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Journal of Back and Musculoskeletal Rehabilitation 28 (2015) 111–117 DOI 10.3233/BMR-140498 IOS Press
Relationship between standing postural alignments and physical function among elderly women using day service centers in Japan Susumu Otaa,∗ , Hiroshi Gotob , Yukari Nodac, Remi Fujitaa and Yasumoto Matsuid a
Department of Rehabilitation and Care, Seijoh University, Aichi, Japan Department of Physical Therapy, School of Health Sciences, Toyohashi SOZO University, Aichi, Japan c School of Social Work, Seirei Christopher University, Shizuoka, Japan d Department of Advanced Medicine, National Center for Geriatrics and Gerontology, Aichi, Japan b
Abstract. BACKGROUND: Posture and physical function have been quantified in mature adults, but not in elderly females. OBJECTIVE: To quantify standing posture and measures of physical function in community-dwelling women over the age of 65 years, and to examine relationships between these variables. METHODS: Fifty-three women were recruited from day care service users (average age: 83.7 ± 6.3 years old). Standing postural alignments were assessed using 2-dimensional analyses with a digital video camera. The time up and go test (TUG) and other physical function tests were conducted. RESULTS: Decreased lower cervical angle (increased forward head position) was significantly correlated with increased upper cervical angle (increased chin-up, r = −0.45), increased thoracic spine angle (increased kyphosis, r = −0.38), and decreased lumbar spine angle (thoracolumbar segments backward relative to the pelvis, r = 0.48). The decreased lumbar spine angle was significantly correlated with increased thoracic angle (increased kyphosis, r = −0.37), increased pelvic plane angle (increased anterior pelvic tilt, r = −0.49), and decreased knee flexion angle (r = 0.46). Increased TUG time (slower walking speed) was correlated to increased forward head position (r = 0.30) and thoracolumbar segments forward relative to the pelvis (r = 0.34). CONCLUSIONS: Posture and physical function measures were provided for community-dwelling females who were > 65 years of age. They did not demonstrate any correlation between measured knee strength, back strength or single leg standing with measures of postural alignment, but TUG showed a moderate correlation with the lower cervical and lumbar spine posture measures. Keywords: Posture, frail elderly women, physical function
1. Introduction In aging societies, maintaining or improving physical function, activities of daily living (ADL) and qual∗ Corresponding author: Susumu Ota, Department of Rehabilitation and Care, Seijoh University, 2-172 Fukinodai, Tokai, Aichi 4768588, Japan. Tel.: +81 52 601 6735; Fax: +81 52 601 6001; E-mail: [email protected].
ity of life (QOL) of the elderly are important, because they allow them to live independently and have longer, healthier lives. Posture change is one of the alterations that comes with aging, and thoracic kyphosis in particular has been studied in its relation to physical function [1,2]. Thoracic kyphosis was also reported to be associated with the risk of falling [2], poor QOL [3], and mortality [4]. Women are more predisposed to develop thoracic kyphosis than men [5], due to their
c 2015 – IOS Press and the authors. All rights reserved ISSN 1053-8127/15/$35.00
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S. Ota et al. / Relationship between standing postural alignments and physical function among elderly women
prevalence of vertebral fractures caused by osteoporosis and lower trunk extensor muscle [6,7]. However, recent studies have reported that the postural alignments focusing on kyphosis were not associated with physical functions [8] and functions according to self-reported QOL questionnaires [9] in cross-sectional study. The association with thoracic kyphosis and physical function remains controversial. Recent systematic review has concluded the need for high-quality randomized trials of studies related to posture with osteoporotic vertebral fracture and physical functions [10]. Many studies using posture assessment have recruited elderly people who were able to come to the place of assessment, or who were independent in activities of daily living as community-dwelling elderly [2, 5,9,11–13]. It was assumed that the subjects maintained relatively good physical function, and the elderly who required supervision during walking were not recruited as participants. Therefore, the relationships between measures of postural alignments and physical function in an elderly population with poor movement ability and high care needs remains to be examined. Clinically, forward head position has often been seen in the elderly [14], and has been described as having a connection to carpal tunnel syndrome [15], neck pain [16], as well as the occurrence of falls [17], and poor balance control assessed with Berg balance scale [18]. The assessment of forward head position is often made using the angle between the pass-through horizontal line and a line extending from the tragus of the ear to C7 [15–18]. However, Kuo et al. [19] pointed out that the measurement of the neck slope is influenced by knee bend and lean trunk, and they indicated that the neck-trunk angle using the suprasternal notch is an adequate method for forward head position with the elderly. Other reported features of elderly posture were the chin up position [19], decreased lumbar lordosis [20], and knee flexion position [21]. These features affect the whole body alignments, and this whole body posture in the elderly is called the flexed posture [22]. Unfortunately, there are few studies about the relationship between standing postural alignments, including head, neck and lower leg, and physical functions, and there are also few studies addressing relationships between each standing postural alignment in elderly people. If posture of particular body regions were to demonstrate a relationship with physical function, this would aid in the assessment and management of disorders in posture and physical function.
The purpose of this study is to quantify standing posture and measures of physical function in communitydwelling frail elderly women > 65 years of age, and to examine the associations between posture and physical function variables.
2. Materials and methods 2.1. Subjects Before the study was started, its contents were introduced at the Hanaso-kai, a day service center selfstudy group, at an explanatory meeting in Toyohashi City. Participants who were recruited from 5-day service center facilities gave their consent after a previous explanatory meeting. Inclusion criteria included > 65 years of age, being able to walk independently or under supervision, having no severe cognitive impairment (no orientation disorder and being able to do a 3-digit span backward). All of the measurements were made from August to September, 2010. Fiftythree women participated in this study (average age: 83.7 ± 6.3 years old), all participants were informed as to the nature of the study, and informed consent in writing was obtained, as required by the Ethics Committee of Nagoya University. 2.2. Posture evaluation The measurement of whole body posture was used according to previous reports [19,23]. Twelve spherical colored-reflective markers with a diameter of 30 mm were attached to specific anatomic landmarks of participants’ bodies in the standing position (Fig. 1). An ear marker was attached to the center of an earphone with an ear hook, and another face marker was attached to the midpoint between the right corner of the mouth and the right nasal ala. Suprasternal notch, T1 (T: thoracic vertebra), T3, T11, L1 (L: lumbar vertebra), S2 (S: sacral vertebra), anterior superior iliac spine (ASIS), greater trochanter, lateral epicondyle, and lateral malleolus also had markers attached. Participants wore black fitting shirts and short pants during video recording. The right side of the participants was videotaped as they stood with bare feet in a quiet erect position for 5 seconds and watched a target adjusted to eye height. Participants placed both hands lightly on a stable anterior support positioned approximately at the groin, and each had her posture measured three times. Subjects were allowed to sit in a chair dur-
S. Ota et al. / Relationship between standing postural alignments and physical function among elderly women
ing set up, and then their postures were recorded immediately after they stood stably. Figure 1 illustrates the angle definitions and calculations. The location of each skin reference marker on the 5-second videotaped images taken by a digital video camera (GR-D850, Victor Company of Japan, Limited, Japan) was automatically digitized at a frequency of 60 samples per second using a Total motion coordinator Lite (Toso System Ltd., Japan). The average of the three measurements of these posture data was used in the final analysis. An increase in upper cervical angle is associated with rotation about the ear to lift the chin. A decrease in lower cervical angle is associated with the head moving further forward relative to the thorax. Increased thoracic spine angle (flexion) indicates a greater thoracic kyphosis. Increased lumbar spine angle indicates that the thoracolumbar region is moving further forward relative to the pelvis. An increase in pelvic plane angle indicates an increasing anterior pelvic tilt. 2.3. Physical function The timed up and go (TUG) test, one–legged standing time with eyes open test (OLST), and tests of back muscle strength and knee extensor strength, were conducted as the physical fitness test, and four tests were chosen especially for the following reasons. First, the tests required simple methods and had to be conducted in a small space, because a few day service centers did not have enough extra space for the measurements. Second, TUG and OLST are the common physical function tests related to fall risk for elderly in community settings [24,25], and knee extension and back muscle strength was also associated with physical performance in the elderly [26–28]. Additionally, decreased back muscle strength was described in relation to increased kyphosis [6]. The measurement method used for each item is described below. The TUG procedure includes rising from a chair, walking 3 m, turning around, walking back, and sitting down again. The subjects were asked to walk 3 m at a normal speed. With the OLST, the length of time subjects were able to stand on one leg with their hands placed on their waist was measured using a stopwatch. The dominant leg was measured twice, and the maximum length of time was taken as the measured value. The dominant side was determined as the leg used to kick a ball. Isometric knee extension strength was tested twice using a hand-held dynamometer (Micro-FET2, Hog-
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Fig. 1. Marker placement and angle definitions: upper cervical angle (Face-Ear-T1), lower cervical angle (Ear-T1-Suprasternal notch), thoracic spine angle (the angle between the line of T1 and T3 and the line of T11 and L1), lumbar spine angle (the angle between the line of T11 and L1 and the line perpendicular to the line of S2 and ASIS), pelvic plane angle (absolute value in relation to horizontal line: the angle between the line of S2 to anterior superior iliac spine and horizontal dashed line), and knee joint angle (the angle between the line of greater trochanter and lateral epicondyle and the line of lateral epicondyle and lateral malleolus).
gan Health). The maximum isometric muscle strength of both legs was measured while the participant was sitting on a chair without a backrest and the knee was flexed to 90◦ . A testing pad was attached to the front lower leg of the participant and strapped to the leg of the chair. The participant was instructed to push the pad with maximal strength. Two trials were conducted, and the peak force of the higher score was recorded. Back muscle strength was determined from the maximal isometric strength of the trunk muscles in a standing posture with 30◦ lumbar flexion using a back muscle strength meter (TTM, Takei Co., Ltd., Japan). The maximum strength in each trial was measured, and the maximum force from two trials was used in the final analysis. 2.4. Reliability study Prior to the study we established the intratester reliability of each angle measurement on 2 separate days (day 1, day 2). Intratester reliability of each angle was assessed using ICC and 95% CI. Descriptive statistics of each angle on two separate occasions and test–retest
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S. Ota et al. / Relationship between standing postural alignments and physical function among elderly women Table 1 The reliability of measures of standing postural alignments
Upper cervical angle Lower cervical angle Thoracic spine angle Lumbar spine angle Pelvic plane angle Knee joint angle
ICC (1,3) 0.84 0.89 0.97 0.92 0.86 0.80
0.40 0.57 0.87 0.71 0.46 0.26
95% CI − − − − − −
0.96 0.97 0.99 0.98 0.96 0.95
Descriptive statistics of each angle on two separate occasions and test–retest reproducible results. ICC = indicates interclass correlation coefficient; CI = confidence interval. Table 2 Demographic and clinical characteristics of subjects Total number Age (years) Height (cm) Weight (kg) Timed Up and Go test (sec) One-legged standing time with eyes open (sec) Back muscle strength (kg) Knee extension strength, right (N) Knee extension strength, left (N) Upper cervical angle Lower cervical angle Thoracic spine angle Lumbar spine angle Pelvic plane angle Knee joint angle
53 83.7 (6.3) 142.9 (6.8) 46.6 (9.3) 15.4 (6.3) 4.2 (3.5) 23.3 (9.6) 126.8 (41.3) 124.3 (42.3) 127.5 (11.5) 61.9 (8.6) 41.5 (15.2) −8.7 (12.8) 1.8 (8.4) 20.1 (9.7)
Values are shown as the mean (SD).
reproducible results were presented in Table 1. Clinically, good reliabilities (ICC > 0.75) [29] were obtained. 2.5. Statistical analysis The relationships between standing postural alignments and between standing postural alignments and physical function were obtained using Pearson’s correlation. All analyses were performed using SPSS version 16. The significance level was set at P < 0.05.
3. Results Clinical characteristics of the subjects are shown in Table 2, and the average angles (± SD) of the lower cervical angle, thoracic spine angle, and lumbar spine angle were 61.9 ± 8.6 degrees, 41.5 ± 15.2 degrees and −8.7 ± 12.8 degrees, respectively. The average ± SD times of TUG and OLST in the participants were 15.4 ± 6.3 and 4.2 ± 3.5 seconds, respectively. Figure 2-A demonstrates statistically significant correlations between adjacent spinal regions, and between
A
B
Fig. 2. A. Schema shows significant relationships between all posture alignments. When the posture alignment angles change in the plus or minus direction, the parenthesized characteristic becomes stronger. For example, if the UCA (upper cervical angle) increases, the chin-up increases; and if the LCA (lower cervical angle) decreases, the forward head position increases. All values show the correlation of coefficient (P < 0.05) between each posture alignment. UCA = Upper cervical angle; LCA = Lower cervical angle; TSA = Thoracic spine angle; LSA = Lumbar spine angle; PPA = Pelvic plane angle; KJA = Knee joint angle; Th-L = thoracolumbar segments relative to the pelvis. B. Schema shows the significant relationship on the sagittal spine alignments. Decreased lower cervical angle (forward head position), increased thoracic spine angle (thoracic kyphosis), and decreased lumbar spine angle (thoracolumbar segments backward relative to the pelvis).
the lumbar angle and knee joint angle. Each angle between the lower cervical, thoracic spine, and lumbar spine angle were significantly correlated with each other, and the Fig. 2-B shows the schema of these relationships. Table 3 shows the correlations between each posture variable and each measure of physical function. The lower cervical and lumbar spine angles were significantly and positively correlated with the TUG time (0.30 and 0.34, respectively).
4. Discussion For the relationship between each measure of standing postural alignment, Fig. 2-A shows that there were
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Table 3 Correlation between measures of standing postural alignment and physical functions
Timed Up and Go test One-legged standing time with eyes open Back muscle strength Knee extension strength, right Knee extension strength, left ∗ Significant
Upper cervical angle 0.17 −0.19 −0.07 −0.08 −0.08
Lower cervical angle 0.30∗ 0.15 −0.02 0.17 −0.07
Thoracic spine angle −0.15 0.16 −0.16 −0.02 −0.01
Lumbar spine angle 0.34∗ −0.13 −0.19 0.04 −0.04
Pelvic plane angle 0.11 −0.09 0.16 −0.11 −0.10
Knee joint angle 0.12 −0.27 −0.02 0.04 0.04
at the 0.05 level.
significant correlations between the angles in the upper body regions, but not between the pelvic and knee joint angles. The adjacent alignments of standing posture from cervical to lumbar spine in the sagittal plane could be closely related in elderly women. Figure 2-B shows the schema of the correlation in cervical to lumbar spine alignments. However, because the present study was a cross-sectional study, the original alignment change was not verified. For the relationship between posture and physical function, lower cervical and lumbar spine angles were significantly and positively correlated with only the TUG time. The result revealed that increased TUG time (decreased walking speed) was significantly related to increased forward displacement of the head and thoracolumbar segments relative to the pelvis. The posture with forward head and thoracolumbar segments forward relative to the pelvis are thought to move the upper body mass forward, and the relations indicated that the elderly with the upper body mass further forward in standing posture would walk that much slower. However, the factors between the posture and movement could include a variety of sensory, perception cause and effects; and since there was no measurement for center of pressure in this study, it was not possible to evaluate any relationships between postural alignment or TUG and center of pressure. The average times of TUG and OLST in the participants were 15.4 and 4.2 seconds, respectively. Previous studies described the relationship between physical function and posture, especially thoracic kyphosis [1,2,5]. The physical function in participants of the previous study took around 9.5 seconds of the average TUG time [1]. The average OLST in the elderly of a similar age (average in 85-year-olds) was around 11–12 seconds in another study [30]. Therefore, physical function performance of the participants in this study is considered poor compared to those of previous study participants among the community-dwelling elderly [1,30]. In the present study, given that the subjects were very advanced in years with poor physical function, the standing postural alignments (forward
head position and thoracolumbar segments forward relative to the pelvis) and physical function (TUG) were significantly associated, but only two out of the 30 correlations assessed were statistically significant (6 angles × 5 measures of function). With low r values (r = 0.30 and r = 0.34 respectively), it is difficult to determine whether chance may have contributed to the statistical significance of one or both of these findings. Additionally, in a longitudinal study, there were no significant relations between kyphosis at the baseline and walking speed over 15 years [8]. The movement ability in the very elderly could include several factors involving exercise physiology, physical environment, and psychological variables. A recent systematic review of the intervention exercise (mainly back extensor training or manual therapy) for improving posture and physical functions (TUG) with osteoporotic vertebral fracture concluded that the intervention did not affect postural alignment [10]. However, the TUG test performance did improve with exercise intervention. This finding demonstrates that variables affecting postural alignment and the TUG test may be independent. A limitation of the present study is the lack of past and current medical information (i.e. comorbidities and medications) in these patients with vertebral fractures and osteoporosis, because the day service centers are not associated with medical facilities. However, posture in elderly patients is an important health issue, and these data represent an important step in understanding this process. The second limitation is that the study design was cross-sectional, therefore making it impossible to verify the cause-effect relationship between static postural alignments and physical movement ability. Future intervention or longitudinal studies are warranted to explore this relationship.
5. Conclusion In a cohort of 53 females who were > 65 years of age, it was found that increased forward head position
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was associated with increased chin-up, thoracic kyphosis, and posterior tilt of the lumbar spine relative to the pelvis. The values of lower cervical angle and lumbar spine angle were also correlated with performance in the timed up and go test, but other measures of strength and balance did not appear to be related to sagittal postural alignment.
Acknowledgments The authors are very grateful to the subjects and staff of the day service centers, Nanohana, Yayoi Ohjuen, Yoshidagata, Hosho Life, Aichi Clinic, and Kosumosu, for their generous cooperation. The study was supported by the Japan Society for the Promotion of Science (Grant-in-Aid for Scientific Research [C] #21500467).
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Journal of Back and Musculoskeletal Rehabilitation 28 (2015) 111–117 DOI 10.3233/BMR-140498 IOS Press
Relationship between standing postural alignments and physical function among elderly women using day service centers in Japan Susumu Otaa,∗ , Hiroshi Gotob , Yukari Nodac, Remi Fujitaa and Yasumoto Matsuid a
Department of Rehabilitation and Care, Seijoh University, Aichi, Japan Department of Physical Therapy, School of Health Sciences, Toyohashi SOZO University, Aichi, Japan c School of Social Work, Seirei Christopher University, Shizuoka, Japan d Department of Advanced Medicine, National Center for Geriatrics and Gerontology, Aichi, Japan b
Abstract. BACKGROUND: Posture and physical function have been quantified in mature adults, but not in elderly females. OBJECTIVE: To quantify standing posture and measures of physical function in community-dwelling women over the age of 65 years, and to examine relationships between these variables. METHODS: Fifty-three women were recruited from day care service users (average age: 83.7 ± 6.3 years old). Standing postural alignments were assessed using 2-dimensional analyses with a digital video camera. The time up and go test (TUG) and other physical function tests were conducted. RESULTS: Decreased lower cervical angle (increased forward head position) was significantly correlated with increased upper cervical angle (increased chin-up, r = −0.45), increased thoracic spine angle (increased kyphosis, r = −0.38), and decreased lumbar spine angle (thoracolumbar segments backward relative to the pelvis, r = 0.48). The decreased lumbar spine angle was significantly correlated with increased thoracic angle (increased kyphosis, r = −0.37), increased pelvic plane angle (increased anterior pelvic tilt, r = −0.49), and decreased knee flexion angle (r = 0.46). Increased TUG time (slower walking speed) was correlated to increased forward head position (r = 0.30) and thoracolumbar segments forward relative to the pelvis (r = 0.34). CONCLUSIONS: Posture and physical function measures were provided for community-dwelling females who were > 65 years of age. They did not demonstrate any correlation between measured knee strength, back strength or single leg standing with measures of postural alignment, but TUG showed a moderate correlation with the lower cervical and lumbar spine posture measures. Keywords: Posture, frail elderly women, physical function
1. Introduction In aging societies, maintaining or improving physical function, activities of daily living (ADL) and qual∗ Corresponding author: Susumu Ota, Department of Rehabilitation and Care, Seijoh University, 2-172 Fukinodai, Tokai, Aichi 4768588, Japan. Tel.: +81 52 601 6735; Fax: +81 52 601 6001; E-mail: [email protected].
ity of life (QOL) of the elderly are important, because they allow them to live independently and have longer, healthier lives. Posture change is one of the alterations that comes with aging, and thoracic kyphosis in particular has been studied in its relation to physical function [1,2]. Thoracic kyphosis was also reported to be associated with the risk of falling [2], poor QOL [3], and mortality [4]. Women are more predisposed to develop thoracic kyphosis than men [5], due to their
c 2015 – IOS Press and the authors. All rights reserved ISSN 1053-8127/15/$35.00
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S. Ota et al. / Relationship between standing postural alignments and physical function among elderly women
prevalence of vertebral fractures caused by osteoporosis and lower trunk extensor muscle [6,7]. However, recent studies have reported that the postural alignments focusing on kyphosis were not associated with physical functions [8] and functions according to self-reported QOL questionnaires [9] in cross-sectional study. The association with thoracic kyphosis and physical function remains controversial. Recent systematic review has concluded the need for high-quality randomized trials of studies related to posture with osteoporotic vertebral fracture and physical functions [10]. Many studies using posture assessment have recruited elderly people who were able to come to the place of assessment, or who were independent in activities of daily living as community-dwelling elderly [2, 5,9,11–13]. It was assumed that the subjects maintained relatively good physical function, and the elderly who required supervision during walking were not recruited as participants. Therefore, the relationships between measures of postural alignments and physical function in an elderly population with poor movement ability and high care needs remains to be examined. Clinically, forward head position has often been seen in the elderly [14], and has been described as having a connection to carpal tunnel syndrome [15], neck pain [16], as well as the occurrence of falls [17], and poor balance control assessed with Berg balance scale [18]. The assessment of forward head position is often made using the angle between the pass-through horizontal line and a line extending from the tragus of the ear to C7 [15–18]. However, Kuo et al. [19] pointed out that the measurement of the neck slope is influenced by knee bend and lean trunk, and they indicated that the neck-trunk angle using the suprasternal notch is an adequate method for forward head position with the elderly. Other reported features of elderly posture were the chin up position [19], decreased lumbar lordosis [20], and knee flexion position [21]. These features affect the whole body alignments, and this whole body posture in the elderly is called the flexed posture [22]. Unfortunately, there are few studies about the relationship between standing postural alignments, including head, neck and lower leg, and physical functions, and there are also few studies addressing relationships between each standing postural alignment in elderly people. If posture of particular body regions were to demonstrate a relationship with physical function, this would aid in the assessment and management of disorders in posture and physical function.
The purpose of this study is to quantify standing posture and measures of physical function in communitydwelling frail elderly women > 65 years of age, and to examine the associations between posture and physical function variables.
2. Materials and methods 2.1. Subjects Before the study was started, its contents were introduced at the Hanaso-kai, a day service center selfstudy group, at an explanatory meeting in Toyohashi City. Participants who were recruited from 5-day service center facilities gave their consent after a previous explanatory meeting. Inclusion criteria included > 65 years of age, being able to walk independently or under supervision, having no severe cognitive impairment (no orientation disorder and being able to do a 3-digit span backward). All of the measurements were made from August to September, 2010. Fiftythree women participated in this study (average age: 83.7 ± 6.3 years old), all participants were informed as to the nature of the study, and informed consent in writing was obtained, as required by the Ethics Committee of Nagoya University. 2.2. Posture evaluation The measurement of whole body posture was used according to previous reports [19,23]. Twelve spherical colored-reflective markers with a diameter of 30 mm were attached to specific anatomic landmarks of participants’ bodies in the standing position (Fig. 1). An ear marker was attached to the center of an earphone with an ear hook, and another face marker was attached to the midpoint between the right corner of the mouth and the right nasal ala. Suprasternal notch, T1 (T: thoracic vertebra), T3, T11, L1 (L: lumbar vertebra), S2 (S: sacral vertebra), anterior superior iliac spine (ASIS), greater trochanter, lateral epicondyle, and lateral malleolus also had markers attached. Participants wore black fitting shirts and short pants during video recording. The right side of the participants was videotaped as they stood with bare feet in a quiet erect position for 5 seconds and watched a target adjusted to eye height. Participants placed both hands lightly on a stable anterior support positioned approximately at the groin, and each had her posture measured three times. Subjects were allowed to sit in a chair dur-
S. Ota et al. / Relationship between standing postural alignments and physical function among elderly women
ing set up, and then their postures were recorded immediately after they stood stably. Figure 1 illustrates the angle definitions and calculations. The location of each skin reference marker on the 5-second videotaped images taken by a digital video camera (GR-D850, Victor Company of Japan, Limited, Japan) was automatically digitized at a frequency of 60 samples per second using a Total motion coordinator Lite (Toso System Ltd., Japan). The average of the three measurements of these posture data was used in the final analysis. An increase in upper cervical angle is associated with rotation about the ear to lift the chin. A decrease in lower cervical angle is associated with the head moving further forward relative to the thorax. Increased thoracic spine angle (flexion) indicates a greater thoracic kyphosis. Increased lumbar spine angle indicates that the thoracolumbar region is moving further forward relative to the pelvis. An increase in pelvic plane angle indicates an increasing anterior pelvic tilt. 2.3. Physical function The timed up and go (TUG) test, one–legged standing time with eyes open test (OLST), and tests of back muscle strength and knee extensor strength, were conducted as the physical fitness test, and four tests were chosen especially for the following reasons. First, the tests required simple methods and had to be conducted in a small space, because a few day service centers did not have enough extra space for the measurements. Second, TUG and OLST are the common physical function tests related to fall risk for elderly in community settings [24,25], and knee extension and back muscle strength was also associated with physical performance in the elderly [26–28]. Additionally, decreased back muscle strength was described in relation to increased kyphosis [6]. The measurement method used for each item is described below. The TUG procedure includes rising from a chair, walking 3 m, turning around, walking back, and sitting down again. The subjects were asked to walk 3 m at a normal speed. With the OLST, the length of time subjects were able to stand on one leg with their hands placed on their waist was measured using a stopwatch. The dominant leg was measured twice, and the maximum length of time was taken as the measured value. The dominant side was determined as the leg used to kick a ball. Isometric knee extension strength was tested twice using a hand-held dynamometer (Micro-FET2, Hog-
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Fig. 1. Marker placement and angle definitions: upper cervical angle (Face-Ear-T1), lower cervical angle (Ear-T1-Suprasternal notch), thoracic spine angle (the angle between the line of T1 and T3 and the line of T11 and L1), lumbar spine angle (the angle between the line of T11 and L1 and the line perpendicular to the line of S2 and ASIS), pelvic plane angle (absolute value in relation to horizontal line: the angle between the line of S2 to anterior superior iliac spine and horizontal dashed line), and knee joint angle (the angle between the line of greater trochanter and lateral epicondyle and the line of lateral epicondyle and lateral malleolus).
gan Health). The maximum isometric muscle strength of both legs was measured while the participant was sitting on a chair without a backrest and the knee was flexed to 90◦ . A testing pad was attached to the front lower leg of the participant and strapped to the leg of the chair. The participant was instructed to push the pad with maximal strength. Two trials were conducted, and the peak force of the higher score was recorded. Back muscle strength was determined from the maximal isometric strength of the trunk muscles in a standing posture with 30◦ lumbar flexion using a back muscle strength meter (TTM, Takei Co., Ltd., Japan). The maximum strength in each trial was measured, and the maximum force from two trials was used in the final analysis. 2.4. Reliability study Prior to the study we established the intratester reliability of each angle measurement on 2 separate days (day 1, day 2). Intratester reliability of each angle was assessed using ICC and 95% CI. Descriptive statistics of each angle on two separate occasions and test–retest
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S. Ota et al. / Relationship between standing postural alignments and physical function among elderly women Table 1 The reliability of measures of standing postural alignments
Upper cervical angle Lower cervical angle Thoracic spine angle Lumbar spine angle Pelvic plane angle Knee joint angle
ICC (1,3) 0.84 0.89 0.97 0.92 0.86 0.80
0.40 0.57 0.87 0.71 0.46 0.26
95% CI − − − − − −
0.96 0.97 0.99 0.98 0.96 0.95
Descriptive statistics of each angle on two separate occasions and test–retest reproducible results. ICC = indicates interclass correlation coefficient; CI = confidence interval. Table 2 Demographic and clinical characteristics of subjects Total number Age (years) Height (cm) Weight (kg) Timed Up and Go test (sec) One-legged standing time with eyes open (sec) Back muscle strength (kg) Knee extension strength, right (N) Knee extension strength, left (N) Upper cervical angle Lower cervical angle Thoracic spine angle Lumbar spine angle Pelvic plane angle Knee joint angle
53 83.7 (6.3) 142.9 (6.8) 46.6 (9.3) 15.4 (6.3) 4.2 (3.5) 23.3 (9.6) 126.8 (41.3) 124.3 (42.3) 127.5 (11.5) 61.9 (8.6) 41.5 (15.2) −8.7 (12.8) 1.8 (8.4) 20.1 (9.7)
Values are shown as the mean (SD).
reproducible results were presented in Table 1. Clinically, good reliabilities (ICC > 0.75) [29] were obtained. 2.5. Statistical analysis The relationships between standing postural alignments and between standing postural alignments and physical function were obtained using Pearson’s correlation. All analyses were performed using SPSS version 16. The significance level was set at P < 0.05.
3. Results Clinical characteristics of the subjects are shown in Table 2, and the average angles (± SD) of the lower cervical angle, thoracic spine angle, and lumbar spine angle were 61.9 ± 8.6 degrees, 41.5 ± 15.2 degrees and −8.7 ± 12.8 degrees, respectively. The average ± SD times of TUG and OLST in the participants were 15.4 ± 6.3 and 4.2 ± 3.5 seconds, respectively. Figure 2-A demonstrates statistically significant correlations between adjacent spinal regions, and between
A
B
Fig. 2. A. Schema shows significant relationships between all posture alignments. When the posture alignment angles change in the plus or minus direction, the parenthesized characteristic becomes stronger. For example, if the UCA (upper cervical angle) increases, the chin-up increases; and if the LCA (lower cervical angle) decreases, the forward head position increases. All values show the correlation of coefficient (P < 0.05) between each posture alignment. UCA = Upper cervical angle; LCA = Lower cervical angle; TSA = Thoracic spine angle; LSA = Lumbar spine angle; PPA = Pelvic plane angle; KJA = Knee joint angle; Th-L = thoracolumbar segments relative to the pelvis. B. Schema shows the significant relationship on the sagittal spine alignments. Decreased lower cervical angle (forward head position), increased thoracic spine angle (thoracic kyphosis), and decreased lumbar spine angle (thoracolumbar segments backward relative to the pelvis).
the lumbar angle and knee joint angle. Each angle between the lower cervical, thoracic spine, and lumbar spine angle were significantly correlated with each other, and the Fig. 2-B shows the schema of these relationships. Table 3 shows the correlations between each posture variable and each measure of physical function. The lower cervical and lumbar spine angles were significantly and positively correlated with the TUG time (0.30 and 0.34, respectively).
4. Discussion For the relationship between each measure of standing postural alignment, Fig. 2-A shows that there were
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Table 3 Correlation between measures of standing postural alignment and physical functions
Timed Up and Go test One-legged standing time with eyes open Back muscle strength Knee extension strength, right Knee extension strength, left ∗ Significant
Upper cervical angle 0.17 −0.19 −0.07 −0.08 −0.08
Lower cervical angle 0.30∗ 0.15 −0.02 0.17 −0.07
Thoracic spine angle −0.15 0.16 −0.16 −0.02 −0.01
Lumbar spine angle 0.34∗ −0.13 −0.19 0.04 −0.04
Pelvic plane angle 0.11 −0.09 0.16 −0.11 −0.10
Knee joint angle 0.12 −0.27 −0.02 0.04 0.04
at the 0.05 level.
significant correlations between the angles in the upper body regions, but not between the pelvic and knee joint angles. The adjacent alignments of standing posture from cervical to lumbar spine in the sagittal plane could be closely related in elderly women. Figure 2-B shows the schema of the correlation in cervical to lumbar spine alignments. However, because the present study was a cross-sectional study, the original alignment change was not verified. For the relationship between posture and physical function, lower cervical and lumbar spine angles were significantly and positively correlated with only the TUG time. The result revealed that increased TUG time (decreased walking speed) was significantly related to increased forward displacement of the head and thoracolumbar segments relative to the pelvis. The posture with forward head and thoracolumbar segments forward relative to the pelvis are thought to move the upper body mass forward, and the relations indicated that the elderly with the upper body mass further forward in standing posture would walk that much slower. However, the factors between the posture and movement could include a variety of sensory, perception cause and effects; and since there was no measurement for center of pressure in this study, it was not possible to evaluate any relationships between postural alignment or TUG and center of pressure. The average times of TUG and OLST in the participants were 15.4 and 4.2 seconds, respectively. Previous studies described the relationship between physical function and posture, especially thoracic kyphosis [1,2,5]. The physical function in participants of the previous study took around 9.5 seconds of the average TUG time [1]. The average OLST in the elderly of a similar age (average in 85-year-olds) was around 11–12 seconds in another study [30]. Therefore, physical function performance of the participants in this study is considered poor compared to those of previous study participants among the community-dwelling elderly [1,30]. In the present study, given that the subjects were very advanced in years with poor physical function, the standing postural alignments (forward
head position and thoracolumbar segments forward relative to the pelvis) and physical function (TUG) were significantly associated, but only two out of the 30 correlations assessed were statistically significant (6 angles × 5 measures of function). With low r values (r = 0.30 and r = 0.34 respectively), it is difficult to determine whether chance may have contributed to the statistical significance of one or both of these findings. Additionally, in a longitudinal study, there were no significant relations between kyphosis at the baseline and walking speed over 15 years [8]. The movement ability in the very elderly could include several factors involving exercise physiology, physical environment, and psychological variables. A recent systematic review of the intervention exercise (mainly back extensor training or manual therapy) for improving posture and physical functions (TUG) with osteoporotic vertebral fracture concluded that the intervention did not affect postural alignment [10]. However, the TUG test performance did improve with exercise intervention. This finding demonstrates that variables affecting postural alignment and the TUG test may be independent. A limitation of the present study is the lack of past and current medical information (i.e. comorbidities and medications) in these patients with vertebral fractures and osteoporosis, because the day service centers are not associated with medical facilities. However, posture in elderly patients is an important health issue, and these data represent an important step in understanding this process. The second limitation is that the study design was cross-sectional, therefore making it impossible to verify the cause-effect relationship between static postural alignments and physical movement ability. Future intervention or longitudinal studies are warranted to explore this relationship.
5. Conclusion In a cohort of 53 females who were > 65 years of age, it was found that increased forward head position
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was associated with increased chin-up, thoracic kyphosis, and posterior tilt of the lumbar spine relative to the pelvis. The values of lower cervical angle and lumbar spine angle were also correlated with performance in the timed up and go test, but other measures of strength and balance did not appear to be related to sagittal postural alignment.
Acknowledgments The authors are very grateful to the subjects and staff of the day service centers, Nanohana, Yayoi Ohjuen, Yoshidagata, Hosho Life, Aichi Clinic, and Kosumosu, for their generous cooperation. The study was supported by the Japan Society for the Promotion of Science (Grant-in-Aid for Scientific Research [C] #21500467).
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