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5 - Evidence-Based ISICO concepts in other spinal deformities5.1
Sagittal
plane deformities
5.1.1
Theoretical
basis of sagittal plane deformities treatment
Spinal
sagittal deformities
are posterior (kyphosis) or anterior (lordosis) pathological deviations,
irreducible to a variable extent, being caused by structural disco-legamentous
modifications and vertebral bones changes of different aetiologies12. Because these deviations occur
within the physiological curvatures of the spine, the latter can be excessively
increased (thoracic hyperkyphosis or round back, lumbar hyper-lordosis),
reduced (flat back, hollow back, hypo-lordosis, lumbar kyphosis) or modified in
their normal distribution (kyphosis of the thoraco-lumbar junction,
cervico-thoracic kyphosis)47,106 (Fig. 1). During
growth, we must distinguish between structured and functional hyperkyphosis,
the latter being of minor clinical importance, and entirely corrigible (round
back or postural hyperkyphosis). All adult kyphoses are structured, being
characterised by rigidity of the curve, which cannot be totally reverted. The
maturation of the spine is a process that causes, at the end of adolescence
(Risser stages 3 to 5) a progressive stiffening of kyphosis. With this normal
mechanism, a pathological but still functional curve can become a structured
hyperkyphosis47. In some cases, rigidity can also
be found in children, while on film vertebral bodies have normal size profiles
and show no sign of wedging or endplate irregularity. In this case, too, there
is a structured hyperkyphosis. Scheuermann’s
thoracic hyperkyphosis is the most frequent form of hyperkyphosis, having a mean estimated
incidence of 1%-8% in the population.76,182 This disorder is essentially caused
by smaller height growth in the anterior region of vertebral bodies
(wedge-shaped deformity) due to a transient histopathological modification of
fertile cartilages, with a consequent irregularity of endplate profile and an
inhibition of somato-vertebral growth correlating to secondary mechanical
factors.6,36,143 This deformity is often accompanied
by a thoracic backache related to movement and posture (mechanical thoracic
pain), which sometimes is the symptom that first brings the patient to the
physician.
Fig. 1. Spinal sagittal deformities occur within the physiological curves of the spine, that can be excessively increased (thoracic hyperkyphosis or round back, lumbar hyper-lordosis), reduced (flat back, hollow back, hypo-lordosis, lumbar kyphosis) or modified in their normal distribution (kyphosis of the thoraco-lumbar junction, cervico-thoracic kyphosis).47,106 Thoraco-lumbar
junctional kyphosis is
a so-called “long” kyphosis because it descends below T12, i.e., it also
includes L1 and L2 in the kyphotic tract (and sometimes other lumbar
vertebrae). It can have a postural origin: uscle hyposthenia and poor back
control drive the patient to “sit” on his/her back, with an inversion of
physiological lordosis in the upper part.47,106 Otherwise, it can be caused by an
osteochondrosis localisation at the cranial lumbar vertebrae (type II
Scheuermann’s disease). Kyphosis is pathological solely on the basis of its
positioning and the seriousness of somato-vertebral modifications, not for its
angular value, which is generally limited to a few degrees. This condition
predisposes the patient to backaches as soon as early adolescence and even more
in adulthood, given the degenerative nature of long-term outcomes. That is why
it must be treated regardless of the angular value. Lumbar
lordosis rarely
requires treatment. It is indeed a totally mobile spinal region, inserted
between two stiff tracts (sacral and thoracic kyphosis), that is shaped
according to postural needs due to fixed points: pelvic orientation and
horizontality of the eyes. Therefore, a hyper-lordosis in upright posture is
generally due to an increase of thoracic kyphosis and/or a pelvic antiversion. 5.1.2
Why
and when to treat sagittal plane deformities
According to these premises, our treatment choices include the following:47,106 - Observation, in the case of functional hyperkyphosis of a low degree, asking parents to require their children to practice postural control; - Exercise treatment, when we presume (because of its high degree) or have verified the impossibility of spontaneous correction of a functional kyphosis, in all cases of structured or junctional kyphosis that we think could be reverted without bracing (or we want to at least try because the spine is stiffening but is not too rigid yet), and if there is Scheuermann’s disease without a pathological curvature; - Bracing, only in the case of structured hyperkyphosis or junctional kyphosis that is no longer reversible through exercises because it is too rigid or because exercises have already proved insufficient; and in all cases of Scheuermann’s disease with pathological curvature. 5.1.3
Practical
application of sagittal plane deformities treatment
5.1.3.1 Patient’s evaluation The patient’s evaluation allows us to
achieve two essential goals: to adapt therapeutic modalities and evaluate
treatment results. The examination regards the body as a whole. Therefore, it
is necessary to have a global view of the subject, bare-chested, in any upright
posture; and in the frontal, lateral and back views. In the static
examination, we must highlight the following: feet equilibrium, lower limb
alignment, sagittal and frontal pelvic balance, hip asymmetry, the abdomen, the
spine as a whole, every possible morphological disharmony of the chest, and
finally the shoulders and bearing of the head. We measure sagittal posture through the
distances from the plumb line in order to highlight the different forms of
deviation and their magnitude (Fig. 2). We performed a study to compare various
sagittal surface methods of measurement,195 and today this classical one150 is not significantly exceeded by
any other. Regardless, in our opinion surface measurements are, in the case of
sagittal spinal disease, the most important ones. In fact, Cobb degrees on
radiographs are greatly impaired by the need for flexure of the shoulder so as
to let the spine be visible, and this is known to greatly change sagittal
posture. Radiographs are nevertheless very important because they allow us to
see the vertebrae and their deformation, but more generally for diagnostic
purposes than follow-up.
Fig. 2 – Measurement of sagittal distances from the plumb line at the level of C7 and L3, used to evaluate kyphosis and lordosis.150,195 The evaluation of joint mobility in
general and of the spine in particular, through axial auto-stretching, allows
us to highlight stiff regions within the curvatures. We should be particularly
careful during the evaluation of musculo-articular stiffness, particularly in
regard to the stretching of certain muscular groups (pectoral muscles, upper
recti, psoas, ischio-crural retraction) that have a negative influence on
sagittal curves. To complete the evaluation, we will proceed to
the analysis of the moving subject given that the observation of
coordination and balance can influence therapeutic choices. Equally important
is the need to record possible aggravating factors such as visual disorders,
excessive shyness, psychological disorders and so on, which can sometimes
require the intervention of an expert in such problems. 5.1.3.2 SEAS exercises for sagittal plane deformities Correction strategies through SEAS exercises are essentially
based on a first moment of identification and mobilisation of the stiff muscles
and regions, then on correct posture learning and stabilisation through
muscular strengthening and cortical control of the spine. Whatever the
hyperkyphosis aetiology, rehabilitation requires us to respect the following phases
17,21,90,103,132: - Becoming aware of the spine; - Becoming aware of the correct posture; - Mobilisation, stretching and breath training; - Muscular strengthening and neuromotor integration; - Ergonomy. SEAS exercises are not meant to
passively correct the spine but are mainly intended to create all facilitating
conditions, both musculo-skeletal (harmony of structures, with sufficient
elasticity of joints and muscles and muscular endurance) and neuro-motorial
(knowledge of the correct spatial positioning), so as to allow the patient
to reach and maintain a posture that is better than what was initially
presented. Because posture is a matter of anatomy, functional requirements,
psychological feelings, personal beliefs and self-knowledge, rehabilitation and
exercises work on nearly all these points (even if differently on each).
Nevertheless, achieving a “correct” sagittal posture is a personal task, but
without good facilitation it would often be impossible.
Fig. 3.
A - Endurance strengthening of paravertebral muscles.
Sitting with hands under the table who offers resistance: extend the spine.
B - Mobilisation of the spine in extension. On the
knees with the hands on the wall. Push up the hands and extend the spine
pushing the chest to the wall. To add a strengthening element, it’s possible to
ask the patient to detach the hands from the wall, without loosing the acquired
position. C - Endurance
strengthening of antigravity muscles. Sitting with an elastic band behind the
pelvis. Lengthen the band while extending the spine 5.1.3.3 Bracing for sagittal plane deformities Bracing is needed in the case of
hyperkyphosis with a stiffness that does not allow a good therapeutic outcome
on the basis of exercise alone. The “timing” of the start is decisive in
obtaining the final outcome:145 it is important not to arrive at an excessive
degree of stiffness that would endanger the achievement of an adequate
correction even if, in the first instance, it is nearly always better to
implement exercise treatment, which is less invasive and thus a preferable
first approach. In the case of sagittal plane deformities, brace therapeutic goal is a full
correction.106 If the patient shows an adequate compliance,
correction is complete for hyperkyphosis, very good for a thoracic
Scheuermann’s disease (mainly on the overall sagittal shape of the spine, and
much less on the deformity of the single metamers, which in part can recover)
and good to moderate for a kyphosis of the thoraco-lumbar junction. We apply the same principles of bracing that are proposed for
scoliosis, including: active brace; mechanical efficacy, versatility and
adaptability; teamwork; compliance; perfect body design and minimal visibility;
maximal freedom in the ADL (Activities of Daily Life); assumption of
responsibilities and cognitive-behavioural approach. The mechanical efficacy
of braces for hyperkyphosis is based on a direct push on the kyphosis
apex, which is the actual stiff zone to be corrected. Thrusts in other region
of the spine must be avoided so as not to cause an excessive straightening in
unaffected areas. The anterior thrust to the spine is obtained by directly acting
on the clavicles so as to have an effective posterior push of the spine, in a
place that is not highly sensitive and where dresses can succeed in masking the
brace. Conversely, we don’t use sternal pushes, which mostly cause a closure of
the shoulders that drives towards kyphosis. Neither do we use acromial pushes,
because they usually cause pain and excessively (and uselessly) limit the
mobility of the shoulders. Again, the active bracing principle as applied to scoliosis is
also totally effective in hyperkyphosis, even if it is slightly modified. We
teach the patient to escape from the clavicle pushes all day long in order to
learn a new posture, strengthen useful muscles and progressively mobilize the
rigid tract of the spine against the posterior apical push. This is much better
achieved through specific in-brace exercises, as well as through a
stabilizing one during the weaning period. 5.1.3.3.1 The Maguelone brace The Maquelone brace is a custom-made, two-valve TLSO with posterior
thoracic and sacral thrusts interconnected by three metal bars (Fig.
4) and one anterior plastic abdomen
moulded in hypolordosis and connected with two stiff metal clavicle pushes. The
name “Maguelone” is due to its origin from the kyphosis corrective principles
described by Perdriolle, but it has been developed by Sibilla147 et al. This brace is highly effective and very
dedicated to the most frequent pure thoracic hyperkyphosis with apex from T5-6
to T8-9. However, because its structure is not very versatile it should not be
used in other kyphoses, nor should it be used if there is an associated
important scoliosis.
Fig. 4. The Maguelone brace has been developed by Sibilla et al.147 from the kyphosis corrective principles described by Perdriolle 5.1.3.3.2
The
Lapadula-Sibilla brace
The Lapadula-Sibilla brace is a one-valve, custom-made plastic LSO with
a median frontal clasp that enwraps the chest from the submammary line to the
groin, and posteriorly from T5 to the buttocks
(Fig. 5). This brace, originally created for
lumbar and thoraco-lumbar scoliosis, is versatile and allows the control of all
situations in which kyphosis is not the typical thoracic one with a T8 apex.
This is because it can also protect the frontal and horizontal planes while
following the entire course of sagittal curvatures. Pushes are obtained through
pads that are properly moulded and positioned, in symmetrical or asymmetrical
ways, at the metameric level demanded by the specific clinical situation, as
well as the escapes, which are usually obtained through posteriorly openable
windows in the body of the brace. Maguelone clavicle pushes can be applied to
the Lapadula-Sibilla brace as well, but their use must be avoided in lumbar and
thoraco-lumbar diseases that involve a straightening of the upper thoracic
spine.
Fig. 5. The Lapadula-Sibilla brace for a thoracic hyperkyphosis with lumbar left scoliosis. 5.1.4
Results
sagittal plane deformities treatment
We performed a study140 in order to evaluate the efficacy
of a one-year rehabilitation treatment based on SEAS.02 exercises in 85
patients. The first group (48 patients) used the SEAS protocol and was compared
to classical exercises. According to what stated before, we did not use
radiographs but C7, T12 and L3 plumb line distances as outcome measures, and
they were considered changed when the difference exceeded 10 mm195. We found a statistically
significant variation (0.0001) only for C7 in the whole sample: in the SEAS
group we found a higher number of improved patients. In conclusion, exercises
are an effective treatment for hyperkyphosis. 5.2
Spondylolisthesis
5.2.1
Theoretical
basis of spondylolisthesis treatment
The term “spondylolisthesis” indicates the anterior subluxation
of a vertebral body on the lower one75,187,188 (Fig. 6). This phenomenon can occur at every
spinal level, but in most cases it involves the fifth lumbar vertebra that
moves anteriorly from the sacral base. Spondylolisthesis normally appears in
association with a pre-existing spondylolysis (solution of continuity at
isthmus level, i.e., the part of the vertebral arc comprised between the upper
and the lower joint apophyses).
Fig. 6. The term “spondylolisthesis” indicates the anterior subluxation of a vertebral body on the lower one. Its incidence has been estimated in 4%-6%75,161,162, with some variations (sometimes remarkable)
depending on race (Japanese 9%, Eskimo 27%).192 Interestingly, although defects in the pars
interarticularis are less common in girls than in boys, high grade shift is
four times more frequent in girls.75 The most known classification is
Wiltse’s,187,188 in which six types are described: - Type I, dysplastic or congenital: Congenital deficiency of facet joints - Type II, isthmic or spondylolytic: Pars interarticularis lesion with three subtypes: lytic fracture of the pars; elongated but intact pars; acute fracture of the pars - Type III, degenerative: Facets or intervertebral disc degeneration - Type IV, traumatic: Acute fracture in a vertebral area other than the pars - Type V, pathological: Pars or pedicle lesion caused by a general bone disease - Type VI, post-surgical: Ablation of vertebral support structures after a decompressive osteotomy The first two forms are characteristic of children: dysplasia normally
includes more severe forms, while the isthmical one is far more frequent.187,188 Taillard states that in children a
localisation at L5 constitutes 86% of cases, at L4 10% and at L3 4%.161,162 Exceptionally, cervical localisations have
been described at the C6 level. No olisthesis has ever been found at the
thoracic level. Repeated micro-traumas and growth have been connected to spondylolysis
and spondylolisthesis.8,75,126,185,186 Hyper-extensions, in which the caudal
margin of the L4 lower facet joint touches L5 pars interarticularis, are
considered causative traumas. This is confirmed by the higher incidence of
spondylolysis in those who participate in certain sports: female
gymnasts, football players and weightlifters.8 Spondylolysis is not reported in adults who
have never walked. Even growth plays a definite role: defects do not
appear in infants, reach a 4% prevalence at six years of age and equal adult
prevalence at fourteen years of age.75 The shift extent increases during the entire
growth, with a progression peak related to the pubertal growth spurt.
This progression generally stops or is minimised after skeletal maturity.75 Females have a higher risk of progression to a
higher shift grade. 5.2.2
Practical
application of spondylolisthesis treatment
5.2.2.1 Patient evaluation Lumbar pain is the main symptom of spondylolisthesis.7,8,55,75,133 Sciatica is less frequently recorded. It is generally accepted that a
certain number of spondylolistheses and an even higher number of spondylolyses
are asymptomatic. The lumbosacral pain caused by spondylolisthesis seems to be
correlated with an abnormal stimulation of posterior joints and ligaments. When
present, manifestations of radicular suffering are ascribable to root
compression or sprain within a conjugation channel that has been deformed and
narrowed by the anterior shift of the arc portion that is united with subluxed
vertebral body.173 At the first evaluation of a child, we always search for the
so-called “step sign” or “bar sign,” i.e., the abrupt
depression of spinous processes line, which is perceivable with the fingertips
at the shifted vertebra level. This sign has been proposed but never thoroughly
studied, though in our experience it has both false positive and negative
results. The finger-pressure searching for the previous sign usually causes an
elective pain increased by a hyperextension of the patient with the finger
positioned on L5 (Sibilla’s sign, which can be with or without
reaction). Spondylolysis diagnosis is radiographic75 and often perceivable in the classical views, even if oblique ones are
specific to study of the isthmus and apophyseal joints. To evaluate
spondylolisthesis, we need a lateral view of the patient in upright posture. We
must underline the criticality of radiographic centring at the lumbosacral
joint level, with a radiographic field that includes the lumbosacral area but
does not extend to the entire lumbar spine. Small variations can lead to a high
bias rate. To document a progression, a 10%-15% or 4-5 mm shift
variation is necessary.188 It is always important to analyse a possible vertebral instability
through dynamic radiographic exams. On latero-lateral
projections we can radiographically evaluate: - Shift grade; - The clear-cut reduction of intersomatic space; - Trapezoidal deformation of vertebral body. To measure vertebral shift we use a modified Taillard’s method161,162, tracing a perpendicular of the inferior endplate of the lysthesis
vertebra to the superior endplate of the lower vertebra. In this way, we split
in two the length of the lower vertebra endplate so as to identify a segment
(the posterior one) that expresses the shift value. The shift extent will be
expressed as a percentage on the basis of the following proportion: shift value: length of lower vertebral
endplate = X : 100. The measurement of shift extent, indicated as a
percentage, can be classified into four grades125,187,188, as follows: - Grade I: Equal to or less than 25%; - Grade II: 26% - 50%; - Grade III: 51% - 75%; - Grade IV: More than 75%. 5.2.2.2 Treatment of spondylolisthesis The shift extent, which correlates to symptom
duration and severity as well as to the significance of radiographically
detected morphological changes, will guide the therapeutic approach. Several
studies have documented the efficacy of spondylolisthesis conservative
treatment,7,8,55,128,133 particularly with regard to grade I and II shifts. All treatments in
the literature focus on symptoms, but we have developed a new approach to reduce
the extent of the shift itself in Grade I and II spondylolisthesis. There is
an expert consensus that says the greater the shift is the greater the problems
will be, mainly in adulthood. On this basis, a treatment that during growth
could stop shift progression, or even revert and reduce it if not eliminate the
spondylolisthesis, should be of high importance.
Fig. 7. Measurement of spondylolisthesis: grade I, II and IV (almost ptosis) examples. Sibilla first developed such a treatment, and then we improved it.113,123 This treatment is based on a modified Lapadula-Sibilla
brace (Fig. 8), that pushes on the lowest abdomen
and the sacrum while increasing the abdominal pressure. This way, we cause a
vector from anterior inferior to posterior superior to the listhesis vertebra
through the low abdomen thrust, while blocking the sacrum with a pad. Therefore
it is no longer a simple antilordotic brace, as initially proposed by Sibilla. Specific
exercises are extremely useful in order to eliminate pain,55,75,128,133,173 and can help prevent shift progression, being
effective alone when there is only a lysis or when spondylolisthesis is under
10%. Otherwise, the specific exercises work together with bracing. 5.2.3
Results
of spondylolisthesis treatment
A retrospective study113,123 that we preliminarily conducted confirms that
by using a TLSO brace and an exercise program for lumbar stabilisation it is
possible to block and reduce the shift extent in grade I and II
spondylolisthesis. We studied nineteen consecutively recruited subjects
(including six males) aged 13.5 years at the start of treatment and 16.8 at the
end, with 20.0 ± 5.6% (range 15-30) isthmic
spondylolisthesis.
Fig. 8. The Lapadula-Sibilla brace for spondylolisthesis pushes on the lowest abdomen and the sacrum, while increasing the abdominal pressure. This way, we cause a vector from anterior inferior to posterior superior to the listhesis vertebra through the low abdomen thrust, while blocking the sacrum with a pad. We used the full-time antilordotic Lapadula-Sibilla brace, progressively
reduced according to bone age, and stabilizing physical exercises twice a week.
Spondylolisthesis was reduced to 12.2 ± 8.4% according to radiographs after at least twelve hours without the
brace (up to six months). Only one case progressed (from 15% to 22%) and one
did not change, while nine improved by more than 50%, five by more than 90% and
three reached 0% (complete reduction). All patients at the end of treatment
were stable on dynamic radiographs. These results suggest the possible usefulness
of braces for spondylolisthesis in adolescents, even if a controlled study is
needed. We have recently confirmed these results in a case series of sixty-one
patients aged 12.5 years, and followed up for a maximum of thirty months
(seventeen cases), in which we had an average reduction of 5.2%.104
Fig.
9. Brace
treatment in growth period reduces spondylolisthesis on average, with complete
recovery in 17,5%.104 5.3
Adult
spinal deformities
5.3.1
Why,
when and how to treat adult scoliosis
The types
of treatments that can be applied in adult scoliosis are comparable to those of
the growth years, but they’re dependent on the actual deformity and disability
as well as the risks the patient would face. Excluding surgery, which
must always be considered an option in high-degree scoliosis and/or curvatures
that have progressed in adulthood, the possible treatments include: -
Observation: Due to the fact that all scoliosis
can progress in adulthood,3,45 over 20° of curvature at the end of
growth observation should be considered even if with a long time span (five
years), while this should be reduced and become regular over 30°. At the end of
treatment during growth, in our view even an important scoliosis over 45° in a
patient who does not want to be operated on should be only observed regularly
so as to guarantee a period of “wash out,” which is of high psychological
importance. Sports activities must always be proposed as a way to maintain
mobility, balance, strength, endurance and overall fitness while preventing
pain: all activities can be used, the only limitation being high-intensity
sports activities that increase the range of motion, and that could therefore
destabilize the spine.85,130 -
SEAS
stabilizing exercises:
Over 45° if the patient does not want to be operated on, and/or in cases of
proven progression, exercises should be prescribed as the primary means to stop
the evolution of the curve. These exercises are described later. -
Cognitive-behavioural
physical exercises approach to pain: The treatment of back pain in scoliosis, even
of a high degree, is not different from that in other patients.4,31,32,59,109 In the case of scoliosis, the risk
of chronic pain is increased,93 and according to what we know of
chronic back pain, the cognitive-behavioural approach gains high importance127 from the beginning. We must pay
attention to stabilizing the spine, though after recovering from pain and
regaining functioning the treatment should focus on scoliosis. This approach is
described later. -
SPoRT
(Sforzesco) bracing:
This can be applied only in the first years of adulthood (from skeletal
maturity to an age ranging from twenty-five to thirty-five) in cases of proven
progression of deformity, or in cases of high-degree curvature in patients not
well treated before who do not want to be operated on, or when there is
relevant subjective psychological impact of the aesthetic deformity. The
protocol includes bracing full-time for six months, then rapidly decreased and
weaned after twenty-four to thirty months. While bones are already formed,
ligaments are still not completely rigid, and the bone and muscular mass are to
be definitively acquired. In this period, the experience since the 1960s in
Lyon by Stagnara150 continued afterwards in Milan by
Sibilla144,145 have shown that aesthetic results
can always be achieved, with a balanced posture that, together with some degree
of rigidity due to the treatment, could prove to reduce the risk of progression
(studies are underway in this respect). -
Bracing
in the elderly: In
our minds, this should be avoided as much as possible because it is rarely
tolerated, while the efficacy is very low because there are no real mechanical
means to recover a fixed deformity in flexion like that usually seen in the
elderly. Obviously, these considerations relate to real bracing, not to
supports that sometimes achieve a small reduction in pain. 5.3.2
Adult
scoliosis
5.3.2.1 Theoretical basis Structural vertebral deformity is a vertebral
curvature involving loss of flexibility 62. Vertebral deformities that are most
frequently present in adults, namely scoliosis and hyperkyphosis, slowly and
insidiously evolve, involving both the anatomical structure of the curve
and the functional status of the patient. This worsening seems to be a postural
collapse that at first is not a real deformity, because it is not
structured. However, as time goes by the permanent asymmetric load tends to
modify the vertebral structure and can no longer be recovered. Curvature
development is accompanied in a linear way by an increase in chronic pain
and psychological suffering -- in the most serious cases even by a
reduction of cardio-pulmonary function.49,60,62,74 Among adults, the most disabling deformity of the spine is scoliosis,
that can be idiopathic, degenerative (“de novo” scoliosis) or idiopathic with a
superimposition of several degenerative changes 2. In addition to the concern for present
disabilities, there is also the awareness of the high probability of a
progressive and continuous worsening as time goes by. Furthermore, when the
major curve is at the lumbar and thoraco-lumbar levels, besides the worsening
of rotation and lateral curve there is the risk of a collapse into kyphosis
(which is extremely disabling) and/or of a lateral drop.52,57
Fig. 10. When the major curve is at a lumbar and thoraco-lumbar level, besides the worsening of rotation and lateral curve, there is the risk of a collapse into kyphosis (which is extremely disabling).52,57 In the literature we find a growing number of data confirming the
possibility that exercise alone can in some cases slow down the
development of the scoliotic curve, not only in the child but also in the
adult.62 The reduction of scoliotic curve certainly
does not indicate a reduction of deformity but a recovery of the postural
collapse, which is present in upright posture. From a study by Torell and
Nachemson, there is evidence that in adolescents, regardless of curve
magnitude, the mean difference between a standing radiography and a supine one
is 9° Cobb (Cap. 3 - Fig. 4).164 There are no data in the literature to
indicate precisely what this difference is (Duval-Beaupère called it “postural
collapse” – Cap. 3, Fig. 5)44 in adult scoliotic patients. Probably the
recovery of this collapse is the key to avoid any worsening of adult curves.
On the other hand, the functional, cosmetic and psycho-social damages caused by
scoliosis are directly proportional to curve magnitude,49 so an initial improvement, followed by
stability over time, must be considered a remarkable success in adult scoliosis
therapy. 5.3.2.2
Practical
application: SEAS in adults
5.3.2.2.1
Goals
of adult scoliosis treatment
The goals at the neuromotor and
biomechanical levels are the recovery of postural collapse, postural control
and vertebral stability. Another paragraph describes what to do in the case of
back pain. 5.3.2.2.2
Therapeutic
modalities
- Becoming aware of pathology consequences and recovery possibilities for postural collapse; - Muscular strengthening and vertebral stabilisation, always done in auto-correction, i.e., in the position of maximum postural collapse recovery (Fig. 11);
Fig. 11.
Recovery of postural collapse and antigravity muscles endurance strengthening.
A: the patient pushes hard against the table, heeping down his shoulders, to
recover postural collapse. B: the patient liftes his hands holding
auto-correction, with dumbbells and a weight on his head.. - Global improvement of patient’s function, even with a partial recovery of possible deficits in joint range of motion and of muscular retractions, if present; - Development of balance; - Postural integration, which includes the neuromotor integration of correct postures and an ergonomic education program; - Functional improvement, with aerobic and respiratory exercises in the case of cardio-pulmonary function reduction; - Cognitive-behavioural approach, even in the absence of pain. 5.3.2.2.3
Organisation
of the treatment plan
Therapy includes at least two
weekly exercise sessions lasting forty-five minutes each, that the patient
can freely do at home or at the Centre under the supervision of a qualified
technician. The exercise plan differs every three months. During the first
year of treatment we require greater diligence—on a daily basis in certain
cases—so as to obtain a more rapid recovery from postural collapse. 5.3.2.3 Scientific results ISICO is conducting a study on adult scoliotic patients. These patients
have had curvatures of more than 30° Cobb on the first radiography done after
the end of bone maturation. Preliminary data indicate that in the years
preceding our examination, during a mean observation period of 5.81 years,
scoliotic curves worsened by an average 0.84 degrees per year. These
data are higher than the ones presented in the literature on natural history
(yearly worsening 0.44°, with variations depending on initial severity and
curve localisation),170 but the sample is not
representative of the general scoliotic population since it includes only those
who have decided to be evaluated by ISICO physicians because they perceived a
worsening of their pathology, had cosmetic concerns or experienced back pain.
In a mean therapy period of 5.68 years, the improvement obtained
with SEAS exercises is 0.47 degrees per year. Particularly, there was a
high improvement in Cobb degrees during the first years of therapy, followed by
stability. As time goes by, this stability is very comforting and in striking
contrast with the relatively rapid worsening noticed on the radiographies done
during the years preceding therapy. Scoliotic curve reduction, obtained with
exercises following the SEAS protocol (in one case 15° in one year), in our
opinion certainly does not indicate a deformity reduction but a recovery of the
postural collapse in upright posture. 5.3.2.4 Clinical results We are perfectly aware that a
clinical case is not comparable to scientific data, but they anyway have the
benefit of the real life. 5.3.2.4.1 Anna G.: 24 years old when progressed Anna (Fig. 12) had been treated during growth with bracing with the final result in
May 2000 of a right thoracic T6-T12 curve of 28° and a left lumbar T12-L4 of
33°, reported in the Fig. 12
A. She was stable at 1 year follow-up (Fig. 12
B: T6-T12 26°, T12-L4 33°), but the 4 year follow-up did show a progression
(Fig. 12
C: T6-T12 26°, T12-L4 37°): in the meantime she had continued swimming, that
was her preferred sporting activity. Being results inside the possible
measurement error, it was only suggested to repeat the exam in one year, while
continuing normally activities of daily life. One year later, progression was
definite (Fig. 12
D: T6-T12 33°, T12-L4 42°), and even increased; clinically Anna appeared to
have a bad posture. SEAS exercises were started with the aim of avoiding
surgery, and in one year she recovered her posture, and according to
radiographs she was even better than at the end of bracing treatment (Fig. 12
E: T6-T12 28°, T12-L4 27°).
Fig. 12. Case history of Anna. In each radiograph month and year are represented, while Cobb degrees have been reported in the text. 5.3.2.4.2 Francesca F.: 41 years old when progressed Francesca (Fig. 13) had never been treated during growth and, because of pain and perceived
worsening of posture, she was radiographed in September 2004 (Fig. 13 A) and
discovered a left thoracic T2-T6 curve of 31° and a right lumbar T6-T12 of 27°.
She was then required to perform a specific technique of exercises: Postural
Reeducation according to Souchard. After 1 year (May 2005) there were no real
changes (Fig. 13
B: T2-T6 30°, T6-T12 of 25°) but, because she perceived herself worsened,
Francesca performed 9 months later new radiographs that demonstrated
progression (Fig. 13
C: February 2006 T2-T6 33°, T6-T12 of 32°). Suggested that there could have been some mistakes in that exam, she
repeated it with no real changes (Fig. 13
D: April 2006 T2-T6 33°, T6-T12 of 31°). She was proposed surgery, that she wanted to avoid. SEAS exercises were
then started with this aim, and in one year (March 2007) according to x-rays
exams she was even better than at start of her adult progression (Fig. 13
E T2-T6:27 T6-T11:23).
Fig. 13. Case history of Francesca. Month, year and Cobb degrees have been reported in the text. 5.3.3
Back
pain and adult scoliosis
The
literature on spinal pain and scoliosis in adults is fairly uniform: in
adult scoliotic subjects, researchers found that the incidence of lumbar pain
was similar to that of subjects without any vertebral deviation,70 while prevalence was higher.59-61,63 This pain seems to be more frequent
in women after pregnancy or after a period of spinal mechanical overload3, even if researchers did not find
any risk of debilitating low back pain in adult patients with untreated lumbar
scolioses. Moreover, there is a similar rate of surgery for lumbar pain in
patients, with and without scoliosis.93 Even if pain symptom is the main
cause of surgical-treatment requests for stabilisation purposes, its extent
cannot be connected with to magnitude of curvature.148 Instead, there is a
significant relationship between lumbar lordosis magnitude and pain: the
increase of pain and reduction in quality of life are indeed directly
proportional to the flattening of the lumbar curve.142 For this reason, in
the treatment of an adult patient with scoliosis and persistent lumbar pain,
one of our goals is to recover/maintain sagittal curves with particular
attention to the research of a good lumbar lordosis. Strength-endurance
training exercises toward extension of the spine, can be particularly useful.
In any case, the three-dimensional nature of scoliotic deviation requires that
we pay attention to the starting position, which should be chosen after doing
several tests to find the one most appropriate for the patient (Fig. 14).
Fig. 14 – Example of extension exercise Correcting
the lateral or rotational misalignments by putting small shims under the pelvis
allow us to identify the least painful position (Fig. 15).
Fig. 15 – Example of a support for the starting position Like all subjects who report chronic pain, the scoliotic patient also tends to develop a progressive fear-avoidance behaviour, i.e., a growing reduction of his/her activities for the sake of avoiding pain. In the acute phase, this fear-avoidance behaviour, like rest, claudication or stick usage, has a protective effect against pain thanks to the reduced stress on the recovering structure. Consequently, this behaviour can persist in order to
avoid pain, but can cause a progressive "disuse syndrome”.11 For that reason the
treatment schedule for a patient who experiences chronic pain must be organised
from the cognitive-behavioural perspective (Fig. 16).
Fig. 16. A representation of some of the vicious cycles who lead to the development and then maintain chronic low back pain. Fear avoidance behaviours and progressive "disuse syndrome”11 must be confronted in a cognitive-behavioural perspective.
Learning in order to change can be
considered the treatment slogan that will have the following main goals: - Clear the patient from wrong beliefs; - Let him/her give up fear avoidance behaviors; - Eradicate behaviours that increase risks; - Seek good physical fitness. One of the main weapons is an effective educational program ideated in such a way that it offers the patient every clarification useful for understanding his/her own problem. This is because the patient should be aware of the real extent of his/her problem and should not overestimate it, which often occurs when information is misinterpreted. We will stimulate thoughts about what endures and what, on the contrary, allows us to manage pain, underscoring how a different approach can have a decisive influence on pain perception and the status of disability it can achieve. We will pay considerable attention to avoiding the development of a “catastophisation” attitude, meaning the perception of pain as an extremely threatening element that will have irreparable consequences on one’s future life. Because catastrophisation is influenced by patient-therapist interaction, the way that messages are transmitted is a fundamental element for goal achievement. Cognitive-behavioural approach will be particularly
effective if some realistic goals are established before treatment
begins, and if auto-monitoring techniques are used in order to clear the
patient from preconceived ideas and allow him/her to reach an awareness of
his/her wrong behaviours and thus document his/her improvements. We will emphasize self-treatment and personal
management in order to ensure the conscientious involvement of the patient,
who must become the main "actor" in the recovery process.
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