Ebook: The Conservative Scoliosis Treatment

This is the first of a series of Instructional Course Lectures (ICL) Books of the International Society On Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT). In the contents of this book the reader can find the SOSORT STATUTES and become familiar with the aims of the creation of this society. This will hopefully be the initiation of a series of books on conservative scoliosis treatment and a valuable library for SOSORT. The philosophy of the commencement of such ICL book series is the achievements of an ultimate aim, the improvement of early detection and non operative treatment of the patient care pathway for scoliosis.

For this endeavor, a number of eminent clinicians and scientists around the world, who are devoted and high-quality “students” of scoliosis, are involved and contributing with their fabulous work.

There is no doubt that this book is not able to cover every aspect of the issue. However, the future volumes of this series of books will continuously complete the latest relevant knowledge.

In this volume there are chapters reporting on various aspects of the current state of the following topics: IS aetiology, recent trends on scoliosis research, genetics, prevention-school screening, various methods of physiotherapy, various types of braces, the inclusion criteria for conservative treatment, together with the SOSORT guidelines for conservative treatment, clinical evaluation and classification, study of the surface after brace application and outcomes for each brace.

Our belief is that doctors dealing with spinal deformities and in particular with scoliosis, ought to be efficient in treating the disease from “A–Z”, that is, to be familiar with all the existing therapeutic strategies.

We hope that the book, by its distribution to the attendees of the 5th International Conference on Conservative Management of Spinal Deformities at the Eugenidou Foundation, April 3–5 2008, Athens, Greece, will be disseminated around the world. Thus the important idea of proper conservative treatment of scoliosis will re-emerge, which in the past decades has been somewhat overlooked in favor of surgery, which is anyway necessary when indicated.

We would like to express our deep appreciation to all the authors and co-authors for spending their valuable time in order to share with us their profound knowledge on the issue. We would also like to express our gratitude to IOS Press publishers for making our dream a reality.

Dr Theodoros B. GRIVAS, MD, 23 September 2007, Athens, Greece

There is no generally accepted scientific theory for the causes of adolescent idiopathic scoliosis (AIS). Encouraging advances thought to be related to AIS pathogenesis have recently been made in several fields including anthropometry of bone growth, bone mass, spinal growth modulation, extra-spinal left-right skeletal length asymmetries and disproportions, magnetic resonance imaging of vertebral column, spinal cord, brain, skull, and molecular pathogenesis. These advances are leading to the evaluation of new treatments including attempts at minimally invasive surgery on the spine and peri-apical ribs. Several concepts of AIS are outlined indicating their clinical applications but not their research potential. The concepts, by derivation morphological, molecular and mathematical, are addressed in 15 sections: 1) initiating and progressive factors; 2) relative anterior spinal overgrowth; 3) dorsal shear forces that create axial rotational instability; 4) rotational preconstraint; 5) uncoupled, or asynchronous, spinal neuro-osseous growth; 6) brain, nervous system and skull; 7) a novel neuro-osseous escalator concept based on a putative abnormality of two normal polarized processes namely, a) increasing skeletal dimensions, and b) the CNS body schema – both contained within a neuro-osseous timing of maturation (NOTOM) concept; 8) transverse plane pelvic rotation, skeletal asymmetries and developmental theory; 9) thoraco-spinal concept; 10) origin in contracture at the hips; 11) osteopenia; 12) melatonin deficiency; 13) systemic melatonin-signaling pathway dysfunction; 14) platelet calmodulin dysfunction; and 15) biomechanical spinal growth modulation. From these concepts, a collective model for AIS pathogenesis is formulated. The central concept of this model includes the body schema of the neural systems, widely-studied in adults, that control normal posture and coordinated movements with frames of reference in the posterior parietal cortex. The escalator concept has implications for the normal development of upright posture, and the evolution in humans of neural control, the trunk and unique bipedal gait.

At growing ages, the progression of the idiopathic scoliosis with a curve under 25° outlines many features related to the chaos theory. The image of the scoliosis calls to mind the “strange attractors” of the chaotic spine. We describe the 7 main characteristics of the dynamical scoliotic system classified as chaotic. It is an open set system, unpredictable, multi-factorial complex, discontinuous with thresholds that you can model, and it is an inter-phase between childhood and adult time. The chaotic model enables us to understand more the progression of the idiopathic scoliosis. It positively modifies the speech with the patient and its family as well as the therapeutic treatment.

A cure to prevent scoliosis from developing does not seem to be available in the near future. Primarily this is because of a lack of understanding of the aetiology of this devastating disease or cosmetic deformity. While extensive research has been performed in this area over the past 100 years many experiments have been poorly designed because they have been developed on the premise that patients with AIS all have the same, single underlying cause despite much evidence to the contrary. Consequently, much of the data in the literature can be challenged and perhaps explains the lack of significant progress. Certainly, the results from this previous research suggest strongly that a new approach needs to be adopted or the same confusing results will continue to be collected and little progress will be made. There are certain areas of research that hold the greatest potential for success in finding a cure. These are identified in this paper and included in a theoretical research laboratory. It is suggested that this laboratory need not be theoretical if modern, cheap communication systems were readily adopted throughout the world and if people were willing to share ideas readily and contact each other regularly. In perhaps an unconventional way, the emphasis of this paper is on finding a cure to prevent scoliosis from developing and uses the area of research into the aetiology of scoliosis as the platform for discussion.

It is unclear why some children with a small magnitude scoliosis at the onset of the adolescent growth spurt develop a progressive curve. Normally the skeleton grows symmetrically, presumably because genetic and epigenetic factors regulating growth to maintain growth symmetry despite activities and environmental factors causing asymmetrical loading of the spine. This chapter reviews the recently published data relating to the notion that progression of scoliosis is a result of biomechanical factors modulating spinal growth (‘vicious cycle’ theory). Quantitative data exist for the key variables in an analysis of scoliosis curve progression. In a predictive model of the evolution of scoliosis simulating the ‘vicious cycle’ theory, and using these published data, a small lateral curvature of the spine can produce asymmetrical spinal loading that causes asymmetrical growth and a self-perpetuating progressive deformity during skeletal growth. This can occur if the neuromuscular control of muscle activation is directed at minimizing the muscular stress (force per unit cross section), although other activation strategies may produce differing spinal growth patterns. Mechanical modulation of vertebral growth is a significant contributor to the progression of an established scoliosis deformity. Quantitative simulation of this mechanism demonstrates how therapeutic interventions to alter neuromuscular control of trunk muscles or otherwise modify spinal loading may alter the natural history of progression.

The aim of school screening is to identify most or all the individuals with unrecognized idiopathic scoliosis (IS) at an early stage when a less invasive treatment is more effective. However like other medical screening programs it has not escaped controversy about its value. The present study summarises the contribution of school screening in research of IS epidemiology, natural history and aetiology. Such contribution is beyond the original aim of school screening but is very important to expand our knowledge and adequately understand the pathogenesis of IS. The role of biological factors such as the menarche, the lateralization of the brain, the handedness, the thoracic cage, the intervertebral disc, the melatonin secretion, as well as the role of environmental factors such as the light and the impact of the geographical latitude in IS prevalence were studied in children referred from school screening. The present study provides evidence to support that school screening programs should be continued not only for early detection of IS but also as a basis for epidemiological surveys until we learn much more about the aetiology of IS.

Understanding the cause of a disease or disorder is key to developing effective and humane strategies for early intervention and treatment. School screening programs have made it possible to demonstrate the high prevalence of childhood scoliosis, worldwide, and to reliably identify spinal curvatures early in the disease process before progression to a fixed structural deformity. Unfortunately, effective early interventions have not been established. Developing strategies to prevent scoliosis has been compromised, in general, by lack of understanding of its causes on a case by case basis. Information about genetic loci associated with disorders including scoliosis is emerging rapidly, since completion of the human genome sequence in 2003. These data can be used to identify children at high risk for developing spinal deformities and to design strategies for prevention.

The value of school screening for idiopathic scoliosis (IS) has been questioned recently, because of its high false positive referrals and its excessive cost, although in areas where screening programs exist, fewer patients ultimately require surgery for IS. In a typical school screening setting there are numerous factors which can determine the effectiveness. The present study identifies some of these factors and provides evidence based recommendations for the improvement of school screening effectiveness. After reviewing all the research papers which originated from the Thriasio school screening program and published in peer-review journals, specific suggestions for the organization, the optimal age of screening according to the geographical latitude, the best examined position, the standardization of referrals, the follow up of younger referrals with trunk asymmetry and the reduction of the financial cost are made. We strongly suggest the introduction of these recommendations to all the existing school screening programs in order to improve their effectiveness and to reduce the negative impact they may have on families and on the health system.

The clinical evaluation, even today, remains a central point in the diagnosis, prognostic definition and treatment prescription regarding scoliosis. The clinical evaluation of a scoliotic patient has been established for a long time, but it has not been standardized. The aim of the present work is to report the most common clinical measures for the assessment of scoliosis, explain the usefulness of each clinical measurement, and report the repeatability and limits in order to help the physician in making appropriate clinical choices.

Methods. The height of the hump, the angle of trunk rotation, the sagittal and frontal profiles, and the Trunk Aesthetic Clinical Evaluation (TRACE) have been fully described, and their reliability and repeatability have been assessed.

Results. The measures analyzed showed good reliability and repeatability on the intra-operator basis. The inter-operator repeatability is usually not that good.

Conclusion. The main measures of the clinical assessment of scoliotic patients have been tested, and their reliability has been evaluated. The knowledge of measurement error, as well as intra- and inter-operator reliability, are essential for the clinical evaluation and treatment of scoliosis. This is an unavoidable basis for decision making in the assessment and the treatment of scoliosis.

The third-dimension of scoliosis represent a great challenge for clinicians used to think in two dimensions due to the classical radiographic representation of the deformity. This caused problems in everyday clinical approaches, and led to the development of new bidimensional classifications (King, Lenke) who tried in different ways to face these problems, mainly in a surgical perspective. Recently, some three-dimensional classifications have been proposed, all developed in laboratory by bioengineers. In this paper we present the existing classifications of scoliosis, both bi-dimensional and three-dimensional and we thoroughly discuss the 3-DEMO (3-D Easy Morphological) that has been first presented years ago, and recently thoroughly published; this classification has been developed by clinicians with the main aim of being understandable and easily applicable to everyday clinical life.

The efficacy of brace or conservative treatment in adolescent idiopathic scoliosis is controversial due to variations in inclusion and assessment criteria. This makes the interpretation of brace studies and their comparisons difficult. The Scoliosis Research Society recently introduced new standardized inclusion and assessment criteria for future brace studies. The inclusion criteria include: age 10 years or older at initiation of bracing, Risser sign 0–2, primary curve magnitude 25 to 40 degrees, no prior treatment, and females either premenarche or less than one year post-menarche. The assessment criteria include: percentage of patients with ≤5 degree curve progression and percentage of patients with ≥6 degree curve progression at skeletal maturity, percentage of patients who had surgery or recommended before skeletal maturity, percentage of patients with curves exceeding 45 degrees at maturity, and a minimum of 2 years follow-up beyond skeletal maturity for those patients felt to have been successfully treated. All patients treated irregardless of compliance are to be included in the results (intent to treat).The use of these criteria should assist in the determination of the effectiveness of brace treatment, as well as accurate comparison between patient groups and different braces.

This guideline has been discussed by the SOSORT guideline committee prior to the SOSORT consensus meeting in Milan, January 2005 and published in its first version on the SOSORT homepage: http://www.sosort.org/meetings.php [1]. After the meeting it again has been discussed by the members of the SOSORT guideline committee to establish the final 2005 version submitted to Scoliosis, the official Journal of the society, in December 2005. This chapter is a republication from the original paper published in “Scoliosis” BioMed journal and it is included in this book due to its high importance.

Different methods of physiotherapy are applied in scoliosis management and different opinions exist about the efficacy of conservative scoliosis treatment. Because this divergence of opinions corresponds to a great variety of standards applied, it is not surprising that also the results of conservative treatment greatly differ. Scoliosis normally does not have such dramatic effects that immediate surgery would be indicated. Moreover it is clear that functional and physiological impairments of scoliosis patients–including pain, torso deformity, psychological disturbance and pulmonary dysfunction–require therapeutic intervention.

The triad of out-patient physiotherapy, intensive in-patient rehabilitation (SIR) and bracing has proven effective in conservative scoliosis treatment in central Europe. Indication, content and results of physiotherapy are described and discussed in this paper. The differential indication of methods of physiotherapy assigned to current “Best Practice” is documented here as well.

The positive outcome of current “Best Practice” conservative management validates a policy of offering conservative treatment as an alternative to scoliosis patients, including those for whom surgery is discussed.

SEAS is an acronym for “Scientific Exercises Approach to Scoliosis”. Main characteristics of SEAS are team approach and cognitive-behavioural approach because in our view these are two indispensable elements in chronic disease rehabilitation. In this article we describe the main differences between SEAS approach and other exercise techniques as well as theoretical bases and therapeutic goals. We illustrate practical application of SEAS concept and scientific results in order to reduce the patient's progress of scoliosis so that a brace would be needed. When compared to usual care, improvement of scoliosis parameters and balance normalization in scoliosis patients.

Conservative management of idiopathic scoliosis (IS) and other spinal deformities is a real alternative to surgical treatment. Most of adolescent with IS can be managed conservatively with high safety. Many infantile and juvenile cases show also a good immediate response to conservative care, which can be considered a sign of good prognosis. Only patients showing a continue deterioration even treated conservatively with efficient techniques should be considered candidates to surgical correction and stabilization. Rehabilitation (including specific exercises) and bracing are usually involved in conservative care of IS. In this paper we describe our personal approach in conservative scoliosis care regarding rehabilitation. Bracing has been described in a different paper also published in the present book. Specific exercises can change the signs and symptoms in scoliosis patients. Specialists in physiotherapy for spinal deformities teach the patient how to perform a routine of ‘curve pattern’ specific exercises with the purpose to facilitate the correction of the asymmetric posture and to teach the patient to maintain the corrected posture in daily activities. Principles of correction are based on those developed by the German physiotherapist K. Schroth.

The method developed since 1979, comprises active 3-dimensional auto-correction, concerning the primary curve mobilization towards the correction of the curvature, with special emphasis on the kyphotization of the thoracic spine, carried on in closed kinematic chains, and developed on a symmetrically positioned pelvis and shoulder girdle, followed by active stabilization of the corrected position, and endured as postural habit. The positions for exercising and the movements involved are described in details. Small, moderate and important curves can be managed with DoboMed, however the effectiveness of the therapy depends on the curve flexibility and patient's compliance. DoboMed has been used as a single therapy or together with bracing, as well as preparation for scoliosis surgery. The published results demonstrated that the DoboMed has a positive influence on inhibition of the curve progression in idiopathic scoliosis, the improvement of respiratory functions, assessed by the spirometric values, and the general exercise efficiency evaluated using ergospirometry.

The paper presents the review of pathological changes which develop within the respiratory system in patients with structural progressive idiopathic scoliosis. The impairment of the function of the respiratory system is one of the principal impact of idiopathic scoliosis on the general health and function, as well as on the quality of life. Although the fatal outcomes of respiratory failure are usually prevented by a successful conservative treatment or by the spinal surgery, the reduction of the volume of the thorax, the restriction of the thorax, as well as decreased efficacy of the respiratory muscles are still a major issue (problem) for many patients with structural scoliosis that may lead to respiratory insufficiency or failure. The papers presents main functional tests to assess the respiratory impairment and the basic rules for interpretation of the results of the examination.

We use side-shift exercise and hitch exercise for the treatment of idiopathic scoliosis. Outcomes of side-shift exercise used for the curves after skeletal maturity or used in combination with part-time brace wearing treatment are better than the natural history. Side-shift exercise and hitch exercise are useful treatment option for idiopathic scoliosis.