You are on page 1of 5

Research into Spinal Deformities

A. Tanguy and B. Peuchot
IOS Press, 2002


3D Back Shape in Normal Young Adults


J.A. B E T T A N Y SALTIKOV \ P. V A N S C H A I K , J.A. B E L L , J.G. W A R R E N ,

A.S. W O J C I K , S.L. P A P A S T E F A N O U
S e n i o r L e c t u r e r i n R e h a b i l i t a t i o n , University
S e n i o r L e c t u r e r i n P s y c h o l o g y , University
Physiotherapist at Airedale General Hospital,
L e c t u r e r in V i s u a l i z a t i o n , University
Consultant Orthopaedic Surgeon, Hinchingbrooke Hospital, Huntingdon
Consultant Orthopaedic Surgeon, Middlesbrough General Hospital,

Abstract. In today's climate of evidence based medicine, there is an increasing

emphasis on objective assessment to monitor treatment effectiveness.
Although spinal posture and back shape are commonly assessed by clinicians, current
practice is based on subjective findings and unreliable objective tools. Numerous
management protocols aim to improve both posture and shape, however data related to
normal back shape is quite scarce. The aim of this study was to investigate normal back
shape in young adults, in order to produce normative values against which deformity
could be defined. The Integrated Shape Imaging System (ISIS) was used to measure the
three-dimensional back shape. A convenience sample of 48 normal adults, aged 18-28
volunteered to participate in this study. A small minority of individuals showed no
curve (8%), 55% showed a single curve and the rest showed a double one. Right spinal
asymmetry was more frequent than the left (77% to 52%). Mean values and 95%
confidence intervals were 14.1 (11.7-16.5) for upper Lateral asymmetry, 5.6 (3.3 7.9) for lower lateral asymmetry, 24.9mm (20.6mm -29.2mm) for thoracic kyphosis
and 14.9mm (12.5mm -17.2mm) for lumbar lordosis. Increasing upper lateral
asymmetry correlated with decreasing thoracic kyphosis (p=0.01). Maximum skin
surface angle correlated positively with only upper lateral asymmetry (p<0.0001).
Similar topographical interrelationships have been demonstrated in scoliosis. It is
important that clinicians in relevant disciplines objectively assess all three dimensions
of back shape, as our research shows that changes in one plane are associated with
changes in the other two planes.

Assessment of back shape and posture in current clinical practice is largely
subjective and based on visual, non-standardized criteria and methods [1]. These can be
subject to significant error and provide no objective or reproducible three-dimensional
measurements. Only recently has a consensus been reached on the threshold of clinically
significant frontal plane spinal deformities [2]. However, this is still arbitrary and this is a
result of lessons learnt from the high incidence of false positive referrals of school
screenings. Indeed clinical decision making based on these results influences management,
as postural dysfunction is thought to relate to deformity and pain [3].
Although numerous commercial optical and computer systems are at our disposal
([4], [5], [6]) data on normal adolescent and adult back shape have so far been scarce [7],
[8j. This is obviously affecting the clinical certainty with which we can establish an
observed spinal curve as abnormal and therefore initiate an appropriate treatment. The
purpose of this study was to produce measurable values of normal back shape in young
adults, against which deformity could be defined.

J. A . Bettany



et a l . / 3D Back Shape in Normal



1. Subjects
The participants were 48 volunteering young adults perceiving themselves as
"normal". All subjects had previously been cleared by school screening. Their age (18-28
years old) precluded curve deterioration, but which was close enough to adolescent
measurements at the end of growth.
2. Material and Methods
Back shape was assessed with the ISIS system. The ISIS frame was used in
conjunction with the "Stanmore" footplate so as to increase reliability [9], [10]. While
standing on the footplate within the frame, ten points on the patients' spines were palpated
and marked with black adhesive stickers, according to the protocol [11]. A light projector
scanned each patient's back using a rotating mirror, and the information was fed to and
processed by the ISIS computer. Trunk measurements in the frontal, sagittal and horizontal
planes were collected (a typical scan is shown in figure 1).
3. Results
Only 4 participants (8%) showed no curve. More than half of them (26 subjects 55%) demonstrated a single curve and the remaining, 18 subjects (37%), had a double
curve. Preponderance for a right sided spine shift was more pronounced than the left, as
indicated by the number of right and left sided curves found (77% right compared to only
52% left).

Table 1. Incidence of curves by side of asymmetry.

No curve

Right curve only


Left curve only


Right and left curve

18 .

Mean values, standard deviations and confidence intervals for five variables in the
frontal, sagittal and horizontal planes were produced (Table 2). On average, thoracic
kyphosis was almost twice as large as lumbar lordosis.


J.A. Bettany


et a l . / 3D Back Shape in Normal



Table 2. Asymmetries in the frontal, sagittal and horizontal planes.

Upper lateral
Lower lateral
Thoracic kyphosis
Lumbar lordosis
N = 42
N = 20
N = 48
N = 48
* mean value; ** standard deviation; *** 95% confidence interval

Maximum skin
surface angle
N = 48

Increasing upper lateral asymmetry correlated negatively with decreasing thoracic

kyphosis (r = -0.40, p = 0.01). Maximum skin surface angle correlated positively with only
upper lateral asymmetry (r = 0.52, p < 0.001). Decreasing thoracic kyphosis correlated
negatively with increasing lumbar lordosis (r = -0.39, p = 0.006). Other correlations were
not significant.

4. Discussion and Conclusions

"Normal" standing posture is generally described as one with a straight back and no
trunk asymmetries [12]. However, it is clear that, from the results of this study, "normal"
and "ideal" back shape are not synonymous. Indeed, only four subjects showed no curve
(8%). Duff and Draper [7], in a study of normal adolescent back shape (median age 12.9)
found similar results: only 10% of children did not have a curve. However, whereas Duff
and Draper [7] found very little difference in curve distribution between left and right, our
study found that 40% of the subjects had single right curves and only 15% had single left
curves. We found 37% double curves compared to 35% in the Duff and Draper [7] study.
Comparison between studies using quantitative results is difficult because of the
different quantitative measurements produced and the different statistics calculated. For
example, Burwell et al. [13] measured back shape in the forward bending position. In our
study, the mean value for upper l a t e r a l asymmetry
was 16.1 (median 15 with lower and
upper deciles 8.3-26) with a mean value of 13.4 (median 13.5, deciles 2.4 -26) for
l o w e r l a t e r a l asymmetry
in young adults. Carr et al. [8] found the mean female right lateral
asymmetry in adults to be 13.2 and the male 10.9. Mean values for left lateral asymmetry
were 8.5 for females and 6.1 for males. Duff and Draper describe a median value of 12.8
(deciles: 8.2-20.4) for single curves.
This study found a mean t h o r a c i c kyphosis
of 24.9mm (median 24mm, deciles:
6.8mm-47.2mm). The thoracic kyphosis values found in this group of young adults are very
similar to the children in Duff and Draper's study who reported a median value for thoracic
kyphosis of 27.8mm (17mm-40mm). Carr et al. reported these values in degrees and
therefore, values were not directly comparable.
In our study, the mean l u m b a r l o r d o s i s was 14.9mm (median 14mm). The lumbar
lordosis values were found to be greater in our study, compared to the Duff and Draper
study (median 9mm). This suggests that lumbar lordosis may increase during growth from
young adolescence to young adulthood. Carr et al. [8] however reported no significant
differences in lumbar lordosis angles between children and adults. It is possible that these
changes may be due to variables such age, race and other population differences.
This study reported a mean maximum skin surface angle of 7.2 and a median of 7
( deciles 3.9M2.0 ). It is similar to that reported by Carr et al. They reported a mean of 5.9
for female adults and 6.3 for males. However, our results differ from those reported by
Duff and Draper (median of 2, deciles: 2.3-6.5).

J.A. Bettany


et al. I'3D Back Shape in Normal




The following three findings show similar topographical interrelationships to those

found in idiopathic scoliosis. First, increasing upper lateral asymmetry in the frontal plane
was associated with a decreasing thoracic kyphosis in the sagittal plane. Second, decreasing
thoracic kyphosis was negatively associated with increasing lumbar lordosis in the sagittal
plane. Third, maximum skin surface angle was positively associated with only upper lateral
These results suggest that changes in back shape may occur with age although this
is still controversial. It is also important to consider that all previous studies on normal back
shape referred until now were carried out on British populations.
In today's climate of evidence based medicine, there is an increasing emphasis on
objective assessment to monitor treatment effectiveness. Our results stress the need for
clinicians to objectively assess back shape and posture in three dimensions, as our study
shows that changes in one dimension can be associated with changes in other dimensions.
Future studies should focus on measuring normal back shape throughout the life
cycle as well as evaluating the effectiveness of various management strategies on back
shape and posture. This is necessary to provide a positive shift towards more objective and
evidence based profession practice.

1] Gaily P M , Forster A L Human Movement,
A n Introductory
Text for Physiotherapy
Edition. Churchill Livingstone, London, 1987, pp. 86-97.
[2] British Scoliosis Society. F i s t report of the multi-centre
study. Proceedings of the Annual Meeting 1986.
Exercise, Foundations
and Techniques
(Third Edition). F.A. Davis,
[3] Kisner C, Colby L A Therapeutic
Philadelphia, 1990, pp. 530-550.
[4] Moreland, M S, Pope, M H, Stokes, I F, Weierman, R. the clinical use of Moire topography for spinal
deformity. A perspective challenge. In Drerup, B, Frobin, W, Hierholzer, H, eds, Moire fringe
and spinal deformity Gustav-Fisher, Stuttgart, New York, 1983, pp. 129-140.
[5] Turner-Smith, A R . A television computer three dimensional surface shape measurement system. Journal
of B i o m e c h a n i c s , 21(6), 1988, 515-529.
[6] Poncet, P, Delorme, S, Dudley, R et al. 3-D reconstructions of the external and internal geometries of the
trunk using laser and stereo-radiographic imaging techniques. In I A F Stokes (ed.) Research
2, 1999, pp. 21-24.
[7] Duff E S, Draper R C. Survey of Normal Adolescent Back Shape as Measured by ISIS. In Stokes, I F,
Pekelsky, Moreland, M S (eds.). Surface Topography
and Spinal Deformity IV, Gustav-Fisher, Stuttgart, New
York, 1987, pp. 163-169.
[8] Carr, A J, Jefferson, R J, Turner-Smith, A R, Beavis, A. An analysis of normal back shape measured by
ISIS scanning, Spine, 16(6), 1991, 656-659.
[9] Bettany, J A, Harrison, D J. The ISIS experience at the Royal National Orthopaedic Hospital. In Alberti,
A, Drerup, B, Hierholzer, E (ed.) Surface topography
and spinal deformity,
Gustav-Fisher, Stuttgart, New
York, 1992, 70-75.
[10] Bettany J A (1993). Topographical,
and Psychological
factors in the Surgical
of A d o l e s c e n t Idiopathic
S c o l i o s i s . PhD Thesis, University of London, pp. 116-121.
[11J Oxford Metrics. Isis operating manual version 4.0, 1987, p. 11.
[12] Kendall H, Kendall F, Boynton D. Posture a n d P a i n . Williams and Wilkins, Baltimore, 1952.
[13] Burwell R, James N, Johnson F, Webb J, Wilson Y. Standardized Trunk Asymmetry Scores: A Study of
Back Contour in Healthy Schoolchildren. Journal of Bone and Joint Surgery, 65B(A), 1983 452-463.