Sagittal balance: Population and physiotherapist knowledge, non-radiographic measurement and non-surgical intervention

There is evidence that the vertical alignment of the spine (sagittal balance) is associated with increased back pain and reduced quality of life. There is also emerging evidence that the “ideal” sagittal spinal curves are patient specific and depend on the morphological width of the pelvis. This is recognised by spine surgeons who have developed theoretical models to determine the ideal curves for restoration. Physiotherapists do not appear to have considered the relationship between pelvic morphology, sagittal curves, and sagittal balance and this may have contributed to diminished understanding of the potential links between posture and back pain in the profession. The aim of this thesis was to enhance the understanding of sagittal balance to inform the profession around its potential use in physiotherapy practice. The thesis included six projects. It identified gaps in the sagittal balance literature and provides novel findings with direct implications for surgeons, physiotherapists and patients. Firstly, there is a knowledge gap impacting physiotherapists, spine-surgeons and patients. Secondly, although several radiographic sagittal balance classification systems are being used, they require further development and validation for spine surgery as well as prior to consideration for adoption into the physiotherapy profession. Non-radiographic measurement tools are available and may with caution be used presently for the assessment of sagittal balance. Lastly, lumbar lordosis is an important factor associated with sagittal balance, but it is unclear if it is modifiable with conservative interventions. Given the impact of back pain on the burden of disease within society and the aging population, the findings described in this thesis can lay a foundation for future studies aimed at improving patient care for those with anterior sagittal balance.