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= Search Strategy  =
We used databases such as Pubmed and ResearchGate to find scientific articles.<br>Our keywords consisted of “Scheuermann’s disease”, “Scheuermann’s kyphosis”, “Juvenile kyphosis” whether or not combined with “description”, “symptoms”, “diagnosis”, “treatment”, “measurement”, “examination”, “physical therapy” and so on.<br>We only used articles of which the full text was available.<br><br>


== Definition/Description  ==
== Definition/Description  ==
 
[[File:Scheuermanns disease.jpg|right|frameless]]
Scheuermann’s disease or Scheuermann’s kyphosis is a form of osteochondritis of the spine. <ref name="1( 
LoE: 3A)">Makurthou, Ater A, et al. Scheuermann Disease: Evaluation of Radiological Criteria and Population Prevalence. Spine. September 2013,38(19):1690-1694</ref>&nbsp;(LoE: 3A)<br>&nbsp;It is a rigid kyphosis of the thoracic or thoracolumbar spine occurring in adolescence. <ref name="2">E: Tyrakowski, Marcin MD, et al. Radiographic Spinopelvic Parameters in Skeletally Mature Patients Scheuermann Disease. Spine. August 2014,39(18):1080-1085fckLR
LoE: 3A</ref>&nbsp;<ref name="32 LoE: 2B">Faldini C, et al. Does Surgery for Scheuermann kyphosis influence sagittal spinopelvic parameters?. European Spine Journal. November 2015, Volume 24,7:893-897
LoE: 2B</ref>&nbsp;(LoE: 2B)<br>&nbsp;Scheuermann’s disease is characterized by an increased posterior rounding of the thoracic spine in association with structural deformity of the vertebral elements. It’s the most prevalent in pediatric population and it’s the most common cause of structural hyperkyphosis. There are two types: the typical thoracic pattern, the more common, with non-structural hyperlordosis of the cervical and lumber spine and the atypical thoracolumbar pattern that is thought to be more likely to progress in adulthood. Until now the cause of Scheuermann’s disease remains unknown.<ref name="1( 
LoE: 3A)" /><br>By radiographic techniques the disease can be defined as three adjacent wedged vertebrae angled by at least 5 degrees. This definition can be altered according to different authors, as some of them consider the disease to be present if there is one vertebra wedged and associated with irregular vertebral endplates. <ref name="3">Clèmence Palazzo et.al; Scheuermann’s disease: An update fckLR
LoE : 3A</ref><br><br><br>
Scheuermann kyphosis, also known as Scheuermann disease, juvenile kyphosis or juvenile discogenic disease, is a condition of hyperkyphosis that involves the vertebral bodies and discs of the spine identified by anterior wedging of greater than or equal to 5 degrees in 3 or more adjacent vertebral bodies. The thoracic spine is most commonly involved, although involvement can include the thoracolumbar/lumbar region as well.<ref name=":0">Mansfield JT, Bennett M[https://www.ncbi.nlm.nih.gov/books/NBK499966/ . Scheuermann Disease.] InStatPearls [Internet] 2019 Jan 17. StatPearls Publishing. Available from:https://www.ncbi.nlm.nih.gov/books/NBK499966/ (last accessed 20.4.2020)</ref> Image R severe case - pre-operative image of a 22 year old male with Scheuermann's Disease
* Most commonly, diagnosis is made in adolescents aged 12 to 17 years who present after their parents notice a postural deformity or “hunchbacked” appearance.
* Pain in the affected hyperkyphotic region may also be the cause of initial evaluation
* Scheuermann's disease is the most common cause of kyphotic deformity in adolescents.<ref name="Savvidou">Papagelopoulos PJ, Mavrogenis AF, Savvidou OD, Mitsiokapa EA, Themistocleous GG, Soucacos PN. [https://search.proquest.com/openview/ff361ff1a9fb8c730bcf25b99dc8ffec/1?pq-origsite=gscholar&cbl=40235 Current concepts in Scheuermann's kyphosis]. Orthopedics (Online). 2008;31(1):52.</ref>
There are two major forms of Scheuermann's kyphosis.
* The thoracic form is most common and has an apex between T7-T9.  
* Secondly, the thoracolumbar form can occur with an apex between T10-T12 and is more likely to continue into adulthood.<ref name="Savvidou" /><ref name="LoweTG">Lowe TG, Line BG. [https://journals.lww.com/spinejournal/fulltext/2007/09011/Evidence_Based_Medicine__Analysis_of_Scheuermann.9.aspx Evidence based medicine: analysis of Scheuermann kyphosis]. Spine. 2007 Sep 1;32(19):S115-9.</ref> <ref name="Weiss">Weiss H, Turnbull D. Kyphosis (Physical and technical rehabilitation of patients with Scheuermann's disease and kyphosis). International encyclopedia of rehabilitation. 2010.</ref>
&nbsp;


== Clinically Relevant Anatomy  ==
== Clinically Relevant Anatomy  ==
[[File:Spineanatomy.png|right|frameless|502x502px]]
The spine of an adult is naturally shaped in an S-curve. The [[Cervical Anatomy|cervical]] and [[Lumbar Anatomy|lumbar]] regions are concave (lordosis), and the [[Thoracic Anatomy|thoracic]] and sacral regions are convex (kyphosis). According to the Scoliosis Research Society, the thoracic spine has a kyphosis between 20 to 40 degrees. A spinal deformity is considered when the curve is greater (or lesser) as mentioned degrees. <br> 


The upper and middle-back is called the thoracic spine. It joins the cervical spine and extends down about five inches past the bottom of the shoulder blades, where it connects with the lumbar spine. This region has a gentle convex curve.<br>The thoracic spine consists of 12 thoracic vertebrae, labelled T1-T12.These vertebrae are larger and thicker than the cervical vertebrae, but smaller than the lumbar vertebrae. They provide the stability which is very important to hold the body upright and to provide protection for the vital organs in the chest.<br>There is a limited flexibility in the thoracic spine because planar joints connect the ribs to it. Each thoracic vertebra supports a pair of ribs and contains a pair of smooth, concave joint-forming processes known as facets on its sides.<br>T1 is unique because it supports two pairs of ribs through a pair of facets and a pair of demi-facets.<br>T1-T9 have a pair of demi-facets, where a facet is split between two adjacent vertebral bodies.<br>T1 and T10-T12 contain a pair of full facets on their vertebral bodies to support ribs.<br>Also the intervertebral discs distinguish from the cervical and lumbar intervertebral discs because they are thinner. The spinal canal is most narrow in the thoracic spine, which makes the spinal cord much vulnerable. <ref name="6">6 Taylor T. Thoracic Vertebrae. [Internet]. 2015 [Cited 2015 Nov 15]
Available from:
http://www.innerbody.com/anatomy/skeletal/thoracic-vertebrae-lateral</ref>&nbsp;<ref name="7">Davis E. Lumbar Spine Anatomy and Pain. [Internet]. 2013 [Cited 2015 Nov 15] Available from: http://www.spine-health.com/conditions/spine-anatomy/lumbar-spine-anatomy-and-pain</ref><br>The lumbar spine refers to the lower back. It connects to the thoracic spine and has a gentle concave curvature. Each vertebra is connected by an intervertebral disk made of tough fibrocartilage with a jelly-like centre. The inner layer, nucleus pulposus, acts as a shock absorber. The outer layer, annulus fibrosus, holds the vertebrae together and provides strength and flexibility to the back during movement. The lumbar vertebrae are larger and heavier than the cervical or thoracic vertebrae. The vertebral body of the lumbar vertebrae has to bear most of the body weight. That’s why the vertebral body makes up the majority of the lumbar vertebrae’s mass. The body is posteriorly connected to a thin ring of bone known as the arch. It surrounds the hollow vertebral foramen and connects the body to the bony processes on the posterior of the vertebra.<ref name="7" /><ref name="6" /><ref name="8">Kishner S. et al. Lumbar Spine Anatomy. [Internet]. 2015 [Cited 2015 Nov 15] Available from :http://emedicine.medscape.com/article/1899031-overview#a2
LoE : 5</ref>
Scheuermann’s disease is a structural deformity of the vertebral bodies and spine. The kyphosis of the thoracic region will be around 45 to 75 degrees. Also there will be vertebral wedging greater than five degrees of 3 or more adjacent vertebrae. <ref name="Sorenson">Soerensen KH. Scheuermann's juvenile kyphosis. Munksgaard; 1964.</ref>&nbsp;The wedge shaped bodies characterize the rigid hyperkyphosis we see in Scheuermann’s disease. The hyperkyphosis can be compensated by a lumbar and cervical hyperlordosis.
 
== Epidemiology /Etiology  ==
 
The disease mostly develops during puberty and is seen equally in both sexes. Depending on which criteria are used, 5 to 40% of the population has this anomaly. In the United States the disease occurs in 0,4 to 8 percent of the general population.10 31 32<ref name="10">Sorensen et al: Scheuermann’s Juvenile Kyphosis. Clinical Appearances, Radiography, Aetiology, and Prognosis. Copenhagen, Munksgaard,1964  
LoE : 3A</ref><ref name="31">Nowak J. Scheuermann Disease [Internet] Februari 2015 [Cited 2015 Nov 15] Available from:
http://emedicine.medscape.com/article/311959-overview#a6</ref><ref name="32 LoE: 2B" /><br>Many theories have been proposed for the etiology of Scheuermann's disease, but the real cause is still unclear. Here are some of these theories:


<br>
== Etiology  ==


*The skeleton of a newborn consists mainly of cartilage, which in childhood is transformed into bone5. Schmorl found that the lumbar Scheuermann’s disease could be related to defects of ossification process. The defect is often located at the anterior of the lumbar vertebrae, more precisely at the endplates. This results in an anterior wedging of the vertebrae and thus an increased kyphosis.  
Definitive and universally accepted etiology of Scheuermann kyphosis remains undetermined.  
*Ferguson suggested that the anterior wedging is caused by the persistence of the anterior vascular groove. It creates a weak point in the vertebrae, which can lead to the collapse of the vertebral body. But these findings have not been observed in other studies.
* An hereditary component is understood to contribute to this condition's development, although the mode of transmission is still unclear.
*There could be mechanical factors contributing to the disease. Partial reversal of the anterior wedging has been noted in patients who wore a brace during the active of the disease, suggesting that mechanical factors play a role in the development of the deformity.
* One growing theory, supported by histologic findings, suggests discordant vertebral endplate mineralization and ossification during growth which causes disproportional vertebral body growth and resultant classic wedge-shaped vertebral bodies that lead to kyphosis<ref name=":0" />
*Osteoporosis could also be responsible for the development of Scheuermann's disease.  
* Other theories proposed include mechanical, metabolic, and endocrinologic causes, but the real cause is still unclear.<br>
*Mostly, the patients have a greater lordosis in the lumbar spine than people without this pathology.<ref name="11">Blumenthal S, Roach J, Herring J. Lumbar Scheuermann’s: a clinical series and classification. Spine 1987; 12:929-932. 
LoE : 2B</ref>&nbsp;<ref name="12">Eorthopod. Content. Scheurmanns disease. www.eorthopod.com/content/scheuermanns-disease (accessed 20/10/2010).</ref>  
*There also could be a correlation between disc generation, reduced intradisc distance and abnormal configurations of the vertebral bodies.<ref name="11" />&nbsp;<ref name="31" />
*Ascani et al. found that patients who had Scheuermann's disease were taller than average and that their skeletal age was ahead of their chronological age. They also found increased levels of growth hormone in these patients.<br>


Nowadays scientific literature considers Scheuermann’s disease to be hereditary but the methods of transmission is still undefined. <br>Other important factors are biomechanical factors, most importantly hamstring contracture that prevents a normal pelvic inclination when flexing the trunk. When this movement is repeated it can cause a progressive anterior wedging of the vertebrae.<ref name="13" />&nbsp;<br>Findings of a research by Ogden et al. states that the appearance of an asymmetric biomechanical stress on the vertebral bodies will result in changes in the remodelling process. In this case kyphosis would be a result of the imbalance of the load supported between the anterior and the posterior parts of the spine.<ref name="13" /><br>Other factors such as elevated growth hormone levels, idiopathic juvenile osteoporosis, deficiency of vitamin D, dural cysts, spondylolysis, infections, spinal deformities and other disease are also implicated in the development of Scheuermanns disease. The disease can also be a result of several of these factors acting simultaniously.&nbsp;<ref name="13">Tomè-Bermejo F, Tsirikos Al. Conceptos actuales sobre la enfermedad de Scheuermann: presentation clìnica, diagnostic y controversias sobre su tratamiento. Rev Esp Cir Ortop Traumatol. 202, 56:491-505 (article was in English but the authors asked to cite this study in Spanish) English citation: F. Tomè-Bermejo, A.I Tsirkos, Current concepts on Scheuermann kyphosis: Clinical presentation, diagnosis and controversies around treatment, Rev Esp Cir Ortop Traumatol. 2012, 56(6): 491-505 
LoE: 3A</ref><br>According to a study by G. Armbrecht et.al about the prevalence of Scheuermann’s disease in Europe both men and women aged 50 and over, the prevalence of the disease is 8% in both sexes but it variated a lot between centres of Europe.<ref name="38">G. Armbrecht et.al; Vertebral Scheuermann’s disease in Europe: prevalence, geographic variation and radiological correlates in men and women aged 50 and over; Osteoporos Int (2015) 26:2509-2519 fckLRLoE: 2B</ref><br>Highest prevalence of the disease is seen in Germany and a bit lower prevalence in the United Kingdom, the Netherlands and Russia. In these high prevalence countries was Scheuermann’s disease the most common cause of hyperkyphosis in adolescence which will have an effect for a lifetime of the patient.&nbsp;<ref name="38" /><br>Central European centres such as Slovakia and Hungary had much lower prevalences but the reason behind these findings remain unclear because there has been no data collected which could prove that these differences have a genetic or an environmental background.<ref name="38" /><br>  
== Epidemiology  ==
* Prevalence: 1% to 8% in the United States
* Sex: Male to female ratio is at least 2:1
* Age: Most commonly diagnosed in adolescents 12-17 years
* Rarely diagnosed in children less than 10 years.
* Classification: Type I (Classic) - Thoracic spine involvement only, with the apex of curve T7-T9Type II - Thoracic and lumbar involvement, with the apex of curve T10-T12<ref name=":0" />


== Characteristics/Clinical Presentation  ==
== Characteristics/Clinical Presentation  ==
[[File:Scheuerman2.png|right|frameless|382x382px]]
According to Sorenson <ref name="Sorenson" />, Scheuermann’s kyphosis is characterized by following criteria. 
* Three or more adjacent vertebrae must be wedged 5° or more 
* Must be no evidence of congenital, infectious or traumatic disorders of the spine.
The adolescent will present with
* Cosmetic/postural deformity 
* Possible Subacute thoracic pain, usually no identifiable inciting event. The pain is worse with activity and improved with rest.
* Deformity is typically appreciated in the early-mid teenage years by child, parents, or on a school screening exam. 
* Physical exam shows rigid hyperkyphotic curve, accentuated with forward bending.
* Hyperkyphosis does not resolve with an extension or lying prone/supine, further supporting the “rigid” nature of this deformity.
* Other associated findings on an exam might include cervical or lumbar hyperlordosis, scoliosis, and tight hamstrings. Although neurologic deficits are uncommon, a thorough neurologic exam must be completed<ref name=":0" />
* Muscle stiffness and fatigue, especially at the end of the day
* Decreased flexibility of the torso
* In severe cases, heart and lung function can be impaired or severe neurological symptoms can occur. These symptoms are extremely rare.


Most patients with Scheuermann's disease are presented with a history of deformity. The most common cause is structural kyphosis in adolescence. <ref name="14">Wenger D R, Frick S L. Scheuermann Kyphosis. Spine. 1999,24(24):2630-2639 
LoE: 2A</ref><ref name="15">Ristolainen et al. Untreated Scheuermann’s disease: a 37-year follow-up study, European Spine Journal. May 2012,21(5):819–824.
LoE: 2B</ref><ref name="35">Axelrod T, et al. Scheuermann’s Disease (Dystosis) of the Spine. Orthopedics. January 2015, volume 38 (1):4, 66-71
LoE : 2B</ref><br>If the Scheuermann’s disease is located in the upper thoracic region, there will be a kyphotic deformity that will be best demonstrated in the forward flexed position. The normal curvature of the thoracic spine is between 20 and 45 degrees. If the patient has a curvature of more than 50 degrees, where the spine has three contiguous vertebral bodies that have wedging of five degrees or more, scheuermann’s disease is included. <ref name="8">Kishner S. et al. Lumbar Spine Anatomy. [Internet]. 2015 [Cited 2015 Nov 15] Available from :http://emedicine.medscape.com/article/1899031-overview#a2 
LoE : 5</ref><ref name="14" /><ref name="15" />&nbsp;<ref name="16">Bezalel T, Kalichman L, et al. Improvement of clinical and radiographical presentation of Scheuermann disease after Schroth therapy treatment. Journal of Bodywork and Movement Therapies. April 2015,19(2):232-237
LoE: 2A</ref><ref name="17">Platero D. et al, Juvenile Kyphosis: Effects of Different Variables on Conservative Treatment Outcome. Acta Orthopaedica Belgica. October 1997
LoE: 2B</ref><br>Palpation in this region can&nbsp;be tender.&nbsp;<ref name="35" /><br>In the lumbar spine, hyperlordosis can occur and there is a strong correlation between Scheuermann’s disease and scoliosis.<br>Hamstring tightness may be present in these patients.<ref name="35" /><br>As the disease progresses, there will be more complaints such as back pain. The pain is located just distal to the apex of the deformity and then radiates laterally in a paraspinal pattern. The pain also is activity related and often abates with rest) and fatigue, muscle stiffness (especially at the end of the day) and neurological symptoms. In severe cases, heart and lung function can be impaired. Other secondary changes are Schmorl nodes, irregular vertebral endplates and disc space narrowing (Figure 1). Pain related to the pathology can be made worse by activity including sports that require a lot of twisting, forceful bending or arching backward such as gymnastics. Some studies have found Scheuermann’s disease to be more prevalent among boys than girls. Other studies have reported kyphosis to be more prominent in females than males. <ref name="14" /><ref name="15" /><ref name="16" /><ref name="36">Xinhu G, et al. Comparison between two types of “Scheuermann disease-like people”: thoracolumbar disc herniation patients and healthy volunteers with radiological signs of Scheuermann’s disease. Chinese Medical Journal. 2014,127(22):3862-3866</ref><br>After the puberty growth stops, the disease will also stop. Only some residual abnormalities will exist.<br>There’s no conclusive evidence that people with lumbar Scheuermann’s disease have a higher chance of low back pain compared with healthy people. More research is needed.<ref name="8" />


<sup></sup><br>  
Patients with Scheuermann's disease may also complain of inability to participate in physical exercise, work and activities of daily living secondary to pain or the presence of their deformity negatively affecting their cosmetic appearance.<ref name="Ristolainen">Ristolainen L, Kettunen JA, Heliövaara M, Kujala UM, Heinonen A, Schlenzka D. [https://link.springer.com/article/10.1007/s00586-011-2075-0 Untreated Scheuermann’s disease: a 37-year follow-up study]. European Spine Journal. 2012 May;21(5):819-24.</ref><br>Possible to see cutaneous skin pigmentation at the area of greatest curvature due to skin friction on chair backs.<ref name="Ristolainen" /><br>The natural history of Scheuermann’s kyphosis is unclear, with conflicting reports as to the severity of pain and physical disability. <ref name="Bezalel">Bezalel T, Carmeli E, Been E, Kalichman L. [https://content.iospress.com/articles/journal-of-back-and-musculoskeletal-rehabilitation/bmr00483 Scheuermann's disease: current diagnosis and treatment approach]. Journal of back and musculoskeletal rehabilitation. 2014 Jan 1;27(4):383-90.</ref><br>


== Differential Diagnosis ==
== Differential Diagnosis   ==
 
* Postural [[kyphosis]] (flexible postural deformity)
Most patients with Scheuermann's disease are presented with a history of deformity. The most common cause is structural kyphosis in adolescence. <ref name="14" /><ref name="15" /><ref name="35" /><br>If the Scheuermann’s disease is located in the upper thoracic region, there will be a kyphotic deformity that will be best demonstrated in the forward flexed position. The normal curvature of the thoracic spine is between 20 and 45 degrees. If the patient has a curvature of more than 50 degrees, where the spine has three contiguous vertebral bodies that have wedging of five degrees or more, scheuermann’s disease is included. 8 14 15 16 17<ref name="8" /><ref name="14" /><ref name="15" /><ref name="16" /><br>Palpation in this region can be tender.&nbsp;<ref name="35" /><br>In the lumbar spine, hyperlordosis can occur and there is a strong correlation between Scheuermann’s disease and scoliosis.<br>Hamstring tightness may be present in these patients.<ref name="35" /><br>As the disease progresses, there will be more complaints such as back pain. The pain is located just distal to the apex of the deformity and then radiates laterally in a paraspinal pattern. The pain also is activity related and often abates with rest) and fatigue, muscle stiffness (especially at the end of the day) and neurological symptoms. In severe cases, heart and lung function can be impaired. Other secondary changes are Schmorl nodes, irregular vertebral endplates and disc space narrowing (Figure 1). Pain related to the pathology can be made worse by activity including sports that require a lot of twisting, forceful bending or arching backward such as gymnastics. Some studies have found Scheuermann’s disease to be more prevalent among boys than girls. Other studies have reported kyphosis to be more prominent in females than males. 15 14 16 36<ref name="14" /><ref name="15" /><ref name="16" /><ref name="36" /><br>After the puberty growth stops, the disease will also stop. Only some residual abnormalities will exist.<br>There’s no conclusive evidence that people with lumbar Scheuermann’s disease have a higher chance of low back pain compared with healthy people. More research is needed.<ref name="8" /><br><br>
* [[Thoracic Hyperkyphosis|Hyperkyphosis]] attributable to another known disease state
* Postsurgical kyphosis
* [[Ankylosing Spondylitis (Axial Spondyloarthritis)|Ankylosing spondylitis]]
* [[Scoliosis]]


== Diagnostic Procedures  ==
== Diagnostic Procedures  ==


A first type of test is radiography. The radiographs include anteroposterior and lateral standing on long films. The entire thoracolumbar spine had to be on one film. The patient had to stand in neutral position with his hips and knees fully extended. Also side- and backward bending x-rays are recommended to understand the flexibility of the spine. If we see three adjoining vertebral bodies with an anterior wedging of 5 degrees on the lateral radiographs, Scheuermann's disease is confirmed. This is measured with the Cobb technique. Also secondary changes such as irregular vertebral endplates, Schmorl nodes and disk space narrowing should be noted.<br>As said earlier, scoliosis and spondylolisthesis is associated with Scheuermann’s disease. These pathologies can be documented on plain radiographs. It has to be treated as separate entities.1 19 20 33 35 37<ref name="1( 
LoE: 3A)" /><ref name="33">Etemadifar M, et al. Comparison of Scheuermann’s kyphosis correction by combined anterior-posterior fusion versus posterior-only procedure. European Spine Journal. September 2015:1-7
LoE : 2B</ref><ref name="35" /><ref name="37">Liu N, et al. Radiological Sings of Scheuermann Disease and Low Back Pain: Retrospective Categorization of 188 Hospital Staff Members With 6-Year Follow-up. Spine. 2014 Sep,39(20): 1666-1675
LoE : 3A</ref><br>If the patient has leg pain or symptoms of neurological dysfunction, an MRI is taken. 1 19 20<ref name="1( 
LoE: 3A)" /><br><br>  
History and physical along with AP/lateral radiographs comprise the essential components for evaluating Scheuermann kyphosis. Lateral radiographs are required for diagnosis, and diagnostic criteria including the following:
* Rigid hyperkyphosis, greater than 40 degrees
* Anterior wedging, greater than or equal to 5 degrees in three or more adjacent vertebral bodies<ref name=":0" /><ref name="Ali">Ali RM, Green DW, Patel TC. [https://europepmc.org/article/med/10084088 Scheuermann's kyphosis]. Current opinion in pediatrics. 1999 Feb 1;11(1):70-5.</ref>
Other Associated Findings Noted on AP/Lateral Radiographs
* Irregular vertebral endplates
* Schmorl nodes
* Loss of disc space height
* Scoliosis
* Spondylolysis/spondylolisthesis
* Disc herniation
Typically not a necessity, MRI can be helpful to further evaluate anatomic changes or for pre-operative planning. CT imaging is usually not needed. There are also no specific laboratory tests or histologic findings necessary for the diagnosis of Scheuermann kyphosis<ref name=":0" />.<br>


== Outcome Measures  ==
== Outcome Measures  ==
[[Occiput to Wall Distance OWD|Occiput to Wall Distance]]
Following self-reported outcome measures can be used after an operative treatment <ref name="Poolman">Poolman R, Been H, Ubags L. [https://link.springer.com/article/10.1007/s00586-002-0418-6 Clinical outcome and radiographic results after operative treatment of Scheuermann's disease]. European Spine Journal. 2002 Dec;11(6):561-9.</ref>&nbsp;or for untreated Scheuermann’s disease as well <ref name="Ristolainen" />:


The diagnosis of Scheuermann’s disease is based on radiological criteria reported by Sorensen which means that there are at least 3 consecutive vertebral bodies with a minimum of 5° of wedging.2 21 32<ref name="2" /><ref name="32" /><br>Other criteria include endplate irregularity, thoracic kyphosis greater than 35° or 45°. 1 35<ref name="1( 
LoE: 3A)" /><ref name="35" /><br>On the lateral radiographs, there are four spinal parameters. The first parameter defines the sagittal vertebral axis as a linear horizontal distance between the C7 plumb line (originating in the centre of the vertebral body) and the posterior corner of the S1 endplate. If the C7 plumb line is anterior to the S1 posterior corner, the sagittal vertebral axis is defined as positive.&nbsp;<ref name="2" /><br>The thoracic kyphosis Th4-Th12 is the angle measured between the proximal endplate of Th4 and the distal endplate of Th12. This angle is measured using the Cobb method.Between the proximal endplate of the Th11 vertebrae and the distal endplate of L1 vertebrae the Th11-L1 angle is measured. If the Cobb method is negative, lumbar lordosis is indicated. 2 30 32 34<ref name="2" /><ref name="30">E : 3BfckLR30 Piotr J, et al. Cervical Sagittal Alignment in Scheuermann Disease. Spine. December 2015, E1226-E1232

LoE : 4B</ref><ref name="32">Faldini C, et al. Does Surgery for Scheuermann kyphosis influence sagittal spinopelvic parameters?. European Spine Journal. November 2015, Volume 24,7:893-897
LoE: 2B</ref><ref name="34">Yanik H.S, et al. Selection of distal fusion level in posterior instrumentation and fusion of Scheuermann kyphosis: is fusion to sagittal stable vertebra necessary? European Spine Journal. July 2015:1-7
LoE : 2B</ref><br>The lumbar lordosis L1-S1 is defined as the angle between the proximal endplate of the L1 vertebrae and endplate of S1 is measured with the Cobb method. Also three pelvic parameters can be measured. The pelvic incidence was defined as the angle between the line joining the centre of the bicoxofemoral axis and the centre of the S1 endplate and the line orthogonal to the S1 endplate. The angle between the line joining the centre of the bicoxofemoral axis and the centre of the S1 endplate and vertical line is the Pelvic tilt. If the midpoint of the S1 endplate was anterior to the centre of the bicoxofemoral, the value is negative. The angle between the line parallel to the S1 endplate and the reference horizontal line is the sacral slope (Figure 3). 1 2 30 32 34&nbsp;<ref name="1( 
LoE: 3A)" /><ref name="2" /><ref name="30" /><ref name="32" /><ref name="34" /><br>Also Schmorl nodes will be seen.<ref name="32" /><br>
#Scoliosis Research Society Instrument (SRSI): This questionnaire can be used for follow- up of an individual to see if the patient reports improvements in level of activity, pain, personal relationships etc.
#Back pain and disability scores: [http://www.physio-pedia.com/Visual_Analogue_Scale Visual Analogue Scale (VAS)], [http://www.physio-pedia.com/Quebec_Back_Pain_Disability_Scale Quebec Back Pain Disability Scale (QBPDS)], [http://www.physio-pedia.com/Roland‐Morris_Disability_Questionnaire Roland-Morris Disability Questionnaire], [http://www.physio-pedia.com/index.php?title=Oswestry_Disability_Index Oswestry Disability Index (ODI)] and SF-36: measures Quality of Life (QoL) across eight domains, which contain a physical component score (PCS) and a mental component score (MCS)


== Examination  ==
== Examination  ==
* The most significant feature of patients with Scheuermann’s disease is the thoracic kyphosis. 
* Often the kyphosis is accompanied by a lumbar and/or cervical hyperlordosis. 
* The cervical lordosis can be increased with a protrusion of the head. The shoulders mostly are positioned anteriorly. 
* These abnormalities can be accompanied by a mild to moderate scoliosis. 
*[[File:Scheuermann's Kyphosis Example.JPG|right|frameless]]Patients with Scheuermann's disease are well muscled compared to patients with postural kyphosis. <ref name="LoweTG" /><br>The examination consist of:
# Postural assessment: examination of the posture from anterior, posterior and lateral view
# Neurological screening: <ref name="Weiss" /> rarely the spinal cord can be stretched over the posterior aspect of the vertebral bodies at the apex of the curvature which may cause neurological signs of impending paraplegia with clonus and hyperreflexia.<ref name="Lemire">Lemire JJ, Mierau DR, Crawford CM, Dzus AK. [https://europepmc.org/article/med/8728463 Scheuermann's juvenile kyphosis]. Journal of manipulative and physiological therapeutics. 1996 Mar 1;19(3):195-201.</ref>
# [http://www.physio-pedia.com/Adam%27s_forward_bend_test Adam’s forward-bend test]: Scheuermann’s kyphosis can be accompanied by a scoliosis. <ref name="Hart">Hart ES, Merlin G, Harisiades J, Grottkau BE. [https://journals.lww.com/orthopaedicnursing/FullText/2010/11000/Scheuermann_s_Thoracic_Kyphosis_in_the_Adolescent.5.aspx Scheuermann's thoracic kyphosis in the adolescent patient]. Orthopaedic Nursing. 2010 Nov 1;29(6):365-71.</ref>
#Muscle length testing: the disease can be accompanied by tightness of the [[Pectoralis major|M. Pectoralis]], [http://www.physio-pedia.com/Hamstrings M. Hamstrings], [[Cervical Anatomy|M. suboccipitalis]] and the hip flexors with possible contractures of the anterior shoulder and hip <ref name="Savvidou" /><ref name="LoweTG" />
#Range of motion: Flexibility of the extremities and spine can identify impairments and track changes over time.<ref name="Hart" />
#[[Muscle Strength Testing|Muscle strength testing:]] strength of the abdominals, core, trunk extensors and gluteal muscles must be assessed<br>
== Medical Management    ==


Scheuermann’s disease can be seen during examination as a well-defined, angular, thoracic hyperkyphosis and as a compensatory effect the therapist will also see a cervical and lumber hyperlordosis. This happens as a result of the balancing attempts of the column. These curves of compensation can also become a source of pain. 13<ref name="13" /><br>The head and neck will be seen in an anterior position called “gooseneck deformity”. In some cases the shoulders can also follow the same anterior protrusion. 13<ref name="13" /><br>These symptoms can be seen during flexion of the trunk as an angular and sharp hump on the thoracic or thoracolumbar region. This deformity is considered to be relatively fixed and is not corrected with spinal hyperextension (Figure 4). 13<ref name="13" /><br>Other findings of examination are the presence of contractures of the pectoral muscles, hamstrings and the hip flexors. 13<ref name="13" /><br>Almost one third of the patients also have mild or moderate scoliosis. 13<ref name="13" /><br>The therapist will observe the patient in different types of views: frontal, lateral and back. However, there are some components which are assessed during a static examination: feet equilibrium, lower limb alignment, sagittal and frontal pelvic balance, hip asymmetry, abdomen, spine, morphological disharmony of the chest, shoulders, neck and head. By measuring the distances from the plumb line we can discover deformities of the sagittal posture (Figure 5).18 <ref name="18" /><br>When the patient is evaluated during movement, it will give information about the level of coordination and balance which will later influence the therapeutic choices.<br>Other aggravating factors should also be assessed such as visual/psychological disorders which may require a mulit-disciplinar approach during the therapy.18<ref name="18">Zaina et al. Review of rehabilitation and orthopedic conservative approach to sagittal plane diseases during growth: hyperkyphosis, junctional kyphosis, and Scheuermann disease. EUR J PHYS REHABIL MED 2009;45:595-603.</ref><br>
'''Nonoperative Management'''
# Stretching, lifestyle modification, NSAIDs, plus/minus physical therapy
Indication
* Kyphosis less than 60 degrees and asymptomatic
Course
* Majority of patients fall into this category
* Patients typically do well without significant long term sequelae
[[File:Milwaukee brace.jpg|right|frameless]]
2. Extension bracing plus above


== Medical Management <br>  ==
Indication
* Kyphosis 60 to 80 degrees plus/minus symptomatic
Course
* Bracing typically required for 12 to 24 months
* [[Milwaukee brace|Milwaukee]] brace (see image R), Kyphologic brace or Thoracolumbosacral orthosis-style Boston brace
* Most effective in skeletally immature patients
* Typically, does not improve curve but rather impedes progression


The treatment of Scheuermann’s Disease depends on the patient’s age, degree of angulation, and estimated remaining growth.<ref name="35" /><br>


=== Non-operative treatment  ===
'''Operative Management'''


<br>If the thoracic kyphosis exceeds 40-45° during the growth period and if there are radiological sings of Scheuermann’s disease, non-operative treatment is indicated. This consists of bracing, casting and exercises (LoE 2A).&nbsp;<br>The initial management of patients with Scheuermann’s disease includes documentation and assessment of the degree of deformity and/or pain, as well as an overall “gestalt” of the negative impact of the deformity on the patient’s life. Physical therapy for postural improvement exercises focusing on the trunk and hamstring extensor strengthening is often recommended. A physical therapist can also evaluate whether there is any tendency toward increased hip flexion contracture and may work on associated lumbar lordosis (LoE 2A).&nbsp;<ref name="14" /><br>Until now, there is no scientific evidence that exercise improves the kyphosis. 21 14<ref name="14" /><ref name="21" /><br>Only patients with mobile kyphotic deformity and with at least one year of remaining growth will experience improvement of bracing and casting (LoE 2A). 14 18 21 22&nbsp;<ref name="14" /><ref name="18" /><br>Results of brace treatment for relieving pain have not been published because bracing has been used primarily for the treatment of deformity (LoE 2A). 14<ref name="14" /><br>The prerequisites for the bracing treatment in patients with Scheuermann’s disease include that the patient has at least a 45°-curve and that patients with a kyphosis of up to 65° may be successfully managed by bracing. There is a higher failure rate in patients with curves of greater than 74°. As mentioned before, it’s necessary to have some flexibility in the curve and the patient needs to be skeletally immature (LoE 2A). 14 18 21 23&nbsp;<ref name="14" /><ref name="18" /><br>A modified Milwaukee brace (Figure 6) that has posterior pads attached to the uprights pushing anteriorly on the kyphosis, with both the neck and pelvis controlled by the upper and lower segment of the brace is a classic treatment. It’s ideally to wear the brace 23 hours a day for 1 to 2 years. The brace is adjusted monthly (LoE 2A).&nbsp;<ref name="14" /><br>If the patient’s Risser sing is 4 or 5, bracing and casting is known to become ineffective.<br>According to some authors, cast treatment has a successful outcome in patients with rigid Scheuermann’s disease (LoE 2A).&nbsp;<br>The Bradford series with the Milwaukee brace treatment remains the largest series of conservative treatment. Patients following this treatment had stabilization or a small improvement of deformity (LoE 2A). 21<br>Also other braces like the modified Boston, Lyon brace and the Maguelone brace are effective (Figure 6)&nbsp;<br>The Boston lumbar brace is recommended for flexible curves below 70° with an apex at or below T7. The Lyon brace is a bivalve rigid brace with a posterior shell usually T7-S3 and an anterior shell with a manubrial thrust reinforced by a metallic bar.<br>The Maguelone brace is highly effective and very dedicated to the most frequent pure thoracic hyperkyphosis with apex from T5-6 to T8-9. With this brace, the patient can do specific in-brace exercises.<br>Braces must be carried a minimum of 18 months to have an effect on vertebral wedging (LoE 2A). 21<br>As patients grow older, they feel increasing ashamed of their body. They are more concerned about the future effect of the deformity on their body.<br>Patients, whose bracing time increases, have more probability to get low back pain. So girls have a higher probability to get low back pain than boys. Patients with larger spinal curves have more difficulties in bending and increased incidence of back pain than patients with smaller curves.<br>Low compliance in adolescence with spinal deformities treated with body orthosis is mostly caused by psychological reasons mainly associated with relations at school and back pain. Therefore it’s recommended to give these patients careful instructions and psychological support &nbsp;&nbsp;<br>
Spinal fusion, typically combination of anterior release + fusion as well as posterior instrumentation + fusion


<br>  
Indications
* Kyphosis greater than 75 degrees causing unacceptable deformity
* Kyphosis greater than 75 degrees with associated pain
* Neurologic deficit/spinal cord compression
* Severe refractory pain
Course
* Majority of patients experience symptomatic improvement as well as improved curve deformity towards normal
* Operative/postoperative complications must be considered<ref name=":0" /><br>


<br>
== Physical Therapy Management  ==
Non Surgical Treatment


=== <br>Operative treatment  ===
A child or youth with a mild kyphosis may simply need to be observed for changes in the curve, as well as be educated on their posture and activities by the physiotherapist.
* Unless the curve or pain becomes worse, no other treatment may be needed.
* Some children eventually improve without having a noticeable abnormal kyphosis and have no long-term problems.
* Others may always have a mildly exaggerated thoracic kyphosis but are able to function normally without subsequent pain or other problems.<ref name=":1">Advantage Physiotherapy [https://www.advantagephysiotherapy.com/Injuries-Conditions/Upper-Back-and-Neck/Upper-Back-Issues/Scheuermann-s-Disease/a~5944/article.html SCHEUERMANN'S DISEASE] Available from:https://www.advantagephysiotherapy.com/Injuries-Conditions/Upper-Back-and-Neck/Upper-Back-Issues/Scheuermann-s-Disease/a~5944/article.html (last accessed 20.4.2020)</ref>


<br>Patients with Scheuermann’s disease rarely undergo surgery because the natural history of the disease is in most cases benign. Conservative treatment is usually not effective for large curves (above 75°) or in the adult. Spinal pain and unacceptable cosmetic appearance are the most common indications for surgery. It’s important to be careful in counselling these patients because these criteria are subjective. Because of this, there are also no evidence-based criteria for an indication of surgery. Other indications for surgery are exceptional complications like neurologic decompression through an anterior thoracotomy or posterolateral decompression. According to the literature, operative treatment should be considered in patients presenting with a kyphotic deformity over 75°, significant pain that has not responded to conservative measures associated with significant kyphosis (&gt;65°) and/or respiratory problems due to severe kyphosis usually above 100° (LoE 2A). 14 21 22 33 34&nbsp;<ref name="14" /><ref name="33" /><ref name="34" /><br>The results of the surgical treatment can be considered relative to the two most common indications listed for surgery: relief of pain and correction of deformity (LoE 2A).14 23 32<ref name="14" /><ref name="32" /><br>Before the operation there will be a clinical examination. The stiffness of the hamstrings, a popliteal angle of less than 30° and neurological findings will be tested. Stiff hamstrings can cause sagittal decompression. Radiographs will include long, scoliosis and the hyperkyphosis.<br>To rule out exceptional thoracic disc herniation, epidural cyst or possible spinal stenosis an MRI is recommended. Clinical photographs are mandatory because the operation is essentially cosmetic. Surgeons need to know: if the curve needs an anterior release, which levels must be included in the spine fusion, which correction technique they have to use and what the amount of correction is.<br>If the patient can’t make a thoracic curve less than 50°, anterior release is indicated.<br>Also the posterior shortening technique can help to reduce the curve. In this technique the superior and inferior facets at the apex are removed. Posterior fusion alone exposes the patient to loss of progression over time. The long-term result with pedicle screw instrumentation is not known but with an anterior fusion it will never be wrong. This because thoracoscopic procedures render the anterior release less morbid and may prevent loss of correction in the future.<br>For a classic Scheuermann’s disease, where the apex is at T8, one would release from T5-T6 down to T10-T11. It’s recommended to perform an anterior release of 5-6 levels around the apex of the curve and grafting the intervertebral disc spaces with pieces of autologous rib.<br>5-10% in patients with segmental posterior instrumentation has late operative-site pain. Even with a solid posterior fusion, removal of posterior instrumentation may lead to recurrence of the deformity. Therefore, an anterior fusion of large and stiff Scheuermann’s disease is considered safer for a long-lasting correction. The anterior release will be necessary in adult patients with anterior bridging (LoE 2A). 21 34<ref name="34" /><br>A major instrumention-related complication after surgical correction of Scheuermann Kyphosis is Distal junction kyphosis. <br><br>
The doctor may suggest bracing along with exercise.
* A brace is most effective when used before the skeleton matures at about age 14.
* Ideally, bracing should begin at the onset of puberty, be worn for approximately 2 years, and removed at the end of skeletal maturity. <ref name="Weiss" /><ref name="Sorenson" />  
* Doctors commonly chose a Milwaukee brace, which is made of molded plastic that conforms to the waist and is designed to hold the shoulders back and gradually straighten the thoracic curve. The brace has two upright, padded bars line up along the sides of the spine. Pressure from the upright bars straightens the spine ( won't reverse the curve a fully developed spine, nor is it helpful for rigid curves that angle more than 75 degrees).


== Physical Therapy Management <br> ==
=== Bracing  ===
* Younger patients (under 15) generally wear the brace all the time including at night, although they usually remove the brace to shower.
* The doctor adjusts the brace regularly as the curve improves.
* When the thoracic curve has improved enough, the brace is worn part-time (eight to 12 hours per day) until the skeleton is fully mature, which is typically around age 14 or 15.
* Sometimes adults obtain partial correction of the kyphosis and pain relief with bracing even though they have reached full bone growth. Bracing for pain relief in adults is also considered when surgery is not an option.<ref name=":1" />
'''Physiotherapy''' is recommended in combination with bracing. 
* Exercises appear to maximize the effect of the brace by strengthening muscles that help align the spine
* Advice from a physiotherapist regarding posturing and activity modification can be extremely useful in the treatment of Scheuermann’s kyphosis.
* Even if a brace is not used, physiotherapy is recommended to assist with any pain that may be present, to teach proper posturing for the spine, and to assess and treat any muscular imbalances that may be affecting the mechanical pull on the spine.
Doctors may prescribe anti-inflammatory medication for pain. Younger patients generally use this medicine on a short-term basis, in combination with other treatments. Adults who have ongoing pain sometimes require long-term use of anti-inflammatory medication<ref name=":1" />.


Treatment of Scheuermann's disease depends on the severity or the progression of the disease, the presence or absence of pain and the age of the patient.<br>Patients with a mild form are suggested to exercise and get a prescription from the doctor for physiotherapy. <br><br>  
According to Lowe, brace treatment is almost always successful in patients with kyphosis between 55 degrees and 80 degrees if the diagnosis is made before skeletal maturity. 
* Bracing therapy has a few shortcomings: as the bracing time increases, the probability to develop low back pain increases
* In adolescents the compliance is usually low
* Other bracing strategies have been attempted such as the use of a soft brace but this however has not shown to be successful. With a soft brace no correction can be achieved in rigid curvatures.<ref name="Sorenson" /><ref name="Weiss" />  
'''Other aspects of Physiotherapy Treatment''' 


The methods of physical therapy include exercise programs to maintain flexibility of the back, correct lumbar lordosis, and strengthen the extensors of the back (LoE 2A) 25 26<ref name="25" /><ref name="26" />, electrostimulation and vertebral traction for increasing flexibility before a cast is applied. Although physical therapy has no role in correcting the underlying deformity. 35<ref name="35" /> Physical therapy is recommended in combination with bracing (LoE 3A).<ref name="17" /><br>According to Zaina et al. exercise programmes should always include patient awareness of spinal alignment and neutral and correct position of the vertebral column and awareness of and ergonomic position for work and study. Also mobilisation of the thoracic cage and muscular reinforcement and neuromotor integration are important. Another systematic review (Romano et al. 2013) indicates that there is lack of strong evidence for specific exercises and that higher quality research in this field is necessary (LoE 2B).<ref name="24" /><br>Katharina Schroth developed a three-dimensional exercise therapy program. She divided the trunk into three parts: cervical, thoracic and lumbar body segments, which can be shifted against one another. This special program was designed to correct the relative position of the three blocks in sagittal plane together with self-elongation of the vertebral column, proprietary corrective breathing techniques and re-education of the neuromuscular system in order to improve postural perception. This method is based on kinaesthetic and sensorimotor principles (LoE 2A).&nbsp;<ref name="16" /><br>Spinal self-elongation is the initial force involved in every Schrotch exercise. It’s necessary to teach the patient how to strengthen the musculature surrounding the spine when they are in place associated with the newly formed posture. The patient learns an individual correction routine by using sensorimotor feedback mechanisms. Another type of feedback is the mirror monitoring. It allows synchronizing the corrective movement and postural perception. By using a mirror, the patient is able to see how the kyphotic posture changes into a more favourable one. Also the skeletal imbalance and how musculature gradually transforms into an upright position will be seen in the mirror (LoE 2A).&nbsp;<ref name="16" /><br>Changing the patient’s breathing pattern in order to decrease the risk of spinal deformity curve progression and to promote a more balanced posture is also an important part of the therapy. <br>Other components essential in the Schroth method are motivation and cooperation (LoE 2A).<ref name="16" /><br>Treatment objectives are stretching pectoral and hamstring muscles and passive and active reduction of the kyphotic curve. They learn to utilize active trunk muscle forces correctively and to maintain an erect posture. This correct posture is maintained in daily living activities. Particularly the “two stool” exercise and the “door frame” exercise show elements of muscle stretching and improvement of the thoracic kyphosis (LoE 2A). <ref name="16" /><ref name="36" /><br>Exercises include corrections in sitting and supine positions and correction against resistance in standing position. <br>The Schroth therapy may be effective in preventing impairment and reducing the thoracic curvature in Scheuermann’s patients. Further research is needed to implement this method in an evidence based clinical practice model (LoE 2A).&nbsp;<ref name="16" />  
Patient education includes 
* Extension-based stretching/strengthening program
* Hamstring stretching exercise program
* Proper postural and body mechanic techniques for ADLs
* Appropriate use and handling of braces<ref name=":0" />
Postural improvement:
* Focuses on hamstring and pectoralis stretching and trunk extensor strengthening as well as improving function.<ref name="Weissetal">Weiss HR, Turnbull D, Bohr S. [https://scoliosisjournal.biomedcentral.com/articles/10.1186/1748-7161-4-22 Brace treatment for patients with Scheuermann's disease-a review of the literature and first experiences with a new brace design]. Scoliosis. 2009 Dec;4(1):1-7.</ref>&nbsp;
* These exercises can be effective when the thoracic spine has not developed a relevant stiffness and when the sagittal curve is not too high: [http://www.physio-pedia.com/Cobb's_angle Cobb angles] from 44° to 55°. <ref name="Goodman">Goodman CC, Fuller KS. Goodman and Fuller’s Pathology E-Book: Implications for the Physical Therapist. 3rd edition Elsevier Health Sciences; 2009.</ref>&nbsp;
* Practice normal posture standing and sitting <ref name="hansrudolf" /><ref name="dieckmann" /><ref name="Ball" /><ref name="montgomery" /><ref name="zaina" />  
Exercises 
* Flexibility exercises to relieve lower extremity contractures eg Hamstrings<ref name="Tomer">Bezalel T, Kalichman L. [https://www.sciencedirect.com/science/article/pii/S1360859214000606 Improvement of clinical and radiographical presentation of Scheuermann disease after Schroth therapy treatment]. Journal of bodywork and movement therapies. 2015 Apr 1;19(2):232-7.</ref>
* Strengthen core musculature, back extensors . <ref name="hansrudolf">Weiß HR, Dieckmann J, Gerner HJ. [https://ebooks.iospress.nl/volumearticle/19945 Outcome of in-patient rehabilitation in patients with M. Scheuermann evaluated by surface topography]. Research into Spinal Deformities 3. 2002:246-9.</ref><ref name="dieckmann">Weiß HR, Ddeckmann J, Gerner HJ. [https://ebooks.iospress.nl/doi/10.3233/978-1-60750-932-5-254 Effect of intensive rehabilitation on pain in patients with Scheuermann’s disease]. InResearch into Spinal Deformities 3 2002 (pp. 254-257). IOS Press.</ref><ref name="Ball">Ball JM, Cagle P, Johnson BE, Lucasey C, Lukert BP. [https://link.springer.com/content/pdf/10.1007/s00198-008-0690-3.pdf Spinal extension exercises prevent natural progression of kyphosis]. Osteoporosis International. 2009 Mar 1;20(3):481.</ref><ref name="montgomery">Montgomery SP, Erwin WE. [https://europepmc.org/article/med/6782681 Scheuermann's kyphosis--long-term results of Milwaukee braces treatment]. Spine. 1981 Jan 1;6(1):5-8.</ref><ref name="zaina">Zaina F, Atanasio S, Ferraro C, Fusco C, Negrini A, Romano M, Negrini S. [https://isico.it/images/uploads/pubblicazioni/completo/ID00304.pdf Review of rehabilitation and orthopedic conservative approach to sagittal plane diseases during growth: hyperkyphosis, junctional kyphosis, and Scheuermann disease]. Eur J Phys Rehabil Med. 2009 Dec 1;45(4):595-603.</ref>
Sports
* Extension sports are advised: such as gymnastics, aerobics, swimming, basketball, cycling and hyperextension exercises. 
* Some sports should be discouraged: like sports associated with jumping, marked stress and functional overuse of the back. <ref name="engell">Damborg F, Engell V, Andersen M, Kyvik KO, Thomsen K. [https://journals.lww.com/jbjsjournal/Fulltext/2006/10000/Prevalence,_Concordance,_and_Heritability_of.3.aspx Prevalence, concordance, and heritability of Scheuermann kyphosis based on a study of twins.] JBJS. 2006 Oct 1;88(10):2133-6.</ref><ref name="sturm">Sturm PF, Dobson JC, Armstrong GW. [https://europepmc.org/article/med/8516695 The surgical management of Scheuermann's disease]. Spine. 1993 May 1;18(6):685-91.</ref>&nbsp;
Postoperative physical therapy
* Necessary and must contain breathing exercises, mobilizations and strengthening exercises. <ref name="Lowe">Lowe TG. [https://journals.lww.com/jbjsjournal/Citation/1990/72060/Scheuermann_disease_.26.aspx Scheuermann disease]. JBJS. 1990 Jul 1;72(6):940-5.</ref>&nbsp;<br>
'''Scheuermann's disease in adults'''
* Regarded differently from that of the teenager because the major manifestation is pain and not aesthetic quality.
* The functional rehabilitation on an outpatient basis is the favoured treatment and referral for surgery or dorso-lumbar braces is rare.
[[File:Scheuerman3.png|right|frameless|400x400px]]


Jaeger J et al found a significant reduction in kyphosis using the CBP protocol. Initially the therapy included full spine diversified spinal manipulation to the cervical, thoracic and lumbar regions. Also traction in the axial cervical spine/upper thoracic spine was performed with 20lbs for 10 minutes. To reduce pain and inflammation while mobilizing they put ice packings between the table top and the patient’s spine. Afterwards the patient started the CBP technique. This included mirror image postural adjusting using a drop table and with use of impulse handheld adjusting instrument. Each visit the patient did 3 sets of 15 repetitions of mirror image head retraction exercise while also pulling the pelvis posterior to the wall to extend the thoracic spine. Also thoraco-lumbar anterior and posterior core stability exercises on a Theraball were performed. They found a significant positive difference (LoE 2B).&nbsp;<ref name="25" />  
The kyphotic posture can be treated with the [[Scoliosis|Schroth]] method <ref name="Tomer" />  


<br>  
Examples of Schroth exercises are shown at R<br>  


<br>  
<br>
[[File:Scheuerman5.jpg|right|frameless|400x400px]]


<br>  
Another treatment regime is outline her, using a different method  <ref name="hagit">Berdishevsky H. [https://scoliosisjournal.biomedcentral.com/articles/10.1186/s13013-016-0094-7 Outcome of intensive outpatient rehabilitation and bracing in an adult patient with Scheuermann’s disease evaluated by radiologic imaging—a case report]. Scoliosis and spinal disorders. 2016 Oct;11(2):47-51.</ref>&nbsp;There are five Principles of Correction:<br>
* Trunk elongation and expansion
* Symmetrical sagittal straightening: identical exercises must be performed for both sides of the trunk (right and left):<br>&nbsp; &nbsp; &nbsp; Bilateral thoracic expansion in a posterior to anterior (PA) direction to reduce the thoracic hyperkyphosis<br>&nbsp; &nbsp; &nbsp; Bilateral lumbar expansion in an anterior to posterior (AP) direction to reduce the hyperlordotic low back
* Shoulder traction: the traction enhances the expansion of the thorax and corrects the spine
* Correction of breathing: it allows the subject to feel an increased expansion in his/her initially collapsed regions. The goal is to expand the thorax in a back-to-front and a lateral direction.
* Muscle activation by increasing tension: to achieve the best possible correction, muscle balance, stabilization and to increase the proprioceptive input. It helps to integrate the ‘corrected body schema’ in the brain.
* This intensive physical therapy combined with bracing (SpinoMed brace) is successful to treat an adult patient with Scheuermann’s kyphosis. <ref name="hagit" />&nbsp;<br>


=== <br>Exercises (LoE 2B) <ref name="29">29 Turqueto Duarte R, et al. Physical therapy on the conservative treatment on adolescent with Scheuermann’s Disease – a case report. MTP &amp;amp; Rehab journal. March 2014,12:101-105 fckLR
LoE : 3B</ref>:  ===
More clinical trials are necessary to evaluate the effectiveness of conservative interventions, especially different exercises and manual therapies. These should also be combined/compared with braces. <ref name="Bezalel" /><br>  
 
== Clinical Bottom Line  ==
* The majority of patients are successfully treated with conservative measures as discussed above.
* Pain in the affected region typically improves after skeletal maturity is reached, although patients with Scheuermann kyphosis are at increased risk of chronic back pain as compared to the general population.
* Patients with a kyphotic curve less than 60 degrees at skeletal maturity typically have no long-term sequelae<ref name=":0" /><br>


Bilateral external rotators associated with thoracic extension with elastic resistance: 3 x 20 rep (LoE 3B)<ref name="29" />
== Key Research  ==


*∗ Low rowing with elastic resistance. 3 x 20 rep (LoE 3B)<ref name="29" />
#Bezalel T, Kalichman L. [https://www.sciencedirect.com/science/article/pii/S1360859214000606 Improvement of clinical and radiographical presentation of Scheuermann disease after Schroth therapy treatment]. Journal of bodywork and movement therapies. 2015 Apr 1;19(2):232-7.
*the two stool exercise (LoE 3B)<ref name="29" />:  
#Berdishevsky H. [https://scoliosisjournal.biomedcentral.com/articles/10.1186/s13013-016-0094-7 Outcome of intensive outpatient rehabilitation and bracing in an adult patient with Scheuermann’s disease evaluated by radiologic imaging—a case report]. Scoliosis and spinal disorders. 2016 Oct;11(2):47-51.<br>
*∗ The door frame exercise (LoE 3B)<ref name="29" />
*∗ Exercise on the wall bars (LoE 3B)<ref name="26" />


<br>
== Resources    ==


More Exercises:  
Deutchman: Schroth Method Exercises for Scoliosis:  


*[https://www.youtube.com/watch?v=t3BYGr47gmg Movie 1]: Heal Thoracic Kyphosis With Six Simple Exercises
{{#ev:youtube|JUXcQvzx2H0}}
*[https://www.youtube.com/watch?v=IeKnHtGysBc Movie 2]: Improving Your Posture (kyphosis, rounded shoulders, forward neck) - Reece Tomlinson


== Key Research  ==
Strott: The Scheuermann’s Disease Fund:


#Zaina et al. Review of rehabilitation and orthopedic conservative approach to sagittal plane diseases during growth: hyperkyphosis, junctional kyphosis, and Scheuermann disease. EUR J PHYS REHABIL MED 2009;45:595-603. LoE&nbsp;: 2A
{{#ev:youtube|bzsGnsENJow}}
#Bezalel T, Kalichman L, et al. Improvement of clinical and radiographical presentation of Scheuermann disease after Schroth therapy treatment. Journal of Bodywork and Movement Therapies. April 2015,19(2):232-237 LoE: 2A
#Wenger D R, Frick S L. Scheuermann Kyphosis. Spine. 1999,24(24):2630-2639 LoE: 2A
#Arlet V, Schlenzka D. Scheuermann’s kyphosis: surgical management. European Spine Journal. 2005,14:817-827 LoE: 2A
#Negrini S, Minozzi S, Bettany-Saltikov J, et al; Braces for idiopathic scoliosis in adolescents. Cochrane Database Syst Rev. 2010 Jan 20;(1):CD006850. LoE&nbsp;: 2A<br><br>


== Resources <br>  ==
Spine Universe. Scheuermann's Kyphosis (Scheuermann's disease): abnormal curvature of the spine. Available on: [https://www.spineuniverse.com/conditions/kyphosis/scheuermanns-kyphosis-scheuermanns-disease www.spineuniverse.com/conditions/kyphosis/scheuermanns-kyphosis-scheuermanns-disease]


#http://cirrie.buffalo.edu/encyclopedia/en/article/125/
Tribus C. Medscape Reference. Scheuermann Kyphosis. Available on: [http://emedicine.medscape.com/article/1266349-overview#showall emedicine.medscape.com/article/1266349-overview#showall]
#http://www.spine-health.com/conditions/spine-anatomy/lumbar-spine-anatomy-and-pain
#http://emedicine.medscape.com/article/1899031-overview#a2
#http://www.innerbody.com/anatomy/skeletal/thoracic-vertebrae-lateral&nbsp;
#www.eorthopod.com/content/scheuermanns-disease<br>


== Clinical Bottom Line  ==
http://cirrie.buffalo.edu/encyclopedia/en/article/125/


The management of SD depends upon the type of condition, the severity, the prognosis and the patient's tolerance for various interventions. Early diagnosis and intervention are beneficial. <br>Standing lateral and anteroposterior radiographs showing anterior wedging or consecutive thoracic vertebrae are the gold standard for diagnosis.<br>Conservative treatment with physical therapy and bracing is effective in limiting pain and fatigue until skeletal mature is reached for lesser degrees of kyphosis. If the kyphosis is more severe, surgery with spinal fusion is indicated to improve the deformity and symptoms. 35<ref name="35" /><br>The International Scientific Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT) produced its first guidelines in 200527. These have recently been revised and their scientific quality has been increased. Their aim is to offer to all professionals and their patients an evidence-based updated review of the actual evidence on conservative treatment of Scheuermann's disease / idiopathic scoliosis.28<ref name="28">28 Negrini S, Minozzi S, Bettany-Saltikov J, et al; Braces for idiopathic scoliosis in adolescents. Cochrane Database Syst Rev. 2010 Jan 20;(1):CD006850. fckLR
LoE : 2A</ref><br><br>
http://www.spine-health.com/conditions/spine-anatomy/lumbar-spine-anatomy-and-pain


== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==
http://emedicine.medscape.com/article/1899031-overview#a2


#http://www.ncbi.nlm.nih.gov/pubmed/?term=scheuermann's+disease
http://www.innerbody.com/anatomy/skeletal/thoracic-vertebrae-lateral<nowiki/>&#x20;<br><br>
#http://www.ncbi.nlm.nih.gov/pubmed/?term=scheuermann+kyphosis
#http://www.ncbi.nlm.nih.gov/pubmed/?term=juvenile+kyphosis


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== References  ==
== References  ==


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[[Category:Primary Contact]]
[[Category:Paediatrics]]
[[Category:Paediatrics - Conditions]]
[[Category:Thoracic Spine - Conditions]]
[[Category:Conditions]]
[[Category:Genetic Disorders]]

Latest revision as of 11:35, 12 March 2022

Original Editors - Liza De Dobbeleer

Top Contributors - Nicolas D'Hondt, Leen Meylemans, Liza De Dobbeleer, Lucinda hampton, Kim Jackson, Admin, Rachael Lowe, Fasuba Ayobami, WikiSysop, Aminat Abolade, 127.0.0.1, Uchechukwu Chukwuemeka, Claire Knott, Meaghan Rieke, Anna Fuhrmann and Elaine Lonnemann -

Definition/Description[edit | edit source]

Scheuermanns disease.jpg

Scheuermann kyphosis, also known as Scheuermann disease, juvenile kyphosis or juvenile discogenic disease, is a condition of hyperkyphosis that involves the vertebral bodies and discs of the spine identified by anterior wedging of greater than or equal to 5 degrees in 3 or more adjacent vertebral bodies. The thoracic spine is most commonly involved, although involvement can include the thoracolumbar/lumbar region as well.[1] Image R severe case - pre-operative image of a 22 year old male with Scheuermann's Disease

  • Most commonly, diagnosis is made in adolescents aged 12 to 17 years who present after their parents notice a postural deformity or “hunchbacked” appearance.
  • Pain in the affected hyperkyphotic region may also be the cause of initial evaluation
  • Scheuermann's disease is the most common cause of kyphotic deformity in adolescents.[2]

There are two major forms of Scheuermann's kyphosis.

  • The thoracic form is most common and has an apex between T7-T9.
  • Secondly, the thoracolumbar form can occur with an apex between T10-T12 and is more likely to continue into adulthood.[2][3] [4]

 

Clinically Relevant Anatomy[edit | edit source]

Spineanatomy.png

The spine of an adult is naturally shaped in an S-curve. The cervical and lumbar regions are concave (lordosis), and the thoracic and sacral regions are convex (kyphosis). According to the Scoliosis Research Society, the thoracic spine has a kyphosis between 20 to 40 degrees. A spinal deformity is considered when the curve is greater (or lesser) as mentioned degrees.

Scheuermann’s disease is a structural deformity of the vertebral bodies and spine. The kyphosis of the thoracic region will be around 45 to 75 degrees. Also there will be vertebral wedging greater than five degrees of 3 or more adjacent vertebrae. [5] The wedge shaped bodies characterize the rigid hyperkyphosis we see in Scheuermann’s disease. The hyperkyphosis can be compensated by a lumbar and cervical hyperlordosis.

Etiology[edit | edit source]

Definitive and universally accepted etiology of Scheuermann kyphosis remains undetermined.

  • An hereditary component is understood to contribute to this condition's development, although the mode of transmission is still unclear.
  • One growing theory, supported by histologic findings, suggests discordant vertebral endplate mineralization and ossification during growth which causes disproportional vertebral body growth and resultant classic wedge-shaped vertebral bodies that lead to kyphosis[1]
  • Other theories proposed include mechanical, metabolic, and endocrinologic causes, but the real cause is still unclear.

Epidemiology[edit | edit source]

  • Prevalence: 1% to 8% in the United States
  • Sex: Male to female ratio is at least 2:1
  • Age: Most commonly diagnosed in adolescents 12-17 years
  • Rarely diagnosed in children less than 10 years.
  • Classification: Type I (Classic) - Thoracic spine involvement only, with the apex of curve T7-T9Type II - Thoracic and lumbar involvement, with the apex of curve T10-T12[1]

Characteristics/Clinical Presentation[edit | edit source]

Scheuerman2.png

According to Sorenson [5], Scheuermann’s kyphosis is characterized by following criteria.

  • Three or more adjacent vertebrae must be wedged 5° or more
  • Must be no evidence of congenital, infectious or traumatic disorders of the spine.

The adolescent will present with

  • Cosmetic/postural deformity
  • Possible Subacute thoracic pain, usually no identifiable inciting event. The pain is worse with activity and improved with rest.
  • Deformity is typically appreciated in the early-mid teenage years by child, parents, or on a school screening exam.
  • Physical exam shows rigid hyperkyphotic curve, accentuated with forward bending.
  • Hyperkyphosis does not resolve with an extension or lying prone/supine, further supporting the “rigid” nature of this deformity.
  • Other associated findings on an exam might include cervical or lumbar hyperlordosis, scoliosis, and tight hamstrings. Although neurologic deficits are uncommon, a thorough neurologic exam must be completed[1]
  • Muscle stiffness and fatigue, especially at the end of the day
  • Decreased flexibility of the torso
  • In severe cases, heart and lung function can be impaired or severe neurological symptoms can occur. These symptoms are extremely rare.


Patients with Scheuermann's disease may also complain of inability to participate in physical exercise, work and activities of daily living secondary to pain or the presence of their deformity negatively affecting their cosmetic appearance.[6]
Possible to see cutaneous skin pigmentation at the area of greatest curvature due to skin friction on chair backs.[6]
The natural history of Scheuermann’s kyphosis is unclear, with conflicting reports as to the severity of pain and physical disability. [7]

Differential Diagnosis[edit | edit source]

Diagnostic Procedures[edit | edit source]

History and physical along with AP/lateral radiographs comprise the essential components for evaluating Scheuermann kyphosis. Lateral radiographs are required for diagnosis, and diagnostic criteria including the following:

  • Rigid hyperkyphosis, greater than 40 degrees
  • Anterior wedging, greater than or equal to 5 degrees in three or more adjacent vertebral bodies[1][8]

Other Associated Findings Noted on AP/Lateral Radiographs

  • Irregular vertebral endplates
  • Schmorl nodes
  • Loss of disc space height
  • Scoliosis
  • Spondylolysis/spondylolisthesis
  • Disc herniation

Typically not a necessity, MRI can be helpful to further evaluate anatomic changes or for pre-operative planning. CT imaging is usually not needed. There are also no specific laboratory tests or histologic findings necessary for the diagnosis of Scheuermann kyphosis[1].

Outcome Measures[edit | edit source]

Occiput to Wall Distance

Following self-reported outcome measures can be used after an operative treatment [9] or for untreated Scheuermann’s disease as well [6]:

  1. Scoliosis Research Society Instrument (SRSI): This questionnaire can be used for follow- up of an individual to see if the patient reports improvements in level of activity, pain, personal relationships etc.
  2. Back pain and disability scores: Visual Analogue Scale (VAS), Quebec Back Pain Disability Scale (QBPDS), Roland-Morris Disability Questionnaire, Oswestry Disability Index (ODI) and SF-36: measures Quality of Life (QoL) across eight domains, which contain a physical component score (PCS) and a mental component score (MCS)

Examination[edit | edit source]

  • The most significant feature of patients with Scheuermann’s disease is the thoracic kyphosis.
  • Often the kyphosis is accompanied by a lumbar and/or cervical hyperlordosis.
  • The cervical lordosis can be increased with a protrusion of the head. The shoulders mostly are positioned anteriorly.
  • These abnormalities can be accompanied by a mild to moderate scoliosis.
  • Scheuermann's Kyphosis Example.JPG
    Patients with Scheuermann's disease are well muscled compared to patients with postural kyphosis. [3]
    The examination consist of:
  1. Postural assessment: examination of the posture from anterior, posterior and lateral view
  2. Neurological screening: [4] rarely the spinal cord can be stretched over the posterior aspect of the vertebral bodies at the apex of the curvature which may cause neurological signs of impending paraplegia with clonus and hyperreflexia.[10]
  3. Adam’s forward-bend test: Scheuermann’s kyphosis can be accompanied by a scoliosis. [11]
  4. Muscle length testing: the disease can be accompanied by tightness of the M. Pectoralis, M. Hamstrings, M. suboccipitalis and the hip flexors with possible contractures of the anterior shoulder and hip [2][3]
  5. Range of motion: Flexibility of the extremities and spine can identify impairments and track changes over time.[11]
  6. Muscle strength testing: strength of the abdominals, core, trunk extensors and gluteal muscles must be assessed

Medical Management[edit | edit source]

Nonoperative Management

  1. Stretching, lifestyle modification, NSAIDs, plus/minus physical therapy

Indication

  • Kyphosis less than 60 degrees and asymptomatic

Course

  • Majority of patients fall into this category
  • Patients typically do well without significant long term sequelae
Milwaukee brace.jpg

2. Extension bracing plus above

Indication

  • Kyphosis 60 to 80 degrees plus/minus symptomatic

Course

  • Bracing typically required for 12 to 24 months
  • Milwaukee brace (see image R), Kyphologic brace or Thoracolumbosacral orthosis-style Boston brace
  • Most effective in skeletally immature patients
  • Typically, does not improve curve but rather impedes progression


Operative Management

Spinal fusion, typically combination of anterior release + fusion as well as posterior instrumentation + fusion

Indications

  • Kyphosis greater than 75 degrees causing unacceptable deformity
  • Kyphosis greater than 75 degrees with associated pain
  • Neurologic deficit/spinal cord compression
  • Severe refractory pain

Course

  • Majority of patients experience symptomatic improvement as well as improved curve deformity towards normal
  • Operative/postoperative complications must be considered[1]

Physical Therapy Management[edit | edit source]

Non Surgical Treatment

A child or youth with a mild kyphosis may simply need to be observed for changes in the curve, as well as be educated on their posture and activities by the physiotherapist.

  • Unless the curve or pain becomes worse, no other treatment may be needed.
  • Some children eventually improve without having a noticeable abnormal kyphosis and have no long-term problems.
  • Others may always have a mildly exaggerated thoracic kyphosis but are able to function normally without subsequent pain or other problems.[12]

The doctor may suggest bracing along with exercise.

  • A brace is most effective when used before the skeleton matures at about age 14.
  • Ideally, bracing should begin at the onset of puberty, be worn for approximately 2 years, and removed at the end of skeletal maturity. [4][5]
  • Doctors commonly chose a Milwaukee brace, which is made of molded plastic that conforms to the waist and is designed to hold the shoulders back and gradually straighten the thoracic curve. The brace has two upright, padded bars line up along the sides of the spine. Pressure from the upright bars straightens the spine ( won't reverse the curve a fully developed spine, nor is it helpful for rigid curves that angle more than 75 degrees).

Bracing[edit | edit source]

  • Younger patients (under 15) generally wear the brace all the time including at night, although they usually remove the brace to shower.
  • The doctor adjusts the brace regularly as the curve improves.
  • When the thoracic curve has improved enough, the brace is worn part-time (eight to 12 hours per day) until the skeleton is fully mature, which is typically around age 14 or 15.
  • Sometimes adults obtain partial correction of the kyphosis and pain relief with bracing even though they have reached full bone growth. Bracing for pain relief in adults is also considered when surgery is not an option.[12]

Physiotherapy is recommended in combination with bracing. 

  • Exercises appear to maximize the effect of the brace by strengthening muscles that help align the spine
  • Advice from a physiotherapist regarding posturing and activity modification can be extremely useful in the treatment of Scheuermann’s kyphosis.
  • Even if a brace is not used, physiotherapy is recommended to assist with any pain that may be present, to teach proper posturing for the spine, and to assess and treat any muscular imbalances that may be affecting the mechanical pull on the spine.

Doctors may prescribe anti-inflammatory medication for pain. Younger patients generally use this medicine on a short-term basis, in combination with other treatments. Adults who have ongoing pain sometimes require long-term use of anti-inflammatory medication[12].

According to Lowe, brace treatment is almost always successful in patients with kyphosis between 55 degrees and 80 degrees if the diagnosis is made before skeletal maturity.

  • Bracing therapy has a few shortcomings: as the bracing time increases, the probability to develop low back pain increases
  • In adolescents the compliance is usually low
  • Other bracing strategies have been attempted such as the use of a soft brace but this however has not shown to be successful. With a soft brace no correction can be achieved in rigid curvatures.[5][4]

Other aspects of Physiotherapy Treatment

Patient education includes

  • Extension-based stretching/strengthening program
  • Hamstring stretching exercise program
  • Proper postural and body mechanic techniques for ADLs
  • Appropriate use and handling of braces[1]

Postural improvement:

  • Focuses on hamstring and pectoralis stretching and trunk extensor strengthening as well as improving function.[13] 
  • These exercises can be effective when the thoracic spine has not developed a relevant stiffness and when the sagittal curve is not too high: Cobb angles from 44° to 55°. [14] 
  • Practice normal posture standing and sitting [15][16][17][18][19]

Exercises

  • Flexibility exercises to relieve lower extremity contractures eg Hamstrings[20]
  • Strengthen core musculature, back extensors . [15][16][17][18][19]

Sports

  • Extension sports are advised: such as gymnastics, aerobics, swimming, basketball, cycling and hyperextension exercises.
  • Some sports should be discouraged: like sports associated with jumping, marked stress and functional overuse of the back. [21][22] 

Postoperative physical therapy

  • Necessary and must contain breathing exercises, mobilizations and strengthening exercises. [23] 

Scheuermann's disease in adults

  • Regarded differently from that of the teenager because the major manifestation is pain and not aesthetic quality.
  • The functional rehabilitation on an outpatient basis is the favoured treatment and referral for surgery or dorso-lumbar braces is rare.
Scheuerman3.png

The kyphotic posture can be treated with the Schroth method [20]

Examples of Schroth exercises are shown at R


Scheuerman5.jpg

Another treatment regime is outline her, using a different method [24] There are five Principles of Correction:

  • Trunk elongation and expansion
  • Symmetrical sagittal straightening: identical exercises must be performed for both sides of the trunk (right and left):
          Bilateral thoracic expansion in a posterior to anterior (PA) direction to reduce the thoracic hyperkyphosis
          Bilateral lumbar expansion in an anterior to posterior (AP) direction to reduce the hyperlordotic low back
  • Shoulder traction: the traction enhances the expansion of the thorax and corrects the spine
  • Correction of breathing: it allows the subject to feel an increased expansion in his/her initially collapsed regions. The goal is to expand the thorax in a back-to-front and a lateral direction.
  • Muscle activation by increasing tension: to achieve the best possible correction, muscle balance, stabilization and to increase the proprioceptive input. It helps to integrate the ‘corrected body schema’ in the brain.
  • This intensive physical therapy combined with bracing (SpinoMed brace) is successful to treat an adult patient with Scheuermann’s kyphosis. [24] 

More clinical trials are necessary to evaluate the effectiveness of conservative interventions, especially different exercises and manual therapies. These should also be combined/compared with braces. [7]

Clinical Bottom Line[edit | edit source]

  • The majority of patients are successfully treated with conservative measures as discussed above.
  • Pain in the affected region typically improves after skeletal maturity is reached, although patients with Scheuermann kyphosis are at increased risk of chronic back pain as compared to the general population.
  • Patients with a kyphotic curve less than 60 degrees at skeletal maturity typically have no long-term sequelae[1]

Key Research[edit | edit source]

  1. Bezalel T, Kalichman L. Improvement of clinical and radiographical presentation of Scheuermann disease after Schroth therapy treatment. Journal of bodywork and movement therapies. 2015 Apr 1;19(2):232-7.
  2. Berdishevsky H. Outcome of intensive outpatient rehabilitation and bracing in an adult patient with Scheuermann’s disease evaluated by radiologic imaging—a case report. Scoliosis and spinal disorders. 2016 Oct;11(2):47-51.

Resources[edit | edit source]

Deutchman: Schroth Method Exercises for Scoliosis:

Strott: The Scheuermann’s Disease Fund:

Spine Universe. Scheuermann's Kyphosis (Scheuermann's disease): abnormal curvature of the spine. Available on: www.spineuniverse.com/conditions/kyphosis/scheuermanns-kyphosis-scheuermanns-disease

Tribus C. Medscape Reference. Scheuermann Kyphosis. Available on: emedicine.medscape.com/article/1266349-overview#showall

http://cirrie.buffalo.edu/encyclopedia/en/article/125/

http://www.spine-health.com/conditions/spine-anatomy/lumbar-spine-anatomy-and-pain

http://emedicine.medscape.com/article/1899031-overview#a2

http://www.innerbody.com/anatomy/skeletal/thoracic-vertebrae-lateral

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 Mansfield JT, Bennett M. Scheuermann Disease. InStatPearls [Internet] 2019 Jan 17. StatPearls Publishing. Available from:https://www.ncbi.nlm.nih.gov/books/NBK499966/ (last accessed 20.4.2020)
  2. ↑ 2.0 2.1 2.2 Papagelopoulos PJ, Mavrogenis AF, Savvidou OD, Mitsiokapa EA, Themistocleous GG, Soucacos PN. Current concepts in Scheuermann's kyphosis. Orthopedics (Online). 2008;31(1):52.
  3. ↑ 3.0 3.1 3.2 Lowe TG, Line BG. Evidence based medicine: analysis of Scheuermann kyphosis. Spine. 2007 Sep 1;32(19):S115-9.
  4. ↑ 4.0 4.1 4.2 4.3 Weiss H, Turnbull D. Kyphosis (Physical and technical rehabilitation of patients with Scheuermann's disease and kyphosis). International encyclopedia of rehabilitation. 2010.
  5. ↑ 5.0 5.1 5.2 5.3 Soerensen KH. Scheuermann's juvenile kyphosis. Munksgaard; 1964.
  6. ↑ 6.0 6.1 6.2 Ristolainen L, Kettunen JA, Heliövaara M, Kujala UM, Heinonen A, Schlenzka D. Untreated Scheuermann’s disease: a 37-year follow-up study. European Spine Journal. 2012 May;21(5):819-24.
  7. ↑ 7.0 7.1 Bezalel T, Carmeli E, Been E, Kalichman L. Scheuermann's disease: current diagnosis and treatment approach. Journal of back and musculoskeletal rehabilitation. 2014 Jan 1;27(4):383-90.
  8. ↑ Ali RM, Green DW, Patel TC. Scheuermann's kyphosis. Current opinion in pediatrics. 1999 Feb 1;11(1):70-5.
  9. ↑ Poolman R, Been H, Ubags L. Clinical outcome and radiographic results after operative treatment of Scheuermann's disease. European Spine Journal. 2002 Dec;11(6):561-9.
  10. ↑ Lemire JJ, Mierau DR, Crawford CM, Dzus AK. Scheuermann's juvenile kyphosis. Journal of manipulative and physiological therapeutics. 1996 Mar 1;19(3):195-201.
  11. ↑ 11.0 11.1 Hart ES, Merlin G, Harisiades J, Grottkau BE. Scheuermann's thoracic kyphosis in the adolescent patient. Orthopaedic Nursing. 2010 Nov 1;29(6):365-71.
  12. ↑ 12.0 12.1 12.2 Advantage Physiotherapy SCHEUERMANN'S DISEASE Available from:https://www.advantagephysiotherapy.com/Injuries-Conditions/Upper-Back-and-Neck/Upper-Back-Issues/Scheuermann-s-Disease/a~5944/article.html (last accessed 20.4.2020)
  13. ↑ Weiss HR, Turnbull D, Bohr S. Brace treatment for patients with Scheuermann's disease-a review of the literature and first experiences with a new brace design. Scoliosis. 2009 Dec;4(1):1-7.
  14. ↑ Goodman CC, Fuller KS. Goodman and Fuller’s Pathology E-Book: Implications for the Physical Therapist. 3rd edition Elsevier Health Sciences; 2009.
  15. ↑ 15.0 15.1 Weiß HR, Dieckmann J, Gerner HJ. Outcome of in-patient rehabilitation in patients with M. Scheuermann evaluated by surface topography. Research into Spinal Deformities 3. 2002:246-9.
  16. ↑ 16.0 16.1 Weiß HR, Ddeckmann J, Gerner HJ. Effect of intensive rehabilitation on pain in patients with Scheuermann’s disease. InResearch into Spinal Deformities 3 2002 (pp. 254-257). IOS Press.
  17. ↑ 17.0 17.1 Ball JM, Cagle P, Johnson BE, Lucasey C, Lukert BP. Spinal extension exercises prevent natural progression of kyphosis. Osteoporosis International. 2009 Mar 1;20(3):481.
  18. ↑ 18.0 18.1 Montgomery SP, Erwin WE. Scheuermann's kyphosis--long-term results of Milwaukee braces treatment. Spine. 1981 Jan 1;6(1):5-8.
  19. ↑ 19.0 19.1 Zaina F, Atanasio S, Ferraro C, Fusco C, Negrini A, Romano M, Negrini S. Review of rehabilitation and orthopedic conservative approach to sagittal plane diseases during growth: hyperkyphosis, junctional kyphosis, and Scheuermann disease. Eur J Phys Rehabil Med. 2009 Dec 1;45(4):595-603.
  20. ↑ 20.0 20.1 Bezalel T, Kalichman L. Improvement of clinical and radiographical presentation of Scheuermann disease after Schroth therapy treatment. Journal of bodywork and movement therapies. 2015 Apr 1;19(2):232-7.
  21. ↑ Damborg F, Engell V, Andersen M, Kyvik KO, Thomsen K. Prevalence, concordance, and heritability of Scheuermann kyphosis based on a study of twins. JBJS. 2006 Oct 1;88(10):2133-6.
  22. ↑ Sturm PF, Dobson JC, Armstrong GW. The surgical management of Scheuermann's disease. Spine. 1993 May 1;18(6):685-91.
  23. ↑ Lowe TG. Scheuermann disease. JBJS. 1990 Jul 1;72(6):940-5.
  24. ↑ 24.0 24.1 Berdishevsky H. Outcome of intensive outpatient rehabilitation and bracing in an adult patient with Scheuermann’s disease evaluated by radiologic imaging—a case report. Scoliosis and spinal disorders. 2016 Oct;11(2):47-51.
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