Uroflowmetry nomogram in Iranian children aged 7 to 14 years

Background

As the voiding habits of Iranian children differs from other children because of some cultural and religious considerations, we aimed to establish normal reference values of urinary flow rates in Iranian children between 7 to 14 years of age.

Methods

Eight hundred and two uroflowmetry studies were performed on children with no history of a renal, urological, psychological or neurological disorder, between the ages 7 and 14. Five hundred twenty five studies from 192 girls and 335 boys were considered in this study excluding the staccato/interrupted voiding pattern or voided volume less than 20 ml. The voiding volume, the maximum and average urinary flow rates were extensively analyzed.

Results

The maximal and average urine flow rate nomograms were plotted for both girls and boys. Mean maximum urine flow rate was 19.9 (ml/sec) for boys and 23.5 (ml/sec) for girls with a mean voided volume of 142 (ml) for boys and 147 (ml) for girls. Flow rates showed a close association with voiding volume in both sexes. The maximum and average flow rates were higher in girls than in boys, and they showed a significant increase in flow rates with increasing age, where boys did not. The mean maximum urine flow rates (19.9 ml/sec for boys and 23.5 ml/sec for girls) were found to be higher in this study than other studies.

Conclusion

Nomograms of maximal and average flow rates of girls and boys are presented in centile form, which can help the physician to evaluate the response to medical or surgical treatment and be useful for the screening of lower urinary tract disturbances in children, for a wide range of voided volumes.     

Evaluation of bladder capacity in Korean children younger than 24 months: a nationwide multicenter study

Purpose

Bladder capacity is an important factor in the diagnosis and treatment of children with voiding dysfunction. The purpose of this study was to define the normal maximal voided volume formula in Korean children younger than 2 years.

Methods

We measured the bladder capacities of 151 Korean children between 0 and 24 months of age (83 boys and 68 girls) who did not have clinical voiding dysfunction. The maximal voided volume was determined in all subjects using a 2-day frequency volume chart with a four-hour voiding observation. The largest voided volume for each patient was considered to be the maximal voided volume. Statistical analyses were carried out using linear regression analysis.

Results

The maximal voided volume increased with age and weight (P = 0.0001). There was no significant difference between males and females (P = 0.771). A formula that approximates bladder capacity with respect to age is the following: bladder capacity (ml) = [1.6 × age (months)] + 45 (t = 8.757, P = 0.0001). A formula that approximates bladder capacity with respect to weight is the following: bladder capacity (ml) = [4.1 × weight (kg)] + 28 (t = 10.152, P = 0.0001).

Conclusions

These formulas may be useful for the diagnosis of abnormal bladder capacity and the evaluation of voiding dysfunction in Korean children younger than 24 months.     

1024例儿童尿流率调查

目的 寻求长沙地区儿童尿流率正常值及其列线图。方法 对1024名正常儿童进行1048次尿流率检测。将所得资料按性别、年龄、体表面积、排尿量分组后进行统计学分析，并绘制出各组相应的列线图以阐明尿量、体表面积、平均尿流率、最大尿流率4者的相互关系。结果 正常儿童尿流率曲线为典型的钟形曲线。〈7岁男性儿童的最大尿流率随年龄增加而增加，年龄每增加1岁最大尿流率增加1．7ml／s，〉7岁者其最大尿流率同成年人相仿。〈9岁女性儿童的最大尿流率随年龄增加而增加，年龄每增加1岁最大尿流率增加1．2ml／s，〉9岁其最大尿流率同成年人相近。儿童最大尿流率、平均尿流率及排尿量均随体表面积增加而增加，同时，最大尿流率、平均尿流率也均随排尿量的增加而增加。结论 〈9岁的女童和〈7岁的男童最大尿流率的正常值有明显的年龄依从性。     

FOUR-HOUR VOIDING OBSERVATION IN YOUNG BOYS WITH POSTERIOR URETHRAL VALVES

Purpose

We evaluated 4-hour voiding observation as a method of basic assessment of bladder dysfunction in young boys with posterior urethral valves.

Materials and Methods

Voiding pattern, including number of voids, voided and residual urine volume, and bladder capacity, was determined noninvasively in 24 boys younger than 4 years with posterior urethral valves and compared to that of healthy age matched controls. Results were then compared to those of standard cystometry.

Results

The number of voids was higher, voided was smaller and residual urine volume was higher in the posterior urethral valve group. There was no difference in voiding pattern before and after removal of the anatomical obstruction. Voided and residual urine volume, and bladder capacity were higher on standard cystometry than on voiding observation.

Conclusions

Four-hour voiding observation is an easy noninvasive method that focuses on emptying difficulties and clearly detects differences in voiding patterns between boys with posterior urethral valves and healthy, nontoilet trained children. We recommend the method as a complement to standard cystometry for the diagnosis and followup of bladder dysfunction in young boys with posterior urethral valves to identify the need for treatment.     

Age Related Urodynamic Changes in Patients with Benign Prostatic Hyperplasia

Purpose

We determined age related urodynamic changes in patients with untreated symptomatic benign prostatic hyperplasia (BPH).

Materials and Methods

A total of 222 patients (mean age 67.3 years, range 45 to 90) with the clinical diagnosis of symptomatic BPH was entered into a prospective protocol evaluating the international prostate symptom score (I-PSS), prostate volume, noninvasive uroflowmetry, residual volume and a pressure-flow study. To obtain a homogeneous study population only patients with a noninvasive maximum flow rate of 15 ml. per second or less and an I-PSS of 7 or more were eligible.

Results

There was no correlation between age and I-PSS (p greater than 0.05) but there was a statistically significant decrease in maximum flow rate (p = 0.045) and voided volume (p = 0.0013) with age. Prostate volume increased constantly from 31.3 to 64.4 ml. in patients 45 to 50 and older than 80 years, respectively (p less than 0.0001). Pressure-flow studies revealed an age related decrease in cystometric bladder capacity (p = 0.0003) and invasive maximum flow rate (p = 0.0057) but no changes in detrusor pressure at maximum flow rate (p greater than 0.05), maximum detrusor pressure (p greater than 0.05) and linear passive urethral resistance relation (p greater than 0.05). The incidence of urodynamically proved bladder instability increased from 20 to 47 percent in men 45 to 50 and older than 80 years, respectively.

Conclusions

The well established age related decrease in maximum flow rate and voided volume in patients with prostatism cannot be attributed to an increase in bladder outflow obstruction or impaired detrusor function. Because 60 percent of all men older than 80 years did not have urodynamic obstruction despite a decreased maximum flow rate of 10 to 15 ml. per second, all patients meeting these criteria and having symptoms bothersome enough to justify surgery should undergo pressure-flow studies before surgical intervention.     

Fluid intake and voiding parameters in asymptomatic Turkish women

Introduction and hypothesis

For an accurate evaluation of bladder diaries, we aim to investigate normal urinary habits and determining factors on functional bladder capacity, frequency, and 24-h volume in the bladder diaries of asymptomatic women.

Methods

One-hundred and fifteen asymptomatic women who recorded a 24-h bladder diary were included in the study. Linear regression analyses were used to explore associations between diary values and patient characteristics.

Results

Total number of voids was related to age, body mass index, total voided volume, total fluid intake, total diuresis rate, and maximum fluid intake in one go. Maximum, average, and minimum volumes per void were found to be related to body mass index, total voided volume, total fluid intake, total diuresis rate, and maximum fluid intake. When we used multiple regression analysis, only maximum fluid intake was found to be related to the total number of voids, maximum, average, and minimum volumes per void.

Conclusions

Maximum fluid intake rather than total voided volume seems to be an important determinant factor for total number of voids and functional bladder capacity.     

Evaluation of maximum voided volume in Korean children by use of a 48-h frequency volume chart

Study Type – Diagnostic (validating cohort) Level of Evidence 2a What's known on the subject? and What does the study add? The relationship between the maximum voided volume followed a linear curve. The formula presented, bladder capacity (mL) = 12 ×[age (years) + 11], is thought to be a reasonable one for Korean children. Korean children have a smaller bladder capacity than that reported in previous Western studies.

OBJECTIVE

• ? To develop practical guidelines for the prediction of normal bladder capacity in Korean children measured by a frequency volume chart (FVC), maximum voided volume (MVV) is an important factor in the diagnosis of children with abnormal voiding function.

SUBJECTS AND METHODS

• ? In all, 298 children, aged 3–13 years, with no history of voiding disorders volunteered for the study. The MVV was determined in 219 subjects by use of a completely recorded FVC.

RESULTS

• ? Linear regression analysis was used to define the exact relationship between age and bladder capacity. An approximate formula related age to bladder capacity as follows: bladder capacity (mL) = 12 ×[age (years) + 11].

CONCLUSIONS

• ? The relationship between the MVV measured by a FVC by age (3–13 years) of Korean children followed a linear curve.
• ? When applied to normal voiding patterns, the formula presented appears to be a reasonable one for Korean children.

     

A clinical postural model of sagittal alignment in young adolescents before age at peak height velocity

Introduction

From a clinical point of view, knowledge of customary standing positions among healthy young adolescents is of primary importance. The purpose of this study was to document the correlations between sagittal standing posture parameters in a pre-peak height velocity (pre-PHV) cohort.

Materials and methods

This cohort study included 639 pre-PHV boys (age 12.6 [SD, 0.54] years) and 557 pre-PHV girls (age 10.6 [SD, 0.47] years). Gross body segment orientations and spinopelvic orientation/shape indexes were quantified using a clinical screening protocol. Pearson’s correlation coefficients were determined for all sagittal standing plane alignment parameters, and a postural model was used to analyze the correlations between parameters.

Results

Both at the gross body segment and spinopelvic level, an interdependence was found between postural parameters. No correlations were observed between ‘global’ parameters related to the pelvis, trunk or body anteroposterior translation postures and ‘local’ spinopelvic geometries. A similar pattern and strength of correlations was obtained in pre-PHV boys and girls, except for the reciprocal relationships between the craniovertebral angle and adjacent anatomic segment characteristics and between thoraco-lumbar geometries.

Conclusions

Although the correlation schemes do not imply a causal relationship, the proposed postural model allows conjecture about standing posture to be organized slightly differently in pre-PHV boys and girls. Whereas the standing posture in pre-PHV boys might be organized predominantly according to an ascending mode, bottom-up and top-down organizations appear to coexist in pre-PHV girls.     

Flow rate nomograms in 7- to 16-year-old healthy children

To construct flow rate nomograms for children, 180 healthy boys and girls aged 7–16 years were examined with a new kind of flowmeter. Each child presented at least two registrations. The flow rate was significantly higher at the second examination and these micturitions were used to construct the nomograms. The relation between flow rate and volume may be described by the function flow = b volume^c, where b and c describe the slope and curvature, respectively. The advantages of using this relation are that non-parametric statistics can be employed, the variation around the median increases with increasing volume, and it is easy to calculate volume corrected flow rates. The exponent 0.5, often used earlier, was found to overestimate flow rates obtained at low volumes. In the constructed nomograms, the exponent varied between 0.29 and 0.42. The volume corrected maximum flow rate was about 2 ml/s higher in girls than in boys. This difference was significant. The difference of about 1.5 ml/s in average flow rate was not significant. The flow rate increased significantly with age. For volume corrected flow rates, there was, however, no significant change with age. Thus, the increase in flow rate with age is secondary to an increase in voided volume. As a result of these analyses, four nomograms were constructed showing the maximum and average flow rates for boys and girls separately. The flow rates of the new nomograms are on a level with or somewhat higher than the flow rates in previously presented nomograms for both children and young adults. © 1994 Wiley-Liss, Inc.     

High urinary flow in women with stress incontinence: corrected flow–age nomogram evaluation after a transobturator tape procedure

Introduction and hypothesis

We noninvasively compared urinary flow in both pre- and post-transobturator tape (TOT) procedures in stress urinary incontinence (SUI) patients using previously reported corrected flow–age nomograms in healthy women.

Methods

This retrospective cohort study included patients who underwent a successful TOT procedure to treat SUI. Non-instrumented uroflowmetry was performed before and 3 months after surgery. Corrected maximum flow rate (cQmax) and average flow rate (cQave) were calculated using Qmax/√voided volume (VV) and Qave/√VV respectively. The ratio of corrected flow to age-adjusted corrected flow in healthy women was calculated in each patient. Each parameter was compared against pre-TOT and 3-months post-TOT values.

Results

Sixty-two patients were eligible for study inclusion. All urinary flow parameters were significantly higher pre-TOT than at 3 months post-TOT. The number of patients with cQmax and cQave over mean flow–age nomogram, compared with healthy women, before the TOT procedure decreased 3 months post-TOT; however, in many patients, cQmax and cQave were higher than in the corrected flow–age nomogram post-TOT. No significant difference in the ratio of cQmax to age-adjusted cQmax between pre- and post-TOT in the normal urinary flow group was observed, but significantly decreased in the high urinary flow group 3 months after TOT.

Conclusions

Urinary flow rates were higher in SUI patients compared with age-matched controls and successful TOT procedures normalized urinary flows in patients with high urinary flow. A simple evaluation of urinary flow using a corrected flow–age nomogram may be clinically useful in SUI patients.

     

Body surface related flow rate nomograms in a normal pediatric population

Uroflow studies for 511 normal pediatric subjects (272 boys, 239 girls) were analyzed statistically. Nomograms relating peak flow to volume voided and body surface were established. An acceptable lower limit for peak flow was obtained from the data and a volume voided range was calculated so that both criteria could be used with 90% probability to define the normal voiding situation. Body surface area was found to be a more reliable index than age in the establishment of nomograms. In the male population the 90% probability applied to a significantly greater volume voided reliability. In the female population mean peak flow rate rose with increased body surface. Finally, in both sexes the 10% lower limit was closer to the regression mean, allowing a tighter distribution around this value.     

Neonatal Estrogenization of the Male Mouse Results in Urethral Dysfunction

Purpose

Analysis of voiding pattern, urodynamic measurements and immunohistochemical methods were performed in order to evaluate the effects of neonatal estrogenization on voiding functions of adult male mice.

Materials and Methods

Metabolic cages were used for recording the voiding volumes and frequencies. Bladder pressure and mean flow during voiding were measured in transvesical cystometry. Location of estrogen receptors and organization of smooth muscles in lower urinary track were demonstrated using immunohistochemical staining.

Results

Neonatally estrogenized (neoDES) male mice had lower voided urine volumes (the average voided urine volume and average of the three largest volumes) and higher voiding frequencies than control mice. In transvesical cystometry, the maximum bladder pressure during the high-frequency oscillation phase of voiding was significantly elevated. The average urinary flow rate was decreased.

Conclusions

Urodynamically, these findings are consistent with the concept that neonatally estrogenized mice have infravesical obstruction. The predominance of estrogen receptors in the periurethral region and changes in urethral smooth muscle cells immunocytochemically stained with alpha-actin-antibody support the concept of urethral wall musculature as a target of estrogen action.     

Urodynamic Evaluation of Hypospadias Repair

Purpose

We performed a cross-sectional evaluation of voiding in a population undergoing hypospadias repair to determine whether patients had urinary obstruction at various intervals of followup after the last operation.

Materials and Methods

Of approximately 600 patients undergoing hypospadias repair at our department during a 30-year interval 175,40 months to 66 years old were evaluated. Therefore, we created a cross-sectional study group for evaluation of voiding function. All patients had undergone the final operation for hypospadias at least 1 year previously and were toilet trained. Severity of the initial hypospadias was scored together with the operative technique. Parameters evaluated were medical history, physical examination and uroflowmetry using a rotating disk. Uroflowmetry data (maximum flow rate and voided volume) were plotted in age-related nomograms in 4 different age groups: less than 8 (28 patients), 9 to 14 (18), 15 to 21 (39) and more than 21 (91) years old. All flow charts were evaluated by 2 of us (J. F. A. v. d. W. and E. B.).

Results

The severity of initial disease was grade 1 in 30% of the patients, grade 2 in 57%, grade 3 in 10%, grade 4 in 2% and unknown in 2%. The operative technique performed was a van der Meulen repair in 113 patients (65%), a combined Byars-Denis Browne repair in 56 (32%) and miscellaneous in 6 (3%). According to the uroflowmetry nomograms there was a tendency for an increased number of patients to have a normal maximum flow rate with increasing age. A total of 14 patients had a flow curve that suggested distal urethra obstruction and none was symptomatic. There was no difference in uroflowmetry characteristics regarding the operative technique.

Conclusions

No difference in uroflowmetry could be established among the operations. There seemed to be a tendency towards improvement in uroflowmetry with increasing followup. There was no direct relationship between low maximum flow rates and clinical apparent obstruction.     

Classification system of the sagittal standing alignment in young adolescent girls

Purpose

The purpose of this cohort study was to classify sagittal standing alignment of pre-peak height velocity (pre-PHV) girls, and to evaluate whether identified subgroups were associated with measures of spinal pain. This study further aimed at drawing attention to similarities and differences between the current postural classification and a previous system determined among pre-PHV boys.

Methods

557 pre-PHV girls [mean age, 10.6 years (SD, 0.47 years)] participated in the study. Three gross body segment orientation parameters and five specific lumbopelvic characteristics were quantified during habitual standing. Postural subgroups were determined by cluster analysis. Logistic regression was applied to assess the relationship between postural subgroups and spinal pain measures (pain and seeking care, assessed by self-administered questionnaire). Chi-square statistics, independent samples T test, and distribution-based methods were used for comparison with postural categorization in pre-PHV boys.

Results and conclusion

Among pre-PHV girls, clinically meaningful posture clusters emerged both on the gross body segment and specific lumbopelvic level. The postural subtypes identified among pre-PHV girls closely corresponded to those previously described in pre-PHV boys, thereby allowing the use of the same, working nomenclature. In contrast to previous findings among pre-PHV boys, no associations between posture clusters and spinal pain measures were significant in girls at pre-PHV age. When comparing discrete ‘global’ alignment scores across corresponding posture types, some intriguing differences were found between genders which might involve different biomechanical loading patterns. Whether habitual posture forms a risk factor for developing spinal pain up to adulthood needs evaluation in prospective multifactorial follow-up research.     

Japanese Men Have Smaller Prostate Volumes But Comparable Urinary Flow Rates Relative to American Men: Results of Community Based Studies in 2 Countries

Purpose

We compared prostate volume and peak urinary flow rate in Japanese and American men 40 to 79 years old.

Materials and Methods

Prostate volume and peak urinary flow rate were measured in eligible Japanese men and results were compared to those of a randomly selected American cohort.

Results

Mean prostate volume plus or minus standard deviation averaged 20.3 plus/minus 10.6 ml. in Japanese and 29.6 plus/minus 13.4 ml. in American men, while predicted cross-sectional increases with age decade were 1.5 and 5.5 ml., respectively. Peak urinary flow rate was higher but the decrease with increasing age was greater in Japanese men.

Conclusions

Prostate volume is larger and the increase with age is more pronounced in American than in Japanese men. However, Japanese men may have a higher peak urinary flow rate and greater cross-sectional decrease with age.     

The impact of abdominal aortic calcification and visceral fat obesity on lower urinary tract symptoms in patients with benign prostatic hyperplasia

Objectives

To investigate the impact of abdominal aortic calcification and visceral fat area (VFA) on lower urinary tract symptoms (LUTS) and clinical parameters in patients with benign prostatic hyperplasia (BPH).

Methods

We retrospectively studied 250 patients with LUTS associated with BPH. Each participant was examined with routine examination including measurement of various data; (1) voided volume (VV), maximum urinary flow rate on free uroflowmetry, (2) postvoid residual urine volume and prostate volume using transabdominal ultrasound, (3) International Prostate Symptom Score (IPSS) and Overactive Bladder Symptom Score (OABSS), and (4) aortic calcification index (ACI) and VFA were measured by abdominal CT.

Results

Mean age of the patients was 72.4 ± 9.6 years. ACI significantly correlated with VV (P = 0.0392) and tended to correlate with maximum urinary flow rate, while ACI did not correlate with subjective symptoms. VFA significantly correlated with nocturia score of IPSS (P = 0.0177) and frequency score of OABSS (P = 0.0166) and tended to correlate with urgency score of IPSS and maximum urinary flow rate.

Conclusions

Aortic calcification index (ACI) correlated with only objective parameters, while VFA correlated with only storage symptoms. This study suggested that abdominal aortic calcification and VFA have certain influence on LUTS and clinical parameters in patients with BPH.     

Urinary citrate excretion in healthy children depends on age and gender

Background

Hypocitraturia is considered a major risk factor for calcium stone formation. However, there is no widely accepted reference database of urinary citrate excretion in children. The aim of our study was to determine the amount of citrate eliminated in the urine over a 24-h period in a pediatric cohort and to determine an optimal unit reflecting excretion.

Methods

The study cohort comprised 2,334 healthy boys and girls aged 2–18 years. The levels of urinary citrate were assessed by an enzymatic method in 24-hour urine and expressed in absolute values, as urinary concentration, citrate/creatinine ratio, per kilogram of body weight, in relation to 1.73 m², and as the calcium/citrate index.

Results

Similar incremental age-related citraturia rates were observed in both male and female subjects until puberty during which time citrate excretion became significantly higher in girls. Urinary citrate adjusted for creatinine and for body weight showed a significantly decreasing trend with increasing age in both sexes. Urinary citrate corrected for body surface was weakly correlated with age. Thus, the assumption of 180 mg/1.73 m²/24 h for males and 250 mg/1.73 m²/24 h for females as lower cut-off values appeared to be reliable from a practical perspective.

Conclusions

We found distinct sex-dependent differences in citraturia at the start of puberty, with significantly higher values of urinary citrate in girls than in boys. Further prospective studies are warranted to elucidate whether this difference represents a differentiated risk of urolithiasis.     

Assessing bladder capacity in children: Is it feasible at all?

AIM: The aim of the study was to assess correlations between body parameters and bladder capacity in healthy schoolboys and schoolgirls. On the basis of those anthropometric data functional bladder capacity (FBC) in children was estimated. MATERIALS AND METHODS: The questionnaires were sent to 1,055 parents of children aged from 6 to 14 years. Voided volumes were assessed during uroflowmetry, which was performed under typical conditions in separate rooms (Urodyn 1,000, Dantec, Skovlunde, Denmark). Residual volume was measured thereafter. Precise anthropometric parameters were obtained in standing the position. Children with dysfunctional problems, those who voided less than 100 ml and those with residual volumes > 5% of voided volume were excluded. Statistical analysis was done on the basis of the results gathered from 288 children. Pearson's correlation coefficient between body measurements and voided volume was calculated (P < 0.05). Regression modeling was used to propose the best formula for calculating FBC in children. RESULTS: Mean FBC is higher in girls than in boys (P < 0.05). The correlation between FBC and flow parameters was found (0.3 < "r" < 0.5). The value of the coefficient indicates loose relationship. We revealed correlation between weight, height, and length of the trunk, pelvic dimension and FBC. The best mathematical equation to estimate FBC in children based on the body measurements fits to 54% of population (FBC = -268.4 + 7.38 x flow time + 3.15 x suprasteral height + 1.25 x thickness of fat fold.     

Associations between subjective overactive bladder symptoms and objective parameters on bladder diary and filling cystometry

Introduction and hypothesis

A study was conducted to assess associations between different overactive bladder (OAB) symptoms and their outcomes on bladder diary and filling cystometry parameters.

Methods

We performed a retrospective cohort study in database of 6,876 Urinary Distress Inventories, 3,185 bladder diaries and 2,153 filling cystometries from women referred to our urogynecological center between 2003 and 2009. Women were dichotomized into two groups. Group I: those women without symptoms, and those with symptoms that were not bothersome. Group II: women with bothersome symptoms. Data obtained from bladder diaries were: daytime urinary frequency, nocturnal frequency, minimum voided volume, maximum voided volume, average voided volume, and incontinence episodes. From filling cystometries, volumes at first desire to void, normal desire to void, strong desire to void and maximum cystometric capacity, were extracted. Univariate and multiple linear regression analysis were performed to determine associations between OAB symptoms and bladder diary and filling cystometry measurements.

Results

After multivariate analysis the objective daytime frequency was most strongly associated with the frequency symptom (β 0.27, p?<?0.05), night time frequency with the nocturia symptom (β 0.40, p?<?0.05) and the number of incontinence episodes with the urge incontinence symptom (β 0.37, p?<?0.05). Both frequency and nocturia symptoms were significantly associated with bladder diary and cystometry filling volumes, and their effect size was the same. The urgency symptom proved to be poorly associated with objective parameters.

Conclusions

In contrast to the frequency and nocturia symptom, the urgency symptom is poorly associated with objective parameters on bladder diary and filling cystometry. Therefore, the current practice of using frequency and incontinence episodes in outcome research of OAB trials is justified.     

A shared biomechanical environment for bone and posture development in children

Background Context

In each specific habitual standing posture, gravitational forces determine the mechanical setting provided to skeletal structures. Bone quality and resistance to physical stress is highly determined by habitual mechanical stimulation. However, the relationship between bone properties and sagittal posture has never been studied in children.