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MSc. Bogdani Andis, Faculty of Physical Activity and Recreation, Department of Physical Activity, Recreation and Tourism Sports University of Tirana, Albania.
E-mail: abogdani@ust.edu.al Dr. Pano Genti Sport Sciences Research Institute, Head of Department, Physical Activity Health and Recreation Research. Sports University of Tirana, Albania. E-mail: genti.pano@outlook.com
THE RELATIONSHIP BETWEEN BODY POSTURE AND BALANCE IN YOUTH AND ADOLESCENTS
Abstract: body posture is an individual characteristic, it shows great differentiation - especially in people during their progressive development. Postural balance is the ability to keep the body in equilibrium. The aim of this paper was to review the latest literature regarding the relationship between body posture and balance in adolescents. We searched in PubMed. More research studies should address the contribution on the relationship between body posture and balance in earliar ages to prevent the future spinal problems.
Keywords: Posture, Balance, Adolescents.
Introduction
Body posture is an individual feature, which shows a great differentiation, especially at the age of puberty. Puberty is accompanied by major maturational physical alterations in body shape and dimensions, and substantial brain changes [1; 2]. Because of development variability and lack of physical activity, body posture defects appear in children and youths [3; 4]. Cieszkowski S [5] Mialkowska J [6] found that schoolchildren with body posture defects had significantly lower levels of power dynamic, static strength and endurance, and interestingly presented a higher level of flexibility. This fundamental motor skill is learned at an early age and represents an essential basic for daily routine tasks and athletic activities [7]. Postural balance is the ability to keep the body in equilibrium and to regain balance after the shift of body segments [8].
Postural change occurs continuously throughout the entire time of ontogenesis, with critical periods at school age and puberty. Large cohort studies analyzing children and adolescents reported reference values of spinal and pelvic sagittal parameters [9-14]. Other studies have characterized the changes in sagittal plane alignment
during growth [15; 16]. External pelvic motion has a critical role in maintaining the balance of the spinopelvic axis: varying rotational position (pelvic tilt) and anteroposterior translation are well documented [17; 18].
One of the main spinal deviation in adolescents is scoliosis, which is a three-dimensional (3 D) deformation of the spine and rib cage resulting in a prominent trunk distortion. Its more common form is adolescent idiopathic scoliosis (AIS) usually affects young girls [19]. Most studies describe the differences between scoliotic and non-scoliotic girls and focus primarily on a single set of parameters derived from spinal and pelvis morphology [20], posture [21; 22] or standing imbalance [23; 24]. Few addressed a combination of different types of parameters, for instance, curve type and postural sway [25] or body posture and standing stability [26] in AIS. Fewer reported differences in untreated adolescent idiopathic scoliosis of different severities for standing balance [27; 28] and pelvis morphology asymmetries [29]. Often studies include more than a single curve type [22] or combine different form of scoliosis such as adolescent idiopathic scoliosis infantile idiopathic scoliosis
and scoliosis associated with another condition and back problems [30]. Correlations between the Cobb angle and radiographic, morphologic, postural and standing balance parameters met mitigated successes [31]. Attempts have been made to link standing balance to body posture [32; 33], to morphology [34], and to curve type [25], or to associate scoliotic severity to standing imbalance [35]. These studies confirm that scoliosis and its progression are related to more than a single type of biomechanical factors. Simoneau M [36], advocate a sensory integration hypothesis to explain balance control problems observed in AIS. This concept is based on the dynamic regulation of sensorimotor integration by the inappropriate weighting of sensory inputs. They conclude that AIS girls have difficulty in reweighing sensory inputs following a briefperiod of sensory deprivation. Bruyneel AV [36], also attribute the variability in ground reaction forces during forward and lateral step initiation to the ontogenesis of adaptive strategies. In opposition, a biomechanical hypothesis gives importance to trunk shape posture adjustments. [29], who have observed a significant correlation between the Cobb angle and pelvic abnormal growth, support this. Others like Bur-well RG [38], Goldberg CJ [30], and Ramirez L [39], found strong relationships between spinal deformity and asymmetrical postures reinforcing the biomechanical concept. The included curve types (single or double), number of different curve types, location of curves (thoracic and lumbar), and/or Cobb angles vary considerably between studies, and all of these factors individually have been shown to influence postural balance. For example, patients with single lumbar curves showed poorer postural balance than those with double major curves [25] and greater Cobb angles were also associated with poorer postural balance [27; 28]. Based in all this datas and different discussion on this topic we thought that it will with great interest to underwent a review study focusin on the latest paper dealing with body posture and and his relationship with balance.
Objectives
The main obj ective of this paper was to review the latest literature regarding the possible relationship between body posture and balance in adolescents.
Methodology
The search was made in PubMed, for studies focusing on Body Posture and Balance in Adolescents. The
main key words used were; Posture, Balance, and Adolescents. Selection criteria were: Article type: Clinical Trial, Randomized clinical trial: Text avilability: Free full text. Publication dates: Last 10 years.
Results and Discussion
From 125 studies, only six papers fulfilled the criterias.
The selected studies were:
1. Dolphens. M et al., - 2011.
2. Dalleau G et al., - 2012.
3. Stylianides A. G et al., - 2013.
4. Lizis P & Walaszek R., - 2014.
5. Schimmel JP. J et al., - 2015.
6. Ludwig O., - 2017.
Dolphens. M et al., 2011 study aim was to document the correlations between sagittal standing posture parameters in a pre-peak height velocity (pre-PHV) cohort. Study included 639 pre-PHV boys (age 12.6 [SD, 0.54] years) and 557 pre-PHV girls (age 10.6 [SD, 0.47] years). Gross body segment orientations and spinopelvic orientation/shape indexes were quantified using a clinical screening protocol. Pearson's correlation coefficients were determined for all sagittal standing plane alignment parameters, and a postural model was used to analyze the correlations between parameters.
Results Both at the gross body segment and spino-pelvic level, an interdependence was found between postural parameters. No correlations were observed between 'global' parameters related to the pelvis, trunk or body anteroposterior translation postures and 'local' spinopelvic geometries.
In Dalleau G et al., 2012 study the first objective was to test if there were differences in some parameters between pre-braced AIS girls with a right thoracic sco-liosis of moderate (less than 27u) and severe (more than 27u) deformity. The second objective was to identify which of these parameters are related to the Cobb angle progression either individually or in combination of thereof. Forty-five scoliotic girls, randomly selected by an orthopedic surgeon from the hospital scoliosis clinic, participated in this study. Parameters related to pelvis morphology, pelvis orientation, trunk posture and quiet standing balance were measured. Generally moderate pre-brace idiopathic scoliosis patients displayed lower values than the severe group characterized by a Cobb angle greater than 27u. Only pelvis morphology and trunk posture were statistically different between
the groups while pelvis orientation and standing imbalance were similar in both groups. Statistically significant Pearson coefficients of correlation between individual parameters and Cobb angle ranged between 0.32 and 0.53. Collectively trunk posture, pelvis morphology and standing balance parameters are correlated with Cobb angle at 0.82. The results suggest that spinal deformity progression is not only a question of trunk morphology distortion by itselfbut is also related to pelvis asymmetrical bone growth and standing neuromuscular imbalance.
The purpose of Stylianides A. G et al., 2013 study was to determine how pelvic morphology, body posture, and standing balance variables of scoliotic girls differ from those of able-bodied girls, and to classify neuro-biomechanical variables in terms of a lower number of unobserved variables. Twenty-eight scoliotic and twenty-five non-scoliotic able-bodied girls participated in this study. 3D coordinates of ten anatomic body landmarks were used to describe pelvic morphology and trunk posture using a Flock of Birds system. Standing balance was measured using a force plate to identify the center of pressure (COP), and its anteroposterior (AP) and mediolateral (ML) displacements. A multivariate analysis of variance (MANOVA) was performed to determine differences between the two groups. A factor analysis was used to identify factors that best describe both groups. Statistical differences were identified between the groups for each of the parameter types. While spatial orientation of the pelvis was similar in both groups, five of the eight trunk postural variables of the scoliotic group were significantly different that the able-bodied group. Also, five out of the seven standing balance variables were higher in the scoliotic girls. Approximately 60% of the variation is supported by 4 factors that can be associated with a set of variables; standing balance variables (factor 1), body posture variables (factor 2), and pelvic morphology variables (factors 3 and 4). Pelvic distortion, body posture asymmetry, and standing imbalance are more pronounced in scoliotic girls, when compared to able-bodied girls. These findings may be beneficial when addressing balance and ankle proprioception exercises for the scoliotic population.
Lizis P & Walaszek R., 2014 study aim was to evaluate the relations between correct body posture parameters, measured with the photogrammetric method, with some of the somatic features and motor abilities of boys
at the age of 14. The study included 133 boys aged 14 attending junior secondary schools in the Krakow area of Poland. Only boys with the correct body posture were examined. Posture was examined by the Moire method, through which six parameters were obtained in the sagittal plane, seven in the frontal plane, and one in the transverse plane. The somatic measurements included basic parameters, such as body weight and body height. The measurements of motor features included: marching balance test, speed movement test of the arms and their functional strength. To evaluate the relationships between correct body posture with the characteristics of somatic and motor abilities, the Spearman rank correlation was used. The lowest level of statistical significance was accepted at p < 0, 05. No correlations were noted between some of the correct body posture features and the somatic features, and some of the motor abilities of the examined boys at the level ofp < 0.05 and p < 0.01.
In Schimmel JP. J et al., 2015-study purpose was to determine whether AIS patients have defective postural balance compared to a healthy age-matched control group and whether potential deficits are similar between patients with single and double curves. The second purpose was to delineate the effects of corrective posterior spinal fusion on postural balance in the same group of patients with AIS. Postural balance was tested on a force plate, in 26 female subjects with AIS (12-18 years old; preoperative Cobb-angle: 42-71°; single curve n = 18, double curve n = 6) preoperatively, at 3 months and 1 year postoperatively. We also conducted a balance assessment in 18 healthy age-matched female subjects. Subjects were tested during quiet double-leg standing in four conditions (eyes open/closed; foam/solid surface), while standing on one leg, while performing a dynamic balance (weight shifting) task and while performing a reaching task in four directions. According to the results, AIS subjects did not demonstrate greater COP velocities than controls during the double-leg standing tasks. In the reaching task, however, they achieved smaller COP displacements than healthy controls, except in the ante-rio direction. AIS patients with double curves had significantly greater COP velocities in all test conditions compared to those with a single curve (p < 0.05). For the AIS group, a slight increase in COP velocities was observed in the foam eyes closed and right leg standing condition at 3 months post surgery. At 1-year post surgery,
however, there were no significant differences in any of the outcome measures compared to the pre-surgery assessment, irrespective of the curve type.
In Ludwig O., 2017 paper the pourpose was to examine possible interrelationships between postural sway and posture parameters in children and adolescents with a particular focus on posture weakness. 308 healthy children and adolescents (124 girls, 184 boys, aged 12.3 ± 2.5 years) participated in the study. Posture parameters (posture index, head protrusion, trunk inclination) were determined based on posture photos in the sagittal plane. Postural sway was measured during 20 seconds on a force plate. The Pearson's product-moment correlation coefficients between the anthropometric and posture parameters and the sway path length (SPL) were calculated, as well as the coefficient of determination R2. Study results showed that there is a weak but significant correlation between age or body mass index of the test subj ects and the SPL. There is no statistically significant correlation between posture parameters and the SPL. Children and adolescents with posture weakness do not exhibit a changed SPL.
Cunclusions
Based on the reviewed studies we can conclude that there are few studies focusing on the relationship between body posture and balance in adolescents.
According to Dolphens. M et al., 2011 study conclusions reveal that the sagittal standing balance in normal pre-PHV subjects, and describes a scheme of correlations in the framework of the segmental theory of postural organization. Generally, the pattern and strength of correlations was similar between both genders, showing a similar interdependence between orientation and shape parameters at both the gross body segment and spino-pelvic level. According to Dalleau G et al., 2012 study conlusions, generally moderate pre-brace idiopathic scoliosis patients displayed lower values than the severe group characterized by a Cobb angle greater than 27u. Only pelvis morphology and trunk posture were statistically different between the groups while pelvis orientation and standing imbalance were similar in both groups. Statistically significant Pearson coefficients of correlation ranged between 0.32 and 0.53 and were within the reported values. Also Stylianides A. G et al., 2013 study has shown that pelvic distortion, body posture asymmetry, and standing imbalance of scoliotic girls are more pronounced when compared to a comparable able-bodied
group. Upright stance in able-bodied girls is mostly characterized by the control they exercise to maintain balance since there is little pelvic distortion and their posture is relatively erect. Untreated scoliotic girls were shown to have an abnormal pelvic morphology combined with body posture asymmetries. Their ability to maintain balance is also perturbed, but it could be a compensatory mechanism or one that develops or manifests itself in the later stage of the scoliotic progression.
In Lizis P & Walaszek R., 2014 study conclusions was showed that regarding photogrammetric posture, somatic and motor features revealed the following: The angle of tilt of the trunk correlated with body weight, and the difference in the height of the anterior superior iliac spine correlated with body height. This means that heavier persons are often predisposed to a round back, and that lean people frequently have an asymmetrical pelvis; The thoracic kyphosis angle, depth of the kyphosis, and fixing of the triangles of the waist determine marching balance. Thus, worse body posture accompanies worse marching balance;
The compensation ratio correlates with the speed of the upper limbs (knocking on the circle, tapping in the rings). This means that better eye-movement coordination accompanies better body posture; The correlation between the maximum leaning of the line of the spine from the upright position C7-S1 in the frontal plane and functional strength (overhang - arms bent) means that systematical exercises on muscle strength should be used at children with body postures defects, especially defects of the spine.
In Schimmel JP. J et al., 2015 study conclusions is showed that the postural balance in the current cohort of 26 AIS patients with large curves is the same as in an age matched healthy control group. After surgery, in which a substantial part of the spine is made rigid by spinal fusion, some variables slightly deteriorated for a short period, but after one year, the patients' postural balance had recovered to preoperative values. This suggests that disturbed motor-sensory integration does not play a role in the development of a spinal malalignment in AIS. These findings also suggest that postural balance in AIS is neither affected by the trunk asymmetry, nor by spinal fusion.
Also after reviewing all these studie we can conclude that more research studies should address the contribution on the relationship betweem body posture and balance in earliar ages in order to better prevent the future
spinal problems and also to orientate the children involv- foacusing in prenvntion and also in the improvement of
ing in the wright and proper physical activity programs pastural problem and in the same time balance problems.
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