Procedures of assessment on the quantification of thoracic kyphosis and lumbar lordosis by radiography and photogrammetry: A literature review

Accepted Manuscript Procedures of assessment on the quantification of thoracic kyphosis and lumbar lordosis by radiography and photogrammetry: a literature review Alessandra Beggiato Porto, MSc, Victor Hugo Alves Okazaki, PhD PII:

S1360-8592(17)30008-6

DOI:

10.1016/j.jbmt.2017.01.008

Reference:

YJBMT 1473

To appear in:

Journal of Bodywork & Movement Therapies

Received Date: 2 September 2016 Revised Date:

20 December 2016

Accepted Date: 3 January 2017

Please cite this article as: Porto, A.B., Okazaki, V.H.A., Procedures of assessment on the quantification of thoracic kyphosis and lumbar lordosis by radiography and photogrammetry: a literature review, Journal of Bodywork & Movement Therapies (2017), doi: 10.1016/j.jbmt.2017.01.008. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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Title: Procedures of assessment on the quantification of thoracic kyphosis and lumbar lordosis by radiography and photogrammetry: a literature review.

Alessandra Beggiato Porto - MSc1, Victor Hugo Alves Okazaki – PhD1 1

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Londrina State University – Laboratory of Research and Teaching on Biomechanics – Londrina, Paraná-Brazil

Conflict of interest: none

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This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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Corresponding Author: Alessandra Beggiato Porto Rua Espírito Santo, 875 apto 1202, Centro, Londrina-Paraná-Brasil [email protected]

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ABSTRACT The quantification of thoracic kyphosis and lumbar lordosis can be assessed in different

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ways; among them radiography and photogrammetry. However, the assessment procedures are not consistent in the literature for either method. The objective of this study was to conduct a literature review about postural assessment through radiography and photogrammetry, for delineating the procedures for both methods. In total 38

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studies were selected by an online search in the MEDLINE and LILACS databases with

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the keywords: radiograph and posture, postural alignment, photogrammetry or photometry or biophotogrammetry. For the radiographic method, the results showed divergences in arm positioning and in the calculation of thoracic and lumbar angles. The photogrammetry demonstrated differences in relation to the camera, tripod, plumb line and feet positioning, angle calculation, software utilization, and the use of footwear.

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Standardization is proposed for both methods to help establish normative values and comparisons between diagnoses.

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Keywords: Evaluation. Kyphosis. Lordosis. Radiograph. Photogrammetry.

ACCEPTED MANUSCRIPT INTRODUCTION Radiography and photogrammetry are methods of postural evaluation used to assess thoracic kyphosis and lumbar lordosis angles in the sagittal plane (De Oliveira

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Pezzan et al., 2011; Leroux et al., 2000a; Ran et al., 2014; Iunes et al., 2005). However, both methods present nonconformity in their analysis procedures that may interfere in the measures. Radiography, considered as the gold standard method of postural

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assessment, allows the quantification of the spine´s angles from calculations performed from the vertebrae visible through the x-ray (De Carvalho et al., 2010; Vacari et al.,

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2013). Normally, the calculations are obtained using the Cobb method (Kado et al., 2006; Harrison et al., 2001) by the intersection of a straight line drawn from the endplate of one vertebra of reference to a straight line drawn from the endplate of another vertebrae of reference (Findikcioglu et al., 2013; Kado et al., 2006; Harrison et

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al., 2001). However, the vertebrae of reference seem to vary between studies, which may lead to different measures, and make comparisons and establishment of normative values difficult.

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Arm positioning is another discrepancy in the radiologic assessment that may impair the assessment. Studies have described the arms forward with shoulders in

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different angles (Jang et al., 2007; Karaaslan et al., 2013; Ploumis et al., 2009), hanging onto a support (Boulay et al., 2006; Roussouly et al., 2005), crossed on the chest (Lee et al., 2014; Park et al., 2013) or relaxed in a free position (Mac-Thiong et al., 2004). Faro et al. (2004) showed differences up to

= 50 (DP=9) in thoracic kyphosis in

radiographies with arms flexed in front with elbows totally extended compared to elbows flexed with fists on the clavicles. As arm position may cause differences in angle measures, it is necessary to define which is more appropriate in radiography analysis, to avoid compromising the results.

ACCEPTED MANUSCRIPT Photogrammetry, on the other hand, is a reliable manner of obtaining information about an object and the environment through the measurement and interpretation of photography images, allowing quantification of the human body measurements (Tommaselli et al., 1999). However, in photogrammetry, the assessment

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is not only divergent regarding the vertebrae of reference as occurs in radiography, but also in the method used to assess the kyphosis and lordosis angles. For example, in the study of Iunes et al. (2005) the angles were obtained from the extension of three straight

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lines formed from markers attached to three vertebrae in relation to the plumb line. However, Saad et al. (2009) and Rodrigues et al. (2009) calculated the angles following

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the Cobb method. Therefore, to assess the posture through photogrammetry, some methodological issues need to be clarified, such as equipment assembly, calibration, and photograph quality.

According to Watson (1998), photographs can give a good support on the

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postural assessment. However, the photos must be of high quality and free from distortions, the equipment must be precisely set and remain in the same position during the assessment, and the ambient must be calibrated, appropriately illuminated, and

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provide privacy to the subject who is being photographed (Watson, 1998). As seen in radiography studies, discrepancies have also been noticed in photogrammetry studies.

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Therefore, it is necessary to identify the differences between the studies and set a suitable procedure that enables photogrammetry to be used as a good method of postural analysis.

Within this scope, both methods present divergences in their procedures that may make the analysis and diagnosis of postural deviation and the comparison between the measurements difficult. It is important to identify the divergences and establish an adequate procedure to avoid errors and measurement distortions. Indeed, no study was

ACCEPTED MANUSCRIPT found analyzing radiography and photogrammetry procedures in order to standardize the procedures of these methods. Therefore, the present study aimed to perform a review of the literature regarding the studies that assessed thoracic kyphosis and lumbar lordosis measurements through radiography and photogrammetry, in order to

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standardize an adequate procedure for each method that reduces errors, providing more reliability to the measures.

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METHOD

Studies from January 2000 to February 2015 were selected from the PubMed

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and Lilacs databases using the following keywords: a) radiograph and posture, b) postural alignment and c) photogrammetry or photometry or biophotogrammetry. The authors choose to select articles from 2000 in order to get recent information about how the postural evaluation have advanced in both method, once the postural assessment has

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been updating over the years with the equipment improvement and medical progress. The inclusion criteria established that the studies included the analysis of the thoracic kyphosis and lumbar lordosis through radiography or photogrammetry, in the

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sagittal plane and standing position. The exclusion criteria were; articles related to other parts of the body than the spine; samples including patients with: a) metabolic illness, b)

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cancer disease, c) any kind of prosthesis; studies of dentistry, postural control, range of motion; and literature reviews, meta-analysis and case studies.

RESULTS Figure 1 shows the flowchart of the selection of the articles. Our search in the databases resulted in 38 studies. Among them, 22 were related to radiography and 16 to photogrammetry. Tables 1 and 2 detail the procedures described in all studies found for

ACCEPTED MANUSCRIPT radiography (table 1) and photogrammetry (table 2). All selected studies reported that the radiograph and photos were taken in a standing position and a lateral view. However, studies with breast reduction surgical interventions, participants with idiopathic scoliosis, and pregnancy found in the search were also selected. The authors

the thoracic kyphosis and lumbar lordosis.

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INSERT FIGURE 1 HERE

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decided to keep these articles because they described the procedures of assessment of

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The radiography presented discrepancies in arm positioning during the x-ray exam and in reference vertebrae used for angle calculations. Among all the studies selected, nine did not mention the arm positioning. However, different arm positions were described in 13 studies, such as hands on a support in front at different heights,

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arms flexed forward at different degrees, fists on clavicles or arms crossed on the chest. The vertebrae of reference varied among the studies. For the thoracic kyphosis angle calculation, the majority of studies used the T1 superior endplate and T12 inferior

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endplate vertebrae as references and for the lumbar lordosis, the L1 superior endplate

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and S1 superior endplate were most frequently used as references (see table 1).

INSERT TABLE 1 HERE

The photogrammetry, on the other hand, demonstrated nonconformity in; positioning the participant/patient for the photo, setting calibrations, feet positioning and footwear, equipment assembly, photo resolution, analysis software, reference vertebrae, and method used for angle calculations. Among all the photogrammetry

ACCEPTED MANUSCRIPT studies selected, seven reported the use of a device between the feet, two positioned the patient on a wooden support base, and five studies used a mat to demarcate the feet positioning. The plumb line for the calibration was present in 10 studies, although it was placed in different positions.

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The camera distance varied between 1.95 m and 3 m and tripod height varied from 0.63 to 1.20m, but in two studies the tripod was set as half the patient’s height. The photo resolutions were reported in five studies and varied from 1600x1200 pixels to

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3072x2304 pixels. The most commonly used software was SAPO. Different vertebrae of reference and methods were used to calculate the angle. In six studies, the authors

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calculated the thoracic kyphosis angle by the intersection of a straight line linking the C7 spinous process to a horizontal extension of the T7 spinous process to the plumb line and a straight line linking the T12 spinous process to a horizontal extension of the T7 spinous process to the plumb line. However, in seven studies the lumbar lordosis angle

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was calculated by the intersection of a straight line linking the T12 spinous process to the horizontal extension of the L3 spinous process to the plumb line and a straight line linking the L5 spinous process to a horizontal extension of the L3 spinous process to the

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plumb line (see table 2).

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DISCUSSION

The present study aimed to perform a literature review of studies that assessed

the thoracic kyphosis and lumbar lordosis measurements through radiography and photogrammetry, in order to standardize an adequate procedure for each method that reduces errors, providing more reliability of the measures.

ACCEPTED MANUSCRIPT Different arm positioning was reported in the studies. Been and Kalichman, (2014), in a review study, highlighted that it is not advisable to place the arm at the sides of the body (neutral position), because the arm bones overlay the spine which may compromise the measurements. Furthermore, these authors also highlighted that the

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lack of standardization in arm position represents a problem when attempting to compare data and in the definition of normal values. Faro et al. (2004) showed that patients with idiopathic scoliosis assessed by radiography presented lower changes in

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the sagittal vertical axis and pelvic parameters with fists resting on the clavicles, when compared to the position in which the arms were forward from the shoulders at

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approximately 450 with elbow fully extended. However, no differences were found between the measures of the column segment between the two arm positions. Zaina et al. (2012) also analyzed the spine in different arm positions using video-rasterstereography with patients in a standing position. The authors verified

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differences in angle measurements between the positions, stressing the importance of arm position standardization when performing radiography. However, although the radiograph method shows reliability, there is no standardization for the arm positioning

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during the exam. Therefore, due to the lack of studies with different arm positioning, it is advisable to perform the radiograph with arms flexed and fists resting on the

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clavicles, ensuring that changes in the sagittal vertical axis and pelvic parameters do not occur. In addition, the angle calculation of the thoracic kyphosis and lumbar lordosis is another example of absence of standardization in radiography. Commonly, in radiograph assessments, the spine angle is measured by the Cobb angle method, which consists of determining the angle measurements of the spine through the intersection of the straight lines drawn from the endplate of one vertebra to the endplate of another (Harrison et al., 2001; Kado et al., 2006). According to Harrison

ACCEPTED MANUSCRIPT et al, (2001), this method can be passive of human errors when four straight lines are drawn to assess the angle. On the other hand, there is software to calculate the angles by the Cobb method that may contribute to reducing human error (Kado et al., 2006). However, Kado et al. (2006) analyzed the measurement reliability of radiography

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acquired manually and by digitized reading in a computerized program and verified that both methods showed high reliability (0.99 and 0.98, respectively), with practically the same kyphosis measurements ( =44.80 and SD=12.70).

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In the majority of studies with radiography in the present review, the calculation of the thoracic kyphosis was performed from a straight line drawn from the superior

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endplate of the T1 vertebra and inferior endplate of the T12 (Findikcioglu et al., 2013; Ghandhari et al., 2013; Harrison et al., 2002; Karaaslan et al., 2013; Park et al., 2013; Ploumis et al., 2009). In contrast, the lumbar lordosis angle was assessed from a straight line drawn from the superior endplate of the L1 vertebrae and superior endplate of the

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S1 vertebra (De Carvalho et al., 2010; Findikcioglu et al., 2013; Gonçalves and Pereira, 2008.; Jang et al., 2007; Karaaslan et al., 2013; Lee et al., 2014; Park et al., 2013; Pinto et al., 2000; Ploumis et al., 2009; Ran et al., 2014).

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To analyze the lumbar lordosis by the Cobb method, the affirmation of De Carvalho et al. (2010) agrees with the majority of studies mentioned in the results, in

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which to assess the lumbar lordosis angle, straight lines are drawn from the superior endplate of the L1 and superior endplate of the S1. On the other hand, some analyses were performed from the inferior endplate of the T12 (Souza et al., 2008; Harrison et al., 2002; Leroux et al., 2000) and inferior of the L5 (Ghandhari et al., 2013; Leroux et al., 2000). The review realized by Been and Kalichman (2014) analyzed different studies that used distinct vertebrae to assess the lumbar angle. These authors verified discrepant values obtained from the calculations based on the different endplates and

ACCEPTED MANUSCRIPT lumbar and sacral vertebrae. After the review, Been and Kalichman (2014) suggested that the lumbar angle assessment should be performed from the L1 superior endplate to the S1 superior endplate. The explanation was that all lumbar segments would be included in the lumbar lordosis measurements, as this would be the most commonly

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used measure.

(Damasceno et al., (2006), on the other hand, classified the measures of the lumbar portion in two regions, namely: (a) lumbolumbar, measured from the L1

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superior endplate to the L5 inferior endplate; and (b) lumbosacral, measured from the L1 superior endplate and S1 superior endplate. According to these authors, there was a

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difference of approximately 150 between the two portions. When they analyzed the intervertebral disc participation in the measurement, the authors found that, the L5/S1 intervertebral discs contributed to 26.07% of lumbosacral curvature (L1/S1) (Damasceno et al., 2006). Therefore, apparently, there is a divergence between the

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definition of the lumbar segment, which could be the segment compounded by its vertebral body and adjacent vertebral discs (L1/S1) or the segment compounded by two vertebral bodies and the disc interjacent between them (L1/L5).

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Eleven studies, from the total of 16 studies that assessed the lumbar lordosis by the Cobb method in this review, used as a reference the L1 superior endplate and the S1

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superior endplate. However, the thoracic kyphosis was assessed from the T1 superior endplate and T12 inferior endplate in six of the 10 studies that used the Cobb method, not considering the T12 subjacent intervertebral discs. Therefore, the existence of an agreement between the procedures is necessary, because, as seen, the thoracic angle involves only the vertebral bodies related to the region (T1 to T12) and for the assessment of the lordosis angle, the intervertebral discs between L5 and S1 are involved. Consequently, as a method of standardization, the thoracic kyphosis angle

ACCEPTED MANUSCRIPT assessment should be performed from the T1 superior endplate and T12 inferior endplate and the lumbar lordosis angles should be assessed from the L1 superior endplate and L5 inferior endplate (see figure 2). In other words, in this proposal, only the vertebral body that involves each region of interest would be considered, since the

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calculation including the vertebral discs would present different measures. Thus, the standardization procedure of the radiography method also needs to occur between the

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studies and clinical analysis.

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INSERT FIGURE 2 HERE

Alternatively, photogrammetry has been used in postural assessment due to the exposure to x-ray radiation and its high cost (Levy et al., 1995; Ron, 2003; Vacari et al., 2013). Nevertheless, several specific procedures to perform the photo may cause

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distortions and hinder the postural analysis, for example the participant/patient positioning at the moment the photo is taken. Mota et al. (2014) analyzed the influence of an individual´s body rotation on the

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photo analysis using software. They concluded that the participant´s body assessed perpendicularly to the camera demonstrated fewer measurement errors in relation to

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body rotations of 40, 80, and 120. This may happen when the participants are requested to change their position to pose for photos in different plains. Therefore, if the individual is not positioned perpendicularly to the camera, measurement errors may occur. Furthermore, the photo and environment calibration is another factor that can influence the measurements. The easiest and most useful way to perform the calibration in photogrammetry is using a plumb line. The calibration consists of finding a scale factor between the object-

ACCEPTED MANUSCRIPT space and space-image through previously known measures (Ricieri 2005). In addition, the plumb line is useful to recover the radial distortion parameters and lens decentralization (Tommaselli and Reiss., 2005). Therefore, when the plumb line is suspended in a stable place, it presents itself perpendicularly to the floor, arranged in a

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straight line. Thus, when its measurements is known, it becomes possible to relate the image values to the real object value and correct possible errors of image distortion.

Mota et al. (2014) also analyzed the calibration with different plumb line

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positions, such as (a) 0.5 meter, parallel to the participant, (b) 1 meter, parallel to the participant, (c) 1 meter, anterior to the participant and (d) 1 meter, posterior to the

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participant. Fewer measurement errors were observed when the 1-meter and 0.5-meter plumb lines were set parallel to the individual´s body. The largest errors found were with the plumb line positioned anteriorly and posteriorly to the participant´s body, due to parallax errors. Thereby, the software increases measurement errors, when the plumb

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line is placed next to or away from the camera and assigns the same distance values to the points marked on the plumb line (1-meter and 0.5-meter). However, the plumb line placed parallel to the individual, aligns the markers of analysis positioning placed on the

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participant, decreasing the parallax errors. The plumb line with a 1-meter demarcation length allowed the measures to remain close to the real individual´s measures, providing

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more precision (Mota et al., 2014). Therefore, it is suggested that the individual´s body be placed perpendicularly to the camera with the plumb line parallel to the body. Moreover, it is also important to use the plumb line with greater extension, preferably contemplating the participant´s height or a minimum of 1 meter to guarantee the accuracy of the image calibration. Several studies (Iunes et al., 2010; Lima et al., 2011; Iunes et al., 2008; Iunes et al., 2005; Morais et al., 2012) used a device between the participant´s feet, to maintain

ACCEPTED MANUSCRIPT the same feet position during the assessment, even when the participant was asked to change position, as happens in analysis in different plains (sagittal and coronal, for example). This instrument was also used to help keep the body perpendicular to the camera, since the device makes trunk rotation difficult. However, a device between the

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feet may direct the individual´s focus of attention to the feet and not to the evaluator directing the photo positioning, not allowing the participant to stand naturally.

The use of a device with a standardized width for all participants could also

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modify their posture, since the size of the bipedal support base adopted by each person does not follow a general pattern. Thus, as a way of standardizing the measure, it would

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be more appropriate to ask the participants to position themselves with a support base of the same width as the shoulders or hips, with feet parallel, to avoid body rotation. Consequently, in case of the possibility of a reevaluation or changes in position, it would be interesting to demarcate the shape of the feet on a specific mat, in order to

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maintain the same position. Therefore, it is important to use a specific mat to demarcate the feet position so that the posture adopted at the moment of the photo does not suffer variations in relation to the bipedal support base. However, it is necessary to maintain

photo.

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an individualized support base, avoiding distracting the individual when taking the

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Some studies reported the use of a wooden platform over the participant’s feet

(Penha et al., 2009; Saad et al., 2012). However, this platform was normally used when the assessment was performed with a symmetrograph, to visualize the feet in the first quadrant of the instrument (Kendall et al., 2007). Nevertheless, this technique is unnecessary for photogrammetry analysis, since it does not interfere in the postural assessment, while, on the other hand, it may cause changes in posture due to the individual’s exposure to a higher base. Finally, other procedures should not be forgotten

ACCEPTED MANUSCRIPT when assessing posture through photogrammetry, such as photographic equipment assembly, which should be carried out in a proper position and cannot be moved during the assessment; the participant´s privacy and comfort have to be guaranteed as well as adequate ambient illumination (Watson 1998). Consequently, in addition to the

which also present divergence between the studies.

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procedures to perform the photos, there are procedures to assess the angle calculations,

The studies presented in this review used different angle calculations to assess

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postural deviations. For example, some studies (Ferreira et al., 2011; (Graup et al., 2010; Rodrigues et al., 2009) performed the angle calculations through the Cobb

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method, that is, by the intersection of the projection of the two markers placed in the reference vertebrae process. However, there are also studies that chose to assess the thoracic kyphosis angles through the intersection of the straight-line extension of the markers placed on the C7 and T12 vertebrae in relation to the extension of a marker on

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the T7 to the plumb line. The lordosis lumbar angle assessment, was assessed through the intersection of straight-line extension of the markers on T12 and L5 in relation to a straight-line extension of the L3 marker to the plumb line (Lima et al., 2011; Iunes et

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al., 2010; Iunes et al., 2005; Iunes et al., 2009; Iunes et al., 2008; De Oliveira Pezzan et al., 2011). Moreover, some studies assessed the angle from the point of greater

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concavity and convexity of the regions of the spine (Dohnert and Tomasi, 2008; Saad et al., 2012). These divergences related to the angle calculation may occur due to lack of established procedures on photogrammetry and studies testing the reliability of the angle calculation method. We suggest that the thoracic kyphosis and lumbar lordosis angle should be assessed by the Cobb method as shown in Figure 3, since this is the most commonly used method in radiography and it is possible to calculate by the

ACCEPTED MANUSCRIPT photogrammetry method. Therefore, several pieces of software can be used to perform the angle calculations.

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INSERT FIGURE 3 HERE

The present review demonstrated the use of different software to aid the calculation of the angles, such as SAPO (de Oliveira Pezzan et al., 2011; Lima et al.,

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2011; Morais et al., 2012; Santos et al., 2012), Corel Draw (Penha et al., 2009; Saad et al., 2012), AUTOCAD (Rodrigues et al., 2009), ALCimagem (Iunes et al., 2009; Iunes

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et al., 2010; Iunes et al., 2005; Iunes et al., 2008), PEAK MOTION (Smith et al., 2008), and calculations in centimeters, not in degrees (Basso et al., 2010). However, no studies were found testing the reliability of Corel Draw, ALCimagem, PeakMotion or AUTOCAD on postural assessment. On the other hand, SAPO software is a free tool

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developed exclusively to assess posture, in which it is possible to assess the global body posture by calculation of angles and distances independently (Ferreira et al., 2011). Moreover, SAPO software provides accurate data, and is considered a reliable tool

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(Ferreira et al., 2011). Although, the calculation precision depends on the markers digitized in the software, adequate photo resolution helps to provide more accurate

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analysis.

The influence of image resolution on analysis was studied by (Sacco et al.,

2012), in which four image resolutions were manipulated (1536, 1200, 600, 384 pixels) from a reference resolution (768 pixels). The reference resolution (768 pixels) demonstrated good reliability between three measures of three raters. However, the photos manipulated with higher resolutions (1536 and 1200) presented excellent reliability between the same raters. Therefore, the authors concluded that the higher the

ACCEPTED MANUSCRIPT photo resolution the better the measure reliability will be. Thus, we advise that the photos should be taken with a resolution higher than 1200 pixels to decrease measure errors. Moreover, the postural assessment of the participant also seems to be influenced by the type of footwear worn.

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De Oliveira Pezzan et al. (2011) analyzed the lumbar lordosis behavior in 100 adolescents who did not wear high heeled shoes and adolescents that frequently wore high heeled shoes. These two groups were exposed to both conditions and differences

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between the conditions and groups were verified. Morais et al. (2012) analyzed the posture of 10 women who did not wear high heels frequently and 10 women that

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frequently wore high heels in three conditions: barefoot, sneakers, and high heels. No differences were found related to the type of footwear between the participants. Finally, Iunes et al. (2008) analyzed the thoracic kyphosis and lumbar lordosis of 20 women who often wore high heels and 20 women who sporadically wore high heels, in three

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conditions: barefoot, high platform heels, and high stiletto heels. No differences were found regarding the frequency of high heel use or the type of shoes. Despite the divergence found between these studies, the standardization of footwear is necessary in

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postural assessment. Although most people wear shoes most of the time, we suggest that the photos should be taken with the participant barefoot, because shoe standardization

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between the participants could be a complicating factor when performing the assessment.

CONCLUSION In conclusion, the radiograph exams presented two aspects that need to be standardized: a) the arm positioning and b) the vertebrae of reference for the Cobb angle calculation. It is suggested that the arm be positioned fully flexed with fists resting on

ACCEPTED MANUSCRIPT the clavicles. On the other hand, the Cobb angle should be calculated from the superior endplate of the T1 vertebra and inferior endplate of the T12 vertebra for thoracic kyphosis and for lumbar lordosis, the superior endplate of the L1 vertebra and inferior

calculated for both regions of the spine.

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endplate of the L5 vertebra. Thus, only the vertebral bodies are considered to be

For better analysis with photogrammetry, during the photos, the subject should be placed perpendicular to the camera, with a plumb line (at least one-meter long), and

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parallel to the measurement plain. These adjustments will diminish the parallax error and improve the measurement accuracy. We suggest that the Cobb method should be

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used to quantify the angles, as it is commonly used in radiograph analysis. A well trained evaluator, with experience and knowledge of anatomy should perform the anatomic palpation. Furthermore, the use of a foot device should not interfere in the support base or individual´s posture. The software of choice has to be reliable and

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appropriate for postural evaluation and preferably high-resolution photos should be

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taken with the participants barefoot.

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TABLES AND FIGURES

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Table 1: Procedures of thoracic kyphosis and lumbar lordosis assessment by radiography. Procedures Standing on a foot template, arms positioned slightly in front of the trunk.

Thoracic Kyphosis Calculations Superior endplate of T2 and inferior endplate of T12.

Lumbar Lordosis Calculations Inferior endplate of T12 and inferior endplate of L5.

Roussouly et al. (2005)

Superior endplate of T1 and inflection point*.

Inflection point* and superior endplate of S1.

Ran et al. (2014)

Erect and comfortable position, hands placed on a support and knee in extension. Information absent

Superior endplate of T5 and inferior of T12

Superior endplate of L1 and superior of S1

Ploumis et al. (2009)

Information absent

Superior endplate of T1 and inferior of T12.

Superior endplate of L1 and superior of S1.

Faro et al. (2004) “Scoliosis”

Hip and knee fully extended. Arms in two conditions: (1) Flexed forward, shoulders at 450 elbows fully extended; (2) fists on clavicles.

Harrison et al. (2002)

Hands placed anteriorly on a vertical pole at waist level.

Findkcioglu et al. (2013)

Barefoot

Jang et al. (2007)

Arms held at 600 of forward flexion, hips and knees fully extended.

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Araújo et al. (2014) Arms held on a support in front.

Mac Thiong et al. (2004)

Comfortable position and knees fully extended.

Endo et al. (2012)

Hands slightly crossed in front of the trunk.

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De Carvalho et al. (2010)

*Point where the lumbar lordosis transitions into thoracic kyphosis

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Author, year Leroux et al. (2000)

Segmented analysis: T2-T12; T5-T12; T10-L2 and L1- sacrum.

Superior endplate of T1 and inferior of T12 and superior of T2 and inferior of T11. Superior endplate of T1 and inferior of T12.

Inferior endplate of T12 and superior of S1.

Superior endplate of T5 and inferior of T12.

Superior endplate of L1 and superior of S1.

Superior endplate of L1 and superior of L1.

Inflection point* Superior endplate of L1 and superior of S1. Angles contained by the arcs of a circle used to model the thoracic and lumbar segments. Superior endplate of L1 and superior of L5.

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Table 1: Procedures of thoracic kyphosis and lumbar lordosis assessment by radiography - continuation Procedures Information absent

Thoracic Kyphosis Calculations Superior endplate of T4 and inferior of T12.

Lumbar Lordosis Calculations Superior endplate of L1 and inferior of L5.

Park et al. (2013)

Relaxed head position, looking straight ahead with arms crossed on the chest.

Superior endplate of T1 and inferior of T12.

Superior endplate of L1 and superior of S1.

Lee et al. (2014)

Arms crossed, looking forward and 150 upward, hip and knees fully extended.

Karaaslam et al. (2013)

Relaxed position and barefoot

Souza et al. (2008) Gonçalves and Pereira (2008)

Looking horizontally, knees extended and feet parallel Feet aligned, knees extended, weight evenly distributed on lower members, looking horizontally.

Inferior endplate of T12 and superior of L5. Superior endplate of L1 and inferior of L5 (lumbo-lombar). Superior endplate of L1 and superior of S1 (lumbo sacra)

Pinto et al. (2000)

Arms extended forward at shoulder height, barefoot and comfortable position.

Superior endplate of L1 and superior of S1.

Ghandhari et al. (2013)

Shoulders flexed at 900 with elbows fully flexed (fingers touching the ipsilateral shoulder).

Superior endplate of T1 and inferior of T12.

Superior endplate of L1 and inferior of L5.

Bouley et al. (2006)

Arms lying forward horizontally on a support.

Angle between the vertebrae the most forward tilted in sagittal plain.

Angle between the vertebrae the most backward tilted in sagittal plain.

Chaléat-Valayer et al. (2011)

Information absent

Angles contained by the arcs of a circle used to model the thoracic and lumbar segments.

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Author, year Mac Thiong et al. (2003)

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Superior endplate of T1 and inferior of T12.

Superior endplate of L1 and superior of S1.

Superior endplate of L1 and superior of S1.

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Table 2: Procedures of thoracic kyphosis and lumbar lordosis assessment by photogrammetry

Device of 7.5 cm between feet

Half of subject height

1m

Thoracic kyphosis calculations Camera resolution

Software

beside

8.1 megapixels

SAPO

Standing on a 12 cm support base

Symmetrography behind the subject

7.2 megapixels

CorelDraw

Device of 7.5 cm between feet

Parallel to the subject

Beside the subject

2.40 m

Lima et al. (2011)

2.85 m

1m

Device of 7.5 cm between feet

Donhert and Tomasi (2008)

2.40

0.85

Floor marked with an X

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Iunes et al. (2009)

ALCimagem

7.1 megapixels 3072x2304

SAPO

2592x1944

CorelDraw

Lumbar lordosis calculations

Angle formed between the point of greater concavity of the cervical and lumbar spine and the point of the highest convexity of the thoracic spine

Angle formed by the intersection of a straight line that links the spinous process of T12 to the horizontal extension of L3 to the plumb line and a straight line that links L5 to the horizontal extension of L3 to plumb line. Angle between the point of the greatest convexity of the thoracic spine and gluteal regions and the point of greater concavity of lumbar spine.

Angle formed by the intersection of a straight line that links the spinous process of C7 to the horizontal extension of T7 to the plumb line and a straight line that links T12 to the horizontal extension of T7 to plumb line. Angle formed by the intersection of a straight line that links the spinous process of C7 to the horizontal extension of T7 to the plumb line and a straight line that links T12 to the horizontal extension of T7 to plumb line. Angle formed by the extern vertex of the cervical lordosis apex and dorsal kyphosis apex

Angle formed by the intersection of a straight line that links the spinous process of T12 to the horizontal extension of L3 to the plumb line and a straight line that links L5 to the horizontal extension of L3 to plumb line. Angle formed by the intersection of a straight line that links the spinous process of T12 to the horizontal extension of L3 to the plumb line and a straight line that links L5 to the horizontal extension of L3 to plumb line. Angle formed by the extern vertex of the lumbar lordosis apex and dorsal kyphosis apex

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1m

Procedures Plumb line

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Feet base

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Saad et al. (2012)

Tripod height

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De Oliveira Pezzan et al. (2011)

Distance of the camera 2.40 m

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Author, year

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Table 2: Procedures of thoracic kyphosis and lumbar lordosis assessment by photogrammetry – continuation Feet base

1m

Device of 7.5 cm between feet

Rodrigues et al. (2009)

2.86 m

0.75 m

Santos et al. (2012)

3m

Half of subject height

Iunes et al. (2005)

2.40 m

1m

Graup et al. (2010)

3m

Smith et al. (2008)

Device of 7.5 cm between feet

Thoracic kyphosis calculations Camera resolution

Software

5.1 megapixels

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AutoCad

6.0 megapixels

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Plumb line in front, Symmetrography in front of the subject 1 meter on the right side

beside the subject

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1.20 m

Beside the subject

present

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Iunes et al. (2010)

Procedures Plumb line

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Tripod height

1600x1200 pixels

7.1 megapixels 3072x2304

SAPO

ALCimagem

Angle formed by the intersection of a straight line that links the spinous process of T12 to the horizontal extension of L3 to the plumb line and a straight line that links L5 to the horizontal extension of L3 to plumb line.

Angle formed by the acromion and the medium point of the nipples and the last rib and the inferior angle of the scapula as a vertex

Angle formed by the intersection of a straight line drawn parallel to the floor and tangent to the greater trochanter of the femur and the sacrum adjacent vertebrae

Angle formed by the intersection of a straight line that links the spinous process of C7 to the horizontal extension of T7 to the plumb line and a straight line that links T12 to the horizontal extension of T7 to plumb line.

Angle formed by the intersection of a straight line that links the spinous process of T12 to the horizontal extension of L3 to the plumb line and a straight line that links L5 to the horizontal extension of L3 to plumb line. Angle formed by the intersection of two straight lines drawn parallel to the markers Angle formed from a straight line drawn from T12, ISAS and trochanter markers

Not mentioned PeakMotion

Lumbar lordosis calculations

Angle formed by the intersection of a straight line that links the spinous process of C7 to the horizontal extension of T7 to the plumb line and a straight line that links T12 to the horizontal extension of T7 to plumb line. Angle formed by the intersection of two straight lines drawn parallel to the markers

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Distance of the camera 2.40 m

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Author, year

Angle formed from a straight line drawn from C7, T12 and trochanter markers

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Table 2: Procedures of thoracic kyphosis and lumbar lordosis assessment by photogrammetry – continuation

Penha et al. (2009)

2.40 m

1m

Wooden base support

Ferreira et al. (2011)

1.95

0.63

Mat with feet markers

Iunes et al. (2008)

2.40 m

1m

Device of 7.5 cm between feet

Basso et al. (2010)

3m

1m

Software

Parallel to the subject

7.2 megapixels 3072x2304

SAPO

Calibrated with the dimension of the wooden base support. Symmetrography in front of the subject

4.1 megapixels

CorelDraw

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Device of 7.5 cm between feet

Thoracic kyphosis calculations Camera resolution

SAPO

Parallel to the subject

1600x1200 pixels

ALCimagem

present

4.1 megapixel

SAPO

Lumbar lordosis calculations

Angle formed by the intersection of a straight line that links the spinous process of C7 to the horizontal extension of T7 to the plumb line and a straight line that links T12 to the horizontal extension of T7 to plumb line. Angle formed by the concave curvature between the superior cervical and the lumbar. The greater convex curvature as a vertex.

Angle formed by the intersection of a straight line that links the spinous process of T12 to the horizontal extension of L3 to the plumb line and a straight line that links L5 to the horizontal extension of L3 to plumb line. Angle formed by the convex curvature between the superior thoracic region and gluteal. The greater lumbar concave curvature as the vertex.

Calculated using the “x” and “y” coordinates as input in trigonometry, from T2 and T12 vertebrae. See Leroux, 2000

Calculated using the “x” and “y” coordinates as input in trigonometry, from T9 and S1 vertebrae. See Leroux, 2000

Angle formed by the intersection of a straight line that links the spinous process of C7 to the horizontal extension of T7 to the plumb line and a straight line that links T12 to the horizontal extension of T7 to plumb line.

Angle formed by the intersection of a straight line that links the spinous process of T12 to the horizontal extension of L3 to the plumb line and a straight line that links L5 to the horizontal extension of L3 to plumb line. Curve measured by a straight line drawn from a vertical plain tangent to the most prominent region of thoracic kyphosis (in cm)

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1m

Morais et al. (2012)

Procedures Calibration

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Feet base

TE D

Tripod height

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Distance of the camera 2.40 m

EP

Author, year

M AN U

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Figure 1: Flowchart of the article selection.

Figure 2: Suggestion of thoracic kyphosis and lumbar lordosis angle assessment by radiography using the Cobb method.

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Figure 3: Suggestion of thoracic kyphosis and lumbar lordosis angle assessment by photogrammetry.