Photogrammetry as a tool for the postural evaluation of the spine: A systematic review

Table 1 Results of the quality assessment of studies by downs and black scale

Ref.	Criteria checklist downs and black												Total
	1	2	3	6	7	9	10	11	12	16	18	20	(No. of √)
Almeida et al[15]	√	X	√	X	√	√	√	?	?	√	√	√	8
Cheng et al[16]	√	√	√	√	√	√	√	?	?	√	√	√	10
Fortin et al[17]	√	√	√	√	√	√	√	?	?	√	√	√	10
Annetts et al[18]	√	√	√	√	√	√	√	X	X	√	√	√	10
Weber et al[19]	√	√	√	√	X	?	√	X	X	√	√	√	8
Edmondston et al[20]	√	√	√	√	√	√	√	X	X	√	√	√	10
Milanesi et al[21]	√	√	√	√	√	√	√	?	?	√	√	√	10
de Oliveira Pezzan et al[22]	√	√	√	√	√	√	√	?	?	√	√	√	10
Yang et al[23]	√	√	√	√	?	√	√	?	?	√	√	√	9
Silveira et al[24]	√	√	√	√	√	√	√	?	?	√	√	√	10
Iunes et al[25]	√	√	√	√	X	√	√	?	?	√	√	√	9
Belli et al[26]	√	√	√	√	√	√	X	√	√	√	√	√	11
Chase et al[27]	√	√	√	√	√	?	√	√	√	√	√	?	10
Iunes et al[12]	√	√	√	√	√	√	√	X	X	√	√	√	10
Iunes et al[28]	√	√	√	√	√	√	√	?	?	√	√	√	10
Penha et al[29]	√	√	√	√	√	√	√	√	√	√	√	√	12
Rodrigues et al[30]	√	√	√	√	√	√	√	X	X	√	√	√	10
Straker et al[31]	√	√	√	√	√	√	√	√	√	√	√	√	12
Iunes et all[32]	√	√	√	√	X	√	√	X	X	√	√	√	9
Smith et al[3]	√	√	X	√	√	√	√	?	?	√	√	√	9
Yi et al[33]	√	√	√	√	√	√	√	?	?	√	√	√	10
Min et al[34]	X	√	√	√	√	√	?	?	?	√	?	√	7
Straker et al[35]	√	√	√	√	√	√	√	√	√	√	√	?	11
Szopa et al[36]	√	√	√	√	√	X	√	?	?	√	?	√	8
Amsters et al[37]	√	√	√	√	√	√	X	?	?	√	?	X	7
O’Sullivan et al[38]	√	√	√	√	√	√	√	?	?	√	√	√	10
Milosavljevic et al[39]	√	√	√	√	√	√	√	√	√	√	√	√	12
Munhoz et al[40]	√	√	√	√	√	√	√	√	√	√	√	√	12
Lima et al[41]	√	√	√	√	X	?	√	?	?	√	√	?	7
Raine et al[42]	√	√	√	X	√	X	√	X	X	√	√	√	8
Christie et al[43]	√	√	√	√	√	√	√	?	?	√	√	√	10
Watson et al[44]	√	?	√	X	√	√	X	?	?	√	√	√	7
Raine et al[45]	√	√	√	√	√	√	√	X	X	√	√	√	10
Mitchell et al[46]	X	√	√	√	√	√	?	?	?	√	?	X	6
Dieck et al[47]	√	√	√	√	X	?	√	?	?	√	√	√	8

Downs and black criteria: (1) Is the hypothesis/objective clearly described? (2) Are the main results to be measured clearly described in the Introduction or Materials and Methods? (3) Were the characteristics of the patients included clearly described? (6) Are the main findings of the study clearly described? (7) Does the study estimate the random variability in the data of the main results? (9) Were the characteristics of the lost patients described in the study? (10) Were the true probability values reported for the main results? (11) Are the subjects asked to participate in the study representative of the entire population where they were recruited? (12) Are the subjects recruited to participate in the study representative of the entire population where they were recruited? (16) If any of the results of the study were based on “data dredging”, was it clear? (18) Were statistical tests used to assess the main results appropriate? (20) Were the main results evaluated accurate (valid and reliable)? Responses to the criteria: √: Yes; X: No; ?: Unable to determine.

Table 2 Synthesis of the 35 studies included in this systematic review

Ref.	Objective	Type of study	Methodology	Results
Almeida et al[15]	To assess the correlation between pulmonary function and posture; to investigate the correlation between body composition and body posture	Observational	n = 34 adult patients with asthma. Measurements: Bioelectrical impedance, spirometry, whole-body plethysmography, measurement of diffusing capacity for carbon monoxide and assessment of respiratory muscle strength. The lumbar lordosis was assessed by the pelvic anteversion (PAS)	The patients exhibit lumbar hyperlordosis. These postural abnormalities correlate with patients' pulmonary function and body composition
Cheng et al[16]	To investigate the influence of lower body stabilization and pencil design on body biomechanics (postural alterations) in children with CP	Observational	n = 14 children with CP. In the posterior view was measured the trunk lateral inclination angle and posterior superior iliac spine-C7/L4 angle; and in the lateral view was measured the trunk forward inclination angle (AutoCAD software)	A chair which provides proper positioning was effective in improving trunk posture in children with CP during handwriting activity. A pencil with assigned grip height or with a biaxial design, when compared with a regular one, could improve trunk alignment
Fortin et al[17]	To explore differences in standing and sitting postures and to compare differences between thoracic and thoraco-lumbar or lumbar scoliosis	Observational	n = 50 (29 thoracic scoliosis, 14 thoraco-lumbar scoliosis and 7 lumbar scoliosis). The cervical lordosis (sagittal plane) and scoliosis (frontal plane) was assessed by angles in standing and sitting positions (software program developed by their multidisciplinary team)	The cervical lordosis was not different in the two postures and scoliosis angle was significantly lower in the standing position. No significant difference was found for the index scoliosis angle in groups of scoliosis
Annetts et al[18]	To investigate the difference in lumbar angle and neck angle when comparing four seating designs; and consider the postures adopted on the four chairs in relation to an "ideal" posture	Observational	n = 14. The lumbar and neck angle was assessed in sit posture in the four seating designs (Matlab programme)	All chairs also resulted in a negative value for the lumbar region indicating a lordotic posture was adopted. All chairs resulted in a positive value for neck angle demonstrating the extent of the forward head position. No chair seemed to consistently produce an ideal posture across all regions
Weber et al[19]	To evaluate the relationship between cervical lordosis, and forward head posture and head position	Observational	n = 80 women. The cervical curvature was measured by the horizontal distance from a vertical line tangent (postural assessment software - SAPO®). Three angles measured the position of the head: Head flexion/extension (between C7, tragus and palpebral commissure), forward head posture A1 (between line of the tragus-C7 with the horizontal), and forward head posture A2 (between the external acoustic meatus, chin and sternal notch)	There were negative moderate and significant correlation between cervical lordosis and forward head posture A1. There were moderate and significant correlation between cervical lordosis and head flexion/extension
Edmondston et al[20]	To examine the extension mobility of the thoracic spine; and to evaluate the influence of the thoracic kyphosis on the thoracic extension range of motion, and the end range extension position	Observational	n = 40. The thoracic mobility was measured by kyphosis angle between T1, T6 e T12, in standing, sitting, 4-point kneeling, and prone lying (ImageJ Software)	The total sagittal range of motion in standing was 20.2°± 6.6°, consisting of 8.7°± 5.8° of extension and 11.5°± 3.7° of flexion. The mean amount of thoracic angle was 21.6°± 5.6°. The magnitude of the thoracic kyphosis was associated with the end range extension position but not with the range of motion toward extension
Milanesi et al[21]	To verify the impact of the mouth breathing occurred in the childhood on the body posture in the adult age	Observational	n = 24 study group (subjects with history of mouth breathing during childhood) and 20 control group. The cervical and lumbar lordosis were assessed by angles and distances; and the thoracic kyphosis was assessed by angle (postural evaluation software-SAPO v 0.68®)	The cervical lordosis angle and the cervical distance measures were larger in the study group. The lumbar lordosis angle was smaller in the study group, meaning greater lumbar lordosis in these subjects. No significant difference was observed between the groups for thoracic kyphosis and lumbar distance
de Oliveira Pezzan et al[22]	To analyze the influences of wearing wedge high-heeled shoes on lumbar lordosis angle among adolescents who were users and nonusers of high-heeled shoes and to correlate these angles with ages and the time of high-heel use	Observational	n = 50 UG and n = 50 NUG of high-heeled shoes. The photographs were taken in a barefoot condition and with high-heeled shoes. Lumbar lordosis was assessed by angle (Postural Analysis Software)	The UG had lower lordosis angles compared with the NUG. In the barefoot condition, the lumbar lordosis angle in the NUG decreases, whereas the UG increases. In the high-heeled condition, the lumbar lordosis angles in the UG increased and in the NUG decreases
Yang et al[23]	To analyze the correlation between cost density and cosmetic outcomes in the surgical treatment of AIS	Observational	n = 58 cases of IAS. Measurements: Photographic preoperative and follow-up and determination of cost. The scoliosis was assessed by angles (trunk shift and rib hump) and distances (waist line asymmetry) (Adobe Photoshop CS4)	On all post-operative photographic variables measured there was no statistically significant correlation between increasing cost density and change in cosmetic variables from pre-op to follow-up
Silveira et al[24]	To assess postural changes based on age and their association with the respiratory function in mouth breathing children	Observational	= 17 nasal breathing and 17 mouth breathing children. The pulmonary function was assessed by forced spirometer. It was assessed the neck lordosis and lumbar lordosis angle (Fisiometer®3.0 Software)	Mouth-breathing children have neck hyperlordosis which increase with age, besides reduction in spirometry values. There was no difference in the lumbar lordosis between the groups
Iunes et al[25]	To analyze the efficacy of the Klapp method for treating scoliosis	Randomized clinical trial	n = 16 patients with scoliosis. The cervical lordosis, thoracic kyphosis and lumbar lordosis were assessed by angles (ALCimagem® - 2000 software) before and after of treatment with 20 sessions of the Klapp method	Only the lumbar lordosis angle suffered modification post-intervention with Klapp method, with a trend to its decrease
Belli et al[26]	To assess the body posture of children with asthma compared to a non-asthmatic control group matched for gender, age, weight and height	Observational	n = 30 asthmatic children and 30 control group. The cervical lordosis, thoracic kyphosis and lumbar lordosis was assessed by angles (ALCimagem®-2000 software)	A significantly lower thoracic kyphosis angle value was observed in the asthmatic children. However, no significant differences were found between groups for the other angles
Chase et al[27]	To determine whether a sample of children and adolescents with STC had trunk musculoskeletal characteristics different from age- and sex-matched control subjects	Observational	n = 40 subjects with STC and 40 control subjects. The passive angle of the trunk flexion-extension was measured in the in prone-lying and trunk forward flexion and sagittal plane sitting posture was assessed by measurement of thoracolumbar flexion-extension angle (ImageJ Software)	There was no difference in spinal mobility between the two subject groups. The thoracolumbar flexion angle during sitting was statistically higher in the STC group than control group
Iunes et al[12]	To compare the agreement between the visual postural assessment carried out and the postural assessment carried out through computerized photogrammetry	Observational	n = 21. Evaluations: Visual postural assessment and computerized photogrammetry. In the photogrammetry, the cervical lordosis, thoracic kyphosis and lumbar lordosis were assessed by angles (ALCimagem®-2000 software)	For the cervical lordosis, thoracic kyphosis and lumbar lordosis it was not possible to compare the visual analysis with that from photogrammetry because there are not reports in the literature about normality values of the vertebral curvatures
Iunes et al[28]	To compare cervical spine alignment among individuals, with and without TMD	Observational	n = 90 (30 control group, 30 muscle signs and symptoms of TMD and 30 muscle signs and symptoms of TMD such as established diagnoses of dislocation and joint disorders). The cervical lordosis was assessed by angle (ALCimagem®-2000 software)	There were no differences among the three groups regarding cervical lordosis. The presence of TMD did not influence cervical posture, independent of TMD type or lack
Penha et al[29]	To quantitatively characterize spinal posture to verify any differences in the postural aspects analyzed and their possible correlation to sex or age in 7- and 8-year-old public school students in the city of Amparo, São Paulo, Brazil	Observational	n = 230 (115 in 7-year-old and 115 in 8-year-old). The thoracic kyphosis, lumbar lordosis and lateral spinal deviation were assessed by angles (CorelDraw v.11.0 software)	Only the group of 7-year-old boys showed lower angles in the lumbar lordosis from the other groups. In the thoracic kyphosis, there was a difference between the age groups, the 8-year-old children were more kyphotic than the 7-year-old. Eighty eight point seven percent of the children showed lateral spinal deviation. The most common side was to the left, the most frequent location was thoracic, and the proportion of the deviation was greater for boys (63%) than for girls (45%)
Rodrigues et al[30]	To measure the degree of thoracic kyphosis in older adult women with and without spinal osteoporosis and to verify the difference between the obtained values	Observational	n = 12 (6 women with a spinal osteoporosis and 6 women with a spinal osteopenia). The thoracic kyphosis was measured by angles (Autocad-2006)	The degree of thoracic kyphosis of the women with osteoporosis (66.8°) were higher when compared with the values of the women with osteopenia (53.0°)
Straker et al[31]	To evaluate the relationships between cervical, thoracic and lumbar sagittal sitting postures and adolescent prolonged NSP, with consideration of gender	Observational	n = 1593 adolescents. NSP was assessed by a questionnaire. It was assessed the cervicothoracic, lumbar and trunk angles in three static sitting postures: Looking straight ahead, looking down at their lap, and sitting slumped (Peak Motus motion analysis system v.8)	There were significant differences between gender in cervicothoracic, lumbar and trunk angles. Females showed more erect and lordotic postures when looking straight ahead. Adolescents with prolonged NSP sat with a more flexed cervicothoracic angle, a lower extended trunk angle, and a lower lordotic lumbar angle
Iunes et al[32]	To assess whether the frequency of high heel use has any influence on postural changes, and whether the type of high heel interferes in the posture	Observational	n = 40 (20 women that wore high-heeled shoes every day and 20 women that wore high heels occasionally to social functions). The subjects were photographed wore a two-piece swimsuit and no shoes. The cervical lordosis, thoracic kyphosis and lumbar lordosis were assessed by angles (ALCimagem® - 2000 software)	The frequency of use and type of high heel did not modify static posture in women
Smith et al[3]	(1) To determine whether photographic assessment could result in similar subgroups to previous, radiographically determined subgroups and clinically used subgroups of sagittal standing posture; (2) To explore the profiles of the clusters on gender, height and weight, and to explore the relationship of various spinal pain variables with identified clusters	Observational	n = 766 adolescents. Back pain experience was assessed by a questionnaire contained 130 questions. It was assessed the lumbar and trunk angle (Peak Motus motion analysis system)	Using 2-dimensional photographic images, the standing, sagittal thoraco-lumbo-pelvic alignment of adolescents can be classified into 4 groups: Neutral, sway, hyperlordotic, and flat. Adolescents classified as having non- neutral postures when compared with those classified as having a neutral posture demonstrated significantly higher odds for back pain ever
Yi et al[33]	To investigate the relationship between diaphragm excursion and spinal curvatures in mouth breathing children	Observational	n = 52 children (22 nose breathing group - control and 20 mouth breathing group). Images of diaphragm excursion were recorded using anteroposterior X-ray. The cervical lordosis, thoracic kyphosis and lumbar lordosis were assessed by angles (postural evaluation software-SAPO)	There is no relationship between spinal curvatures and diaphragm excursion in the groups studied
Min et al[34]	To describe the WBKA measured on preoperative clinical photographs and its significance in operative planning	Observational (retrospectively)	n = 11 patients who underwent lumbar spine osteotomy. The WBKA were measured in preoperative and at the last follow-up (mean 4 yr)	The average WBKA was 41 degrees (20 to 70 degrees) preoperatively and was 10.5 degrees (8 to 14 degrees) at the last follow up
Straker et al[35]	To test the hypothesis that the duration of computer use is associated with habitual postures in male and female adolescents	Observational	n = 884 adolescents. The computer use was assessed by questionnaire. The angles of thoracic flexion (line of C7 to T12 with respect to vertical), cervico-thoracic angle (angle between line of tragus to C7 and line of C7 to T12), trunk (angle between line of C7 to T12 and line of T12 to greater trochanter) and lumbar (angle between line of T12 to ASIS and line of ASIS to greater trochanter) were assessed in three sitting postures: Looking down, looking straight ahead and slumped position (Peak Motus motion analysis system)	Males - sitting looking straight ahead: no significant associations were observed between levels of computer use and variable postures. Males - sitting looking down: Significant but weak linear trend was observed, with thoracic flexion increasing with computer use. Females - sitting looking straight ahead: Increasing levels of computer use associated with increased lumbar lordosis. Females - sitting looking down: increasing levels of computer use associated with decreasing lumbar angle. Males and females - sitting slumped: Increasing of computer use associated with decreasing lumbar angle, only in females
Szopa et al[36]	To identify and define some compensatory postural patterns in children with CP in vertical positions	Observational	n = 18 children with CP. The angle of mechanical spinal axis deviation from the anatomical axis, the relation of the plumb line to the gluteal slitin was measured in these positions: Standing with both feet, and one (right and left) foot, two-knee kneeling, one-knee (right and left) kneeling and sitting (software manufactured by INFOMED)	Two main compensational postural patterns were distinguished on this basis in hemiparetic children, called antigravitational and progravitational posturing. The lateral curve of the spine in both types was directed towards the healthy body side, but in the antigravitational type the healthy side was the overloaded one, whereas in the progravitational type it was the unweighted one
Amsters et al[37]	To compare the posture of people with tetraplegia of short duration and long duration, in a static but functional position in a manual wheelchair	Observational	n = 30 people with tetraplegia; n = 30 control group. The thoracic kyphosis was assessed in sit posture in the wheelchair by chest angle	Significantly greater of the kyphosis thoracic were demonstrated for the tetraplegic group compared with able-bodied groups
O’Sullivan et al[38]	To examine whether a relationship exists between spinal posture and LBP in a specific sub-group of industrial workers who reported flexion-provoked pain	Observational	n = 21 control subjects and 24 LBP subjects. The low back pain was assessed by questionnaire. The lumbar lordosis was measured as the angle between the intersection of the tangents drawn through the T10/L2 markers and the L4/S2 markers. Positions: Natural sitting and maximal slumped sitting postures, natural standing and maximal sway standing postures, and lifting and maximal standing lumbar flexion postures (Scion Image analysis software)	No difference was observed between the two groups when comparing their "usual" sitting, standing and lifting lumbar flexion angles. When comparing the lumbar angle difference between "usual" sitting and maximal slumped sitting, the LBP group sat significantly closer to their end of range lumbar flexion in their "usual" sitting posture
Milosavljevic et al[39]	To determine whether adaptive postural and movement characteristics were evident in the thoracic and lumbar spine as well as the hips of shearers, and to determine whether any observed adaptive changes were associated with either current or previous LBP	Observational	n = 64 shearers and 64 non-shearers. Lumbar sagittal lordotic posture was determined by cord angular change between T12, L3 and the PSIS and it was expressed in radians per metre (rad/m). Mid-upper and mid-lower sagittal thoracic curves were also calculated and expressed in rad/m about the T1, T4, T8, and T4, T8, T12 respectively. Three positions were analyzed: Flexion, normal stance, extension (CAD program)	The mean value for lumbar extension for shearers (9.88) was significantly less than for non-shearers (14.08). Lumbar flexion demonstrated similar mean scores for both groups and no significant differences were noted. Lower thoracic curvature for shearers (2.14 rad/m) was significantly "flatter". than for nonshearers (2.48 rad/m). Comparisons of both lumbar lordosis as well as upper thoracic kyphosis did not demonstrate any significant differences between the two groups. In the non-shearing group, participants with previous LBP had significantly reduced ranges of lumbar extension and lumbar flexion. Shearers with previous LBP did not demonstrate any significant reduction of either of these ranges of lumbar motion. The mean lumbar extension in the non-shearing subgroup with previous LBP was still greater than that of the shearer group
Munhoz et al[40]	To investigate the relationship between internal derangements of the TMJ and body posture deviations	Observational	n = 50 (30 individuals with TMJ internal derangement and 20 control group). The cervical lordosis, thoracic kyphosis and lumbar lordosis were assessed by distances of the most prominent region until of the plumb line (CorelDraw v.9.0 software)	No statistically significant body postural differences between the groups were observed
Lima et al[41]	To determine and compare the posture of children with OMB and FMB in relation to NB children	Observational	n = 62 children (17 OMB group, 26 FMB group and 19 NB group). The cervical lordosis, thoracic kyphosis, lumbar lordosis and lateral deviation of the spine were assessed by angles (ALCimagem®-2000 software)	Significant alterations were observed in cervical straightening in the OMB group. Significant changes were observed in the thoracic kyphosis, indicating convexity in the OMB group. For the lumbar lordosis and lateral deviation of the spine, no significant alterations were observed in any of the groups
Raine et al[42]	To quantitatively describe the curvature of the thoracic spine in the sagittal plane	Observational	n = 160 asymptomatic men and women. The upper and lower thoracic kyphosis was assessed by the tangent angles in radians/mm between C7-T6 and T6-T12, respectively	Results of thoracic kyphosis were not shown
Christie et al[43]	To evaluate any static standing or sitting postural aberrations in chronic and acute low back pain patients in comparison with healthy individuals, in search of potential risk factors or associations for LBP	Observational	n = 59 (39 participants with LBP and 20 control group). Pain intensity was recorded using a VAS. The subjects were divided in acute and chronic pain. The lumbar lordosis and thoracic kyphosis was assessed by angles between C7-T12 and T12-L5, respectively, in standing and sitting positions	Standing positions: The chronic pain group had a significantly increased lordosis compared with the control group. The acute group had an increased kyphosis than the control group. Lumbar lordosis is the parameter most important in prediction of LBP group. Sitting positions: individuals with acute pain had an increased thoracic kyphosis. Thoracic kyphosis, indicated contribution to the prediction of study group
Watson[44]	To investigate possible relationships between the incidence of sports injury and the existence of body posture defects in football players	Observational	n = 52 football players (soccer, rugby, Gaelic football). The injuries were divided in four categories: Back injuries, knee injuries, ankle injuries and muscle strains. The assessment of the scoliosis, thoracic kyphosis and lumbar lordosis were not clear	Back injuries were associated with thoracic kyphosis, lumbar lordosis and scoliosis. Subjects who suffered from two, three or all four types of injuries had significantly lower scores for lordosis than subjects who sustained less than two types of injuries
Raine et al[45]	To identify gender differences in the thoracic kyphosis and to correlate thoracic kyphosis with head and shoulder position	Observational	n = 39. The upper (C7-T6) and lower (T6-T12) thoracic curvature were measured from the surface contour of the thoracic spine by the tangent angles in radians/cm (GTCO digitizer)	No significant difference between females and males for the measurement of upper thoracic, however the lower thoracic was significant higher in males. The sagittal plane head alignment was negatively correlated with upper thoracic curvature; there was increased curvature of the upper thoracic spine when the head was placed more anteriorly
Mitchell et al[46]	To report a new method of measuring the angle of curvature of the lumbar spine in pregnant women	Observational	n = 13 pregnant women. The lumbar lordosis was assessed by angle between T12-L1 and L5-S1	The degree of lumbar spine curvature in pregnant women was 33.9° (± 3.6°)
Dieck et al[47]	To examine the relationship between postural asymmetry and the subsequent development of back and neck pain	Observational	n = 903 women. Back and neck pain and risk factors were obtained by questionnaire. Deviation of the spine from de midline of the body to scoliosis measurement was assessed by angle	There was no evidence of a relationship between increasing midline deviation and subsequent low back pain

PAS: Postural Assessment Software; CP: Cerebral palsy; AIS: Adolescents idiophatic scoliosis; STC: Slow transit constipation; TMD: Temporomandibular disorder; UG: Users group; NUG: Nonuser group; NSP: Neck/shoulder pain; WBKA: Whole body kyphosis angle; LBP: Low back pain; TMJ: Temporomandibular Joint; OMB: Obstructive mouth breathing; FMB: Functional mouth breathing; NB: Nasal breathing; VAS: Visual analogue scale.