Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

Users Online : 31894

AbstractDiscussionConclusionReferencesDOI and Others
Article in PDF How to Cite Citation Manager Readers' Comments (0) Audio Visual Article Statistics Link to PUBMED Print this Article Send to a Friend
Advertisers Access Statistics Resources

Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Reviews
Year : 2022 | Month : June | Volume : 16 | Issue : 6 | Page : YE06 - YE10 Full Version

Quantification of Lumbar Lordosis by Tactile and Non Tactile Methods: A Revisit


Published: June 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/53685.16474
Anushree Rai, Zubia Veqar

1. Assistant Professor, Department of Faculty of Physiotherapy, SGT University, Gurugram, Haryana, India. 2. Associate Professor, Department of Centre for Physiotherapy and Rehabilitation Sciences, Jamia Millia Islamia, New Delhi, India.

Correspondence Address :
Dr. Zubia Veqar,
Associate Professor, Department of Centre for Physiotherapy and Rehabilitation Sciences, Jamia Millia Islamia, New Delhi, India.
E-mail: veqar.zubia@gmail.com

Abstract

Lumbar lordosis alteration results in various disabilities and common problem like low back pain among others which severely impacts the quality of life of a person. This paper focuses on postural evaluation used to identify this alteration, which till date has received little attention even though it is an important outcome measure in various experimental studies. This review focuses on both quantitative and qualitative postural evaluation methods. Conventional methods ranges from visual observation method to gold standard method like radiography and various other non invasive methods like photogrammetric, flexicurve, spinal mouse, inclinometer. However, recent research suggests some 3 Dimensional (3D) analysis methods like 3D radiographs, inertial sensors and posturometer. There is a lack of consensus on the most suitable method of this evaluation hence, the selection is difficult for clinical as well as research purposes. Although there are few reviews available, neither of them has attempted to establish the pros and cons of all these methods. This review provides a comprehensive overview of different 2D, 3D, tactile and non tactile methods or tools that have been developed to measure posture or shape of lumbar spine. This review will also provide practical recommendations to researchers as well as clinicians about the tool selection for lumbar lordosis assessment.

Keywords

Cobb’s angle, Inclinometer, Lumbar spine, Photogrammetry, Posture, Posturometer

Lumbar lordosis is the anterior convexity in the mid-sagittal plane. It compensates for the inclined sacrum and to avoid anterior inclination. It gives lumbar spine toughness and ability to resist compressive forces. Any alteration in the lumbar lordosis due to congenital condition, trauma, degenerative and inflammatory conditions, compressive forces is transferred to the intervertebral disc through vertebral bodies and can cause low back pain and disabilities. Hence, assessment using reliable methods is used for measuring this alteration of curve and for adequate restoration of lumbar lordosis (1),(2).

A variety of postural assessment methods have been used for clinical and research purposes. Some are conventional (non tactile or tactile methods), while some are advanced (non tactile or tactile methods).

In light of the recognition that lumbar lordosis assessment plays an important role in the prevention and management of low backache and its associated problems, its assessment needs to be given due importance. The primary aim of this review was to provide the readers with a comprehensive information regarding different tools and instruments used for assessing it. It further aimed at finding the most appropriate method among many on the basis of cost, availability, portability, reliability, validity, and ease to use. This information will help researchers as well as clinicians to decide about the most suitable tool/ method which can be used on their subjects/patients for the lumbar lordosis assessment.

TWO-DIMENSIONAL ANALYSIS OF POSTURE

Methods of Measurement

Visual observation method

It is one of the oldest, easiest and most commonly used method for assessment of posture in clinical practice as it doesn’t require any tool. The main disadvantage of this method is its inability to do a quantitative assessment which leads to variability. It also fails to diagnose minor postural alteration (3).

A study was done by Fedorak C et al., for evaluation of reliability of visual assessment for lumbar lordosis (4). It was reported poor (k<0.40) inter-rater and fair (k=0.50) intra-rater reliability. Another study conducted by Iunes DH et al., compared the inter-rater reliability between visual and photogrammetry method in 21 volunteers aged between 22 to 26 years (3). Inter-rater reliability for lumbar lordosis measurement by visual method was 28.6%. The result of both studies concluded that it has poor inter-rater agreement. With this method of postural assessment, reliable results cannot be obtained so more accurate methods should be used in clinical practice.

Radiographic method

Radiography, considered as the gold standard method of postural assessment allows the quantification of the anteroposterior curvature of spine, which is important for structural stability, protection of spinal cord and spinal segment mobility (5). Assessment of lumbar lordosis by lateral radiograph is done routinely and cobb method is the most commonly used technique. Cobb’s angle is measured through the intersection of line drawn from endplate of one vertebra to the endplate of another vertebrae (1),(6) and usually superior endplate of L1 segment and superior endplate of S1, segment is used for this assessment (1),(7),(8). Hicks GE et al., determined the inter-rater reliability (0.98), MDC (3.90) and SEM (1.99 degree) of 4-line cobb method for measuring lumbar lordosis and Intraclass Correlation Coefficient (ICC) value after 2 years (0.81) (9). Chung NS et al., determined the validity and reliability of spinopelvic and lumbar lordosis measurement by lateral lumbar radiograph and compared it with lateral whole radiograph (10). They reported similar correlation coefficient 0.93-0.95 and intra and inter observer ICC values as > 0.75 for both. Even though the reliability of both the measurements were similar; lateral lumbar radiograph has certain advantage over lateral whole- spine radiograph like special film is nonessential, radiograph is easy to obtain and radiation exposure is lesser. Although studies concluded excellent reliability of radiographic method but the radiation exposure is an important health concern along with its cost (11).

Photogrammetric method

Photogrammetry is a non invasive method used by healthcare professionals and researchers, as it allows precise evaluation by recording the postural changes over multiple frames. It is helpful for giving information in sagittal and frontal planes (12).

Drzal-Grabiec J et al., evaluated the validity of this method with radiographic method for measuring cobb angle and size of anteroposterior curvature of spine among participants (n=50) aged between 35 to 65 years. A significant correlation was reported between these methods for length of lordosis (r-value=0.88; p-value <0.001) and cobb’s angle (r-value=0.30; p-value <0.001) (13). Other validity studies reported no significant difference for lumbar lordosis angle (p-value=0.817) for photogrammetric and inclinometer in healthy elderly women (14). The validity of prediction equation from skin surface is (r-value >0.85) for T10-S2 level (5). Apart from validity its reliability was also examined well in the literature with its ICC values ranging from (0.98-0.99) and (0.97-0.99) for inter and intra-rater reliability respectively (5).

Numerous studies have reported the use of photogrammetric method for postural evaluation as it is:

(i) Non invasive tool which provide precise qualitative postural evaluation;
(ii) Good agreement with radiograph;
(iii) Repeatability and also;
(iv) Reduces exposure to radiation during radiographic evaluation.

The main limitation associated with this method is the possibility of error while marking the points and their positioning on the computer screen and it is indistinct how photogrammetric technique is utilized to screen postural treatment or to record posture in observational studies (12), (13).

Tactile Methods of Measurement

Flexicurve

This method is used in healthy and patient population from children (15) to adolescents, and adults to analyse spinal curvature (16). It has a malleable ruler which is moulded to the back to trace the shape of the spine onto paper, which is followed by calculation of angle of curvature of spine (17).

The reliability studies conducted in the literature among healthy population reported ICC value for lumbar length and width ranging from (0.72-0.74) and (0.56-0.58) for intrarater and inter-rater reliability respectively (16). Furthermore, de Oliveira TS et al., reported excellent inter and intra rater reliability with ICC values 0.83 and 0.78 respectively (18). The results of both studies showed that flexicurve is a reliable tool to assess the lumbar curvature in sagittal plane.

Validity is not very extensively studied, however a study conducted by de Oliveira TS et al., demonstrated strong correlation between radiographic measurement and flexicurve (r=0.60). The limitation associated with flexicurve measurement are the following (15),(16),(18):

• Firstly, difficulty in moulding the flexicurve in the lumbar spine which causes greatest variability in the measurements.
• Secondly, difficulty in palpation of anatomical landmarks in the lumbar region.
• Thirdly, high chances of measurements error due to patient and examiner variability during data collection and angle measurement, also lack in the concurrent validation to ensure its diagnostic capacity.
Spinal mouse

It is a hand-held, non invasive device with inbuilt accelerometers and small wheels that roll along the length of spine to record the distance and alteration of inclination with respect to the plumb line as well as spinal angle and shape in frontal and sagittal plane, regional kyphosis and lordosis, mobility of the thoracic and lumbar spine, mobility and posture of single vertebral segments, hypomobility and hypermobility of a particular segment, postural competence, posture and mobility of the sacrum/pelvis, posture of the upper body in space (19),(20).

Various reliability studies were conducted to measure the spinal curvature in sagittal and frontal plane among healthy participants. The ICC value for lumbar lordosis ranges from (0.90-0.99) and (0.87-0.99) for intrarater and inter-rater reliability respectively (19),(21). Miyazaki J et al., reported ICCs of 0.94 and 0.89 over skin and clothing respectively (22). Russell BS et al., reported high reliability with ICC values >0.99 of Spinal Mouse unit in measuring lumbar lordosis by use of wooden spine model among 50 participants with or without high- heeled shoes (23). The result of above-mentioned studies showed that Spinal Mouse is a reliable skin- surface device to measure lumbar lordosis in sagittal and frontal plane (22),(23).

Validity of Spinal Mouse in sagittal plane measurement has not been established yet (23). There has been difference in the lumbar lordosis measurements using Spinal Mouse as reported by various authors. Liberg EM et al., reported a mean lordosis of 15°; Keller S et al., reported about 27°; Takihara Y et al., below 20°; and Miyazaki J et al., 19° and 20° over skin and clothing respectively (24),(25),(26). Spinal Mouse measurements are not correlated with radiographic measurement as

(i) Measurement using skin surface device follow line of posterior elements while X-ray measures uses vertebral bodies;
(ii) Distribution of subcutaneous tissue mainly in the lumbar region (19),(21), but comparable with other skin surface devices.

Majority of the studies mentioned above was conducted among healthy asymptomatic participants, there are chances that the use of Spinal Mouse may be more difficult for symptomatic patients.

Inclinometer

Inclinometer is a reliable, handy, affordable and non- invasive device which is used to assess the anteroposterior curvature of the spine and helps the clinician to diagnose or to record patient progress efficiently (14),(27). The baseline digital inclinometer offers the speed and ease of use of a digital display. It can be used in conjunction with a second unit for neck and back measurements. Baseline gravity inclinometer and Bubble inclinometer also provides accurate range of motion measurements which can be read directly from the dial. They are used for diagnosis in hospitals, clinics and tracking the progress of therapy (28).

Various authors reported the reliability of inclinometer in measuring lumbar range of motion and lumbar lordosis. Good to excellent intrarater reliability has been reported with ICCs value ranging between (0.90-0.95) for lumbar lordosis measurement using inclinometer among healthy subjects (27),(29). Ng JK et al., (29) measured lumbar lordosis with inclinometer at T12-L1 and L5-S1 level. Van Blommestein, AS et al. (27) calculated the lumbar lordosis at T12-L1 and S2-S3 using Isomed Inclinometer (Isomed, 975 Sandy Blvd., Portland, OR 97214) which consists of a protractor with a freely swinging pointer and two feet that project from its base. Czaprowski D et al. (30) measured the lumbar lordosis using Saunders Digital Inclinometer (Baseline Digital Inclinometer, The Saunders Group Inc, Chaska, MN, USA) in healthy subjects by setting the inclinometer at lumbosacral junction. It was found to have good intrarater reliability with Cronbach’s alpha coefficient (0.87), but significant difference was reported between inter rater measurements (p=0.02). Inclinometer is a reliable tool to assess posture in both asymptomatic and symptomatic individuals. MacIntyre NJ et al., reported the interrater (0.64), intrarater (0.94) reliability of Saunders Digital Inclinometer in measuring spinal curvature of postmenopausal women with osteoporosis (31). MacIntyre NJ et al., determined the interdevice reliability with ICC value (0.97) and Standard Error of Measurement (SEM) (1.33°) using IONmed mobile phone application and digital inclinometer in individuals with osteoporosis and osteopenia (32). Inclinometer is a reliable tool in assessing posture, classification of women with postmenopausal osteoporosis and increased risk of fracture, monitoring progression and response to intervention aimed to improve abnormal posture (31),(32).

Limitations include (33),(34):

• Measurement in single plane (sagittal);
• Higher Body Mass Index (BMI) can make the palpation of landmarks difficult;
• Error in the measurement can be due to inability to maintain constant pressure during movement;
• Misplacement of device or holding the inclinometer slightly off plumb.

Reliability studies of ihandy smartphone application

Smartphones have become our new friends. A free software has been developed to evaluate the posture called as iHandy®. It is available on phones that uses android?SUP?TM#SUP# operating system as well as iPhone®. This smartphone application can be used as an alternative to inclinometer from accessibility perspective. It provides the capacity to convert the phone into an inclinometer using a built-in tilt sensitive system. The reliability of ihandy smartphone application has been found with ICCs value 0.96 and 0.81 for inter and intrarater reliability respectively using iPhone® model 4 with iHandy® level application (iPhone® is a trademark of Apple Inc, Cupertino, CA). It has a build-in accelerometer and digital display to show angle (34). Concurrent validity for ihandy and bubble inclinometer was comparable with r=0.86 (34). Similarly, Koumantaki GA et al., establishes the intrarater reliability (0.93,0.96) for male and female respectively, Standard Error of the Measurement (SEM) (2.13), Minimum Detectable Change (MDC) (5.9) using ihandy level smartphone among healthy adults (33).

Although inclinometer is a reliable instrument but it may not be available in every clinical setting. Studies confirms that mobile phone application offers a quick, convenient, easily accessible and alternative method for assessing sagittal plane spine curvature in clinical settings. Both studies were conducted in young population, so the result cannot be generalized to older population, more studies should be done in older, symptomatic group to increase generalizability (32),(33),(34).

THREE-DIMENSIONAL ANALYSIS OF POSTURE

Method of Measurement

3D radiographic imaging

Biplanar radiographic or open magnetic resonance imaging are used to assess 3D spinal and pelvic alignment, vertebral and intervertebral orientation. Gangnet N et al., and Janssen MMA et al., conducted studies to assess spinopelvic alignment using Biplanar radiographic technique, which provides high-definition digital radiograph which further uses 8-10 times lesser radiation dose than conventional imaging among asymptomatic subjects (35),(36). It was found that Pearson correlations exist between pelvic incidence, L1-S1 lordosis (R-value= -0.40, p-value= 0.02); pelvic radius-S1 angle, pelvic radius-L4 lordosis (R-value= 0.72, p-value< 0.0001); sacral slope, L1-S1 lordosis (R-value=-0.64, p-value< 0.0001); and T12-S1 lordosis, T1-T12 kyphosis (R-value=-0.60, p-value= 0.005) (35). The inter-rater and intra-rater reliability ranges from (0.97-1.00), (0.95-1.00) respectively among asymptomatic subjects (36),(37).

The advantage of 3D imaging techniques are:

• It allows better understanding of 3D aspects of posture (35),
• Higher reproducibility and quicker processing once the user is familiar (37)

Inertial sensors

Inertial sensors are objective measurement tools, used to measure spinal motion or evaluation of spinal shapes (38). Vision- based Inertial sensor system consist of high-speed cameras, reflective markers or 3D cameras. Vicon is one of the most commonly used marker-based vision sensor system in research and clinical setting (39). It is an advanced 3-dimensional motion analysis system for measurement. Surface markers positioned on the body and infrared cameras are used to detect the movement of markers precisely (40).

The Cartesian Optoelectronic Dynamic Anthropometric (CODA) motion analysis system is a 3-Dimensional kinematic analysis instrument. It is a highly reliable and valid tool for measuring cervical range of motion (41), upper extremity kinematics (42). O’Sullivan K et al., reported the intra (0.75-0.97) and inter rater (0.57-0.95) reliability of upper and lower lumbar spine using CODA motion analysis system (43).

This marker-based vision system has certain disadvantages.

• Firstly, it requires large laboratory setup with expensive equipment.
• Secondly, installation of setup is time consuming and require technical expertise.
• Thirdly, soft tissue artefacts due to incorrect marker positioning may affect the measurement accuracy (39).

Other portable, non invasive wearable sensors used in the posture assessment are E-textile, wearable spine monitoring system and Epionics Spine. Electronic textile (E-textile) has electronic components or sensors such as Inertial Measurement units (IMUs), LEDs, capacitive, resistive or inductive sensors embedded within the fabric. The advantage of E textiles is that it is light weight, small- sized fabric that allow unassuming monitoring (44). A study was done by Sardine E et al., to detect the posture with wearable T- shirt, an inductive sensor was integrated in the T-shirt. It measures the deformation applied on the T- shirt due to lengthening or straightening of the posture which will generate change in impedance (45).

Another wearable sensor used by Voinea GD et al., was “wearable Monitoring System” to generate the shape of spine (38). It has following components: A shirt on which sensors are embedded to detect movement and a controller, used to record data from sensors which is then transmitted to smartphone, so that individual can visualize posture. It has five sensors evenly distributed on the entire spine to detect curvature.

Epionics spine system is an advancement of former SpineDMS system and is used for assessment of thoraco-lumbar posture and motion using strain-gauge technology (46). Inbuilt accelerometer allows the additional detection of orientation of the upper body relative to the earth’s gravitational field. The system is portable and lightweight. It is advantageous because it assesses the lumbar spine during activities of daily living. Consmuller T et al., investigated the intra-rater reliability and compare normative data in healthy subjects using Epionics spine. Significant correlation was exhibited with ICC value 0.85. The lordosis angle during standing measured with Epionics spine was 32.4±9.7 degree (47). The device is also capable of detecting movements out of sagittal plane but certain limitations are also reported like difficulty in determining a curvature in subjects with short height as the same sensor strip size is used for all heights, slippage of sensor strips, also this device measures the shape of the back and not shape of the spine, so the measurements of subjects with higher BMI can differ considerably. A brief summary of existing sensing systems for measurement of lumbar lordosis is given in (Table/Fig 1).

Tactile Method of Measurement

Posturometer-S

Posturometer-S is a non invasive device designed to analyse body posture. It consists of three coupled systems:• Mechanical- uses a pointing stick to indicate position of measured point,

• Electronic-calculate the position of marked points
• Informatique-used to analyse the results.

Its setup includes measuring device, platform for subjects, seat and computer set (48),(49). It also helps in determining parameters of angular and linear in the planes (50). Posturometer is used to measure angle of lumbar lordosis among children with different body type, children with hearing impairment which will help in early correction of posture (48),(50). The main limitation the authors reported in the studies was that the posturometer-S was not user-friendly, consumes area and requires an intensive understanding of the instrumentation along with training before it can be used (51).

Discussion

The present article has reviewed a number of methods used for lumbar lordosis assessment, including visual observation, radiography and various other non invasive methods like photogrammetric, flexicurve, Spinal Mouse, Inclinometer and some 3-dimensional analysis methods like 3D radiographs, Inertial sensors and posturometer, and their possible clinical application as well as advantages and disadvantages. Each methods/tool reviewed here comes with its own set of strengths and limitations. The most common method which is used to assess posture in clinical practise is the visual observation method, but it is unable to provide the assessor with a reliable and valid quantitative tool. With this method, quantitative data cannot be obtained as well as there is difficulty in assessing minor posture alteration and possesses poor interrater reliability. Hence, it’s usage should be discouraged in research as well as clinical settings.

Radiography is considered as the gold standard method of postural assessment. But its risk of exposure to radiation and cost limits its use in clinical settings and this further encourages the use of non invasive methods like, photogrammetry, flexicurve, spinal mouse, inclinometer Photogrammetry is capable of giving information in sagittal and frontal planes (12). This method has been compared with visual, and radiographic method. Flexicurve also has good reliability, but limited number of validity studies are available for this method, has limited availability. It also has high chances of measurement error during data collection and angle measurement which limits its use in clinics (15),(16),(18). Spinal Mouse, Inclinometer are some other non invasive reliable devices but may not be available in every clinical setting. As a result, convenient, easy, accessible, reliable smartphone application such as “ihandy” can be used as an alternative method for posture analysis (14),(27).

Some of the 3-dimensional methods are also used for posture assessment like 3D radiographic imaging, inertial sensors, raster stereography, posturometer. These methods and tools can give information about the posture in transverse, sagittal and frontal plane, but they have certain limitations like they are expensive, not user friendly, also require large laboratory settings to measure posture.

Conclusion

The evidence reviewed support the conclusion that photogrammetry and iHandy smartphone application are reliable, quick, convenient, non-invasive methods which can be used to measure posture of lumbar spine. The use of these methods is recommended for future studies in different population to increase the generalizability of these methods.

References

1.
Okpala FO. Comparison of four radiographic angular measures of lumbar lordosis. J Neurosci Rural Pract. 2018;9(3):298-304. [crossref] [PubMed]
2.
Lee CS, Chung SS, Park SJ, Kim DM, Shin SK. Simple prediction method of lumbar lordosis for planning of lumbar corrective surgery: Radiological analysis in a Korean population. European Spine Journal. 2014;23(1):192-97. [crossref] [PubMed]
3.
Iunes DH, Bevilaqua-Grossi D, Oliveira AS, Castro FA, Salgado HS. Comparative analysis between visual and computerized photogrammetry postural assessment. Rev Bras Fisioter. 2009;13(4):308-15. [crossref]
4.
Fedorak C, Ashworth N, Marshall J, Paull H. Reliability of the visual assessment of cervical and lumbar lordosis: How good are we? Spine. 2003;28(16):1857-59. [crossref] [PubMed]
5.
Furlanetto TS, de Oliveira EBC, Candotti CT, Vieira A, de Mesquita PV, Navarro IJ, et al. Development and validation of prediction equations for spinal curve angles based on skin surface measurements. J Manipulative Physiol Ther. 2017; 40(9):692-9. Available from: https://doi.org/10.1016/j.jmpt.2017.06.015. [crossref] [PubMed]
6.
Harrison DE, Harrison DD, Cailliet R, Janik TJ, Holland B. Radiographic analysis of lumbar lordosis: centroid, Cobb, TRALL, and Harrison posterior tangent methods. Spine. 2001;26(11):e235-42. [crossref] [PubMed]
7.
De Carvalho DE, Soave D, Ross K, Callaghan JP. Lumbar spine and pelvic posture between standing and sitting: a radiologic investigation including reliability and repeatability of the lumbar lordosis measure. J Manipulative Physiol Ther. 2010;33(11):48-55. Available from: http://dx.doi.org/10.1016/j.jmpt.2009.11.008. [crossref] [PubMed]
8.
Lee ES, Ko CW, Suh SW, Kumar S, Kang IK, Yang JH. The effect of age on sagittal plane profile of the lumbar spine according to standing, supine, and various sitting positions. J Orthop Surg Res. 2014;9(1):01-10. [crossref] [PubMed]
9.
Hicks GE, George SZ, Nevitt MA, Cauley JA, Vogt MT. Measurement of lumbar lordosis: Inter-rater reliability, minimum detectable change and longitudinal variation. J Spinal Disord Tech. 2006;19(7):501-06. [crossref] [PubMed]
10.
Chung NS, Jeon CH, Lee HD, Won SH. Measurement of spinopelvic parameters on standing lateral lumbar radiographs: Validity and reliability. Clin Spine Surg. 2017;30(2):E119-23. [crossref] [PubMed]
11.
Navarro MV, Leite HJ, Alexandrino JD, Costa EA. Control of health risks in radiodiagnosis: a historic approach. História, Ciências, Saúde-Manguinhos. 2008;15(4):1039-47. [crossref] [PubMed]
12.
Furlanetto TS, Sedrez JA, Candotti CT, Loss JF. Photogrammetry as a tool for the postural evaluation of the spine: a systematic review. World journal of orthopedics. 2016;7(2):136-148. [crossref] [PubMed]
13.
Drzal-Grabiec J, Truszczyńska A, Tarnowski A, Plaszewski M. Comparison of parameters characterizing lumbar lordosis in radiograph and photogrammetric examination of adults. J Manipulative Physiol Ther. 2015;38(3):225-31. [crossref] [PubMed]
14.
Walicka-Cuprys K, Wyszyńska J, Podgórska-Bednarz J, Drzal-Grabiec J. Concurrent validity of photogrammetric and inclinometric techniques based on assessment of anteroposterior spinal curvatures. European Spine Journal. 2018; 27(2):497-507. Available from: https://doi.org/10.1007/s00586-017-5409-8. [crossref] [PubMed]
15.
Sedrez JA, Candotti CT, Rosa MI, Medeiros FS, Marques MT, Loss JF. Test-retest, inter-and intra-rater reliability of the flexicurve for evaluation of the spine in children. Braz J Phys Ther. 2016;20(2):142-47. [crossref] [PubMed]
16.
Dunleavy K, Mariano H, Wiater T, Goldberg A. Reliability and minimal detectable change of spinal length and width measurements using the Flexicurve for usual standing posture in healthy young adults. J Back Musculoskelet Rehabil. 2010;23(4):209-14. [crossref] [PubMed]
17.
Raupp EG, Candotti CT, Marchetti BV, Vieira A, Medeiros FS, Loss JF. The validity and reproducibility of the Flexicurve in the evaluation of cervical spine lordosis. J Manipulative Physiol Ther. 2017;40(7):501-10. [crossref] [PubMed]
18.
de Oliveira TS, Candotti CT, La Torre M, Pelinson PP, Furlanetto TS, Kutchak FM, Loss JF. Validity and reproducibility of the measurements obtained using the flexicurve instrument to evaluate the angles of thoracic and lumbar curvatures of the spine in the sagittal plane. Rehabil Res Pract. 2012;2012:01-09. [crossref] [PubMed]
19.
Mannion AF, Knecht K, Balaban G, Dvorak J, Grob D. A new skin-surface device for measuring the curvature and global and segmental ranges of motion of the spine: reliability of measurements and comparison with data reviewed from the literature. European Spine Journal. 2004;13(2):122-36. [crossref] [PubMed]
20.
Biotechindia. Spinal Assessment Device- Spinal Mouse. [Internet].Mumbai: Biotech; Available from: http:// www.biotechindia.net/physiotherapy-rehabilitation/product/spinal-mouse.html.
21.
Ripani M, Di Cesare A, Giombini A, Agnello L, Fagnani F, Pigozzi F. Spinal curvature: comparison of frontal measurements with the Spinal Mouse and radiographic assessment. J Sports Med Phys Fitness. 2008;48(4):488-94.
22.
Miyazaki J, Murata S, Arakawa C, Suzuki S. Reproducibility of spinal curve angle measurements using spinal mouse. Rigakuryoho Kagaku. 2010;25(2):223-26. [crossref]
23.
Russell BS, Muhlenkamp KA, Hoiriis KT, DeSimone CM. Measurement of lumbar lordosis in static standing posture with and without high-heeled shoes. J Chiropr Med. 2012;11(3):145-53. Available from: http://dx.doi.org/10.1016/j.jcm.2012.02.002. [crossref]
24.
Liebig EM, Kothe R, Mannion AF, Grob D. The clinical significance of the lumbar lordosis: relationship between lumbar spinal curvature and low back pain. European Spine Journal. 2000:286.
25.
Keller S, Mannion A, Grob D. Reliability of new measuring device spinal mouse in recording sagital profile of the back. European Spine Journal. 2000;9(4):303. Available from:https://www.sid.ir/en/journal/ViewPaper.aspx?ID=279970.
26.
Takihara Y, Urabe Y, Nishiwaki GA, Tanaka K, Miyashita K. How back-muscle fatigue influences lumbar curvature. J Sport Rehabil. 2009;18(2):327-36. Available from: https://journals.humankinetics.com/view/journals/jsr/18/2/article-p327.xml. [crossref] [PubMed]
27.
van Blommestein AS, Lewis JS, Morrissey MC, MaCrae S. Reliability of measuring thoracic kyphosis angle, lumbar lordosis angle and straight leg raise with an inclinometer. Open Spine J. 2012;4(1):10-15. [crossref]
28.
Quickmedical. Inclinometer. [Internet]. England: quickmedical; Available from: https://www.quickmedical.com/inclinometer.html.
29.
Ng JK, Kippers V, Richardson CA, Parnianpour M. Range of motion and lordosis of the lumbar spine: reliability of measurement and normative values. Spine. 2001;26(1):53-60. [crossref] [PubMed]
30.
Czaprowski D, Pawlowska P, Gebicka A, Sitarski D, Kotwicki T. Intra-and interobserver repeatability of the assessment of anteroposterior curvatures of the spine using Saunders digital inclinometer. Ortop Traumatol Rehabil. 2012;14(2):145-53. [crossref] [PubMed]
31.
MacIntyre NJ, Bennett L, Bonnyman AM, Stratford PW. Optimizing Reliability of Digital Inclinometer and Flexicurve Ruler Measures of Spine Curvatures in Postmenopausal Women with Osteoporosis of the Spine: An Illustration of the Use of Generalizability Theory. ISRN Rheumatol. 2011;2011:01-08. [crossref] [PubMed]
32.
MacIntyre NJ, Recknor CP, Recknor JC. Spine Curve Measures Taken in Individuals with Osteoporosis and Osteopenia Using the IONmed Mobile Phone Application Are Highly Consistent with Digital Inclinometer Measures. ISRN Rehabil. 2014;2014:01-06. [crossref]
33.
Koumantakis GA, Nikoloudaki M, Thacheth S, Zagli K, Bitrou K, Nigritinos A, et al. Reliability and validity measurement of sagittal lumbosacral quiet standing posture with a smartphone application in a mixed population of 183 college students and personnel. Advances in orthopedics. 2016;2016:01-09. [crossref] [PubMed]
34.
Salamh PA, Kolber M. The reliability, minimal detectable change and concurrent validity of a gravity-based bubble inclinometer and iphone application for measuring standing lumbar lordosis. Physiotherapy theory and practice. 2014;30(1):62-67. [crossref] [PubMed]
35.
Gangnet N, Dumas R, Pomero V, Mitulescu A, Skalli W, Vital JM. Three-dimensional spinal and pelvic alignment in an asymptomatic population. Spine. 2006;31(15):507-12. [crossref] [PubMed]
36.
Janssen MMA, Drevelle X, Humbert L, Skalli W, Castelein RM. Differences in male and female spino-pelvic alignment in asymptomatic young adults: a three-dimensional analysis using upright low-dose digital biplanar X-rays. Spine. 2009;34(23): E826-32. [crossref] [PubMed]
37.
Okamoto M, Jabour F, Sakai K, Hatsushikano S, Le Huec JC, Hasegawa K. Sagittal balance measures are more reproducible when measured in 3D vs in 2D using full-body EOS® images. Eur Radiol. 2018;28(11):4570-77. [crossref] [PubMed]
38.
Voinea GD, Butnariu S, Mogan G. Measurement and geometric modelling of human spine posture for medical rehabilitation purposes using a wearable monitoring system based on inertial sensors. Sensors. 2017;17(1):03. [crossref] [PubMed]
39.
Zhang Y, Haghighi PD, Burstein F, Yap LW, Cheng W, Yao L, Cicuttini F. Electronic Skin Wearable Sensors for Detecting Lumbar-Pelvic Movements. Sensors. 2020;20(5):1510. [crossref] [PubMed]
40.
Mjøsund HL, Boyle E, Kjaer P, Mieritz RM, SkallgÃ¥rd T, Kent P. Clinically acceptable agreement between the ViMove wireless motion sensor system and the Vicon motion capture system when measuring lumbar region inclination motion in the sagittal and coronal planes. BMC Musculoskelet Disord. 2017;18(1):01-09. [crossref] [PubMed]
41.
Gao Z, Song H, Ren F, Li Y, Wang D, He X. Reliability and validity of CODA motion analysis system for measuring cervical range of motion in patients with cervical spondylosis and anterior cervical fusion. Exp Ther Med. 2017;14(6):5371-78.
42.
Levanon Y, Gefen A, Lerman Y, Givon U, Ratzon NZ. Validity and reliability of upper extremity three-dimensional kinematics during a typing task. Gait Posture. 2010;32(4):469-74. [crossref] [PubMed]
43.
O'Sullivan K, Clifford A, Hughes L. The reliability of the CODA motion analysis system for lumbar spine analysis: a pilot study. Physiotherapy Practice and Research. 2010;31(1):16-22. [crossref]
44.
García Patiño A, Khoshnam M, Menon C. Wearable device to monitor back movements using an inductive textile sensor. Sensors. 2020;20(3):905. [crossref] [PubMed]
45.
Sardini E, Serpelloni M, Pasqui V. Wireless wearable T-shirt for posture monitoring during rehabilitation exercises. IEEE Transactions on Instrumentation and Measurement. 2014;64(2):439-48. [crossref]
46.
Taylor WR, Consmüller T, Rohlmann A. A novel system for the dynamic assessment of back shape. Med Eng Phys. 2010;32(9):1080-83. [crossref] [PubMed]
47.
Consmüller T, Rohlmann A, Weinland D, Druschel C, Duda GN, et al. Comparative evaluation of a novel measurement tool to assess lumbar spine posture and range of motion. European Spine Journal. 2012;21(11):2170-80. [crossref] [PubMed]
48.
Stachoń A, Burdukiewicz A, Andrzejewska J, Pietraszewska J. The imaging and evaluation of body posture defects in hearing impaired children. Bio-Algorithms and Med-Systems BAMS. 2012; 8(2):221-36. [crossref]
49.
Mieszala W, Demczuk-Wlodarczyk E, Chromik K, Hawrylak A, Malachowska-Sobieska M. Examining relationships of the anterior pelvic tilt angle with the anterior-posterior curvatures and elongation of the spine. Acta Bioeng Biomech. 2019;21(1):37-44.
50.
Kuligowski T, Cieslik B, Radziszewski L, Czerwiński B, Pióro A. Body Somatic Type Influence on the Spinal Curvatures in Early Age School Children: Preliminary Report. Dev Period Med. 2015; 19(3):362-36.
52.
Kandasamy G, Bettany-Saltikov J, van Schaik P. Posture and Back Shape Measurement Tools: A Narrative Literature Review. In: Spinal Deformities in Adolescents, Adults and Older Adults. 2020. Available from:http://dx.doi.org/10.5772/intechopen.91803. [crossref]

Tables and Figures
[Table / Fig - 1]
DOI and Others

DOI: 10.7860/JCDR/2022/53685.16474

Date of Submission: Jan 21, 2022
Date of Peer Review: Feb 24, 2022
Date of Acceptance: Mar 04, 2022
Date of Publishing: Jun 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? NA
• Was informed consent obtained from the subjects involved in the study? NA
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Jan 22, 2022
• Manual Googling: Feb 24, 2022
• iThenticate Software: May 11, 2022 (27%)

ETYMOLOGY: Author Origin

JCDR is now Monthly and more widely Indexed .
  • Emerging Sources Citation Index (Web of Science, thomsonreuters)
  • Index Copernicus ICV 2017: 134.54
  • Academic Search Complete Database
  • Directory of Open Access Journals (DOAJ)
  • Embase
  • EBSCOhost
  • Google Scholar
  • HINARI Access to Research in Health Programme
  • Indian Science Abstracts (ISA)
  • Journal seek Database
  • Google
  • Popline (reproductive health literature)
  • www.omnimedicalsearch.com