Adolescent idiopathic scoliosis and back pain

Introduction

Fig. 1 A patient with AIS and her X-ray image of her spine (Paria et al., 2015).
Scoliosis can be described as an abnormal curvature of the spine. The Cobb angle (fig.2) and Risser sign are measures commonly used to assess the degree and progression of the curvature. Adolescent idiopathic scoliosis (AIS) is a type of idiopathic scoliosis.

Prevalence of AIS

AIS is a common disease with an overall prevalence of 0.47-5.2 % in the current literature[1]. It develops at the age of 11-18 and takes up 90% of idiopathic scoliosis cases in children. The female to male ratio ranges from 1.5:1 to 3:1 and increases substantially with age. Genetic factors play a role as well. [1]

Back Pain in AIS

Back pain is approximately twice as prevalent in patients with AIS compared to non-scoliosis patients [2][3][4]

Back pain most commonly occurs in the lumbar region followed by the thoracic region in AIS for both sexes.[2][3][4] A statistically significant association was found between thoracic pain and thoracic scoliosis in patients with AIS.[2] . Most AIS patients with back pain reported their pain as moderate to mild intensity[2][3][4]. It has also been shown that back pain in AIS lasted longer and occurred more frequently when compared to patients without scoliosis.[3]

Back Pain and Cobb Angle

Fig. 2 Cobb angle (Greiner, 2002)

No statistically significant evidence was reported between pain intensity and Cobb angle severity.[2][5] [6] However, it was suggested that patients without pain tend to present with smaller curves; and the incidence and intensity of back pain was higher in more severe curves (>40°-45°).

The Scoliosis Research Society (SRS) suggested that the presence of back pain may due to reduced trunk strength or hamstring flexibility. However, no evidence supports this statement.

Back Pain and Quality of Life in AIS

Lower back pain (LBP) in AIS patients can cause deterioration of patients’ quality of life. Other than pain, patients' self-image such as attitude their own physical appearance is also one of the contributing factors of the deterioration of quality of life.[7]

Dysfunctional respiratory function in AIS

Dysfunctional and asymmetrical breathing pattern often presents in patients with scoliosis.[8] Trunk rotation is increased as a result of inspiratory breathing forces being directed downwards to the convexity of the spinal curvature.[8] There is also a linkage between dysfunctional breathing and LBP or neck pain.[9][10]

Conservative Treatment

Various methods and exercises have been documented to help reduce the Cobb Angle in AIS however as discussed in the above paragraphs a reduction in Cobb Angle does not necessarily lead to reduction in pain.

General exercise

Patient specific exercises have been shown to be effective in the initial management of patients with AIS. These may include:

  • Spinal mobility/ flexibility exercises
  • Trunk strengthening exercises[11]
  • Stretching of hamstrings or other tight muscles in lower limbs
  • Gait re-education
  • Compound functional exercises such as squats, lunges and getting on/off the floor
  • Advice on cardiovascular exercise and fitness
  • Pilates/yoga[12]
  • Patient specific rehabilitation i.e. drills relating to optimising function in a sport the patient enjoys

Schroth method

The Schroth method is a set of exercises which is specifically designed for patients with scoliosis, especially for idiopathic scoliosis.[13] It was developed by Katharina Schroth in Germany. Schroth method aims at preventing curve progression before the end of growth with the following goals[14][15][16]:

  • Proactive spinal corrections to avoid surgery
  • Postural training to avoid or decelerate progression
  • Information to support the decision-making process
  • Home-exercise program
  • Support network
  • Prevention and coping strategies for pain

Braces

In a systematic review, few studies measured back pain in patients with AIS this study suggested that bracing did not have an effect on back pain in long term[17].

Another systematic review suggested that bracing has no influence on back pain when compared to the observation group, however, conflicting evidence was reported in this review.[18]

Osteopathic manipulation

There is currently no evidence to support osteopathic manipulation as the treatment for AIS[18].

Taping

It has been suggested that Kinesio Taping decreases back pain and increases quality of life in patients with type 1 AIS under the Lenke classification of scoliosis. This is a RCT and the only study on Kinesio Taping for AIS. Therefore, there is insufficient evidence.[19]

Surgical Treatment for AIS

Surgery may be recommended if the scoliosis is worsening and other treatments are ineffective, or if the scoliosis is severe and the adolescent has stopped growing.

Surgical treatments are indicated when the Cobb angle is greater than 45 to 50 degrees.[20] Posterior fusion with instrumentation is usually performed for idiopathic scoliosis.[20]

Conclusion

Back pain is very common in adolescent idiopathic scoliosis which can effect the quality of life in these patients. There are many contributing factors for the presence of back pain in AIS, including altered anatomy and breathing pattern. There is a lot of research surrounding the best way to manage patients with AIS, a holistic approach should be undertaken and patient specific goals kept in mind throughout to improve pain, function and overall well being.

Resources

NHS Scoliosis

Scoliosis Research Society

References

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