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5. Pulmonary function testing is useful in the preoperative evaluation of patients.^[2]
Spirometer

• FVC gives an assessment of lung volume
• FEV1 provides an assessment of flow function.

Medical Management

Patients with early-onset scoliosis, defined as a lateral curvature of the spine under the age of 10 years, are offered surgical treatment when the major curvature remains progressive despite conservative treatment (Cobb angle 50 degrees or more). Spinal fusion is not recommended in this age group, as it prevents spinal growth and pulmonary development.^[16]

Conservative treatment

With regard to conservative treatment of patients with congenital scoliosis, it should be noted that there are limited data available in the literature. A review concluded that patients with specific types of segmentation failures, like unilateral unsegmented bars, will not benefit from conservative treatment, while the same applies to formation failures with curves of > 20 degrees in infancy. Nevertheless, there are reports that a conservative approach might be beneficial in mild cases with formation failures in the first three years of life. Furthermore, the review concluded that in patients with formation failures further investigation is needed to document where a conservative approach (bracing treatment) would be necessary. In general, most congenital scoliotic curves are not flexible and therefore are resistant to repair with bracing. For this reason, the use of braces mainly aims to prevent the progression of secondary curves that develop above and below the congenital curve, causing imbalance. In these cases, they may be applied until skeletal maturity^[17].

Surgical treatment

Spinal surgery in patients with congenital scoliosis is regarded as a safe procedure and many authors claim that surgery should be performed as early as possible to prevent the development of severe local deformities and secondary structural deformities that would require more extensive fusion later. Mostly it is done during adolescence, but newer techniques allow good correction to be accomplished into early adulthood. The goals for surgical treatment are to prevent progression and to improve spinal alignment and balance. The hips and shoulders should be level, and the head over the sacrum while maintaining sagittal alignment. The spine is corrected with a combination of rods, hooks, screws and wires while being fused by bone graft – either from the patient, a cadaver or artificially. On the other hand, early and late complications are also described in literature, concerning not only intraoperative and immediate postoperative problems, but also the safety and efficacy of the spinal instrumentation and the possibility of developing neurological disorders and the long-term effect these may have on both lung function and the quality of life. A review (2011) concluded that patients with segmentation failures should be treated surgically early, according to the rate of deformity formation and certainly before the pubertal growth spurt to try to avoid cor-pulmonale, even though there is lack of evidence for that in the long-term^[17]. A magnetically controlled growing rod (MCGR) is a nobel technology that enables non-invasive spinal lengthening in an awake patient in an out-patient setting. The indications for MCGR are identical to those of traditional growing rods, but MCGR has advantages of obviating the need for repeated surgical distractions.^[16]

Physical Therapy Management

Physical therapy and bracing are used to treat milder forms of scoliosis to maintain cosmesis and avoid surgery.^[8] Scoliosis is not just a lateral curvature of the spine, it’s a three dimensional condition. To manage scoliosis, we need to work in three planes: the sagittal, frontal and transverse. Different methods have already been studied.^[17]

The conservative therapy consists of: physical exercises, bracing, manipulation, electrical stimulation and insoles. There is still discussion about the fact that conservative therapy is effective or not. Some therapists follow the ‘wait and see’ method. This means that at one moment; the Cobb degree threshold will be achieved. Then, the only possibility is a spinal surgery.^[18]

The physical therapist has three important tasks: to inform, advice and instruct. For the treatment of scoliosis, it’s not only important to do the correct exercises but the physical therapist also needs to inform the patient &/or parents about his/her situation. An educational program makes sure that the therapy accuracy from the patient improves. Some physical therapists recommend a brace to prevent the worsening of the scoliosis. An often used brace is the Milwaukee brace. Nevertheless the evidence for bracing is controversial. Maruyama T., Nakao Y. and Takeshita T. studied the effect of bracing in a review (2011). They compared brace treatment with no-treatment, other conservative treatments or surgery. The analyzed outcome measures were the radiological progression of the curve, surgery and quality of life. Results demonstrate that brace treatment is better than no-treatment (observation) or electrical stimulation. There is also no negative influence on the quality of life of patients with an idiopathic scoliosis. We can conclude that bracing is recommended as a treatment for female patients with a Cobb angle of 25-35°. The evidence level of some studies in the review was limited, so further research is necessary.^[19] In the literature there is evidence that exercises have beneficial effects on patients with idiopathic scoliosis.^[20] 

Physiotherapists may also address biopsychosocial factors. Adolescents who are presenting with idiopathic scoliosis and chronic low back pain symptoms may also have other factors such as insomnia, depression, anxiety and stress, and daytime sleepiness that need to be assessed and addressed as contributing factors to a chronic low back pain experience.^[7]

Aims

The aims of the physical therapy consist of: ^[21][20]

• Autocorrection 3D
• Coordination
• Equilibrium
• Ergonomical corrections
• Muscular endurance/ strength
• Neuromotor control of the spine
• Increase of ROM
• Respiratory capacity/ education
• Side-shift
• Stabilisation

Exercises

An important one is the conservative three-dimensional Schroth method consisting of curve-specific exercises and corrective breathing techniques. The purpose of these exercises is to derotate, deflex and to correct the spine in the sagittal plane while elongating the spine.^[17]

The elevation of both arms leads to an increase of the flatback deformity.

Patient with right thoracic scoliosis (functional 3-curve pattern as seen on the left) performing the ‘Door handle exercise’ according to the new ‘Power Schroth’ principles (right). The corrected head alignment is not yet achieved but correction of the sagittal profile is already visible.

Patient with right thoracic scoliosis (functional 3-curve pattern as seen on the left) performing the exercise ‘Frog at the pond’ according to the new ‘Power Schroth’ principles (right). The corrected head alignment is not yet achieved but correction of the sagittal profile is already visible.

The patient needs to be focused about re-establishing spinal symmetry. The key to a successful therapy is to work consistently to correct the spine. Another difficult part of the therapy is to learn to shorten the muscles on the convex side of the spine and lengthen the muscles on the concave side of the side. This is because the muscles become imbalanced on opposite sides.^[22] The exercise position approaches the functional/structural threshold. Schroth therapy takes advantage of the overcorrected positions. Basic corrections are reviewed by using mirrors in front and at the back of the patient. This posture requires concentration and coordination, applying the correct breathing, and well-adapted muscle length and tension.^[18]

There are also other exercises that have been found effective. Scientific Exercises Approach to Scoliosis (SEAS) exercises is for example been found effective in reducing the rate of progression of scoliosis compared with usual care and help to avoid brace prescription. Evidence also supports that SEAS is found to be effective in reducing spinal deformities compared with control groups.^{[20] [23][24]} The SEAS exercises are, according to the Italian Scientific Spine Institute (ISICO), based on a specific form of Active Self-correction (ASC), that is taught individually to each single patient. This is to achieve the maximum possible correction. ASC is then associated with stabilizing exercises that include neuromotor control, proprioceptive training and balance. The exercises are also incorporated into their daily living activities. SEAS approach does also involve the parents. They are getting together with the patient a cognitive-behavioral approach to maximize compliance to treatment.^[20][21]
The severity of the curvature can cause a pressure on airways and lungs. The patient can experience trouble while breathing. Therefore the therapist must involve [19] Solache-Carranco and M.G. Sánchez-Bringas (2011) studied the effectiveness of a respiratory rehabilitation program in children with scoliosis. The techniques that they used are:

• Respiratory education techniques (abdominal-diaphragmatic ventilation, thoracic mobilisation, ventilation at rest and during activities of daily living) for mobilisation and prevention of stiffness of chest and skeletal muscles.
• Postural drainage and vibration to evacuate mucus and decrease the resistance of the airways.
• Relaxation techniques to make sure that the patients would have better control of respiration (to counteract dyspnea).

They found that the respiratory rehabilitation had a positive effect on increasing pulmonary function of children with scoliosis.^[21]
Anwer et al. reported in a systematic review (2015) that evidence, of moderate-quality, suggest that an exercise program is superior to the control intervention. They reported a reduction in the following outcome measures: Cobb angle, angle of trunk rotation, thoracic kyphosis angle and lumber lordosis angle and improving the quality of life in patients with AIS. Evidence of lower quality, low-quality, suggested that an exercise program is superior to controls in reducing average lateral deviation in patients with AIS.^[3]

Management of non–structural scoliosis^[20]

Pilates: This intervention was divided in three parts:

1. Preparation (warm up + stretch)
Warm-up consisted of eight minutes walking on a treadmill or an elliptical machine. After the warm-up each patient had to do some stretching exercises:

Spine forward stretching:

The patient sits on the floor with a straight back and the legs stretched. The patient has to bring the trunk forwards. Goal: Stretching the posterior muscle chain and mobilizing the vertebral spine

Upper rolling:

The patient lies supine with the arms besides the body. The patient has to raise both legs till the toes touches the floor. Then, unroll spine slowly (vertebra by vertebra) Goal: stretching the posterior chain, mobilizing the spine and strengthen the abdomen.

Child position:

The patient sits in a four support position and has to stretch the spine, arms and push the hands against the floor. Then lower the spine. Goal: Stretching the thoracic paravertebral, lumbar and gluteal regions and mobilizing the vertebral spine

Forward leg pull

The patient sits in a four support position. Then raises the right arm and leg while the spine stays aligned. Than the same exercise but change arm and leg. Goal: Stretching the concavity of the vertebral spine.

2. Specific exercises: For these exercise Swiss balls, FlexBall Quarks are used. It’s important that the patients learn to breath right during exercise.

Hip movements with a large ball (65 cm diameter). Goal: Strengthening the gluteal muscles and developing the equilibrium.

Inverted abdominal skills with a ball (55 cm diameter). Goal: Strengthening the infraabdominal region and the ischiotibial muscles.

Rising into a seated position. Goal: Strengthening the M. rectus abdominis.

Lateral spine movement on a step chair with a spring of 0.1410 kg positioned in the rings to provide major resistance. Goal: Stretching the lateral muscle chain according to the direction of convexity of the scoliosis.

Lateral spine movement. Goal: Stretching the lateral muscle chain according to the direction of convexity of the scoliosis.

Flexibility on the step chair with a spring of 0,1410 kg positioned in the rings to provide major resistance. Goal: Mobilize the spine and stretch the paravertebral thorax and lumbar muscles.

3. Returning to a relaxed position (relaxation) :It consist of three movements, the patient has to repeat each exercise three times for five minutes. All exercises has to be performed rapidly. The purpose of these exercises are metabolic recovery and relaxation of the used muscles.

Prognosis

Surgery

The outcome needs to be age matched since the demands of daily life, professional performance, and leisure activities vary substantially in the different age groups. Most of the patients who are still professionally active do not return to their previous work if it was a physically demanding job, but almost all of those had already stopped working before the surgery, because of pain limitations. When analyzed, regarding their overall daily activity by different questionnaires, most of these patients irrespective of age have improved in almost all categories. Quality of life, and the use of regular pain medication is reduced substantially in more than 70% of these patients.^[23] However for the elderly the outcome is less positive because of the age. The major problem of these patients after surgery, once surgical complications and implant failures have not occurred, is the residual back pain mostly as an expression of muscular spasms and pain due to unbalanced or chronic contractures of the paravertebral muscles.^[24]

Bracing

Whether brace treatment for scoliosis is successful is often described using the curve progression of more than 5° before skeletal maturity as a benchmark for bracing failure rather than spine surgery.^[21] Some use 10° of curve progression or preventing the curve from reaching 45° at skeletal maturity. The outcome data should be determined from the percentage of patients with less than 5° or greater than 6° of progression at maturity, curves exceeding 45° at maturity, and progression resulting in the recommendation for surgery. Bracing studies should have a minimum of 2 years follow up beyond skeletal maturity. The first study to use these criteria determined a brace should prevent progression in 70% of patients to be considered effective. Regardless of the recommended standardized parameters, the goal of bracing idiopathic curves remains consistent: control the curve, prevent progression, and avoid surgical intervention.^[19]

Clinical Bottom Line

In conclusion it’s important to make a good diagnosis about the kind of scoliosis and the cause of the scoliosis. Management interventions should be weighed with the choices and complaints of the patient and the kind of scoliosis the patient is suffering from. It’s important to note that not all patients with scoliosis are actually suffering from this spine deformation. Every patient is different and deserves attention to deploy the appropriate treatment.

References

1. ↑ Burnei G, Gavriliu S, Vlad C, Georgescu I, Ghita RA, Dughilă C, Japie EM, Onilă A. ↑ 2.0^2.12.2 Johari J, Sharifudin MA, Ab Rahman A, Omar AS, Abdullah AT, Nor S, Lam WC, Yusof MI. ↑ 3.0^3.13.2 Anwer S, Alghadir A, Shaphe A, Anwar D. ↑ Hacquebord JH, Leopold SS. ↑ Alison Middleditch et al., Functional Anatomy of the Spine 2005 2-6p.
2. ↑ Konieczny MR, Senyurt H, Krauspe R. ↑ 7.0^7.17.27.3 Wong AY, Samartzis D, Cheung PW, Cheung JP. ↑ 8.0^8.18.2 Jonathan A. et al., ↑ Ireneusz M. Kowalski et al., ↑ Balestroni G, Bertolotti G. EuroQol-5D (EQ-5D): ↑ Pineda S, Bago J, Gilperez C, Climent JM. ↑ Carreon LY, Sanders JO, Polly DW, Sucato DJ, Parent S, Roy-Beaudry M, Hopkins J, McClung A, Bratcher KR, Diamond BE, ↑ Bago J, Sanchez-Raya J, Perez-Grueso FJ, Climent JM. ↑ Juan Bago´ et al., Outcome instruments to assess scoliosis surgery, Eur Spine J (2013) 22 (Suppl 2):S195–S202.
3. ↑ Patias P, Grivas TB, Kaspiris A, Aggouris C, Drakoutos E. ↑ 16.0^16.1 Helenius IJ. ↑ 17.0^17.117.217.3 Kaspiris A, Grivas TB, Weiss HR, Turnbull D. ↑ 18.0^18.1 Fusco C, Zaina F, Atanasio S, Romano M, Negrini A, Negrini S. ↑ 19.0^19.119.2 Maruyama T, Grivas TB, Kaspiris A. ↑ 20.0^{20.120.220.320.4} Negrini S, Zaina F, Romano M, Negrini A, Parzini S. ↑ 21.0^21.121.221.3 Negrini S, Donzelli S, Aulisa AG, Czaprowski D, Schreiber S, de Mauroy JC, Diers H, Grivas TB, Knott P, Kotwicki T, Lebel A. ↑ Schreiber S, Parent EC, Moez EK, Hedden DM, Hill DL, Moreau M, Lou E, Watkins EM, Southon SC. ↑ 23.0^23.1 Negrini S, Negrini A, Romano M, Verzini N, Negrini A, Parzini S. ↑ 24.0^24.1 Negrini A, Parzini S, Negrini MG, Romano M, Atanasio S, Zaina F, Negrini S. function gtElInit() { var lib = new google.translate.TranslateService(); lib.setCheckVisibility(false); lib.translatePage('en', 'pt', function (progress, done, error) { if (progress == 100 || done || error) { document.getElementById("gt-dt-spinner").style.display = "none"; } }); }