Adolescent Idiopathic Scoliosis and Back Pain

Aims

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.

Objectives

• To introduce AIS
• 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

Fig. 2 Cobb angle (Greiner, 2002)

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 angle (fig.2) and Risser sign.

One type of idiopathic scoliosis is AIS.

Prevalence of AIS

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 age (Konieczny et al., 2013). Genetic factors play a role as well (Konieczny et al., 2013).

Back pain in AIS

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).

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.

Back pain and Cobb angle

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) in AIS

Makino et al. (2015) reported that low back pain (LBP) in AIS patients can cause deterioration of patients’ QoL. 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.

Dysfunctional breathing in AIS and back pain

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

This section will cover the direct or indirect conservative and surgical treatment for back pain in AIS.

Conservative treatment

Schroth method

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).

Schroth method aims at preventing curve progression before the end of growth with the following goals:

• Proactive spinal corrections to avoid surgery
• Postural training to avoid or decelerate progression
• Information to support a decision-making process
• Teaching a home-exercise programme
• Support help for self-help
• Prevention and coping strategies for pain

(Berdishevsky et al., 2016)

Evidence for the effectiveness of Schroth method exercises

Schreiber et al. (2015)

Schreiber et al. (2015) did a randomised controlled trial (RCT) which suggested that Schroth method exercises with standard 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.

Table 1 Table showing the PICO model of the study done by Schreiber et al. (2015)

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

* 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

• The intervention group has a better improvement overall in terms of SRS-22r pain score
• SRS-22r pain score difference between the two groups from baseline to 3 months was not statistically significant: -29.16; p=0.45
• 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.

Table 2 Table showing the results of the study done by Schreiber et al. (2015)

Outcome	Intervention group (n=25)		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	0.45	-
SRS-22r (pain): 3 month	460.76	32.37	415.71	32.62		0.02
SRS-22r (pain): 6 month	525.99	33.38	395.68	32.36	-

SRS-22r=Scoliosis Research Society-22r

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

• Only overall pain was measured
• 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

Lee et al. (2016)

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.

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

Table 4 Table showing the results of the study done by Lee et al. (2016)

Subject no.	Subject characteristics	Results
		VAS		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

• 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

There are evidence suggesting the use of breathing exercises as a treatment for chronic LBP (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.

Rotational Angular Breathing (RAB)

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)

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).

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 below).

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 (see videos below).

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.

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

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

• 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 have 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 RAB as a treatment for back pain in AIS.

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