Adolescent Idiopathic Scoliosis and Back Pain: Difference between revisions

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== Aims ==
 
[[File:Adolescent idiopathic scoliosis (Paria et al., 2015).jpg|thumb|510x510px|'''Fig. 1''' A patient with AIS and her X-ray image of her spine (Paria et al., 2015).]]This article aims to discuss the relationship between adolescent idiopathic scoliosis (AIS) (fig. 1) and back pain, and the management plan for it.
<div class="editorbox">'''Original Editors '''- [[User:Man Nok Tam |Man Nok Tam]] as part of the [[Nottingham University Spinal Rehabilitation Project]]<br>
== Objectives ==
'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}} - &nbsp;
* To introduce AIS
</div>
* To discuss the relationship between AIS and back pain, with considering of dysfunctional breathing
 
* To discuss the potential treatments for back pain in AIS
== Introduction ==
== Introduction ==
[[File:Cobb angle (Greiner, 2002).png|thumb|'''Fig. 2''' Cobb angle (Greiner, 2002)|376x376px]]
[[File:Adolescent idiopathic scoliosis (Paria et al., 2015).jpg|thumb|510x510px|'''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's angle|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|idiopathic scoliosis]].  
Scoliosis is where the spine twists and curves to the side (National Health Service (NHS), 2017). See [[Scoliosis]] for full details.


The common outcome measure for the curvature of scoliosis is the [[Cobb's angle|Cobb angle]] (fig.2).
== Prevalence of AIS ==
AIS is a common disease with an overall prevalence of 0.47-5.2 % in the current literature<ref name=":0">Konieczny MR, Senyurt H, Krauspe R. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3566258/ Epidemiology of adolescent idiopathic scoliosis.] Journal of children's orthopaedics. 2012 Dec 11;7(1):3-9.</ref>. 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. <ref name=":0" />


One type of idiopathic scoliosis is AIS.
== Back Pain in AIS ==
Back pain is approximately twice as prevalent in patients with AIS compared to non-scoliosis patients <ref name=":1">Théroux J, Le May S, Fortin C, Labelle H. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4447159/ Prevalence and management of back pain in adolescent idiopathic scoliosis patients: a retrospective study.] Pain Research and Management. 2015;20(3):153-7.</ref><ref name=":2">Sato T, Hirano T, Ito T, Morita O, Kikuchi R, Endo N, Tanabe N. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3030705/ 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.</ref><ref name=":3">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.</ref>


== Prevalence of AIS ==
Back pain most commonly occurs in the lumbar region followed by the thoracic region in AIS for both sexes.<ref name=":1" /><ref name=":2" /><ref name=":3" /> A statistically significant association was found between thoracic pain and thoracic scoliosis in patients with AIS.<ref name=":1" /> . Most AIS patients with back pain reported their pain as moderate to mild intensity<ref name=":1" /><ref name=":2" /><ref name=":3" />. It has also been shown that back pain in AIS lasted longer and occurred more frequently when compared to patients without scoliosis.<ref name=":2" />
AIS is a common disease with an overall prevalence of 0.47-5.2 % in the current literature (Konieczny et al., 2013). It develops at the age of 11-18 and takes up 90% of idiopathic scoliosis cases in children (Konieczny et al., 2013). The female to male ratio ranges from 1.5:1 to 3:1 and increases substantially with increasing age (Konieczny et al., 2013). Genetic factors play a role as well (Konieczny et al., 2013).


== Back pain in AIS ==
=== Back Pain and Cobb Angle ===
Back pain is approximately twice as prevalent in patients with AIS compared to non-scoliosis patients (Théroux et al., 2015; Sato et al., 2011; Joncas et al., 1996).
[[File:Cobb angle (Greiner, 2002).png|thumb|Cobb angle]]


Théroux et al (2015), Sato et al (2011) and Joncas et al (1996) reported that back pain most commonly occurred in the lumbar region followed by the thoracic region in AIS for both sexes. A statistically significant association was found between thoracic pain and thoracic scoliosis in patients with AIS as well (Théroux et al, 2015). Most AIS patients with back pain reported their pain as moderate (Théroux et al., 2015; Joncas et al., 1996) to mild (Sato et al, 2011) intensity. Sato et al. (2011) also reported that back pain in AIS lasted longer and occurred more frequently when compared to patients without scoliosis.
No statistically significant evidence was reported between pain intensity and Cobb angle severity.<ref name=":1" /><ref>Balagué F, Pellisé F. [https://scoliosisjournal.biomedcentral.com/articles/10.1186/s13013-016-0086-7 Adolescent idiopathic scoliosis and back pain.] Scoliosis and spinal disorders. 2016 Dec;11(1):27.</ref> <ref>Rigo M. [https://scoliosisjournal.biomedcentral.com/articles/10.1186/1748-7161-5-S1-O44 Differential diagnosis of back pain in adult scoliosis (non operated patients)]. Scoliosis. 2010 Sep;5(1):O44.</ref> 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°).


=== Back pain and Cobb angle ===
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.
No statistically significant relationship was observed between pain intensity and Cobb angle severity (Théroux et al, 2015; Balagué et al., 2016). Rigo (2010) also suggested the idea  that Cobb angle does not correlate with back pain. However, this paper also suggested that patients without pain tend to present smaller curves and the incidence and intensity of back pain was higher in more severe curves (>40°-45°). The Scoliosis Research Society (SRS) (c2019) suggested that the presence of back pain may due to reduced abdominal and back strength or hamstring flexibility. However, no evidence supports this statement.


=== Back pain and quality of life (QoL) ===
=== Back Pain and Quality of Life in AIS ===
Makino et al. (2015) reported that low 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 (Makino et al., 2015) of the deterioration of QoL.
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.<ref name=":4">Makino T, Kaito T, Kashii M, Iwasaki M, Yoshikawa H. [https://www.ncbi.nlm.nih.gov/pubmed/26261755 Low back pain and patient-reported QOL outcomes in patients with adolescent idiopathic scoliosis without corrective surgery]. Springerplus. 2015 Dec 1;4(1):397.</ref>


=== Dysfunctional breathing in AIS and back pain ===
Patients with LBP or thoracic pain with AIS are more prone to having severe insomnia and daytime sleepiness, whether chronic back pain is associated with moderate depression.<ref>Wong AYL, Samartzis D, Cheung PWH, Cheung JPY. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6437349/#R4 How Common Is Back Pain and What Biopsychosocial Factors Are Associated With Back Pain in Patients With Adolescent Idiopathic Scoliosis?] Clinical Orthopaedics & Related Research. 2018 Nov 13;477(4):676–86.</ref>
Dysfunctional and asymmetrical breathing pattern often presents in patients with scoliosis (Weiss et al., 2016). Trunk rotation is increased as a result of breathing forces being directed downwards to the convexity of the spinal curvature (Weiss et al., 2016). There is also a linkage between dysfunctional breathing and LBP (Chaitow, 2014; Kiesel et al., 2017) and neck pain (Kiesel et al., 2017).


== Treatment ==
=== Dysfunctional Respiratory Function in AIS ===
This section will cover the direct or indirect conservative and surgical treatment for back pain in AIS.
Dysfunctional and asymmetrical breathing pattern often presents in patients with scoliosis.<ref name=":5">Weiss HR, Moramarco MM, Borysov M, Ng SY, Lee SG, Nan X, Moramarco KA. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4917779/ Postural rehabilitation for adolescent idiopathic scoliosis during growth]. Asian spine journal. 2016 Jun;10(3):570.</ref> Trunk rotation is increased as a result of inspiratory breathing forces being directed downwards to the convexity of the spinal curvature.<ref name=":5" /> There is also a linkage between dysfunctional breathing and LBP or neck pain.<ref>Bradley H, Esformes JD. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3924606/ Breathing pattern disorders and functional movement]. International journal of sports physical therapy. 2014 Feb;9(1):28.</ref><ref name=":6">Kiesel K, Rhodes T, Mueller J, Waninger A, Butler R. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5685417/ Development of a screening protocol to identify individuals with dysfunctional breathing]. International journal of sports physical therapy. 2017 Oct;12(5):774.</ref>


=== Conservative treatment ===
== Conservative Treatment ==
Conservative approaches are  employing patients with low Cobb angles. Medication, physiotherapy, lifestyle changes and braces are helpful strategies when managing a patient conservatively. Under the exercises category their are general exercises and scientific exercise approaches ([[Schroth Method|Schroth method]]).


==== Schroth method ====
=== General Exercise ===
The Schroth method is a set of exercises which is specifically designed for patients with scoliosis, especially for idiopathic scoliosis (Berdishevsky et al., 2016). It is developed by Katharina Schroth in Germany (Kim et al., 2017).
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<ref>Zapata KA, Wang-Price SS, Sucato DJ, Thompson M, Trudelle-Jackson E, Lovelace-Chandler V. [https://www.ncbi.nlm.nih.gov/pubmed/26397085 Spinal stabilization exercise effectiveness for low back pain in adolescent idiopathic scoliosis: a randomized trial]. Pediatric Physical Therapy. 2015;27(4):396-402.</ref>
* Stretching exercises
* [[Interventions for Gait Deviations|Gait re-education]]
* Compound functional exercises such as squats, lunges and getting on/off the floor
* Advice on cardiovascular exercise and fitness
* [[Pilates]]/[[yoga]]<ref>Blum CL. [https://www.sciencedirect.com/science/article/pii/S0161475402932549 Chiropractic and Pilates therapy for the treatment of adult scoliosis.] Journal of Manipulative and Physiological Therapeutics. 2002 May 1;25(4):E1-8.</ref>
* Patient-specific rehabilitation i.e. drills relating to optimising function in a sport the patient enjoys


Schroth method aims at preventing curve progression before the end of growth with the following goals:
=== Schroth Method ===
The Schroth method is a set of exercises that is specifically designed for patients with scoliosis, especially for idiopathic scoliosis.<ref name=":7">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. [https://www.ncbi.nlm.nih.gov/pubmed/27525315 Physiotherapy scoliosis-specific exercises–a comprehensive review of seven major schools]. Scoliosis and spinal disorders. 2016 Dec;11(1):20.</ref>  It was developed by Katharina Schroth in Germany. Schroth method aims at preventing curve progression before the end of growth with the following goals<ref name=":8">Kim MJ, Park DS. [http://www.jptrs.org/journal/view.html?doi=10.14474/ptrs.2017.6.3.113 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.</ref><ref>Schreiber S, Parent EC, Moez EK, Hedden DM, Hill D, Moreau MJ, Lou E, Watkins EM, Southon SC. [https://www.ncbi.nlm.nih.gov/pubmed/26413145 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.</ref><ref>Lee HJ, Seong HD, Bae YH, Jang HY, Chae SH, Kim KH, Lee SM. [https://www.ncbi.nlm.nih.gov/pubmed/27821972 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.</ref>:
* Proactive spinal corrections to avoid surgery
* Proactive spinal corrections to avoid surgery
* Postural training to avoid or decelerate progression
* Postural training to avoid or decelerate progression
* Information to support a decision-making process
* Information to support the decision-making process
* Teaching a home-exercise program
* Home-exercise program
* Support help for self-help
* Support network
* Prevention and coping strategies for pain
* Prevention and coping strategies for pain
(Berdishevsky et al., 2016)
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<ref>Day JM, Fletcher J, Coghlan M, Ravine T. [https://www.ncbi.nlm.nih.gov/pubmed/31463082 Review of scoliosis-specific exercise methods used to correct adolescent idiopathic scoliosis.] Archives of physiotherapy. 2019 Dec 1;9(1):8.</ref>.


===== Evidence for the effectiveness of Schroth method exercises =====
=== Braces ===
<u>'''Schreiber et al. (2015)'''</u>
[[Milwaukee brace]] and Boston brace are the most common braces which are using in conservative management.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<ref>Negrini, S., Minozzi, S., Bettany-Saltikov, J., Chockalingam, N., Grivas, T., Kotwicki, T., Maruyama, T., Romano, M. and Zaina, F. [https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD010663.pub2/pdf/standard Braces for idiopathic scoliosis in adolescents]. ''Cochrane Database of Systematic Reviews''. . 2015. Issue 6, art. no.: CD006850. </ref>. 


Schreiber et al. (2015) did a randomised controlled trial (RCT) which suggested that Schroth method exercises with standard of care improved pain in patients with AIS over a 6-month intervention. Table 1 shows the participants, intervention, comparison, outcomes (PICO) model of the study.
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.<ref name=":11">Balagué F, Pellisé F. [https://scoliosisjournal.biomedcentral.com/articles/10.1186/s13013-016-0086-7 Adolescent idiopathic scoliosis and back pain.] Scoliosis and spinal disorders. 2016 Dec;11(1):27.</ref>
{| class="wikitable"
[[File:Boston Brace - Donna's Own Image.jpg|right|frameless|Boston brace]]
|+'''Table 1''' Table showing the PICO model of the study done by Schreiber et al. (2015)
However, for the purpose of reducing the rate of bracing, Scientific Exercise Approaches are more effective than Usual Physiotherapy, while Physiotherapeutic Specific Scoliosis Exercises persist as additional tools for the treatment of AIS.<ref>Negrini S, Donzelli S, Negrini A, Parzini S, Romano M, Zaina F. [https://www.sciencedirect.com/science/article/pii/S1877065718314416?ref=cra_js_challenge&fr=RR-1 Specific exercises reduce the need for bracing in adolescents with idiopathic scoliosis: A practical clinical trial.] Annals of Physical and Rehabilitation Medicine. 2019 Mar;62(2):69–76.</ref>
!Participants
!Intervention
!Comparison
!Outcomes
|-
|50 patients
* AIS
* Cobb’s angle 10-45°
|25 patients
* Schroth method exercises and standard care
* 5 initial 1-hour private training sessions during first 2 weeks after baseline measurement
* Followed by weekly 1-hour group classes combined with a 30-45 min. daily home exercise programme
|25 patients
* Standard care
|Collected at baseline, 3 and 6 months
* Scoliosis Research Society-22r (SRS-22r) questionnaire*
* Biering-Sorensen back muscle endurance
* Spinal Appearance Questionnaire (SAQ) scores
|}
<nowiki>*</nowiki> SRS-22r is a scoliosis-related QoL questionnaire that assesses five domains: function, pain, self-image, mental and satisfaction with care. Each question is scored from 1 to 5, where 1 is the worst, and 5 the best.


Results
=== Osteopathic manipulation ===
* SRS-22r pain score difference between the two groups from baseline to 3 months was not statistically significant: -29.16; p=0.45
There is currently no evidence to support osteopathic manipulation as the treatment for AIS<ref name=":11" />.
* Schroth group has significant improvement in SRS-22r pain score from 3 to 6 months when compared to the control group: 85.25; p=0.02
Table 2 shows the results of the study.
{| class="wikitable"
|+'''Table 2''' Table showing the results of the study done by Schreiber et al. (2015)
! rowspan="2" |Outcome
| colspan="2" |Intervention group (n=25)
| colspan="2" |Control group (n=25)
|0 to 3 months difference in change between group
|3 to 6 months difference in change between groups
|-
|Mean
|Standard errors
|Mean
|Standard errors
|p''-''value
|p''-''value
|-
|SRS-22r (pain): baseline
|422.84
|31.53
|348.63
|31.36
| rowspan="2" |0.45
| -
|-
|SRS-22r (pain): 3 month
|460.76
|32.37
|415.71
|32.62
| rowspan="2" |0.02
|-
|SRS-22r (pain): 6 month
|525.99
|33.38
|395.68
|32.36
| -
|}
SRS-22r=Scoliosis Research Society-22r[[File:Exercise prescription for each curve type (Schreiber et al., 2015).png|thumb|521x521px|'''Fig. 3''' Exercise prescription for each curve type (Schreiber et al., 2015)]]
Strengths
* The assessors and the statistician were blinded to the treatment allocation
* Standardised treatment by developing the classification and exercise prescription algorithms
* Specific exercise prescription for each curve type (fig. 3)


Limitations
=== Taping ===
* Only overall pain was measured
It has been suggested that [[Kinesiology Taping|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.<ref>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.</ref>
* The therapists, patients and accessors could not be blinded to the exercises in which they were involved
* Pain is a subjective outcome
* RCT is not at the top of the hierarchy of evidence
<u>'''Lee et al. (2016)'''</u>


Lee et al. (2016) did a case study which showed a decrease in pain and Cobb’s angle in all subjects after applying the Schroth method with emphasis on active holding. Table 3 shows the PICO model of the study and table 4 shows the results of it.
=== Surgical Treatment for AIS ===
{| class="wikitable"
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.  
|+'''Table 3''' Table showing the PICO model of the study done by Lee et al. (2016)
!Participants
!Intervention
!Comparison
!Outcomes
|-
|3 patients
* Idiopathic scoliosis
* Cobb angle ≥ 10°
|3 patients
* Individual Schroth method exercise programme with emphasis on active holding
* 60-min sessions, 3 times per week, for 15 weeks
|Patients baseline before intervention
|
* Cobb angle
* Pain: visual analogue scale (VAS) score
|}
{| class="wikitable"
|+'''Table 4''' Table showing the results of the study done by Lee et al. (2016)
! rowspan="3" |Subject no.
! rowspan="3" |Subject characteristics
! colspan="4" |Results
|-
! colspan="2" |VAS
! colspan="2" |Cobb angle
|-
|Pre-test
|post-test
|Pre-test
|post-test
|-
|1
|
* 21 years old
* Male
* LBP
* Iliocostal impingement syndrome
|4
|0
|20°
|10.8°
|-
|2
|
* 29 years old
* Female
* Neck pain
* Headache
|8
|0
|20.3°
|4°
|-
|3
|
* 25 years old
* Female
* Neck pain
* Psoas syndrome
|8
|3
|30.6°
|18.5°
|}
LBP=low back pain; VAS=visual analogue scale


Limitations
Surgical treatments are indicated when the Cobb angle is greater than 45 to 50 degrees.<ref name=":12">Maruyama T, Takeshita K. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3676291/ Surgery for idiopathic scoliosis: currently applied techniques]. Clinical medicine. Pediatrics. 2009 Jan;3:CMPed-S2117.</ref> Posterior fusion with instrumentation is usually performed for idiopathic scoliosis.<ref name=":12" />
* A very small sample size
* Case study is not considered as the “best evidence” as it is low in terms of level of evidence
* No detailed description about the Schroth method program with emphasis of active holding
* Participants presented with different pain and underlying conditions
* Long term effects were not measured, the benefits might be temporary
* Not addressing directly to AIS patient, patients were all over 18


==== Breathing retraining and exercises ====
== Conclusion ==
There are evidence suggesting the use of breathing exercises as a treatment for chronic low back pain (Anderson et al., 2017). This review included 3 RCTs of medium quality with reference to the Physiotherapy Evidence Database (PEDro) scale (Liao et al., 2018). The searches were conducted across 5 databases and 10 years (2005-2015). However, one thing to note is that the patients included in the studies may not have scoliosis and this review is not specific to adolescents.
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.  


===== Rotational Angular Breathing (RAB) =====
== Resources ==
[[File:RAB (Berdishevsky et al., 2016).png|thumb|370x370px|'''Fig. 4''' Before (A) and during (B) rotation angular breathing (RAB). The arrows represent directional breathing used to fill the collapsed lungs with air and reshape the thorax (B) (Berdishevsky et al., 2016)]]
[https://www.nhs.uk/conditions/scoliosis/treatment-in-children/ NHS Scoliosis]
Schroth method is considered to be more effective than manual treatments because of its three-dimensional nature and its rotational angular breathing (RAB) component (Kim et al., 2017). It ‘helps in vertebral and rib cage derotation and in increasing vital capacity’ (Berdishevsky et al., 2016).
{{#ev:youtube|https://youtu.be/dyNrxq-PKmQ|||||start=16}}
RAB helps expand the ribcage by pushing the ribs ‘sideways and backwards’ and helps return the vertebrae closer to their normal, untwisted position (Berdishevsky et al., 2016) (fig. 4) (see video above).
[[File:Schroth's method lying (Berdishevsky et al., 2016).jpg|thumb|371x371px|'''Fig. 5''' A patient performing Schroth’s method exercises on side-lying position with assistance from therapist (Berdishevsky et al., 2016)]]
Equipment such as wall bars and elastic bands can also be used with RAB as part of the Schroth’s exercises. It can be done in different position like forward bending, sitting and side-lying (fig. 5) (see videos below).
{{#ev:youtube|https://www.youtube.com/watch?v=xGUojrDPkP4}}
{{#ev:youtube|https://www.youtube.com/watch?v=cmWYhpT6Qfk|||||start=127}}
===== Respiratory muscle exercises =====
The RCT done by Kim et al., 2017 has shown that breathing muscle strengthening can improve both Cobb angle and respiratory function (Kim et al., 2017). Table 5 shows the PICO model of the study and table 6 shows the results of it.
{| class="wikitable"
|+'''Table 5''' Table showing the PICO model of the study done by Kim et al. (2017)
!Participants
!Intervention
!Comparison
!Outcomes
|-
|15 patients
* Korea
* Cobb angle ≥ 10°
|8 patients
* Warm up (5 mins)
* Respiratory muscle exercises (10 mins)
** SpiroTiger (rapid deep breathing with resistance) (see video below)
* Schroth’s exercises (40 mins)
* Cool down (5 mins)
|7 patients
* Warm up (5 mins)
* Fixed bike exercises (10 mins)
* Schroth’s exercises (40 mins)
* Cool down (5 mins)
|
* Cobb angle
* Functional movement score
* Pulmonary function
|}
{{#ev:youtube|https://www.youtube.com/watch?v=EvqzAPqh6HE|||||start=60}}
{| class="wikitable"
|+'''Table 6''' Table showing the results of the study done by Kim et al. (2017)
!Cobb angle (°)
!Intervention group (n=8)
!Controlled group (n=7)
!Independent t-test
|-
|Pre-test (mean±SD)
|24.49±8.32
|27.16±12.44
| -0.495
|-
|Post-test (mean±SD)
|20.23±7.54
|24.47±12.45
| -0.810
|-
|Difference (mean±SD) (p-value)
|4.26±1.36 (p<0.05)
|2.69±1.11 (p<0.05)
|2.415 (p<0.05)
|}
SD=statistical difference


Strength
[https://www.srs.org/patients-and-families/conditions-and-treatments/parents/scoliosis/adolescent-idiopathic-scoliosis Scoliosis Research Society]
* PEDro scale: 7/10 (high quality (Liao et al., 2018))
Limitations
* Unknown external validity and clinical significance
** Unknown minimally clinical important difference for Cobb angle
* High risk of type 2 error
** Small sample size
* Questionable internal validity
** Unknown blinding conditions
* Lack of evidence for using SpiroTiger as respiratory muscle exercises
* Uncertain relationship between Cobb angle and pain, although breathing exercises has been used to treat LBP in other studies (Anderson et al., 2017)
 
==== Braces ====
Negrini et al., 2015 did a systematic review on the use of braces on back pain in AIS. Out of the seven studies, there is only one that measured back pain and it suggested that bracing did not have an effect on back pain in long term (Negrini et al., 2015). However, the evidence included in this review is of very low quality (Negrini et al., 2015).
 
Another systematic review done by Balagué et al. (2016) suggested that bracing has no influence on back pain when compared to the observation group. However, conflicting evidence was reported in this review (Balagué et al., 2016).
 
==== Osteopathic manipulation ====
There is currently no evidence to support osteopathic manipulation as the treatment for AIS (Balagué et al., 2016).
 
==== Taping ====
Atici et al. (2017) suggested Kinesio Taping decreases back pain and increases the QoL 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.
 
=== Surgical treatment for AIS ===
Surgery may be recommended if the scoliosis is worsening and other treatments are ineffective, or the scoliosis is severe and the adolescent has stopped growing (NHS, 2017).
 
In general, surgical treatments are indicated when the Cobb angle (degree of curvature of the spine) is greater than 45 to 50 degrees (Maruyama et al., 2009).
 
Posterior fusion with instrumentation is usually performed for idiopathic scoliosis (Maruyama et al., 2009).
 
== Conclusion ==
Back pain is very common in AIS, which can affects the QoL of patients. There are many contributing factors for the presence of back pain in AIS, including altered anatomy and breathing pattern. Current evidence mainly suggests the use of Schroth's method with breathing exercises as a treatment for back pain in AIS.


== References ==
== References ==
alanaInformFitness. 2011. ''SpiroTiger Demo with Lachlan Davey_0001.wmv''. [Online]. Available at: https://www.youtube.com/watch?v=EvqzAPqh6HE. [Accessed on 23rd May 2019].
[[Category:Nottingham University Spinal Rehabilitation Project]]
 
Align Therapy. 2018. ''What are Schroth Method Exercises for Scoliosis?''. [Online]. Available at: https://www.youtube.com/watch?v=cmWYhpT6Qfk. [Accessed on 23rd May 2019].
 
Anderson, B. E. and Bliven, K. C. H. (2017). The Use of Breathing Exercises in the Treatment of Chronic, Nonspecific Low Back Pain. ''Journal of Sport Rehabilitation''. 26 (5), pp. 452-458.
 
Atici, Y., Aydin, C., Atici, A., Buyukkuscu, M., Arikan, Y. and Balioglu, M. (2017). 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''. 51 (3), pp.191-196.
 
Balagué, F. and Pellisé, F. (2016). Adolescent idiopathic scoliosis and back pain. ''Scoliosis and Spinal Disorders''. 11 (1), pp. 27.
 
Berdishevsky, H., Lebel, V. A., Bettany-Saltikov, J., Rigo, M., Lebel, A., Hennes, A., Romano, M., Białek, M., M’hango, A., Betts, T., de Mauroy, J. C. and Durmala, J. (2016). Physiotherapy scoliosis-specific exercises – a comprehensive review of seven major schools. Scoliosis and Spinal Disorders. 11 (20), [no pagination].
 
Chaitow, L. (2004). Breathing pattern disorders, motor control, and low back pain. ''Journal of Osteopathic Medicine''. 7 (1), pp. 33-40.
 
Greiner, K. A. 2002. Adolescent Idiopathic Scoliosis: Radiologic Decision-Making. ''American Family Physician''. 65 (9), pp. 1817-1823.
 
Joncas, J., Labelle, H., Poitras, B., Duhaime, M., Rivard, C. and Le Blanc, R. (1996). Dorso-lumbal pain and idiopathic scoliosis in adolescence. ''Annales de Chirurgie''. 50 (8), pp. 637-640.
 
Kiesel, K. Rhodes, T., Mueller, J., Waninger, A. and Butler, R. (2017). Development of a Screening Protocol to identify individuals with dysfunctional breathing. ''International Journal of Sports Physical Therapy''. 12 (5), pp. 774-786.
 
Kim, M. and Park, D. (2017). 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''. 6 (3), pp. 113-119.
 
Konieczny, M., Senyurt, H. and Krauspe, R. 2013. Epidemiology of adolescent idiopathic scoliosis. ''Journal of Children´s Orthopaedics''. 7 (1), pp. 3-9.
 
Lee, H., Seong, H., Bae, Y., Jang, H., Chae, S., Kim, K. and Lee, S. (2016). 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''. 28(10), pp.2975-2978.
 
Liao, C., Xie, G., Tsauo, J., Chen, H. and Liou, T. (2018). Efficacy of extracorporeal shock wave therapy for knee tendinopathies and other soft tissue disorders: a meta-analysis of randomized controlled trials. ''BMC Musculoskeletal Disorders''. 19 (278), [no pagination].
 
Makino, T., Kaito, T., Kashii, M., Iwasaki, M. and Yoshikawa, H. (2015). Low back pain and patient-reported QOL outcomes in patients with adolescent idiopathic scoliosis without corrective surgery. ''SpringerPlus''. 4 (1), pp. 397.
 
Maruyama, T. and Takeshita K. 2009. Surgery for Idiopathic Scoliosis: Currently Applied Techniques. ''Clinical Medicine: Pediatrics''. 3 (2009), pp. 39-44.
 
Negrini, S., Minozzi, S., Bettany-Saltikov, J., Chockalingam, N., Grivas, T., Kotwicki, T., Maruyama, T., Romano, M. and Zaina, F. (2015). Braces for idiopathic scoliosis in adolescents. ''Cochrane Database of Systematic Reviews''. [Online]. Issue 6, art. no.: CD006850. Available at: https://doi.org/10.1002/14651858.CD006850.pub3. [Accessed on 23<sup>rd</sup> May 2019].
 
NHS. (2017). ''Scoliosis''. [Online]. Available at: https://www.nhs.uk/conditions/scoliosis/. [Accessed on 22nd May 2019].
 
NHS. (2017). ''Treatment in children - Scoliosis''. [Online]. Available at: https://www.nhs.uk/conditions/scoliosis/treatment-in-children/. [Accessed on 22nd May, 2019].
 
Paria, N. and Wise, C. A. 2015. Genetics of adolescent idiopathic scoliosis. ''Seminars in Spine Surgery''. 27 (1), pp. 9-15.
 
Rigo, M. (2010). Differential diagnosis of back pain in adult scoliosis (non operated patients). ''Scoliosis''. 5 (S1), pp. O44.
 
Sato, T., Hirano, T., Ito, T., Morita, O., Kikuchi, R., Endo, N. and Tanabe, N. (2010). Back pain in adolescents with idiopathic scoliosis: epidemiological study for 43,630 pupils in Niigata City, Japan. ''European Spine Journal''. 20 (2), pp. 274-279.
 
Schreiber, S., Parent, E., Moez, E., Hedden, D., Hill, D., Moreau, M., Lou, E., Watkins, E. and Southon, S. (2015). 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'', 10 (1), pp.24
 
Scoli-Fit NYC Scoliosis Systems LLP. 2015. ''Directional Breathing Band''. [Online]. Available at: https://www.youtube.com/watch?v=xGUojrDPkP4. [Accessed on 23rd May 2019].
 
Scoliosis Care Centers. 2010. ''Adams Test and Schroth Breathing Exercise for Scoliosis Treatment''. [Online]. Available at: https://www.youtube.com/watch?v=dyNrxq-PKmQ. [Accessed on 23rd May 2019].
 
Scoliosis Research Society. (c2019). ''Adolescent Idiopathic Scoliosis''. [Online]. Available at: https://www.srs.org/patients-and-families/conditions-and-treatments/parents/scoliosis/adolescent-idiopathic-scoliosis. [Accessed 21 May 2019].
 
Théroux, J., Le May, S., Fortin, C. and Labelle, H. (2015). Prevalence and Management of Back Pain in Adolescent Idiopathic Scoliosis Patients: A Retrospective Study. ''Pain Research and Management''. 20 (3), pp. 153-157.
 
Weiss, H., Moramarco, M. M., Borysov, M., Ng, S. Y., Lee, S. G., Nan, X. and Moramarco, K. A. (2016). Postural Rehabilitation for Adolescent Idiopathic Scoliosis during Growth. ''Asian Spine Journal''. 10 (3), pp. 570-581.
[[Category:Pain]]
[[Category:Pain]]
[[Category:Paediatrics]]
[[Category:Paediatrics]]
[[Category:Paediatrics - Conditions]]
[[Category:Conditions]]
<references />

Latest revision as of 11:39, 24 November 2023

Original Editors - Man Nok Tam as part of the Nottingham University Spinal Rehabilitation Project

Top Contributors - Man Nok Tam, Kim Jackson, Simisola Ajeyalemi, Abbey Wright, Charika Dissanayake, Vidya Acharya, Lauren Lopez and Alisa Chak Yung Choa -  

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]

Cobb angle

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]

Patients with LBP or thoracic pain with AIS are more prone to having severe insomnia and daytime sleepiness, whether chronic back pain is associated with moderate depression.[8]

Dysfunctional Respiratory Function in AIS[edit | edit source]

Dysfunctional and asymmetrical breathing pattern often presents in patients with scoliosis.[9] Trunk rotation is increased as a result of inspiratory breathing forces being directed downwards to the convexity of the spinal curvature.[9] There is also a linkage between dysfunctional breathing and LBP or neck pain.[10][11]

Conservative Treatment[edit | edit source]

Conservative approaches are employing patients with low Cobb angles. Medication, physiotherapy, lifestyle changes and braces are helpful strategies when managing a patient conservatively. Under the exercises category their are general exercises and scientific exercise approaches (Schroth method).

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[12]
  • Stretching exercises
  • Gait re-education
  • Compound functional exercises such as squats, lunges and getting on/off the floor
  • Advice on cardiovascular exercise and fitness
  • Pilates/yoga[13]
  • 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.[14] It was developed by Katharina Schroth in Germany. Schroth method aims at preventing curve progression before the end of growth with the following goals[15][16][17]:

  • 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[18].

Braces[edit | edit source]

Milwaukee brace and Boston brace are the most common braces which are using in conservative management.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[19].

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.[20]

Boston brace

However, for the purpose of reducing the rate of bracing, Scientific Exercise Approaches are more effective than Usual Physiotherapy, while Physiotherapeutic Specific Scoliosis Exercises persist as additional tools for the treatment of AIS.[21]

Osteopathic manipulation[edit | edit source]

There is currently no evidence to support osteopathic manipulation as the treatment for AIS[20].

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.[22]

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.[23] Posterior fusion with instrumentation is usually performed for idiopathic scoliosis.[23]

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. ↑ Wong AYL, Samartzis D, Cheung PWH, Cheung JPY. How Common Is Back Pain and What Biopsychosocial Factors Are Associated With Back Pain in Patients With Adolescent Idiopathic Scoliosis? Clinical Orthopaedics & Related Research. 2018 Nov 13;477(4):676–86.
  9. ↑ 9.0 9.1 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.
  10. ↑ Bradley H, Esformes JD. Breathing pattern disorders and functional movement. International journal of sports physical therapy. 2014 Feb;9(1):28.
  11. ↑ 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.
  12. ↑ 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.
  13. ↑ 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.
  14. ↑ 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.
  15. ↑ 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.
  16. ↑ 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.
  17. ↑ 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.
  18. ↑ 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.
  19. ↑ 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.
  20. ↑ 20.0 20.1 Balagué F, Pellisé F. Adolescent idiopathic scoliosis and back pain. Scoliosis and spinal disorders. 2016 Dec;11(1):27.
  21. ↑ Negrini S, Donzelli S, Negrini A, Parzini S, Romano M, Zaina F. Specific exercises reduce the need for bracing in adolescents with idiopathic scoliosis: A practical clinical trial. Annals of Physical and Rehabilitation Medicine. 2019 Mar;62(2):69–76.
  22. ↑ 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.
  23. ↑ 23.0 23.1 Maruyama T, Takeshita K. Surgery for idiopathic scoliosis: currently applied techniques. Clinical medicine. Pediatrics. 2009 Jan;3:CMPed-S2117.
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