Guideline: Conservative Management of Scoliosis

Authors: H.R. Weiss, M. Rigo, T. Kotwitcki, M. Hawes Coauthors: T. Maruyama, T.B. Grivas, F. Landauer

Epidemiology: Prevalence of adolescent idiopathic scoliosis (AIS) is 2-3% when defined a curve greater than 10° according to Cobb. The prevalence of curve with more than 20° is between 0.3 and 0.5% where curvatures with Cobb angles of more than 40% can be found in less than 0.1% of a population. Scoliosis of other aetiologies is even more seldom than AIS (Weinstein 1999).

Definition: Scoliosis is defined as a lateral spinal curvature with torsion of spine and chest as well with a disturbance of the sagittal profile (Stokes 2003).

Aetiology: Idiopathic scoliosis is the most common of all forms of lateral deviation of the spine. By definition, it is a lateral curve of the spine in an otherwise healthy child, for which a currently reckonizable cause has not been found. Besides idiopathic scoliosis, scoliosis of neuromuscular origin, congenital scoliosis, scoliosis in neurofibromatosis, mesenchymal disorders like Marfan’s syndrome have to be named. There are other origins of scoliosis however those are rarely seen even in the practice of a specialist (Winter 1995)

Classifications: The anatomical level of the deformity has received attention from clinicians as a basis for scoliosis classification. The level of the apex vertebra (i.e. thoracic, thoracolumbar, lumbar or double major) forms a simple basis for description. In 1983, King and Moe classified different patterns of curve by the extent of spinal fusion required, however recent reports indicated issues relating to poor reliability. Recently a new description has been developed by Lenke and collegues to assess scoliosis and kyphosis clinically in the context of sagittal profile and curve components (Dangerfield 2003). For conservative management the classification by Lehnert-Schroth (Functional three-curve and functional four-curve scoliosis) seems important (Lehnert-Schroth 2000). For brace construction and application the Rigo classification seems helpful (Rigo 2004).

Aims of conservative management: The primary aim of scoliosis management is to stop curvature progression. Improvement of vital capacity as well as pain treatment is also of major importance. The modules of conservative management of scoliosis are physical therapy (Méthode Lyonnaise, Side-Shift, Dobosiewiecz, Schroth and others). Although discussed contrarily in the international literature, there is some evidence for the effectiveness of scoliosis treatment by physical therapy alone (Negrini et al. 2003). The second module of conservative management is scoliosis in-patient rehabilitation (SIR) which seems effective with respect to many signs and symptoms of scoliosis and with respect to curvature progression (Weiss, Weiss und Petermann 2003). Brace treatment is effective preventing curvature progression and there is evidence that the rate of surgery can be reduced (Rigo, Reiter, Weiss 2003) and that sagittal profile can be restored (Rigo 1999). Systematic application of the treatment modules with respect to Cobb angle and maturity:

I. Children (no signs of maturity) 6-10 (12) years of age a. < 20° Cobb: Observation (6 – 12 Month intervals) b. Cobb angle 20-25°: Out patient physiotherapy with treatment free intervals (with low progression risk). c. More than 25°: Out patient physiotherapy, scoliosis intensive rehabilitation programme (SIR) when available and brace (part time 12-16 hours [low risk, low effort])

II. Children and adolescents, Risser 0-3, first signs of maturation, less than 98% of mature hight a. progression risk less than 50%: Observation (3 Month intervals) b. progression risk 50%: Out patient physiotherapy c. progression risk 60%: Out patient physiotherapy, scoliosis intensive rehabilitation programme (SIR) when available + relative brace indication (16 – 23 hours [low risk]). d. progression risk 80%: Out patient physiotherapy, scoliosis intensive rehabilitation programme (SIR) when available + absolute brace indication (23 hours [high risk])

The estimation of the prognostic risk is based on the calculation of Lonstein and Carlson (1984).

III. Children and adolescents presenting with Risser 4 (more than 98% of mature hight). a. less than 30° according to Cobb: Observation (6 – 12 Month intervals) b. 30 - 35° according to Cobb: out patient physiotherapy c. more than 35° according to Cobb: Out patient physiotherapy, scoliosis intensive rehabilitation programme (SIR) when available + brace (part time, about 16 hours are sufficient [low risk, low effort]) d. for brace weaning: Out patient physiotherapy, scoliosis intensive rehabilitation programme (SIR) when available + brace with reduced wearing time.

IV. Beginning with Risser 5 (more than 99.5% of mature hight) a. more than 35° according to Cobb: Out patient physiotherapy b. more than 45° according to Cobb: Out patient physiotherapy, scoliosis intensive rehabilitation programme (SIR) when available. V. Adults with Cobb angles > 45°: Out patient physiotherapy, scoliosis intensive rehabilitation programme (SIR) when available

VI. Adolescents and adults with scoliosis (more than 20° according to Cobb) and chronic pain: Out patient physiotherapy, scoliosis intensive rehabilitation programme (SIR) when available with a special pain programme (multimodal pain concept / behavioural + physical concept)

In boys prognosis as a whole is more favourable. The prognostic estimation and indication refers to the main indication of idiopathic scoliosis, in other types of scoliosis a similar procedure can be applied with the exception of those cases, where the prognosis is clearly worse, for example in neuromuscular scolioses where a wheel-chair is necessary (early surgery for maintaining sitting capability).

This guideline was established to be used regularily in scoliosis management. However there may be exceptions from the rules given to be made by scoliosis specialists but only if there is a good reason documented. Exceptions should be made for reasons like - severe decompensation - severe sagittal deviations with structural lumbar kyphosis - lumbar, thoracolumbar and caudal component of double cases with a disproporcioned rotation compared to the Cobb angle and with high risk for future instability at the caudal junctional zone - and others to be named.

Definitions: Out patient physiotherapy: 1 – 2 exercise sessions at the physiotherapist / week at the beginning + daily 30 Min. home exercise programme. After 3 Month or after SIR 1 exercise session every 2 week may be enough. Without the performance of the regular (4 - 5 x / week) home exercise programme the prescription of exercises is not useful in the long term.

Scoliosis intensive rehabilitation programme (SIR) : 3 - 4 week intensive programme (4 – 6 hour training sessions / day) for patients with bad prognosis (brace indication, adult with Cobb angle of > 40°, chronic pain & scoliosis). This kind of treatment at the moment is available in Germany and Spain.

References WEINSTEIN, S.L.: Natural history. Spine, 24: 2592-2600, 1999. STOKES, J.: Die Biomechanik des Rumpfes. In: H.R. Weiß: Wirbelsäulendeformitäten. Konservatives Management. München, Pflaum: 59-77, 2003 WINTER, R.B.: Classification and Terminology. In: Moe’s Textbook of Scoliosis and Other Spinal Deformities, Philadelphia Saunders, pp 39-43, 1995.

DANGERFIELD, P.H.: Klassifikation von Wirbelsäulendeformitäten. In: H.R. Weiß: Wirbelsäulendeformitäten. Konservatives Management. München, Pflaum: 78-83, 2003. LEHNERT-SCHROTH, CH.: Dreidimensionale Skoliosebehandlung. 6. erw. Auflage, Urban/Fischer, München, 2000. RIGO, M.: Intraobserver reliability of a new classification correlating with brace treatment. Pediatric Rehabilitation 7:63, 2004. NEGRINI S., ANTONINI, Gl, CARABALONA, R., MINOZZI, S.: Physical exercises as a treatment for adolescent idiopathic scoliosis. A systematic review. Pediatric Rehabilitation 6: 227-235, 2003. WEISS, H.R., WEISS, G, PETERMANN, F.: Incidence of curvature progression in idiopathic scoliosis patients treated with scoliosis in-patient rehabilitation (SIR): an age- and sex-matched cotrolled study. Pediatr. Rehabil. 2003 Jan-Mar ;6(1) :23-30

RIGO, M., REITER, CH., WEISS, H.R.: Effect of conservative management on the prevalence of surgery in patients with adolescent idiopathic scoliosis. Pediatric Rehabilitation  6 :209-214, 2003.

RIGO, M.: 3D Correction of Trunk Deformity in Patients with Idiopathic Scoliosis Using Chêneau Brace. In: I.A.F., Stokes (editor). Research into Spinal Deformities 2. (Amsterdam: IOS Press), pp. 362-365, 1999. LONSTEIN, JE, CARLSON JM: The prediction of Curve Progression in untreated idiopathic scoliosis during growth, J. Bone Joint Surg, 66-A, 1061 – 1071, 1984