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i- 1
Clinical Biomechanics 1989; 4: 25-33
Clinica/ and functional examination of the
spine in ,-1- working
. communities:
occurrence of alterations, in the male
control-----,group
E Occhipinti PhE)
D Colombina PhD, G Molteni PhD
Olga Menoni RPT, S Boccardi PhD, A Grieco PhD
Research Unit E.P.M. (Ergonomics of Posture and Movements), Clinica del Lavoro
"Luigi Devoto", Milano, Italy
Summary
The paper reports the results obtained by applying a clinical method for the study of spina) disease as described elsewhere
l in a contro) group of 200 male subjects, strati -
fied for age, who had not been exposed to classically accepted occupational risk indi -catore- for spina/ disorders. For each age class the following data are supplied: frequency of cervata/ thoracic and lumbar d isease ; frequency of sco lios is and dissymmetry of lower limbs; mean values and range of mobility parameters for the varicus spina] . regione. The possible application are discusseti
Relevance
The values presented here, obtained from a structured examination, provide a set of age-related reference values for males in light industry. They form a basis for compari-son with other male occupational groups, to assess the effects on these variables from work-related demands on the spine.
Key Words: Spine, Mobility, Occupational medicine, Back pain, Clinical examination
Introduction
It is common practice in occupational medicine that
possible work-induced impairment be studied alongside
assessment of the risk fattore. In the case of manual hand-
ling and of incorrevi work postures, such study is of
necessity aimed at morphological and functional
alterations of the locomotor system.
To this aim, we have described and validated a method
for the clinical and functional examination of the loco-
motor system and of the spine in part icularl-
2. The signs
and symptoms observed by this method are organized,
according to standardized criteria, for classification finto
Submitted: li May 1987 Accepted: 19 May 1988 Correspondence and reprint requests io: Dr E Occhipínti, CEMOC, via Villasaute, li. 20100 Milan, Italy
@ 1989 Butterworth & Co (Publishers) Ltd 0268-0033/891010025-09$03.00
different p ic tures o f c l inica l– funct ional spondy-
loarthropathy. In generai, this means the presente of a
regional spinai disorder, probably degenerative, shown
by anamnesis, clinical procedures and functional impair -
ment, independent from the radiologica) pitture.
The application of the method in working communi-
ties does, however, require appropriate reference data,
on the basis of which a more exhaustive analysis of the
group results can be made.
The aim of this research was to establish such refer -
ence data and parameters for males by studying a group
of subjects not exposed to occupational postura/ hazards,
such as prolonged fixed postures (both sitting and
standing), manual materia/ handling and whole body
vibrations during their lifetime. In this context, brief
notes will be provided regarding the clinical method used.
(1 95
r26 Cl in . Biomech. 1989; 4 : No 1 It should be noted
that 'pre l iminary studies of the reproduceability of
-the method regarding qualiative vari ables (Le. the
classification of positive anamnesis) and
quantitative variables ariables (Le. the measurement of trunk movements) showed good intra- and inter-observer re-produceability of the variables observed'.
Figure 1. Frontal piane behind the scol iosometer: observation of the patient facing the instrument.
Figure 2. Measurement of thoracic kyphosis and lum-
bar lordosis with flexicurve.
Measurement of some anthropometric parameters:
The anthropometric parameters chosen are those that have a functional role in the generai aims of the clinical examination, especially for spinai mobility assessment. Among them, length of lower limbs is routinely meas- ured in order to check leg length inequality. e
ence ot a nb-Vúmp suggestive of-a-strutturai scoliosis is C considered. Then the thoracic kyphosis and lumbar lor-dosis angles are calculated by means of a flexicurve placed alono, the spine between C7 and the beginning of the intergluteal fold (Figure 2). The double curve (tho-racic kyphosis and lumbar lordosis) thus obtained is then transferred to a suitably sized sheet of paper. The inver-sion point of two curves and the points of maximum kyphosis and lordosis are identified; by drawing lines from the inversion point and from the ends of the curves to the respective maximum points, the angles are ob-tained (Figure 3).
i
Metho'ds
Clinical àamination,
The examination used consisted of six basic parts,outlíned below.:
..Physiological' and occupational anamnesis: It is of fúnd,àmental importante to assess the presente of
._past and_ présent exposures to the mechanical factors Which,àt work or at home, overload the spine.
Diseáse . history_.
Diseasès which have occurred in the last 12 months are particular.", int erést. -The area;-tadiation, characteristics
and tempo ral pattéms 1 of the dis'~ase are recorded. Even-
ìsabilíties'.--ìnduéed by the disease are also investi-
P -é~ciìC,A réshol .'~cr_iténa—allòw assessment of the —.,--_ —— ! óf the d is as-e`:`with—wy'iew to the dia-nostic
classificatiorì .1 ( S" VEANAMNà1S
Occhip in t i e t a l : Spina i examinat ion in work ing c o m
muni t ies 27
Figure 4. Measurement of head extension by incli -nometer.
Assessment of mobility:
The following movements are examined separately: ex-
tension, flexion, lateral inclination (side-bending) and
rotation, respectively, for the cervical and thoraco-lum-
bar spine.
For the cervical spine, passive movements are exam-
ined (subject prone or supine with fixed shoulder) using
an inclinometer (Figure 4) with the exception of the lat-
eral inclination when a goniometer is used. For the tho-
raco-lumbar spine active movements are evaluated with
the pelvis fixed, estimating the linear measurements and
Figure S. Measurement of rotation angle of the spine (cervical spine excluded).
their transformation finto angular values, except for rota-
tion when a goniometer is used (Figure 5).
The flexion angle is measured using the following
parameters: a) Height from suprastemal notch to bed
surface (with the subject seated and perfectly upright); b)
Height from suprastemal notch to bed surface (with pa-
tient flexed holding the pelvis stili).
The right and left inclination angles'are calculat ed
usingthe following two parameters: a) Height from C, to
e Height 7
bed surface (with patient perfectly upright) (Figure 6); b)
Figure 6. Measurement of distance between C, and seating piane with patient in upright seated position.
MAXIMUM KIPHOSIS
INVERSION POINT
MAXIMUM LORDOSIS
Figure 3. Cálculation of dorsal lumbar, lordosis.angle -(p). -- -
kyphosis angle (a) and
28 Clin. Biomech. 1089; 4: No 1
Figure 7. Measurernent of distante between C, and seating surface with patient bending sideways.
Figure 8: Procedure to calculate the flexion and incli -nation angle of the spine (cervical spine excluded).
Height to bed surface (with patient bending right
ght from C7
and left) (Figure 7).
The above parameters are used in the trigonometrical
formula shown in Figure 8 to calculate the flexion and
inclination angles. The extension angle is measured us-
ing the following parameters: a) Distance between the
suprastemal notch and the centre of the line that joins the
ASIS (with patient supine on the bed); b) Distance (with
patient prone and forehead resting on the bed) between
suprastemal notch and surface of the bed; c) Distance
between suprasternal notch and bed surface (with spine
beni backwards).
The above parameters are used in the trigonometrical
formula shown in Figure 9 to calculate the extension
angle. It should be noted that in the different trigonom-
etrical formulas presented there exists a slight discrep-
ancy between A and Al. Nevertheless, as a preliminary
test of reproduceability, the method was demonstrated to
be statistically satisfactory, whilst that was not the case
when the measurements avere taken with the goniome-
ter3.
It is obvious that the angles measured in this way are
not equivalent to those taken from X-rays. They are,
therefore, considered indices of the flexibility of the
thoraco-lumbar spine along the sagittal and frontal e sagitta
In the study of spine mobility it should be noted
whether the patient feels any pain during movement.
classification:
To facilitate standardized analysis of the results, an origi-
nai classification procedure was developed, based on
clinical and functional features (Table 1).
The classification procedure! is derived from a combi-
natila of the various anamnestic, tic, clinical—morphological z:
Figure 9. Procedure to obtain the extension angie of the sp ine (cervical sp ine excluded) from lengths A—B—C.
A- A'
B- A.sina a - arc sin SIA'
6 - 90*-a
A=A'
à =90' C-E2A'. sin a a -%
a r t t a n
( C -B ) A'
Occhipinti et al: Spina, examination in working communities 29
Table 2. Criteria for assessnierit of cervical, thoracic and lumbar mobility
Movements Reduced mobility Painful mobility
Cervical region
Thoracic region
Lumbosacral region
Flexion Extension Right inclination Left inclination Right rotation Left rotation
Right rotation Left rotation
t inclination Right nc— Left inclination
Flexion * Extension
Right inclination
Left inclination
4 out of 6 reduced
3 out of 4 reduced or 2 main movements reduced
3 out of 4 reduced or
2 main movements reduced
out of 6 painful
3 out of 4
painful 2 main movements painful
3 out of 4
painful or 2 main movements painful
. Main movements of regions
Table 3. Head and trunk movements: reference values per age class, in males *
Segments
Parameter 16-25
min—max 26-35
min—max
36-45
min—max
46-55
min—max
Head Flexion 55-98 54-94 49-88 47-85 Extension 35-77 31-72 29-66 26-68 Right inclination 38-66 36-63 34-62 32-57 Left inclination 40-65 38-62 35-60 33-58 Right rotation 74-101 69-97 65-97 60-99
Left rotation 76-98 69-98 66-95 61-93
Trunk Flexion 33-56 30-54 30-53 31-54 Extension 19-37 15-33 14-31 13-30 Right inclination 27-46 25-44 23-43 22-39 Left inclination 26-47 24-44 23-43 23-39 Right rotation 34-68 29-69 28-61 25-58
Left rotation 32-67 27-69 29-61 24259
* Movement values < or > minimum and maximum reference values are considered 'reduced' and 'increased'
and clinical—functional variables in three separate pic-
tures that are not necessarily connected by a single linear
process. These three pictures are clinical—functional
spondyloarthropathy of first, second and third deRree.
The thoracic spine is treated separately in the procedure
since, from the point of view of clinical—functional al-
terations, it behaves differently from the other vertebral
regions.
For flexion, extension, inclination and rotation of head
and trunk, and for the parameters `thoracic kyphosis
anale' and 'lumbar lordosis angle', the values corre -
spondina to the 5th and to the 95th percentiles of the
distributions were calculated.
Values for mobility parameters were treated separately
in four aie classes, since a-e is an influencino,
factor; data
Table 4. Thoracic kyphosis and lordosis angle: refer -ence values for 16-55 years age group, in males *
Minimum Maximum
15
12 30 ---Tó identify reference values for some of the
parameters studied, the data collected in several studies
on adult male subjects were suitably selected and
statistically analysedI'.
Thoracic kyphosis
Lumbar lordosis
* Angle values < or > minimum and maximum refer -ence values are considered 'reduced' and 'increased'
. 1 — _ —
30C1ín,B3íOme7ch.<~1989; 4: No 1
on the angles of the sàgittal curves of the spine were, however, treated independently of age. In faci age, in our data, had no effect on these parameters, at least for the age group considered here.
Table 3 gives the reference values for the head and trunk movements in males. Table 4 shows the reference values for the thoracic kyphosis and lumbar lordosis angles in males. According to these values, for an indi -vidua) diagnosis, the angles may be classif ied as ' re -duced' or 'increased'.
;«C
*
S A P ®s o j.;TOT SAP
r
x C E R V I C A L S A P
5G-
30. The g roup examined
In the present study, the clinical method previously il -lustrateti was applied to a control group of male subjects in order to achieve the following:
a) Estimate the frequency of clinical–functional cervi-cal, thoracic and lumbosacral spondyloarthropathy in four age classes (15-25, 26-35, 36-45, 46-55 years) of male subjects not exposed to occupational postural hazards;
b) Identify mean values and confidence interval of the mean of the various articular-mobility parameters stud-ied within these age classes.
Such data are necessary in order to make comparisons with similar data obtained in investigations on workers exposed to occupational postural hazards, even though a verification of the aetiolo g ical basis of the risk factors under study will require lon g itudinal epidemiologica) studies. Other aspects considered here were the occur -rence of scoliosis and dissymmetry of lower limbs in the aduli population.
Two preliminary conditions were established for the choice of characteristic for the control group: a) stratifi -cation into four age classes (16-25, 26-35, 36-45, 46-55 years); b) inclusion of subjects who had not, either pres -ently or in the past, been employed in jobs involvine exposure to risk factors such as prolonged fixed (both sittine, and erect) postures, manual lifting, moving or transport of load or whole-body vibrations.
The size of the control group was established in rela -tions to the variability of the spinai mobility parameters, so as to keep the 95% confidence interval of the mean of these parameters to 5 degreees5-1. The size of the sample that adequately guaranteed the aims of the study was calculated to be 50 subjects for each a ge class, i.e. a total of 200 subjects6.
In this sample size the confidence limits for the fre -quency (f) of pathological cases under study were f- 0.14 according to the formula used to calculate these limits, and in the most unfavourable circumstances where f=
0.509.
Data analysis
The statistica) analyses have been carried out takin a into
account the following points':
a) Absolute frequency and percentage (f) of qualitative
'/-THORACIC SAP
5c
so
Figure 10. Per cent frequency of cl inical functional cervical , thoracic, lumbosacral spondyloarthopathy (SAP), by age classes, in the male control group. Cases are reported by grade and as a whole.
variables (in particular diagnosis) and estimation of relative confidence limits (1) for each a ge class, according to the formula:
1 =f + 1.96 [f x
b) Mean, standard deviation and 95% conf idence interval of the mean of quantitative parameters (in particular amplitude of movements of cervical, thoracic and lum-
Table 5. Per cent frequency (95% confidence limits) of cervical, thoracic and lumbar spondylarthropathy in four age groups of the male population not exposed to occupational postural risk
Age class
Spondylar- 16-25 thropath
26-35 35-45 46-55
cervical 12 10 32 40
(3-21) (1.7-118-3) (19.1-44-9) (12.2-32-8)
Thoracic 8 10 18 24
(0.5-15-5) (1.7-18-3) (7.4-28-6) (12.2-35-8) Lumbosacral 6 12 28 50
(0-12) (3-21) (15.6-40-4) (32.2-63-8)
15-25 26-35 36-45 45
LUMBO - SACRAL SAP
AGE GROUP
26-35 36-45 45 AGE
GROUP
Occh ip in t i e t a l : Spina/ examinat ion in work ing c O mmunit íes 31 -
Table 6. Head movements: Imean value (*), standard deviation (in brackets) and 95% confidence interval of the -
mean, by age class in ,che contro) group. F test value and relative leve) of significante s hown for each parameter
Age class
Head 16-25 26-35 36-45 46-55 F
movements n=50 n=50 n=50 n=50
Flexion 74.1(11-75) 73.8(11-8) 67.7(11-05) 64.4(11-65) 8 . 2 8—
70.8-77-4 70.4-77-2 64.3-71-7 61.1-67-7
Extension 56.4(11-l) 48.8(10-7) 44.7(11-43) 43.1(11-76) 13.85***
53.2-59-6 45.8-51-8 41.4-48-0 39.8-46-4
Right 51.6(9-01) 49.0(7-45) 45.1(7-01) 43.8(5-6) 14.24***
inclination 49.1-54-1 46.0-51-1 43.1-47-1 42.2-45-4
Left 51.9(6.55) 50.0(7-21) 46.8(6-87) 43.7(5-32) 15.46***
inclination 50.0-53-8 48.0-52-0 44.9-487 42.2-45-2
Right 87.1(4-92) 86.3(5-42) 83.5(7-17) 81.2(9-91) 7. 1 -
rotation 85.7-88-5 84.8-87-8 81.5-83-5 78.4-84-0
Left 88.5(3-81) 87.4(4-78) 84.1(7-41) 81.6(7-92) 12.72***
rotation 87.4-89-6 86.7-88-7 82.0-86-2 79.4-83-8
20
***P < 0.0001
bar spine) for each age class; confidence intervals avere
calculated by the formulati:
i inC ,uP X
+ tn. . 0-05 x sHn
c) Analysis of 2 x 4 tables or i the prevalente, according
to age, of pathological. cases; calculation of the relative e
Figure 11. Per cent frequency of scoliosis, by age classes and as a whole, in the male contro) group.
40.
16-25 26-35 36-45 46-55 AGE GROUP
Figure 12. Per cent frequency of leg dissymmetry, by age classes and as a whole, in the male control group.
chi-square to test the existence of significative statistica)
differences.
c) One-way analysis of variante (ANOVA) for the quantica
tive parameters in relations to the four age classes.
Results
Figure 10 shows, by means of histograms, the observed
per cent frequency of subjects with 'clinical-functional
cervical, thoracic and lumbosacral spondyloarthropathy'
for each of the age classes considered. The cases of
spondyloarthropathy are reported by -rade (I, 11, III)
according to our classification, and as a whole. These
data and the relative 95% confidente limits for estima-
tion of the occurrence of the disease studied in similar
populations are shown in more detail in Table 5. Consid-
ering the per cent frequencies of pathological cases inde-
pendently of the degree, it cari be observed that they tend
to increase with increase in age; ;the increase is minima)
for the thoracic re-ion, but becomes more evident for the
cervical region and even more marked for the lumbosac-
ralre-ion; For -both the cervical and the lumbosacral._..., cri
reons, thè differente between a ge classes in frequency
of norma) and pathological cases was statistically signifi -
cano (x2 = 18
.3 for the cervical region, x
2 = 31
.8 for the
lumbar region; p <0.001).
Figure 11 shows the per cent frequency of the cases of C scoliosis observed in the four age classes, and within the
entire control group. The frequency of cases of scoliosis,
TOT 19%
16% N, 20% 22%
TOT 54% 54%
56%
48%
30.
la
16-25 26-35 36.45 46.55 AGE GROUP
32 Clin. Biomech. '1989; 4: No 1
Table 7. Trunk m.overrie.n.t: mean value (*), standard deviation (in brackets) and 95% confidence interval of the mean, by age class in the control group. F test value and relative leve] of significante shown for each parameter
Age class
Trunk 16-25 26-35 36-45 46-55 F
movements n=50 n=50 n=50 n=50
Flexion 45.4(6-28) 42.7(5-86) 41.7(5-91) 41.11(7-08) 3.23*
43.2-47-1 41.0-44-4 40.0-43-4 40.1-44-1
Extension 28.8(4-36) 27.3(4-12) 25.5(4-87) 23.6(5-11) 11-74***
27.6-30-0 26.1-28-5 24.1-26-9 22.2-25-0
Right 36.5(5-0) 33.6(4-86) 30-.5(6-44) 30.6(4-88) 14.28***
inclination 35.1-37-9 32.2-35-0 28.7-32-3 29.3-32-0
Left 36.7(4-77) 34.4(5-22) 32.4(5-16) 31.5(5-45) 10-03***
inclination 35.4-38-0 32.9-35-9 30.9-33-9 30.0-33-0
Right 53.8(8-29) 54.5(9-31) 50-0(9-44). 45.3(9-95) 10.26***
rotation 51.5-56-1 51.9-57-1 47.3-52-7 42.5-48-1
Left 51.6(9-23) 53-7(9-0) 50.5(8-97) 45
.6 (10.04) 6.82***
rotation 49.0-54-2 51.2-56-2 48.0-53-0 43.0-48-2
P5 0.05
" ' p < 0 . 0 0 1
which were all slight (between 10 and 15° of convexity), n 1
is somewhat high (on avera
ge 54%, with 95% confidence
limits of 47.1-60-9) and, as was to be expected, there
were no substantial differences between the different age
classes.
Figure 12 shows, for age classes and in the control
group as a whole, the frequency of subjects with leg dis-
symmetry greater than 1 cm. In this case, too, the fre -
quencies observed are certainly not negli
gible and are
independent of age.
Tables 6 and 7 report, for the four age classes and for
the cervical and the thoraco-lumbosacral spine, respec-
tively, the following data regarding joint mobility para-
meters (angles of flexion and extension, left and right
inclination, left and right rotation): a) mean angle value;
b) standard deviation; c) 95% confidence interval of the
mean for estimation of the mean value of this feature in
the generalpopulation; d) the value of F and the relative
leve] of significante.
Discussion
A method for the clinical-functional examination of the
spine was devised by us. It was applied to a group of male
subjects, stratified by age, who were not exposed to
occupational postura] risks, in order to provide referente
data in epidemiologica) studies.
firm conclusione are not
possible. Moreover, in this specific case, the limited
numbers of the sub-groups
gave rather avide
confidence limits. It follows that, in the present state of
knowledge, only marked differences in the occurrence of
the diseases examined between the exposed and the
control groups may be judged as significant. C -tr
On the other hand, comparisons for spine mobility will
be much more detailed, since the values of the standard
error of the mean of the relative parameters were generally more restricted.
In addition to the above remarks, some practical
ad-vice will be appropriate on how the groups of
exposed subjects should be selected, so that, even with
the above limits, the comparisons meet the minimum
requirements in order to be valid.
a) The groups
of exposed male subjects should be strati fied
according to the saure age classes as those proposed
here; each age class musi comprise no lese than 50
subjects. If the age class is not sufficiently large it is
preferable to omit it from the comparison; an
alternative is to use the overall rate for all aees and
compare it with an expected rate obtained with the
indirect standardization method. 1
b) It should first be checked that no marked selection
phenomena exist within the group for the disease under
study; selection phenomena may occur either when the
job is not assigned to subjects who, when recruited,
already suffered from spinai disease, or when subjects who
Occhipinti et al: Spina/ examination in working communities 33
a r e m o v e d f r o m t h e i r j o b fo I l o w i n g a d i a g n o s i s o f
spond y loa r th ropa thy a t . a pe r iod i c hea l th check . Both
these phenomena would lead to an underestimation of the
occurrence of the disease in the group under study.
c ) I t i s ad v i s a b l e tha t t he g r oups und er s tud y i nc lud e
subjects who have been employed on the job for at least 5
year s , so a s to guar antee tha t ther e has been adequat e
time for any disease to develop.
d ) I t i s p re fe rab l e to exc lude sub ject s who avere pr ev i -
ously employed for more than 5 years altogether on jobs
involving hazards for the spine.
The purpose of this select ion is to ensure that any in -
creased occurence of a d i sease be at tr ibuted to one and
not many jobs . On the other hand , i t shou ld be remem -
bered that , besides the jobs which involve a sana le r isk
for the sp ine , there are some which involve more than
one risk factor (e. - . (1) vibrations and static postures for
heavy vehicle drivers; (2) postures with the trunk f lexed,
l i f t ing of load and , commonly, t ractor vibrat ions in agr i -
cultural work, etc .) . In these cases, the hi eher occurence
of d i sease wh ich may be observed i s gener i ca l l y a t t r ib -
u ted to the job and i t i s not poss ib le to d i s t in gu ish the
proportion due to_ each hazard.
References
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indagine e principi di prevenzione. Ed Comune di Milano 1986; 63-91
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6 Armitage P. Statistica medica. Milano: Feltrinelli Editore, 1975
7 Occhipinti E, Colombini D, Menoni O, Grieco A, Motilità del rachide in soggetti maschi adulti: valori di riferimento per classi di età (unpublished data)
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9 Spiegel MR. Statistica. Collana Schaum. Milano: Etas Libri Editore, 1976
10 Ticchiarell i L. Combxa P, Belli S, Grandolfo M, Verdecchhia A, Bertazzi PA, Duca PG, Marchi M. Introduzione alla biometria in igiene e medicina del
lavoro. Roma: rapporto ISTISAN 84/20, 1984