by: Brett Jackson
Scheuermann's disease(SD) is hyperkyphotic disease that typically develops early puberty(12-15 years old) that mainly affects the thoracic spine bodies. The anterior region of the vertebral body does not develop enough, forming a wedge-shaped deformity.1-5 The disease tends to involve 3 or more vertebrae, can involve just one.3
Scheuermann's disease is differentiated by a 5o or more angle of the vertebral body viewed laterally via radiographs.3,5 In addition there may a thicknening, undulence, Schmorl nodes, and a COBB angle greater than 40o.3,5 Individuals with SD typically have excessively protracted scapula secondary to the hyperkyphotic posture.
Scheuermann's Disease is the most prominent hyperkyphosis with a mean incidence rate of 18% in the population.5
Patients with SD present with a hyperkyphotic curvature of the thoracic spine and potentially the upper lumbar (L1/2), bilaterally rounded shoulders, and thoracic backache related to posture and movement.2
The cause of SD is unknown, however there are several theories suggesting an increase of growth hormone, smaller length of sternum, defective formation of collagen fibrils with secondary weakening of the vertebral endplate(s), juvenile osteoporosis, trauma, vitamin A deficiency, polymyelitis and epiphysitis. A potential trend that increases SD severity may be an increased height and weight leading to more gravitational forces working on the spine.2-5
At this time general PA and lateral spinal radiographs are the only diagnostic tests need for diagnosis. The cobb angle is measured by drawing a perpendicular line to the upper thoracic 4th vertebrae to the lower 12th thoracic vertebrae.2-5
Evaluation/Special Orthopedic tests
Visual inspection of posture with the aid of a plumb line for a line of reference.5 Looking at the body as a whole is key. Adam's test may be performed to see if there scoliosis is another potential disorder.5 Adam's test has the patient bend into forward flexion of spine/trunk. The therapist looks posterior and anterior to see if one side is not symmetrical in the transverse plane.
A rigid brace is the first method of intervention in patients with Scheuermann's disease if the kyphosis Cobb angle between 55+/- and 75+/- degrees. The rigid brace is on for a period of 1-2 years beginning at 23 hours of daily use and tapering off as indicated by success in rehabilitation. Some research indicates if the Cobb angle is between 65+/- and 75+/- degrees a plaster cast brace may be indicate, however there is not conclusive evidence currently. 75 degrees conservative rehab has not proven successful and surgery is indicated. For patients with a a kyphosis Cobb of less than 55 degrees can utilize rehabilitation exercises/treatment without bracing.5
The Milwaukee brace is the most commonly researched brace. The brace has posterior pads that push the kyphosis anteriorly, while keeping the neck and pelvis in a controlled position by the brace. The brace is initially worn for 23 hours a day for 1-2 years. Research has indicated a potential decrease in mean hyperkyphosis of 40-50% and and mean lumbar lordosis after from an average of 14-34 months of full-time use.
The Boston brace is indicated for flexible curves below 70 degree with an apex at or below T7. The theory with this brace will flatten the excessive compensatory lumbar lordosis will result in the patient hyperextending the thoracic spine, standing more erect. In research this brace has had a 27% average improvement in hyperkyphosis
A hyperkyphosis bi-valave rigid brace that utilizes a three point concept . The brace has a posterior rigid shell usually at T7-S3 and an anterior shell with a manubrial thrust reinforced by a metallic bar. In certain cases an additional cervical collar, Spitz collar, may be used to aid in intervention.
A custom-made, two valve TLSO with posterior thoracic and sacral thrusts interconnected by three metal bars and one anterior plastic abdomen moulded in hyperlordosis and connected to two stiff metal clavicle pushes. The Maguelone brace is highly effective and very dedicated to the most frequent pure thoracic hyperkyphosis with an apex from T5-6 to T8-9. However, other than the aforementioned hyperkyphosis this brace is not very versatile. The Maguelone brace has been shown to improve 70% of hyperphosis patients in some research.
This custom-made plastic LSO has a median frontal clasp that enwraps the chest from the submammary line to the groin and posteriorly from T5 to the buttocks. This brace is very versatile and allows control of atypical hyperkyphosis with an apex at T8.
No specific rehabilitation exercise protocol has been established in research currently. However, to goals need to made to look at the disorder globally. Objectives, but are not limited to, are:5
1. increase of mobility/elasticity of the thoracic spine in the direction of the extension(usually patients are stiff especially at the apex)
2. reinforce of endurance capability of trunk extensor muscles
3. recover of muscular retractions when present
4. learning of correct posture to be adopted in everyday life activities
To achieve goal one thoracic extension activities can be as simple as laying supine with a pillow at the apex of the kyhposis. The patient, keep the pelvis on the floor can bring arms at their side to above their head in thoracic extension.
To achieve goals two to four patients must be educated what is the correct posture to avoid forward bending. Patients will perform isometric contractions while performing correct postures. These exercises should be performed in positions of normal activities of daily living to increase postural awareness focusing on forward flexed positions such as sitting.
Physical Agent Treatment
Currently there are little to no direct research studies indicate modality usage for patients with Sheuermann's kyphosis. However, an article from Papagelopoulos references(reference #18) an article indicating electrical stimulation usage.6 Unfortunately this article was in German and unaccessable through PubMed and Google Scholar in full text. The concern with patients with SD is if Harrington rods were used in treatment, which would be a general contraindication to electrical stimulation. A search using keywords "sheuermanns kyphosis and treatment", "sheuermanns kyphosis and electrical stimulation", "sheuermanns kyphosis and modalities", and "sheuermanns kyphosis and physical agents" utilizing PubMed and Google Scholar yielded no further results. Conservitive treatment for general back pain has traditionally been cryotherapy and a treatment of an ice bag over the painful area for 15 minutes can be used.7
Surgery and post-op treatment
Surgery is indicated if the Kyphotic Cobb angle is 75+/- or greater.8 Surgery generally involves fusion of the abnormal vertebrae with surgical implants.8 The procedure involves an anterior and posterior approach.8 The surgery can range from 7-10 hours.
For more detailed information on the surgery visit:
Patient Experience with Scheuermann's Disease, surgery, and Rehabilitation
Additional web-based resources
1. Collins JD, Saxton EH, Miller TQ, Ahn SS, Gelabert H, Carnes A. Scheuermann's disease as a model displaying the mechanism of venous obstruction in thoracic outlet syndrome and migraine patients: MRI and MRA. J Natl Med Assoc. 2003;95(4):298-306.
2. Fotiadis E, Kenanidis E, Samoladas E, Christodoulou A, Akritopoulos P, Akritopoulou K. Scheuermann's disease: focus on weight and height role. Eur Spine J. 2008;17(5):673-678. 10.1007/s00586-008-0641-x.
3. Summers BN, Singh JP, Manns RA. The radiological reporting of lumbar Scheuermann's disease: an unnecessary source of confusion amongst clinicians and patients. Br J Radiol. 2008;81(965):383-385. 10.1259/bjr/69495299.
4. Wischnewski W, Pfeiffer A. Scheuermann disease as predisposition of later spinal disease and its effect on expert assessment in occupational disease examinations. Versicherungsmedizin. 1996;48(4):126-128.
5. Zaina F, Atanasio S, Ferraro C, et al. Review of rehabilitation and orthopedic conservative approach to sagittal plane diseases during growth: hyperkyphosis, junctional kyphosis, and Scheuermann disease. Eur J Phys Rehabil Med. 2009;45(4):595-603.
6. Papagelopoulos PJ, Mavrogenis AF, Savvidou OD, Mitsiokapa EA, Themistocleous GS, Soucacos PN. Current concepts in Scheuermann's kyphosis. Orthopedics. 2008;31(1):52-8.
7. Hanrahan S, Van Lunen BL, Tamburello M, Walker ML. The Short-Term Effects of Joint Mobilizations on Acute Mechanical Low Back Dysfunction in Collegiate Athletes. J Athl Train. 2005;40(2):88-93.
8. University of Maryland Medical Center. A Patient's Guide to Scheuermann's Kyphosis. . http://www.umm.edu/spinecenter/education/scheuermanns_kyphosis.htm.