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EVALUATION OF ISOKINETIC TRUNK MUSCLE

STRENGTH IN ADOLESCENTS WITH NORMAL AND


ABNORMAL POSTURES
Katarzyna Barczyk-Pawelec, PhD, a Jerzy Rafa Piechura, PT, PhD, b Wioletta Dziubek, PT, PhD, c and

Krystyna Roek, PT, PhD d

ABSTRACT
Objective: The aim of this study was to assess existing differences in the isokinetic trunk muscle strength in males
and females aged between 10 and 11 years depending on body posture.
Methods: The study included 145 children (67 males and 78 females) divided into 2 age groups: 10-year-old males
(x = 9.98 2.34 years) and females (x = 9.85 2.94 years) and 11-year-old males (x = 11.14 2.22 years) and
females (x = 11.15 2.32 years). Posture in the sagittal plane was assessed by photogrammetry using the moir projection
technique. Based on a classification system, the participants were divided into subgroups of males and females with normal
and abnormal postures. Trunk muscle strength was measured using isokinetic dynamometry.
Results: A high prevalence of abnormal posture in children aged between 10 and 11 years was observed, primarily
represented by an excessive curvature of the spine in the sagittal plane. The males and females with poor posture
recorded lower values in isokinetic trunk muscle strength.
Conclusion: The results of the study point to the need for the application of suitable physiotherapy treatment
(corrective measures/exercises) to treat musculoskeletal disorders to compensate for the loss of trunk flexor muscle
strength in children with improper posture. (J Manipulative Physiol Ther 2015;38:484-492)
Key Indexing Terms: Posture; Moire Topography; Muscle Strength

he normal curvature of a neutral spine consists of a


posteriorly convex curve in the upper back (thoracic)
region and anteriorly convex around the lower back
(lumbar) region. In this neutral position, the cervical and

T
a

Academic Teacher, Faculty of Physiotherapy and Occupational Therapy, Academy of Physical Education in Wroclaw,
Wroclaw, Poland.
b
Academic Teacher, Department of Physiotherapy and Occupational Therapy in Locomotor Dysfunction, Academy of
Physical Education in Wroclaw, Wroclaw, Poland.
c
Academic Teacher, Department of Physiotherapy and Occupational Therapy in Conservative and Interventional Medicine,
Academy of Physical Education in Wroclaw, Wroclaw, Poland.
d
Professor, Department of Physiotherapy and Occupational
Therapy in Conservative and Interventional Medicine, Academy
of Physical Education in Wroclaw, Wroclaw, Poland.
Submit requests for reprints to: K. Barczyk-Pawelec, PhD, PT,
Academic Teacher, Faculty of Physiotherapy and Occupational
Therapy, Academy of Physical Education in Wroclaw, al. I.J.
Paderewskiego 35, 51-612 Wroclaw, Poland.
(e-mail: kasiabar@autograf.pl).
Paper submitted October 14, 2013; in revised form August 29,
2014; accepted September 4, 2014.
0161-4754
Copyright 2015 by National University of Health Sciences.
http://dx.doi.org/10.1016/j.jmpt.2015.06.010

lumbar spine is slightly anteriorly convex, whereas the


thoracic spine is slightly convex posteriorly. In an abnormal
postural position, the pelvis may feature anterior, posterior, or
lateral tilt. Such pelvic obliquity involves abnormal simultaneous movements of the back and hip joints. 1
Generally, trends cultivated in modern society and the
changes observed in how leisure time is spent have caused
children to be considerably less physically active than in the
past. This has led to adverse effects on the health, posture, and
physical fitness of today's youth. Abnormal body posture has
become a major issue of concern for parents, teachers, and
health professionals. 2 This is especially so as correct posture
is an important component of a healthy musculoskeletal
system. 3 It allows for the body to be neutrally aligned without
involving excessive muscular effort or overloading the
supporting structures of the musculoskeletal system. 4
Research on posture and the identification of the
interrelationships between the positioning of various body
segments by using a variety of measurement methods has
been of core interest for many researchers. 2,5-11 One of the
most frequently reported research methods is the use of
radiography, with most studies focusing on the position of
the pelvis and its impact on maintaining balance in an
upright standing position. 5,6,8 Significant relationships

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Volume 38, Number 7

were observed between the position of the pelvis and other


body segments depending on sex and age.
Other studies used photography (photogrammetry) to
assess posture by using surface markers to determine
bilateral symmetry, 12 which was regarded as a determinant
of correct postural alignment. The use of photography is
considered to be a reliable and valid tool in assessing the
posture of children in the sagittal and coronal planes 9 -11
and, most importantly, does not expose children to any
harmful radiation devices. Other authors have also
emphasized that photography is applicable in assessing
the shape of the spine in the anterior-posterior plane to areas
such as diagnosing posture and also finding the incidence of
normal/abnormal posture in a population. 7 Also noteworthy
are studies presenting a body posture classification system
based on photogrammetric research on large populations of
children and adolescents. 7,13,14
Apart from the aforementioned methods, an assessment
of muscle function has recently come to the forefront as a
diagnostic tool in evaluating posture. Measurement of
muscle function has been previously used in a wide gamut
of analysis in physiotherapy, physical education, and sports
and also in monitoring the efficacy of therapy and training
programs. Several studies have determined a significant
relationship between the curvature of the spine in the
sagittal plane and trunk muscle strength in a variety of cases
as well as in individuals with musculoskeletal
disorders 15 -18 Today, one of the most reliable and accurate
methods of assessing muscle function is considered to be by
isokinetic dynamometry and has been subject to numerous
studies. 15 -20 However, both isokinetic dynamometry and
the other various methods available for assessing muscle
function have largely been carried out on adults, with little
research available on children and adolescent populations.
In addition, no reports defining the relationship between
body posture and trunk muscle function are available in
healthy children at ages critical in the development of
correct posture. From a biological standpoint, the age of
between 10 and 11 years is considered to be an important
stage in life as it marks the period when maturation begins,
with the onset of puberty at approximately 10 years of age
in females and around 12 years in males. There is
nonetheless a wide age range when maturation begins due
to genetically determined growth rate, environmental
factors, and lifestyle. 21 However, studies have shown that
musculoskeletal disorders may develop even before the
initial phase of puberty. 10,22
It is, therefore, necessary to conduct research that, alongside
an assessment of posture, evaluates trunk muscle strength in
regard to the different types of posture children can exhibit.
Knowledge of these interrelationships can help identify early
musculoskeletal irregularities and develop effective treatments. Therefore, the goal of this study was to evaluate
isokinetic trunk muscle strength in a group of adolescents aged
between 10 and 11 years in relation to posture.

Barczyk-Pawelec et al
Posture and Muscle Strength in Adolescents

METHODS
Participants
The study was composed of 145 children (67 males and
78 females) aged between 10 and 11 years from randomly
selected primary schools located in the city of Wrocaw,
Poland. The schools were located in close proximity to the
city center and had similar educational and athletic
facilities. All the children attending these schools and
meeting the age requirement were selected for inclusion.
All lived in the city boroughs belonging to each school's
district.
A preliminary orthopedic examination was used to
eliminate children with any discrepancies in leg length,
scoliosis, exaggerated kyphosis or lordosis, or any
musculoskeletal disorder.
Written parental consent was obtained for every
participating child. The children who met the right criteria
for participation were then divided into 2 groups: younger
group, 31 males and 48 females aged 10 years (x = 9.98
2.43 and x = 9.85 2.94 years, respectively), and older
group, 34 males and 32 females aged 11 years (x = 11.14
2.22 and x = 11.15 2.32 years, respectively).
The research was performed by the same group of
researchers, at the same time of day (morning hours), and in
similar conditions at each school. Due consent was obtained
from the school districts, the participating children, and
their parents. The study procedure was approved by the
Ethics Committee for Scientific Research of the University
of Physical Education in Wroclaw, Poland.
It was assumed that trunk muscle strength will depend on
age and the anterior-posterior curvatures of the spinal
column, where children with abnormal posture would
record lower values of isokinetic trunk muscle strength due
to increased thoracic kyphosis and lumbar lordosis when
compared to children with right posture.

Postural Assessment
The participants' body height, weight, and body mass
index (BMI) were measured. 23 Posture was assessed by
photogrammetry using a projector/camera system 24 from
CQ Electronic (www.cq.electronicsystem.com). This system is based on the moir projection technique and
topographically measures the curvature of the spinal
column by having anatomical markers placed on the back.
The moir phenomenon is a type of optical distortion
created by the interference of light waves, as if an image
was refracted. A light is used to project a series of visible
lines on the surface of the back, which, at different angles,
are distorted depending on the distance of each anatomical
marker from the projector, mirroring the shape of the back.
A camera records the image, and the software is used to
create a contour map of the entire observed surface, in effect
providing a 3-dimensional coordinate image of the back.

485

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Barczyk-Pawelec et al
Posture and Muscle Strength in Adolescents

Measurement of the anterior-posterior curvature of the


spine was performed by having each child undress to their
underwear and stand facing backwards toward the projector/
camera at a distance of 2.6 m. Markers were placed on the
spinous processes of the C7-S1 vertebrae. Each child was
made to assume a habitual posture, relaxed standing position.
The child was made unaware of to what extent their back was
being photographed, and as a precaution, a series of images
were taken to best capture natural standing posture. Posture
was assessed by evaluating the following angular parameters
of the spine (degree) (Fig 1): thoracic spinal curvature (),
thoracolumbar spinal curvature (), and lumbosacral spinal
curvature ().
The accuracy of the projector/camera device in terms of
image resolution and angular dimensions is 1 mm and 0.1.
However, in practice, it is almost impossible to ascertain
physiological points on the skin to an accuracy smaller than
5 mm due to various anthropometric interferences. Hence, a
value of 10 mm was adopted as the maximum deviation for
all anatomical markers. 25
The posture of each child was classified by mathematical
(trigonometric functions) and statistical ( 2 test for
significance levels of P = .01 and P = .05) models
according to Wolaski 26 as modified by Zeyland-Malawka. 27
On this basis, the children were divided into 2 groups
according to posture. The study group included children
with abnormal posture where the combined value of the
angle of the thoracic and thoracolumbar spinal curvatures
exceeded 29 and where the combined value of the angle of
the thoracolumbar and lumbosacral spinal curvature was
greater than 25. The control group was composed of children
with correct posture for whom the combined value of the
angle of the thoracic and thoracolumbar spinal curvatures was
less than 28 and the combined value of the angle of the
thoracolumbar and lumbosacral spinal curvature did not
exceed 24.

Examination of Trunk Muscle Function


The strength of the trunk muscles (flexors and extensors)
was assessed using a Biodex Multi-Joint System 3
dynamometer. At an angular speed of 60/s, each child
performed 5 repetitions of sagittal trunk extension and
flexion without interruption, followed by a rest for 3
minutes, and then 10 repetitions at 120/s without
interruption. These speeds were selected as they are
considered to be the most suitable measures of strength
(60/s) and endurance (120/s), and that slow speed tests are
generally conducted with 5 repetitions and faster speeds are
usually performed for 10 to 15 repetitions. 28,29
The seat and the dynamometer were adjusted for each
child before testing so that the lower cushion of the
dynamometer was at the height of L5/S1 spine segment.
The range of motion was configured to be approximately
90 (35 extension and 55 flexion). The trunk and thighs

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September 2015

Fig 1. The points and parameters needed to calculate the shape of

curvature of the spine. Legend: , inclination angle of an upper


part of the thoracic spine; , inclination angle of a thoracolumbar
spine; , inclination angle of a sacrolumbar spine.

were stabilized by straps attached to the seat so as to provide


proper support and stability. The starting position began
with a maximum extension of the trunk. The children were
told to complete the extensions and flexions using their
maximum strength as fast as possible.
The recorded torque values over time for each
participant were used to calculate variables describing the
force-velocity characteristics of the examined muscle
group, being 16,29:
- Peak torque (the single highest torque value recorded
regardless of motion range) (Newton meter): peak torque
of the extensor muscles (PT E60 and PT E120), peak
torque of the flexor muscles (PT F60 and PT F120).
- Total work (the total volume of work under the torque
curve with each repetition regardless of speed, range of
motion, or time) (joules): total work done by the extensor
muscles (TW E60 and TW E120); total work done by
the flexor muscles (TW F60 and TW F120).
- Opposing muscle group work ratio (the agonist to
antagonist ratio of muscle strength) (percentages):
agonist to antagonist ratio (A/A E60 and A/A F60
and A/A F60 and A/A F120).

STATISTICAL ANALYSIS
Statistical analysis was performed using Microsoft Excel
and Statsoft Statistica PL 8.0 software. All raw data were
analyzed. Normality of the raw data was checked using the
Shapiro-Wilk test, 30 with findings that the hypothesis of

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Barczyk-Pawelec et al
Posture and Muscle Strength in Adolescents

Table 1. Characteristics of Participants


Height (cm)
Sex
Male
Female

Age Group
10
11
10
11

y (n
y (n
y (n
y (n

= 31)
= 34)
= 48)
= 32)

Body Weight (kg)

Mean (SD)

Statistical Difference

Mean (SD)

Statistical Difference

139.71 (6.86)
147.35 (5.45)
139.61 (6.70)
145.09 (7.12)

0.0000 a

33.68 (6.48)
41.14 (8.41)
35.46 (7.71)
37.87 (6.87)

0.0002 a

0.0004 a

0.8042

Values are expressed as mean (SD).


a
P .05.

Table 2. Mean and SD of the Anteroposterior Spinal Curves and Force-Velocity Parameters of Trunk Muscles in Males With Correct
and Incorrect Postures
Correct Posture, n = 19

Incorrect Posture, n = 46

10 y, n = 10

11 y, n = 9

10 y, n = 21

11 y, n = 25

Parameter

Mean (SD)

Mean (SD)

Mean (SD)

Mean (SD)

Angle
Angle
Angle
PT E60
PT F60
TW E60
TW F60
PT E120
PT F120
TW E120
TW F120
A/A E60
A/A F60
A/A E120
A/A F120

12.8 (2.1)
10.8 (2.8)
13.1 (1.9)
112.8 (36.2)
72.5 (19.8)
424.7 (45.3)
284.2 (77.9)
129.0 (37.0)
93.5 (18.9)
1014.5 (490.2)
705.9 (241.7)
63.5 (16.3)
66.3 (1.2)
60.6 (15.9)
71.2 (23.5)

10.8 (2.65)
9.5 (2.4)
15.4 (3.4)
147.7 (12.4)
90.1 (12.3)
616.8 (86.8)
353.0 (74.6)
163.3 (21.7)
92.6 (13.2)
1527.8 (321.4)
853.5 (203.6)
62.9 (9.7)
49.0 (9.6)
58.7 (12.2)
51.0 (11.0)

13.9 (4.98)
15.6 (2.7)
16.6 (3.3)
106.3 (26.4)
69.7 (14.9)
382.6 (132.8)
242.2 (63.9)
127.5 (23.4)
76.5 (15.6)
910.6 (297.3)
550.1 (175.6)
64.6 (17.4)
67.2 (10.7)
61.6 (16.9)
72.7 (22.1)

15.2 (4.18)
13.8 (2.3)
16.5 (3.04)
133.4 (28.9)
86.8 (20.5)
543.6 (139.8)
323.2 (52.3)
151.6 (32.9)
86.9 (10.9)
1394.6 (430.0)
786.9 (173.6)
63.5 (10.2)
50.7 (10.2)
59.1 (12.7)
57.7 (3.6)

Values are expressed as mean (SD).


A/A E60 (%), A/A F60 (%), A/A E120 (%), and A/A F120 (%), muscle ratios: agonists-to-antagonists ratio; angle , lumbosacral spinal curvature;
angle , thoracolumbar spinal curvature; angle , thoracic spinal curvature; PT E60 and PT E120, maximum force moment of extensor muscles;
PT F60 and PT F120, maximum force moment of extensor muscles and flexor; TW E60 and TW E120, the work of all repositions for the
extensor muscles; TW F60 and TW E120, the work of all repositions for the flexor muscles.

normal distribution was not rejected. Descriptive statistics


(mean and SD) were calculated for each variable. Comparison
of the somatic characteristics, BMI, and isokinetic trunk muscle
strength characteristics of the trunk muscles in both age groups
of the males and females with normal and abnormal posture
was performed using the post hoc least significant difference
(LSD) test. Statistical significance was set at P .05.

RESULTS
Analysis of the somatic features showed significant
differences in body height between the separate age groups
of the males and females. In addition, statistically
significant differences were found in body weight between
the older and younger group of males (Table 1).
Table 2 presents the spinal curvatures and force-velocity
characteristics of the trunk muscles for the 2 age groups of
males with normal and abnormal postures. Irrespective of
age, higher angular values of the analyzed spine segments

were found in males with abnormal posture, whereas the


trunk muscle force-velocity characteristics were higher in
both age groups of males with normal posture (Table 2). The
spinal segment that differentiated the males with normal and
abnormal postures was angle (P .05). Irrespective of
muscle group (extensors vs flexors) and tested angular
velocity ( = 60/s vs = 120/s), the groups of older males
with normal and abnormal postures achieved significantly
higher values of these variables compared with the younger
groups of males (P .05). In addition, the males with correct
posture achieved higher values of all the measured variables
compared with their peers with abnormal posture, albeit these
differences were not statistically significant (Table 3).
In the females, higher angular values of the spinal
segments were found among females with abnormal posture
regardless of age (Table 4). In both age groups, the spinal
segment that differentiated female with normal and
abnormal postures was angle (P .05) (Table 4).
Among the younger females, higher values of the trunk
muscle force-velocity characteristics were found in females

487

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Barczyk-Pawelec et al
Posture and Muscle Strength in Adolescents

Journal of Manipulative and Physiological Therapeutics


September 2015

Table 3. Least Significant Difference Test Between the Size of the


Anteroposterior Spinal Curves and Force-Velocity Parameters of
Trunk Muscles in Males With Correct and Incorrect Postures
LSD Test
Parameter
Angle
Angle
Angle
PT E60
PT F60
TW E60
TW F60
PT E120
PT F120
TW E120
TW F120
A/A E60
A/A F60
A/A E120
A/A F120

CP1-CP2
0.2750
0.2978
0.1133
0.0032 a
0.0229 a
0.0016 a
0.0292 a
0.0043 a
0.9119
0.0037 a
0.1298
0.4112
0.0213 a
0.2114
0.0145 a

CP1-ICP1
0.4713
0.0000 a
0.0032 a
0.5042
0.6665
0.3981
0.1106
0.9615
0.0138 a
0.4759
0.0301 a
0.6952
0.5662
0.5116
0.4998

CP2-ICP2
a

0.0047
0.0001 a
0.3412
0.1483
0.6161
0.1481
0.2615
0.2444
0.4071
0.3669
0.5007
0.5241
0.4332
0.5291
0.1669

ICP1-ICP2
0.2568
0.0240 a
0.8642
0.0004 a
0.0007 a
0.0000 a
0.0001 a
0.0029 a
0.0500 a
0.0000 a
0.0000 a
0.3695
0.0311 a
0.2585
0.0201 a

A/A E60 (%), A/A F60 (%) and A/A E120 (%), and A/A F120 (%),
muscle ratios: agonists-to-antagonists ratio; Angle , lumbosacral spinal
curvature; angle , thoracolumbar spinal curvature; angle , thoracic
spinal curvature; CP1, correct posture in 10-year-old males; CP2, correct
posture in 11-year-old males; ICP1, incorrect posture in 10-year-old males;
ICP2, incorrect posture in 11-year-old males; PT E60 and PT E120,
maximum force moment of extensor muscles; PT F60 and PT F120,
maximum force moment of extensor muscles and flexor; TW E60 and TW
E120, the work of all repositions for the extensor muscles; TW F60 and
TW E120, the work of all repositions for the flexor muscles.
a
P .05.

with normal posture, although these results were not


statistically significant (Table 5). Higher values of these
characteristics were found in females with abnormal posture
in the older age group, with these differences being
statistically significant (P .05) (Table 5).

DISCUSSION
In this study, analysis of the participants' somatic
features showed significant differences in body height
between the 2 age groups of the males and females. The
observed differences between the groups of males demonstrate that the children are at the prepubertal dip, when
growth slows down at around 10 years of age only to be
followed by the pubertal growth spurt. 21 This tendency has
been observed by other authors evaluating the variability of
somatic characteristics during puberty in children from
Lithuania, Germany, and Japan. 31 -33
The children in this study were classified according to their
body posture based on a longitudinal study of sagittal spinal
curvature in a sample population of more than 3000 urban
children and adolescents from Poland. 26 In the study, the state
of health of the participants and the curvature ranges of the
thoracic kyphosis and lumbar lordosis were used to develop
and present, using mathematical and statistical models, a list of
characteristic types of postures at a given age.

Based on this classification system, using the segmental


angles of the spine, the results of our study showed that the
incidence of abnormal posture was high in the studied
group. It was found that only 30% of the participating males
and females had correct posture, whereas more than 70%
featured poor posture. In the group of children with
abnormal posture, all of the analyzed angular parameters
of the anterior-posterior curvatures of the spine were higher,
although in most cases, the differences between the children
with normal and abnormal postures were not statistically
significant. The only exception was thoracolumbar spinal
curvature (). In both age groups of males, those with
proper posture obtained statistically significantly lower
values (10.8 2.8 and 9.5 2.4) compared with the
males with abnormal posture (15.6 2.7 and 13.8
2.3). A similar situation was observed in the groups of
females with normal posture (10.7 1.8 and 7.6 1.3)
and abnormal posture (15.0 3.1 and 13.2 2.9). The
differences between these angular values were statistically
significant (P .05). Using the classification structure
adopted in this study, the angle of this curve was measured
between the top of the thoracic kyphosis and lumbar
lordosis and by the plumb line from the peak of the thoracic
kyphosis. Angle , as such, determines the segment of the
spine above the peak angle of lumbar lordosis, with our
findings showing that children with abnormal posture
presented significantly larger values. It can be inferred that
correcting the size of this angle would most likely improve
their posture. It is nonetheless difficult to compare the
results of this study with those reported in available
literature as the method used to measure the anteriorposterior curvature of the spine, which was developed for a
population of Polish children.
In the available literature, there is a lack of large
population-based studies using the photogrammetric (moir
projection) method and similar posture classification categories to which our results could be compared. However, other
studies measuring similar variables were found albeit using
different measurement methods. Pausi and Dizdar, 7 using
photogrammetry and Image Posture Analyzer Cluster
Analysis Software, assessed the anterior-posterior curvature
of the spine and trunk asymmetry in a group of males aged
between 10 and 13 years. They defined 3 types of sagittal
posture in the group, where 29.3% of the males had
correct sagittal body posture, 41.8% were with mild impaired
sagittal body posture, and 28.9% featured marked impaired
sagittal body posture. In the frontal plane, their examination
showed that 19.4% had symmetrical posture, 47.6% featured
mild scoliosis in the lumbar segment, and 33% were with a
double curvature of the spine. 7 In the present study, we
found a higher percentage of children with abnormal posture.
These differences may stem from the adopted research
methodology and in using other criteria to determine normal
and abnormal body postures as well as the different age
ranges that were examined.

Journal of Manipulative and Physiological Therapeutics


Volume 38, Number 7

Barczyk-Pawelec et al
Posture and Muscle Strength in Adolescents

Table 4. Mean and SD of the Anteroposterior Spinal Curves and Force-Velocity Parameters of Trunk Muscles in Females With Correct
and Incorrect Postures
Correct Posture, n = 18

Incorrect Posture, n = 62

10 years, n = 13

11 years, n = 5

10 years, n = 35

11 years, n = 27

Parameter

Mean (SD)

Mean (SD)

Mean (SD)

Mean (SD)

Angle
Angle
Angle
PT E60
PT F60
TW E60
TW F60
PT E120
PT F120
TW E120
TW F120
A/A E60
A/A F60
A/A E120
A/A F120

11.2 (2.6)
10.7 (1.8)
13.3 (1.7)
92.1 (19.8)
64.9 (10.1)
312.3 (56.9)
227.9 (6.8)
118.5 (13.8)
87.4 (21.9)
787.2 (177.9)
503.5 (34.0)
65.7 (4.2)
56.6 (16.6)
70.6 (16.6)
53.8 (13.6)

13.4 (1.7)
7.6 (1.3)
14.5 (2.5)
124.9 (29.9)
77.0 (25.1)
470.2 (108.9)
275.1 (84.5)
128.2 (18.2)
92.8 (24.4)
1021.1 (379.2)
591.7 (224.1)
60.4 (11.2)
56.9 (15.1)
65.6 (13.8)
57.6 (19.4)

16.9 (4.0)
15.0 (3.1)
15.4 (2.9)
90.5 (20.1)
60.4 (16.3)
322.2 (114.8)
225.7 (64.7)
115.5 (20.2)
79.9 (18.5)
698.4 (333.1)
483.0 (163.5)
66.7 (14.5)
57.9 (17.4)
71.2 (16.2)
53.9 (14.1)

14.9 (4.3)
13.2 (2.9)
15.2 (3.7)
118.4 (25.8)
76.5 (15.4)
500.8 (163.5)
310.7 (82.9)
146.3 (27.6)
94.8 (20.4)
1245.2 (468.5)
718.5 (212.1)
61.1 (12.3)
57.2 (16.8)
66.1 (14.1)
58.6 (19.9)

Values are expressed as mean (SD).


A/A E60 (%), A/A F60 (%), and A/A E120 (%), A/A F120 (%), muscle ratios: agonists-to-antagonists ratio; angle , lumbosacral spinal curvature;
angle , thoracolumbar spinal curvature; angle , thoracic spinal curvature; PT E60 and PT E120, maximum force moment of extensor muscles;
PT F60 and PT F120, maximum force moment of extensor muscles and flexor; TW E60 and TW E120, the work of all repositions for the
extensor muscles; TW F60 and TW E120, the work of all repositions for the flexor muscles.

Table 5. Least Significant Difference Test Between the Size


of the Anteroposterior Spinal Curves and Force-Velocity
Parameters of Trunk Muscles in Females With Correct and
Incorrect Postures
LSD Test
Parameter
Angle
Angle
Angle
PT E60
PT F60
TW E60
TW F60
PT E120
PT F120
TW E120
TW F120
A/A E60
A/A F60
A/A E120
A/A F120

CP1-CP2
0.1954
0.0289 a
0.4543
0.0375 a
0.1748
0.0220 a
0.1883
0.4637
0.5608
0.2424
0.3667
0.1258
0.6321
0.4132
0.3997

CP1-ICP1

CP2-ICP2

ICP1-ICP2

0.0000 a
0.0000 a
0.0359 a
0.8470
0.4094
0.8139
0.9240
0.7251
0.1990
0.4734
0.7337
0.6352
0.5112
0.5996
0.6721

0.5691
0.0000 a
0.6245
0.7191
0.9641
0.6283
0.2848
0.1543
0.8152
0.2261
0.1617
0.5698
0.6112
0.6114
0.5993

0.0587
0.0133 a
0.8319
0.0000 a
0.0002 a
0.0000 a
0.0000 a
0.0000 a
0.0013 a
0.0000 a
0.0000 a
0.2366
0.6523
0.4023
0.2113

A/A E60 (%), A/A F60 (%) and A/A E120 (%), A/A F120 (%), muscle ratios:
agonists-to-antagonists ratio. Angle , lumbosacral spinal curvature; angle ,
thoracolumbar spinal curvature; angle , thoracic spinal curvature; CP1, correct
posture in 10-year-old females; CP2, correct posture 11-year-old females; ICP1,
incorrect posture 10-year-old females; ICP2, incorrect posture 11-year-old
females; PT E60 and PT E120, maximum force moment of extensor muscles;
PT F60 and PT F120, maximum force moment of extensor muscles and flexor;
TW E60 and TW E120, the work of all repositions for the extensor muscles;
TW F60 and TW E120, the work of all repositions for the flexor muscles.
a
P .05.

Dolphens et al 14,34 recently published an innovative posture


classification system for males and females who had not
reached prepeak height velocity. They specified 3

categories of body posture that included a number of


lumbopelvic subcategories depending on the relative
position of spinal segments in relation to the gravity vector.
Within their sample population, they identified that 40.0%
of females and 41.6% of males had neutral alignment,
31.8% of females and 31.1% of males had sway-back, and
28.2% of females and 27.2% of males had leaning-forward
posture. 14,34 Particularly noteworthy is the incidence of
neutral posture in both males and females.
Our findings showed significant differences in isokinetic
trunk muscle strength between the different age groups,
whereas only a few significant differences were found
between children with normal and abnormal postures.
This may be due to the fact that the classification system
that we adopted has a relatively small margin between
children who are categorized as having normal or
abnormal posture based on the sizes of thoracic kyphosis
and lumbar lordosis and that this difference might not
have been large enough to significantly affect the strength
of the trunk muscles between the 2 groups. Nevertheless,
our results show that individuals with excessive curvature
of the spine (thoracic kyphosis and lumbar lordosis)
achieve lower isokinetic trunk muscle strength compared
with those with correct posture. The lack of significant
differences in trunk muscle strength between the participants with normal and abnormal postures may be the
result of the differences in the number of children
classified as to their type of posture.
When analyzing the data, a clear increase in trunk
muscle strength with age increase was observed among the
children. This evidently points to the influence of age and
possibly body weight on the development of trunk muscle

489

490

Barczyk-Pawelec et al
Posture and Muscle Strength in Adolescents

strength and endurance. This was confirmed by Eek et al 35


in a group of children, showing a strong correlation between
the torque generated with the arm muscles (r = 0.79-0.90)
and lower extremities (r = 0.84-0.95) with age and body
weight. Kati and Bala 36 showed that females aged
between 13 and 14 years achieved better results in motor
tests assessing flexibility, agility, and speed and also
cognitive functioning than younger females aged 10 to
12 years.
In modern and available literature, there are studies that
have found correlations between isokinetic trunk muscle
strength and posture in individuals with musculoskeletal
disorders. In a research by Anwajler et al, 15 where
photogrammetry and the typology determined by
Wolaski, 26 as modified by Zeyland-Malawka, 27 were
used to assess the anterior-posterior curvature of the spine
in females aged 14.7 2.3 years with scoliosis, findings
showed differences in the strength of flexor and extensor
trunk muscles depending on the exhibited posture profile.
The lowest values of the trunk muscle force-velocity
characteristics were found among females with an equivalent posture or where the sizes of thoracic kyphosis and
lumbar lordosis were similar (, 19.4 2.00; . 9.2 4.6; ,
19.4 2.6). 15 In turn, a study by Skrzek et al 16 that also
used the Biodex Multi-Joint System 3 dynamometer
showed a greater degree of postural muscle weakness in
females aged 14.7 2.3 years with scoliosis compared
with their healthy peers. All of the observed differences
were statistically significant. At the same time, this
group found that an irregular spinal curvature, such as
scoliosis, degrades the biomechanical function of the
trunk muscles. 16
In turn, Malicka et al 17 also used photogrammetry to
assess body posture including Wolaski's typology, as
modified by Zeyland-Malawka, in a group of women
after mastectomy to find decreased trunk muscle strength
in those diagnosed with exaggerated thoracic kyphosis
compared with healthy women. This may have been the
result of oncological treatment in this group, which, in
turn, may have had advanced agerelated changes on
body posture. 17
The application of the typology according to Wolanski
as modified by Zeyland-Malawka for determining normal
and abnormal postures showed no significant differences
in trunk muscle strength (in both sexes), which may
possibly be as a result of very minor differences in the
angular parameters classifying body posture as either
normal or abnormal. On the other hand, statistically
significant differences of muscle strength values were
found among children older in age and increased body
weight. The age range of the sample population was not
incidental, as this period of life is characterized by
relatively stable development between the prepubertal
and pubertal phases. At the same time, this is a period
when adverse changes in body posture have been

Journal of Manipulative and Physiological Therapeutics


September 2015

frequently observed. Various studies have linked the


development of abnormal posture among adolescents
with sedentary lifestyle, an excess of curricular and
extracurricular activities, limited physical activity, or bad
eating habits. 37 -39 Also worrying is the rise of nonspecific
back pain in ever younger and younger children, causes of
which are idiopathic. 37
In summary, the results of the present study show the
possibility of diagnosing body posture in children with
trunk muscle strength depending on the angles of thoracic
kyphosis and lumbar lordosis. Poor posture seemed to be
associated with lower isokinetic trunk muscle strength. This
points to the potential need for the application of a suitable
physical treatment (eg, corrective exercises) to compensate
for the loss of trunk flexor muscle strength observed in
children with abnormal posture.

STUDY LIMITATIONS
There are several limitations that need to be acknowledged and addressed regarding the present study. The first
limitation was the lack of factors in the children's physical
activity levels using available questionnaires. The second
limitation was concerns in the incongruous body positions
that were analyzed, where posture was assessed in the
standing position and measurement of trunk muscle
strength in the half-sitting position. This was as a result of
the adopted test methodology. Posture is most commonly
assessed in the upright standing position, as this best
reflects the anterior-posterior curvature of the spine,
whereas isokinetic dynamometry of the trunk muscles
(using in this case the Biodex Multi-Joint System) requires
a half-sitting position as the only possible way to measure
isokinetic trunk muscle strength.
An additional limitation was the placement of the
anatomical reference markers during postural assessment, as
their spatial accuracy depends largely on the skills of
the researcher. This was counteracted by having only 1
experienced researcher perform this task in the present study,
but this aspect nonetheless warrants some consideration.
However, the parameters adopted in the study are
determined automatically based on the external contour
of the body and, therefore, minimizes the possibility of
human error.

CONCLUSIONS
Based on the adopted typology, the present study
showed a high incidence of abnormal posture in children
as determined by the increased angular parameters of
the anterior-posterior curvature of the spine. This deepened spinal curvature was observed mainly in the thoracic
segment. Among the males and females with poor
posture, abnormal anterior-posterior curvature of the spine

Journal of Manipulative and Physiological Therapeutics


Volume 38, Number 7

was associated with lower values of isokinetic trunk


muscle strength.

FUNDING SOURCES AND POTENTIAL CONFLICTS OF INTEREST


No funding sources or conflicts of interest were reported
for this study.

CONTRIBUTORSHIP INFORMATION
Concept development (provided idea for the research):
B.P.K.
Design (planned the methods to generate the results):
B.P.K., R.K.
Supervision (provided oversight, responsible for organization and implementation, writing of the manuscript): B.P.K.
Data collection/processing (responsible for experiments,
patient management, organization, or reporting data):
B.P.K., P.R., D.W.
Analysis/interpretation (responsible for statistical analysis, evaluation, and presentation of the results): B.P.K.,
R.K.
Literature search (performed the literature search):
B.P.K., P.J.R., D.W., R.K.
Writing (responsible for writing a substantive part of the
manuscript): B.P.K., R.K.
Critical review (revised manuscript for intellectual
content, this does not relate to spelling and grammar
checking): B.P.K., R.K.

Practical Applications
The results of the present study indicate a high
incidence of abnormal posture in children with
exaggerated spinal curvature in the sagittal plane.
This may be as a result of cultivated improper
habits associated with the sitting or standing
position.
Exaggerated anterior-posterior curvature of the
spine may also be one of the factors reducing
trunk muscle strength.

REFERENCES
1. Kendall FP, McCreary EK, Provance PG, Rodgers MM,
Romani WA. Muscles testing and function with posture and
pain. Lippincott Willims&Wilkins; 2005.

Barczyk-Pawelec et al
Posture and Muscle Strength in Adolescents

2. Widhe T. Spine: posture, mobility and pain. A longitudinal


study from childhood to adolescence. Eur Spine J 2001;10:
118-23.
3. Hertzberg A. Prediction of cervical and low-back pain based
on routine school health examinations. A nine- to twelve-year
follow-up study. Scand J Prim Health Care 1985;3:247-53.
4. Grimmer K, Dansie B, Milanese S, Pirunsan U, Trott P.
Adolescent standing postural response to backpack loads: a
randomised controlled experimental study. BMC Musculoskelet Disord 2002 Apr 17;3:10 [Epub 2002 Apr 17].
5. Mac-Thiong JM, Labelle H, Berthonnaud E, Betz RR,
Roussouly P. Sagittal spinopelvic balance in normal children
and adolescents. Eur Spine J 2007;16:227-34, http://dx.doi.
org/10.1007/s00586-005-0013-8.
6. Mac-Thiong JM, Berthonnaud E, Dimar II JR, Betz RR,
Labelle H. Sagittal alignment of the spine and pelvis during
growth. Spine 2004;29:1642-7.
7. Pausi J, Dizdar D. Types of body posture and their
characteristics in boys 10 to 13 years of age. Coll Antropol
2011;35:747-54.
8. Cil A, Yazici M, Uzumcugil A, et al. The evolution of sagittal
segmental alignment of the spine during childhood. Spine
2005;30:93-100.
9. Smith A, O'Sullivan P, Straker L. Classification of sagittal
thoraco-lumbo-pelvic alignment of the adolescent spine in
standing and its relationship to low back pain. Spine 2008;33:
2101-7.
10. Penha PJ, Baldini M, Joo SM. Spinal postural alignment
variance according to sex and age in 7- and 8-year-old
children. J Manipulative Physiol Ther 2009 Feb;32:154-9,
http://dx.doi.org/10.1016/j.jmpt.2008.12.009.
11. Pausi J, Pedisi Z, Dizdar D. Reliability of a photographic
method for assessing standing posture of elementary school
students. J Manipulative Physiol Ther 2010 Jul-Aug;33:
425-31, http://dx.doi.org/10.1016/j.jmpt.2010.06.002.
12. Ferreira EA, Duarte M, Maldonado EP, Bersanetti AA,
Marques AP. Quantitative assessment of postural alignment in
young adults based on photographs of anterior, posterior, and
lateral views. J Manipulative Physiol Ther 2011;34:371-80,
http://dx.doi.org/10.1016/j.jmpt.2011.05.018.
13. Wolaski N. Typology and formation of body posture in town and
rural children and youth. Anat (Basel) 1964;56:157-83.
14. Dolphens M, Cagnie B, Coorevits P, Vleeming A, Vanderstraeten G, Danneels L. Classification system of the sagittal
standing alignment in young adolescent girls. Eur Spine J 2014;
23:216-25, http://dx.doi.org/10.1007/s00586-013-2952-9.
15. Anwajler J, Skrzek A, Mraz M, Skolimowski T, Woniewski
M. The size of physiological spinal curvatures and functional
parameters of trunk muscles in children with idiopathic
scoliosis. Isokinetics Exerc Sci 2006;14:251-9.
16. Skrzek A, Anwajler J, Mraz M, Woniewski M, Skolimowski T.
Evaluation of force-speed parameters of the trunk muscles in
idiopathic scoliosis. Isokinetics Exerc Sci 2003;11:197-203.
17. Malicka I, Hanuszkiewicz J, Stefaska M, Barczyk K,
Woniewski M. Relation between trunk muscle activity and
posture type in women following treatment for breast cancer. J
Back Musculoskelet Rehabil 2010;23:11-9.
18. Yahia A, Jribi S, Ghroubi S, Elleuch M, Baklouti S, Habib
Elleuch M. Evaluation of the posture and muscular strength of
the trunk and inferior members of patients with chronic
lumbar pain. Joint Bone Spine 2011;78:291-7.
19. Jones J, Stratton G. Muscle function assessment in children.
Acta Paediatr 2000 Jul;89:753-61.
20. Merati G, Negrini S, Carabalona R, Margonato V, Veicsteinas
A. Trunk muscular strength in pre-pubertal children with and
without back pain. Pediatr Rehabil 2004;7:97-103.

491

492

Barczyk-Pawelec et al
Posture and Muscle Strength in Adolescents

21. Wolaski N. The biological development of humans. The


fundamentals of auxology, gerontology, and health promotion.
8th ed. Warszawa: Wydawnictwo Naukowe PWN; 2012:469-82.
22. Penha PJ, Joo SM, Casarotto RA, Amino CJ, Penteado DC.
Postural assessment of girls between 7 and 10 years of age.
Clinics (Sao Paulo) 2005;60:9-16 [Epub 2005 Mar 1].
23. Martin R, Saller K. Lehrbuch der Anthropologie. Stuttgart:
Fisher; 1957.
24. Porto F, Gurgel JL, Russomano T, Farinatti Pde T. Moir
topography: characteristics and clinical application. Gait
Posture 2010;32:422-4.
25. Skolimowski J, Barczyk K, Dudek K, Skolimowska B,
Demczuk-Wodarczyk E, Anwajler J. Posture in people with
shoulder impingement syndrome. Ortop Traumatol Rehabil
2007;9:484-98.
26. Wolaski N. Studies on the formation of posture in children
and adolescents in cities. Chir Narzadow Ruchu Ortop Pol
1961;26:175-91 [Polish. No abstract available].
27. Zeyland-Malawka E. Classification and evaluation of body
posture by means of the modified method of Wolaski.
Fizjoterapia 1999;7:52-5.
28. Dvir Z. Isokinetics: muscle testing, interpretation and clinical
applications. Edinburgh, United Kingdom: Churchill Livingstone; 1995.
29. Davies G. Compendium of isokinetics in clinical usage and
rehabilitation techniques. 4th ed. Onalaska, WI: S&S
Publishers; 1992.
30. Garson GD. Testing statistical assumptions. Blue Book series.
North Carolina: Statistical Associates Publishing; 2012.

Journal of Manipulative and Physiological Therapeutics


September 2015

31. Karklina H, Apinis P, Kalnina L, et al. Analysis of body


composition of 9- and 10-year-old children in Latvia. Medicina
(Kaunas) 2011;47:573-8.
32. Zellner K, Jaeger U, Kromeyer-Hauschild K. Height, weight
and BMI of schoolchildren in Jena, Germanyare the secular
changes levelling off? Econ Hum Biol 2004;2:281-94.
33. Nakao T, Komiya S. Reference norms for a fat-free mass
index and fat mass index in the Japanese child population. J
Physiol Anthropol Appl Human Sci 2003;22:293-8.
34. Dolphens M, Cagnie B, Coorevits P, Vleeming A, Danneels
L. Classification system of the normal variation in sagittal
standing plane alignment: a study among young adolescent
boys. Spine 2013;38:E1003-12.
35. Eek MN, Kroksmark AK, Beckung E. Isometric muscle
torque in children 5 to 15 years of age: normative data. Arch
Phys Med Rehabil 2006;87:1091-9.
36. Kati R, Bala G. Relationships between cognitive and motor abilities
in female children aged 10-14 years. Coll Antropol 2012;36:69-77.
37. Chen SM, Liu MF, Cook J, Bass S, Lo SK. Sedentary lifestyle
as a risk factor for low back pain: a systematic review. Int
Arch Occup Environ Health 2009;82:797-806, http://dx.doi.
org/10.1007/s00420-009-0410-0.
38. Lamari N, Corderio J, Marinon L, Lamari M. Intervening
factors in forward flexibility of trunk in adolescents in sitting
and standing position. Minerva Pediatr 2010;62:353-61.
39. Karppanen AK, Ahonen SM, Tammelin T, Vanhala M,
Korpelainen R. Physical activity and fitness in 8-years-old
overweight and normal weight children and their parents. Int J
Circumpolar Health 2012;23:17621-5.