Shape Shifting Lens
The existing evidence suggests that a shape-shifting bi-directional
association exits between posture and QOL in youth with scoliosis (aged
8 to 21 years) and adults with osteoporosis (over age 50
years).15 If this remains true in children with
cancer, a child’s QOL could be evaluated with a simple, non-invasive
clinical measurement tool. The inclinometer may avoid otherwise
unnecessary spinal radiographs, and may be more feasible to collect in
children with cancer evidenced by the completion rate in our study for
the inclinometer measure (68%) was higher than the child report on the
PedsQL questionnaire (60%).12
While four studies demonstrated consistently that kyphosis is modifiable
with exercise,8,31-33 two of the studies supported
that the improvement in kyphosis was in fact accompanied by improved
QOL,8,32 a finding not explained by the known
improvement in QOL with exercise. Perhaps this concept could be
generalized to children with temporary kyphosis due to the effects of
cancer and its treatment, whereby measurement of kyphosis over time
could be a simpler measure of QOL to more easily tailor supportive care.
Furthermore, the scoliosis studies showed that measurement of kyphosis
is feasible in the pediatric population, and perhaps the more malleable
spines in children without orthopedic disorders could show improvement
in kyphosis with improved QOL with cancer treatment. This concept was
supported by a recent RCT in children with cystic fibrosis. Although the
investigators did not include QOL as an outcome, rendering it ineligible
for inclusion here, they demonstrated improved posture with a physical
exercise intervention.35 If kyphosis is modifiable,
even in elderly adults and patients with orthopedic disorders, and
tracks with QOL, it could be an appropriate surrogate measure showing
the impact of QOL interventions.
In shape-shifting contrast, the behavioral studies consistently
demonstrated an inverse association between QOL (as depression or mood)
and posture. Three of the studies used behavioral techniques to evoke
positive and negative emotions to demonstrate the
association.26,29,30 Additionally, these three studies
further supported that by measuring thoracic kyphosis, the assessment of
a child’s mood (as an aspect of QOL) could be measured with an
inclinometer.36 Similarly, we found correlation
between mood measured by the Faces scale and the posture measure in our
study in children with cancer (β = 0.26).12 The
finding of a statistically significant correlation with a strong effect
size between depression and shoulder inclination may also be highly
clinically useful.23 If mood is related to posture in
older women with osteoporosis, perhaps this finding can be replicated in
children with cancer. Indeed, our prospective study did confirm this
concept without a significant difference between males and females,
specifically in children with cancer.12
The bi-directional relationship between QOL and posture are
bi-directionally could be explained physiologically by established
connections between the limbic system, shown to govern emotional
response, and the postural response seen in major depression. This was
recently supported in a study of electroconvulsive therapy for
depression and the effects on the neuroplasticity of the limbic system
in the brain where brain volumes increased significantly related to
symptom improvement (p < .01).37 Similarly,
the field of rehabilitation medicine has used the Bobath practice model
based in neuroscience to integrate posture by evaluating critical client
cues such as postural alignment on the outcomes of pain and function
(but not QOL) in the recovery from stroke and spinal cord
injury.38