The prevalence of posture pathology in school-aged children (results of a population-based study with the use of the computerized photo-geometric program “Posture”)

Results. Deviation of the spinal column from the midline in the frontal, sagittal plane (functional and organic disorders of posture) was observed in 75.3 % of children. Among them, signs of scoliotic spinal deformity were found in 72.5 % of children, in girls – 1.5 times more often. The angle of maximum deflection of the scoliotic arch from the median line was ≥5o in 13.7 % of children with scoliosis and in 9.9 % of all the examined children.

Pathology of posture in children includes persistent (organic) and functional curvatures of the spinal column and remains, until recently, an unresolved problem. Children usually visit to a doctor with scoliosis II or higher, when obvious signs of scoliosis are already visualized at the simple examination of a child. Television, video games, a sedentary lifestyle, smartphones and tablets as well as a lack of regular physical activity are the most common risk factors for posture curvatures in children [1,2].
Approximately 10 % of these diagnosed cases require conservative treatment, and approximately 0.1-0.3 % require urgent correction of the deformity [3].
Therefore, it is so important to diagnose posture pathology in children timely [2,4,5]. The data on the epidemiology of this pathology are very contradictory.

Aim
The aim of our work was to study the prevalence of posture pathology in children of school-age applying the screening method of the computerized photo-geometric program "Posture" in Kyiv (Ukraine).

Material and methods
The study included 1922 schoolchildren residents of Kyiv (Ukraine) from various schools, at the ages from 6 to 17 years, between 2017 and early 2019.
Examination rules: -The undress child wearing the underwear and socks. Longer hair of the girls examined should be pinned up so as not to cover the earlobes or neck contour.
-The initial position of the child: upright position, legs closed, the child is relaxed.
-The place of photographing should be provided with a plumb line.
-The child should be photographed in its original position in 2 projections.
-Computerized photo processing after "Posture" program (using control points on the child's body set by a specialist, skew angles are calculated (shoulders, shoulder blades, pelvis, etc.), the presence, value in degrees, location of the spinal curvature) are determined.
-Questionnaire filling: age, height, weight, grade, type and style of school bag carrying.
-Parents are given a card with processed photos and examination results as well as recommendations.
Examination and interpretation of the results obtained by the photo-geometric method "Posture" took 5 minutes. The photos were included in assessment forms for postural analysis and identification of changes in the frontal plane, sagittal plane, such as kyphosis, lordosis, hypokyphosis, hypolordosis, and anterior head tilt.
The sensitivity was define as Se = A / (A + C), where A is the proportion of true positive test results; A + C is the total number of true scoliosis patients. The specificity was define as Sp = D / (B + D), where D is the proportion of true negative test results among patients without spinal deformity; B + D -diagnostic information value [6].

Results
The sex-specific characteristics of schoolchildren included in our study are presented in Fig. 1 and 2.
Among 1922 examined persons, it was found that the deviation of the spine in sagittal and frontal plane (along the spinous processes) was observed in 1447 (75.3 %) children; accordingly, the rest 475 had physiological posture, the incidence of which decreased with the child's age ( Table 1).

Оригинальные исследования
According to the study results, scoliotic disease was 1.5 times more often in girls.
During data analysis, which were obtained with computerized photo-geometric "Posture" method, the angle of scoliotic arc maximum deflection from the median line was more than ≥5º in 191 (13.7 %) children with scoliosis and in 190 (9.9 %) of all the examined children (Fig. 3).
Children with scoliosis were proposed X-ray investigation in an upright position. According to X-ray images, scoliosis of varying severity was detected in 80 children, in 5 of them -S-shaped scoliosis of III-IV stage of thoracolumbar area. The study results demonstrated that the prevalence of scoliosis Cobb angle of ≥20º increased with the children age ( Table 2).

Discussion
Deviation of the spinal column from the median line along the spinous processes in the frontal and sagittal planes (functional and organic disorders of posture) was observed in 75.3 % of children. Among them, signs of scoliotic spinal deformity were detected in 72.5 % of children, in girls 1.5 times more often. In 13.7 % of children with scoliosis and in 9.9 % of all the examined children, the angle of maximum deviation of the scoliotic arc from the midline was ≥5º.
According to epidemiological investigations in other countries, in the general population, the frequency of idiopathic scoliosis occurrence in adolescents with an angle above 10º according to Cobb ranges from 0.93 % to 12.00 %. In about 20 % of cases, scoliosis is secondary to another pathological process. The remaining 80 % are cases of idiopathic scoliosis [7][8][9][10][11].

Original research
Among 79 122 schoolchildren in the city of Wuxi, eastern China, adolescent idiopathic scoliosis was found in 2.4 %, and in the Shanghai area, among 5327 investigated secondary school students (grades 6-8), scoliosis was diagnosed by screening method in 520 children (9.76 %) and spinal X-ray was performed in 102 of them (33.9 %) [12,13].
Ueno M., et al. performed school screenings for more than 250 000 children aged 11-14 years from 2003 to 2007 in the city of Tokyo. Scoliosis was confirmed in 3424 children by radiographic examination, and false-positive results were found (Cobb 0) in 39 cases [14].
2822 schoolchildren were examined in Spain (mean age 8.5 ± 1.8 years), where the number of patients with scoliosis was 1023 (36.3 %). Rib hump was twice common in girls. The risk of hump developing increased with age by 1.12 times. Children wearing school backpacks had a lower risk of scoliosis progression [15].
966 schoolchildren aged 10-16 years were examined in Southern Portugal. The results of the study demonstrated that scoliosis had been present in 41 (4.2 %) children. The highest prevalence was observed among girls (4.5 %), especially at delayed menarche (8.6 %) [16].
In some Polish cities, there are preventive programs aimed at detection of spinal dysfunctions and disorders in children and adolescents. Our study participants were children aged between 6 and 18 years with permanent residence in Poznan. The study enrolled 1.325 boys and 1.355 girls. In the whole study population, the incidence of scoliotic posture, assessed according to the chart of postural dysfunctions by Dega, amounted to 14.6 % in boys and 17.0 % in girls. There were no significant differences between the boys and the girls in particular age groups. It was found that scoliotic posture both in boys and girls (P < 0.05) was associated with age (the correlation was significantly different from zero and positive), and the proportions of students with scoliotic posture rose with age. Scoliometer examination revealed that the incidence of scoliotic posture was more frequent among girls (25.7 %) than among boys (22.2 %). The differences were statistically significant. The boys subjected to the study showed a correlation (r = 0.12) significantly different from zero and positive, in the group of tested girls, the correlation (r = 0.14) was significantly different from zero and positive [17].
Chaves P. J. et al. examined 117 schoolchildren in Brazil and stated that high incidence of postural changes was observed in the studied population. About 56 % (n = 14) presented some type of head alteration and the other 44 % (n = 11) presented no head position changes. Among the postural alteration in the alignment of the head, 12 % represented head protrusion and 44 % represented head tilt to the right or left. 64 % represented a shoulder elevation and 24 % had a shoulder protrusion. Other postural alterations also were observed in the studied population, and 67.27 % (n = 74) had pelvic alterations, such as anteversion and pelvic retroversion [19].
Referring to the literature data [6], we have established sensitivity and specificity of the computerized photo-geometric program "Posture", which has indicators 95 % and 85 %, respectively. Diagnostic information content of this method is 0.9.
The spine deviation angle, equal to 5º and determined by a scoliometer, is a criterion for determining the Cobb angle equal to 20º in computer analyzes [22][23][24]. In our studies, scoliosis of the II degree and higher was observed in 9.9 % of 1922 schoolchildren in Kyiv, respectively, 13.7 % of children had all types of scoliosis, which exceeded the data of modern researchers of the world [2,7,20].
Such a high prevalence of posture pathology in children is probably because of the lack of medical examination, a change in the lifestyle of modern children (long "monitor" time, using of gadgets, low physical activity, etc.) [25].
Quite possible that the personalized approach to the treatment may contribute to regression and/or compensation, reducing the risk of scoliotic disease further progression [26][27][28][29][30]. Treatment result was provided with an integrated approach using exercises, physiotherapy, corset wearing and, possibly, patient compliance [30][31][32].
According to the Australian Association of Physiotherapists, the correct balance between screen time and physical activity should be achieved for the prevention and treatment of posture pathology [33]. Therefore, it is so important to diagnose pathology at the early stages.

Conclusions
Sensitivity (95 %) and specificity (85 %) of the computerized photo-geometric program "Posture" were determined, which point to the necessity to be applied in health care maintaining practice.
Posture disorders in schoolchildren of Kyiv were diagnosed in more than 75 % among them signs of scoliotic spinal deformity were found in 72.5 %. The scoliosis incidence with a deflection angle of spinal deformity ≥5º was 9.9 %.
It attests to the fact that it is necessary to develop medical and social programs for the prevention and treatment of posture pathology in children.

Practical recommendations
1. It is recommended to provide photo-geometric screening to school-aged children in order to detect posture disorders.
2. Detection of posture disorders in children will prevent the development of scoliosis of the II degree and higher.
Conflicts of interest: аuthors have no conflict of interest to declare. Конфлікт інтересів: відсутній.