Scoliosis

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Original Editors - Gregory Maes

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Search Strategy

I searched for articles about scoliosis on pubmed and web of knowledge. Searched for basic information and treatments for scoliosis on the internet using google. And I found a lot of information in a chapter about scoliosis in a syllabus of Professor Vaes.

keywords: scoliosis, physical therapy, idiopathic scoliosis, scoliosis treatment, scoliosis diagnosis

Definition/Description

Scoliosis is a sideward’s curving of the spine, resulting in one or even two curves, making the spine look like a S. In some cases the spine even shows a rotation component This rotation starts when the scoliosis becomes more pronounced. This is called a torsion-scoliosis, causing a gibbus. Scoliosis can be present from birth. It is then called congenitive scoliosis. Other sorts of scoliosis can be developed during growth, any causes for this are still not found. We then speak of idiopathic scoliosis. There are several types of idiopathic scoliosis. They are classified by location of the (single or double) curve in the spine.

Clinically Relevant Anatomy

The spine is a number of vertebra that are connected with muscles and ligaments. Between each vertebra we can find a disc. Each disc content a nucleus pulposis surrounded by an annulus fibrosis.
We have 7 cervical vertebra, 12 thoracic vertebra and 5 lumbar vertebra.
For more detailed information I’d like to add next link, which has all the information needed to understand the working of the spine: http://www.spineuniverse.com/anatomy

Epidemiology /Etiology

Epidemiology studies reveal that there are several types of scoliosis, we can conclude that the most frequent scoliosis are from the thoracal type. From a population of ten year olds the prevalention for scoliosis balances between 2% and 4%. From this 2-4% the major part stays stable during the lifetime of the subjects. In 7% of the cases the scoliosis gets worse and in 3% the scoliosis even disappears. It is known that of those 7% the majority is girls (5 to 1).

Characteristics/Clinical Presentation

Scoliosis presents itself as a curved spine that in most cases results in forming an S.
Causes of idiopathic scolioses are:
- Interruption of ligament connections between ribs and vertebra (Langenskjöld 1961-1968) (1)
- Muscular disbalance of muscles from the trunk (Stilwell 1962; Roaf 1968) (1)
- Hindrance of collagen metabolism (Ponseti 1954; Zorab 1971) (1)
- Hindrance of growth of the backside of one or more vertebra. This results in a local lordosis that results in a scoliolordosis. (Sommerville 1952) (1)

Differential Diagnosis

Symptoms for scoliosis can be (2):
- Sideways curvature of the spine
- Sideways body posture
- One shoulder raised higher than the other
- Clothes not hanging properly
- Local muscular aches
- Local ligament pain

Diagnostic Procedures

The most common diagnostic procedures are (2):
- X-rays of the spine
- Measuring the leg length.
- A bone scan, MRI, or computed tomography (CT) scan may be necessary in difficult diagnostic problems.

Outcome Measures

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Examination

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Medical Management

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Physical Therapy Management

Scoliosis is not just a lateral curvature of the spine, it’s a three dimensional condition. To manage scoliosis, we need to work in three planes: the sagittal, frontal and transverse. Different methods have already been studied. [5]
The conservative therapy consists of: physical exercises, bracing, manipulation, electrical stimulation and insoles. There is still discussion about the fact that conservative therapy is effective or not. Some therapists follow the ‘wait and see’ method. This means that at one moment; the Cobb degree threshold will be achieved. Then, the only possibility is a spinal surgery. [4]
The physical therapist has three important tasks: to inform, advice and instruct.
For the treatment of scoliosis, it’s not only important to do the correct exercises but the physical therapist also needs to inform the patient about his/her situation (if the patient is still a child, then he needs to inform the parents too). An educational program makes sure that the therapy accuracy from the patient improves. [1]

Some physical therapists recommend a brace to prevent the worsening of the scoliosis. An often used brace is the Milwaukee brace. Nevertheless the evidence for bracing is controversial. Maruyama T., Nakao Y. and Takeshita T. studied the effect of bracing in a review (2011). They compared brace treatment with no-treatment, other conservative treatments or surgery. The analyzed outcome measures were the radiological progression of the curve, surgery and quality of life. Results demonstrate that brace treatment is better than no-treatment (observation) or electrical stimulation. There is also no negative influence on the quality of life of patients with an idiopathic scoliosis. We can conclude that bracing is recommended as a treatment for female patients with a Cobb angle of 25-35°. The evidence level of some studies in the review was limited, so further research is necessary. [2]

In the literature there is evidence that exercises have beneficial effects on patients with idiopathic scoliosis. [7] [11]

The aims of the physical therapy consist of:[3][7][11]

• Autocorrection 3D
• Coordination
• Equilibrium
• Ergonomy
• Muscular endurance/ strength
• Neuromotorial control of the spine
• Increase of ROM
• Respiratory capacity/ education
• Side-shift
• Stabilisation

In the literature there are different exercise therapies.
An important one is the conservative three-dimensional Schroth method consisting of curve-specific exercises and corrective breathing techniques. The purpose of these exercises is to derotate, deflex and to correct the spine in the sagittal plane while elongating the spine. The patient needs to be focused about re-establishing spinal symmetry. The key to a successful therapy is to work consistently to correct the spine. Another – difficult- part of the therapy is to learn to shorten the muscles on the convex side of the spine and lengthen the muscles on the concave side of the side. This because the muscles become imbalanced on opposite sides. [5]
The exercise position approaches the functional/structural threshold. Schroth therapy takes advantage of the overcorrected positions. Basic corrections are reviewed by using mirrors in front and at the back of the patient. This posture requires concentration and coordination, applying the correct breathing, and well-adapted muscle length and tension. [6]

But there are also other exercises that have been found effective. Scientific Exercises Approach to Scoliosis (SEAS) exercises is for example been found effective in reducing the rate of progression of scoliosis compared with usual care and help to avoid brace prescription. [7] [8] [9]
The SEAS exercises are, according to the Italian Scientific Spine Institute (ISICO), based on a specific form of Active Self-correction (ASC), that is taught individually to each single patient. This is to achieve the maximum possible correction. ASC is then associated with stabilising exercises that include neuromotor control, proprioceptive training and balance. The exercises are also incorporated into their daily living activities. SEAS approach does also involve the parents. They are getting together with the patiënt a cognitive-behavioral approach to maximize compliance to treatment. [7][10]
We mentioned earlier that one of the aims is respiratory capacity/education. The severity of the curvature can cause a pressure on airways and lungs. The patient can experience trouble while breathing. Therefore the therapist must insert breathing exercises to complete his/her management. If the risk of pulmonary dysfunction (as a result of the pressure of the spine) is too high, surgery is indicated. [11][12]
Solache-Carranco and M.G. Sánchez-Bringas (2011) studied the effectiveness of a respiratory rehabilitation program in children with scoliosis. This are the techniques that they used:
- Respiratory education techniques (abdominal-diaphragmatic ventilation, thoracic mobilisation, ventilation at rest and during activities of daily living). This for mobilisation and prevention of stiffness of chest and skeletal muscles.
- Postural drainage and vibration to evacuate mucus and decrease the resistance of the airways.
- Relaxation techniques to make sure that the patients would have better control of respiration (to counteract dyspnea).
They found that the respiratory rehabilitation had a positive effect on increasing pulmonary function of children with scoliosis. [13]

Key Research

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Resources

P. Vaes, Tekstboek Module Onderzoek en Behandeling Deel IIB.
http://www.physiotherapy-treatment.com/scoliosis-exercises.html
http://www.medicinenet.com/scoliosis/article.htm
http://www.wrongdiagnosis.com/s/scoliosis/

Clinical Bottom Line

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Recent Related Research (from Pubmed)

Carman D, Roach JW, Speck G, Wenger DR, Herring JA. Role of exercises in the Milwaukee brace treatment of scoliosis.
Kluba T, Dikmenli G, Dietz K, et al. Comparison of surgical and conservative treatment for degenerative lumbar scoliosis
Langensk. A, Snellman O. Correction of idiopathic scoliosis using Milwaukee brace and Harrington method.

References

(1) P. Vaes, Tekstboek Module Onderzoek en Behandeling Deel IIB
(2) http://www.wrongdiagnosis.com/s/scoliosis/
(3) Maruyama, T; Takesita, K; Kitagawa, T; Nakao, Y ; 2011 : Milwaukee brace
(4) Carman D, Roach JW, Speck G, Wenger DR, Herring JA. Role of exercises in the Milwaukee brace treatment of scoliosis.
(5) Miyasaki R.A., 1980: Immediate influence of the thoracic flexion exercise on vertebral position in Milwaukee brace wearers.