Biomechanical Evidence: The complexity of human standing and its associated compensatory mechanisms

Virginie Lafage PhD Frank Schwab MD Jean-Pierre Farcy MD NYU Hospital for Joint Diseases, New York, NY

Human Standing Position

http://pmgagey.club.fr/

Balance
state of equilibrium; equal distribution of weight

Posture
relative disposition of the bodys parts

Stability
state or quality of maintaining equilibrium, selfrestoring

Biospace / ENSAM

Balance
[In a state of equilibrium ...] the body is positioned between two aligned, equal and opposite forces. [Brisson MJ, 1803]

Human Body
Gravity Force => Center of mass (COM) Ground Reaction => Center of Pressure (COP)

COM

Balance = COM & COP aligned on the same vertical

COP

Biospace / ENSAM

Stability
Body = moving parts
Perfect Alignment almost never reached Sophisticated Control System (NCS)

Two stabilization Strategies [Gagey]

COM Maneuver
Body parts motion Localize COM above COP

COM

COP Maneuver
Feet pressure distribution Localize COP below COM

Maintain Stability

COP

Dynamic Measurements
Stabilometry platform
Ground reaction measurements (COP) Over time (sample rates) Travel over time

Static Measurements
Pressure data obtained
Gravity Line (GL) = COP in static condition [Zatiorsky, 1998] Foot pressure distribution => foot location

Force Plate vs. X-rays Analysis

X-rays
Global alignment Spinal parameters Pelvis

Forceplate technology
Location
anatomical structures vs GL and Feet

Compensatory mechanisms
Pelvis (rotation / translation) Lower extremity feet

Sagittal Plane Analysis

Sagittal Imbalance

Adult Sagittal Imbalance

Degenerative Pathologic Iatrogenic

Remains poorly understood and challenging

Sagittal Imbalance
Glassman, Bridwell, Dimar, Horton, Berven, Schwab. SPINE 2005

Loss of global alignment

Plumbline shift anteriorly

=> Increasing disability

SF-12, SRS-29, ODI (p<0.001)

=> Lumbar kyphosis marked disability

SRS-29, ODI (p<0.05)

Compensatory Mechanisms
Lumbar lordosis modifications Pelvic retroversion Hip Hyper Extension Knee flexion

Clinical Group (Prospective IRB)

Inclusion criteria
131 Adults No Previous spine surgery Cobb angle < 20 C7 Frontal Imbalance < 5cm

Subdivision by SVA [Jackson, Spine 1994]

Sagittal Backward (Sb) Inclusion criteria (SVA) Mean SVA (cm) Number Mean age (year) Neutral (N) Sagittal Forward (Sf)

< -2.5cm -4.8 1.4 43 35 16

-2.5 => 2.5cm 0 1.6 51 51 18

> 2.5cm 8.2 4.8 37 68 17

Measurements
Simultaneous assessment of X-Rays and load distribution

1. Frontal & Sagittal XRays Free standing position

2. Load distribution

Measurements

3. Vertebrae and FH location on XRays

SpineView

4. Gravity Line (GL) and heel line projected on X-rays

=> Distance between GL, Heel line and anatomical points

Pelvic Parameters

Sacral Slope

Pelvic Tilt

Pelvic Incidence

PI = PT + SS

Results

Spinal parameters
Sagittal Backward (Sb) Neutral (N) Sagittal Forward (Sf)

Kypho (deg) Lordo (deg) SVA (mm)

-41 11 63 12 -45 17

-42 15 57 11 0 13

-51 20 50 13 80 50

With increasing SVA Kyphosis increases (Sf group vs. the 2 others) Lordosis decreases

Pelvic parameters
Sagittal Backward (Sb) Neutral (N) Sagittal Forward (Sf)

Sacral Slope Pelvic Tilt Incidence

38 9 10 7 48 10

36 10 16 6 52 9

35 10 21 8 56 11

With increasing SVA

No significant differences in Sacral Slope Pelvic Tilt increases Higher Pelvic Incidence (Sf group vs. the 2 others)

=> Differences in pelvic morphology and orientation

Forceplate parameters
S. Backward Neutral S. Forward

GL vs. Heels = constant Pelvis shifts posteriorly

Heels Line

Gravity Line

Conclusions
Gravity Line vs. Heel = Constant
Required to keep our standing position Age and spinal deformity do not affect this constraint By definition, the whole body mass is equally distributed around the gravity line

Young Adult

Conclusions
How to maintain balance if the trunk inclines forward ?
=> Body mass distribution should compensate trunk inclination to keep the GL within foot imprint

What do we know ? Pelvis shifts posteriorly Pelvic tilt increases Feet are fixed in standing position

Adaptation of lower extremities

Young Adult Hip flexion ? Knee flexion ? Ankle regulation ?

Force Plate Analysis

Permits essential quantification of foot position
Relationship feet / pelvis Offset of Gravity Line (GL)

If GL-heel offset is fixed.then a

balance formula

exists

Further quantification of spino-pelvic relationship necessary

Pelvic Incidence ?

Clinical Impact
X-rays offer only part of the story

Jean Dubousset, MD

S1 Fixed

Heels Fixed