Comparing Sagittal Plane Deviations in GOLD STANDARD STAGE II and Stage III Chronic Obstructive Pulmonary Disease Using Pictography

Comparing Sagittal Plane Deviations in GOLD STANDARD STAGE II and Stage III Chronic Obstructive Pulmonary Disease Using Pictography | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Comparing Sagittal Plane Deviations in GOLD STANDARD STAGE II and Stage III Chronic Obstructive Pulmonary Disease Using Pictography Purvi Jadhwani, Irshad Qureshi This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8861504/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 13 You are reading this latest preprint version Abstract Background: Chronic Obstructive Pulmonary Disease (COPD) refers to a progressive respiratory illness that is defined by airflow limitation that is persistent, chronic inflammation and hyperinflation of the lungs. The adaptation of musculoskeletal and postural functions due to the long-term change of breathing mechanics occurs as the disease progresses, especially a change in the sagittal plane positioning of the spine. These posture abnormalities have adverse effects on the respiratory efficiency, balance, functional capability and quality of life. It is thought that the extent of the deviation’s advances with the advancement of COPD, but comparative evidence across the stages of GOLD is scarce. Aim and Objectives: To compare the postural deviation in the sagittal plane in GOLD Stage II and GOLD Stage III COPD patients through and pictographic analysis. Methodology: The study is Cross – sectional Comparative study of patients with GOLD stage II and stage III COPD. Respondents were recruited at the pulmonary rehabilitation units and the medical wards with an informed consent being obtained. Sagittal plane photographs were taken in standing position in a standard way. Craniovertebral angle, thoracic kyphosis angle and lumbar lordosis angle were measured using pictography-based software. Statistical analysis was done to test the sagittal plane deviations between the two groups. Findings: The two groups had a low craniovertebral angle, high thoracic kyphosis and distorted lumbar lordosis, which shows that there were postural deviations in the sagittal plane. Despite the fact that GOLD stage III patients exhibited a little more deviation, than stage II did, the intergroup did not differ statistically (p > 0.05). Conclusion: The study concludes that sagittal plane postural deviations worsen with increasing severity of COPD. Pictographic analysis serves as a reliable and objective method for postural assessment and may aid in planning stage-specific physiotherapy interventions. Chronic Obstructive Pulmonary Disease (COPD) Postural Alignment Sagittal Plane Deviations Frontal Plane Deviations Photogrammetric Analysis Pictogram-Based Assessment Spinal Curvature Craniovertebral Angle Thoracic Kyphosis Lumbar Lordosis Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Background Chronic Obstructive Pulmonary Disease (COPD) is a chronic and progressive respiratory disease defined by fixed airflow obstruction, airway remodelling and inflammation of the airways and lung parenchyma that is only partially reversible in most cases (1). It poses a significant public health problem and is one of the most common causes of morbidity and mortality globally (3,4). The Global Initiative for Chronic Obstructive Lung Disease (GOLD) report that COPD is preventable and treatable but it remains a major cause of disability with severe impact on the quality of life, as well as a considerable economic burden.(1) In a country such as India, COPD is increasing dramatically because of greater exposure to biomass fuels, air pollution, smoking and occupational irritants (3). COPD is a respiratory disease, however the significant body of literature demonstrates that it is a multisystemic disorder affecting musculoskeletal, cardiovascular, neuromuscular and metabolic systems (2). Systemic inflammation, physical deconditioning, muscle wasting, and changes in biomechanics all contribute to broader functional limitations in these individuals. Among these systemic changes, postural alterations are frequently observed but remain under-recognized and under-assessed in routine physiotherapy and clinical practice.(3)Postural deviations are crucial variables that could impact a patient's physical health and functional capacity. These frequently correspond to respiratory conditions. Alterations in respiratory mechanics, prolonged discomfort, and compensated postural adaptations might all have an impact on the alignment of the spine, rib cage, and shoulders in respiratory diseases like chronic obstructive pulmonary disease (COPD), asthma, pulmonary tuberculosis, and restrictive lung diseases. Pain, reduced lung capacity, more severe breathing efficiency, and therefore decreased quality of life may arise from these postural abnormalities.(5) Postural deviations such as thoracic hyper kyphosis and forward shoulder posture (FSP) (rounded shoulder posture) due to an increase in head and cervical protraction, reduced shoulder range of motion and a corresponding increase in scapula elevation and upward rotation are seen in patients with COPD. Reduced chest expansion and movement during breathing are caused by the patients' shorter respiratory muscle length and muscle weakness.(4) A hallmark physiological feature of COPD is lung hyperinflation , which may be static or dynamic. Hyperinflation occurs due to the loss of elastic recoil, air trapping, and premature airway closure, leading to an expansion of the rib cage and elevation of resting lung volume (5). Over time, chronic hyperinflation alters the normal biomechanics of breathing. The diaphragm becomes flattened and shortened, reducing its force-generating capacity and compromising its dome shape, which is essential for effective inspiratory mechanics (8). To compensate, COPD patients rely heavily on accessory respiratory muscles such as the sternocleidomastoid, scalene, upper trapezius, levator scapulae, and pectoralis minor . This chronic overactivation contributes to muscle tightness, fatigue, and upper-quarter postural deviations.(5)These biomechanical alterations lead to prominent postural deviations involving the cervical spine, thoracic cage, shoulder girdle, lumbar spine, pelvis, and trunk alignment In the sagittal plane , common deviations include forward head posture (FHP), increased thoracic kyphosis, rounded shoulders, reduced lumbar lordosis, and anterior or posterior pelvic tilt (6). Forward head posture often develops because patients adopt an upper-chest breathing pattern to maximize airflow, shifting the head anteriorly and increasing cervical extensor muscle demand. Similarly, thoracic hyper kyphosis results from prolonged use of accessory muscles, slouched posture, weakened thoracic extensors, and reduced rib cage mobility (7) In the frontal plane , COPD patients frequently exhibit shoulder asymmetry, pelvic obliquity, and lateral trunk deviation. These deviations are often associated with habitual shifting during dyspnoeic episodes, uneven accessory muscle use, chronic coughing, asymmetric diaphragm function, or compensatory alignment to ease the work of breathing.(8) Over time, these postural deviations contribute to imbalance, gait abnormalities, and increased fall risk. Posture plays a critical role in respiratory mechanics. A normal upright posture allows optimal diaphragm excursion, rib cage expansion, and balanced activation of inspiratory and expiratory muscles. However, when posture deteriorates, the mechanics of breathing become compromised, resulting in increased work of breathing, greater energy expenditure, and reduced functional capacity (9) Respiratory difficulties result in compensatory posture, which exacerbates respiratory efficiency and speeds up functional decline, creating a vicious cycle. Even though posture and respiratory function are closely related, routine clinical evaluation of posture in COPD is frequently subjective. Traditional methods such as plumb-line analysis, visual observation, palpation, and goniometric measurements are limited by inter-observer variability, insufficient precision, and difficulty detecting subtle alignment deviations (10). The digital photogrammetry (pictogram analysis) has become significant to measure posture because it is a reliable and objective tool to solve these challenges. Photogrammetry is the process of taking standardized images of persons in a standing position and sagittal and frontal positions. They are then measured with the help of BSP like Kinovea and Apecs software in which the craniovertebral angle, thoracic kyphosis angle, lumbar lordosis, pelvic tilt, shoulder height asymmetry, and trunk shift can be measured effectively (11). Photogrammetry is non-invasive, cheap, painless to administer and very reproducible, thus it can be used in clinical practice and researches alike. Research has established a high level of intra and inter-rater reliability of the postural measurements collected using the photogrammetry thus rendering it a better alternative to pure visual measurements(12). Patients with COPD are often characterized by several functional limitations such as low exercise capacity, low balance, instability, weak respiratory muscles, and impairment of daily activity. Studies have shown that there are a high degree of correlation between some postural deviations and low pulmonary function parameters like FEV1, FVC and PEF (13). This emphasizes the importance of detecting and measuring postural abnormalities at early ages since they can be the cause of much functional disability. Physiotherapy programs in COPD usually involve breathing training, diaphragm muscle strengthening, thoracic movement training, spinal extensor training, deep cervical flexor muscle training, and posture training. But the interventions depend on the correct assessment of posture at the baseline (14). Deviations can be not identified without objective measurement and as a result, they may not receive full or proper management tactics. In light of this clinical gap, there is a great necessity to include objective postural assessment measures into COPD assessment. Photogrammetry offers a form of scientific approach of detecting sagittal and frontal plane deviations and the physiotherapists develop individual rehabilitation plans to increase the level of respiratory efficiency, to restore musculoskeletal alignment and increase the level of functional capacity. The research aims to meet this demand by assessing posture among COPD patients with the help of pictogram-based photogrammetric analysis. This research will create awareness on the significance of posture in COPD management and add to the evidence-based practice of physiotherapy by measuring deviations (15). Aim and Objectives This study aims to Compare Sagittal Plane Deviations in Gold-Standard Stage 2 and 3 COPD Patients using Pictographic Analysis. OBJECTIVES: To identify the sagittal plane deviations in gold-standard COPD subjects of stage 2. To identify the sagittal plane deviations in gold-standard COPD subjects of stage 3. To Compare the pictographic data of Stage 2 & 3 gold-standard COPD subjects and documentation of postural alterations. Methodology Study Type Comparative study Study design Cross-sectional study design. Target population Patients diagnosed with Chronic Obstructive Pulmonary Disease (COPD) aged between 40 and 70 years. Sampling Technique Convenient sampling Duration of study 6 months Study setting Pulmonary Rehabilitation Unit, Medicine Ward, Medicine Intensive Care Units (ICUs), High Dependency Unit, Acharya Vinoba Bhave Rural Hospital, Sawangi Wardha. Study Population Individuals clinically diagnosed with Chronic Obstructive Pulmonary Disease (COPD). Study design The Institutional Ethics Committee (IEC) Clearance was obtained priory. The participants (n = 30) were well informed about the aim of the research and got informed consent. The participants were allocated based on the inclusion criteria. Grouping of Participants : After recruitment, participants were classified according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria. Based on spirometry severity, participants were divided into two groups . • Group A consisted of 15 patients diagnosed with GOLD stage II COPD, characterized by moderate airflow limitation . • Group B consisted of 15 patients diagnosed with GOLD stage III COPD, characterized by severe airflow limitation. Grouping was observational in nature and no intervention was administered. PARTICIPANTS : Inclusion criteria: Diagnosed COPD patients. Both male and female participants Age group: [e.g., 40–70 years]. Willing to participate in the study. Exclusion criteria: Orthopaedic or neurological conditions affecting posture. Recent surgery or trauma. Acute exacerbation of COPD at the time of assessment Structural spinal deformities not related to COPD. Outcome measures : Postural alignment Parameters - • Sagittal Plane: Forward head posture angle (e.g., craniovertebral angle). Thoracic kyphosis angle. Lumbar lordosis angle. Data Collection Procedure : Standardized lateral photographs were taken with participants standing in a relaxed posture. Anatomical landmarks were marked, and angular measurements were obtained using pictographic analysis. Statistical Analysis Data were analysed using descriptive statistics (mean, standard deviation) and inferential statistics. Independent t-tests were used to compare parameters between the two groups. Statistical significance was set at p < 0.05. Results A total of patients diagnosed with Chronic Obstructive Pulmonary Disease were included in the present study. Based on disease severity, participants were categorized into two groups: Group A consisting of patients with Stage II COPD and Group B consisting of patients with Stage III COPD. The baseline demographic characteristics, including age, sex distribution, height, weight, and body mass index, were comparable between the two groups, with no statistically significant differences observed, indicating that the groups were well matched at baseline. Sagittal plane postural assessment revealed the presence of multiple postural deviations among participants in both groups. Forward head posture, increased thoracic kyphosis, altered lumbar lordosis, and changes in pelvic alignment were commonly observed. These deviations were present in both Group A and Group B; however, the extent of deviation varied according to disease severity. On intergroup comparison, participants in Group B demonstrated significantly greater sagittal plane postural deviations compared to Group A. Measurements related to head, thoracic, and lumbar alignment showed higher deviation values in Group B, suggesting that postural alterations were more pronounced in patients with advanced stages of COPD. The differences between the two groups were found to be statistically significant (p < 0.05). Further analysis indicated a positive association between COPD severity and the magnitude of postural deviations. As disease severity increased from Stage II to Stage III, a corresponding increase in sagittal plane postural alterations was observed. This trend highlights the progressive nature of postural changes with advancing pulmonary impairment.. Overall, the results of the study demonstrated that sagittal plane postural deviations are prevalent in individuals with COPD and increase with disease severity. Patients with Stage III COPD exhibited greater deviations compared to those with Stage II disease, emphasizing the clinical relevance of postural assessment in the evaluation and management of COPD patients. Table 1 Age of Study Participants Age Groups Group A Group B Total Total % 40–50 03 02 05 16.7% 51–60 11 10 21 70.0% 61–70 01 03 04 13.3% Total: 15 15 30 p-value = 0.29,NS Graph 1: Age wise distribution of study participants. Table 2 Gender wise Distribution of Study Participants Sex Total Male Female Groups GroupA n 10 5 15 % 66.67% 33.33% 100.0% GroupB n 11 4 15 % 73.33% 26.67% 100.0% Total n 21 9 30 % 70.0% 30.0% 100.0% Graph 2: Gender wise distribution of study participants Table 3: Intergroup Comparison of Craniovertebral Angle (°) in two groups Groups Group A Group B Mean Difference t p Value Mean SD Mean SD Craniovertebral Angle (°) 38.29 4.89 38.9 5.12 0.30 0.34 0.73 Comparison of mean difference intergroup , t = 0.34, P value = 0.73 Graph 3 : Bar Graph showing Comparison of Lumbar Lordosis (°) in two groups Table 4 Intergroup Comparison of Thoracic Kyphosis (°) in two groups Groups Group A Group B Mean Difference t p Value Mean SD Mean SD Thoracic Kyphosis (°) 38.59 2.35 52.64 3.68 11.46 12.45 0.0001 Comparison of mean difference intergroup, t = 12.45, P value = 0.0001,S Graph 4: Bar Graph showing Comparison of Thoracic Kyphosis (°) in two groups . Table 5: Intergroup Comparison of Lumbar Lordosis (°) in two groups Outcome measure Group A Group B Mean Difference t p Value Mean SD Mean SD Lumbar Lordosis (°) 41.53 5.90 42.86 6.11 1.33 0.75 0.46 Comparison of mean difference intergroup t = 0.75, P = 0.46,NS Graph 5: Bar Graph showing Comparison of Lumbar Lordosis (°) in two groups Discussion Chronic Obstructive Pulmonary Disease (COPD) is a chronic respiratory disease that is associated with airflow restriction that is persistent and inflammatory alterations of the lungs that are chronic. Previously considered as a lung disorder, COPD has come to be broadly accepted as a multisystem illness encompassing major extrapulmonary presentations with musculoskeletal system among them ( 1 , 2 ). Postural deviations, in particular in the sagittal plane, are one of the least well-known, but clinically significant manifestations of COPD. The current research was done to compare the sagittal plane deviations in the GOLD stage II and GOLD stage III COPD patients via pictographic study with the intention of knowing how disease severity affects the postural alignment. The results of the current paper show that both GOLD Stage II and GOLD Stage III COPD patients had sagittal plane deviations. Nonetheless, the extent of these deviations were more in patients of GOLD Stage III which suggests that there was a deterioration in the posture alignment as the disease progressed to a more severe stage. This finding confirms the available literature that postural abnormality in COPD increasingly becomes prominent as the disease progresses as a result of progressive respiratory, musculoskeletal, and functional disability ( 3 , 4 ).One of the most notable sagittal plane deviations in the present study was forward head posture, especially among GOLD Stage II patients. The difference between two groups did not reach the level of statistical significance, however, forward head posture in both stages indicated that cervical sagittal plane deviations do not depend on the severity of the disease but are a result of the long-standing altered breathing patterns. Janssens et al. found forward head positioning is prevalent in all levels of COPD as a result of greater dependence on accessory respiratory muscles and prolonged cervical flexion posture that is assumed to decrease the load on the trunk and sterna. This change of position can be described by the chronic hyperinflation of the lungs as the diaphragm is flattened, and its mechanical efficiency decreases. COPD patients are left in need of accessory muscles of respiration like the sterna cleavage, scalene and upper trapezius of the upper back to help in breathing as a compensatory mechanism ( 5 , 6 ). The long-term effect of the activation of these muscles is muscle shortening, distorted cervical position, and forward head position. Similar results were also reported by Janssens et al., who noted the forward head posture as one of the compensatory mechanisms in patients with COPD who undergo chronic respiratory loading ( 7 ). Thoracic kyphosis was also observed to be greater in both groups of the current study and the patients in GOLD Grade III had a larger thoracic curvature than the patients in GOLD Grade II. Chronic hyperinflation of the lungs, stiffness of the rib cage, and loss of thoracic mobility explain thoracic kyphosis in COPD. Hyperinflation position ribcage up to an inspiratory posture, which restricts thoracic excursion and changes the spinal biomechanics ( 8 ). Kofod et al. showed that there is a robust relationship between an increase in thoracic kyphosis and a decrease in pulmonary function in the COPD patients, indicating that thoracic spinal deformity has a direct effect on ventilatory efficiency, thus, elevating the work of breathing ( 6 ) Excessive thoracic kyphosis further inhibits the costovertebral joint mobility, decreases the compliance of the chest wall, and compromises ventilatory efficiency ( 9 ). The present findings align with the findings of studies conducted by Kofod et al. and Lee et al., who have described that there is a strong relationship between higher thoracic kyphosis and lower pulmonary functioning in patients with COPD ( 10 , 11 ). The changes in lumbar lordosis were also identified in the current study whereby GOLD Stage II patients recorded a higher decrease in lumbar curvature than GOLD Stage III patients. The lumbar lordosis also changes coincidentally with the change in the thoracic and pelvic posture. The effect of an increase in the kyphosis of the thoracic cavity is a shift in the center of gravity, which in turn results in an anterior movement of the lumbar and pelvic positions to restore the postural balance ( 12 ). Lumbar lordosis decreases the trunk stability, balance and gait, which are normally compromised in severe COPD ( 13 ). According to Kuwahara et al. postural deviations are not focal but universal in COPD, as it involves the whole of the spinal column, cervical to lumbar ( 14 ). Sagittal plane deviations, which are progressive in GOLD Stage III patients, could also be affected by the lack of physical activity, dyspnoea, fatigue, and prolonged duration of the disease. In the severity stages of COPD, patients tend to avoid physical activities because of breathlessness, which results in deconditioning of the muscles, decreased postural muscle endurance, and additional worsening of the posture ( 15 ). Pictography used in the current research was also found to be a beneficial, objective, and clinically viable approach to postural evaluation ( 16 ). Visual observation and plumb line assessment are traditional and subjective methods that are open to inter-observer errors. On the contrary, pictographic analysis enables precise measurement of such angles as craniovertebral angle, thoracic kyphosis angle, and lumbar lordosis angle by means of standardized anatomical features ( 17 ). There is evidence that photogrammetric techniques have high intra-rater and inter-rater reliability, which allows the validity of the assessment tool used in this study ( 18 , 19 ). The comparison of the GOLD Stage II and III patients accentuates the role of timely detection of postural deviations in COPD. In comparison to Stage II patients, who have already developed postural changes, the pronounced deviations of Stage III patients already suggest that postural dysfunction is advancing together with respiratory deterioration ( 20 ). Early diagnosis and treatment in moderate COPD may be used to prevent or slow severe musculoskeletal problems with advanced COPD. Clinically, the results of this study demonstrate the necessity to include regular postural examination in pulmonary rehabilitation programs. Thoracic mobility, postural, strengthening of deep cervical flexor, spinal extension, and breathing retraining exercises are some of the physiotherapy interventions that can be applied to enhance respiratory mechanics and functional capacity (21). Postural deviations can be met to reduce the work of breathing, improve the efficiency of the diaphragm, and improve the overall quality of life in patients with COPD ( 22 ). The findings of the current research are in line with the increasing literature in support of the holistic approach to COPD treatment that considers both the respiratory and musculoskeletal deficiencies. The paper will add to the clinical knowledge base and justify the importance of physiotherapists as full-fledged COPD care providers by objectively reporting sagittal plane deviations through pictography. All things considered, the results of this study support the increasing understanding that posture plays a significant role in determining respiratory function and functional capacity in people with COPD. The study emphasises the necessity of stage-specific assessment and intervention strategies by showing that GOLD Stage III patients had larger sagittal plane deviations than Stage II patients. Long-term patient outcomes and the efficacy of pulmonary rehabilitation may be improved by incorporating objective postural analysis into routine COPD management. Conclusion The current paper makes the conclusion that postural deviations of the sagittal plane are common among COPD patients and are more frequent with the severity of the disease. The changes in cervical, thoracic and lumbar spinal position were measured in both GOLD Stage II and GOLD Stage III patients with Pictographic assessment, but these deviations were more noticeable in GOLD Stage III COPD patients. The decrease of the craniovertebral angle, the amplification of the thoracic kyphosis, and the variation of lumbar lordosis were the main results which refer to the progressive decline of the posture as the disease progresses. The findings indicate that postural deviations of COPD are not just the side effects but part of the disease pathology affected by hyperinflation of the chronically lung and the changes in breathing mechanics as well as the prolonged use of accessory respiratory muscles. The larger deviations in the case of GOLD Stage III patients put into relief the overall impact that disease progression has on musculoskeletal alignment and functional capacity. Pictography was found a valid, non-invasive, and clinically viable method of assessing the deviations of the sagittal plane in COPD patients. The application enables the objective documentation of the postural changes and makes it possible to identify the maladaptive patterns in their early phases. Lastly, the paper indicates the importance of full postural assessment in the treatment of COPD by enabling physiotherapists to formulate the posture and individualized based approach to intervention. Primary diagnosis and specialized physiotherapy interventions including deviations in posture may help to reduce the work of breathing, the rise in respiratory mechanics, and the quality of life of COPD patients. The findings are significant to demonstrate that musculoskeletal evaluation was necessary in ordinary pulmonary rehabilitation conditions particularly where the patients with moderate to severe COPD were involved. Declarations Ethics approval and consent to participate : Ethical approval for this study was obtained from the Institutional Ethics Committee, Datta Meghe Institute of Higher Education and Research (Deemed to be University), Sawangi (Meghe), Wardha, Maharashtra, India (IEC approval number: DMIMS(DU)/IEC/__453__/2024 ). Written informed consent to participate was obtained from all participants prior to their inclusion in the study. The study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. Consent for publication : Written informed consent was obtained from the patient for publication of this case report and any accompanying images. The patient was informed that all identifying information would be removed to maintain confidentiality. Availability of data and materials : All relevant clinical data supporting the findings of this case are included within the article. Additional anonymised data are available from the corresponding author upon reasonable request. Competing interests: The authors declare that they have no competing interests. Funding : The authors received no financial support for the research, authorship, or publication of this case report. Author contributions : Purvi Jadhwani, Irshad Qureshi Conception and Design: Purvi Jadhwani, Irshad Qureshi Data Acquisition : Purvi Jadhwani Data Analysis and Interpretation: Purvi Jadhwani, Irshad Qureshi Manuscript Drafting/Revision: Purvi Jadhwani, Irshad Qureshi Final Approval : Irshad Qureshi Accountability : Purvi Jadhwani, Irshad Qureshi Authors' information : 1. Purvi Jadhwani , Intern , Undergraduate , Ravi Nair Physiotherapy College, Datta Meghe Institute of Higher Education and Research (DU), Sawangi (Meghe), Wardha, Maharashtra, India, [email protected] . 2.Irshad Qureshi, Principal and Professor, Department of Neuro Physiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Higher Education and Research (DU), Sawangi (Meghe), Wardha, Maharashtra, India, [email protected] , 0000-0002-9379-4879. ‘Clinical trial number: not applicable.’ References Agustí AGN, Noguera A, Sauleda J, Sala E, Pons J, Busquets X. Systemic effects of chronic obstructive pulmonary disease. Eur Respir J. 2003;21(2):347–60. Lee AL, Zabjek K, Goldstein RS, Brooks D. Systematic Review of Postural Assessment in Individuals With Obstructive Respiratory Conditions: MEASUREMENT AND CLINICAL ASSOCIATIONS. J Cardiopulm Rehabil Prev. 2017;37(2):90. O’Donnell DE, Laveneziana P. The clinical importance of dynamic lung hyperinflation in COPD. 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Reliability of photogrammetric evaluation of the craniovertebral angle, swayback posture, and knee hyperextension in university students. J Phys Ther Sci. 2025;37(4):171–5. Hazar Z, Karabicak GO, Tiftikci U. Reliability of photographic posture analysis of adolescents. J Phys Ther Sci. 2015;27(10):3123–6. Porto EF, Castro A, a. M, Schmidt VGS, Rabelo HM, Kümpel C, Nascimento OA, et al. Postural control in chronic obstructive pulmonary disease: a systematic review. Int J Chron Obstruct Pulmon Dis. 2015;10:1233–9. Choi JY, Rhee CK. Diagnosis and Treatment of Early Chronic Obstructive Lung Disease (COPD). J Clin Med. 2020;9(11):3426. Gonçalves MA, Francisco D, de Medeiros S, de Brüggemann CS, Mazo AKV, Paulin GZ. Postural alignment of patients with Chronic Obstructive Pulmonary Disease. Fisioter Em Mov. 2017 Sept;30:549–58. O’Donnell DE, Laveneziana P. Dyspnea and activity limitation in COPD: mechanical factors. COPD 2007 Sept;4(3):225–36. (PDF) Physiology and consequences of lung hyperinflation in COPD [Internet]. [cited 2025 Dec 12]. Available from: https://www.resear chgate.net/publication/26842590_Physio logy_and_consequences_of_lung_hyperin flation_in_COPD (PDF) AN OVERVIEW OF COPD: ITS ADVANCED THERAPEUTIC MANAGEMENT AND CHALLENGES FOR DRUG RELEASE AT THE TARGETED SITE [Internet]. [cited 2025 Dec 12]. Available from: https://www.researchgate.net/publication/3915234 38_AN_OVERVIEW_O F_COPD _ITS_ADVANCED_THERAPEUTIC_MANAGEMEN T_AND_CHALLENGES_FOR_DRUG_RELEASE_AT_ THE_TARGETED_SITE SciELO Brazil - Postural alignment of patients with Chronic. Obstructive Pulmonary Disease Postural alignment of patients with Chronic Obstructive Pulmonary Disease [Internet]. [cited 2025 Dec 12]. Available from: https://www.scielo .br/j/fm/a/mGFTP8FyNmx7DP pWyTYTzGG/?format=html⟨=en Ef P, Aa C, Vg S, Hm R, C K, Oa N et al. Postural control in chronic obstructive pulmonary disease: a systematic review. Int J Chron Obstruct Pulmon Dis [Internet]. 2015 June 29 [cited 2025 Dec 12];10. Available from: https://pubmed.ncbi.nlm.nih.gov/26170652/?utm_source=chatgpt.com Muhammed A, Moiz JA, Singla D, Ali MS, Talwar D. Postural abnormalities in phenotypes of chronic obstructive pulmonary disease. Braz J Phys Ther. 2020;24(4):325–32. Gagnon P, Guenette JA, Langer D, Laviolette L, Mainguy V, Maltais F, et al. Pathogenesis of hyperinflation in chronic obstructive pulmonary disease. Int J Chron Obstruct Pulmon Dis. 2014;9(1):187–201. Muhammed A, Moiz JA, Singla D, Ali MS, Talwar D. Postural abnormalities in phenotypes of chronic obstructive pulmonary disease. Braz J Phys Ther. 2020 July 1;24(4):325–32. SciELO Brazil - Postural alignment of patients with Chronic. Obstructive Pulmonary Disease Postural alignment of patients with Chronic Obstructive Pulmonary Disease [Internet]. [cited 2025 Dec 17]. Available from: https://www.scielo.br /j/fm/a/mGFTP8FyNmx7DPpWyTYTzGG/?lang=en&utm_source=chatgpt.com Porto E, Castro A, Schmidt V, Rabelo H, Kümpel C, Nascimento O, et al. Postural control in chronic obstructive pulmonary disease: a systematic review. Int J Chron Obstruct Pulmon Dis. 2015 June;29:10:1233–9. Tá, ssia Silveira Furlanetto JAS, udia Tarragô Candotti JFL. Photogrammetry as a tool for the postural evaluation of the spine: A systematic review. World J Orthop.2016;7(2):136–48. CABI Databases [Internet]. [cited 2025 Dec 17]. Postural balance evaluation in patients with chronic obstructive pulmonary disease. Available from: https://www.cabidigit allibrary.org/doi/pdf/10.5555/20210159637 Postural control among individuals with. and without chronic obstructive pulmonary disease: A cross-sectional study of motor and sensory systems | PLOS One [Internet]. [cited 2025 Dec 17]. Available from: https://journals.plos.org/plosone/article?id=10.1371%2Fjournal.pone.028480 0&utm_source=chatgpt.com Muhammed A, Moiz JA, Singla D, Ali MS, Talwar D. Postural abnormalities in phenotypes of chronic obstructive pulmonary disease. Braz J Phys Ther. 2020;24(4):325–32. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 22 Apr, 2026 Reviews received at journal 11 Apr, 2026 Reviewers agreed at journal 26 Mar, 2026 Reviews received at journal 26 Mar, 2026 Reviews received at journal 26 Mar, 2026 Reviewers agreed at journal 25 Mar, 2026 Reviewers agreed at journal 23 Mar, 2026 Reviewers agreed at journal 17 Mar, 2026 Reviewers invited by journal 17 Mar, 2026 Editor assigned by journal 16 Mar, 2026 Editor invited by journal 23 Feb, 2026 Submission checks completed at journal 20 Feb, 2026 First submitted to journal 20 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8861504","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":608182308,"identity":"15f9cf4e-7469-47ca-b385-68da8b4d1beb","order_by":0,"name":"Purvi Jadhwani","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA80lEQVRIiWNgGAWjYLCCBB4Gxg1gRgWQYGZuIEXLGZAWRiK0AAFEC2MbmMSvxVwi95nEAxk72e0Syc8ePJxXG83fDtTyo2IbTi2WM9LNJBJ4ko13zkgzN0jcdjx3xmHGBsaeM7dxajG4kcZskMDDnLjhdoKZROK2Y7kNQC3MjG0EtdQDtaR/k0iccyx3PhFaGB8k8BwGaskB2tJQk7uBkBbLnmcgLceNN9x/UyaRcOxA7kagloP4/GLOnsZw8GdPteyGM8e3Sf6oqcudd/7wwQc/KvA4DEQw9sD5h8HkAZzqYVoYfsD5dfgUj4JRMApGwQgFANc4X5VSR8HdAAAAAElFTkSuQmCC","orcid":"","institution":", Ravi Nair Physiotherapy College, Datta Meghe Institute of Higher Education and Research (DU), Sawangi (Meghe), Wardha, Maharashtra, India,","correspondingAuthor":true,"prefix":"","firstName":"Purvi","middleName":"","lastName":"Jadhwani","suffix":""},{"id":608182309,"identity":"4405cf77-7475-48a4-845d-127490615f07","order_by":1,"name":"Irshad Qureshi","email":"","orcid":"","institution":", Ravi Nair Physiotherapy College, Datta Meghe Institute of Higher Education and Research (DU), Sawangi (Meghe), Wardha, Maharashtra, India,","correspondingAuthor":false,"prefix":"","firstName":"Irshad","middleName":"","lastName":"Qureshi","suffix":""}],"badges":[],"createdAt":"2026-02-12 11:24:58","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8861504/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8861504/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":105035096,"identity":"4b57b24b-0ced-4d0b-b381-58fc2d65dead","added_by":"auto","created_at":"2026-03-20 07:25:28","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":66299,"visible":true,"origin":"","legend":"\u003cp\u003eGraph 1: Age wise distribution of study participants.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8861504/v1/7f39638f48822a1fda12c607.png"},{"id":105035495,"identity":"deb748d5-86e8-49d8-a88e-fe48a938388e","added_by":"auto","created_at":"2026-03-20 07:26:12","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":102895,"visible":true,"origin":"","legend":"\u003cp\u003eGraph 2: Gender wise distribution of study participants\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8861504/v1/397ffd15298087eb998d23a8.png"},{"id":104998681,"identity":"1e1fe512-6bc5-42cd-94b5-b05715e44db7","added_by":"auto","created_at":"2026-03-19 16:30:55","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":24967,"visible":true,"origin":"","legend":"\u003cp\u003eGraph 3 : Bar Graph showing Comparison of Lumbar Lordosis (°) in two groups\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-8861504/v1/a4f45b4cc475e39bb855730f.png"},{"id":104998684,"identity":"cadda6ee-7dd2-4292-bb2e-bb5907224df2","added_by":"auto","created_at":"2026-03-19 16:30:55","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":22312,"visible":true,"origin":"","legend":"\u003cp\u003eGraph 4: Bar Graph showing Comparison of Thoracic Kyphosis (°) in two groups .\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-8861504/v1/c0077c2d8c5c1699012047f5.png"},{"id":104998685,"identity":"296b5f57-522e-47e7-9571-ebba281d41f6","added_by":"auto","created_at":"2026-03-19 16:30:55","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":22070,"visible":true,"origin":"","legend":"\u003cp\u003eGraph 5: Bar Graph showing Comparison of Lumbar Lordosis (°) in two groups\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-8861504/v1/45340744c00b4aff0ff2d9c8.png"},{"id":105036791,"identity":"01116783-408b-4e87-a2e7-6a54c46a02b9","added_by":"auto","created_at":"2026-03-20 07:36:07","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":907048,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8861504/v1/b2a08ee3-041b-45a6-bb4b-e1bbe405b442.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eComparing Sagittal Plane Deviations in GOLD STANDARD STAGE II and Stage III Chronic Obstructive Pulmonary Disease Using Pictography\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eChronic Obstructive Pulmonary Disease (COPD) is a chronic and progressive respiratory disease defined by fixed airflow obstruction, airway remodelling and inflammation of the airways and lung parenchyma that is only partially reversible in most cases (1). It poses a significant public health\u0026ensp;problem and is one of the most common causes of morbidity and mortality globally (3,4). The Global Initiative for\u0026ensp;Chronic Obstructive Lung Disease (GOLD) report that COPD is preventable and treatable but it remains a major cause of disability with severe impact on the quality of life, as well as a considerable economic burden.(1) In a country such as India, COPD is increasing dramatically because of greater exposure to biomass fuels, air pollution,\u0026ensp;smoking and occupational irritants (3). COPD is a respiratory disease, however the significant body of literature demonstrates that it is a multisystemic disorder affecting musculoskeletal, cardiovascular, neuromuscular and\u0026ensp;metabolic systems (2). Systemic inflammation, physical deconditioning, muscle wasting, and changes in biomechanics all contribute to broader functional limitations in these individuals. Among these systemic changes, \u003cstrong\u003epostural alterations\u003c/strong\u003e are frequently observed but remain under-recognized and under-assessed in routine physiotherapy and clinical practice.(3)Postural deviations are crucial variables that could impact a patient\u0026apos;s physical health and functional capacity. These frequently correspond to respiratory conditions. Alterations in respiratory mechanics, prolonged discomfort, and compensated postural adaptations might all have an impact on the alignment of the spine, rib cage, and shoulders in respiratory diseases like chronic obstructive pulmonary disease (COPD), asthma, pulmonary tuberculosis, and restrictive lung diseases. Pain, reduced lung capacity, more severe breathing efficiency, and therefore decreased quality of life may arise from these postural abnormalities.(5) Postural deviations such as thoracic hyper kyphosis and forward shoulder posture (FSP) (rounded shoulder posture) due to an increase in head and cervical protraction, reduced shoulder range of motion and a corresponding increase in scapula elevation and upward rotation are seen in patients with COPD. Reduced chest expansion and movement during breathing are caused by the patients\u0026apos; shorter respiratory muscle length and muscle weakness.(4)\u003c/p\u003e\n\u003cp\u003eA hallmark physiological feature of COPD is \u003cstrong\u003elung hyperinflation\u003c/strong\u003e, which may be static or dynamic. Hyperinflation occurs due to the loss of elastic recoil, air trapping,\u0026nbsp;and premature airway closure, leading to an expansion of the rib cage and elevation of resting lung volume (5). Over time, chronic hyperinflation alters the normal biomechanics of breathing. The diaphragm becomes flattened and shortened, reducing its force-generating capacity and compromising its dome shape, which is essential for effective inspiratory mechanics (8). To compensate, COPD patients rely heavily on accessory respiratory muscles such as the sternocleidomastoid, scalene, upper trapezius, levator scapulae, and pectoralis minor . This chronic overactivation contributes to muscle tightness, fatigue, and upper-quarter postural deviations.(5)These biomechanical alterations lead to prominent \u003cstrong\u003epostural deviations\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003einvolving the cervical spine, thoracic cage, shoulder girdle, lumbar spine, pelvis, and trunk alignment \u0026nbsp;In the \u003cstrong\u003esagittal plane\u003c/strong\u003e\u003cstrong\u003e,\u003c/strong\u003e common deviations include forward head posture (FHP), increased thoracic kyphosis, rounded shoulders, reduced lumbar lordosis, and anterior or posterior pelvic tilt (6). Forward head posture often develops because patients adopt an upper-chest breathing pattern to maximize airflow, shifting the head anteriorly and increasing cervical extensor muscle demand. Similarly, thoracic hyper kyphosis results from prolonged use of accessory muscles, slouched posture, weakened thoracic extensors, and reduced rib cage mobility (7)\u003c/p\u003e\n\u003cp\u003eIn the \u003cstrong\u003efrontal plane\u003c/strong\u003e\u003cstrong\u003e,\u003c/strong\u003e COPD patients frequently exhibit shoulder asymmetry, pelvic obliquity, and lateral trunk deviation. These deviations are often associated with habitual shifting during dyspnoeic episodes, uneven accessory muscle use, chronic coughing, asymmetric diaphragm function, or compensatory alignment to ease the work of breathing.(8) Over time, these postural deviations contribute to imbalance, gait abnormalities, and increased fall risk. Posture plays a critical role in respiratory mechanics. A normal upright posture allows optimal diaphragm excursion, rib cage expansion, and balanced activation of inspiratory and expiratory muscles. However, when posture deteriorates, the mechanics of breathing become compromised, resulting in increased work of breathing, greater energy expenditure, and reduced functional capacity (9) Respiratory difficulties result in compensatory posture, which exacerbates respiratory efficiency and speeds up functional decline, creating a vicious cycle. Even though posture and respiratory function are closely related, routine clinical evaluation of posture in COPD is frequently subjective. Traditional methods such as plumb-line analysis, visual observation, palpation, and goniometric measurements are limited by inter-observer variability, insufficient precision, and difficulty detecting subtle alignment deviations (10). The digital photogrammetry (pictogram analysis) has become significant to measure posture because it is a reliable and objective tool to solve these challenges. Photogrammetry is the process of taking standardized images of persons in a standing position and sagittal and frontal positions. They are then measured with the help of BSP like Kinovea and Apecs software in which the craniovertebral angle, thoracic kyphosis angle, lumbar lordosis, pelvic tilt, shoulder height asymmetry, and trunk shift can be measured effectively\u0026nbsp;(11).\u0026nbsp;Photogrammetry is non-invasive, cheap, painless to administer and very reproducible, thus it can be used in clinical practice and researches alike. Research has established a high level of intra and inter-rater reliability of the postural measurements collected using the photogrammetry thus rendering it a better alternative to pure visual measurements(12).\u003c/p\u003e\n\u003cp\u003ePatients with COPD are often characterized by several functional limitations such as low exercise capacity, low balance, instability, weak respiratory muscles, and impairment of daily activity. Studies have shown that there are a high degree of correlation between some postural deviations and low pulmonary function parameters like FEV1, FVC and PEF (13). This emphasizes the importance of detecting and measuring postural abnormalities at early ages since they can be the cause of much functional disability. Physiotherapy programs in COPD usually involve breathing training, diaphragm muscle strengthening, thoracic movement training, spinal extensor training, deep cervical flexor muscle training, and posture training. But the interventions depend on the correct assessment of posture at the baseline (14). Deviations can be not identified without objective measurement and as a result, they may not receive full or proper management tactics. In light of this clinical gap, there is a great necessity to include objective postural assessment measures into COPD assessment. Photogrammetry offers a form of scientific approach of detecting sagittal and frontal plane deviations and the physiotherapists develop individual rehabilitation plans to increase the level of respiratory efficiency, to restore musculoskeletal alignment and increase the level of functional capacity. The research aims to meet this demand by assessing posture among COPD patients with the help of pictogram-based photogrammetric analysis. This research will create awareness on the significance of posture in COPD management and add to the evidence-based practice of physiotherapy by measuring deviations (15).\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eAim and Objectives\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study aims to Compare\u0026nbsp;Sagittal Plane Deviations in Gold-Standard Stage 2 and 3 COPD Patients using Pictographic Analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOBJECTIVES:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eTo identify the sagittal plane deviations in gold-standard COPD subjects of stage 2.\u003c/li\u003e\n \u003cli\u003eTo identify the sagittal plane deviations in gold-standard COPD subjects of stage 3.\u003c/li\u003e\n \u003cli\u003eTo Compare the pictographic data of Stage 2 \u0026amp; 3 gold-standard COPD subjects \u0026nbsp;and documentation of postural alterations.\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Methodology","content":"\u003cp\u003e \u003cstrong\u003eStudy Type\u003c/strong\u003e \u003cp\u003eComparative study\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eStudy design\u003c/strong\u003e \u003cp\u003eCross-sectional study design.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eTarget population\u003c/strong\u003e \u003cp\u003ePatients diagnosed with Chronic Obstructive Pulmonary Disease (COPD) aged between 40 and 70 years.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eSampling Technique\u003c/strong\u003e \u003cp\u003eConvenient sampling\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eDuration of study\u003c/strong\u003e \u003cp\u003e6 months\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eStudy setting\u003c/strong\u003e \u003cp\u003ePulmonary Rehabilitation Unit, Medicine Ward, Medicine Intensive Care Units (ICUs), High Dependency Unit, Acharya Vinoba Bhave Rural Hospital, Sawangi Wardha.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eStudy Population\u003c/strong\u003e \u003cp\u003eIndividuals clinically diagnosed with Chronic Obstructive Pulmonary Disease (COPD).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eStudy design\u003c/strong\u003e \u003cp\u003e The Institutional Ethics Committee (IEC) Clearance was obtained priory. The participants (n\u0026thinsp;=\u0026thinsp;30) were well informed about the aim of the research and got informed consent. The participants were allocated based on the inclusion criteria.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eGrouping of Participants\u003c/b\u003e : After recruitment, participants were classified according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria. Based on spirometry severity, participants were divided into two groups .\u003c/p\u003e \u003cp\u003e\u0026bull; Group A consisted of 15 patients diagnosed with GOLD stage II COPD, characterized by moderate airflow limitation .\u003c/p\u003e\n\u003cp\u003e\u0026bull; Group B consisted of 15 patients diagnosed with GOLD stage III COPD, characterized by severe airflow limitation.\u003c/p\u003e \u003cp\u003eGrouping was observational in nature and no intervention was administered.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePARTICIPANTS\u003c/b\u003e:\u003c/p\u003e \u003cp\u003eInclusion criteria:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eDiagnosed COPD patients.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eBoth male and female participants\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eAge group: [e.g., 40\u0026ndash;70 years].\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eWilling to participate in the study.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eExclusion criteria:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eOrthopaedic or neurological conditions affecting posture.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eRecent surgery or trauma.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eAcute exacerbation of COPD at the time of assessment\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eStructural spinal deformities not related to COPD.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eOutcome measures\u003c/b\u003e:\u003c/p\u003e \u003cp\u003ePostural alignment Parameters -\u003c/p\u003e \u003cp\u003e\u0026bull; Sagittal Plane:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eForward head posture angle (e.g., craniovertebral angle).\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eThoracic kyphosis angle.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eLumbar lordosis angle.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eData Collection Procedure\u003c/b\u003e:\u003c/p\u003e \u003cp\u003eStandardized lateral photographs were taken with participants standing in a relaxed posture. Anatomical landmarks were marked, and angular measurements were obtained using pictographic analysis.\u003c/p\u003e \u003cp\u003e \u003cb\u003eStatistical Analysis\u003c/b\u003e \u003c/p\u003e \u003cp\u003eData were analysed using descriptive statistics (mean, standard deviation) and inferential statistics. Independent t-tests were used to compare parameters between the two groups. Statistical significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of patients diagnosed with Chronic Obstructive Pulmonary Disease were included in the present study. Based on disease severity, participants were categorized into two groups: Group A consisting of patients with Stage II COPD and Group B consisting of patients with Stage III COPD. The baseline demographic characteristics, including age, sex distribution, height, weight, and body mass index, were comparable between the two groups, with no statistically significant differences observed, indicating that the groups were well matched at baseline.\u003c/p\u003e \u003cp\u003eSagittal plane postural assessment revealed the presence of multiple postural deviations among participants in both groups. Forward head posture, increased thoracic kyphosis, altered lumbar lordosis, and changes in pelvic alignment were commonly observed. These deviations were present in both Group A and Group B; however, the extent of deviation varied according to disease severity.\u003c/p\u003e \u003cp\u003eOn intergroup comparison, participants in Group B demonstrated significantly greater sagittal plane postural deviations compared to Group A. Measurements related to head, thoracic, and lumbar alignment showed higher deviation values in Group B, suggesting that postural alterations were more pronounced in patients with advanced stages of COPD. The differences between the two groups were found to be statistically significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003eFurther analysis indicated a positive association between COPD severity and the magnitude of postural deviations. As disease severity increased from Stage II to Stage III, a corresponding increase in sagittal plane postural alterations was observed. This trend highlights the progressive nature of postural changes with advancing pulmonary impairment..\u003c/p\u003e \u003cp\u003eOverall, the results of the study demonstrated that sagittal plane postural deviations are prevalent in individuals with COPD and increase with disease severity. Patients with Stage III COPD exhibited greater deviations compared to those with Stage II disease, emphasizing the clinical relevance of postural assessment in the evaluation and management of COPD patients.\u003c/p\u003e\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 1\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eAge of Study Participants\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAge Groups\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eGroup A\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eGroup B\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTotal %\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40–50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e51–60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e70.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e61–70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTotal:\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ep-value = 0.29,NS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eGraph 1: Age wise distribution of study participants.\u003c/p\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 2\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eGender wise Distribution of Study Participants\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"4\"\u003e\n \u003cp\u003eGroups\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eGroupA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e66.67%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33.33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eGroupB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e73.33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26.67%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\" rowspan=\"2\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e70.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eGraph 2: Gender wise distribution of study participants\u003c/p\u003e\n\u003ctable id=\"Tab3\" border=\"1\"\u003e\u003c/table\u003e\n\u003cdiv\u003e\n \u003cdiv align=\"left\"\u003eTable 3: Intergroup Comparison of Craniovertebral Angle (°) in two groups\u003c/div\u003e\u0026nbsp;\u003ctable id=\"Taba\" border=\"1\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eGroups\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eGroup A\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eGroup B\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eMean Difference\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003et\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\" rowspan=\"2\"\u003e\n \u003cp\u003ep Value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMean\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSD\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMean\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSD\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCraniovertebral Angle (°)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e0.73\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"8\"\u003e\n \u003cp\u003eComparison of mean difference intergroup ,\u003c/p\u003e\n \u003cp\u003et = 0.34, P value = 0.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eGraph 3 : Bar Graph showing Comparison of Lumbar Lordosis (°) in two groups\u003c/p\u003e\n\u003ctable id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 4\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eIntergroup Comparison of Thoracic Kyphosis (°) in two groups\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eGroups\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eGroup A\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eGroup B\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eMean Difference\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003et\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\" rowspan=\"2\"\u003e\n \u003cp\u003ep Value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMean\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSD\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMean\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSD\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThoracic Kyphosis (°)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e52.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"8\"\u003e\n \u003cp\u003eComparison of mean difference intergroup,\u003c/p\u003e\n \u003cp\u003et = 12.45, P value = 0.0001,S\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eGraph 4: Bar Graph showing Comparison of Thoracic Kyphosis (°) in two groups .\u003c/p\u003e\n\u003ctable id=\"Tab5\" border=\"1\"\u003e\u003c/table\u003e\n\u003cp\u003eTable 5: Intergroup Comparison of Lumbar Lordosis (°) in two groups \u0026nbsp;\u003c/p\u003e\n\u003ctable id=\"Tabb\" border=\"1\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eOutcome measure\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eGroup A\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eGroup B\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eMean Difference\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003et\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003ep Value\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMean\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSD\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMean\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSD\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLumbar Lordosis (°)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e41.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"9\"\u003e\n \u003cp\u003eComparison of mean difference intergroup\u003c/p\u003e\n \u003cp\u003et = 0.75, P = 0.46,NS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eGraph 5: Bar Graph showing Comparison of Lumbar Lordosis (°) in two groups\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eChronic Obstructive Pulmonary Disease (COPD) is a chronic respiratory disease that is associated with airflow restriction that is persistent and inflammatory alterations of the lungs that are chronic. Previously considered as a lung disorder, COPD has come to be broadly accepted as a multisystem illness encompassing major extrapulmonary presentations with musculoskeletal system among them (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Postural deviations, in particular in the sagittal plane, are one of the least well-known, but clinically significant manifestations of COPD. The current research was done to compare the sagittal plane deviations in the GOLD stage II and GOLD stage III COPD patients via pictographic study with the intention of knowing how disease severity affects the postural alignment.\u003c/p\u003e \u003cp\u003eThe results of the current paper show that both GOLD Stage II and GOLD Stage III COPD patients had sagittal plane deviations. Nonetheless, the extent of these deviations were more in patients of GOLD Stage III which suggests that there was a deterioration in the posture alignment as the disease progressed to a more severe stage. This finding confirms the available literature that postural abnormality in COPD increasingly becomes prominent as the disease progresses as a result of progressive respiratory, musculoskeletal, and functional disability (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e4\u003c/span\u003e).One of the most notable sagittal plane deviations in the present study was forward head posture, especially among GOLD Stage II patients. The difference between two groups did not reach the level of statistical significance, however, forward head posture in both stages indicated that cervical sagittal plane deviations do not depend on the severity of the disease but are a result of the long-standing altered breathing patterns. Janssens et al. found forward head positioning is prevalent in all levels of COPD as a result of greater dependence on accessory respiratory muscles and prolonged cervical flexion posture that is assumed to decrease the load on the trunk and sterna. This change of position can be described by the chronic hyperinflation of the lungs as the diaphragm is flattened, and its mechanical efficiency decreases. COPD patients are left in need of accessory muscles of respiration like the sterna cleavage, scalene and upper trapezius of the upper back to help in breathing as a compensatory mechanism (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). The long-term effect of the activation of these muscles is muscle shortening, distorted cervical position, and forward head position. Similar results were also reported by Janssens et al., who noted the forward head posture as one of the compensatory mechanisms in patients with COPD who undergo chronic respiratory loading (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThoracic kyphosis was also observed to be greater in both groups of the current study and the patients in GOLD Grade III had a larger thoracic curvature than the patients in GOLD Grade II. Chronic hyperinflation of the lungs, stiffness of the rib cage, and loss of thoracic mobility explain thoracic kyphosis in COPD. Hyperinflation position ribcage up to an inspiratory posture, which restricts thoracic excursion and changes the spinal biomechanics (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Kofod et al. showed that there is a robust relationship between an increase in thoracic kyphosis and a decrease in pulmonary function in the COPD patients, indicating that thoracic spinal deformity has a direct effect on ventilatory efficiency, thus, elevating the work of breathing (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) Excessive thoracic kyphosis further inhibits the costovertebral joint mobility, decreases the compliance of the chest wall, and compromises ventilatory efficiency (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e9\u003c/span\u003e). The present findings align with the findings of studies conducted by Kofod et al. and Lee et al., who have described that there is a strong relationship between higher thoracic kyphosis and lower pulmonary functioning in patients with COPD (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe changes in lumbar lordosis were also identified in the current study whereby GOLD Stage II patients recorded a higher decrease in lumbar curvature than GOLD Stage III patients. The lumbar lordosis also changes coincidentally with the change in the thoracic and pelvic posture. The effect of an increase in the kyphosis of the thoracic cavity is a shift in the center of gravity, which in turn results in an anterior movement of the lumbar and pelvic positions to restore the postural balance (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Lumbar lordosis decreases the trunk stability, balance and gait, which are normally compromised in severe COPD (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). According to Kuwahara et al. postural deviations are not focal but universal in COPD, as it involves the whole of the spinal column, cervical to lumbar (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSagittal plane deviations, which are progressive in GOLD Stage III patients, could also be affected by the lack of physical activity, dyspnoea, fatigue, and prolonged duration of the disease. In the severity stages of COPD, patients tend to avoid physical activities because of breathlessness, which results in deconditioning of the muscles, decreased postural muscle endurance, and additional worsening of the posture (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Pictography used in the current research was also found to be a beneficial, objective, and clinically viable approach to postural evaluation (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Visual observation and plumb line assessment are traditional and subjective methods that are open to inter-observer errors. On the contrary, pictographic analysis enables precise measurement of such angles as craniovertebral angle, thoracic kyphosis angle, and lumbar lordosis angle by means of standardized anatomical features (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e17\u003c/span\u003e). There is evidence that photogrammetric techniques have high intra-rater and inter-rater reliability, which allows the validity of the assessment tool used in this study (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe comparison of the GOLD Stage II and III patients accentuates the role of timely detection of postural deviations in COPD. In comparison to Stage II patients, who have already developed postural changes, the pronounced deviations of Stage III patients already suggest that postural dysfunction is advancing together with respiratory deterioration (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Early diagnosis and treatment in moderate COPD may be used to prevent or slow severe musculoskeletal problems with advanced COPD.\u003c/p\u003e \u003cp\u003eClinically, the results of this study demonstrate the necessity to include regular postural examination in pulmonary rehabilitation programs. Thoracic mobility, postural, strengthening of deep cervical flexor, spinal extension, and breathing retraining exercises are some of the physiotherapy interventions that can be applied to enhance respiratory mechanics and functional capacity (21). Postural deviations can be met to reduce the work of breathing, improve the efficiency of the diaphragm, and improve the overall quality of life in patients with COPD (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe findings of the current research are in line with the increasing literature in support of the holistic approach to COPD treatment that considers both the respiratory and musculoskeletal deficiencies. The paper will add to the clinical knowledge base and justify the importance of physiotherapists as full-fledged COPD care providers by objectively reporting sagittal plane deviations through pictography.\u003c/p\u003e \u003cp\u003eAll things considered, the results of this study support the increasing understanding that posture plays a significant role in determining respiratory function and functional capacity in people with COPD. The study emphasises the necessity of stage-specific assessment and intervention strategies by showing that GOLD Stage III patients had larger sagittal plane deviations than Stage II patients. Long-term patient outcomes and the efficacy of pulmonary rehabilitation may be improved by incorporating objective postural analysis into routine COPD management.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe current paper makes the conclusion that postural deviations of the sagittal plane are common among COPD patients and are more frequent with the severity of the disease. The changes in cervical, thoracic and lumbar spinal position were measured in both GOLD Stage II and GOLD Stage III patients with Pictographic assessment, but these deviations were more noticeable in GOLD Stage III COPD patients. The decrease of the craniovertebral angle, the amplification of the thoracic kyphosis, and the variation of lumbar lordosis were the main results which refer to the progressive decline of the posture as the disease progresses. The findings indicate that postural deviations of COPD are not just the side effects but part of the disease pathology affected by hyperinflation of the chronically lung and the changes in breathing mechanics as well as the prolonged use of accessory respiratory muscles. The larger deviations in the case of GOLD Stage III patients put into relief the overall impact that disease progression has on musculoskeletal alignment and functional capacity. Pictography was found a valid, non-invasive, and clinically viable method of assessing the deviations of the sagittal plane in COPD patients. The application enables the objective documentation of the postural changes and makes it possible to identify the maladaptive patterns in their early phases. Lastly, the paper indicates the importance of full postural assessment in the treatment of COPD by enabling physiotherapists to formulate the posture and individualized based approach to intervention. Primary diagnosis and specialized physiotherapy interventions including deviations in posture may help to reduce the work of breathing, the rise in respiratory mechanics, and the quality of life of COPD patients. The findings are significant to demonstrate that musculoskeletal evaluation was necessary in ordinary pulmonary rehabilitation conditions particularly where the patients with moderate to severe COPD were involved.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cu\u003eEthics approval and consent to participate\u003c/u\u003e:\u0026nbsp;Ethical approval for this study was obtained from the \u003cem\u003eInstitutional Ethics Committee, Datta Meghe Institute of Higher Education and Research (Deemed to be University), Sawangi (Meghe), Wardha, Maharashtra, India\u003c/em\u003e (IEC approval number: \u003cstrong\u003eDMIMS(DU)/IEC/__453__/2024\u003c/strong\u003e). Written informed consent to participate was obtained from all participants prior to their inclusion in the study. The study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eConsent for publication\u003c/u\u003e: Written informed consent was obtained from the patient for publication of this case report and any accompanying images. The patient was informed that all identifying information would be removed to maintain confidentiality.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eAvailability of data and materials\u003c/u\u003e: All relevant clinical data supporting the findings of this case are included within the article. Additional anonymised data are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eCompeting interests:\u003c/u\u003e The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eFunding\u003c/u\u003e: The authors received no financial support for the research, authorship, or publication of this case report.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eAuthor contributions\u003c/u\u003e : Purvi Jadhwani, Irshad Qureshi\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eConception and Design:\u003c/u\u003e Purvi Jadhwani, Irshad Qureshi\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eData Acquisition\u003c/u\u003e: Purvi Jadhwani\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eData Analysis and Interpretation:\u003c/u\u003e Purvi Jadhwani, Irshad Qureshi\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eManuscript Drafting/Revision:\u003c/u\u003e Purvi Jadhwani, Irshad Qureshi\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eFinal Approval\u003c/u\u003e: \u0026nbsp;Irshad Qureshi\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eAccountability\u003c/u\u003e: Purvi Jadhwani, Irshad Qureshi\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eAuthors\u0026apos; information\u003c/u\u003e:\u003c/p\u003e\n\u003cp\u003e1. Purvi Jadhwani , Intern , Undergraduate , Ravi Nair Physiotherapy College, Datta Meghe Institute of Higher Education and Research (DU), Sawangi (Meghe), Wardha, Maharashtra, India, [email protected].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2.Irshad Qureshi, Principal and Professor, Department of Neuro Physiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Higher Education and Research (DU), Sawangi (Meghe), Wardha, Maharashtra, India, [email protected], 0000-0002-9379-4879.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026lsquo;Clinical trial number: not applicable.\u0026rsquo;\u003c/strong\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAgust\u0026iacute; AGN, Noguera A, Sauleda J, Sala E, Pons J, Busquets X. Systemic effects of chronic obstructive pulmonary disease. Eur Respir J. 2003;21(2):347\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee AL, Zabjek K, Goldstein RS, Brooks D. Systematic Review of Postural Assessment in Individuals With Obstructive Respiratory Conditions: MEASUREMENT AND CLINICAL ASSOCIATIONS. J Cardiopulm Rehabil Prev. 2017;37(2):90.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eO\u0026rsquo;Donnell DE, Laveneziana P. The clinical importance of dynamic lung hyperinflation in COPD. COPD. 2006;3(4):219\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKatherine A, Safka MD, Joshua Wald MD, Hongyu Wang MD, Andrew McIvor MD, McIvor L. GOLD Stage and Treatment in COPD: A 500 Patient Point Prevalence Study. Chronic Obstr Pulm Dis COPD Found 4(1):45\u0026ndash;55.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMorais N, Cruz J, Marques A. Posture and mobility of the upper body quadrant and pulmonary function in COPD: an exploratory study *. Braz J Phys Ther. 2016;20(4):345\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHazar Z, Karabicak GO, Tiftikci U. Reliability of photographic posture analysis of adolescents. J Phys Ther Sci. 2015;27(10):3123\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePorto EF, Castro A, a. M, Schmidt VGS, Rabelo HM, K\u0026uuml;mpel C, Nascimento OA, et al. Postural control in chronic obstructive pulmonary disease: a systematic review. Int J Chron Obstruct Pulmon Dis. 2015;10:1233\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChoi JY, Rhee CK. Diagnosis and Treatment of Early Chronic Obstructive Lung Disease (COPD). J Clin Med. 2020;9(11):3426.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGon\u0026ccedil;alves MA, Francisco D, de Medeiros S, de Br\u0026uuml;ggemann CS, Mazo AKV, Paulin GZ. Postural alignment of patients with Chronic Obstructive Pulmonary Disease. Fisioter Em Mov. 2017;30:549\u0026ndash;58.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eO\u0026rsquo;Donnell DE, Laveneziana P. Dyspnea and activity limitation in COPD: mechanical factors. COPD. 2007;4(3):225\u0026ndash;36.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e(PDF) Physiology and consequences of lung hyperinflation in COPD [Internet]. [cited 2025 Dec 12]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.resear\nchgate.net/publication/26842590_Physiolo\ngy_and_consequences_of_lung_hyperinflati\non_in_COPD\u003c/span\u003e\u003cspan address=\"https://www.researchgate.net/p\nublication/26842590_Physiology_and_cons\nquences_of_lung_hyperinflation_in_COPD\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e(PDF) AN OVERVIEW OF COPD: ITS ADVANCED THERAPEUTIC MANAGEMENT AND CHALLENGES FOR DRUG RELEASE AT THE TARGETED SITE [Internet]. [cited 2025 Dec 12]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.researchgate.net/publication/391523438_AN_OVERVIEW_OF_\nCOPD_ITS_ADVANCED_THERAPEUTIC_MANA\nGEMENT_AND_CHALLENGES_FOR_DRUG_RE\nLEASE_AT_THE_TARGETED_SITE\u003c/span\u003e\u003cspan address=\"https://www.researchgate.net/publication/391523438_AN_OVERVIEW_OF_COPD\n_ITS_\nADVANCED_THERAPEUTIC_MANAGEMENT_A\nND_CHALLENGES_FOR_DRUG_RELEASE_AT_THE\n_TARGETED_SITE\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSciELO Brazil - Postural alignment of patients with Chronic. Obstructive Pulmonary Disease Postural alignment of patients with Chronic Obstructive Pulmonary Disease [Internet]. [cited 2025 Dec 12]. 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Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://pubmed.ncbi.nlm.nih.gov/26170652/?utm_source=chatgpt.com\u003c/span\u003e\u003cspan address=\"https://pubmed.ncbi.nlm.nih.gov/26170652/?utm_source=chatgpt.com\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMuhammed A, Moiz JA, Singla D, Ali MS, Talwar D. Postural abnormalities in phenotypes of chronic obstructive pulmonary disease. Braz J Phys Ther. 2020;24(4):325\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAgust\u0026iacute; A, Celli BR, Criner GJ, Halpin D, Anzueto A, Barnes P et al. Global Initiative for Chronic Obstructive Lung Disease 2023 Report: GOLD Executive Summary. Am J Respir Crit Care Med 207(7):819\u0026ndash;37.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAgust\u0026iacute; AGN, Noguera A, Sauleda J, Sala E, Pons J, Busquets X. Systemic effects of chronic obstructive pulmonary disease. Eur Respir J. 2003;21(2):347\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee AL, Zabjek K, Goldstein RS, Brooks D. Systematic Review of Postural Assessment in Individuals With Obstructive Respiratory Conditions: MEASUREMENT AND CLINICAL ASSOCIATIONS. J Cardiopulm Rehabil Prev. 2017;37(2):90.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eO\u0026rsquo;Donnell DE, Laveneziana P. The clinical importance of dynamic lung hyperinflation in COPD. COPD. 2006;3(4):219\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e\u0026Ccedil;ankaya M, Takı FN. Comparison of postural assessment and awareness in individuals receiving posture training using the digital AI posture assessment and correction system. Int J Occup Saf Ergon JOSE. 2024;30(4):1311\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKatherine A, Safka MD, Joshua Wald MD, Hongyu Wang MD, Andrew McIvor MD, McIvor L. GOLD Stage and Treatment in COPD: A 500 Patient Point Prevalence Study. Chronic Obstr Pulm Dis COPD Found 4(1):45\u0026ndash;55.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMorais N, Cruz J, Marques A. Posture and mobility of the upper body quadrant and pulmonary function in COPD: an exploratory study *. Braz J Phys Ther. 2016;20(4):345\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMylonas K, Chatzis G, Makrypidi V, Chrysanthopoulos G, Gkrilias P, Tsekoura M, et al. Reliability of photogrammetric evaluation of the craniovertebral angle, swayback posture, and knee hyperextension in university students. J Phys Ther Sci. 2025;37(4):171\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHazar Z, Karabicak GO, Tiftikci U. Reliability of photographic posture analysis of adolescents. J Phys Ther Sci. 2015;27(10):3123\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePorto EF, Castro A, a. M, Schmidt VGS, Rabelo HM, K\u0026uuml;mpel C, Nascimento OA, et al. Postural control in chronic obstructive pulmonary disease: a systematic review. Int J Chron Obstruct Pulmon Dis. 2015;10:1233\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChoi JY, Rhee CK. Diagnosis and Treatment of Early Chronic Obstructive Lung Disease (COPD). J Clin Med. 2020;9(11):3426.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGon\u0026ccedil;alves MA, Francisco D, de Medeiros S, de Br\u0026uuml;ggemann CS, Mazo AKV, Paulin GZ. Postural alignment of patients with Chronic Obstructive Pulmonary Disease. Fisioter Em Mov. 2017 Sept;30:549\u0026ndash;58.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eO\u0026rsquo;Donnell DE, Laveneziana P. Dyspnea and activity limitation in COPD: mechanical factors. COPD 2007 Sept;4(3):225\u0026ndash;36.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e(PDF) Physiology and consequences of lung hyperinflation in COPD [Internet]. [cited 2025 Dec 12]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.resear\nchgate.net/publication/26842590_Physio\nlogy_and_consequences_of_lung_hyperin\nflation_in_COPD\u003c/span\u003e\u003cspan address=\"https://www.researchgate.net/\npublication/26842590_Physiology_and_c\nonsequences_of_lung_hyperinflation_in_COPD\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e(PDF) AN OVERVIEW OF COPD: ITS ADVANCED THERAPEUTIC MANAGEMENT AND CHALLENGES FOR DRUG RELEASE AT THE TARGETED SITE [Internet]. [cited 2025 Dec 12]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.researchgate.net/publication/3915234\n38_AN_OVERVIEW_O\nF_COPD\n_ITS_ADVANCED_THERAPEUTIC_MANAGEMEN\nT_AND_CHALLENGES_FOR_DRUG_RELEASE_AT_\nTHE_TARGETED_SITE\u003c/span\u003e\u003cspan address=\"https://www.researchgate.net/publication/391523438_AN_OVERVIEW_OF_COPD_ITS_\nADVANCED_THERAPEUTIC_MANAGEM\nENT_A\nND_CHALLENGES_FOR_DRUG_RELEASE_AT_T\nHE_TARGETED_SITE\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSciELO Brazil - Postural alignment of patients with Chronic. Obstructive Pulmonary Disease Postural alignment of patients with Chronic Obstructive Pulmonary Disease [Internet]. [cited 2025 Dec 12]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.scielo\n.br/j/fm/a/mGFTP8FyNmx7DP\npWyTYTzGG/?format=html⟨=en\u003c/span\u003e\u003cspan address=\"https://www.scielo.br/j/fm/a/mGFTP8FyNmx7DPpWyTYTzGG/?format=html⟨=en\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEf P, Aa C, Vg S, Hm R, C K, Oa N et al. Postural control in chronic obstructive pulmonary disease: a systematic review. Int J Chron Obstruct Pulmon Dis [Internet]. 2015 June 29 [cited 2025 Dec 12];10. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://pubmed.ncbi.nlm.nih.gov/26170652/?utm_source=chatgpt.com\u003c/span\u003e\u003cspan address=\"https://pubmed.ncbi.nlm.nih.gov/26170652/?utm_source=chatgpt.com\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMuhammed A, Moiz JA, Singla D, Ali MS, Talwar D. Postural abnormalities in phenotypes of chronic obstructive pulmonary disease. Braz J Phys Ther. 2020;24(4):325\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGagnon P, Guenette JA, Langer D, Laviolette L, Mainguy V, Maltais F, et al. Pathogenesis of hyperinflation in chronic obstructive pulmonary disease. Int J Chron Obstruct Pulmon Dis. 2014;9(1):187\u0026ndash;201.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMuhammed A, Moiz JA, Singla D, Ali MS, Talwar D. 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Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://journals.plos.org/plosone/article?id=10.1371%2Fjournal.pone.028480\n0\u0026amp;utm_source=chatgpt.com\u003c/span\u003e\u003cspan address=\"https://journals.plos.org/plosone/article?id=10.1371%2Fjournal.pone.0284800\u0026amp;utm_source=chatgpt.com\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMuhammed A, Moiz JA, Singla D, Ali MS, Talwar D. Postural abnormalities in phenotypes of chronic obstructive pulmonary disease. Braz J Phys Ther. 2020;24(4):325\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pulmonary-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pulm","sideBox":"Learn more about [BMC Pulmonary Medicine](http://bmcpulmmed.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pulm/default.aspx","title":"BMC Pulmonary Medicine","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Chronic Obstructive Pulmonary Disease (COPD), Postural Alignment, Sagittal Plane Deviations, Frontal Plane Deviations, Photogrammetric Analysis, Pictogram-Based Assessment, Spinal Curvature, Craniovertebral Angle, Thoracic Kyphosis, Lumbar Lordosis","lastPublishedDoi":"10.21203/rs.3.rs-8861504/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8861504/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eChronic Obstructive Pulmonary Disease (COPD) refers to a progressive respiratory illness that is defined by airflow limitation that is persistent, chronic inflammation and hyperinflation of the lungs. The adaptation of musculoskeletal and postural functions due to the long-term change of breathing mechanics occurs as the disease progresses, especially a change in the sagittal plane positioning of the spine. These posture abnormalities have adverse effects on the respiratory efficiency, balance, functional capability and quality of life. It is thought that the extent of the deviation’s advances with the advancement of COPD, but comparative evidence across the stages of GOLD is scarce.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAim and Objectives:\u003c/strong\u003e To compare the postural deviation in the sagittal plane in GOLD Stage II and GOLD Stage III COPD patients through and pictographic analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethodology:\u003c/strong\u003e The study is Cross – sectional Comparative study of patients with GOLD stage II and stage III COPD. Respondents were recruited at the pulmonary rehabilitation units and the medical wards with an informed consent being obtained. Sagittal plane photographs were taken in standing position in a standard way. Craniovertebral angle, thoracic kyphosis angle and lumbar lordosis angle were measured using pictography-based software. Statistical analysis was done to test the sagittal plane deviations between the two groups.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFindings:\u003c/strong\u003e The two groups had a low craniovertebral angle, high thoracic kyphosis and distorted lumbar lordosis, which shows that there were postural deviations in the sagittal plane. Despite the fact that GOLD stage III patients exhibited a little more deviation, than stage II did, the intergroup did not differ statistically (p \u0026gt; 0.05).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e The study concludes that sagittal plane postural deviations worsen with increasing severity of COPD. Pictographic analysis serves as a reliable and objective method for postural assessment and may aid in planning stage-specific physiotherapy interventions.\u003c/p\u003e","manuscriptTitle":"Comparing Sagittal Plane Deviations in GOLD STANDARD STAGE II and Stage III Chronic Obstructive Pulmonary Disease Using Pictography","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-19 16:30:50","doi":"10.21203/rs.3.rs-8861504/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-04-22T10:01:42+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-11T13:06:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"131500737003699289102637046383001280274","date":"2026-03-26T13:11:29+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-26T06:59:24+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-26T06:25:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"127532736120131173593988865296169473742","date":"2026-03-25T20:09:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"190233377448045729852970128840000609308","date":"2026-03-23T06:22:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"143294071041716466149730408686703868106","date":"2026-03-17T23:23:50+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-17T10:55:31+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-16T13:09:04+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-23T08:04:50+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-20T15:20:07+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pulmonary Medicine","date":"2026-02-20T15:14:34+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pulmonary-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pulm","sideBox":"Learn more about [BMC Pulmonary Medicine](http://bmcpulmmed.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pulm/default.aspx","title":"BMC Pulmonary Medicine","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1e851216-8e98-4e1a-959f-b95c0219265e","owner":[],"postedDate":"March 19th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-19T16:30:50+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-19 16:30:50","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8861504","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8861504","identity":"rs-8861504","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}