Non-radiographic methods of measuring global sagittal balance: a systematic review

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Abstract

Background

Global sagittal balance, describing the vertical alignment of the spine, is an important factor in the non-operative and operative management of back pain. However, the typical gold standard method of assessment, radiography, requires exposure to radiation and increased cost, making it unsuitable for repeated use. Non-radiologic methods of assessment are available, but their reliability and validity in the current literature have not been systematically assessed. Therefore, the aim of this systematic review was to synthesise and evaluate the reliability and validity of non-radiographic methods of assessing global sagittal balance.

Methods

Five electronic databases were searched and methodology evaluated by two independent reviewers using the13-item, reliability and validity, Brink and Louw critical appraisal tool.

Results

Fourteen articles describing six methodologies were identified from 3940 records. The six non-radiographic methodologies were biophotogrammetry, plumbline, surface topography, infra-red motion analysis, spinal mouse and ultrasound. Construct validity was evaluated for surface topography ( R = 0.49 and R = 0.68, p < 0.001), infra-red motion-analysis (ICC = 0.81) and plumbline testing (ICC = 0.83). Reliability ranged from moderate (ICC = 0.67) for spinal mouse to very high for surface topography (Cronbach α = 0.985). Measures of agreement ranged from 0.9 mm (plumbline) to 22.94 mm (infra-red motion-analysis). Variability in study populations, reporting parameters and statistics prevented a meta-analysis.

Conclusions

The reliability and validity of the non-radiographic methods of measuring global sagittal balance was reported within 14 identified articles. Based on this limited evidence, non-radiographic methods appear to have moderate to very high reliability and limited to three methodologies, moderate to high validity. The overall quality and methodological approaches of the included articles were highly variable. Further research should focus on the validity of non-radiographic methods with a greater adherence to reporting actual and clinically relevant measures of agreement.

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Statistical Methods Used to Test for Agreement of Medical Instruments Measuring Continuous Variables in Method Comparison Studies: A Systematic Review

Rafdzah Zaki, Awang M Bulgiba, Roshidi Ismail … (2012)

Background Accurate values are a must in medicine. An important parameter in determining the quality of a medical instrument is agreement with a gold standard. Various statistical methods have been used to test for agreement. Some of these methods have been shown to be inappropriate. This can result in misleading conclusions about the validity of an instrument. The Bland-Altman method is the most popular method judging by the many citations of the article proposing this method. However, the number of citations does not necessarily mean that this method has been applied in agreement research. No previous study has been conducted to look into this. This is the first systematic review to identify statistical methods used to test for agreement of medical instruments. The proportion of various statistical methods found in this review will also reflect the proportion of medical instruments that have been validated using those particular methods in current clinical practice. Methodology/Findings Five electronic databases were searched between 2007 and 2009 to look for agreement studies. A total of 3,260 titles were initially identified. Only 412 titles were potentially related, and finally 210 fitted the inclusion criteria. The Bland-Altman method is the most popular method with 178 (85%) studies having used this method, followed by the correlation coefficient (27%) and means comparison (18%). Some of the inappropriate methods highlighted by Altman and Bland since the 1980s are still in use. Conclusions This study finds that the Bland-Altman method is the most popular method used in agreement research. There are still inappropriate applications of statistical methods in some studies. It is important for a clinician or medical researcher to be aware of this issue because misleading conclusions from inappropriate analyses will jeopardize the quality of the evidence, which in turn will influence quality of care given to patients in the future.

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A new skin-surface device for measuring the curvature and global and segmental ranges of motion of the spine: reliability of measurements and comparison with data reviewed from the literature.

G Balaban, Jiří Dvořák, Anne F Mannion … (2004)

There is an increasing awareness of the risks and dangers of exposure to radiation associated with repeated radiographic assessment of spinal curvature and spinal movements. As such, attempts are continuously being made to develop skin-surface devices for use in examining the progression and response to treatment of various spinal disorders. However, the reliability and validity of measurements recorded with such devices must be established before they can be recommended for use in the research or clinical environment. The aim of this study was to examine the reliability of measurements using a newly developed skin-surface device, the Spinal Mouse. Twenty healthy volunteers (mean age 41 +/- 12 years, nine males, 11 females) took part. On 2 separate days, spinal curvature was measured with the Spinal Mouse during standing, full flexion, and full extension (each three times by each of two examiners). Paired t-tests, intraclass correlation coefficients (ICC), and standard errors of measurement (SEM) with 95% confidence intervals were used to characterise between-day and interexaminer reliability for: standing sacral angle, lumbar lordosis, thoracic kyphosis, and ranges of motion (flexion, extension) of the thoracic spine, lumbar spine, hips, and trunk. The between-day reliability for segmental ranges of flexion was also determined for each motion segment from T1-2 to L5-S1. The majority of parameters measured for the 'global regions' (thoracic, lumbar, or hips) showed good between-day reliability. Depending on the parameter of interest, between-day ICCs ranged from 0.67 to 0.92 for examiner 1 (average 0.82) and 0.57 to 0.95 for examiner 2 (average 0.83); for 70% of the parameters measured, the ICCs were greater than 0.8 and generally highest for the lumbar spine and whole trunk measures. For lumbar spine range of flexion, the SEM was approximately 3 degrees. The ICCs were also good for the interexaminer comparisons, ranging from 0.62 to 0.93 on day 1 (average 0.81) and 0.70 to 0.94 on day 2 (average 0.86), although small systematic differences were sometimes observed in their mean values. The latter were still evident even if both examiners used the same skin markings. For segmental ranges of flexion, the ICCs varied between vertebral levels but overall were lower than for the global measures (average for all levels in all analyses, ICC 0.6). For each examiner, the average between-day SEM over all vertebral levels was approximately 2 degrees. For 'global' regions of the spine, the Spinal Mouse delivered consistently reliable values for standing curvatures and ranges of motion which compared well with those reported in the literature. This suggests that the device can be reliably implemented for in vivo studies of the sagittal profile and range of motion of the spine. As might be expected for the smaller angles being measured, the segmental ranges of flexion showed lower reliability. Their usefulness with regard to the interpretation of individual results and the detection of 'real change' on an individual basis thus remains questionable. Nonetheless, the group mean values showed few between-day differences, suggesting that the device may still be of use in providing clinically interesting data on segmental motion when examining groups of individuals with a given spinal pathology or undergoing some type of intervention.

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Change in classification grade by the SRS-Schwab Adult Spinal Deformity Classification predicts impact on health-related quality of life measures: prospective analysis of operative and nonoperative treatment.

Eric Klineberg, Behrooz Akbarnia, Peter J S Smith … (2013)

Multicenter, prospective, consecutive series. To evaluate responsiveness of the Scoliosis Research Society (SRS)-Schwab adult spinal deformity (ASD) classification to changes in health-related quality of life (HRQOL) after treatment for ASD. Ideally, a classification system should describe and be responsive to changes in a disease state. We hypothesized that the SRS-Schwab classification is responsive to changes in HRQOL measures after treatment for ASD. A multicenter, prospective, consecutive series from the International Spine Study Group. ASD, age more than 18, operative or nonoperative treatment, baseline and 1-year radiographs, and HRQOL measures (Oswestry Disability Index [ODI], SRS-22, Short Form [SF]-36). The SRS-Schwab classification includes a curve descriptor and 3 sagittal spinopelvic modifiers (sagittal vertical axis [SVA], pelvic tilt, pelvic incidence/lumbar lordosis [PI-LL] mismatch). Changes in modifiers at 1 year were assessed for impact on HRQOL from pretreatment values based on minimal clinically important differences. Three hundred forty-one patients met criteria (mean age = 54; 85% females; 177 operative and 164 nonoperative). Change in pelvic tilt modifier at 1-year follow-up was associated with changes in ODI and SRS-22 (total and appearance scores) (P ≤ 0.034). Change in SVA modifier at 1 year was associated with changes in ODI, SF-36 physical component score, and SRS-22 (total, activity, and appearance scores) (P ≤ 0.037). Change in PI-LL modifier at 1 year was associated with changes in SF-36 physical component score and SRS-22 (total, activity, and appearance scores) (P ≤ 0.03). Patients with improvement of pelvic tilt, SVA, or PI-LL modifiers were significantly more likely to achieve minimal clinically important difference for ODI, SF-36 physical component score (SVA and PI-LL only), SRS activity, and SRS pain (PI-LL only). The SRS-Schwab classification provides a validated system to evaluate ASD, and the classification components correlate with HRQOL measures. This study demonstrates that the classification modifiers are responsive to changes in disease state and reflect significant changes in patient-reported outcomes. 3.

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Author and article information

Contributors

Larry Cohen: +61 2 9351 2222 , lcoh0894@uni.sydney.edu.au

Sarah Kobayashi: skob9241@uni.sydney.edu.au

Milena Simic: Milena.Simic@sydney.edu.au

Sarah Dennis: Sarah.Dennis@sydney.edu.au

Kathryn Refshauge: kathryn.refshauge@sydney.edu.au

Evangelos Pappas: Evangelos.Pappas@sydney.edu.au

Journal

Journal ID (nlm-ta): Scoliosis Spinal Disord

Journal ID (iso-abbrev): Scoliosis Spinal Disord

Title: Scoliosis and Spinal Disorders

Publisher: BioMed Central (London )

ISSN (Electronic): 2397-1789

Publication date (Electronic): 3 October 2017

Publication date PMC-release: 3 October 2017

Publication date Collection: 2017

Volume: 12

Electronic Location Identifier: 30

Affiliations

ISNI 0000 0004 1936 834X, GRID grid.1013.3, Faculty of Health Sciences, Discipline of Physiotherapy, , The University of Sydney, ; 75 East Street, Lidcombe, NSW 2141 Australia

Article

Publisher ID: 135

DOI: 10.1186/s13013-017-0135-x

PMC ID: 5625601

PubMed ID: 29026895

SO-VID: 665cf1bc-04d7-4ded-a67c-74d86feaacf7

License:

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

History

Date received : 2 April 2017

Date accepted : 11 May 2017

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Keywords: spine posture,spine shape,non-invasive assessment,sagittal vertical axis,sva,measurement,reliability,validity

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Keywords: spine posture, spine shape, non-invasive assessment, sagittal vertical axis, sva, measurement, reliability, validity

Non-radiographic methods of measuring global sagittal balance: a systematic review

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Most cited references 32

Statistical Methods Used to Test for Agreement of Medical Instruments Measuring Continuous Variables in Method Comparison Studies: A Systematic Review

A new skin-surface device for measuring the curvature and global and segmental ranges of motion of the spine: reliability of measurements and comparison with data reviewed from the literature.

Change in classification grade by the SRS-Schwab Adult Spinal Deformity Classification predicts impact on health-related quality of life measures: prospective analysis of operative and nonoperative treatment.

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