of pregnancy [31]. All these suppositions could change the adequate muscle control to overcome the influence of extra-uterine gravity. Supine load bearing varied, according to the level, from trunk, pelvis and feet.

De Groot and colleagues described the postural behavior of preterm infants in terms of faulty muscle power, defined as an imbalance between the active adjustments to changes in posture and passive muscle tone [29].

Proper postural tension determines proper alignment of singular body segments such as the head, shoulder girdle and pelvic girdle. When this alignment is dysfunctional, due to compensatory changes adjusting kinesthetic needs of child to his abilities conditioned by proper or faulty functioning OUN, the alignment of feet, knees, pelvis, shoulders and head becomes dysfunctional as well, leading to secondary neuroorthopedic changes in body posture [32].

During the development and growth, the body posture control system is trying to maintain a stable, vertical posture of the head and trunk resisting the gravitation, to create the basis of proper reaching, sitting, standing and walking patterns [33].

However, in case of children of age similar to those included in hereby study, those differences seem to diminish. According to Kluenter et al., static and dynamic postural control was not significantly different between full-term and preterm infants with very low birth weight at the age of 7 [34].

Although in statistical terms the preterm infants presented a sequence in the development of postural control similar to that of the full-term infants, and matched the age range at each level elaborated by Pountney et al. for normal infants, they still presented a different trend in the acquisition of motor abilities [35].

The current research is the first study that evaluates the parameters of body posture in preterm children in detail. The research was conducted on children age 6 in both standing and sitting position. The qualification criterion, such as 32 weeks gestation age, can be considered a very significant threshold of the research process.

The lack of analysis concerning the prematurity level can be considered the limitation of this study, however such analysis has never been considered an assumption of this research due to its statistical insignificance. This research requires further follow-up and continuation due to insufficient volume of available sources concerning its main subject.

5. Conclusions

The posture of preterm children is characterized by a smaller angle of upper thoracic curvature and a smaller angle of lumbar lordosis.

The posture of preterm children in the sitting position is characterized by a smaller angle of thoracic kyphosis.

Preterm birth disturb the development of proper antigravitational mechanism and cause possible posture dysfunctions at the age of 6.

Footnotes

Conflict of interest

None to report.

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Parameters characterizing the posture of preterm children in standing and sitting position

Abstract

BACKGROUND:

MATERIALS AND METHOD:

RESULTS:

CONCLUSIONS:

Keywords

1. Background

Table 1 Anthropometric parameters in the research group

2.1 Participants

Table 2 Body posture – standing position

Table 3 Body posture – standing position – girls

4. Discussion

5. Conclusions

Footnotes

Conflict of interest

References

Table 1
Anthropometric parameters in the research group

Table 2
Body posture – standing position

Table 3
Body posture – standing position – girls