Journal of Biomechanics 70 (2018) 67–76

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Journal of Biomechanics
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www.JBiomech.com

How do we stand? Variations during repeated standing phases of

asymptomatic subjects and low back pain patients
Hendrik Schmidt a,⇑, Maxim Bashkuev a, Jeronimo Weerts a, Friedmar Graichen a, Joern Altenscheidt b,
Christoph Maier b, Sandra Reitmaier a
a
Julius Wolff Institut, Charité – Universitätsmedizin Berlin, Germany
b
Department of Pain Management, BG-University Hospital Bergmannsheil, Bochum, Germany

a r t i c l e i n f o a b s t r a c t

Article history: An irreproducible standing posture can lead to mis-interpretation of radiological measurements, wrong
Accepted 13 June 2017 diagnoses and possibly unnecessary treatment. This study aimed to evaluate the differences in lumbar
lordosis and sacrum orientation in six repetitive upright standing postures of 353 asymptomatic subjects
(including 332 non-athletes and 21 athletes – soccer players) and 83 low back pain (LBP) patients using a
Keywords: non-invasive back-shape measurement device.
Human posture In the standing position, all investigated cohorts displayed a large inter-subject variability in sacrum
Standing
orientation (40°) and lumbar lordosis (53°). In the asymptomatic cohort (non-athletes), 51% of the
Lumbar lordosis
Sacrum orientation
subjects showed variations in lumbar lordosis of 10–20% in six repeated standing phases and 29% showed
Age variations of even more than 20%. In the sacrum orientation, 53% of all asymptomatic subjects revealed
Gender variations of >20% and 31% of even more than 30%.
MiSpEx It can be concluded that standing is highly individual and poorly reproducible. The reproducibility was
independent of age, gender, body height and weight. LBP patients and athletes showed a similar variabil-
ity as the asymptomatic cohort. The number of standing phases performed showed no positive effect on
the reproducibility. Therefore, the variability in standing is not predictable but random, and thus does not
reflect an individual specific behavioral pattern which can be reduced, for example, by repeated standing
phases.
Ó 2017 Elsevier Ltd. All rights reserved.

1. Introduction
The degree and progression of spinal disorders is frequently
evaluated in full-length sagittal-plane radiographs of the spine
and pelvis in an upright standing position. For standardized cap-
ture of the current state of alignment (Amonoo-Kuofi, 1992;
Hammerberg and Wood, 2003) and for a more precise assignment
of patients to appropriate treatments (Lin et al., 1992; Tuzun et al.,
1999), different anatomical parameters have been identified: e.g.,
pelvic incidence, pelvic tilt (Hansson et al., 1985; Schwab et al.,
2006), vertical plumb line (Gelb et al., 1995; Jackson and
McManus, 1994; La Grone, 1988), lumbar lordosis (Pellet et al.,
2011; Troke et al., 2005; Van Herp et al., 2000) and sacrum orien-
tation (Peleg et al., 2007a; Peleg et al., 2007b). During radiographic
examination, patients are requested to stand relaxed with
⇑ Corresponding author at: Julius Wolff Institut, Charité – Universitätsmedizin
Berlin, Augustenburger Platz 1, 13353 Berlin, Germany. Fax: +49 2093 46001.
E-mail address: hendrik.schmidt@charite.de (H. Schmidt).
extended knees and parallel shoulder girdle and pelvis (Stagnara
et al., 1982). Despite these instructions, variations in the adopted
posture cannot be avoided. Just a slight pelvic rotation combined
with hip extension was found to markedly shift the anterior-
superior corner of the sacrum, causing a change in the horizontal
distance of the plumb line to the S1 vertebra (Gelb et al., 1995;
Jackson and McManus, 1994).
To provide adequate visualization of the spine, the typical diag-
nostic lateral radiograph is often taken with the subject’s arms
flexed forward (Gelb et al., 1995; Vedantam et al., 1998). The effect
of different arm positions on the segmental and global changes in
the sagittal alignment of the spine associated with two standing
radiographic positions (arms forward-flexed to 45° vs. fists-on-
clavicles) was examined in asymptomatic subjects (Aota et al.,
2009) and in patients with adolescent idiopathic scoliosis (Faro
et al., 2004). It was attempted to define the most functional stand-
ing position for the evaluation of an accurate sagittal balance. Aota
et al. (2009) showed that fists-on-clavicles caused less negative
shift in plumb line and less compensatory posterior rotation of

http://dx.doi.org/10.1016/j.jbiomech.2017.06.016
0021-9290/Ó 2017 Elsevier Ltd. All rights reserved.
68 H. Schmidt et al. / Journal of Biomechanics 70 (2018) 67–76
the pelvis, and therefore appeared more appropriate for defining a
patient’s functional balance. However, in patients with a previous
spinal fusion, Vedantam et al. (1998) recommended positioning
the arms at 30° for a lateral radiograph to prevent a negative shift
in the plumb line and to gain a more functional position.
Currently, it has not been investigated how sagittal alignment
parameters can change under repetitive upright standing posi-
tions. Therefore, the reproducibility of lumbar lordosis and sacrum
orientation among six repetitive upright standing postures of 353
asymptomatic subjects (including 332 non-athletes and 21 ath-
letes) and 83 low back pain (LBP) patients was evaluated. We pos-
tulated the following hypotheses:
1. The variability in lumbar lordosis and sacrum orientation in
repetitive upright standing postures decreases with the number
of standing phases. After an initial adaptation-phase it was
expected that subjects will get more and more familiar with
the test set-up and, therefore, the variability will decrease in
repeated standing phases.
2. Age and gender significantly affect the variation in lumbar lor-
dosis and sacrum orientation. Own previous findings indicated
a significant correlation between gender/age and lumbar lordo-
sis/sacrum orientation (Dreischarf et al., 2014; Pries et al.,
2015a).
3. LBP patients show a significantly greater variability in lumbar
lordosis and sacrum orientation than asymptomatic subjects
due to pain-related functional adaptation and/or pain and
movement avoidance behavior.
4. Athletes with a higher and more uniform fitness level stand
more reproducible than non-athletes. The authors assumed that
neuromotoric and muscular adaptations support athletes to
have a more stable and reproducible posture in comparison to
the general population and especially to patients.
2. Methods
2.1. Ethics
The Ethics Committee of the Charité – Universitätsmedizin Berlin for asymp-
tomatic subjects (registry numbers: EA4/011/10, EA1/162/13) and the Ruhr Univer-
sity Bochum for LBP patients (registry numbers: 4385-2012 (06.07.2012); 4427-12
(20.08.2012); 5233-15 (26.03.2015)) approved this study. All participants were
informed about the study’s procedure and signed a written consent giving their per-
mission to conduct measurements.
2.2. Asymptomatic subjects – non-athletes
This group includes data from 332 subjects (187 females; 145 males) from a
previously published cohort on the measurement of lumbar spinal posture and
motion (Consmuller et al., 2012a). These subjects did not experience pain in the
lower back or pelvis in the 6 months prior to the measurements and never under-
went spinal or pelvic surgery. More details are provided in Table 1.
2.3. Athletes - soccer players
This group includes data obtained from 21 men without pain in the lower back
or pelvis in the 6 months prior to the measurements and who had no history of
spinal or pelvic surgery. They were recruited from a professional soccer team and
regularly performed seven training sessions for 90 min per day (10.5 h/week).
Table 1
Data for asymptomatic subjects (non-athletes, soccer players) and low back pain (LBP) patients. Median and ranges are given for age, body height, body weight and body mass
index (BMI).
Study groups Number women/men
Asymptomatic subjects (non-athletes) w: 187
m: 145
Soccer players m: 21
LBP patients w: 45
m: 38
2.4. LBP patients
This group includes data from 83 patients with chronic LBP of >12 months dura-
tion (range: >12 month to >20 years). Patients with paresis, for example, after
nerve-root compression, other acute serious conditions (e.g., tumor, infection, com-
pression fracture, heart insufficiency) and prior fusion surgery of more than two
segments were excluded.
2.5. Measurement system
The Epionics SPINE system (Epionics Medical GmbH, Potsdam, Germany) was
used to assess lumbar spinal shape as well as sacrum orientation and rotation in
the sagittal plane (Fig. 1). The system involves two flexible sensor strips, each con-
sisting of twelve 2.5-cm-long segments based on differential strain-gauge elements
which provide a sensitive measure of the curvature in each segment. During a mea-
surement, the sensor strips are inserted into two hollow plasters attached to the
back paravertebrally, 7.5 cm away from the spinal column on each side.
The lower end of each strip was aligned with the spina iliaca posterior superior,
which was approximately in line with the first sacral vertebra. A tri-axial
accelerometer was located at this end, allowing the system to assess sacrum orien-
tation. This acceleration sensor determined the spatial orientation of the sensor rel-
ative to the vertical direction of the earth’s gravitational field. The sensor strips
were connected to a storage unit (size: 12.5 cm  5.5 cm; mass: 80 g) that collected
data with a frequency of 50 Hz. The sensor strips of the system exhibit high accu-
racy and repeatability (interclass correlation coefficient, ICC > 0.98) with test–retest
reliability ICCs of >0.98. Previous studies confirmed the suitability of the system for
assessing lumbar and pelvic motion (Consmuller et al., 2012a,b; Pries et al., 2015b;
Rohlmann et al., 2014; Taylor et al., 2010).
2.6. Measurement protocol
All study participants were equipped with the Epionics SPINE system and per-
formed a standardized choreography consisting of (1st standing) flexion, (2nd stand-
ing) extension, (3rd standing) left and (4th standing) right lateral bending as well as
(5th standing) left and (6th standing) right axial rotation (Fig. 1). Each exercise was
repeated three times before going to the next exercise. Before each exercise, the
subjects were explicitly requested to stand in a relaxed upright position with
extended knees for 2 s. In these 2 s, the lumbar lordosis and sacrum orientation
were recorded in a frequency of 50 Hz and subsequently the mean value of both
was calculated.
2.7. Data analysis
The lumbar angle was individually calculated by summing all Epionics’ seg-
ments that were lordotically curved in the individual volunteer, as shown by the
transition from lordosis to kyphosis (change of sign) during standing, accounting
for differences in subjects’ anthropometrics. The corresponding data from the left
and right sensors were averaged. Sacrum orientation was determined from the ori-
entation of the accelerometer (Pries et al., 2015a). All data were processed using in-
house developed MATLAB routines (MATLAB R2009b, MathWorks, Inc., Natick, MA,
US).
2.8. Statistics
The Kolmogorov-Smirnov-Lilliefors test was applied to evaluate the normal dis-
tribution for each investigated group. To detect the presence of outliers, the Grubb’s
test was performed. Levene’s test was used to test for variance homogeneity. For
normally distributed data and variance homogeneity, Student’s t-test was applied
to access gender-specific differences and a one-way analysis of variance (ANOVA)
followed by post hoc Scheffé’s test to analyze differences between cohorts. The sub-
jects were later grouped based on the variability in the sacrum orientation and lum-
bar lordosis during different standing phases. Due to small size of the individual
sub-groups, the non-parametric Friedman test was performed to assess the differ-
ences between repeated measurements in the subgroups, followed by post hoc
Nemenyi test. Additionally, a regression analyses was applied and the coefficient
Age (yrs.) Body height (cm) Body weight (kg) BMI (kg/m2)
36 (20–75) 168 (148–184) 61 (45–88) 22.0 (16.7–26.9)
39 (20–74) 180 (159–206) 76 (55–98) 23.4 (17.9–26.9)
23 (19–28) 181 (163–193) 79 (63.3–111) 23.8 (21.4–26.5)
57 (24–84) 167 (152–189) 75 (52–120) 26.5 (19.8–44.1)
54.5 (25–80) 181.5 (164–199) 93 (74–150) 30.0 (21.2–42.4)
 H. Schmidt et al. / Journal of Biomechanics 70 (2018) 67–76 69

Fig. 1. The Epionics SPINE system affixed to a volunteer’s back in standing. The system consists of two flexible sensor strips utilizing strain-gauge sensors, tri-axial
accelerometers and a storage unit. Demonstration of the assessment of the total lordosis angle, which is the sum of all lordotically curved segments during standing (average
lordosis range highlighted in green: S1–S6) as well as the orientation of the sacrum given by ‘a’, with respect to the vertical direction. The measurement protocol consisted of
six standing phases and six exercises. Each exercise was repeated three times before going to the next exercise. Standing was recorded before the first flexion and after each
exercise. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

of determination (R2) was calculated. p-values of <0.05 were considered statistically
significant. The statistical analyzes were performed with R 3.2.5 (R-Core-Team,
2016).
3. Results
In the standing position, all investigated cohorts displayed a
large inter-subject variability in sacrum orientation and lumbar
lordosis (Fig. 2). As an example, for asymptomatic subjects, the
sacrum orientation ranged between 1.2° and 38.5° while the lum-
bar lordosis varied between 7.7° and 59.5°. The lumbar lordosis in
LBP patients did not differ significantly from asymptomatic sub-
jects (p = 0.29); however, the sacrum orientation was significantly
smaller (11.6°, p < 0.001). Moreover, both lumbar lordosis and
sacrum orientation significantly differed between asymptomatic
subjects and soccer players. While the lumbar lordosis of soccer
players was larger (39.1°; range: 21.7–59.5°; p < 0.001), the sacrum
orientation was smaller (13.3°; range: 1.9–26.8°; p = 0.003). A sig-
nificant difference was detected between LBP patients and soccer
players in lumbar lordosis (30.1° vs. 39.1°, p < 0.001), but not in
sacrum orientation (11.6° vs. 13.3°, p = 0.51). After adjusting the
data for age and gender, the difference in the lumbar lordosis
remained significant only between asymptomatic subjects and
soccer players (p = 0.034). The sacrum orientation in asymptomatic
subjects was still significantly different from both soccer players
(p = 0.002) and LBP patients (p = 0.017).
In six repeated standing phases, 51% of all asymptomatic women
and men showed on average variations in lumbar lordosis between
10% and 20%; 20% between 20% and 30% and 6% between 30% and
40% (Figs. 3, 4). In the sacrum orientation, 42% of all asymptomatic
women and 29% of all asymptomatic men revealed variations of
10%-20%. Interestingly, 18% of all asymptomatic men showed vari-
ations in sacrum orientation >40%. For variations of 10–20%, sacrum
orientation and lumbar lordosis did not show significant differ-
ences between repeated measurements (① and ② in Fig. 3;
p = 0.34). For variabilities >50%, the variations in sacrum orientation
decreased significantly with the number of repetitions (③ in Fig. 3,
p = 0.003 between the first and the last standing phases). Similarly,
high variability in the lordosis demonstrated no significant changes
between the repeated measurements (④ in Fig. 3; p = 0.34).
70 H. Schmidt et al. / Journal of Biomechanics 70 (2018) 67–76
Fig. 2. Box plots for sacrum orientation and lumbar lordosis. The upper diagram represents the entire cohorts, the lower diagram summarizes age- and gender-adjusted data.
Box plots are based on the median of all six standing phases. Dashed lines indicate statistical significances.
The percentages of subjects of different variability levels did not
substantially change between men and women or between asymp-
tomatic subjects and LBP patients (Fig. 4). However, soccer players
displayed a more uniform distribution in sacrum orientation and
lumbar lordosis, with up to 40% variability.
In the absolute values, the majority of study participants
showed variations of 2–10° (Fig. 5). However, 2% of the asymp-
tomatic subjects, 5% of LBP patients and 10% of the soccer players
displayed variations of >12°, mostly in sacrum orientation. Maxi-
mum values of 16.3° in sacrum orientation and 19.9° in lumbar lor-
dosis were found for asymptomatic subjects, 13.8° and 23.8°,
respectively, for LBP patients and 10.6° and 14.4°, respectively,
for soccer players.
Body height, body weight and age displayed no effect on the
variability in sacrum orientation and lumbar lordosis (R2 < 0.033;
Fig. 6). Similar trends could be observed for LBP patients and soccer
players (R2 < 0.04) as well as separately for gender sub-cohorts
(R2 < 0.04). Moreover, the time of the day showed also no effect
on the variability of both parameters in all three cohorts
(R2 < 0.012).
4. Discussion
An irreproducible standing posture can lead to false radiological
measurements, incorrect diagnoses and possibly unnecessary
treatment. For X-ray examination, physicians usually instruct the
patient to stand in a relaxed position, as this is assumed to be
the most reproducible posture and allows the best possible over-
view of the spinal shape. Furthermore, standing often forms the
basis (as an anatomical reference frame) for motion analyzes in
laboratory setup. However, numerous relaxed positions are possi-
ble, and thus inconsistent postures may be taken. Therefore, it is
difficult to ensure a reproducible state in this posture. This work,
exploiting data collected in earlier studies, was designed to evalu-
ate the variations in sacrum orientation and lumbar lordosis in six
repetitive upright standing postures of different cohorts: 332
asymptomatic non-athletes (general population), 21 asymptomatic
soccer players and 83 LBP patients. It was demonstrated that
sacrum orientation and lumbar lordosis in the standing position
are highly variable (individual). For asymptomatic non-athletes,
the lordosis angle varied between 7.7° and 59.5° and the sacrum
orientation between 1.2° and 38.5°. Previous studies have also
indicated a large degree of normal variability in the sagittal align-
ment of the spine in young, healthy subjects (Stagnara et al., 1982),
middle- and older-aged patients (Gelb et al., 1995) and patients
with back pain (Jackson and McManus, 1994; Kumar et al.,
2001). It is therefore unreasonable to expect one ‘‘normal lordosis”
or ‘‘normal sacrum orientation” of subjects/patients in the standing
position.
The results further demonstrated a high variability in lumbar
lordosis and sacrum orientation between six repeated standing
phases. In the sacrum orientation, for example, 53% of all asymp-
tomatic subjects displayed variations of >20%, 31% of >30% and
18% of >40%. In absolute values, 2% of the asymptomatic subjects,
5% of the LBP patients and 10% of the soccer players showed vari-
 H. Schmidt et al. / Journal of Biomechanics 70 (2018) 67–76 71

Fig. 3. Number of asymptomatic subjects classified into groups of different variability ranges in sacrum orientation and lumbar lordosis in six repeated standing phases.
Diagrams ①–④ show the relative variations of sacrum orientation and lumbar lordosis of six individuals for all standing phases: ① and ② 10–20%, ③ >50% and ④ 40–50%.
The bars represent the entire cohort. The dashed lines indicate significant differences.

ations of >12°. Maximum variations of 16.3° in the sacrum orienta-
tion for asymptomatic subjects and 23.8° for LBP patients were
found. Several studies have indicated that the sagittal alignment
can be accurately measured and that the measurements were
repeatable when the same subject was examined at two different
points in time (Jackson and Hales, 2000; Jackson et al., 1998). This
cannot be supported by the present findings. At this point it should
be mentioned that the measurement device was fixed at the sub-
ject’s back once and not removed and reattached during the mea-
suring session. This prevents additional measurement inaccuracies
(variations in lumbar lordosis and sacrum orientations between
different standing phases) due to an imprecise reattachment of
the device.
Contrary to our first hypothesis, the variability in lumbar lordo-
sis and sacrum orientation did not decrease with the number of
standing phases. The authors hypothesized that the greatest varia-
tions in lumbar lordosis and sacrum orientation occur between the
first and second standing phase. They assumed that the first mea-
surement provokes the subjects to think too much about what they
are requested to do and thus take an unusual posture. After the
first flexibility measurement (three times flexion), the subject
should be standing more relaxed, and therefore, the variability
should diminish with increased standing phases, which was, how-
ever, not supported by the results.
Contrary to our second hypothesis, no influence of gender and
age on the variability in standing was found. LBP patients did not
show a greater variability of different standing postures, which dis-
agrees with our third hypothesis. Therefore, it is important to
understand that the variability in standing is not predictable but
random, and thus does not reflect an individual specific behavioral
72 H. Schmidt et al. / Journal of Biomechanics 70 (2018) 67–76

Fig. 4. Relative number of subjects (with respect to the cohort size) classified into groups of different variability ranges in sacrum orientation and lumbar lordosis in six
repeated standing phases.

pattern which can be reduced, for example, by repeated standing
phases.
The fourth hypothesis that regularly trained subjects improve
the reproducibility of standing postures was also not supported
by the present findings. The authors assumed that their muscular
adaptations support them to have a more stable and therefore a
more reproducible posture in comparison to the general popula-
tion and especially to patients.
The present results showed no effect of the time of the day on
the variability in lumbar lordosis and sacrum orientation in all
three cohorts. This is in contrast to previous measurements on
spinal flexibility which clearly showed diurnal variations (intra-
day variations) in spinal stiffness. A simple flexibility test by mon-
itoring temporal changes in the fingertip-to-floor distance could
potentially indicate the trunk ‘‘stiffness/flexibility” and temporal
variations therein with the maximum stiffness occurring early in
the morning after rising (Gifford, 1987). Maximum flexibility
occurs late in the evening before going to bed (Adams and Dolan,
1996). A similar response is seen in the lumbar flexion with the
maximum stiffness early in the morning and the maximum flexi-
bility late in the afternoon (Gifford, 1987; Manire et al., 2010). This
corroborates findings of Adams et al. (1987) who showed that the
range of trunk flexion increased by about 5° during the day. These
previous findings would suggest that also the variability in
 H. Schmidt et al. / Journal of Biomechanics 70 (2018) 67–76 73

Fig. 5. Classification of subjects into groups of different variability ranges in sacrum orientation and lumbar lordosis in six repeated standing phases. In contrast to Fig. 5,
absolute values are given on the horizontal axis.

repeated standing phases is time dependent, which was however
not the case in the current analyses.
Given the high impact of a reproducible posture, practical rec-
ommendations for patient positioning during X-ray radiography
have been given by different authors. Dewi et al. (2010) suggested
a balancing plate, BalancAid, which consists of a square board with
a cylindrical disc at the center point attached at the center of the
bottom. This design should realize a forced balance in the sagittal
and frontal planes. The balancing effect from the device forces
the subject to stand balanced and directs the posture in a specific
upright position. The authors showed a greater reproducibility
when using BalancAid compared to standing on the ground by
grasping a supporting bar. However, it has to be noted that the
position during standing on such an apparatus is not comparable
to naturally relaxed standing. Koreska et al. (1978) implemented
the ‘‘Throne” to reproduce the positioning of the patients. How-
ever, this device merely enabled the patient to be imaged in a sit-
ting position, whereas the standardized method for curvature
measurement using X-ray requires standing. Other researchers
showed that the arm position is not only important in having an
optimal vertebral visibility in X-ray radiographs but also plays an
important role in the generation of a reliable three-dimensional
representation of the spine (Hayashi et al., 2009; Schmidt and
Gassel, 1994; Vialle et al., 2005).
Given that from one standing posture to the next standing pos-
ture, the study participants performed different exercises (e.g.,
flexion or extension), it is likely that some of the observed variabil-
ity was due to differences in exposures. Such results would high-
74 H. Schmidt et al. / Journal of Biomechanics 70 (2018) 67–76

Fig. 6. Scatter plot with variability in sacrum orientation and lumbar lordosis vs. body height, body weight and age. The median of all six standing phases are shown. The plots
are presented for the asymptomatic cohort, except for the influence of the body weight (second line), where the results of the LBP patients are also shown because they cover
a greater body-weight range.

light the need for the development of protocols capable of making
standing posture more reproducible. The present results showed a
tendency towards larger variability in lumbar lordosis after 3 times
flexion (1st exercise) and smaller variability after 3 times exten-
sion (2nd exercise). Although these differences were not signifi-
cant, the present results support the development of
standardized protocols; the including exercises, however, have to
be investigated in future studies.
In accordance with other non-invasive measurement tools, Epi-
onics SPINE has certain limitations. First, it should be noted that
the Epionics SPINE system measures the back shape and not
directly the curvature of the lumbar spine and the orientation of
the sacrum. Recent studies have found a significant correlation
between lumbar lordosis assessed via the back shape and deter-
mined radiologically only for subjects with a body mass index
(BMI) < 27.0 kg/m2 (Adams et al., 1986; Guermazi et al., 2006;
Stokes et al., 1987). In our own validation studies, we could addi-
tionally show that the correlation between the back and spinal
shape is poor in overweight and obese persons, which limits this
study to normal-weight subjects (BMI < 27.0 kg/m2). Therefore, to
ensure a strong correlation between back shape and underlying
spinal structures, only subjects with a BMI < 27.0 kg/m2 were
included in the asymptomatic cohort. For the LBP patients’ cohort,
this criterion could not be fulfilled and therefore, the lumbar lordo-
sis measured with Epionics cannot be directly transferred to the
actual shape of the spine. However, since the study focused not
on the validity of the spinal shape measurements, but on the vari-
ability in posture between repetitive measurements, the authors
assumed this a minor limitation. Moreover, the acceleration sen-
sors estimate the sacrum orientation from the spina iliaca posterior
superior. This procedure is in accordance with other non-invasive
measurement approaches (Granata and Sanford, 2000; Maduri
 H. Schmidt et al. / Journal of Biomechanics 70 (2018) 67–76
et al., 2008; Tafazzol et al., 2014), but does not directly reflect clin-
ically relevant sacrum or pelvic parameters, which can only be
obtained from radiographs.
The sensor stripes are seated inside hollow plasters, which are
taped along their entire length to the subject’s back and allow
the sensors to slide relative to the back’s surface. The elastic fibers
in the plasters are aligned longitudinally to allow stretching during
flexion and extension of the subject’s back. The plasters are able to
elongate by about 50% (24 cm) of its original length which is much
more than the maximum value of 13 cm found in the present
study. In the transverse direction (perpendicular to the subject’s
back), the plasters are least compliant to avoid deviations of the
stripes in both perpendicular directions and to ensure that the sen-
sors remain closely attached to the subject’s back. Due to possible
relative motion of the sensor stripes inside the hollow plasters and
due to the large stiffness of the sensor stripes in comparison to the
skin, the measurement is less sensitive to skin movements. There-
fore, the measured variations in lumbar lordosis and sacrum orien-
tations are assumed to be due mainly to the inherent
irreproducibility and not because of detachment of sensors.
It can be concluded that standing is highly individual and poorly
reproducible. The reproducibility was not affected by age, gender,
BMI, body height and body weight. Back pain patients and athletes
did not show a different behavior to asymptomatic non-athletes.
The number of standing phases also showed no positive effect on
the reproducibility. Therefore, it should be considered that each
examination in standing and the resulting measurements, for
example, the sacrum orientation and lordosis angle, can greatly
vary in subsequent analyses.
5. Conflict of interest
There is no conflict of interest.
Acknowledgments
This study was partially financed by the Bundesinstitut für
Sportwissenschaft, Bonn, Germany (MiSpEx Network).
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