**1. Introduction**

Abnormalities of back shape and posture are a common cause of pain and disability with the range of effect from discomfort to incapacitating disability being related to both the **severity**

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as well as to the **persistence** of the faults [1]. While the terms "back shape" and "back posture" are sometimes used interchangeably it is important to be clear of what precisely is meant by each term. The focus of the term "posture" is on **muscular and skeletal balance** as seen from the definition provided by the American academy of orthopedic surgeons. The society define "good" posture as "that state of muscular and skeletal balance which protects the support‐ ing structures of the body against injury or progressive deformity irrespective of the attitude [sitting, lying erect] in which these structures are working or resting." Under such conditions the muscles will function most efficiently and the optimum positions are afforded for the thoracic and abdominal organs [2]."

The focus of the term "back shape" on the other hand is on the **back surface** and generally refers to the surface topography of the back. "Topography [from Greek topo‐, "place," and graphia, "writing"] is the study of the back's surface shape and includes the measurement of parameters that may or may not be similar to those measured for back posture." For instance, thoracic kyphosis and lumbar lordosis are usually measured when assessing both back shape and back posture.

The measurement of the surface equivalent of the spinal curvature [Cobb angle] in the frontal plane, however is usually measured solely during the assessment of spinal deformities within orthopedic clinics or private practices. A further key difference is that different professional health practitioners traditionally use different terminologies. Spinal deformity clinics within orthopedic medical practice generally refer to back shape whereas within physiotherapy practice the term 'posture' is usually the term of choice.

The assessment of back shape and posture is common practice in a number of disciplines within rehabilitation [1]. Within physiotherapy practice one of the most common methods of assessing posture and/or back shape is by visual observation of standing posture as viewed from the back and sides and is a routine part of all back assessments for patients with low back pain and/or spinal dysfunctions. Kipling et al. [3] in a survey on Common methods of assessing posture in Physiotherapy practice, found that up to 82% of physiotherapists reported using observation alone to evaluate patients posture.

A more recent survey was developed very recently in 2016 by Johnson et al. [4] who created the "The Postural Assessment Survey." The authors surveyed a group of manual therapists (chiropractors, physical therapists, osteopaths and sports therapists) to ascertain whether or not they actually used postural assessment within their practice, and if so what type of assess‐ ment they used. 432 therapists answered the question about which method of postural assess‐ ment they used. The large majority of therapists (98.15% n = 424) said that they used visual postural assessment.

Back shape/postural assessment is also part of the clinical examination for patients with spi‐ nal deformities in musculoskeletal clinics. Within Physiotherapy and Orthopedic clinical settings, the parameters evaluated may differ. Physiotherapists primarily evaluate asymme‐ tries in standing back posture at four key areas; the shoulder level, scapular level, pelvic level and the posterior superior iliac spines (PSIS) levels [5]. In the orthopedic setting however the assessment of back shape and posture is predominantly focused on the assessment of the skeletal measurement of spinal curvature on x‐ray together with the measurement of the maximum trunk inclination values in forward bending [5].

as well as to the **persistence** of the faults [1]. While the terms "back shape" and "back posture" are sometimes used interchangeably it is important to be clear of what precisely is meant by each term. The focus of the term "posture" is on **muscular and skeletal balance** as seen from the definition provided by the American academy of orthopedic surgeons. The society define "good" posture as "that state of muscular and skeletal balance which protects the support‐ ing structures of the body against injury or progressive deformity irrespective of the attitude [sitting, lying erect] in which these structures are working or resting." Under such conditions the muscles will function most efficiently and the optimum positions are afforded for the

The focus of the term "back shape" on the other hand is on the **back surface** and generally refers to the surface topography of the back. "Topography [from Greek topo‐, "place," and graphia, "writing"] is the study of the back's surface shape and includes the measurement of parameters that may or may not be similar to those measured for back posture." For instance, thoracic kyphosis and lumbar lordosis are usually measured when assessing both back shape

The measurement of the surface equivalent of the spinal curvature [Cobb angle] in the frontal plane, however is usually measured solely during the assessment of spinal deformities within orthopedic clinics or private practices. A further key difference is that different professional health practitioners traditionally use different terminologies. Spinal deformity clinics within orthopedic medical practice generally refer to back shape whereas within physiotherapy

The assessment of back shape and posture is common practice in a number of disciplines within rehabilitation [1]. Within physiotherapy practice one of the most common methods of assessing posture and/or back shape is by visual observation of standing posture as viewed from the back and sides and is a routine part of all back assessments for patients with low back pain and/or spinal dysfunctions. Kipling et al. [3] in a survey on Common methods of assessing posture in Physiotherapy practice, found that up to 82% of physiotherapists

A more recent survey was developed very recently in 2016 by Johnson et al. [4] who created the "The Postural Assessment Survey." The authors surveyed a group of manual therapists (chiropractors, physical therapists, osteopaths and sports therapists) to ascertain whether or not they actually used postural assessment within their practice, and if so what type of assess‐ ment they used. 432 therapists answered the question about which method of postural assess‐ ment they used. The large majority of therapists (98.15% n = 424) said that they used visual

Back shape/postural assessment is also part of the clinical examination for patients with spi‐ nal deformities in musculoskeletal clinics. Within Physiotherapy and Orthopedic clinical settings, the parameters evaluated may differ. Physiotherapists primarily evaluate asymme‐ tries in standing back posture at four key areas; the shoulder level, scapular level, pelvic level and the posterior superior iliac spines (PSIS) levels [5]. In the orthopedic setting however

thoracic and abdominal organs [2]."

4 Innovations in Spinal Deformities and Postural Disorders

practice the term 'posture' is usually the term of choice.

reported using observation alone to evaluate patients posture.

and back posture.

postural assessment.

Normative values of back shape and posture values may assist in classifying back shape types and provide normal ranges of different back surface parameters for the purpose of research or clinical decision making.

Two key studies in this area are those by Bettany‐Saltikov [6] and Duff and Draper [7]. Bettany‐Saltikov conducted a study evaluating normal back shape in young adults using the Integrated spinal imaging system (ISIS1). This is an optical computer system that is able to measure the 3D surface topography of the back. We were able to produce a representative scan for the interpretation of the back shape for all participants included in the study. This study found a mean *thoracic kyphosis* of 24.9 mm (median 24 mm, deciles: 6.8–47.2 mm). The thoracic kyphosis values found in this group of young adults are very similar to the chil‐ dren in Duff and Draper's study [7] who reported a median value for thoracic kyphosis of 27.8 mm (17–40 mm).

Carr et al. [8] reported these values in degrees and therefore values were not directly com‐ parable. In this study the mean *lumbar lordosis* was 14.9 mm (median 14 mm). The lumbar lordosis values were found to be greater in Saltikov's study [6] that evaluated young adults compared to the Duff and Draper study (median 9 mm) that evaluated children. This suggests the possibility 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.

Duff and Draper [7] conducted a survey of back shape in children using the Integrated spinal imaging system (ISIS1). with a sample of 105 boys and 101 girls, with an age range of 12.28–13.69 years. It was noted by the authors that these parameters were specific to the age group of the subject's used. Duff and Draper [7] also commented on the need for a standardized value for what should be considered a "normal" degree of back shape and spinal curvature that may be used as a reference against which back posture and shape parameters can be measured in young teenagers.

Within both fields therefore uncertainly still remains as to what constitutes "normality" within the context of standing back shape and/or posture. More pertinently the question remains "what are the limits of normality in standing back shape and posture?" In other words, how do physiotherapists and other clinicians know when a patient's posture is abnormal, if the ranges of normality are not known? Knowledge of what actually constitutes normality would significantly benefit clinicians in this field as it would enable them to decide when postural retraining exercises or other treatment modalities are warranted.

A further problem with regards to the quantification of back shape is that no boundaries of "normality" have been established that are *universally accepted*. Sahrmann [9] comments on the need for establishing normative values with standard deviations for spinal curvature that would benefit the analysis of extreme variations of spinal alignment and better inform the cli‐ nician as to the nature of the condition as a whole. However, in the literature while numerous spinal deformities have been defined, sparse information is available on the quantification of normal back parameters in standing. Kawchuk and McArthur comment that the primary limi‐ tation in the study and treatment of scoliosis is the lack of an accurate, reliable, convenient and completely safe form of scoliosis quantification [10]. Indeed, normative data of standing back shape and posture for comparison and reference in young adults is not currently available.
