Revista Adolescência e Saúde

Revista Oficial do Núcleo de Estudos da Saúde do Adolescente / UERJ

NESA Publicação oficial
ISSN: 2177-5281 (Online)

Vol. 16 nº 1 - Jan/Mar - 2019

Original Article Imprimir 

Páginas 33 a 45


Factors associated with postural deviation in the sagittal plane of public-school adolescents

Factores asociados a las alteraciones posturales en el plano sagital de adolescentes de escuelas públicas

Fatores associados às alterações posturais no plano sagital de adolescentes de escolas públicas

Autores: Verônica Winik1; Litiele Evelin Wagner2; Marciele Silveira Hopp2; Cézane Priscila Reuter3; Éboni Marília Reuter4; Miria Suzana Burgos5; Dulciane Nunes Paiva6

1. Physiotherapist at the University of Passo Fundo - UPF. Master in Health Promotion from the University of Santa Cruz do Sul - UNISC. Santa Cruz do Sul, RS, Brazil
2. Residents of the Multiprofessional Integrated Health Residency Program of Santa Cruz Hospital. Santa Cruz do Sul, RS, Brail
3. Doctor in Child and Adolescent Health, Federal University of Rio Grande do Sul - UFRGS - UFRGS. Teacher of the Department of Physical Education and Health and the Postgraduate Program in Health Promotion of the University of Santa Cruz do Sul - UNISC. Santa Cruz do Sul, RS, Brazil
4. Master in Health Promotion from the University of Santa Cruz do Sul - UNISC. Teacher at the Department of Physical Education and Health of UNISC. Santa Cruz do Sul, RS, Brazil
5. Doctor in Sciences of the Education by the Pontifical University of Salamanca - Spain. Doctor em Ciências da Motricidade Humana pela Universidade Técnica de Lisboa (UTL) - Portugin Human Molecular Sciences from the Technical University of Lisbon (UTL) - Portugal. Teacher Professor of the Physical Education Course and the Postgraduate Program in Health Promotion of the University of Santa Cruz do Sul - UNISC. Santa Cruz do Sul, RS, Brazil. In memoriam
6. Doctor in Medical Sciences from the Federal University of Rio Grande do Sul (UFRGS). Professor of the Department of Physical Education and Health and the Postgraduate Program in Health Promotion of the University of Santa Cruz do Sul - UNISC. Santa Cruz do Sul, RS, Brazil

Dulciane Nunes Paiva
Avenida Independência, nº 2293, Bloco 42 - Mestrado em Promoção da Saúde
Santa Cruz do Sul, RS, Brasil. CEP: 96815-900
dulciane@unisc.br

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How to cite this article

Keywords: Evaluation; Posture; Life Style; Adolescent Health.
Palabra Clave: Evaluación; Postura; Estilo de Vida; Salud del Adolescente.
Descritores: Avaliação; Postura; Estilo de Vida; Saúde do Adolescente.

Abstract:
OBJECTIVE: Identify the postural changes in the sagittal plane and its associated factors in adolescents from public state schools of the city of Capão da Canoa - RS.
METHODS: Was performed a cross-sectional study that evaluated 185 adolescents (14 to 19 years old) regarding backpack weight, thoracic and lumbar curvature angles. Self-reporting questionnaires were used to assess postural habits, lifestyle, health and well-being, and socioeconomic status, being the postural alterations evaluated by the Flexi curve method. The data were analyzed through Chi-square test, Fisher Exact test and Poisson Regression (p<0.05).
RESULTS: There was a high prevalence of back pain in 125 adolescents (67.60%) and postural alteration in 75 (40.5%), with 5 (2.7%) presenting thoracic deviation and 70 (37.9%), lumbar deviation, in which 5.6% of the sample presented more than one postural alteration. There was an association between male gender with thoracic kyphosis (p=0.014) and lumbar rectification.
CONCLUSION: The present study evidenced a high prevalence of back pain and inappropriate postural habits that can be pointed out as the associated factors responsible for the evidenced postural alterations.

Resumen:
OBJETIVO: Identificar las alteraciones posturales en el plano sagital y sus factores asociados en adolescentes de enseñanza media de escuelas estaduales de la ciudad de Capão da Canoa - RS.
MÉTODOS: Fue realizado un estudio transversal que evaluó 185 escolares (14 a 19 años) respecto al peso de las mochilas, ángulos de curvatura torácica y lumbar. Fueron utilizados cuestionarios autoaplicables para evaluar hábitos de postura, estilo de vida, salud y bienestar y nivel socioeconómico, siendo las alteraciones posturales evaluadas por el método Flexicurva. Los datos fueron evaluados a través del test Chi-Cuadrado, Exacto de Fisher y Regresión de Poisson (p<0,05).
RESULTADOS: Se constató alta prevalencia de dolor en la espalda en 125 escolares (67,60%) y de alteración postural en 75 escolares (40,5%). Cinco (2,7%) presentaron desvío torácico y 70 (37,9%) desvío lumbar. En el 5,6 % de la muestra ocurrió más de una alteración postural. Hubo asociación del sexo masculino con hipercifosis torácica (p=0,014) y con rectificación lumbar.
CONCLUSIÓN: El presente estudio dejó en evidencia alta prevalencia de dolor en la espalda y de hábitos posturales inadecuados que pueden ser apuntados como los factores asociados responsables por las alteraciones de postura evidenciados.

Resumo:
OBJETIVO: Identificar as alterações posturais no plano sagital e seus fatores associados em adolescentes do ensino médio de escolas estaduais da cidade de Capão da Canoa - RS.
MÉTODOS: Foi realizado um estudo transversal que avaliou 185 escolares (14 a 19 anos) quanto ao peso das mochilas, ângulos das curvaturas torácicas e lombares. Foram utilizados questionários autoaplicáveis para avaliar hábitos posturais, estilo de vida, saúde e bem-estar e nível socioeconômico, sendo as alterações posturais avaliadas pelo método Flexicurva. Os dados foram avaliados através do teste Qui-Quadrado, Exato de Fisher e Regressão de Poisson (p<0,05).
RESULTADOS: Constatou-se elevada prevalência de dor nas costas em 125 escolares (67,60%) e de alteração postural em 75 escolares (40,5%). Cinco (2,7%) apresentaram desvio torácico e 70 (37,9%), desvio lombar. Em 5,6 % da amostra ocorreu mais de uma alteração postural. Houve associação do sexo masculino com hipercifose torácica (p=0,014) e com retificação lombar.
CONCLUSÃO: O presente estudo evidenciou elevada prevalência de dor nas costas e de hábitos posturais inadequados que podem ser apontados como os fatores associados responsáveis pelas alterações posturais evidenciadas.

INTRODUCTION

The human body is in constant adaptation as a function of the evolutionary process of the species and the impositions of the habits of life of the modern civilization, and posture is the result of daily habits adopted throughout life.1 Postural changes when they do not cause immediate pain can be neglected and, in the long run, become responsible for muscular adaptations capable of severely damaging bodily structures in adult life.2

From the age of seven the child's posture undergoes a great transformation to achieve a balance compatible with the new corporal proportions and to meet the psychosocial demands3. It is in the period from 12 to 14 years for girls and from 14 to 16 years for boys, phase known as growth spurt, which occur increases in height and body proportions, hormonal changes, balance adjustments and ligamentous hypermobility.4

Among students, the most frequent static posture alterations in the sagittal plane are thoracic hyperkyphosis and lumbar hyperlordosis, characterized by increased curvatures5 and lumbar and thoracic rectification, characterized by the reduction or absence of physiological curvatures of the spine6. Long-term sitting in inadequate body position6,7, high body mass index (BMI) 8, inadequately transported and overloaded backpacks9, sedentary lifestyle9, socio-cultural factors10, sleeping position7, emotional characteristics11, and hereditary load3 are associated factors that predispose to the development of postural alterations.

Although there is an increase in risk factors for postural changes in the growth spurt stage, it is also considered an excellent stage for interventions to prevent the development of postural changes and diseases associated with these changes in adulthood7,12. Identifying postural changes and relating them to their associated factors allows a complete approach to postural changes and their consequences in the medium and long term7,13. In view of the above, the present study aimed to identify postural changes in the sagittal plane and its possible associated factors in high school students in the city of Capão da Canoa - RS.


METHODS

The school population consisted of 9,504 students from primary and secondary schools, public and private, of which eleven are municipal, four are state and two are private schools located in the municipality of Capão da Canoa - RS. These data were collected at the 11th Regional Education Coordination and in the Municipal Education Department of Capão da Canoa. It was a cross-sectional study carried out from January to September 2015, which included a sample of high school students from the state public school in the municipality of Capão da Canoa - RS. To be representative of the municipality, a sample of 157 schoolchildren was estimated using the G * Power software (version 3.1.9.2), based on a statistical power of 0.90 and a level of significance of 5%14. Considering a loss of follow-up of 20%, a minimum sample size of 188 students was required.

We included individuals aged 14 to 19 years for girls and 16 to 19 years for boys, who were able to answer the questionnaires. Those with systemic or neurological diseases, congenital orthopedic dysfunctions, psychiatric dysfunction, physiotherapeutic or orthopedic treatment and those enrolled in the private state educational network were excluded. It is emphasized that the age range of the study excluded the growth spurt phase for both sexes.

The project met the criteria of the current resolution of the National Health Council on ethics in research with human beings (nº 466/12), and was approved by the Research Ethics Committee of the University of Santa Cruz do Sul (UNISC) under opinion nº 907.502 of 12/09/14. The signing of the Free and Informed Consent Form was obtained by the legal guardian and the Minor Student Assent Term by the evaluated student, after providing detailed information about the research procedures.

The self-administered Back Pain and Body Posture Evaluation Instrument (BackPEI)2 questionnaire was used which consists of 21 closed questions, using the questions: "Do you feel or have you had back pain in the last 3 months?", "This back pain occurs how often? "," Does this back pain prevent or prevent you from performing activities such as playing, studying and practicing sports? ". This instrument also allowed for anamnesis, which was carried out on the same day and in the other stages of the students' evaluation. The intensity of back pain in the last 3 months was assessed using the Visual Analogue Scale.

For the evaluation of the individual's lifestyle and well-being, a questionnaire adapted from "The Pentacle of Welfare" 15 was used, which consists of closed questions about lifestyle, nutrition, weight control, physical activity, behavior, relationships, stress, cultural and leisure activities. The socioeconomic indicators of the family of the adolescent were evaluated through the survey of the Brazilian Association of Research Companies16, composed of questions about the family's possessions and the degree of education of the head of the family.

A calibrated portable digital scale (model W801, Wiso Sports Technology® Brazil) with a capacity of 180kg and a graduation of 100g was used to verify body mass. The stature of the sample was evaluated through a measuring tape (Wiso Sports Technology®, Brazil), fixed to the wall and adjusted with a bubble level device up to a height of 2.20 m, and individuals were asked to remain with bare feet and clothes comfortable. We calculated the BMI and the classification by the percentile curves recommended by the Center for Disease Control and Prevention according to sex and age17. The weight of the backpacks was measured using a portable digital scale with a calibrated capacity of 40 kg (WeiHeng®, China), and the backpack weight of up to 10% of the evaluated body weight was considered appropriate.

The postural evaluation was performed with the adolescent in an orthostatic position and with posterior view for the researcher, with parallel feet, knees in extension and 90º of elbow and shoulder flexion. Spinal processes of the vertebrae C7, T1, T12, L1, L5 and S1 were marked with subsequent molding with Flexicurva (Trident®, Brazil), which is a flexible metal molding ruler 80 cm in length. The Biomec-Flex® Software18 was used to calculate the angles of sagittal and thoracic curvatures. Such methods present validity and reproducibility for the adult population19 and for children and adolescents20.

The points referring to the spinous processes were marked on the flexible ruler, the contour of the ruler being transcribed to a graph paper containing a Cartesian plane in which x represents the cranio-caudal axis and y, the anteroposterior axis. In addition to the points related to the spinous processes of the selected vertebrae, a further six random markings were made in the spaces of the thoracic and lumbar curvature. Such markings generated 18 ordered pairs, which when transcribed in the Biomec-Flex® Software generated the angles of the thoracic and lumbar curvature. Subsequently, the values were classified according to Cobb angle for children and adolescents. Regarding the classification of the column curvatures in the sagittal plane, it was considered normal curvature in the thoracic region with angles from 20º to 50º21 and in the lumbar spine, angles from 31º to 49.5º22. Values above 50º in the thoracic region and above 49.5º in the lumbar region represent increased physiological curvatures, characterizing thoracic hyperciphosis and lumbar hyperlordosis, respectively. Values below 20º in the thoracic region and below 31º in the lumbar region represent the reduction of physiological curvatures and characterize thoracic and lumbar rectification7.

It is noteworthy that all data collection was performed by a single evaluator, being an experienced physiotherapist, trained and trained in the Exercise Research Laboratory of the School of Physical Education, Physiotherapy and Dance of the Federal University of Rio Grande do Sul ( ESEFID-UFRGS). The study was blinded only to the data obtained. Statistical analysis was performed using the SPSS software (Version 22.0, USA). The normality of the data was assessed using the Kolmogorov Smirnov test and the data were expressed as mean, standard deviation and frequency. The association between postural habits, lifestyle, health and well-being, and socioeconomic status with postural changes was performed using Chi-Square and Fisher Exact tests (p <0.05). Association between the independent variables with the outcome (presence of postural alteration) was tested by Poisson regression, using the prevalence ratio (PR) and confidence interval (CI) values for 95%.


RESULTS

The sample consisted of 600 students from the state public network, of which 363 individuals expressed their desire not to participate in the study and 52 were excluded because they lacked the research steps. The final sample consisted of 185 eligible students according to the inclusion criteria of the study (Figure 1). Table 1 presents the anthropometric and sociodemographic characteristics of the sample evaluated.


Figure 1. Flow chart representative of the sample loss and of the individuals who participated in the study.




It was observed that 75 (40.5%) adolescents evaluated had a postural alteration in the sagittal plane and of these, five (2.7%) presented thoracic deviation and 70 (37.9%), lumbar deviation. Regarding the thoracic curvature, four (5.3%) presented hyperkyphosis and one (1.3%) had rectification. In relation to the lumbar spine, two (2.6%) presented hyperlordosis and 68 (90.6%) had lumbar rectification, and two (5.6%) adolescents presented more than one postural alteration in the sagittal plane.

Tables 2 and 3 show the prevalence of thoracic and lumbar diagnoses stratified by gender, backpack weight and percentile classification, as well as posture and behavioral habits of the students evaluated. Among the total sample, 177 (96.2%) presented a backpack with adequate weight, with the weight of the backpacks represented 5.89% of the body mass of adolescents. In the present study, it was possible to identify the prevalence of back pain in 125 students (67.60%) (Table 3).






There was an association between sleep in the supine position and the presence of lumbar rectification (p = 0.014). Regarding the socioeconomic class, class C showed a significant association (p = 0.048) regarding the tendency to present lumbar rectification, while class B tended to postural normality (p = 0.019). Of the adolescents belonging to class B, 34.4% presented postural alterations, while among those in class C, 47.16% presented such an occurrence (Table 4).




An association was observed between the adolescents who carried the backpack symmetrically (on both shoulders) and the presence of lumbar rectification (p = 0.031), noting that of all adolescents with postural alteration and using a backpack with two loops, 128 69.7%) carried it symmetrically. The male gender presented a positive association with the presence of lumbar rectification (p <0.001) and thoracic hyperciphosis (p = 0.014). However, the habit of sitting inappropriately for writing and taking a sitting position on a bench to talk to friends, to use the computer, and to pick up objects from the floor was not associated with postural change. As a result of the students who reported correctly sitting at school, 38.5% presented postural alterations, while those who sat inappropriately, 39.2% presented postural alteration. There was no evidence of an association between physical activity and the presence of postural alterations (Table 4).

Higher prevalences of postural alterations presented the following positions: v dorsal decubitus, improper posture to sit on a bench and to pick up object on the floor. Inadequate posture and female gender presented lower prevalences when compared to the other categories (Table 5).




DISCUSSION

The present study identified postural alterations in the sagittal plane and its possible associated factors in high school students of the city of Capão da Canoa - RS. The main results showed a prevalence of 40.5% of postural alterations in the sagittal plane, being 2.7% in the thoracic spine and 37.9% in the lumbar spine, as well as the association of these changes with the lowest socioeconomic level, with males, the act of sleeping in the dorsal decubitus and the use of a backpack in a symmetrical way. A similar prevalence was evidenced by Kunzleret al. 13 who identified 20% of thoracic deviations and 37.0% of lumbar deviations after identifying the prevalence of static changes in the sagittal plane and the posture habits of 75 students aged 14 to 17 years of the Lajeado municipality - RS, through the questionnaire BackPEI and arcometer to evaluate the curvature of the spine. These results differ from those found by Martelli and Traebert5 who verified, by means of individual postural evaluation in 344 students aged 10 to 16 years in the municipality of Tangará - SC, the prevalence of postural alteration of 28.2%, being 11% in the thoracic spine and 20.3% in the lumbar spine.

In the present study, the most prevalent alteration was lumbar rectification, which was present in 68 (36.8%) adolescents. In contrast, some authors describe hyperlordosis as the most prevalent alteration, such as Bueno and Rech23, who reported 27.9% of lumbar hyperlordosis and 3.6% of rectification in a sample of 864 students. Similarly, Lemos et al.24, in a study with 467 students aged 10 to 16 years in Porto Alegre - RS, found 78.20% of the occurrence of lumbar hyperlordosis evidenced by means of postural evaluation with a symmetry.

There was a higher prevalence of postural alterations between males, with a 60% occurrence, besides the observed association between boys and lumbar rectification and thoracic hyperciphosis. The results obtained by Sedrezet al.7, when evaluating 59 children and adolescents aged 7 to 18 years of age in the city of Porto Alegre - RS, using photogrammetry, showed an association between thoracic kyphosis and female gender. The differences found in the cited studies may be associated to the different age groups studied, which made it difficult to have an adequate comparative analysis between the studies.

Kastenet al. 6 carried out a systematic review with meta-analysis to identify the prevalence of postural changes in the column of school children and adolescents in Brazil, and although they considered a robust sample size in the analyzes of each type of postural alteration, it was not possible to establish a consensus on the prevalence of anteroposterior and lateral-lateral postural changes in the spine. This result may have occurred due to the great heterogeneity of the studies, as they differ greatly in the methods used for postural evaluation, in the sample size and in the variability of the reference values for the classification of the spinal curvatures.

However, in our study it was possible to show a significant association between the presence of postural alterations and the lower socioeconomic classes (C2). Detschet al.25 also found a higher prevalence of postural changes in public school students when compared to students in private schools, as well as in students whose parents studied to elementary school in comparison to those in which parents studied until higher education and post -University graduate. It is suggested that a greater degree of instruction of the parents predisposes to a greater care with the habits of life and with the posture to be adopted by the children.

The weight of backpacks and the way they are transported have been a topic of interest and discussion, since this is a risk factor for postural changes. Corroborating with the present study, Sedrezet al.26 found that 70.8% of the evaluated students used the backpack symmetrically. Bueno and Rech23 identified 75.9% of those evaluated with adequate weight of backpacks and 80.7% using it symmetrically. In their study, Candottiet al.27 observed that 80% of the students presented backpacks without overload and 75.9% used it in a symmetrical way. Ritter and Souza28 found backpacks with a percentage of 5.46% of the body mass of primary school students in Porto Alegre, Brazil, in order to compare the mean weight of the backpacks with 5.89% RS.

As in the present study, the mentioned studies did not find a significant association between the weight, type or form of transportation of the backpacks and the presence of postural alterations. On the other hand, Sedrezet al.7 found a significant association between the mode of transportation of the backpack and the posture of the thoracic and lumbar and Neryet al.29 showed a significant association between the weight of backpacks and the presence of scoliosis. In the present study, a significant association was found between the use of the backpack in a symmetrical way and the presence of lumbar rectification, an evidence that contrasts with the initial hypothesis that asymmetric transport would be related to postural alterations. However, Candottiet al.27 suggest that the lack of adjustment of the backpack straps may justify such association, but it should be emphasized that this variable was not analyzed in the present study.

Despite the high prevalence of inappropriate posture habits, we did not observe a significant association with the postural changes evidenced, diverging from the initial hypothesis that daily habits would be related to the presence of postural alterations. These data are in agreement with the study by Sedrezet al.26 that showed a significant association between improper picking and the presence of thoracic kyphosis, lumbar changes and the presence of back pain.

The position analysis during sleep identified a significant association between dorsal decubitus posture and the presence of lumbar rectification, as corroborated by Vasconcelos et al.30, who found a higher prevalence of postural alterations in those students who responded to sleep in dorsal decubitus and in decubitus, and by Sedrezet al.26 who found a significant association between posture and the presence of scoliosis. According to Vasconcelos et al.30, postural changes may result from the adoption of repeated asymmetric positions that cause muscle imbalances and compensations. It was not possible to establish cause for these associations, since the adoption of dorsal decubitus is considered adequate, and it is therefore suggested to investigate the type of mattress and pillow used by these adolescents in an attempt to identify the causes of these associations.

In the present study, it was possible to identify a high prevalence of back pain (67.6%), a finding corroborated by several authors7,8. Vasconcelos et al.30 found a significant association between pain and thoracic hyperciphosis, however, Sedrezet al.26 evidenced an association between pain and alteration of lumbar lordosis. It is necessary to point out that the finding of different prevalences of postural changes among adolescents in the school phase among the evaluated studies is justified by the methodological differences and age groups evaluated in the various studies, besides the local and regional characteristics that impose habits and lifestyle characteristics to each locality, making it impossible to compare groups of different cities. In this sense, Kastenet al.6 recommended that the macro and micro regional differences of the states and the country be investigated.

It was evidenced a moderate prevalence of postural changes in the sagittal plane, with lumbar rectification being the most prevalent alteration. It was also observed that boys tend to present more postural alterations in the sagittal plane, as well as they are associated to the presence of lumbar rectification and thoracic hyperciphosis. It was found an association between the presence of postural alteration in the sagittal plane and the use of the backpack symmetrically with the lower socioeconomic classes, as well as between the position of sleep in the supine position and lumbar rectification. In this sense, there was a high prevalence of inappropriate posture habits adopted daily and back pain.

The present study presented limitations that should be emphasized, such as the lack of studies that used the Flexicurva method in adolescents, which limited the discussion of the data obtained. The adjustments of the backpack straps of the evaluated students were not measured, and this may have influenced the association between the use of backpacks with symmetrical loops and the presence of lumbar rectification. The risk of occurrence of selection bias due to the number of sample loss should be highlighted, where this may have overestimated the prevalence of postural deviation and pain, and the results should be interpreted with caution.

In our study, there was a high prevalence of back pain in schoolchildren evaluated and a moderate prevalence of postural changes in the sagittal plane, with lumbar rectification being the most prevalent alteration. It was observed that boys tend to present more postural alterations in the sagittal plane, as well as they are associated to the presence of lumbar rectification and thoracic hyperciphosis. There was a high prevalence of inappropriate posture habits adopted daily and back pain that can be identified as the associated factors responsible for the postural changes evidenced. These findings may support guidance to health and education professionals regarding the possible factors associated with postural changes in adolescents in the school phase, aiming at the implementation of actions that seek to promote adolescent health in order to facilitate the adoption of postural habits and the consequent improvement in quality of life.


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