Journal of

Functional Morphology
and Kinesiology

Article
Postural Evaluation in Young Healthy Adults through a Digital
and Reproducible Method
Bruno Trovato 1 , Federico Roggio 1,2 , Martina Sortino 1 , Marta Zanghì 1 , Luca Petrigna 1, * , Rosario Giuffrida 3
and Giuseppe Musumeci 1,4,5

1 Department of Biomedical and Biotechnological Sciences, Section of Anatomy, Histology and Movement
Science, School of Medicine, University of Catania, Via S. Sofia No. 97, 95123 Catania, Italy
2 Sport and Exercise Sciences Research Unit, Department of Psychology, Educational Science and Human
Movement, University of Palermo, Via Giovanni Pascoli 6, 90144 Palermo, Italy
3 Department of Biomedical and Biotechnological Sciences, Section of Physiology, School of Medicine,
University of Catania, 95125 Catania, Italy
4 Research Center on Motor Activities (CRAM), University of Catania, Via S. Sofia No. 97, 95123 Catania, Italy
5 Department of Biology, Sbarro Institute for Cancer Research and Molecular Medicine, College of Science and
Technology, Temple University, Philadelphia, PA 19122, USA
* Correspondence: luca.petrigna@unict.it

Abstract: Different tools for the assessment of posture exist, from the simplest and cheap plumb line
to complex, expensive, 3D-marker-based systems. The aim of this study is to present digital postural
normative data of young adults collected through a mobile app to expand the possibilities of digital
postural evaluation. A sample of 100 healthy volunteers, 50 males and 50 females, was analyzed with
the mobile app Apecs-AI Posture Evaluation and Correction System® (Apecs). The Student’s t-test
evaluated differences between gender to highlight if the digital posture evaluation may differ between
groups. A significant difference was present in the anterior coronal plane for axillary alignment
(p = 0.04), trunk inclination (p = 0.03), and knee alignment (p = 0.01). Head inclination (p = 0.04),
Citation: Trovato, B.; Roggio, F.;
tibia shift (p = 0.01), and foot angle (p < 0.001) presented significant differences in the sagittal plane,
Sortino, M.; Zanghì, M.; Petrigna, L.;
while there were no significant differences in the posterior coronal plane. The intraclass correlation
Giuffrida, R.; Musumeci, G. Postural
coefficient (ICC) was considered to evaluate reproducibility. Thirteen parameters out of twenty-two
Evaluation in Young Healthy Adults
through a Digital and Reproducible
provided an ICC > 0.90, three provided an ICC > 0.60, and six variables did not meet the cut-off
Method. J. Funct. Morphol. Kinesiol. criteria. The results highlight that digital posture analysis of healthy individuals may present slight
2022, 7, 98. https://doi.org/ differences related to gender. Additionally, the mobile app showed good reproducibility according to
10.3390/jfmk7040098 ICC. Digital postural assessment with Apecs could represent a quick method for preventing screening
in the general population. Therefore, clinicians should consider this app’s worth as an auxiliary
Academic Editor: Vítor P. Lopes
posture evaluation tool.
Received: 12 October 2022
Accepted: 27 October 2022 Keywords: posture; reproducibility; mobile app; movement; kinesiology
Published: 28 October 2022

Publisher’s Note: MDPI stays neutral

with regard to jurisdictional claims in
published maps and institutional affil- 1. Introduction
iations. Posture is defined as the position acquired by the human body in various situations,
opposed to the force of gravity and adapting to different environments [1]. Moreover,
posture is essential for maintaining postural balance both in static and dynamic conditions.
Remaining in a non-ergonomic position for an extended period can predispose people to
Copyright: © 2022 by the authors.
manifest musculoskeletal pain [2]; thus, assuming good postures is considered necessary
Licensee MDPI, Basel, Switzerland.
for general health at both a musculoskeletal and psychological level [3]. Nowadays, the
This article is an open access article
evaluation of human posture is performed consistently in healthcare clinics and fitness cen-
distributed under the terms and
ters, considering that postural misalignments can cause individuals to manifest headaches,
conditions of the Creative Commons
Attribution (CC BY) license (https://
lower back pain, neck pain, neurological pathologies, and a reduction in overall psycholog-
creativecommons.org/licenses/by/
ical well-being [4]. Currently, the literature does not provide any gold standard procedure
4.0/). for postural assessment. The types of exams employed can vary from a visual evaluation

J. Funct. Morphol. Kinesiol. 2022, 7, 98. https://doi.org/10.3390/jfmk7040098 https://www.mdpi.com/journal/jfmk

J. Funct. Morphol. Kinesiol. 2022, 7, 98 2 of 11

with goniometers and plumb lines to motion capture systems, such as Vicon, for dynamic
evaluation and 3D camera infrared systems, such as rasterstereography, for static evalua-
tion [5]. Regarding the feasibility of using a markerless system to assess human posture,
rasterstereography is a system that generates a 3D model of the spine by calculating specific
deformities and analyzing the convexity and concavity of the spine [6]. It is commonly
used to investigate the presence of scoliosis and is considered reliable for the assessment of
parameters such as pelvic obliquity, thoracic kyphosis, and lumbar lordosis angles [7,8].
However, this system has a high cost, and it is difficult to implement in postural screening
for the general population. Other valid tools such as inertial measurement units (e.g.,
accelerometers, magneto inertial units) are also employed in the field of postural evaluation
for the assessment of the thoracic kyphosis and the lumbar lordosis angles [9] and also for
gait and balance assessment [10].
All the available methods for evaluating posture present some biases or disadvantages.
The visual evaluation with a plumb line is cheap, but it requires specialized personnel, is
prone to bias, and lacks scientific validation [11]. The use of goniometers is feasible for the
measurement of the range of motion and angles of different joints with good reliability [12];
it has a low cost and is easy to perform, although it presents some methodological issues
when assessing postural deviations [13], and it is only considered useful for one postural
variable examination at the time [5]. Marker-based advanced technologies that can provide
highly accurate data on joint angles and translations are potentially available for clinicians;
however, these evaluation systems are too expensive for the average clinic, and often they
are employed for research purposes only [14].
In this heterogeneous scenario regarding the available postural evaluation tools, the
advancement in image-based technologies will come in handy for clinicians and researchers
who want to find a postural assessment system with good reproducibility and an affordable
cost. Tablet and phone apps for postural evaluation can fill this gap, with different postural
apps demonstrating promising results in the evaluation of the frontal plane [15], standing
posture [13], angulation variables [14], and head shift in sagittal and frontal planes [4];
however, the literature is insufficient to confirm the quality of these methods. Considering
that the complete visual evaluation of body posture with goniometers and a plumb line
can be long and not free from biases, and taking into account the high costs of 3D systems,
the use of a mobile app could represent a quick, safe, and accurate method for researchers
and clinicians to quantitatively evaluate general posture. Moreover, laboratory tests are
often more expensive than field-based ones [16], and adopting a mobile, affordable tool for
postural assessment could benefit the primary prevention of musculoskeletal disorders of
the spine. The aim of this study is to present normative data about digital posture evaluation
collected through a mobile app Apecs and, moreover, to evaluate the reproducibility.

2. Materials and Methods

2.1. Participants
We recruited and evaluated a sample of 100 healthy volunteers, 50 males and 50 fe-
males, with a mean age of 23.4 (standard deviation (SD) ± 6.2) years. Prior to testing, all
participants were informed about the study procedure, risks, and benefits and provided
written, informed consent to participate in the study and for us to use their data. The
study followed the Helsinki Declaration principles and was approved by the University of
Catania (protocol no.: CRAM-017-2020, 16 March 2020).
Exclusion criteria comprised: past or current major musculoskeletal injuries, spine
pathology, and neurological pathologies. All the participants selected after the oral inter-
view underwent a static postural evaluation provided by expert clinician (experience of
7 years) to confirm their eligibility for the study.

2.2. Study Design

The evaluation took 30 min per participant at the University Laboratories and consisted
of evaluating their health status and history of previous conditions that could meet the
 2.2. Study Design
The evaluation took 30 min per participant at the University Laboratories
J. Funct. Morphol. Kinesiol. 2022, 7, 98
sisted of evaluating their health status and history of previous conditions 3 of 11
that cou
the exclusion criteria. After the screening process, participants were always ask
tend the laboratory at the same time (between 10:00 a.m. and 12:00 p.m.). The
evaluation
exclusion wasAfter
criteria. performed by three
the screening different
process, operators
participants with
were always similar
asked experience
to attend the in
laboratory
analysis at(3the
tosame time of
4 years (between 10:00 a.m.
experience). andmobile
The 12:00 p.m.).
appThe postural evaluation
Apecs-AI Posture Evalua
was performed by three® different operators with similar experience in postural analysis
Correction System (New Body Technologies SAS, Grenoble, France) (Apecs a
(3 to 4 years of experience). The mobile app Apecs-AI Posture Evaluation and Correction
used ®to(New
System acquire
Bodythe images of
Technologies theGrenoble,
SAS, participants
France)in standing
(Apecs position.
app) was used to The
acquireparticipa
asked
the to ofdress
images in minimal
the participants clothing,
in standing shortsThe
position. forparticipants
men andwere shorts and
asked bras for wo
to dress
inminimize biases relating
minimal clothing, shorts fortomenwrong landmark
and shorts and braspositioning
for women,during the postural
to minimize biases ana
relating to wrong landmark positioning during the postural analysis; for
the same reason, markers were placed by expert clinicians on the body of the par the same reason,
markers were placed by expert clinicians on the body of the participants in correspondence
in correspondence to the app’s predetermined landmarks. Four pictures were c
to the app’s predetermined landmarks. Four pictures were captured, one for the anterior
one for
coronal the one
plane, anterior
for the coronal
posterior plane, one for
coronal plane, andthe
twoposterior coronal
for the sagittal plane plane,
(left andand two
sagittal
right). plane (left
Participants wereand right).toParticipants
instructed place their feetwere
at theinstructed
same widthto as place their feet at t
the shoulders
(Figure 1).
width as the shoulders (Figure 1).

Figure
Figure 1. Landmarks
1. Landmarks positioning.
positioning.
J. Funct. Morphol. Kinesiol. 2022, 7, 98 4 of 12

J. Funct. Morphol. Kinesiol. 2022, 7, 98 4 of 11

To avoid any wrong camera leveling during the image acquisition, the app’s interface
shows a target that becomes green when the camera is leveled. After the picture is
acquired,Tothe
avoid
app any wrong camera
immediately steersleveling
the userduring thethe
to crop image
imageacquisition, the app’s head
at the individual’s interface
andshows
feet toaminimize
target thatinconsistency
becomes green inwhen the cameraofisdifferent
the proportion leveled. After theThe
images. picture is acquired,
Apecs app
usesthe app immediately
standardized digitalsteers the user
landmarks andtoanatomical
crop the image at the
angles fromindividual’s
one to fourhead and feet
pictures,
to minimize
depending on theinconsistency in the proportion
number of variables ofthe
of interest to different images.The
investigation. Theapp
Apecs app uses
calculates
standardized digital landmarks and anatomical angles from one to four pictures,
24 postural variables from the predetermined anatomical markers in the three planes of depending
on theexamined.
the space number ofFigure
variables of interest
2 shows to theevaluated
the points investigation.
in theThe app calculates
anterior 24 postural
coronal plane (a),
variables
the sagittal from(b),
plane theand
predetermined
the posterior anatomical
coronal plane markers
(c). in the three planes of the space
examined. Figure 2 shows the points evaluated in the anterior coronal plane (a), the sagittal
plane (b), and the posterior coronal plane (c).

Figure 2. Evaluation of the anterior coronal plane (A); of the sagittal plane (B); of the posterior coronal
plane (C).

After the cropping phase, the app drives the user to position the digital markers,
fostering this process with examples of the proper positioning with images. Table 1 shows
all the anatomical landmarks taken into consideration by the app for calculating the postural
variables.
J. Funct. Morphol. Kinesiol. 2022, 7, 98 5 of 11

Table 1. Anatomic landmarks and postural variables studied with Apecs.

Plane of the Space Anatomical Landmarks Postural Variables

Acromion
Anterior axillary folds Body alignment
Anterior superior iliac spine Head alignment
Jugular notch Acromion alignment
Lobulus auriculae Axillae alignment
Lowest point of costal margin Trunk inclination
Anterior coronal
Midpoint between malleoli Ribcage tilt
Most intended point of the trunk Antero superior iliac spine
Philtrum inclination
Second metatarsophalangeal joint Knee angle
Tibial tuberosity
Xiphoid process
Lobulus auriculae
Body alignment
C-7 vertebrae
Head alignment
Acromion
Shoulder alignment
Anterior axillary folds
Axillae alignment
Inferior angle of the scapula
Scapulae alignment
Posterior coronal T-6 vertebrae
Trunk inclination
Most intended point of the trunk
Postero superior iliac spines
Posterior superior iliac spine
Knee angle
Superior end of intergluteal cleft
Foot angle
Popliteal fossa
Calcaneal tuberosity
Tragus
Body alignment
C-7 vertebrae
Head alignment
Acromion
Acromion alignment
Posterior superior iliac spine
Sagittal Pelvic tilt
Greater trochanter
Tibia shift
Lateral joint line
Fibula alignment
Lateral malleolus
Foot angle
Head of the fifth metatarsal bone

2.3. Statistical Analysis

Data analysis comprised descriptive statistics to present the mean and standard
deviation of the whole sample divided by gender. Inferential statistics comprised the
Shapiro–Wilk test to assess the data distribution; the Student’s t-test was used to compare
means between the male and female groups; statistical significance was set at p ≤ 0.05.
Cohen’s effect size (d) was applied to identify meaningful differences between the groups.
Based on Cohen’s criteria, d = 0.80 (absolute value) was considered a large effect size, and
d = 0.50 (absolute value) was considered a medium effect size. Post hoc power calculations
were performed with G*Power v.3.1. Three qualified examiners were selected to perform
the positioning of the markers and the postural analysis in the two different parts of the day
to assess the reproducibility of the app. The two-way mixed effect for absolute agreement
was the model for calculating the intraclass correlation coefficient (ICC) for inter-rater
agreement. The cut-off values for reproducibility based on a 95% confidence interval of
the ICC estimate were <0.5 (poor), between 0.5 and 0.75 (moderate), between 0.75 and 0.9
(good), and >0.9 (excellent) [17]. All the statistical analyses were performed with R Project
for Statistical Computing (Vienna, Austria).

3. Results
Anthropometric measurements were taken for each subject and grouped by gender,
with a mean male height of 175 (SD ± 5.6) cm, a mean female height of 164.6 (SD ± 6.5)
cm, and a mean male weight of 75.5 (SD ± 8.8) kg and a mean female weight of 58.13
(SD ± 7.41) kg.
J. Funct. Morphol. Kinesiol. 2022, 7, 98 6 of 11

The post hoc power calculation analysis with G*Power 3.1 returned a statistical power
J. Funct. Morphol. Kinesiol. 2022, 7, 98 6 of 11
of 0.696 for our sample. The analysis of the digital anatomical landmarks collected with the
Apecs app and the ICC values are presented in Table 2. The Student’s t-test statistically in-
dicated differences in the postural evaluation performed by the mobile app Apecs between
the
malesworst
andresults
femalesfor forthe axillary
specific alignment,
variables. The which
postural resulted
variables in greater deviation
with significant from the
differences
ideal
betweenalignment
male and thanfemale
that ofgroups
the female group.
in the In the
anterior sagittal
coronal plane,
plane statistically
were axillary significant
alignment
differences were found for head inclination (p = 0.04), tibia shift
(p = 0.04), trunk inclination (p = 0.03), and knee alignment (p = 0.01). The female (p = 0.01), and foot group
angle
(p < 0.001). The head of the female group was more significantly
presented more body inclination to the right than men, more trunk inclination, and a wider shifted from the ideal
alignment compared to that of the male group and also showed a
knee angle in the anterior coronal plane. The male group showed the worst results for the more accentuated ante-
rior tibial
axillary shift. Instead,
alignment, whichthe male in
resulted group presented
greater deviation a wider
from the foot angle
ideal than the
alignment female
than that
group. No statistically
of the female group. In significant
the sagittaldifferences were found
plane, statistically between
significant groups for
differences werethefound
evalua-for
tion
headofinclination
the posterior(p = coronal plane.
0.04), tibia shiftAccording
(p = 0.01), to
andCohen’s d, there
foot angle was a small
(p < 0.001). effectofsize
The head the
only
female forgroup
ribcagewastiltmore
(d = significantly
−0.35) in theshifted
anteriorfromcoronal plane,
the ideal for head compared
alignment alignment to inthat
the
sagittal plane (d = −0.38), and a large effect size for knee angle in the
of the male group and also showed a more accentuated anterior tibial shift. Instead, the anterior coronal plane
(d = −0.89),
male group tibia shift in
presented the sagittal
a wider planethan
foot angle (d =the−0.95),
female and foot angle
group. in the sagittal
No statistically plane
significant
(d = 1.6). were found between groups for the evaluation of the posterior coronal plane.
differences
Figures
According to3–5 showd,
Cohen’s the boxwas
there plotsa for gender
small effectdifferences
size only for inribcage
the three (d = −
tiltspace planes.
0.35) in the
The coronal
anterior ICC showedplane,promising results for inter-rater
for head alignment in the sagittal plane (d = −with
reproducibility, 0.38),values
and a>large
0.90
effect
for size forout
thirteen kneeof angle in the anterior
the twenty-two coronal
postural variables = −0.89), and
plane (dexamined tibia>0.60
shift in
forthe
thesagittal
other
three (d = −0.95),
plane variables; andsixfoot
only angle indid
variables thenot
sagittal
meet plane (d = 1.6).
the cut-off criteria required to be consid-
ered reliable. Table 2 shows the ICC for the postural variablesthe
Figures 3–5 show the box plots for gender differences in three space planes.
evaluated.

Figure
Figure 3.3. Box
Box plots
plots of
of the
the differences
differences between
between male
male and
and female
female groups
groups inin the
the anterior
anterior coronal
coronal plane
plane
with indication of significance. Figure (a) is for body alignment; figure (b) is for head alignment,
with indication of significance. Figure (A) is for body alignment; figure (B) is for head alignment,
figure (c) is of acromion alignment, figure (d) is for axillae alignment, figure (e) is for trunk inclina-
figure (C) is of acromion alignment, figure (D) is for axillae alignment, figure (E) is for trunk inclina-
tion, figure (f) is for ribcage tilt, figure (g) is for antero superior iliac spine inclination, figure (h) is
tion,
for figure
knee (F) is
angle. *: for
p < ribcage
0.05; ***:tilt,
p <figure
0.001. (G) is for antero superior iliac spine inclination, figure (H) is
for knee angle. *: p < 0.05; ***: p < 0.001.
J. Funct. Morphol. Kinesiol. 2022, 7, 98 7 of 11

J. Funct. Morphol. Kinesiol. 2022, 7, 98 7 of 11

J. Funct. Morphol. Kinesiol. 2022, 7, 98 7 of 11

Figure
Figure 4. 4.Box
Boxplots
plots of
ofthe
thedifferences
differencesbetween
between male and
malefemale
and groups
femaleingroups
the posterior
in thecoronal plane.
posterior coronal
Figure
Figure4. Box
(a) isplots
for of the
body differences
alignment; between
figure (b) is formale
head and femalefigure
alignment, groups(c)in
is the
of posterior
shoulder coronal plane.
alignment,
plane. Figure (A) is for body alignment; figure (B) is for head alignment, figure (C) is of shoulder
Figure
figure(a)(d)
is is
forforbody alignment;
axillae alignment,figure
figure(b)
(e) is
is for head alignment,
for scapulae alignment, figure
figure(c)(f)isisof
forshoulder alignment,
trunk inclina-
alignment,
figure
tion,(d) isfigure
figure for (D) isalignment,
(g)axillae
for axillae
is for postero
alignment,
figure
superior iliac(e)
spine
figure
is for (E) isfigure
scapulae
inclination,
for scapulae
alignment, alignment,
(h) is forfigure (f) is for
knee angle,
figure
trunk
figure
(F) is for
(i) isinclina-
trunk
tion, inclination,
forfigure (g) is for postero superior iliac spine inclination, figure (h) is for knee angle, figureangle,
foot angle. figure (G) is for postero superior iliac spine inclination, figure (H) is for knee (i) is
figure
for foot(I)angle.
is for foot angle.

Figure 5. Box plots of the postural differences between male and female groups in the sagittal plane
with indication of significance. Figure (a) is for body alignment; figure (b) is for head alignment,

Figure 5. Box plots of the postural differences between male and female groups in the sagittal plane
Figure 5. Box plots of the postural differences between male and female groups in the sagittal plane
with indication of significance. Figure (a) is for body alignment; figure (b) is for head alignment,
with indication of significance. Figure (A) is for body alignment; figure (B) is for head alignment,
figure (C) is of acromion alignment, figure (D) is pelvic tilt, figure (E) is for tibia shift, figure (F) is for
fibula alignment, figure (G) is for foot angle. *: p < 0.05; **: p < 0.01; ***: p < 0.001.
J. Funct. Morphol. Kinesiol. 2022, 7, 98 8 of 11

Table 2. Description of group means and ICC of the postural variables analyzed.

Postural Variables Total Males Females t-Test ICC Cohen d

Mean ± SD Mean ± SD Mean ± SD
Body alignment 0.9◦ ± 0.5 0.7◦ ± 0.4 1◦ ± 0.5 0.430 0.95 −0.54
Head alignment 2◦ ± 1.4 2.2◦ ± 1.8 1.8◦ ± 1.4 0.989 0.51 0.25
Acromion alignment 1.3◦ ± 1 1.4◦ ± 0.9 1.2◦ ± 1.1 0.423 0.91 0.17
Anterior Axillae alignment 1.3◦ ± 1 1.4◦ ± 1.4 1.2◦ ± 0.8 0.044 * 0.25 0.16
coronal Trunk inclination 1.6◦ ± 1.2 1.4◦ ± 1.3 1.8◦ ± 1.1 0.462 0.44 −0.29
Ribcage tilt 1.9◦ ± 1.6 1.7◦ ± 1.2 2.2◦ ± 1.8 0.039 * 0.93 −0.35
ASIS inclination 2.3◦ ± 1.6 2.5◦ ± 1.7 1.5◦ ± 0.3 0.321 0.94 0.24
Knee angle 6.2◦ ± 3.3 4.8◦ ± 2.9 7.5◦ ± 3.1 0.001 *** 0.93 −0.89
Body alignment 1◦ ± 0.8 1◦ ± 0.8 0.9◦ ± 0.8 0.717 0.84 0.07
Head alignment 2.7◦ ± 1.5 1.6◦ ± 1.4 1.8◦ ± 1.5 0.652 0.30 −0.14
Shoulder alignment 1.5◦ ± 1.2 1.4◦ ± 1.1 1.7◦ ± 1.4 0.444 0.93 −0.19
Axillae alignment 1.6◦ ± 1.2 1.4◦ ± 1 1.7◦ ± 1.2 0.348 0.43 −0.26
Posterior
Scapulae alignment 2.7◦ ± 2.2 2.8◦ ± 2.3 2.7◦ ± 2.2 0.879 0.92 0.05
coronal
Trunk inclination 1.4◦ ± 1.2 1.6◦ ± 1.2 1.3◦ ± 1.2 0.925 0.26 0.23
PSIS inclination 1.9◦ ± 1.4 2◦ ± 1.6 1.8◦ ± 1.3 0.247 0.66 0.15
Knee angle 1.9◦ ± 1.4 1.8◦ ± 1.2 2.1◦ ± 1.6 0.172 0.94 −0.23
Foot angle 2.1◦ ± 1.6 1.9◦ ± 1.4 2.3◦ ± 1.8 0.151 0.75 −0.24
Body alignment 2.6◦ ± 1.2 2.6◦ ± 1.1 2.5◦ ± 1.3 0.691 0.94 0.1
Head alignment 31.4◦ ± 5.4 30.3◦ ± 4.3 32.4◦ ± 6.2 0.047 * 0.91 −0.38
Acromion alignment 19.6◦ ± 12.3 19.9◦ ± 12.1 19.4◦ ± 12.8 0.866 0.24 0.04
Sagittal Pelvic tilt 16.9◦ ± 5.7 16.6◦ ± 5.3 17.1◦ ± 6.1 0.763 0.94 −0.07
Tibia shift 5.7◦ ± 3.3 4.2◦ ± 2.2 7.1◦ ± 3.5 0.017 ** 0.91 −0.95
Fibula alignment 5.5◦ ± 3 6.3◦ ± 3.1 4.8◦ ± 2.7 0.491 0.94 0.49
Foot angle 29.8◦ ± 6 33.7◦ ± 26.2 26.2◦ ± 4.2 0.001 *** 0.93 1.6
ASIS: anterior superior iliac spines; PSIS: postero superior iliac spines. * p-value < 0.05; ** p-value < 0.01;
*** p-value < 0.001.

The ICC showed promising results for inter-rater reproducibility, with values > 0.90
for thirteen out of the twenty-two postural variables examined and >0.60 for the other
three variables; only six variables did not meet the cut-off criteria required to be considered
reliable. Table 2 shows the ICC for the postural variables evaluated.

4. Discussion
This study aimed to present normative data about the digital posture evaluation of
healthy young adults performed by the mobile app Apecs and to evaluate its reproducibility.
The first finding was that the app is sensible to postural variation, considering that it was
capable of detecting postural differences between males and females. The second finding
of the study was that this mobile app presents a good inter-rater reproducibility for all
the postural variables examined except for head alignment, trunk inclination and axillae
alignment in the anterior and posterior coronal plane, and acromion alignment in the
sagittal plane.
The Apecs app has already been used for research purposes to evaluate postural
behaviors related to specific ergonomic studies’ work [12] and to evaluate body segment
angles in subjects with adolescent idiopathic scoliosis [18]. However, the studies mentioned
above had small samples; the first used the app only to compare their sample’s posture at
rest and during working activity, and the second only evaluated angles in the frontal and
sagittal plane. Hence, to the best of our knowledge, this is the first study that employs the
mobile app Apecs to evaluate global posture, providing normative data and assessing its
reproducibility as a posture evaluation tool.
The sample in this study was composed of 100 participants equally distributed be-
tween males and females, and the Apecs mobile app was capable of detecting postural
differences when present. It emerged from the postural analysis of the anterior coronal
J. Funct. Morphol. Kinesiol. 2022, 7, 98 9 of 11

plane that females presented a wider knee angle; this could be due to the overall increased
knee laxity and reduced stiffness in females compared to males [19]. In a previous study by
Raine et al. [20], no sex differences were found for head inclination on the sagittal plane;
conversely, we found that the head inclination was more accentuated in the female group
compared to the male group. However, Raine et al.’s study dates from 1997, and they
considered an older sample size. These observations may be the cause of the differences
compared to our study. Iacob et al. [21] analyzed the posture of a sample of people with
malocclusion through the PostureScreen® mobile app, comparing it with a healthy sample.
We found a difference between our postural data gathered with Apecs and those reported
by Iacob et al. for the same variable analyzed. These authors found, on the frontal plane,
a head alignment in their sample of 3.86◦ ± 2.45, a shoulder alignment of 1 ± 0.97, and a
hip deviation of 1.42 ± 1.28, while, for the same variable, we reported a head alignment
of 2.7 ± 1.5, a shoulder alignment of 1.5 ± 1.2, and postero superior spine inclination of
1.9◦ ± 1.4. The differences in the postural evaluation between the two apps might be due
to the differences in the samples considering that the control group of young healthy young
adults investigated by Iacob et al. was composed of only 14 people, and they were almost
exclusively females.
We found a statistically significant difference in the sagittal plane for foot angle, with
the male group presenting higher values; this finding could be related to the generally
bigger size of the foot anthropometrics of males [22]. In the anterior and posterior coronal
planes, we did not find any statistically significant difference between gender for foot
posture parameters, in line with previous studies [23,24].
The reproducibility analysis of Apecs showed excellent results for all the variables
examined on the sagittal plane except for the acromion alignment. The marker placed on
the acromion was not clearly visible during the positioning of the digital marker in this
plane of space, making it difficult to evaluate with consistency among raters. The same
issue occurred in the posterior coronal plane for the trunk inclination, where the app asks
raters to identify “the most intended point of the trunk”, which was not easy to replicate for
the raters. Interestingly, the two less reliable measures in the anterior coronal plane were
the axillae alignment and the trunk inclination, indicating that this mobile app should be
carefully considered when a precise measure of these variables is needed. Accordingly, with
what was stated by Szucs et al. [14] when evaluating the PostureScreen® mobile app, we
suggest that the quality of the evaluation is higher when markers are placed on the subject
and are clearly visible during the positioning of the digital markers; however, neither the
Apecs manufacturer nor the PostureScreen mobile one specifies this in their instruction for
postural analysis.
The current study presents some limitations. First, we considered a sample composed
exclusively of young adults, so we could not assess whether the Apecs app is a feasible
tool to employ in the postural evaluation of pediatric and elderly populations. Second, all
the individuals in the sample were healthy, thus, these results should be carefully inter-
preted when examining individuals with pathologies that influence the musculoskeletal
system. Third, we did not compare measures collected with Apecs with those collected
by postural gold standard instruments to assess the validity of the app. Further studies
should investigate the validity of Apecs as a reliable postural assessment tool, comparing it
with rasterstereography or marker-based systems. However, these normative data may
help those involved in the analysis of postural alterations as a comparative standard with a
healthy sample. Finally, the digital landmark positioning accomplished with the app may
be challenging for less experienced users and might change the evaluation results.

5. Conclusions
The mobile postural app Apecs demonstrated good reproducibility for most of the
postural variables analyzed and could detect postural differences between males and fe-
males when present. The app was easy to use for all the raters, from the more experienced
to the less experienced ones, indicating that Apecs could be a cheap and feasible good
J. Funct. Morphol. Kinesiol. 2022, 7, 98 10 of 11

alternative to more expensive postural assessment devices for researchers and clinicians.
However, trunk inclination and axillae alignment were unreliable in all the planes of space
where they were evaluated, and head alignment was reliable only in the sagittal plane.
Clinicians should be aware of this issue when using Apecs and carefully predetermine
the landmark positioning and digital identification during the analysis to minimize the
possibilities of errors for the postural variables not clearly described by the Apecs manu-
facturer. In conclusion, the Apecs app could be a potentially useful tool for clinicians and
researchers to implement in the preventive care of postural disorders given its ease of use
and cheap costs.

Author Contributions: Conceptualization, B.T. and F.R.; Methodology, B.T., F.R., and L.P.; Statistical
Analysis, F.R., B.T., and R.G.; Investigation, G.M.; Resources, G.M.; Data Curation, M.S. and M.Z.;
Writing—Original Draft Preparation, B.T., F.R., and L.P.; Writing—Review and Editing, R.G. and
G.M.; Visualization, M.S. and M.Z. Supervision, G.M.; Funding Acquisition, G.M. All authors have
read and agreed to the published version of the manuscript.
Funding: This work was supported by the University Research Project Grant PIACERI Found—
NATURE-OA—2020–2022, Department of Biomedical and Biotechnological Sciences (BIOMETEC),
University of Catania, Italy.
Institutional Review Board Statement: The study was conducted according to the guidelines of
the Declaration of Helsinki and approved by the scientific committee of the University of Catania
(protocol no.: CRAM-017-2020, 16 March 2020).
Informed Consent Statement: All subjects gave their informed consent for inclusion before they
participated in the study.
Data Availability Statement: Data are available upon appropriate request.
Conflicts of Interest: The authors declare no conflict of interest.

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