|Year : 2011 | Volume
| Issue : 2 | Page : 65-71
Lumbar spinal mobility changes among adults with advancing age
Ismaila Adamu Saidu1, Stanley Monday Maduagwu2, Abdullahi Digil Abbas3, Omotayo O Adetunji4, Abdurahman Mohammed Jajere2
1 Department of Physiotherapy, College of Medical Sciences, University of Maiduguri; Department of Physiotherapy, University of Maiduguri Teaching Hospital, Maiduguri, Nigeria
2 Department of Physiotherapy, University of Maiduguri Teaching Hospital, Maiduguri, Nigeria
3 Department of Orthopaedics and Traumatology, College of Medical Sciences, University of Maiduguri, Maiduguri, Nigeria
4 Department of Physiotherapy, College of Medical Sciences, University of Maiduguri, Maiduguri, Nigeria
|Date of Web Publication||3-Feb-2012|
Ismaila Adamu Saidu
Department of Physiotherapy, College of Medical Sciences, University of Maiduguri, Maiduguri
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Limitations in spinal mobility can interfere with the attainment of important functional skills and activities of daily living and restrictions in spinal mobility are usually the earliest and reliable indicator of diseases.
Objective : The aim of this study was to determine the differences of lumbar spinal mobility among healthy adults with advancing age.
Materials and Methods : The modified Schober's method was used to measure anterior flexion. The guideline of the American Academy of Orthopaedic Surgeons was adapted to measure lateral flexion and extension.
Results : The results of this study indicate that spinal mobility decreases with advancing age. The most significant (P < 0.05) differences occurred between the two youngest and the two oldest age categories.
Conclusion : Using these data, we developed normative values of spinal mobility for each sex and age group. This study helps the clinicians to understand and correlate the restrictions of lumbar spinal mobility due to age and differentiate the limitations due to disease.
Keywords: Age, change, mobility, lumbar, spine
|How to cite this article:|
Saidu IA, Maduagwu SM, Abbas AD, Adetunji OO, Jajere AM. Lumbar spinal mobility changes among adults with advancing age. J Mid-life Health 2011;2:65-71
| Introduction|| |
Whatever steps are taken to stay young, the combined effects of biological aging and adverse environmental influence eventually declare themselves. A mature adult around the age of 25 will experience the maximum physical, sexual, and reproductive capacity which decline gradually as the age advances.
Ayad and Weiss  reported that normal morphology and biochemistry of the intervertebral disc and bone undergo changes during maturation and aging process which differ from grossly exaggerated morphological changes and biochemical alteration observed in degenerative bone and disc diseases. Aging is accompanied by loss of bone minerals from the skeleton, atrophy of muscles and joints range of motion limitation with considerable differences in the pattern of development between both sexes. 
Movement of the vertebral column like any other synovial joints or joint complex can be classified into physiological and accessory movements. A physiological movement is the one that can be normally performed by a subject whereas accessory movement can only be produced by an external device or a person upon a subject.  Normal spinal physiological movements include anterior flexion, extension, lateral flexion, and rotation while the accessory includes distraction and compression of the vertebral column. 
During evaluation of the spine, accurate measurement of spinal mobility can be used to determine whether abnormal limitation exists in spinal mobility and to determine the effectiveness of treatment procedures.  Limitations in spinal mobility can interfere with the attainment of important functional skills and activities of daily living such as dressing and picking up objects from the floor and also contribute to gait abnormalities. 
Distinguishing between age-related decrease in spinal mobility and pathological limitations on spinal mobility is difficult because within the same age group, values of spinal mobility may vary widely. ,,,
The purpose of this study was to determine the difference in spinal mobility with advancing age among healthy adults in both sexes. Although normative values of spinal mobility have been established for healthy women,  children,  and adolescents  in the western world, no empirical data have been established yet for adults in both sexes in developing countries such as Nigeria.
| Materials and Methods|| |
A total of 135 normal adults with age range 20-76 years participated in this study. They were students from College of Medical Sciences, University of Maiduguri as well as adults living in Maiduguri metropolis, Nigeria.
The inclusion criteria were as follows:
It is a cross-sectional observational study. The consecutive sampling technique was used in recruiting the participants. Non-elastic tape measure and 180° standard goniometer were used to measure spinal mobility for anterior flexion and for lateral flexion and trunk extension, respectively. The institutional ethical committee approval was obtained before the start of the study.
- Subjects that are 20 year old and above.
- Subjects with no history of back surgery.
- Subjects with no history of low back pain within the last 3 months that require medical attention.
- Subjects with no symptomatic rheumatoid arthritis, osteoarthritis of the hip, Marfan's syndrome, or spinal deformity.
- Subjects with no obesity or big abdomen.
- Subjects who could give informed consent and obey instructions.
This research was aimed at studying four spinal movements; anterior flexion, right lateral flexion, left lateral flexion, and extension.
The subjects stood erect, feet positioned approximately shoulder-width apart with their spines fully exposed. The left and right posterior superior iliac spines were fully exposed. The left and right iliac spines were palpated and marked with a small dot. A small, straight line was drawn between the two posterior superior iliac spines, so that it bisected the vertebral column into upper and lower parts. A dot (A) was marked over the vertebral column 10 cm above the line joining the two posterior superior iliac spines, and another dot (B) was marked over the vertebral column 5 cm below it. The superior aspects of the iliac crests and the spinous process of C7 were located by palpation. The mid-axillary line, the line halfway between the anterior and posterior axillary folds, was determined visually.
Measurement of anterior flexion
Anterior flexion was measured using Macrae and Wright's modification of Schober's technique.  The subject was asked to stand erect with his feet about shoulder-width apart. This position helped the subject stabilized the pelvis, aided him in maintaining his balance and helped us to increase the consistency of our measurements. The subject was instructed to bend over as far forward as he could and to keep his knees straight. When maximum anterior flexion was reached, the distance between points A and B was measured with the tape rule and the difference was recorded. For each of the spinal motions measured, the end of the ranges of motion (ROM) was defined by instructing the subject to report that he could not move any further. After each measurement, the subject was asked to return to the upright position.
Measurement of right and left lateral flexions
The right and left lateral flexions were measured with a standard goniometer following the guidelines of the American Academy of Orthopaedic Surgeons as described by Einkauf et al. The movement was demonstrated to the subject and the importance of staying in the coronal plane was emphasized. The subject was then positioned standing erect with his feet shoulder-width apart to increase stability. The goniometric axis was placed over the sacrum midway between the two posterior superior iliac spines. The stationary arm of the goniometer was placed perpendicular to the floor, and the moving arm was aligned with the spinous process of C7. The subject was instructed to bend sideways directly to his right and then to his left as far as possible while keeping his knees straight. The stationary arm of the goniometer was held against the subject's pelvis during the movement rather than being kept perpendicular to the floor. The pelvis could have tilted during spinal movements, but by holding the arm of the goniometer to the pelvis, it ensured that the measurement was the angle between the spine and the floor. After maximum lateral flexion was achieved, the spinous process of C7 was palpated and the moving arm of the goniometer was positioned in line with it. The ROM was measured and recorded in degrees. The subject was asked to return to the upright position, and the same procedure was repeated to measure left lateral flexion.
Measurement of spinal extension
Spinal extension also was measured with a standard goniometer, the guidelines of the American Academy of Orthopaedic Surgeon was adopted.  The spinal extension was demonstrated to the subject, and he was then instructed to stand erect with his feet shoulder-width apart. The goniometric axis was placed at the junction of the superior iliac crest and the mid-axillary line. Those subjects who demonstrated a lordotic standing posture, the amount of extension was measured, recorded in degrees and considered to be the 'zero point' for that subject. The subject was instructed to bend straight backward as far as he could without bending his knees. The stationary arm of the goniometer was held against the subject's pelvis because he might not be able to keep his pelvis perpendicular to the floor during the movement. After the subject had achieved maximum spinal extension, ROM was recorded in degrees and subtracted from the initial amount of extension.
Descriptive statistics of mean, standard deviation, and percentage were used to summarize data for age and sex and inferential statistics of independent t-test to compare mean age and spinal mobility measurements (SMM) in both sexes and one-way analysis of variance (ANOVA) was used to determine the significant level between and within each age group in both sexes. Alpha was set at 0.05. The data were analyzed with SPSS version 15 statistical package.
In order to minimize bias, the statistical analysis was done independently of data collectors. SIA and AOO took the measurement of the lumber spinal mobility of the participants while MSM and JAM did the statistical analysis and the interpretation was conducted by ADA.
| Results|| |
A total of 135 normal subjects aged between 20 and 76 years (mean = 44.2 ± 17.0 years) participated in this study. They comprised of 69 (51.1%) males (mean age = 45.7 ± 16.7) and 66 (48.9%) females (mean age = 42.6 ± 17.1) [Table 1]. The female participants were of similar age to the male participants (P < 0.05) and the majority was above the age of 40 years in both sexes [Table 2].
|Table 1: Frequency and percentage of the age group and sex distributions of participants|
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|Table 2: Mean, standard deviation, and independent t-test of spinal mobility measurements by sex and age group|
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[Table 1] shows the frequency and percentage for each age group and sex distributions for the participants. The mean, standard deviation, and independent t-test of SMM based on sex and the age group is presented on [Table 2]. [Table 3] shows ANOVA for SMM in both sexes while the least of square difference post hoc ANOVA comparison revealed that significant differences existed between each age group in both sexes is presented in [Table 4]. All differences were significant at P < 0.05.
|Table 4: Least of square difference post hoc trend analysis for spinal mobility measurements on both sexes|
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| Discussion|| |
This study examined the changes in lumbar spinal mobility in healthy Nigerian adults aged 20-76 years. Our results demonstrated that spinal mobility in both sagittal and coronal planes decreased with advancing age, a finding that corroborated the results of previous studies. ,,
Furthermore, we found that the greatest difference in almost all the four ROM occurred only between the two youngest and oldest age groups in both sexes with middle age groups showing no significant differences. Also, our results showed that spinal mobility was significantly different among all age groups and that the amount of range decreased in 18 years interval especially in anterior trunk flexion and right lateral trunk flexion in both sexes. In a similar study, Fitzgerald et al. found the same trend among all age groups and that the amount of ROM decreased in 20 years interval.  The results of this study indicated that ROM in females were slightly higher, but not statistical difference (P< 0.05), and they are more flexible than male participants in all ROM measurements recorded across all the age groups. The results of a previous study of adolescents from the ages of 10-15 years contradicted these findings, but found boys to be more flexible than girls in anterior flexion for each age group, although girls continued to be more flexible in lateral flexion than boys during adolescence.  Lateral flexion measurements for both right and left in both sexes showed a significant positive linear trend in almost all the age groups except between the age groups of 20-29 and 30-39 in both sexes and 40-49 and 50-59 in male while 50-59 and 60-69 in female for right lateral trunk flexion.
The participants in the study by Fitzgerald et al. were predominantly male patients in a Veteran Administration Hospital, whereas the participants in our study were healthy adults who met our inclusion criteria in all gender distributions. On this basis, we assumed that our results represented more accurately a general population of males and females with normal spinal ROM.
Our mean values, for example, anterior trunk flexion were within 4 cm of those reported by Macrae and Wright who also used the modified Schober method.  Specifically, our values for example for anterior trunk flexion in order of advancing age were 7.2, 6.8, 6.4, 6.2, 5.8, and 5.6 cm, respectively, for males and 7.0, 7.0, 6.5, 6.2, 5.9, and 5.7 cm, respectively, for females, whereas the values obtained by Macrae and Wright  were 6.6, 6.2 5.8, 5.5, 5.0, and 4.7 cm for women aged 21-71 years. Similarly, the results obtained by Einkauf et al. were 6.9, 6.0, 6.1, 6.3, 5.0, and 5.2 cm, respectively, for women aged 20-84 years. The similarity of the values from the three studies validated the reliability of this method as an objective technique for anterior trunk flexion. Although the reliability of this method appears to be high for most subjects, values obtained from obese subjects may not be as reliable for anterior trunk flexion as those obtained from nonobese subjects because the excessive amounts of subcutaneous fat and skin tissues in obese subjects make accurate location of bony landmarks difficult.
Our results uncovered that extension had the greatest decrease in ROM with age. One explanation for this notable decrease in extension is that it is performed less commonly in activities of daily living than anterior trunk flexion and lateral flexion. ,,,,,, However, older individuals demonstrated difficulty in performing extension, possibly because of abdominal and back muscle weakness, tightness of the hamstrings or a fear of losing their balance. These findings are supported by McKenzie's clinical observation where he stated "from my own observations it appears that few adults reach thirty years of age and maintain normal extension movements". 
When taking a patient's SMM, the clinicians should know what is considered for each motion based on the patient's age and sex. The observation is important to clinicians who have the primary role of instructing patients of all ages in proper body mechanism, good posture, and flexibility exercises for the lumbar spine. More research about spinal ROM is needed. We recommend the conduction of a similar study with a much larger sample size. The study should use a consistent method in both sexes to make inferences about the general population and determine the effects of body mass index. Another consideration should be the inclusion of spinal rotation as one of the movements.
The results of this study confirm that spinal mobility decreases with advancing age. Although, we assume we have described an acceptable clinical method for measuring SMM, we encourage further research on spinal ROM.
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[Table 1], [Table 2], [Table 3], [Table 4]