|Year : 2015 | Volume
| Issue : 1 | Page : 23-27
The relationship between Lumbar range of motion with hamstring flexibility among 6-12 years children from South India: A cross-sectional study
Vaidehi C Varangaonkar1, Sailaksmi Ganesan2, K Vijaya Kumar1
1 Department of Physiotherapy, Kasturba Medical College, Manipal University, Mangalore, Karnataka, India
2 Department of Physiotherapy, The Institute of Neurological Sciences, Voluntary Health Services, Chennai, Tamil Nadu, India
|Date of Web Publication||13-Jan-2015|
K Vijaya Kumar
Department of Physiotherapy, Kasturba Medical College, Manipal University, Mangalore, Karnataka
Source of Support: None, Conflict of Interest: None
Background: Assessment and management of abnormal lumbar spine mobility are essential in the clinical setting. There are limited studies carried out to obtain lumbar range of motion values in children of the Indian population and to explore the anthropometric measurements on it. Purpose: The purpose was to find any association of anthropometric measurements, hamstring muscle length with lumbar range of motion in school age children from South India. Methodology: Active flexion, extension, and right- and left-side bending, and rotation of the lumbar spine were measured using modified Schober's test for 294 normally developing school going children 6-12 years (147 girls, 147 boys) from Mangalore, Karnataka, India. Means were determined for each motion by age and sex. Further, the correlation between spinal mobility and individual factors such as body mass index and hamstring flexibility was explored. Results: Females were identified as have a significantly higher forward flexion, lateral flexion, and rotation range of motion than males. Age, anthropometric parameters, and hamstring length were significant correlates of lumbar spinal mobility. Conclusion: This study provides the reference values for lumbar spinal flexibility in healthful school going children (6-12 years) from India. Females were found to have a considerably higher forward flexion, lateral flexion, and rotation range of motion than males. Age, anthropometric parameters, and hamstring length were significant correlates of lumbar spinal flexibility.
Keywords: Children, lumbar spine, range of motion, reference values, spinal mobility
|How to cite this article:|
Varangaonkar VC, Ganesan S, Kumar K V. The relationship between Lumbar range of motion with hamstring flexibility among 6-12 years children from South India: A cross-sectional study. Int J Health Allied Sci 2015;4:23-7
|How to cite this URL:|
Varangaonkar VC, Ganesan S, Kumar K V. The relationship between Lumbar range of motion with hamstring flexibility among 6-12 years children from South India: A cross-sectional study. Int J Health Allied Sci [serial online] 2015 [cited 2019 Sep 20];4:23-7. Available from: http://www.ijhas.in/text.asp?2015/4/1/23/149243
| Introduction|| |
The normal function or mobility of the adult mature spine is highly dependent on the process of growth and development in spine which results in maturation of individual spinal vertebra, spinal postures, which occurs during the developing child. This process of development and bone growth affected by numerous factors which further influences structure, function, and pathology of the vertebral column. , Lumbar spine mobility is a key feature of childhood as adequate back mobility helps the child to perform his/her daily activities. Previous studies demonstrate that lumbar spine mobility is greater in children than in adults. , Developmental factors may contribute to this observation ligamentous laxity,  strength, and length of spinal musculature, , and factors such as body mass index (BMI)  and length of muscles like hamstrings  can also have an effect on the mobility of the lumbar spine.
Quantifying spinal mobility is a beneficial component of the physical therapy examination process for both adults and children who experience limited spinal mobility as the result of spinal disorders or injury. Assessment and management of abnormal lumbar spine mobility are essential in the clinical setting. There are many methods for assessing lumbar spine mobility such as using radiographs,  a spondylometer (a type of protractor) and rotation using a rotameter,  Modified Schober's test,  inclinometer,  Back Range of Motion II device  etc.
In contrast to the literature on adults, mobility of the lumbar spine has received little attention in the literature on children. There are limited studies done to obtain normal lumbar range of motion values in children of Indian population and the effect of anthropometric measurements as it is noted as the difference in values for different countries. , Hence, this study aims at developing a reference values for active lumbar range of motion for school age children in Mangalore and its association with anthropometric values.
| Methodology|| |
This study was approved by Institutional Ethical Committee KMC, Mangalore, Manipal University. Permission from the Block Education Officer of Mangalore city was taken in order to select four schools from the list randomly. 294 children within the age group of 6-12 years (147 boys and 147 girls) were selected from two government schools and two private schools of Mangalore City from March 2010 to April 2011. Sampling was made according to stratified random sampling for age and gender. Permission from the school authorities to undertake the study was taken. A call for a staff member in each of the four schools to identify the target group. Parental consent form, subject assent form, and screening form were sent home with every 6-12-year-old children in four elementary schools.
A screening form with questions specific to each exclusion criterion was completed by the parent or guardian of each subject prior to admission to this study. Once the required forms were completed, and consent/assent was given, data collection was carried out during teacher approved, non-academic times within the school day. Children were screened according to the exclusion criteria included with any history of disorders or activity that may affect spinal posture or mobility, any history of diagnosed neurological or musculoskeletal disorder, any history of surgery confined to thoracic, lumbar or abdominal region, obese children (BMI >27.8 for males and BMI >27.3 for females)  and any history of low back pain.
The documentation of age (years, months, and days) from date of birth mentioned in admission certificate/school register, weight in Kilograms (kg) measured by calibrated weighing machine, height measured in centimeters (cm) by measuring tape was done. The lumbar flexion, extension, side bending, and rotation ranges were measured according to the procedure mentioned by modified Schober's test. The subject was requested to repeat each movement 6 times. First three repetitions served as a warm-up and as training for the movement. The mean of the next three readings was considered for data analysis. Rest period of approximately 1 min was given in between the trials.
Macrae and Wright (1969) modified the original Schober method by marking a point 5 cm below and 10 cm superior to the lumbosacral junction.  Later Moll and Wright (1976) suggested that the modified Schober method might be helpful for assessing lumbar extension by measuring the attraction of the skin marks as they approach each other during backward bending.  Several authors have reported the reliability and validity of lumbar measurements obtained by the modified Schober method. ,, hamstring muscle length was checked with the use of sit and reach test. 
| Measurements|| |
Anthropometric measurements included height, weight, BMI. Height needed to be measured to the nearest 0.1 cm with a height meter calibrated from 0 to 200 cm. The subject stood barefooted on the platform of the scale looking straight ahead while the horizontal bar attached to the height meter was set to touch the vertex of the head. Weight was measured nearest to the 0.5 kg on a bathroom weighing scale calibrated from 0 to 120 kg with the subject in minimal clothing, barefoot and standing in an erect posture looking straight ahead.
Procedure to measure range of motion by modified Schober's test
The modified Schober's test is used to measure the amount of flexion occurring in the lumbar spine. A point is marked midway between the two PSIS, which is the level of S2 then points 5 cm (2″) below and 10 cm (4″) above that level are marked. The distance between three points is measured, the patient is asked to flex forward and the distance is measured again. The difference between two measurements is an indication of the amount of flexion occurring in the lumbar spine. Similarly, the subject is asked to bend backward and the extension range is measured. To measure side flexion ranges, the subject is asked to bend sideways, and the distance between the tip of the middle finger and the ground is measured bilaterally. To measure the rotation ranges two points are marked, one on xiphisternum and other on T12. The distance between these two points is measured. Then the subject is asked to rotate and the distance is measured again. The difference between two measurements is the amount of rotation occurring in the lumbar spine.
Procedure to measure hamstring flexibility
The participants sat at the SR box and fully extended both legs so that the sole of the feet were flat against the end of the box. The hands were put on top of each other with their palms down.
The participants slowly reached forward while sliding their hands along the box scale as far as possible. Reading of the distance reached along the scale after the subject held the position for 2 s was recorded to the nearest centimeter. Average of three trials on each limb was recorded for analysis. The order of doing the test was in an uniform sequence. During the testing, verbal commands like "bend as far as you can" were given to the subject in order to gain a maximal effort.
Statistical Package for Social Science Version 13.0 [SPSS: An IBM Company] for Windows was used for analysis. Descriptive statistics was used to obtain normal values of lumbar ranges for each age group with 95% confidence interval based on mean and standard deviation (SD). Spearman's correlation coefficient was used to check the correlation between ranges obtained by Modified Schober's test, with BMI and hamstring length.
| Results|| |
[Table 1] summarizes the mean and SD of lumbar ranges using modified Schober's test. Results show similarity in the values of extension lumbar ranges of all the age groups of 6-12 years and lumbar side flexion (R and L) shows an increasing trend with age 6-12 years. The mean flexion, lateral flexion, and rotations of female participants were also higher than that of their male counterparts for all the age groups of 6-12 years.
|Table 1: Normative mean values of lumbar range of motion by modified schober's test|
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[Table 2] summarizes mean and SD values of the BMI and the hamstring length of the children. Findings were in agreement with the Indian norms for the respective age groups except for males whose BMI was more than the normal values.
|Table 2: Mean and SD of BMI & hamstring length according to age and gender|
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[Table 3] summarizes the correlation among age, modified Schober's test, BMI, and hamstring length. Results show a significant negative relationship observed between Age (r = −0.15, P < 0.05) and BMI with Lumbar rotation ranges (r = −0.15, P < 0.05) and also no correlation between hamstring muscle length and the Lumbar range of motion in the present study except in forward flexion with (r = 0.18, P < 0.05).
|Table 3: Correlation between modified schober's test, BMI & hamstring length|
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| Discussion|| |
The purpose of the present study was to establish the reference values for active lumbar flexion, extension, side bending, and rotation in school going children using modified Schober's test and to find any correlation between modified Schober's test with BMI and hamstring length. The anthropometric measurements such as height and weight of the subjects included in the present study were in agreement with the Indian norms for the respective age groups except for males whose BMI was more than the normal values. 
Several studies have been done to evaluate lumbar ranges of motion using different methods and for different age groups. ,,,, Clinicians prefer modified Schober's test to measure lumbar range of motion because of its easy procedure and feasibility. However, there are many potential errors affecting the values of lumbar ranges measured by the Modified Schober's method like occurrence of skin distraction in the absence of movement of underlying bony structures of T12 to S1 segments and sacrum, absence of sacral dimples etc.  Close examinations of patterns within the modified Schober's data reveals similarity in the values of extension lumbar ranges for all the age groups from 6 to 12 years. Extension, which may be limited by bony approximation,  has little variability within age groups or between sexes and decreases in small amounts with increasing age. ,
Results of the present study depicted that lumbar side flexion (R and L) shows an increasing trend with age 6-12 years. Haley et al.  measured lumbar side flexion ranged using the tape method and suggested an increase in ranges of the lumbar spine with an increase in age, which was similar to the results of the present study. The result of this study revealed that the mean flexion, lateral flexion, and rotations of female participants were significantly greater than that of their male counterparts. These results are in agreement with previous studies that suggest that females are more flexible than males. ,
In addition to structural differences, males appear to have greater stiffness and decreased segmental motion in the lumbar spine compared to females,  however, Mellin and Poussa (1992)  who found no significant differences in forward flexion of the lumbar spine between male and female our study found there is a difference in forward flexion between male and female. Although conclusive evidence is lacking, several factors, including anatomical and physiological differences, may account for the difference in flexibility between the sexes. Additional factors could be smaller muscle mass, joint geometry, and gender-specific collagenous muscle structure. 
This study investigated the correlation between spinal flexibility and individual factors. From the result, there was an important inverse relationship between age and lumbar rotations both right and left. This result is in agreement with previous reports that flexibility decreases with advancing age. ,
Alter (1996)  submitted that the inverse relationship between age and flexibility is due to the age-related physiological changes in the connective tissues. These changes causes an increased in the amount of calcium deposits, adhesions, and cross-links in the body, an increase in the level of fragmentation and dehydration, changes in the chemical structure of the tissues, loss of suppleness due to the replacement of muscle fibers with fatty, and collagenous fibers. Furthermore, certain anthropometric measures were found to be substantially related to flexibility in this study. A significant direct relationship was observed between BMI and lumbar rotation ranges and also no correlation between hamstring muscle length and the lumbar range of motion in the present study except in forward flexion. Esola et al. found that Forward Bending motion occurs mainly at the hips, with a 2:1 ratio of lumbar spine to hip motion between 0° and 30°, building to a 1:2 ratio between 60° and 90°.  This means it is likely that hamstring is most influential when approaching the end of pelvic rotation range. Results of the present study were comparable to the previous study  investigating the relationship between hamstring flexibility and pelvic rotation during forward bending in healthy individuals which concluded that decreased hamstring flexibility was observed with limited movement of the lumbar spine.
The limitations of the present study were children who participated in the study lived within similar geographic location so Normal values of lumbar ranges obtained in the present study may not be generalized to all Indian children; the therapist was not blinded while reading the measurements during the study due to manpower constraints; For proper mobility of the spine, adequate trunk muscle strength is very important. Studies have shown that mobility and strength are inter-dependent on each other which means if mobility is hampered it has a direct impact on the strength of the trunk muscles.  Trunk muscle weaknesses may lead to altering curvature thus reducing mobility hence relationship between core muscle strength, and lumbar mobility should be addressed.
These normative data contribute to a better knowledge of the flexibility behavior with age and gender are able to be useful for professionals who assess flexibility in their professional practice. Normative values of lumbar range of motion for children from 6 to 12 years of age were established in the present study which can be used as a baseline for evaluation and monitoring progress during periods of physical therapy intervention.
| Conclusion|| |
This study established a set of reference values for lumbar spinal flexibility in healthful school going children (6-12 years) from India. Females were found to have a considerably higher forward flexion, lateral flexion, and rotation range of motion than males. Age, anthropometric parameters, and hamstring length were significant correlates of lumbar spinal flexibility.
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[Table 1], [Table 2], [Table 3]
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