ORIGINAL ARTICLE

 

Prevalence of postural deviations in the spine in schoolchildren: a systematic review with

 

Prevalência de desvios posturais na coluna em escolares: revisão sistemática com metanálisemeta-analysis

 

 

Ana Paula Kasten; Bruna Nichele da Rosa; Emanuelle Francine Detogni Schmit; Matias Noll; Cláudia Tarragô Candotti

Federal University of Rio Grande do Sul

Correspondence

 

 

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ABSTRACT

INTRODUCTION: The Information Age has had a major impact on citizens' lives. The invention of machinery, automobile, television and computer have induced individuals to adopt the "sitting" body posture in order to adapt to new technological needs.
OBJECTIVE: To estimate the prevalence of spine postural deviations in Brazilian schoolchildren.
METHODS: Searches were conducted in databases EMBASE, LILACS, PubMed, SCOPUS, SciELO, Science Direct, and Web of Science, as well as manual searches to identify studies that evaluated the prevalence of spine postural deviations in Brazilian schoolchildren. Two independent reviewers realized the study selection, evaluated the methodological quality and the risk of bias and extracted data. The homogeneity between the studies was evaluated and the quality of evidence level using the GRADE system.
RESULTS: 29 studies were included, of which extracted the frequency of positive events to changes in cervical, thoracic and lumbar spine, as well as the frequency of scoliosis between schoolchildren. Even performing the meta-analysis separated by subgroups according to the spine region, the heterogeneity level it was up to 90%, it is not possible to perform the meta-analysis to estimate the prevalence of spine postural deviations in Brazilian schoolchildren.
CONCLUSION: There is low strength of evidence to establish a consensus about the values of the prevalence of spine postural deviations in Brazilian schoolchildren.

Keywords: posture, spine, child, adolescent.

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RESUMO

INTRODUÇÃO: A Era da informação e da tecnologia tem causado grande impacto na vida dos cidadãos. As invenções de máquinas, de automóveis, da televisão e do computador, induziram os indivíduos a adotarem a postura corporal "sentada" a fim de se adaptar as novas necessidades tecnológicas.
OBJETIVO: Estimar a prevalência de alterações posturais na coluna vertebral de escolares brasileiros.
MÉTODO: Foram realizadas buscas nas bases de dados EMBASE, LILACS, PubMed, SCOPUS, SciELO, Science Direct, e Web of Science, além de buscas manuais a fim de identificar estudos que avaliassem a prevalência de alterações posturais na coluna vertebral em escolares brasileiros. Dois revisores independentes realizaram a seleção dos estudos, avaliaram a qualidade metodológica e o risco de viés dos estudos selecionados e extraíram os dados. Foi realizada a análise de homogeneidade interestudos e a qualidade do nível de evidência foi avaliada utilizando o sistema GRADE.
RESULTADOS: Foram incluídos 29 estudos, dos quais foram extraídas as frequências de eventos positivos para as alterações na coluna cervical, torácica, lombar, bem como a frequência de escoliose entre os escolares. Mesmo realizando a metanálise separada por subgrupos de acordo com a região vertebral avaliada, o nível de heterogeneidade ficou a cima dos 90%, não sendo possível estipular a prevalência de alterações posturais na coluna vertebral em escolares brasileiros a partir da metanálise.
CONCLUSÃO: Existe baixa força de evidência para se estabelecer um consenso acerca dos valores de prevalência de desvios posturais na coluna vertebral de escolares brasileiros.

Palavras-chave: postura, coluna, criança, adolescente.

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INTRODUCTION

The Information Age has had a major impact on citizens' lives¹. The invention of machinery, automobile, television and computer have induced individuals to adopt the "sitting" body posture in order to adapt to new technological needs. Also, the increasing rate of adhesion of individuals to the new demands of convenience comfort has been an important causal factor of poor posture and back pain. Thus, both inadequate and sedentary habits, since childhood, contribute to the appearance of muscle weakness and ligament laxity, overloading the spine, which results in suffering, pain and disability^2-5.

In addition, it has been accepted that postural problems related to changes in body shape often have their origin in childhood, especially those related to the spine⁶. In this sense, the identification or diagnosis of postural deviations during childhood and adolescence is of great importance in this phase of body growth and development, since the correction of these changes is mainly based on global posture reeducation. In fact, investing in reeducation during childhood and adolescence tends to minimize the need for a future conservative treatment that only aims to improve symptoms, since, after adolescence, bone growth has already ceased^7,8.

Some factors are preponderant in the causes of postural deviations in school-age children, such as, hours sitting in inappropriate positions in the classroom, inadequate seats, carrying school supplies in an inadequate way^9-11 and / or with weight above 10% of body weight^5-10. In addition, the increase in Body Mass Index (BMI) in students diagnosed as pre-obese and obese results in a higher prevalence of asymmetry in the anterior, posterior and lateral planes^12-14. In fact, these factors are evident worldwide, in both developed and developing countries. In Iran, a developing country, two studies found a higher prevalence of changes in the spine of girls associated with sedentary lifestyle and excess weight carried in backpacks during the carrying of school supplies^15,16. In Japan, a developed country, a longitudinal study found an inverse relationship between paravertebral muscle strength and lumbosacral postural change. That is, during a 10-year follow-up, there was both a decrease in paravertebral muscle strength and an increase of around 10° in the lumbosacral angle, suggesting the need to promote activities to maintain muscle strength from childhood and adolescence^17,18.

Regarding developing countries, although Brazil stands out for the amount of research on the subject of school posture, as far as we know, no study was conducted synthesizing the Brazilian reality about the prevalence of postural deviations, especially those related to the spine. Thus, considering that knowledge of the profile of postural deviations in schoolchildren and adolescents is essential to assist in the development of public policies and intervention strategies, the objective of this study is to estimate the prevalence of postural deviations in Brazilian schoolchildren's spine through a systematic review with meta-analysis.

 

METHODS

Type of study

This study comprised a systematic review of the literature¹⁹, registered in PROSPERO under the code CRD42015026504, and guided according to the recommendations of the Joanna Briggs Institute Reviewers Manual (The Systematic Reviewer of Prevalence and Incidence Data)²⁰, the guidelines of Collaboration Cochrane²¹ and the MOOSE (Meta-Analysis of Observational Studies in Epidemiology) report²².

Search strategy

In order to achieve the proposed objective, we conducted searches from September 23 to 25, 2015, in the EMBASE, LILACS, PubMed, SCOPUS, SciELO, Science Direct, and Web of Science databases. The terms and Boolean operators used were: "students" [AND] "spinal curvatures" [AND] "prevalence". No restriction of language and year of publication was done in the search, which was performed from the beginning of the bases until the moment of the search. The studies should be of the observational type. Manual searches were also conducted in the references of included studies. Table 1 presents the search strategy used in the PubMed database, and in the other databases this strategy was adapted according to the guidelines of each database.

Eligibility Criteria

Two independent evaluatorsselected the potentially relevant studies from the titles, abstracts and full text. The studies selected for reading in full were evaluated according to the following eligibility criteria: (a) observational study; (B) exclusive sample of Brazilian schoolchildren aged 6 to 18 years; (C) to address the prevalence of postural deviations in the spine. Discordant cases were resolved by consensus²³.

Assessment of Studies

The evaluators obtained the study data independently and in a standardized form according to the following information: authors, year of publication, place of the holding of the study, sample evaluated, methods used and prevalence of changes in the spine.

Likewise, the studies were evaluated with respect to methodological quality and risk of bias through the Prevalence Critical Appraisal Instrument²⁴, an instrument developed to evaluate the methodological quality of studies that present prevalence data. This instrument consists of 10 items, which must be filled in as Yes, No, Unclear or Not Applicable, and then the items filled with Yes are punctuated. In this perspective, the evaluation of each study can present a score between 0 and 10, and the higher the score, the better the methodological evaluation of the study. In order to graduate and establish categorical divisions of quality, a cutoff point was stipulated, with the minimum score of seven as the divisor between studies of high quality (score of 7 to 10) and low or moderate (score from 0 to 6). This cut-off point was chosen arbitrarily, since there are no stipulated classifications for this tool²⁰. In order to measure the agreement between the reviewers in assigning the scores for each study, an Intraclass Correlation Coefficient was performed via SPSS v. 20.0 software, which was classified as: poor (ICC <0.4), satisfactory (0.4 ≤ ICC <0.75) and excellent (ICC ≥ 0.75)²⁵.

Statistical Analysis

The data was initially analyzed by means of descriptive statistics, separated into subgroups according to the vertebral region associated with the changes and the instrument of analysis. A meta-analysis was performed using the Comprehensive Meta-Analysis, version 2.2.04 (Biostat, Inc. ©, Englewood, New Jersey) and MedCalc²⁶, version 11.0 (MedCalc Software, Mariakerke, Belgium) software by means of inferential statistics with the Higgins Inconsistency Test (I²)²¹ to verify homogeneity of the subjects. The heterogeneity was considered low if I²<50% and moderate / high if I²≥50%. In cases of I²≥50%, we opted for the adoption of the random models effect. The sensitivity analysis encompassed the exclusion of studies based on a sample calculation performed for each subgroup, using the recommendations of Santos, Abbud and Abreu²⁷, that is, for each subgroup, sample calculations were performed from three different values of prevalence - low, intermediate and high (Table 2). Thus, the studies included in the systematic review that had not recruited the minimum sample to meet the proposed objective were excluded from the meta-analysis. However, even with the sensitivity analysis based on the inclusion of studies with a minimum sample size corresponding to the one obtained by the sample calculation, it was not possible to reduce or minimize the heterogeneity present in the studies. Therefore, the presentations of the meta-analysis in subgroups according to the vertebral region associated with the changes were maintained in general, in order to highlight the methodological differences between the studies. (Supplementary material)

Strength of evidence

In order to summarize the general quality of the evidence, the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) system was used²⁸. GRADE classifies the quality of evidence and the strength of recommendation provided by systematic reviews, scientific advice, and clinical guidelines. It is a way of representing confidence in the information provided, by classifying the level of evidence and by expressing the emphasis so that a particular conduct is adopted or rejected in the case of reviews of clinical trials²⁹. We analyzed only observational studies, and only the classification of their level of evidence was used. The quality of evidence evaluation was based on the following criteria: design of studies included in the systematic review; methodological limitations of included studies; Inconsistency (homogeneity of studies); whether the studies present direct evidence; accuracy of the results presented in included studies; and if the systematic review has a publication bias, not including all the published studies about the research problem. Using these criteria, the level of evidence was classified, among the four levels presented by the GRADE system: high quality, moderate quality, low quality and very low quality. In high quality evidences, it is very unlikely that additional research change the prevalence estimate presented by the systematic review; When the study presents very low quality evidence, its prevalence estimate is very uncertain²⁹, thus new studies are necessary.

 

RESULTS

The initial search identified 1193 studies, of which 221 were duplicates, thus 972 remained. However, 950 were excluded based on the title and abstract, so that only 22 remained for detailed analysis, six of which were excluded after screening for the eligibility criteria. Manual searches were carried out in the references of the 16 studies, and a further 12 studies were included. Thus, 29 studies were reviewed. Figure 1 shows the flowchart of the study selection, Table 3 summarizes the characteristics of the studies and Table 4 explains the methodological quality of the studies.

In order to summarize the evidence from the 27 studies, with regard to postural deviations in the spine, we can list, in ascending order of involvements: lumbar hyperlordosis (found in 14 studies, prevalence between 19% and 78.1%); Thoracic hyperkyphosis (found in 13 studies, prevalence between 9.7% and 49%) and scoliosis (in four studies, prevalence between 5.2% and 28%). In addition, the contrasting sample sizes between the studies, from 47 to 1340 students, stand out. The number of studies carried out in the different geographic regions of Brazil, conducted mainly in the South (n = 14), followed by the Southeast (n = 7), and in a smaller number in the Northeast (n = 4), also stand out, which is possibly related to regional economic constraints and resources.

Regarding the strength of evidence of this systematic review, based on the main criteria established by GRADE²⁹, 14 studies are in the high category of methodological quality, presenting an excellent agreement of punctuation between the reviewers (ICC = 0.833] 0.675; 0.918 [p <0.001), which implies a low risk of bias. However, with regard to inconsistency, high values were found, which reiterate the heterogeneity of the studies, making the quantitative information from analysis to meta-analysis inaccurate, a fact that is added to the high confidence intervals obtained in the calculations of prevalence by subgroup. Given the above, it is possible that future studies are likely to have a significant impact on the confidence in estimating the prevalence of postural deviations in the spine of schoolchildren, which makes this review with low strength of evidence.

 

DISCUSSION

The meta-analysis aimed to identify the prevalence of postural deviations in the spine of schoolchildren and adolescents in Brazil. Although the meta-analysis has a sample of individuals of over a thousand students in the analysis of each type of postural change, it was not possible to establish a consensus about the prevalence of anteroposterior and latero-lateral postural deviations in the spine of Brazilian schoolchildren. This result can be due the great heterogeneity of the studies, since they differ significantly regarding the methods used for evaluation of the posture and the sample space. Therefore, the prevalence of postural deviations were discrepant, reaching, thus, heterogeneity indexes above 90%.

Among the ways of assessing spinal posture, visual inspection depends exclusively on the experience of the professional performing the assessment, besides not allowing to quantify objectively the changes, being an evaluation associated with major errors and disagreements^30,31. Likewise, the postural evaluation by photogrammetry, although providing quantitative evidence on the curvatures of the spine³², is also subject to recurrence of errors, either due to the inherent difficulty of palpation or by the different mathematical procedures that the software have³³. In fact, the results of the studies that used photogrammetry were also discrepant with each other. Nevertheless, both methods, visual inspection and photogrammetry, were the most used by the studies included in this systematic review, factors that may contribute to the impossibility of reaching consensus on the prevalence of postural deviations in the Brazilian schoolchildren population.

Another factor that may have contributed to the variability of the results between the studies is a wide range of reference values for the classification of spinal curvatures. For example, for Bernhardt & Bridwell³⁴, Cobb angle values for a normal lumbar spine curvature ranged from 14° to 69°, while for Propst-Proctor and Bleck³⁵ they ranged from 22° to 54°. In this sense, depending on the reference values used in the studies, these different spectra may have generated large differences in the posture classifications of the spine.

Despite the biases found in the methodologies of the studies included in this review, when the studies were submitted to the methodological quality and bias risk assessment through the Prevalence Critical Appraisal Instrument²⁴, 14 studies were classified with high quality. According to GRADE²⁹, this result indicates a low risk of bias in the systematic review. Nevertheless, the meta-analysis indicates an inconsistency, due to the high heterogeneity among the studies. In this perspective, it is emphasized that there are studies of high methodological quality presenting the panorama of the problem of postural deviations in Brazilian schoolchildren, however such panoramas cannot be extrapolated to the context of the country, as they show only the reality of the region in which each study was developed. An example of this question is the fact that there are students whose habit of sleeping in hammocks is so recurrent that this factor was evaluated in the study by Baroni et al.³⁶, being considered a protective factor for the development of scoliosis. This life habit was evaluated only in the study developed in north of Brazil, and was not found in any other Brazilian study. Therefore, since different regions of Brazil present different behavioral and life habits due to the different regional cultural influences, we can expect different types of postural deviations and different prevalence among their populations.

Thus, it was not possible to reach a consensus regarding the prevalence of postural deviations in the spine of Brazilian schoolchildren. From this perspective, we see the need for future studies designed to eliminate the biases pointed out by this systematic review, so that the Brazilian reality regarding the posture of the spine of schoolchildren can be documented. We understand that from a global knowledge, health promotion and education actions can be developed and put into practice at federal level, a fact that is still not possible today and therefore requires strategies at regional levels.

 

CONCLUSION

Based on the results obtained from the systematic review of articles developed in Brazil, we conclude that there is a low strength of evidence to establish a consensus about the values of prevalence of postural deviations in the spine of schoolchildren. We suggest that future studies be more rigorous in the screening and establishment of methodologies, as well as using validated instruments for evaluation, and investigating the macro and micro-regional differences of the states and the country.

 

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Correspondence:
Ana Paula Kasten
E-mail: anapaulakasten@hotmail.com

Manuscript submitted 2016
Accepted for publication Jun 2016

 

 

Supplementary material

 

Table 1 - Clik to enlarge

 

 

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Table 4 - Clik to enlarge