A NEW METHOD OF MEASURING THE DEGREE OF LUMBAR SPINE CURVATURE IN PREGNANT WOMEN Jeanette Mitchell BSc (Physiotherapy), BSc Hons, MSc** Donnee Ness BSc (Physiotherapy) Sandra Whitelock BSc (Physiotherapy) Key words: lumbar spine curvature; pregnancy; photographic method. INTRODUCTION L um bar spine curvature has been m easured in a num ber o f ways, with the^subject moving from flexion to extension o f the spine; side-lying, and standing in the erect position1,2,3,4. T he measuring instrum ent has included the standard tape m easure, kyphometer, goniom eter and diasonograph ultrasound1; the flexicurve2; the radiograph3, and the cliniometer4. T h e accurate m easurem ent o f lum bar spine curvature in preg­ nant women has posed a problem for some time. T h e radiographic m ethod used by Fernand & Fox3, for example, cannot be used because o f the teratogenic properties o f X-rays. T h e diasonograph ultrasound proposed by Salisbury & P o rte r1 is not easily available to many researchers. The inherent inaccuracies in the surface m easure­ m ents o f spinal curvatures using th e flexicurve2, and th e tape m easure, kyphometer and goniom eter1, preclude these instrum ents too. Bullock et a f w ere able to m easure the curvature o f the lum bar spine and the angle o f lordosis in pregnant women successfully, using the cliniometer. This is the best m easure o f this variable reported in the current literature to date. A part from this study by Bullock et a /4, th ere is a lack o f normative data on the degree o f lum bar spine curvature, particularly in preg­ nant women, but in oth er population groups too. Such d ata would be o f value not only for com parative studies but for use as a base-line in the clinical diagnoses o f conditions, such as low back pain, which may be related to poor posture o r to musculo-skeletal pathology. Thus, in the course o f study o f third trim ester pregnant w omen, we developed a simple m ethod o f measuring the lum bar spine curvature, which has not been reported in the literature to date. Tbis m ethod involves photographing the women in side-view and m easu r­ ing the degree o f spinal curvature on the photographs. This m ethod, we feel, is cost-effective, non-invasive and easy to carry o u t quickly and with a good degree o f accuracy. It also offers normative data from a group o f healthy, third trim ester pregnant women in South Africa. This paper reports the procedure and results o f such m eas­ urem ents m ade on a sample o f 13 subjects. MATERIALS AND METHOD Sample selection A population o f 130 w om en attending antenatal classes was interviewed for a study o f third trim ester pregnant w omen. O f this num ber, which included second and third trim ester pregnancies, 13 (10% ), who were all in the third trim ester o f their pregnancies, were prepared to participate in the study to m easure lum bar spine curva­ tures by means o f photographs o f the women. Inform ed consent was obtained from each o f the women. T he study sample, therefore, consisted o f 13 Caucasian, middle- class, English-speaking, South African women, aged between 20 and 40 years, with a m ean age o f 31,5 ± 5,1 years (Table I). T he subjects had no history o f musculoskeletal disease and all pregnancies had progressed normally to the third trim ester stage. Measurement procedure In order to dem arcate the lum bar spine o f each subject, the spinous processes o f the twelfth thoracic vertebra (T12), the first and fifth lum bar vertebrae (L I and L5) and the first sacral vertebra (S I) w ere carefully palpated, with the subject sitting on a high stool, and m arked by m eans o f a skin marking pen. An adhesive pointer was placed exactly over each o f these processes. O nce the pointers were in place, their positions were checked with the subject standing, to ensure that each lay directly over the spinous processes o f T12, L l ,‘ L5 and S I respectively. Each adhesive pointer was m ade from a disposable E E G elec­ trode (type R-00-S), 4,5 cms in diam eter, the one side o f which is adhesive. A strip o f cardboard, 1 cm wide by 10 cms long, was firmly taped at right angles to the non-adhesive side o f each disc. Each subject was photographed in side-view while standing erect (Fig 1). T he feet were placed on a fixed foot-board, so that the heels were against the restraining blocks and 1 cm apart. T he photographic procedure was rep eated th ree times, the subject slumping forwards in a relaxed posture and then resuming the erect standing position before each photograph was taken. All photographs were taken in the mid-morning period o f the day. SUMMARY There are very few studies which record measurements of the degree of lumbar spine curvature. This study reports a new method of measuring the angle of curvature of the lumbar spine in pregnant women, using photography. It is a simple, cost-effective and non-invasive method which can be used in the laboratory or the clinical situation. The study sample con­ sisted of 13 healthy, middle-class, English-speaking, South African, Caucasian women, aged between 20 and 40 years, in the third trimester of pregnancy. A mean angle of 33,9 ± 3,6 (SD) degrees, representing the degree of lumbar spine curva­ ture, was obtained. OPSOMMING Baie min studies is gedoen met betrekking tot die meting van die lumbale werwelkolom buiging. Hierdie studie bespreek 'n nuwe metode vir die meting van die lumbale werwelkolom buiging vir swanger vroue met die gebruikmaking van foto- grafie. Dit is ’n eenvoudige, goedkoop en nie-binnedringende metode wat in die laboratorium of die kliniese situasie gebruik kan word. Die studie groep bestaan uit 13 gesonde, middel- klas, Engelssprekende, Suid-Afrikaanse, Kaukasiese vroue, tussen 20 en 40 jaar oud, in die derde trimester van swanger- skap. 'n Gemiddeld van 33,9 ± 3,6 (SD) grade, wat die metings van die lumbale werwelkolom buiging verteenwoor- dig, was gemeet. * This research was conducted as a student project in the Department o fA n a to m y and H um an Biology, University o f the Witwatersrand Medical School, 7 York Road, Parktown, Johannesburg 2193 ** Conespondence to: Jeanette Mitchell, Lecturer, Department o f Physiotherapy, University o f the Witwatersrand m edical School, 7 York Road, Parktown, Johannesburg 2193 Physiotherapy, November 1992 Vol 48 no 4 Page 51 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Boehringer Ingelheim nebulising solutions R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) New—Atrovent Inhalant Solution Unit Pose Vials • Added always to your standard (32 solution • Precise dose every time • Simple and convenient • Preservative-free Bisolvon® solution • Reduces bronchial and nasal secretion viscosity • Facilitates mucocilliary transport and expectoration Boehringer / j [ \ Inhalation Ingelheim Therapy Creating a better clim ate for your patients S2 S2 S2 Atrovent 0,025% Inhalant Solution. Each ml contains 0,250 mg ipratropium bromide Reg. No. Q/10.2.1/117 Atrovent U.D.V. 0,5 mg/2 ml Inhalant Solution. Each 2 ml contains 0,5 mg ipratropium bromide (preservative free) Reg. No. X/10.2.1/322 Bisolvon Solution Each 5 ml contains bromhexine HC110 mg Ref. No. G642 (Act 101/1965) For further information about these and our other products, please contact; Boehringer Ingelheim (Pty) Ltd Reg. No. (69/08619/07) Private Bag X3032, Randburg, 2125 S P E C T R .U M 1 1 3 1 2 2R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) A Reduce your treatment time drastically with the new cluster head applicators! SURFACE LASER FLA 03 WITH 3 LASER DIODES • S p e c ia l la s e r a p p lic a to r fo r in te n s iv e a n d o p tim u m fa c ia l a n d b o d y tre a tm e n ts . • A ls o ide a l fo r jo in ts , re fle x z o n e s a n d la s e r ly m p h d ra in a g e • T h re e la s e r d io d e s a n d a h igh c a p a c ity u ltra re d ra d ia to r e n s u re a n in te n s iv e a n d o p tim u m p h o to -s im u la tio n o f th e fa c e o r b o d y th a t is a c c u s to m e d to Sw ivelling la ser head perm its easy and fatigue-free radiating of all body region. ULTRA EFFECTIVE DIGITAL AREA LASER FLD 09 • N e w p o ly fre q u e n c y s p e c tru m fo r o p tim u m a re a tre a tm e n t, • A d d itio n a l b io -s tim u la tio n in te n s iv e p h o to- in d u c tiv e u ltra re d light. T h e n e w p o ly -s p e c tra l u lti-ta c t m e th o d of m e d ic a l e le c tro n ic s c o n s id e ra b ly ^ in te n s ifie s the la s e r effe ct. INFRARED LASER SYSTEM LSI 2030/90 • U ltra e ffe c tiv e h ig h -c a p a c ity c o m p a c t la s e r m e e ts th e h ig h e s t re q u ire m e n ts . • F irst c o m p a c t la s e r w ith s p e c ia l g ro w th a n d h e a lin g fre q u e n c ie s (p itu ita ry g la n d s ). • D ig ita l q u a rtz c o n tro lle d fre q u e n c y sy n th e s is . • D ig ita l p o ly fre q u e n c y s p e c tru m . • D ig ita l a lp h a fre q u e n c y . Sole Agents: LASER - COSMEDTECH CC Laser Equipment for Cosmetic and Medical Treatment 63 Westwoldway Parkwood2193 Johannesburg S.A. Tel: 442-7578 , b .« : % HOLIDAY INN JOHANNESBURG South Africa Mil Park - JOHANNESBURG Empire Road Owl Street, Box 31556 NOV. 16, 1992 5-7 P.M. HOLIDAY INN UNION AVENUE Bloemfontein 9300. BLOEMFONTEIN NOV. 17. 1992 • 5-7 P.M. HOLIDAY INN DURBAN BEACH 73 Marine Parade, DURBAN NOV. 19. 1992 - 5-7 P.M. HOLIDAY INN CAPETOWN SOUTH AFRICA Melbourne Road P.O., Box 2979 - CAPETOWN NOV. 2 0 , 1 9 9 2 - 5 - 7 P.M. We are an affiliate of a highly professional and long-standing U.S. company, Total Rehabilitation, Inc., which supplies Rehabilitation Services to various medical centers. We offer a challenging career In all areas of physical medicine and rehabilitation Including: ORTHOPEDIC SPORTS MEDICINE • NEUROLOGY • GERIATRIC IN-& OUTPATIENT GENERAL ACUTE • IN-& OUTPATIENT REHABILITATION Excellent salary, benefits and relocation allowance. For more Information on this moving opportunity. Ann Bevans will hold Interviews at the above location. Call collect or fax a resume for additional information. PLACEMENT ■ RELOCATION ■ TRAINING Count on us to settle you In! 30100 TELEGRAPH, SUITE 408, BINGHAM FARMS, MICHIGAN 48025 USA 3 1 3 /6 4 5 -2 1 4 0 FAX 313 / 647-3674 TOTAL REHABILITATION INTERNATIONAL LTD. An Offer Made to Move You! Meet In the Lobby! INTERNATIONAL PHYSICAL THERAPY RECRUITING R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) ing the results than there is in those m ethods using any o f the commonly known measuring instruments, such as the tape m easure, the goniometer and the flexicurve 1,2 FIG 1: Measurement of the degree of lumbar spine curvature The primed photographs were used to calculate the angles of lumbar spine curvature in each subject. T he points marking the spinous processes o f T12 and L I, then L5 and SI were joined with straight lines on cach of the photographs (Fig. 1). Perpendicular lines between the first two and the second two points were then extended posteriorly to bisect, and the angle thus formed was m easured with a standard protractor. Each o f these angles was taken to represent the angle, and therefore the degree o f lumbar spine curvature for that particular subject. This procedure was carried out three times for each subject and the mean m easurem ent of the degree o f lumbar spine curvature calculated. RESULTS T he m easured degree of lumbar spine curvature for each o f the 13 subjects is shown in Table I. These m easurem ents ranged from 29 ± 0,6 degrees to 39 ± 0,6 degrees, with a mean o f 33,9 ± 3,6 degrees. DISCUSSION AND CONCLUSIONS Although lumbar spine curvature has been m easured successfully in the past 1’2’3’4, Bullock et a t are the only authors who have reported such m easurem ents on a sample o f pregnant women to date. However, their method requires the use o f a cliniometer, which is not regarded as standard equipm ent for basic anthropom orphic m easurem ents for research or as a clinical diagnostic tool. We feel that although the m ethod o f measuring lum bar spine curvature in pregnant women reported in o u r study may require m ore time for the development o f the photographs, it has the advantage o f being easy to carry out in any clinical situation and in all anthropom orphic m easurem ent laboratories, w here the standard cam era is usually basic equipment. T here is less chance, with our method, o f the variable o f hum an error in m easurem ent confound- TABLE I: Degree of lumbar spine curvature CASE AGE (years) ANGLE OF CURVATURE (degrees) m fin fill) X ± SD 1 35,4 39 39 40 39 ± 0,6 2 30,6 37 37 36 37 ± 0,6 3 34,0 30 30 29 30 ± 0 ,6 4 34,0 34 34 35 34 ± 0,6 5 29,5 38 36 36 37 ± 1,2 6 22,4 41 37 37 38 ± 2,3 7 34,1 37 35 39 37 ± 2,0 8 40,7 33 29 29 30 ± 2,3 9 22,9 28 29 29 29 ± 0,6 10 34,1 28 28 31 29 ± 1,7 11 34,7 35 33 33 34 ± 1,2 12 28,4 30 32 3 2 ' 31 ± 1,2 13 28,3 35 33 33 34 ± 1,2 X ± SD 31,5 ± 5,1 33,9 ± 3,6 KEY: X = mean; SD = standard deviation T he results o f o ur study cannot meaningfully be com pared with those o f Fernand & Fox3, who m easured the “normal lum bar lor­ dotic angle” in 973 adults (males and non-pregnant women). They also used two dem arcations o f the lum bar spine : from L2 to L5, when a m ean angle o f 29,96 ± 0,74 (SEM ) was found, and from L2 to SI, giving a m ean angle o f 45,05 ± 0,85 (SEM ). The subjects were m easured in the “lateral recum bent position” o r side- lying and not the erect standing position when the lum bar spine curvature is most obvious. Both Salisbury & P o rter1 and Stokes et al2 studied spinal motion, from full flexion to extension o f the spine. Thus, these studies report on the range o f motion o f the spine and how it is m easured, and no angles o f spinal curvatures are given. O ur results com pare most favourably, however, with those o f Bullockef a t . We found, in our sample o f 13 third trim ester pregnant women, that the m ean angle o f lum bar spine curvature was 33,9 ± 3,6 degrees while Bullock et a t report a m ean angle o f 33,9 ± 10,9 (SD) degrees in 34 women in the last stage o f pregnancy (third trim ester). This suggests that the m ethods used in the two studies are comparable. This study, as a pilot study, offers normative data for the degree o f lum bar spine curvature, in the erect or standing position, in third trim ester pregnant women. Acknowledgements This study was approved by the Com m ittee for Research on H um an Subjects, University o f the Witwatersrand, Johannesburg (Protocol No. 11/2/90). T h e authors gratefully acknowledge the participation, in this study, o f those pregnant women who were attending antenatal classes at the Family and Child Centre, R and- burg. Thanks are due too, to the staff o f the D epartm ent o f Anatomy and H um an Biology, for the use o f the Somatotype Laboratory and for the processing o f the photographs used in this study. REFERENCES 1. Salisbury PJ, Porter RW. Measurement o f Lumbar sagittal mobility: A comparison o f Methods. Spine 1987;12(2):190-193. 2. Stokes 1AF, Bevins TM, Lunn R A Back surface curvature and measurement o f lumbar spinal motion. Spine 1987;12(4):355-361. 3. Fernand R, Fox DE. Evaluation o f lumbar lordosis: A prospective and retrospective study. Spine 1985;10(9):799-803. 4. Bullock JE, Jull G A , Bullock M l. The relationship o f low back pain to postural changes during preg i& n cy.A u strJP h ys 1987;33( 1): 10-17. Physiotherapy, November 1992 Vol 48 no 4 Page 55 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )