Evaluation & the Health Professions

Thoracic spine mobility and posture: correlation and

predictive values in physically independent elderly.

Journal: Evaluation & the Health Professions

Manuscript ID EHP-23-0150

Manuscript Type: Original Manuscript

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Keywords: Inclinometer, thoracic schober, spinal mobility, aging, Posture

The posture undergoes changes during aging and may serve as a marker
for the evaluation of the thoracic spine. The objective of this study was
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to classify the posture of physically independent elderly people, correlate

the variables for the evaluation of thoracic spine mobility and propose
predictive equation models from the measurements of the thoracic
Schober test and the digital inclinometer. The mobility of thoracic flexion
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and extension by levels (T1, T8 and T12) of 41 elderly subjects (66 ± 7

years) was quantified with a digital inclinometer (degrees) and Schober's
test (cm). Results: 11 elderly subjects had straightening (G1), 15
Abstract:
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kyphosis (G2) and 15 hyper kyphosis (G3). There was a moderate

positive correlation between the digital inclinometer and Schober test at
T1 (r = 0.69), T12 (r = 0.60) and total flexion levels T1 to T12 (r =
0.74). Simple linear regression equations showed that thoracic Schober
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predicts thoracic mobility measures for these same levels. Conclusion:

The posture of the elderly was classified and there were moderate to
strong correlations between inclinometer and Schober Test. Predictive
equation models using the thoracic Schober test may contribute to the
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prediction of spinal mobility in physically independent elderly.

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Page 1 of 14 Evaluation & the Health Professions

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3 Thoracic spine mobility and posture: correlation and predictive values in physically
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5 independent elderly.
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10 Summary
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The posture undergoes changes during aging and may serve as a marker for the evaluation of
16 the thoracic spine. The objective of this study was to classify the posture of physically
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18 independent elderly people, correlate the variables for the evaluation of thoracic spine mobility
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20 and propose predictive equation models from the measurements of the thoracic Schober test
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and the digital inclinometer. The mobility of thoracic flexion and extension by levels (T1, T8
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23 and T12) of 41 elderly subjects (66 ± 7 years) was quantified with a digital inclinometer
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(degrees) and Schober's test (cm). Results: 11 elderly subjects had straightening (G1), 15
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25
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27 kyphosis (G2) and 15 hyper kyphosis (G3). There was a moderate positive correlation between
28 the digital inclinometer and Schober test at T1 (r = 0.69), T12 (r = 0.60) and total flexion levels
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30 T1 to T12 (r = 0.74). Simple linear regression equations showed that thoracic Schober predicts
31
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32 thoracic mobility measures for these same levels. Conclusion: The posture of the elderly was
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classified and there were moderate to strong correlations between inclinometer and Schober
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Test. Predictive equation models using the thoracic Schober test may contribute to the
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37 prediction of spinal mobility in physically independent elderly.
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42 Keywords: Inclinometer, thoracic schober, spinal mobility, aging.
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3 INTRODUCTION
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6 Posture change is one of the changes that accompany the aging process, and kyphosis
7 changes are described as being common among the elderly, with a reported prevalence of 20%
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9 to 40%. This percentage is believed to increase as the population ages (HIJIKATA et al., 2022).
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The evaluation of thoracic spine mobility can be performed using different resources.
13 Analyses by video systems (3D optoelectronics) are considered the gold standard (NEGRINI
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15 et al., 2016), however, the high cost of acquisition, the need for a controlled space and
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17 specialized evaluators make the method clinically unfeasible. On the other hand, simpler and
18 clinically applicable methods have been explored in the literature, among them the digital
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20 inclinometer and the Schober test stand out (NORLANDER et al., 1995; TAKATALO et al.,
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22 2020; MÄÄTTÄ et al., 2022).

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24 MacIntyre, Lorbergs, and Adachi (2014) performed an assessment of thoracic spine
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26 posture using the digital inclinometer and concluded that increased kyphosis can serve as a
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28 marker for mobility limitations in the elderly. On the other hand, according to Takatalo et al.
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(2020) several measuring devices have been used to quantify posture, but as for thoracic spine
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31 mobility, it has been neglected in the study of the spine, and further investigations with simple
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33 methods for clinical examination of the spine are needed. In addition, it is observed that most
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35 studies have been performed with young individuals and rarely in the elderly.
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37 The relationship between methods of measuring thoracic spine mobility in people already
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39 experiencing the aging process is unclear and studies evaluating thoracic spine mobility and the
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correlation with posture in physically independent elderly are scarce. Instead, many studies
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42 focus on exploring changes in kyphosis with functional performance and even with the risk of
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44 falls (HIJIKATA et al., 2022), which is quite useful in helping to identify risk factors for aging,
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46 however, this requires a thorough understanding of segmental spinal biomechanics.
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48 Within this context, there is a need to explore a practical and low-cost clinical test to
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50 measure the mobility of the thoracic spine to improve the models for assessing the spine in the
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elderly. Thus, the objective of this study is to classify the posture and correlate the variables for
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53 assessing the mobility of the thoracic spine of physically independent elderly people.
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55 Furthermore, it is expected to propose models of predictive equations from the measurements,
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57 in degrees, obtained by the digital inclinometer and the thoracic Schober test, obtained in
58 centimeters, to assist in the biomechanical characterization of the thoracic spine in physically
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60 independent elderly people.

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3 METHODS
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6 Participants
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8 This is a cross-sectional study, with elderly participants recruited voluntarily and by
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10 convenience from the local community through personal contacts. A total of 41 elderly
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completed the tests and were included in the analysis of this study. The eligibility criteria for
13 this study were: elderly individuals over 60 years of age considered physically independent,
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15 classified in level 3 or 4 of the functional status scale proposed by Spirduso, which characterizes
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17 the elderly as being able to perform the basic activities of daily living and also the instrumental
18 activities of daily living (SPIRDUSO, FRANCIS & MACRAE, 2005); absence of any type of
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20 neurological, metabolic and/or orthopedic disease of high severity, such as spinal surgeries or
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22 fractures. Elderly people who were unable to perform the proposed movements were excluded.
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The research was approved by the Ethics Committee of Pitágoras Unopar University (#:
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25 5.103.494).
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28 Patient Preparation
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30 All data were collected in a sports activity center for the community, which has adequate
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32 lighting and temperature (± 22°C). Before the evaluation, each participant answered a brief
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questionnaire about anthropometric characteristics, presence of acute (< 4 weeks) or chronic (>
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12 weeks) low back pain, and level of physical activity using the International Physical Activity
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37 Questionnaire (IPAQ). The mobility assessment sessions using spinal movements were a
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39 maximum of one hour for each participant. All participants were familiarized with the
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equipment and procedures before the measurements. All measurements were obtained by a
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42 trained physical therapist with 10 years of experience in spinal assessment.
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Measurement of thoracic spine mobility with inclinometer and tape measure
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47 The mobility of the thoracic spine was actively measured during flexion and extension
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49 movements by means of the tape measure in the Schober test, and by the digital inclinometer
50 "ExaMobile S. A. Laser Level and Inclinometer" integrated into the Iphone 11. The integrated
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52 digital inclinometer is a fast, convenient, accurate and reliable method (Intraclass correlation
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54 coefficient = 0.995 - 0.998) to measure angles of the thoracic spine (HUANG et al. 2022;
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FURNESS et al., 2018). Although they are not the gold standard for assessing spine dynamics,
57 the inclinometer and tape measure are the most accessible and low-cost way with good
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59 portability, presenting relevant external validity for clinical applicability. For the measurement
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3 of mobility, the thoracic spine was divided into 3 points: level of the first thoracic vertebra (T1),
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5 eighth thoracic vertebra (T8) and twelfth thoracic vertebra (T12). The difference of 15 cm
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7 counted from C7 to T5 was considered for the location of the spinous processes, and for the
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other underlying spinous processes, the difference of 3 cm for each vertebra, as suggested by
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10 Norlander et al. (1995). The integrated digital inclinometer was first positioned at the level of
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12 T1, with the base of the smartphone attached to this region indicating horizontally the direction
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14 of angulation on the ninety (90) degree line, and vertically indicating 0 (zero) degrees. The
15 measurements were obtained while the participant was seated to minimize the influence of the
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17 lumbar spine on the observed amplitude. With hands positioned crossed on opposite shoulders,
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19 the maximum active thoracic flexion was requested and the angular values of the initial and
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final positions of the active movement shown on the inclinometer were recorded, after which
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22 the participant was instructed to return to the initial position. The same procedure was
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24 performed for T8 and T12. To measure the total mobility of the spine in flexion (T1 to T12) the
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26 total sum of the mobility values obtained for each level T1, T8, and T12 was considered, which
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were summed and divided by 3 (TABARD-FOUGÈRE et al., 2019). For the thoracic extension
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29 movement, the hands were asked to be positioned at the base of the nape and asked to actively
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31 extend, and the values of the initial position and that of total extension were then recorded. For
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33 the Schober test of the thoracic spine, the measuring tape was placed at the marking points from
34 the spinous process of T1 to the level of T12, active flexion of the thoracic spine was requested,
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36 and the difference between the initial and final measurements (T1 and T12) was recorded as the
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38 Schober test flexion value of the thoracic spine, as suggested by Takatalo et al., (2020).
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40 Posture Classification
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After the evaluations, the participants were divided into three groups according to the
44 angular values obtained in the digital inclinometer, considering the seated position: G1) group
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46 with thoracic rectification (<20º); G2) group with physiologic kyphosis (between 20º and 40º);
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48 and G3) group with hyper kyphosis (>40º) according to the cut-off points described in Lam &
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Mukhdomi (2022).
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52 Statistical Analysis
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54 The sample size calculation was performed based on the estimates assigned for
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56 correlation between two spinal evaluation variables (angle x centimeters). Considering an alpha
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58 of 0.05 and power of 90%, correlation: 0.50 (MÄÄTTÄ et al., 2022), the number needed for
59 the present study was 37 participants, the sample size calculation was performed in G*Power
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3 version 3.1.5. The data were presented by descriptive statistics with measures of central
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5 tendency, mean and standard deviation.
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7 The parametric distribution of data was verified by the Shapiro Wilk test. Tests for
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9 comparison between groups and variables were applied according to data distribution (1-factor
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11 ANOVA test and Kruskal-Walli’s test), and for comparison of categorical data the Chi-square
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test of independence was applied. Correlations between variables were performed to identify
14 the association between thoracic Schober test measurements (in centimeters) and thoracic spine
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16 flexion mobility measurements (in degrees). The correlation between the variables was
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18 classified as: 0.0 to 0.30 insignificant correlation; 0.30 to 0.50 low correlation; 0.50 to 0.70
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moderate correlation; 0.70 to 0.90 strong correlation; 0.90 to 1, very strong correlation
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21 (MUKAKA, 2012). Simple regressions were calculated and analyzed to propose predictive
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23 equation models considering the obtained values of thoracic spine mobilities. For all statistical
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analyses, a significance of p<0.05 was accepted and data analysis was performed using the
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26 software packages IBM SPSS Statistics for Windows (Version 20.0. Armonk, NY: IBM Corp)
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28 and Graph Prism (Version 6.01).
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RESULTS
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33 A total of 41 elderly people were included in the study. Anthropometric data are presented
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35 below in mean and standard deviation and in median and interquartile range [25/75]. The mean
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36 age was 66.15 (± 7.02), height 1.60m [1.43-1.76] and weight 70.1 kg [50.6-116.0]. Of the 41
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38 participants, 32 were female (78%) and 9 were male (22%).
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Regarding the characterization of the level of physical activity, occurrence of low back
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42 pain, posture classification and occurrence of falls among the participants included in the study
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44 (n=41) the following data were found: 6 (14.6%) participants had no low back pain, while 35
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46 (85.4%) had chronic low back pain (>12 weeks). The level of physical activity (IPAQ) was
47 considered active for 9 (22%) participants; Irregularly Active A for 18 (43.9%); Irregularly
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49 Active B for 11 (26.8%); and sedentary for 3 (7.3%) participants, according to the time of
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51 physical activity, in minutes, per week.
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53 The classification of posture showed thoracic rectification in 11 (26.8%) elderly; kyphosis
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55 in 15 (36.6%); and hyper kyphosis in 15 (36.6%) participants. Of the 41 elderlies included in
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57 the study, 22 (53.7%) had suffered falls in the last 12 months and 19 (46.3%) had not fallen in
58 the same period. However, none had major or disabling consequences.
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3 In general, significant differences were found only between the low back pain and posture
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5 classification group, in which the Chi-square test of independence showed that there is an
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7 association between posture alterations in hyper kyphosis (with residual adjustment = 2.6) and
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the occurrence of low back pain [X2 (2) = 6.846; p = 0.03]. For the other variables (level of
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10 physical activity and falls in the last 12 months) no significant differences were found (p >
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12 0.05).
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14 Table 1 shows the comparison of the data referring to the mobility of the thoracic spine
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16 according to the groups of elderly who had the thoracic spine straightened (G1), physiological
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18 kyphosis (G2) and hyper kyphosis (G3). Significant differences were found only in flexion at
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the T8 level (p = 0.019) and in total mobility in flexion T1 to T12 (p = 0.018).
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22 Table 1: Comparison of thoracic spine mobility values among participants (n=41).

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24 VARIABLE G1 G2 G3 p
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25 THORACIC SCHOBER TEST

26 (cm)
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28 T1 - T12 3 [2 - 7] 3 [2 - 4] 3 [2 - 4] 0.750
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29 ACTIVE FLEXION (º)

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31 T1 32 (16) 20 (10) 24 (13) 0.057
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33 T8 20 (13) 28 (13) § 19 (11) 0.019*
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36 T12 17 [4 - 29] 7 [1 - 16] 13 [6 - 16] 0.140

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ACTIVE EXTENSION (º)
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39 T1 23 (8) 24 (13) 16 (6) 0.970

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41 T8 14 [8 - 26] 13 [5 - 22] 14 [6 - 18] 0.930
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43 T12 7 [4 - 15.0] 6 [3 - 10] 8 [4 - 13] 0.530
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45 TOTAL MOBILITY IN
46 FLEXION (º)
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48 T1 - T12 26 (12)§ § 14 (9) 18 (8) 0.018*
49 TOTAL MOBILITY IN
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51 EXTENSION (º)
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53 T1 - T12 16 (6) 16 (7) 13 (5) 0.270
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55 Data are presented in mean and (standard deviation) and in median and [interquartile range
56 25/75]. G1 (Rectification); G2 (Kyphosis); G3 (Hyperkyphosis) according to postural
57 classification; p with significance <0.05. §: G2 > G1. §§: G1 > G2.
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3 Table 1 shows the comparison of the data referring to the mobility of the thoracic spine
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5 according to the groups of elderly who had the thoracic spine straightened (G1), physiological
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7 kyphosis (G2) and hyper kyphosis (G3). Significant differences were found only in flexion at
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the T8 level (p = 0.019) and in total mobility in flexion T1 to T12 (p = 0.018).
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11 The results obtained from Tukey's post-hoc analysis to explore the significant differences
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of thoracic spine mobilities obtained in table 1 presented the following results: In the flexion
14 variable, a significant difference was found between G2 and G1 (p = 0.015); For total mobility
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16 in flexion, a difference was also observed G1 and G2 (p = 0.014). Thus, for active flexion (T8)
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18 the group with kyphosis had greater amplitude in degrees, while for total flexion mobility the
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group with rectification had greater amplitude.
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22 When correlating the thoracic spine mobility measurements and posture, insignificant
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correlations were observed (r = 0.17 - 0.29), but when correlating the mobility measurements
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25 obtained through the Schober test with the measurements obtained through the digital
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27 inclinometer, the correlation results were moderate to strong (r = 0.60 - 0.74), where the linear
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29 correlation was positive between the thoracic Schober test measurements (in centimeters) and
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the thoracic spine flexion mobility measurements T1, T12, and total T1 to T12 (in degrees).
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32 This result can be demonstrated by means of Figure 1.

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35 [insert Figure 1]
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37 The predictor variable entered the regression model was the thoracic Schober test, and
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39 the output variables were the measurements of flexion at the T1 level, flexion at the T12 level,
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and total flexion mobility from T1 to T12. Extension mobilities (all levels) and flexion at the
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42 T8 level did not correlate with the Schober test and therefore were not entered as predictor
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44 variables in the regression model.
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46 Simple linear regression showed that the thoracic Schober test predicts thoracic mobility
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48 measures for the following levels: T1 flexion [F (1,39) = 36.951; p<0.001; R2 = 0.487]; T12
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50 flexion [F (1,39) = 24.626; p<0.001; R2 = 0.387]; and total mobility in flexion from T1 to T12
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[F (1,39) = 48.466; p<0.001; R2 = 0.554]. The equations that best predicted the thoracic mobility
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53 measures are described in Table 2.
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3 Table 2: Prediction equations for thoracic spine mobility obtained by simple Linear Regression for
4 Schober's test values (in cm) and inclinometer (in degrees) (n = 41).
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6 Variable Equation R2 S p
7 Flexion (º)
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9 Level - T1 7,564 + 5,279 × (TS) 0,487 9,769 < 0,001
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11 Level - T12 0,729 + 3,758 × (TS) 0,387 8,519 < 0,001
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13 Total mobility in
14 flexion (º)
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16 Level - T1 a T12 4,577 + 4,467 × (TS) 0,554 7,217 < 0,001
17 R2: proportion of variance explained; S: standard error of estimate; TS: Thoracic Schober Test.
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DISCUSSION
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24
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25 This study investigated the correlation between the thoracic spine mobility assessment
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27 variables and the posture classification of physically independent elderly people and sought to
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29 propose predictive equations between the measurements of this mobility. Overall, moderate to
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strong correlations were found between the assessment variables (digital inclinometer and
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32 Schober test) and insignificant correlations for mobility and posture classification, and
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34 predictive values were proposed for thoracic spine mobility using the Schober test.
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36 Studies evaluating the mobility of the thoracic spine and the correlation with posture in
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38 physically independent elderly people are scarce. However, even with few works available for
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40 comparison, although with some peculiarities in methodology and population, we can observe
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that our results are in agreement with described data of overall increased mobility in thoracic
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43 segments from T8 (p = 0.019) (IGNASIAK; RÜEGER; FERGUSON, 2017; WILKE et al,
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45 2017; MÄÄTTÄ et al., 2022), total mobility in flexion from T1 to T12 (p = 0.018) (HINMAN,
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47 2004); and with a moderate positive association between Schober test and spine mobility (r =
48 0.53 - 0.69) ( MÄÄTTÄ et al., 2022 ).
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51 Määttä et al. (2022) assessed the thoracic spine mobility of 73 individuals (22-56 years
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old) using an inclinometer and found greater mobility at the upper thoracic level of T 8, which
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54 was associated with worse reported thoracic spine pain (OR = 0.95; 0.92-0.99). Another in vitro
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56 biomechanical study by Wilke et al. (2017) with 68 functional human thoracic spinal units
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58 investigated the segmental and neutral zone range of motion of the healthy human thoracic
59 spine by applying thoracic flexion and extension and found a greater range of motion in the
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3 upper half of the thoracic spine from T6-T8, corroborating with the findings of the present study
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5 for greater mobility in the T8 segments.
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7 Some specific features influence the range of motion of the regions and levels of the spine.
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9 The mobility of the spinal functional unit is influenced by other structural factors, such as
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11 intervertebral discs, thoracic spinal ligaments at the level of T8-T10 as the cross-sectional areas
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of the discs of the upper thoracic spine (T1-T2 to T6-T8) which are relatively small compared
14 to those of the lower thoracic spine (T11-T12) and although the disc heights are approximately
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16 the same in the upper and lower thoracic spine, there is a greater WMD in the motion segments
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18 of the upper thoracic spine due to the lower moment of inertia area (POONI et al., 1986;
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HORTON et al., 2005; PANJABI et al., 1993; MIMURA et al., 1994). In addition, the T8
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21 segment could potentially have a greater stabilizing effect along with the costotransverse joints
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23 and here, the preservation of physiological kyphosis contributed to better mobility
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(HENEGHAN, RUSHTON, 2016; HORTON et al., 2005).
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27 Regarding gender, there was no statistical difference in mobility between genders studied
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29 in this study, which can be explained, in part, by the low number of male participants (n=6),
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while the number of women was higher (n=35). Thus, there is no evidence that mobility has an
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32 impact on gender, and in the studies found in the literature there was also no difference in
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34 mobility between men and women (MÄÄTTÄ et al., 2022).
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36 In our study we found differences in total mobility in flexion from T1 to T12, where the
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38 kyphosis group showed less mobility, agreeing with the data of Hinman (2004), who aimed to
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40 examine age-related postural rigidity, and to evaluate changes in the size of the thoracic curve
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(T1 to T12) of 51 women, 25 younger (21-51 years) and 26 elderly (66-88 years), in their usual
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43 relaxed posture versus their maximum erect posture, by means of the Flex curve instrument.
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45 Postural rigidity, in this case, was defined as the inability to actively correct or improve spinal
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47 alignment and influence the size of the thoracic curve (kyphosis). As expected, older women
48 demonstrated more stiffness, with differences in relaxed thoracic spine (p = 0.018) and upright
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50 posture (p = 0.001).
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Increased thoracic kyphosis and postural stiffness are commonly associated with aging
54 and many pathological conditions, and simple clinical measures are needed to estimate the
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56 relative degree of postural stiffness to determine whether clinical interventions, such as
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58 exercises, are effective (HINMAN, 2004). The presence of hyper kyphosis can serve as a
59 marker for mobility limitations in the elderly in terms of function (NEGRINI et al., 2016), and
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3 various measuring devices have been used to quantify posture. However, we believe that only
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5 measuring the chest curve in kyphosis or hyper kyphosis is not enough to identify the risks of
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7 deterioration of function as well as increased risk of falls for the elderly.
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9 One hypothesis would be that the limits of body stability can be influenced by hypomobile
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11 structures of the spine, and not only by peripheral joints such as the ankle and hip, as for
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example, in hyper kyphosis, where the elderly can adopt the strategy of stepping accompanied
14 by an increase in thoracic curvature, thus modifying the support base (HOUDIJK et al., 2009).
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16 Based on this assumption, it is questionable how the mobility of the thoracic spine could
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18 interfere in this process of adaptation of postural control and in the increased risk of falls,
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opposing what the literature has been showing as hyper kyphosis being the most important
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21 factor.
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To date, studies in the literature that explore the relationship between thoracic spine
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25 mobility and the risk of falls are practically nonexistent. Knowing that the decreased ability of
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27 the elderly to maintain balance reduces the quality of the tasks performed and can increase the
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29 risk of falling, it is essential to elucidate issues related to the structural compliance of the spine,
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not limited only to the identification of increased kyphosis, but also to relate the mobility
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32 deficits to the occurrence of falls, since aging is associated with structural and functional
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34 deterioration of the systems associated with the control of balance and mobility, as well as
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36 changes in the integration of sensory and structural afferences (ROSSAT, 2010).

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38 The Schober test method has been validated in several studies (REZVANI et al., 2012;
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40 TOUSIGNANT et al., 2005). However, the method is commonly applied to the lumbar region,
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but the thoracic Schober test is rarely studied and, despite being a validated and low-cost clinical
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43 tool, there are few studies correlating the Schober test with other thoracic spine assessment
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45 instruments, such as the inclinometer. However, we found similar results in the study by
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47 Norlander et al. (1995), which despite being older is a study that brings a relevant clinical
48 method to measure the segmental flexion distribution of mobility in the thoracic spine. We also
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50 have the study by Määttä et al. (2022), which, despite being carried out in an adult population
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52 (22-59 years old) and not elderly, was the study that came closest in detail to our methodology
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and objectives.
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56 According to Rezvani et al., (2012), the Schober test evaluates spinal mobility through
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58 distraction measurements performed on the skin. One of the most significant factors affecting
59 the accuracy of these tests is the stretching of the skin to accommodate the movements of the
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3 spine. During thoracic flexion, the skin is exposed to tensile force, and after the skin elasticity
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5 limit, spinal flexion is completed not by stretching the skin, but by sliding the skin over
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7 subcutaneous adipose tissue. Thus, as the Schober test showed higher values in our study, there
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was also greater mobility in degrees recorded on the inclinometer and thus a positive linear
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10 correlation at T1 (r = 0.69; p<0.001), T12 (r = 0.60; p<0.001) and total T1 to T12 (r = 0.74;
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12 p<0.001).
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14 It is important to note that the clinical applicability of the thoracic Schober Test does not
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16 apply in the quantification of kyphotic curvature, statically, as observed in Table 1, where there
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18 was no statistically significant difference in Schober between the G1, G2 and G3 posture groups
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(p=0.750), being a method of measurement relevant only to the mobility of the spine
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21 (REZVANI et al., 2012).
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Regarding the Schober measurements correlated with the inclinometer measurements, a
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25 non-linear trend was also observed when the Schober showed low degrees of amplitude,
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27 especially when it marked 2 cm of distraction, at the T1 and T12 levels, where a non-similar
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29 behavior was observed in the inclinometer compared to the other subjects who obtained the
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same measurement. This fact may be related to the influence of the cervical and lumbar
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32 segments on mobility at T1 and T12 levels, respectively, where ROM restriction at these levels
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34 may be accompanied by an increase in compensatory mobility of the cervical and lumbar spine
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36 and, in these cases, inclinometer values may vary from subject to subject and have interfered
37 with this nonlinear trend (POONI et al., 1986; HORTON et al., 2005; PANJABI et al., 1993;
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39 MIMURA et al., 1994).

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Overall, however, there is a moderate linear relationship between spinal flexion mobility
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43 at the T1 level (in degrees) and Schober's test (R2 = 0.44; p< 0.001). Norlander et al. (1995)
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45 validated the use of the tape measure in skin distraction (Schober test) in the assessment of
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47 thoracic spine segmental mobility using the inclinometer (n = 42). The results of the analysis
48 of the relationship between spinal flexion mobility and skin distraction (R2 = 0.48; p< 0.001)
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50 revealed data similar to the results found in our study.
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In the study by Määttä et al. (2022), who evaluated a total of 73 study participants, 21
54 (29%) male and 52 (71%) female, with a mean participant age of 39 years (range 22 to 56),
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56 they found correlations in the Schober test with mobility in flexion T1 (r = 0.53; p<0.050); T6-
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58 T8 flexion ( r = 0.53; p<0.050); and T1-T12 total flexion (r = 0.69; p<0.050), corroborating
59 with our results which were moderate correlation with T1 flexion (r = 0.69; p< 0.001); T12
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 Evaluation & the Health Professions Page 12 of 14

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3 flexion (r = 0.60; p< 0.001); and T1-T12 flexion (r = 0.74; p<0.001). On the other hand, they
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5 did not find a linear regression in their correlations because their logistic regression model was
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7 adjusted for age, and the fact that their sample contained young and adult participants at the
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beginning of the aging process made a total difference from our study, which evaluated only
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10 elderly participants. In the present study, it was possible to find a linear model, and, through a
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12 thorough analysis, we were able to arrive at the predictive equations described in Table 2.
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14 To date, we have not heard of any chest mobility prediction equations available for the
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16 elderly developed from community participant samples. We believe this is a strength in our
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18 study, as our linear regression showed that it is possible to predict what approximate value will
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be generated using the inclinometer, which may contribute to better applicability in practice
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21 among health care professionals.
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One of the main problems of clinical measurements of the spine is because the values
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25 expressed in these tests vary not only due to the different degrees of aptitude and experience of
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27 the examiners, but also due to the lack of standardization of the tests. Ideally, professionals
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29 should have at their disposal a simple, standardized, and reliable battery of tests to evaluate
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patients and different examiners should achieve similar results when evaluating the same patient
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32 (Souza Filho et al. 2007).

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35 In this sense, the prediction equations can facilitate the quantification of thoracic spine
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36 mobility, since the measurements obtained with the inclinometer followed a protocol already
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38 described in the literature (Norlander et al., 1995), which further improves the standardization
iew

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40 issue, and also the portability of the evaluation instrument, since when applying the prediction
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equations, the professional will only need a measuring tape, dispensing with the use of the
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43 inclinometer, integrated or not.
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46 We highlight as a strength of the findings that the equations also enable a quick analysis
47 of mobility in degrees, without the need for direct application of the inclinometer, which
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49 represents a time saving, especially if the professional is not familiar with the inclinometer,
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51 where the chances of measurement errors are greater and can lead to incorrect observations.
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Our study may encourage practitioners to perform thoracic spine mobility assessment in a quick
54 and simplified manner and consider thoracic spine assessment in their clinical practice.
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57 Some limitations may be presented, among them, the results of the present study are from
58 specific equations for postures assessed in sitting, and this could generate different values about
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60 their applicability in postures assessed in standing. However, we believe that these equations

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3 can be replicated under these conditions, as Määttä et al. (2022) found strong to very strong
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5 intra-examiner reliability (Kappa 0.78 and 0.87) for postural assessment in sitting and standing
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7 positions, however, this should be tested. Another limitation would be in relation to the sample
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characteristics, with the participation of more women (n=35), while the number of men was
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10 low (n=6), and our equations need to be validated in other populations. Finally, we hope that
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12 this study may encourage further research exploring the relationship between mobility measures
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14 with other points of interest for aging such as functional performance measures.
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16 CONCLUSION
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18 The results of this study showed that it is possible to classify posture and that there are
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20 moderate to strong correlations between the variables of thoracic mobility evaluation and
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Fo

22 insignificant of mobility and posture in physically independent elderly. Furthermore, predictive

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equation models were proposed by means of the thoracic Schober test, obtained in centimeters.
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25 With this, we believe that characterization of thoracic spine mobility may in the future support
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27 the identification of abnormal movements and/or be used to improve biomechanical models of
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29 the spine in physically independent elderly.

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Conflict of interest declaration
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36 There is no conflict of interest.

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Figure 1: (A) Spinal flexion assessment at the level of T1; (B) Flexion assessment at T12; (C) Total flexion
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