A comparison of sagittal spine deformities among elementary school students using spinal mouse device

Abstract

BACKGROUND:

Sagittal spine curvature deformities are common among elementary school students due to long malposition and lack of physical activity.

OBJECTIVES:

This study aims to compare sagittal spine deformities among first graders (young and elder school students) in elementary schools.

METHODS:

The sagittal spinal curvatures of 45 young school students aged 5–7 years and 50 elder school students aged 9–11 years were examined by using spinal mouse device.

RESULTS:

Independent sample t-test shows statistically significant differences in sagittal spinal deformities with increased thoracic kyphosis and spinal flexion in young children than elder children (P = .000, t = 10.72). However, young children show lesser lordosis than elder children (P = .001, t = –4.47). In addition, the young children established a higher significant coefficient of compensation (CC) than elder children (P = .000 t = 12.58).

CONCLUSION:

The results suggest that the forward flexion of the trunk is more common among young children than elder children. This may be attributed to differences in postural awareness and way of sitting among students of elementary school. So, it is recommended to encourage the proper postures among students of first graders especially young children.

Keywords

Elementary school screening spine deformities spinal mouse device

1 Introduction

Sagittal spinal deformities are common among elementary school students due to long improper position and lack of parents’ awareness to enhance the physical activity of children by exercises [1]. In addition, constant asymmetrical overloading alters the normal growth of the vertebra and changes the normal curvature of the spine into pathological curvature [2]. Unfortunately, there is no reliable definition of “deformity” in the literature of children’s spine. The term deformity is defined in this setting as undesirable deviation of the sagittal spinal curvatures in young school children in comparison with elder children. Children are the most frequent carriers of heavy school bags and common users of computers, which expose them to spine asymmetry and more spine flexion posture than adults. Also, posture variations are present among children [3, 4]. So, the process of early recognition of different spinal deformities and clinical monitoring should be involved in postural screening programs in elementary schools [1]. Children between 7–9 years old are in a critical age of skeletal growth, when there should be an avoidance of the postural deformities [5].

The first graders in primary schools spend most of time at school. Children tend to sit in classes for long period of time, which changes the shape of sagittal spinal curvatures because of improperly designed classroom furniture [6]. A study performed by Bubanj et al. [7] related the sagittal spinal deformities among school students (male and female) to the muscle imbalance and lack of physical activity. Another study conducted on 12 year students confirmed the presence of bad lordotic posture due to non-participation in sport activities [8]. Many research works were performed on elementary school pupils to discover the causes of sagittal spinal deformities, but there is lack of studies on finding the sagittal postural variations among young and elder children.

A systematic review on school pupils found that the relationship between students’ musculoskeletal disorders and subsequent musculoskeletal disorders in adult life is unknown. Although today’s young school pupils are tomorrow’s elder school students, there are no studies to prove that musculoskeletal disorders are progressive or related to postural problems in elder age [9]. Dockrell and Kelly suggested that young children might be exposed to greater postural deformities than adults because of their small age and lack of postural awareness. Furthermore, most of the classroom furniture and computer workstations are designed to be suitable only for adults [10].

X-ray imaging is considered the gold standard for spinal deformity diagnosis, however it is so difficult to apply for children’s screening inside schools [1]. Moreover, children’s exposure to a dose of radiation is considered one of the major x-ray limitations. There were continuous efforts to find a safe diagnostic procedure for different spinal deformities, such as the software program, Spinal Mouse (SM). Spinal Mouse is practical, safe, easy and reliable for patient follow up and research work [11].

It is obvious that most of the previous research works focused on the comparison of postural spinal deformities between children and adults, without considering the postural variations among school children. Furthermore, there is lack of research on sagittal spinal deformities (hyper-kyphosis and excessive lordosis) among children rather than other spinal pathologies [2 , 12–14]. So, the main aim of the current study was to compare sagittal spine deformities among elementary school students (young and elder) by using non-invasive device like spinal mouse. The study’s null hypothesis stated that there is no difference in sagittal spinal curvatures among elementary school students with different ages.

2 Material and methods

2.1 Participants

Forty-five young (Age = 6±.8 yr, Mass = 23.7±3, Height = 123±6, BMI = 15.5±1.3) and fifty elder (age = 10±.7 yr, Mass = 35±7, Height = 136.6±6, BMI = 18.8±2.6) school students were engaged through elementary school screening program. Written agreements from the school and parents were obligatory before the investigation, and the procedure was explained in detail to the parents. Each group was well-adjusted for gender, and all students were right-handed. As part of the inclusion criteria, the participants had to be free from any musculoskeletal pain or other abnormalities or any sign and symptoms of visual, auditory and balance disturbances. Also, they were not engaged in any specific sport training or any other activities, except mandatory physical education classes. The two groups of children (young and elder) were using computers two hours per week in a frequency of twice per week. The study has taken an ethical approval from the review board of Cairo University (P.T.REC/012/001794).

2.2 Study design

Two groups comparison cross sectional study was conducted to detect sagittal spinal variability among first graders of elementary school students. The sagittal spinal curvature angles (thoracic kyphosis and Lumbar lordosis) were detected among young and elder children.

2.3 Instrumentations

Body height and weight were measured with a medical scale, and the body mass index was calculated from the height and weight. SM with System G6 software was used to measure sagittal spinal angles (kyphotic and lordotic angles). The SM program uses a very complex algorithm to calculate the spinal angles. It consists of the main operating unit (measuring unit), portable lap top and USB, as shown in Fig. 1. The reliability and validity of SM program is acceptable for thoracic and lumbar range of motion measure [15 –17]. The intra-rater reliability of SM during standing, full flexion, and full extension in healthy children ranged from 0.61 to 0.96, and the inter-rater was from 0.70 to 0.93. The standard error of measurement ranged from 0.61° to 13.18° [18 –21].

Fig. 1

Different parts of Spinal Mouse device; 1) Main operating unit, 2) Lap top, and 3) software USB.

2.4 Procedure

Each participant assumed a comfortable standing posture in front of one examiner, and the assistant freed the areas of upper and lower back from clothes. The participant’s arms were kept hanging freely on either sides of the body. Each child was asked to focus on a fixed object in front of him/her and to maintain the stable posture as much as possible. All the children were wearing flat shoes with a firm surface to increase the sense of standing and assist balance [22]. The measuring unit of SM was guided manually by the thumb of the examiner along the spinous process of thoracic and lumbar regions (from the spinous process of C7 as a large prominent bony landmark till the area of the sacrum S3) (Fig. 2). The measuring unit of SM followed the contour of the spine from sagittal plane and recorded the variables of interest (kyphotic and lordotic angles). The features and instructions of this software tool are available on the web (http://spinalmouse.ro/en).The mean of three measurements were calculated and statistically processed.

Fig. 2

The examiner’s thumb guided the measuring unit of spinal mouse along the spine.

2.5 Statistical analysis

Statistical Package for Social Sciences (SPSS) Version 20.0 was used for the data analysis. Data exploration and descriptive statistics were conducted as preliminary check to ensure homogeneity, normality, and linearity of variances in each group. Intra-rater reliability test (single session, between measurements with the same examiner) of each group was performed. Independent sample t-test was applied to identify the sagittal spinal variations between the young and elder groups. Also, the coefficient of compensation (CC) was calculated, which represents the difference between thoracic kyphosis and lumbar lordosis angles to detect the degree of spinal compensation [23, 24].

3 Results

3.1 Data reliability and consistency (between measurements)

As explained in the previous section, the intra-rater reliability and consistency in single session were detected by calculating interclass correlation coefficient (ICC) for each variable of interest in each group with excellent category (P > 0.8), as presented in Table 1.

Table 1
Intra-class correlation coefficient (ICC) for sagittal spinal curvatures of each group

Variables ICC

Young children kyphotic angle 0.801

Young children lordotic angle 0.891

Old children kyphotic angle 0.899

Old children lordotic angle 0.834

Variables	ICC
Young children kyphotic angle	0.801
Young children lordotic angle	0.891
Old children kyphotic angle	0.899
Old children lordotic angle	0.834

Abbreviations: ICC; Inter-class correlation.

3.2 Descriptive analysis

The sagittal spinal curvatures which included the thoracic kyphosis and lumbar lordosis were carefully detected and sent to SPSS for processing and analysis. The mean and SD of each variable of interest are shown in Table 2. Shapiro-Wilk test confirms the homogeneity of each group. The test revealed that there were no statistically significant differences (P > 0.05) in the mean values of age, weight, height, and body mass index (BMI). The equality of variance was assumed by Levene’s Test for each variable of interest in each group (P > 0.05).

Table 2
Means, SD and independent t-test for the variables of interest between both groups

Young children Elder children P value

Kyphotic angle (°) 45±5.8 31±6.9 P < 0.05

Lordotic angle (°) 21±2.3 24±4.9 P < 0.05

CC (°) 24.6±5.7 6.8±7.8 P < 0.05

	Young children	Elder children	P value
Kyphotic angle (°)	45±5.8	31±6.9	P < 0.05
Lordotic angle (°)	21±2.3	24±4.9	P < 0.05
CC (°)	24.6±5.7	6.8±7.8	P < 0.05

Abbreviations: CC; Compensation Coefficient (kyphotic - lordotic angle).

3.3 Independent t-tests

The results of the independent t-test showed statistically significant differences in thoracic kyphosis and lumbar lordosis angles between both groups (P < 0.05) as summarized in Table 1. The mean thoracic kyphosis of the young group was greater than that of the elder group, while the lumbar lordosis angle of the young group was lesser than that of the elder group. However, there was no statistically significant difference between males and females in each group. The mean of thoracic kyphotic angle of females was greater than that of males in the young group by 6%. In addition, the young children established a significantly higher CC than elder children (P = .000).

4 Discussion

The main aim of this study was to compare the sagittal spinal curvatures of elementary school students (young and elder) to detect the sagittal spinal deformities and individual variations. The postural differences of young and elder children were detected in the form of both thoracic kyphosis and lumbar lordosis. The young children of age 5–7 years were more kyphotic than the elder children of age 9–11 years, whereas the young children showed less lordotic angle than the elder children. Our results agree with the study of Maslen and Straker [25] who confirmed that young children (5-6) demonstrate more postural flexion than elder children (10–12) and young adult. Moreover, there was developmental tendency to exhibit less postural flexion and rotation with age [26].

The main cause of sagittal spinal deformities, especially among elementary school students, may be due to the lack of sports activities and the adoption of static posture for long periods of time. This was proved by Bogdanović and Marković who attributed the presence of significant differences in sagittal postural alignment among primary school children to lack of sports activities. Besides, the study by Imhof et al. [27] declared that, children (6 to 8 years old) who are physically active have a better physical fitness and lesser postural insufficiencies.

There are significant differences in CC between both groups, with the young children showing more CC than elder children, which indicates large differences between thoracic kyphosis and lumbar lordosis in small children; this refers to higher postural flexion in young children compared to elder children (more thoracic kyphosis with flattening in lumbar spine). This result agrees with the result of Widhe [28] who showed that thoracic kyphotic angle decreased significantly in relation to lumbar lordotic angle during growth, while there were no differences between males and females in the earlier age groups. Moreover, the homogeneity of our sample is consistent with the study of Wojtys et al. [29], which confirmed that there were no significant differences in thoracic and lumbar spine sagittal angles among males and females of age 8–18 years. In addition, Mac-Thiong et al. [30] showed no changes in the pelvic angle or sagittal spinal curvatures between genders in young (age ≤10 years) and elder children (age ≥10 years).

According to Obradović and Milošević [31], by regular follow-up and assessment of postural status of children, many health problems could be specified on time, before the condition becomes serious. So the early evaluation and follow-up examination of young school students are recommended to avoid any associated problems during spinal growth and development. Also, it is recommended to use different shoulder and back support designs to improve the sagittal spine curvatures especially for young school students. The results of this study reject the null hypothesis by showing that there are statistically significant differences in the sagittal spinal curvatures among elementary school students. However, there were some limitations such as: i) the sample size was limited by the voluntary participation of the students, and parents’ agreements, and ii) the collection of data was limited to the standing position due to time limitation. Therefore, future studies should consider the effect of different activities from sitting position such as watching TV, using mobile-phones, and other gadgets that demand sitting. Moreover, the present study may be extended by selecting different samples from different elementary schools.

5 Conclusion

Postural variations and sagittal spinal deformities are common among the elementary school students of different ages. However, the postural deviations between young children and elder children in the first graders have not been previously studied. This study detected that young children have more spinal flexion than elder children. These posture variations may increase the risk of musculoskeletal disorders with growth. Moreover, sagittal spinal variations send prevention messages by encouraging the young children to maintain the proper postures and engage in different physical activities.

Conflict of interest

The authors declare that there is no conflict of interest.

References

Elizabeta

, Anastasika

and Leonid

. School screening for spine deformity with clinical test and spinal mouse device. Jokull Journal. 2013;63(7):97–105.

Hawes

and O’Brien

. The transformation of spinal curvature into spinal deformity: Pathological processes and implications for treatment. Scoliosis. 2006;1(1):3.

Somayeh

, Hamidreza

, Reza

, and Andrew

. Ergonomics evaluation of school bags in Tehran female primary school children. Work. 2017;56(1):175–181.

Ingrid

, Hellen

, Witness

, Nonceba

. The effect of a computer-related ergonomic intervention program on learners in a school environment. Work. 2015;51(4):869–877.

Andrzej

. Schoolbag weight carriage by primary school pupils. Work. 2014;48(1):26–12.

Oyewole

, Haight

, and Freivalds

. The ergonomic design of classroom furniture/computer work station for first graders in the elementary school. International Journal of Industrial Ergonomics. 2010;40:437–447.

Bubanj

, Živković

, Milenković

, Bubanj

, et al. The incidence of sagittal postural deformities among high school students: Preliminary study. Acta Kinesiologica. 2012;6(2):27–30.

Bogdanović

and Marković

. Presence of Lordotic poor posture resulted by absence of sport in primary school. Acta Kinesiologica. 2010;4(1):63–66.

Grimes

and Legg

. Musculoskeletal Disorders (MSD) in School Students as a Risk Factor for Adult MSD: A Review of the Multiple Factors Affecting Posture, Comfort and Health in Classroom Environments. Journal of the Human-Environmental System. 2004;7(1):1–9.

10.

Dockrell

and Kelly

. Computer-related posture and musculoskeletal discomfort in school children, International Ergonomics Association Conference. 2006; Maastrich, Nether-lands.

11.

Livanelioglu

, Kaya

, Nabiyev

, Demirkiran

, and Fırat

. The validity and reliability of “Spinal Mouse” assessment of spinal curvatures in the frontal plane in pediatric adolescent idiopathic thoraco-lumbar curves. European Spine Journal. 2016;25(2):476–482.

12.

Jung

, Cha

, Kim

, Won

, et al. Influence of pelvic asymmetry and idiopathic scoliosis in adolescents on postural balance during sitting. Bio-Medical Materials and Engineering. 2015;26(s1):S601–S610.

13.

Seckin

, Tur

, Yılmaz

, Yağcı

, Bodur

, and Arasıl

, The prevalence of joint hypermobility among high school students. Rheumatology International. 2005;25(4):260–263.

14.

Grivas

, Wade

, Negrini

, O’Brien

, et al. SOSORT consensus paper: School screening for scoliosis. Where are we today? Scoliosis. 2007;2:17.

15.

Bićanin

, Milenković

, Radovanović

, et al. Postural Disorders in Preschool Children in Relation to Gender. Physical Education and Sport. 2017;15(1):1–10.

16.

Guermazi

, Ghroubi

, Kassis

, et al. Validity and reliability of Spinal Mouse to assess lumbar flexion. Annales de Réadaptation et de Médecine Physique. 2006;49(4):172–177.

17.

Barrett

, McCreesh

, and Lewis

. Reliability and validity of non-radiographic methods of thoracic kyphosis measurement: A systematic review. Manual Therapy. 2014;19(1):10–17.

18.

Kellis

, Adamou

, Tzilios

. and Emmanouilidou G: Reliability of Spinal Range of Motion in Healthy Boys Using a Skin-Surface Device. Journal of Manipulative and Physiological Therapeutics. 2008; 31(8): 570-576.

19.

Mannion

, Knecht

, Balaban

, Dvorak

, and Grob

. A new skin-surface device for measuring the curvature and global and segmental ranges of motion of the spine: Reliability of measurements and comparison with data reviewed from the literature. European Spine Journal. 2004;13(2):122–136.

20.

Ripani

, Di Cesare

, Giombini

, Agnello

, Fagnani

, Pigozzi

. Spinal curvature: comparison of frontal measurements with the Spinal Mouse and radiographic assessment. The Journal of Sports Medicine and Physical Fitness. 2008;48(4):488–94.

21.

Topalidou

, Tzagarakis

, Souvatzis

, Kontakis

, and Katonis

. Evaluation of the reliability of a new non-invasive method for assessing the functionality and mobility of the spine. Acta of Bioengineering and Biomechanics. 2014;16(1):117–124.

22.

Alghadir

, Zafar

, Anwer

. Effect of footwear on standing balance in healthy young adult males. Journal of Musculoskeletal and Neuronal Interaction. 2018;18(1):71–75.

23.

Grabara

. Comparison of posture among adolescent male volleyball players and non-athletes. Biology of Sport. 2015;32(1):79–85.

24.

Ameer

, and Abdel-aziem

Relationship between anthropometric measures and sagittal spinal curvatures in adult male handball players. Human Movement. 2017;18(4):41–48.

25.

Maslen

, and Straker

. A comparison of posture and muscle activity means and variation amongst young children, elder children and young adults whilst working with computers. Work. 2009;32:311–320.

26.

Straker

, Coleman

, Skoss

, Maslen

, Burgess-Limerick

, and Pollock

. A comparison of posture and muscle activity during tablet computer, desktop computer and paper use by young children. Ergonomics. 2008;51(4):540–555.

27.

Imhof

, Faude

, Strebel

, Donath

, et al. Examining the Association between Physical Fitness, Spinal Flexibility, Spinal Posture and Reported Back Pain in 6 To 8 Year Old Children. Journal of Novel Physiotherapies. 2015;5(5):1000274.

28.

Widhe

. Spine: posture, mobility and pain. A longitudinal study from childhood to adolescence. European Spine Journal. 2001;10(2):118–123.

29.

Wojtys

, Ashton-Miller

, Huston

, and Moga

. The association between athletic training time and the sagittal curvature of immature spine. Poster Session - The Spine - VALENCIA FOYER. 46th Annual Meeting, Orthopaedic Research Society. 2000. Orlando, Florida.

30.

Mac-Thiong

, Berthonnaud

, Dimar

, Betz

, and Labelle

. Sagittal Alignment of the Spine and Pelvis During Growth. Spine. 2004;29(15):1642–1647.

31.

Obradović

, & Milošević

. Posture of preschool boys and girls at the age of 6. Journal of the Anthropological Society of Serbia. 2008;43:310–318.