What do we know about the determinants of sagittal standing posture?

Introduction Effective primary strategies are expected to be a costefficient approach to reduce attributable morbidity caused by sagittal spino-pelvic misalignment. For such strategies to emerge we need to synthesized what is known on the causes of sagittal misalignment. This review aims to critically summarize published evidence on the determinants of non-neutral sagittal standing posture. Discussion Age is directly correlated with positive sagittal imbalance, but spino-pelvic age-related changes do not seem to cause relevant modifications to overall sagittal alignment. Gender differences are likely to exist, but only regarding postural patterns: men more often present an overall flat spine than women. Environmental circumstances of early life seem to have an important role in defining the organization of sagittal posture in adulthood. Increased body mass index gathers the strongest evidence supporting its role in determining non-neutral sagittal standing posture. However, the mechanisms by which central obesity may influence sagittal spino-pelvic alignment remain largely unknown. Despite hazardous behavioural characteristics have the most potential to be prevented, they have been less frequently studied and results are still controversial. Conclusion Evidence is scarce and dominated by cross-sectional evaluations and crude correlations between characteristics and isolated parameters. Future prospective studies, focused on overall postural patterns and accounting for plausible confounders are necessary in order to sustain judgement about causation of potential risk factors for sagittal misalignment.