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Pressure ulcers are localized damage to the skin from an applied force over a period of time. The
applied pressure, if not treated, will aggregate blood cells as well as damaging capillaries, which
causes necrosis and cell destruction. In adults, ulcers are most likely to develop in the sacrum
and heel regions. In children, especially those 12 months or younger, ulcers may occur within the
scalp region. Despite recent pediatric recommendations promoting pressure distribution
surfaces, few studies exist assessing peak pressure points in children and methods to prevent
pressure ulcer development. Thus, the objectives of this pilot study were to: i) Identify the
location of peak pressure and corresponding contact area while children (age 3-5) lay supine; ii)
Assess the differences in peak pressure/contact area between two surfaces (crib mattress/yoga
mat); iii) Determine correlation between peak pressure and child weight.
Preliminary results indicate the peak pressure point for children is at the scalp region opposed to
the sacrum/heel in adults. Higher peak pressure over a smaller contact area is present on the
yoga mattress compared to the crib mattress.

I. Introduction

Pressure ulcers, commonly known as bedsores, are defined as localized damage to the

skin and underlying tissue over any bone prominence, including the joint region such as the heels

or elbows. Applied pressure is the amount of force placed on an object perpendicular to the its

surface area (Curley). Pressure can be monitored through redistribution-surfaces, such as

pressure mattresses, that can visually indicate regions via color coding or numerical values.

There have been many studies related to ulcer development in adults, some in which define

maximum loads before injury or prominent development regions; however, there is a lack of

evidence to suggest both the maximum load of applied pressure before injury and the location of

pressure points in infants.

Pressure Ulcer Development:

As mentioned previously, pressure ulcers are defined as localized damage to the skin over

bony prominences. If not treated, the applied pressure will lead to blood cell aggregation,

damage to capillary walls of the skin, and necrosis/cell destruction (Wounds International).
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Figure 1. Tissue Distortion due to pressure (Source:

According to Figure 1, pressure development occurs when an external force created by

contract with a surface causes skin tissue to press up against a bony prominence. The pressure

created from the bone causes three stresses to occur: (i) shear, (ii) tensile, (iii) compression.

Shear stress is defined as the parallel force applied to the skin’s surface, in other words, it is the

amount of friction applied on the skin tissue. Tensile stress, or tension, is the perpendicular force

in the skin which occurs during this state of contact. And lastly, compression stress is the applied

force between both surface and bone. All three stresses cause the skin to stretch and break down

as the pressure load increases or remains constant over an extended period of time (Curley).

According to the article Pressure Ulcers in the Surgical Patient by Drs. Susan Shoemake and

Kathleen Stoessel, the amount of pressure exceeding approximately 32 mmHg (millimeters of

Mercury), or 0.618777 psi (Pound-force per Square Inch), to the skin places an adult patient at

high risk to ulcer development.

For adults, common ulcer development occurs mainly in the lower regions of the body.

These regions include the sacrum, heels, knees, ankles, and even in upper joint areas such as the

elbows or shoulders. Both the joint and sacrum regions are known for their larger bony
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prominences, and due to the large amount of activity most adults partake in, various amounts of

pressure are applied daily to the skin (Allman, Goode, Burst, Bartolucci, & Thomas). Ulcer

development can also be attributed to the level of comfort applied towards these mentioned

regions; for example, if an individual were to sit on a surface that they would deem

uncomfortable for over a certain period of time, they would experience soreness in their sacrum

region, that if not treated, could lead to pressure ulcers.

For children, mainly infants, pressure injuries mainly occur in the developmental regions:

the scalp and the sacrum. Since infants mostly remain immobile for the first few months of their

lives, it is important for the parent to monitor the position of the infant at all times. The infant

shouldn’t always remain lying down on its back since the amount of pressure over time will

cause injury towards the head. Also, when lying on its back for a long period of time, the head

should remain propped up on a soft, yet firm surface to ensure comfort and reduce any

deformities from occurring (Razmus et. al, 2001).

Other known causes of pressure ulcer development can occur due to a patient’s

compromised mobility. Having impaired mobility can lead to difficulties reliving interface

pressure, resulting in impaired circulation of the skin and ulcer formation. The use of medical

casts or braces can also lead to ulcer development due to the excessive amounts of applied

pressure/circulation occurring in the body. If not relieved on a regular basis, there will be a

substantial risk of ulcer formation. Lastly, patients with poor tissue integrity are also known to

have a low tolerance to various loads of applied pressure, leading to possible ulcer development

(Allman, Goode, Burst, Bartolucci, & Thomas).

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Pressure Redistribution Mattresses:

To help diagnose regions of potential ulcer development, specialized redistribution

surfaces are used. These surfaces are designed to both monitor these regions and prevent

pressure related injuries via redistribution. There are two specified categories for pressure

redistribution surfaces: static and dynamic. In a review written by Madhuri Reddy (2006), he

defines static pressure redistribution surfaces as mattresses or mattress overlays that are filled

with air, water, mesh, or gel (sometimes a combination of these elements). Meanwhile, a

dynamic support surface helps mechanically vary the distribution of pressure based on the

applied pressure from the patient. The most famous example of this dynamic support surface is

the alternating pressure mattress which produces both high and low pressures between both the

patient and surface to diminish any instances of high pressure.

This research focuses on static pressure redistribution for the following reasons. Static

redistribution surfaces offer a variety of comfort levels towards a patient, especially infants, that

are proven to be safe. Soft bedding surfaces, such as sheep skin or cloth, are beneficial towards

infants due to their softness and low-risk of inhaling fabric particles or other toxins that could

come from other surfaces or blankets. Dynamic surfaces, such as low-air pressure mattresses,

have been shown to give a high risk towards skin breakdown, especially when turning, in some

pediatric studies. To prevent such a risk from occurring, it is recommended to turn the infant

patient every 1-2 hours, which ultimately limits the effectiveness of a dynamic surface (McCord

et. al).

The goal of this research is to conduct a pilot study that identifies the pressure points of

children lying on two different mattress surfaces, a crib and yoga mattress. While performing this

study, predictions were made that there will be a correlation between the amount of contact
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pressure and the child’s weight, as well as the highest amount of contact pressure being present

in the head region for children 5 years of age or younger.

The data was obtained via pressure sensor (Tekscan 5400N) and the Tekscan Body

Pressure Measurement System (BPMS) research software, measuring out the amount of pressure

(mmHg) and contact area (in2). An approved IRB form was given for each participant, assuring

their safety and full knowledge of this study.

II. Methodology

To obtain pressure data, this study utilizes different mattress surfaces, a pressure sensor,

and a pressure measurement program (BPMS) for analysis. Child participants would lie on top of

the mattress while the sensor retrieved their pressure data. This data is further extracted and

analyzed via Microsoft Excel.


The conducted study focuses on the use of two mattress surfaces to measure a difference

of recorded contact pressure. The first mattress used was the “Heavenly Dreams White Crib and

Toddler Mattress” by Safety 1st. This mattress weighs approximately 50 lbs., and measures at

52.5” x 27.5” x 5.5” according to its product description via Amazon. The purpose for using this

mattress is to demonstrate possible amounts of contact pressure experienced on a child while

sleeping in a bed. The second mattress was a yoga mattress by the company Series-8 Fitness.

This mattress is somewhat thicker than standard yoga mats for added comfort, as stated by the

packaging, and measures at 24” x 68” x 0.1969”. The purpose for using the yoga mattress in the

study was to obtain the highest amount of contact pressure possible as the child would lie closest

to the floor. On top of these mattresses is the applied pressure sensor, the Tekscan 5400N, that

measures out the contact pressure and the contact area.

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Tekscan 5400N and BPMS:

The method of measurement for pressure and contact area will come from a medical

sensor from the company Tekscan, known as the Medical Sensor Model 5400N Body Pressure

Measurement System (BPMS). Table 1 below displays its technical information, while Figure 2

displays the layout of the sensor.

Overall Overall Tab Matrix Matrix Columns Rows

Length Width Length Width Height Pitch Pitch Spatial
CW RW No. of
L W A MW MH CS Qty. RS Qty. Sensels Resolution
(mm) (mm) (mm) (mm) (mm) (mm)
(mm) (Sen/𝒄𝒎𝟐 )

1060.0 640.0 120.0 578.0 884.0 10.0 17.0 34 10.0 17.0 52 1,768 0.3
Table 1. Medical Sensor 5400N (Tekscan) Parameters

Figure 2. 5400N Sensor Layout (Source:

These parameters help define the 5400N sensor. This sensor can withstand applied

pressure up to approximately 4,861 mmHg (millimeters of Mercury). There are approximately

1,768 sensels (or sensor cells) placed within the sensor as shown in Figure 2 above. Since a

single sensor only covers roughly half of the mattress, another sensor was purchased to help
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cover the full body. Data from both these mattresses are merged on the BPMS CONFORMat

program via the program’s settings.

Tekscan’s Body Pressure Measurement Software was used to obtain the pressure and

contact area data. Using two 5400N CONFORMat sensors and their connector ports (as shown in

Figure 3), the program records pressure data in real-time at a sampling rate of 10 Hz/s or 22,880

sensel data/s, and saves pressure data within a program compatible video file.

Figure 3. CONFORMat USB connectors for 5400N sensors

The pressure mapping can be further analyzed by selecting different areas of the body

with a customized window (sample shown in Figure 4A). The data is then taken from each

individual region and put into graphical form (seen in Figure 4B), with the option to further

extract it into data analysis programs such as Microsoft Excel.

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(A) (B)
Figure 4. (A) Sample Peak Pressure Data; (B) Sample Body Map

These figures were used to extract pressure and contact area per selected region. The

regions analyzed for this study are the head, back, sacrum, both elbows, and both heels. Since the

analyzed data is raw, a moving average was applied in the extracted Excel files to filter out any

possible outliers and to give an accurate measurement of high peak pressures per region.

Experimental Design:

With the consent of the participants, measurements such as height, weight, and other

regions were taken to help calibrate the sensitivity of the 5400N sensors (see Appendix A for

measurement diagrams). Calibrating the sensors towards the subject’s weight helps assure

accurate measurements for both peak contact pressure and the contact area. The pressure sensors

were placed inside a mattress cover, provided by Tekscan, and were set atop the mattresses (see

Figure 5).
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Figure 5. 5400N Mattress Cover with Marked Areas

Figure 5 displays the cover used in this study. The marked areas display the regions

where participants had to lie in. The two outermost regions were used to indicate how far out the

hands and elbows should lie so the 5400N sensors can pick up the pressure data, while the

middle region is where the participant should lie on. After measurements were made, a quick

calibration test was done by having the subject lie on and off the mattress for 60 seconds. Once

the sensitivity is set, the subject was tasked to lie on the mattress for approximately 10 to 30

seconds (each 0.6 seconds being a frame of data). This process was done for both mattresses due

to the differences in surface area and applied pressure when recorded.

Data Analysis:

The extracted data was analyzed through the Microsoft Excel program. Since the data

was raw, a moving average was applied to remove outliers and to ensure accuracy of the peak

pressure and contact area. After filtering the dataset, the maximum and means of each region was

calculated and then compared per subject. Overall averages for both the max and mean data was

given and further compared between both mattress surfaces. Furthermore, the correlation

between the subject’s weight and the contact peak pressure was also analyzed and compared,

finding the line of best fit.

III. Results
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Four children participated in this study, with an age ranged from 3 to 5 years old (4 years

old on average). Specific subject data is shown in Table 2, while body measurements is given in

Figure 6.

Table 2. Subject Background Information

Subject # Date DOB Age Sex
1 6/19/2018 11/5/2012 5 M
2 6/19/2018 11/5/2012 5 F
3 6/19/2018 10/26/2014 3 F
4 6/19/2018 10/26/2014 3 F













Figure 6. Subject Measurements in Various Regions

Figure 6 compares measurements of the selected regions for all four subjects. While the

subject’s weight is vital in terms of calibrating the mattress’s sensitivity, these other

measurements feature the prominent areas in which the pressure points exist.

After these measurements were made, participants lied on top of the pressure sensor for

approximately 10-30 seconds and their data was extracted focusing on the following regions of

peak pressure and contact area: head, back, sacrum, elbows, and heels. The maximum and mean

values for all frames of data in each boxed region were calculated and compared between all
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participants in the study. The purpose of comparing both the max and mean data for each subject

per region was to identify a common region of highest peak pressure. In Figure # below, the

average values (peak pressure and contact area) between all four subjects were compiled and

compared between both mattresses for both the maximum and mean values for each region.

Mean Subject Peak Pressure (n = 4) Max Subject Peak Pressure (n = 4)

Crib Yoga Crib Yoga
120 120

100 100
Peak Pressure (mmHg)

Peak Pressure (mmHg)

80 80

60 60

40 40

20 20

0 0
Sacrum Chest Head Left Left Heel Right Right Sacrum Chest Head Left Left Heel Right Right
Elbow Elbow Heel Elbow Elbow Heel
Regions Measured Regions Measured

Mean Subject Contact Area (n = 4) Max Subject Contact Area (n = 4)

Crib Yoga Crib Yoga
60 60

50 50
Contact Area (in^2)
Contact Area (in^2)

40 40

30 30

20 20

10 10

0 0
Sacrum Chest Head Left Left Heel Right Right Sacrum Chest Head Left Left Heel Right Right
Elbow Elbow Heel Elbow Elbow Heel
Regions Measured Regions Measured
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Figure 7. Subject Peak Pressure and Contact Area (Mean and Max)

After examining the maximum and minimum values per region, the correlation between

peak pressure and weight was observed. Each region was examined for all four participants

between each of the different mattresses. Like previous, both the maximum and mean values

were compared. Figure 8 A-B below includes the highest regions of peak pressure, the head and

sacrum, for both the crib and yoga mattress.

Correlation of Weight and Peak Correlation of Weight and Peak

Pressure on Head (Mean, Crib) Pressure on Sacrum (Mean, Crib)
80 35
4 1
70 1 30
Peak Pressure (mmHg)
Peak Pressure (mmHg)

3 25 2
2 20 3
20 y = 0.9323x + 26.41 y = 0.3297x + 16.494
10 R² = 0.1773 5 R² = 0.0372
0 0 Max Subject Contact Area (n = 4)
0 10 20 30 40 50 0 10 20 30 40 50
Weight (lbs.) 60 WeightCrib
(lbs.) Yoga

Correlation of Weight and Peak 50 Correlation of Weight and Peak

Pressure on Head (Mean, Yoga) Pressure on Sacrum (Mean, Yoga)
Contact Area (in^2)

120 70 40
4 60
1 30 1
Peak Pressure (mmHg)

Peak Pressure (mmHg)

80 3 20 y = 2.7087x - 56.503
2 40
R² = 0.8792 43
10 2
40 y = -0.434x + 102.89
20 0
R² = 0.0098 Sacrum Chest Head Left Left Heel Right Right
20 Elbow Elbow Heel
Regions Measured
0 0
0 10 20 30 40 50 0 10 20 30 40 50
Weight (lbs.) Weight (lbs.)
Figure 8A. Correlation of Weight and Peak Pressure (Mean Data)
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Correlation of Weight and Peak Correlation of Weight and Peak

Pressure on Head (Max, Crib) Pressure on Sacrum (Max, Crib)
80 40
4 1 4 1
Peak Pressure (mmHg)

Peak Pressure (mmHg)

60 30
50 2 2
40 20
30 15
20 10
y = 0.4315x + 49.913 y = 0.2543x + 20.759
10 5
R² = 0.0342 R² = 0.022
0 0
0 10 20 30 40 50 0 10 20 30 40 50
Weight (lbs.) Weight (lbs.)

Correlation of Weight and Peak Correlation of Weight and Peak

Pressure on Head (Max, Yoga) Pressure on Sacrum (Max, Yoga)
120 70
4 1 60
100 1
Peak Pressure (mmHg)
Peak Pressure (mmHg)

y = 3.1399x - 69.913
3 50
80 R² = 0.872
2 40 3
60 4 2
y = 0.4061x + 81.31
20 10
R² = 0.0072
0 0
0 10 20 30 40 50 0 10 20 30 40 50
Weight (lbs.) Weight (lbs.)

Figure 8B. Correlation of Weight and Peak Pressure (Max Data)

IV. Discussion
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The obtained data demonstrates the possibility of peak contact pressure a child can

experience when active or inactive in their daily lives. In Figure 7, all four subjects on average

experienced higher peak contact pressure while lying down on the yoga mattress in every

measured region. The highest region of peak pressure occurred in the head, followed by the

sacrum on both the crib and yoga mattresses. The contact area in each region was higher on the

crib mattress, this was because contact pressure is widely and evenly distributed on a thicker,

more comfortable surface than on the yoga mattress, where contact pressure was more direct

towards the ground. This supports the hypothesis of the head region experiencing the highest

amount of peak contact pressure in a child’s body.

With the correlation between child weight and contact pressure, seen in Figure # A and

B, the head and sacrum regions had the highest correlations compared to the others which were

significantly low. Looking through both the max and mean datasets, the highest possible

correlation achieved was in the sacrum region when the child lied down on the yoga mattress

(Figure 8A displays this in the bottom right graph). This also supports the given hypothesis for

this pilot study.

The correlation between an individual’s weight and the contact pressure they experience

with any surface is a common study, especially when developing comfort-based products.

Products such as foot inserts exist to reduce discomfort in shoes while walking and to prevent

any skin or muscle breakdown in the heels. In a study titled “The impact of increasing body mass

on peak and mean plantar pressure in asymptomatic adult subjects during walking” by John B.

Arnold and his research team, pressure data was obtained using three different types of stances

while walking with weighted vests (0 – 15 kg). This research examined several regions of the

foot: hallux, the toes, all five metatarsals, the midfoot, and the heel. As hypothesized, the applied
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pressure increased in all regions when more weight was applied. Although this research was

aimed towards observing heel contact pressure in both diabetics and non-diabetics, the

correlation between the two factors helps support this pilot study.

Moving Forward:

This study can be expanded upon for future research utilizing different factors as well as

expanding upon the ones already included. Different surfaces that the child can lie on can be

considered, such as the use of foam, gel, or air mattresses. Each of these surfaces are known to

have different methods of pressure distribution and their contribution towards the subject’s

overall peak contact pressure can vary tremendously. Having a wider participant age range, from

infancy to early grade school (approximately 7 years), can also impact the weight/pressure

correlation and with more participants comes a larger variety in obtained measurements.

Other examinations can revolve around types of posture and positioning of an infant. In

the research article, Infant trunk posture and arm movement assessment using pressure mattress,

inertial and magnetic measurement units (IMUs) by Andraz Rihar and his research team, their

goal was to examine the kinetics of the arm and trunk of an infant when placed on a pressure

mattress. This research involved the use of multiple IMUs (inertial measurement unit), pressure

sensors, and infrared LED cameras, to focus on obtaining information for non-invasive sleep

patterns as well as posture assessment that can lead to preventing ulcer development. The setup

was very complex, since placement of the IMUs were very precise and having a living subject

was noted to have its difficulties; however, having several methods of data collection can lead to

much more accurate results.

V. Conclusion
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Skin injuries, mainly pressure ulcers, are developed from increased loads of force from a

surface over a bony prominence for a discrete period of time. Pressure points can be analyzed

and identified through redistribution surfaces and various medical sensors. Identifying these

regions for infants benefit pediatric studies tremendously, leading to the prevention of skin

breakdown and recognizing potential discomforts in posture. In turn, these benefits also lead to

the effectiveness of pressure mattresses for infants, especially those with weaker skin integrity,

and create industry standards for pediatric healthcare.

Works Cited:

[1] Allman, R. M., Goode, P. S., Burst, N., Bartolucci, A. A., Thomas, D. R. (1999). Pressure

ulcers, hospital complications, and disease severity: impact on hospital costs and length

of stay. Advances in Wound Care: The Journal for Prevention and Healing 12, 22-30.

[2] Arnold, John B. et al. “The Impact of Increasing Body Mass on Peak and Mean Plantar

Pressure in Asymptomatic Adult Subjects during Walking.” Diabetic Foot & Ankle 1

(2010): 10.3402/dfa.v1i0.5518. PMC. Web. 19 July 2018.

[3] “Body Pressure Measurement System (BPMS)”. Tekscan. 2018. Web. 14 April 2018.



[4] Curley, M. A. Q., Razmus, I. S., Roberts, K. E., & Wypij, D. J. (2003). “Predicting pressure

ulcer risk in pediatric patients”. Nursing Research, 52(1), 22-33.


[5] “International review. Pressure ulcer prevention: pressure, shear, friction and microclimate in

context – A consensus document”. London: Wounds International, 2010. Web. 8 April

2018. <>.
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[6] “Medical Sensor 5400N - Pressure Mapping, Force Measurement, and Tactile Sensors.”

Tekscan. Product. Web. 2018. <


[7] “Pressure Mapping for Test & Design”. Tekscan. 2018. Web. 10 April 2018.


[8] Razmus, I. S., Roberts, K. E., & Curley, M. A. Q. (2001). Pressure Ulcers in Critically

Ill Infants and Children Incidence and Associated Factors. Critical Care Medicine, 29

supp, A148

[9] Reddy M, Gill SS, Rochon PA. Preventing pressure ulcers; A systematic review. JAMA.

2006;296:974-984. <rmatology/main03.htm.htm>.

[10] “Research Software”. Tekscan. 2018. Web. 14 April 2018.


[11] Rihar, Andraž et al. “Infant Trunk Posture and Arm Movement Assessment Using Pressure

Mattress, Inertial and Magnetic Measurement Units (IMUs).” Journal of

NeuroEngineering and Rehabilitation 11 (2014): 133. PMC. Web. 23 Apr. 2018.


[12] Sharp, Catherine, and Mary-Louise McLaws. “A discourse on pressure ulcer physiology:

the implications of repositioning and staging.” World Wide Wounds. October 2005. Web.

8 April 2018. <


[13] Shoemake, S., & Stoessel, K. (2007). Pressure ulcers in the surgical patient. Knowledge

network: Kimberly-Clark health care education. Retrieved from

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[14] Siddiqui et al. “A Continuous Bedside Pressure Mapping System for Prevention of Pressure

Ulcer Development in the Medical ICU: A Retrospective Analysis”. WOUNDS


[15] Stinson, AP Porter-Armstrong and PA Eakin. “Pressure mapping systems: reliability of

pressure map interpretation”. Clinical Rehabilitation 2003; 17: 504–511.

Citation of Figures:

[1] “International review. Pressure ulcer prevention: pressure, shear, friction and microclimate in

context – A consensus document”. London: Wounds International, 2010. Web. 8 April

2018. <>.

[2] “Medical Sensor 5400N” Tekscan. Product. 3 April 2018.

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Section A – Body Measurement Visual Guide:

(A) (B) (C)

(D) (E) (F)

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(G) (H) (I)

Appendix Figure A-1. Body Measurement Postures Guide

Source: Yellow Springs Webb Associates. Anthropometric source book. 1. Anthropometry for
designers. NASA, 1978.

These figures, provided on the IRB consent form for each participant, demonstrates the

appropriate measures taken to help assure calibration of the pressure sensor and for correlation

data. Each region of the figure (labeled A – I) is identified and given a short description of the

measurement in question. This is listed below.

Measurement Regions:

(A) Weight – subject body weight measured on a physical scale

(B) Stature – vertical distance from the surface to the subject’s head, with the subject facing

(C) Acromial Shoulder Height – vertical distance from surface to the top of the subject’s
lateral shoulder area

(D) Waist Height – vertical distance from surface to the waist landmark

(E) Tibiale Height – vertical distance from the surface to the subject’s proximal medial
margin of the tibia (knee)

(F) Thumb-Tip Reach – horizontal distance from the subject’s back against the wall, to the
tip of their thumb when reaching straight out

(G) Shoulder-Elbow Length – distance from the top of the acromion process to the bottom
of the elbow; subject sits erect with the arms placed vertically and the hands extending

(H) Forearm-Hand Length – using the same position as demonstrated in F, the distance
from the tip of the elbow to the tip of the longest finger of the hand

(I) Head Circumference – maximum circumference of head, above the brow ridges

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