Journal of Biomechanics 79 (2018) 248–252

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Journal of Biomechanics
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Short communication

Between-session reliability of opto-electronic motion capture in

measuring sagittal posture and 3-D ranges of motion of the
thoracolumbar spine
Seyed Javad Mousavi a,b, Rebecca Tromp a, Matthew C. Swann a, Andrew P. White a,b,
Dennis E. Anderson a,b,⇑
a
Beth Israel Deaconess Medical Center, Boston, MA, United States
b
Harvard Medical School, Boston, MA, United States

a r t i c l e i n f o a b s t r a c t

Article history: This study evaluated between-session reliability of opto-electronic motion capture to measure trunk pos-
Accepted 29 August 2018 ture and three-dimensional ranges of motion (ROM). Nineteen healthy participants aged 24–74 years
underwent spine curvature, pelvic tilt and trunk ROM measurements on two separate occasions. Rigid
four-marker clusters were attached to the skin overlying seven spinous processes, plus single markers
Keywords: on pelvis landmarks. Rigid body rotations of spine marker clusters were calculated to determine neutral
Trunk posture and ROM in flexion, extension, total lateral bending (left-right) and total axial rotation
Kinematics
(left-right). Segmental spine ROM values were in line with previous reports using opto-electronic motion
Motion analysis
Repeatability
capture. Intraclass correlation coefficients (ICC) and standard error of measurement (SEM) were calcu-
Spine curvature lated as measures of between-session reliability and measurement error, respectively. Retroreflective
markers showed fair to excellent between-session reliability to measure thoracic kyphosis, lumbar lordo-
sis, and pelvic tilt (ICC = 0.82, 0.63, and 0.54, respectively). Thoracic and lumbar segments showed highest
reliabilities in total axial rotation (ICC = 0.78) and flexion-extension (ICC = 0.77–0.79) ROM, respectively.
Pelvic segment showed highest ICC values in flexion (ICC = 0.78) and total axial rotation (ICC = 0.81) trials.
Furthermore, it was estimated that four or fewer repeated trials would provide good reliability for key
ROM outcomes, including lumbar flexion, thoracic and lumbar lateral bending, and thoracic axial rota-
tion. This demonstration of reliability is a necessary precursor to quantifying spine kinematics in clinical
studies, including assessing changes due to clinical treatment or disease progression.
Ó 2018 Elsevier Ltd. All rights reserved.

1. Introduction Opto-electronic motion capture systems have been used to

Spinal disorders remain common and costly complaints in clin-
ical practice (Martin et al., 2008). Various disorders, including back
pain, developmental disorders, vertebral fracture, and spinal steno-
sis, impact trunk posture and kinematics (Christe et al., 2017; Chun
et al., 2017; Kuwahara et al., 2016; Schmid et al., 2016). Therefore,
objective evaluation of trunk posture and motion can help in
assessing the functional impact of spinal disorders (e.g. diagnosis
of segmental instability, assessment of spine mobility), and in the
development and evaluation of evidence-based treatments for
spinal disorders (e.g. surgical planning, tracking rehabilitation
progress).
⇑ Corresponding author at: 330 Brookline Ave, RN115, Boston, MA 02215, United
States.
E-mail address: danders7@bidmc.harvard.edu (D.E. Anderson).
measure trunk posture and motion (Hidalgo et al., 2012; Ignasiak
et al., 2017; Marich et al., 2017; Nairn et al., 2013; Preuss and
Popovic, 2010; Rast et al., 2016; Schmid et al., 2016), but there is
no preferred or standardized method. Establishing motion capture
reliability in assessing three-dimensional spine position would
facilitate its use in clinical studies and clinical trials. A few studies
have reported between-session reliability of motion capture in
measuring trunk posture (Dunk et al., 2004, 2005; Muyor et al.,
2017) and range of motion (ROM) (Hidalgo et al., 2012;
Montgomery et al., 2011; Rast et al., 2016). However, none of these
utilize marker clusters applied to the spine, which are needed for
appropriate assessment of three-dimensional motion including
evaluation of non-sagittal and coupled motions of the spine. Fur-
thermore, only one study has examined within-session reliability
of motion with marker clusters on the spine (Schinkel-Ivy et al.,
2015). Therefore, the aim of this study was to measure thoracic

https://doi.org/10.1016/j.jbiomech.2018.08.033
0021-9290/Ó 2018 Elsevier Ltd. All rights reserved.
 S.J. Mousavi et al. / Journal of Biomechanics 79 (2018) 248–252
kyphosis (TK), lumbar lordosis (LL), and pelvic tilt (PT), as well as
three-dimensional spine flexion, extension, lateral bending, and
axial rotation ROMs, with three-dimensional marker clusters on
the spine, and to determine the between-session reliability of these
measurements.
2. Methods
2.1. Participants
Nineteen healthy (8 female) volunteers participated in this
study. The mean ± SD (range) age, height, weight, and BMI of the
participants were 47 ± 17 (24–74) years, 172 ± 7 (162–185) cm,
71.4 ± 13.9 (44.7–98.1) kg, and 24.0 ± 3.3 (17.0–31.0) kg/m2,
respectively. Individuals with recent back pain, history of spinal
surgery, traumatic fracture, thoracic deformity, or conditions that
affect balance, movement, or ability to stand were excluded. This
study was approved by the Institutional Review Board of Beth
Israel Deaconess Medical Center, and all participants provided
written informed consent before participation.
2.2. Procedure
Each participant underwent the same set of measurements on
two separate occasions, an average of 7 days apart (range
2–14 days). In each session, before marker placement, spine
curvature and pelvic tilt were measured with the flexicurve and
Palpation Meter, respectively (see Supplement 1 for details and
related results). Then anatomical landmarks were found for marker
placement, but no marks were made on the skin (e.g. with grease
pencil or marker) as they might have affected placement in the sec-
ond session. Rigid clusters with four markers each were attached to
the skin overlying the T1, T4, T5, T8, T9, T12 and L1 spinous pro-
cesses using double-adhesive tape. Pelvic markers were placed
on the posterior (PSIS) and anterior (ASIS) superior iliac spines
and iliac crests. An additional 69 single markers were placed on
C7, head, sternum and clavicles, and extremities. Marker data
was collected with a 10-camera motion analysis system (Vicon
Motion Systems, Oxford, UK) while the participant stood in the
middle of the room with feet shoulder-width apart. Marker posi-
tions were first captured in the neutral upright standing posture
(5 s). Next, participants were instructed to move their trunk
toward full flexion, extension, right and left lateral bending, and
right and left axial rotation as smoothly as possible, and hold each
position for 5 s while data was collected (Fig. 1). The same protocol
was followed and all participants received consistent instructions
in both sessions.
2.3. Data reduction, processing, and analysis
Marker positions were averaged over one second from each trial
with minimal movement and/or noise in the marker data (or the
Fig. 1. Posterior views of a subject performing range of motion trials, with spine marker clusters visible. From left to right: neutral posture, full flexion, extension, left lateral
bending, right lateral bending, left axial rotation, right axial rotation trials.
249
first one second if no movement or noise was seen). A custom
MATLAB (The Mathworks, Inc., Natick, MA, USA) program was used
to evaluate 3D orientations. A local coordinate system was created
for each spinal marker cluster and the pelvis with x positive to the
right. In the spine y and z were normal and tangent to the neutral
spine curvature, respectively. In the pelvis y and z were parallel
and perpendicular to the plane of the ASIS and PSIS markers,
respectively. An Euler angle sequence of x (flexion-extension), y
(lateral bending), z (axial rotation) was used to calculate segment
orientation and relative orientations between segments, following
previous studies (Cotter et al., 2014; Preuss and Popovic, 2010).
The relative rotations between clusters in the neutral position were
measured for thoracic kyphosis (T1-L1) and lumbar lordosis (L1 –
Sacrum), and the orientation of the pelvis for pelvic tilt. Similarly,
the relative rotations in ROM trials were calculated to determine
ROM outcomes. ROM was defined as the difference in angle for a
spine segment (or the pelvis) between neutral posture and the
trial. Total ROM was defined as the largest magnitude of angular
motion between neutral, flexion, and extension trials (for flexion
– extension), and between neutral, left, and right trials (for lateral
bending and axial rotation). Circle fitting (Schmid et al., 2016) and
polynomial fitting (Ignasiak et al., 2017) approaches were also
applied to estimate sagittal plane angles from marker data, with
details and results provided in Supplement 2.
2.4. Statistical analysis
Primary outcomes were magnitude and reliability of thoracic
(T1-L1), lumbar (L1 – Sacrum), and pelvic neutral posture and
ROMs. Specifically, the primary outcomes for flexion and extension
trials were flexion-extension angles. Since lateral bending and
axial rotation include significant coupling with other motions, total
ROMs of both primary and coupled motions were examined.
Secondary outcomes, including ROMs for left and right ROMs
separately and for thoracic sub-segments, are presented in
Supplement 3. Outcomes were checked for normality by Shapiro-
Wilk tests.
Reliability of each outcome was examined using intraclass cor-
relation coefficients (ICC), and classified as poor (ICC < 0.4), fair to
good (ICC between 0.4 and 0.75) or excellent (ICC > 0.75) (Shrout
and Fleiss, 1979). Standard error of measurement (SEM) as a
parameter of absolute reliability indicates magnitude of error and
within-subject variability across repeated trials and was calculated
as:
pffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
SEM ¼ SD 1  ICC ð1Þ
Reliability can be improved by averaging repeated trials, which
provides a better estimate of the true measure. Given the ICC for an
individual trial, ICC(1), the ICC for m repeated trials can be esti-
mated using the Spearman-Brown formula:
mICCð1Þ
ICC ðmÞ ¼ ð2Þ
1 þ ðm  1ÞICCð1Þ
250 S.J. Mousavi et al. / Journal of Biomechanics 79 (2018) 248–252

Thus, using Eqs. (1) and (2), the required number of trials, m,
was calculated for each outcome measure to meet the criteria
ICC(m)  0.80 and SEM% < 25% as proposed by Schinkel-Ivy et al.
(2015). Analyses were performed with Stata/IC 13.1 (StataCorp
LP, College Station, TX, USA).
3. Results
About 13% of primary outcome variables had significant
Shapiro-Wilk tests (p < 0.05), more than would be expected by
chance, suggesting some outcomes may not be normally dis-
tributed. Thus, both mean (SD) and median (IQR) are reported as
descriptive statistics. In the neutral posture mean TK, LL, and PT
were 42.4°, 17.8°, and 4.6°, respectively (Table 1). Lumbar and pel-
vic segments combined to produce the majority of flexion and
extension ROM (Table 1). The thoracic segment accounted for
about half of lateral bending ROM, with the rest split between lum-
bar and pelvic motion (Table 2). Thoracic and pelvic segments
combined produced the majority of axial rotation ROM (Table 3).
The ICC values ranged from 0.54 to 0.82 for trunk posture, 0.56
to 0.78 for flexion ROM, 0.69 to 0.79 for extension ROM, 0.56 to
0.71 for lateral bending ROM and 0.51 to 0.81 for axial rotation
ROM (Tables 1–3). Reliability of the trunk segments for coupled
motions during lateral bending and axial rotation ranged from
poor to good (Tables 2 and 3). The SEM values of the trunk seg-
ments in all ROM trials showed a varied range from 1.6° to 11.5°
(Tables 1–3).
4. Discussion
Opto-electronic motion capture showed excellent between-
session reliability to measure trunk sagittal posture in healthy par-
ticipants. Our results are in agreement with prior studies reporting
fair to excellent between-session reliability of thoracic and lumbar
sagittal curves and pelvic tilt with spinal markers (Dunk et al.,
2004, 2005; Muyor et al., 2017). However, these prior studies did
not use motion analysis of spinal clusters.
In agreement with other kinematics studies, lumbar and pelvic
segments contributed most to flexion and extension ROM, thoracic
segment to lateral bending, and both thoracic and pelvic segments
to axial rotation ROM. Mean angles of thoracic and lumbar seg-
ments are also in line with previously reported marker-based mea-
surements (Schinkel-Ivy et al., 2015; Tojima et al., 2013; Willems
et al., 1996). Greater contribution of a segment to a particular
motion was often associated with higher reliability. In general,
we found fair to excellent between-session reliability to measure
ROM during flexion and extension trials. Our results also show fair
to excellent between-session reliability for trunk ROM in lateral
bending and axial rotation trials for primary and most coupled
direction motions. It should also be noted that reliability does
not guarantee accuracy of measurement. Motion analysis is subject
to error, for example due to soft tissue artefacts, although it has
been shown that sagittal angles and motions can be measured with
reasonable accuracy (Schmid et al., 2015; Zemp et al., 2014). Prior
studies measuring 3D spine motion have used rigid clusters that

Table 1
Mean (SD) and median (IQR) of neutral postural measures, flexion ROM and extension ROM (in degrees), between-session ICCs (95% CI), and thoracic, lumbar and pelvic segments.
Negative angles indicate kyphosis, flexion, anterior tilt or anterior pelvic rotation, positive indicate lordosis, extension, posterior tilt or posterior rotation. The number of trials, m,
required to meet the criteria ICC(m)  0.80 and SEM% < 25% are also reported. Bold ICC values are significant (p < 0.05).

Measurement Mean (SD) Median (IQR) ICC (95%CI) SEM # Trials

Neutral posture
Thoracic kyphosis 42.4 (10.9) 43.5 (17.5) 0.82 (0.59–0.93) 4.6 1
Lumbar lordosis 17.8 (7.9) 17.6 (11.4) 0.63 (0.26–0.84) 4.8 3
Pelvic tilt 4.6 (5.6) 3.6 (7.4) 0.54 (0.12–0.79) 3.8 >10
Flexion
Thoracic 7.1 (11.8) 5.9 (12.6) 0.56 (0.17–0.80) 7.8 >10
Lumbar 47.4 (15.6) 46.3 (22.5) 0.77 (0.50–0.91) 7.5 2
Pelvic 51.8 (15.1) 52.8 (21.4) 0.78 (0.51–0.91) 7.1 2
Extension
Thoracic 9.5 (14.2) 8.9 (11.8) 0.78 (0.48–0.92) 6.7 10
Lumbar 10.9 (10.9) 8.1 (5.8) 0.79 (0.50–0.92) 5.0 4
Pelvic 12.5 (6.1) 12.6 (6.4) 0.69 (0.35–0.87) 3.4 2

IQR; InterQuartile Range, ICC: intraclass correlation coefficient; SEM: standard error of measurement (in degrees).

Table 2
Mean (SD) and median (IQR) of the ranges of motion (in degrees), between session ICCs (95% CI), and SEM for the trunk segments in lateral bending tests. Results are reported for
total ranges of motion (left-neutral-right) in primary and coupled directions of motion. The number of trials, m, required to meet the criteria ICC(m)  0.80 and SEM% < 25% are
also reported. Bold ICC values are significant (p < 0.05).

Measurement Mean (SD) Median (IQR) ICC (95%CI) SEM # Trials

Thoracic
Lateral bending 56.2 (16.3) 56.7 (21.9) 0.56 (0.17–0.80) 10.8 4
Flexion-extension (coupled) 12.0 (7.5) 10.4 (9.7) 0.65 (0.29–0.84) 4.4 3
Axial rotation (coupled) 28.4 (14.4) 28.0 (21.6) 0.60 (0.22–0.82) 9.1 3
Lumbar
Lateral bending 28.6 (10.9) 29.2 (18.1) 0.70 (0.37–0.87) 6.0 2
Flexion-extension (coupled) 12.0 (5.7) 12.6 (6.9) 0.04 (0.44 to 0.48) 5.6 >10
Axial rotation (coupled) 10.9 (7.9) 8.6 (9.5) 0.22 (0.27 to 0.61) 7.0 >10
Pelvic
Lateral bending 26.5 (8.8) 26.5 (11.3) 0.71 (0.39–0.87) 4.7 2
Flexion-extension (coupled) 6.5 (4.9) 4.8 (6) 0.48 (0.03–0.75) 3.5 9
Axial rotation (coupled) 15.5 (9.3) 15.8 (13.8) 0.27 (0.22 to 0.64) 7.9 >10

IQR; InterQuartile Range, ICC; intraclass correlation coefficient, SEM; standard error of measurement (in degrees).
 S.J. Mousavi et al. / Journal of Biomechanics 79 (2018) 248–252 251

Table 3
Mean (SD) and median (IQR) of the ranges of motion (in degrees), between session ICCs (95% CI), and SEM for the trunk segments in axial rotation tests. Results are reported for
total ranges of motion (left-neutral-right) in primary and coupled directions of motion. The number of trials, m, required to meet the criteria ICC(m)  0.80 and SEM% < 25% are
also reported. Bold ICC values are significant (p < 0.05).

Measurement Mean (SD) Median (IQR) ICC (95%CI) SEM # Trials

Thoracic
Axial rotation 108 (18.3) 103.5 (24.5) 0.78 (0.50–0.91) 8.6 2
Flexion-extension (coupled) 40.9 (17) 40.7 (20.8) 0.75 (0.46–0.89) 8.5 2
Lateral bending (coupled) 23.8 (15.2) 19.2 (18.9) 0.46 (0.02–0.75) 11.2 7
Lumbar
Axial rotation 21.2 (13.4) 20.4 (18.1) 0.51 (0.05–0.78) 9.4 6
Flexion-extension (coupled) 14.7 (8.7) 13.6 (9.1) 0.44 (0.00–0.74) 6.5 6
Lateral bending (coupled) 32.4 (18.6) 33.7 (28.4) 0.62 (0.22–0.83) 11.5 3
Pelvic
Axial rotation 103.1 (2.5) 107.7 (34.8) 0.81 (0.55–0.92) 11.0 1
Flexion-extension (coupled) 5.7 (2.6) 5.1 (3.7) 0.62 (0.25–0.83) 1.6 3
Lateral bending (coupled) 8.9 (6.3) 7.1 (3.5) 0.51 (0.06–0.77) 4.4 7

IQR; InterQuartile Range, ICC; intraclass correlation coefficient, SEM; standard error of measurement (in degrees).

spanned the spine and paraspinal musculature (Cotter et al., 2014;
Preuss and Popovic, 2010). We used smaller clusters that fit on the
spine midline with little overlap of paraspinal muscles. While this
may reduce error due to soft tissue artefact, having markers closer
together may have increased noise and reconstruction errors.
We estimate that three to four trials would provide satisfactory
between-session reliability for the majority of measures examined
in this study. Repeated measurements improve error and reliabil-
ity, and good within-session reliability can reportedly be obtained
with two to five trials for most trunk kinematic measures
(Schinkel-Ivy et al., 2015). While between-session reliability might
be expected to be lower than within-session, this suggests that the
two are not dissimilar. Overall, this shows that reliable measure-
ments of key spine motions can be obtained with a reasonable
number of trial repetitions.
While testing a relatively small sample of healthy adults is a
limitation of this study, our participants included men and women
and ranged in age from 24 to 74 years old. Thus the reliability
results are applicable for both sexes and across the age span. The
BMI of the recruited participants mostly fell in the normal to over-
weight range of BMI, so our results may not be applicable to obese
people, in whom reliability might be affected by increased soft tis-
sue artefacts. Additional studies would be required to examine
whether reliability might vary with characteristics such as age,
sex, and obesity, or in patients with pain or other pathological
conditions.
In summary, this study demonstrates that opto-electronic
motion capture measurements afford objective, quantitative and
reliable data on a patient’s posture and kinematics. Importantly,
we demonstrate that reliable data can be obtained with a reason-
able number of trial repetitions for most outcomes. In addition
motion capture allows for three-dimensional and dynamic out-
comes to be assessed, which would not be possible with standard
diagnostic approaches such as radiographic studies. We also report
results for the thoracic spine, lumbar spine, and pelvis, including
non-sagittal and coupled ROMs, which provide a more comprehen-
sive set of spine ROM outcomes than prior studies. Overall, this
information supports the use of motion capture systems to assess
spine posture and motion in future clinical studies, for example to
better understand the effects of aging and spine disorders.
Acknowledgments
This work was conducted with support from the National Institute
on Aging of the National Institutes of Health (R00AG042458), the
Department of Orthopaedic Surgery at Beth Israel Deaconess Med-
ical Center, and Harvard Catalyst|The Harvard Clinical and Transla-
tional Science Center (National Center for Advancing Translational
Sciences, National Institutes of Health Award UL1 TR001102) and
financial contributions from Harvard University and its affiliated
academic healthcare centers. The content is solely the responsibil-
ity of the authors and does not necessarily represent the official
views of Harvard Catalyst, Harvard University and its affiliated aca-
demic healthcare centers, or the National Institutes of Health. The
study sponsors had no role in the study design, data collection,
analysis, manuscript preparation, or the decision to submit the
manuscript for publication.
Conflict of interest
All authors have declared no conflict of interest.
Appendix A. Supplementary material
Supplementary data associated with this article can be found, in
the online version, at https://doi.org/10.1016/j.jbiomech.2018.08.
033.
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