Adolescent Idiopathic Scoliosis and Back Pain

Introduction[edit | edit source]

Fig. 1 A patient with AIS and her X-ray image of her spine (Paria et al., 2015).

Scoliosis can be described as an abnormal curvature of the spine. The Cobb angle (fig.2) and Risser sign are measures commonly used to assess the degree and progression of the curvature. Adolescent idiopathic scoliosis (AIS) is a type of idiopathic scoliosis.

Prevalence of AIS[edit | edit source]

AIS is a common disease with an overall prevalence of 0.47-5.2 % in the current literature[1]. It develops at the age of 11-18 and takes up 90% of idiopathic scoliosis cases in children. The female to male ratio ranges from 1.5:1 to 3:1 and increases substantially with age. Genetic factors play a role as well. [1]

Back Pain in AIS[edit | edit source]

Back pain is approximately twice as prevalent in patients with AIS compared to non-scoliosis patients [2][3][4]

Back pain most commonly occurs in the lumbar region followed by the thoracic region in AIS for both sexes.[2][3][4] A statistically significant association was found between thoracic pain and thoracic scoliosis in patients with AIS.[2] . Most AIS patients with back pain reported their pain as moderate to mild intensity[2][3][4]. It has also been shown that back pain in AIS lasted longer and occurred more frequently when compared to patients without scoliosis.[3]

Back Pain and Cobb Angle[edit | edit source]

No statistically significant evidence was reported between pain intensity and Cobb angle severity.[2][5] [6] However, it was suggested that patients without pain tend to present with smaller curves; and the incidence and intensity of back pain was higher in more severe curves (>40°-45°).

The Scoliosis Research Society (SRS) suggested that the presence of back pain may due to reduced trunk strength or hamstring flexibility. However, no evidence supports this statement.

Back Pain and Quality of Life in AIS[edit | edit source]

Lower back pain (LBP) in AIS patients can cause deterioration of patients’ quality of life. Other than pain, patients' self-image such as attitude their own physical appearance is also one of the contributing factors of the deterioration of quality of life.[7]

Dysfunctional Respiratory Function in AIS[edit | edit source]

Dysfunctional and asymmetrical breathing pattern often presents in patients with scoliosis.[8] Trunk rotation is increased as a result of inspiratory breathing forces being directed downwards to the convexity of the spinal curvature.[8] There is also a linkage between dysfunctional breathing and LBP or neck pain.[9][10]

Conservative Treatment[edit | edit source]

Various methods and exercises have been documented to help reduce the Cobb Angle in AIS however as discussed in the above paragraphs a reduction in Cobb Angle does not necessarily lead to a reduction in pain.

General Exercise[edit | edit source]

Patient-specific exercises have been shown to be effective in the initial management of patients with AIS. These may include:

  • Spinal mobility/ flexibility exercises
  • Trunk strengthening exercises[11]
  • Stretching of hamstrings or other tight muscles in lower limbs
  • Gait re-education
  • Compound functional exercises such as squats, lunges and getting on/off the floor
  • Advice on cardiovascular exercise and fitness
  • Pilates/yoga[12]
  • Patient-specific rehabilitation i.e. drills relating to optimising function in a sport the patient enjoys

Schroth Method[edit | edit source]

The Schroth method is a set of exercises that is specifically designed for patients with scoliosis, especially for idiopathic scoliosis.[13] It was developed by Katharina Schroth in Germany. Schroth method aims at preventing curve progression before the end of growth with the following goals[14][15][16]:

  • Proactive spinal corrections to avoid surgery
  • Postural training to avoid or decelerate progression
  • Information to support the decision-making process
  • Home-exercise program
  • Support network
  • Prevention and coping strategies for pain

Literature review suggests that Schroth and Scientific Exercise Approach to Scoliosis (SEAS) methods have positive outcomes in improving the Cobb angles in patients with AIS compared to no intervention[17].

Braces[edit | edit source]

In a systematic review, few studies measured back pain in patients with AIS this study suggested that bracing did not have an effect on back pain in long term[18].

Another systematic review suggested that bracing has no influence on back pain when compared to the observation group, however, conflicting evidence was reported in this review.[19]

Osteopathic manipulation[edit | edit source]

There is currently no evidence to support osteopathic manipulation as the treatment for AIS[19].

Taping[edit | edit source]

It has been suggested that Kinesio Taping decreases back pain and increases quality of life in patients with type 1 AIS under the Lenke classification of scoliosis. This is a RCT and the only study on Kinesio Taping for AIS. Therefore, there is insufficient evidence.[20]

Surgical Treatment for AIS[edit | edit source]

Surgery may be recommended if the scoliosis is worsening and other treatments are ineffective, or if the scoliosis is severe and the adolescent has stopped growing.

Surgical treatments are indicated when the Cobb angle is greater than 45 to 50 degrees.[21] Posterior fusion with instrumentation is usually performed for idiopathic scoliosis.[21]

Conclusion[edit | edit source]

Back pain is very common in adolescent idiopathic scoliosis which can affect the quality of life in these patients. There are many contributing factors for the presence of back pain in AIS, including altered anatomy and breathing pattern. There is a lot of research surrounding the best way to manage patients with AIS, a holistic approach should be undertaken and patient-specific goals kept in mind throughout to improve pain, function and overall well being.

Resources[edit | edit source]

NHS Scoliosis

Scoliosis Research Society

References[edit | edit source]

  1. 1.0 1.1 Konieczny MR, Senyurt H, Krauspe R. Epidemiology of adolescent idiopathic scoliosis. Journal of children's orthopaedics. 2012 Dec 11;7(1):3-9.
  2. 2.0 2.1 2.2 2.3 2.4 Théroux J, Le May S, Fortin C, Labelle H. Prevalence and management of back pain in adolescent idiopathic scoliosis patients: a retrospective study. Pain Research and Management. 2015;20(3):153-7.
  3. 3.0 3.1 3.2 3.3 Sato T, Hirano T, Ito T, Morita O, Kikuchi R, Endo N, Tanabe N. Back pain in adolescents with idiopathic scoliosis: epidemiological study for 43,630 pupils in Niigata City, Japan. European Spine Journal. 2011 Feb 1;20(2):274-9.
  4. 4.0 4.1 4.2 Joncas, J., Labelle, H., Poitras, B., Duhaime, M., Rivard, C. and Le Blanc, R. Dorso-lumbal pain and idiopathic scoliosis in adolescence. Annales de Chirurgie. 1996;50 (8), pp. 637-640.
  5. Balagué F, Pellisé F. Adolescent idiopathic scoliosis and back pain. Scoliosis and spinal disorders. 2016 Dec;11(1):27.
  6. Rigo M. Differential diagnosis of back pain in adult scoliosis (non operated patients). Scoliosis. 2010 Sep;5(1):O44.
  7. Makino T, Kaito T, Kashii M, Iwasaki M, Yoshikawa H. Low back pain and patient-reported QOL outcomes in patients with adolescent idiopathic scoliosis without corrective surgery. Springerplus. 2015 Dec 1;4(1):397.
  8. 8.0 8.1 Weiss HR, Moramarco MM, Borysov M, Ng SY, Lee SG, Nan X, Moramarco KA. Postural rehabilitation for adolescent idiopathic scoliosis during growth. Asian spine journal. 2016 Jun;10(3):570.
  9. Bradley H, Esformes JD. Breathing pattern disorders and functional movement. International journal of sports physical therapy. 2014 Feb;9(1):28.
  10. Kiesel K, Rhodes T, Mueller J, Waninger A, Butler R. Development of a screening protocol to identify individuals with dysfunctional breathing. International journal of sports physical therapy. 2017 Oct;12(5):774.
  11. Zapata KA, Wang-Price SS, Sucato DJ, Thompson M, Trudelle-Jackson E, Lovelace-Chandler V. Spinal stabilization exercise effectiveness for low back pain in adolescent idiopathic scoliosis: a randomized trial. Pediatric Physical Therapy. 2015;27(4):396-402.
  12. Blum CL. Chiropractic and Pilates therapy for the treatment of adult scoliosis. Journal of Manipulative and Physiological Therapeutics. 2002 May 1;25(4):E1-8.
  13. Berdishevsky H, Lebel VA, Bettany-Saltikov J, Rigo M, Lebel A, Hennes A, Romano M, Białek M, M’hango A, Betts T, de Mauroy JC. Physiotherapy scoliosis-specific exercises–a comprehensive review of seven major schools. Scoliosis and spinal disorders. 2016 Dec;11(1):20.
  14. Kim MJ, Park DS. The effect of Schroth’s three-dimensional exercises in combination with respiratory muscle exercise on Cobb’s angle and pulmonary function in patients with idiopathic scoliosis. Physical Therapy Rehabilitation Science. 2017 Sep 30;6(3):113-9.
  15. Schreiber S, Parent EC, Moez EK, Hedden DM, Hill D, Moreau MJ, Lou E, Watkins EM, Southon SC. The effect of Schroth exercises added to the standard of care on the quality of life and muscle endurance in adolescents with idiopathic scoliosis—an assessor and statistician blinded randomized controlled trial:“SOSORT 2015 Award Winner”. Scoliosis. 2015 Dec;10(1):24.
  16. Lee HJ, Seong HD, Bae YH, Jang HY, Chae SH, Kim KH, Lee SM. Effect of the Schroth method of emphasis of active holding on Cobb’s angle in patients with scoliosis: a case report. Journal of physical therapy science. 2016;28(10):2975-8.
  17. Day JM, Fletcher J, Coghlan M, Ravine T. Review of scoliosis-specific exercise methods used to correct adolescent idiopathic scoliosis. Archives of physiotherapy. 2019 Dec 1;9(1):8.
  18. Negrini, S., Minozzi, S., Bettany-Saltikov, J., Chockalingam, N., Grivas, T., Kotwicki, T., Maruyama, T., Romano, M. and Zaina, F. Braces for idiopathic scoliosis in adolescents. Cochrane Database of Systematic Reviews. . 2015. Issue 6, art. no.: CD006850.
  19. 19.0 19.1 Balagué F, Pellisé F. Adolescent idiopathic scoliosis and back pain. Scoliosis and spinal disorders. 2016 Dec;11(1):27.
  20. Atici, Y., Aydin, C., Atici, A., Buyukkuscu, M., Arikan, Y. and Balioglu, M.The effect of Kinesio taping on back pain in patients with Lenke Type 1 adolescent idiopathic scoliosis: A randomized controlled trial. Acta Orthopaedica et Traumatologica Turcica. 2017;51 (3), pp.191-196.
  21. 21.0 21.1 Maruyama T, Takeshita K. Surgery for idiopathic scoliosis: currently applied techniques. Clinical medicine. Pediatrics. 2009 Jan;3:CMPed-S2117.