**3.3. Procedure**

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.

**1.** To identify the limits of normality and symmetry/asymmetry of back shape and posture in a group of healthy young male and female subjects (i.e., to establish normative reference

**2.** To evaluate the symmetry/asymmetry between key anatomical landmarks and distances between the left and right sides of the back in normal young female and male subjects.

A convenience sample of 100 TU students were recruited for this study (n = 59 females and 41 males). Their ages ranged from 18 to 40 years old. Subjects were excluded if they had any lower limb or back injury that prevented the subject standing for the duration of data collec‐ tion, any vestibular problems that prevented the subject maintaining normal balance for the duration of data collection or a known allergy to self‐adhesive stickers when in contact with the skin. Ethical approval was granted by Teesside University School of Health and Social

The Middlesbrough Integrated Digital Assessment System (MIDAS) (**Figure 1**) is a tool for acquiring a static 3‐D computer recording of a physical object. A counterbalanced mechanical arm has optical sensors in each joint for X, Y, Z coordinate awareness with a mean accuracy of 0.23 mm. A footplate was created with marks to standardize foot position and a chart was

Through assessment with an anatomical mannequin this system demonstrated very high intra‐rater reliability (ICC > 0.999, p < 0.0001) [12], with a sample of 50 human subjects (r = 0.92–0.99, p < 0.001). Further intra and inter rater reliability were also found excellent when evaluated by McAlpine et al. [14]. Additionally previous work has found improvements

placed on the wall in front of the subject with markers to focus on [11–13].

**3.** To compare back shape and posture in normal young males and females.

**2. Objectives**

values).

**3.1. Subjects**

Care ethics committee.

**3.2. Instrumentation**

**3. Materials and methods**

6 Innovations in Spinal Deformities and Postural Disorders

Subjects read the subject information sheet and after consenting to participate were attired so that their back was visible for landmark identification. Subjects stood and fixed their vision to a point on a wall chart, in agreement with other studies of postural assessment tools [14]. The landmarks used were identical to those used in previous MIDAS studies [11, 15]. Landmarks were identified as shown in **Table 1**. Selection of anatomical landmarks.

The landmarks above were carefully chosen from current clinical methods, back shape stud‐ ies as well as studies related to spinal deformities [16]. The intention was to produce a map of the back for cervical, thoracic and lumbar regions that enabled the two sides of the back to be identified and produced a "normal" back shape profile in three dimensions. To date it is still unclear what "normal" back shape is although attempts have been made in school children [8]. The spinal vertebrae chosen were those at the ends of the apices of each curve, i.e., VP TA and T12 in the cervical thoracic and lumbar regions. For landmarks on either side of the back, bony points were chosen that were as far from the spine as possible to enable a total picture of back shape to be produced. It needs to be remembered that this is a work in progress and changes could be made in future in response to the results obtained.

Data collection involved the tester touching the MIDAS stylus tip to each of the marked points in a standardized order dictated by the software and pressing the foot pedal of the MIDAS to store the position on the computer. Data was analyzed using the Statistical Package for Social Sciences (SPSS) version 23.


**Table 1.** Key to standing back anatomical landmarks measured.
