Sexual maturity, body mass index, dorsal force, and scoliosis

Maturação sexual, índice de massa corporal, força dorsal e escoliose

Abstract

Introduction:  Idiopathic scoliosis is a multifactorial postural deformity showing a concerning increase among children and adolescents; surgical correction is recommended for 42% of this population with scoliotic curves > 40°.

Objective:  To analyze the association between sexual maturation, body mass index (BMI), back strength, and scoliosis.

Methods:  The Tanner questionnaire, BMI, Trunk Lift test, and Digital Image-based Postural Assessment were applied. Data were analyzed using IBM SPSS 24.0, Pearson’s chi-square test, Fisher’s exact test, Mann-Whitney U test, and binary logistic regression.

Results:  Statistically significant results were identified between back strength and scoliosis (p < 0.05). After adjusting for age and sex using binary logistic regression, students with back strength classified as unhealthy had a 52.2% greater chance of presenting scoliosis when compared to students with healthy back strength (OR = 1.522; 95% CI: 1.013 - 2.295).

Conclusion:  No statistically significant associations were found between scoliosis, sexual maturation, and BMI. Statistically significant results were identified regarding the relationship between back strength and scoliosis; students with back strength classified as unhealthy were 52.2% more likely to present with scoliosis compared to students with healthy back strength.

Keywords:
Scoliosis; Puberty; Physical fitness; Children; Adolescents

Resumo

Introdução:  A escoliose idiopática é um desvio postural multitifatorial, apresentando preocupante aumento entre crianças e adolescentes sendo recomendado a correção cirúrgica em 42% desta população com desvios escolióticos ≥ 40°.

Objetivo:  Analisar a associação entre a maturação sexual, índice de massa corporal (IMC), força dorsal e a escoliose.

Métodos:  Foram aplicados a ficha de Tanner, o IMC, o teste Trunk Lift, e a Avaliação Postural baseada em Imagem Digital. Os dados foram analisados através do IBM SPSS 24.0, teste qui-quadrado de Pearson, exato de Fisher, Mann-Whitney e a regressão logística binária.

Resultados:  Foram identificados resultados estatisticamente significativos entre a força dorsal e a escoliose (p < 0,05). Após ajuste para idade e sexo por meio de regressão logística binária, estudantes com força dorsal classificada como não saudável apresentaram 52,2% maior chance de apresentar escoliose quando comparados aos estudantes com força dorsal saudável (OR = 1,522; 1095%,: 1,013 - 2,295).

Conclusão:  Não foram encontradas associações estatisticamente significativas entre escoliose, maturação sexual e IMO Foram identificados resultados estatisticamente significativos entre força dorsal e escoliose, sendo que estudantes com força dorsal classificada como não saudável apresentaram 52,2% mais chance de apresentar escoliose quando comparados aos estudantes com força dorsal saudável.

Palavras-chave:
Escoliose; Puberdade; Aptidão física; Crianças; Adolescentes

Introduction

In Brazil, from the 1990s to the present day, relevant data have been highlighted regarding the evolution of adolescent idiopathic scoliosis (AIS), showing a significant incidence of 5.2%.¹ AIS is a multifactorial postural deformity, presenting not just a single risk factor predisposing to its installation,² with reports indicating that growing children with scoliotic curves ≥ 40° showed a 42% rate of curve progression, thus recommending surgical intervention for its correction.³

Scoliosis is a postural deformity classified as a three-dimensional alteration of the vertebral column located in the trunk region, presenting lateral deviations in the frontal and sagittal planes,⁴ as well as vertebral rotation in the transverse plane. Of idiopathic etiology - that is, without a specific underlying cause - it is classified as infantile (0-4 years of age), juvenile (4-9 years of age), and AIS from 10 years of age onward,⁵ being the most frequently ob-served spinal deformity by pediatricians, physicians, and spine surgeons specifically during this developmental period.^{4 5 6}

During puberty, due to hormonal changes, bone growth occurs at an accelerated rate, which can lead to rapid and uncontrolled progression of AIS.⁷ Early diagnosis and timely intervention are paramount to prevent this vertebral deformity from becoming permanently established,⁸,⁹ with recent studies pointing out that its increment can reach percentages above 90% among children and adolescents aged 10 to 18 years.¹⁰

Cardiorespiratory capacity, muscular fitness (muscle strength and endurance), body composition, and flexibility are among the core components of Health-Related Physical Fitness (HRPF), and these have been extensively investigated among children and adolescents in both home and school environments.¹¹ Recently, in a systematic review and meta-analysis by Wang et al.,¹² statistically significant risk factors such as sex, physical exercise, and body mass index (BMI) were identified among children and adolescents with AIS, corroborating prior studies pointing to low levels of HRPF in the pediatric population.¹³,¹⁴

Such a scenario is particularly concerning because body composition and muscular strength and endurance are among the key risk factors related to the onset of AIS.¹⁵,¹⁶ However, when these physical capacities reach satisfactory levels, they offer significant possibilities for preventing postural deviations, reducing ligamentous injuries, and decreasing pain in the lumbar spine region.¹⁷ Therefore, the present study aimed to analyze the association between sexual matu-ration, BMI, back strength, and scoliosis in children and adolescents.

Methods

This research was approved by the Research Ethics Committee of Faculdade Estácio do Amazonas under protocol CAAE No. 73683517.9.0000.5017. Participants were students duly enrolled from grades 5 to 9 at two public municipal schools in Manaus, Amazonas, Brazil, aged between 10 and 18 years, with a mean age of 12.1 (± 1.7) years. Students were included in the study only after their parents or legal guardians consented and signed the informed consent form. The exclusion criteria were: students diagnosed with neurological, rheumatological, or orthopedic diseases or any other condition affecting body posture and the musculoskeletal apparatus; students with frequent school absenteeism; and students who refused during the research to perform any of the physical tests, postural analysis, or complete the identification forms requested.

Data collection began with completing the student identification form, which recorded age, sex, date of birth, grade level, parental/guardian education level, and school shift; these data were subsequently verified in the school administration office. Following this stage, students completed the self-assessment form for pubic hairiness proposed by Tanner¹⁸ through visual inspection of figures categorized into five sexual maturation stages. Stage 1 is considered prepubertal; stages 2, 3, and 4, pubertal; and stage 5 is considered postpubertal. Students marked an ‘X’ on the corresponding figure, and were subsequently classified by the researcher.

To calculate BMI, male students wore jersey shorts, were shirtless, and were barefoot.¹⁸ Female students wore a two-piece outfit (jersey shorts and top/short shirt) and were also barefoot. Body mass and height were measured at this time. Body mass was measured using a Filizolla anthropometric scale with a maximum capacity of 150 kg and precision of 100 grams. Height was measured using a stadiometer attached to the scale (1 mm resolution), recorded in centimeters to one decimal place. BMI classification was performed according to the protocol of Conde and Monteiro.¹⁹

Subsequent to physical measurements, students performed the trunk extension test (Trunk Lift), that assesses back extension strength and endurance from a prone position with legs and arms extended, hands placed under the thighs, and head facing the ground, aiming to reach a target height of 30 cm across two attempts. Measurement was recorded using a ruler (cm) measuring trunk elevation from the ground to the chin. Students who achieved the 30 cm mark were classified as ‘healthy’; those unable to reach 30 cm were classified as ‘unhealthy’. Reference values, trunk extension test protocol, and BMI standardization calculations adhered to the Fitnessgram physical fitness assessment program.²⁰

Body posture analysis was then conducted using digital photogrammetry via the Digital Image-based Postural Assessment (DIPA) software version 3.1. This method is minimally invasive, low-cost, and represents a simple, valid, and practical assessment tool for analyzing the spine in the sagittal and frontal planes, providing measurable intra- and inter-evaluator data.²⁰

During this procedure, students stood upright in orthostatic position in the posterior view, with arms relaxed at their sides and chin parallel to the floor against a black backdrop. The procedure involved: palpation and marking of specific anatomical landmarks per the DIPA protocol using eleven small white Styrofoam markers (1.0 cm diameter) double-taped at CO, C7 (cervical spine), and thoracic/lumbar/sacral anatomical points (T2, T4, T6, T8, T10, T12, L2, L4, and S2); positioning a Canon digital camera (PowerShot SX500 IS, 16 megapixels) on a leveled tripod at 2.80 m distance and 0.95 m height with a 35 mm lens; a plumb line with two medium white markers spaced 1.00 m apart; photograph acquisition and computer analysis; landmark digitization; and generation of the DIPA postural report. Scoliosis classification was determined using the scoliotic arrow method via the lateral tilt component, classified as ‘healthy' if lateral tilt was < 1.0 cm and ‘unhealthy' if ≥ 1.0 cm.²¹

Statistical analysis

Pearson’s chi-square test and Fisher’s exact test were used to analyze associations between qualitative variables. The Mann-Whitney U test was applied for group comparisons, and binary logistic regression was performed to examine whether back strength predicts scoliosis occurrence, adjusting for age and sex. Data were processed using IBM SPSS Statistics 24.0.²²

Results

A total of 380 students participated in the study (54% female, 46% male). Overall scoliosis prevalence was 44% (n = 165). The mean age of students with postural deviation was 12.8 ± 1.8 years compared to 12.8 ± 1.6 years in the group without deviation. Students aged 16 to 18 years exhibited the highest scoliosis prevalence (62%), followed by 11-year-old students (52%), as detailed in Table 1.

Table 1
Sample description and scoliosis prevalence by age(n = 380)

Age (years)	No scoliosis (n = 215)	Scoliosis (n = 165)
10(n = 28)	15(54)	13(46)
11 (n = 73)	35(48)	38(52)
12(n = 83)	53(64)	30(36)
13(n = 56)	36(64)	20(36)
14(n = 69)	40(58)	29(42)
15(n = 50)	28(56)	22 (44)
16 -18 (n = 21)	8(38)	13(62)

• Note: Data presented as n (%).

Regarding pubertal stages (Table 2), in females, stage P5 showed the highest proportion of students with scoliosis (67%), followed by P1 (59%). In males, stage P1 presented the highest percentage (75%), followed by P4 (52%). Fisher’s exact test indicated no statistically significant differences in scoliosis proportions across pubertal stages for females (p = 0.395) or males (p = 0.506), demonstrating that pubertal maturation was not significantly associated with scoliosis occurrence in either sex.

Table 2
Frequency of students with and without scoliosis by pubertal stage (n = 380)

Pubertal stage	No scoliosis	Scoliosis
Female group (n = 204)	(n = 118)	(n = 86)
P1 (n = 17)	7(41)	10(59)
P2 (n = 54)	34(63)	20(37)
P3(n = 75)	44(59)	31 (41)
P4(n = 52)	31 (60)	21 (40)
P5 (n = 6)	2(33)	4(67)
Male group (n = 1 76)	(n = 97)	(n = 79)
P1 (n = 4)	1(25)	3(75)
P2 (n = 56)	33(59)	23(41)
P3(n = 65)	37(57)	28(43)
P4(n = 42)	20(48)	22 (52)
P5(n = 12)	6(67)	3(33)

• Note: Data presented as n (%). P1 = prepubertal; P2, P3, P4 = pubertal; P5 = postpubertal. Female group: p = 0.395; male group: p = 0.506; both p-values were non-significant.

Regarding BMI classification and scoliosis, 57% of underweight students and 53% of obese students presented scoliosis (Table 3), with no statistically significant association observed (p = 0.160). The overall mean BMI of the sample was 19.40 ± 3.53 kg/m².

Table 3
Association between scoliosis occurrence and body mass index (BMI) classification

BMI classification	Scoliosis
	No(n = 215)	Yes(n = 165)
Underweight (n = 7)	3(43)	4(57)
Normal weight (n = 285)	167(59)	118(41)
Overweight (n = 73)	38(52)	35(48)
Obese (n = 15)	7(47)	8(53)

• Note: Data presented as n (%); p = 0.160 (non-significant).

Analyzing back strength and scoliosis, lack of back strength ('unhealthy' classification) was significantly associated with a higher percentage of scoliosis cases (p = 0.044): among 1 78 students classified as unhealthy, 49% had scoliosis, compared to 39% in the healthy back strength group (n = 202) (Table 4). When stratified by sex, back strength showed statistical significance in females (p = 0.048), whereas in males the association was not statistically significant (p = 0.405). In both sex groups, the highest scoliosis occurrence was observed among unhealthy students (49.5% female, 48.2% male).

Table 4
Association between back strength and scoliosis in students

Back strength	No scoliosis	Scoliosis
Overall sample (n = 380)	(n = 215)	(n = 165)
Unhealthy(n = 178)	91 (51.1)	87(48.9)
Healthy(n = 202)	124(61.4)	78(38.6)
Female group (n = 204)	(n = 118)	(n = 86)
Unhealthy(n = 95)	48(50.5)	47(49.5)
Healthy (n = 109)	70(64.2)	39(35.8)
Male group (n = 1 76)	(n = 97)	(n = 79)
Unhealthy(n = 83)	43(51.8)	40(48.2)
Healthy(n = 93)	54(58.1)	39(41.9)

• Note: Data presented as n (%). Overall sample: p = 0.044; female group: p = 0.048 male group: p = 0.405 (non-significant).

A binary logistic regression model was fitted with scoliosis occurrence as the outcome variable and back strength classification as the primary predictor, adjusted for age and sex as potential confounding factors. Students classified as having unhealthy back strength demonstrated significantly higher odds of presenting scoliosis compared to those with healthy back strength (odds ratio [OR] = 1.522; 95% confidence interval [95% CI]: 1.013-2.295; p = 0.044). This result indicates an approximate 52.2% increase in scoliosis odds, independent of age and sex.

Age (OR = 1.014; 95% CI: 0.900-1.143; p = 0.814) and female sex (OR = 0.901 ; 95% CI: 0.597-1.361 ; p = 0.621) did not show statistically significant associations with scoliosis, but were retained in the model as adjustment variables (Table 5).

Table 5
Adjusted binary logistic regression model for scoliosis occurrence

Variable	OR (95% CI)	p-value
Back strength (unhealthy)	1.522(1.013-2.295)	0.044*
Age (years)	1.014(0.900-1.143)	0.814
Female sex	0.901 (0.597-1.361)	0.621

• Note: OR (95% Cl) = odds ratio (95% confidence interval). *p < 0.05.

Discussion

Scoliosis was identified in 44% of the evaluated students, while 56% did not present this postural alteration. Other investigations conducted among children and adolescents have reported relevant prevalence figures for this postural deformity.²³, ²⁴ Souza et al.,²³ in a study conducted in Goiânia (Goiás state, Brazil), identified elevated AIS rates among public school students aged 10 to 14 years, with a 4.3% prevalence rate. Baracat et al.²⁴ reported even higher rates among children and adolescents aged 10 to 16 years (10.12%).

In the present study, the highest scoliosis occurrence was identified among students aged 16 to 18 years (62%), followed by 11-year-old students (52%). These findings may be related to pubertal development, as numerous bodily changes emerge during this period and persist until late adolescence. According to the World Health Organization,²⁵ puberty spans from ages 10 to 19, a period during which extensive biological and morphological transformations occur, including secondary sexual character development, rapid stature growth, skeletal muscle development, and neuroendocrine and cardiovascular maturation.²⁶

When analyzing scoliosis frequency across pubertal stages, scoliosis appeared at pubertal onset and in late stages in both sexes, which may relate to the age at which children enter puberty. According to Carvalho and Santos,²⁷puberty initiates around 10-11 years in females and 11-12 years in males, concluding for both sexes around age 21.²⁸

Regarding pubertal stage distribution, scoliosis occurred most frequently in females during late puberty (postpubertal stage P5, 67%) and early puberty (prepubertal stage P1, 59%). In males, the highest occurrence was at pubertal onset (stage P1, 75%) and late pubertal stage P4 (52%), suggesting that scoliosis can develop throughout puberty in both sexes. Although percentage differences across pubertal stages were observed, these results lacked statistical significance, precluding a definitive association between sexual maturation and scoliosis in this sample. Furthermore, scoliosis showed notable prevalence at specific chronological ages: 10 years (46%), 11 years (52%), and 16 years (62%), highlighting the importance of aligning chronological age with biological maturation stages in these pediatric cohorts.²⁹

The association between scoliosis and BMI was not statistically significant, yet a high scoliosis prevalence was observed among underweight students (57%). This finding suggests that dramatic muscle mass reductions occur when body weight falls below normal standards,³⁰ as muscle mass levels appear to directly influence postural control patterns.³¹ In a study of children aged 11 to 13 years, it was reported marked asymmetry in inferior scapular angle heights in the frontal plane among children with lower muscle mass.³¹ Thus, increasing fat-free mass and skeletal muscle mass may represent key preventive strategies against postural deformities in growing children.³²,³³ Conversely, high scoliosis prevalence was also observed among obese children (53%). However, these findings lacked statistical consistency to assert that body fat accumulation directly drives postural alteration, contrasting with findings by Pontes et al.³⁰ where statistical significance was established.

Several researchers have highlighted that adolescents with progressive AIS³⁴ (before skeletal maturity) present reduced trunk muscle strength and have stressed the importance of core and back muscle strengthening in correcting postural deviations.³⁵,³⁶ In the present study, students with unhealthy back strength exhibited a 49% scoliosis rate compared to 39% among healthy students of both sexes, demonstrating a statistically significant association (p = 0.044) between reduced back strength and scoliosis. Some studies have emphasized statistical associations between female sex and AIS.³⁴ However, in the adjusted logistic regression model (Table 5), back strength remained significantly associated with scoliosis even after controlling for age and sex, with no evidence that sex modifies the effect of back strength on scoliosis occurrence.

Study limitations

First, the cross-sectional design precludes establishing causal relationships among the variables analyzed; second, scoliosis screening relied on digital photogrammetry via DIPA without radiographic confirmation using Cobb’s angle (the diagnostic gold standard); and third, sexual maturation was self-reported using Tanner stages, which is susceptible to misclassification bias. Consequently, longitudinal studies incorporating radiographic verification and adjusted statistical modeling are required to deepen understanding of these relationships.

Conclusion

Statistically significant results were identified between back strength and scoliosis: students with back strength classified as unhealthy presented a 52.2% greater chance of having scoliosis compared to students with healthy back strength. However, no statistical evidence indicated that this association differs between boys and girls. Likewise, no statistically significant associations were found between scoliosis, sexual maturation, and BMI.

Acknowledgements

This work was partially funded by national funds through the Foundation for Science and Technology (FCT), under the scope of projects of the Child Studies Research Center (CIEC) at the University of Minho (reference UID/00317).

Data availability statement

Data are available from the corresponding author on reasonable request.

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*Correspondence:

[e-mail]

Associate editor:

Ana Paula Cunha Loureiro

Publication Dates

• Publication in this collection
  26 Oct 2026
• Date of issue
  2026

History

• Received
  15 Jan 2026
• Reviewed
  04 July 2026
• Accepted
  24 Sept 2026