Adolescent Idiopathic Scoliosis (AIS)
Scoliosis is defined as an abnormal lateral curvature of the spinal column greater than ten degrees and is measured using the Cobb method. This curve can occur in either direction and the vertebrae rotate about their axis causing a rib cage deformity1. Curves toward the right are more common in the thoracic spine and curves toward the left are more common in the lumbar spine1. The term idiopathic is included when the cause of the scoliosis is unknown. Scoliosis is further classified by the age that is first detected; in this case “adolescent” refers to ten years of age until skeletal maturation (between 18 and 20 years of age). The majority of cases of scoliosis are idiopathic (80%)1, and the adolescent age group has the majority of cases2.
Scoliosis may be found in 2 to 4 percent of adolescents who are between the ages of 10 and 16 years old3. The presence of an abnormal lateral curve is more prevalent in females3. The prevalence of scoliosis by gender changes with the severity of the curve. The between gender ratio is equal with a 10 degree curvature, but at 30 degrees the ratio is 10 females for every male3. Curves of greater than 30 degrees account for only 0.2 percent and curves greater than 40 degrees shows only 0.1 percent prevalence4.
The typical patient will present with a lateral curvature of the spinal column which measures greater than 10 degrees using the Cobb method. Patient will also likely have a rotational deformity causing a rib hump to be evident when the patient bends forward. Usually AIS does not cause any severe secondary health problems, but may affect the patients quality of life and cause self esteem issues5. In severe cases patients may present with pain, disability, functional limitations, and pulmonary complications5. Below are pictures of some typical scoliosis patients.
The Cause of adolescent idiopathic scoliosis remains unknown4,6. Research is still being conducted to try and find the cause.
The most basic form of diagnostic testing for scoliosis is observing the patients posture in standing. The examiner will look at the alignment of the spine checking for any abnormal lateral curvature. One step up from postural analysis is the Adam’s forward bend test. In this test the patient is asked to bend forward. The examiner then looks at the contour of the patients back from behind and from the side. The most obvious finding from this test will be a “rib hump”, which is caused by the rotation of the vertebra. Sufficient evidence exists that the Adam’s forward bend test is accurate and reliable5. If an abnormality is found upon physical examination an x-ray will be required to allow for measurement of the degree of the curvature2. The X-ray view used to assess the spinal curvature is referred to as a standing radiograph. This implies that the patient will standing when the xray is taken and the views taken will be anterior to posterior. An MRI may be required with “left thoracic curves, unusual pain, abnormal neurologic findings, or other red flags to check for spondylolisthesis, tumors or syringomyelia6.
Evaluation/Special Orthopedic Tests:
The Adam’s forward bend test is the easiest test to use for evaluation of suspected scoliosis. The patient stands with their feet together and bends forward reaching toward their toes. The examiner then assess the spine from the back and side looking for any deviation of the normal straight spine. The examiner will also be checking for a rib hump which is caused by the rotational deformity caused by scoliosis. Other testing may be done to assess leg length, muscle length, and neurological signs and symptoms.
The main goal of conservative treatment of adolescent idiopathic scoliosis is to halt the progression of the scoliotic curve. There is much debate over which type of treatment is most effective in the conservative management of AIS. In the United States, the general course of care in patients with growth remaining is; watchful waiting, followed by bracing if there is a curve progression to greater than 25 degrees7. The main goal of bracing is to halt the progression of the curve until the patient reaches skeletal maturity7. There are many different types of braces used for treatment of scoliosis. These include but are not limited to: TriaC brace, SpineCor, Wilmington brace, Rosenberg brace, Boston brace, Charleston bending brace, and the Cheneau brace (click on names to be redirected to pictures). There are a few studies that show the longer the brace is worn, the more effective they are7.Physical therapy is the main treatment in European countries7. Physical therapy utilizes different spinal proprioception techniques, and movement coordination activities, and strengthening exercises to try and halt the progression of the curve. The evidence for usage of either bracing of physical therapy as a treatment for AIS is weak. A quote from Weinstein et al says this clearly; “No definite evidence has shown that physical therapy or bracing reduces the risk of curve progression, corrects the existing deformity, or decreases the need for surgery.” 7.
Surgery & post-op treatment:
Surgery for scoliosis is a spinal surgery with instrumentation. This means that it is a surgery on the spinal column where a combination of wires, hooks, and lumbar pedicle screws may be used to internally fixate the spine and correct the spinal curvature. Advances in medicine have allowed for multi-planar correction, reduction of fusion, and decreased need for immobilization following surgery9. The indication that is generally agreed upon for surgery for AIS is a Cobb angle of greater than 45 degrees. There are numerous types of instrumentation that may be used but posterior instrumentation is the main type9. Physical therapy following surgical treatment will vary between patients. Gait training, muscle reeducation, strengthening, wound care, core stabilization techniques, and scar tissue mobilization will likely be the focus of treatment sessions10,11.
Pictures of types of surgeries:
- Anterior spinal instrumentation:
Transcutaneous electrical nerve stimulation has been used as a conservative treatment for idiopathic adolescent scoliosis2. This modality may be combined with bracing, exercise, or used on as a primary treatment approach. However, according to Lenssinck et al6, there are no significant differences in the effect of this type of treatment to decrease the degree of the scoliotic curve when compared to other conservative treatments such as bracing or exercise alone. One study did show that TENS was effective in management of low back pain associated with scoliosis12. In this study four standard sized pads were place on the lower back and set at 4/30 Hz for 20 minutes12.
The modalities listed above have either shown no clinical benefit or do not have enough quality evidence to state that they are useful treatments regarding low back pain caused by scoliosis13.
Additional Web Based Resources:
1. Catherine Cavallaro Goodman, Kenda S. Fuller. Pathology: Implications for the Physical Therapist. Vol 1. 3rd ed. St. Louis, Missouri: SAUNDERS W B CO; 2009:1738. http://evolveebooks.elsevier.com/#/books/978-1-4160-3118-5/pages/11737134. Accessed 11 2010. 978-1-4160-3118-5.
2. Reamy BV, Slakey JB. Adolescent idiopathic scoliosis: review and current concepts. Am Fam Physician. 2001;64(1):111-116.
3. Roach JW. Adolescent idiopathic scoliosis. Orthop Clin North Am. 1999;30(3):353-65, vii-viii.
4. Miller NH. Cause and natural history of adolescent idiopathic scoliosis. Orthop Clin North Am. 1999;30(3):343-52, vii.
5. Negrini S, Minozzi S, Bettany-Saltikov J, et al. Braces for idiopathic scoliosis in adolescents. Spine (Phila Pa 1976). 2010;35(13):1285-1293. 10.1097/BRS.0b013e3181dc48f4.
6. Lenssinck ML, Frijlink AC, Berger MY, Bierman-Zeinstra SM, Verkerk K, Verhagen AP. Effect of bracing and other conservative interventions in the treatment of idiopathic scoliosis in adolescents: a systematic review of clinical trials. Phys Ther. 2005;85(12):1329-1339.
7. Cote P, Kreitz BG, Cassidy JD, Dzus AK, Martel J. A study of the diagnostic accuracy and reliability of the Scoliometer and Adam's forward bend test. Spine (Phila Pa 1976). 1998;23(7):796-802; discussion 803.
8. Oestreich AE, Young LW, Young Poussaint T. Scoliosis circa 2000: radiologic imaging perspective. I. Diagnosis and pretreatment evaluation. Skeletal Radiol. 1998;27(11):591-605.
9. Weinstein SL, Dolan LA, Cheng JC, Danielsson A, Morcuende JA. Adolescent idiopathic scoliosis. Lancet. 2008;371(9623):1527-1537. 10.1016/S0140-6736(08)60658-3.
10. Weiss HR. Rehabilitation of scoliosis patients with pain after surgery. Stud Health Technol Inform. 2002;88:250-253.
11. Mahaudens P, Detrembleur C, Mousny M, Banse X. Gait in thoracolumbar/lumbar adolescent idiopathic scoliosis: effect of surgery on gait mechanisms. Eur Spine J. 2010;19(7):1179-1188. 10.1007/s00586-010-1292-2.
12. Yokoyama M, Sun X, Oku S, et al. Comparison of percutaneous electrical nerve stimulation with transcutaneous electrical nerve stimulation for long-term pain relief in patients with chronic low back pain. Anesth Analg. 2004;98(6):1552-6, table of contents.
13. Harris GR, Susman JL. Managing musculoskeletal complaints with rehabilitation therapy: summary of the Philadelphia Panel evidence-based clinical practice guidelines on musculoskeletal rehabilitation interventions. J Fam Pract. 2002;51(12):1042-1046.