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Prosthetics and Orthotics International
http://poi.sagepub.com/content/early/2014/10/29/0309364614554031
The online version of this article can be found at:
DOI: 10.1177/0309364614554031
published online 31 October 2014Prosthet Orthot Int
Peter Dankerl, Andrea Kerstin Keller, Lothar Häberle, Thomas Stumptner, Gregor Pfaff, Michael Uder and Raimund Forst
Rasterstereographic evaluation
Effects on posture by different neuromuscular afferent stimulations and proprioceptive insoles:
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DOI: 10.1177/0309364614554031
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INTERNATIONAL
SOCIETY FOR PROSTHETICS
AND ORTHOTICS
Background
Proprioceptive neuromuscular stimulating insoles (PNSI)
have been stated to alter posture.1–11 Furthermore, PNSI are
considered to be beneficial for patients with neurological
disabilities,2,4 orthopaedic foot disorders3 as well as postop-
erative discomfort,6 and they are said to reduce chronic pain
in patients with musculoskeletal complaints.5 Therefore,
common aches and conditions, such as splayfoot, knee or
lower back pain, neck myogelosis, jaw grinding or head-
aches,2–8 are being treated using PNSI.
Neurophysiologically PNSI are explained to modu-
late the neuronal afferent signals by stimulating
Effects on posture by different
neuromuscular afferent
stimulations and proprioceptive
insoles: Rasterstereographic evaluation
Peter Dankerl1, Andrea Kerstin Keller2, Lothar Häberle2,3, Thomas
Stumptner4, Gregor Pfaff5, Michael Uder1 and Raimund Forst6
Abstract
Background: Proprioceptive neuromuscular stimulating insoles are increasingly applied in treating functional complaints,
chronic pain, foot disorders and so on.
Objectives: To evaluate rasterstereography as a tool in objectifying postural changes resulting from neuromuscular afferent
stimulation and proprioceptive neuromuscular stimulating insoles and to compare the respective effects on posture.
Study design: This is a prospective experimental study.
Methods: A total of 27 healthy volunteers were consecutively exposed to six different varying intense neuromuscular
afferent stimulating test conditions at three different times. One test condition featured proprioceptive neuromuscular
stimulating insoles. In each test condition, a sequence of 12 rasterstereographic recordings of back shape was documented.
Changes between six different test conditions and over time for 14 posture characterising parameters were investigated,
for example, trunk inclination, pelvic torsion, lateral deviation of the spine’s amplitude or sagittal spinal curve.
Results: Standard deviation of our rasterstereographic measurements (±2.67 mm) was better than in most comparable
reference values. Different neuromuscular stimuli were found to provoke significant changes to various posture
parameters, including trunk inclination, pelvic torsion and so on ( each p < 0.001, F-tests). Proprioceptive neuromuscular
stimulating insoles induced significant changes for parameter lateral deviation of the spine’s amplitude (p = 0.03).
Conclusion: Neuromuscular afferent stimulation and proprioceptive neuromuscular stimulating insoles induce postural
changes, which can be detected reliably by rasterstereography.
Clinical relevance
We demonstrated that rasterstereography – a radiation-free imaging modality – enables visualisation and documentation
of subtle postural changes induced by varying intense neuromuscular afferent stimulation and the application of
proprioceptive neuromuscular stimulating insoles.
Keywords
Proprioceptive insoles, neuromuscular afferent stimulation, posture, rasterstereography
Date received: 25 November 2013; accepted: 10 September 2014
1Department of Radiology, University Hospital Erlangen, Erlangen,
Germany
2Department of Medical Informatics, Biometry and Epidemiology,
University of Erlangen, Germany
3Department of Gynecology and Obstetrics, University Hospital
Erlangen, Erlangen, Germany
4Consultant for Orthopaedics, Nürnberg, Germany
5Consultant for Orthopaedics, München, Germany
6Department of Orthopaedic Surgery, University Hospital Erlangen,
Erlangen, Germany
Corresponding author:
Peter Dankerl, University Hospital Erlangen, Erlangen, 91054, Germany.
Email: peter.dankerl@uk-erlangen.de
554031POI0010.1177/0309364614554031Prosthetics and Orthotics InternationalDankerl et al.
research-article2014
Original Research Report
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3. 2 Prosthetics and Orthotics International
proprioceptive receptor organs in the foot, for example,
muscle spindles. Following cerebral integration, the
altered afferences cause a complex modulation of mus-
cle activity3,5–8,11–13 and thereby an alteration of posture.
Correspondingly, following the concept of propriocep-
tion, various authors5,11,13 also implied that sensomotoric
stimulation of the equilibrium organ, stereoscopic vision
and the jaw joint effect posture. Although PNSI are
widely applied as orthotic therapeutic insoles,1–15 their
suspected effects on posture have not been generally
accepted or rejected by orthopaedic school of thought or
central health insurance due to a lack of methodical
research.
Numerous diagnostic means, for example, electromyo-
graphy or pedography,14 patient inquiry,7 gait analysis and
muscle power assessment15 or evaluation of sagittal trunk
curvature,9 have been applied in objectifying the effects of
PNSI. Nevertheless, none have been accepted as the refer-
ence standard.
Rasterstereography16,17 is a radiation-free three-
dimensional (3D) imaging modality which assesses vari-
ous posture describing parameters (trunk inclination (ti),
lordoticangle(la),pelvictilt(pti),etc.).Rasterstereography
has been proven to detect changes of surface profile in
the sub-millimetre range.18 Moreover, rasterstereography
has been demonstrated to provide clinically practicable
3D back shape information for the monitoring of scolio-
sis patients.19–21 Furthermore, spinal deviations resulting
from craniofacial morphology variations have been cor-
related precisely applying rasterstereography.22,23 In the-
ory and in accordance with previous research,16–23
rasterstereography should be sensitive enough to reliably
measure expected effects on posture due to neuromuscu-
lar stimulation and PNSI. Expected effects are investi-
gated by 14 different postural parameters, characterising
the frontal, horizontal and lateral planes, which are tar-
geted by different neuromuscular afferent stimulations
and PNSI.
In previous research, rasterstereography has been
applied to try to objectify the effects of PNSI.5–7,9 However,
these studies do have limitations, either in the experimen-
tal setup,5 in the limited number of evaluated rasterstereo-
graphic posture parameters,9 or they are case reports.6,7
Additionally, no one has evaluated whether rasterstereog-
raphy is a feasible means to detect and objectify postural
change derived from supposedly various intense stimula-
tion of neuromuscular afferent receptor organs. However,
there is no generally accepted scaling for the intensity of
neuromuscular afferent stimulation. By stimulating differ-
ent afferences (in the foot as well as in the jaw joint) with
varying severities (active muscle contraction vs passive
adjustment of joint position and muscle tension), we con-
clude that they are of varying intensities.
We conducted an experimental study with the working
hypothesis that varying intense neuromuscular afferent
stimulation and PNSI provoke different postural reactions
that can be detected and compared utilising rasterstereog-
raphy in a prospective manner.
Methods
Study group
The Institutional Review Board of the University Erlangen
Nuremberg approved the study, and all experiments were
in accordance with the Helsinki Declaration. A total of 27
healthy adults (8 women, 19 men, mean age: 29.6 years)
were recruited. They gave their informed consent prior to
the experimental procedure.
Rasterstereography
The Rasterstereograph Formetric III (Diers International
GmbH, Schlangenbad, Germany) was used to scan the
patients. The system was set up, tested and approved by
the manufacturer. Patients were examined following the
suppliers recommendations (Figure 1).
Based on an extensive literature review,16–29 we
selected 14 different rasterstereographic posture param-
eters that have been shown to demonstrate postural
changes representing movement in all three spatial
directions for our investigation. Different parameters are
specifically dedicated to investigate movements of the
hips (e.g. pti, pelvic torsion (pto) and pelvic rotation
(pr)), movements of the lower back (e.g. flèche lombaire
(fl) and la) and upper back (e.g. flèche cervicale (fc) and
kyphotic angle (ka)) as well as symmetry of the whole
spine in the different spatial directions (sagittal: ti, fc, fl,
ka and la; frontal: pti, rotation of back surface to the left
(brl), rotation of back surface to the right (brr), back sur-
face rotation’s amplitude (bra), lateral deviation of the
spine to the left (ldl), lateral deviation of the spine to the
right (ldr) and lateral deviation of the spine’s amplitude
(lda); plane: the axial: pto and pr) (see online supple-
mentary material).
We suppose that these 14 parameters provide a compre-
hensive representation and characterisation of posture.
Therefore, postural changes due to neuromuscular afferent
stimulation are expected to have an effect on these param-
eters. To evaluate accuracy and reliability of rasterstereo-
graphic measurements, the intra-individual distance in
millimetre of distance between left and right lumbar dim-
ples (DL-DR) was documented with every measurement.
PNSI
The PNSI utilised in this study (MedReflexx®; München,
Germany) feature nine firm-elastic pads arranged accord-
ing to the short foot muscles.11 The proprioceptive stimu-
lus can be individually adjusted by adapting the pressure in
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4. Dankerl et al. 3
each firm-elastic pad (Figure 2). An expert (10 years of
experience) in the use of PNSI manually adjusted the pad
pressure to the starting pressure level that is usually
adopted during therapy. This afferent (proprioceptive)
stimulation changes its intensity while walking due to
strain and relief in every step.5–7
Test conditions
Proprioceptive stimulation was tested by six different test
conditions in a fixed order representing one test row.
Derived from the implications by Pfaff,5 Fusco11 and
Bricot13 concerning the effects of proprioceptive stimulation
on different receptor organs and respective alteration of pos-
ture, we stimulated afferences in the foot and jaw joint and
evaluated active intentional and passive undeliberate stimu-
lations. During the stance in these test conditions, the raster-
stereographic back measurements were taken.
•• Test condition 1: habitual posture (HP) – the sub-
ject stands barefoot in a normal relaxed stance. This
provides the rasterstereographic measurements that
were taken as a reference compared to the other test
conditions.
•• Test condition 2: foot elevation (FE) – the subject
stands barefoot, left foot on the ground, while the
right foot stands on a 10-mm thick plank. This
exclusive one-sided foot elevation is expected to
distort the proprioceptive afferent neuromuscular
system and cause quasi-continuous functional
movements of the hip and possibly the spine. Based
on previous work24–26 with similar experiments,
alterations in pelvis position (namely, pto) are
expected. Furthermore, we expect this pelvic tor-
sion to consequently cause movement of the spine
in the frontal plane (e.g. lda). However, this has not
been demonstrated before. Therefore, we examine
significantly more posture parameters than Drerup
et al.24,26 and Meyer zu Bentrup25 in previous work.
•• Test condition 3: Janda’s short foot (JS) – the sub-
ject stands barefoot and is instructed to firmly plan-
tar flex all toes and simultaneously press them hard
into the ground. This is a proprioceptive foot mus-
cle exercise termed ‘Janda’s short foot’according to
its inventor.27 Pfaff28 claims that condition JS stimu-
lates the foot’s afferences in a comparable fashion
as PNSI, resulting in similar cerebrifugal modula-
tion of afferences and comparable alteration in pos-
ture. Due to forceful muscle contraction of the foot
and its connected muscle chains, condition JS is
anticipated to modify posture in all three dimen-
sions: for example, trunk inclination and spinal cur-
vature (sagittal plane), pelvic torsion and rotation
(axial plane) pelvic tilt, as well as possibly lateral
deviation of the spine (frontal plane) due to a more
forceful activation of subjects’ dominant leg.
Figure 1. (a) Rasterstereographic measurement setup. Rasterstereography (Rasterstereograph Formetric III; Diers International
GmbH, Schlangenbad, Germany) provides optical three-dimensional (3D) back surface measurements. It consists of (1) a detector
camera and (2) a light projector. The measurement system projects horizontal parallel lines of white light onto the patient’s back. The
uneven back surface distorts these lines, and the camera detects the distorted pattern from a different angle of view as compared
to the location of the projector. This reveals precise shape information. The projection and scanning is performed synchronously
in 0.04 s. The short measurement time eliminates errors from patient movement or breathing. (b) The system’s software utilises
sophisticated mathematical shape analysis algorithms and reconstructs the 3D shape of the spine. This allows the localisation of the
anatomical landmarks of the processus spinosi and the left and right spina iliaca posterior superior (pelvic dimples).
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5. 4 Prosthetics and Orthotics International
•• Test condition 4: loose jaw (LJ) – normal relaxed
barefoot stance, combined with a dental cotton roll
held loosely between the mandibular and maxillary
dental arches on the right side of the jaw. By sepa-
rating the jaw and altering the joint position, this
condition is supposed to modulate the tension of
the masseter muscle and its adjacent neck and back
muscles. According to the concept of propriocep-
tion,13,29 altered joint position and muscle tension
cause modulation of the neuromuscular afferences
inducing an alteration in cerebral efferent signal
which, therefore, induce an alteration of posture.
Condition LJ is expected, among others, to alter
thoracic curvature as measured by flèche cervicale
or back surface rotation.
•• Test condition 5: bite (BT) – normal relaxed bare-
foot stance with a forceful bite onto the dental cot-
ton roll placed between the mandibular and
maxillary dental arches on the right side of the jaw.
This one-sided muscle contraction is believed to
affect posture parameters primarily representing the
frontal plane.
•• Test condition 6: stance with PNSI (PNSI) – normal
relaxed barefoot stance on a pair of PNSI. Each sub-
ject received PNSI which were fitted to individual
shoe sizes. The pressure in each of the nine firm-elas-
tic pads was manually adjusted to the starting pres-
sure level that is usually adopted during therapy. This
was performed by an expert with 10 years of experi-
ence in the use of PNSI. We expect to detect an alter-
ation of posture parameters similar to the ones altered
in test condition JS. With test condition PNSI induc-
ing passive reflectory movement, we do not expect to
see similar change in amplitude compared to the
active and most intense stimulation in JS.
Experimental protocol
The sequence of measurements is set up using three inde-
pendent single test rows. Each test row is conducted with a
1 h break in-between. Every test row includes three sepa-
rate sets of data acquisition for every subject in all six test
conditions, each with a 1 min break. Each set of data
acquisition contains four single rasterstereographic meas-
urements (Figure 3). In total, 216 different measurements
were taken from each subject.
Data analysis
Individual repeated measures within a test row were
averaged and served as outcome variables for further
analyses. The data are presented as mean (±standard
deviation) referring to the measures either regarding a
specific test condition in general or a specific test condi-
tion at the assigned time point (test row). In order to com-
pare the six test conditions, boxplots are displayed. Due
to the model assumption of normality, Box–Cox transfor-
mation was applied for trunk inclination (ti), right and
left back surface rotation (brr and brl) and lateral devia-
tion amplitude (lda). Furthermore, only positive values of
pelvic inclination (pi), flèche cervicale (fc), kyphotic
angle (ka) and lordotic angle (la) were analysed as a
result of excluding outliers. To detect differences among
the test rows and conditions, a mixed linear model with
test row and condition as fixed effects and patient as ran-
dom effect was performed for each of the remaining pos-
ture parameters. The p values of the F-test for the fixed
effects were gained. If the F-test was significant, corre-
sponding pairwise Tukey–Kramer post-hoc tests were
conducted. All hypothesis tests were two-sided, and a p
value less than 0.05 was considered statistically signifi-
cant. Reliability was investigated utilising the standard
deviation (in millimetres) of the collective intra-individ-
ual DL-DR. This value has been established by previous
rasterstereographic studies as the parameter for measure-
ment accuracy.24,25,30–32
Statistical analyses were carried out using the SAS pro-
gram version 9.2 (SAS Institute, Cary, NC, USA), and
Figure 2. Examined proprioceptive neuromuscular stimulating
insoles (PNSI) (MedReflexx) feature nine firm-elastic pads
which can be individually fitted, and their pressure can be
adapted during therapy.
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6. Dankerl et al. 5
graphs were produced with the R system for statistical
computing (version 2.11.1; R Development Core Team,
Vienna, Austria).
Results
Reliability analysis
The standard deviation of the collective intra-individual
distance of DL-DR was ±2.67 mm. This indicates that in
each individual, the distance between the two lumbar dim-
ples was detected with good precision.
Separate evaluation of the posture parameters
1. Trunk inclination (ti): parameter ti differed statisti-
cally significantly between the six test conditions
(p 0.0001, F-test). In particular, condition JS
leads to a significantly higher trunk inclination
angle than all other test conditions (p 0.0001).
Hence, in condition JS, the subjects are tilted more
forward. Mean values of the angle of the trunk var-
ied between 3.27° ± 2.40° for HP and 4.54° ± 2.99°
for JS (Figure 4).
2. Flèche lombaire (fl): among the test conditions,
statistically significant differences were present
(p 0.0001, F-test). A smaller fl was apparent for
JS in comparison to the remaining conditions
(p 0.0001) (Figure 5).
3. Flèche cervicale (fc): similar results concerning
the test conditions were obtained for fl (p 0.0001,
F-test). Significant differences were found for JS
compared to each of the remaining conditions
(p 0.0001).
4. Pelvic tilt (pti): positive values of pti varied sig-
nificantly among the test conditions (p = 0.001,
F-test). More precisely, differences were apparent
for JS in comparison to HP (p 0.01), LJ (p 0.01)
and BT (p = 0.03). Mean values of positive pelvis
inclination were 17.25° ± 4.83° for JS,
15.43° ± 6.12° for HP, 15.84° ± 5.79° for LJ and
16.04° ± 5.28° for BT.
Figure 3. Experimental protocol: four single
rasterstereographic measurements are taken in each of the
three sets of data acquisitions with 1 min break in-between,
for all six test conditions. In the experimental setup, three test
rows are performed with 1 h break in-between.
(1) Test condition 1: habitual posture (HP) – relaxed barefoot stance;
(2) test condition 2: foot elevation (FE) – barefoot stance left foot on
the ground and right foot on a 10-mm thick plank; (3) test condition 3:
Janda’s short foot (JS) – barefoot stance toes firmly plantar flexed and
simultaneously pressed hard into the ground; (4) test condition 4: loose
jaw (LJ) – barefoot stance combined with a dental cotton roll held
loosely between the tooth rows on the right side of the jaw; (5) test
condition 5: bite (BT) – barefoot stance with a forceful bite onto the
cotton roll placed between the tooth rows on the right side of the jaw;
(6) test condition 6: proprioceptive neuromuscular stimulating insoles
(PNSI) – relaxed barefoot stance on a pair of size and pressure adapted
proprioceptive neuromuscular stimulating insoles.
Figure 4. Boxplot featuring the results for parameter trunk
inclination (ti) in degree in all six test conditions: bite (BT), foot
elevation (FE), habitual posture (HP), short foot according to
Janda (JS), loose jaw (LJ) and proprioceptive insoles (PNSI).
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7. 6 Prosthetics and Orthotics International
5. Pelvic torsion (pto): the F-test revealed significant
differences between the test conditions (p 0.0001).
In comparison to all other conditions, smaller val-
ues of the pelvis torsion were observed for FE
(p 0.0001).
6. Lateral deviation of the spine’s amplitude (lda): the
absolute deviation amplitude was proven to differ
significantly among the six test conditions (p 0.01,
F-test). The deviation in condition FE was signifi-
cantly higher than in conditions JS (p 0.01) and
PNSI (p = 0.03). On average, amplitudes of
17.03 ± 7.19 mm for FE, 15.41 ± 7.70 mm for PNSI
and 14.75 ± 6.82 mm for JS were measured.
Evaluation over the three different points in time
Studying the temporal sequence of tests, significant differ-
ences between the three examination times for ti (p 0.01,
F-test), fc (p = 0.02, F-test), fl (p 0.0001, F-test) and lda
(p = 0.03, F-test) were revealed. Mean values of ti
decreased from the first row (3.81° ± 2.62°) to the last row
(3.15° ± 2.47°) with p 0.01; fl increased from the first
row (38.40 ± 15.62 mm) to the second row
(40.28 ± 15.55 mm) with p 0.01, and even more to the
last row (41.59 ± 14.75 mm) with p 0.001; lda increased
from the second to the third test row with p = 0.03 from
15.52 ± 7.69 mm to 16.14 ± 7.24 mm.
Further analysis
No relevant evidence for an association between the other
parameters (la, ka, pr, brl, brr, bra, ldl and ldr) and the test
conditions or test rows was apparent.
Discussion
One objective of this study was to evaluate how reliably
rasterstereography can objectify postural changes induced
by different neuromuscular afferent stimulation and PNSI.
In order to investigate whether our rasterstereographic
measurements are sound and reveal conclusive data, we
examined the standard deviation of a rasterstereographic
precision parameter. Previous works have found the devia-
tion of the intra-individual distance DL-DR as the preci-
sion parameter for the evaluation of standard deviation.
This study demonstrates a standard deviation of 2.67 mm
for DL-DR. Comparing our standard deviations with pre-
vious studies which produced a DL-DR of 4.6 mm,25
1.04 mm31 or 1.8 mm,32 the accuracy of this study can be
rated as being good. As this proves the accuracy of our
experimental setup and rasterstereographic measurements,
we also conclude our measured postural parameters to be
accurate. Our study stands in consistency with previous res
earch,16–23,29–33 which demonstrates the method of rasterst-
ereography to be able to measure postural parameters in a
clinical setting.
Another objective was to investigate whether rasterste-
reography can detect postural alteration resulting from
neuromuscular stimulation. Therefore, we implemented
test conditions with various intense stimuli (JS vs PNSI;
LJ vs BT) and stimulated afferent proprioceptive receptors
in the foot and jaw.
We proved JS to provoke the biggest alteration in pos-
ture. For this test condition, we detected an increased trunk
inclination with a high level of significance. We found an
increased forward ti of about 1.3° in the mean together
with significantly smaller fl and bigger fc (Figure 6). A
similar alteration of measured parameters regarding pos-
ture alterations in dependence of Matthias test was demon-
strated by Drerup et al.30 and Betsch et al.31 Our research
demonstrates that the well-known phenomenon of various
stimuli inducing different afferences34 can be quantified by
rasterstereographic measurements. Alterations of posture
were proven for biomechanical (test condition FE) and
neuromuscular proprioceptive stimuli (test conditions JS
and PNSI).
A further objective of this investigation was to evaluate
whether rasterstereography serves as a tool in objectifying
postural change provoked by PNSI. PNSI are claimed to be
a dynamic active stimulator due to varied afferent stimuli
during walking (similar to barefoot walking on natural sur-
face). Furthermore, in theory, PNSI are said to have similar
effects on the foot muscles as the proprioceptive exercise
JS in our test condition.5,12,25 Therefore, postural changes
should be similar to those documented in condition JS.
In our study, significant postural alteration was
revealed for lateral spinal movement for test conditions
PNSI and JS (both vs FE). Furthermore, postural reac-
tions for both test conditions were aligned in the same
direction, since lda reduced in both test conditions, which
made them comparable in form. Moreover, for various
posture parameters (pto, pti, pr, fc, fl, la and ka), slight
but not statistically significant postural changes were
found for conditions PNSI versus HP. It revealed in a
Figure 5. Boxplot featuring the results for parameter flèche
lombaire (fl) in millimetre in all six test conditions: bite (BT),
foot elevation (FE), habitual posture (HP), short foot according
to Janda (JS), loose jaw (LJ) and proprioceptive insoles (PNSI).
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8. Dankerl et al. 7
comparable way the postural alterations detected between
conditions JS and HP. As expected, parameters represent-
ing pelvis positioning and spinal curvature were affected
by conditions JS and PNSI. However, our findings indi-
cate differing intensities. In contrast to JS, no significant
differences for ti, ldl or ldr were detected. We believe that
this supports our interpretation of JS and PNSI as stimu-
lating in a similar way but in different intensities.
Therefore, we conclude that the obviously small subcon-
scious insole stimulus is not as intense as an active inten-
tional contraction of foot muscles, and therefore, the
postural changes are smaller. Nevertheless, effects to
posture from PNSI were observed reproducibly.
Therefore, follow-up studies regarding the postural
effects of neuromuscular stimulating insoles should, in
contrast to previous studies,9 include all posture parame-
ters presented in this study.
It has to be emphasised that this study was exclusively
designed to investigate reproducible immediate short-
term effects of neuromuscular stimulating insoles on pos-
ture. This study with a 1-h interval between test rows
demonstrated significant postural changes over time for
ti, fc, fl and lda. In clinical practice, patients were PNSI
continuously for 8–10 weeks6,7 Furthermore, patients
being treated with PNSI usually have one to two adjust-
ments to pad pressure before their posture is re-evaluated
rasterstereographically. So far, no long-term study has
investigated the postural effects of PNSI. However, as
demonstrated by this study, the method of rasterstereog-
raphy supplies the ability to monitor postural effects
caused by PNSI in long-term studies. Furthermore, long-
term research can be directed at systematically analysing
different rasterstereographic posture parameters in order
to establish a scoring system for a simple evaluation of
proprioceptive effects on posture.
Conclusion
We proved that varying intense neuromuscular afferent
stimulations alter posture and demonstrated that PNSI to
elicit immediate effects on posture. All these postural reac-
tions were reliably and reproducibly detected utilising ras-
terstereography. This reveals the clinical relevance and
necessity of utilising this non-invasive clinical diagnostic
test for posture evaluation, for example, when monitoring
the therapeutical effects of PNSI.
Author contribution
All authors contributed equally in the preparation of this
manuscript.
Declaration of conflicting interests
None declared.
Figure 6. Sagittal profile changes of a subject in the study comparing (a) test condition habitual posture (HP) with (b) test
condition short foot according to Janda (JS).
BT: bite; FE:foot elevation; HP: habitual posture; JS: short foot accordingto Janda; LJ: loose jaw; PNSI: proprioceptive insoles; VP: vertebra prominens;
DM: midpoint between left and right dimples; LA: lordotic apex; KA: kyphotic apex.
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9. 8 Prosthetics and Orthotics International
Funding
This research received no specific grant from any funding agency
in the public, commercial or not-for-profit sectors.
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